approach to the patient with neurologic disease neuroscience module year level 7 sy 2010-2011
TRANSCRIPT
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Approach to the Patient with Neurologic Disease
Neuroscience ModuleYear Level 7 SY 2010-2011
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Neurologic Method
Step 1 : Locate the Lesion
“where is the lesion?”
Step 2 : Define the pathophysiology
“what is the lesion?”
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Neurologic Method
CNSCerebral cortexBasal gangliaBrainstem,CerebellumSpinal cord
PNSNerve rootsPlexusMotor nervesSensory nerves
• Meninges • Neuromuscular junction
• Muscle
Upper Motor Neuron Lower Motor Neuron
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Neurologic Method
Focal ? Mulitifocal? Diffuse? Secondary to a Systemic illness?
History - provides clues in localizationNeurologic Examination - confirms and rules out
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Neurologic Method Disturbances of Cerebrospinal Fluid and Its Circulation, including
Hydrocephalus, Pseudotumor cerebri, and Low-Pressure Syndromes Intracranial Neoplasms and Paraneoplastic Disorders Infections of the Nervous System and Sarcoid Viral Infections of the Nervous System and Prion Diseases Cerebrovascular Diseases Craniocerebral Trauma Multiple Sclerosis and Allied Demyelinative Diseases The Inherited Metabolic Diseases of the Nervous System Developmental Diseases of the Nervous System Degenerative Diseases of the Nervous System The Acquired Metabolic Diseases of the Nervous System Diseases of the Nervous System due to Nutritional Deficiency Alcohol and Alcoholism Disorders of the Nervous System due to Drugs and Other Chemical Agents
Major Categories of Neurologic Disease
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Steps in the Diagnosis of Neurologic Disease
Elicitation of Clinical Facts
By history
By neurologic examination
Interpretation of symptoms and signs in terms of physiology and anatomy
Syndromic formulation and localization of lesion
ANATOMIC DIAGNOSIS
Anatomic diagnosis+Mode of onset and course+ Other medical data+Appropriate lab tests
Pathologic or etiologic diagnosis
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Neurologic History
Often permits an accurate localization and determination of probable cause of the complaints, even before the neurologic examination is performed
Brings to focus the neurologic examination that follows
Each complaint should be pursued as far as possible- "What are the associated features?"
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Neurologic History
Temporal course of the illness
Time of appearance
Rate of progression of the symptoms
Rapid, gradual, transient, stuttering, relapsing remitting
Patients' descriptions of the complaint
The same words often mean different things to different patients
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Neurologic History
Corroboration of the history by others
Factors may impair patient's capacity to communicate
Episodes of loss of consciousness Family History
Many neurologic diseases have an underlying genetic component
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Neurologic History
Medical illnesses
Neurologic diseases occur in the context of systemic disorders (DM, hypertension)
Drug use and abuse and toxin exposure
Prescribed and illicit Formulating an impression of the patient
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Taking the History
Avoid leading questions, encourage to give accurate description of the symptom
Take notes, verify the history The setting, mode of onset and evolution and
course are important Decide if the patient is competent to give a
history
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The Purpose of the Clinical Method of Neurology
Accurate Diagnosis Determine the proper treatment Helpful in prognosis Genetic counseling Initial step in the scientific study of clinical
phenomena and disease
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Neurologic Examination
Needs practice Essential for ALL clinicians for screening for
neurologic dysfunction Performed in an orderly and systemic fashion to
avoid errors and serious omissions
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Neurologic Examination
Describe what is found Compare the patients performance on tasks that
require simultaneous activation of both cerebral hemispheres
Reproduce the activity that elicits the symptoms Use of tests tailored to the patients problem can
be of value in assessing changes
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Neurologic Examination
• Begins with observation of the patient
• Ends as the last part of the general physical examination
• Performed and recorded in sequential manner
• Thoroughness governed by clinical problem
• Modified according to the condition of the patient
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Neurologic Examination
• Testing of Higher Cortical Functions
mini-mental examination
• Testing of Cranial Nerves
• Somatic Motor
• Somatic Sensory
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Neurologic Examination
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Mental Status Examination
Level of conciousness Awareness of self and environment Describe the responses to the minimum
stimulus necessary to elicit a reaction Orientation
Name, location and time Speech
Articulation, rate, rhythm, and prosody
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Mental Status Examination
Language Content of patients verbal and written output Response to verbal commands Ability to read
Memory Immediate memory Short term memory Long term memory
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Mental Status Examination
Fund of Information Inquire about major historic or current events
Insight and Judgement How patient would respond to situations with a
variety of outcomes
Abstract Thought Describe similarities between various objects List items of the same attributes
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Mental Status Examination
Calculation Ability Have patient carry out a computation that is
appropriate to the patient's age and education Word problems involving simple arithmetic
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Mental Status Examination• Intergrative sensory function
astereognosis
agraphesthesia
two-point discrimination
allesthesia
extinction
unilateral neglect and anosognosia
disorders of spatial thought
• Integrative motor function
apraxia
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Mini Mental Status Examination
Orientation
TIME year, season, date, day, month
(1 point each)
PLACE state, country, town, hospital, floor
(1 point each)
Registration
Repeat names of 3 objects
(1 point per object)
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Mini Mental Status Examination
Attention and Calculation
Serial 7’s or spell a 5 letter word backward
(1 point per subtraction or letter)
Recall
Recall names of three objects repeated previously
(1 point per object)
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Mini Mental Status Examination
Language
Name a pencil, and watch (1 point each)
Repeat “no ifs, ands or buts”(1 point)
Follow a 3-stage command (1 point per step)
Read and obey the command (1 point)
Write a complete sentence (1 point)
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Mini Mental Status Examination
Construction
copy two intersecting pentagons (1 point)
TOTAL = 30score of <24, more detailed investigation
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Points
Orientation
Name: season/date/day/month/year 5 (1 for each name)
Name:hospital/floor/town/state/country 5 (1 for each name)
Registration
Identify three objects by name and ask the patient to repeat 3 (1 for each object)
Attention and calculation
Serial 7s; subtract from 100 5 (1 for each subtraction)
Recall
Recall the three objects presented earlier 3 (1 for each object)
Language
Name pencil and watch 2 (1 for each object)
Repeat "No ifs, ands or buts" 1
Follow a 3-step command (e.g., "Taek this paper, fold it inhalf, and place it on the table"
3 (1 for each command)
Write "close your eyes" and ask patient to obey writtent command
1
Ask the patient to write a sentence 1
Ask the patient to copy a design (e.g. intersecting pentagons) 1
Total 30
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Cranial Nerves
CN I - smell
CN II - acuity, peripheral fields, inattention,
pupillary light reflexes and size of pupils,
opthalmoscopy
CN III, IV, VI - ocular movements, convergence, nystagmus
CN V - inspect masseter, temporalis tone/bulk,
corneal reflex, sensory V1, V2, V3
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Cranial Nerves
CN VIII - otoscopy, threshold and acuity, Rinne, Weber, vestibular function
CN IX, X - phonation, nasality, swallowing, gag reflex
CN XI - SCM, trapezius
CN XII - lingual articulation, midline, lateral protusion, atrophy, fasciculations
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Somatic Motor System
• Inspection
• Palpation
• Speed, strength of movement
• Muscle bulk, tone, coordination
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
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Muscle Stretch Reflexes
Jaw jerk
Biceps (C5-6)
Triceps (C7-8)
Finger flexion (C7-T1)
Quadriceps (L2-4)
Ankle jerk (L5-S1-3)
Cutaneous abdominal
Plantar
22
22
22
22
22 22
22 22
11 11
+ ++ +
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Cerebellar System
Finger to nose, rebound, alternating movements
Heel to knee
Nerve root stretching tests
Nuchal rigidity
Leg raising tests
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Somatic Sensory SystemSuperficial sensory modalites
Light touch
Pain
Temperature
Deep sensory modalies
Vibration
Position Sense
Stereognosis
Romberg swaying test
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SignsCerebrum Abnormal mental status or cognitive impairment
SeizuresUnilateral weaknessa and sensory abnormalities including head and limbsVisual field abnormalitiesMovement abnormalities (e.g., diffuse incoordination, tremor, chorea)
Brainstem Isolated cranial nerve abnormalities (single or multiple)"Crossed" weaknessa and sensory abnormalities of head and limbs, e.g., weakness of right face and left arm and leg
Spinal cord Back pain or tendernessWeaknessa and sensory abnormalities sparing the head Mixed upper and lower motor neuron findingsSensory levelSphincter dysfunction
Table 361-2 Findings Helpful for Localization Within the Nervous System
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SignsSpinal roots Radiating limb pain
Weaknessb or sensory abnormalities following root distribution (see Figs. 25-2 and 25-3) Loss of reflexes
Peripheral nerve Mid or distal limb painWeaknessb or sensory abnormalities following nerve distribution (see Figs. 25-2 and 25-3) "Stocking or glove" distribution of sensory lossLoss of reflexes
Neuromuscular junction
Bilateral weakness including face (ptosis, diplopia, dysphagia) and proximal limbsIncreasing weakness with exertionSparing of sensation
Muscle Bilateral proximal or distal weaknessSparing of sensation
Table 361-2 Findings Helpful for Localization Within the Nervous System