ThinkinglikeneurologistIsitdifference?

Dr.SuratTanprawate,MD,FRCP(T)NorthernNeuroscienceCenter

ChiangmaiUniversity

ThinkinglikeaNeurologist

Where‘sthelesion?

What’sthelesion?

Simplyword

Complexway

Seriesofstepstocollectdata

Chiefcomplaint

History

Confirma<onofanatomicallocaliza<on

Possibleanatomicallocaliza<onande<ologies

Task Goal

ReviewofPa<ent‐specificfeature

Listofpossibledisease

Neurologicalexamina<on

Possibleanatomicallocaliza<onande<ologies

RankoforderofLikelihoodofpossibledisease

Differen<aldiagnosis

Complexbrainprocessing

HowtobeJedi…

• Symptomsapproach

• Basicneuroanatomy

• Basicneurophysiology

Symptomsapproach‐1

• Disorderofconsciousness– Levelofconsciousness– Contentofconsciousness

• Mentaldisorder– Memory– Intelligence– Personality– Behavioral– Demen<a

• Highercor<calfunc<ondisorder– Apraxia,aphasia,agnosia,

others

• Visualdisorder– Visualloss– Diplopia

Inyourhead

Symptomsapproach‐2

• Languageandspeechdisorder– Dysarthria– Dysphasia

• Lowercranialnervedisorder– Deafness/<nnitus– Ver<go– Balance/staggering– Swallowing– Voicechange

Inyourhead

Symptomsapproach‐3

• Sensorydisorder– Paindisorder

• Headacheandfacialpain

• Otherspaindisorder

– Numbness/<ngling

• Motordisorder– Weakness

– Movementdisorder

• Sphincterdisorder

Inyourhead

Symptomsapproach‐4

• Episodicdisorder– Seizure/epilepsy– Syncope– TIA– Abnormalmovement

–Migraine

Inyourhead

Skilltocollectthedata

Chiefcomplaint–Gettherightdata– Firststeptoapproach

ConsistofGroupsymptoms+Modeofonset

Commonmisinterpretsymptoms

• PalalysisVSnumbness

• DizzinessVSweaknessVSFa<gueVSataxia

• DysphasiaVSdysarthria

• BlurvisionVSDiplopia

• Blackout:lossofconsciousnessVSlossofvisionVSsimpleconfusion

Presentillness

SymptomsClarifysymptom

Onset,dura<on,progression

Onset

Somedisability

DatafromCCandPI:

What’sandwhere‘sthelesion?

Ifcannotinterpretedthedata

Recollectthedata

Neurologicalexamina<on

• Focusedneurologicalexamina<on– Detailofneurologicalfunc<onthatrelevanttothehistory

– Specificneurologicalexamina<on

• Screeningneurologicalexamina<on– Checkremainingpath.

• Recordneurologicalsign– PresenceVSAbsence

– HardsignsVSSo_signs

– NormalVSabnormal

– Lateralizingsign:• TrueVSfalselocalizingsign

• Normalvaria<on

Generalneurologicalexamina<on

• Mentalstatus• Cranialnerve

– 1‐12CNfunc<on

• Limb– Voluntarymovement

– Muscle:bulk,tone,power– Coordina<on:FTN,HTS,rapid

alterna<ngmovement

– Reflex:tendon,plantarresponse

– Sensa<on:pinprick,JPS,vibra<onsense

• Gaitandbalance• Rombergtest

Conceptof“so_”neurologicalsign

• “Hardsign”:– neurologicalsignresultfromalesionataknownsiteorthataffectaknownpathway

• “So_sign”:– anystructuralorfunc<onaldevia<onfoundmorefrequentlyinbrainimpairmentpersonsthaninnormalpersons

– Butdoesnotcorrelatewithanypar<culartypeofbrainlesionatanypar<cularsite,orinterrup<onofanypar<culartract

Conceptof“false”localizingsign

• TruesignthatoccurssecondarytoalesionelsewhereintheCNS.

• Thesignisnotfalse,butisdistantfromtheactualsiteofprimarylesion

• Cause:– Shi_ofbrain:compressordisplacestructure(distant)orbloodvessel(ACA,MCA)

– Hydrocephalus:CN6palsy,Pretectal(sylvian)syndrome

Differen<aldiagnosis

Discussioneachproblemlist

• 1)

• 2)

• 3)

• 4)

• 5)

ListofproblemsIntegrateofHistoryandPE

• First:anatomicallocaliza<onoflesionorneurologysystem– Focal,Mul<‐focal,Diffuse

– Nuclear,tract,systemdisorder

– CNS,PNS,Boths

• Second:causeoflesion– Congenital,Gene<c

– Trauma

– Tumor

– Infect/Inflamma<on

– Vascular– Toxic/metabolic/Nutri<onal

– Degenera<on/Demyelina<on

– Idiopathic

– Psychogenic

Thinkingoutsidethebox

Example

• Female,35Y.O:SLEpa<ents,onpred.5mg/d

• PresentedwithacuteRt.Hemiparesis1dPTA

• CTbrain:acuteLt.MCAinfarc<on

• Atadmission:EKG:AFwithRVR,CHF

• Summaryofproblemlist– Acutestroke– AFwithCHF– SLEonpred.

Organizedyourthought

AFwithCHF

SLEAcutestroke

AcutestrokefromAFOthersproblemisSLE

Acutestrokefromothercaused(non‐AF)SLEassociatedcausedofstroke(vasculiPs,APL)SLEtreatmentassociatedcausedofstroke(infecPon)AFcancausedbystoke?

AcutestrokefromAFAFfromcardiPsCardiPsfromSLE

SLEcancausedacutestroke:direct:vasculiPs,APLAb

Indirect:cardiPs,autoimmuneendocardiPs

AF:direct:cardiPs

indirect:Associatedautoimmunethyrotoxicosis

ExerciseyourthoughtprocessbyDiscussionbedsideCaserecord(MGH)

EquipmentNeeded

• ReflexHammer• 128and512(or1024)Hz

TuningForks

• ASnellen’sEyeChartorPocketVisionCard

• PenLightorOtoscope

• WoodenHandledColonSwabs

• PaperClips

“Neurologytutorialprogramformedicalresident”

Neurologicalsymptomatology

Emergencyneurology

Diseasebasedorientedapproach