Thinking
like
neurologist

Is
it
difference?

Dr.
Surat
Tanprawate,
MD,
FRCP(T)
Northern
Neuroscience
Center
Chiangmai
University
 Thinking
like
a
Neurologist

Where
‘s
the
lesion?
What’s
the
lesion?

Simply
word
Complex
way
 Series
of
steps
to
collect
data
Task
 Goal

Chief
complaint
Possible
anatomical
localiza<on

and
e<ologies
History

Possible
anatomical
localiza<on

and
e<ologies
Neurological
examina<on Confirma<on
of
anatomical
localiza<on
List
of

possible
disease Review
of
Pa<ent‐specific
feature
Rank
of
order
of
Differen<al
diagnosis
Likelihood
of
possible
disease
Complex
brain
processing
How
to
be
Jedi…

• Basic
neuroanatomy
• Basic
neurophysiology

• Symptoms
approach
 Symptoms
approach‐1

• Disorder
of
consciousness
In
your
head – Level
of
consciousness
– Content
of
consciousness
• Mental
disorder
– Memory
– Intelligence
– Personality
– Behavioral

– Demen<a

• Higher
cor<cal
func<on

disorder
– Apraxia,
aphasia,
agnosia,

others
• Visual
disorder
– Visual
loss
– Diplopia
 Symptoms
approach‐2
• Language
and
speech
 In
your
head
disorder
– Dysarthria
– Dysphasia

• Lower
cranial
nerve

disorder
– Deafness/<nnitus
– Ver<go
– Balance/staggering
– Swallowing
– Voice
change
 Symptoms
approach‐3


In
your
head • Sensory
disorder
– Pain
disorder
• Headache
and
facial
pain
• Others
pain
disorder
– Numbness/<ngling
• Motor
disorder

– Weakness
– Movement
disorder
• Sphincter
disorder
 Symptoms
approach‐4
• Episodic
disorder In
your
head
– Seizure/epilepsy
– Syncope
– TIA
– Abnormal
movement
– Migraine

 Skill
to
collect
the
data


 Chief
complaint
– Get
the
right
data
– First
step
to

approach

Consist
of

Group
symptoms+

Mode
of
onset
 Common
misinterpret
symptoms

• Palalysis
VS
 • Blur
vision
VS

numbness Diplopia
• Dizziness
VS
 • Blackout:
loss
of

weakness
VS
Fa<gue
 consciousness
VS
loss

VS
ataxia of
vision
VS
simple

• Dysphasia
VS
 confusion
dysarthria
 Present
illness









Symptoms
Clarify
symptom
Onset,
dura<on,
progression

Some
disability

Onset
 Data
from
CC
and
PI:

What’s
and
where
‘s
the
lesion?


If

can
not
interpreted
the
data
Recollect
the
data
 Neurological
examina<on
• Focused
neurological
 • Record
neurological
sign

examina<on
 – Presence
VS
Absence
– Detail
of
neurological
 – Hard
signs
VS
So_
signs
func<on
that
relevant
to
 – Normal
VS
abnormal
the
history
– Lateralizing
sign:

– Specific
neurological
 • True
VS
false
localizing
sign
examina<on • Normal
varia<on
• Screening
neurological

examina<on
– Check
remaining
path.
 General
neurological
examina<on
• Mental
status • Gait
and
balance
• Cranial
nerve
 • Romberg
test
– 1‐12
CN
func<on
• Limb

– Voluntary
movement
– Muscle:
bulk,
tone,
power

– Coordina<on:
FTN,
HTS,
rapid

alterna<ng
movement
– Reflex:
tendon,
plantar

response
– Sensa<on:
pinprick,
JPS,

vibra<on
sense
Concept
of
“so_”
neurological
sign
• “Hard
sign”:

– neurological
sign
result
from
a
lesion
at
a
known

site
or
that
affect
a
known
pathway
• “So_
sign”:

– any
structural
or
func<onal
devia<on
found
more

frequently
in
brain
impairment
persons
than
in

normal
persons
– But
does
not
correlate
with
any
par<cular
type
of

brain
lesion
at
any
par<cular
site,
or
interrup<on
of

any
par<cular
tract
 Concept
of
“false”
localizing
sign
• True
sign
that
occurs
secondary
to
a
lesion

elsewhere
in
the
CNS.

• The
sign
is
not
false,
but
is
distant
from
the

actual
site
of
primary
lesion
• Cause:
– Shi_
of
brain:
compress
or
displace
structure

(distant)
or
blood
vessel
(ACA,
MCA)
– Hydrocephalus:
CN
6
palsy,
Pretectal
(sylvian)

syndrome
 Differen<al
diagnosis
Discussion
each
problem
list
• 1)
• 2)
• 3)
• 4)
• 5)
 List
of
problems
Integrate
of
History
and
PE
• First:
anatomical
localiza<on
 • Second:
cause
of
lesion
of
lesion
or
neurology
 – Congenital,
Gene<c
system – Trauma
– Focal,
Mul<‐focal,
Diffuse – Tumor
– Nuclear,
tract,
system
disorder – Infect/Inflamma<on
– CNS,
PNS,
Boths – Vascular
– Toxic/metabolic/Nutri<onal
– Degenera<on/Demyelina<on
– Idiopathic
– Psychogenic

Thinking
outside
the
box
 Example

• Female,
35
Y.O:
SLE
pa<ents,
on
pred.
5
mg/d
• Presented
with
acute
Rt.
Hemiparesis
1
d
PTA
• CT
brain:
acute
Lt.
MCA
infarc<on
• At
admission:
EKG:
AF
with
RVR,
CHF
• Summary
of
problem
list
– Acute
stroke
– AF
with
CHF
– SLE
on
pred.
Organized
your
thought

AF
with

CHF

Acute

SLE
stroke
 Acute
stroke
from
AF
Others
problem
is
SLE

Acute
stroke
from
AF
AF
from
cardiPs
CardiPs
from
SLE

Acute
stroke
from
other
caused(non‐AF)
SLE
associated
caused
of
stroke(vasculiPs,
APL)
SLE
treatment
associated
caused
of

stroke(infecPon)
AF
can
caused
by
stoke?
SLE
can
caused

acute
stroke:
direct:
vasculiPs,
APL
Ab
Indirect:
cardiPs,
autoimmune

endocardiPs
AF
:
direct:
cardiPs
indirect:
Associated
autoimmune

thyrotoxicosis

Exercise
your
thought
process
by

Discussion
bedside
Case
record(MGH)
 Equipment
Needed

• Reflex
Hammer

• 128
and
512
(or
1024)
Hz

Tuning
Forks

• A
Snellen’s
Eye
Chart
or

Pocket
Vision
Card

• Pen
Light
or
Otoscope

• Wooden
Handled
Colon

Swabs

• Paper
Clips

“Neurology
tutorial
program
for

medical
resident”

Neurological
symptomatology
Emergency
neurology
Disease
based
oriented
approach