Neurological disease

Introduction-presentation of
neurological disease
• Headache-
– Onset eg acute in acute subarachnoid
– Aggravating factors e.g noise,light in
migraine,menses,fatigue
– Relieving factors-analgesic,sleep
– Associated symptoms eg vomiting in increased
intracranial pressure, neck stiffness on meningitis
– Symptoms of depression e.g lack of sleep,poor
appettite,
 introduction
• Dizziness and vertigo -associated neurolgical deficit
,tinnitus,
• Ataxia lack of coordination and lack of balance-
associated symptoms of nystagmus,dysarthria and
tremors
• Delirium,confusion and coma-
vascualr,metabolic,infectious,endocrine,poisoning,
• Weakness-rate and pattern of
onset,progression,headache etc
• Convulsion-focal vs generalised.associated
incontinence,fever,trauma,drugs,alcohol etc
• Speech- sensory(wernickes) and motor (broca area)
aphasia,conduction aphasia etc
• Dysarthria-problem with articulation
• Sensory abnormalities-numbness,pain,paraesthesia
• Memory loss-gradually as in dimentia,retrograde for
prior experience and anterograde for new experiences
• Cognitive disturbance
• Cranial nerves abnormalities
• Visual disturbance-diplopia,reduced acuity
• Urinary and bowel habits
• Abnormal movements
• Motor examination
– Tone-resistance to passive movements.hypertonia
in upper motor and lower motor neuron disease
– Reflex-biceps (C5, C6), brachioradialis (C5, C6),
and triceps (C7, C8) reflexes in the upper limbs
and the patellar or quadriceps (L3, L4) and Achilles
(S1, S2) reflexes in the lower limbs
• Normal
• Absent.hporeflexia-lower motor neuron disease
• Hypereflexia-upper motor neuron disease
– Power
• 0 = no movement
• 1 = flicker or trace of contraction but no associated
movement at a joint
• 2 = movement with gravity eliminated
• 3 = movement against gravity but not against resistance
• 4– = movement against resistance
• 5 = full power
 Lower motor Upper motor
lesion Roots,peripheral Spinal cord,brain
nerves
reflex hyporeflexia hyperreflexia
tone hpotonia hypertonia
others fasciculation Clonus,barbinski
sign
• Sensory examination-light touch, pain,
temperature, vibration, and joint position
• Cordination- refers to the orchestration and
fluidity of movements e.g rapid alternating
movements of the hands and the finger-to-
nose and heel-knee-shin maneuvers.
Cerebellar and basal ganglia
 examination
• Vitals –bradycardia and hypertension in
increased intracranial pressure (ICP)
• Pupils-unequal,reactivity in
ICP,papilloedema,extrocular eye
movement,visual field defect
• Sinus tenderness in sinusitis
• neckstiffness
 GLASGOW COMMA SCALE
• Motor 6
– 6-follows command
– 5-localises pain
– 4-withdraw to pain
– 3-flaxion to pain
– 2-extension to pain
– 1-none
• Eye opening 4
– 4-spontanous
– 3-to voice
– 2-to pain
– 1-none
• Speech 5
• Speech
– 5-appropriate
– 4-confused
– 3-inappropriate
– 2-incomprehensible
– 1-none
 investigations
• Lumbar puncture-cerebrospinal fluid analysis done at
L3/4 intervertrebral disc space
– Biochemistry-protein normally 0.15-0.45g/L
– Glucose compare to plasma
– Microscopy,culture,sensitivity
– TB PCR
– Indian ink stain and cryptococcal antigen for cryptococcal
meningitis
– VDRL for sphillis
• Complications-cerebral herniation, injury to the spinal
cord or nerve roots, hemorrhage, or infection
• Minor-backache,post LP headache
• altered level of consciousness, a focal
neurologic deficit, new-onset seizure,
papilledema, or an immunocompromised
state are at increased risk for potentially fatal
cerebellar or tentorial herniation following LP.
Neuroimaging should be obtained in these
patients prior to LP to exclude a focal mass
lesion or diffuse swelling
• CT SCAN brain-first line in acute change in
neurological status eg cerebrovascular
accident,trauma
• MRI brain-seizure,brain
tumor,infections,spinal cord lesions
• Electroencephalogram(EEG)-seizure
• Nerve conduction and electromyelography in
peripheral neuropathy of motor neuron
disease