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APPROACH TO

NEUROLOGIC DIAGNOSIS
ERMAN C. FANDIALAN MD FPNA
UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL
MEDICAL CENTER
STEPS TO FOLLOW IN A PATIENT
PRESENTING WITH NEUROLOGIC
SIGNS AND SYMPTOMS
A. DATA GATHERING
B. ANATOMIC LOCALIZATION
C. ETIOLOGIC DIAGNOSIS

Elicit clinical facts
By history
And by neurologic exam
Interpret data in terms of
neuroanatomy and
physiology
Syndromic formulation
Anatomic localization
Syndromic diagnosis+mode
of onset+lab test
PATHOLOGIC OR
ETIOLOGIC DIAGNOSIS
HISTORY TAKING
1. Special care must be taken to avoid suggesting to the
patient the symptoms that one seeks e.g. asking the patient
to choose a single word to describe his dizziness
2. Pls do symptom analysis- mode of onset,evolution,
character,aggravating ang relieving factors, setting in
which the illness occurred, location
e.g. headache- throbbing- migraine
Band like- tension headache

HISTORY TAKING
3. As neurologic diseases often impair mental function, it is
important for the physician to decide whether patient is
competent to give the history
4. If patients memory, attention and coherence is
inadequate, ask the relative, friend or the employer who
witnessed the attack.
THE NEUROLOGIC
EXAMINATION
1. TESTING OF HIGHER CORTICAL FUNCTION
2. TESTING OF CRANIAL NERVES
3.TESTING OF MOTOR FUNCTION
4. TESTING OF SENSORY FUNCTION
5. TESTING OF REFLEXES
6. TESTING OF GAIT AND COORDINATION
ANATOMIC LOCALIZATION
BENEFITS OF LOCALIZATION
1. It directs the diagnosis or work up
E.g. if the localization points to a muscle disease, then you
will order emg-ncv or cpk mm
2. It estimates the extent of the lesion
e.g. a subcortical stroke or lacunar infarct as against an mca
infarction
It limits differential diagnosis
HOW DO WE LOCALIZE ?
1. List down all abnormal signs- it is derived from a good
and adequate neurologic examination
2. Determine all anatomic correlates- example, a patient
with right sided weakness may involve, the left motor
cortex, the corticospinal tract etc.
3. LOOK FOR THE INTERSECTION
This is your localization
ANATOMIC LOCALIZATION
UPPER MOTOR NEURON LOWER MOTOR NEURON
Muscles affected in groups
Atrophy is slight and of disuse
Spasticity
Hyperactive reflexes
Presence of Babinski
Absent Fasciculation
Individual muscles maybe affected
Atrophy pronounced
Flaccidity
Normal or hyporeflexia
Absent Babinski
Fasciculations present
UPPER MOTOR NEURON

A.Supratentorial
1. Cortical- abnormal MSE + long tract signs
2. Subcortical- internal capsule, thalamus, basal ganglia
B. Infratentorial
1. Brainstem- crossed paralysis, ipsilateral cranial nerve
involvement and contralateral long tracts
2. Cerebellum- vertigo and imbalance
3. Spinal cord- usually follows dermatomal or myotomal
involvement

LOWER MOTOR NEURON

1. Anterior Horn Cell- combination of upper motor neuron
and lower motor neuron manifestation
2. Roots- generally there is pain
3. Peripheral Nerves- stocking and glove distribution, distal
and symmetrical
4. Neuromuscular junction- fluctuating weakness
5. Muscle- proximal and symmetrical weakness
Ant. Horn
cell
roots Peripheral
nerves
Neuromusc
ular
junction
muscles
motor +++ +++ +++ +++ +++
sensory (-) +++ +++ (-) (-)
others UMN+LMN
polio
Pain
sciatica
Distal
symmetrical
dm
neuropathy
Fluctuating
weakness
Myasthenia
Proximal
and
symmetrical
, atrophy
pronounced
Myositis
ETIOLOGIC DIAGNOSIS

CVD DEMYE
LINATI
NG
INFECTI
ONS
METAB
OLIC
TRAUM
ATIC
NEOPL
ASTIC
DEGEN
ERATIV
E
TEMP
ORAL
PROFIL
E
ACUTE ACUTE ACUTE,
OR
CHRON
IC
ACUTE ACUTE
OR
CHRON
IC
CHRON
IC
CHRON
IC
FOCAL
OR
DIFFU
SE
FOCAL FOCAL DIFFUS
E OR
FOCAL
DIFFUS
E
FOCAL
OR
DIFFUS
E
FOCAL
MAYBE
DIFFUS
E
FOCAL
MAYBE
DIFFUS
E
PERTI
NENT
RISK
FACTOR
S
PRECEE
DED BY
INFECTI
ONS
FEVER PUPILS
SPARED
TRAUM
A
HEADA
CHE
PROGR
ESSIVE
Clinical pearls
1. Focus the clinical analysis on the principal symptom and
signs and avoid being distracted by minor symptoms and
uncertain clinical data.
2. Avoid early closure of diagnosis.
3. When several of the main features of a disease in its
typical form are lacking, an alternative diagnosis should be
made.
4. It is preferable to base diagnosis on the clinical
experience with the dominant symptoms and signs and not
on statistical analysis of the frequency of the clinical
phenomena.
DIAGNOSTIC MODALITIES
1. EEG
2. Cranial CT Scan
3. MRI
4. Lumbar puncture
5. EMG-NCV
6. Others
THANK YOU