Approach to Patient with

Neurologic Disorder
Daisy Marie B. Mendoza-Garbo, MD, FPCP
Internal Medicine
Introduction
Neurologic diseases are common and costly.
According to estimates by the World Health Organization, neurologic
disorders affect over 1 billion people worldwide, constitute 12% of
the global burden of disease, and cause 14% of global deaths.
The proper approach begins with the patient and focuses the clinical
problem first in anatomic and then in pathophysiologic terms; only
then should a specific neurologic diagnosis be entertained.
Define the Anatomy
• The first priority is to identify the region of the nervous system that is likely to
be responsible for the symptoms.
• Can the disorder be mapped to one specific location, is it multifocal, or is a
diffuse process present?
• Are the symptoms restricted to the nervous system, or do they arise in the
context of a systemic illness?
• Is the problem in the central nervous system (CNS), the peripheral nervous
system (PNS), or both?
• In the CNS, is the cerebral cortex, basal ganglia, brainstem, cerebellum, or
spinal cord responsible? Are the pain-sensitive meninges involved?
Define the Anatomy
• In the PNS, could the disorder be located in peripheral nerves and, if
so, are motor or sensory nerves primarily affected, or is a lesion in the
neuromuscular junction or muscle more likely?
• Deciding “where the lesion is” accomplishes the task of limiting the
possible etiologies to a manageable, finite number. In addition, this
strategy safeguards against making serious errors.
• Once the question, “Where is the lesion?” is answered, then the
question “What is the lesion?” can be addressed.
Define the Pathophysiology
• Primary neuronal (gray matter) disorders often present as early cognitive
disturbances, movement disorders, or seizures,
• white matter involvement produces “long tract” disorders of motor, sensory,
visual, and cerebellar pathways.
• Progressive and symmetric symptoms often have a metabolic or degenerative
origin; in such cases lesions are usually not sharply circumscribed.
• A Lhermitte symptom (electric shock–like sensations evoked by neck flexion)
is due to ectopic impulse generation in white matter pathways and occurs
with demyelination in the cervical spinal cord; among many possible causes,
this symptom may indicate MS in a young adult or compressive cervical
spondylosis in an older person.
Neurologic History
• Attention to the description of the symptoms experienced by the patient and
substantiated by family members and others often permits an accurate
localization and determination of the probable cause, even before the
neurologic examination is performed.
• What are the associated features?
• Does the patient have difficulty with brushing hair or reaching upward
(proximal) or buttoning buttons or opening a twist-top bottle (distal)?
• Negative associations may also be crucial.
• A patient with a right hemiparesis without a language deficit likely has a
lesion (internal capsule, brainstem, or spinal cord) different from that of a
patient with a right hemiparesis and aphasia (left hemisphere).
Pertinent Features of History
1. Temporal course of the illness. It is important to determine the
precise time of appearance and rate of progression of the
symptoms experienced by the patient
2. Patients’ descriptions of the complaint. The same words often mean
different things to different patients
3. Corroboration of the history by others. It is almost always helpful to
obtain additional information from family, friends, or other
observers to corroborate or expand the patient’s description.
4. Family history. Many neurologic disorders have an underlying
genetic component.
Pertinent Features of History
5. Medical illnesses. Many neurologic diseases occur in the context of
systemic disorders. Diabetes mellitus, hypertension, and abnormalities
of blood lipids predispose to cerebrovascular disease.
6. Drug use and abuse and toxin exposure. It is essential to inquire
about the history of drug use, both prescribed and illicit.
7. Formulating an impression of the patient. Use the opportunity while
taking the history to form an impression of the patient.
The Neurologic Examination
• Mental Status Examination
• Cranial Nerves Examination
• Motor Strength Examination
• Reflexes
• Sensory Examination
• Coordination
• Gait
Mental Status Examination
• The bare minimum: During the interview, look for difficulties with
communication and determine whether the patient has recall and
insight into recent and past events.
• The mental status examination is under way as soon as the physician
begins observing and speaking with the patient
• Mini-Mental State Examination (MMSE) is a standardized screening
examination of cognitive function that is extremely easy to administer
and takes <10 min to complete.
Mini Mental Status Examination
• level of consiousness
• orientation
• speech
• language
• memory
• fund of information
• insight and judgement
• abstract thought
• calculation
Cranial Nerve Examination
• CN I • The bare minimum: Check the
• CN II fundi, visual fields, pupil size and
• CN III, IV, VI reactivity, extraocular
movements, and facial
• CN V movements.
• CN VII
• The CN are best examined in
• CN VIII numerical order, except for
• CN IX, X grouping together CN III, IV, and
• CN XI VI because of their similar
• CN XII function.
Motor Strength
• The bare minimum: Look for muscle • 0 = no movement
atrophy and check extremity tone. • 1 = flicker or trace of contraction but no
associated movement at a joint
• Assess upper extremity strength by
• 2 = movement with gravity eliminated
checking for pronator drift and
strength of wrist or finger extensors. • 3 = movement against gravity but not against
resistance
• Assess lower extremity strength by • 4– = movement against a mild degree of
checking strength of the toe resistance
extensors and having the patient • 4 = movement against moderate resistance
walk normally and on heels and • 4+ = movement against strong resistance
toes. • 5 = full power
Motor Strength
• it is more practical to use the following terms:
• Paralysis = no movement
• Severe weakness = movement with gravity eliminated
• Moderate weakness = movement against gravity but not against
• mild resistance
• Mild weakness = movement against moderate resistance
• Full strength
Reflexes
• The bare minimum: Check the biceps, patellar, and Achilles reflexes.
• Muscle Stretch Reflexes Those that are typically assessed include the
biceps (C5, C6), brachioradialis (C5, C6), triceps (C6, C7), and
sometimes finger flexor (C8, T1) reflexes in the upper limbs and the
patellar or quadriceps (L3, L4) and Achilles (S1, S2) reflexes in the
lower limbs
0 = absent
1 = present but diminished
2 = normoactive
3 = exaggerated
4 = clonus
SensoryExamination
• The bare minimum: Ask whether the patient can feel light touch and
the temperature of a cool object in each distal extremity. Check double
simultaneous stimulation using light touch on the hands. Perform the
Romberg maneuver
The five primary sensory modalities— are tested in each limb
• light touch,
• pain,
• temperature
• vibration
• joint position
Coordination
• The bare minimum: Observe the patient at rest and during
spontaneous movements. Test rapid alternating movements of the
hands and feet and finger to nose.
• Coordination refers to the orchestration and fluidity of movements.
• Even simple acts require cooperation of agonist and antagonist
muscles, maintenance of posture, and complex servomechanisms to
control the rate and range of movements.
• Part of this integration relies on normal function of the cerebellar and
basal ganglia systems. However, coordination also requires intact
muscle strength and kinesthetic and proprioceptive information
Gait
• The bare minimum: Observe the patient while walking normally, on
the heels and toes, and along a straight line.
• Watching the patient walk is the most important part of the
neurologic examination.
• Normal gait requires that multiple systems—including strength,
sensation, and coordination—function in a highly integrated fashion.
Neurologic Diagnosis
• Cerebrum • Brainstem
• Abnormal mental status or • Isolated cranial nerve
cognitive impairment abnormalities (single or multiple)
• Seizures • “Crossed” weaknessand sensory
• Unilateral weakness and sensory abnormalities of head and limbs,
abnormalities including head and e.g., weakness of right face and
limbs left arm and leg
• Visual field abnormalities
• Movement abnormalities (e.g.,
diffuse incoordination,tremor,
chorea)
Neurologic Diagnosis
• Spinal cord
• Back pain or tenderness
• Weakness and sensory abnormalities sparing the head
• Mixed upper and lower motor neuron findings
• Sensory level
• Sphincter dysfunction
• Spinal roots
• Radiating limb pain
• Weakness or sensory abnormalities following root distribution
• Loss of reflexes
 Neurologic Diagnosis
• Peripheral nerve
• Mid or distal limb pain
• Weakness or sensory abnormalities following nerve distribution
• “Stocking or glove” distribution of sensory loss
• Loss of reflexes
• Neuromuscular junction
• Bilateral weakness including face (ptosis, diplopia, dysphagia) and proximal limbs
• Increasing weakness with exertion
• Sparing of sensation
• Muscle
• Bilateral proximal or distal weakness
• Sparing of sensation
Thank you!