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Neurology. Dr Chris Derry Consultant Neurologist Department of Clinical Neurosciences WGH, Edinburgh. Outline. What is neurology? What is a neurologist? Elements of neurological diagnosis History Examination Demonstration Signs/ videos Laboratory tests Final diagnosis.
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Neurology Dr Chris Derry Consultant Neurologist Department of Clinical Neurosciences WGH, Edinburgh
Outline • What is neurology? • What is a neurologist? • Elements of neurological diagnosis • History • Examination • Demonstration • Signs/ videos • Laboratory tests • Final diagnosis
What is Neurology? • The medical specialty concerned with the diagnosis, investigation and management of disorders of the nervous system. • Clinical neurosciences vs basic neurosciences • Nervous system • Central Nervous System (CNS) • Peripheral Nervous System (PNS) • Autonomic nervous system (ANS)
What does a neurologist do? • Diagnostics of nervous system disease • Traditional role • Management of acute neurological conditions • Status epilepticus, encephalitis, acute stroke etc • Management of chronic neurological diseases • Epilepsy, parkinsons disease, multiple sclerosis • Research
Other nervous system specialists… • Neurosurgeon • Surgical treatment of neurological disease. Open and stereotactic procedures • Neuroradiologist • Neuroimaging. Interventional neuroradiology • Neurophysiologist • EEG, NCV/EMG, evoked potentials • Neuropathologist • Biopsy analysis, autopsy • Psychiatrist • Mental illness
Why are patients referred to aNeurologist? • GP • Neurological symptoms worrying patient/ doctor • headache/ numbness/ weakness • Other specialists • Neurological complications of other diseases • Confusing clinical pictures • Many tests not definitive • Some invasive/expensive
Example… • 32 year old female. • Background of migraine • Persistent daily headache for 1/12 • Worsening headache, presented to A&E • Admitted, MRI Does she have MS?
Making a neurological diagnosis • Where is the problem? • CNS (brain/ spinal cord) • Nerves • Muscle • What is the nature of the problem? • ‘vascular’ • ‘inflammatory’ • ‘infection’ • ‘neoplastic’ etc.. 3. What is the definitive diagnosis?
How are those stages reached? • History • 80% of diagnostic information • Particularly useful for localisation and mechanism • Examination • Can confirm localisation • Investigations • Can help with pathological/ definitive diagnosis
The neurological history • Presenting complaint • Headache, blackouts, dizziness, weakness, sensory symptoms, memory difficulties etc etc etc • Evolution of symptoms • Acute, subacute, chronic • Episodic, persistent • Systematic review • Additional neurological symptoms. ?Focal, multifocal or systemic disorder
The neurological history • Previous medical history • Earlier neurological symptoms, including symptoms seemingly unconnected • Family history • Many neurological disorders have a genetic basis • Social history • Consequences for job, family, driving, hobbies, sport, recreation • Smoking, alcohol • Drug history
Neurological examination • After the history, you usually have a fair idea of: • Where the lesion is • Type of lesion • And you may also know the final diagnosis… • Examination serves several purposes • Confirm localisation/ hypothesis testing • e.g Spinal cord vs peripheral nerve • Screening for unsuspected abnormalities • Closely observe patient behaviours • Reassure patient • Think!
Neurological examination • Cognition (Addenbrooke’s Cognitive Examination) • Cranial nerves • Limbs • Inspection (wasting etc) • Tone • Power • Co-ordination • Reflexes • Sensation • Romberg’s/ Unterberger’s/ Hallpike’s • Gait
1. Cranial nerves • ‘Head’ functions (including special senses) • Smell • Sight • Facial sensation • Facial movements • Taste • Hearing • Tongue movements • Swallowing
UPPER LOWER EXTREMITIES Neck movement and strength Motor function Muscle bulk Tone Power Reflexes Co-ordination Sensory examination AXIAL EXAMINATION Shoulder girdle muscles Curvature Rise from supine Abdominal reflexes Unterberger’s Romberg’s Hallpike’s Limb Examination
Some “Spot” diagnoses • Parkinson’s Disease • Huntingdon’s Chorea
Magnetic Resonance (MR) imaging • Similar looking machinery to CT • No radiation source • Works via powerful magnets • Very high definition of anatomy • eg white matter v grey • Better than CT for detecting most brain pathology, particularly small/subtle abnormalities
Case • 32 year old female. • Background of migraine • Persistent daily headache for 1/12 • Worsening headache, presented to A&E • Admitted, MRI Does she have MS?
Assessment • Full history • Remote neurological episodes (even minor) • Family history • Examination findings suggestive of previous neurological events • Consider investigations • repeating MRI • lumbar puncture • Uncertainty may persist…