Neuropsychiatry Module 20102011

History and Topical

Diagnosis in Neurology
Dr Jofizal Jannis Sp.S(K)
Dr. Darma Imran SpS
Department of Neurology
Faculty of Medicine University of
Indonesia

Learning objectives
The importance of history
taking in neurology
Topical diagnosis in nervous
system
Clinical method
Clinical Case

Introduction
We enter medicine for many different
reasons but two most frequently reasons :
we love humanity and science.
Patients and family want a doctor with :
A doctor who is caring and who will understand
the patients problems and who will listen, advise
and support both the patients and their families.

Our job is not simply about making a

diagnosis, it is about helping and caring for
patients with their medical problems.

History
History taking is usually your first
contact with the patient
It is establishes the foundation for
your future relationship with the
patient and their family.
It is a time when you begin to build :
trust, confidence and authority.

History taking requires :

1.
2.
3.
4.
5.
6.

time,
skill,
concentration
experience
tact and diplomacy
patience.

your only lack is only on point 4

Coma
Coma history (from relatives or attendants)
Onset of coma (abrupt, gradual)
Recent complaints (headache, focal weakness,
vertigo etc)
Recent injury
Previous medical illnesses (e.g., diabetes,
renal failure, heart disease)
Previous psychiatric history
Access to drugs (sedatives, psychotropic
drugs)

The onset of coma

Sudden onset :
In a previously healthy, young patient : drug
poisoning, subarachnoid hemorrhage, or head
trauma
In the elderly : cerebral hemorrhage or infarction.

Gradual onset :
A history of premonitory signs, including focal
weakness such as dragging of the leg or complaints
of unilateral sensory symptoms or diplopia,
suggests a cerebral or brainstem mass lesion.
Most patients with metabolic disorders

Case 1
A 50 year old man with a sudden lost
of counsciouness while in the
meeting at his office
Physical examination :
Blood pressure 200/110 mmHg
GCS E1M4V1=6
Pin point pupil

Where is the possible lesion

Brain lesion : pons

Changes in pupils in patients with lesions at

different levels of the brain that cause coma

Case 2
Sheet B1

A 40 year old
man with left
lower limb and
upper limb
weakness :

Where is the
possible
lesion

Case 3
Sheet B1

A 30 year old
man, compos
mentis but had
an all-four limb
weakness :

Where is
the lesion ?

Case 4
A 73-year-old woman had a 4-days history of fever,
nausea, and vomiting.
she awoke on the third day and found it difficult to walk to
the bathroom, by the afternoon she had difficulty in
swallowing

Physical examination :

Vital sign normal, E3M6V5.

Pupils were equal and constricted from 3 to 2 mm with light,
Diplopia when try to look to the left side
left-sided facial numbness
left lower motor neuron facial weakness.
the tongue deviated to the right
the left limbs were clumsy comparing to her right side

Case 4 : question
1. Did the patients had a neurological
problem ?
mention her deficits

2. Where is the lesion (anatomical

diagnosis)

Case 4 : answer
Left abducens palsy (N. VI)
Left facial palsy (N. VII)
Left trigeminal (sensory) nerve deficit
(N.V)
Left hypoglossal palsy (N XII)
..

Where is the lesion ?

Case 4 : answer

Look at
your C1
sheet

Peter
Duus.2005
page65

Case 4 : question
Is it possible to have brain stem
lesion and at the same time retain
relatively good consciousness ?

Case 4 : answer
Look at your A1 and A2 sheet

Plum 2007
page29-30

Case 5
History

A 28 year-old man was riding a motor cycles, when suddenly

he crash to another motor cycle approaching from the side.
Luckily After the accident he is alert, with out a significant
injury.
Further inquiry from the doctor , revealed that in the past 6
several times he bumped into something in his side while
walking.
He also complaint that he can not get an erection since 3
month ago.
Physical examination :
Vital sign normal
Visual acuity normal
Confrontation visual field testing : peripheral visual field lost on both
side

What is his problem ? Eye problem

or Neurological problem ? Or both ?

Case 5 : answer

Peter
Duus.2005
page 131

Case 5 : answer
What are the possible pathology
underlying this case ?

Clinical method
Through case 1 - 5 we already
exercise clinical method to
understand patients problem

Clinical method
This is an orderly series of steps,
as follows:
1.
2.
3.
4.

Symptoms and signs

Anatomic diagnosis
Pathologic and etiologic diagnosis
Prognosis and treatment

Symptoms and signs

The fundamental steps in diagnosis
always involve the accurate
elicitation of symptoms and signs
and their correct interpretation in
terms of disordered function of the
nervous system.
Most often when the diagnosis is wrong, it will
be found later that the symptoms were
incorrectly interpreted in the first place.

Symptoms and signs

History and physical examination.
symptoms and physical signs considered
relevant to the problem at hand are
interpreted in terms of physiology and
anatomy :
identifies the disorder(s) of function
pathophysiology -pathogenesis
the anatomic structure(s) that are
implicated.

Conclusion
Neurology is not a difficult subject,
enjoy taking care of your patients
sign and symptoms and give a
solution to their problem.

Thank you
Dr Jofizal Jannis Sp.S(K)
Dr. Darma Imran SpS
Dep of Neurology Faculty of
Medicine University of Indonesia
correspondence
darma_imran@yahoo.com

Hemiparesis
Phys reflexes
Patho reflexes
Cranial nerve palsy
Cortical brain fc dist

Radiks

Monoparesis
Phys reflexes
No path reflexes
Sensory ~ dermatome segment

Neuromuscular junction
Muscle

Quadry/paraparesis
Phys reflexes
Path reflexes
Sensory level
Autonom disturb

Proxymal > distal

Gower sign
Duck gait
No sensory disturbances

Paralysis asendens
Symmetry
KPR -/-

GBS

Fluctuate, recurrent
Activity influences
Palpebra, dysphagidisphonia
Miastenia Gravis