out-patient management in neurology อ. ลักษนันท์...

Out-patient Management in Neurology

อ.ลั�กษนั�นัท์� ชี�วะเกรี�ยงไกรีแผนักปรีะสาท์ว�ท์ยา กองอาย�รีกรีรีม

โรีงพยาบาลัพรีะมงก�ฎเกลั�า

Common consultation• Headache

• Numbness

• Weakness

• Seizures

• Dizziness, vertigo

• Ataxia

• Ptosis

• Diplopia

• Visual failure

• Memory impairment

• Confusion

• Dysphagia

• Tremor, abnormal movement

Concepts of Neurology

• History: – CC, PI, PH– Onset, chronological progression– Underlying, associated symptoms– Systemic review

• Physical examination: – General medical examination– Neurological examination

Concepts of Neurology

•Anatomical localization– Where is(are) the lesion(s)?

•Etiology– What is(are) the etiology?

Concepts of Neurology

Concepts of Neurology

Concepts of Neurology

Concepts of Neurology

Concepts of Neurology

Overview in Common Symptoms in Neurology

For OPD practice

Headache

• Anatomical localization– Intracranial– Extracranial

• Etiology– Primary headache– Secondary headache

SNOOP

Numbness

• Anatomical localization– CNS– PNS

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Weakness

• Anatomical localization– Upper motor neuron lesion– Lower motor neuron lesion

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Seizures

• Anatomical localization– Cortical lesion– Subcortical lesion– Focal/ multifocal/diffuse (generalized)

• Etiology: provoked or unprovoked seizure– Genetics – Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Dizziness, vertigo

• Anatomical localization– Central vertigo– Peripheral vertigo

• Etiology– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Ataxia

• Anatomical localization– Cerebellar ataxia– Sensory ataxia

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Ptosis

• Anatomical localization– 3rd nerve nuclei or true nerve– NMJ– Muscle

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Diplopia

• Anatomical localization– 3rd, 4th, 6th, cranial nuclei or nerve– NMJ, muscles

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Visual failure

• Anatomical localization– Anterior visual pathway– Posterior visual pathway

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Memory impairment

• Anatomical localization– Libic areas

• Etiology– Primary dementia

• Alzheimer’s disease

– Secondary dementia (treatable dementia)

Confusion

• Anatomical localization– Intracranial cause– Extracranial cause (delirium)

• Etiology– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Dysphagia

• Anatomical localization– Balbar palsy– Pseudobulbar palsy

• Etiology– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Tremor, abnormal movement

• Anatomical localization– Extrapyramidal pathway

• Parkinson or non-Parkinson

• Etiology:– Congenital (inherited)– Trauma– Tumor, infection– Toxic, metabolic, endocrine– Inflammatory– Vascular – Degeneration – etc.

Work up

• Lab:– General medicine

• CBC, UA, blood chemistry, septic work up, EKG

• Radiology

• Genetic testing

• Pathology

• Consultation

Neurological tests• Lumbar puncture

• Prostigmine test

• V-EEG: routine, long-term

• Polysomnography

• Carotid Doppler

• EMG, NCV

• Etc.

Imaging

• CT brain

• MRI brain, MRA, MRV

• Angiogram +/- intervention

Management

• Pharmacologic

• Non-pharmacologic

• Counselling

• OPD

• ER, observe

• Admission

Follow up plans

• Depending on diagnosis, underlying disease, severity of illnesses

Thank You