Makindo Medical Notes

Related Subjects: |Neurological History taking |Cortical functions |Motor System |Sensory System |Mental state Examination |Speech and Language Exam |Cranial nerves and examination |Assessing Cognition

🧠 Neurological diagnosis relies ~90% on a good history, supported by examination, imaging, and investigations. Establish a clear timeline and pattern of evolution of symptoms.

🧭 Five-Step Approach

• 📍 Location: Where is the lesion? Use history + neuroanatomy.
• 🧬 Causation: What is it? Think onset speed, periodicity, risk factors, age.
• 📑 Confirmation: Imaging, neurophysiology, genetics – only when it adds value.
• 💬 Explanation: Clear communication with the patient and family.
• 💊 Treatment: Decide if treatable, untreatable, or high-risk (e.g., surgical danger).

⏱️ Symptom Timings & Periodicity

• Seconds–Minutes: Stroke/TIA/SAH (🛑 negative signs), seizures (⚡ positive signs).
• Hours–Days: Inflammatory (MS, ADEM), infections (meningitis, encephalitis).
• Weeks–Months: Tumours 🎗️, MND, CJD, subacute combined degeneration.
• Months–Years: Alzheimer’s, Parkinson’s, slow-growing tumours (e.g. meningioma).

🔄 Patterns

• ⏳ Transient & recurrent: TIA, epilepsy.
• 💥 Sudden worst onset → gradual recovery: Stroke, MS relapse.
• 🌙 Diurnal:
  • Myasthenia → worse as day progresses.
  • Raised ICP → headache worse on waking.
• 📅 Relapsing-remitting: MS.

🧩 Levels of Damage

🧠 Cortical

• Functional disorders (real, not malingering) – need empathy.
• Right cortex → left weakness ± cortical signs: dysphasia, neglect, apraxia.
• Internal capsule → pure motor/sensory deficit, no cortical signs.

⚙️ Subcortical

• Basal ganglia: Parkinsonism, chorea, hemiballismus.
• Thalamus: Sensory integration loss, thalamic pain, amnesia.

🚦 Brainstem

• “Crossed signs” = ipsilateral CN palsy + contralateral motor/sensory deficit.
• Midbrain: CN III/IV, red nucleus, substantia nigra.
• Pons: CN V–VIII, cerebellar connections.
• Medulla: CN IX–XII, corticospinal decussation.

🎯 Cerebellum

• Lateral → ipsilateral limb incoordination.
• Midline/vermis → truncal ataxia.

🦴 Spinal Cord

• Above C5–T1 → quadriplegia.
• Below T1 → paraplegia.
• Syndromes depend on tract involvement (DCML, spinothalamic, corticospinal).

🐎 Cauda Equina

• LMN weakness, saddle anaesthesia, areflexia, loss of anal tone 🚨.
• Emergency MRI & decompression.

⚡ Anterior Horn Cell

• LMN signs: wasting, fasciculations, weakness. Classic in MND.

🌐 Peripheral Nervous System

• Nerve roots: Dermatomal pain/weakness, reflex loss.
• Peripheral nerves: Glove-and-stocking loss (neuropathy).
• Individual nerves: Predictable mixed motor + sensory loss.
• NMJ: Myasthenia gravis → fatigable weakness, ptosis, diplopia.
• Muscle: Weakness, wasting, pseudohypertrophy (e.g., muscular dystrophies).