Approach to a Neurologic Diagnosis Lesion Upper Motor Lower Motor

Lecture by Dr. Jesus Poblete Neuron Neuron

Atrophy (-) (+)
Neurologic Diagnosis Fasciculation (-) (+)
I. History Tone Increased Decreased
- age of onset Weakness Movement Muscles at
- onset & course below level of level of lesion
- other medical ata lesion
- family history Superficial (-) (-)
- social history reflexes
II. Physical & Neurological Exam Deep tendon ↑↑↑ (-)
- mental status reflexes
- cranial nerves Pathological (+) Babinsky (-) Babinsky
- motor reflexes
- cerebellar
- reflexes 4. Cerebellum = incoordination, poor
- sensory equilibrium
- meningeal signs - truncal ataxia – lesion sa vermis (midline)
- gait ataxia
Is there a neurologic problem? - intention tremor
A. Meningeal Irritation (sub-arachnoid space * ipsilateral limb ataxia & incoordination
affected) 5. Reflexes
- if w/ fever = meningitis - reflex asymmetry
- if w/o fever = sub-arachnoid hemorrhage - pathologic reflexes (e.g. Babinsky)
- presents as headache/vomiting with: - level of lesion same as yung nagcocontrol
1. Nuchal rigidity – resistance to passive neck (e.g. ankle jerk = S1, knee jerk = L2-L4,
flexion biceps = C5-C6, triceps C7-C8.. kung
2. (+) Brudzinsky – passive flexion of the absent ang ankle jerk for example, the
neck is accompanied by bending of the lesion is at the level of S1)
knee 6. Somesthetic System = sensory impairment
3. (+) Kernig – pain/resistance to leg in trunk & extremities
extension when the thigh is passively - pain & temperature
flexed - touch, position, and vibration sense
B. Increased ICP 7. Autonomic Nervous System = autonomic
Headache/Vomiting with: disturbances in bowel, bladder, and sex
1. Papilledema – swelling of disc - other complaints: changes in temperature,
- if increase in ICP is acute, vision is color, sweating, BP, heart rate
normal
2. Diplopia w/ internal squint (lateral rectus Extrapyramidal System
palsy 2ndary to abducens nerve lesion)
- squint is in the direction of the strong Basal Ganglia
muscle - caudate nucleus
- can be interpreted as focal neurologic - putamen
deficit at the level of the pons - globus pallidus
- but if it is associated w/ lots of headache - subthalamic nucleus
& vomiting, it’s due to increased ICP = - substancia nigra
false localized sign
3. Deterioration in the level of consciousness Clinical Manifestations
(awake  coma) 1. Increased tone = rigidity
4. Bulging fontanel, separation of sutures, 2. Abnormal involuntary movements = dyskinesias
rapidly enlarging head size - rest tremor
C. Focal Neurologic Deficit - chorea
1. Cerebrum = Disturbance in higher - athetosis
intellectual functions - ballismus
- memory impairment - dystonia
- emotional & behavioral changes (organic)
- language disturbance (usually left side) Where is the neurologic problem?
- seizure (excessive, abnormal firing of - Levelize (e.g. brachial plexus C5-T1 = innervates
cerebral cortex) upper extremities, lumbosacral plexus L1-S2 =
2. Brainstem = Cranial nerve deficis innervates lower extremities.. so kung may
- diplopia weakness sa upper or lower ex, alam mo san
- dysphagia hahanapin)
- dysarthia - Localize
- facial weakness & numbness - Lateralize
3. Motor pathway = Weakness or paralysis of
extremities
Case 1: Case 4:
- Right hemiplegia - Weakness of all 4 extremities, worse over both
- (+) Babinsky – right shoulder and pelvic girdle muscles
- Normal reflexes w/ (-) Babinsky
Lesion Upper Motor Neuron - Normal sensation
Atrophy (-)
Fasciculation (-) Lower motor neuron
Tone Increased - anterior horn cell (spinal cord)
Weakness Movement below level - peripheral nerve
of lesion - neuro-muscular junction
Superficial reflexes (-) - muscle
Deep tendon reflexes ↑↑↑
Pathological reflexes (+) Babinsky Muscle dysfunction
Weakness Proximal, symmetrical
Structures involved: Objective sensory None
1. Cerebrum – disturbance in higher intellectual deficits
functions (memory impairment, emotional & Autonomic disturbances None
behavioral changes, language disturbance, Reflexes Depends on severity of
seizures) weakness
2. Brainstem
a) “Crossed motor/sensory syndrome”
- ipsilateral cranial nerve deficits Disease Category
- contralateral hemiparesis w/ Babinski Group I Group III
b) ipsilateral limb ataxia Congenital/developmental Degenerative
c) intranuclear opthalmoplegia – median Trauma Neoplasm
longitudinal fasciculus syndrome Infection Vascular
3. Spinal cord (cervical) Group II Group IV
Metabolic/Endocrine Demyelinating
Intoxication Immunologic
Case 2: Nutritional deficiency
- Weakness & numbness of both lower extremities *Group II lang yung medical systemic diseases –
- (+) bladder distention functional, not structural defect
- (+) bilateral Babinsky  bilateral UMN
Sensory level – nipple line 1. Congenital/Developmental
- craniostenosis
Structures involved: - spina bifida
1. Cerebrum - ABSENT - neurofibromatosis
2. Brainstem – ABSENT - syringomyelia
3. Spinal cord (Cervical) = (+) sensory level 2. Trauma
- epidural, subdural, sub-arachnoid,
Case 3: intracerebral hemorrhage
- Weakness of both hands & both feet 3. Infection
- Generalized areflexia - meningitis
Lesion Lower Motor Neuron - encephalitis
- brain abscess
Atrophy (+)
4. Metabolic/Endocrine
Fasciculation (+) - hypoglycemia
Tone Decreased - hypoxia
Weakness Muscles at level of - hyponatremia
lesion - uremic & hepatic encephalopathy
Superficial reflexes (-) 5. Intoxication
Deep tendon reflexes (-) - drug overdose
Pathological reflexes (-) Babinsky - chemicals
- poison
6. Nutritional deficiency
Lower motor neuron structures: - Vit. B1, B6, B12 deficiency
- anterior horn cell (spinal cord) 7. Degenerative
- peripheral nerve - Alzheimer’s disease
- neuro-muscular junction - Parkinson’s disease
- muscle - Amyotropic lateral sclerosis
8. Mass
Peripheral nerve dysfunction - Neoplasm (primary or metastatic)
Weakness Distal, symmetrical - Abscess
Objective sensory Distal, symmetrical - Hematoma
deficits - Granuloma
Autonomic disturbances May be present - Cyst
Reflexes Areflexia
9. Vascular Case 6:
- Cerebral infarction or hemorrhage - 5 y/o boy
- Sub-arachnoid hemorrhage - For 3 months  headache & vomiting
10. Demyelinating - For 1 month  frequent falling
- Post-infectious/post-vaccinal - NE = conscious, bilateral papilledema
- Encephalomyelitis
- Multiple sclerosis
11. Immunologic
- Polymyositis
- Dermatomyositis
- Guillian-Barre
- Myesthenia Gravis

 insidious onset of brain dysfunction =

consider mass lesions or degenerative Case 7:
diseases - 50 y/o male physician
 rapid onset (w/in 24 hours) = stroke - Hypertensive 5 years
- On waking up this morning – weakness of RUE &
Types of Lesions RLE, difficulty talking
1. Focal - PE: BP 150/90
- mass lesion (neoplasm, abscess) - NE: alert w/ difficulty talking but can follow orders
- infarction, hematoma w/o difficulty; right hemiparesis (worse in upper
2. Multifocal extremities); right Babinski
- multiple tumors, abscesses
- multiple sclerosis
3. Diffuse
- toxic = metabolic encephalopathy
- peripheral neuropathy
- myopathy

Case 5:
- 40 y/o male
- s/p splenectomy (2003)
- fever, headache, vomiting for 3 days
- PE: febrile
- NE: resistance on passive flexion of the neck

** Always check for mass lesions before performing CSF

exams to prevent cerebellar tonsillar herniation, which is
the quickest way to die