Approach in Neurology

Te & Chin
Contents 1. UMN+LMN SS 2. Tremor 3. Seizure 4. Motor Weakness 5. Spinal cord lesion 6. Intermittent weakness 7. Proximal muscle weakness 8. Peripheral neuropathy 9. Ataxia 10. Bulbar weakness 11. facial diaplegia 12. Wasting hand 13. Fasciculation 14. Chronic meningitis 15. Blindness 16. Isolated pupil involvement 17. Abnormal pupil 18. EOM 19. Ptosis 20. Horners syndrome 21. Diplopia 22. Approach to CN lesion 23. Visual loss 24. Chronic Progressive External Opthalmoplegia (CPEO) 25. Headache 26. White matter diseae 27. Neck drop 28. Stiffness of neck 29. Transient loss of conscious 30. Alteration of conscious 31. Sensory loss + Facial sensation 32. CNS infections 33. Abnormal movement 34. Hiccup 35. Dementia 36. Vertigo / Dizziness

1. Clinical signs of UMN + LMN lesion Spinal Cord Syringomyelia and other intrinsic cord disease MS Motor neuron disease ALS Nerve MMN with conduction block Lead poisoning Muscle disease Myotonic dystrophy Other Thyrotoxicosis 2. Tremor Resting tremor Parkinsonism Action tremor (2) Intention Proximal : Rubra tremor Distal : Cerebellar Postural Wilsons disease Alcohol Drugs Thyrotoxicosis Essential Anxiety 3. Seizure Stereotyped Associated with excessive neuronal discharge Synchonous Mostly Self-limited : not Status epilepticus Recurrent Epilepsy Character Stiff falls Eye open and sustained deviation Tongue bitting !!! Post-ictal period DDX Syncope Non epileptic convulsion : Tetanus Hysterical

Classified Focal (Aura) Intracranial lesion : Cerebral cortex lesion Simple Complex (Temporal lobe) : Automatism DDX Absence seizure Focal to generalized seizure Generalized Idiopathic rarely intracranial causes Convulsive Myoclonic Tonic-clonic Atonic Absence Imaging in only Focal seizure / Focal to secondary generalized seizure Aura / Neurological deficit / Todds paralysis / Age<25 yr. (Late onset epilepsy) Causes Intracranial Extracranial Focal Hyperglycemia Hypercalcemia Generalized Hyponatremia / Hypernatermia Hypocalcemia / Hypomagnesemia HT encephalopathy Rumfit 7-30 hr. GTC without focal features Not > 6 times/day 4. Motor weakness Confirm weakness R/O Hysterical Pattern If isolated muscle group always LMN mostly n. lesion Line approach to peripheral n. If hemiparesis-plegia always UMN Other pattern can be both UMN and LMN lesion

DDX by Tone / DTR / BBK-Clonus-Hoffman Atrophy / Fasciculation

Pattern Monoplegia Hemiplegia

UMN Cortex Hemicord below T Cortex Subcortex Brainstem Hemicord below C Parasagital lesion Spinal cord T level Bilat Cortex-subC Brainstem Spinal cord C level

LMN AHC Plexopathy None !!!

Paraplegia Quadriplegia

Bilateral spinal n root Polyneuropathy NMJ M.

5. Spinal cord lesion Motor weakness + Sensory loss (level) + UMN signs Principle on anatomy based LST from contralateral AST from contralateral PCL from ipsilateral CST from ipsilateral cord-BSt from contralateral subcortex and cortex

Syndrome Hemiparesis Paraparesis

Brown Sequard Below Lower C Intact PL : Anterior 2/3 Impair PL : Complete cord Ataxia Posterior column Localization 2 aspect : transverse / longitudinal Transverse Localization Pattern Syndrome Function loss Paresis Sensation Bowel-Bladder Associated SS EDEM Bone Soft tissue Epidural sac Extramedullary Anterior 2/3 Always M > S Ascending Below lesion (level) Late involvement Back-root pain Spine Abnormality Intramedullary Central cord S > M or M > S Descending Suspended Early involvement SS UMN-LMN Muscle atrophy

IDEM Meningioma Neurofibroma (Neurilemmoma) Arachnoiditis Meningitis

IDIM Syringomyelia Glioma Myelitis Infection Demyelinating-MS CNT : SLE Sarcoid

Longitudinal Localization Motor QP C-level RS failure : phrenic n. C3-5 PP T or L-level HP C-level MP T or L level Sensory Above intact level + 2 Autonomic Horners syndrome C8-T2 Other Pain or Abnormal spine Nystagmus : Cervicomedullary junction Acute Transverse Myelopathy (5) Infection Infarction Systemic disease Demyelinating disease Idiopathic

6. Intermittent weakness Periodic paralysis Familial Associated with thyrotoxicosis Associated with RTA NMJ disease Myasthenia Gravis Eaton-Lambert disease TIA Relapsing-remitting MS Inborn Error of metabolism 7. Proximal muscle weakness Motor neuron disease Peripheral nerve Demyelinating disease NMJ MG (Gold standard treatment : single fiber EMG) MG LAM Proximal m. weakness Distal m. weakness Associated with Thymoma Associated with SCLC / Oat cell Pre synaptic disease Post synaptic disease Decremental response to low F Incremental response to high F Repetitive n. stimulation Repetitive n. stimulation Positive fatigability test Reverse fatigability test Commonly Bulbar involvement Rarely Bulbar involvement Present Enhance ptosis Absent Enhance ptosis Absent autonomic dysfunction Present autonomic dysfunction Improve by Ice pad test Not improve by Ice pad test Steroid / IMM- / Thymectomy Treatment underlying disease Muscle Increase CK Inflammatory Myopathy Muscle membrane : Muscular dystrophy Metabolic disease : Mcardle / (March Mburia) Drugs and toxins Slow turn over rate : Hypothyroidism Rhabdomyolysis Prolong seizure / Trauma / Hyperthermia Drugs Severe Hypokalemia

Inflammatory myopathy Secondary Idiopathic (IIM) DM / PM / IBM Non inflammatory myopathy Hereditary Drugs / Toxins Metabolic K / Ca Glycogen Storage Myopathy Lipid metabolism affecting m. Mitochondrial myopathy Endocrine disorders HypoTH / HyperTH Cushings syndrome Primary hyperaldosteronism Pheochromocytoma Others Central core / Nemaline MG : AntiChE / Anti-musk Single fiber EMG Neostigmine test CXR / CT chest CBC (pure red cell aplasia) Ocular / Generalized Treatment Acute crisis IVIG / Plasmapharesis Chronic Steroid Immunosuppressive : MMF / AZ / CP Mestinon Rehabilitation 8. Peripheral neuropathy LMN sings almost always decrease DTR Sensory loss except Pure motor polyneuropathy Anatomy of nerve Axon Myelin sheath Perineurium / Epineurium CNT : deposit or infiltrative VV. : Vasa nervorum

Classified by pattern Mononeuropathy : Local cause Entrapment (most common) Wallerian degeneration Granulomatous inflammation Tumor Occlusion casa nervorum Bilateral DDX (7) DM Acromegaly Hypothyroidism RA Leprosy Amyloidosis Sarcoidosis Mononeuritis multiplex or Multiple mononeuropathy 2/3 vasculitis : line approach 1 / 2 Vasculopathy DM Paraproteinemia MM / MGUS Waldenstorm macroglobulinemia Mixed Essential Cryoglobulinemia Infection Thrombosis-Thrombophilia Polyneuropathy Always DDX (3) : HIV / DM / Paraneoplastic Demyelinating Asym-Symmetrical Mild muscle atrophy Varies sensory loss Non-length dependent Rapid recovery Proximal > Distal DTR decrease Axonopathy Symmetrical Markedly muscle atrophy Gloves & Stockling pattern Length dependent LE > UE Slow recovery Distal > Proximal DTR absent

Demyelinating disease (3) Acute(4wk.) AIDP (GBS) Motor dominate Always CN involvement Chronic CIDP Associated with systemic disease Osteosclerotic MM / MGUS Waldenstorm / CryoGb Infection : HBV / HCV / HIV DM Idiopathic Axonopathy Pure Motor polyneuropathy (3) Lead poisoning Dapsone MMN with conduction block Bilateral propioception / no weakness (5) HIV Paraneoplastic syndrome (Anti-Hu) B6 deficiency Cisplatin Sjogren Diffuse bilateral symmetrical DM / HIV / Paraneoplastic Drugs and toxin : Alcohol Thyroid disease + Others Autonomic neuropathy Most common DM / Amyloidosis Orthostatic hypotension Anhydrosis Abnormal micturition Erectile dysfunction Decrease GI motility Find out Associated signs and symptom

9. Ataxia (3+Sensation) Cerebrum Normal pressure hydrocephalus Lacunar Ataxic Posterior limb Brainstem esp. pons Cerebellum Congenital and malformation SCA3 / Arnold chiari / Friedreich Infection Trauma Tumor : Primary / Metastasis Degenerative : MS Vascular : Stroke Metabolic : Alcohol / B1 / Wilsons disease Sensation Peripheral nerve Sensory neuropathy Posterior column SY / MS / B12 deficiency Eyes and Ears signaling 10. Bulbar weakness LMN (True bulbar) / UMN (Pseudobulbar palsy) Pseudobulbar palsy Increase Jaw jerk Pathological laughing and crying Bulbar palsy AHC / Motor neuron disease Peripheral nerve NMJ Muscle 11. Facial Diaplegia LMN Motor neuron disease Nerve Bilateral Bells palsy Demyelinating disease : GBS / CIDP NMJ Myasthenia Gravis Muscles FSHMD

12. Wasting hand Cervical Cord Compressive : Spondylosis Syringomyelia Motor neuron disease ALS Peripheral n. Compression : CTS Non compression Polyneuropathy ex. Charcot Marie tooth Muscle disease Disuse atrophy 13. Fasciculation (5) Motor neuron disease ( diffuse atrophy ) Motor neuropathy Hyperthyroidism / Hyperparathyroidism Hypomagnesemia Drugs 14. Chronic Meningitis Idiopathic Infection CNT disease Malignancy Drugs Parameningeal infection 15. Blindness Pupil sparing : Posterior visual pathway Pupil involvement : Anterior Visual pathway Vascular : vasculitis / amourosis fugax Demyelination 16. CN III : Isolated pupil involvement Early uncal herniation Holmes Ades Others + EOM Unilateral Compressive : P.com / Tumor Non compressive : Inf-Infm / WG / Tolosa Bilateral : Ischemic / Demyelinating

17. Abnormal pupil Small Horners syndrome Argyll-Robertson (DM / SY) Large Drugs Adie-Tonic pupil response to 0.1% pilocarpine CN III : local or non vascular diffuse systemic Brain stem : herniation 18. EOM Gaze Horizontal 3 pattern Internuclear opthalmoplegia One and a half syndrome Conjugate eye movement Destructive Dolls eye intact / weakness : Supranuclear ( lesion) Lesion ipsilateral eye deviate Contralateral weakness Dolls eye negative : N-Pons Lesion contralateral eye Irritative Supranulear : lesion contralat eye Nuclear : lesion ipsilateral eye deviate Conclusion Type of lesion Location Side Eye deviate Destructive SupraT Rt. FEF Right InfraT Rt. BSt Left Irritative SupraT Rt. FEF Left InfraT Rt. BSt Right Conclusion MLF Ipsilateral MR palsy (INO) Pons PPRF + MLF (One and a half) Ipsilaral with one Vertical Dolls head correctable : Supranulear PSP Dolls head incorrectable : N-MB Non Gaze : LMN approach N. / NMJ / M.

19. Ptosis Complete CN III line approach CN Incomplete Unilateral Sm m. : Congenital / Horners syndrome Sk. m. : CN III lesion Bilateral Nerve GBS / CIDP NMJ MG M OPMD 20. Horners syndrome Ptosis / Anhydrosis / Meiosis / Endopthalmos Normal PLR and accommodation Central (4) (Face and Trunk) Hemispheric : Surgery / Massive infarction Hypothalamus Brainstem : Wallenburg / MS / Glioma Cervical cord C8-T2 : tumor / syringomyelia Peripheral (Face only) face (C8-T2 sympathetic ganglion) Pulmonary Apex T1 root : Pancoast tumor Mediastinum Symp chain neck Sx thyroid / Head& neck cancer Common carotid artery forehead Internal carotid + Superior cervical ganglion Base of skull Carvernous sinus 21. Diplopia Unocular Eye disease Binocular EOM CN III unilateral / complete ptosis NMJ MG / LAM / Botulism M. Congenital : OPMD / Myotonic D Acquired not involve EOM except TH+ 22. Approach to CN lesion CN function loss Intra-axial / Extra-axial (Long tract signs)

Intra-axial : Locate lesion + Nature Ipsilateral : Contralateral above BSt of CN Alternating : Ipsilateral BSt that CN impair Extra-axial Unilateral CN lesion Local disease Subarachnoid space-Meninges Base of skull Sphenoid sinusitis Foramen and Carvernous sinus Diffuse systemic Vascular : Artherosclerosis / Vasculitis Demyelinating disease (CN II) Increase ICP (CN VI) Parenchyma Local : Space occupying lesion Mass /Abscess / Hematoma Diffuse : Brain edema CSF : Hypdrocephalus / Meningitis Communicating Non-communicating Venous : CVST Pseudotumor cerebri Infiltrative : CA / Amyloid / Sarcoid Idiopathic cranial neuritis Bilateral NMJ M. N. Symmetrical : Diffuse Systemic > Local Asymmetrical : Local > Diffuse systemic Principle of CN III Vascular cause Spare pupil Compression Pupil impair Spare pupil Vascular cause Pupil impair R/O Vascular cause Both local / diffuse systemic Both compressive and non Non compression Pupil spare or impair

Branch of CNIII Superior branch : levator palpabrae / SR ptosis + upward gaze palsy Inferior branch : MR / IR / IO / Parasym / Pupil Foramen III / IV / VI / V1 Superior orbital fissure + V2 Carvernous sinus + II Orbital apex syndrome V2 rotundum / V3 ovale / VII-VIII intl acoustic canal IX-X-XI Jugular foramen / XII Hypoglossal canal 23. Visual loss Transient Emboli / Amourosis Fugax-TIA Hypoperfusion Vasospasm Migraine / Epilepsy Obscuration HT encephalopathy Permanent Pupil intact : Post chiasmatic lesion VF intact : Cortical blindness VF impair : VF pathway Pupil impairment : Prechiasmatic lesion Anterior Posterior : Retinal / V. / N. 24. Chronic Progressive External Opthalmoplegia (CPEO) R/O Thyroid disease / MG Congenital Opthalmoplegia Muscular Dystrophy Mitochondrial myopathy Nuclear opthalmoplegia with bifacial weakness (Mobius) 25. Headache Functional / Organic Acute / Sudden Nocturnal / Awakening Onset in elderly Neurological deficit SS of systemic disease

Primary or functional Migraine Tension Cluster IHS Secondary Neurological deficit : Line approach Locate lesion and identify nature of disease Without neurological deficit (7) SAH CVST Increase ICP Pseudotumor cerebri Chronic meningitis Paracranial : infection / inflammation / tumor Brain tumor in silent area 26. White matter disease Demyelinating disease of CNS Multiple sclerosis ADEM PML Reversible posterior leukoencephalopathy (RPLE) 27. Neck drop : MG / DM-PM / ALS 28. Stiffness of neck Meningitis SAH Cervical spondylosis Posterior fossa mass 29. Transient loss of conscious Epilepsy / Syncope / TIA of Brainstem !!! SAH (Bloody CSF DDX Herpes encephalitis / Trauma) Rupture intracranial aneurysm or AVM Dissecting artherosclerosis Gnathostomiasis Bleeding disorders Hypoglycemia Acute increase ICP : CVST / Pituitary apoplexy with transient bilateral blindness (obscuration)

30. Alteration of conscious Disturbance of RAS system (3) Brainstem Diencephalon : Thalamus / Hypothalamus Bilateral Cerebral cortex GCS / Motor / DTR Eyes : Pupil / EOM-Gaze / Eye ground Always R/O Status epilepticus Disease Abnormal neuro signs Intracranial Normal neuro signs / Symmetrical Flapping Extracranial Encephalopathy Hypoglycemia / HHS Electrolyte Hyponatremia / Hypernatremia Hypercalcemia HT encephalopathy Adrenal crisis Thyroid storm / Myxedema coma Drugs and toxins Heat stroke / Hyperthermia Wernicke encephalopathy Septic encephalopathy (Flapping tremor + mostly 4 ) Uremia encephalopathy Hepatic encephalopathy Hypoxic encephalopathy Hypercapnic encephalopathy + Intracranial (4) Encephalitis CVST Epidural / Subdural hematoma SAH 31. Sensory loss Non distribution Hysterical Distribution of n. Mononeuropathy mostly entrapment Mononeuritis multiplex 2/3 vasculits Gloves & Stocking Polyneupathy (line approach polyneuropathy)

Suspended sensory loss / Dissociative sensory loss Central cord syndrome Paraparesthesia level on dermatome Spinal cord lesion Monoanesthesia with contralateral weakness Brownsequard syndrome Alternating hemianeathesia or Hemianesthesia alternans Braintem lesion Lower pons Medulla Walenberg (Lateral medullary syndrome) Total Hemianesthesia Thalamus : thalamic pain Fiber from Thalamus to Parietal lobe Postr limb of IC (Anterior Choroidal a.) Facial Sensation Hair line and angle of mandible C2-C3 Total loss Motor involvement Anterior to GG Motor intact GG / Senssory root Distribution along division V1 / V2 / V3 Dissociative sensory loss Pontine region Preserve touch Spinal N of CNV Perioral numbness Pons Onion skin pattern Lateral Medullary 32. CNS infection Meningitis Acute Subacute +TB / Crypto / SY Chronic Parasite can present with all onset Systemic infection not run chronic TB / Crypto / SY rarely Acute Lab clues PMN predominate > 50% G/S : Bacteria + Clues Fresh smear : Protozoa

Bacteria / Virus / Protozoa + Systemic infection

Lymphocyte predominate > 50% Sugar normal (Aseptic meningitis) SY / Systemic infection / Virus Parameningeal infection Sepsis / Brain abscess Sugar < 40-50% PG TB / Crypto Eosinophil predominate > 10% Syndrome that consists of Eo > 10% in CSF No fever Hemodynamic stable CSF sugar > 405 PG Mostly parasitic infection A. cantonensis Headache / Eating G. spinigerum MultiICH-SAH Root pain / Myelitis Cysticercosis Parenchyma Ventricular Subarachnoid etc. Meningoencephalitis Always R/O Cerebral malaria Bacteria Virus 2 pathoonomonic clues Herpes Temporal lobe JE Bithalamic hemorrhage Systemic infection not coma Brain abscess Rim enhancement with peri-lesional edema Abscess + Clues HIV 1st DDX Toxoplasmosis Steroid 1st DDX Norcadiosis Well-being Cysticercosis Granuloma Malignancy Nodular enhancement with peri-lesional edema Granuloma TB / Fungus / Toxo / Cysticerc / Norcad Malignancy

33. Abnormal Movement Hypokinetic / Hyperkinetic Hypokinetic Parkinsonism Resting tremor Cog wheel rigidity Bradykinesia !!! Loss of postural reflex (Postural instability) Flexed posture / Freezing / Increase m. tone Others : dystonia / catatonia / psychomotor depress Hyperkinetic Rhythmic Tremor : sinusoidal movement Seizure Dysrhythmic Sustained : dystonia (m. contraction resulting in abnormal posture) Intermittent / Non sustained Voluntary suppress : Tics Briefly jerky movement + Premonitory urge Involuntary Stereotyped : Myoclonus Intermittent brief jerky Distal predominate Exaggerated startle Unidirection Random / Non stereotype Proximal : Ballism Large amplitude Distal : chorea-athetosis Low amplitude 34. Hiccup Mechanism Unintentional contraction of diaphragm Spasm of inspiratory muscles abruptly terminated by glottis closure Approach Recurrent & Intractable hiccup work up o Self-limted hiccup is no need to be Ix

 Most common = laughter, gastric distension w/ rapid eating/drinking, smk, emotional stress, alc, spicy food Cause of hiccup Excitation of phrenic reflex arc o Neck Tumor pharyngitis o Mediastinum Mediastinal mass/LN Thoracic aortic aneurysm o Distal esophagus & diaphragm GERD Diaphragm abscess Suppression of higher center o Central lesion Supratentorial lesion Vascular = CVA Tumor Infection = encephalitis Demyelin = MS Other: sarcoidosis Infratentorial = Brain stem & meninges Tu/ Infarction Basilar meningitis o Metabolic abnormalities Uremia hypocapnia hypoNa HypoK HyperGlycemia HypoCa Drugs Alcohol BZD Dexamethasone Methyldopa General anesthesia Barbiturate

Diaphragm pathology o Above diaphragm Lung & pleura Basal lung pneumonia Pericardium = pericarditis Distal esophagus = CA o Diaphragm Trauma: Surgery esp upper abd Hiatal hernia o Below diaphragm Liver Liver mass/ metastasis Spleen Splenic infarction o AF o Endocarditis o Sickle cell anemia Other Subdiaphragmatic abscess

35. Dementia acquired deterioration in cognitive abilities that impairs the successful performance of activities of daily living Cognitive ability o Memory most common loss o Language o Emotion o Executive fn o Visuospatial skill o Attention o Calculation o Judgement o Problem solving Neuropsychiatric & social deficit Dementia syndrome o Depression o Withdrawal o Hallucinations o Delusions o Agitation o Insomnia o Disinhibition Functional anatomy Cortex AD entorhinal cortex hippocampus post temporal & parietal neocortex diffuse degeneration Multi-infarct dementia random Dorsolat prefrontal cortex connect w/ caudate, Globus pallidus, thalamus poor organization/ planning, cognitive flexibility, judgement Lat orbital cortex irritability, impulsiveness, and distractibility Ant cingulated cortex apathy and poverty of speech or even akinetic mutism Subcortex o Diffuse white matter disrupt intracerebral connections dementia synd Leukodystrophies o MS o Binswangers dz FTD PD MSA

CBD Presentation of dementia syndrome AD = Memory loss assoc w/ aphasia & language Frontal cortex FTD Huntingtons dz = attention, judgement, awareness, behav problem Causes of dementia Reversible o Depression o Hydrocephalus (NPH) Neuroimaging o Alcohol dependence o Hypothyroidism TFT o Thiamine deficiency enz assay o Vit B12 def B12 level, CBC o Subdural hematoma Neuroimaging o Chr infection VDRL, HIV, CSF o Brain Tu Neuroimaging, Brain Bx o Drug intoxication Irreversible o AD o FTD o Huntingtons dz o DLB o Vascular o Leukoencephalopathies o PD Severity Benign forgetfulness of the elderly not so progressive, not impair daily fn Mild cognitive impairment (MCI) interfere daily activities Frank dementia o conversion rate from MCI to AD is ~12% per year History Onset, duration, progression o Ac or Subac Ddx Delirium Intox, Infection, Metabolic Rapid progress + rigidity + myoclonus CJD o Chr: AD

Step wise progression Multi-infarct dementia Behav change FTD Early presence of visual halluc, Parkinsonism, Delirium, REM sleep disorder DLB Gait disturbance o Multi-infarct dementia o PD o NPH Recent head trauma o Chr SDH o Dementia pugilistica o NPH Alcoholism o Malnutrition o Thiamine def o Alcohol GI Sx B12 def Environmental battery or chemical industry Heavy metal intox Medication: Sedatives, tranquilizers FH: Familial AD, FTD, Prion disease Very psychotraumatic event depression w/ pseudodementia Physical examination Neuro exam o Other sign of NS involvement o AD does not affect motor systems until later in the course o FTD patients often develop axial rigidity, supranuclear gaze palsy, or features of amyotrophic lateral sclerosis o In DLB, initial symptoms may be the new onset of a parkinsonian syndrome (resting tremor, cogwheel rigidity, bradykinesia, festinating gait) with the dementia following later, or vice versa o CBD dystonia, alien hand, and asymmetric extrapyramidal, pyramidal, or sensory deficits or myoclonus o PSP unexplained falls, axial rigidity, dysphagia, and vertical gaze deficits o CJD is suggested by the presence of diffuse rigidity, an akinetic state, and myoclonus o Hemiparesis or other focal neurologic deficits Multi-infarct dementia Brain Tu o Myelopathy or Neuropathy B12

o Peripheral neuropathy B1, B12, Heavy metal Other system o Thyroid status o Other Dementia with parkinsonism DDx o PD motor 10 yr o DLB o PSP o CBD: asymmetrical involuntary movement (Alien hand) o MSA: orthostatic hypotension, Fall o Clue Non-PD Fall Poor resp to Levo-Dopa Motor sign Progress No tremor ANS dysfn or orthostatic hypotension Approach o Dx Dementia Physiologic memory loss , DDx 3D+1M Decline of memory in normal age Depression Delirium Mild cognitive impairment (MCI) o Treatable causes & Treat D rug: sedative, TCA, Anti-psycho, Mood stabilizer, Anti-PD, Narcotic, Antihistamine, GC E motion: depression M etabolic: B12, Folate, Wilson, Endocrine thyroid, PTH, insulinomas, pitu Tu E ye & Ears N utrition, NPH T umor, Trauma I nfecion: Sy, Chr meningitis A rtherosclerosis o Dementia syndrome o Ix Hx/PE

 Brief cognitive test MMSE

sense

MoCA CDT (clock drawing test) Mini-Cog 5min o = dementia o 3 = Normal o 1-2 = CDT =normal = dementia Lab: CBC, BUN, Cr, LFT, TFT, B12 level routine indicatiton Neuropsychological test CT/MRI detect hematoma, NPH Functional imaging: PET/ SPECT Indication for CT o Age <60 yr o Rapid progressive in 2yr o Hx head trauma o Neuro def o CA o On anticoagulant o Gait disturbance Management o ABC o ADL o BPSD: Behav & Psychological symptom of diarrhea Drug & Non-drug ( ) Aggressive behave Hadol 0.5mg o Cognitive Mild to Mod AD: AChEI Donepezil, Rivastigmine, Galantamine Side eff = N/V Mod to Severe: Memantine

36. Vertigo / Dizziness = an illusory or hallucinatory sense of movement of the body or environment, most often a feeling of spinning o Disturbance of Vestibular system o Other 2 sensory system maintain posture Visual system (retina to occipital cortex) Somatosensory system (skin, jt, muscle) Dizziness o Faintness o Vertigo Physiologic vertigo Seasickness Unusual head/neck position: painting a ceiling Spin Space sickness Pathologic vertigo Labyrinthine dysfn Acute unilat: infection, Trauma, ischemia (VBI) o VBI & no tinnitus Acute bilat: Drugs (Aminogly) or Alcohol Recurrent unilat: cochlear disease o Mnire's disease ( SNHL + tinnitus) o Vestibular neuronitis o TIA of VB system (rare) Positional vertigo: o Periperal common:BPPV o Central rare: lesion at 4th ventricle Perilymphatic fistula episodic vertigo precipitated by Valsava or exertion o Other Episodic vertigo = migraine aura, Vestibular Epilepsy Vertigo of vestibular nerve origin Involve nerve at petrous bone or CP angle Less severe & less paroxysmal vertigo Hearing usually affected

labyrinthine

Most common = Schwannoma central compensation less vertigo Auditory symptom Central vertigo Brainstem or Cerebellum Acute lesion

Labyrinthopathy

Approach Dizziness Presyncope vertigo o Provocative test o The simplest provocative test for vestibular dysfunction is rapid rotation and abrupt cessation of movement in a swivel chair vertigo o Positional vertigo Test Hallpike maneuver o Central vertigo Neuroimaging pay attention at CP angle Cerebellum Brainstem o Peripheral vertigo VBI (spare hearing) drug & alcohol TIA, migraine, epilepsy ENT