Dr Azrung Fayaz

13/09/2025

No investigation can ever replace a clinical examination.

The cranial nerve examination, though, tends to scare a lot of doctors off.

Here's the best demonstration I have seen (from my virtual mentor, Dr Marti Samuels): https://youtu.be/ONRX9yGLXXM?si=1eQffOvzNqWQiGQL

Worth every second!

Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.

12/09/2025

We see a lot of CNS infections in our setup. This video provides a quick, high-yield review of everything (although the demographics vary) we should be aware of as treating clinicians.

Hope you find it useful and use it to help your patients:

What are central nervous system (CNS) infections? CNS infections include meningitis, which is when pathogens infect the meningeal layers; encephalitis, when ...

06/09/2025

Question everything. It can save lives.

I recently saw a child with seizures and delirium.

He had been labeled “CP” by a renowned physician.

That label was never questioned.

Everyone assumed his cognition was always impaired.

The team thought this was the best he could ever be.

But a little history changed everything.

He had normal development until age 4.

Later mobility problems were due to Charcot-Marie-Tooth disease—not CP.

This is a problem.

Too often, once a label is given, it stays forever.
In settings with poor documentation, that label becomes the full story.

Imagine if he had gone home labeled just “CP.”
He would have been denied proper care—because nobody thought to question it.

Studies show diagnostic error is common.

Misdiagnosis rates can be as high as 60–70%.

So please:
Question every label.

Don’t accept it blindly.

That label might define—or limit—a patient’s care.

I have issues with “CP” as a term—it’s often over-used or unclear.

That’s a discussion for another day.

But today, I ask you this:

Be responsible before you label anyone.

Because the label you choose can follow them for life.

02/09/2025

In medical school, we were amazed by consultants.

They would walk into the ward.
Glance at a patient.
Call the diagnosis.

Like magic.

But maybe it wasn’t magic.
Maybe it was the brain’s 2 + 2 system at work.
Quick. Pattern-based. Reflexive.

Not the slower 234 × 457 system.
That one needs time. Effort. Careful thought.

Both systems are useful.
But if you lean only on the fast one, you will miss.

Because intuition alone is like throwing darts in the dark.
Sometimes you hit.
Most times you don’t.

Diagnosis is not one-shot.
It’s a process.

And processes need systems.

In neurology, the proven system I use (regardless of patient complaint) is:

Step 1. Localize.

In other words, where is the problem. The more specific you can get with this the better.

For instance, localizing a headache to the head is not enough. Is it the skull, the meninges, parenchyma or something else entirely?

Step 2. Use VITAMINS.

- Vascular

- Infectious

- Traumatic / Toxic

- Autoimmune

- Metabolic

- Immune mediated

- Neoplastic

- pSychogenic

Basically, you're trying to describe the category of disease your patient's complain fall into.

You may end up with something like this...
Vascular headache localizing to the CSF-Meninges Barrier.

Simple. Reliable. Time-tested.

Once you do this, your tests have direction.
You know what to look for on the CT.
Your yield goes up.
Your patients get better care.

Fast thinking may look genius.
But systems flip the light on.
You can see.
You can aim.
You can help.
You owe it to your patient's to turn the lights on.

Please join this group for more: https://whatsapp.com/channel/0029Vb6rW8M4inoro4ba1o2V

28/08/2025

22/08/2025

I still remember this like yesterday.

I was just starting my Neurology residency.

A 24-year-old young man came to the ward in a wheelchair. Before I could talk to him, his attendant pulled me aside: “Doctor, he’s a drug addict. We use together. He likely overdosed. Please don’t tell his family.”

With that frame in mind, I walked up to the patient. His father added: “He had hernia surgery a few days ago. Since then, headache. He's never had a headache before. Today, he seems confused.”

I asked him to stand up and walk.

He looked off.

But in my head I said: “He’s just intoxicated.”

He pointed to his head. “It hurts.”

And I thought: “Of course, you junkie.”

So I gave painkillers and sent him home.

Next day, same patient.

My heart sank.

This time on a stretcher. On oxygen. Unconscious. He had had many seizures overnight. A subsequent CT showed a brain bleed.

The truth: I had missed a dangerous headache.

Today, I would not make this mistake. Because now I use a system. A simple, repeatable system to make sure serious headaches are not missed. I use this, no matter what bias I have.

Always, begin with the basics:
- Airway
- BP
- Pulse
- Oxygen
- Random Blood Sugar

If anything is off → Alarm bells.

Next, I look for anything suggestive of a secondary (dangerous headache). These include [mnemonic: SNOOP]:
- Systemic features like fever or weight loss
- Neurological deficits like objective weakness or confusion (like my patient)
- Out of nowhere i.e. never had a headache before (like my patient)
- Onset age > 40 years
- Papilledema (it's not practical to check everyone's eyes. So simply ask them if they have any acute vision issues).

This sounds good in theory, but in reality...

Patients don’t speak in mnemonics. They tell stories.

If you try to ask them direct, point-blank questions, the quality of information is very low.

You're not getting a diagnosis with low quality information.

So let them speak.

My opening line when I first encounter a patient is simple: “Ji?”

Then silence. Let them talk.

After that, I dig deeper. Here's how [mnemonic: SOCRAAT]:

- Site: Where does it hurt? (ask them to point with hand). Pro tip: It's never the whole head. Push them to localize exactly where it hurts.

- Onset: Since when? How did it start? (the latter of these is my favorite question)

- Character: What type of pain (stabbing, dull, burning)?

- Radiation into the neck or chest?

- Alleviating factors: What makes it better?

- Aggravating factors: What makes it worse?

- Time course: Getting worse, better, or the same?

The process does not end here.

You must do a quick review of systems for symptoms that the patient may have missed.

Ask about:
- Fever, weight loss?
- Vision change or gritty eyes?
- Oral ulcers?
- Chest pain, palpitations?
- Bowel/bladder issues?
- Joint pains, rashes, stiffness?

By this point, you have all the information you need to determine if this is a secondary headache. If so, you'll already have a very good idea which one it is.

Most dangerous secondary headaches fall in 3 groups:
- Vascular (these are sudden onset and maximal in severity from the start)
- Infectious
- Miscellaneous (Ocular or Neoplastic)

[Mnemonic: MiSS GGTT R]

- Meningoencephalitis
- Stroke (ischemic or hemorrhagic, venous or arterial)
- Subarachnoid hemorrhage
- Glaucoma
- Giant cell arteritis
- Trauma
- Tumor
- RCVS

And no — this does not take long. A good, focused history takes only minutes. And can save a life. I feel that it is worth it.

Ask yourself: are you treating every headache the same? Is painkiller and done your default?

If so, you are doing a disservice to your patients and yourself. You have been blessed with the ability to think and help people. Use it!

With our patient flow, it is not practical to document everything we have asked the patient.

But it hardly takes seconds to write: Probable vascular secondary headache. Urgent CT brain.

So please, don't use time as an excuse. People's lives are in your hands (or should I say mind).

P.S. Digging out information is a skill. You'll get better the more you practice with a repeatable system.

💡 If you find value in structured frameworks like these join my WhatsApp channel where I share neurology cases, clinical pearls, and practical approaches every week.

👉 https://whatsapp.com/channel/0029Vb6rW8M4inoro4ba1o2V

Don’t just read cases. Train your clinical mind.

15/07/2025

Migraine – Know the Truth

1 in 7 people has migraine.
But more than half don’t know it.
They think it’s just a normal headache.

That’s why diagnosis is step one.
You must know what’s really going on.

Migraine has many types.
And each one needs a different plan.
Guessing is not the answer.

The good news?
You don’t need to travel.
You don’t need to wait in lines.
You can get help online.
From your home.

Once migraine is treated the right way…
Sleep gets better.
Mood gets better.
Work gets easier.
Life becomes lighter.

It all starts with answers.
Let’s find them.

Dr Azrung Fayaz
Neurologist