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Neuro History References

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Neuro History References

  1. 1. NEUROLOGIC HISTORY APPROACH TO THE NEUROLOGIC PATIENT PHYSICAL DIAGNOSIS ICP-II John G. Quinlan, M.D. VOCABULARY A. Anesthesia: Absence of sensation. B. Coma: Depressed consciousness to the degree of unresponsiveness to noxious stimuli. C. Diplopia: Seeing two images where only one exists. D. Vertigo: A hallucination of movement. TOPICS/FOLLOWING PAGES A. General approach to the neurologic patient. B. Introductory comments vis-à-vis the neurologic history. C. An outline for lecture. 1
  2. 2. APPROACH TO THE NEUROLOGIC PATIENT A physician evaluating a patient with a potential neurologic problem must try to answer three questions: 1. Is there a neurologic problem? 2. If so, where is the lesion in the nervous system? 3. What is the underlying pathophysiology? 1. IS THERE A NEUROLOGIC PROBLEM? The initial and often most difficult part of the diagnostic process is to determine if the presenting symptoms are due to a neurological disorder or non-neurologic disease. The neurologic history is the most significant factor in making this determination. For instance, fatigue is a common presenting complaint that may be attributed by the patient or physician to dysfunction of the nervous system. However, fatigue without any other neurologic complaints or findings is rarely due to an identifiable neurologic disease. This first question is particularly difficult since some patients with documented neurologic disease may also have functional (non-neurologic) complaints. Pseudoseizures, for example, most commonly occur in patients with documented seizures. A good rule of thumb is always to give the patient the benefit of the doubt when deciding between functional and neurologic disease. 2. WHERE IS THE LESION? This question is actually composed of several questions: • Is the neurologic problem in the central or peripheral nervous system? • If central, does it involve the cerebral hemispheres, the posterior fossa structures (brainstem or cerebellum), or the spinal cord? • Is the problem focal, multifocal, or diffuse? • If monofocal, is it on the left, right, or middle? 2
  3. 3. 3. WHAT IS THE UNDERLYING PATHOPHYSIOLOGY? This is the most difficult of the three questions. However, if one knows the time course of the neurologic problem and can answer the second question, “Where is the lesion?” the differential diagnosis can be narrowed considerably. Time course can be divided into three categories: • Acute = onset and evolution over minutes to hours • Subacute = onset and evolution over days • Chronic = onset and evolution over months In addition, one can characterize a disease as transient, progressive, or stable. Neurologic diseases that are focal and sudden in onset include stroke and trauma. Neurologic diseases that are diffuse and sudden include toxic-metabolic diseases (e.g. hypoglycemia), global cerebral ischemia (cardiac arrest), and subarachnoid hemorrhage. Inflammatory and infectious diseases of the nervous system have a subacute time course. Two classic focal and subacute neurologic diseases are brain abscess and multiple sclerosis. The classic diffuse and subacute neurologic diseases are meningitis and encephalitis. Toxic and metabolic diseases can also have a diffuse and subacute presentation. The classic focal and chronic neurologic lesion is a neoplasm, or something that acts as an enlarging mass, such as a subdural hematoma. Finally, chronic and diffuse deterioration usually represents a degenerative disease such as Alzheimer’s Disease. THE NEUROLOGIC HISTORY The neurologic history is the critical part of the neurologic evaluation. It is here where most of the answers to the three main questions lie. The physician should focus on the chief complaint and try to reconstruct a “videotape of the mind” concerning the sequence of events. The time course of events is critical in deciding the possible cause. Less precise words like dizziness and numbness need to be clarified with other descriptors. If the patient has recurrent transient events or spells, one should ask the patient to describe in detail, from start to finish, a typical spell. Also, exact descriptions of the first and most recent spells may be helpful. Because neurologic disease often affects the patient’s own awareness of his or her problem, it is essential that the family be interviewed whenever there is any question of cognitive or behavioral dysfunction. Also, many neurologic diseases will have a profound effect upon the daily life of family members, and they should be included in discussions with the patient. 3
  4. 4. OUTLINE I.` CHIEF COMPLAINTS A. Losses: 1. 2. 3. 4. B. Unwanted Additions 1. 2. 3. 4. II HISTORY OF PRESENT ILLNESS A. Timing 1. 2. 3. 4. B. Associated Symptoms 1. 2. 3. 4. C. Aggravating and Alleviating Factors III. PAST MEDICAL HISTORY A. Major Diseases B. Medications or Treatment 4
  5. 5. Past Medical History, Cont’d. C. Think about A & B together IV. SOCIAL HISTORY, FAMILY HISTORY V. NEUROLOGICAL REVIEW OF SYMSTEMS 5