Case Files Neurology, (LANGE Case Files) 2nd Ed.

Part 1. Approach to the Patient

Applying “book learning” to a specific clinical situation is one of the most challenging tasks in medicine. To do so, the clinician must not only retain information, organize facts, and recall large amounts of data but also apply all of these to the patient. The purpose of this text is to facilitate these processes.

The first step involves gathering information, also known as establishing the database. This includes taking the history, performing the physical examination, and obtaining selective laboratory examinations, special studies, and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients. A good clinician also knows how to ask the same question in several different ways, using different terminology. For example, patients may deny having “tremulousness” but will answer affirmatively to feeling “shaky.”

CLINICAL PEARLS

Images The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.

HISTORY

1. Basic Information:

a. Age: Some conditions are more common at certain ages; for instance, forgetfulness is more likely to be caused by dementia in an elderly patient than the same complaint in a teenager.

b. Gender: Some disorders are more common in men such as cluster headaches. In contrast, women more commonly have migraine headaches. Also, the possibility of pregnancy must be considered in any woman of child-bearing age.

c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as type 2 diabetes mellitus in Hispanic patients).

d. Course: Certain conditions are characterized by a particular clinical course such as relapsing-remitting, slowly progressive, or acute/subacute, which aids in making a differential diagnosis.

CLINICAL PEARLS

Images The discipline of neurology illustrates the importance of understanding how to correlate the neuroanatomical defect to the clinical manifestation.

2. Chief complaint: What is it that brought the patient into the hospital? Has there been a change in a chronic or recurring condition or is this a completely new problem? The duration and character of the complaint, associated symptoms, and exacerbating/relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry.

CLINICAL PEARLS

Images The first line of any presentation should include age, gender, marital status, handedness, and chief complaint. Example: A 32-year-old married white right-handed male complains of left arm weakness and numbness.

3. Past Medical History:

a. Major illnesses such as hypertension, diabetes, reactive airway disease, congestive heart failure, angina, or stroke should be detailed.

   i. Age of onset, severity, end-organ involvement.

   ii. Medications taken for the particular illness including any recent changes to medications and reason for the change(s).

   iii. Last evaluation of the condition (eg, when was the last stress test or cardiac catheterization performed in the patient with angina?).

   iv. Which physician or clinic is following the patient for the disorder?

b. Minor illnesses such as recent upper respiratory infections should be noted.

c. Hospitalizations no matter how trivial should be queried.

4. Past Surgical History: Note the date and type of procedure performed, indication, and outcome. Surgeon and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated including anesthetic complications, difficult intubations, and so forth.

5. Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medication. Immediate hypersensitivity should be distinguished from an adverse reaction.

6. Medications: A list of medications, dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, herbal remedies, and recreational or illicit drugs are all relevant. If the patient is currently taking antibiotics, it is important to note what type of infection is being treated.

7. Immunization History: Vaccination and prevention of disease is one of the principal goals of the primary care physician; however, recording the immunizations received including dates, age, route, and adverse reactions if any is critical in evaluating the neurology patient as well.

8. Social History: Occupation, marital status, family support, and tendencies toward depression or anxiety are important. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded.

9. Family History: Many major medical problems are genetically transmitted (eg, Huntington’s disease and muscular dystrophy). In addition, a family history of conditions such as Alzheimer dementia and ischemic heart disease can be a risk factor for the development of these diseases. Social history including marital stressors, sexual dysfunction, and sexual preference are of importance.

10. Review of Systems: A systematic review should be performed but focused on the life-threatening and the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, and infectious symptoms are important to note. In an elderly woman with generalized weakness, symptoms suggestive of cardiopulmonary disease should be elicited, such as chest pain, shortness of breath, fatigue, or palpitations.

PHYSICAL EXAMINATION

1. General appearance: Note mental status, alert versus obtunded, anxious, in pain, in distress, interaction with other family members and with examiner. Note any dysmorphic features of the head and body, which may also be important for many inherited or congenital disorders.

2. Vital signs: Record the temperature, blood pressure, heart rate, and respiratory rate. Oxygen saturation is useful in patients with respiratory symptoms. Height and weight are often placed here with a body mass index (BMI) calculated (BMI = kg/m2 or lb/in2).

3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter and thyroid nodules, and carotid bruits should be sought. In patients with altered mental status or a head injury, pupillary size, symmetry, and reactivity are important. Mucous membranes should be inspected for pallor, jaundice, and evidence of dehydration. Cervical and supraclavicular nodes should be palpated.

4. Breast examination: Inspection for symmetry and skin or nipple retraction as well as palpation for masses. The nipple should be assessed for discharge, and the axillary and supraclavicular regions should be examined.

5. Cardiac examination: The point of maximal intensity (PMI) should be ascertained, and the heart auscultated at the apex as well as base. It is important to note whether the auscultated rhythm is regular or irregular. Heart sounds (including S3 and S4), murmurs, clicks, and rubs should be characterized. Systolic flow murmurs are fairly common as a result of the increased cardiac output, but significant diastolic murmurs are unusual.

6. Pulmonary examination: The lung fields should be examined systematically and thoroughly. Stridor, wheezes, rales, and rhonchi should be recorded. The clinician should also search for evidence of consolidation (bronchial breath sounds, egophony) and increased work of breathing (retractions, abdominal breathing, accessory muscle use).

7. Abdominal examination: The abdomen should be inspected for scars, distension, masses, and discoloration. For instance, the Grey-Turner sign of bruising at the flank areas can indicate intraabdominal or retroperitoneal hemorrhage. Auscultation should identify normal versus high-pitched and hyperactive versus hypoactive bowel sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Then careful palpation should begin away from the area of pain and progress to include the whole abdomen to assess for tenderness, masses, organomegaly (ie, spleen or liver), and peritoneal signs. Guarding and whether it is voluntary or involuntary should be noted.

8. Back and spine examination: The back should be assessed for symmetry, tenderness, or masses. The flank regions particularly are important to assess for pain on percussion that may indicate renal disease.

9. Perform genital examination and rectal examination as needed.

10. Extremities/Skin: The presence of joint effusions, tenderness, rashes, edema, and cyanosis should be recorded. It is also important to note capillary refill and peripheral pulses.

11. Neurologic examination: Patients who present with neurologic complaints require a thorough assessment including mental status, cranial nerves, muscle tone, and strength, sensation, reflexes, and cerebellar function, and gait to determine where the lesion or problem is located in the nervous system. Locating the lesion is the first step to generating a differential of possible diagnoses and implementing a plan for management.

a. Cranial nerves need to be assessed: Ptosis (III), facial droop (VII), hoarse voice (X), speaking and articulation (V, VII, X, XII), eye position (III, IV, VI), pupils (II, III), smell (I); visual acuity and visual fields, pupillary reflexes to light and accommodation; hearing acuity and Weber and Rinne test, sensation of three branches of V of face; shrug shoulders (XI), protrude tongue (VII).

b. Motor: Observe for involuntary movements, muscle symmetry (right vs. left, proximal vs. distal), muscle atrophy, gait. Have patient move against resistance (isolate muscle group, compare one side vs. another, and use 0–5 scale).

c. Coordination and gait: Rapid alternating movements, point-to-point movements, Romberg test, and gait (walk, heel-to-toe in straight line, walk on toes and heels, shallow bend and get up from sitting).

d. Reflexes: Biceps (C5,6), triceps (C6,7), brachioradialis (C5,6), patellar (L2–4), ankle (S1,2), frontal release signs or pathologic reflexes (plantar reflex, palmomental, glabellar, snout), and clonus.

f. Sensory: Patient’s eyes should be closed, compare both sides of body, distal versus proximal; vibratory sense (low-pitched tuning fork); subjective light touch; position sense, dermatome testing, pain, temperature.

g. Discrimination: Graphesthesia (identify number “drawn” on hand), stereo-gnosis (place familiar object in patient’s hand), and two-point discrimination.

12. Mental status examination: A thorough neurologic examination requires a mental status examination. The Mini-Mental Status examination is a series of verbal and non-verbal tasks that serves to detect impairments in memory, concentration, language, and spatial orientation.

CLINICAL PEARLS

Images A thorough understanding of functional anatomy is important to optimally interpret the physical examination findings.

13. Laboratory assessment depends on the circumstances.

a. Complete blood count (CBC) can assess for anemia, leukocytosis (infection), and thrombocytopenia.

b. Basic metabolic panel: Electrolytes, glucose, blood urea nitrogen (BUN), and creatinine (renal function).

c. Urinalysis and/or urine culture to assess for hematuria, pyuria, or bacteruria. A pregnancy test is important in women of child-bearing age.

d. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase for liver function; amylase and lipase to evaluate the pancreas.

e. Cardiac markers (creatine kinase myocardial band [CK-MB], troponin, myoglobin) if coronary artery disease or other cardiac dysfunction is suspected. CK, CK-MB is often elevated in many neuromuscular disorders. Aldolase is more specific for skeletal muscle.

f. Drug levels such as anti-seizure medication level, or acetaminophen level in possible overdoses. Drug screen should be considered in pertinent cases.

g. Arterial blood gas measurements give information about oxygenation, but also carbon dioxide and pH readings.

14. Diagnostic adjuncts

a. Electroencephalogram (EEG) if focal or gross central nervous system pathology is suspected. Evoked potentials (visual, auditory, sensory) if disruption of afferent sensory pathways is suspected.

b. Computed tomography (CT) is useful in assessing the brain for masses, bleeding, strokes, and skull fractures.

c. Magnetic resonance imaging helps to identify soft tissue planes very well.

d. Nuclear medicine imaging (PET or SPECT scans) may be helpful in some selected instances.

e. Tissue analyses of nerves, muscles, or less commonly of the brain are rarely used.

f. Lumbar puncture is indicated to assess any inflammatory, infectious, or neoplastic processes that can affect the brain, spinal cord, or nerve roots.

g. Electrodiagnostic testing (EMG/NCV) is an extension of the neurologic examination and is used to assess nerve and muscle disorders.