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

Part 2. Approach to Clinical Problem Solving

CLASSIC CLINICAL PROBLEM SOLVING

There are typically four distinct steps that the neurologist undertakes to systematically solve most clinical problems:

1. Making the diagnosis;

2. Assessing the severity of the disease;

3. Treating based on the stage of the disease; and

4. Following the patient’s response to the treatment.

Making the Diagnosis: This is achieved by carefully evaluating the patient, analyzing the information, assessing risk factors, and developing a list of possible diagnoses (the differential). Usually a long list of possible diagnoses can be pared down to a few of the most likely or most serious ones, based on the clinician’s knowledge, experience, and selective testing. For example, a 30-year-old patient who complains of acute onset of right facial weakness and drooling from the right side probably has a cranial nerve VII palsy. Yet another individual who is a 60-year-old man with right-sided facial weakness and left arm numbness likely has an ischemic stroke.

CLINICAL PEARLS

Images The first step in clinical problem solving is making the diagnosis.

Assessing the Severity of the Disease: After establishing the diagnosis, the next step is to characterize the severity of the disease process; in other words, to describe “how bad” the disease is. This can be as simple as determining whether a patient is “sick” or “not sick.” Is the patient with a hemorrhagic stroke comatose or with a “blown pupil?” In other cases, a more formal staging can be used. For example, cancer staging is used for the strict assessment of extent of malignancy.

CLINICAL PEARLS

Images The second step is to establish the severity or stage of disease. This usually impacts the treatment and/or prognosis.

Treating Based on the Stage of the Disease: Many illnesses are characterized by stage or severity because this affects prognosis and treatment. As an example, a patient with mild lower extremity weakness and areflexia that develops over 2 weeks may be carefully observed; however, once respiratory depression occurs, respiratory support must be given.

CLINICAL PEARLS

Images The third step is tailoring the treatment to fit the severity or “stage” of the disease.

Following the Patient’s Response to the Treatment: The final step in the approach to disease is to follow the patient’s response to the therapy. Some responses are clinical such as improvement (or lack of improvement) in a patient’s strength; a standardized method of assessment is important. Other responses can be followed by testing (eg, visual field testing). The clinician must be prepared to know what to do if the patient does not respond as expected. Is the next step to treat again, to reassess the diagnosis, or to follow up with another more specific test?

CLINICAL PEARLS

Images The fourth step is to monitor treatment response or efficacy. This can be measured in different ways—symptomatically or based on physical examination or other testing.