refining the neurological history
TRANSCRIPT
REFINING THE NEUROLOGICAL HISTORY
There is still much GLORY in the STORY
Randy M. Rosenberg, MD FAAN FACPClinical Assistant Professor of Neurology
Temple University School of Medicine
Sir William Osler1849-1919
1872 MD Degree from Magill and later Professor of Medicine
1884 Chairman of Clinical Medicine University of Pennsylvania
1888 Professor and Chief of Medicine Johns Hopkins
1905 Regius Chair of Medicine Oxford University
Quotable Sir William Osler
"If you listen carefully to the patient they will tell you the diagnosis“
"Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.“
“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”
An Unusual Familial Neuromyopathy
Becker’s or Limb Girdle Dystrophy Variants?
What Is The Inherant Distinction Of The Neurological History?
The neurological history should be a focused, goal directed exercise that answers the following questions:
Where in the nervous system is the lesion? What is the pathological process (e.g. inflammatory, vascular, infectious)?Is this a purely neurological problem or a neurological manifestation of a systemic disease?
Why Is the Neurological History Still Relevant?
• Safest and most cost effective DIAGNOSTIC MODALITY available
• The most direct method to cultivate trust and a sound doctor-patient relationship
• For some people there is a very thin line between the laying of hands and assault and battery.
• False negative MRI or “When all else fails take a history!”
Remember The Introduction!
NONSENSE DIAGNOSIS (MOST OF THE TIME)
Change in Mental StatusDrowsiness, hunger and rage are all changes
in mental status too!
NONSENSE DIAGNOSIS (MOST OF THE TIME)
Change in Mental Status
Syncope Temporary loss of consciousness with interruption of
awareness of oneself and one’s surroundings OFTEN INCORRECT HALF BECAUSE OF FAILURE TO TAKE A
HISTORY. Rarely a justification for CT in the ER
Less than 4% of studies provide new information Age greater than 65, anticoagulation, significant head trauma,
accompanying symptoms of headache or other focal neurological complaints change the paradigm
If someone has fallen, this does NOT mean that they have lost consciousness
NONSENSE DIAGNOSIS (MOST OF THE TIME)
Change in Mental Status
Syncope
TIA R/O CVA Confuses the history (conclusion vs impression) Are we talking about a clinical, radiological or patholophysiological
diagnosis of ischemia? 50% of TIAs are acute strokes on MRI False negative MRI scans
In patient with lacunes or small brainstem strokes, initial MRI DWI will be negative in 25% of cases especially with NIH score < 4 and stroke age <3 days
In an age of observational units, the honest consultant is deprived an appropriate payment for service
KILLER WORDS DIZZINESS
SLURRED SPEECH
BLURRED VISION
NUMBNESS
All of these symptoms are invisible BUT just like love, loyalty and patriotism, they all exist.
The patient knows exactly what they are talking about (even if you may not)
DIZZINESS Spinning
Fast or Slow rotation Fast-usually labyrinthian or vestibular Slower-may be central
Often with a sense of “rocking boat” Positional
Lightheaded or fainting Orthostatic? Hyperventilation? Hypotension?
“Are you dizzy in your head or in your feet?”
Three Most Common Causes Of Dizziness
Hemodynamic Hyperventilation may
= sighing Positional Vertigo
NUMBNESS
Often used interchangeably by the patient for weakness
Paresthesias = pins and needles Dysthesias=unpleasant or unnatural
sensation Anesthesia=no feeling Remember to get the zip code right
(anatomical localization) Diagrams of radicular and cutaneous
innvervation Load on jump drive
Sensory “Road Maps” For Patients
“SLURRED SPEECH”: DEFINITIONS
Problem with articulation or pronouciation (dysarthria)
Problem with language or word finding (aphasia) Problem with vocal quality (dysphonia or hypophonia) Problem of fluency (stutters, stammers, bradyphrenia
tachyphemia) Mumbled speech is not an expressive aphasia
Patient with profound facial weakness with dense hemiplegia may have lost the capacity to articulate but is not aphasic
Slurred Speech: Hints to Localization
Slow speech ?Aphasia == Dominant hemisphere? ?Bradyphrenia == Global, diffuse
subcortical, extrapyramidal or psychiatric disease
Difficult putting words together Impaired attention == Global dysfunction Lesions in the prefrontal cortex Parietal lesions Psychiatric disease
Slurred Speech: Hints To Localization
Conversational repetition Impaired attention=short term memory
impairment Mesial temporal, thalamic or mammillary body
pathology Abnormalities in articulation or
pronunciation Lesions of the corticobulbar tract Brainstem motor nuclei, cranial nerves,
cerebellum, basal ganglion or vocal cords Disorders of arousal and/or wakefulness
BLURRED VISION Most difficult aspect of the history Ask instead:
Double vision? See something that shouldn’t be there?
Typically of migraine such as scotoma Is something missing in your vision?
Field cut Remember that a field cut is usually sensed by the
patient as being in one eye Speed of onset
Stroke is sudden and dark Migraine is wavelike in onset and resolution
and usually bright
FIRST AND LAST WORD ABOUT TPA
“When was the patient last seen in their normal state?” Most important piece of history Must be documented, especially if the decision is
made NOT to give thrombolytics Just to have TPA brought up increases the risk of
litigation Victory for the plaintiff in such cases is almost always
for FAILURE to give TPA Defendants (ER/neurology/hospital) still prevail the
majority of the time
Helpful Hints To Avoid Polarizing The Interview
“Brute force approach” How much do you drink,
Mr. Brown?
Do you know where you are, Mr. Brown?
Do you know why they brought you here?
“Blame it on the other guy” approach Is a cocktail or a beer
something you enjoy regularly, Mr. Brown?
Did anyone have a chance to tell you the name of this place? Well, anyone can get mixed up in here.
Are they treating you well here? What are they doing for you?
In Conclusion…
There are no coincidences in neurology….EVER! Multiple events in a single patient occur for a reason. If you can figure out the relationships, you can make the diagnosis.
Randy M Rosenberg, MD
Neurologists only have to worry about two things…what the patient really has and what will kill the patient tonight.
Arnold Bank, MD
Every patient you see is a lesson in much more than the malady from which he suffers.The good physician treats the disease; the great physician treats the patient who has the disease
William Osler MD