• Part 1 Approach to the Patient

• Part 2 Approach to Clinical Problem-Solving

• Part 3 Approach to Reading

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 this to the patient. The purpose of this text is to facilitate this process.

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 values, 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.”

HISTORY

1. Basic information:

   1. 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.

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

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

   4. 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 PEARL

   • The discipline of neurology illustrates the importance of understanding how to correlate the neuroanatomic 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 PEARL

   • 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 man complains of left arm weakness and numbness.

3. History of present illness: This is the most important part of the history and should include a detailed description of the complaint, including:

   1. Neurological deficits—motor, sensory, cognitive, coordination.

   2. Onset and course of the problem.

   3. If pain, then location of the pain, character, nature, and severity.

   4. Aggravating and alleviating factors.

   5. Associated conditions or complaints.

   6. How the neurological condition affects the patient including disability and limitations in normal activity.

   7. Treatments or medications that the patient has tried.

   8. Medical, surgical, family, or environmental conditions that may have an impact on the patient’s condition.

   9. Patient’s greatest concern.

4. Past medical history:

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

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

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

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

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

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

   3. Hospitalizations, no matter how trivial, should be queried.

   4. In pediatric patients, pregnancy complications, delivery route and gestational age, developmental history, genetic considerations, or dysmorphisms should be noted.

5. 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.

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

7. Medications: A list of medications, dosage, route of administration, frequency, and duration of use should be developed. Prescription, over-the-counter drugs, 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.

8. 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.

9. 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.

10. Family history: Many major medical problems are genetically transmitted (eg, Huntington 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.

11. Review of systems: A systematic review should be performed but focused on life-threatening and 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, and the patient’s interaction with other family members and with the examiner. Note any dysmorphic features of the head and body that may 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 should be performed. 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 should be auscultated at the apex as well as at the 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 intra-abdominal 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 indicated by the history and review of systems.

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. For rashes, it is important to note the pattern of the rash on the patient’s body and/or face.

11. Neurologic examination: Patients who present with neurologic complaints require a thorough assessment, including mental status, cranial nerves, muscle tone and strength, sensation, reflexes, 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.

    1. 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; shoulder shrugging (XI); and protruding the tongue (VII).

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

    3. 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, rising from squatted position or from sitting) should be assessed.

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

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

    6. Discrimination: Evaluate graphesthesia (identify number “drawn” on hand), stereognosis (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 State Examination and Montreal Cognitive Assessment (MoCA) are a series of verbal and nonverbal tasks that serves to detect impairments in memory, concentration, language, and spatial orientation.

13. For pediatric patients: A thorough developmental assessment should be performed, including careful evaluation of speech, hearing, socialization, gross and fine motor ability, and gait.

    CLINICAL PEARL

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

14. Laboratory assessment depends on the circumstances.

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

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

    3. Urinalysis and/or urine culture to assess for hematuria, pyuria, or bacteruria. A pregnancy test is important in women of childbearing age.

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

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

    6. Drug levels such as antiseizure medication level or acetaminophen level in possible overdoses. Drug screens should be considered in pertinent cases.

    7. Arterial blood gas measurements give information about oxygenation and also about carbon dioxide and pH readings.

15. Diagnostic adjuncts:

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

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

    3. Magnetic resonance imaging (MRI) helps to identify soft tissue planes very well.

    4. Nuclear medicine imaging (positron emission tomography [PET] or single-photon emission computed tomography [SPECT] scans) may be helpful in some selected instances.

    5. Tissue analysis of nerves, muscles, or less commonly of the brain is rarely used.

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

    7. Electrodiagnostic testing (electromyography [EMG]/nerve conduction velocity [NCV]) is an extension of the neurologic examination and is used to assess nerve and muscle disorders.

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

4. Following the patient’s response to the treatment

Making the diagnosis: This is achieved by carefully evaluating the patient, analyzing the information, assessing the 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 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.

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 the extent of malignancy.

Treating based on stage: Many illnesses are characterized by the stage or severity because this affects the 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.

Following the response to 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?

Part 3. Approach to Reading

The clinical problem-oriented approach to reading is different from the classic “systematic” research of a disease. Patients rarely present with a clear diagnosis; hence, the student must become skilled at applying textbook information to the clinical scenario. Because reading with a purpose improves the retention of information, the student should read with the goal of answering specific questions. There are several fundamental questions that facilitate clinical thinking. These are as follows:

1. What is the most likely diagnosis?

2. How would you confirm the diagnosis?

3. What should be your next step?

4. What is the likely neuroanatomic defect?

5. What are the risk factors for this condition?

6. What are the complications associated with the disease process?

7. What is the best therapy?

WHAT IS THE MOST LIKELY DIAGNOSIS?

The method of establishing the diagnosis has been covered in the previous section. One way of attacking this problem is to develop standard approaches to common clinical problems. It is helpful to understand the most common causes of various presentations (see the Clinical Pearls at the end of each case), such as “the worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage.”

The clinical scenario would be something such as the following:

“A 38-year-old woman is noted to have a 2-day history of a unilateral, throbbing headache and photophobia. What is the most likely diagnosis?”

With no other information to go on, the student would note that this woman has a unilateral headache and photophobia. Using the “most common cause” information, the student would make an educated guess that the patient has a migraine headache. If instead the patient is noted to have “the worst headache of her life,” the student would use the clinical pearl: “The worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage.”

HOW WOULD YOU CONFIRM THE DIAGNOSIS?

In the scenario above, the woman with “the worst headache” is suspected of having a subarachnoid hemorrhage. This diagnosis could be confirmed by a CT scan of the head and/or LP. The student should learn the limitations of various diagnostic tests, especially when used early in a disease process. The LP showing xanthochromia (red blood cells) is the gold standard test for diagnosing subarachnoid hemorrhage, but it can be negative early in the disease course.

WHAT SHOULD BE YOUR NEXT STEP?

This question is difficult because the next step has many possibilities; the answer can be to obtain more diagnostic information, stage the illness, or introduce therapy. It is often a more challenging question than “What is the most likely diagnosis?” because there may be insufficient information to make a diagnosis, and the next step may be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis, and the next step is to stage the disease. Finally, the most appropriate answer may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of the following:

Frequently, the student is taught to “regurgitate” the same information that someone has written about a particular disease but is not skilled at identifying the next step. This talent is learned optimally at the bedside, in a supportive environment, with freedom to take educated guesses and with constructive feedback. A sample scenario can describe a student’s thought process as follows:

1. Make the diagnosis: “Based on the information I have, I believe that Mr. Smith has a left-sided cerebrovascular accident.”

2. Stage the disease: “I don’t believe that this is severe disease because his Glasgow score is 12, and he is alert.”

3. Treat based on stage: “Therefore, my next step is to treat with oxygenation, monitor his mental status and blood pressure, and obtain a CT scan of the head.”

4. Follow response: “I want to follow the treatment by assessing his weakness, mental status, and speech.”

WHAT IS THE MOST LIKELY NEUROANATOMIC DEFECT?

Because the field of neurology seeks to correlate the neuroanatomy with the defect in function, the student of neurology should constantly be learning the function of the various brain centers and the neural conduits to the end organ. Considering the location of the lesion is essential in the differential diagnosis. Conveniently, neurology can be subdivided into compartments such as movement disorders, stroke, tumor, and metabolic disorders for the purpose of reading, yet the patient can have a disease process that affects more than one central nervous function.

WHAT ARE THE RISK FACTORS FOR THIS PROCESS?

Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding risk factor analysis may help in the management of a 55-year-old woman with carotid insufficiency. If the patient has risk factors for a carotid arterial plaque (such as diabetes, hypertension, and hyperlipidemia) and complains of transient episodes of extremity weakness or numbness, she may have either an embolic or thrombotic disease mechanism.

WHAT ARE THE COMPLICATIONS TO THIS PROCESS?

Clinicians must be cognizant of the complications of a disease so that they will understand how to follow and monitor the patient. Sometimes the student will have to make the diagnosis from clinical clues and then apply his or her knowledge of the consequences of the pathologic process. For example, “A 26-year-old man complains of severe throbbing headache with clear nasal drainage.” If the patient has had similar episodes, this is likely a cluster headache. However, if the phrase is added, “The patient is noted to have dilated pupils and tachycardia,” then he is likely a user of cocaine. Understanding the types of consequences also helps the clinician to be aware of the dangers to a patient. Cocaine intoxication has far different consequences such as myocardial infarction, stroke, and malignant hypertension.

WHAT IS THE BEST THERAPY?

To answer this question, not only do clinicians need to reach the correct diagnosis and assess the severity of the condition, but they must also weigh the situation to determine the appropriate intervention. For the student, knowing exact dosages is not as important as understanding the best medication, route of delivery, mechanism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy.

SUMMARY

1. There is no replacement for a meticulous history and physical examination.

2. There are four steps in the clinical approach to the neurology patient: making the diagnosis, assessing the severity, treating based on the severity, and following the response.

3. There are seven questions that help to bridge the gap between the textbook and the clinical arena.

REFERENCES