REFINING THE NEUROLOGICAL HISTORY

There is still much GLORY in the STORY

Randy M. Rosenberg, MD FAAN FACPChief, Division of Neurology

Aria HealthClinical Assistant (Adjunct) Professor of

NeurologyTemple University School of Medicine

Randy M. Rosenberg, MD FAAN FACPChief, Division of Neurology

Aria HealthClinical Assistant (Adjunct) Professor of

NeurologyTemple 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!”

• 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) 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

inpairment 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

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

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

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