REFINING THE NEUROLOGICAL HISTORY Randy M. Rosenberg, MD FAAN FACP Randy M. Rosenberg, MD FAAN FACP Chief, Division of Neurology Chief, Division of Neurology Aria Health Aria Health Clinical Assistant (Adjunct) Professor of Neurology Clinical Assistant (Adjunct) Professor of Neurology Temple University School of Medicine Temple University School of Medicine There is still much GLORY in the STORY
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.”
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 neurologicalmanifestation of a systemic disease?
Why Is the Neurological History Still Relevant?•• Safest and most cost effective Safest and most cost effective DIAGNOSTIC MODALITY available DIAGNOSTIC MODALITY available•• The most direct method to cultivate trust The most direct method to cultivate trust and a sound doctor-patient relationship and a sound doctor-patient relationship •• For some people there is a very thin line For some people there is a very thin line between the laying of hands and assault and between the laying of hands and assault and battery. battery.•• False negative MRI or “When all else False negative MRI or “When all else fails take a history!” fails take a history!”
NONSENSE DIAGNOSIS (MOST OF THE TIME) Change in Mental Status Drowsiness, 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 NUMBNESSAll 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
“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 “Blame it on the other guy”“Brute force approach” approach How much do you drink, Mr. Is a cocktail or a beer Brown? something you enjoy regularly, Mr. Brown? Do you know where you are, Did anyone have a chance to Mr. Brown? tell you the name of this place? Well, anyone can get mixed up in here. Do you know why they Are they treating you well brought you here? here? What are they doing for you?
In Conclusion…Every patient you see is a lesson in much Every patient you see is a lesson in muchmore than the malady from which he more than the malady from which hesuffers. suffers.The good physician treats the disease; the The good physician treats the disease; thegreat physician treats the patient who has great physician treats the patient who has There are no coincidences in There are no coincidences inthe disease the disease neurology….EVER! Multiple events neurology….EVER! Multiple events William Osler MD William Osler MD in a single patient occur for a in a single patient occur for a reason. If you can figure out the reason. If you can figure out the relationships, you can make the relationships, you can make the diagnosis. diagnosis. Randy M Rosenberg, MD Randy M Rosenberg, MD Neurologists only have to worry about two Neurologists only have to worry about two things…what the patient really has and what things…what the patient really has and what will kill the patient tonight. will kill the patient tonight. Arnold Bank, MD Arnold Bank, MD