Approach To The Patient With Neurological Problems
The overall aim of the
history, examination and investigation of a patient is to establish if there is
a neurological problem and if so:
· WHERE is the site of that pathology?
· WHAT is the nature of the
abnormality?
· HOW can one best investigate it?
· HOW can one best treat it?
History taking
This may require input
from a carer/spouse/relative/friend in the case of disorders of altered
consciousness (e.g. epilepsy) or central nervous system (CNS) degenerative
processes or major injury (e.g. head injury; Alzheimer’s disease), especially
if there is frontal lobe damage as this causes patients to lose insight into
their problems.
The main elements of the
history require the following information:
· What is the primary complaint?
· When did it begin?
· How has it progressed?
· Is it a recurrent problem?
· What associated features are seen
with the main complaint?
· Have you had any neurological
problems/injuries in the past?
· Is there a family history of
neurological problems?
· What medication are you taking?
· What medical illnesses to date do
you have or have had?
· What is your occupation?
· Do you smoke/drink/use illicit
drugs?
· Any recent travel abroad?
Obviously, further
direct questioning can be targeted to try to better define the nature of the
problem depending on the initial complaint. It is worth bearing in mind that
psychiatric problems can present with neurological symptoms.
Examination
What the patient
complains about is a symptom and what you find on examination is a sign.
The process by which one examines the nervous system is detailed in Chapter 51.
However on occasions it may be necessary to also do a brief psychiatric
assessment, and in cases where the disorder is thought to not be neurological
then examination of other systems is mandatory (e.g. cardiovascular system with
blackouts).
Investigations (see Chapters 52 and 53)
The number and type of
investigations is driven by the answers to the above questions 1–3. Many tests
are non-invasive and easy to do, but careful consideration must always be given
as to why a test is being done and whether it is necessary.
Blackouts (see also Chapter 61)
This can be due to
epilepsy, disturbances of circulation (faints, cardiac dysrhythmias, aortic
stenosis) or on occasions due to anxiety/psychiatric problems. It is important
to get a clear history of when the attacks occur, what causes them and what
happens during them, which typically requires a witnessed account.
Dizziness
This is a very common
problem and it is often hard to make a diagnosis. It is rarely due to CNS
disease. It is more commonly a feature of an inner ear problem (see Chapter 29)
or anxiety with hyperventilation.
Sensory symptoms (see Chapter 54)
Many patients complain
of focal sensory disturbances – numbness or tingling. If very focal and not
associated with weakness then the chances of finding a cause for it are very
rare. Indeed if no ‘hard’ signs can be elicited, again, it is unlikely that a
cause will be found.
Fatigue
This is a very
non-specific symptom and rarely yields to a diagnosis. It is important to
differentiate between fatigue/tiredness and:
•
weakness
= motor neurone involvement;
•
daytime
somnolence = sleep problem;
• fatiguable
weakness = neuromuscular junction problem. Fatigue is a common feature of
depression but can also be seen in ultiple sclerosis (MS) and Parkinson’s
disease.
