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?
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.
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.
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.
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.