Orest Hurko, M.D.
It has been said that neurologic diagnosis is 85 percent history, 10 percent physical examination, and 5 percent ancillary testing. Thus, evaluation of the patient with a neurologic complaint starts with analysis of the patients history. The second step is the formulation of an anatomic differential diagnosis: which area of the nervous system could be malfunctioning to give rise to the patients symptoms? A carefully taken history will yield only a small number of anatomic hypotheses. The neurologic examination is the third step. Its purpose is to determine which of the limited number of possibilities is the most likely. Because the number of neurologic diseases is so large, it is critical for the primary care physician to follow this three-step procedure. A successful examiner must have a notion of what the anatomic possibilities might be before beginning the actual physical examination. Only by letting the history focus the examination will the physician arrive at a clinical diagnosis that can become an efficient tool.
For the primary care physician, it is sufficient to know the features of the commonly encountered clinical situations described in this book as well as a few basic neurologic tests described in this chapter. With this information, it should be possible to decide when to refer to a specialist and when to initiate management without such consultation.
What anatomic hypotheses need to be considered? For a first approximation, it is sufficient to consider six major neuroanatomic possibilities. Working from the periphery inward, the physician should consider whether the primary problem is in (1) skeletal muscle, (2) the neuromuscular junction, (3) peripheral nerves, (4) the spinal cord, (5) the posterior fossa (brainstem and cerebellum), or (6) the telencephalon (cortex, deep white matter, or basal ganglia). One should always consider a seventh anatomic category: does the problem originate outside the nervous system? The knowledge of these patterns, rather than the niceness of the neurologic examination, distinguishes the experienced practitioner from the novice.
Dysfunction in any of the six anatomic regions gives rise to a characteristic pattern of neurologic signs. Rarely, if ever, does a single sign yield a diagnosis; it is the pattern that is distinctive. The examiners aim is to elicit signs that will distinguish between the anatomic diagnoses suggested by the history. Working this way, the clinician will become aware of the importance of even subtle signs—if they are part of a larger pattern that fits the patients clinical situation.
How are these patterns to be constructed? As in all physical diagnosis, the examiner begins with vital signs and direct examination of the part of the body where the symptoms originate (e.g., the stiff neck, the painful back, the weak or painful limb). The neurologist adds to this basic approach six specific examinations: (1) mental state, (2) cranial nerves, (3) motor system, (4) reflexes, (5) coordination, and (6) sensation.
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