Neurological history and the importance in making a diagnosis

1. 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

2. Sir William Osler
1849-1919
 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

3. 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.”

4. An Unusual Familial Neuromyopathy

5. Becker’s or Limb Girdle Dystrophy Variants?

6. 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?

7. 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!”

8. Remember The Introduction!

9. NONSENSE DIAGNOSIS (MOST OF THE TIME)
 Change in Mental Status
Drowsiness, hunger and rage are all changes in
mental status too!

10. 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

11. 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

12. 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)

13. 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?”

14. Three Most Common Causes Of Dizziness
 Hemodynamic
 Hyperventilation may =
sighing
 Positional Vertigo

15. 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

16. Sensory “Road Maps” For Patients

17. “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

18. 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

19. 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

20. 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

21. 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

22. 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?

23. In Conclusion…
Every patient you see is a lesson in much
Every patient you see is a lesson in much
more than the malady from which he
more than the malady from which he
suffers.
suffers.
The good physician treats the disease; the
The good physician treats the disease; the
great physician treats the patient who has
great physician treats the patient who has There are no coincidences in
There are no coincidences in
the 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