Approach to the Neurological Patient PDF

Approach to the Neurological Patient Clinical Reasoning Lee Scott, M.D.. 1 Objectives Time to Use your Tools!! 1. Take an appropriate History (including ROS) for a given Neurological complaint. 2. Conduct an appropriate Physical Exam for a given Neurological complaint. 3. Offer a patient a basic Ass...

Approach to the Neurological Patient Clinical Reasoning Lee Scott, M.D.. 1 Objectives Time to Use your Tools!! 1. Take an appropriate History (including ROS) for a given Neurological complaint. 2. Conduct an appropriate Physical Exam for a given Neurological complaint. 3. Offer a patient a basic Assessment and Plan at the end of your evaluation. 2 Previously an ILA Read through the short History taking sections of the Neuro chapters in Bates' and Macleod's texts. These can really help you put together what you learned over the past two months. 1. Make a list of the ways neurological conditions can present- headaches, weakness, vision changes, paresthesias, falls, vertigo, tremor, seizure, slurred speech, etc. 2. List the differential diagnosis for each presenting symptom with focus on the most common and most deadly. 3. Now, think about the key features in a patient's history of present illness that make 1 or 2 of the diagnoses more likely- age, gender, abrupt vs. insidious onset, constant vs. intermittent, etc. 4. For each diagnoses, what key questions do you need to ask in PMH, SH, FH and ROS? For instance, if you think a patient is having a stroke, you should specifically ask about history of hypertension or arrhythmias. 5. What physical exam should you do to help 'rule in' or 'rule out' your potential diagnoses? 6. What testing or treatment should you recommend for the patient? 3 Common Presenting Symptoms Headache Dizziness or vertigo Weakness (generalized, proximal, or distal) Numbness, abnormal or absent sensation Fainting and blacking out (near-syncope and syncope) Seizures Tremors or involuntary movements 4 The Neuro History Chief complaint (“What brings you in today?”) Neurological symptoms may be difficult for patients to describe, so clarify exactly what the patient means. Words such as ‘blackouts’, ‘dizziness’, ‘weakness’ and ‘numbness’ may indicate a different symptom from what you first imagined, so ensure you understand what the patient means. Clarifying or reviewing the history with the patient and/or witness is essential and provides diagnostic clues. “Tell me more about that” is always good!! 5 The Neuro History What does the patient think?? Always ask what they think or fear might be wrong with them, as neurological symptoms cause much anxiety. Patients commonly research their symptoms on the internet. Searches of common benign neurological symptoms, e.g. numbness, usually list the most alarming (and unlikely) diagnoses (MS, motor neuron disease, tumors) first. - BRAIN TUMOR 6 The Neuro History Time relationships The onset, duration and pattern of symptoms over time often provide clues to the diagnosis. When did the symptoms start (or when was the patient last well)? Are they persistent or intermittent? If persistent, are they getting better, worse, or staying the same? If intermittent, how long do they last? Was the onset sudden? (subarachnoid hemorrhage) or gradual? (migraine headache) 7 The Neuro History Precipitating, exacerbating or relieving factors What was the patient doing when the symptoms occurred? Was there trauma? Does anything make the symptoms better or worse, e.g. time of day, menstrual cycle, position? 8 The Neuro History Associated symptoms (OPPQRSTA) Associated symptoms might aid diagnosis e.g. headache may be associated with other symptoms such as nausea, vomiting and photophobia. This suggests migraine and speeds up your interview. Ask, “Are you having any other symptoms?” 9 The Neuro History Past Medical History Birth history and development may be important in some situations, e.g. epilepsy. Contact parents or family doctors to obtain such information. If considering a vascular cause for neurological symptoms, ask about important risk factors, e.g. other vascular disease, hypertension, family history and smoking. (vascular dementia) Always consider medications, including prescribed, over-the-counter and complementary therapies, as they may cause many neurological symptoms. Adverse reactions may be idiosyncratic, dose-related or caused by chronic use. (delirium, parkinsonism) 10 The Neuro History Family History Many neurological disorders are caused by single-gene defects. Others have an important polygenic influence multiple sclerosis. Some conditions have a variety of inheritance patterns Charcot–Marie–Tooth disease. Neurological disease may also be caused by mitochondrial DNA abnormalities. Ask: “Are there any Neurological disorders that run in your family?” 11 The Neuro History Social History Alcohol is the most common neurological toxin and damages both the CNS (ataxia, seizures, cognitive symptoms) and the PNS (neuropathy). Poor diet with vitamin deficiency compounds these problems. (B12, Thiamine) Other recreational drugs may damage the nervous system, e.g. cocaine and ecstasy can cause seizures and strokes, and smoking contributes to vascular and malignant disease. Always consider sexually transmitted or blood-borne infection, e.g. human immunodeficiency virus (HIV) or syphilis, especially in high-risk groups. 12 The Neuro History Social History cont’d Social circumstances are relevant. How are patients coping with their symptoms? Do they drive? If so, should they? What are the physical and emotional support circumstances? Occupational factors are relevant to several neurological disorders. Examples: Toxic peripheral neuropathy due to exposure to heavy or organic metals Lead causes a motor neuropathy. Manganese causes a parkinsonian syndrome. 13 The Neuro History Review of Systems Varies depending on presenting symptom/differential diagnosis Forgotten symptoms may be important. e.g. a history of recovered visual loss (optic neuritis) in a patient now presenting with numbness suggests multiple sclerosis. Neuropsychiatric Specific: fainting, paralysis, tingling (paresthesia), decreased sensation (hypesthesia), absent sensation (anesthesia), tremors, loss of memory, seizures, speech disorders, dizziness or vertigo, poor balance (ataxia),depression, mania, apathy or loss of interest, loss of enjoyment of life (anhedonia), suicidal thoughts, anxiety/nervousness, inability to get to sleep or stay asleep (insomnia), excessive sleep (hypersomnolence), nightmares, symptoms without an explanation (somatization), bizarre or unrealistic thoughts (intrusive thoughts), bizarre or unrealistic perceptions (hallucinations) Choose the ones that will help you rule in or out a diagnosis you are considering!! 14 Physical Exam Possibilities You don’t always do a full neurological exam. You pick based on the history and DDx. -What if the patient has numbness? -What if they have weakness? -What about slurred speech? -facial droop? 15 Headache Case 28-year-old woman presents with chief complaint of “a bad headache since I woke up this morning”. What is the differential diagnosis for headache? (VINDICATE, Systems) Let’s talk about Differential Diagnosis… 16 Differential Diagnosis A list of diagnoses or conditions that could cause a patient’s symptoms There are several ways that you can generate your DDx… 17 VINDICATE 18 Systems Approach Neuro? ENT? Cardiovascular? Respiratory? GI? … … … 19 Headache DDx Migraine Tumor Meningitis Hemorrhage NPH Sinus Infection Tension HA Temporal Arteritis Hangover Caffeine Withdrawal 20 Headache Two helpful ways to approach headaches: Primary vs. Secondary Most common, Most deadly See next slide 21 Headache Primary -without an identified underlying disease Secondary-with an identified underlying disease Most common? Tension Migraine Most deadly? Meningitis SAH Mass Lesion 22 Headache HPI OPPQRST(A) What are some Key Features you want to know: Is it unilateral or bilateral? Severe with sudden onset, like a thunderclap? Steady or throbbing? Is there an aura? Is the headache “typical” or is there something different? Does it intensify over several hours? Is it episodic? Or is it chronic or recurring? Is there a recent change in its pattern? Does the headache recur at the same time every day? Does coughing, sneezing, or changing the position of the head affects the headache? Notice that you may need to ask more than 1 question for each letter!! 23 Headache Case cont’d Headache was present on waking this morning. Right side of head, throbbing pain. About a 7/10. Asked her husband to drive her to the appointment. Hasn’t had a headache like this before. Concerned about what could be going on. 24 Headache- PMH, FH, SH What kind of questions do you need to ask to rule in/rule out various types of headache? Tension Sinusitis Migraine SAH Tumor Meningitis 25 Headache- ROS What kind of questions do you need to ask to rule in/rule out various types of headache? Tension Sinusitis Migraine SAH Tumor Meningitis 26 Headache Case cont’d PMH Patient is healthy. Only medication is birth control pills. No allergies. FH Mom and sister have migraines. SH Nonsmoker. No alcohol. No illicit drugs. Elementary school teacher. ROS: *If you asked associated symptoms with HPI, she probably would’ve given you the positives! (+) nausea, photophobia (-) blurred or double vision, stiff neck, neck pain, numbness, tingling, weakness, fever, chills, stuffy nose, earache or postnasal drainage 27 Headache What exam should you do based on that history? What if she had said her right arm feels funny? What about for each of the following, if suspected? Tension Sinusitis Migraine SAH Tumor Meningitis 28 Headache Case cont’d VS: 128/78 90 14 98.6 Appears uncomfortable, wearing sunglasses Neck: Able to flex neck. No cervical muscle tenderness to palpation. Neuro: No papilledema, PERRL, EOMI. CN V, VII and XI intact. Strength and sensation intact BUEs and BLEs. Balance and gait intact. What do you tell your patient? 29 Dizziness/Balance Problems/Falls/Vertigo A 72-year-old man is brought into the Urgent Care department by his wife who reports that he almost fell getting out of bed this morning. When asked what’s going on, he says, “I’m just a bit off kilter this morning”. What’s your differential? 30 Dizziness/Balance Problems/Falls/Vertigo Patients may complain of: “Dizziness” “Lightheadedness” “Off balance” “Falls” Differential is huge. What are the possibilities?: Vertigo a spinning sensation (accompanied by nystagmus and ataxia) peripheral (∼40% of “dizzy” patients) Benign Positional Vertigo, Meniere’s Ear Infection, Acoustic Neuroma, Medication, Acute Labyrinthitis, Vestibular Neuronitis… central (∼10%) multiple sclerosis, infarct/hemorrhage, vertebrobasilar migraine, Infection, Tumor Disequilibrium unsteadiness or imbalance when walking Generalized weakness, LE weakness from a variety of causes, visual loss, weakness and peripheral neuropathy (up to 15%) Presyncope a near faint from “feeling faint or lightheaded” causes include orthostatic hypotension, arrhythmias, vasovagal attacks (∼5%) 31 Dizziness/Balance Problems/Falls/Vertigo Clarify what the patient means by dizziness, etc. “Do you feel as if the room is spinning or tilting?” (vertigo) “Do your symptoms get worse when you move your head?” “Do you feel as if you are going to fall or pass out?” (presyncope) “Do you feel you are unsteady or losing your balance?” (disequilibrium) 32 Balance Case A 72-year-old man is brought into the Urgent Care Department by his wife who reports that he almost fell getting out of bed this morning. When asked what’s going on, he says, “I’m just a bit off kilter this morning”. Patient answers that he does not feel like the room is spinning and does not feel that he will pass out. Just feels like his balance is off. What else do you need to know about HPI? 33 Balance Case cont’d Symptoms were first noticed this morning. Hasn’t gotten better or worse. Never had anything like this. Not bad at rest. Very noticeable when he tries to get up or walk. Had a little trouble getting dressed. No pain. Wife says he falls to his right when he gets up or tries to walk. What PMH, FH, SH do you want to know? 34 Balance Case cont’d What PMH, FH, SH do you want to know? PMH: HTN, Hyperlipidemia. Takes Lisinopril HCT for blood pressure and atorvastatin for cholesterol. NKDA. No history of stroke or MI. FH: Dad died of a massive stroke. Mom died in an MVA. SH: 50 pack year smoking history, No alcohol, No elicit drugs, retired. 35 Balance Case cont’d What ROS do you want to know? (+) very mild posterior headache, mild nausea, incoordination- trying to button clothes, pick up glasses and put them on. Wife says speech seems a little slurred. He says his eyes don’t seem quite right. Again, some of this might come out if you ask early about associated symptoms. (-) numbness, tingling, burning, limb weakness, hearing loss, ear pain or vomiting 36 Balance Case cont’d What physical exam should you do? Neuro: (+) Romberg, ataxic gait- stumbles to right, abnormal rapid alternating movements on the right, past pointing with finger-to-nose, poor performance of heel to shin, strength/sensation intact BLE and BUE. CN IIXII intact. No nystagmus. Carotids- no bruit Heart-RRR Ears-TMs clear What’s your assessment and plan? 37 Numbness, Abnormal or Absent Sensation A 40-year-old female comes in with complaint of “numbness and tingling in my hands”. What’s your DDx? 38 Numbness, Abnormal or Absent Sensation 39 Numbness, Abnormal or Absent Sensation What are some key features to find out during your HPI? Ask the patient to be more precise in their description. Is there tingling like “pins and needles” (paresthesias) or a burning sensation? Burning pain occurs in painful sensory neuropathies from conditions like diabetes. Are there distorted sensations (dysesthesias)? In dysesthesias, light touch or pinprick, for example, may cause a burning or irritating sensation. Is sensation reduced or completely absent? 40 Numbness, Abnormal or Absent Sensation Establish the pattern of sensory loss. Is there a stocking-glove distribution? Is there a dermatomal distribution? Is there a peripheral nerve distribution? Is there a large body area affected? Are sensory deficits patchy, nondermatomal, and occurring in more than one limb? 41 Numbness, Abnormal or Absent Sensation Stocking-glove distribution polyneuropathies, especially from diabetes Peripheral neuropathies tend to affect the lower limbs first (lengthdependent). Dermatomal distribution nerve root compression from vertebral bone spurs or herniated discs; 42 Numbness, Abnormal or Absent Sensation Peripheral nerve distribution local nerve compression or “entrapment” Median Common Peroneal Radial Ulnar Lateral Cutaneous 43 Numbness, Abnormal or Absent Sensation Is there a large body area affected? central lesion like stroke Are sensory deficits patchy, nondermatomal, and occurring in more than one limb? multiple patchy areas of sensory loss in different limbs suggest mononeuritis multiplex, seen in diabetes and rheumatoid arthritis. 44 Numbness Case cont’d Mainly a tingly sensation. Touch feels “funny” “like when your leg falls asleep when you cross it”. Points to palmar aspect of hands-lateral aspect as well as thumb, index finger and part of middle finger. Worsening over past few months. Constant. Sometimes seems worse when she awakens. Actual has awoken her a few times recently. Tries to “shake it out”. Worse sometimes at work – she’s an ER scribe. What else do you want to know? 45 Numbness Case cont’d PMH: No chronic problems, No meds, NKDA FH: Parents alive with HTN, Sister healthy, son healthy. Unsure about grandparents. SH: No tobacco, EtOH or elicit drug use. Scribe- uses uncomfortable keyboard. 12-hour shifts. ROS: No numbness anywhere else. No neck pain, back pain or headaches. Maybe some weakness in the hands- Seemed to have trouble pouring milk this morning. What physical exam will you do? 46 Numbness Case cont’d PE VS: 122/72 76 14 98.8 Alert, no distress Altered sensation median nerve distribution bilaterally- soft touch and pin prick. 4/5 strength opposition of thumb bilaterally, BUE otherwise 5/5 Full ROM BUE and neck (+) Tinel’s and Phalen’s bilat No atrophy noted. 47 Numbness Case cont’d What’s your diagnosis? What do you tell her? 48 Weakness What conditions can cause weakness? It is important to clarify what the patient means! Fatigue? Apathy? Drowsiness? Lightheadedness? Actual loss of strength? 49 Weakness True motor weakness can arise from: CNS Stroke Tumor MS Peripheral nerve Herniated disc The neuromuscular junction Myasthenia gravis Lambert-Eaton A muscle You’ll learn these in MSK 50 Weakness Time course and location are especially relevant. Is the onset sudden, gradual or subacute, or chronic, over a long period of time? Abrupt onset of motor and sensory deficits occurs in TIA and stroke. Progressive subacute onset of lower extremity weakness suggests Guillain–Barré syndrome. Chronic, more gradual, onset of lower extremity weakness occurs in primary and metastatic spinal cord tumors. 51 Weakness What areas of the body are involved? Is the weakness generalized, or focal to the face or a limb? Does it involve one side of the body or both sides? What movements are affected? As you listen to the patient's story, identify the patterns below: Proximal—in the shoulder and/or hip girdle, for example Distal—in the hands and/or feet Symmetric—in the same areas on both sides of the body Asymmetric—types of weakness include focal, in a portion of the face or extremity; monoparesis, in an extremity; paraparesis, in both lower extremities; and hemiparesis, in one side of the body 52 Weakness Proximal—in the shoulder and/or hip girdle, for example To identify proximal weakness, ask about difficulty with movements such as combing hair, reaching up to a shelf, getting up out of a chair, or climbing stairs. Does the weakness get worse with repetition and improve after rest (suggesting myasthenia gravis)? Are there associated sensory or other symptoms? Proximal limb weakness, when symmetric with intact sensation, occurs in myopathies from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders like polymyositis and dermatomyositis. In the neuromuscular junction disorder myasthenia gravis, there is proximal typically asymmetric weakness that gets worse with effort (fatigability), often with associated bulbar symptoms such as diplopia, ptosis, dysarthria, and dysphagia. Distal—in the hands and/or feet To identify distal weakness, ask about hand strength when opening a jar or using scissors or a screwdriver, or problems tripping when walking. Bilateral predominantly distal weakness, often with sensory loss, suggests a polyneuropathy, as in diabetes. 53 Weakness Symmetric—in the same areas on both sides of the body Asymmetric—types of weakness include focal, in a portion of the face or extremity; monoparesis, in an extremity; paraparesis, in both lower extremities; and hemiparesis, in one side of the body Focal or asymmetric weakness has both central (ischemic, thrombotic, or mass lesions) and peripheral causes ranging from nerve injury to the neuromuscular junction disorders to myopathies. 54 Weakness Cases 68 year old female c/o “trouble moving the right side of my body” What do you want to know? HPI PMH FH SH ROS What Physical Exam? 55 Tremors or Involuntary Movements Tremor “a rhythmic oscillatory movement of a body part resulting from the contraction of opposing muscle groups,” the most common movement disorder. It may be an isolated finding or part of a neurologic disorder. Ask about any tremor, shaking, or body movements that the patient seems unable to control. Does the tremor occur at rest? Does it get worse with voluntary intentional movement or with sustained postures? 56 Tremors or Involuntary Movements Resting (Static) Tremors These tremors are most prominent at rest and may decrease or disappear with voluntary movement. Example is the common relatively slow, fine pill-rolling tremor of parkinsonism, about 5 per second. This low-frequency unilateral resting tremor, rigidity, and bradykinesia typify Parkinson disease. Postural Tremors These tremors appear when the affected part is actively maintaining a posture. Examples include the fine rapid tremor of hyperthyroidism, the tremors of anxiety and fatigue, and benign essential (and often familial) tremor. Essential tremors are high-frequency, bilateral, upper extremity tremors that occur with both limb movement and sustained posture and subside when the limb is relaxed; head, voice, and leg tremor may also be present. Intention Tremors Absent at rest Appear with movement Often get worse as the target gets closer. Causes include cerebellar disorders such as multiple sclerosis. 57 Tremors 64 year old male c/o “shaking in my right hand”. What do you want to know? HPI PMH FH SH ROS What Physical Exam? 58 Fainting and Blacking Out (Near-Syncope and Syncope) Patient reports of fainting or “passing out” are common and warrant a meticulous history to guide management and possible hospital admission. Begin by finding out whether the patient has actually lost consciousness. Did the patient hear external noise or voices throughout the episode, feel lightheaded or weak, but fail to actually lose consciousness, consistent with near syncope or presyncope? Or did the patient actually experience complete loss of consciousness, a more serious symptom representing true syncope, defined as a sudden but temporary loss of consciousness and postural tone from transient global hypoperfusion of the brain? 59 Syncope/Near Syncope Causes include: Seizures “Neurocardiogenic” conditions vasovagal syncope postural tachycardia syndrome carotid sinus syncope orthostatic hypotension Cardiac disease causing arrhythmias especially ventricular tachycardia and bradyarrhythmias. Stroke or subarachnoid hemorrhage are unlikely causes of syncope unless both hemispheres are affected. 60 Syncope/Near Syncope Elicit a complete description of the event. What was the patient doing when the episode occurred? Was the patient standing, sitting, or lying down? Were there any triggers or warning symptoms? How long did the episode last? Could voices still be heard? Importantly, were onset and offset slow or fast? Were there any palpitations? Is there a history of heart disease, which has a sensitivity for a cardiac cause of more than 95% (with a specificity of ∼45%)? In vasovagal syncope, the most common cause of syncope, look for the prodrome of nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event, then vagally mediated hypotension, often with slow onset and offset. In syncope from arrhythmias, onset and offset are often sudden, reflecting loss and recovery of cerebral perfusion. Try to interview any witnesses. Consider the possibility of a seizure, especially if the onset was abrupt and without warning. 61 Seizures Patients may report “spells” or fainting that raises suspicion of seizure. Seizure-a sudden excessive electrical discharge from cortical neurons. Seizures may be symptomatic, with an identifiable cause, or idiopathic. A careful history is important to rule out other causes of loss of consciousness and acute symptomatic seizures that have discernible explanations. 62 Seizures Epilepsy does not always involve loss of consciousness, depending on the type. generalized vs partial If available, ask a witness how the patient looked before, during, and after the episode. Was there any seizure-like movement of the arms or legs? Any incontinence of the bladder or bowel? What about any drowsiness or impaired memory after the event suggestive of a postictal state? Tonic–clonic motor activity, bladder or bowel incontinence, and postictal state characterize generalized seizures. Unlike syncope, tongue biting or bruising of limbs may occur. Ask about age at onset, frequency, change in frequency or symptom pattern, and use of medications, alcohol, or illicit drugs. Check for any history of head injury. 63 64 65 Cases 66 67 68 69 70 71 72 73 Questions? [email protected] Rm. 215 74