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Information ⬇

Author: Simon Rinaldi

Priorities ⬆ ⬇

  • Identify or exclude an immediately life-threatening disorder (see Figure 14.1, Table 14.1) such as stroke, cord compression, or meningo-encephalitis.
  • The history (Table 14.2) is usually the critical step in establishing a differential diagnosis:
    • Pattern recognition may suggest some diagnoses, for example an acute onset, right sided hemiparesis with dysphasia and homonymous hemianopia in a hypertensive smoker is recognized as a left cerebral hemisphere anterior circulation stroke.
    • In more difficult cases, a logical system for working through potential diagnoses can be based on the localization (Table 14.3) or temporal evolution of symptoms (Table 14.4).
  • A systematic ‘full’ or ‘screening’ neurological examination is not usually indicated. It may be better to target the examination to test the differential diagnostic hypotheses generated during history taking (Table 14.5).
    • Asymptomatic areas should still be examined. For example, demonstrating normal arm function in suspected spinal cord compression is helpful in placing the lesion below the level of the cervical cord.
    • Remember that performance in the different domains is not independent. For example a patient with limb weakness may appear uncoordinated despite normal proprioceptive and cerebellar function.
  • The distinction between upper and lower motor neuron pathology and the implication of certain patterns of weakness is discussed in further detail in Chapter 17. Specific patterns of visual loss also have clear value in localization (Chapter 19).
  • Table 14.6 summarizes the indications and limitations of the tests most often needed.

Further Management ⬆ ⬇

  • Some presentations may allow discharge and deferred outpatient investigations following initial assessment, with or without a short period of observation, for example gradual-onset resolving headache without red flag features or signs (Chapter 15) or a fully resolved solitary seizure without systemic upset (Chapter 16).
  • Transient symptoms may not be benign:
    • Transient loss of consciousness suggestive of intermittent raised ICP/CSF outflow obstruction will require urgent neurosurgical management (Chapter 72).
    • Suspected cardiac syncope will require cardiac workup (Chapter 9).
    • Transient ischaemic attacks (TIAs) require urgent assessment even if all symptoms have resolved; clinical scoring schemes provide an indication regarding how quickly subsequent investigations should be performed (Chapter 66).
  • For patients requiring admission, there should be a clear plan for monitoring:
    • What is to be monitored?
    • How often should observations be performed?

    • What are the thresholds for action?

      These should be clearly documented and communicated to the relevant staff.

  • The patients requiring closest monitoring are typically those in whom potentially life-threatening complications may occur, especially when these may be subtle and when interventions are available to modify the disease course, for example:
    • Neuromuscular respiratory failure. Symptoms can be minimal even with profound hypoventilation, emphasizing the need for regular vital capacity measurement.
    • Patients with or at risk of coma and rising ICP. This may range from regular assessment of conscious level and/or pupillary and other reflexes, to serial imaging studies and invasive ICP monitoring.

Further Reading ⬆

O'Brien MD (2014) Use and abuse of physical signs in neurology. Journal of the Royal Society of Medicine 107, 416–421. DOI: 10.1177/0141076814538785

Shibasaki H, Hallett M. (2016) The Neurologic Examination: Scientific Basis for Clinical Diagnosis. Oxford University Press.

Stone J, Reuber M, Carson A. (2013) Functional symptoms in neurology: mimics and chameleons. Pract Neurol 13, 104–113.