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Hello and welcome to the neuro transmitters, a podcast about everything neurology with the goal of reducing your neur a phobia. I'm Doctor Michael Ken Trees. Today, we'll be talking about how to approach a patient with a suspected neurologic issue. This will likely be very basic information for anyone who's been practicing medicine for any significant length of time. But for those who are just starting clinical work or if the person has a passing interest and what goes into the thought process behind assessing a patient and coming to a diagnosis. Hopefully, this will provide some first principles in terms of how to think about the approach to a patient which can be broadly applied across medicine in general and some will be a little more specific to neurology. So as a neurologist, a lot of times people referred for what is thought to be a neurologic issue. And one of your first jobs is to figure out is it in fact a neurologic problem or is it related to something else going on? Some of the most common complaints that you'll see in the outpatient setting will include things like headache, numbness, weakness and while you can get similar complaints on the inpatient side of things. A lot of times you're going to see more altered mental status or confusion, uh stroke or stroke like symptoms, other types of more acutely developing neurologic problems and even from just the chief complaint, you're already kind of starting to formulate. All right, what are the things that I think this could be? And what are the things I need to look into? What kind of work that has already been done and kind of gathering all this information together, create your differential diagnosis. What things do you think are most likely to be causing the problem and what can you do to hopefully help it? So as you're talking with the person, you're trying to get a thorough history, right? You want to be clear, logical, comprehensive and hopefully lead you towards the answer. There are a lot of no monix that students are taught to do this old carts opqrst uh to try and make sure that you don't miss any kind of those essential elements of the history. Personally, I'm not a big fan of the review of systems as it is typically taught where you kind of go organ system by organ system and ask about things that may be totally irrelevant to the reason why the patient is there to see you today. Of course, it's important to ask about questions to relevant problems, but that I think should be up to your discretion as the physician. So I keep talking about the history a lot and that's because it is so important to making a correct diagnosis. Uh in every field of medicine, there was actually a nice little summary article written by Devin Xander just in January of 2022 where they were looking at the aphorism, quote, 80% of diagnosis can be made by history alone. This idea is based off of several papers of the first one of these is from the Lancet by Robert Platt back in 1947 who showed that in the 74 out of 100 patient's the history correctly predicted the final diagnosis. And this was again tested back in 1975 by Hampton and colleagues who showed a similar rate around 82%. And when the studies were averaged out, it came to around 75% where the diagnosis, the final diagnosis was the same as the initial diagnosis after the initial history. Like this article also points out a couple potential biases. Obviously, the first is that the first thing you're doing with the patient when they come to you for a problem is you're taking a history. And so that is going to be the first thing that guides your evaluation. I also like that it points out that the history can also be limited in an emergency setting or in a patient who's not able to express themselves uh increasing the utility of an exam and additional studies in those situations. Anecdotally. I would say this also matches up with my own experience of just taking a thorough history. More likely than anything else is going to get you closer to the right answer than most tests you're probably going to think of. I remember a specific case. Um, when I was a resident, one of my co residents was presenting someone in morning report and it had been a patient who, you know, had smelled something burning and then passed out. And so we had gotten consulted on the neurology service for concern from, you know, what did they have a seizure? Is that why they lost consciousness? And so he went and saw this patient and it turns out no, that is not what had happened. What had happened was the patient's house had been on fire and they passed out because of the smoke. So obviously not a primary neurologic issue in this case. But if you just get a very superficial story like, well, yeah, I guess that could be. And I want to contrast this with the story of another patient. Uh they've been having about 34 months of these new onset of panic attacks, which would last for maybe a minute or two at a time. There was no real history of panic attacks or any significant mental health disorders in the past. And this person was middle aged. So it was a little atypical. I ended up seeing them after an episode of loss of consciousness resulting in a car accident. And this was obviously very suspicious for not just anxiety attacks or panic attacks. Uh We got some head imaging and it did show a right temporal mass. The EG was done which did show epileptiform discharges in that same area. So obviously contrast this with the first story. Um this one, we have spells that were initially written off as not neurologic, which in hindsight, very likely were uh small seizures without loss of consciousness. Again, the point here is just to emphasize how important the history is and how sometimes innocuous things may eventually become important and just being as thorough as you can to make sure that you have all the pertinent information so that you can get your patient to a correct diagnosis anecdotally. I find that just having a regular conversation with someone is one of the best ways to get that information to establish that rapport that is going to help facilitate that physician patient relationship. Um You know, in neurology, we often do have long conversations I've gotten in the habit. I know not every doctor carries a black bag anymore. I I do have one and inside of it, I actually have a folding stool and we'll often sit down with the patient talk for a while and that lets them know that you're, you're there to have this conversation to talk for however long it takes to try and get to the right answer. And I, I do think that that uh unspoken communication comes through. Well, after you finish getting your story down, we move on to the neurologic exam. And hopefully you're able to focus in the pertinent parts of the neurologic exam based off of the history. What you think is going on by this point in time, the first time you see any patient, you should do a thorough and complete neurologic assessment. But depending on the nature of the complaint, maybe you'll do a little more extra mental status testing, maybe some extra strength testing, some more obscure reflexes. So there are lots of ways that the neurologic exam can be tailored to the individual depending on what you're thinking, what you need to evaluate for. So linking the history with your exam, you're able to take these two pieces and that really forms the bedrock of creating a neurologic differential diagnosis using the timeline that you got in your history. Whether the problem has been more acute, occurring over seconds, minutes, hours versus subacute over days, two weeks or even chronic problems over months to years. With where do you localize the neurologic dysfunction in the nervous system? Where in the neuro access, do you think the problem is most likely? And this approach is described in many different books. But the one that I found at most approachable and most concisely written was actually in a book by Doctor Erin Berkowitz called Clinical Neurology and Neuroanatomy. I think this is actually a very well written book. Uh The sentences are very digestible, especially when you compare it to some of the more Bible esque neurology textbooks like Victor's or Bradleys, things like that. Uh This is a great starting neuro book. Uh It's very well divided the first half into Neuroanatomy, the second part into Clinical Neuropathology. So you're able to go back and forth between those two very readily. And I think it's great for real new to neurology, for people wanting more review, wanting a little bit more in depth. And that can guide you into some of these more dense uh neurology textbooks or even into the current literature. I'll include a link to that book in the show notes as well. So let's talk a little bit more about the neurologic exam. Uh neurologist oftentimes are very fond of the neurologic exam and physical exam in general and that's part of what leads them into the specialty. It's one of the fields of medicine where the exam still matters heavily in our decision making and can't really readily be replaced by any specific diagnostic testing. The neuro exam is generally broken up into about seven different categories, although that can vary a little bit depending on what book you're looking at. But generally speaking, we have mental status which includes things like alertness, speech, many other higher cortical functions, the cranial nerves which include a lot of the special nerves around the head, uh site, hearing many many others, motor including strength, muscle, bulk sensation, including different types of sensation, which tells things about different pathways, reflexes, both your typical knee jerk. Although many patient's give me a surprise look when I actually check reflexes in their arms. But there are many accessory reflexes throughout the body that can be useful in certain situations. Coordination, looking at complex movements, tremors, things of that nature and finally, gate, which requires the coordination of many of these systems together to make sure that someone is able to stand up right move without falling over by taking all the elements of the neurologic exam together. And we're able to synthesize that. Hopefully, if we're practicing well into a lesion, an abnormal area of function somewhere in the nervous system in the neuro access. And by combining that with the timeline of the history as well as where we think the lesion is. Hopefully, we can create a very short list of problems on our differential diagnosis and that will guide our work up, guide our evaluation, what tests need to be done and what kind of treatments should we consider? Right from the get go going forward, we're going to dig into each of these aspects of the neurologic exam more in depth. Hopefully give some useful tips and tricks when you're performing it and give some useful resources as we go my goal for this episode and the next subsequent ones in this more basic vein of neurology is to provide that background for those who aren't in neurology or who are interested or considering neurology or want to just get better at neurology uh to get some of those first principles so that we can build that knowledge up and build on that as we go into specific disease processes and talk about the literature and things like that down the road. If you've enjoyed this podcast, please consider leaving a five star review on Apple itunes, Spotify or wherever you're listening from today and please subscribe for future episodes. You can also reach me on Twitter at Doctor Ken Trees. That's Kentris or by email at the Neuro Transmitters podcast at gmail dot com. Thank you so much for listening today and I hope you join us again for the next episode of the Neuro Transmitters.