case files neurology
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case files neurology

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or nipple retrac-
tion as well as palpation for masses. The nipple should be assessed for
discharge, and the axillary and supraclavicular regions should be
5. Cardiac examination: The point of maximal intensity (PMI) should be
ascertained, and the heart auscultated at the apex as well as base. It is
important to note whether the auscultated rhythm is regular or irregular.
Heart sounds (including S3 and S4), murmurs, clicks, and rubs should be
characterized. Systolic flow murmurs are fairly common as a result of the
increased cardiac output, but significant diastolic murmurs are unusual.
6. Pulmonary examination: The lung fields should be examined system-
atically and thoroughly. Stridor, wheezes, rales, and rhonchi should be
recorded. The clinician should also search for evidence of consolida-
tion (bronchial breath sounds, egophony) and increased work of
breathing (retractions, abdominal breathing, accessory muscle use).
7. Abdominal examination: The abdomen should be inspected for scars,
distension, masses, and discoloration. For instance, the Grey-Turner sign
of bruising at the flank areas can indicate intraabdominal or retroperi-
toneal hemorrhage. Auscultation should identify normal versus high-
pitched and hyperactive versus hypoactive bowel sounds. The abdomen
should be percussed for the presence of shifting dullness (indicating
ascites). Then careful palpation should begin away from the area of pain
and progress to include the whole abdomen to assess for tenderness,
masses, organomegaly (i.e., spleen or liver), and peritoneal signs.
Guarding and whether it is voluntary or involuntary should be noted.
8. Back and spine examination: The back should be assessed for symme-
try, tenderness, or masses. The flank regions particularly are important
to assess for pain on percussion that may indicate renal disease.
9. Perform genital examination and rectal examination as needed.
10. Extremities/Skin: The presence of joint effusions, tenderness, rashes,
edema, and cyanosis should be recorded. It is also important to note
capillary refill and peripheral pulses.
11. Neurologic examination: Patients who present with neurologic com-
plaints require a thorough assessment including mental status, cranial
nerves, muscle tone, and strength, sensation, reflexes, and cerebellar
function, and gait to determine where the lesion or problem is located
in the nervous system. Locating the lesion is the first step to generat-
ing a differential of possible diagnoses and implementing a plan for
a. Cranial nerves need to be assessed: ptosis (III), facial droop (VII),
hoarse voice (X), speaking and articulation (V, VII, X, XII), eye
position (III, IV, VI), pupils (II, III), smell (I); visual acuity and
visual fields, pupillary reflexes to light and accommodation; hearing
acuity and Weber and Rinne test, sensation of three branches of V
of face; shrug shoulders (XI), protrude tongue (VII).
b. Motor: Observe for involuntary movements, muscle symmetry
(right vs. left, proximal vs. distal), muscle atrophy, gait. Have
patient move against resistance (isolate muscle group, compare
one side vs. another, and use 0\u20135 scale).
c. Coordination and gait: Rapid alternating movements, point-to-point
movements, Romberg test, and gait (walk, heel-to-toe in straight
line, walk on toes and heels, shallow bend and get up from sitting).
d. Reflexes: biceps (C5,6), triceps (C6,7), brachioradialis (C5,6),
patellar (L2\u20134), ankle (S1\u20132).
e. Clonus and plantar reflex.
f. Sensory: Patient\u2019s eyes should be closed, compare both sides of
body, distal versus proximal; vibratory sense (low pitched tuning
fork); subjective light touch; position sense, dermatome testing,
pain, temperature.
g. Discrimination: Graphesthesia (identify number \u201cdrawn\u201d on
hand), stereognosis (place familiar object in patient\u2019s hand), and
two-point discrimination.
12. Mental status examination: A thorough neurologic examination requires
a mental status examination. The Mini-Mental Status examination is a
series of verbal and non-verbal tasks that serves to detect impairments
in memory, concentration, language, and spatial orientation.
\u2756 A thorough understanding of functional anatomy is important to
optimally interpret the physical examination findings.
13. Laboratory assessment depends on the circumstances
a. Complete blood count (CBC) can assess for anemia, leukocytosis
(infection), and thrombocytopenia.
b. Basic metabolic panel: electrolytes, glucose, blood urea nitrogen
(BUN) and creatinine (renal function).
c. Urinalysis and/or urine culture to assess for hematuria, pyuria, or
bacteruria. A pregnancy test is important in women of child-
bearing age.
d. Aspartate aminotransferase (AST), alanine aminotransferase
(ALT), bilirubin, alkaline phosphatase for liver function; amylase
and lipase to evaluate the pancreas.
e. Cardiac markers (creatine kinase myocardial band [CK-MB], tro-
ponin, myoglobin) if coronary artery disease or other cardiac dys-
function is suspected.
f. Drug levels such as acetaminophen level in possible overdoses.
g. Arterial blood gas measurements give information about oxygena-
tion, but also carbon dioxide and pH readings.
14. Diagnostic adjuncts
a. Electroencephalogram (EEG) if focal or gross central nervous sys-
tem pathology is suspected.
b. Computed tomography (CT) is useful in assessing the brain for
masses, bleeding, strokes, skull fractures.
c. Magnetic resonance imaging helps to identifies soft tissue planes
very well.
d. Lumbar puncture is indicated to assess any inflammatory, infec-
tious, or neoplastic processes that can affect the brain, spinal cord,
or nerve roots.
Classic Clinical Problem-Solving
There are typically four distinct steps that the family physician undertakes to
systematically solve most clinical problems:
1. Making the diagnosis
2. Assessing the severity of the disease
3. Treating based on the stage of the disease
4. Following the patient\u2019s response to the treatment
Making the Diagnosis This is achieved by carefully evaluating the patient,
analyzing the information, assessing risk factors, and developing a list of pos-
sible diagnoses (the differential). Usually a long list of possible diagnoses can
be pared down to a few of the most likely or most serious ones, based on the
clinician\u2019s knowledge, experience, and selective testing. For example, a 30-
year-old patient who complains of acute onset of right facial weakness and
drooling from the right side probably has a cranial nerve VII palsy. Yet another
individual who is a 60-year-old man with right sided facial weakness and left
arm numbness likely has an ischemic stroke.
\u2756 The first step in clinical problem solving is making the diagnosis.
Assessing the Severity of the Disease After establishing the diagnosis, the
next step is to characterize the severity of the disease process; in other words,
to describe \u201chow bad\u201d the disease is. This can be as simple as determining
whether a patient is \u201csick\u201d or \u201cnot sick.\u201d Is the patient with a hemorrhagic
stroke comatose or with a \u201cblown pupil\u201d? In other cases, a more formal stag-
ing can be used. For example, cancer staging is used for the strict assessment
of extent of malignancy.
\u2756 The second step is to establish the severity or stage of disease. This
usually impacts the treatment and/or prognosis.
Treating based on Stage Many illnesses are characterized by stage or severity
because this affects prognosis and treatment. As an example, a patient with mild
lower extremity weakness and areflexia that develops over 2 weeks may be care-
fully observed; however once respiratory