case files neurology
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case files neurology


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depression occurs, then respiratory sup-
port must be given.
CLINICAL PEARL
\u2756 The third step is tailoring the treatment to fit the severity or \u201cstage\u201d
of the disease.
Following the Response to Treatment The final step in the approach to dis-
ease is to follow the patient\u2019s response to the therapy. Some responses are clin-
ical such as improvement (or lack of improvement) in a patient\u2019s strength; a
standardized method of assessment is important. Other responses can be fol-
lowed by testing (e.g., visual field testing). The clinician must be prepared to
know what to do if the patient does not respond as expected. Is the next step
to treat again, to reassess the diagnosis, or to follow up with another more spe-
cific test?
CLINICAL PEARL
\u2756 The fourth step is to monitor treatment response or efficacy. This can
be measured in different ways\u2013symptomatically or based on
physical examination or other testing.
10 CASE FILES: NEUROLOGY
PART 3. APPROACH TO READING
The clinical problem-oriented approach to reading is different from the classic
\u201csystematic\u201d research of a disease. Patients rarely present with a clear diagno-
sis; hence, the student must become skilled in applying textbook information
to the clinical scenario. Because reading with a purpose improves the retention
of information, the student should read with the goal of answering specific
questions. There are several fundamental questions that facilitate clinical
thinking. These are:
1. What is the most likely diagnosis?
2. How would you confirm the diagnosis?
3. What should be your next step?
4. What is likely neuroanatomical defect?
5. What are the risk factors for this condition?
6. What are the complications associated with the disease process?
7. What is the best therapy?
CLINICAL PEARL
\u2756 Reading with the purpose of answering the seven fundamental clin-
ical questions improves retention of information and facilitates
the application of \u201cbook knowledge\u201d to \u201cclinical knowledge.\u201d
What Is the Most Likely Diagnosis?
The method of establishing the diagnosis has been covered in the previous sec-
tion. One way of attacking this problem is to develop standard approaches to
common clinical problems. It is helpful to understand the most common
causes of various presentations (see the Clinical Pearls at the end of each case),
such as \u201cthe worst headache of the patient\u2019s life is worrisome for a subarach-
noid hemorrhage.\u201d
The clinical scenario would be something such as:
\u201cA 38-year-old woman is noted to have a 2-day history of a unilateral,
throbbing headache and photophobia. What is the most likely diagnosis?\u201d
With no other information to go on, the student would note that this woman
has a unilateral headache and photophobia. Using the \u201cmost common cause\u201d
information, the student would make an educated guess that the patient has a
migraine headache. If instead the patient is noted to have \u201cthe worst headache
of her life,\u201d the student would use the clinical pearl: \u201cThe worst headache of
the patient\u2019s life is worrisome for a subarachnoid hemorrhage.\u201d
HOW TO APPROACH CLINICAL PROBLEMS 11
CLINICAL PEARL
\u2756 The more common cause of a unilateral, throbbing headache with
photophobia is a migraine, but the main concern is subarachnoid
hemorrhage. If the patient describes this as \u201cthe worst headache of
his or her life,\u201d the concern for a subarachnoid bleed is increased.
How Would You Confirm the Diagnosis?
In the scenario above, the woman with \u201cthe worst headache\u201d is suspected of hav-
ing a subarachnoid hemorrhage. This diagnosis could be confirmed by a CT scan
of the head and/or lumbar puncture (LP). The student should learn the limitations
of various diagnostic tests, especially when used early in a disease process. The LP
showing xanthochromia (red blood cells) is the gold standard test for diagnosing
subarachnoid hemorrhage, but it can be negative early in the disease course.
What Should Be Your Next Step?
This question is difficult because the next step has many possibilities; the
answer can be to obtain more diagnostic information, stage the illness, or
introduce therapy. It is often a more challenging question than \u201cWhat is the
most likely diagnosis?\u201d because there may be insufficient information to make
a diagnosis, and the next step may be to pursue more diagnostic information.
Another possibility is that there is enough information for a probable diagno-
sis, and the next step is to stage the disease. Finally, the most appropriate
answer may be to treat. Hence, from clinical data, a judgment needs to be ren-
dered regarding how far along one is on the road of:
1. Make a diagnosis \u2192 2. Stage the disease \u2192 3. Treat based on stage \u2192
4. Follow response
Frequently, the student is taught \u201cto regurgitate\u201d the same information that
someone has written about a particular disease but is not skilled at identifying
the next step. This talent is learned optimally at the bedside, in a supportive envi-
ronment, with freedom to take educated guesses and with constructive feedback.
A sample scenario can describe a student\u2019s thought process as follows:
1. Make the diagnosis: \u201cBased on the information I have, I believe that
Mr. Smith has a left-sided cerebrovascular accident.\u201d
2. Stage the disease: \u201cI don\u2019t believe that this is severe disease because
his Glasgow score is 12, and he is alert.\u201d
3. Treat based on stage: \u201cTherefore, my next step is to treat with oxygena-
tion, monitor his mental status and blood pressure, and obtain a CT scan
of the head.\u201d
4. Follow response: \u201cI want to follow the treatment by assessing his
weakness, mental status, and speech.
12 CASE FILES: NEUROLOGY
CLINICAL PEARL
\u2756 Usually, the vague query, \u201cWhat is your next step?\u201d is the most dif-
ficult question because the answer can be diagnostic, staging, or
therapeutic.
What Is Likely Neuroanatomical Defect?
Because the field of neurology seeks to correlate the neuroanatomy with the
defect in function, the student of neurology should constantly be learning the
function of the various brain centers and the neural conduits to the end organ.
Conveniently, neurology can be subdivided into compartments such as move-
ment disorders, stroke, tumor, and metabolic disorders for the purpose of read-
ing; yet, the patient can have a disease process that affects more than one
central nervous function.
What Are the Risk Factors for This Process?
Understanding the risk factors helps the practitioner to establish a diagnosis
and to determine how to interpret tests. For example, understanding risk fac-
tor analysis may help in the management of a 55-year-old woman with carotid
insufficiency. If the patient has risk factors for a carotid arterial plaque (such
as diabetes, hypertension, and hyperlipidemia) and complains of transient
episodes of extremity weakness or numbness, she may have either embolic or
thrombotic insufficiency.
CLINICAL PEARL
\u2756 Being able to assess risk factors helps to guide testing and develop
the differential diagnosis.
What Are the Complications to This Process?
Clinicians must be cognizant of the complications of a disease, so that they
will understand how to follow and monitor the patient. Sometimes the student
will have to make the diagnosis from clinical clues and then apply his or her
knowledge of the consequences of the pathologic process. For example, \u201cA 26-
year-old male complains of severe throbbing headache with clear nasal
drainage.\u201d If the patient has had similar episodes, this is likely a cluster
headache. However, if the phrase is added, \u201cThe patient is noted to have
dilated pupils and tachycardia,\u201d then he is likely a user of cocaine.
Understanding the types of consequences also helps the clinician to be aware
of the dangers to a patient. Cocaine intoxication has far different consequences
such as myocardial infarction, stroke, and malignant hypertension.
HOW TO APPROACH