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069-Workshop-Food Allergy WORKSHOP Practical Pointers For Your Practice Short Snappers in Neurology: Clinical Strategies and Problems Alan E. Goodridge , MD, FRCPC Presented at Memorial University’s Wednesday at Noon Ask the Consultant Seminar, January 17, 2007. Scenario 1 The approach to the neurological hen faced with a examination Wneurological The neurological exam can be daunting, but strate - problem, it is helpful, gies can be developed to target the key aspects of the during the history, to n neurological exam to answer the clinical questions make ©a judgment utio raised by the history. When faced with a neurologi - ht rib ig ist ad, cal problem, it is helpful, during the history, to mayke rregarding Dwhetwhnelor the p ial n do a judgment regarding whether the probleom is more rc rs ca use C proeblemuseis monoarl e likely likely to be of peripheral or central nervous system mm rised pers o utho y for (CNS) origin. r C ed. Ato bceopof peripheral or o hibit ingle When there are localizianglseymptomprs,osuch ats a s S use prin CNS origin. acute presentatiofnoofra hemirpisleegdia, the ceanntrdal origin t utho view of theNprooblem wUilnl abe obvioluasy. ,With clinical prob - This approach contrasts with problems that, disp lems where there are usually no localizing symp - based on the history, suggest a peripheral nervous toms, such as a headache or a seizure, the clinical system origin. For example, when the symptoms are exam is primarily directed towards the question of a localized to one limb ( i.e., with pain and numbness possible problem of central origin. in one arm). In this situation, the focus of the exam In both of these settings, the neurological examina - is different and requires more attention to a detailed tion should emphasize screening for deficits localized examination in the affected region. Knowledge of a to the CNS. Visual fields should be checked. The face small amount of classical anatomy is the key to should be examined for evidence of lower quadrant quickly assessing this type of problem to resolve the facial weakness. The limbs should be examined for established differential diagnosis. Try to identify upper motor neuron findings by assessing for prona - one or two key findings that will help resolve the tor drift of the outstretched arms, hyperreflexia and an differential diagnosis, as outlined in Scenario 3. upgoing toe. Simultaneously touching the arms bilat - With a gait disturbance, the differential diagno - erally and then the legs is useful for screening purpos - sis is extensive and the exam must be comprehen - es as is quickly checking sensation to pin prick in one sive, but clearly targeting the differential diagnosis part of each of the four limbs. Observation for incoor - in the examination usually helps localize the prob - dination by checking the finger-to-nose test and gait lem. Once anatomically localized to a region or sys - are useful quick screens. tem, the previously extensive differential diagnosis The Canadian Journal of CME / May 2007 51 WORKSHOP becomes highly focused. Assessment of proprio - istal leg weakness, ception will evaluate the possibility of a sensory ataxia. The presence of bilateral spasticity will cor - Despecially with relate with bilateral upper motor neuron lesions due to: reflex loss, points to a • a myelopathy, • multiple strokes, variety of peripheral • multiple sclerosis, or a neuropathies with motor • hereditary syndrome. involvement. Distal leg weakness, especially with reflex loss, points to a variety of peripheral neuropathies with In many cases with such a history, the examina - motor involvement. Proximal weakness suggests a tion will be normal or equivocal ( i.e., hurts to move myopathy such as polymyositis. A wide-based gait head but no definite neck stiffness). No matter what suggests cerebellar involvement and ridigity points the findings, in this scenario, the diagnostic to a Parkinsonian syndrome. Difficulty initiating approach is dictated by the history of a sudden and gait may suggest a frontal lobe gait apraxia. severe headache. During questioning, many patients will state their Scenario 2 headache began suddenly, but this must be explored further to determine if investigations are necessary. The sudden headache “Sudden” relates to the time a headache takes to reach peak severity, either instantaneously or almost so (with - in a minute). Headaches that start mildly and gradual - Meet Victor ly increase over many minutes are much less likely to be due to a subarachnoid hemorrhage. Victor, 29, presents with an acute onset of a diffuse, If the history does indicate a truly sudden and severe severe throbbing headache while playing hockey. headache, even in the absence of physical findings, the There is a prior history of migraine with visual aura following ingestion of Chinese food twice in the physician is obliged to confirm or rule out the question past. of subarachnoid hemorrhage. Therefore the patient He has never had a headache of such rapid onset in should have a CT scan of the head. However, this may the past. He is otherwise perfectly healthy. be negative even in the presence of subarachnoid hem - There is a family history of migraine. orrhage and if so, the clinician must proceed to do a lumbar puncture. The clinical problem in Victor’s case is to determine Only after the CT scan and lumbar puncture are if this is a non-life threatening problem such as both normal can a subarachnoid hemorrhage be effec - migraine, or a sinister cause such as subarachnoid tively ruled out and an alternate benign syndrome, such hemorrhage. The key aspects of the clinical exami - as migraine or thunderclap headache, becomes much nation are to look for meningeal signs, such as neck more likely. stiffness and to assess for any alteration in the level of consciousness. Screening for other signs suggesting Dr. Goodridge is an Assistant Professor of CNS pathology is reasonable, but the yield will be very Medicine (Neurology), Chief, Division of Neurology, Eastern Health, Memorial low in the absence of any other symptoms. University of Newfoundland and Labrador, St. John’s, Newfoundland. 52 The Canadian Journal of CME / May 2007 SHORT SNAPPERS IN NUEROLOXXGXY Scenario 3 The key in the assessment of this type of problem The numb hand is to establish a (relatively short) localizing differ - ential diagnosis and to use the physical exam to test or refute your various diagnostic hypotheses. Meet Annette It is useful to rely heavily on the history to estab - lish where the sensory symptoms predominate. If Annette, 56, presents to her FP with numbness and the symptoms predominate in digits one, two or tingling but no pain in digits one, two and three of three, carpal tunnel syndrome is an important con - the left hand. sideration. However, do not forget to consider a She has had treatment for left breast cancer several superficial radial neuropathy when the symptoms years ago, with no subsequent problems. will be on the dorsum of those digits and the adja - She saw a surgeon who believed she had carpal tunnel syndrome (CTS) and did a CTS release cent part of the hand. The C6 nerve root territory procedure without any electrodiagnostic testing. includes digit one and the C7 nerve root sensory The surgery did not help and she returns to you for dermatome includes digit three. These root territo - reassessment. ries usually include the adjacent digit(s) and corre - sponding part of the hand and forearm. If the clinical problem is defined by the present - Numbness and tingling in a few digits of one limb ing sensory symptoms, the motor and reflex exam as in Annette’s case whichstrongly favours a prob - can also help resolve the differential diagnosis. If lem of peripheral nerve origin which could extend the sensory symptoms includes digit one, the pres - from the spinal cord to the digital nerves. For this ence of wasting/weakness and reflex loss in the clinical problem, the differential diagnosis includes biceps or brachioradialis makes a C6 nerve root not only carpal tunnel syndrome but also superficial problem likely. If the sensory symptoms includes radial neuropathy, upper/middle brachial plexopathy digits three, the presence of wasting/weakness and C6/C7 radiculopathy. reflex loss in the triceps points to a C7 nerve root A careful examination of Annette reveales senso - problem. ry loss, not only in the symptomatic digits but Also, look for associated clinical signs. Do not including the entire lateral aspect of the left hand, forget to exam for a Tinel’s sign (mechanical sensi - adjacent forearm and upper arm. The biceps, bra - tivity of an injured nerve). Consider looking for a chioradialis and triceps tendon reflexes were all Tinel’s sign over the superficial radial nerve at the reduced and mild weakness was present in all of distal lateral forearm and not just over the median these muscles. nerve at the carpal tunnel. Look for impaired range This pattern of motor, reflex and sensory find - of movement of the neck, skin indentations from ings all correlate with involvement of the C6 and C7 tight wrist bands at the wrist (affecting superficial nerve roots, or corresponding parts of the brachial radial nerve) or wrist deformity from prior fracture plexus. Annette did have left breast cancer treated (affecting median nerve). with radiation. While imaging of the neck would be When numbness predominates in digit five, the a reasonable thing to do, the clinical history and differential diagnosis shifts considerably to include findings alone in this clinical context provide com - an ulnar neuropathy and C8 radiculopathy and the pelling evidence that her symptoms were due to a principals of identifying the overlapping and distin - radiation induced plexopathy. guishing motor and sensory findings should again be applied. The Canadian Journal of CME / May 2007 53.
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