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The Neurologic Diagnosis: A Practical Bedside A...

SYNOPSIS: Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our Viewpoint is based on neuroscientific principles. We highlight 6 challenges for clinicians when conducting neurological examinations and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. J Orthop Sports Phys Ther 2023;53(3):107-112. Epub: 28 October 2022. doi:10.2519/jospt.2022.11281.

The Neurologic Diagnosis: A Practical Bedside A...

Saccades are one of the most useful types of eye movements in the evaluation of the movement disorders patient. The presence of characteristic saccadic abnormalities can be enormously helpful in guiding diagnosis in the outpatient clinic. We present a simplified review the anatomy of horizontal and vertical saccades, discuss practical aspects of their examination, and review saccadic abnormalities in hyperkinetic and hypokinetic movement disorders. Further, we provide an algorithm illustrating the value of saccadic abnormalities in the differential diagnosis of the movement disorders patient. The goal is to provide a practical guide to bedside evaluation of saccades in the context of the movement disorders patient. As such, comprehensive coverage of normal and abnormal ocular motor anatomy and physiology are not included and the reader is referred to comprehensive coverage elsewhere [1, 2].

This book is based on the personal experience of the author as a neurologist and lecturer for seven years. The author has strived to discuss the clinical approach to diagnosis in the simplest and yet most comprehensive manner. The algorithms help medical students to organize their thoughts so that they are prepared to examine any neurological patient. The ultimate aim is to help medical students make neurological diagnosis at the bedside after five minutes of physical examination. The highly practical approach of this book makes it very useful for reference in the ward and clinic.

Neurophobia, a discomfort with assessing and treating neurologic complaints, is very common among medical providers. Among British medical students, house officers, and general practitioners, neurology was ranked as the most difficult subspecialty and was the subject doctors felt least confident handling at the bedside.1,2 Studies of US medical students and residents confirmed these findings.3

The ongoing COVID-19 pandemic has placed an increased emphasis on virtual and remote learning. Although virtual education can be beneficial in certain circumstances, our results show that residents prefer to learn neurology via bedside teaching. We propose that future educational interventions for internal medicine residents not only address the above topics but incorporate bedside teaching where possible. At our institution we are currently piloting a bimonthly program that pairs a senior neurology resident with an internal medicine team for bedside teaching on the neurologic exam.

Background: Evaluating a patient with brain injury (traumatic or non-traumatic) is challenging. Potential outcomes are often unclear as the manifestations of brain injuries evolve over time and can result in dynamic changes in consciousness. This can create confusion for prognostication and clinical decision-making. Appropriate classification of disorders of consciousness (DOC) involves a careful assessment of neurologic function at the bedside and an understanding of the expected time frame during which neurologic function can evolve. Although neurologic assessment and diagnosis is the role of a neurologist, it is important for palliative care clinicians to understand the diagnosis so they can appropriately educate and counsel families. This Fast Factaims to help clinicians understand the terminology around DOC. Prognosis in DOC will be discussed in a future Fast Fact.

Approach to examination: Assessment of consciousness and neurologic function are determined by the bedside exam. Brain imaging and neurophysiologic testing are performed to aid in determination of the extent of neurologic injury but are not definitive for determination of diagnosis and prognosis which is done by monitoring clinical change over time. A careful mental status exam assessing conscious awarenessand wakefulnessis critical to establishing the diagnosis of DOC.

In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.

For neurology 80% presence during practical training and during obligatory seminars (Clinical seminars with controlled presence), passing bedside practical exam on neurological examination and proving basic knowledge on general neurology (syndromes and topical diagnosis) is required. 041b061a72

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