Neurological thinking

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Neurological thinking

How does an experienced clinical neurologist come to a clinical diagnosis? Considering how this is done helps to appreciate the knowledge and skills that are needed and to understand how they are applied.

The process of diagnosis involves:

image Background knowledge of neurological symptoms and signs, the clinical features of neurological syndromes and diseases, neuroanatomy and an appreciation of the incidence of different neurological syndromes.
image The techniques of taking a neurological history and conducting a neurological examination. The techniques that are used will depend on the patient’s problem and different approaches will be used in different clinical settings.
image A method of synthesizing this information: ‘neurological thinking’ (Fig. 1).
image

Fig. 1 Neurological thinking.

The background knowledge of the different neurological conditions is dealt with mainly in section 5 of this book. The techniques of history taking and examination are described in section 2, and their application in particular situations in section 4. The process of synthesis of information is best acquired with clinical experience and is learnt from teaching at the bedside or by watching a neurologist in outpatients. However, it is easier to learn if you understand what is involved in the process.

Making a neurological diagnosis

There are two ways of making a neurological diagnosis clinically.

‘Wiring diagram analysis’ or anatomical localization

This method tends to be emphasized in teaching because it involves deduction of the site of a lesion from knowledge of neuroanatomy and of the neuropathological process from the history, for example the recognition that a combined trigeminal, facial and auditory nerve lesion is sited at the cerebellopontine angle. This is useful, and having seen one constellation of signs, the pattern is recognized the next time.

This process is led by the history but is primarily a synthesis of findings on clinical examination. In trying to make sense of the physical signs, one should think about which level of the nervous system is being affected (p. 2). The onset and progression of the anatomically determined symptoms reflect the underlying pathology; this information is taken from the history, and is discussed further on pages 8–9.

Pattern recognition or syndromic diagnosis

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