Approach to the Patient with Neurologic Disease
Neurologic diseases are common and costly. According to estimates by the World Health Organization, neurologic disorders affect over 1 billion people worldwide, constitute 12% of the global burden of disease, and cause 14% of global deaths (Table 415-1). These numbers are only expected to increase as the world’s population ages. Because therapies now exist for many neurologic disorders, a skillful approach to diagnosis is essential. Errors commonly result from an overreliance on costly neuroimaging procedures and laboratory tests, which, while useful, do not substitute for an adequate history and examination. The proper approach begins with the patient and focuses the clinical problem first in anatomic and then in pathophysiologic terms; only then should a specific neurologic diagnosis be entertained. This method ensures that technology is judiciously applied, a correct diagnosis is established in an efficient manner, and treatment is promptly initiated.
TABLE 415-1Global Disability-Adjusted Life-Years (DALYs) and Number of Annual Deaths for Selected Neurologic Disorders in 2015 |Favorite Table|Download (.pdf) TABLE 415-1 Global Disability-Adjusted Life-Years (DALYs) and Number of Annual Deaths for Selected Neurologic Disorders in 2015
|Disorder ||DALYs ||Deaths |
|Low back and neck pain ||94,941,000 ||— |
|Cerebrovascular diseases ||118,627,000 ||6,326,000 |
|Meningitis and encephalitis ||33,848,000 ||529,000 |
|Migraine ||32,898,000 ||— |
|Epilepsy ||12,418,000 ||125,000 |
|Dementia ||23,779,000 ||1,908,000 |
|Parkinson’s disease ||2,059,000 ||117,000 |
|% of total DALYs or deaths for all causes that are neurologic ||9.7% ||16.3% |
|% change of DALYs for neurologic disorders between 2005 and 2015 ||17.0% ||35.2% |
The first priority is to identify the region of the nervous system that is likely to be responsible for the symptoms. Can the disorder be mapped to one specific location, is it multifocal, or is a diffuse process present? Are the symptoms restricted to the nervous system, or do they arise in the context of a systemic illness? Is the problem in the central nervous system (CNS), the peripheral nervous system (PNS), or both? In the CNS, is the cerebral cortex, basal ganglia, brainstem, cerebellum, or spinal cord responsible? Are the pain-sensitive meninges involved? In the PNS, could the disorder be located in peripheral nerves and, if so, are motor or sensory nerves primarily affected, or is a lesion in the neuromuscular junction or muscle more likely?
The first clues to defining the anatomic ...