Chapter e70: Evaluation of Neurologic Illness

KEY CONCEPTS

• Accurate diagnosis of neurological disorders leads to effective pharmacotherapy.

• The clinical neurologic history and examination are the cornerstones of neurologic diagnosis and management.

• History and examination should be modified for the pediatric patient as appropriate.

• The neurologic history and examination are directed at localization of the disease process so that a differential diagnosis can be formed.

• After forming the differential diagnosis, appropriate testing helps pinpoint the correct diagnosis.

• Accurate diagnosis leads to appropriate therapy and management of neurologic conditions.

• Appropriate history taking and examination techniques are useful for monitoring and evaluating the pharmacotherapeutic plan.

• Lumbar puncture (LP) should only be performed when it can be done safely. Relative contraindications may include increased intercranial pressure, mass lesions, papilledema, and coagulopathies.

Patient Care Process for Neurological Evaluation

Collect

• Patient characteristics (eg, age, sex, pregnant)

• Patient medical history (personal, family, birth, and developmental) (see section “Signs and Symptoms of Neurologic Disorders”; Table e70-1)

• Social history (eg, tobacco/ethanol use)

• Current and previous medications including nonprescription medications, herbal products, and dietary supplements (see section “Signs and Symptoms of Neurologic Disorders”)

• Objective data

  • Neurologic examination (ie, higher cortical function, cranial nerves, motor function, reflexes, cerebellar function, sensory function, and gait) (see section “The Neurologic Examination”; Table e70-2)

  • Blood pressure (BP), heart rate (HR), height, weight

  • Laboratory examinations as appropriate for the differential diagnosis and possibly including examination of the cerebrospinal fluid (CSF) (see section “Laboratory Findings for Neurologic Disorders and Their Interpretation”; Table e70-3; Fig. e70-1)

  • Imaging studies as appropriate (eg, computed tomography [CT] of head) (see section “Diagnosing Neurologic Anatomic Abnormalities”)

  • Electrophysiology studies as appropriate (eg, nerve conduction velocities [NCV], electromyography [EMG], and electroencephalogram [EEG]) (see section “Assessing Neurologic Dysfunction”)

Assess

• Results of history and neurological examination

• Ability/willingness to obtain diagnostic testing (eg, insurance coverage, travel, undergoing invasive testing)

• Relative contraindications for lumbar puncture (see section “Laboratory Findings for Neurologic Disorders and Their Interpretation”)

  • Relative contraindications for magnetic resonance imaging (MRI) (see section “Diagnosing Neurologic Anatomic Abnormalities”)

• Emotional status (eg, presence of anxiety, depression)

Plan^*

• Order appropriate diagnostic testing

• With established diagnosis, develop therapeutic plan (see disease-specific chapters)

• Monitoring parameters including efficacy and safety of any therapies; frequency and timing of follow-up

• Patient education regarding testing and diagnosis

• Referrals to other neurology specialists when appropriate (eg, memory disorders, stroke)

Implement

• Provide patient education regarding all elements of evaluation and treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence to any therapies

• Schedule follow-up

Follow-up: Monitor and Evaluate

• Resolution of neurologic symptoms

• Presence of adverse effects of therapy

• Patient adherence to treatment plan using multiple sources of information

• Reevaluate as needed

Preclass Engaged Learning Activity

Watch the video entitled “The Neurologic Screening Exam” in AccessPharmacy by Daniel H. Lowenstein. https://accesspharmacy.mhmedical.com/MultimediaPlayer.aspx?MultimediaID=12986884

This 9-minute video provides a brief overview ...