Neurologic diagnosis is considered difficult by many. Lesions at different levels of the nervous system can cause the same physical finding. For example, weakness of foot dorsiflexion can be caused by disease of the brain, brainstem, spinal cord, spinal nerve root, peripheral nerve, and muscles. In addition, neurologic pathophysiology can have positive or negative effects, or both. Loss of sensory or motor function may be transient or permanent. Alternatively, some nervous system structures have inhibitory effects. When destroyed, there may be increased function such as heightened muscle tone or pathologic hyperreflexia from upper corticospinal tract lesions. There may be irritative phenomena such as the pinsand-needles sensation of paresthesias, myoclonus, or focal seizures with jerking of a limb on one side of the body. In addition, some parts of the nervous system are relatively silent—extensive lesions can even be present without causing symptoms or abnormal findings.
In many neurologic conditions the neurologic examination may be normal, as when a patient recovers from attacks of epilepsy or a transient ischemic attack (TIA). In some neurologic diseases such as migraine, normal findings are expected—abnormal findings would trigger alarm and further evaluation. In some instances, symptoms in the absence of findings would raise concern, as with a TIA.
When you conduct the neurologic examination, it is wise to adopt a fixed routine or examination sequence to minimize omission of one of its important components. Pursue more detailed testing of areas targeted by symptoms and abnormal function. Follow-up examination over time is important for determining whether the patient's condition is getting worse, improving spontaneously, or responding to treatment. The goal of your assessment is not just diagnosis, but treating and restoring the patient to health and the full range of activities of daily living.
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