Thursday, December 6, 2007

A thorough neurologic exam...

A thorough neurologic exam only delays the MRI.
--my neurosurgical resident when I was a 3rd year medical student

Primary care doctors do a lot of neurologic exams. We should. They are important for the assessment of many complaints. Unfortunately, I find them to be extremely low yield from a diagnostic perspective.

In general, I get all of the information that I need from the patient's history. If someone presents with a history of stroke symptoms, a normal exam does not preclude them from a trip to the ER. True neurologic disease is also generally quite obvious from the history. The diagnosis isn't always obvious, but the decision for additional labs and imaging (as well as a neurologic consult) has been made before my hands touch the patient. Lots of patients present with kooky neuro symptoms, heralded by a "good luck" from my nurse when she hands me the chart. I always know in advance that their exams are going to be normal.

It's true that for most medical complaints, the history yields more than the physical exam. But I've been surprised by virtually every organ system, happening upon something that I really wasn't expecting. Rashes, murmurs, masses, lymph nodes, foreign bodies...but the neuro exam has never surprised me.

So I was so excited this week to find something on a neuro exam! Hypertonicity, clonus, muscle weakness...but then I realized that even with a normal exam this unfortunate young lady would still have warranted an MRI, and her multiple sclerosis would have been discovered that way.

So I will continue to do my neurologic exams, when indicated.

But I'm beginning to think that arrogant resident was right.

1 comment:

Shauna said...

My FP diagnosed my MS...though she sent me for a neuro consult anyway and an MRI. I'm glad she knew what to look for as I had no history of neuro symptoms.