Practice only makes permanent. Perfect practice makes perfect

Journal of the Royal Society of Medicine, 2014

Journal of neurology, neurosurgery, and psychiatry, 2015

This review argues that even with the tremendous advances in diagnostic neuroimaging that the clinical skills involved in clinical neurology (ie, history, examination, localisation and differential diagnosis) remain key. Yet a number of recent audits suggest that large numbers of patients are failing to be assessed properly with a risk of patient harm, costly, unnecessary or inappropriate investigations, or delayed diagnosis. We review some of the reasons why patients are not being assessed properly neurologically, in part as many doctors have limited neurological exposure and are hence neurophobic. We propose that a solution to these issues centres around ensuring that a core set of basic neurological skills is taught at an undergraduate level, whereas higher level skills, such as the use of heuristics, are taught at postgraduate level.

Journal of Clinical Neuroscience, 2012

The diagnostic value and reliability of selected neurological clinical tests was studied in control subjects with normal neuroimaging (n = 42), and subjects with a focal brain lesion (n = 38). The items were studied by two examiners blinded to group membership and using standardized protocols, and subsequently by a neurologist who was not blinded to diagnosis. The positive likelihood ratios ranged from 1.06 (pronator drift) to 22.11 (single leg stance with eyes open, while the negative likelihood ratios ranged from 0.47 (tandem gait) to 0.97 (pupil symmetry). Three items (single leg stance -eyes closed -firm surface; single leg stance -eyes open -foam surface; and tandem gait) successfully distinguished between the two groups (odds ratio p < 0.05). The inter-rater reliability was generally poor, with only tandem gait showing excellent agreement (kappa [K] = 0.92). Tandem gait was the only item to show noteworthy agreement (K = 0.93) between the examiners and the neurologist. The tests varied considerably in their ability to detect radiologically demonstrated structural brain lesions, and several items were poorly reproducible, questioning their value as part of a routine neurological examination.

Annals of neurology, 2012

Arquivos de neuro-psiquiatria, 2015

The objective of this article is to highlight some of the most important pioneering books specifically focused on the neurological examination and their authors. During the XIX Century, Alexander Hammond, William Gowers and Charles Mills pioneered the neurological literature, followed in the XX Century by Aloysio de Castro, Monrad-Krohn, Derek Denny-Brown, Robert Wartenberg, Gordon Holmes, and Russel DeJong. With determination and a marked sense of observation and research, they competently developed and spread the technique and art of the neurological exam.

Journal of Parkinson's disease, 2014

2011

eMedicine Specialties &gt; Clinical Procedures &gt; none Neurological History and Physical Examination Kalarickal J Oommen, MD, FAAN, Professor and Crofoot Chair of Epilepsy, Department of Neurology, Chief, Section of Epilepsy, Texas Tech University Health Sciences Center; Medical Director, Texas Tech University Health Sciences Center (TTUHSC) Covenant Comprehensive Epilepsy Center Updated: Nov 25, 2009 Neurological History

Neurosciences

Neurology, 2011

Objective: We hypothesized that trainees would perform better using a hypothesis-driven rather than a traditional screening approach to the neurologic examination. Methods: We randomly assigned 16 medical students to perform screening examinations of all major aspects of neurologic function or hypothesis-driven examinations focused on aspects suggested by the history. Each student examined 4 patients, 2 of whom had focal deficits. Outcomes of interest were the correct identification of patients with focal deficits, number of specific deficits detected, and examination duration. Outcomes were assessed by an investigator blinded to group assignments. The McNemar test was used to compare the sensitivity and specificity of the 2 examination methods. Results: Sensitivity was higher with hypothesis-driven examinations than with screening examinations (78% vs 56%; p ϭ 0.046), although specificity was lower (71% vs 100%; p ϭ 0.046). The hypothesis-driven group identified 61% of specific examination abnormalities, whereas the screening group identified 53% (p ϭ 0.008). Median examination duration was 1 minute shorter in the hypothesis-driven group (7.0 minutes vs 8.0 minutes; p ϭ 0.13). Conclusions: In this randomized trial comparing 2 methods of neurologic examination, a hypothesis-driven approach resulted in greater sensitivity and a trend toward faster examinations, at the cost of lower specificity, compared with the traditional screening approach. Our findings suggest that a hypothesis-driven approach may be superior when the history is concerning for an acute focal neurologic process.