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QUESTIONS

DIRECTIONS: Choose the one best response to each question.

In evaluating a patient with a new focal neurologic deficit, which of the following should be the first diagnostic priority?

A. Obtaining an echocardiogram to evaluate for possible etiology of emboli

B. Obtaining an electroencephalogram to rule out seizures

C. Obtaining laboratory studies to rule out a metabolic reason for the supposed neurologic complaint

D. Obtaining rapid MRI with and without contrast

E. Obtaining the history and examination to identify the region of the nervous system that is likely to be responsible for the symptoms

The answer is E. (Chap. 415) The first priority is to identify the region of the nervous system that is likely to be responsible for the symptoms. Localization is usually possible from the history and physical examination. Errors commonly result from an overreliance on costly neuroimaging procedures and laboratory tests, which, while useful, do not substitute for an adequate history and neurologic 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. Deciding “where the lesion is” accomplishes the task of limiting the possible etiologies to a manageable, finite number. In addition, this strategy safeguards against making serious errors. For example, symptoms of recurrent vertigo, diplopia, and nystagmus should not trigger “multiple sclerosis” as an answer (etiology) but “brainstem” or “pons” (location); then a diagnosis of brainstem arteriovenous malformation will not be missed for lack of consideration.

Which of the following is usually the first to be affected (e.g., is the patient most likely to name incorrectly) in assessment of patient orientation?

A. Location

B. Name

C. Time

D. None of the above

The answer is C. (Chap. 415) In the neurological examination, orientation is tested by asking the person to state his or her name, location, and time (day of the week and date); time is usually the first to be affected in a variety of conditions. Simply asking these questions also allows initial assessment of speech and language. Speech is assessed by observing articulation, rate, rhythm, and prosody (i.e., the changes in pitch and accentuation of syllables and words). Language is further assessed by observing the content of the patient’s verbal and written output, response to spoken commands, and ability to read. A typical testing sequence is to ask the patient to name successively ...

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