Talk More, Examine Less

Abstract & Commentary

Source: Dooley JM, et al. The utility of the physical examination and investigations in the pediatric neurology examination. Pediatr Neurol. 2003;28:96-99.

In this original study, 500 consecutive pediatric referrals for neurologic consultation were assessed to determine what influence, if any, was played by the history, neurologic examination, and investigations, with respect to final diagnosis and patient management. Upon receipt of a referral letter, the consulting neurologist was asked to predict what he or she would find on examination, what the final diagnosis would be, and what testing might be necessary. Upon seeing the patient, the neurologist was blinded to the previous predictions and, after obtaining the history and once more after the examination, opinions were again sought with respect to the final diagnosis and need for investigations. Data were analyzed using EPI Info version 6.04b, a microcomputer word-processing, database, and statistics program for epidemiology.1

Final diagnoses for the 500 children included headache (n = 150), seizures (n = 68), Tourette syndrome (n = 58), attention-deficit-hyperactivity disorder/learning disability (ADHD/LD) (n = 41), cerebral palsy (n = 21), developmental delay (n = 18), or other neurologic disorders (n = 144). Among headache patients, Tourette syndrome, ADHD/LD, and developmental delay, the neurologic examination never influenced management or outcome. Examination was influential in 4 patients each with seizures or cerebral palsy. Investigations never influenced Tourette syndrome, ADHD/LD, or cerebral palsy but did influence management or outcome in 16 seizure patients. Investigations were rarely useful in developmental delay, where only 1 suspected fragile X was found to have normal chromosomal analysis, or in headache referrals, where in only 2 patients other disorders were excluded by imaging and/or EEG. Neither examination nor investigations influenced Tourette syndrome or ADHD/LD. For the majority of pediatric neurology consultations, most efforts should be expended on history, by far the singular critical component to appropriate patient care.

Commentary

The underpinnings of the neurologic examination can be traced back to antiquity. Herophilus and Eristratus (ca 280-290 bce), of Alexandria, Egypt, first mention the cranial nerves, though it was left for Rufus of Ephesus (ca 100) to note that they and the brain constituted an anatomic continuum. Galen of Pergamon (d 216) authored 15 volumes titled On Anatomic Procedures, identifying 10 pairs of cranial nerves, at least 1 incorrectly. Thomas Willis (1621-1675) correctly labeled 6 pairs, but it was Samuel Thomas von Soemmering (1755-1830) who classified 12 cranial pairs, later formalized in 1895 with the publication of Basle Nomina Anatomica. 2

Gowers elegantly outlined the orderly examination of the motor system in 1886 with publication of his Manual of Diseases of the Nervous System, incorporating the concept of an upper and lower motor neuron with notation of their different signs.3 Earlier, Erb and Westphal had simultaneously introduced deep-tendon reflexes to the medical literature, with Erb correctly interpreting the phenomenon as representing a true reflex arc.4 Dysdiadochokinesis was coined by Babinski in 1902, while rebound was described by Gordon Holmes in 1904, who also described dysmetria in 1917. These components of the cerebellar examination were soon incorporated into contemporary textbooks of neurology and included in the neurologic examination.5 Brown-Sequard, Edinger, Rinne, and van Gehuchten, among others, contributed to elucidating the anterolateral, pain and temperature, and posterior, vibration, and position sensory pathways.

Steeped though it is, in the ancient past, the neurologic examination is not yet ready for the ashbin of history. However, as managed care evolves, its cost-effective delivery will likely demand that we take Dooley and associates’ results into consideration in the not-too-distant future. Further confirmation of these findings, with their extension into adult counterparts, will be welcome. — Michael Rubin

Dr. Rubin is Professor of Clinical Neurology, New York Presbyterian Hospital - Cornell Campus.

References

1. Dean AG, et al. CDC. Atlanta, GA. 1977.

2. Steinberg DA. Semin Neurol. 2002;4:349-356.

3. York GK. Semin Neurol. 2002;4:367-374.

4. Louis ED. Semin Neurol. 2002;4:385-390.

5. Fine EJ, et al. Semin Neurol. 2002;4:375-384.