In the presence of risk factors for thromboembolism, a focal
neurological episode which has a sudden onset should be assumed to be
embolic until proved otherwise. Whether or not that episode is purely
ischaemic, or whether or not it undergoes subsequent hamorrhagic
transformation is a separate issue which should not detract from the
urgency to identify the embolic source by means of echocardiography. That
is why I am so...
In the presence of risk factors for thromboembolism, a focal
neurological episode which has a sudden onset should be assumed to be
embolic until proved otherwise. Whether or not that episode is purely
ischaemic, or whether or not it undergoes subsequent hamorrhagic
transformation is a separate issue which should not detract from the
urgency to identify the embolic source by means of echocardiography. That
is why I am so surprised that echocardiography was not performed as a
matter of urgency in this patient(1). The "mantra" of "thromboembolism
until proved otherwise" is one which has stood the test of time in other
contexts, notably in the context of acute abdominal pain(attributable to
mesenteric embolism) in the presence of risk factors for thromboembolism
such as atrial fibrillation, myocardial infarction, and infective
endocarditis(2). "Frequently, [however], acute occlusive mesenteric
ischemia remains unrecognised, initially, so that specific treatment is
delayed for > 24 hours"(3). This is, arguably, attributable, at least
in part, to underrecognition of the diagnostic utility of the "mantra",
and the same might be true of the delayed recognition of the embolic
nature and the embolic source in the case reported by the authors(1).
Where the index of suspicion is sufficiently high, it should also be
recognised that normal intensity anticoagulation is no bar to
thromboembolism, as shown by the graph depicting occurence of embolic
stroke despite chronic anticoagulat therapy in patients with non valvular
atrial fibrillation, some of whom had international normalized ratios in
the range 2-3.4(4)
References
(1) Nieuwkamp DJ., Kirkels JH., Rinkel GJE
Multiple intracerebral haematomas during normal intensity anticoagulation
Practical Neurology 2010;10:45-47
(2)Jolobe,O
Intestinal ischaemia(letter)
British journal of Hospital Medicine 2002;63:695
(3)Menke J., Luthje L., Kastrup A., Larsen J
Thromboembolism in atrial fibrillation
Am J Cardiol 2010;105:502-10
(4)Hylek EM., Skates SJ., Sheehan MA., Singer DE
An analysis of the lowest effective intensity of prophylactic
anticoagulation for patients with non rheumatic atrial fibrillation
N Engl J Med 1996;335:540-6
Sometimes it is necessary to make a point with overemphasis and we
believe that was done in the letter by Chris Hawkes. We agree that it is
essential to talk to a patient and to watch them and observe how they
speak, what they are saying and what they are doing with their body as
they walk in and out of a room. However, to exclude the examination is a
form of conceit. The only reason that a very senior neurologist can
o...
Sometimes it is necessary to make a point with overemphasis and we
believe that was done in the letter by Chris Hawkes. We agree that it is
essential to talk to a patient and to watch them and observe how they
speak, what they are saying and what they are doing with their body as
they walk in and out of a room. However, to exclude the examination is a
form of conceit. The only reason that a very senior neurologist can
observe so much is from a long period of diligently examining all patients
and slowly learning shortcuts by pattern recognition. But you
can't teach neurology that way. Students must
first be taught the discipline of a routine in order to learn which part
of the routine can be discarded in individual patients. When a TIA is
caused by atrial fibrillation a finger on the pulse will lead you to the
ECG as the first test. A stethoscope on the neck will suggest that a
Doppler should happen immediately. When resources are limited (which
occurs in much more than half the world) it is important to direct your
tests sensibly rather than blindly ordering a battery. If a student
can't distinguish between an upper and lower
motor lesion then the differential of a paralysed limb trebles and an EMG
as well as an MRI needs to be done routinely. We are not against spending
more time talking to a patient, even if it means less time examining, but
don't eliminate the examination.
It's like throwing the baby out with the
bathwater. When in doubt the most cost effective investigation is to
retake the history and to examine the patient. We
mustn't forget that an essential part of any
consultation is to gain the trust and respect of the patient; if a patient
doesn't trust the consultant they are unlikely
to accept the diagnosis and treatment plan. We have all seen patients for
second and third opinions when on completing the examination they
complement you on how thorough you have been and inform you that their
previous consultants hadn't bothered to examine
them. The "laying on of
hands" is as essential to
today's consultation as it was in the past. In
today's litigious environment not examining a
patient would be welcomed by the opposing legal team with glee. We doubt
any expert witness would support the notion of not examining a patient as
standard clinical practice. In the new era of revalidation admitting to
your peers that you do not examine your patients would be inviting an
early retirement or a change in career.
I am in general agreement with the notion expressed in Professor
Hawkes' editorial that many patients in
neurology outpatient clinics do not need examination. Certainly, the full
neurological examination has a rather Zen-like quality: it takes a great
deal of work to master it and then one finds one
doesn't really need it. However, I would like
to express a number of disagreements with some of what Professor Hawkes
wr...
I am in general agreement with the notion expressed in Professor
Hawkes' editorial that many patients in
neurology outpatient clinics do not need examination. Certainly, the full
neurological examination has a rather Zen-like quality: it takes a great
deal of work to master it and then one finds one
doesn't really need it. However, I would like
to express a number of disagreements with some of what Professor Hawkes
wrote.
The examination is, of course, not purely diagnostic. I have listed
a number of other features in Box 1.
Fundamentally, Professor Hawkes appears to suggest that the
examination can be replaced by investigation. It could be argued that this
replaces one unnecessary activity (and a relatively cheap one) with
another unnecessary activity (and a much more expensive one). Waiting
times for individuals to be seen in outpatient clinics have been reduced
in recent times. However, there are often significant delays for
necessary investigations, such as MR Imaging and Neurophysiology. One
reason for this is that many arguably unnecessary investigations are
undertaken, particularly imaging for headache, neck pain and back ache.
The majority of patients in general neurology outpatient clinics can in
fact be dealt with by a careful history taking.
On a more specific point, Professor Hawkes states that
"if your patient has a
headache...he or she is going to need a brain
scan". This is an extremely contentious point.
Indeed, Professor Hawkes does imply that this
"need" is for
reassurance rather than for specific diagnostic purposes and, of course,
the majority of causes of headache have normal scans, therefore this
investigation is indeed not diagnostic. He states that no matter how much
one reassures the patient that it is not a serious form of headache, they
will still want a scan. On a purely anecdotal basis, it does seem as
though the desire for brain scans in patients with headaches does vary
greatly, not only from patient to patient but also according to which
clinician they see. One important point is that simple reassurance of a
non-serious cause is not always sufficient: the patient may require a
positive diagnosis. If they accept that diagnosis, they may not wish for a
scan; it is to be hoped that such acceptance depends not simply on the
"charm" of the doctor
(as Professor Hawkes puts it) but also on their perceived competence and
the way they explain the diagnosis.
Professor Hawkes does not deal with the issue of incidental abnormalities.
There are publications indicating that brain scanning in cases of headache
uncovers incidental abnormalities in a proportion of patients, causing
additional anxiety and greater use of medical time 1,2,3. As a taxpayer,
I might feel somewhat aggrieved if my financial support for the headache
patient with extends over dismaying a series of cost events: a general
practice consultation, a neurological consultation, a high-tech
investigation, further investigation because of doubtful abnormalities on
the first test and, finally, additional consultation time to deal with the
uncovered incidental abnormalities. Professor Hawkes states that patients
may wish to pay for a scan "in the private
sector". (As an aside here, all NHS
consultations are indeed private. I think Professor Hawkes is referring
here to the commercial sector.) If indeed a patient requires a medically
unnecessary scan, then it might be reasonable for them to pay for it - providing that all subsequent matters arising
from the scan, including reassurance about abnormal results, are also
dealt with in the commercial sector.
As a final point, Professor Hawkes discusses the issues of
"video clinics". I
can understand that this is a potential way of dealing with certain
problems. However, there is an irreducible human element in the medical
consultation and face-to-face consultations can be extremely important,
allowing interaction, assessment and reassurance that is simply not
possible through remote video or audio connection.
References
1. Computed Tomography in the headache patient: Is routine evaluation
really necessary? Mitchell et al Headache 1993 33:82-86
2. Incidental Findings in magnetic resonance imaging of the brains of
healthy young men. Weber & Kopf J Neurol Sci 2006 240:81-84
3. Incidental findings on brain magnetic resonance imaging: systematic
review and meta-analysis. Morris et al BMJ In Press
Box 1
Non-diagnostic aspects of the examination
o To give the clinician time to think
o To help establish doctor/patient relationship
o To allow the patient to volunteer aspects of the history not given
during direct enquiry
o To demonstrate to the patient features which are important in their
management
o Non specific therapeutic effect of examination
I read the title of Dr. Hawkes’ editorial three times before I was
certain I had read it correctly1. As a fourth year medical student about
to apply for a neurology residency, I was initially bewildered. When I
read on though, I was impressed not only with his candidness, but also by
the validity of what he was saying; although I am a newcomer, it does not
take long to appreciate that imaging is cent...
I read the title of Dr. Hawkes’ editorial three times before I was
certain I had read it correctly1. As a fourth year medical student about
to apply for a neurology residency, I was initially bewildered. When I
read on though, I was impressed not only with his candidness, but also by
the validity of what he was saying; although I am a newcomer, it does not
take long to appreciate that imaging is central to current diagnosis of
neurological disorders. However, from the perspective of someone about to
commence her career, I would like to make a plea to save the neurological
examination.
Neurology traditionally has been a field which medical students find
intimidating. Full of esoteric names, bizarre pathologies and a lengthy
examination the significance of which is often unclear to us at our stage
of training. As we go through our rotation, some like me are captivated by
the complexity and organization of this supercomputer, when many of its
secrets and pathologies are revealed after acquiring the necessary
examination skills. The exam further provides us with an opportunity to
feel like a true physician because it helps seal the doctor patient
relationship, providing the healing touch if I may say.
Lastly, we find
the neurological exam quirky and fun to practice on each other.
Finally I do have a more pragmatic argument. After decades of
experience, it makes sense that Dr. Hawkes feels confident diagnosing and
treating certain patients without a formal exam. However, he himself notes
that "the ability to take a history and examine simultaneously is a
technique that takes a few years to acquire". This level of mastery is
indeed something to strive for, but in the meantime it would be hugely
irresponsible of me to neglect a thorough examination of my patients. And
if those with such expertise as Dr. Hawkes sit back and let things change,
how will the next generation of neurologists ever acquire the skill set
necessary to practice the art of neurology?
I read with interest the editorial by Dr. Hawkes titled “I have
stopped examining patients!”1. The title appropriately has an exclamation
mark at the end highlighting his shocking claim. I have to commend Dr.
Hawkes for finally coming out and admitting boldly and maybe somewhat
proudly what most neurologists already know but are afraid to accept.
Bedside clinical neurology is a dyin...
I read with interest the editorial by Dr. Hawkes titled “I have
stopped examining patients!”1. The title appropriately has an exclamation
mark at the end highlighting his shocking claim. I have to commend Dr.
Hawkes for finally coming out and admitting boldly and maybe somewhat
proudly what most neurologists already know but are afraid to accept.
Bedside clinical neurology is a dying art and I admit many times in the
office I have been guilty of a cursory neurological examination. A brief
flash of the pen light into the patient’s eyes, a tap with the reflex
hammer here and there, stand up, walk and voila I am done. The founding
fathers of our great art would surely be turning in their graves if they
saw a modern neurologist like me at work today.
But should we just sit back and let things change? Dr. Hawkes says
yes and why not? It is for the best after all. Why swim against the tide?
I have a slightly different view. I still remember what made me choose
neurology from among the various disciplines of medicine. The thrill of
watching the big toe go up in a patient with a hemispheric stroke, the eye
signs in a patient with multiple sclerosis and the first time I saw facial
myokymia. My joy and fascination with neurology was unparalleled and
remains to this day. James Parkinson in his short monograph on shaking
palsy in 1817 described six patients in total. Parkinson was an astute
observer, and his report contained observations from three patients he saw
in his clinic and three individuals he observed on city streets. Much of
the description of the longitudinal course of the illness was derived from
his observations of a single case only. Till today the diagnosis of
Parkinson’s disease remains a clinical diagnosis. One made after taking a
history and examining the patient for the three cardinal signs namely
resting tremor, rigidity and bradykinesia. None of the advanced
neuroimaging capabilities at my disposal can improve my ability to
diagnose this and many other neurological conditions.
I am sure that Dr. Hawkes shall agree with me that the "joy" and
"fun" of neurology lies in the examination. For that reason in itself we
all should strive to save this dying art.
Perhaps because I don't have Dr. Hawkes' degree of experience (I have
approximately 25 years of practice experience), I disagree very strongly
with his conclusion. Careful examination remains the cornerstone of
neurologic practice. I agree that a great deal of information is gleaned
from informal examination - watching the patient walk into the exam room,
etc. I agree as well that for paroxysmal d...
Perhaps because I don't have Dr. Hawkes' degree of experience (I have
approximately 25 years of practice experience), I disagree very strongly
with his conclusion. Careful examination remains the cornerstone of
neurologic practice. I agree that a great deal of information is gleaned
from informal examination - watching the patient walk into the exam room,
etc. I agree as well that for paroxysmal disorders - migraine, epilepsy,
TIAs, etc. - history is the most important aspect of the evaluation. But
efficient and careful examination is indispensable. Lets look at one of
the examples cited by Dr. Hawkes. No younger patient, for example, with
typical migraine features should undergo imaging unless they have an
examination abnormality. Deferring to patient wishes is a pallid excuse
and leads to waste of tax dollars (this is true in the US and UK).
Indeed, imaging of all headache patients will result in identification of
a significant number of unrelated and largely benign findings, additional
imaging studies, and heightened patient anxiety. Polite discussion and
deflection of patient requests for inappropriate imaging is better care.
At a time when we are likely to see increased emphasis on clinical
evaluation and decision making, it would be an enormous mistake for
neurologists to permit erosion of reliance on the powerful and distinctive
method of clinical examination.
The admission that a neurologist has stopped examining patients(1) is
a disturbing one, given the fact that "the practice of medicine is the
art of drawing conclusions from incomplete evidence"(2), thanks to the
fact that, as clinicians, "we work in a probabilisic enviroment in which
the evidence we gather bears an imperfect relationship to its cause"(3).
The admission that a neurologist has stopped examining patients(1) is
a disturbing one, given the fact that "the practice of medicine is the
art of drawing conclusions from incomplete evidence"(2), thanks to the
fact that, as clinicians, "we work in a probabilisic enviroment in which
the evidence we gather bears an imperfect relationship to its cause"(3).
Accordingly, the evidence initially gathered from history taking has to
undergo subsequent "fine tuning" through the medium of clinical
examination, special investigations, and, in some intances, also through
the medium of the literature search. We omit any of the stages of that
work up to our peril, given the fact that "the dominant cause of error in
the faulty data-gathering category [lies] in the subcategory of
ineffective, incomplete, or faulty work up", exemplified by a missed
diagnosis of subdural hematoma in a patient seen after a car accident
because "the physical examination was incomplete"(4). A potential benefit
of clinical examination is that it might reduce the risk of "premature
closure" whereby the clinician fails to consider other possibilities once
an intitial diagnosis has been reached(4). With the benefit of clinical
examination, even a clinician who is guilty of premature closure can learn
from the experience of recognising that "I didn't reassess the situation
when things didn't fit"(5). Clinical examination also helps to cut down on
the number of "blunderbuss" investigations,thereby releasing scarce
resources such as computerised tomography(CT) and magnetic resonance
imaging(MRI) for use in patients who are too old and frail to cooperate
with meticulous and long-drawn out clinical examination.
These are the
patients who "miss out" in the era of high-tech medicine. On the one
hand,after presenting with atypical symptoms, they do not receive the
benefit of even a cursory clinical examination. To compound diagnostic
error, their atypical symptoms are then falsely attributed to old age,
and, as a consequence, they are also denied the benefit of the high-tech
investigations that are themselves supposed to be a short cut to
diagnosis.
It is not correct that the Democratic Party has historically been the
major underwriter of biomedical research in the USA. American science,
and biomedical science in particular, benefited historically from
substantial bipartisan support. The major increase in NIH funding of the
Clinton period owed at least as much to actions of moderate Republicans
like Rep. John Porter (Republican of Illinois) an...
It is not correct that the Democratic Party has historically been the
major underwriter of biomedical research in the USA. American science,
and biomedical science in particular, benefited historically from
substantial bipartisan support. The major increase in NIH funding of the
Clinton period owed at least as much to actions of moderate Republicans
like Rep. John Porter (Republican of Illinois) and Sen. Arlen Spector
(Republican of Pennsylvania) as it did to the Clinton administration. The
predominance of the hard right in the Republican Party, with its
marginalization of Republican moderates, and the anti-intellectualism of
the Bush administration had a deplorable effect on federal funding of
science. Bush administration science funding policies, however, are not
the historic norm of the Republican Party.
I write as a fervent Obama supporter and very, very left of center
Democrat - but fair is fair.
Richard Hughes does not include leprosy in his list of peripheral
nerve disorders.(1) While it is true that new cases of leprosy are
declining rapidly , as a result of effective anti-bacterial therapy, there
are still frequent numbers with residual disabilities in endemic
countries.
In neurological text books, a mononeuropathy or multiple
mononeuropathy is regarded as the sole neurolog...
Richard Hughes does not include leprosy in his list of peripheral
nerve disorders.(1) While it is true that new cases of leprosy are
declining rapidly , as a result of effective anti-bacterial therapy, there
are still frequent numbers with residual disabilities in endemic
countries.
In neurological text books, a mononeuropathy or multiple
mononeuropathy is regarded as the sole neurological lesion in leprosy. In
1923, Monrad-Krohn described a sensory polyneuropathy involving
superficial sensory modalities in patients with leprosy.(2) A similar
pattern of sensory loss was found in a group of northern Nigerian leprosy
patients, without prior knowledge of Monrad-Krohn’s observations.(3)
There are still no references to Monrad-Krohn’s findings in neurological
text books. This omission is serious because a patient with this sensory
polyneuropathy can develop trophic ulcers, mutilation of the extremities
and Charcot’s joints. Moreover, this polyneuropathy, because of the
distribution of the sensory loss, cannot be caused by direct invasion of
the peripheral nerves by Mycobacterium leprae
Sensory loss in leprosy can be acute in onset with simultaneous
involvement of all four limbs(3) and could be an autoimmune response to an
antigen in sensory peripheral nerve rather than a direct response to
M.leprae . In order to test this hypothesis, rabbits were injected with a
homogenate of human sensory peripheral nerve plus adjuvant and
electrophysiological recordings were made from the hind limb. It was found
there was a diminished amplitude in the slower component of C fibres but
the conduction velocity and amplitude of A delta fibres were normal.(4) An
animal model of diabetic neuropathy could be developed as a result of
these experiments.(5) Some of the rabbits previously injected with sensory
nerve developed a state of granulomatous hypersensitivity. ie. Skin
testing in sensitised rabbits results in the formation of a granuloma,(6)
with invasion of mononuclear cells into the endoneurium of dermal nerves,
together with axonal damage.(7) The antigen involved is a non-myelin
membrane fraction.(8) A similar antigen in the central nervous system
could be used to induce tolerance, which if successful could lead to a
vaccine against multiple sclerosis.(9)
The observations on the clinical aspects of leprosy may therefore
lead to a greater understanding of the pathogenesis of diabetic neuropathy
and multiple sclerosis, in which case it will reinforce the maxim that
there is no substitute for precise clinical examination, with no need for
auxiliary aids, apart from a pin and a piece of cotton wool.
7. Crawford CL, Hardwicke PMD. Somatic unmyelinated degeneration in
rabbits with granulomatous hypersensitivity produced by a non-myelin
antigen sensory peripheral nerve.
Acta Neuropath 1979; 45: 1-7.
8. Hardwicke PMD, Crawford CL. Nature of the antigen of human sensory
nerve that induces granulomatous hypersensitivity.
J Neurochem 1978; 30:
1609-1611.
9. Crawford CL. Is it possible to induce oral tolerance using a non-myelin
peripheral nerve antigen?
Available at
http://www.jci.org/eletters/view/32132 Accessed 22 January 2009.
I wish to commend the authors for their paper on functional vitamin
B12 deficiency.
It is important that despite the array of investigative tools that may be
available at the disposal of clinicians, clinical signs and symptoms are
given their due emphasis particularly in Vitamin B12 deficiency. The
authors report a case where the serum cobalamin was normal in the face of
anaemia and neurol...
I wish to commend the authors for their paper on functional vitamin
B12 deficiency.
It is important that despite the array of investigative tools that may be
available at the disposal of clinicians, clinical signs and symptoms are
given their due emphasis particularly in Vitamin B12 deficiency. The
authors report a case where the serum cobalamin was normal in the face of
anaemia and neurological damage, at the other end of the spectrum are
cases with normal haemoglobin levels but with significant morbidity. A
recent report by Rajkumar AP and Jebaraj P (1) was of a non anaemic
patient with psychosis who returned to complete self care following
treatment with Vitamin B12.
The diagnostic value of properly elicited clinical signs and symptoms
cannot be overemphasized.
Reference
1. Chronic Psychosis associated with Vitamin B12 deficiency.
J Assoc
Physicians India 2008 Feb; 56: 115-6
In the presence of risk factors for thromboembolism, a focal neurological episode which has a sudden onset should be assumed to be embolic until proved otherwise. Whether or not that episode is purely ischaemic, or whether or not it undergoes subsequent hamorrhagic transformation is a separate issue which should not detract from the urgency to identify the embolic source by means of echocardiography. That is why I am so...
Sometimes it is necessary to make a point with overemphasis and we believe that was done in the letter by Chris Hawkes. We agree that it is essential to talk to a patient and to watch them and observe how they speak, what they are saying and what they are doing with their body as they walk in and out of a room. However, to exclude the examination is a form of conceit. The only reason that a very senior neurologist can o...
I am in general agreement with the notion expressed in Professor Hawkes' editorial that many patients in neurology outpatient clinics do not need examination. Certainly, the full neurological examination has a rather Zen-like quality: it takes a great deal of work to master it and then one finds one doesn't really need it. However, I would like to express a number of disagreements with some of what Professor Hawkes wr...
Dear Editor,
I read the title of Dr. Hawkes’ editorial three times before I was certain I had read it correctly1. As a fourth year medical student about to apply for a neurology residency, I was initially bewildered. When I read on though, I was impressed not only with his candidness, but also by the validity of what he was saying; although I am a newcomer, it does not take long to appreciate that imaging is cent...
Dear Editor,
I read with interest the editorial by Dr. Hawkes titled “I have stopped examining patients!”1. The title appropriately has an exclamation mark at the end highlighting his shocking claim. I have to commend Dr. Hawkes for finally coming out and admitting boldly and maybe somewhat proudly what most neurologists already know but are afraid to accept.
Bedside clinical neurology is a dyin...
Dear Editor,
Perhaps because I don't have Dr. Hawkes' degree of experience (I have approximately 25 years of practice experience), I disagree very strongly with his conclusion. Careful examination remains the cornerstone of neurologic practice. I agree that a great deal of information is gleaned from informal examination - watching the patient walk into the exam room, etc. I agree as well that for paroxysmal d...
Dear Editor,
The admission that a neurologist has stopped examining patients(1) is a disturbing one, given the fact that "the practice of medicine is the art of drawing conclusions from incomplete evidence"(2), thanks to the fact that, as clinicians, "we work in a probabilisic enviroment in which the evidence we gather bears an imperfect relationship to its cause"(3).
Accordingly, the evidence initial...
Dear Editor,
It is not correct that the Democratic Party has historically been the major underwriter of biomedical research in the USA. American science, and biomedical science in particular, benefited historically from substantial bipartisan support. The major increase in NIH funding of the Clinton period owed at least as much to actions of moderate Republicans like Rep. John Porter (Republican of Illinois) an...
Dear Editor,
Richard Hughes does not include leprosy in his list of peripheral nerve disorders.(1) While it is true that new cases of leprosy are declining rapidly , as a result of effective anti-bacterial therapy, there are still frequent numbers with residual disabilities in endemic countries.
In neurological text books, a mononeuropathy or multiple mononeuropathy is regarded as the sole neurolog...
Dear Editor,
I wish to commend the authors for their paper on functional vitamin B12 deficiency.
It is important that despite the array of investigative tools that may be available at the disposal of clinicians, clinical signs and symptoms are given their due emphasis particularly in Vitamin B12 deficiency. The authors report a case where the serum cobalamin was normal in the face of anaemia and neurol...
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