In clinical situations there are three principal factors that can legitimately influence the decision making process. These are:
The scientific evidence
The practitioner’s clinical experience
The practical situation, including the patient’s wishes, other people’s concerns, the patient’s lifestyle and culture, the social environment, and realistic observations to the delivery of technically ideal interventions
These can be thought of as a triangle of forces.
There are some problems with each of these factors as a primary guide to treatment. Consequently, they should remain metaphorically in a state of balance in the clinician’s mind, so that he is able to establish treatment plans that are evidence based (but not mechanistic), patient centered and contextualized (but not irrational), and informed by experience (rather than by a faith in idiosyncratic ideas). Treatment frequently goes wrong because one or more of these factors have been neglected. Rob Poole & Robert Hisso.
(Clinical Skills in Psychiatric Treatment. Cambridge University Press, 2008.)
I. THE ROUTINE SCREENING NEUROLOGIC EXAMINATION WHEN THE PATIENT HAS NO SYMPTOMS SUGGESTING NEUROLOGIC DISEASE
A. What is the minimum allowable neurologic examination?
Every new patient (Pt) and every routine physical checkup requires the examiner (Ex) to complete a minimum screening neurologic examination (NE) of all body systems. To this requirement students often respond fretfully: “But it takes too long to do the NE on everyone!” In fact, with sufficient practice, you can learn to do a basic screening NE in about 6 minutes in the mentally normal, cooperative Pt who has no neurologic symptoms. This statement presupposes a thorough history. The better the history, the briefer the examination required. The Ex need not and should not do every test on every Pt but should expand or trim the examination to fit the Pt’s history. If a Pt presents only with a sore throat and has no neurologic symptoms whatsoever, the Ex squanders time in testing smell and taste, doing caloric irrigation, a detailed aphasia examination, and in tugging against every muscle. The expanded examination to explore neurologic symptoms often requires the time for these tasks. For a brand new Pt, we schedule a full hour to complete the history and physical examination, dictate notes, and arrange for laboratory tests or referrals. Recall that the history and clinical examination still constitute the most efficient methods known to establish the relationship between physician and the Pt that is optimum for detecting disease, and for planning a healthy lifestyle.
B. Format for the mandatory 6-minute neurologic examination for every patient
Appraisal during the history: During the history, the Ex appraises the Pt’s mental status, notes the facial features, the eyes and ears, ocular movements, speech and swallowing and observes the posture, gait, and movement patterns.
Examination of the head: Inspect the head shape and palpate the head. Record the occipitofrontal circumference (OFC) of every infant.