Disorders of the central and peripheral nervous systems run the gamut from mild to severe, hyperacute to chronic, and extremely common to exceedingly rare. This large group of disorders reflects pathology that can be localized anywhere along the neuraxis, from the level of the molecule to the level of complex thalamic-subcortical-cortical circuits and at every level in between. Additionally, the nervous system can be involved in a multitude of systemic diseases across the life span. Because of this heterogeneity of pathologies and presentations, the management of neurologic problems occurs in a multitude of clinical settings, from the outpatient office to the intensive care unit. In caring for patients in these various settings, neurologists often collaborate closely with other medical specialists. Despite the increasing availability of sophisticated diagnostic tools such as genetic testing, magnetic resonance imaging (MRI), and electroencephalography (EEG), neurologists still rely substantially on a comprehensive examination to localize the lesion along the neuraxis, narrow the differential diagnosis, and guide subsequent evaluations. Child neurology is particularly unique in its use of play to obtain the best version of this examination, much to the delight of those lucky enough to practice in this field.
In the adult neurology clinic, the history and physical examination are typically conducted in a standardized manner so that nothing is missed. A similarly systematic approach is ideal but not always obtainable in pediatric patients. As the adage goes, children are not just little adults. Indeed, part of what makes child neurology both challenging and fun is that both diagnosis and treatment must account for the maturational stage of the patient, whether the relevant developmental issues are subtle or striking. Thus, the neurologic exam of a pediatric patient must often be focused or at least adapted and prioritized. Sometimes the history must be similarly abbreviated.
This book is intended to serve as a useful reference that is accessible to child neurology practitioners at multiple levels, including learners. This chapter in particular is intended to serve as a framework or foundation upon which one can build their own approach to a child with a neurologic problem. We encourage those who are new to the field to dive into an active role in the evaluation of patients as soon as possible, since the best learning comes by doing rather than observing. With the neurologic exam of an infant or child, frequent practice develops confidence, deepens our knowledge base, and (as anyone who works with children knows) keeps us humble and laughing. Although the authors of this book admit to bias, we consider child neurology to be the richest and most rewarding field of medicine, and we are thrilled to share with you some of what we have learned from our patients.
GENERAL APPROACH TO THE ENCOUNTER
The key to a successful patient encounter is rapport. Within the first minute or two of the encounter, it is ...