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Surveying Symptoms and Signs of Neurological Illness

The first stage in the journey of arriving at a correct diagnosis is to be in touch with your symptoms. Reporting them accurately to your neurologist and in your own words is always an asset. I recommend that patients arrive to a first appointment with a narrative of the temporal progression of symptoms replete with dates and recollections of when certain symptoms emerged and describe how they progressed to the present. This, the neurological history, is best told in person by patients themselves, and secondarily by a parent, spouse or close sibling. It is said that the history provides a window to the type of ailment, whether of a metabolic, inflammatory autoimmune, genetic, degenerative, or infectious natures, while the physical examination yields the location within the nervous system that the problem may reside. Some neurological symptoms will be unmistakable for a given disorder and yield the answer in short order, while others may be so vague as to straddle several disorders at once. Here are some examples. Neurological disorders can be conveniently divided into those that affect the brain and spinal cord, or central nervous system (CNS); those that affect the peripheral nerves such as neuropathy; and others that affect automatic or autonomic function and remain beyond our conscious control. Amyotrophic lateral sclerosis, or ALS, better known as Lou Gehrig disease for the baseball player it famously struck, unmistakably involves the brain and spinal cord. It is recognized by symptom cluster of progressive weakness, muscle wasting and twitching, accompanied by stiffness, speech difficulty, and spasticity, that result from degenerative loss of upper and lower motor neurons of the brain and spinal cord, with little else resembling it. One other disorder of the CNS, multiple sclerosis, is recognized by visual loss, facial weakness, vertigo, gait and limb ataxia, incoordination, bowel and bladder incontinence, and sensory symptoms that results instead from inflammatory demyelinating plaques in white matter tracts not the neurons.  

The largest group of movement disorders lends its name to a collection of six features including tremors at rest, rigidity, bradykinesia, loss of balance, flexed posture, and freezing of movement so qualifying for Parkinsonism, due to a variety of primary causes. However, selected patients may fall into the more dismal course of Parkinson disease and other subgroups, when no other proximate cause is found for their relentless progression. By way of inference, no one questions the familiarity of the description of a spinal disc herniation, that impinges upon roots emerging from the spine as the commonest cause of back pain, proposed more than a century ago, and described as," the moment at which one feels the crack in his back, the back must have been bent forward, with the lumbar and abdominal muscles in full action, such that it would cause powerful compression of the intervertebral discs, and if that were possible, placing the displacement of the pulp of the intervertebral disc backwards".

 Few people will fail to recognize the presentation of Guillain-Barre syndrome, abbreviated GBS, for the easily recognizable weakness and sensory disturbance that worsens over days resulting in progressive paralysis of the legs and arm, but few know that the commonest cause is a preceding viral or bacterial infection that triggers the immune system, resulting in the onslaught of damage, often leaving that information when recounting the history. Another French disorder named for its authors, Charcot-Marie-Tooth, describes dominantly-inherited leg weakness beginning in childhood or early adulthood, with high arches or pes caves, and hammer toe foot deformities, and areflexia. More than 30 genetic subtypes now exist making it the commonest inherited neuropathy worldwide. Bladder, bowel, sexual dysfunction, labile vital signs and over- and underactive gastrointestinal function, and labile vital signs with postural changes in vital signs describes autonomic nervous system disorders. They affect individuals of all ages, from childhood to old age. Unmistakable presentations of postural orthostatic tachycardia syndrome (POTS) with reflex increase in heart rate leading to palpitations with even mild exertion, and hypotension due to a fall in systolic blood pressure that occur with orthostatic hypotension dysautonomia syndrome, can be due to an acute infectious illness, autoimmune state, or lesion in the hypothalamus pituitary adrenal axis. Such patients may give an erroneous history of fatigue, mental change, panic attacks, and anxiety suggesting a psychological cause for their disorder that regrettably worsens with psychotropic therapy due to inadvertent neurochemical side effects. 



[1] Middletown GS, Teacher JH. Injury of the spinal cord due to rupture of an intervertebral disc during muscular effort. Glasgow MJ 1911; 76:1-6.