Neurology

K. Gardill and H. Wietholter

Normally, patients with visual disturbances initially seek the care of an ophthalmologist, even though the underlying cause of the problem, and more importantly its management, falls more into the field of the neurologist. The ophthalmologist is therefore heir to an important responsibility and must be on the watch for other symptoms that might accompany the visual problems. Only in this way can patients be given prompt and appropriate referral to neurological or neuroradiological consultants. Frequently, the clinician can accomplish this with only a few specific neurological tests, which can yield important information needed for the planning of further investigation and management of the problem.

As a rule, a complete neurological evaluation should be governed by a specific and well-thought sequence of tests (analogous to the sequence discussed in this chapter), to ensure that the function of all relevant systems is covered. Particularly in neurology is it generally possible to identify accurately the disease locus at fault by means of a careful clinical examination, combined with a detailed history. Given the limitations of time, an ophthalmological examination will be able to include only a few specific elements of the neurological examination, and yet with an adequate knowledge of the neuroanatomic and physiologic principles involved, should allow a close topographic localization and etiologic classification, based on a few specific symptoms and their associated findings.

History, Psychological Findings, and Neuropsychological Disorders

At the start of every neurological examination, there should be at least a minimal attempt to take a history of the patient's symptoms. This practice provides the physician with an opportunity to learn in general about the patient's psychological state, including speaking and language disorders or other neuropsychological deficits. Other individual or isolated problems may be difficult to draw out and require a more targeted form of questioning.

Psychological State | Pearl

The state of the patient's awareness of his or her identity and orientation to time and place is essential information and fundamentally important for an understanding of the problems he/she faces (■ Table 21.1).

Clues about the presence of a neurodegenerative disorder (for example, vascular encephalopathy with dementia and ocular motility disturbances, or Richardson-Steele-Olsze-wski syndrome with dementia and vertical gaze palsy) also help with assessing the reliability of the patient's historical accounts.

Neuropsychological Disorders

Acquired neuropsychological disorders are, as a rule, the product of pathological events affecting the cerebral hemispheres. Most commonly, these are encountered in the setting of a recent stroke. Other potential causes include hemispheric tumors, head trauma, encephalitides, and neurodegenerative diseases.

Table 21.1. Psychological data

Vigilance

(quantitative assessment of awareness)

State of awareness

Awake, sleepy, stuporous, comatose

Orientation

(qualitative assessment of awareness)

Temporal

"What day of the week is this? What is today's date?"

Locational

"What city is this? What is the name of this hospital? Do you know what floor this is?"

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