Page 92 Guide to Pain Management in Low-Resource Settings

80 Paul Kioy and Andreas Kopf

an basic neurological examination is inevitable for ev- the neurological status. If cooperation is impaired, it
erybody dealing with pain patients (together with an should be noted in the progress notes (e.g., “unexpect-
orthopedic and psychosocial evaluation). ed/inadequate fi nding”). Th us, objective fi ndings such
as muscle atrophy have greater value, since they may
What is a systematic diagnostic not be voluntary infl uenced!
Every examiner will experience at times “inade-
procedure in a neurological
quate” or “unexpected” results from the examination. To
examination? diagnose a “psychogenic” etiology, however, thorough
experience is needed. Th e patient should never be con-
Th e examiner has to use a certain systematic ap-
fronted with the suspicion of aggravation or simulation,
proach when examining the patient. Starting with
so as to avoid an irreversible loss of mutual trust, but
the symptoms presented by the patient, it is advisable
the suspicion should be integrated into the whole pic-
to continue trying to identify a syndrome, which in-
ture of the patient evaluation.
cludes all symptoms. A topical diagnosis may then be
made (which is the “level” of neurological dysfunc-
tion), which should lead to the fi nal etiological diagno- What technical support do I need

sis. Paraclinical testings, such as electrophysiology and for the physical neurological
imaging techniques, help by confi rming or ruling out a examination?
certain etiological diagnosis. However, the availability
of such technical examinations is not a prerequisite to Everything necessary for an orientating neurological
make a diagnosis in many cases. Th erefore, in environ- examination should be easily available. A small collec-
ments without the possibility for further testing, careful tion of instruments should be at hand. With a patellar
and thorough history taking and physical examination hammer, a sharp instrument (e.g., a wooden stick or
will be able to collect relevant and most often suffi - sterile cannulas), a soft brush or a piece of cotton wool,
cient fi ndings to make a diagnosis, helping the clinician a wooden tongue depressor, a small fl ashlight, a tuning
to understand and possibly treat neurological diseases fork (128 Hz), spatulas, and a pair of glass test tubes it
causing pain. should be possible to detect relevant motor, coordina-
tion, trophic, and vegetative dysfunctions of the nervous
How do I prepare the patient system. If available, an ophthalmoscope would complete
the test battery. Remember that in a very busy clinic,
for the examination?
one may not be able to do a thorough examination for
In the usual clinical manner, establish a rapport with the all patients. But with experience, one develops a quick
patient and explain the nature and purpose of the exami- and effi cient personal examination protocol.
nation to reassure him or her. Endeavour to gain the pa-
tient’s confi dence and trust in order to achieve the level What is the stepwise approach
of cooperation that is essential for the interpretation of to performing a neurological
fi ndings. Th e patient should be comfortable on the ex-
examination?
amination couch and adequately but decently exposed.
Th e physician normally begins the examination of any
How can I draw conclusions from patient with an examination of the appearance of the
the neurological examination? subject in general, his/her skin and mucous membranes,
followed by palpation for lumps, lymph nodes, pulses,
To be able to draw conclusions from the neurological ex- and any superfi cial points of tenderness. An evalua-
amination, it is advisable to follow a certain stepwise ap- tion of vital functions should normally be done at this
proach to avoid imperfection. However, following a step- time, including blood pressure, pulse, respiration, and
wise approach does not mean being overly schematic! temperature. Care should of course be exercised during
It is important to explain the examination to palpation to avoid the obvious points of severe pain and
the patient before starting because the patient’s co- tenderness this early in the examination so as to retain
operation and alertness are necessary to ascertain the patient’s cooperation.