4. Patient Presentations Related to the Nervous System and Mental Health

Patient presentations span all relevant age categories, special populations, and varied clinical settings.

The guide to clinical presentations in this category may include, but is not limited to, the following ways in which patients present for osteopathic medical care:

abuse and neglect, child or elder • acalculia • action tremors • adjustment disorder • agnosia • agraphia • akinesia • amyotrophic lateral sclerosis • anomia • anxiety disorders, including generalized anxiety, anxiety secondary to another medical condition or mental disorder or induced by illicit, prescribed, or over-the-counter drugs or substances • apraxia • arteriovenous malformations • athetosis • atrophy of extremity muscles • ballismus • behavioral abnormalities, including avoidance, dependency, and obsessive-compulsive disorder • bipolar and related disorders • brain concussion/mild traumatic brain injury • brain tumors, including sellar/pituitary masses, neoplasms, and metastatic tumors; paraneoplastic syndromes • cerebral palsy • cerebrovascular disorders, including aneurysms and vasculitis (e.g., temporal arteritis) • chalazion • chronic fatigue syndrome, fibromyalgia • cognitive impairments, including altered level of consciousness, mild cognitive impairment, amnesia, coma, confusion, delirium, disorientation, subcortical and cortical dementia (e.g., Alzheimer disease, Huntington disease, Parkinson disease) • cyclothymic disorder • depressive disorders • disruptive behaviors, including attention deficit/hyperactivity disorder, pediatric anxiety (e.g., disruptive mood dysregulation disorder, selective mutism, separation anxiety) • dissociative disorders • dizziness and true vertigo (e.g., peripheral or central vestibular dysfunction, benign paroxysmal positional vertigo, labyrinthitis, Ménière disease) • dysautonomias • dyskinesias • dystonias • ear and hearing disorders, including acoustic neuroma and other neoplasms; conductive, sensorineural, or neurogenic hearing loss; presbycusis; otosclerosis; ototoxic drugs; Ménière disease • eating and feeding disorders (e.g., anorexia nervosa, bulimia, pica, binge eating) • elimination disorders (e.g., enuresis, encopresis) • encephalopathies (e.g., Reye syndrome, Wernicke-Korsakoff encephalopathy, shock) • epidural hematoma • eye and vision disorders, including discharge, pain, lacrimal drainage, blepharitis, iritis, subconjunctival hemorrhage, hordeolum, floaters, cataracts, glaucoma, red eye, eye trauma (e.g., orbital floor fracture), diplopia, amblyopia, nystagmus, strabismus, refractive error, ptosis, optical migraine, photophobia, blurred vision (e.g., acute narrow-angle glaucoma), unilateral and bilateral vision loss, acute vision loss (e.g., amaurosis fugax [temporary blindness]) • fasciculations • gambling disorder • gender dysphoria • grieving and normal bereavement • head and spinal cord injury • headache (acute and chronic), including cluster, migraine, tension; episodic and constant; unilateral and bilateral; primary and secondary, with and without red flag symptoms (e.g., aura); trigeminal autonomic cephalalgia; headache attributed to a substance or its withdrawal; headache from trauma/traumatic brain injury • hoarding disorder • Huntington disease • hypomania • infantile and pediatric seizures and spells • infections (e.g., systemic, central nervous system, sinusitis, encephalitis, meningitis) • learning disorders • malingering • mood disorders, including depressed mood, elevated mood with or without depressed mood, mania, cyclothymia • mouth and jaw disorders, including taste disorders, mastication pain • movement disorders, including voluntary and involuntary abnormal movements, such as cerebellar and sensory ataxias, chorea, and other hyperkinetic (e.g., Tourette syndrome) and bradykinetic (e.g., Parkinson disease) disorders and diseases • myoclonus • nerve-, muscle-, and pain-related syndromes, including complex regional pain syndrome, post-herpetic neuralgia, meralgia paresthetica, compression or diabetic neuropathy, spinal stenosis, Guillain-Barré syndrome, multiple sclerosis, Bell palsy, myasthenia gravis • neurologic gait disorders (e.g., hemiplegic gait, spastic diplegic gait, neuropathic gait, myopathic gait, Parkinsonian gait, choreiform gait, ataxic [cerebellar] gait, sensory gait) • obsessive-compulsive and related disorders (e.g., body dysmorphic disorder, trichotillomania, excoriation disorder) • olfactory disorders • pain, including chronic, nonmalignant, neuropathic, nociceptive, mixed, and sympathetic • panic disorder • paraphilias • personality disorders (e.g., paranoid, schizoid, schizotypal, antisocial, histrionic, borderline, narcissistic) • phobias (e.g., specific phobias, agoraphobia), social anxiety disorder • postpartum depression or psychosis • premenstrual dysphoric disorder • psychotic disorders, brief, including schizophreniform disorder, schizophrenia spectrum, and other psychotic disorders • psychotic disorders, hallucinations, delusions, and disturbances of perception • psychotic disorders, specific, including delusional disorders; shared psychotic disorder; psychosis secondary to illicit, prescribed, and over-the-counter drugs and substances; psychosis secondary to medical conditions • pupillary abnormalities (e.g., isocoria, anisocoria, mydriasis, miotic pupils) • relational problems • resting tremors • seizures, atonic or convulsive, focal and generalized, including epilepsies and secondary seizures • seizures secondary to illicit, prescribed, or over-the-counter drugs or substances • sleep disorders, including obstructive sleep apnea, somnambulism, insomnia, excessive daytime sleepiness, sleep-wake disorders, narcolepsy, night terrors, parasomnias • somatic symptoms and related disorders (e.g., conversion disorder, factitious disorders, psychological factors affecting other conditions) • speech/language-related disorders, including alexia, aphasia (fluent and nonfluent), dysphasia, and dysarthria • stereotypy • stroke (e.g., transient ischemic attack, hemorrhagic stroke) • subarachnoid hemorrhage • subdural hematoma • substance-related and addictive disorders, including oral and intravenous abuse of tobacco, alcohol, opioids, cocaine, and cannabis; intoxication; withdrawal symptoms (e.g., delirium tremens) • suicidal ideation • tactile disturbances, including sensory loss, numbness, vibration/temperature/proprioception loss, tingling, and paresthesia • tics and tic disorders (e.g., Tourette syndrome) • tinnitus, unilateral or bilateral, with or without hearing loss, including tinnitus secondary to ototoxic medications, tinnitus with somatic triggers (e.g., labyrinthitis, Ménière disease) • trauma and stressor-related disorders (e.g., adjustment disorders, posttraumatic stress disorder) • weakness and paralysis, focal (e.g., hemiplegia); postural instability or tremors

CONSTITUTIONAL SIGNS AND SYMPTOMS
fatigue • fever • generalized weakness • involuntary weight loss • malaise • night sweats • pallor

PHYSICAL EXAM FINDINGS
abdominal reflex • Chvostek sign • clonus • cognitive testing (e.g., mini-cog, mini-mental status examination) • cogwheel rigidity • corneal reflex, nystagmus • cranial nerve findings • cremasteric reflex • decreased muscle tone • deep tendon (muscle stretch) reflexes and grading • dysdiadochokinesia • funduscopic findings and cup-to-disc ratios • Glasgow coma score • heel-to-shin test • Hoffmann sign • increased muscle tone • light reflex • micro-aneurysms • optic and retinal abnormalities (e.g., papilledema, cotton wool spots) • plantar (Babinski) reflex • proliferative changes • red reflex • Romberg sign • signs of meningitis (e.g., nuchal rigidity, Kernig sign, Brudzinski sign) • slit-lamp exam findings • tuning-fork testing • visual acuity testing

LABORATORY TEST FINDINGS AND DIAGNOSTIC IMAGING
angiography • cerebrospinal fluid findings • CT scanning • electroencephalography • magnetic resonance imaging • nuclear medicine imaging • radiography • serum creatine kinase levels • ultrasonography • vitamin levels (e.g., vitamin B12)