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The Neurologic Diagnosis wwwwwwwwww Jack N. Alpert The Neurologic Diagnosis A Practical Bedside Approach Jack N. Alpert, MD St. Luke’s Episcopal Hospital Department of Neurology University of Texas Medical School at Houston Houston, TX, USA [email protected] ISBN 978-1-4419-6723-7 e-ISBN 978-1-4419-6724-4 DOI 10.1007/978-1-4419-6724-4 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011941214 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) In Memory of Morris B. Bender, a superlative clinical neurologist of the twentieth century, who stimulated my lifelong interest in the manifestations, evaluation, and diagnosis of patients with neurologic diseases. His infl uence permeates this text. wwwwwwwwww Foreword Assessment of neurological complaints, a high percent of a family practitioner and internist’s practice, requires an accurate history and a careful neurological examination. As Dr. Alpert expertly discusses in detail, the history provides clues to the clinical diagnosis while the complementary neurological examination localizes the lesion(s). Dr. Alpert is able to distil out from his over four decades of a busy practice and from his excellent teaching of medical students and neurological trainees a logical, readable, and provocative approach to each neurological complaint. In a chapter of 36 cases of “Diagnostic Dilemmas ,” one’s clinical acumen is challenged with practical questions and astute observations. By discussing neurological disorders in terms of ten “ Neuroanatomic Diagnoses ,” Dr. Alpert compartmentalizes neurological diseases into conve- nient and manageable discrete entities. By building upon the unique anatomy and physiology of each unit, greater logic is made in one’s deductive reason- ing for a diagnostic conclusion. Special emphasis is given to the “Six Major Decussations ” with clinical correlations, as with strokes, autonomic disorders, neuromuscular diseases and the poorly responsive patient. A separate chapter on “ Common Symptoms in the Neurology Clinic ” is a potpourri of frequently seen and rare cases which will challenge the beginner and the experienced practitioner of neurology. This textbook is highly recommended to the serious student of clinical neurosciences, be they medical students, trainees, or practitioners. Houston, TX, USA Frank M. Yatsu Chairman, Emeritus Department of Neurology University of Texas Medical School at Houston vii wwwwwwwwww Preface The purpose of this introductory text is to simplify the method of making a neurologic diagnosis. Medical students are often intimidated by a deluge of data and extensive differential diagnoses. They have no organizational struc- ture to follow. Diagnostic techniques of general medicine are not applicable. Neurology is a unique specialty since it requires the intermediary step of an anatomic diagnosis prior to proffering a differential diagnosis. Yet, the required knowledge of neuroanatomy need not be profound for the student who will specialize in any fi eld other than neurology and neurosurgery. This text is directed to medical students and residents who will all be regu- larly faced with numerous patients who have neurologic symptomatology. Typical one month rotations out of 4 years of medical school are clearly inad- equate training to make a cogent neurologic diagnosis, especially since subse- quent instruction is commonly provided by upper level residents who have the same background and numerous misconceptions. This is not a comprehensive text. The emphasis will be on establishing a neuroanatomic diagnosis before formulating a differential diagnosis. A thorough discussion of diseases will not be included. Treatment will seldom be discussed since it is likely to change radically over time. Redundancy of basic principles is purposeful. Repetition is the mother of learning or as William Gowers, an eminent neurologist of the early twentieth century, remarked, “A teacher who hesitates to repeat, shrinks from his most important duty, and a learner who dislikes hearing the same thing twice over lacks his most essential acquisition.” Houston, TX, USA Jack N. Alpert ix wwwwwwwwww Acknowledgments Without the encouragement, assistance, and patience of my wife, Ruth, this book would never have been realized. My children, Richard, Daniel, Ariela, Jessica and my sister Barbara supplied never-ending interest and support. After a desultory beginning, the urging of Jessica, in particular, prompted me to actively pursue publication. Dr. Srinivasa Kandula contributed crucial assistance in selecting, creating, and sketching many of the illustrations. His eager, enthusiastic collaboration was vital to the completion of this text. Mike de la Flor added his expertise to several illustrations. Drs. Ernesto Infante and Frank Yatsu provided me with sound and indis- pensable advice with their reviews of the entire manuscript. I am grateful for their hard work, assistance, and positive feedback. Donna J. Williams was my invaluable, conscientious transcriptionist. Her technical expertise was outstanding. Her willingness to work late at night, answer questions, and complete just another chapter revision was truly remarkable. Additional neurologists who added useful critiques, interest, and sugges- tions include Drs. Stanley Appel, Randolph Evans, James Grotta, Victor Rivera, and Loren Rolak. Dr. Irving Fishman assisted in reviewing the physiology of the genitourinary system. I am most appreciative of their help and encouragement. xi wwwwwwwwww Contents 1 Introduction .................................................................................. 1 2 The Ten Neuroanatomic Diagnoses ............................................ 3 Common Neurologic Signs: Localizing Value .............................. 4 Central Nervous System Disease (CNS), Peripheral Nervous System (PNS), and Muscle Disease (M) ............................................................ 4 Cerebral .......................................................................................... 4 Extrapyramidal ............................................................................... 7 Brainstem/Cerebellum ................................................................... 8 Spinal Cord Lesions (Myelopathies) ............................................. 11 Radiculopathy ................................................................................ 14 Plexopathy ...................................................................................... 16 Neuropathy ..................................................................................... 17 Neuromuscular Junction ................................................................ 19 Myopathy ....................................................................................... 20 Meningeal Disease ......................................................................... 21 Synopsis ......................................................................................... 23 Multiple Choice Questions ............................................................ 24 Answers .......................................................................................... 25 Bibliography .................................................................................. 26 3 The Neurologic History Holds the Diagnostic Keys .................. 27 Neurologic Symptoms in Psychiatric Disease ............................... 33 Bibliography .................................................................................. 35 4 Neurologic Examination .............................................................. 37 Vital Signs ...................................................................................... 37 Mental Status Examination ............................................................ 38 Visual Observations ................................................................... 38 Auditory Observations ............................................................... 39 Aphasia ...................................................................................... 39 Agnosia ...................................................................................... 41 Apraxia ....................................................................................... 41 Cranial Nerve Examination ............................................................ 45 Olfactory Nerve

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