Clinical Neurology

T.J. Fowler, John W. Scadding, Nick Losseff, J.W. Scadding

• Publisher: CRC Press
• Year: 2011
• eBook ISBN: 9780429586606
• Edition: 4
• Topic: Medicine
• Subtopic: Neurology

Concise yet comprehensive, Clinical Neurology, Fourth Edition builds on the success of three previous editions in helping medical students, junior doctors, and practicing physicians acquire an improved understanding of the principles of neurology.The fourth edition has been fully revised and updated to take into account current developments in the

CHAPTER 1

INTRODUCTION

John Scadding and Nick Losseff

■ Epidemiology

■ Anatomical diagnosis

■ Pathological diagnosis

■ Neurological investigations

■ Cerebrospinal fluid

■ References and further reading

Clinical neurology is often considered to be difficult. It is true that the structure of the nervous system is complex, but the knowledge and skills needed to localize most lesions and to perform a reliable examination are relatively easily acquired. The applied anatomy and physiology needed for the competent practice of clinical neurology is relatively straightforward, the essential requirement being a logical and consistent approach to history taking and examination. For the student of neurology, there is no substitute for taking histories and examining patients as frequently as possible; familiarization with the sequence will eventually bring fluency, accuracy and consistency.

The first chapters of this book place great emphasis on neurological clinical skills. While taking the history and during the examination, the clinician needs to have two questions in mind. First, ‘where is the lesion?’ (anatomy). The distribution of the symptoms will indicate the anatomical site of the patient’s problem in the great majority of cases. And second, ‘what is the lesion?’ (causative pathology). The timing of the onset and the evolution of symptoms will provide important clues as to the nature of the underlying pathology. The importance of accurate assessment of the patient’s symptoms is such that it is no exaggeration to say that if, by the time the history has been taken, the clinician has no idea either where the problem lies, or what type of pathological process might be responsible, then the physical examination is unlikely to be very rewarding.

The clinician needs to follow the trail of clues presented by the patient. History taking needs to be focused and logical, and not simply take the form of a rigid and mechanical comprehensive enquiry of a catalogue of symptoms. First, the presenting complaints need to be pursued, with supplementary questions about important related symptoms that the patient, devoid of neurological knowledge, may not have connected with the presenting symptoms. However, while advocating a directed approach to neurological diagnosis, it is essential to undertake a screening enquiry about a range of symptoms and perform an examination that systematically and efficiently covers the nervous system, in a systematized order, or there is a danger that important signs and diagnoses will be missed.

It is important to recognize also that many patients, particularly those seen in outpatient clinics, have no abnormal signs on examination. This is true of the majority of patients presenting with headache, dizziness and episodes of loss of consciousness, and in patients with a variety of other complaints, for example facial pain. In such patients, the diagnosis rests entirely on the clinician’s ability to take a detailed and accurate history. Of course, an examination must be performed in all patients.

Chapters 2 and 3 are devoted to neurological symptoms and examination. It is worth making the point that despite the enormous advances in diagnostic technology in recent years, clinical skills remain the starting point and cornerstone of all neurological diagnosis. Chapters 4 and 5 outline the principles of neurological imaging and clinical neurophysiology. These core investigative arms of neurology are followed by consideration of neurogenetics, which has an increasingly wide relevance to the understanding and management of neurological disease. The remaining chapters of the book are devoted mainly to a systematic description of the many neurological disorders. Although this textbook deals principally with the clinical neurology of adults, there is a chapter on some of the neurological disorders of childhood. The later chapters in the book cover the generic topics of neurorehabilitation, respiratory problems seen in neurological disease, and the special characteristics and management of pain seen in many neurological conditions. An understanding of neuropsychiatry is essential to the competent practice of clinical neurology, and the psychiatric syndromes commonly seen in patients with neurological symptoms are succinctly but comprehensively described in the final chapter.

Major advances have been made in the assessment and treatment of numerous neurological conditions and these are described throughout the book. The previous frequent criticism of neurologists, that while they were good at making diagnoses, they could not offer treatment for their patients, is no longer justified. On the contrary, a great deal can now be done for very many patients. It is of course unfortunately true that neurological disease can lead to disability that is sometimes severe and may be irreversible. A sensitive, caring and compassionate approach in helping patients come to terms with the effects of their neurological illnesses, and offering means of amelioration of symptoms, together with support, sometimes over many years, are also essential qualities and responsibilities of the clinical neurologist.

EPIDEMIOLOGY

The epidemiological study determines how often a disease occurs in the population, why it occurs and why different populations may show variable patterns. An understanding of the frequency with which different neurological disorders present both to general practitioners and to hospital clinics is a great help to the doctor concerned. Furthermore, some 20 per cent of acute medical admissions to a general district hospital arise as a result of neurological disorders. Table 1.1 gives an indication of the prevalence of some common neurological disorders and Table 1.2 an approximate annual incidence of some neurological conditions in England and Wales.

A number of surveys have provided figures for the ‘top 20’ and percentage of new patient consultations with neurologists in outpatient clinics in the UK (Table 1.3). It can be seen that headaches (including migraine and tension-type) and blackouts (including ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Preface
• Acknowledgements
• 1. Introduction
• 2. Symptoms of neurological disease
• 3. Examination of the nervous system
• 4. Neuroimaging
• 5. Clinical neurophysiology
• 6. Cranial nerve syndromes
• 7. Nerve and root lesions
• 8. Neurogenetics
• 9. Raised intracranial pressure
• 10. Headache
• 11. Craniofacial pain
• 12. Head injury
• 13. Epilepsy and sleep disorders
• 14. Neuro-oncology
• 15. Spinal disease
• 16. Peripheral neuropathies
• 17. Motor neurone disease and spinal muscular atrophy
• 18. Diseases of muscle and the neuromuscular junction
• 19. Dementia
• 20. Movement disorders
• 21. The cerebellar ataxias and hereditary spastic paraplegias
• 22. Multiple sclerosis and related conditions
• 23. Cerebrovascular disease
• 24. Neurological rehabilitation
• 25. Infections of the central nervous system
• 26. HIV
• 27. Neurological manifestations of medical disorders
• 28. Paediatric neurology
• 29. Respiratory aspects of neurological disease
• 30. Pain in neurological disease
• 31. Psychiatry and neurological disorders
• Index