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An engagingly written text that bridges the gap between neuroanatomy and clinical neurology. Clinical Neurology and Neuroanatomy delivers a clear, logical discussion of the complex relationship between neuroanatomical structure and function and neurologic disease. Written in a clear, concise style, this unique text offers a concise overview of fundamental neuroanatomy and the clinical localization principles necessary to diagnose and treat patients with neurologic diseases. Unlike other neurology textbooks that either focus on neuroanatomy or clinical neurology, Clinical Neurology and Neuroanatomy integrates the two in manner which simulates the way neurologists learn, teach, and think.
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Investigative Studies 27 Confusional States 65 Medical science and technology have progressed spectacularly. This new edition of Clinical Neurology has been mandated by the many advances that have occurred over the last few years in the clinical neurosciences and, more specifically, in the investigation and management of patients with neurologic disorders.
We have endeavored to incorporate these developments while, at the same time, limiting the size of the text so that it remains useful to medical students and residents, introducing them to the field of neurology as practiced on the wards and in an outpatient setting. We have been aided in doing so by our own experience over many years as practicing neurologists and clinical teachers.
We hope we have been successful and have been able to replace the ambivalence of medical trainees with more confidence and interest as they approach patients with neurologic disorders. Over the years, medical curricula have continued to expand, and the scientific and fundamental aspects of medicine have sometimes seemed to overshadow the more clinical aspects. We have attempted to balance these various approaches. All the chapters in the book have been updated and in large part rewritten to maintain the emphasis on the practical aspects of neurology while discussing its scientific underpinnings.
Colored illustrations were introduced in the last edition, but several new ones have been incorporated to illustrate new points or replace older black-and-white figures. We have not included a lengthy bibliography at the end of each chapter because of the sheer volume of the literature but instead have pointed to key references after different sections in the text and have included limited suggestions for further reading at the end of each chapter.
This new edition of Clinical Neurology is available not only in print format but also online as part of the popular www. This makes it more accessible for many readers and also facilitates searches for particular topics and comparison of its content with other standard medical works on the same Web site.
We thank Drs. Catherine Lomen-Hoerth, William Dillon, and Paul Garcia who read selected portions of the text and made helpful suggestions for revisions.
At McGraw-Hill, Ms. Ann Sydor helped to guide us through the complexities of early planning of this new edition, and Ms. Karen Edmonson oversaw the production process and ensured that the final product was of the highest quality. We thank them and all the other staff at McGraw-Hill for their help. Michael J. Aminoff David A. Greenberg Roger P. The goal is for the patient to describe the nature of the problem in a word or phrase. Common neurologic complaints include confusion, dizziness, weakness, shaking, numbness, blurred vision, and spells.
Each of these terms means different things to different people, so it is critical to clarify what the patient is trying to convey. Taking a history from a patient with a neurologic complaint is fundamentally the same as taking any history. Epilepsy, multiple sclerosis, and Huntington disease usually have their onset by middle age, whereas Alzheimer disease, Parkinson disease, brain tumors, and stroke predominantly affect older individuals.
Confusion Confusion may be reported by the patient or by family members. Symptoms can include memory impairment, getting lost, difficulty understanding or producing spoken or written language, problems with numbers, faulty judgment, personality change, or combinations thereof. Dizziness Dizziness can mean vertigo the illusion of movement of oneself or the environment , imbalance unsteadiness due to extrapyramidal, vestibular, cerebellar, or sensory deficits , or presyncope light-headedness resulting from cerebral hypoperfusion.
Weakness Weakness is the term neurologists use to mean loss of power from disorders affecting motor pathways in the central or peripheral nervous system or skeletal muscle. However, patients sometimes use this term when they mean generalized fatigue, lethargy, or even sensory disturbances. Shaking Shaking may represent abnormal movements such as tremor, chorea, athetosis, myoclonus, or fasciculation see Chapter 11, Movement Disorders , but the patient is unlikely to use this terminology.
Correct classification depends on observing the movements in question or, if they are intermittent and not present when the history is taken, asking the patient to demonstrate them. The severity of symptoms should also be ascertained. Although thresholds for seeking medical attention vary among patients, it is often useful to ask a patient to rank the present complaint in relation to past problems.
Location of Symptoms Patients should be encouraged to localize their symptoms as precisely as possible because location is often critical to neurologic diagnosis. The distribution of weakness, decreased sensation, or pain helps point to a specific site in the nervous system anatomic diagnosis. Time Course It is important to determine when the problem began, whether it came on abruptly or insidiously, and if its subsequent course has been characterized by improvement, worsening, or exacerbation and remission Figure Severity 2 Stroke E.
Patients occasionally also use this term to signify weakness. Blurred Vision G. Spells Spells imply episodic and often recurrent symptoms such as in epilepsy or syncope fainting. Severity Blurred vision may represent diplopia double vision , ocular oscillations, reduced visual acuity, or visual field cuts. Quality of Symptoms Severity The history of present illness should provide a detailed description of the chief complaint, including the following features.
Some symptoms, such as pain, may have distinctive features. Temporal patterns of neurologic disease and examples of each. Precipitating, Exacerbating, and Alleviating Factors Vaccination can prevent neurologic diseases such as poliomyelitis, diphtheria, tetanus, rabies, meningococcal or Haemophilus influenzae meningitis, and Japanese encephalitis. Rare complications include postvaccination autoimmune encephalitis, myelitis, or neuritis inflammation of the brain, spinal cord, or peripheral nerves.
Some symptoms may appear to be spontaneous, but in other cases, patients are aware of factors that precipitate or worsen symptoms, and which they can avoid, or factors that prevent symptoms or provide relief. Associated Symptoms Associated symptoms can assist with anatomic or etiologic diagnosis. For example, neck pain accompanying leg weakness suggests a cervical myelopathy spinal cord disorder , and fever in the setting of headache suggests meningitis.
Illnesses Preexisting illnesses that can predispose to neurologic disease include hypertension, diabetes, heart disease, cancer, and human immunodeficiency virus HIV disease. Operations Open heart surgery may be complicated by stroke or a confusional state. Entrapment neuropathies disorders of a peripheral nerve due to local pressure affecting the upper or lower extremity may occur perioperatively. Obstetric History Pregnancy can worsen epilepsy, partly due to altered metabolism of anticonvulsant drugs, and may increase or decrease the frequency of migraine attacks.
Pregnancy is a predisposing condition for idiopathic intracranial hypertension pseudotumor cerebri and entrapment neuropathies, especially carpal tunnel syndrome median neuropathy and meralgia paresthetica lateral femoral cutaneous neuropathy.
Traumatic neuropathies affecting the obturator, femoral, or peroneal nerve may result from pressure exerted by the fetal head or obstetric forceps during delivery. Eclampsia is a lifethreatening syndrome in which generalized tonic-clonic seizures complicate the course of pre-eclampsia hypertension with proteinuria during pregnancy.
Immunizations F. Diet Deficiency of vitamin B1 thiamin is responsible for the Wernicke-Korsakoff syndrome and polyneuropathy in alcoholics. Vitamin B3 niacin deficiency causes pellagra, which is characterized by dementia.
Vitamin B12 cobalamin deficiency usually results from malabsorption associated with pernicious anemia and produces combined systems disease degeneration of corticospinal tracts and posterior columns in the spinal cord and dementia megaloblastic madness. Inadequate intake of vitamin E tocopherol can also lead to spinal cord degeneration. Hypervitaminosis A can produce intracranial hypertension pseudotumor cerebri with headache, visual deficits, and seizures, whereas excessive intake of vitamin B6 pyridoxine is a cause of polyneuropathy.
Excessive consumption of fats is a risk factor for stroke. Finally, ingestion of improperly preserved foods containing botulinum toxin causes botulism, which presents with descending paralysis.
Tobacco, Alcohol, and Other Drug Use Tobacco use is associated with lung cancer, which may metastasize to the central nervous system or produce paraneoplastic neurologic syndromes. Alcohol abuse can produce withdrawal seizures, polyneuropathy, and nutritional disorders of the nervous system. Intravenous drug use may suggest HIV disease, infection, or vasculitis. Several neurologic diseases are inherited in Mendelian or more complex patterns, such as Huntington disease autosomal dominant , Wilson disease autosomal recessive , and Duchenne muscular dystrophy X-linked recessive Figure Hypothyroidism may lead to coma, dementia, or ataxia.
Simple Mendelian patterns of inheritance.
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An engagingly written text that bridges the gap between neuroanatomy and clinical neurology. From the Foreword by Allan H. Clinical Neurology and Neuroanatomy delivers a clear, logical discussion of the complex relationship between neuroanatomical structure and function and neurologic disease.
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