Adams and Victor's Principles of Neurology

 
3
1
Approach to the Patient with
Neurologic Disease
Neurology is regarded by many as one of the most diffi-
cult and exacting medical specialties. Students and resi-
dents who come to a neurology service for the first time
may be easily discouraged, and may already be intimi-
dated by the complexity of the nervous system through
their brief contact with neuroanatomy, neurophysiology,
neuropathology, neurogenetics, and cell biology. The rit-
ual they then witness of putting the patient through a
series of maneuvers designed to evoke certain mysterious
signs is hardly reassuring; in fact, the procedure often
appears to conceal the intellectual processes by which
neurologic diagnosis is made. Moreover, the students
have had little or no experience with the many special
tests used in neurologic diagnosis—such as lumbar punc-
ture, EMG (electromyography), electroencephalography,
CT, MRI, and other imaging procedures—nor do they
know how to interpret the results of such tests. Neurology
textbooks only confirm their fears as they read the
detailed accounts of the many rare diseases of the nervous
system.
The authors believe that many of the difficulties in com-
prehending neurology can be overcome by adhering to
the basic principles of clinical medicine. First and fore-
most, it is necessary to learn and acquire facility in the use
of the 
 
clinical method
. Without a full appreciation of this
method, the student is virtually as helpless with a new
clinical problem as a botanist or chemist who would
undertake a research problem without understanding the
steps in the scientific method. Even the experienced neu-
rologist faced with a complex clinical problem depends on
this basic approach.
The importance of the clinical method stands out more
clearly in the study of neurologic disease than in certain
other fields of medicine. In most cases, the clinical method
consists of an orderly series of steps, as follows:
1. The symptoms and signs are secured by history and
physical examination.
2. The symptoms and physical signs considered relevant
to the problem at hand are interpreted in terms of
physiology and anatomy—that is, one identifies the
disorder(s) of function and the anatomic structure(s)
that are implicated.
3. These analyses permit the physician to localize the
disease process, i.e., to name the part or parts of the
nervous system involved. This step is called 
 
anatomic
,
or 
 
topographic
, 
 
diagnosis
. Often one recognizes a char-
acteristic clustering of symptoms and signs, constitut-
ing a 
 
syndrome
of anatomic, physiologic, or temporal
type. The formulation and aggregation of symptoms
and signs in cohesive terms is particularly helpful in
ascertaining the locus and nature of the disease. This
step is called 
 
syndromic diagnosis
and is often con-
ducted in parallel with anatomic diagnosis.
4. From the anatomic diagnosis and other medical data—