The Fast Neurological Examination

The final chapter is a coalescence of material already detailed in earlier chapters but in a form that will save time in the clinic. The suggested approach is for the patient you wish to screen, having predicted from the history that there will be few physical signs. This would apply to most patients with nonspecific headache and dizziness for example. The cranial nerves are listed first followed by brief examination of limbs.

Dementia and Cognition

This chapter emphasizes the value of preliminary observations in making a provisional diagnosis of dementia. Significant aspects of the history are detailed, such as head injury or brain hemorrhage that could lead to hydrocephalus or superficial siderosis. Handles are given that facilitate identification of Alzheimer’s disease and its mimics, such as the posterior cortical variant. The importance of temporal pattern of disease is emphasized. Further Handles are outlined for frontotemporal dementia variants. The value of physical examination is stressed as it may disclose an underlying structural lesion.

Cerebellar Ataxia

This chapter deals with disorders of the cerebellum and its connections. These conditions may be identified by the pattern of onset—whether acute, chronic, or episodic. The chronic ataxias are inherited in various patterns: autosomal dominant, autosomal recessive, X-linked. Some episodic ataxias have variable inheritance. Other episodic ataxias without a clear genetic basis are detailed.

Cranial Nerves

This chapter describes each cranial nerve (CN I through XII) and the Handles and Red Flags associated with disorders of each. These range from trauma, neoplastic lesions, infectious and inflammatory causes, and the effects of aging, to psychological manifestations. Diagnosing disorders of the cranial nerves requires various combinations of history and careful examination.

First Encounters

This chapter describes disorders that can be diagnosed as the patient enters the consulting room by observing closely how he or she turns to close the door, walks toward you, and shakes your hand. Much information is gleaned by inspecting the face, clothes, fingernails, and jewelry or by listening to the voice or smelling the breath. From chronic conditions to congenital disorders to addictions, the competent neurologist will depend first on keen observation in the construction of a diagnosis. Neurological diagnosis requires good detective work; the good neurologists must play at being a “bedside Sherlock Holmes.”

Movement Disorders

This chapter deals with classic Parkinson’s disease and the main variants such as progressive supranuclear palsy, multiple system atrophy, and the corticobasal syndrome. There are details on chorea, particularly Huntington’s disease, chorea-acanthocytosis, McLeod’s syndrome, Sydenham’s chorea, Wilson’s disease. The main varieties of tremor are described as are neurodegeneration with brain iron accumulation. Subsequent parts deal with tics, restless legs syndrome, periodic movements of sleep, and painful legs and moving toes. Several Handles are specified for dystonia and its subdivisions, Lesch-Nyhan syndrome, gait disorders, paroxysmal dyskinesias, stereotypies, psychogenic movement disorders, and myoclonus.

Epilepsy and Sleep Disorders

This chapter lists Handles that would allow identification of various disorders associated with seizures by inspection alone, such as tuberous sclerosis, Sturge-Weber syndrome, lipoid proteinosis, Angelman’s syndrome, and Rett syndrome. Other diagnoses require further detail from the history and examination. Guides to localization and lateralization are provided, and the main causes of refractory seizures are detailed. The problem of non-epileptic attacks is addressed and characteristic EEG patterns are illustrated. Handles for the major sleep-related disorders are exemplified.

Headache

This chapter enumerates various features that are reassuring and do not point to serious disease. Several Red Flags are given that indicate the need for investigation. Clues for cluster headache, orthostatic headache, and several other headache syndromes are mentioned. Also listed are a few specific headaches that respond to indomethacin.

Peripheral Neuropathy

This chapter divides peripheral neuropathy into mononeuropathy, radiculopathy, and polyneuropathy. Disorders of major peripheral nerves are highlighted: namely, median, ulnar, radial, sciatic, and femoral nerves, and how their associated dysfunction may be identified speedily. Polyneuropathy is subdivided according to pattern of onset; accompanying pain; axonal or demyelinating; length- or non–length-dependent; inherited or acquired; presence of nerve thickening; occurrence of tremor; skin, hair, or nail changes; deafness; ophthalmoplegia; anosmia; ageusia, or cataract.

Demyelination

This chapter describes various clues to the diagnosis of multiple sclerosis (MS) based on the history, physical examination and investigation. Red flags that should alert the clinician to an alternative diagnosis are listed. Disorders that may present like MS and lead to erroneous diagnosis are discussed.