By the manner in which the patient expresses ideas and responds to spoken or written requests, it is possible to determine whether there are hallucinations or delusions, defective memory, or other recognizable symptoms of brain disease merely by watching and listening to the patient. On occasion, mute and resistive patients judged to be psychotic prove to have some widespread cerebral disease.
The reader is referred to the special methods of examination described by Volpe and the staff members of the Mayo Clinic, which are listed in the references and described in Chap. 27. Many of these tests address the developmental aspects of the child’s nervous system, and although some signs may be difficult to obtain because of the age of the patient, they still stand as the best reflections of the child’s neurologic state.
The general medical examination often reveals evidence of an underlying systemic disease that has secondarily affected the nervous system. In fact, many of the most serious neurologic problems are of this type. Two common examples will suffice: adenopathy or a lung infiltrate implicates neoplasia or sarcoidosis as the cause of multiple cranial nerve palsies, and the presence of low-grade fever, anemia, a heart murmur, and splenomegaly in a patient with unexplained stroke points to a diagnosis of bacterial endocarditis with embolic occlusion of cerebral arteries. The examination of a patient with stroke is includes a determination of blood pressure, auscultation for carotid bruits, heart murmurs, and palpation of the pulse for heart rhythm.
INTEGRATION OF NEUROANATOMY, NEUROPHYSIOLOGY, MOLECULAR
GENETICS, NEUROIMAGING, AND NEUROPATHOLOGY WITH THE
Once the technique of obtaining reliable clinical data is attained, knowledge of the basic sciences of neurology is necessary to determine the cause of disease and its treatment. For this reason, each of the later chapters dealing with the motor system, sensation, special senses, consciousness, memory, and language is introduced by a review of the anatomic and physiologic facts that are necessary for understanding the associated clinical disorders.
Physicians wishing to master neurology should be familiar with the anatomy of the corticospinal tract; motor unit (anterior horn cell, nerve, and muscle); basal ganglionic and cerebellar motor connections; main sensory pathways; cranial nerves; hypothalamus and pituitary; reticular formation of brainstem and thalamus; limbic system; areas of cerebral cortex and their major connections; visual, auditory, and autonomic systems; and cerebrospinal fluid pathways. A working knowledge of neurophysiology should include an understanding of neural excitability and nerve impulse propagation, neuromuscular transmission, and contractile process of muscle; spinal reflex activity; central neurotransmission; processes of neuronal excitation, inhibition, and release; and cortical activation and seizure production. The genetics and molecular biology of neurologic disease have assumed increasing importance in the past few decades. The practitioner should be familiar with the terminology of mendelian and mitochondrial genetics and the main aberrations in the genetic code that give rise to neurologic disease.
The physician must be familiar with the imaging characteristics of the multitude of clinical diseases encountered in practice, and the risk and pitfalls of each technique, including computed tomography (CT), magnetic resonance imaging (MRI), radiographs, including those incorporating contrast agents, and ultrasound as discussed in Chap. 2.