Dr. Sashank Prasad, a seasoned general neurologist with special training in neuro-ophthalmology and a director of our neurology training program. We hope that reading the book will feel akin to attending our ward rounds, clinics, or morning report, thus giving the reader an intimate window into demands of practice, without being prescriptive. We hope this edition allows the physician to use the material as a basis for continued professional growth and enjoyment.  Welcome to our world.
Allan H. Ropper, MD
Martin A. Samuels, MD
Joshua P. Klein, MD, PhD
Sashank Prasad, MD
Approach to the Patient With
Neurology is the practice and study of diseases of the nervous system. It is among the most complex and exacting medical specialties and yet it is perhaps the most rewarding, encompassing as it does all aspects of human behavior, cognition, memory, movement, pain, sensory experience, and the homeostatic functions of the body that are under nervous control. Among the provocative aspects of neurology is the manner in which diseases disrupt the functions of the mind, but the field also encompasses study of the diseases of nerves, muscles, spinal cord, and cerebral hemispheres.
The neurologist occupies a special role by using extensive synthetic and analytical skill to explain neurological symptoms and findings. Neurology is distinctive in allowing a type of detailed interpretation of signs and symptoms that, as a result of the fixed structure of the nervous system, provides certainty in diagnosis that is not possible in other fields. This is the method of localization that is almost unique to neurology.
Part of the excitement of modern neurology is the incorporation of advances in imaging, and in the neurosciences including neurogenetics, neurochemistry, neuroepidemiology, and neuropathology, which now offer deep insights into the fundamental nature of disease. The close connections among neurology and the fields of internal medicine, psychiatry, neuropathology, developmental medicine and pediatrics, critical care, neurorehabilitation, and neurosurgery extend the purview of clinical neurology. As has occurred in other branches of medicine, increased understanding of disease and therapeutic options has led to the emergence of numerous subspecialties of neurology (Table 1-1).
Neurological symptoms, of course, do not present themselves as immediately referable to a part of the nervous system and the neurologist must therefore be knowledgeable in all aspects of nervous system function and disease. The authors believe that a successful application of medical knowledge is attained by adhering to the principles of the clinical method, which has been retained to a greater degree in neurology than in other fields of medicine. Even the experienced neurologist faced with a complex clinical problem uses this basic approach.
In most cases, the clinical method consists of an orderly series of steps: 1.
The symptoms and signs are secured with as much confidence as possible 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—i.e., one identifies the disorder of function and the anatomic structures that are implicated.
3.
These analyses permit the physician to localize the disease process, i.e., to name the parts of the nervous system affected. This is the anatomic, or topographic diagnosis, which often allows the recognition of a characteristic clustering of symptoms and signs, constituting a syndrome.
4.
From the anatomic diagnosis and other specific medical data—particularly the mode of onset and speed of evolution of the illness, the involvement of nonneurologic organ systems, the relevant past and family medical histories, and the imaging and laboratory findings—one deduces the etiologic diagnosis and its pathogenesis.
5.
Finally, the physician should assess the degree of disability and determine whether it is temporary or permanent (functional diagnosis); this is important in managing the patient’s illness and judging the potential for restoration of function (prognosis).