Chapter 1: Introduction

Barbara Scherokman MD, FAAN, FACP; Patrick C. Alguire, MD, FACP

I. GOALS

Internal medicine physicians are confronted by numerous symptoms while in the clinic or hospital, and neurologic symptoms are routinely included in the top 10 chief complaints mentioned by patients. The American College of Physicians (ACP) and the American Academy of Neurology (AAN) partnered to develop this multimedia tool to give internists a systematic approach to common neurologic problems.

This material covers the most common and the most dangerous neurologic disorders. Every effort is made to present only the most pertinent history and examination features used to evaluate each symptom. Every chapter is coauthored by an internist and a neurologist to ensure that the information is applicable to patients presenting to internal medicine physicians.

II. STRUCTURE

This multimedia tool uses a symptom-based approach. Each chapter starts with several case histories that simulate common clinical problems. Following this is a section on pertinent history containing focused questions that allow a problem-solving approach. An emphasis is on time course: acute (seconds to minutes), subacute (hours to days), and chronic (weeks to months to years) (Figure 1-1), since symptom onset and progression are necessary to determine the most likely etiologies. The examination section details only the most important parts of the neurologic examination for the specific symptom. Throughout this section hyperlinks to videos and photos will illustrate important examination techniques and abnormal findings.


Figure 1-1

The assessment of symptoms following the history and examination requires a combination of the localization of the problem in the nervous system with the time course. Only three etiologies are of sudden onset: vascular, trauma, and electrical (seizure). A mnemonic that can be useful for remembering all etiologies is as follows:

    V: vascular—acute (transient ischemic attack [TIA], stroke, hemorrhage)
    I: infectious—subacute (bacterial, fungal, viral)
    T: traumatic—acute (subdural or epidural hematoma, fracture)
    A: autoimmune—subacute (lupus, multiple sclerosis, myasthenia gravis)
    M: metabolic—subacute (hypoglycemia, hypercalcemia, etc.)
    I: iatrogenic—subacute (drug, radiation, etc.)
    N: neoplastic—chronic (tumor)
    D: degenerative—chronic (Alzheimer disease, Parkinson disease)
    E: electrical—acute (seizures)
    C: congenital—chronic (Chiari malformation)

In each chapter the plan details any red flags to look for and how quickly the patient should receive diagnostic tests. Also, there are suggestions on when and how rapidly the patient should be referred to a neurologist. In general the rapidity of evaluation directly correlates with how rapidly the symptoms came on for the patient. Continuing medical education questions are at the end of each chapter.

III. BASIC ANATOMY

A detailed knowledge of neuroanatomy is not necessary to localize lesions in the nervous system in most cases. Pattern recognition of distribution of symptoms and signs can be used to locate where the problem is in the central or peripheral nervous system. In broad terms the nervous system can be broken down into central nervous system (CNS) and peripheral nervous system (PNS). The CNS consists of the brain and spinal cord. The PNS is made up of nerve roots, nerves, neuromuscular junction, and muscle. CNS lesions tend to cause increased reflexes and possible Babinski signs (upper motor neuron). PNS lesions usually cause decreased or absent reflexes (lower motor neuron). The following patterns of neurologic signs and symptoms (Figures 1-2 through 1-11) can be used to determine what part of the nervous system is involved.


Figure 1-2


Figure 1-3


Figure 1-4


Figure 1-5


Figure 1-6


Figure 1-7


Figure 1-8


Figure 1-9


Figure 1-10


Figure 1-11

IV. GENERAL SCREENING EXAMINATION FOR PATIENTS WITH NO NEUROLOGIC SYMPTOMS

A detailed neurologic examination is not necessary in a patient presenting to an internal medicine office with no neurologic symptoms. A quick general screening examination can be used as demonstrated in Video 1-1. Pupils, extraocular movements, and facial symmetry can be included as part of the general medical examination. Examination of the gait should also be included since most of the CNS and PNS needs to be intact for a patient to walk normally.