Pain is the chief complaint in many patients. Although pain may arise from a variety of nonneurologic causes, this chapter will cover the diagnosis and management of six pain syndromes that are uniquely neurologic. Headache is covered in Chapter 15 . Treatment of pain, independent of the underlying cause, is usually possible with appropriate therapeutic agents, but rational management decisions can be made only after identification…

Syncope is brief loss of consciousness caused by a sudden reduction of cerebral blood flow. Patients will often use the words “fainting” or “passing out” to describe a syncopal event. Presyncope refers to the sensation of impending loss of consciousness, but the patient does not actually pass out. Presyncope and syncope represent varying degrees of the same disorder and should be addressed as manifestations of the…

Generalized weakness is usually the primary complaint in patients with severe neuromuscular disease. The most common diseases presenting as acute paralysis and acute respiratory failure are myasthenia gravis and Guillain-Barré syndrome (GBS) (acute inflammatory demyelinating polyneuropathy). Patients may also present with acute respiratory failure as a presenting symptom of myasthenia gravis or GBS. Weakness of the bulbar or respiratory muscles could lead to life-threatening respiratory failure…

Headache is one of the most common complaints presented to neurologists. This symptom can be caused by two broad categories of disorders. One group comprises the primary headache disorders , including migraine, tension-type headache, cluster headache, and other trigeminal autonomic cephalalgias (TACs). Secondary headache disorders include those attributed to trauma or injury to the head; vascular and nonvascular intracranial lesions; systemic diseases; or local diseases of…

Dizziness and vertigo are among the most common neurologic complaints. The etiology of these conditions may range from the relatively benign, such as labyrinthitis, to the potentially serious, such as cardiac syncope or life-threatening cerebellar hemorrhage. Vertigo may be defined specifically as a sensation of movement, either of the environment or of the patient. A spinning sensation is most commonly described, but feelings of acceleration or…

Increased intracranial pressure (ICP) is not a symptom; rather, intracranial hypertension is a pathologic state common to a variety of serious neurologic illnesses ( Table 13.1 ). All conditions that result in increased ICP are characterized by an increase in intracranial volume. Accordingly, all therapies for ICP (hyperventilation, mannitol, etc.) are directed toward reducing intracranial volume. Table 13.1 Conditions Associated With Increased ICP Intracranial Mass Lesions…

Few symptoms may be as disturbing or dramatic to a patient as acute visual loss. Although acute ocular diseases such as uveitis, retinal detachment, and some forms of glaucoma may require urgent evaluation by an ophthalmologist, a high percentage of acute visual disturbances fall within the province of the neurologist. Neurologic visual symptoms may be reported as blurriness, double vision, focal obscurations or shadows, vision loss,…

The control of gait and posture involves numerous components of the nervous system. Gait ataxia implies decomposition in the coordinated control of posture and gait that are typically controlled by the cerebellum and other subcortical structures. A call for a patient with gait failure requires consideration of a broad differential diagnosis. Successful evaluation begins with an assessment of the time course of the symptoms. Associated signs…

Introduction Focal brain masses are a common reason for neurologic consultation, particularly in the inpatient setting. The main etiologic considerations include malignancy, infection, and, less commonly, inflammatory disease. The management of the brain mass varies widely depending on the etiology. This chapter will focus on the initial diagnostic evaluation and initial management of focal brain lesions. Phone call Questions 1. Is the patient fully awake and…

The initial assessment of head injury in the emergency room (ER) can be frantic, with resuscitation measures, history taking, and examination occurring simultaneously. An organized approach is essential to ensure that vital components of the evaluation are not omitted. The immediate goal is to judge the severity of the injury as minimal, moderate, or high. This aspect of the injury can be quickly assessed at the…

The term delirium is synonymous with the term acute confusional state . Delirium is common in hospitalized patients, particularly in the elderly, and refers to an acute, global disorder of thinking and perception, characterized by impaired consciousness and inattention. Restlessness, agitation, and combativeness may be seen, as well as bizarre behavior and delusions. A call to evaluate delirium may therefore be one for “agitation” or “confusion.”…

Spinal cord compression is one of the few true neurologic emergencies. The more severe the syndrome, the more acute the injury is likely to have been. Unlike the brain, which may have remarkable functional recovery, the spinal cord, once damaged, rarely recovers function. Patients with cord compression resulting from neoplastic disease of the spine who cannot walk before the onset of treatment will rarely walk again.…

Stroke should be suspected whenever a patient presents with the characteristic sudden onset of focal neurologic signs such as hemiparesis, hemisensory loss, hemianopia, aphasia, or ataxia ( Table 6.1 ). Time is of the essence for treating stroke because reperfusion therapy always works better when given as early as possible. It has been estimated that every 15-minute reduction in onset-to-treatment time translates into a meaningful reduction…

Stupor and coma refer, respectively, to moderate and severe depression of the level of consciousness. The acute onset of stupor or coma is a medical emergency. A wide variety of metabolic and structural disorders can produce this state. Management should focus on stabilizing the patient, establishing a diagnosis, and treating the underlying cause. Phone call Questions 1. What are the vital signs? 2. Is the airway…

Seizures are abnormal, paroxysmal synchronous discharges of cortical neurons resulting in abrupt neurologic manifestations that depend on the area of the brain involved. Seizures are classified as generalized ( Fig. 4.1 ) when they involve the entire brain, producing an abrupt alteration in consciousness with or without motor manifestations. Focal seizures (see Fig. 4.1 ) involve a single brain region, causing limited dysfunction, which may include…

A thorough history and examination should enable you to localize the disease process and generate a differential diagnosis. Confirmation of the diagnosis will usually require neurodiagnostic testing. When any of the tests described here is performed, it is essential to know what you are looking for and to understand the sensitivity (likelihood of a true positive result if the disease is present) and specificity (likelihood of…

Clinical examination is of primary importance in the practice of neurology, even with the availability of advanced neuroimaging techniques. This is because the neurologic examination provides critical information that no other test can provide, such as whether the patient’s nervous system is working normally. Unfortunately, many clinicians never master the neurologic examination because it is taught in a way that makes it seem time-consuming, excessively complicated,…

It is in the early morning hours. You get a call from a resident in the emergency room (ER). A 48-year-old teacher has headache, neck pain, and urinary incontinence, and, as of this morning, is no longer able to hold a pen in his right hand. How do you proceed? What do you tell the ER resident? What tests should be ordered? How urgent is this…