Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Approach to the Patient with Nose, Sinus, and Ear Disorders

Patients with nose, sinus, and ear disorders may have a variety of chief complaints. Nasal symptoms, including rhinorrhea and congestion, may be due to allergic, infectious, inflammatory, neoplastic, or structural causes. Sinus disorders generally result in concomitant nasal inflammation, so the term rhinosinusitis is preferred. Patients who have rhinosinusitis are more likely to present with purulent rhinorrhea, facial pressure, loss of smell, and pain or headache…

Diseases of the Mouth and Salivary Glands

More than 200 primary lesions or diseases occur in the oral mucosa, gingiva, teeth, jaws, and minor or major salivary glands. In addition, secondary abnormalities of the oral mucosa or salivary glands can be caused by systemic diseases or drugs. The most common or important of these diseases may be observed during physical examination. Oral Mucosal Diseases Acute Ulcerations Painful, short-lasting ulcerations can be caused by…

Neuro-Ophthalmology

A mechanistic understanding of vision impairment along with disturbances in pupillary and oculomotor control is often critical for diagnosing neurologic disorders. Although all physicians should be able to recognize neuro-ophthalmologic abnormalities, precise diagnosis and treatment commonly requires specialty consultation. Vision One of the most difficult diagnostic problems is vision loss that cannot be explained by obvious abnormalities of the eye. To evaluate such a patient properly,…

Diseases of the Visual System

The eye is a compact, complicated structure ( Fig. 391-1 ) that is remarkably stable throughout life. Once the growth of the eye is complete, at approximately age 7 to 8 years, the structure of the eye changes very little throughout one’s life. Open full size image FIGURE 391-1 Anatomy of the eye. The eyelids physically protect the eye. The pathway of light through the eye,…

Disorders of Neuromuscular Transmission

Definition The clinical recognition of neuromuscular transmission disorders ( Table 390-1 ) is critically important because all are treatable. Afflicted patients have the potential to improve substantially or even return to normal function, whereas undiagnosed or untreated disease leads to severe morbidity and death. Each of these disorders compromise the postsynaptic potential, thereby reducing the force generated by muscles. Myasthenia gravis and Lambert-Eaton syndrome are autoimmune…

Muscle Diseases

Definition Muscle diseases, which are also called myopathies, are disorders of skeletal muscle structure or function. Myopathies can be primary and occur in isolation, or they can be part of a multisystem disorder. Epidemiology Many muscle diseases ( Table 389-1 ) are inherited as autosomal dominant, autosomal recessive, X-linked, or maternal (mitochondrial) conditions. Environmental factors that may precipitate myopathies include recent infection, foreign travel, exposure to…

Peripheral Neuropathies

Approach to Peripheral Neuropathy The term peripheral neuropathy is used to describe a group of disorders that are caused by injury to the peripheral nervous system, which encompasses the final pathways of motor, sensory, and autonomic function. Epidemiology As a group, peripheral neuropathies are among the most common neurologic problems encountered in medical practice. The prevalence of peripheral neuropathy increases with age from 2 to 3%…

Amyotrophic Lateral Sclerosis and Other Motor Neuron Diseases

Definition The motor neuron diseases ( Table 387-1 ) are a heterogeneous group of disorders in which selective loss of function of upper motor neurons, lower motor neurons, or both results in impairment of the nervous system’s control of voluntary movement. The most common acquired motor neuron disease, amyotrophic lateral sclerosis (ALS), is a combined upper and lower motor neuron disorder. The features of lower motor…

Autonomic Disorders

Systemic Autonomic Disorders Definition Autonomic dysfunction, which is an important cause of disability, accompanies many diseases that affect the central or peripheral nervous system. It may manifest as autonomic failure or autonomic hyperactivity, may be generalized or focal, and may have a subacute, chronic progressive, or intermittent temporal profile. The prognosis of autonomic disorders depends on the underlying condition. Epidemiology The most common causes of autonomic…

Developmental and Neurocutaneous Disorders

The understanding of many neurodevelopmental disorders has improved dramatically because of high-resolution neuroimaging, which can detect structural defects that previously went unrecognized, genetic testing, and a better grasp of molecular mechanisms. As a result, targeted treatments are now available for some conditions. Neural Tube Defects The worldwide incidence of neural tube defects is about 1 to 10 per 1000 live births. In the United States, neural…

Nutritional and Alcohol-Related Neurologic Disorders

Vitamins and minerals, which are essential to cellular function, must be obtained from the environment because the body cannot produce them. They are necessary for embryonic and early development as well as the subsequent maintenance of metabolic function of both the central and peripheral nervous systems. Deficiencies can cause a variety of neurologic syndromes ( Table 384-1 ), each with a well-described constellation of symptoms that…

Encephalitis

Definition Encephalitis is a diffuse or focal inflammation of the parenchyma of the brain. The term encephalitis indicates that the predominant clinical syndrome arises from infection and inflammation in the parenchyma of the brain rather than in the leptomeninges. When both the leptomeninges and brain parenchyma are involved, the term meningoencephalitis is used. In the United States, about 50% of cases of encephalitis are viral in…

Brain Abscess and Parameningeal Infections

A brain abscess affects the brain’s parenchyma directly, whereas parameningeal infections produce suppuration in potential spaces covering the brain and spinal cord (epidural abscess and subdural empyema) or produce occlusion of the contiguous venous sinuses and cerebral veins (cerebral venous sinus thrombosis). Brain Abscess Epidemiology The frequency of various causes of brain abscess ( Table 382-1 ) in the population is difficult to ascertain because of…

Meningitis: Bacterial, Viral, and Other

Bacterial Meningitis Definition Meningitis is an inflammation of the arachnoid membrane, the pia mater, and the intervening cerebrospinal fluid (CSF). The inflammatory process extends throughout the subarachnoid space around the brain and spinal cord and involves the ventricles. Pyogenic meningitis is usually an acute bacterial infection that evokes a polymorphonuclear response in CSF. By comparison, tuberculous meningitis ( Chapter 299 ) is often subacute and characterized…

Multiple Sclerosis and Demyelinating Conditions

The disorders of myelin encompass a wide range of diseases in which myelin is not produced (hypomyelination), myelin is not formed in a normal fashion (dysmyelinating disease), or normally formed myelin is destroyed or not maintained appropriately (demyelinating disease and myelinolysis) ( Table 380-1 ). Hypomyelinating and dysmyelinating diseases are uncommon and include an array of leukodystrophies that have a genetic basis and may affect the…

Other Movement Disorders

Definition Movement disorders are first divided into hypokinetic and hyperkinetic categories. Hypokinetic disorders , which are characterized by akinesia, bradykinesia, and rigidity, are parkinsonian syndromes and are discussed in Chapter 378 . The common hyperkinetic movement disorders ( Table 379-1 ) are defined by specific clinical phenomena. TABLE 379-1 HYPERKINETIC MOVEMENT DISORDERS Tremor Chorea Ballism Dystonia Athetosis Tics Myoclonus Startle Stereotypies Miscellaneous Clinical Manifestations and Diagnostic…

Parkinsonism

Parkinsonism is a clinical syndrome that consists of four cardinal signs: tremor, rigidity, akinesia, and postural disturbances. Parkinson disease is a common cause of the syndrome, but there are numerous other causes ( Table 378-1 ). TABLE 378-1 DIFFERENTIAL DIAGNOSIS OF PARKINSONISM Modified from Cloutier M, Lang AE. Movement disorders: an overview. In: Factor SA, Lang AE, Weiner WJ, eds. Drug Induced Movement Disorders . Malden,…

Hemorrhagic Cerebrovascular Disease

In the United States, about 13% of strokes are caused by intracranial hemorrhage, but the worldwide percentage is about 20% because of countries where hypertension is common but atherosclerosis is less common. Intracerebral hemorrhage, which accounts for about 75% of cases, usually occurs when small penetrating arteries rupture and produce a focal collection of blood within the parenchyma. Subarachnoid hemorrhage, which accounts for about 25% of…

Ischemic Cerebrovascular Disease

Definition Ischemic cerebrovascular disease is caused by a reduction of blood supply to the brain. The injury may be focal (related to occlusion of a single artery), multifocal (related to occlusion of several arteries), or global. Although certain clinical features (e.g., severe hypertension, headache, impaired consciousness) may suggest brain hemorrhage ( Chapter 377 ) rather than ischemia, it is not possible to differentiate the two types…

Approach to Cerebrovascular Diseases

Definition The term cerebrovascular disease refers to a group of conditions in which the brain or spinal cord is injured by a vascular cause. The onset is generally abrupt, but it also can be insidious. Clinical manifestations depend on the location and extent of damage to neural structures. Although risk factors and treatments may overlap, cerebrovascular diseases are pathophysiologically divided into those in which an insufficiency…