Challenging Cases in Neurologic Localization. An Evidence-Based Guide PDF
Preview Challenging Cases in Neurologic Localization. An Evidence-Based Guide
Challenging Cases in Neurologic Localization An Evidence-Based Guide Joel I. Shenker Nakul Katyal Junaid Siddiqui Raghav Govindarajan Editors 123 Challenging Cases in Neurologic Localization Joel I. Shenker • Nakul Katyal Junaid Siddiqui • Raghav Govindarajan Editors Challenging Cases in Neurologic Localization An Evidence-Based Guide Editors Joel I. Shenker Nakul Katyal Department of Neurology Department of Neurology University of Missouri Health System University of Missouri Columbia, MO, USA Columbia, MO, USA Junaid Siddiqui Raghav Govindarajan School of Medicine Department of Neurology University of Missouri University of Missouri Columbia, MO, USA Columbia, MO, USA ISBN 978-3-030-92982-4 ISBN 978-3-030-92983-1 (eBook) https://doi.org/10.1007/978-3-030-92983-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface This book is about using clinical stories to learn how to practice neurology. For many years, the neurology residency program at University of Missouri has used a weekly clinical storytelling conference as a learning tool. At these confer- ences, a junior resident uses a standardized format to present a case for other resi- dents and faculty to hear and discuss. A presenting resident’s challenge is to tell a clinical story, appropriately focused in a concise but thorough manner. The goal is to capture the important points of what a patient experiences and what others around the patient observe. By developing skill in telling and using clinical stories, neurol- ogy learners can begin to grasp how clinical neurology cases evolve, and how they drive clinical decision making. Why focus on clinical stories? One reason is that this is what the patient and fam- ily focus on. A clinical story is what is real to people. The experiences that a patient goes through, and the phenomena others observe, are the only things that most people relate to about health and disease. People seldom care about a lab or study finding that causes no symptom. Similarly, the upset of a symptom experience mat- ters more, to most people, as compared to the medical reassurance a normal test finding might have implied. So, the people who ask for clinical care want their clini- cal stories listened to and cared about. Neurology is a medical specialty that must stay especially close to clinical sto- ries. Given the variety of functions that the human nervous system creates, and the complexity and precision with which neuroanatomy accomplishes those functions, it is critical that the neurology clinician understands the true nature of the problem needing to be explained. Take, for example, the seemingly simple complaint of leg weakness. The clinician must distinguish between a loss of capacity for motor strength (weakness), versus something (e.g., pain, a swollen joint) preventing a per- son from being able to use an otherwise intact underlying neurological capacity for strength, versus a higher motor control problem failing to direct motor strength in a correct or timely manner (as in a movement disorder, or an ideomotor apraxia). Making distinctions such as these is the essence of a clinical story. Nonetheless, in an era of expanding medical technology, precision health care, and increasing biomarkers that more carefully mark diseases, one may still ask why the v vi Preface modern neurology clinician still cares about clinical stories for neurology decision making? The answer is that however terrific a lab or piece of technology may be, a test finding cannot tell a clinician if the data generated are the data needed. The story of the patient’s presentation is still what rules that matter. Whether or not a test finding is relevant rests on the insight and judgment of the clinician, and that clinician’s under- standing begins with asking: What story am I trying to explain? A competent neurol- ogy clinician must be more than a test ordering machine, lazily assuming any abnormal finding explains whatever the complaint was. Instead, the competent neurologist needs to understand the story he or she is trying to explain to know if a test finding is relevant. In the neurology stories that follow, the reader will see that clinical neurology storytelling remains heavily tied to a detailed understanding of neuroanatomy. To control a wide variety of functions, the nervous system uses a complex but often precisely organized anatomy. Nonetheless, the so-called “eloquence of the nervous system” refers to the maxim that strategic dysfunction in discrete nervous system areas is betrayed by particular clinical signs and symptoms. The astute clinician remains keenly vigilant to spot these signs and symptoms. Doing so is important since the specific clinicopathologic processes that can cause neurological dysfunc- tion are differently likely to do so in different neuroanatomic locations. Thus, the neurology clinician classically starts an analysis of clinical neurology stories by considering a differential diagnosis for neuroanatomic localization before consider- ing an etiologic differential diagnosis. The neuroanatomic localization can be focal (one spot or region), multifocal (two or more physically discrete separate regions), or diffuse (widely dispersed across a broad but selected part of neuroanatomy). Finally, we present clinical neurology stories herein with the idea that the gather- ing of clinical neurology information is a process of hypothesis testing. The astute clinician begins a clinical interview with open ended questions, followed by silent active listening. But, very quickly, the neurology clinician’s questions must help evaluate different diagnostic possibilities. At some point, for a patient with possible migraine, the neurology clinician may need to ask, “was there any nausea with the headache?” or for a patient with possible normal pressure hydrocephalus, the neu- rology clinician may need to ask, “has there been any bladder incontinence?” and so on. To capture the hypothesis testing point of view, for each case in this book, the author pauses to offer different diagnostic possibilities based on presenting history alone, and then the author revises those possibilities after testing them further with physical exam findings and later with test data. At each point, the exercise is to understand what the possibilities are based only on the information available at that point of the hypothesis testing and data collection processes. So, we offer the cases that follow as examples of clinical stories our residents have used to start the process of learning to think as a clinical neurologist. We hope that you too can use them in your learning journey. Columbia, MO, USA Joel I. Shenker Nakul Katyal Junaid Siddiqui Raghav Govindarajan Contents Part I Neuro-Oncology Case: Elusive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Swathi Beladakere Ramaswamy Case: Summer Butterflies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Angela M. Richmond Part II S pinal Cord Case: Come and Gone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Swathi Beladakere Ramaswamy and Sachin M. Bhagavan Part III Headache Every Day Is a Sunday . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Sachin M. Bhagavan and Ross Smith Mi Cabeza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Sachin M. Bhagavan, Swathi Beladakere Ramaswamy, and Gurtej Singh Part IV Neuromuscular Case: Make Me Smile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Chetan S. Nayak Part V N eurovascular Case: Eye of the Tiger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Navpreet K. Bains vii viii Contents Part VI Neuro-immunology Case: The Last Ride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Nakul Katyal Part VII Cognitive Neurology Case: He Loves Me, He Loves Me Not . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Angela M. Richmond The Minister, His Ferrari and His New Wife . . . . . . . . . . . . . . . . . . . . . . . . . 79 Aisha Abdulrazaq Part VIII Neuro-ophthalmology Case: Doc I See Aliens! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Chetan S. Nayak and Zalan Khan Case: Still Can’t See (NMSOD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Zalan Khan Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Contributors Aisha Abdulrazaq, MD University of Missouri, Columbia, MO, USA Navpreet K. Bains, DO, MBA University of Missouri, Columbia, MO, USA Sachin M. Bhagavan, MD Department of Neurology, University of Missouri, Columbia, MO, USA Nakul Katyal, MD Department of Neurology, University of Missouri, Columbia, MO, USA Zalan Khan, MD University of Missouri School of Medicine, Columbia, MO, USA Chetan S. Nayak, MD University of Missouri School of Medicine, Columbia, MO, USA Swathi Beladakere Ramaswamy, MD Department of Neurology, University of Missouri, Columbia, MO, USA Angela M. Richmond, MD, PhD University of Missouri School of Medicine, Columbia, MO, USA Gurtej Singh, MD Department of Neurology, University of Missouri, Columbia, MO, USA Ross Smith, MD Department of Neurology, University of Missouri, Columbia, MO, USA ix Part I Neuro-Oncology
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