How to Think Like a Neurologist: A Case-Based Guide to Clinical Reasoning in Neurology

265 Pages·2022·17.076 MB·English

by  Ethan Meltzer

ADVANCE PRAISE FOR HOW TO
THINK LIKE A NEUROLOGIST
“Meltzer’s How to Think Like a Neurologist is even more than that—it’s a mas-
terful clinical handbook for learning how to tackle unknowns. What do you
do if the diagnosis is not already obvious and there is no algorithm to follow?
How do you tailor your history by asking probing questions that will help to
refine hypotheses? And how do you refute your hypotheses through directed,
customized neurological examinations? The syndromic approach beautifully
elaborated by Meltzer is a prerequisite for delivering the kind of value-based
and patient-centered care we all seek—and to do so one patient at a time.”
—William J. Schwartz, MD, Assistant Dean for Faculty Affairs,
Distinguished Teaching Professor, Professor and
Associate Chair of Research & Education, Dept. of Neurology,
Dell Medical School, The University of Texas at Austin
“How to Think Like a Neurologist presents a clear, practical approach to
clinical reasoning in neurology. Working step by step through a series of
real-world cases, Dr. Meltzer uses a conversational style to elucidate the
principles of neurologic diagnosis. This is essential reading for students on
their neurology rotation, residents in neurology, and any medical provider
seeking to improve their understanding of clinical neurology.”
—Aaron Berkowitz, MD, PhD, Professor of Neurology,
Kaiser Permanente, Los Angeles, CA and author of Clinical
Neurology and Neuroanatomy: A Localization-Based Approach
“Finally, a book that captures the intangibles of neurologic diagnosis.
The synthetic ability that combines knowledge of how diseases affect the
nervous system, personal clinical experience, and systematic inquiry is on
display. Nowhere do these qualities come together more obviously than in
neurology. By analyzing clinical cases that delve into the inner workings of
a master clinician, Meltzer has provided a terrific contribution to pedagogy
and to clinical work in the field.”
—Alan Ropper, MD, Department of Neurology,
Brigham and Women’s Hospital, Boston, MA

HOW TO THINK LIKE
A NEUROLOGIST
A Case- Based Guide to
Clinical Reasoning in Neurology
Ethan Meltzer, MD
ASSISTANT PROFESSOR
DEPARTMENT OF NEUROLOGY
THE UNIVERSITY OF TEXAS AT AUSTIN DELL MEDICAL SCHOOL
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Library of Congress Cataloging-in-Publication Data
Names: Meltzer, Ethan, author.
Title: How to think like a neurologist : a case-based guide to clinical
reasoning in neurology / Ethan Meltzer.
Description: New York, NY : Oxford University Press, [2022] |
Includes bibliographical references and index.
Identifiers: LCCN 2022000243 (print) | LCCN 2022000244 (ebook) |
ISBN 9780197576663 (paperback) | ISBN 9780197576687 (epub) | ISBN 9780197576694
Subjects: MESH: Nervous System Diseases | Clinical Reasoning | Case Reports
Classification: LCC RC346 (print) | LCC RC346 (ebook) | NLM WL 140 |
DDC 616.8—dc23/eng/20220204
LC record available at https://lccn.loc.gov/2022000243
LC ebook record available at https://lccn.loc.gov/2022000244
DOI: 10.1093/ med/ 9780197576663.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent
on the individual circumstances. And, while this material is designed to offer accurate information
with respect to the subject matter covered and to be current as of the time it was written, research
and knowledge about medical and health issues is constantly evolving and dose schedules for
medications are being revised continually, with new side effects recognized and accounted for
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the contents of this material.
1 3 5 7 9 8 6 4 2
Printed by Marquis, Canada
To my father, David, for his encouragement and advice,
without which this book would not have been possible.

CONTENTS
Preface xv
Acknowledgments xix
1. How to think like a neurologist 1
Introduction 1
What is pace? 2
What is localization? 8
What is the syndrome? 11
What is the clinical context? 12
What is the differential diagnosis? 13
Organization of the remaining chapters 18
2. A woman with rapid onset of aphasia 21
What is the pace? 22
What is the localization? 23
What is the syndromic diagnosis? 24
What is the etiologic diagnosis? 24
Clinical course and additional information 25
vii
Contents
What is the localization? 26
Conclusion 27
3. A woman with sudden numbness 28
What is the pace? 29
What is the localization? 29
What is the syndromic diagnosis? 33
What is the etiologic diagnosis? 33
Conclusion 34
4. A woman who couldn’t hold a cigarette in her mouth 35
What is the pace? 37
What is the localization? 37
What is the syndromic diagnosis? 39
What is the etiologic diagnosis? 40
Conclusion 40
5. A woman who didn’t realize she couldn’t see half the
world 41
What is the pace? 42
What is the localization? 42
Additional information 43
What is the syndromic diagnosis? 45
What is the etiologic diagnosis? 45
Conclusion 46
6. A woman who developed weakness after windsurfing 48
What is the pace? 49
What is the localization? 49
What is the syndromic diagnosis? 51
What is the etiologic diagnosis? 52
Conclusion 54
viii
Contents
7. A man who became unresponsive 55
What is the pace? 56
What is the localization? 56
What is the syndromic diagnosis? 59
What is the etiologic diagnosis? 59
Conclusion 60
8. A woman who appeared intoxicated 62
What is the pace? 64
What is the localization? 64
What is the syndromic diagnosis? 66
What is the etiologic diagnosis? 66
Conclusion 67
9. A man who appeared jumpy 68
What is the pace? 69
What is the localization? 70
What is the syndromic diagnosis? 73
What is the etiologic diagnosis? 73
Conclusion 74
10. A woman who only ate fast food 75
What is the pace? 76
What is the localization? 76
What is the syndromic diagnosis? 78
What is the etiologic diagnosis? 78
Conclusion 79
11. A woman whose cruise was cut short 80
What is the pace? 81
What is the localization? 82
What is the syndromic diagnosis? 87
What is the etiologic diagnosis? 87
ix