Neurology: Clinical Cases Uncovered

170 Pages·2011·13.4 MB·English

by  Malcolm Macleod

Neurology
CLINICAL CASES UNCOVERED

Neurology
CLINICAL CASES UNCOVERED
Malcolm Macleod Suvankar Pal
BSc (Hons), MBChB, PhD, FRCPEdin BSc(Hons), MBBS(Distinction), MRCP,
Reader and Head of Experimental MD(Res)
Neuroscience, Centre for Clinical Brain Neurology Registrar, Department of Clinical
Sciences, University of Edinburgh, UK Neurosciences, Western General Hospital,
Honorary Consultant Neurologist and Edinburgh, UK
Clinical Lead for Neurology, NHS Forth
Valley, Stirling, UK
Marion Simpson
BSc(Hons), MBChB(Hons), MRCP
Neurology Registrar, Department of
Neurology, The Austin Hospital, Melbourne,
Australia
A John Wiley & Sons, Ltd., Publication
This edition fi rst published 2011, © 2011 by Malcolm Macleod, Marion Simpson, Suvankar Pal
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Library of Congress Cataloging-in-Publication Data
Macleod, Malcolm, Ph. D.
Neurology / Malcolm Macleod, Marion Simpson, Suvankar Pal.
p. ; cm. – (Clinical cases uncovered)
Includes bibliographical references and index.
ISBN 978-1-4051-6220-3
1. Nervous system–Diseases–Problems, exercises, etc. 2. Nervous system–Diseases–Case
studies. 3. Neurology–Problems, exercises, etc. 4. Neurology–Case studies. I. Simpson,
Marion. II. Pal, Suvankar. III. Title. IV. Series: Clinical cases uncovered.
[DNLM: 1. Nervous System Diseases–Case Reports. 2. Nervous System Diseases–Problems and
Exercises. WL 18.2 M165n 2011]
RC343.5.M28 2011
616.8–dc22
2010024552
A catalogue record for this book is available from the British Library.
Set in Minion 9 on 12pt by Toppan Best-set Premedia Limited
1 2011
Contents
Preface, vii
Acknowledgements, viii
How to use this book, ix
List of abbreviations, x
Part 1 Basics, 1
Basic science, 1
Approach to the patient, 10
Part 2 Cases, 18
Case 1 A 76-year-old man whose hand went weak, 18
Case 2 A 60-year-old man with back pain and weakness, 22
Case 3 A 25-year-old woman with weakness and tingling in her arms and legs, 27
Case 4 A 45-year-old man with uncontrollable seizures, 32
Case 5 A 24-year-old woman with headaches and abnormal optic fundi, 36
Case 6 A 37-year-old man with sudden, severe headache, 39
Case 7 A 17-year-old girl who becomes unresponsive after a late night, 46
Case 8 A 30-year-old woman found fi tting on the train, 51
Case 9 A 66-year-old woman with confusion and weakness, 54
Case 10 An 18-year-old girl with headache, fever and confusion, 58
Case 11 A 30-year-old woman with double vision and fatigue, 61
Case 12 A 29-year-old woman with tingling weakness of the left arm and leg, 67
Case 13 A 45-year-old woman with pain in the leg, 70
Case 14 A 29-year-old woman thrown from her horse, 73
Case 15 A 67-year-old man who is unsteady on his feet, 77
v
vi Contents
Case 16 A 49-year old man with burning in the feet and diffi culty walking, 81
Case 17 A 72-year-old woman with memory problems, 86
Case 18 A 54-year-old woman with tingling hands, 90
Case 19 A 26-year-old woman with right-sided weakness, 93
Case 20 A 19-year-old woman with acute headache and tingling, 97
Case 21 A 63-year-old man whose hands have got so weak he can’t work, 101
Case 22 A 55-year-old woman with episodes of excruciating facial pain, 105
Case 23 A 38-year-old man with heaviness of the legs, 108
Case 24 An 84-year-old man with confusion and unsteadiness, 112
Case 25 A 45-year-old man with constant headache, 115
Case 26 A 68-year-old man with a 2-week history of unsteadiness, 118
Case 27 A 15-year-old girl with fi dgeting movements, 121
Part 3 Self-assessment, 124
MCQs, 124
EMQs, 131
SAQs, 135
Answers, 140
Index of cases by diagnosis, 146
Index, 147
Preface
This book has been written by three neurologists who broad coverage of neurological conditions commonly
(we hope!) are nearer the beginning of our careers than encountered in clinical practice.
the end, and at the time of writing two were still in formal The book is organized in three parts. Part 1 deals with
neurological training. Our intention is to give the reader the basic scientifi c principles underlying neurological
a new perspective to understand better what the phe- disease, and with the fundamentals of neurology history -
nomenal advances in our understanding of the brain t aking and examination. Part 2 provides 27 clinical cases
mean in day to day clinical practice. In the past such covering a range of neurological conditions. The sequence
books existed as the major medium through which of these cases has been determined by formal randomisa-
factual knowledge was communicated to medical stu- tion, and so the reader may either start at the beginning
dents and clinicians. However, such has been the pace of or dip in and out. Some students may wish to use a par-
scientifi c discovery, that role has for some time been ticular chapter to ‘ w alk them through’ the presentation
obsolete. More recently, textbooks found a role in pro- of a patient seen in clinic or on the wards. Each case is
viding research syntheses, bringing together primary presented in sequence, with initial presentation, followed
evidence to give recommendations for diagnosis and by a discussion of the key features to elicit on history and
management. However, with the growth of systematic then on examination; discussion of the implications of
tools to provide unbiased and timely research synthesis evidence collected; appropriate investigations and the
(such as used by the Cochrane Collaboration), that role implications of fi ndings; and management options. Each
too is now obsolete. case ends with a case review and listing of key points
But reports of the death of the textbook have been and references. Part 3 provides plentiful self- a ssessment
exaggerated. At its best, clinical medicine brings the fruits material including multiple choice questions, extended
of scientifi c research to the bedside. That requires not just choice questions and self - assessment questions.
a knowledge of scientifi c facts, but an understanding of T he book is designed for medical students with clinical
how these inform disease processes, therapeutics, and attachments in neurology and in the run up to examina-
how they can help you better understand the patient in tions. However, it will also be useful to junior doctors
front of you. Neurological conditions such as headache, who are faced with patients with neurological conditions
stroke, epilepsy and dementia contribute to considerable and to those undertaking further training in internal
morbidity, accounting for a large proportion of presenta- medicine, geriatric medicine or neurology. We hope
tions to doctors in both primary and secondary care. that you fi nd this book both useful and interesting, and
Medical students fi nd neurological assessment of patients we hope it conveys some idea of how stimulating and
notoriously daunting and this ‘ neurophobia ’ persists rewarding neurology can be.
throughout postgraduate training. Our purpose here
is to show how a patient’ s journey can be informed by Malcolm Macleod
both scientifi c and clinical knowledge. In doing so, we Marion Simpson
use illustrative cases which, taken together, provide Suvankar Pal
vii
Acknowledgements
W e wish to acknowledge the contribution of those Writing this book has taken longer than we promised
who have taught us what we know about neurology ourselves, our families and our publisher. We are espe-
and neuroscience; the mentors and teachers who have cially grateful to Lindsay, Calum and Magnus, to Richie
encouraged, cajoled and educated us over the years. Our and to Lynn for their love and support. At Wiley -
colleagues in neurology, neurosurgery, neuropathology B lackwell we would like to thank Martin Sugden for
and neuroradiology have broadened our perspective on the opportunity to write the book, to Karen Moore and
disease. The other health professionals with whom it has to Laura Murphy for sticking with us until the end.
been a pleasure to work, in particular the nursing staff Particular thanks are due to Rustam al Shahi Salman and
and specialist nursing staff, have taught us of the realities Will Whiteley for helpful discussions and input to the
of life with a chronic neurological condition. Foremost early development of the book.
among our teachers are the patients who, through their We would like to acknowledge the Department of
symptoms and signs, their diseases and their reactions to Neuroradiology, Western General Hospital, Edinburgh
adversity, have educated us more than a library of books. for the provision of some of the radiological images. MM
We hope to have distilled some of that education into is especially grateful to Judi Clark, Steph Fleming and
this book. The errors that remain are our own. Carole Condie for their administrative support.
viii