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Preface	4	DISORDERS OF COGNITION	86
		Memory disorders	86
Contributors	4	John Greene
		Speech and language disorders	94
Abbreviations	5	John Greene
1 HISTORY TAKING AND		DISORDERS OF SPECIAL SENSES	104
1 HISTORY TAKING AND		Visual loss and double vision	104
PHYSICAL EXAMINATION	7	James Overell, Richard Metcalfe
Ian Bone, John Greene		Dizziness and vertigo	131
Introduction	8	James Overell, Richard Metcalfe
Concepts of history taking	8
Taking the history	8	DISORDERS OF MOTILITY	148
Neurological examination	11	Weakness	148
Cranial nerve examination	20	Richard Petty
Motor examination	23	Tremor and other involuntary movements	163
Sensory examination	25	Vicky Marshall, Donald Grosset
Coordination	26	Poor coordination	176
Stance and gait	26	Abhijit Chaudhuri
References	26
		DISORDERS OF SENSATION	187
2 NEUROLOGICAL		Headache	187
2 NEUROLOGICAL		Stewart Webb
INVESTIGATIONS	27	Spinal symptoms: neck pain and backache	204
Ian Bone, John Greene		John Paul Leach
Introduction	28	Numbness and tingling	214
Investigating the head	28	Colin O’Leary
Investigating the spinal cord	47
Investigating the peripheral nervous system		4 MULTIPLE CHOICE QUESTIONS	229
(nerve, neuromuscular junction, and muscle)	52	4 MULTIPLE CHOICE QUESTIONS	229
Investigating specific sites	56
3 THE PROBLEMS	63	Index	235
3 THE PROBLEMS	63
DISORDERS OF CONSCIOUSNESS	64
Blackouts: epileptic seizures and other events	64
Rod Duncan
Acute confusional states	76
Myfanwy Thomas

Preface

While traditional neurology textbooks tend to be organized by disease process, patients, being unaware of this, arrive with a complaint, (e.g. headache, dizziness, memory problems), that requires an explanation. This multi-author book adopts a problem-oriented approach to the commonly presenting complaints seen by neurologists. We have drawn on the experience of practising clinicians in a busy department based in the Southern General Hospital, Glasgow.

The problem-based approach illustrates the manner in which clinicians, in the real world, focus on particular elements of history and examination in order to narrow down their differential diagnosis and by so doing formulate a diagnostic approach or

sometimes (quite often actually) offer no more than confident professional reassurance.

This is not a comprehensive textbook of these neurological conditions in themselves, nor a manual of neuro-therapeutics. Neurology is a speciality requiring a ‘good listener’ and a capable examiner, no more and no less.

We hope that this book will demystify what should have never been mysterious in the first place and prove useful to medical undergraduates. It should also be of benefit to junior doctors preparing for MRCP. If trainee neurologists also derive benefit from reading it, so much the better!

John Greene and Ian Bone

Contributors

John Greene	Vicky Marshall
Consultant Neurologist, Institute of Neurological	Research Registrar in Neurology, Institute of
Sciences, Southern General Hospital, Glasgow	Neurological Sciences, Southern General Hospital,
	Glasgow
Ian Bone
Consultant Neurologist and Honorary Professor of	Donald Grosset
Neurology, Institute of Neurological Sciences,	Consultant Neurologist, Institute of Neurological
Southern General Hospital, Glasgow	Sciences, Southern General Hospital, Glasgow
Rod Duncan	Abhijit Chaudhuri
Consultant Neurologist, Institute of Neurological	Consultant Neurologist, Essex Centre of
Sciences, Southern General Hospital, Glasgow	Neurological Sciences, Oldchurch Hospital,
	Romford, Essex
Myfanwy Thomas
Consultant Neurologist, Paris, France. Formerly	Stewart Webb
Consultant Neurologist, Institute of Neurological	Consultant Neurologist, Institute of Neurological
Sciences, Southern General Hospital, Glasgow	Sciences, Southern General Hospital, Glasgow
James Overell	John Paul Leach
Consultant Neurologist, Institute of Neurological	Consultant Neurologist, Institute of Neurological
Sciences, Southern General Hospital, Glasgow	Sciences, Southern General Hospital, Glasgow
Richard Metcalfe	Colin O‚Leary
Consultant Neurologist, Institute of Neurological	Consultant Neurologist, Institute of Neurological
Sciences, Southern General Hospital, Glasgow	Sciences, Southern General Hospital, Glasgow
Richard Petty	We would like to thank colleagues in
Consultant Neurologist, Institute of Neurological	Neurophysiology and Neuroradiology at the
Sciences, Southern General Hospital, Glasgow	Institute for help with providing figures.

Abbreviations	5

Abbreviations

ACE Addenbrooke’s Cognitive	CTP CT perfusion
Examination/angiotensin-converting enzyme	CTV CT venography
AChRAb anti-acetylcholine receptor antibody	DMD Duchenne muscular dystrophy
ACTH adrenocorticotrophic hormone	DNA deoxyribonucleic acid
AD Alzheimer's disease	DRG dorsal root ganglion
AICA anterior inferior cerebellar artery	DSA digital subtraction angiography
AION anterior ischaemic optic neuropathy	DWI diffusion-weighted imaging
ALP alkaline phosphatase	ECG electrocardiography
ALS amyotrophic lateral sclerosis	EEG electroencephalogram
ANA antinuclear antibody	EMG electromyography
AP antero-posterior	ENA extractable nuclear antigen
ARAS ascending reticular activating system	ENG electronystagmography
AST aspartate aminotransferase	ERG electroretinography
AVM arteriovenous malformation	ES epileptic seizure
BIH benign intracranial hypertension	ESR erythrocyte sedimentation rate
BOLD blood oxygen level dependent	FBC full blood count
BPPV benign paroxysmal positional vertigo	FLAIR (MRI) fluid-attenuated inversion recovery
BSAEP brainstem auditory evoked potential	(MRI)
CADASIL cerebral autosomal dominant	fMRI functional magnetic resonance imaging
arteriopathy with subcortical infarcts and	FP-CIT fluoropropyl carboxymethoxy iodophenyl
leucoencephalopathy	nortropane spectroscopy
CAT computer assisted tomography	GH growth hormone
CBD corticobasal degeneration	GnRH gonadotrophin releasing hormone
CBF cerebral blood flow	GP general practitioner
CBV cerebral blood volume	GT glutamyl transferase
Cho choline	HD Huntington’s disease
CJD Creutzfeldt–Jakob disease	HIV human immunodeficiency virus
CK creatine kinase	HMPAO hexamethylpropyleneamine oxime
CMAP compound muscle action potential	HMSN hereditary motor and sensory neuropathy
CNS central nervous system	HSV herpes simplex virus
COPD chronic obstructive pulmonary disease	ILAE International League against Epilepsy
Cr creatine	INR international normalized ratio
CRP C-reactive protein	IQ intelligence quotient
CSF cerebrospinal fluid	JME juvenile myoclonic epilepsy
CT computed tomography	LMN lower motor neurone
CTA CT angiography	LP lumbar puncture

LSD lysergic acid diethylamide	PNES psychogenic nonepileptic seizures
MELAS mitochondrial encephalopathy, lactic	PSP progressive supranuclear palsy
acidosis, and stroke-like episodes	PWI perfusion-weighted imaging
MERRF myoclonic epilepsy and ragged red fibres	RAPD relative afferent pupillary defect
syndrome	RF radiofrequency/ rheumatoid factor
MI myocardial infarction	SAH subarachnoid haemorrhage
MMSE Mini-Mental State Examination	SCA superior cerebellar artery/spinocerebellar ataxia
MND motor neurone disease	SEEG stereo-EEG
MRA magnetic resonance angiography	SNAP sensory nerve action potential
MRI magnetic resonance imaging	SPECT single photon emission computed
MRI-ADC magnetic resonance imaging apparent	tomography
diffusion coefficient	SSEP somatosensory evoked potential
MRS MR spectroscopy	SSPE subacute sclerosing panencephalitis
MS multiple sclerosis	SSRI selective serotonin reuptake inhibitor
MSA multiple system atrophy	TCD transcranial Doppler ultrasound
MTT mean transit time	TFT thyroid function test
NAA N-acetyl aspartate	TIA transient ischaemic attack
NART National Adult Reading Test	TRH thyrotrophin releasing hormone
NCS nerve conduction study	TTP time-to-peak
NMJ neuromuscular junction	UMN upper motor neurone
OCB oligoclonal band	VEP visual evoked potential
PD Parkinson’s disease	VER visual evoked response
PET positron emission tomography	WAIS-R Wechsler Adult Intelligence Scale-Revised
PICA posterior inferior cerebellar artery

CHAPTER 1: HISTORY TAKING AND

PHYSICAL EXAMINATION	7

Ian Bone, John Greene

INTRODUCTION

CONCEPTS OF HISTORY TAKING

TAKING THE HISTORY

NEUROLOGICAL EXAMINATION

CRANIAL NERVE EXAMINATION

MOTOR EXAMINATION

SENSORY EXAMINATION

COORDINATION

STANCE AND GAIT

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Contents

Preface

Contributors

Abbreviations