Table Of ContentChallenging 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
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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
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Part I
Neuro-Oncology
