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Neurology is regarded by many as one of the most difficult and exacting medical specialties. Students and residents who come to a neurology service for the first time may be easily discouraged, and may already be intimidated by the complexity of the nervous system through their brief contact with neuroanatomy, neurophysiology, neuropathology, neurogenetics, and cell biology. The ritual they then witness of putting the patient through a series of maneuvers designed to evoke certain mysterious signs is hardly reassuring; in fact, the procedure often appears to conceal the intellectual processes by which neurologic diagnosis is made. Moreover, the students have had little or no experience with the many special tests used in neurologic diagnosis—such as lumbar puncture, EMG (electromyography), electroencephalography, CT, MRI, and other imaging procedures—nor do they know how to interpret the results of such tests. Neurology textbooks only confirm their fears as they read the detailed accounts of the many rare diseases of the nervous system.

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The authors believe that many of the difficulties in comprehending neurology can be overcome by adhering to the basic principles of clinical medicine. First and foremost, it is necessary to learn and acquire facility in the use of the clinical method. Without a full appreciation of this method, the student is virtually as helpless with a new clinical problem as a botanist or chemist who would undertake a research problem without understanding the steps in the scientific method. Even the experienced neurologist faced with a complex clinical problem depends on this basic approach.

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The importance of the clinical method stands out more clearly in the study of neurologic disease than in certain other fields of medicine. In most cases, the clinical method consists of an orderly series of steps, as follows:

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  1. The symptoms and signs are secured by history and physical examination.

  2. The symptoms and physical signs considered relevant to the problem at hand are interpreted in terms of physiology and anatomy—that is, one identifies the disorder(s) of function and the anatomic structure(s) that are implicated.

  3. These analyses permit the physician to localize the disease process, i.e., to name the part or parts of the nervous system involved. This step is called anatomic, or topographic, diagnosis. Often one recognizes a characteristic clustering of symptoms and signs, constituting a syndrome of anatomic, physiologic, or temporal type. The formulation and aggregation of symptoms and signs in cohesive terms is particularly helpful in ascertaining the locus and nature of the disease. This step is called syndromic diagnosis and is often conducted in parallel with anatomic diagnosis.

  4. From the anatomic diagnosis and other medical data—particularly the mode and speed of onset, evolution, and course of the illness, the involvement of nonneurologic organ systems, the relevant past and family histories, and the laboratory findings—one deduces the pathologic diagnosis and, when the mechanism and causation of the disease can be determined, the etiologic diagnosis. This may include the rapidly increasing number ...

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