Neurological Examination Made Easy Rajendra Bhalchandra Kenkre
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1NEUROLOGICAL EXAMINATION Made Easy®
2NEUROLOGICAL EXAMINATION Made Easy®
Rajendra Bhalchandra Kenkre MD FRS Consultant Neurologist Cabeca Santacruz, Goa, India
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Neurological Examination Made Easy®
© 2008, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2008
9788184483703
Typeset at JPBMP typesetting unit
Printed at Ajanta
4Dedicated to
My Father, Mother
and
Teachers
5Preface
When I sat down to write a book catering to the needs of undergraduates and postgraduates in neurology, I thought what I was going to say which could be of more than marginal importance in an era where technicalization of medicine as a profession has made neurology a not different specialty than other branches of medicine. Probably where neurology has triumphed over psychiatry is in exact understanding of many disorders of higher cerebral function such as brain death, brainstem death, schizophrenia, epilepsy; the success being largely attributed to newer advances in diagnostics and therapeutics and their application at the bedside. Many of the neurological diseases hitherto left sequale inspite of better therapeutic advances.
We knew very little until a few years ago and could only speculate as to whether central nervous system has ability to regenerate. We now know for certain it does. It is with this aspect in mind rehabilitation is likely to play a crucial role in management of many chronic and acute diseases of central nervous system such as stroke, spinal cord injury, head injury to name a few. I may add that past thirty years have witnessed remarkable developments in neurology. The invention of computerized axial tomography, and subsequent 6modification of the system to better imaging methods such as MRI and PET scanning has revolutionized both diagnostic and therapeutic aspects of neurology. Averaging techniques in electrophysiology pertaining to nerve and muscle besides understanding of evoked potentials of the central nervous system and the peripheral nervous system has provided valuable aid to understand many diagnostic enigmas and to exact therapeutic interventions where Nihilism was considered order of the day. Especially in dealing with many neurological diseases such as multiple sclerosis, encephalitis, spinocerebellar degeneration, Huntington's disease.
The importance of electroencephalography lies in defining brainstem death and understanding of consciousness and sleep. The science of molecular genetics using recombinant DNA technology has in the past few years transformed our understanding of many neurological disorders. The classic example of interplay of genes and environment is multiple sclerosis and during the past few years Parkinson's disease and motor neuron disease have also been linked to environment and genes. Stem cell therapy promises to be another boon in therapy of inherited as well as degenerative diseases of the central and peripheral nervous systems.
Certain immunological principles need to be enunciated to highlight antigen-antibody reaction in etiopathogenesis of viral diseases such as Madcow disease (Bovine spongiform encephalopathy) and other diseases of uncertain etiopathogenesis such as myasthenia gravis, 7polymyositis, systemic lupus erythematosus. The understanding of therapeutics in neurology deserves a brief mention namely in terms of manipulation of neurotransmitters in treatment such as Parkinson's disease, schizophrenia and cerebral edema due to any cause. Care of the chronic neurological patient following spinal cord injury is supplemented by enhancing motor disability through newer techniques of functional neuromuscular stimulation. Neurological workshop engineering has devised computer communication system for aphasias and dysarthrias patients.
The basic text of the book I believe still adheres to simple principle of fundamentals of clinical neurology namely basic knowledge of anatomy and physiology of brain function orderliness in history taking, clinical examination combined with subtle psychological aspects. The neurologist has to make the diagnosis first anatomical one then a pathological one and finally a diagnosis which may be termed as functional assessment of the patient to help in overall management of the patient. It is with this aim in mind the book is written with a fond hope that it will make neurology an attractive clinical discipline for undergraduates and postgraduates for decades to come. As it has been for me having worked in the wards and departments of some eminent neurologists from India? England and the USA whose teachings and clinical methods have stood me in good stead in my practice of clinical neurology in a small provincial outpost of India – Goa for over a generation. I have only elucidated 8known methods of approaching a patient with neurological diseases.
I wish to express my gratitude to these teachers, clinicians and others with whom I had occasion to meet and discuss on various neurological topics over the years. It is not possible to individually refer to authors of books, manuscripts and journal articles I have referred to in writing the book. I want to thank all of them for writing on the referred works in lucid English prose and having had the foresight in doing so which has to a great extent contributed to continuity in specialty of neurology.
But for unstinted support and encouragement of the Dean of the Goa Medical College who has established neurosurgical services at the college and Librarian and the staff who provided me access to books and manuscripts and journals this book probably would not have been written and to them I express my thanks.
Rajendra Bhalchandra Kenkre
9Acknowledgements
The author thanks the persons who directly or indirectly contributed to this book. This book is a tribute to those teachers, clinicians in neurology and pioneers in the specialty of neurology who have been constant stimulation to me in my endeavour to practice clinical neurology in a small provincial outpost of India - Goa. I wish to express my gratitude to my colleagues in the American and British Neurology in whose wards and laboratories I studied and worked for quite a few years during my training as a specialist in neurology, and for their support, help and understanding.
I acknowledge with deep gratitude the invaluable help and constructive suggestions rendered to me by Shri Jitendar P Vij, Chairman and Managing Director and staff of Jaypee Brothers Medical Publishers during the preparation of this book.