How to Think Like a Neurologist: A Case-Based Guide to Clinical Reasoning in Neurology 2022 pdf


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“Meltzer’s How to Think Like a Neurologist is even more than that—it’s a mas
terful clinical handbook for learning how to tackle unknowns. What do you
do if the diagnosis is not already obvious and there is no algorithm to follow?
How do you tailor your history by asking probing questions that will help to
refine hypotheses? And how do you refute your hypotheses through directed,
customized neurological examinations? The syndromic approach beautifully
elaborated by Meltzer is a prerequisite for delivering the kind of value-based
and patient-centered care we all seek—and to do so one patient at a time.”

“How to Think Like a Neurologist presents a clear, practical approach to clinical reasoning in neurology. Working step by step through a series of real-world cases, Dr. Meltzer uses a conversational style to elucidate the principles of neurologic diagnosis. This is essential reading for students on their neurology rotation, residents in neurology, and any medical provider seeking to improve their understanding of clinical neurology.”

“Finally, a book that captures the intangibles of neurologic diagnosis. The synthetic ability that combines knowledge of how diseases affect the nervous system, personal clinical experience, and systematic inquiry is on display. Nowhere do these qualities come together more obviously than in neurology. By analyzing clinical cases that delve into the inner workings of a master clinician, Meltzer has provided a terrific contribution to pedagogy and to clinical work in the field.”

Pace is the onset or evolution of a patient’s symptoms. You likely already incorporate many questions into your history of present ill- ness with the intent to define the pace. When did the symptoms start? How long did the symptoms last? How have the symptoms changed since onset? Critically important in neurology, we define pace based on the initial onset and evolution of symptoms, rather than the total duration of symptoms. For example, a patient may have a fixed deficit from a stroke suffered years prior, but the pace would still be defined as quite rapid (hyperacute) if their symptoms initially developed over seconds to minutes. This principle holds true for all categories of pace.

Subacute symptoms develop over days to weeks to months. The boundary between the patient’s baseline and the onset of symptoms starts to blur, and the patient may not be aware of when their symptoms started. However, they might remember a specific event when their symptoms first became noticeable. For example, a pa- tient might report, “I was an avid runner, but a month ago I started noticing that it was taking me longer to do my usual route. About a week later, I tripped over a small step on the sidewalk. Since that time, I have stumbled over my left foot a few times, and my hus- band says that he can hear my foot dragging across our floor when I walk.” Distinguishing between a subacute versus a chronic onset of symptoms might be challenging for a patient or their family (as well as the clinician) to define, since the boundary between normal and abnormal may not be clearly demarcated. Questions that attempt to draw a frame around the timeline can be helpful: “Were your symptoms present 2 months ago when you took a trip with your family?” or “When was the last time that your mother was able to handle her bills on her own?” Chronic Lastly, chronic symptoms develop over months to years. The boundary between the patient’s baseline and the onset of symptoms might not exist. There is no official start time, but typically, a patient


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