This particular clinical impression was offered by an enthusiastic fourth-year medical student and refers to a patient who actually did, in fact, suffer from lumbar radiculopathy. Indeed, this diagnosis was confirmed by clinical history, physical exam, neuroimaging, and electromyography. However, the patient initially reported severe pain that seemed to be shooting up his leg, not down, which led the medical student to doubt the diagnosis. This bright young student’s prior experience with lumbar radiculopathy was limited to a single written case study that described pain radiating down the limb.

As we are reminded frequently, most patients do not read the textbooks (i.e., “follow the rules”), and each person presents with a unique story. This represents a challenge for those learning clinical neurology. There is an immense body of detailed information that is
absorbed by first- and second-year medical students (including neuroanatomy and neurophysiology) that must eventually be organized and applied to each individual patient. This transition to clinical neurology can, at times, seem overwhelming because subjective descriptions are the norm, and the nervous system accounts for so much function. Students and residents are acutely aware that being able to recognize muscle fiber ultrastructure under a microscope or memorize a list of types of myopathy does little for those who are not yet able to diagnose myopathy presumptively based on their clinical history and examination.