This is arguably the most famous chapter in the book. Patten brilliantly dissects the history-taking needed to distinguish a vasovagal syncope (fainting) from an epileptic seizure. He emphasizes subtle clues like tongue biting (anterior vs. lateral), urinary incontinence, and post-ictal confusion. For the PDF searcher, this chapter alone is worth the download.
(Brief lists per syndrome — use these clinically to generate targeted tests.)
Altered mental status / encephalopathy
Headache (new severe or thunderclap)
Seizures (first unprovoked)
Peripheral neuropathy (length-dependent sensory loss)
Acute flaccid paralysis
Ataxia (acute vs chronic)
Movement disorders (new-onset tremor, bradykinesia) neurological differential diagnosis john patten pdf top
Cognitive decline / dementia
The "Top" 40 differentials from a standard source include: BPPV, Meniere’s, Vestibular neuritis, Labyrinthitis, Cerebellar stroke, MS, Migraine, Acoustic neuroma, Brain tumor, etc.
Patten’s approach (from his PDF):
By the time you finish the first page of Patten’s chapter on dizziness, you have already ruled out 35 of the 40 causes. You are left with a "top" two: Peripheral vs. Central. That is the power of this text. This is arguably the most famous chapter in the book
Never list "MS, Lupus, Sarcoid, Lyme" until you know where. Is it the cortex (aphasia, seizures), the basal ganglia (tremor, rigidity), the cerebellum (ataxia, dysmetria), or the peripheral nerve (stocking-glove, areflexia)?
If you secure a copy (digital or print), do not read it cover to cover. Use this "Top 3" strategy:
Why are users specifically searching for the PDF version with the "top" ranking? It isn't about piracy (though availability is a factor); it is about utility. The PDF format of John Patten’s masterpiece offers specific advantages for the busy clinician:
Long before AI triage tools, Patten created a logical framework for the "worst headache of my life." He provides a clear differential for subarachnoid hemorrhage, meningitis, migraine, and giant cell arteritis. His "temporal arteritis checklist" is a clinical classic. Altered mental status / encephalopathy