CRC INTG NERV SYS PDF

Preface

This book is about integration—how the nervous system itself integrates information from different sensory modalities, from the past and the present, and how you, as a nonneurologist, can integrate your knowledge of neuroanatomy with the art and science of clinical neurology.

The coauthors of this book include a neuroanatomist (WH), an adult neurologist (CS), and a pediatric neurologist (PH), all of whom have been involved in teaching a combined neuroscience and neurology course to second-year medical students. This is a six-week course, problem-based with lectures, organized on the principle of adult learning in small groups, with expert tutors. Clinical disease entities (e.g., multiple sclerosis) are used as the "problems" in the course. One of the real challenges in a course that includes both neuroscience and neurology is the enormous scope of the subject matter; this leads to significant information overload when the process is compressed into a short period of block learning. A by-product of this compressed learning process is the observation by both clinicians that most of their students—members of their tutor groups who knew their material and passed the course, often with a good grade—when returning as clinical clerks or while taking a neurology elective, were unable to use the knowledge they once had mastered to solve clinical problems at the bedside.

This lack of integration of basic science and clinical information has been postulated as the basis of a syndrome called neurophobia, which apparently can affect one of every two medical students. This lack of ability to reason through clinical problems results in anxiety and dislike of the subject matter, and eventually negative sentiments about and even fear of neurology (Jozefowicz, 1994). This book has been created to bridge these two worlds and to overcome this pedagogical deficit by use of a problem-based approach with clinical disease entities. Our objective is to bridge the gap between the book and the bedside, or in other words, between the classroom and the clinic.

To help you understand the neurological disorders that you will encounter in this text, and the challenges that patients and relatives face when such disorders appear, we have created a fictional family (the Family Tree can be found preceding the Introduction) whose various members develop different clinical symptoms related to nervous system dysfunction. We meet the central figure of this family in the Introduction, which lays out the complexity of the nervous system and its capacity to multitask. The Introduction exposes the reader to neuroanatomical pathways which, by the end of the book, should be quite familiar in terms of both their function and their importance in neurology.

The first chapter deals with the basics of nervous tissue and presents an overview of the nervous system, enough to set the stage in terms of the basic knowledge of the nervous system needed for this book. The second chapter is devoted to the neurological history and physical examination, and the integration of the information garnered from these activities with respect to the functioning nervous system, for example, the assessment of reflex activity. Patients with neurological problems present great challenges to their physicians (as well as to their relatives and caregivers) to accurately and completely gather the information required to make a working diagnosis and plan of investigation based on a single clinic visit.

Chapter 3 introduces the student to neurological clinical reasoning for the purpose of localizing the disease or lesion within the nervous system and determining the etiology, the pathophysiological mechanism of disease. The approach used in this chapter and its accompanying worksheets is designed to provide students and non-neurologist clinicians with practical guidelines and tools with respect to diagnosis for the full range of neurological problems seen by a neurological generalist. This approach is applied throughout the book.

The succeeding nine chapters deal with important specific clinical diseases or syndromes that have afflicted our fictional family and their friends, each with the focus on a different component of the nervous system (e.g., peripheral nervous system, brainstem, etc.). For each of these cases, the history is presented followed by the findings of the neurological examination. Additional neuroanatomical, neurophysiological, and neurochemical information is added, where required, as it pertains to the clinical condition discussed in the chapter. Notwithstanding the information given, it is suggested that students review their knowledge of neuroanatomy, neurophysiology, neuropharmacology, and neuropathology, using other resource books (given in the suggested readings and references sections at the end of each chapter and in the annotated bibliography at the end of the book). In each of these chapters, there is an application of the process of neurological reasoning to narrow the possibilities of where the lesion is located. This is followed by a systematic analysis in order to determine what disease (or diseases) should be considered. Relevant selected investigations are then presented and the results discussed. Finally, the diagnosis is made, with its prognosis, and an outline of the appropriate management is given, ending with the outcome of the case.

The text illustrations have been prepared with an emphasis on the functioning nervous system. In addition to neuroanatomical drawings related to the cases and tables with relevant clinical data, there are figures illustrating neurophysiological concepts, clinical findings (such as radiographic images and EEGs) and microscopic neuropathological images. Again, the information is described in the context of the disease presented in that chapter. The glossary of terms also emphasizes clinical terminology.

The final two chapters were written by guest authors: a physiatrist (a specialist in rehabilitation medicine) and a senior neurologist with expertise in ethics. Both discuss other important dimensions of neurological problems: rehabilitation and ethics. Currently, rehabilitation has much to offer for those afflicted by disease or injury of the nervous system; there is now a certain air of hopefulness that there can be recovery of function following an insult to the nervous system, in adults as well as in children. The ethical principles and reasoning on the basis of which decisions (sometimes quite unique) are taken in neurological cases are presented in the context of an inherited disease of the nervous system.

There is a DVD included with this textbook. It contains the worksheets that have been developed to apply the clinical reasoning approach to neurological problem solving. It is highly recommended that you, the non-neurologist student/learner, apply this approach when confronted with a neurological patient. The authors want you to learn how to think like a neurologist and propose that you adopt a contract for this purpose. Please read The Learning Contract; hopefully, you will agree to fulfill its obligations. In addition, the DVD has all the illustrations found in the book, with animation added to assist in the understanding of various pathways and reflect circuits. It also includes the glossary. The DVD also has a learning module to assist you, as a nonexpert, in understanding neuroimaging, how the various modes of CT and MRI assist in localizing a lesion and defining the likely etiology.

Now for the final value-added feature—the additional cases for each of the clinical case chapters, referred to in the text as e-cases. This book is not intended to be a detailed compendium of the basic sciences related to neurology, nor is it intended to contain all of the most frequent neurological disease entities. The e-cases enlarge the scope of the book by adding other commonly seen neurological diseases for each level of the nervous system. These are presented in a more straightforward fashion, although once having learned the analytic approach it is hoped (expected) that you, the learner, will work through each clinical case on your own, using the worksheets, before reading the case evolution, investigations, and resolution. The e-cases are found on the accompanying DVD and are listed as case studies for each of the clinical chapters; they will also be found on the text Web site (http://www.integratednervoussystem.com). The Web site will also be utilized to provide updates on the cases presented as well as new cases, so it may be wise to check it periodically. We would appreciate your honesty in not copying the DVD for others and in not sharing the URL.

We believe that this book, the DVD, and the associated Web site will be of practical value to all the professionals who deal with people who have neurological conditions, not only medical students and residents. This includes physiatrists, physiotherapists, occupational therapists and speech therapists, and nurses who specialize in the care of neurological patients. We think that this text will also be of value for family physicians and specialists in internal medicine and pediatrics, all of whom must differentiate between organic pathology of the nervous system and other conditions.

The aim of this book is to enable you, the learner, to use your knowledge of the nervous system combined with a neurologically based, problem-solving clinical reasoning approach to neurology to help in the diagnosis and treatment, in the broadest sense, of those who sufferfrom a neurological disease or injury. We hope that this approach meets with success, insofar as it leads to an improvement in the diagnosis and care of persons afflicted by neurological problems.