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MATHEMAGICAL CLINICAL MATHEMAGICAL CLINICAL NEUROLOGYNEUROLOGY
Prof.A.V.SRINIVASAN
M.D.D.M. Ph.D.F.I.A.N. F.A.A.N.
Additional Prof.of Neurology
Madras Institute of Neurology
TO TEACH IS AN HONOUR THAT IS SACRED
MIN - MOTTO
Mathemagical Clinical Neurology ABSTRACTOBJECTIVE: To construct a teaching model for easier clinical neurological examination to help
the medical students and paramedical personal to understand the neuroanatomy and etiopathological disorders of the nervous system.
BACKGROUND: Neurophobia is a fear of neural sciences and clinical neurology and half of the medical students and paramedical personal experience this disorder during their training. We have evolved an easy, faster ten step approach in clinical neurological examination using mathematical numbers.
METHODS: One characterizes consciousness / mind, Two represents the two cerebral hemispheres and Three, the major functions of the brain namely cognition, conation and affect. Four represents the four lobes and four ventricles. Five represents five special senses. Six explains the six major functional systems of the brain, basal ganglia (programmer), cerebellum (computer), cerebral and its efferents (output), sensory systems (input), autonomic nervous system (emergency situations) and the limbic system (integrator of all). Seven characterizes the LMN (anterior horn cells anterior nerve root posterior nerve root peripheral nerve neuromuscular junction muscle intracellular organelles. Eight represents eight language disorders, four with normal repetition and four with abnormal repetition. The Nine etiologies in fingertips Thumb (Tumour, Toxin, Trauma), Index Finger (Infection), Middle finger (Metabolic), Diamond finger (Demyelination), Little finger (vascular) and Hand (Hereditary and nutritional disorders). Ten represents the ten pairs of cranial nerves with olfactory and optic nerves, which are extensions of brain.
CONCLUSION: This faster and easier method of neurological examination will help the epidemiological field workers. Ten step approach of clinical neurology teaching will replace Neurophobia with Neurophilia, and will effectively integrate the basic sciences with clinical neurology.
ALBERT EINSTEINALBERT EINSTEIN
EVERY THING SHOULD BE MADE
SIMPLE, BUT NOT SIMPLER
-
AIMS AND OBJECTIVESAIMS AND OBJECTIVES
To Evolve a teaching model for easier, faster clinical neurological examination to help the Neuroscientists including medical students and paramedical personal to
understand the Neuroanatomy, Neurophysiology and Etiopathological approach of the nervous system.
BACKGROUNDBACKGROUND Neurophobia is a fear of Neuro sciences and clinical
neurology. Most of the medical students and paramedical personal experience this disorder during their training. Physical examination in the chapter of the nervous system in Hutchison’s Clinical methods 2002 W.B.Saunders,London, expanded more than 50% from 19,110 words to 29,632 words,while in Respiratory and Cardiovascular system decreased by 47% and 70% respectively when compared to the first edition of clinical methods-A guide to the practical study of medicine in 1897(Alisdair Mcneill-Practical neurology,2005,5,180-3).Clinical evaluation of the nervous system becoming too unwieldy for routine use and certainly for the modern medical student curriculum.We have evolved an easy, faster ten step approach in clinical neurological examination using mathematical numbers
MATHEMAGICAL CLINICAL MATHEMAGICAL CLINICAL NEUROLOGYNEUROLOGY
ONE - CONSCIOUSNESS/MIND
TWO - CEREBRAL HEMISPHERES
THREE - FUNCTIONS OF BRAIN
COGNITION CONATION AFFECT
FOUR - LOBES OF BRAIN
FIVE - SPECIAL SENSES
SIX - UPPER FUNCTIONAL MOTOR
NEURON SYSTEMS OF BRAIN
SEVEN - LOWER FUNCTIONAL MOTOR
NEURON SYSTEMS OF BRAIN
EIGHT - LANGUAGE DISORDERS
NINE - ETIOLOGY
TEN - TEN CRANIAL NERVES WITH
OLFACTORY AND OPTIC NERVES – EXTENSIONS OF BRAIN
TEACHING METHODS-TEN STEPSTEACHING METHODS-TEN STEPS I AM HAPPY THAT PROF.A.V.SRINIVASAN HAS THOUGHT IT FIT TO
INTRODUCE A NEWER CONCEPT OF NEUROLOGICAL EXAMINATION WHICH IS BASED ON AREAS OF ANATOMY AND FUNCTION IN A STEP WISE FASHION STARTING AT THE CORTICAL LEVEL AND RIGHT DOWN TO THE NEUROMUSCULAR LEVEL AND INCURS THE ABILITY TO TRANSLATE THIS INTO A RESORTMENT PATTERN IN NEUROLOGICAL INTERPRETATION.THIS IS A NEW CONCEPT WHICH,HE HAS ENTERED, HAS DONE EXTREMELY WELL TO SHOW IT TO HIS COLLEAGUES.I AM SURE THAT THE ARDENT GROUP OF STUDENTS OF NEUROLOGY AND EVEN STUDENTS OF INTERNAL MEDICINE AND NEUROSURGEONS WILL BENEFIT WITH THIS NEW TECHNIQUE,METHOD OF A WAY OF EVALUATING NEUROLOGICAL DISEASES
Prof.K.V.THIRUVENGADAM
B.Sc,M.D.,D.Sc(hon).F.R.C.P(EDIN), FAMS,FCCP,FCAI FORMER DIRECTOR OF MEDICINEMADRAS MEDICAL COLLEGE AND GOVT.GENERAL HOSPITAL CHENNAI,TAMIL NADU, INDIA
.
CLINICAL DIAGNOSIS IN NEUROLOGY IS USUALLY ARRIVED AT BY DETECTING SIGNS WHICH INDICATE DISTURBANCE OF A FUNCTION IN THE CEREBRAL SPINAL AXIS.IN THE PRESENT SYSTEM OF DIAGNOSIS,BY VIRTUE OF COMBINING POSITIVE SIGNS TO FIND A MEANINGFUL LOCATION IN THE CENTRAL NERVOUS SYSTEM OR THE PERIPHERAL NERVOUS SYSTEM.THIS METHOD OF ARRIVING AT CLINICAL DIAGNOSIS HAS STOOD THE TEST OF TIME BUT HAS AN INHERENT DEFECT BEING TIME CONSUMING.
THE NEW SYSTEM BY VIRTUE OF DETECTING THE DEFECTS IN THE SYSTEM STRAIGHT WAY BY VIRTUE OF THE SIGNS PICKED UP AT THE TIME OF THE EXAMINATION HELPS IN THE BEDSIDE DIAGNOSIS EASIER AND QUICKER.ELECTROPHYSIOLOGICAL STUDIES AND IMAGING TECHNIQUES ARE USED ONLY TO CONFIRM THE CLINICAL IMPRESSION GIVING EASIER RECOGNITION OF ANATOMICAL LEVELS OF INVOLVEMENT.
DEMONSTRATION OF SOME OF THE CASES EXAMINED BOTH WAYS REVEAL THE ACCURACY OF DIAGNOSIS MORE IN THIS SYSTEM AS AGAINST THE CONVENTIONAL ONE.
THIS SYSTEM WILL HELP LEARNING AND DIAGNOSING NEUROLOGICAL AILMENTS.IT IS BOTH COMPLIMENTARY AND PRIMARY IN CLINICAL EXAMINATION AT THE BED SIDE PROBABLY GIVING A BETTER INSIGHT TO THE STUDENT REGARDING THE FUNCTIONAL DERANGEMENT CORRELATING WITH FUNCTIONAL ANATOMY AND WILL BE USEFUL IN EVALUATING NATURAL EVOLUTION OF MANY NEUROLOGICAL DISORDERS.
WITH THE REDUCTION OF TIME IN THE PRIMARY AND FOLLOW UP EXAMINATION,PATIENT CARE IMPROVES.THIS SYSTEM IS ALSO COMPUTER COMPATIBLE BY PROPER DATA COLLECTION AND ANALYSIS. THIS SYSTEM WILL BE A GREAT BOON IN HELPING QUICKER AND MORE SPECIFIC TREATMENT SCHEDULES.
Prof.K.JAGANNATHAN M.D.,D.T.M.,F.R.C.P.,F.A.M.S
Former Head and Prof. of Neurology
Madras Medical College and Govt.Gen.Hospital
Chennai,Tamilnadu, India
EXAMINATION OF EXAMINATION OF CONSCIOUSNESS(COMA)CONSCIOUSNESS(COMA)
GLASGOW COMA SCALEEYE OPENING SPONTANEOUS 4
TO LOUD VOICE 3 TO PAIN 2 NIL 1
VERBAL RESPONSE ORIENTED 5
CONFUSED,DISORIENTED 4 INAPPROPRIATE WORDS 3 INCOMPREHENSIBLE SOUNDS 2 NIL 1
MOTOR RESPONSE OBEYS 6 LOCALIZES 5 WITHDRAWS(FLEXION) 4 ABNORMAL FLEXIONPOSTURE 3 EXTENSION POSTURE 2 NIL 1
RANCHO LOS AMIGOS COGNITIVE SCALE
NO RESPONSE 1
GENERALIZED RESPONSE 2
LOCALIZED RESPONSE 3
CONFUSED/AGITATED 4
CONFUSED- NOT APPROPRIATE 5
CONFUSED-APPROPRIATE 6
AUTOMATIC-APPROPRIATE 7
PURPOSEFUL-APPROPRIATE 8
LEFT LEFT HEMISPHEREHEMISPHERE
(VERBAL)(VERBAL)
ANALYSISANALYSISDEDUCTIONDEDUCTION
FACTSFACTSLOGICALLOGICAL ORDER ORDER
MATHEMATICMATHEMATICPRACTICALPRACTICAL
RIGHT
HEMISPHERE
(VISUAL)
ARTISTIC
CREATIVE
HOLISTIC
INTUITION
IDEAS
IMAGINATION
SPATIAL
THREE FUNCTIONS
COGNITION -- Perception & Thinking
CONATION -- Movement
AFFECT -- Motor expression of Emotions
EXAMINATION OF COGNITIVE DECLINE-DEMENTIAEXAMINATION OF COGNITIVE DECLINE-DEMENTIA
IDEAL BED SIDE MMSE
RESEARCH ICD-10
DSM-IV
NINCDSADRDA
ADDTC-VASCULAR
DEMENTIA
CONATIONCONATION – –MOVEMENTMOVEMENTSECOND FUNCTION OF BRAINSECOND FUNCTION OF BRAIN
WHAT ARE THE MOVEMENTS?
IDENTIFY THE OVERALL SYNDROME.
DECIDE THE DISEASE.
AFFECT- MOTOR EXPRESSIONAFFECT- MOTOR EXPRESSION OF EMOTIONS OF EMOTIONS
THIRD FUNCTION OF BRAINTHIRD FUNCTION OF BRAIN
EXAMINATION
OBJECTIVE MEASUREMENT DIFFICULT, SUBJECTIVE SCALES ARE AVAILABLE
NORMAL EMOTION
EMOTIONAL LABILITY
EMOTIONAL INCONGRUITY
FOUR
LOBES OF CEREBRUM
AND
FOUR VENTRICLES
EXAMINATION OF HIGHER EXAMINATION OF HIGHER FUNCTIONS AND LOBAR FUNCTIONSFUNCTIONS AND LOBAR FUNCTIONS
HIGHER FUNCTIONS TRADITIONAL
FRONTAL LOBE EXECUTIVE FUNCTION
EMOTIONAL RESPONSE
SOCIAL BEHAVIOUR
PARIETAL LOBE CALCULATION
STEREOGNOSIS
SPATIAL ORIENTATION
TEMPORAL LOBE AUDITORY PERCEPTION
MUSIC TONE SEQUENCES
OLFACTION
SPEECH
OCCIPITAL LOBE VISION
FIVE SPECIAL SENSES
SMELL VISION
HEARING
TASTE
TOUCH
TRADITIONAL
1. Basal ganglia – Programmer
2. Cerebellum – Computer
3. Cerebral hemisphere &
connections - effector system
4. Sensory System
5. Autonomic nervous system – flight or fight
6. Limbic system - Holistic integrator of all
UPPER MOTOR NEURONUPPER MOTOR NEURONSIX FUNCTIONAL SYSTEMS OF THE SIX FUNCTIONAL SYSTEMS OF THE BRAIN (ABOVE FORAMEN MAGNUM)BRAIN (ABOVE FORAMEN MAGNUM)
TRADITIONALSPINOMOTOR SYSTEM
BASAL GANGLIA-INVOLUNTARY BASAL GANGLIA-INVOLUNTARY MOVEMENTSMOVEMENTS
PLENTY OF MOVEMENTS
A THETOSIS
B ALLISMUS
C HOREA
D YSTONIA
E SSENTIAL TREMOR
F ASCICULATIONS M YOCLONUS
PAUCITY OF MOVEMENTS
AKINETIC RIGID STATES
PARKINSONISM DRUG INDUCED IDIOPATHIC WILSONS DISEASE
PROGRESSIVE SUPRANUCLEAR PALSY
MULTIPLE SYSEM ATROPHY
CORTICOBASAL DEGENERATION
HUNTINGTONS -JUVENILE VARIANT
NIEMMAN-PICK DISEASE TYPE C
CEREBELLUM-(computer)CEREBELLUM-(computer)
FUNCTIONS-COORDINATION
GAIT ANTERIOR LOBE
TRUNCAL VERMIS
LIMBS AND LANGUAGE HEMISPHERE
EYE MOVEMENTS FLOCCULONODULAR LOBE
SIGNS OF CEREBELLAR SIGNS OF CEREBELLAR DYSFUNCTIONDYSFUNCTION
INCOORDINATION OF EYE- NYSTAGMUS HEAD-TITUBATION SPEECH-DYSARTHRIA TRUNK-ATAXIA LIMB-ATAXIA GAIT-ATAXIA WRITING-MACROGRAPHIA
CEREBRAL HEMISPHERESCEREBRAL HEMISPHERES(key board) (key board)
MOVEMENT - FRONTAL LOBE
SENSATION -PARIETAL LOBE
MEMORY
AND HEARING –TEMPORAL LOBE
VISION - OCCIPITAL LOBE
FUNCTIONS OF FUNCTIONS OF AUTONOMIC NERVOUS SYSTEMAUTONOMIC NERVOUS SYSTEM
SYMPATHETIC
HEART RATE INCREASED
BLOODPRESSURE INCREASED
INCREASED BLADDER SPHINCTER TONE
DECREASED BOWEL MOTILITY
BRONCHODILATATION
SWEATING
PUPIL DILATATION
PARASYMPATHETIC
HEART RATE DECREASED
BLOOD PRESSURE DECREASED
VOIDING (DECREASED TONE)
INCREASED BOWEL MOTILITY
BRONCHOCONSTRICTION
DECREASED SWEATING
PUPIL CONSTRICTION
SEVEN LOWER MOTOR NEURON SYSTEMSSEVEN LOWER MOTOR NEURON SYSTEMS
ANTERIORHORN CELL
ANTERIOR NERVE ROOT
POSTERIOR NERVE ROOT
PERIPHERAL NERVE
NEUROMUSCULAR JUNCTION
MUSCLE
INTRACELLULAR ORGANELLES
SPINAL CORD
SPASTICITY WEAKNESS FASCICULATIONS EARLY BLADDER AND BOWEL TROPHIC CHANGES
ANTERIOR NERVE ROOT SEGMENTAL WEAKNESS SEGMENTAL WASTING
POSTERIOR NERVE ROOT PAIN PARESTHESIA NUMBNESS
LOWER MOTOR NEURON SYSTEMS-CONTDLOWER MOTOR NEURON SYSTEMS-CONTD
4. PERIPHERAL NERVE
BILATERAL DISTAL SYMMETRICAL NUMBNESS AND
WEAKNESS WITH WASTING(NEUROPATHIC)
5. NEUROMUSCULAR JUNCTION DIURNAL VARIATION WITH FATIGABILITY OF
MUSCLES
6. MUSCLE
BILATERAL SYMMETRICAL PROXIMAL MUSCLE
WEAKNESS AND WASTING( MYOPATHIC)
7. INTRACELLULAR ORGANELLES
MITOCHONDRIA, SARCOGLYCANS
EIGHT-LANGUAGEEIGHT-LANGUAGE
DISORDERS OF LANGUAGEDISORDERS OF LANGUAGE
ABNORMAL REPITITION
BROCAS APHASIA
WERNICKES APHASIA
GLOBAL APHASIA
CONDUCTION APHASIA
DISORDERS OF LANGUAGEDISORDERS OF LANGUAGE
NORMAL REPITITION
TRANSCORTICAL SENSORY TRANSCORTICAL MOTOR ANOMIC ALEXIA
NINE –ETIOLOGIESNINE –ETIOLOGIES
THUMB - TUMOR, TOXIN, TRAUMA
INDEX FINGER - INFECTION
MIDDLE FINGER- METABOLIC
DIAMOND FINGER- DEMYELINATION,DEGENERATION
LITTLE FINGER - VASCULAR
(LITTLE FLOW/ABSENT FLOW)
HAND - HEREDITY AND NUTRITIONAL DISORDERS
TEN PAIRS OF CRANIAL NERVESTEN PAIRS OF CRANIAL NERVES
CRANIAL NERVES
III,IV,VI NERVES - OCULAR MOVEMENTS
V NERVE - FACIAL SENSATIONS
MUSCLES OF MASTICATION
VII NERVE - MUSCLES OF FACIAL
EXPRESSION
SECRETORY FUNCTIONS
IX AND X NERVE - PALATAL AND
PHARANGEAL MUSCLES
XI NERVE - STERNOMASTOID AND
TRAPEZIUS
XII NERVE - TONGUE MOVEMENTS
MATHEMAGICAL CLINICAL MATHEMAGICAL CLINICAL NEUROLOGYNEUROLOGY
ONE - CONSCIOUSNESS/MIND
TWO - CEREBRAL HEMISPHERES
THREE - FUNCTIONS OF BRAIN COGNITION CONATION AFFECT
FOUR - LOBES OF BRAIN
FIVE - SPECIAL SENSES
SIX - UPPER MOTOR NEURONS SYSTEMS
OF BRAIN
SEVEN - LOWER MOTOR NEURONS
SYSTEMS OF BRAIN
EIGHT - LANGUAGE DISORDERS
NINE - GENERAL PRAESENS AND OTHER
SYSTEMS
TEN - ETIOLOGIES
ACKNOWELDGEMENTSACKNOWELDGEMENTS
OUR SINCERE THANKS TO THE HEAD OF THE DEPARTMENT OF NEUROLOGY, DIRECTOR OF INTERNAL MEDICINE OF MADRAS MEDICAL COLLEGE AND ALL THE FACULTY MEMBERS OF THE DEPARTMENT OF NEUROLOGY AND MEDICINE