X. A Book for Young Physicians and Nurses and also for Everybody

Physician's Notebooks 9 to 10 - http://physiciansnotebook.blogspot.com - See Homepage
Updated 20 Septr 2021

               Contents

 First Part: "Down the Rabbit Hole"

     Second Part: A clinical method of diagnosis and pitfalls

A book I recently read and recommend general reader and students and workers is "Reaching Down the Rabbit Hole" by Allan H. Ropper and B.D. Burrell. Dr Ropper is a top clinical neurologist. He was senior author of "Adams and Victor's Principles of  Neurology", the latest and 11th edition of which was issued, May 2019.
   "Reaching Down the Rabbit Hole" is a memoir of Dr Ropper's clinical experiences. It is filled with short descriptions of neurological conditions. They are fascinating in that they give the reader good information about how a neurological illness could develop in him or her, but they are also finely written human documents. Then, the book gives an insider view of what life as a young doctor or nurse in training would be like.
Finally, it is excellently written so that, no matter who the reader is, she or he will not be able to put the book down.
Now, we are not going to tell more, and curious readers here can order the book on Amazon.com. This is a book you will read and keep in your library because it has so many exciting neurological conditions and stories of hospital life that most readers will want to go back to satisfy curiosity and relieve anxiety about a particular medical condition that they or their loved ones may be worrying about.

Below is pasted an index not in the published book, which is especially relevant for the medical conditions. With this index; for example, if you are worrying that you are developing Lou Gehrig disease aka Amyotrophic Lateral Sclerosis, or ALS, and you want to read a vignette about what it might be like if you got the disease, you just scroll to the index entry for "Lou Gehrig disease" and you will find the page numbers to read about it. The numbers are the page reference in the book.

 Index for "Reaching Down the Rabbit Hole"

"A and O times three" (Hospital slang), 23

Dr (Raymond) Adams, 136, 217, 231, 248

ALS, or Amyotrophic Lateral Sclerosis, aka Lou Gehrig Disease, 145

   Survival with, George K, 150, 166-182

Amnesia, Total Global Amnesia or TGA, the patient Godfrey, 69, 78, 79

Aneurysm, berry in brain, 115

Aphasia

   Wernicke’s aphasia 22

    If he gets a joke, … faking, 60 bottom, fake or hysteria 83

(The) apnea test, 236

Autopsies, 218

Barbiturate overdose, 226

Baseball, 44

Basilar artery thrombosis, 135

Bipolar psychosis, 64

(The) book, 12, 246, 247

Brain dead, 227

  (The) coroner in Wizard of Oz on brain death, 241

  Dr Alan Shewmon on brain death, 237

Brain modules, 59 bottom

Brian D. Burrell, in Acknowledgements at end of book

(The) Brigham (and Women's Hospital), 6

Blindness, faking, 88

Code, 41, 75

Confusion, 52

Coma, the Glasgow coma scale, 224

Conversion disorder, 93

Coup de Poignard sign, 211

Cranial nerves, 228

Creutzfeldt-Jakob Disease, 57

CT big dose radiation, 85

Death choice, 159, 215

DBS (Deep Brain Stimulation) 204

Decrum’s Disease, 164

Dejerine-Roussy syndrome, 183

Dementia, story of Dr. Vandermeer, 1, 38

(A) Diagnotic Error, Harry C, 205

Disorientation as to place, Walter, 49

(Dr. Irving) Cooper, 194

Drug Addict Ethan R, 102

Eclampsia in a hippie, 127

EEG slowing, 57

Elliot the neurologist, 33, 92, 100, 118, 163, 230, 245, 257

Elliot Hochstein, medical student philosophy, 122

Emboli to brain, 26

(The) English Strategy, 93

Epilepsy, the story of Gary, 3

  Pseudoseizure, 90, 91, 98 (P-NES)

  Status epilepticus, 61, 83, 127

Eye pupil size, criterion of brain death, 235

Factitious disorder, 100

Fasciculations, muscle twitches, 145

Fisher, Dr C. Miller, neurologist, 76

Glioma of frontal lobe, story of patient Dennis, 8

Graphomania, a sign of Manic Dipression, or Bipolar Disorder, 64

Guillain-Barre syndrome, 206, 207

“Hairline”, slang for type of EEG, 83

Hallucinations from dopamine drug for Parkinsonism, 188

Hannah, chief neurology resident, 21, 249

(The) Harry Potter books 171

Heroin overdose, pupils sign, 133

Hirayama disease, 251

(The) Hospital chaplain Edgar, 111

Hydrocephalus, patient Mrs G, 34, 39

Hysterical symptoms, 83-85, 86, 97

  Pink-bunny or teddy-bear-next-to-pillow sign, 104

Inattention to beautiful scene, 58

(The) Irish Strategy, 93

Jamais vu, of Gordon, 47, 48, of Tikvah 185

Joke, 19

   Jokester , Sheldon, 164, 183

Korsakoff syndrome confabulation, 55, 76

Language deficit, 2
Lou Gehrig disease, 145, 150,  166-182

Malingerer, 102

Medical residency, San Francisco General Hospital, description, 128

Medical school, 121

   Psychiatric 126

Medical student, Gilbert, 245

Meningioma, rt temporal lobe, 2

Mother –Daughter psychological syndromes, 104, 105

Neurologist, 7, 10, 248

  Gilbert, choice of, 244

  The Queen not the king, 11

  Why Dr. Ropper became a neurologist, 134

Nocardia from a mummy, 40

Nurses in trauma rooms, 130

Osler, Wm, 217

Parkinsonism of patient Tikvah, 185, 186, 187, 188

   Deep Brain Stimulation, DBS for, 198

   Dr. James P., original descriptions of the disease, 189

   Impulse control, 244

   Lewy Body Dementia, 201

   Michael J. Fox’s Lucky Man 189, 195, 203

   Surgery for, 194

Paraneoplastic neuro syndrome of patient Cindy, 24

Pentaplegia (term for a severe quadriplegia) of patient Harry C, 215

Perseveration as symptom 15,16

Piersall, Jimmy, baseball hero, his bipolarity, 65

Poisonings, metals, 250, 251

Progressive supranuclear palsy, axial dystonia, patient Mack, 137

Psychotic break, story of patient Cindy, 16

  William James idea, 64

Resident physicians and interns, 31, 217

  Dr Lenny K., former, 189

  Executive skills of, 216

  Stanley, 206

(The) risk-taking patient, 109

(Dr Martin) Samuels, 225

Schizophrenia, 101

Sinn Fein tattoos, 224

Spinal epidural abscess giving tetraplegia, 205

Stroke, 19, 28, 80

Subarachnoid hemorrhage of patient Ruby, 107, 108

Subdural hematoma, 224

Symptoms & Signs, 87

(The) thalamus, Dr. Raymond Adams, 139

Toxic shock from tampon, Dr Bob’s sister, 130

Tracheostomy, 154

Tremor, Albert, fake, 94

   DBS cures it, 200

   Parkinson's, 192,193

   Pinkie finger, 1^st sign of, 193

   Thalamotomy, 200

Tuberculous meningitis in a Chinese, 140

Tumor of heart valve source of brain emboli, 29

Ventricular shunt, 44

Writing creativity (monkey at typewriter like) patient Wally, 63

Vertebral artery dissection from chiropractic 18

Virus encephalitis, 23

Second Part 
Readers who are interested in accumulating medical knowledge will do well to subscribe to AccessMedicine http://neurology.mhmedical.com. This is an online medical education reading club through which you may read many medical tomes. I have been using for the last several month and I found it is an improvement over normal education also because of the very good illustrations that can be enlarged and the very accessible text.

All readers who want to become involved in a medical treatment and care knowledge base will benefit by knowing the clinical method and arriving at disease diagnosis and the pitfalls involved in diagnosing. We excerpt from Allan H. Ropper, Martin A. Samuels, Joshua P. Klein, and Shashank Prasad's forthcoming 11th edition preliminary of Adams & Victor's Principles of Neurology as follows:

THE CLINICAL METHOD of DIAGNOSIS reviewed below

In most cases, the clinical method consists of an orderly series of steps:

1. The symptoms and signs are secured with as much confidence as possible by history and physical examination.
2. The symptoms and physical signs considered relevant to the problem at hand are interpreted in terms of physiology and anatomy—i.e., one identifies the disorder of function and the anatomic structures that are implicated.
3. These analyses permit the physician to localize the disease process, i.e., to name the ... system (and its part) affected. This is the anatomic, or topographic diagnosis, which often allows the recognition of a characteristic clustering of symptoms and signs, constituting a syndrome.
4. From the anatomic diagnosis and other specific medical data—particularly the mode of onset and speed of evolution of the illness, the involvement of ... organ systems, the relevant past and family medical histories, and the imaging and laboratory findings—one deduces the etiologic diagnosis (the basic cause) and its pathogenesis.
5. Finally, the physician should assess the degree of disability and determine whether it is temporary or permanent (functional diagnosis); this is important in managing the patient’s illness and judging the potential for restoration of function (prognosis).

The likely causes of a ... disease are judged in the context of a patient's personal and demographic characteristics, including his age, sex, race, ethnicity, and geographic circumstances. Knowledge of the incidence and prevalence of diseases among populations defined by these factors (base rates) is a valuable component of the diagnostic process. These undergo changes over time as for example, during epidemics, and may differ even within neighborhoods or regions of one country.

In recent decades, some of these steps have been eclipsed by imaging methods that allow precise localization of a lesion and, furthermore, often characterize the category of disease. Parts of the elaborate examination that were intended to localize lesions are no longer necessary in every patient. Nonetheless, insufficient appreciation of the history and examination and the resulting overdependence on imaging leads to diagnostic errors and has other detrimental consequences. A clinical approach is usually more efficient and far more economical than is resorting to imaging. Images are also replete with spurious or unrelated findings, which elicit unnecessary further testing and needless worry on the part of the patient.

All of these steps are undertaken in the service of effective treatment, an ever-increasing aspect in neurology. As is emphasized ..., ... there is always a premium in the diagnostic process on the discovery of treatable diseases. Even when specific treatment is not available, accurate diagnosis may in its own right function as a therapy, as uncertainty about the cause of an ... illness may be as troubling to the patient than the disease itself.

....

It is advantageous to focus the clinical analysis on the principal symptom and signs and to avoid being distracted by minor signs and uncertain clinical data. Of course, ..., if the main sign has been misinterpreted, ,,, the clinical method is derailed from the start.

Expert diagnosticians make successively more accurate estimates of the likely diagnosis, utilizing pieces of the history and findings on the examination to either affirm or exclude specific diseases. It is perhaps not surprising that the method of successive estimations works well; evidence from neuroscience reveals that this is the mechanism that the nervous system uses to process information. As the lessons of cognitive psychology have been applied to medical diagnosis, several heuristics (shortcuts to knowledge) have been identified as both necessary to the diagnostic process and as pitfalls for the unwary clinician ... . Awareness of these heuristics offers the opportunity to incorporate corrective strategies. ... (T)he following categories of cognitive mistakes that are common in arriving at a diagnosis:

1. The framing effect reflects excessive weighting of initial data in the presentation of the problem.
2. Anchoring heuristic, in which an initial impression cannot be subsequently adjusted to incorporate new data.
3. Availability heuristic, in which experience with recent cases has an undue impact on the diagnosis of the case at hand.
4. Representative heuristic refers to the lack of appreciation of the frequency of disease in the population under consideration.
5. Blind obedience, in which there is undue deference to authority or to the results of a laboratory test.

...  Any of these shortcuts produce a tendency to come to early closure in diagnosis. Often this is the result of premature fixation on some item in the history or examination, closing the mind to alternative diagnostic considerations. The first diagnostic formulation should be regarded as only a testable hypothesis, subject to modification when new items of information are secured.

When several of the main features of a disease in its typical form are lacking, an alternative diagnosis should always be entertained. In general, however, one is more likely to encounter rare manifestations of common diseases than the typical manifestations of rare diseases. Should the disease be in a stage of transition, time will allow the full picture to emerge and the diagnosis to be clarified.

,,, Students tend to make mistakes, in failing to recognize a disease they have not seen, and experienced clinicians may fail to appreciate a rare variant of a common disease. There is no doubt that some clinicians are more adept than others at solving difficult clinical problems. Their talent is not intuitive, as sometimes is presumed, but is attributable to having paid close attention to the details of their experience with many diseases and having cataloged them for future reference. The unusual case is recorded in memory and can be resurrected when another one like it is encountered. To achieve expert performance in all areas, cognitive, musical, and athletic, a prolonged period of focused attention to the subject and to personal experience is required.

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