Neuro stuff
Yesterday I was on call (although we were sent home at about nine which was quite nice). Not much happened during the day, but we saw 3 or 4 consults in the ER that evening.
One was an alcoholic who complained of having about 5 seizures an hour for the last day. He didn’t have any while we were in the ER, and his exam was not particularly convincing. He got admitted for seizure monitoring. The next was a woman who has had weakness for the last seven months. She was hospitalized last July for two months then sent to rehab for another two months after some improvement. Her neurologist diagnosed her with Guillain Barre (an autoimmune disorder that usually resolves with time), but now questioning his diagnosis and referrred her to the chairman of neurology at my school. She has an appointment in March, but her husband (who has been her caretaker) had gotten to the point where he didn’t think she was safe in the house. He couldn’t get her into a rehab facility, so he brought her here thinking that the chairman would be able to see her sooner (not correct unfortunately). There was really absolutely nothing we could offer them that she hadn’t received in the last seven months. The resident told them that if they didn’t feel she was safe at home he could admit her and after the weekend have the social workers try to find a facility for her, and the woman flipped out. She started screaming at her husband that she wanted to go home, and that she would die if she stayed at the hospital that night. When the husband tried to tell her that he didn’t want her to fall and hurt herself at home, she started screaming and kicking like a three year old having a temper tantrum. We excused ourselves to let them sort it out. He ended up calming her down and she was admitted. When we left for the night we passed by her room and she was much calmer and apologized for freaking out.
The last patient was a woman with a numb foot for the last day. The ER did a CT scan and chest x-ray (not clear on why the CXR—our resident on being asked made a joke about its being because she walked through the door of the ER), both of which were normal as was expected. The resident thought she had somehow injured her peroneal nerve peripherally.
One of the problems with this rotation is that there are a lot of fakers. The clerkship director told us that half of neurology is weeding out the fakers from the patients with genuine conditions. We’ve already had a couple on our service, it’s making me very cynical.
One was an alcoholic who complained of having about 5 seizures an hour for the last day. He didn’t have any while we were in the ER, and his exam was not particularly convincing. He got admitted for seizure monitoring. The next was a woman who has had weakness for the last seven months. She was hospitalized last July for two months then sent to rehab for another two months after some improvement. Her neurologist diagnosed her with Guillain Barre (an autoimmune disorder that usually resolves with time), but now questioning his diagnosis and referrred her to the chairman of neurology at my school. She has an appointment in March, but her husband (who has been her caretaker) had gotten to the point where he didn’t think she was safe in the house. He couldn’t get her into a rehab facility, so he brought her here thinking that the chairman would be able to see her sooner (not correct unfortunately). There was really absolutely nothing we could offer them that she hadn’t received in the last seven months. The resident told them that if they didn’t feel she was safe at home he could admit her and after the weekend have the social workers try to find a facility for her, and the woman flipped out. She started screaming at her husband that she wanted to go home, and that she would die if she stayed at the hospital that night. When the husband tried to tell her that he didn’t want her to fall and hurt herself at home, she started screaming and kicking like a three year old having a temper tantrum. We excused ourselves to let them sort it out. He ended up calming her down and she was admitted. When we left for the night we passed by her room and she was much calmer and apologized for freaking out.
The last patient was a woman with a numb foot for the last day. The ER did a CT scan and chest x-ray (not clear on why the CXR—our resident on being asked made a joke about its being because she walked through the door of the ER), both of which were normal as was expected. The resident thought she had somehow injured her peroneal nerve peripherally.
One of the problems with this rotation is that there are a lot of fakers. The clerkship director told us that half of neurology is weeding out the fakers from the patients with genuine conditions. We’ve already had a couple on our service, it’s making me very cynical.
posted by Chris Emlyn at 1:26 PM
2 Comments:
The lady with weakness x7months sounds interesting. Have you figured out any more about her yet? (Did her tantrum demonstrate more energy/strength than her story had implied, or is that just my cynical misinterpretation?)
It was a loud but weak tantrum:). No, she definitely has something seriously wrong. Our chairman saw her on professor's rounds--she has no proprioception, no vibratory sensation, no reflexes, and 4/5 strength in all extremities. She has almost constant leg movements which he described as "choreoathetotic dystonia" and also is ataxic. So far all our (very extensive) work-up has been negative. They did a sural nerve biopsy and EMG, but I've not yet heard the results. Tomorrow she's getting a PET scan. The most likely diagnosis at this point is some type of paraneoplastic disorder, they sent a number of labs off to the Mayo clinic. Unfortunately, tomorrow is my last day of neuro so I'll probably never find out what she has:(.
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