Wednesday, August 20, 2008

The brain!

I enjoyed my Neurology and Neurosurgery rotation. Most of the people I dealt with on the wards and in theatres were lovely, and they enjoyed teaching.

Here are the highlights and lowlights:

  • Best moment: Brain surgery. 'Nuff said.

  • Weirdest moment: The patient who lied.
    This patient in his 30s came in with acute cerebellar ataxia. He told us that he'd had brain surgery as a child, but didn't remember what for. CT and MRI showed the craniotomy scar and some calcification where the surgery was done, and also showed severe cerebellar atrophy. The registrar examined the patient and asked him to get out of bed so we could check his gait. As he did this, a red and white capsule rolled out of his bed. He told us it was a vitamin pill that his friend gave him. It sounded very odd, but wasn't pursued at that time.
    About half an hour later, the patient asked to see the doctor again because he'd lied about the tablet and felt guilty. He told us that it was Dilantin (phenytoin), an anticonvulsant, and that he doesn't take it very often. However his phenytoin level was VERY high, and the docs concluded that it was causing his cerebellar signs. He improved off the Dilantin, but will have permanent damage to his cerebellum.
    (He also lied about the brain surgery - it was done about 10 years ago to remove a cavernoma, and he was taking the Dilantin to prevent seizures caused by the scarring.)
    I still don't understand why he lied - I guess he was scared. Read this interesting post by Edwin Leap about patients who lie and deceive.

  • Worst moment: The patient who died.
    This university professor was in his 70s, but still lecturing occasionally. Then one day he suddenly lost his speech and collapsed. He had all manner of neurological investigations, but imaging and other investigations were inconclusive. It didn't look like a stroke, or epilepsy, or a hypo, or syncope.
    However a suspicious lesion on the chest X-ray was explored further (with a CT), showing advanced small-cell lung cancer. There were no metastases, but it was decided that his neurological signs were explained by a paraneoplastic syndrome.
    The prognosis was poor. He was on the ward for the first 3 weeks I was there. In week 1 he was able to talk and follow commands. In week 2 he deteriorated, and by week 3 he was moribund. He passed away in the middle of week 3. It was very sad.
My next placement was supposed to be at a rural location, but it was cancelled. It's kind of a long story, so I'll save it for another post. I'm doing Immunology and Infectious Diseases instead, which so far is very interesting.

Oh, and my long case exam (described at the end of this post) went well, I think. We get the results next week. My patient had lot of things wrong with him, and I spent too long taking his history, but my presentation was good and I think I answered (most) questions intelligently. My two examiners were very nice - not at all scary.

Now I'm having a week off from study and focusing on:
  • My sister's wedding this Friday - will be fantastic, as long as family dramas are avoided (is it possible for me to get a divorce from my father?)
  • My netball grand final on Saturday - I hope my hangover is not too bad (luckily the game's in the afternoon)!

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