This past week was my first of two weeks on neurology service. I am working on the consult team, meaning that I am with the neurology resident called by other medical services when their patients' have a neurological problem they cannot solve or don't know how to best manage. Two other medical students are with me, and we all three work under our resident's tutilage. I'll outline a typical day:
At 7 a.m. I arrive at the neurology swamp (where the residents have their desks and a couple computers for work) and start running through the day's patient list with Scott, who often gets there just before I do. We add current medications to the table with patient info on it, as well as their location, age, medical record numbers, and so on. Any medication that has an effect on the nervous system is also listed with dosages. The third medical student, Mackenzie, often arrives shortly after I do, and our resident Aarti arrives just after 7. Aarti acts as the quarterback of our crew, making the decision on which patients we will see that day.
We run through the patient list for the day over the next hour, checking the medical records for any pertinent labs or progress notes, MRI's and CT's, and discuss any patients that we saw the previous day. By 8 a.m. we are ready to start rounds.
Oftentimes this week we start from the top down, taking the west elevators straight to the 6th floor and checking on any patients on the medical service there. Then we take the stairs to the 5th floor medical service, and round on patients there. We continue in this fashion, also rounding on patients in the medical-neurosurgical ICU, the surgical ICU, and the cardiac ICU. Sometimes our patients are in a coma (often those in the ICU). Others may be conscious but have a trach (a tube in their neck to help them breath) and they cannot speak. After checking on all our patients with Aarti, and sometimes doing part of the physical exam, the attending (a physician who has completed residency and trains other residents) arrives and makes rounds with us over the patients we have just seen, and the resident presents each patient and the treatment plan. During this time us students are more so observers than active workers. The afternoon may be filled with research on the conditions our patients have and how to treat them, or clinic duties, or more consults as they are called in throughout the day. Sometimes it's a time to follow up on work that we couldn't finish in the morning.
Occasionally as a medical student, you get to actually feel as though you've contributed significantly to the care of a medical patient. I had that experience this week. One of the patients on our consult service, I'll call him Mr. Brooke, a chronic COPD'er who presented to us with muscle weakness that was more pronounced in the shoulders and hips than at the ends of his arms and legs. I was instructed by my resident to go examine him one afternoon this week before she would go see him. I went and introduced myself to the patient as a member of the neurology team that would be assessing him and trying to help determine why he was experiencing weakness. I moved through the neurological exam with less grace and efficiency than my resident Aarti, but effective nonetheless. After gaining a medical history on my patient and documenting all my findings I left to organize my information to present in the morning.
On the next morning I presented my patient to Aarti in the typical structured fashion we have been trained in as student-physicians. I was interrupted occasionally as she smoothed out my delivery, and questioned me on certain aspects of the history and exam. After presenting my patient she asked me for my differential (a list of possible diagnoses that would explain the symtomatology of your patient). My top diagnosis was ankylosing spondylitis, an inflammatory disease of the spine that can cause weakness, pain and stiffness. I came to this conclusion based on my patient telling he he had a "spondylitis" that had affected him since high school. My resident disagreed, considering glucocorticoid myopathy as a more likely choice, given his history of lung disease and high doses of steroids. A quick look at his chart and his lab levels showed that steroid myopathy couldn't be right, and we were still considering what could be the case. The next day, when revisiting his chart and reading a pulmonary consult note, we discovered that he had a restrictive lung process, something that can coincide with a diagnosis of ankylosing spondylitis.
It turned out I was right on with my diagnosis the first time, and with further reading was able to justify my diagnosis. It also earned me a high five from my resident. Despite being right, however, I was easily swayed around towards other possibilities once I found my resident disagreeing with me. It's a common thing to second guess yourself when you are the student working under the expert, but sometimes you just might be right. With a little bit of time and a lot more experience in seeing patients, it'll be much easier to hold fast to my convictions and not question my gut-instincts.
