16 September 2006

Out patient clinic

This past Friday I shadowed one of the attendings for a full day of out-patient neurology clinic. Thankfully I have been attending grand rounds, neuroscience conference and stroke conference regularly so I managed to at least follow the conversations and define most of the acronyms. Unlike the aforementioned conferences though, today was a mixed bag - I saw children (recall I am in pediatrics) with mitochondrial disorders, stroke, neuropathy resulting from traumatic or premature birth and descriptive clinical disorders (ie Turrets or Cerebral Palsy). There were also patients with unknown etiologies and highly atypical presentations.

A few things really surprised me. First, there is a marked difference in the involvement and knowledge level of the parents. Some could name every date and time of a symptom and the dates of every doctor's appointment for the next year, others were a little more relaxed. At first I thought the laid-back ones didn't care or didn't understand, but then I realised the real difference was which parents had accepted their children's diagnosis and prognosis.

The only children that were dysmorphic (physically looked malformed) were the developmentally delayed babies. This may have been coincidence, but pretty much all of the toddlers through teenagers looked like everyone else you see in school (some were a little hyper).

A basic neurology exam, one that looks for deficts and clinical abnormalities, is deceptively simple. I'm actually reading a book right now called The End of Medicene (it's making me angry) in which he critisizes how simple some of the tests performed in a physical are. The thing is, tests don't need to be complicated and digital to provide the information you need. An example. Put your arms straight out in front of you, palms up, parallel to the floor. Close your eyes and vigourously shake your head no. Open your eyes. Your hands are probably still level, but someone with a single hemisphere deficit will find one hand drifted downwards. Which hand also tells us which hemisphere. Yes, we need the 4D MR perfusion imaging and other complicated, high tech tests to help us accurately diagnose and treat, but that doesn't mean a simple test is worthless or unrevealing.

My favourite patient was a young boy with a head of short fuzzy blong hair in a McNabb jersey who was hyperinsulinemic/hyperammoniec. During his exam he refused to pay attention to the attending and instead was staring at me. In the end I had to stand behind the doctor to help the boy focus. While his mom was discussing recent events the boy played catch with me and climbed up onto my lap - he's going to be a real heartbreaker when he's older.

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