Monthly Archives: August 2014

Post-Neurology Rotation Update: On Studying and the Shelf

I wasn’t sure what to expect from the neuro shelf. Because the neuro block that our class went through was reimagined from the ground up, we all felt that we did not have as solid a foundation in the neuroanatomy as classes before us. Some people told me that the neuro shelf was the hardest one they had taken. Others told me they didn’t finish in the allotted time. So I fully expected to walk out feeling pretty awful about how I did. It ended up not being that bad; it was definitely a really tough exam, but I didn’t walk out kicking myself.

Since this rotation was only 4 weeks long, study time was of the essence. I found myself trying to “reinvent” my study plan based on how much sleep I thought I needed or how early I needed to get up. I technically didn’t get through everything–there were tons of provided reading materials that I just did not have the time or stamina to touch–but I feel like I accomplished quite a bit anyway. The resources I used:

  • Blueprints in Neurology: The first book I went through. I felt the same about it as I usually feel about the Blueprints books: lots of information, tiny print, hard to get through.
  • CaseFiles Neuro: I like the CaseFiles series quite a bit. The 53 cases were like brief “refresher courses” on some common presentations encountered in neurology. Sometimes I would read a case at night and see a patient with a similar chief complaint the following morning!
  • Pretest Neuro: I hit this book hard. Actually got through all 500 questions this time. It was worth it; going through questions is one of the best ways to prepare for the shelf exams, although I’m not sure I’d feel very confident if I went through questions exclusively.
  • UWorld: Didn’t use it this time. There’s not a separate neurology section in the Step 2 question bank (there are about 150 questions in the medicine section instead) so I focused my attention elsewhere.

That’s all for now. After about 6 months of being on the wards, I’m on a much-needed week-long break at home. After that, I’ll start on OBGYN.

Post-Neurology Rotation Update: Clinic (Week 4)

On the last week of the rotation, I spent a few half-days in various clinics. I like that we were allowed a “whirlwind tour” of many types of clinic environments instead of being assigned to a single location for the week. I spent a half-day each in peds neuro, adult epilepsy, and adult neuro clinics, and I also shadowed in peds neuroradiology and EMG/neurodiagnostics.

Peds neuro was probably my favorite clinic. It was very hands-on; I saw patients alone, presented to the attending, and then accompanied the attending as he saw the patient afterward. Many diagnoses are represented by the peds clinic–migraines, epilepsy, Tourette’s, developmental delay, etc. The interesting thing about the management of some of these conditions is the overlap between neurology and psychiatry. On more than one occasion, I witnessed an attending discuss the relationship between emotions and behavior with a patient and caregiver; for example, parents were told that stress of various kinds may make tics worse, or a frustrating situation may cause a child to exhibit symptoms that look like seizures or fainting spells. I find the relationship between neuro and psych–or, more broadly, the mind and the body–to be absolutely fascinating.

I saw one patient in the adult epilepsy clinic, as part of a direct observation session in which I took a history and performed the physical exam while the attending watched me and interjected where necessary (read: lots of times). The patient we saw not only had trouble recalling old memories, but also seemed to have trouble forming new ones! It was quite a feat to piece together the story from this patient and his family.

In the adult neuro clinic, I worked with an attending who was more than willing to teach and converse as he saw patients. He talked with the patients and me about everything from medications for Parkinson’s Disease to acupuncture to movies about ALS. I even watched him administer Botox injections to a woman with severe migraine headaches–before that morning, I never realized that it was used as a treatment.

My afternoon in peds neuroradiology allowed me to become a bit more familiar with CTs, MRIs, and ultrasounds, all of which I have had little experience with interpreting. It also made me wonder how radiologists are able to sit in dark rooms in front of computer screens for so long, because that can’t be easy on the eyes.

I saw electromyography and nerve conduction studies in the neurodiagnostics suite on my last morning of the rotation. Here, needles and electrodes are used in various ways to help the clinician understand whether particular muscles or nerves might be responsible for a patient’s symptoms. Yes, needles and electrodes. Sticks and shocks, if you will. These studies were a bit difficult to watch because they caused the patients a considerable amount of pain. I understand the utility of these studies, but I still wouldn’t wish them on my worst enemy…

Post-Neurology Rotation Update: Consults (Week 3)

For the next week of the rotation, I spent 3 days on the adult consult team and 2 days on the child consult team. The student I was with on stroke did consults the same week as me, and since we’re both interested in pediatrics we divided the week up so both of us could have exposure to both sides of the service.

On the adult side, the team meets in the morning to go over the most recent list of patients whom neuro was consulted for but who have not been seen by an attending physician. The team splits up to see those patients as well as any new consults in the morning. Then they round on all of those patients with the attending in the afternoon. However, due to the attendings’ varied clinic schedules and other duties, and due to the sheer size of the patient census, the team often rounds until late in the evening–sometimes until 9 or 10 pm. During all of this, a representative from the consult team is also expected to go to stroke alerts when they come in. As you can guess, the adult consult team is extremely hectic, so there is often not much time for the residents to formally sit down and teach medical students–in fact, it can be difficult for medical students to see patients alone because the residents have to be efficient and get their work done. Some of my peers get really frustrated when there is no time for them to independently take a history and do a physical exam, or to present the patients they saw on rounds. However, I have tried to see every moment as a learning experience if I can, even if I am simply watching a resident do a neuro exam. This mentality worked well for me in this setting: I could honestly say that I learned quite a bit from the team in the short time that I spent with them.

I enjoyed my 2 days on child consults as well–I love a good excuse to spend time in the Children’s Hospital! The mornings were earlier than on adult consults (6:30 instead of 8), and a bit more structured. The neuro consult resident and I reviewed EEGs with one of the epilepsy attendings, rounded in the Peds ICU and with the Epilepsy Monitoring Unit team, and saw quite a few children (and their parents) come through the ED for complaints such as headaches, limb weakness, and lethargy. When there was downtime, the neuro residents gave me topics to read about and taught me things that would be useful on the wards and on the shelf exam.

Despite the very limited time that I spent with both consult teams that week, I feel like I saw quite a variety of problems and was allowed to be fairly independent when schedules permitted.

Post-Neurology Rotation Update: Stroke (Weeks 1-2)

I started the neuro rotation on the stroke service with one other student; as with other services and other rotations, each of us had a few patients to see in the morning and were expected to present to the attending and the residents on rounds–i.e., give progress updates, report on physical exam findings and lab/imaging results, and formulate a plan for management for that day.

In addition to these typical med student duties, we also accompanied the team for “stroke alerts” which came through the teams’ pagers. When someone comes in and it’s thought that they’ve had a stroke, one of the most important questions to ask is whether the patient can receive intervention in the acute setting, in the form of tPA (tissue plasminogen activator, which breaks down blood clots). There is a very structured approach to answering this question, and the process is executed as quickly as possible–“time is tissue,” as they say.

In order to determine whether the team can give tPA, the patient is immediately sent down to the CT scanner to get imaging that may help diagnose the type of stroke–put simply, whether his/her symptoms are a result of a bleed (hemorrhagic stroke) or compromised blood flow to the brain (ischemic stroke). Ischemic stroke patients can be given tPA if they meet certain criteria, while hemorrhagic stroke patients can’t receive it at all (if you’re already bleeding, tPA would make you bleed worse). While the patient is in the scanner, the team gets background information such as the time when the patient was last seen normal, medical conditions and risk factors, and current medications. At some point during this process, the patient is examined using the NIH Stroke Scale protocol to get an idea of the severity of their stroke; a score that is too high may prevent the team from administering tPA. Usually, the patients are then admitted, and the stroke team orders labs and imaging studies to figure out what caused the stroke. The team also starts medications to lower the risk of another stroke, which may include a baby aspirin and/or Plavix to prevent clot formation, antihypertensives to start lowering blood pressure, or a statin to manage cholesterol.

Sometimes we’d admit or get pages about people who hadn’t actually had strokes; there were one or two people who had weakness due to hypoglycemia, a man who had trouble with balance due high blood levels of one of his medications, and a patient who had symptoms that may have been secondary to extreme stress. The latter is a phenomenon typically called conversion disorder. Which brings up an important point–don’t ever tell a patient that his/her symptoms are “psychosomatic,” or get a psychiatry consult without telling him/her first, because this endangers the therapeutic relationship and makes the team’s work that much harder.

In addition to all of this, there were a number of aspects of my time on the stroke service that made me feel like a true part of the team. I gave a few presentations on topics that I found interesting or that the team suggested for me–thankfully they were brief with no powerpoint slides required! The residents sometimes had me lead the discussion about the current treatment plan or new lab results with patients I was following, and I also had to call a few family members and outside hospitals for information about their care. I was present for a family meeting where my clerkship director expertly delivered the grim news that a patient would not survive his stroke. I saw another interaction in which a patient admitted that she had been under intense stress which may have manifested itself as stroke-like symptoms. One of the attendings we worked with, a neurointerventionalist, even invited us to the OR to observe angiograms and Wada tests being performed. All in all, this service was a great learning environment and a fantastic way to kick off the rotation.

Post-Neurology Rotation Update: Intro

Hey there, readers!

I took my Neurology shelf exam yesterday, which means it’s time for another update. This was a 4-week rotation in which I spent 2 weeks on the inpatient stroke service, 1 week on neurology consults, and 1 week in clinic. I was really worried about this rotation because I knew that neuro was one of my weakest points before starting clerkships. I’d heard that the rotation and the shelf exam were fairly intense, and I did not know what to expect. But it turned out great. The neuro clerkship director is an excellent teacher, and he walked us through various lectures on neuroanatomic pathways, observed us as we examined patients in groups and tried to localize the lesion that caused their stroke, and led sessions on how to do a Glasgow Coma exam or how to deliver bad news to a patient’s family. I came out of this rotation feeling like I had learned many things that will be useful to me regardless of what I go into.