Tuesday, April 15, 2008

Neurology at CMC Hospital

Hello all,
Well, this week I'm on the Neurology service, mostly with the N2 service. The wards at CMC are like the old-school kind we used to have back in the US. There is one big room sub-divided into three "halls". Each subdivision is just a big open room with 4-6 beds along each side. Not much privacy, although you can pull drapes when dealing with sensitive issues. The patients are grouped by sex and adult vs pediatric. Most of the kids have at least one parent sitting by their side at all times. These people had to leave their jobs and make the journey all the way here, so the staff trys to make them as comfortabel as possible and get them discharged ASAP. Mixed in with our patients are Neurosurgery patients. One of these is attended at all times by what I believe to be her son. He has not left her side the whole time I've been here, not even changed clothes. I wonder if he sleeps here too? There is also a neuro ICU on our floor. You take off your shoes and put on their flip-flops when you go in. It has a/c! What I noticed in there, though, was how quiet it was. No beeping or booping or other loud alarms like I am used to in ICUs. No ventilators either. Patients that had tracheostomies were on CPAP only. I'm told that the ICU downstairs has vents. Maybe I will see that later this week. The hospital is crowded, but other than the ward set-up and heat, pretty much like other hospitals. All the windows are open and the fans are going, but it is still pretty toasty. I can't imagine what it is like in June when it is really really hot.

The residents stay pretty busy, handling about 10-15 patients each. Several days a week they spend in the OPD, which is the outpatient clinic. They will have two exam tables crammed into a room we can only fit one into, and run through patients as quickly as possible. Because the neuro exam takes a while to do, they may see only twelve patients an afternoon each, but that still means getting out after 6pm or later.

Some interesting cases I have seen so far:
- Cerebral venous thrombosis. Not commonly seen in the US, it is very common here. Occurs predominaely in post-partum women. The residents I spoke to said the etiology is not completely clear, but trhey blame it on local customs regarding childbirthm not giving the mother anything to drink, etc. It presents as a headache with bilateral neurological deficits, and occasionally seizures. This is a diagnosis of exclusion, but is high on the differential list due to the history and physical findings. They rule out Cerebral Hemmorhage because the headache is not as severe, the patient is not so severely obtunded, and the neuro deficits cannot be localized to an arterial source. They also use neuro-imaging regularly, so the MRA helps cement the Dx.
Treatment is similar to a DVT: heparin for several days, then discharge on anti-coagulants for 6 months. Most patients recover well.

- a case of possible Isaac's Syndrome. Isaacs' syndrome is a rare nerve and muscle (neuromuscular) disorder. It may also be referred to as neuromyotonia, Isaacs-Mertens syndrome, or continuous muscle fiber activity syndrome. It's characterized by abnormal nerve impulses from motor neurons of peripheral nerves. These impulses cause continuous activity in muscle fibers. Our patient was in to get an EMG, and the history I gathered was that over a 2yr span, he has developed weakness on one side when trying to run or exert himself. Sometimes when running to catch a bus his hand will clench up in a claw and his foot will suddenly internally rotate due to muscle spasm. He can avoid this if he sees the bus coming and starts to pace a little, "warming up" before he has to jog over to it. The Dx on him is still pending.

- a case of Hansen's (leprosy) vs Myeloradiculopathy. A 63yo male with a history of decreased sensation of tough, temperature, and pain, beginning in his distal lower extremities and progressing proximally up to his mid abdomen (approx T10). He alsso reports recent onset of parethesias and burning, and again greatest in distal lower extremities, gradually diminshing proximally. These have also abated distally as total insensation has set in. Of note, he states the right side is worse in all symptoms than the left. As the Over the past 6 months, also onset of urine retention and constipation. His symptoms have all prgressed to the point where he is bedridden now and dependent on intermittent catheterization. He was diagnosed originally with Hansen's disease at another hospital, and given a course of antibiotics, but these were discontinued after less than 2 months due dermatologic reactions. On physical exam he exhibits significant bilateral lower extremity muscle atrophy, complete lack of sensation to pain, temp, touch, and vibration in both of his legs. He regains sensation around navel level (T10), which is a burning sensation when touched lightly. The jury is still out on him too.

So, due to a case of "thats how it has always been done", the neurology service also gets every attempted suicide by hanging. They don't want them, provide no psychiatric treatment, but still they get them. I saw a resident advise a patient to next time try to drown herself, as it is less traumatic. I think he's pretty sure she'll try it again, but if she fails he doesn't want to have her on the service again.

Also of note, the CMC is apparently not a public hospital. Patients come up to the residents throughout the day complaining of their bills and their inability to pay. I've seen this handled relatively well by the younger residents. The upper levels, who have been dealing with this for years, have not patience. I saw one yell at a woman to sell her bad and her house, do whatever it takes, but pay the bill. Pretty brutal.

Ok, thats all the medical stuff for now. Will post again later.

25 comments:

Dr. J said...

Hi, Dr. Nick!
Nice blog so far, Patton! Val and I are enjoying your antics and photos. I can't believe that resident recommended drowning--geez. Sounds like resident disillusionment is not just a US phenomenon.
You are having some very cool experiences, man. The picture in a skirt is a keeper. All those alley-way temples are so elaborate--holy cow (intended).
Not that this will make you overly jealous, but Val and Jake and the dogs and I are heading up to Pedernales Falls today for a break from boxing up all our junk. Should be good. Do you have a therapy recommendation should I get leprosy from an armadillo?--tyler

Chris said...

my advice....dont pick up armadillos. If you do get leprosy, just gut it out, man. Be tough.

swati said...

hello sir,
i m swati sharma from jharkhand(dhanbad)need an appointment for my sister sneha sharma.as per the local concern doctor she is suffering from some nerves problem,suddenly she losse her sense of the right side of the body.
sir,please help me out.
my email- swatipoddar25@yahoo.in

swati said...

sir please i need an urgent appointment for my sister,plese sir help me out.

Shibaji said...

sir,i am 21 yrs old and i am from west bengal and for last 3-4 months i have a pain in my waist,now it has transmitted in my spinal chord and my waist,legs are getting thin day by day..it looks really odd..sir i am in real trouble...i have done X-ray of my waist which says"spinae biofida at S1 level"...plzzz suggest what i have to do..i cant take any decisions.

chandhu said...

My name is Poornachander-29 years working in DR. REDDYS-HYDERABAD. and suffering from foot burning sensation, there was some mild back pain but a different sensation that is hurting me since 2 years, there is a mild disc bulge in my L4-L5, i contacted many neuro surgeons, but they had told me that there is no much nerve compression.and surgery is not required at all.
i took 3 epidural steriods and much medication, but my leg burning and differnt sensation is hurting my cychological feeling, i want to compromise my foot due to this and i decided that i dont want to live with this in this age. Recently i had undergone Percutanious laser decompression, but my foot is as such..
I have Flexibility X-ray, MRI of two years, CT-scan, Neurological studies report etc.,
kindly understand my problem that i am facing and what i have to do please suggest me sir. Can i meet you once.......AND WHAT TO DO?

chandhu said...

My name is Poornachander-29 years working in DR. REDDYS. and suffering from foot burning sensation, there was some mild back pain but a different sensation that is hurting me since 2 years, there is a mild disc bulge in my L4-L5, i contacted many neuro surgeons, but they had told me that there is no much nerve compression.and surgery is not required at all.
i took 3 epidural steriods and much medication, but my leg burning and differnt sensation is hurting my cychological feeling, i want to compromise my foot due to this and i decided that i dont want to live with this in this age. Recently i had undergone Percutanious laser decompression, but my foot is as such..
I have Flexibility X-ray, MRI of two years, CT-scan, Neurological studies report etc.,
kindly understand my problem that i am facing and what i have to do please suggest me sir. Can i meet you once.......

chandhu said...

and my email id is honey_mailbox@yahoo.com

Sapan said...

Sapan; Hello sir. I m From Bilaspur C.G. My father met with an accident 2 years back. tis winter some pain started in his left shoulder. Aftr givng him Treatments Dr asked For an MRI. At MRI it was seen Tat 2 nerves are Blocked. The condition is becomng Serious for the arm as there is high muscle wasting. Plz tell me wats d treatment possible for tis case. Can it be cured through medicines or surgery? are there ne complications in the treatment. My id is sapankalda30@yahoo.in. waitng for ur rply vry urgently. plz sir.

Anonymous said...

SIR,I AM FROM MADURAI.MY WIFE IS 48 YRS OF AGE AND SHE IS SUFFERING FROM HEMI FACIAL SPASM FOR THE PAST 10 YRS.
SHE HAS PAIN AND TWITHCHING IN THE RIGHT SIDE OF HER FACE FROM CHEEKS TO EYE.I WANT TO KNOW WHETHER THIS CAN BE CURED BY MEDICINES OR IT NEEDS A SURGERY?AND ALSO WHETHER YOU HAD SEEN SUCH CASES AND CURED SUCCESSFULLY?

Anonymous said...

Dear Sir,

I am writing this email on behalf my father from Bangladesh. My father had recently developed some early Parkinson symptoms and doctors at Dhaka has recommended CMC Vellore. Can you please suggest us whom we should contact regarding neurological problems. We are planning to come around June 15. Regards, Asif Rizwan
,

Anonymous said...

Dear Sir,
I am writing this on behalf of my mother . She aged 47 and she is getting frequent severe pain in her right half of her body since last four years.
Kindly help me out as the doctor whom should I consult and how can I get an appointment.
With regards,
Indrajeet
Bokaro steel city
jharkhand

Anonymous said...

Dear Sir,
I am writing this on behalf of my mother . She aged 47 and she is getting frequent severe pain in her right half of her body since last four years.
Kindly help me out as the doctor whom should I consult and how can I get an appointment.
With regards,
Indrajeet
Bokaro steel city
Jharkhand
my email:ikrsah.bit09@gmail.com

J. ANJU said...

Sir
my baby is suffering from spinal disorder, their is a partially fusion in between L1,L2 and in outer part of the back their is hair growth this is from the birth. She is 4years old girl.
she can walk,she can run
only difference is that left leg is thiner then the right.As no one can notice the difference.
Now my problem is that is this a spina bifeda or what.
What is treatment how to get the treatment.
Is she will face in futher any major disbility due to this.
Please guise me or sujest me that what should i do.

ajay said...

Sirs,

My nephew, Avijit Mandal, H NUM :769779D is under your treatment. We consulted you earlier on (1st) 30.08.10 and repeated after tests on 06.09.10. On leaving you, we request you to issue us medical report and for it we have deposited requisite fees vide Receipt No. 50741R179921 dt. 06.09.10, Unit NU 3, Bill No. 8015550043.
I am regret to mention that till date no report reached to us where we have already provided, in the office of Neurology, a addressed envelope.

I am giving once more our address as under :

AVIJIT MANDAL,
S/O AJAY KUMAR MANDAL,
VILL : GOBAG
P.O. RAMKANALI
DIST : PURULIA (W.B)

NOW WE REQUEST YOU PLEASE ARRANGE TO SEND THE REQUIRED MEDICAL REPORT OF THE SAID PATIENT. THE SAME MAY ALSO BE POSTED ON MY EMAIL ID :
mritunjaymandal@yahoo.in

Your kind action in the matter is solicited.

Thanks

Sashi Thapa said...

Happy New Year from Land of Peace & Tranquility -Sikkim!

Dear Doctor,
I would like to inform you that my son (DOB 22 Nov 2007) was born caught with breathing problem (Pneumonia), immediately during his birth we had to rush to Siliguri from Sikkim. He got bit well after keeping in Pediac Care in Siligrui Hospital under veltelator.
Now he's okai but he has some problem in walking, his legs are bit diffrent, he trolls his one leg uneasily while walking, he's not yet speaking (Says Mama, Baba only). Sometimes he catches with fever and we give him oral crocin. He also had developed a allergec type blisters after 5 months he bron, we referred to one doctor in Siliguri annually, blood tested, on doctor's advice we gave Rekfa Acid for almost from age of 5 months (2007-2008) till 2010 (Feb) without discontinuing.Now we have stopped since last 1 year. Doctor said that Rekfa will control blisters. Now blisters are gone but when he's in sun it develops.
His wrist bone are big larger, mean to say bigger than normal babies.

I would be please doctor is he has some problem or genetic disorder. His both knees are are also quite different big, one leg is little bent (Unnoticeable). Pls help and guide us.

On 22 Nov he stepped in 4 year,
Thanking you

Sashi Thapa
Gangtok, Sikkim, India
Ph: 94341 84203
Email: voiceofsikkim@yahoo.co.in

Nitay Nanda said...

Sir during last few years I surrering from Panic, Depression, anxity, Chest pain, Giddiness,uneasy feeling, Panic attack etc. please give me an appointment

Arun Kumar said...

hello sir,
i m Arun Mishra from Bangalore.My 3 years son having some problem by Birth Doctor in bangalore said its meningocele and doctor did operation and after 1 month shunt operation. I have quiry that farther any treatment is there.

sir,please help me out.

towhid68@yahoo.com said...

Dear Dr,
My aunt,Mrs.Hajera Begum has got Meningioma in the left frontal region having age related cerebral atrophy as per MRI of brain..She is of 55 years having episodic headache & vertigo for previous 2 years.MRI was done applying technique- Multi planner axial T1W1,T2W1 & FLAIR,sagittal and coronal T2W1 scans of brain were performed.
Your utmost suggestions are required for her recovery.

Nibbles said...

Hi Dr,

My dad has been diagnosed with ALS and I would like to know about the stem cell research for same in CMC Vellore. Can we register for it. If so how to proceed for the same. Please do reply.

rahul tiwari said...

hello sir this is rahul tiwari.i want to some information about neurological problems.actually my father is suffring from neurological.actually his speaking power is so down,body has more weekness,unbalance body,and also he cant climb the stair case if he sit on the floor he cant stand up.so dr please help me and give me some suggestion to me.

apoorvaa bharadwaj said...

Hello sir,
this is apoorvaa from Bangalore,sir ma frnd is suffering from headache since past 6 years.past 3 year he is under treatment bu nt getn'g cured.sir thus i plz request u to plz suggest me smthng wat to do n ur appoinment too.

rehan khan said...

Dear'sir
My name is irshad khan frm kishanganj (bihar) i need a apoinment for my big brother he is acciedent before 20 years he got attack on morning so plzz sir help uss.
My email rehan.khan.k.n.e@gmail.com

Sneha Agrawal said...

My father, 49 years old, has myasthenia gravis from past 6 months..He was having distinon(60mg) 4 times daily, azaron(50mg) twice daily & wysolone(40mg) once daily.Wysolone was tapered down slowly n stopped one month before..as he was gettin severe infections frequently.. 20 days back Nocardiosis (in lungs) was diagonised n medications were started..( ceftriaxone 2gm once daily & linezolid 600mg twice daily)
CT scan of lungs and abscess in upper hand (abscess was drained out n culture of pus & sputum)diagonised nocardiosis..
Hence Azaron for myasthenia was stopped 20 days back.. He is getting myasthenia symptoms again..Like body weakness, slurred speech and pumping of nerves at intervals.. Like body weakness, slurred speech and pumping of nerves at intervals..
Sir, i wil be really grateful to u.. if u can help me out with the consultation and appointment at the earliest..Your suggestion will be really valuable.. Looking forward for ur reply. My email id is- sneha.sin2009@gmail.com

MUNESH BABU said...

Hi Doctor,
this is munesh, actually my sister is suffering with fits. before she is severlly stroked with fits. now what is the problem means she is forgetting some information. in all reports doctors said that she has no problem, but she is suffering with that problem, so plz give some suggestion to solve her problem.