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.