Neurology - Last day

I went to the ICU and saw the old lady whom I first met on day 3 in the ICU. She was still in a semi-coma state. The nurses were washing her. She was still being monitored closely.

We then went to ward run and saw the patients we did the last couple of days. They were more stable.

My day ended with the conference in the afternoon. The presentation was about ARDs of AED and SJS. The discussion was in Taiwanese so I did not understand much. But there was handout of the main points so that helped.

I had some time to reflex on the neurology rotation week. I feel so blessed to have been able to come to Taiwan to intern. My preceptor was amazing and I learned a lot from him. Ms. Yu Yu, Jessica and Angie were so kind. I cannot ask for a better first week than this.

Neurology - Day 3

On Thursday, we went to NCV/EMG lab but there wasn't any study so the doctors in Physical Therapy dept. showed us around their facility. Again, the head of physical therapy told us that some patients do come in more than they should. So we asked how they determined who get tx if the patient # becomes more than the facility could accomodate for each session, and he told us that they prioritize patients (who will get the most of out this, who could really improve from the tx's, severity, etc).

We went to meet with the superintendent at 11. That was pretty cool. He's so nice. He is a busy man and he took time to meet with us students.

In the afternoon, we went on ward run. I saw the same patients I did on Monday. They all seemed to be doing better. They were more alert this time.

In the ICU, an old female patient suffered ischemic stroke, most likely due to her A.Fib. She was being monitored carefully to prevent edema which develops 4 days, and she had been in the hospital for 2 days. I learned about neurological index: eyes are rated 1-4; best verbal respponse 1-5; best motor response 1-6; arms 1-5 (There are more categories but I didn't get them all down).

I also learned about:

Cogwheel rigidity (def from medical dictionary): muscle response with cogwheel- like jerks to the use of force in bending the limb (e.g. Parkinson)

Lead pipe ridigity: a state of inflexibility and stiffness that remains uniform throughout the range of passive motion --> associated with disease of basal ganglia

I would go on youtube to watch how the techniques are performed

On brain CT, old stroke appears as dark as CSF while new stroke is darker than brain matter but lighter than CSF

Plasticity develops 1-2 weeks after stroke

Later that day, we went to EMG lab

Indications for NCV include: CTS; ulnar neuropathy; peripheral neuropathy; brachial plexopathy; radiculopathy; myasthenia gravis; muscle disease

Indications for EMG include: radiculopathy; neuropathy; muscle diseases; motor neuron diseases

neurology last day

The last day in neurology was very interesting but short. We went on rounds in the morning and visited all of the same patients that we had seen the last few days. Most of them hadn't had a lot of change. The only one that had significantly changed had moved into the ICU because he needed ventilation. A couple of the others were being transferred to rehabilitation because their conditions were stabilized. At lunch a neurosurgeon gave a seminar on case studies of drug overdose and Stevens-Johnson syndrome. He lectured really fast and in Chinese. It was interesting and it gives me something to research so that I can understand it better.

neurology

The last few of days in neurology has only shown me how much I still have to learn. Nicole and I have learned so many things in the last 2 days. We learned the cardinal signs of Parkinson's disease: tremor, rigidity and bradykinesia. We have also learned about the examination and diagnostic tests used in neurology. The technicians in the EMG and EEG labs have been very helpful in showing us how the tests are done. We watched a 2 year old have an EEG done, which was a little difficult to watch as he was not happy at all to have electrodes in his hair. The second patient was an adult and was much easier to watch. The EEG is a test to look at the conductance in the brain to see if there is any sort of seizure-like activity. The EMG is a test to that looks at the status of the nerves of muscles. The patients often have some sort of spinal injury and this test shows which specific nerve is damaged. We watched 2 EMGs done on 2 young men. The first one was rather painful to watch. A needle probe is put into the belly of the muscle and the patient is asked to contract that muscle to test for the neurological stimulus that is being sent by the brain. A polyphasic wave suggests that there is a problem in the innervation of that muscle. The first patient we saw was in quite a bit of pain as he contracted the muscles with the needle. His test was done on his calf muscles and lower back. The second patient that we saw had his test done on his arms and didn't seem to be in any sort of pain. He must be a stoic. I can only imagine how much pain there would be if I had to contract my muscle with a needle stuck through it. It was quite difficult for me to watch the first patient as he lay in pain. The last test that we were able to watch was an EP (evoked potentials). The patient's brain is monitored with electrodes as they play sounds in each ear. This tests the auditory pathway in the brain stem and the acoustic nerve. It seems like a very easy and non-invasive way to test the sensory pathways to the brain. The patient just lays down on a table and listens to sounds. Much easier to watch than the EMG.

While we were waiting to see the EMG we were able to tour the physical therapy department and see the different modalities they use to rehabilitate patients. It was quite interesting to see the different machines and tools they had for the patients. It is also interesting to note that patients can continue physical therapy as long as they want. All they have to do is pay $60 (Taiwan) per visit to use the facility. The therapists said that many patients take advantage of this and use the facility far more than is necessary for their condition. Even though the facility remain quite busy all the time, it seems nice that the national insurance program allows patients to use the facility for their condition.

Going to the wards showed the realities of patients with serious neurological problems. The doctor is prepped by a nurse who sees all of his patients. She also follows him during the rounds to understand what the doctor is ordering for the patients. We saw several patients that had gone through a stroke and were recovering. One of the patients was in the ICU and the doctor was monitoring her closely because brain edema could occur in the next couple of days. She also had congestive heart failure and hypertension which also required close monitoring to keep her condition stable. Using the things that we studied last year, we were able to discuss her condition and understand the fine balance in fluid intake/outtake that the staff was trying to achieve. We learned about the coma scale and the tests that are done to determine the consciousness of a patient. The neurological workings of the body are quite intricate and interesting; I am privileged to get this sneak peak into the things that we will be studying this fall. I have so much to learn not only in neurology but in patient care in general. It makes me nervous about our year to come in school but this rotation will definitely give me a head start.

Neurology - Day 2

I spent the afternoon in the clinic. Dr. Yu did consultations in the clinic. Here in Taiwan, the patients come into the clinic room. Dr. Yu knew most of the patients and their conditions really well. The pace was really fast.

Many of the patients had Parkinson disease. Cardinal signs of Parkinson's: rigidity, resting tremor, bradykinesia.

I also learned about:

Tinel sign: performed by tapping over the nerve to elicit a sensation of tingling/pins or needles. It is used to detect irritated nerves. (e.g. test median nerve for Carpal Tunnel Syndrome)

Romberg sign: to test drunken drivers and neurological disorder. if +, suggests poor propioception

Phalen test: used to diagnose Carpal Tunnel Syndrome.

Later in the afternoon, EEG lab:

Indications: altered consciousness; seizure disorders; tumors; head trauma; headaches; brain absess; mtabolic encephalopathy; behavioral changes; adolescent disorders; intermitten explosive disorder; OCD; anxiety & panic disorder; bi-polar; RLS; Shaken baby syndrome; ETOH (from telemedx.com)

The use of hypoventilation in EEG lab is to wash out CO2 --> vasoconstriction of vessels in brain --> enhance abnormality

The use of light in EEG lab is to stimulate alpha wave

Ask patient to close eyes --> alpha waves should be present. Open eyes --> alpha waves should go away

Epileptic discharge --> see spiky alpha waves

Dr. Yu told me, at our level, it is important to know when to order EEG. The interpretation part of EEG takes a "life time."

I asked Dr. Yu on Day 1 which I forgot to blog what differences he noticed btw US Health care and Taiwan Health care system (since he's been to the US). He told me that most people have the government insurance, which is fairly cheap, so a lot of patients come to see doctors more often. Health care is very accessible in Taiwan, and some patients take advantage of this and come in to see doctors more often than they should, which is not good sometime. He also said that in the US, we have stricter requirements about ordering tests (order necessary tests with appropriate reasons).

I noticed that everything at TIHTC is very fast paced, while as Dr. Yu mentioned there are many procedures or "layers" to US health care system.

Neurology - Day 1

We started off the day with a case study. That was pretty interesting. It totally reminded me of our pathology labs in which we had to discuss cases with our TBL group. I always found myself learning a lot from case studies.

So, at 9am I went on rounds with Dr. Yu.

Case 1: 65 yo female found unresponsive at home for 2 days. H/o DM which is under control with diet and medication. General weakness (3/5) upon admission. Stable after 2 days at the hospital. On Furosemide to help with pitting edema. Was given ASA but had GI bleed so stopped ASA. Give 1st generation Cephalosporin because of lower UTI.

Case 2: 56 yo male with h/o HTN and DM. Present with right hemiplagia. He has cerebromuscular disease. Severe hematuria present in urine but is getting better. Continuous flushing blood clots with intravesicular water

Case 3: 80 yo male present with behavioral dysfunction after stroke. Came to hospital in May because of 2nd stroke. Has central nystagmus, suspect central lesion of brainstem. Dysmetria. Brain CT: no hemorrhage (we need to know the differences btw ischemic vs. hemorrhage stroke). An ischemic stroke usually takes 24 hrs to show on CAT, so do MRI (diffusion MRI very sensitive) which is more sensitive to early sign of ischemia. MED: Persantin which enhances ASA effect, Diphenidol for stroke, Colchicine for Gout. Entrococcus spp. found in culture

What I learned on the rounds:

1. How to perform Babinski reflex

2. A. Fib --> blood stasis and blood deposits in dead spaces in atrium--> heart pumps out emboli --> to brain --> can occur major arteries or small vessels

3. Clinical presentations are very important to diagnosis. They guide reasons to order appropriate tests

In the Doppler lab, I got to see how technician performs the study. RI = resistance index. Increase RI if stenosis of arteries.

Indications for Doppler study:

1. Syncope

2. Suspect of atherosclerosis of arteries supplying brain in high-risk patients

3. others (I need to look these up)

What I learned from Doppler lab:

1. Know the circle of Willis anatomy

2. Toast classification of ischemic stroke: a. thrombosis or emboli due to artherosclerosis. b. embolism of cardiac origin. c. occlusion of small vessels. d. other determined or undetermined causes

3. Know hemodynamic criteria for ICA stenosis

At Botox clinic:

1. Indications: dystonia, local pain, cosmetic reasons, writer's cramp, etc.

2. Effects of botox on facial muscle spasm take about 1 week. Do not wash face with hot H2O because that will speed up the effects of botox which last about 3 months (The government only allows 3 tx/yr so most patients come in with full on signs of dystonia)

What I learned at the clinic:

1. Know the muscles of face and neck (very important)

2. #1 sign of dystonia = excessive blinking

3. Meige's syndrome = a type of dystonia, usu. a combination of blepharospasm and OMD

outpatient clinic

Having seen two days of outpatient clinic (in neurology and oncology) has shown me the differences between Taiwanese and US styles of patient care. The Taiwanese clinic seems to be more efficient because the doctor is able to see 10-20 patients per hour. The doctor here sits in his office/exam room with 2 nurses and patients come in and out to speak with him. The patients are all numbered and, like the DMV in the US, are called in by number outside of the door. The doctor spends about 5-10 minutes with the patient, answering any questions and doing any quick exam that is necessary. If the patient needs lab tests, the patient is sent directly to the lab and the results are sent back to the doctor fairly quickly to be discussed with the patient. The insurance system is electronic and the doctor does the billing while speaking with the patient. The charting is also done simultaneously and is printed out for the nurses to paste into the patients chart. And this all occurs in the short time that the patient sees the physician. The doctors that I have shadowed also seem to make time to explain small things to me in English, which is quite impressive considering the speed at which they are working. Comparing this to the US, where the doctor probably sees four patients in one hour, and has to do his charting and billing separately, this seems to be very efficient. I have really enjoyed seeing this difference and appreciate the fact that the US should possibly learn from other countries to make the system more efficient.