One thing I learned from my neurology rotation thus far is that I must stop being so awkward in front of patients. Here are some memorable moments, which are mostly humorous interactions that only point to how awkward of a medical student I still am, even as a ‘wizened’ 4th year!
The Mini Mental Status Examination: Usually I start off the neurological evaluation with cognition. I stumble with this part a great deal. I feel like it’s a nonsensical Q&A session and the patient wonders why I’m asking silly questions about puppies and math and sticking out the tongue…
Is the patient awake, somnolent, lethargic, or comatose/unconscious? If the patient is awake, how alert is he or she? Well that’s tested with several components: orientation to person (self), time (date, month, year) & place (hospital, city, state); registration (repeating 3 named objects, like “apple, dog, cup”); attention and/or calculation (spelling WORLD backwards or serial 7’s by counting back by 7s from 100); short-term recall (of the previously named objects); language (naming of 3 objects I point out on or around me); repetition; and complex commands, including obeying (“stick your tongue out”), reading (“close your eyes” and do as it says), writing (a full sentence, with subject and predicate to be fancy), and drawing (a complex figure of 2 overlapping pentagons to bring out the inner kindergartener).
So one day, my partner in neurology crime and I set off to do a consult on a patient evaluated for stroke vs. syncope vs. seizure. He was under the trauma service for several days status post motor vehicle collision where he was amnesiac to the event. The problem? He was pretty uncooperative. And obese… and could care less what we were doing for him. He was falling asleep during our encounter, basking beneath of the beaming rays of sunlight infiltrating his side of the room. Add to that, he was an Italian guy with a heavy mafia-man accent.
Now, I try my best to go through the mental status examination. I think, I speak louder, I enunciate, I repeat.
I get to the attention and serial calculation section, which has always been a hiccup for me AND the elderly patient. Why me you ask? Mostly dealing with the frustrated patient who stalls, scratches head and gives up. Well, this elderly, big and burly, sleepy Italian guy with an accent was a unique one. I asked him, “Okay sir, can you spell the word WATCH forwards for me?” He furrowed his brows, gave me a dazed look, and stumbled like a wobbly toddler. He said, “What? … Uhhhh, [bumbles a bit]… blergh…” Okay, so it was well established that he could not spell a word forwards. What I did next was beyond my comprehension. I looked at him again and commanded, “Now, spell WATCH backwards.” What an epic fail?!! Go ahead and laugh, I’m laughing at myself too.
Fast forward through the neurological exam to the cerebellar testing, with the same Italian patient. Typically for testing of cerebellar function, the primary center of balance and coordination, you do finger-to-nose, rapid alternating hand movements, or heel-to-shin. I stand in front of him, face-to-face, with my finger held up in front of my face. I asked him to do the following: “Okay, use your finger and touch your nose, then my finger. Back and forth like that… And I’ll be moving my finger.” So he touched his nose, smiled a little, overshot my finger, and touched MY NOSE. Startled like a buzzed monkey, I jerked and nearly fell over backwards. He laughed, my friend laughed, and I probably turned tomato-red.
This was not the only time I was touched by a patient, literally. For general neurology consult in the ED this week for a patient with 2 day history of severe headaches associated with nausea and photophobia, who also happens to be a happy hunter (which classically points toward a viral meningitis picture, especially when the patient had similar symptoms and the stated diagnosis 20 years ago, but the ED physicians somehow failed to get a lumbar puncture and consider it in the differential diagnosis BEFORE calling neurology…) Anyway, I was obtaining his history and asked him to point to the location of his headache. Normally, patients would localize with their hands, on themselves. Well now, this gentleman reached over the banister and up, busted into my Connie bubble, and palmed my head. That’s right, he essentially gave me a big pat on the head as he was describing his headache. We all found it pretty comedic moments later, when he realized he was supposed to point to his own head. When I performed the routine finger-to-nose test to assess coordination, he, like the Italian guy, touched my nose and found it humorous. This time, I was less caught off-guard and did not nearly fall back onto my rear end. Man, do these patients enjoy ruffling my feathers for kicks and giggles. Oyyyy… The embarrassing moments for me did not end there…
Same meningitis guy who palmed my head… during the mini-mental status exam, I asked him to follow some basic commands. I said to him, “Okay sir, take your right finger and touch your left nose.” Awkward silence, a confused expression on the patient’s face, finger immobilized in mid-air …. then a burst of laughter as my partner next to me cracked and nearly died. I shook my head as I wanted to face palm myself right there. What I meant to say was, “Take your right finger and touch your left ear” to gauge cross command comprehension and execution. Instead, I made an idiotic blunder when I looked at the guy’s face, in particular his nose, the one nose, as I was anticipating and saying aloud the next step.