Its funny to know who read this blog. I guess this has always been my secret passion – writing. While I love that YOU are reading this, I find this blog is more for me. Really, just a log of all the crazy experiences that I hope to remember when I am old and gray and still some sort of doctor. But still, you secret reader you, I appreciate it.
The last few months have been so busy that I have a backlog of all these patients that I need to write about. Bear with me – I’m on surgery now and sadly have little free time. When I am on Vacation Rotation aka Radiology, I’ll have time to catch up.
One of the best things that happened during my medicine block was the new team that I got at the end of my month at the VA. The team I started with was amazing and my resident at the time is still the best resident I have had thus far, but as a team, my last one at the VA was the best. We picked up one new resident (K), one Brigham intern (S) and one BU intern (W). We also picked up another medical student from Harvard (D). I’ll leave D out of my stories since we seemed to work independently of each other. It was during this part of the rotation that I was really challenged to be a better student and more importantly a better future doctor. After I was done with my short time with them, I was ready to treat patients on my own.
One of my triumphs of my medicine block was a result of all the time the team had invested in me. Mr. R walked in the ED with complaints of back pain. On a whim, a chest xray was ordered which showed multiple pulmonary nodules. Since very few things present at multiple pulmonary nodules, it was known to all – Mr. R had lung cancer. As he made his way to our team, he came with a battery of tests. He had a CT scan that confirmed that the nodules were well-circumscribed. It also showed that he had 1 metastasis to the bone – the likely cause of this back pain.
It was my last day on the service and I had one appointment: to pick up Ronak at the airport by 11 PM. At 8 PM, I started talking to Mr. R. The first thing that struck me was how incredibly nice Mr. R was. He was the ideal med student patient. He answered all my questions in full the first time around. Within 10 minutes I had his full story – the back pain had started after lifting a heavy machinery into the back of his truck. After talking to Mr. R for a half hour to iron out his story, past medical history, ect., I started the physical exam. He was grossly normal until I hit the neurologic exam. I started with the head which was normal. Then, the arms and trunk which were also normal. I moved onto the legs. Everything was normal once again. Remembering that I should be thorough when there is question of nervous system involvement, I started on a better neuro exam (including those things that we normally skip).
I had gotten through most of the exam when it was time to test Mr. R’s response to sharp and dull. Mr. R did well – he did better than well, he was great. Well great, except for the defecits on the later part of both his legs. To me, there was something wrong – he answered correctly maybe 60% of the time. While that can be normal in some patients – what whas thowing me off was how quick he was to answer normally, but in this particular region of the body, he deliberated for several seconds. I finished the exam and went to report the results to the intern.
As I walked away, I thought that maybe I was mistaken…I should probably repeat that portion of the exam. I went back in the room 2 more times with various tool. Each time, Mr. R was trying so hard to give me the right answers. I couldn’t tell if it was because he wanted to be as helpful as possible or if it was because he knew that his problem might be bigger than just lung cancer. After another half hour – I called the intern. I was instructed to but in a STAT MRI and to call neurology to repeat the exam. The neurologist came back to us to report that the exam was normal.
There was a predicament – was I right or was the neurologist…did we need to make a move on what might be acute cord compression? I went back in with S. He noticed what I noticed – Mr. R was trying really hard to give us the right answers when it came to that one region of the body.
We went for it – Mr. R was in MRI when I called the BU radiologists to give them the story. At 1 AM, I got my read – there were multiple spinal cord lesions but there was one specifically in the part of the spinal cord that distributed to the lateral legs. Mr. R was started on steroids that night.
From what I heard after I left, Mr. R was doing well and was discharged from the hospital. His legs “felt more alive” when he started the steroids.
I think that is another point for me.