Neurology complete!

And just like that, it's a wrap on my Neurology rotation. 

The day started with me running around trying to get my Certificate of Completion signed and stamped. I spent the morning going through my Clinical Skills booklet with my doctors. We looked to see what I had done so far and if there was anything additional we could do today for them to sign off on. The skills listed for Neurology included performing a neurological history taking and physical examination, preparing a diagnostic and therapeutic plan, evaluating test results, compiling patient documentation, EMG, EEG etc. 

Once we finished my doctor and I went to take bloods. While eating lunch I attended an online lecture about plasma exchange. Then in the afternoon, I had another bedside teaching lesson. Since it is my last week and during Wednesday's bedside teaching we didn't get to practice performing a physical examination, the doctor that leads the session offered to give us this additional teaching. We meet at the Maida Vale Ward and there were three students, but it wasn't a problem. The doctor knew of a patient on the ward and left us to gain the consent of the patient. Once the patient agreed, the doctor returned to inform us it was okay and we put on aprons and gloves. 

As we were standing outside the patient room preparing, the other two students saw the patient and mentioned that they were familiar with the case. The doctor asked if it was okay we re-examine them, we all thought it was fine. The other students had an advantage over me because they already knew the patient history and diagnosis, but I didn't think this was a big deal. We entered the room and I began with the cranial nerve examination. When I got halfway through the cranial nerves, the doctor stopped me and performed a test. The doctor asked the patient to look up at his finger for a minute or two, then the doctor asked the patient to look straight ahead. The patient's eyelids began to droop a bit. 

Doctor: (looking at me) Do you know what I am testing?

Me: No.

Another student: Fatigability. 

Doctor: (looking at me) Knowing this, do you have any idea what the diagnosis could be?

Me: I don't think so.

Doctor: This patient has Myasthenia Gravis.

The other student continued by examining the upper limbs, and finally, the third student performed the lower limb examination. We thanked the patient, removed our aprons and gloves, and exited the room. Outside the room, we discussed Myasthenia Gravis. It is an autoimmune disease, now my knowledge was coming back to me. We talked about which antibodies cause it, the signs and symptoms, how to diagnose a patient and possible treatment methods.

Before we could finish the consultation, I had to leave. I noticed it was 2:45 pm and I had agreed with my ward doctors to be back at 2:30 pm for a lumbar puncture. I arrived just as they were inserting the needle, phew, I didn't miss it.

After the doctor finished cleaning up and discarding the sharps, we discussed capacity assessments and walked back to the doctor's office together. First of all, having the capacity to make a decision is not the same as giving consent to medical treatment or procedure. A patient may have the capacity to say they would like to go to the bathroom but lack the capacity to make complex decisions regarding their finances or surgery. Capacity can fluctuate with time - someone may lack capacity at admission but may be able to decide at a later point during their admission. At different stages of care, it is necessary to assess a patient's capacity, especially in patients with dementia, brain injuries, stroke etc. There can be good days and bad days for patients. Remember to think about this when assessing. What will make this easier for the patient?

Unfortunately, there is no standardised questionnaire for a capacity assessment. As a doctor, you have to come up with the questions to ask your patience and ultimately, make a decision. My doctor explained four main points. The simplest breakdown of which could look something like this:

1. Understanding - Does the patient know where they are? Does the patient know why they are in hospital? Does the patient understand what is wrong with them? Be sure to explain the patient's condition to them in as simple terms as possible. Give them some time to process. Provide the patient with the next steps. Discuss the pros/cons, advantages/disadvantages, benefits/drawbacks etc.

2. Retaining - Does the patient retain the previous information they have been given about their condition? Do you remember what we talked about before? 

3. Weighing - Can the patient weigh the pros/cons of the procedure, treatment, or care you are recommending to them?

4. Verbalising - Can the patient verbalise the decision which they think is best for them?

If any one of these cannot be done, then the patient is considered as lacking capacity. A best interest meeting should be held with the patient, their family, and the rest of the treatment team to decide on how to proceed with the patient's care. Capacity is needed to make decisions about admission, procedures such as surgery or lumbar punctures, and even, discharge. Can the patient make a serious life-changing decision like whether or not to move into a care home? The help of speech and language therapists as well as social workers is very important in this kind of assessment. 

This was the moment when my day concluded and I had to say goodbye. Sadly, my time at UCL Queen Square Institute of Neurology has ended, but I am happy to have another rotation completed.

The past four weeks have been incredible. I am extremely grateful to all the doctors that have taken the time to teach me during my time here. I have learnt so much. I have attended Neurophysiology seminars, Epilepsy and Neuro-ophthalmology outpatient clinics, Neurosurgery case-based tutorials, bedside teaching and ward rounds. I have seen both common and uncommon neurological conditions and diseases. I have seen patients with Cranial nerve palsies, Traumatic Brain Injuries (TBI), Stroke, Tuberculous meningitis, Neuromyelitis Optica, Guillain-Barré syndrome (GBS), Neurosarcoidosis, Amyotrophic Lateral Sclerosis (ALS),  Juvenile Myoclonic Epilepsy, Temporal Lobe Epilepsy, Myasthenia Gravis...and those are just the ones I remember. 

Tonight, I'll be enjoying my last night out for dinner with my brother and tomorrow I'll catch my flight back to Hungary.

I have one more rotation left, but that's not for another few weeks. In the meantime, I'll be studying and taking some of my exams. During these weeks, you'll be seeing and hearing less from me. I'm going to cut back my blog posts from every weekday to once a week. 

I hope you all will continue to follow my journey even though my posts will be less frequent. See you all soon!