Trying Tuesday or Teaching Tuesday

From the beginning, this Tuesday has been trying. It started when I walked to the tube station, in the rain, for what turned out to be no reason. When I got there I thought it looked pretty empty, but I didn't think too much of it. I was excited that it wouldn't be crowded with a zillion people when I got on. My excitement was short-lived. I quickly came to find out that there was a legitimate reason why it was so quiet. The majority of the services were suspended. 

I checked my phone, which I now realise I should have done before leaving home and found out that the entire London Underground had been shut down today as staff staged the first of two 24-hour strikes planned for this week. I slowly settled with the fact that I wasn't going to make it to the hospital. 

As I made my way back home, also in the rain, I thought what can I do? I looked at Uber, but the prices were outrageous. The cost was triple the usual because of "increased demand" the app said. I checked the teaching schedule. Luckily, there was my usual Tuesday morning teaching and three more in the afternoon. All of these could be attended online and I decided that it would just be a Teaching Tuesday. I emailed my administrator and explained everything. Thank goodness they were very understanding and it made me feel less anxious about missing today.

At 10 am, I had the final session of my Neurosurgery case-based tutorial. The Neurosurgical Fellow wrapped up the fifth case from last week. It turns out the patient who presented with a tonic-clonic seizure ended up having a high-grade glioblastoma. 

There was one more case to end this 4-week teaching series. We ended with a sixth case and were given the following information,

A 75-year-old male presents with a 1-month history of progressive confusion (not oriented to time, place or person) associated with memory impairment. The patient has had three falls within this period. No preceding symptoms. No loss of consciousness (LOC). No fractures. The patient also had one episode of urinary incontinence. Past medical history of atrial fibrillation (AF), hypertension (HTN), and type 2 diabetes mellitus (T2DM). The patient has a drug history of apixaban, metformin, and amlodipine.

Vitals: HR 78 bpm, BP 145/80 mmHg, RR 19 bpm, T 37.1 degrees C, O2 Sat 97%

Physical examination: Heart sounds - I + II + O, Chest - clear, Abdomen and calves - soft, non-tender, no neurological deficits, mildly agitated, AMTS 6/10

Similar to the last time, we analysed the patient history as a group. Taking it a sentence at a time, I'll share a breakdown of how we did this.

A 75-year-old male presents with a 1-month history of progressive confusion (not oriented to time, place or person) associated with memory impairment. 

Another student and I both said at the same, that this made us think of Alzheimer's disease. 

The patient has had three falls within this period. No preceding symptoms. No loss of consciousness (LOC). No fractures. 

These symptoms added Parkinson/Parkinson-plus syndromes as differential diagnoses.

The patient also had one episode of urinary incontinence. 

The three sentences together strongly suggest Normal Pressure Hydrocephalus (NPH) and this should now be at the top of your list of diagnoses. Why? Patients suffering from NPH usually present with three symptoms known as Hakim's triad. The symptoms are gait disturbance, urinary incontinence, and dementia. This patient has all three so we should think of NPH as his diagnosis. 

HR 78 bpm, BP 145/80 mmHg

All the vitals were normal, besides the heart rate and blood pressure.

Mildly agitated, AMTS 6/10

From the physical examination, the only abnormality was the agitation and Abbreviated Mental Test Score (AMTS). AMTS of 6 or less suggests delirium or dementia, although further tests are necessary to confirm the diagnosis.

The next steps included a urine dipstick, bedside glucose and ECG, bloods, and imaging. A native head CT showed ventriculomegaly (enlarged ventricles), transependymal oedema, a narrow callosal angle, and Evan's index > 0.3. All signs of normal pressure hydrocephalus so we had a confirmed diagnosis. 

The Neurosurgical Fellow let us ask any questions we had and concluded the session.

In the afternoon, there were three teachings Neurosurgery Masterclass, Neuro-ophthalmology teaching, and Journal Club. 

Also, I attended an online meeting for the English Program Committee at my University. The task of the English Program Committee is to follow and monitor the whole admission process of international students to the General Medicine, Dentistry, and Pharmacy programs at the University of Pécs Medical School. The Committee is made up of professors and lecturers of the General Medicine, Dentistry, and Pharmacy programs at the University of Pécs Medical School as well as two students. One of the representatives is the English President of the English-German Student Council and the other... Well, a few weeks ago I was asked if I would be the other student representative for this semester and I accepted. I am honoured to have been asked to represent students in such a capacity. As a committee member, I am officially invited to take part at the meetings and can give my opinion regarding the raised topics, initiate a new topic, and vote if there is a voting. 

A list of all the committee members can be found here. 

At today's meeting, we discussed some of the current issues like the upcoming entrance exams, the current war in Ukraine and what it means for the University, and a new Biotechnology Bachelors program. No voting took place, but based on our conversations recommendations would be made to the University leadership. 

My day ended up being quite busy despite the chaos in the morning. 

I am hopeful I will make it to the hospital tomorrow. Articles advised that travellers allow extra time for travel on the days following the strike so I am planning to leave home extra early to make sure I make it on time.

The second 24-hour strike is scheduled for Thursday. I am already making arrangements on how I will get to the hospital on Thursday since I am now aware that there will be no London Underground services. I'll be sure to share my experiences on that in Thursday's post. 

Now, I am going to study. From London, Happy Pancake Day!