Halves

Hi,

A very busy week, leading to me not actually having time to write up this blog properly this Sunday, so very sorry for that. I hope this will do, I had a very busy weekend! I saw some very interesting neurological medical cases this week, which I want to mainly concentrate on, and went on a very polarised ward round around a cardiac unit, where half of the patients seemed to be chatty and fine, and the other half slipping down towards death... Odd having them all right next to one another.

This week seemed to be a week of neurological halves. As I am sure I have said before, neurology is a very interesting speciality, and can have some very unusual clinical presentations. I think I mentioned "The Man Who Mistook His Wife for a Hat" by Sacks before as a good example of some unusual clinical presentations. This week I met two patients who had 'split' neurological signs cutting the presentations in halves across the body because of the neurological pathology.


The first patient I saw was a woman who had suffered a stroke in her past, which had affected part of the thalamus. Most strokes lead to numbness, weakness or odd tingling sensations (paraesthesia) in the affected areas of the body. This stroke, due to its thalamic involvement, had instead lead to sensations of pain in one of the patient's arms and a burning sensation across one side of her back all of the time. This pain made the use of this one hand and arm almost impossible, because on contact with objects, the pain would make her draw her hand away sharply because it felt as though her fingers were being stabbed or burnt. She gave examples of being unable to open a can, or peel a banana because the pain made such operations impossible. The other hand was fine, but many tasks require two hands to carry out. On this background diagnosis of central post stroke pain, the patient had developed trigeminal neuralgia. This disease causes notoriously painful symptoms, and has been classed as among the more painful medical conditions. It involves the trigeminal nerve, one of the cranial nerves which supplies sensory nerve endings to the face. The disorder causes the face to become hyper-sensitised, with the slightest touch on the affected side causing excruciating pain. This can be as little as hair brushing against the face, and obviously has major impacts on the patients life and nutrition. The poor patient described curling up on the floor because of the pain she was in and crying whenever the face was touched, but the tears tracking down the side of her face made the pain worse. Fortunately, this had just been treated when we saw her, and it was no longer causing this pain. The diagnosis had taken some time, because the dentist had been telling her that she needed root canals, because of this pain, and she had been making repeated trips to the dentist to have a succession of teeth ''sorted out''. If anyone is interested, how to recognise trigeminal neuralgia over a dental problem is that the trigeminal neuralgia will cause the pain when the skin of the face is touched, whereas dental problems will be much less exacerbated by skin contact. This patient seemed to have been split in half by her symptoms, one side of her functioning normally and the other a well of pain.


The second patient I saw was 'split' horizontally rather than vertically. It was just one pathology which had caused this second patients split, he had a benign tumour growing around his cervical spine roots. This tumour had affected the nerve roots C4, C5. C6 leaving the spine to supply the arms, and the compression it caused had affected the movement and sensation in the legs. The interesting thing about this patient was that 'upper' motor signs are very different from 'lower' motor signs, and this patient displayed both at once. Upper motor neurone signs are usually seen in limbs where there is a problem with the central nervous system, whereas lower motor neuron signs are usually seen where there is a problem between the central nervous system and the affecting muscle / sensory nerves. Both have different clinical signs. Upper motor neurone problems cause 'brisk' (very responsive) reflexes and increased muscle tone due to the fact that they have damaged the signals from the brain which calm the muscle response. This means that the muscle is always a little contracted (hence the increased tone) and when a reflex is tested (for instance the knee jerk reflex) it is much more responsive than normal because the brain and spine are not damping it down as they normally would. This does make it very easy to find the sites to hit with the tendon hammer, however, as instead of the normal twitch of the muscle they give a good kick out. Lower motor signs give opposite signs, with decreased reflexes, tone and strength, because they muscles are getting less innervation from the supplying nerves. It is hard to explain so you will have to take my word for it!

Either way, he was a very interesting patient to examine because of all of these signs, and because of the complexity of a full neurological examination I took well over an hour with the procedure. He seemed to appreciate having someone to talk to and explain things to, so I didn't exactly rush things, but all of the effort that went into plotting the affected dermatomes by working out the affected muscle groups and sensory areas (see picture below) was unfortunately wasted in the presentation to the registrar. Normally pretty simple, just regurgitating facts and findings, I managed to get myself in a right tangle involving all of these 'Upper motor signs in the lower limbs' and 'Lower motor signs in the upper limbs' and the corresponding levels of increased and decreased tone/strength/reflexes/sensation. pretty embarrassing as it made it look as though I had no idea what I was talking about. While I rarely fully understand a neurological picture (I think it is one of the hardest specialities, but that's a personal opinion) I at least understood the simple basis which I have (poorly) tried explaining here. Oh well, I suppose I will be off of this rotation in a few weeks, and off to surgery, so I will not be around the reg who seems to think I am easily confused. I am obviously digressing, its not just medicine I find hard, just simple conversation now! I would love to blame being on call for hours, or dehydration, or any other external factors but I think I was just having 'one of those' moments.

The ward round I found myself on was, as I said before, very polarized. While only a small ward, there seemed to be either very well patients there, who were waiting for discharge or being observed, of very ill patients who were deteriorating daily and had DNR forms filled out beside their beds. One of the most interesting cases on this ward round was one of the seemingly well patients, who was chatty, lively and much younger than the others on the ward. Aged in her early 30s or late 20s this patient had been admitted by ambulance after her heart stopped in the community. She had had a 'down time' of around 50 minutes, meaning that it was about 50 minutes before they could restart her heart, which involved her receiving about 5 shocks and almost constant CPR. At least she was with people who knew how to perform CPR when she first arrested. The mystery with this patient was why her heart had stopped in the first place. She was fine now, and all of the tests at the time (such as toxicology screens and the like) had come back negative. Her heart appeared normal under all of the investigations that have been carried out, so what made it stop? Is it going to stop again? What if she is asleep when it stops, so no-one realises until she is hours dead? Nothing in the history gave any suggestion as to why her heart had stopped, so she was being kept at the hospital in the hope that something 'odd' would happen to her while she was being monitored. Stressing the heart with chemicals and exercise didn't help. It is these sort of mysteries which make medicine interesting, like detective work. The consultant said that the odds are that the patient may be fitted with a pacemaker to shock the heart back into rhythm should it stop again. I hope they get a diagnosis for the reason though, I am a curious person, and I don't believe that things happen for no reason!

This will have to do as an updated blog, and thanks for bearing with me. I would promise something better next week, but I always seem to be busy with something.