My Neurology Station

Station 3: Neurology

We had 5 minutes of "relaxation moments" before we went on with the exams. I started of with Station 3. Not my biggest strength. Then again it was too late to turn back. I was worried as few friends told me that alcohol rub not easily available in UM and the external examiners are usually very concerned about this. Waiting for the staff to get the rub would definitely be a waste of time! I guess UM had a feedback on this from previous sessions. Alcohol rubs are at every corner of the examination place.. "relaxation" area, each patient's table, you name it. And the examiners would remind you to do so while you are reading the instruction for the next case. So, when the examiners introduced me to the first patient, the instruction was something like this:

"Ms X, has ocular problem. Please examine her"

I didn't know whether I should be happy or not. No fool can miss the diagnosis when one look at her.. Definitely a myasthenic patient who is currently in exacerbation and has had thymectomy in view of nicely healed sternotomy scar. But what lingered in my head was how to proceed further and to give extra ummpphh. I tried to remember back in my head the "myasthenia protocol" and completed it earlier than the time given.. I was not sure if I have missed anything until I did something extra.. which I think now, looking back, may not be wrong but may not be necessary.

The Q & A session.. The examiner asked what my findings were and my conclusion <- this works for all the stations. Next questions were about:

• investigations and guess what, I'd forgotten to mention "Tensilon test" and that answer need to be prompted by the examiner.
• Subsequently it was about the treatment. I had few moments of "delusion" like saying edrophonium as treatment of MG. Maybe it was obvious that it was an accident so they didn't pin-point on that so much.
• Regarding what would be the causes of difficulty in breathing in such patient - other than myasthenic crisis and infection, think about cholinergic crisis too!
• They emphasize on patient education - asked how would we advise the patient and family when we see them in the clinic.. practical questions.

Time's up! Time to move on to the next station!

Example of MG protocol.. I compiled from several books I mentioned in the "Getting started" post.

1. ptosis protocol – check pupil, if normal, check extraocular muscle movement to look for variable strabismus and diplopia
2. eye fatigability (look up for 2 minutes)
3. incomplete eye closure
4. facial diplegia – wrinkle forehead, ask to smile, show teeth
5. weak voice and nasal – bulbar palsy (ask to count)
6. weaker neck flexion than extension
7. proximal muscle weakness + fatiguability (normal reflexes)