13.9 Neurology Rounds

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9. Starting
First day of hospital training, 1 July, is Sunday. Despite the Sunday, the patients are waiting in the beds to see the doctors on rounds.
   At 8 AM, Dr Stanley Pelc, who likes to be called "Dr Stan", in white shirt with shiny blue tie under the white coat that marks him as senior physician sits at the nurses station on the Neurology ward. Though a research fellow, he is acting chief on Neurology this first month. His new intern is Irving Goldberg, a curly black-haired guy, medium weight and height, in white intern jacket & pants. They sit and Dr Stan gives the intern's duties - the morning rounds at 8, the doing of history & physical examination on new patient and the scut work by which is meant drawing blood samples and IV treatment, inserting catheter in penis in incontinent patient, doing various tests, and other menial intern duties.
   Dr Stan calls his intern, Irving, without first asking if he may, but Goldberg addresses Stan as Sir.
   Stan starts his teaching: "Irving, in getting a history from a patient, keep in mind you are no longer in medical school. If you spend time asking every question from your intern manual, you will never get your scut done. You got to zero in on the chief complaint, make a list of possible diagnoses and figure what signs and symptoms and what physical findings you want to check for. Watch me with this new patient."
   They get up and walk to where an age mid-30's, healthy-looking dark-hair, sallow complexion man is sitting up in bed, looking toward their approach.
   "Hello, Mr DeCico, I am Dr Pelc the resident and this is Dr Goldberg the intern. We'll need your medical history."
   "Sure, guys! I'm willin'."
   "What is your chief complaint that caused you to see your doctor and got you in the hospital?
   "I got da twitches."
   "Twitches?"
   "Yeah, looky here?" He holds out his right hand, palm up and it is obvious - small twitches are going on under the skin at the base of his thumb - about 1 or 2 a minute, causing jerky movements in the skin.
   "How long has it been going on?"
   "Oh, I always get a twitch now an' den but dey weren't so much until a mont' ago.  Now dair all over me."
   "Anything else?"
   "Yeah, No strengt'. Can't even finish a round on da golf course.
   Dr Stan quickly gets a review of the history. Then he thanks the patient, telling him the intern will be back later, and he and Goldberg go and sit down to discuss the case.

   "Now, Irving, I was very brief in my history to show you the importance of zero-ing in immediately on the chief complaint. Everything comes from it. And note how I made sure to explain chief complaint. You got to be sure the patient understands your question the same as you do. Many patients might answer your What is your chief complaint? with I don't got no complaints, Doc, I like it here."
   Goldberg laughs at Dr Stan's mimicking the patient's accent.
   "A patient's words and his meaning are very important. For example, he used Twitches for his chief complaint. In my usual speech Twitches means some kind of involuntary flick of a finger or blink of an eyelid. But this patient was trying to describe in his limited vocabulary what we medically call fasciculations - brief, sudden involuntary contractions of small muscle units under the skin."
   Goldberg suddenly exclaims "ALS! Lou Gehrig's disease!"
   "Good, Irving!" Dr Stan knew from having reviewed Goldberg's application for the internship that Goldberg had been near top in his medical school grades. He thinks, I got a sharp one. Must direct this fellow into Neurology as a next year resident here.
   He continues. "We hit it lucky with this patient. In a word or two, he gave us the diagnosis in his chief complaint. Most of the time you've got to dig for it. Most of the patients will start off with non sequitur - you know, something like Yesterday I had a fight with my wife and she threw me out and I went to a bar and got drunk and that's why I felt bad and saw my doc and ended up a guinea pig for you guys."
   Goldberg laughs out loud. But he realizes he just got a useful tip and is thinking: Boy, this Dr Pelc is sure a gem of a teacher. I think I'm going to like it here.
   So it goes. Quite a first day of internship for Dr Irving Goldberg.  For next, click 13.10 Neurosurgery