Life of a doctor | Neurology Rotation

[Music] hi everyone this is dr yoki i'm really excited about today because i'm currently on my neurology consult service rotation and i'm really excited to be bringing you all along with me to show you what it's like to be on the neurology consult service so first and foremost neurology consult is very different than in patient neurology for many reasons one of the main reasons is that there is a primary team responsible for the patient and it's not the consul service it's just whatever primary team is requesting the consult and on the console service you give your recommendations you evaluate the patient you answer a specific question that the primary team has for the consulting provider and then the primary team decides whether or not they want to accept those recommendations and follow those recommendations so the good part about being on the consul service is that you don't have to see the patient every single day unless they're very very sick you usually just have to see them a few times if that provided recommendations answer the question at hand and that's it so my day usually starts at around 10 a.m and it ends at around 6 p.m unless i get a late console in which case it will end at around 7 30 p.m the latest i usually don't see any more than three new consults a day usually it's around two on a really busy day i might have to see three but that's usually what the day looks like for me um and i'll show you guys in a second the first thing i do when i go in on my neurology console rotation so the first thing i do when i come in the morning is i log into the emr so any patient that's already been staffed on the neurology console service don't necessarily need to be seen again in person but they do need follow-up of course so what we do is we look at the chart we look at the progress notes from the primary team we look at the vital signs and the lab results just to make sure that the patient is improving and that our recommendations are helping the patient important things to follow up on of course are things like eeg is the patient having any epileptiform discharges or in other words seizures other things that we look at is any brain imaging any lumbar puncture csf findings all of that i need to make sure that i follow up with on a timely manner so that nothing gets missed yeah that's pretty much what my mornings look like on neurology consults it's all on the computer but it's not necessarily a terrible way to start the morning if you ask me my first console usually comes at around 12 or 1 o'clock all right so we're gonna go see this patient in the emergency department um this older patient came in with vision loss in one eye um not complete vision loss but um her visual cutie which means that her ability to see things is less she was referred from an ophthalmology clinic an eye specialist because her vision really got a lot worse over the past few weeks so patients being referred now to the emergency department's own neurology workup and you'll find out what's going on so i just finished seeing the first console of the afternoon let me actually just take this off and get settled in so the first console question was for a patient who i already kind of described you guys well i was on my way to the emergency department this patient had progressive vision loss in one eye so i obviously can't reveal the details of the case just to protect patient privacy but what i can say is my thought process for how i'm going to go about this case the most scary things you want to roll out in a patient who has vision loss in one eye and also who's older is giant cell arteritis which is an inflammation of the temporal artery and this can lead to permanent vision loss so you definitely want to rule that out one of the ways in which you can roll it out is get an esr and a temporal artery biopsy now for this particular case um i have a low suspicion for that because the patient didn't have other signs or symptoms for that including like tenderness over the temporal artery they also didn't have any jaw claudication which just means that their jaw after chewing for a certain period of time either hurts or kind of gets very tired so they didn't have any of those symptoms and also the person already had an optimal an ophthalmology exam which ruled out any kind of signs of ischemia so lower threshold or lower on the differential another potential cause for this patient's vision loss could potentially be optic neuritis which is just inflammation of the optic nerve and usually the only way to really see if they're having that is to get an mri of the brain so i'm certainly going to recommend that for this patient a lot of things can cause optic neuritis for example multiple sclerosis nmo and a number of other autoimmune diseases can cause that another finding on exam that could lead you to this diagnosis is having a fair pupillary defect which just means that when you shine a light in the opposite eye the other eye does not constrict so normally if you shine a light in the pupil the opposite one will constrict but the patient in this case didn't have that so that is concerning for the inflammation of the optic nerve so we'll see what the mri shows another thing that you want to rule out and someone who has progressive vision loss in one eye is central retinal artery occlusion which is when someone gets either an emboli that travels through the internal carotid artery and then that leads to the artery that supplies the eye or they have carotid internal carotid artery stenosis which can cause that as well which reduces the blood flow to that area that is less likely in this case because the patient's vision loss is more progressive it wasn't all of a sudden which is what you would expect in um central retinal artery collusion it's more all of a sudden painless and you would have severe vision loss not progressive over time so that's really my thought process for this particular case we'll see what those images show and then we'll provide more recommendations based on that but that was the first case very interesting um really interested to see what this patient actually has and how we're going to manage it so i actually forgot to mention that neurology consults is an entire team of residents it's not just me usually there is a psych intern and i'm obviously the psych intern on service for this the next two weeks but there's also either two or three other neurology residents and they range from either first year residents second year residents or third year residents and then there's a senior who is essentially in their fourth year in their last year residency and they pretty much run the whole service they assign cases to the other residents they supervise our work they let us know what other recommendations and things that we can do for these patients that we're getting consulted for yeah so it's not just me just wanted to put that out there so i've already seen one console and any consults that come throughout the day we have to staff them by the with the attending by around 2 30 p.m i've already rounded with the attending we've seen all the new cases and any follow-ups that you needed to be talked about so any consoles that we get after we round which we finish at around 3 30 from rounding or four o'clock depending on how many patients we see any consoles that come after that get stopped in the morning with the new attending in the morning so i've already gotten the second console of the afternoon after rounds and the console question was for tournamental status alternate mental status is a very common console question in the inpatient service and it's very broad it could be a lot of different causes for alternate mental status it could be toxic metabolic because of course your brain in order to function correctly needs like the appropriate balance of electrolytes it needs you know oxygen it needs blood flow so patients that are in the hospital sometimes they're here for an infection their blood pressure could drop there they could have really severe elevated temperatures which can certainly cause alternate mental status or they can even have delirium which in that case there might not be any metabolic or electrolyte abnormalities and just being in the hospital can have really negative consequences on someone's attention and mental status as a neurology council service we want to rule out anything that's really scary so major stroke that can be really devastating reason why someone's having confusion and not acting like themselves so we definitely run a robot stroke um and you don't necessarily always need imaging for that you can just examine the patient is there any other evidence that they might have had a stroke do they have weakness on one's eye are there any cranial nerve deficits so all of these things pretty much will give you information on whether this person is having a devastating stroke or maybe some other cause another common neurologic reason why someone could be altered not acting like themselves in the hospital is of course seizures this is another really big reason again all the things that i mentioned before could contribute to lowering the seizure threshold which just means makes it easier for someone to have a seizure in the hospital so we if there is a clinical concern for seizures we recommend the patient is placed on eeg which measures the brain waves and gives us an idea of if they're having any epileptiform discharges that we can see on eeg and then diagnose that as a reason for why they're having altered mental status and lastly one of the scariest things that we want to rule out in addition to just a stroke seizures oh i forgot to mention is not only schema stroke hemorrhagic stroke so not just stroke seizures but also any infections in the brain so encephalitis meningitis very scary very deadly we want to roll that out as well again you don't have to do a lumbar puncture which is what is usually used to diagnose that in order to rule out any infection in the brain again you rely a lot on your exam i think that's one of the things that i really like about neurology is you rely really heavily on your exam to guide you [Music] to one direction or another whether you need a certain test whether you don't need a certain test based on what you find on an exam that's one of the things that's really interesting about neurology is you can tell a lot about a patient's neurologic exam and then let's see if there's anything else i can think of about medications medications are another big reason why someone could be altered in the hospital so it's a very broad differential diagnosis so once i go see this patient you know i'm gonna obviously do my neurologic exam and rule out any of those major causes for alternate mental status so i'm almost done for the days almost six o'clock but i wanted to show you guys this beautiful view from this window look at that bridge and the sunset of course very nice view so that's it for me i'm done for the day i hope that gives you guys an idea what it's like to be on neurology consults the workload is a lot less than you would be doing on the inpatient neurology awards which is why i like neural consults the work is also the work day is also a lot shorter i usually only work you know like i mentioned ten to seven or ten to six at most um in patient wards you can work anywhere from 12 hours to 16 hour days so it's a lot less work on your consults and you get to see a lot of really interesting cases on neural consults for example um i've previously seen a case of a patient who was psychiatrically hospitalized and we were consulted on because the patient was having myoclonic jerks it turned out this patient's psychiatric presentation and her myoclonic jerks were consistent with autoimmune encephalitis after she was on eeg discovered as she was having seizures she got an lp turned out to be autoimmune encephalitis which is kind of scary to think about that the patient was in the psychiatric award as opposed to the neural ward but thankfully in the end they got the diagnosis right um it's kind of like that case on brain on fire the movie i don't know if you guys ever seen that i absolutely love that movie it's one of my favorite movies if you haven't seen it i recommend it but yeah a lot of really interesting cases so thank you for joining and see you next time [Music] bye

Channel: Dr. Yoki and Dr. Lu

Views: 22,220

Keywords: Dr. Yoki and Dr. Lu, Residency, Psychiatry, neurology, neurology rotation, neurology day in the life, neurology consult rotation, life of a doctor, what its like to be a neurologist, what its like to be on neurology, neurologists, day in the life of a neurologist

Id: lKxDgLUDoIQ

Length: 14min 44sec (884 seconds)

Published: Sun Jan 31 2021