After getting my ID card and pager (having never been in this hospital before), I paged the attending, Dr. Isakson. He answered and said, “Go print off the neurology patient list. There are two new patients. Mrs. X came in in status epilepticus last night. No previous seizures. Mrs. Y had a stroke yesterday. Go see them, write the H&Ps, and call me when you’re done. They’re your patients. Just call me if you think Mrs. X is still seizing. . . You would recognize that, right?”

Ooh. Only a slight twinge of regret for vacation at the VA being over (along with continuous internet access). I have some patients. I’m supposed to figure out what to do with them.

Actually I’ve seen more pseudoseizures than real seizures. Mrs. X’s case was complicated by the fact that she has no legs left. I couldn’t tell whether her clenched hands and rigid arms indicated really bad seizures, or just chronic contractures. The fact that the nurses seemed totally unconcerned inclined me to believe it was nothing serious. She was also minimally responsive, completely nonverbal, and unable to cooperate with a neurological examination. (Do you realize how many parts of the neuro exam depend on the legs? Reflexes, strength, sensation, primitive reflexes, cerebellar coordination, gait. . . )

The main thing I figured out was that since she had a temperature of 102, we needed to rule out meningitis. Dr. Isakson’s mood on rounds took a definite turn for the worse when he discovered this. He’s a funny guy: tall, middle-aged, going bald, an experienced neurologist with lots of patients and consults and referrals; but he seems almost shy, as socially awkward as I am (which makes for some very stumbling conversations), with his feelings written on his face. He let me try to start the LP; which on an unconscious bilateral amputee lying on her side was obviously not very simple. After a couple of unsuccessful tries, he took over. After another half an hour, we gave up and sent the patient down to radiology for them to try; they didn’t get any farther. But this morning her fever and white count are gone, and she’s alert, semi-oriented (if thinking this is February, and she’s still at home counts as oriented), and chattering away, full of perseveration and incoherency. We are hopefully assuming this is baseline (no family anywhere in sight, sadly), and preparing to send her back to the nursing home on some antiepileptic drugs. Idiopathic adult onset of seizures. No one’s happy with that diagnosis.

Mrs. Y was a dignified elderly lady. I get the sinking feeling that she really doesn’t like me that much, for intruding on her, and putting her through all of these undignified tests, and being a student. She looks so self-possessed, even in a hospital gown and uncomfortable bed, that I feel rude for asking about her symptoms. Tsk. She’s been healthy, but now had a small stroke, whose symptoms are mostly gone by this morning. Unfortunately, now that she’s let doctors look at her, we discover that she has diabetes, hypertension, and hyperlipidemia. [persons over 60 are not allowed to wander around the US without taking at least five pills a day; doctors are very good at tracking down all fugitives and rectifying omissions]

This morning, another new patient: a man in his 40s, crack user, alcoholic, third stroke in the last few months. He undoubtedly has some new deficits, but I can’t help feeling that he’s exaggerating them. Shouldn’t be so cynical, Alice.