clinical confidence

today, a nice intern told us to have a look at a patient, and perform a neuro exam of her lower limbs.

now, neuro, is certainly not one of my best topics in internal medicine (gastro is, by far). in fact, i used to have ZERO confidence in it at all, thankfully, 1 month of subinternship in neuro (and seeing nothing but neuro) did give me a fair bit of confidence.

however, in this dear old lady (who happily chatted with us the whole way through and really made us laugh! :) i hope i'm like that when i'm old too!), her constellation of signs was puzzling.
- slight hypertonia of the Right LL, normal on the Left
- no reflexes at all bilaterally
- upgoing plantar on the Left, equivocal on the Right.
- normal power on the Right, weak on the Left.
- sensory loss in a stocking fashion

so the overall picture is that of a mixed pattern, with peripheral neuropathy thrown into the picture.
she told us that she had an old stroke, which explains the weakness and upgoing plantar on the Left.
the peripheral neuropathy explains the missing ankle jerks bilaterally.
so how does that explain away the Right hypertonia and the missing knee jerks?

her upper limbs were fine, no cerebellar signs or cranial nerve signs. she was admitted for a fall (her Left sided weakness), and there was a bruise over her left knee.

i then started questioning myself- were my signs correct? did i do the right thing? did i examine correctly? am i thinking straight? maybe this is ALS or SACDC instead?

so, unsure, i went off to ask the intern - who happily assured me all my signs were correct and it was due to many pathologies!
(the absent knee jerks were due degenerative disc disease/PID that was large, and the hypertonia was due to a new stroke, albeit a small one).

in short? clinical confidence is very important. you've really got to know what you're doing!

another 2 friends of mine were told by the resident to examine the cardivascular system of a patient - both could not hear heart sounds and were depressed and anxious.
the resident proceeded to tell them," that is exactly what i wanted you to hear!"
it turns out the patient had a pericardial effusion (with bulging neck veins) so therefore the heart sounds were muffled!