General Neurology & Stroke rotation at Boston University Medical Center

I spent the month of October at Boston University Medical Center rotating through both the General Neurology and Stroke services. I worked with several attendings and four of the neurology residents. I also met most of the other residents, all of whom are amazing.

A few great things about the Neurology residency program at BMC include the tremendous diversity of the patient population (i.e. ethnicity, pathology), the large volume of patients who come through the hospital's doors, the camaraderie among the residents, and the incredible support of the program director (PD). She's young, energetic and passionate about teaching and ensuring wellness among the residents. The Department Chair, the PD, and the associate PDs are all incredible and I felt so welcomed and supported by everyone (as well as the Neurology clerkship director and coordinator!).

Rotating at BMC has helped solidify my passion for Neurology. It also pushed me to reach new heights in my training. I'm still on a steep learning curve and I definitely have a long way to go, but I'm grateful for how much I was able to learn within just four short weeks. I honed my neurological exam skills by practicing the basics a thousand times on patients. I became more efficient with seeing consults and presenting the key portions (history, physical exam, and assessment and plan) to the attendings. I improved my ability to read different neuroimaging modalities, including CT scans and MRIs of the brain and vasculature. I enjoyed spending time speaking with patients who did not understand the pathophysiology of their neurologic diseases (i.e. stroke, seizure, etc). It is gratifying to demystify their clinical condition and encourage them to take charge of modifiable risk factors that may have led to the pathology in the first place (i.e. a young man with polysubstance use came in with a first-time seizure; a middle-aged African man with poorly controlled diabetes, hypertension, and hyperlipidemia presented with a stroke, etc).

Interesting cases

I'd like to mention a couple of interesting cases from the General Neurology service during my time at BMC. One unique case (Mr. A) deepened my excitement about Neurology, and another (Mr. B) emphasized for me the vital importance of social work involvement, especially for patients who have particularly complicated social situations. (To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families).

Mr. A 

A 55-year-old man ("Mr. A") with a history of pancreatic cancer presented to the emergency room with increasing generalized pain and worsening abnormal movements of the left leg. We (Neurology) were consulted shortly after his admission because the primary team was concerned about choreiform movements in the left leg. (Chorea = jerky involuntary movements that can be seen in neurological diseases such as Huntington's). Mr. A reported that the shaking of the leg began several years ago after a knee replacement surgery. 

Picture from here

We noted the shaking during our assessment, but our neurological examination was also remarkable for findings related to cerebellar dysfunction (the cerebellum is a region in the back of the brain that plays an important role in coordination and balance). We noted scanning speech (or "ataxic dysarthria"; his syllables were choppy, and the inflections and rhythm of his voice varied considerably), and frank dysmetria (impaired coordination) with some of our tests, including a finger-to-nose, heel-to-shin, and finger-chase (skip to 0:32-0:40). Because of these concerning findings, we immediately recommended that an MRI of the brain be ordered to take a closer look at the cerebellum. (The MRI later revealed chronic cerebellar atrophy).

Most of the time, Mr. A was very pleasant and cooperative. I looked forward to seeing him every morning during my pre-rounds. Unfortunately though, I often walked into his room right as he started eating breakfast. I tried to time my pre-rounding so that I would see him before the meals usually arrived on his floor, but regardless of the time, they always seemed to get there right before I did. It was unbelievable. "Why are ya'll ALWAYS comin' in here disturbin' my meals?" He barked. "I'm so sorry, Mr. A," I'd tell him. I felt awful, but thankfully I managed to calm him down most of the time. I was also able to convince him to let me ask a few routine questions and perform a quick examination. Then I would hurry off to rounds.

Upon further history taking, Mr. A noted worsening symptoms over the past several months with poor penmanship, inability to hold items stably in his hands, and difficulty walking. He reported first noticing these symptoms shortly after his first cycle of FOLFIRINOX therapy for the pancreatic cancer. Included in this chemotherapy regimen are the drugs: 5-fluorouracil (5-FU), leucovorin, irinotecan, and oxaliplatin. Though extremely rare, the drug 5-fluorouracil (5-FU) can cause an acute cerebellar syndrome (example cases: the first documented case was in the U.S. in 1964; 1996 case in France; 2015 case in India, etc).

We also recommended a lumbar puncture to rule out any potential neuroinflammatory or infectious causes of the cerebellar findings. A lumbar puncture (or "spinal tap") is a procedure in which a needle is inserted between the vertebrae of the lower back to remove some cerebrospinal fluid (the fluid that bathes the brain and spinal cord) for diagnostic testing. Unexpectedly, Mr. A's CSF fluid was positive for the varicella-zoster virus (VZV). This further confounded the clinical picture, and we are not 100% certain if Mr. A's cerebellar dysfunction can be attributed to the 5-fluorouracil in his chemotherapeutic regimen (which the oncology team vehemently disagrees with) or the VZV infection. He was immediately started on anti-viral therapy to treat the infection.

Could Mr. A's cerebellar symptoms possibly be due to the VZV infection? He is a very interesting case! I grew excited to research the effects of 5-FU on the cerebellum (although there isn't much out there, I was initially convinced that this was causing his symptoms) and search for cases of adult VZV infection (without rashes) causing a cerebellar syndrome. There is not a lot in the literature about this! We are continuing to research Mr. A's case.

Mr. B 

Mr. B is a 40-year-old man with the most complex social situation I'd ever encountered in a patient. He presented to the ED after suffering a seizure while riding his bike on the way home from work. After he seized on the concrete ground, he was found to have severe facial injuries, missing front teeth, and a terrible headache. It was such an unfortunate situation. Mr. B was admitted for pain control, brain imaging, and proper arrangement to a safe location upon discharge. He has profound developmental delay and reports neglect and abuse from family at home. Though he has a stable job as a cleaning staff employee at a local school, he had no medical insurance and refused to return home. 

Social work and case management spent days trying to identify a safe location for Mr. B to be sent after discharge. He was medically stable and ready to go, but he claimed that his family was taking advantage of him. My heart went out to him. His circumstances were so unfortunate. He shared with me that he first came to the U.S. from the Caribbean in the late 90s at the age of 20 and was placed in elementary school at that time. He couldn't remember up to which grade he completed. It became clear throughout the course of Mr. B's stay (and particularly after completing a cognitive assessment) that he is very developmentally delayed and would be unable to live a fully independent life without the assistance of others with his medications, financial management, living situation, etc. 

Picture from here

He claimed that his family made him sleep on the floor of the attic for the past two months. He also mentioned that on some days his mother would lock the fridge and fiddle with the pipes somehow, preventing him from eating or drinking any water. Mr. B claimed that he was forced to drink water from the toilet bowl sometimes because he was so thirsty. He also reported that his mother locked him out of the house on a few occasions, forcing him to sleep by the dumpster outside. These abhorrent accounts left me speechless and raging with anger towards his mother. How can a mother treat her child like that? I had to continually tell myself that while this may be true, we only heard one side of the story. We didn't know for sure what was really happening at home.

I worried that things began to look grim when it was discovered that Mr. B had no medical insurance, no group home would take him given his circumstances, and his mother came to the hospital many days after he'd been admitted to insist that he return home with her. We called her number (and several other family members) for days but no one ever picked up. I struggled with disgust towards Mr. B's mother. It was wrong for me to judge her without fully knowing everyone's side of the story.

We all sat down to have a discussion about her son's care and living circumstances. It was decided that his mother would no longer be in charge of administering his medications, and social work would help him identify a new medical guardian. His mother confirmed that her son had been sleeping on the attic floor for the past couple of months. I was surprised to see that she actually seemed a little remorseful. We didn't delve into the other details of neglect and abuse that Mr. B shared with us, although to be honest I wish we had. 

Mr. B was discharged that same day. Unfortunately, social work could not identify a location other than his home. He is there for now, but we are hoping that his previous social worker can help him find a more permanent home situation.

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