On my love for the physical exam (or halfway through Neuro/Psych)

Inpatient neurology was more fun than I had expected.

On Monday, my assigned attending was a fast-paced and no-nonsense kind of fellow. He enjoyed poking me with pimp questions and prickled whenever I answered incorrectly (which was often). Despite the sometimes tense learning environment, I learned quite a bit. I saw a dozen or so cases with him while rounding on the H3 Stroke Neurology service, all of them interesting. A cerebellar stroke with the classic finger-to-note ataxia on physical exam. A 50yo suffering from alcohol withdrawal while acutely recovering from a right MCA infarct: classic left sided weakness of his upper and lower extremity. The only thing keeping the limbs moving was his excellent collateral circulation so we kept his systolic blood pressure over 180 in the ICU.

A friend of mine, Manny, got pulled from an interest in psychiatry during third year to applying for neurology residencies during fourth year. A major draw for him laid in the physical exam: touching and interacting with patients. With neurology, you need to have proficient exam skills to localize pathology as well as track recovery.

For the 50yo with the left-sided weakness, the difference between being able to lift his left arm off the hospital bed versus struggling to move the limb at all laid in 20 millimeters of mercury. You need to observe and interact with the patient thoroughly to track these changes. The treating team tried to ride the line between outright ischemia to the affected motor areas of the brain and inducing the collateral blood flow. Keep the blood pressure too high and you run the risks associated with a constant drip of vasopressors. Keep the blood pressure too low and this 50yo could have permanent damage to his ability to walk.

In neurology, these exam skills are supplemented and enhanced by modern imaging techniques such as MRI or CT. Have a patient with finger-to-nose ataxia, weakness in his left arm, with visual field losses, and difficulty reading? No one lesion explains this complicated case, and imaging would confirm a shower of emboli, clots originating from the heart. In other fields, the technology becomes the basis for tracking, with the physical exam in the backseat. Why listen to the heart when you can see it on ultrasound?

I pride myself on observational abilities. I know that I will utilize them in the field of psychiatry, but for the subtle and characteristic, not the pathologic and life-saving. I can see why this practice drew my friend to neurology. I feel it too. It helps that my second attending for the remainder of the week suited me well: she allowed for independence, created a relaxed learning environment, and actually found ways for me to contribute to the team rather than feel like the tag-along friend.


The past few weeks have been full of life. Challenges and changes in addition to the rigors of clinic. Six weeks of Neuro/Psych have sped by me. Internal Medicine feels so recent. The next few weeks will keep me occupied, two weddings in three weeks. The Shelf exam, and the end of this rotation, will land on the week of Thanksgiving. Just a turn and a half from the moon.

Then, a whole new chapter.


Long Form Sundays

On Death Podcast

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