How to impress the attendings during Sub-Is?

Discussion in 'Neurology' started by spinnerette, Aug 3, 2011.

  1. spinnerette

    2+ Year Member

    May 28, 2011
    Likes Received:
    Just wondering...

    I've been having trouble during my neuro AI.....
    Take this Monday for instance, I have 2 hrs to do a consult on a delirious female patient who had been in the hospital for 20s.
    I mean, it literally took me 30-40 min just to do the MSE alone because she kept falling asleep and being confused half the time.
    By the time I got back to the work room, it was already time for evening rounds (5pm) and I had literally no time to look up all 20 days worth of notes and labs in 10min.

    I sounded unprepared and stupid half the time during the round and I literally couldn't think of a clear ddx except to rule out something obvious to me at the time.

    How do you interns and residents handle these situations? I'm not used to doing consults on the spot. Any advice?
    I feel really bad because I want to rock the AI and get good letters out of this.......
  2. Mattchiavelli

    5+ Year Member

    May 23, 2010
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    Attending Physician
    10 mins for chart biopsy and 30 mins for MMSE... where did the other hour 20 go? Alien abduction?

    I kid. However, 20 mintues is way too long for an MMSE.. after the patient falls asleep a few times or cannot follow simple commands I consider the patient as delerious and move on to other physical exam issues. Remember, if you have to coach people through it or repeat instructions you aren't administerring it properly. At that point the patient can't give a history or do any ROS type things, so that shortens up the consult. A decent chunk of the full neuro exam requires proper patient participation, so that shortens that up a bit as well (as in you can't really establish that the patient's strength is 3/5 if they're not getting that they need to resist your pull to the best of their ability, they might actually have 5/5 strength ). Check reflexes, check for gross defecits in strength or movement, check cranial nerves to best of the ability, and if the patient fails their MMSE (not oriented to place time or person I would consider failed) at least evaluate them as to their GCS.

    Some of what goes into a good consult starts with talking to the person consulting, which when you're given someone to see this is sometimes out of your control, but if you talk to the person consulting make sure you know why the patient is in the hospital, what treatments they have been getting, what specifically they want addressed, and how long this has been going on, and also their baseline. Example, if I am evaluating someone for AMS I want to know what their baseline function is, they might have dementia and not be very oriented to place or time but they were able to follow directions and stay alert but now they are somnolent and not following commands.

    Make sure you have some tool to help you with differentials, like the pocket medicine book from the mass gen dept of internal medicine, so before you go to see the patient you have some more focused areas of investigation rather than asking the patient about every event in their life in meticulous detail and pulling out every physical exam maneuver you have ever heard of.

    As far as what level people usually want med students at, you should be able to recognize abnormal labs/exam findings and how they fit into the picture and change the differential. If you can make the diagnosis, great, but at this point in training you should at least be able to show a thought process and how it changes what you're thinking about. Suggest some additional labs/studies, what you expect from them, and how they would change what you would do depending on results.

    Finally, try to find out from the students or interns or residents what the attending likes. Some are busy and don't like any extra info at all, and some are very oldschool and want med students giving full formal presentations. It's irritating that the same presentation can get you praises or criticized depending on the attending. Ask for feedback from the resdents too, at least asking them how they would have done it.
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  3. Fencer

    Fencer MSTP Director
    Physician PhD Faculty 10+ Year Member

    Oct 10, 2007
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    Attending Physician
    For each patient under your care, you should be able to say the following:

    XX year-old X handed X gender with h/o (i.e.: relevant conditions such as A fib, Diabetes, HTN, etc) who presented with XXX (i.e.: sudden onset of right sided weakness and inability to speak). Semiology of event (if pain, headache, or spell) or chronology (i.e.: subacute progressive deficit over 6 weeks). On physical exam, she/he had arterial hypertension and an irregularly irregular heart rhythm. On neurological exam, mental status (i.e.: was intact/ or /revealed a non-fluent aphasia with intact repetion); cranial nerves showed (i.e.: decreased nasolabial fold and V1-V3 sensation to LT); motor showed (i.e.: a right flaccid hemiplegia worse on the arm than leg); sensory showed (i.e.: a dense sensory deficit to LT); reflexes were (i.e.: depressed bilaterally, no ankle jerks); and there was a right Babinski.
    The neurological deficits localize to (i.e.: the left corticospinal tract with superimposed diffuse peripheral neuropathy). Given the timecourse of onset of the lesion, the differential diagnosis is: ischemic stroke, hemorrhagic stroke, tumor with bleed, etc.

    You should know WHY your patient was brought to the hospital, and WHERE your patient will likely need to go out of the hospital. You also will need to be on top as to WHAT the team is doing for the patient (i.e.: studies imaging/labs, therapy, etc).

    Do this for each patient, and you will impress your attending.
  4. typhoonegator

    typhoonegator Neurointensivist
    Moderator Physician Verified Expert 10+ Year Member

    Dec 22, 2006
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    Attending Physician
    All of these things get easier with time as you learn to recognize certain patterns and categorize information. Don't be too hard on yourself.

    Fencer is absolutely right (as per usual) that a simple distillation of the case with straightforward progression of information will impress your attending. What is deceptive is that such a "simple" presentation requires a lot of organizational thought and a facility with dissecting a chart and quickly gathering information from the exam. That is, of course, why such a presentation is impressive.

    No one expects you to catch everything. If you can at least make your team's job easier by giving an overview of the case, your contribution will be noted.

    If you start every consult by figuring out how you can best provide a service to the consulting team, you will automatically focus down on the more important issues. If the primary team has already diagnosed HSV encephalitis and are asking you about managing temporal lobe seizures, then you can cone down immediately on that issue and eliminate a bunch of clutter. If, as is unfortunately often the case, the consultant is calling you because his/her patient looks "neuro-ish", then you have more to do. But if you can pick out the low-hanging fruit and offer a basic differential and rudimentary workup, you're off to a good start.

    And budget your time. They can't draw a clock if their GCS is 8. Don't waste time begging them to do it. Give them a sternal rub and move on. Our ED neuro consult resident (a PGY-2) sees > 20 new consults per 24 hour period.

    You gotta be efficient. and quick but not fast. Fast is sloppy, quick is economical.

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