Anything But Typical

Abstract

A graduating child neurology resident reflects upon how her first neurology “patient” single-handedly taught her an entire textbook worth of knowledge and became the guiding force that led her to leave general pediatrics.

The first time I relied on neurology, it failed me. I was two months into my intern year in pediatrics, unsure of a future as a general pediatrician and equally uncertain about subspecialty. I had gone home to visit my mother, who had endured three PCP visits and a multitude of lab work for three months of nonspecific and evolving symptoms. She was fatigued, had mild weight gain, and developed a puzzling numbness limited to only the fingertips of her right fourth and fifth digits. She was also experiencing difficulty playing the piano: she had once played beautiful Mozart sonatas from memory and now had trouble playing with more than one hand.

I rolled up my sleeves and set out to perform the full neurologic exam as I remembered it from medical school. Thirty minutes later, I ended up with three yields: slight tongue deviation to the right (or was it intern syndrome of over calling and overanalyzing every exam finding that wasn’t completely normal?), mild intention tremor of her left upper extremity (ditto), and sensory loss to fine touch and pinprick over the palmar surface of the two fingertips (full disclosure: I had no idea where my tuning fork was).

Even to this day, I am unable to localize her symptoms to one lesion. Back then, I found myself telling my mother that her exam seemed normal, but what I had wanted to say was, “This is why I didn’t go into neurology.” I went through all the motions of what I thought neurology entailed, and yet, my non-neurologist brain had become more confused than it had been thirty minutes ago. A few days later, my mom was driving to work when parts of her peripheral vision went black for a couple of minutes. Her coworkers tried to take her to the emergency room, but she refused, so they took her to a nearby neurologist's office, where she underwent a spot EEG (normal) due to the episodic nature of her visual symptoms, and they gave her an appointment for the following week.

I accompanied her to the visit, eager to compare a bona fide neurologist's exam to my own rusty attempt. It was a rather anticlimactic affair. A medical student performed most of the exam, and the neurologist unceremoniously pronounced it normal. My mom's intention tremor appeared less conspicuous at the office, and they swept her odd sensory symptoms under the rug, a fate often met by sensory symptoms that did not make sense. The neurologist reassured us, explaining that my mom's symptoms could be due to new-onset myasthenia gravis. She ordered acetylcholine receptor antibodies and an outpatient brain MRI to rule out any central nervous system lesions, although she reassured us the brain MRI would likely be normal.

My mom asked me if myasthenia gravis was bad, and I said no, giddy with relief reserved for the ignorant. But perhaps she could sense what was to come, for that weekend, she took my dad to a trendy coffee shop and ordered a latte for the first time in her life. She said she needed to “enjoy life,” a phrase that had never before been a part of her vocabulary.

At the MRI, the radiologisty detained my mom and immediately sent her to the adjoining ED, where we learned that the MRI showed “hundreds of lesions too numerous to count throughout the brain,” including larger lesions in the left parietal lobe, pons, and cerebellar peduncles, consistent with metastases. Subsequent whole-body CT and biopsy of a lung mass confirmed the diagnosis of non-small cell lung adenocarcinoma. During that moment when the chaos of confused and hopeless thoughts threatened to swallow me, the one constant that flashed with impressive clarity was that her neurologic exam was the only thing that made sense when nothing else did. Neurology hadn’t failed me (or her) after all. My mother exhibited signs of three different lesions, and to say those lesions were represented in her brain would be an understatement. No wonder her exam didn’t fit my classic medical school localizations illustrated by smooth lines that somehow always intersected at a single point. As I went on to learn, neurology is often anything but typical, and the exam is a guiding light I have come to trust.

Over the next four years, my mother experienced all the chapters in a neurology textbook: Broca's aphasia, hemiparesis, hemineglect, focal seizures, gait apraxia, bradykinesia, resting tremor, truncal ataxia, radiation-induced leukoencephalopathy, and finally, such severe frontal lobe syndrome that it could only be described as akinetic mutism. In November 2019, seven months before I completed child neurology residency, she passed away peacefully in hospice from complications of stage IV lung adenocarcinoma.

It is true what they say: your patients are your best teachers, but you don’t always get to pick who your patients are.