Just 17

One thing I don't miss at all about adult medicine is having patients several times larger than myself. I had a run of teenagers in clinic today, from the largest 12 year-old I've ever seen (over 6 foot and weighing 85 kilos) , to an autistic 18 year old whose mom has to shave his unruly facial hair.

12 year old boy, learning disability, seizure disorder, behavioural problems. Mom worried about sexualised behaviour ever since started sex education at school. Good school reports but mom struggling to cope with behaviour at home. Mom unwilling to be referred to our pschologists as boy managed to fall out with one over "talking about poo" a few years ago when he was referred for problems with soiling. EEG - no seizure activity but suggests epileptic tendency. Plan: refer to clincial psychology at Big Famous Hospital; start carbamazepine.

16 year old girl, accopanied by mother. headaches since age 6 years; pineal cyst on CT at age 7; thought to be benign. Headaches increasing in severity and occasionally waking her at night. 2 year history of sudden "blackouts" always associated with yawning and stretching. Family history of migraine. Meds: propranolol as migraine prophylaxis - but patient had stopped these herself 6 months ago. Impression: likely carotid body hypersensitivity syndrome; plan: ECG, refer to cardiology. also MRI brain. Adult or paediatric cardiology?


18 year old boy, high functioning autism. Mother opens the consultation by whipping out Certificate of Achievement from vocational taster course and beaming proudly at me. I try to look suitably impressed as she relates that he can walk to the DLR station and get to college all by himself. (but still needs help shaving and supervision bathing). He looks about 20, with marked 6 oclock shadow and scraggly moustache despite it being 3 oclock in the afternoon. Is on fluoxetine for anxiety; mom feels this helps. I wonder if it is appropriate to refer him on to the adult clinic?

And others. When do you refer to adult clinic? I guess the patient attending clinic on their own is always a good sign. It's the age old question. When is one truly grown up? And what matters more, mental or chronological age? Part of the reason teenagers unsettle me is I guess deep down I do feel as if I am still living in much-extended adolescence myself. Each birthday I think, maybe I will feel finally grown up when I....
live independently? - nah, been doing that 10 years now
graduate? - that was a while ago now, but that didn't do it
start work? - that didn't do it either
watch someone die and then have to speak to their relatives? - nope
make a 'good save' that keeps someone alive? - nope, not that either
get married?
have my own children?
become a consultant?
buy a house?
who knows. maybe the moment you stop growing up is the beginning of the end.

FFP2s and AFBs

Like Dr. P is what I want to be when I "grow up" - a respected paediatric neurologist - the Ferragamo shoes would be a bonus. Everytime a parent asks specifically to see Dr. P, she makes me see them. I suppose it works out "well" on all sides - the pushy parent gets "punished" by having to see the most junior doctor on the team, I get practice dealing with difficult parents, and Dr. P gets to sit back and have a coffee.

The last patient on Tuesday's clinic list threatened to be one of these. "Look at her, she's sick," said the father, a burly, bear-like man. "I want to see Dr. P! She said she would see *Amina." Dr. P sat in her consulting room dictating her clinic letters. "You see them," she said to me, ignoring his protests. "When I say I will see you," she said to the man, "I mean one of my team will see you." With that, she retreated behind the door again and left me with the irate parents and their languid daughter. Someone had given her a sick bowl, which she was coughing into.

Amina has epilepsy, which is well controlled on sodium valproate, but because she is approaching puberty, Dr. P had been trying to change her over to topiramate, a less teratogenic drug with fewer undesirable effects. "That topiramate," began Dad, "Amina has been very ill ever since we got to 100 miligrams." They had come to hospital before, with Amina complaining of pain in her chest (an unusual symptom in children), and tiredness. The A&E doctors had told them that topiramate can cause tiredness, and reduced appetite; sometimes even weight loss. "She is not right, we need to stop it. Look, how she coughs!" I explained that topiramate certainly didn't cause chest infections. "How long has she been coughing?" I asked. Since 100 miligrams!" he said, exasperated that I wouldn't acknowledge the link. "And fever too!" I looked back at her previous clinic letter, and calculated that she had had a cough and intermittent fever for three months. This being Whitechapel, I thought immediately of TB. Turned out I wasn't the first to consider this diagnosis - she had attended A&E just the day before, and had been sent home after having a Mantoux test administered. It was already strongly positive. So we admitted her from the Neurology clinic into a barrier-nursed cubicle.

Later that day, I went to see her on the ward. The window blinds were down and a trolley laden with plastic aprons, gloves and FFP2 masks sat outside the door. I put a mask on and pushed the door open. Amina had been a timid little thing before, but now she looked postively terrified lying in bed with the sheets up to her chin, and surrounded by relatives, each with a beaked TB mask on. I bent down and tried to reassure her, but it was difficult, wearing a mask, particularly when I had been examining her closely without a mask on just hours before. Her father looked over at me, and despite the mask I could make out that he wore a completely different expression from the scowl he had had on earlier. "Thank you," he mumbled from under the mask.

the job offer came through 2 days before my birthday

The telephone and the tendon hammer

It was in my second year of medical school that I became fascinated by the workings of the brain, but it was in fourth year that I first decided I wanted to become a Neurologist. I have vivid memory of our first tutorial; the professor perched himself on the edge of his consulting room desk, and began: "In diagnosing epilepsy, the telephone is more important that the tendon hammer." He explained that though neurologists often order large batteries of esoteric tests (like cerebrospinal fluid neurotransmitters and other things that need to be rushed to the lab on dry ice), neurology is no different from any other specialty - a good history (or, in the case of epilepsy, a good eyewitness account) often provides the best clues to diagnosis.

4 years on, and my very own mobile telephone has helped reach a diagnosis of infantile spasms. But not in the way the professor had envisaged. Everyone has camera phones these days, and we often send parents home with advice to try and capture an episode (of what might or might not be a seizure) on camera. Sometimes they return for the follow-up appointment without the child - but with the precious video recording, and appropriate treatment can then be started. I guess this helps particularly in an area like ours, where many parents have a limited grasp of English.