The whole purpose of education is to turn mirrors into windows.—Sydney J. Harris
Last week, I taught a group of students the neurologic examination. I had prepared the students by asking them to bring all the necessary equipment: reflex hammer, otoscope, push pins, cotton balls. They came to the laboratory in shorts and T-shirts excited and ready to learn. I had a checklist to follow that had been carefully put together by the faculty in charge of the patient care course. We allotted two hours to go through the checklist and practice the various maneuvers. I thought this would be ample time.
The checklist started with a mental status screening test and ended with testing for meningeal signs. I began with the importance of looking at the patient: level of consciousness, posture, dress, grooming, affect. As we discussed the nuances of observation, I used clinical vignettes to highlight my teaching. I described the patient with mania who would present to the ED in gaudy makeup and flamboyant clothing. She would spiral and spin into triage, not really having time to sit to talk. I knew just by her clothing that she had stopped taking her lithium and was likely manic. I talked about the patients who wear long sleeves to cover up their scars from self-injury, and the shame and reticence they often feel. We discussed the flat effect of the patient with depression … and how I found that somehow their mood would invariably infuse the entire room and seep into my soul.
We talked about insight, judgment, hallucinations and super powers. I spoke of the patients brought in for yelling at the children and animals that only they see. The fear instilled in them and their caregivers. I described the fight-or-flight response of a paranoid schizophrenic I once saw who was convinced he was being pursued, and how he had reminded me of a gazelle under the eyes of a lioness on a plain in sub-Saharan Africa. I witnessed his fight-or-flight response when he believed he had become prey: his head turning, eyes flickering, muscles contracted, brain deciding where or how to run.
Consequently, the assessment of mental status and behavior took me longer than I expected.