Tuesday, October 27, 2015

Blog #63: What Your Doctor's Exam Tells About Your Nervous System (Part 2)

The following blog comes directly from Chapter 26 of my novel, DINGS. DINGS is described on my website: LanceFogan.com. It follows a family and their 8-year-old whose non-convulsive epilepsy had not been recognized. DINGS is available as an audiobook, softcover and an eBook at popular internet stores. I will continue excerpting from the book if this blog entry receives comments from my followers on lancef46@gmail.com.

(Continued): The neurologist walked over to a shelf and picked up a dark vial. He shook it a couple of times, unscrewed the cap and sniffed. He returned to Conner, who was swinging his dangling legs over the edge of the exam table. Our boy appeared quite comfortable being the center of attention.
The neurologist gently pressed Conner’s left nostril closed and waved his other hand with the open vial under his right nostril. “Can you smell this?”
Conner jerked his head back and contorted his face. “Ahhhh! Nooooo!” He covered his nose and mouth with his hands.
“No, Conner. You don’t have to do that,” Dr. O’Rourke reassured him. “This one’s a good smell. Can you tell me what it is?”
Cautiously, Conner bent forward and took another sniff. Before he could answer, Dr. O’Rourke repeated, “Can you smell that?”
He tested the other nostril.
“It’s good,” Conner pressed. “Is it gum?”
The neurologist turned around and held the vial under my nose. I sniffed. “It smells like something, uh…is it, uh, some spice? No. Cloves! It’s cloves.”
“Right! That’s what it is.” Then he placed it under Sam’s nose.
“Yeah. It smells good. You’re right, son. It did smell like chewing gum.”
The neurologist replaced the cap and placed the vial back on the shelf. Then he picked up a handheld eye chart. Conner tested twenty-twenty in each eye.
“Good job. Now, keep your right eye closed and look into my eye.”
The doctor stood three feet in front of Conner. Dr. O’Rourke closed his own left eye and pointed to his open right eye. “Keep looking right here in my eye,” he instructed. The neurologist stretched out both of his hands to the sides. “Look only into my eye, Conner. I want to out find how well you can see out of all of the corners of your left eye.” Dr. O’Rourke wiggled a finger off to the side and had Conner say “now” when he saw the movement.
After the exam the doctor explained, “You did great, Conner! The fact that he sees my fingers move when they’re off to the sides means that the visual nerve tracts between Conner’s eyeballs and the visual cortex at the back of his brain are working well. All of that function takes up a lot of space in the brain. My finger-visual field-testing suggests that there are no hidden abnormalities where these pathways are. That’s very important.”
I sat back and shook my head. My mind churned with his explanation and trying to visualize what he was talking about. I had never seen a neurologist at work, and I was so proud of my Conner’s mature cooperation.
“He’s doing great, Sandra!” Sam whispered.
The neurologist switched off the overhead lights and lifted a cylindrical instrument off its perch on the wall behind Conner. “You’re doing very well. Now I am going to shine a light into your eyes so I can check the area where the retina and nerves are. Keep looking straight ahead and try not to move your eyes. Just stare at the X on that wall. Keep looking at it even if my head gets in the way.”
The doctor aimed a beam of light at Conner’s right pupil and moved within a couple inches from our son’s face. As Dr. O’Rourke peered through the instrument, he told us he could see where the optic nerve entered the back of Conner’s eye and the little veins pulsating around it. Then he examined the other eye. “There’s no abnormal pressure inside Conner’s head,” he announced and replaced the cylindrical device on its wall holder.
“That’s a relief,” I sighed. Sam and I looked at each other. We chuckled. Conner’s face had a quizzical expression, but he smiled, too.
During this neurological evaluation, I thought that Dr. O’Rourke had evolved from being just a medical specialist to now being a powerful member of our family. We were literally in his hands. He had the power to guide all of our futures. For this little while—and possibly for years to come—Conner would be his charge, too. I wondered how long he would be around and when he would retire.
The neurologist removed a small flashlight from his breast pocket and twisted the end to activate its bright white light. “Just keep looking at that X on the wall behind me, Conner,” he instructed.
Conner squeezed his eyelids closed and turned his head away. “That’s too bright! Ow! It hurts!”
“I know,” Dr. O’Rourke commiserated. “It’s very bright. Try not to close your eyes or move your head, though. This will take just a second.” He aimed the light at one pupil and then at the other. Then he swung the light quickly back and forth several times between Conner’s eyes. “Good. That’s all normal.”
“Doctor, I’d like to ask you…Everyone sees doctors shining lights into pupils on those medical shows. I have always wondered about that. They make it seem real important. What does it tell you?” Sam asked.
The neurologist turned to us as he replaced the switched-off light to his coat’s breast pocket. Conner watched Dr. O’Rourke with disinterest as Dr. O’Rourke started to speak. Conner looked at the wall and back at us and then back to his neurologist. Then he made little bubble- bursting popping sounds with his lips as he looked down at his swinging feet.
“The pupil normally gets smaller when a light shines into it. If it doesn’t constrict—if it doesn’t get smaller—we suspect that something’s wrong, but we need other information from the total neurological examination in order to isolate the problem. The pupil might not get smaller to light if there’s something wrong in the pupil itself or with the optic nerve and retina.
“Now, Conner, follow my finger with your eyes. Don’t move your head, just move your eyes.” The doctor moved his finger to the far right and then left, up, down and in toward the tip of Conner’s nose.
Conner’s eyes obediently followed the doctor’s finger. I put my hand over my mouth to hide my smirk when Conner looked cross-eyed at the tip of his nose. “Good. Okay, Conner. Now, smile real big and scrunch up your eyelids tight, like you have soap in them.” The doctor gently attempted to pry Conner’s eyelids apart, but he couldn’t. Next, he broke a wooden tongue depressor and touched different parts of our Conner’s face with its sharp point. “Does this sharpness feel the same all over?”
Conner nodded. “Uh-huh. It tickles, it doesn’t hurt.”
Then Dr. O’Rourke rubbed his fingers together near one of Conner’s ears and then the other. “Hear that?”
Dr. O’Rourke pulled out his pocket flashlight again. “Great. Now, open your mouth and say ‘Ahhhh.’” The doctor peered in. “Now, stick out your tongue and move it from side to side. Good! His throat and tongue muscles are moving normally, Mom and Dad.”
The doctor returned the flashlight to his breast pocket. “Okay, lift up your arms and hold them out straight in front of you. Good. Now, close your eyes and keep your arms right there. Don’t move.” Dr. O’Rourke stood still and watched Conner’s hands for about five seconds. “I’m looking for downward drifting of either arm, which could indicate a subtle weakness. There is none. Conner’s fine.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.