Physical Diagnosis

April 26, 2010

6 weeks until my Board Exam!  Between studying and family visitors, this week has been fun and busy.  Wednesday will be my last weekly Physical Diagnosis class at the hospital, and I want to commemorate the occasion by describing this experience, which has been the highlight of my semester.

For the past 14 weeks, each Wednesday I have gotten up at 5:15am to commute to school, then ride a bus 1.5 hours west, and spend a day at a large regional hospital to learn Physical Diagnosis skills.  I travelled with 17 other students to participate in interactive lectures, and practice history and exam skills with in-patients at the hospital.  The day was organized so we had one hour of lecture, two hours with a patient for a complete history and exam, lunch with another lecturer, and then time to present our patient to a physician and revisit the patient.  Each week we were expected to write a complete report and submit it by e-mail for feedback.

I was worried about being exhausted (waking up at 5:15am  and commuting 1.5 hours each way), but every Wednesday I’ve felt so excited.  Rather than our typical medical lectures, which are focused around organs, these lectures were organized around symptoms, such as “dizziness” and “fever.”  My classmates and I were challenged by real patient cases, including one memorable autobiographical story that our favorite physician lecturer shared to introduce the topic of “headaches.”  He told a dramatic story about driving to work at the hospital, going 70 mph on the highway, when suddenly he felt a “pop” and experienced the worst headache of his life.  He instantly knew the diagnosis, which he described as “the most awesome diagnosis I ever made in my life.”

Any thoughts?  That’s how each day began, brainstorming, guessing and creating what is called a “differential diagnosis.”  We were encouraged to separate the “common” and “lethal” causes.  Along the way, we also learned about physical exam tests, such as the Dix-Hallpike maneuver (an exam to diagnose benign positional vertigo, a type of dizziness).  We also sharpened exam skills that we already covered, such as the eye exam.

Most importantly, we had a lot of time devoted to each patient.  I introduced myself, taking care to clarify that I am a second year medical student practicing my physical exam skills.  I saw patients from 6-months to 86 years-old, in Spanish and English, and suffering from a variety of ailments: a 22 year-old with septic bacteremia (from an infected pimple), a pregnant woman who had been vomiting blood for 2 weeks, a homeless man who had been admitted 22 times in the past year, a diabetic man who confessed he ate a Big Mac and large fries daily, and multiple chronic smokers who had not stopped smoking despite severe COPD (lung damage resulting in less ability for oxygen intake).

Often I felt overcome by gratitude for these patients who were willing to share stories, and let a fledgling examine them.  Although I came to medicine because I wanted to serve people, I usually feel that people are serving me.  I can only hope that by compassionate attention and listening, I provided some sort of healing service that complimented their care.  However, at times I wasn’t sure of this, especially when I was told to wake up patients who seemed exhausted.

I wish there were some way to thank these patients, and convey how much it means to have these experiences.  Each new patient who I meet with a certain condition becomes forever engraved in my mind with that illness.  They give me a face and meaning, and help the massive amounts of information begin to stick to something more substantial than a pneumonic or acronym.

No doubt this class was my favorite, and also the most valuable learning experience in medical school so far.  There were many visible improvements, such as increasing comfort while performing exams and asking questions, less pauses during my oral presentations and less time to type my reports.  This weekly experience will soon be my daily experience as I start my 3rd year in a few months, and frankly I cannot wait.

3 Comments | Medical Procedures, Patients | Permalink
Posted by Liz

Getting My Wisdom Tooth Pulled

April 3, 2010

RIP tooth #16.

Now that I am a medical student, it feels stranger than ever before to be a patient.  I have a new awareness of how the clinician perceives the interaction, as well as lots of new medical facts floating around in my head.  I want to be concise and concrete when I explain myself, and ask questions to learn relevant information.  I want to know the medical language.  In short, I want to make a memorable scientific experiment of my own body.

This week I needed a tooth extraction, which is the first “medical” procedure (besides routine exams, blood draws or vaccines) that I’ve had as a medical student.  My upper left wisdom tooth #16 had descended into my mouth- so far down that it was creating what I coined the “space of doom.”  I thought about putting off the extraction until after my Board exam in June, but in January I got a tooth ache and it was clear that the root might be partially exposed.  So, I decided to schedule it sooner.

I got ready.  I reviewed the head and neck anatomy, and followed the branches of the trigeminal nerve that would need to be numbed.  I reviewed the “caine” family of drugs, their mechanisms and side effects.  I examined my own digital copy of dental x-rays that I had requested.  I went over numbering the teeth.

I sat in the chair, and set my watch to time the procedure- exactly 35 minutes from first injection to walking out the door.  When I started to become numb, I touched my face in different areas to try to figure out if any of the superficial sensory branches had gotten blocked too, and which ones.  Then the dentist came, and I asked him questions about the x-ray.  What did they show about the root?  What did it mean?

He asked me if I had any questions about the consent form, and naturally I did.  Was he going to give me any prescriptions?  Were antibiotics really necessary?  And then, the actual procedure of removing my tooth came, and I paid attention to how he did it.  He asked for a smaller tool, but then as soon as the assistant left the room, he got my tooth out.  Immediately I wanted to see it.

The dentist obliged to my curiosity.  He explained what he was doing (I like that).  He pressed on my gum afterwards and told me that he was pushing the buccal bone in because it is so thin it tends to stretch outward during this extraction.  Who knew bones stretched?

Then, he even talked to me for a little while about my missing baby teeth (hypodontia).  He showed me the letter scheme for baby teeth to go along with the number scheme for adult teeth.  He arranged for me to pick up my tooth on Monday after it is autoclaved (a new safety precaution to sterilize teeth before patients can take them home).

And as I laid down at home, dreams of clotting factors began to dance in my head.  The epithelial damage of the tiny blood vessels around my tooth, the intrinsic and extrinsic factors, and the fibrin cross-linking to form a meshwork.  Then I began to think of the transient bacteremia in my body, and all my immune cells springing into action!  I have such appreciation for a successful medical procedure, and one that taught me a few memorable things too.  Sometimes it is good to be the patient, and be reminded of the natural feelings like fear and curiosity that go along with the experience.

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Posted by Liz

Breast and Pelvic Session

February 10, 2010

My hospital day was cancelled today due to a impending snowstorm.  I don’t have time to be disappointed since I have a final exam on the lungs, a.k.a. “pulmonary,” Friday morning.  I’m home studying in my favorite spot (the couch), and it’s time for an update about something exciting… pelvic and breast exams!

Last week we had a special 4-hour evening session for Physical Diagnosis entitled “Breast and Pelvic.”  Like many PD sessions, we weren’t given a lot of information ahead of time.  We were asked to sign-up in groups, and then sent a reminder e-mail with two bullet points.

*Professional dress, white coat and name tag are required.  You will be given a syllabus at the orientation…

*Personal appearance and demeanor are important.  A pleasant appearance and polite approach demonstrate respect for the patient and encourage trust.  Careful consideration should be given to grooming, with special attention to hands and nails… Examine hand jewelry for risk of injury to the patient or risk of exposure to the examiner through puncture of a protective glove.

Needless to say, my classmates and I were wondering what would happen.  I did not feel nervous since I already assisted with many papanicolaou smears and three male GU (genito-urinary) exams.  Also, I have experience as patient, having received annual pelvic and breast exams.  These exams are not only important, but they are especially sensitive for women, so learning warranted a specialized session.

I was surprised to discover that the male exam was not covered in this session, and we will not have a dedicated session for males.  This means that I will have to learn on the plastic models or by following doctors’ examples, and reading texts.  While the male exam is supposedly “easier,” I have reservations about my first attempt at any procedure being in an exam room with a real patient.

I am reminded of a family friend whose daughter had brain surgery as a toddler, and the surgeon allowed a rotating medical student to do part of the suturing.  When she lifted up her hair to show me the scar, I immediately knew which side the medical student sutured.  It makes me cringe to think that I could be that medical student whose first attempts could figuratively or literally leave patients scarred for life.  I would rather have good practice before I’m asked to do something, so I can proceed without as much fear and worry.

Therefore, I was thrilled with the woman who helped us learn the pelvic exam.  I’ll never forget her.  She was bubbly, talkative, and natural about the entire process. She was a good teacher who knew how to keep the atmosphere relaxed while giving us straight-forward instructions and feedback.  I also appreciated that she had us help and observe one another since team-work is such an important, and often overlooked, lesson of medical training.

The breast and pelvic exam we were taught included more than I have witnessed or experienced before.  Step 1 was the vaginal exam with a speculum.  This included going slowly, using proper draping, helping the patient get into the right position, and explaining my movements.  “You will feel my hand on your thigh.  Now I’m examining the mons, labia… everything looks healthy.  Now I’m going to insert the speculum.”  It’s important to know how to hold the speculum, so it won’t pinch the skin, and insert it at a downward angle away from the urethra and clitoris.  Then, once inside it hits resistance, and then is pulled back a little before opening slowly.  Ideally, I would open it and the cervix, like a little mini-donut, would be right there, but often the cervix is at a different angle or to the left/ right.  Then, on the way out the walls of the vagina are observed.

Step 2 was the bi-manual exam.  This is where you put one or two fingers inside the vagina, then twist and press up on the bottom of the cervix.  With your other hand, you feel the abdomen to locate the uterus and ovaries.  For me, this was the trickiest part of the entire exam.

Step 3 was the vaginal-rectal exam.  This is the part that I have never seen or experienced before.  Apparently it is part of the “normal” exam, but it seems not many doctors actually do it unless they suspect a problem with the rectal wall.  In this exam, the index finger is inserted in the vagina and the middle finger in the rectum.  Those two fingers are swept left and right to feel for polyps or prolapses.

Then there is the breast exam.  Like many physical exams, I was taught to observe first.   We were told to ask the patient to raise their arms, then put them on their hips and move their shoulders forward.  Then the patient lies down and we have to properly place a pillow to make them comfortable.  With one arm raised, we palpate all the breast tissue using the preferred “lawn-mower” (I’d rather say “ zig-zag”) technique.  And for bonus points, we should ask the patient about self breast exams.

When my group was almost complete with the session, one male classmate was left to finish the breast exam.  He gave our standardized patient instructions to raise her hands, and then without thinking he said “Awesome.”  She immediately told him that one should never say “awesome” during the breast exam.   We all had a good laugh!  Additionally we were told to stay away from phrases including “touch,” “feel,” “rub,” “stick” and “put.”

One of my favorite parts of medical school training has been working with standardized patients.  I was astounded by how well this patient knew her body.  Equipped with only a small mirror, she told us detailed information about where to look and what to see.   I also have access to a skills center with large “life-like,” anatomical, blinking, and talking manikins, but nothing is more helpful for practicing procedures than a real human being.  And nothing is better than an educated standardized patient who can make an awkward situation seem relaxed and even, dare I say it, “awesome.”

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Posted by Liz

My First H&P

January 20, 2010

I just peeled myself off the couch to come update the blog.  I was reading about metabolic alkalosis (when your blood becomes basic due to metabolic imbalance).   It is already my third week of second semester and the academic work goes along as usual: lectures, reading, diagrams, note-cards, and trying to get enough sleep.  The lecture-hours to organ-size ratio is extremely high right now.  Kidneys do a LOT- those busy little beans!  (Just checked, and the next unit is the lungs which only lasts 2 weeks for comparison.)

Last Wednesday I began my weekly hospital rotation for Physical Diagnosis II, and I felt the happiest that I’ve been in a long time.  In fact, I had such a good time that waking up early and commuting 1.5 hours each way felt negligible.  The first day was mainly an introduction, but I already fell in love with the doctors and hospital.

I can’t wait to see my first patient there tomorrow.  I just gathered all my medical equipment in a small pile (I really need to get some kind of doctor bag).  Tomorrow I’ll have lecture in the morning, then 2 hours to take a history and physical exam with a patient (who could be a child or an adult from almost any department).

The big change from anything I’ve done before is that I’ll be responsible for writing my own notes.  Doctor’s notes are referred to as “the H&P” which stands for “History & Physical  (Examination).”  Not “H&PE!”  That would be TOO obvious.  Sorry, but abbreviations in doctor-world don’t make much sense to me yet!

We had a sample H&P due this past week.  The assignment was based on a staged appointment with a standardized patient actor who had chest pressure.  It took me about 3.5 hours to finish it!  I can hardly imagine that eventually it should be possible to write my notes in 10 minutes or less.  There’s going to be a steep learning curve (this along with everything else of course).

The main reason why it feels so hard is that I’m not used to the proper formula.  Much like a lab report, an H&P is a scientific report that has sections for specific information.  I’m learning that a good H&P will be as objective as possible .  That means rather than using phrases like “normal,” “as expected,” or “acceptable,” I need to actually DESCRIBE what I did or observed.

I struggled with descriptive phrasing, and I’m sure someday I’ll be rolling on the floor laughing at what I wrote.   ”Hears fingers rubbing in both ears.”  ”Warm and dry, fingers pink.”  ”Symmetric head, no wasting of facial muscles.”  ”Tongue in midline.”  Well, I have to start somewhere.

And tomorrow is the real start to seeing patients and performing focussed physical exams.  I’m so excited!  Oh yes, THIS is the reason I came to medical school; to be present with people.  Now back to metabolic alkalosis…

6 Comments | Medical Procedures, Medical School Life | Permalink
Posted by Liz

Some Signs I’ve Grown

August 25, 2009

After one week of classes, I already feel like I’ve fallen into the same rhythm. Unlike last year, this rhythm and the people around me are familiar. I can’t help but marvel at how fast my first year went by, and wondering where I’ll be this time next year; already through several third year rotations if all is “on track.” This fast-paced academic schedule and my classmates will be replaced with clinical rotations, shelf-exams, residents, and doctors. Now that I am a second year, I realize that the familiarity I’ve found will be short-lived, so I am trying to enjoy it.

I’m less exhausted by the schedule, people, and studying, even though we started lectures immediately: Introduction to Pharmacology (an overview of drug classes and calculations), Neuroscience (neurology), and Phsycopathology (psychiatry). Introduction to Pharmacology is only a 2-week course, so my final exam is this Friday! Yet it seems expected, and I’m already back in high study gear. This afternoon I spent several hours working through math problems to determine drug clearances, volumes of distribution, and half lives (which involved graphing on logarithmic paper- something I never imagined would be part of medical school training).

Yesterday I had a phlebotomy session where I practiced drawing blood on a classmate with a butterfly needle (a thin needle connected to tubing which goes to a test tube) and a straight needle (a needle directly connected to the test tube). The straight needle is a bit thicker, and harder to maneuver. In fact, the hardest part of the whole job (for me) is popping the test tube in and out of the needle device while holding the needle perfectly still. But I managed to get blood with both needles. Unfortunately my partner did not have the same luck with me because my instructor determined that I did not “have the veins for it.” She meant my veins were too small, possibly because the room was freezing! Then, I practiced putting IV’s into a dummy arm, but made a huge mess of that.  The instructor told me not to worry, since we’ll have plenty of time to practice.  For once, I left without doing it right and I was not worried about it.

Tonight I am off to volunteer my evening at my medical school’s free clinic. I expect to see a lot of new first-year students there, and wonder what it will be like to be part of the “experienced” second-year students at the clinic. I certainly don’t feel so experienced, but in comparison to where I was a year ago, there is clearly a big difference.

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Posted by Liz

Cadaver, Colposcopies, and Drawing Blood

January 11, 2009

I’ve been back at school for a week, and I feel as though medical school plucked me up by the scruff of my neck and set me down on a treadmill spinning at 60mph!  Needless to say, I don’t have much time to post a blog entry, but I can’t let this important week go by without writing a word about it.

My first day back was a blur of picking up gloves, scrubs, and realizing the amount of homework I was being assigned in my first week.  Then 24 hours later, I met “Priscilla,” my cadaver, along with my group of 5 other students.  We unzipped the bag, I felt as though we were having a birth.  Boy or girl?  The first thing I noticed were the bright pink fingernails!  I confess I was hoping for a girl, and I got my wish.  I wanted to spend more time with body like mine because as I meet Priscilla, I am imagining myself.  She’s much older of course- she was 82 when she died.  But she’s small and extremely thin.  Her arms and skin remind me of my grandmother’s arms, and I can easily imagine her being alive.

Other people have commented about the smell or the “grossness” of anatomy lab.  But the smell isn’t as strong as I imagined, and doesn’t linger as I was told it might.  Looking at her body isn’t that gross either.  It’s not scary- I can promise that because I haven’t had any dreams about her, and I always have bad dreams when I’m scared.  In fact, Priscilla just amazes me- maybe because I have never seen a dead person before, or maybe because I haven’t been so close to many bodies before.  When I’m standing there with her, I want to explore her, and each part is a surprise.  Her back has a decubitis ulcer (bed sore) on it, which means she was confined to a bed during the end of her life.  Her muscles are thin, and we’ve found aneurisms in her arteries which look a bit like beads on a string.  Our information sheet says she died of a head injury from falling, but I wonder how this frail, bed-confined woman fell?

We’ve started with the thighs and legs, which have fairly large muscles, veins, arteries, and nerves.  The insides look as I imagined with one exception- the amount of different muscles working in correlation with one another.  I always thought of my butt and thigh as being composed of some large muscles.  Actually there are many muscles working together like many different strings side-by-side.  The muscle tissue is beautiful- red lines fading to white tendons.  The tendon is luminescent. The muscles on her left side are deeper red-colored, while her right side is a light shade of pink.  We’re not sure why.  She and I will spend a lot of time together this semester- and somehow the time flies when I’m with her.

As if meeting my first dead body weren’t enough, I also had my first week of mentorship in a family medicine clinic AND I learned how to draw blood!  I took a patient history for the first time alone, and presented it as personally as possible (because I feel awkward when patients are presented as if they are a scientific object who isn’t listening).  I saw pap-smears, colposcopies (a small biopsy of the cervix performed when the pap-smear is not normal), a broken/ healing finger, a chronic cough, etc.  The doctor was a wonderful teacher and warm physician.  She gave me more explanations and attention than any doctor I have ever been around before.

With the patients’ permission, she let me look at the cervixes with the special binoculars, and I found it so fascinating that I wished I could project the image back to the patient to show them their own cervix.  Maybe some people would find that disturbing or weird, but I thought the cervix was breathtaking up close, and I wished there was some way I could see my own.   Also, I couldn’t imagine going through the discomfort of a colposcopy procedure without being able to understand why.  Once I got a glimpse at the abnormal tissue, I could see the reason, but the patients did not get the chance to see. This seemed unfair.

Drawing blood wasn’t too difficult either, although I really could use 3 hands!  Balancing the tubes, and popping them in and out without letting them fall… all while holding a steady needle without moving it 1mm.  It’s tricky business.  I thought the most difficult part would be finding the vein, but I learned to find the veins by using the elastic band, and going inside seemed easy.  Hopefully with time, my 2 hands will suffice.

That’s my first week back… with lots of firsts.  I find myself excited as next week approaches.  I am exhausted, but thinking about Priscilla and the clinic give me a lot of energy.

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Posted by Liz