Friday, March 11, 2011

What Brings You In Today?

So I didn't do as bad on my pharm exam as I had feared. Not as well as I'd like, but it's an acceptable score. Moving on . . .


One of our courses this year is on learning how to take a history and physical exam. It is almost entirely what you make of it. I have friends who simply go through the motions of doing a physical exam and are almost unable to distinguish a normal heart sound from bowel sounds (a slight exaggeration). It is insufficient to simply go through the motions when, come July, interns and residents will ask us to do a physical on a patient and expect to trust our findings.

Last week I had a 71-year-old patient. He had a rather extensive history and an "impressive" medication list. I recognized and knew the mechanisms of action for over half the drugs he was on (because we were just tested on those drugs the day before). His physical exam was a bit tough (as for some reason geriatric patients are always tough for me). Being overweight doesn't help either. :-/

This week I had a 13-year-old patient. Have I ever mentioned how I love pediatric patients (insofar as doing physical exams)? I could hear her heart and lung sounds so clearly. Her reflexes were easier to find. I felt her abdominal aorta. I've never felt anyone's abdominal aorta before (because one has to be rather lean in order to feel it, unless one has an abdominal aortic aneurysm - in which case it's a medical emergency!). I finally figured out the ophthalmoscope and saw the red reflex and the optic disk in the back of the eyes. Looking in ears have always been rather easy for me - I even once got a 2-year-old with an ear infection to cooperate with me!

It is truly a privilege to be able to ask someone, "What brings you in today?" and "How can I help you?", and have them tell you something so intimate and for you to (hopefully) be able to do something tangible about it. It is a privilege that people allow us to touch their bodies in sometimes weird and uncomfortable ways to figure out what's wrong.

Come July, I expect myself to be able to do a physical exam to the point where I can, at minimum, tell a resident what is "normal" and what is "abnormal." Unlike my friend, I will not mistake a bowel sound for an abnormal heart sound.

P.S. I've really got to get myself a clipboard.

7 comments:

Ron said...

It's so true that it seems easier to perform a physical exam on a kid/teen than a really old person/ridiculously obese person.

I still need to improve my examination skills. I feel I have my history-taking skills at an all-right level, it's quite systematic anyway. I'm not TOO bad with exams on the cardio/resp, GI/abdo. I fail with neuro or musculoskeletal.

Maybe we should do practice OSCE's.

Fly over to Australia for a weekend.

We'll be great study partners.

I KNOW IT.

- Ron

naturgesetz said...

I suppose taking the history can vary with the self-awareness and memory of the patient.

Are there times when the examination suggests something that the patient didn't mention in the history?

It must be great to have that sort of knack for examining pediatric patients.

James said...

The clipboard makes all the difference. I say go for something fancy like varnished teak.

naturgesetz said...

James's comment reminds me about the clipboard. I've decided that the word should be pronounced analogously to cupboard, i.e., with the "p" silent (as in "swimming" LOL) and a schwa sound in the second syllable.

IOW — CLIBBerd

Anonymous said...

You will have to listen to hundreds or maybe thousands of hearts to reliably detect abnormal heart sounds.

Really pay attention to the thyroid exam, so many attendings, residents, interns, and students pass over it too easily and miss early cancer.

tracy said...

Oh, Aek,

It sounds like you are doing terrific in the Physical exams...great! i love the way you say that it is a "priviledge"...you show so much respect, that is lovely!

Must admit how envious i am of your being a Med Student!

Hugs,
tracy

Aek said...

Ron: Dude, what're you talking about? We'd be AMAZING study partners! :-D

naturgesetz: Yeah, patients forget to mention things all the time (and doctors forget to ask things too). We're only human. Sometimes the exam actually does reveal something the patient didn't mention or didn't know. But most problems can be diagnosed from a good history.

James: Lol. I just want one that's convenient to care and effective. :-P

Anonymous: Yeah . . . I did forget to do the thyroid exam. Sigh. I did remember to do it at a free clinic once though, because the patient mentioned something in her history and had symptoms that pointed to a possible thyroid problem! :-D

tracy: Don't be envious. There are better professions to be envious about, hehe.