I’ve written quite a bit this academic year about our Physical Diagnosis class, including encounters with standardized patients. But starting in a couple of weeks, things change dramatically. Instead of practicing skills on standardized patients, we enter the hospital under the guidance of an assigned “tutor” to apply our lecture knowledge of the physical exam.
By the time we come out of our exam at the end of the month, I’ll be seeing patients. Alone.
(Yeah, I’d run, too).
The way it works in the hospital is this: the “tutor,” who incredibly volunteered for this assignment, schedules a patient of theirs to come in for our evaluation. Along with one unfortunate classmate (they’re paired with me, after all), we’ll see the patient alone and perform a history and physical, focusing on whatever skill we learned the previous week.
Once we see the patient, we’ll leave the room and present the patient to our “tutor.” For inexperienced students like us, it’s a way to explain what we’ve learned so the doctor can “check our work;” for upper-level students and residents, it’s a safeguard before the student/resident proceeds with their own evaluation and treatment. It’s terrifying. When our course director was explaining the process to us, he kept using the phrase, “Your tutors will expect you to know…” and then saying something I don’t know. Uh oh.
I have presented a couple of times before, albeit in the lowest-stress environment we have: our student-run clinic. There, every knowledgeless first-year student is paired with a worldly and experienced almost-doctor fourth-year. We see the patient together, discuss the patient together, and present the patient to one of the circulating “attendings” there.
(Unfortunately, this is nothing like presenting the starting lineup of your favorite team, though medicine would undoubtedly be more dramatic if that were so. “INTRODUCING… IN ROOM SIX… FROM NORTH… CAROLINA…. TWO-TIME MVP OF CLINIC… THE PATIENT!!!!!!!”)
You want to watch that link. I couldn’t resist.
This is supposed to be an easy way to learn how the process works. In practice, when the attending is staring at you without blinking as you deliver a monologue, you tend to get nervous. Or maybe that’s just me.
The format goes like this:
1) Patient, age, gender, brief relevant history, and complaint. “Mr. Friedman is a 25-year-old male with a history of compulsions, binge-eating Reese’s peanut butter cups, and hypochondria who presents to clinic for evaluation of abdominal pain.” (please stop staring at me. Am I doing this right?) I feel my shirt beginning to stick to my skin. Thankfully my absurd white coat will hide this.
2) History of present illness. “The history of present illness is that last night, Mr. Friedman ate approximately 25 Reese’s after feeling panicked about his upcoming exam. He states that lately, he has had trouble remembering things, such as everything. At approximately 8PM yesterday, he finished studying for the day and realized that he could not recall the events of the past ten hours, besides a brief four-hour break to watch “The Rock” because it was just starting on AMC, and Nic Cage has to stab himself in the chest with atropine at the end, so it was relevant. After dinner, he says he went to the freezer and ate all of the candy his grandmother sent him yesterday, even though he asked her repeatedly to not send such contraband because he experiences episodes of loss of control eating when she does.
Upon awakening this morning, Mr. Friedman said he felt like there was a large mass in his stomach that hurt to touch and that gave him throbbing pain that radiated to his mid-back. He rates this pain as a 4/10 on the pain scale. He didn’t take anything for the pain and came straight here. He is convinced he was infested with the Alien.
(Also, for those of you counting, this is my third Alien reference on this blog.)
3) (Relevant) Past medical history and past family history. “Mr. Friedman told us that he cannot resist eating chocolate, especially Reese’s, in times of stress, but is otherwise healthy and has no relevant history. His parents are both healthy with no family history of pretty much anything.” (What am I forgetting? I must be forgetting something this is terrifying) I nonchalantly try to wipe the sweat off my brow before it cascades down my nose. That would be a dead giveaway.
4) Medications and allergies. “The patient reports he is allergic to cats, which he hates with a virulent passion. He is taking no medication, but probably should be.”
5) Social history: “He lives locally with his roommate, Ryan, and attends medical school here. (God, am I only halfway done?)
6) Physical Exam: “On physical exam, Mr. Friedman is well-appearing, alert, fat, and agitated. His blood pressure is 110/60, heart rate is 62, and his respiratory rate is 14 per minute. His lungs are clear and equal bilaterally with no crackles, rales, or wheezes. I do not know what any of those realistically sound like. On cardiac exam, he has a normal rate and rhythm with a mild S4 gallop present, although I don’t know what that means anymore.
His abdominal exam is remarkable for a large, tender mass palpated in the left upper quadrant that feels exactly like 25 Reese’s peanut butter cups all mashed together. I have no idea what this is.” (The attending hasn’t moved his gaze in like an hour.) I can’t read anything written on my note, possibly because I was overwhelmed by an impending sense of incompetence.
7) Assessment/Plan: “Um… I’m a first-year medical student and I don’t know anything HELP ME I’m hopeless.”
In a normal presentation, at this point you explain your differential diagnosis – the various things it could be – and how you plan to further evaluate and treat the patient. The attending asks a few questions (“did you remember to ask about…” no, I didn’t) and then you go see the patient all together.
In this case, you would probably… actually, I don’t know, because we don’t do the abdominal exam for another like four months. Probably some kind of imaging (X-ray, ultrasound, CT, MRI?) to determine if this is the Alien or merely a large ball of chocolate and peanut butter.
As a first-year, my differential includes the following (pretty much regardless of presentation):
- Tumor: if I’ve learned anything, it’s that “tumor” is always a possible answer.
- Lupus: it can always be lupus.
- Diabetes: do they have diabetes? No? Maybe they do now.
That’s pretty much it for my diagnostic capabilities. I’m going to go present to a mirror now. Also, I think I have a Reese’s in the freezer.