I’m a bonafide genius!

A couple weeks ago I had to do an OSCE where I interview a “patient” (actor) and conduct a short physical and then discuss what I think the problem is and what I want to do with the patient.

These “patient interactions,” as they call them, are recorded and we are required to come back and watch them and evaluate ourselves.

I hate watching myself on video. And today I just saw the video of me interviewing a patient who had a complaint of frequent falling. Got that? She came in complaining of falling.

Well I do the interview, asking about when the problem started and blah blah blah. Her three episodes of falling were sporadic, occurring at different times of the day and in different places. And it wasn’t because of any injuries.

Ten minutes later before I move on to the physical exam, I ask the patient, “Have you noticed any changes in balance?”

What the heck, Jeff?!? She has been complaining about falling and you ask if she has had a change in balance?!?

The patient sat silently and just stared — totally confused, I’m sure. And I, realizing what I had just asked her, quickly recovered and pretended like I was clarifying myself and asked if she had felt any dizziness, headaches, or nausea.


Talking To A Hero

I’ve been meaning to watch Band of Brothers. I have seen a few episodes, but I recently got a hold of the entire mini-series. The above picture shows the characters from the show.

The reason I thought of the show is that I recently had the opportunity to chat with an amazing patient. The patient fought in World War II. He landed in Normandy and fought in Europe until the war ended.

I can’t even begin to imagine the kinds of stories this man could tell. My attending physician told me that in the past, the patient has brought in pictures from the war. I wish I could have sat with him and talked casually about the war. I would have loved to see the pictures and hear him retell the tales. But it was neither the time, nor place for this. We were in clinic. But I still felt like I was in the presence of one our national heroes.

He was so polite and gracious, thanking me — a medical student — for what I was doing. And here I was sitting in front of someone who lived through some of the most violent years in modern history, who fought for his country through the worst of times.

I truly felt honored to have been able to participate, in a very small way, in this veteran’s care. I’ve heard that the ranks of men who came back from the 2nd World War are slowly thinning. It’ll be a sad day when the last of these men finally leaves us.

Note: I realize that I was vague about the time this occurred as well as on details of the patient’s service and case. Again, this is to comply with HIPAA regulations and to protect the patient’s privacy.


Sometimes Patients Just Won’t Give You The Answers

Some time ago I saw a patient that came into the clinic with a complaint of cough and congestion that had lasted for longer than the patient was comfortable with. I’ll call this patient, Gloria. Before seeing the patient, I spoke with the attending1 regarding Gloria.

He asked me for my thoughts regarding the differential2, but I didn’t really have a good answer. My first thought was that the symptoms were due to an infection. However, I was already told that this was not the most likely etiology for her symptoms for a couple of reasons: 1) symptoms started about a month ago, 2) blood pressure, temperature, respiratory rate were all within normal range 3) the chest x-ray came back normal, and 4) Gloria’s file showed that she had come in annually around the same time of the year with similar complaints.

At this point, the attending told me that the most likely cause of the symptoms was allergies. And, looking into Gloria’s file I saw that she had a history of allergic rhinitis3. Mentally, I chastised myself for not thinking of allergies. The attending, though, just moved on and ignored my ignorance.

The good thing about being a lowly 2nd year medical student attending clinic is the low expectations — expectations that you probably won’t even be held to. The doctors know that you are still just going through your basic sciences and know that your clinical knowledge/skills still have a ton of room for improvement.

I went to the waiting room, called Gloria inside, and walked her to the exam room. She explained that she had been congested for a month and also had a cough. Her symptoms had a seasonal pattern, occurring around the same time each year. They had also worsened in the days leading up to her clinic visit. This had coincided with the increased winds.

I proceeded to ask for specific symptoms. I asked Gloria about her eyes. I asked if she had any pain. I asked if there was a change in vision. I asked if she had any problems with her eyes. Each time I asked she said, “no.” And so I moved on to other organ systems.

When I finished the interview I listen to Gloria’s lungs. The lung fields were clear with normal breath sounds. Feeling pretty sure it was allergies (and not something more serious like a pneumonia), I left the patient in the exam room and waited for my attending so that we could discuss Gloria’s case.

After reporting my findings to the doctor, he asked if I had done a HEENT exam4. Sheepishly, I told him I hadn’t. Another thing had slipped my mind. He then asked if the patient had any problems with dry, itchy, red, and/or watery eyes since those are common with allergies.

I hadn’t thought about asking specifically, but I told him that I had asked the patient about eye problems in general, and more specifically, about pain and visual acuity changes. She told me she had no complaints about her eye.

Well a few minutes later when the attending pulled Gloria in to see her for himself, he asked her if she had experienced and itching or redness in her eyes. Her eyes lit up. “Why, yes,” she exclaimed.

And I, standing in the corner, shook my head — mentally. Physically, I just kind of looked straight ahead.

Sometimes patients just won’t give you the answers.

  1. An attending physician is a doctor who as completed his or her residency. See here for more details. []
  2. I like to compare a differential diagnosis to a lineup of suspects that may be causing the patient’s complaint(s). Click here for Wikipedia entry. []
  3. Medline Plus: Allergic rhinitis is a collection of symptoms, mostly in the nose and eyes, which occur when you breathe in something you are allergic to, such as dust, dander, or pollen. []
  4. Head, eyes, ears, nose & throat exam []