Week 24: Training Wheels

Note: The “patients” I speak of are actors/actresses hired and trained to simulate real patient encounters.

I remember learning how to ride my first bike. It started easy, with four wheels: two bike wheels and two training wheels. Over time, little by little, inch by inch, my parents would gradually raise the training wheels. With each incremental rise, I would wobble for some time, struggling to maintain my balance, but I would eventually adapt to each change. After much practice, the training wheels were finally safe to remove, and, at last, I was proudly riding my, now, two-wheeled bike…

Tuesday afternoon, we received details about the standardized patient lab we would all be participating in three days later (today). No longer would we have one patient to interview, examine, and diagnose, as expected, but we would rather have two appointments and therefore two separate patient encounters, twenty minutes each. We would not know until speaking with the patient what he or she has scheduled the appointment for, and so, all of the thinking, questioning, and examining would have to be determined on the spot. Unlike the gradual rising of the training wheels on my bike in childhood, I quickly discovered that my PA school training wheels rise much more quickly. And so, today, I found myself standing in front of exam room #9, stethoscope around my neck, waiting to meet my first of two patients. When prompted, I knocked on the exam door three times, and cast my training wheels aside…

My first patient, a middle-aged male, was very pleasant and friendly. He scheduled his appointment for loss of hearing and aching of his right ear with an associated frontal headache. Within seconds of hearing his complaint, I began to think of the most likely causes for his symptoms, like an outer or middle ear infection or preceding sinus infection, for example. After eliciting specific information about his symptoms, it became a bit more clear that the symptoms he was experiencing were likely the result of seasonal allergies. Following the interview, I performed most of the physical exam techniques that I learned in my Clinical Skills class, just to assess his ears, hearing, nose, sinuses, lymph nodes, and throat. The only stumble, in fact, three stumbles, that occurred during this first encounter was due to the uncooperative nature of the earpieces I tried to attach to my otoscope. For some reason, those darn things didn’t want to snap on to the otoscope, as they usually do, and three earpieces in a row popped off of the otoscope and onto the floor before even making it into the patient’s ear. Fortunately, I was able to brush off the stumbles, and I surprisingly still have some earpieces to spare!

Upon entering the second exam room, my second patient, another middle-aged male, appeared to be in bit more pain and distress. He had much difficulty responding to my first question: “tell me, what brings you in today?” The patient complained of a sore throat, difficulty swallowing, and a feeling of something in his neck, and this is what made his verbal responses difficult. Again, a few potential diagnoses came to my mind, some more likely than others, like pharyngitis, tonsillitis, or even an enlarged thyroid gland. He did report that he was suffering from a lot of pain, and that other members of his family were previously ill. After about ten minutes of questioning, I performed a similar exam as I had performed on my first patient, examining this patient’s throat, lymph nodes, nose, and sinuses. He winced as I put pressure on several of his lymph nodes, another sign of pharyngitis, which eventually became my ultimate diagnosis. I felt that this second encounter went more smoothly relative to my first encounter, at least the fluidity of questioning and physical exam techniques (the earpieces decided to cooperate with me this time too!). And so, within forty minutes, I had questioned, examined, and diagnosed two patients. It was my first attempt at what I will likely be doing every day for the rest of my life…and I loved it.

After each encounter, we received feedback from the patients, as usual. The only critique that my first patient reported pertained to my management of time. The allotted appointment time for each encounter was twenty minutes, but I finished about six or seven minutes early with my first encounter, and the patient felt that I might have thought of additional questions to ask him had I stayed those extra minutes. The second patient’s main critique focused on my note taking during the interview. He recommended that, when taking notes, I should angle the clipboard upward and more towards me, such that the patient doesn’t focus on my moving pen or the notes that I am jotting down. Overall, this was an amazing experience, yet again, and I love the feedback that these standardized patients give. I guess just as I once learned how to ride a two-wheeled bike, I’ll eventually become increasingly more comfortable and confident with patient encounters.

Question of the week: True or false: Warfarin promotes blood clotting.

My midterms are finally over (though I have my Cardiology and Pulmonology finals over the next two weeks)! How did you do on your midterm?

Last week’s answers: Three times a day; False (an otoscope); True; Pancreas; A medical setting; The ABCDE rule; An otoscope; 20/15, 20/20, 20/200; Lungs; Electrocardiography

Week 23: Spring “Break”

The professor shuffled three index cards, each labeled with one of the three physical exams (vital signs, skin, and HEENT) we have learned how to perform thus far in Clinical Skills. Spreading the index cards face down on the exam table, the professor then prompted me to choose one of the three cards; the exam written on this card would be the physical exam I would have to perform within fifteen minutes on my patient (a classmate). After practicing each exam option many, many times (at home), I knew that both the vital sign and skin exams would take only half of the allotted time to complete, whereas the HEENT exam would require double that time to complete due to the use of much more equipment (relative to the other exams). In the end, I randomly selected the index card with “HEENT” written prominently across it, and so I proceeded to perform the head, eyes, ears, nose, throat, neck, and thyroid exam on my patient. At some points, especially when using the equipment (opthalmoscope, otoscope…etc), the professor would closely watch my exam techniques (luckily I wasn’t shaking from my nerves), and at other points, the professor would listen to my explanations of why I was performing each test and/or what I was examining during each test. At the completion of the exam, I was relieved to be informed that I only failed to mention one detail of the approximately seventy details I had to examine or mention throughout the physical. And so, as quickly as that, I checked yet another midterm off my list.

All of my other classes progressed well this week. In Lab Medicine we began learning how to interpret blood test results. It’s amazing how much information can be interpreted from a simple blood test, once you know and understand what all of the values imply. In Pharmacology we learned when and how to prescribe medications for the eyes, ears, nose, mouth/throat, and skin. In our final Cardiology class we covered an enormous amount of information from valvular heart diseases (mitral valve prolapse, aortic stenosis…etc) to congenital heart defects (like tetralogy of Fallot). Luckily, my Cardiology final is not until the first week of April…I need much time to learn this information, all of which is exceedingly important. In Pulmonology we learned how to diagnose and treat obstructive lung disorders (asthma, emphysema, chronic bronchitis…etc.) and restrictive lung disorders (fibrotic lung disorders, asbestosis, sarcoidosis…etc.). Finally, today in Epidemiology, I completed the second of my two midterms for this week, and so I left class with a huge sigh of relief.

I am thrilled to be able to say that next week is spring break! Unfortunately, I do have another load of midterms the week I return, but I have never been happier to have the extra time off to study…I’m going to need it. One of these midterms includes the second of three midterms for Clinical Skills, that being a standardized patient lab (which my next blog will focus on). Unlike last semester, where our standardized patient labs focused on breaking bad news to our patients (high breast cancer risk and a fatal brain cancer), this semester focuses on actually diagnosing our standardized patients using the physical exam techniques that we are learning. I like to think of these standardized patient labs now as mini, practice appointments. We will not know what the patient’s appointment is for until we knock on the door and walk into the exam room, so we have to diagnose them on the spot based on the symptoms they report. Since we have limited experience with exam techniques, I expect the patient’s complaint to focus on HEENT, like earache, blurred vision, sore throat…etc., but I can never be so sure with these standardized patient labs. The complaints may be a bit more complex than what I expect…so, stay tuned for the next blog (two weeks from now, since I’m off next week), it’s sure to be an interesting one!

While I’m studying for my never-ending midterms and finals, enjoy a midterm of your own:

1. A P.A. prescribes a medication to be taken “tid.” How many times per day will you be taking this medication? Hint: The “t” gives you the answer.

2. True or false: A P.A. will likely use an opthalmoscope to examine your ears.

3. True or false: Anti-diuretic hormone decreases one’s volume of urine output.

4. Type 1 diabetes mellitus is an autoimmune disease in which the insulin-secreting cells of this organ are negatively affected. What is this organ?

5. In what setting would you expect “white coat hypertension” to occur?

6. You are performing a dermatological exam on a patient and observe a skin lesion. What rule should you apply to thoroughly examine the lesion?

7. Your patient presents with an earache. What piece of medical equipment will you use to examine this patient’s aching ear?

8. Order these visions from best vision to worst vision: 20/20, 20/200, 20/15

9. Pulmonology is the study of the __________.

10. What does ECG (or EKG) stand for?

Last week’s answer: The hypoglossal nerve controls movement of the tongue.

Week 22: Traversing The Canal

          Peering through the aperture of my otoscope, I entered the ear canal of my patient (a classmate). Traversing the canal (after about one or two centimeters), I eventually found the structure I sought to examine. The structure, namely the tympanic membrane (ear drum), glowed, illuminated by the bright light of my otoscope. There it was, my patient’s pearly white, transulent, and definitely uninfected ear drum, the first of many ear drums that I will likely examine.

          This week in Clinical Skills, we proceeded to practice the techniques of an HEENT (head, eyes, ears, nose, and throat) physical exam, with a major focus on ear, nose, throat, lymph node, and thyroid exams. There was a lot of new techniques to learn, but after much practice, I am starting to get used to the variety of tests and hands-on procedures. Next week is our first of three midterms for this class. For next week’s midterm, I will be paired with another classmate, who will pose as my patient. With a professor present, I will randomly choose one of the three physical examinations that we have learned thus far (vital signs, skin exam, or HEENT exam) to perform on my patient. I will perform the randomly selected physical exam while being observed and evaluated by the professor. The physical exam must be performed within fifteen minutes, and in that time I must mention and complete all of the techniques associated with that physical exam to score the maximum amount of points. So this component of the midterm is mainly concerned with assessing our hands-on examination skills. One of the other two midterms is a typical written/multiple-choice exam, and the last of the midterms is a standardized patient lab, which we haven’t received much detail on yet.

          Besides Clinical Skills, this week in Pharmacology we finished learning how to treat infections of the human body, from head to toe (those infections treated with antibiotics). So, as predicted, the list of drugs/doses that I have to memorize quickly grew within the span of the four hour lecture. Overall, the class offers a great review of many of the diseases we learned how to diagnose last semester in our specialty courses, but there is of course always a strong focus on the ultimate treatment of the conditions (assuming they were properly identified/diagnosed from the start). In Cardiology, we focused on hypertension (high blood pressure), from its initial diagnosis to the final management of patients with the condition. In Pulmonology, we focused on the diagnosis and treatment of respiratory tract infections (bronchitis, pneumonia, whooping cough, tuberculosis…etc).  

          This week was a chaotic one. Two, expected, midterms in one week is more than bearable, but when you throw three pop-quizzes, a twelve-hour school day, and a couple of 5:00 a.m. morning wake-ups to the mix, it makes a once seemingly bearable week a bit more exhausting. Luckily all five of these exams (the expected and unexpected ones) all went smoothly. The only thing pushing me through this next week is that spring “break” is in sight. In fact, it’s only one week away! Next week I only have two midterms: the Clinical Skills midterm and a midterm for my Epidemiology course. Unfortunately, we must turn all clocks one-hour forward this weekend. It’s not so unfortunate that it will feel as if I am awakening at 4:00 a.m. Monday morning, it’s more so unfortunate that I will be losing an hour of study time on Sunday. But, what can I do…

Question of the week: The hypoglossal nerve controls the movement of this body structure.

Last week’s answer: Patient A, who has 20/40 vision in each eye, has better vision than Patient B, who has 20/60 vision in each eye. A vision of 20/40 implies that Patient A, when standing 20 feet away from a Snellen eye chart, can read the same horizontal line of similarly-sized letters, that an average patient, with normal sight, can read when standing 40 feet away from the chart (a further distance). A vision of 20/60 implies that Patient B, when standing 20 feet away from a Snellen eye chart, can read the same horizontal line of similarly-sized letters, that an average patient, with normal sight, can read when standing 60 feet away from the chart (a further distance). In general, the lower the second number, the better the vision. 

Week 21: What A Sight

          All fell dark as I stood across from the patient (a classmate) and raised my opthalmoscope for its first use. Peering through the opthalmoscope, I centered its light onto the pupil of my patient. The pupil began to glow, taking on an orange hue, and I steadily inched closer to my patient’s glowing eye with the opthalmoscope. As one peers through a peephole to determine who just rang the doorbell to his her home, I peered through the pupil’s aperture to examine the back surface of my patient’s eye (the retina). After several (and I mean many, many) tries, I was finally able to view several blood vessels penetrating the retina, the main goal of this week’s eye examination.

          This week in Clinical Skills, we began our two week physical examination of the head, eyes, ears, nose, and throat. Focusing mainly on the eye examination, we learned the technique for measuring visual acuity (using a Snellen eye cart), checking reflexes of the pupil, assessing eye movements and proper muscle functioning, and for using an opthalmoscope. An opthalmoscope is fairly easy to use, but staying focused on the retina (back surface) of one’s eye with the opthalmoscope is not so simple. The more dilated (open) the pupil of an eye is, the more of the retina that’s visible, but since we aren’t dilating each other’s pupils in class, we have very little space (a tiny pupil) to work with and peer through. I’ll definitely need more practice to master use of the opthalmoscope, but I was very happy to at least see some vessels within the retina of my patient this week. It’s the little steps that count…

          The rest of my classes also continued this week. In Clinical Lab Medicine we focused on the value of genetic testing, especially as it relates to prenatal screening for a variety of genetic disorders. The intricacy of some of these tests is unbelievable! In Cardiology, we focused on coronary artery disease and the steps to take when a patient presents with “chest pain.” Though not all chest pain is attributable to a heart attack, we focused on the tests/procedures that would be performed if we did suspect a heart attack in a patient. In Pulmonology (study of the lungs), we learned how to interpret ABGs (arterial blood gases), pulmonary function tests, and the basics of analyzing chest x-rays. Although our Pharmacology class was postponed until next week, I’ve still been studying my antibiotics, used to treat bacterial infections from one’s head to toes.

          Endocrinology ended yesterday and the final went well. Again, the time constraint is always the main issue, especially when some questions are seven to eight sentences long, with lists of symptoms to quickly skim through and analyze. I try to have a diagnosis in mind by the time I finish reading through these longer questions and hope that what I suspect to be the issue is one of my five multiple-choice options. Sometimes it’s not as simple as diagnosing, but rather the ultimate question will ask how to best treat the presenting patient. So, if your diagnosis is wrong from the start, your treatment choice will be inevitably wrong as well. Midterms begin next week, and are spread throughout the next month. Next week, the only two exams I have are my Clinical Lab Medicine and Medical Informatics midterms, so hopefully they both start my month of March midterms off well…

Question of the week: You have determined that Patient A has 20/40 vision in each eye. You have also determined that Patient B has 20/60 vision in each eye. Does Patient A or Patient B have better vision?

Last week’s answer: Your patient presents with symptoms, which you identify as those of a common cold. The patient requests that you prescribe him an antibiotic to shorten the course of his cold and alleviate the severity of his symptoms. You should undoubtedly prescribe him the antibiotic he is requesting, right? You should actually refrain from prescribing this patient an unnecessary antibiotic and rather treat him symptomatically. His common cold is likely the result of a viral infection and antibiotics are effective against bacterial, not viral, infections.