Weeks 37 & 38: Stuck In The Middle

Note: The “patients” I speak of are paid actors/actresses, hired to simulate real patient encounters for us students.

Last Wednesday, at 1:30, I found myself standing in front of examination room #12, waiting for the cue to knock on the door and meet my first patient for the day. When instructed to enter the exam room, I knocked three times, entered the room, and introduced myself to my patient, a middle-aged female, who seemed relatively at ease. When I inquired what brought her to the office, she stated that a few nights ago, while watching her favorite television show, the right side of her face drooped and the entire right side of her body (arm and leg) became paralyzed for a short period of time. My immediate thought was that this patient experienced a temporary stroke (called a transient ischemic attack). After asking a variety of questions to get a more detailed description of the patient’s symptoms throughout the event, in addition to her past medical history (including a long history of smoking), it became more clear that a transient ischemic attack was indeed the most likely diagnosis. I performed a neurological physical exam to assess her muscular strength, sensory capabilities, and to ascertain the presence of all of her reflexes. The entire neurological exam takes quite a while to do (too long for a twenty minute appointment), so I had to tailor the exam a bit more to her main complaint. When I was warned that two minutes remained for my encounter, I quickly completed the patient’s physical exam and provided my impressions and recommendations. The patient was very concerned that she had experienced a stroke, and actually asked me if this was the case even before I began stating my impressions. I tried to calm her down as best as possible and explained that the form of stroke she had experienced was a temporary one, and to avoid future cases of the same episode, she may consider smoking cessation to minimize her risk for recurrence. At 1:50, I was instructed to leave the exam room, and, as quickly as that, my first appointment was complete.

At 2:00, I knocked on the door of exam room #9 and introduced myself to my second patient, an older female who appeared to be in a bit of discomfort. Once again, I asked this patient what brought her to the office, and she reported that she was experiencing frequent migraine headaches. She reported a history of migraines since adolescence, in addition to a family history of them, so my diagnosis was fairly clear from the beginning of the encounter. I proceeded with the neurological exam, and completed the physical components that I thought were most pertinent to this patient’s complaint (assessment of her cranial nerves). This encounter was a bit different than those of the past in that all of the patient’s responses painted a clear picture of a classic migraine headache. So, most of my questions were tailored to ruling out other, more serious, causes for her headaches (at worst, a brain tumor). My ultimate advice for this patient was that she should discontinue the current medication that she was taking to try to alleviate her discomfort, and I would rather prescribe her a stronger medication, specifically targeted to prevent the onset of her migraines (and all of the symptoms associated with them). At 2:20, my second encounter ended, and yet another patient encounter was complete.

I remember my first simulated patient lab one year ago, when I couldn’t hold my pen still from my uncontrollable anxiety and hand-shaking. At last, I found that during these two encounters especially, those nerves dissipated. This time, both patients reported (during feedback sessions) that I seemed very calm, unrushed, and confident throughout my questioning and while performing my physical exam techniques. It only took five or six encounters, but I finally feel like I’m getting even more comfortable with the patient communication and especially with eliciting all of the information I need during the limited amount of time provided for each appointment. My last two encounters of the semester are next month, so hopefully I get similar feedback after those (I’ll always be a bit nervous though! The cameras in the exam rooms don’t help…).

The past two weeks, as apparent by my skipping yet another weekly post, have been unrelenting to say the least. I’ve had midterms/finals for a handful of classes (Clinical Skills, Pharmacology, Health Promotion/Disease Prevention, and Hematology/Oncology), in addition to my physical exam practical (where the professors observe us performing the neurological exam on one another), and the two patient simulations. In other words, I haven’t had much time to breath. Honestly, I’ve lost count of how many classes I’m taking at one time, something like nine or ten. Last week, a new specialty class began, Psychiatry, and we focused on diagnosis of depression and a variety of other mood disorders. This week, a second specialty course began, Neurology, and we focused on the diagnosis and treatment of stroke, in addition to the methodology of localizing in what region/vessel of the brain the stroke occurred based on the patient’s presenting symptoms. In Pharmacology, we discussed a variety of psychiatric drugs (like Xanax), including anti-anxiety and sleep-aid medications. I only have two more finals next week, General Surgery and Obstetrics, and then I am FINALLY done with midterms and finals for a long while. Next Friday cannot come soon enough…

Here’s your midterm for the semester:

  1. Late in pregnancy, a female’s cervix may dilate as much as ____ centimeters leading up to delivery.
  2. Your 65-year-old patient complains of right-sided hearing loss. What do you suspect is the most likely cause of your patient’s hearing loss?
  3. You are performing a prostate exam on your 52-year-old patient. You estimate his prostate size to be 3.6 centimeters. This is the average size of a male prostate, right?
  4. True or false: Butter is an example of a saturated fat.
  5. Bonus question: How many days are there between today (Friday night) and the first day of my rotations: 317, 219, or 178 days?

Last week’s answer: Were you able to count down from the number 100 by intervals of 7? This is one of several components of the frequently used mini-mental state exam. This question assesses the patient’s attention and calculation abilities. Don’t worry if you couldn’t complete the count-down task. A variant used to assess attention in those who struggle with numbers is to ask them to spell the word “WORLD” backwards.

Weeks 35 & 36: Doubling Up

Well, it was bound to happen. After thirty-four weeks of consistent blog posting, I couldn’t find even one hour to spare last weekend to write about my thirty-fifth week of PA school. With the thesis project to balance on top of everything else, time was a bit sparse this past week. But, the great news is that my group successfully made our first research deadline (this past Tuesday), so all the time spent/hours of sleep lost paid off in the end. Approval of our research concept is still pending, but our next deadline is not until late November, so I’m thrilled that I can devote the bulk of my time now to studying. I’ll catch you up on the events of these past two weeks…

In the past two weeks of Pharmacology, we focused on drugs used in the treatment of thyroid disorders and conditions of the gastrointestinal system (diarrhea, constipation, nausea/vomiting…etc). This week, we learned how to calculate doses of drugs for pediatric patients, most of which must be dosed based on the child’s weight. We also began practicing how to write these prescriptions out on prescription pads. Much care must be taken at this step to avoid any ambiguities and ensure that the pharmacist and, more importantly, the patient correctly carry out our instructions. In Surgery, we focused on the surgical correction of gallbladder and liver abnormalities (gallbladder stones and cirrhosis of the liver). We had our midterm for this class last week, and it was one of the tougher exams that I’ve taken thus far in PA school, but not the worst. In our final class of Hematology/Oncology, we focused on the diagnosis of various platelet/clotting disorders (hemophilia), and our final for this specialty is in a couple of weeks. Next week, we begin our next two specialty courses: Psychiatry and Neurology. The past few weeks of my Health Promotion/Disease Prevention class have focused on educating patients about nutrition and exercise, tobacco/alcohol abuse cessation, and screening/treatment for sexually transmitted diseases. Today, we completed our final class of Obstetrics, and focused on management of premature births and postpartum care of both the mother and her newborn. So, yes, my brain is a bit saturated at the moment. I don’t think I’ve crammed so much new information into my head all at one time before…

Next week, midterms begin! I start with my Pharmacology midterm on Tuesday, and I have the first (of two) standardized patient labs of the semester (for my Clinical Skills class) on Wednesday. Thus far in Clinical Skills, we have mainly learned the techniques of the neurological and psychological physical exams, so I definitely expect the patient complaints to center around these two systems. Maybe they will present with muscle weakness of the arms or legs or with loss of sensation in a specific area of their body…who knows, I can never really predict accurately. Next week’s blog will focus on these two patient appointments (should be interesting, as always).

It’s unbelievable that I’m already six weeks into this semester, and clinical rotations are just around the corner (233 days away). Without going into too much detail, our clinical phase lasts fifty-two weeks and consists of eight rotations, some of which are four weeks and others eight weeks. One of the eight rotations is an elective, which means we can select a specialty of our own interest. I have a few in mind, including pulmonary medicine and endocrinology, but I definitely have some things to think about in the upcoming weeks…

Question of the week: Can you count down from the number 100 by intervals of 7? See how far you can get, and I’ll explain the significance of this test next week. Starting counting! I’ll start you off…100…93…86…

Last week’s answer: Unsaturated fats (like oils) are a healthier form of dietary fat than saturated fats (like butter).