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.