A Retrospective Review

Today, my preceptor group had its last of ten sessions together. I have had the great fortune of working with an amazingly thoughtful, intelligent, and patient preceptor as well as three hardworking, clever, and insightful classmates. It is amazing looking back at my previous admission notes (e.g. patient write-ups on admission) and seeing how far my preceptor has guided me along my developmental path. I have previously kept a brief record of my clinical experiences on this journal, but I unfortunately lost that information prior to my weblog’s migration to a new server and address. Nonetheless, I would like to chart my progress on this journey thus far: one of the most convincing and meaningful arguments for the length of medical training for physicians is the importance of exposure. When you have examined and worked with a patient with a particular condition, asked a particular question, or performed a particular physical exam maneuver once, the intricate web tying the patient, pathology, social circumstances, examination, and treatment is forever burned in one’s memory. And so, as a quick self-reminder, anonymous and indistinguishable to all but me:

Cases

1. A 55-year-old man with several ulcerated, discharging skin lesions behind his left shoulder and deep pain in the shoulder. Diagnosis: osteomyelitis of the left shoulder and a potential recurrence of lung cancer. The lung cancer may have exhibited local spread to the shoulder, triggering the deep tissue infection.

2. A 68-year-old woman unable to lift her right leg. She felt “pins-and-needles” in her right leg, then felt it was “heavy as lead,” and then felt “jabbing” pains in her right knee and neck. Diagnosis: spinal stenosis.

3. A 36-year-old nurse with vomiting, nausea, “churning” abdominal pain, and 10 pounds of weight loss in the past month. He was HIV+ with AIDS. Diagnosis: HIVAN (HIV-associated nephropathy).

4. A 57-year-old with a one-week history of incapacitating weakness, coughing, fever, productive cough, and shortness of breath. Diagnosis: CAP (community-acquired pneumonia).

5. A man with very painful periorbital headaches of short duration. He was HIV+ with AIDS and slowed mentation. Diagnosis: cryptococcal meningitis and HIV dementia.

6. A 26-year-old man with severe, persistent pain in his inner thighs, tea-colored urine, and a highly elevated CK (creatinine kinase). He reported no trauma, excess alcohol use, street drug use, or medication use. Diagnosis: rhabdomyolysis (of unknown etiology).

7. An 84-year-old woman with shortness of breath and a productive cough unrelieved by use of her asthma inhaler. Diagnosis: atopic asthma (exacerbation) and CAP (community-acquired pneumonia).

8. A 54-year-old man coughing up blood clots without mucus, “stabbing” epigastric pain, unspecified weight loss, and a rapid onset of full-body non-pruritic red macular rash. He reported a 2-month history of a “flu”-like illness. Diagnosis: secondary tuberculosis, syphilis (latent), chronic HCV, polysubstance abuse, bipolar disorder.

9. A 60-year-old woman with a 2-month history of difficulty breathing (shortness of breath, dyspnea, and orthopnea), “flu,” “diarrhea,” and weight loss and a recent traumatic fall. She was very restless and irritable during the interview and did not tolerate a full physical exam. Diagnosis: congestive heart failure, with hyperthyroidism as the likely etiology.

10. A man with prominent scleral and sublingual icterus.

Statistics and Observations

• Used my diagnostic set (ophthalmoscope and otoscope) during 4 out of 9 physical exams. Used the ophthalmoscope 3 times to rule out papilledema (my ophthalmological skills need significant improvement, but I can now regularly examine the optic disk using a coaxial head in a lit or unlit hospital room). Used the otoscope with specula once to examine nasal passages (e.g. atopic asthma with severe sinus congestion – hold your breath!).

• Entered respiratory isolation at least 3 times using N-95 masks where patients were suspected of having tuberculosis. Performed two patient interviews and physical exams wearing N-95 masks (obstrusive, but necessary).

•  Using my Littman Master Classic II stethoscope was at first difficult due to the tendency of the rubber tubing to brush against skin and impede efficient and effective auscultation of the heart. I have since found ways of stabilizing the tubing to prevent this from occurring, but I still question my choice of stethoscopes.

• I have yet to use my 256 Hz tuning fork or reflex hammer when examining an inpatient. I have not been carrying these with me, but this may change during my third and fourth year clinical clerkships. On the other hand, my stethoscope and penlight are always used.

• Practiced writing admission notes, admit orders, and outpatient prescriptions.

• Found many of the experiences very challenging and difficult, but I feel much more prepared for inpatient clinical care now.

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