Yesterday, my patient was a 37 year old man who was complaining of a dry cough for two weeks and progressive shortness of breath. He said he's had a heart murmur ("Something is wrong with my aorta valve," he said) since birth. And when I was asking him more about this cough and shortness of breath (SOB) he said that it's worse upon exertion, and at night, he can't lie flat to go to sleep; he has to use two to three pillows under his head. This is a classic sign of congestive heart failure-- it's called orthopnea, where basically fluid rushes to your lungs when you lie flat and so you have to be propped up. And so all signs led me to congestive heart failure, and I was like, bam, I got this!
So I started my physical exam and his pulses were fine, his respiratory rate was a little high, muscle power normal, cranial nerves intact. His lungs sounded clear. I palpated his abdomen and couldn't really figure out where his liver and spleen were, but I attributed that to the fact that I'm not very good at palpating those organs. And then I listened to his murmur. A loud whooshing sound as soon as I put my stethoscope to his chest. I probably could have heard it even without my steth! It obliterated his normal heart sounds. I could here it on the midline, but when I went to hear it above his mitral valve (which is like by the 5th rib, close to your left mid-clavicular line) I couldn't hear anything. Not even heart sounds. Just silence.
Part of me panicked. Was my patient going into heart failure as I was talking to him? Why couldn't I hear anything? And then part of me blanched. How stupid is my attending going to think I am, that I can't even hear the heart! Should I lie and say I did? Should I say I didn't and risk humiliation?
In the end, honesty won out. My attending ridiculed me a little bit, but said that we could check it out afterward. He laughed when I told him I couldn't palpate the liver, which made me feel a little small. By the time I was done presenting, my attending and I agreed that signs pointed to congestive heart failure, so we decided to go with that, while we checked his labs.
Oh, how wrong we were. Our patient was severely hypoxemic (he didn't have enough oxygen!- only about 50% as much as he should have been getting!) and as a result, his kidneys were releasing massive loads of this protein called erythropoietin, which goes and stimulates red blood cell production. So my patient was making astronomically high levels of red blood cells- so much so, that his blood had become ridiculously viscous. Like sludge. (Polycythemia, is what it's called.)
But then we came across the problem of trying to figure out why he was hypoxemic in the first place. So we went back to congestive heart failure once more. To see if we were right, we checked his CT scan, to check his heart, to see if it was big. And our jaws dropped. I think I squeaked.
Everything was wrong. Backwards, in fact. My patient had an EXTREMELY rare condition called Situs Inversus Totalis, which means all his organs were flipped. His liver was on the left. Spleen was on the right. Even his lungs were flipped! And his heart- he had dextrocardia. His heart was on the right side. Which is why, when I tried to listen on the left, I heard nothing. Situs Inversus Totalis. We learned about it in class a few weeks ago, and the only thing I could think was- that is SO COOL. It sounds like a spell from Harry Potter.
Now, I'm not sure why SIT would cause hypoxemia- maybe his enlarged heart was compressing on the aorta, and that, compounded with his leaky valve was doing the trick. I'm going to leave that up to the real doctors. I'm just going to bask in the glory that my second patient ever had a condition that was so rare, that my smart-ass, stick-up-his-butt (but ultimately a good teacher) attending had never seen it in his 30 years of practicing. Hmph!
Oh, and in case you are wondering how we treat for polycythemia (the sludge blood)? We blood let them. Yup. Leeches to Room 1088, stat!
Friday, February 25, 2011
Sunday, February 20, 2011
The Saline Burn
This post is going to be a little bit introspective, so I hope it doesn't bore you. I could promise you tall tales of doing my first physical exam on a patient (30 year old man presents with increased bloody urination with pain on voiding for 5 days) but I have to say that the experience was quite pleasant. My patient was a plump young man, who was very forthright with his answers to my incredibly prying questions, and who asked me why I was doing each of the maneuvers and what they told me. The teacher in me kicked in, and I had a really good time! That is, until my attending pimped me and I realized that I hadn't asked half the questions that I was supposed to ask, and I'm terrible at coming up with differential diagnoses. (He had cystitis- inflammation of the bladder- in case you are interested.)
This post is mostly dedicated to becoming absurdly comfortable with one's own body during medical school. Now, my college roommates can attest to the fact that not-so-many years ago, I was the girl who tried to shove herself in the closet to change her clothes. Ashley, one of my roommates, was on the field hockey team, and so she was pretty used to being almost-naked with a bunch of other people. (Hi Ash!) My other roommate, Cara, had a history in theater, which requires a whole set of comfort levels about one's body that I don't think I will ever, ever, reach. To put it bluntly, I was a prude. (Acceptance is the first step to recovery, right?)
And then, fast forward to medical school. I dissected a human body (Oh, Lucille, I miss you!) during my first year, which forced me to discover and confront things about anatomy that I never knew about it. Is that really what a heart looks like? A uterus with fibroids? Fatty breast tissue? And then this year, it's all about getting comfortable with what a live body looks and feels like.
We had these Teaching Associate sessions, where a highly trained (and I'm serious when I say that-- they had more knowledge than me, easily!) professionals used their bodies as teaching tools. I learned how to do a breast, pelvic, and male genitourinary exam on real live human beings. In fact-- while I was doing it, they were talking to me and coaching me! That was weird. (My weirdest experience was when I was doing the male GU exam, and I was lifting my patient's scrotum with two hands -which is apparently not the best way to do it, since he had "very sensitive epididymal heads"- and he stopped me - yes, while I was still holding his scrotum - to give me a 3 minute lecture on good scrotal lifting techniques. I was like, wtf is happening.) And vaginas? Yeah, not so much of a fan of doing those exams. At least my lady didn't have her period...
But all of this is to say that I was shoved into these small rooms and had to get over my fears absurdly quickly. In fact, there was even no time to say goodbye to them! Whoosh, they were gone.
And in ECM (one of the most useless classes that we all have to take) we had to practice all of the non-invasive parts of the physical exam on each other. It made me appreciate what I am going to put my patients through, you know? When my partner was palpating my abdomen (which basically means pressing down really hard on my stomach) or checking for costovertebral angle tenderness (punching my back near my kidneys), I really couldn't complain, since I knew that I'd be doing these things to my patients in the future, and how hypocritical would that be? I felt the same way when I went to get blood drawn. If you know me, you know that I have terrible veins, simply terrible. So they have to stick me at least 3 or 4 times to get a good one. And I used to complain and flinch and bite my lip. Now I find myself taking it stoically, because if I can't handle it, how can I inflict that on my patients?
I find that I'm absurdly comfortable with my body now. I don't mind rolling up my pant legs so that my partner can check my popliteal pulses (in the back of the knee) or taking off my shirt in class (that sounds weirder than I meant for it to) so that my lungs could be auscultated. And I'm not really sure when that happened. But boy, am I glad it did.
There's still a lot to learn though, specifically in terms of overcoming my own fears of contracting a disease that my patient has, while actually doing a good physical exam. One of my partner's patients last week had MRSA septicemia. (MRSA is an aggressive, antibiotic resistant bacteria, and septicemia means that it's basically running rampant through the blood.) Plus, she had pneumonia, so she was coughing all over the place. Even though I could have gone with him to help examine her, I refused to go within a ten foot radius of her room. And even then, I compulsively washed my hands every 10 minutes or so.
The title of this post comes from the one thing that I am still a baby about. Now, giving PPDs are like the easiest things ever, even though it can seem a little scary. The needle goes just below the skin, and you only insert it until the beveled edge has disappeared (maybe 2 mm). And then you squirt the solution under the skin and watch a little bubble form, and then you are done!
But before you are allowed to use the actual tuberculin solution, you have to practice. With saline. Saline is just saltwater, so you'd think that it would be no problem, right? Wrong. I had to stop my partner from injecting the entire amount, what was it- maybe .1 cc? Because that stuff BURNS. And then, when you're done, it itches like WHOA.
Talk about salt on your wounds, huh?
This post is mostly dedicated to becoming absurdly comfortable with one's own body during medical school. Now, my college roommates can attest to the fact that not-so-many years ago, I was the girl who tried to shove herself in the closet to change her clothes. Ashley, one of my roommates, was on the field hockey team, and so she was pretty used to being almost-naked with a bunch of other people. (Hi Ash!) My other roommate, Cara, had a history in theater, which requires a whole set of comfort levels about one's body that I don't think I will ever, ever, reach. To put it bluntly, I was a prude. (Acceptance is the first step to recovery, right?)
And then, fast forward to medical school. I dissected a human body (Oh, Lucille, I miss you!) during my first year, which forced me to discover and confront things about anatomy that I never knew about it. Is that really what a heart looks like? A uterus with fibroids? Fatty breast tissue? And then this year, it's all about getting comfortable with what a live body looks and feels like.
We had these Teaching Associate sessions, where a highly trained (and I'm serious when I say that-- they had more knowledge than me, easily!) professionals used their bodies as teaching tools. I learned how to do a breast, pelvic, and male genitourinary exam on real live human beings. In fact-- while I was doing it, they were talking to me and coaching me! That was weird. (My weirdest experience was when I was doing the male GU exam, and I was lifting my patient's scrotum with two hands -which is apparently not the best way to do it, since he had "very sensitive epididymal heads"- and he stopped me - yes, while I was still holding his scrotum - to give me a 3 minute lecture on good scrotal lifting techniques. I was like, wtf is happening.) And vaginas? Yeah, not so much of a fan of doing those exams. At least my lady didn't have her period...
But all of this is to say that I was shoved into these small rooms and had to get over my fears absurdly quickly. In fact, there was even no time to say goodbye to them! Whoosh, they were gone.
And in ECM (one of the most useless classes that we all have to take) we had to practice all of the non-invasive parts of the physical exam on each other. It made me appreciate what I am going to put my patients through, you know? When my partner was palpating my abdomen (which basically means pressing down really hard on my stomach) or checking for costovertebral angle tenderness (punching my back near my kidneys), I really couldn't complain, since I knew that I'd be doing these things to my patients in the future, and how hypocritical would that be? I felt the same way when I went to get blood drawn. If you know me, you know that I have terrible veins, simply terrible. So they have to stick me at least 3 or 4 times to get a good one. And I used to complain and flinch and bite my lip. Now I find myself taking it stoically, because if I can't handle it, how can I inflict that on my patients?
I find that I'm absurdly comfortable with my body now. I don't mind rolling up my pant legs so that my partner can check my popliteal pulses (in the back of the knee) or taking off my shirt in class (that sounds weirder than I meant for it to) so that my lungs could be auscultated. And I'm not really sure when that happened. But boy, am I glad it did.
There's still a lot to learn though, specifically in terms of overcoming my own fears of contracting a disease that my patient has, while actually doing a good physical exam. One of my partner's patients last week had MRSA septicemia. (MRSA is an aggressive, antibiotic resistant bacteria, and septicemia means that it's basically running rampant through the blood.) Plus, she had pneumonia, so she was coughing all over the place. Even though I could have gone with him to help examine her, I refused to go within a ten foot radius of her room. And even then, I compulsively washed my hands every 10 minutes or so.
The title of this post comes from the one thing that I am still a baby about. Now, giving PPDs are like the easiest things ever, even though it can seem a little scary. The needle goes just below the skin, and you only insert it until the beveled edge has disappeared (maybe 2 mm). And then you squirt the solution under the skin and watch a little bubble form, and then you are done!
But before you are allowed to use the actual tuberculin solution, you have to practice. With saline. Saline is just saltwater, so you'd think that it would be no problem, right? Wrong. I had to stop my partner from injecting the entire amount, what was it- maybe .1 cc? Because that stuff BURNS. And then, when you're done, it itches like WHOA.
Talk about salt on your wounds, huh?
Subscribe to:
Posts (Atom)