You win some....

...and you lose some. We had our practical exams over the physical exam today, and I definitely lost some.

We all got dressed up and slipped into our white coats and stood around, waiting to be told what to do. By the time we actually got into the room, my heart was going a mile a minute (as generally happens before any kind of evaluation). A group of 11 of us were clustered in a room used for ICM (introduction to clinical medicine), sitting along the wall, all facing the patient sitting on an examination table. The proctor and a 4th semester student sat behind a desk facing us, and, like pagan fortune-tellers, laid out the cards that would determine our fate. People did their tasks - everyone missed a few things, and thankfully the girl before me picked the JVP card (jugular venous pressure). So, it came to my turn, and I drew the examination of the respiratory system without auscultation.

This is a really, really long one. Some of them - like the examination of the spleen, or the search for ascites - are very short, including only about three tasks. Mine however, was doozy. First I greeted the patient and commented on the symmetry or her chest wall, noting the lack of abnormalities. I made sure that her trachea was in the middle (deviation is an ominous sign), and that she wasn't in any visible cardiorespiratory distress. Then I palpated for tenderness, checked her AP diameter, and started percussing. I've gotten pretty good at it; the body is like a drum, and different sounds tell you different things. Resonance in the lung fields is good; it means that there's air where there should be air. Dullness, however, can signal a mass or lobar pneumonia. That complete, I moved on to diaphragmatic excursions - the idea is that you have the person exhale all of the air in the lungs, an percuss down their lung-fields until you hear dullness - the signal that you've reached the diaphragm. Then you have them breathe in as deeply as possibly, percuss again, and measure the difference. This is one way of determining diaphragmacit paralysis, and it's a hell of a lot easier to do when your patient takes a deep breath when requested, and exhales when requested, and sits up straight when requested. The local Dominican woman who posed as the patient for our exam clearly didn't want to be there, and made the whole thing difficult. It was like she couldn't be bothered to comply with any but the most simple of requests.

It was very annoying, but even if she'd been the best patient imaginable, I doubt it would have changed much for me - I forgot to measure the respiratory rate, I forgot to have her cross her arms, and to continue the examination on the front of the thorax. I answered the follow-up question like an encylopedia, though ("Please define Kussmaul Breathing"), and I did everything else, so I may still make it out of this experience with an A.

The Behavioral sciences have launched all their salvos as once, it seems - next up is the interview (which is worth significantly more of the grade), and then the itnerview write-up. Also, the questions for mini three, instead of differentiating between the types of schizophrenia, or epidemiological inferences, will be composed of psychopharmacological details. So, I've got some work ahead.