My New Patient Narrative, Part I

Last year, in our Medicine in Society course, we had to write our own "patient narrative."  As future physicians, it is easy to forget what it means to be sick, even though we will see sick people every single day.  We tend to forget what it means to be sick ourselves, since we're supposed to be the healthy ones, caring for those in need.  So, each of us discussed a time in our lives when we were ill, and what it was like to be a patient, how we felt, etc.  (See September 2009 post: The Story Behind the Story).  I argued that I have never really been "ill" although I've been sick quite frequently.  To be "ill" implies something much more than a common cold or the seasonal flu. Illness is more serious, and it has just as much to do with access to health insurance and socioeconomic status as severity of disease.  I argued that even in my sickest, I have never been ill.  I still have yet to be ill; but if I were writing that assignment today, I would use a different story.

Before I started school, I was told there are two types of med students: those who think they have every disease they learn about, and those who believe they are invincible.  I now know that I fall into the former category.  Copious purulent sputum?  That used to be a run-of-the-mill sinus infection for me, but now it's bronchiectasis from primary ciliary dyskinesia.  Headache and disorientation in the morning?  Not from drinking.  It's probably encephalopathy due to acute liver failure.  So it should be no surprise that when I had my blood pressure last checked, the high reading made me think I was 3 months away from my first transient ischemic attack.

On the offhand chance it was worth checking out, I mentioned this to my friend Klara Klein during this year's Cardiology block.  Klara is my resident cardiologist, since her dad is a real one here at UNC.  She ran it by her pops, and the next thing I knew I was getting my first ultrasound.  Now it is important to note that there were a couple steps in between.  I did see my primary care physician, and we did check my blood pressure consistently over a 1 month period (and it was consistently high).  I never had a reading under 135/85, and most were in the 140/90 range.  This is unusual in a slender, former athlete, who eats fairly healthy and is sodium conscious.  So the recommendation was to go on a low dose diuretic.  It's dirt cheap and would lower my pressure about 10-15 points, about what I need.  The only downside would be that I would have to pee a bit more in the mornings. I did want a second opinion, though, if I was going to be on a medication for the rest of my life.

On principle, I would like to be taking as few medications as possible, i.e. zero.  With the exception of the weekend brews, I want to keep my body as drug free as possible.  But I've also held in my hand the aorta of a hypertensive 40 year old man who died of an aortic aneurysm.  Hypertension is a silent killer.  It may take decades of high blood pressure to kill you, but it will do just that.  It was the experience of actually feeling the rough atherosclerotic plaque, and comparing it to the smooth, normal aorta, that pushed me over the line. If I need to do something about my health, I might as well start now.

The echo was meant to see if I had any congenital abnormalities that would cause my blood pressure to be abnormally high.  It was not meant to see what it did...  that I have a large right heart.  Now initially I thought that was a good thing (doesn't it just mean I have more room for love?!?), but I have taken enough cardio to know that this is abnormal.  There are numerous etiologies to "big right heart" syndrome, such as pulmonary hypertension or atrial septal defect (ASD), or it may be just idiopathic, and that's just who I am.  But it's important to rule out these pathologies first.  So, next thing I knew, I had a "bubble study," where bubbles of normal saline were shot into my right arm to see whether any bubbles crossed into my left atria from the right (it's a very cool study; you can see your heart and the bubbles in real time on echo!).  If they did, that would show that there's a hole between the two atria (ASD), and that hole could be closed with surgery.  That test was negative, and an MRI was indicated to r/o (rule out) other etiologies.

I have simplified the tests, appointments, and discussions because they have all gone by very quickly.  But I won't gloss over the fact that I have been a bit apprehensive during this entire process (which can't help my blood pressure).  My father has made fun of me because many of my stories have become more morbid over the past year and a half.  If all you learn about are things that go wrong, then the cup is half empty.  We have learned about some serious conditions that are associated with right atrial and ventricular hypertrophy, and frankly it's a bit unnerving.  Whatever the mechanism, this could have gone unnoticed for decades.  It is scary to think that I've had no control over whatever is going on.

If you haven't experienced an MRI, it's best to stay away.  Frankly, I think every med student should have to have one, just so we know what we're putting our patients through.  I sat in that tiny little tube for an hour and a half with loud beeping and banging going on constantly.  It was uncomfortable, but I know there are people who have to have MRIs much more often than I do (my mother for one).  But for me, to what end?

A cardiac catherization has been thrown around as an idea to find out what the pressures are in my heart, but since we probably won't do anything about it yet, there's no reason to rush.  So, for now we monitor.  The MRI looked clean (except for my monstrous coronary arteries which received "highest honors" for their impressive size).  It is probably nothing.  Most likely, this is just who I am.  I have a weirdly large right side of my heart.  It will probably never affect me, and I will live my life like nothing happened.  Every few years I will have an echo to keep an eye on it.  It certainly didn't affect me as a swimmer, and if I want to go out and run 10 miles tomorrow, I know that I can still do that.  However, deep down I was hoping they would find something.  Something fixable.  That way I would know.  If you know what's going on, you have some control over the situation.  The ambiguity is disheartening (pun intended).  In all seriousness though, the word "idiopathic" has suddenly become personal.

Know Thyself

Last November, the United States Preventive Services Task Force (USPSTF) published a controversial article in the Annals of Internal Medicine, creating a firestorm in the general media as well as the medical profession.  In brief summary, it recommended against routine mammography for women under 50 years old and over 74 years of age.  The USPSTF also failed to find evidence that at-home self breast exams and exams in a clinic resulted in a decrease in breast cancer mortality, ultimately "recommend[ing] against clinicians teaching women how to perform breast self-examination" (see citation at the end).  These guidelines created such a brouhaha, that Congress felt the need to legislate against the use of these recommendations regarding mandatory insurance coverage.  The Patient Protection and Affordable Care Act signed into law this past March requires that insurance companies cover "evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force [PPACA as amended, Section 2713(a)(1)]," but...

For the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography and prevention shall be considered the most current other than those issued in or around November 2009.  [PPACA as amended, Section 2713(a)(5)].

Now I have not read enough of the literature to comment confidently on the utility of these guidelines.  I have read articles from different groups that support or refute this science.  The scientific community seems to fall into both camps, and I'll let them debate the merits of mammography and biopsies.  Personally, I have difficulty supporting the idea that Congress should be able to strike down science as worthless, but that discussion is for another blog.  Today I am more concerned about the recommendations not to teach women a self-breast examination (SBE).  Having learned the full breast exam this past week, and having a mother who is a breast cancer survivor, I feel the need to tackle the SBE head on.

We can't screen every person for every disease; it's that simple.  We just don't have the resources or the money.  Most people would say that if there was a test that costs $10,000 to catch 1 person in every 1,000,000,000 from dying, screening wouldn't be an option.  However, if it is easy, cheap, and noninvasive to screen for a fairly common problem, then why not?  The gray area becomes significant, however, when costs go up and the number needed to treat (NNT), or screen, increases.  If the likelihood for developing breast cancer in your 40s were 1 in 2, everyone would be screened.  But what about 1 in 20, or 1: 50, or 1:2000.  Mammograms, MRIs, and biopsies do have associated morbidities, so when does performing the test outweigh the risks?

Here I make an argument for an easy, inexpensive, noninvasive test.  A test that actually costs nothing. A test that any woman can be taught.  A test that doesn't require any high-tech diagnostic equipment or special procedures.  This test requires just a few minutes of your time and two hands.

Subjectively it makes sense that a self-breast exam would be a wonderful screening tool for early prevention.  Women are recommended to start monthly self-screenings after their first menstrual cycle, but rarely do.  The key is to learn what "normal" feels like.  Say a woman starts these monthly exams at age 15.  By age 45, she has performed about 360 self exams.  You better believe that she will know something is different or wrong if she feels an abnormal lump or a round calcification on her 361st exam.

Being an athlete I have a tendency to use sports analogies.  When I was swimming, we used to take our heart rate at least a few times a practice.  This was fairly regular by the age of 14, and aerobic sets were a huge part of my training even through college.  If, during this time, I averaged seven practices a week, with 1 HR reading each day, that's 1 reading x 7 days a week x 50 weeks a year with breaks x 8 years.  That's at least 2,800 times I took my heart rate (and I can assure you that I've taken it much more than that).  The key is that, by the end of college, I didn't even have to count the actual heart rate.  I could feel my pulse and know immediately if it was 140 or 170 beats per minute.  In reality, I didn't even have to take my pulse.  I could estimate HR very accurately by my swimming pace, or by how exhausted I was at the end of an interval.  I knew my body.

Example #2.  My preceptor, a pediatrician, has been guessing the weight of children since the beginning of his residency.  He estimates the weight of every child that comes into his clinic, and then puts the child on the scale.  After almost 30 years, he has it down to a science.  He has no need for the scale because he's seen thousands and thousands of children, and weighed them all.  He knows their weight through experience and repetition.  (And now you know how those people at the state fair guess your age and weight... it's all practice, with a little bit of technique!).

It's hard for me to understand why, if providers properly and thoroughly teach women how to do a self-exam, and if women consistently perform this test monthly, we won't see results.  Women are recommended to do the exam a few days after their cycle when the breast is the least tender.  Some breasts have normal lumps, and these lumps may change throughout the cycle.  So it is important to identify "normal" at the same time each month.  These lumps can be identified during a clinical exam, and women can be taught what is normal and what is abnormal (NB: per our teachers: if it feels like a frozen pea, you might want to consult your physician).  So why shouldn't we empower women to know and understand their bodies?  Nobody knows your body better than you.  Shouldn't we empower patients to help their providers know their bodies just as well?  Especially because we may only see a patient once a year.

I've written numerous times about the patient who was assigned to me last year during Medicine and Society.  She is a perfect example of this empowerment.  A few years ago, she developed a pain in her side.  She already had had one bout with cancer, and this pain felt much like the onset of years before.  When she told her physicians, it was initially dismissed, but they agreed to run a few tests.  The tests came back negative, but she pushed and pushed.  Something was wrong, she could feel it, and it felt like cancer.  A couple appointments later, 3 liters of fluid were drained from her thorax, and the cancer was back.  She knew her body.

I won't refute the scientific merits of the USPSTF's recommendations; that battle is for the experts.  I personally think we overmedicalize here in America and we test too damn much.  But, if the test is free, easy, and noninvasive, why not?  Women can learn the SBE through pamphlets or during a normal exam.  It doesn't even take much of the provider's precious time.  It's simple.

So why not?  Learn the self-exam, do it every month, and know thyself.


US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2009 Nov 17;151(10):716-26, W-236.

The Pelvic Exam

I am not exaggerating when I say that for some of my colleagues, yesterday was the most terrifying day of their medical school careers (or perhaps lives).  For most of us men, this was the first time we experienced the female anatomy in a 100% medical and professional manner, firsthand; and for others, it was an unforgettable inital foray and first discovery of the female reproductive system.  I will not speak for the women of my class; I am sure there were many mixed emotions involved in this teaching experience.  As noted by our instructors, many women may consider this yearly exam as a mild annoyance, others with trepidation, and still others with fear.  In practice, we as physicians will meet women for whom it is their first time, their fortieth, or some who have never had an exam performed.  Some women who have been victims of sexual assault, abuse, or rape (or even those who have not) may have difficulty with this experience.  It is our job as physicians to 1) never make assumptions, and 2) empower women during the exam to be advocates for their own health.

This, however, has proven difficult for many practitioners.  In the hum-drum of today's New York minute medicine, patience and sensitivity are often thrown out the window.  The simple gesture of knocking and waiting for your patient to answer before entering the room is often overlooked.  Allowing the patient to maintain a modicum of privacy and control over the exam can go a long way.  Offering to help her up after completion of the exam is a reminder to both parties that she's human, not a diagnostic specimen.  With this in mind, I will recreate last night's pelvic exam as we learned it, intertwining my own experiences and emotions with the process.  I will ask Perry, Olivia, and Kenton to correct me later concerning any omissions.  I hope to reflect on this experience after having done this exam for many years, recalling the care, attention to detail, and sensitivity of our first time.  And, more importantly, I hope that years from now my attention to the patient has not changed, and that I am still waiting for my patient's voice after knocking...

I was the first one to volunteer, so of course I made all the mistakes.  Now to be quite honest I wasn't nervous; I was more concerned that I would forget the steps our instructors taught us, and look like a fool in front of my fellow sophomores.  So the exam began as I knocked on the door.

"(Knock, knock, knock) Come in!  Hi, my name is Robby.  Karen, right?  Is it okay if I call you that?  Sure.  Okay, Karen.  Today I'm going to be performing your pelvic exam.  This is my assistant, and these are a couple medical students who are here to watch the exam.  They are here to learn, not to observe you specifically.  This is part of their medical training.  Is it okay if they watch?  Umm, I guess so.  Okay, Karen, you can let me know if they make you uncomfortable, and I can have them leave.  Now, you've had one pelvic exam before, correct?  Yes.  Okay, well, just as a refresher, the pelvic exam has three parts to it.  The first is external.  I will palpate your external genitalia and mons pubis, seeing if I feel any bumps or anything abnormal.  The second part is internal.  Here we will use the speculum to look at your cervix, and do a pap smear and STD test.  Would you like to take a look at it?  No.  Okay, then the third part is "bi-manual."  This means that I will use both of my hands, one externally and one inside your vagina to feel your uterus and ovaries.  Do you have any questions, Karen, before we started?  Umm, we're going to do that STD test, right?  Yes, that will be done during the internal exam.  Do you have any other questions?"

Pause.

"Would you like to hold a mirror and flashlight to follow along?  Sure.  Okay, also this exam is not supposed to be painful.  If you feel any discomfort, please let me know.  That may be easily fixed by simply adjusting my hand or the instrument.  Also, let me know if you would like a blanket, or for me to change the temperature of the room.  Okay."

Now is when the practitioner adjusts the table to 45 degrees.  The patient's feet are put in the footstools (NB: the word "stirrups" is now taboo), and the patient moves her buttocks to the end of the table where my hand rests.  Standing in front of the patient, I can then place my hands where I would like the patient's knees and say, "you can let you knees fall to my hands."  Words to avoid: "spread your legs" or "open up."

Here is a time for silence.  While washing my hands and putting on gloves, our instructors told us to allow some time for reflection and questions before the exam.  Eye contact is key when answering all questions.  (If only I could have been as matter of fact and confident as this reads).  The gown/sheet is then rolled from the bottom up, maintaining as much privacy and autonomy as possible.

"Okay, first I'm going to perform the external exam.  You can feel me touching you here."

The back of your non-dominant hand is placed on the patient's inner thigh so the first time you touch her is not on her genitalia.  This is for comfort, and so you don't scare your patient.  Twice during the exam I forgot this important gesture.

"Now I'm am palpating your external genitalia to feel for any bumps or lesions.  I will palpate down to your labia majora, and then inspect your labia minor.  You will feel me push up your clitoral hood and see your clitoris.  This is where many nerve endings are located, and these can be stimulated during sex.  With your mirror you can see your urethra here; that is where you pee from.  Here is your vagina, and here is your anus.  Any questions?"

"Now I'm going to perform the internal exam."  (Reach for speculum that has been resting in warm water).  "You can feel me touching you here.  Now I am going to insert one finger to find your cervix.  Okay.  Now I'm going to ask you to clench like you are stopping yourself from peeing.  And relax."   (Curling my fingers so they don't rest on my patient's perineum, I remove my finger until the first knuckle and press down).    Okay you will now feel me insert the speculum."

You insert the speculum at a 45 degree angle, open it slowly, and remove your finger simultaneously to visualize the cervix.  I did not observe the cervix on my first attempt.  I did not observe the cervix on my second try.  Nor the third.  Not until the fourth attempt did the cervix come into partial view.  Embarrassed, I apologized to my instructor.  Pap smear was feigned, and I continued, frustrated.

"The third part of the exam is bi-manual.  You will feel two fingers and my right hand will be on your abdomen feeling for you uterus and then your ovaries.  You can feel me touching you here..."

No uterus or ovaries were felt, although not feeling the latter is normal.  I convinced myself that I felt the uterus "rocking" back 'n forth, but this most likely was a figment of my imagination.

"Okay we're all done.  Do you have any questions..."

It was a rocky first attempt.  Had I been able to read from this dialogue, it would have gone a helluva lot smoother.  Instead I was concentrating intently on remembering the order for the exam, and what to say.  More importantly, I was thinking about what not to say.  You "insert," not "put in" or "penetrate."  You "remove," not "pull out."  You don't "scrape the cervix," "stick" anything in it, or use "stirrups.".  I was terrible about maintaining eye contact, and it felt like a year putting on my gloves.  Of course I didn't dry my hands well enough, and so it took me an hour to coax the gloves all the way onto each finger.  I maintained that silence awkwardly; being able to hear a pin drop was eerie.

The exams got better and better as the group took turns.  Perry was absolutely fantastic, not only with the physical aspects (insert, open, and boom: there's the cervix), but also with his patient care.  He asked all the right questions, knew all the right answers, and even knew how to make a dental dam out of a condom (cut it in half on one side... who knew?!).  Simply his manner and demeanor though; it is a style worth emulating.

Experiences like these prove to me over and over again that I learn more from my peers than from any class or textbook.

SOAPin' without a Scope

If you read my last blog post, you should have been able to feel how excited I was to hear my first murmur (if not, just take my word for it). Man, was I pumped. I was going to get in the clinic and hear tons of 'em: murmurs, gallops, rubs. I was going to hear them all. I was ready to diagnose an aortic stenosis or perhaps an atrial septal defect. Throw me an EKG, doc; I see ST-elevation in the inferior leads (II, III, and aVF)! On Sunday night, my three roommates knew I was in the zone.  I literally looked like I was ready to catch some kid right then and there. And after HemeOnc and Cardio, I had the blood and CV system down cold. Dammit I was ready. Except for one tiny, itty bitty detail... I forgot to bring my stethoscope.

Yes, 2.5 hours away, sitting on top of my EMS bag and uniform, lay my trusty scope. Literally the ONLY thing I had to bring to Community Week was that item. I didn't need my white coat; I didn't need a tie. John Younce even forgot his keys to the apartment we were staying in! The only thing I had to remember was that stethoscope, and I dropped the ball. I actually remembered at 10 pm Sunday night, just as my head hit the pillow. Needless to say I was extremely embarrassed when I had to ask my preceptor if I could borrow one for the week. Fortunately, I was working at a doctor's office; there were tons of them lying around. But I was a carpenter without a saw, a surgeon without a scalpel, a catcher without a mitt, a shoemaker without a.... well you get the idea. A med student needs a stethoscope!

Disappointment #2: I didn't hear ONE murmur. Not one. I told my preceptor if he heard one to come grab me if I was in another room. But he didn't hear one, and neither did I in three days. Not even a S3, which can be normal in kids. Instead, I found a lot of mucus, and a boat-load of cerumen (that's the medical term for "earwax"). Not that my time wasn't valuable; I learn more in that clinic than I do in the classroom. Very high yield (and I can potty train your kid by 21 months if you need me too), but damn you I wanted a bloody murmur! Afterwards, I called Clodagh on the drive home, and she was batting like .700 for murmurs. Everyone had one! Holosystolic, midsystolic, crescendo, decrescendo. Ahhh, the luck of the Irish...

But as promised, here is my first SOAP note on a real patient. Doctors get ready to cringe, professors enjoy a nice laugh. Please note that identifying information has been subtly changed for patient privacy.


Medical Student Progress Note
Robert Swendiman, MS2
10/7/2010, 11:15am

S – Jane Doe is an 5 year old female complaining of fever and a “broken brain” over the last 2 days. She is autistic and has a significant hx for recurrent strep throat.

O – Medications: ibuprofen (for fever); Allergies: NKDA; Vitals: mild tachycardia with all other vitals WNL; PE: Jane is found sitting comfortably on exam table. HEENT: tonsilar hypertrophy and irritation with purulent exudate, mild discomfort while swallowing, tympanic membrane of left ear slightly opaque and irritation noted. Lungs: bilateral breath sounds CTA. CV and Neuro: nl. No other significant findings. Labs: positive rapid strep test.

A/P – Jane, 5 y/o F with fever and a “broken brain” over the last two days, presents with tonsilar hypertrophy and exudate on her soft palate and mild left auricular tympanic membrane opaqueness/irritation. She tested positive for strep in clinic.
1. Fever/Tachycardia – significant PMHx for strep throat and positive rapid antigen test, symptoms most likely due to Streptococcus pyogenes infection, otitis media also considered, patient given antibiotic and mother counseled about continuing Motrin regiment for fever
2. Tonsilar Hypertrophy/Exudate and Difficulty Swallowing – (see above)
3. Inflamed Left Tympanic membrane – Streptococcal infection may have spread to left ear, superinfection considered and antibiotic chosen to cover both strep throat and otitis media
4. “Broken Memory” – PMHx of autism, patient counseled that she will feel better after recovering from infection since both symptoms presented at the same time

Discussion – Which antibiotics are most effective for treating Group A Streptococcus?

In children with tonsilar pharyngitis and an associated bacterial infection, Group A Streptococcus (GAS) is the most common microbial culprit. Since the 1950s, penicillin has been the gold standard for treating this infection, but recently this antimicrobial agent has proven less effective (over 20% of patients are not cured with standard therapy), and treatment choices have changed. Some research demonstrates that over time, other antimicrobials such as cephalosporins and some macrolides may be more effective than penicillin.

Debate continues concerning the choice of antibiotics and the duration of treatment. Untreated strep throat can lead to pernicious sequelae such as rheumatic fever, and numerous studies have been done comparing the clinical effectiveness of different treatment plans. For example, when comparing a short 5 day course of cefuroxime axetil versus a standard 10 day oral penicillin regimen, both therapies were proven to be equally effective and in curing the infection and subsequent prevention of post-infection sequelae. Since Streptococcus pyogenes has never been linked to penicillin resistance, this 10 day therapy still remains the most common treatment. Other treatments are used based on recurrence and physician preference.

References:
1. Pichichero ME. Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med. 1995;25(3):390-403.
2. Adam D, Scholz H, Helmerking M. Comparison of short-course (5 day) cefuroxime axetil with a standard 10 day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrob Chemother. 2000;45 Suppl:23-30.
3. Colletti T, Robinson P. Strep throat: guidelines for diagnosis and treatment. JAAPA. 2005;18(9):38-44.

Robert A. Swendiman, MS2
Pager/Cell – 301.275.9566

Block III: Cardio and Community Week

Whew... and breathe. It's good to finally have a break. Block III: Cardiology ended Thursday, with a final exam average over 10 points higher than that of the HemOnc-ster. We literally went from the hardest block in the first two years to the easiest (as far as grades go). But as far as importance, this material was certainly the highest yield. Every patient we see in the clinic and hospital will receive a full cardiovascular (CV) exam; and since heart disease is the number 1 killer in the United States, all of us will see patients with CV pathophysiology: strokes, heart attacks, murmurs, palpitations, etc. Nothin' more important than the ole ticker.

Having Cardio right before Community Week #3 is going to turn out to be quite fortuitous. Last year I was frustrated with how little I brought to the table during these weeks here in Boone, NC. I could take a history, perform a focused physical, and I learned how to make helicopters out of Popsicle sticks. But I was annoyed with how little I actually knew. This time around, I feel like I now know at least a little bit about something. With Immunology/Microbiology under my belt, I have a better understanding of the diseases that most kids present with in clinic. Mycoplasma, Group A Streptococcus, otitis media: these are no longer abstract words associated with simple phenotypes. I have (at least basic) knowledge of the mechanisms of these diseases, and a bit of epidemiology behind them. That course allows me to develop more coherent differential diagnoses in clinic.

Cardiology will make the physical exam so much more meaningful. Last year I felt I was just going through the motions. I would listen to the heart in the aortic, pulmonic, tricuspid, and mitral areas over the chest and say, "Yup, there's a heart in there all right." But now I can listen to each beat and attempt to hear other sounds like murmurs, snaps, and thrills. I can ask a kid to take a deep breath and hold it, then listen to physiologic splitting of S2! (As the chest wall expands, a decrease of intrathoracic pressure during inspiration causes increased venous return and right heart volume, thus delaying the closure of the pulmonic valve, essentially... look at me with all this knowledge!). Pathologic splitting can be due to many things, including an atrial septal defect (ASD - fistula between the left and right atria), aortic stenosis, etc. These are the types of things I get to listen for this week!

So my goal for this Community Week is twofold. First, I am going to attempt to perform a full CV exam on as many patients as possible. That will include inspection (simply looking for pathological findings such as cyanosis or "clubbing"), palpation (touching the patient to identify the point of maximal impulse of the heart, i.e. is the heart oriented properly), and auscultation or "listening" with my trusty stethoscope. Hopefully by the end of this I will have that exam down cold. Secondly, I have to write two SOAP notes by week's end. SOAP stands for Subjective, Objective, Assessment, and Plan, and this is the type of note that I will be writing every day next year in the hospital to update a patient's status. Next week's blog will feature one of the SOAP notes I write this week (obviously with much of the information tweaked for patient privacy), and will essentially be my first attempt at documenting patient care. Hopefully in years to come I can look at how awful my first notes were and laugh.

This is nice. It is much easier this time around to focus on learning and preparing for third year. No more haphazard shadowing.

Upon return it's back to the grind with a three week Pulmonary unit, then GI, Thanksgiving, and the Urinary System. It will be Christmas before ya know it!