I just finished my two month surgery rotation, and as a third-year medical student new to the wards, I had a steep learning curve. One of the things I learned the hard way, causing me to nearly cry during rounds, was how to properly present a patient’s history and physical examination findings.
The Preparation
Extracting relevant clinical history information from a patient for the first time was not an easy task for me. Heightening the difficulty was my uncertainty about whether the questions I was preparing to ask were capable of pinpointing the correct diagnosis. However, when I was called upon for duty, I played my part. I asked the questions and received relevant answers that allowed me to narrow down the differential diagnoses on my list … at least, in my opinion.
The Excitement
I thought that I had completed all that was required for a comprehensive history and physical examination: facts about present illness, review of systems, inspection, palpation, percussion and auscultation. If I arranged my negative and positive findings neatly, I thought that I would be able to confidently determine the correct diagnosis of the newly-admitted patient and impress my seniors and the attending physician, who was a consulting surgeon, during rounds the following morning.
After all this and a thoughtful review, I finally fell asleep rather late that night. I had been busy assimilating the patient’s information and thinking of answers for the potential questions or critiques that may be hurled towards me by the attending physician in the morning. Even though my exhaustion allowed me to fall asleep, when I woke up the next morning, I realized that I had never conquered the fear I felt leading up to my first bedside presentation. However, I said to myself, “Let the sun rise.”
The Pause
I presented a case of a newly-admitted 70-year-old female patient with a chief complaint of intermittent severe pain and swelling in the right upper quadrant for the past three months. My presentation of the patient’s history was flawless as I read it aloud to the team during rounds. Anticipating the storm of questions that may be awaiting, I presented one fact after another, pausing in between each new piece of information during the subjective portion. No questions so far … phew!
Unfortunately for me, the consulting surgeon knew the patient very well as they had met prior in the surgical outpatient clinic, and he already knew her diagnosis. Fortunately for the surgeon, he did not have to solely rely on the information I was sharing with him. He began to ask questions as I presented the physical exam.
The Questioning
The first question posed to me by the consulting surgeon was, “Student Doctor Mlay, could you show the locations of the dorsalis pedis and posterior tibial arteries you just mentioned on your physical exam findings?”
“Anatomy. Oh great, I have to get in my mental time machine and travel back to the first year of medical school,” I complained in my head. Pausing for a bit, I directly and correctly identified the locations of the two arteries … with mild self-assurance.
“Okay, good,” said the consulting surgeon. “Now, how can we tell if the swelling is intra-abdominal or simply fluid that is third-spacing in the abdominal wall?”
“Oh! That’s a tough one,” I thought.
Luckily, this question was directed to the group at large; he didn’t specifically ask me, and it was my first presentation, so I kept quiet. No one on the rounding panel knew either, so we all stood there in silent solitude hoping that we would not be called upon individually for the answer.
While scanning the faces of everyone in the group, the surgeon stood there and finally focused his gaze on me while grumbling in disbelief, “Kids these days don’t study.” With a sigh, he then went on to explain how to examine abdominal swelling and how to determine if it is indeed of intra-abdominal origin.
I finished the objective portion and continued until I had reached to the assessment part of the SOAP presentation. I stated what I thought was the most likely diagnosis, which was carcinoma of the gallbladder.
Then, the consulting surgeon interrupted me with a question: “Student Doctor Mlay, do you think your clinical history and examination lead us to the diagnoses you just mentioned?”
I nodded and reaffirmed what I believed to be the most likely diagnosis: gallbladder carcinoma.
He agreed and explained the high likelihood of of gallbladder carcinoma in this patient. He put in some orders, and then the panel moved on to another patient.
As the surgeon caught up with me by the patient’s door, he said, “Allen, you really tried your hardest presenting today, but nothing you said painted a compelling picture of the patient’s most likely diagnosis. In the future, try to emphasize the points that you believe make your suspected diagnosis the most clear.”
“Yes sir,” I replied. Even though I wanted to explode with explanations about how I hadn’t slept very much the night before because I was preparing for rounds, I guess that I could not blame the amount of sleep I had for my less-than-ideal presentation. Therefore, I still needed to perfect my clinical history-taking, examination and presentation skills.
The Struggle
In the days following that first presentation, I performed a heavy literature review of any clinical skills tips I could find on the internet. I read chapters upon chapters about performing and presenting the clinical examination, and I practiced incorporating even the tiniest suggestions. My attending was right; I had presented unorganized information then forced it to fit a possible diagnosis. It took me a great deal of study time to understand that, and it was worth it.
I am still learning about what skills make a great doctor. My first presentation was a struggle because I had to prove to myself that I could get through it and that I will be a master of clinical examinations one day… even though I don’t yet know the exact date. For now, it is time to listen, watch and learn one new clinical skill at a time while understanding that as a student, I am not expected to be perfect, but I am expected to continue learning, observing and perfecting my skills.
Contributing Writer
University of Dar es Salaam in Tanzania
Allen is a third year medical student at University of Dar es Salaam in Tanzania. He is interested in the wonders of basic science in transforming lives. In his free time, Allen enjoys playing soccer, reading and spending time with friends. After medical school, Allen's single pursuit is to become a surgeon.