Clinical Thursday and My First Chest X-ray
October 8, 2015 § 3 Comments
Thursday is my one true clinic day of the week. I start with dermatology at 8:00, followed by pulmonology at 12:40 and cardiology at 15:45. Each of the practicals lasts 1.5 hours and there are pulmonology and cardiology lectures before their respective practicals. It’s probably the one day of the week where I feel most like a medical student and yet it’s easy to become sort of numb to it. When we are constantly focusing on how much we have to study when we’re done with class, it’s hard to actually enjoy it while we’re there. The one thing that helps is a good teacher! I love my teachers for pulmo and cardio because they are systematic in their teaching and take the time to describe disease mechanisms in detail, while still highlighting major points. Here’s a breakdown of my day today:
We see up to maybe 5 or 6 patients during the practical. When we first go in to the room, we are expected to describe the skin lesions using correct dermatological terminology and then get the patient history. Once we’ve done that, we are asked if we know the diagnosis. Sometimes it’s really obvious (like psoriasis) and other’s it can be more difficult. One thing I noticed today is that I had a hard time recognizing some things we learned for patho – because I’d never seen then before. I might have looked at a random picture here and there, but when you are studying skin lesions for your patho final, everything looks the same!
- Patient 1: Erythematous patches on bilateral anterior axillary folds, erosions and scales in inguinal region and under gluteal fold. Diagnosis: Scalded Skin Syndrome. It is the result of a staphylococcus infection. It usually occurs in infants, but this patient had a history of diabetes with foot ulcers that may have aided in the establishment of the infection.
- Patient 2: Erythematous macules with erosions and bloody crusts on the trunk and upper and lower extremities. Diagnosis: pemphigous. An autoimmune disease where the antibodies attack a protein in the skin (desmoglein 3, transmembrane glycoprotein in the desmosomes) that is necessary to hold skin cells together. Our teacher suspected that the outbreak of the lesions could be due to internal malignancy and said that they were doing tests to see if this was the case.
- Patient 3: Large brown plaques on lower abdomen and inguinal region (should’ve been firm to the touch, characteristic for this disease, but they weren’t). Diagnosis: morphea/localized scleroderma. A localized thickening of the skin resulting from several different etiologies, e.g. local injury, tick bite (borrelia infection), pregnancy, autoimmune disease.
- Patient 4: Numerous solitary papules with slightly white surface (kind of like candle wax drops) around the wrists and ankles. Diagnosis: lichen planus. An autoimmune disease in which immune cells attack an unidentified protein in the skin.
During this practical we usually see 2 or 3 patients and then follow their cases through all the way, including lab tests and imaging. Today we saw two patients, both with COPD, but very different manifestations. These are my notes from the practical:
I’ve actually missed the past two weeks of this class because I’ve been quite sick (and my nasty cough just won’t leave!). One girl in my group joked to our teacher that he should examine me and he – without hesitation – said that we could do an X-ray. I’ve never had an X-ray of my chest before, so I jumped at the opportunity. At the end of the class, another classmate (curious about his new chest pain) went down with our teacher to check our insurance details at the registration desk and then headed straight for the X-ray room. Within 5 minutes, we were back up in his office looking at our X-rays on the computer. It turns out that my lungs and heart are quite healthy, but he wrote me a prescription for my audibly-obvious bronchitis (not seen on the X-ray). He emailed me my X-ray (have I mentioned how much I love technology) and now I have it to compare to future ones. Pretty cool to see my heart and lungs! I’ve looked at so many others before, I’ve forgotten I have my own.
Here you can see how different the chest x-ray can look:
These practicals vary quite a bit. Sometimes we have special lessons focusing on specific topics and others we examine patients and then discuss their cases afterwards.
Today our focus was heart failure. We met two patients and watched our teacher perform their echocardiograms (an ultrasound of the heart and the gold standard for diagnosing heart failure).
Afterwards, we walked through the gorgeous gardens of the cardiology hospital (probably the nicest of the hospitals we visit) to get to the Phd student lab. Here, our teacher went through heart failure in perfect “this is how you need to know it” form.
I notice such a big difference this year compared to the others. Of course, there are some teachers that are a little extra hard on us, but most of them are excited when we show interest in a subject. On numerous occasions we have been invited to join an operation or a night shift, anything we want. The opportunities are endless so long as we take advantage. It feels so good to know that they are so willing to teach us and that we can take it as far as we want it to go.
Night coughing has started up again and I have to be up early for anatomy TAing. Skjalg’s family arrives tomorrow and I’m excited to do some non-school-related activities these weekend – despite the horrible weather!