Tag Archives: physical exam

really?

“Until I get there,” the urology resident instructed me, “you must apply direct manual compression to mechanically disperse the penile and preputial edema.  This will hopefully minimize the swelling and allow for manual retraction by the time I get there.”

So in other words, as my attending so eloquently directed me “grab that thing and hold on tight.”

There are a lot of awkward moments in the emergency department.  Many of them have to do with interactions with nurses (I am really sorry my patient threw up on your leg AGAIN yes he can have some Zofran), paramedics (last time I saw you, I am pretty sure you were making out with one of my co-residents in the middle of a bar), and even correction officers (um, please, just un-handcuff him for the lung exam. Fine, you can keep his feet chained to the bed).

My most awkward moment of late, however, had to do with one particular patient with one particular penis problem.

Paraphimosis is when, in an uncircumcised or partially circumcised male, the foreskin gets retracted behind the glans penis, starts to swell, and gets stuck in that position.  The reason this is an emergency is that this swelling then cuts off blood flow to the head of the penis.  The head will start to turn dark and eventually may become necrotic.  It’s usually iatrogenic in nature, meaning, we cause it.  In this case the patient has a foley catheter in his urethra (secondary to a recent surgery).  He resides at one of the homeless shelters that also provides some medical care, and the nursing staff inadvertently forgot to replace the patient’s foreskin after the most recent foley catheter change. This is actually a great case for me, it’s one of the few urologic emergencies and a case up until now I had only read about.

As great of a case as it may be, the treatment is nothing short of mortifying. Very reluctantly I pulled a chair into the room, and for the next fifteen minutes I sat by my 65 year old patient’s side and “mechanical dispersed the penile and preputial edema,” AKA, I very firmly held his penis in my hand.  For fifteen freakin’ minutes.

Really? I am really doing this right now? Please, just for a moment, put yourself in my shoes.  What are you going to talk about to make this less awkward… football? The weather?

I am a doctor, and this is what I do at work.  Really.

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Filed under emergency medicine, intern year

a turd

My attending storms out of the bathroom and looks over at me, “It’s a fucking turd!”

Let’s back up a few minutes.

My patient has been having (if you are squeamish you might as well stop reading now) copious, purulent, pungent discharge coming out of her vagina for two months.  When I say copious, I mean she had to change her pad every two hours.  When I say pungent I mean it was rank.  Imagine a smell that stings your nostrils and sits like a rotting mouse on top of your gag reflex, now multiply that by twelve.    This poor woman has been living with this for 60 days, and so far no one has been able to tell her what’s wrong.

While prepping for the pelvic exam my attending put on his camping head lamp started to tell me a story.  When he was a third year medical student a classmate on his rotation was in line to do the next pelvic exam. Well, his classmate got lucky.  Half way through the exam the emergency room smells fetid and the student started pulling small body parts from the woman’s vagina.  A miscarriage hadn’t completely evulsed.  Pieces of the fetus embedded themselves in the walls surrounding the cervix.

Don’t worry, today there were no body parts.

As we were chatting my patient went to use the restroom.  Then there was commotion.  I need the nurse! I need the doctor! My attending screams from the bathroom, get me a paper towel! Get me a specimen jar! Things quiet down and the nurse, my attending, and the specimen jar emerge from the restroom.

I ask, “Um, what just happened?”

The nurse: “Something was coming out of her vagina.”

My attending: “It was a fucking turd.”

That begs another question, so in my most professional voice I ask, “Uh, how did a fucking turd come out of her vagina?”

My attending: “A g.d. fistula? I don’t know if it really was a fucking turd but holy shit it smelled like one.”

And so we regain our composure, get our patient calmed down and back in the bed, and begin the pelvic exam.  We proceed, head-lamp and all, and see something peeking out from the crevices behind the cervix.  A tampon. It was fermenting.  It had been there for two months, and started abscessing the side of her vaginal wall.

Tampon goes into a new specimen jar.  Both specimen jars are sent to path.  We tell her to schedule a follow up with her gynecologist and the woman is saved.  Hooray!

And no, I still don’t know what came out of her vagina in the bathroom.  It might’ve been a piece of the tampon we found later, it might’ve been a sponge, and yes, it might’ve even been a turd.

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Filed under clerkships, medical school, medical student

off-site

Last Thursday at my off-site hospital, I started off on the right foot. I got there early, and remembered to bring all my toys.

I sat down with the attending/preceptor to go over the H&P I turned in last week, and that’s when things started to take a turn for the worse. My classmate who was assigned to the same site went into another room to go over his with his attending. While my guy was on the phone, yelling at someone, I heard the other guy offering him good advice about what format he should use. My guy sat down and the next five minutes were, What! What is this?! I don’t even know what this means, why did you put this here?! This doesn’t go here, why did you do this. Telling him I followed to sample the school gave me was pointless.

So I followed him to the floor where he introduced me to the patient I would be working with for the rest of the morning. He left (thank goodness). And it was just me and the patient (not so thank goodness).

There were some mishaps. I spent about five minutes fumbling through the drawers looking for the little disposable black cone that goes on top of my otoscope, at the same time trying to make awkward small talk. Have you been outside lately? The weather is beautiful! (He has been confined to a hospital bed for the last seven days, smartypants.) After all that, while looking at the first tympanic membrane the damn thing ran out of charge. I went back to his heart sounds at least four times (they were really hard to hear, I swear), but the patient humored me. He was very ill, in pain, and was honestly really very nice to put up with me as I made my way from his head to lungs to heart to abdomen to extremities in no particular order.

But I did it! And it was time to give my report to the attending.

In the middle of the HPI I was cut off:

Name some causes of dyspnea! Okay, pulmonary embolus, myocardial infarction… NO! (really??) Why don’t you do a report on dyspnea for me next week? Sure.

The patient reports three previous hospitalizations within the past three years for similar symptoms… NO. You are wrong, it’s more like eight. GO ON.

And so I went on.

What about his meds?!! Why didn’t you record his meds?!! He couldn’t remember them and told me to look in the chart (which, for your information, you forbade me to look at).

Our patient has right sided heart failure. Cor pulmonale. Ah right, we just learned about that this week. Great, why don’t you do a report on that for me next week too.

Really looking forward to this Thursday.

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Filed under med school

pink stethoscope

I just made my mother, who came home from the hospital today, put a pink stethoscope around her neck and pretend to be an attending. Poor woman. Just home from surgery, practically bed-ridden, and I’m already harassing her.

BUT I had to practice the oral presentation I have to give tomorrow afternoon.

Tomorrow morning I will be back at my off-site hospital, doing my best to be a second year med-student. Tomorrow I will be expected to take a full history and preform a full physical (without the rectal, gyn, and breast parts) on an inpatient. Full-history? Piece of cake. Full physical? Haha. Wait, you are serious? You think I know how to do a full physical? We had a lecture at the beginning of the year, which was at the beginning of AUGUST, mind you, where we briefly ran down the parts of the full physical. It is now October. Uh, I have the memory of a goldfish. A bit of a road block when you are a med student.

Two weeks ago when I was there we had the same assignment. The patient I was interviewing was in the ICU recovering from brain surgery. When I walked into her room I noticed about eight million tubes and machines and IVs sticking out of her body. The first thing that ran through my head was, SHIT. How does one preform a physical on a fragile woman in the midst of eight million tubes. Okay, well, top down, begin with the head. Palpate the scalp. Wait, she just had brain surgery, perhaps I should lay off the head. Shit. So I begin with the full history, and just as I was getting to the part where I am supposed to ask the fragile 80 something year old woman about her sex life, her family came for visiting hours. Saved by the bell. The attending was busy and told me to go home, I was spared the awkward physical exam, yet (in a medical-student kind of way) sort of bummed because I really do need the practice.

My mother, the attending lawyer in the pink stethoscope, told me to just act confident. If you act like you know what you are doing, people think you know what you are doing. And as long as you are in no position to do any harm, I suppose she is right. I just hope I don’t get a horrific attending tomorrow who makes me feel like an ass. I hope I get someone who will start teaching me the basics. It’s about time I learn this stuff and stop feeling like an idiot.

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