24 October 2012

Sweat the small stuff

Our professor began our small group session, on how to properly examine a patient with lung disease, by leaping onto a table. He held up his hands and explained that we would get started soon, after he returned a phone call from a patient. In one bound, he leapt down from the table and exited the room.

My classmates and I were mystified. We had never met this physician before. Although he was at least 65 years old, he had hopped off of the impressively high table with a gymnast's ease. He wore a white coat, tie, and dress shoes, and rather incongruously, a bright orange baseball cap.

After a few minutes he returned and hopped yet again onto the table. He held up his hands. "What's different about me?"

We all noticed that his baseball cap was gone. I mentioned that something looked different about his tie. That was it.

The doctor explained that he had altered his appearance dramatically. He had switched from a blue necktie to a red one. His wedding ring had switched from his left hand to his right, and his wristwatch vice versa. He had even changed out of his dress shoes, into loafers.

"One of the most important parts of the patient examination is 'inspection,'" he said. "You're now at a stage in your medical training where you need to start looking for subtle visual details. Otherwise, you'll miss something important in a patient."

And so, as a group we inspected a set of lung-disease patients with an eye for detail. We spotted tiny surgical scars that suggested that the patients' lungs had been biopsied. We noticed the "buffalo hump" (an accumulation of fat on the back of the neck) that is the signature of high doses of corticosteroids. We watched one patient who was breathing quite fast, and another who coughed constantly and whose neck muscles were pathologically straining to help her inspire. We listened with our stethoscopes to the 'crackles' at the base of one patient's lungs. The crackles sounded like the faint popping of bubble-wrap.

Slowly, without the patients saying a word, we began to piece together what diseases they might have and what their life story might be. Our spry professor had mischievously taught us a good lesson.