Twas the week before Christmas, and all was quiet on the ward.
Not a phone was stirring, while IV infusers gently whirred.
The fluid charts were hung by the bedsides with care,
in hopes that the ward round soon would be there.
The patients were nestled all snug in their beds… and somewhere on a bay, stood behind a curtain, was me performing my first assessed clinical examination.
Due to COVID pressures, my team and I had actually not found the time to supervise me performing a clinical examination before now. So not only was this my first assessed examination, it was also the first examination I performed on a patient. Boy was I nervous!
Seeing as we are an intestinal failure team, we started with a system of the body we all felt comfortable with – an abdominal examination. In hindsight, starting with the system my team perform with the most expert skill and consideration, probably wasn’t a great idea.
The examination was performed on a gentleman complaining of abdominal pain. After explaining that I would be doing this under supervision and that it required exposing his chest and abdomen to allow us to look, listen and feel for any pathological signs, consent was obtained and I got gowned up and started.
I began by inspecting his hands, worked my way up to his face, down across his chest and under his arms. All the while, verbally listing the things I could or could not see. Finally I moved to inspect and examine his abdomen. To do this, I brought the bed down flat (after first fussing around with the various operational controls until I found the correct setting – why aren’t all these remote controllers the same?!). I palpated all nine quadrants, then ineloquently pressed the side of my hand into various parts of his abdomen to feel for organ edges. As I went to place my stethoscope on the right lower abdominal quadrant to listen for bowel sounds, I suddenly recalled that the patient had 30cm of small bowel and a defunctioned colon. I hesitated...Where should I place my stethoscope?
“Just move on,” my supervisor intoned.
“Umm, okay. Right. Well that completes the examination,” I said.
I thanked the patient and looked over at my medical supervisor. He just stared, and after a pause asked, “Have you forgotten anything?”
My mind went blank. I looked at the patient and he looked back at me – his face willing me to remember.
“Umm… Oh! I haven’t palpated for lymphadenopathy.”
I subsequently did this – awkwardly reaching over the side of the bed to feel under his chin, around his head and neck and down into his apices. I should point out that I barely reach over five foot in height and it didn’t occur to me to make this easier by adjusting the bed height or lifting off the back-board.
When I decided that I had done enough to demonstrate what barely touching the locations of his lymph nodes would look like, the patient and I looked over at my medical supervisor expectantly.
Another pause. “Have you forgotten anything?”
The patient and I swivelled our heads back towards one another. I could see in his face that he was doing his best to recall what might have been missed as much as I was.
“Umm. No. I can’t think what else I would do,” I said.
Another pause.
“Okay,” my supervisor said. “ We can discuss it after.”
Ominous.
As it turned out, there were quite a few things to discuss after. So I caution all trainees when performing abdominal examinations in the presence of gastroenterologists to please remember the following:
- Check for asterixis! – I seem to always forget that one
- If you can’t pronounce acanthosis nigricans just say that no hyperpigmentation could be seen
- Blanch spider naevi if any noted
- When palpating for organ edges, press in on inspiration not expiration. I was also shown a nice, flowing hand motion that bore no comparison to whatever I was doing.
Tis all a learning process I suppose.
Subsequent examinations have gone mildly better. With the exception of neurological or MSK examinations, which I happen to be fairly good at. Is it just me, or is examining for those conditions just more intuitive when you’re a dietitian? Regardless, with the New Year upon me, I now begin preparations for my upcoming academic exams. And so on that note…
As dry leaves that before the wild hurricane fly,
When they meet with an obstacle, mount to the sky.
So up to my books and my study notes I flew,
With my head full of knowledge, and a coffee cup or two.
But hear me exclaim, 'ere I dash out of sight,
"Happy New Year to all, and to all a good-night!”