The palpable border

For the last 4 weeks we have been going once a week to work with a preceptor. We are to work in two pairs in conjunction with the preceptor in order to improve our history taking and exam skills. The last weeks have seen me in a nursing home near school. The clinical encounters we have rehearsed at school with standardized patients and in the lecture hall were not sufficient preparation to seeing real people. Our standardized patients are all very stereotyped and presenting in a pseudo-outpatient setting with some well defined chief complaint. The nursing home however, provides quite a different experience. The patient only grudgingly will consent to talk with you, as there is a bingo game impending, and they don't have any 'chief complaint' as such. "I'm doing ok" is not really a chief complaint. I also realized in this setting that, in the absence of a stilted semi-scripted interview, I suck at taking a history. I also suck at performing a physical exam.

To learn PE we were first instructed by one of our professors who demonstrated on a standardized patient. In small groups on various days, we then all took turns learning the PE from the standardized patient. While admittedly this saves on manpower because you don't have to get 8 different MD's to come in to teach small groups, this strategy also leaves somthing to be desired. I would prefer to have been taught by someone who has actually done a physical, rather than by an actor who knows approximately what a particular exam should include. There were sometimes 4th years around to help, but they were usually not helpful, nor particularly trustworthy. Usually I felt like I was being instructed by someone only marginally more familiar with this than me.

Last week and this week, my group and I asked our preceptor to help us improve our techniques in the various exams. Last week we did heart, lungs, and abdomen on real patients and this week it was the neuro exam. It's nice to examine someone who has real findings as well, because you're not just going through the motions.

Today we were examining a patient with stage 4 colon cancer. They were cachexic, but their abdomen was protruding outward, despite the patient's emaciated appearance. After talking briefly about their abdominal surgical scars, I palpated, percussed, and auscultated the abdomen. It was definitely unlike any standardized patient. This individual's liver margin was palpable nearly at the level of the iliac crest. Normally the liver is found approximately at the lower edge of the ribcage. There were firm nodules scattered diffusely over it as well. Our patient had metastases that had infiltrated the liver and caused the massive hepatomegaly that we observed.

It was a long, but very informative afternoon. I realize that it must sound callous that this poor individual's plight was educational for me in a very dry, clinical way.

SS