“Let’s get you to see
another patient and see if you can do a little better with her,” my examiner said,
smiling; clearly enjoying my distress. He asked me to listen to the heart of an
extremely breathless lady who was lying on a nearby couch. My
spirits rose slightly. In the previous three months I had regularly
attended the cardiology clinic. I’d listened to the heart sounds of hundreds
of different patients and considered myself to be something of an expert. I
rarely had any difficulty in identifying the heart sounds and the various
murmurs that could be heard and was usually able to make the correct diagnosis.
‘A chance to show that
I’m not a complete muppet,’ I thought as I applied my
stethoscope to the patient’s chest. Once again though I discovered that my
confidence was entirely misplaced. The
noise I heard was unlike anything I had ever heard before. It
sounded as if there was a concrete mixer churning continuously inside her chest.
It was rasping and grinding and was so loud
that it completely obliterated the normal heart sounds. I
hadn’t a clue what was causing it but it struck me that it might be coming, not
from the heart, but from the lungs. If
that were the case, the noise would disappear if the patient were to hold her
breath.
“Please would you stop breathing for a moment,” I asked the
patient politely.
“Good God man,” the
examiner exclaimed. “Do you want to kill
her? Don’t you think she’s breathless enough
already? If she stops breathing now, she
may never start again!”
At this the patient got alarmed, had a fit of coughing and
became quite cyanosed.
I became flustered. I
had no idea what was causing this incredible noise and my examiner knew it. He had me on the ropes and, as before, was enjoying
my obvious distress. He was playing
with me as a cat might play with a mouse.
He asked if I had
reached a diagnosis, knowing full well that I hadn’t! Whilst
able to describe the sound I’d heard I had to confess that I had no idea what was
causing it.
The bell tolled to indicate that the time allotted for the
examination was over; my torture was complete. No doubt it tolled as well to indicate that I
was doomed to failure.
The examiner looked me straight in the eye and told me the diagnosis.
“This lady has
pericarditis and therefore the noise is ............” he stopped and waited.
Suddenly the penny dropped. Why on earth hadn’t I recognised it? It was a rare abnormality but one, none the
less, that was very characteristic. I ought
to have diagnosed it.
“A pericardial friction rub.” I said.
“Caused by?” the visiting professor wanted to know.
“Inflammation of the
pericardium.”
“That will be all, thank you.” The tone of the voice indicated more clearly
than the words, his opinion of my diagnostic skills.
Despondently I moved towards the door.
As I left the room I chastised myself. When told the cause of the ‘machinery sounds’
it was so obvious. The noise had not
been coming from within the heart at all. This
was a case of inflammation of the pericardium, (the sack that surrounds the
heart). As the heart moved there was
friction between it and the sack within which it was contained, creating this
rough sound. Since the heart was moving
all the time, the noise was continuous. No wonder the patient was so breathless. I knew at that moment that I had failed the
medical examination and would have to spend the next six months swotting for
the ‘resits’, whilst my friends and colleagues started work as doctors.
Thought for
the day
In examinations,
those who do not wish to know, ask questions of those who cannot tell. Walter Raleigh 1861-1922
Comments
It was to be many years, when I became an examiner myself, before
I realised that most examiners actually did their best to help medical students
pass the exam by building their confidence and leading them to the correct
answers. The examiner described above
was clearly the exception to the rule! These
were the days before tuition fees when students in the UK were trained at the
expense of the state. Having invested in
them for five years, the state really couldn’t afford to allow them to fail.
What a shame that in future nurses and those training in the
paramedical professions will have to pay tuition fees. Wouldn’t it be better
if, instead of paying for their education, students in healthcare professions
were contracted to work in the Health Service for a number of years after qualification.
Your views in the ‘Comments Box’ below are welcomed.
Misprint in a doctor’s letter: She has no rigors or shaking chills but her husband says she was very
hot in bed last night.
Hi!
ReplyDeleteThis blog has so many lessons to learn for students. This experience should be shared with all doctor students so that get prepare themselves in advance rather than depend on cheating or any other cheap source.
Thank you for sharing your experience.
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