Post 17 A traumatic experience for a student doctor

“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


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.


  1. Hi!
    This 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.

  2. Hi I really appreciate all the great content you have here. I am glad I cam across it! I would like you to visit here for more education stuff for your visitors !!


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