Taking a History, Examination and Presenting – My Embarrassing (but slightly funny) Attempts
I am on week 6 of my hospital placement. Sure, I’m not quite at the level of House but I am slowly getting better at taking histories. And by that, I meant that I’m getting better at being able to structure the key components of the history. I am still rather rubbish at exploring the history of the presenting complaint – that is, trying to work out what exactly it is the patient has that required them to come into hospital at this exact time. Basically, the important stuff is the bit that I am not good at.
Anyway, there was recently a case which was rather funny for the doctors. Embarrassing for me at the time, but rather funny in hindsight.
As there was nothing really going on in my ward, I decided to go to the cardiology ward to practise taking histories and examinations. I found Mr Y, an elderly gentleman who kindly agreed for me to practise on him. The history was going rather well. I was cheating slightly as Mr Y had already been in hospital for a few days and had already been told a diagnosis. He was therefore very quick to tell me that he had a ‘leaky’ valve.
Great, I thought to myself. This means he must have some sort of regurgitation. It would likely be aortic or mitral as it is very rare to have tricuspid or pulmonary regurgitation. At least, I think so. I thought that it would be good for me to have a listen to his heart too as I would likely hear a murmur that could tell me what type of valvular disease it was.
“Mr Y,” I said after I placed my stethoscope towards his mitral valve. “Could I get you to roll on to your left for me please?”
“Fantastic. Could you please take a deep breath in for me and then all the way out and hold it there?”
Once again, he did as I told him to do. I couldn’t really hear the heart as it was so faint. I couldn’t quite hear any sort of whooshing sound either, however, so I assumed that there was no murmur there. “Thank you, Mr Y,” I said and told him that he could roll on to his back again. While I was preparing myself to listen to his aortic valve, he suddenly started coughing.
“Oh, are you OK?” I asked.
“Yes, sorry,” he spluttered. “Sorry, I can’t hold my breath for that long. Shall I hold it again now or does that mean you’ll have to get me to roll back on to my side again and start over?”
I was slightly confused for a bit. Then I realised. Saying “thank you Mr Y” wasn’t a clear enough instruction that he was free to breathe again. Poor Mr Y thought that I still required him to hold his back even after I took my stethoscope off. I apologised to him profusely and explained that it had been my fault.
I then got him leaning forwards and using the same technique, tried to listen to his aortic valve. Once again, there was no whoosh or sound suggestive of a murmur. In fact, I was sure that there was no heart sound either.
After failing to hear any murmurs, I was just about to leave when Mr Y said: “Oh, by the way, I forgot to say – sometimes when I’m watching TV at home with my wife, I just seem to…doze off randomly. I don’t know what it is but I’m changing the channel and for a few seconds, I just seem to be gone.”
I stumbled. This man was blacking out! I remembered from my lectures just a few months ago that a blackout in patients with valvular heart disease was a very bad sign. Were the other medical staff aware of this? If not, then surely I should go and raise it? But what if they thought that I was trying to get too big for my boots? After contemplation and telling Mr Y that I would raise it with the medical team, I decided that it would be best for me to go and raise the matter with the real doctors.
The doctors office
I cleared my throat nervously. The junior doctors in their office turned around and looked at me curiously. “Hi,” I said nervously. “I’m thedepressedmedstudent and am a third year Medical Student. I just took a history from Mr Y and was wondering if I could discuss the case with you?”
The doctors smiled and said that I could. Phew, they were smiling. That’s always a good sign.
“OK, so, erm, yeah, Mr Y, I was wondering…”
“How about you present him to us?” a doctor asked. I gulped and looked around at all the doctors. All of them were staring at me intently.
“Sure!” I said, trying to sound more confident than I felt. “Erm…I took a history from a…” (crap, how old was he?) “from an elderly gentleman who presented to this department a week ago with chest pain and shortness of breath. He had no other symptoms as far as I know and erm…he had pneumonia 25 years ago for which he was admit in hospital and…was in hospital when his wife gave birth too. But ahem, that wasn’t for him.”
I am forever grateful that the doctors didn’t laugh at me. I wish I stopped but instead I decided to continue.
“So erm…yeah. He also has a history of high blood pressure for which he is taking enalapril. Otherwise, he has no other health conditions and has never had surgery. In terms of drug history, he’s on thyroxine as he has hypothyroidism following a thyrodectomy he had and is also on some medication” (crap, what was the name of it? And I just said he had no surgeries or other health conditions but now I’m listing drugs which completely disprove that!) “because he had benign prostatic hyperplasia and…yeah.
“OK,” said the FY1. “What risk factors did he have for cardiovascular disease?”
“Erm…he wasn’t a smoker,” I said.
“Good,” she said. “Now what about the others?”
What others? I hasn’t asked about any others! You get the idea. The presentation was a complete and utter disaster. But I seemed intent on wanting to embarrass myself further because after being scolded a little, I continued:
“In terms of family history…”
The blackout and absent heart sounds
After trying to present, I told them that I was unable to hear the heart sounds. “I mean, I was looking for aortic or mitral regurgitation as they are common and Mr Y told me he had a leaky valve so…”
“He has aortic stenosis,” the FY1 told me. What?! That made no sense! He told me he had a leaky valve, not a narrowed one so how could that be right? Seeing the look on my face, the FY1 said: “Remember that your patients aren’t medically trained. They may not properly understand what they’ve been told, or may have been told badly by someone else.”
Of course. How could I have been so stupid? The fault lay entirely with me. But I was still sure that I couldn’t hear any heart sounds. The FY1 asked to look at my stethoscope and, of course, I had twisted it the wrong way so that I was meant to listen to it with the bell to hear anything. The ‘faint heart sounds’ I thought I heard weren’t real at all. I was just using the wrong side of my stethoscope.
“Oh!” I suddenly remembered. “He told me he blacks out! Like, when he is watching TV at night, he suddenly just doses off and…”
“Maybe he actually does dose off?” the FY1 asked me. She didn’t ask in a malicious way. “Did you ask him how long this has been happening for?”
I stayed silent.
“He has obstructive sleep apnoea too. He barely gets proper sleep at night and so doses off randomly throughout the day. It has been happening for a while now.”
I felt incredibly stupid.
The way you learn in third year Medicine is to make a fool out of yourself. We are very new to the ward rounds so it’s inevitable that we will end up doing or thinking rather silly things. Sure, we end up looking absolutely stupid but it ensures that we learn lessons for the future. At least, that’s what I try to tell myself to make myself feel a little better.