Introduction to Clinical Medicine

I saw my first live patient yesterday.  At Ross, we start clinical medicine in the first semester.  I love this because so much of what we study right now is scientific minutiae (important, but very fine details.)  Seeing a real person reminded me that this is why I love medicine and want to study all of these things, so I can help real people with real problems.

So we saw a "standardized patient" in class yesterday.  These are professionally trained individuals who have probably done this a 100x.   Our lecture was concerning the abdominal exam.  First, we did a visual inspection of her abdomen.  Was it protuberant (pregnant? air filled?), round (a little obese, but when laying down, matches what we'd expect from her standing up), or flat?  Then we looked at her sides (or "flanks").  If they are bulging out, it could indicate that fluid has built up in what are called the paracolic gutters (spaces between the sides of your colon and the abdominal walls.)  That fluid indicates that something is wrong inside.  Finally, we looked for surgical scars, rashes, lesions, stretch marks (called abdominal striae), and tattoos.

Next, we performed what's called "auscultation" (listening to the patient's belly with a stethoscope.)  We listen in all four quadrants of the abdomen.

(from Wikipedia)

We are listening for bowel sounds.  You should have bowel sounds called "gurgling" because your stomach/intestines/colon are working to push food through.  If you don't have bowel sounds, that is a surgical emergency so we'd have to be very confident that there are no sounds (I was told that you have to listen for at least two minutes in different quadrants to assure that there are no sounds.)  Next, we listened for "bruits."  Bruits (sounds kind of like "brew-ries")  are the result of turbulent flow in arteries from plaque build up or other obstructions.  We listened to the aorta, renal arteries, and iliac arteries.  It is normal to hear nothing; an intermittent whoosh-ing sound would indicate a bruit.  

(from Study Blue)

Next, we percussed the abdomen.  "What is percussion?" you might ask?  Percussion is a special method of tapping on the abdomen to hear what's underneath because sounds are different whether they are over a fluid-filled, air-filled, or solid space.  Basically, you press the middle finger of your non-dominant hand onto the patient so that the joint closest to your fingertip takes all the pressure (your fingernail shouldn't be white.)  Trying not to let any of the rest of your hand touch the patient, (because it changes the sound), you strike that joint with the tip of your middle finger on your dominant hand.  (This should hurt if you have long fingernails, that's how you know you are striking with the correct portion of your finger.)  My finger nails were longer, so I immediately cut them last night so that I don't hurt the patient, or myself.

Finally, we palpated the abdomen.  Palpation is pressing on the abdomen in the different quadrants (see the picture above) to see if it induces pain in the patient, or to see if we can feel the organs (if they are enlarged, you can sometimes feel the liver or the spleen.)

I was honored that our patient would let us practice this exam.  She's done this so many times that she was able to sometimes correct us or reposition our hands for better auscultation/palpation.  

Overall, it was a great reminder that at the end of the exams come the patients.  The whole point of everything I'm studying is to be ready to help those people. 

Now, back to the books! 

For His Glory,

KCE