Things they don’t always teach you at medical school

This post is primarily aimed at fellow medics, so forgive me if it is a bit technical in places.

The first thing we learn in medical school once we have been released onto the wards is how to examine patients. Actually the first thing they taught me was how to take blood. We were each given a syringe and told to pair up, and that was more-or-less it. It was a good introduction to the “see one, do one, teach one” school of invasive procedures, and how I learned to do lumbar punctures, put in chest drains, pacing wires, central lines etc.

When it comes to clinical examination, the important thing is to be systematic. Follow the mantra “INSPECTION – PALPATION – PERCUSSION – AUSCULTATION” and you will be fine. Provided you don’t confuse auscultation with osculation, of course. Even if you don’t know what you are doing, muttering these words under your breath a few times will at least give you a framework to stop yourself from looking too stupid. Usually. Though there was that Irish medical student who was asked to demonstrate to her classmates how to examine the scrotum. She was a good Catholic and well brought-up, so it was the first time she had ever seen a live one (the dissecting room doesn’t really count). She looked at it from all sides, felt it rather gingerly, then started percussing, tapping the poor fellow’s genitalia as if she were trying to ascertain the extent of an effusion. Finally she got out her stethoscope. The consultant who was doing the teaching had been watching in fascination, and asked her what she could hear. “Normal scrotal sounds”.

When examining it is vital to use the correct technique. If you don’t, you won’t find what you are looking for, and more importantly, if you can’t demonstrate the signs you won’t pass your exams (this is particularly true for MRCP where they are trying to fail as many candidates as possible). You also have to be careful to use the correct language when you describe what you have found. If you say that you have heard a rough rumbling murmur, to an examiner that is synonymous with a diagnosis of mitral stenosis. It is a sort of ritual and it requires the correct incantations.

It is quite a thrill when you hear your first murmur. The easiest, of course, are systolic, with a high-pressure jet of blood forced through a narrowed valve producing an obvious whooshing sound. But what about the rough rumbling murmur of mitral stenosis? It took me years before I first heard one of those. It turned out that all the time I had been listening out for completely the wrong thing. I finally twigged when I came across a lady who had had a mitral valve replacement. Mechanical valves tend to make a lot of noise, and associated murmurs are much more obvious. Though I do wonder what it must be like for the poor patient with a Starr-Edwards ball valve (so-called, someone once would have me believe, from the star-shaped artefact it gives on a CT scan), having to live with a loud, irregular (they all have atrial fibrillation) click accompanying every heartbeat and announcing their entry into the room. Actually my Godmother was delighted with hers; after travelling from New Zealand for my brother’s wedding she took every opportunity to show off the pictures of her “Sputnik” to the other guests. Rather like Samuel Pepys producing his bladder stone from his pocket.

Imagine a little rubber ball, one of those really bouncy ones with a high coefficient of restitution. I’m sure you had a lot of fun bouncing them around the house when you were younger, smashing things in the kitchen. Put it in a little plastic cup and roll it around a bit. That’s what a rough rumbling mitral stenosis murmur sounds like. And even if you can hear it easily, you still have to turn the patient onto their left side, get them to hold their breath in expiration and listen with the bell of your stethoscope (pressed gently against the skin, so as not to stretch it into a diaphragm) to emphasise low-pitched sounds. If you don’t do all this the examiner will fail you.

Pericardial friction rubs are another thing that you will never pick up until you have heard a loud one. The loudest I ever heard came from a gentleman with a horrible form of vascular disease that caused him to occlude one major artery after another. He had just infarcted his second kidney and he didn’t yet have an AV fistula so we were dialysing him through a large catheter in his subclavian artery. This had taken a couple of attempts to put in as it wasn’t the first time this site had been used and it was getting a bit scarred. Somehow the site had become contaminated with Staph. aureus which had followed the track as far as his pericardium, and his heart was now sloshing around in 500ml of pus. The noise it made was audible from a couple of metres away.

(Just an aside on terminology. There is a technical word in ManagementSpeak that non-clinical staff are fond of using, and that is “diarise”. It is a sort of portmanteau of dialyse and diurese, though I have never been able to find out exactly what it means. Most jargon exists to enable succinct and unambiguous communication between specialists, but ManagementSpeak is designed to obfuscate and in particular to convince the speaker that they are cleverer than they really are. I once received a memo about changes to hospital policy with respect to the car park going forward. I replied that I was OK then as I always reversed into the space.)

Most pericardial rubs are quite quiet. They usually disappear after a few hours once the inflamed pericardium starts to produce fluid and the surfaces are no longer rubbing together. They are also posture-dependent. The patient will want to sit forward as this relieves the pain (a useful feature in diagnosing pericarditis), but you are more likely to hear it if they are lying back at 45 degrees, or even flat. Now, you know when you are listening to someone’s heart there can be a sort of scratching sound from the stethoscope rubbing against their chest? This may well be in time with the heartbeat, particularly if they have a heave from a dilated or hypertrophic ventricle? Since it is an extraneous sound you very soon learn to tune it out, and once you have been using your stethoscope for a while you won’t even realise any more it is there at all. That’s what a pericardial rub sounds like.

In real life you are more likely to encounter a pericardial effusion than a rub, and it is important that you can diagnose it because the patient is often very sick with cardiac tamponade (this is not a fizzy drink – the word comes from the same same root as tampon and tamping iron, such as the one that lobotomised Phineas Gage) and if so they need the right treatment urgently. The heart sounds (murmurs, rubs and anything else) may well be quite quiet as they are attenuated by the fluid around the heart. For the same reason the QRS complexes on the ECG might be a bit smaller than usual, the heart being further from the skin. If you are lucky it will be moving around a bit inside the sack of fluid, so the QRS will vary in height from beat to beat and give you a Clue. But you are unlikely to be lucky enough to have the sagging ST segment that is in all the textbooks. The JVP is very useful here, though. It is usually raised, and it goes up and down markedly with respiration. The real giveaway, however, is the blood pressure. These days blood pressure is usually taken using an automatic device, which is no good here. You will have to locate a sphygmomanometer, and hope that the department still has one hidden in the store room (you will be amazed at what you might find – when I was an ENT houseman we had somebody who was so deaf that the only thing that worked was an ear trumpet; we still had one as one of the consultants thought it would be a pity to throw it out; I’m not sure he could hear us, though, as he carried on smoking in his sideroom despite our exhortations and the burns in the sheets). Take the blood pressure manually, letting the mercury fall very slowly. Note when the first Korotkov sound appears – it will be intermittent and will come and go as the BP changes with respiration. Listen for when it stops fading out and is audible for every beat and note the pressure again. The difference between the two is the degree of paradox (referring to pulsus paradoxus, which is when the the radial pulse disappears entirely with each breath). Anything more than 10 mmHg is significant. You may be able to spot some changes on a chest x-ray. If the effusion has been present for a long time (which is usually less of an acute problem) it might be quite big, and the heart shadow will be enlarged and maybe a bit globular. Otherwise look at the edge of the cardiac shadow. Normally it is slightly blurred due to movement of the heart during the 1/4 second or so of the exposure. If there is an effusion it will be sharper. You may even see a double shadow of the heart and the pericardium separately. The gold standard investigation is an echocardiogram, but you will have already involved the cardiology team at the point of ordering it.

I’m an oncologist. Why am I talking about cardiology? How about x-rays instead? These days they are stored digitally on the hospital’s PACS system and are instantly available on the ward and in the clinic. Even though you won’t have the specialist high dynamic range monitors used by radiologists you can still see a lot, and since you can readily view the images then really that means you are obliged to. Poring over scans used to take up time in my clinics (which always overran) but it is essential.

The first thing to do is to scroll down to the bottom of the report and see who wrote it. Individual radiologists tend to have their own areas of expertise, and if a cancer scan, say, has been reported by a non-oncology radiologist then they might have missed something important. If you know their area of expertise is golf, for instance, then you can safely ignore anything else in the report. I once had a patient referred to me with a PSA of 100. He had attended Casualty a few weeks earlier with neck pain and been sent away with painkillers. His bone scan showed a hot spot at C6 so I put him on hormones and arranged a radiotherapy appointment to ease the pain. When he turned up, we screened him on the radiotherapy simulator and C6 was completely missing. Pulling the Casualty films showed that it was largely eaten away even then. He was a very stoical man, who used to take two buses and a train to get to the hospital. After two years in a hard collar he finally persuaded the neurosurgeons to let him take it off. His PSA fell to zero soon after starting Zoladex and he remained well for years (with no neurological damage at all).

Happily most cancer scans get read a second time by a specialist, usually for the multidisciplinary meeting where the case is discussed. And most radiologists are happy to go through scans with you – they are usually delighted to know something more of the clinical history of the patient other than a couple of words scrawled on the referral note.

Actually that is very important. Whenever you request an opinion from another colleague, please always ask a specific question. Otherwise they are going to have to guess what it is you want from them. Even if it is a chest x-ray or a blood test, this is still important. CT and MRI scans can be done in many different ways, and only if the radiologist knows what you are after can they choose the best protocol for finding it. Sometimes it is even better to ring them up first and describe the problem so that they can advise you how best to investigate it.

I used to work with a radiologist who was really a physician at heart. He rang me once to say that he had been asked by the ENT department to biopsy a neck lump in a young man. He had taken it upon himself to do a CT scan of the rest of the body while he was at it, and an ultrasound of the testicles (where the primary tumour was, of course). He wanted to know whether I could see him the next day and whether there were any blood tests he should send off in the meantime. I said yes, and while he was at it could he send some urine for a pregnancy test (with that degree of spread from testicular cancer his HCG may well have been high enough to show in his urine, and a pregancy test usually comes back more quickly than tumour markers). Now that’s my sort of radiologist.

You can also get a radiologist on your side by bribery. When I was a house officer I used to take cremation forms to the x-ray department for the radiologists to sign part 2. They were always grateful for the fee, and none of my fellow juniors had had the same idea. This works both ways, too. There was one radiologist who was always rude to me when I was a junior. Later on I was appointed a Consultant in the same hospital, and I always referred my private patients to somebody else.

Looking at medical images takes a lot of practice. I still find ultrasound images to be like looking for a snowball in a blizzard (apart from prostates, which I have mastered after years of putting in radioactive implants). I’m sure those beautiful pictures of babies which my pregnant friends show me were constructed beforehand in Photoshop. But sometimes you can use the skills that you already have in pattern recognition to good effect.

One serious, but sadly very common, complication of malignant spread to the bones is spinal cord compression. Often this is diagnosed on Friday afternoons, when the ward is getting ready to hand over to the weekend shift and somebody realises that Mrs Jones hasn’t got out of bed all week. All radiotherapy departments keep treatment slots free of Fridays for just this reason. The early symptoms are severe pain, worse on movement, often in a band around the chest or abdomen, and this is followed by sensory and motor loss, and bladder dysfunction. It is vital to maintain a high index of suspicion, as without immediate treatment it will rapidly progress to total and permanent paralysis, which in a cancer patient is usually also an early death sentence.

Sometime you can spot that this is going to happen on an x-ray of the thoracic spine. In the AP view, the vertebrae look like owls standing on each other’s shoulders, like a totem pole. Look for the owls. The beak is the spinous process and the eyes are the pedicles. One of them is winking at you…

The left T10 pedicle is missing. This is a radiotherapy planning film, which is why it appears to be back-to-front
This is the same patient’s CT scan, showing bone erosion and lateral displacment of the cord

I don’t know about you, but I find owls much easier to recognise than unfamiliar x-ray views.

Even more important than getting radiologists on your side are the nurses, particularly if you have to see a patient on another ward and you don’t know any of the staff there. What you should do is look out for a Filipino nurse (the NHS is completely reliant on immigrants so you can generally find one). Then you need to say:

Magandang humaga (if it is before midday)

Magandang hapon (between 12 and 6 pm)

Magandang gabi (after 6 pm)

Thos are the Tagalog phrases for Good Morning, Good Afternoon and Good Evening, and they are fairly exact when it comes to the time of day (just as you should never greet anybody with Ohaiyou Gozaimasu in Japan after 10 a.m.); they also double up for Goodbye. If you can you should attempt a Filipino accent, closing your throat and pushing up the pitch. I get the same response every time. First they look at me as if I am mad. Then they laugh. Then they do everything they can to help.

The other word you should know is salamat, which means thank-you.

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