Ups and Downs, Part Two

I was in the VA today and got the chance to interview a patient. In our Essentials of Clinical Medicine (ECM) class, we're working specifically on the history of presenting illness (HPI). For the most part, I've been okay with ECM throughout the year - talking about culture, patient communication, teamwork and whatnot. But this semester, we're getting into more history-taking, ethical issues, and other traditional aspects of medicine. A random fact that's been thrown around in ECM a few times: upwards of 80% of diagnosis can be made from a good history. If that's true, it benefits everyone. No extra, expensive images or labs are needed - saving everyone time and money. Of course, some people probably feel like if they didn't have x-rays or blood taken, the doc wasn't really trying. And of course there are some that think that procedures are more deserving of compensation than cognition. But, I digress.

Back to the HPI. Basically it involves looking into anything related to the patient's chief complaint - duration, onset, aggravating/relieving factors, patterns, quality, patient action, etc. Having shadowed and worked with Dr. Parks a bit, I'd already picked up on a lot of this type of stuff. It's just now these different questions are grouped together and have a name. And now I'm starting to see how they relate to a complete history. It was a pretty cool feeling being able to get through this HPI in a coherent and semi-organized manner. Sure, I don't have the knowledge to focus down the HPI. Still, kinda knowing what I was doing felt pretty sweet. And actually, I've gotten some positive feedback about my HPIs this past week. Also, the patient was pretty grateful to have a listening ear, even if it was about his (substantial) medical problems. And he felt like I helped him, even though I didn't really do anything. Either way, it felt good to "help" him out - mostly since he's been through so much.

Mr. C is caucasion male in his 60s who's been in the VA for one week with congestive heart failure. Worsening lower extremity edema and breathing problems brought him to the hospital, per his physician's recommendation. This appears to be his first CHF related hospitalization. Related to the CHF, he has a substantial cardiovascular history. Mr. C had a quintuple bypass in 2001, which itself was performed a few days after a heart attack. The bypass was performed due to finding 70-90% blockage of his coronaries. Mr. C also suffered a thrombotic stroke in January 2002, in which "all of his left sided function was affected." His wife notes losses in vision, cognition, short term memory, and math." Of note are the reduced cognitive skills, since he had previously been an electrical engineer and drafter, including work on numerous downtown buildings such as the Standard Oil (now Aon) tower. On 10/10/07 Mr. C suffered a broken nose, and on 10/28/07, he sustained a fall and broke his left hip. As a result he underwent a left socket replacement in November. His wife believes both injuries are related to stroke related motor deficits. Other surgical history includes a 1989 rhinoplasty and a 1991 bilateral leg fracture (from a 3-story fall) with resultant treatment including left ankle fusion. Family history is positive for maternal diabetes mellitus and paternal prostate cancer but with both having lived into their 80s. Mr. C served in Vietnam where he was exposed to agent orange. He denies tobacco, alcohol, and illicit drug usage. Chronic problems are numerous and include a 20 year history of diabetes mellitus (II), hypertension, elevated lipids and cholesterol, congestive heart failure, and renal failure (25% function bilaterally, not yet on dialysis). Over the course of his stay, he is noted to have mild pericardial effusion and pulmonary edema. Patient is remarkably coherent, without slurred speech and is in inexplicably good spirits.

Over the past 48 hours, I've definitely been reminded of why I'm in this. I couldn't imagine how those who are in med school for the "wrong" reasons get through the down times. The studying sucks ass (and there's a lot of it) - and there are easier and more profitable ways to make money.

On a totally unrelated "ups and downs" note. Two weeks ago it was 65°. In January Chicago. Definitely a record high. Global warming anyone? Tomorrow we're in the single digits, wind chills in the negative teens to -20°. Brrr. Some of us are heading up to Wisconsin for a skiing daytrip though. Hopefully I'll fare better this time than last time.