Today is Thursday. (Yes, I'm smart.) That means, oh right, the class of the day is Introduction to Clinical Medicine, which lucky second-year medical students get to take. With a scant week's worth of "training" (in quotations, because people either ditched it or if they were there, didn't really pay attention), they let us loose into hospitals to practice our giving-full-body-physical-exam skills upon the lucky patients who happen to be there. Not the patients you would normally give physicals to, the ones who come in for their annual checkup, but rather those who had to check in for some (usually serious) medical problem.

Okay, it's not as bad as it sounds. We only really focus one part of the physical exam per week, adding the newly learned tasks to our steadily growing repertoire (system by system, starting with vital signs, then the HEENT - head, ears, eyes, nose, throat, then the respiratory system, cardiac, abdominal.. you get the idea. It starts to become quite timeconsuming. Luckily, we are not getting to the genitalia this semester. I don't think I could handle doing a rectal exam quite yet), and the patients are usually soooo bored from being in the hospital that they love to have someone to talk to, and they like helping out med students. Then they get to tell us what *they would ideally have in a doctor, and that just makes their day.

The problem is when the patient you're assigned to is sleeping (the docs tell us to just wake them up, but I feel so bad, I just can't do it), or has family visiting, or is in so much pain that interviewing him (I say him, because I've been assigned to the VA, and the majority of patients are male) is really not productive.

(I don't think I'm violating any HIPAA (some patient privacy thingy) codes here.. there are no real identifying factors, are there? I'm not giving out names and SSN#s, so I should be okay.)

That was the case today. The patient my partner and I had to interview/do a practice physical on was with family and looked half knocked-out anyway. I mumbled, "Where the hell do they get these patients from?" to my partner, as in the past semester, we've been graced with some patients in so much pain that they can barely sit up, which makes listening to their lungs from the back rather difficult, some patients who can't walk - hello, no musculoskeletal exam today!, etcetc. (We also have been lucky enough to have some very chipper, talkative, and knowledgeable patients too.. but those are so rare, especially in the VA, where it seems the majority of the patients are suffering from a number of congenital deteriorating diseases..)

Anyhow, so our patient was otherwise occupied, so my very-enterprising partner and I just decided to go find ourselves another patient, rather than page our preceptor to get another one off his list. And boy, find one we did. I'll call him Mr. A, so I don't have to keep saying "he" and "him."

Mr. A looked coherent and bored - usually the best sort of combination, because he would, in an ideal world, not only be able to talk to us, but do so in an understandable manner.. and he even looked healthy enough for us to perform part of the exam-of-the-day, the neurological exam, on him. Today, after taking a full patient history, we'd do a mini mental status exam (which consists of questions such as, "Do you know where you are?" and "please count backwards from 100 by 7s" - which, I'm sorry, sometimes I don't know the former and the latter takes too much brain power.), a motor exam (testing muscle strength by checking their resistance) and a reflex check (where we get to use the fun examining mallet, yay!)

"So, what brought you to the hospital?" Always start with this question. This is the chief complaint, and you better get it. So Mr. A had a small heart attack.. okay.. "Can you describe the pain for me? blahblahblah.." And it's all very standard, and while he has a rather flat affect, it's okay, he knows what was done to him, seems very alert and with it, and then comes out with..

"So, yeah, I have post-traumatic stress disorder, dating back to 'Nam." Okay, fine. We haven't really learned how to do a mental exam for psychiatric patients yet (no, we weren't in the psych ward), so I stumbled a bit, not really knowing what the appropriate words were in this instance, having never really encountered a patient with a real psych problem. And then comes the kicker: "Yeah, I checked myself into the ER a couple of weeks ago for suicidal thoughts.. and homicidal thoughts.. I didn't really get help that time, I got fed up with the nurse and having to wait there for a long time so I just left."

Oh. Son-of-a-freaking-gun. So *this is what happens when you don't get a patient from the preceptor and decide to find one yourself. Now what to say? ("So, these homicidal thoughts, are you still having them? Are they directed towards dingbatty med students who are asking you questions you don't really want to answer, perhaps?")

But, after some soft "Oh, I'm sorry"s, the rest of the interview continued, (although I felt a little funny explaining to the patient that we were going to perform a neurological exam on him...) and we walked out unscathed, but all the same, it was just slightly freaky. He seemed stable, but what would have happened if he suddenly felt another homicidal thought coming on? Eeek.

And how do you act in an instance like that? We don't have enough training to know what to do, and are essentially just like anyone else on the street, except with that white coat of authority on, which makes us seem smarter like we really are. I was left fumbling, grasping at straws in order to come up with something to get us over that bump..

Just another fun Thursday. The best part was attempting to find the doc we're supposed to be reporting to, not being able to find him anywhere in the hospital, and getting to leave without another "When I was your age..." lecture.