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The importance of the basics | Stories from medical rotations

Last time I wrote about the prevention of varicose veins with compression socks, this time the stories from medical rotations continue with an anecdote of a patient at the pulmonology department. This particular time reminded me of the importance of starting from the basics – talking to and looking at your patient.

When I was just starting medical rotations, a teacher told us that senior doctors often miss the basic steps and that we as interns have the luxury of having more time for a patient. One of the things that, according to this teacher, many senior doctors miss during performing a physical exam is to look inside a patient’s mouth. I remember thinking “who cares?”.

The teacher cared. It’s the beginning of the digestive system, the party zone of all sorts of infections, the home to the gums, the teeth and the tongue, the giveaway of oral hygiene and telltale tooth-decay caused by sweets consumption etc.

This thinking of the basics came in handy one day when I was at the internal medicine department.

At internal medicine, I learned two things: that nurses and doctors get along like cats and dogs (ie. it’s possible if they know each other very well), and that internal medicine covers a broad scope of all the processes that happen inside the body – from cancer to cardiology, from electrolytes to endocrinology.

During the fourth week there, I was attending the pulmonology department. Besides the already admitted patients who were at the department for a couple of days or longer, we could receive an urgent patient the same day if need be.

One day, an out-patient clinic patient called. He was a lung cancer patient, and although his treatment was going well, he had trouble swallowing since a day or two.

The senior pulmonologist spoke to him on the phone and then spent the whole morning calling back and forth to organize this patient to be admitted the same afternoon and get an MRI. “It’s probably spinal cord injury due to metastasis of the lung cancer!”, said the pulmonologist as he was prepping me to see this case. I was like – wow *big googly eyes*, that’s intense! “You can speak to him before his emergency MRI at 14 o’clock.”

“Okay!” I thought (we interns always have extra time on our hands, so why not!). The pulmonologist wouldn’t have time to see him this afternoon, but the MRI would give an indication of how bad it is.

I grabbed my white coat and my purple stethoscope and rushed to the room where the patient would be. I was going to take the patients history, do a whole physical exam, and even practice my skills with the neurological exam.

The patient had just arrived (his bag on the floor next to the bed, and his coat still on) and was standing in the middle of the room as I entered. I thought he looked quite fit for someone with spinal cord injury. I greeted him and told him I’d be asking him some questions about his symptoms.

As I asked away, he informed me he is doing well, his last treatment was a couple of weeks ago, he hasn’t lost weight, is enjoying the spring – but is having trouble swallowing since a day or two.

Hmmm, no big clues there. 

“What exactly is the problem with the swallowing?”, I asked. “Well, it’s not so much the swallowing actually, as that my tongue feels dry“, said the patient.

Hmmm… let’s have a look.

I take a look inside the patient’s mouth and see a tongue covered in a white – from the tip all the way to the back of the tongue. It looks painful.

I complete the rest of the physical exam and neurological exam and don’t find anything unusual.

“Sir, your tongue is covered in a white rash called candida!”

This finding was not unlikely, as candida overgrowth is possible in oncological patients due to the decreased immune system following treatments. I chase down the pulmonologist and tell him what I found. He looks a bit bedazzled, goes into the patient’s room to take a look for himself and then cancels the MRI.

He prescribes medication for the candida overgrowth and seems relieved at how well the patient is doing. We send the patient home before he’s even unzipped his bag.

And just like that, by starting from the basics of speaking to and looking at the patient, we prevented redundant imaging, an unnecessary hospital admission, and a whole lot of grief to family and friends who would have anxiously been waiting for the results of the MRI.

After this heroism, I spent the afternoon logged off the computer and staring out of the office window since medical interns infamously have nothing to do. But still, staring outside is nice – it’s sunny, the sky is blue and the trees are green. I relax, enjoy the sunshine and think of how happy I am that I looked into the patient’s mouth.


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All the images are from my private collection so please ask permission if you wish to use them.
Featured image from https://tvgag.com/gag/ya-basic/ – I just couldn’t help myself, hahaha!

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