Mudgee, Day 10 - Flying solo in Cas

I spent the day in hospital today, doing cas duty with Dr P. Although I've mostly been happy to just tag along and observe (because as per my previous post, I don't really know anything yet), Dr P insisted that the best way to learn is to swim out on your own. So throughout the day, he assigned me to patients and told me that he was going to leave me entirely responsible for taking their history, examining them, asking him to order any tests/investigations that I thought would be useful, and then forming a management plan. He said that he would let me go as far as I could within reason before intervening if he thought I was on the right track, but otherwise trust whatever choices I made. Argh (but of course it was mostly pretend because he reviewed all the patients again briefly and wrote notes in their folders ;-)!

The idea was probably scarier than the reality because, as I came to realise, he only assigned me patients who (based on the triage nurse's initial assessment) he deemed non-serious or life-threatening. This was completely fine by me of course, as the opportunity to do something like this on a real patient (read: not my perfectly healthy family or fellow med students!) with real signs and symptoms was amazingly invaluable! I was able to continue the whole way without him intervening at all for a few patients (female with an U+LRTI; male with gastro+nausea; female with syncope; kid with fever); but he also stepped in with a few patients who had red flag symptoms that he picked up when I reported the findings of the Hx and Ex back to him. In a few instances, he told me to go back and ask one or two questions that he thought may be significant and which turned out to change the most probable diagnosis altogether. While most diagnoses are based a combination of information derived from the Hx, Ex and Ix; it's scary to think that in some instances, one or two extra/different things swerve the likelihood towards something else. Like this one guy who presented with abdominal pain in his LIF. When I examined him I noticed that he had a scar in his RUQ (from a cholecystectomy) so I immediately took anything gallbladder-related off my list; in fact, I took the liver off my list all together as well and didn't bother to check for jaundice in the sclera because the pain was on the polar opposite end (you can see where I'm going with this right?!). Anyway, suspecting that his symptoms were just a flare up of the diverticulitis he was diagnosed with 3 weeks ago, I asked Dr P to write an order for blood tests, to which he added LFTs. When the results came back, his Bilirubin, GGT and ALP where all elevated so Dr P asked me to go back and ask about the colour of his urine and stools (which I'd completely omitted from the history (!)). Urine darker and stools paler than usual. Anyway, long-story short: it turned out that in addition to the flare-up of his diverticulitis, he also had a common bile duct obstruction.

Another day, another lesson learnt. I really know nothing... but I'm learning.