The Diagnosis

By Rebecca King, rking

The moment you make your first diagnosis, on your own, with no help from attendings or preceptors, using just the patient interview and physical exam, that is a day a medical student will never forget. It is a moment of surprise, like a light bulb being turned on, followed by pride and most likely a satisfied smile. I was looking forward to this moment in my training. I always wondered what it would be, what the patient would be like. Little did I know my first diagnosis would not be a joyous moment for me at all.

I can remember the patient perfectly. A very sweet man in his 50s. He reminded me a lot of my grandfather. He had a perpetual smile on his face, was extremely happy to entertain a medical student interviewing him, and made witty quips throughout the physical exam. He was comfortable in the ER, he’d been there before.

He came in because all of a sudden he was short of breath that morning. He couldn’t go very far without feeling like he needed to stop and catch his breath. This was new for him. He had a history of atrial fibrillation and other standard elderly American conditions. I hadn’t had cardiology yet, so I wasn’t sure what atrial fibrillation was and he was all too happy to explain it to me. When I finally had the course a few months later, I realized he had told me everything my professor was teaching me; he knew all about it.

During the physical exam, I heard for the first time what rales sounded like. I also heard an S3 heart sound for the first time, but I didn’t know what it was or recognized it. When I later reported it to my preceptor, I told her his heart sounded funny. The exam finding that finally clicked for me was his pitting edema in his legs. I couldn’t quantify it at the time, I just knew it was present. Everything came together for me when I saw the edema, the light bulb went off as I stood at the foot of his bed pressing on his ankles.

Except I wasn’t proud or happy or satisfied. I was deeply saddened. Given his history of heart problems with fluid in his lungs and legs, I didn’t need cardiology to figure out what this kind man was experiencing: heart failure. I tried very hard not to show any sadness or deep concern when I asked him again if there wasn’t any other heart conditions he’d been diagnosed with. No, just atrial fibrillation. So this was the first time someone was going to tell him he had heart failure, but I couldn’t tell him. As a second year medical student it wasn’t my role yet. I explained I was going to go tell my preceptor everything, and I left the room feeling as if I had a great weight on my shoulders. I’d made my first diagnosis and it was mostly likely the process that this wonderful patient was going to die from. I will never forget my first diagnosis.

16th February, 2014