A Learning Point - How medical students learn on the ward

It was a pretty uneventful Wednesday morning in the general medical ward, until one of the endocrine consultants came into the room and asked for one medical student to “take a full medical history” from a particular patient in another ward.

It is not common for a consultant to actively offer such an opportunity for a purely learning exercise. We looked at each other, smiled nervously to each other. There were three of us in the room – two of my friends had to leave early that day. We were obviously quite shocked. I stepped ahead as the others had other commitments in the afternoon.

I was brought to meet this lovely man, Mr X in a side room in the ward next to ours. The registrar introduced me to him and then left the room. He is a South Asian man who had moved from Bangladesh to East London for close to two decades. He was referred to his GP after 6 weeks of very sore and painful neck and intermittent fever. He had finished two courses of antibiotics, which had not alleviated his symptoms. He had a past medical history of gastrooesophageal reflux disease and an anal fistula operation.

As I was speaking to him, a nurse clad in a full PPE gown and a surgical mask, came into the room to deliver some IV paracetamol for Mr X. I was initially quite surprised as to the way the nurse was dressed. My mind went racing and I tried to recall if I had seen a ‘green’ notice on the front of the side room door (a 'green notice' is a warning sign indicating that the patient is potentially harbouring an infectious respiratory disease).

I immediately thought of TB!

I asked him about whether he had been experiencing night sweats, weight loss and dry cough (or even coughing out blood). He mentioned that he had lost 5kg in 6 weeks. He alluded to the idea of ‘night sweats’. He talked about how he had to get up at night to change his shirt because he was sweating so much at night.

After a good 1 hour of taking a full medical history, I went on to examine his abdomen (because he complained of having an intermittent pain lasting a few seconds in his tummy/RUQ) – no significant finding on examination here. Then, I moved on to examine his lungs but there was no clinical findings suggestive of respiratory infections of any kind. By this time, his wife had come in and I felt that I had to wrap up my examinations quickly. So, I decided to do a focused thyroid examination for his primary complaints are his very painful neck.

I asked him to lift his beard and to swallow a glass of water (goitre moves with swallowing) and stick out his tongue (for thyroglossal duct). There was nothing really obvious.  I tried to palpate his neck but it was so exquisitely tender that I was not able to have a good feel of the neck. By this time, I was convinced that TB is probably the primary suspect. But, at the back of my mind, I thought "why is his neck so tender!". There was candidiasis of the tongue (and possibly the throat) but could that possibly account for the amount of pain he was in? I quickly checked for other findings of thyroid dysfunction e.g. reflex changes.

On presenting the case to the consultant, I realised that I had missed out a lot on the history-taking process. On hindsight, I should have realised that ‘night sweats’ was a red herring as he was obviously profusely sweating as I was speaking to him. He even wiped off his sweat and pointed out that his shirt was drenched in sweats.

After discussion with the consultant and registrar, the primary differentials were DeQuervain’s thyroiditis. Patient then went on to have ultrasound of the thyroid gland and nuclear medicine scan to check for the activity of the thyroid gland.

I did not manage to follow up with this patient as I rotated to another ward but I became more appreciative of the diagnostic difficulty in a patient with an extensive past medical history. It is easy to get muddled by the extensive history. Besides, I was overly reliant on environmental cues and ethnicity [not all South Asians in East London have TB!]. Looking back, I am disappointed that I did not think of DeQuervain's, given the painful and tender neck; But being a medical student, it is a learning process. This is how medical students in clinical years learn on the ward. It is a steep learning curve for me. But, I am enjoying every step of the way.