General description
Valerie Painter is a 25-year old M3. She is generally regarded as an
aggressive medical student who is a self-starter, talks fast and has a
reputation as a "gunner." Valerie comes across as self assured and very
confident of her knowledge and skills. Before entering medical school
Valerie was an EMT.
Valerie is in her final M3 clerkship, Internal Medicine. This morning she
is rounding with you at the hospital. Mrs. Stanton was admitted last
night and Valerie is prepared to present her case to you.
As an attending, you know the importance of feedback during teaching.
Standardized Student - Valerie Painter, MS3
FP or IM Clerkship
Script
This case is intended to teach faculty/residents:
- How to recognize when a student has committed too early to a diagnosis
and has not thought through the case.
- Recognize that a mistake has been made and correct the mistake in a
supportive manner.
1. General Behavior
You are very sure of yourself. SOME PEOPLE think you are "cocky". YOU DO
like to take control. You like to move quickly AND not spend a great deal
of time on "simple" cases. You present your case very quickly with the
case presented in declarative statements. There is no doubt in your mind
that you know "exactly" what is going on with this patient. You quickly
present the data and move directly to a diagnosis. YOU only CONSIDER one
diagnosis.
THIS IS THE WAY YOU SEE THE GREAT DOCTORS BEHAVING. THEY RARELY NEED TO
CONSIDER A WHOLE DIFFERENTIAL. IT IS BEST TO LEARN TO BE PARSIMONIOUS IN
MEDICINE, THAT WAY LESS TIME IS TAKEN, EXTRANEOUS LAB TESTS ARE
UNNECESSARY, QUICK CARE IS ADMINISTERED, AND COSTS ARE KEPT TO A MINIMUM.
2. Answers to specific questions
When asked about the jugular distention, you are clear to say that you did
not see any distention. However, you failed to perform the assessment for
distention adequately.
Technical drawback in medicine:
- Jumping to a diagnosis too early - not thinking through all the
possibilities or entertaining other possible diagnoses.
- Did not perform the assessment of jugular distention correctly. Just
looked at the neck and then thought "no distention." Unaware of the
necessity for correct positioning, etc. to do an adequate assessment.
3. Here is what you describe:
Ms. Florence Stanton is a 72 year old retired tax accountant. She was
admitted last night to the ward for shortness of breath. She has a
history of cigarette smoking (1/2 a pack a day for 40 years). She has also
had some sharp, left-sided chest pain on and off for several months. She
has never had a heart attack but has had high blood pressure since her
50's. The only medicine she takes is Procardia, 30 mg daily for her blood
pressure.
Upon physical exam Ms. Stanton had the following
- Some peripheral edema (+1or +2).
- Some rhonchi and crackles in lungs (bilateral).
- It is difficult to hear her heart sounds due to the lung sounds.
- "I did not see any distended neck veins - JVD APPEARED NORMAL."
- Her O2 saturation is 88% on room air.
- Her pulse was 90. B/P was 170/100. Respirations were 32.
You state that Ms. Stanton has an acute exacerbation of lung disease. You
would like to start her on Albuterol, Atrovent and Rocephen.