Collapse, falls and funny turns week was mostly based at a smaller hospital talking to people who'd fallen and broken their hips and were under long term rehab. It was my first placement of the week however, that really made my time special. It was my eureka moment; my achievement to cement in my mind that I can be a Doctor, I do know what I'm doing. It was quite possibly one of my favourite moments of the year. I was sent to go to the Clinical Decision Unit ward round. This is where people are sent from the Emergency Department if they need a little observation and so would break the 4 hour target, but aren't sick enough to be admitted. It tends to be full of people who have fallen, head injuries and over doses.
After the ward round I sat and chatted to a lovely elderly patient who had fallen at home while down visiting their children. They were adamant they had just tripped on the rug and stuck to the story despite specific questioning about dizziness, light headedness or any peculiar feelings before the fall. I always do a systems review after I have explored the presenting complaint and social history, just for completeness. It was then that they admitted that actually, maybe, possibly they just might have been a tiny bit dizzy and that's why they missed their footing and tripped over the rug. I moved onto the examination, and as I was listening to their heart something just didn't sound right. There wasn't the normal lub-dub I had heard before, there was something else. I was so excited by the possibility of hearing my first ever heart murmur, I quickly abandoned the rest of the exam to find a doctor to confirm that I was actually hearing a murmur. There was nothing in their notes about a murmur and so I really doubted myself.
The doctor confirmed my findings, a clear murmur suggesting aortic stenosis which was probably the cause of the the patient's fall. I felt elated, I practically skipped for the rest of the week. The best thing, was that the patient was called away to have a scan and their lunch after I had finished my history but before my examination. I had seen the Consultant round on them so I knew the examination findings for the dislocated patella they had sustained in the fall and I was really tempted to go home and make up the other findings for the heart and lungs that hadn't been examined. The weather was disgusting and my two partners had already long since finished and left. The doctor I was due to feedback the patient to would never get a chance to meet them, so they wouldn't know if I had presented the correct findings or not. I could just tell the Doctor about the dizziness and hope he followed it up later, althought the doctor was the only one covering the ward due to staff difficulties getting in because of the weather and he was due to go off on mandatory training at lunch time for the afternoon, when the patient would be discharged. The only niggling doubt in my mind that made me wait an hour and half to talk to them again was that in their ED notes and their CDU notes, no one had listened to their heart. Nowhere was documented heart sounds 1+2 and nothing else. If there had have been, I probably wouldn't have stayed. I am so glad I chose diligence over laziness in the end.
The frightening thing, is that the heart murmur was quite clear and so the problem was fairly advanced. No one else had done a cardio exam, even though they definitely should have done, and no on else had the time to sit with the patient and build up the relationship enough for them to confide in them about the dizziness that might make you suspect a cardiac cause. They told a very convincing story otherwise that would have you believe it was entirely mechanical. If left untreated, something much worse could have happened, so it shouldn't really have been down to me to spot the murmur. But it goes to show that medical students can be useful on the wards, that you should always trust your judgement and be thorough.