Picture this.
It is 9’o clock in the morning on one very ominous day in a very badly lit hospital. You are extremely tired and it is way too early to think. *smack* what’s that? Your professor just slapped you with a million investigations to decipher. ‘Is this the Da Vinci Code in real life?’, you ask. ‘Somewhat’, I tell you. ‘You have five minutes before he comes back and you better be prepared with the answers because having a stroke/MI right now is a little impractical’.
Hey you! Yes, you. Does your patient’s ECG look like modern day hieroglyphics? Does it bother you that you don’t know where the heart is on a chest X-ray? Do you often miss the liver on an abdominal CT? Well friend, look no further! You don’t have to be an expert in symbology like Robert Langdon! I have prepared a comprehensive list for you after 4 years of intensive research as a med student in one of the most over populated hospitals in the universe. So brush up on your X-Ray/CT/MRI/ECG/clinical signs interpretation as I teach you how to be an absolute expert in reading an X-Ray while expertly dodging that patient the X-Ray belongs to. (heads up: He definitely has TB)
1. How to interpret a few important clinical signs in the head and neck
(PSA: to be very honest I do not know the myriad clinical signs in the head and neck because I am never going to be a neurologist, and I am most certainly never going to be an ophthalmologist or an ENT surgeon. No sir, I am not a masochist)
Does he have a head? Check.
This is going really great.
Is the patient staring at you? 9 times out of 10 it is Stellwag’s sign.
Differential: You have spinach stuck in your teeth.
You know the textbooks will tell you to check for corneal and conjunctival reflexes, but the day a patient will let you poke him in the eyes with a cotton wisp is the day you will revolutionise medicine as the guy who actually does a complete physical examination.
Invite the patient for lunch. Is he drooling? What must you think of?
That’s right, facial nerve palsy.
Differential : My mum makes really good biryani.
Look at his general facial expression.
Is he grinning? What’s so funny?
SHIT! Is this risus sardonicus? I thought the textbook authors only wrote that as a prank.
Does your patient say he has a headache? It’s because the damn nephrologist next door WON’T stop suggesting dialysis, even if my patient only has a paper cut.
I think we can all agree that doing the fun tests like the smell test and the taste test are cool, whereas doing impossible things like testing the pharyngeal (gag) reflex by tickling the inside of someones throat is not cool and I really don’t want to get vomited on I have a hard life as it is.
2. How to read an X-ray better than the radiologist who is minting money faster than the Indian Government right now.
Start with the date on the X-ray. Is it really today? I joined med school four years ago. How did time fly by so quickly.
Don’t get carried away like radiologists who are on a perpetual vacation in the confides of their air conditioned CT scan rooms.
Next, look if the film is lateral view, PA or AP.
It isn’t AP anymore you uninformed doofus. It is Telangana now. Be very careful around KCR’s AP view X-rays.
All that empty space there is the lung. If you see hilar lymph node enlargement, it is TB.
If there is a cavitation, it is TB.
If you see a silhouette sign, it is pneumonia (but it is actually TB)
Can you see the heart hiding partially behind the sternum? It’s too shy to come out and say hi.
If the heart does come out and say hi, it might be ventricular hypertrophy. But you can never rule out TB.
3. How to get into the mindset that ECG is actually legit and not a toddler’s attempt to draw a straight line.
This one is really hard, I have PTSD from the transition.
So you need to know 3 things about the ECG. P wave, QRS complex and the T wave. If an ECG has all these three waves then your patient is alive and kicking.
Cardiologists will tell you about axis deviation and stuff but it’s totally fake. Do you want proof? Ask a cardiologist about axis deviation and watch him sweat buckets and mumble vaguely about it being left or right.
4. How to read lab reports and not freak out.
So you have a bunch of papers with numbers on them and you can’t figure them out?
Let me help.
The first one is random/fasting blood sugar – look around you. This is India. Everyone has diabetes. You don’t need to look at a lab value to figure it out.
Full Blood Screen – This one is standard. If you see malarial parasites, don’t freak out. At least it’s not TB.
Kidney function tests – Whatever you do, the nephrologist will most definitely start steroids and dialysis. STAT.
Liver function tests – He might/might not be an alcoholic. If you pretend to look away your patient will do a shot of vodka and act like nothing happened. Cirrhosis confirmed.
5. My favourite part of this list – Clinical signs in the abdomen.
Most of these signs have become obsolete after the advent of the ultrasound and CT, but internal medicine guys love to torture med students in a last bid to seem cooler than the general surgery guys.
Does the patient have tenderness in the Mc Burney’s point? Wheel him away to surgery. Internal medicine guys just lost one patient from their ward.
That one patient keeps throwing up from second hand stress every time he sees the professor grill the students about the grades of clubbing (serioulsy, why do you guys do that?). Congratulations, your patient now has a Mallory Weiss tear and he must be wheeled into surgery.
Internal med guys lose 2 patients from the ward.
Why does your patient have bruising around the umbilicus? It’s not because someone punched him square in the gut for asking to split a 1000 rupee bill, it’s the Cullen’s sign. Sorry but this patient has to be wheeled into surgery too.
What are the internal med guys left with? That cirrhosis patient who won’t stop drinking behind their backs.
This list could go on but by the time you’re done reading the X-ray your professor will be either raging with anger at your incorrect diagnosis of TB or terribly disappointed at the fact that you are holding the X-ray upside down.
True story : My surgery professor quizzed me on the life of Wilhelm Röntgen when he ran out of questions to ask and then proceeded to look devastated when I could not answer his questions about what Mr. Röntgen’s favourite breed of dog was. And then he started blaming the medical education system.
So I hope you learn from my extensive and extremely detailed guide on how to decipher the complexities that are investigations and clinical signs.
PS. The differential is always TB.
humerushumorous 