P.E.

Most of my medical education at this stage has been presented as easily digestible small bits of data, whether by a textbook or lecturer, proclaiming for example, “this is Kaposi’s sarcoma.” I would have told you with some confidence that KS manifests as dark flat skin lesions; perhaps I could have dredged up the HHV-8 etiological details with some concentration. But here, after just seven days in the hospital, I’ve been surprised so many times by physical presentations that it feels like I’m seeing patients for the first time. On one of our first days here, we watched Dr. Sadigh really use the details of the physical exam, starting with nails and hair, to work through a differential (for ascites), something I’ve never seen an attending do before. I now find myself searching for physical findings not to fulfill the half-hearted routine series of gestures that I’ve seen on the wards at Yale, but because I’m curious about what I’m going to find. It actually reminds me a bit of gross anatomy from first year, the amazement of seeing things for the first time, tinged with conflicting emotions about the power of disease and particularly my right to invade another’s body as a learning experience.

Here, pathologies are often so advanced and imaging and lab data are so much less available, that physical diagnosis is moved back to center stage. Regular rounds on any service here could be roughly equivalent to unusual physical diagnosis rounds at home. In clinic, for example, I saw a man with KS. Rather than dark flat skin lesions, I saw a leg swollen to five times its normal size, looking for all the world like elephantiasis, the lymphatic system hard and indurated, the skin weeping with superimposed infection. The doctor noted my surprise and laughed, “it’s not like the textbook, is it?!” I feel like I go through ward rounds with a running silent commentary of disbelieving “that’s,” as in: That’s Kaposi sarcoma? That’s a skin lesion of cryptococcal meningitis? That’s what superior vena cava syndrome can look like? That’s the spleen, way down there? That’s the PMI, all the way over there? That’s the LV, barely moving on echo? It’s making me think about pathophysiology in different ways, and making me want to reread physical diagnosis textbooks, hoping to eventually gain the confidence to feel secure in my PE skills.