Other Features: Teaching and Learning Moments
Dr. Goodell is program director, Racine Family Medicine Residency, Racine, Wisconsin; and assistant professor, Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
The preceptor introduced me to a pleasant, thin man, around 50 years old, dressed in two-piece pajamas and resting comfortably. He was the “willing hospitalized patient” on whom I would demonstrate an abdominal exam as part of the final grade for Introduction to Physical Diagnosis.
After some small talk, I tentatively raised the patient’s top and began the usual protocol of abdominal inspection, percussion, palpation, and auscultation. Both patient and preceptor were watching me intently, and I felt a knot forming in my stomach. Although I was generally comfortable with my exam skills, I was more anxious knowing I was being examined as well.
I saw no evidence of distension, skin changes, or mass. There were no abnormalities on percussion. I moved on to palpation, nervously prodding him. His abdomen was flat and soft. I elicited no pain and found no hepatosplenomegaly. Finally, I placed my stethoscope and auscultated four areas.
Stepping back, I took a deep breath to relax and looked inquiringly at my preceptor. “Can you suggest a diagnosis?” he asked. I stared blankly, unable to formulate an assessment for this apparently normal exam.
Had my preceptor chosen this patient for the exam because of a known abnormality that I should be capable of detecting, yet couldn’t find? Or was my task to recognize a normal exam? I paused and haltingly replied, “I think his exam is normal.”
“How do you define the borders of the four abdominal quadrants?” my preceptor asked.
That’s easy, I thought, and confidently replied, “Lines drawn vertically and horizontally through the umbilicus separate the abdomen into four quadrants.”
His eyes shifted to the patient’s abdomen. “Have you fully examined all quadrants?”
Something was wrong. My heart leapt, my throat tightened, and my palms became sweaty. Following his gaze, I realized that the patient’s pajama bottoms rose almost to his umbilicus. We’d been taught repeatedly about both adequate exposure and proper draping of the patient. In my nervousness and attempt to respect the patient’s privacy, I had confined the exam to the area above the waistband, creating “four” truncated quadrants out of the right and left upper quadrants.
I watched with chagrin as my preceptor lowered the pajama bottoms and exposed a large scar and mass in the right lower quadrant. Instantly I recognized the evidence of a recently transplanted kidney, which I now understood was the reason for this patient’s hospitalization. As I shuffled out of the room behind my preceptor, he gently stated, “The importance of exposure cannot be overemphasized.”
I have never forgotten this lesson. I have drawn upon it frequently, especially when teaching my own medical students and residents. Whenever I observe them listening to a patient’s heart or lungs through a shirt, or examining a knee after unsuccessfully trying to pull up a pant leg far enough, I share this anecdote. Although I learned about proper exposure in an embarrassing way, I hope they will learn it more easily.
Maryellen Goodell, MD