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Teaching and Learning Moments

The Ah(a) Moment

Chretien, Katherine Chang, MD

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doi: 10.1097/ACM.0000000000000203
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I had just walked into the patient’s room when the smell of cheery fruitiness assaulted me. I wondered, cherry cough drops? His packed bag sat on the hospital bed alongside his large athletic frame, which was donned, quite fittingly, in a Redskins football jersey. He greeted me with a wide smile, always nice to see when I come to ask patients to allow students to learn from their bodies.

I looked at my list and read, “Tonsillitis; has gag reflex.” I explained that I was bringing medical students around and teaching them elements of the physical examination; would he mind if we peered into his mouth? Mindful of how often he likely had been gagged already, I was quick to add, “We wouldn’t probe, just looking!”

He smiled again and said, “Sure, come on in.”

I motioned for the students to enter, and they filed in, greeting him with smiles. I had them each introduce themselves and their hometowns. The patient immediately launched into praise over how he had been treated at the hospital and how impressed he was that everyone was so nice, giving an impromptu lecture about the importance of smiling when you enter a patient’s room.

I asked the students to tell me what they had observed already about this patient and his possible diagnosis, using any clue in the room to help them. They immediately scanned the room, not having taken in the details before, and settled on the IV pole that was disconnected but still holding an empty bag of antibiotics. An infection, they offered. Good. What else?

The patient, of course, looked so well. Energetic, cheery, articulate, and not even in patients’ clothes. What else?

“Do you smell anything?”

Blank stares.

“It smells like something in here.…”

Their eyes searched while they begged their noses to work extra hard. No, nothing.

“It smells fruity in here. Cherry?” I asked. “Jello?”

“I just had Jello!” the patient exclaimed. I felt the breeze of the students’ awe swirl around us, their eyes widening. I stood taller. Lucky shot, but I’d take it.

He explained that he was on a clear liquid diet, “I’m seeing how it goes down and if I can swallow okay.”

With that clue, they focused on his face … searching, searching.

“The right side of his face and neck look fuller,” said one student.

“Let’s look in his mouth,” I suggested.

The students took turns holding the penlight and peering in.

“Poor dentition,” someone noted. “There may be some brown areas by his upper back teeth.”

One by one, they inspected his mouth, and nothing but the suspicious brown area turned up. I was the last to take a look. I shined the light in his open mouth and noted the crowded airway. With his large tongue, his pharynx and tonsils were completely out of view. “Can you stick out your tongue and say, ‘Ah?’” I asked. With that, my view opened way up and the inflamed right tonsil popped into view from behind the hills of the posterior tongue. Bingo.

Again, they took turns, this time, exposing the findings. They exchanged glances, murmuring quiet exclamations of satisfaction.

Tonsillitis, strep A positive.

We thanked the patient, wished him the best, and filed out with light steps. In the hall, we collectively sighed, exuberant and sated by this physical diagnosis session—a simple diagnosis but many teaching points; an illuminating exam; a happy, helpful patient.

This is what bedside physical diagnosis rounds are all about—the patient as teacher, the art of observation, and that unforgettable “Aha” moment. Sometimes, it almost feels like magic.

Katherine Chang Chretien, MD

Dr. Chretien is associate professor of medicine,

George Washington University, and medicine

clerkship director, Washington DC VA Medical Center,

Washington, DC; e-mail:

© 2014 by the Association of American Medical Colleges