Exam Season

A 27-year-old African American woman walks into your office. Does she have sickle cell or sarcoid?

A 23-year-old female comes in with heart palpitations and shortness of breath. Her EKG is unconcerning, her d-dimer is negative, and her other labs are all within normal limits. Why are women the only ones who get panic attacks on standardized tests?

A 7-year-old boy presents with a fever and a rash (figure A). What body part is this rash on? Is that an armpit? No, it’s his butt. Are you in a public place? Are the people next you at this cafe wondering why you’re looking at a picture of a kid’s butt?

A 32-year-old male comes into the office for his annual physical. He drinks 20 beers a week and has no concerns about his alcohol use at this time. Why is everyone having more fun than you?

A 24-year-old male comes in with heart palpitations after drinking 6 cups of coffee. Suck it up kid, we’ve all been there.

A 52-year-old female with a history of type II diabetes, chronic kidney disease, cirrhosis, CHF, and COPD comes in with progressive shortness of breath and abdominal distension. How did she get so sick?

A 32-year-old mountain climber and his friend are on a climbing trip in the Andes. They get lost in the mountains for several days. Night is falling and they haven’t seen another human for a week and they are starting to wonder whether they’ll find anyone who can help them find their way. They ran out of food 16 hours ago and their glycogen stores have been depleted; what is alanine converted to in the process of gluconeogenesis?

A 26 year old female presents with sudden-onset nausea and vomiting with 10/10 pain in the right lower quadrant of her abdomen. A doppler ultrasound confirms the diagnosis of ovarian torsion. She is taken for emergency laparoscopy, and the surgeon removes a 5 cm dermoid cyst from the right ovary. You feel your belly in sympathy, where you’ve got a benign little dermoid of your own. Are you going to torse your ovary one of these days? What if you’re in the middle of a backpacking trip, and you can’t get into surgery in the 6 hours you’ve got before that ovary dies? Sounds painful. It definitely wouldn’t help your fertility – mom would be disappointed. But you don’t even know if you’d want to have kids, anyway. You could live with one ovary, you decide. Next question.

A 34-year-old female comes in with sudden-onset, painful blindness in her right eye. She is diagnosed with multiple sclerosis. Are you going to be struck by a terrible disease in your prime?

A 58-year-old woman with a history of COPD and CHF presents with progressive dyspnea and increased sputum progression. She sounds like a patient you saw several times in follow-up. You wonder whether your patient was able to quit smoking. You wonder whether she’ll live out the year. You realize that you’ve spent 5 minutes staring at the computer screen, time’s up, move on to the next question.

A 27-year-old male is involved in a motor vehicle accident. EMS gave him 2 liters of normal saline in the ambulance, but upon arrival his blood pressure is 70/30 and his pulse is 133. His chest has significant bruising and his neck veins are distended. He does not respond to vocal commands but withdraws from painful stimuli. At the ER fluid resuscitation is continued but his blood pressure continues to drop and all of the sudden everyone is running, he lost his pulse, where’s the crash cart, get the crash cart, someone start compressions or we’re losing him. Is he going to make it?

Standardized patient encounter. A 57-year-old female comes in for a discussion of end-of-life care. She was diagnosed with breast cancer 3 years ago and underwent surgery and radiation at that time. Last week, she started having trouble with her breathing, and she was found to have a malignant pleural effusion. She has weeks to months left to live. She tells you that she has come to terms with her prognosis, and hopes to pass away peacefully. You wonder if you’ll have that equanimity at the end. You ask her who she will designate as her healthcare power of attorney, then you ask yourself if you could ever trust someone enough to let them make life-or-death decisions for you. She tells you that she trusts her husband more than anyone in the world. You wonder, not for the first time, whether class rank and test scores are distracting you from more meaningful measures of a life well-lived. You ask about her hopes for her care, about what she wants if she – “Students, you have five minutes remaining with the patient.” The ‘patient’ jumps, and you lean back and take a breath. Pull it together, this isn’t even real.

A 77-year-old male is found confused and lethargic, lying on the floor of his apartment. He was there for seven hours before a neighbor found him. The test is asking whether you can give him a thrombolytic medication, but the real question is why was he alone, what was it like to spend seven hours on a linoleum floor, watching the seconds tick by with his cheek pressed to the ground?

A 78-year-old female presents with confusion. She is pulling out her IVs and shouting at the staff. You’re supposed to figure out if: A) this is her baseline dementia, or whether B) she’s got an acute-onset delirium. A urinalysis comes back with 15-20 WBCs/hpf, 2-3 RBCs/hpf, and is positive for leukocyte esterase and nitrates. Is sanity so tenuous at 78 that a UTI can tip you into delirium? Who was she before she got this sick? When you’re 78 and delirious, will your doctors know that you used to be the one in the white coat, dispassionately assessing baseline cognitive function?

A 45-year-old male comes in with insomnia. Sometimes he spends 2-3 hours staring at the ceiling at night, wondering if he’s ever going to sleep. He describes the failed trial of melatonin, the empty bottles of benadryl, the caffeine pills he takes when his stomach hurts too much for more coffee. You rub the crease that appeared under your left eye a month ago and seems to be here to stay. You click ‘counsel patient on caffeine reduction and sleep hygiene techniques’, as if it were ever really that easy.