Friday, May 3, 2013


We recently completed the pelvic, breast, and rectal exams. There was a steady stream of students sitting outside the clinical simulation rooms and all the professors that passed by mentioned something about how glum we all looked. I was actually kind of thrilled, but they were running late and it's hard to keep excitement going for very long. Finally, after studying buzz words, clinical presentations, and going through the motions of pretending to be doing something important we were finally able to do something rather than just imagine it. It was kind of refreshing and made me look forward even more to June when we start clinical rotations.

I started off first with the female genital exam. Before I entered the room, the doctor that was walking me through the procedure showed me on a plastic model what structures and landmarks I should see, how to hold the speculum, etc. We walked in the room, I introduced myself to the girl on the exam table, and reached for the extra large green nitrile gloves as the model explained to me that she was on the tail end of her period and was a little bit embarrassed by the small amounts of blood I might see. I tried to put her at ease, and all things considered, she did seem pretty calm, but that might be because I was the fourteenth student to prod her that afternoon. I put the jelly on the speculum and inserted it at a fourty-five degree angle just as I was shown and tried to run it along the vaginal floor until my guiding hand reached the pubic symphysis. When it looked like I was in far enough, I was given the go ahead to open the speculum to try to grasp the cervix. As I opened the jaws, the cervix seemed to find it's way into my view from the left. The doctor explained where the opening of the cervix was and said that it was easier on this woman because of the posterior positioning of the uterus which pushed the cervix forward, but that I could count on having a harder time of it on a different patient. Next came the palpation of uterus and ovaries so I withdrew the speculum and used my pointer and middle finger to feel the cervix. Once I felt what was described as the cartilage on the tip of the nose, I brought my exterior hand to the belly button and palpated downward until when I moved the cervix I could feel motion of the uterus under my palpating hand. From there I swung out laterally to either side to try to palpate the ovaries. I felt like I might have been imagining the almond-sized nodules, but the patient said I was in the right place. Then it was over. I threw my gloves away, shook hands, and walked out for some final pointers.

The next room was the breast exam. We were told originally that all we had to say during the exams was, "Hi, my name is..." but the facilitator told me to ignore him and treat it like this was real even if it were my first time and that if I ran out of conversation pieces I should start talking about the weather to avoid any awkward silence. So again, I introduced my self, got some gloves, tried to make her feel at ease, and had her lower her gown. The first part is visualizing the breasts together to check symmetry and how they move with the hands over her head, on her hips, and flexing her pectoralis muscles. Then she covered up, laid down, revealed the right breast, and I told her I was going to palpate for any abnormalities (that's the word we were told to use because they recommend against using technical jargon like nodules, fibrosis, discharge, etc.) They recommend starting on the areola closest to the sternum and palpating in clockwise concentric circles until you reach the bra line inferiorly and the clavical superiorly. Then you move out laterally toward the armpit to palpate for the lymph nodes there. One breast done, I move on to the other while trying to engage in conversation. It's tough to keep so many things in my head at once, but we get through it and I didn't have to talk about the weather.

I got asked if I felt like I was being unfaithful to my wife by examining other women. I think you'd have to be a pretty sick person to find the clinical experience appealing in that way.

The last room was the male genital, hernia, and rectal exam. The facilitator here was really talkative and all I had to do was ask questions every now and then. He points out the testicles, epidydimus, and vas deferens then shows me how to insert a finger into the inguinal canal. That looks like it should hurt so I ask him and he says no. I guess I should have known. I've had it done during physicals, but I never knew how far the finger was stuck inside. If there is a hernia you should feel the intestines slapping at your finger. Also, the turning the head to the side to cough is only to keep the patient from coughing on the physician. Finally, its time for the DRE and this drew the most sympathy from me out of anything else that day. Vocalizing to the patient what I was doing, I spread the cheeks, placed my gloved and lubricated finger on his anus, and waited for the tone to relax. When I felt the resistance lessen, I started pushing and was struck by how warm it was. I tried to feel the prostate which is supposed to be the size of a walnut, but I couldn't be sure I was really feeling it. When I felt like welcome was overstayed, I got out, listened to a few final pointers, washed my hands and went about the rest of my life. However, the following ditty was stuck in my head.

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