Disclaimer: The following entry is not meant to ridicule; rather it is meant to educate and for some light hearted banter. If you disagree, kindly press Alt-F4.
Day 2 of exams saw me in a station where a ‘simulated patient’ has a thyroid problem and the task of the students was to elicit the following:
1. Features suggestive of thyroid problems on general inspection.
2. Look for lid lag.
3. Look for fine tremor.
4. Elicit the biceps reflex.
5. Tell me what kind of reflex to expect in hypothyroidism.
Let me write the bloopers according to the structure above.
Student: What is your name?
Patient: Beng* (name changed to protect patient’s identity)
Student: Can I call you Ah-Beng ah? Can?
Sad to say, almost all the students failed to address the patient properly. Most simply called him ‘Beng’; only one or two respectly addressed him as ‘Mr. Beng’.
Another student said:
“I am going to examine you and YOUR neck”. (as if the patient and his neck has disconnected)
Like a programmed robot, almost all students began their presentation with the following words:
“The patient is alert, conscious, communicative, not in obvious pain, not in respiratory distress, no discoloration… (actually a lot of students had no idea we were asking for features consistent with thyroid problems)
Of course others were more creative, in addition to the above, they also mentioned:
“the patient also has no discharge, ulcerations, sinuses, dilated veins”
“the patient has no gadgets attached” (I wonder what gadgets the student had in mind?)
“the patient looks a bit shy”
“the patient is not cold intolerant…because he did not button his shirt”
“he does not look agitated, angry, annoyed, anxious, depressed, excited…”
“he looks slightly bored” (ho hum….how true)
“there is no frightening facies”
“he doesn’t look scared”
“he is not frightening”
“he does not appear to be suffering from any discoloration” (Hard to imagine anyone actually suffering from discoloration!)
“he has no thinning of hair (and proceeded to play with the patient’s hair!)”
Looking for Lid Lag
For some reasons, a lot of students used the ‘H’ test to look for lid lag. As far as I know, the ‘H’ test is used to look for ophthalmoplegia.
One student gave this instruction:
“I want you to look at my finger and follow my eyes” (ooo, multitasking!!!)
Looking for fine tremor
One student asked the patient to stretch out his hands, placed a paper on the fingers of both hands and proceeded to stare at his watch (because they were instructed to wait 15 seconds). I asked him if he was looking for tremors in his watch.
Another student gave this instruction:
“I want you to stretch out your hands, and close your mouth” (the student wanted to say “close your eyes”)
Eliciting the Biceps Reflex
“it won’t hurt because you see the hammer is made out of rubber”
“I am going to hit you with this”
Many students continued to hit the tendon over and over again when they did not get the desired reflex. A few were clever enough to use ‘reinforcement’ by asking the patient to clench his teeth. Still, there were some who continued to whack and whack even after they have obtained the reflex! I just want to say that reflex being a reflex, it will diminish with each subsequent whacking, so whacking till the skin is bruised isn’t going to help.
Naming the reflex in hypothyroidism
The correct answer was “slow relaxing reflex” or “delayed relaxation”
There seemed to be a lot of Madonna fans among the students, as one after another boldly proclaimed the answer is a “HUNG UP REFLEX“. Frankly I have never heard of this term before. The students, when asked, told me that they learnt it either from their seniors, their friends, a book (but they cannot tell me which book) and finally, the video in the teaching session. Hmm, I must inquire about this video, maybe it does feature Madonna!!!
Still, I gave marks to those to explained correctly what they meant by ‘hung up’. Some thought it meant the arm will be hunged in mid-air after a whacking, others thought both the contraction and relaxation phase are slow, still others thought that only the contraction is slow. Many stated that the reflex will be absent in hypothyroidism which may be true but definitely not unique to just this condition.
Funnily a number of students didn’t even know who Madonna was when I mentioned her! Gosh, I feel so old (and I don’t even like Madonna!).
And that was Day 2.
But the biggest blooper of all is this…there is a Day 3 (gasp!!!), because the Day 1 exam had to be declared null and void due to some ‘discrepancies’.
Fri, 290607 @ 0805; so glad to be back doing clinical work.