IT WAS a hot afternoon in April. I was one amongst a dozen medical students, who sat in rows beside the entrance to M1 General Medicine ward at Medical College, Trichur. A few of the girls read furiously, heads bent, eyes glued to the textbooks that lay open on their laps.
Most of the boys joked and laughed nervously. It was a defence against the feeling of impending doom. In the silent intervals, I tried to lean back and breathe normally. And I sweated beneath the full-sleeved white coat.
The weather was sweltering hot, and mirrored our feverish minds. I must have produced a litre of sweat per hour. My armpits, particularly, were damp. It wasn’t simply the heat; it was partly fear.
Fear stimulated special apocrine sweat glands in the armpits into overdrive.
Stop, I told myself. My mind had become a raging forest of medical trivia. This was the result of cramming for the crucial final exams. I shook off my thoughts, leaned back, and tried to relax. It would be a good idea to close my eyes and meditate.
Towards the end of one breath, you had to relax all the muscles. But I could hear my damned cardiac muscles – they wouldn’t slow down. Now the catacholamines were making the beats go crazy.
I could feel each one. This was called palpitation due to anxiety. Hyperthyroidism, an excess of the thyroid hormone, also could lead to this.
There I go again, I thought. I tried to recollect my clinical training. The General Medicine or Internal Medicine practical exam was the toughest, and the most important, test a medical student had to take.
Surgeons and gynaecologists were believed to be a little more lenient with their students. To take a proper history within a limited period was an art.
The patient’s account of his or her problem, symptoms, and their chronology could be insufficient data. You had to sift through it as it was told. Leading questions were a must; otherwise one was liable to get totally lost.
A physical examination had to follow. It consisted of ‘inspection’, ‘palpation’ or feeling, ‘percussion’ or tapping, and ‘auscultation’ or listening – as with a stethoscope.
All major systems had a different series of tests. For a long case you were given an hour, and twenty minutes for a short one.
In this short time, you had to complete the history and physical examination and arrive at a provisional diagnosis.
Some of the examiners were merciless. Suresh Gopan, my friend from the senior batch, had failed because he couldn’t find a slightly enlarged spleen in one of the patients.
The patient was so fat, he told me, that nobody could feel anything unless one had a look at the scan report. Another chap failed because he said he could feel the spleen in the same patient.
‘You had a look at the scan!’ the examiner thundered.
‘No, sir,’ the poor guy insisted.
‘Then one of the interns must have given you a tip-off.’
Another senior failed because she did not examine the private parts of a male patient. The patient had cough, and there were chest findings.
‘How beastly.’ We expressed our sympathy. To be fair to the examiner, the patient had lung secondaries from a testicular cancer.
‘But how was I to know? The man did not complain of any swelling.’
‘You should find out. That is your job,’ the examiner said pointedly.
‘Yes, sir. I will take proper care, sir, from now on.’
‘Good. You have six months,’ the senior doctor told her ominously.
###### ~ o ~ o ~
I thought about all these episodes, and sweated some more. The wait was agonising.
I stood up, and took a small walk along the corridor to stretch my limbs. The window on the adjacent wall of the ward was wide open. I peeped through it.
The examiners were bent over some patients, probably discussing which cases to give us. Deciding our fates. I saw a familiar face talking to the professors.
It made me feel dazed. I wanted to sit down. Running back to the seat, I shook Premkumar sitting by my side with unnecessary force.
‘What is Rajesh Kumar Jha doing there?’ I blurted out to him.
‘He is the skilled assistant today. Didn’t you know that? And don’t shake me like this.’
I sank deeper into my seat. He was the tutor in General Medicine, unit one. He had joined the hospital six months ago.
He did not have an MD yet, so his pomposity was something I found difficult to bear. I remembered his first class vividly. I had presented a patient with swelling in the liver.
I listed the findings and described the mass. ‘It is firm to hard in consistency, and nodular, er – sir.’
‘Yes. Good boy. It is, therefore, an obvious case of cirrhosis of the liver,’ he said, in quite a patronising tone.
I looked at his thin face, spectacles, and walrus moustache. The only thing mature about him was the moustache. Who was he calling a boy?
He was hardly three years older than I was.
‘It is secondary cancer of the liver, sir. The findings are classical.’
Rajesh Kumar Jha looked sheepish for an instant, then reverted to his pretentiousness. ‘It is a possibility, I admit, even though the nodularity of the liver in cirrhosis is extremely well described.’
‘Those nodules are microscopic, sir. It is the description of a liver biopsy specimen. Usually, in cirrhosis, the liver is shrunken and not felt at all,’ I clarified, with barely-suppressed glee.
Some of the pretty girls tittered.
Dr Jha reddened. ‘Theory is useless, man. It is experience that is important in Medicine. I will shave off one half of my mush if it turns out to be liver cancer.’ He smiled confidently.
Many similar episodes followed, and I knew I was a marked man. I couldn’t care less, as tutors at the bottom of the academic ladder did not have any powers.
I had recently met Jha, just two weeks before the exams. I wanted him to sign my case record.
‘Don’t include the biopsy reports in this. They are redundant in clinical records, don’t you know that?’ He looked at me with a pitying smile. I have to say that of him: he was always smiling.
‘There is another thing that is redundant, sir.’
‘What’s that?
‘One half of your moustache, sir.’
The patient was already dead from cancer of the stomach, with secondaries in the liver. I had turned out to be right about him. The biopsy report had arrived the very next week after our little rendezvous.
###### ~ o ~ o ~
What rotten luck. Rajesh Kumar Jha was the man who would allot cases to each student now. And he hated me. There was no doubt he would sneak the most difficult cases to me.
As I was ushered in for my first short case, I clutched my stethoscope and other accessories like the tendon hammers, torch, and the neurological examination kit, and steeled myself for a battle. This patient was a middle-aged stocky man with a dull, puffed up look.
After introducing myself, I asked him what his problem was.
‘Oh, thome problem with my thpeech,’ he drawled slowly.
‘For how long have you had this problem, sir?’
‘ah … thoo or three mon … thss.’
‘Any other complaints?’
‘No … no … thing.’
It was not much to go on. But I had a deadline to meet. Twenty minutes were all I had. A cursory survey detected mild pallor, which was common in our population. Then I plunged straight into the neurological examination.
All the cranial nerves – optic, oculomotor, ophthalmic. Trochlear, Trigeminal, auditory, facial. Abducent, glossopharyngeal, accessory, hypoglossal. I did all the tests for each of them. Hypoglossal was responsible for tongue movements, and I gave it particular importance.
To my surprise, it was normal. Then I checked the sensory and motor systems and reflexes. Everything was normal. Apparently, he had abnormal speech, but the entire neurological examination showed that he was quite all right otherwise.
I did a quick examination of all the other systems. The heart sounds were normal. No cardiomegaly. No breathlessness. Respiration and lungs were normal. No abdominal signs either.
The heat seemed to give way to paralysing cold in my heart. My palms were dripping now. I dried them against my white apron.
My own heart sounds were turning highly abnormal every moment.
Don’t panic, I said to myself, and thought furiously. The neurological examination had revealed normal reflexes, and yet – I quickly took my tendon hammer, positioned the patient’s leg sideways, and tapped gently on the Achilles tendon once more.
As before, the calf muscle contracted normally. It was neither diminished nor exaggerated. But, as it relaxed, I saw that something was not right. I tapped once more, apologetically.
This time I got it. The calf muscle was contracting normally, but it was relaxing too slowly. The delay was barely noticeable. It remained tense for a split second longer. This obscure clinical sign, called delayed relaxation of a tendon reflex, saved me.
Now everything fell into place. The dull look, the puffed up face, and the cold and dry hands. Slow speech reflected slowing down of ordinary mental functions.
It was a physiological disorder caused by a reduced basal metabolic rate.
‘Do you always feel cold?’ I asked the patient.
Yes, he had been unusually sensitive to cold in recent days. In fact, he was wearing a sweater on this hot, blistering day. And, when I began to examine him after removing it, he shivered.
The realisation made me notice a lot of other subtle signs, including a mildly enlarged thyroid gland in the neck. Hypothyroidism! A reduced thyroxin hormone level clogged up the physiology and slowed down the entire machine.
I quickly finished writing my case record. One short case down. Another short case, and a long case, was still pending.
I was ushered to the next patient by Jha, who was suspiciously courteous and had a malevolent gleam in his eyes. This particular young man I had to examine next was thin, and laboured with his breathing.
He gave a history of progressive difficulty in breathing and moderate to severe cough. As soon as I removed his shirt I spied the bit of cotton, browned with tincture benzoin, stuck to the left side of his chest. I heaved a sigh of relief.
This was a straightforward case of left-sided pleural effusion. Collection of inflammatory fluid in the double membrane called pleura, encasing each lung like a protective cocoon, led to breathlessness.
The cotton signalled the site from where the fluid was sucked out with a needle for various tests. It was a dead giveaway.
I completed the history, and general survey, and moved on to examination of the respiratory system. I looked and felt for reduced movements on the left side of the chest, and tapped both sides trying to pick up a duller note.
Then I listened with the stethoscope, and expected decreased breath sounds. Nothing was fitting.
The findings seemed strangely contradictory to my presumption of a left-sided pleural effusion. I rechecked my findings, and suspicion brewed in my mind.
‘The doctor drained the fluid in your chest with a needle, didn’t he?’ I enquired. I hadn’t taken the treatment history from my patient properly.
‘Yes, doctor. Two days back they sucked a lot of fluid from the right side of my chest. There was immediate relief from breathlessness. But now it is back again.’
‘Right side? What the –? You mean the right side?’
‘Yes, of course.’ He looked perplexed.
‘But the cotton stuck to the puncture site is here, on the left side.’
‘It was on the right side. But this morning, before bringing me to this ward, the thin, dark doctor with glasses removed it and stuck it on the left side of my chest.’
The bastard! I cursed him bitterly. If one was misled from the beginning, the pressure of the situation could floor anybody. Now, everything fell into place.
Hardly had I finished writing when the notorious Jha rushed in, bleating ‘Time is up!’ in an offensively jovial manner. Seeing my flustered face, he smiled with satisfaction.
I suppressed an impulse to hit him over the head with the tendon hammer and, instead, accompanied him to the bedside of another patient.
The ‘long case’ was a decisive one by any clinical examination. But, by now, I was quite scared, as I realised my adversary would stoop to any level to see me go down for the count.
This one was a fifty-something man with a morose face. As I approached him with what I thought was a friendly smile, he turned on the bed to face the other side. It was not very encouraging.
‘Excuse me, sir, I want to have a word with you about your illness, if you don’t mind.’
There was silence. He seemed to be sulking. After a few more desperate requests on my part, he turned to face me and said, ‘Oh, there is nothing much. I just felt a little tired, and the doctor admitted me here. That is all.’
‘Did you have any pain? Maybe a cough?’ I tried to keep the tremor in my voice under control.
‘Nothing, sir. Please leave me alone.’
After that, he clammed up completely, and no amount of pleading could open him up. With a sinking heart, I tried to get down directly to the examination.
‘Maybe if you removed your shirt, I could – ’ I stammered.
‘What for? I don’t want to remove my shirt.’
‘I could examine and tell you what is wrong with you.’
‘The senior doctor has already done that. Thank you.’
It was a medical student’s worst nightmare – to get a totally ‘non cooperative patient’ during the final exams. The failure of the patient to cooperate with you was considered a failure of your interpersonal skills.
No student deserved to pass if he didn’t have proper skills in patient interaction. It was a tricky situation. I wanted to run to the examiner and beg him to change my patient.
Then I decided against it. One of my friends, some five years senior to me, was a child specialist. In his final examination as a post-graduate candidate in Pediatrics, he had got a baby who seemed to cry incessantly.
He had requested a change of patient. It was impossible to examine a crying baby, who refused to be pacified by any means. He had tried everything.
‘Better change your specialty rather than the patient, doctor,’ the chief examiner had retorted.
He had had to reappear for the exam after cooling his heels for six months.
As a last-ditch effort, I tried once more. ‘This is an exam, sir. You know that. I will fail. Please, sir.’
‘So you are not a doctor? Don’t touch me then,’ he said with a hint of contempt.
I resigned myself to my fate. Computers were in fashion. Maybe I could learn it in six months. Some courses were open to admissions near my house. Suddenly, out of the corner of my eye, I spied Dr. Varun, an assistant professor, on the way to his OPD.
I knew him well. Making sure that neither Jha nor any of the examiners were within sight or earshot, I rushed to him and told him about the situation.
He was a kindly man with oval glasses, and faintly resembled the Father of the Nation.
‘Oh, you got Azhagappan? He is a veteran in many exams.’
‘But what should I do, sir? Please help me. He is not letting me look at him.’
‘You have a Gandhi with you? No? I will give you one. Pay me back later.’
He fished out a five-hundred rupee note from his purse. Gandhi flashed his famous toothless smile at me, from the unfurled currency note. He thrust it into my trembling hands, and was gone.
I ran to the patient and, with an earnest smile, pressed the folded note into his hands. He pocketed it calmly. Then he sat up on his bed and smiled.
Slowly, he started to recite the long history of his illness like a parrot, omitting no relevant details.
‘So, now I have slight breathlessness due to my damaged heart valves, you see? And don’t forget to note the rheumatic fever in my childhood, which was responsible for causing the damage in the first place,’ he said.
I nodded gratefully.
He removed his shirt and continued, ‘You can see the elevated jugular venous pulse on my neck. It shows mild cardiac failure, you know that?’
He turned his neck to the left, and gave a graphic demonstration of the engorged veins on the right side of the neck. Then he lay down, and I commenced the cardiovascular examination.
I went through inspection, palpation, and noted the enlarged heart size or cardiomegaly – helpfully pointed out by the patient himself.
After putting the stethoscope to the four areas of the heart, I straightened up.
‘What is the diagnosis, doctor?’ he asked me eagerly.
‘You have mitral regurgitation, a leaky mitral valve,’ I answered. The systolic high-pitched murmur was unmistakable.
‘You got only that? Oh, you missed the opening snap. And the rough, rumbling diastolic murmur of mitral stenosis. It is best heard with the bell of the stethoscope with me in the left lateral position.’
He promptly obliged me by turning his body in the right direction. Needless to say, I confirmed the findings.
In a short while, I was ushered to the formidable panel of three examiners, two externals from another university and the internal examiner, my own professor.
The exam went like a breeze. I confidently presented all my cases and answered the questions.
Eventually, my professor leaned back and said, ‘You have done well, doctor. You can leave now.’
Doctor! He had said doctor! I ran out laughing with relief. On my way out I encountered Rajesh Kumar Jha, who greeted me with a sheepish smile on his face. He had witnessed the entire presentation.
‘Everything went well,’ I informed him. ‘I have to be thankful to you. All the cases you gave me were easy. I am looking forward to joining your unit as an intern. I can hardly wait.’
But my enthusiasm was wasted on Jha, who did not seem very thrilled at the idea.(Jimmy Mathew)
