Day 278: Synthesis

Today’s inane image of the day:

I could go for another one of these Miami sunsets right about now… 

Mimi presented to the emergency room because of excruciating chest pain.

The seven of us delved deep into the case starting with the patient interview. We started with the generic, “Why are you here today?” and maneuvered our way toward the history of her present illness. She had been lifting boxes at home when the pain started. After probing for more details on her symptoms, she noted that “it felt like something tearing in my chest.”

We all had that keyword ingrained in our minds — it meant an aortic dissection.

After completing the rest of the pertinent medical history, we started a physical examination. We palpated the precordium and the abdominal area. We noted that the intensity of the point of maximum impulse was increased, suggesting a thickened left heart. Importantly, there was evidence of a dilated pulsatile mass in area of the abdominal aorta. It all made sense.

We wanted to visualize what we were working with, so we ordered a chest x-ray. The widened mediastinum and prominent descending thoracic aorta was more fuel for the fire. We ordered an echo to check on the heart and surrounding vessels. It confirmed our suspicion about the hypertrophic left heart and even revealed an intimal tear within the descending thoracic aorta. Everything fit together perfectly.

Following a few more labs and tests, we generated a problem list, submitted a diagnosis and suggested a management plan for Mimi. Then we joined the other six groups to debrief on the case.

[If you haven’t guessed yet, Mimi is a computer-simulated patient. This would be a blatant HIPAA violation if she wasn’t.]

This was our first case in our Synthesis course. I imagine this is what problem-based learning is like [if you have PBL at your school, do share about the experience!] and overall, I’m impressed by the modality. I like that we are working in a larger group than in TBL [we had 5 members for TBL, 7 now in Synthesis] because it is a better representation of a healthcare setting. I like that we are given the opportunity to work through all the nitty-gritty details of the case at our own leisurely pace. And I enjoyed the debriefing discussion [Dr. Misra led it — she’s wonderful!]. However, because we are forced to discuss and dissect every single detail, the session seemed to move slowly. I suppose it’s important to start slow and make sure you’ve covered all of your bases rather than delve straight into an algorithmic approach, but since there weren’t any huge curveballs thrown into the mix we knew the diagnosis within ten minutes due to her report of “tearing” chest pain.

Finally, the feedback portion of the program was valuable because it pointed out where we were on-track with our interview, physical exam and tests but also listed other important aspects that we missed. Although we had the diagnosis from extremely early on, we still missed a couple of smaller steps that would have been important to report. Regardless of the things we missed, I’d say that our group did a relatively good job investigating our first patient.

We have our OSCE tomorrow so I should rest up for it… hm, I guess it’s a bit late for that now.