"Whaaatcha dooo-in"......"learnin' stuff."

As a PA student in my first rotation, I am learning so many new things each day. Sometimes it's really hard to keep up. Check out these 3 gems I discovered lately:

1)Addicts will do anything for drugs, ANYTHING
60yo gentleman, w/ R shoulder pain, injured on job 5-10 years ago but has a "flare up". Other than that he's been great for 3 years. He states "only thing that's ever helped is oxycodone". He tried "Vico-Dans" and it wasn't powerful enough. I look over the chart and "shoulder pain" is on almost every visit, and he's received lots of oxycodone. My gut says "malingerer", but I withhold judgement. After all, it's been 3 years w/o a visit.
He states no recent trauma, "just a flare up". I notice in the chart he was actually fired from the practice 3 years ago for repeated +tox-screens and bad pill counts, but somehow got an appointment again. I decided that I was gonna do a FULL physical exam. If he was a malingerer, at least I would get to practice all my exams. If he really did have some pathology, hopefully I would find it (besides, he's 60 and probably hasn't seen a doctor in 3 years). Either way we both were gonna get something out of this. I approach it by telling him it's been awhile, and we should check on everything; a full tune up rather than just an oil change. He likes this idea and goes with it.

I do the usual as well as really detailed stuff. Tactile fremitus, fundoscopy, clonus, visual fields, spleen palpation and percussion, diaphragmatic excursion, stereognosis, patellar ballotment, etc. (by the way, everything is setting off his shoulder pain; palpation, A&PROM, axilla palp, +Neer, rotator strain/sprain, decr. strength, and biceps groove. He even grimaces when I press on the sternoclavicular joint, saying it hurts in his shoulder. Basically, he's somehow positive for every shoulder injury discoverable. Up to now he's been compliant. Hell, better than compliant, he's been patient and willing to prove his legitimacy. When I ask him to drop his drawers he finally asks what this has to do with his shoulder, and I can tell he's getting impatient. "Sir, you are 60yo, rectal and prostate checks are pretty standard for a man your age. I have just this last thing and then we can talk about options for your shoulder pain." Bingo, pants go down and he's whistling.

Except for some vision problems and the shoulder thing, it's all negative. I go to my preceptor, who sees the name and refuses to dispense narcotics. When he finds out all he's getting is Naprosyn 500mg and instructions for stretching, he goes ape shit. Hollering that we wasted his time for this "weak smurf shit", he doesn't seem to notice his suddenly increased ROM as he waves his arms to make his point (I claim this cured him). Leaves, promising never to return.


2)ALWAYS get a complete history.
63 year old woman presents complaining of fall from short stool onto kitchen floor. Really twisted her ankle, and oh yeah, hit her ribs on the counter on the way down. She seems kinda short of breath so a more rigorous physical is warranted after my "complete" history:

GEN: WDWN, A&Ox3
Skin:Pink, warm, intact
HEENT: Normocephalic/atraumatic, PERRLA, EOM's intact, normal conjunctiva, TM's normal, neck is soft/supple w/o JVD or lymphadenopathy, mouth/throat normal.
CV: RRR, w/o MRG, pulses intact, good cap refill
PULM: clear to ausultation...on one side? No sounds on the other at all? What the... OOOOOOOHHH SHHIIIIIIIITT!!!!

I stop the physical, excuse myself and run to the nurses station. Gallantly I shout that we need to have the ER (across the parking lot) send over a gurney immediately for a possible pneumothorax. Beaming like the hero from a comic book cover, with chin up and hands on my Stethescope of Salvation, I go to inform the preceptor. The nurse reaches across the desk and grabs my coat, stopping me short.

"*JW*, are you talking about *Gertrude*? Cause she's missing a lung on the right side, has for years cuz' of lung cancer. You wouldn't start yelling for a gurney without asking her if something like that was normal, would you?" THANK GOD for nurses.
(**=Names changed to something ridiculous to protect the moronic and innocent)


3) Everyone knowing everyone's business isn't always bad. HIPAA be damned!
See #'s 1&2