"'My mother,' Garp wrote, 'was not one for making fine distinctions.'"

-The World According to Garp, John Irving

My preceptor is a family medicine doctor. On the daily, she sees patients with things ranging from scabies, annual physicals, and pain. I always feel like the last is tricky because you do not know if you are prescribing opiates to treat pain or to feed an addiction. My preceptor said that you have to trust your instinct and figure out whether you can rely on the information given to you by your patient. You can get burned. She has, but you have to do what you can to treat your patients, who may very well be confiding in you their pain and suffering.

Since I have to learn it, so should you. Bruits: turbulent blood flow causes vibration in blood vessels producing sound. Left ventricular pressure rises as left ventricle contracts and when LVP rises LAP, mitral valve closes. The S1 sound (lower pitched) is mitral valve closing and S2 (higher pitched) is aortic valve closing, aortic pressure rise distinguish sounds. Sternal Angle (of Louie) is continuous with second rib. The intercostal space on the right side is aortic area, left side is pulmonic area. The 3rd and 4th are known as tricuspid area or right ventricular area. Apex of heart is felt for apical impulse in 5th intercostal space. The base of heart is the pulmonic area and aortic area.

Palpation
Pulmonic Area: hypertension
Aortic: stenosis
Sternum: RV hypertrophy
Precordium (chest wall in front of heart): Apical impulse to palpate in intercostal spaces to feel it.

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"One striking difference she might have seen between clams and people was that people had some sense of humor, but Jenny was not inclined toward humor. There was a popular joke among the nurses in Boston at that time, but it was not funny to Jenny Fields. The joke involved one of the other hospitals in Boston. The hospital Jenny worked in was Boston Mercy Hospital, which was called Boston Mercy; there was also Massachusetts General Hospital, which was called the Mass General."