How they do it.
You’re divided into groups of four according to your index area and briefed in the holding area. In my case, it was the super cramped tutorial room outside ward 73, SGH. Each member of the group of 4 has a tag with different colour. There are 4 stations - A, B, C, D. Everyone starts at the same station in that group. Eg. My group had C, D, A. Other groups can have B, C, D and so on… heng heng we missed station B, that was the neuro station. You have 10min per station, once the bell rings you enter and look for the examiner wearing the same tag colour as you. At the end of the 10min, bell rings, you go out to wait for just a few seconds along the corridor, when the next bell rings, you’ll head for the next station… It’s over really quickly. Even if you don’t perform well in that station, you gotta just put it behind you and try to impress the examiners at the NEXT station. We have different examiners (2-3) at different stations so it kinda helps. :D
1. Man with aortic prosthetic valve replacement
Could hear the clicking, really loud! Presented as an aortic prosthetic valve replacement because there is a prosthetic second heart sound, metallic in nature, a click, no transvalvular leak, no signs of heart failure. Felt that the underlying aetiology was AR cuz of the displaced apex beat, and I think I saw a Corrigan’s sign. But then no collapsing pulse. Felt like I just contradicted myself, looked v lost. Examiner went on to ask how to differentiate venous from arterial pulse: venous can see 2 waveforms/heart beat, arterial only one; venous is occludable and not palpable, arterial is stronger, less occludable, palpable. Asked on what complications? I said over-anticoagulation but pt doesn’t have cuz no bruises, and also infection of heart valves but pt doesn’t have cuz didn’t feel febrile, no signs of IE ie. splinter haemorrhages, Osler nodes, Janeway lesions, no splenomegaly or petechiae. Examiner asked, what else do you notice in this pt? I said, got varicose veins. Other examiner asked me to listen to the left AND right sternal edges again. Die. So I listened, thought I heard a 2/6 ESM there… damn odd, can’t figure out where it was loudest, they asked what’s the cause? Paused a bit then said… er… the RING… then they still persisted in asking so I said erm, aortic valve problem? But it doesn’t radiate to carotids. Looked v traumatised, but nice guy said don’t worry, it’s good, you can go now…
2. Old cachexic man with R pneumonectomy scar from TB/bronchiectasis
Prof Chia BL leh… hehehe he was so cute, he practically gave the game away: Pls examine this patient’s chest, CHEST only, and his TRACHEA! Don’t need to examine the LN, you don’t have a lot of time…
Signs: Posterior R pneumonectomy scar, no breath sounds over R lung field A&P, dull to percussion (but not stony dull), just crepitations in the L basal area. Did vocal resonance but didn’t present, I don’t think they cared much for it anyway… Trachea deviated to the R. (I damn blur, mixed up L&R initially but then they all HAH?!?! again and I apologised for my blunder…) The examiners were very distracted, and kept asking me to repeat my findings… Then Prof got a phone call, he apologised for the interruption and then asked me to REPEAT my findings again… waaaa I was so scared not enough time… Then anyway, apparently still got time to tekan me, so the other examiner asked why op? - previous TB (it was the rx last time), or resectable lung CA. How does this op help to rx TB? - collapsing the lung decreases oxygen supply to this bacteria, it requires oxygen to survive… (sounds so crappy and layman but it’s correct rite?) Then asked got clubbing or not, I said no. So probably not lung CA. I think more like TB. Then they asked if I heard creps. (I already told them TWICE got creps liao rite…) Sigh, so I repeat fourth time. -_- They asked if TB can cause bronchiect and explain how. - yes, cuz the bronchiect causes tissue destruction and dilatation of airways, then TB can get reactivated blah blah… so hazy all of a sudden.
Then Prof Chia asked an odd question, it was as if he couldn’t bear to do just respi or he was really bored… He asked if I could just see if this patient has a raised JVP. He stressed, I want INTERNAL JUG, not external. I looked around, Prof asked pt to stop breathing… but Pt getting a bit chuan… haha… I said no, I dun think elevated but then Prof like din hear me (he’s a bit hard of hearing apparently), he just said nevermind, it’s hard to see in this pt… Then another examiner asked me to choose whether it’s collapse, consolidation, fibrosis or dunno what? Then I was like, huh tot already told u his lung collapsed liao mah… Then I said collapse! RING! Prof walked me over, and then went to visit someone else, I suppose in the cardiac cubey? haha…
3. Middle-aged lady with this whooping huge mass, v nodular.
I tot the pt looked Cushingnoid leh… But damn, shouldn’t have said it, cuz I think she was jsut fat around the face. So paiseh… I actually said, I think this patient looks a bit Cushingnoid, saw their expression, but then again, probably not, not likely on steroids. Sigh. I hope they have short term memory. Then excluded any signs of CLD. Said huge irregular nodular firm liver 13 cm below xiphoid and costal margins, like got spleen 2cm (but actually later on chked with the others, it was just a super big liver lobe masquerading as the spleen. :( ) then felt got another mass in the LIF. Tender, round, can get below it. No idea wat it was leh. Not ballotable. They asked me to ballot again, I was sooooo stupid, should have just lied and said yes it’s ballotable now! Sigh. But this image of Edna swum into my mind and I tot, she would have said: Don’t LIE! Don’t make up signs… so… I idiot-like said, erm sorry, I don’t think I can feel it. Examiners said what’re yr differentials then? - HCC, mets to liver…. or…. many liver cysts! Examiners visibly brightened up and I just added, then it’s likely she might have polycystic kidneys too, sorry I didn’t feel them just now. :( Asked me what are the cx: infection (loin pain, fever), rupture of cyst, haematuria, renal impairment, aneurysm… Hmmm, something more common? Much earlier before renal impairment? Er… I was a bit lost. Floundered a bit, then another examiner suddenly popped up and said it’s something you were asking to do just now (actually I didn’t) and it’s what we do everyday… *Clouds clear and…* BLOOD PRESSURE! Pt should have HYPERTENSION! All 3 examiners visibly relieved… What other cx? more distant? - Berry aneurysms, rupture leading to SAH. Might even have a third nerve palsy from compression by aneurysm. Then RING!
Really no time to do much confirming of signs, it’s all expected to be spinal. Sadly mine not very spinal yet… Still get tongue-tied. Surgical shorts definitely went much better but medical was already far better than expected. I’m soooo glad it’s over, this was the part that I’d most dreaded. Now it’s left with paeds on Saturday. :) Felt so happy just now I went to buy this cute little rattle and squeaky toy. :D 2 bux only!
