I’ve never, repeat never had to change my emotion state and mindset so many times in a day, and so quickly. Yet, I guess this is what we’ll have to do in the future…

Here goes today’s stations, 10 min each. No rest stop manz…

Station 1: Written station
Old woman admitted 3 days ago for a fall with brief loss of consciousness, she had a previous fall last year. Currently suddenly became more confused and disoriented and you are asked to order a radiological investigation for her. Fill in the form.

Pt: For URGENT non-contrast CT head. Then you must fill in all the empty boxes la… No pt sticker was given so I wrote out her details on the form too. Learn all this in SIP…

Station 2: GM - geriatric
Mr Khan 75 yo man admitted with recurrent falls after one week of fever and cough. Lives alone, premorbid ADL indpt. On warfarin 2mg, medical problems of IHD, AF. Vision 6/12. Daughter is very worried about the dad. Counsel.

Pts: They mainly wanted you to talk abt community services available and discuss about the pros and cons of warfarin use in this patient.

Station 3: Paeds - writing blue letter
18mths old infant with biliary atresia diagnosed at 4 weeks, s/p Kasai op at 7 weeks, persistently jaundiced, with recurrent attacks of cholangitis requiring bactrim prophylaxis and first episode of UBGIT at x mths. OGD shows esophageal varices. Started on oral propranolol 5mg. Has pruritus and excoriations. Growth (ht & wt) both below 3rd percentile, recently started nocturnal NG feeding.
PE: enlarged liver 4 cm, hard; enlarged spleen 8cm.
Ix results: a whole lot of them…
Pt admitted for assessment for liver transplant. Write a blue letter to the dental surgeon for clearance.

Pts: I remember seeing a few of these letters during Paeds posting, but they were all rather brief… But I didn’t dare to write too briefly, so I guess in the end, my letter was a bit too chong hei. Heh.

Station 4: GM - insulin injection (Dr is the pt)
DM pt comes in with blood glucose of 24mmol/L. Your MO tells you to give him 8 units of regular soluble insulin.

Pts: Some pple made the cardinal error of choosing the WRONG insulin syringe!!! It’s the tiny one with the ORANGE cap! Then for the insulin, the regular is CLEAR; the NPH is CLOUDY!!! Then make sure you know your technique for giving insulin. Needle enters at right angles. Pinch the subQ before you jab and rem to swab both the bottle (b4 withdrawing the insulin) and before you jab the pt (and yes, you use the same syringe).

Station 5: GS - the angry pt’s son
Mr X was admitted 6mths ago for total knee replacement. After the surgery, developed infection of the knee joint that required 6 weeks of iv antibiotics. Now presents with recurrent septic arthritis. Probably requires another operation. Son flew in from overseas, VERY angry about the state of affairs. Wants to know why there’s this problem again? Wasn’t it treated already? Whose fault? Costs mounting, wants to downgrade from A to B2, will the standard of medical care be the same? Will the SAME specialist be seeing his dad? Pt used to be active golfer, now can’t golf anymore, very depressed, loss of weight, can anything else be done for him?

Pts: Pt’s son will be angry, standing, arms folded, get him to sit down. :)
As for his sad state, I suggested a short course of some SSRI (anti-depressants) that can also help perk his appetite but once his ambulatory status improves as it most likely will, we’ll tail it off.
As for the downgrading, I talked about MEANS testing (but not sure whether he qualifies… sigh) but dunno the details so I offered to refer to MSW.

Station 6: GS - counsel on wt loss
Young boy due for NS soon, height 176 cm, wt 80 kg. Admitted for observation for suspected acute appendicitis. But now thought to be mesenteric adenitis, can be discharged. He asked to speak to you as he wants you to prescribe him some diet pills.

I think this was my lousiest case. Didn’t see the calculator for doing BMI until the pt pointed it out to me. Haha… Anyhow crap and even said, ‘I’m sure you’ve heard of the horror stories about slimming pills?’ haha… Cham la…

Station 7: O&G - call on-call reg for advice (great fun)
You are the HO on call, a 32 yo woman 22 wks pregnant has been admitted complaining of SOB since this morning. Saw a GP earlier, treated as for anxiety with alprazolam, but no improvement. H/o SLE for 8 yrs, with 2 T1 miscarriages. Was started on aspirin 5 mths ago by her doctor. Currently, PR 110 BP 90/60 Sats 88% on 50% oxygen. PE shows no cardiac signs, except a loud P2.
Ix: ABG shows hypoxemia with pH 7.48, Hb 12, TW 13, plt 90. UECr normal except Cr is 100.

Pt: I think some pple didn’t identify themselves when they called…
Dx: PE cuz of the hx, the pro-thrombotic state of pt, hypoxemia, loud P2.
Plan: iv fluid resus with NS, careful not to overload; chk for signs of DVT, send for VQ scan/CT thorax (and my mum, when I told her abt this scanning suddenly said, pt pregnant leh! Can scan meh? WAAAAAAAAAA I dunno. Or are we gng to do pul angio for her just to keep the baby? Or I suppose a bit of XR won’t kill a T2 pregnancy? Hmmmm…) Then refer to interventional radiologist urgently to do thrombolysis is clot found, start heparin. Then check on the foetus as well with doptone, FHR… Chop chop the Dr Chen on the other side said ok, then bye liao… This was my last station.

Station 8: O&G - counselling
32 yo female 22 wks pregnant came in with abdo pains and PV bleed. Speculum exam shows open os with incompletely extruded products of conception. You are the HO and you have to take her consent for a hysteroscopy as well as counsel her.

This station was really one of the best counselling sessions I’ve done. (I think) Patient was a very good actor.

Station 9: Paeds - filling IMR + counselling
No time for this station! Almost didn’t make it.
Infant with UTI, 39 degrees fever, poor feeding. You have to fill in the IMR to give him iv ampicillin, iv gentamicin and prescribe his maintenance fluids. Also got to talk to the mother.

Pt: A lot of pple forgot to ask the mum whether the child has drug allergies!
PS: Don’t worry, the calculator and drug booklet (a bit like abbrev MIMS) will be provided.

Station 10: GS - consent for chest tube insertion (Dr was the pt)
24 yo man had a L sided chest pain and SOB while jogging. CXR shows a moderate pneumothorax. Take consent for chest tube insertion.

Pt: Some pple didn’t know that the consent form has a page TWO. So don’t forget! Pt also wanted to know if there were any other options, instead of chest tube.

It was a whole lot of fun if you took out all that exam stress!