The Pensieve

GS shorts: repaired ACL tear, thyroid mass, sebaceous cyst on head, colostomy with hepatomegaly
Examiners: Prof Ngoi (private consultant), Dr Tan SM (breast surgeon, CGH)

1. Pls examine this gentleman’s knees.
I freaked, 4 min how to examine both knees? wanted to measure for quads wasting prof ngoi said no time, pls do what u think is necessary.
The guy had a vertical scar over R knee + arthroscopic scars, I blurly blurted out TKR and the two of them said HAH!?!?! Quickly recovered, kowtowed and apologised fervently for my slip of tongue. Sigh. Pt looked very amused. Quickly did the ROM, ligaments… ACL a bit lax… Lachman was kinda effy. No McMurray or problems with the MCL/LCL.
Bell RANG. So I just blurted out, this man has had an arthroscopy and an open operation to reconstruct his ligament, probably ACL.
Prof ngoi seemed to breathe a sign of relief, said ok, gd, let’s go… Dr Tan kept asking me to squirt ie. use the alcohol.

I thought maybe next case can be a short one but….

2. Pls examine this man’s neck.
Thyroid mass… Happy like siao. They fired qns alternatively, like firing squad. They talked so fast…. then I also started talking v v fast. Hands were trembling as I poured water out for that guy to do his swallowing test. Haha poor guy, wonder if he needs to go to the toilet in the middle of the exam cuz everyone keeps asking him to drink water.
The QnA was so intense… It’s like once Dr Tan asked a qn, I just answer… A bit like spinal liao. Felt like I was playing ‘the pyramid game’ haha…
Why does it move up? Attached to pretracheal fascia
What problems can it give? Cosmesis, dysphagia, dyspnoea, malignant change, thoracic outlet obstr
What are signs of malig? Cervical LN, hoarseness, fixity. I felt, then said, dun have… meanwhile more questions…
Why hoarse? Infiltration of RCL
Then pause… awkward silence… I think they wanted me to ask pt if his voice changed… so I just asked, pt said no.. :)
What ix? US, radioisotope uptake scan (Dr Tan looked a bit off.. ) then FNAC (then she smiled).

3. Sebaceous cyst on head
This was easy, except that it was totally HAIR covered, no point hunting for punctum but just say attached to skin, not bony outgrowth fr skull, superficial. Then say excise with elliptical incision completely so as not to have recurrence.. . prof Ngoi was halfway out the room by then…

We all ran to another room…

4. Pls examine this lady’s abdomen.
Waa i was so happy cuz got colostomy. SPOT!!! Lemme share my song.

This is a middle aged lady, fairly cachexic. midline lapartomy scar, well healed, no keloids/hypertrophic scar with a stoma in the LIF. (asked pt to cough, looked and felt for herniation, Prof asked why so I explained). There’s no incisional hernia, no parastomal hernia. Stoma is a large calibre single barrel stoma flush to skin, no spout. Has a diaphragm below, unable to see the skin underneath, colostomy bag contains solid faeculent material.
I would like to do a digital examination of colostomy opening for any stricture, to check if anus is patent. I would like to palpate for abdo masses. Prof says: go ahead.
Barely felt the 9 quads when he asked: What do u feel? I blur… tried to chk again…
Vaguely got liver but not entirely sure… then ya, got liver… erm didn’t feel nodular or hard… percussed the upper border, then measured the span i think was abt 13cm… Damn scared bell will ring soon and didn’t want Prof to promt too much so…
Quickly said: I think this woman has a colorectal carcinoma or a rectal carcinoma for which Hartmann’s procedure or an abdominal perineal resection was done, (pause, it would depend if the anus is still present. Prof says yes, it’s there), so… it’s a Hartmann’s with a colostomy created, and might have liver mets cuz the liver’s enlarged.
I really got to thank my tutor Mr foo at CGH for teaching me abt stoma examinations!

I dunno why they rushed me like that, cuz I still ended up finishing abt a min plus ahead of time… felt so out of breath and spaced out when it ended.

And for the record NO ONE WAS ON THE VIVA LIST THAT DAY!!! YAHOOOOOOOOOOO!!! I hope no one gets called back for surgery viva this year!

GS Long Case: bilateral patellofemoral compartment OA knees with bilateral Baker’s cysts

They were ALL very nice, tell us the examiners’ names before the exam. Mine were Prof Satku (very nice, puts you at ease) and A/P Lim TC (very nice guy too), and one more Dr (observer) plus one bustling MO who helps you to put up the XRs and even drops in ard the midst of yr clerking to confirm that you’ve got the right diagnosis.

OA knees with bilateral Baker’s cyst with limitation of function. Screened for depression, function as well. I cannot over-emphasize the importance of functional hx in ortho.
PMH: likely essential thrombocytosis BMA clear, on hydroxyurea, dyspepsia + old ulcer on barium meal on domperidone, omeprazole, previous nephrectomy with renal impairment on losartan (causes v bad cough), hypertension on hydrochlorthiazide, atenolol.

PE: NO genu varum, some bilateral medial joint line tenderness (prof S specifically wants to see WHERE exactly the line is! I went a bit off-course at one point) No FFD/scars/obvious swelling. Bilateral two popliteal cysts (Prof S wanted a ‘nicer’ name, so I said Baker’s cyst :) good.

Questions:
What are the essential points supportive of OA? - mechanical pain, period of stiffness (15min) after inactivity, +/- swelling, age, what’s the underlying cause?
What duration of morning stiffness is significant for inflammatory pain? I said 30min but Prof S said… hmm… So I said, 30min to an hour. Hah. Ok accepted.
If I say that this woman has some fluid in the joint cavity, and there’s the cyst posteriorly, how would you explain it? I said that it’s a Baker’s cyst coz got connection btwn the joint fluid and the cyst posteriorly. Said also that it should disappear on flexion.
Tried to make me do cross-fluctuation on the suprapatellar bursa, I said did already, but couldn’t elicit it, just some fullness and mild tenderness there… Just for ‘fun’, Prof S asked what was the Baker’s cyst originally named for, I didn’t know but mumbled ‘aneurysm’ (siao… brain short circuited), Prof was like huh, but that’s an aneurysm… then he said, oh it’s for TB anyway…
Asked what definitive ix, said AP knee XR, before I could say wt-bearing the very efficient MO had flashed the XR, haha so I nonchalantly just added in, wt-bearing XR by the way… very impt. Lolz… Shown AP knee XR. IT WAS PERFECT except prominent pencilling aka prominent vertical trabeculae (was so gan jiong I said prominent trabecal verticulae…) ! Since no OA changes, not even narrowed jt space was present, Prof asked if I wanted to ‘eat my words’, haha, but no lor… I asked for skyline view. WAAAAA NO joint space left laterally, subluxed patellar, ouch, no wonder so painful!

Mx:
- lifestyle changes: loss wt (but not req in this pt), how to walk (more painful leg descends first and so on…), avoid flexing activities
- PT: strengthen muscles, maybe can help to realign the patellae
- pain relief eg. tramadol, intra-art injection, but avoid NSAIDS (dyspepsia and renal impairment)
- Sx: realignment, replacement of that compartment

A/P Lim got a bit restless, and since Prof S didn’t have anymore qns, he let Lim grill me. Lim just asked given her nephrec hx, what would u be concerned about when u mx her? I crapped a bit about the drug-drug side effects and then he still wasn’t extremely happy, then it CLICKED. I said oh, just now I did mention her bone was osteopaenic, and plus she’s on soooo many anti-hypertensives, probably at high risk of fall and high morbidity too. Was going to go on about mx of osteoporosis but I guess he was just happy when I said the magic word… Hehe then MO shooed me away, said ok la, good enough can go… I was a bit puzzled cuz I ended like 5 min earlier…

We had a short break of an hour and a half before short cases…

Lucky no WHK turned up that day… Heng ah…