Ok, today’s exam was the SIMPLEST yet it was the one I floundered MOST!
Still feel so irritated at my ‘blank-out’ performance today that sigh, I have this irresistible urge to bang my head on the wall everytime I think of it…
Examiners were Dr Quak SH and another female doc (who has the look that BOSS likes! hahaha)
1st case - teenager with ?TR
The teen was very gan jiong, and I got super gan jiong when I saw him all tensing up and not relaxing… Was so ganjiong I think I must have had some sort of heart block, cuz I counted him as having only 48 beats per minute of pulse rate, and tremblingly told the examiner so. The female examiner had this extreme look of displeasure on her face and asked me what causes bradycardia?
I blank, then said ‘physiological… drugs like yr b-blockers… and um…. heart block’ Then she let me continue presenting… No collapsing, JVP can’t assess, palpable thrill over LSE, palpable P2, apex not displaced though. I heard a loud 4/6 PSM over LLSE without any radiation. Could also be heard elsewhere on praecordium but softer. No MDM at apex, no EDM at LSE, no bibasal creps, no hepatomegaly, no ankle oedema. Concluded as VSD of moderate severity.
Prof asked: What are your differentials?
THEN I JUST BLANKED OUT, I TOOK A DEEP BREATH BUT STILL WHITE-WHITE… THEN SEI LOR…. I JUST BLANKED OUT! WTH… Never done this in my THREE years of clinicals… Then Prof took pity on me (or maybe he thinks I got NO hope liao…) said, NEVERMIND and questioned me on why I was looking out for the EDM… So just said might be juxta-arterial (ie. btwn AV and PV) which prone to AR… so will have EDM, more severe got to repair, so must look out for. Said didn’t find in this place… Then the female examiner asked why MDM. I said, it’s probably due to flow murmur. And she mumbled, ‘STENOSIS’, and looked like someone put pickles under her nose. DIE. But then well, we’re talking abt the MDM of a VSD, not like MS rite?!?!?!? wa sei… is she from paeds or med?
Anyway… I think my fate almost sealed liaoo… They didn’t ask me much else…. er… die lor… Maybe I failed this case?
Then I heard fr the other person who did this case that when she finally got the differential of TR squeezed out, they visibly brightened up and quizzed her a bit on it… so maybe this was a TR after all. Sigh. I doubt I got enough marks to pass this one leh. :(
Case 2: DA
Examiners: cardio prof (the very nice one) fr KKH and A. Yeoh.
Haiz, so hard to establish rapport with the kid cuz she’s Malay and I don’t know what sort of Malay to speak to a kid! -_- Very cute gal though… Went thru the works… Almost forgot to give her pen and paper to scribble but Yeoh intervened… hengz! In the end, put her as 20 months. Kind of a feeling thing la… But I didn’t ask the examiners what her real age was. Later on checked with my partner, she said they told her the kid was 18m. I guess should be safe for this case, though I didn’t exactly shine doing it. :(
Dang. Had to end the exam on such a low note. :(
All the best to those doing tomorrow! I hope we all will PASS as a whole cohort and start work together!!!
Brings back memories of my final MBBS. First short case I had was a woman roughly 30-40s…told to examine the feet. I half assumed it must be a diabetic foot but no. No obvious sensory or motor neurological deficits, no diabetic dermopathy or NLD on the skin, no varicose veins, no obvious signs of ischaemia, no deformities, no obvious joint problems (this was Int Med), no nail deformities, livedo reticularis etc…nothing to see. Only abnormality was that I couldn’t feel the pulse at the dorsalis pedis and posterior tibial art. Wasn’t too worried by that cos’ my fingers aren’t always sensitive enough to detect a pulse of the dorsalis pedis, especially under exam conditions. Told the examiner what I found…”So what else do you want to do?’…since I didn’t find anything else that was wrong and hadn’t got a clue in my head, I asked to examine the other pulses to buy time to think. “Go ahead..”.
Then I hit jackpot….couldn’t feel any pulse at all…popliteal, femoral, brachial, radial….apart from carotids. I know my clumsy fingers and thick skin usually mean that I will miss some of the pulses, but I had never failed to detect a pulse from the radial artery before.
As I told them what I found, they were all smiling and nodding….guess I was on the right track. That can only mean one thing: obstruction of all the peripheral arteries apart from the carotids…’pulseless disease’ in a youngish woman..the only diagnosis I could think of then was Takayasu’s arteritis, which it was.
What I learned from the experience: just be honest and tell the examiners what you found and talk logically along. Most of them are not out to kill the candidate and will help you on the right path…
Comment by oxford mushroom — March 30, 2007 @ 4:18 am
wow dr mushroom, you are v ZAI!!!
thanks for sharing yr cool experience!
Comment by dopey — March 30, 2007 @ 10:04 pm