The Pensieve

Disclaimer

A quote worth remembering! Tomorrow is THE DAY! RESULTS OUT!!! It’s kind of ironic to be posting this quote the day before results are released haha…

“I am teaching you all how to be doctors next time. If I’m teaching you all only to pass exams, then this will be the greatest disservice I have ever done as your tutor.” x 3

— from our lovely Edna

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!!!

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!

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…

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!

I remember being a bundle of nerves, even felt faint-ish during the O&G MBBS in year 4. But somehow, things have toned down A WHOLE LOT today.

Still felt nervous, about 5 min before the exam.

Felt a bit nauseous when the bell rang, but told myself, ‘THIS IS IT! DUN BE SO WIMPY!’ and went into the room.

My examiners were really nice people. In fact EVERYONE’S examiners were very pleasant. No one out to sabo us today… Except hypoC who kena ’sabo-ed’ by a parent who made a joke he probably shouldn’t have made.

PAEDS long first for me…

Me: Hello SX, what medical condition have you been having that brings you to the hospital?

SX: Er, I got joint swelling…

Me: my heart sank to the depths of the Atlantic, maybe around the depth of the Titanic…

Anyway to summarise:

It was an adolescent with autoimmune pauciarticular arthritis of the big joints, mainly both ankles, knees and hips
p/w: recurrent joint swelling and tenderness
a/w:
- back pain (but not stiffness)
- morning stiffness
- irritation of eyes
- no systemic features, no skin lesions
with significant family h/o: sibling with back and hip pain with stiffness.
currently on NSAIDS, DMARDS and MTX.
main dx: juvenile chronic arthritis
differentials of anklylosing spondylitis, systemic lupus erythematosus, gout (not likely cuz young), septic arthritis (not likely but must rule out in 1st presentation)
PE: normal, just joint swelling.
Ix that are most impt: ESR, CRP, HLA-B27 (for AS) and ***autoantibodies: Rh, ANA, ANCA, anti-Ro/La/dsDNA.
Side effects of drugs: NSAIDS - dyspepsia, GI bleeding, ulcers; sulphasalazine: nausea, vomitting, rashes, oligospermia; methotrexate: bone marrow suppression… anyway then ran out of time.

Examiner said good, the other one still wants to ask questions about drug side effects when the bell finally rung. haha… She was like very bu gan yuan to let me off.

Anyway the 2 min of time where we can gather our thoughts was MOOT. Useless one la! I think I had time to read the findings, and just think of my first line in my summary. -_-

Adult long case. This one wasn’t very good. :(

Bronchiectasis on ventolin! Dubious history of chronic large amts of foul-smelling sputum being produced. Had some wooley lung disease when he was a child… -_-
Current functional status was definitely not good though he denied it. Effort tolerance was only 1 flight of stairs.
Claims he copes well. Not depressed. (A nice doc reminded us not to ask the patient ‘Do you feel like dying’ cuz that would be insensitive.)
Patient DENIED having had lung function test, any CT scan or been admitted. Followedup at the GP clinic, which is soooo odd, cuz how would he be recruited for the MBBS if he wasn’t followed-up in the hospital or been admitted? -_-
Good to rule out other causes of SOB on history (everytime I ruled out something, they tick the boxes haha…)
Anyway, asked on differentials:
1. Bronchiectasis
2. COPD
3. Asthma (but nah din sound like it)
got asked what my diff would be IF he din have sputum:
1. fibrosing alveolitis/pulmonary fibrosis secondary to other causes (no time to elaborate)
Causes of bronchiectasis:
Infx: measles, TB, pertussis; obstructive: retained FB, bronchogenic ca (guy has significant smoking hx)
Why you ask for family history?
- congenital causes eg. cystic fibrosis leading to bronchiectasis or passive smoking worsening his symptoms
Ix: high resolution CT scan (damn, I forgot about the high resolution part, din get the marks liao…
- GS and culture sputum
- lung function test, CXR (They asked me to describe tram-tracking… They just sounded amused, maybe should have just left out the stupid tracks)
Mx:
- chest physio, teach postural drainage
- mucolytics, ventolin (esp if the LFT shows it responds to bronchodilator)
- no smoking/stop smoking/discourage 2nd hand smoke
- make sure work env no pollutants
- if pt presents looking like he’s having infx, give broad spectrum abx, then change when culture results out.
- asked what abx to give: amox/augmentin PO (damn I went to say oral respiratory quinolone, think too much abt the pneumonia CPG liao lah. Sigh)
Bell rang, no time to change my mind abt the abx. Darn.

I hate the bell. >_<

Disclaimer

1. ‘I would like to retract my statement.’
Edna: Don’t retract here and retract there, make up your mind! This is a really bad statement to say you know… (shakes head)

2. 61 wat? Milligrams? Millimoles? Pulse rate 80, 80 what? 80 beats per 15s? Units, units, units!

3. IPPA
Student: On inspection, my patient is a …… on palpation…. on percussion…
Edna: You don’t present in that year three way!

4. Long-windedness
Edna: What are your differentials?
Student: Based on my history and clinical examination… And by the fact that… I…
Edna: Don’t chong hei! Just give me your differentials!

5. ‘generic symptoms’
There has been a recent spate of patients admitted through the ED with chief complaint of ‘generic symptoms’. It irritates the hell out of all of us. Will the MO doing it please please please stop doing it… How can someone who comes in with a stroke have a chief complaint of ‘generic symptoms’… At least put a weakness of left side of body or unsteady gait rite…

6. Not tested say not assessed! Don’t put NAD NAD NAD…
Edna: Sensation, power, proprioception, vibration… all NAD. Don’t was it really tested or you all just put NAD. If not tested, put not assessed! At least next time when we want to know, we’ll know it’s not been assessed and then, we can go and test it. All this initial documentation by you all is very important, it’s the baseline of all things! It’s medico-legal…

7. ‘One-track mind’
PLEASE! Don’t one-track mind! Why didn’t you exclude cardiac failure or respiratory causes? How can you one track mind and say that the cause of his SOB is ascites? Maybe he has a pneumonia as well? Maybe he is in fluid overload from renal failure?

8. Lights! Positions! Haiz, why so messy!
Lights lights! The patient is lying all over the place… (proceeds to fold the blankets and sweater and places them at the foot of the bed…)

9. Duration, not dates!
Student: My patient, Mdm XYZ, 40 year old lady was admitted on the 10th of January for the chief complaint of…
Edna: Don’t give me dates? Now I have to think back and count…
Student: Sorry, my patient was admitted 3 weeks ago…

10. Me. Sadly. *Sob Sob*
Edna: ‘dopey’, why do you persistently irritate me!

Finally, in our thank you card, some left quite ‘cheeky’ comments such as:
- ‘I promise not to say I retract my statement ever again!’
- ‘I will not be one-track mind.’
- ‘I promise not to copy from the ED notes’
- and for myself, wanted to put a ‘I promise not to be chong hei’ comment, but I had already written many sentences there…. so…

Almost everyone said the surg mcqs were doable… easy… actually MUCH easier than medicine.

I die liao. Cuz I was totally whacked by the surgery mcqs today. :(

Got 180 freaking questions! I felt like I’d aged centuries, especially getting hit by one after another of questions that I’d never go think about…

Like whether the electrolyte composition of our small bowel fluid is similar to:
A. Normal saline
B. Hartmann’s solution (Ringer’s lactate)
C. Half strength saline
D. Half strength Hartmann’s
E. Can’t remember what the option was. Sigh.

And another one about the no. of thermal zones? I didn’t even understand the question!!! Shucks.

BBBS. Sian.

1. 38 yo lady presents to clinic with pregnancy of 10 weeks. Previously, one NVD at 39 weeks, had gestational DM but well controlled with diet only.

What would you look out for in history and physical examination, and how would you investigate and manage her condition to ensure the well-being of the baby? [20marks]

2. 70 yo woman comes in with 2 day history of sudden acute onset back pain. She has been bed bound for the past 2 days. Her daughter is worried about her condition. A spine xray shows a wedge compression at T12.

List four differential causes of her back pain. [4 marks]
How would you differentiate them based on history, physical examination and investigations? [10 marks]
Based on ONE most likely diagnosis, outline her management plan and what you would tell her daughter. [6 marks]

3. A 33 yo lady presents with acute onset of severe right lower abdominal pain with increasing severity over one day.
What are the differential diagnoses [4 marks], findings on history [4 marks], physical examination [4 marks], investigations [4 marks] and how would you approach management? [4 marks]

4. A 65 yo man comes in with a pale, painful right leg. On examination, no pulses are palpable. Diagnosis is that of an acute ischaemic limb.

What are the causes of an acute ischaemic limb? [4 marks]
What are the findings in history and the key physical findings that would point to the diagnosis? [8 marks]
What is one specific complication that can occur after a successful operation and how can it be prevented? [4 marks]

Thank goodness, only a little bit of smoke was created.

Thanks Sanz, but your fire engines weren’t needed… Lol…

Can save’em for tomorrow! lolz…