Thursday, March 22, 2007
I'm praying that it surely will be the last. No viva list for today's surgical long and short cases, so it's good. Anyway, surgical long case consists of taking history and examination from 1 patient for 30 minutes, then the examiners come in and blast your balls out for the next 20 minutes. The short cases consist of 4 patients, do examination and discuss the case in 4 minutes (SICK!).
Long case - Buerger's Disease aka thromboangiitis obliteransOUCH. Ouch, ouch, ouch! Of all things, why Buerger's Disease?? I have never seen one, just read about it in books. Scenario - I rush into the ward cubicle to find my patient sleeping, and he had a surgical drape tied around his leg. First thought - OOOOOH, struck gold! Diabetic foot! All my medical information on diabetes started flashing through my head. Then the first blow came. He talked like he was still asleep, I was slightly rudish and had to ask close-ended questions. And the second blow? No diabetes. And he had MULTIPLE ulcers and TONNES of amputations everywhere - I mean everywhere - hands, legs, everywhere. No way this can be a diabetes. The ulcers took more than a year to heal ("Arterial ulcers??" shot through my head - damnit) but ah. He had classical signs of chronic arterial insufficiency - pain at night, needing to hang legs over the bed. Nice. Except that in my hurry, I actually forgot to ask for a history of vascular claudication and had to admit that to my examiners, while hurling obscenities at myself inside.
I won't even begin to talk about the examination. Having a diabetes case with 1 ulcer is something, but a patient with ulcers EVERYWHERE? Started with carotids, took pulse and listened for bruit. Then the arms, documenting all the skin changes and pulses. Then the legs, skin changes, Buerger's test and pulses. Then a cardiovascular examination, and was so totally put off already, when the Reg popped in, asked if I managed to get the diagnosis, gave me a wink and a thumbs up when I told him incredulously, "Buerger's Disease???".
Examiners came flooding in, 3 of them plus the Reg. Urghhhhhh. They looked mildly surprised that I managed to get the diagnosis. Questions:
1. Please present your history -
blah blah blah2. Have you examined the patient? -
blah blah blah. Before I could finish, they asked for diagnosis (I wouldn't be able to finish the examination findings in 20 mins, I think!!) When I presented the ulcers as a punched out edge, OUCH. Apparently it was sloping edge. And pointed out that there was, in fact, some granulation tissue in the ulcer. Felt demoralised and wilted in front of them. So I changed my song and started describing some features of chronic venous insufficiency I saw, hyperpigmentation, loss of hair, pitting oedema, shiny skin etc. 3. What are your differential diagnoses? -
Buerger's Disease (happy nods), atherosclerosis (nods), chronic venous insufficiency (some frowns, so i quickly said that it's unlikely since he doesn't have diabetic history), Reynaud's Disease (nods). 4. Why do you think it's Buerger's? -
Young age, smoker, multiple ulcers even on upper limbs (excludes venous ulcers), involvement of lower limbs (excludes Reynaud's, usually on upper limbs and associated with connective tissue diseases like scleroderma), no history of diabetes or cardiovascular risk factors. 5. What investigations will you do? -
Duplex scan for lower limb occlusion, ankle-brachial pressure index (was asked what it is, what the values signify - got stopped halfway, I think they know I know it ...). Totally forgot about angiogram until they led me to the computer and I saw from afar an angiogram and quickly suggested it before we reached the computer. 6. Arteriogram interpretation.
LOL - you know what, they actually thought I could read it at first!! Quickly pointed out filling defect in the femoral artery, they looked mildly impressed and alas ... wrong move. Thinking I could read it, they dished out more and more slides until my ignorance finally got exposed. Apparently, you're supposed to see arterial beading as well. I remember this vaguely from lectures, but couldn't remember it. 7. Where is the dye injected from? -
Femoral artery, at the inguinal area8. Lower limb vascular anatomy.
Shit. Could only tell them a few. Bad. 9. How to manage Buerger's?
Ouch. Suggested thrombolysis in acute ischaemia, medical therapy with arteriodilators, and bypass grafting. Short cases - F*CCCCCK
My examiners were kinda nice ... Please, please don't be mean to me!! Please be nice about the marks, I promise I'll be a better person.
1. Young lady who hitched up her right pants to show me her knee. Saw a lump on the medial aspect of the knee, proceeded to describe lipoma. Prof said, "Is there a similar lump on the other knee?" I said yes, and he told me that it's actually gravity pulling on the fat. "Go home and look at your mom's knees ..." he said. Huh? So he told me if I see anything else, I found a TINY patch of varicose veins near that same area. Asked me the distribution of the long saphenous and short saphenous veins, and what these are. Erm .. varicose? So asked me where varicose veins can be found - lower limbs, oesophagus, cardia of stomach, anus. He then told me, "Actually, they can be found anywhere on the body" - I died on the spot. So why is he asking me these?? I felt the patch of veins, they were warm. Got asked about differentials, I said arterio-venous malformation. Riiiiiiing. Urgh. Still dunno what these are. Obviously he didn't want me to look at varicose veins, cos there wasn't a bed for the patient.
2. Gouty tophi which were SO HARD, so fixed to the bone, and so not typically chalky that I said they were multiple exostoses. Had to be led into the diagnosis, and I seriously wasn't that convinced until he told me to feel one particular tophus at the elbow - "if you pull it hard enough it should move just a little". Felt that this one was unfair. It seriously felt like it was stuck to the bone. Got asked investigations, I said blood for uric acid, joint aspiration for crystals, he actually wanted X-ray. Bleargh.
3. Irreducible inguino-scrotal hernia. Crap lah, wasn't too good cos most hernias I felt were reducible, and I was slightly lost when the Uncle couldn't push this one in. Plus the testes were pushed to the back and top of the hernia so that for one wild moment I thought it couldn't be felt. "What will you be thinking of if you can't feel the testes?" Said hydrocoele, Prof smiled and nodded. "What's your management?" Said mesh repair, they were satisfied.
4. Another hernia! Paraumbilical, I claimed it was umbilical. It came through the umbilicus what, I'm sure of it. Sigh. "What is the defect in an umbilical hernia?" Said weakness of the linea alba. "What age do patients come with umbilical hernia?" - infants, usually, or very young children. "So what's the pathogenesis of an umbilical hernia?" - OMG, I actually launched into a treatise on the embryological development of the gut. Prof nodded and smiled though, I dunno if it's what he wanted. "How would you manage this hernia?" - gross. I actually said the wrong thing, conservative. Guys, DO NOT WAIT FOR PARAUMBILICAL HERNIAS. Repair asap, the orifice is small and it can strangulate. I suddenly saw the light, apologised for the wrong answer and told him I would want to repair it asap.
Sigh. Didn't go as well as I would have liked, but I suppose it wasn't all that bad.
Other cases that my friends got:
Breast cancer (long case) - ARGHHH!!! I WANT!!!
Osteoarthritis of knee (long case) - ARGHHH!!! I WANT!!!
Ankylosing spondylitis (long case) - as above
Gastric caner (long case) - as above
Diabetic foot (long case) - as above, lol.
Lipoma (short) - as above
Sebaceous cyst (short) - as above
Frozen shoulder (short) - no thanks ...
Now for a short rest, I feel so drained from today. Definitely one of the most stressful exams, ever!!
Wenky
3:01 PM
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