Tuesday, March 20, 2007
1 last major one to go (actually, it's THE last major one) and 1 last one that I just need to make sure I pass. Or better yet, score.
Today was the best I've felt so far about the exams, it was medicine short case. Guess what? No neuro!! =D
1) Abdo - Polycystic kidney diseaseOMG,
I fucked up my trump card, I totally can't believe it. (YX, you remember me wishing last night that I'd get a PKD??) Wanted to hurl myself out of the window after that. I prepared and prepared and prepared for PKD, and made a mess out of it. You know what? I actually forgot to measure the liver span and to auscultate for bruit! OMG! While presenting I think I turned green and hastily admitted that I'd have done those, but forgot to, and offered to do it NOW.
"Sirs, Mdm, my patient has hepatosplenomegaly with gross ascites and a fluid thrill. My - " Woman's face turned melanotic, nice guy examiner had a face that said "Shit!" and scary-looking guy examiner (who turned out to be ultra nice) gave me a look that said "No, nooooo!!!" Quickly retracted and said that I am not sure if there was also an enlarged kidney. I just wanted to die on the spot, since I already said I saw an arteriovenous fistula , made a show of feeling for thrill, and presented scratch marks on hands and legs.
Ended up re-examining the patient, OOOOOOOOOOOPS. It's a kidney with hepatomegaly. Oh come on, seriously, how good can this PKD patient be? Ultra-classic signs, complete with an arterio-venous fistula on the arm - and I messed it up ... ARGHH. Wanted to slap myself and squeeze my balls. So, the discussion session was centred around, "How do you differentiate a kidney from a spleen?" (can get above it, no splenic notch, band of resonance, ballottable etc.) and "What do you think caused the hepatomegaly?" (liver cysts) and "So what's your diagnosis now?" (PKD with end-stage failure on haemodialysis ... )
In a last-ditch attempt to score that extra mark and show them I knew all about PKD just that I mistook the kidney for a spleen, when the bell rang I quickly blabbered that I would also like to check for berry aneurysms in the brain. External examiner smiled and nodded. Should pass it, but a low one I think. Unless the woman is nasty.
2) Cardiology - prosthetic aortic valve complicated by aortic regurgitationHa .. this guy's my own patient! LOL. He doesn't recognise me (dozens of students rushed to see him while he was warded, when word spread that he had been listed for the exams) so I just went on. In all honesty, I only remembered he had a replacement, but not the details. Taken by 2 ang mohs, they were very, very nice. They let me present my song! Woot! Mixed up aortic regurg with aortic stenosis, but quickly remedied it within 5 seconds. Loved that phrase I picked up in Baliga - "Sir, I hear an audible metallic click even with the unaided ear."
Not many questions, maybe cos I pretty much covered all grounds - no complications of anaemia or over-anticoagultation and no diastolic murmurs heard ... except, "Why do you think he needed an aortic replacement?" -
likely aortic regurgitation, because no evidence of heart failure which will be seen in stenosis. Dunno leh. 3) Respi - COPD +/- bronchiectasis + Cushing'sGross. OK, 2 guy examiners were super-nice. You know, it's alarming when you get NO SIGNS except for hyperinflation and coarse creps. Forgot to mention hyper-resonant percussion sounds, and had to be prompted for that. Prompted into Cushing's as well. OK lah, I suppose if I had said ,"COPD on steroids, complicated by bronchiectasis and Cushing's syndrome" I'd probably have gotten distinction, so it wasn't that bad. A lot of things, you only recap and realise most-mortem.
Questions:
"What are the other causes of fibrosi - ooops - crepitations?" -
lol. he gave it away! So just expounded on the differences with fibrosing alveolitis and bronchiectasis without prompting, knew they'd ask that next anyway. Should have mentioned pulmonary oedema as well. Was a little disappointed that they didn't ask about the causes and treatment of bronchiectasis. "Why do you think he has Cushing's syndrome?" -
COPD on steroids, so most prob Stage III or IV. Should I have mentioned the possibility of asthma, or would that be grave-digging? "What investigations, and what do you want to see on that?" -
Spirometry, looking for reversibility and variability. Now this is the odd question - "So for which kind, reversible or non-, do you give steroids?" -
Wanted to tell him about GOLD guidelines using only FEV1 values to guide treatment, but decided not to antagonise examiner since obviously he isn't too familiar with GOLD, so I just gave it a go and said "Reversible" ... Was it a trick question? Well, they both nodded, so I guess that's fine. Just a little note. You know how I have a problem with crazy sweating during short cases. Most examiners find it amusing, the HOD of anaesthesia at NUH remembers me specifically for profuse sweating while intubating patients. =\ At the end of Case 2, the 2 ang moh examiners offered me an entire box of tissues to carry around even though I had my own. By the time I reached my last case, the 2 examiners were
visibly alarmed by my drenched shirt. Plus I almost buckled during percussion of the chest due to a very ill-timed exacerbaton of slipped disc. At the end, "Here, take these tissues .. get dry before you go out, or else everyone will think we tortured you in here!!" =D Smiled, thanked them profusely, and ran off.
Would have been a beautiful day, if not for that first case. Now, just 1.5 days for the WHOLE of surgery. Sick!!!
Wenky
10:13 AM
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