Friday, September 14, 2012

USIM Medical Final Professional Clinical Exam - Long Case

Assalamualaikum wbt.... =)

Bismillahirrahmanirrahim

Hehehehehe skemanye tajuk hahahahahaha

Ok mari kita singkap kembali kenangan masa clinical exam mase pro exam bulan 7 aritu. Mungkin adik2 junior dah penah baca/dengar dari senior2 lain, tapi ini hakak punya versi. Satu2nya exam yang penuh drama dan air mata. Hoho!

Kitorg start final exam pada 25th June, started with theory papers for 5 days (25th-29th June). The papers are (tak mengikut turutan exam kitorg aritu):

MCQ 1 (medical base - medical, paeds, psy, etc)
MCQ 2 (surgical base - surgery, ortho, ENT, Ophthal, O&G, etc)
PMP 1 (medical base)
PMP 2 (surgical base)
Data Interpretation (includes all postings termasuklah Community Health ye adik2...huhuhu)

So on the next week, which was on 2nd July, we had our clinical exam.

Beberapa hari sebelum exam, kitorg dikumpul untuk briefing oleh coordinator clinical, iaitu Prof Shahrir Mohd Said. Nombor giliran untul clinical exam adalah berdasarkan undian. Dari cabutan undi, aku dapat no.40 daripada 42 orang calon. So sah2 hari kedua, orang ke-3 akhir. Masa dapat nombor tu, alahai lambatnye habis. Tapi kupujuk hatiku bahawa itulah yang terbaik untukku sebab nombor tu Allah yang bagi. Hoho. Jadi tak perlu pikir pasal nombor. Tapi lepas tu aku bersyukur sangat sebab diberi lebih masa untuk bersedia dan sampai sekarang aku nak nasihat adik2 junior supaya doa2 dapat hari ke2. Hehe.

Group pertama seramai 24 orang telah berangkat pada hari isnin, 2 Julai. Kami yang kat asrama pun turut cuak sejak dari awal pagi time tengok diorang berangkat pergi. Lagi bertambah cuak bile menjelang tengahari, lecturer2 yg happy go lucky, Dr.Azlina, Dr.Maiza & Dr.Hana start upload gambar2 scenario kat dewan exam clinical sana. Macam live streaming, oh!

Maka menjelang hari kedua, iaitu pada 3 Julai 2012, Hari Selasa, giliran kami kumpulan kedua pula meneruskan perjuangan yang berbaki. Hari terakhir peperiksaan akhir di tahun akhir pengajian selama 6 tahun ini! I'm gonna give my best shot, getus hati kecilku.

Jam 7++ (err tak ingat) pagi kami bertolak ke HUKM dengan menaiki bas USIM. Kalau senior dulu kate diorang senyap je sepanjang perjalanan di pagi hari peperiksaan tu, oh kami tidak. Setiap detik yg berbaki kami pot pet pot pet diskus2 dan bertanye2 sesiapa saje di sekeliling akan apa saje topik yg terlintas. Ikut bisikan hati, kate kami. Nota2 yang sempat aku capai makin lama makin bercampur aduk, tapi tak nak kalah, selagi tak sampai HUKM tu selagi tu nak baca, hahahaha

So bila sampai, alahai rase cepat sangat pulak perjalanan pagi ni, kenapalah jalan tak jem plak hari ni hahahahaha So kitorg terus naik ke tingkat 10. Jangan tersilap naik lift ye, ade lift yang tak pegi tingkat 10. Sebab tu la penting kena datang time Prof bagi briefing pasal tempat exam aritu. Supaya tak tersesat dan kalut lalu panik.

Berkumpul di luar dewan peperiksaan. Sarapan tak diberi, cuma ade air mineral je. So elok la bwak bekal siap2 klu tak sempat nak breakfast kat ostel tu.

Exam dimulakan dengan long case. 5 orang pertama dipanggil, diselang 30 minit kemudian, 5 orang seterusnya dan seterusnya sampai lah ke giliran aku, group terakhir skali. Masa tu dah habis cuak dah. Tapi  cuak la jugak...dan doa banyak2 dalam  hati bukan kes paeds. huhuhuuhu

Maka kami pun menuju ke bilik2 yg disediakan. Tapi masa tu kena tunggu dulu sebab ada sorang patient tak sampai2 lagi. Dalam 10 minit camtu baru kami masuk. Mula2 ternampak patient aku, about 50+ Malay lady, nampak sihat dan gembira je, so aku suspect gynae. Hee sukati je nak saspek, tp time tu terpulang la korang nak buat assumption ke xnak.

So aku try2 la recall ape soalan gynae yg kena tanye mase tengah tunggu kat luar tu. Tapi tup2 bila tanye, patient tu "puan datang ni department mana yg panggil ye, maksud saya, doktor pakar ape ye?" soalan ni lah yg kami diajar untuk tanye mula2 skali, since pesakit2 yg datang time klinikal exam tu bukan datang sebab sakit, tp diorg kena panggil oleh doktor2 kat spital tu. Sekali dia jawab, "Ortho.."

Waaaaa...!! Aku menjerit2 dalam hati. rilek2..I can do it insyaAllah.. "Oh...ortho.. boleh sy tau ape masalah, puan ye?"

"Saya sakit lutut...dua2 belah.. ni sakit.." OK! The moment dia bgtau chief complaint tu dah kena set a list of differential diagnoses dalam kepala. And my provisional was bilateral osteoarthritis. Ok so my long case was as below, seperti yg telah aku coretkan dalam koleksi soalan2 exam kitorg yg dah bagi kat junior final year skarang..


Bilateral Knee OA (Examiners: Prof Masbah ortho, Prof Hashim OnG & Prof Syed paeds)


56 yr old malay lady presented with bilateral knee pain for 2 years
- gradual onset, worsen at evening n towords the night, aggravated by walking n prolong standing, relived by rest & analgesic, no calf pain, no involvement of joints in UL, no early morning stiffness, no malar rash or photosensivity,no hx of gout, no hx of mva or trauma to the knee

PE - bilateral varus deformity, right knee swollen..no joint tenderness, no effusion..  etc etc

Q&A

1) What is ur provisional dx? A: bilateral knee OA

2) DDx? 
A:
1. RA – no joint stiffness, no UL involvement
2. Gouty arthritis – no hx of gout
3. SLE with arthritis – ni malar rash, photosensitivity

3) What is OA? A: Degenerative disease of the joint cartilage

4) You said patient’s main concern is about the increasing body weight (due to physical inactivity due to joint pain), so what do u think is important? 
A: Advice pt to reduce weight, refer to dietician, go to physiotherapy

5) What ix u want to do? A: Xray of bilateral knee

6) How many view? A: 2 views; AP n lateral view

7) In standing or supine? why? A:  Standing position, to look for the varus deformity. -Exactly

8) What are the xray findings u expect to see? A: Reduced jt space, osteocytes, subchondral cyst, sunchondral osteosclerosis

9) Which one is the earlist changes? A: Reduce in joint space. Prof: yes

10) Ok lets go to see the patient. Tell me what are the positif finding u got

11) Before that, how about the vital signs? Are they normal? Ans: yes, everything is normal. (Dont ever miss the vital signs!! no matter how simple ur case is)

12) Ok, tell me your findings. Ans: Bilateral varus deformity, an.. err.. the gait was.. abnormal gait (?? Aku x ckp antalgic since pt xsakit – sbb dh mkn pain killer la kot, tp prof prompt aku utk sebut antalgic gait jgk.. huhu..), dilated veins, swollen right knee but not erythematous. Lateral – what to look for? Fixed flexion deformity but pt didn’t has it. Post – what to look for? – popliteal cyst. What does it call, popliteal cyst in OA? (duhh dlm kepala ade ‘B---- cyst’ tp xdpt recall ape jadahnye) ans: baker’s cyst la T-T.

13) Show how do you palpate for joint line tenderness,...etc, and some more Qs I couldn’t remember. But the pt has told me most of Prof’s Qs earlier and teach me a lil bit! tQ so much aunty for helping me a lots!! :D

- Went back to the room.

14) If the pain is still worsening despite of medical therapy, what would u suggest? A: Knee replacement (arthroplasty)

15) Right. But what will be the complication? A: early-bleeding, infection, late-bone erosion, damage of the prosthesis. (Prof added– failure the prosthesis)

16) What is the nature of pt’s job? Is it an office job? Does she need to take the stair? Ans: yes, it is an office job, where pt is sitting most of the time. She took the lift instead of the stair.

17) But how does she go to work? Isn’t it important? Ans: yes, but I didn’t ask about that. Prof: ok, it's ok (he always tried to calm me down whenever I couldnt anwer any Q..hehe..fuhh)

18) How about her house? Is it a single storey house, apartment without the lift? Isn’t it important? How if she needs to climb the stairs? A: (cis, cemane la bleh lupe ni T_T) sorry prof, I didn’t ask about that. Prof: It’s ok.. it’s ok… (very supportive!)

19) Prof syed: u said previously the patient was an active lady. So did u ask how does she feel about the disease? Specifically, did she feel depressed about it? Did u ask about loss of appetite, loss of interest, insomnia?..  (Waaa dah agak dah akan kena soal pasal psy jugak.....even kes ortho pun..huhuhuhu..... kan dah kate smalam kene tanye psl ni, cis cemane la buleh lupe..grrr!) No, I didn’t ask.. hee.. prof: ok, never mind.. 

Ok, u can wait outside. 

fuhh...lega legaa.... macam baru lepas kena tembak berdas2 tembakan (tipuu)... dalam hati... bila la nak habis ni, sebab takut terkena soalan yg will drag me down into my own grave hahahahaha cuak gile... tp Alhamdulillah, Allah bagi ketenangan... Aku tak de palpitation pun sepanjang exam clinical aritu... which is weird jugakla, sebab aku ni darah gemuruh, kalau nak present kat depan kelas pun dah berdebar tak hengat! 

Tapi memang sangat2 bersyukur dengan patient yg aku dapat. Puan tu, atau dia bahasakan diri dia makcik, sangat educated. So senang dia nak cerita pasal penyakit dia termasuk la name ubat-ubatan yg dia ambik. Plus, that was her 2nd day being a subject for the exam, so she knew exactly what I need from her, plussssss she did tell me some of the Q yg prof akan tanye... sebenarnya manela aku tau the same examiner will be taking me on that case, tapi atas nasihat aunty tu aku ikut je la, buat je ape yg dia suruh. Siap tlg ingatkan apa yg aku tertinggal nak tanye atau cek. And you know what?? Memang pun! It turned out semua yg makcik tu bagitau aku dan suruh aku buat semua prof tanye!! hahahahahaha Alhamdulillah.. Alhamdulillah... =))

2nd thing, case tu quite straight to the point. Tak bermakna confirm lulus, kes simple2 pun boleh je drag kite teruk2 tapi as long as kite tak dig our own grave, pastu tahu ape yg kite kena tau, insyaAllah buleh nye.... Ce optimis skettt =p

Anyway, osteoarthritis... I admit that memang aku x sempat pun baca tajuk OA ni... ape lagi nak prepare untuk long case yg kite lagi takut dapat kes medical, paeds (hahaha bias nye aku hahaha)... huhuhuhu.... tp Alhamdulillah skali lagi kes tu tak complicated. Aunty tu plak takde underlying illness cam diabetes and hypertension..fuh, takpayah susah2 buat urine dipstix! =D

Prof Masbah pun sangat cool, menenangkan dan supportive... banyak gila soalan dia... sampai takleh nak recall...tp sume tu sebab nak tolong kite gak... Dan syukur prof2 lain tak tanye soalan banyak, 99% prof masabah je soal hehehehee

Ok lepas tu kitorg makan tengahari..lunch was served kat dalam hall tu jugak, ade bilik makan kat belakang so memang tak payah keluar dari dewan tu. Makan nasik minyak yg sedap plak tu nyam2... hehe... pastu solat, kat dalam bilik2 kosong, kat celah2 katil. Telekung kitorg bawak sendiri. ade sejadah disediakan, tp ade jugak kwn2 yg bawa sejadah. 

Pastu kena terus get ready sebab nombor giliran adalah tak sama dengan nombor time long case tadi, so kite tak tau kita start at what time. Aku punya group yg 2nd last. 

So ni plak my short cases.... eh sambung laen kali la part short case... mengah nak nulis lagi pepanjang.. adeh


From left: Dr.Rahman Omar, Marahaini, Zarin, Ayie, Nadiah Ahmad, Me, Dr.Maiza, Prof Shahrir.  Prepared for our short case.  (Me - Muka terpaksa senyum hahahaha)
[Credit photo: Dr. Maiza]

Suasana di kaunter dewan clinical exam.
[Credit photo: err.. xpasti gamba Dr.Hana ke Dr.Maiza hehehehe =D]

Ok wassalam! =))






"Boleh tak, kali ni, pergi kenduri kawen sedara pulak, ok?" - Mak

"ok.... T-T"










ps 1 : semalam (khames) aku dah berjaya buat laksa, moist chocolate cake, dan 2 bekas puding caramel (jiran order) hahahahahahahahahahhahahahahahaha esok buat lagi 1 caramel hahahahahhaha
ps 2 : nasib baik ade ura2 surat KKM dah nak dapat, kalau tak nyaris aku tukar profesyen ni muahahahahahahhahaha 
ps 3 : ade kenduri kawen dan open house lagi weekend ni huwaaaaaahahahahahahaha tak tau nak hepi ke nak sedih hahahahahahahahahahahaha
ps 4 : 'errk, takde plak air mata dalam entry ni, manic banyak la...' heeee tapi biasanye clinical exam aku slalunye ade laa..... heeee 

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