Friday, September 14, 2012

USIM Medical Final Professional Clinical Exam - Short Case

Assalamualaikum! =)))

Kali ni lebau sket senyum heh sebab siang tadi baru dapat surat chinta hak2. cinta la sangat, karang dah start kerja baru kau tahu chinta ke tak chinta.

Iaitu surat panggilan pegi induksi pada 25 Sept ni. Nice. tepat2 3 bulan after final exam aritu kan kan....which was on 25th June.. haha..

oo..camnila rupenye surat induksi yg sumeorang duk tunggu2 tu... huhu.... 
Surat induksi je baru, belum tahu dapat spital mane lagi... time induksi nanti baru dapat tau. 

Induction mcm bese, 4 hari lah, from tues-friday, then ade masa 2 hari untuk buat preparation ape yg patut lalu bergegas ke tempat keje memasing. Kalau yg dpt nun sabah sarawak tu gi la book tiket flight terus... huhuhu... 

Ok seperti yg telah dijanjikan, mari sambung citer short case plak. Mengikut firasat aku, entry sebegini adalah membosankan. Kerana berdasarkan pengalaman peribadi, pembaca2 yang nak amik final exam je akan menghayati tulisan2 sebegini... Hihihihi... Tulah ape yg kitorg buat dulu.... lagi brape hari before clinical exam, kitorg selongkar balik blog2 senior yg sangat rajin sharekan diorg punye clinical exam dulu... begitulah kehidupan kerana tak berapa nak ade senior..senior kitorg 1 batch je ade... hakhak.. Ya Allah sangat helpful entry2 mereka pasal hekzam.. terharu they care to share their stories with us *kesat air mata*

Sesi short case start after lunch break, lebih kurang pukul 2 ptg. Same jugak, we were called 5 by 5. So my group was the 2nd last (eh nape rase mcm dah cakap je bab ni, okla skip lah). There were 3 short cases.....

Case 1 : Medical (Dr. Najib, USIM)
CVS examination 
[Introduce myself and the examiners to the pt first. and ask for permission. Then ask pt to remove his cloth (shirt only). Ensure he is lying 45 degree. Observe the surrounding – any branula, oxygen- well ofcourse takde but still need to observe ok. Do all this in few seconds, while pt is removing his cloth] then begin with peripheral examination and cvs examination.
As I finished auscultation, Dr.N: just finish ur examination. How would u like to complete ur examination?
Ans: before that, I’d like to examine the leg, looking for scar and bipedal edema
Dr. N: show me how do u look for bipedal edema?
Expose the both LL and tell the pt that’s im to press on his leg and plis tell me to stop if there’s any pain. Look at the pt’s face. Start pressing at the ankle level for few secs and FEEL for the pit. – no bipedal edema.
Dr. N: Present ur findings
A: pt’s alert and conscious, and he’s not tachypneic. pulse rate bla bla…. There’s midline sternotomy scar  measuring about 16 cm and a vertical surgical scar at the anteromedial aspect of the left leg (measuring about 25cm).
Ok what else? (seems he just want to hear the positive findings)
A:  There’s an audible click heard over the chest
Ok, yes, there’s an audile click. So what u found on auscultation? (Examiner was trying to safe me by saving the time)
A:  there’s loud S1
Can u hear the heart sound?
A: oh yes, S1 and S2 can be heard (just tell what I heard, don’t care whether it was correct or not), but the S1 was loud. I mean there’s click heard at the first heart sound
Ok what do u think the patient has? (oh, nak dgr aku cakap click tu rupenye)
A: since it is at S1, so, I think the patient’s having mitral valve replacement
Ok. If it’s that so, what medication do u think the patient’s on?
A: anticoagulant, which is warfarin
What precaution do u need to take before the patient take that tx?
I’ll first ask about any tendency of bleeding. Than do coagulation profile to ensure he’s not having coagulopathy
Ok what is the range of INR we need in pt on warfarin WITH PROTHESTIC VALVE? (ade dalam oxford handbook..Thanks Allah for showing me that tiny table about warfarin & INR).
Ans: 3-4
Ok. What advice do u need to give to the pt on warfarin?
To come early if any bleeding occur, and to avoid food high in vit K. (plis don’t ask me what bcoz I can’t really remember what are those)
Ok. What is the thing that we’re afraid of if pt is on warfarin?
Ans: bleeding tendency, such as UGIB, hematuria or from the nose or gum …. zzz (examiner still not satisfied)
Ok ok..but what is the most dangeraous thing that we need to be careful of?
Ans: (err ape bleeding yg paling dahsyat aa??) Intracranial bleed!
Ok. done. Let’s go! 

Case 2 : Paeds (Dr. Norlijah, UPM) 
Cerebral palsy. 9 yr old girl, she was sleeping on the bed. Inspect & describe what u see. Do peripheral nervous system examination. Fumbled teruk sangat kat kes ni huk huk...

Case 3 : Ophtal  (Dr. Norlela, USIM)
Glaucoma
Patient: An elderly male. Q: Examine the pt’s eye
Ans: [introduce myself and the examiners to the pt. and ask for permission]. the red reflexes were present. And the pupils… the pupils… (cane ni, xkan pakcik ni ade bilateral RAPD… mcm xlogik je..) but the pupils were not…constricted.. HAhahaha! (examiners laughing at me… memangla, bcoz both eyes were already dilated, dah buh ubatt T_T ) Dr. Lela: it’s ok, do the finduscopy

Ask permission form the pt, and then ask him to look straight and not to move the eyes. Start with right eye, then left eye

Findings: optic disc is pink, CDR high 0.7-0.8, no new vessel at the disc. AVR normal, 2:3. Peripheral retina – no dots n blots, no bleeding, no new vessels. Macula – not edema, no bleeding, exudates.

Impression: Open angle glaucoma

Qs:
What are the risk factors?
If pt came in ED with acute angle closure glaucoma, how to manage? – IV diamox, analgesic, (examiners and that uncle nodded)
Other than that?
Ans: check the IOP by tonometer,
If there’s no slit lamp. No tonometer?
Ans: Palpate the eyeball, it will be painful
Yes yes, it will be painful, hard eyeball. But let say u’re just an ordinary MO in the ED?
Emm…  (ordinary MO.. xpaham ape yg Dr nak sanye?)
Dr. Lela: refer to ophthal….. u r just an ED MO in a district hosp....what more can u do, rite? =)
Me: (Ohh…. Cakap la awal2 part kat spital district uh.. haha)
Ok u’re done, wait outside..



Camtulah lebih kurang... lepas abes tu..ya Allah risau giler... pasal fumbled teruk sgt mase paeds.... 

Tapi Alhamdulillah Allah tolong.. Lepas habis short case, siap2 balik dlm pukul 4 tu. Prof bgtau siap2 esok ready kat tgkat 10 by 2 pm for result announcement. Ya Allah, sepanjang malam dan pagi sebelum dapat result tu adalah saat2 aku paling takut, sangat takut, jantung berdegup laju2, kalah time nak amik exam  di hari2 sebelum tu... 

Alhamdulillah everything is now over.... and all of those things has brought me into a new journey of life... a working life.. Yahuuu!! & Huwaa T_T = Mixed feeling. Nak kate happy sangat pun tak, tak happy pun tak. Tapi yg paling significant skrg adalah.... TAKOTT!! 

Takut, risau nak pegang tanggung jawab. Kalau dulu boleh la, "Dr, xdapat la ambik blood pt tu...skin die tebal, sy xnampak vein die,.. (kecewa)" Doc: "ok, xpe xpe. Letak je situ..meksih.. (senyum)". Pastu blah... 

Lepas ni... tebal ke nipis ke, nampak ke tak nampak ke, kena jugak dapatkan! mesti.... oh takpe, tetibe teringat dulu penah blaja macam mana nak buat kalau x dapat2 nak prick vein dia.. ajaran houseman2 di spital jugaklah kan, sape lagi huahaha.... nostalgianye gi wad tgh2 malam n pepagi buta untuk nak amik darah org time org tengah tido....macam hape je..serius masa tu aku rase tak kurang macam dracula..cume bezanye, dracula tak amik medik, wahaha...

Maksudnye nak cakap kat sini, ape pun yg terjadi, kite kena jugak buat sampai abes keje tu, dan pikul tanggungjawab jaga pt tu bebetul....takbley lepas tangan je ok..

End of our final pro exam, yayy! Mase ni sangat happy.... lepas tu baru rase cuak balik hahaha
[Credit photo: Khalida]







InsyaAllah... =) 










Wassalam...... =))



ps 1 : Wah terus hilang mode raya dan kenduri aku hahahaha
pas 2: wah nebesnye nak tau dapat spital mane ni.... wuwuwuwu....... 

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