Surgery Practical Examination

Dear me. Please undo this mistakes. DO NOT REPEAT THEM !

Sincerely,

The idiot medic student.

I came to the department of a foreign hospital. I did not study here. Tapi, aku redha dengan apa yang akan terjadi. Sebab ini salah aku sendiri. Aku yang tak kuat untuk hadapi peperiksaan. Hari ni , aku kena hadapai semua yang kat depan mata dengan sendiri. Tak ada siapa yang akan tolong aku. Aku ibarat anak yatim. Tiada tempat nak bergantung. Tiada tempat nak mengadu. 

Malam tu, kepala agak serabut nak study yang mana satu dahulu.

Sepertimana nasihat kat sticker note aku,

" The key to success is not prioritizing your schedule, 

but rather scheduling your priorities"

Well said advice i think.

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0700 am : Went to hospital early. 

0800 am: Start taking history of each cases.

1000am : Surgery viva session commenced.

1.30 pm: Lunch break.

200pm : Viva commenced. Ortho viva started.

500pm : Instruments surgery, specimens, X-rays for ortho, simple surgery procedures, 



Long case surgery

35 year old male, Jaya, came with swelling of the right mouth and chin  for the last ____month.
Also c/o wound and halitosis in the mouth.

GPE: 
- concious , cooperative
-well built, moderately nourished
- Pallour -ve, icterus -ve, clubbing -ve, cyanosis -ve, lymphadenopathy +ve, edema -ve.

Mouth and oral cavity examination:

Inspection and palpation:

• Nose: Normal
• Maxilla: Normal
• Mandible (jaw) - Right angle 3 multiple swelling , border diffused in nature, surface irregular,extent 7x5cm extending from right angle of the lip and lateral border of mandible,part of swelling covered by hair, firm on palpation, fixed to the bone, skin over swelling not pinchable.
• Lip: Normal
• Oral cavity: 2 ulcer wound present on the right side of buccal mucosa extending to the inferolateral border of the tongue. wound size on buccal mucosa(4x1cm). Wound on tongue (4cmx2.5cm). Both wound no discharge, covered by pus and  slough unhealthy granulation tissue,beaded(?) elevated border(?) , blood tinged discharge, no bleeding on palpation, firm on palpation, involved teeth shaky mobile upon palpation, tenderness mildly present on palpation, 
• Gingiva: swelling , oedematous, cyanosed, tobacco stained,firm on palpation, 
• Tongue: An oval wound present over lateral margin of the right side of the tongue, induration present, border elevated, covered with pus and serous discharge.
• Teeth: Poor dental hygine, carries present, mobile teeth, tobacco stained.
• Uvula: Normal, no deviation.
• Lymph node : multiple ipsilateral nodes but all less than 6cm N2B

DDx: Carcinoma of buccal Mucosa (  Viva : Squamous Cell Carcinoma) invading the right jaw and tongue. 

Stage 4: T4,N2B,M1 

Short surgery case

A 40 year old male from kerala presents with swelling behind his back.

Inspection:

• A diffuse swelling present over the ________(lumbar vertebra/back?)
• Puncta present over the swelling. 
• No discharge present.

Palpation:

• no local rise of temperature.
• no tenderness.
• Cystic in nature
• margin well defined, border not indurated,
• Skin over swelling; not pinchable
• Center : indented
• Mobility: Horizontal+ve, Vertical +ve,
• Slip sign -ve
• Fluctuation test +ve
• Translumination test: -ve

DDx: Sebaceous cyst/ Lipoma/

Rx: Surface excision.(?)


Surgery short case

A 30 year old female with neck swelling c/o hoarseness of voice since 1 month.
C/o pain radiating the shoulder, aggravated on drinking, relieved on medication.
No h/o headache, no h/o deafness.

Inspection: 

• One diffuse swelling, present over the middle of the neck.
• Size 3cmx5cm, 
• no redness or discharge.

Palpation:

• No local rise of temperature
• No tenderness
• Mobility: non mobile(fixed?)

Ddx:

 -Papillary thyroid cancer invading recurrent laryngeal nerve.(Under 45 year,female,solitary nodule,deep cx LN involved,fixed LN,) 

-Tuberculous LN

-Secondaries in neck 

Orthopaedics Short Case

A 55 year old female, Mangala from Bankart came with trauma of the right hand two month back.

HOPI: 

H/o trauma suddenly and was treated by plaster cast for 25 days. When the trauma has not been cured, she was admitted to FMH for 5 days. Plaster cast was changed for 5 days.After 1 month of care , she was sent for operation when the trauma still not cured. She c/o pain since 2 month back , and not relieved  even after treatment. H/o of decreased movement range.
c/o pain and swelling of the right wrist.


Examination of the hand

• Irregularity of the lower end of radius ( dinner fork deformity)
• Th styloid process came to lie at the same level / higher than the ulnar styloid process.
• Dorsal tilt present.
• Tenderness present

DDx: Colle's fracture complicated by Sudecks osteodystrophy(pain,swelling,stiffnessof hand after removal of plaster) 

Rx: immobilise, below elbow plaster cast for six weeks



Orthopaedics Short Case

A 65 year old male came with a  left foot drop(?) since 15 years. 

HOPI: 

H/o foot drop for 15 years, h/o leprosy  for 45 years , on medication for 5 years,
 Right leg: No sensation from middle calf to ankle, heel normal, 
Left leg: foot drop for 40 years back, decreased sensation,
Both legs have skin desquamation,No pain on both legs.
Able to walk, gait normal, left foot touching the ground.
No h/o physiotheraphy.

Examination of left leg

• Attitude: Patient sitting on the bed, both knees same level, adducted, heels touching the floor, normal dorsiflexion of the ankle, no shortening, no swelling, skin desquamation present,no tenderness, no local rise of temperature, sensation decreased, wasting of muscles present, 
• movement active: inability to dorsiflex  left ankle ,  both knee extension and flexion normal,
• Movement passive: no rigidity/spasticity on both legs. left ankle in plantar flexion upon elevation of left leg above ground.

DDx: Foot drop caused by common peroneal nerve palsy affected by leprosy.

p/s: In ortho no need to write case sheets , but they ask for the paper anyway. So, just write in the paper.

Post Mortem Exam : Day 3

Yeah i know.

I'm supposed to write this few days back. But i was too emotional to do so. I've been really moody and sensitive since that last practical exam. Traumatized i would say.

2 cases, each 40 marks with instruments.

We were supposed to come at 8 am. Luckily i came  30 minutes early and get ample time to finish history taking and case examination. There are a lot of confusions as that was the only case i took since forever. It had been a very long time since i took and Opthal case.

I just want to tell that the first case presentation went well. However, the second one was a disaster. i couldn't even answer a basic most simple question which brought me to panic attack as well as inability to hold my tears right after i finish my exams. Yeah, i didn't cry in front of those people. I cried for my stupid mistake in front of Allah, the one who knows whats in our hearts. I rather not say anything when i am feeling bad or weepy.I just cry and just say what i want to say in front of Him during solah.


I made a mistake where i mistook 10 years of decrease of vision which was aggravated since last 1 month with loss of vision.

It is not SUDDEN, but GRADUAL onset of loss of vision which contribute to my failure to diagnose the case.

The moral of the day is : 1 month is NOT SUDDEN ONSET, but rather a GRADUAL ONSET.It may started suddenly and progressed for 1 month duration. 

Among questions asked:

-What is uniocular movement
-causes of gradual loss of vision
-complication of pseudophakia
-


 1st case: Right Nebula on the inferior-lateral margin of the cornea surface was right. They did asked about treatment, management.(keratoplasty,soft contact lenses, tattooing, peripheral iridectomy)


2nd case: Pseudophakia. Yup, i was wrong. I didn't see the whole picture although i've given it a thought about the man having a cataract removal few days back. But, because i was SOO FOCUSED ON SUDDEN ONSET LOSS OF VISION, i missdiagnosed my case as anterior uveitis wtih scleritis following surgery.

She also said that,

"You don't know ANYTHING!"

With that utterly disappointing look on her face.

Well, it was bad for the second case presentation compared to the first one. I was given compliment and said it was good. Two different aura in two different case.

That night i studied all the theory parts and out weighs the practicals part which was the instruments and probable cases. I didn't think straight and was so obsessed with theory part and sacrificing the score-marks on instruments and diagnosis.Argh, they didn't even bother to do a theory viva unlike community medicine as if they already given up on us, the reapeaters. Although, this is my first time taking this exam, i think i did okay.

When people start asking hows your exams? My answer would be, OKAY. Because i want it to be okay. I did okay. It will be okay.

It is not GOOd or not FINE.

 Good means you did extremely good and you are confident enough to say you will pass with flying colours.

Fine means that you did terribly but hoping that you actually get a different outcome.

Okay means it is in the middle. Not to positive. Not too negative. Just prepare ourselves for the worst case scenario.

I promise my self to be better. Better at managing my time during exams and control the urge to sleep. Sleep freshly. Use time wisely. Prepare for the worst. THink simple and basic. Schedule your priority.

Post Mortem Exam 3rd Year : Day 2

Community Medicine

I slept only for 2 hours. If i'm not mistaken. But, i'm glad i had finished whatever target that i want to achieve within one day of studying. More than 70 slides spotters, epidemiological cases, exercises on statistics and so on.  I didn't read the theory part because i am depending on what i have read last two weeks during my theory exams. Anyways, i've got plenty of  time to study while waiting for others to finish their viva. I'm somewhat contented of becoming among the last in a row. Any exams will give that extra time to study and gained something from the ones who have the honour to answer first.

So far, i think i did good. Alhamdulillah.

8.30 am- Went to Y Hospital. Waited at lobby. Said on third floor. Went up by foot. Saw no one there. Text my friend, said its not in hospital. Fast paced walk to college building. Climbed three floors before seeing the others. Waited  while sweating profusely.

9.00am- We sat and waited. A chubby looking invigilator came with answer sheets. We filled in our details. 3 sets of papers were given. One for Medico social case, epidemiological case, and spotters.45 minutes were given to answer epidemiological case. I did okay. Forgot the IMR,MMR,CBR values but it was okay. Then, we had spotters. 1 half minutes for each spotter. I answered all. Alhamdulillah. Then, we were told to pick a random paper with patients name and department. I was the first one to pick and i chose the paper which was thrown out of its group. Alhamdulillah again i got paediatric case. Razika,14 year old. We were told to get back to the hall by 11.40am.Owh, plenty of time to take case. :)

10.45am- Rushed to the  hospital straight to 8th floor. Climb becaused waiting for the lift took so much time. Again, sweating profusely upon arriving the deparment. The kid looked flustered and giggled a bit when she saw sweat dripping from my forehead. I looked aroud and there is no one to help me. So i did the examinations first making sure nothing was left. Yes, i did learnt my lesson yesterday. No findings because she was healthy and was about to get discharged. I took  the history by my self even though there is language barrier. I'm thankful because the kid was able to speak little english and i was able to memorize little Kannada.we complement each other.Ngee. (^_^) So, i scribbled on some A$ paper and rushed to the hall 3 minutes away from the hospital. Again, walking from 8th floor down to the third floor up. Arrived with sweating again. Searched a seat directly under a fan. Wrote the case in the answer paper. was told to shift to lecture hall 5. It has air conditioning. Alhamdulillah, i need it so much. Allah, your blessing never end.

11.40am- Case presentation started. I was the last to go. I had a female examiner and she didn't ask much. Only Investigations and treatment of malaria. Any variations in fever grades...She asked why not typhoid ? What differentiates between typhoid and malaria fever? What test to be done in typhoid? How to prevent typhoid?Then, she let me go. Alhamdulillah, it was clean and satisfacory.

1.00pm-Theory viva started. there three examiners altogether. I waited too long and managed to read the book. I just flipped through all the pages quickly as if i can read like Superman. Heheh...(-__-)"

Examiner 1 : Looked hard at the topics to be question and later he came up with ,

 What is sewage disposal types? I answered and he seemed satisfied although i hesitated a bit. Then, he asked "What is incineration?". I was bewildered but answered anyway. Then, the bell rang.

Examiner 2 : The female lady was there yawning. Already sleepy due to rain or maybe she is just so hungry.

Name some Polio Programs. What is Oral Polio vaccine? How does it transfer? What is Intensified Pulse Polio? How to prevent transmission?

Examiner 3 : Its my Head of the department in our college. First thing he asked was," how was your paper? You think you can pass this time?" I said, it was good and i think i can pass with a smile. Then he proceed with the questions. What caught me was his question about if given a choice to work in hospital or in PHC with same salary which one i would choose? I said, " Sir, i would love to go where i was needed. There is more self satisfaction. Anyways, i'm using peoples money to  study and its time for me to give back to community."He agreed and question of my intention so as to impress him by choosing helping the poor and needy. I clarified my intention and he smiled. Alhamdulillah, with that i was let go.

What is emporiatics? what is ergonomics? Which chapter is it? Define Primary health center. What is Multi Purpose worker? What is Mudeliar Committee?  

p/s: The theory part was so random. I t could be anything. Bye, gotta go break fasting. 

Post Mortem Exam : Day 1

ENT

• We were given two cases.
• Took the case for 15 minutes each.
• Did all the tests necessary before taking the help of translator for history taking.
• I did forgot to do few vital tasks.
• It was so haphazard and unsystematic at all.
• The case presentation was okay. Although i gave a different provisional diagnosis from others. The examiner says its ok, provided that i've given a solid strong reason for my opinion.
• The viva..hurm, i don't know what to say.
• Instruments? No need to say much. Just take what ever that i know and describe it. St Clair Thompson adenoid curette with guard was the one i chose without any thinking. Actually i chose that because i finished presenting a case related to it. He gave the the marks in front of me. i could care less. Pufft.
• So, i wrote provisional diagnosis as Hypertrophied Rhinitis with Sinusitis and Total perforation of the tympanic membrane of atticoantral type.
• I argued and gave reasons as why i did so, but unfortunately the diagnosis i gave was not perfect.
• It should be adenoiditis with sinusitis which usually present over early childhood and persisit for long time as causes nasal obstruction.
• The second case could be subtotal perforation( i can't really make out the annulus or margin, hence total perforation) because of the continuous discharge of the ear. I deduced it based on the fact that the patient had foul smelling discharge and total perforation with no ossicles left in the middle ear cavity.

Community Medicine: The Practical That I Hate

That day, we have to prepare early as the bus will get going by 8.30 am. That night, i flipped through all the spotters written in the record and memorize each and every answer to the question. That night is the first night that we actually preparing for community medicine practical.So, i had no idea what to do, in detail. I had not made any mistakes before and there is no possible way that i could improve or not to make the same mistakes this time because we never had any exams for practicals before. I can't really blame them for NOT having a LOT of practical exams during sessional. I understood , that it is a tedious job for the department to prepare the materials and allocating houses etc for each student.Not to forget the answer sheet is way difficult for the lecturers to mark, you know the lecturers are very old, true story. Hmm, they say why bother coming to class to teach when students were not even  interested to listen what they say  in class. I've always sit in front and blurr all the time. I've always felt bored and unease with people whispering behind,some were reading novels, the noisy drill at the upper floor and with  teachers yelling in front.

I make this entry to remind myself what to do and what not to do for exam. So, i shall start from the beginning of community medicine practical revision.

Revision Time - I have to read the 66 spotters, 8 epidemiological exercises and  statistical exercise. It took for about 5 hours to complete revision as well as memorizing everything by heart. Next, flip through all topic related to field case. For example,maternal  infant morbidity, nutrition,housing, primary health center, environment and a little bit of other topics.

What to Bring - Bring stethoscope,scale, calculator, language book for kannada malayalam and a sheet of copied format of field case. 

Our practical exam consist of 5 part. The field visit to local area, case exercise, spotters, case viva and theory viva..

Field Visit-

The bus goes by 8.30 am. We are not supposed to take our record or bag to the field as it may be considered cheating. However, i just kept mine in my bag and carry it in bus. Well, all equipment needed is in there and i am reluctant to leave my lovely beloved new bag without proper supervision in college. Anyway, we arrived at the supposed area by 9 am. and began to go separate ways under lecturers guide to allocated houses. Each student got one house each. All students are required to take the cases independently without help. For international students and students who did not speak local languages, we were told that translators will be allocated for each student during final exam. But, for that day, there were no translators or lecturers to help us with the translation and thus, i had to figure out everything myself. 

 I got an infant case in a house with family of 13 members. We were given 45 minit to finish the family case and the clinical case. I am so lucky because that day, because they can speak Kannada which is very easy to learn and understand. Plus, the family had a card that list all the members in the family. The card states everything i needed.but, the real problem is i had no idea what is it because it is written in Kannada. Thank God, the card had pictures and numbers on them and i simply 'cook' the rest info on the sheet. The vital info such as name,age,occupation, relation, education level,house environment  and income can be easily acquired. The real trouble is when i needed to figure out the nutrition and family planning. If only i bring the language manual book, i think it would be a lot easier to deal with them. I know  my sheet was totally messed up because it was my first time writing it. I forgot the nutrition table and the answer sheet looked horrible and unsystematic. I managed to finish the interview, physical examination of the infant and write the sheet. When i finished, we went to college at 10am. Attendance were taken in the bus  and the case sheets were given to respective guide lecturers.

Case Exercise

This exercise consist of 2 epidemiological case and one statistic case both to be written in separate answer sheet. The limit to answer the question is 40 minutes. From 20 students in the exam hall, i could see that everyone is trying their best to answer as fast and as they could. Some are like me, trying to figure out what to do without a calculator for statistic question. How could i forgot about the most important thing in practical? Pfftt... Obviously, all the equation and formulas should be remembered.

Spotter

Spotter session started at 11 am.For this part, we have to identify each spotter given on the table within 1 minute. 10 spotters from 66 spotters given in the record must be memorized well. No need to remember calories as we can see the spotters right before entering the exam hall. It will be pretty obvious. Pay attention to drugs and parasite spotters. I messed up a lot for drugs and parasite. So study that more!

Field visit case viva is easy. The batch was separated into two groups. Each group for one examiner.I am among the last students.So, i had ample time to read for the viva. Present the case like we usually do in the clinical subject if the examiner ask you to. If not, take your time to think the answer and answer with confidence. Do not hesitate to say that you do not know to questions you have no idea about. Study everything related to the clinical case. Since mine was infant morbidity case, he kept asking about the antropometry measurement. Well, i  didn't have the wight and height scale that time. I decided to cook everything up not realizing that he actually pay attention towards these  silly little things. I am busted for those question and end up giving excuses that i just jot down what the mother had said and i told him about the languange problem. It seems that he doesn't even care. Maybe next time i should just cheat something but make sure whatever i cooked up make some sense. In the end he gave me just 25/35. Well, quite good i think.

Theory viva. Gosh! It could be anything!Just read more on primary health center and diseases. They asked me this:What is primary health center? What is the meaning of disease? How many type of epidemic do you know? How to prevent rheumatic fever? What is transmissible disease? etc...

So, that is all what i can say about practical. i'm  pretty sure that i messed up a lot.

  Otoke?(What to do? = in Korea) 

Want to do it again? Oh hell yeah! I have to have at least one more time to do it right before the finals. Please don't screw it up next time okayh!