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CSFC tests

Finally can take a breather now that both tests are over.

Medicine was a disaster while surgery went surprisingly well. I always thought we had learnt more about med than surg these past weeks, but turned out that there was no breadth and depth in med. As for surg..thanks to our tutor for making life so easy.

My long case was in the air con ward at AH. As we were walking to the lift, my examiner asked whether I can handle dialect. I told him my cantonese cmi, then he suggested hokkien. I winced. Was given 30 min to clerk this middle aged lady. History taking was a nightmare. It wasn't the language since she could speak a little mandarin; it was her inconsistent history. The first time I asked, she said she was at home babysitting her grandchildren when she fell. I asked again and she said 2 weeks ago she was crossing the road when she tripped and fell. So I gathered she did fall. Went on to test the power, coordination, reflexes, proprioception, sensation. Diagnosis: A fall that damaged her spinal cord? A lesion higher up? But before the 30 min was over I did elicit a jaw jerk.

When time was up, I was still uncertain of the diagnosis..when he came in.

"Too easy?"

Wth. That's when he listed all my mistakes. I should have tested her cranial nerves as well. I can't conclude that she had a lesion higher than the pons juz based on a solitary jaw jerk. I should have done a full cranial nerve exam. I failed to notice her slightly slurred speech, weak facial muscles and weak smile. I should have asked for the blood pressure in this case becos its relevant. She had a stroke! Her high blood pressure might have triggered it. Argh.. stroke. It seems so obvious after everything, but while I was taking her history, I was so convinced she was alright and she fell in such a way that she injured her cord.

Next was short case. We interrupted this elderly lady who was about to have her lunch. CVS exam this time. Everything went well at first, until I realised I was taking too much time and began to forget steps when I reached the praecordium. It was the first time I was doing CVS on a female patient. It was hard to ausculate and harder to locate the apex. I only remembered after the test that I forgot to feel for parasternal heave, thrills and P2. Forgot to switch the stethoscope to the bell when I auscultated the apex at the left lateral position. I should have tested for edema by pressing medial and not lateral to the shin.

What I found: irregularly irregular pulse suggesting atrial fibrillation, gallop rhythm S3 and crepitations suggesting heart failure. But I missed a murmur! After I reported everything he told me to listen again. This time I picked up a PSM and I guessed it was mitral regurgitation. Anyway, it turned out to be a tricuspid regurgitation.

What I missed: PSM. Giant v wave. I did not palpate for a pulsatile liver.

And he had a lot of things to say about my presentation too. I should have been clear about my terms, like heaving, thrusting, and tapping apex. I said "gentle heave" and he asked which book I read it from. Erm. I din read la..I got that from a tutor who said the normal apex is a gentle heave.

"So is the apex normal or abnormal?"

Of course he wanted me to say its abnormal. Haha..but the point is we have to be sure of the terms we use. And he added, "You won't make it if this is a year 3 test." I know. It's only when someone corrects you in such a stressful setting will you remember your mistakes.

Surgery test was a welcome change. Our tutor rocks!!

posted by Alvin @ 10:44 PM |