Wednesday, March 24, 2010

surgery session 4 0730hrs

it has finally come, the day where we sit for our final mbbs clinical exams (or actually this is just for the surgical track) . all the late nights, or attempts at it, and all the facebook learning have come down to the next few hours. or rather, 30+20+16minutes.

the night before, insomnia and eventually a strange dream about barney stinson from himym bullying a little kid in the mirror.

the morning itself, palpitations. even more than the 4 days of serious palpitations every time i read the accounts from my classmates. here's my own account.

SYSTEM: ortho
TESTERS: CT, AT (i have no idea who was active or passive because both talked to me, and after a while my brain got tired, and it became just a friendly voice and 2 eyes)

ACCOUNT: not my birthday, didn't get the 2 prof lows for shorts or longs. but the 2 mentioned are rather cute, smiley and very encouraging. really helped when you get freaked out after reading 4 days worth of scary accounts.

Summary: Right OA knee X 3 years, secondary to right tibial fracture (fixed in a cast, no plates or screws, healed with malalignment 35 years ago) currently on glucosamine daily and paracet prn, on follow up at ttsh, not for any op in the near future, woohoo. Typical history of right mechanical knee pain, ruled out inflammatory causes, malignancy, septic arthritis, and screened for other joints. Function limited due to the pain, can't jog his normal 10km/day (this 71 year old uncle is fitter than all of us now) and sometimes difficulty kneeling to pray in the mosque. no DM, only htn and chol. 30 minutes passed really quickly, but in between i was talking rubbish with my patient. NO MO TO HELP WITH ANYTHING. but nvm, OA knees, damn happy already. Examine knee, remember to walk the patient. This man compensated with his other leg, which i suspect is also in pain but he refused to say cos he was scared i'd have to present more things.

They came in while i was examining his limb length which the patient pointed out to me in the beginning but i just got carried away after my initial knee exam, heart lungs abdo. can i just mention that i LOVE this man, he spoke english fluently, clarified every point for me, and even said "er i have back pain also but i can don't tell the examiners later, it's not that important" when i looked a bit shocked after taking an entire OA knee history. "no no, uncle, thank you but every pain is important to me, but if it's not bothering you, then we concentrate on the main knee problem la okay."

AT said, why don't you leave and consolidate, while we talk to him a while (is this what everyone got to do?? it's surg right, not med??) quickly summarised my points on a separate paper while i overheard the testers asking the patient for his main complaint. then the invisible MO came to tell me, eh not much time leh, just go back in. 71 year old malay man, retired protocol officer (CT interrupted and was like, wow what is a protocol officer, and started asking the patient which VIPs he escorted etc etc... WASTE TIME)

After i finished presenting, the typical qns ensued.
1. What are your differentials? "RA, gout, septic arthritis are not so likely"
AT: Huh? Girl, where's your main diagnosis, why did you say the rest first! Calm down! "oh yes, sorry i thought i made it clear in my history and summary that my main diagnosis is OA knee"

2. Oh, so in this case, we learn that there's more to OA than just primary OA right. what is the main cause of his right knee pain? - "the tibial fracture causing malalignment so development of genu varum and redistribution of weight causing increased wear and tear of medial compartment of the knee joint. "

3. Why did you tell me about no LOA LOW night sweats and night pain? to rule out TB/mets.
4. What other parts of the history are important.
5. Show me how you examine his knees, so i rolled up his trousers and started describing the genu varum, 8cm intercondylar distance. Name me the effusion tests, how to do.

6. Oh i see you marked his quads, very good. Oh i see you marked his asis and medial malleoli, very good. So is there limb length discrepancy? "sir i measured and found that there's NO discrepancy even after squaring the pelvis etc" (i really found no discrepancy but then when i looked down i saw there really was shortening, argh!) "however i would expect there to be in this case because of his genu varum as well as the tibial fracture causing shortening" OH okay, we believe you then, since you already marked everything nicely.

7. Okay, show me range of movements. What does he have? "Fixed flexion deformity." Prove it.
Tell me what it's called when on passive movement he CAN extend? BRAIN BLOCK. "er, flexion deformity, not fixed." AT laugh laugh laugh, yes you just described what i asked but is there a name for this, girl? "er, extensor lag!!!!!" YES, let's move on.

8. They brought me outside the cubicle and showed me an xray THEN asked for investigations. "As a HO and on admission, do typical bloods, and AP/lateral (weightbearing) + sky line xrays" Describe the xrays, which compartment is affected?

9. How to manage? Regurgitated everything in the last 20seconds after the bell rang.

1. Clerk quickly, examine quickly, 30 minutes passed so quickly.
2. Give a good summary.
3. NO MO IN ___ TO HELP, except to tell you that there's 5minutes left. but if i pass and if i'm a HO in ___, and if i'm free, i'll come and help :)
4. If the tester wastes time, just use the time to think about what to say next
5. Just say simple things and don't shoot yourself in the foot esp if you have a nice straightforward case
6. Thank your patient! Build KARMA!

SURG: Short cases

TESTERS: CNL (nice nice!!) and some other nice old man (i love old men!! :)

1. AC joint subluxation
- didn't even notice the asymmetry or step deformity until palpation.
- wtf i thought i read shoulder (ant dislocation, frozen shoulder, rotator cuff tears) but i really didn't think i'd get this. don't even recall ever having known anything about it.
- the testers might as well have taken my hand, put it at the deformity and asked me qns. they were really nice to try and lead and get me to look more carefully. do not rattle off "no asymmetry, no squaring etc" MUST REALLY LOOK.
- what are the gradings (i really didn't know but mentioned, stable unstable, and he kinda just nodded and moved on knowing that i really didn't know)
- what's the difference between subluxation and dislocation
- how to manage
- will you manage differently if he is a professional badminton player
(I DUNNO but i just said yes/no/yes until someone nodded and pushed me off to the next case, who was actually just sitting in a chair 20cm away from the 1st man, and the 3rd case for that matter)

2. thyroglossal cyst
- first damn obvious one i've seen in my life!
- how to manage, describe the op (sistrunk procedure, removal of the cyst, its tract and the central portion of the hyoid bone)

3. dorsal ganglion cyst
- examine (soft, cystic, more prominent (not bigger) on wrist flexion)
- what is a dorsal ganglion cyst attached to
- management, draw on his wrist how to excise
(testers rocked, i just drew an elliptical thing, then he said really? i changed to a vertical incision, then he said really? i changed to a horizontal incision. then he said, VERY GOOD!)
- advice to patient after excision? may recur

4. direct hernia, irreducible
- examine his right groin
- went to examine scrotum instead, cos i thought the right scrotum looked abnormally low compared to the left "can't get over the scrotal mass, not separable from testis, soft in nature, no cough impulse"
- was later educated on how actually that's normal >.< damn sian. girls, pls go look at more balls haha. no wonder while i did running commentary there was absolute silence
- tester repeated, "examine his right GROIN, girl!!"
- looked upwards, saw a vague mild fullness in right groin, just imagined a cough impulse cos i heard some bells ringing, quickly described a direct hernia and got him to lie down to reduce. he tried and he said, okay can only reduce half. there was NO VISIBLE DIFFERENCE after he reduced half of it lor. the most unhernia-ish hernia in the world =/
- nvm carry on, what are the types of hernia (irreducible, incarcerated, strangulated) and how will a strangulated hernia present. THE END. argh.

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