Professional Exam Episode V: Saatku disapa ujian HEBAT...

Tanggal 27 Mei 2011, aku diduga dengan sebuah ujian hebat yang bukan calang-calang, kukira ini antara uijan yang paling hebat pernah melandaku setakat hidupku selama hampir 25 tahun ini.

Allah telah mengujiku dengan menganugerahkan Distinction dalam final professional exam, sebuah ujian nikmat yang tak pernah kupinta, tak pernah ku sangka-sangka. Bahkan sebelum professional exam, aku sudahpun bersedia utk menghadapi apa sahaja kemungkinan setelah kuusaha sehabis daya.

Selama berbulan-bulan aku memohon dalam doaku, “Ya Allah izinkanlah kami satu batch lulus professional exam, itu pintaku ya Allah, Kau qabulkanlah”

Namun hanya beberapa hari sebelum exam, doaku bertukar, “Ya Allah, kurniakanlah apa yang Kau Tahu terbaik utk kami. Andainya gagal dalam professional exam itu yang terbaik untukku, maka aku bersedia menerimanya, kerana Engkau Maha Tahu. Namun Kau terbitkanlah redha dan sabar dalam hatiku”

Dan saat itulah, baru aku merasai kemanisan tawakkal yang sebenar-benarnya. Bilamana kita berserah sepenuh hati pada Allah... dan kita gantungkan semua harapan padaNya, sedang kita bersedia menerima apapun ketetapan yang Allah Tahu terbaik utk kita, sekalipun ianya pahit di hati kita, buruk di mata manusia...

Sesuatu yang nampak impossible, bilamana Allah mengatakan ‘kun fayakun’, maka terjadilah perkara yang paling mustahil sekalipun.

Awalnya kurasakan, aku tidak ingin pun distinction untuk diriku sendiri, apatah lagi bila ia mampu menerbitkan penyakit-penyakit hati yang tidak diingini. Namun andai distinction ni untuk Islam, untuk dakwah, ku berdoa moga Allah kurniakan yang terbaik. Tak penting pun bagiku, distinction atau tidak. Yang lebih penting adalah menjadi Dr dengan attitude yang distinction, dan seperti yang kunyatakan dalam ‘speech bidan terjunku’, yang paling penting adalah distinction di sisi Allah, dan itulah yang seharusnya menjadi target utama kita semua, insyaAllah...

Semoga kita semua dapat menjadi Dr luarbiasa, yang bukan setakat menyembuh manusia dengan izin Allah, tapi sebagai ‘agen’ Allah untuk menyembuh ummah dari segala penyakitnya, dan gemilangkan Islam di muka bumi ini... Ameen!

Professional Exam Episode IV: The VIVA

A bit sharing on the 4-VS-1 VIVA session...

SURGICAL

Examiner: What is the current most common Ca in Malaysia?

Me: Male – colorectal; female – breast Ca

Examiner: Is there anything you can do for common Ca?

Me: Screening

Examiner: What are the pre-requisites before you do screening?

Me:

- We need to have data, i.e. the Ca is common

- The Ca is treatable, if not curative pun we can offer treatment modalities

- The screening tool is available, with acceptably high SPECIFICITY & SENSITIVITY

Examiner: What can you offer in screening for breast ca?

Me: US if <35y/o. Mammogram if >35y/o

Examiner: How frequent do you screen?

Me: Generally yearly beginning at the age of 40-59, since the incidence is highest in those age-group, then can probably reduce the frequency

Examiner: What are the disadvantage of mammogram

Me: radiation, especially if done yearly

Examiner: What else can you offer other than imaging?

Me: Genetic studies e.g. BRCA 1, BRCA 2

Examiner: So, would you offer a prophylactic mastectomy if they have BRCA 1 & BRCA 2 genes?

Me: (Owh, ni soalan dpt masa seminar breast Ca masa muda2 preclinical dulu. Soalan yang ditanya oleh wani Ca). Erm, that’s a very controversial issue (jawapan politic). I think, 1^st we have to counsel the patient (goreng...), advice on yearly screening and regular BSE ke, if a lump is detected, then...

Examiner: Nevermind, I agree with you that it is a very controversial issue. How about the screening for colon Ca?

Me: For low risk group, advice start at the age of 45 or at least 50. For high risk group (e.g. FAP, HNPCC); FAP screen at the 10 years old, HNPCC start screening for Ca at the age which the 1^st family member develop Ca

Examiner: How do you screen? You don’t do colonoscopy in everyone do you?

Me: No, we can offer FOBT

Examiner: How often?

Me: Same, depending upon low & high risk group

O&G (tak ingat sangat, sorry)

Examiner: Tell me what you know about cervical cancer. The pathology behind it.

Examiner: What are the treatments available

Examiner: Prevention? – HPV vaccination

Examiner: How does the vaccine work?

MEDICAL

Examiner: 39 y/o Malay gentleman, come with palpitation. You check his BP, it is 150/90. Persistently high. What do you think?

Me: I’d like to ask further Hx, PE... (Sebenarnya examiner nak dengar Pheochromocytoma but I was blur...)

Examiner: How do you treat AF?

Me: Rate & rhythm control, bla.. bla.. bla..

Examiner: Other drug in treating AF?

Me: Warfarin

Examiner: How do you administer warfarin, monitoring, etc...

Examiner: If patient refuse drugs, how do you treat? – radio-something... err, can’t remember, never heard of it

Examiner: What is the latest drug to treat AF in the market now? – Don’t know (tak ingat Dato’ mention ubat apa)

PAEDIATRICS

Examiner: Since 2008, you know that there have been changes in the immunization schedule in Malaysia. What are the changes, and why?

Me: Hep B previously 0,2,3,5 months, currently 0,1,6 months (more effective?). Dulu 3 in 1, now 5 in 1. Dulu OPV, now IPV (less vaccine-associated poliomyelitis). Dulu cellular pertussis, now acellular (less side-effects). I can’t remember the exact reasons...banyak goreng...

Examiner: Let’s say you are a houseman in the ward, there’s this boy with thalassemia, come for blood transfusion. Blood running, you wait for 10 minutes, patient ok. So you go to your room to take a rest. Suddenly the SN call and told you, “Dr, this patient develop sudden HGF with chills & rigors!” What are you going to do?

Me: I would go to the patient, assess the ABC...

Examiner: No, what are you going to tell the SN there and then on the phone?

Me: STOP the transfusion

Examiner: OK. You go to the patient and examine, he has urticaria rashes all over the body. What to do?

Me: Give IV Hydrocortisone?

Examiner: How long does it take for IV hydrocortisone to work?

Me: I’m not sure

Examiner: 2-3 hours. So what else can you offer, one with more immediate effect?

Me: IV adrenaline

Examiner: OK. How else can you administer adrenaline?

Me: IM

Examiner: How else?

Me: Errr.. I’ve never heard of any oral preparation of adrenaline...?

ExaminerS: Gelak berjemaah. The answer was subcutaneous.

This distinction does not mean I’m smarter, neither am I any better in any way. Allah yang bagi, everything was by His Help, His Will, His plan.

"This is by the Grace of my Lord - to test me whether I am grateful or ungrateful! And whoever is grateful, truly, his gratitude is for (the good of) his ownself and whoever is ungrateful, certainly! My Lord is Rich and Bountiful." (An-Naml: 40)

Alhamdulillah ‘ala kulli haal.

Professional Exam Episode III: The Day (Shortcase)

Next came the short cases. My first shortcase was a uterus larger than date. The first time I examined the patient, I was ‘kicked’ by the fetus at the right iliac fossa. Initially I wrongly diagnosed the patient with polyhydromnios.

Examiner: Do you think in polyhydromnios, patient can be lying comfortably like this?

Me: Unlikely.

Examiner: Would you like to examine again?

Me: OK. Minta maaf kak, boleh saya periksa semula?

The second time I examined the patient, her second baby kicked me at the left hypochondriac region. OK. Alhamdulillah, again Allah helped me by giving a clue. Padahal tak rasa pun multiple poles! This has to be a multiple pregnancy. It was a twin.

Examiner: How do you manage this patient?

Me: I would like to know the patient’s chief complaint

Examiner: Patient is comfortable, no complaint

Me: In this case I would like to prolong the pregnancy until term. Provided that this is not a MCMA twin, and the leading twin is in cephalic presentation, I would like to attempt vaginal delivery and anticipate the complications associated with twin pregnancy including PPH (maternal) due to overdistension of the uterus and...

Examiner: OK2. How do you classify twins?

Me: According to zygosity, chorionicity, amniocity

Examiner: If you have a twin pregnancy, which one would you prefer?

Me: DCDA, since it is associated with the least complications

Examiner: What complications do you mean?

Me: TTTS for MCDA, cord accidents for MCMA...

I had a CVS examination for my 2^nd short case, the patient had a raised JVP, lower limb oedema, (and collapsing pulse which I failed to detect)... He had a displaced apex beat, thrills, various murmurs, MR, TR & AR. But I only detected MR & TR. Since he had multiple findings, I spent almost 8 minutes on examination alone, there were not much time left to discuss.

Examiner: So Dx?

Me: MR & TR and patient is in failure

Examiner: Only MR & TR? How about pulmonary area?

Me: Err...

Examiner: OKlah nevermind (he actually had an AR also, according to Dr. Hasnur). Differential?

Me: VSD, but unlikely since patient is old, but it can occur due to MI rupturing the septum

Examiner: So you say patient is in failure, give him one advice.

Me: Fluid restriction?

Examiner: OK

My third case was an orthopaedic case.

Examiner: Examine the left lower limb

Me: (I asked permission to be on patient’s left side, and then I presented by running commentary) There were limb length discrepancy, muscle wasting, old scar. PLUS old sinus. No active signs of inflammation. I proceeded with FEEL & MOVE (range of movement). Positive Galeazzi’s sign.

Examiner: How many types of scar?

Me: Two – from the lesion & from the external fixator

Examiner: What do you want to do next?

Me: Calculate the true length

Examiner: OK, lain?

Me: I would like to attempt to move the limb. There was a pseudojoint at the distal third of left tibia, moveable and PAINLESS

Examiner: Ok. What is your Dx?

Me: Non-union of distal third of left tibia secondary to OM

Examiner: What are the factors affecting bone healing?

Me: Can be divided into bone factor, patient factor, surgeon factor... bla bla bla...

Examiner: What do you think was the problem with the patient?

Me: Infection, probably OM

Examiner: How did he get the infection?

Me: He may have had an open fracture through which infection was introduced...

Examiner: How do you know he had an open fracture?

Me: He had an external fixator (from the scar)

Examiner: Ok, I agree. What else was the patient’s problem?

Me: Hmm, maybe patient factor, uncontrolled DM?

Examiner: Hmm, OKlah, what else?

Me: ???

Examiner: Look at the calf. Do you think the soft tissue was enough to cover his fracture?

Me: Oh, insufficient soft tissue cover.

Examiner: OK. Dah, cukuplah...

Alhamdulillah, I have never felt this calm in any exam before this (I mean, I was magically calm during the professional exam.. But before the exam, Allah jelah yang tahu...). In this exam, I felt confident, well-directed, Alhamdulillah my answers were mostly smooth, and at instances I even had ‘speech diarrhoea’ which almost never occurred before...! At one point I did not feel like myself, it felt like an external force was controlling my every movement and sayings. And NO, I do not have any other Schneiderian first rank symptoms. I just felt like Allah was with me in my every step, He was eyes with which I used to observe, He was my hand with which I examined the patients, He was my legs with which I walked, He was my tongue with which I presented and answered the questions, seriously! I did not feel like myself. Allah helped me all along, Alhamdulillah, thumma Alhamdulillah...

“My servant constantly approaches Me through supererogatory acts of worship until I love him, and when I love him, I become His eyes with which he sees, his hands with which he holds, and his legs with which he walks.” In another version, the wording is: “So through Me he hears, through Me he sees, and through Me he understands.” (Bukhari)

Tidak ada kedekatan hambaKu yang lebih Aku sukai melainkan dengan apa-apa yang Aku wajibkan kepadanya. Kemudian, hambaKu masih mendekatkan diri kepadaKu dengan amalan sunnah sehingga aku mencintainya. Apabila Aku sudah mencintainya, maka Akulah yang akan menjadi pandangannya ketika dia melihat. Dan Aku yang akan menjadi kakinya ketika dia melangkah. Apabila dia meminta perlindungan kepadaKu maka pasti aku lindungi. Dan apabila dia meminta ampunanKu pasti Aku ampuni. (Bukhari)

May we all become those whom He loves...