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...

Professional Exam Episod II: The Day (Longcase)

My clinical examination was scheduled on Wednesday, so I have a back-to-back continuous exam one day after the other without a break – a break which I badly wanted to prepare for my clinical examination. But Allah knows best, Wednesday is my exam day. The morning before clinical exam, I could not take any food despite feeling very hungry for not eating even from the day before. I could not tolerate even a sip of water. Wretching is common in any clinical exam, therefore consuming any amount of food or drink carries a high risk of regurgitation or worse off, vomiting.

So I went to the exam with an empty stomach, a tachycardic heart, a laboured ventilation, and a mounting tawakkal only to Allah. I called my parents to ask for their prayers as well.

In the quarantine room before my longcase, I flipped through the topic ‘Nephrotic Syndrome’ from the Paediatrics Protocol, deep down hoping that I would NOT get a Paediatric case since Paeds was the least I prepared for. So I was brought to the exam hall, with “Allahumma yassir, wa la tu’assir” repeatedly chanted. When the screen was uncovered, there laid a boy with a Cushingoid face, “Hah, a Paediatrics case!”. Again, Allah knows best. And subhanallah, it was a case of Nephrotic syndrome, which I skimmed through just before the longcase. The memories of my previous Paediatrics exam came flashing back as I recalled Prof Wahab’s advices.

This poor boy had steroid-resistant nephrotic syndrome. The questions asked were directly from the Paediatrics protocol. Alhamdulillah Allah helped me answer the questions well. I also stressed on social aspect of the patient – his deteriorating academic performance, steroid side-effects on his daily activities, declining health, family support, financial problems, effect of the illness to patient and his family, etc. I think these had managed to capture the examiner’s attention.

Among the questions asked were:

- Pathophysiology – starting from loss of negative charges, etc

- Secondary causes of nephrotic syndrome

- Complications of nephrotic syndrome

- Complications of steroids

- Difference between stunted and arrested growth

- Surgical complication (Asked by Dato’ J) – spontaneous bacterial peritonitis

- Meaning of remission, relapse, frequent relapse, steroid dependant, steroid resistance, etc

- How to manage relapse

- Histological types of nephrotic syndrome

- Side effects of cyclosporin, cyclophosphamide

- Mechanism of action of cyclosporin, cyclophosphamide

Alhamdulillah, Allah eased my long case.

Professional Exam Episode I: My Road to the ‘D’

Please excuse me for the delay in sharing my Professional exam case which has ended more than 1 month ago.

Masih baru melayari bahtera rumahtangga,

Menghirup manisnya nikmat bercinta,

Dengan seorang jejaka,

Yang langsung tidak pernah dikenali sebelumnya,

Melalui satu-satunya saluran perCINTAan yang HALAL di sisiNya...

Maybe dah basi, but I promised myself I would share my experience in professional exam with others, and late is better than never. To begin with, I don’t have a proper study group like others. We met as rare as once a month or so. I could not commit to any study group due to other ‘co-curricular’ programmes I needed to attend almost every weekend, in Kuantan and in KL. The nights during my weekdays are mostly devoted to usrah, at least 3 times per week. Near the exam, I only managed to parasitically attach with other study groups, special thanks I bid for their willingness to accept this ‘parasite’.

I had to do most preparation for my wedding myself. I had to find the caterer, I had to buy and do the hantaran, make the invitation card, order and buy the doorgifts, buy and order my wedding attire, and about a week before professional, I had to buy a new lace for my wedding attire because the tailor wrongly sewed the original lace. 3 days before the big exam day, I was still searching for a house to rent in Selayang area for us to stay after our wedding (with the hope that I’ll get a placement in Hospital Selayang). Indeed, preparing for the wedding was fun and pleasurable, but thinking about the approaching professional exam gave me bees in the stomach...

More than once, being a mere human, I was engulfed by stress; I felt afraid and unready. No matter how far we tried to run away from the exam, the clock kept ticking, the professional exam kept chasing us from second to second. When I was conquered by anxiety, I just cried & turn to Allah and recite the Holy Quran. And He never failed to console me. I remembered once, I cried to my fullest and randomly opened the Quran, this was the first verse which my eyes caught, a relief from Allah:

(This is Allah's Way) regarding those who deliver the Messages of Allah and who fear Him, and fear no one else than Allah. Allah is Sufficient as a Reckoner [33:39]

“(iaitu) orang-orang yang menyampaikan risalah-risalah Allah, mereka takut kepadaNya dan tidak merasa takut kepada siapapun selain kepada Allah. Dan cukuplah Allah sebagai pembuat perhitungan...”

Subhanallah, Thank You Allah...!

The weekend before the exam (21^st & 22^nd May), I had yet another programme which I have to attend. It was a decision which tested my tawakkal, priority, faith and trust in Allah. I know well that Allah had promised, “O you who believe! If you support (the cause of) Allah, He will support you and make your foothold firm”. But knowing and believing are two different entities. When you believe, you need to prove it. Just like a delusion, due to the strong belief, patient will act upon it.

So although my professional exam preparation was hardly even 50%, I braved myself to go to the programme, with all the books and notes brought along, together with my forever supportive soulmates – iman, solehah, and kak mirah. When other people was fast asleep, I read my orthopaedic notes, topics I encountered for the 1^st time since Orthopaedics posting in 4^th year – yup, 2 days before the exam! And subhanallah, among the topics read during the programme was those which came out in my clinical exam. Alhamdulillah. Innallaha laa yukhliful mi’aad. Allah never breaks His promise!

Begitu sekalikah SIBUKmu?

Seperti biasa, di akhir-akhir posting, biasanya medical students bertungkus lumus memenuhkan logbook i.e. mengambil darah, memasang branula, memasang CBD, etc. Lebih-lebih lagi bila FNAC tak berkesempatan nak tengok, scope pun sikit, jadi kenalah compensate dengan blood-related procedure ni.

Bagi yang jujur dan yakin setiap perkara akan dipertanggungjawabkan, mereka akan berusaha mencari procedure sendiri sehingga stay sampai malam atau weekends. Tapi bagi yang kurang peduli apa yang bakal dijawab di depan Allah esok, mereka akan menipu dengan pelbagai cara, termasuk meminta H.O. sign ‘blank cheque’ agar dia boleh isikan procedure yang sebenarnya tidak ia lakukan.

Beberapa hari terakhir posting surgeryku, aku meng-hunting procedure sampai ke wad IM. Jam menunjukkan pukul 6.40pm. Seorang H.O. sedang bertugas dan agak teruja mempersilakan aku membantunya mengambil blood C&S, FBC, VBG etc. Selesai habis procedure, aku kembali ke kaunter utk mendapatkan sign H.O. tersebut. Dengan mask yang masih melekat di muka, tiba-tiba dia bertanya kepada staff nurse di sebelahnya,

“Eh, kat wad ni boleh solat tak? Aku tak solat Asar lagi ah”

Aku melihat jam sambil berpandangan dengan temanku. 7.00pm. Tak solat Asar lagi?

Aku pun dengan rela hati menawarkan “Dr, saya boleh hantarkan specimen STAT ni semua. Saya boleh tunggu kat bawah, Dr tak solat lagi kan,”

“Oh, baiknya ko. OK, FBC ni semua takyah tunggu, ko tunggu VBG je. Thanx eh”

Aku pun bergegas ke bawah utk hantar specimen. Jam sudah pukul 7.15pm. Syukur golongan wanita Allah kurniakan MC setiap bulan, jadi tidaklah aku risau pasal solat maghrib waktu tu. Sedang aku menunggu di lab, tiba-tiba muncul kelibat H.O. tadi, dengan cemasnya panggil lab assistant,

“Kak, boleh tolong trace tak result patient ni? Potassium dia high, 8.2 ni. Tolong checkkan balik boleh?”

Aku melihat jam. 7.20pm. Eh Dr ni dah solat Asar ke? Aku cuba berbaik sangka, mungkin tadi dia dah solat kejap sementara aku turun dan tunggu result patient. Tapi... alahai, masknya masih melekat di muka...

Aku cuba bayangkan. Nanti H.O., takkanlah takda masa langsung sampai solat 5-10 minit pun tak sempat? Seorang temanku, H.O. di Hospital Serdang nasihatkan, “Jadi H.O. ni kena selalu berwudhu’”

Rasanya bolehlah disimpulkan, hendak seribu daya... mungkin ada masa-masa emergency yang betul2 tak sempat, e.g. kalau kita tinggalkan patient utk pegi solat, patient boleh mati... Tapi itu mungkin situasi terpencil, kenalah jama’ maybe. Tapi kalau kebiasaannya, kitalah yang kena pandai curi masa. Kita kan tak tahu bila emergency tu akan terjadi, mcm tadi, tetiba potassium patient high pulak, jadi kalau ada masa yang ‘tak emergency sangat’, cepat-cepatlah tunaikan solat... Kalau dari awal dah ‘lenient’, tak set pun dalam mind masa utk solat walaupun 5 minit, kononnya sbb “Aku kan H.O., akulah yang paling sibuk dalam dunia”, jadi dengan mindsetting mcm ni, mungkin mudahlah utk seseorang tu tinggalkan solatnya...

Na’uzhubillah, semoga Allah pelihara kita... semoga kita semua menjadi hamba-hamba yang sentiasa cuba utk taat dalam menunaikan hak Tuannya, dalam situasi apapun jua...