test!

i had my end-of-medicine-posting-test on monday this week, which was rather nothing short of traumatic.

first of, i had a funky hot russian lady as my tester (who looks fabulous and oozes fabulousness out of every pore! even her clogs were so funky i wanted to faint at her feet), but sadly, i had a hard time understanding her accent. uh oh :(

next thing - she's a gastro attending, so i thought gastro would be alright, given that it's my pet topic! sadly, it wasn't to be :(

my patient was a previous healthy young gentleman, who's a permanent resident in my country, working for the railway system.
he presents with:
1. fever of 1 week, 40 deg. worse at night and spiking
2. diarrhoea of 1 week, 5 times a day, watery and of normal colour
3. vomiting of 5 days, non-bilious non-bloody. unable to keep food down. up to 11 times a day
4. jaundice of unknown length, recognised by his wife on the 3rd day of fever "eyes turning yellow"

past history of pulmonary TB, treated for 6 months and deemed cleared. nil other history of note. no previous surgeries or blood transfusions.

family history of diabetes mellitus (type 2) and hypertension on his mother's side. father has a prosthetic valve inserted (unknown reason). uncle had liver cancer.

not currently on any meds, no recent illness, no known drug allergies.

has been residing in my country for past 4 years, wife and child came over 2 months ago.
not stressed about work in any form over last 2 months.
previous sexual history except for ex-wife (now divorced), and she is well.
no contact or travel history, colleagues are all fine.
no recent ingestion of seafood.

so there i was, heading happily to a diagnosis of hepatitis A (most common and transmitted faecal-orally), with differentials of cholangitis and other forms of hepatitis.

and stupid me, only notices the PICC line in the last minute, and upon asking about it - it is revealed he had a liver abscess, went for I&D and is now on iv antibiotics.

ARGHHHHHHHH!!!!!!!!!!!!!!!!
and all this was revealed in the last minute of my test - my whole test is now changed from a diagnostic problem to a management one. and i know shat about liver abscesses because they're usually managed surgically where i come from (and surgery is my next posting so obviously i haven't read up on liver abscesses AT ALL).

and of course, i got royally screwed over by my funky fabulous examiner, who must have thought i was an idiot for not knowing a thing, plus my friend (who took the test with me), managed to get an easy case of painless jaundice (diagnostic problem - the actual answer was a cholangiocarcinoma! goodness). :(
strike one :(

strike 2 came when my friend had a 6th nerve palsy with some conductive hearing loss in a young lady, and she was unable to even come up with a proper list of differentials for the causes of an abducens palsy. i was biting my tongue so hard i thought it would bleed, and i felt like the small kid in class who desperately wants to answer questions! :(

and my case? an elderly man with:
1. diffuse large B cell gastric lymphoma (cachexic looking)
2. pulmonary fibrosis (but not cushingoid in appearance thanks to his cancer)
3. infective exacerbation of his pulm fibrosis (there's consolidation, coarse crackles)
4. bilateral pleural effusions
5. a secondary spontaneous pneumothorax (so it's now a hydropneumothorax on one side)
6. a chest tube with fluid inside

so my diagnosis was:
pulmonary fibrosis with superimpose infection, and bilateral pleural effusions.

she was so pissed/miffed/angry/etc that i missed the pneumothorax, and she said she'd initially rejected this case for exam because she thought it was too easy with the chest tube.
i don't think she for one moment remembered that chest tubes drain BOTH effusions and pneumothoraces, and if she'd bothered looking at the chest drain - she'd have noticed BOTH air and fluid inside.
instead, all i got was her ranting about how pneumothoraces are a medical emergency etc etc etc and how i could have missed that is beyond her and i would make a totally unsafe intern. :(

then she marched me over to the x-rays to have a look, and when i pointed out that it wasn't a tension pneumothorax (no tracheal deviation, no mediastinal shift, no diaphragm depression), she got all huffy and pissed off with me even more and said all pneumothoraces were medical emergencies regardless of whether they were tension or not. (is she right?)
so, strike 2 :(

my second short case was a man with cervical myelopathy, presenting with frequent falls.
he had spastic weakness of both lower limbs, hyper-reflexia and ?upgoing plantars (couldn't tell because he was really ticklish and kept withdrawing).
upper limbs - slight hypertonia, brisk triceps, normal supinator and biceps reflexes.
so i thus presented him as having cervical myelopathy at the level of C7 due to normal biceps reflex and exaggerated triceps.
she wasn't happy about my ?plantars, saying that it was obviously upgoing (but the guy kept retracting his foot! so how can you really be sure?), and she said that the upper limb reflexes were brisk as well, and that i didn't do it correctly. oh well. but i did manage to answer all her questions on cord compression etc (all thanks to ortho!!!! :) so it wasn't a complete waste of time! after all!) and spinal shock and bulbocavernosus reflex. YAY! :)
she did concede that my neuro is far better than my respi exam. :\ but at least i gave her a decent impression. whew :)
(so, NO strike 3!)

my friend's last case was a dead easy bronchiectasis, coarse crackles heard all over the lungs, marked clubbing, chesty cough and purulent sputum.

after the test was over, she did admit that i'd gotten much harder cases than she did. but i cant' help feeling it wasn't so fair :(

oh well i hope the real exams won't be this hard! :(