Thursday, January 16, 2014

Year 5 Exempting Exam; Univ of Manchester

Assalammualaikum.
My exempting exam is Day 2, in South.

I tried to remember as much of the wordings of the questions as I could.
I know it is easier to practice when we know the question structure.
To maintain the confidentiality, where possible I will not disclose the patient's gender as well.

Station 1

Please examine this patient's cardiovascular system.
You may need to tailor your examination according to your findings.
Please tell the examiner what you are looking for and what are your findings.

The patient's blood pressure is normal.
An ECG taken last week is provided for you to refer to.


Ok, this was apparently an AF station.
When I felt the pulse, at first I thought it was irregular.
But when I tried to tap the rhythm with my head, it became regular. Haih~
So the chest was clear, I could not find any other signs.

When I was given the ECG, it was clearly AF.
But the examiner challenged me saying I did not pick up the AF while examining the patient.
But he wasn't mean. He asked why wasn't I able to get the irregularity of the rhythm.
So I mentioned the patient might be having paroxysmal AF and when the bell goes off, I managed to say "because he has been rhythm controlled!!" literally while walking out of the station.



Station 2

This patient had a cerebrovascular accident (CVA) affecting one or both arms.
Please examine the patient's arms.
Please tell the examiner what you are looking for and what are your findings.

At the end of the station, the examiner will ask the nerve and muscle groups that are affected.

OK.
So this is quite a straightforward upper limb neurological examination.
I performed only the motor bit, I did not do sensory or coordination.
It was UMN signs on the left arm.

For the muscle groups and nerve, I managed to say deltoid, biceps, triceps, anterior compartment of the forearm, posterior compartment of the forearm, and lumbricals for shoulder abduction, elbow flexion and extension, wrist flexion and extension and fingers abduction and adduction respectively.

The examiner did not prompt me of the nerve supplies. I am not sure if that means she is satisfied with my examination/answers but to be fair, I only had like 30secs left.

My friend said he would have done the coordination and some sensation as well.

But I did offer saying I would to do sensory of the upper limb and full neuro of lower limb to see if the CVA has affected the legs as well.


Station 3

You are the Foundation Year doctor in the general practice.
This is Natasha XXXX, a 28 year-old woman who has recently given birth and is now breast-feeding.
She is here for oral contraceptive pill.

Please discuss the options available for her.

It was an SP.
Since the question specifically mentioned ORAL PILL, it became a lot easier.
Pt is breast-feeding so we cant give the oestrogen bit, and I don't have to explain all the implants and coils. Only PILL.

Pt asked about:
1) Side effects - irregular bleeding.
2) Immediate protection - yes if taken on day 1 menses.
3) What happens if she vomits aft the pill - if within 5 hours, u may need to take another dose. Check the leaflet in the box.
4) Does it protect against STI? - No. (I cant understand why she ask this. She's married! Ok, being judgmental here. Anyway...)
5) Why can't she go back to her microgynon (a COCP) - bcos oestrogen affect breast milk production.



Station 4

This is XXXXX. She was admitted 4 days ago for severe iron deficiency anaemia.
She was given blood transfusion and an upper GI endoscopy was normal.

She is going to be discharged today.
A colonoscopy has been arranged for her as an out-patient next week and she has been given sachets for bowel prep.

Please discuss with her about the discharge issues and the colonoscopy.

Woohooo...
New type of Q from the university!
Discharge planning has never came out before.
When I knew it came out in Day 1, I was so surprised and luckily I read about it.
Or else I would not know what to say.

Well basically just ask how she is feeling, is she ready to go home..
Who is at home with her - husband.
It was all okay until I asked, "Is your husband well?"
Then only the drama begins...
"Oh..my husband has severe Parkinsons......."

She asked about:
1) I am the patient, but I don't need carer. My husband will need carer. Can the ward arrange carer for my husband? - I dont know the exact ans for this.
2) What will the social services do? - plan care package, tailored to individual needs.
3) What does OT do? - come to ur house and see how they can help with the condition of the house to make it easier to live in.
4) What is the bowel prep? - STRONG LAXATIVES to empty your bowel.

I FORGOT TO ASK ABOUT MEDS! Haih~
DC planning will always include meds changed in hospital stay.



Station 5

This patient has pain in the right hip.
Please examine the patient's hip.
Please tell the examiner what you are looking for and what are your findings.

Again, a straight forward ortho exam.
My patient was a medical student I think.
He understood all my instructions. So nice~

Was asked by the examiner what is the diff with true and apparent leg length.



Station 6

This patient have difficulty passing urine.
Please take history to find out how it was diagnosed, include discussion about complications and any plans for definitive treatment.

This was a REAL patient, without scripts.
I don't think I can divulge the case here, since it's supposed to be confidential.

Enough said that I think UoM is trying to test us on how we communicate with actual patients.
All this while we are tested on our ability to EXAMINE real patients, but never actually TALK to them.
So I really felt like those days where I spend a very long time talking to patients in the ward, that most of the time they didn't understand what you asked and went completely off-tangent.
Sometimes you can't even understand what the patient said.
It was exactly that same feeling just now - the difference is there is someone watching you from behind and ticking the boxes.

My pt knew quite a lot of things - it was almost just a case of me sitting there listening to his story.


Station 7

This patient has pain in his/her legs while walking.
Please examine the arterial circulation of the patient's leg.
Please tell the examiner what you are looking for and what are your findings.

There is an Duplex provided. You need to use the probe.

At the end of the examination, the examiner will ask what your diagnosis is and next management plan.

Again, a straight forward PAD exam.
This was a real patient.
I cant feel pt's pulses - all the way till popliteal.
But apparently no one couldn't.
But the arterial flow via Duplex was very clear.

Examiner asked Dx: PAD
What to do now: Straight leg raising, as it is one of my differentials. ABPI. Fasting glucose and lipids.


Station 8

Please examine this patient's hands.
Please tell the examiner what you are looking for and what are your findings.

At the end of the examination, the examiner will ask your diagnosis and the conditions associated with this findings.

When I was outside the station, I was very happy thinking it is going to be a RA hand. I hummed pulmonary nodules, pulm fibrosis, vasculitis etc to myself.

But when I got in and started inspecting - turns out it wasn't RA.
At first I thought it was trigger finger but then I realised this is Dupuytren's!

So I did the hand exam just like I would for RA. But it was very hard because patient's hands were in severe fixed flexion deformity.

Qs: What is this? - Dupuytrens
Where can u find this? - idiopathic, cirrhosis bla bla bla
How would u say the severity of this contracture? - moderate
Rx? - reconstructive fasciotomy



Station 9

You are the FY in A&E.
This patient has blurred vision last week, but it has resolved since.

Please examine the patient's visual field and perform fundoscopy.
You are not required to examine the visual acuity and pupillary reflexes.

Please tell the examiner what you are looking for and what are your findings.
At the end of the examination, the examiner will ask for your findings, and diagnosis.

Again, straightforward eye exam.
Examiner very nice~~~

All normal, I can't visualise the optic disc.
Was asked:
1) Present ur findings
2) If the Hx is blurred vision for one week and has resolved since, what do you think is happening? - Optic neuritis.
3) Cause? - MS
4) Ok, if it is MS, what findings will u expect? - Central scotoma, pain on eye movement and I just simply said blurred optic disc. Truth is, I dont know! What is the findings on fundoscopy in optic neuritis? I forgot. You better check.


Station 10

You are the FY in A&E.
This patient has come in with acute chest pain.
Please take a focussed history and perform a focussed examination on the patient.

Please tell the examiner what you are looking for and what are your findings.
At the end of the examination, you are required to present your findings, diagnosis and management plan.


Acute chest pain.
Pt had this a few times for the past 2 weeks - all on exertion.
Usually it goes away with resting. Today the pain persist even after 2 hrs.

Obs given were all normal. I cant remember if they gave respi rate - sorry.

Examiner was mean.
Didn't even respond to me, I asked if I can get the observations and he pointed his CHIN to the wall. I didn't understand at first.
Then only I realised that the set of observation is pasted on the wall!!


Station 11

You are the FY in general practice.
This is Mrs XXXXXX.


Please take a history from her to find out the problem.
In the last 2 minutes the examiner will ask for your diagnosis and management plan.

I knowww....the question was so unhelpful..
I sat outside banging my head on the wall. Nothing to prepare.

Anyway, this pt kept saying she was very embarrassed to talk about this matter.
I thought she has dyspareunia or PCB or something.
Turns out she has heavy menses bleed.
Well to be honest, by this stage of med school, I am no more embarrassed about heavy menses bleed.

Remember ICE ICE!
Pt's concern was cancer - as usual...
I mentioned that cancer of the womb usually happens to older women, it is not the first thing that came to my mind for a woman of her age. But we will still do all the necessary investigations. She seemed very happy for that.

Examiner asked:
1) What pt has - menorrhagia
2) Possible causes - DUB, bleeding disorder.
3) Mx - bloods: FBC, U&E, TFT, Prolactin. What else did I say jz now? Forgot adi. USS to check endometrial thickness.


Oh...I'm getting more tired of typing now..

Station 12

You are the FY in general practice.
This is Mrs XXXXXX.

She has come today because she is feeling very anxious.
Please take a history from her.

In the last 2 minutes, the examiner will ask your diagnosis and the reasons.

Generalised Anxiety Disorder with secondary panic attacks.
Did some MSE but not risk assessment.
I wanted to explain the possible Mx but pt cut me off and jz said she wants leaflet. Weird..


Station 13

You are the FY in general practice.
This is Mrs XXXXXX.

She is a regular patient in the practice.
She usually sees Dr Rayburn.
Dr Rayburn is on leave today hence she has booked in to see you.

Please talk to her and discuss the reason of her attendance today.

Jz by reading, I know this is ethics adi...
Pt said she has STD, she doesnt want me to put this on her note bcos Dr Rayburn will know about it. Dr Rayburn is a close family friend and she doesnt want her husband to know.

I said I need to write about our consultation, it is a legal requirement.
And Dr Rayburn and I are duty-bound to keep the confidentiality. She wasn't convinced.

I asked how did she know she has STD - she said because she vaginal discharge.
I said she can go to GUM clinic to get treatment, everything there will be confidential. No letter will be sent to us. She said can I then not write anything about today, because she wants to go GUM. I said cannot, I have to write it down.
She said then no point she go GUM, I will write anyway.
I told her I don't know if she has STD. I have not tested her yet. So I cant write she has STD, I can only write that she suspects its STD.

Anyway at the end pt agreed to go GUM and did not make any trouble anymore. I managed to advise safe sex until complete treatment. She said it's gonna be very uncomfortable anyway with the discharge. Lululz~


Station 14

You are the FY doctor in the ward.
You are required to administer the first dose of IV medication for this patient that has been prescribed by a senior member of the team.

This medication is usually given as a slow infusion but for the purpose of this examination, you are to give it in a bolus injection.

You will all learn this in OSS block.. So lazy to write. Anyway, got Px chart but no BNF or product leaflet. Confirm with the examiner to mix the med with saline or water for injection and how much to mix it with.


Station 15

You are the FY in A&E.
This is a patient who came in because he vomited blood.
He is very upset.

Please take a focussed history and discuss the need of admission with this patient.
You do not need to examine him.

Weird Hx. At first I didn't know what was it at all. It didn't sound like ruptured varices (but pt is a heavy drinker) because pt shd not be able to talk to me if it is varices.
Didn't sound like Mallory-Weiss tear either. He vomited a pint of fresh red blood this morning! No stomach content. No assc pain, just some dizziness.

Vomitted once 7-10days ago, but small amount.

Halfway through I found out that he regularly takes Nurofen 2tabs 3x a day, every day.

So at last I can say we suspect you are bleeding from your gut. We may need to keep you in. And he was unhappy because his vry busy at work. But it didn't take him long to agree - because I said we need to pass scope in to see what actually is happening.



Station 16 AAAhhhh.. last one~

You will be given a case history of a patient together with blood results, ECG and CXR.
You have minutes to look at the information provided.

You should then tell the examiner what was going on and your next management plan.

Bloods: all normal apart from 8.5kPa pO2 on ABG.
ECG: AF
CXR: some say collapse, some say pneumothorax. Whatever...

I dont think I did well in this station.
Thank God it was my last one. I would have felt very stupid otherwise, while doing the other stations.


With that, I bid goodnight~

Hope this helps!


-Because life is a test-
-AkMaR-
http://nur-akmar.blogspot.com

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