Medicine shorts

had medicine shorts yesterday... think i got pretty standard cases. but it's the nerves that made me stumble here n there. a few glitches but i think i can pass la...

waited 2 hours for my turn cos i was in the last batch (4 batches altogether!!). My profs were generally quite nice peops i thought... gave me lotsa hints and help.

Case 1: examine the cardiovascular system.

i went through all the motion... din miss any steps... examine examine examine until i wanted the patient to sit up and they stopped me.

Prof: tell me what you found so far.
Me: irregular pulse. i hear a pansystolic murmur loudest over the apex of grade 3/6 intensity and radiates to the axilla. there was no parasternal heave, palpable p2 or loud second heart sound. i think this patient has mitral regurgitation with atrial fibrillation but no signs of pulmonary hypertension or congestive cardiac failure. (i did not say all these smoothly la... was erming and pausing here n there...)
Prof: what kind of irregular pulse did u feel? (meanwhile, the other prof was feeling the pulse of the patient.)
Me: (oh oh... am i wrong?) i felt an irregularly irregular pulse.
Prof: would you like to feel the pulse again?

(felt again... shucks!! why is it regular now?)

Me: (sheepishly) on feeling the pulse for the 2nd time, the pulse is regular and the patient does not have atrial fibrillation.
Prof: ok... so what do you think are the causes for this patient's MR?
Me: Because he is an elderly gentleman, a possible cause is rheumatic heart disease.
Prof: (asked something abt why the association of RHD with elderly)
Me: said some stuff abt RHD associated with streptococcal infection and nowadays it's adequately treated and hence, the younger generation don't get chronic sequelae like RHD.
Prof: (looked half dubious half satisfied) ok... so what other causes? if i say this is of acute onset?
Me: acute myocardial infarction with papillary muscle dysfunction (should've said rupture too)
Prof: (looks more satisfied now) ok.. let's go!

Case 2: Examine the peripheries and abdomen.

examine examine examine... quite ok... but liver edge was quite difficult to feel.
Percuss percuss...

Prof: you're percussing so hard that it's going through the bed!!
Me: (laughed... properly stuck out my tongue too) sorry prof... (then went on to percuss more softly... i tot they wanna hear the percussion note loud and clear?!?!)

they stopped me when i just finished palpating the spleen with patient supine.

Prof: ok... tell me what you found.
Me: scleral icterus. bruising over cubital fossa. no stigmata of chronic liver disease. on examination of abdo, scar at the suprapubic region.
All 3 profs: SCAR?? (and they started peering but din say anything cos there was really a scar what! haha!)
Me: hepatomegaly... liver edge blahblah... liver span blahblah... abdo distension...

(prof was examining the abdo while i was presenting... *and stuttering*)

Prof: what do you think is the diagnosis of this patient? (does that mean my signs were correct? hope so!!)
Me: hepatocellular carcinoma with cirrhosis, metastatic disease of the liver possibly from GI origin... severe right heart failure with liver congestion
Prof: do you see that often?
Me: erm... no... not really.
Prof: ok... let's move on.

Case 3: Examine the upper limbs.

Did the screening test... stretch out arms, open and close fist, check for pronator drift... NOTHING!!! die... how?!?!
continued with tone... NOTHING... maybe some hypertonia but no cogwheeling? why why?

Prof: hmm... why dun we walk the patient then you examine the upper limb after that?

patient walked with a high-stepping gait. a bit like circumduction too. a bit unsteady too. HUH? what's happening?

Prof: ok... so what would u like to do now?
Me: check the reflexes... (decided to hantum bola)
Prof: (disapproving look) dun you think he was a bit unsteady?
Me: OH! i would like to look for cerebellar signs.

(do do do... not bad... presented hand signs. said wanna look for other cerebellar signs... like nystagmus, dysarthria, leg signs... prof then said to check the eye and speech.)

Me: aahh... boleh cakap "satu, dua, tigga..."
(patient gave blank looks...)

Prof: (started asking patients a series of questions in malay... so nice right!!)
Me: thank you prof. this patient has nystagmus when looking to the right, and has some slurring of speech.
Prof: so is this unilat or bilat cerebellar problem?
Me: unilat... because.. blahblah... causes include...
Prof: so if stroke, what else do you wanna do?
Me: cranial nerves, sensory testing of lower limbs... to look for lateral medullary syndrome.
Prof: What is lateral medullary syndrome?
Me: constellation of signs which suggest lesion is at blahblah... features include blahblah...
Prof: what particular syndrome?
Me: (din get what he was asking...) erm... wallenberg syndrome?
Another prof: it's ok... tt's for distinction.
Prof: Horner's syndrome!
Me: oh... (hmph! i knew that!! if only he asked his question properly... haha)

haha... think as what everyone says, it's really the nerves that kill you in the end. doesn't matter even if i know the 10 causes. when i'm nervous, the weirdest things come out of my mouth. in the end, all u use are the reflex actions rather than the brain cortex to answer questions and perform.