Friday, August 07, 2015

The Final Professional Examination

I would like to share my experience sitting for this BIG exam. This post is mainly for my beloved juniors, to serve as their future reference.

DAY ONE 

Paper I : PMP (Internal Medicine and Paediatrics)
100 marks
Exam Hall
8.00 am - 10.00 am

Medical PMP was about a man presented with shortness of breath, with underlying atrial fibrillation, diabetes mellitus and hypertension. He had vomiting, epigastric pain and  later became drowsy with hyperrreflexia and clonus. Investigations revealed that he had hyperthyroidism.

Basic questions were asked, like list the patient's problem, history you would like to elicit, physical examination and expected findings, complications of his problems etc. You must be able to understand patient's problem and anticipate what is going to happen next.

In the exam, I failed to explore his atrial fibrillation in the first trigger. So I missed to write down thyroid storm as a complication in the next trigger. During the last trigger, only then I realised my silly mistake.

Paediatric PMP was about a child presented with fever and rash, associated with red conjunctiva, red tongue, cervical lymphadenopathy. ECHO revealed endocarditis and minimal pericardial effusion.

Fever and rash is common in paediatrics, so you must know the differential diagnosis, signs and symptoms of each disease. One of the questions was, how did this child develop heart problem?

I don't really like pathophysiology questions because I am weak in that area. So when I were asked that, I answered based on what I knew. Since Kawasaki Syndrome is inflammation of blood vessels, it can affect coronary arteries bla bla bla. Just write down what you can think of. As long as it doesnt sound rubbish, you should be alright.

Paper II : PMP (O&G and Surgery) 
100 marks
Exam Hall
10.30 am - 12.30 pm

Obstetric PMP was about a post-date pregnant lady who later ended up with caesarean section due to cord prolapse.

Important questions in obstetric that you want to elicit? What is your initial management? Interpret CTG and what are you going to do next? Postnatal management?

For me, the most frustrating part was the CTG part. It showed Type 1 deceleration pattern and yet, I wanted to push the mother straight away to operation theatre. When I received the the last trigger, I was like, yeahhh she didnt have amniotomy performed yet! Grrr.

Surgical PMP was about a man presented with per rectal bleeding. He was diagnosed to have rectal carcinoma.

For this one, know the common cause of per rectal bleeding. You must have at least an idea on how to manage rectal carcinoma. The investigations, chemotherapy, radiotherapy, surgery and all.

In the ward, the patient asked you on how to perform prayer. What is your advice? Islamic Input question was a bonus and I love that. It was like 4 marks for that question, and yet I wrote like it was worth 10 marks. If only I had more time, I would have written longer hahaha

Paper III : Data & Picture Test
20 questions
Dissection Hall and Multipurpose Hall
Group 1, 3 (2.30 pm - 3.30 pm)
Group 2, 4 (3.30 pm - 4.30 pm)

Regarding OSPE, all I can say is that, you have to have the ability to think really quick. We were only given two minutes for each station, so yeah. Chop chop.

Among the stations I can remember:

1. CXR showing honeycomb appearance
2. XRay femur typical of osteosarcoma
3. Hemorrhoids
4. Nasopharyngeal carcinoma
5. Funduscopy showing retinal tear/detachment?
6. Family tree, asking about pattern of inheritance
7. Forceps
8. Odd Ratio

When I looked at the Odd Ratio question, my mind quickly went to Dr. Razman. 'Sorry Doctor, I just cannot think of an answer...' Questions on forceps were easy, but since the time was limited, I only answered half. 6 pre-requisite of forceps, I totally know that! Prof. Hamizah was there collecting my answer sheet, and I was like, 'Huhuhu sorry Prof I have disappointed youu..'


DAY TWO

Paper IV : MCQ I & OBA I (Medical)
60 MCQs and 10 OBAs
Exam Hall
9.00 am - 11.30 am

Paper V : MCQ II & OBA II (Surgical)
60 MCQs and 10 OBAs
Exam Hall
2.00 pm - 4.30 pm

Medical : Int. Med, Paeds, Psychi, ComMed, FamMed
Surgical : Surg, O&G, Ortho, Ophthal, ORL, Anaes, Radio, IRK

The most important thing is to manage your time well. I had to rush in answering the first MCQ paper because I spent too much time focusing on some of the questions. Personally, I think surgical paper was easier than the medical one.

They can ask you anything, really.


DAY THREE

Long Case
Level 1 JHC
8.00 am - 5.00 pm

I was in Group 8, so I got the evening session. At 2.00 pm, we were called and given a tag number to be worn, with A4 papers on a clip board. Mr. Chan walked us to our patients located in respective room.

When I pushed the curtain aside, there was my patient. A female patient, thank you God. In my mind, I was thinking that this may be Gynae or Medical case!  

I introduced myself to her and started clerking. There was a female staff sitting at the corner, observing and chaperoning. The stopwatch was ticking. I had one hour to take history and do physical examination.

Me : Makcik, makcik dari rumah ke dari ward?
Pt : Dari rumah. Makcik baru je datang pukul 1 tadi...

Me : Makcik ingat doktor bahagian mana yang panggil makcik untuk datang hari ni?
Pt : Makcik tak ingat nama doktor, tapi dari Gastro klinik..

Me : Makcik ada apa-apa masalah ke sekarang?
Pt : Hmm tak ada.. cuma dulu makcik ada masalah hati.. sekarang dah ok. Doktor kata hati makcik dah jadi kecik..

Me : Oh.. mata makcik kuning ni sejak bila?
Pt : Kuning ye? Entah.. tak perasan pulak makcik..

Me : Makcik, pernah tak perut makcik jadi besar, air kencing makcik bertukar warna macam warna teh, najis makcik warna putih pudar?
Pt : Dulu perut makcik ni lagi besar.. sekarang kurang sikit... Lepas tu baru baru ni pusat makcik macam terkeluar...

I was thinking of putting jaundice as my chief complaint, but since patient did not notice it, I took abdominal distension instead. And guess what - she had umbilical hernia! 

If your patient does not have any complaint and tell you that she comes for exam, try to ask what's her current problem, what does she have now. She may have abdominal mass, or abdominal pain or abnormal urinalysis - just take that as the chief complaint.

As for my patient, Chronic Liver Disease it is! So I tailored my history based on the disease. I made sure that I performed physical examination earlier so that I wont miss anything. When you get a diabetic patient, don't forget to ask for funduscopy from the staff ok!

I had 30 minutes left to organise my history and physical examination. I realised I forgot to check other systems, so I quickly did respiratory, cardiovascular and neurological examination. In the last few minutes, I asked her on smoking and alcohol status.

Teet teet teet! Time's up!

All of us were brought to another area. We were told to sit and wait outside the room according to our number. I glanced at the door and looked at the examiners' names.

Prof. Dr. Shahril Yusof (Ortho-UMS)
Dr. Ariff (Medical-IIUM)
Dr. Mohamad Nasser (Paeds-IIUM)
Dr. Hanisah (Psychi-IIUM)

A few minutes later, Dr. Mohamad came out and called me to go inside. I took a deep breath in and out - and go inside. Bismillah..

The external examiner, Dr. Shahril asked for my name and matric number, introduced every examiners and asked if I had any problem in clerking the patient. I said no problem, so he asked me to start presenting.

Assalamualaikum doctors. I am presenting - Puan Rohaya, a 57-year-old Malay housewife with underlying chronic liver disease, diabetes mellitus and hypertension, presented with 3 years history of abdominal distension and 2 years history of umbilical hernia.

She was diagnosed to have chronic liver disease in 2012, presented with jaundice, tea-coloured urine and abdominal distension. Hepatitis B/C/HIV results were non-reactive. She does not smoke or drink alcohol. There is no family history of liver disease or malignancy. OGDS, ultrasound, CT scan and liver biopsy were done. However, she did not know the result of any of the investigations or the diagnosis. She was told by the doctors that her liver had become smaller, in which I suspect it's liver fibrosis.

From 2012 to 2015, she had been admitted to the ward multiple times. She had suffered complications of chronic liver disease such as esophageal varices (2x banding were done), anemia (up to 4 pints of blood transfused every admission) and umbilical hernia. She did not have any other complications such as hepatic encephalopathy or hepatorenal syndrome.

Regarding diabetes mellitus, she was diagnosed in 2011 during screening where her blood glucose level was 20 mmol/L. She was started on T. Metformin for 3 years, and then changed to SC Insulin last year. She did not have any complications such as retinopathy, nephropathy, neuropathy, vasculopathy or immunopathy.

Regarding hypertension, she complained of ocassional giddiness and epigastric pain.

Currently, she complained of abdominal distension and umbilical hernia, associated with jaundice and tea-coloured urine. She did not have any symptoms of anemia such as shortness of breath, palpitation or syncope.

On physical examination, she was alert and comfortable. Vital signs were normal. She had mild jaundice but not pale. She had ascites with umbilical hernia. There were no other signs of chronic liver disease noted. Funducsopy was normal. Other organ system examinations revealed normal findings.

Next, SUMMARY of history and physical examination. Don't forget this!

I was about to go straight to investigations when Dr. Ariff suddenly stopped me and asked external examiner, 'Shall we go see the patient?'

I was like, 'GO SEE PATIENT?!!!! OHGODDDD' But I acted cool, of course. Palpitations and sweating you name it, I had it all hahaha. Relax Nurul Ain, you can do this! I motivated myself. I prayed hard that everything will turn out okay.

Since the patient went out for prayer, the examiners asked me questions. Among the questions asked were:

1. Causes of chronic liver disease that you know of?
Viral hepatitis, Alcoholic hepatitis, Wilson's disease, Autoimmune disease

2. Complications that this patient have?
Esophageal varices, anemia and umbilical hernia

3. What type of anemia you expect this patient to have in FBC?
Anemia of chronic liver disease (normochromic normocytic)
Iron deficiency anemia due to chronic blood loss (hypochromic microcytic)

4. If this patient had thrombocytopenia, what is it due to?
Dr. Mohamad asked me this, I had a thought block and could not answer. After exam finished only then the answer came - due to hypersplenism, destruction of platelet! GRR.

5. If OGDS revealed esophageal varices, how do you manage?
Inject adrenaline?, banding and give IV Octreotide

Then the patient came to the bed. I was asked to show signs of chronic liver disease. Dupuytren's contracture, clubbing, palmar erythema, injection marks, tattoos, jaundice, parotid swelling, spider naevi, ascites, pedal edema.

6. How does palmar eythema look like?
Erythema of palmar surface with central pallor

7. How does spider naevi look like?
Central arterioles with surrounding capillaries

Dr. Mohamad then asked me, does this patient have splenomegaly? I answered slowly, Umm.. from my examination.. this patient..does not have...splenomegaly. Dr. Shahril then asked me to examine Traube space.

It was dull. Oh great. I totally missed that. 'Sorry doctor...' I said.

8. What is decompensated liver failure?
It is when the patient had symptoms of hepatic encephalopathy such as drowsy, changing in sleeping pattern, loss of consciousness..

9. What are the signs you can see in the patient?
Flapping tremor, reduced GCS, ascites

10. Do you know any scoring system?
Yes! Child Pugh score. It has A, B and C. The parameters are ascites, hepatic encephalopathy, albumin and.... (slowly I said) LDH?

Dr. Hanisah giggled. I totally forgot one more parameter haha. Then Dr. Ariff said, bilirubin.

11. If this makcik asked you what kind of diet she should take, what would be your advice?
I would advice her to take low protein diet

12. Are you sure?
Yes. Because high protein diet will worsen hepatic encephalopathy.

That's all. Thank you. I let out a sigh of relief. Alhamdullilah. I thanked the patient and went back to lecture hall, took my bags and went home.


DAY FOUR

Short Case
Level 1 JHC
8.00 am - 5.00 pm

At 2.30 pm, Group 8 was called and given a number, then went to respective room.

I looked at the examiners' names:
Assoc. Prof. Dr. Oteh Maskon (Med-UKM)
Dr. Fatham? (External Examiner)
Mr. Zamzuri (Ortho-IIUM)
Dr. Muna (O&G-IIUM)

First case with Dr. Muna : Uterus smaller than date 

Instruction : This is a pregnant lady with underlying beta thalassemia minor. Examine her obstetrics.

This is a medium build lady, lying in supine position, comfortable and not in pain. On inspection, abdomen is distended with presence of gravid uterus. There is a 23 cm vertical surgical scar on left upper abdomen, most probably due to splenectomy. There is no striae gravidarum or linea nigra seen.

On palpation, symphysio-fundal height is 32 cm. There is a singleton fetus lying in longitudinal lie with cephalic presentation. The fetal back is on maternal left side. Head is 5/5th palpable, not engaged. Estimated fetal weight is around 1.6-1.8kg. Liquor is adequate.

I did not comment on the fetal heart because I could not hear anything using Pinard!

1. If this patient's POG is 35 weeks, what is your impression?
My impression would be that the uterus is smaller than date

2. In this patient, what is the cause of small for gestational age?
It can be due to mother having chronic condition such as anemia, thalassemia or preeclampsia.

3. What investigations do you want to do?
I would like to do serial ultrasound scan and plot fetal growth chart.

4. What do you want to see in ultrasound?
There are 4 parameters we can look at such as biparietal diameter, head circumference, abdominal circumference and femur length.

5. What else do you want to do?
I would like to do fetal Doppler ultrasound to check the fetal umbilical artery..

Teet Teet Teett - 10 minute's up!

We then went out of the room to another section - ORTHO wehh! *shudder*


Second case with Mr. Zamzuri : Volkmann's ischemic contracture

Instruction : Examine this patient's right lower limb. You can do running commentary.

Me : First, I would like to ask the patient to walk to assess his gait.
Mr. Zam : Yes, you may do that.

I asked patient to walk to and fro. This patient has high-stepping gait, I told Mr. Zam.

Mr. Zam : Okay inspect this patient's leg. What do you see?
Me : He has muscle wasting of right lower limb. There are three scars seen. The two lateral scars most probably due to fasciotomy. The other scar is a surgical scar, maybe surgery for internal fixation.

Mr. Zam : What else? Look at the patient's toes and heel.
Me : He had contractures of all toes. He had one scar at big toe (I think it's probably due to K-wire insertion but I wasnt so sure), high arched foot and callous.

Mr. Zam : I give you 2 minutes to do what you want to do to this patient.
In my mind, I remember Look, Feel, Move. So I felt for tenderness and tested his power. I checked for sensation using my finger.

Mr. Zam : Is that how you test for sensation?
Me : Ohhh *quickly take out the stick while cursing myself* and test for sensation.

Mr. Zam : Ok. So what is your full diagnosis?
Me : This patient had history of mid tibial fracture with fasciotomy secondary to compartment syndrome, with deep peroneal nerve palsy

Mr. Zam : So how about the contracture?
Me : Volkmann....ischaemic contracture?

Mr. Zam : Yes. Volkmann ischaemic contracture. Teeett Teett Teet. Ok finish.  

Footnote : Mr. Zam was very helpful I felt like hugging him! If I were left to examine the patient alone, I wouldnt know what to do! Thankfully he guided me along the way. Thank you doctor!


Third case with External Examiner : Thalassemia

Dr : This is Syazwani. Tell me what do you see.
Me : She has mild jaundice. She seems smaller than her age. She has thalassemic facies. She has short stature.

Dr : What are the causes of short stature?
Me : Syndromic such as Turner syndrome, chronic disease such as thalassemia and ortho disease such as osteogenesis imperfecta, skeletal dysplasia (Dr. gave this last answer)

Dr : So what examination do you want to do?
Me : I would like to do abdomen examination.
Dr : Okay proceed.

After I finished examination, doctor asked me to present my findings.

This is a small build female, lying in supine position. She is jaundiced and has Thalassemic facies such as frontal bossing and prominent maxilla. On abdomen examination, there is 20 cm splenectomy scar with multiple injection marks seen due to deferoxamine injection. On palpation, liver span is 10 cm and I think she has hepatomegaly.

Dr : How about spleen? Did you check? How do you know if it's partial or full splenectomy?
Me : Oh Dr.. I did not check Traube space.. Can I check now?

Dr : Yes you may.
Me : Traube space is resonant. She does not have splenomegaly. Kidneys are not ballotable. Bowel sound present.

Dr : What are the side effects of deferoxamine that you know of?
Me : Local effects?
Dr : Other than that?
Me : Umm...

Dr : What are other medications that you know of?
Me : Oral deferiprone and Def....Des....
Teet teett Teeet

Dr : Deferasirox
Me : Deferasirox! 

Deferoxamine can cause blurring of vision and hearing problems! I forgot! GRR.

That was the end of my short cases session. Alhamdulillah I got cases that I know and can answer. When I looked at my friends' cases, I wasnt sure if I could perform if I were in their place. Developmental assessement in Down Syndrome, Spinal Muscular Atrophy, Giant Cell Tumor, Exosthosis...wow. 


DAY FIVE

Re-examination
Level 1 JHC
9.00 am

For our batch, 13 students sat for re-examination.

Distinction VIVA
Level 1 JHC
11.00 am

No candidate for distinction VIVA.

Board of Examiners' Meeting
12.00 pm

The result was announced by 12.00 pm at Lecture Hall 3, JHC. 119 students passed the exam, 6 students have to repeat 6 months, 1 student has to repeat one year.

I have heard people talking about how awesome Batch 14 is (yes, we are awesome! lol) but seriously, I think that we have to work together as a team. If possible, we want all of our friends to pass the exam.

Some tips for my beloved juniors, based on my personal experience.

1. Know the common diseases.
In the exam, they are not going to ask you something you have never heard of. If you don't even know how to manage Diabetes Mellitus, then you are in big trouble.
 
2. Be humble, respect our lecturers and examiners.
Don't be cocky. Smile and don't create any trouble. If the examiner says you're wrong then you are wrong. Say sorry and don't argue.

3. Be professional.
Do not laugh and make jokes during examination. Show the examiners how cool you are. Be confident. UIA students boleh!

3. Practise, Practise, Practise!
Especially short cases. Not only you have to practise on how to examine, but to present as well. Don't rush, say things clearly word by word.  

4. Don't study last minute.
Have at least one friend to study together. Do past year's compilations so that you will be familiar with the exam format.

5. Be positive. Don't stress out!
Study smart, not study hard. You have your own way of studying. You know your own capabilities. Keep telling yourself that you can do it.

6. Doa and Tawakkal.
Pray so that Allah ease everything. Pray so that Allah give you cases that you are familiar with. Pray so that the examiners go easy on you.

If your seniors can pass the exam, then you can too!

Think about how it feels like to be wearing this
Just take a deep breath in and out and in and out... and sit for pro exam like a pro ;)

YOU CAN DO IT!

2 comments:

  1. Well said and well done pah! :)

    ReplyDelete
  2. Awesome ain 😍 it was very stressing week but wearing the graduation robe worth it all😍

    ReplyDelete