The End of the Beginning

Alhamdulillah... I passed my final professional MBBS examination. Many thanks to my teachers, hospital staffs, colleagues, and especially those patients (who "sacrificed" themselves to be interviewed, examined, and being set up procedure upon by the 'noob' like me). Without their support, I don't think I will be able to pass this exam. Thank you very much.

I would also like to express my gratitude towards my parents and my siblings for their relentless support, financially and more importantly, morally. Not forgetting my relatives who really support my effort - particularly my auntie who taught me on proper technique of interview skills when I was going for interview with JPA a few months back. Thank you very much.

Too bad, some of my friends didn't make it. I bet this is how life is. Sometimes you are on the top, the next day you may fall to the bottom. Some of them are much better than me. But God knoweth best. Surely there is hikmah behind all the events that took place.

As for me, I will not take this success for granted. Perhaps a week of relaxation and vacation might do, but soon I will resume my struggle to become more competent than I am today. Medicine is a lifelong learning process. You may know best in certain area, but absolutely not in ALL area. With this, I hereby wish myself luck and all the best for my career path as a medical practitioner / healthcare worker / or just simply, a doctor.

"Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning". - Churchill

Developmental Assessment

Theoretically, it is straight forward & well guided. Practically, it is quite difficult if you are not used to it. So, the keyword is "Practice". Basically, it is divided into four components, namely, "Gross motor", "Fine motor and vision", "Language and Hearing", and "Social". (DA is culture specific. Although there is not much difference, it is better for us to refer to the one in the Paediatric Protocols by KKM in addition to those in the Paediatric textbooks from the Western countries - Nelson, 'Sunflower' etc). Some of them can be assessed by simply observing the child whereas the others may require cooperation from the child. Most of the time, the child would be irritated at most, and shy away at least. Some might even cry and refuse to cooperate. Sigh, this is one of the reasons why I don't like Paediatrics. It's because it is difficult for me to get close to the kids. My lecturer used to tell me once when I was examining a baby, "Why are you being so formal to the child?" (lolz).

Part of the reason is that I didn't have enough experience playing with kids (except during my childhood, of course). I am the youngest sibling, and my cousins live quite far from my home. Furthermore, I was sent to a boarding school for five years. By the time I finished my secondary school, they have all grown up. But the good news is that, my eldest brother is married! Soon, I will become Uncle and I would have all the opportunity to improve my difficulty in dealing with kids. As for the time being, perhaps I should be frequenting the ward to get used to doing DA on a child.

p.s. The exam is over, but I still have to prepare just in case I might be called to sit for special examination (i.e. viva borderline) on Monday. Till then, please wish me luck and pray for me. Thanks~

Short Case - Useful Tips from (a) Friend(s)

1- i know looking at patient face very important, but look at examiner face more important ah!!!.. if cant see, then listen for voices like 'huh? ermmm' and so on.. dun hesitate to change ur answer haha

2- plz identify questions to say yes to!!
eg: when examiner ask u direct question like- dont u think the spleen is enlarged? plz say YES!!!!

- a quote from a friend, taken from the discussion board of a facebook group where we compile all the questions asked during this final exam.

Yes I believe he is right. As far as I remember, one of my lecturers used to say, "For your level (MBBS) , the examiners will always try their best to pass you. Unlike the post graduate exam. " So if they are asking you, say,"Are you sure?", then it is time for you to reconsider your answer immediately.

Calm down, even if you perform quite badly on the first case (there will be three cases within 30 minutes).

Make sure to use "standard" sentences, such as "I would like to complete my examination by doing neurovascular examination,..bla,...bla..." just like what is written in the textbooks as well as those useful reference books.

Always "back to the basics" whenever you are stuck. For example, if a Paediatric patient presented with a syndromic facies that you are not sure of, just describe whatever you see even though you don't know the diagnosis. Some of my friends (or should I call them fellow doctors by now, albeit unofficially) had had a patient diagnosed as osteogenesis imperfecta, but they failed to provide the diagnosis. However, they managed to describe the facies as well as other signs properly and the examiners were satisfied. Of course I am not sure whether the examiners will pass them or not, because the result is not out yet. But that's the least that we can do rather than kept ourselves silent for the next few minutes during the exam.

Last but not least, practice makes perfect. Must start from the very beginning of the clinical years. Then, once you are in the final year just top it up with the management of the diseases. Do as I say (read:write), not as what I did. I was not so serious with the physical examination when I first entered the final year. I never practiced the whole steps every time I did my physical examination (because in a long case, we have the information about the patient prior so that we can focus on looking for the expected findings) .Instead, I just focused on the area where there's possible findings only (except during end of posting examination). The result is, I still have to keep reminding myself not to miss the steps in the physical examination and have to arrange them accordingly.

***This post is written based on my personal experience, as well as from the advices given by my fellow colleagues and lecturers throughout the last two years. You should know yourself better. Hence whatever is best for you just take it, and leave the rest. And if you don't mind, do correct me if I'm wrong. Thank you in advance...

Alright, now it's time for me to continue struggling... Please pray for my success... =)

Unwell

I'm feeling a little bit unwell for the last few hours. Feverish. I'm worried that it might last long enough to affect my revision. Hopefully I will get well soon.

This is one of the reasons why last minute revision is not good for students. If you are the ones with such habit, please break it. You'll never know what might happen to you in future at the crucial moments. Accident may occur, or at least you might end up being unwell just like me. An orthopaedic specialist cum visiting lecturer once shared with us the story of his friend who suffered from sports injury while playing rugby weeks before their final exam. He suffered a blow to his face during the scrum which resulted in basal skull fracture and amnesia. He was lucky to survive and managed to sit for the exam. He passed the exam. He's a specialist now. If I were him, I don't think I will be able to sit for the exam, let alone passing it.

Of course, it is never too late. "It ain't over till it's over" - quote from a song. Keep on struggling with all the resources that you have, within the period of time left. Just make sure not to repeat the mistake. I don't want to be the last minute man anymore. That's for sure.

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To-do list for the remaining 2 days:

1) Obgyn and Ortho physical examination.
2) Travel to nearest teaching hospital to practice on real patients
3) Respi and CVS
4) Abdominal and Neurological
5) Paediatrics - especially Developmental Assessment.

Long Case - Lessons Learned

The key to guide your history taking during long case exam lies within the line, "Which ward are you admitted currently?", "Which doctor?" or "Which clinic that have been following you up?" ; because it will indicate what is the chief complaint that should be tackled. Of course, it may not be entirely true as some patients may have been followed up for certain chronic diseases but they volunteered for the exam with different presentation or with a totally different diagnosis that has no relation to those chronic diseases at all.

I may be wrong, but it is imperative to make sure that you try your best not to refer to the written text when you are presenting the history to the examiners. It is part of the "showmanship", so as to make us appear confident and well prepared to answer any questions that will be asked later. Unfortunately, I still have to take a peek to the scribbled text during presentation. Apart from that, like any other "interview", other soft skills such as mastery of English, proper use of terms, smooth narration (rather than point by point), manipulation of tones (to stress some points from the others) etc are just as important. However, like I have mentioned prior, "showmanship" is my biggest weakness. Even though there are much improvements, yet I'm still not at my personal best. There's still room for further improvement.

If the patient is not a good historian, do mention about it to the examiners earlier during case presentation. It will affect their perception towards your history taking and presentation skills, which in turn will affect your marks.

Never ever forget to include systemic review in your history. Most of us will forget, unless we are consciously reminding ourselves about it.

Don't wait for the examiner to prompt you, keep on presenting unless you are stopped by them.

Summary - Keep it short and simple. Summary must lead the examiners to your working diagnosis rather than repeating the chief complaint. E.g. Chief complaint: Low mood, loss of appetite, reduced sleep for three weeks, and suicidal ideation. Summary : [Patient's particular] , presented with symptoms suggestive of depressive disorder, associated with suicidal ideation for the last three weeks. [I still have to practice... T_T]

Usually after the presentation, we will be brought to the bedside to perform physical examination or mental status examination for psychiatric patients. Plan with the patient on how he/she should respond when she was given certain instruction in front of the examiners as you proceed with physical examination prior to presentation. E.g. "Makcik, nanti bila saya minta makcik beritahu saya bahagian mana yang sakit, makcik tunjuk pada bahagian yang paling sakit kemudian baru beritahu kawasan lain yang turut sakit..." (Ma'am, later when I ask you to show me where the pain is, please pinpoint the site where it has the highest intensity and then show me the rest of the site that is less painful if any).

This is just my 2 cents worth of advice. I am not the best, just feels like sharing so that you won't repeat my mistakes. Hopefully this will be my last long case presentation as a medical student. Hopefully I will secure a pass for this examination... Ameen.

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Next: Short Cases examination on Saturday. The final 30 minutes for this examination.

Long Case... 8 hours to go, and counting...

This is it. The day has come. Approximately 8 hours left before it's my turn to sit for the long case examination. I'm prepared... But perhaps I would still have to revise for the last few hours. Just to refresh my mind, especially on the aspect of management as well as the normal values for the investigations.

This session, and the short cases on Saturday would be my final few 'official' hours as a medical student. Hopefully I can make it and doesn't have to extend my studies for the next 6 months. Hopefully I will get a simple and straight forward case, answerable questions, a cooperative patient, and finally nice and helpful examiners. Ameen.

Come what may, I will accept whatever the outcome will be with open heart (figure of speech). Yet I will still struggle for the short cases session no matter how well I perform during the session later today.

p.s. Nervous... Have to calm myself down.

"Dear Me, don't compare yourself with others, whether the ones who were doing much better than you, or those who were not doing well. Just focus on yourself and pray hard. You can do it~!"

Long Case! (btw, it's my 40th post - deleted ones included)

From tomorrow until Wednesday, we will be sitting for long case examination. Then followed by another three (3) days for short cases examination. My turn for long case will be on Tuesday, whereas for short cases will be on the last day, i.e. Saturday. Hopefully I will perform well for the last two 'papers'. Facebook statuses of my fellow batchmates have already shown aura of nervousness and anxiety especially for those who will be sitting for the exam tomorrow. Me? Surely I am extremely nervous and anxious to the extent that I don't know what else to do. So, I turned to God and prayed hard that I will be given a simple and known case, in a package with kind and cooperative patient as well as good & 'angel'-like examiners. However, I still have to revise more, especially on the aspect of management. Perhaps I should flip through the CPGs for the purpose of covering the aspect of management.

Hints? I don't know much. And based on previous recent history, I don't want to rely much on hints. It didn't work out for the CPC and Theory Paper. Neither it was during OSCE day 1. However, I should not totally ignore them. So, I decided to flip through the case summaries that I have made throughout the clinical years based on the hints, as well as based on "common cases" that have been listed by my seniors.

A friend of mine once told me, "For long and short cases, these three study weeks are not the key. It is either you practiced enough throughout the clinical years or not that really matters". He may be right, but I'm not taking any chance. In fact, there is still time for me to prepare. At least physically and mentally. Should practice more on showmanship and brush up my presentation skills. "There is still hope..." (quoting from the LoTR trilogy).

Basically, that's what I am going to do from tonight onwards until the end of examination. Once I'm done with short cases exam this Saturday, I will take a break for half day before preparing just in case my name were listed in the viva list. Obviously not viva distinction, if you were asking... lolz...

Till then, see you again next time (as if there is anybody reading my rantings... ^^) ~!!!

OSCE Day 1 - Checked. 3 more clinical exams to go~!

I fell asleep relatively early yesterday, so I didn't have the opportunity to blog on that day. Now, the first part of OSCE is done, with 8 stations plus two rest stations. Tomorrow will be the second half of it, comprising of the remaining disciplines in the syllabus. As for today, the eight stations were as such:

Station 1 : Primary Care Medicine. A young male adult (Damn, I forgot to ask his name. I only introduced myself to him) presented with history of back ache for 3 days. After detailed history and physical examination, you have made the diagnosis of muscle sprain. However he requested for an x-ray. How do you respond?

Station 2 : Rest Station

Station 3 : Ophthalmology. Picture of cataract given (My friends answered with complete full mark i.e. posterior capsular cataract). We were asked about the findings and give the diagnosis. Then we were asked to list one local cause and 2 systemic causes. We were also asked to name two procedures that can be used to treat the condition and list 4 complications that may arise from the procedures.

Station 4 : Radiology. We were provided with two exhibits. The first one is a PA erect chest x-ray with haziness and consolidations all over the lung fields - diagnosis: miliary TB. Then what is the other test to confirm the diagnosis? - Sputum culture and sensitivity or smear to look for acid fast bacilli (choose one).

The second exhibit shows the x-ray of knee joints from two views, AP and lateral. A male patient in his 30's presented with history of sudden pain on the left thigh associated with swelling while he was playing badminton. Comment on the findings (AP view, no visible fracture but there is multiple cystic lesions on the distal part of the left femur. Lateral view, there is spiral fracture at the distal part of the femoral shaft of the left lower limb). What is the diagnosis? (Pathological fracture secondary to aneurysmal bone cyst).

Station 5 : Surgery. You as an HO in the ward saw Mr. Z unconscious following a surgery. Re-assess the Glasgow Coma Scale (GCS) level. It was written on the question "Treat mannequin as a real patient". After assessing, summarize the findings (supposed to be at the minimum, because a mannequin will surely not respond to any stimulus. Hence it will be 3 over 15.) . Then the examiner will give you another set of finding and asks you what is the GCS? Finally you will be ask what is the GCS level that you would intubate the patient? (I answered less than 8. But please check because I'm not sure. Some of my friends said 8 and below.)

Station 6 : Primary Care Medicine - Drug Prescription. 2 year old (weight and height provided) presented with history of fever. Prescribe antipyrexia for this patient from what is listed. Tablet Paracetamol, Syrup Paracetamol, Tablet Aspirin, Soluble tablet aspirin. (I'm sorry I can't recall the dosage.)

Station 7 : Rest station.

Station 8 : Ophthalmology. Do visual acuity test. Since the test was done in limited, confined space, mirror had to be used. ( I knew the "patient". She is a doctor. lol)

Station 9 : Psychiatry. Patient presented with history of low mood for three months, and had suicide intention for two weeks. Assess the suicidal risk in this patient. Use SAD PERSONS scale, and "SAMPAH" mnemonics to assess whether the suicide was well planned or just to gain attention from others. [S - Suicidal note. A - Avoidance (e.g. want to commit it in a locked room) M - Method (e.g. overdose, hanging, or slit wrist etc) P - Plan (when, where) A - Arrangement (I think it's redundant, but that's what the mnemonic is) H - Hint (e.g. by writing will, buy insurance).]

Station 10 : Orthopaedic Surgery. Patient had a fall and suffered anterior dislocation of the shoulder on the left arm. Ask for written consent for this patient for the close manipulation and reduction (CMR).

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So, for tomorrow there will be no more stations for Ophthalmology, Surgery, Primary Care Medicine, Radiology, Orthopaedic Surgery and Psychiatry. Let's revise for Obs-Gyn, Paediatrics, Emergency Medicine, Anaesthesiology, and Otorhinolaryngology (ENT). Medicine? I'm not sure, because some said that it won't come out because we have had our CPC under Department of Medicine (SLE with Anti-phospholipid syndrome). But, I think I still have to prepare just in case it may come out tomorrow. But for sure, I have to cover the rest first!

Let's do it...

p.s. Have to struggle for tomorrow because I think I'm not doing well enough. I must secure at least pass for this component. After this paper, there will be a gap before my long case paper on Tuesday and Short cases on Saturday (the last day!). Please, please, please, dear God please guide and help me to pass this exam and become a good and safe doctor. Ameen.

Wohoo... 2 days to go~

Yes, two days to go and yet I still feels 'empty' without much input for the last few days. Even though there's much progress but I felt like I'm not doing enough for this exam. Just like previous exams. Hopefully I will be able to pass this exam. I think I should stop from blogging for now. Maybe, just maybe, I will come back after I'm done with theory paper, the day before OSCE. Please pray for me.

Action plan:

1) Proceed with Past Years Questions attempt

2) Review on the investigations and their interpretation (including radiology)

3) Flip through short notes that I've prepared prior.


That's all for now. Till then, bye~

Graphics from HERE. Special thanks to Mr. Adnan i.e. the owner of the blog for the pic. Now it's my turn for the exam. =)