candidate : MS 33
Examiner :
1. Dr R (external examiner) - alpha female
2. Dr ??? Malay, female lecturer of CUCMS kot since she was wearing the labcoat. - didn't ask much. angguk2 for most of time
Station : BBQ station of Medical - not my favourite. (NSTEMI)
My patient is a middle aged chinese lady who could not speak Malay properly!
After about 5-10 minutes, i gave up and decided to inform the staffs for a translator.
The admin took time to find one and in the end, i got another old chinese lady in wheelchair as the translator -.-;; better, but still had difficulty in translating some words to Malay and they took some time to talk to each other.
-.-;;;;;;;;;
in summary,
Madam L, 58 y.o, Chinese lady
Day 8 of admission
Underlying DM for 17 years and HPT for 20 years
C/O : SOB
- a/w central chest pain + palpitation
- no failure symptoms
- no hyperglycemic symptoms
- compliant to medication and not informed of having any TOD during her regular follow up
- then, patient was admitted to the ward and she mentioned "tiga", "tiga". so i suppose 3-vessels disease lah right?
- Hx of gynaecological surgery at the age of 40. the translator mentioned CHIGONG CHIGONG, sakit sakit. have no freaking idea but patient got menopause after that. i suppose hysterectomy kot.
physical : displaced apex beat but otherwise DRNM, presence of dressing at the femoral area (post angiogram), diabetic dermopathy changes (dry skin, hyperpigmented legs, loss of hair), all others seem to be ok.
QUESTIONS :
1. How was your patient? Did you have any difficulty?
- yes, i experienced language barrier with her.
2. Did you mention about this to the admin?
- yes, i tried to clerk her but after 5 to 10 minutes i decided to just inform the admin.
3. Did u manage to get a translator? Is the translator provided for the patient or is it only just on the spot?
- yes, they gave me another elderly chinese lady but i still had difficulty. i am not sure who she is but it could be one of the patients for the exams.
4. It's okay. We will note that down in your marking sheet. So present your history.
5. what is your diagnosis?
AMI
6. Okay going back to your history, if you could clerk the patient properly, what else should you asked the patient about for the shortness of breath? symptoms of pulmonary embolism, PUD, pneumothorax
7. what is the different between the pain in pulmonary embolism and AMI? blur blur blur. she asked is it diffuse or sharp?
i said sharp. "are you sure look" pops up.
8. name me other types of pain that you know of? colicky, dull, burning, sharp, radiating pain, pleuritis
9. okay, what would be the kind of pain in PUD? worsened by food, hx of NSAID
10. how can you tell patient has good control of DM and HPT?
- she said her dr didnt mention of any TOD
- i want to look at her HbA1c and BP trend
* still tak puas hati lagi* you have already mentioned that in your hx.
*pause*
oh, she has been DM and HPT for quite some time but she is only on 1 type of OHA and anti HPT. *Yes. Good*
let's meet the patient
11. show me the relevant negative and positive finding. in the end, she asked me to show reflex at the lower limbs.
- for ankle reflex, i told the patient to position her legs like the way i demonstrated to her.
E : shouldn't reflex be done in a passive manner?
Me : err..
E : what should be the condition of the muscles if you wanna do the reflex?
Me : relaxed
E : so, if you ask the patient to position herself, wat would the muscles be?
Me : contracting. she gave the "TAU PUN" face.
then, went back to discussion room
12. since you mentioned patient is big built, did u take her BMI?
- i did ask the admin for a weighing scale but instead, Dr M came in and said, no need. then she roughly estimates her (by the power of observation) as 60-65kg.
Oh. so u did try to get the BMI?
yes, i did.
13. ivx that you would like to order - ECG - to look for MI changes
14. How do you differentiate the symptoms between Unstable Angina and NSTEMI? answered ivx but she insisted in hx.
(battery span at that time- 50%). she answered : well, it's quite hard to distinguish but there are some distinguishing fx.
15. causes of ST depression? *thought block* no idea
16. which one are u more worried of? ST elevation or ST Depression?
17. other ivx?
FBC - to look for anaemia due to chronic HPT and DM. she wasnt satisfied and asked the relevance of anaemia in MI. answered : oh. anaemia can further precipitate her to get Heart failure. which patient is already at risk of due to MI.
*Yes, that is even better answer than saying anaemia of chronic disease*
18. Others ?
cardiac enzyme - which ones? Troponin and CK enzymes. relevance? so that we can estimate how long patient has been experiencing MI and to confirm dx.
Coagulation profile - for thrombolytic therapy later on / heparin
Lipid Profile - risk factor
Renal profile - need to make sure electrolyte is balance so that it doesn't further worsen her heart condition, to look for renal /dm nephropathy
19. since you mentioned about timing of MI, what is the relevance?
- can decide whether patient needs thrombolytic therapy or PCI.
20. which is?
- door to needle time is 30 mins.
21. where should you thrombolyse patient?
- in cardiac unit?
22. only in there? - not sure.
well, u mentioned that you thrombolyse the patient A.S.AP, so you can also do it in....?
Red Zone, ED. yes.
23. so how are you going to take care of patients before she undergo bypass?
- ensure the glucose and BP are controlled
- advise ambulation to prevent DVT
- ensure enough hydration
24. how about medication?
- Start on B-blocker, ACE-i, Statin and Heparin.
25. how about other non-pharmacological?
- since patient does not exercise regularly, then i would advise her to do light activities e.g briskwalking for 30 mins if possible on daily basis.
- advice her to control her diet
26. how are you going to advice her on diet?
- erm, i would prefer to refer her to dietitian.
E: Oh, you cannot simply do that without trying to explain to her something about it.
- well, reduce carb intake, increase on fruits, vegetables and increase protein diet.
*times up*
PENGAJARAN :
- a straight forward case but due to the problem i had earlier on, i did not have time to prepare for the discussion. ended up mengelabah like Shhhh... especially when answering the questions
- to the juniors, if you experience language barrier, please call for help A.S.A.P. it is possible u get to change patient.
- follow your instinct : quite fortunate, i studied CPG of AMI the day before. at least i wasn't that hopeless in answering the questions.
- cramping everything up 1 day prior to exam can make u experience thought block.
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