You Don't Need Luck ... You Need A Miracle .... Part II

This book served me well over the years. Check out the vintage. I bought this before my Finals. Don't ask me when because I'm old!

Thanks so much for indulging me and more importantly, for being patient. I was updating my slides for a tutorial I am giving to Anaesthetics Masters students tomorrow. Took me some time but finally got it out of the way. Let's get down to business.

Long case. You need luck for this one. You need to pray that the solitary case that you are going to have is on a subject matter at least you have a clue on. Luckily when it comes to medical cases, there aren't very many. Let's go through the system. By the way, I am not involved in recruiting any cases, even for my unit. I am just going through these by experience, and in no way indicating they will be asked. It is just merely a checklist for your benefit.

Cardiology - chronic IHD, hypertension, rheumatic heart, mitral stenosis, chronic atrial fibrillation. These should be familiar to you by now. Respiratory - asthma/COPD, bronchiectasis, TB. Gastro - chronic liver disease, viral hepatitis, peptic ulcer disease, inflammatory bowel disease, irritable bowel (if you are unlucky).

We move on to Neurology - Parkinson's, spinocerebellar disorders, facial/Bell's palsy, carpal tunnel, diabetic peripheral neuropathy. Endocrine - thyroid with or without eye disease, hypo or hyper, diabetes (obviously), hypertension (essential or premature eg Conn's, pheochromocytoma), Cushing's, hypopituitary. Rheumatology - rheumatoid arthritis, OA, gout, ankylosing spondylosis, psoriatic arthropathy. Renal - nephrotic syndrome, polycystic kidney. Haematology - thalassemia, CML, myelofibrosis, AIHA. Dermatology - eczema, psoriasis. Did I miss any major subjects?If you think you want to add something, just put it in the comment section below so we can all share it. You can add them anonymously, so don't worry.

MAKE SURE YOU KNOW INSIDE OUT ON DIABETES AND HYPERTENSION. Make sure you present, ask all about the complications and all aspects of target organ damages. So in diabetes, ask about current and previous treatments, complications as in hypo or DKA. Any retinopathy, IHD, nephropathy, neuropathy and peripheral vascular complications. Ask about the cardiac risk factors without fail - the major 5 - BP, DM, high cholesterol, smoking and family history. 

So you have 1 hour to talk to your subject. The first 2 questions should be 1) what medications are you on, 2) when was your last clinic appointment and slyly ask them which clinic. You have the diagnosis in front of you by then and gear your questions towards it but during the systemic review, ask everything. Always ask your patient before you go to the examination part, "is there anything else you would like to tell me before I examine you?". The examiners wold like to hear you discuss about the family history and social background. What is the occupation, how much do they earn, what kind of house they live in. Take a thorough family history. Draw a family tree.

After you finish examining, do the urine dipstick, measure the BMI, measure the BP, measure the PEFR as applicable. There is a reason why the equipments were provided. In diabetics, make sure you open their shoes and check the foot for neuropathy and ulcers! During long case presentation, if a diabetic was still wearing their shoes it means that you have not been thorough. Tolak markah!

You must then formulate your main diagnosis and list of differentials. When you present your management plan, always consider them in terms of pharmacological and non-pharmacological. Diet change, exercise, physiotherapy are just as good as using drugs. This pointers are not exhaustive. Please add anything you think is relevant in the comment section so that we can all share them. We'll talk short case tomorrow hopefully. I will be driving up to Penang after my tutorial. I will be blogging from there. In the meantime, happy slogging and burn them midnight oil! Adios!