A note on examination..

ALHAMDULILLAH I am now reminiscing the examination day, in the quiet ambience of my own bedroom. But if one thinks everything went well yesterday, I have to apologize for delivering such a wrong message- it was worse than worst. That was how I described it to a friend :p

For my long case I THINK I got a Community Acquired Pneumonia case. It sounds simple enough, but the problem was, the patient came in with SHOCK. She was confused, not oriented to time, place and person, incapable of following instructions -SIGH- And I clerked the daughter and granddaughter who had very little knowledge on the illness itself.. -sigh-

A JVP catheter was inserted however on the day of clerking (examination) it was already removed. But she was still not oriented, and worst was it was almost impossible to do Physical Examination on her as she was moving all the time (She was drowsy and kind of.. not agitated, but still she moved all the time, holding my hands and trying to hug me...) On top of that she was lethargic and couldn't ambulate except turning & toss on the bed. 

I presented to Dr Hadzri, and I think I flunked it huu. Thought I had to be re-examined, but my name was not called. It made me wonder whether I had a clear fail huuu. 

Next was short case (SC). Examiner: Dr Ijaz. Pheww~ lega sket. Followed her in ward 8b, walked pass the nurse counter. Nak feel relieved again. Respiratory system? (Because the respiratory wing was located at the back of the ward, next to the nurse counter. Kept praying silently "Ya Allah, please let it be Respiratory system. Please don't ask me to check weird things huu". Aku yang ketakutan dapat patient with haematological malignancy presented with enlarged testes, because I am not well versed neither well prepared to do inguinal hernia examination!!!

Arrived at the bed, a bit upset to see the curtain was drawn around the patient. Dr and me intai dalam curtain, saw Ashraf and Dr Harris doing the SC, Dr Ij decided to find another patient.. ah kecewa tak dapat respi..

Dr lead me downstairs. Ahh a female???? Ketakutan lagi ~sigh~ it's hard to examine a female. Sempat sengih2 kat mimi while we walked pass her and the others near the staircase.

Dr Ij brought me to a young patient (age: 20+), from general exam I can't detect anything except a tinge of jaundice (cuak lagi). I was asked to examine Cardiovascular System! Haa~. For CVS, the problem is not with the technique, but with the interpretation..

So I asked for the patient's permission, pull the curtain, position her (I elaborated on the position haha, siap tengok katil dari tepi nak betul2 tunjuk that I aimed for 45 degrees. Try tarik bantal tinggi sket, suruh kakak tu duduk betul2 sket.. ces memang berlakon tahap melampau hehe) 

Then I moved to the end of the bed for general examination. Took a long time to count the respi rate 

Dr Ijaz: What are you doing so long over there?? (dengan muka yang pelik)

Me: (dengan muka cuak and bersalah) I would like to count the respi rate because the patient appears tachypnoeic....

Dr Ij just nodded in wonder.

Started with periphery. Bersungguh-ungguh I looked for collapsing pulse. Teringat pulak my advise to Hana :Don't ever depend on auscultation! EXTENSIVELY, ELABORATIVELY, SERIOUSLY look for signs in the periphery, so that before you auscultate, you have an idea of what you are going to find. But I myself fails to that in the exam huuu. Apsal la takde orang yang pernah cakap pasal patient ni ada murmur ape2 haisyyyy

Failed to find anything in the hand, I examined the face. takde malar flush tp patient had mild pallor. I denied jaundice although I did think she had TINGE of jaundice.. aiseh ketakutan dah, i have arrived at the neck but no positive signs yet.

examined the neck. Raised JVP. YEAY! Measured it, 5 cm. carotid normal character. tp i thought the patient had corrigan sign. carotid pulsation macam sangat obvius, but i just put that aside. I'll only present it if it agrees with auscultation finding (not to mention that I'm not good at detecting murmur truthfully!!)

examined the chest. waktu ni dah berdebar melampau because i had very few signs in my pocket. No precordial bulge, but obvious precordial pulsation. There was a horizontal scar at the left subcostal area, medial to mid clavicular line measuring 5cm. At that time, I think my own chest would have revealed vigorous precordial pulsation!! Takut yang AMAT AMAT AMAT sangat becuase I thought the scar might due to valvuloplasty. I just don't know what to expect in the auscultation. The clicking sound of prosthetic valve?? aiseh!!! Searched for apex beat. Displaced. 6th intercostal space, anterior axillary line. YEAY! I don't know the character, sorry huu. Parasternal heave! Lega sket. 

Auscultation ni yang memerlukan imagination yang paling tinggi -sigh- Antara dengar dan tak dengar (lebih kepada tak dengar laa huu), she had a systolic murmur. Checked for radiation, tp tak berani plak nak check for carotid radiation just to confirm it was not aortic regurg (i was pretty sure it was not a diastolic murmur). I was confused whether it was tricuspid or mitral. I was sure it was mitral, becuase there was radiation to axilla, but the SCAR confused me. Judging by the scar, i think it should be tricuspid valvuloplasty.. Did some manouvre for inspiratory and expiratory phase.

Examined the leg for pedal edema. Positive up to the knee. Then asked the patient to sit, checked for bibasal crept. ALHAMDULILLAH it was very gross!!! It made me feel confident to claim she is in failure. But sacral edema was absent. By then Dr dah bising2 that I took to long a time. I don't know why, I did everything in a slow motion way huu. 12 minutes! I said I would like to check for hepatosplenomegaly, but she made faces to me. I said never mind, I just presented.

Presentation was not that smooth. Tachypnoeic (i think up to 30bpm, but i was dead afraid to commit to such a severe tachypnoea, i just mentioned 26bpm), pale. JVP raised, pulse (radial and carotid) normal. When I mentioned the scar, she was kepelikan huu. She examined the patient again, ALHAMDULILLAH i didn't bluff about the scar. She asked the patient, and the patient claimed it was present since she was a child huu not a surgical scar!! What a waste to worry in the first place :p Then i said there was a parasternal heave (muka takut je waktu cakap benda ni but when Dr nodded in agreement, I felt relieved). Then murmur haisy..

Me: emm aa emm..

Dr Ij: cepatle. time is running. with your emm oo aaa, u are losing time! cepat sket

Me: emm (lagi) S1 and S2 heard. There was a systolic murmur (tak berani lagi cakap pan systolic murmur). Heard best at... (was reluctant to say) tricuspid area..

Dr Ij: Ha??

Me: No no no! Pan systolic murmur, heard best at mitral area, grade 3, radiating to axilla! (termuntahkan semuanya dengan begitu cuak dan laju. Dr mesti terkejut) 

Dr Ij: (looked satisfied i think....) Yes. During inspiration or expiration?

Me: (meekly answered) i tried to listen but could not appreciate....

Dr Ij: ok, never mind. what else?

Me: pedal edema up to knee. No sacral edema. Bibasal crept present. Tp hepatosplenomegaly could not be elicited.. (continued in muka sedih..) tak sempat....

Dr Ij: You were too slow. Buat cepat sket.

Me: (nodded)

Dr Ij: apex beat kat mane? 

Me: (aiseh, terlupa mention la pulak) 6th intercostal space lateral to midclavicular line

Dr Ij: Yes. Where is it exactly?

Me: Anterior axillary line.

Dr Ij: YES!! is it displaced?

Me: (meekly answered) yes.

Dr Ij: So what's your diagnosis? 

Me: Mitral regurgitation

Dr Ij: with?

Me: with heart failure

Dr Ij: Yes mitral regurg in failure with??

Me: (blank)

Dr Ij: eh look at the precordium. what can you see? Pulsation kan? I can even see it with her clothes on. What more when she took it off!! (Dah start geram?? huu) Can you see it?

Me: Yes. But there was no precordial bulging. Only the pulsation (she initially tried to question my statement 'no precordial bulging')

Dr Ij: yes. td you said parasternal heave. what does it indicate?

Me: Right ventricular hypertophy. 

Dr Ij: Yes, so what is it?

Me: (suddenly i see a light bulb in my head) Pulmonary hypertension.

Dr Ij: YES!! She was finally lega that i could come to the diagnosis with her extensive clues and hints huu) You ni bagi la diagnosis lengkap

Me: Mitral regurg in failure with pulm hypertension

Dr Ij: Ok what can cause MR?

Me: Many differential iagnoses. First is Chronic Rheumatic Heart Disease.

Dr Ij: Ok. (session ended aku masih terpinga-pinga) You took 15 minutes in total. 

Me: (Eh bukan 3rd year dapat 20 minutes ke? 10 minutes for examination and 10minutes for presentation)

After she went away, I talked to the patient, apologizing for whatever inconvenience i have done to her, told her i was having my examination. Asked her what was her chief complain, and she said "batuk berdarah" Aku macam terkejut dengar, so it is true she had pulm hypertension.. Her first presentation. Ver nice lady, her third child is now 2 months old!! Huu. i wonder whether she had cardiomyopathy with severe MR accelerated pulm HPT.. i don't know.. 

So that was it. i leave the rest for Him to decide