Wednesday, February 18, 2009

On the Short Case Postmortem [Paeds]

So here's the post-mortem of the paediatrics short case that happened this morning. 3 hours waiting in the ward before it was finally my turn. Only to know that I have quite a high possibilty of failing the end-of-posting exam. We were examined by 2 lecturers.

Dr. C: Do a respiratory system examination.

A while later,

Dr.C: Tell me what have you found at the peripheries.
Me: Erm. No peripheral cyanosis, no clubbing noted. Pulse rate was 120 beats per minute...
Dr.C: Good. 120 beats per minute. What do you think?
Me: It's tachycardia...
Dr.C: Are you sure? He's 12 years old.
Me: Erm... Yeah... A bit high.
Prof A: Pulse rate? Why do you do pulse rate? Is there any significance?
Me: Erm... Well...
Prof A: Just because everyone said so, and you check?
Me: Erm...
Dr. C: Okay fine. Let's just say you did the pulse rate and you find that he's got tachycardia. Why?
Me: Drugs maybe?
Dr. C: What sort of drugs?
Me: Bronchodilators can cause increase in heart rate.
Dr. C: Okay. What else?
Me: Maybe anxiety?
Prof A: No. But you're doing a respiratory examination. What is there in the lung pathology that could lead to increase pulse rate?
Me: Hypoxia?

One point out.

Me: Dik, can take off your whole shirt?
Patient: Okay.
Prof A: Should've thought about that earlier isn't it?

And me taking off the shirt.

Prof A: EEEEHHHH!!! STOP STOP STOP!!! Did you see what's on his hand?
Me: Ooops sorry sorry, Dik, painful not?
Prof A: NO! It's not about pain! If the branula is pulled out, the MO will come and kill you!

Second point out.

Me: Apex beat is in the fifth intercoastal space, on the mid clavicular line.
Prof A: On or around?
Me: Sorry?
Prof A: ON or AROUND the midclavicular line?

Okay, that I really don't know what she was referring to. But she corrected that it should be AROUND the midclavicular line, and not ON the line. I was confused.

Third point out.

Me: Chest expansion is normal. Tactile fremitus is also normal.
Prof A: Are you sure? Did you even perform a proper chest expansion technique?
Me: Erm...
Prof A: From the look of your hands, I already know you don't know how to perform chest expansion. Did you ask the patient to take in a deep breath?
Me: Erm...
Prof A: You should! Another steps gone.

4th point out.

Me: Percussion note was normal on all the lung region. There is liver dullness.
Prof A: There is liver dullness? Where is the liver dullness?
Me: It starts at the 5th intercoastal space.
Prof A: So is that normal?
Me: Yes, it's normal.
Prof A: So you mean in all the other people there is no liver dullness?
Me: Huh?
Prof A: If you say there is liver dullness in this case, that means it is something wrong. You should've said that liver dullness is present!

5th point out.

Prof A: What else? Did you feel the cardiac dullness?
Me: Erm... but it was resonant...
Prof A: So?
Me: Erm...
Prof A: So where's the heart? Dextrocardia?
Me: No... Apex beat was palpable...
Prof A: Exactly... So what are the causes?
Me: Erm... Pneumothorax?
Prof A: In this patient?
Me: No not likely... Erm... I dunno... Lung abcess??
Prof A: No no no no no no no.... Fine, let's not waste time, in obstructive airway disease there is hyperinflated lung. So the heart is covered by the hyperinflated lung, that's why there's no dullness. After 8 weeks of paeds, I'm sure you know about that right? Didn't Dr. C teach you guys?

6th point out.

Me: The breath sound was vesicular. Air entry is normal on both sides of the lungs. There is no additional sound heard. Vocal resonance is also equal on both side.
Dr. C: No findings?
Prof A: Are you sure?
Me: Yeah... I'm quite certain.
Prof A: He's a 12 years old boy. And he's so cooperative. So I expect you to do your examination properly. Did you even ask him to take in deep breath?
Me: I did.
Prof A: But not deep enough. You have to make sure that your patients take in a DEEEEEEEEEEEEP breath for you to appreciate the rhonchi. Because the lung is not stretched to the extreme, that's why you cannot appreciate the rhonchi.

7th point gone.

And I feel as if it's a confirm that I'm failing. Sigh...

I hope she won't fail me. For another one will seriously hurt the confidence. *sobs*

16 Jujus:

Sam said...

Awwwww... come here you. *big hug*

I'm sure you will do just fine. Keep your chin up, whatever is done is done now. Just hope for the best.

But god, that's tough. I would be totally lost if I were in medicine. o-o

jase said...

oh my.. dun let that put you down!! You can keep on going! You're bound to reach the the end as well! Good luck kay!!

and why is professor A being such a biatch... ?

TZ said...

Dude, don't worry now... you are still a student... it's tough to know what exactly is the case... practise make perfect ...

Now, go and enjoy yourself before the result out ...

savante said...

Deep breaths, man! Physical examinations are always difficult - especially when you have someone right there to point out each and every single error.

*Anton* said...

*wakes up*
*pengsan lagi*

Checking car engine ody makes me perspire profusedly.*haiz*

JD Cole said...

i seriously dun understand the conversation ;P

just chill....even if u failed...make sure the next won't happen the same~

Bengbeng said...

oh dear oh dear..things are not turning out the way you expected it to. just grin and bear it and wait for the results. it is already done so hope for the best. hugs medie

Ban said...


I just hope you're mistaken and actually you did okay. *hugs*

nase said...

Don't be too hard on yourself, ok. Looks like you had an old hawk as your examiner, tough luck. But seriously, the case you have is so not ideal for exam case. my guess is they ran out of good exam cases and hence gives you an asthma patient instead. Never answer back with a question or one that shows your doubt, big no, no, no. All the best!

Medie007 said...

Sam, thanks for the *big hug* :)

jase, thanks for the wish. :) well when they become prof, they memang biatches dy...

TZ, enjoying myself la ni. :P

Medie007 said...

savante, it's not easy when it's a "maglinent" prof.

Anton, i aso know nothing abt cars. and i bet i know nothing about what u specialize in as well.

JD, i basically will be failing all my exams if i keep on failing lor. *sobs*

Medie007 said...

bengbeng, thanks... will pray hard lor...

Ban, thanks. i hope what i feel is a mistake as well...

nase, thanks.

Peng Loon said...

gosh... "why do you take pulse rate??" she thinks she's being clever la hor?

now i noe wat they mean when they say she's fussy... lol

all the best! just enjoy first la.. results won't be out anytime soon anyway =P

Nicholas Rashidee said...

i tried. i really did. read one by one.

but i still don't understand any medical jargons.

u know all that is ok what. if i become doctor, sure ppl die liao. choi choi choi~

K|E|E|N|Y|E|E said...

Oh dear, it wouldn't be as bad as you thought. However, I'm not in the position that can give you some good advices though. Just don't pressure yourself too much ya.

Little Dove said...

It's okay to make mistakes now when you are still a student. This is the time to learn. When we become doctors in the future, errors should be as minimal as possible.

p/s: 2 examiners at the same time is quite scary.