On Sitting for a Long Case Exam

This post would be most beneficial to the clinical students. But I've made it as layman as possible so that non-medical people could be able to enjoy it as well. Hope you will enjoy reading what it's like to be in my shoes in one of the most feared examination in the medical school.

I'm sure clinical students in all medical schools will at some point sit for a long case examination. What's difference probably will only be the location. But I guess, more or less, it's about the same. You're given one hour to spend with the patient and at the end of that one hour, you will be spending 30 minutes with the examiner (or examiners in my case), and present your case. Discussions followed suit. And by the end of 30 minutes, that was it. You're done.

The exams itself isn't as nerve wrecking as the waiting period, as in days before the day of the long case itself, or perhaps the one hour while you're with your patient taking history, worrying about who your examiners will be and how they're going to screw you... But at the end of the day, before you know it, it's all over. You'll come out either with a heavy feeling worrying whether or not you'll be able to pass; or you'll come out feeling numb, not even sure how you perform; or, you'll heave a relieve and be thankful it's all over. Which, I was the last with a mix of the former two.

I was nearly late for my session as I was reading the Heart of Sutra, but I managed to get into the registration room 5 seconds before it closed. The examination ward was so crowded and so busy. Patients and families were waiting outside along the corridor. Doctors in charge of the long case examinations would be guiding the patients as well as the candidates. It was in fact, busier than the normal ward.

We were ushered into the examination hall 10 minutes later, perhaps due to some unforseen trouble inside the ward. Do bear in mind that some of the patients are actual in-ward patients, while some of them are regular patients on follow up who were invited just for the exam. Which, well, in my case, was the later. You have no idea how relieved I was when I came to the side of the bed of a Chinese gentleman instead of a young baby. My worst nightmare it was, to have a baby or a young child instead.

But it wasn't before long that I found out this patient of mine, has numerous other problems other than the first answer he gave me when I asked what his complaint was, to which he answered "Liver problem".

He had reccurent cellulitis, 7 times thus far. Been having high blood pressure for 30 years, diabetic for 10 years. Underwent hernia repair before, as well as vein strippling for varicose veins. He's got grossly distended stomach, which I was quite sure is due to fat, although the examiners were hesitant later on during the physical examination portion. And well, yeah, he was told that he's got liver disease about 3 years ago.

It was a mess really. To have a patient with you, despite being very very cooperative and well versed in English and know in and out about all his diseases as well as some of the medical jargons, (to which I'm SO SO VERY THANKFUL of), one hour with the patient is merely enough! I wasn't able to get the random blood glucose meter right and I had to poke the patient three times with the aid of the nurses before I could get a reading. And I was so nervous that I got the wrong side of the blood pressure cuff thingy that I couldn't even get it inflate properly, until I got the nurse to come in and to turn it around in front of me, so that I finally managed to get the reading of 130/85. And don't even mention about the fundoscope, that tool doctors used to check your eye, where they'll shine from far, then move closer and closer until you're feeling their breath on your chin and they'll move their heads around and around examining your eye while looking through that thing. I can't even get it switched on!

And my patient commented, "You're not really good in instruments, are you?"

Shame on me! Shame on me! Shame on me! Even the nurses were pretty irritated when I came out asking for help for the zillionth time.

Just right after I got my thoughts sorted and when I think I've got everything I need, one of the examiner called me in. None of them taught me before, though I've heard of them as they did went to teach some of the other groups throughout the last one year.

So it was a smooth presentation with repetitive bouts of "ummm"s and "ehh"s until they stopped me to ask me questions. I failed to obtain any history regarding the other risk factors that could lead to a liver disease, i.e. intravenous drug usage, blood transfusion, multiple sexual partners etc, because I was blinded by the fact that the patient was a heavy alcoholic. Pitfall number one, NEVER EVER ASSUME! Well, all in all there were a lot of questions asked really. I can't really recall as I think I did manage to answer them, with much prompting though.

As I was brought back to the patient for the physical examination, it was when the nightmare started. I failed to recognise some of the signs of a liver failure. I failed to perform the examination on a swollen calf. I failed to give the differentials for a unilateral calf swelling. I failed to answer the simple basic questions regarding cellulitis.

But the seniors said we SHOULD be pretty safe when the discussions come to investigations. As in, the examiners would ask you about what investigations would you order for this patient. The thing is, when we headed back to the room, the 30 minute allocated was just 30 seconds from being over!!!! I was asked ONE tiny question as to how I could determine the stage of the liver disease, to which I think I irritated the professor with my answer, and finally I was saved by the bell with the last question. "What would you check to see if the liver disease was due to alcohol?"

"The ratio of ALT to AST."

"Alright, thank you. You may leave now."

I have no idea how I fared. I would bang myself into the wall or jump off the highest floor of the hospital building if I failed to pass. My colleagues all gave me the similar "Oh, should be okay larh." Hopefully. Hopefully...

I shuddered at the thoughts that some of my colleagues got far more complicated cases compared to myself... So I solemnly wish I would be able to proceed to the following year...

And suddenly now I remembered I used the wrong medical term. Hemetemesis vs hemoptysis. The professor gave me a talk "Don't use term you're not sure of!" *sobs*