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Final we come! ;)

Salam...just now, i just finished reading the notes tagged in FB by our committed seniors who are very kind to share their experience during their previous Final Professional exam..Thank you very much senior! May Allah bless u always! Semoga kita akan lebih bersemangat untuk melangkah ke alam final year dan berusaha untuk menjadi yg terbaik! Aminn.. ;)

First: notes by Dr Nadhir ( Pro Exam 2010 simplify version)
This is a VERY simply version of my Cases for Pro,hope it will bring some use for you guys(juniors)

Long Case
30+,Indian gentlemen,married and work as a lorry driver,
C/O presented with back ache for 1 year duration
Pain:gradual and progressively worsening, radiating to the R lower leg on exertion.
Associated with night sweat, loss of appetite and weight 20 kg in 1 month.Otherwise no fever, cough or hemoptysis.No contact with TB patient said by the patient.No MVA/trauma to the spine.
The problem worsened when he noted to develop progressive back deformity(bending forward) and weakness of the right lower leg.
After a month,his ADL was affected, he was unable to move and quited his work.
He went several time to the OPD( 6x), but was only treated with URTI infection before he went to the HTAA.
He was admitted and several blood and radiological investigations were done.
Told to have TB spine,with no focal elsewhere.
Stayed in Ortho ward for 3/12, and was started on anti TB medications for 1 year course.
The whole family was screened and but no one was positive.
Patient was discharged with medications and regular follow up.
He was compliant and have no side effects/problem with his medications.
Currently after 10 month of medication,he noted major improvement his back pain and right leg weakness.He is currently able to move and do ADL.

2 admission for lung infection,which required 2 month admission.Chest tube was inserted and was started on antibiotics.Responded and was discharged.Was diagnosed with hepatitis

Social history
Stopped working, married with 2 child, is supported by the wife a teacher and mother (RM 1000+).Currently waiting for his OKU card and welfare support.Smoking 30 packs year.History of high risk behavior,alcohol and drug abuse(heroin).No sexual promiscuity. After marriage stopped and enter the Methadone program.


Dx-TB spine with empyema
IX-TB workout and radiological test

1)Dr Hussain Imam
2)Prof How
3)Mr Shukrimi
4)A/P Zalina
5)Dr Ramli

This was supposed to be a medical case, but since the patient complain of back pain, my discussion was change to ortho and medical too(TB and neurology)
In conclusion, before you clerk, as the MLT what type of case do we need to present to the examiners.

Questioned asked;
TB and Spinal Cord-history of infecition, spine TB(gibbus, nerve involved, what do you look for if spine is involved from history and PE, common extrapulmonary TB,CXR and spine XRay changes in regard to this patient), patient spinal injury mechanism, type of cord injury, complications

Short cases
1) Multiple gestation- Dato Ghazali- instruction examine this patient abdomen
-question: differential larger than date, Ix-U/S, what do want to look for.Complications of multiple gestation

2)Thallesemic child with splenectomy-Dr Nargis-examine this child general then continue with neccessary examination
-question: Dx, scar for splenectomy description, indication for splenectomy

3) Bell's palsy-Prof Yusuf- examine this patient face and do subsequent exmanition( 7th nerve exm)
question:whats your diagnosis,7th nerve pathway, pathology according to the pathway. Tx- steroid, when to start and when to stop

so i hope this might help you guys to figure out the type of questioned asked by the examiners

Second: Notes by Dr Fiza (My Clinical Exam Saga)

I think I heard Dr Azarisman mentioned my name yesterday. But guess what, my matric number was not in the list. I believe it was a typing error. It was supposed to be ****982 but it was typed as ****902. I hope it was a typing error because when the grouping for clinical came out, they put my name with that wrong number. Huhu~ I am not happy with this situation actually. Syazana wanted to help by telling Kak Riza but she forgot so I have to wait for another 3 days. And with my obsessive compulsive personality, I am SO not comfortable with this situation. I think I heard Dr Azarisman mentioned my name. Did anyone else hear it? Bla, bla, bla~ Sorry. Enough about that.

I know a lot have been said about our recent IIUM 9th Final Professional Exam. I just want to share a bit about my clinical exam, hopefully it would benefit my juniors with special dedication to HafizJoe who have been so eager to listen to the story :-)

My clinical exam was on the 3rd day so it has been a long wait. I saw people cried, laughed and even have blunted affect after their exams.

Long Case

I prayed hard not to get Psychiatry for my LC so I felt so relief to see a little boy with his mother behind the curtain. He is a 11 YO Malay boy. The mother told me he has thallasaemia diagnosed at 5 YO but I tried my best to look if there is any new complaint. Mr Hafiz's reminder was very clear to me "don't be so happy when you got the "k/c/o osteoarthritis" from the patient, he might actually has back pain as his acute problem now". The mother was nice. Thinking back, throughout my 3 years of clinical years I never had any difficulty during exams until the day of my Pro. My LC patients were very co-operative. And I thank Allah for that. Alhamdulillah.

Abbo told me Azhar forgot to do anthroprometric measurement for his type 1 DM in child and Dr Hussain Imam told him that it was a big mistake. So I made a note to myself so that I won't forget it. Thank you Azhar. It was a careless mistake that anyone could have made.

My patient has no active complaint. Noted to become easily lethargy, pale and progressive abdominal distension since 1 1/2 YO and diagnosed of thallasaemia at 5 YO. On regular monthly blood transfusion since then with one history of allergic reaction. On desferrioxamine but poor compliant d/t pain. Planned for splenectomy end of this year. The anthroprometric measurements were all at the lower sides. Oh, and he is a slow learner at school. I have no idea what my chief complaint would be. 10 minutes before the end of clerking, I decided to put "lethargy, pale and progressive abdominal distension since the age of 1 1/2 YO" as my chief complaint. It was a mere tawakkal.

They told me to go to Room 4. I waited outside and read the names:
1) Dr Hussain Imam - Oh. He is the chief author of Malaysian Paediatric Protocol and "chief paediatrician in Malaysia" according to Prof Wahab. He came to Kuantan when I was in 3rd year Paediatric posting and I presented a seminar to him. And I remember him being a nice person.
2) A/P Dr Zalina
3) A/P Dr Nazri/ Dr Shukrimi - I prayed in my heart not to see Mr Shuk inside the room. I was so worried I'll let him down if I didn't perform well. Haha~ Along said I was weird because she got the same set of examiners and she prayed she would see Mr Shuk.
4) Dr Ramli
5) A/P Dr How Soon Hin

I went in and I recognize Dr Hussain immediately. Prof Zalina, Mr Nazri, Prof How and Dr Umeed were there (instead of Dr Ramli).

Thallasaemia was the first thing I read during our Pro revision. Nazu had her clinical exam on 2nd day and she told me she got thallasaemia for SC. I decided to read it again, just in the evening before the exam. It was a rezeki. Alhamdulillah, I am so grateful.

Dr Hussain was so nice and listen attentively to my history. He stopped me after past medical history for discussions before jumped straight to examination. I was able to answer most of his questions and he seemed quite satisfied with my answers. Mr Nazri helped to clarify some of the questions that I didn't get and he was smiling most of the time. Prof Zalina asked me about genetic counselling and the possibility of stem cell therapy for my patient. Dr Umeed and Prof How did not ask me anything but Prof How was smiling all the time and kept giving me positive response whenever I answered well.

I was quite happy with my LC. Dr Azarisman told me "don't worry, you did well". Time for short cases. I know LC is a my strength but SC is my weakness. Indeed it was so true.

Short Cases

I waited outside the room and I saw Mr Zailani from the door. He saw me too. I heard rumours that he will be taking exam on the 3rd day and some of my friends were quite anxious that they would get him. But I told them not to worry as "Mr Zailani is a fair examiner". Haha~

Talking to myself, I must get O&G, IM and Surgery/Ortho for my short cases. I looked at the names:
1) Dr Hatta Shaharom - External psychiatrist
2) A/P Dr Hamizah
3) Dr Marzuki
4) A/P Dr Junaini/ A/P Dr Kyaw Tin Hla/ Dr Mohd Zailani
5) A/P Dr Aye Aye

Oh. No Orthopaedic surgeon. So it has to be Surgery. And I was happy to see the names of Prof Hamizah and Dr Marzuki.

I prayed I'll get O&G first, and that I would get obstetric case. My wishes were granted. The patient was at 38 weeks POA. I never forget to do clinical fundal height before this but I forgot to do it on the day of my Pro. Astagfirullah~ The SFH measured 35 cm but Prof Hamizah asked to measure again and I got 31 cm. It was not quite a transverse lie or oligohydramnios. I couldn't feel the fetal parts. Seriously. I was so stressed out and spend quite a lot of time doing it. I finally said it was an oblique lie but Prof Hamizah directed it to discussion on uterus smaller than date and IUGR. The bell has already rang for quite some time. Yeah, I know.

Again, I prayed not to get cranial nerve examination and I didn't get it. "Examine the patient's cardiovascular system". I was so slow that I think I took 9 minutes for examination. I was not sure about the collapsing pulse but I think I saw Corrigan sign. The JVP was raised. There was PSM radiated to axilla. And thrill. And ankle edema. Ya Allah. The bell rang before I could reach the chest during presentation but all of the examiners just ignore it. Dr Marzuki was struggling to help me. It was painful to see him doing that. I'm so sorry Dr Marzuki. Huhu~ AR? TR? MR? I thought the patient was too old for congenital heart disease. I believed the final diagnosis was VSD in failure. Oh, only then I realised that I forgot to listen for bibasal crepitation. I was so thankful Dr Marzuki was my examiner. If I got Prof Tahir, Prof Tariq, Prof Fauzi - I believe I'm dead.

Mr Zailani asked me to "examine the patient's lower limb". Eh, lower limb in Surgery? I looked at the limb. Oh my God, varicose vein. (I hope Mr Zailani won't be reading this :p) I never examine any patient with varicose vein before. It was my first examination, during Pro exam. Lin just taught me 2 days prior to my clinical exam to lift up the patient's leg and put it over my shoulder to empty the vein. I did that, for the first time in my life in front of my 5 examiners. The vein did not refill upon occlusion of the sapheno femoral junction so I did not proceed with multiple torniquet test. Mr Zailani was very supportive. He asked me up to the management. However, I stumbled somewhere that forced him to asked me "the anatomy of venous system in the lower limb" which I managed to answer. I don't know what was in Mr Zailani's mind when he saw me doing the examination. I hope I didn't embarass him being my surgeon-teacher. Oh, and I thank my friends, Mr Junaini and Mr Faidzal who taught me the examination. At least I know how to examine varicose vein. I remember seeing HOs in surgical ward have no idea on how to examine a patient with varicose vein. InsyaAllah, I'll be able to do it.

I don't know how much they gave me for my short cases. I might actually fail. If I didn't, it was probably due to the examiners being my own lecturers who know me themselves.

So my dear junior. Practice, practice and practice. Don't be like me. I did practised. A lot. But only yesterday I realized that it might actually not quite enough.

I thank the lecturers from the bottom of my heart.

Thank you.
Thank you.
And thank you.

These people are among the nicest persons I've ever knew in my life :-)

I hope I fulfilled the criteria to be one of Dr Marzuki's "good students".
Oh, for the discussion:
- Definition, inheritance
- Types of thal
- Ddx, how to differentiate, protective factor towards thal
- When to transfuse, aim
- Role of splenomegaly, how to prepare pt (vaccine), indication, complication
- Cx of iron overload (cirrhosis, DM, hypopituitarism, hypothyroid, cardiomypathy, etc)
- Causes of premature death (cardiomyopathy), slow learning (hypothyroid)
- Diagnostic Ix
- How to monitor for iron overload (growth, puberty, TFT, RBS/FBS, LFT, echo)
- Other choices for chelating agent, pros and cons for each
- Long term plan for thal pt
- Definitive treatment, stem cell therapy, genetic counselling
Uterus smaller than date:
- Causes
- IUGR vs SGA, definition, how to differentiate
- Expected finding from U/S, biophysical profile, Doppler
VSD in failure:
- DDx
- Complications
Varicose vein:
- Definition, principle of examination, role of Perthe's test
- Causes/risk factors
- Ix, what to look for before op (patency of deep system)
- Anat of venous system
- Complications
- Indication for op
- Choices of op
- Management for venous ulcer

Third: Notes by Dr Suhaili (A piece of experience from my Final Pro exam)
*Reading my friends' experience inspires me to write something about my exam as it might be useful for my juniors; though it's not really me to write notes =p

My turn was on the second day of examinations.

The most important thing in clinical exam is to stay calm and relax. Treat it like the other end-posting examination (but it was difficult! because you wanted it to be the final one).

Long case

With Mr Shukrimi, Dr Hussin Imam, Prof Zalina, Dr Ramli, Prof How. I was excited to have Dr Hussin Imam as my examiner; really wanted to meet him because I enjoyed reading the Paediatric Protocol very much~ Thank you Allah.

I got an orthopaedic case; a 13-year-old Malay boy with no known medical illness, in his day 42 admission, non smoker; complaining of painful and erythematous swelling at the distal 1/3 of the right leg for 4 days which progressively worsened after 1 day - unable to ambulate and associated with high grade fever and constitutional symptoms. No history of trauma or insect bites. He only seek for medical treatment after day 4 of illness due to shortness of breath.

During admission, he had undergone 2 times operations (debridement) - 1 months apart; as the patient persistently had fever after the first operation. After the second operation, he was told that the infection has reached the bone. He was treated with intravenous antibiotics.

He was transfused with pack cells before the first operations and after that was admitted to ICU for 2 days after the 1st operation (maybe because of septicaemia).

*I had difficulty to take detail chronological history throughout admission period.

On examination, the right leg was swollen but not erythematous. There were multiple healthy incision wounds over the medial aspect of the right leg except for the wound over the distal third of the right leg which was having pus discharge. Otherwise, there was no bony tenderness and the patient was able to move all the joints with restricted dorsiflexion due to pain. The peripheral pulses were also present. He was unable to stand straight and walk.

* I did not have problem while presenting the history. We went to see the patient to present the physical examination and I was quite satisfied with it (hope the examiners felt the same). My provisional diagnosis was cellulitis complicated by osteomyelitis - in view of the history of starting with superficial pain. But the examiners were so kind, they guided me to the right way in which the diagnosis was acuet hematogenous osteomyelitis (they asked me; which one is more common - OM-->cellulitis / cellulitis -->OM. I frankly answered I was not sure).

* They asked about other differential diagnosis. After giving a few, they still did not satisfy with my list. Mr Shuk said, "Think, what is the condition when patient had painful swollen and erythematous leg and later come with shortness of breath. Prof How must be happy to see this case". I looked at Prof How's face and straightly answered pulmonary embolism secondary to DVT. At that time, I said to myself, why didn't I think about it before? This is because when they asked about the cause of SOB, I answered it might be due to anaemia as the patient said he was transfused with blood after admission. They continued asking the investigations and management which I was able to answer; the antibiotics used etc. I had to interpret the radiograph and the last question was about complication of OM.

*Dr Hussin Imam asked me about the common site of OM and the reason. I managed to answer it - at the metaphyseal area due to the distribution of the blood supply.

The end of my long case. Though not very satisfied because of the diagnosis, I went out the room with a relieve and smile; praying for the next session =)

My short cases

Smile. Smile. Smile. Just trying hard to stay calm and compose myself while waiting for the examiners from room 4.

I was glad to see Dr Marzuki, Prof Hamizah, Prof Kyaw, Dr Aye Aye (all the familiar faces to me) and Prof Hatta.

Case 1 - Paediatric

Please perform CVS examination.

Despite trying hard to stay calm, I was disturbed by myself in the earlier part of examination as I did not know how to prop up the bed. The different set of bed from the hospital's. It was at the end of bed! When I wanted to prop up the bed, our kind Prof Hamizah offered her help to do it and asked me to continue examine the patient. I think I took quite a longer time than my usual practice. But never mind. It was all anxiety. I felt blessed at the time I put my stethoscope at the apex, I could immediately recognize the pansystolic murmur which radiated to axilla. It so obvious and I thanked Allah for that. (I 'hated' determining murmur especially when I was in third year =p, but not now =)) After presenting the case with diagnosis of MR, not in failure, the bell rang and we went to the next case. Initially, I felt bad because no discussion but later I calmed myself to just concentrate on the next case.

Smile =) though worried inside as there was no further discussion.

Case 2 - OnG

This 30-year-old Malay lady, G3P0+2 at her 34 weeks POA. Please examine her.

There was uterus larger than date (grossly larger than date with SFH 45cm). The abdomen was not shiny and there was no dilated vein noticed. I knew, I have to find multiple poles or fluid thrill. I found 2 firm and non ballotable poles at the right and left hypochondrium but I did not get any round, hard and ballotable poles. The fetal part was difficult to palpate..huhuhu..which one is the diagnosis? I said to myself that I have to decide whether this is a multiple pregnancy or polyhydromnios. At that time, fluid thrill was my last resort for decision. I did not get the fluid thrill!!! Maybe I tapped it softly. And I presented the case as a multiple pregnancy as evidenced by 2 poles of similar characters.

*Prof Hamizah led the discussion by asking me what am I going to do next. I answered that I'd like to request for TAS to confirm the number of pregnancy and to look at AFI. She said that the AFI was 28. So it was polyhydromnios!!! (the poles are the same pole moving freely in the amniotic fluid after I palpated and tried to ballote it).

*She asked me about MOGTT and asked me to interpret the result. She also asked about HbA1c and things that we'd like to assess in ultrasound. I answered biophysical profile - fetal tone, fetal breathing movement and fetal activity as well as to assess if there is congenital anomalies like congenital heart disease, sacral agenesis / caudal regression syndrome and duodenal atresia (causing polyhydromnios).

End of second case. Smile =) - though was worried inside because of wrong initial diagnosis

In the middle of exam, on the way to the next case, I said to Dr Marzuki, "Dr, bagi kes yang senang ye." then, only I realized I shouldn't say was spontaneous..anxiety coping mechanism..hehe.. I'd not do it again.

Case 3 - Medical

Please examine the respiratory system.

She was an elderly Malay lady who was obese and appeared comfortable with no respiratory distress.

*Once again, Prof Hamizah helped me to prop up the bed.

I had difficulty to examine this patient as the bed was quite high for me. I have to step on my toes to examine chest expansion, percussion and auscultation especially at the left lung field. It was quite uncomfortable for me..huhuhu. But, alhamdulillah, I got the signs. Thanks to Allah as the signs were so obvious! Reduced chest expansion and coarse crepitation at the left lung field - more prominent at the middle and lower zone.

*I gave my diagnosis as bronchiectasis with a 'but' as I did not find any apparent clubbing. Then, Dr Marzuki asked me to check it again and I asked the patient to approximate her nails of the right and left index finger and I saw loss of angle of the nail bed. So, there was clubbing! Grade 2 clubbing.

*Dr Marzuki asked me about the causes; I answered recurrent pneumonia. He guided me - something more common in this region. Oh, pulmonary tuberculosis! Others..err.. The bell rang for the last time.

End of case 3 - Smile =) though was worried inside of unable to list other differential diagnosis.

I went out of JHC with a great relief and leaved everything to Allah.

My conclusion

*Usaha. Doa. Tawakal.

*Usaha since early. I mean study and catch up well in every posting. 7 weeks in every posting is adequate (at least to pass the end-posting exam) with the help of Allah.

*Manage the stress well. Have enough good sleep! (but my case is bad..sleeping as early as 9.30pm -10pm..haha)

*Manage the emotion and anxiety well especially during exam. Make a pray for it.

*The final pro atmosphere was so different than the end-block exam (at least in my experience). The lecturers are guiding us much. When I examined my patient, Prof Hamizah kept talking to me with her soothing voice for me to be calm and relax. Thanks to them! Alhamdulillah~

*Always pray for our friends.

*Always pray for our teachers.

* Be humble. Be humble. Be humble.

Hope this can benefit my juniors!
p/s: Sharing is Caring ;)
Category: 5 comments


pezol said...

gud luck semua...

totalmotion said...

That is really good information and thanks for sharing with us. You can get more from online physical therapy seminars

gumuruhsspj said...

MBBS tu ape ye?

admin@10thbatch said...

Bachelor of Medicine and Bachelor of Surgery

Anonymous said...

medic student..
Thank you for sharing brother...May God reward u and make it easy for you, inshAllah*

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