Next came the short cases. My first shortcase was a uterus larger than date. The first time I examined the patient, I was ‘kicked’ by the fetus at the right iliac fossa. Initially I wrongly diagnosed the patient with polyhydromnios.
Examiner: Do you think in polyhydromnios, patient can be lying comfortably like this?
Examiner: Would you like to examine again?
Me: OK. Minta maaf kak, boleh saya periksa semula?
The second time I examined the patient, her second baby kicked me at the left hypochondriac region. OK. Alhamdulillah, again Allah helped me by giving a clue. Padahal tak rasa pun multiple poles! This has to be a multiple pregnancy. It was a twin.
Examiner: How do you manage this patient?
Me: I would like to know the patient’s chief complaint
Examiner: Patient is comfortable, no complaint
Me: In this case I would like to prolong the pregnancy until term. Provided that this is not a MCMA twin, and the leading twin is in cephalic presentation, I would like to attempt vaginal delivery and anticipate the complications associated with twin pregnancy including PPH (maternal) due to overdistension of the uterus and...
Examiner: OK2. How do you classify twins?
Me: According to zygosity, chorionicity, amniocity
Examiner: If you have a twin pregnancy, which one would you prefer?
Me: DCDA, since it is associated with the least complications
Examiner: What complications do you mean?
Me: TTTS for MCDA, cord accidents for MCMA...
I had a CVS examination for my 2nd short case, the patient had a raised JVP, lower limb oedema, (and collapsing pulse which I failed to detect)... He had a displaced apex beat, thrills, various murmurs, MR, TR & AR. But I only detected MR & TR. Since he had multiple findings, I spent almost 8 minutes on examination alone, there were not much time left to discuss.
Examiner: So Dx?
Me: MR & TR and patient is in failure
Examiner: Only MR & TR? How about pulmonary area?
Examiner: OKlah nevermind (he actually had an AR also, according to Dr. Hasnur). Differential?
Me: VSD, but unlikely since patient is old, but it can occur due to MI rupturing the septum
Examiner: So you say patient is in failure, give him one advice.
Me: Fluid restriction?
My third case was an orthopaedic case.
Examiner: Examine the left lower limb
Me: (I asked permission to be on patient’s left side, and then I presented by running commentary) There were limb length discrepancy, muscle wasting, old scar. PLUS old sinus. No active signs of inflammation. I proceeded with FEEL & MOVE (range of movement). Positive Galeazzi’s sign.
Examiner: How many types of scar?
Me: Two – from the lesion & from the external fixator
Examiner: What do you want to do next?
Me: Calculate the true length
Examiner: OK, lain?
Me: I would like to attempt to move the limb. There was a pseudojoint at the distal third of left tibia, moveable and PAINLESS
Examiner: Ok. What is your Dx?
Me: Non-union of distal third of left tibia secondary to OM
Examiner: What are the factors affecting bone healing?
Me: Can be divided into bone factor, patient factor, surgeon factor... bla bla bla...
Examiner: What do you think was the problem with the patient?
Me: Infection, probably OM
Examiner: How did he get the infection?
Me: He may have had an open fracture through which infection was introduced...
Examiner: How do you know he had an open fracture?
Me: He had an external fixator (from the scar)
Examiner: Ok, I agree. What else was the patient’s problem?
Me: Hmm, maybe patient factor, uncontrolled DM?
Examiner: Hmm, OKlah, what else?
Examiner: Look at the calf. Do you think the soft tissue was enough to cover his fracture?
Me: Oh, insufficient soft tissue cover.
Examiner: OK. Dah, cukuplah...
Alhamdulillah, I have never felt this calm in any exam before this (I mean, I was magically calm during the professional exam.. But before the exam, Allah jelah yang tahu...). In this exam, I felt confident, well-directed, Alhamdulillah my answers were mostly smooth, and at instances I even had ‘speech diarrhoea’ which almost never occurred before...! At one point I did not feel like myself, it felt like an external force was controlling my every movement and sayings. And NO, I do not have any other Schneiderian first rank symptoms. I just felt like Allah was with me in my every step, He was eyes with which I used to observe, He was my hand with which I examined the patients, He was my legs with which I walked, He was my tongue with which I presented and answered the questions, seriously! I did not feel like myself. Allah helped me all along, Alhamdulillah, thumma Alhamdulillah...
“My servant constantly approaches Me through supererogatory acts of worship until I love him, and when I love him, I become His eyes with which he sees, his hands with which he holds, and his legs with which he walks.” In another version, the wording is: “So through Me he hears, through Me he sees, and through Me he understands.” (Bukhari)
Tidak ada kedekatan hambaKu yang lebih Aku sukai melainkan dengan apa-apa yang Aku wajibkan kepadanya. Kemudian, hambaKu masih mendekatkan diri kepadaKu dengan amalan sunnah sehingga aku mencintainya. Apabila Aku sudah mencintainya, maka Akulah yang akan menjadi pandangannya ketika dia melihat. Dan Aku yang akan menjadi kakinya ketika dia melangkah. Apabila dia meminta perlindungan kepadaKu maka pasti aku lindungi. Dan apabila dia meminta ampunanKu pasti Aku ampuni. (Bukhari)May we all become those whom He loves...