Finals: Clinical Practice Examination

5 years into the MBChB (for the uninformed, that's Bachelor of Medicine and Surgery, although I cannot explain why it is MBChB) course at the University of Edinburgh boils down to the 4 day stint that we're gonna pull - the FINALS.

Ok, of all the exams that I've done, I am truly and wholly committed to being a non fan of OSCEs.

At all.

Or CPE (that is the revamped name for the finals OSCE exam but does not change it's level of hatefulness one single bit) for that matter.

Yes, OSCEs is the most annoying test I can think of, where you go in and have to examine patients and present your findings and get grilled by the consultants who are there to grade you.

So why do I hate it?

Because I detest being put on the spot, and having to answer someone's question when I clearly do not know the answer to it.

But guess what? I HAVE to go through it and what more, PASS it as one of my components to attain my MBChB title.

So today was D-Day for the final OSCE/CPE showdown.

9.40am and there I am sitting and reciting gospel songs in my head to calm my nerves (yes, you will turn to God in your bleakest hour) and also psyching myself that I am here today to show off what I know.

Which really,
Isn't Heck of A Lot.

So, I get my gadgets out - name tag, stethoscope, measuring tape, black ballpoint pen and... CRAP! I forgot my pen torch!!

*oh no, oh no.. starts panicking*

I went to tell the invigilator that I do not have a pen torch and hence would not be able to perform my well-practiced-close-to-perfect examination of the eyes if required to do so. I also fully regret I will not be able to elicit that bitemporal upper quadrantinopia of the patient and roll off my list of differential diagnoses because I do not have a pen torch.
At to which she tells me that I most probably would not need it.

GOOD. I no likey the eyes anyway and whatever perfect examination I can do is total bull.

Pretty soon, I was standing outside the door of my first station which was the Short Cases, aka examination exam.
To my utmost delight, I saw Dr Flappan, my cardiology tutor in 3rd year and Professor Hayes whom I know is a liver consultant and they were both going to examine me. My heart rate immediately dropped from 200 beats per minute to about 100.
Like my flatmate puts it - you put a person who acts like a clown and the other person who IS a clown - together.. forms what another ang moh friend call - the Dream Team.
Obviously none remembered who I was.

So Prof asks for my name and checks my name badge (which reads Rachel Hung) against the clipboard and says in a slightly miffed tone, "Why do you guys have so complicated names?!?"
At to which Dr Flappan immediately retorts, "Right, Rachel. How complicated can you get with that name!?"

And everyone laughs.

"NO, look at this paper, there are tonnes of other names on it!" Prof Hayes defended.

Sorry la, my name got chinese name and yes, very unfamiliar, but I reckon Rachel Hung Kar Ying is seriously better than Karolina Skorupskaite or Etohan Anne Ogembudia. (no pun intended, those two girls are extremely friendly, nice and clever)

But, hey, argue about my name all you want docs, I'm Good. Just PASS Me.

So as we were walking in, Dr Flappan turns and asks me, "What's your favourite system?"

Flabbergasted, I did consider saying cardiology (he is a cardiologist ma, so must polish boots) but I did consider the awful fact of what if I got a cardiology patient and could not diagnose his condition? That will be downright rude.

So, I merely said, "All systems. And I like simple things. SIMPLE."

Yeahla, with my level of knowledge, things HAVE gotta be simple.

First patient up.
Dr Flappan opens the case, "Mr. X has a problem with his heart. He is applying to the Royal Bank of Scotland for a loan to buy a Ferrari. But before his loan is approved, the officers needs a medical check up on him. You are his doctor."

Ah, Ferraris.

So I start with the wash my hands, introduce myself, stand at end of bed..

While I examined to see if he had a collapsing pulse, Dr Flappan exclaimed in wonder, "Wow, that's a very good technique! Who taught you cardiology?"

Me, without skipping a beat, "I did cardiology under Professor Newby and you."

Polish, polish, polish... but it is true okay.

Ask me questions that is not academic sure can answer.

Prof Hayes, "Hmm, she looks very promising... "

YES. OF COURSE I DO.

So I moved on to finish the examination and presented what I found, at which was I think.... a wrong diagnosis, but oh well, too late now...

Next was a guy with a diabetic foot.
Dr Flappan starts again, telling me that this patient is diabetic and is complaining of numbness in his leg. "You are allowed to ask him 1 question. Ask him what he has."

Me, wah, this is going well, already give me answer : "Ok, sir, what do you have?"

And patient goes off in a torrent of symptoms til Prof Hayes tells him to shut up.

So I proceed with the usual neurology examination of the foot while both my examiners chatted about the sun and the sky, the sand and the sea.
I'm not sure if theywere actually looking at what I am doing, but hey, I was not sure if I could feel the pulses in the patients leg at all and am not sure whether they are supposed to be there or not in the first place. Nah, I'm not very good with pulses. A good thing they were discussing the more dire problems of the Earth than asking me what my findings were, lest I dig a huge hole for myself if I were to lie.
Halfway through, I was cut short by Dr Flappan asking me to go immediately to examine the ankle reflexes.

"Who taught you how to test the reflexes at the ankles like that?!"

"Oh, er, I can do it the other way."

And the external examiner whispers to them both, "What she is doing is the easy way."

OMG. I had no idea that was an easier way, I just thought that they were both the same! They call it ankle jerk for a reason. But come to think of it, she probably had saved my @ss here as the other two examiners obviously had no flippin' idea of what I was doing.

So I quickly do it the other way I know of and moved from the right side to the left side of the bed to examine his left ankle reflex when Prof Hayes injects and asks again, "Has no one taught you to do it from the right side of the bed?!"

Totally gone with the wind now, I quickly retort, "Oh, it's easier to do it from this side..."

Wat the... of course make my life easier if I can move right?!
But cannot, need to say .. sorry, sorry.

Dr Flappan adds the icing on the cake when he hits the bulls eye with, "You are evidently better at cardio than you are at neuro..."

BABI. My good first impression is slowly fading away liao...

Next case was a lady whom Prof asks me to examine her gastrointestinal system.

I start the normal wash hands, intro myself to the patient, inspection bla bla.. and I reach the neck where I mention confidently that I want to check the patient's JVP.

Prof Hayes, in a most annoyed tone, "Why do you want to check his JVP?!?"

Before I could answer, Dr Flappan interjects with an even more annoyed tone, "The JVP is very important! It could mean a lot of .... bla bla bla... " as I drowned out their voices and turned back to my patient.

I'd welcome any help of answering any questions in any form.

A few scars later and a feel of her tummy got Prof Hayes asking me what I felt, at to which I commented a rubbish answer of 'fullness in her right upper quadrant' and then mentioned my differential diagnosis as dyspepsia as she is complaining of epigastric pain.
How does RUQ fullness combine with epigastric pain and dyspepsia... I HAVE NO IDEA.

Thankfully the buzzer went and I thanked both examiners profusely as I quickly stepped out.

Station 2 was the history station where I stood outside for a good 15 seconds before Jennifer Hill, the invigilator tells me to KNOCK and GO IN.

So I did and completed my history taking in what I hope was a good empathetic, hypocritical face full of sympathy and of course, boasting top class acting skills.
Diagnosis was multiple sclerosis and I mentioned I'd like to do an ECG.. at to which the examiner asked me WHY.. and I was like.. er.. cause.. she could be anaemic? heart rate... and noticing my obvious torrent of nonsense, the examiner says IS IT GOING TO HELP YOUR DIAGNOSIS... at to which I say... noo.... SO WOULD YOU STILL WANT AN ECG.... nooooooooo..............

Finally was to break bad news to the patient that it could be multiple sclerosis and she bursts into tears and claims, 'Oh, I can't tell my mother, I won't I won't" and ting! I remembered that a marking point in the breaking bad news marking scheme is asking the patient if they wanted a relative in with them, so I quickly interjected, "Do you want your mother in with you.." and then added.. "oh, but you do not want your mother to know.... "

Right.

That station ended with me just staring at the patient and her obvious agony (all make believe of course) and me just zombie-fied because I did not know what else to do.

Moving quickly on...

Drug prescribing was for renal colic where the patient had crap kidney function. Like any good doctor would know, with crap kidney function, you Do Not, repeat DO NOT prescribe an NSAID.
Drug kardex out, and I smile to myself as I wrote - Diclofenac (a f*^%ing NSAID) 50mg..
Wait, I'm not sure about the dose.. a quick dive into the BNF shows that it's 75mg.. and I cancel out my first prescription, smiling even wider as the examiners have now seen that I am being safe and counter checking all my doses so I do not kill a patient with a wrong one.
Moving on to prescribe his normal doses for his other drugs.... it suddenly dawned on me, alike receiving enlightenment from the tree or something to the same effect...that his kidney function is BAD.
Like BAD BAD, he is going to need dialysis.

And with terror, I quickly flip to the front and cross out the heroic 'Diclofenac' and pop down Cyclizine 10mg, Morphine 1o mg.. CRAP.. 10mg morphine is way too much and another cross out to Morphine 2.5mg.

By now, my drug kardex looks like a Snake and Ladders game board.

So I hand my horrible looking answers to the examiners (I did ask if I could use a new one but they said No) and obviously my chance of exhibiting the many thousand hours I spent in my kitchen with my study mates prescribing drug after drug for the many different medical/surgical conditions were blown away by the myriad of lines on my answer sheet.

Good thing it was right though. Or at least that's what I think.

Then fluids prescription came for this guy who was vomiting and shitting blood and it totally didn't cross my mind that DAMN, I NEED TO BE CROSS MATCHING BLOOD FOR HIM AND ACTIVATING THE MAJOR HAEMORRHAGE PROTOCOL!

They got it out of me in the end and asked me a whole lot of questions that I myself do not even know what they were about.

And the nurse would also refuse to give the patient fluids because I forgot to sign my name after I prescribed them. ERGH.

But...

It's over.

And I pretty well better pass.

If not, seriously membabikan d.

ps: I realise that there are a lot of medical terms there and sorry if you cannot understand it, please use the tool called Google.