Yesterday, I had my very first ever long case exam for my Medicine rotation. Alhamdulillah, it went well.
I got a patient, Mr J, a 65 years old obese man presented to the hospital by GP referral with bilateral ankle swelling for the past 2 months with the background history of hypertension.
He was well until 2 months ago, he start noticed leg swelling on both of his legs. He went to his GP for weeks ago, and his GP put him on water tablets but it did not resolved the swelling much.
He also complaints of intermittent stabbing pain at both of his legs with severity of 8/10 which is relieved by taking painkillers medication.
He denies any chest pain, shortness of breath, fever, weight loss or malaise.
Past medical history includes hypertension for 3 years and Type 2 Diabetes Mellitus for 10 years. His blood pressure and blood sugar are well-controlled for the past years.
He is currently on Metformin and Diamicron for his diabetes and on Xalatan and Bisoprolol for his hypertension. He is also on Atorvastatin and Hydrochlorothiazide/Telmisartan. He has no known drug allergies.
Family history is non-contributory.
Socially, he is a retiree from agricultural sector. He lives with his wife and children. He is an ex-smoker for 17 years and drink occasionally.
Review of system is negative.
My impression for this patient are:
3. Congestive cardiac failure
So, after I have presented my case, then Dr C asked me a few questions.
"What is the obvious clinical sign that you can see from this man?"
There was actually very obvious bilateral leg swelling with erythematous and scaly skin.
Then, he asked me what else can cause leg swelling besides all those that I have already said. And he gave a clue something to do about the kidney. Oh yeah it is nephrotic syndrome and he asked my what is nephrotic syndrome.
Briefly, nephrotic syndrome is a triad of hypoalbuminemia, proteinuria and .... (try to remember the other one..) and Dr C said " and oedema.."
And then he asked me again, what else? So then, I mentioned liver cirrhosis and he asked me, how? Well, the function of the liver is to produce albumin and clotting factors. So, when the liver is damage, there will be lack of albumin and hence causing hypoalbuminemia. This later on decrease oncotic pressure and increase venous pressure. Therefore more fluid pass across the capillaries and lead to swelling.
Next, he asked how I want to know whether the swelling might be due to hypoalbuminemia or due to congestive cardiac failure. First, I said from bedside, when can check if there any signs of leukonychia. And then he replied, what is other obvious sign? Then, oh yeah, raised JVP in congestive cardiac failure.
Dr C loves clinical sign so much and so he kept asking me, what else do I noticed from this patient?
So I mentioned the patient has right red eyes, corneal arcus, telangiectasia on his cheeks, ecchymoses on his abdomen.
What else? Gynaecomastia.
And he asked me back, are you sure it is gynaecomastia or it just because of obesity? Haha so I just knew there is actually they are different. In patient that have gynaecomastia, you can feel subareolar gland around it.
What else? Central abdomen distension. (Lol this description is just way too medic. In malay term we may say, perut buncit mengandung like 9 months)
Thus, he asked me what can cause abdomen distension.
So, I said, fat, flatus, fluid, faeces and fetus.
And the he asked, how about for this man?
I straight away said, fat. Supposedly I should say adipose tissue, because "fat" is just not so nice term to be heard by the patient. My bad!
Lastly, Dr C showed me the patient's drug chart and asked me about one of the side effect of Nifedipine. It is a calcium channel blocker and can cause vasodilation. And for that patient, it the medication that cause he got bilateral leg swelling and thus the doctor has stopped him from taking that medication.
Overall, it was not too bad. Dr C did gave feedback afterward and said he gave honours for my performance in long case. Alhamdulillah, it was a good start for other long case exam in next rotations..
So, another one week left for medicine rotation. How fast time flies. This upcoming week need to work on my short case exam which is due next April, pheww.
Top 3 things that medical students love to complaint about:
1. Complaints of too much studyloads, workloads, packed hospital schedules
2. Complaints of stress because a lot of exams
3. Complaints of consultant ni kan, dia kan, bla bla bla..
But today, I just learnt that I shouldnt complaint too much because I am currently in a training to be a competent doctor. So, that's why I have to know a lot of stuffs in medicine so that I know how to manage and treat my patients then.
The phrase "Training to be a competent doctor" is really like; no matter how hard it is life as a final year medical student, all of these hardship is for me to be a good doctor next year. So, I will do anything for 6 months left for me before graduation (ameen insyaAllah). Now, it is not about passing all exams, but it is all about whether I'm going to be a safe doctor or not in the future.
What triggers me about this is after Dr O asked me to clerk a new patient that arrived in Medical Assessment Unit this evening and do examination on that patient. And the he asked me to write my own plan for that patients.
For example the patient I clerked,
60 years old male presented with flu-like symptoms, productive cough with yellow phlegm, fever and night sweats for the past 2 weeks. On examination, first and second heart sound are normal, no added sound or no murmur. Chest are clear and there is no added sound or reduced air entry. Abdomen is soft and non tender. Sensory and motor systems are intact.
So first I have to make an intelligent guess of what are the possible diagnosis for this patient. My impression for this patient is lower respiratory tract infection. But I would like to exclude TB because he complaint of night sweats.
Now, what is my "plan"?
1. Blood test - Full blood count, urea and electrolyte, inflammatory markers
2. Sputum culture
3. Blood culture
4. Chest X Ray
6. Broad spectrum antibiotic such as Co-amoxiclav for possible infectiom
7. Paracetamol for fever
So, this is what Dr O asked me to do and thus I feel, so this is how doctor do their job, integrate their knowledge and manifest them in medical practise. How cool is that to help people yeahh?
So, now I would encourage all my medic colleagues to stop or maybe reduce our complaining habits but start working hard on being a safe doctor next year, shall we?