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Saturday, January 23, 2016

OBG practical and Internship Dreams

Woohoo. Finally.

I already wrote about the first three practical exams.

OBG was a breeze. Went early to the special (examination) ward. Had a 24 year old lady with a previous Caesarean section as my Obstetrics case. And a 65 year old with procidentia uterus as the gynaecology case.

I told the examiners that the reason for previous Caesarean was respiratory distress (instead of telling fetal distress) and I had to tell everything about fetal distress, all the things that are monitored, and what management to go with, and in VBAC-TOL how to manage first, second, and third stage; whether to cut-short second stage or not. It was more like they were testing if I could go work in the labour room tomorrow.

Same thing followed in Gynaecology. My patient had decubitus ulcer and I had to explain how to manage it (and how to manage the "corresponding" ulcer in surgery (which happens to be venous ulcer)).

Viva had 4 stations.

Station 1: Ultrasound and x-rays. Luckily I got X-ray because I knew nothing about ultrasound. And the X-ray of pelvis showed a bent Copper T being assessed by a uterine sound? I had to tell the long term side effects of Copper T too.

Station 2: Specimens. There were some 5 specimens and I could only recognize the anencephaly kid and so I chose it. I had to tell how I recognized it, that it is a neural tube defect, other examples of NTD

Station 3: Instruments. I identified a manual vacuum aspiration syringe (Girls also had to pull it against vacuum to prove that they have the strength to do it) and a ventouse. Then I got a CuT and was asked how it is inserted the keyword I had to say being "withdrawal technique" which I didn't.

Station 4: Pelvis. Had to show bispinous diameter and give the common value. Then, I was asked to identify what was obturator foramen; followed by "what is its clinical significance?" which apparently was asked to many of my friends and nobody got the correct answer to.

We came out and none of us could believe that it was all over. In just 4 (gruelling) days that went by like a quick cold shower, we had gone from students to doctors.

Well, I say doctors because since yesterday I am addressing all my friends "Doctor" and dreaming of all the hospital work to follow. The only thing between Akshay and Dr Akshay now is RGUHS announcing the result with PASS return next to my name.

And so am I reading through the thousand medical posts in Polite Dissent which I discovered by searching for that House scenario I talked about in the last post. And through so many nice posts in the underwear drawer.

That is also why I got scared reading this horror story of a first year PG getting beaten up last week for the death of an accident victim and even read Hippocratic oath and MCI code of ethics.

I can't wait to finish Harrison's now :D

Acronyms used in this post:
OBG - Obstetrics and Gynaecology
VBAC-TOL - Vaginal Birth After Caesarean - Trial of Labour
NTD - Neural Tube Defect
CuT - Copper T
RGUHS - Rajiv Gandhi University of Health Sciences

Thursday, January 21, 2016

Medicine, Paediatrics, Surgery practicals.

Oh, the last three days! If I had a moment for myself, I would have posted this one a bit earlier.

I am usually not very tensed before any exam. But being the last set of exams, and losing 6 months if I don't get through gave me some horrible horrible dreams on the night of 18th-19th. Being the first batch to go into Medicine practical, with MCI inspection as an added thing to worry about didn't help at all.

Thanks to some very helpful friends I had everything ready - CNS kit, watch, thermometer, what not. I even bought an aneroid sphygmomanometer hoping that I will permanently need it in two months when I become an intern.

I even called dad and he helped calm some nerves, but there were simply too many of them left jumping at the slightest thoughts.

Temporal sensation was lost to dreams mixed in reality - the first time I woke up (at 2) everything was normal, the next time I woke up (just before 5 when my alarm was supposed to wake me up) I had a morbid dream (which I happily have forgotten now) and the next time I woke up (it was 2.30!!) I was in my old home. The last time I woke up, just before 5 again, I was being asked by the external examiner to examine the internal examiner while all the patients were growling in the background in a room full of worn clothes (and yes, I had forgotten to wear apron and so couldn't proceed to examine and that's how I woke up). If someone does an analysis of my dreams, they can write novels about them.

Dreams apart, on the day (19th), we went to the specially made exam ward where all patients were waiting for us. Cases were assigned randomly and I received a case of fibrothorax (?) with ascites (ALD? TB Peritonitis?) who had defaulted twice off ATT. I couldn't finish examining the case and writing the case sheet in the 1 hour that was provided but somehow I wrote everything that came to my mind.

And then I took two short cases - anemia and COPD.

I had to use all my experience in presenting case in making a good appearance to compensate for my incomplete (and at several places, wrong) case sheet. After history I was presenting my impression as a case of fibrothorax due to PTB and ALD due to alcoholism. And then Dr Srinivas asked me for a single cause that would connect both the symptoms (breathlessness with ascites, limb edema) and I came up with COPD, cor pulmonale in failure. I thought the patient had clubbing of third grade, but there are these fingers that people have that look just like small parrot beaks but aren't. Lesson learned: always check for grade 1 and 2 clubbing before going for grade 3 clubbing. After examination, I zeroed in on fibrothorax (the chest expansion and lung sounds were reduced on the left side) and ALD. But, the examiners helped me to a better diagnosis - that of TB peritonitis. And I gave a battery of tests for confirmation.

The short cases were very short in presentation. The anaemic guy had no organomegaly on abdomen examination (we were supposed to do GPE and PA only). I could figure out some paleness in the palpebral conjunctiva but I don't think I picked up platynychia. And I had never heard of fish tapeworm (Diphyllobothrium latum) which causes Vit B12 deficiency. The COPD guy looked emaciated and his chest expansion was just about a centimeter. Percussion over chest was hyperresonant and thus my diagnosis was emphysema.

Later, in the afternoon, after some hot bread omelettes (burning through the superficial layer of my hungry gums) and soft drinks from the Jayadeva canteen below we had spotters followed by viva.

All that I now remember of the spotters is that X-ray of hydropneumothorax which I almost missed.

For viva, on the first table, I got an x-ray, this time with a large heart and some diffuse opacities around. I guessed pericardial effusion and had to give causes. The ECG showed ST elevation in almost all leads and I said it was pericarditis.

On the other table, I had to identify Ryle's tube and give another name (I gave the name nasogastric tube. How's this different from Levin tube?) Turns out it is contraindicated not just in corrosive poisoning but also in kerosene poisoning. And then I got a chart showing CSF report of increased lymphocytes, high protein, and normal sugar levels. I diagnosed Tuberculous meningitis. And turns out the one drug that you give other than ATT is corticosteroids.

I walked out like a champion, don't know why.

Even more horrible dreams before pediatrics (accidents, ambulances, everything morbid). But the cases I got were lovely - normal newborn, ADD.

The newborn was very cute and his mother was just 20 years old. The examiners asked many others the steps of washing hands before examining. Wish they asked me that. I had to tell about warm chain, five cleans, about problems with teenage pregnancy, causes of jaundice on day 1, and so on.

The ADD baby was weak, but irritable. And she slept with the chilum chilum toy I gave her. The examiners asked me the management of some dehydration. Then they asked me when ORT would fail. (I should have guessed vomiting, and I had no idea about "rate of purging" although I did tell highly "virulent" organisms, instead of telling cholera). Just before standing up for lunch, they asked me which other drug I would give, just to hear my Malayali pronunciation of "Zinc".

Not to forget the MCI squad who were filming the proceedings.

After lunch, 4 stations for viva.

Station 1: Diazepam. What are the uses? Status epilepticus, convulsions.. What dose? Who knows.
Rotavirus vaccine. ... Silence... (Oh, describe. Tell whatever you know). 6 weeks, 10 weeks... What are the side effects? Well, something with GIT? Have you heard of intussusception? Aah!

Station 2: AMBU bag. What are the parts? Self-inflating bag, valve, etc. How do you put this in place? I pick up the laryngoscope parts and put them together and hold it like I was about to intubate the instrument tray. The anesthesia training last year was probably not impressive enough. What are the contraindications of positive pressure ventilation? Well, hyaline membrane disease? And the disease where the baby has scaphoid abdomen, bluish fingers, ...? Blinks. Congenital diaphramatic hernia, you idiot.

Station 3. Salt. Sodium chloride. Sometimes iodized. Used in all drugs. Should not be given in hypertension, kidney diseases, etc. Ragi. Rich in iron? What else? Staple diet of Karnataka? Not Kerala? Groundnut. Rich in protein? And? Carbohydrate? Have you heard of groundnut oil? Oh yes, rich in fat. Given in? PEM, to fill the energy gap.

Station 4. X-rays. Identify. I searched everywhere in the left chest talking about pneumonia, consolidation, etc. What is on the left side? Pneumothorax!! How many tubes do you see in this x-ray? ICD, ...and in the stomach there was a Ryle's tube. Two more x-rays were shown with cardiomegaly. I still can't say which is which.

There was sunlight left when I left the building that I had went in without apron that morning.

Last night I decided to sleep, come what may. Less of dreams too.

Ran to Surgery block in the morning after having some breakfast (in so many days). Took short cases first - solitary nodule of thyroid, diabetic foot ulcer. And then Carcinoma breast.

I couldn't classify ulcer correctly! But told almost everything in a jumble. With thyroid I had to name some soft swellings. I remembered thyroglossal cyst. Then I had to say the development of thyroglossal cyst.

For breast, I wasn't even asked a lot of questions. Management, importance of movement with breast tissue, and done.

In Orthopaedics which was going on the other side of the room, I got multiple exostosis and chronic myelitis. They asked me why it is multiple and why it is exostosis. They gave me the x-ray of the myelitis patient and asked me what other thing could cause it (tuberculosis, with some "Indianness" clues). I picked up the Austin Moore prosthesis and told what it is, where it is used. And they gave me the x-ray of an intertrochantric fracture.

Then there was the lunch break in which some of my dumbest friends ate one chicken biriyani meant for the examiners. They would have had all five if the PG hadn't arrived on time. Excellent time for revision too. Instruments, procedures, x-rays.

Viva was quick. Went to x-rays first. There was air under the diaphragm. Intestinal perforation. Management would be antibiotics and then exploratory laparotomy. Then to instruments. Deaver retractor, Kocher's forceps. Where else do you find Kocher's? Turns out, a lot of places. Then, among some pathological specimens I identified the one Dr Balakrishna pointed out - testicular cancer. How do you say it is testis? Well, I could have just said that the epididymis was right there. But rather, I tried telling everything about its organization and shape and stuff. Then I had to tell the contents of spermatic cord. I told almost everything except messing up genital branch of genito femoral nerve with ilioinguinal nerve.

And the last table was fun. I opened a chit with suprapubic cystoscopy written in it. I would say "block", "block" instead of obstruction. And then, the examiner asks me, you are the medical officer in a remote place. You don't have Foley's catheter or anything. A patient comes with acute urinary retention. What do you do?

All the 8 seasons of House became meaningful at that moment when I remembered House doing a suprapubic tap (spoilers in the link) in the season ending episode of first season.

And now I must study for tomorrow.

Abbreviations used in this post:
TB - Tuberculosis
PTB - Pulmonary Tuberculosis
ATT - Anti Tubercular Therapy
ALD - Alcoholic Liver Disease
GPE - General Physical Examination
PA - Per Abdomen
COPD - Chronic Obstructive Pulmonary Disease
MCI - Medical Council of India
CNS - Central Nervous System
ECG - Electro Cardio Gram
CSF - Cerebrospinal fluid
ADD - Acute Diarrhoeal Disease
ORT - Oral Rehydration Therapy
AMBU - Ambulatory Mechanical Breathing Unit
PEM - Protein Energy Malnutrition
ICD - Intercostal drainage

(Update: Read about OBG here)

Obstetrics, Gynaecology, and Paediatrics Theory question papers

 The trend of poor specificity in answers continued.

Overall, there's very good chances that I won't make it in one theory paper at least. Can't figure out which one.