Long case

Wednesday, 28th July 2010

I was awake a few times by my house mates' alarms for a in wee hours. Every time I was awake, I told myself "long case", then I looked at the time, I off to sleep again. But I did not dream of anything about case in the hospital. I didn't remember what is in my lala land, anyway.

Off to hospital while sending text to Nalini. Then I met her and Hiang Jin around Ward 5. I am not very nervous at that moment. Nalini kept prompting me with a lot of questions about investigations and management I would like to do in different diseases. I didn't really study much the night before, nothing run through my mind and I went to bed early.

Prof. Dr. Sheikh Anwar, my long case supervisor met us in Endoscopy Room which give us no clue at all what we were going to do. Some groups only did teachings instead of observed long case. Some group did very typical and classy observed long case where all your group members and the supervisor watching you taking history from the patient and do physical examination as well. We joked that we will be learning endoscopy today and pass our long case without efforts.

That proved 5 of us wrong when he brought us out of Endoscopy Room and took a lift up back to 6th floor (I just came from there to 1st floor). We wanted him to turn left when we reached 6th floor because most of us know better the case in Ward 5 and 6. Anyway, our wish was not granted, he turned right! Maybe supervisor is always right.. Duh. Then each of us were assigned to a patient all at the same time. He gave us 30 minutes to take history and perform physical examination plus preparation for our case presentation. He informed us that he will be around this ward watching 5 of us at the same time.

History taking and physical examination went all right for me. My patient presented with shortness of breath for the past 1 week with known history of asthma. So, I proceed with respiratory examination. Well expected, I missed out something again. Trachea deviation, this time. Presentation was usual and I was able to give a few differential other than the clear provisional diagnosis in the history.

My Q&A session was pretty bad.

1. How do you grade asthma?
I am not sure, doctor. Is it the same grading as shortness of breath by NYHA?
=After that, he didn't really say anything. I didn't know the answer actually=

2. How do you grade the severity of asthma?
Emm.. I am not sure about this.
=You grade the severity by assessing whether the patient can speak one full sentence in a breathe=
(Yikes! How can I forget about this???)

3. What is your management for this patient?
For immediate management, I will first sit the patient upright and give her oxygen for 100%. I will then give her salbutamol with ipratoprium to relieve her asthma. After that, IV assess, if she is dehydrated, I will give normal saline IV. Besides, I will give steroids as well such as hydrocortisone. At the same time, I will do an ECG on her. Later, I will ask for investigations such as ABG, FBC, lung function test and etc...

Fortunately, I didn't get much questions from him as I had mentioned a lot during investigations and I gave my reasons and expected values. Bronchial asthma is something I had prepared and I was lucky to get the patient. Anyhow, 2 out of 3 questions I started with "I am not sure", which I think it was kind of bad as the question was not very tough.

After everyone had present their case, our supervisor seems to be happy but he did not give any comment. He just mentioned that everyone was not bad. I guess we can pass, but not distinction, I guess. However, in my opinion, my group members did a good job. Most of us did not stumble during the presentation and tried to convince the supervisor even though we seems to be shaky in some parts.

There goes my first not very typical observed long case with half of my big group members (Group G). Hope we didn't disappoint Dr. Ting (my supervisor) and Dr. Arif (my registrar) after 6 weeks of teachings.

Next, short case on 6th August, last day of Internal Medicine before we have a week of break and also Sue Ann's birthday.. See ya

P.S to my brother, Sam : My patient did not run away and is not crazy...

Love