So, its good that I have two blogs.
Yesterday was just another end of posting (EOP) exam for fourth year medical students. As usual, the examiners are mixed hospital doctors and university lecturers.
We were at the female general medical ward yesterday, and to me, the cases were nothing unusual.
I had seven students to examine. Students have started clerking patients at around 8.30am, as the clinical instructor will have to allocate students based on patients chosen by the hospital doctors.
I came in at 9.30am, and this is the usual starting time for internal medicine EOP exams.
The first student had started about 5 minutes late, usually not the students fault, its just that things in the hospital can be very busy in the morning. So I let the student finish and then invite them to the doctors office, which is normally quiet in the morning as the hospital staff as busy with ward rounds.
Other students who are waiting their turn can actually sit and listen, I have no problem with that as long as the cases are not repeated (same patient used for different students). However, if the student is doing badly, this can make the already anxious audience, increasing anxiety. So I don't know what to advice on that.😅
The student will be given an envelope with the marking scheme, and I will ask the student for their ID card. Its still amazes how many students do not have their college ID card with them all the time, which is a requirement in the wards. Sure, accidents are pardoned, but there should not be too many of them.
- Students: Please bring your ID card with you to all exams, both clinical and written.
The quiet calm of the doctors office may not reflect the usual chaos on the wards in the morning. Maybe not chaos, but rather noisy environment.
By the fourth year, most students are reasonably good at the history and physical examination, but most struggle at the differential diagnosis, and management.
Our first case was a patient with known thalassemia major and who was non-compliant to treatment.
Thalassemia is such a common condition in Malaysia that medical students really need to know everything about it well.
Most patients will be admitted due to some complication arising from the disorder.
Do not say that iron supplement is part of the treatment because the anaemia is not caused by iron deficiency and repeated blood transfusions can actually cause iron overload.
- Thalassemia is a very common condition in Malaysia and also in internal medicine in-patients, so know the disease well.
Read more on thalassemia:
Read the treatment of thalassemia, medical and surgical:
https://emedicine.medscape.com/article/206490-treatment#d10
Hepatomegaly in thalassemia patients:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3915436/
Another general point to make is that the investigations should reflect the differential diagnosis. While it is acceptable to divide investigations into lists of:
- Blood tests including haematological, biochemical etc
- Radiological
- Others example urine, sputum, ECG, spirometry etc
Sometimes it is better to list the diagnostic tests first.
Yesterday, as is many other days in general medicine, is dengue day. There were several dengue cases. Perhaps three out of seven patients!
For many cases, the NS1 antigen test is helpful in making the diagnosis as it will influence management, and please know the management and complications of dengue too, as it is too common in Malaysia.
The clinical practice guidelines for dengue are also useful but might be a bit long, so focus on the summary:
- You must know everything about dengue
I like to ask about warning signs and the management of severe dengue.
Also, one student described a patients rash as petechial, but when we looked at the patient together, it is actually a blanching macular rash.
To be continued...
