Dedicated to Syaimaa Ahmad and a fan who wished me early this morning and reminded me to update. Here's a long case for the two of you. Haha.
Alhamdulillah for the smooth exam, whatever the outcome may be. We had three patients to examine with five true/false questions regarding our findings after each case and a fourth patient to take a long case "in ten minutes" to be vivaed later. (Long case in ten minutes examination? My dad examined me a long case Down syndrome and gave me an hour!)
I was the first up for my group. The first patient was a recurrent inguino-scrotal hernia case and the uncle was so eager to help he showed me his hernia as soon as I greeted him. Lulz. I was scrambling to put on my gloves because no one is interested to examine a groin without gloves.
I asked him to stand so I can properly examine him but he refused and told me where to put my hands while telling me about his case in Arabic, using English terms.
Very distracting, but otherwise helpful. I complimented his English and asked for his history while examining the swellings. Even showed me his left hydrocele which I stowed away away away from my focus because that's sixth year curriculum, not fifth. Plus my torch was in my backpack.
My earlier scrotal neck test was inconclusive because it was really hard to do a scrotal neck test with the patient laying down. I asked him to stand up to redo it but he told me "Why? I told you everything already."
Time was up, the begrudging "Move!" was called by the resident. I went to answer the questions and the final question was "The patient has hepatomegaly."
I forgot to palpate for any organomegaly and I blamed it on the chatty patient. But I calmly answered 'false' because the patient didn't tell me he had hepatomegaly. Hahaha.
Case 1
1- content is omentum
2- swelling is recurrent
3-
4-
5- patient has hepatomegaly
The second case was a simple nodular goiter. I was on to palpate her preauricular lymph nodes so I asked the patient to clench her teeth, to which she laughed at me. "I don't have any teeth."
Case 2
1- surface is irregular
2- swelling is recurrent
3- there is retrosternal extension
4- attached to sternomastoid
5-
The third was a subcutaneous lipoma on the left side of the neck. I wanted to examine for its attachment to the underlying sternomastoid but her neck was so redundant with fat that I couldn't elicit anything... lulz.
Case 3
1-
2-
3- swelling is mobile in one direction
4- swelling is sub-fascial
5- surgical excision is the treatment of choice
Picked my last patient who wasn't exactly friendly. I was onto his previous surgical history when he cut me off to reprimand me for mixing female with male verbs. Sobs.
"Are you sure you're not a first year?"
"Sorry sir I know my Arabic is not fluent. I'm working on it."
"You have, what, two years to graduate?"
"Yeah one and half. I'm from Malaysia and we use Malay back in our country, so, yeah."
Cheap excuse but we weren't here to small talk. I was nearly halfway through my ten minutes with him so I needed his full cooperation. He nodded and let me examine his swelling.
Great teamwork with the classmates who got the same case, lulz. We compared and completed the long case sheet while waiting for viva with our senior doctor. I was the first up for my case and the first question after locating the patient was "What's your diagnosis?"
"Incisional hernia from a previous open heart surgery, not complicated."
"Why'd you say it's a hernia?"
"Because it shows expansile on cough and there's the scar of previous operation on it, condition started four months after his previous operation. Gradual onset and progressive course. Increase in size during work, straining and coughing; reduced by rest and laying down. Reducible when I tried to reduce it."
"What'd do you think of the content?"
"Omentum. It has smooth surface and the last part of it was a bit difficult when I tried to reduce it."
"And?"
"Oh. Doughy. No intestinal sound on auscultation."
"Is it strangulated?"
"Nope. I can reduce it, there's no vomiting, no abdominal distention, no colicky abdominal pain, no absolute constipation-"
The doctor blinked. "Your patient has all that?"
"Eh no. It's not complicated."
"If your case strangulates, how will he present?"
"All that."
"No he won't. Why?"
"Eh." I blinked.
"Because the content is?"
"Because the content is omentum.. So there can't be intestinal obstruction." Lulz.
"What will he have then?"
"Loss of expansile on cough."
"Good. So what would you suggest for his treatment?"
"I'd suggest herniotomy and mesh hernioplasty."
"Not herniotomy."
"Why not?" Haha who's vivaing whom?
"What do you think?"
"Erm. We still need to remove the sac so why not herniotomy?"
"Because the neck is large-"
"Oh!"
"-so we just invaginate the content inside and do mesh hernioplasty." He calmly answered his own question. Thanks doc for being patient with me, hopefully this knowledge won't cost me marks.
"Oh okay."
"What other hernia we don't do herniotomy?"
Time to throw darts. Other hernia with wide neck, eh. "Paraumbilical hernia?"
"No. Inguinal."
"Erm. Indirect?" But I clearly remembered discussing indirect hernia with Dr. Hany and we definitely do a herniotomy here.
"Direct. We can just push the content back inside and apply a mesh."
"Okay I see."
"You can go now."
"Thanks doctor. Have a nice day."
AND HARU IS A FREE (WO)MAN! Except I have work to do. After I was dismissed, I went to check for my MCQ Internal Medicine exam and lucky me, the date was out. It was scheduled for this Saturday the 16th.
So, yeah. Allah was serious when He said
Therefore, when thou art free (from thine immediate task), still labour hard,
Surah Ash-Sharh verse 7
Yosh. Let's work hard.