My Experience during Final Year MBBS Long Case Clinical Examination

So I decided to write a blog about my long case clinical examination because it was a great learning experience for myself and I wanted to be able to read about it whenever I was going to attend any other examination feeling all nervous and jittery.

We had 2 days of clinical exam sessions, the first day for long case followed by short case the next day. I had my long case at Hospital Sultanah Bahiyah (Alor Setar) and at that time I was staying at my campus hostel in Sungai Petani. So very early morning on the day of examination, a friend of mine and I drove to Alor Setar. I wouldn't say that I felt prepared because I have always felt that way before any exam. That happens at times. No matter how much you study, you get that dreadful feeling that you might have missed something really important. 

Once we reached the hospital, we were brought to a waiting room and we had to wait for our turns according to roll numbers. I wasn't feeling that nervous up to that point but when my turn was nearing, I started feeling all those butterflies in my stomach and somewhat a little nauseous. After about an hour maybe, it was my turn. 13 of us were brought to another room and we were asked to draw lots to pick our cases. I was praying that I should not get an orthopedic case because I was not very confident in it but I guess on that day, my law of attraction was so strong that among the 13 of us, I was given an orthopedic case. I was feeling really doomed already but I was thinking that life goes on and whatever it is, I will just enter the room and give it my best. 

For long case we were given an hour to clerk and examine the patient. After that, 2 examiners will enter the room and question us. So my patient was a middle aged Chinese lady and she was very friendly. I greeted her, introduced myself and started asking her history. I asked her what was the reason she came to the hospital and she actually replied that she was asked to come specifically for the examination. I wasn't sure if she was asked to say that or maybe she was just being honest but to be safe I asked her again. She replied that she had pain in the right knee. 

So the thing about this patient is her story started a long time ago. When she was 11 years old and since then she had multiple trauma to the same knee. She underwent many surgeries to correct the problem. This meant I had to really rush and get the history quickly since I only allocated about 20 minutes for history. But my plan didn't really work out well because I took almost 50 minutes only to understand her very long history and thank God I was able to come up with a provisional diagnosis and a few differentials. Since I only had about 10 minutes to examine the patient, I did a few special tests to confirm my diagnosis. I was really so tensed up at that time because I knew I was going to have to present my history and examination findings without worrying about what I have scribbled on my papers since I didn't have time to rewrite my history at all. 

When the examiners entered my room, I really thought that I was going to do badly, firstly because I was so tensed up and secondly, I didn't have time to thoroughly examine the patient and thirdly, I wasn't sure if any of my diagnoses were actually correct. But I have done this so many times, presenting cases to specialist during our clinical teachings feeling the exact same way. The only difference was this was a real exam that was going to decide whether or not I am going to get my MBBS degree and I thought to myself that no matter what happens, I will take this as a learning experience to improve myself. With only that in my mind, I started presenting about my patient. 

I wouldn't say the presentation went very smoothly, I did stutter here and there but I would say it went alright overall. Then I was asked to summarize my history and that I had to do without referring to anything because I didn't really have the time to write a summary anyway. Summary is very important because at times the examiners are too tired to listen to the rest of your history and the summary is all they want to listen to. 

I was asked to say my provisional diagnosis and then proceed to show the examiners the technique of examining the patient. I did the standard examination method of knee joint and then proceeded with the special tests. My patient had a positive posterior drawer test and even that, I was entirely sure because there wasn't much of a posterior translation but there was a little bit of laxity (apparently that is considered as positive). So at the end of examination, I told the examiners that my provisional diagnosis was posterior cruciate ligament tear with underlying secondary osteoarthritis of the right knee. They asked me to justify my diagnosis which I did. During physical examination, I was asked the reason for doing each steps and also the difference between a fixed flexion deformity and an extension lag. I was asked regarding the management of this patient and also to interpret the patient's knee joint X-ray. One of the consultant asked me, if I was a houseman officer and I had to request for an X-ray for this patient, how would I present the case and request for it from a new radiologist that has never seen this patient before. They asked a few other basic questions and finally how would I manage a similar problem in a patient who's very much elderly and I answered total knee joint replacement as subjecting an elderly patient to multiple surgeries would only give the patient more harm than benefit and this justifies the reason to replace the joint completely. 

At the end, one of the consultants asked me if I would like to be an orthopedic surgeon someday and I replied definitely if there is an opportunity. So it was a real good experience for me because I was hoping to get a medical or surgical or O&G patient for my long case instead, I got an orthopedic patient and it went pretty well I would say. I thank God for giving me wonderful examiners who taught me so much on that day. :-) 

~ I never lose. I either win or learn. ~ Nelson Mandela