Woke up early?
So? What i do today? Got up early in the morning. i mean not early, 9.10 am.. In my timetable given by department, class start at 9.30. I'm not in a rush anyway, because hospital was just nearby my college. Then later when i came, Dr Sajar was there. She claims that she was there waiting us at 8.00.. owh.. so pity.. we all except Syud was coming at 9.30am. Then the dept get one of our phone number so that in case of something happen, they will call us.. Sorry Dr Sajar, she was so busy this week because of the ongoing Master's Exam now. That's why a lot of unknown people in the college currently.
Class
This time she managed to get us a past year questions.. It seems to be simple, but i thought it was challenging. There is 3 scenario question, basically all of them can be in the paper, OSCE or long case. Ok i managed to get the question in my note, roughly let see the question!
Question One
Mrs Tan 38 years old teacher present to the clinic with a 6 months history of lower abdominal pain, bloated, increased flatulance and diarrhoea. She stated that she can pass up to three loose bowel movement per day. There is no fever loss of wt(LOW) and loss of appetite(LOA). She was recently diagnose to have diabetes melitus and is on regular follow up and treatment.
1) What futher hx would you elicit and give reason? (8 marks)
2) Give 3 differential diagnoses (3 marks)
On physical examination, she looks well, in pink, not febrile and not in pain. Her height is 163 cm, and her weight is 67 kg. Abdomen was soft and there was very mild generalized tenderness.
3) What other physical examination and investigation would you like to do? (7 marks)
4) She has went to 4 different GP for the past 6 months and on antacids and antibiotics for her current condition. She request for a scope to be done. How do you respond to her request? (4 marks)
5) Outline the management for this patient (8 marks)
Discussion
This is a typical question in paper 1 for PCM every year. It just so typical that the question will start by asking, what futher hx u would elicit and what are the differentials?
So how to answer?
Read the questions first! Patient having chronic diarrhoea for the past 6 months. What do u think in your mind? Although the first question is what futher hx you want to take, but i usually start the 2nd question. So it will be easier for me to answer the 1st question, isn't it?
The DDx in mind are:
Irritable Bowel Syndrome (IBS)
SE of drugs such antibiotics, antacids, acarbose
DM
Hyperthyroidism
Diverticulosis
So the next things is to elicit history from the DDx above, rite?
Just answer like Steps on History Taking so you wouldn't miss a thing.
History presenting Illness
1) Characteristic of the stools, is it watery, mucous, blood, malaena, soft stool?
2) Any aggravating/relieving factor such as food stressor?
3) Any associated symptom such as nausea or vomiting
4) Patient malnurish? Assess the symptom of hydration status such as cramps, very weak or lethargy, thirsty, reduce urine output.
5) Symptom of thyrotoxicosis such as heat intolerance, increase appetite, reduce weight, eye problems
Then go to past medical and past surgical hx.
DM, HPT? any thyroid surgery - past hyperthyroidism
Drugs Hx
DM- what type of drugs? acarbose, metformin can cause diarrhoea
Antibiotics? Antacids? - can cause diarrhoea also
Dietary Hx?
Family Hx - any GI malignancy in the the first degree relatives?
Social Hx - any stress event occur? such as financial prob, increase workload as a teacher? - stress can induce diarrhoea
So basically, it complete. eventhough u might miss something, but hey, the above answers already make u have 8 out of 8.
Ok 3rd question.
The question already done Abdominal, take her BMI(overweight skit). What other PE?
Hehe.. simple la.. Same principle. Start with vital sign. Temperature, BP, pulse. Then do the Hydration status such as reduce capillary refils, skin turger, sunken eye etc..
Thyroid examination jgn lupa aaa..- Goiter, thyroid eye disease, pulse - AF, thyroid acropathy, proximal myopathy and etc.
Per rectal examination!!
and because patient has DM - check the eyes, peripheral neuropathy
Investigation such as - stools for culture, ova and cyst!!
then DM - we do, urine dipstick, UFEME, renal profile etc.
Haha.. 7 marks already~!
4th question.
4 marks means 4 point to be inserted... This question basically testing your generals knowledge. Even a layman can answer it.. If you meet this type of question, it means, it is a PCM question.
TIPS: PCM will always ask about this and the answer will always rejecting the patient request! The answer should be basically like this:
Firstly i would like to like to assess the patient consern about why she want to do scope? What does the patient thinks? Did she thinks about GI malignancy?
I would tell her that currently patient is not indicated for scope yet.(be in mind what are the indications for endoscopy)
Tell her about the complication if she done the scope such as bleeding, perforation etc, and it is costly wasting your money
But, if after stopping the antibiotic and antacid, patient still having diarrhoea then we can discuss about doing the scope later
Nice isn't it? If you have another type of answer pls do not hesitate to give it at the comment section.
Last.. Outline the management.
Outline management means make it simple. First of all address the issues that the patient having now.
Issues are Diarrhoea, DM, Overweight, Stress, Multiple GP, anxious about malignancy
Diarrhoea can be settle by non pharmaco and pharmaco. Non pharmaco such as stop triggering factors and takes care of her diet and takes plenty of water. Anti-diarrhoea can be given to her.
DM - Compliance to medication, healthy lifestyle, reduce intake of sugar, fats, eat a lot of fibres, reffered her to dietician.
Overweight - Lose weight, excersize regularly 30 minutes and 3 times a week.
Stress - Reduce stress by plan management, sleep adequately.
Reassure again that this is not due to malignancy and give simple explanation about symptom of GI malignancies.
That its.. Penat menaip.. 2nd and 3rd questions will coming.. later.. i nak eat first...
