The day my final exams end! Finally, the end of six years of medical school! No more undergraduate exams again ... ever! ... Assuming I pass, of course.

Odds are roughly even that most of what I currently know about medicine will vanish in a haze of alcohol not long after ...

Update: November 3rd, 2000

Day log:
Woke up at 0600, Australian Eastern Standard Time. Watched a bit of news on the TV while having breakfast which consisted of a couple of Kellogg's breakfast bars and some coffee. Took a ride from a classmate to Westmead Hospital in Western Sydney where I had my exam. We arrived at 0710, early.

My turn for the exams was not until 0900.

Short cases
I had my short cases to do first and one of my examiners was none other than Prof. N Talley (author of several famous books on clinical examination and related subjects) - the other examiner was Dr. N Wilcken. My first case was a lady in her 60s where I was asked to examine her cardiovascular system. My findings were that she had a prosthetic heart valve and a pacemaker in her. This was gleaned from the plasticky heart sounds over the apex of her heart and the scars on her chest - she had a large midline sternotomy scar and a smaller scar over her left shoulder. I hope that there were actually no murmurs to be heard (I didn't hear any).

My second short case was a man in his 50s and I was asked to examine his legs from a neurological point of view. The examiners told me to skip testing for gait and posture. There were no fasciculations or muscle wasting or any ulcers. Muscle tone was spastic on both legs, with perhaps more spasticity on the left side. Power was normal (5/5) in all areas except for dorsiflexion of the left foot (power 3/5). Reflexes were abnormally brisk in both legs and there was a (possibly) positive Babinski reflex in both feet. At this point I asked for permission to test coordination and sensation but I was stopped and asked what I had found so far. I deduced that there was some upper motor neurone damage to both legs and some lower motor neurone damage to the muscles causing dorsiflexion of the left foot. When prodded, I suggested that there might be damage to the common peroneal nerve supplying that area. (I'll go check this tonight)

I had time for a third short case, where most people had only two. This was another man in his 50s who had a distended abdomen. He also had a nasogastric tube in place, an intravenous line in his arm and a subcutaneous line in his right thigh. I was asked to carefully examine his abdomen as he had some abdominal tenderness. I found a vague mass in the center of his abdomen and another mass in his abdominal wall in his left iliac fossa. Before I could examine further, time was up. The two examiners told me I had done reasonably well.

Long case
(some points obfuscated to protect identity) I started a one hour session with my patient for my long case, a woman in her late 60s who was born in Sudan and had come to Australia about 30 years ago. She had massive splenomegaly, which had been extensively investigated and was still of unknown cause (i.e. it was idiopathic) - kala azar came to mind as she came from Africa. This big spleen was causing her mechanical trouble, giving rise to recurrent episodes of reflux and abdominal pain which were complicated by a story of night sweats and weight loss (I thought of lymphoma and leukaemias). She also had a history of several episodes of faints, to which she attributed some carotid artery stenosis (left 40% stenosed, right negligible stenosis) she had. She also had poor eyesight, with macular degeneration diagnosed in 1985 and cataracts.

In her past medical history, she had a history of ureteric stones removed from her right side, tonsils taken out as a child, rheumatoid arthritis in several joints (not seriously affecting function though), had never been pregnant and an unremarkable O&G history. She also had never had epileptic seizures, hypertension, asthma, ulcers or any bowel changes.

She had never been married, had no children, lives by herself in a flat on the second story of a building to which she has no problems going up and down from and is independent in the activities of daily living. She survives on welfare, having retired from working as a health worker several years ago. She has a brother and nieces and nephews who visit her often. She has never smoked, drunk alcohol or used illegal drugs.

She is currently on aspirin, ranitidine (Zantac) and vitamin B12 tablets. She is apparently allergic to several drugs (which I can't remember offhand) to which she develops shortness of breath on ingestion.

She has no family history of note - her parents both lived to past 90 and all her brothers and sisters are still alive. One sister has diabetes but she is uncertain what type it is.

On examination, she was alert, orientated and cooperative. She had a pulse of 80 beats/minute of regular rhythm, was afebrile and had a blood pressure of 130/80mmHg (a postural drop was not looked for ... darn). She was not clubbed and had no peripheral signs (of infective endocarditis or chronic liver disease or anything else). On examination of her abdomen, she had a massive spleen enlarged up to the level of her umbilicus and a scar in her left flank consistent with her operation. There were no other abnormalities in her abdomen - her liver span was normal, bowel sounds were present, there was no abdominal aortic aneurysm, there was no bruit audible over the aorta and there was no shifting dullness.

Examining her haemopoietic system, I noted that there were no palpable lymph nodes in her inguinal area, her axillae or in her supraclavicular area.

Moving on to her eyes, she had a visual acuity of less than 6/60 in both eyes unaided and, with glasses, a visual acuity of 6/38 in her right eye and 6/24 in her left eye. Fundoscopy was largely normal - I thought (or might have imagined) some pigmentary changes in her macula consistent with her macular degeneration. Visual fields were normal. Other cranial nerves were normal as well.

There were no abnormalities found in her respiratory system or her cardiovascular system.

Neurological tests of her upper and lower limbs were normal as well.

I had a LONG wait of almost an hour between the end of my time with this patient and when I had to present to my two long case examiners, Prof. J Wiley and Prof. J Fletcher.

When I finally did present, after mentioning all the findings above, they asked me about the causes of splenomegaly. I started by mentioning kala-azar since my patient was from Africa - they seemed happy that I did so. I went on to mention acute and chronic infections but ruled out acute infections and told them chronic infections such as tuberculosis and malaria were unlikely in a patient candidate for medical student exams. Then I mentioned haematological malignancies such as leukaemia and lymphomas and went on to rare things such as sarcoidosis and amyloidosis and connective tissue diseases and metabolic disorders. I forgot to mention myeloproliferative diseases such as myelofibrosis ... a point to which they reminded me (ohwell).

We then discussed her falls. I had to come up with a list of other causes for her falls other than the transient ischaemic attacks that I thought were the principle problem. I came up with vaso-vagal attacks and cardiac arrhythmias and cardiac outflow obstruction. We talked a little more about fainting episodes and how her being put on Adalat some time ago would make her more prone to fainting if TIAs were the actual cause of her faiting episodes. I countered that her fainting episodes began in June and that her Adalat was only started in October ... but we did talk about how giving a antihypertensive drug to someone who had impaired brain perfusion is not going to help the situation much.

In the end we ended with them asking me about the signs of chronic liver disease. I could come up with fingernail changes, purpura, spider naevi, fetor hepaticus, hepatosplenomegaly, signs of portal hypertension (including caput medusae) and ascites. I think they were happy enough.

They took about two minutes to discuss things and brought me back in. All in all, they said I did well but that I should sound more confident. I did tell them that it was difficult not being nervous in a viva exam with live examiners where the culmination of six years study came to a head in one setting.

I think I passed. Yay!!!

It's all over!!