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Post Exam Stress

Posted Oct 15 2011 5:47pm
I took my clinical examination (PACES) today. It was my 2nd attempt...I failed it by 2 points previously. I arrived early at the hospital. It certainly didn't do anything to calm my nerves.... The other candidates and I waited anxiously for the exam to start. And with a blink of an eye, the exam ended, just over 2 hours later. It's amazing how quickly the time flew by.

How did it go?

To be honest, I was definitely more confident. I presented fluently, and was not hesitating much. I started with station 4 again, similar to my first attempt. I can't stop thinking of all the stations that I went through...therefore, I need to let it all out!

Station 1 (respiratory/abdo)
The chest station was a case of pulmonary fibrosis, which was pretty straightforward I thought, and lucky of me. I finished the clinical examination well before the time limit ended. The abdomen station was a patient with only splenomegaly. I gave a few differential diagnosis for splenomegaly, however, none of them relate to the patient. The examiner then asked me, "Have you not heard of hairy cell leukaemia?" "No." *krrriiinnng (the bell indicating that the station has ended ). I dunno if I were sort of "saved by the bell" so to speak...

Station 2 (History)
The history was on a patient presenting with bilateral ankle joints swelling and a dry cough. It was not too bad a station. The patient was pleasant and I was able to build rapport quite quickly. I gave my differential as inflammatory arthropathy with pulmonary fibrosis or sarcoidosis.

Station 3 (CVS/Neuro)
This went ok. The patient I examined had a metallic AVR. I don't know why, but somehow, I found consultants who wear bow ties pretty old school. He didnt help to ease my anxiety.
I was glad that I could hear the metallic click at the end of the bed. However, he tried to make me doubt myself by saying, "Are you sure it is his heart sounds? Don't you think the sound is coming from this clock above?"

Why is he making my life difficult?!

Neuro, on the other hand, was not straight forward. I did not have time to complete my neurological examination, as I had to also perform full sensory examination. The patient's signs were not classic. On hindsight, I think it was either a case of spastic paraparesis or brown sequard syndrome. arrghh... my brain failed to perform adequately during this particular station!! I felt really awful.. hope i didn't fail it!

Station 4 (communication/ethics)
I've been asked to speak to the daughter of a patient who is comatose following a major stroke. She was not responding to any stimuli, but was still able to breathe on her own. She also has mild dementia. As her daughter does not live locally, she has been placed in a nursing home for some support. We, doctors, have thought of feeding her through a nasogastric tube, but felt that it would be futile. My role was to break this news to her daughter and also tell her that we are going to withdraw treatment.

I guess this is the type of scenario that I have and will continue to face throughout my career. The conversation went ok. I introduced her to the end of life care pathway. But, I didn't manage to answer all of the patient's daughter's questions, as she began to fire them to me towards the end.

After the conversation ended, it was the examiners' turn to ask me questions. One of them asked, "So, if this patient presents to you in A&E, what would you do? Is she someone whom you consider thrombolysable? " I replied, " If she turns up in the hospital within 4 hours of presentation, I would assess her against the criteria to see if she is suitable." The examiner then said, "Well, would you? She has dementia, and dementia itself is a contraindication for thrombolysis."

I really disagreed with him. The patient only has mild dementia, but she is still able to conduct her daily living with just minimal assistance. I kept my thoughts to myself. It is never a good step to disagree with examiners!

Station 5
This is the most dreaded station! In this station, you are expected to review 2 patients in 8 minutes (which includes a brief history and quick targeted clinical examination). I was really nervous as I sat outside the room while reading my 2 scenarios. The examiner didn't help to ease me either by saying, " You have 2 cases, 10 minutes each. You have 8 minutes to examine the patient, while the other 2 minutes is for you to shine!" Shit. I dislike it when he said the word "shine." I felt like there was alot more pressure on me now!

My first case was a review of a lady with unilateral leg swelling. The second case was on chronic diarrhoea. Looking back, I felt I could have done better in the latter case. I think the patient probably has inflammatory bowel disease, so therefore, apart from examining her abdomen, I should have also looked for other signs of IBD, you know, like skin rashes, anaemia etc. Oh well, can't do anything about it now!

I am feeling SO STRESSED that my heart is aching and I could still feel intermittent palpitations until now. All I can say is I have given it my best shot...but is my best shot enough for me to pass it this time? Fingers-crossed! I will find out 2 weeks later!

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