Nocturnale

One of the more unforgettable experiences I had when I attended the 2nd Penang MRCP PACES Preparatory Course a couple of weeks ago was this encounter in the Respiratory Station with a Dr Hooi.

I can still recall the intimidating stare from Dr Hooi as I examined a patient who has pulmonary fibrosis. She has this intense, serious expression and demeanor, which I reckon would not have shamed the best criminal prosecutor in the court of law. But I am digressing.

Instead. I want to share with you an important lesson I learnt from this particular Dr Hooi who inspite of her harassing disposition, was truth be told one of the most insightful instructors of the entire course.

We were brought before a middle-aged patient who has obvious finger clubbing. The instruction is: “This gentleman has fever and cough. Please examine his chest.” My fellow participant was asked to give a running commentary of her examination. She detected finger clubbing and promptly mentioned it to Dr Hooi. At which point Dr Hooi interrupted her and asked, “So what do you think could be the causes in this patient?”

The candidate responded, quite confidently for that matter,”Pulmonary fibrosis.”

“What? Did you read the instruction clearly?”

“Oh.”

“The instruction says the gentleman has a fever, does it not? So, what are the causes of fever with clubbing?”

“Bronchiectasis.”

“Ok, what else?” Dr Hooi was visibly peeved as she turned towards the audience.

“Empyema, lung abscess.” Somebody blurted.

“Yes, suppurative lung diseases. The examiner’s instruction is penned for a reason. Please read it carefully. It will even help you establish the likely diagnosis!”

Well said. More often than not, the examiner’s introduction or instruction is phrased in such a way so as to direct the course of the examination in a manner that will lead to a more focused elicitation and interpretation of signs. In other words, there is much to be gleaned from a sheet of paper denoting the patient’s presenting complaint and what a candidate is expected to do in a particular short station.

Always read the instruction with an open-minded anticipation that possible diagnoses may already have been alluded to in the very first place!

For the record, the patient has empyema of his right lung.