PRIMARY CARE MEDICINE POSTING

KICKSTART!
10th BATCH MBBS UITM
A)

GETTING TO KNOW PCM :

1. PCM susah gila! Baik mati dari masuk posting PCM! Rileks guys,
jangan cuak. Trust me, its not as bad as the mitos you heard.
2. But I did die a little while in this posting.
3. Primary care acts as the FIRST CONTACT and principal care of
continuing care for patients. So basically, korang akan duduk kat KK je
sepanjang posting ni (zzzZZzz)

B)
WHAT TO DO IN PCM? :
1. You guys will be divided into 3 groups and setiap minggu each group
akan rotate between 3 respective clinics :
KK Taman Ehsan
KK Sungai Buloh
CTC Selayang (PCSC)

P/S : JANGAN PONTENG KLINIK! ATTENDANCE IS VERY VERY

VERY VERYYYY STRICT IN PCM! SETIAP HARI ADA SPOTCHECK

MENGEJUT DI KK AND ADA MATA-MATA DR DI KK. DATANG

LAMBAT PUN JANGAN! NANTI SETIAP AHLI GROUP AKAN DISOAL SIASAT (GULP). KALAU KELAS CANCEL, KENA AMIK SIGN
FROM LIBRARY.

2. Sesi mengenali doctors in PCM

Dr yang ada dalam kotak hitam je yang ada time kteorg. Dont you worry
cuz all the doctors are angel (cewahh) Tapi since semua dr perempuan
soooo.... cerewet sikitlah hekkk.

3. The LOGBOOK
Outpatient diary

Join MO/FMS clinic, isi case apa

MCH clinic

Palliative care

Others (pharmacy/lab and

procedures)

korang jumpa hari tu. Ada dr yg suruh

clerk case and present atau korang
boleh mintak sendiri dari dr boleh tak
nak clerk case and present.
Join MCH clinic (doctor or nurse) and
sama jgk, isi case apa yg korang
jumpa. If dtg for antenatal follow up
just tulis situ came for antenatal
follow up. Learning needs semua tu
pepandailah isi
Korang akan kena follow hospis (once
je) Nanti ikut nurse hospis pergi rumah
patient and korang kena isi logbook at
least 2 cases yg korang encounter on
that day.
Treatment room : Time PCM lah
korang boleh buat mcm2 (ECG,
IM/SC injections, pasang line,
venipuncture, wound dressing,
etc etc) dgn tangan korang
sendiri. Approach je semua
nurse, MA and sister yg baik
gilos tu. Confirm semua korang
boleh buat. So jgn risau, column
procedures tu sampai tak cukup
nak isi haha.
Masuk farmasi rajin2lah hafal
nama ubat and dose sbb PCM ni
dr akan expect korang utk tau
dose ubat2 yg common eg. PCM
500 mg.

4. DOC session (Direct Observed Consultation)

 Korang kena dtg klinik awal and cari patient for this session.
Basically, it involves a group of 4. So nanti 1 person from that
group akan consult a real patient depan doktor. Nanti dr akan
observe and komen. (Setiap sorang sekali je)
You guys will be expected to : consult the patient, perform physical
examination (kena amik manual BP), manage the patient (including
prescribing medications). P/S : tak perlu present balik case kat
dr. Just consult je. So better jaga eye contact with patient
instead of writing their details in a paper.

(lebih kurang cmni, yg duduk tu korang and patient, yg diri tu dr.

Lagi 3 members duduk tepi and observe jugak.)
Examples of cases done in DOC (kudos 1st rotation mates) :CASE
a. Chest pain
(Atypical chest
pain secondary
to stress?)

-Dr Punitha

b. Follow up for

DISCUSSION
C/C : chest pain (atypical presentations, when
explore further, patient was under stress due to work
and her children)
PE : CVS examination
DDX?
How would you manage the patient?
Relaxation techniques (have some me time, go
to spa, go for a holiday, massage, take a day
off work)
Any drug needed? (rasanya takde prescribe)
ECG
Other investigations?
Need to ask patient for any active complaint + ask

HPT, DM
and
dyslipidemia
(to review
blood result)

-Dr Punitha
-

c. Tension
headache

- Dr Suraya
-

d. Vertigo
- Dr Hasidah

e. TRO ovarian
cyst/chronic
appendicitis
-Dr Nafiza

for all the complications.

Mcm patient aku, bila tanya ada any active
complaint? He said no. But when I asked further
question, he actually had hypoglycaemic attacks for
quite some time.
Dont waste time tanya psl his past history dgn
mendalam. Dr lebih nak tau about his current wellbeings.
How would you manage his frequent hypoglycaemic
episodes? (titrate the insulin unit, have some light
meals before sleep)
C/C : G3P0+2, came due to generalized, pulsating
headache, radiate to back of the neck, a/w tiredness,
unable to sleep, nausea and vomiting. Worsened at
night. No fever, no neurological abnormalities
Ddx : sinusitis, tension headache, TRO UTI +,
hyperem gravidarum
Examinations : urut kepala and cervical area, do obs
examination and eye examination.
Learning needs :
Antenatal hx
Gynae hx
Screening for obs?
Past obs hx
Types of headache and clinical features!
C/C : dizziness (when woke up from sleep), 1st
episode
Ask further hx TRO other causes
DDX?
How would you manage this patient?
C/C lower abdominal pain
At first generalized, then localized to lower
abdomen.
Regular menstrual cycle
DDX?
Management?

 Other DOC cases :

Cataract (Dr Farnaza)
TRO ovarian cyst, C/C : chronic left iliac fossa pain
Hypertension + DM
Sagittal sinus thrombosis
Acute viral gastroenteritis (Dr Han)
Follow up for HPT, DM and dyslipidemia. Active complaint of
peripheral neuropathy for a month (Dr Hasidah)
URTI (Dr Punitha)
UTI, C/C : suprapubic pain (Dr Nafiza)

C)

WHAT TO READ FOR PCM?

Bruh, everything under the sun bruh. Seriously, you guys hv to know
EVERYTHING, all the disease existing in this world. Nanti masuk klinik
ni, ada new case. Masuk clinic ni, new case. And some of the doctors
expected you guys to be able to answer their questions about that disease.
Medicine, ortho, surgery, paediatric, A&E, neuro, dermato, semua kena
tau. Gudluck!
Khatamkan semua CPG if possible (which is impossible but you ken
duit!)
Hypertension, DM and dyslipidemia kena master inside out. Ini
pokok segala PCM. Management semua kena umph!
For MCH, baca balik how to take o&g history. EDD, USS and olls,
you still remember? (i didnt and i still dont hehe)
Taktau nak ckp disease apa yg common sbb mcm2 boleh dapat.

Haaa, buku Murtaghs ni wajib ada setiap sorang. Takyah share, kemut sikit.
Boleh grab dekat library selayang tingkat dua the second rak bahagian hujung.
Murtagh ni bapa primary care. So korang bacalah semua case dalam ni. Red
flags sign & symptom for every disease kena tau. Tu yg penting dr nak dgr kita
tanya patient waktu consultation.

o Examples of cases (Murtaghs table of content) :

D)

Exam (OSCE)
For PCM, you have OSCE for EOP exam.
You have 15 min to consult, formulate a diagnosis, explain the
diagnosis, explain the investigation and provide management to the
patient (aka the primer)
Tak payah buat PE sebab dah diberi dalam soalan. (belajar baca
ECG cuz you might be the chosen one treng treng)
Its best if you buy the OSCE book by Dr Farnaza and Dr Nafiza
kat kedai buku CTC. Buku ni ada bg cth soalan2 OSCE.

(Hensem kan abe senior kt cover page ni)

In 15 minutes, you have to (exam + DOC template) :
Intro (2)
C/C and exploring C/C SOCRATES (2)
Ddx symptoms (ruling in and ruling out) (2)
Other personal/social/relevant history (2)
I,C,E Idea, Concern, Expectation (WAJIBBB) (2)
Diagnosis and explaining dx in simple language (2)
Explain investigations + what further investigations to do (2)
Management non pharmacological (2) + pharmacological (2)
Follow-up
Safety netting
MC

 Our general performance calm, professional, etc etc (2)

10TH BATCH 1ST ROTATION OSCE :

a) Chronic case (1st station) :
Question :
Mr Sam, a 60 years old man came to clinic due to chest discomfort.
His BMI is 28 kg/m2.
Below is his latest blood investigations done on 1st October 2015 :
HbA1C
Total cholesterol
HDL
TG
LDL

10 %
5.2
0.9
High
High

BP : 128/80 mmHg
You are expected to :
1. Explore his further history
2. Explore his Idea, Concern and Expectations
3. Formulate a diagnosis and explain to the patient
4. Manage him accordingly

Answer (Eh bukan answer, ni aku yg tanya)

1. S : center of chest
O: 1 week ago, still bearable at first but the discomfort
worsened 2 days ago.
C : dull chest discomfort, like chest tightness
R : radiates to his neck
A : associated with SOB, sweating and palpitation
T : it only came when he jogs. The chest discomfort
disappeared when he stopped jogging. So, the timing is
unpredictable.
E : No exacerbation (only came when he jogged). Alleviated
by resting
S : 5/10 pain score

Otherwise, no pleuritic pain, no orthopnea, no PND, no sour

taste, no episode of chest pain before, no chest pain at rest,
no etc etc.
Patient has U/L HPT, DM and dyslipidemia for 30 years.
Claimed to be compliant to medications, follow up and
healthy lifestyle. Hes a smoker of 3 packs per day for 30
years. No target organ damage/complication symptom (eg :
blurred vision, frothy urine, pain in the calf while walking,
body weakness, etc etc)
No significant past medical hx, no surgery done before,
medications : metformin 500 mg BD, Gliclazide, simvastatin
40 mg OD, Perindopril (kot, tak igt ubat HPT dia)
FMHx : (aku lupa tanya wuwuwuuu) His father passed away
due to heart attack at 50 yrs old. His mom is healthy.
2. Idea : Patient thought he might be having heart attack
Concern : Concern he couldnt go jogging anymore
Expectation : Help to manage his condition
3. (Diagnosis aku mengarut : uncontrolled DM and
uncontrolled dyslipidemia koyak rabak diagnosis) Ada
orang kata the diagnosis is STABLE ANGINA. So script
dia, Okay Mr Sam, I think you have what we call in
medical term as stable angina. It is _______ (explain in
layman) Explain the investigations to the patient
4. Manage patient accordingly.
Non-pharmaco : reduce BMI, healthy lifestyle, smoking
cessation, restrict salt intake bla bla baca sendiri dlm CPG.
Pharmaco : HbA1C 10% (aku add basal insulin) and
increase the dose for his statin as his dyslipidemia is
uncontrolled. (lupa nak bagi GTN kat dia. Padahal primer
dah tanya how bout my chest discomfort dr? Uwaaaaa!!)
Follow up (aku bagi TCA 1 month)
Safety netting : if your condition worsen despite taking
the medication and if you suddenly get chest pain at rest,

please come immediately to the nearby clinic or emergency

department.
b) Acute case (2nd station) :
Question :
A 43 years old businesswoman came today to the clinic. You are
required to take her further history.
BP : 142/80
Cranial nerves examination : intact
Other neuro examination : intact
You are expected to :
1. Explore her history
2. Explore her I, C, E.
3. Formulate a diagnosis and explain
4. Manage patient accordingly

Answer (eh bukan answer jugak tp aku yg tanya)

1. C/C : Headache of her right side of head (unilateral
headache)
S : right side of head
O : 2-3 days ago (on and off in nature)
C : throbbing in nature, no pulsating
R : no radiation, it localized there. No periorbital pain.
A : associated with nausea but no vomiting. No visual loss
but she became sensitive to light. No LOA and no LOW
T : each attack lasts for 5-10 minutes
E : No exacerbation, but the pain will come when she takes
coffee and chocolate.
S : 7/10 (tp lakonan primer tu mcm 10/10 je aku tgk)
No aura sx (no sensitive to sound, no flashing light or
blinking stars, no feeling tingling or numbness at the end of
fingers)
No dizziness, no spinning sensation, no ear pain, no URTI
symptom, no fever and olls. Normal sleep-wake cycle.

Lupa tanya lacrimation (TRO cluster headache)

When asked further (yg ni wajib tnye in every patient where
you suspect depression masquerade) : Sorry, this question is
quite sensitive but it might be related to your condition. How
are things at home and work? Are you under stress lately?
Any problem at home or work?
Turned out the patient was worried of her son yg nak
menduduki SPM, she always worry about him and shes also
worried of her headache. Shes afraid it might be due to
brain tumor.
2. Idea : brain tumor
Concern : cant do her work properly anymore
Expectation : manage her condition
3. Diagnosis : Tak sure, aku jawab common migraine
4. Management ke lautttt. Aku advice her on relaxation
techniques, ask her to have a healthy lifestyle as she has an
U/L HPT. And then I prescribed her with aspirin. Kahhhh
suka suki aku je.
5. Primer aku ni byk tanya. Suka berlakon lak tu. (Dr, can it
be cured? Dr, bla bla. Dr, etc etc) Rasa nak lepang muka dia
SHUT UPPPP!

OKAY THATS ALL JE AKU MAMPU BAGI.

KALAU YG LAIN LAIN TU, CASE WRITE
UP, GROUP DISCUSSION AND OTHERS,
PEPANDAI SENDIRILAH NAK ADAPT YE.
GOODLUCK AND HAVE FUN! SERIOUSLY
PCM BESSSSTTTT SANGAT! GOODLUCK
GUYS!