Station 4

Station 4

Station 4 in MRCP PACES is an assessment of communication skills and ethics. Many, particularly Asians whom english is not their first medium find it difficult. However, I believe practice makes perfect. Like history taking station, this is a station that you will be able to practice at anytime, anywhere, all you need is a study partner and An Aid to the MRCP PACES vol. 2 by Ryder.

What I did with my study partners was each of us will take turn to become candidate and surrogate while the others will observe and give their comments after the session. Initially we practised with the senarios from the books. Later, we created our own senarios.

When reading the case senario, you should be able to relate your senario to the 4 ethical principals, this could help you in the discussion with the surrogate later.
The 4 ethical principals:

1. Patient's autonomy

2. Beneficence

3. Non-maleficence (do no harm)

4. Justice

There are few senarios that I think sometimes are difficult to discuss about, one of it is brain death.

Case Senario - Brain death

You are the SHO in medical ITU and you are about to see Mr L, the father of Miss L, a patient in ITU.

Miss L, 25 year-old Chinese lady who was admitted 3 days ago with massive intracranial bleed due to a ruptured cerebral aneurysm. She was intubated immediately in ED for poor GCS and subsequent CT brain showed massive ICB with midline shift. She was referred to neurosurgical team for intervention which was done before she was sent to ITU with 3 inotropes. Sedation was halted 36 hours ago and Miss L has shown no neurological response. Your neurology consultant and the ICU consultant has decided for a brainstem testing which was done earlier today and Miss L has been confirmed brain dead. Currently, Miss L is ventilated, her BP is 100/60 mmHg on 3 inotropes and ECG showed sinus rhythm. Your task to to explain to Mr L the diagnosis of brain death and explore the possibility of organ donation.

I shall leave this to you and your study partners to discuss about it.


Useful website:
Brain Death: A Simple Explanation for Donor Families
http://www.kidney.org/transplantation/donorFamilies/infoBooksBrain.cfm

Station 5 - Reduced Effort Tolerance (part 2)

This is a straight forward senario, this young lady has Marfan syndrome.

First picture - tall and thin build young lady with disporpotionately long arms and legs

Second picture - high-arched palate

Third picture - left eye showing superotemporal subluxation of the lens.

It is not difficult to get the diagnosis of Marfan syndrome as the features are quite prominent. What the examiner want to see is how you take history and perform physical examination to confirm your diagnosis and look for any possible complications of the disease. Of course, not to forget to answer to patient's concerns.

History:
- Family history
- Symptoms of heart failure
- Eye problem

Physical examination:
- Noted tall patient with arm span exceed the height
- Hands – thumb sign and wrist sign
- Eyes – vertical subluxation, myopia
- Head – long headedness
- Palate – high-arched
- Chest – pectus excavatum, cystic lung disease
- Heart – MVP, AR
- Spine – kyphosis and scoliosis

There are few systems that are involved in Marfan syndrome, therefore you have to be systematic when you perform physical examination. The only way to be smooth and systematic in the exam is by practising a lot. Get a member in your group to be the simulated patient and practice the flow on him/her. This is particular useful in cases with multiple systems involvement and neurology cases.

Investigations
Echocardiography, chest and spine radiography, CT/MRI

Management
- Yearly echo – monitor aortic diameter and mitral valve function
- Ophthalmology and orthopaedics referral
- Genetic counseling

A few useful websites:
1. Diagnostic criteria
http://www.marfan.org/cms/uploaded_files/8XJIUG81F3/89/docs/factsheet_mfsbodysystem.pdf
2. National Marfan Foundation
http://www.marfan.org/marfan/

Station 5 - Reduced effort tolerance

Station 5

You are the SHO in medical clinic. You received a referral from a G.P.

Dear Doctor,

Thank you for seeing miss R, 16 year-old Malay lady who complained of reduced effort tolerance for the past 2 months. Her FBC and ECG are both normal. Kindly see her for further assessment and management. Thank you.

Sincerely,
Dr G.P


Please take history from this patient and perform necessary physical examination. You are also required to answer to her concerns.

This is the patient:






What do you think is the most likely diagnosis? How would you approach?

(Special thanks to my ophthalmology colleagues for providing the photos above)

Station 5 - Blurring of Vision (part 2)

This patient has bilateral papilloedema, giving the history of headache and vomiting, the most likely cause is increased in ICP secondary to SOL.

Other differentials that needed to be considered are:
- Raised intracranial pressure d/t space occupying lesions, meiningitis, subarachnoid haemorrhage, benign intracranial hypertension.
- Cerebral oedema following head injury or cerebral anoxia
- Metabolic causes such as carbon dioxide retention, steroid withdrawal, thyroid eye disease, vitamin A intoxication, lead poisoning
- Haematological and circulatory disorders eg central retinal vein thrombosis, superior vena cava obstruction, polycythaemia rubra vera, multiple myeloma, macroglobulinaemia

From history
- Headache
- Transient visual disturbances
- Diplopia (due to associated 6th nerve palsy)
- History of hypertension, brain tumour
- History of ingestion of steroid, hypervitaminosis A (a cause of benign intracranial hypertension)

Physical examination – 1st manifestation of papilloedema is engorgement of veins, field defect – enlargement of blind spot.

Investigations
- CT scan of brain
- CSF analysis depending on CT scan findings

In a young female with blurring of vision and headache, benign intracranial hypertension need to be considered.

Features to suggest BIH – pt alert, no localizing neurological signs except 6th nerve palsy, opening pressure of CSF > 20 cmH2O, normal ventricles and normal study in CT and MRI

Treatment of BIH – discontinuation of steroids, weight loss, drugs such as carbonic anhydrase inhibitor, diuretics, serial lumbar puncture, lumboperitoneal shunt, optic nerve fenestration, subtemporal decompression.

Station 5

Station 5 – Blurring of Vision

You are the SHO in medical clinic. You received a referral letter from a G.P.

Dear Doctor,

RE: Mr S, 40 year-old Indian gentleman

Thank you for seeing the above named, who complained of blurring of vision for the past 1 month, worsening past 2 weeks, associated with headache and vomiting. Kindly see him and do the needful. Thank you.

Sincerely,
Dr G.P

You are required to take appropriate history and examination. Please address his concerns.

How would you approach this scenario?

History Taking - Joint Pain

Differential diagnoses to consider:

Ankylosing sponlylitis
- Any history of back pain, back stiffness

Reactive arthritis – post infection
- Ask about history of gastroenteritis, urethritis, conjunctivits

Gout
- History of similar joint pain, tophi, drug history

Enteropathic arthritis (with inflammatory bowel disease)
- Symptoms of IBD

Psoriatic arthropathy
- Rashes, nail changes

Rheumatoid arthritis
- Symmetrical involvement


Sjögren’s syndrome
- Dry eyes, xerostomia

Vasculitis
- Constituitional symptoms, painful skin lesions, neuropathy

Septic arthritis
- History of gonorrhoea (TRO gonococcal arthritis)

This patient actually has reactive arthritis, Reiter’s syndrome, characterized by triad of arthritis, conjunctivitis and urethritis. He had history of travelling to India 3 weeks before onset of symptoms and developed diarrhoea when he was there. Onset of reactive arthritis usually begins 2-6 weeks after an initiating infection at a distant site (dysentery / urethritis)

Investigations:
Inflammatory markers – ESR, CRP
Culture and sensitivity – Stool sample, sample from urogenital tract
Synovial fluid analysis – to exclude septic arthritis (failure to treat septic arthritis may result in joint destruction) and gout
Radiography of the affected joint

Treatment and management:
Pain relief with NSAIDs
Steroid
Referral to ophthalmology for conjuctivitis
Physiotherapy

History Taking

There are 2 opinions in history taking session, some think it is not difficult to score, some especially those whose English is not their mother tongue might think that it is difficult. My friends and I practiced history taking a lot before our exam. One of my friend taught me a technique to tackle this question and I found that it is very useful.

First of all, read the scenario carefully and take note of the important points, it could be the history itself, from physical examination or investigations. Subsequently, generate a list of differential diagnoses (pen and paper will be provided). When you are with the surrogate, you should be able to ask history according to the differential diagnoses in order to exclude them one by one. In between, if you realized there are still other differentials that you have missed, just add it in your list. With this method, you should be able to narrow down your list. If you are still uncertain of the diagnosis, continue with a full systemic review from head to toe. Of course, for an examination like this, knowing the social history and sometimes sexual history is important as well. Some candidates find it difficult to ask about sexual history. You can try opening sentence like this “ I know it could be a little uneasy for you, but there are a few personal question that I have to ask in order to know what is wrong with you, is it ok?” Find out whether the surrogate has a partner, and whether the partner is male or female (particularly important if you sit for exam in UK), whether there is recreational drug usage, smoking and alcohol.

Before you end the session, give the surrogate a summary of what he or she had told you. You may try asking “ Is there anything that I missed?” or “ Is there anything else that you would like to tell me?”. However, sometimes you might not get an answer as the surrogate might be taught to ask you back “Like what?” Then you should ask if he or she has any particular worries and answer to the worried. Lastly, inform the surrogate about what you think could be the diagnosis and advice on further investigations.

The examiner usually would ask for the diagnosis and whether there are other differentials, then the approach to confirm the diagnosis as well as treatment.

Here I have a scenario that my consultant rheumatologist gave me while she took me for a history taking session. Let’s see how we can approach it.

HISTORY TAKING
You are the SHO in the rheumatology clinic, about to see the patient below. Please read the letter from the patient’s general practioner.

Dear doctor,

Re: Mr Mohan, aged 40, lecturer

Mr Mohan has two weeks history of joint pain of right wrist and left knee. He is unable to walk because of the pain. On examination, his right wrist and left knee are swollen , erythematous and tender. X-ray of the right wrist and left knee showed no significant abnormality. His FBC is normal and ESR is 100.

Please give us your expert opinion and advice on the management of this patient.

Yours truly,
Dr G. Practioner.