Renal transplant

This image is taken from the TransplantCafe.com website

This is an example of renal transplant scar - a J-shaped scar at the lower anterior abdomen. Important in Station 1 - abdomen. Must look hard for a mass beneath the scar and ballotable kidneys, in case the aetiology of ESRD is ADPKD.

Genetic Testing (Q)

You are the SHO in the neuro clinic. Madam S, who is 27 is here to see you today with her father who has recently been diagnosed with Huntington's disease. Madam S wants to speak to you privately about the possibility of a genetic blood test to determine whether she is at risk of developing this disease in later life and when would she expect her symptoms to appear. She also wants regarding the possibility of transmitting the disease to her future offspring.

Your tasks are to obtain her reasons for a genetic test, counsel for this and answer all her queries regarding this test/disease.

Renal transplant (A)

INTRODUCTION

• Spend the first 1-2 minutes introducing yourself and defining the purpose of the encounter. If the surrogate attacked you by saying, "I was expecting to see your consultant. Are you sure you are capable to discuss this matter with me?".. DO NOT PANIC!
• Just say something like this, "I have discussed with my consultant about you coming here. Unfortunately he can't join us today as he has to attend an emergency meeting. Be well assured I will try to answer your queries and convey the result of our discussion with my consultant later." Most of the time, the surrogate will be satisfied with this kind of answer

MAIN CONTENT

• get to know how much she knows about the subject of organ donation and renal transplantation
• ask her what made her come forward - forced by husband or other family member etc.
• once you know how much information she needs.. start telling her some facts (this is where knowledge is useful).
• Tell her the pros of non-related live renal transplant (if the wife is the donour)

- better outcome, matching can be assessed, no delay, so can remove the need for haemodialysis, can be done in a planned condition, does not require transportation, psychological satisfaction that she can get by helping her husband.

• tell her the cons of it - more to the donour.

- small peri and post-operative risks

- long term risk with a single kidney

- risk of developing hypertension

• if the donour agrees, she will be assessed by the transplant team
• briefly inform regarding the life long need for medications for the recipient
• relay possible risk if failure of transplantation as a result of rejection
• possible hidden agenda

- getting transplant in other country ie. China

- not encouraged, not properly assessed, government will not pay for the medications when recipient comes back

- getting other family members to donate

- for living non-related organ transplant - only allowed for husband/wife. Others will need approval from the transplant committee. (in UK it is called Unrelated Live Transplant Regulatory Authority, in short ULTRA)

ENDING

• ALWAYS.. ALWAYS.. SUMMARIZE. Do this by emphasizing regarding reason for the encounter and important points from the discussion.
• do remember to set for another appointment, may it be with the consultant around or other teams.. to get back their feedback
• offer leaflets, websites, contact no. of the transplant team or support group.

Reading a patient information leaflet is helpful for you to be able to explain to the surrogates in laymen terms. For candidates sitting in Malaysia, National Kidney Foundation of Malaysia may help.

Examples of Case Scenarios

Communication skills as I have mentioned earlier.. needs a lot of practise.. role play in particular. I will post some of the cases that my friends and I used.. some were directly from Ryder, some from other websites, some are self-written and some are from various books with some editing.

After each scenario, I will try to give some examples on possible approach.. like what my friends and I discussed.. do give some input if you have other ways.

Again, communication skill station is not about testing your knowledge.. this has been tested previously. If not, you would not be able to sit for PACES! It is about your communication skill and how you convey your knowledge to patients/relatives and knowing your limitations. Of course a bit of knowledge will be quite useful.. If not, through out the station, you will say.. "I will have to discuss this with my consultant". I will give some links on how can this useful knowledge can be obtained. It is also good to read some patient-information leaflet to know how a terminology is explained in laymen terms. Try http://www.patient.co.uk. More will be linked to this blog later. And remember... each case usually has hidden agenda - patient's concern.. so try hard to dig into this!

Renal transplant (Q)

Mr Lee is a 40-yr-old pt who has ESRD secondary to DM on regular HD 3 x /week for 2 yrs. He is a lawyer in a big law firm. However, since he is commenced on haemodialysis (HD), he has difficulty arranging his time for the HD and his work. He is in the transplant list since 1 yr ago. However, he red the news that the waiting list for a cadaveric kidney transplant is probably about 10 yrs in Malaysia.

He is keen for live renal transplant. However, he is the only son and his parents are both more than 60 yrs old with DM and IHD and was told not suitable as donor.

His wife, Madam Lee, is a healthy 32-yr-old teacher who wish to donate her kidney to her husband. She also wonders whether her husband would benefit from kidney transplant at China.

She comes to see you for advice.

Your task is to explain the pros and cons of non-related live renal transplant and manage her concerns.

HOW WOULD APPROACH YOU THIS?

My station 5 - brief clinical consultation 1

I had 5 minutes to read and prepare notes/approach for both encounters in this new station 5. My first question is something like this:

" 50 + year old lady complains of painful joints over the fingers. She also has psoriasis for the past many years.
You have 8 minutes to take brief history and examination and address her concerns. You are not required to take a detailed history of perform a detailed examination in this lady. You have 2 minutes to present your findings and discuss about the case."

I was quite happy when I got this case because I am very familiar about this topic and very well versed in the examination too... My rheumatology posting as a medical officer is really useful here... I was hoping I could do well here.

That was the first time they perform this station in such a way.. In my opinion it was quite chaotic. The examiners were right behind/beside through out the encounters. After taking brief history, I proceeded with the examinations. I started off with joint examination - started from the hands and later the back, scalp, behind the ears, trunk and legs... Then the lead examiner told me... "that is not necessary." they reminded me I was short of time. So I finished it off by asking her occupation and her concerns.. Luckily I managed to ask her this bit! She's an Indian dance teacher and definitely uses a lot of fine motor movements of the hands! 8 minutes up! Time for discussion.

They asked me to present my findings. The lead examiner commented my examination technique. Got to admit. With the examiners around me (the Chief Examiner of MRCP (UK) that is!), I didn't examine her in my usual manner. Wasn't sure how detail the examination/history needed. Guess I didn't use my rheumatology experience well here. Other questions were about diagnosis and its differentials and of course management. Results came out... Didn't do well on the examination part.. Others were okay.

Communication skill

A lot of my senior colleagues said they didn't pay much attention to this station while preparing for PACES and could still pass the exams. More attention was given towards the clinical part. I bag to defer. In my opinion, as a local graduate who didn't have much exposure on this in the undergraduate studies.. a lot of work needed! This is the time to learn good communication skill which is extremely important in real life. This makes MRCPians a little bit different from others. You can even practise it with real patients/relatives.. see if this more tactful way can improve your rapport with patients/relatives?!

No doubt reading every little word in Ryder is important, but what is more important again.... PRACTISE.. PRACTISE.. PRACTISE. Have a good team and have a role-play session. I believe this is the best way to study and learn + ACE the communication skill station. This is the time for you to act.. be the most terrible patient who is aggressive, harsh, violent, cold or the most irritating relatives who want to do decisions for the patient or in denial.. this is THE WAY for you to prepare yourself for the real day. With that, you are ready to tackle any kind of patients and remain calm through out the encounter. I highly recommend this technique!

My Communication Skills and Ethics Station

Time for the "talking" station! Quite worried about this as most people say that Asian candidate usually do not do as well as they would in clinical stations. I had 5 minutes to calm myself down before the question was given. Anxiously waiting there, I tried not to think about how bad I did in the CVS station.

Kringg!! I finally got the question and it was a bit different as compared to the case scenarios that I always practised.. Communication skill, ethics and a bit of history taking needed there. The case scenario is something like this:

"Mr X was admitted about several months ago for uncomplicated MI. Since then he, who has underlying Diabetes Mellitus, Hypertension and Hyperlipidaemia was under the cardiac protection programme. He was started on various medications (.... names of medications were listed including Aspirin).
Of late Mr X complains of shortness of breath and lethargy. He was seen by his GP who has taken his full blood count, Hb: 7.1g/dL, MCV low and MCHC low.
(.... the results of his last FBC when he was admitted in the hospital for uncomplicated MI was also given - Hb11.5g/dL).
Mr X is here to see you to discuss further regarding his problem.
Your task is to explain to his possible diagnosis and further assessment as well as address his concern"

Not the typical case scenario where they would give you a diagnosis/particular investigation/step of action up front and you need to disclose/discuss it etc..

I see that the question can be divided to several parts:
1. a little bit of history taking to confirm or exclude other diffential diagnosis
(my provisional diagnosis here is bleeding ulcer secondary to aspirin)
2. digging out his concern - in this case, his concern was malignancy
3. explaining to him what i think needs to be done to rule out/rule in the probable diagnoses (OGDS and colonoscopy) - briefly explain what it is and patient worried if it is suitable for him - just had MI
4. lastly explain to him plan of management

During the discussion with the examiners, it was about what I think is the diagnosis and my plan of management for it.

phew.. it went well! And now I'm starting to like the "talking" station.

I can't hear that?!

A lot of people say CVS station is easy. I don't think so. I don't think I have good ears to hear the murmurs. But then again, most senior people will say, "It's not about auscultation only. most diagnoses can be made even before putting your stethoscope". To me, that is a bit dangerous! Because, if you already have an idea what the diagnosis is, you may not be prepared for the unexpected ones! And of course... you will be a bit bias.. hearing something that is not there. Whatever it is, DO NOT CREATE SIGNS. Just tell them what you think. You may still get some marks for the honesty, and in maintaining patient welfare and clinical judgement.

Some find listening murmurs only helpful.. kind of train your ears to listen to all sorts of murmurs. Try these sites:

1. Heart Sounds and Murmurs - Texas Heart Institute
http://www.texasheart.org/education/cme/explore/events/eventdetail_5469.cfm

2. The Auscultation Assistant - Hear heart murmurs, heart sounds and breath sounds
http://www.wilkes.med.ucla.edu/intro.html

3. Merck Manual Professional
http://www.merck.com/mmpe/sec07/ch076/ch076a.html

4. Cardiology Site
http://www.cardiologysite.com/index.html

However, nothing beats real patients! So, grab your chance to go to INR clinic at your centre.

My CVS Station

Right after the neurology station, it’s time to move on to CVS station. While rubbing my hands with the septic gel, I read the instruction… which I can’t really remember.

I started of with the usual manner.. adequate exposure by asking the patient to remove his shirt. He was already lying down in semi-recumbent position but with a pillow behind his back.. I wasn’t sure if the bed could be reclined and thought it was okay, I left it as it is. General examination was like the usual and I saw a median sternotomy scar.. is this a good or bad??? By checking the pulse I detected that he has atrial fibrillation with good rate-control. JVP wasn’t elevated. Time to go to the chest… click.. click… I could very well hear the metal click! Again.. is this good or bad? At this point… I know that this gentleman has had valvular heart disease with AF and the valve has been replaced. Most likely a mitral valve disease. So my task was to confirm it and look for any other valvular heart lesion or any other valves that have been replaced as well. Also to look for any complications ie: valvular leakage, heart failure, infective endocarditis, evidence of overwarfarinazation.
Coming the chest, I was hoping for an easily palpable apex beat.. but NOT! I struggled to feel for the apex beat.. what my friend who has just passed his PACES in June 2009 said echoed… “Do not create signs.. show them your effort, including taking a little bit of time to look for apex beat”. So that was what I did…. By the time I took out my stethoscope to auscultate the heart sounds, the lead examiner reminded me that I had 1 MINUTE to complete my examination. Panic.. Panic! I tried my very best there… until I didn’t’ have much time to auscultate the carotids, and this case… very important! what I could gather is that,

“ Mr X is in atrial fibrillation with the rate controlled at 80 bpm. He is not in respiratory distress. He is not cyanosed or jaundice. He has no peripheral sign of infective endocarditis. The venous pressure not elevated. He has a well-healed median sternotomy scar with audible click. I had difficulty locating the apex beat and is displaced. The first and second heart sounds are metallic in quality. He has a systolic murmur at the aortic area. There is no pan-systolic murmur at the mitral area to suggest mitral valve leak and there is no early-diastolc mumur to suggest aortic valve leakage. He has no pedal oedema and no evidence to suggest over-warfarinization. So in conclusion I think Mr X has atrial fibrillation currently in good rate-control with both aortic and mitral valve replacement. Currently he is not in failure, no evidence of valvular leakage, infective endocarditis and over-warfarinization”

Then, he asked if I think that both the valves were replaced with bioprosthesis or metallic? There I thought I might be wrong in either one of it.. but I was certain about the metallic one!

He asked me if I could hear any radiation to the carotids… again! I honestly told him, I didn’t have time to check for it. Given more time, I would do so.

Further questions were about the management of the patient.

His final question was.. what would my advise be regarding exercise and the type of jobs that he can do… I got confused there as I couldn’t really link my diagnoses with the question.. and I gave a very general answer and kringgggggg!! SAVED OR UNSAVED by the bell!

Time to relax for 5 minutes. I know I didn't do well in this station!

My Neurology Station

Station 3: Neurology

We had 5 minutes of "relaxation moments" before we went on with the exams. I started of with Station 3. Not my biggest strength. Then again it was too late to turn back. I was worried as few friends told me that alcohol rub not easily available in UM and the external examiners are usually very concerned about this. Waiting for the staff to get the rub would definitely be a waste of time! I guess UM had a feedback on this from previous sessions. Alcohol rubs are at every corner of the examination place.. "relaxation" area, each patient's table, you name it. And the examiners would remind you to do so while you are reading the instruction for the next case. So, when the examiners introduced me to the first patient, the instruction was something like this:

"Ms X, has ocular problem. Please examine her"

I didn't know whether I should be happy or not. No fool can miss the diagnosis when one look at her.. Definitely a myasthenic patient who is currently in exacerbation and has had thymectomy in view of nicely healed sternotomy scar. But what lingered in my head was how to proceed further and to give extra ummpphh. I tried to remember back in my head the "myasthenia protocol" and completed it earlier than the time given.. I was not sure if I have missed anything until I did something extra.. which I think now, looking back, may not be wrong but may not be necessary.

The Q & A session.. The examiner asked what my findings were and my conclusion <- this works for all the stations. Next questions were about:

• investigations and guess what, I'd forgotten to mention "Tensilon test" and that answer need to be prompted by the examiner.
• Subsequently it was about the treatment. I had few moments of "delusion" like saying edrophonium as treatment of MG. Maybe it was obvious that it was an accident so they didn't pin-point on that so much.
• Regarding what would be the causes of difficulty in breathing in such patient - other than myasthenic crisis and infection, think about cholinergic crisis too!
• They emphasize on patient education - asked how would we advise the patient and family when we see them in the clinic.. practical questions.

Time's up! Time to move on to the next station!

Example of MG protocol.. I compiled from several books I mentioned in the "Getting started" post.

1. ptosis protocol – check pupil, if normal, check extraocular muscle movement to look for variable strabismus and diplopia
2. eye fatigability (look up for 2 minutes)
3. incomplete eye closure
4. facial diplegia – wrinkle forehead, ask to smile, show teeth
5. weak voice and nasal – bulbar palsy (ask to count)
6. weaker neck flexion than extension
7. proximal muscle weakness + fatiguability (normal reflexes)

Station 1 - Respiratory System

• step-by-step approach to respiratory system is easily available in any clinical medicine book ie. Clinical Examination by Talley O'Connor
• for those who has just begun to prepare for PACES, it is good to go through such books - to remind us back the physiology/pathophysiology of clinical signs
• go through the steps until you master it and able to perform it naturally. Need not to be on real patients.. teddy bear, friends, or even in your mind...
• time issue? make an effort to perform full clinical examination during ward rounds or clinic encounter. It should only take 6 minutes of your time for 1 system.
• preparing a good and impressive presentation need a lot of hard work and practice. Unless you have exceptionally good command of english.
• Maybe at the initial period as you are just starting to get yourself used to PACES, conservative way (from periphery to the the organ of concern) is a good idea. In a way it helps you not to forget examination steps. Once you are more matured in terms of exam preparation, you can choose to present "hit-hard" or maintain the conservative way
• Most importantly, choose a method that you are comfortable with so that you look smart on the exam day
• In general.. examiners like "hit-hard". I say this because, unless you are the first candidate, by the end of the 6th minute, their question: "Tell me your positive findings"
• Important in the presentation to make sure the presentation is short and sweet. Ryder and Freeman has good examples of presentations
• end the examination by requesting to see sputum pot, temperature chart, oxygen saturation, PEFR (if necessary)
• at the end of presentation, tell the examiner the diagnosis, likely cause and current functional status.
• example a case of pleural effusion:

Mr X is in respiratory distress as he is tachypnoeic, tachycardic and using his accessory muscles of respiration to breathe. He requires oxygen therapy via 2L/min nasal prong. He has bilateral finger clubbing and nicotine staining. He is not cyanosed and does not have signs of carbon dioxide retention. His trachea is deviated and apex beat displaced/not felt (if necessary, comment on pulmonary component of the second heart sound). On examination of the chest the findings are localized to: _____ whereby there is reduced chest expansion, reduced vocal resonance and fremitus, stony dull to percussion and diminished breath sound.

In conclusion, Mr X has massive pleural effusion, most likely secondary to ___, currently in respiratory distress.

Getting started for PACES

To get started.. good references will be extremely important. Here are the "must-have":

• these two great books are still relevant though they have changed the station 5 to "brief clinical consultation

• Next will be the "Look & Proceed - A guide for the clinical medicine examination" by Derrick Aw - this great book gives a step-by-step approach for each systems and important disease in PACES.

Will be great if you have this too:

Destination: MRCP

For a lot of house officers in Malaysia, by the end of their postings, they already started to think what they should do next. Taking up external examination papers? Or Masters programmes in whatever field they are interested in. Some will be lucky enough to be attached to the department that will be relevant to their future career path. Paediatric was my third posting.. I wasn't sure whether I should do paediatric or adult medicine. Later, I got posted to Department of Medicine and I was told that I would have to stay there until forever.. usual reason... shortage of doctors there. Not to say experience in the department was awesome, but I could well see myself as a physician more than a paediatrician. So, the chance to stay back in Medical Department was just great!

Again I was at the crossroad.. deciding to take MRCP (Membership for the Royal College of Physicians) or Masters in Internal Medicine. My environment at that time was encouraging for MRCP.. had few other friends who wanted to pursue MRCP and few other seniors who were still in the process to complete their membership. Plus, I had to wait for another 3 years before I could send my application for Masters. Knowing how I am.. waiting too long will definitely kill off my interest and momentum to study.

I decided to take up Part 1 MRCP in 2007. It wasn't really a road trip to Part 1.. it was an air trip down to Singapore. So after adequate break, I proceeded with the second part in 2008. This time in UM.

Here comes 2009.. PACES time! Again decisions.. decisions... when, where? At that time I did not know how to start studying. Plus short cases really not my strength when I was a medical student. Again, my friends and I were lucky. We had a great tutor. He was the first person who exposed us to the examination style. Until now I haven't forgotten how I performed and presented my first case. I did terribly bad! Just like medical students and even worse than them! Knowing what was lacking, my friends and I continued practising and correct each other.. including with "heart-slicing" comments. Just to see each other successful.

Again.. opening date... everybody was busy checking the websites, printing forms and getting money ready.. that's a lot of money! Finally decided to take in Singapore (June) though I knew chances of getting a place was slim.. and true enough.. our money was returned back to us. I guess I was fated not to take it at that time.. not so ready anyway.

It was different this time. We had to queue in front of the MRCP Secretariat in UM, just to secure our place for the exams. We waited for almost an hour before the door of the office opened. When it finally accepted our applications... big relief! However... on a bigger picture..... get your bottom up! Time to go full force for the preparation... and we did!

Some of us was queuing up to hand in our application to MRCP Secretariat in UMMC.

It was really a road trip for me and for a lot more I think, as now Seremban is a new examination centre! I spent 1 day before the exam driving from my house to UMMC. I tried parking at the faculty.. not a good choice! It was raining but that was good in the sense that I could test how I would end up looking if I were to park there the next day on the real exam day... WET! So, I tried parking at the UMMC itself... horrendous! Very stressful! So, I decided to follow Dato Dr Kiew's advice.. get someone to send you. So I did.. I got a taxi-driver to send me there. Good choice! I arrived in good time, enough to calm myself down.

Kringggg!! Exams started and so I gave my best on that day and what a big relief after all of it over! To go through it again?? Given a choice.. nobody would! Too tiring but at the same time... enjoyable. Especially if (quoting from a friend) you are fated to have a good bunch!

4 weeks we all waited... since 20th Nov.. we were not at rest.. looking at the MRCP website so frequently! And finally 24th November 2009.. the results were out... PASS! I am so happy and grateful to Allah, my family, teachers, and friends! (You all know who you are!).

So, MRCP is not about the destination alone.. the road trip that is more important. It teaches friendship, responsibility, maturity.. I hope this blog will be a beneficial adjunct to help you prepare yourselves along the road trip, also for others to share their road trip too! I hope it will serve a map, compass and backpack for the journey. Have a safe and successful journey!