Station 5

A young lady with unilateral leg swelling... in station 5. How would you approach this case.

First thing.. in the 5 minutes that you are given to prepare the case.. you should start thinking about the probable differential diagnoses:

1. DVT
2. Lymphoedema
3. Cellulitis
4. Less likely causes - may not be relevant but just standby at the back of your mind.. heart disease, kidney disease, liver disease etc..

Once you start seeing the patient.. you would likely be able to exclude or include the diagnosis and focus in that area more.

I had a patient recently in the ward with the exact problem.. So I told my other colleagues who are going for the exams to see this patient.. in this case.. she had DVT.

Getting the diagnosis of DVT is easy. So what it takes to have 2 in all the 7 components that is full marks? Of course while talking and examining her, keep her comfortable. DVT legs are painful. Any "ouch" will cause you big time "OUCHHHHH".

Once you have ascertained the diagnosis.. again aetiology and risk factors.. especially this young lady, 3 months post-partum.. DO NOT FORGET OCP history (she just delivered, so she might take the Pill). Next thing will come to your mind.. antiphospholipid syndrome (APLS). You now need to determine whether it is primary or secondary.. If secondary, in this part of the world, excluding systemic lupus erythematosus (SLE) is important.. so run through questions related to this and quickly look for the hard signs in the patient.. ie. rash, discoid lesions, alopecia, joint swelling, oral ulcers, vasculitc lesions etc..

Talking about APLS.. getting comprehensive Ob & Gyn history is very important.. number of pregnancies, at what month baby delivered, any complication during delivery ie. pre-eclampsia, any miscarriages (if yes, at what month?), status of the baby at birth and the current status.

Next is to look for complications and associated features ie. migraine, central venous thrombosis, pulmonary embolism, non-healing leg ulcer etc.

Above all else.. maintain patient's welfare and ADDRESS her concern. As she is still young, I am sure she is concerned about subsequent pregnancy, treatment and her future.. ie. can she work etc.

May sound long.. but try practising with your friends.. If you can't get all the points out during exam, getting some of the important once and MAINTANING PATIENT'S WELFARE might suffice.

If you are interested to know more about APLS.. I find this helpful...

1. Guidelines on the Investigation and Management of Antiphospholipid Syndrome
2. Patient information leaflet for Antiphospholipid syndrome

DVT is a very common topic in daily practise... from time to time I am sure we get referrals from our Ob & Gyn colleagues. So it is good to know about this...

In my patient.. the patient fulfilled clinical criteria for APLS - had 2 miscarriages after 10 weeks POA, 1 preterm baby at 32 weeks secondary to pre-eclampsia, had DVT 2 years go and now present with 2nd DVT. Even so, she was treated as left leg cellulitis by the GP for almost 1 month before referred to hospital. Her first anticardiolipin antibody detected. So, this is a case of primary APLS.

Station 5

Mdm Fadilah is 25 year-old lady who has just delivered a baby 3 months ago. Now she comes with left sided lower limb pain and swelling.

Your task is to assess the patient’s problems and address any questions or concerns raised by the patient.

Respiratory Station

Mr A is 60 year old gentleman presents with 1 month history of dyspnoea. Please examine him.

Obviously this is a respiratory station... before you start examining him, you would have to INSPECT him and guest probably diagnosis, ie. bronchiectasis, lung fibrosis, COAD, pleural effusion and pulmonary tuberculosis...

Therefore, from the start of the examination, you would start looking for signs to exclude or include your diagnosis, at the same time looking for aetiology, current status and presence/absence of complications.

Examination techniques.. oh well.. for that you just have to practise till perfect and doesn't show at all on your face that you are thinking while examining. 6 minutes to finish off everything in a respiratory station might not be enough. A tips I had was... once I feel for the trachea, if it is central, I can either go straight to the back first then come back to the front or do the front part quickly. If trachea is central, the pathology most likely won't be detected anteriorly.

Coming back to the case.. this gentleman actually has pleural effusion.. So I leave you with that for now and share with us how you would want to present it, when the examiner tells you.. "Tell me your diagnosis."

Station 5

Increasing weight.. seems to be a simple complaint. At this point when you have that 5 minutes, you must think about several differential diagnoses:

1. Hypothyroidism
2. Cushing's syndrome/disease
3. Metabolic syndrome

Then you must structure your thoughts on how to ask questions and perform physical examination to include or exclude your diagnosis. At the same time, pay attention to her concern (this is VERY important). Don't be to excited to get the diagnosis and forgot about the patient, as this station tests how you interact with your patient.

Once you have the diagnosis, you must get into the aetiology of the diagnosis and later assess the complications of the problem/s.

And this is how the patient may look like...

Photo taken from: http://neuromuscular.wustl.edu/msys/mend.htm

Intermittently, explain to the patient what you think as this is usually what the patient is concern about. Tell the patient if this is serious and how you want to go about after that. REMEMBER NOT TO BE TOO TECHNICAL. If patient understands what you want to do with her, you are doing well!

Share with us how would you approach this.. don't mind having a Q&A session here...

If you notice, this kind of scenario may also appear in your history taking station. So, study smart by studying for both stations at the same time! Good luck!

Station 5

Ms Gina is a 30 year old Indian lady. She complains of increasing weight for the past 2 months.

Your task is to assess the patient's problems and address any questions or concerns raised by the patient.

The road trip never ends....

How are all of you doing? Manage to secure a place for the upcoming PACES exams in October? Congratulations to those who have manage to get a place there.. I have a few friends who wanted to sit for the exams in October but didn't get a place... DO NOT FRET! There is always a blessing in disguise... perhaps, other times will be a better time for you. Anyway, to those who manage to get a place, GOOD LUCK! It's time to work hard and smart towards perfection! By the way, do not just study for the exams.. but more importantly, the learning process teaches you to become a better and humane doctor. I particularly think this true about MRCP exams. Some may think MRCP exams is just about who is the best actor or actress. This is not Oscar we are talking about. Dealing with patients is all it is about. I am happy that I decided to take MRCP. It taught me a lot about dealing with patients and their relatives... and I hope it does the same to you...

And the road trip as a doctor never ends... passing MRCP is not the end.. more to come, especially if you are the ambitious type. Some may decide to speed things up and take advanced specialists training in the neighbouring country and some like me... decide to stay back, relax a little bit before focusing in the advanced specialist training. No matter what.. the road trip goes on. Can be easy and can be difficult. Up to us how to go about. While then, enjoy it!

Trying to prove him wrong...

When I first mentioned the idea of creating a blog for MRCP.. must friend reminded me to think about this carefully. He reminded me that I'll be full of spirit creating just few months after passing the exams and I may not continue doing so after awhile. Promised myself to prove him wrong, I continued with my idea on creating this blog... then again, he knew me too well.. I stopped updating this blog for a very long time.. and I am truly sorry about it. I will try my best to keep on updating this blog at least once a week. Meanwhile, stay tune and do give me some response... Thanks!