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.

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.

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)