New Station 5 - Brief Clinical Consultation (BCC)

As everyone knows… from time to time RCP will make changes to the examination format or even marking format. So called to keep up the standard. Oct 2009 was the first time ever those radical changes were introduced. Station 5 had 180 degree transformation. Marking format also changed. I will talk about change in the marking scheme in a different post.

Whatever it is, I think the new Station 5 is more practical and more realistic. It’s not about showing “museum” cases involving locomotor, skin, eyes and endocrine systems. Here, it is about knowing what is important in history and physical examination when dealing with a particular complaint. And of course, not to forget, dealing with patient’s concerns and not neglecting the patient’s welfare.

Before you start the station, you have 5 minutes to read and prepare both questions – about 2.5 minutes each question. The case scenario is usually short and may not be able to help you much until you actually see the patient. However, important history ie. underlying Psoriasis might be disclosed to you. Once the bell rings, it is time for you to start seeing your first patient, please make sure you have the correct patient for the correct case. Then start the show… you have 8 MINUTES to clerk and examine… do it in any order or even simultaneously. I prefer to take a quick look at the patient and start talking with the patient.. just to get hints on how to proceed further. If necessary.. do take past medical history, drug history.. better if can be done in the right order. This can be done while examining the patient. One of the PACES examiner I met during a course said.. even though it can be done in any order, she would prefer it to be done systematically.. ie.. try not to examine the tummy then only look at the face or mouth.

If you notice in the MRCP website, they mentioned that the cases can be of the 4 systems from the old station 5, or CVS, Respiratory, Neurology or Abdomen. They even advise you to study 20 common medical presentation from the JRCPTB website. Well, at this moment, since this new Station 5 stil new.. I personally think more attention will be given towards one of the 4 systems from the old station 5. Here are the possible case scenarios:

• Sudden onset of blurring of vision with irregular pulse

- It could also be transient body weakness/numbness etc associated with irregular pulse

• Blurring of vision in a patient with newly diagnosed HPT (acromegaly with pituitary tumour)
• increasing ring size with diabetes (acromegaly)
• underlying asthma with symptoms of diabetes (Cushing’s secondary to iatrogenic steroid), or any underlying medical problem that usually requires steroid ie. SLE, autoimmune bullous disorder,
• patient admitted with uncontrolled DM and complains of whitish patches at his hands (Autoimmune Polyendocrine Syndrome)
• admitted with recurrent seizure and has multiple skin nodules (tuberous sclerosis)
• admitted with UGIB, and has hyperpigmentation at the lips and buccal mucosa
• underlying psoriasis with multiple joint pains
• underlying psoriasis with neck stiffness (spondylitic type PsA)
• underlying RA with painful red eye/SOB
• complains of SOB (but when you see the patient, she has features of scleroderma)
• complains of blurring of vision (when see the patient, has exophtalmus and ophthalmoplegia – Grave’s ophthalmopathy)
• bilateral LL weakness – prior to that had multiple blisters over a dermatomal distribution (transverse myelitis post Zoster infection)
• abdominal pain (renal colic) in patient who has tophaceous gout.
• Carpal tunnel syndrome in patient who has gout

Basically… it can be anything! Until there is new publication on this nStation 5, I suggest you continue reading Ryder/Baliga. While reading/studying it.. imagine how it’ll come out in Station 5.. possible complaints and how to approach it. I will share some example.. from what my friends and I did and cases I had during PACES courses.

HAPPY NEW YEAR

2009 ended very quickly and now 2010 has arrived. To some 2010, might be just another year that one has got to go through. But I am sure, to most of us, 2010 is much awaited for. A brand new year with a brand new phase in life. Let it be about work, family or social status. Whatever it is, there is more to come!

2009 has brought lots of joy to my life. Just like most of us, 2010 is very much awaited too. Jumping to a slightly different phase in life, I can't wait to get things going. Hope all of us will be able to continue with our road trip with minimal speed trap!

To those who has just got a promotion, congratulations and keep it up! Who has just become a parent.. all the best! Who has just got married, congratulations! And many more good wishes to all of us. Never think that you have never achieved anything just because you didn't get what you want. Being able to wake up in the morning and breathe the air is a SUCCESS indeed.

HAPPY NEW YEAR! LET'S BEGIN 2010'S ROAD TRIP WITH A FRESH MIND.

Genetic Testing (A)

These are some of the important issue need to be covered when handling an issue of genetic testing.

• informed, voluntary decision
• only available to subjects who have reached the age of maturity
• subjects must not be discriminated in any way after the results known
• not part of routine blood investigation without permission, including in symptomatic subjects
• ownership of the results remain with the subject who requested the results
• consent form
• multidisciplinary team involve, including genetic counselor
• select companion
• results should be presented verbally and in written form
• prenatal testing is possible

To know more about Huntington's Disease in particular, a useful site will be at Huntington's Disease Association UK.

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!