AMC Handbook of Clinical Assessment

Table of Contents Foreword — Joanna M Flynn ix Preface — Roger J Pepperell x Contributors Editorial Committee Additional Contributors xi Acknowledgements xvii Introduction — Vernon C Marshall 1 Role of the Australian Medical Council (AMC) — Ian B Frank 9 Construction, Scoring and Validation of Assessments — Neil S Paget 25 The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format — Heather G Alexander 31 How to Use this AMC Handbook of Annotated MCATs — Vernon C Marshall 34 MCAT Format Example: Candidate Information and Tasks, Performance Guidelines 001 A cut to the thumb of a 22-year-old man 37 MCAT Candidate Information and Tasks, MCAT Performance Guidelines; Five Principal Categories and Domains 44 1 CLINICAL COMMUNICATION (C) 45 • 1-A Communication, Counselling, and Patient Education — Introduction: Alan T Rose ~ MCAT Candidate Information and Tasks 002-021 ~ MCAT Performance Guidelines 002-021 45 DETAILS OF MCAT SCENARIOS 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman 51-67 68-130 CIT PG 53 69 53 54 55 56 57 58 58 59 60 61 72 75 77 79 81 84 87 90 92 95 i 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism CIT PG 62 99 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 62 102 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 63 105 16 A duodenal ulcer found on endoscopy in a 65-year-old man 64 108 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 65 111 65 66 67 67 115 121 125 129 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 1-B Case presentations and summaries to Examiner — Introduction: Vernon C Marshall 131 DETAILS OF MCAT SCENARIOS 022-029 Headache, neck lump, previous shoulder dislocation, dysphagia, low back pain, knee pain, abdominal discomfort, gastric ulcer with haemorrhage 132-135 2 CLINICAL DIAGNOSIS (D) 137 2-A The Diagnostic Process — History-taking and Problem-Solving — Introduction: Reuben D Glass ~ MCAT Candidate Information and Tasks 030-043 ~ MCAT Performance Guidelines 030-043 DETAILS OF MCAT SCENARIOS 30 Jaundice in a breastfed infant 31 A convulsion in a 14-month-old boy 32 Loud and disruptive behaviour of a 6-year-old boy 33 Tremor in a 40-year-old man 34 Headache in a 35-year-old woman 35 Lethargy in a 50-year-old woman 36 Syncope in a 52-year-old man 37 A painful penile rash in a 23-year-old man 38 Primary amenorrhoea in an 18-year-old woman 39 A skin lesion on the cheek of a 50-year-old man 40 A pigmented mole on the trunk of a 30-year-old woman 41 An itchy rash on the hands of a 19-year-old woman 42 Red painful dry hands in a 30-year-old bricklayer 43 Swelling of both ankles in a 53-year-old woman 137 142 -154 155 -195 143 144 144 145 145 146 147 148 149 150 151 152 153 154 156 159 161 164 167 170 173 177 180 182 184 186 189 191 ii CIT • 2-B Physical Examination — Introduction: Vernon C Marshall and Barry P McGrath ~ MCAT Candidate Information and Tasks 044-057 218 ~ MCAT Performance Guidelines 044-057 DETAILS OF MCAT SCENARIOS 044 Assessment of a comatose patient 045 Recent onset of poor distance vision in a 17-year-old male 046 A painful rash on the trunk of a 45-year-old child-care worker 047 Acute low back pain and sciatica in a 30-year-old man 048 Fever and a recent rash in a 30-year-old man 049 A heart murmur in a 4-year-old boy 050 A knife wound to the wrist of a 25-year-old man 051 Multiple skin lesions in a Queensland family 052 Subcutaneous swelling for assessment 053 Examination of the knee of a patient with recurrent painful swelling after injury 054 Assessment of hearing loss, first noted during pregnancy in a 35-year-old woman 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 056 Assessment of a groin lump in a 40-year-old man 057 Eye problems in an aboriginal community • 2-C Choice and Interpretation of Investigations — Introduction: Reuben D Glass and Vernon C Marshall ~ MCAT Candidate Information and Tasks 058-064 ~ MCAT Performance Guidelines 058-064 DETAILS OF MCAT SCENARIOS 058 Positive test for hepatitis C in a 26-year-old woman 059 Diagnosis of 'brain death' prior to organ donation 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 061 An elbow injury in an 11-year-old schoolgirl 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman 063 Atypical ureteric colic in a 25-year-old man 064 Investigation for male factor infertility in a 25-year-old man 234 PG 196 -23 3 -29 6 219 220 221 222 223 224 225 226 228 235 241 246 248 252 255 257 264 274 229 280 230 282 231 232 233 286 289 293 297 312- 319 320- 342 313 314 321 325 315 316 329 331 317 318 319 334 337 340 iii CIT 2-D The General Consultation — Introduction: Barry P McGrath ~ MCAT Candidate Information and Tasks 065-073 ~ MCAT Performance Guidelines 065-073 DETAILS OF MCAT SCENARIOS 065 Acute chest pain in a 60-year-old man 066 Palpitations and dizziness in a 50-year-old man 067 Muscle weakness and urinary symptoms in a 60-year-old man 068 Aches and pains in a 62-year-old man 069 Lack of energy in a 56-year-old suntanned man 070 Recent haematemesis in a 50-year-old man 071 Anaemia in a 28-year-old pregnant woman 072 Acute vertigo in a 50-year-old man 073 Urinary frequency in a 60-year-old man 2-E The Paediatric Consultation PG 343 347-354 355-396 348 349 350 351 352 352 353 353 354 356 363 368 371 374 377 380 383 394 397 — Introduction: Peter J Vine ~ MCAT Candidate Information and Tasks 074-077 ~ MCAT Performance Guidelines 074-077 401-403 404-416 DETAILS OF MCAT SCENARIOS 74 Neonatal jaundice in the first day of life 402 405 75 Immunisation advice to the parent of a 6-week-old baby 402 408 76 Dark urine, facial swelling and irritability in a 5-year-old boy 403 412 77 Fever and sore throat in a 5-year-old boy 403 414 2-F The Obstetric and Gynaecologic Consultation — Introduction: Roger J Pepperell ~ MCAT Candidate Information and Tasks 078-082 — MCAT Performance Guidelines 078-082 417 419-422 423-435 DETAILS OF MCAT SCENARIOS 78 Breech presentation in labour at 38 weeks in a 25-year-old woman 79 Vaginal bleeding in a 23-year-old woman 420 427 80 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 421 430 421 432 422 434 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 082 Vaginal bleeding after 8 weeks amenorrhoea, in a woman with previous irregular cycles 2-G The Psychiatric Consultation — Introduction: Frank P Hume ~ MCAT Candidate Information and Tasks 083-089 ~ MCAT Performance Guidelines 083-089 iv 420 424 436 446-454 455-481 CIT Pfi schizophrenia 084 Demand for urgent treatment for 'sudden hair loss' from a 447 456 29-year-old man 085 Poor work performance in a 30-year-old female police officer 086 Lifestyle stress in a 45-year-old man 087 Binge drinking in a 25-year-old man 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 089 Collapse of a 30-year-old woman on the way to a court attendance 448 449 450 452 453 454 459 463 466 470 474 478 483 DETAILS OF MCAT SCENARIOS 083 Medication changes for a 35-year-old woman with chronic 3 CLINICAL MANAGEMENT (M) • 3-A Management Objectives, Therapeutics, Prevention and Public Health — Introduction: Alan T Rose, Michael R Kidd and Ronald McCoy ~ MCAT Candidate Information and Tasks 090-100 ~ MCAT Performance Guidelines 090-100 DETAILS OF MCAT SCENARIOS 483 489499- -498 -536 090 Acute right sided pain and haematuria in a 25-year-old man 091 Faecal soiling in a 5-year-old boy 092 Psoriasis in a 30-year-old man 093 Temporal arteritis in a 58-year-old woman 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 490 491 492 493 500 503 507 510 40-year-old man 095 Dysuria and urinary frequency in a 40-year-old man 096 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 097 An abnormal glucose tolerance test (GTT) in a 34-year-old 494 495 496 512 519 522 primigravida 098 Bed-wetting by a 5-year-old boy 099 Acute gout in a 48-year-old man 100 Request for repeat benzodiazepine prescription from a 496 497 497 525 528 531 25-year-old man • 3-B Clinical Procedures 498 534 537 543548- -547 -563 101 Resuscitation of a 24-year-old man after head and chest injury 102 Fluid balance assessment in a 50-year-old patient after 544 549 abdominal surgery 103 Evaluation of lung function by spirometry in a 22-year-old man 104 A suspected fractured clavicle in a 20-year-old man 545 546 547 551 558 561 — Introduction: Peter G Devitt and Barry P McGrath ~ MCAT Candidate Information and Tasks 101-104 ~ MCAT Performance Guidelines 101-104 DETAILS OF MCAT SCENARIOS V CIT PG INTEGRATED DIAGNOSIS AND MANAGEMENT (D/M) 565 4-A Clinical Perspective and Priorities 565 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 105-112 ~ MCAT Performance Guidelines 105-112 DETAILS OF MCAT SCENARIOS 570 578 -577 -600 105 Abdominal pain and vaginal bleeding after 9 weeks amenorrhoea, in a 39-year-old woman 106 Recent insomnia in a 25-year-old man 107 Dandruff or head lice in a 6-year-old girl? 108 Recent orchidectomy for a testicular neoplasm in a 571 572 573 579 582 585 28-year-old man 109 Postnatal fatigue and exhaustion in a 28-year-old woman 110 Fundus greater than dates in a 26-year-old woman at 574 575 587 589 30 weeks gestation 111 Tiredness and anaemia in a 55-year-old woman 112 Colonoscopy findings in a 24-year-old man with chronic diarrhoea 4-B Life-threatening Emergencies — Priorities of Treatment 575 576 577 593 596 599 601 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 113-118 ~ MCAT Performance Guidelines 113-118 DETAILS OF MCAT SCENARIOS 113 A severely ill 4-month-old baby girl with fever 114 A lethargic febrile 2-year-old boy with a rash 115 Wheezing and breathing difficulty in a 5-year-old girl 116 Cuts to the wrist of a 25-year-old man 117 Severe postpartum haemorrhage in a 25-year-old primigravida 118 Emergency management of a snake-bite in a 20-year-old man 602- 608 609- 627 603 604 605 606 607 608 LEGAL, ETHICAL AND ORGANISATIONAL (LEO) 610 612 614 618 622 625 628 5-A Ethical and Legal Dilemmas 629 — Introduction: Kerry J Breen ~ MCAT Candidate Information and TasKS 119-124 ~ MCAT Performance Guidelines 119-124 DETAILS OF MCAT SCENARIOS 633640- 639 659 119 A man requesting disclosure of his wife's medical condition 120 Obtaining consent for leg amputation in a 35-year-old man after 634 641 a motor vehicle injury 121 Several bone fractures in a 9-week-old baby 635 636 644 647 VI CIT PG 637 649 638 652 639 MCAT TRIAL EXAMINATIONS 655 661 • Preparatory Instructions 661 122 A parent requesting sterilisation of her intellectually disabled daughter 123 Blood transfusion consent for a 33-year-old pregnant woman with severe APH at 7 months 124 End-of-life request from a terminally ill patient — Roger J Pepperell 16 Station Trial Assessment ~ MCAT Candidate Information and Tasks T1-T16 ~ MCAT Performance Guidelines T1-T16 DETAILS OF MCAT TRIAL ASSESSMENTS 125 126 127 128 129 130 131 132 133 [T1] [T2] [T3] [T4] [T5] [T6] [T7] [T8] [T9] 664 -678 679 -730 Meconium staining of liquor in labour in a 25-year-old primigravida 665 680 A heart murmur in a 5-year-old girl Vigorous vomiting by a 3-week-old boy Urinary incontinence in a 50-year-old woman Migraine in a 30-year-old woman Past history of hip dislocation in a 35-year-old man Tiredness in a 45-year-old man Review of lung function tests in a 65-year-old man with 666 667 668 668 669 670 683 685 688 691 694 696 shortness of breath 671 700 Assessment of a 28-year-old primigravida at 34 weeks with fundus less than dates 672 705 Delirium in a 25-year-old man after a burn injury Chronic diarrhoea in a 45-year-old man Fever, irritability and ear discharge in a 2-year-old boy Review of cytology after aspiration of a breast lesion in a 672 673 674 708 712 716 134 135 136 137 [T10] [T11] [T12] [T13] 138 139 140 [T14] Nocturnal hand discomfort in a 35-year-old schoolteacher [T15] An attack of asthma in a 25-year-old man [T16] Preparing a 30-year-old woman with suspected acute 28-year-old woman appendicitis for surgery 675 718 677 677 721 724 678 728 8 Station Trial Retest Assessment ~ MCAT Candidate Information and Tasks R1-R8 ~ MCAT Performance Guidelines R1-R8 DETAILS OF MCAT TRIAL RETEST ASSESSMENTS 141 142 143 [R1] [R2] [R3] Intravenous cannula insertion for antibiotic prophylaxis Heartburn in a 35-year-old man Spontaneous bruising and nosebleed in a 3-year-old boy 732 740 -739 -765 733 734 735 741 744 748 Vii CIT PG 144 [R4] Nausea and vomiting in the first trimester in a 25-year-old primigravida 145 [R5] Visual difficulties in a 50-year-old man 146 [R6] Cognitive state assessment of a 50-year-old barman 147 [R7] Jaundice in a 25-year-old man 148 [R8] Assessment of prominent leg veins in a 38-year-old woman INTERACTIVE CLINICAL ASSESSMENT — OTHER METHODS AND OSCE MODIFICATIONS — Peter G Devitt and Heather G Alexander 736 750 736 737 738 739 753 756 760 763 767 149 Confusion and delirium after surgery in a 50-year-old man 150 Postoperative fever in a 45-year-old woman 151 The 4 station progressive OSCE 771 771 773 GLOSSARY OF TERMS AND ABBREVIATIONS 776 779 781 EPONYMS 790 APPENDICES 1. AMC Objectives of Medical Education 803 2. AMC Instructions to Standardised Patients and Clinical Examiners 3. MCC/AMC Clinical Task Categories; AMC Function/Process; 806 810 System/Region/Speciality; and Discipline classification MCATs with full Domain listing and AMC Anthology Reference 814 MCATs by Discipline (Condition and page listings only) 843 MCATs by System/Region/Speciality (Condition and page listings only) 847 MCATs by Function/Process (Condition and page listings only) 856 Suggested Additional Groupings of MCATs for self-test trial assessments 862 Guidelines for further reading 863 EPILOGUE 867 INDEX 868 Viii The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format Heather G Alexander The student is to collect and evaluate facts. The facts are locked up in the patient. To the patient, therefore, the student must go.' Abraham Flexner (1866-1959) Medical Education, a Comparative Study The MCAT is an integrated OSCE-style clinical examination where each candidate proceeds through the same number of stations — 16 stations in the full exam, 8 stations in the retest. CONTENT OF STATIONS At each station, two minutes are allocated for preliminary reading outside the room. An instruction sheet giving the candidate specific information and tasks required is provided. This introduces the candidate to the consultation setting and clinical situation. It may also include patient profile test results or an illustration. Specific tasks that the candidate will be asked to perform are itemised. A duplicate copy of the instructions is provided in the examination room. This is followed by eight minutes performing the required task in a room The aims of the with a standardised patient. When the candidate first enters the room, the station, the tasks observing examiner will check that the instructions for the station have that candidates are been read and will then introduce the candidate to the patient. The asked to perform, examiner will then observe the performance and record the the key issues and candidate's performance on a tailored mark sheet. The standardised assessment patient may be a real patient or a simulated patient (role player) who domains defined plays the role of either the patient or a relative. Doctor-patient for the station are communication performance contributes to the assessment and requires all closely aligned. a well-trained role player. Where scenarios are based on physical examination, the 'role player' may be a real patient. FIGUREIII. History-taking FIGURE iv. Commencing the Physical Examination The aims of the station, the tasks that candidates are asked to perform, the key issues and assessment domains defined for the station are all closely aligned. 031 The MCAT scenarios developed for assessment purposes are designed to simulate closely real life situations within medical consultations. These may be in a general practice setting, a hospital emergency department, or a hospital inpatient or outpatient setting. Scenarios deal with different phases of illnesses. Diagnostic scenarios include the diagnostic phases of history taking, physical examination, and ordering and interpreting investigations. The management phases incorporate patient explanation and education, advice and referral, therapeutics and preventive medicine, clinical procedures and counselling. Scenarios are focused precisely so that the assessment domains, key issues and critical errors are accurately related to the station aims and the tasks set down in the candidate's instructions. Members of the AMC clinical examination panel suggest MCAT clinical scenarios based on their prevalence, seriousness, preventability and whether they can be simulated as real life situations within the inherent time constraints. Scenarios are thoroughly reviewed and approved by the multidisciplinary clinical panel prior to use. The current 16 or 8 station MCAT formats cover a broad spectrum of skills in clinical medicine, psychiatry, surgery, obstetrics/gynaecology, and paediatrics, including emergency, hospital and community practice medicine. MCAT MARKING In an MCAT, candidates are assessed at the level of a final year medical student, i.e. a doctor about to commence an intern year (PGY1). Mark sheets for examiner use. The examiner scores the candidate's performance on a mark sheet which specifies the assessment domains, key domains, and critical errors if appropriate. The assessment domains match the tasks outlined on the instructions the candidates receive during the two minutes preliminary reading. The marking domains are identified from among a total of 14 covering: • approach to patient and responses to patient's questions; • patient counselling and education; • history-taking; • physical examination choice and technique; • physical examination accuracy; • choice of investigations; • interpretation of investigations; • diagnosis and differential diagnosis; • initial management plan; • explanation of clinical procedure; • performance of clinical procedure; • familiarity with test equipment; • commentary to examiner; and • answers to examiner's questions, No single station is likely to have assessment in more than five of these domains. Each domain has a 4-point marking scale: • Very satisfactory Clear pass • Satisfactory Pass • Unsatisfactory Fail • Very unsatisfactory Clear fail 032 An example mark sheet is included later with the example MCAT 001. (see page 44) Critical errors are defined and derived from one or more of the key issues, when relevant. Not all stations have critical errors. If the candidate makes a critical error the candidate is very likely to fail that station, regardless of performance in other domains, unless performance in other domains is outstanding and the critical error is deemed possibly related to lack of time or misunderstanding of the task. MCAT performance is checked and reviewed by the Clinical Panel of Examiners after each use in an examination. All details, particularly presence and definition of critical errors, are reassessed and retained or modified in light of candidate performance and examiner feedback. Station failure would probably result from two or more 'unsatisfactory — fail' assessments or one 'very unsatisfactory — fail' assessment in a key issue domain, or from making a critical error in a key issue domain. After scoring each of the domains, the examiner will provide an overall (final) rating that is either 'Pass' or 'Fail' for each station. All 16 MCAT scenarios are of equal weighting and for each scenario there are only two outcomes — pass or fail. Candidates must obtain a pass in 12 or more of the 16 stations, including a pass in at least one paediatric and one obstetric/gynaecology station, to pass the MCAT as a whole. Candidates scoring pass levels in nine or less of the 16 stations, or with failures in all three of the paediatric or obstetric/gynaecology stations, fail the examination and must resit. Candidates who pass 10 or 11 of the 16 stations (including a pass in at least one obstetric/ gynaecology station and one paediatric station) will be eligible for a pass/fail Retest Examination of 8 stations. Retest candidates will be required to pass six or more of the eight retest stations to pass the examination. Candidates scoring five or less passes will fail and be required to resit the whole examination. Heather G Alexander July 2007 033 How to use this AMC Handbook of Annotated MCATs Vernon C Marshall 'In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.' Sir William Osier (1849-1919) The MCAT self-test scenarios are arranged in groups under the principal categories and domains tested. In each instance the reader is provided with a synopsis heading, outlining the clinical problem/condition together with the information available to the candidate and details of the task to be undertaken, exactly as this appears in the MCAT examination. INSTRUCTIONS TO CANDIDATES You may wish to attempt to complete the tasks in each of the major categories before moving to the next group. If you would prefer to review tasks by system and region, or by discipline, the appropriate groupings of these are listed in later pages. Page numbers of individual MCATs are listed in the table of contents at the beginning of the book for easy reference. After reading carefully the information provided to you for each clinical scenario and the required tasks, jot down how you will approach this consultation, how you will advise the patient or relative of your findings and recommendations, and how you would structure responses to queries from patient or examiner. Then turn the pages to check your responses against the optimum Performance Guidelines, Examiner Instructions and Commentaries. Note the station Aims, Key issues and Critical Errors outlined. In this book the scenarios are grouped into five main categories. The groupings are to some degree artificial in that communication skills are relevant to all scenarios. For example, aspects of diagnosis, management, and patient counselling and education are frequently combined to varying degree, but the groupings are arranged to emphasise and categorise the principal domains even though most scenarios are assessed over multiple domains. The five groupings below condense the total of 14 domain assessments into five categories covering skills principally in: 1. Clinical Communication (C) — with patient, relative and observer, and including a number of domains: approach to patient, patient counselling/education, history-taking, commentary to examiner, answers to patient's or examiner's questions, explanation of procedure, case presentation and summary. 2. Clinical Diagnosis (D) — includes history-taking, technique and accuracy of physical examination, choice of investigations and their interpretation, diagnosis/differential diagnosis. 3. Clinical Management (M) — includes initial management plan, performance of procedure/task, treatment and prevention of disease, clinical procedures. 4. Integrated Diagnosis and Management (D/M) — includes clinical perspectives and priorities, life-threatening emergencies, integrative reasoning skills and clinical problem-solving. 5. Legal, Ethical and Organisational (LEO) — includes scenarios where ethical and legal issues are significant. 034 INTRODUCTORY GUIDELINES for candidates (see Table below) The MCAT self-test are provided at the start of each of the main categories and their scenarios are arranged domains. in groups under the After completing individual case scenarios you may find it helpful to principal categories revise your knowledge of similar and linked conditions by referring and domains tested. In to appropriate clinical texts and references. The AMC Anthology of each instance the Medical Conditions contains other self-test strategies for individual reader is provided with conditions. a synopsis heading, Try making up your own variations on the conditions tested, and outlining the clinical practise role playing and interactions with a colleague or in a group. problem/condition Once you are familiar with the mechanics and time constraints, together with the pace yourself through the trial examinations (one containing 16 information available to stations and one containing 8 multi-disciplinary stations), and the the candidate and other suggested groupings provided later in the book, under details of the task to be undertaken, exactly as simulated examination conditions. this appears in the The Editorial Committee hopes you find the examples helpful and MCAT examination. extends its good wishes for a successful assessment. SCENARIO HEADINGS FOLLOWED IN THE AMC HANDBOOK OF CLINICAL ASSESSMENT The MCAT scenarios and performance guidelines are set out in a standardised sequence as follows. Groups of self-test candidate information and tasks are arranged under principal categories and domains tested. Table 3 MCAT Introductory Guideline Scenario Headings CONDITION AND ID NUMBER A generic and non-diagnostic summary of the presenting symptom, physical sign or investigation result in diagnostic-type cases, such as: • Assessment of acute abdominal pain in a 30-year-old woman. • Assessment of a vesicular rash in a 50-year-old man. • Review of liver function test results in a 50-year-old man with jaundice. The diagnosis or most likely diagnosis in management/counselling-type cases, such as: • Management of shingles ('herpes zoster') in a 25-year-old woman. • Counselling the relative of a patient after recent major surgery. CANDIDATE INFORMATIO N AND TASKS Under this heading the background information and tasks are given precisely as they appear in the MCAT examination. Page references to the matching Performance Guidelines are given at the foot of each Candidate Information and Tasks sheet. YOURTASKS ARE TO: Lists requested tasks for candidates. 035 Performance guidelines follow in similar category and domain groups linked to the preceding scenarios by ID number and page reference. PERFORMANCE GUIDELINES CONDITION AND ID NUMBER Principal category and assessment domains in detail; and classitication by function, system/region and discipline (see Appendix 3) are listed for each station just prior to the index. AMC Anthology of Medical Conditions reference is listed to aid further self-testing. The MCC/AMC Clinical Task Category is also listed. AIMS OF STATION A brief outline of station and assessment aims, matching the tasks. The expected responses and levels of performance required to complete the tasks successfully are outlined in the examiner instructions and commentaries. EXAMINER INSTRUCTIONS These provide the following: Instructions from examiner to standardised patient Candidate information and tasks and role player instructions are detailed and provided to examiners and standardised patients so that there is standardised behaviour across multiple patients. Cues assist in directing the consultation pathway. The instructions are set out using lay terminology to maintain realism, and outline: • Clinical setting — hospital emergency department, hospital ward or outpatient department, primary care facility, community practice office consultation. • Clinical situation — description of illness and symptoms and phase of the consultation. • Patient profile — age and gender, past history, family history, habitus, as relevant to the case. • Opening statement — one sentence provided as the patient's opening gambit. • How to play the role — advice on further responses, posture, gestures, affect, mood and ways to react to the doctor, including where the task is a physical examination. Questions to be asked by patient/role player — set down in a loose priority and which will depend on whether these have already been covered by the doctor/candidate. Any examiner questions or prompts to the candidate are also outlined, with the required responses. EXPECTATIONS OF CANDIDATE PERFORMANCE These are clarified for the examiner and match the tasks and the domains. KEY ISSUES These are selected from the assessment domains and expectations of candidate performance for each case and highlighted accordingly. CRITICAL ERROR(S) These list significant errors likely to lead to a fail performance. COMMENTARY This discusses and comments further on the condition, highlighting performance standards and common errors. 036 EXAMPLE CASE SCENARIO: The following case scenario exemplifies the formatting for a combined Diagnosis and Management MCAT. MCAT FORMAT EXAMPLE: Sample - Condition 001 Candidate Information and Tasks Condition 001 A cut to the thumb of a 22-year-old man You are the Hospital Medical Officer (HMO) in a hospital Emergency Department. The patient injured his left thumb at work an hour ago. He is aged 22 years and works as an orchard labourer and fruit picker. He is right handed. He was pruning fruit trees today and the pruning knife slipped and he cut his left thumb. He was wearing cotton gloves. The knife cut through the glove and cut the thumb as shown in the illustration below. Bleeding was minor and controlled by a pressure dressing, which has been removed for examination. The wound appears as a linear knife cut as shown, the edges of which have sealed after the initial bleeding which has now stopped. YOUR TASKS ARE TO: • Examine him and assess the injury. • Explain to him the nature of the injury and your recommended management. You may ask other questions of the patient as you proceed with the examination and explanation. Near the end of the eight-minute time allotted for your task, the examiner will ask you one or two questions. CONDITION 001. FIGURE 1. Knife wound to the left thumb The Performance Guidelines for Condition 001 can be found on page 40 037 Sample-Condition 001 Candidate Information and Tasks CANDIDATE ADVICE You should: Prepare and document your responses and how you would approach this task. Test yourself thoroughly after reading the MCAT Candidate Information and Tasks, before proceeding to read the performance guidelines, examiner and patient instructions and commentary which you will find on subsequent pages. Follow a similar process for the other MCATs. The best way to develop proficiency in an MCAT assessment is to work in pairs or as a group. Your colleague reads the performance guidelines and plays the patient/relative, while you read the candidate information and perform the tasks, while another group member takes the role of examiner/observer. SUMMARY OF STUDY TASKS Read the candidate information and task(s), preferably working with a colleague or group. Formulate and document a logical approach for responding to and solving the consultative problem given. Then read the performance guidelines that follow, and note the aims of the station, expectations of your knowledge and performance, key issues and critical errors and other points raised in the commentary. Check for any deficiencies in your performance. Reread the introductions to the section in which the MCAT appears. For this MCAT about a thumb wound, revise your knowledge of applied surface anatomy relevant to wounds giving risk to underlying structures and how you should check for local and distal effects of injury. Construct alternative scenarios for other wounds and self-test yourself on these (for example, injuries to radial nerve in the arm, common peroneal nerve in the leg). Revise the Anthology scenarios 113, 113H, 113J and 113K and complete the self-test exercises. Reinforce your understanding of the condition by completing other self-assessment tasks (for example from the AMC Anthology of Medical Conditions) and construct at least one other related task for solving. Finally, one complete MCAT 16 station assessment and one complete MCAT eight station assessment are provided later in the book as examples of whole examinations for trial. 038 Sample-Condition 001 Candidate Information and Tasks Additional groupings of MCATs into further self-test trial examinations are also suggested at the end of the book. MCATs are also grouped into one of the principal disciplines of medicine, obstetrics/gynaecology, paediatrics, psychiatry, surgery if you wish to use the book in this way. MCATs are similarly grouped into the relevant function and process and into system/region/specialty. For these latter groups, MCATs are often listed more than once when they cover more than one system or function. Pace and test yourself through these. Keep practising within a group of your peers until fully familiar with the routine. We hope that you will find the self-discipline and requirements to adhere to logical clinical reasoning pathways in approaching the wide range of clinical problems selected for this book will stand you in good stead, not just for assessment examinations, but throughout your subsequent career. Vernon C Marshall 039 Sample - Condition 001 MCAT FORMAT EXAMPLE: Performance Guidelines Condition 001 A cut to the thumb of a 22-year-old man AIMS OF STATION To assess the candidate's ability to use clinical reasoning skills to diagnose and manage important injuries associated with skin wounds. In this instance, the knife cut has severed the two extensor tendons to the thumb. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The examiner will draw the linear cut with a red marking pen on the role-playing patient, and show the patient how to respond to requests to bend his thumb and testing of sensation as follows: • You have not yet noticed and should not volunteer any information about limitation of thumb movement, until specifically asked to extend each of the two end joints, which you are unable to do. Sensation is normal. • You had a tetanus booster shot about a year ago for a leg graze and were immunised against tetanus as a child. Opening statement: • 'Will it be okay for me to go back to work tomorrow with a dressing over it now it's stopped bleeding, Doc?' Other questions to ask: • If the candidate/doctor diagnoses tendon injury with normal sensation, you will accept the recommendations for operation, and should ask about the operation 'Will I need an anaesthetic?' (Appropriate answer — Yes: regional block or general anaesthesia). • If no mention of a tetanus prophylaxis or antibiotics is made during the interview you will subsequently ask 'Will I need another tetanus shot?' (A booster dose of toxoid would be appropriate). Examiner's questions to candidate: • At the end of 6-7 minutes, if the candidate has identified that a tendon injury has occurred, the examiner should ask: 'What are the names of the injured tendons?' (Extensor pollicis longus [EPL] and extensor pollicis brevis [EPB]) and 040 Sample - Condition 001 Performance Guidelines 'Which joint does each tendon act upon?' (Interphalangeal [IP] and metacarpophalangeal [MP] joint respectively). If no tendon injury has been identified just ask: 'If antibiotics are to be given, what would you choose?' (Broad spectrum cover such as one dose of amoxycillin, cephalosporin or other antibiotic). EXPECTATIONS OF CANDIDATE PERFORMANCE Cuts and stabs of various types commonly present to emergency departments. Attending doctors must be aware of the anatomy of deeper structures at risk from injuries at specific sites and the methods of diagnosing such injuries. Diagnosis of injury to the two main long thumb tendons and recognition of the treatment requirements for primary surgical repair in this 'tidy' (clean contaminated) wound. Explanation of treatment would optimally advise preparation for early surgery using local (field) block or general anaesthesia. Antibiotic and tetanus prophylaxis would be appropriate. KEY ISSUES Ability to identify deeper tendon injuries resulting from stabs or cuts. Failure to appreciate that the whole thumb extensor mechanism (involving two tendons) has been damaged would comprise a fail (unsatisfactory) in the domains of examination technique and diagnosis. Failure to name the tendons correctly would not necessarily be a fail performance, providing the presence of tendon injury was diagnosed and appropriate advice given in other areas. Failure to mention antibiotic or tetanus prophylaxis would be unsatisfactory, but would not be considered a critical error in the presence of a 'tidy' recent wound; such omission would most likely be corrected with subsequent specialist referral for surgery and anaesthesia. CRITICAL ERROR Failure to test and identify the injury to the extensor tendons would comprise a clear and irremediable fail for this station at a very unsatisfactory level. 041 Sample - Condition 001 Performance Guidelines COMMENTARY The knife cut has severed the two extensor tendons to the left thumb {extensor pollicis brew's and extensor pollicis longus, from radial to ulnar side). These tendons form the margins of the anatomical snuff box as illustrated. The tendons have been severed at the knuckle level of the metacarpophalangeal joint. The patient has no obvious thumb deformity but is unable actively to extend either the metacarpophalangeal (MP) joint or the interphalangeal (IP) joint of the thumb. The digital cutaneous nerves have not been cut and distal sensation is normal apart from tenderness around the cut. Extension of the joints of the thumb occurs from the actions of: • Extensor pollicis longus (EPL) the ulnar-sided of the two thumb tendons running on the dorsal aspect of the thumb. The long tendon of EPL runs obliquely across the back of the hand after angulating around the tubercle of the radius (Lister tubercle) before inserting into the base of the distal phalanx. EPL is the prime mover and sole extensor of the terminal (interphalangeal) joint. By passing across the metacarpophalangeal (MP) and carpometacarpal (CM) joints of the thumb. EPL can also act as an accessory extensor of these joints. EPL, like other superficial tendons, may be injured by cuts and penetrating injuries. • Extensor pollicis brevis (EPB) is the lateral of the two thumb extensors. EPB runs in the same synovial sheath as the tendon of abductor pollicis longus on the lateral surface of the radius and continues over the dorsal shaft of the metacarpal to insert into the base of the proximal phalanx. EPB is the prime mover in extension of the MP joint and an accessory extensor of the CM joint. Cuts around the knuckle of the metacarpophalangeal joint are likely to sever one or both tendons. In this patient, both EPL and EPB have been severed. • Abductor pollicis longus (APL). This stout tendon, often multiple or ridged like a stalk of celery, inserts dorsolateral^ into the base of the thumb metacarpal. APL is the prime mover of radial abduction and extension of the thumb at the carpometacarpal joint, separating the thumb from the other digits in the plane of the palm. In this patient, radial abduction will be unaffected as APL has not been injured. 042 Sample - Condition 001 Performance Guidelines CONDITION 001. FIGURE 2. Normal Anatomy — Left hand and thumb The Examiner mark sheet for MCAT 001 follows. 043 Candidate ID card sighted Very Satisfactory - PASS Satisfactory - PASS *-■ KEY ISSUE Covers all essential Minor technical Choice & Technique of Examination, Organisation and Sequence Did the candidate carry out an appropriate focused and relevant examination as per examiner instructions? aspects competently - minimal errors or omissions. •-■ KEY ISSUE Identified most or Accuracy of Examination Did the candidate identify the physical findings accurately as per examiner instructions? all findings accurately. •^ KEY ISSUE Covered all essential Diagnosis/Differential Diagnosis Did the candidate formulate and describe an appropriate diagnosis/ differential diagnosis as per examiner instructions? aspects competently - minimal or no errors or omissions. Logical, clear, well organised. •-. KEY ISSUE Covered all essential Initial Management Plan Did the candidate formulate and describe an appropriate initial management plan as per examiner instructions? aspects competently - minimal errors or omissions. Optimal management plan. Answers to Questions Covered all aspects Answers to questions asked by examiner? completely, minimal errors or omissions. OVERALL RATING FOR THIS CANDIDATE FOR THIS STATION: □ □ □ □ □ faults but examination completed reasonably. □ □ Minor errors in findings. □ Minor omissions or errors in explanations of findings. Diagnosis and differential diagnosis appropriate to the case even if not completely accurate. Minor errors but did not interfere with an adequate initial management plan. □ Minor errors in answers to questions. PASS □ Unsatisfactory - FAIL Very Unsatisfactory - FAIL Candidate displays Serious errors or omissions in technique. one or more of the following: - significant omissions - significant errors of technique - poor technique One or more significant errors in findings. Significant errors in CRITICAL ERROR? Significant errors X 3-i <T CD 3 A (1 □ □ explanations of findings. Wrong interpretations of findings. Unclear and poorly organised. Diagnosis inappropriate to the ;ase. which did interfere with an adequate management plan. T U) □ i1 ^+ n 1 A 1 II X— o [11 Serious errors or omissions in findings: reported findings not consistent with physical signs CRITICAL ERROR? Diagnosis not given. Serious omissions or errors in interpretations of findings. Clinical reasoning and diagnostic skills markedly deficient. Very poor organisation. Wrong diagnosis could result in serious harm to the patient. CRITICAL ERROR? Serious errors or omissions. Inappropriate management and/or management proposed is potentially harmful to patient. CRITICAL ERROR? Significant errors in Serious errors or omissions in answers to questions indicating lack of in knowledge/expertise these areas. the answers given, or complete unfamiliarity with the subjects asked. rr nX ZS cp o Tl n § 1 O n —i in O oo GO O CRITICAL ERROR? FAIL 044 Clinical Communication (C) 1-A: Communication, Counselling & Patient Education Alan T Rose 'Oh, that's your doctor, is it? What sort of a doctor is he?' Well, I don't know much about his ability, but he's got a very good bedside manner!' George du Maurier, Punch Cartoon, 15 March 1884. 1-A COMMUNICATION, COUNSELLING AND PATIENT EDUCATION Communication is the exchange of messages and thoughts by speech, signals or writing. Communication skills are employed to ensure that exchanges are readily and clearly understood. Exchanges involve the sharing of information, ideas, emotions, and empathy. Communication is the foundation on which medical consulting takes shape, supplemented by the practitioner's skill in physical examination and diagnostic reasoning. Failure of communication is an important contributor to clinical situations of perceived malpractice and is the most important factor in a high proportion of medicolegal actions. Most medical consultations and activities require the doctor and patient to communicate rationally and effectively with each other.The AMC examination Exceptions are when the patient is an infant or is intellectually process places handicapped — communication is then with a relative or carer — considerable emphasis or when the patient is unconscious (including when on assessment of anaesthetised) or suffering from certain psychotic states, or effective communication when doctor and patient do not share the same language. between candidate and Communication requires special techniques with patients who patient during clinical are blind, mute, aphonic or aphasic. Impaired hearing may consultations, during affect either patient or doctor. The role of the interpreter, when discussions with required, is also critical. Involvement of third parties (such as relatives, and during relatives, friends, or outside agencies) requires the patient's case presentations and consent. In these situations the patient's legal right to commentaries. confidentiality and privacy must be respected. The AMC examination process places considerable emphasis on assessment of effective communication between candidate and patient during clinical consultations, during discussions with relatives, and during case presentations and commentaries. Written communications are important for letters of referral and discharge summaries, but are less readily assessed within the current AMC format. Verbal communication depends on a mutual understanding of the language being used and the way it is articulated. This includes pronunciation, auditory level, speed, tone and the unique voice qualities and cadences of the speaker. The AMC examination assesses communication in the English language in a medical and clinical context. English is not the first language for many IMGs, but all IMGs are required to have adequate clinical communication skills in English by medical registration boards. 045 Nonverbal communication (such as facial expression, posture, gesturing, silence, and emoting) by either doctor or patient, also conveys messages as well as influencing the understanding of what is being said and its emotional context. Effective verbal and nonverbal communication in medical practice facilitates the establishment of empathy and rapport, trust and confidence, mutual understanding, education about the clinical condition, and satisfactory compliance with advice and treatment. The term 'bedside manner', used to describe a doctor's communication skills, was first used in a London 'Punch' cartoon by George du Maurier. Wide variations in clinical communication skills occur because of each individual doctor's inherent personality traits and individual approach to patients. These can be modified and improved by education and self awareness, so that time is saved and any frustrations felt by the doctor or dissatisfaction by the patient are minimised. Similarly, the cultural characteristics of the patient (and of the doctor) can profoundly affect the quality of doctor-patient communication. Doctors practising in Australia require multicultural competence across all fields of medicine. Special care is required in the case of Aboriginal and Torres Strait Islanders, and for culturally and linguistically diverse groups. Communication skills, although important, are not sufficient. Good communication skills must be accompanied by sound clinical skills, attitudes and professional behaviour. The (fortunately) rare physician serial criminal murderers have usually been superb communicators. Other personal factors can interfere with the doctor's use of communication skills. Many clinical realities are unpleasant to both patient and doctor. If the doctor retreats behind a professional fagade of a stilted and portentous style of speech, or adopts a pompous or pretentious attitude, or one interpreted as such, the patient can be daunted from further enquiry. Rejection by the doctor of a patient's attitude or behaviour engenders lack of understanding and trust. Value judgements of the doctor are best avoided or concealed. Care and compassion should be evident but not forced or obtrusive. This is especially important when treating users of illicit drugs or dependent alcoholics. Mention should also be made of the so-called 'difficult patient' whose underlying but sometimes unrecognised personality disorder reduces or eliminates the effectiveness of the communication skills described below. The application of communication skills Effective communication is of most value when taking a history, providing patient education about the condition diagnosed, giving advice about treatment, counselling patients, and when discussing the patient's illness with anxious relatives or friends. History-taking There are two main methods. Transition from one to the other occurs depending on the clinical setting and progress of this phase of the consultation. The aim is to define the presenting problem to a point where the diagnosis moves from possible to probable to definite. Firstly, the nondirective or 'open-ended' approach: this allows and encourages patients to outline the problem ('tell their story') in their own way while the doctor listens with little interruption. Although apparent irrelevancies may be brought up, this method gives an opportunity for patients to reveal concerns initially unstated. These concerns may explain their real reason for attending and why they have come at this particular time. 046 This approach is most useful when the patient is consulting the doctor for the first time about undifferentiated symptoms such as 'tiredness', 'bloating', 'being run down', 'sleeplessness', or 'requesting a checkup'. Secondly, the directive, closed or interrogative approach: this confines the patient to the doctor's agenda. This is appropriate in emergencies and, if the problem has already been well defined, when a patient's progress is being reviewed in followup. The doctor takes early control of the interview by the use of a series of direct or closed questions. This approach is well summarised by the traditional term — history 'taking'. The directive approach risks the omission of significant information, particularly from a patient who is anxious, reticent, embarrassed, or has feelings of shame or guilt. Nonverbal communication is very useful in the nondirective approach and can replace some parts of the verbal component, for example, expressing surprise by facial expression. Transition from nondirective to directive mode occurs when the doctor begins to ask direct or closed questions, but the two modes are usually phased or overlap. The type of question used will change the direction of the interview. Using questions about pain as examples: open ended 'Tell me about the pain?' direct Where Is the pain?' closed 'Have you had this pain before?' leading 'The pain isn't severe?' A series of direct or closed questions is usually necessary to complete the history regarding occupation, past and family illness, domestic habits, medications, allergies and sensitivities, where relevant. Facilitation is also a valuable nondirective tool. Facilitation uses nonspecific inviting or encouraging remarks, for example, 'go on', 'I'm listening carefully', 'tell me more about the pain', 'anything else?', 7 see', or 'uh uh'. Listening is an essential basis of communication. Adequate time must be given and the doctor's nonverbal behaviour should indicate to the patient that the listening is attentive. Note-taking should be discreet and avoid distraction. The use of a personal computer by the doctor in the consulting room while taking a history requires, more than ever, that the doctor's nonverbal behaviour assures patients that they are being 'listened to'. Silence is not the same as listening. Silence may be the best response when there is an emotional or confrontational component in the consultation. Confrontation can defuse an issue ('Wouldn't we progress better if we leave aside for the moment your previous dissatisfaction with treatment and try to work out how best to fix things now?') but should be used with care. Frequently initial aggression or anger from the patient is better deflected in the first instance. Summarising briefly what the doctor believes the patient has said so far is often useful to confirm that mutual understanding at that point in the interview is present. As previously noted, these techniques are modified by the personality and instinctive behaviour of the doctor, who may not always be fully aware of their effect on a patient. The perceptive doctor attempts always to appreciate the patient's perspectives as well as the doctor's own. In summary, the following guidelines apply to history 'taking' from a patient presenting with a nonurgent diagnostic problem. 047 Following the formalities (or informalities) of introduction, the doctor should: • begin with an open-ended approach; • listen carefully and attentively; • use facilitation and open-ended questions to encourage the patient; • limit direct questions early in the interview; • use indirect and reflected questions as appropriate; • use direct and closed questions to take control at an appropriate time; • take note of any display of emotion by the patient and respond appropriately; • briefly summarise what is being learnt or understood (or not) from the patient; • gradually increase control of the interview as it proceeds; • use nonverbal communication, to supplement verbal communication; and • be alert to the patient's nonverbal behaviour. With loquacious and garrulous patients, transition from open-ended to direct questioning needs to proceed expeditiously but tactfully because of time constraints. In many of the MCAT clinical scenarios, direct questioning is essential to enable a focused history to be taken within the time period available. Communication skills are especially important when the patient has concerns other than those expressed in the first statement to the doctor. Such hidden concerns may include fears of cancer, heart disease, stroke, blindness, sexually transmitted infection, work capacity, relationships, serious illness in an unborn child or infant, dissatisfaction with treatment and feelings of grief or guilt — to mention only a few. Patient education Once the diagnosis has been made, it should be stated to the patient using both medical and lay terminology appropriate to the patient's understanding. Initial reassurance should be given when appropriate ('I'm pleased to tell you that the biopsy showed no evidence of cancer'). Failure to do so may allow patient anxiety to block the reception of other information. Reassurance may be the only therapy that is necessary — unnecessary prescribing may follow if the doctor has not understood this basic need of the patient for reassurance. The patient's knowledge and understanding of the condition should then be established so that education can be pitched at the correct level. This includes the correction of incorrect beliefs and responses to the patient's questions. The use of a chart, diagram or of printed notes, may be additionally helpful. As previously stated, anxiety may reduce the efficiency of absorbing and understanding information. Patients will also differ in their interest and tolerance of information about their ailments. Most will want to know if the condition is serious, whether it can be treated, when they will recover and resume normal activities, and what forms treatment will take, even though these questions may not be asked directly. Overloading the patient with information can be counterproductive and have unwanted effects including the creation of pessimism and anxiety. Further information can be added at a subsequent consultation. Handing out previously prepared written material is helpful for most patients but is no substitute for verbal education from the doctor. Adverse information should be given in such a way so as to not destroy hope, and also to assure the patient of the doctor's continuing support. An adequate level of understanding is the only basis on which patients can share the responsibility of decision-making about treatment and give informed consent. Many patients 048 however still prefer to leave all decisions to the doctor. If thought necessary, confrontation can be used to bring to the attention of patients their own responsibilities in aiding effective treatment. Giving advice about treatment The wide ranges of treatments, which may be indicated, include giving simple advice, prescribing, minor or major procedures, the use of allied health professional services, referral to another doctor or to a hospital service, and counselling. All require the use of communication skills, either verbal, nonverbal, or written. When counselling is the main component of treatment, additional special skills are required. The duration of intended treatment should be advised to the patient and opportunities for giving preventive advice taken whenever appropriate. This may involve other members of the patient's family. Prescribing should be supported by a statement of the name of the medication, which may also be written down for the patient, the dose and timing, expected effects including the most important side effects, and significant adverse reactions. Patients will also wish to know general details about any procedure which has been recommended, and what to expect when a referral has been made. Patients should not be left wondering what happens next. Certainty about followup arrangements, particularly after investigations or referral, should be made quite clear. Neglect of these can have medicolegal consequences. Patient Counselling Counselling is a term widely used in the community to describe the provision of support to individuals or groups who are experiencing significant emotional stress. Counsellors, usually with special training in psychological skills, attend survivors or observers of accidents and disasters and provide support. Doctors frequently need to give 'bad news' to patients and relatives, and are involved with bereavement and grieving responses. Allowing patients and relatives to work through their feelings by means of facilitation and attentive listening, and providing support and reassurance whenever possible, with unforced compassion and sympathetic understanding, is required every day in clinical practice. However, when 'patient counselling' is used in treatment, there are two types: directive and nondirective. As with other communication skills these may overlap or be used in an integrated way. However, one type usually predominates according to the clinical situation. Directive counselling is when straightforward advice or instruction are given to the patient. In contrast, nondirective counselling is a special communication skill which involves more than patient education or giving advice about treatment. Its objective is that the patient, instead of the doctor, is the final decision-maker and shares or accepts, in part or fully, responsibility for the subsequent course and outcome of the problem. Nondirective counselling begins with an accurate definition of the problem using the skills outlined under nondirective history-taking, particularly listening and the use of silence. The doctor then provides education about the problem including possible outcomes that are likely to follow alternative forms of behaviour or non-compliance by the patient. Patients are then asked what course they intend to follow, based on the options that have been discussed. The process may occur rapidly or may take more than one consultation to work through. It is essential for the doctor to maintain a nonjudgmental attitude throughout the process. 049 This skill is most useful in dealing with difficult behavioural problems such as smoking, heavy drinking, eating disorders, drug use, marital problems and when dealing with anxious parents. When the use of addictive substances is involved, counselling has shortcomings as do other techniques, but is always worth using — results can be surprisingly effective. Assessing communication skills Communication skills are assessed continuously throughout the whole of every case scenario and consultation. Other domains are usually assessed in sequential segments (for example physical examination follows history, diagnosis follows investigations, and so on). Particular communication skills are also defined within the domains in current use in the AMC examination. These are: Approach to patient • • • • • Empathy, comfort, consideration, Explanation, using language that the patient understands (no jargon), Checking for patient understanding, Answering patient's, parent's or relative's questions, and Obtaining verbal consent to proceed. History • Taking an appropriately focused medical history. Commentary to examiner • Describing the findings of physical examination with appropriate commentary; and • Presenting a case analysis in summary to the examiner. Diagnosis/differential diagnosis • Describing an appropriate diagnosis/differential diagnosis plan. Initial management plan • Describing an appropriate initial management plan. Patient counselling/education • Educating the patient/relative/carer about the condition; and • Giving appropriate counselling. Explanation of procedure • Explaining a procedure and its implications to the patient. Answering questions asked by the patient or examiner • Most scenarios include cued questions to the doctor by the patient, parent or relative; and • Some scenarios have specific prompts or questions from the examiner. Each of the above domains (plus others such as technique and accuracy of examination 14 in all) attracts separate assessment by the examiner. The number of domains being assessed in any individual MCAT rarely totals more than five. Communication skills may affect performance in all domains. Experienced examiners, who are themselves skilled in communication, have no difficulty in integrating communication components with those of knowledge and attitudes and other clinical skills. 050 Communication, Counselling & Patient Education Conclusion The effectiveness of virtually all consultations is enhanced by the doctor's understanding and use of communication skills. The establishment of trust and confidence, empathy and rapport, diagnostic precision, appropriate prescribing, patient education and understanding, patient compliance, and self-help lifestyle modifications are all facilitated when doctor and patient understand each other to an optimal level, as a result of the proper application of communication skills. Alan T Rose 051 1-A Communication, Counselling and Patient Education Candidate Information and Tasks MCAT 002-021 2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 16 A duodenal ulcer found on endoscopy in a 65-year-old man 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 052 002-003 Candidate Information and Tasks Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in an antenatal clinic, seeing a 28-year-old woman for her antenatal visit at 35 weeks of gestation. She wants to discuss infant feeding with you. She has heard a lot about the benefits of breastfeeding, but her mother told her recently that babies grow better with formula feeds. She is uncertain whether she should breastfeed or formula-feed her baby. YOUR TASKS ARE TO: • Discuss the advantages and disadvantages of breast-feeding and formula-feeding with her. • Outline the steps involved in safe formula-feeding. The Performance Guidelines for Condition 002 can be found on page 69 Condition 003 Advice on neonatal circumcision for a couple expecting their first child CANDIDATE INFORMATION AND TASKS A young couple, the wife pregnant with their first child, have come to see you in a general practice to discuss with you the place of routine neonatal circumcision if their baby is a boy. YOUR TASK IS TO: • Discuss with the couple the perceived risks and benefits of this procedure. ] J The Performance Guidelines for Condition 003 can be found on page 72 053 Candidate Information and Tasks Condition 004 Suspected hearing impairment in a 10-month-old child ( CANDIDATE INFORMATION AND TASKS ) You are working in a community health centre. Your next patient is a 10-month-old female infant, baby Helena, seen with her mother, who has been referred by the local child health nurse. The pregnancy and delivery were normal. The child presented to the nurse six weeks ago for review and general screening including hearing. The nurse was concerned that the baby has a hearing problem and wanted her checked by a doctor. The child's parents have never had cause to worry about her hearing. She is the third child in a healthy family and has been well, apart from a few upper respiratory infections. She is crawling, does not walk yet, but pulls herself up to standing beside a small table. Initial examination findings A busy infant girl who objects to being restrained by her parent. She babbles during assessment. Otoscopic examination is normal. No abnormal physical signs are present on general examination. The parents are puzzled at the need for referral and seek information about further investigation and management. YOUR TASKS ARE TO: • Ask the parent for additional relevant and focused history. • Counsel the parent after you have obtained a further history. • Explain possible causes of any suspected hearing loss to the parent. • Discuss your plan of management with the parent. The Performance Guidelines for Condition 004 can be found on page 75 054 Condition 005 Counselling a family after sudden infant death syndrome (SIDS) CANDIDATE INFORMATION AND TASKS 1 You work in a general practice. You are counselling the family of a four-month-old male infant who was rushed to the Emergency Department of the local hospital the day before but was dead on arrival. The provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a Coronial autopsy. You had seen him for the first time two months previously, with his single mother, when he was thriving and developing normally and had commenced immunisations. Two days before his death you saw him again, this time with mild upper respiratory snuffles which were causing minor difficulties with breastfeeding. However, over the next two days he apparently improved, and his mother had advised you that he appeared normal and fed well from the breast just prior to his death. You are unaware of any suspicious circumstances surrounding the death. The family members have attended to seek details of why the baby died and why an autopsy is necessary. The spokesperson for the group is the mother's sister, the aunt of the infant. The mother is also present, but is too distressed to ask any questions herself. YOUR TASKS ARE TO: • Answer the questions of the aunt relating to the death of the infant. • Counsel the aunt and family. The Performance Guidelines for Condition 005 can be found on page 77 055 Candidate Information and Tasks Condition 006 Hair loss in a 38-year-old man CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital. This 38-year-old male newsagent has just consulted you about recent (2-3 weeks) hair loss from the scalp. One eyebrow is also affected. He is otherwise well with no significant past or family history. The patient is very concerned about possible future progression and wishes to ask you about the diagnosis and possible treatments. You have completed an examination of the scalp. The findings are as depicted below. YOUR TASKS ARE TO: • Discuss the condition with the patient. • Advise him about treatment. CONDITION 006. FIGURES 1 AND 2. The Performance Guidelines for Condition 006 can be found on page 79 056 Condition 007 An unusual feeling in the throat in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 30-year-old man who is consulting you about a throat problem. He is a previous patient of the clinic, is married with two children, parents and his siblings are well. He smokes 10-15 cigarettes daily and takes 2-3 alcoholic drinks only at weekends. He had a vasectomy two years ago and has had no serious illnesses. YOUR TASKS ARE TO: • Take a focused history about his throat problem. The examiner will then give you the examination findings. • Discuss the most likely causes of the problem and its nature with the patient. • Discuss whether any investigations are necessary and if so, what is most likely to be found. . The Performance Guidelines for Condition 007 can be found on page 81 057 008-009 Candidate Information and Tasks Condition 008 Pain in the testis following mumps in a 25-year-old man CANDIDATE INFORMATION AND TASKS Your next patient in a general practice is a 25-year-old man who consulted you five days ago because of painful swellings on both sides of his face associated with fever and malaise You made a confident diagnosis of mumps. You had previously diagnosed mumps in the patient's five-year-old son, a little less than three weeks beforehand. The son has now fully recovered. The patient's other child, aged three years, is well. You are aware that the couple have contemplated having another child. You advised the patient to rest at home, suggested paracetamol as an analgesic, and asked him to see you in a few days time before returning to work. The patient has come to see you today because of a relapse of his fever associated with the onset of severe pain in his left testis. You have found the left testis to be swollen to twice the size of the right one. It is very tender. The right testis feels normal. The patient has a temperature of 38.4 °C. His face is slightly swollen. Apart from a tachycardia, there are no other abnormal clinical signs. YOUR TASKS ARE TO: • Advise the patient of the diagnosis. • Advise him about treatment and prognosis. • Answer any questions asked by the patient. The Performance Guidelines for Condition 008 can be found on page 84 Condition 009 Contraceptive advice for a 24-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 24-year-old woman has come to see you for advice as to the most appropriate pill she should go on for contraception for the next two to three years. She knows that various types of pills are available and wants to know how to decide which is the most appropriate pill for her. YOUR TASKS ARE TO: • Take a further relevant and focused history. • Ask the examiner about findings you wish to elicit on general and gynaecological examination. • Advise the patient of the appropriateness of oral contraceptive pill (OCP) therapy, which pill should be given, and how it should be administered. The Performance Guidelines for Condition 009 can be found on page 87 058 Condition 010 Rape of a 20-year-old woman CANDIDATE INFORMATION AND TASKS J You are a Hospital Medical Officer (HMO) in the Emergency Department of a metropolitan general hospital. Your patient is a 20-year-old university student who is brought to the Emergency Department of the hospital because she was raped by a man that she met at a disco and who offered her a lift home. The rape occurred six hours ago after he had stopped the car in an undeveloped area. She has decided not to involve the police as the person concerned is known to her family. She has had no previous operations or illnesses and no pregnancies. YOUR TASKS ARE TO: • Take any further relevant history you require. • Ask the examiner about appropriate findings likely to be evident on initial general and gynaecological examination. • Advise the patient of the investigations required and the management you would propose. The Performance Guidelines for Condition 010 can be found on page 90 059 Candidate Information and Tasks Condition 011 Cancer of the colon in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 60-year-old man, whose father died of colon cancer, consults you following a screening colonoscopy. This revealed a lesion shown in the photograph given to the patient (see illustration below). The biopsy report confirms an adenocarcinoma of the colon. The patient insists he has no symptoms and refuses to have any operative treatment. However, he is still concerned enough to ask you what will happen if nothing is done. The specialist who did the colonoscopy said the lesion was on the left side of the colon. The patient also wishes to know what are the prospects of cure if he changes his mind and has the lesion removed by surgery, and would the surgery ever entail having a colostomy (which he dreads)? YOUR TASKS ARE TO: • Advise him what symptoms and signs may occur in the future, what complications may develop and how they would be treated. • Address his concerns and counsel him about surgery. You are not required to take any further history. CONDITION 011. FIGURE 1. Clinical notes: Biopsy of ulcerating tumour of rectosigmoid at 15 cm from anus. Biopsy report: The specimens show numerous fragments of a moderately well differentiated adenocarcinoma of the colon with invasion into the submucosal tissues.' Diagnosis: Adenocarcinoma of colon. The Performance Guidelines for Condition 011 can be found on page 92 060 Candidate Information and Tasks Condition 012 Thalassaemia minor in a 22-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 22-year-old woman who recently had a self-limiting febrile illness, which was suspected to be infectious mononucleosis (IM). She is now fully recovered. Blood tests for IM were negative, but the full blood examination showed a hypochromic microcytic anaemia of 108 g/L. The mean corpuscular volume (MCV) was below normal (68 cubic microlitres — normal 80-101). You followed this up but there was no evidence of chronic blood loss (other than normal menstruation). Serum iron and ferritin estimations were also normal. You suspected /j-Thalassaemia minor ('Mediterranean anaemia') and this has been confirmed by electrophoresis which showed an elevated Hb H2 level (4.3%). You are aware of her Greek descent and that she has just become engaged to be married. Her fiance is also of Greek descent. The family history is that her mother, father and brother are all alive and well. Her grandparents died in Greece and both were very old. One of her father's brothers was reported to have died in childhood from an unknown cause. The patient is very worried about being told she is anaemic, and as she is to be married shortly, is worried about the effects on any of the children she hopes to have. The patient has returned to discuss her results with you. YOUR TASKS ARE TO: • Explain the nature of the condition to the patient. • Answer the patient's questions. • Advise the patient what should be done now. The Performance Guidelines for Condition 012 can be found on page 95 061 013-014 Candidate Information and Tasks Condition 013 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 28-year-old woman, who had one pregnancy 18 months ago, which was complicated by deep vein thrombosis and a postpartum pulmonary embolus. She has come to see you for pre-pregnancy counselling as she wishes to conceive again. At the time of a previous assessment twelve months ago, she had ceased warfarin. When assessed six months ago, there were no sequelae or symptoms and she had no signs of chronic venous insufficiency in the legs. There are no abnormalities on physical examination and she is not overweight. YOUR TASKS ARE TO: • Take any further relevant history you require from the patient. • Advise the patient on the management she will require before and during the next pregnancy. The Performance Guidelines for Condition 013 can be found on page 99 Condition 014 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus CANDIDATE INFORMATION AND TASKS You are working in the primary care facility of a teaching hospital. Your patient is a woman aged 24 years (para 0, gravida 0), a known diabetic for 15 years and well controlled on insulin. She has come to see you for counselling and advice about possible future pregnancies. YOUR TASKS ARE TO: • Take any further relevant history you require. • Advise the patient of the information she needs to be given for pre-pregnancy counselling. The Performance Guidelines for Condition 014 can be found on page 102 062 Candidate Information and Tasks Condition 015 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital. Your next patient is a 25-year-old primigravida who has just had an ultrasound performed at 18 weeks of gestation, which has revealed an anencephalic fetus (as shown in illustration below). A maternal serum screening (MSS) was done at 16 weeks and this had shown elevated levels of alpha fetoprotein. YOUR TASKS ARE TO: • Take any further relevant history. • Advise the patient, in lay terms, of the relevance of the diagnosis and the subsequent management you would propose in this pregnancy. • Advise the patient of the care you would recommend in a subsequent pregnancy. You will not be expected to request examination findings, nor to arrange any further investigations. CONDITION015.FIGURE1. Anencephalic fetus at 18 weeks of gestation The Performance Guidelines for Condition 015 can be found on page 105 063 Candidate Information and Tasks Condition 016 A duodenal ulcer found on endoscopy in a 65-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You recently referred a 65-year-old man with a history of self-medication for arthralgia and a subsequent six week history of epigastric pain and indigestion to a gastroenterologist who performed an upper gastrointestinal endoscopy. The endoscopist told the man he had detected a duodenal ulcer and gave him a photograph of the ulcer, taken during endoscopy. The patient has come back to you seeking answers to several questions. The photograph is as shown. YOUR TASKS ARE TO: • Discuss the endoscopic findings with the patient in terms of the: ~ pathogenesis of the ulcer; ~ natural history and possible complications of the condition; and ~ treatment options available to him. CONDITION 016. FIGURE 1. The Performance Guidelines for Condition 016 can be found on page 108 064 017-018 Candidate Information and Tasks Condition 017 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a middle-aged man booked for a total hip replacement. You referred him to an orthopaedic surgeon who has arranged elective surgery for his severely osteoarthritic hip. The patient has now come back to see you, as he has some questions and in particular, is concerned about the risks of blood transfusion (if required) and would like to find out about using his own blood for the operation. The patient wishes to discuss this with you, as he did not take in everything that was explained by the surgeon. YOUR TASKS ARE TO: • Explain the principles and indications for preoperative blood collection and intra operative autologous blood transfusion. • Answer any questions from the patient about the blood transfusion procedure. The Performance Guidelines for Condition 017 can be found on page 111 Condition 018 Advice on stopping smoking to a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. The next patient is a 30-year-old man who has returned to your practice for followup following a recent chest infection. He is a smoker (20 cigarettes per day). On his previous visit, you had told him that the 'best thing that he could do for his health would be to stop smoking'. You have examined his chest which is clinically normal. At this visit, you are expected to follow up his response to your previous advice and counsel him further about tobacco cessation. YOUR TASKS ARE TO: • Assess his motivation to stop smoking. • Counsel him appropriately. • Discuss treatment options and general resources. • Respond to any questions he may have. The Performance Guidelines for Condition 018 can be found on page 115 065 Candidate Information and Tasks Condition 019 Excessive alcohol consumption in a 45-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You are about to review a 45-year-old businessman who consulted you two days ago about his drinking after seeing a TV program about the harmful effects of alcohol. At the previous consultation you established the following: • He is drinking excessively (at least five standard drinks every day); • This is of long standing — at home, at work and socially; • He has problems at work; • He has trouble with his close family relationships; • His sexual performance is impaired; • He has had two minor traffic accidents in the last year; • He has a family history (grandfather) of alcoholism; and • On examination he is overweight (BMI 28 kg/m2), hypertensive 180/90 mmHg, and has hepatomegaly. You told him that his use of alcohol appears to be excessive and you ordered liver function tests and a full blood examination. He is seeing you today for the results of the tests which are as follows: Liver Function Tests Bilirubin Total 14 umol/L (<20) ALP (Alkaline phosphatase) AST (Aspartate transaminase) GGT (Gamma glutamyl transaminase) Serum albumin 50u/L 45 u/L* 63 u/L* 32g/L (25-100) (<40) (<50) (32-45) Full Blood Examination This showed a normal haemoglobin level (145 g/L) with a macrocytosis and elevated mean corpuscular volume (MCV) of 106 fL (normal range 10-96) and some variations in red cell size and shape (anisocytosis and poikilocytosis). Other features were normal. YOUR TASKS ARE TO: • Explain the results of the tests to the patient. • Discuss the effects of the excessive alcohol consumption. • Counsel him about his drinking. You do not need to take any further history, nor perform any examination. The Performance Guidelines for Condition 019 can be found on page 121 066 020-021 Candidate Information and Tasks Condition 020 Type 1 diabetes mellitus in a 9-year-old boy CANDIDATE INFORMATION AND TASKS A nine-year-old boy, Roger, is admitted to the paediatric unit to which you are the Hospital Medical Officer (HMO). This is his first presentation of insulin-dependent Type 1 diabetes mellitus. His general condition is satisfactory, not requiring intravenous resuscitation, and he has already commenced insulin therapy and has stabilised with good blood sugar control. As the Ward HMO, his mother has asked you for further information about his ongoing care in relation to his diabetes from now on. YOUR TASK IS TO: • Answer the queries the mother has, related to the ongoing care of Roger's diabetes. The Performance Guidelines for Condition 020 can be found on page 125 Condition 021 Request for vasectomy from a 36-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You are seeing a man aged 36 years who indicates that he wishes to discuss vasectomy with you. You have enquired about his past medical, family and social history (see below). He is asymptomatic across all his body systems. Physical examination is normal, including his scrotum, testes and penis. Blood pressure is 120/70 mmHg, urinalysis normal. He is not overweight. You believe that he is in good physical health. You have already obtained the following patient details: • He has been married for 12 years and has two children (a boy aged seven and a girl aged nine years). There are no marital problems of any kind; • He is a senior constable in the police force, does not smoke but is a moderate alcohol drinker (three standard drinks a day); • He has no known drug sensitivities; • His mother, father and brother are well, as are his wife and two children; and • He is not on any medication. YOUR TASKS ARE TO: • Explain the sterilisation procedure and its consequences to the patient. • Answer the patient's questions and provide counselling accordingly. There is no need for you to take any additional history from the patient. The Performance Guidelines for Condition 021 can be found on page 129 067 1-A Communication, Counselling & Patient Education 1-A Communication, Counselling and Patient Education Performance Guidelines MCAT 002-021 068 2 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 16 A duodenal ulcer found on endoscopy in a 65-year-old man 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 18 Advice on stopping smoking to a 30-year-old man 19 Excessive alcohol consumption in a 45-year-old man 20 Type 1 diabetes mellitus in a 9-year-old boy 21 Request for vasectomy from a 36-year-old man 002 Performance Guidelines Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman AIMS OF STATION To assess the candidate's ability to advise a young expectant mother on the advantages and disadvantages of breastfeeding and bottle-feeding. This scenario tests the candidate's ability to identify the conflict the young mother has in trying to respect what her mother has told her, while knowing that this advice is contrary to her own feelings. It also tests ability to discuss logically the advantages and disadvantages of the different feeding methods as well as testing knowledge on safe bottle-feed preparation. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 28-year-old mother having your first baby. You now have only five weeks to go and although you always hoped to breastfeed your infant, you have had some doubts about its value recently when your mother mentioned that formula-fed babies grow better than babies who have been breastfed. You have come to discuss this. You realise that you may have to defend what the doctor says to you (about breastfeeding being advantageous), and your own previously held ideas about breastfeeding, against the ideas of your mother with whose opinions you have to live. Opening statement 'My mother feels that bottle-fed babies gain more weight than breastfed babies and therefore are more healthy. What do you think, doctor?' Questions to ask if not already covered: • 'What are the advantages of breastfeeding? I would have thought it is easier to breastfeed.' • ‘Is there anything special about breast milk? I always thought there was.' • 'Do you have to prepare bottle feeds in any special way?' • 'Are the formula feeds safe? I thought they contained cow's milk and what if you are allergic to cow's milk?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Be nonjudgmental, avoiding comments like 'Where on earth did your mother get such an idea?'; rather asking 'Why do you think your mother made such a recommendation?' • Discuss that while breastfeeding is the optimal method of feeding the human infant, and that the majority of mothers successfully breastfeed, a variety of reasons may prevent breastfeeding in practice, including: ~ illness in the mother; ~ failure to establish lactation, which may be hormonally based; ~ possible illness in the baby (e.g. cleft palate); 069 002 Performance Guidelines ~ prematurity, which requires the mother to express regularly to maintain her supply; ~ previous extensive breast surgery in the mother; and ~ heightened anxiety in the mother. Explain that if for some reason breastfeeding is unsuccessful, formula-feeding is a safe and very effective alternative. Discuss that formulas are designed to contain the same nutritional components as breast milk, but that exact reproduction is difficult as the concentration and components of breast milk change throughout each feed. Advise that there is no advantage of formula-feeding over breastfeeding. Discuss the specific advantages of breastfeeding: ~ the practical advantages of being able to feed almost whenever and wherever the baby wants it without having to prepare formula, carry bottles around and without problems with sterility; ~ increased resistance of the baby to infection, from immunological constituents in breast milk including lymphocytes and antibodies; and ~ satisfaction derived from feeding the infant as well as the development of a close relationship with the infant. • • • • • In response to her mother's comment, advise that weight gain is not the only criterion for success as excess weight gain in the first 12 months of life may in fact be detrimental in later life. The candidate should stress the importance of optimal formula-feeding as follows: ~ sterility in preparing the bottle feeds is essential; ~ bottles need to be washed clean with a bottlebrush to ensure that all milk residue is removed; ~ bottles and teats need to stored in solution (e.g. Milton®), to ensure continuing sterility, but the bottles need to be rinsed free of this solution prior to use; ~ the fluid used to make the formula and to rinse the bottles should be cooled boiled water; ~ each can of formula has explicit makeup instructions on the side of the can or packet; if followed these will produce the exact required concentration; ~ there is no place for any added scoops, which can be harmful; ~ the day's requirements are best made up at the one time, although each feed can be made separately. If the former, the day's feed should be stored in the refrigerator; ~ only one day's feed at a time should be prepared in advance; and ~ each feed should contain approximately 30 ml more than it is anticipated the baby may take, and any excess discarded at the end of the feed. KEY ISSUES • Empathic answering of this young mother-to-be's questions. • Recognition that she is uncomfortable with what her mother has told her but is seeking reassurance and support for her own view which she feels is accurate. • Satisfactory explanation of the advantages and disadvantages of the different methods of feeding. • Candidates should know how formula feeds are prepared. 70 002 Performance Guidelines CRITICAL ERROR - none defined COMMENTARY Ability to discuss impartially and accurately the relative merits, indications, contraindications and techniques of infant feeding by breastfeeding and by formula-feeding is a requisite for all medical graduates as outlined and is an area where good communication skills are paramount. 071 003 Performance Guidelines Condition 003 Advice on neonatal circumcision for a couple expecting their first child AIMS OF STATION To assess the candidate's ability to give impartial advice about neonatal circumcision. EXAMINER INSTRUCTIONS The examiner will have instructed the parents as follows: You are a couple who are expecting your first baby. Your family members have suggested that if the baby is a boy he should be circumcised. You are very unsure about this, as you cannot see any reason why circumcision is essential. You have no religious beliefs that dictate that circumcision must be done. You have therefore come to discuss the process and learn what the advantages and disadvantages of the procedure are before making your own decision on the matter. Opening statement ‘We have come to discuss with you whether to have our baby circumcised.' Questions to ask unless already covered: • • • • • ‘What does the procedure involve?' 'What are the complications that can happen?' ‘What are the advantages of having it done?' 'Are there any times when it definitely should or shouldn't be done?' 'Has anyone looked into this in detail and come to any conclusions about it?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • give an impartial but informed explanation to the parents on the advantages and risks involved in routine neonatal circumcision; • indicate that when religious grounds are stated as the reason for the procedure, these are generally respected; and • realise that many are unaware of the actual process of circumcision and may ask for the procedure more as a ritual; and stress that the parents should consider the advantages and disadvantages of the procedure before making a decision. During the discussion, the candidate would be expected to advise along the following lines: • The perceived advantages of routine neonatal circumcision commonly quoted are: ~ Reduced incidence of urinary tract infections (UTIs) in circumcised boys. While circumcision may assist the uncircumcised boy who is suffering recurrent UTIs, routine general circumcision of all boys is not indicated to achieve this, but can be selectively applied at a later age if this situation exists. ~ Reduction in the incidence of sexually transmitted infections (STIs) and HIV infection. This remains a controversial point. The literature currently is divided on this issue, but some evidence suggests the risk of HIV infection is lessened by circumcision. 072 003 Performance Guidelines ~ Circumcision is indicated for phimosis or its prevention. This is true only if all conservative methods of treatment have failed. Often, phimosis, developing after birth, is secondary to inappropriate foreskin care and subsequent trauma and scarring. If asked, the candidate should indicate the appropriate care of the foreskin, which is minimal, until the foreskin can be retracted easily, which is usually by about five years of age. ~ Neonatal circumcision minimises the risk of subsequent development of carcinoma of the penis. But poor penile hygiene associated with human papilloma virus infection is the major contributor in adults, cancer being rarely seen in men who can retract and clean the foreskin. • The recognised complications and disadvantages of routine neonatal circumcision should also be discussed and include: ~ haemorrhage; ~ infection, including septicaemia/meningitis (rare); ~ ulceration of the glans; ~ inadvertent injury to the urethra; ~ too much skin removed leading to unsatisfactory cosmetic appearance; - anaesthetic complications; and ~ secondary phimosis. The complication rate has been estimated to occur with an incidence of between 1-5% (range 0.2%—10%); but these are figures at all ages, not just in the neonatal age range. The skill of the operator is obviously of paramount importance. The most common complication is haemorrhage. • The candidate should also discuss the absolute contraindications to routine neonatal circumcision explaining each in turn: ~ hypospadias and other congenital anomalies of the penis (e.g. epispadias); ~ chordee; ~ buried penis; ~ sick infants, including jaundiced infants; ~ family history of a bleeding disorder or known recognised familial bleeding disorder possibility (e.g. haemophilia A); and ~ inadequate expertise and facilities. • The candidate should be able to explain the procedure of circumcision and indicate that: ~ it is usually done under local anaesthesia; and ~ if performed after six months of age, it is done under general anaesthesia. KEY ISSUES • The ability to discuss in an unbiased manner the perceived advantages and disadvantages of routine neonatal circumcision. • Capacity to summarise that the recommendations of various national and international paediatric and paediatric surgical associations, who have extensively reviewed the literature on the subject, do not support routine neonatal circumcision. 073 003 Performance Guidelines CRITICAL ERROR - none defined COMMENTARY This topic is one that has been controversial for many years. While circumcision for religious reasons has been done for many centuries, the issue in the scenario is related to the secular trend towards routine neonatal circumcision of all males soon after birth. This has become more of a ritual rather than for any recognised medical indication, although this tendency has reduced in recent times. In fact there are many recognised complications of circumcision, not just routine neonatal circumcision, but circumcision at any age. However there are recognised medical indications for the procedure (e.g. established phimosis in boys and men). CONDITION 003. FIGURES 1 AND 2. Circumcision in ancient Egypt Phimosis Many young parents are unaware of the issues involved and are often ill-informed by family members who recommend that their infant should have the procedure performed without any explanation as to why. They then request circumcision without any information about the procedure and hence the need for informed discussion to allow them to make a rational decision in the interests of their baby. This scenario illustrates that medical practitioners are obliged to provide accurate information on the risks and benefits of routine neonatal circumcision and should attempt to avoid any personal bias. The decision should be left to the parents after a full and accurate discussion. Unbiased up-to-date written material summarising the evidence should be made available to the parents. The review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for neonatal circumcision as a routine procedure. The Policy Statement on Circumcision from the Paediatric and Child Health Division of the Royal Australasian College of Physicians (September 2004) is recommended as an excellent summary with 78 references to the evidence for and against circumcision. This is available on the open website of the Royal Australasian College of Physicians under Policies (http://www.racp.edu.au). 074 004 Performance Guidelines Condition 004 Suspected hearing impairment in a 10-month-old child AIMS OF STATION To assess the candidate's ability to deal with suspected hearing loss in an infant aged 10 months and ability to appropriately counsel the parent. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You have a 10-month-old girl called Helena. You have been referred by the local childcare nurse for a suspected hearing loss in your daughter. You and your husband are concerned as you feel baby Helena's hearing is normal. Your responses to questions asked are outlined below. You will accept advice about referrals. If referral is not suggested, you should ask — do you think further tests would help?' The candidate is expected to take a relevant history to determine if hearing loss may be present as suspected by the child health worker despite the good sign of babbling, and to provide succinct, accurate advice to concerned parents, who have noted nothing amiss with her development or hearing. The candidate should ask for history details as below (your response is indicated in brackets): • ‘Is there a family history of deafness?' (none); • Maternal problems in pregnancy — 'Were there any problems with the mother during pregnancy especially infectious diseases?' (none) • Perinatal problems — 'Were there any health problems with the baby during or soon after birth?' (none) • General development — 'Is the baby growing and thriving?' (satisfactory same as the other children) • 'Does the baby respond to sounds, including loud sounds?' (seems to hear them and respond) • 'Does the baby respond when called by her name?' (usually) • 'Does the baby turn towards the sources of the sounds?' (sometimes) • 'Does the baby respond to television?' (sometimes). In regard to any of the above aspects, the parents have noted no abnormalities in regards to her response to sound. 075 004 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The history should cover most of the questions detailed above. The candidate should explain that: • Hearing loss is common in preschoolers — most cases are mild and transient due to conductive deafness from middle ear effusions. • Sensorineural hearing loss is less common but important to detect as early as possible. • Distraction tests are only a screening tool and do not diagnose deafness. • Often it is the parents who recognise that there is something wrong; but the child health nurse is also a professional and her concerns must be followed up. • If there is a problem then the earlier the diagnosis the better. The candidate should give the following advice: • Refer the child to a Paediatric Audiologist as soon as possible for more formal hearing assessment by an audiogram. • Review following audiogram. • If normal, reassure and review hearing and early language development in about three months. • If abnormal, refer to appropriate specialist for further evaluation. The candidate should exhibit understanding for the parent's concern and provide guarded reassurance and support. KEY ISSUES • Appropriate history relevant to deafness. • Counselling with reference to early definitive screening for hearing. • Providing appropriate level of support and reassurance. CRITICAL ERROR • Failure to refer for specialist assessment (audiogram) for definitive diagnosis. COMMENTARY The candidate is expected to proceed from the cue of 'possible hearing loss' to assess whether other evidence, such as failure to turn to sound, is present to support this diagnosis. In addition, enquiry regarding features suggesting associated developmental delay is appropriate. Given a working hypothesis of possible hearing loss, features in the history which could be causative, such as maternal illness in pregnancy, perinatal problems such as jaundice or drug administration, should be evaluated. However, the importance of early diagnosis and treatment of significant hearing deficit in this age group make referral for definitive diagnosis mandatory despite no other concerning features being present. Adequate communication skills in dealing with a concerned patient are essential, used in combination with appropriate knowledge-based clinical skills. 076 005 Performance Guidelines Condition 005 Counselling a family after sudden infant death syndrome (SIDS) AIMS OF STATION To assess the candidate's ability in approach to the family and providing empathic counselling in this tragic situation of presumed sudden infant death syndrome (SIDS) where there are no suspicious circumstances. Candidates should outline the statutory requirements (i.e. notifying police and coroner), in a caring and sympathetic manner. EXAMINER INSTRUCTIONS The examiner will have instructed the relative as follows: You are the aunt of an infant who died, apparently of SIDS, the day before. The family members including the young single mother have attended to ask questions about the baby's death but the mother is still too distressed to ask them herself. You are the spokesperson of the family. Opening statement ‘We can't understand why Andrew has died!' Questions to ask unless already covered: • • • • • • ‘Why do the police have to be involved? Do they think my sister killed her baby?' ‘Why does he have to have an autopsy?' ‘When will we get further information and results of this?' ‘When can we arrange his funeral?' ‘We feel so alone. Is there anyone we can talk to about this?' 'Should the snuffles have been treated?' EXPECTATIONS OF CANDIDATE PERFORMANCE Explanation of diagnosis The most likely cause of the child's death is SIDS. Candidates should explain what is known about SIDS along the following lines: • the frequency of SIDS has fallen from 1 in 500 live births to now approximately 1 in 1000; • the peak incidence occurs at about four months of age; and • there are no certain causes known. Many theories exist, but none is proven. Explain that there can be other causes of sudden infant death (for example, overwhelming infection), but the child's history does not suggest this cause. Andrew's snuffles were not a warning sign and there is no suggestion that any medical treatment would have influenced the outcome. 77 005 Performance Guidelines Immediate management following a death due to apparent SIDS — should be advised empathically as follows: • Explain that the police and the Coroner must be notified by law because Andrew's death was sudden and unexplained. • Explain that the role of the Police Officer is to assist the Coroner — police are required to interview all people concerned including the baby's general practitioner. • Explain the need for the autopsy in all cases, and that autopsies are done by very experienced pathologists in an attempt to find out what causes SIDS, and to exclude other possible causes of death. • Explain that tissues will be removed for further examination under the microscope. • Offer to contact the Coroner later to obtain information on the initial findings after the autopsy has been performed or advise that the Coroner's office will contact the mother at a later date to giver further information. • Offer to contact other family members for support for the mother. • The Coroner will decide if an inquest needs to be held, but with SIDS this is generally not necessary. • Offer to contact the local SIDS Support Group, if one is available. Future management Followup contact with family and with the Coroner/pathologist to confirm diagnosis. Liaise with support group in counselling the mother when results are available. KEY ISSUES • Appropriate empathic explanation. • Ability to explain the involvement of appropriate authorities and support groups. • Offering to arrange for continuing followup, contact and support with the family. CRITICAL ERRORS • Failure to display empathy in counselling. • Failure to recognise and explain need for coronial notification and autopsy. COMMENTARY Empathy in communication is essential in these tragic circumstances, together with accurate knowledge of legislative requirements. All deaths under these circumstances must be reported to the Coroner and the police must take statements. This is often the most distressing part of the process for young parents and should be explained carefully to the family why this process needs to happen by law. The caring practitioner will also offer to liaise with the Coroner on behalf of the parents, and in this way is often able to receive preliminary reports if the Coroner is agreeable to them being released, which many Coroners are. Several pathologists who perform these autopsies actually interview the parents themselves when the autopsy is completed. The caring practitioner will offer to keep contact with the grieving couple or parent until confident that this tragic event has been accepted. 078 006 Performance Guidelines Condition 006 Hair loss in a 38-year-old man AIMS OF STATION To assess the candidate's ability to deal with a cosmetic problem, almost certainly alopecia areata, for which treatment and prognosis are uncertain. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 38-year-old male newsagent, married, with two children. Your general health is excellent and you do not smoke or use alcohol. Past history is clear and there is no significant family history including baldness. You work long hours with the usual stress associated with running a small business, but otherwise have no social or family problems. You are worried about your appearance because of your contact with customers. You are concerned about the cause of the hair loss and are very anxious to have treatment and also to be assured of effectiveness of treatment. Become impatient if simple reassurance is the main advice given. Opening statement 'What is happening to my hair?' Questions to ask if not already covered: • 'Will I go completely bald?' • 'Will it improve?' • 'How long will it last?' • 'What can be done about it?' • ‘Is treatment effective?' • 'Should I see a specialist?' • 'Could it have anything to do with my glands? OR with my thyroid gland?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise that the patient has alopecia areata and is concerned about his appearance; and should explain the nature of the condition in such a way that the possibility of improvement or return to normal is emphasised but the natural history is unpredictable in individual cases. The objective is to achieve patient understanding and acceptance of his condition based on correct information. The patient's questions should be answered directly with supportive explanation. The candidate should explain that: • Initial management is by topical medication which aims to stimulate hair regrowth. Any one agent should be used for 3-6 months before changing therapy. ~ Potent topical corticosteroid applied once or twice daily — e.g. betamethasone dipropionate .05%. ~ Intralesional corticosteroid such as triamcinolone acetonide 10 mg/mL is useful for small areas on the scalp or eyebrows. Multiple injections are usually required. 079 006 Performance Guidelines • • • • • ~ Topical dithranol applied once daily, commencing at 0.5% increasing gradually to 2% (avoid eye contact). ~ Topical minoxidil (5% lotion) applied twice daily in cases not otherwise responding (but has very limited effectiveness). Oral corticosteroids may be Mailed if topical treatment is ineffective, tapering dosage downwards over two months. If the condition worsens, disguising the hair loss with a wig may be considered. Consideration of topical immunotherapy and ultraviolet phototherapy would require referral to a dermatologist. Some patients may require early referral for confirmation of the diagnosis and reinforcement of advice about the likely course. Followup arrangements should be made appropriately. KEY ISSUES • Effective communication skills are very important in this case. Appropriate language, verbal and nonverbal communication, and good interpersonal skills should be displayed by the candidate. • Showing empathy, sensitivity and perceptiveness, as well as being honest and generating trust and confidence are particularly important in a chronically relapsing condition such as this which significantly affects the patient's appearance. • Place of topical and systemic treatment and prognosis. CRITICAL ERROR - none defined COMMENTARY Alopecia is a generic term for hair loss. Alopecia areata is a descriptive term for one or more discrete circular areas of hair loss. These areas can occur anywhere on the body including the beard area in males. Alopecia universalis is where there is complete hair loss from the whole body and is a variant of alopecia areata. The condition is a chronically relapsing autoimmune disease with an extremely variable natural history. Patches on the scalp may regrow spontaneously, remain unaltered or enlarge and coalesce into alopecia totalis (whole scalp). In a case such as this scenario, there is approximately a 33% chance of complete regrowth within six months and a 50% chance within one year. Approximately 80% of patients, however, will eventually relapse. If the hair loss persists for years, the prospect of regrowth is diminished, although the potential for hair regrowth always remains because the hair follicle is not destroyed. The aetiology is unknown, but a family history is present in 20% of cases and there is a linkage with other organ-specific autoimmune diseases. There may be a specific trigger such as a febrile illness or severe emotional stress (for example, the death of a family member). Less severe day-to-day stress is not considered to be a trigger. The condition itself is stressful, especially in females. 080 007 Performance Guidelines Condition 007 An unusual feeling in the throat in a 30-year-old man AIMS OF STATION To assess the candidate's ability to take a satisfactory history about globus pharyngeus disorder and to display perspective in selecting appropriate investigations, and skill in counselling and educating a patient about the condition. EXAMINER INSTRUCTIONS Examiners should note that the scenario covers the initial consultation about the problem and that ongoing management is not being assessed. The examiner will have instructed the patient as follows: You are a 30-year-old man, happily married with two children. Your parents and siblings are in good health and apart from vasectomy two years ago, your past medical history is clear. You smoke 10-15 cigarettes daily and only drink socially at weekends. You are consulting the doctor about an unusual feeling in your throat. Opening statement ‘I keep getting a lump in my throat. It feels like a knot.' Provide more information as follows: Without prompting: Present your symptoms in a straightforward manner. You have become concerned since the recent vomiting episode. You have had no previous worry about your health and you have no idea what the nature of your complaint is, but you now wish to have it thoroughly investigated. Over the last 4-6 weeks you notice that: • your throat tightens up; • you have excessive saliva; • you clear your throat repeatedly; • a few days ago, it was very bad and you vomited; and • • • • it occurs mostly after your evening meal. if questioned, answer as follows: the feeling lasts 3-4 hours, usually until you go to bed; you swallow more often when you have it; there is definitely no difficulty swallowing solids or liquids which go down easily without discomfort; • when your throat tightens, your voice can 'catch', and your eyes water; and • your voice is otherwise unaffected. There is: • no hoarseness of the voice; • no sore throat, cough or nasal discharge or discharge from the back of the nose into the throat (called postnasal discharge); 081 007 Performance Guidelines • no loss of weight, appetite change, abdominal pain or regurgitation (water brash); • no shortness of breath, palpitations, chest pain or dizzy spells; • no aggravation of symptoms brought on by lying down; and You: • sleep well, have no other symptoms and do not take any medications; • believe you are in good health; • never take time off work; • feel fit; • have no past history of anxiety or other psychiatric illness; • do not feel depressed or anxious; • have no particular worries about your everyday life, wife and children; • are conscientious and hardworking but not a worrier; and • usually enjoy work, but have felt annoyed in the past few months when having to work weekends — you feel you should be with your family. A cousin died from cancer of the larynx, three months ago. You used to be close as children. He had been a heavy smoker and drinker in adult life, and you grew apart. You were upset by his death, but no more than you would expect for normal grief. His death is still on your mind, as well as the thought of cancer at times. If the doctor reassures you without discussing the possibility of any investigations say: 'You don t seem to be taking my complaint seriously'. Alternatively, if the doctor advises multiple investigations all of which are to be done at once say: 'Isn't there just a simple test to check my throat out?' Examiner statement When the candidate has completed the history or after five minutes the examiner should say: 'Physical examination of this patient is completely normal. You should now discuss the problem with the patient as stated in your tasks'. EXPECTATIONS OF CANDIDATE PERFORMANCE • The focused history is expected to exclude dysphagia and hoarseness, any disturbance in general health and to reveal the patient's concerns about the cause of his cousin's death. • The diagnosis of globus disorder (subject to laryngoscopy) should be made, but may not be directly stated to the patient. Examiners should use their discretion in assessing how the candidate describes this functional disorder to the patient. Other than gastrooesophageal reflux, there is a list of much less likely differential diagnoses for this patient. • Choice of investigations: ~ Laryngoscopy and pharyngoscopy must be done. ~ Chest X-ray with thoracic inlet views and barium swallow are acceptable. ~ Upper gastrointestinal endoscopy may be suggested for reassurance. ~ Bronchoscopy is not indicated. 082 007 Performance Guidelines CONDITION 007. FIGURE 1. Laryngoscopic view — normal vocal cords • Patient counselling and education: the correct diagnosis should be explained as most likely being a nonserious condition with transient change in sensation or function of the throat; ~ the condition is brought on by emotional factors; ~ the condition needs limited investigations which should be explained; and ~ investigations are unlikely to reveal any serious process. KEY ISSUES • Ability to take a focused history. • Ability to discuss a probable functional disorder with a concerned patient. CRITICAL ERRORS • Failure to request laryngoscopy or upper pharyngeal/oesophageal endoscopy. • Failure to indicate to the patient that serious disease is extremely unlikely. COMMENTARY This patient is presenting with recent onset of mild symptoms localised in the same anatomical region as his cousin's recent cause of death, the role of normal grief and worry about cancer being largely unrecognised. Globus pharyngeus disorder (globus hystericus) is a physiological symptom associated with altered mood states, often grief, but not associated with any specific psychiatric disorder or necessarily requiring psychiatric treatment. Elevated cricopharyngeal pressure or abnormal hypopharyngeal motility may exist at the time of the symptoms. The same sensation may result from gastro-oesophageal reflux or from frequent swallowing and mouth dryness. Other causes of upper oesophageal or laryngeal compression are retrosternal goitre, carcinoma of laryngopharynx, oesophageal or cricothyroid web (sideropenic dysphagia). Skeletal muscle disorders, myasthenia gravis, myotonia dystrophica, and polymyositis are other potential causes of dysphagia. None is likely in this case. 083 008 Performance Guidelines Condition 008 Pain in the testis following mumps in a 25-year-old man AIMS OF STATION To assess the candidate's knowledge of mumps orchitis including natural history, management, prognosis and preventive medicine aspects, and communication skills in dealing with an unwell and anxious patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You thought you were recovering from mumps, having noticed the onset of facial swelling about a week ago. You contracted the disease from your older son aged five years. You are now consulting the doctor about a painful and very tender left testicle. Analgesics (Panadol®) have had little effect. The doctor has examined you and will now advise you about your condition. You are in quite severe pain and feel most unwell. You are anxious about possible sterility (you and your wife would like to have a daughter), whether the other testis will also be affected, possible impotence, your infectivity (you have a wife and other younger son) and how long you will be away from work. Be cooperative and willing to accept the doctor's advice if presented clearly. Questions patient should ask if not already covered (the candidate's expected response is in brackets): • 'What is the connection between the mumps and this trouble?' (Doctor should explain how mumps virus is related to testicular problems — viral aetiology) • ‘What can I take for the pain?' (Pain killers that contain codeine compound analgesics) • 'Are there any antibiotics or other drugs for this condition?' (Not at this stage) • ‘Will it affect both of my testicles?'(Unlikely, usually only one is affected. Unless the other testicle becomes affected, there would not be any expected influence on fertility. Sterility can rarely follow if both testicles are affected) • ‘Will we be able to have another child, if we decide to?' (Yes, fertility is not likely to be affected) • 'Will my sex life be affected?' (No problems anticipated) • ‘What will happen to the testicle eventually?' (Possibly reduction in size, but usually remains fully functional. Function of the other testis is usually unaffected) • When will I be able to go back to work?' (Depends on how rapidly the pain and swelling persists — about 7-10 days) • ‘Why wasn't my son affected in this way?' (Orchitis — inflammation of the testicle — is extremely rare in childhood) • ‘Will our younger son get mumps too?'(If he is immunised already with measles-mumps-rubella (MMR) vaccines, he is at minimal risk. If he is not immunised, he is unlikely to contract mumps from his brother, but he may still be infected from his father. The younger son should be immunised if not already done) • 'Are there any other complications of mumps?'(Very occasionally mild meningitis, which is inflammation of the coverings of the brain) 084 008 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should be confident with the diagnosis of mumps orchitis and should state this to the patient. Torsion of the testis need not be considered under the circumstances. A sympathetic and reassuring manner is expected. The candidate should indicate that the patient's anxiety over testicular function (fertility and sexual activity) and infectivity to his younger child, are recognised and that possible reduction in size of the left testis is not likely to be of any consequence to fertility. • Pain control — paracetamol with 8 or 30 mg of codeine (for example, Panadeine®, Panadeine Forte®). • Steroids can be used to relieve severe pain but have no other effect on the illness. Their use in mumps is controversial. • Advise general measures for a febrile illness — adequate fluids, light diet, and rest, until pain and swelling have subsided. • Local measures — scrotal support, application of heat. • Provide information about immunisation for mumps — live attenuated vaccine combined with rubella and measles vaccines (MMR) is available. However, this will not immediately protect the wife or son from patient's infectivity. Immunoglobulin is not effective. Monovalent vaccine is not available. Immunisation is advised for all children after 12 months of age, with booster dose before going to school. • The risk of infectivity to other adults is very low. In counselling, the candidate should tell the patient the diagnosis, determine the patient's knowledge of the condition including any fears he may have, discuss these and reassure him appropriately. KEY ISSUES • Confidence in diagnosing mumps orchitis. • Recognising patient anxiety about possible infertility and impotence and giving appropriate reassurance. • Giving an adequate explanation of the condition including the infectivity of mumps, and its prevention by immunisation. CRITICAL ERROR - none defined COMMENTARY Mumps has the following associations: • The infecting organism is a paramyxovirus, spread by droplet infection or direct contact. • Infectivity is 50-60% (sufferer to unimmunised person). • Incubation period is 12-25 days (usually about 18). • Period of infectivity is from 6 days before swelling of face occurs till 9 days after, so his wife (if she has not had mumps) and younger son can still contract it from the father. • One attack gives lifelong immunity. 085 008 Performance Guidelines • Complications of mumps: ~ Common — orchitis and aseptic meningitis; and ~ Rare — encephalitis, arthritis, pancreatitis and oophoritis in females. • Orchitis complicating mumps: ~ occurs in 20-30% of postpuberal males; ~ onset is 3-4 days after the parotitis is subsiding; ~ usually is unilateral. Subsides over one week; ~ significant atrophy of testis occurs in 50% of cases; ~ sterility is rare — only if bilateral involvement; ~ sexual performance is not affected after recovery; and ~ mumps orchitis does not predispose to testicular malignancy. 086 009 Performance Guidelines Condition 009 Contraceptive advice for a 24-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately assess and advise a patient requesting oral contraception. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 24 years, work as a secretary and live alone, but have a steady boyfriend. You have never been pregnant and have no history of gynaecologic or medical problems. You have been in a stable monogamous sexual relationship with your boyfriend for the past 12 months, using barrier contraception with condoms. In response to specific questions, the following list of responses is likely to cover most questions: • You have no previous deep vein thrombosis, active liver disease, breast cancer or abnormal bleeding. Periods have always been irregular, occurring every 2-3 months, but are otherwise normal. • Blood pressure has always been normal. • You have no history of migraine. • You are not on any medications, do not smoke and only drink alcohol occasionally. Examination findings to be given by the examiner after the history are basically normal, but the candidate is expected to ask specifically for the important relevant findings: • Blood Pressure 120/80 mmHg • Pelvic and abdominal examination no abnormality. • Pap smear normal six months ago. • Breast examination normal. No hirsutes. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: A patient wishing to take the oral contraceptive pill (OCP) requires the following assessments: • Exclude absolute contraindications on history. Need to exclude deep venous thrombosis, oestrogen-dependent malignancies particularly breast cancer, active liver disease or previous cholestatic jaundice, unexplained vaginal bleeding and focal migraines. • Check for relative contraindications to see whether the therapy can be justified. A wide variety of relative contraindications has been described including hypertension, cigarette smoking, diabetes, and very irregular cycles or oligomenorrhoea. 087 009 Performance Guidelines • Choice of pill: ~ Choose a low monophasic dose oestrogen pill (such as Microgynon 30®). This has a low breakthrough bleeding and low failure rate. It is also less costly than Microgynon 20®. Because her cycles are irregular (oligomenorrhoea) it is probably better to choose a triphasic preparation such as Triphasil® or Triquilar® as these have less post-pill amenorrhoea associated than a monophasic constant dose pill. - If she had been an epileptic or on an antituberculous drug, a 50 ug oestrogen-containing pill such as Microgynon 50® should have been chosen. This is because these drugs increase liver enzyme activity, resulting in an increased metabolism of the hormones administered in the OCR ~ If she had been hirsute, or with acne (consistent with polycystic ovarian syndrome) an oestrogen-dominant pill such as Ovulen 0.5/50®, or (probably more appropriate) Diane 35® if the patient can afford it, should have been advised. ~ If she was still breastfeeding, or previous oestrogen-containing pills have produced problems or she has had a previous thrombosis, a low dose progestogen pill should have been chosen and a failure rate of 3% accepted. • In this instance, a low-dose oestrogen or triphasic pill would have been appropriate. • Need for followup in about three months. This is required to check the blood pressure and to advise her as to whether the pill prescribed needs to be changed because of persistent problems such as break-through bleeding. • Patient starts in red sector at time of next period. Contraceptive efficacy is satisfactory after seven hormone tablets have been taken. • Explain about breakthrough bleeding, missed pills and diarrhoea and the appropriate management of these: take the normal dose the following day, and take appropriate additional precautions depending on circumstances. • Common side effects — breakthrough bleeding for first three months, sore breasts in the first 1-2 cycles. [ KEY ISSUES • Ability to take an adequate history to exclude absolute contraindications to the OCP and facts that would influence the pill chosen, and its dose. • Ability to advise a patient as to how to take the pill, the timing of its effectiveness and the likely problems during its use. CRITICAL ERROR Failure to exclude absolute contraindications to OCP use. 088 009 Performance Guidelines COMMENTARY A young woman needs to be fully informed of all the benefits and side effects and risks of taking the OCR She also needs to be carefully assessed to ensure that she has no condition making her unsuitable to take the pill. Any patient prescribed the OCP must have a full explanation of how to commence taking the pill, when it becomes effective as a contraceptive, and what to do if a pill is missed accidentally. As part of the assessment of a patient who is to be prescribed the OCR the type of pill and its cost, should be taken into account as part of the advice to the patient. Having excluded absolute and relative contraindications to use of the OCP (as is the case in this patient), an appropriate low dose oestrogen pill should be advised with a low breakthrough bleeding rate and low failure rate. Alternatively a triphasic preparation could be used which has less post-pill amenorrhoea. Appropriate advice along the above lines is required. Common problems likely with candidate performance are: • failing to advise patients as to when contraception will be achieved following the commencement of therapy; • what to do if a pill is missed or the patient gets diarrhoea; and • failing to advise the common side effects. 089 Condition 010 Rape of a 20-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately assess and manage a woman who gives a history of having recently been raped. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to respond as follows: • • • • menses are regular and normal and your last menstrual period started ten days ago. you have not been taking or using any contraceptive agents. you have had no previous operations, illnesses or pregnancies. the rape followed a threat of severe injury if you did not comply. No bleeding followed rape. He did ejaculate into the vagina. • you have been sexually active in the past, but not for the last six months. No previous known pelvic infections. • you have no allergies to drugs or chemicals. • you do not use drugs of addiction, and are not on any medications at present. Questions patient to ask unless already covered (candidate's expected responses as outlined in expectations of candidate performance): • 'Has he caused me any harm?' • 'Will I be able to have children when I want to?' • 'Do I need any treatment now?' Initial examination findings to be given to the candidate by the examiner on request: • general examination: no evidence of bruising or trauma; • vulva: looks normal — not bruised and not bleeding; and • speculum examination and PV have not yet been done. The candidate should now discuss these with patient, and advise on management plan. EXPECTATIONS OF CANDIDATE PERFORMANCE The history should have: • determined the date of her last menstrual period; and • noted that she was not on the contraceptive pill. The candidate should advise the patient along the following lines: • Explanation as to what examination is required and why. Speculum examination is required to check that there are no lacerations in the vagina, to take swabs to exclude infections as indicated below and to collect a specimen for pathologic analysis. • The need to exclude sexually transmissible infections and get a baseline blood sample for HIV and syphilis. A cervical smear and culture should be done for gonococcus and Chlamydia (or urine can be collected for polymerase chain reaction [PCR] analysis to exclude Chlamydia). Penicillin (or azithromycin) and doxycycline should be given prophylactically. 090 010 Performance Guidelines • The need to prevent pregnancy. As she is in the late follicular phase of the cycle, the Yuzpe method of the oral contraceptive pill (two doses of two tablets given twelve hours apart with associated metoclopramide [Maxolon®], or high dose levonorgestrel [Postinor®]), should be given. • The need to review patient in three weeks to check whether she has conceived, and to review test results and decide if any need to be repeated. Screening for syphilis and HIV will need to be repeated in 1-3 months time. By that time, reassurance about subsequent pregnancy should be possible. • The need to collect a specimen from the vagina to see if spermatozoa are present and keep the specimen for DNA analysis later. For legal purposes, there would need to be a strict 'chain of security and continuity' of handling the specimen if the results are to be admissible in court. • Offer referral for rape crisis counselling with the rape crisis team or medical social worker. • If the candidate prefers to refer the patient to a doctor in a rape crisis centre immediately, a summary as above must be given, indicating what action would be expected from the staff at the rape crisis centre. KEY ISSUES • Ability to assess a patient who has recently been raped. • Ability to arrange the appropriate followup investigations and care. CRITICAL ERRORS • Failure to consider need for post-rape contraceptive methods and management. • Failure to refer to appropriate clinic or to discuss taking appropriate swab to exclude sexually transmissible infections (STI) and taking specimen for DNA analysis. • Failure to consider use of prophylactic antibiotics to prevent pelvic inflammation with an STI. COMMENTARY This patient will need to be treated with great empathy and support. As she does not wish to involve the police at this stage, there may be no indication to collect forensic specimens, but it would be appropriate to preserve any specimens collected in case she changes this decision. She needs a full explanation as to the reasons for your examination (to exclude trauma and STI), and she may well need the support of a social worker or a rape crisis counsellor. She needs explanation that pregnancy might occur as a result of the rape, and that the time of the incident in her menstrual cycle should be established, as well as the possible use of post-coital contraception to prevent conception. She should also be counselled that a review of testing in three months time will be necessary to follow up from the initial potential infection. Antibiotics should be given as prophylaxis against STI. Common problems likely with candidate performance are: • failure to review to exclude pregnancy and to arrange followup infection testing; and • failure to arrange appropriate counselling. 091 011 Performance Guidelines Condition 011 Cancer of the colon in a 60-year-old man AIMS OF STATION To assess the candidate's ability to counsel an anxious patient, recently diagnosed with colon cancer. Knowledge of the clinical presentation and natural history of carcinoma of the colon is required, including the clinical features of left colon carcinoma, and the necessity for urgent operation should acute bowel obstruction occur, in which case, a temporary colostomy may be performed. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Your father died from bowel cancer in his late sixties. You were advised about followup periodic colonoscopy, but as you had no symptoms, you did not attend for further studies after the first one five years ago, which you were told was clear. You recently attended for a further screening colonoscopy at your wife's insistence. You have had no bowel symptoms, and no general symptoms. You were shocked and upset when told by the gastroenterologist that a bowel lesion suspicious of cancer had been found, and that the biopsy confirmed that cancer was present. You have been advised that referral for early surgery is required, but you dread this prospect. Now that the implications of the positive diagnosis have sunk in, you wish to discuss matters with your general practitioner to check what is likely to occur if you continue to refuse surgery, whether any other treatment is possible, and the likelihood of a colostomy being required. Opening statement ' What will happen if I don't have surgery?' Questions to ask unless already covered: • 'What are the prospects of cure if I have the operation?1 • ‘Is any other treatment apart from surgery possible ' • 'Would I need a colostomy like my father had?' 9 At the conclusion of the interview if your concerns have been addressed adequately, thank the doctor and ask him to arrange surgical referral. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to know the natural history and clinical presentations of left sided colon cancer as outlined in the commentary, and to address the patient's concerns appropriately. 092 011 Performance Guidelines KEY ISSUES • Discussion of natural history of left sided colon cancer if not treated. • The candidate is expected to know: ~ that urgent operation is necessary if acute large bowel obstruction with caecal distension ensues; and ~ the general principles of surgical management for a rectosigmoid cancer. CRITICAL ERRORS • Failure to counsel patient on natural history of untreated colon cancer. • Failure to advise need for urgent operation in the event of acute obstruction. COMMENTARY If surgery is not performed the tumour may become evident due to bleeding, bowel obstruction or tumour spread. Carcinoma of the left colon may present with the passage of red blood mixed with the stools (or even bleeding apart from defaecation), increasing constipation, or alternating constipation and spurious diarrhoea. If obstruction develops, subumbilical central pain ensues with persisting constipation. If acute complete obstruction ensues in the presence of a competent ileocaecal valve, then distension will follow with increasing pain. The risk of rupture of the caecum means urgent operation is essential to decompress the bowel from the 'closed loop' obstruction. Nasogastric tube suction and intravenous fluid replacement alone is incorrect management. A colostomy may need to accompany emergency surgery at the surgeon's discretion, but would usually be temporary unless operation revealed extensive unexpected tumour spread. CONDITION 011. FIGURE 2. CONDITION 011. FIGURE 3. Bowel obstruction — gross caecal distension Metastatic carcinoma liver 093 011 Performance Guidelines Cancers commonly arise in premalignant adenomatous polyps. The likelihood of malignant change increases with increasing polyp size. Spread of the tumour occurs by direct invasion through the bowel wall, which can be followed by malignant ascites and peritoneal metastases. Lymphatic spread in left colonic cancer, which significantly worsens prognosis, is via epicolic, paracolic and preaortic nodes. Blood spread occurs via the portal system to the liver and beyond. The prognosis after resection of colon carcinoma relates directly to the degree of spread of the carcinoma as indicated in Dukes classification: • Stage A: carcinoma confined to the mucosa, over 95% five year survival; • Stage B: carcinoma involves the muscle of the colonic wall, 75-80% five year survival: • Stage C: lymph node involvement, 50% five year survival; and • Stage D: spread into the peritoneal cavity or by blood spread to the liver and beyond, 25-35% five year survival. Elective surgery on confirmation of diagnosis offers the best prospect of cure, and colostomy is not usually required. If a colostomy is performed under conditions of elective surgery, it would normally only be temporary. In low left sided colonic cancer, adjuvant chemotherapy has been shown to improve survival in selected cases. Preoperative investigations normally check for general fitness for anaesthesia, absence of anaemia and normal renal function. Abdominal imaging by computed tomography (CT) can provide information regarding intra-abdominal spread as an aid to whether curative resection is likely to be possible, and should be advised in this concerned patient to facilitate informed consent for surgery. Perioperative prophylactic antibiotics can minimise infective complications of surgery. 094 012 Performance Condition 012 Thalassaemia minor in a 22-year-old woman AIMS OF STATION To assess the candidate's knowledge of the Mendelian inheritance of / β -Thalassaemia minor, its management, and the candidate's counselling skills in dealing with a sensitive issue involving her prospective spouse. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The doctor will discuss the results of the tests and will explain to you the implications of you being a carrier of the condition of / β -Thalassaemia. You should be reassured that the condition is not serious to your own health, but there are inheritance implications which will depend on your fiance's genetic status. If the doctor does not suggest testing your fiance, ask: • Will this have any effects on our children?' • Should my fiance have any test done?' EXPECTATIONS OF CANDIDATE PERFORMANCE Candidates are expected to know that Thalassaemia is a recessive inherited trait so that the heterozygous (carrier) state gives Thalassaemia minor, whilst the homozygous state results in Thalassaemia major. • Approach to patient: ~ This scenario deals with a sensitive issue, namely that if the patient's fiance is also a carrier, future children may be affected, with a significant risk of / β -Thalassaemia major. ~ Minimisation of anxiety by careful explanation, a supportive attitude and with guarded reassurance about present day management is expected. • Interpretation of investigations: The characteristics of / β -Thalassaemia minor include: ~ FBE — a symptomless hypochromic microcytic anaemia (rarely below 100 g/L) with decreased mean corpuscular volume (MCV) and usually normal red blood cell count (RBC); ~ diagnosis needs confirmation by serum electrophoresis (elevated Hb A2); and ~ the anaemia does not respond to any form of iron therapy, unless the patient happens also to be iron-deficient, which is very rare. • Initial management plan: ~ Reassure the patient regarding the effect on her health. Iron therapy is not indicated. Oral folic acid of 1 mg per day will more than meet the requirements of the mildly increased red cell turnover. 095 012 Performance Guidelines ~ The candidate should offer to see her fiance to arrange appropriate testing, advise that the fiance consults his own doctor, and offer to refer the couple to a geneticist or haematologist. Suggest also that her brother should seek advice in regard to testing for the trait. If the fiance is not a carrier there is no immediate problem, although the couple should be advised to inform their children of the situation at an appropriate time, including how the carrier state is diagnosed. ~ This problem cannot be resolved at this consultation. Followup with patient and also fiance (if possible) is required after results of fiance's genetic status are known. • Patient counselling/education: The candidate should counsel regarding the following issues: ~ Thalassaemia minor is a recessive inherited trait ('carrier' state). ~ Nature of this condition and possible consequences if conjugal partner also carries the trait. ~ Information about β -Thalassaemia major and risks of its occurrence in offspring if both partners are carriers. Availability of antenatal diagnosis and management of pregnancy (including termination) if fetus is shown to have β -Thalassaemia major. • Patient counselling regarding inheritance implications. • Initial management plan. • Failure to advise that the prospective spouse should be investigated for carrier state. • Failure to understand principles of Mendelian recessive inheritance. Thalassaemia is a common anaemia in certain areas of the world, including the Mediterranean region, India, Southeast Asia and Africa. In Australia, there is a high prevalence of this condition in individuals descended from these regions. At the molecular level, there are hundreds of globin abnormalities leading to either alpha-chain or beta-chain underproduction. The underproduction of either alpha or beta chains results in a microcytic red blood cell. There is also haemolysis because the imbalance results in excess globin chains, which are oxidised and result in premature red blood cell removal in the spleen. β -Thalassaemia major is a rare, but very serious, congenital anaemia requiring lifelong transfusional support and patients with this condition also need treatment to avoid complications of iron overload related to the frequent transfusions. There is a markedly reduced life expectancy with devastating consequences for both the child and family. The most important points being assessed are: • Knowledge of Mendelian inheritance (what is a recessive inherited trait and what are its implications?). • Meaning of ~ heterozygous inheritance: results in β -Thalassaemia minor; and ~ homozygous inheritance: results in B-Thalassaemia major. • Advise that fiance be tested for β-Thalassaemia minor 096 012 Performance Guidelines The pattern of inheritance is as illustrated. She has the carrier state /J-Thalassaemia minor. • If fiance is negative for β -Thalassaemia minor; Either sex can be carriers. Half the children of either sex will be carriers (β -Thalassaemia minor). None should have β -Thalassaemia major. • If fiance is positive for β-Thalassaemia minor: Half the children of either sex will be carriers. One in four children will have β -Thalassaemia major, which affects children of either sex. • Management If the haemoglobin test for β -Thalassaemia minor in the fiance is negative: ~ No further action or tests are required. ~ Explanation of carrier state is required (can affect male or female children) — each offspring will have an equal chance of being carrier or noncarrier (normal). ~ If the fiance has a positive test for β -Thalassaemia minor, they will need counselling about risks to fetus which are 1:4 for β -Thalassaemia major (25%) and 1:2 for β -Thalassaemia minor (50% — carrier status). The diagnosis of β -Thalassaemia major can be made by in utero genetic sampling at 12-14 weeks. If both partners are carriers there is no cause for undue alarm because of increased awareness, diagnostic certainty, known risks and availability of antenatal diagnosis and safe termination procedures (unless this is not an acceptable option). 097 Performance Guidelines Beta-Thalassaemia is a condition involving the beta ( β ) chains, with both homozygous and heterozygous states being compatible with survival to term but with major differences in outlook. Heterozygous alpha-Thalassaemia (which involves the alpha ( a ) chains) is also compatible with survival; however the homozygous state of alpha-Thalassaemia results in fetal hydrops and death-in-utero. CONDITION 012. FIGURE 3. β -Thalassaemia major: the slide shows microcytosis, anisocytosls, hypochromia, a normoblast and target cells 098 013 Performance Guidelines Condition 013 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism AIMS OF STATION To assess the candidate's ability to advise a patient of the appropriate management she should receive during her next pregnancy, when the last one was complicated by a pulmonary embolus during the puerperium. Because of her previous deep venous thrombosis (DVT) and pulmonary embolus, she is at increased risk (probably at least 20%) of a repeat thrombosis in her next pregnancy. The examiner will have instructed the patient to respond as follows: • Previous DVT and pulmonary embolus: your pulmonary embolus occurred on day three after the birth. After this DVT in the right pelvic veins was diagnosed when the doctor performed a venogram. • You were treated with intravenous heparin for two weeks, in full dosage, followed by full dose warfarin therapy for six months. • You have now been off all treatment for 12 months. • Contraception: you are using condoms. You had previously been on the contraceptive pill prior to the first pregnancy without problems. • You have had no previous DVT or pulmonary embolus apart from as outlined in the previous pregnancy. • You have had no trauma or operations on legs or pelvis. • There is no shortness of breath currently. • There are no varicose veins, but you do have occasional ankle oedema on the right side (the side of the previous thrombosis). • Your previous delivery was a spontaneous vaginal delivery of a live male infant weighing 3550 grams. A small episiotomy was cut to facilitate delivery. You did not breastfeed. • You have no family history of any clotting problems or thromboses. • During the last pregnancy, you were shown to be rubella-immune and took folic acid from before pregnancy and for the first 16 weeks. Questions to ask unless already covered: • Will I get another deep vein thrombosis and pulmonary embolus?' • 'Do I need anticoagulant treatment during the next pregnancy? If so, what?' • ‘Is there any risk from anticoagulant treatment during pregnancy to my baby or me?' Investigation results No investigations have been done since you ceased warfarin therapy and none had been done prior to commencing anticoagulants after the pulmonary embolism. 099 013 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should provide the substance of the following information in lay terms: • The pregnancy should be managed in consultation with a consultant physician or haematologist and an obstetrician. • There is a need to screen her for a clotting propensity (thrombophilia) prior to her becoming pregnant (tests should include the measurement of anticardiolipin antibody, lupus anticoagulant, protein S, protein C, anti-thrombin 3, and factor V Leidin — these tests will screen for both inherited and acguired thrombophilias). If a thrombophilia is identified, anticoagulant therapy throughout the pregnancy and the puerperium should be advised. • Even if there is no underlying problem discovered, she should still be treated with anticoagulants at least during the puerperium, and it is safer to treat her throughout the pregnancy. The treatment should therefore probably be started at about 14 weeks of gestation and continued until at least 4-6 weeks postpartum. • Optimal anticoagulant therapy is best given as subcutaneous low dose heparin in a dosage of 7500 units twice daily, or with a low molecular weight heparin such as enoxaparin, in a dose of 20-40 mg 12 hourly (in the past it would have been common for heparin to be changed to warfarin, in full dosage, between 16 weeks and 36 weeks, and then from one week postpartum). Treatment with warfarin, however, has problems such as a 5% risk of teratogenesis when given in the first trimester and an increase in miscarriage rate, fetal and maternal haemorrhage, neurologic problems in the baby and stillbirth. For all of these reasons, warfarin is not used during pregnancy, although it is commonly used if treatment is continued postpartum. • Avoid prolonged immobilisation during pregnancy, and consider using compression stockings by day throughout the pregnancy. • Deliver in a controlled manner at about 38-39 weeks of gestation, rather than allowing a spontaneous labour to occur in someone who has just had her dose of heparin. Although the heparin dose is not full dosage, and unlikely to affect clotting tests, it is best to arrange induction at a time when the morning dose of heparin can be withheld, with the treatment being reinstituted after delivery. • Take her folic acid therapy as on the previous occasion. • Ability to recognise that she is at increased risk of a recurrent thrombosis in her next pregnancy and requires at least low dose heparin during the puerperium if not for most of the antenatal period as well. • Recognition of relative risks and indications for heparin and warfarin therapy. • Recognition of significant risks of warfarin during pregnancy. • Failure to screen for an inherited or acquired coagulation disorder. • Failure to advise anticoagulant therapy at least for 4-6 weeks postpartum in the next pregnancy. • Advising warfarin therapy throughout pregnancy. 100 013 Performance Guidelines COMMENTARY This young woman has survived a life-threatening pulmonary embolus in a previous pregnancy. She must receive treatment to prevent a similar episode occurring in her next pregnancy. It is essential to exclude any acquired or inherited coagulation disorder. However, in any event, she will need anticoagulant therapy for the majority of her next pregnancy. The benefits of heparin must be carefully explained, as opposed to the risks of warfarin in pregnancy. It is also important that the anticoagulant therapy be continued beyond the birth of her infant for at least 4-6 weeks. Common problems likely with candidate performance are: • failure to enquire about the particulars of the previous thrombosis/pulmonary embolism. • suggesting that warfarin therapy should be given throughout the pregnancy, which can be teratogenic if given in the first trimester, and is impossible to reverse quickly in the late third trimester when labour is likely to occur 101 014 Performance Guidelines Condition 014 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus AIMS OF STATION To assess the candidate's ability to counsel a nulliparous diabetic woman about the effects of her diabetes on a future pregnancy, the effect of future pregnancies on her diabetes, and the actions she should take to minimise the risk of potential problems. The examiner will instruct the patient to reply, as indicated below, when her history is being taken by the candidate. • Your diabetes was diagnosed at the age of 9 years (that is, 15 years ago). • Your diabetes has been well controlled on insulin and is currently very well controlled on long-acting insulin given twice daily. • Your last review by the diabetic physician was 12 months ago. You manage your own insulin dosages and test blood sugar levels three times a day. Generally you are able to keep the blood sugar levels at 6-8 mmol/L. • You have not been troubled with urinary infections or vaginal infections. • Your vision has been good and kidney function has been normal. • You have never had a hyperglycaemic coma, but occasionally have hypoglycaemic episodes. • You have not had any of the other pre-pregnancy blood tests done, such as rubella antibodies, full blood examination (FBE), blood group, indirect Coombs test or syphilis serology. Questions to ask if not already covered: • 'Will I be able to have a baby?' • ‘Will my baby be OK?' • ‘Will the pregnancy adversely affect my diabetes?' • 'How does the diabetes affect my pregnancy?' EXPECTATIONS OF CANDIDATE PERFORMANCE In general, the candidate needs to advise her of the need to have very good blood sugar control prior to conception and during the pregnancy, that the pre-pregnancy counselling applicable to all pregnant women is also applicable to her, that the risk of certain pregnancy complications are increased, that the baby is also at increased risk, and that delivery at 38 weeks or sometimes earlier will probably be required. 102 014 Performance Guidelines Specific advice to the patient The candidate should explain that: • Pre-pregnancy counselling must take the form of assessment of her diabetic control and looking for any evidence of effects of the diabetes on target organs. Her haemoglobin A1C (HbA1c) should therefore be measured and her blood glucose assessments reviewed to ensure they are satisfactory. It is particularly important to keep the blood glucose levels within the range of 5-7 mmol/L during the first trimester to reduce the risk of fetal malformation to an absolute minimum, and during the remainder of the pregnancy to reduce the fetal and maternal complications (particularly macrosomia and unexplained fetal death). • Referral to her diabetic physician to check her general state is mandatory, with assessment for peripheral neuropathy, renal function (renal function tests and 24 hour urinary protein), and a check of her optic fundi by her ophthalmologist. • Providing all of these are normal, she could be advised to attempt to become pregnant, and commence folic acid in a dosage of 0.5-1 mg per day from the time pregnancy is attempted until at least mid-gestation. • In addition, the routine tests which would normally be performed at the first antenatal visit are better performed prior to pregnancy. These tests should include blood group and indirect Coombs test, full blood examination (FBE), hepatitis screening, Venereal Disease Research Laboratory Test (VDRL). rubella serology, and midstream urine specimen to exclude urinary infection. If a Pap smear has not been performed in the last two years, this should also be performed. Any abnormalities found in these tests should be addressed prior to the pregnancy. • She should also be advised about the care which is likely to be required during pregnancy as follows: ~ Referral to a consultant obstetrician who will manage her in conjunction with a diabetic physician. ~ Her insulin requirement will markedly increase and she will need to keep her blood sugars between 5-7 mmol/L to keep the fetal malformation rate to a minimum, and the macrosomia (large fetal size) rate to an acceptable level. ~ The insulin requirement after delivery usually returns to pre-pregnancy requirements within 24 hours of delivery, ~ Ultrasound examination should be performed at 12 and 18 weeks looking for fetal abnormalities, and at 32 weeks looking for macrosomia. ~ Iron and folic acid therapy should be continued throughout the pregnancy. ~ In general, even where the diabetes is well controlled, delivery should be planned for 38-40 weeks in someone who has had diabetes for 15 years and is on insulin therapy. Earlier delivery might be necessary if problems occur during the pregnancy. ~ Despite adequate monitoring and care during pregnancy, the pregnancy is more likely to be complicated by pre-eclampsia, polyhydramnios and macrosomia of the fetus. There is also an increased risk of unexplained fetal death-in-utero late in pregnancy and of respiratory distress in the baby after delivery. All of these matters need to be raised with the patient prior to pregnancy, so that she can make an informed decision as to whether she wishes to proceed. 103 014 Performance Guidelines KEY ISSUES • Ability of the candidate to counsel a diabetic woman, prior to a pregnancy, about the care she will require and the methods of keeping the complication rate to herself and her fetus to a minimum. • Failure to ensure the patient is aware that her diabetic control prior to pregnancy should be good to ensure the risk of fetal abnormality is kept as low as possible. • Failure to do pre-pregnancy blood tests (haemoglobin estimation, blood group, rubella antibodies and tests as above) and failure to recommend pre-pregnancy and early pregnancy folic acid therapy (routine pre-pregnancy counselling). The most important aspect of managing pregnancy in an established insulin-dependent (Type 1) diabetic is that the pregnancy must be managed in consultation with a physician specialising in diabetes and a specialist obstetrician. The most important advice that the patient should receive is that pre-pregnancy and pregnancy control of blood sugar levels is essential for an optimum outcome of the pregnancy. Common problems likely with candidate performance are: • inability to advise the patient adequately concerning the special problems seen in pregnancy that can affect either the baby or the mother; • lack of knowledge that good blood-sugar controi reduces the risk of unexplained fetal death-in-utero and fetal macrosomia; • lack of knowledge that the insulin dose required will usually increase dramatically during the pregnancy, but fall back to pre-pregnancy requirements within 24 hours of delivery; and • failing to suggest that the pregnancy should be managed in consultation with a diabetic physician and a specialist obstetrician. 015 Performance Guidelines Condition 015 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida AIMS OF STATION To assess the candidate's ability to appropriately counsel a patient found to have an anencephalic fetus at the time of an ultrasound examination at 18 weeks of gestation. The examiner will have instructed the patient as follows: This is your first pregnancy at 18 weeks. You are seeing the doctor to discuss your recent ultrasound test. Screening blood tests two weeks ago raised concerns about the fetal condition. The list of appropriate answers below is likely to cover most of the doctor's questions: • if asked about your periods, indicate they had been normal prior to the pregnancy; • you did not take any folic acid in early pregnancy; • no family history of neural tube defect (spina bifida,) in pregnancy; • if after explaining the diagnosis, the candidate explains termination of the pregnancy as an appropriate action, or asks you what you would prefer, answer: ‘I do not wish to continue with the pregnancy if this can be arranged'; • your blood group is O positive, indirect Coombs test negative; and • there is no history of asthma or other contraindication to prostaglandin therapy. Opening statement ‘Is there anything wrong with my baby?' Questions to ask if not already covered: • 'Can I have the pregnancy terminated?' — Ask only if the candidate informs you of the diagnosis but doesn't mention termination of the pregnancy being an option. • ‘Is this problem likely to occur again in a subsequent pregnancy?' • 'How can I prevent the problem from occurring again?' EXPECTATIONS OF CANDIDATE PERFORMANCE Diagnosi Fetal anencephaly is a developmental defect of the brain which occurs somewhere between five and eight weeks of gestation. In this patient, the condition has been diagnosed unequivocally at the 18 week ultrasound as illustrated. The condition is always fatal soon after birth. The patient has the option to terminate the pregnancy forthwith, or continue until labour occurs. If the latter is chosen, and if hydramnios occurs, the labour is likely to be premature, otherwise labour post-term is common. 105 015 Performance Guidelines Advice expected to be given to the patient: • The information concerning anencephaly should be given as indicated above. • As the patient has indicated she should wish to have the pregnancy terminated, this needs to be discussed. Termination of the pregnancy could be performed by using prostaglandins, or by the surgical procedure of dilatation and evacuation. This latter procedure has the advantage of being performed under general anaesthetic with the procedure being over when the patient wakes up. This procedure is quite difficult except in expert hands, and cervical damage resulting in subsequent cervical incompetence in any subsequent pregnancy may result when the procedure is done after 16 weeks ol gestation. • Prostaglandin termination may take several hours — or even days — and results in uterine contractions similar to those experienced in labour, followed by vaginal delivery of the fetus. There is also a possible need for curettage to remove any retained placental fragments. • Post-mortem examination should be performed on the fetus to check that no other abnormality is present that might influence the advice given concerning the successor otherwise of any subsequent pregnancy. • The risk of recurrence of a neural tube defect (NTD) such as anencephaly, or spina bifida, is somewhere between 2% and 5%. Folic acid administration (in a dosage of 5 mg per day) should be commenced prior to conception and continued until about 12 weeks of gestation, as this has been shown to reduce the risk of a neural tube defect Ultrasound examination in a subsequent pregnancy is imperative. • Maternal serum alpha fetoprotein assessment is also useful as a screening test and should be performed at about 16 weeks of gestation in any subsequent pregnancy. Ability to advise the mother: • empathically of the fact that her baby has a lethal abnormality; • of the appropriate options regarding her further care in this pregnancy; and • of the methods available to reduce the recurrence risk of this abnormality Failure to: • recognise and advise the patient that this is a lethal abnormality to the baby: or • determine the preferences of the mother in respect to termination of pregnancy; or • counsel the patient appropriately concerning management in a subsequent pregnancy. The most important aspect of managing this case is to understand the anxiety and disappointment of the mother. She will need considerable support and understanding when discussing the abnormality with her and the management of the termination of the pregnancy that she has requested. While helping her to deal with the extreme disappointment of the outcome of this pregnancy, the candidate should be positive in terms of prevention (folic acid) and screening tests in a subsequent pregnancy. 106 015 Performance Guidelines Common problems with candidate performance are: • Not focusing enough on the actual problem when taking the history, but asking for information such as the date of the last menstrual period, irrelevant past history, social history etc. This just takes time to do and reduces the time available for the remaining tasks. • Advising the patient that a suction curette would be the preferred method of termination. This is not the case at 18 weeks of gestation, although it would be appropriate for a pregnancy termination being performed at less than 15 weeks of gestation. • Advising that maternal serum screening at 11-12 weeks gestation in the next pregnancy would be appropriate to exclude another NTD. This test would be appropriate to assess the likelihood of a chromosome abnormality but an alpha-fetoprotein assessment at 15-16 weeks gestation is also necessary for recognition of a likely NTD. Earlier ultrasound examination, at 11-12 weeks of gestation, may allow a diagnosis of anencephaly to be made, but would not exclude spina bifida. An understanding of the recent methods and timing of genetic screening in early pregnancy is required. CONDITION 015. FIGURE 2. Ultrasound showing anencephalic fetus 107 016 Performance Guidelines Condition 016 A duodenal ulcer found on endoscopy in a 65-year-old man A I M S OF STATION To assess the candidate's ability to counsel a patient on the aetiology and complications duodenal peptic ulceration and the principles of management. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a retired bank clerk. You have had dyspepsia (epigastric pain after meals) for abo six weeks. Your general health has been reasonably good apart from some rec generalised aches and pains in your joints. You have been taking Nurofen"1 table (ibuprofen), which you obtained from the pharmacist, which have not given much relief, i do not smoke or drink alcohol. Questions to ask if not already covered by doctor: • 'Why have I developed the ulcer?' • ‘Is it contagious? Can my family members be affected?' • ‘'What treatment do I need to get rid of this duodenal ulcer?' • ‘'Would those NuroferP tablets have anything to do with this?' • ‘Is it likely to come back once it has healed? If so, can this relapse be prevented?' • ‘Is the ulcer cancerous?' • '’Would surgical treatment ever be required?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain that: • The majority of duodenal ulcers are a consequence of mucosal damage caused Helicobacter pylori and gastric hydrochloric acid. The relationship of H. pylori a gastric acid to gastric ulcer is less definite. Non-steroidal antiinflammatory dru (NSAIDs) commonly contribute to peptic ulcer formation. Management of peptic ulc depends on the underlying cause. For Helicobacter pylori-related ulcers, triple ther (usually a proton pump inhibitor and two antibiotics) will heal more than 90% of ulc within one week of starting treatment and, provided the organism is eradicated (u breath test at six weeks), the chance of ulcer recurrence is low. For NSAID-relat ulcers, the patient will only require acid suppression to achieve ulcer healing. • Recommended therapy for an H. pylori-related ulcer includes a proton pump inhib' (for example, omeprazole) plus antibiotics (clarithromycin or amoxycillin plus metr dazole given for 1-2weeks), followed by continued antisecretory therapy foruptoat of 4-8 weeks. • Cessation of potential aggravating factors such as NSAID use and smoking is important. Whilst tobacco and alcohol may hinder the healing of ulcers, they d o n ’ t contribute to the development of the ulcer. The patient should replace ibuprofen alternative analgesia such as paracetamol. The bacterial infection is not highly contagious to other family members. 108 016 Performance Guidelines • Peptic ulcers are common, more so in men. About 70% are related to H. pylori. Left untreated, most ulcers will spontaneously heal, but relapse, often after several months. Thus peptic ulcer disease can be a lifelong problem, with about 10% of patients developing complications (bleeding, perforation or gastric outlet obstruction). • Most patients can be managed with medical therapy and without surgery. Complications of peptic ulceration, which require surgical intervention, include perforation, gastric outflow obstruction and severe persistent bleeding. Malignancy occurring in a chronic peptic ulcer is uncommon (1-2% in gastric ulcer) but would need examination and monitoring to ensure permanent healing. Haemorrhage from peptic ulcers produces haematemesis and/or melaena. Bleeding is usually self limiting, but more likely to persist in older patients with arterial medial sclerosis. In these patients, endoscopic haemostasis using a heater probe or injection of adrenaline, is often successful in preventing further bleeding. Surgery is indicated when excessive or persistent bleeding occurs and should be considered when blood loss exceeds 3000 mL. However, each patient should be evaluated individually. • Knowledge of the usual medical therapy and risk factors for patients with peptic duodenal ulceration. • Understanding that surgery is required for perforation, obstruction and for patients with severe, persistent bleeding or intractable pain. With the advent of the proton pump inhibitors and the identification of the pathogen Helicobacter pylori, the • Informing the patient that the duodenal ulcer is likely to be malignant. management of peptic ulcer disease has undergone a considerable change in the last two decades. From being a chronic, indolent problem, frequently requiring surgical intervention, peptic ulcer disease is now a relatively benign and easily treated condition. The mucosal lining of the stomach and duodenum is normally protected from acid-attack and autodigestion by a layer of mucus. This layer of mucus forms an 'unstirred layer' which is constantly replaced by secretion from the underlying cells. Bicarbonate is also secreted from the surface cells to help with mucosal defence. Both mucus and bicarbonate secretion are modulated through the actions of prostaglandins, cyclic AMP (cAMP) and several other agents. There are a number of ways in which the integrity of this mucous layer can be broken. Replenishment of the layer can be interrupted through interference with prostaglandin synthesis and reduction in bicarbonate secretion. This is an important side effect of NSAIDs. The layer itself may be disrupted and acid allowed to infiltrate and damage the underlying mucosa. The most common mechanism of this kind of damage is brought about by the presence of Helicobacter pylori. To survive in the hostile acid environment, this bacteria surrounds itself in a neutral zone, brought on by the breakdown of urea (through the enzyme urease) and formation of ammonium ions. This change weakens the integrity of the mucous layer. 109 016 Performance Guidelines CONDITION 016. FIGURE 2. Helicobacter pylori associated peptic ulceration CONDITION 016. FIGURE 3. Urease test on biopsy with sample The existence of H. pylori and its role in peptic ulcer disease was only appreciated in the early 1980s, mainly through the seminal contributions of B Marshall and R Warren from Perth, Australia, leading to their receipt of the Nobel Prize in Medicine for 2005. On a worldwide basis, most peptic ulcers will be related to the presence of H. pylori. Whilst the prevalence of H. pylori is high in many communities — especially amongst those in lower socioeconomic groups — the rate of ulcer formation is still relatively low. When a peptic ulcer is not related to the presence of H. pylori, the most likely aetiological factor will be an NSAID. A great deal of false expectation occurred with the development of the Cyclo-oxygenase-2 (COX-2) inhibitors (such as celecoxib), from belief that this class of compound would be associated with a lower incidence of gastrointestinal side effects. This has not proven to be the case. Ideally, all patients with a suspected peptic ulcer should have an endoscopy performed. The aim of the procedure is two-fold: first, to confirm the diagnosis; and secondly, to test for the presence of H. pylori. As part of the diagnosis, any ulcer in the stomach must be biopsied to exclude malignancy. Duodenal ulcers are not associated with malignancy. If H. pylori is present, part of the treatment will be to eradicate the infection. Provided this is done and the ulcer is healed, the chance of recurrence is low. If the ulcer does recur this is probably because the patient has become reinfected. If H. pylori is absent, the likely cause of the ulcer is an NSAID. Treatment consists of withdrawing the NSAID and giving the patient an acid-suppressing agent for long enough for the ulcer to heal. Treatment for 4-8 weeks will lead to H. pylori eradication and ulcer healing in over 90% of cases. If the initial ulcer was a duodenal ulcer, success of treatment can be judged by relief of symptoms and a breath test to check for H. pylori eradication (if the infection was present in the first place). If the cause of the problem had been a gastric ulcer, the patient should be endoscoped again, and the ulcer biopsied again if still present. 110 017 Performance Guidelines Condition 017 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery AIMS OF STATION To assess the candidate's ability to explain the principles of preoperative blood collection for autologous intraoperative transfusion. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to ask questions of the candidate as follows (unless the matter has already been covered): The answers expected by the candidate are in brackets. Opening statement: 'Are there any advantages in using my own blood it I need a transfusion?' (Specifically minimising infective and incompatibility risks) Questions to ask if not already covered: • 'How long is the blood good for?' ( U p to five weeks) • 'How much do they take?' (Up to 2 litres over a period of 2-5 weeks) • 'Don't I need all my own blood?' (Your blood rapidly regenerates, being a renewable tissue from the bone marrow) • ‘'Won't it make me very weak?' (Not significantly) • ‘'What are the advantages of my blood over blood bank blood?''(It is your own. which is fully compatible). EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should display ability to counsel about the following issues: • The candidate is expected to explain the normal functions of bone marrow and blood, and that blood is a renewable tissue with the main functions of oxygen transport to tissues and maintenance of circulatory volume. • Blood donors can give readily 10-15% of the blood volume (450 mL) and the fluid volume is rapidly replaced within hours from the body's reserves. Replacement of the red cells starts immediately after donation and the slight anaemia resolves within weeks as the blood cells are replaced. • Blood can be stored safely for reuse within a few weeks (up to five weeks), so that one. two or more donations can be collected over the weeks prior to operation. The blood units can then be stored and saved to be used during operation as whole blood or reconstituted red cells to replace operative blood loss requirements in operations (such as this patient is having) on large joints or blood vessels, where blood loss can be such as to require transfusion. • The procedure removes the risk of disease transmission (particularly by viruses) or incompatibilities and allergies inherent in standard homologous blood transfusion from another donor. 111 017 Performance Guidelines • The procedure is recommended in patients with no medical contraindications to blood donation, who are to have a planned major elective surgical operation on a defined date some weeks ahead at which blood losses are expected to be moderate or high. • The procedure of donation does not cause any increase in liability of operative problems or complications and the modestly lowered haemoglobin level causing temporary 'thinning' of the blood may be protective against thrombotic clotting complications such as deep venous thrombosis, pulmonary embolism, heart attack or stroke, because the thinned blood flows more freely. • The procedure would not necessarily remove all likelihood of requiring an additional non-autologous transfusion, which will depend on volume of operative loss, but will significantly reduce such prospects. Non-autologous/homologous blood transfusion itself is used to save many thousands of lives each year, and although not entirely free of risk, is rigorously supervised and a safe procedure in Australia. • Preoperative autologous blood collection for subsequent operative use depends on a verified and non-cancellable time for surgery, so there is always a possibility that the blood would be unavailable for use if the operation was inadvertently long delayed or cancelled for any reason. KEY ISSUES • Appropriate explanation of blood being a renewable tissue, thus allowing for preoperative collection and storage including: ~ advantages of autologous over homologous blood transfusion: and ~ circumstances in which autologous transfusion may be considered. CRITICAL ERROR - none d e f i n e d COMMENTARY There are two components to the task: • To provide education on the transfusion of blood and blood products. • To explain the benefits, risks and principles of autologous blood transfusion. In industrialised communities, blood transfusion is now extremely safe. Blood is usually collected from volunteer donors only. In Australia there is no remuneration or any form of inducement other than a demonstration of community spirit. All blood samples are carefully screened for important communicable diseases, including human immunodeficiency virus (HIV), hepatitis B and C virus (HBV, HCV) and syphilis. There will always be a risk of infection and of concern is the rare hepatitis G virus and the prion transmission agent responsible for Creutzfeldt-Jacob disease (CJD). Some countries will not accept donors who have come from countries where 'mad cow' disease has been identified. Screening for HIV does not give absolute freedom from risk, as a window period occurs after primary infection until antigen is detectable and seroconversion occurs after several weeks. Blood is only given to patients when strictly necessary. Donors are screened for high risk circumstances and the donated blood tested, and the blood is grouped, screened for antibodies and cross-matched with the potential recipient. There are strict guidelines for the administration and monitoring of blood and any adverse events are documented and reported. Blood transfusion is used sparingly for elective surgery and otherwise healthy patients can tolerate haemoglobin concentrations down to 80 g/L. 112 017 Performance Guidelines Autologous transfusion is only considered when: • the date of the surgical procedure can be virtually guaranteed: • the patient's haemoglobin concentration exceeds 110 g/L (135 g/L in women); and • it is likely that a substantial amount of blood will be lost during the procedure. Concerns about the safety of blood transfusion, particularly in the 1980s about risks of transmission of HIV infection, stimulated interest in avoiding or reducing the use of donor blood, particularly single unit transfusions (Give blood by the gallon, not by the gill). Several techniques can be used to avoid the need for bank blood. Autologous blood transfusion is one such technique, which reduces the risk of transfusion of viral infection and also of alloimmunisation and incompatibility reactions. Stored blood at 4"C has a 'shelf-life' of up to five weeks, at which time around 70% of the red cells still survive normally. With pre-deposit autologous transfusion, patients can donate 2-5 units (of450mL) at approximately weekly intervals before elective surgery. Alternatively, deliberate preoperative haemodilution can be induced by removing one or two units immediately before surgery to be used during surgery to replace operative losses. Collection and administration of blood for autologous transfusion is an expensive exercise. Because the donor (the patient) is not a standard blood donor, if the blood is not used for any reason, it cannot be put into the general donor pool and will be wasted. Starting a maximum of five weeks before the planned procedure, the patient donates a unit (450 mL) a week and is given ferrous sulphate supplements. Another variant on autotransfusion, as noted above, is to take off 1 L of blood immediately prior to operation, haemodiiute the patient with crystalloid and then use the freshly removed blood as required. Other techniques that can be used include intraoperative autotransfusion (operative blood salvage) and erythropoietin. Blood salvage techniques to collect and retransfuse blood lost during surgery can be employed, providing the operative site is known to be free of bacteria, intestinal content, or tumour. Intraoperative autotransfusion can be used in major trauma and vascular surgery. As the equipment required to run such systems is expensive, intraoperative autotransfusion does not usually make significant dollar savings over standard banked blood. Recombinant human erythropoietin can be used to stimulate the body's own blood reserves prior to elective surgery. The technique can be considered for chronic renal failure patients who are anaemic and as a blood-saving strategy in major surgery. In Australia and UK. where blood transfusion is generally perceived as being safe, and where emergency surgery and pressures and operating list revisions make it difficult to set definite dates of elective surgery, the techniques of autologous transfusion are applied only in a minority of cases. This contrasts to other communities, such as USA. where the use of autologous transfusion is more common (up to 5% in some regions). The future: The use of allogenic blood will always involve the need for compatibility testing. The shelf life of allogenic blood is limited and although current techniques of blood transfusion are very safe, disease transmission from viruses is unlikely to be completely eliminated because of false negative results during the window period. A clinically effective red blood cell substitute would thus be beneficial in terms of universal compatibility, immediate availability, freedom of disease transmission, and long-term storage. Major potential candidates are haemoglobin solutions and perfluorochemical emulsions. 113 017 Performance Guidelines The haemoglobin molecule, the tetramer, chemically binds and carries oxygen (1 g Hb binds 1,39 ml_ 02 and is fully saturated at ambient pressure). Oxygen is unloaded from Hb in capillaries at 40 Torr. The unmodified tetramer is potentially nephrotoxic and vasoconstrictive. Efforts to modify the tetramer to improve safety include polymerisation and other techniques. Continuing research into synthetic blood substitutes thus continues in an attempt to produce a non-toxic temporary fluid combining volume replacement, and intravascular oncotic stability equivalent to that exerted by plasma proteins with oxygen-carrying capacity. In the meantime, the major alternative volume replacement fluids available are albumin solutions, solutions utilising other colloids (gelatin, dextrans), and simple balanced electrolyte solutions. 114 018 Performance Guidelines Condition 018 Advice on stopping smoking to a 30-year-old man AIMS OF STATION To assess the candidate's knowledge of nicotine-dependence and the ability to obtain relevant information to counsel the patient appropriately and to answer his questions about the withdrawal process and treatment options. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 30-year-old information technology specialist, employed in a State Government Department. You are engaged to be married and have attended your general practitioner as a followup to a recent episode of an upper respiratory infection associated with a cough. You have been a cigarette smoker since your mid-teens and currently smoke 20 cigarettes a day (on average). With your impending marriage, you have been considering stopping smoking. On the previous visit to your general practitioner, the doctor had briefly suggested that you should stop smoking for the benefit of your health. Opening statement: Start the interview by saying: I've been thinking about your advice last time about my smoking. I would like to stop. What can you do to help me?' Appear interested, engaged and genuinely motivated at this time to stop smoking Listen carefully to the advice and information provided by the doctor, and respond appropriately. Ask questions and seek clarification, depending on the content provided. Questions to ask if the topic has not already been covered by the candidate: • ‘Is it too late for me to stop? Is the damage already done?' • 'How easy is it to stop?' • 'Do / have to stop abruptly or can I just cut down gradually?' • 'Do hypnotherapy or acupuncture or alternative remedies like herbs or vitamins work?' • 'What are the risks/benefits of nicotine patches/gum or mood tablets? Are they expensive? What are the side effects?' • 'What should I expect by way of withdrawal symptoms? • ’Will the treatment affect my sex life?' • ‘Do I need to do a course or join a quit smoking group?' • ‘Is the desire to smoke inherited? Will I pass it on to my children?' 115 018 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should display appropriate empathy, rapport and enthusiasm for explaining the benefits and pitfalls of smoking cessation. Cigarette dependence is a chronic relapsing condition which, once established, involves a long term, even lifetime struggle to achieve abstinence. Motivation to stop in this patient should be assessed by the candidate asking direct questions about his intentions and desire to stop (for example, on a scale from 'not at all' to Very much'). The patient is in the preparation' stage of behaviour change (planning to stop in the near future) and is hoping to learn 'action' strategies that will help him succeed in overcoming his dependence on nicotine. In order to assess how dependent the patient is on nicotine, the candidate should not only ask about the number of cigarettes a day the patient smokes, but focus more on the pattern of smoking during the day (smoking more in the first hours of waking is more significant and suggests a greater degree of dependence). Questions which would be appropriate from the candidate to the patient are: • 'How many cigarettes a day do you smoke? 1 • ‘How soon after you wake up do you have your first cigarette?' • 'Do you find it difficult not to smoke in nonsmoking areas?' • ‘Is the first cigarette of the day the hardest to give up?' • ‘'What is your pattern of smoking during the day?' • 'Do you smoke even if you are so ill that you cannot get out of bed?' • ‘Have you tried to stop smoking for good in the past but found you could not?' The patient's answers to these questions will shape the advice that the candidate then gives. A 'yes ' response to the last question suggests that the patient will need help to stop smoking. When a patient smokes 20 or more cigarettes/day and has to have the first smoke within half an hour of waking up then the patient is likely to benefit from nicotine replacement therapy (NRT) or bupropion. ADVICE ON NICOTINE WITHDRAWAL Within 24 hours of reducing or stopping nicotine intake you may experience: • depression or otherwise feeling unwell; • insomnia; • restlessness and irritability; • anxiety and difficulty concentrating; • drop in heart rate over time; • increase in appetite so that you may gain up to 3 kg over the next 12 months: • cravings for sweet things; and • cravings for cigarettes. About 5% of nicotine-dependent individuals can stop smoking unaided and less than 25% of people succeed at their first attempt to quit. Overall the successful quit rate is about 45% eventually. Withdrawal symptoms: • peak in intensity over the first four days of abstinence; • most residual symptoms improve significantly within a month; • hunger and weight gain may persist for a year or so. 116 018 Performance Guidelines KEY ISSUES • Counselling abilities. • Awareness of principles of a tobacco quitting programme. CRITICAL ERROR • Lack of awareness of the key elements of a nicotine quitting programme. COMMENTARY Principles of a tobacco cessation programme follow. Candidates should have a broad knowledge of the content, and are expected to be aware of, and incorporate most of. the following key elements into their counselling. KEY ELEMENTS OF CIGARETTE/NICOTINE WITHDRAWAL PROGRAMME The key elements of a cigarette/nicotine withdrawal programme include: • Set a definite QUIT BY date (within two weeks of making the decision to quit). • Aim for total abstinence — not just 'cutting down'. • Review previous attempts at quitting and what went wrong! • Inform family and friends, particularly other smokers, of the plan, • Avoid alcohol, which is an important trigger for smoking, and similarly review coffee intake. • Anticipate and discuss likely individual pitfalls and difficulties (for example, weight gain or depression). • Practise problem solving as a way of dealing with 'what do I do if/when'. • Encourage the use of nicotine replacement therapy unless there are contraindications (e.g. coronary artery disease or pregnancy). • Recommend starting or increasing physical activity and the importance of a balanced diet. • Schedule followup visits and supportive phone calls. NICOTINE REPLACEMENT THERAPY (NRT) The aim of nicotine replacement therapy (NRT) is mainly to ameliorate nicotine withdrawal. Neither patches nor gum give the arterial 'high' concentration of cigarettes and the overall dose of nicotine they provide is about 40% of that provided by cigarettes, but they are not accompanied by tar. carcinogens or carbon monoxide. Smokers extract about 1 mg of nicotine per cigarette independent of the brand used, although each cigarette may contain up to 14 mg of nicotine. Costs of NRT may influence patient choice, but are generally cheaper than continuing to smoke. Forms of NRT include: • NICOTINE GUM contains nicotine 2 or 4 mg per piece in a sugar-free resin base. The gum should be chewed slowly, then left between cheek and gum before being repositioned and chewed intermittently for up to 30 minutes, 10 times a day. Because nicotine is poorly absorbed from an acid environment, acid drinks such as fruit juice should be avoided. Mouth soreness or dyspepsia may occur. Lozenges are an alternative. 117 018 Performance Guidelines • TRANSDERMAL PATCHES, preferred by many patients, come in a variety of dosage strengths from 7 mg to 21 mg and in preparations designed to be used for 16 or 24 hours. They are designed to release nicotine slowly through the adhesive layer of the patch to the skin and hence into the circulation. Patches are applied each morning on a rotational basis to non-hairy skin sites. Skin reactions or rashes may be severe enough to warrant discontinuation. They are not available on the Pharmaceutical Benefits Scheme, and are used for 8-12 weeks. • NICOTINE INHALERS are less popular. Gaseous nicotine is released after deep inhalation through the mouthpiece of a plastic cartridge. About 4 mg of nicotine is released by the device which is single use only and cannot be reused or recycled, which may mean 10 or more cartridges need to be used per day for up to 6 months. All forms of NRT are effective as aids to stopping smoking. There is no reliable evidence to recommend gum over patches or inhaled, each roughly doubling the chances of successfully quitting. They may be used together but monotherapy is preferred. The initial strength of nicotine dosage will depend on severity of dependence as well as average daily intake of nicotine from cigarettes. Whilst NRT is effective by itself in achieving abstinence, behavioural support from the doctor, family and friends will increase the success rate. OTHER SMOKING CESSATION STRATEGIES AND AIDS INCLUDE: • Bupropion (slow-release — Zyban®) is an atypical antidepressant with both noradrenergic and dopaminergic activity. ~ Mechanism of action as an aid to smoking cessation is not related to its antidepressant action, but to common addiction pathways. ~ Treatment starts at 150 mg/day for the first three days and then increases to 150 mg twice daily. ~ The standard treatment period is nine weeks which is subsidised under the Pharmaceutical Benefit Scheme in Australia. Maintenance may last a further six months. ~ Nausea, insomnia and dry mouth are the commonest early side effects. - Bupropion is absolutely contraindicated in patients with a history of epilepsy: and is relatively contraindicated when there is a history of Type 1 or 2 diabetes. ~ It must not be prescribed during pregnancy. ~ Sustained-release bupropion has been shown to be efficacious in producing abstinence in cigarette smokers either with or without adjunctive psychological interventions. • Clonidine is uncommonly used to moderate withdrawal symptoms. • Nortriptyline 10 mg/day has also been trialled as an alternative to bupropion. • Pamphlets, stickers, badges and audiovisual and multimedia tapes in different languages are available through the various state health departments, which can supplement face-to-face counselling. 118 018 Performance Guidelines General Health 0109 - 2004 SMOKING Quitting smoking is one of the most important actions you can take to protect yourself from chronic disease and early death. One in two lifetime smokers will die from their addiction. Half of these deaths will occur in middle age. Quitting at any age will give major health benefits and reduce your risk of tobacco related illnesses. With planning and determination you can quit and stay a non-smoker. Health effects of smoking Tobacco smoke contains more than 4,000 chemicals, Harmful ones include: • Nicotine - is an addictive drug and can make it hard, but not impossible, to quit. It also affects vour heart rate and blood pressure. • Carbon monoxide - replaces some of the oxygen in your blood, leaving your muscles, heart and brain with less oxygen. • Tar - contains many cancer causing chemicals. Lower tar or 'light' cigarettes are not any better as you are likely to take deeper putts, more often, to get the amount of nicotine you need. Smoking increases the risk of cancer, heart disease, stroke and lung disease. It affects fertility levels in men and women and can lead to impotency in men, and miscarriage and complications in pregnancy and labour. Smoking affects your immune system and is ■ cause of many other conditions such as blindness and osteoporosis. Harm to others Environmental tobacco smoke comes from both the burning end of a cigarette and from the smoke breathed out by a smoker. This harms not just the jjf smoker, but also family members and coworkers. Passive smoking causes heart disease and lung cancer in non-smokers living with smokers. Pharmacy Serf Care is a program Children exposed to passive smoking are more likely to suffer from health problems including asthma, meningococcal disease, coughs and chest infections. Smoking by the mother is a major risk factor for sudden infant death syndrome (SIDS or 'cot death). Do you know why you want to stop smoking? It's important to be clear about your reasons. These are some of the best reasons to quit. You will: • Breathe, and taste and smell food better within weeks • Improve vour circulation, immune system and the health of your heart and lungs • Have fewer days of illness and fewer health complaints than continuing smokers • Provide a positive example for children and others • Save money, a minimum of $2300 per year for a pack a day habit. Before you quit Chemicals in cigarettes change the way some medications work. We know that stopping smoking can be Ï stressful. So if vou have suffered from depression, anxiety or other mental illness, and/or are taking medication, speak to your doctor before quitting. of the Pharmaceutical Society of Australia CONDITION 018. FIGURE 1. Smoking cessation pamphlet 119 018 Performance CONDITION 018. FIGURE 2. Examples of some nicotine replacement therapies (NRT) available Guidelines 120 019 Performance Guidelines Condition 019 Excessive alcohol consumption in a 45-year-old man AIMS OF STATION To assess the candidate's knowledge of hazardous drinking, including early presentation, sequelae, types of dependency, and skill in counselling a person who has been drinking hazardously over a long period of time. The examiner will have instructed the patient as follows: You are a 45-year-old businessman who has become concerned about the harmful effects of alcohol. You have been a regular, now daily, drinker for many years, but you considered yourself to be an 'average drinker' for your personal situation in life. You consulted this doctor two days ago. The doctor enquired about your use of alcohol and other concerns at length, and then examined you. The doctor said your use of alcohol was of concern and asked you to have some blood tests. You have returned today to discuss the results. You should be rather passive, exhibiting acceptance of the doctor's advice, while showing a contemplative demeanour that suggests that you may not have made up your mind about modifying or stopping your alcohol intake. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate's approach to the patient should be nonjudgmental and supportive. The candidate should: • Explain test results and their interpretation ~ The elevated Gamma glutamyl transaminase (GGT) and Aspartate transaminase (AST), elevated mean corpuscular volume (MCV) and macrocytosis should confirm the candidate's clinical suspicion of liver disease due to excessive harmful drinking. - The candidate should make this clinical suspicion clear to the patient and explain that excessive drinking is also linked with his hypertension and excessive weight. • Discuss the effects of excessive drinking in counselling and educating the patient ~ Other physical sequelae on gastrointestinal tract, cardiovascular system and central nervous system. ~ Family problems, work problems, sexual problem, minor accidents, as revealed from the history obtained at the previous consultation. Be complimentary about patient's initiative to consult about his drinking (this is positive and helps probability of compliance). 121 019 Performance Guidelines • The 'CAGE' or 'AUDIT' questionnaires could be applied during this discussion, or during counselling: ~ Cutting down on your drinking?: Annoyed by criticism of drinking?; Guilty about your drinking?; Eye opener needed in the morning? ~ Alcohol Use Disorders /dentification Test. • 1 Counsel the patient about safe drinking using National Health and Medical Research Council (NHMRC) Guidelines for men: ~ low risk: less than 4 standard drinks per day; ~ hazardous: 5-6 standard drinks per day; and ~ harmful (high risk): more than 6 standard drinks per day. • Counsel the patient that the test results show that his drinking level is above safe drinking levels: ~ A 'standard drink' contains approximately 10 grams of alcohol. When conventional glasses/containers are used, the volume of each drink reduces as the strength increases. Adjustments must be made for the different strengths of beer because cans/bottles are the same size. ~ The test results show that he is demonstrating clearly harmful and progressive effects of excessive drinking. • Explain types of dependency: ~ Social (applies to this patient); ~ Psychological (may apply to this patient); ~ Physical (probably applies to this patient). • Discuss the significance of amount and duration of alcohol use in determining risk oi physical dependency. Hallmarks of physical dependency include: ~ increasing alcohol tolerance (which decreases in later stages); ~ withdrawal symptoms (tremor, sweating, hyperarousal through to delirium tremens); and ~relief from withdrawal (benzodiazepine). symptoms by further alcohol consumption, or agonist • Discuss the social, behavioural, emotional and cognitive sequelae of excessive alcohol use in family, work, social and individual settings. • Explain that excessive habitual consumption/dependence can be associated with target organ damage without psychological or social disorders and vice versa. • As initial management, advise a period of abstinence to test presence and/or degree of physical dependency. Indicate availability to assess and treat any symptoms which may arise such as tremor, sweating, excitability and craving. • As followup management, the candidate should: ~ suggest further consultation shortly; ~ offer to see wife; 1Curtin: Research Centres: University Research Institutes: National Drug Research Institute. Screening for I I hazardous alcohol use and dependence in psychiatric in-patients using the AUDIT questionnaire, Hulse. G.K., Saunders. J.B., Roydhouse, R.M., Stockwell, T.R. and Basso, M.R., 2000. http://espace.list.curtin.edu.au/archive/00000076/ 122 019 Performance Guidelines Self Help 0506-2004 ALCOHOL Alcohol can interact with some medications and certain medical conditions can be made worse bv drinking alcohol. In Australia, alcohol problems affect the health and well being of many individuals, families and communities. Many people drink in ways that put themselves at risk of alcohol‐related harm. The Australian Alcohol Guidelines recommend levels for low‐risk drinking. How much is too much? • Drinking at risky or high‐risk levels means drinking many drinks in one day. You do not need to do this regularly to cause harm. • Hxcessive alcohol consumption can cause health problems in the longer term. You do not need to get drunk tor this to cause harm. Who are the Guidelines for? The Guidelines indicate the low‐risk drinking levels for the general population. They are for people who are not on medications, do not have medical conditions that are made worse by drinking, and are not elderly, pregnant or breastfeeding. If you weigh less than 60 kg for men or 50 kg for women, or are about to drive or operate machinery, the levels recommended in the guideline for the general population should be reduced. drinks in any one day Number of alcohol‐free days per week 1‐2 1‐2 What is a standard drink? The pictures below show the number of standard drinks found in typical serving containers. Be careful ‐ glasses of wine and spirits can vary widely in size and alcohol content. 375ml full strength beer 180ml average restaurant serve of wine What do the Australian Alcohol Guidelines recommend? People who drink regularly (almost daily), more than eight standard drinks a day, should see their doctor before attempting to change their drinking habits. Average number of drinks per day Men 4 or less Women 2 or less Maximum number of drinks per week Maximum number of Australia 28 14 6 4 1.8 .Wml spirit nip I 300ml alcoholic soda 1.2 Check the label All alcoholic beverages have the number of standard drinks in the container on the label. Use this to calculate the number of standard drinks. Pharmacy Serf Care is a program of the Pharmaceutical Society of CONDITION 019. FIGURE 1. Alcohol ingestion guidelines 1 019 Performance Guidelines ~ mention availability of Alcoholics Anonymous. Weight reduction and control of hypertension will need to be undertaken but cannot be successful unless use of alcohol is modified; and ~ make clear to the patient that he has to come to his own decision about what to do, but that he can expect ongoing support in followup. The above points serve as guidelines only. The content, order and emphasis offered by the candidate will vary and examiners will need to give a global assessment of the candidates interpretation of the test results and counselling skills with regard to hazardous drinking. • Interpretation of results of liver function tests (LFTs) and full blood examination (FBE). • Explanation of effects of hazardous and harmful drinking. • Advising a period of abstinence to establish type and degree of dependency. • Taking a judgmental attitude and blaming patient for his condition As well as knowledge of hazardous drinking, this case allows assessment of the candidate's communication skills and knowledge of counselling as the principal form of management in a behavioural problem, in which the type of dependency is uncertain at this stage. The patient is likely to have true physical dependency; the next step in management is to test this assumption by asking the patient to try abstinence and see what happens. Subsequent management will depend on the result and the willingness of the patient to accept and control the type and degree of dependency on alcohol. 124 020 Performance Guidelines Condition 020 Type 1 diabetes mellitus in a 9-year-old boy AIMS OF STATION To assess the candidate's knowledge of practical aspects of childhood diabetic care — which is not very dissimilar to adult Type 1 diabetic care — and the candidate's ability to answer queries of a concerned parent. The questions chosen are similar to those asked by parents who are anticipating the problems that they may encounter in the months after initial diabetic education and discharge from hospital EXAMINER INSTRUCTIONS The examiner will have instructed the mother as follows: As many candidates have a tendency to refer any question they are uncertain of to a higher authority (for example, their registrar or consultant), you should not accept that answer, but ask what sort of things the consultant is likely to say about that question. Each question asked by the parent requires an answer from the candidate so that examiners should keep a close watch on the time, and indicate to the parent to move to the next question if the candidate is either spending too much time on detailed information, or does not provide the appropriate explanation. This will ensure that the candidate has the opportunity to cover all of the questions in the allotted time. Satisfactory candidates will answer each of the following questions asked and cover most of the following points. Questions to be asked by the mother (in this order) Opening Statement 'Will he need insulin injections each day from now on?' If the candidate indicates (correctly) that the child will require daily insulin, ask how often and then ask 'Who is going to be giving Roger's insulin from now on?' ‘How do I assess the day to day control of his diabetes?' 'What do I need to do about his school?' 'Will he be able to go to school camps? What should I do about them?' ‘He went to his first sleepover party a few weeks ago — could he still go on these now?' 'Can he play sport?' The above questions are designed not only to test the candidate's knowledge but ability to reassure the parent that with appropriate tuition, she will be confident in handling her child's diabetes and in teaching other people with whom he will be in contact to understand and manage his diabetes. 125 020 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Opening statement/Need for insulin injections? The candidate should indicate that the child will be on life-long injections of insulin and should go on to describe that this is usually in a regimen of twice daily insulin injections consisting of a combination of a short-acting insulin and an intermediate-acting insulin to allow for a 24-hour cover. At this age it is usually inappropriate for children to be on basal/bolus insulin regimen. This is best left until teenage and when the child is ready to accept four injections per day. Q 2 Who injects? The candidate should advise that both parents if available, and perhaps an older sibling, should learn the injection technique in case of parental sickness or absence. Similarly they should understand how and when to give glucagon. Candidates should indicate that the Paediatric Unit staff and educators will ensure that parents are confident of drawing up and administering insulin before discharge, and if necessary will arrange help at home from the District Nursing Service after discharge. Q 3 Monitoring? The candidate should indicate that blood sugar levels are monitored several times daily by a glucometer (illustrated), the details of which will be shown to the parent. These levels are usually assessed before each meal and before bed at night. This allows the clinician and the parent, when confident, to be able to review the blood sugar levels and to recognise if an adjustment in the insulin dosage is required. This is usually adjusted based on a trend over several days rather than on a day-to-day basis. The doctor should also indicate that urine testing for ketones should also be done if the blood sugar levels are persistently high, or if the child is unwell for any reason. CONDITION 020. FIGURE 1. Glucometer kit for blood glucose monitoring 126 020 Performance Guidelines 0 4 School liaison? The candidate should advise that the parent should notify Roger's school of his diagnosis and indicate that the school will probably be visited soon after the child's discharge from hospital by the Ward diabetic educator in association with the parent to instruct the relevant school staff as to the important features related to possible complications at school (the most likely one being hypoglycaemia and how to detect and manage it). The parent will also be advised to take every opportunity to review these important aspects of care with the school staff and to ensure that any new staff are made aware of the child's condition. Similarly the school should be given phone numbers to ensure that the parents, the child's general practitioner and if necessary the Hospital/Children's Ward can be contacted in an emergency. In an emergency most schools will contact the Ambulance service who will be capable of managing the situation on arrival. Q 5 School Camps? Management at school camps may vary often depending on the age of the child. With young children, parents are often encouraged to attend as camp parents and this would be appropriate for this family if one or other parent is able to do so. Management is related to the confidence and experience of the teachers involved and how comfortable the parents are with the teacher's knowledge. The Paediatric Unit, in conjunction with the parent will support the teachers by education and telephone support. Many camps for young children are held relatively close to the school district. If the camp is in a distant town, supervising teachers with good clinical acumen are a prerequisite, but a letter should be supplied to a local medical practitioner explaining the child's diagnosis and providing details of the insulin regimen, blood sugar levels and telephone contacts. Some school camps have permanent staff who have children attend with a variety of medical conditions (for example, epilepsy and diabetes), and these staff are given special detailed instructions as to the complications and management of these conditions. The parent should be encouraged to enquire as to the knowledge of the staff involved. The parent should be advised that the aim of the treatment and education program is to allow the child to live as normal a life as possible and Roger should be encouraged to participate in all the school activities. This usually is possible; but the parent should be satisfied that the personnel involved are cognisant with the treatment for the child. Q 6 Sleepovers? These should also be encouraged for reasons previously discussed. Sleepovers should usually be at the home of a family who know the child and parents well; so that there can be a frank informative discussion on the child's management, which is highly likely to be known to the host family. Similarly, this should usually be at a home close to the child's home so that if necessary the child's parent may be able to call over and do the blood test as well as give the insulin in the evening and next morning, until the child is old enough and reliable enough to do these by himself. Q 7 Sport? The parent should be assured that there is no reason why the child cannot play most sports. He will be excluded from some activities (for example, piloting an aeroplane). A good candidate will mention that insulin doses may need to be adjusted prior to active sport to allow for the increased glucose metabolism associated with physical activity. 127 020 Performance Guidelines The candidate should be able to counsel the parent in a reassuring manner that parents will not be left entirely on their own in the management of their child, and that help is but a phone call away. Most candidates should be able to handle this discussion with ease and confidence by applying general principles in their discussion and this should comprise part of the overall assessment of the candidate. Most of the detail for this case is provided in the examiner's instructions. Much of the advice to be given is • Ability to answer the specific questions of the parent accurately and sensibly CRITICAL ERROR • Failure to discuss symptoms and treatment of insulin-induced hypoglycaemia common sense in relation to the ongoing care of a person with diabetes and should not be a problem to the competent candidate. The scenario is designed to assess both the knowledge of the topic and the candidate's ability to provide accurate information in a reassuring manner to a parent who is trying to cope with a diagnosis, which to most parents is initially devastating and upsetting. The emphasis in many of the answers should be allowing the child to lead as normal a life as possible, so that school and social activities should be maintained wherever possible. Under most circumstances this can be achieved. The key to success in these situations is whether parents are well educated in their child's condition and can confidently instruct others accurately in the management of the child. Families who achieve this are generally very successful in managing their child's diabetes confidently and appropriately; and the child is generally able to progress satisfactorily through childhood with minimal restriction, if any, in lifestyle. 128 021 Performance Guidelines Condition 021 Request for vasectomy from a 36-year-old man AIMS OF STATION To assess the candidate's ability to explain the surgical procedure of vasectomy, its complications, effectiveness, reversibility and effects on sexual performance. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Your wife aged 34 years, who works as a secretary, wishes to cease oral contraception because of weight gain. She has taken 'the pill' since the birth of your son now aged seven years. You also have a daughter aged nine years. Your wife would prefer not to have a tubal ligation. You are happily married with a mutually satisfactory sexual relationship and neither of you wishes to have another child. You have no extramarital relationships. You want a-vasectomy but have reservations about the operation because of possible complications, reliability, absence from work, and any adverse effect on your sexual performance. Questions to ask unless already covered (the candidate's expected responses are in brackets): • ‘Is it 100% effective?' (No, recanalisation of vas can occur rarely). • ‘How do you know it has worked?' (Semen analysis showing no spermatozoa after 20 or so ejaculations, test repeated on at least two occasions). • ‘Can the operation be reversed?' (Reversal requires microsurgery, success uncertain. Because sperm antibodies can occur, and these reduce fertility, even if the tubes can be connected satisfactorily, success is not 100%). • 'Are there any complications?' (Wound infection, temporary discomfort, bruising, and haematoma). • ‘Will there by any change in my sexual performance?' (No. not after recovery from operation). • 'How long afterwards can we resume normal sex?' (As soon as you are comfortable. A condom must be used until the result of the postoperative sperm count is known; or wife should continue to use the pill until the sperm count is clear). • ‘Does my wife have to sign anything^' (Preferable if both provide written permission). • ‘What is actually done?' (Description of identification and division of vas). • ‘Will my wife notice any difference?' { N o ) . • ‘What happens to the semen?' (Semen ejaculated but no sperm). • 'Can it be done as a day procedure?' (Yes). • 'Will I have a general anaesthetic?' (General or local used with sedation). 129 021 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • Give reassurance about result of checkup (good health). • Be supportive and give honest advice about the procedure. • Provide information in a clear and concise manner. • Deal with patient uncertainties. Explanation of the procedure • Surgical procedure of vasectomy — how it is done. • Inconvenience and complications. • Postoperative sperm counts. • Effectiveness and reversibility — although reversal is sometimes possible, vasectomy should effectively be regarded as a method of permanent sterilisation. • Timing and effect on sexual activity/performance. • Use of diagram, patient education material (e.g. Royal Australasian College of Surgeons patient information brochure). Counselling • Recommend involvement of patient's wife — offer to discuss procedure with her. • Advise that she should preferably also give written permission. • Discussion of alternatives, (i.e. condom or diaphragm with spermicidal). • Clarification that they need to use contraception until seminal analysis is negative. • Adequate explanation to the patient of the procedure and its followup. • False reassurance that the procedure is 100% effective before at least two negative sperm counts. • False reassurance that a vasectomy is easily reversed. • Refusal to discuss sterilisation. Appropriate consent for vasectomy is required. Permission of the patient's wife is not obligatory but is strongly advised by medical defence organisations. The candidate may have religious or cultural objections to contraception in general or vasectomy in particular. If so. candidates have been advised to inform the patient of their position at the beginning of the consultation. However, medical knowledge of the procedure is still expected together with the communication skills required in explanation. This recognises the patient's right to seek the procedure and the doctor's right not to remain nvolved beyond this consultation, but to suggest appropriate referral after initial discussion. 130 1-B: Case Presentations to Examiner Vernon C Marshall 'Begin with an arresting sentence; close with a strong summary; in between speak simply, clearly and always to the point; and above all be brief.' William J Mayo (1861-1939) American physician Case Presentation and Discharge Summary scenarios 022-029 02 2 02 3 02 4 02 5 02 6 02 7 02 8 02 9 Headache Neck lump Previous shoulder dislocation Dysphagia Low back pain Knee pain Abdominal discomfort Gastric ulcer with haemorrhage Verbal Case presentation to an observing examiner or senior colleague is a fundamental part of clinical medicine. It may consist of an informal exchange of information between colleagues on a ward round or it may be a more formal presentation to an examiner or to a group in examination circumstances. Whatever the circumstances, it is essential that the listener's interest and attention are kept and that information is clearly accurately and sensitively transmitted. 131 1-B Case Presentations to Examiner CONDITION 022 CASE PRESENTATIONS A number of AMC MCAT communications with examiners will involve answering questions or prompts asked by the examiner to clarify points of diagnosis or management. These usually require brief and succinct candidate answers. Example 022 Examiner: What do you believe is the most likely diagnosis from the information you have found so far?' Candidate: 'Tension headaches. ' Examiner: 'Are any alternative diagnoses likely?' Candidate: ‘I think the clinical presentation fits tension headaches rather than migraine. I don't think a serious cause like temporal arteritis or raised intracranial pressure is likely.’ Examiner: 'Please now advise your patient of the likely diagnosis and your management plans.’ In most of these multiple short assessments your oral presentation to the observing examiner will be necessarily brief, with most of your communication interchange being with the standardised patient. However, practice in delivering summarised case presentations to an observing examiner (as could occur in an extended or composite station) is well worthwhile as an aid to improving your communication skills, and to organising and presenting clinical reasoning skills in data acquisition, assimilation and interpretation, to best effect and in a logical manner. You may find it easiest to do this along disease-centred diagnosis approaches by succinctly summarising history, examination findings, diagnostic and investigational plans and management — separately or sequentially. Alternatively, a biopsychosocial approach, centred on the individual patient's presenting condition and problem and the demographic and psychosocial environment, may be preferred. Verbal Case presentation to an observing examiner or senior colleague is a fundamental part of clinical medicine. It may consist of an informal exchange of information between colleagues on a ward round, or it may be a more formal presentation to an examiner or to a group in examination circumstances. If the patient is also present and listening, the presentation needs to be given in such a way as not to upset the patient. Whatever the circumstances, it is essential that the listener's interest and attention are kept and that information is clearly, accurately and sensitively transmitted. Relevant data should be given in a systematic and concise form highlighting the presenting problem, and evolving into a coherent whole. To summarise a patient's problem fully, begin with patient identification (age is essential) and reason for presentation. Proceed to a narrative, which may sequentially summarise examination findings, investigation findings, systems review, risk factors, and diagnostic and treatment plans; or may be confined to one of these domains, depending on circumstances. If asked to describe what task you are doing as you proceed (such as performing a physical examination), make sure you both describe and perform. 132 1-B Case Presentations to Examiner CONDITIONS 023-027 Example 023 Candidate: 'The patient has a lump in the right anterior triangle of the midneck which feels like a lymph node enlargement. I shall proceed to examine the skin of face and scalp, the oropharynx and nasopharynx, and the external ear for any primary pathology'. Then go ahead and do what you said you will do. One of the most common errors is failing to observe appropriately. 7 am now looking for muscle wasting. Next I shall test reflexes and power... 'and missing the obvious muscle atrophy which is present, by not actually looking. Example 024 Candidate: (To the examiner) 'The patient has had a past history of dislocated shoulder of his dominant right arm and my task is to assess the current status. I shall begin by inspection of contour looking in particular for wasting or deformity None is apparent (make sure you have looked). / shall now test the range of active movements, comparing these to the opposite normal side. ' (To the patient) 'Please face me and move your arms as I do'. Example 025 Examiner: 'What is your provisional diagnosis?' Candidate: 'The patient is aged 60 years and has a history of progressive painless dysphagia for the past 6 months associated with weight loss. I think the most likely diagnosis is an oesophageal lesion, probably a neoplasm. You have informed me that physical findings are noncontributory in the chest, neck and abdomen. He needs further investigation by diagnostic imaging or endoscopy. I shall explain this to him and arrange appropriate referral and followup... '. Examiner: 'Which of the two investigations would you choose?' Candidate: 'Endoscopy usually is most definitive. Preliminary contrast imaging may help by identifying the site of a stricture and can show extralumenal aspects like extrinsic compression, so I shall order a contrast swallow now as well as arranging consultation for an endoscopy'. Examiner 'Please now advise the patient of your recommendations'. : Example 026 Examiner: Please summarise your history and findings and your provisional diagnosis ' Candidate: 'The patient is aged 25 years and has had low back pain with sciatic radiation after a lifting strain at work two weeks ago. He has painful limitation of back movements and symptoms and signs suggesting lower lumbar nerve root impingement. I believe the most likely diagnosis is a lumbar disc prolapse with L5 radiculopathy'. Example 027 Examiner: Please summarise your findings on physical examination so far'. Candidate: 7 was asked to examine the right knee area in this young man with a past history of twisting strain to his knee and persisting pain on its inner side. He walks with a painful limp favouring the right leg. He finds it difficult to bear weight on that side, and painful to kneel or squat'. 133 1-B Case Presentations to Examiner CONDITION 028 He cannot fully extend the right knee, the deficiency is 15°. and flexion range is normal. I cannot detect any joint effusion, and there is no local swelling. Joint stability is stable testing the collateral ligaments and cruciate ligaments. Patellofemoral mobility and tracking appears normal; patellofemoral friction is not painful. He has localised tenderness over the joint line anteriorly on its inner side. There is no muscle wasting. The other knee appears normal'. Examiner: What is your provisional diagnosis?' Candidate: 'Injury to the medial intraarticular cartilage'. Example 028 Examiner: 'Please summarise the history you have obtained so far and your provisional diagnosis from the history'. Candidate: 'Mrs S is a 65-year-old widowed pensioner with a number of problems. 'She has a recent history of increasing abdominal discomfort and bloating related to meals over the past four weeks, with episodes of greater discomfort which have woken her from sleep intermittently. The pain is epigastric and diffuse without radiation. She has occasional reflux of bitter fluid, she has not vomited nor passed blood. She gets some relief from a glass of milk. She neither smokes nor drinks alcohol. 'She has a number of relevant associated problems. 'She has had rheumatoid arthritis, affecting predominantly the hands, for 15 years and has been treated with anti-inflammatory agents and steroids and has required periodic increased steroid dosage for exacerbations. She is currently on 5 mg prednisolone and Celebrex®. Type 2 Diabetes: Non-insulin dependent diabetes mellitus was diagnosed 5 years ago. She is on diet and oral hypoglycaemics and blood sugar control has been good — BS 5-6 mmol/L. She has regular eye and foot and blood checks, and has been told these are all satisfactory. 'She had a myocardial infarction 10 years ago with no sequelae. She remains on low dose aspirin. 'She has hypertension which has been controlled by an ACE-inhibitor. 'She has always been overweight despite dieting. 'There is a family history of diabetes and of coronary artery disease. There is no other relevant medical past history. 'She was widowed 5 years ago She lives by herself and her three grown children live interstate. Her rheumatoid arthritis has progressively worsened and has caused increasing difficulties in activities of daily living Examiner: How would you plan to proceed?' Candidate: Her multiple medical comorbidities and problems have been mentioned and are likely to be contributory to the presenting problem. 'She has a number of risk factors for peptic ulcer disease. I believe an upper gastrointestinal endoscopy will be needed to check for peptic ulcer, gastritis or reflux oesophagitis as a cause other abdominal discomfort. Gall stones should also be excluded by ultrasound. ' The above is a good demonstration of a problem-based summary. 134 1-B Case Presentations to Examiner CONDITION 029 Scenarios requiring presentation of diagnostic case summaries to the examiner are exemplified in Conditions 65 (chest pain) and 66 (palpitations and dizziness) as well as in scenarios in other sections. In a patient whom you have been treating as an inpatient, the communication required may be a written discharge summary Example 029 Copy of Discharge Summary to local medical officer. Discharge Summary Name: Mr B, aged 66years, DOB. 16.8.1937. Hospital Record No . . . Inpatient dates: Problem number 13.2.2004-20.2.2004 Title of problem # 1 Gastric ulcer with haemorrhage ~ Haematemesis and melaena ~ Endoscopic fulguration Onset 13.2.2004 Rheumatoid arthritis 1988 # Myocardial infarction 1992 Status Active Active Inactive #1 Gastric ulcer with haemorrhage — haematemesis and melaena Mr B, a 66-year-old pensioner, has been taking anti-inflammatory drugs for rheumatoid arthritis diagnosed in 1988. His medications have been Celebrex® with intermittent steroid courses for exacerbations. At time of admission had been on prednisolone for past two weeks. He had a past history of myocardial infarction in 1992 with no sequelae. He presented with a history of having vomited blood on two occasions, and passed a tarry melaena stool earlier that day. He was haemodynamically stable on admission. Urgent endoscopy was arranged which showed a shallow gastric ulcer in the prepyloric region with a bleeding point which was fulgurated. Biopsy of the edge was performed which confirmed a benign gastric ulcer. He was begun on a proton pump inhibitor (omeprazole) and his steroids and NSAID were discontinued. He was discharged after being observed in hospital for a week without recurrence of bleeding. Prognosis is guarded in view of associated risk factors of arthritis likely to require resumption of anti-inflammatory and steroid treatment. He will require long term acid inhibition medication. #2 Rheumatoid arthritis Rheumatoid arthritis since 1988 affecting mainly the hands and wrist. Significantly disabled by pain, stiffness and deformity causing loss of function. Referred to rheumatology clinic for advice on continuing management. Medications on discharge: • Omeprazole 40 mg daily • Paracetamol tablets two q.i.d. Followup • Gastroenterology outpatients one week • Rheumatology clinic one week • Local medical officer, Dr S.B 135 136 2 Clinical Diagnosis (D) 2-A: The Diagnostic Process — History-taking and Problemsolving Reuben D Glass 'Listen to the patient, he is telling you the diagnosis.' Sir William Osier (1849-1919) History-taking usually provides the most important diagnostic evidence. Obtaining this evidence requires the communication skills previously discussed in Section 1 Clinical Communication'. Good clinicians organise knowledge so they can quickly retrieve and use relevant data, by 1 grouping knowledge into 'chunks', often groups of three items of information. In addition to recognising diseases by patterns, they recognise groups of symptoms and signs, which have value in discriminating between one disease and another, or between one group of diseases and another. The alert clinician also notes unexpected variations from a common pattern. For example, a child with fever is usually flushed. The child with an infection who is pale is unusual; the pallor may result from the circulatory insufficiency of septicaemia. Experienced clinicians gather important evidence early in a consultation. A number of cues are noted within seconds of meeting a patient. Where are we meeting? Is the patient male or female, young or old, relaxed, anxious, or When solving clinical unconscious? What else do I see? What is the opening problems, clinicians tend to sentence or two of the presenting complaint? The combination review hypotheses either by of verbal and nonverbal information, which impresses the some form of rule, by clinician when first meeting the patient, has been called the informally weighing 'dominant cue'. It is the starting point for action or information- probability, by considering the gathering, by triggering ideas from the clinician's memory. The soundness of the cause-andmost frequent error in the diagnostic process arises from faulty effect relationships of the triggering. It is important to check what the patient means by evidence, or by a comb I nation of methods. what was said. 'Framing the problem' is an art requiring practice to avoid going on a false trail. For example: a 45-year-old man, who had an appendicectomy for appendicitis two years ago now presents with symptoms of an acute small bowel obstruction. The most likely and most common cause is adhesions. In such instances spontaneous resolution often follows conservative management. The careful clinician will ensure that less common but weightier causes — external hernia or colonic malignancy, which would require corrective urgent surgery — are considered and excluded. The dominant cue may provoke urgent action by triggering a process of pattern-recognition, which is close to an end-diagnosis. This is essential in life-threatening situations. For example, if a patient presenting after a motor crash is gasping for breath and has a weak pulse with one side of his chest moving less than the other, then does he have 1 Glass, Reuben D. Diagnosis: A Brief Introduction. Oxford University Press, Australia. 1996 137 2-A The Diagnostic Process — History-taking and Problem Solving a life-threatening tension pneumothorax requiring urgent needling? Pattern-recognition is also helpful in dealing efficiently with common diseases, provided the clinician remains alert for deviations from the regular pattern. Excessive reliance on pattern-recognition may lead to failure to consider diagnostic alternatives methodically. If the dominant cue does not demand immediate action, further evidence is gathered. The clinician changes from a rapid, pattern-recognition mode of functioning, to a measured consideration of hypotheses. The first task is to elaborate details of the patient's presenting complaint and confirm that the dominant cue has been interpreted correctly. Then provisional hypotheses, which the cue suggests, are explored. Groups of observations may raise the possibility of related diseases. Problem-oriented questions probe a subject in depth when the dominant cue suggests that this is warranted, keeping in mind the likelihood of a disease, and the value of treating it. Most questioning attempts to elicit symptoms to support a diagnosis, but the absence of a feature in history or examination may be of great diagnostic value. During the diagnostic encounter, the clinician is mindful of the events that have influenced the patient's life, leading to the presentation for medical attention. Screening questions, to assess whether a problem may exist in another system or subject area, form part of a complete assessment. These questions reflect a doctor's style. In a full consultation, the background of the patient needs to be known. This involves a history of past illnesses, enquiry about other family members, their health and occupations, and interpersonal relationships. Rather than relying on question lists for system reviews, experienced clinicians choose questions that give the highest yield for the specific situation, collecting the most critical information early in the interview. They structure data, processing a limited amount of information at one time in meaningful packets. It is often helpful to summarise the events that led to the patient's presentation for medical attention, and to repeat this concisely to the patient. This helps to ensure that the clinician understands what the patient meant by what he said, For example, the patient may have said 7 seem to have peed an awful lot lately'. The clinician may summarise this as 'you have been concerned about passing large amounts of urine'; and the patient may respond lno, I don't do much, it's just I have to go often'. By repeating the information in unambiguous but nontechnical language to the patient, this clinician has avoided the traps of incorrectly mentally coding the dominant cue as 'polyuria instead of 'frequency'. On other occasions, the clinician's summary may trigger a further comment from the patient, about some important item that was not mentioned. If the situation does not require immediate action, the clinician usually develops a number of hypotheses — often three — about how the patient's symptoms might be explained. Thus abdominal pain may be due to an intra-abdominal cause, or result from referred pain due to intrathoracic or spinal causes. The data is checked to see if it explains the various hypotheses. If so, the hypothesis becomes active; otherwise it is rejected. Beginners tend to jump to conclusions too rapidly, considering one hypothesis at a time, until the evidence against it is overwhelming, only then allowing them to move to another hypothesis. Experts 3onsider a number of possibilities and rank them. This process occurs early in diagnostic :hinking. The ultimate refinement is called a 'differential diagnosis'. Early lists of hypotheses nay include some specific diagnoses (for example, 'acute appendicitis'), but are mainly ideas about disease groupings (for example, 'intra-abdominal mischief). Compiling a set Df active hypotheses often involves including some inclusive category (such as 'something 138 2-A The Diagnostic Process — History-taking and Problem Solving odd'), which serves until attention is drawn to that situation and is evaluated more fully. Thus sudden vomiting without preceding nausea is unusual and raises the possibility of intracranial disease. Diseases have a variety of forms and their manifestations often do not follow the typical textbook example. Experience provides a picture of the variations. A common strategy is to alternate between questions aimed at confirming a hypothesis, and others aimed at distinguishing it from other hypotheses. Hypotheses remain active longer if they include common situations, or if they involve 'high stakes' — that is, potentially serious diagnosis. Logically, this means that hypotheses favour readily treatable or remediable situations even if they are unlikely (though even more if they are probable). As with history-taking, clinical examination can be divided into problem-oriented and screening signs. Problem-oriented signs are best given in clusters, which relate to disease groups. Here, normal, or negative findings can also be given in some detail. Less detail is generally appropriate in the screening component of the examination. An outline of pathways of diagnostic and management planning is shown in Figure 1. When solving clinical problems, clinicians tend to review hypotheses either by some form of rule, by informally weighing probability, by considering the soundness of the cause-and-effect relationships of the evidence, or by a combination of methods. For descriptive purposes, consideration of each hypothesis may be divided into stages. To determine the probability of disease, the clinician needs an awareness of the prevalence of the disease in the population, and the usefulness of the observation. Thus stronger evidence is required for diagnosing a rare disease than for a common one. Diagnostic reasoning involves considering the value of items of information. Artificial methods can be used to analyse the process. One method is 'revising the odds'. Before an observation is made, the 'prior odds' of disease (chances of disease compared with nondisease) are expressed as a number or fraction. This is multiplied by the 'likelihood ratio' (chances of observation in disease, compared with nondisease; or 'leverage of the evidence'), to give 'revised odds'. A simpler method involves 'weighing the evidence', where the initial idea and subsequent observations are given scores which are added. Diagnostic errors arise when clinicians confuse populations with differing frequency of disease. Malaria may be the probable diagnosis of a febrile patient in a tropical area where the disease is endemic, but in a similar patient in a temperate zone, more evidence will be required to confirm that diagnosis. Hoof beats usually imply horses, not zebras — but the odds require revision in Africa. It is also important to realise that the absence of a feature does not necessarily have the same leverage or weight as its presence: the relative value of each may be completely different. Thus severe crushing central chest pain associated with pallor strongly suggests myocardial infarction, however, as this feature is absent in half of the patients with acute infarcts, the absence of the 'classical pattern' is of limited diagnostic value. Similarly, the presence of a bruit over the thyroid is diagnostic of hyperthyroidism. The absence of a bruit, however, is only weak evidence against the diagnosis. Sometimes absence of a feature — a 'normal' finding — may be of great value in differential diagnosis. For example, absence of anorexia or nausea is evidence against the diagnosis of appendicitis, though the presence of these features is of little diagnostic value. Knowledgeable candidates will highlight discriminatory 'normal' findings in problem definition, in contrast to 'normal findings' on screening. The need for action depends on the likelihood of a disease, and the value of treating it. Thus evaluating fully the possibility of a rare disease that is amenable to treatment is important, although perhaps less important if treatment is unsatisfactory. 139 2-A The Diagnostic Process — History-taking and Problem Solving Gathering clinical or laboratory information about a patient costs money — whether from doctor or patient time, inconvenience, or equipment. While information must be complete for the purpose of deciding management, it needs to be obtained efficiently. In deciding on patient management, two threshold levels of likelihood of disease are important. Below the lower level, no amount of new evidence would suggest that treatment is warranted. Above the upper threshold, no additional evidence is going to alter the treatment decision. While some redundancy of information is appropriate when there is significant doubt or risk, unnecessary investigations should be avoided. At times, they may even be misleading. For example, if acute appendicitis is confidently diagnosed on clinical evidence, a normal leucocyte count should not be taken as a contraindication for surgery. Pathways in the diagnostic process are summarised in Figure 1. Examination candidates should recognise that questions have been designed to test skills in different aspects of the diagnostic process, generally using role playing patients. Candidates should read and follow instructions carefully. On occasions, they may be asked to elaborate on a patient's history; on others, to examine a particular organ or system or region. Other scenarios may give all relevant information, requiring a candidate to deduce the diagnosis, or differential diagnostic possibilities, and explain the management to the patient. In all cases, the ability to achieve rapport with the patient is expected. Reuben D Glass 140 2-A The Diagnostic Process — History-taking and Problem Solving SECTION 2-A. FIGURE 1. Pathways in the diagnostic process. In practice, the clinician uses all these methods. Examination scenarios are often designed to test one component of the process. Arrange follow up if required □ Pattern recognition. Rapid diagnostic pathway, essential for urgent solutions. Recognition of a typical pattern may be used for common problems. □ Problem-oriented diagnosis generating and evaluating hypothesis. □ A full systematic enquiry is needed for complete patient care. 141 2-A The Diagnostic Process — History-taking and Problem-solving 2-A The Diagnostic Process — History-taking and Problem-solving Candidate Information and Tasks M CAT 030-043 30 Jaundice in a breastfed infant 31 A convulsion in a 14-month-old boy 32 Loud and disruptive behaviour of a 6-year-old boy 33 Tremor in a 40-year-old man 34 Headache in a 35-year-old woman 35 Lethargy in a 50-year-old woman 36 Syncope in a 52-year-old man 37 A painful penile rash in a 23-year-old man 38 Primary amenorrhoea in an 18-year-old woman 39 A skin lesion on the cheek of a 50-year-old man 40 A pigmented mole on the trunk of a 30-year-old woman 41 An itchy rash on the hands of a 19-year-old woman 42 Red painful dry hands in a 30-year-old bricklayer 43 Swelling of both ankles in a 53-year-old woman 142 030 Candidate Information and Tasks Condition 030 Jaundice in a breastfed infant CANDIDATE INFORMATION AND TASKS Baby Helen is brought to see you in a general practice setting, as her mother is concerned about her continuing jaundice. Helen is now two weeks old and was born at term by easy vaginal delivery weighing 3.7 kg. Apgar scores were 9 and 10 (at 1 and 5 minutes respectively). She became jaundiced in the neonatal period starting on day three. Investigations then revealed no blood group incompatibility, both mother and baby being group O positive and no red blood cell (including enzymes) abnormality. The infant was treated with phototherapy for two days. Since discharge from hospital at eight days of age the jaundice has persisted and the mother is concerned. Baby is feeding well from the breast. Current weight is 3.9 kg. Examination findings The baby was active and clinically normal apart from the jaundice when you saw her yesterday. You arranged investigations as set out below. The mother has now returned with the baby to discuss the results and your advice about treatment. Investigation results • Serum bilirubin ~ Conjugated: Total: 250 umol/L less than 10 umol/L • Neonatal thyroid screening normal • Urine culture sterile • Full Blood Examination (FBE) normal YOUR TASKS ARE TO: • Obtain any further necessary history you require. You should not take more than 2-3 minutes to do this. • Discuss the results of investigations with the mother. • Explain the diagnosis to her and advise about future management. The Performance Guidelines for Condition 030 can be found on page 156 143 031-032 Candidate Information and Tasks Condition 031 A convulsion in a 14-month-old boy CANDIDATE INFORMATION AND TASKS Benjamin, a 14-month-old boy, has been brought in to the hospital Emergency Department by his parent following an episode at home the previous evening. His parent explains that he had been unwell all day with a high fever (40 °C), and while he was being cuddled, he was staring and did not respond to his name. They noted that his body twitched all over for several seconds and the whole episode lasted 60 seconds. He then went off to sleep and slept for the rest of the night. Examination findings Benjamin is alert and normal neurologically. He has a low grade fever and signs of an upper j respiratory tract infection. YOUR TASKS ARE TO: • Take any further history to ascertain the most likely cause for this episode. • Explain your diagnosis and subsequent management to the child's parent. The Performance Guidelines for Condition 031 can be found on page 159 Condition 032 Loud and disruptive behaviour of a 6-year-old boy CANDIDATE INFORMATION AND TASKS You are seeing a 6-year-old boy, Jonathan, for the first time with his mother, who complains how active he is. He is in his second year at school, and his teacher has commented that he is disruptive and loud in class. YOUR TASKS ARE TO: • Take a focused history from the mother to determine the possible causes for the child's presentation. • Indicate to the mother your probable diagnosis and a brief plan of management. The Performance Guidelines for Condition 032 can be found on page 161 144 033-034 Candidate Information and Tasks Condition 033 Tremor in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 40-year-old man who is consulting you because of a tremor ('the shakes'). YOUR TASKS ARE TO: • Take a focused history about his condition. • After completing the history, discuss possible diagnoses with the patient. • The examiner will then question you about the physical findings you would check to clarify the diagnosis, and any investigations you would arrange. The Performance Guidelines for Condition 033 can be found on page 164 Condition 034 Headache in a 35-year-old woman CANDIDATE INFORMATION AND TASKS Your patient, a 35-year-old woman, is consulting you in the Emergency Department of the local hospital about headaches. You have not seen the patient before. YOUR TASKS ARE TO: • Take a focused history from the patient. • Request from the examiner the essential features of the physical examination you would look for in this patient as the next stage in diagnosis. The examiner will inform you of the results. • Tell the patient what you consider to be the most likely diagnosis and what investigations, if any, should be undertaken. The Performance Guidelines for Condition 034 can be found on page 167 145 035 Candidate Information and Tasks Condition 035 Lethargy in a 50-year-old woman CANDIDATE INFORMATION AND TASKS You are consulting in a general practice setting. Your next patient is a middle-aged widow (see Figures 1 and 2 below) who is presenting for a 'check-up'. She looks apathetic and lethargic on first impression. YOUR TASKS ARE TO: • Take a focused history. • Ask the examiner for the results you would wish to elicit on a focused physical examination. • Give your diagnosis and differential diagnosis to the examiner, and indicate what further investigations you would require. CONDITION 035. FIGURE 1. CONDITION 035. FIGURE 2 The Performance Guidelines for Condition 035 can be found on page 170 146 Candidate Information 036 and Tasks Condition 036 Syncope in a 52-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 52-year-old technician who is consulting you about recent transient loss of consciousness. YOUR TASKS ARE TO: • Take a history from the patient. • Ask the examiner for the findings of the focused physical examination you would perform. • Tell the examiner your diagnosis and the reason(s) for this. • Indicate to the patient how you would proceed in your further assessment of his condition. The Performance Guidelines for Condition 036 can be found on page 173 147 Condition 037 A painful penile rash in a 23-year-old man CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. A 23-year-old man presents with penile pain and a penile rash. YOUR TASKS ARE TO: • Take a focused history to assess the presenting problem. • Explain to the patient your provisional diagnosis and recommended management. • The penis appears as in the illustration below. CONDITION 037. FIGURE 1. The Performance Guidelines for Condition 037 can be found on page 177 148 038 Candidate Information and Tasks Condition 038 Primary amenorrhoea in an 18-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is an 18-year-old woman who is concerned because she has never had a menstrual period. YOUR TASKS ARE TO: • Take any further relevant history you require. • Ask the examiner for relevant findings you wish to ascertain on general and gynaecologic examination. • Advise the examiner of investigations you wish to order and your provisional diagnosis. • Counsel the patient appropriately. The Performance Guidelines for Condition 038 can be found on page 180 149 039 Candidate Information and Tasks Condition 039 A skin lesion on the cheek of a 50-year-old man CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. A retired 50-year-old builder presents with a skin lesion on his right cheek. YOUR TASKS ARE TO: • Assess the lesion by a focused history and physical examination. • Present your case summary and diagnosis to the examiner. • Explain to the patient your recommended management. • The lesion appears as in the illustration below. CONDITION 039. FIGURE 1. The Performance Guidelines for Condition 039 can be found on page 182 150 Candidate Information 040 and Tasks Condition 040 A pigmented mole on the trunk of a 30-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. A fair complexioned 30-year-old schoolteacher seeks advice concerning a 'mole' on her trunk. The skin lesion appears as in the illustration of her back shown below. YOUR TASKS ARE TO: • Assess the lesion by a focused history and physical examination. • Explain to the patient your diagnosis and recommended management. CONDITION 040. FIGURE The Performance Guidelines for Condition 040 can be found on page 184 151 041 Candidate Information and Tasks Condition 041 An itchy rash on the hands of a 19-year-old woman CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in a general medical outpatient clinic. A 19-year-old female computer student presents with an itchy rash on her hands. The rash has been present for about one week and appears as shown in the photograph. There are no other abnormal examination findings apart from the rash. YOUR TASKS ARE TO: • Take a further focused history. • Explain the most likely diagnosis to the patient and how this can be confirmed. • Advise the patient about treatment. CONDITION 041. FIGURE 1. The Performance Guidelines for Condition 041 can be found on page 186 152 Candidate Information 042 and Tasks Condition 042 Red painful dry hands in a 30-year-old bricklayer CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. A 30-year-old man presents with red dry hands. The rash appears as in the illustration below, and is on the front and back of both hands YOUR TASKS ARE TO: • Take a history about the presenting problem. • Explain to him your diagnosis and the possible causes of the condition. • Outline your management of the problem. CONDITION 042. FIGURE 1. The Performance Guidelines for Condition 042 can be found on page 189 153 043 Candidate Information and Tasks Condition 043 Swelling of both ankles in a 53-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. The patient you are about to see is a 53-year-old clerical worker who is consulting you about bilateral swollen ankles, as illustrated below. YOUR TASKS ARE TO: \ • Take a relevant history from the patient (you have five minutes to do this). • Tell the patient your working diagnosis as to why the ankles are swollen after concluding the history. • Describe to the examiner the essential features you would look for in physical examination to confirm your provisional diagnosis. CONDITION 043. FIGURE 1. The Performance Guidelines for Condition 043 can be found on page 191 154 2-A The Diagnostic Process — History-taking and Problem-solving 2-A The Diagnostic Process — History-taking and Problem-solving Performance Guidelines MCAT 030-043 30 Jaundice in a breastfed infant 31 A convulsion in a 14-month-old boy 32 Loud and disruptive behaviour of a 6-year-old boy 33 Tremor in a 40-year-old man 34 Headache in a 35-year-old woman 35 Lethargy in a 50-year-old woman 36 Syncope in a 52-year-old man 37 A painful penile rash in a 23-year-old man 38 Primary amenorrhoea in an 18-year-old woman 39 A skin lesion on the cheek of a 50-year-old man 40 A pigmented mole on the trunk of a 30-year-old woman 41 An itchy rash on the hands of a 19-year-old woman 42 Red painful dry hands in a 30-year-old bricklayer 43 Swelling of both ankles in a 53-year-old woman 155 030 Performance Guidelines The examiner will have instructed the parent as follows: Condition 030 Jaundice in a breastfed infant AIMS OF STATION To assess the candidate's knowledge of the causes of persisting neonatal jaundice, ability to make an appropriate diagnosis and to convey this to the patient This is your first baby. You have always intended to breastfeed, and you established breastfeeding successfully. Baby Helen has been normal in all respects since birth. She has gained weight and is having normal bowel actions — motions and urine are both normally coloured. You are a healthy, breastfeeding mother, nonsmoker, on no medication. Questions to ask unless already covered: • 'Does Helen need to go under those lights again?' • ‘Is t h e r e s o m e t h i n g w r o n g w i t h m y m i l k , s h o u l d I s t o p b r e a s t f e e d i n g ? ' • If the candidate indicates that breastfeeding should be ceased for 1-2 days to see if the jaundice decreases, ask ' W i l l t h i s a f f e c t m y c a p a c i t y t o c o n t i n u e b r e a s t f e e d i n g ? ' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise the significance of the baby's unconjugated hyperbilirubinaemia and come to the most likely diagnosis (breastmilk jaundice) without need for further investigations. Establishing that a well baby with persisting jaundice has normal-coloured urine and motions and no abnormality on examination virtually clinches the diagnosis. The candidate should explain that: • The most likely diagnosis is breast milk jaundice. • The condition is self-limiting and requires no treatment. • The diagnosis can be confirmed by suspending (not stopping) breastfeeding for 24-48 hours which will result in a fall in the serum bilirubin after which breastfeeding can be continued. This is acceptable but not necessary. • The mother should be advised to express her milk in order to maintain lactation if temporary suspension of breastfeeding is advised. • Emphasise that there is nothing wrong with her milk. No treatment is indicated and further phototherapy is not indicated. 156 030 Performance Guidelines KEY ISSUES • Establishing that urine and stools are of normal colour. • Accurate interpretation of important pathology results. • Reassurance to mother that her milk is not harmful to her baby. • Accurate explanation of the possible causes for the jaundice and logically excluding other important diagnoses. • Not appreciating the significance of predominant unconjugated hyperbilirubinaemia and insisting that the baby has biliary atresia or haemolytic disease. • Insisting that the breast milk is unsatisfactory for the baby and recommending permanent cessation of breastfeeding. Jaundice in the newborn is very common, affecting at least 50% of full term infants and a significantly higher proportion of premature infants. Generally termed physiological jaundice, this is an adaptation process to extrauterine life that takes some days to mature. Most physiological jaundice resolves by the end of the first week of life in full term infants and up to 10 days to a fortnight in preterm infants. With such a common condition, guidelines are therefore required to determine what aspects of jaundice fall outside this physiological range. There are a multitude of causes for jaundice besides physiological jaundice and all must be considered before assuming that the jaundice has a benign origin. However, jaundice generally can be considered pathological if it occurs outside the above age range or is more pronounced than expected. Usually physiological jaundice does not become obvious in full term infants until day three of life and by late day two in premature infants. Jaundice that is manifest in the first 24 hours of life usually has a pathological cause and this must be sought. The most common cause for this in our community is a haemolytic process, usually ABO incompatibility although there are several other more rare causes of haemolysis that may also present at this time (such as hereditary spherocytosis and glucose-6-phosphate dehydrogenase [G6PD] deficiency). Rh isoimmunisation is usually known prior to birth from the screening tests done on the mother during her pregnancy. The other extreme of the natural history of jaundice is prolonged jaundice, that is. jaundice that persists longer than the time when it would have been expected. There are many possible causes for prolonged jaundice which can usually be differentiated by whether the jaundice is predominantly u n c o n j u g a t e d or c o n j u g a t e d , the latter often indicating a more significant aetiology, for example, biliary atresia. 1 030 Performance Guidelines Breast milk jaundice fits into the unconjugated variety but should be considered as a diagnosis by exclusion of the other important causes of unconjugated hyperbilirubinaemia. There are, however, important clinical features that also would support this diagnosis Obviously the babies are breastfed, but are thriving and gaining weight well. Their bowel motions and urine are normal colour, a feature that must be determined when assessing these infants Physical examination, except for the jaundice, is entirely normal and important investigations to exclude other causes, for example, hypothyroidism, are normal. Breast milk jaundice is a benign condition, which requires no treatment except explanation and support. Breastfeeding should not be interrupted although some authorities indicate that the diagnosis can be confirmed by ceasing breastfeeding temporarily and demonstrating a significant fall in the bilirubin level. This is rarely necessary and tends to give the message to young mothers that their milk is harmful to their infant, which is not true. The cause is unknown, with many theories expounded in an attempt to explain this phenomenon, although it is thought to be due to a factor in breast milk that causes increased enteric absorption of bilirubin. The jaundice may persist for up to three months but over that time the baby thrives and remains well. Despite its persistence for many weeks in some infants it may disappear in just a few days in others. 158 031 Performance Guidelines Condition 031 A convulsion in a 14-month-old boy AIMS OF STATION To assess the candidate's ability to relate appropriately with the parent of a boy who had a febrile convulsion the previous evening, by taking a relevant history making and explaining the diagnosis, and advising preventive measures. The examiner will have instructed the parent as follows You are the parent of 14-month-old Benjamin who had a convulsion with generalised twitching the previous evening. You did not know what the episode was at the time but as he went off to sleep, you let him sleep and brought him in the next day to be checked. He now seems well and is back to normal, but you are concerned as to what the episode was as it frightened you when it occurred. If asked about his development, reply that all has been normal. • His birth history was normal — born at term weighing 3600 g (good Apgar birth scores). • He has been well since birth and has not been sick until last night. • There is no family history of epilepsy. • Your own younger sister had a similar episode when aged two years, but has had no further problems (this is potentially important information but should be provided only if the candidate asks). Opening statement Benjamin seems fine now that he is less feverish. ' Questions to ask if not already covered: • 'Why would he have this episode?' • If the candidate indicates that this was a febrile convulsion, then ask 'what is a febrile convulsion?' • ‘Is this epilepsy? Should he have some medicine for this?' • 'Does he need to have any tests done?' • ‘Will it occur again?' • ‘What should we do if it does occur again or when he gets a high temperature?' EXPECTATIONS OF CANDIDATE PERFORMANCE Although this boy has had a simple febrile convulsion, the candidate should question specifically to exclude any risk factors for epilepsy or recurrence, including birth history developmental history, and family history of febrile convulsions or epilepsy. The candidate should: • Indicate that this is most likely a simple febrile convulsion • Explain that a febrile convulsion is a common reaction to fever in young children — about 3% of the population have a seizure associated with fever. 159 031 Performance Guidelines • Emphasise that generally this is a benign condition. • Point out that the condition commonly runs in families. • Explain that the fever is almost always caused by a viral infection, which would usually manifest as an upper respiratory tract infection in an adult, but immature brains are susceptible to the effects of high fever. • Explain that such convulsions do not cause brain damage or subsequent epilepsy. • Give advice as to a 30% risk of recurrence especially in the first 24 hours after this episode and advise the parent what to do if it occurred again (tepid sponging and antipyretics when he is feverish). • Advise against any drug treatment (except an antipyretic), as this is unnecessary. • Reassure that this is most unlikely to be epilepsy. Only around 3% of children who have had febrile convulsions subsequently develop epilepsy, being mainly in the high risk group (positive family history of epilepsy, prolonged convulsion, a focal element, abnormal development before the seizure). • Candidate may mention the use of rectal diazepam for recurrent febrile seizures, but this should be reserved for special circumstances and its use is not without risk. KEY ISSUES • Appropriate questioning and history-taking. • Appropriate education and reassurance. • Advice on preventive measures. CRITICAL ERROR • Suggesting on the strength of this episode of a brief febrile convulsion that he has epilepsy. COMMENTARY In this scenario, the dominant cue is the recognition of the change in sensorium in this child while he has a high fever. Pattern recognition leads to the likely diagnosis and should allow the candidate to make a definitive diagnosis and be confident in the advice given to the parent. The scenario tests not only knowledge of a common condition, but also skill in being able to impart a logical explanation in language that the parent can understand without causing alarm. It also requires reassurance and confidence in the diagnosis. While epilepsy may be raised as a possibility, the clinical features at the time, the normal appearance of the child when examined and absence of risk factors, make this highly unlikely at this stage. The candidate should therefore recognise this as a simple febrile convulsion with an excellent prognosis. A simple febrile convulsion is a common condition and candidates must be aware of risk factors that would suggest an alternative diagnosis of epilepsy should be considered: prolonged convulsion lasting greater than 15 minutes; a focal element to the seizure; a family history of epilepsy; or abnormal neurological behaviour in the child prior to the seizure. Any of these features would throw doubt on the diagnosis of simple febrile convulsion. This is the process of diagnostic reasoning. None of these features is present in this child and hence the diagnosis is clearly most likely to be a simple febrile convulsion. 160 032 Performance Guidelines Condition 032 Loud and disruptive behaviour of a 6-year-old boy AIMS OF STATION To ensure that the candidate considers all other possibilities as to why Jonathan is behaving as he is, before concluding that he most likely has attention deficit hyperactivity disorder (ADHD). The candidate will therefore be assessed on ability to ask pertinent questions that confidently exclude other important diagnoses. The examiner will have instructed the parent as follows: You are the mother of Jonathan aged six years and are concerned about how active he is. Both teachers he has had in the first two years at school have commented on how disruptive he is in class. The candidate is required to take a concise history from you to try to determine the possible causes for Jonathan's behaviour. Listed below are suggested answers that you should provide in response to questions from the candidate. At six minutes, the examiner will indicate to you to ask the candidate what is the problem and how should Jonathan be managed. For ease of response, questions are grouped based on how the candidate may question you. Hyperactivity and other associated symptoms • Jonathan has always been very active from the time he walked (13 months). • Even as an infant he was a restless, irritable baby who was difficult to feed. • His sleeping pattern since birth has been very bizarre with frequent waking. • He is impulsive and often acts without thinking what the consequences might be. • He is easily frustrated and rarely plays at any particular activity for any length of time. • His teacher complains he never sits still and tends to wander around the classroom, which at times is disruptive to the rest of the class. School progress • His reading and learning are behind the level of the other children in the class. • He constantly talks loudly in class. • He tends to interrupt frequently and has great difficulty taking turns. • He has trouble keeping friends, as he is so boisterous. • His preschool teacher commented on similar behaviour. Home situation • He is the first in the family; he has a four and a half-year-old sister who already is reading, almost to the level that Jonathan has achieved. • He lives in a caring family and you have tried just about anything that anyone has suggested to help him. • The description given by the teachers is exactly as he is at home as well. • He cannot concentrate on tasks for any length of time. 161 032 Performance Guidelines • He tends to disrupt his younger sister's play. • He demands attention from you frequently, not being able to take 'no' for an answer which you are finding exhausting. • You consider your home situation to be very stable with both parents active in supporting each other and rearing the children. There are no parental interpersonal problems. Family history • His father is a plumber who struggled at school, left school as early as he could to take up his apprenticeship and who found it difficult to study at Technical College (TAFE). • Father is described by his own parents as being very similar to Jonathan at Jonathans age. • Father even now tends to leave tasks unfinished around the home. This is not a problem at work where he is supervised. • There is no family history of intellectual disabilities or deafness. • Mother was previously a secretary for a builders' supply firm. Pregnancy • You had a normal pregnancy. Jonathan's birth weight was 3600 g at term after normal labour; good Apgar scores; only mild and transient jaundice in the neonatal period. • You noticed very active movements even in utero compared to when you were pregnant with his sister. • Jonathan thrived and gained weight well, development was normal except slow in speech development compared to his younger sister. Past medical history • Physically well. • No serious illnesses (in particular no history of meningitis, encephalitis). • No history of head injury, although he appears uncoordinated and constantly seems to run into things. • You have had his hearing and vision tested and were assured both were normal (give this information ONLY if asked). When indicated by the examiner, you should ask: ‘What do you think is causing this, and what can we do about it?' EXPECTATIONS OF CANDIDATE PERFORMANCE This scenario is designed firstly to assess the candidate's ability to explore the reasons a ! child may present with hyperactivity. While it has been written to suggest ADHD, the assessment is essentially based on whether the candidate approaches the problem in a logical manner, exploring all other possibilities for the behaviour. It is not at all critical that the correct diagnosis is made, but rather that the child's history is fully explored to exclude: • Physical or congenital lesions. • Behaviour secondary to neonatal problems. • Subsequent medical or physical illnesses including significant head injury. • Reaction to unfavourable home circumstances or child rearing and family environment. • Difficulties in the child's adaptation to school. • A visual or auditory problem. 162 032 Performance Guidelines Importantly, the candidate should question as to similar behaviour in other family members (see note on father's history) In outlining briefly the probable diagnosis and plan of management, the candidate should: • Give a logical explanation as to the possible causes for Jonathan's presentation having excluded organic pathology and indicate that ADHD is a strong possibility (the diagnosis of ADHD is not essential to pass, provided history has been satisfactory). • Suggest a neurodevelopmental assessment be performed with an experienced psychologist if possible. • If hearing and vision have not been enquired about, suggest having hearing and vision assessed (can then be told this has been done and is normal). • Briefly outline the management of ADHD by behavioural modification with or without stimulant medication. • Indicate willingness to review and monitor progress in a supportive manner. • Obtaining a logical and focused history to exclude various possible causes for Jonathan's behaviour. • Showing empathy with the parent's frustration. • Having a clear approach to the management plan. CRITICAL ERROR • Coming to a premature conclusion of ADHD and recommending stimulant medication, without having explored the history for other causes. This presentation of childhood hyperactivity is common in both paediatric and general practice and skill is required to sort out the myriad of causes for the behaviour exhibited. This is done by a careful history exploring the child's past history, current developmental status, and family and school situation. Monitoring progress over several consultations may be required to give a positive diagnosis of ADHD. The great majority of children presenting in this manner have major family dynamics problems and the scenario could easily have been modified to indicate this. However the current scenario is designed to indicate that a diagnosis of ADHD is by exclusion of all the other causes for this symptom; and that stimulant medication is not the immediate treatment in this situation, a tendency for which has developed in the general community and is often the expectation of family members who have spoken with neighbours or read the lay press. The doctor is often under great pressure to prescribe these medications at first visit and this should be resisted. There are no specific tests available that make a diagnosis of ADHD. Diagnosis is made from the pattern of behaviour, which can be confirmed by psychometric testing. While behavioural modification is recommended, parents have often already arranged this prior to the consultation, and also have often tried a variety of exclusion diets that in some cases may be helpful, but overall are not. Parents should be supported to try exclusion diets if they are keen to institute them; but the practitioner should monitor progress and make a critical appraisal as to the success or otherwise of this treatment and support the parent accordingly. 163 033 Performance Guidelines Condition 033 Tremor in a 40-year-old man AIMS OF STATION To assess the candidates skill in defining a presenting symptom of tremor, making a probability diagnosis from the history and selecting with discrimination which aspects of physical examination and investigations will clarify the diagnosis. The examiner will have instructed the patient as follows: You are a 40-year-old man who has consulted a general practitioner complaining of the shakes'. The doctor will seek details of your symptoms and will ask questions about your health status, medical and social history. Opening statement 'I've got the shakes doctor. I spill my drink sometimes'. Provide the following information without prompting: ‘I have had the shakes since my early 20s. It happens when I get nervous about something, but it hasn't been a problem until recently (6-12 months). Sometimes my head shakes and often I spill my drink when I put a glass to my mouth. I feel much better after a couple of beers. Recently I heard something about Parkinson's disease which can cause the shakes, so I thought I should see a doctor'. In response to further questioning: 'It doesn't seem to bother me when I get up in the morning and doesn't stop me going to sleep. It can go away for a few days then comes back. Seems to be when I am doing something with my hands like using a knife and fork, or writing. The newspaper shakes when I am trying to read it. Sometimes I have trouble lighting a cigarette. My right hand is the worst. I don't have any stiffness and I don't have trouble moving from one position to another, nor in walking. I can control the shakes by gripping things firmly. ' • You have noted that your hands and fingers shake if you hold your arms out in front of your body. You may ask the doctor if your voice could be affected because you have noticed some shakiness in your voice, but only occasionally and of minor degree. • Shakes were first noted in your dominant right hand. Left hand is less affected and not until recently. • You have always been a tense and nervy person, stress makes the shakes worse. You like to have a 'few beers' especially at the weekends but never get 'drunk'. • Deny any other symptoms affecting the central nervous system, cardiovascular system, respiratory, gastrointestinal or urinary systems, but admit to a diminished libido and difficulty in maintaining an erection if asked directly or if the doctor provides an opportunity for you to do so. No loss of weight. • You work as a storeman. You are married with two teenage children. You smoke 10-15 cigarettes daily and drink up to five 375 mL cans of full strength beer on most days. You have had no serious illnesses or operations. 164 033 Performance Guidelines • Family history: Father died from lung cancer aged 58 years. He also used to get the 'shakes'. He was a non-drinker. Mother died of stroke aged 62 years. Her father had Parkinson disease. Your brother, sister, wife and two children all keep in good health. • You are anxious about the cause of your symptoms. You are ignorant of long term harmful effects of alcohol. If the doctor facilitates your story and maintains an open-ended approach whilst you are giving details of the shakes', continue to amplify your symptoms. If, however, the doctor controls the interview too early, by only asking questions and not listening to your story, just answer the questions asked. If asked, admit to concern about Parkinson disease because of your grandfather. The same applies to your alcohol use: be reluctant to confirm or reveal the true level of your alcohol intake. You have never been charged with exceeding .05, and have never had an injury or motor accident associated with alcohol use. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should assess the patient's tremor as follows: History (see patient instructions) By the process of listening (using an open-ended approach followed by direct questioning), to develop the two most likely diagnostic pathways: benign tremor and tremor associated with heavy drinking. Other differential diagnoses such as an anxiety state. Parkinsonism and thyrotoxicosis are much less likely from the history. Past, family and social histories should be sought. Discussion with patient after the history This may or may not be specific. It is included to assess the candidate's diagnostic approach to the patient. Knowledgeable candidates will be reassuring because of their confidence in the likelihood of a benign tremor. Questions from the examiner after six minutes with expected responses: • What are your differential diagnoses?' ~ Benign or essential tremor (familial); effects of heavy drinking: Parkinson disease: cerebellar disease; thyrotoxicosis • 'At this stage what do you consider to be the most likely diagnosis?' ~ Benign tremor or alcoholic tremor • "What are the essential physical signs you would look for in this patient?' ~ Hepatomegaly and any stigmata of chronic liver disease, cerebellar signs, increased muscle tone, tachycardia, cardiomegaly • 'What investigations would you advise assuming the physical examination to be normal?' ~ Full Blood Examination (FBE), liver function tests, possibly thyroid function tests. • Approach to patient — establishing trust and confidence by having a non-judgmental attitude, listening to patient's concerns and being reassuring. • History — comprehensive but focused, using appropriate communication skills Diagnosis must include benign tremor and alcoholic tremor. 165 033 Performance Guidelines Answer to examiner questions ~ Physical examination should include checking for hepatomegaly and stigmata of chronic liver disease, tachycardia and cerebellar signs. ~ Investigations — must advise liver function tests, but thyroid function tests not essential. CRITICAL ERRORS Failure to indicate the most likely diagnosis is essential tremor. Failure to advise liver function tests. COMMENTARY Essential tremor is one of the most common neurological disorders, with prevalence increasing with age. An autosomal dominant family history is present in 50-60% of patients and the genetic basis is unknown. Functional imaging reveals abnormal cerebellar activity and no histological or structural changes have been identified. Age of onset is bimodal. with the largest peak in the second decade, and a smaller peak in the fifth decade. The characteristic finding is a postural and kinetic tremor of the upper limbs which interferes with fine manual tasks. Head tremor is also present in 40%. Less commonly legs are involved or there is voice tremulousness. With advancing age, the tremor frequency often slows and amplitude increases, leading to a coarse tremor which can be disabling, although this is uncommon. Patients with benign essential tremor often drink as a means of controlling the tremor as alcohol has an ameliorating effect in 50% of cases. In this case, the patient may also be suffering from the effects of prolonged heavy drinking. This would require further assessment with the investigations recommended above. 166 034 Performance Guidelines Condition 034 Headache in a 35-year-old woman AIMS OF STATION To assess the candidate's communication skills in defining the nature of the patient's headache. In addition, knowledge of types and causes of headache and the essential components of an appropriately focused physical examination are tested. Examiner Instructions The examiner will have instructed the patient as follows: You are consulting the doctor about headaches. You are aged 35 years and work as a telecommunications manager. You have not seen this doctor before. Use the following information to respond to the doctor's enquiries. Opening Statement ’I want to find out what is causing my headaches.' History without prompting: You have been suffering from intermittent headaches for at least five years, attacks occurring irregularly every few months, lasting for a few days. They are temporarily relieved by Panadol®, up to six a day at a maximum. You have not previously sought advice. You are concerned because in the past few months, the headaches have occurred more often, that is, every few days, and now last longer, for most of the day. In response to questioning: • The headache has not increased in intensity — only in frequency and duration. • It feels like a tight band or pressure around or on top of your head, or a dull ache, not pulsating. • It affects the forehead and both the temples and radiates to the back of the head. • It usually starts in the morning and lasts all day, getting worse by evening, not interfering with sleep. • The pain reduces after taking Panadol®, after your evening meal, and with rest and local heat. • On a scale from 1 to 10, the headache pain rates about 3 to 4. • Headaches are not accompanied by nausea, vomiting, visual disturbance, photophobia, or associated with menstrual cycle. • They are not related to posture, exercise or position of head or neck. • You can continue to work and to do household duties during attacks. You have lost no time from work. Review of General Health • You consider your general health to be satisfactory. • You do not often seek medical advice. • You do not regard yourself as a 'nervous' type and have not noticed any change in your usual mood. • Your marriage and family life is satisfactory. 167 034 Performance Guidelines • Negative response to questions about all body systems except as already stated. • Menstrual cycle normal. Other Significant Information You are very busy, rush through work, domestic and family duties, and have less relaxation time now. You are a perfectionist by nature and are finding it more difficult to cope with all of the activities of your growing family. You have a dual income and no financial problems. You recently saw a TV documentary about a person who had a cerebral tumour. Current medication — Panadol® (paracetamol) 500 mg 1-2 tablets to relieve headache taken not more than three times daily. No known drug sensitivities. Nonsmoker. Alcohol is used occasionally at weekends. Appear worried and tense and display concern. You had previously been complacent about the headache. You are now seriously worried about having a cerebral tumour. Indicate the site of the headache (forehead, temples, and occiput). Be prepared to be reassured by the doctor if history and physical examination are adequate. If not, press the doctor to have tests or be referred to a specialist. Note that you are also at a peak in your family responsibilities. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should assess the patient's headache along the following lines: History (see patient responses) • Characteristics of headaches, including assessment of severity. • Recent change in chronic condition. • Identify acute patient concern that a serious cause may be present (cerebral tumour). • Recognition of typical characteristics of tension headache. • Identification of relevant psychosocial and environment factors (lifestyle stress) Essential features which candidates should look for on physical examination (supplied from examiner on request) • Inspection of head and neck and testing for neck stiffness. • Neurological examination may be limited but must include ophthalmoscopy. • Cardiovascular examination must include blood pressure. THE EXAMINER SHOULD INFORM THE CANDIDATE THAT NO ABNORMALITIES ARE FOUND ON PHYSICAL EXAMINATION. Communication skills • Use of facilitation, active listening and relevant enquiry, to fully define the nature of the headache and its associations; • Communicate understanding and concern that there is a recent change in a chronic problem; and • facilitate disclosure of relevant psychosocial history and worry about brain tumour. Diagnosis/Differential Diagnosis • Tension headache (muscle contraction headache) is the most likely diagnosis. Other diagnostic possibilities include: ~ Migraine. 168 034 Performance Guidelines ~ Cluster headache. ~ Raised intracranial pressure (excluded by history typical of tension headache and negative examination findings). ~ Cervical spondylosis. Patient counselling • Headache is of muscle contraction type due to tension and associated with personality and daily pressures of work and family life. No special investigations are indicated at this stage. Referral to neurologist for opinion is acceptable. Reassurance should be strongly given with offer to follow up results of this first contact with the doctor. • Investigations are not indicated. • Discussion and education about the role and function of investigations is indicated. • Referral for computed tomography (CT) brain or magnetic resonance imaging (MRI) would detract from overall performance but is not a key issue especially if a patient requires additional reassurance that the headache is not due to a cerebral tumour. X-ray skull is not indicated. KEY ISSUES • Use of communication skills to elicit the most relevant and important points in the history. • Focused physical examination in a patient complaining of longstanding headache. • Confidence in diagnosis of tension headache based on typical history, normal physical examination, patient concern about a serious cause and lifestyle factors. • Recourse to investigations (CT or MRI) unnecessary at this stage but allowable to diminish patient concern. • Arrange followup to assess therapeutic effect of this initial assessment. CRITICAL ERRORS • Failure to request blood pressure and ophthalmoscopy findings. • Failure to indicate the most likely cause is tension headache and that a serious cause is most unlikely. COMMENTARY This case is deliberately set in a hospital Emergency Department where the time constraint matches the eight minutes allowed for the candidate to complete the focused tasks set. The candidate who takes immediate control over the interview by asking a series of direct questions about site, duration, intensity etc. may successfully reach the diagnosis of tension headache, but is likely to overlook the patient's recent concern about a serious cause and miss the real cause (lifestyle factors) with two consequences: • referral for unnecessary investigations which also increases the patients anxiety about a serious cause; and • missing the opportunity to convert the diagnostic approach into the appropriate therapy by improving self understanding by the patient. The initial response from the candidate should be to facilitate the history given by the patient with an open-ended approach, listening, and encouraging the patient to tell the whole story including concerns and life situation. 169 035 Performance Guidelines Condition 035 Lethargy in a 50-year-old woman AIMS OF STATION To assess the candidate's history-taking skills and diagnostic acumen in a patient with the symptoms and signs of hypothyroidism. The case is deliberately presented as an undifferentiated problem but the patient's initial unprompted statements should lead to the correct diagnostic pathway with confirmation of suspected hypothyroidism by a focused selective physical examination. Examiner Instructions This case requires the patient to reveal the symptoms of hypothyroidism in a slow and hesitant, but nevertheless positive manner, in response to appropriate history-taking. The examiner will have instructed the patient as follows: You are a 50-year-old widow. Opening statement 'My daughter wants me to have a check-up because she says I am always tired. ' • Respond to the doctor's enquiries as follows — w i t h o u t p r o m p t i n g . • You have not felt well lately (be vague about the duration). • You feel weak especially your arms and legs. • You also feel lethargic. • Your daughter says you are not interested in anything, go to sleep during the day and can't be bothered talking to people. • Your voice has become 'croaky' — people say it has changed over the past year. • You are always constipated and this seems to be getting worse. • Your periods stopped last year and were scanty and irregular for a year before that. • You have put on weight. • Your responses are apathetic, lacking expression. • You are slow to react with a croaky, husky, thick voice and poor memory. • You respond slowly to doctor's questions, but appropriate questions evoke correct responses. • Do not be evasive. Show paucity of body movements. In response to other questions: • No history of thyroid surgery. • You feel cold all the time. • Your hair has become thinner. • You find it hard to concentrate. • Your memory is not good. • You are able to manage your own personal care but everything is an effort and takes longer. • You get constipated if you don't take Coloxyl® regularly. 170 035 Performance Guidelines • Your joints feel stiff and the muscles are sore. • You wake up early in the morning and can't get back to sleep. • Answer in the negative to any other questions about your health except to indicate that you feel you are gradually going downhill. • If asked, state that you have just come to stay with your daughter because you were unable to carry on living alone. • Past medical history and family history — nothing of note. Parents died from old age. Current medication • 'Tonic' obtained from Pharmacist by daughter. • Aspirin irregularly for the rheumatism. • Dioctyl sodium 120mg (Coloxyl®) 'for my bowel' 1 or 2 tablets daily, taken for about a year. • Physical examination — the examiner should give the findings for selective and specifically requested components of the physical examination. • Appearance — as illustrated ~ Looks tired and dull. Expressionless face, coarse features and skin. ~ Overweight — BMI 29 kg/m2 ~ Pulse rate 56/min regular, blood pressure 130/70 mmHg ~ Thyroid not palpable ~ Skin dry sparse axillary hair ~ Cold hands and feet ~ Power and tone reduced in arms and legs ~ Reflexes sluggish with delayed ankle jerks At six minutes the examiner will ask the candidate for the diagnosis/differential diagnosis and proposed investigation. EXPECTATIONS OF CANDIDATE PERFORMANCE • Diagnosis/differential diagnosis Candidate's response to examiner's request for the diagnosis: candidate should strongly suspect hypothyroidism as indicated by pattern recognition and from the patient's symptoms and signs. Other possibilities such as depression, anaemia, early dementia may be mentioned but should be considered unlikely. • Investigations Must request thyroid function tests and full blood examination. Key Issues • History • Choice and sequence of examination • Diagnosis/differential diagnosis • Appropriate investigations 171 035 Performance Guidelines CRITICAL ERROR • Failure to consider hypothyroidism in differential diagnosis. COMMENTARY Spontaneous atrophic hypothyroidism often gives gradually progressive symptoms as ir this case. The pathology is destructive lymphoid infiltration of the thyroid gland leading tc atrophy with no visible enlargement, or in some patients, associated with goitre. Diagnosis is suspected by the constellation of symptoms and signs as exhibited in this patient and would be confirmed by elevation of serum TSH with lowered T4 levels. The condition is an organ-specific immune disorder and responds well to thyroxine treatment, beginning with a low dose (50 ug daily) and increasing slowly to the dose required to restore TSH to normal. 172 036 Performance Guidelines Condition 036 Syncope in a 52-year-old man AIMS OF STATION To assess the candidate's ability to take a focused history regarding transient loss of consciousness with possible causes in mind. The candidate should also know the essential components of a selective physical examination which should identify a probable cause and be able to specify the investigations which would confirm the diagnosis Examiner Instructions The examiner will have instructed the patient as follows: You are a 52-year-old technician who is consulting a doctor about recent transient loss of consciousness. Opening statement ‘I was playing tennis yesterday when I suddenly blacked out. My friends thought I was dead!' If given the opportunity by the doctor, follow with this information: '/ was enjoying my usual Sunday morning game of tennis. It was a hot day. I had been serving and the game was pretty fast — when I suddenly blacked out. There was no warning and I must have 'come to' pretty quickly because my friends told me they were about to start pushing on my chest. They couldn't tell whether I was breathing or not and they said they couldn't feel my pulse. Anyway I woke up and felt that nothing had happened except for this graze on my elbow. I decided not to play on although I felt ok'. Provide the following information in response to specific, appropriate questioning: • You feel well today. • This was the first such attack. You have not had any previous fainting or dizzy spells • No convulsions or fitting from your friend's description. Before or after the attack you had no palpitations or awareness of heart beating abnormally, no vertigo, no headache, no disturbance of your vision, no numbness or tingling. • No one said anything about your colour. • You had no loss of control of your bladder or bowel function during the attack. • You get short of breath whilst playing and this has been more noticeable lately. You have attributed this to your age. You don't get short of breath lying down or at night. • You also have some 'muscle soreness' in your chest, which sometimes comes on when you are playing, this has been noticed over recent months, but it is not severe and goes away when you stop playing tennis between games. This occurs if a game is strenuous or prolonged and is a tight feeling. • You don't feel it anywhere else, just across your chest. • There has been no swelling of ankles. • Negative responses to all questions reviewing body systems. 173 036 Performance Guidelines Other significant information • Your last cholesterol check was three or four years ago when you last saw a doctor. You were told that it was in the 'high normal' range and advised to reduce intake of fatty foods. • Blood pressure always normal. • No regular medication. • If asked about your past history, family history, habits, social history or other information, respond as for yourself. • You are a mature middle-aged person without previous health concerns. Because you were unaware of the details of yesterday's events (except for the graze on your elbow) and because you feel so well, you are not unduly concerned. • Do not reveal the chest soreness or the excessive shortness of breath on exertion, without proper enquiry from the doctor. • After obtaining the results of the physical examination the doctor should give you an opinion as to the cause of your symptoms. Accept what the doctor says. EXPECTATIONS OF CANDIDATE PERFORMANCE History • Eliciting the triad of symptoms of syncope, exertional dyspnoea and angina which raise a high index of suspicion of aortic stenosis. • Excluding symptoms suggestive of other causes, particularly epilepsy (see differential diagnosis). Physical examination (provide these on request) Cardiovascular examination • pulse • blood pressure • jugular venous pressure • auscultation of neck • heart ~ prominent left ventricular impulse ~ apex beat not displaced ~ ejection systolic murmur (3/6) best heard over aortic area ~ radiates to neck and apex 70/min regular 118/88 mmHg lying and standing normal - systolic bruit (transmitted) over both carotid arteries at base of neck — loudest on right. Neurological examination normal There are no other abnormal physical findings. The examiner should limit the candidate's requests for physical examination findings to the cardiovascular and central nervous systems (the latter is normal). After six minutes ask the candidate the most likely diagnosis, then direct the candidate to discuss these with patient. 174 03 Performance Guidelines Diagnosis (opinion to patient) That the loss of consciousness was most likely due to an abnormality in one of the heart valves which requires investigation by ECG and echocardiogram (X-ray chest and full blood examination are addtionally acceptable), and referral to a cardiologist (may use term aortic stenosis with further explanation). • History must elicit details of syncope, exertional dyspnoea and chest discomfort. • Examination must request pulse, blood pressure, presence of carotid and cardiac murmurs. • Choice of investigations must include ECG, and echocardiogram • Diagnosis must recognise that this patient's syncope has a serious underlying cause. Syncopal episodes are common, accounting for 3-5% of attendances at Emergency • Failure to ask about cardiovascular symptoms. • Failure to request examination findings for both carotid and cardiac bruits. Departments and affecting 15-25% of the population over any 10 year period. The prevalence of syncope increases with age and can cause significant morbidity in the elderly. An attack of syncope is associated with major morbidity such as fractures and motor vehicle accidents in 6% of cases, and minor injuries such as lacerations and bruising occur in about a third of cases. It is essential to distinguish syncope from seizures and syncope caused by benign causes from syncope caused by serious underlying illness. This middle-aged patient with syncope evinces the triad of symptoms classical of aortic stenosis. Causes of syncope include neurally-mediated syndromes (such as vasovagal/ vasodepressor syncope and carotid sinus syncope), orthostatic syncope (including volume depletion, drugs, autonomic failure syndromes), cardiac arrhythmias (bradycardias and tachycardias), structural heart disease and cerebrovascular disease. Taking a careful history, including an eyewitness account, is critically important in syncope and can prevent inappropriate and costly investigations. The history in this middle-aged patient with syncope has the important feature of coming on with exertion and against a background of cardiovascular symptoms of chest pain and shortness of breath pointing towards a cardiac cause. The absence of palpitations is against the diagnosis of cardiac arrhythmia but this could still be a possibility on the history. The candidate is expected to use appropriate questioning to try to exclude epilepsy and other neurological causes. Carotid sinus syncope and vasovagal/vasodepressor syncope may be considered as differential diagnoses but other features of these conditions are not apparent (for example, relationship with head turning or warning symptoms). 175 036 Performance Guidelines The next step is a careful cardiovascular examination. The candidate is expected to look for evidence of structural heart disease, in particular for features of aortic stenosis. The examination requested should be systematic, starting with the peripheral pulse and blood pressure, moving on to an examination of the carotid pulses. The nature of the cardiac apex beat, and a request for details on the heart sounds and the cardiac murmur, its characteristics, site and radiation are key findings that help to refine the diagnostic process. The most important investigations to perform in this patient are an ECG and an echocardiogram. Referral to a cardiologist would be an appropriate step to take. A lack of understanding of the condition would be exhibited if a candidate requests a whole range of investigations such as: 7 would like to perform full blood count, electrolytes, blood glucose, carotid Doppler studies, electroencephalogram, Hotter or loop monitoring and coronary angiography. ' 176 037 Performance Guidelines Condition 037 A painful penile rash in a 23-year-old man AIMS OF STATION To assess ability to diagnose and manage genital herpes. This patient has penile herpes simplex. The patient also needs to be assessed in terms of other possible sexually transmissible infections. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement ‘I've got a problem with my penis, doctor. ' You are a carpenter. Volunteer the following history without prompting: • You have had penile pain for two days. • It started as intermittent tingling, but is now constant. • You have noticed today a lumpy penile rash with blisters. In response to questions from the doctor indicate that: • You have had no serious past illnesses and are on no medications. • You have no allergies. • There is no history of mental illness. • Sexual history — you have no steady partner. You are heterosexual and you last had sex with a woman you met at a disco a week ago. • Do not volunteer information about sexual behaviour unless asked specifically Questions to be asked of the candidate unless already covered: • ‘What is wrong with me?' • 'What is the cause?' • 'Can I pass it on?' • 'How can it be treated?' • 'Will I be cured?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to take an appropriate sexual history and to be able to identify the vesicular penile rash as most likely due to genital herpes simplex and to confirm diagnosis by viral testing. Testing for associated sexually transmissible infections as part of the differential diagnosis should include Venereal Disease Research Laboratory (syphilis), chlamydial, gonococcal and HIV testing. Patient counselling and education is important to reduce risk of transmission; and management advice should be: • Confirm diagnosis with virological testing. • Explain the Cause to the patient. 177 037 Performance Guidelines • Assess the risk of possible exposure to other sexually transmissible infections, for which the patient should be screened. • Counselling to reduce risk of transmission of any sexually transmissible infections is essential. • Antimicrobial therapy: reduces the length of illness and may decrease virus transmission. First clinical episodes of genital herpes, when severe, are treated with a five day course of oral aciclovir, or similar agent. • Topical treatments can help symptomatic management: for example, topical povidone-iodine; lignocaine. • Supportive treatment: rest, salt baths, ice packs, analgesics, wear loose clothing. • Further investigations ~ The risk of other sexually transmissible infections, including HIV infection needs to be investigated. ~ This may involve swabbing oral, genital and anal areas for Chlamydia and other infections. All testing needs to be done with informed consent. KEY ISSUES Ability to identify rash as herpes simplex. Ability to take a sexual history and investigate possible concomitant sexually transmissible infections. Counselling to reduce risk of further transmission of herpes simplex virus. Ability to treat herpes infection. CRITICAL ERROR Failure to assess for other sexually transmissible infections. COMMENTARY Herpes Simplex Virus (HSV) is one of a family of herpes viruses, which includes HSV 1 and HSV 2, varicella zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV) and human herpes virus 6. HSV 1 and HSV 2 cause patterns of disease which differ clinically and epidemiologically, but share some characteristics. HSV 1, HSV 2 and herpes zoster all establish permanent latency in sensory nerve ganglia following the primary infection. HSV 1 is more common and is usually acquired during childhood presenting most commonly as acute gingivostomatitis, but can occur anywhere on the skin. In the eye. keratoconjunctivitis is a feared infection because it can cause scarring of the cornea and loss of vision. HSV 2 is largely associated with genital infection and is most common in young, sexually active adults. The risk of infection increases with numbers of sexual partners. Transmission is by vaginal, oral or anal sex. Condoms reduce the risk of transmission. The infection appears at the site of virus entry, on the glans penis or penile shaft in men, or on the vulva or vaginal mucosa in women. Perianal and rectal lesions can develop as a result of anal intercourse. Primary herpes simplex infections have an incubation period of 3-6 days but this may be longer. 178 037 Performance Guidelines During the first attack, there may be a tingling and burning over the affected area. • The rash is vesicular, often occurring in crops, • After a day, the vesicles leave small red, painful ulcers. These heal within a few days. • There may be associated fever, myalgia and local lymphadenopathy. • The first (primary) attack lasts around two weeks. • • • • Recurrence occurs in about 50% and may be associated with shooting pains in the buttocks and legs. Recurrences often occur at times of stress and tiredness. Systemic manifestations are uncommon. Recurrences are also more frequent in presence of immunosuppression including HIV infection. HSV infection may be associated with other sexually transmissible infections. 179 L 038 Performance Guidelines Condition 038 Primary amenorrhoea in an 18-year-old woman AIMS OF STATION To assess the candidate's ability to define the cause of primary amenorrhoea in a young woman who has gone through an apparently normal puberty EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You have come to see the doctor because you are worried that you have not yet had a period. You are 18 years old. List of appropriate answers in response to likely questions • Evidence of pubertal changes: ~ You had a growth spurt three years ago. ~ Breast changes started three years ago. ~ Pubic hair began to develop three years ago. You are now of similar height to peers from school. • You have no history of abdominal or pelvic pain. • Your mother had her first period at the age of 17 years. • Your sister (aged 14) has not yet started to have breast development. • You have had no operations or significant illnesses. • You have never been sexually active. Questions to ask unless already covered: • 'Why hasn't my period started yet?' • 'All my friends at school started years ago. Will I ever have periods?' • 'Will I be able to have a baby?' Examination findings from examiner These should be given to the candidate on request for specific components of the examination. • Her weight is 48 kg and she has normal height for weight. • Breasts show Tanner stage 5 of puberty. Pubic and axillary hair also show stage 5. • Blood pressure 120/80 mmHg. • Vulval inspection — normal appearance. Hymen intact, but apparently perforate. Lower vagina above hymen appears normal. EXPECTATIONS OF CANDIDATE PERFORMANCE Pelvic examination per vaginum should not be done and should not be specified by candidate. 180 03 Performance Guidelines Investigations required • Ultrasound examination (abdominal-pelvic ultrasound, not vaginal): to check the development of the uterus and vagina and to confirm that these are normal • Hormone tests: should order follicular stimulating hormone (FSH), luteinising hormone (LH), prolactin, and oestradiol levels. • Chromosome analysis is not necessary if uterus is shown to be normal and above hormonal levels are normal. Advice to patient (the candidate should convey the substance of what follows to the patient): • Reassurance that this is likely to be just a physiological delay in the first period as all else appears normal on examination. The investigations which have been arranged should confirm this. The first period usually occurs two years after the first breast development, but can be delayed for three years or longer as normal variation in menarche. • She will be reviewed after investigations have been established as normal and again in 12 months time. If a period has still not occurred, estimation of oestradiol levels should be repeated. • Ability to define the most likely cause of primary amenorrhoea (delayed menarche). • Ability to arrange the appropriate investigations. CRITICAL ERRORS • Inadequate history to evaluate current pubertal status. • Performance of pelvic vaginal examination as she is virginal. Requesting that pelvic examination should be done would be a significant and potentially failing error. • Failure to order abdominal ultrasound. Pelvic (vaginal) ultrasound is also inappropriate • Failure to order hormonal analyses of FSH, prolactin and oestradiol. This case illustrates the situation where a slightly delayed menarche can be a normal situation particularly where there is a familial trait. It is therefore essential to obtain an appropriate history, both in regard to her own history and that of other family members. Noninvasive investigations will enable this patient to be reassured in the presence of other pubertal changes. Common problems likely with candidate performance are: • Failure to recognise that an apparently normal puberty is occurring. Therefore the cause of the primary amenorrhoea is likely to be just a slight delay in the first period with everything else being normal. Other less likely possible causes are obstruction to the outflow of blood from the uterus to the exterior by an intact hymen or vaginal septum or an absence of development of the uterus. Ultrasound examination is essential to make these latter diagnoses. • Failure to reassure the patient and failure to advise review in 12 months time if a period has still not occurred. 181 039 Performance Guidelines Condition 039 A skin lesion on the cheek of a 50-year-old man AIMS OF STATION To assess the candidate's ability to diagnose a facial skin lesion suspicious of basal cell carcinoma EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a builder aged 50 years. Most of your working life has been spent outdoors. • You have had a firm nodule on your cheek for a year or so, which has slowly increased in size. It has recently developed an ulcer in the centre of it, and has bled a little. You think this may have followed you picking at it. You are otherwise healthy and well with no serious past illnesses. • You have no allergies and are on no medications. Otherwise answer as for yourself. Opening statement: 'I've had this thing on my cheek for about a year doctor. ' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise from the history and physical findings that this is a 'suspicious' lesion which requires excision, and should advise the patient accordingly. KEY ISSUES • Ability to present a focused case summary. • Ability to identify and manage a 'suspicious' skin lesion, in this case basal cell carcinoma. CRITICAL ERROR • Failure to diagnose that this is a 'suspicious' skin lesion needing excision. COMMENTARY This scenario has been arranged in the format of a summary case presentation to the examiner of a suspicious skin lesion, followed by advice to the patient about treatment. It tests accuracy of observation and ability to summarise the problem concisely. The diagnosis should be straightforward. The most likely diagnosis is an ulcerating basal cell cancer and the most appropriate treatment is local excision with an adequate margin. Differentiating a basal cell cancer from a squamous lesion or other skin malignancies is less important than identifying the lesion as requiring appropriate histologic diagnosis after adequate excision. 182 039 Performance Guidelines • Common clinical features of basal cell carcinoma (BCC) are: ~ BCC is the most common skin cancer comprising 80% of skin cancers, occurring usually in people older than 35 years, more frequently in males and in fair-skinned people, ~ BCC occurs most commonly on sun-exposed areas: face (mainly), neck, upper trunk, limbs (10%); but can occur on covered areas as well. ~ Ulceration produces the characteristic 'rodent' ulcer as illustrated by this example ~ BCCs grow slowly over years, and can occur in various forms: nodular, ulcerated, morphoeic, cystic or pigmented, - They do not metastasise, but local spread can cause problems with surrounding structures as they can spread deeply around nose, eye, or ear ('nothing burrows like a basal cell'). • Patients need to be educated about avoiding direct sunlight when the sun is at its strongest: wear a broad rimmed hat; wear a shirt; and use sun block cream when exposed. 183 040 Performance Guidelines Condition 040 A pigmented mole on the trunk of a 30-year-old woman AIMS OF STATION To assess the candidate's ability to diagnose a pigmented focal skin lesion and to identify a 'suspicious' lesion. EXAMINER INSTRUCTIONS This patient has a 'suspicious' pigmented skin lesion: a melanocytic naevus suggestive of a dysplastic naevus. Excluding melanoma by excision is critical to successful case management. The examiner will have instructed the patient as follows: • You are a 30-year-old schoolteacher. • You have had a dark spot on your back for many years. You think you were born with it. The spot has become darker over the last few months so you thought you would have it checked out. You have a few other dark spots, but they have not changed. • You are otherwise healthy and well, and have had no serious past illnesses. You have no allergies, and are on no medications. Opening statement: 'It seems to have changed and become more itchy lately, doctor. ' EXPECTATIONS OF CANDIDATE PERFORMANCE The presence of change in appearance and irritative symptoms in a previously stable pigmented naevus, should raise concerns about malignant change, especially in a large lesion with appearances suggesting a dysplastic naevus. The candidate should refer the patient for excisional biopsy. KEY ISSUES • Ability to identify a 'suspicious' pigmented lesion, possibly at risk of malignant melanoma. • Ability to manage pigmented skin lesions appropriately. CRITICAL ERROR • Failure to suspect malignant potential. COMMENTARY Most pigmented skin lesions are benign. About one third of melanomas arise in pre-existing naevi. Removal of such naevi is important for melanoma prevention. The incidence of melanoma is rising in Australia and around the world. Incidence is higher in fair-skinned people; appears to be related to brief intense sunlight exposure as well as effect of chronic exposure. 184 040 Performance Guidelines Most people have an average of 5-10 benign melanocytic naevi. Multiple dysplastic naevi carry a greater risk of malignant change. Clinical features of 'suspicious' dysplastic melanocytic naevi include: • Large (> 5 mm) irregular moles, such as this patient exhibits, appearing usually on the trunks of young adults. • Lesions with irregular, ill-defined borders, irregular pigmentation, background redness, variable colours — brown, black, tan, pink. • Most are stable and do not lead to melanoma, but excision is indicated if any diagnostic concerns. Dysplastic naevus syndrome is diagnosed because of the presence of multiple, large, irregular pigmented naevi, mainly on the trunk. It is important to exclude malignant melanoma Signs indicative of possible malignant melanoma include: • any change in size of a presenting lesion (lateral spread or thickening); • change in shape; • change in colour (brown, blue, black, red, white and combinations of these colours); • change in surface; • change in the border; • bleeding or ulceration; and • other symptoms (itching). Development of satellite nodules and lymph node involvement are late signs. Differential diagnosis of pigmented skin lesions includes: • haemangioma (thrombosed); • dermatofibroma (sclerosing haemangioma); • pigmented seborrhoeic keratosis; • pigmented basal cell carcinoma; • junctional and compound benign melanocytic naevi; • blue naevi; • dysplastic naevi; and • lentigines. Management: • In this case, the solitary dysplastic naevus may have no significant malignant potential at this stage. However, because of the size of the lesion and the patient's concern, this lesion should be excised. • Suspicious pigmented lesions should have complete excisional biopsy, and not be treated by cryotherapy. 185 041 Performance Guidelines Condition 041 An itchy rash on the hands of a 19-year-old woman AIMS OF STATION To assess the candidate's ability to diagnose, confirm and treat scabies, and to prevent recurrence. Examiner Instructions: The examiner will have instructed the patient as follows: Opening statement 'I want to get rid of this rash on my hands. ' • Follow with 'It started about a week ago and I can t stop scratching my hands because of the itch. ' • In response to questions the doctor may ask: ~ You have not had anything like this before, ~ No rash or itchiness elsewhere on your body. ~ The itch is intense and made worse by warming your hands, as when washing up in hot water or bathing or showering. ~ The itch is worst at night and interferes with sleep. ~ Your hands have not been in contact with any irritants, chemicals or plants. ~ Your general health is excellent. ~ No past history of any serious illness. ~ No known allergies. ~ No history of mental or behavioural disturbance. ~ No recent travel away from home. ~ No medication except oral contraception. ~ Your boyfriend with whom you are sexually active has had a similar rash though not as bad and he has not sought medical advice about it. Scratch and rub the backs of your knuckles and between the bases of your fingers. Answer the doctor's questions in a straightforward manner including about the relationship with your boyfriend. Do not reveal this spontaneously. EXPECTATIONS OF CANDIDATE PERFORMANCE • • • Approach to patient. Display interest and intention to deal effectively with the condition. Be nonjudgmental about possible sexual transmission of scabies from boyfriend. Provide reassurance that condition is simply cured and not serious. Compliance with the whole of the treatment regimen should be obtained. History. Identify site and severity of itch and question about sexual activity after other possible sources have been excluded. Confirmation of diagnosis. The candidate may diagnose scabies from illustration and history as given above, but should advise the patient that diagnosis must be confirmed by taking skin scrapings from the lesions for microscopy. 186 041 Performance Guidelines Examiner should intervene at this point by stating 'Please assume that the skin scrapings are positive for scabies, and advise the patient accordingly. ' The examiner should only state this if the candidate has mentioned the need for skin scrapings to diagnose scabies. • Patient education and counselling. In this case, the condition is transmitted by close contact during sexual activity. Description of the scabies mite is expected with reassurance that the condition is not serious, although very uncomfortable, and is readily treatable. Patient should advise boyfriend to seek medical advice. • Management. ~ Application of permethrin cream or lotion 5% (Lyclear®) or benzyl benzoate emulsion 25% (Ascabiol®) to entire body from jawline down including nails, flexures and genitals. Leave permethrin cream or lotion overnight then wash off thoroughly, but benzyl benzoate lotion should be left on for 24 hours. ~ Avoid hot baths or scrubbing before application ~ Treat household contacts even if nonsymptomatic ~ Wash clothing and bed clothes in hot water and expose to sun to dry ~ Repeat treatment in one week if infestation is considered to be severe ~ Avoid intimate contact with boyfriend until he has also been properly treated Key Issues • Approach to patient — Ability to establish satisfactory relationship with patient to achieve compliance and cooperation of patient to get boyfriend to seek treatment. • History — Ability to take an appropriate history including site and severity of pruritus and sexual partner as source of infection. • Diagnosis — Should advise microscopy of skin scrapings to facilitate diagnosis. • Management — Provide adequate advice for proper treatment and advise the patient to avoid intimate contact with boyfriend until he has been treated Critical Error • Failure to suspect scabies or to take action to confirm diagnosis. Commentary Scabies is a highly contagious infestation which is spread through close contact including sexual contact. Scabies can affect entire households, especially if overcrowded, although this is now uncommon. It is characterised by widespread inflammatory papules and severe pruritus and it can be endemic among school children and institutionalised older patients. The female scabies mite (illustrated below) burrows just beneath the skin in order to lay her eggs and then dies. The eggs hatch into mites which spread out across the skin and live for about 30 days. A mite antigen in the excreta induces a hypersensitivity rash. 187 CONDITION 041. FIGURE 2. Scabies mite (Sarcoptes scabiei) CONDITION 041. FIGURE 3. Penile scabies Clinical features include intense itching, worse at night and when hands and body are warm (for example, after a shower), with an erythematous papular rash usually on hands and wrists. The rash also can occur in web spaces, on male genitalia as illustrated, on elbows, axillae, feet and ankles, or nipples of females. Diagnosis is confirmed by microscopy of skin scrapings. 188 Condition 042 Red painful dry hands in a 30-year-old bricklayer AIMS OF STATION To assess the candidate's ability to diagnose occupational dermatitis and advise an initial management plan. This patient has occupational contact dermatitis secondary to concrete exposure. After 6 minutes, if the candidate has not identified the condition as contact dermatitis ask the questions: • What is the likely cause of the condition?' • 'How would you manage this condition?' The examiner will have instructed the patient as follows: You are aged 30 years, and have been working as a bricklayer/contractor for about a year. Opening statement 'I've got problems with this rash on my hands. ' Following without prompting: Your hands have been itchy and dry for some months now, and are getting worse. The rash is on no other part of the body. You are otherwise healthy and well, with no serious past illnesses. You have no allergies. You are on no medications. State if questioned about the relationship of rash to work: the rash definitely improved significantly after a holiday from work. Your brother has skin problems but you are not sure what type. 189 042 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • History — must elicit occupational history. • Diagnosis — should suspect allergic contact dermatitis and its cause in this patient from the history and from the physical findings as illustrated, which involve palmar and dorsal surfaces of both hands. Confirmation of diagnosis is by patch testing by dermatologist (not essential). • Management — explain to the patient that the rash will persist as long as there is exposure to cement although its severity may be reduced by the following initial management: ~ Wash only with water and avoid soap. ~ Pat dry after washing ~ Apply topical corticosteroid cream to gain initial control. Oral prednisolone is reserved for severe cases. ~ Oral antibiotics may be required for secondary infection in severe cases ~ Consider using emollient agents for future prevention. ~ For cement dermatitis, specific measures involve avoiding contact with wet cement: using barrier creams before putting on gloves (do not use barrier creams on damaged skin); using protective gloves when working and washing hands after being exposed to cement. KEY ISSUES • Ability to identify the type and cause of the dermatitis. • Ability to manage occupational contact dermatitis. • Consideration of cement as most likely cause of dermatitis. CRITICAL ERROR • Failure to suspect causal work association in diagnosis. COMMENTARY Allergic contact dermatitis is due to a delayed hypersensitivity reaction. While physical appearance of the skin can be similar to other forms of dermatitis, rash site and exposure history are critical for diagnosis, management and prevention. Trigger factors only affect some people. Common trigger factors include cosmetic ingredients including perfumes and preservatives, topical antibiotics, topical anaesthetics, topical antihistamines, plants (rhus. grevillea, primula, poison ivy), metal salts (nickel sulphate, chromâtes — as occur in cement and concrete), dyes, rubber/latex, epoxy resins, glues, acrylates, coral. In cement dermatitis, individuals can become sensitised to chromate salts at any time, even after working with cement for many years. 190 043 Performance Guidelines Condition 043 Swelling of both ankles in a 53-year-old woman AIMS OF STATION To assess the candidate's ability to take a detailed history concerning swelling of the ankles, knowledge of possible causes and the components of the physical examination necessary to reach a firm provisional diagnosis. The examiner will have instructed the patient as follows: You are a 53-year-old clerical worker and are consulting the doctor about swelling of your ankles. The doctor will take a history about this complaint but will not examine you Opening statement 'I have come to see you about swelling of my ankles. ' Provide the following without prompting 'Over the past eight weeks my ankles have been swelling. I usually notice this is worse at the end of each day. They have mostly gone down by the mornings. My ankles have never swelled up before'. Provide the following in answer to appropriate questioning • The swelling is the same in both lower legs, there is no discolouration of the skin. • There has been no pain in your legs. • If asked about shortness of breath: you believe that you are not as fit as you used to be because you become noticeably breathless when walking up stairs or hurrying. This passes when you rest. • Regarding exercise: you gave up playing tennis about a year ago because you became very breathless for a short time after a rally and also you felt exhausted afterwards. • Recurring palpitations: for some years you have noticed that your heart seems to 'bounce around in your chest' particularly when you are going off to sleep (thumps and misses beats). Your heart also seems to race after any strenuous exertion although this settles down after a few minutes. You have not counted your pulse rate but you are sure that it is faster than normal. You have the feeling that it may not be regular at times, but you find it hard to be sure. • No associated dizziness or blackouts. • No suggestion of a fever, no chills or shakes. • No cough or blood in sputum. • You have not had any recent chest pain with or without exercise, you may comment that this is why you haven't worried about the other symptoms. If asked about chest pain in the past say ' Four years ago I had a bad pain in the centre of my chest. I was on holidays at the time. The pain lasted about two hours and I felt unwell for a few days afterwards. ' • You sleep well, lying flat in bed: you do not snore. 191 Review of general health • You consider yourself to be in good health. You have never suffered any serious ill health. • You have not had a medical check-up recently. 'After all. my father was 90 when he died'. • If asked other specific questions, reply in the negative. You have never had any kidney problems (for example, blood in urine) or liver disease (jaundice). Review of relevant systems • Positive responses are confined to the cardiovascular system. • In particular, no gastrointestinal symptoms including no rectal bleeding. Other significant information • You are very busy at work. • You work for a large legal firm as a legal secretary. • The only exercise you have these days is when gardening and this does not cause any problems, unless you are digging for more than a short time, then you get 'puffed' • You have noticed this over the past six months. Patient profile • You are married. • Your spouse is well. • You have three married children. • You smoked 20 cigarettes a day from age of 18 years and stopped a year ago. • You drink three glasses of wine daily. • You are not taking any medication. • You eat a normal, well-balanced diet. Family history • Mother died aged 77 years (stroke). • Father died aged 90 years. • No brothers or sisters. Past medical history • No serious illnesses. • No operations. • No history suggestive of rheumatic fever. • Blood pressure has been checked several times in recent years and was always normal. Other instructions • Appear calm and not unduly concerned about your swollen ankles. • You have attributed them to your age. • Be cooperative, but do not disclose all of the cardiovascular symptoms without facilitation, prompting and appropriate questioning by the doctor, as indicated above. • You are not worried about heart trouble because you no longer smoke and, apart from the short episode 4 years ago, do not have chest pain. • You have never suspected that your various symptoms could be connected and would not have attended without the insistence of your spouse. 192 043 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE History • This should include a reasonable number of questions detailed in the patient's advice above. Some questions out of each section should be included, but clearly time limitations will influence the choice and number • The history must at least cover key questions relating to possible cardiac, hepatic and renal causes for the oedema. • Venous thrombosis, causing inferior venacaval obstruction or bilateral lower limb deep venous thrombosis is unlikely but needs to be considered. • Possible diagnosis given to patient after history must include cardiac failure as the most likely condition. • Other potential causes could also include hepatic and renal disease (consider cirrhosis, nephrotic syndrome or malignancy as most unlikely causes in this patient). • If, after five minutes the candidate has not started to discuss with the examiner some of the likely causes for the symptoms, encourage the candidate to do so • After five minutes, if the candidate has not already done so, instruct the candidate to tel the patient the working diagnosis, and then ask the examiner for physical findings to confirm this. Examination • The examiner is not required to provide specific examination findings but should encourage the candidate to relate the examination findings sought to the previously stated diagnostic possibilities. • These should include: ~ temperature; ~ pulse rate and rhythm; ~ blood pressure; ~ jugular venous pulse and pressure; ~ mucous membranes; ~ cardiac examination (apex beat and auscultation); ~ respiratory examination (any reference to effusion, adventitious sounds or rub acceptable); ~ liver, spleen ~ inguinal region and lower limbs (symmetry of oedema, discolouration, tenderness, heat); and ~ urinalysis must be requested or come up some time in the assessment. • Candidates are not expected to indicate the investigations required in this station, although candidates may indicate the tests required to confirm the proposed diagnosis. 193 043 Performance Guidelines KEY ISSUES • Ability to take an appropriate history. • Ability to explain to the patient why she has swollen ankles and shortness of breath. • Ability to provide a sensible differential diagnosis. • Ability to state precisely what would be sought on physical examination and why. This station assesses the candidate's ability to take a comprehensive, but ordered and concise history in a patient with recent onset of bilateral leg oedema. It also examines clinical reasoning abilities in understanding the potential causes of leg oedema and proceeding in a logical way to accumulate the relevant positive and negative features of the history in order to form a satisfactory probability diagnosis. Congestive heart failure can present in a subtle way with symptoms of right heart failure, such as bilateral leg oedema, which is worse after prolonged standing and reduces with supine rest. As in this case, there is often a coexisting history of left heart failure symptoms, such as exertional dyspnoea. It is very important in a patient with possible congestive heart failure not to be satisfied with this as a complete diagnosis, but to ask the questions 'Why has this patient developed heart failure? What is the underlying cause? This will require an understanding of the pathophysiology of heart failure. Heart failure is difficult to define. Various definitions include the following: • A pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues.' • A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.' • A biomechanical definition is that the failing heart exhibits a reduction of power such that it cannot maintain a normal cardiac output without abnormal elevation of systemic and/or pulmonary venous pressures. The underlying causes of heart failure are many and it is useful to consider these under the following group headings: • Primary myocardial disease (ischaemic heart disease, cardiomyopathy). • • Pressure overload (hypertension, aortic stenosis). Volume overload (aortic regurgitation, mitral regurgitation, ventricular septal defect, high output states). • Obstruction to ventricular filling (mitral stenosis). • Restriction of ventricular filling (hypertrophic cardiomyopathy, constrictive pericarditis). 194 043 Performance Guidelines In this station the patient presents with important history features of probable ischaemic heart disease and cardiac arrhythmia. The onset of atrial fibrillation is often a precipitant of heart failure, and this is particularly true in patients who are older, have hypertension and/or diabetes, or underlying mitral valve disease. In patients who have stiff (noncompliant) hearts due to age, left ventricular hypertrophy, hypertension, diabetes, ischaemic heart disease or a combination of these — the first presentation may be due to cardiac diastolic dysfunction where heart failure is caused by an increased resistance to filling of one or both ventricles. Atrial fibrillation is often a cause of diastolic heart failure because of the effects on ventricular filling with loss of the atrial systole and an increased ventricular rate. With diastolic dysfunction of the left ventricle, the presentation is usually with breathlessness on exertion and episodes of acute pulmonary oedema. In this patient, the presentation with leg oedema is an indication of right heart failure, which in the great majority of patients is secondary to a longstanding problem with the left heart, the so-called 'backward failure'. CONDITION 043. FIGURE 2. Pitting oedema in CCF 195 2-B: Physical Examination Vernon C Marshall and Barry P McGrath 'One of the unexpected and disturbing results of the development of increasingly precise and useful diagnostic measures in the laboratory and X-ray departments is a significant and often alarming decrease in emphasis on the training of the medical student to perform with excellence the average comprehensive physical examination.' Journal of the American Medical Association (1962) LOOK! MOVE! FEEL! LISTEN! MEASURE! COMPARE! INTERPRET! This aide-memoire comprises the seven champions of physical examination. Used in the correct sequence (and remember the above sequence, eyes first and foremost and only then fingers, hands and ears), they form the basis of all physical examination techniques. Whether one is examining the whole patient, a focal region (head and neck, back, chest, abdomen, limbs) or a body system (integument, cardiovascular, respiratory, gastrointestinal, neuroendocrine), an ordered, well practised and logical sequence is essential. Sound technique facilitates accurate findings and diagnostic acumen. Physical examination still matters and, along with a careful history, will confirm the diagnosis in the majority of consultations despite the plethora and utility of available investigations. In preparing themselves to be good noticers and good examiners of physical signs, clinicians should gain practice in: • Pattern recognition: the ability to define and group a constellation of features in order to diagnose, for example, shock, hyperthyroidism or cardiac failure. • Focused examination of an area or region such as a limb, the neck, the chest or the abdomen. Here one must concentrate on checking features — normal and abnormal-of the multiple local structures which comprise focal components of several body systems grouped at a common site. A sound knowledge of clinical anatomy is an essential prerequisite. • Examination of multiple sites and areas logically, sequentially and expeditiously to provide global assessment of a body system (cardiovascular, gastrointestinal, etc) A sound knowledge of clinical physiopathology is an essential prerequisite. This introductory segment and the MCATs following provide selected examples of these techniques. Skill development in physical examination is sequential throughout undergraduate medical education and extends into independent and specialist practice. Like the acquisition of any skill, medical practitioners in their attempts to become skilled clinicians must: • have a good understanding of correct methodology; • assiduously develop the correct techniques; • have the right equipment and know how to use it; • know the range of normality and what constitutes abnormality; • be aware of the limitations of clinical signs, but use adjuvant investigations thoughtfully and selectively; and • practise, and practise frequently. 196 2-B Physical Examination Central to correct physical examination, and unique to the health domain, is the manner in which the examiner interacts with the patient. Common problems that are observed in candidates undertaking physical examination include the following: • lack of empathy and skill in engaging the patient; Physical examination still matters, and along with a • failure to spend time in general inspection of the patient, thus missing careful history, will confirm the diagnosis in the important aspects of pattern recognition; majority of consultations, despite the plethora and • causing undue discomfort to the patient; utility of available investingations. • incorrect techniques; • failure to develop a careful, systematic approach; • a slipshod approach, missing important signs along the way; • inaccuracy of sign characterisation and of measurements; • missing obvious pathology by overlooking physical signs; • finding things that are not there; • over-interpretation; and • inability to provide a succinct, accurate clinical summary. PHYSICAL EXAMINATION — REGIONAL EXAMINATION • The integument The skin is the largest body organ. Skin rashes should be assessed as macular, papular, maculopapular, vesicular or pustular, itchy or nonitchy. Rashes are commonly allergic, irritative or infective. Atopic eczema is a blotchy ill-defined red macular rash which can progress to papule and pustule formation. Irritative contact dermatitis can be wet (intertrigo, nappy rash), or dry and associated with hyperkeratosis, lichenification and pigmentation. Infective rashes are legion and range through bacterial (impetigo, acne), fungal, or viral (molluscum contagiosum, herpes simplex and zoster, HIV). Involvement of scalp or nails may occur (psoriasis). The distribution of the rash (e.g. pretibial erythema nodosum) and associated features (e.g. focal skin ischaemia in vasculitis; central clearing in fungal lesions), give important diagnostic clues. SECTION 2-B. FIGURE 1. Flexural eczema SECTION 2-B. FIGURE 2. Acne vulgaris 197 2-B Physical Examination SECTION 2-B. FIGURE 3. Molluscum contagiosum SECTION 2-B. FIGURE 4. Microsporum canis ('ring worm') Focal skin lesions are also of immense variety. In Australia, malignant skin lesions are common, particularly in higher latitudes and in fair-haired and pale-skinned individuals. Basal cell cancers are the most common cancers, and although mostly seen on the face and other exposed parts, can occur anywhere. By contrast squamous cancers are almost always confined to sun exposed areas. Melanomas are the most serious lesions; their incidence is increasing in Australia and in most parts of the world, so picking up dysplastic or premalignant lesions is important. Most focal skin lesions are, however, benign and include benign melanocytic and other naevi, calluses and viral warts. Solar keratoses, seborrhoeic keratoses, dermatofibromas (sclerosing hemangiomas), 'senile' melanocytic and purpuric freckling, and cherry angiomas (Campbell de Morgan spots), are seen with increasing frequency with increasing age. SECTION 2-B. FIGURES 5 AND 6. Neurofibromatosis Type I — von Recklinghausen disease of nerves Note numerous cutaneous neurofibromas (molluscum fibrosum) 198 2-B Physical Examination SECTION 2-B. FIGURES 7 AND 8. SECTION 2-B. FIGURE 9. Portwine stains — cavernous haemangiomas Nodular portwine stain Cutaneous neurofibromas form part of the syndrome of von Recklinghausen disease of nerves (neurofibromatosis). The syndrome is usually readily identified by pattern recognition. Solitary cutaneous neurofibromas are also often found apart from the inherited syndrome. Congenital 'portwine' stains (cavernous haemangiomas) have a classical appearance and may become nodular with age. It is usually possible following a focused and accurate history and examination to classify lesions into clearly benign', 'clearly malignant', and 'suspicious' with the latter two needing appropriately wide excisional biopsy. • Subcutaneous lumps These are mostly benign and often merely need accurate diagnosis and reassurance. The diagnostic features of most importance are site, physical characteristics, and relationships of the lump to its surroundings (which includes the regional nodes). Critical features to note are the Ss, Cs, Ts, Fs, and Ps. • Site, Size, Shape, Surroundings. • Contour, Consistency, Colour, Compressibility, Cough impulse. • Tenderness, Temperature, Transillumination. • Fluctuation, Fixity, Fields. • Pulsation, Percussion. The lump should always be layered' — is it in subcutaneous fat, and if so is it attached to overlying skin, or underlying fascia and musculature? 199 The mobility of subcutaneous lumps in relation to their superficial and deep surroundings is important in picking up infiltrative rather than expansile enlargement. The former is very suggestive of malignant or inflammatory fixation and fibrosis. The lump's 'mobility' or fixity helps in checking whether it is below deep fascia, attached to nearby bone or vessel or nerve, in the abdominal parietes or intra-abdominal. Most lipomas, 'sebaceous' and other cysts, ganglia, bursae, lymph node swellings, hernias, vascular swellings and other subcutaneous lumps will be readily diagnosable if the above simple rules of focused assessment are combined with basic knowledge of local anatomy and likely pathologies. • Head and neck lumps With neck lumps it is particularly important always first to observe the effects of movement: swallowing, coughing, protruding the tongue, and tensing underlying muscles such as sternomastoid or trapezius. Remember to examine the accessible nasopharynx and oropharynx. The laryngopharynx and oesophagus are not accessible to your examining hands and fingers, but remember the importance of endoscopic evaluation in the diagnosis of occult primary neoplasms presenting as neck lumps. With neck lymph node swellings always keep in mind the possibility of: • lymphatic spread from areas outside head and neck (chest and lungs, the abdomen or genitals); and • focal presentation of systemic lymphoid pathology. SECTION 2-B. FIGURE 10. Hodgkin lymphoma SECTION 2-B. FIGURE 11. Nodal metastasis from papillary carcinoma thyroid Examination of a cytologic aspirate will often clarify the diagnosis and point the way for further diagnostic tests. For example, squamous neoplastic cells in a neck lymph node point to a potential primary neoplasm of skin, laryngopharynx, oesophagus, or lung, rather than from thyroid or stomach. Cytology may be specific for melanoma. If suggestive of adenocarcinoma, cytology commonly points to a lung, stomach, colon, breast, or testicular origin of the primary. Cytology is particularly useful in diagnosis and classification of lymphomas. Careful application of the above techniques facilitates identification of the common head and neck lumps and their primary pathologies. The most common swellings will involve lymph nodes, thyroid, salivary glands, or developmental lesions (branchial cysts, cystic hygromas, sternomastoid 'tumour'). Rarer lesions include chemodectomas such as carotid body tumours and neurilemmomas. 200 2-B Physical Examination • Examination of the hands and wrists This assessment will include structural and functional changes across multiple systems. A logical approach is to think successively of the various tissue layers, checking for structure and function of each. Inspect carefully for deformities, and any abnormalities of skin and nails, then probe deeper. Test active and passive movements of each joint, always checking active movements first. Palpate carefully and carry out clinical testing for vascular insufficiency, musculotendinous disorders, bone and joint problems, and neurologic abnormalities. Common conditions encountered include: • Skin and nails: circulatory, neurotropic and occupational changes; a large variety of dermatoses and nail changes; pitting; infective lesions (Osier nodes, etc.); and vasculitis (nailfold capillaries). SECTION 2-B. FIGURES 12 AND 13. Osier nodes in bacterial endocarditis • Subcutaneous fasciae: Dupuytren nodularity and contracture, carpal tunnel syndrome. • Muscles, tendons and sheaths: Volkmann contracture (long forearm muscles) and short hand muscle contractures (intrinsic-plus deformity); trigger finger (stenosing tenosynovitis), De Quervain tenosynovitis; spontaneous tendon rupture (dropped finger, thumb); and ganglia (dorsal, ventral, digital). • Bones and joints: changes of osteoarthritis (Heberden and Boucher nodes, carpometacarpal joint of thumb); rheumatoid arthritis (synovial thickening, rheumatoid nodules, metacarpophalangeal subluxations and ulnar deviation fingers. Z-thumb, swan-neck. boutonnière, mallet finger deformities); and gout. SECTION 2-B. FIGURES 14 AND 15. Hands in rheumatoid arthritis Rheumatoid nodules 201 2-B Physical Examination Nerves: check median, ulnar and radial nerve motor, sensory and autonomic function;! differentiate peripheral nerve lesions from more centrally located cervical nerve root, and| upper or lower brachial plexus lesions. SECTION 2-B. FIGURES 16 AND 17. Testing interossei function • Thenar atrophy Vessels: observe for vascular ischaemic digital lesions, palpate pulses, check dominant! arterial supply (Allen test), check for proximal lesions (cervical rib, listen for axillary bruit)! • With hand and wrist trauma, check for bone and joint injuries, and local and distal tendonj nerve and vascular effects. • Functional assessment: test grip strength in dominant and nondominant hand: testl power, precision, and hook grips and opposition of fingers and thumb. Finally ask patient to perform everyday tasks of using a key, undoing buttons, writing, and combing hair. • Remember that any regional examination (for example, of head and neck, abdomen,; chest, limbs) necessarily involves assessment of several systems. A systems-based examination, by contrast, involves examination of several regions. Note the differing focused techniques required in performing an abdominal examination from examination of the gastrointestinal system PHYSICAL EXAMINATION SKILLS: EXAMINATION OF THE MAIN BODY SYSTEMS The structured approaches which follow provide succinct information on how to perform aq examination of each of the main body systems. The aim is to provide guidance for a thorough examination of each system such that important signs are not overlooked Readers are provided with learning objectives for each system and a brief guide on how to prepare both themselves and the patient in order to conduct the system specific examination. This material is based on the Clinical Skills curriculum for Monash University Faculty of Medicine, Nursing and Health Sciences. Generic learning objectives • Conduct physical examinations across the following: ~ Integument (see previous description) ~ Neurological system and mental status ~ Cardiovascular system ~ Respiratory system ~ Gastrointestinal system 202 2-B Physical Examination ~ Haematological system ~ Endocrinological system ~ Rheumatoiogical system ~ Renal and urogenital system • Interpret and integrate history and physical examination findings to arrive at an appropriate diagnosis or differential diagnosis in commonly presenting complaints and conditions. • Describe and use clinical reasoning skills. Preparing the patient • Establish patient's level of communication capacity. • Introductions: ~ Set the scene. ~ Explain your status. ~ Exhibit a human interest in the patient. ~ Gain patient permission. • Demonstrate professionalism. • Show sensitivity to patient's modesty, health status and comfort. • Involve patient in the process with clear initial explanation and stepwise instructions regarding what you are doing and why and what you wish the patient to do. • Establish what difficulties and discomfort (especially pain) the patient may have before and during the conduct of the physical examination, and avoid causing pain wherever possible. What equipment is needed? Have your own basic set of items to aid in eliciting signs. Items marked with an asterisk are standard requirements for personal use • watch with stop watch or second hand.* • stethoscope with capacity to detect low frequency (bell) and high frequency (diaphragm) sounds.* • pencil torch.* • disposable tongue depressors.* • measuring tape.* • reflex hammer (Queen Square pattern, best with a large-size rubber head).* • pins — these must be single use only and must not be hypodermic needles or diabetic lancets. Neurotips are excellent.* • cotton wool.* • 128 or 256 Hz tuning fork for vibration testing.* • Snellen chart for testing visual acuity. • mini-mental state examination (MMSE) card. • sphygmomanometers will be available in all wards and clinics and other items will also be available for relevant stations, but items starred you should have for personal use. 203 2-B Physical Examination 1. THE NEUROLOGICAL SYSTEM 1.1 Objectives Objectives for a neurological examination • Perform a stage-appropriate, technically competent neurological examination, incling ~ mental status ~ speech - gait ~ cranial nerves ~ limbs • Localise neurological disorders based on the results of physical examination. Other objectives Demonstrate stage-appropriate knowledge of the selection and use of standard neurological investigations (magnetic resonance imaging [MRI], computed tomography [CT], single proton emission computed tomography [SPECT], positron emission tomography [PET], electroencephalography [EEG], nerve conduction studies [NCS], electromyography j [EMG], lumbar puncture [LP]) based on the results of history and physical examination, 1.2 Preparation What specific equipment is needed? Essential • A red-topped pin for visual field examination • A bright pocket torch (a focusing torch with a halogen bulb, [e.g. mini-Maglite® or : similar] is best) • Visual acuity chart (Snellen) — the half-size 3 metre chart is the most practical for ward work Desirable • Ophthalmoscope • 512 or 1,024 Hz tuning fork for hearing tests • Glasgow Coma Score card as an aide mémoire Usually readily obtainable • Cotton wool (for corneal reflex testing) • Large size paper clip (straighten, bend in centre, then bend tips at right angles to ft a serviceable 2-point discriminator) 1.3 Physical examination 1.3.1 The neurological examination • Assessment of mental status ~ level of consciousness ~ attention (e.g. digit span) ~ language (comprehension, repetition, spontaneous speech, naming) ~ memory ~ visuoconstructional ability ~ executional ability ~ MMSE (for scaling) 204 Physical 2-B Examination ● Assessment of speech ~ dysphasia/dysarthria/dysphonia ● Observation of gait and posture ~ free gait and turning ~ tandem (heel to toe) gait ~ Romberg test ~ toe/heel stance and walk, rising from squat or chair. Trendelenburg test ● Cranial nerve examination involves ~ olfaction (not routinely tested, anosmia usually due to olfactory nerve or bulb injury) ~ vision: acuity, visual fields (red pin), colour vision, fundoscopy ~ pupils: shape, size, symmetry, reactivity (light and accommodation) SECTION 2-B. FIGURE 18. Trendelenburg test ~ eye movements: smooth pursuit (H-shape), diplopia, nystagmus ~ trigeminal: corneal reflex, cutaneous sensation, motor function, jaw jerk ~ facial: facial movements, strength of eye/mouth closure, corneal reflex ~ hearing and balance: whispered voice, otoscopy, tuning fork tests; vertigo; nystagmus ~ palatal: sensation, gag reflex/palatal movement, cough ~ accessory: sternocleidomastoids, trapezius ~ hypoglossal: tongue protrusion/fasciculation SECTION 2-B. FIGURE 19. Papilloedema SECTION 2-B. FIGURES 20 AND 21. Right hypoglossal nerve palsy ● Examination of the limbs ~ observe for deformity/wasting/fasciculation/adventitious movements ~ tone (spasticity, extrapyramidal) ~ power ~ reflexes (tendon/cutaneous) ~ coordination and rhythm ~ sensation joint position/vibration pin prick/temperature 2-point discrimination 205 2-B Physical Examination 2. THE CARDIOVASCULAR SYSTEM 2.1 Objectives for a cardiovascular examination • Inspect for general and peripheral signs of cardiovascular disorder • Accurately record vital signs — pulse and blood pressure • Assess the jugular venous pulse • Perform comprehensive central examination of the heart • Detect and differentiate normal and abnormal impulses, heart sounds and murmurs • Examine the lung bases, abdomen and lower limbs for signs of heart failure • Examine the central (carotid and aorta) and peripheral arterial pulses and listen for bruits • Provide an accurate summary of your findings 2.2 Preparation • Specific to the cardiovascular examination ~ have adequate exposure of the patient's chest wall ~ comfortably position the patient in the supine, 45 degree and sitting positions, 2.3 Physical Examination 2.3.1 The cardiovascular examination • Observe general appearance - colour ~ respiration ~ peripheral swelling • Observe and feel the hands ~ colour ~ warmth • ~ fingernails Feel and listen: the arterial pulse — radial: character, rate, rhythm, symmetry, brachial, the vessel wall • Measure and interpret blood pressure • Observe the face, tongue, sclera and conjunctivae • The neck ~ JVP: height, character, waveform ~ carotid arteries, feel and listen ~ trachea: position • The precordium ~ inspect for scars, pulsations ~ feel apex beat, and over 4 valve sites (impulses, thrills) ~ listen for heart sounds, murmurs — 4 sites ~ special manoeuvres for mitral, aortic murmurs • The chest ~ percuss and auscultate lung bases 206 2-B Physical Examination • The abdomen ~ look, feel, and percuss liver edge (check for pulsation and movement with breathing) ~ look, feel, and percuss spleen ~ look, feel, and listen to aorta ~ examine femoral pulses (radial-femoral delay) • The limbs ~ inspect skin ~ check for pitting oedema ~ check pulses and peripheral circulation ~ check venous system 3 THE RESPIRATORY SYSTEM 3.1 Objectives for a respiratory examination • Inspect for signs of respiratory disorders, respiratory distress • Accurately record vital signs • Recognise clubbing SECTION 2-B. FIGURES 22 AND 23. Finger clubbing • Recognise different breathing patterns ~ paradoxical, asymmetrical, recruitment of accessory muscles, diaphragmatic dysfunction • Examine the thorax ~ the chest wall and spine ~ the lung fields ~ central cardiac examination • Assess JVP, the abdomen and lower limbs for evidence of right heart failure • Assess for metastatic disease — lymph nodes in neck and axillae, liver, bony tenderness • Provide an accurate summary and interpretation of findings 207 1 1 3.2 Useful specific equipment • Peak flow meter SECTION 2-B. FIGURES 24 AND 25. Peak flow meter 3.3 Physical examination 3.3.1 The respiratory examination • Look for use of sputum cup, inhalers, oxygen • General inspection of patient ~ obesity/cachexia ~ inspired oxygen requirements ~ cyanosis ~ respiratory distress and ventilatory pattern • Inspect hands ~ nicotine staining ~ clubbing ~ peripheral cyanosis ~ metabolic flap ~ pulmonary osteoarthropathy • Blood pressure — measure, determine if there is paradox • Head and neck ~ JVP height, character and waveform ( c o r p u l m o n a l e ) ~ mouth/tongue (central cyanosis) ~ trachea (tug, deviation) ~ lymph node groups • Cardiac examination ~ apex beat position ~ parasternal heave ( c o r p u l m o n a l e ) ~ heart sounds 208 2-B Physical Examination • Thorax ~ chest inspection — scars, deformity, kyphosis, barrel chest, rib crowding (anterior upper chest) ~ the lung fields (start posteriorly) ~ chest expansion — demonstrate symmetry/asymmetry, check for flail segment. ~ percussion — Compare sides for normality, dullness, hyper-resonance ~ auscultation — vocal resonance, normal and abnormal breath sounds (bronchial breathing) and added breath sounds (wheezes or crackles) ~ anterior chest — repeat lung fields examination ~ test for upper lobe expansion, symmetry ~ percuss over clavicles ~ percuss and auscultate upper chest, axillae and laterally (remember right middle lobe region) ~ percuss spine and spring ribs for bony tenderness ~ assess sacral oedema • Abdomen ~ liver span — look for ptosis, feel for pulsatile liver • Lower limbs ~ oedema, rashes • Bedside lung function testing ~ forced expiratory time (obstructive disorders) ~ counting time (restrictive and/or obstructive disorders) ~ peak flow measurement (special test) 4 THE GASTROINTESTINAL SYSTEM 4.1 Objectives for a gastrointestinal examination • Inspect for general and peripheral signs of gastrointestinal disease • Accurately record vital signs (including lying and standing blood pressure) • Recognise ~ anaemia and hypovolemia ~ jaundice, ascites and signs of chronic liver disease ~ abdominal veins (Caput Medusae) ~ hepatomegaly and splenomegaly SECTION 2-B. FIGURES 26 AND 27. Scleral jaundice Ascites — chronic liver disease 209 2-B Physical Examination • Detailed assessment of the ~ abdomen ~ periphery • Assessment of JVP and heart for evidence of right heart failure • Assessment for metastatic disease • Summary and interpretation of findings 4.2 Physical examination 4.2.1 The gastrointestinal examination • Position the patient correctly (bed flat, single pillow, abdomen and chest exposed) • General inspection of patients ~ jaundice ~ weight and wasting ~ abdominal distension and peripheral oedema ~ skin (pigmentation and bruising) ~ mental state (encephalopathy) • Inspect the hands ~ nails (leuconychia, clubbing) ~ palms (erythema, anaemia, Dupuytren nodularity) ~ flap (asterixis) SECTION 2-B. FIGURE 28. Leuconychia • Inspect the arms ~ bruising, petechiae, scratch marks ~ spider naevi ~ pulse and blood pressure • Inspect the face ~ eyes: jaundice, anaemia, xanthelasma ~ parotid glands ~ mouth: dentition and breath (fetor) ~ tongue 210 Physical 2-B Examination • Inspect the neck and chest ~ cervical and supraclavicular nodes ~ spider naevi ~ gynaecomastia and body hair ~ JVP 4.2.2 The abdomen • Inspection ~ scars, herniae (inspect with coughing and straining before palpation). ~ distension or local swellings (inspect on deep breathing) ~ prominent veins ~ skin lesions and striae ~ periumbilical or flank discolouration (Cullen sign, Grey Turner sign) SECTION 2-B. FIGURE 29. SECTION 2-B. FIGURE 30. Dilated abdominal veins in portal hypertension Combined Cullen and Grey Turner signs in acute pancreatitis • Palpation ~ superficial palpation (tenderness, rigidity, outline of any masses) ~ deeper palpation (define masses; liver, spleen, kidneys, other abnormal masses) ~ measurement of organ(s) if enlarged ~ roll onto right side to palpate spleen • Percussion ~ visceral outline ~ ascites and shifting dullness (away from examiner; midline to left flank) ~ listen — bowel sounds, bruits, hums • Inspect the groin (seek patient's specific permission) ~ genitalia ~ lymph nodes ~ hernias 211 2-B Physical Examination • Inspect the lower limbs ~ oedema ~ bruising ~ neurological signs (alcohol) • Other ~ ask to perform a rectal (PR) examination ~ temperature chart ~ urine analysis — check this routinely for all systems 5 THE HAEMATOLOGICAL SYSTEM 5.1 Objectives for a haematological examination • inspect general appearance • inspect the hands and face and eyes • examine the lymph node groups: epitrochlear, axillary, facio-cervical, supraclavicular, abdominal, inguinal • assess for bone tenderness • perform an abdominal examination • examine the legs • perform a urinalysis with dipsticks • provide an accurate summary of your findings — oral and written 5.2 Physical examination • General appearance (position patient lying on the bed with one pillow) ~ geographical and ethnic origin — thalassaemia ~ pallor — anaemia ~ bruising — distribution and extent ~ jaundice — haemolysis ~ scratch marks/pruritus — lymphoma or myeloproliferative disorders SECTION 2-B. FIGURES 31 AND 32. Spontaneous bruising and abdominal wall haematoma from warfarin 212 Rectus sheath haematoma confirmed on CT 2-B Physical Examination • Hands ~ nails — koilonychia, dry, brittle, ridged, spoon-shaped nails due to iron deficiency ~ pallor nail beds — anaemia ~ rheumatoid arthritis or other connective tissues disorders, anaemia of chronic disease ~ gout — myeloproliferative disorders ~ pulse — tachycardia ~ anaemic patients have increased cardiac output and compensated tachycardia because of reduced oxygen-carrying capacity of blood ~ purpura — macular bruising within the skin, which can vary in size ~ petechiae — pinhead bruising on the dependent parts of the body ~ ecchymoses — large bruises • Epitrochlear lymph nodes ~ must always be palpated ~ place the palm of the right hand under the patient's right elbow. Examiner's thumb can then be placed over the area that is proximal and anterior to the medial epicondyle ~ enlarged epitrochlear lymph node is suggestive of Non-Hodgkin lymphoma • Axillary lymph nodes ~ five main groups of axillary lymph nodes — anterior and posterior, central, lateral and medial • Face ~ eyes - scleral jaundice — haemolysis - haemorrhage — platelet or bleeding disorder - injection — polycythaemia - conjunctival pallor — anaemia ~ mouth - gum hypertrophy — leukaemia especially acute monocytic leukaemia - gum bleeding - atrophic glossitis — megaloblastic anaemia, iron deficiency anaemia - Waldeyer ring — lymphatic tissue involving the tonsils and adenoids — enlarged in Non-Hodgkin lymphoma • Cervical and Supraclavicular Lymphadenopathy ~ sit patient up and examine from behind and in front ~ eight groups — submental, submandibular, jugular chain, posterior triangle, occipital, postauricular, preauricular and supraclavicular • Bone tenderness ~ tap spine ~ press ribs ~ gently press sternum and clavicle ~ enlarging marrow due to infiltration by myeloma, lymphoma or carcinoma 213 2-B Physical Examination • Abdominal examination ~ splenomegaly — palpate, percuss and measure ~ hepatomegaly — palpate, percuss and measure ~ para-aortic lymph nodes ~ inguinal lymph nodes — transverse and vertical groups ~ testicular masses • Legs ~ bruising ~ pigmentation ~ scratch marks ~ leg ulcers — haemolytic anaemia ~ neurological abnormalities — vitamin B12 deficiency 6 THE ENDOCRINE SYSTEM 6.1 Objectives for an endocrine examination • Inspect for general physical features associated with endocrine disorders • Develop skills in symptom pattern recognition in endocrine diagnosis • Identify typical appearances of patients with hypothyroidism, hyperthyroidism, acromegaly, Cushing syndrome, Addison disease, Klinefelter syndrome and hypogonadism SECTION 2-B. FIGURES 33 AND 34. Coarse facial features and skeletal enlargement characteristic of acromegaly. • Tailor the examination to the specific organ system • Evaluate signs of hormone over-secretion or under-secretion • Provide an accurate summary of your findings — oral and written 6.2 Physical examination 6.2.1 The endocrine examination • • General inspection: observe for features of specific endocrine disorders: e.g. Cushing syndrome, acromegaly, diabetes mellitus, hypoglycaemia, thyrotoxicosis, hypothyroidism Vital signs — blood pressure (postural hypotension) and pulse (bradycardia/ tachycardia) 214 2-B Physical Examination • Inspect and feel hands ~ overall size ~ length of metacarpals ~ abnormalities of nails ~ tremor ~ palmar erythema ~ sweating of palms • Examine axilla ~ loss of axillary hair, a c a n t h o s i s n i g r i c a n s , skin tags • Inspect eyes ~ visual fields ~ fundi • Face ~ hirsutism/hairless ~ skin greasiness, acne, plethora • Mouth ~ protrusion of chin ~ enlargement of tongue ~ buccal/lip pigmentation SECTION 2-B. FIGURE 35. Peutz-Jeghers syndrome • Neck ~ always look first and check effect of movements ~ examine for thyroid enlargement — smoothly diffuse, multinodular, or uninodular ~ palpate lymph nodes from behind and from in front ~ feel for thrill, listen for bruit over thyroid 215 2-B Physical Examination • Chest wall ~ hirsutism/loss of body hair ~ reduction in breast size/gynaecomastia ~ nipple pigmentation SECTION 2-B. FIGURE 36. Gynaecomastia • Abdomen ~ scars, purpura, striae, masses, hepatomegaly, cirrhosis, lipohypertrophy ~ hirsutism ~ external genitalia ~ central fat deposition • Legs ~ reflexes, tone ~ diabetic changes • Body mass index (BMI — kg/m2) 7 RHEUMATOLOGICAL/MUSCULOSKELETAL SYSTEM 7.1 Objectives for a rheumatological examination • • Perform accurate focused physical examination of joints, bones, tendons, muscles and bursae Follow sequence of look, move, feel, listen, measure, compare and Interprettor identifying normal and abnormal findings • Assess joints of limbs, spine and face — identify evidence of arthritis and whether acute or chronic, monarthritic or polyarthritic • Identify normal locomotor system anatomy and joint movement ranges, and anomalies including disorders of stance, gait and deformities • Identify extra-articular manifestations of systemic rheumatologic/connective tissue disorders • Compare sides in unilateral abnormalities and effects of dominant/nondominant hand in upper limb disorders 216 2-B Physical Examination SECTION 2-B. FIGURE 37. SECTION 2-B. FIGURE 38. Knee joint examination Positive Thomas test — left hip 8 RENAL AND UROGENITAL SYSTEM 8.1 Objectives for a urogenital examination • Perform accurate focused physical examination of male and female genitalia and identify abnormalities • Perform abdominal, vaginal and rectal examination with accurate interpretation of signs • Identify signs of acute and chronic renal insufficiency and their causes • Perform focused inguinoscrotal examination with accurate interpretation • Identify urinoscopy as a global screening test of wide utility • Identify signs and sites of urinary infections • Identify and diagnose sites and causes of haematuria, pyuria, bacilluria • Identify and diagnose sexually transmitted infections Vernon C Marshall and Barry P McGrath 217 2-B Physical Examination 2-B Physical Examination Candidate Information and Tasks MCAT 044-057 44 Assessment of a comatose patient 45 Recent onset of poor distance vision in a 17-year-old male 46 A painful rash on the trunk of a 45-year-old child-care worker 47 Acute low back pain and sciatica in a 30-year-old man 48 Fever and a recent rash in a 30-year-old man 49 A heart murmur in a 4-year-old boy 50 A knife wound to the wrist of a 25-year-old man 51 Multiple skin lesions in a Queensland family 52 Subcutaneous swelling for assessment 53 Examination of the knee of a patient with recurrent painful swelling after injury 54 Assessment of hearing loss, first noted during pregnancy, in a 35-year-old woman 55 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 56 Assessment of a groin lump in a 40-year-old man 57 Eye problems in an Aboriginal community 218 044 Candidate Information and Tasks Condition 044 Assessment of a comatose patient CANDIDATE INFORMATION AND TASKS This young patient has been found unconscious this morning at home by a flatmate. The flatmate is unable to provide any history, only becoming a flatmate a week ago. When found, the patient was in bed and there was no explanation as to why the patient might have become unconscious. The patient is now in the Emergency Department where you are about to do an examination. The airway is patent, and the patient is breathing without difficulty, the blood pressure is stable (140/70 mmHg) and temperature is 37.5 °C. YOUR TASKS ARE TO: • Perform an examination to determine the level of unconsciousness and to try to identify the cause. • Tell the observing examiner what you are doing and why. This can be as you proceed or at the end of each component of your examination. • Towards the end of the examination (after approximately six minutes), you will be required to provide the examiner with an assessment of level of unconsciousness, a list of possible and likely explanations for the patient's unconscious state and the investigations you would arrange. The Performance Guidelines for Condition 044 can be found on page 235 219 045 Candidate Information and Tasks Condition 045 Recent onset of poor distance vision in a 17-year-old male CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 17-year-old apprentice who is complaining of poor distance vision of recent onset. He can no longer read notices, street signs, scoreboards etc. at a distance. He says this is most inconvenient and is gradually getting worse. Both eyes are affected. He has asked you if he may be short-sighted like his father and his older brother. He wants to be tested to check for short-sightedness or any other problems, to ask whether he will need glasses or contact lenses, whether surgery can help and whether he should see an optician or an eye specialist doctor. YOUR TASKS ARE TO: • Examine the patient's eyes to exclude serious eye disease. • Test the patient's visual acuity using the Snellen test chart provided and state your findings to the patient. • Explain the problem to the patient. You do not need to take any further history. The Performance Guidelines for Condition 045 can be found on page 241 220 046 Candidate Information and Tasks Condition 046 A painful rash on the trunk of a 45-year-old child-care worker CANDIDATE INFORMATION AND TASKS You are a medical officer in a hospital primary care clinic. A 45-year-old child-care worker presents with a painful rash on the trunk, as illustrated below. YOUR TASKS ARE TO: • Take a history about the presenting problem. • Explain your diagnosis and the nature of the condition to the patient. • Advise the patient about management. (Near the end of the time allotted, the examiner will ask you one or two questions). CONDITION 046. FIGURE 1. The Performance Guidelines for Condition 046 can be found on page 246 221 047 Candidate Information and Tasks Condition 047 Acute low back pain and sciatica in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 30-year-old self-employed landscape gardener who is complaining of disabling left sided low back pain. The pain came on suddenly yesterday whilst lifting a heavy rock. The pain is also felt down the side of the left thigh and leg and the outer side of the foot. It is made worse by coughing and movement. The patient could not sleep last night despite taking two Panadeine® tablets (paracetamol 500 mg codeine phosphate 8 mg per tab). The patient has previously been in excellent health and has no other relevant past or family history. Abnormal examination findings are: He has difficulty standing or walking on his toes on the left side. He has severe limitation to left straight leg raising, with a positive stretch test, diminished left ankle jerk and diminished sensation to light touch on the outer aspect of the left foot, and painful limitation of lumbar spine movements, particularly flexion/extension and left lateral bending. YOUR TASKS ARE TO: • Advise the patient of the most likely diagnosis and management required. • Counsel the patient about when he can return to work and any necessary modifications that may be required. There is no need for you to take any additional history, nor request any further examination findings. All the information you need is detailed above. The Performance Guidelines for Condition 047 can be found on page 248 222 048 Candidate Information and Tasks Condition 048 Fever and a recent rash in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital primary care clinic. A 30-year-old man who works as a fashion consultant in a clothing store is presenting to you with fever and rash, onset two days ago. The rash appears as in the illustration below. It is a generalised erythematous maculo-papular rash. You have just finished examining him. Your other findings on physical examination were a fever of 38.5 °C, an inflamed palate, a palpable spleen and generalised tender lympha-denopathy in the neck, axillae and groins. YOUR TASKS ARE TO: • Take a further focused history from the patient. • Explain to the patient the possible nature of his condition and how you intend to proceed. • Briefly discuss differential diagnosis and investigations with the examiner. CONDITION 048. FIGURE 1. The Performance Guidelines for Condition 048 can be found on page 252 223 049 Candidate Information and Tasks Condition 049 A heart murmur in a 4-year-old boy CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 4-year-old boy has been seen with his mother. He was taken to another doctor with a cold whilst the family were on holidays and a soft cardiac murmur was heard. His parents were asked to bring him to see the family doctor, to decide if anything further needs to be done. His general health and exercise tolerance are excellent and he is on the 50th centile for height and weight. He has never been cyanosed. There is no history of heart disease in the immediate family but a cousin had a hole-in-the-heart operation. His parents feel he has no concerning symptoms. On examination you have confirmed a soft vibratory midsystolic murmur (grade 2/6) located between the lower left sternal edge and the apex, which varies with respiration. Full physical examination is otherwise completely normal. You have finished your history-taking and examination and are about to discuss things with the child's mother. YOUR TASK IS TO: • Explain your diagnosis and further management to the child's mother. The Performance Guidelines for Condition 049 can be found on page 255 224 050 Candidate Information and Tasks Condition 050 A knife wound to the wrist of a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working as a Hospital Medical Officer (HMO) in a hospital Emergency Department. The patient you are seeing has presented with a history of a knife wound to the left wrist from an assailant after an argument in a pub. He has been brought to hospital by an ambulance. The wound bled profusely at first and was controlled by a pressure dressing which is still on the wound. The ambulance personnel described the wound as a nasty deep knife wound and its extent is illustrated in the photograph. You are about to examine the patient for evidence of damage to important structures. Do not remove the dressing. Assume that the illustration represents accurately the extent of the skin wound. YOUR TASKS ARE TO: • Perform a focused and relevant examination to determine the likely extent of injury. Explain to the examiner what you are doing, and why, as you proceed, or at the conclusion of that segment of the examination. • Describe your findings and your diagnosis of the injuries to the examiner. • The examiner will ask you one or two questions at the conclusion of your commentary CONDITION 050. FIGURE 1. The Performance Guidelines for Condition 050 can be found on page 257 225 051 Candidate Information and Tasks Condition 051 Multiple skin lesions in a Queensland family CANDIDATE INFORMATION AND TASKS You are working in a general practice in a small country town. A 58-year-old farmer, who lives with his family, 160 km outside of town, comes to see you as he is concerned about his family members, having seen a television programme about skin cancer. He has taken photographs of his family's various skin lesions and asks for your advice about the need for them to seek medical attention, and whether attendance is urgent. They are all very busy harvesting crops and will be so for several weeks. The farmer presents the following photographs showing: 1. The lip of his 35-year-old son 2. The neck of his 50-year-old brother CONDITION 051. FIGURE 1. CONDITION 051. FIGURE 2. 3. The face of his 82-year-old father CONDITION 051. FIGURE 3. 226 4. The leg of his 56-year-old wife CONDITION 051. FIGURE 4. 051 Candidate Information and Tasks 5. The chest of his 52-year-old brother (who drinks a large amount of alcohol) 6. The face of his 22-year-old daughter CONDITION 051. FIGURE 6. CONDITION 051. FIGURE 5. YOUR TASKS ARE TO ADVISE HIM AS FOLLOWS AFTER REVIEWING THE PHOTOGRAPHS: • Indicate which lesions are likely to be benign, and which are likely to be malignant or suspicious of malignancy. • Indicate which member(s) of the family require(s) the most urgent treatment. • Indicate the mode of spread of any malignant lesions you diagnose. The Performance Guidelines for Condition 051 can be found on page 264 227 052 Candidate Information and Tasks Condition 052 Subcutaneous swelling for assessment CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your patient is seeking advice about a subcutaneous swelling which has been present for about 10 years. The patient thinks it may have grown slowly over this period but not much change in size has occurred. It has never been painful or otherwise symptomatic. The patient is not particularly concerned about it but is curious as to its cause. YOUR TASKS ARE TO: • Perform an appropriately focused and relevant physical examination in order to determine the nature of the lump. • Describe your findings to the examiner as you proceed. • Tell the examiner the likely diagnosis. • Explain your findings and diagnosis to the patient and indicate what further evaluation and/or treatment is required. You may ask relevant questions of the patient during your examination, but your princip task is to perform a physical examination and come to a diagnosis. The Performance Guidelines for Condition 052 can be found on page 274 228 Condition 053 Examination of the knee of a patient with recurrent painful swelling after injury CANDIDATE INFORMATION AND TASKS The patient you are about to see in a general practice setting has a history of twisting the right knee six months ago when he caught his foot on a piece of broken pavement. He fell on the knee and it became swollen and painful on the inner side. The swelling caused a painful limp for a few days and then subsided with easing of symptoms. Since then he has had intermittent attacks of pain on the inner side of the knee with swelling, which settles within 24 hours, and has had difficulty in straightening the leg fully. He is, on occasion, apprehensive when twisting to the right. Between attacks of pain he can walk normally with only a minor feeling of pain on the inner side of the knee. He is otherwise well. This is the first time he has consulted a doctor about this problem. YOUR TASKS ARE TO: • Perform a focused and relevant physical examination of the knees, giving a commentary to the observing examiner as you proceed, describing what you are doing and why, and your findings. • After seven minutes, you will be expected to present a diagnostic/differential diagnostic plan to the examiner. The Performance Guidelines for Condition 053 can be found on page 280 229 ^1 054 Candidate Information and Tasks Condition 054 Assessment of hearing loss, first noted during pregnancy, in a 35-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice and your next patient is a young woman who gave birth to her first child one month ago. She is complaining of loss of hearing, which she first noted about midway through her pregnancy. It has become progressively worse since and affects both ears. She is otherwise well and her infant (breastfed) is thriving. YOUR TASKS ARE TO: • Take a further focused history concerning her hearing loss (limit this to one minute). • Examine the patient and test her hearing, telling the examiner what you are doing, including your findings. • Tell the examiner the type of hearing loss present. • Inform the patient of the most likely cause of her hearing loss. • Suggest to the patient what further action is indicated for her hearing loss, including a prognosis. The Performance Guidelines for Condition 054 can be found on page 282 230 Candidate Information and Tasks Condition 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO). Your next patient dislocated her shoulder playing competitive basketball six months ago. It was a typical anterior dislocation which was complicated by a nerve injury and was treated by closed reduction, several weeks immobilisation in a sling, subsequent physiotherapy and a gymnasium programme. The patient has returned for a check up at the hospital outpatient department, has told you the shoulder now seems to be working fine, and that she would like to recommence playing basketball next season. YOUR TASKS ARE TO: • Perform an appropriately focused and relevant physical examination of the area. • Describe your findings to the observing examiner as you proceed. • Discuss future activities with the patient. • In the final two minutes you will be asked questions by the examiner. CONDITION 055. FIGURE 1. Film of previous dislocation 6 months ago The Performance Guidelines for Condition 055 can be found on page 286 231 056 Candidate Information and Tasks Condition 056 Assessment of a groin lump in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are working in a primary care clinic attached to a teaching hospital. Your next patient is a 50-year-old man who works as a builder's labourer. Two weeks ago he felt a pain in his right groin after heavy lifting at work and a week later noticed a lump in the groin which had not been there before. The lump is not acutely painful, but is uncomfortable on exertion or walking. Discomfort is eased on lying down. He is in good general health, without relevant past history and has no problems with lungs or heart, bladder or bowels. YOUR TASKS ARE TO: • Perform a focused physical examination to assess the lump, which is illustrated below. • Give your diagnosis and management plan to the patient. You do not need to take any further history. CONDITION 056. FIGURE 1. The Performance Guidelines for Condition 056 can be found on page 289 232 Condition 057 Eye problems in an Aboriginal community CANDIDATE INFORMATION AND TASKS You are a doctor working in a general practice in a remote setting in the Northern Territory. You are about to see a nurse who has recently joined the staff of the general practice clinic. The nurse made a time to see you to discuss eye problems she has noticed in the local Aboriginal community. The nurse has taken digital photographs of eye problems that were noticed in a number of affected individuals (see figures below of four separate individuals). In the upper two photographs the upper eyelid is everted. The nurse wants you to explain what can cause these appearances, and what can be done about the problem in the local community. YOUR TASKS ARE TO: • Study the photographs and describe the abnormalities to the clinic nurse. • Explain to the nurse what disease is illustrated in the photographs, and its epidemiology. • Discuss with the nurse how the problem should be managed. • Answer any questions that the nurse may have. CONDITION 057. FIGURE CONDITION 057. FIGURE 2. CONDITION 057. FIGURE 3. CONDITION 057. FIGURE 4. Figures 1 and 2 were photographs taken after everting the upper eyelid. The Performance Guidelines for Condition 057 can be found on page 293 233 2-B Physical Examination 2-B Physical Examination Performance Guidelines M CAT 044-057 044 Assessment of a comatose patient 045 Recent onset of poor distance vision in a 17-year-old male 046 A painful rash on the trunk of a 45-year-old child-care worker 047 Acute low back pain and sciatica in a 30-year-old man 048 Fever and a recent rash in a 30-year-oid man 049 A heart murmur in a 4-year-old boy 050 A knife wound to the wrist of a 25-year-old man 051 Multiple skin lesions in a Queensland family 052 Subcutaneous swelling for assessment 053 Examination of the knee of a patient with recurrent painful swelling after injury 054 Assessment of hearing loss, first noted during pregnancy, in a 35-year-old woman 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 056 Assessment of a groin lump in a 40-year-old man 057 Eye problems in an Aboriginal community 234 044 Performance Guidelines Condition 044 Assessment of a comatose patient AIMS OF STATION To assess the candidate's ability to examine and diagnose a patient presenting with coma. The examiner will have instructed the patient as follows: You are to play the part of a young person found in a coma in your flat this morning breathing without difficulty with a Glasgow Coma Score of 10 out of 15 (see following pages about Glasgow Coma Scale). You are wearing shorts and T-shirt and are feigning unconsciousness and stupor on a hospital bed. Your responses should be: • Maintain your level of consciousness and responses as follows during the candidate's examination. Keep your neck stiff when candidate attempts to flex it. ~ Eye opening: eyes should be closed. Do not open them spontaneously or to verbal command but open them in response to painful stimulation. ~ Best motor responses: no response to verbal command. Localise pain when stimulated — move arms towards source of pain or withdraw limb if stimulated. ~ Best verbal responses: use of inappropriate words. When painful stimuli applied say 'piss off', or 'damn'or 'shit'. The candidate will probably: • Do a general examination looking for evidence of injury. • Examine your eyes and pupils, and will open your eyelids to do this and shine a torch. • Examine your response to commands and painful stimuli. • Examine you for neck stiffness (which you have). • Check your pulse and breathing. Blood pressure and temperature have been given as normal. • Check your arms for evidence of intravenous drug abuse. In summary, you are being examined to check the level of coma and possible causes for this. • You are feigning a partially responsive coma, with a Glasgow Coma Score of 10-11 out of the normal score of 15, breathing spontaneously, reacting by localising to pain, and with inappropriate verbal response when stimulated. • Remain in this role throughout the examination. • Remember, your neck is stiff if flexion is attempted. 235 044 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is examining, in the Emergency Department, a comatose young person found in bed this morning, who is haemodynamically stable. The candidate is expected to: • Examine for evidence of injury to the head or elsewhere. • Look for evidence of neck stiffness. • Examine eye movement by gently opening the lids. • Examine pupillary size and response to light (direct and consensual). • If candidates say they are going to test the corneal response, indicate that there is normal eye closure to cotton wool testing. Similarly, if the candidate wishes to look at the fundi or ear drums, advise that they are normal. • Examine breathing pattern — no hyperventilation (as in a hyperglycaemic coma) or hypoventilation (as in a drug overdose) is present. • Examine for evidence of intravenous drug use or insulin injection sites in patients with diabetes. • Check for pulse rate, rhythm and character, which are normal. • Arrange immediate blood sugar estimation — this may be asked by the candidate as part of the examination. Alternatively, it should be done as part of the investigations recommended. After six minutes, the examiner will ask the candidate three questions: 1. 'What is the Glasgow Coma Scale level?' Answer: around 10-11 out of possible 15 (Table 1) 2. 'Name at least four possible causes of the coma?' Acceptable causes would be: ~ drug overdose ~ meningitis ~ cerebral vascular accident (subarachnoid haemorrhage) ~ diabetic hypoglycaemia or hyperglycaemia ~ head injury ~ psychiatric problem 3. 'What investigations would you do?'— all these are required urgently: ~ brain computed tomograph (CT) / magnetic resonance imaging (MRI) (if available-lumbar puncture generally should NOT be done until the results of head imaging are available. If results from CT/MRI are not available, lumbar puncture using a 25 gauge needle would be appropriate in view of neck stiffness). ~ blood and/or urine for drug screen ~ serum electrolytes and blood glucose ~ oxygen saturation 236 044 Performance Guidelines KEY ISSUES • Ability to perform a focused, relevant and accurate examination to aid determination of the level and cause of the coma. ~Neck stiffness should be tested and identified. ~ No response to verbal command but response to pain. ~ The candidate should indicate appropriate knowledge of the Glasgow Coma Scale. • Ability to provide an adequate differential diagnosis. • Ability to describe an initial investigation plan. ~ Mandatory investigations should include Brain CT or MRI. drug screen and blood sugar level. If CT/MRI is not readily available, a lumbar puncture should be performed if there is no evidence of papilloedema. • Failure to determine reasonably the level of coma by the Glasgow Coma Scale score. • Failure to check for neck stiffness. Coma is a state of deep unconsciousness where the patient shows no meaningful response to external stimuli. The comatose patient has no verbal response, does not obey commands and does not open the eyes spontaneously or in response to command. Stupor is also a state of inaccessible consciousness without awareness, but the stuporous patient shows some response to painful stimuli. Coma and stupor, and other levels of deep unconsciousness, are best graded on the Glasgow Coma Scale. This has three elements: eye opening, and best verbal and motor responses to standard stimuli (Table 1). 237 044 Performance Guidelines CONDITION 044. TABLE 1. Glasgow Coma Scale score CRITERIA Eyes open Spontaneously To speech or verbal command To pain No response Best motor response SCALE 4 3 2 1 - To verbal command Obeys - To painful stimuli 6 Localises pain Withdrawal Abnormal flexion (decorticate rigidity) Extension (decerebrate rigidity) No response Best verbal response 5 4 3 2 1 Oriented Confused conversation Inappropriate words Incomprehensible sounds No response TOTAL SCORE 5 4 3 2 1 Range of 3-15 NOTE: A score of 15 represents a fully responsive and conscious patient. A score of 3, the lowest level, a deeply comatose patient unresponsive to external stimuli. A score of 3 of course does not indicate 'brain death' or a 'vegetative state or any other prognostic features as a single reading Guidelines for neurological examination and conscious state chart are shown in Figures 1 and 2 1 . 1Reproduced from Hunt P and Marshall V, Clinical Problems in General Surgery, Butterworths 1991 238 CONDITION 044. FIGURE 1. Conscious state and head injury chart1 1Reproduced from Hunt P and Marshall V, Clinical Problems in General Surgery, Butterworths, 1991. 239 044 Performance Guidelines CONDITION 044. FIGURE 2. Guide to recording neurological observation chart1 1Reproduced from Hunt P and Marshall V, Clinical Problems in General Surgery, Butterworths, 1991 240 Condition 045 Recent onset of poor distance vision in a 17-year-old male AIMS OF STATION To assess the candidate's knowledge of myopia, and ability to test visual acuity and distance vision using a Snellen test chart. The examiner must check the myopic patient's visual acuity in each eye before the examination commences. The patient should have mild myopia and does not require any special instructions other than the knowledge of having his eyes tested and providing appropriate responses. The doctor/candidate will explain and perform the procedures. EXPECTATIONS OF CANDIDATE PERFORMANCE Exclude serious eye disease The candidate should indicate that the following would be examined: • eyelids (ptosis, retraction of upper or lower lids) • conjunctiva (chemosis, injection, pallor) • cornea (ulceration) • anterior chamber (blood or pus) • sclera (jaundice) • orbit (tenderness, paraesthesia) • eyeball (intraocular pressure, glaucoma) The candidate should indicate use of the ophthalmoscope to: • test the red reflex (to exclude cataract); • examine the retina (detachment, exudates, haemorrhage, new vessel formation); • examine the optic disc (bulging, blurring of margins): and • examine the macula (exudates). The pupil will not be dilated. The candidate is expected to describe the proposed use of the opthalmoscope to the examiner who will then say 'fundoscopic examination is normal'. A thorough examination of the eye will also include instillation of fluorescein (cornea), dilatation of the pupils (appropriate view of the posterior chamber), tonometry (intraocular pressure) and the pinhole test. The pinhole test A pinhole test card should be placed in an obvious position and used by the candidate for both eyes If visual acuity is not improved by looking through a card with a 1 mm pinhole, the defective vision is not solely due to a refractive error. Macular degeneration, cataract and glaucoma will need to be excluded. If the unaided visual acuity is less than 6/12, the patient should be referred to an ophthalmologist. 241 045 Performance Guidelines Test visual acuity The term 'visual acuity' refers to the clarity of vision (from the Latin acuitas or sharpness). Visual acuity is expressed as a proportionate relationship between the subject's vision and a person with normal vision. The subject is asked to read from a Snellen chart. The chart, with letters of different sizes on each of its ten or eleven lines, is placed 6 metres (20 feet) from the subject. An individual with visual acuity of 6/6 (or 20/20 if feet are used) is just able to identify a letter whose height subtends 5 minutes of arc at the eye. Such letters are found on one of the lower lines of the Snellen chart. Acuity of this degree is referred to as normal vision. Being able to discern letters below this line shows increased visual acuity and if the individual can only decipher letters above this line, the visual acuity is diminished. A near-sighted (myopic) individual will have better visual acuity at close distance, whereas a far-sighted (hyperopic) person will have better visual acuity at far distance. With the onset of presbyopia, near visual acuity diminishes and reading glasses are required. Testing visual acuity Visual acuity is measured using the Snellen chart, displaying letters of progressively smaller size. Visual acuity is recorded in the form of a fraction but it is NOT a fraction in the mathematical sense of the word. The numerator indicates the distance of the patient from the chart (e.g. 6 metres), and the denominator indicates the distance at which the normal eye can read the line. Normal vision is 6/6 (20/20). Visual acuity of 6/6 means that the test subject sees the same line of letters at 6 metres (20 feet) as that seen by a person with normal sight at 6 metres (20 feet), whereas 6/12 (20/40) vision means that the test subject sees at 6 metres (20 feet) what a normal person sees at 12 metres (40 feet). Because the visual nomenclature used does not représenta mathematical fraction, it is incorrect to say that 6/12 represents 50% of normal sight. In fact, for legal assessment of visual impairment, 6/30 is regarded as a 50% impairment. Visual acuity of 6/5 (20/15) vision is better than normal 6/6 (20/20). A person with 6/5 (20/15) vision can see objects at 6 metres (20 feet) that a person with normal vision sees at 5 metres (15 feet). Note that the Snellen notation applies only to distance vision. Near vision is recorded using font size, usually in this country the American point-type. Thus normal reading vision is N5 (5 point type). Newsprint is N8 (8 point type). Levels of vision 6/6 — Normal vision. This is the visual requirement for a fighter pilot 6/12 — The visual requirement for a Driver's Licence in Australia 6/60 — Legal blindness. Testing should be done as follows: • The patient faces a Snellen chart at 6 metres distance. Formal testing requires a distance of 6 metres (20 feet), necessitating use of a large room or a small room with a mirror to adjust for the distance. A 6-metre chart should always be employed for formal visual acuity testing. Preliminary office testing can employ a 3-metre chart. 242 045 Performance Guidelines • Explain procedure to patient: Start reading at top (largest) line of letters. If only the top line can be read, acuity is 6/60. If the patient is unable to read the top line, the chart should be moved closer to the patient, 1 metre at a time, until the top line can be read. If the top line can be read at 3 metres, this is recorded as 3/60. If the patient cannot see 1/60, he is asked to identify a moving hand, and this is recorded as 'Hand Movements' (HM). If unable to see a moving object, a light is shone in the eye and the patient is asked if he can appreciate the light, and this is recorded as 'Perception of Light' (PL). If the patient can point to the light accurately, this is recorded as 'PL with accurate projection'. If the light is not seen, the acuity is NLP (No Light Perception). • Visual acuity corresponds to the lowest line which can be read. The small numbers corresponding to the lowest line which can be read give the denominator — the distance in metres at which a person with normal vision can read the line. In a line with 5 or more letters, the patient should correctly identify 3 letters to be regarded as having read the line. • Examine each eye separately by using an occlusive card in a systematic way which includes asking the patient to read the lines backwards when testing the second eye. • If the visual acuity is worse than 6/6, the candidate should perform a pinhole test. Ask the patient to hold a piece of paper with a 2 mm hole in it over the uncovered eye. This manoeuvre utilises the 'pinhole camera effect' and results in an improvement in visual acuity if a refractive error is the cause of the diminished acuity. The patient should be referred for refraction and prescription of glasses. • The candidate should give findings to examiner in the conventional way, normal vision being 6/6. The smaller the ratio, the poorer the vision (6/12, 6/24, etc). Explain problem • Nature of myopia. • Management options. KEY ISSUES • Exclusion of serious eye disease with ophthalmoscope and pinhole test. • Correct use of the Snellen test chart. • Accuracy of examination (compare with examiner's findings). • Diagnosis — must state myopia, or short-sightedness or near-sightedness. • Patient counselling/education — cause, treatment, need for periodic check of intraocular tension when over 40 years of age. CRITICAL ERRORS • Failure to exclude serious eye disease. • Failure to mention myopia as a possible diagnosis. 243 045 Performance Guidelines COMMENTARY A comprehensive history and careful physical examination will provide a diagnosis in most common ophthalmic disorders. Although unlikely in this case, the possibility of the patient's complaint of recent impaired vision being due to a serious cause (namely retinal detachment, glaucoma, cataract or macular degeneration) should be considered by the candidate Ophthalmoscopic examination and the use of the pinhole test cover these concerns at this stage of assessment of vision. Myopia (near-sightedness or short-sightedness) is a common inherited condition which in most cases is due to the axis of the eyeball being too long so that the visual image is focused in front of the retina. Less often the refractive power of the lens is too strong. The condition is readily corrected by the use of a concave (minus) lens. Onset can be in childhood, but more commonly in late teens. The condition tends to worsen in early adult life and then stabilises. The prescription: The refractive error of the eye can be expressed in numeric terms. The power of the lenses necessary to correct vision is measured in units called dioptres (see below). The first number in a spectacle prescription designates the amount of myopia (minus numbers) or hyperopia (plus numbers). The second number (if present), indicates the amount of astigmatism. The third number indicates the axis of the steepest meridian of the cornea (e.g. +3.00/-2.50 X 170'). The fourth number is the additional correction needed to bring the focal point of the eye to the reading distance. The dioptre is the unit of measurement of the strength of a lens. A lens deviates light and the amount of deviation is proportional to the amount of curvature and the density of the lens. A lens of power of 1 dioptre has a focal length of 1 metre (i.e. parallel rays of light are brought to a focus 1 metre from the lens). As the refractive power of a lens decreases, the focal length increases. The strength of a lens = 1/focal length. Thus a 4-D lens has a focal length of 'A metre. The power is a negative number of a concave lens (myopia, near-sightedness) or a positive number for a convex lens (hyperopia, far-sightedness). The corrective lens can be prescribed by an optician, although an initial assessment by an ophthalmologist is preferable to exclude any other cause of visual impairment, especially retinal detachment and macular degeneration, both more common if myopia is severe. Contact lenses can be worn to correct myopia, without the risks of surgical correction. Corrective operations (excimer laser surgery) can produce excellent results by altering corneal curvature and thus the refractive power of the eye. This procedure is not without significant risk. Otherwise glasses will need to be worn. Reading is not affected much until middle age. Myopia can affect the accurate measurement of intraocular pressure, and therefore intraocular pressure should be checked periodically to detect chronic open angle glaucoma which is asymptomatic in the early stages. This applies to all patients, and particularly to myopes. The 'acute red eye', although not relevant to this case, is an important and urgent clinical problem. Most of the causes of red eye (conjunctivitis, foreign body, inflammation ulceration, glaucoma and subconjunctival haemorrhage) are associated with pain and/or trauma and can be excluded on the history alone in this patient. 244 Sudden loss of vision is usually associated with a vascular or neurological problem and again, these types of problem are not relevant in the present case. Diabetes mellitus must be considered, as presentation of this disorder with an ophthalmological complication may occur. Some diabetics present with cataract; others with mature onset diabetes may present with poor central vision due to oedema of the macula. The assessment of the ophthalmoscope and pinhole test should exclude the serious disorders that can be associated with gradual visual loss (and others such as retinal detachment, glaucoma, cataract and macular degeneration). CONDITION 045. FIGURES 1 AND 2. Visual acuity charts (not to scale) 245 046 Performance Guidelines Condition 046 A painful rash on the trunk of a 45-year-old child-care worker AIMS OF STATION To assess the candidate's approach to a patient with a dermatomal rash from herpes zoster plus weight loss and tiredness, which could be incidental but may be associated with underlying malignancy. These symptoms need to be further assessed. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a child-care worker in a kindergarten. You are single and live by yourself. Opening statement: 'I've had a pain in my lower chest and now there is this rash. ' Answer questions about your condition as follows: • You have been feeling a bit unwell for a few days. • You have had a burning pain over your lower chest and flank for a few days. • You noticed today that you have developed a blistery rash that runs in a line around your chest and abdomen in the area where the pain started. • In addition, you have lost 6 kg in weight over the past few months and have been feeling more tired than usual (you have nothing to add to this general statement. You have noted no disturbance to any body system function). • You have had no serious past illnesses, there is no relevant family history. You have no allergies and are on no medications. Describe the pain and the skin rash without prompting. Do not volunteer the weight loss and associated recent tiredness unless questioned first about How has your health been in general?'or something along those lines. You have been considering having a checkup but have no other symptoms, and you had not considered that there might be something seriously wrong until the pain and this rash appeared. EXPECTATIONS OF CANDIDATE PERFORMANCE • History • Diagnosis ~ Typical history and rash (see Figure 1) of herpes zoster with prodromal preherpetic neuralgia. ~ Must make diagnosis of herpes zoster. Must show concern over recent weight loss and tiredness. • Initial management ~ Treat the rash with symptomatic measures such as calamine or cold compresses and a drying lotion. ~ Use analgesics with or without codeine. ~ Treat with antiviral medications if patient presents (as in this instance) within firs! 72 hours of the rash — aciclovir, famciclovir or valaciclovir. 246 046 Performance Guidelines ~ Monitor for the development of postherpetic neuralgia which may require further management. ~ Examine patient and perform investigations for any possible precipitating cause. In this case, the weight loss and tiredness demand further investigation (no details are required at this stage). • Patient education and counselling ~ Explain the cause to the patient (i.e. relationship of herpes zoster to varicella [chicken pox]). ~ Explain that the condition is only mildly contagious, but that chickenpox can be acquired by those persons in close contact with the patient who have not previously had chicken pox. Therefore appropriate infection control measures need to be taken including management of occupational and community contacts (for example, she is a child-care worker in a kindergarten and young children and babies should not be exposed to vancella zoster virus). After 5-6 minutes, if the candidate has not discussed these issues, the examiner will ask ~ 'Are there any unusual features of the condition in this patient? ~ 'How would you manage this particular patient?' KEY ISSUES • History-taking must elicit weight loss and tiredness. • Diagnose herpes zoster/shingles • Management must consider use of aciclovir or other related antiviral drugs. • Must advise further assessment regarding weight loss and tiredness and discuss implications of infectivity. CRITICAL ERRORS • Failure to diagnose herpes zoster. • Failure to consider the possibility of an additional underlying cause in this patient. • Failure to assess implications for contacts in community and work settings. COMMENTARY Herpes zoster (shingles) is caused by reactivation of varicella zoster virus (VZV) acquired originally through primary infection with chicken pox. • The condition is more common in people over 50 years of age. • The virus is found in the dorsal root ganglion. In most cases the reason for reactivation is unknown, although occasionally this can be related to an underlying malignancy such as a lymphoma, leukaemia or immunosuppression including HIV infection. • Occasionally patients may get rare complications including meningoencephalitis. • Post-herpetic neuralgia is an important sequel. The incidence of post-herpetic neuralgia increases with age, affecting around 30-50% of adults aged 70-79 years. 247 047 Performance Guidelines Condition 047 Acute low back pain and sciatica in a 30-year-old man AIMS OF STATION To assess the candidate's ability to diagnose and treat the problem of acute exertion-related low back pain and sciatica. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a self-employed landscape gardener aged 30 years. You have consulted this doctor because of the sudden onset of severe disabling pain in your lower back yesterday which moved down your left thigh and leg into your foot. It came on when you lifted a heavy rock and you have not been able to work. You could not sleep last night despite taking Panadeine® tablets. It hurts to move and to cough. You usually keep in excellent health with no serious medical problems in the past. The doctor has taken your history and examined you. He will explain the problem and what you have to do. • Show concern about how you are going to be able to work now and in the future. • Appear to be in severe pain - sit uncomfortably be restless. • State dissatisfaction with level of pain relief — you could not sleep last night. • Expect the doctor to 'do something' to get rid of the pain. • Resist advice (irrationally) not to go to work even in a supervisory capacity because of important jobs needing to be finished. • Become compliant if the doctor explains the situation and gives appropriate advice. Questions to ask unless already covered (candidate's likely response is detailed in brackets): • W h a t h a s h a p p e n e d t o m y b a c k ? ' (Explain 'slipped disc' — intervertebral disc prolapse with • H o w d o e s t h i s h a p p e n ? ' ( V e r y common, related to stress on back whilst lifting). • H o w l o n g w i l l I b e a w a y f r o m w o r k ? ' (Depends on progress. Usually settles rapidly with I herniation of nucleus pulposus — use of a diagram can be helpful). adequate rest. If so, off work for 1-2 weeks. If pain does not settle, must be investigated by CT orMRI). • ' S h o u l d I s e e a c h i r o p r a c t o r ? ' (Definitely not at this stage; manipulation may worsen the condition). • W i l l I b e a b l e t o l i f t h e a v y o b j e c t s i n t h e f u t u r e ? ' (Give advice on how to lift with gooi self-maintenance strategies). • ' W i l l I a l w a y s h a v e a b a d b a c k ? ' { N o , likelihood of recovery is good). • 'Do / n e e d t o s e e a S p e c i a l i s t ? ' (Not at this stage, will be arranged if symptoms persist! • ' C a n ' t I h a v e a n o p e r a t i o n t o f i x i t a n d r e l i e v e t h e p a i n ? ' (Usually not necessary, but wil • ' W h a t e l s e c a n I t a k e f o r t h e p a i n ? ' (Panadeine forte03). depend on progress). 248 047 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Diagnosis and explanation of condition • Anatomy of lumbar spine (this is an L5/S1 level problem, involving the S1 nerve root) • Causes of pain particularly disc prolapse with nerve impingement/irritation (radiculopathy). • Expected course both short and long term — most resolve completely • A diagram would assist. Immediate management • Adequate rest is essential (3-4 days rest at home, but up and about as tolerated) • Pain-relieving medication — Panadeine®, Panadeine forte® or similar (including NSAID). • Subsequent physiotherapy and back-strengthening exercises. • Indications for further investigation — lack of, slow, or incomplete resolution. Then needs CT orMRI. • Avoidance of manipulation. • Gentle traction may have a place in treatment if progress slow — would be advised after specialist referral. • Emphasis on positive approach. Prognosis for recovery within a few weeks is good despite ankle jerk being affected. • Need for investigation — this is particularly important if there is no improvement, or there is continuing evidence of neurologic or muscle weakness (CT acceptable, MR I preferred, plain X-ray gives limited information only). • Physiotherapy — stretching and arching active mobilising exercises appropriate once initial symptoms ease. • Orthopaedic, neurological or rheumatologic consultation — will be required for lack of resolution. Preventive measures 'Back education' including advice regarding bending and lifting, and the value of walking, swimming. Future management Reassessment in short term (2-3 days). This is essential. • Ability to determine the likely cause of the sciatica and to explain the cause to the patient. • Adequate knowledge of the management of a patient with acute sciatica including what further investigations or referral are required and when these should be done. • Ability to advise the patient about work practice modifications required to prevent a recurrence of the problem. • Ability to advise early rest and short term review. 249 047 Performance Guidelines CRITICAL ERRORS • Failure to make correct diagnosis of a likely disc lesion. COMMENTARY Low back pain is a very common problem in Australian society. The incidence increases with age and is more common in manual workers than sedentary workers. A major problem in spinal assessment is the fact that there is often a poor correlation between clinical presentation (the patient's history and examination finding) and the imaging findings. Imaging abnormalities will be found with increasing frequency in individuals with or without accompanying symptoms from their third decade onwards. Back pain, acute and chronic, is thus one of the most common of all conditions encountered but precise pathology is very frequently lacking. The portmanteau and nonspecific term 'Mechanical low back pain' is useful in that it codifies a very common condition from which almost all individuals will suffer at some time of their lives. In such instances the precise pathology is indeterminable and no specifically diagnostic imaging or other test is available. Back pain may (or may not) follow an identifiable injury or strain as occurred in this patient Pain is usually self-resolving over a period of days or weeks, but may become recurrent, relapsing or chronic, and is influenced by cultural, psychological, socioeconomic and other personal factors in its incidence and persistence. Against such a background, it is hardly surprising that the condition and its preferred treatment remain controversial. The outcome of physical treatments such as massage, manipulation, heat, light, sound/ultrasound, electricity and magnetism (and surgery) are each difficult to separate from placebo and are prone to fashion and fetish. Clinical studies are possible and literature search and meta-analysis can be helpful and reveal (for example) that laser treatment of low back pain is free of concerning side-effects, but gives short term outcomes no different from placebo, and is expensive and not cost-effective. Distinguishing true radicular sciatic pain ('sciatica') due to nerve root compression requires symptoms of pain of lancinating or cramping type, extending usually from low back and buttock down the leg to foot and toes corresponding to sensory disturbance within the dermatomal distribution of appropriate nerve roots (most commonly L5 or S1 ), exacerbated by straining or coughing, with positive nerve tension signs, and sometimes with objective motor weakness and sensory loss corresponding to the appropriate motor nerve root. Such a constellation of objective signs (as in this patient) is virtually pathognomonic and diagnostic of nerve root foramen compression (from intervertebral | disc prolapse, facet joint arthropathy or other encroachments on the relevant nerve root or spinal canal). Confirmation of the diagnosis can usually be made by noninvasive imaging, of which MRI is the most accurate. Persistence of unrelieved pain after one month is an | indication of the need for a full history and examination (including diagnostic imaging), concentrating on the search for pointers of more serious pathology (malignancy, referred back pain from intra-abdominal lesions, bone infections, or cauda equina symptoms such as interference with bowel or bladder control). This case scenario has been chosen to exemplify the classical syndrome of nerve impingement radiculopathy, the most likely diagnosis being compression from an intervertebral disc prolapse between L5 and S1. 250 047 Performance Guidelines By contrast, most cases of simple mechanical back pain due to musculoligamentous soft tissue strain injuries will resolve within one to two weeks with explanation and encouragement, early mobilisation without bed rest ( ' d o n ' t t a k e b a c k p a i n l y i n g d o w n ) and simple analgesics, aided where indicated by a short course of physical therapy concentrating on early mobilisation and an active exercise program, and patient education regarding good back strategies. Plain radiographs for patients with persisting chronic pain rarely are of clear cut diagnostic value, but may show loss of disc height, gas formation in the nucleus pulposus, adjacent vertebral marginal sclerosis and osteophytes, or other radiological signs of lumbar vertebral spondylosis affecting the facet joints. However, similar radiological signs or evidence of minor spondylolysis or spondylolisthesis are also present commonly in nonsymptomatic middle-aged or elderly people. MRI is the investigation of choice for defining spinal pathology when surgery is being considered. Surgery is, however, indicated in only a very small percentage of patients with low back pain and it is quite rare to demonstrate treatable new pathology in patients with chronic low back pain, which has lasted for more than a year. Associated job dissatisfaction, depression, obesity and socioeconomic deprivation are commonly found in such instances. Long-term treatments with laser, shortwave diathermy, ultrasound, acupuncture, transcutaneous electrical nerve stimulation, formal physiotherapy or chiropractic have not convincingly been demonstrated to have other than placebo effects. The effects of repeated image-guided facet joint, epidural or nerve root foraminal injections of local anaesthetic or corticosteroids are also disappointing in the long-term. Percutaneous semisurgical procedures (radiofrequency rhizolysis) also seem of little convincing long-term value. Surgical techniques have improved in the small group of patients requiring surgery, and release surgery for focal major nerve root compressions confirmed by imaging can be dramatically effective. By contrast, spinal fusion techniques for chronic low back pain are various, results can seldom be guaranteed and persisting pain after surgery is common. 251 048 Performance Guidelines Condition 048 Fever and a recent rash in a 30-year-old man AIMS OF STATION To assess the candidate's diagnostic approach to a young man presenting with fever and rash of 48 hours duration with signs of splenomegaly and lymphadenopathy. The examiner will have instructed the patient as follows: Opening statement: 'I think I may have developed an infection. ' • Follow with: ~ You have been feeling unwell for two days. ~ You have a fever and a sore throat. ~ You have also developed a rash over the past one to two days. ~ The rash is all over your body, and is especially apparent on the face and trunk. • In response to questions the doctor may ask: ~ The rash is not itchy. ~ You have 'aches and pains' throughout your body in the legs, arms and back. ~ You have a headache and bright lights hurt your eyes. ~ You have previously considered your health to be good. ~ You have had no serious past illnesses or family history of relevance. ~ You have no allergies and take no medications. ~ No history of mental illness, no history of blood transfusion. ~ You do not use injectable drugs. ~ You have been in a sexual relationship with another man for two years and have been having anal sex without condoms for a few months now. You have also had a number of casual sexual relationships in the past six months. ~ You have never had an HIV test in the past. Answer the doctor's questions honestly. Be open about your homosexuality but do not reveal this without specific questioning by the doctor. Be very concerned about the possibility of HIV infection when this is mentioned, and anxious to proceed with investigations at once. EXPECTATIONS OF CANDIDATE PERFORMANCE The key to diagnosis is the history of unprotected anal sex. • Approach to patient: the history should be taken and diagnostic possibilities discussed in a matter of fact and nonjudgmental way. Support for the patient should be shown when the possible seriousness of his condition is discussed. • History: must obtain detailed sexual history. • Explanation to patient: his condition is possibly due to one of a number of viral infections, such as infectious mononucleosis. However, the most likely infection is with human immune deficiency virus (HIV) and this must be confirmed or excluded by laboratory investigations. These must include HIV serology. 252 048 Performance Guidelines Informed consent is required for HIV testing: ensure patient has pretest counselling. ~ Laboratory tests may not be clear during time of acute seroconversion illness and may require consultation with HIV laboratory and/or specialist unit to manage his condition. ~ If HIV infection is confirmed, referral to a specialist infectious diseases unit is required for management during seroconversion illness. ~ Other tests are indicated (see differential diagnosis) and the candidate may mention other viral causes of this patient's fever, rash, sore throat, lymphadenopathy and splenomegaly. ~ The examiner should intervene at this stage and say: 'We should now discuss the differential diagnosis and appropriate investigations. ' • Differential diagnosis apart from HIV: ~ Epstein-Barr virus infection; ~ secondary syphilis; ~ toxoplasmosis; ~ rubella; ~ cytomegalovirus (CMV); ~ herpes simplex infection; ~ disseminated gonococcal infection; ~ hepatitis A. B, C, D or E; and ~ other viral infections. • Investigations — these are related to the differential diagnosis and should include: ~ full blood examination and Epstein-Barr serology: ~ tests for rubella, CMV infection and toxoplasmosis; ~ Venereal Disease Research Laboratories/syphilis serology; ~ liver function tests; and ~ tests for hepatitis A,B,C,D or E. KEY ISSUES • History must include sexual history • Investigations must include HIV serology. • Differential diagnosis must include HIV infection. • Approach to patient must discuss informed consent for HIV testing. CRITICAL ERRORS • Failure to consider HIV infection as a likely cause of this patient's presentation. • Failure to discuss informed consent for HIV testing. 253 048 Performance Guidelines COMMENTARY Diagnosis of HIV infection requires a careful history to identify potential high-risk behaviour and recognition of the constellation of clinical symptoms and signs. The rash of acute HIV infection is usually an erythematous, maculopapular rash. From 40-90% of patients who have acquired HIV infection will develop an acute febrile illness within the first six weeks of infection, often sooner. Common symptoms include: fever, night sweats, malaise, myalgia, arthralgia, headache, photophobia and sore throat. Neurological manifestations including headache and photophobia are common as well as transient neurological signs including peripheral neuritis and other central nervous system manifestations. These symptoms usually last for less than two weeks. Other nonspecific viral sequelae such as mucosal ulceration, desquamation and herpes simplex may also occur. Acute symptoms are self-limiting. The condition resembles infectious mononucleosis but is seronegative for infectious mononucleosis. Chronic lethargy, depression and irritability may persist after initial illness. Key to diagnosis in this patient is checking for recent risk exposure history of unprotected oral or anal sex. reuse of contaminated needles or other exposure, such as occupational exposure. 254 049 Performance Guidelines Condition 049 A heart murmur in a 4-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose an innocent heart murmur in a young child and to advise a concerned parent. EXAMINER INSTRUCTIONS Opening statement: 'What is the matter with my child?' The examiner will have instructed the parent as follows: You are the parent of an only child, puzzled and concerned at being told that the child may have something the matter with his heart. Be prepared to accept reassurance if the explanation is adequate. If not, insist on referral and ask what tests might be performed. EXPECTATIONS OF CANDIDATE PERFORMANCE This is almost certainly an innocent murmur. No concerning symptoms or signs are present which might suggest an alternative diagnosis. Parents need reassurance that the child is normal and that normal physical activity is allowed. Referral to a paediatrician/paediatric cardiologist is only indicated if parents wish it, or seem unconvinced. The consultant would consider echocardiography. It would be reasonable do to a chest X-ray and ECG, depending on degree of parental concern. This is unlikely to show any abnormality and may be reassuring, and may then render unnecessary further referral to a cardiologist. KEY ISSUES • Ability to assess confidently the features of an innocent heart murmur. • Avoidance of unnecessary extensive investigation. CRITICAL ERROR - none defined COMMENTARY Cardiac murmurs in young children are very common. It is estimated that careful auscultation under ideal circumstances will detect an innocent soft murmur in over 50% of normal four-year-olds. Hence medical facilities would be overwhelmed if all of these murmurs were referred for specialist assessment. Primary care physicians should be confident in distinguishing innocent functional murmurs from those that are associated with an organic heart lesion. Rheumatic fever in our community is unusual these days unless practising in areas where large numbers of Aboriginal or Torres Straight Islander peoples are treated. So the usual task is to differentiate an innocent murmur from one due to an organic heart lesion, most likely of congenital origin. 255 049 Performance Guidelines As in many situations in paediatrics, the diagnosis can usually be determined by a careful history and examination. The child with an innocent murmur, is well and thriving, has a normal exercise tolerance, is not cyanosed, and does not suffer from recurrent chest infections. Physical examination reveals: • a soft midsystolic murmur, which is an almost musical high-pitched murmur at the base of the heart with no radiation; • the murmur varies with posture and respiration, and has no associated thrill; and • the murmur has no diastolic component. In comparison, an organic murmur may be: • loud; • associated with a palpable thrill; • radiating either to the axilla or neck; • associated with cyanosis; and • associated with significant symptoms. In determining the possible aetiology, the clinician should seek information along these ines to determine if any of these features exist in the history, and must perform a thorough examination. If all features indicate an innocent heart murmur, no investigations are warranted. The parent should be reassured of the innocent nature of the murmur and that the practitioner will continue to observe the child until the murmur spontaneously disappears, usually between the ages of five and seven years. If the parents are still concerned despite adequate explanation and reassurance, referring the child to a paediatrician who is skilled in assessing murmurs is acceptable. If necessary, the paediatrician will refer the child to a paediatric cardiologist for full cardiological investigations, including echocardiography. 256 050 Performance Guidelines Condition 050 A knife wound to the wrist of a 25-year-old man AIMS OF STATION To assess the candidate's ability to diagnose tendon and nerve injuries in a deep wound EXAMINER INSTRUCTIONS The knife wound is across the wrist just above the crease line as in the illustration and the candidate can observe this. The examiner will indicate to the candidate 'The bleeding has been stopped by the dressing. Proceed to your examination to ascertain the extent of injury describing your findings to me, the examiner. ' The examiner will have instructed the patient as follows: You have presented to the Emergency Department with a knife wound to the left wrist produced by an assailant after an argument in a pub. You lifted your arm to protect your face and he slashed your wrist with a knife. It bled a lot at first, but your friends reduced this by local pressure and the ambulance staff put on a dressing which controlled the bleeding, but which you think made your hand feel numb. You are unable to move your fingers freely. Specifically, you have lost sensation and muscle power as follows: • Sensation to touch and pin over the whole palmar aspect of your hand, fingers and thumb. The numbness and loss of feeling extends onto the back of the fingers and thumb, over the nails and the end of the joint. • You should hold your hand as depicted in the illustration so all the fingers and thumb are stretched out straight. When asked to flex your fingers and thumb, you are unable to do so at the end two joints of the thumb, and unable to bend any of the three joints of your four fingers. You are able to stretch them out straight again if the candidate bends them forwards. • You also cannot flex your wrist (bend it forward), but are able to extend it (bend your wrist back). • If asked to put your thumb across to touch the other fingers, you cannot move the other fingers towards the thumb (cannot bend fingers and thumbs inwards towards the palm); and you cannot move the thumb across the palm towards the base of the ring and little fingers. • If asked to do the movement of abduction of the thumb by lifting the thumb away from the palm, you cannot. • You can only move the thumb outwards and away from the other fingers in the plane of the palm. • If asked to hold a card between your fingers, or to move your little finger away from the others, you cannot. 257 050 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to diagnose accurately the deep and extensive injury to: • the median nerve • the ulnar nerve. • all of the following flexor tendons, which have been severed above the wrist: ~ wrist flexors: f l e x o r c a r p i r a d i a l i s , u l n a r i s , ( p a l m a r i s l o n g u s ) ~ finger flexors - f l e x o r d i g l t o r u m s u p e r f i c i a l l s to all four fingers (normally flexes proximal inter-phalangeal [PIP] joint) - f l e x o r d i g l t o r u m p r o f u n d u s to all four fingers (normally flexes distal interphalangeal [DIP] joint) ~ thumb flexor: f l e x o r p o l l i c i s l o n g u s (normally flexes thumb interphalangeal [IP] joint). • Arteries — probably one or both, but these injuries have not disturbed the viability of the hand. • Neurologic effects — Paralysis of all thenar and hypothenar small muscles of the hand preventing ~ palmar abduction of the thumb ( a b d u c t o r p o l l i c i s b r e v i s — median nerve) ~ abduction of little finger ( a b d u c t o r d i g i t i m i n i m i — ulnar nerve) ~ flexion of metacarpophalangeal [MP] joints of fingers (lumbricals, interossei — ulnar and median nerves); and of MP joint of thumb (flexor pollicis brevis) ~ abduction/adduction of fingers (interossei — ulnar nerve) ~ opposition — median and ulnar nerves ~ ulnar adduction of the thumb (adductor pollicis — ulnar nerve) • Sensory loss is of combined median/ulnar nerve injury. Knowledgeable candidates may recognise that the dorsal cutaneous branch of the ulnar nerve has been spared. Candidates are expected to conduct a logical and systematic examination to detect nerve, tendon and vascular injury. Candidates should achieve the diagnosis of combined median and ulnar nerve and flexor tendon injury. Knowledge of all of the individual muscle groups is not expected but candidates should be aware of the effects of median and ulnar nerve division and the appropriate tests (sensory and motor) to detect these. Candidates should also be expected to recognise that the failure to flex the distal joints of the fingers and thumb are due to concomitant tendon injury, and not to the effects of nerve damage to median and ulnar nerves at the level of the cut just above the wrist. At the end of the candidate's commentary, or at seven minutes, the examiner will ask: • 'Why is he unable to hold a card between his fingers?' • 'Why is he unable to flex the end joints of fingers or ~ Answer: Because the ulnar nerve injury has paralysed the interossei. thumb?' ~ Answer: Because the long tendons have been damaged. KEY ISSUES • Ability to correctly identify the structures damaged, by an appropriately focused examination. 258 050 Performance Guidelines CRITICAL ERROR • Failure to identify the combination of nerve and tendon injury. COMMENTARY Cuts to the wrist and hands from knives, glass breakages and other sharp items need careful evaluation to identify damage to important underlying structures, particularly major blood vessels, nerves and tendons. Of the three main nerves of the arm (median, ulnar and radial), the median and ulnar nerves run to the hand on the volar aspect of forearm and wrist, carrying motor fibres to the intrinsic short muscles of the hand, sensory fibres to the vital grasping surfaces of thumb and fingers, and autonomic sympathetic fibres subserving sweating and vasomotor responses. The median nerve, as its name implies, runs a midline course throughout the forearm and lies in close proximity to the tendon of flexor digitorum superficialis running to the middle finger. The important sensory and motor branches are given off after the nerves have entered the hand by passing under (median nerve) or around (ulnar nerve) the carpal tunnel. The ulnar nerve lies more deeply on the ulnar side of forearm and wrist flanking the ulnar artery on the surface of the deep long flexor muscle (flexor digitorum profundus). Clearly both nerves were at risk from the cut illustrated. The superficial terminal branch of the radial nerve, by contrast, is at this stage a much less important nerve, with no motor fibres. It runs to the back of the hand and fingers along the radial side of the forearm, supplying sensation to the dorsum of hand and only the backs of the radial three digits for a short way along their length. The ulnar nerve gives a dorsal sensory branch to supply the other one and a half or two ulnar digits. If you extend your thumb and tense the tendon of extensor pollicis longus you may be able to feel the terminal branch of the radial nerve crossing the snuff box superficial to the taut tendon by running your finger along the tendon. The radial nerve is thus unlikely to have been at risk. Testing for damage to the other two nerves is usually easy and rapid with a cooperative patient. Median nerve The pulp of the index finger is virtually always supplied by the median nerve. Can the patient feel you touch here (with a blunt pin, or wool, or your own finger)? The pulp of the little finger similarly is supplied by the ulnar nerve, so repeat the process there to check for ulnar nerve damage. To confirm your suspicions, now check the motor functions — the median nerve first. In checking for motor paralysis due to nerve injury, think of the muscles innervated by the nerve distal to the injury, find an action which is performed by one muscle only, check that action, and if possible, see and feel the responsible muscle contracting. For median nerve, abductor pollicis brevis (APB), the short abductor of the thumb, is virtually always supplied by the median nerve just after entering the palm. You test its action by asking the patient to move the thumb directly upwards, with the palm flat, away from the palm and the other fingers, keeping the thumb inside the margin of the index finger so the thumb pushes straight up against resistance. 259 050 Performance Guidelines That movement is palmar abduction. Only APB can perform it, you can test the power and you can see and feel the muscle contract. The branch to the muscle is given off immediately after the median nerve enters the palm after passing under the flexor retinaculum. In patients with longstanding carpal tunnel syndrome with median nerve compression affecting the motor fibres as they go through the tunnel the muscle may waste and atrophy as illustrated elsewhere in the book. But don't of course expect wasting, or the deformities arising from such wasting, in an acute injury. The ulnar nerve has a much greater effect on the motor function of the hand than does the median — it supplies at least a dozen important small muscles, compared to the handful from median (conversely the sensory loss from median nerve injury is much more significant than from ulnar nerve damage). Use two tests here — they will help remind you of the muscles involved. • Can the patient abduct the little finger away from the other fingers against resistance? This is done by • Can the patient hold a piece of paper between outstretched fingers? This is done by the interossei, all abductor digiti minimi, supplied by ulnar nerve by its deep palmar branch. supplied by the ulnar nerve. There are many other tests for other muscles supplied by the ulnar nerve — pinch test for adductorpollicis (Froment sign), the deficiencies seen in opposition (Sunderland sign), and so on — but further tests are not needed, having already made the diagnosis of an injured ulnar nerve at wrist level or above, corresponding to the site of the cut. In cooperative patients, this is easy and conclusive — but supposing the patient was drunk and uncooperative, or stuporous, or a young child, and cannot or will not cooperate with you. In this case you can still diagnose a nerve injury from effects on the sympathetic efferent fibres. If the nerve carrying them is cut, they too will be paralysed, and the affected skin in the distribution of the nerve will be dry and unable to sweat. This can be demonstrated elegantly by sprinkling a starch powder over the skin and observing the colour change. Also check if any differences can be seen or felt distal to the cut compared to the other hand — a small point but sometimes quite helpful. Next check for damage to the next important group of structures — the long tendons to the thumb and fingers and the tendons to the wrist. These lie in three layers from superficial to deep. • The wrist flexors: ~ Flexor carpi radialis — the largest and most visible tendon ~ Flexor carpi ulnaris — the most ulnar sided ~ The inconstant palmaris longus between them. You can check these by asking the patient to flex his wrist. If he can do so. he may of course be using deeper finger flexors, which because they cross multiple joints, can act as accessory flexors of the wrist. In this instance no wrist flexion is possible. • The superficial and deep long flexor tendons to thumb and fingers. Flexor digitorum superficialis (FDS) and profundus (FDP), each with four tendons, and the solitary tendon of flexor pollicis longus (FPL). ~ FDS — This group of four tendons to index, middle, ring and little fingers flexes the proximal interphalangeal joints. It is difficult to test their independent action becauseof the last and deepest layer — flexor digitorum profundus; these can act as accessory flexors of the more proximal joints, which they also cross to reach the end of the digit The deepest tendons are prime movers of the most distal joints of thumb and fingers. 260 050 Performance Guidelines ~ FDP and FPL — Test the abilities to flex the end joints of the digits first — thumb index through to little finger. In this patient, no spontaneous movement against resistance is possible — all of these deep tendons have been severed. Clearly given this finding, it is very likely that the more superficially placed flexor digitorum superficialis tendons have been also severed, and you will find this confirmed when you test the ability of the patient to flex the proximal interphalangeal joint (which in the absence of action of FDP is left as the only muscle which can flex the joint). Identifying damage to the flexor digitorum superficialis in the finger is easy in this patient with a cut wrist, because the flexor digitorum profundus is also cut and cannot confuse things by itself acting as a flexor of the proximal IP joint. But what if the FDP is not damaged? How can the action of flexor digitorum superficialis on the PIP joint be checked in such circumstances if the sole injury is to FDS? Answer: To test the action of the superficial finger flexors in the presence of intact deep flexors is a difficult task and needs a knowledge of the anatomical arrangements of the muscles, and in particular, the deep layer of flexor digitorum profundus. Note that with fingers extended, it is possible to flex the index finger at its end joint independent of other fingers, just as with the end joint of the thumb. But to flex the end joint of the middle, ring or little finger alone is rather difficult — the end joints of adjacent fingers tend also to flex, unless concentrating or holding them down. This is because, of the four separate tendons of FDP in relation to the muscle, the one to the index finger is virtually a separate muscle (flexor indicis), whereas the other tendons are communally joined until just above the wrist This fact can be used to advantage to eliminate the influence of the deeper tendons of FDP to these three fingers on the proximal joint as follows — try this trick. Hold down flat all fingers but one of a colleague, then ask them to flex the remaining finger at the proximal IP joint to a right angle as illustrated. By restraining the long tendons of FDP to the other fingers, and preventing their movement, you have very effectively inactivated the remaining FDP tendon to the middle finger. You can easily check that FDP is not having any effect by flicking the terminal phalanx with your finger — note that the distal IP joint is freely floppy and the only muscle now causing flexion of the PIP joint is FDS. CONDITION 050. FIGURE 2. Testing for function of FDS alone 261 050 Performance Guidelines An injury to the long flexor tendons should have already been suspected in this patient on inspection alone. In the normal hand at rest, the fingers and thumb are progressively flexed into the palm from index to little finger with the thumb at right angles as illustrated. This is the position of rest of the hand with a balanced postural tone of flexors and extensors. In your patient (a trained role player) the fingers are extended instead of curled and the thumb is also extended, and the whole hand looks very unnatural; because the imbalance caused by the unopposed natural resting tension of the finger extensors, with all the long flexors cut, has distorted the normal position of rest. CONDITION 050. FIGURE 3. CONDITION 050. FIGURE 4. Figures 3 and 4 show position of rest from palmar and radial aspects CONDITION 050. FIGURE 5. Note position of fingers and thumb after long tendon injury The inabilities to move the terminal two joints of the fingers and the terminal jointot the thumb are not, and could not be, due to the injury to the median or ulnar nerves The branches to the extrinsic long flexors come off from much higher in the forearm and are unaffected by nerve injury at the wrist, which can only affect the function of intrinsic muscles in the hand. These effects on the terminal joints are due to tendon injuries. 262 050 Performance Guidelines Moving proximally, also note that he cannot flex the metacarpophalangeal joints of the fingers (or of the thumb). This action in the fingers is done by the lumbricals, supplied by branches from median and ulnar nerves in the palm, and this inability is due to the nerve damage, as are all the other tests for intrinsic muscle function testing thenar and hypothenar muscles and interossei apart from those we have already done. These additional tests also give characteristic signs: on attempted ulnar adduction, pinch test of the thumb (Froment sign) and failure of opposition of little finger (Sunderland sign). These latter signs are accentuated and even more obvious in patients with longstanding effects of muscle wasting, which need not concern us further in this patient. The most superficial muscles are the wrist flexors FCR and FCU and PL. The patient cannot flex the wrist actively either because all of these are divided as well (plus the long finger and thumb flexors which can of course act as accessory flexors of the wrist as well as prime movers of their respective finger or thumb joints). Finally the blood vessels — the very superficial radial artery and more deeply placed ulnar artery. These are very likely both to have been cut but vascular spasm and compression may have caused bleeding to stop. Examine the colour of the fingers and test capillary refilling after pressure, but the anastomoses and collateral circulation across the wrist are very efficient and it is very unlikely that the hand will be grossly ischaemic even if both arteries have been divided. The final diagnosis, after checking that sensation to the back of the hand and proximal back of fingers is intact, confirming that radial nerve and dorsal branch of ulnar nerve have escaped injury, is: Severe deep knife wound of wrist severing all volar long flexor tendons to wrist and hand and severing median and ulnar nerves — a very severe injury requiring early reconstructive surgery. Fortunately this is a 'tidy' wound without major contamination and there is no contraindication to primary repair. Treatment will necessarily require a subsequent intensive rehabilitation programme of initial rest, with early mobilisation and supportive physiotherapy over many months. The final functional outcome will be very much influenced by his occupation — if he is a concert pianist, thoughts about vocational retraining should start early. 263 051 Performance Guidelines Condition 051 Multiple skin lesions in a Queensland family AIMS OF STATION To assess the candidate's ability to diagnose a variety of common benign and 'suspicious' skin lesions and to advise on management. EXAMINER INSTRUCTIONS A careful history of how long the lesions had been present would normally be required; this scenario focuses on pattern recognition from physical appearance. EXPECTATIONS OF CANDIDATE PERFORMANCE The farmer is very concerned about six members of the family and has photographs of each of the lesions. He has come in from his farm, which is a long way from the town. The photographs demonstrate: • Figure 1. His son has a lesion suspicious of squamous cell carcinoma (SCC) of the lip. • Figure 2. His 50-year-old brother has a lesion suspicious of basal cell carcinoma (BCC) • Figure 3. His father has a seborrhoeic keratosis on his face, which is benign. • Figure 4. His wife has a lesion suspicious of malignant melanoma of the leg. of the neck. • Figure 5. His 52-year-old brother has a benign spider naevus of the chest. • Figure 6. His daughter has a lesion suggestive of a benign melanocytic dermal naevus of the face. The SCC, BCC and melanoma, assuming diagnosis is confirmed by excision, are malignant The seborrhoeic keratosis, the spider naevus and the melanocytic dermal naevus are benign and probably require just reassurance. His wife, who has the malignant melanoma, requires the most urgent treatment. The excision of her lesion should not be delayed, even though she would prefer to delay treatment for several months because they are busy on the farm. The SCC and the BCC should also be removed without excessive delay. The BCC only spreads directly, but local infiltration may be extensive, although this occurs slowly. The SCC spreads directly and mainly by lymphatics, and occasionally by blood spread. Malignant melanoma is the most serious of the lesions and spreads locally, by lymphatics and by blood spread. Widespread metastases can occur even from a small lesion. The risk of spread is proportional to the depth of the melanoma seen on microscopic examination. The prognosis is favourable if the depth is less than 0.75 mm. KEY ISSUES • The candidate should indicate which lesions are likely to be benign (seborrhoeic keratosis, melanocytic dermal naevus and spider naevus) and do not have to be excised; and which are suspicious of malignancy (SCC, BCC and melanoma) and should be excised. 264 051 Performance Guidelines CRITICAL ERROR • Failure to suspect that the wife's lesion is a malignant melanoma, and that surgical excision should occur without delay. COMMENTARY This scenario illustrates six of the most common focal cutaneous lesions seen in the Australian population (benign melanocytic naevus, seborrhoeic keratosis, spider naevus, basal cell cancer, squamous ceil cancer, malignant melanoma). Clearly benign, longstanding lesions are the most commonly seen pigmented skin 'moles'; and most can be confidently diagnosed. Benign skin lesions: Benign melanocytic naevi (intradermal, junctional and compound) These are classified according to the site of the benign pigment-containing melanocytes. Junctional naevi have melanocytes at the junction of epidermis and dermis, they are flatter than the other more mature naevi and may be wholly macular. Intradermal and compound naevi have melanocytes intradermally, or at both epidermal and dermal levels. Macroscopically they vary from a light or dark brown nodule (often containing hair, a helpful diagnostic point — hairy moles are almost invariably benign). CONDITION 051. FIGURE 7. CONDITION 051. FIGURE 8. Benign melanocytic naevus Benign melanocytic naevus of neck Seborrhoeic keratoses ('seborrhoeic warts') These lesions arise from the epidermis as the result of proliferation of keratinocytes. They are often multiple. There is no dermal involvement and the keratoses are so superficial that they are often said to have a 'painted on' appearance. Seborrhoeic keratoses occur in older people and are most often found on the trunk, although they may be found on the face and scalp. The lesions are raised or flat and plaque-like, with a waxy texture. Haemosiderin deposition in the plaques may produce a brownish-black colour. Occasionally the lesion may be situated on a part of the body that makes it prone to trauma, but the only real reason for excision of a seborrhoeic keratosis is for cosmetic purposes. They are quite benign and their fissured, variegated, rough textured appearance usually allows confident diagnosis. 265 051 Performance Guidelines CONDITION 051. FIGURE 9. CONDITION 051. FIGURE 10. Multiple seborrhoeic keratoses of trunk Seborrhoeic keratoses of back Spider naevi These small lesions have a red central spot surrounded by flaring telangiectases. Pressure on the central arteriole causes blanching. Multiple ones on the upper trunk, upper limbs, or face can be stigmata of alcoholic liver disease. Papillomas Otherwise known as skin tags, papillomas may be found at any site and are either sessile or pedunculated overgrowths of skin seen frequently around flexural areas of axilla or groin. They may be excised for cosmetic reasons. Pyogenic granulomas These lesions may arise in response to minor trauma. At the site of puncture of the skin there is a mass of rapidly growing granulation tissue which characteristically forms an exophytic growth. This may appear over a few weeks and bleeds easily on contact. Treatment is by excision and curettage of the area underlying the granuloma. CONDITION 051. FIGURE 11. CONDITION 051. FIGURE 12. Pyogenic granuloma of palm Pyogenic granuloma of finger 266 051 Performance Guidelines Verrucae Verrucae are most commonly seen in children and are caused by viruses. Common sites are hands and soles of feet. The lesions may spread to adjacent sites or other individuals. They consist of raised and rounded keratinised projections above the skin surface. Those on the sole are commonly 'endophytic' due to weight-bearing. Histologically there is hyperplasia of the epidermis and increased keratinisation. Treatment can be difficult, as the verruca is likely to return if the virus is not completely eradicated. As many verrucae will completely regress, if the lesions are asymptomatic, they are better left alone. Those warts that occur around the genital and perineal regions are known as condyloma acuminata. They are caused by the human papilloma virus and spread by sexual contact. Keratoacanthomas These lesions are characterised by rapid growth, a macroscopic appearance resembling a squamous cell carcinoma and spontaneous regression. A keratoacanthoma usually occurs on the face (often on the nose or ear) or hand and appears over the course of a few weeks. The centre of the lesion ulcerates and may contain a plug of keratin. Histologically these lesions can resemble squamous cell carcinoma, but are identified by a central core of proliferating cells extending down into the dermis. The site of the tumour and its rapid development should make the diagnosis. Keratoacanthomas should be excised and sent for histologic examination to exclude squamous cell carcinoma. Accurate histologic diagnosis is usually possible if the whole lesion is provided; only a small margin of excision is required. CONDITION 051. FIGURE 13. Keratoacanthoma of face Fibrohistiocytic tumours: dermatofibroma, xanthoma There is a considerable histological range of soft tissue tumours and the two benign lesions that may be considered of true skin origin are the cutaneous fibrous histiocytoma (dermatofibroma) and the xanthoma. A dermatofibroma is a relatively common skin nodule and typically occurs on the legs of young or middle-aged women. 267 051 Performance Guidelines CONDITION 051. FIGURE 14. Dermatofibroma of leg The lesions are usually raised from the skin surface and about 1 cm in diameter. Most are asymptomatic but they can be itchy and tender which is the usual reason for excision. Xanthomas occur when an area of skin becomes infiltrated by lipid-filled macrophages or histiocytes. They may occur at any site on the body and the most common form is the xanthelasma. These soft, yellow plaques are characteristically found at the inner canthus of the palpebral fissure. Appendage tumours Cylindromas (arising from sweat gland cells) and other skin appendage tumours are rare. Treatment is excision, to confirm the diagnosis. Premalignant neoplasms of skin: Actinic keratoses Actinic (solar) keratoses are the result of solar damage and are characteristically found on areas of the body most at risk of prolonged sun exposure. The back of the hand is a common site. The lesions occur most frequently in older people and those who work outdoors. Fair skinned people living in the tropics and subtropics are most at risk. The actinic keratosis represents a gradual dysplastic change in the epidermis and underlying dermis. There is a build-up of excessive keratin in the epidermis and elastosis in the dermis. Actinic keratoses appear as scaly lesions with hyperaemic bases that bleed easily with trauma. They can be treated by cryotherapy, application of a cytotoxic cream or excision. Left untreated, 15-20% of actinic keratoses will progress to squamous cell carcinoma. CONDITION 051. FIGURE 15. Multiple actinic keratoses of hands 268 051 Performance Guidelines Bowen disease This is an unusual condition and presents as a scaly red plaque with clearly defined margins. The surface is keratotic and often crusted and fissured. The lesion is not related to solar damage and in some instances arsenicals have been implicated in the aetiology Bowen disease may occur on any part of the body and is a premalignant condition and represents squamous cell carcinoma in-situ. There is hyperplasia of the epidermis, atypical epithelial cells are present and infiltration of this layer with pleomorphic malpighian and giant cells. Treatment is with cryotherapy or cytotoxic creams. Larger lesions and those that are suspicious or frankly malignant are best treated by excision. Skin grafting may be required. Malignant skin neoplasms 7 49333535 CONDITION 051. FIGURE 16. Bowen disease of skin The skin is the largest organ of the human body and not surprisingly it is the most common site of tumours. Skin cancer is the most common malignancy in fair-skinned people. Tumours can arise from any of the skin structures — epidermis, dermis, connective tissue, glands, and muscle or nerve elements. Although not all skin tumours are neoplastic, from a management perspective, the suspicion of malignancy must always be uppermost in the clinician's mind when dealing with a skin tumour, be it pigmented or not. Malignant skin lesions are very common in Australia with a susceptible population and excessive solar exposure. By contrast, melanoma and other skin malignancies are uncommon in indigenous Aboriginal peoples. Basal cell carcinomas (BCC) This is the most common type of skin cancer and is almost totally confined to fair skinned people. Basal cell carcinomas are rare in Asiatic peoples and almost never occur in dark skinned people. They tend to occur in people over the age of 40 and are usually found on areas of the body subject to chronic exposure to the sun, particularly the face. Characteristically these tumours are found on the face above an imaginary line running from the corner of the mouth to the ear. The tumours are slow-growing and may take years to get to sufficient size to bother the patient. Left untreated, a basal cell carcinoma will spread relentlessly and destroy all the surrounding tissues without ever metastasising. The tumour characteristically has a raised, rolled edge which often takes on a pearly appearance. Most basal cell carcinomas are the same colour as the adjacent skin, but some are heavily pigmented and mistaken for 269 051 Performance Guidelines melanomas. There may be central regression of the tumour with ulceration, producing the so-called 'rodent ulcer.' Other morphological patterns of basal cell carcinomas include those resembling Bowen disease with a thin pink plaque (erythematous basal cell carcinoma) and those known as sclerosing tumours with white plaque and a fine pearly edge (morphoea carcinoma). The erythematous variety of basal cell carcinoma tends to occur on the trunk. Apart from nodular BCC (the most common presentation), ulcerative, sclerosing/cicatrising ('brush-fire'), cystic, psoriatiform, comedoform and pigmented variations are commonly seen. CONDITION 051. FIGURES 17 AND 18. Morphoeic BCC Ulcerative BCC CONDITION 051. FIGURES 19 AND 20. Sclerosing BCC behind ear Pigmented BCC Small basal cell carcinoma can be treated by cryotherapy, topical chemotherapy or radiotherapy. Radiotherapy is used for cancers in areas where surgical resection would be difficult and risk damage to surrounding structures, such as tear ducts and eyelids. Radiotherapy should not be used for lesions adjacent to cartilage, which might undergo radionecrosis. The major disadvantage of these types of treatment is that no tissue is obtained for histological analysis. The optimum treatment for basal cell carcinomas — and particularly for lesions greater than 1 cm diameter — is surgical excision. A margin of at least 1 mm of normal tissue is required. To minimise tissue loss, particularly for lesions on the face, a technique of serial slicing can be employed. Whilst this is time-consuming, the serial excision and immediate microscopic examination of the resected tissue will allow an intraoperative assessment of clearance of tumour in depth and width. Larger basal cell carcinomas will require skin grafting a reconstructive surgery. 270 Squamous cell carcinomas (SCC) These are the second most common cancer of the skin. Whilst basal cell carcinomas arise from the basal layers, squamous cell carcinomas arise from the keratinocytes of the epidermis. Sunlight is an important aetiological factor and solar keratoses and Bowen disease are precursors. Squamous cell cancers can also occur in scars or chronic ulcers (Marjolin ulcer). Most squamous cell carcinomas occur in the fair skinned people, but these tumours are also found in darker-skinned people, particularly in depigmented skin following scarring. These cancers are usually seen in the older population, but with excessive sun exposure in childhood, squamous cell carcinoma is also a disease of young adults. As most of the tumours are sun exposure-related, they tend to occur on exposed parts of the body, particularly the head and the hands and on the lips, invariably involve the lower lip. On the ears, squamous cell cancers occur particularly on the outer helix, in contrast to BCC which occur in the retroareolar sulcus. CONDITION 051. FIGURE 21. CONDITION 051. FIGURE 22. Squamous cell carcinoma of lip SCC of ear Squamous cell carcinoma has a variable natural history. Those tumours that arise from actinic keratoses can be quite slow growing, while those that complicate Bowen disease tend to be more aggressive. Whilst a squamous cell carcinoma can morphologically resemble a basal cell carcinoma, the crucial difference is the ability of the former to metastasise. Optimal treatment of squamous cell carcinoma of the skin is surgical excision. Although the tumours do metastasise to lymph nodes there is no evidence that prophylactic lymph node dissection confers any benefit. For those patients who undergo a curative resection, the prognosis is good, with a 95% 5-year survival rate. Malignant melanomas The most malignant of all skin tumours, more common in exposed skin, occurring throughout adult life, particularly prevalent in fair-skinned populations of tropical climates, but incidence is increasing in most countries. Any brown or black mole showing an increase in size, irritation, bleeding, nodularity or ulceration should be regarded as suspect and should be excised with an adequate margin Spread to regional nodes is common and markedly worsens prognosis. Bloodborne metastases to lungs, liver, brain and small bowel are common. Prognosis worsens with increasing depth of invasion. Several macroscopic types are recognised with progressively worsening prognosis. 271 051 Performance Guidelines CONDITION 051. FIGURES 23-25 • Hutchinson melanotic freckle (lentigo maligna melanoma) • Superficial spreading melanoma (most common type) • Nodular melanoma • Nonpigmented amelanotic melanoma. Kaposi sarcoma Classical Kaposi sarcoma is found in elderly males of Mediterranean or East European origin and tends to run an indolent course. The disease associated with AIDS and other acquired immunodeficiency states runs a more aggressive course. Kaposi sarcoma is a spindle cell tumour and is characteristically a multicentric angiomatous lesion of the skin. The lesions vary in appearance from nodule or macule to plaque and may be several centimetres in diameter. In its aggressive form the body may be covered in confluent, violaceous skin nodules. CONDITION 051. FIGURE 26. Kaposi sarcoma 272 051 Performance Guidelines Visceral involvement is uncommon with the classical form of Kaposi sarcoma, but gastrointestinal and pulmonary disease often occurs in AIDS-related Kaposi tumour. Localised cutaneous lesions can be treated with radiotherapy, cryotherapy, intralesional chemotherapy or topical retinoids. Other primary cutaneous tumours Malignant histiocytoma (dermatofibrosarcoma protuberans) is a lesion with a tendency to biphasic growth spurts and local recurrence after excision. CONDITION 051. FIGURE 27. Malignant histiocytoma There are numerous other uncommon primary cutaneous tumours, but only three need to be considered because of their similarity to basal cell carcinoma. The three are Merkel cell carcinoma, microcystic adnexal carcinoma and sebaceous gland carcinoma Merkel cell carcinoma is of neuroendocrine origin and is an aggressive tumour with a high rate of local recurrence. It may resemble a basal cell carcinoma, both in its appearance and preferential distribution on the head and neck. The other two tumours are rare, slow growing and prone to local recurrence if not adequately excised. Secondary tumours The skin is a common site of metastatic deposits, particular for aerodigestive tract neoplasms. In most instances the skin deposits will only become manifest after the primary disease has been diagnosed or treated. Occasionally, a cutaneous metastasis may be the presenting feature of an otherwise asymptomatic tumour of the lung or oesophagus. 273 052 Performance Guidelines Condition 052 Subcutaneous swelling for assessment AIMS OF STATION To assess the candidate's ability to perform an appropriately focused diagnostic examination of a subcutaneous lump. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The case scenario is a real patient with a longstanding subcutaneous swelling — the findings and diagnosis are to be checked by the examiner personally prior to commencement of the examination. The lump will usually be a lipoma, sebaceous cyst, ganglion or bursa, or occasionally a less common diagnosis. Real patients should just answer questions as asked and will expect to be reassured about conservative treatment being offered, or note advice about possible surgery. Opening statement: 'What is this lump?' EXPECTATIONS OF CANDIDATE PERFORMANCE Major points of technique and accuracy in examination are • Establishing the lump's physical characteristics — particularly contour and consistency. • 'Layering' the lump — is it in subcutaneous fat, attached to or beneath deep fascia, and if the latter is it arising from muscle, tendon, ligament, bone, nerve or blood vessels? • Does the lump pulsate and is this intrinsic or transmitted pulsation? • What are its attachments? Superficially is it attached to the skin and deeply what are the effects of tensing or contracting underlying muscles or tendons. • Is it a fluid-filled cystic lump? The most helpful test here will be whether it is transilluminable, a test often inadequately performed. This test must be performed properly by correct torch placement behind the lump and must be done by suitably darkening the surrounds — turning off lights and covering with sheet or blanket as required. When brilliantly positive, it gives irrefutable evidence of contents being liquid or gas. Gas cysts do occur in lung, neck and bowel; but in a subcutaneous site, the fluid will almost always be a liquid, and usually a clear serous liquid (such as in scrotal cystic swellings, bursae and tendon sheath swellings, or branchial cysts) rather than pultaceous material or blood. A negative transillumination sign does not of course exclude a fluid collection as the cyst may contain a complex and viscous fluid, or may have a thick lining. 274 052 Performance Guidelines Candidates should familiarise themselves with the normal extent of transilluminability of other tissues, which vary rather like the scale of sonicity characteristics of an ultrasound. Try illuminating the finger and areas of normal skin to see the extent of normal transillumination of fat and other tissues. Lipomas are not transilluminably separate from surrounding fatty tissues, nor are most sebaceous' cysts transilluminable, because the content is viscous or pultaceous keratin. • Testing for fluctuation is often poorly performed also. The lump must be capable of being fixed by two fingers at the perimeter while a third finger compresses it centrally. If the other fingers are displaced and expanded symmetrically, and if this occurs when tested in several directions and in planes at right angles to each other, then this again is irrefutable evidence of contained liquid (by virtue of the incompressibility of liquids which causes transmission of outside pressure in all directions). Lipomas and other soft compressible solids may give an impression of fluctuance, but they do not exhibit true fluctuation, merely effects of deformation. • Ultrasound confirmation and positive yield of liquid on needle aspiration are definitively diagnostic of a cystic collection. In deeper lumps, such as those in breast or thyroid, where neither transillumination nor fluctuation is relevant or possible, these techniques become the best diagnostic aids. • Is the lump vascular? Candidates should not omit feeling for vascular pulsation, or a transmitted venous impulse, or listening for a vascular bruit or hum. Remembering normal vascular surface anatomy makes egregious errors less likely — such as missing an aneurysm. • Does the lump show emptying and refilling after compression or with joint movements? This important sign should alert the clinician to a possible bursal communication with an underlying joint and candidates should know which bursae are likely to communicate with which joints. Test your knowledge of the prepatellar bursa, the suprapatellar bursa, the pretibial bursa, the anserine bursa, the semimembranous bursa and a Baker cyst: all are near the knee joint, but only some communicate with (or are part of) the joint synovium. • Is the lump attached to the skin? If this sign is unequivocally positive, the lump is very likely to be a 'sebaceous' cyst or one of its variants, like a pilomatrixoma ('calcifying epithelioma of Malherbe'). This sign is sometimes easy to elicit and is accompanied by obvious skin dimpling or a punctum. But often, in areas where the skin is thick and relatively fixed to deeper layers such as on the back of neck or scalp, the test is equivocal and the clinician must rely on other findings such as contour and consistency to help diagnose subcutaneous lumps, and to differentiate between lipomas and keratinous 'sebaceous' cysts. At the end of the candidate's examination, or after five minutes, the examiner will: ASK — 'What is your diagnosis?' ASK — 'I s there any significant risk of malignant change?'JUe answer is NO for lipomas, sebaceous cysts, ganglia and bursae. ASK — 'I s there any significant risk of infection?' The answer is YES for infection complicating bursae and sebaceous cysts, but not lipomas or ganglia. ADVISE the candidate 'please counsel your patient about the lump. ' 275 052 Performance Guidelines KEY ISSUES The candidate should be able to: • Perform an appropriately focused and accurate physical examination of the subcutaneous lump. An appropriate and optimal examination will determine in which tissue layer the lump lies, its physical shape, size, contour and consistency, and its relationship to adjacent anatomical structures such as skin, muscle and tendons, joints, vessels and nerves. Testing for skin and deeper attachments and for fluctuation and transillumination, where appropriate, will be observed for technique and accuracy. • Display appropriate reasoning skills in making the correct diagnosis: ~ Most lipomas, sebaceous cysts, ganglia and bursae will not be difficult to diagnose. Distinction between sebaceous cysts and lipomas may be easy and aided by diagnostic clues, such as an obvious punctum. and knowledgeable candidates will recognise the differences and the potential risks of infective complications of sebaceous cysts and bursae. ~ Knowledgeable candidates will be able to make a confident diagnosis and to counsel the patient briefly but appropriately. The station is however predominantly to serve as a test of technique and accuracy of physical examination, and of appropriate clinical reasoning skills. CRITICAL ERRORS • Very unsatisfactory examination technique. • Major errors in accuracy of findings. COMMENTARY The most common subcutaneous swelling is a lipoma. Sebaceous (epidermoid) cysts, bursae and ganglia are also common. Subcutaneous lipomas (Figures 1 and 2) are slow growing, soft, painless, tabulated and mobile swellings beneath the skin. CONDITION 052. FIGURE 1. CONDITION 052. FIGURE 2. Subcutaneous lipoma of back Subcutaneous lipoma under arm 276 052 Performance Guidelines Epidermoid Cyst (keratinous cyst, implantation dermoid cyst, pilosebaceous follicle cyst, 'sebaceous cyst') Epidermal (epidermoid) cysts are common. They can occur at any age and at any site although they tend to be seen in older people and most often on the face, scalp or trunk. They have several different causes. Some are inclusion or implantation cysts, traumatic in origin, and others result from the occlusion of the pilosebaceous unit. Traumatic implantation cysts tend to occur on the hands and fingers. Others will be found at the site of surgical scars. Some epidermoid cysts are associated with hereditary syndromes (e.g. Gardner syndrome). The cyst is lined with squamous epithelium and full of desquamated debris, which has a characteristic soft cheesy texture and offensive odour when infected (Cock peculiar tumour). These cysts are often and mistakenly called 'sebaceous' cysts. A true sebaceous cyst is rare and arises from a sebaceous gland. A keratinous cyst is a preferable term. CONDITION 052. FIGURE 3. 'Sebaceous' cyst with punctum CONDITION 052. FIGURE 4. An epidermoid cyst tends to be elevated and many, but not all, will have a central punctum. These cysts may discharge or become infected. Uncomplicated cysts may be enucleated, whereas an infected cyst should be incised and drained, with later excision. CONDITION 052. FIGURE 5. Multiple 'sebaceous' cysts of scrotum CONDITION 052. FIGURE 6. Large 'sebaceous' cyst of scalp 277 052 Performance Guidelines 'Sebaceous' cysts (Figures 3, 4, 5 and 6) move with and not separate from the skin. They occur within any area of hair-bearing skin. They are usually round, fluctuant and non-transilluminable with a smooth nonlobulated contour which differentiates them from lipomas. The other differentiations (skin attachment versus the subcuticular mobility of lipomas) are not always easy signs to detect in areas of thick skin like the back of the neck - but 'sebaceous' cysts always have a focal point of skin fixation with or without a punctum, and have a round non-lobulated contour. Dermoid cyst (congenital inclusion cyst, hamartomatous cyst) Dermoid cysts can be found as cystic tumours of the ovary or within the cranium and spine and for the purposes of this section, in subcutaneous tissues. Apart from the confusing use of this term, the dermoid cyst is a congenital lesion and those found in the skin and subcutaneous layer usually occur on the face, neck or scalp. They are thin-walled cysts and contain fatty material and occasionally, hair. Although these cysts can appear at any age, those on the face and neck are usually evident at birth. Those on the face occur mainly around the eyes and are often attached to the underlying periosteum. They may also be found in the mouth and upper neck. Dermoid cysts are true hamartomas and develop when skin and skin structures become trapped during embryonic development, such as at lines of fusion anteriorly in the midline and around the eyes in the head and neck. Treatment is by excision. Imaging may be necessary, to assess the degree of involvement of underlying structures. Ganglia (Figures 7, 8 and 9) present as deeply placed subcutaneous lumps around joints or tendon sheaths. They may be made more prominent by tendon contraction or tensing and on joint movement. These are helpful diagnostic tests in the optimal examination sequence of: Look, Move, Feel, Listen. The common ganglia — those around wrist or ankle — do not communicate with the adjacent joints. They are, however, often formed by cystic degenerative change in the fibrous joint capsule or fibrous tendon sheath, so their removal necessitates opening the joint or sheath. CONDITION 052. FIGURE 7. Ganglion of lateral aspect of foot 278 052 Performance Guidelines CONDITION 052. FIGURES 8 AND 9. Ganglion of wrist — the most common site Bursae are cystic sacs between the skin and underlying bony prominences or they separate and aid gliding of adjacent tendons and ligaments. Some bursae communicate with joints or tendon sheaths. CONDITION 052. FIGURE 10. CONDITION 052. FIGURE 11. Olecranon Bursitis Double pathology — 'sebaceous' cyst of neck with submandibular salivary gland swelling behind it Candidates should show appropriate perspective in counselling. Many or most of these lumps require no active treatment other than reassurance. Subcutaneous lumps are very common and typical examples as indicated in the figures. Knowing that the lump has been present for a long time without significant symptoms or change in character is reassuring and makes a benign condition most likely. 279 053 Performance Guidelines Condition 053 Examination of the knee of a patient with recurrent painful swelling after injury AIMS OF STATION To assess the candidate's technique of physical examination of the knee joint and the accuracy of examination. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement: 'What is wrong with my knee?' You have a history of twisting your right knee six months ago when you caught your foot on a piece of broken pavement. You fell on the right knee which became swollen and painful on the inner side of the knee. The swelling caused a painful limp for a few days then subsided. Since then you have had intermittent attacks of pain felt on the inner side of the right knee with swelling which settles within 24 hours. You have difficulty in straightening your right leg fully and occasionally have apprehension twisting to the right. You are otherwise well and between attacks can walk normally with only a minor feeling of pain on the inner side of your knee. • You should complain of tenderness at the inner joint line anteriorly when the right knee is examined. • You cannot fully straighten the affected knee because of pain (a deficit of around 15 of extension). EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should examine both knees: Expected technique of knee examination: • Checks stance and gait. • Checks active range of movement initially — flexion/extension (range/power) notes positive signs of inability to fully extend affected knee and medial joint tenderness • Checks passive range of movement with care, ensuring that the range of active movement is not exceeded. • Checks for tenderness at joint line and around margins over sites of attachments of collateral ligaments and patellar ligament Should identify tenderness anteriorly, at the joint line, on the inner aspect of the right knee. • Checks for joint effusion (patellar tap' and 'bulge test' for cross fluctuation). • Checks patellofemoral mobility and tracking • Checks integrity of ligaments appropriately: valgus and varus strain to slightly flexed joint for collaterals; anterior and posterior glide (drawer) test for cruciates — all of these are normal 280 053 Performance Guidelines • Checks quadriceps for strength and wasting • Compares symptomatic side with normal side. • Examines back of joint (popliteal fossa) as well as front and sides. Diagnosis/Differential Diagnosis • Probable injury to medial intra-articular meniscus (medial cartilage) • Alternative: traumatic osteochondritis/synovitis right knee. • Unacceptable: cruciate/collateral ligament rupture. KEY ISSUES • Perform a focused and accurate physical examination of the knee joints (physical examination skills). • Formulate a diagnostic/differential diagnosis plan appropriate to the clinical problem (clinical reasoning skills). CRITICAL ERRORS • Failure to test movements of the left knee to compare with the other (affected) side. • Failure to test ligament integrity. COMMENTARY The knee joint is the most complex synovial joint in the body. Traumatic soft tissue internal derangements of the knee (IDK) are common after domestic, recreational and sporting injuries giving: • injuries to the intra-articular cartilages (more commonly to the medial meniscus); • tears of the collateral ligaments from valgus or varus strains; • cruciate ligament tears; • traumatic synovitis; and • chondromalacia or osteochondritis dissecans. Candidates should not omit examining the back of the affected knee. Occasionally candidates may mistakenly examine the normal knee instead of the affected one after asking the patient to turn over — a moderately serious mistake induced by nervousness and lack of concentration. 281 054 Performance Guidelines Condition 054 Assessment of hearing loss, first noted during pregnancy, in a 35-year-old woman AIMS OF STATION To assess the candidate's knowledge of types of hearing loss and their differentiation on examination. EXAMINER INSTRUCTIONS Opening statement: 'What is wrong with my hearing?' The examiner will have instructed the patient as follows: • you gave birth to your first child a month ago; • about midway during the pregnancy you became aware of reduced hearing; • this has become progressively worse and is the reason for you consulting the doctor today; • your infant is breastfed and thriving; and • you have no other complaints. The doctor is expected to ask you about a family history of deafness but provide this information only when asked. Your mother had operations for deafness on both ears many years ago. Your father, brother and sister are not deaf. The doctor may ask you further questions about your hearing loss: • both ears are affected; • it has no other special characteristics — 'just getting deaf: • you have not had exposure to very loud music (e.g. heavy metal music via earphones), or industrial noise; and • you have no past history of ear infections. Regarding severity: • you have difficulty hearing the baby cry if he is not in the same room as you are; • you have to have the television volume turned up (partner complains it is too loud): and • you have noticed that you seem to hear a bit better when there is a lot of outside noise. Other points: • The examiner will NOT ALLOW the doctor to use the otoscope provided to examine your ear canals but will ask about its use and what conditions are being looked for. Candidates should indicate they will look for complete occlusion of the ear canal by wax (cerumen). • Hearing capacity — the doctor will whisper numbers or words in your ear, masking your other ear — respond by saying that you CANNOT HEAR these sounds when they become soft. • Tuning fork tests: ~ When placed on top of your head say — 'same on both sides', in response to the doctor's question. 282 054 Performance Guidelines ~ When placed beside your ear and then pressed on the bone behind your ear, say that 'the latter is the louder.' The doctor may then repeat the test with the fork beside your ear, to test air conduction, asking you to say when the sound can no longer be heard. Respond accordingly after about 10 seconds 'can't hear it now'. The doctor should then press the tuning fork on the bone behind your ear to test bone conduction. Respond by saying 7 can hear that'. ~ If the candidate does the test in the reverse order (i.e. tests bone conduction prior to air conduction) react as follows: 7 can hear that' (on bone). When it can no longer be heard say 7 can't hear that anymore and when air conduction is tested, say 7 can't hear that either'. • The candidate should advise that referral for an audiogram or otolaryngological (ENT) opinion is necessary. EXPECTATIONS OF CANDIDATE PERFORMANCE Ability to distinguish types of hearing loss (in this patient conduction loss due to otosclerosis). KEY ISSUES • Skill in use of tuning fork tests to define types of hearing loss — conductive versus sensorineural. • Ability to explain to the patient the problem and its management. CRITICAL ERRORS • Failure to correctly use tuning fork in assessing hearing loss. • Failure to advise a referral for audiometry and/or ENT opinion. COMMENTARY 'There are two kinds of deafness. One is due to wax and is curable; the other is not due to wax and is not curable.' Sir William Wilde (1815-1876). father of Oscar Wilde We have made some progress in diagnosis and treatment since the above statement! This station is predominantly a test of skill in clinical assessment of hearing loss requiring that the candidate has a basic knowledge of types of hearing loss: conductive versus sensorineural, and that conductive deafness due to wax occlusion or other causes must be excluded. The patient evinces conductive deafness due to otosclerosis. Deafness is a common problem in older people in our community. The onset of bilateral deafness in a young woman during pregnancy is uncommon. The positive family history of a mother requiring surgery for her hearing loss points towards an inherited cause, namely otosclerosis. The onset of this condition is generally in early adulthood and may progress rapidly in pregnancy. The stapes footplate becomes ankylosed in the oval window causing conductive type deafness. Patients may notice they hear more clearly in noisy surroundings. The condition can be treated by prosthetic stapedectomy and vein grafting. 283 054 Performance Guidelines The eighth cranial nerve has two functional parts, the vestibular and the cochlear components. The cochlear branch subserves hearing. Afferent cochlear fibres from the inner ear pass through the internal auditory meatus and enter the upper medulla at the level of the inferior cerebellar peduncle to reach the dorsal and ventral cochlear nuclei. Fibres from these nuclei cross to the other side and end in the inferior colliculus. Fibres from that body go to the medial geniculate body and the auditory radiation to the temporal cortex. It is important to note that there are bilateral connections in the cochlear nucleus and above. Sensorineural deafness occurs when there is damage to the cochlear nerve fibres anywhere from the inner ear to the cochlear nuclei. The most common cause is degenerative changes in the elderly. Other causes include a fracture of the petrous temporal bone and an acoustic neuroma. Conduction deafness is caused by blockage of the ear canal and by damage or disease of the tympanic membrane or ossicular chain or fluid in the inner ear. • Establishing type of deafness — conductive versus sensorineural. Hearing should first be tested clinically for each ear with the examiner's finger occluding the other ear. Few people now have a ticking watch, so the examiner stands to the patients side and whispers numbers, which are repeated by the patient. The meatus, canal and drum are inspected with an otoscope, retracting the ear upwards and backwards to straighten the canal. This excludes other nonacute causes of conductive deafness (such as wax, osteomas, otitis externa, chronic otitis media). In this instance candidates will be informed that otoscopy is normal. Deafness may be due to impaired conduction of sound through a muffled middle ear (conductive or middle ear deafness); or to a lesion of auditory nerve, cochlear or brain (perceptive or sensorineural deafness). A tuning fork of high pitch (256 Hertz or greater) is used to compare hearing by bone conduction and air conduction. Normally air conduction is better than bone conduction. In nerve deafness air conduction remains better than bone conduction in the affected ear or ears. In middle ear/conduction deafness, bone conduction becomes better than air. RinneTest The vibrating tuning fork is placed on the mastoid, then at the auditory meatus: and the patient is asked which is louder. Air conduction (AC) is normally louder and is also iouder in nerve deafness. Hearing the fork louder on bone conduction (BC) indicates conductive deafness (BC > AC). Alternatively, put the fork on the mastoid until no longer audible, and then put it outside the meatus. The sound will in normal individuals be heard again and will also be heard again in nerve deafness, but not in conductive deafness. Weber test This can be very useful in unilateral deafness. The fork is placed on the centre of forehead in the midline; ask whether this is louder in one ear or equal. Normally the sound is heard equally in both ears. Occlude one ear with a finger or ear plug, and the sound will become louder in the affected ear (conductive deafness). In nerve deafness the sound is heard better on the normal side. So in unilateral conduction deafness Weber test localises to the affected side, in nerve deafness to the normal side. 284 054 Performance Guidelines In bilateral conductive or bilateral nerve deafness the sound will be the same. Unilateral nerve deafness must be due to a lesion of the nerve itself, as cortical radiations are bilaterally and diffusely represented in the temporal cerebral cortices. Common causes of conductive deafness are wax, otitis media, otosclerosis and Paget disease. Nerve deafness can be due to cochlear degeneration, acoustic nerve tumour, drug ototoxicity, or trauma (fracture of petrous temporal bone). Knowledge of features of otosclerosis is required to identify the likely cause. Otosclerosis is a common cause of bilateral symmetrical hearing loss in adults. The stapes footplate is ankylosed in the oval window. The condition is familial (autosomal dominant), more common in women and worsens with pregnancy so that patients may present during pregnancy. Patients may notice they hear more clearly in noisy surroundings, whereas in perceptive hearing loss background noise worsens hearing. Investigation by audiometry will be diagnostic. The condition can be treated by prosthetic stapedectomy and vein grafting. A hearing aid is less effective for this condition and effectiveness gradually diminishes. 285 055 Performance Guidelines Condition 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago AIMS OF STATION To assess the candidate's ability to perform a focused examination of the shoulder joint and of axillary nerve function. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You dislocated your right shoulder six months ago whilst playing competitive basketball. The dislocation was reduced successfully without anaesthesia at courtside. You initially noticed you had an area of numbness (with loss of sensation) the size of your fist over the lateral side of the upper arm below the shoulder tip, and you couldn't raise or keep your arm above your head. You were told this was due to a nerve injury. Over the next month the feeling gradually returned and the power in the arm came back. By four weeks you were having active shoulder exercises out of the sling, and by four months you were able to move the shoulder quite normally. You then began a graduated gymnasium programme under the supervision of your physiotherapist. Your current programme includes weight work and you have a full range of movements without loss of power as compared with the other side. You have resumed fully your normal activities of daily living and are keen to return to playing basketball when the season starts again in three months. Your physiotherapist and gym supervisor feel you are ready to return to this sporting activity but have suggested you get a final clearance from your doctor. Your shoulder will be examined by the candidate and it is now normal and without discomfort. The candidate will give the findings to the examiner and then will discuss things with you. Near the end of the assessment, the examiner will ask questions concerning shoulder function and what nerve was originally damaged. Appropriate prompts could be used as follows if the candidate does not provide you with the information you require regarding returning to basketball. Questions to ask unless already covered: • 'Am I able to restart sport in three months, doctor?' • 'Do I need any other tests done?' • 'Would it help if I saw a specialist in Sports ' Medicine?' • 'Is it likely to happen again?' 286 055 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to check: • Range of movement — flexion, extension, abduction, adduction, internal and external rotation and circumduction — all will be normal • Power of movement — normal • Scale of muscle power used: ~ 0 = nil ~ 1 = flicker ~ 2 = active movement possible but not against gravity ~ 3 = active movement possible against gravity ~ 4 = active movement possible against gravity and resistance ~ 5 = full power — absence of wasting, particularly of deltoid muscle, which is supplied by axillary nerve • Sensation — now normal. After six minutes, the examiner will ask (preferred answers in parentheses): • 'Is shoulder function and movement now normal?' (Yes). • 'Which nerve is at most risk from the usual type of shoulder dislocation?' (Axillary nerve). If the candidate is unable to indicate which nerve is involved, a very unsatisfactory mark should be given in the diagnosis category of assessment. As knowing the name of the involved nerve is not a "KEY ISSUE" it would not mean a fail mark overall must be awarded, but failing to test for axillary nerve function would be a critical error and generate a fail assessment. • 'Could you please now finish your discussion with the patient about her desire to return to sport?' (All seems satisfactory for you to return to playing basketball. There is a small likelihood that the shoulder dislocation will happen again. It would be advisable for you to have the shoulder strapped before each game to reduce the likelihood of a recurrence of the problem. Your physiotherapist will be able to teach you the best method of strapping, and you then should be able to do it yourself, or get your coach to do it for you). KEY ISSUES • Examination of the shoulder area indicating the appropriate technique to be used to evaluate the shoulder and axillary nerve function. • Display appropriate counselling skills when advising the patient concerning her desires to return to sporting activities. CRITICAL ERRORS • Inability to assess adequately the normal range of movement of the shoulder joint. • Failure to test the sensory and motor functions covered by the axillary nerve. • Giving inappropriate advice concerning the likelihood of recurrent dislocation. 287 055 Performance Guidelines COMMENTARY A dislocated shoulder is a common injury in body contact sports. The shoulder joint is the most mobile synovial joint in the human body. Protection is supplied by the overlying acromion and clavicle, and by the rotator cuff musculature that closely envelops the joint. The major weak spot is below, where protection by surrounding muscles is less, and the capsule is more lax to allow freedom of full flexion and abduction. The common mechanism of dislocation is therefore displacement of humeral head from the glenoid downwards and forwards. The axillary nerve runs between the muscles immediately below the capsule from front to back and is therefore at hazard from stretching injury in shoulder dislocations. The axillary nerve gives motor branches to deltoid and to teres minor, and supplies sensation as the upper lateral cutaneous nerve of the arm. It is important to test for the integrity of the vulnerable nerve before reduction is undertaken and afterwards; just as it is to test sciatic nerve function before and after reducing a posterior dislocation of the hip (the most common hip dislocation). 288 056 Performance Guidelines Condition 056 Assessment of a groin lump in a 40-year-old man AIMS OF STATION To assess the candidate's ability to perform a focused inguinoscrotal assessment, and to diagnose and advise on management of a reducible groin hernia. EXAMINER INSTRUCTIONS The real patients, with a variety of groin lumps will play themselves. The examiner will check the physical findings prior to the assessment. The patient illustrated has a reducible right inguinal hernia. KEY ISSUES • Performance of an appropriately focused inguinoscrotal assessment with appropriate technique and accuracy CRITICAL ERRORS • Failure to display appropriate clinical skills in diagnosis of a reducible groin hernia • Causing significant patient discomfort by rough technique. COMMENTARY Inguinoscrotal lumps are very common and present throughout life from birth to old age. The history of onset of pain following a lifting strain and followed by a lump is very suggestive of a groin hernia, and the appearance of the lump also supports this diagnosis. The examination should be thorough but gentle. The groin area needs to be exposed and the patient examined unclothed below the waist. It may be convenient to start with the patient standing, as small hernias are often made more prominent when standing. However, full examination and definition of all inguinoscrotal lumps is best performed with the patient comfortably lying; and with an anxious, apprehensive or modest patient it is best to start the examination with the patient lying supine. Examination with the patient standing should not be omitted, however, as various swellings (such as varicocele, saphena varix) may only be apparent on standing. Inspection and palpation of the area enable one to answer: • 'Is a groin hernia present?'A groin lump with an expansile impulse on coughing confirms the diagnosis in this case. The lump is seen and felt to expand uniformly and expansively when the patient coughs. The impulse ceases and the lump lessens or disappears when he relaxes. • 'Is the hernia reducible?' Check this visually and by feel. Always ask the patient himself to reduce the swelling before you try — in lumps of long standing he will be much more adept than you! • 'Is it an inguinal or femoral hernia?' This question is mainly of concern to the treating surgeon, but usually the differentiation is clear. This lump's relations to the groin land- 289 056 Performance Guidelines marks with an inguinal hernia are that the swelling is above the inguinal ligament and medially placed in regard to the pubic tubercle. When you feel the impulse it is clear that it is arising from the external (superficial) inguinal ring, the key to diagnosis. • This patient's hernia is clearly an inguinal hernia. It arises from the external ring, has an expansile cough impulse and reduces on lying down. If the lump had come out from the region of the saphenous opening below the inguinal ligament and more laterally (4 cm below and lateral to pubic tubercle) it would have been a femoral hernia. Sometimes in obese people it is impossible to be quite sure clinically which type of hernia is present. CONDITION 056. FIGURE 2. Right inguinal hernia CONDITION 056. FIGURE 3. Left inguinal hernia CONDITION 056. FIGURE 4. Right femoral hernia CONDITION 056. FIGURE 5. Larger right femoral hernia CONDITION 056. FIGURE 6. Bilateral femoral hernias CONDITION 056. FIGURE 7. Large left scrotal hydrocele 290 056 Performance Guidelines • 'Is the inguinal hernia direct or indirect?' The brief answer is — often you cannot tell clinically, and the diagnosis is made at operation for hernias confined to the groin alone. But if the hernia is a larger one, which clearly extends well down into the scrotum, the answer becomes obvious. Only indirect inguinal hernias descend into the scrotum by virtue of the anatomy of the sac, which is within the spermatic cord. Whereas the sac of a direct hernia, which never descends, is behind the spermatic cord. The candidate must check that an inguinoscrotal lump reduces completely on lying down — there may in fact be two lumps — a reducible hernia coming down from above and an unreducible scrotal hydrocele below! CONDITION 056. FIGURE 8. Bilateral large inguinal hernias, probably indirect CONDITION 056. FIGURE 9. Large right indirect inguinoscrotal hernia Patients with chronic obstructive airways disease and a chronic cough often develop acquired bilateral direct inguinal hernias. These present as small swellings confined to the groin which bulge directly forward through the enlarged external inguinal rings as illustrated. CONDITION 056. FIGURE 10. Bilateral direct inguinal hernias CONDITION 056. FIGURE 11. Varicocele 291 056 Performance Guidelines After having arrived at the correct diagnosis (a reducible right inguinal hernia), the examination is not yet finished. Multiple pathologies are very common. Both right and left sides must be checked — both inguinal and femoral orifices — to check that the hernia is unilateral. Additionally carefully check the spermatic cords/testes and their coverings to exclude an additional testicular swelling, hydrocele, or epididymal cyst. Feel femoral pulses and check that no abnormal lymph node enlargements are present. Do not forget to stand the patient up to check for venous swellings or small hernias Once a full diagnosis is made, consider treatment. Although surgery is not obligatory for all hernias, it is likely to be appropriate in this manual worker. So, refer him appropriately, explaining that the benefits of surgery usually outweigh risks (of which a number exists). 292 057 Performance Guidelines Condition 057 Eye problems in an Aboriginal community AIMS OF STATION To assess the candidate's ability to interpret photographs of trachoma, to assess their knowledge of the disease, and their ability to advise on appropriate management of the condition, EXAMINER INSTRUCTIONS The examiner will have instructed the nurse as follows: You are a trained nurse and have come to work in a small community in outback Australia. You have no previous experience of this type of work and in particular, you have little knowledge of the diseases often endemic in remote Australian Aboriginal communities. You have been in the community for a couple of weeks and have noticed that a significant proportion of the community appears to have eye problems. You have taken photographs of some of these individuals and have brought the images to the community doctor so that you can get a medical opinion on the problems and how they might be managed. Questions to ask unless already covered: • 'Do you think these might all be due to the same problem?' • 'How does the infection get from one person to another?' (if infection is mentioned as a cause) • 'What will happen if the condition is not treated?' • 'Is this condition found anywhere else and how common is it?' • 'Is it preventable9 If so, how can it be prevented?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should be able to: • recognise that eversion of the upper eyelid facilitates diagnosis; • describe the changes in the photographs: • recognise that the condition is trachoma, because of the setting of an indigenous Australian Aboriginal community, with classical appearances of trachoma: • describe the agent responsible for the disease (Chlamydia trachomatis), and the vector of transmission (flies, hand contact, fomites); • understand the pathological changes produced by the organism; and • describe some simple and appropriate measures that might be employed to reduce the risk of infection. KEY ISSUES • Interpretation of clinical photographs of eye changes produced by trachoma. • Knowledge and understanding of trachoma, its mode of transmission and measures used to reduce the risk of infection. 293 057 Performance Guidelines CRITICAL E R R O R • Failure to recognise trachoma COMMENTARY Globally, trachoma is the most common infectious cause of blindness and is a preventable disease. It is endemic in Africa, the Middle East, Asia and Aboriginal communities of Australia. More than six million people are blind as a result of trachoma. It is a disease of poverty and the marginalised members of society. The condition was known from ancient times as a contagious disease, and given the name trachoma (Greek), meaning a 'rough' swelling. Trachoma is caused by an obligate intracellular Gram-negative bacterium. Chlamydia trachomatis. The disease is usually transmitted by direct contact or fomites between children and their mothers, or others involved in the care of children, and by flies. Poor facial hygiene facilitates spread by attracting flies and there are often recurrent bouts of infection within a family. Recurrent infection will cause chronic conjunctival inflammation, which is followed by scarring of the tarsal conjunctiva. As scars mature, the tarsal plate becomes distorted and entropion (turning in of the eyelid) develops and this results in trichiasis (misdirection of the eyelashes towards the globe). Chronic irritation of the globe will lead to corneal abrasions, infection, opacification and finally, blindness. Candidates should be able to identify the stages of trachoma, easily remembered by the acronym FISTO — • Follicles; • Inflammation; • Scarring; • Trichiasis; and • Opacity of the cornea. Follicles are the sign of active trachoma infection, and represent the sites of replication of the causative organism. The diagnosis of trachoma is confirmed by the presence of more than 5 follicles. They lead to scarring after multiple attacks (dozens). The scarring of the deep surface of the lid distorts the lid and results in lashes rubbing on the cornea, which ulcerates and becomes infected and scarred. The resulting blindness is permanent. Candidates should know that azithromycin is specific for the causative organism Chlamydia trachomatis. The active disease is usually seen in young children, with inflammatory changes most apparent in young adults. The scarring effects of infection develop in middle-age, when the patients present with trichiasis and corneal opacity. A simplified grading scheme for trachoma which can be taught to and used by community health workers, was introduced by the World Health Organisation (WHO) in 1987. 294 057 Performance Guidelines Grade Definition TF Five or more follicles seen on the tarsal conjunctiva of the everted upper lid. (Figures 1, 5) Tl Intense inflammation of the upper tarsal conjunctiva, obscuring the view of more thanhalf of the deep tarsal blood vessels on the everted upper eyelid. (Figure 6) TS White lines of subconjunctival scarring visible on the surface of the everted upper eyelid. (Figure 2) TT Trichiasis, at least one eyelash rubbing on the globe, or evidence of recent removal. (Figures 3, 4, 7) CO Corneal opacity, obscuring at least part of the pupil margin. (Figures 3, 4, 7) The candidate should be able to discuss public health measures. Some practical advice for a community nurse would be along the lines of the SAFE strategy, developed by the WHO. • Surgery: identification of individuals in the community who might benefit from correctional eyelid surgery for trichiasis and entropion. • Antibiotics: children should be examined (with eversion of the upper eyelid) for trachoma and all members of a family where there is active trachoma should be treated with oral azithromycin • Facial cleanliness communities, and particularly affected families, need to be educated about the disease, its mode of spread, and that simple measures such as ensuring facial cleanliness will reduce the risk and severity of trachoma. • Environmental upgrade: any improvement in water supplies, household sanitation, personal and community hygiene will reduce the risks of infection. Improved cleanliness in sleeping areas with fly and dust control should be emphasised. Additional trachoma examples are shown below. Upper eyelid eversion to inspect for follicles facilitates early diagnosis. 295 057 Performance Guidelines CONDITION 057. FIGURE 5. Inflammatory follicles on the under surface of the upper tarsus (TF) in closeup CONDITION 057. FIGURE 7. Entropion with trichiasis (TT) and corneal opacification (CO) 296 CONDITION 057. FIGURE 6. Inflammatory changes on the everted upper eyelid (Tl) 2-C: Choice and Interpretation of Investigations Reuben D Glass and Vernon C Marshall 'It is not of decisive significance whether the clinician confronts an overwhelming or a modest amount of material, if only he understands how to exploit it: in other words, he must be in a position to put the right questions and to find the right methods for answering them.' Rudolf Virchow (1821-1902) Disease, Life and Man Modern medicine relies considerably on the results of special investigations. Previously, the traditional stock-in-trade of the astute clinician has been the manner in which his unaided clinical senses of observation, hearing and touch are used in making diagnoses and in formulating strategies of management. But times and clinical practice have changed. Investigations play an increasingly important (though still not all-important) part in the practice of medicine. Major growth of special investigations has occurred in the fields of laboratory medicine and in organ imaging. The clinician in such instances often assumes the role of consumer, and must be alert to the possibility that an opinion given by another (or the data issued by a machine) is not always absolutely reliable and may occasionally be wrong. This short introduction aims to give a general idea of the circumstances in which special investigations are essential, useful, profitable, redundant, or potentially dangerous, and to help in their choice and interpretation. Patients often assume that when a test is ordered, it will answer whether disease is present or not. Clinicians sometimes make the same mistake. A test may be useful for helping to confirm, or helping to exclude the possibility of a disorder, but will seldom give a perfect answer. A frequent error is to suppose that a given test is equally useful for confirming or excluding disease, but this is usually not true. The clinician who orders a test should always be mindful of the reason for its use. If the test result will not alter the patient's management, there is little point in ordering it. Diagnostic accuracy of any test will depend upon how well it performs in comparison with its performance against another so-called 'gold standard'. The histological diagnosis of cancer is the usual yardstick against which the performance of another less invasive test is measured. More often, however, one must compare the accuracy of several available tests to determine which is best. TEST RESULTS AND THEIR IMPLICATIONS A frequent error is to suppose that a given test is equally useful for The performance of a test may be studied in a survey of a particular confirming or excluding population. disease, but this is The test sensitivity is the percentage of patients k n o w n t o h a v e a usually not true. The particular disease, whose test proves positive ( t r u e p o s i t i v i t y ) The clinician who orders a down side of high sensitivity is a potentially high false positivity rate: test should always be the proportion without the disease who also test positive. mindful of the reason for The test specificity is the percentage of patients in that population its use. If the test result k n o w n t o b e f r e e of the disease, in whom the test proves negative will not alter the patient's { t r u e n e g a t i v i t y ) The down side of high specificity would be a high management, there is false negativity rate: the proportion with the disease who also test little point in ordering it. Sensitivity and Specificity negative. 297 2-C Choice and Interpretation Investigations of The following examples explore these concepts: Example 1 A group of 1,000 patients is tested for the presence of a certain disease (Table 1 ). Results SECTION 2-C. TABLE 1. Test results in 1,000 patients affected with a disease. Disease Present Test Positive Test Negative Total: 18 2 20 (a) (c) (a+c) Disease Absent 20 960 980 (b) (d) (b+d) Total 38 (a+b) 962 (c+d) 1.000 (a+b+c+d) The sensitivity is a/(a+c) which in example 1 is 18/20= 90% The specificity is d/(b+d) which in example 1 is 960/980=98% Results of research studies are often presented in this way. Sensitivity and specificity are epidemiological measures, which need to be adapted for clinical use. Predictive values In considering individual patients with unknown disease status on presentation, the clinician wishes particularly to know the predictive value of the test: that is, the likelihood of a positive or negative test confirming or excluding the disease. • Positive Predictive Value is the proportion of persons testing positive who actually have the disease. (The false positives comprise the 'false alarm rate'). • Negative Predictive Value is the proportion testing negative who in fact do not have the disease. (The false negatives comprise the 'false reassurance rate'). The clinical interpretation of the test may be given as: The positive predictive value is a/(a+b) The negative predictive value is d/(c+d) The false alarm rate is b/(a+b) The false reassurance rate is c/(c+d) which in example 1 which in example 1 which in example 1 which in example 1 is 18/ 38 is 960/ 962 is 20/ 38 IS 2/962 = 47% = 99.8% = 53% = 0.2% Implications: This test has a high specificity (98%). and thus is very helpful in excluding disease. If it gives a negative result, there is a very high likelihood that disease is absent (99.8% negative predictive value). Conversely, there is a very low chance that this negative result will give false reassurance (0.2% false reassurance rate). It has a lower sensitivity (90%), and is much less useful in confirming disease. It misses 10% of cases with the disease and is more likely to be positive — and thus gives a false alarm — in patients without the disease (53%) than in those with the disease (47%). 298 2-C Choice and Interpretation of Investigations The ideal test should have absolute sensitivity — all people within the test group with the condition will give a positive test result. The ideal test should also be absolutely specific (the converse of sensitivity) — all people within the test group who do not have the condition will give a negative result. If a test had a sensitivity of 1 and a specificity of 1 its probability of error would be zero, and positive and negative predictive values would be 100%. With such an ideal test there would be no false positives and no false negatives. The ideal test should also be attended by a very low level of random or systematic errors of measurement. It should be highly reproducible: the error within and between observers should be very low. No test absolutely measures up to all these ideals. Biochemical tests are based on results from a healthy population sample. These results will usually have a Gaussian normal distribution bell-shaped curve pattern when plotted. Laboratory reports often imply that results falling outside two standard deviations from the mean are 'abnormal'. Such reports should be treated with caution, as by statistical definition, one in 20 healthy individuals would fit this category. A similar spread of results is obtained when examining patients with a particular disease. As there is overlap between the values in healthy and diseased patients, the choice of a cut-off point between a positive and negative test result is artificial. In such tests, specificity and sensitivity are likely to be inversely related. For example, in screening tests for prostate cancer, a serum prostate specific antigen (PSA) level of 4 ng/mL is frequently used as the cut-off level. The test has a range of levels, and at high levels the risk of prostatic cancer being present is increased. At lower levels more patients will be identified who have a condition other than prostate cancer (prostatitis, benign prostatomegaly etc.). Reducing the cut-off level of the test to 2 ng/mL would increase the test sensitivity but reduce the specificity. This will increase the number of false positives and create anxiety for a greater number of patients who would subsequently be worked up to decide whether the test was truly positive for prostate cancer. Implications: A highly sensitive test is an appropriate one for screening a population for an abnormality. A negative result in a highly sensitive test will effectively rule out the diagnosis. The fact that the test is not absolutely specific for the abnormality but also identifies a number of individuals, who are normal or have some other condition, can subsequently be taken care of by applying to the identified group a further test which is highly specific (but not so sensitive). In the highly specific test on individuals picked up by the sensitive screening test, a positive result will effectively give a definite diagnosis. In the prostatic example above the subsequent test would be a tissue biopsy confirming cancer. Faecal occult blood testing for bowel malignancies is another example of a test with a relatively high sensitivity but poor specificity, which will require further assessment (endoscopy) of those identified with a positive result. The sensitivity is determined also by the biology of the condition. In colorectal cancer, a faecal occult blood test will not detect neoplasms which do not bleed. Other relevant aspects of testing are the frequency and importance of a disease and its duration and natural history. Unfortunately, measures of predictive value have limitations in clinical practice, as they depend on the prevalence of the disease in the population (Disease prevalence: the number of people with the disease in the test population at the time of testing. This should not be confused with disease incidence: the number of new cases of the disease occurring in the population over a set time interval). 299 2-C Choice and Interpretation of Investigations The utility of a test is influenced by population differences. Suppose the same number of affected patients (20) with the disease illustrated in Example 1 in a population of 1,000, were spread about a population 10 times the size (10,000 — Example 2, Table 2): The prevalence of the disease is 20 1000 20 10000 (a+c)/ (a+b+c+d) which in Example 1 is and in Example 2 is Example 2 = 2% (Table 1) =0.2% (Table 2) SECTION 2-C. TABLE 2. Test results in 10,000 patients in a region of lower disease prevalence. Disease Present Test Positive Test Negative Total: 18 2 20 (a) (c) (a+c) Disease Absent 200 9,780 9,980 (b) (d) (b+d) Total 218 (a+b) (c+d) 9,782 10,000 (a+b+c+d) The test sensitivity (90%) and specificity (98%) are unchanged in Example 2 from Example 1 However, in this larger population, with a disease prevalence of 0.2% (compared to a prevalence of 2% in Example 1 ), the negative predictive value has increased to almost 100%, while the positive predictive value is now only 8%. The predictive value of a positive test depends on the frequency of disease in the population Example 3: breast cancer evaluation The following table gives results of a highly specific test (T: needle core biopsy) performed in 600 women showing focal mammographie abnormalities, to diagnose or exclude the worst case disease (D: breast cancer). SECTION 2-C. TABLE 3. Test results for 600 women with focal mammographie abnormalities. Test(T) Patients with cancer Patients found free of Needle core biopsy subsequently confirmed (D positive) cancer subsequently (D negative) Total Needle core biopsy Positive for cancer 143 a 2 b 145 Needle core biopsy Negative for cancer 15 c 440 d 455 Breast cancer 158 Benign Conditions 442 600 Total 300 2-C Choice and Interpretation of Investigations Sensitivity of test (true positivity) Specificity of test (true negativity) False Positivity Rate False Negativity Rate Positive Predictive Value Negative Predictive Value False Alarm Rate False Reassurance Rate Prevalence of breast cancer in test population a/( a+c) d /(b+d) b/ (a+b) c/( c+d) a/( a+b) d/(c+d) b/(a+b) c/(c+d) (a+c)/( a+b+c+d) 143 /158 440/ 442 2/ 145 15 /455 143/145 440/455 2/145 15/455 158/600 91% 99% 1% 3% 99% 97% 1% 3% 26% Implications: Positive and negative predictive values are seen to be strongly affected by the characteristics of the test (sensitivity and specificity) and by characteristics of the population (disease prevalence). Here 26% of those showing focal abnormalities on mammography (the original screening test) ultimately proved to have cancer. Core biopsy had very good (99%) positive predictive value, but not quite so good (97%) negative predictive values. A small but not insignificant group (3%) had cancer found at operation done to remove the mammographie abnormality, after preoperative false reassurance. Likelihood ratios and scoring systems Use of likelihood ratios, which may be considered as measuring the 'leverage' of a test, is a method of separating the characteristics of a population from the inherent value of a test. In assessing the result of a test, the clinician may follow the following thought process: Depends on population Depends on test characteristics Before performing a test, the clinician should have an idea of the possibility of disease in the population. This can be expressed mathematically as prevalence probability (a+c)/(a+b+c+d), or more usefully here as 'prior odds', which is the ratio comparing the number of patients with disease to the number of patients without disease, or (a+c)/(b+d) The usefulness of a test is measurable by the likelihood ratio. The likelihood ratio of a positive test is the frequency of a positive test in disease compared with its frequency without disease, or [(a)/(a+c)]/[(b)/(b+d)]. The value in example 1 is thus [(18/20)]/[(20/980)]. or approximately 50. 301 2-C Choice and Interpretation of Investigations Multiplying the prior odds by the likelihood ratio gives revised odds, or chances that disease will be present, compared with absent: In example 1, the prior odds are 20/980, or approximately 0,02 in favour of disease (or 50:1 against); revised odds are 0.02 x 50 = 1, i.e. 1:1 or a 50:50' toss-up. In example 2, the prior odds are 20:9980 or 0.002 in favour of disease (or 500:1 against); revised odds are 0.002 x 50 = 0.01 in favour of disease (or 10:1 against). Implications: It should be noted that the likelihood ratio often has a different value for a positive or a negative test. If the test is negative, the likelihood ratio (negative) is the frequency of a negative test without disease, compared with a negative test in disease, or [ d / ( b + d ) ] / [ c / ( a + c ) ] . This is not the reciprocal of the likelihood ratio (positive); a test will not be equally useful for confirming or excluding disease. In example 1, the likelihood ratio (negative) is [(960/980)/(2/20)] or approximately 10. In that example, where the prior odds of no disease were 50:1, the revised odds against disease, given a negative test, are now 500:1. In example 2, the prior odds of no disease were approximately 500:1, the revised odds are now 5000:1. Various scoring systems have been proposed, which follow a similar logic, using addition of mathematically derived scores, rather than the multiplication of odds and ratios. While some believe that addition of 'weights' in this way may parallel the clinician's thought processes more closely, these systems have not been widely adopted. Test Error The possibility of error in any test must thus always be considered. Most disturbing of all is the prospect of a mistake in the distinction between life and death. Now that the transplantation of cadaveric tissues has become a clinical reality, and because procurement of such tissues within a short time of death is essential to success, the unequivocal early diagnosis of brain death has demanded diagnostic tests of scrupulous and unparalleled stringency. As will be seen in the book example relating to brain death, note that virtually all the tests for brain death involve direct observation of the patient by at least two experienced clinicians rather than the application of potentially imperfect technologies. USEFULNESS OF TESTS1 The more tests that are performed on a patient the more likely it is that one or another will give a falsely abnormal result by pure chance. Another important factor is that multiple deviations from normality are common in any individual, especially in an ageing population. So, if multiple diagnostic tests are applied to a given patient in a mindless scattergun fashion, it is almost inevitable that one or more will be reported as positive. These positive results may be true or false, important or unimportant, relevant or irrelevant to the patients problem. Relatively simple clinical problems can all too easily become lost sight of in the maze created by multiple investigations. 1 Glass, R.D., Di ag n os i s : a bri e f i n tr od ucti o n , Oxford University Press, Australia, 1996 302 2-C Choice and Interpretation of Investigations Diagnostic utility of a particular test is thus determined by: • the prevalence and importance of the condition tested for; • the diagnostic accuracy of the test and how it compares to that of other well established tests; • the invasiveness of the test and the risk to the patient from its performance; • the test's cost and availability; and • whether the outcome of the test will influence the management of the patient's complaint. Case Example The following case study demonstrates the optimal integration of morphologic and functional imaging and biochemical investigations with diagnostic and management plans and pathways in a patient with an unexpected incidental finding on initial investigation. A 66-year-old man presented to his general practitioner after an episode of right upper quadrant abdominal pain, which had resolved after four hours. Clinical examination was noncontributory. An abdominal ultrasound was ordered with a provisional diagnosis of gallstones and associated biliary pain. The ultrasound showed a normal gall bladder and biliary system free of stones, but revealed a focal round solid mass 5 cm in diameter, above the right kidney, inferior to the liver, and in the position of the right adrenal gland. (Figure 1 ) SECTION 2-C. FIGURE 1. Ultrasound findings An abdominal CT was next done to delineate more accurately the pathology. Intravenous and oral contrast material were used to enhance imaging. (Figure 2) The mass was confirmed to be a focal 5 cm round, solid mass within the right adrenal gland, extrinsic to the posteroinferior right lobe of the liver, and to the right of, and lateral to, the inferior vena cava, and superomedial to the right kidney. The mass had smooth borders and appeared well encapsulated without any evidence of infiltration of surrounding structures. The left adrenal was normal and no other intra-abdominal mass or pathology was noted. 303 2-C Choice and Interpretation of Investigations SECTION 2-C. FIGURE 2. Computed tomography (CT) of abdomen Was this adrenal mass relevant to his symptoms, or was It an 'Incidentaloma '? Small benign adrenal adenomas of no clinical relevance are very common in patients of this age, but are mostly less than 2 cm in diameter. This one is larger (5 cm) and masses of 5 cm or above are more suspicious of malignancy. Removal is often advised for larger tumours even it nonsymptomatic. He was referred for specialist opinion. Further detailed history with focused questioning was helpful. For the last 8 years he had noticed 'funny turns ' episodically. These caused him to feel dizzy and nauseated, and were associated with thumping and pounding in his chest, and a throbbing in his head thai lasted for several minutes. The experienced clinician recognised that such a pattern would be consistent with catecholamine surges produced by an adrenal medullary tumour — a phaeochromocytoma. Family history can be important in phaeochromocytomas associated with multiple endocrine neoplasia Type 2, with associated parathyroid hyperplasia (C cells) and medullary thyroid cancer. No such family history was obtained here; and clinical examination of neck was normal as was the serum calcium level. There was no family history of hypertension. His father died of a stroke and his mother of gastric cancer, both in their 80s. He had a past episode of a bleeding peptic ulcer 30 years ago (duodenal ulcer is associated with phaeochromocytomas) and minor symptoms currently of urinary hesitancy. His prostate felt normal on rectal examination. He had no cough, chest pain, dyspnoea or sputum and did not smoke (adrenal metastases from lung or other primary sites need to be remembered). 304 2-C Choice and Interpretation of Investigations The range of endocrine overactivities from an adrenal tumour can involve singly or in combination: • Glucocorticoids from adrenal cortex: Cortisol excess (Cushlng syndrome). There were no stigmata of hypercortisolaemia clinically — no moon face, no hypertension, no body fat redistribution, no cataracts. • Mineralocorticoids from adrenal cortex: aldosterone excess (Conn syndrome). Hypertension is the common association here, together with hypokalemia. His electrolytes were normal. • Adrenal sex hormones from adrenal cortex: these may give virilisation in women. • Catecholamines from adrenal medulla (adrenaline and noradrenaline): phaeochromo-cytoma. This seems most likely from the history. Again hypertension is a common association. Thus the three most common adrenal tumours each can cause secondary hypertension, although his blood pressure was normal on review. However hypertension may be episodic, particularly with phaeochromocytoma. Functional endocrine investigative studies were arranged. Modern endocrinological tests have high specificity and sensitivity. Initial screening urinary or serum analyses are most reliable following an episode of symptoms but do not of course localise the site of origin. A battery of screening tests was ordered, as well as standard preoperative screening tests. • Full blood examination normal, Hb 151 g/L • Cardiovascular status ECG sinus rhythm, no evidence cardiac ischaemia • Echocardiogram • Electrolytes • Coagulation studies • Blood glucose no ventricular hypertrophy normal no abnormalities mild elevation • Specific urinary catecholamine excretion analysis can be for end products (VMA — vannylmandelic acid), or for adrenaline and noradrenaline themselves (normally 80% adrenaline and 20% noradrenaline). Urine 24 hour analyses for excretion of adrenaline and noradrenaline were done in this case and were markedly elevated, with high levels of both noradrenaline and adrenaline — noradrenaline 1160 mmol/day (45-600), adrenaline 720 mmol/day (5-80). As adrenal tumours may produce more than one hormone, a check for aldosterone effects was also done measuring plasma aldosterone, renin activity levels, and aldosterone/renin ratio. All were within normal range. Hydrocortisone (Cortisol) levels were also normal. The diagnosis of right adrenal phaeochromocytoma was thus definitively established, and Conn and Cushing syndrome excluded. But was the tumour only at one site? Phaeochromocytoma often causes attacks of episodic hypertension only and can be at multiple sites. It is designated the 10% tumour — 70% are bilateral, 10% are at extra-adrenal sites, 10% are malignant. Previously, extended open laparotomy was required to check fully for other abdominal sites — the opposite adrenal, the retroperitoneum down to the pelvis, the urinary bladder, and in the presacral area around the great vessels. Open surgery required large incisions, major surgical dissection of hazardous tissue planes, and inpatient stays of up to 2 weeks. The advent of nuclear medicine has enabled accurate preoperative functional imaging to confirm one or multiple sites precisely. Extra-adrenal tumours secrete noradrenaline only and are almost always associated with hypertension, but the opposite adrenal always needs to be excluded as a source. 305 2-C Choice and Interpretation of Investigations Final investigation: Radionuclide localising scan Metaiodobenzylguanidine scan (MIBG): A radioiodine labelled agent (MIBG). which is taken up by catecholamine precursors, is injected. Abdominal scintigraphy will localise the functioning tumour as illustrated (Figure 3). The test is specific and sensitive. SECTION 2-C FIGURE 3. Functional nuclear scan for catecholamines, showing hot spot below liver on right The scan confirmed a single hot area at the site of the right adrenal with no activity in the left adrenal or elsewhere. Preparation of the patient for surgery now began. Preoperative elective catecholamine blockade over a period of 1-2 weeks has now virtually eliminated the hazard of operative adrenal crisis due to a catecholamine surge with life-threatening hypertension. Adrenaline and noradrenaline stimulate a and /3 (vascular and cardiac) receptors. Initial a-receptor blockade was begun with phenoxybenzamine, followed by (1-receptor blockade (propranolol) after a-blockage had occurred. During surgery nitroprusside and phentolamine should be available to control bleed pressure swings precisely. Laparoscopic surgery is particularly applicable to well localised functioning adrenal tumours. Excellent views are obtained, separation of the tumour from major adjacent vasculature is facilitated, required hospital stay is reduced, and rapid convalescence ensured. Only very large tumours, malignant tumours, or evidence of tumours at multiple sites are contraindications to a laparoscopic approach. The operation was uneventful with removal of the right adrenal and its contained tumour. His convalescence was straightforward with discharge from hospital within 2 days of surgery. 306 2-C Choice and Interpretation of Investigations SECTION 2-C. FIGURE 4. Adrenalectomy specimen Diagnostic utility was appropriate in this instance for each of the carefully planned sequential investigations across a spectrum of imaging, biochemical, and radionuclide tests, leading to precise diagnosis and focused surgery with every expectation of complete cure. OFFICE TESTS USED IN PATIENT ASSESSMENT Body Temperature Measurement This test illustrates many of the points discussed. Temperature recording is easily performed and inexpensive, can be done accurately, is non-invasive and effectively free from risk. In terms of detecting abnormality, it is extremely sensitive, but very low in specificity. It is a cost effective test that can and should be applied to almost all clinical problems. A significantly elevated body temperature indicates (in the absence of factitious malingering) an organic inflammatory or infective ailment. The test is thus an excellent all round screening measure. Urinalysis This shares many of the performance characteristics of temperature measurement and can be applied at minimum cost to virtually all clinical patients. Observer error has been reduced to a minimum by the development of user-friendly dipsticks. These can provide highly specific and highly sensitive identification of glycosuria, proteinuria, biliuria, haematuria and other abnormalities. Medieval manuscripts used depictions of inspection of a urine flask (urinoscopy) as a convenient symbol of the medical practitioner — a convention based on clinical reality at the time. Modern technology has enhanced rather than diminished the utility of urinoscopy/urinalysis in diagnosis. Urinary positivity for glucose will depend upon renal threshold. Blood glucose fingerprick analysis, now also readily available by user-friendly office instruments (glucometer), allows rapid identification of hyperglycaemia and can often establish the presence of diabetes. An elevated random blood glucose level over 11 mmol/L will effectively confirm the diagnosis of diabetes. Glycosuria and glycaemia here serve as complementary screening and diagnostic tests — high sensitivity screening augmented by specific diagnostic testing. 307 2-C Choice and Interpretation of Investigations Urine tests for pregnancy diagnosis Another very widely used urinary test for office or home use, which gives results within a few minutes, is urinary detection of human chorionic gonadotrophin (hCG) using monoclonal and polyclonal antibody test strips. Positive testing for pregnancy can occur from the first day of the missed period with a sensitivity of 25 mu/ml. Sensitivity and specificity progressively increase thereafter as the pregnancy progresses. In many clinical consultations with women of childbearing age with abdominal pain, particularly if accompanied by menstrual irregularities, a spot urinary pregnancy test is prudent and often diagnostically helpful. Urine tests for diagnosis of ovulation time Home monitoring of urinary luteinising hormone (LH) antibody from 17 days before the expected period can detect the LH surge indicating that ovulation will occur within 24-36 hours. Electrocardiograph/electrocardiogram (ECG) Previously a quite sophisticated test, ECG is now increasingly available for on-the-spot office consultation and provides sensitive and specific information regarding cardiac rate and rhythm and cardiac function, complementing cardiologie history and examination. Ultrasound/Doppler probes Hand held battery-operated ultrasound probes can be used to more accurately identify arterial or venous blood flow, aiding diagnosis of peripheral arterial insufficiency, arteriovenous shunting, or venous obstruction and incompetence. In the wards they can aid physical examination to detect a full or empty urinary bladder in postoperative patients. Mass screening of populations, used in our community to identify common life-threatening diseases (cancer of breast, colon) and cardiovascular disease (coronary artery disease and stroke), involves mammography, faecal occult blood examination, measurement of blood pressure and serum lipids, and other programmes. The effectiveness of these programmes is determined by sensitivity and specificity of the tests employed and their cost, plus the prevalence and importance of the disease in the community. The ultimate goal of such screening programmes is to diminish mortality by early detection of diseases, or by detecting persons who are at high risk of developing disease and introducing preventive strategies. The additional requirement of cost-effectiveness in achieving such goals often requires years of prospective study. 308 2-C Choice and Interpretation of Investigations USE OF INVESTIGATIONS IN CLINICAL PROBLEM-SOLVING: CHOICE OF INVESTIGATIONS Tests used to aid clinical diagnosis of the patients presenting problem should utilise discriminative strategies rather than the cumulative strategy of performing more and more tests in the hope that something will turn up. Tests used discriminatively and with appropriate perception and perspective will enable the diagnostic process to move along appropriately focused lines to best advantage. Data collection from focused history and physical examination leads to the discriminative clinician asking the questions: • What is the patient's presenting condition? • What is the diagnosis? • What else could it be? • Have I enough certainty to stop testing and go on to treatment? • If more tests are required which are the best and in what sequence, and over what time interval? For example, in diagnosing headache, acute headache is often part of an upper respiratory tract infection presentation associated with other symptoms of general loss of well being. Chronic and recurring headaches are most usually due either to tension headache, migraine or cervical dysfunction/spondylosis. Of the many other causes, warning flags should be looked for in the clinical assessment to exclude temporal arteritis, subarachnoid haemorrhage and cerebral tumour. A persisting headache is also an associated symptom secondary to a wide range of other conditions. CT head scan is only required in the minority of instances, when an intracranial lesion causing cerebral compression with increased intracranial pressure is suspected. Low back pain and neck pain are most often due to temporary soft tissue musculo-ligamentous strains ('nonspecific mechanical back pain'). Precise anatomical or pathologic diagnosis is often not possible. The place of investigations is confounded by the facts that degenerative change in discs and facet joints which could be associated with symptomatic pain are found in a significant proportion of nonsymptomatic individuals, especially those aged over 40 years, where the prevalence is likely to be at least 30%. Contrariwise in patients with chronic low back pain, no significant organic pathology is demonstrable in around 30% of patients. Plain X-rays will exclude serious bony lesions and may give evidence of soft tissue pathology, but CT (or nowadays and increasingly, MRI scanning) gives the most accurate assessment of soft tissues; and despite its expense the latter investigation of MRI is usually the preferred investigation in chronic spinal pain. Ultrasound is of limited use in spinal pain, but ultrasound is usually the investigation of first choice in acute or chronic shoulder pain following injury. However, ultrasound is very observer-dependent, and again MRI is likely to be more sensitive and specific. With acute abdominal pain, a small group of patients with a catastrophic syndrome of 'acute abdominal surgical emergency' requires urgent surgery with minimal preoperative investigations. In this case surgery is the major and most urgent investigation, and leads directly to diagnosis and management of such causes as acute abdominal aortic aneurysm rupture, and acute ischaemic strangulation of bowel. Upper abdominal pain which is less urgent, or chronic, can be investigated by plain or contrast X-ray. ultrasound, isotope studies, endoscopy, CT or MRI together with a host of biochemical and other laboratory tests. If gallstones are thought to be the most likely pathology causing abdominal 309 2-C Choice and Interpretation of Investigations pain ultrasound is the most appropriate first investigation. Ultrasound is noninvasive, can be used both in emergency and elective situations, displays the gallbladder wall and contents as well as the bile duct system and picks up many associated or alternative diagnoses (particularly in liver, kidneys, pancreas and spleen). If peptic ulcer is thought most likely, endoscopy is usually the best initial investigation and aided by biopsy can distinguish benign from malignant lesions. Pain thought to arise from the pancreas is likely to require early CT. The use of combined noninvasive modalities such as helical CT or magnetic resonance cholangiopancreatography (MRCP) can now provide high sensitivity and specificity with high resolution imaging. Newer techniques such as multi-slice CT (MSCT) are becoming the examinations of choice for assessment of various body systems and organs. MSCT allows greater information to be gained due to the thinner multiplanar slices acquired, which can be reviewed in multiple planes or in three dimensions to give superbly detailed images as illustrated (Figures 5-9).2 SECTION 2-C. FIGURE 5. SECTION 2-C. FIGURE 6. SECTION 2-C. FIGURE 7. Spine Extremity Abdomen SECTION 2-C. FIGURE 8. SECTION 2-C. FIGURE 9. Angiography CT Angiography 2 Figures reproduced by permission of MIA Victoria, a member of l-MED/MIA Network; A Guide to Multi-Slice CT Scanning. 310 2-C Choice and Interpretation of Investigations In patients with jaundice, liver function tests are usually of limited value in diagnosing the cause of the jaundice, but they provide information which must be taken into account in formulating further diagnostic and management plans. Ultrasound and helical CT or MRCP comprise investigative mainstays. Important investigations prior to surgical management include blood coagulation tests and tests of renal function. Patients with suspected bowel pathology can be investigated either by radiology or endoscopy. Colonoscopy is preferred to diagnose mucosal lesions. For focal subcutaneous lumps and focal skin lesions, in many instances no investigations are required and an accurate diagnosis can be obtained from the clinical history and examination. If the lump or skin lesion is clinically suspicious then the definitive investigation is often histological examination of an operative specimen. Preliminary diagnostic investigations are often done to determine more accurately the physical nature of deep lumps. Ultrasound can differentiate between cystic and solid lesions, while CT or MRI will give more precise diagnosis. Once the decision is made that microscopic examination is necessary, fine needle aspiration cytology (FNAC) is often a highly specific test, particularly for patients presenting with breast lumps (palpable or picked up by imaging), or subcutaneous lymph node swellings. Aspiration cytology gives cytological rather than histological diagnosis; but using flow cytometry and assessing surface receptors to differentiate subsets of T and B lymphocytes can diagnose and differentiate polyclonal and monoclonal lymphomas, as discussed in Section 4-A. Cytological studies may also demonstrate the likely origin of metastatic lesions by finding squamous neoplastic cells in a lymph node neck swelling, or by finding a papillary thyroid lesion in neck lymph nodes. Primary growths of pharyngolarynx and thyroid can be small and occult in association with larger nodal metastases. Accurate cytology can point the way to a further appropriate sequence of diagnostic investigations. Finally core biopsy by percutaneous needling is widely used and is the preferred diagnostic method for solid breast lumps and other deeper lumps where tissue diagnosis is required. In the examples which follow, candidates should exercise care in the choice and interpretation of investigation in order to direct and focus diagnostic and management pathways. Reuben D Glass and Vernon C Marshall 311 2-C Choice and Interpretation of Investigations 2-C Choice and Interpretation of Investigations Candidate Information and Tasks M CAT 058-064 58 Positive test for hepatitis C in a 26-year-old woman 59 Diagnosis of 'brain death' prior to organ donation 60 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 61 An elbow injury in an 11-year-old schoolgirl 62 Sudden onset of chest pain and breathlessness in a 20-year-old woman 63 Atypical ureteric colic in a 25-year-old man 64 Investigation for male factor infertility in a 25-year-old man 312 058 Candidate Information and Tasks Condition 058 Positive test for hepatitis C in a 26-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 26-year-old woman who has been sent to see you because she was tested for hepatitis B and C and for HIV when she attended the Red Cross blood bank as a blood donor one week previously and was found to be hepatitis C positive. She has just been notified that she was found to be hepatitis C positive and advised to see her local doctor for further assessment. Other blood tests were negative for both hepatitis Band HIV. She had never given blood before, and had not been tested for any of these infections previously. YOUR TASKS ARE TO: • Take a relevant history from the woman. • Advise her about subsequent management and likely prognosis. The Performance Guidelines for Condition 058 can be found on page 321 313 059 Candidate Information and Tasks Condition 059 Diagnosis of 'brain death' prior to organ donation CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a secondary school science teacher. Next week a doctor from the Australian Kidney Foundation is going to speak at a class seminar to all the Year 11 students about organ transplantation and the donation of organs and tissues from donors who have died. The teacher is to chair the seminar which has been titled The Gift of Life'. The teacher has heard about 'brain death' and found the protocol below on the internet and printed it out. He wants you to explain it to him in understandable language to help him comprehend the implications and facilitate his chairmanship. CONDITION 059. TABLE 1. Brain death protocol. PREDETERMINED CRITERIA BEFORE TEST • Core body temperature > 35 °C • No central nervous system (CNS) depressant drugs for > 48 hours (longer if CNS depressants given in large amount or for a long time) • No neuromuscular blocking drugs for > 12 hours • No endocrine problems, eg hypothyroidism, hypopituitarism • PaC02 > 50 mmHg ▪ No hypoglycaemia TESTS 1. Pupils fixed and unresponsive to light 2. Absent corneal reflexes 3. Absent pain response in cranial nerve distribution 4. Absent gag reflex on endotracheal tube movement 5. Oculocephalic reflexes absent (no 'dolls' eyes' response) 6. Vestibulo-ocular reflexes absent (no nystagmus) 7. No spontaneous respirations after 10 minutes (patient ventilated on 100% oxygen at a rate of 4 breaths/min with a tidal volume of 7 mL/kg). Arterial blood gases taken at 5 and 10 minutes. BRAIN DEATH Diagnosis to be made by two doctors independently including the intensive care consultant. Neither will be a member of the transplant team where organ donation is considered. Two groups of tests, preferably separated by 24 hours. The results of examination must be recorded in the case notes or a suitable devised form. YOUR TASK IS TO: • Discuss the subject with him and respond to his queries. The Performance Guidelines for Condition 059 can be found on page 325 314 060 Candidate Information and Tasks Condition 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer CANDIDATE INFORMATION AND TASKS Your next patient for office consultation in a primary care community practice clinic is for review of a 20-year-old single woman whom you saw four weeks ago with a complaint of cyclical mastalgia for the last six months. Physical examination of the breasts was normal. She had no previous history of breast problems. Her 50-year-old mother, also a patient of the clinic, had a Stage 1 breast cancer treated by mastectomy and axillary dissection five years ago and is well on follow up. You ordered an ultrasound of the breasts in this young woman, which showed an impalpable, focal well-circumscribed solid parenchymal lesion in the right breast 1 cm in diameter consistent with a fibroadenoma. You referred her to the female surgeon who treated her mother, who suggested an ultrasound-guided percutaneous core biopsy to confirm the imaging diagnosis of benign fibroadenoma. The patient was also reassured that if this showed, as expected, a benign lesion, surgery would not be required, and she could be observed clinically with periodic ultrasound assessments. The patient is unhappy with this advice and feels she would like the lump removed and has come back to you to discuss this further. She is worried that the lump may be malignant or will become so, and feels that just taking a piece of it will leave her still worried. YOUR TASK IS TO: • Discuss her concerns with her and advise her on the future management you would propose. The Performance Guidelines for Condition 060 can be found on page 329 315 061 Candidate information and Tasks Condition 061 An elbow injury in an 11-year-old schoolgirl CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. Emily an 11-year-old schoolgirl, fell at school injuring her right elbow which is swollen and painful. You arranged for X-rays which have been taken and are shown below. You are interviewing Emily's mother after examining Emily and her X-rays. The elbow region was swollen, painful and tender, with marked pain on attempted movement. There were no signs causing concern on examination of the hands. YOUR TASKS ARE TO: • Advise the parent regarding diagnosis and treatment. • Answer questions from the observing examiner near the end of the interview. CONDITION 061. FIGURE 1. CONDITION 061. FIGURE 2. The Performance Guidelines for Condition 061 can be found on page 331 316 062 Candidate Information and Tasks Condition 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman CANDIDATE INFORMATION AND TASKS This young woman has presented to the Emergency Department of the local hospital with the sudden onset of right sided chest pain and breathlessness while walking to work. She is otherwise in good health and is a nonsmoker. Physical examination of the chest showed no definite abnormality. Her breathlessness is less now. A chest X-ray has been taken, and is illustrated below. YOUR TASKS ARE TO: • Examine and interpret the patient's chest X-ray. • Explain to the patient the diagnosis and how she should be treated. There is NO need to take any further history from the patient NOR repeat the physical examination. CONDITION 062. FIGURE 1. The Performance Guidelines for Condition 062 can be found on page 334 317 063 Candidate Information and Tasks Condition 063 Atypical ureteric colic in a 25-year-old man CANDIDATE INFORMATION AND TASKS You are a medical officer in the hospital followup clinic. A few days ago your next patient, a 25-year-old driver, previously in good health, attended the Emergency Department with very severe acute colicky mid-line lower abdominal pain. Abdominal examination was normal. Because the patient's urine tested positive for blood, a diagnosis of atypical ureteric colic was made. The pain was controlled by an injection of pethidine. A plain X-ray of the abdomen was normal so an intravenous pyelogram (IVP) was arranged. The films are available for you to review (see below), but a formal report from the radiologist has not yet been received. The patient is seeing you today to find out the result of the IVP. He is now well and has been straining his urine but no calculus has been found. YOUR TASKS ARE TO: • Examine the IVP film, and give a commentary to the examiner. • Explain the X-ray findings to the patient. • Advise the patient about further management. CONDITION 063. FIGURE 1. Intravenous pyelogram The Performance Guidelines for Condition 063 can be found on page 337 318 064 Candidate Information and Tasks Condition 064 Investigation for male factor infertility in a 25-year-old man CANDIDATE INFORMATION AND TASKS A married couple (husband 25, wife 23 years) have been trying to conceive for the last 12 months. Examination of both the husband and the wife is normal. Investigations arranged by you, from a general practice setting, have shown she is ovulating each month, and has patent Fallopian tubes. The husband's recent semen analysis is not normal. His result is as follows: SEMEN ANALYSIS Collected after three days of abstinence. Examined 30 minutes after collection by masturbation, normal values in brackets Volume 6 mL Count 2 million/mL Motility 20% Velocity 20 microns/second Abnormal morphology 95% Antisperm antibodies nil (2-6 mL) (Greater than 20 million/mL) (Greater than 40%) (Greater than 30 microns/second) (Less than 80%) (Nil) The husband has come to see you today for the result of the semen specimen. His wife is aware of her results. She was unable to come today. When you examined him previously, you found no abnormality on general or genital examination. Both testes were normal in size (20 mL estimated volume), felt normal in consistency, there was no indication of a varicocele or hydrocele. YOUR TASKS ARE TO: • Take a further relevant and focused history from the husband in regard to the results obtained. • Advise the husband regarding the couple's fertility problem. The Performance Guidelines for Condition 064 can be found on page 340 319 2-C Choice and Interpretation of Investigations 2-C Choice and Interpretation of Investigations Performance Guidelines MCAT 058-064 58 Positive test tor hepatitis C in a 26-year-old woman 59 Diagnosis of 'brain death' prior to organ donation 60 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 61 An elbow injury in an 11-year-old schoolgirl 62 Sudden onset of chest pain and breathlessness in a 20-year-old woman 63 Atypical ureteric colic in a 25-year-old man 64 Investigation for male factor infertility in a 25-year-old man 320 058 Performance Guidelines Condition 058 Positive test for hepatitis C in a 26-year-old woman AIMS OF STATION To assess the ability of the candidate to take a focused history assessing the possible mechanism for her becoming hepatitis C positive, and then to appropriately advise the patient in regard to the mode of contracting the disease, the tests required to assess the current activity of the disease, the likely long-term outcome, whether any treatment is likely to be helpful, the likely possibility of transmitting the disease to other people, and the need for notification of the disease, EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The candidate will be expected to take an appropriate history from you to determine how the hepatitis C infection occurred, and whether you are likely to spread it to another individual. The candidate will also be expected to provide you with information concerning the investigations now required to assess any potential adverse effect of the hepatitis C virus on your body and whether you have cleared the infection spontaneously. Advice concerning your subsequent management will also be given and the need for notification of the disease to the local state health department within five days. The following history is likely to be sought from you (give answers to specific questions as outlined below): • Information in regard to likely cause of the hepatitis C infection ~ You were an intermittent intravenous drug-user over a two-year period, but last had a 'shot' about six years ago. ~ On occasions you had shared needles with a friend. ~ You have never had a blood transfusion or given blood products ~ You have had two sexual partners in your life. The first relationship lasted three years and the second, the current one, has lasted four years. You married your current partner two years ago. ~ No family history of hepatitis of any sort. ~ No previous operations or illnesses. ~ No tattoos or body piercing ~ You work in a hospital as a cleaner. ~ You never had a needlestick injury • You feel well, have a normal level of energy and no difficulties at work • In response to any questions about symptoms (such as change in appetite, change in weight, skin changes, abdominal discomfort, bowel function) reply that there have been no such problems. • Your alcohol intake is 1 or 2 glasses of wine a day. • You are taking the oral contraceptive pill (Microgynon 30®) and wish to have a child in about two years time. • You have no past history of clinical hepatitis. You have never been jaundiced. 321 058 Performance Guidelines • After taking your history, the candidate should explain to you that the infection is likely to have occurred as a result of your intravenous drug use. • You are likely to be advised that you need blood tests to define whether the infection has cleared spontaneously from your body (polymerase chain reaction [PCR] test) and whether it has had any effect on your liver function (liver function tests). Knowledge of these results will then determine what the subsequent risks to you are. Questions to ask if not already covered: • 'Do I need to have any more tests?' • 'Will I be able to have a baby?' • 'Can anyone catch this infection from me?' • 'Must you notify this to the health department?' EXPECTATIONS OF CANDIDATE PERFORMANCE History taking should include: • Information in regard to the likely cause of the hepatitis C infection as outlined in instructions to patient. Current status • She has no current symptoms of liver disease: no tiredness, bruising, itch, appetite change, abdominal discomfort, gastrointestinal bleeding, leg swelling. • Alcohol intake is moderate. Investigations Investigations required are those to assess any effect of hepatitis C on her liver, and whether the actual viral infection has spontaneously cleared, (i.e. liver function tests and a polymerase chain reaction test for hepatitis C virus [HCV PCR]). In addition to the above tests, the possibility of blood group immunisation due to the use of shared needles needs to be assessed by the indirect Coombs Test. If positive this will influence the care required in a pregnancy. Counselling In counselling about hepatitis C and risk to the patient, the candidate is expected to know that hepatitis C is a viral infection transmitted mainly via infected human blood. In most patients the diagnosis is made only when the disease is established and chronic. In this patient, the exposure was almost certainly at the time of intravenous drug use 6-8 years ago. In order to best identify the risk of liver disease, LFTs and HCV PCR should be performed • An HCV PCR should be performed to help determine if the patient has spontaneously cleared the infection. • In any patient, if serum alanine aminotransferase (ALT) is persistently normal (three estimations over a six month period) the prognosis is good and it is likely no long-term adverse liver effects will ever be found. In this patient if ALT is normal on the first test, given the likely exposure was many years ago, the patient can be reassured, but further ALT monitoring should still be advised. 322 058 Performance Guidelines • If ALT is elevated, referral to a gastroenterologist would be appropriate for full liver assessment, including biopsy, as antiviral therapy, including interferon and ribavirin, may be of use if there is significant fibrosis in the biopsy specimen. Ultimately liver failure and liver transplantation may be required in a small percentage of cases, and the patient is also at increased risk of hepatocellular carcinoma. When the above aspects have been sorted out, a decision can be made regarding the advisability of a pregnancy. Pregnancy should not be allowed until at least 6 months has elapsed after cessation of antiviral therapy, if this has been given, due to the teratogenicity of the ribavirin. If pregnancy is to be allowed, the oral contraceptive pill should be ceased and the pregnancy awaited. The chance of the baby being infected by vertical transmission during the pregnancy is about 5% in patients who have a positive PCR for HCV. Counselling about hepatitis C and risk to others Prevention of infection of others can only be achieved by ensuring all people who come in contact with her blood take appropriate precautions, and that the sharing of needles is never done. There is no risk of hepatitis C transmission by hugging, kissing, casual contact, sharing food or eating utensils. However it is important to avoid sharing objects with potential for blood contamination, such as razors and toothbrushes. The risk of vertical transmission is very low. There are no recommendations against breastfeeding. The risk of spreading this infection during sexual activity is extremely low, and there is little or no evidence that condom usage will be of value in protecting her husband from his very low risk of getting infected in this way. Hepatitis C is a notifiable disease — notification is confidential. Patient education The good candidate will seek to provide the patient with appropriate supplementary patient education material. KEY ISSUES • Taking a focused history in regard to determining the source of the infection. • Advising the patient appropriately regarding subsequent care, the risk of liver pathology, and the need to ensure blood transmission does not occur, as this would be likely to result in hepatitis C infection in the recipient. CRITICAL ERRORS • Failure to recognise the need for LFT (ALT) assessments. • Advising the patient of a benign course of disease in all instances. COMMENTARY Hepatitis C is a single stranded RNA virus. Risk factors for hepatitis C infection include intravenous drug use (70%), sexual exposure (-10%), blood transfusion (6%), occupational exposure (3%), unknown (-10%). The risks of tattoos, body piercing and intranasal cocaine are not well defined. The viral infection is established and chronic at the time of diagnosis in most patients. If identified early, treatment with interferon within 3 to 6 months of infection can prevent chronicity in 98% of patients. 323 058 Performance Guidelines The natural history of hepatitis C infection is that 15-50% resolve completely with no adverse end result and normal liver function (i.e. PCR is negative and liver function and ALT are normal). The remaining 50-75% will have chronic infection (PCR positive). Twenty percent of those with an elevated ALT will develop cirrhosis, of which 1-5% will develop hepatocellular carcinoma, and 20% will develop liver failure requiring transplantation. LFTs and HCV PCR therefore need to be done to assign the patient to the appropriate group. This station requires that the candidate has knowledge of the natural history of hepatitis C and how this infection is detected, monitored and treated. Good communication skills are required to address sensitive issues in a situation where the patient is likely to be very anxious, having just been informed about a potentially serious infection. The station examines the ability of the candidate to take a focused medical history, relating to potential source of the infection, and any effects on her health. The patient needs to be advised about the necessary investigations (blood tests for HCV PCR and LFTs) and why these are required. Counselling skills are evaluated as the candidate talks with the patient about the possible effects of the hepatitis C virus on her health and the potential of passing on the infection to others. There is a good opportunity at this first consultation to establish a good rapport, to give some basic education about hepatitis C. to provide some reassurance about transmission risk, and to set the scene for the next visit when the ordered test results will be discussed. Candidates should be aware that hepatitis C is a notifiable disease with confidentiality maintained. 324 059 Performance Guidelines Condition 059 Diagnosis of 'brain death' prior to organ donation AIMS OF STATION • To assess the candidate's knowledge of the principles of diagnosis of brain death and its certification. • To assess the candidate's communication skills in public education by discussing and explaining aspects of cadaver organ donation in the context of brain death with a layperson. EXAMINER INSTRUCTIONS The standardised 'patient' in this instance is a secondary school science teacher with enquiries as described. Responses and questions will depend upon the clarity of explanation and information from the doctor. Questions to be asked unless already covered: • 'What does'brain death'mean?' • What are these predetermined criteria about?' • 'Can you explain these tests to me?' EXPECTATIONS OF CANDIDATE PERFORMANCE You would expect the imminent medical graduate to understand clearly the principles, although not necessarily the detail, of the diagnosis of brain death and its implications in gaining of consent for cadaver organ donation as outlined in the commentary. KEY ISSUES • Ability to discuss principles of 'brain death' to a lay person. • Ability to discuss principles of cadaveric organ donation for transplantation CRITICAL ERROR - none defined COMMENTARY The candidate should be familiar with legislation in Australia (which is broadly similar to that pertaining in most developed countries) providing for legal certification of death by either of two methods: • permanent and irreversible cessation of heart beat and loss of cardiac function; and • permanent and irreversible loss of brain function The concept of 'brain death', as an alternative to 'cardiac death' has important implications in transplantation of organs and tissues from a cadaver donor. Removing organs once brain death has been diagnosed and certified improves significantly the prospect of immediate function of the organ graft in the recipient after revascularisation in its new host. Immediate graft function is essential for successful heart and liver transplantation, and highly desirable in grafts of kidneys, lung, pancreas, bowel and other tissues. 325 059 Performance Guidelines Removal of organs from the brain-dead, heart-beating cadaver with permanent and irreversible apnoea (cessation of spontaneous breathing) due to brain stem death, whose respiration is maintained by artificial mechanical ventilation of the lungs, minimises the critical time of 'warm' ischaemia before cold perfusion of the removed organs. Thus, immediate function of the graft in its new host can be anticipated provided total ischaemic times after organ removal do not exceed the tolerated time periods for the individual organs — around 6 hours for hearts and up to 24-48 hours for liver, kidneys and other organs. Clearly the diagnosis of irreversible and permanent loss of brain and brain stem function must be an unequivocal and certain one, with absolutely no prospect of error. We need tests of absolute specificity and sensitivity. The several criteria and tests listed outline the ways of ensuring that irreversible loss of function has occurred both in the higher cortical brain functions, and also in the functions of the brain stem, where the respiratory centre and cranial nerve origins are clustered. The criteria listed for diagnosis of brain death first require the appropriate clinical setting (usually massive head injury or a catastrophic stroke), and the presence of deep and totally unresponsive coma with permanent loss of function of the respiratory centre, so no spontaneous breathing can occur because the brain stem centre for breathing has been irreversibly destroyed (and in the absence of respiratory activity, cardiac arrest inevitably follows within 30 minutes or less unless ventilation is restored by artificial ventilation). The other criteria are the exclusion of other possible contributors to prolonged coma (hypothermia, continuing central nervous system paralysis from drugs or curare-like respiratory depressants, or gross metabolic and endocrine disturbances). The tests then employed as listed in the criteria of brain death are diagnostic of destroyed and absent brain stem reflexes, involving successively the midbrain, pons and medulla, so that loss of brain stem function is progressively confirmed from above downwards, testing reflexes subserved by cranial nerves 2 through 12 via their sensory and motor pathways, and the brain stem reflex arcs from highest to lowest level. Permanent irreversible apnoea (failure of spontaneous breathing) due to death of the respiratory centre is confirmed over a 10-minute interval in the presence of a high level of build up of carbon dioxide in the blood, which in the presence of a responsive respiratory centre will stimulate spontaneous breathing. Criteria for confirmation of findings is by two groups of tests separated by an appropriate period of observation, and confirmed by two independent doctors, including a senior and experienced clinician. Meticulous application of these defined and universally accepted worldwide criteria has ensured that brain death can be diagnosed clinically with absolute confidence and without any risk of misdiagnosis. Diagnosis of brain death is made by meticulous clinical observations and tests and does not require elaborate technology for certainty of diagnosis. The doctor here has been put on the spot by the bluntness and directness of the science teacher's request. How should the request best be handled? It may be best initially to broaden the discussion into a general outline of the usual setting of cadaver organ donation and the tragic circumstances of sudden and unexpected death of a loved one highlighting the many sensitive human, ethical and cultural issues which make empathie and 326 059 Performance Guidelines compassionate communication between the treating and transplant medical teams and grieving relatives and next of kin so essential. Certainly all doctors should be conversant with the laws governing consent for donation given by the next of kin, but the request would come normally from an experienced senior member of the intensive care team, and not from a junior Hospital Medical Officer (HMO). Initial discussion with the candidate could then be followed by a subsequent briefing in which the doctor could read up about the more specific details of diagnosis of brain death and the science and ethics of cadaver organ transplantation before meeting the teacher again. This station is a rather extreme example of the increasingly common practice of patients presenting to doctors with printed internet reports related to their presenting problem, often quite detailed but not always appropriate in their perspective or application to the particular problem posed by the patient. In this instance, the isolated table the teacher brought was presumably taken from a larger general account, which would be more relevant than the specifics of agonochemical events and the specifics of tests used to diagnose permanent and irreversible death of the brain and brain stem. The essential principle is that the criteria and tests provide the legal basis for medical certification of the death of a person (because the brain is dead) even though other functions of the body (heartbeat and machine-driven ventilation) are still going on with the support of machines and transfusions so the person (who is now actually a cadaver) 'looks alive'. Knowledgeable candidates should be able to give a general description, similar to the above, of brain death. In particular, that: • all the vital brain stem centres have been destroyed, including the respiratory centre and consciousness centre, so the condition presents as a totally unresponsive individual with permanent loss of consciousness, with permanent loss of the capacity to breathe: • the various tests described are tests of these brain stem and higher functions to be certain that all are permanently and irreversibly destroyed over a repeated period of observation: and • all other potential influences on consciousness (like effects of drugs) have been eliminated with certainty. Doctors should also know that the condition of brain death, its certification and its legal and ethical implications have been ratified by all major religions, and that the time of brain death is seen by theologians to equate with the time at which the soul leaves the body. It is also important to understand that brain death means death of the individual as surely as does recognition of death by cessation of heartbeat. Objections from next of kin to obtaining consent for organ donation after certification of brain death are usually cultural and emotional and associated with fear of mutilation of the body. The vegetative state comprises the condition of deep coma with present but ineffective spontaneous breathing and with retention of other brain stem activities and reflexes, requiring artificial feeding (and often respiratory assistance), and responding to a variety of stimuli. It is NOT brain death. Knowledgeable candidates will stress this fact. 327 059 Performance Guidelines Much confusion in the public mind was initially stimulated by misinformed or unsubstantiated, (but sensational) reporting of doctors removing organs from struggling and responsive patients in whom brain death was said to be wrongly diagnosed. Doctors always need to employ great empathy and compassion in obtaining consent in indicating to the relatives of the brain dead individual what organs are to be removed for transplantation, and in answering direct questions from them in regard to these and other matters. 328 060 Performance Guidelines Condition 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer AIMS OF STATION To assess the candidate's counselling and educational skills in a patient with concerns about familial breast cancer risk. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are very worried that this lump could be a cancer You feel it should be removed so you don't have to worry about it anymore. If the doctor's reassurances are clear and convincing, you are prepared to change your mind. If not, ask if you can have a second surgical opinion Opening statement: 'I think this lump should be removed'. Questions to ask if not already covered: • 'How can you be sure it's not a cancer?' • 'Isn't it likely to turn into a cancer'? • 'Can’t I just have it out and then forget about it? EXPECTATIONS OF CANDIDATE PERFORMANCE • Reassurance about likely benign diagnosis, • Reassurance that impalpable fibroadenomas are very common in nonsymptomatic women on imaging and do not reguire excision and that they are not cancers and do not become cancerous. • Reassurance that the biopsy takes several representative pieces and can save unnecessary surgery and avoid potentially unsightly scarring. • Reassurance that with a homogeneous lesion such as this, the biopsy could be relied upon to give a definitive diagnosis. • Sympathy for concerns of patient about cancer, and about continuing clinical and ultrasound monitoring; reassurance of noninvasive nature of ultrasound monitoring: reassurance of noninvasive nature of ultrasound • Assurance that if patient is still concerned, the surgeon would be likely to accede to her wishes, and if not, she could be referred for a second opinion. • Whatever the patient decides, periodic followup with clinical and imaging reviews will be advisable because of her family history and her concerns. KEY ISSUES • Counselling and communication skills in dealing with an anxious patient. • Knowledge of pathology and natural history of breast fibroadenomas. 329 060 Performance Guidelines CRITICAL ERROR - none d e f i n e d COMMENTARY The scenario illustrates a common problem. Breast cancer is very common in Australian women and around 1 in 14 women will develop breast cancer in their lifetime. The risk is increased in the presence of family history of breast cancer in first degree relatives, as is the case here. This young patient requires regular clinical screening and appropriate imaging. The ultrasound ordered by the family doctor was appropriate as initial investigation. Note that her original problem (cyclical mastalgia) has now been replaced by the more serious problem of 'I have a breast lump which could be cancerous' Her natural reaction (which might be the correct solution to the problem) is 'I want it out.' Benign impalpable (or palpable) fibroadenomas and other benign parenchymal lesions are very common in this age group. We know from mass screening that benign lesions occur throughout all stages of life, and that the natural history of fibroadenomas may be to remain unchanged, to increase in size or to regress. No convincing evidence exists that benign fibroadenomas are premalignant, and much collateral evidence on screening programme followup suggests that they are not. Whether total excisional biopsy or partial core biopsy should be performed will depend on circumstances, but an appropriate core biopsy would take five or more representative samples and would be expected to give a definitively accurate diagnosis with minimal likelihood of either a falsely negative or falsely positive result, and with minimal morbidity in experienced hands. This lesion is impalpable and both clinical findings (normal breasts) and imaging findings (typical ultrasound appearance of a benign lesion) already favour a benign fibroadenoma. But these findings alone are no! enough, and pathological confirmation by biopsy is required additionally to make our reassurance quite positive ('triple test check' — clinical, imaging, and pathology all confirmed and negative for cancer). Pathology can be determined by fine needle aspiration cytology (FNAC) or by percutaneous image-guided needle core biopsy. Choice will depend on circumstances and availability of expert cytology and pathology services; but core biopsy will give a tissue diagnosis and has higher sensitivity and specificity, so is generally preferred. If the 'triple test' is negative, the lesion is virtually certain to be benign. The patient will require continuing periodic clinical and imaging review from her family doctor and surgeon. The surgeon's advice was therefore appropriate and concise, but she has not convinced the patient that it is the right plan. The utility of any advice regarding management is only relevant and helpful if patient acceptance is present. If this patient remains unconvinced and unhappy, despite repeated reinforcement by the family doctor, clearly the best decision may be to agree to her own wishes that the lesion is removed. This will require an image-guided needle localisation operation. It is unlikely that the surgeon would not agree to this, even though she (the surgeon) correctly regards core biopsy and observation as the best option. 330 061 Performance Guidelines Condition 061 An elbow injury in an 11-year-old schoolgirl AIMS OF STATION To assess the candidate's ability to identify a supracondylar humeral fracture on X-ray and advise regarding treatment. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: Your 11-year-old daughter, Emily, fell at school and now has a sore, painful swollen right elbow. The candidate has finished examining your child and has examined the X-rays. Opening statement and questions from the parent: • 'Is the arm broken, doctor?' • 'What treatment will she need?' • 'What about school and writing?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to advise the parent and describe the diagnosis, initial treatment plan and followup in response to the questions along the following lines: (Expected responses in parentheses) • 'Is the arm broken?' (Yes. Emily has fractured the arm bone [humerus] just above the elbow. There is minimal displacement and no complications. She should get excellent results with full functional recovery). • 'What treatment will she need?'(\Ne will apply a back slab/plaster/splint to the elbow with a bandage and sling. No anaesthetic will be needed. Pain relief will be ensured by paracetamol as required, dose for age. She will need to keep the elbow in plaster for several weeks [4-6 weeks] as illustrated. She will need a first followup tomorrow to check plaster and fingers, and that she is comfortable with the plaster and sling. The parent should report earlier if hand or fingers swell further. She should sleep with arm supported on a pillow. Subsequent unrestricted use of hand and fingers should be encouraged with self-maintenance finger stretches). • 'What about school and writing?' (Can write as soon as finger movements allow this. Can return to school when pain eases in a day or two). CONDITION 061. FIGURE 3. X-ray after application of backslab 331 061 Performance Guidelines The examiner should ask the following question at seven minutes: 'What complication is most to be feared in these fractures if they are displaced?' (Vascular njury to the brachial artery). KEY ISSUES • • Recognition of fracture on X-ray. Understanding principles and practice of management of an undisplaced uncomplicated closed supracondylar fracture. • Understanding of potential complications in this type of fracture. CRITICAL ERRORS • Missing the diagnosis of fracture • Failing to arrange appropriate review and followup. • Failure to know of risk of vascular complications in displaced supracondylar fractures. COMMENTARY Supracondylar humeral fractures are common in children following falls on the arm or hand. Undisplaced fractures or those with minor displacements can be treated without need for reduction by immobilising the elbow using a padded backslab or plaster (leaving shoulder and wrist and hand free to move) in the position of function of partial elbow-flexion of around 100° flexion. Severely displaced fractures will require reduction under anaesthesia and similar splintage after alignment is checked. A serious complication to be watched for is injury to the brachial artery from the anteriorly displaced upper fragment, giving ischaemia of the hand and fingers shown by pallor, insensitivity and absent radial pulse. Unless circulation is clearly restored after reduction, such ischaemia must be treated by open exploration of the fracture site and the injured artery with restoration of adequate blood flow by vascular surgery, otherwise Volkmann ischaemic contracture of forearm muscles can occur. Fortunately in the majority of cases, displacement is minor or alignment is readily corrected and no vascular complications are present; but circulation must always be checked by review after 24 hours, and parents and patients advised to report earlier if symptoms of numbness, finger swelling or severe hand pain occur. Immobilisation is usually only needed in children for 4-6 weeks and active mobilising exercises then begin. Emily would be expected to make a full functional recovery after this injury and did so as llustrated (Figure 4). 332 061 Performance Guidelines CONDITION 061. FIGURE 4. 333 062 Performance Guidelines Condition 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman AIMS OF STATION To assess the candidate's ability to recognise the right-sided pneumothorax on the chest X-ray and explain the diagnosis to the patient. The candidate needs to reassure the patient and then explain how the problem will be managed. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You developed chest pain while walking to work. A chest X-ray has just been done at the local hospital and you are about to be informed of the result of this. Opening statement • 'I've got a bit of a pain in my chest and I feel a bit breathless' — indicate site of pain which is on the right below the clavicle and at the back in the same area. You were walking to work when the pain came on suddenly. You were also breathless. The pain is: • sharp and stabbing (if asked it is not tight, heavy or gripping); • not made worse with every breath • worse if you take a deep breath; • also radiating to your shoulder tip; and • moderately severe at onset, but easing now You also have: • A feeling of breathlessness (not severe) at rest as well as on exertion. • An irritating dry cough - not severe or distressing You are a nonsmoker and drink alcohol on social occasions only (2-4 standard drinks). You have no known drug sensitivities. You live 2 km from the hospital and there are several others at home most of the time. Indicate area where pain is felt, upper chest, both back and front. Also indicate that you are concerned about the cause of the pain and what the doctor will do to relieve it. Be cooperative and answer the doctor's guestions without evasiveness You have a moderate-sized pneumothorax, a partial collapse of the lung. The candidate must make the correct diagnosis, explain it to you and how the problem will be managed Inserting a catheter to take the free air out of the chest is a possible response, and admission to hospital may be recommended. If so, ask if you could be treated at home. 334 062 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Candidate should respond along the following lines: Response to patient • Pneumothorax is the diagnosis, confirmed by chest X-ray. A pneumothorax of this size may not need active treatment. It would be prudent and reasonable to admit the patient overnight for observation and serial X-ray. Sending the patient home if she lives nearby is a less acceptable option with a pneumothorax of this size. Recurrence is possible after spontaneous pneumothorax, and the recurrence rate is approximately 35% on the same side and 10-15% on opposite side. Most recurrences occur within 12 months. • The general consensus regarding the need for intercostal drainage is as follows: ~ If 25-30% or less lung collapse and no symptoms — observe. This is a reasonable option in this patient. ~ If 25-30% or less lung collapse and persisting symptoms — drain. The patient may fall into this category with observation. The pneumothorax is around 30% and her symptoms are currently mild. ~ If greater than 30% collapse, whether symptomatic or not — drain. Displaying clinical knowledge and skills • Aetiology of pneumothorax — rupture of bleb on surface of lung. • Nature of pain associated with pneumothorax — possibly due to tear of adhesion as lung collapses. • Associated breathlessness — depends on size of pneumothorax. • Confirmatory investigation — chest X-ray diagnostic. This is a moderate (25-30%) pneumothorax. It may need a formal chest drain. Inserting a catheter with a Heimlich valve is an option to be discussed should the pneumothorax increase in size. Demonstrating Communication skills • Reassuring approach to patient anxious about the cause of the pain. • The pain should be recognised as being of respiratory origin, rather than cardiac. KEY ISSUES • Correct interpretation of chest X-ray. • Explaining the diagnosis and appropriate management to the patient. CRITICAL ERROR • Failure to identify the pneumothorax on the chest X-ray. 335 062 Performance Guidelines COMMENTARY Spontaneous pneumothorax is usually due to the rupture of a previously nonsymptomatic bleb on the pleural surface of the lung. Symptoms of breathlessness and local discomfort are proportional to the size of the pneumothorax which is often small, in which case no active interventional treatment is required. Elective intercostal catheter drainage is indicated for a large (> 30% chest volume) initial pneumothorax or progressive increase in size on serial X-rays. The common smaller size pneumothoraces are often difficult to identify on plain X-ray, even with erect films and magnified views. Larger pneumothoraces, as illustrated, are usually easy to identify. CONDITION 062. FIGURE 2. CONDITION 062. FIGURE 3. CONDITION 062. FIGURE 4. Examples of pneumothoraces and haemopneumothorax on plain X-ray (Figures 2,3) and chest CT (Figure 4) 336 063 Performance Guidelines Condition 063 Atypical ureteric colic in a 25-year-old man AIMS OF STATION To assess the candidate's ability to interpret an X-ray of an intravenous pyelogram (IVP). explain the findings to the patient, and give further advice about future management to the patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 25-year-old driver who has always kept in good health. A few days ago you suddenly developed very severe lower abdominal pain for which you attended the Emergency Department at this hospital. You were diagnosed as most probably having a stone in one ureter (the tubes which connect the kidneys to the bladder). The pain was relieved by an injection and has not returned. An X-ray of your kidneys was arranged (IVP). You were told to strain your urine but so far nothing has been found. Today you are attending the follow up clinic for the result of the X-ray. Be yourself. Be more concerned about the kidney abnormality (which the candidate should explain to you) than about the possibility of a stone in the ureter. Questions to ask if not already covered: • 'What does this mean for the future?' • 'Why is my kidney in the wrong place?'— ask this if the candidate advises you that your right kidney is not in its normal position. • 'Is the stone still in there somewhere?' • 'Will I get another stone?' • 'Is this kidney likely to develop a cancer?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should in commentary to the examiner interpret the IVP appropriately and indicate that the abnormality shown is a left-sided crossed fused ectopic kidney with separate calyceal systems and ureters. This anomaly is obvious on the film. The abnormal position of the right kidney must be described. There is no evidence of a calculus in either ureter on the single film available The candidate, in discussion with the patient, should: • check and confirm that no stone has been found on straining the urine. Reassure patient that on the X-ray there is no sign of any urinary calculus. Avoid alarming the patient about the congenital renal abnormality. • explain that the stone is likely to have been passed spontaneously. No need to strain urine anymore. Ensure adequate fluid intake in future especially in hot weather. Report further symptoms. Inform future medical attendants of the renal abnormality, especially if suffering from an abdominal complaint. Estimation of serum calcium to exclude hyperparathyroidism would be appropriate. 337 063 Performance Guidelines • Patient Counselling/Education — the abnormal position of the right kidney would explain the atypical nature of the pain. Otherwise the renal abnormality is of no significance and needs no treatment except awareness of its presence in the case of trauma to the left side of the abdomen or left sided abdominal pain. The condition is congenital (present from birth) and variations in kidney position are quite common. The patient should be reassured concerning the future, although warned that recurrence of renal/ureteric colic may occur if further stone formation occurs. KEY ISSUES • • Interpretation of investigations — must identify abnormal position of right kidney on the X-ray. Initial management plan — no further action required as stone has most likely passed, • Patient counselling/education — reassurance, explanation of renal abnormalities. Ensure patient awareness if any future abdominal pain occurs. CRITICAL ERROR • Failure to describe abnormal position of right kidney. COMMENTARY Although intravenous urography/pyelography (IVP) is now largely replaced by computed tomography (CT) when scanning for suspected urinary calculi, in this case a urogram is used to assess the candidate's ability to interpret an X-ray finding which is quite obvious if anatomical knowledge is sound. Congenital anomalies of the kidney and its vascular and urinary drainage systems are relatively common: up to 10% of infants may be born with some anomaly of the genitourinary system. Unilateral renal agenesis (congenital absence of one kidney) occurs in about 1 in every 1000 births, and may be accompanied in a male by the absence of the vas deferens on the affected side. In the female, uterine and vaginal abnormalities commonly co-exist. The kidney begins intrauterine development in the pelvis, ascending to its adult position on the posterior abdominal wall by birth, and acquiring fresh blood supply from progressively higher blood vessels with exclusion of others as differential growth of body segmental somites occurs. Ectopic kidneys One or both kidneys may be in an abnormal position. Most ectopic kidneys are pelvic in position, and may present as a pelvic mass, or be felt on rectal or vaginal examination. An ectopic kidney may be on its own side, or on the side of the normal kidney (crossed ectopia), and may be fused with the normal kidney or pelvic in site — as is this instance of crossed fused renal ectopia. In 'pancake' kidney a single pelvic renal mass is served by two collecting systems and ureters. Ectopic pelvic kidneys usually receive their blood supply from local vessels; the ureter of the displaced kidney often crosses to its own side and opens into the bladder in the normal position. 338 063 Performance Guidelines As kidneys ascend from the pelvis they normally remain separate. If they come into contact and adhere, a horseshoe kidney may result, the kidneys being joined by an isthmus, which the ureters need to cross to descend. Anomalies of the urinary collecting and drainage systems can predispose to urinary obstruction from hydronephrosis or calculus. Obstructive renal and ureteric pain (renal 'colic') is often an acute, constant and unremitting severe pain felt from the site of the kidney towards bladder, penis and testis. An abnormal site of the kidney with anomalous referral of pain can cause difficulties in diagnosis until functional imaging reveals the anomalous anatomy. 339 064 Performance Guidelines Condition 064 Investigation for male factor infertility in a 25-year-old man AIMS OF STATION To assess the candidate's ability to advise a husband with an abnormal semen specimen of the subsequent evaluation and management required for the couple to best achieve a pregnancy. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The doctor will generally be expected to advise you (the husband) of the significance of the semen findings, what further evaluation is required, and what treatment is likely to be given in an attempt to achieve a pregnancy. If there is no reversible factor present, and the semen analysis does not improve with time it will be necessary for you and your wife to consider the place of IVF, or the use of donor sperm not involving the use of IVF. List of appropriate answers: • You are happy to have other tests done, or undertake treatment if this will lead to an improvement in your semen specimen or achieve a pregnancy. • You work in an office writing computer programs for the banking industry. • You have had no contact with any chemicals. • You have had no surgery to your testes or inguinal region. • You have never had any testicular trauma. • You do not smoke and have 3-4 glasses of alcohol, usually wine, per week. • You are not on any drugs and have never taken any tablets except Panadol® when you have a headache. • You have never used any drugs of addiction or hashish. • You have never used anabolic steroids. • You had mumps when aged 10 years There was no testicular involvement (give this latter information only when specifically asked). • You have not had any viral illness, or high fever, nor were you given antibiotics over the last three months (these could have resulted in the current semen specimen being abnormal). • You do not use saunas. • If asked whether you would accept the use of donor sperm to achieve a pregnancy in your wife, indicate 'no'. • If asked whether you and your wife would accept the use of IVF to achieve a pregnancy, indicate 'yes'. 340 064 Performance Guidelines Questions to ask unless already covered: • 'Why is my test so bad?' • 'Can't you do something to improve it?' • 'If there are two million sperm present, why doesn t a pregnancy occur?” • 'Will a change in my diet help?' • 'Will IVF be required for all pregnancies my wife and I want?' Only ask this question if the candidate has already discussed the use of IVF. EXPECTATIONS OF CANDIDATE PERFORMANCE The history should cover the likely causes of the abnormal semen specimen, as detailed in the patient answers. The candidate should advise along the following lines. • One semen specimen is insufficient to make a meaningful prediction of fertility potential. Preferably three specimens obtained about three months apart are required. If these show the same findings as the first one, then clearly there is a problem which is almost certainly a major factor in the infertility. • It is unlikely a cause of the abnormal semen specimen will be found. • A number of blood tests should be performed to provide information as to the likely reversibility of the problem. This would include at least the measurement of serum FSH and testosterone levels. If the FSH is high, spontaneous improvement in the analysis is less likely. • If the semen analysis improves spontaneously with time, the possibility of achieving a pregnancy is increased. • There is no documented evidence for the use of hormone or other treatment, in improving the semen specimen, • There is a definite place for the use of IVF, with intracytoplasmic sperm injection in the oocyte (ICSI). This has a pregnancy rate of about 20-40%/cycle. IVF without the use of ICSI has poor results (about 2-5% pregnancy rate per cycle of transfer). • There is a place for the use of donor sperm and performing artificial insemination, if this had been acceptable. Pregnancy rate is about 20% per cycle of insemination. Use of donor semen is cheaper and more straightforward than other methods of treatment such as IVF, but the baby would not contain any of the husband's genetic material. • Intrauterine insemination using his poor semen sample has a very poor success rate (about 1-2% pregnancies/cycle of insemination). KEY ISSUES • Need for appropriate history from husband. • Knowledge of appropriate tests to assess him, and of the possibility of improvement with time. • Need for empathie counselling. • Ability to understand that a definitive cause is unlikely to be found. 341 064 Performance Guidelines CRITICAL ERRORS • Failure to advise that at least a second semen specimen (3 months after the first) must be examined. • Failure to recognise that persisting severe abnormality of the semen specimen as currently obtained will result in a very low pregnancy rate. • Failure to understand that ICSI (within IVF) is the best method of achieving pregnancy using his genetic material. COMMENTARY In the advice to this young man, it must be recognised that a single sperm test is unreliable as a basis on which to make a meaningful fertility prediction. This test must be repeated 2-3 months later and preferably again after a further 3 months. The comprehensive aspect of the counselling is based upon the assumption that a repeat specimen would show a similar abnormality. Common problems likely with candidate performance are: • Failure to repeat the semen specimen analysis a few months later (i.e. lack of understanding that one semen analysis's result is of little predictive value). • Failure to ask questions to define the possible causes of the abnormal semen specimen. • Failure to ask whether the use of donor semen would be acceptable, as this is very effective and cheap, although the child produced would not obtain DNA from the husband 342 2-D: The General Consultation Barry P McGrath 'In the field of observation, chance favours the prepared mind.' Louis Pasteur (1822-1895) Objectives of the medical consultation — How I Do It' The medical consultation is the cornerstone of medical practice. A properly conducted consultation establishes an effective doctor-patient relationship. The consultation is the basis of the diagnostic and treatment formulations, the vehicle for a patient's education about health promotion, clinical problems, disease processes and test interpretations. It can also motivate a patient to follow treatment recommendations. It is usually not a 'one-off encounter; the first consultation is generally followed by further consultation visits at variable intervals which can extend over many years. The following are the broad objectives of a medical consultation: • Establish or build on an effective, professional doctor-patient relationship. • Determine and evaluate the patient's physical and psychological symptoms. • Identify abnormal physical and mental state signs. • Define the clinical problem(s) — the patient's principal condition(s). • Choose and interpret appropriate investigations. • Reach the correct diagnosis (the doctor is progressively developing and testing hypotheses). • Explain to the patient the nature of the condition, its physical, psychological and social consequences. • Reach agreement with the patient on a plan of management. • Institute treatment. • Arrange referral to other clinicians or health workers appropriately. • Devise methods of relieving pain and suffering. • Provide advice on health promotion. • Reassure the worried well. Some commonly encountered problems during a clinical consultation are: • failure to observe common courtesies; • failure to establish levels of comprehension and communication capabilities; • ignoring emotional réponses and concerns; • overuse of directed, closed questions; • excessive use of leading or loaded questions; • vague or complex questions; • using jargon; • disjointed questioning; • abrupt topic changes; • lack of expressiveness in interviewer's body language or voice; • not discerning patient's ideas and beliefs about the problem; • narrowing the focus of enquiry too soon. 343 2-D The General Consultation Setting the scene for a medical consultation This may take place at any number of settings: general practice, Emergency Department, hospital ward, outpatient/ambulatory care, and specialist consulting rooms. The goals of the consultation will vary with the setting and the urgency of the clinical problem(s). Whatever the setting, the doctor must respect the patient's safety, privacy, dignity, modesty, physical and psychological well-being. Attention should be paid to the interview setting (for example, the seating arrangement). Medical interviewers must be appropriately dressed, with a professional, friendly demeanour and introduce themselves in a way that identifies their roles. The interviewer, if a medical student or if not the patient's usual medical practitioner (for example, a trainee), will need to seek the patient's permission to conduct the consultation. Communication skills First impressions, as in most human encounters, are very important. An expert medical interviewer may adopt a variety of techniques, with an underlying self-questioning approach: 'How can I connect with this patient?' Frequently a patient will attend with a partner, family member or friend. Establishing whether or not the patient wishes, or indeed, if it is appropriate, to proceed to interview in the presence of 'a significant other' needs to be established early. Depending on the circumstances, the interviewer may seek to conduct the medical consultation with the patient alone initially and then subsequently involve the 'significant other' or family members, but again only with the patient's permission. Patient-related factors and doctor-related factors can influence doctor-patient communication. It is critically important to establish, as soon as possible, if there are any impediments to communication such as dementia, physical disability (such as deafness, blindness, stroke), language or cultural attitude. A skilled medical interviewer will exhibit: • an encouraging, warm and empathie manner; • nonjudgmental attitude; • good eye contact; • respect for patient's dignity, awareness of any discomfort; • alertness and responsiveness to nonverbal as well as verbal cues; • good listening skills; • use of mainly open questions; and • note-taking that does not interfere with patient rapport. Some commonly encountered problems include: • failure to observe common courtesies: • failure to establish levels of comprehension and communication capabilities: • ignoring emotional responses and concerns; • overuse of directed, closed questions, excessive use of leading or loaded questions; • vague or complex questions; • using jargon; • disjointed questioning; • abrupt topic changes; • lack of expressiveness in interviewer's body language or voice; • not discerning patient's ideas and beliefs about the problem; and • narrowing the focus of enquiry too soon. 344 2-0 The General Consultation These issues relating to communication skills are vitally important and are re-emphasised here. They are also addressed in a number of excellent text books and in many of the case 1,2,3,4 scenarios. Clinical reasoning in medical history-taking Clinical reasoning mostly involves an efficient, hypothetic-deductive process. The diagnosis is often made early in the medical consultation. Usually a list of alternative hypotheses, or differential diagnoses, are considered, ranked and further addressed Additional information is obtained from the physical examination and specific investigations which serve to confirm the diagnoses, determine their severity and effects and to exclude alternative (differential) diagnoses. The following points are germane to the process of clinical reasoning: • Iterative nature of process: the diagnostic hypothesis is continually being strengthened refined, modified or totally reformulated on the basis of responses to questions. • 80% of clinical diagnoses are reached on the basis of history alone. • Clinical examination often provides confirmatory information; in some cases a new diagnosis is defined. • Investigations provide the diagnosis in only about 10% of instances. The process of problem identification is summarised in the accompanying figure SECTION 2-D. FIGURE 1. Process of problem identification 1 MR Sanders, C Mitchell, GJA Byrne (eds). Me di cal C o ns ul ti n g Ski l l s-Beh avi o ur al an d I n te rp ers on al Di m e nsi o ns o f H eal t h C ar e Addison Wesley Longman Australia Pty. Ltd. Melbourne Australia 1997. 2 SA Cole and J Bird (eds). Th e M edi c al I n ter vi ew — T he T hr e e-F u ncti on Ap p ro ac h . Mosby Inc. St Louis Missouri USA. 2000. 3 M Mloyd, R Boor (eds). Com m u ni ca ti o n Skil l s f or M e di ci ne . Churchill Livingstone. New York USA. 1996. 4 T h e Cl i ni cal Enco u nt er: A G ui d e t o th e Me di cal I n te rvi ew an d C as e Pr es en t ati on . Mosby Inc. St Louis Missouri 1999. 345 2-D The General Consultation The structure of the medical history This is usually arranged along the following lines: • basic information about the patient • the presenting complaint: ~ history of the presenting complaint ~ description of the presenting complaint: - site - severity/intensity - quality/character - time course - setting/context - aggravating and relieving factors - associated features - • risk factors other medical problems: ~ related to presenting complaint ~ additional problems • medication, habits and allergies • systems review • past medical history • family history • social and personal history • psychiatric history Barry P McGrath 346 2-D The General Consultation 2-D The General Consultation Candidate Information and Tasks MCAT 065-073 65 Acute chest pain in a 60-year-old man 66 Palpitations and dizziness in a 50-year-old man 67 Muscle weakness and urinary symptoms in a 60-year-old man 68 Aches and pains in a 62-year-old man 69 Lack of energy in a 56-year-old suntanned man 70 Recent haematemesis in a 50-year-old man 71 Anaemia in a 28-year-old pregnant woman 72 Acute vertigo in a 50-year-old man 73 Urinary frequency in a 60-year-old man 347 065 Candidate Information and Tasks Condition 065 Acute chest pain in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. You are asked to see a 60-year-old man complaining of acute chest pain. YOUR TASKS ARE TO: • Take a concise, relevant and focused history. • Present a summary of the patient's history for the examiner, who will then give you the findings on physical examination which you request. • Tell the examiner your provisional diagnosis and the reasons for this. • Interpret the ECG to the examiner (the ECG will be given to you at about 7 minutes into this consultation). • Institute emergency treatment. CONDITION 065. FIGURE 1. The Performance Guidelines for Condition 065 can be found on page 356 348 066 Candidate Information and Tasks Condition 066 Palpitations and dizziness in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. You are asked to see a 50-year-old man complaining of palpitations and dizziness over the past three days. He has not seen a doctor for the past 10 years and at that last assessment he was told his blood pressure was elevated. His current blood pressure is 150/96 mmHg. The symptoms are still present when you see him to take his history. He is lying down on a trolley. YOUR TASKS ARE TO: • Take a concise, relevant and focused history. • Present a summary of the patient's history to the examiner, who will then give you the findings on physical examination. • Tell the examiner your differential diagnosis. • Interpret the ECG to the examiner (the ECG will be given to you by the examiner about 7 minutes into the consultation). CONDITION 066. FIGURE 1. The Performance Guidelines for Condition 066 can be found on page 363 349 067 Candidate Information and Tasks Condition 067 Muscle weakness and urinary symptoms in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 60-year-old man who is complaining of tiredness, weakness and urinary symptoms. YOUR TASKS ARE TO: • Take a history from the patient. • Ask the examiner for the findings of a selective and focused physical examination you would perform. • State to the examiner any relevant investigations you would order. • Briefly explain to the patient what you believe to be the cause of his symptoms and the first step in management (you are not expected to discuss treatment in detail). The Performance Guidelines for Condition 067 can be found on page 368 350 068 Candidate Information and Tasks Condition 068 Aches and pains in a 62-year-old man CANDIDATE INFORMATION AND TASKS r ; You are working in a general practice You next patient is retiree and aged 62 years. He s consulting you about aches and pains, and you have just finished taking a history, which was as follows: Over the last six weeks, he has had a gradual onset of pain across the upper part of the back, neck and shoulders which feel stiff. In the past week or so his hips are also feeling stiff and sore. Since retirement two years ago he has been playing golf at least three times per week and thought that he may have been overdoing it. At first the pain was just an aching feeling, but is now more definite pain but hard to describe. It is continuous, worsened by movement and is keeping him awake at night. The aching and stiffness is worse early in the morning and he finds it difficult to get out of bed because of muscle weakness and pain which improves during the day. Pain is not relieved by aspirin or Brufen®, nor worsened by coughing. There is no radiation to the arms. Pain is felt in the muscles but not in the joints, although these feel stiff especially after inactivity. He has not played golf for a week. He has noted a little difficulty in lifting himself up from a chair. Muscles feel 'as if they are losing their strength'. He has felt much more tired than usual over the last few weeks, especially after golf. His appetite is not as good as usual. He thinks he may have lost a little weight and sometimes feels hot and slightly sweaty at night in bed. YOUR TASKS ARE TO: • Specify to the examiner the essential features you would like to know from a focused physical examination of this patient. The examiner will give you the results and ask you questions about your provisional diagnosis and further investigations. • Answer the questions put to you by the examiner. • Advise the patient of your diagnostic and management plans. You do not need to take any further history. The Performance Guidelines for Condition 068 can be found on page 371 351 069-070 Candidate Information and Tasks Condition 069 Lack of energy in a 56-year-old suntanned man CANDIDATE INFORMATION AND TASKS You are consulting in a general practice setting in Melbourne, Victoria. Your next patient is a 56-year-old industrial chemist. He is complaining of tiredness, although he has just returned from holidays in Queensland and appears quite suntanned. YOUR TASKS ARE TO: • Take a concise, relevant and focused history. • After four minutes, tell the examiner what would be the most significant clinical signs you would search for on physical examination, including office laboratory tests. The examiner will respond with these findings for this patient. • Advise the patient of your opinion about possible causes for his tiredness, and how you intend to proceed to make a firm diagnosis. The Performance Guidelines for Condition 069 can be found on page 374 Condition 070 Recent haematemesis in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are an intern at the hospital Emergency Department. This 50-year-old patient has presented having had a haematemesis of about 500 ml_ of fresh blood two hours ago, accompanied by a transient feeling of light headedness and sweating. The patient has given you a past history of a previous admission six months ago with a similar episode of haematemesis which settled spontaneously. An endoscopy was done and the patient was told there were dilated veins at the lower end of the gullet and was advised not to drink alcohol. The patient tells you that he has been trying to give up alcohol with limited success. On the basis of the history you have just finished taking, and his prior episode, you believe that the patient may have had a haematemesis from oesophageal varices with portal hypertension and chronic liver disease as the explanation for the current problem YOUR TASKS ARE TO: • Perform a relevant and focused physical examination of the patient. • Explain your actions and what you are looking for to the examiner. • Describe your findings as you proceed. You are not required to take any further history. The Performance Guidelines for Condition 070 can be found on page 377 352 071-072 Candidate Information and Tasks Condition 071 Anaemia in a 28-year-old pregnant woman CANDIDATE INFORMATION AND TASKS This 28-year-old pregnant woman, who is attending a general practice in which you work, has just been found to have a haemoglobin level of 80 g/L when tested at 26 weeks of gestation. YOUR TASKS ARE TO: • Take any further relevant history you require. • Ask the examiner about relevant findings likely to be evident on general and obstetric examination. • Advise the patient of the tests required to define the most likely diagnosis and the subsequent management you would advise. The Performance Guidelines for Condition 071 can be found on page 380 Condition 072 Acute vertigo in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are working in a primary care facility attached to a teaching hospital. This 50-year-old man is consulting you about intense dizziness. He is a previous patient who is overweight, and is on medications for control of hypertension and hyperlipidaemia. He appears unwell and distressed, with a slight drooping of the left eyelid. His wife drove him to the hospital. YOUR TASKS ARE TO: • Take a focused and relevant history. • The observing examiner will then give you the significant findings on physical examination. • Discuss your diagnosis and management plan with the examiner. The Performance Guidelines for Condition 072 can be found on page 383 353 073 Candidate Information and Tasks Condition 073 Urinary frequency in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Your next patient is a 60-year-old man. He has attended the practice infrequently in the past. Today he is consulting you about urinary symptoms. YOUR TASKS ARE TO: • Take a focused history with regard to the presenting symptoms. • Give the examiner a summary of the patient's presenting history with the most likely diagnosis. • Ask the examiner what aspects of physical examination are most likely to confirm this diagnosis and any initial office tests you would perform. The examiner will respond accordingly. • Tell the patient your diagnostic conclusions, what investigations are indicated and the reasons for these. The Performance Guidelines for Condition 073 can be found on page 394 354 2-D The General Consultation 2-D The General Consultation Performance Guidelines MCAT 065-073 65 Acute chest pain in a 60-year-old man 66 Palpitations and dizziness in a 50-year-old man 67 Muscle weakness and urinary symptoms in a 60-year-old man 68 Aches and pains in a 62-year-old man 69 Lack of energy in a 56-year-old suntanned man 70 Recent haematemesis in a 50-year-old man 71 Anaemia in a 28-year-old pregnant woman 72 Acute vertigo in a 50-year-old man 73 Urinary frequency in a 60-year-old man 355 065 Performance Guidelines Condition 065 Acute chest pain in a 60-year-old man AIMS OF STATION To assess the candidate's ability to take a medical history in an older male patient presenting to the Emergency Department with chest pain of two hours duration. The candidate needs to be aware of the potential seriousness of the situation, the importance of taking a focused history to distinguish between cardiac and non-cardiac sources of chest pain, whilst being aware of the patient's discomfort and the need to take steps to relieve this. As in clinical practice, the early performance of an ECG and its correct interpretation is a key step in the assessment of this patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You have acute and worsening chest pain. You are 60 years of age. Opening statement 'I have a very bad tightness in my chest.' Characterisation of symptom: Site: central, retrosternal, radiating to lower jaw. Severity: Time course: severe 8/10 Context: came on two hours ago, steadily getting worse recent angina for two months; this pain started when playing third set of tennis Aggravating factors: none, no association with respiration Relieving factors: anginine, oxygen when given in Emergency Department Associated symptoms: sweating, nausea, breathlessness Other health problems: Systems review: Past history: Drugs: overweight, diabetes (5 years); hypertension (3 years): high cholesterol (3 years); pain in left leg on walking 500 metres (1 year). central chest pain when walking on cold mornings for the past two months: short of breath on exertion and breathless at night (three days); tiredness (two days). No epigastric pain, oesophageal reflux or dysphagia. Recent black bowel motions (five days). If no questions about your bowels, volunteer this information. Myocardial infarct three years ago For blood pressure (enalapril/hydrochlorothiazide); diabetes (metformin); aspirin; lipid-lowering agents Habits: Family History: 356 Smoker until three years ago; alcohol intake 1 glass wine per day. Nil relevant. 065 Performance Guidelines The examiner will provide physical examination findings to the candidate as follows: He is an overweight man of stated age who is in acute distress with pain and who is anxious and sweating. Blood pressure is 150/96 mmHg, pulse rate 96/min and regular. Heart sounds dual rhythm, no murmur. There are no signs of heart failure. Examination otherwise noncontributory EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient The candidate is expected to demonstrate professionalism, empathy and to seek relief of the patient's discomfort with use of oxygen whilst taking the history. Awareness of the potential seriousness of the situation as the history evolves still requires the candidate to be calm, confident and reassuring. History-taking skills The candidate is expected to fully characterise the chest discomfort, its time course, the context and associated symptoms. This needs to be done in a sensitive and focused way. using a mixture of open-ended and direct questioning. The cardiovascular risk factors must be determined, including the past history of myocardial infarction. The occurrence of this pain in the context of recent chest pain on exertion and breathlessness needs to be defined. If the history of recent 'black bowel motions' is not obtained by the candidate, the patient has been asked to bring this to the candidate's attention. What should the doctor be thinking? Meeting the patient: an overweight, anxious-looking, sweaty older man with chest pain: urgent assessment needed: focus on key questions relating to possibility of ischaemic heart disease. The presenting problem: fits pattern of acute myocardial infarction. Check out his medication list: indicates he is diabetic, hypertensive, high Other cardiovascular risk factors: previous acute myocardial infarction; claudication: Other medical problems: Type 2 diabetes; hypertension; central obesity; Physical examination: fits pattern of acute myocardial infarction cholesterol. smoker. hypercholesterolaemia; probable melaena. Treatment starts immediately: This is a medical emergency requiring management by an expert team (what is the candidate's role in the team?); commence oxygen therapy, aspirin, glyceryl trinitrate and morphine; monitor pulse, blood pressure. ECG; assess for thrombolytic therapy. 357 065 Performance Guidelines Ability to provide a concise clinical summary This should be along the following lines and reflect the manner in which a junior doctor would describe the key features of the history to a registrar or consultant. The patient is an overweight, anxious looking, sweaty 60-year-old man with chest pain described as 'a very bad tightness', 8/10 severity, in the central, retrosternal region, radiating to the lower jaw but not to the arms. The pain came on when playing tennis and has been increasing steadily over the past 2 hours, associated with shortness of breath, sweating and partly relieved by anginine and oxygen. In addition he has had exertional chest pain over the past 2 months and shortness of breath, orthopnoea and tiredness over the past few days. A concerning symptom is his 5 day history of passing black bowel motions, which is suggestive of gastrointestinal blood loss. He is at very high risk of acute coronary ischaemia, having had a prior myocardial infarct, and with risk factors of diabetes, hypertension, high cholesterol. EC G findings need to be checked and anaemia considered as a precipitating factor. Diagnosis The most likely diagnosis is acute myocardial infarction. The key features that suggest this diagnosis are the characteristics of the chest discomfort in a patient with significant risk factors and prior myocardial infarction. Interpretation of ECG The ECG shows the following features: • Sinus rhythm, rate 96/min. • There are features of acute inferior myocardial infarction shown by the Q waves in leads II, III, AVF and ST segment elevation in these leads as well. CONDITION 065. FIGURE 2. ECG of patient Tests: confirm acute myocardial infarction; assess anaemia 358 065 Performance Guidelines KEY ISSUES • Approach to patient — sensitivity to the patient's discomfort and a calm and professional manner. • The ability to take an appropriate and focused medical history showing an awareness of the likely causes of chest pain and the main characteristics that distinguish cardiac and noncardiac sources of chest pain. The candidate needs to show an appreciation of cardiovascular risk factors, and an efficient ability to characterise associated symptoms and to define the context in which the symptom of chest pain has arisen. • Commentary to examiner — a succinct summary which brings together the key features of the presenting complaint, the context in which it has arisen, the associated symptoms and the cardiovascular risk factors. The candidate should identify the potential significance of the history of melaena. • Diagnosis/Differential diagnosis — the candidate must consider the diagnosis of acute myocardial infarction and why noncardiac causes of the chest pain are less likely. • Interpretation of investigation — the most important findings on the 12-lead ECG must be defined: sinus rhythm, acute inferior myocardial infarction. CRITICAL ERRORS • Failure to consider the diagnosis of acute myocardial infarction on the history. • Failure to define the main cardiovascular risk factors — prior myocardial infarction. Type 2 diabetes mellitus, hypertension and hypercholesterolaemia, smoking. • Failure to correctly interpret the ECG features of myocardial infarction. COMMENTARY 1 2 The patient's presentation is highly suggestive of an acute myocardial infarction. Cardiovascular risk assessment A prior history of a cardiovascular event is the most important pointer towards a recurrent event. Type 2 diabetes mellitus is associated with a 10-fold increased risk of acute myocardial ischaemia. For hypertension and hypercholesterolaemia and a history of smoking, the risk is also significantly increased. 3 .4,5,6,7 1 Management ot unstable angina guidelines, http://www.heartfoundation.com.au/ 2 Therapeutic Guidelines Cardiovascular Version 4 2003 3 Grundy SM, Pasternak R, Greenland P, Smith S, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. Ci rcul ati o n 1999, 100:1481-92. 4 MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet 2002,360:7-22 5 Genuth S, Eastman R. Kahn R. Klein R, Lachin J, Lebovitz H, et al. Implications of the United Kingdom prospective diabetes study. Di a be tes C ar e 2003, 26 Suppl 1 : S28-32. 6 Neal B, MacMahon S. Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration. L anc et 2000. 356: 1955-64. 7 National Health Committee revised guidelines for smoking cessation 2002. Wellington: National Health Committee; 2001. http://www.heartfoundation.com.au 359 065 Performance Guidelines Acute coronary ischaemia syndromes All the acute coronary syndromes share the underlying pathology of an atherosclerotic plaque which becomes active acutely with rupture of the plaque with resultant platelet adhesion, thrombosis, vasoconstriction and inflammation. The exact syndrome depends on the extent of thrombosis, the degree of distal embolisation of platelet thrombi and the resultant myocardial necrosis. When the thrombus that occurs on a ruptured plaque completely occludes the coronary artery, the result is severe transmural myocardial ischaemia with ST elevation on the ECG. This may cause sudden death from ventricular fibrillation. If the coronary occlusion is not relieved, myocardial infarction develops progressively over the next 6-12 hours. This is often associated with evolution of evidence of transmural myocardial infarction on the ECG as shown by the development of Q waves. The acute coronary syndromes are differentiated on the basis of extent and duration of chest pain, ECG changes and biochemical markers. They are divided into two syndromes: (1) associated with ST elevation on the ECG (ST elevation myocardial infarction, STEMI) and (2) those without ST elevation (non-ST elevation myocardial infarction, NSTEMI) associated with either ST depression, T-wave inversion or no changes on the ECG. NSTEMI is differentiated from unstable angina on the basis of biochemical evidence of myocardial necrosis (elevated troponin level). The following figures give examples of different patterns of myocardial infarction: CONDITION 065. FIGURE 3. Acute anterolateral myocardial infarction Features indicating acute anterolateral infarction are: • ST elevation in leads I, aVL, V2-V6; and • Q waves in aVL, V2, V3 and loss of R waves across chest leads. 360 065 Performance Guidelines CONDITION 065. FIGURE 4. Acute inferior myocardial infarction Features of acute inferior myocardial ischaemia/infarction are: • ST segment elevation in II, III, and aVL; and • The slow rate is also common in this condition. CONDITION 066. FIGURE 5. Acute posterior-inferior myocardial infarction Features of posterior-inferior myocardial infarction are: • Q wave and ST elevation in inferior leads (II, III, aVF); and • the prominent R waves in V1 (labelled C1) and Q waves with ST elevation in V5, V6 indicate postero-lateral infarction. 361 Central chest discomfort is a common presentation of cardiac disease, but it may also be due to disease of the gastrointestinal tract, lungs or a musculoskeletal disorder. The features of the chest discomfort/pain, the context in which the symptom occurs, the associated symptoms and the patient's predisposition to cardiac versus noncardiac disease based on an assessment of cardiovascular risk factors, must all be considered. In taking a history relating to chest discomfort, a number of key descriptors needs to be defined to determine if its origin is cardiac ischaemia. A common sequence of enquiry would be as follows: • 'What is the discomfort like? Describe it in your own words. ' • 'How severe is it — e.g. a score out of 10?' • 'Show me where you feel it? Does it go anywhere else — the abdomen, the back, the neck, the jaw, the arms?' • 'When did it start? How has it progressed? How long has it been present or how long did it • 'Does anything make the discomfort worse? Does anything make it better?' last?' • 'Do you have any other symptoms? Shortness of breath? Dizziness? Palpitations? Sweating? Nausea or vomiting?' In addition there are a number of questions that will be used in trying to determine if there is a non-cardiac cause: • • • • 'Do you get acid indigestion or reflux?' 'Was the onset of the discomfort related to a meal?' 'Does it hurt to take a deep breath?' 'Is the chest sore to touch?' 362 066 Performance Guidelines Condition 066 Palpitations and dizziness in a 50-year-old man AIMS OF STATION To assess the candidate's ability to take a medical history in a patient presenting to the Emergency Department with episodes of palpitations and dizziness. Careful history-taking is essential in assessing such patients. The candidate needs to define the attacks, the nature of the arrhythmia (rate, rhythm, onset, offset, context) and the close association between the two symptoms. Also critical to the assessment is an understanding of potential risk factors and précipitants of cardiac arrhythmias. Underpinning the history-taking, the candidate needs to have knowledge of the causes of cardiac arrhythmias and the manifestations of different types of arrhythmias. Obtaining an ECG during an attack and its correct interpretation is a key step in the assessment of this patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are lying on a trolley in the Emergency Department. You were brought to hospital by ambulance. Opening statement 'I've been getting attacks of palpitations and dizziness over the past three days. ' In response to specific questioning, provide the following information: • History of presenting complaints — The palpitations and dizziness seem to come on together. You have them now. • Palpitations - These are described as a fast beating of the heart going into the neck. If asked to tap out the rhythm on the desk, give a rapid regular beat of about 150/min. There have been four attacks over the past three days, each lasting for about two hours. The attacks come on suddenly and stop suddenly. Three of the episodes occurred after the evening meal and the fourth whilst driving. Nothing you have tried seems to stop the attack. There is no associated chest pain but you are mildly short of breath and sweat during and for a short time after each attack. There is no flushing, headache or nausea. • Dizziness — This is a light-headed, near fainting experience which comes on within a minute of the palpitations and lasts for the duration of the attack. You feel you have to lie down. • Systems review There is no history of heat intolerance, nervousness or tremor. You are overweight with no recent change in weight. Bowel function is normal. • Habits — You smoke 20 cigarettes per day; drink 4 or 5 glasses of wine with the evening meal and 5 cups of coffee per day. You are on no medications. • Social history — You have a sedentary solitary lifestyle. Your job is stressful as a company secretary and the company you work for is restructuring. • Family history — No significant family history of heart disease or cardiac arrhythmias. 363 066 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient The candidate is expected to demonstrate professionalism, empathy and good communication skills. • History-taking skills The candidate is required to carefully define the two symptoms and how they relate. The specific features of the palpitations, the context in which they occur, the potential risk factors and précipitants are all important elements of this patient's history. In addition the candidate is expected to explore possible underlying cardiac diseases, in this case particularly the possibilities of hypertensive heart disease or alcoholic cardiomyopathy. • Ability to provide a concise clinical summary This should be along the following lines and reflect the manner in which a junior doctor would describe the key features of the history to a registrar or consultant. 'The patient is a 50-year-old company secretary who presents with his fourth attack of palpitations and dizziness over the past 3 days. Three of the attacks have occurred in the evenings after his meal and one whilst driving. Each attack lasts approximately 2 hours, they come on suddenly and stop suddenly and the dizziness, which he describes as a near-fainting experience, always accompanies the palpitations. The nature of the palpitations is that they appear to be rapid, approximately 150/min and regular. He is currently experiencing an attack. The attacks are also associated with shortness of breath and sweating, but no chest pain. Considering possible underlying causes for his attacks, he has a history of high blood pressure but no known cardiac disease. He has a high alcohol intake and has recently been under stress at work. He is also at risk of ischaemic heart disease because of his smoking, obesity and sedentary lifestyle. There is no evidence on history to suggest thyrotoxicosis. ' The examiner will provide physical examination findings to the candidate as follows: Physical examination He is an overweight, anxious man in some distress while sitting or lying on a couch. Pulse is 150/min and regular, blood pressure is 150/96 mmHg. Heart sounds show dual rhythm with no bruits and are synchronous with the pulse. There are no signs of cardiac failure. Examination otherwise is noncontnbutory • Diagnosis The most likely diagnosis is paroxysmal atrial arrhythmia, probably atrial flutter. The key features that suggest this diagnosis are the sudden onset and offset, the rapid, regular palpitations and the rate. The potential causes for this arrhythmia are hypertensive heart disease, alcoholic cardiomyopathy, ischaemic heart disease or occult thyrotoxicosis. The differential diagnosis includes atrial fibrillation, supraventricular tachycardia, ventricular tachycardia. 364 066 Performance Guidelines • Interpretation of ECG The ECG shows the following features: CONDITION 066. FIGURE 2. Atrial flutter with variable block KEY ISSUES • Approach to patient — Sensitivity to the patient's discomfort and a calm and professional manner. • History — The ability to take an appropriate and focused medical history with careful definition of the symptom characteristics and showing an awareness of the likely causes and précipitants of cardiac arrhythmias. • Commentary to examiner — This needs to be a succinct summary which brings together the key features of the presenting complaint, the context in which it has arisen, the associated symptoms and the arrhythmia risk factors. • Diagnosis/Differential diagnosis — The candidate must consider the diagnosis of atrial arrhythmia and the potential contributions of hypertension and alcohol. • Interpretation of investigation — The most important findings on the 12-lead ECG must be defined: atrial flutter with variable block. CRITICAL ERRORS • Failure to consider the diagnosis of atrial tachyarrhythmia on the history. • Failure to correctly interpret the ECG features of atrial flutter. 365 066 Performance Guidelines COMMENTARY1 2 3 Palpitations are the symptom of an abnormal awareness of heart rate. They may be due to a change in the rate, rhythm or force of the heartbeats or some combination of these. It is important to ask the patient to tap out with a finger what is noticed when the palpitations arise. Anxious patients may be aware of their normal heartbeat. Isolated forceful beats ('thump in the chest') are usually caused by ectopic beats. Patients may also report their heart 'misses a beat', usually due either to a compensatory pause after a ventricular ectopic beat or a nonforceful ectopic beat. Awareness of a fast heart rate usually occurs when this is of recent origin. It is important to determine whether this is regular or irregular and whether there are any associated symptoms. The development of symptoms in a patient with an atrial arrhythmia will depend on the rate, the rhythm, underlying cardiac disease and patient characteristics. A common problem encountered in older patients with hypertensive heart disease who develop atrial fibrillation is that the presence of a poorly compliant (stiff) left ventricle renders them quite intolerant to this arrhythmia, where there is loss of the contribution of atrial contraction to ventricular filling, leading to left heart failure. Atrial flutter usually presents with 2:1 atrioventricular block and a regular ventricular rate of 150/min. It is often misdiagnosed as supraventricular tachycardia. Rarely conduction occurs 1:1, giving a ventricular rate of 300/min and severe symptoms. Much more frequently greater degrees of AV block are present giving ventricular rates of 100 (3:1 block) or 75 (4:1 block). Patients may be asymptomatic except when the rate changes (e.g. from 4:1 to 2:1 block). An example of atrial flutter with 4:1 block is seen in the figure below (Figure 3). Note the characteristic saw-tooth appearance of the P waves. CONDITION 066. FIGURE 3. Atrial flutter with 4:1 block In untreated patients with a normal AV node, atrial fibrillation (AF) usually presents with an irregular ventricular rate of 160-180/min. Older patients with impaired AV conduction can often present with lower rates. Apart from the first episode, where the natural history is not clear, atrial fibrillation tends to fall into one of three clinical patterns (the so-called 'three Ps'). Patients may progress from one to another. These patterns are: • Paroxysmal AF (episodes which come on suddenly and usually revert spontaneously within 48 hours); • Persistent AF (episodes persist for days or weeks unless active measures are taken to revert to sinus rhythm); and 1 2 Therapeutic Guidelines Cardiovascular Version 4 2003. Wyse DG. Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y. Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N ew E n g l and J o ur n al o f Me di c i ne 2002, 347: 1825-33. 3 Hankey GJ. Non-valvular arial fibrillation and stroke prevention. M e di cal Jo urn al o f Austr al i a 2001. 274: 234-39. 366 066 Performance Guidelines • Permanent AF (inability to sustain sinus rhythm for any length of time or decision made not to try to revert the rhythm). Patients with persistent and paroxysmal AF have at least the same risk of thromboembolism as patients with permanent AF. An example of atrial fibrillation is illustrated (Figure 4). Note that the rhythm is irregularly irregular and that no P waves can be seen. CONDITION 066. FIGURE 4. Atrial fibrillation It is important to identify and manage underlying causes of atrial tachyarrhythmias (for example, hypertension, thyrotoxicosis, heart failure, mitral valve disease, atrial septal defect). Treatment of these two common arrhythmias needs to be considered under two headings: treatment of the arrhythmia itself and prophylaxis against thromboembolic complications. The pharmacotherapeutic approaches to atrial fibrillation and flutter are very similar, however atrial flutter commonly responds very easily to a low energy direct current shock or to pace cardioversion and is often relatively insensitive to antiarrhythmic drugs. 367 067 Performance Guidelines Condition 067 Muscle weakness and urinary symptoms in a 60-year-old man AIMS OF STATION To assess the candidate's ability to take a focused history regarding muscle weakness, symptoms of prostatism and the patient's concerns about their cause, while also being aware of the possibility of an adverse drug reaction. The candidate should know the essential components of a selective physical examination and essential investigations to confirm the diagnosis and exclude other conditions. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows You are a 54-year-old newsagent. Opening statement 'I'm feeling weak and tired which is not like me. I'm also ha ving trouble with my waterworks. ' Follow this, if not interrupted by direct questioning, by telling the doctor that: • Symptoms have only developed over the last six months or so. • You have felt tired and have noted a feeling of weakness in your muscles over the past few weeks. This is not constant and not severe. All your muscles seem to be affected. It gets worse towards the end of the day and you have attributed this to tiredness (long working hours) and increasing age. You have also had some cramps in your calf muscles. • Over the last six months you have also felt an increasingly strong urge to pass urine when standing up after sitting (e.g. on getting out of your car or after watching TV for an hour or so). You also have had to pass urine more frequently at night. Some nights you have to get up at three or four times and then have trouble in starting the passage of urine. In response to appropriate questioning: • The stream of urine is poor and you find it hard to finish, with annoying dribbling. So far you have not lost control or soiled yourself. Passing urine is not painful. The urine does not smell abnormally. Sexual intercourse and ejaculation are not affected except for reduced frequency in recent years. You have learnt to empty your bladder before going out or sitting for long periods. You think that reduction in the amount of beer you drink after work from 4 to 5 glasses to 1 or 2 has helped. • You have always kept in good health. • Other body systems are normal. In particular, no cardiovascular or other neurological symptoms and no related symptoms such as tremor or stiffness. No weight loss. Other significant information: • • You commenced treatment for 'mild blood pressure' about eight months ago. but from a different doctor. Your medication is hydrochlorothiazide 25 mg (Dithiazide®) each morning. You are on your feet all day in the newsagency. You still play tennis on Sunday but the power in your game has 'gone'. No marital, family or financial problems. If asked about your past history, family history, habits or social history, respond as for yourself. 368 067 Performance Guidelines • You are very puzzled by your muscle weakness. You are also concerned about the urinary symptoms and worried that you could have prostate cancer. You have also thought of the possibility that your symptoms might be caused by your medication. • The doctor may not seek all this information. If asked other questions, respond as for yourself. • After obtaining the results of the investigations from the examiner, the candidate will briefly explain the cause of your symptoms to you. Do not question the doctor, simply accept what is said. EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient ~ Use of appropriate communication skills to define the salient points of the history. • History ~ Identification of muscular weakness, cramps, urinary frequency, urgency and dribbling and medication (for hypertension — use of thiazide diuretic should be elicited). Patient concern about cancer should be recognised. • Physical examination ~ The candidate should ask the examiner for certain findings based on diagnostic possibilities suggested by the history. Results will be provided for specific requests as follows: CONDITION 067. TABLE 1. Examination findings General appearance Pallor looks well absent Pulse 72/min regular Blood pressure lying 154/92 mmHg and standing 148/90 mmHg Heart normal Abdomen normal Neurological examination (limited) power of limbs possibly slightly reduced tone normal reflexes normal sensation normal PR —the prostate is enlarged. Features which should be sought: degree of enlargement both lobes consistency moderate yes firm but not hard tenderness surface no smooth nodularity/induration no Urine office testing — normal on chemical testing 369 067 Performance Guidelines • The following investigations should be suggested: ~ Serum potassium ~ Haemoglobin and full blood examination ~ Prostate specific antigen (PSA) ~ Microscopy and culture of midstream urine Explanation to patient ~ How low potassium due to use of a diuretic tablet for treatment of elevated blood pressure could be the cause of the weakness. Effects are fully reversible. ~ Enlargement of prostate is the cause of the urinary symptoms. Reassure that malignancy is very unlikely but that referral to a urologist is advisable for probable operative treatment, which will include examination of tissue for cancer cells. ~ Cease Dithiazide® and perform followup checks of blood pressure for further management. KEY ISSUES • History-taking to identify weakness, prostatism, fear of cancer, current medication. • Examination for pallor, pulse and BP, heart, abdomen, neurological (limited), rectal examination. • Investigations including serum electrolytes and creatinine, PSA, FBE, ECG. urine microscopy and culture and cytology. • Explanation to patient that the likely diagnosis is hypokalaemia (reversible) as the cause of muscle weakness together with benign prostatomegaly. Reassure the patient regarding cancer. CRITICAL ERRORS • Failure to do rectal examination. • Failure to suggest appropriate investigations. COMMENTARY Muscle weakness and fatigue are common symptoms with multiple aetiologies. In this scenario the first dominant cue is the association of tiredness and weakness with urinary symptoms. These latter symptoms and the signs of benign prostatic enlargement suggest bladderneck obstruction requiring further investigation and referral. The other dominant cue is picked up by systems review giving the information that the patient has been on a thiazide diuretic for eight months, and his symptoms of musde weakness began after starting this medication. The diuretic polyuria may have brought to light previously nonsymptomatic prostatic pathology, and caused potassium loss. Even so-called potassium-sparing thiazide diuretics can be associated with potassium depletion, which could be contributing to his muscle weakness and muscle cramps through hypokalaemia. Investigations of serum electrolytes (particularly potassium levels), renal function tests, urine cytology and culture, and full blood examination would be mandatory in a patient of this age with symptoms as described. 370 068 Performance Guidelines Condition 068 Aches and pains in a 62-year-old man AIMS OF STATION To assess the candidate's knowledge of the clinical presentation of polymyalgia rheumatica and the way in which this diagnosis is confirmed or excluded. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a retired office worker and will be advised by the candidate of the diagnostic and management plans. EXPECTATIONS OF CANDIDATE PERFORMANCE Physical examination findings to be sought: • Essential features of focused physical examination to be given to candidate on request by the examiner. ~ Temperature ~ Pulse ~ Blood pressure 37 °C, normal 70/min regular 140/80 mmHg ~ Muscle groups of neck, trunk, upper and lower limbs should be examined. - Active movement of neck, shoulder and trunk muscles causes discomfort. - Normal power and tone and coordination of movements. - Examination of joints, particularly hands, shoulders, neck, sacroiliac joints and hips. These show no abnormalities and a full range of movement. ~ Examination of lymph nodes, abdomen, and respiratory systems is expected to exclude any medical conditions that could possibly give rise to this constellation of symptoms (e.g. lymphoma, carcinoma) — normal findings. ~ Rectal examination to check prostate — normal. After providing results of physicai examination, the examiner will ask the candidate • 'What is your provisional diagnosis and differential diagnosis?' • 'What further tests will you advise?' • 'Please now give to the patient your diagnostic and management plans. ' Diagnosis/Differential diagnosis Polymyalgia rheumatica should be suspected from the history. The examination does not reveal any specific diagnostic features but erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) would be expected to confirm the diagnosis. Underlying malignancy should be a consideration. 371 Management The candidate is expected to indicate to the patient that if the blood tests confirm the suspected diagnosis of polymyalgia rheumatica, then the patient is likely to have a good response to a limited course of prednisolone which may need to be given for up to two years, but that any such treatment, how it is given and monitored, must await the results of the tests. The patient should be advised to report any severe headaches, visual disturbance or pain in the jaw when eating, since giant cell arteritis can occur together with polymyalgia rheumatica. KEY ISSUES • Focused physical examination which must include musculoskeletal system plus rectal examination. • Investigate with ESR and/or CRP. • Polymyalgia rheumatica as the most likely diagnosis. CRITICAL ERROR • Failure to request ESR and/or C-reactive protein. COMMENTARY Polymyalgia rheumatica and giant cell arteritis are linked conditions of unknown aetiology. The incidence varies with ethnicity and these conditions are more common in people of Northern European descent. Polymyalgia rheumatica commonly presents in middle aged or elderly patients with diffuse symptoms of muscle pain particularly in the neck, shoulders and hip girdles. The myalgia is symmetric and often begins in the shoulders. Muscle strength is normal but can appear diminished because of pain. There is often a disparity between the severity of myalgia reported and the physical findings. There are often constitutional symptoms including weight loss, malaise and depression; spiking fevers are rare. The diagnosis in this instance would be confirmed by investigations, specifically ESR and C-reactive protein, and full blood examination (FBE). • Treatment of polymyalgia rheumatica is with oral prednisolone, initially in high dosage. • Differential diagnosis to be considered would include: ~ Chronic fatigue syndrome: This condition is a 'medically unexplained condition'. It is usually seen in younger patients, may follow a viral infection and the dominant feature is incapacitating fatigue with other medical symptoms of subjective memory impairment, headaches, poor sleep, generalised muscle pains, postexertional malaise lasting more than 24 hours, lymph node tenderness. It is best viewed as a symptom complex resulting from interaction of physical and psychosocial factors. The ESR, CRP and FBE tests are normal. ~ 'Fibromyalgia': Another of the 'medically unexplained' conditions, characterised by aching pains across the shoulders and upper back, skin tenderness, poor sleep pattern and often additional constitutional symptoms. ESR, CRP and FBE are normal. 372 068 Performance Guidelines ~ Polymyositis: This is an uncommon inflammatory muscle disorder that may be associated with an underlying neoplasm in older patients. The most frequently encountered mode of presentation is the onset of painful muscles and proximal muscle weakness, often commencing in the neck, shoulder girdle and proximal limb muscles, associated with some atrophy with disproportionate weakness. ESR. CRP and FBE abnormalities may be indistinguishable from polymyalgia rheumatica but elevated creatine kinase and abnormal autoantibodies are characteristic. A positive muscle biopsy is diagnostic. ~ Underlying malignancy: prostate, breast in females, multiple myeloma, lung cancer. 373 069 Performance Guidelines Condition 069 Lack of energy in a 56-year-old suntanned man AIMS OF STATION To assess the candidate's ability to diagnose the cause of tiredness and lack of energy in a 56-year-old man. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 56-year-old industrial chemist. Opening statement 'I have felt very tired lately and for no apparent reason. ' Story in Detail Without prompting — you have felt tired and lethargic since you retired about a year ago You attributed this to a lack of mental stimulation from what was a demanding job. About three or four months ago you also noticed aches and pains in your joints which have persisted. You also realised that you had lost some weight which is why you decided to see the doctor. You have just returned from holidays in Queensland. You have noticed that you have developed a suntan even though you don't spend much time outdoors, and did not do much swimming on holiday. In response to specific questions respond as indicated: • The tiredness is constant and not improved by resting or sleeping (you sleep well). • The aches and pains are mainly in your shoulders, hips and knees. There is some tenderness and swelling in wrists and elbows and pains in the shoulders. The muscles are not sore. • The weight loss is 3-4 kg. • You have also noticed palpitations at times — mainly when going off to sleep, when your heart seems to speed up and miss beats for a few minutes at a time. • Your sexual activity has been less than before; you thought due to your age. • You don't feel depressed • In response to all other questions deny any other symptoms. • You do not smoke or drink any alcohol. • There have been no significant past illnesses. • There is no significant family history but you were adopted and know little about your parents. 374 069 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient — The candidate should show skill in: ~ listening and facilitation of presenting symptoms; and ~ using direct and indirect questioning in a logical, relevant and non-threatening manner. • History-taking — The candidate is expected to take a comprehensive history in a patient presenting with the symptoms of tiredness, arthralgia and weight loss. The additional symptoms of palpitations, change in skin colour and loss of libido, in the absence of other symptoms or significant past history, indicate there is a multisystem disorder. However most candidates will require the examination findings to assist in the diagnostic formulation. • Examination requests should be made for specific diagnostic features. The examiner will respond to a request with the following specifics: ~ Distribution of hyperpigmentation — generalised over body but not mucos ~ Joints swelling and some tenderness of wrists, elbows and knees. Limitation of range of movements and tenderness of the shoulder joints ~ Pulse irregular, atrial fibrillation, confirmed by office ECG ~ Blood pressure 140/90 mmHg ~ Heart no additional findings, no signs of cardiac failure. ~ Abdomen 5 cm enlargement of liver — firm nontender liver edge ~ Genitalia testes softer and smaller than usual for age ~ Urine positive for glucose. Diabetes confirmed by random blood sugar of 12 mmol/L • Diagnosis/Differential diagnosis — The patient presents the classical clinical picture of haemochromatosis ~ Other causes of increased pigmentation — Addison disease, Cushing disease, hyperthyroidism, cirrhosis, porphyria, chronic renal failure, malnutrition/malabsorption, drugs causing photosensitivity (for example, psoralens, phenothiazines, certain antibiotics, amiodarone). • Choice of investigations — The candidate should indicate the need for: ~ full blood examination and erythrocyte sedimentation rate. ~ creatinine and electrolytes ~ serum iron studies (especially transferrin saturation) ~ liver function tests ~ test for gene for haemochromatosis (HFE) gene If the candidate suspects haemochromatosis the next steps in the confirmation of the diagnosis should be explained to the patient. Details of treatment are not required in this case. Specialist referral would be expected for further assessment and management. If the candidate does not recognise the significance of the constellation of symptoms and signs, their choice of investigations and/or referral will indicate the level of performance. 375 069 Performance Guidelines KEY ISSUES • History-taking — the candidate is expected to exhibit appropriate history-taking skills and obtain the key features of the illness given the patients initial presenting complaints of tiredness, joint pains and weight loss. This will require a systematic approach to history-taking and the multisystem nature of the complaints requires a comprehensive but concise history. • Choice and sequence of examination — examination of the joints and of the features of skin pigmentation is expected. The candidate should indicate the need to examine the pulse, cardiovascular system, abdomen and to look for evidence of endocrine dysfunction. • Diagnosis/Differential diagnosis — the condition of haemochromatosis may not be apparent to the candidate on the history and examination findings. However a consideration of the causes of the multisystem disease with skin pigmentation, arthritis, cardiac, liver, and endocrine systems disorder should be sensibly discussed. • Choice of investigations — these should be appropriate to the investigation of the multisystem disease. CRITICAL ERROR - none defined COMMENTARY In primary haemochromatosis there is increased absorption of iron from a normal diet. Repeated blood transfusions can cause secondary haemochromatosis. The primary form is an autosomal recessive condition, known also as 'Bronze Diabetes'. The homozygous state is present in 1:150 in Australia with 1 in 10 carriers (1 in 300 blood donors have iron overload) and is more common in people of Celtic or Northern European background. Typical manifestations are bronze skin pigmentation, diabetes (60%), cardiomyopathy, liver damage and pituitary failure. Fatigue, arthralgia and abdominal pain are leading symptoms, while detection of atrial fibrillation, hepatomegaly, testicular atrophy and hyperglycaemia make a clinical diagnosis possible. The critical confirmatory investigations are iron studies — serum iron, total iron binding capacity, ferritin, transferrin and transferrin saturation, plus testing for the gene for haemochromatosis (HFE gene). 376 070 Performance Guidelines Condition 070 Recent haematemesis in a 50-year-old man AlMS OF STATION To assess the candidate's clinical perspective in examining a patient presenting to the Emergency Department with an acute haematemesis. To check abilities to examine for evidence of chronic liver disease. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The candidates have been told that you have vomited up a large quantity of blood two hours ago and they have been instructed to undertake a relevant physical examination. They are not expected to take a further history from you. They have just finished taking a history. On this occasion you vomited a large amount of fresh blood two hours ago — you think it might have been a pint or so (500 ml_). You felt temporarily faint and broke into a sweat. You have not vomited since. Your wife has driven you to hospital where the Hospital Medical Officer (HMO) has taken your history You are lying on the couch undressed to your underclothes and wearing a hospital gown. The HMO who has taken your history is about to examine you. You have given a past history of a previous admission six months ago with a similar episode of vomiting blood which settled spontaneously, and you were discharged after a few days. You had an endoscopy through the mouth and you were told you had dilated veins at the lower end of the oesophagus leading into the stomach. You were warned about the effects of continued drinking. You've been trying to give this up but you have had limited success. It is likely that the candidates will want to measure your blood pressure and feel the pulses in your arms. They will also examine your hands, face, chest and abdomen. In a patient with liver problems, the findings will be evident on examination, and will have been previously checked by the examiner. EXPECTATIONS OF CANDIDATE PERFORMANCE Candidates should first look for evidence of haemodynamic compromise (looking for evidence of hypotension and postural drop, pulse, peripheral perfusion). Once candidates indicate they would take the blood pressure, they can be told that the BP is 110/70 mmHg and pulse 90/min. As the bleeding occurred only two hours ago, this assessment is particularly important. Candidates should indicate that they would do a rectal examination looking for a melaena stool, and will be informed there is a fresh melaena stool on the glove. 377 070 Performance Guidelines After assessment of stable haemodynamic status as first priority, the candidate should: • Put the patient at ease, correctly position him supine with appropriate exposure to examine the whole abdomen, groin, head and neck and upper limbs. • Make an appropriate examination looking for evidence of chronic liver disease (examination of hands — liver palms, leuconychia, spiders, clubbing), easy bruising, spider naevi elsewhere, gynaecomastia, parotid enlargement, oral cavity and tongue, ascites, portal hypertension (dilated veins and splenomegaly), testicular atrophy. • Examine for liver flap. • Palpate the abdomen adequately for hepatic and splenic enlargement. • Check for evidence of ascites, by palpation for shifting dullness or fluid thrill. • Percuss for evidence of liver and splenic enlargement. • Auscultate abdomen for venous hum, bruit, bowel sounds. • Provide a logical description concerning the examination. • Perform the examination in a logical sequence. KEY ISSUES • Performing a satisfactory physical examination pertinent to an episode of acute haematemesis in a patient in whom evidence of chronic liver disease should be sought • Accuracy of examination will be a key issue for the mark sheet when a real patient is involved. • Satisfactory commentary to examiner. CRITICAL ERRORS • Failure to assess the haemodynamic state of the patient. • Failure to look for evidence of liver failure and portal hypertension. COMMENTARY In this important and common emergency room setting there are three issues the doctor must focus on: • Checking the ABC (Airway, Breathing, Circulation) of immediate resuscitation. • Assessment of the cardiovascular state of the patient and provision of prompt resuscitation, if necessary. • Identification of the cause of the haemorrhage. This patient has had a large haemorrhage and the airway couid be compromised. In this scenario the patient appears fully conscious and is able to give a detailed history, so it is unlikely that there is a major problem with the airway or breathing. Thus the physical examination must start with measurement of the blood pressure (lying and sitting, if necessary) and pulse, and a clinical evaluation of how well the periphery and vital tissues are perfused. Is the patient shocked, cold and clammy, with a shutdown peripheral circulation? If the patient is shocked, the physical examination must cease at this stage and the patient must be resuscitated. 378 070 Performance Guidelines Provided the patient is stable, a methodical examination may be undertaken to look for the cause of the haemorrhage. Although the patient's past history has suggested that the cause is alcoholic liver disease, portal hypertension and bleeding oesophageal varices, this should not be assumed as many patients with known varices will be bleeding from another cause. The examination should look for: • signs associated with chronic liver disease: • signs of possible liver failure; • signs of portal hypertension; and • any other clues suggesting a different aetiology for the haemorrhage. Signs associated with chronic liver disease apart from hepatomegaly include nail changes (leukonychia), salivary gland enlargement, testicular atrophy, gynaecomastia and spider naevi. If the liver is failing, the patient may have ascites and encephalopathic changes. Encephalopathy may have a variety of presentations, ranging from minor mental impairment and flap, through to coma. Portal hypertension may be manifest by the signs of hypersplenism (purpuric haemorrhage), splenomegaly and collateral venous channels. The latter may be visible in the anterior abdominal wall as communications between the umbilical vein and the epigastric venous channels flowing back into the systemic circulation. Of more sinister import are the oesophageal mucosal collaterals that form between the portal and azygos systems through decompression along the left gastric (coronary) vein. Occasionally, the physical examination will reveal other signs that might be associated with haemorrhage, for example, the hereditary haemorrhagic telangiectasia associated with the Osler-Weber-Rendu syndrome. Variations on this theme are also used, in which a real patient with liver disease is to be assessed after admission to the ward and institution of an intravenous drip while blood is being typed and cross-matched. The instructions will in that case state that the patient is now haemodynamically stable and the emphasis of the task is to assess the patient for evidence of chronic liver disease, which is expected to be present. The assessment now concentrates on the technique and accuracy of physical examination as key issues. In this emergency department scenario the emphasis is FIRSTLY on assessment of stable or unstable haemodynamic status in a patient with recent haematemesis. CONDITION 070. FIGURES 1 AND 2. Abdominal distension — Ascites 379 071 Performance Guidelines Condition 071 Anaemia in a 28-year-old pregnant woman AIMS OF STATION To assess the candidate's ability to define the possible causes of anaemia in pregnancy and to arrange appropriate investigations and advise the patient concerning the diagnosis and treatment. The most likely diagnosis is iron deficiency anaemia due to the demands of three pregnancies in a short time interval, but other causes of anaemia including thalassaemia, and folic acid deficiency associated with a multiple pregnancy need to be excluded. Having made the appropriate diagnosis iron therapy should be prescribed. EXAMINER INSTRUCTIONS The examiner will instruct the patient as follows: The list of responses below is likely to cover most of the questions you will be asked. List of appropriate answers to questions • Previous obstetric history — you have had three pregnancies during the last four years. No postpartum haemorrhage. • You did not take iron tablets during these pregnancies: your haemoglobin was always greater than 100 g/L when previously tested. • You noted no excessive blood loss before or between pregnancies — periods have not been heavy. You have had no bleeding from the bowel, and there has been no suggestion of malaria or hookworm infestation; you have always lived in Southern Australia. • • • You had an ultrasound examination at 18 weeks of gestation, this showed a singleton pregnancy was present, and confirmed the period of gestation. Diet — you eat meat occasionally, you don't like green vegetables. No iron tablets have been taken during the pregnancy. • No vaginal bleeding has occurred during the pregnancy. • There is no family history of /^thalassaemia or of anaemia generally. You are Australian born as were your parents, and there is no Mediterranean heritage in the family • You have not had a full blood examination (FBE) done before in this pregnancy. • You have a supportive partner who assists at home. Questions to ask if not already covered: • 'Why have I become anaemic?' • 'Will my anaemia harm my baby?' • 'Do I need a blood transfusion?' • 'How quickly will my haemoglobin come up?' 380 071 Performance Guidelines Examination findings to be given to the candidate from the examiner on request Apart from looking pale, general examination is normal. The uterus is enlarged to about 4 cm above the umbilicus and measures 26 cm above the pubic symphysis. Investigation results None has been recorded for this pregnancy other than the ultrasound. EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to patient (the candidate should convey the substance of what follows to the patient): • She needs an FBE to check on the form of anaemia which is present. • She requires assessment of her iron status — serum iron or ferritin levels should also be checked. • If the FBE suggests possible /Mhalassaemia minor, haemoglobin electropheresis will also be required. • Treatment with iron tablets should begin after taking blood for investigation (Ferro-Gradumet® or Fefol®). Two tablets should be taken a day; she should be warned about the possible effects of these in causing constipation and dark stools. There is no need for parenteral iron therapy at this time, or blood transfusion. • A satisfactory response to oral iron therapy should be able to be achieved well ahead of the time that delivery is likely. The haemoglobin should be checked again in two weeks, along with a reticulocyte count. If the haemoglobin does not increase satisfactorily, referral to a haematologist for advice concerning diagnosis and treatment would be appropriate. Providing the anaemia can be treated satisfactorily, there should be little effect on the pregnancy. In the absence of adequate treatment the placenta becomes larger, however the babies are usually smaller. KEY ISSUES • Ability to evaluate appropriately a patient who has become anaemic during pregnancy. • Ability to commence treatment and arrange appropriate followup in such a patient. CRITICAL ERRORS • Failure to make a provisional diagnosis of probable iron-deficiency anaemia due to the demands of successive pregnancies. • Failure to administer oral iron therapy. • Recommending blood transfusion at this time. 381 071 Performance Guidelines COMMENTARY This case illustrates a common problem of iron deficiency anaemia in a young woman who has had a number of pregnancies in a short period of time. This is the most common form of anaemia under these circumstances and whilst other less common forms of anaemia should be considered, it is important to commence treatment for simple iron deficiency anaemia whilst awaiting the results of investigations. It is also important to remember that blood transfusion is not indicated under these circumstances in mid-pregnancy. Common problems likely with candidate performance are: • Failing to focus on other causes of anaemia when taking the history — failing to ask about menstrual loss, loss from other sites, and failing to consider the possibility of thalassaemia minor. • Failing to arrange appropriate blood tests which would include haemoglobin electrophoresis if the anaemia is hypochromic and microcytic without evidence of iron deficiency, and the assessment of serum iron or ferritin levels. 382 072 Performance Guidelines Condition 072 Acute vertigo in a 50-year-old man AIMS OF STATION To assess the candidate's ability to diagnose an acute vascular 'stroke' presenting with vertigo. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement 'I feel so dizzy that I can hardly stand up. It's like being on a merry-go-round! ' Story in detail without prompting 'This morning just over an hour ago, I was having breakfast when I felt a pain in the left side of my face (indicate the left side). Then I started to feel numb up and down the other side of my body (indicate the right side) and I became so dizzy that I couldn't even sit up. let alone stand up. ' 'My head felt as if it was exploding, and my speech was funny and slurred. ' 'My wife got me into bed and then I felt sick and vomited. I had to lie very still or I wanted to vomit. It was like being very seasick. So I rested while she rang you. If I turn my head to the side the dizziness gets worse. I found it hard to get in and out of the car. I keep falling this way (indicate to the left). Am I having a stroke?' In answer to the doctor's questions • You are feeling a little better now but would prefer to lie down. • Everything seems to be moving and spinning around you. • The pain has gone from your face but the cheek (left) now feels numb too. • You still have a feeling of numbness down your right side, involving the trunk and limbs. • No persisting headache or neck stiffness. • No hoarseness (if asked about swallowing, you did feel that it was difficult to swallow your saliva, but that feeling has now gone. You suspect that your taste has been affected). • No previous episodes. No more vomiting. Your speech has now returned to normal after initial slurring Review of general health Apart from being overweight and having treatment for high blood pressure and high cholesterol, you feel you have been in good health. Your blood pressure has been variable. Lipid levels stable. Appear apprehensive and agitated. Hold firmly onto the desk or chair to keep yourself steady. Lean towards your left side. Although you have just suffered a cerebral event your ability to give a satisfactory history is not impaired. Give a full account of your symptoms unless interrupted by the doctor taking control of the interview at too early a stage. You are very concerned that you are having a stroke. 383 072 Performance Guidelines Social history You are married. You and your wife live in your own home. You do not smoke. You work as a postman. You drink alcohol only occasionally. Family history • Mother died from stroke at 65 years. • Father was diabetic, died from heart attack aged 59 years. • Major continuing health problems are: ~ Hypertension for about 10 years. ~ Hyperlipidaemia identified about 6 years ago. ~ Both conditions have been well controlled. Current medication Norvasc® (amlodipine) 10 mg once daily (calcium channel blocker). Avapro® (irbesartan) 150 mg once daily (angiotensin II receptor antagonist). Lipitor® (atorvastatin) 10 mg once daily (CoA reductase inhibitor). After the history is finished, the examiner will hand to the candidate a separate sheet giving an outline of physical findings as set out in the box below. Physical Findings Cardiovascular examination is normal — blood pressure 145/85 mmHg, pulse 80/min and regular. The main findings on neurologic examination are that he has an ataxic gait and postural unsteadiness without significant change on closing eyes. He has some incoordination of movement of the left arm and hand, but no motor weakness or other motor signs are present. Cranial Nerves • Eye movements and pupil reactions are normal as is fundoscopy. • Nystagmus to the left on looking to the left is present. • A left Horner syndrome is present (ptosis, miosis of pupil). • Pain sensation to pinprick is lost on the left side of the face and the direct corneal reflex is absent. Power of the muscles of mastication is normal. • Hearing is normal in both ears. • Appreciation of pain and temperature sensation is reduced down the whole of the right side of the body below the face. • Vibration and joint position sense and light touch sensation are normal. EXPECTATIONS OF CANDIDATE PERFORMANCE Abilities in communication skills and in diagnostic problem solving are required. This patient is able to give a very full picture of the onset of the condition. The skill required is in listening carefully, prompting or facilitating when necessary and leaving questions to confirm clinical suspicion until after the patient has finished. 384 072 Performance Guidelines Presentation to the examiner requires diagnostic problem-solving skills about: • Causes of vertigo of sudden onset including stroke or transient ischaemic attack. • Knowledge of the clinical picture presented by obstruction of the blood supply to the brain stem and cerebellum. • Significance of crossed signs, particularly loss of pain sensation to left face but to opposite side of trunk and limbs. • Appreciation of cardiovascular risk in this patient. • Ability to use clinical reasoning skills to explain neurological signs found on physical examination. • Appreciating the need for further assessment on an urgent basis. • Choosing the investigation most urgently required. Response to observing examiner The candidate should recognise that vertigo is of central brain stem/cerebellar origin rather than peripheral vestibular origin. Its acute onset, associated symptoms and signs and lack of further progression suggest vascular obstruction rather than haemorrhage. The cerebellum and brain stem are the areas involved. Differential diagnosis All unlikely, but other potential causes of vertigo include • acute labyrinthitis • benign paroxysmal vertigo • Meniere syndrome • migraine • cerebral tumour • multiple sclerosis Response to patient and immediate management There is a need for immediate hospital admission. Advise that the patient has had a 'mild stroke' as suspected, but that confirmatory investigation is necessary. This should include urgent assessment by a specialist physician/neurologist. It would be reasonable to reassure the patient about the future but to emphasise the need to pay attention to the underlying risk factors which will require ongoing management after recovery from this event. The inclusion of a neurological case of this complexity may be more threatening to candidates than other cases. Examiners are asked to take this into account when marking. If the candidate obtains a detailed history, makes a reasonable attempt at explaining the findings on neurological examination, recognises that the presence of neurological signs as described, in addition to nystagmus, is indicative of a brain stem lesion and realises that this is a serious disorder of cerebrovascular origin involving the cerebellum/brain stem and that it requires urgent investigation, then a clear pass level would be achieved. The posterior inferior cerebellar artery (PICA) syndrome is, however, well documented and should not be an unduly difficult diagnosis for a well prepared candidate to suspect from the history and confirm by the physical findings. 385 072 Performance Guidelines Investigations Magnetic resonance imaging (MRI) should be advised associated with hospital admission. Computed tomography (CT) with CT angiography is also acceptable. Other investigations can be undertaken later. Problem solving ability • Clinical reasoning skills. • Data assimilation from history and examination. KEY ISSUES • Recognition of an acute cerebral vascular event affecting the vertebrobasilar system. • Appreciation that this combination of symptoms and signs implies brain stem/cerebellar disease. • Immediate management including appropriate investigation. Knowledge of the disease process Recognition that the patient has had a serious cerebrovascular incident (i.e. 'stroke'). Understanding that the pathology is in the area of the vertebrobasilar arterial system. Knowledgeable candidates may recognise the likelihood of posterior inferior cerebellar artery (PICA) obstruction, most likely due to thrombosis of the vertebral artery. Embolism is also possible. Relationship of this episode to the patient's cardiovascular risk factors should be recognised. CRITICAL ERRORS • Failure to recognise likelihood of cerebral/cerebellar vascular lesion. • Failure to advise hospital admission. COMMENTARY In this scenario, the sudden onset of vertigo has not been associated with tinnitus or hearing loss, so the vestibulocochlear system seems likely to be intact. True vertigo (a sense of rotation between patient and surroundings) is in this instance accompanied by ataxia (= Greek, without order, in particular a disturbed gait) suggesting an acute cerebellar disturbance. A cerebellar source is also suggested by the motor incoordination, without any weakness, in upper and lower limbs. What else is going on? Other clinical features suggest that a unilateral lower brain stem disorder is also present Sensory loss to pain is crossed between the face and the body. There is loss of pain sensation on the left side of the face, but in the trunk and limbs there is dissociated anaesthesia — sensation of pain and temperature is impaired on the right side All forms of ascending sensation for projection into the contralateral cerebral hemisphere come together at the level of the medulla, (where decussation of the uncrossed fibres of vibration and joint sense [and half touch] in the posterior columns occurs to join previously crossed pain and temperature fibres [and half touch] running in the spinothalamic tracts) as illustrated in Figure 1. The combination of cerebellar ataxia and crossed sensory loss suggests a left sided lower midbrain and cerebellar lesion 386 072 Performance Guidelines CEREBRAL HEMISPHERE Internal Capsule MIDBRAIN All sensation modalities now conjoined and contralateral PONS V n. Sensory, nucleus Position, vibration, 1/2 touch cross in upper medulla Cuneate & Gracile tubercles medial lemniscus Spinothalamic tract (s.t ) Pain Temperature 1 /2 Touch Spinal Cord Sensory Ascending Pathways Condition 072. Figure 1 Are any other brain stem nuclei or long tracts involved? Yes, the cervical sympathetic outflow is interrupted. Descending excitatory sympathetic fibres to the cervicothoracic outflow are also concentrated in the medulla. There is a left Horner syndrome (which fits a left sided lesion) catching the sympathetic head and neck outflow. Loss of sensation to the left cheek suggests that the left 5th nerve sensory pain nucleus is involved, with loss also of the corneal reflex. 387 072 Performance Guidelines The findings fit a left posterolateral lower lateral medullary and left cerebellar lesion This would be explained by a focal infarct involving the vertebrobasilar system, nofthe carotid and its branches. The anatomy of the blood vessels and cranial nerves is as illustrated (Figures 2-5). -A MIDBRAIN PONS -----C MEDULLA VENTRAL VIEW - BLOOD VESSELS & CRANIAL NERVES va. vertebral artery b.a. basilar artery a.i.e.a. anterior inferior cerebellar artery p.i.e.a. posterior inferior cerebellar artery a.c.a anterior communicating artery a s a anterior spinal artery __________________________________________________________________________ CONDITION 072. FIGURE 2. 388 072 Performance Guidelines The acuteness of onset suggests embolism or thrombosis. There are no cardiac arrhythmias to favour embolism, so an acute thrombosis affecting a left sided artery supplying cerebellum and brain stem is most likely (distal left vertebral artery). The patient has coexisting vascular risk factors. The absence of progression, and sudden onset make a haemorrhagic stroke less likely. The differential diagnosis would include other causes of vertigo: Meniere syndrome, chronic petrositis, cerebellopontine angle tumour, and other neurological problems. None is as likely as a vascular stroke. Knowledgeable candidates may recognise that this cluster of symptoms and signs is classical of thrombosis of the posterior inferior cerebellar artery (PICA syndrome). The cerebellum and brain stem receive their blood supply via the superior and inferior cerebellar arteries, arising from basilar or vertebral arteries. The relevant vascular and cross sectional anatomy is indicated in Figures 2-5 3rd & 4th nerve Colliculi Ascending contralateral sensory pathways Descending sympathetic fibres Descending ipsilateral upper motor neurone pathways 4 CROSS - SECTION MIDBRAIN - A CONDITION 072. FIGURE 3. 389 072 Performance Guidelines CONDITION 072. FIGURE 4. 390 072 Performance Guidelines CROSS - SECTION MEDULLA - C CONDITION 072. FIGURE 5. The patient's MRI is shown and demonstrates a left sided focal cerebellopontine vascular infarction. The patient made a rapid recovery. CONDITION 072. FIGURE 6. MRI of patient's head showing left cerebellar and brain stem ischaemic infarction 391 072 Performance Guidelines Cerebellar functions include ipsilateral stabilisation of motor movements and coordination and balance. Differentiation of different causes of ataxia can be helped by associated symptoms - sensory ataxia due to loss of position sense is worse in dark conditions. Cerebellar Disturbances cause: Cerebellar ataxic gait — with a staggering broad based gait like a drunken sailor, and a tendency to fall to the side of the lesion. The gait of sensory ataxia from bilateral dorsal column loss with loss of position sense is by contrast a high 'stamping' gait with positive Rombergism (instability standing with eyes shut). Cerebellar incoordination — Various tests evince incoordination of upper and lower limbs 'past-pointing'; 'finger-nose tests' with eyes open or closed; 'dysdiadochokinesia' on rhythmic pronation-supination, or alternate hand slapping; or knee-shin-ankle placement by other foot, or rhythmic flexion-extension of ankle. Additional brain stem damage may be found, for example: • ipsilateral 5th nerve • ipsilateral 7th nerve muscles of mastication, facial sensation loss of taste to side of tongue and motor weakness • ipsilateral 8th nerve disturbance of hearing • ipsilateral 9th nerve difficulties with swallowing • ipsilateral 10th nerve dysarthria The PICA syndrome classically presents, as in this case, with a dramatic onset of cerebellar signs with ataxia and vertigo, usually without tinnitus or deafness. Associated cerebral sympathetic paralysis with an ipsilateral Horner syndrome (ptosis, miosis, anhydrosis, enophthalmos) from medullary brain stem involvement is common, as is an ipsilateral loss of facial sensation to pain due to 5th nerve involvement, and other medullary brain stem nuclei may be affected. Loss of pain and temperature sensation from opposite (right) side of the body due to involvement of left spinothalamic tract is also seen. Dissociated anaesthesia (diminution of pain and temperature sensation with retention of touch and of other forms of sensation) is classical of a brain stem or spinal lesion below the pons, and occurs most notably in Brown-Séquard Syndrome (hemisection of cord) with findings as illustrated (Figure 7): • • • • Focal ipsilateral lower motor neuron lesion at the level of the spinal cord injury. Ipsilateral upper motor neuron lesion paralysis below the injury. Ipsilateral dorsal column sensory loss (position and vibration sense) below the injury Contralateral spinothalamic loss (pain and temperature) below the injury 392 072 Performance Guidelines CONDITION 072. FIGURE 7. 393 073 Performance Guidelines Condition 073 Urinary frequency in a 60-year-old man AIMS OF STATION To assess the candidate's history-taking skills, knowledge of the symptomatology and confirmatory testing for maturity onset Type 2 diabetes and the investigations which should be undertaken in a recently diagnosed diabetic. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 60 years. You are consulting your general practitioner about urinary symptoms. You also have concerns about cancer (your father had prostate cancer) and loss of sexual function, but these should not be immediately revealed to the doctor. Opening Statement: ‘I seem to need to go to the toilet to pass urine more often lately doctor.’ In response to the doctor's enquiries, respond as follows but do not volunteer all this information without appropriate prompting by the doctor. Over about the last three months you have been passing urine more often during the day and have to get out of bed to pass urine at least twice each night. You also suffer from leg cramps, worse at night, and your feet have felt slightly numb. You have felt thirstier lately and your mouth has been dry. You have been worried that your symptoms are due to prostate trouble because of your father's history and recent publicity about prostate cancer Review of general health You have lost 4 kg in weight, over the past three months. Admit to feeling tired recently — 'Maybe I'm just worried.' Admit to loss of libido and inability to obtain and sustain an erection over last 3-4 months. Admit to recent deterioration in eyesight, if asked. ‘I suppose I need new glasses at my age. ' Review of relevant systems No other deviations from normal. No dysuria. No incontinence. Normal stream. No other symptoms suggestive of prostatism with bladder neck obstruction. No chest pain or breathlessness. You are a previous patient but not well known to the doctor. Be pleasant, straightforward, except for some embarrassment over sexual activity. You are worried about prostate cancer. The doctor may ask additional questions about you. If so. respond as follows: Smoking habits: Nonsmoker Alcohol use: Drug Two cans light ale daily sensitivities Nil Family history: Father died from a stroke aged 80 years — also had prostate cancer. Mother in nursing home — Dementia. Past medical history: 394 no serious illnesses. 073 Performance Guidelines Physical examination findings to be given to the candidate from examiner on request He is significantly overweight with abdominal obesity. Blood pressure is 140/90 mmHg, pulse is regular. He has mild blunting of all sensory modalities in his feet. Neurological examination is otherwise normal. Genital and rectal examinations are normal, without evidence of prostatic enlargement or nodularity. EXPECTATIONS OF CANDIDATE PERFORMANCE • Summarise the problems presented by the patient: ~ urinary symptoms, thirst, weight loss; ~ numbness in feet and visual disturbance: ~ fear of cancer; ~ erectile dysfunction/reduced libido; and ~ maturity-onset diabetes as the most likely diagnosis. • Request urinalysis and random blood sugar using glucometer. ESSENTIAL OFFICE INVESTIGATIONS — TO BE PROVIDED BY EXAMINER WHEN REQUESTED Urinalysis — positive for glucose (++++), ketones (+), negative for protein. Random blood sugar should be done in the consulting room with glucometer. Result of 21 mmol/L effectively confirms diagnosis of diabetes mellitus. OTHER INVESTIGATIONS • urea, creatinine and electrolyte levels; • glucose tolerance test to confirm definitive diagnosis (although the level of random blood sugar puts the diagnosis effectively beyond doubt); • microscopy and culture urine — checking for microalbuminuria; • serum lipids — cholesterol, triglycerides, Low/High Density Lipoprotein (LDL/HDL) and ratio; • ECG to check for presence of undiagnosed ischaemic heart disease; • glycosylated Hb should be done as baseline; • full blood examination and erythrocyte sedimentation rate: and • prostate specific antigen (PSA) level indicated in view of his family history and concerns. KEY ISSUES • Diagnosis of Type 2 diabetes mellitus by appropriate consultation (history, examination and office tests). • Appropriate further investigation of newly diagnosed diabetic. • Recognition of fear of cancer and sexual dysfunction. CRITICAL ERROR • Failure to test urine or measure random blood sugar at this consultation 395 073 Performance Guidelines COMMENTARY The constellation of symptoms of polyuria, thirst, weight loss, sensory and visual disturbances, and erectile dysfunction, should raise suspicion of maturity-onset Type 2 diabetes mellitus. Urinary chemical testing and random blood sugar assessment applied to overweight adults over 45 years will pick up at least as many nonsymptomatic undiagnosed diabetics as are found on symptomatic presentation. 396 2-E: The Paediatric Consultation Peter J Vine 'Children are not simply micro-adults, but have their own specific problems.' Beta Schick (1877-1967) There are many very positive features about working with Recognition of the features children — they are much less complex than adults and usually in the history and in the under most clinical situations have only one presenting clinical signs that indicate complaint, unencumbered by a series of complicating past that a child is significantly ill events or of age-related disease. is a skill that must be Medical care and assessment of children is often a developed by anyone caring multidisciplinary process. Contrary to popular belief in some circles, children are not just scaled-down adults, but rather their needs are under the influence of a variety of variable factors, all of which have a profound effect on the development of the child as he or she progresses to adulthood. All of these influences therefore must be taken into account when consulting with children and these vary depending on the age of the child. Children in Australia have generally been spared the traumas experienced by their peers in third world countries, or those torn apart and disrupted by war and natural disaster. Refugee children come from other lands rather than our own, and have their own problems related to this background. However within our indigenous populations, the health of the children often is equivalent to those in developing countries — with high infant mortality, a high incidence of conditions uncommonly seen in the urban populations (for example, rheumatic fever), and a reduced adult life span, Australia is a multicultural nation with 25% of the population being born overseas according to 1 the latest Census. Many children are first generation Australians born in this country to immigrant parents. Our capital cities in particular have people from many nations residing in them who have cultural beliefs and practices of which doctors need to be aware. Except in the case of older children where the direct history from the child is most appropriate, the paediatric history is usually given by a third person, commonly a parent or caregiver. Often with new arrivals, the history is given by yet another intermediary, an interpreter, who may or may not be a relative, which may add yet another dimension to the consultation. Many medical practitioners admit to being rather frightened at the prospect of caring for children, as the process is so different from that related to adults where the history is obtained from the patients themselves. Other doctors are apprehensive at being able to perform an adequate examination of a child. Nowhere else in medicine is it so essential to have expert observation skills than in paediatrics. Many diagnoses can be made just by observation of the child while the history is obtained, before any formal examination is performed. Recognition of the features in the history and in the clinical signs that indicate that a child is significantly ill is a skill that must be developed by anyone caring for children. While they do become ill quickly and, if untreated, deteriorate more rapidly than adults, children also repair and recover quickly. It is imperative that if any child is not improving at a time when improvement is expected, an immediate investigation into what might be complicating the situation must be instigated. 1 Australian Bureau of Statistics 2005 397 2-E The Paediatric Consultation While many illnesses seen in children also occur in adults (for example, asthma) the requisite skill is knowing the variations that must be considered in the child which will influence future management. An example is the method of administering bronchodilator therapy in young children. While the same medications are used, their methods of administration are very different, with small volume spacers and masks designed for very young children. There are also many conditions that are specific to children, for example hypertrophic pyloric stenosis and cystic fibrosis — although the latter has now become an adult disease, and adult practitioners need to be aware of management of this condition. While intussusception can occur in adults in later years, secondary to a number of bowel lesions, 'primary' intussusception is a very prominent condition in infants, which must be considered in any infant presenting with colicky abdominal pain. In this country, the majority of children seen in clinical practice present with relatively minor complaints, but practitioners must always be vigilant for the circumstances when they should be considering more complex conditions specific to infants and children. Such situations are usually recognised from the history or the appearance of the child on examination. Beware of the listless infant or child who allows you to perform any examination you wish. This is usually a very sick child. Prescription of drugs is also different in children: most drugs are given on a mg per kg basis up to a certain weight and age. Similarly intravenous and oral fluids are calculated on a mL per kilogram basis and need to be calculated carefully for each child. Specific pocket handbooks with this information are published by several of the major Australian paediatric teaching hospitals. The needs of children to develop their potential and to remain in good health are legion. While we practise in a so-called developed country, we still have a significant percentage of our child population who live in extremely adverse circumstances, whether these relate to poor nutrition, poor socioeconomic circumstances, poor parenting skills, harmful emotional environment or even deprivation. Many primary schools arrange breakfast for their pupils as for one reason or another the children leave home for school having not eaten. As each year goes by, the needs of the child change. Many parents find it difficult to provide for those needs, to the detriment of the child's development. The general practitioner is often an appropriate person to assess this situation. Unfortunately all too commonly children in our country are the subjects of abuse, whether it be physical, sexual or emotional, and the medical practitioner needs to be alert to this possibility, especially when the presentation is at odds with what is observed. Australian law mandates that in each suspicious case, the relevant appropriate authorities are to be notified. As is typical of the industrialised countries, the spectrum of conditions seen by medical practitioners has changed dramatically over the last couple of decades. Rather than malnutrition, many of the problems we see are related to inappropriate nutritional habits and inactivity leading to obesity. Emotional and behavioural problems are common and often relate to the child's life experiences. 1 Some situations that may influence these are: • many children under two years of age participate in formal child care while parents work, almost a necessity for maintaining a suitable income: 1 Practical Paediatrics Ed. MJ Robinson, DM Roberton 5th Ed. Churchill Livingstone 2003 p2. 398 2-E The Paediatric Consultation • the extended family in many communities is scattered and less accessible, as young adults move freely around the country seeking employment; • one in five children will experience divorce of their parents before mid teens; • a significant percentage of children live in one-parent families; many in two-parent families live in very unhappy circumstances; • with the higher divorce rate, blended families, where children from previous marriages live together, can often be a source of major conflict. Having two 13-year-old females suddenly living together can be quite trying; and • tobacco and/or alcohol use, especially binge drinking, is common in teenagers, and most high school students are aware of where they can obtain cannabis and other drugs. Years ago, Dr Howard Williams of Melbourne, a mentor to many practising Australian paediatricians and one of the forerunners of paediatrics in this country, used to urge his postgraduate students to be aware of 'the new morbidity'. He stated that his generation had overcome much of the infectious disease morbidity and mortality with antibiotics and immunisation, but that behaviour problems, disrupted families and the effect on the children involved would be a major part of the work of the modern practitioner. How right he was, as much of the consultation time of paediatricians in this country is taken up with oppositional defiant behaviour, attention deficit disorder, and other developmental behavioural problems. Much of this may be related to the sociological change in child rearing. Children of today largely depend on artificial media for entertainment in their spare time — television, cinema, electronic games, many of which require little if any intellectual skills and commonly have a strong base of violence and aggression. Add to this a high divorce rate and the loss in many instances of the extended family and the scene may be ripe for acting-out behaviour. The physical and emotional needs of the growing child must therefore be kept to the fore when children are being assessed. The presentation of a child with an emotional problem can be quite varied and commonly may be organically based, so that the practitioner must be very alert to this possibility. The care of the disabled child, whether it is a physical or intellectual disability, often falls to the primary practitioner for day-to-day events. Detailed knowledge of rare conditions is not generally necessary, but the support given to parents as they advocate for their offspring can be a major role asked of the practitioner. Advice concerning screening procedures and genetics is also a common question, which the practitioner should refer to a higher authority, as the explosion of knowledge in these fields is occurring at such an alarming rate that it has outstripped the ability of most of us to keep up-to-date. The internet has revolutionised the practice of medicine, including paediatrics, as parents consult the internet for advice on conditions their children are reported to have. Often parents may self-diagnose based on this information, but generally present with their downloaded information asking for explanation of the contents. Many sites unfortunately are inaccurate and anecdotal. Hence the practitioner's role often is to sift through this information and to give an accurate précis of the particular condition. A complete history, examination and discussion with a parent of a child's problem can take considerable time. In the AMC MCAT examination, only certain aspects will be examined in any one scenario. For example, the task may involve coming to a diagnosis from the information supplied and then counselling a parent on the management of the child's condition. Or it may be taking a focused history to determine the cause of the presentation. 399 2-E The Paediatric Consultation Candidates therefore are assessed on their ability to relate to a worried parent of a sick child at a standard expected by the Australian community. It can be seen then that working with children, while it can be a complex business, is generally quite ordered and rewarding if aware of the various factors that influence the development both physically and emotionally of the child, as well as being mindful and knowledgeable about the specific conditions that are peculiar to children. Children are fun to work with, are honest and much less complex than most adults. They do however have special needs and are afflicted by many conditions specific to their age group, whether it be neonate or teenager, and the competent practitioner needs to be aware of these conditions in order to consider them, no matter how minor the complaint appears to be. The ability to counsel worried parents in an empathie manner is paramount for successful paediatric practice. Peter J Vine 400 2-E The Paediatric Consultation 2-E The Paediatric Consultation Candidate Information and Tasks MCAT 074-077 74 Neonatal jaundice in the first day of life 75 Immunisation advice to the parent of a 6-week-old baby 76 Dark urine, facial swelling and irritability in a 5-year-old boy 77 Fever and sore throat in a 5-year-old boy 401 074-075 Candidate Information and Tasks Condition 074 Neonatal jaundice in the first day of life CANDIDATE INFORMATION AND TASKS History You are asked to see an infant, Jessica, born 24 hours ago, for jaundice. She is the first child of a healthy mother, whose pregnancy was normal. Delivery was at term, by a midwife, and was uneventful. The infant weighed 3700 g at birth. Jaundice was noticed soon after birth, within the first 24 hours. The infant has been sucking well at the breast. The mother wants to go home as soon as possible. Examination Findings The infant is clinically jaundiced but otherwise well and active with no hepatosplenomegaly or other abnormal physical signs. You have obtained all relevant findings on history and examination. YOUR TASKS ARE TO: • Ask the observing examiner for results of any investigations you consider necessary. • Advise the parent on diagnosis and management. The Performance Guidelines for Condition 074 can be found on page 405 Condition 075 Immunisation advice to the parent of a 6-week-old baby CANDIDATE INFORMATION AND TASKS Your next patient is baby Laura brought by her mother to a general practice at six weeks of age, as part of routine postnatal followup. Laura is the couples first child. The babe is breastfed and gaining weight normally. Her mother wants to know what you would advise about immunisation because she and her husband have recently heard conflicting views expressed in the media. General examination of the baby reveals no abnormality. She was given her first hepatitis B vaccination soon after birth. YOUR TASKS ARE TO: • Outline the current immunisation protocol you would recommend and what diseases the programme is protecting against. • Discuss any concerns the parents have about immunisation. You will not be expected to take any additional history or ask for examination findings. The Performance Guidelines for Condition 075 can be found on page 408 402 076-077 Candidate Information and Tasks Condition 076 Dark urine, facial swelling and irritability in a 5-year-old boy CANDIDATE INFORMATION AND TASKS A five-year-old boy is brought to the Emergency Department because of swelling around the eyes. He has only been passing small amounts of urine, which is dark in colour. In the past 12 hours he has become restless and irritable. The child had school sores (impetigo) three weeks ago, treated successfully with a topical antibiotic cream, but has had no other prior illnesses. Both parents are well. The child is an only child and has always kept in good health. YOUR TASKS ARE TO: • Ask the examiner for the relevant physical findings you wish to elicit. • Discuss with the parent your provisional diagnosis. • Advise details of any investigations that are required and advise the parent of the treatment that will be needed. You do not need to take any further history. The Performance Guidelines for Condition 076 can be found on page 412 Condition 077 Fever and sore throat in a 5-year-old boy CANDIDATE INFORMATION AND TASKS Peter, a five-year-old boy is brought to you in a general practice setting by his parent with a fever of 40 °C that developed overnight. He complains of an intensely sore throat and finds it sore when he swallows food or fluid, although he is able to do so. YOUR TASKS ARE TO: • Indicate to the examiner the clinical examination you would perform to diagnose the problem. The examiner will give you the results of the physical examination. • Discuss with the parent any investigations you feel are necessary. • Explain your diagnosis and suggest management to the mother. You do not need to take any further history. The Performance Guidelines for Condition 077 can be found on page 414 403 2-E The Paediatric Consultation 2-E The Paediatric Consultation Performance Guidelines MCAT 074-077 74 Neonatal jaundice in the first day of life 75 Immunisation advice to the parent of a 6-week-o!d baby 76 Dark urine, facial swelling and irritability in a 5-year-old boy 77 Fever and sore throat in a 5-year-old boy 404 074 Performance Guidelines Condition 074 Neonatal jaundice in the first day of life AIMS OF STATION To assess the candidate's knowledge of causes of neonatal jaundice occurring in the first 24 hours after birth, and the appropriate management of the condition. EXAMINER INSTRUCTIONS This scenario illustrates the common problem of ABO blood group incompatibility with the classic combination of a mother group O Positive and a baby A Positive, and a strongly positive Coombs test. The baby's bilirubin level has reached a total of 250 umol/L at 24 hours of age. Phototherapy is required, which should prevent further rise in bilirubin, but will be needed for several days. The problem is compounded by the mother's disappointment. She is a young professional woman who wanted a completely natural delivery and management and is disappointed that she is not allowed to go home as her infant requires treatment. Investigation results/details to be given to candidate by examiner on request Tests performed: • Mother's blood group 0 Rh positive. • Infant's blood group A Rh positive. Direct Coombs test strongly positive. • Infant's Hb 170 g/L. • Blood film microspherocytes. • Bilirubin Total 250 umol/L Conjugated 6 umol/L at 24 hours. The biochemist indicates that this is abnormal, but below the range at which exchange transfusion is indicated. The examiner will have instructed the parent as follows: • You gave birth to your first child 24 hours ago. • You believe childbirth is a natural phenomenon, and resent medical intervention. • You are well educated, and were recently a middle-level manager in a successful company. • You insisted your obstetrician allowed you to have a natural childbirth with appropriate assistance from a midwife, and that you could go home on day two. • Now that your babe has become jaundiced, you are confused and upset. • After appropriate discussion, you will accept the doctor's recommendations if they are given clearly and empathically. 405 074 Performance Guidelines Questions to ask or statements you could make: • ‘I expected everything to be normal. ' • ‘Why do I need to stay longer in hospital? I want to go home. ' • ‘Is treatment really necessary?' • ‘What would happen if no treatment were given?' • 'Are there any side effects of this light treatment?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain the following: • Jaundice occurring in the first 24 hours after birth is not due to immature liver function, but usually due to haemolysis consequence upon blood group incompatibility. In a primiparous woman, ABO incompatibility would be the most likely cause. • ABO incompatibility — this has been confirmed by the tests done. • Consequence of severe neonatal jaundice and the need for phototherapy and monitoring. • Exchange transfusion unlikely to be required but could be an option if jaundice worsens despite phototherapy. • The technique of phototherapy, its side-effects and reassurance regarding aspects which could cause anxiety: ~ Jessica's bowel motion may be a loose green/black colour while under lights. ~ Her eyes will be covered while she is under lights to protect her eyes ~ Baby is only under lights when not feeding and is sleeping. ~ Phototherapy may be able to be given in the room where mother is staying in hospital. • Excellent prognosis. • Arrange continued stay in hospital for mother and infant with facility for mother to continue breastfeeding. • Followup developmental assessment and audiometry — not usually discussed at this first consultation. KEY ISSUES • Recognition of haemolytic disease of newborn and its immediate treatment. • Empathie but realistic communication with new parent. • Ability to relate to mother's disappointment with need for medical intervention. CRITICAL ERROR • Failure to recognise haemolytic disease of newborn and failure to advise phototherapy. 406 074 Performance Guidelines COMMENTARY The dominant cue in this example is neonatal jaundice in the first day of life. Jaundice occurs frequently in the neonatal period, but when seen on the first day of life, it indicates a pathological and potentially dangerous rise in bilirubin level. In the common, so-called 'physiological jaundice', the serum bilirubin rises more slowly, and jaundice is not apparent on the first day. Haemolytic disease is the most common cause of potentially dangerous neonatal jaundice. As it is readily treatable, and complications potentially avoidable, early diagnosis is mandatory. Hyperbilirubinaemia is likely to reach a maximum level around the third day of life. There is a diagnostic rule that 'jaundice on the first day of life is haemolytic unless proven otherwise' This originated in the days when Rh haemolytic disease was a common cause. The jaundice of the affected infant could increase rapidly, so immediate diagnosis and often exchange transfusion were required to avoid the serious complication of kernicterus or later nerve deafness. The candidate familiar with this rule will immediately refine the cue to: 'Jaundice on the first day of life, probably haemolytic' This scenario is an example of the need for pattern recognition where urgent diagnosis is required. To frame the problem more clearly, the clinician needs to seek evidence confirming the existence of haemolysis and defining the degree of hyperbilirubinaemia. The protocol states that hepatosplenomegaly is not present. This makes the severe intrauterine haemolysis seen in some cases of Rh haemolytic disease less likely, but does not exclude less dramatic forms of haemolysis. The crucial laboratory tests in establishing the diagnosis are examination of blood group of mother and infant, and direct Coombs test. The scenario of a group O Positive mother and a group A Positive infant indicates the potential for the infant's blood to be harmed by maternal anti-A antibody. The positive direct Coombs test confirms that the infant's red cells have been sensitised by antibody and establishes the diagnosis of haemolytic disease due to AO incompatibility. In deciding management and providing further confirmation of the diagnosis, estimation of serum bilirubin level (direct-reacting and indirect-reacting) should be performed. Bilirubin is derived from the catabolism of haeme proteins produced in the breakdown of red blood cells. Unconjugated (indirect-reacting) bilirubin is converted in the liver to conjugated (direct-reacting) bilirubin, and excreted into the bile. Conjugated bilirubin is not reabsorbed once it enters the intestinal tract. In the present scenario, the level of bilirubin is insufficient to warrant exchange transfusion, but the clinical picture, combined with laboratory confirmation of an unconjugated hyperbilirubinaemia exceeding 240 umol/L, confirms the need for treatment with phototherapy. The degree of haemolysis should be defined by measuring the infant's haemoglobin, though simple transfusion for correction of the anaemia will rarely be required in AO haemolytic disease and is not needed here. In this scenario, discussion of other haemolytic or nonhaemolytic causes of neonatal jaundice is not required once the problem is correctly framed as 'jaundice on the first day of life'. As indicated in the examiners' 'Performance Criteria', the candidate is not only expected to make the diagnosis, but to provide information in a persuasive and lucid manner to justify medical intervention, while recognising the mother's disappointment. 407 075 Performance Guidelines Condition 075 Immunisation advice to the parent of a 6-week-old baby AIMS OF STATION To assess the candidate's knowledge of the currently recommended immunisation programme in Australia, knowledge of side effects and the latest information concerning claims of associations with serious medical conditions. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: • You are the mother of a six-week-old baby, Laura. • • You are an educated parent in a stable marriage. You are widely read and take an interest in popular medical articles especially during your pregnancy, as you were concerned about some information you had read and heard about immunisation and its possible adverse effects. • You are taking the opportunity of the six week visit to have these concerns clarified. Questions to ask unless already covered: • • • • • • • • • • 'What vaccines or injections will Laura need to be immunised with, up to school age?' 'What problems might she have?' 'Are there any children who shouldn't have these vaccines 9 ' 'I've heard the whooping cough vaccine can cause brain damage. Can we leave it out 9 ' 'What other side effects happen with these vaccines 9 ' 'What if we didn't give these vaccines — can't you just treat any infections with antibiotics anyway?' ‘I have a friend who goes to a homoeopath and he gives the same vaccines, but very diluted, by mouth and there are no side effects. Is that an alternative?' 'What about other alternative vaccines?' 'I've heard babies can get high fever and be guite sick after some of these injections. Can you do anything to ease the side effects?' 'I've also heard about a vaccine for chicken pox. Is this available and do you advise it? EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should give the parent a succinct and accurate regimen for the immunisation that is currently recommended, with special reference to those given at two months. If uncertain, the candidate should be aware of the current NHMRC Immunisation Guidelines and how to access them. Examiners should be aware that the recommended schedule has changed annually over the last several years as new vaccines have been introduced. In the future, combination vaccines which will reduce the number of injections are expected and small variations to the schedule will be needed to accommodate these. To reduce reliance on single suppliers, several versions of these combination vaccines are likely to be approved and thus variations as currently seen in the schedule will become more common. Because of this, candidates should demonstrate familiarity with the basic principles of the immunisation 408 075 Performance Guidelines schedule rather than detailed knowledge of precise recommendations, particularly for States other than the one in which they work. Examiners should also be aware that the level of understanding expected should match the current edition of the immunisation handbook rather than vaccines introduced subsequent to publication of the handbook. The following would generally be recommended: • At birth: Hepatitis B (hepB). • At 2 months and 4 months: Acellular diphtheria, tetanus, pertussis (DTPa); H.influenzae type B (Hib); oral or inactivated polio vaccine (O/IPV); hepatitis B (hepB); 7-valent pneumococcal conjugate vaccine (7VPCV). • At 6 months: Acellular diphtheria, tetanus, pertussis (DTPa); oral or inactivated polio vaccine (O/IPV); (hepatitis B [hepB] in NSW, QLD, SA. NT); 7-valent pneumococcal conjugate vaccine (7VPCV). • At 12 months: Measles, mumps, rubella (MMR); H.influenzae type B (Hib); meningococcus (MenC): (hepatitis B [hepB]) in VIC, WA, TAS). • At 18 months: Varicella zoster virus (VZV); 23-valent pneumococcal polysaccharide vaccine (23VPPV). • At 4 years: Acellular diphtheria, tetanus, pertussis (DTPa); measles, mumps, rubella (MMR); oral or inactivated polio vaccine (O/IPV). Examiners should note that there are slightly different recommendations for the immunisation schedule from State to State. What is being tested in this scenario is whether the candidate is aware of the general principles for DTP, Hib, polio, hepB, MMR, meningococcus, pneumococcus, chicken pox. Candidates should address specific concerns that the mother may have regarding possible side effects and the incidence of these. If the parent has no particular concerns, the candidate should discuss known side effects and how these can be reduced, but stress that these are few and minor and that vaccinations are safe. Also stress the marked decrease in the incidence of side effects with the use of acellular vaccines for pertussis. Candidates should discuss the few absolute contraindications to vaccination. These are encephalopathy within seven days of a previous DTP-containing vaccine or an immediate severe or anaphylactic reaction to vaccination with DTP. A simple febrile convulsion or preexisting neurologic disease are not contraindications to pertussis vaccine. Children with minor illnesses, i.e. without systemic illness and providing the temperature is less than 38.5 "C, may be vaccinated safely. With a major illness or a high fever, the vaccination should be postponed until the child is well. Live vaccines (MMR, oral poliomyelitis, rubella, chicken pox) should not be administered to immunocompromised patients. An anaphylactic reaction to egg is not a contraindication to MMR vaccine, but many authorities recommend that in such a case it should be administered in an area where resuscitative equipment is available and the child be observed for 4 hours. The following are NOT contraindications to any of the vaccines in the standard schedule: • family history of adverse reactions to immunisation; • family history of convulsions; • previous pertussis-like illness, measles, mumps or rubella infection; • prematurity (immunisation should not be delayed); 409 075 Performance Guidelines • stable neurological conditions (e.g. cerebral palsy, Down syndrome); • contact with an infectious disease • asthma, eczema, atopy, hay fever, 'snuffles'; • treatment with antibiotics; • treatment with locally inhaled or low dose topical steroids; • child's mother is pregnant; • child is breastfed; • history of jaundice after birth; • over the age recommended in vaccination schedule; • recent or imminent surgery; and • replacement corticosteroids. Candidates may mention the reported association of measles vaccination with autism The knowledgeable candidate will be aware that no association has been convincingly demonstrated and several studies show no link at all. Candidates should state that there is no evidence for the efficacy of alternative (homoeopathic) oral vaccines given sublingual^ Latest vaccination now available for varicella-zoster virus (the cause of chicken pox) and meningococcus should be discussed and recommended. Candidates should stress that many of these diseases are still prevalent in the community (e.g. pertussis, pneumococcal and meningococcal infections, and varicella). Candidates may suggest paracetamol for fever and pain after vaccination as necessary, including a single dose about 30 minutes prior to DTPa prophylactically and for subsequent immunisation if significant reaction with fever with first or second dose. KEY ISSUES • Knowledge of basic principles of current immunisation regimens. • Explanation and accurate nformation regarding benefits of immunisation • Exploration of parental concerns. CRITICAL ERRORS • • Candidate provides wrong advice regarding contraindications to immunisation. Recommendation or acceptance of sublingual homoeopathic vaccines. COMMENTARY This scenario is concerned with counselling a young mother on the advantages and disadvantages of immunisation. This requires of candidates a sound knowledge of the topic and an ability to give the information to the parent in a manner that gives a balanced overview, without domineering with their own personal feelings. This is a very common situation in general practice where patients will often attend to discuss with the doctor, beliefs they have, or to seek further information on a topic. Doctors should not hesitate to admit that they do not know a particular answer but should offer to seek the answer and communicate it at a later date. Updated immunisation schedules such as the one illustrated are available from paediatric hospitals. Candidates should be aware of the absolute contraindications to the standard vaccinations and also the false contraindications which are so often quoted. 410 CONDITION 075. FIGURE 1. Immunisation schedule guidelines adapted from Royal Children's Hospital, Melbourne, 2006 411 076 Performance Guidelines Condition 076 Dark urine, facial swelling and irritability in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to recognise that this child most likely has acute poststreptococcal glomerulonephritis (PSGN) which requires hospitalisation in view of hypertension and recent irritability. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You are the parent of a five-year-old boy. You are particularly concerned about the dark urine and swelling of the boy's face. Nothing like this has ever happened before. The child has never been really sick before. This illness is all very unusual and worrying. Questions to ask unless already covered: • • • • • • 'Why has this happened?' 'Will my son be all right?' 'What is going to happen now?' (If hospitalisation is recommended) 'What is going to be done to my son in hospital?' (If hospitalisation is recommended) 'What are they looking for with these tests?' 'How long will it take to get results?' If kidney biopsy is mentioned, become even more concerned. • ‘Is that really necessary?' • 'Why is blood testing not enough?' Relevant physical findings to be given to the candidate on request Resting blood pressure 145/90 mmHg. No postural hypotension. Temperature 36.5 °C. Pulse 90/min regular. Periorbital oedema present no oedema elsewhere. no ascites or pleural effusions. Cardiovascular system normal. Liver edge palpable just below the costal margin. Optic fundi normal. ENT examination normal. Urine dipstick strongly positive (++) for blood and protein. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain the cause of the child's clinical picture in terms the parent can understand, and without medical jargon. This would include that the original skin streptococcal infection (impetigo) has triggered an immune reaction of the body against the organism and that this reaction is occurring in the kidneys causing a major effect on 412 076 Performance Guidelines their function. This then leads to a fall in urine output, and salt and fluid retention that causes the swelling of his eyes and raised blood pressure. Hospital admission is desirable in view of the acute presentation and hypertension Investigations required will include blood and urine tests to confirm the provisional diagnosis of PSGN. Tests to be ordered should include: • Urea and electrolytes, creatinine, inflammatory markers — C3, C4, ASOT, DNAase B • Urine micro and culture, full blood examination Immediate management • Admission to hospital. • Strict fluid balance and restricted fluid intake • Test all urine - four-hourly blood pressure and other vital signs. • Daily weight. • Low protein, low salt/high carbohydrate diet. • Antihypertensive treatment. • Penicillin therapy may be suggested — but is not essential • Renal biopsy is not needed for diagnosis at this stage. Future management • Monitor blood pressure and renal function weekly/monthly/quarterly as needed as convalescence progresses. • Regular urinalysis (microscopic haematuria may persist for up to two years). • Long term prognosis is excellent with a very low incidence of sequelae; so positive and sympathetic reassurance is required. KEY ISSUES • Diagnosis of acute PSGN • Ability to specify appropriate plan of investigations. • Development of coherent treatment plan CRITICAL ERROR • Failure to admit to hospital COMMENTARY This scenario involves diagnosis, from clinical signs and appropriate investigations, and an empathie explanation of treatment. From the information given, the candidate should be able to arrive at the correct diagnosis and investigate and treat appropriately. Failing to do so puts the patient at risk. While classical poststreptococcal glomerulonephritis has become rare in many parts of Australia, knowledge of the condition is important in considering the differential diagnosis of this child's symptoms. 413 077 Performance Guidelines Condition 077 Fever and sore throat in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and treat a child with tonsillitis most likely due to Group A β-haemolytic Streptococcus. Some investigations to confirm this are indicated. EXAMINER INSTRUCTIONS The examiner will advise the parent as follows: You are the mother of a five-year-old boy, Peter, who has become unwell overnight with a very sore throat and has difficulty swallowing food and drink. He most likely has an acute tonsillitis which should be treated with penicillin. The candidate may suggest some basic investigations to help confirm the diagnosis. You are worried that Peter has tonsillitis, and are concerned by his high temperature. Family history Both parents are well. Father is an office-worker, mother is at home. Three-year-old sister at kindergarten is well. Your son has had no previous antibiotic reactions. Questions to ask unless already covered: 9 • 'How would he get this infection ' • 'Is he likely to get it again?' • 'What causes this infection ' • 'I've heard that this sort of infection can damage your heart or your kidneys or something - is that right?' • How long will he take to get better?' • 'Is antibiotic therapy reguired?' 9 Examination findings to be given by examiner to candidate on request A flushed child, tonsils acutely inflamed with follicular exudate, with moderately enlarged and tender cervical lymph nodes on both sides. The appearance of his oropharynx and tonsils are shown in the illustration (Figure 1). which the examiner will show to the candidate. There is no evidence of neck stiffness, no hepatosplenomegaly, rash or lymph-adenopathy elsewhere. Temperature is 40 °C, blood pressure 110/70 mmHg, respiration rate 24/min, pulse rate 110/min Tympanic membranes are normal on otoscopy. Examination is otherwise normal. 414 077 Performance Guidelines CONDITION 077. FIGURE 1. Acute tonsilitis EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should enquire as to the important clinical findings on examination allowing confident diagnosis of acute tonsillitis, most likely bacterial. A throat swab could help confirm this prior to antibiotic treatment. The candidate should be able to explain in simple terms the diagnosis and its associated complications in a manner that the parent can understand; and should also arrange for further review in a few days to ensure the expected recovery is occurring and if not, review and possibly seek other aetiologies. Explanation of diagnosis Acute tonsillitis, probably streptococcal. Reassure that with appropriate treatment this should resolve completely. Immediate management The candidate may wish to perform a throat swab for culture (appropriate but not obligatory). There is no need for any other investigations at this stage. Check whether antibiotic reaction previously, and prescribe oral penicillin. Advise the mother of need for frequent fluids. Prescribe analgesics. Although the problem might be viral and settle without antibiotics, the majority opinion would be that penicillin therapy is indicated because of the high likelihood of the diagnosis being streptococcal tonsillitis. If the candidate does not recommend antibiotic therapy the mother should ask whether antibiotics are needed. Antibiotic therapy would not only treat the streptococcal sore throat but would probably reduce the likelihood of serious poststreptococcal complications. Future management Suggest review in few days or earlier if concerned and if the child has not responded as expected. If this is the case, other aetiologies (e.g. infectious mononucleosis) should be sought. Stress that a full course of 10 days penicillin treatment is required. Indicate that viral infection may cause similar features, as might acute infectious mononucleosis. 415 077 Performance Guidelines KEY ISSUES • Appropriate examination interpretation, with appropriate diagnosis. • Adequate treatment plan. • Appropriate explanation. CRITICAL ERRORS • • Failure to consider streptococcal tonsillitis as the diagnosis. Failure to discuss followup and screening for other conditions if there is no initial improvement. COMMENTARY This scenario assesses the ability of the candidate to come to a logical conclusion as to the most likely diagnosis (acute bacterial tonsillitis) in this situation based on the information provided and knowledge of the natural history of disease processes. The scenario tests diagnostic acumen by showing how several conditions can be safely excluded because of the history and the time frame and gives scope to considering other diagnoses if the provisional diagnosis is not confirmed. 416 2-F: The Obstetric Consultation and Gynaecologic Roger J Pepperell 'Man endures pain as an undeserved punishment; woman accepts it as a natural heritage.' Anonymous Although in clinical practice obstetric and gynaecologic consultations may Although it would be unusual for involve a consideration of a complex set of symptoms and history which can you to have to examine the include relevant past history, medical history and social history, the clinical abdomen of a pregnant woman, or scenarios used as part of the MCAT examination are much more focused perform a pelvic examination in the and restricted to fit in with time constraints. The scenarios reflect conditions actual clinical MCAT examination, which should be able to be appropriately assessed and managed by a final you clearly need to know how to do year medical student or a doctor working as an intern in a public hospital or in such clinical examinations and may community practice. well need to do such assessments Some involve the candidate taking an appropriately focused history to enable on models which have been the diagnosis to be made. Because only eight minutes are allocated specifically designed and produced for the assessment, and the history-taking will represent only a fraction of the for this purpose. total time spent, the history-taking must concentrate on relevant issues and not be generalised, verbose and largely irrelevant. Some of the stations involve the candidate requesting the examination findings they would look for if assessing such a patient to allow the examiner to assess whether the candidate knows what examination findings are particularly relevant and important in assisting the candidate make the correct diagnosis in this circumstance. Where investigations are required to assist in making a diagnosis or starting treatment, the candidate is again expected to show perspective rather than ordering a large number of irrelevant and inappropriate tests. If the candidate needs to advise the patient on the initial management plan, this should be provided to the patient in lay language, in terms she can readily understand, with perspective and with empathy and compassion. In obstetrics and gynaecology, all of the options of management which might be appropriate need to be provided to the patient, to enable her to decide which option she will accept, and ultimately to give the clinician informed consent to proceed with the option chosen. In clinical practice today, particularly in obstetrics and gynaecology, communication with the patient, and if appropriate with her partner, is mandatory, and unless done in a manner which is acceptable to the patient, can result in the candidate being reported to the relevant medical board or health complaints commission. Where the clinician is not prepared, on religious grounds, to follow through a particular treatment which might be appropriate, such as a pregnancy termination because the fetus has a lethal congenital abnormality, the clinician has a responsibility to explain the options available to the patient, and has an obligation to offer to refer her to an appropriate physician who would provide the treatment she has accepted as being most appropriate. Personal beliefs should not restrict the matters discussed with the patient although they may affect what the clinician is actually prepared to do in terms of actual management. 417 2-F The Obstetric and Gynaecologic Consultation Clinicians must preserve a nonjudgmental and supportive approach in discussion and must not impose their own religious or other nonmedical views on a concerned patient. Although it would be unusual for candidates to have to examine the abdomen of a pregnant woman, or perform a pelvic examination in the actual clinical MCAT examination, they clearly need to know how to do such clinical examinations and may well need to do such assessments on models which have been specifically designed and produced for this purpose. The various scenarios cover aspects of the female reproductive system including normal development and disorders of uterus, tubes, ovaries, vagina, fertility and contraception, hormonal influences, pregnancy, labour, abortion, obstetrical toxaemia and haemorrhage, menopause, pelvic infection, vaginal discharge, dyspareunia, haemostasis and bleeding disorders. Roger J Pepperell 418 2-F The Obstetric and Gynaecologic Consultation 2-F The Obstetric and Gynaecologic Consultation Candidate Information and Tasks MCAT 078-082 78 Breech presentation in labour at 38 weeks in a 25-year-old woman 79 Vaginal bleeding in a 23-year-old woman 80 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 81 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 82 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles 419 078-079 Candidate Information and Tasks Condition 078 Breech presentation in labour at 38 weeks in a 25-year-old woman CANDIDATE INFORMATION AND TASKS You are working in the Emergency Department of a general hospital. This patient is 3 25-year-old woman in her second pregnancy, at 38 weeks of gestation and is in early labour. Vaginal examination unexpectedly reveals a breech presentation: the legs of the fetus are apparently both extended. The cervical dilatation is 4 cm. The previous pregnancy resulted in a normal cephalic vaginal delivery of a 4 kg baby at 41 weeks of gestation. The current pregnancy has been uneventful to date and the fundal height is 38 cm above the pubic symphysis at the time of admission in labour at 38 weeks. YOUR TASK IS TO: • Advise the patient of the possibilities in regard to subsequent management and the pros and cons of these. You may take any further relevant history you require, but do this briefly as the essential features have been provided above. The Performance Guidelines for Condition 078 can be found on page 424 Condition 079 Vaginal bleeding in a 23-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. Your next patient is a 23-year-old nuliiparous woman who has been trying to conceive, and believes she is pregnant. She has developed vaginal bleeding after eight weeks of amenorrhoea. YOUR TASKS ARE TO: • Take any further relevant history you require. • Ask the examiner about the findings you would look for on general and gynaecological examination and the results of any tests you would expect to be available at the time you are seeing the patient. • Advise the patient of the probable diagnosis and subsequent management you would institute, including any further investigations you would arrange. The Performance Guidelines for Condition 079 can be found on page 427 420 Candidate 080-081 Information and Tasks Condition 080 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) CANDIDATE INFORMATION AND TASKS Your patient is a 30-year-old woman who is taking the oral contraceptive pill (OCP). She has come to see you in a general practice because she did not have a period following the last two courses of pills YOUR TASKS ARE TO: • Take a further focused history. • Ask the examiner about the findings you wish to elicit on general and gynaecological examination. • Advise the patient of the diagnosis and subsequent management (including any investigations you would arrange). The Performance Guidelines for Condition 080 can be found on page 430 Condition 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman CANDIDATE INFORMATION AND TASKS Your next patient is a 26-year-old woman who is now at 37 weeks of gestation in her first pregnancy. You have been looking after her pregnancy in a shared care arrangement in a general practice setting. All has been normal, and at 36 weeks you ordered a vaginal and rectal swab for Group B streptococcal (GBS) testing. This test has shown GBS organisms were detected in the lower vagina. She has returned to receive the results and any implications if the test is positive. YOUR TASKS ARE TO: • Advise the patient of the results of the GBS test. • Advise her about the subsequent management you would advise There is no need for you to take any further history or to request any examination findings or investigation results from the examiner The Performance Guidelines for Condition 081 can be found on page 432 421 082 Candidate Information and Tasks Condition 082 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles CANDIDATE INFORMATION AND TASKS Your patient is a 25-year-old married nulliparous woman who presents to you in a general practice with vaginal bleeding after eight weeks of amenorrhoea. Her cycles are often irregular with the periods occurring at intervals of 4-8 weeks. YOUR TASKS ARE TO: • Take a further focused history. • Ask the examiner about the findings you wish to elicit on general and gynae- | cological/obstetric examination. • Advise the patient of the probable diagnosis and subsequent management, including any investigations you would arrange. The Performance Guidelines for Condition 082 can be found on page 434 422 2-F The Obstetric and Gynaecologic Consultation 2-F The Obstetric and Gynaecologic Consultation Performance Guidelines MCAT 078-082 78 Breech presentation in labour at 38 weeks in a 25-year-old woman 79 Vaginal bleeding in a 23-year-old woman 80 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 81 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 82 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles 423 078 Performance Guidelines Condition 078 Breech presentation in labour at 38 weeks in a 25-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately advise a patient concerning the advantages and disadvantages of vaginal breech delivery or Caesarean section when the fetus is found to be presenting by the breech in early labour at 38 weeks of gestation. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Breech presentation has not previously been diagnosed and all your tests and progress have been normal, as was your previous pregnancy. Opening statement: 'So it is a breech, doctor. Does that cause any problems?' List of appropriate answers to questions by the candidate: • Your desires in relation to mode of delivery are as follows: ~ You would prefer vaginal delivery if possible but would accept Caesarean section if this is recommended as necessary or very much more preferable. ~ You had no problems with delivery of the first baby at 41 weeks of gestation. Forceps delivery was not required. ~ Only a very small episiotomy was necessary, despite the baby weighing 4 kg. ~ Your antenatal course in this pregnancy has been normal. ~ There is no family history of diabetes or other problems. Questions to ask if not already covered: • 'What are my options regarding delivery?' • 'Are there any significant risks to the baby or me if I have my baby normally?' • ‘What are the potential problems to the baby of vaginal delivery versus Caesarean section?' Examination findings The candidate may ask for specific components of the examination, but no additional findings in addition to those outlined in the candidate's instructions need to be given. Investigation results None is to be provided or available. 424 078 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to patient (the candidate should convey the substance of what follows to the patient): • Diagnosis - breech presentation in early labour. The type of breech presentation (extended legs) is a favourable one. and as she is keen to avoid a Caesarean section delivery, an attempt at vaginal breech delivery would be appropriate. • X-ray pelvimetry is unnecessary in view of the size of her previous baby (4000 g) which was born at 41 weeks of gestation. Although second babies are likely to be bigger than the first one. the current baby is being delivered three weeks earlier than the preceding one which means it should be smaller than the previous child • Cardiotocography (CTG) monitoring is necessary in association with breech presentation as there is an increased risk of cord prolapse associated with this abnormal presentation. Vaginal examination as soon as the membranes rupture, to exclude cord prolapse and confirm the type of breech presentation, is also mandatory. • As she is in labour, ultrasound examination will probably be difficult to arrange urgently Had the breech presentation been diagnosed prior to labour, ultrasound would have been of value to check fetal size, type of breech presentation, and whether the fetal neck was extended. • Caesarean section would be indicated if there was slow progress of labour, or if breech extraction was considered required to effect delivery because of fetal distress or inadequate progress, or a significant CTG abnormality occurred in the first stage of labour. • A successful outcome of labour can be anticipated with the findings which are evident in this patient. However about 3-5% of patients do have problems during the latter stages of delivery due to difficulty delivering the legs, arms or head. KEY ISSUES • Ability of the candidate to advise and counsel a patient of the current options in regard to breech delivery by vaginal or Caesarean delivery. CRITICAL ERRORS • Failure to advise of the appropriate risks of vaginal breech delivery • Recommending that external cephalic version should be attempted despite the fact she is in labour. • Indicating to the patient that vaginal breech delivery is absolutely contraindicated despite her desires. COMMENTARY Approximately 4% of all babies present by the breech, and vaginal delivery is safe in selected patients. This particularly applies where the baby is of normal size (between 2.5 and 4.0 kg); the breech presentation is a complete breech or a breech with extended legs: the fetal neck is not extended; where labour occurs spontaneously and progresses at the appropriate rate; and where the pelvic dimensions are normal. 425 078 Performance Guidelines There are risks to the baby of vaginal delivery however, and the risks are higher than when the baby is delivered by Caesarean section. These aspects were well reported in the Term Breech Trial published in 2000. In this patient it would be appropriate to recommend a trial of vaginal delivery with appropriate monitoring. Caesarean section recommendation at this stage would be appropriate depending on the patient's responses and concerns after discussion. The recent trial of vaginal breech delivery as compared to Caesarean section delivery clearly showed the risk of vaginal delivery was higher than that associated with delivery by Caesarean section. Despite this, and the general recommendation that all babies presenting by the breech should be delivered by Caesarean section, some patients will still prefer a vaginal delivery. If the candidate suggests external cephalic version should be attempted at this time, when she is clearly in labour, this is contraindicated and clearly WRONG. Common problems likely with candidate performance are: • Failure to advise of the actual care in labour which would be given. • Failure to advise that the risk of vaginal breech delivery is higher than that of delivery by Caesarean section with the risk being approximately doubled. 426 079 Performance Guidelines Condition 079 Vaginal bleeding in a 23-year-old woman AIMS OF STATION To determine the ability of the candidate to assess and appropriately manage a patient in early pregnancy with eight weeks of amenorrhoea which was then followed by vaginal bleeding. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • Your periods are usually regular and normal and your last menstrual period was eight weeks ago. You think and hope that you are pregnant; this is your first pregnancy. You checked via a chemist two weeks ago, and had a urine pregnancy test which was positive. • You and your husband have been trying to conceive since stopping the pill. • You ceased the oral contraceptive pill (OCP) five months ago, and have had regular menstrual cycles since then until recent amenorrhoea. • No bleeding since last menstrual period until yesterday. Light loss then. Total loss is much less than a normal period. Bleeding seems now to have stopped. • You have minimal pelvic discomfort. • Breasts sore and nipples tender for last six weeks — no reduction in these symptoms recently. • Blood group O Rh negative. Questions to ask if not already been covered: • 'Will my baby be OK?' • 'Can you give me something to make sure I don't lose this pregnancy?' • 'What will happen if I miscarry?' Physical examination findings to be given to the candidate on request General examination Pulse 80/min and regular. Blood pressure 120/80 mmHg, not distressed Pelvic examination cervix closed and firm, no blood in vagina. Uterus retroverted, enlarged to the size of an eight-week pregnancy. Adnexae no mass or tenderness Previous investigation results to be given on request Pregnancy test positive previously, confirmed on spot urine testing now. Blood group O, Rhesus negative 427 079 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to Patient The substance of what follows should be communicated to the patient in lay terms. • She needs an ultrasound of the pelvis to enable the pregnancy to be sited, to confirm the gestation, to check the sac size, liquor volume, and the presence or absence of fetal heart activity. These findings would be expected to confirm and define the diagnosis of threatened abortion (miscarriage). The candidate should ask for these investigations to be done and should explain to the patient that if everything was normal, the pregnancy was in the uterus, and the fetal heart activity was present, the diagnosis is a threatened miscarriage, with a good prospect of a continuing viable pregnancy. • Other investigations required: checking the haemoglobin and check indirect Coombs as patient is Rh negative. If indirect Coombs is negative, give anti-D if abortion occurs. (Anti-D is often not available in Australia for a threatened abortion). Immediate Management • Treat conservatively and rest. No specific therapy is effective in improving the pregnancy outcome. • Chance of successful outcome of pregnancy — prior to performance of the ultrasound the chance of success was only 50%. Providing the ultrasound examination is perfectly normal, the chance of a successful pregnancy is somewhere between 90% and 95%. KEY ISSUES • Ability to define the diagnoses needing to be considered in the presence of eight weeks of amenorrhoea. • Ability to appropriately investigate a woman with these symptoms. CRITICAL ERRORS • Failure to confirm pregnancy by pregnancy testing • Failure to arrange ultrasound to check site and viability of pregnancy. • Failure to consider use of anti-D in view of Rhesus negative state. 428 079 Performance Guidelines COMMENTARY In all cases of bleeding in early pregnancy, the most critical examination findings are those of uterine size, the state of the cervix and the presence or absence of pelvic tenderness. The reliance upon ultrasound examination alone is inappropriate. Ultrasound in this case will enable the viability of the pregnancy to be assessed, thus enabling the patient to be reassured with a degree of confidence. The other aspect of this case is the fact that the patient's blood group is O Rhesus negative. Common problems likely with candidate performance are: • When taking the history, not being focused enough to the actual problem, but asking for information such as irrelevant past history, social history etc. This just takes time to do and reduces the time available for the remaining tasks. • Failure to examine the patient appropriately (cervical closure or opening status was not requested, uterine size was not asked for. possible signs suggesting an ectopic pregnancy were not asked for). • Failure of candidate to advise the patient of the likely prognosis for this pregnancy, following performance of the ultrasound examination and assuming confirmation of normal findings. 429 080 Performance Guidelines Condition 080 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) AIMS OF STATION To assess the candidate's ability to take an appropriate history and to assess findings to define the cause of amenorrhoea developing while on the OCP, and then to appropriately counsel the patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • You were married six years ago. You have been on the OCP since then. You will probably want to conceive in about two years time. • Your menarche was at 14 years of age. When not on the OCP, your cycles were 28 days long and you bled for three days, but lightly. • You have been on Microgynon 30® for six years. Initially the periods were normal, but they have become lighter and lighter. About six months ago the periods were only lasting for one day. Since then they have been shorter and lighter, and no period occurred at all at the end of the last two packs of pills. You have not missed any pills in the last six months (give the information of progressive reduction in menstrual loss only in response to specific request from the doctor). • No problems with sexual activity, usually active 3-4 times per week. • No recent nausea, vomiting, breast enlargement, or nipple discomfort (so nothing to suggest a pregnancy). • No relevant past, medical, surgical, family or social history You have never had a curettage. Questions to ask unless already covered: • 'Does it matter if I don't have a period at the end of the pill month?' • 'Will I be able to have a baby when I want to do so?' Examination findings given to the candidate on request: General and abdominal examination: normal 430 Speculum examination: normal Pelvic vaginal examination: uterus retroverted and of normal size and mobility Adnexae: normal 080 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: • The diagnosis is endometrial atrophy due to the progestogen component of the OCP M (Microgynon 30 ). • There is no real problem with the progestogen-induced secondary amenorrhoea except for the anxiety it produces in the patient about whether she is pregnant. When the oral contraceptive pill is ceased, all will return to normal, including her fertility. • A pregnancy is most unlikely but a p-hCG estimation should be done to confirm this for the patient. • If she is really worried about the amenorrhoea, the pill could be changed to either a higher-oestrogen-containing pill (such as Microgynon 50®), or a triphasic pill (Triquilar®), and the menstrual loss may increase. The other option would be for her to have a break from the oral contraceptive pill and use some other method of contraception. If the assessment of oestradiol, FSH, LH or prolactin levels is suggested, this would suggest little or no insight into the cause of the amenorrhoea or the effect of the OCP on these hormone test results. KEY ISSUES • Ability to diagnose the cause of amenorrhoea when on the OCP. • Ability to counsel the patient appropriately. CRITICAL ERROR • Failure to perform a pregnancy test (/J-hCG) to exclude the unlikely possibility of a pregnancy occurring whilst taking the OCP. COMMENTARY The reduction in the amount of of withdrawal bleeding whilst a patient is on the oral contraceptive pill is not uncommon. The cause is due to a progressive endometrial atrophy (progestogen -induced) over the period of time the patient is taking the pill. The key to the situation is generally the history of gradual reduction of menstrual flow over a period of time prior to the complete cessation of withdrawal bleeding. Whilst the likelihood of pregnancy is very low, a pregnancy test is appropriate to reassure the patient — as conception is possible whilst a patient is taking the oral contraceptive pill. Common problems likely with candidate performance are: • Inadequate history concerning the progressive reduction in the menstrual loss whilst on the OCP. • Inadequate advice concerning the natural history of this symptom after cessation of the OCP. 431 081 Performance Guidelines Condition 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman AIMS OF STATION To assess the ability of the candidate to counsel a patient concerning the significance of the finding of vaginal GBS organisms late in pregnancy and the subsequent management required. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You will be advised of the results of the recent GBS screening and what the doctor advises in regard to treatment. You have no history of allergies to penicillin. Questions to ask unless already covered: • 'What are these GBS organisms?' • 'Why are these bugs there?' • 'Will these bugs do any harm?' • 'Why don't you just give me antibiotics now and get rid of them?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: • The significance of GBS organisms in the vagina is: ~ the organism will not usually produce a problem for the mother, and 10-15% of pregnant women may carry this organism, at this stage of the pregnancy; ~ the risk of the baby being colonised is 40-50%, if mother is GBS positive, and delivers vaginally, and is not given antibiotics in labour; ~ the risk of the baby becoming 'infected' under the above circumstances is 1% but this infection can be very severe; ~ by the time the neonatal diagnosis is able to be made clinically in the infant, it may be too late to treat effectively and mortality is high; and ~ the important principle is therefore to prevent the baby getting infected. • GBS cannot be eradicated from the vagina with certainty by treating with penicillin or amoxycillin during pregnancy. • Having found that she is GBS positive, it becomes important to treat the mother in labour, to prevent fetal infection. Although a low risk situation, consensus best practice is to treat all GBS positive patients during labour. Treatment with parenteral penicillin should be commenced in labour or if membranes rupture prior to onset of labour. The antibiotic crosses the placenta and protects the baby. It is extremely unlikely that the baby will become infected under such a regimen. • Some obstetric units only give antibiotics to 'high risk' patients in labour, such as those in premature labour, those with premature rupture of the membranes, or where there is a maternal fever. Candidates should be aware that such a management protocol does however put about 0.5% of babies at significant risk where the mother is GBS positive. 432 081 Performance Guidelines • If allergic to penicillin, use erythromycin. • Parenteral penicillin to the baby after birth is optional unless signs of infection ensue or in high risk situations (such as prolonged ruptured membranes). KEY ISSUES • Defining the management plan. • Counselling the patient as to why antibiotic treatment in labour is recommended. CRITICAL ERRORS • Failure to advise patient of the significance of GBS organisms to mother and her baby. • Failure to advise antibiotic treatment of the pregnant woman if the membranes rupture, or when labour commences, to protect the fetus from the risk of severe infection. COMMENTARY This case illustrates the now almost universal practice of routinely screening all pregnant women at 34-36 weeks gestation for the presence of GBS colonisation of the vagina. It is important to know that approximately 10-15% of pregnant women will be colonised with Group B streptococcus organisms at this stage. The critical aspect of the management of this situation is that antibiotics are given to the mother only when she presents in labour and not at any time during the pregnancy when the colonisation is discovered. It is important to counsel the mother that colonisation with this organism poses tittle, if any, risk to the mother but may affect the baby. It is important to stress the serious significance of Group B streptococcal infection in the neonate. Common problems likely with candidate performance are: • Recommending administration of antibiotics during pregnancy (antenatally) and assuming that such treatment would eradicate the GBS organism. • Believing that treatment of an infected baby is so effective, that prophylactic antibiotic therapy to the mother in labour is unnecessary. • Believing antibiotic treatment of the mother is necessary now because of the adverse effects GBS organisms will have on her. 433 082 Performance Guidelines Condition 082 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles AIMS OF STATION To assess the candidate's ability to appreciate the significance of vaginal bleeding in a woman with irregular cycles where early pregnancy is a possibility. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • You are a 25-year-old married woman without previous significant illness. • Your last menstrual period was eight weeks ago and was normal. Your periods are often irregular with cycles varying between four and eight weeks duration. • You do not usually identify midcycle mucus to recognise the time of ovulation. You have noticed some breast discomfort and nausea recently. • The current bleeding is minimal and bright in colour. It commenced yesterday spontaneously and is like day two of the period. No tissue has been passed. The bleeding was not related to any sexual activity. • No abdominal or pelvic pain has been associated with the bleeding. • You use condoms for contraception. You would not mind if you were pregnant although you were not planning to become pregnant for another couple of years. No previous pregnancies. • No past medical or surgical history of relevance. No medications. • Last Pap smear was six months ago and was normal. You have never had an abnormal smear test. • Your blood group is O Rh positive. Questions to ask unless already covered: • ‘Do you think I'm pregnant?' • 'If I am pregnant, why am I bleeding? Will the baby be OK?' • ‘Is there any treatment to stop the bleeding?' Examination findings to be given to candidate on request Patient looks well but is overweight (90 kg) Blood pressure 120/80 mmHg Pulse 70/min Abdominal examination no mass or viscus palpable, no tenderness Speculum cervix closed and normal; some minimal blood loss Pelvic vaginal examination uterus is not obviously enlarged, and is retroverted Adnexae 434 normal, no tenderness 082 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The history needs to define the normal cycle regularity and length, enquire about pain, and enquire about symptoms suggestive of pregnancy. The candidate should advise along the following lines: • The diagnosis is unclear from the history and examination. Investigations will need to be done to confirm or exclude pregnancy and then define whether the pregnancy, if present, is progressing satisfactorily. An appropriate plan of investigations would be: • β-hCG to check if pregnant. • If β -hCG is negative, the diagnosis is just a late period, therefore observe. If periods remain irregular, hormonal tests to see if fertility treatment is required may subsequently need to be considered (such as FSH, LH, PRL, TFTs). • If β -hCG is positive, check β -hCG level to assess usefulness of ultrasound examination. • If β -hCG is positive and greater than 1000 U/L, she needs an ultrasound to check the site and normality of the pregnancy, and the gestation and due date. • When all of these results are known it will be necessary to review her. The prognosis regarding the pregnancy can be discussed when it is known what the results are. • If she is pregnant, the diagnosis is probably a threatened miscarriage, and no hormonal therapy is likely to be of value. KEY ISSUES • Ability to evaluate a patient with bleeding after amenorrhoea. • Ability to confirm or exclude pregnancy as a cause. CRITICAL ERRORS • Failure to consider non-pregnancy as well as pregnancy causes. • Failure to arrange ultrasound if pregnant and β -hCG is greater than 1000 U/L. COMMENTARY This is a situation where bleeding occurs some eight weeks after a previous period but where the patient often has an irregular cycle when amenorrhoea may last up to eight weeks. It is therefore important to differentiate whether this woman could be pregnant, or whether she simply is having one of her longer, irregular menstrual cycles. Therefore, symptoms suggesting pregnancy, and tests for pregnancy, must be discussed in the management of this case. It is also important to remember that where pregnancy is proven not to exist, further investigations for the irregular menstrual cycles should be considered. Common problems likely with candidate performance are: • Failure to take an adequate history to define the previous menstrual cycle frequency and to check for symptoms of pregnancy. • Failure to describe appropriate management and investigative plans. • Failure to advise appropriate endocrine tests if she is found to be not pregnant and the irregular cycles persist. 435 2-G: The Psychiatric Consultation Frank P Hume 'The care of the human mind is the most noble branch of medicine.' Aloysius Sieffert (c. 1858) A psychiatric assessment is a structured clinical conversation, complemented by observation and mental state examination and supplemented by a physical examination and the interview of other informants when appropriate. After the initial interview, the clinician should be able to establish whether the individual has a mental health problem or not, the nature of the problem and a plan for the most suitable treatment. A thorough initial assessment may take an hour or more to complete, but when time is short it may be necessary to focus on the immediate problems at first and schedule a longer followup appointment to round off the evaluation. In the context of the AMC assessment, with the time constraints imposed, the tasks are split and focused to allow completion in the time period allowed. For trust and rapport to develop, the clinician must display tact, empathy and genuine respect for the individual's dignity throughout the interview. A private setting is crucial with comfortable seating and ambience and freedom from interruptions. Confidentiality is central, given the personal and intimate nature of the material to be talked about, but it is not absolute when the safety and interests of the patient or others are at issue, or in medicolegal consultations. Comprehensive and contemporaneous case notes are essential. Whenever possible, notes should be taken during the interview rather than relying on recall afterwards. However note-taking should be delayed at the outset until the patient feels that he or she has the clinician's attention. If the patient is highly anxious, agitated, hostile or paranoid it maybe sensible to defer note-taking until after the interview and limit the amount of factual information at the first interview. Clinicians should begin by welcoming patients by name, introducing themselves if unknown, greeting companions if the patient is accompanied and explaining how long they may have to wait and whether they will be interviewed. It is usual to interview the patient alone first and other informants afterwards, with the patient's consent. Let the patient know from the outset how long the interview is likely to take and that you will be taking notes at some stage (which are confidential) Begin with basic census data: contact details, education, occupation and languages spoken. If the interview is to be conducted in a language other than English, then a trained health service interpreter should be used rather than an accompanying relative or friend, depending on the sensitivity and intimacy of the information to be gathered. Experienced interpreters will repeat patient's replies word for word, even if they are obviously delusional or thought-disordered, whereas well-meaning relatives may paraphrase or substitute replies to compensate for confused or disordered responses. When using an interpreter, direct your attention and your enquiries to the patient and not the interpreter. The interview should commence with the history of the presenting complaint by asking an open-ended question such as 'please tell me about your problems in your own words'. The patient should then be allowed to talk spontaneously and without interruption for several minutes, with the clinician maintaining appropriate eye contact, paying attention to the factual content whilst simultaneously monitoring the patient's verbal and nonverbal behaviour. Encouraging the patients to 'go on' or 'tell me more are simple strategies to put them at ease, as are nodding, leaning forwards, expressing concern or repeating key 436 2-G The Psychiatric Consultation phrases, for example, ' s o y o u r s l e e p p r o b l e m h a s b e e n g e t t i n g w o r s e ? ' Avoid using specialised language: for example, anorexia, insomnia, anhedonia. Comments which make patients realise that they are being listened to and understood will increase their confidence and deepen rapport. As the interview unfolds, then more directive questions aimed at clarifying symptoms and their evolution are used, asking for more specific examples of symptoms or experiences Interviewing is an active and dynamic process: initial hypotheses or rough ideas are modified continuously as more information is collected. When there is time pressure or urgency to make treatment or admission decisions, then the clinician may need to be more active or directive from the beginning and use more closed questions (requiring just 'yes' or 'no' answers) Good clinicians should be able to: • put an anxious patient at ease; • gain sufficient trust to encourage an unwilling or suspicious patient to discuss relevant issues by displaying tact, patience and encouragement: • be comfortable, tolerant and empathie when a patient becomes tearful during the interview; • know how to set limits if patients become angry, hostile or abusive; • recognise and respect patient-clinician boundaries especially with dependent, disinhibited, overfamiliar or adulatory patients; • politely interject and refocus garrulous patients, explaining that because of time restraints it may be necessary to break into their flow of conversation from time to time to concentrate on the points that are important for planning treatment: • rapidly identify patients who are demented, disorganised, disorientated, intoxicated, grossly psychotic or dysphasic and for whom other informants will be imperative; and • become aware of and monitor their own countertransference responses to particular patients. By being aware of your own prejudices, weaknesses, blind spots and personal vulnerabilities, and recognising when patients arouse strong feelings of anger, boredom sexual excitement or ' r e s c u e ' fantasies in you, you are accordingly less likely to react inappropriately to them A psychiatric assessment differs from other medical interviews in that more attention needs to be paid to the patient's psychological and social influences. Accordingly, patients' cultural and spiritual backgrounds, formative influences, important relationships, significant life events and their reactions to them; their attitudes, values and beliefs about themselves, other people and the world may all be explored in the course of an assessment. A vertical time line can be used to summarise key events in a person's life from what follows (which is not comprehensive). After the history of the present complaint has been established, then the family history should be reviewed with a family tree or genogram developed as far back as the grandparents. The quality of the relationship of each family member with the patient and its stability over time, parental occupations, family status and atmosphere, familial diseases and illnesses, family psychiatric disorders (and treatment) should all be recorded. 437 2-G The Psychiatric Consultation The patient's personal history may begin with conception, but there may have already been significant family or parental events that have occurred that will influence their development and shape their destiny (e.g. the prior death of siblings, maternal rape, incest, immigration, domestic violence, IVF, the Holocaust). • • Maternal pregnancy and birth: abnormalities, early development and nutrition, milestones. Childhood milieu: separations, illnesses and hospitalisations: anxiety traits and behavioural problems; education and schooling, learning difficulties, experience of bullying, examination success and age of leaving school. • Adolescent pressures: puberty, peer groups, rebelliousness, drug and alcohol taking, fantasy life, psychosexual identity and dysphoria, diet and exercise. • Occupational history in chronological order: training, competence, satisfaction, ambition, experience in armed forces or war. • Marital history: length of courtship; age, occupation and personality of partner: quality and stability of relationship, fidelity, previous relationships, divorce, separations, violence or abuse. • Psychosexual development from childhood: sexual orientation, sexual dysfunction, deviations or fetishes, satisfaction, current libido, contraception. • Children: stillbirths, miscarriages, terminations, childhood deaths, age, sex, health and temper tantrums of the surviving children, attitudes to children and further pregnancies. • Past medical history: should include significant childhood illnesses which may have affected brain development or function; operations, hospitalisations, accidents; menstrual or menopausal symptoms and chronic physical illnesses including fatigue, eating disorders, obesity, neurological disorders, head injury. Previous mental health: includes self-harm, mood disorder, anxiety symptoms, somatic concerns, behaviour disorders and insomnia, with details about treatment or not; duration and severity of symptoms and periods of hospitalisation and outcome. • • Use and abuse of drugs and alcohol: includes tobacco, caffeine, cannabis, stimulants, sedatives, analgesics or narcotics and whether prescribed or not; and the chronological history of use and the quantities involved and patterns of usage over time, attempts to give up and their effects on health, relationships, work and finances. Gambling history should also be explored. • Forensic history: includes delinquency, arrests, convictions, imprisonment, probation and any history of violence, assault or property damage including fire setting and arson. • Current life situation: involves a description of family, housing, social, work and financial circumstances. Relationships with neighbours, peers and colleagues, friends and relatives, employers and superiors. Recent life stresses, bereavement, losses, disappointments, promotions and the patient's reaction to them. Personality refers to the habitual attitudes, behaviours and physical characteristics that define a person as an individual to oneself and others. Psychiatric disorders may change a person's personality, thus other informants, as well as the patient, can help to describe the following: • Attitudes to others: in social, family, work and sexual relationships. • Attitudes to self: e.g. vain, critical, self-conscious, realistic, self-critical. • Moral and religious attitudes: e.g. rigid, permissive, and rebellious. • Predominant mood: and whether stable or changing. 438 2-G The Psychiatric Consultation • Leisure activities: hobbies and interests; creative, physical, solo or team. • Fantasy life: includes daydreams and nightmares. • Resilience: in the face of adversity. It is neither essential nor desirable to enquire exhaustively about all of the above with each patient. Common sense and experience should inform the clinician about what is relevant to each patient as a picture emerges during the interview. In structured assessments at undergraduate level, scenarios must be selective and focused with clear aims and guidelines, to enable appropriate candidate assessment over a brief eight minute doctor-patient encounter. MENTAL STATE EXAMINATION Mental state examination is a History-taking deals with the past while mental state systematic review of the examination is a systematic review of the patient's present patient's present symptoms symptoms and observed behaviour during the interview. It is a and observed behaviour cross-sectional view of the patient and is one of the essential during the interview. It is a elements of psychiatric practice. The principles of the mental cross-sectional view of the state assessment can readily be incorporated into the patient and is one of the examination of any patient. essential elements of Recording mental state begins with: Appearance and behaviour psychiatric practice. The principles of the mental state assessment can readily be A comprehensive, accurate and lifelike word-picture of how the patient looks in terms of appearance, body size, incorporated into the grooming, dress, posture, movement and facial expressiveness. Behaviour refers to cooperation, body language and gestures, psychomotor function and general activity and social relatedness during the interview. Orientation, mood, anxiety, hallucinations and medication may all influence appearance and behaviour. Speech The rate, volume, quality, quantity and tone of speech are recorded. Dysarthria or dysphasia are noted. The form of the patient's talk is considered rather than the content: spontaneity, pressure, slowness, hesitancy, coherence, looseness, response latency unusual sentence construction e.g. Yoda the Jedi in Star Wars, neologisms (made up words), repetitions and distractibility. Mood and affect Mood refers to a person's usual or longterm feeling state. Affect is a more short-term and immediate feeling state and refers to what is observed by the clinician during the interview. ‘Mood is to affect as climate is to weather’. Clues to mood assessment arise from the patient's appearance, mobility, posture and behaviour. Patients could be asked How do you feel in yourself?' or 'What is your mood like?' or ‘How about your spirits?' To assess depression ask about unhappiness, sadness, tearfulness, pessimism about the present, shame or guilt about the past and hopelessness about the future. 439 2-G The Psychiatric Consultation To assess suicidal ideation, begin with the first question, and then progress tactfully: 'Have you ever felt so bad/desperate that you have wanted to end it all?' 'Have you ever thought of harming/or actually harmed... yourself?' 'Do you feel unsafe at the moment?' 'Do you feel desperate enough to kill yourself?’ ' Do you think you are suicidal?’ 'Do you have a 'Plan B'?' Asking about suicidal ideation or plans does not make patients suicidal, nor does it put the idea into their heads. Patients who are depressed and suicidal may be alarmed and frightened by their thoughts and are relieved that someone cares enough to ask what they may be thinking about. Most suicidal patients do not want to kill themselves and find the thoughts repugnant, but may feel it is the only solution to their anguish. Some genuinely suicidal patients may deny being suicidal when asked, because they are determined to succeed and do not wish to be thwarted or prevented from doing so. To assess elation or hypomania ask 'Do you ever/often feel in unusually good spirits?' 'Do you ever/often feel on top of the world or full of energy?' 'Do you ever/often get racing thoughts?' 'Do you ever/often go on uncontrolled spending sprees that leave you in debt?’ 'Do you often feel unusually confident, inventive, fabulous or famous?' Other mood states that may be specifically enquired about include anxiety, anger, irritability, envy, suspiciousness and perplexity. The range of mood should be described as normal, increased, labile, restricted or blunted. Also note whether it is constant or stable. Appropriateness of affect means that the current emotional expression matches what is being said at the time. Depersonalisation and derealisation experiences are difficult for patients to describe. They may describe feeling unreal or detached, emotionless and numb, or as //'they are acting a part or being like a robot. Alternatively they may describe their environment as colourless, lifeless, artificial or cartoon-like. The feelings may vary from mild to severe, but are always seen as alien, unwanted and unpleasant. All or any part of the body may be involved and the feelings may be intermittent or persistent. They are usually accompanied by anxiety and/or depression. Thought form Abnormalities of thought can only be inferred from what patients say or write and may be influenced by mood or psychosis. Depressed patients may have slowed speech with no rhythm or cadence and only give limited or monosyllabic replies after a pause and with a limited range of topics or themes. Manic patients speak very rapidly and their train of thought may shift repeatedly (flight of ideas). They may be difficult to interrupt and their flight of ideas may be triggered by a pun or a clang association — where the sound of a word is rhymed with another word midsentence to produce a different set of ideas. Loosening of associations is the classic formal thought disorder of schizophrenia. A patient may say a lot but it is impossible to grasp the meaning of what is being said. Attempts to clarify with followup questions often only deepen the puzzle, because there is a loss of the normal clarity and structure of thinking. Examples of disorganised speech should be recorded verbatim. 440 2-G The Psychiatric Consultation Circumstantiality infers a lengthy and garrulous response to a question, often to the extent that the patient forgets what the question was. Obsessional patients may be anxious not to leave any doubt about their replies and qualify and exhaustively explore every detail and nuance before they get to the point. Tangentiality is an oblique or irrelevant response to a straightforward question. Concrete thinking is a literal and restricted response to a basic question, for example, 'How are you feeling today?'.................' With my fingers and toes, as usual! ' ........................... or1 You 're the doctor. you tell me!' Thought content A delusion is a false belief which is out of keeping with an individuals educational, cultural, religious and social background which is held with extraordinary and unshakeable conviction and absolute certainty. Subjectively, it is indistinguishable from a true belief and it is not influenced by rational argument or evidence to the contrary. A delusion may arise spontaneously (out of the blue), or be a secondary response to a patient's mood hallucinatory experiences or false memories. Paranoid (persecutory) delusions are the most common. Grandiose, guilty, nihilistic, jealousy, religious, hypochondriacal, sexual, control, and referential delusions also occur. Specific delusions about one's thoughts, involving either thought insertion, withdrawal or broadcasting are pathognomonic of schizophrenia. An overvalued idea is usually a solitary abnormal belief which dominates a patient's life and causes disturbed functioning and suffering to the person or others. The patient's whole life may revolve around this one idea (e.g. anorexia nervosa, body dysmorphic disorder, transsexualism), and cause irreparable harm to significant relationships in the patient's life. Obsessions are recurrent, intrusive, irrational thoughts, impulses or images that persist despite efforts to exclude or resist them. They are recognised as being self-generated and nonsensical and usually deal with issues that the patient finds disturbing or unpleasant (e.g. dirt, germs, violence, sex, illness or religion). Perception Perception is the process of integrating input either from the sense organs or from imagery and fantasy (which are self-generated). It is influenced by mood: mania heightens perception, particularly of colours; anxiety may intensify sound; depression mutes sound and dulls colour. Schizophrenia may affect olfaction and taste. An illusion is the misinterpretation of a real stimulus and is more likely to occur when attention and concentration are unfocused, or when anxiety is high. Hallucinations are false perceptions in the absence of a stimulus. They have the full force and impact of a real perception and occur spontaneously and cannot be controlled or terminated by self-will. To patients, hallucinations are normal sensory experiences. They may be simple: experience of bangs, rattles, whistles or flashes of light: or complex: hearing voices, music, faces, animals or scenes. Auditory hallucinations are characteristic of schizophrenia, but can also occur in alcoholism, amphetamine psychosis and affective disorder. Voices in schizophrenia may be single or multiple; whisper or shout or speak in normal conversational tone: give a running commentary on the patient's behaviour; argue with each other or appear to speak or echo the patient's thoughts out loud. Usually the patient is referred to in the third person (he or she), but occasionally commands and orders are given in the second person (you). 441 2-G The Psychiatric Consultation In organic disorders and depressive states when voices are heard they may adopt an abusive or critical tone and use the second person or simple words or brief sentences. Auditory hallucinations may occur in normal individuals under stress (e.g. sensory deprivation, bereavement) and when falling asleep or on waking up. Blind or deaf people may hallucinate images or sounds. Visual hallucinations usually signify organic illness and are uncommon in schizophrenia. Substance abuse (hallucinogens, glue, alcohol), neurological disorders affecting the visual pathways or the occipital lobe, postconcussional states, temporal lobe epilepsy and various forms of dementia may cause visual hallucinations. Tactile, haptic (touch-related) or somatic hallucinations may occur in acute psychosis and often have a bizarre complexity. Perceptions of heat, touch, water dripping (or blood or bodily fluids); visceral sensations of severe pain caused by 'knives' or 'demons': or of formication (the sensation of ants or insects crawling on or under the skin), have all been described. They may be more indicative of benzodiazepine, cocaine or alcohol withdrawal. Olfactory and gustatory hallucinations are rare, usually occur together and although they may occur in schizophrenia or depressive disorders, are more likely due to temporal lobe phenomena or neurological lesions of the olfactory pathways. Cognition Cognitive function should be assessed briefly in every patient and interpreted in relationship to age, education and intelligence. Orientation, attention, concentration and short-term, recent and remote memory should be tested. If impairment is suspected or revealed, then a more structured and objective review of cognitive functioning, such as the Mini-Mental State Examination, should be performed. Insight Insight refers to the self-awareness of morbid experiences (symptoms), and their effect on personal functioning and relationships. It also encompasses attitudes to assessment, mental disorder and treatment. Insight is not simply present or absent, but depends on the degree to which patients acknowledge, or are aware of. phenomena that other people (including the clinician) have drawn to their attention. Insight depends next on the degree to which patients recognise that the phenomena are abnormal, or may have a psychological or psychiatric cause, and finally whether patients are willing to have treatment or be hospitalised. In psychotic disorders, insight is usually absent or partial at best. Rapport Rapport refers to the degree of relatedness between the patient and the clinician during the interview and is a measure of the quality of the communication and trust achieved. Difficulty in establishing rapport may be symptomatic of the patient's illness or the clinician's countertransference and lack of empathy. Rapport predicts whether a patient will engage in and continue treatment. Risk Depending on the circumstances, the clinician's assessment of the patient's suicidalityand risk of violence to others should be noted and then acted upon, if appropriate. Reliability Whenever there is any doubt about the veracity of the patient's account of symptoms or behaviour change and other autobiographical details, other informants should be interviewed 442 2-G The Psychiatric Consultation to corroborate the history. This applies particularly to patients who are cognitively impaired, disorganised, intoxicated, significantly thought-disordered or affectively distressed. THE MINI-MENTAL STATE EXAMINATION (MMSE) The MMSE was developed by Marshal Folstein and colleagues from the Johns Hopkins School of Medicine in Baltimore. Since its publication in 1975 it has become the most commonly used instrument for bedside cognitive function screening. Its purpose is not to make a diagnosis, but to indicate the presence of cognitive impairment due to delirium, dementia or head injury. It is brief, easily administered, has high inter-rater reliability and may be used to monitor progress or fluctuations in these disorders. The thirty items in the MMSE measure orientation, attention, registration (immediate memory), recall (short-term memory), language and visuo-spatial function Performance in the MMSE is affected by age; years of education; socioeconomic status; ethnicity and whether English is the first or second language. Better educated people may score well on the test despite having significant cognitive impairment. Scores of 25-30 out of 30 are considered normal; 18-24 indicate mild to moderate impairment and scores of 17 or less indicate severe impairment. Once patients reach the more advanced stages of disease or dementia, their scores are so low that progression cannot be assessed. The MMSE was developed primarily to quantify cognitive functioning in elderly patients with delirium and dementia and may not be reliable in every patient in all situations. It may be useless at detecting focal cerebral lesions (aphasia, amnesia), right hemisphere disorders and frontal lobe deficits. It is essential to consider the performance profile of the subsets of the test as well as the overall score. Patients with Alzheimer disease may perform worst on recall, orientation and drawing, whereas subcortical dementias may primarily affect attention and concentration. The MMSE may be supplemented by specifically testing frontal lobe functioning via • verbal fluency tests: for example, naming as many words as possible in one minute starting with the letter F, then the letter A, then S. Normal is 15 words per letter or 30 words in total for the three. Once again allowance must be made for age, education, ethnicity and command of English. Alternatively ask for as many examples as possible from semantic categories: such as animals, fruit or vegetables in one minute (10 or less abnormal); or list as many items as possible that can be bought in a supermarket (15 or less is abnormal); • The interpretation of proverbs or sayings: for example, a bird in the hand is worth two in the bush', 'a stitch in time saves nine] • similarities and differences: e.g. apple and banana, table and chair, child and dwarf, ice and glass: and • motor sequencing tests: either rapidly alternating hand movements or the Luria three-step hand movements: fist-edge-palm; are all easily incorporated adjuncts to a more comprehensive screen of frontal lobe function. Patients with frontal lobe dysfunction score poorly, perseverate and become disorganised under the time pressure of these simple tests. Frank P Hume 443 2-G The Psychiatric Consultation MINI-MENTAL STATUS EXAMINATION (MMSE) 1 Date of Examination: Name: Sex: Date of Birth: Handedness: Occupation (previous): Educational Level: General Remarks Hearing: Vision: Record exact replies. Enter the scores out of the maximum shown. No half marks awarded. 1. Orientation What is the Year? Season? Date? Month'? Day of the week7 Where are we 7 State City Suburb Hospital Floor (if at home, the street number and name) 2. Registration Name three objects, taking one second to say each, then ask the patient to repeat them. e.g. Apple Table Coin Repeat them until the patient learns all three. Ask patient to remember them Number of trials required to learn the answers 3. Attention/Concentration (a) Serial Sevens (take 7 serially from 100 -» 93; 86; 79; stop after five answers): deduct one mark per error Or (b) Spell WORLD backwards (e.g. dlrow = 5, drolw = 3) 4. Recall Ask the patient to name the three objects in Question 2 1Adapted from Folstein M.. Folstein S. and McHugh P.. 1975. J. Psychiatric Research 12 pp 189-198. 444 5. Language (a) Ask the patient to name the following as you point: 'pen'.... 'watch (b) Have the patient repeat: 'No its. ands, or buts (c) Have the patient follow a three stage command: /2 /1 1 /3 Take this paper in your right hand. Fold the paper in half. Put the paper down in your lap'. (d) Have the patient read and obey the following: CLOSE YOUR EYES /1 (e) Have the patient write a sentence (containing subject, verb, object) /1 6. Construction Ask the patient to copy this design /1 Score = /30 445 2-G The Psychiatric Consultation 2-G The Psychiatric Consultation Candidate Information and Tasks MCAT 083-089 83 Medication changes for a 35-year-old woman with chronic schizophrenia 84 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 85 Poor work performance in a 30-year-old female police officer 86 Lifestyle stress in a 45-year-old man 87 Binge drinking in a 25-year-old man 88 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 89 Collapse of a 30-year-old woman on the way to a court attendance 446 083 Candidate Information and Tasks Condition 083 Medication changes for a 35-year-old woman with chronic schizophrenia CANDIDATE INFORMATION AND TASKS You are working in a general practice. A longterm patient of the practice has attended for a repeat prescription of thioridazine (Melleril®). The patient is a 35-year-old woman who has been receiving thioridazine 200 mg daily for chronic schizophrenia over the past 15 years. Due to recent adverse publicity and concern about the effects of longterm thioridazine on cardiac conductivity (as reflected in a prolongation of the corrected QT interval on the ECG), you wish to change her to a newer atypical antipsychotic. Before doing so, you will need to discuss with her the risks and benefits of her current treatment and the risks and benefits of the commonly available atypical antipsychotics. YOUR TASKS ARE TO: • Explain your concerns about continuing on thioridazine. • Educate the patient about the risks and benefits of the newer atypical antipsychotics. • Explain the side effects of the most common atypical antipsychotics. • Respond appropriately to the patient's questions. There is no need for you to take any further history from the patient. The Performance Guidelines for Condition 083 can be found on page 456 447 084 Candidate Information and Tasks Condition 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man CANDIDATE INFORMATION AND TASKS You are the duty Hospital Medical Officer (HMO) in a busy city hospital clinic attached to the Emergency Department. It is early evening. The patient you are about to see is a neatly dressed, well-groomed 29-year-old man who has brought an envelope containing some hair strands to the front desk, asking if they can be 'examined under a microscope'. He appeared to be guite anxious and restless whilst waiting to be seen by you and the triage nurse has told you that he has visited the toilet facilities for lengthy periods of time on several occasions. The triage assessment states that he is worried that he is suddenly going bald because he has begun to lose his hair. He has brought some of his hair to the hospital to be examined to find out what the problem is and have treatment urgently' because he believes that his hair loss is affecting his 'prospects for promotion at work'. He is single and lives at home with his parents. He has worked as a financial analyst in a merchant bank for the past six years. He admits to not having any social life and is a nonsmoker and nondrinker. He appears to have a normal full head of hair as illustrated below. YOUR TASKS ARE TO: • Establish rapport. • Take a sensitive, focused and relevant history. • Reach a diagnostic conclusion, and discuss this with the patient. • Discuss management briefly with the examiner. CONDITION 084. FIGURES 1 AND 2. The Performance Guidelines for Condition 084 can be found on page 459 448 085 Candidate Information and Tasks Condition 085 Poor work performance in a 30-year-old female police officer CANDIDATE INFORMATION AND TASKS You are working in a general practice. The patient is a 30-year-old Police Officer who has been advised to seek medical help by the human services officer (staff counsellor), for the State Police Service. The Police Service has become concerned that she does not appear to be functioning 1 as well in the workplace. She has been having an increasing number of sick days, which are often on the first day of a new set of rostered shifts. YOUR TASKS ARE TO: • Take a focused history — you have six minutes to do this. • Inform the examiner of the three most likely diagnoses. • Answer questions from the examiner about one or more of these diagnoses The Performance Guidelines for Condition 085 can be found on page 463 449 086 Candidate Information and Tasks Condition 086 Lifestyle stress in a 45-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. The patient has come to see you after having insurance medical examinations at work. It was recommended that he see a general practitioner, to monitor his general health, and that he may be 'just stressed'. He did not really think of being a 'stress type' before now, and has no symptoms except for headaches towards the end of the day. Other family members attend your practice, but this patient has not previously consulted you. The patient has been told that cholesterol, blood sugar, and resting ECG are normal, but on two occasions in the last month when tested by the insurance doctor, the BP reading was high (160/80 mmHg) but eventually settled to normal levels. On those days, the patient had come from particularly difficult meetings. The patient is upset by these findings, believing that he has always been in perfect health. The insurance doctor said 'there was nothing to be concerned about really', but now he is worrying about having a heart attack and can't get that out of mind over the past couple of nights. This worry has been reinforced by several episodes of stabbing chest pain each lasting only a few seconds, unrelated to exertion. Last night he took a sleeping tablet, normally only used on long plane trips, to get some sleep, and feels much better now—the patient is now thinking he may have been suffering from stress over the past couple of years. You have obtained the information as listed below in the patient profile, and you have just completed examining the patient, including performing an ECG. No abnormality has been found. Blood pressure today is 130/70 mmHg. Patient profile Marital status Household Occupation Smoking habits Alcohol use Drug sensitivities Family history Married, wife an artist Wife, three teenage children Finance Manager 3-5 cigarettes daily two whiskies/sherries most nights Not known Eldest of five siblings, all alive and well. Father died aged 65 of a heart attack; mother alive and well, although a worrier Past medical history Major continuing health problems Current medication No serious illnesses or operations 450 • None known None 086 Candidate Information and Tasks YOUR TASKS ARE TO: • Discuss his health condition and relevant matters with the patient. • Advise the patient of your diagnosis and proposed management. • Answer any questions the patient asks you. The Performance Guidelines for Condition 086 can be found on page 466 451 087 Candidate Information and Tasks Condition 087 Binge drinking in a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. This patient is well known to you. He is a 25-year-old sole parent of a six-year-old girl — the mother left soon after the girl's birth and there has been no contact since. The patient works full time as a local delivery truck driver. • He regularly drinks heavily at the weekends. • • He intermittently presents on Monday 'feeling seedy' requesting a certificate for the day off. He is otherwise in good health, but has had frequent presentations for minor sporting injuries. • He is not taking any medication; smokes 10 cigarettes per day; there is no other drug history. • He does not have any history of psychiatric illness. • • He is generally a good and caring parent — he has no other regular help with child-care. His relationship with his family is strained — they blame him for his wife leaving. • His father was a violent, heavy drinker during the patient's childhood, and still drinks, but not to excess. The patient came to the practice today for the removal of sutures to a small scalp laceration, well-healed, sustained eight days ago in a fall at the pub after the football. He was briefly unconscious. He was taken, intoxicated to the Emergency Department of the local hospital at 1:00 am eight days ago, the wound was repaired and he was discharged several hours later. Your nurse has just removed the sutures. She has alerted you to discuss the patient's drinking and parental responsibilities. YOUR TASKS ARE TO: • Discuss with this patient his pattern of drinking and its harmful consequences. • Make appropriate recommendations for dealing with the problem. The Performance Guidelines for Condition 087 can be found on page 470 452 088 Candidate Information and Tasks Condition 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk CANDIDATE INFORMATION AND TASKS Your next patient is a 30-year-old bank clerk, who is consulting you in the Emergency Department of a general hospital. She is complaining of severe nausea, headaches and the 'jitters'. She attended here two days ago. Brief notes in the Emergency Department patient record state that she was then complaining of back pain which was diagnosed as 'muscle pain'. The notes also state that she had been taking the selective-serotonin-release-inhibitor (SSRI) Prozac® (fluoxetine) 20 mg daily for depression for three weeks on the advice of her local doctor, without much improvement. An alternative SSRI —Zoloft® (sertraline) 100 mg daily was prescribed when she attended the Emergency Department. YOUR TASKS ARE TO: • Take a further focused history related to this situation. • Ask the examiner for the appropriate examination findings you require to assist in diagnosis. • Inform the examiner of your diagnosis. • Counsel the patient about the likely cause of her symptoms, their treatment, and what you recommend with regard to further management of her depression. The Performance Guidelines for Condition 088 can be found on page 474 453 089 Candidate Information and Tasks Condition 089 Collapse of a 30-year-old woman on the way to a court attendance CANDIDATE INFORMATION AND TASKS This patient was brought to the Emergency Department complaining of a sudden inability to walk. She had collapsed on the way to court where her husband was due to appear on fraud charges. The charges related to embezzlement to cover the husband's gambling debts. She is a 30-year-old housewife who was fully active yesterday and carrying out her everyday life up until this morning. You have reviewed the case and found the patient presented with a similar condition a year ago at the time the fraud was first alleged. At that time, she was admitted to hospital, and investigations including computed tomography of the spine and head were reported as normal. After two weeks in hospital she recovered the ability to walk. YOUR TASKS ARE TO: • Examine the lower limbs with attention to the neurological system — you have six minutes to complete your examination. • Report your findings to the examiner as you proceed. Also take note of the patient's general behaviour and demeanour. • Answer the questions which the examiner will ask you about this problem. • Provide a likely diagnosis to the examiner, and give your reasons for selecting the diagnosis. The Performance Guidelines for Condition 089 can be found on page 478 454 2-G The Psychiatric Consultation 2-G The Psychiatric Consultation Performance Guidelines MCAT 083-089 083 Medication changes for a 35-year-old woman with chronic schizophrenia 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 085 Poor work performance in a 30-year-old female police officer 086 Lifestyle stress in a 45-year-old man 087 Binge drinking in a 25-year-old man 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 089 Collapse of a 30-year-old woman on the way to a court attendance 455 083 Performance Guidelines Condition 083 Medication changes for a 35-year-old woman with chronic schizophrenia AIMS OF STATION To assess the candidate's ability to explain the need for antipsychotic medication change. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 35-year-old woman with chronic schizophrenia characterised by chronic paranoid delusions about being 'spied upon by people who live in your roof cavity'. Occasionally you can hear them whispering amongst themselves or 'operating a computet system that enables them to track you with electromagnetic radiation '. Although you live at home with your aging parents, you are socially isolated and rarely go out. You have been taking thioridazine under protest for 15 years and your condition is relatively stable. You have only limited insight into your illness. You are convinced that a family does live in your roof and you only take medication because your mother supervises this and insists that taking medication daily is a condition of you continuing to live at home. You cannot realistically move out, as you cannot afford to live anywhere else. Your only income is the disability support pension. Your weight is 66 kg and your height is 1.5 metres (BMI 29 kg/m2). You are attending your general practitioner to receive a repeat prescription of your thioridazine (Melleril®). It is a drug that has given you a mild dry mouth, blurred vision and constipation for years, so that when the doctor tells you it is time for a change, you are relieved, but sceptical — unconvinced that you need medication at all. Listen carefully to what the doctor says about the new medication options and respond appropriately depending on what is said. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should advise the patient of the need for medication change by appropriately: • Outlining recent evidence linking her current medication with potentially life-threatening arrhythmias. • Describing the benefits and side effects of alternative medications. • Obtaining informed consent for medication change. • Outlining the management plan as detailed in the commentary. • Responding to patient's queries. KEY ISSUES • Explanation of risks of continuing current medication. • Explanation of benefits and side effects of recommended alternative medications. • Monitoring and followup during medication changeover. 456 083 Performance Guidelines CRITICAL ERROR - none defined COMMENTARY In 2002, Australian prescribers were alerted to the recently established link between thioridazine and prolongation of the QTc interval of the heart. There is a danger of life-threatening ventricular tachycardia if the QTc interval is longer than 500 milliseconds. Pre-existing cardiac pathology, electrolyte abnormalities, thyroid disease, cerebrovascular disease, severe bradycardia and many commonly prescribed drugs may all lengthen the repolarisation phase of the ventricular myocardium, which could trigger the polymorphic tachycardia known as torsade de pointes. This arrhythmia is usually self-terminating but can progress to ventricular fibrillation or sustained tachycardia. Dizziness, syncopal episodes, cardiac arrest or death may result. Blockade of cardiac potassium channels may be the mechanism and genetic factors may play a part. Women are at greater risk. Thioridazine has also long been known to cause lenticular opacities when used in high dosage for long periods. But it is the anticholinergic effects which cause most subjective discomfort. Sedation, postural hypotension and weight gain are other well known side effects. Extrapyramidal toxicity with thioridazine is uncommon, but not rare. Since 1992 there have been several atypical antipsychotic drugs available for prescription in Australia. They are 'atypical' in the sense that their mechanism of action is not solely to block CNS dopamine D2 receptors and they are thus less likely to cause tardive dyskinaesia or other extrapyramidal syndromes. Their efficacy is equivalent to conventional 'typical' antipsychotics. The most important emerging side effects of the atypical agents are weight gain, metabolic disturbances and hyperprolactinaemia. Risperidone, olanzapine, amisulpride and quetiapine are available for prescription on the Pharmaceutical Benefits Scheme for schizophrenia. Weight gain liability is not confined to the atypicals, but olanzapine, quetiapine and risperidone (of the drugs available for prescription by general practitioners) are associated with faster and greater weight gain than typical antipsychotics. Adolescents may be particularly susceptible to this side effect. Weight gain is not dose-dependent, but patients who were relatively underweight prior to treatment may put on the most weight. The mechanism of weight gain may be blockage of the histamine H, receptor (which also causes sedation) and antagonism at 5HT2A receptors, as well as impaired feedback of the adipose tissue-leptin loop. There is an increased risk of Type 2 diabetes mellitus in patients with schizophrenia independent of treatment, but weight gain and inappropriate dietary choice increase the risk further. Atypical antipsychotics, particularly olanzapine, heighten the prevalence of Type 2 diabetes especially in overweight or obese patients, by increasing insulin resistance. The risk is less with risperidone and quetiapine. Triglyceride levels, but not cholesterol, may also be significantly increased by olanzapine. Data about other atypicals are limited. 457 083 Performance Guidelines Hyperprolactinaemia is a well known side effect of typical antipsychotics due to removal of inhibition of prolactin secretion by hypothalamic dopamine receptor blockade. Risperidone, of the atypical antipsychotics, has the greatest risk of hyperprolactinaemia and hence amenorrhoea, galactorrhoea. decreased libido, impotence and anorgasmia. Prolonged uninhibited prolactin release may cause hypogonadism and decreased oestrogen and testosterone secretion, which in turn increases cardiac morbidity and osteoporosis, and gives an increased risk of breast cancer. Hyperprolactinaemia, however, is a laboratory finding and is not always associated with clinical symptoms. Clozapine is the atypical antipsychotic with the most adverse side effect profile, including agranulocytosis, but it is available only through specialist clinics. Amisulpride is the atypical antipsychotic most likely to cause extrapyramidal side effects, although it is claimed to preferentially block limbic dopamine receptors rather than those in the striatum. The decision to change a patient from a typical to an atypical antipsychotic depends on the risk/benefit ratio. A patient on typical antipsychotics, who is stable and whose symptoms have reached equilibrium with minimal side effects, should not necessarily be changed to an atypical agent just because there is a choice. There is an increased risk of relapse requiring hospitalisation during the changeover period and patients need to be warned of the above major side effects. Lifestyle and dietary advice, weight monitoring and an agreed exercise program are all essential elements of the preswitch counselling process. Baseline weight, body mass index, blood pressure must be measured as well as a 12-lead ECG. thyroid function, fasting blood sugar and lipids, prolactin, full blood count, electrolytes, urea, creatinine and liver function tests. Once the decision has been made to change a patient from one antipsychotic to a new one, then for a nonacute patient, a crossover period of 1-2 weeks is recommended by reducing the dose of the previous medication and gradually increasing the dose of the new medication. Patients and caregiver need to be alert to the 'early warning signs' or relapse signature' symptoms which herald the return of acute psychosis. Nonspecific discontinuation symptoms may persist for several weeks after changeover. These include: nausea, headache, restlessness and an influenza-like syndrome. In this patient, because of the length of time on a typical antipsychotic, any change toa newer atypical agent may require dose-titration over several weeks and doses towards the higher end of the therapeutic range may be necessary. 458 084 Performance Guidelines Condition 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man AIMS OF STATION This is primarily a diagnostic and communication skills station, assessing the candidates ability to take an empathie and relatively quick psychosocial history and to rapidly reach the correct diagnostic conclusion. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 29-year-old financial analyst in a large city merchant bank. It is a competitive environment. You have been with the company for six years since graduation from university, but your career progress has stalled. Although you are conscientious and reliable at work, it is three years since your last promotion. Fellow cadets from your intake cohort seem to have left you behind. You have just had a performance appraisal interview and have once again been passed over for promotion. Your explanation for this is that you are losing scalp hair and must be going bald and that it is your hair loss that has cost you your promotion. Since your adolescence you have been concerned about your appearance and grooming. It began with a belief that your face was asymmetrical which you believed was obvious to other people and this led to you checking your facial features in a mirror several times a day. Then you began to notice facial skin flaws and different shades of pigmentation. If you developed a pimple or shaving rash you would touch, pick at and constantly inspect the lesion in a mirror on an hourly basis. Checking your facial appearance on a regular basis during the course of a day has now become part of your daily life. Each mirror checking episode lasts several minutes with you having to reassure yourself that no new blemishes have appeared or that any existing blemishes are improving or fading. Whilst at work you can only do this every two hours for a few minutes, but at home and on weekends it may take you at least half an hour to complete a thorough inspection of your entire head and face region, which you repeat three times a day. If asked, you will concede that the total amount of time you spend checking your appearance in front of the mirror, touching, examining and picking at almost every skin pore or hair follicle, could be four hours a day on weekends. The amount of time you spend monitoring your appearance is slowly increasing. You still live at home with your parents, who are both school teachers approaching retirement. Your mother suffered from agoraphobia during her twenties before her marriage. They have become accustomed to you constantly asking them 'Howdo I look?' or, 7s there something wrong with my face/skin/mouth/eyes/hair?' Their unfailing reassurance that there is nothing wrong with your appearance does not reduce your concerns as you are sure they are only saying that to humour you. In the past decade, you have spent a small fortune on male beauty treatments, face packs, facial massages, hair styling and allergy-free soaps, shave creams and cosmetics in an attempt to treat or camouflage your skin defects. It is your main interest. Your concern for the care of your skin means that you do not like to socialise at parties or clubs where people may smoke. You avoid crowds and public transport to avoid embarrassment of strangers 459 084 Performance Guidelines subjecting your features to close scrutiny. You avoid direct sun exposure. You do not smoke or drink alcohol. Over the past few months you have been monitoring the number of your scalp hairs you have found on the floor of the shower cubicle after a shower. Although it may only be one or two, you have come to believe several things. The first is that the cumulative loss of hairs means that you are going bald and that the resultant change in your hair density and thickness is obvious to other people. You are certain that this obvious hair loss has influenced your employers not to promote you because to have employees with thinning hair is not good for the bank's image when dealing with clients. Finding out that you have yet again not been promoted has driven you to seek advice, about diagnosis and treatment for your hair loss. As you do not trust your family general practitioner, who has dismissed your concerns and said there is nothing wrong, you have sought a second opinion from an unbiased doctor at the city hospital closest to where you work. How to play the role You must be neat, well dressed and have a full head of hair. You will have an envelope with a 7 couple of strands of your hair in it. You will be anxious and somewhat irritable. If there is a mirror in the consulting room, then insist on showing the doctor your 'receding hair line' at an early stage of the interview. (It would be useful to have a small mirror as a prop) Opening statements • • • • ‘Doctor, you've got to find out why I'm losing my hair!' ‘I want these hairs of mine examined under a microscope by a specialist! ' 'Let me show you where I'm going bald'. 'You've got to do something!' Your subsequent behaviour and emotional reactions will be shaped by the way the interview unfolds. If the doctor rushes to judgment and dismisses your concerns without tact, empathy or appropriate discussion, then your irritability and exasperation may increase. If the doctor realises what your underlying problem is. effectively establishes rapport, and the extent of your difficulties and hypochondriacal concerns is realised, then be defensive and sceptical, but be prepared to listen and interact appropriately. Do not willingly volunteer history of your rituals or checking behaviour until asked. These have been behaviours you have kept secret for years, but you may be relieved that at last someone is able to encourage you to talk about them. After six minutes, the examiner will interrupt the consultation and ask 'What is your provisional diagnosis? Describe briefly possible management plans to me. ' EXPECTATIONS OF CANDIDATE PERFORMANCE The patient has a form of Body Dysmorphic Disorder (BDD) presenting with the conviction of impending baldness, when objectively and clinically, there is no supporting evidence. BDD is a form of hypochondriasis which is part of the anxiety disorder spectrum. In this instance there are many obsessive compulsive disorder features. BDD is a condition that affects about 1% of the population, but is infrequently diagnosed because of the lack of awareness by clinicians and patients' secrecy about their bodily preoccupations. 460 084 Performance Guidelines The candidate will be expected to establish the diagnosis, the associated behaviours and the complications in this case, as well as being aware of the common comorbid psychological disorders. Knowledge about the effectiveness of the serotonin reuptake inhibitor antidepressants and cognitive behavioural therapy in this condition would be desirable. Key questions the candidate should ask of the patient would be: • 'Apart from your hair, have you ever been very worried about your appearance in any other way?' • (If yes): 'Can you tell me what your concern was?' • 'Did this concern preoccupy you? Do you think about it a lot and wish you could worry about it less?' • 'What effect has this preoccupation with your appearance had on your life?' • 'Has it affected your social life, family relationships, friends, job or other activities?' • ‘Do you wish to do anything about your concerns?' KEY ISSUES • Ability to take a focused psychosocial history and to come to an appropriate diagnosis. • Ability to communicate with a patient with body dysmorphic disorder. CRITICAL ERRORS - none defined COMMENTARY 'Body Dysmorphic Disorder, or dysmorphophobia, is a chronic preoccupation with an imagined defect in one's appearance. Even if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes significant distress or impairment in the person s social, occupational and other important areas of functioning. Typical complaints commonly involve imagined or slight flaws of the face or head such as thinning hair, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial asymmetry or disproportion or excessive facial hair. Other common preoccupations include the shape, size or some other aspect of the nose, eyes, eyelids, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks or head. Any other body part may be the focus of concern (the genitals, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, overall body size or body build and musculature). The preoccupation may focus simultaneously on several body parts and although it may be often specific: 'a hooked nose'; it may also be vague: 'a flat chest'; or general: 'I'm just ugly'. From Diagnostic and Statistical Manual 4 - Text Revision Most individuals with this disorder experience marked distress over their perceived deformities. They find their preoccupations difficult to control and may make little or no attempt to resist them. Many hours of the day may be spent thinking and worrying about their 'defect' and these thoughts may dominate their lives, leading to significant impairments in functioning and avoidance of work, social and public situations. Repetitive and 461 084 Performance Guidelines time-consuming behaviours are undertaken to reduce their distress, which have no or only minimal benefit. Reassurance that there are no visible defects has no lasting effect on their abnormal beliefs. The core irrational belief in BDD is that the person is somehow defective and unattractive and this is accompanied by low self esteem, shame, embarrassment and fear of rejection. The condition is common if it is looked for and asked about. The most common associated behaviours are mirror-checking, touching, comparing the defect' with other people's body parts either directly or with pictures in magazines, excessive grooming, camouflaging, constantly seeking reassurance and questioning others about their alleged defects or ugliness and then seeking dermatological or cosmetic surgical treatments. Social impairment is the norm. They are socially avoidant and will not willingly visit restaurants, shopping centres, beaches or go to parties or functions because of their self-consciousness about their appearance. Insight is usually poor or partial and their beliefs may become delusional. It is their self-referential ideas, i.e. that other people are taking special notice of their 'defect' and will talk and gossip and laugh about it, that contribute to their social isolation and intensify their suffering to the point of despair, self-harm and sometimes suicide. Psychiatric comorbidity is universal. Major depression is the most common (60%) but social anxiety/phobia, obsessive compulsive disorder, substance abuse and avoidant personality disorder are highly prevalent. There is a roughly equal sex incidence and similar clinical features. Perhaps women are more likely to focus on their skins, lips, and weight, whereas men are more preoccupied with overall physique, their genitals and hair loss or excess. The condition typically begins in adolescence, but may not present or be diagnosed until the thirties. The course is chronic and relapsing. Most patients with BDD seek costly dermatological or cosmetic surgical consultations and treatments, but remain dissatisfied with the results. They may then become litigious or violent. Rarely patients perform their own procedures after consulting internet web sites. Management The specific serotonin reuptake inhibitor antidepressants and clomipramine are often effective. The dosages need to be in the higher range and it may take three months to get a response, but 70% of patients report improvement. Augmentation with antipsychotics may increase the response rate. Treatment must be continued longterm as relapse is common if treatment is discontinued. Cognitive behavioural treatments including psychoeducation, cognitive challenge and restructuring, exposure and response prevention, as well as anxiety management training, can supplement drug treatment and increase response rates to over 80%. Severe comorbid depression may need hopitalisation and/or lithium carbonate augmentation with antidepressants. Trying to convince patients with entrenched ideas that their beliefs are irrational or that they look normal is unlikely to persuade them to accept psychiatric treatment or referral. With the patient's consent, family involvement in psychoeducation and treatment planning and supervision of response prevention strategies and the removal of mirrors from the family home may be valuable. 462 085 Performance Guidelines Condition 085 Poor work performance in a 30-year-old female police officer AIMS OF STATION To assess the ability of the candidate to diagnose a stress-related depression associated with increased alcohol intake. To assess the ability of the candidate to determine when and why the problem started, and what the ramifications of the problem might be at this time or in the future. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You do not wish to be examined by the candidate and resent having been advised to see the general practitioner by the Police Service's staff counsellor. You should present as anxious and initially reluctant to admit that you are having difficulties at work. When the candidate questions you further, answer the following or similar questions directly, but volunteer additional information only if appropriately led. • After candidates introduce themselves, insert the following into your first answer to them: ‘I didn't really want to come today. I am only here because the Police Service thinks I have a problem. ' • If you are asked if there are any problems at work, at first say: ‘I d o m y j o b w e l l — t h e r e have been no complaints about what I do at work. ' • You are a police constable with a variety of service attachments in the field and at office tasks. • You live alone. No current romantic relationships. ‘Too b u s y a t w o r k . ' • Your family is interstate. • You have l o t s o f f r i e n d s ' , but haven't seen them much lately. • Been ill? ' N o t t h a t m u c h m o r e t h a n o t h e r s . I ' v e h a d s i x d a y s o f f i n t h e l a s t month. ' • Days off when shift changes? ‘I guess I ' v e h a d o n e o r t w o d a y s o f f o n t h e l a s t f o u r times the shift changed. ' • What has been wrong? ' I ' v e b e e n f e e l i n g r e a l l y j u m p y a n d o n e d g e . I ' v e b e e n finding it hard to concentrate and just don't have any confidence. ' • When did this start? ' S i x m o n t h s a g o . ' — ' O n e d a y I h a d t o g o t o a f a t a l m o t o r vehicle accident where an adult and two children were killed. The very next day I was called to an armed hold-up and both my work colleague and I were shot at by the offender. I was OK, but my work colleague received serious injuries and he has not returned to work. ' • When has the anxious feeling been worse? ' W h e n I t h i n k a b o u t t h o s e e x p e r i e n c e s , or when I have to deal with another situation where people might get hurt. It's also worse when I'm going back to work after some days off. ' 463 085 Performance Guidelines • What is the anxiety like? Volunteer any two of the following features if asked a general question: ~ Feel terrified something awful will happen. ~ Racing heart (palpitations), breathing faster, and perspiring a lot. ~ Nightmares of both incidents — most nights. ~ Can't watch television or read magazines with pictures or articles of car accidents or Police Officers being shot at. • What will happen in the future? 'It is only a matter of time before I'm injured or killed in the line of duty. ' • Alcohol? Only answer direct questions 'Over the last six months my alcohol intake has increased from 1-2 glasses of wine per week to 6-7 glasses of wine each day on most days. ' • What does alcohol do for you? 'It relaxes me and lowers the anxiety. It's the only thing that helps me "unwind" after work and enables me to get to sleep. ' • Does your use of alcohol bother you? 'I am worried that I have to have a drink to control the anxiety. ' • Suicidal thoughts? 'No. ' If pressed further, add 'I have sometimes thought that life is not worth living. ' • Any plans to commit suicide or past attempts to harm yourself? 'No. Never. I don't want to end my life. ' • What about your gun? 'I have not handed this in nor have I been asked to do so. ' Examiner's questions Towards the end of six minutes, the examiner will ask the candidate to describe three conditions which should be included in the differential diagnosis. Appropriate responses are: 1. Anxiety disorder: post-traumatic stress disorder, panic disorder or generalised anxiety disorder. 2. Depressive disorder: adjustment disorder, major depressive disorder. 3. Alcohol dependence/abuse, or just problem drinking. Next questions for the examiner to ask should be: • 'What is a safe level of alcohol consumption for this patient?' Low risk = maximum of 20 grams per day (two standard drinks) and two alcohol-free days per week (NHMRC Levels for Women). • 'What are the short term risks associated with the patient's current level of alcohol use?’ You should expect at least four of the following: ~ hangover effects — headaches, anorexia, tremor: ~ gastritis; ~ impulsive acts — including suicide attempts; ~ impaired decision-making: ~ accidents, including with firearms; ~ worsening of mood/depression; ~ potentiation of anxiety or post-traumatic stress disorder symptoms; or ~ social or occupational problems. NOTE: If the candidate has not identified alcohol dependence/abuse as a problem, these questions should NOT be asked. Instead ask 'Are there any other possible diagnoses?’ 464 085 Performance Guidelines KEY ISSUES • Ability to take a focused history to define the potential cause of the current problem. • Knowledge of the causes of the problem • Knowledge of the short-term effects of alcohol excess, and the NHMRC recommendations of alcohol abuse. CRITICAL ERRORS • Failure to identify the excess alcohol consumption. • Failure to ask about suicide. COMMENTARY This case concerns a patient with a work experience that has exposed her to severe stress, leading to an alcohol abuse problem to help relieve a post-traumatic stress syndrome with anxiety. The patient is also at risk of comorbid depression and suicide. She has a responsible job and failure to help her may also result in her colleagues or other members of the community being at risk. Candidates must both take an adequate history of alcohol consumption, and also explore the factors that have led to the problem, namely the fatal car accident and the shooting of her work colleague the next day. They should ask about the key features of post-traumatic stress, assess subjective mood and risk of suicide and. particularly in this case, her access to firearms. Identifying the alcohol problem alone is insufficient for a pass. Candidates should be familiar with at least four of the short-term risks or consequences of excess alcohol use and the NHMRC recommendations concerning alcohol consumption. If they are not aware of at least four, a pass mark is unlikely to be given. 465 086 Performance Guidelines Condition 086 Lifestyle stress in a 45-year-old man AIMS OF STATION To assess the candidate's ability to recognise and to communicate to the patient, common behavioural, physiological, psychological and emotional concomitants of lifestyle stress, and to formulate and implement an appropriate immediate and preventive management plan, EXAMINER INSTRUCTIONS The candidate needs to have sufficient skills in evaluation of cardiovascular disease to recognise this is not ischaemic heart disease, and advise the patient accordingly. If candidates attempt to seek further history, examination or investigation of cardiovascular disease, the examiner is to inform them (once) they are to proceed on the basis of a normal examination. No further prompts. The candidate who pursues a physical cause to the exclusion of the psychological matters should be marked down. The examiner will have instructed the patient as follows: You have been recommended to see a general practitioner to review your health after an insurance assessment. You have been told that cholesterol, blood sugar, and resting ECG are normal, but on two occasions in the last month when tested by the insurance doctor, the BP reading was high (160/80 mmHg) but eventually settled to normal levels. On those days, you had come from particularly difficult meetings. You have never thought about having serious physical illness, and believe people who complain of stress 'just aren't motivated enough or don't work out their goals properly'. You enjoy being challenged by work and sports, and people coming to see you for advice. You never take a day off work, even with a bad cold or jetlagged from a trip, and avoid taking tablets, even a Panadol® if you have a headache at the end of the day. The only health problem you have noticed is more frequent headaches towards the end of the day. which you put down to eyestrain. You have never felt depressed, or at any time recognised yourself as being anxious, and you would still enjoy all your usual activities if there was time to do them. You feel rather shocked by what you have been told and by the way you have felt over the past couple of weeks. You have planned to retire at 55. You work 12-15 hour days. Since you were promoted 18 months ago, you have been taking work home on weekends more frequently and there is a lot more pressure. You sometimes feel like escaping, but think of it only being a few more years and anyway you feel happier at work than at home these days. It is just too noisy with three teenage children, and you get irritated with your eldest son who dropped out of university last year, and 'just sits around playing music with his mates'. You did not go on the family holiday this year for the same reason, blaming work. Your spouse is usually very understanding, but got mad with you about that and things have been tense the last few months. You have been more irritable at home, and your spouse complains you criticise the children too much. 466 086 Performance Guidelines You normally get on with a few hours sleep, often thinking through work problems once you are in bed. You never feel tired, but the last year or so you 'catch up with naps' on weekends. The last couple of weeks, you have slept badly, and feel tired in the morning There is little time for sex, but you are sure it is not your lack of interest that is the problem. You used to exercise regularly at the gym and with weekly tennis but have not done so in the last few years because you are just too busy at work, and running around with the children's activities on weekends. Now, you walk up the stairs when you have time. You have gained a few kg over the past few years, but do not consider yourself overweight, or unfit. You have always eaten a balanced diet, except when on overseas trips and at business lunches. You stopped smoking 15 years ago when your father, who was a very heavy smoker and ate badly, died at 65 of a heart attack, but started again smoking 3-5 cigarettes a day in the past 12 months because it helps keep you going through the day. You have never worried about suffering your father's fate, because you have looked after yourself so well. You consider yourself a moderate social drinker. You notice you are drinking more these days. You feel uncomfortable in an unfamiliar environment, and somewhat embarrassed about the problem. Answer any questions from the candidate in a straightforward manner. Seek reassurance about the risk of heart attack, but do not labour the point; and readily accept further investigations, if offered. Expect to be provided with an effective solution and definite results, the sooner the better, but acknowledge the stress levels and sources when identified, and seek advice regarding change. You are more accepting of a straightforward solution (for example, regular recreation, exercise, and sleep pattern). Questions to ask unless already covered: • Opening question: 7s this stress, or some kind of a breakdown?' • 'Could it be the beginning of heart trouble, or cause a heart attack?' • 'If my heart is okay, why did I have those pains in my chest?' • 'What would help the most?' • 'What do you suggest I do?' • 'How long will this all take to make a difference?' • 'What happens if I need these tablets all the time to sleep? Are they addictive?' • 'What else can I do to sleep?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Inform the patient about common symptoms of stress, both psychological and physiological. • Explain the mechanism of physiological symptoms — headaches resulting from muscle tension, sympathetic arousal causing blood pressure rise and initial sleep disruption. • Reassure about nature of stabbing chest pain. • Identify for the patient the sources of stress (overwork, absence of leisure and exercise) and the compensatory measures which increase physical and emotional burden (alcohol and smoking, reduced sleep). 467 086 Performance Guidelines • Educate about the negative role of stress in cardiovascular disease and mental health. • Assist the patient in identifying realistic changes for healthier work/personal balance (e.g. increased recreation through regular exercise, holidays, and sleep pattern). Initial management plan • Appropriate advice regarding lifestyle change, including discussion with spouse • Avoidance of intensive or invasive management. KEY ISSUES • Patient counselling — explanation of diagnosis and patient education and initial management plan. • Provision of an adeguate explanation about stress, its origins and its physical, behavioural and psychological seguelae and complications, acute and chronic. • Reassurance about blood pressure and chest pain. CRITICAL ERROR - none defined COMMENTARY This patient has obsessional personality characteristics of perfectionism, mental and interpersonal control, propensity to overwork, and inflexibility (not personality disorder, on available information). As a coping style, it has brought occupational and personal success, but in the context of promotion and increasingly complex life, especially family demands, it is now being overused; healthy compensatory mechanisms such as pursuit of fitness and competitive sports have been discarded, and dysfunctional habits substituted. The degree of dysfunction is sufficient to produce somatic and behavioural symptoms — increased headache, chest pain, labile hypertension, increased intolerance and isolation. The patient is stressed and does not have a psychiatric or physical illness, but intervention is now needed to modify those behaviours which increase risk of cardiovascular disease and psychiatric illness, as well as relationship breakdown. Recognition of the personality style enables realistic intervention — brief, behaviourally or physically mediated, with extension to include spouse for interpersonal/family issues. Management The essential management is to provide this patient with appropriately focused brief intervention to modify behaviours and lifestyle, after engagement through adequate reassurance regarding physical illness, followed by education of the physiological mechanisms and identification of stressors. Use of hypnotherapy for sleep disturbance (short-term) is acceptable but other measures are preferable, such as a regular sleep pattern, and progressive muscle relaxation. Modification of lifestyle — restrain working hours, alcohol and cigarette consumption. Resume exercise, increase leisure activities, including family pursuits — these are the interventions most able to be implemented. Include the spouse in supporting lifestyle modifications and enable discussion of interpersonal and family issues. Followup and ongoing monitoring of blood pressure and cardiovascular health is indicated. 468 086 Performance Guidelines Communication skills • Ability to take this opportunity to engage a reasonably informed, currently anxious, but usually pragmatic and busy person in appropriate lifestyle change. • Ability to combine the tasks of identifying stressors, with providing psychoeducation, through using direct questions around the main activities of daily living and habits, and empathie listening. • Attitude to alcohol and cigarette use should be nonjudgmental and proportionate to use. • Consideration to inclusion of spouse in further discussion. 469 087 Performance Guidelines Condition 087 Binge drinking in a 25-year-old man AIMS OF STATION To assess the candidate's ability to recognise the specific risks of the patient's drinking pattern and to counsel him accordingly. EXAMINER INSTRUCTIONS This is problem drinking of a binge drinking type with consequential exposure to risk —in this instance, to personal physical injury, neglect of parental responsibilities and potential harm to his daughter. The binge drinking pattern risks impaired judgement and injury to self and others. Other potential problems, some of which he has manifested in the past, are of illness, financial, work, relationship, social, psychological and legal complications. Brief interventions such as this consultation provide a vital opportunity to initiate change in critical patterns of dysfunctional behaviour. The examiner will have instructed the patient as follows: Opening statement • (You are embarrassed and feel tense but attempt to make a joke of it) ‘I deserve this knock and the team lost! I think its put some sense into my head, but I'll listen to your lecture just in case!' • You have no recollection of your fall, or how much you had to drink. • Your mates said you were 'playing up'. • Respond to further questions about the amount you drink, or any other attempt to estimate it (e.g. by cost), defensively — 'not any more than my mates at the club — don't do anybody any harm.' In response to specific questioning: • You drink because it helps you unwind, and makes you more sociable; you need a break by the end of the week with work and taking care of your daughter. • Admit to being stressed by the demands of being a single parent and not being able to call on your family for help because they hold you responsible for your former partner leaving. Now you no longer have a babysitter because the next door neighbour who has filled that role now refuses to do so because of the events last week. She had to go home and left your daughter asleep, alone. • You regard yourself as a responsible and caring parent and had intended to be home. If specifically asked, you admit this has happened before but rationalise your lapses by saying ' The girl is such a good sleeper, she never wakes and would never know.' • You do not feel anxious or depressed. • You do not have any symptoms of panic or phobia of any kind. • You have never had any medical complaints, apart from minor injury like today. • You do have 'blackouts' (episodes of amnesia) quite often. • You do not have any fits, faints, withdrawal symptoms (sweats, tremor and palpitations). • You have had no period of abstinence longer than two weeks. • You have not noted any change in tolerance. 470 087 Performance Guidelines • You do not drink in the morning. • You have had one drink driving charge with no loss of licence several years ago. No other forensic history. Questions which may be asked with appropriate responses • 'Are you saying I'm an alcoholic?' The candidate should indicate there are ranges of consequential problems to excessive drinking, and binge type drinking is associated with increased risk-taking and acute harm events. • 'Look at my father — he's always been a drinker and he's okay' There are various responses, including simply accepting this statement without comment, to a reminder that his father's drinking was associated with violence and family dysfunction, which the patient would want to avoid for his daughter. • 'Howcan I relax if I don't have a few drinks with my mates?'The candidate could respond with an undertaking to discuss this further, or the option of controlled drinking (less feasible with a binge drinking pattern), or some introduction of relaxation techniques. Further instructions: You know this doctor quite well, and generally feel comfortable here. You are embarrassed about your drinking problem being addressed directly and you are initially tense and defensive, especially about any risk or harm to your daughter or doubt about your parenting capacity. However, unless the doctor is unduly critical, you are prepared to listen to the advice and respond in a positive way to changing your drinking habits. EXPECTATIONS OF CANDIDATE PERFORMANCE • Recognise that alcohol overuse — binge pattern — is the primary problem. • Discuss the problem and actual consequences. • Seek out whether there are any aggravating as yet undisclosed issues or current stressors. • Counsel the patient about the risks to his daughter and his relationship with and care of her. • Advise reduction or cessation of alcohol use — discuss. • Demonstrate knowledge of hazardous/harmful drinking levels (NHMRC guidelines for men, safe up to six standard drinks per day. no more than three days a week). • Be able to communicate concern in a nonjudgmental and nonthreatening way so as to maintain rapport and ensure engagement in ongoing review and case management. The candidate is expected to diplomatically but firmly advise that the patient has a habit of binge drinking on weekends, and that change is necessary, for his own wellbeing and his daughter's. The candidate should approach this by discussing this incident and injury and asking about any current problems or stresses, and encouraging the patient to talk about his views about his drinking and other potential problems. KEY ISSUES • Discussion about binge drinking and consequential harm. • Highlight risk to daughter — discuss potential referral to child protective services or equivalent. 471 087 Performance Guidelines CRITICAL ERROR • Not addressing the issue of his daughter's wellbeing, protection and care management in any way. COMMENTARY Alcohol abuse and dependency are linked with genetic and developmental predisposition, developmental, environment, personality traits and other psychiatric illness, especially mood and personality disorders, Sociocultural factors are also significant. The evaluation of all of these elements is important in the individual case, especially identification of concurrent psychiatric illness which requires treatment in its own right, and of interpersonal and sociocultural factors which trigger or maintain the behaviour. Hazardous drinking of excessive quantities of alcohol intermittently is a subtype of alcohol abuse, which is less likely to be associated with addictive/withdrawal symptoms than a daily drinking pattern, and more likely to be associated with injury and other social and interpersonal sequelae of impaired judgement and poor impulse control. The recognition of hazardous drinking depends less on an estimation of the quantity consumed than defining a pattern of drinking, often rapidly, to severe intoxication and consequential risk-taking. The symptom of a 'blackout', a brief period of amnesia without loss of consciousness during a drinking episode, is associated with the rapid consumption/absorption of alcohol and is a useful indicator of this pattern. Incidents of accidental injury to self or others, disinhibition and sexual or aggressive acts, and neglect of self or others are other frequent reasons for intervention. Episodic neglect of financial, occupational and social responsibility is common, such as regularly missing work after weekends. Effectively intervening in such a problem requires identification of the reason for the adverse consequences, sensitive but frank communication about them and the underlying problem and appropriate offers of assistance, including education, assessment of other psychiatric, medical, social, legal and interpersonal problems, motivation for change and ongoing review. In this case, there is a specific need to appropriately address the risk to the patients daughter which must include his responsibility for parental care and protection, and the responsibility of the doctor to monitor and ensure her wellbeing. including consideration of referral to child protective services. In addition to counselling this young man about his hazardous drinking, the doctor may have a statutory obligation to inform an authority such as the Department of Families, Community Services and Indigenous Affairs of his daughter's situation. She is potentially at risk of abuse by neglect. Rather than being punitive or restrictive, the Department's caseworkers should be able to advise him about local child-care and parent support services, as well as possible child-minding options. Consider checking whether notification was made at the time of his presentation to the Emergency Department. Most communities will have single parent support groups and possibly men-only support groups which may be of interest to him. A good general practitioner will either have relevant pamphlets on hand or be able to print the information off line. 472 087 Performance Guidelines In addition to practical support, this man would benefit from understanding simple problem-solving in relation to his daughter's ongoing child-care. For example, through her school he could advertise for part-time child support or pressure the partners of his team mates to care for his daughter during the game and its aftermath. His drinking pattern may jeopardise his ability to drive and hence his livelihood if he should lose his driver's license or have a serious accident. Consider at what point should a clinician notify the local license-issuing authority about CONDITION 087. FIGURE 1. Alcohol content of standard drinks* 'Many thanks to Drug and Alcohol Services South Australia for this poster 473 hazardous drinking. 473 088 Performance Guidelines Condition 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk AIMS OF STATION To assess the candidate's ability to recognise that the history strongly suggests a mild serotonin syndrome. The candidate should ask for findings consistent with the serotonin syndrome, namely: sweating, tremor, elevated blood pressure, increased pulse rate, increased muscle tone and hyper-reflexia. If the candidate has not started to ask for these findings six minutes into the examination, the examiner should advise to proceed with the tasks required, namely advising the patient of the diagnosis and management of both the immediate problem and her depressive illness. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows You are a 30-year-old bank clerk. You suffer from recurrent depression. Your medication has recently been changed (see below). You have come back to the Emergency Department of a nearby general hospital because of severe nausea, headache and the jitters. Your opening statement to the doctor should be: ‘I feel awful doctor — I'm nauseated, I've got a headache and a feeling of the jitters. It all started yesterday'. Without prompting — go on and tell the doctor: 'Three weeks ago my local doctor started me on Prozac® (fluoxetine) 20 mg daily for a relapse of the depression I get. It didn't seem to be helping much'. Two days ago you felt some back pain and attended the hospital Emergency Department. You saw a doctor and mental health nurse and were told it was due to muscle strain'. They were more concerned with your depression and prescribed Zoloft® (sertraline) 100 mg daily. You told them about being on Prozac® which you then stopped taking because you knew that both drugs were antidepressants. In answer to further questions which may be asked: • You feel anxious and 'aroused'. You are still sleeping poorly and waking about 4-5am. You think your appetite was improving before the nausea started. • You have never had suicidal ideas but you remain pessimistic about the future and find it hard to concentrate at work. • Your back pain has resolved. • You have had no other symptoms and your last period was two weeks ago. You are wondering if the medication is the reason you feel so unwell. When the candidate explains that this is the case, you are relieved. You are angry that the hospital doctors did not warn you of this, but on the other hand you think there may well have been some confusion over what was said to whom as they all seemed very busy and distracted and you felt a bit sorry for them and wanted not to bother them too much. You are prepared to follow the doctor's advice about further treatment, but do not want to have another reaction like this. You could say something like 'Could this happen again?' The candidate is not expected to conduct a physical examination, but will ask for appropriate examination findings from the examiner. 474 088 Performance Guidelines Near the end of the exam, if the candidate has not told you to stop the treatment with Zoloft®, you should ask ' S h o u l d I c o n t i n u e w i t h t h e c u r r e n t d o s e o f Z o l o f t ® ? ' Examiner will provide details of physical examination on request as follows: Pulse rate 90/min, regular. Temperature 36.8 °C. Blood pressure 130/80 mmHg She has a tremor, her palms feel sweaty, and tone and reflexes in limbs are brisk and mildly hyperactive. EXPECTATIONS OF CANDIDATE PERFORMANCE • Serotonin syndrome should be diagnosed. • The appropriate advice regarding management is to stop Zoloft® (sertraline) and wait until the symptoms resolve, in about 24 hours. As Prozac® (fluoxetine) has a long half life the candidate should recommend waiting at least another week before reintroducing sertraline, at a lower dose, for example, 25-30 mg. A reasonable alternative is to reintroduce fluoxetine, which has not yet had an adequate therapeutic trial in this patient. The candidate should continue to treat the depression and should arrange followup with the Emergency Department or the patient's general practitioner the next day, and advise the patient to contact the after-hours service immediately if symptoms worsen. Support will need to be provided for the patient during the 'washout' period as she is still depressed. KEY ISSUES • Ability to diagnose the serotonin syndrome due to side effects of a Selective Serotonin Reuptake Inhibitor (SSRI) drug. CRITICAL ERROR • Failure to recognise the need to stop the Zoloft® (sertraline) medication. COMMENTARY This scenario is a timely reminder about aspects of psychopharmacology. Side effects are common with most psychotropics because they may be prescribed too enthusiastically and in dosages that are inappropriately high, especially in management of ' d e p r e s s i o n ' which is a complex multifactorial complaint in our modern society. Not all patients with ' d e p r e s s i o n ' or depressive symptoms need antidepressants, but like antibiotics they are often prescribed reflexly by doctors under time pressure as a ’quick fix – it can’t do any harm’ panacea for a patient in distress or in tears. Often it is the doctor's helplessness that is being treated by the prescription because there is never enough time to establish why this patient is depressed on this occasion. 475 088 Performance Guidelines Another common error is to start with too high a dose if the patient is 'really, really distressed {more must be better and will work faster'). Antidepressants and antipsychotics take 3 4 weeks to work. If the patient's symptoms improve within that time there may be other factors which explain the improvement, such as reduction in anxiety or insomnia or the benefits of a sensitive interview with the discussion of issues and problems, or relief that the problem has been identified and that something is being done. Often it is not symptoms per se that cause patients or relatives to seek treatment. Patients present to doctors when they are worried or anxious about symptoms or behaviours, or someone else is, who influences the patient to attend the consultation. Anxiety intensifies ALL symptoms including 'depression' and is accompanied by typically exaggerated and catastrophic cognitions about the conseguences and outcome of whatever is causing their distress. ‘Is it fatal/terminal? Will I go mad/drop dead etc?' An effective initial consultation with a patient who is 'depressed which attempts a biological-psychologicalsociocultural approach and allows sufficient time for the patient to be listened to, to be understood and to be taken seriously, will in itself relieve a major part of the intensity of the symptoms. This will only enhance the effectiveness of whatever is subseguently recommended or prescribed. Many people with 'depression' have mood fluctuations on a cyclical basis which are subthreshold or relatively mild. These people are more likely to present at their peaks or troughs when they are symptomatic in response to a life event or ongoing environmental stress. Their symptoms may be naturally or temporally transient. If these people (as patients) are then prescribed psychotropics, including antidepressants, when symptomatic (instead of being managed expectantly), and they improve after a few days, they and their clinician may mistakenly attribute their response to the medication. This may commit them to a future psychological dependence on medication rather than learning to tolerate temporary oscillations in mood and biological symptoms by using nonchemical coping strategies. Some doctors and patients have become brainwashed by pharmaceutical companies into believing that any degree of distress or suffering reguires a chemical solution that is quick and effective (but freguently expensive and unnecessary). When a patient has been started on an antidepressant and is appropriately reviewed a week later and reports no improvement, the inexperienced or unaware clinician may recommend doubling the dose and seeing the patient a week later. At two weeks, when there is still no major improvement or cure, the dose will be increased or doubled again. By the third week when the patient reports some improvement at last, this is wrongly attributed to the increase in dosage and not the latent response to the initial dose. SSRIs are potent drugs even in low dosage. Once the dosage increases then side effects and toxicity will increase significantly. Most patients take such medications erratically or in fits and starts (i.e. if they are having ' a good day' they will skip a dose: if it's a bad day', then they will double the dose). Some patients are extremely somatically focused and will develop toxicity just by reading the package inserts about product information. This patient feels aggrieved that she has been mismanaged and ill-served by the doctors who have unknowingly contributed to her serotonin syndrome. Patients deserve better and clinicians must ensure that they are aware of both the risks and benefits of the drugs they prescribe. As patients become better informed, they will not tolerate scenarios like this one lightly. Neither will their legal advisers. 476 088 Performance Guidelines The serotonin syndrome is caused by excess serotonin in the central nervous system, commonly because of drug-drug interaction, in this case inadequate washout between a long half life agent (fluoxetine) and a high starting dose of a second SSRI (sertraline). The syndrome usually presents with changes in mental state (confusion, irritability, labile mood), restlessness, myoclonus, hyper-reflexia. fever, sweating, shivering and tremor and diarrhoea. Hypertension, convulsions, and death have been reported. Treatment is to cease the medication and provide symptomatic care (e.g. cooling blankets). Referral to an emergency specialist may be necessary in more severe cases. 477 089 Performance Guidelines Condition 089 Collapse of a 30-year-old woman on the way to a court attendance AIMS OF STATION To assess the candidate's ability to conduct an examination of the lower limbs focusing on the neurological system. To make a diagnosis based on the neurological findings, observations of the patient's behaviour and the history provided. The examiner will have instructed the patient as follows: • The candidate is to do a neurological examination of your legs and ask you to stand and walk. • Be polite, calm and cooperative. Exhibit a lack of concern for your condition. • Although your spouse is presently in court facing charges linked to his gambling debts, and you cannot walk, behave in an unconcerned manner. • If asked directly, you say that you are a little worried for your spouse but have no concerns for yourself. You have confidence in the hospital that they will be able to help and you will get better. • Candidates are not required to ask any further history from you, and will be directed away from that course by the examiner, should they do so. • During the examination, which involves tests of movement and coordination of your legs, follow the candidate's instructions in a straightforward way while you are on the examination couch — you are not required to simulate any dysfunction or discomfort. • When requested, you are able to lift your legs, and sit over the edge of the examination couch, but you cannot stand, even with support, and firmly decline to walk. • You will not need to ask any specific questions to the candidate. EXPECTATIONS OF CANDIDATE PERFORMANCE When the candidate commences any sensory examination, or asks to do this, the examiner will say that sensation does not need to be tested. The candidate must test: passive and active movement, power, tone, reflexes, coordination and should attempt to test gait. If the candidate attempts to test the plantar reflex, indicate this is down-going. • Tone, coordination and reflexes will be normal. • Inconsistent findings should be noted by the candidate: normal active and passive movements in supine and sitting position, but patient unable to stand or walk, aided or unaided. At six minutes, instruct the candidate to stop the examination, ask the candidate to summarise the findings, and ask the following questions (appropriate answers in brackets): • 'What would you expect to find on sensory examination, given your findings thus far?’ (Normal sensation) • 'What is your likely diagnosis?' (Somatoform conversion disorder or similar term) • 'What has led you to that conclusion?' (Physical findings inappropriate for organic illness) 478 089 Performance Guidelines If there is time, and the candidate has not commented on these features, the examiner could ask: • What have you noticed about the patient's attitude and general behaviour and what does that signify?' • What is your understanding of the psychological reasons for this patient's presentation at this time?' The candidate should be able to: • Perform a systematic motor examination of the lower limbs. • Recognise the presence of incongruous affect, being bland disconcern ('belle indifference'), and its significance for diagnosis. • Formulate a likely diagnosis, being a physical problem developing in an individual under stress: conversion disorder, somatoform disorder, abnormal illness behaviour, sick role behaviour. Malingering is not an acceptable diagnosis because there is no personal gain. Anxiety/stress or other such diagnosis by itself is not an acceptable diagnosis. • Demonstrate familiarity with typically associated findings such as normal sensory examination findings. • Utilise a nonjudgmental approach, in the face of abnormal illness behaviour. • Hypothesise that the 'belle indifference' and physical disability are defences against an overwhelming emotion such as anxiety, anger or shame. KEY ISSUES • Ability to conduct an appropriate focused neurological examination of the lower limbs and identify a somatoform conversion disorder with abnormal illness (sick role) behaviour. CRITICAL ERROR • Failure to conduct a thorough neurological examination as instructed COMMENTARY This station assesses the ability of the candidate to recognise abnormal illness behaviour, to correctly identify conversion disorder and also conduct an examination of the lower limbs. It is an integrated station in that it is assessing both clinical skills in neurological examination and recognition of a psychiatric somatoform disorder. It is thus unacceptable for the candidate to do a cursory or incomplete neurological examination and equally, it is unacceptable for the candidate to conclude the problem is 'stress-related', 'an anxiety disorder' or other such ill-defined diagnosis. Use of terms that are in psychiatric classification schemes, other than the most recent versions of the International Classification of Diseases — ICD10 or American Psychiatric Association DSM-IV, such as hysterical conversion, abnormal illness behaviour and sick role behaviour are acceptable. Stronger candidates may present a more sophisticated diagnosis with formulation, thus correctly linking the conversion disorder to the unresolved emotional conflicts around the impending fraud charges and the candidate's extreme shame and anxiety in regard to this. 479 089 Performance Guidelines The common feature of somatoform disorders is the presence of one or several symptoms or physical signs that suggest an organic or physical illness but which are not explained by any medical condition, or side effects of any medication or substance, or by another psychiatric disorder (e.g. schizophrenia or panic disorder). The symptoms must cause significant distress, impairment or predicaments in the patients social and occupational functioning. These disorders are common and typically first present in general medical or neurological settings. Presentations vary from mild to severe and may be symptom-focused (hypochondriasis) or sign-focused (conversion disorder). This patient has a conversion disorder. Her symptoms are confined to the voluntary central nervous system. The acute disruption in her ability to walk was not associated with any known infection, trauma or physical injury and does not conform to any known neurological damage pattern. Psychological factors associated with the drama and turmoil of her husband's court appearance are highly relevant. Whilst multiple sclerosis, myasthenia gravis and idiopathic periodic paralysis could be considered, they are improbable. The psychological pathogenesis of a conversion symptom is that the individuals somatic symptoms represent a symbolic resolution of an unconscious conflict, thus reducing otherwise overwhelming affects (anger/rage, anxiety, depression, psychosis) and hence keeping the conflict out of conscious awareness ('primary gain'), but at a price. The external benefits of the symptom/illness behaviour may include avoidance or exemption from anxiety-provoking or threatening life experiences (e.g. a court appearance, an exam, a wedding, a job interview), an escape from responsibility, or financial compensation ('secondary gain'). Unlike malingering or the deliberate feigning or faking of symptoms of illness, which is done consciously and with intent, in conversion disorder the motivation is unconscious and unintentional. Typically the neurological findings are bizarre and atypical and do not conform to any known neurological disease, but may reflect the individual's beliefs about how neurological disease may present. Recent functional magnetic resonance imaging and positron emission tomography studies of lower limb psychogenic paralysis, show activation of inhibitory centres in the orbitofrontal and cingulate gyrus areas of the brain with associated nonactivation of the primary motor cortex, when patients were actively trying to move paralysed limbs. Psychogenic paralysis is worse when patients consciously try to move a paralysed limb and are attending to the task, but improves when their attention is distracted. Previous followup studies with conversion disorders suggested that 30% may subsequently develop organic central nervous system disease. With more thorough examination and modern sophisticated investigative technologies missed organic disease may occur in less than 10% nowadays. 'La belle indifference has no diagnostic validity and is nota criterion for diagnosis, nor is there any association with histrionic (or hysterical) personality traits, or repressed sexual conflict in the genesis of most instances of conversion disorder. Diagnosis depends on a careful history and linking a significant life event or interpersonal stress temporally to the onset of the symptoms. Previous episodes of conversion disorder, alexithymia (lack of psychological mindedness). increasing age, lower social class, a family history of physical illness and hence role models and a fear of stigmatisation if psychological disorder is acknowledged, may all predispose to a conversion disorder 480 Performance Guidelines Many conversion disorders resolve spontaneously over a short period of time, especially if the onset was acute, with no specific treatment other than explanation and targetted suggestion (after a thorough history, examination and appropriate investigative workup). Other patients will need active rehabilitation, either as inpatients or as an outpatient, with physiotherapy as the mainstay of treatment. Patients with chronic or multiple sensorimotor disturbances may need treatment in specialised multidisciplinary units or psychiatric units. Patients should be told that their symptoms are real and genuine and that their neurological deficits result from loss of conscious control over the affected function due to a neurochemical disturbance. An expectation of full and complete recovery is provided in conjunction with multimodal therapy, which may include cognitive behavioural treatments antidepressants and physiotherapy. Nontoxic technologies such as ultrasound and transcranial or direct muscle magnetic stimulation may produce dramatic 'cure' of paralysis. An essential part of the treatment is a therapeutic alliance and rapport that allows the patient to recover with dignity and no loss of face. The underlying affects may then emerge and become more florid and obvious, as the weakness or other physical symptoms improve. These patients have exguisite somatic sensitivity and may develop side effects just from reading the manufacturer's package inserts from any medication that is prescribed. Adjunctive psychotropics, usually an SSRI antidepressant and/or an atypical antipsychotic, should usually be prescribed in iow fractional dosages initially and increased very gradually to the normal therapeutic range. Up to 80% of patients make a complete or substantially complete recovery from an individual episode, but 50% may relapse within 5 years. 481 482 3 Clinical Management (M) 3-A: Management Objectives: Therapeutics, Prevention, & Public Health Alan T Rose, Michael R Kidd, and Ronald McCoy 'Disease has social as well as physical, chemical and biologic causes.' H Sigehst (1891-1957) The term management can be used broadly to describe what the doctor does once the history and physical examination have been completed. At that stage, a firm diagnosis may not have been reached so that the next step in management may be to proceed with investigations or referral. Some of the illustrative management cases in this book begin with a statement of the diagnosis which is provided to the candidate. Others provide sufficient information for the candidate to formulate diagnostic and management plans. In others the information provided directs the candidate to undertake investigations to facilitate diagnosis, or the patient may be returning for a second consultation with results of investigations now to hand. Once the cause of the clinical presentation has been fully identified and treatment is about to begin, the emphasis is now on the formulation of a management plan by the candidate, which may include patient education and reassurance, advice and counselling, prescribing medication, recommending a procedure, onward referral, arranging hospital admission, preventive care, and followup. Separation of diagnostic and management phases allows parts of what would be regarded as a long case' in normal clinical practice to be completed within the time allowed. Management will often involve others beside the patient: a parent, spouse/partner, carer, other family members or others, such as employers. The ethical bounds of confidentiality must always be kept in mind. In complex cases, the clinician may be confronted with numerous conditions to deal with some of which may be self-limiting, some insoluble, and others with a low priority. Thus, one may have to use techniques of 'selective attention' and 'selective neglect' whereby a conscious decision is made to focus on some problems, but not on others, putting aside some for exploring at a later consultation. OBJECTIVES OF THE MANAGEMENT PHASE OF THE CONSULTATION ARE TO: • treat appropriately the patient and presenting condition; • educate the patient about the condition; • involve patients as far as possible in the management of their own conditions and ailments; • achieve compliance in therapy; • emphasise preventive opportunities; and • provide appropriate support and reassurance. 483 3-A Management Objectives: Therapeutics, Prevention, and Public Health THE MANAGEMENT PROCESS The following guidelines provide a sequence of steps for the management process. Not all are appropriate to every case, and there will be different emphases according to the nature of the clinical problem. The doctor should: • Tell the patient the diagnosis. ~ The medical term as well as the common or lay name should be given (e.g. Herpes zoster/shingles). An offer to write the medical term down should be made. The use of medical abbreviations should be avoided (e.g. AMI). • Reassure the patient if the condition is minor, or advise the patient of appropriate serious concerns in a nonthreatening and supportive way. ~ An anxious patient may not absorb detailed information adequately before being given time to consider the implications of an important or serious diagnosis • Establish the patient's knowledge, understanding and attitude regarding the condition. ~ Patients are usually reticent to admit ignorance of a condition and need encouragement to make inquiries (because of concern about wasting the doctor's time). • Educate the patient about the condition. ~ Correct any incorrect beliefs. ~ Supplement existing knowledge to a level appropriate to the needs of the patient and the doctor. ~ The use of a diagram, model, or the patient's X-rays, ultrasounds or scans, will often facilitate effective communication. • Answer the patient's questions. These may reveal misunderstandings which require further explanation. The doctor should exhibit tolerance to repetition of questions, and be prepared to repeat or complete the provision of information at a subsequent consultation. • Propose therapy within an appropriate timeframe. ~ Immediate, including when no action is required. Hospital admission may be the most important action to be taken. ~ Longterm, if the illness is chronic or recurrent. • ~ Preventive, which may be specific and may require lifestyle change. Refer as required to a medical specialist or allied health professional. The standard of written referrals is often inadequate. Referrals can be given to the patients to carry or sent separately. Enclosing copies of relevant investigations and other medical reports is advisable. When considering the degree of urgency of the referral it should be remembered that few patients feel they have minor problems in which long delays are acceptable. Candidates in the AMC clinical examination need to recognise that referral to a specialist is not sufficient action, unless the candidate indicates why the referral is necessary, and what action the specialist is likely to take. • Supplement and reinforce the information already given during discussion by providing written instructions, or by supplying leaflets and brochures. • Counsel the patient or relative as required (see also Section 1-A). • Arrange followup — this may include an offer to see another member of the patients family, with the patient's consent. Patients should leave the consultation with a clear understanding of whether the doctor wishes to review this episode of illness, by what means and when. 484 3-A Management Objectives: Therapeutics, Prevention, and Public Health If investigations have been ordered, it is important for the doctor to review these, and to inform the patient of the results, at a subsequent consultation, or by telephone or letter. Unexpected adverse results should be conveyed by further interview, rather than by telephone. Overlooking to inform a patient of serious adverse results can have medicolegal complications, even when the patient has been instructed to ring to check for results and failed to do so. THERAPEUTICS Therapeutics is the selection and use of pharmaceutical agents in the treatment and prevention of ill health and in the maintenance of an individual's health status. Australians are fortunate to have a Pharmaceutical Benefits Scheme which provides federal government subsidies to patients for prescribed approved medicines (outside of public hospitals) by registered medical practitioners who hold a preserver's number issued by the federal health department. Costs to patients are further reduced by concessions to certain income and age groups and ex-service personnel — 'safety net' levels also apply to individual's/family's annual expenditure on prescribed medicines. Candidates for the AMC examinations are advised to be familiar with the 'Schedule of Pharmaceutical Benefits' handbook updated three times a year by the Australian government and issued free to registered doctors, dentists and pharmacists. It contains a list of all subsidised pharmaceuticals classified by disease categories, similarities of actions, generic and trade names, form, prescription quantities and their cost to the government. The use of pharmaceuticals in therapy usually begins once a positive diagnosis has been made. Exceptions are where relief of severe pain is necessary before the diagnosis has been established or proven (renal colic, biliary colic), when a therapeutic trial using medication can confirm a strongly suspected diagnosis (gout, polymyalgia rheumatica), or when medication is given before a diagnosis has been confirmed because early treatment is necessary to avoid serious, even life-threatening consequences (temporal arteritis, meningococcal septicaemia). Some items require government approval before prescribing because of their high cost or risk of adverse reactions. All these considerations have an effect on what pharmaceutical item is selected by the doctor for the treatment of a particular condition. Candidates are also referred to a series of publications entitled 'Therapeutic Guidelines', each covering a different body system. They contain regularly updated advice from dedicated consensus groups on the current therapy for most diseases, and are invaluable aids. Australians also self-medicate with 'over-the-counter' items available from pharmacies and health food or natural lifestyle outlets. Knowledge by the doctor of the use of these substances by patients can assist in understanding the patient's attitude to sickness and health, awareness of possible drug interactions and the possibility of noncompliance. 485 3-A Management Objectives: Therapeutics, Prevention, and Public Health Patient perception of the effectiveness of medications (e.g. the use of antibiotics for viral infections), varies markedly. Patients often attribute their recovery to medications rather than to spontaneous resolution. Also important in considering drug therapy, is the need to treat more than one condition in the same patient (e.g. a diabetic patient who is hypertensive and has hyperlipidaemia). Polypharmacy is common in older age groups where several chronic conditions are being treated simultaneously, or when a patient on longterm medication develops an acute illness which demands additional medication. Patients may be confused when medications are added, existing regimens are altered or dosages changed. Patients may also be uncertain which of their medications relates to which of their ailments and be mistaken about the timing or frequency regimens of their medication. These shortcomings need to be understood by the doctor who must instruct the patient carefully. This may include writing the instructions down. The situation is compounded by patients attending multiple doctors. Patients will not necessarily volunteer what medications they are on to a second doctor, even when referred for specialist care. The creation of medication lists on a patient's computer-generated medical record has not replaced personal communication and enquiry about medication from the doctor to the patient. Pharmacists have limited capacity to detect inappropriate prescribing because patients use different pharmacies, and because it is unethical for a pharmacist to ask a patient what diagnosis has been made by the doctor. Iatrogenic illness has steadily increased because of polypharmacy, drug interactions, and patient confusion over medication dosage, together with adverse reactions, allergies and idiosyncrasies which may be associated with the use of any medication. TAKING A 'DRUG' HISTORY Diagnostic consultations often require a 'drug' history, as follows: • • • ‘Do you take now or in the past any prescription or over-the-counter medicines?' 'What for, and were they helpful or did you have any side-effects?' 'Do you have any allergies to medications?' If a history of allergy is given, establish details and severity to determine risk of anaphylaxis, for example to penicillin. Always consider whether reactions, side effects or drug interactions may be contributing to symptoms (for example, asthma, claudication or cardiac failure from Beta receptor blocking agents; or cough from ACE inhibitors). Of particular importance are the effects of some antibiotics on the efficacy of oral contraception, and drugs which accentuate or decrease anticoagulant actions of warfarin. The proprietary publication MI MS, updated six times annually and circulated to medical practitioners is a very useful guide to such effects, as are databases on office personal computers. Assessment of knowledge of therapeutics frequently takes place in management consultations The use of pharmaceuticals in therapy usually begins once a positive diagnosis has been made. Exceptions are where relief of severe pain is necessary before the diagnosis has been established or proven (renal colic, biliary colic), when a therapeutic trial using medication can confirm a strongly suspected diagnosis (gout, polymyalgia rheumatica), or when medication is given before a diagnosis has been confirmed because early treatment is necessary to avoid serious, even life-threatening consequences (temporal arteritis, meningococcal septicaemia). 486 3-A Management Objectives: Therapeutics, Prevention, and Public Health The first step is for the doctor to select the correct therapeutic agents and name them by generic or proprietary name and then comply with any government restrictions on use decide on dose, form, route and time of administration and ensure that a sufficient supply (which may include repeats) is ordered. These decisions are either written or processed onto personalised numbered prescription forms supplied by the government. These are the instructions which the patient takes to a pharmacy to obtain the medicine. As emphasised above it is the doctor's responsibility to be aware of significant side effects (unwanted symptoms from the drug, potential adverse reactions or drug interactions), and to advise patients or relatives accordingly. It is at the doctor's discretion as to how much of such information should be discussed with individual patients, but pharmacists are required to offer this information to patients, sometimes in printed form. A major objective of the doctor in therapeutics is to achieve patient compliance in the use of medication. The doctor's function of prescribing medication is a complex process dependent not only on knowledge of available therapies for specific diseases, but also on aspects of patient behaviour. Often a wide range of therapeutic agents is applicable to a single condition (e.g. hypertension) where therapeutic pharmacology is complex. Fifty different generic products (classified into 22 different categories) are listed on the PBS for the treatment of hypertension. Most of these agents have several proprietary names. In the MIMS therapeutic classification index, 21 different system and function groupings are listed, each with numerous (up to 14) subcategories. The pharmaceutical companies employ many strategies for marketing their particular product to doctors. More authoritative and referenced information about new drugs, indications, side effects, adverse reactions and interactions is available in 'Australian Prescribe? (also online) circulated free to all doctors in Australia by the Commonwealth Government. Drug usage and dosage need modification in the following circumstances: • Pregnancy — drugs potentially harmful to the fetus, particularly those with teratogenic potential, must be avoided. • Children correct dosage is especially important in infants and small children and must be individualised and based on weight. • Elderly patients — drug tolerance is reduced increasing risks of overdosage (e.g. postural hypotension from antihypertensives). • Impaired organ function — especially liver failure or renal insufficiency. • Previous portal-systemic shunting operations. • The most commonly prescribed drugs cover a wide range, and include blood lipid-lowering agents, antiangina agents, antihypertensives, ACE inhibitors, proton-pump inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), bronchodilator aerosols, diuretics, sedatives and anxiolytics, together with antibiotics. 487 3-A Management Objectives: Therapeutics, Prevention, and Public Health PUBLIC HEALTH MANAGEMENT Medical practitioners have a central role in public health and the prevention of disease To be effective in this role, clinicians need to be • opportunistic in offering preventive care when patients present with other problems or concerns; • anticipatory in routinely assessing the preventive care needs of their patients; • proactive in targeting preventive care most intensively to high risk individuals; and • reaching all of their patients, especially those who are least likely to seek out assistance. This involves looking beyond the individual consultation to the population of patients we serve. For example, to be effective in immunisation or screening, clinicians must reach a large proportion of patients in their practice or community. To do this effectively can be difficult. Each preventive activity uses up some of the clinicians' available time to spend with their patients, and therefore each activity must be based upon sound research evidence of what is effective. Clinicians therefore need to understand which preventive activities are recommended as the costs may outweigh the benefits when assessed by carefully designed research studies. Candidates can access Guidelines on Preventive Activities from the Royal Australian College of General Practitioners website (www.racgp.org.au). These guidelines only include activities of relevance where research has shown a demonstrated benefit. One of the challenges for clinicians is to ensure access to preventive care for all their patients. Some groups have increased risk of diseases because of social or other factors. The links between poor health and socioeconomic disadvantage include a relationship between mortality, social class and how connected people are to their communities. The opportunities for health are affected by where people live, their skills, their communities and lifestyles. Poorer health makes disadvantaged groups major users of general practice and they are also the lowest users of preventive care services. Social and economic factors influencing health include: level of education; occupational status; employment status; income; place of residence and migration. Candidates need also to understand the special public health and preventive issues facing Aboriginal peoples and Torres Strait Islanders. The poor health of Aboriginal peoples and Torres Strait Islanders has many causes including social and economic factors and the history of colonisation, and is also exacerbated by poor access to preventive treatment and late intervention, with many cases of chronic disease only diagnosed when complications are already present. Notification of infectious diseases is an important public health responsibility for all clinicians. Candidates should know which diseases are notifiable to public health authorities and how they are to be reported. Recent Australian experience with SARS and related epidemics have emphasised the importance of knowing how to contact local public health authorities. Candidates should be aware of how to contact relevant public health authorities in the event of requiring assistance and advice in issues of public safety. Alan T Rose, Michael R Kidd and Ronald McCoy 488 3-A Management Objectives: Therapeutics, Prevention, and Public Health 3-A Management Objectives, Therapeutics, Prevention and Public Health Candidate Information and Tasks MCAT 090-100 90 Acute right-sided pain and haematuria in a 25-year-old man 91 Faecal soiling in a 5-year-old boy 92 Psoriasis in a 30-year-old man 93 Temporal arteritis in a 58-year-old woman 94 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man 95 Dysuria and urinary frequency in a 40-year-old man 96 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 97 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida 98 Bed-wetting by a 5-year-old boy 99 Acute gout in a 48-year-old man 100 Request for repeat benzodiazepine prescription from a 25-year-old man 489 090 Candidate Information and Tasks Condition 090 Acute right-sided pain and haematuria in a 25-year-old man CANDIDATE INFORMATION AND TASKS This 25-year-old man is being seen in the hospital Emergency Department with a first episode of severe right-sided abdominal pain. The pain came on two hours earlier and was so severe that the patient writhed in agony unable to relieve his symptoms. The pain started in the right side of his back and radiated into his right groin and testicle. He is now free of pain. He has had no pain like this previously and has been in good general health. Physical examination findings are normal, except that his urine is positive for blood on chemical testing. There is no loin or other tenderness. You have just finished examining him. YOUR TASKS ARE TO: \ • Determine the most likely diagnosis and discuss initial investigations with the examiner. • Explain the diagnosis to the patient. • Outline your management plan, and any further investigations required, to the patient. You will not need to take any additional history. There is no need for you to ask the examiner about any other findings on clinical examination. The Performance Guidelines for Condition 090 can be found on page 500 490 091 Candidate Information and Tasks Condition 091 Faecal soiling in a 5-year-old boy CANDIDATE INFORMATION AND TASKS Mark, a five-year-old boy, is brought to see you in a general practice setting, because for the past six weeks he has been soiling his pants, with increasing frequency, with foul-smelling semifluid faeces. It is now happening almost every day and he is being teased at school. His parent cannot tell you much about his bowel habits as he now attends to his own toilet needs when he feels like it. YOUR TASKS ARE TO: • Take a further focused history from the parent. • Ask the examiner for the appropriate findings on examination of the child which would be relevant to your diagnosis. • Explain your diagnosis to the parent and advise on management. The Performance Guidelines for Condition 091 can be found on page 503 491 092 Candidate Information and Tasks Condition 092 Psoriasis in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You are seeing a 30-year-old man who works as a bank teller. He has consulted you about a rash on the extensor surfaces of both elbows and both knees, over the sternal and lower back areas, and in the scalp. It first appeared after a motor accident six months ago in which he suffered a fractured femur. The patient remembers that his father, now deceased, used to be bothered by a chronic rash. It has been getting steadily worse over the last few months with some improvement following the use of cream obtained from the local pharmacist (Egopsoryl TA®). This has helped the rash on his body but not on elbows, knees and in the hair. Examination has revealed the typical lesions of plaque type psoriasis. The plaques vary in size from a few mm to several cm. They are raised, pink and covered with a silvery waxy scale. The nails are not affected. The level of severity for this patient's psoriasis should be regarded as moderately severe. You are about to discuss the disease and its management with the patient. The photograph shows details of the skin lesions on the knees. YOUR TASKS ARE TO: • Explain the nature of his condition to the patient • Advise the patient about management. CONDITION 092. FIGURE 1. The Performance Guidelines for Condition 092 can be found on page 507 492 Candidate Information 093 and Tasks Condition 093 Temporal arteritis in a 58-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. This 58-year-old woman has consulted you about the recent onset (two weeks) of right-sided headache gradually becoming more and more severe, and which is now constant. Over the last few days, the patient has also had a tight feeling in the muscles on the right hand side of the face when chewing. On physical examination you noted tenderness and tortuosity over the right temporal artery as illustrated. Its pulsation cannot be felt as well as that of the temporal artery on the left. There were no other abnormal physical findings. The patient is normotensive. 093. FIGURE 1. Side view of right temple CONDITION Based on this information you believe that the most likely cause of the patient's symptoms is temporal arteritis ('cranial arteritis' or 'giant cell arteritis'). Brief Patient Profile Married, works as an accountant. Nonsmoker. No significant past or family history except for occasional migraine. Has been taking Panadol® (paracetamol 500 mg) for the headache. YOUR TASKS ARE TO: • Explain the diagnosis, and its implications, to the patient. • Advise the patient about management — both immediate and longterm. This could include any investigations you believe are necessary. You do not need to take any further history. You have just concluded your physical examination and are about to advise the patient of your diagnosis and management plans. The Performance Guidelines for Condition 093 can be found on page 510 493 094 Candidate Information and Tasks Condition 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are consulting in a general practice. You have just completed taking a history from and examining a 40-year-old man who is very upset because of the sudden onset of paralysis of his face. He felt discomfort behind the left ear last night and on waking today found that the left side of his face would not move. He arranged an urgent appointment with you. Examination confirms a near complete left 7th cranial nerve facial palsy of lower motor neurone type. The accompanying illustrations show the findings. There are no other abnormal neurological or other signs including normal ear canals and tympanic membranes. The patients parotid salivary glands show no abnormality. You have made a confident clinical diagnosis of acute idiopathic facial nerve palsy (Bell Palsy') YOUR TASKS ARE TO: • Explain the problem to the patient. • Advise the patient of the management you would advise. • Respond to any questions asked by the patient. The patient is very upset and concerned that this may be a stroke, and wishes to know the cause, whether recovery will occur, what treatment and tests he should have and how long it will take to recover. Time should not be wasted taking further history or asking for any other physical findings. The main issues to be addressed are patient counselling and management. Smiling Blowing out cheeks CONDITION 094. FIGURES 1-4. These illustrations show his facial appearance in repose and with smiling and movements. The Performance Guidelines for Condition 094 can be found on page 512 494 095 Candidate Information and Tasks Condition 095 Dysuria and urinary frequency in a 40-year-old man CANDIDATE INFORMATION AND TASKS This 40-year-old postman is married with two children and has consulted you today in a general practice setting complaining of the gradual onset of dysuria and frequency of micturition over the last three days. There has been no urethral discharge and no history of extramarital sexual contact. On examination the patient is afebrile and you found no abnormality on examination, including rectal examination of the prostate. A midstream urine specimen was collected and the following office laboratory tests were done on the urine • Dipstix — positive for protein, leucocytes and nitrites: negative for blood, glucose and ketones. • Microscopy of uncentrifuged specimen — shows large numbers of leucocytes and bacilli. The patient usually keeps in excellent health. He is aware that he is sensitive to penicillin but otherwise his past history, family history, habits, and use of medication have no relevance to this problem. YOUR TASKS ARE TO: • Advise the patient of your diagnosis. • Advise the patient of your immediate management. • Discuss the condition and answer any questions the patient may ask. CONDITION 095. FIGURE 1. Urine test strip The Performance Guidelines for Condition 095 can be found on page 519 495 096-097 Candidate Information and Tasks Condition 096 Eclampsia in a 22-year-old primigravida at 38 weeks gestation CANDIDATE INFORMATION AND TASKS This 22-year-old primigravida has been seeing you in a general practice clinic for her shared antenatal care since early in her pregnancy. She is now at 38 weeks of gestation. The pregnancy has been progressing perfectly normally until now. Whilst in the waiting room along with her mother waiting to see you for her routine antenatal visit, she has had a g r a n d m a l fit. She had brought a urine specimen with her to the appointment. YOUR TASKS ARE TO: • Take any further relevant history you require from the mother of the patient, who is in the waiting room. • Ask the examiner about the specific findings you would look for on general and obstetric examination and any office test results which should be available to you. • Advise the mother of the patient, in lay terms, of the diagnosis and the subsequent management you would advise for her daughter. The Performance Guidelines for Condition 096 can be found on page 522 Condition 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida CANDIDATE INFORMATION AND TASKS This patient is a 34-year-old obese primigravida whom you are managing in a country general practice. She has had a screening glucose tolerance test performed at 28 weeks of gestation. This revealed a fasting blood glucose of 7.5 mmol/L and a two hour level of 9.5 mmol/L (Normal levels — fasting < 5.5 mmol/L; two hour < 8.0 mmol/L). Progress of her pregnancy has until now been normal. No other investigations have been done apart from routine screening tests at the first antenatal visit which were all normal. YOUR TASKS ARE TO: • Take any further relevant history you require. This should be limited to 1-2 minutes only. • Ask the examiner for the findings you would expect on general and obstetric examination. • Advise the patient of the diagnosis you have made. • Advise the patient of the management you would give in the remainder of the pregnancy. The Performance Guidelines for Condition 097 can be found on page 525 496 098-099 Candidate Information and Tasks Condition 098 Bed-wetting by a 5-year-old boy CANDIDATE INFORMATION AND TASKS Johnny, a five-year-old boy, is brought to see you in a general practice by his mother because of a bed-wetting problem, which occurs nightly. He has • been fully continent by day since he was three years old: and has • previously been treated unsuccessfully with nightly amitriptyline (Tryptanol®). The wetting exasperated his parents initially, but they now accept that it is involuntary and both parents are keen to help him in any way possible. YOUR TASKS ARE TO: • Ask the mother for any further relevant history. • Tell the examiner what relevant examination findings you would seek. • Advise Johnny's mother how you will further assess and manage his condition. The Performance Guidelines for Condition 098 can be found on page 528 Condition 099 Acute gout in a 48-year-old man CANDIDATE INFORMATION AND TASKS You are about to see a 48-year-old taxi driver who consulted you earlier today in a general practice setting about continuous, severe, worsening, throbbing pain in the right first metatarsophalangeal joint, which commenced two days ago. The joint was swollen and felt hot. The overlying skin was red and shiny and the joint was exquisitely tender. There is a history of previous attacks over the last two years. These have been diagnosed as gout. Each time response to treatment was satisfactory. You took blood for serum urate estimation. The patient has returned to find out the result (which was 0.74 mmol/L) and for treatment. The normal serum urate range for males is 0.20-0.45 mmol/L. Urinalysis is normal. The patient has always kept in good health apart from mild hypertension diagnosed two years ago for which he takes hydrochlorothiazide. Over the past two days he has taken two or three aspirin tablets for the pain. YOUR TASKS ARE TO: • Advise treatment of the acute attack. • Discuss further management of his condition. There is no need for you to take any additional history or perform any examination. The Performance Guidelines for Condition 099 can be found on page 531 497 100 Candidate Information and Tasks Condition 100 Request for repeat benzodiazepine prescription from a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. You saw this patient for the first time one week ago and provided a prescription for his usual sleeping tablet, the benzodiazepine oxazepam (Serepax®) 30 mg daily, 25 tablets. At that time, you were satisfied there were no comorbid problems such as depression. The patient has returned today for another prescription. The patient's mental state is unchanged. YOUR TASKS ARE TO: • Evaluate the situation by taking a focused history. • Outline to the patient the nature of the problem you have identified and proposed management. • Answer any questions the examiner asks you. The Performance Guidelines for Condition 100 can be found on page 534 498 3-A Management Objectives: Therapeutics, Prevention, and Public Health 3-A Management Objectives, Therapeutics, Prevention and Public Health Performance Guidelines MCAT 090-100 90 Acute right-sided pain and haematuria in a 25-year-old man 91 Faecal soiling in a 5-year-old boy 92 Psoriasis in a 30-year-old man 93 Temporal arteritis in a 58-year-old woman 94 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man 95 Dysuria and urinary frequency in a 40-year-old man 96 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 97 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida 98 Bed-wetting by a 5-year-old boy 99 Acute gout in a 48-year-old man 100 Request for repeat benzodiazepine prescription from a 25-year-old man 499 090 Performance Guidelines Condition 090 Acute right-sided pain and haematuria in a 25-year-old man AIMS OF STATION To assess the candidate's knowledge of the natural history of urinary calculi, and ability to diagnose and manage a patient with a recent history of renal pain associated with a stone in the ureter. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 25 years and about two hours ago you developed severe right-sided back and abdominal pain. The pain was gripping, severe and constant, with episodes of increased severity each few minutes. The pain extended from the loin to your right testicle. You have been writhing in agony with this pain, and never experienced anything like it before. Fortunately it gradually eased and ceased after about 30 minutes. You have come to the Emergency Department and have seen the doctor. The doctor has listened to your story and taken a full physical examination and you have given him a sample of urine for analysis. The pain has now settled. The doctor will explain to you the diagnosis and proposed management. You have not heard about renal/ureteric colic or a stone passing from the kidney down the ureter (the tube between the kidney and bladder), but have heard of kidney stones. Questions to ask unless already covered and appropriate responses from doctor/candidate (Answers in parentheses after the question): • ‘Do / need to be admitted to hospital?' (Not at this stage) • 'Will the pain come back?' (Possibly, if the stone is still in the ureter). 'Why did I get the stone?' — Ask this if the candidate suggests a stone is the cause of the • pain. • • ‘How will I know if I have passed the stone?' (You will strain your urine). 'What happens if the stone does not pass?' (An instrument may have to be inserted to retrieve it). • 'When do I see you again?' (Followup in a couple of days for investigation results). The candidate should explain that you have a small stone that is passing down your ureter. It may take one to two days to pass the stone. You will be given strong painkillers for the pain in case it recurs. Most stones pass spontaneously. You are unlikely to have future problems, but tests on your urine and blood will be done to check this. The investigations required are likely to include: • Culture of the urine to exclude infection. • An ultrasound of the kidney may be performed looking for evidence of blockage of the ureter caused by the stone. • Imaging by computed tomography (CT) to define the size and site of the stone. • Examination of the stone after you have passed it to determine the type of stone present. • Other blood tests and specialist referral may be required in followup. 500 090 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • The candidate should indicate the pain is almost certainly due to renal colic, due to the fact a small stone is being passed down the right ureter. No need for pethidine now as pain has gone. If pain returns, give pethidine or Panadeine forte® or a nonsteroidal antiinflammatory drug (NSAID). • Give patient a brief description (draw diagram) of the anatomy of the kidneys, ureters, bladder and urethra. • Pass all urine into a container and strain (save any stones found for analysis). • Imaging by computed tomography (CT) abdomen or plain X-ray, to identify the site of the stone and use for subsequent assessment. • Check urine for infection. • Check serum uric acid, and serum calcium, urea and creatinine. • Ultrasound to see if hydronephrosis is present is an acceptable and appropriate test, but definitive imaging is by helical abdominal CT which will pick up very small stones. • Advise high fluid intake. Refer to urologist if stone is not passed in 48 hours or pain recurs and worsens. He may need an open operation, endoscopic removal, or ultrasound destruction if not passed spontaneously (depends on size and site of stone). • Followup to check progress. KEY ISSUES • Diagnosis of renal 'colic', probably due to a stone in right ureter. • Explanation of the problem to the patient incorporating rapport with the patient and communication skills. • Providing an appropriate plan of management (including provision for further pain relief). • Appropriate choice of investigations. CRITICAL ERRORS • Failure to make a diagnosis of renal (ureteric) colic. • Failure to arrange appropriate investigations. COMMENTARY Renal and ureteric pain ('renal colic') frequently accompanies urinary calculi passing from kidney to bladder via the ureter. Although the term, renal 'colic', is hallowed by long usage (as is biliary 'colic'), in neither instance is the pain usually of true 'colicky' type. Renal 'colic' is often an intense, constant, agonising pain which makes the patient writhe and change position in an attempt to gain relief, and does not wax and wane intermittently in a sine-wave pattern, rising through a crescendo of intensity, and then diminishing over a similar period, with regular intervals of relief from pain in between episodes of cramping pain. This is the pattern of true 'colic', as seen in intestinal colic or uterine colic. Renal pain can vary in intensity but not with such cyclical regularity. 501 090 Performance Guidelines Renal (and ureteric) pain is usually recognised by its character as described above, its site (which can be over a wide area from posteriorly and laterally in the loin and flank, to the anterior abdomen, iliac fossa and suprapubically). Pain can also radiate to the penis and testes, and to the upper thigh. Associated urinary symptoms and the presence of blood in the urine (macroscopic or microscopic) help confirm the diagnosis. Investigations of presumed renal colic due to stone are by diagnostic imaging. Most urinary calculi (80%) are radio-opaque so plain abdominal X-ray may be diagnostic (as illustrated), however small stones may be missed and differentiation from pelvic phleboliths impossible. The preferred investigation is a helical CT without intravenous contrast (as illustrated), which will pick up any small stones and also identify urinary tract obstructions. The majority of stones will pass spontaneously, so that treatment is usually expectant while providing pain relief for recurrence of pain. Indications for intervention are large stones not likely to pass spontaneously, calculi associated with uncontrolled infection, and persistence of pain without progress. Radiolucent stones occur with hyperuricaemia and in some types of familial and metabolic calculi. It is prudent in each patient with a urinary calculus to check for hypercalcaemiato pick up cases of primary hyperparathyroidism presenting as renal calculi, a common mode of presentation of parathyroid adenoma. Full investigation for a primary cause is mandatory in patients with a history of recurrent calculi. CONDITION 090. FIGURE 1. Plain X-ray showing opaque ureteric calculi 502 CONDITION 090. FIGURE 2. Helical CT showing obstructing right ureteric calculus 091 Performance Guidelines Condition 091 Faecal soiling in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and manage the problem of encopresis in a young child secondary to constipation and faecal retention and to advise the concerned parent on management. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: The doctor is required to question you further, seeking a possible cause for your child's soiling. Below are a series of answers to possible questions you may be asked' • You are a very concerned parent about your child's constant soiling over the last six weeks. • This is most unlike him as he was fully toilet trained by three. • He is embarrassed by it, especially at school where the other children are calling him names. Sometimes he hides his soiled underpants. • This has been occurring for the last six weeks or so. He had an episode three months ago when his bowel motions were hard and difficult to pass and caused him bleeding and pain when he went to the toilet. However he seemed to get over that with some laxatives. • There is no abdominal pain. • He has had no vomiting. • His appetite is good and he has a well balanced diet with lots of fruit and vegetables. • He has not lost any weight. • His urine is normal and he has no daytime or evening urinary incontinence. • Except for the recent teasing, he enjoys school and he has lots of friends. His progress at school is excellent and he enjoys the teaching he has had this year • He has a good relationship with his younger sibling. • His general health is excellent. • He is the elder of two children. The home situation is very stable with both parents very active in the raising of the children. Once the doctor has finished questioning you, the examiner will provide examination findings on your child, then the candidate is required to explain to you what is wrong and the principles of management. Questions to ask unless already covered: • 'What can we do to treat this?' • 'Surely he must smell It when he does It in his pants? Doesn't he know he is soiling himself?’ 503 091 Performance Guidelines Examination findings — provide findings specifically requested • a shy boy; • normal height and weight on 50th centile; • abdomen is soft; • faecal masses are felt in the lower guadrants; • no other abnormality; • anus appears normal, with some faecal staining adjacent; • no anal fissure is apparent; and • on rectal examination the rectum is packed with firm faeces. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain that: • The most likely diagnosis is chronic constipation which from the history is most likely secondary to the probable anal fissure he had three months previously. The constipation leads to chronic dilatation of the rectum and lower colon. • Liguefaction of the faeces leads to soiling from overflow, but faecal masses remain. • The process often starts as an anal fissure, giving pain, and the child holds on fearing defaecation will be painful. • Other aetiologies should be explored (e.g. emotional disturbances at home or school). None is apparent, and so constipation with overflow is the most likely diagnosis. Management • Empty large bowel by whatever means necessary. Try high dose oral laxative, enema or suppositories. • Explain that if this is not successful he may need oral gastrointestinal lavage (Golytely®). • Next objective is to maintain regular bowel habit by use of laxatives and faecal softeners. Therapy needs to continue for many months to allow resolution of the megacolon and to ensure that the passage of motions is not painful. • Review to ensure constipation is not recurring. • See regularly to encourage and support parent and child in their efforts. Interaction with patient • Explanation with appropriate language to parent to discuss the matters with the child. Behavioural technigues such as a star chart to reward successful defaecation should be encouraged. • Suggest regular toileting after meals for a set period of time; an egg timer is suitable for timing. KEY ISSUES • Explanation of diagnosis • Initial empting of rectum and colon. • Need for prolonged treatment and followup 504 091 Performance Guidelines CRITICAL ERROR • Suggesting that sigmoidoscopy or colonoscopy is required at this stage. COMMENTARY Constipation in young children is a very common problem presenting to primary care physicians and paediatricians alike. The great majority of cases are nonorganic, that is they are related to an episode, in many cases associated with the passage of a hard stool, which may make the child wary of passing a bowel motion subsequently. This can last for a varying length of time. Constipation can be associated with a mucosal tear or anal fissure which distresses the child, further compounding the problem. If one is able to recognise this pattern early and treat it with faecal softeners allowing the fissure to heal, the episode may be short lived. Major problems may develop, however, if the child remains fearful of going to the toilet because of anticipation of pain and this compounds the situation leading to chronic constipation, toilet refusal and in many cases overflow encopresis. This may be more difficult to treat. Young children may also develop a fear of the toilet during toilet training if they are required to perch on a toilet seat without support and this also may lead to deferral and subsequent constipation. In many children, constipation is secondary to an emotional upset or trauma, whether this is at home, school or elsewhere. Careful enquiry is necessary to seek information indicating that this may exist. The aims of management are therefore to: • Exclude any possible organic pathology. • Explore any precipitating features. • Provide adequate explanation of the processes involved for both parent and child with a plan of action to alleviate the problem. The hallmark of care of these children is a thorough and careful history which, in the majority of cases, will clarify the probable aetiology. The history should include a thorough enquiry into the child's environment. While organic conditions like Hirschsprung disease may need to be considered, Hirschsprung disease has usually presented by this age and usually has a history of constipation from birth, often with a delay in the passage of meconium. However, if there is doubt or suspicion of this condition, a paediatric surgical opinion should be sought to arrange bowel biopsies. The history should include a thorough enquiry into aspects of the child's environment including diet, general health, growth pattern, the family dynamics, progress at school, relationship with peers, and the like. From this information a likely diagnosis may be evident. Treatment is essentially careful reassurance and explanation to parent and child of the nature of the condition, if organic pathology is not suspected. This should include a comprehensive explanation about how constipation has developed, preferably with illustrative drawings. To achieve success is very time consuming in resistant cases, and the doctor's role is to be supportive of the efforts of the parent and child, riding with them the inevitable ups and downs towards success. 505 091 Performance Guidelines The bowel however usually needs to be emptied of the retained faeces in the most painless and noninvasive manner possible. This may need at times either simple faecal softeners or more vigorous treatment with microenemas, or aperients from above. In severe cases, manual disimpaction under general anaesthesia may be necessary. Once the bowel is empty the faeces are kept soft with faecal softeners, which preferably do not stimulate the bowel, and a retraining program is instigated. This may vary from child to child, particularly if toilet phobia is a major issue. Many methods are available and are often successful. The programmes used are described well in standard textbooks, and are available as Clinical Guidelines from most major Children's Hospitals. Parent literature is freely available and for the older children story books addressing the situation in terms they can understand are available. It cannot be emphasised too much that the clinician's main role is the support of the child and family over the period of time required to achieve success. Without this support and encouragement, the programme is doomed to failure. 506 092 Performance Guidelines Condition 092 Psoriasis in a 30-year-old man AIMS OF STATION To assess the candidate's knowledge of psoriasis and its management, and the ability to counsel the patient about a chronic, cosmetically disturbing condition, which cannot be completely cured. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are suffering from psoriasis. You have a scaly skin rash for which you have just consulted this doctor. The doctor has taken your history and examined you and will now discuss the condition with you. You are concerned that it may spread and wonder if a recent serious motor accident was the cause. You find the ailment and the ointments distasteful because of the unpleasant smell and staining of clothing and you are worried your wife may become infected. You are hoping to receive reassurance that it can be cured. You wonder whether you should see a skin specialist. Questions to ask unless already covered: • 'What causes this?' • 'Can it be cured?' • 'Will it spread to other parts of my body?' • 'I s it infectious?' • 'Can it affect my health in other ways?' • 'Could I pass it on to my children?' • ‘Does it have anything to do with my accident?' • 'I've heard that there is a chemist somewhere who can cure psoriasis?' EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • The candidate should show interest and concern, listen to and deal with the patient's concerns and give clear instructions, answering questions directly. Explanation of the diagnosis • Description of which parts of the body can be affected (extensor surfaces of elbows and knees, sternal and sacral areas, scalp and nails — but can involve other parts of the skin). • Aetiology, nature, associations, expected course, availability of treatments, prognosis. Good effect of sunlight if not overexposed. Psoriatic arthritis could be mentioned. • Point out that physical or emotional stress can cause flare up. Diet has no effect. Exercise and reduction in alcohol intake may be beneficial. Use of sunscreen applications during summer. 507 092 Performance Guidelines Management — Immediate • The candidate should exhibit a general understanding of the principles and modalities of treatment and that these are applied according to severity. Exact details, generic or trade names, strengths (except for steroids) and doses are not expected although candidates should indicate that these will be ascertained if required. • The candidate should include an offer to refer to a dermatologist. If this is the only management advice given, the patient should ask for more information about treatment and expect discussion of different types of local creams and lotions. Management — Longterm • Monitoring of progress and repeats of medications are required. Review during flare-ups with closer involvement if systemic therapy becomes necessary. Review if secondary infection is suspected. Liaison with dermatologist. Counselling • Ability to achieve patient understanding of the chronicity, variability and difficult therapeutic nature of the condition. Despite this, reassurance that the condition can usually be brought under control. • This requires the establishment of trust and confidence, backed up by clinical knowledge, a willingness to listen to the patient's views about cause and treatments suggested by others, and recognition of when referral to a dermatologist should be made using a patient-centred as well as disease-centred approach. KEY ISSUES • Approach to patient: must listen to and acknowledge patient's concerns and provide support and encouragement. • Management: knowledge of principles of different local measures. Extent of treatment proportional to severity. • Counselling and explanation of diagnosis: must acknowledge chronic nature of psoriasis and that treatment can be demanding and will be prolonged. Must be honest and supportive. CRITICAL ERROR • Failure to explain appropriate principles of treatment. 508 092 Performance Guidelines COMMENTARY Aetiology of psoriasis is unknown but there is a familial predisposition. Onset is most commonly between 10 and 40 years but can occur at any age. There is increased epidermal cell proliferation, with vascular proliferation and inflammation in the upper dermis. Psoriasis affects 2-4% of the population. It is not infective and waxes and wanes in intensity. It can be drug-induced, e.g. lithium, Beta blockers, chloroquine and hydroxychloroquine; and it can be precipitated by infections, trauma or emotional stress. The lesions can become secondarily infected. Diet is not a factor. There is no complete cure but in most cases psoriasis can be reasonably controlled with therapy. Treatment should be at an appropriate level for the type, site and severity of the condition. Psoriasis can be associated with a specific type of arthritis, mainly affecting the hands. In mild cases, emollients or a weak topical corticosteroid may suffice, but disfiguring psoriasis may warrant the use of antimetabolites or immunosuppressants following the use of more potent topical corticosteroids. Complicated or difficult cases need specialist care and open lines of communication between general practitioner, dermatologist, any other medical attendants and the patient. • For mild to moderate plaque psoriasis — use topical therapy — dithranol, tars, corticosteroids, keratolytics, and emollients. Occlusive dressings increase their effect. ~ Dithranol — an antiproliferative agent — is very effective. Salicylic acid can be combined with tars and dithranol. ~ Tars — anti-inflammatory but can stain and smell which are disadvantages. Less when in combination (e.g. with allantoin). ~ Topical corticosteroids are more potent preparations for thicker lesions, large quantities for widespread rash. ~ Keratolytics for lifting and softening thick scale such as sulphur and salicylic acid. ~ Emollients for scaling or irritation. Harsh soaps should be avoided. ~ Calcipotriol (a vitamin D derivative that regulates growth of keratinocytes). • For psoriasis which is widespread, severe, or causing disfigurement or disability, systemic therapy is indicated such as methotrexate or acitretin or cyclosporin. Phototherapy is also often used by dermatologists. 509 093 Performance Guidelines Condition 093 Temporal arteritis in a 58-year-old woman AIMS OF STATION To assess the candidate's knowledge of the treatment of temporal arteritis and its most important possible sequel: visual impairment. EXAMINER INSTRUCTIONS The examiner will have advised the patient that she should ask about side effects of steroids and whether some alternative medication is preferable, as she doesn't like the idea of steroids. She should also ask about further tests such as X-ray and whether the headache might just be a simple migraine. Questions to ask unless already covered: • 'Could it be a migraine?' • 'Are there any (other) complications?' • 'Are you sure that my eyesight will be all right?' • 'Should I see an eye specialist?' • 'Isn't "cortisone" dangerous?' (If 'cortisone' or 'steroids' are recommended) • 'What are its side effects?' • 'How long will the headache last once treatment lasts?' • 'How long will I be on "cortisone"?' • 'Can this trouble affect me in any other way?' EXPECTATIONS OF CANDIDATE PERFORMANCE This can become an emotive situation for the patient after being informed of the nature of the condition and the possibility of severe visual impairment. The doctor should not withhold this information, which should be given with empathy and support. Politeness, respect and consideration rather than an authoritarian approach should be demonstrated when discussing the threat of blindness and obtaining compliance with the use of corticosteroids. The doctor should listen carefully to the patient's queries and provide honest as well as accurate answers. Generating trust and confidence and giving the correct level of reassurance are also expected. Initial management plan An erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) should be arranged immediately with request for a same day report (this requires liaison with the patient who should contact the doctor later in the day). The patient should be commenced on oral prednisolone in high dose at first (60-100 mg). A stronger nonopioid analgesic than paracetamol should also be prescribed. Referral to a surgeon with a view to temporal artery biopsy should be discussed and urgent referral to an eye specialist should be advised. 510 093 Performance Guidelines Patient Education The aetiology and prognosis of temporal arteritis are obscure. It is a manifestation of giant cell arteritis. Confirmation by ESR or CRP (usually markedly elevated) is essential, followed in most cases by biopsy of the superficial temporal artery for confirmation because of the likely need for medium to longterm corticosteroid therapy. Commencement of oral steroid therapy before completing investigations is indicated to reduce the risk of visual impairment, especially in a case of this duration (two weeks). This patient should be seen again within 48 hours by which time significant resolution of symptoms should have occurred. Once symptoms are controlled and ESR levels fall, the prednisolone can be reduced to maintenance levels (5-10 mg three times daily). The patient should be monitored closely by continuing review of symptoms and serial ESR levels. Resolution may take up to 2-3 years. Concomitant use of H2 receptor antagonists should be considered in patients with a history of dyspepsia or peptic ulcer. KEY ISSUES • Skill in conveying unpleasant news to patient in an honest and supportive manner with guarded reassurance about the outcome. • ESR or CRP must be ordered with urgent early report requested. • Must commence prednisolone therapy immediately. • Patient counselling and education is required regarding possible biopsy, referral to eye specialist and longterm nature of the condition. CRITICAL ERRORS • Failure to request ESR or CRP. • Failure to commence prednisolone therapy. COMMENTARY Although this is not a common disorder, the high risk of preventable blindness and response to early treatment makes it essential knowledge. A highly probable diagnosis is possible on clinical grounds alone. Involvement of the ophthalmic artery or ciliary arteries may occur causing optic atrophy and blindness. Vision is impaired in about 50% of patients at some stage. If blindness occurs it is usually irreversible. Temporal arteritis may follow polymyalgia rheumatica in about 20% of cases. The condition is very responsive to corticosteroids which should be prescribed in high doses initially. Maintenance steroid therapy in lower dose over 2-3 years may be required, which raises the possibility of steroid-induced complications of osteopenia, hypertension, diabetes and changed facies. 511 094 Performance Guidelines Condition 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man AIMS OF STATION To assess the candidate's knowledge of Bell Palsy, its prognosis and its management, and skills in counselling an upset and anxious patient. EXAMINER INSTRUCTIONS The patient has the condition as illustrated. He is very concerned, but if informed and reassured appropriately, will accept the diagnosis and management plans. EXPECTATIONS OF CANDIDATE PERFORMANCE You would expect the candidate to: • Acknowledge the patient's distress about his appearance and to provide support and guarded reassurance, particularly reassurance that the patient has not had a stroke. • Explain the diagnosis and natural history of the condition. The cause is unknown but is consistent with inflammatory compression of the facial nerve in the temporal bone (probably viral). • Expected course — about 70% of patients completely recover within two months. First signs of recovery appear within two weeks. About 20-25% take up to six months for full recovery; and 5-10% do not recover by the end of one year. An older patient age is associated with slower recovery. Advise about immediate management: ~ Steroids are usually prescribed empirically: prednisolone 40-80 mg daily for three days then taper off and cease over the next seven days. Antiviral drugs may also be given because of its presumed viral aetiology. ~ Wear patch over left eye at night. ~ May prescribe artificial tears. ~ Review within a few days for support and monitoring. ~ Investigations are not essential but CT head would be appropriate for reassurance in view of patient anxiety about a stroke. ~ Referral to a neurologist should be offered for confirmation of diagnosis and possibly for nerve conduction studies. Referral is also appropriate for confirmation of management, because of possibility of incomplete or nonrecovery. ~ Arrange continuing followup to monitor progress, watch for symptoms of conjunctivitis and corneal injury. ~ Consider early referral to a physiotherapist as an aid to self-management strategies. There is no evidence that exercises or nerve stimulation aid recovery, but they may support patient confidence in recovery. 512 094 Performance Guidelines KEY ISSUES • Approach to patient — acknowledging distress about his appearance, providing support and guarded reassurance about recovery. • Initial management plan — protection of eye and possible use of steroids and antiviral agents. Offer referral to neurologist and physiotherapist. • Patient counselling about prognosis and natural history, stressing that complete recovery is usual (although not invariable). CRITICAL ERRORS • Telling patient that complete recovery always occurs. • Very unsatisfactory counselling skills displaying insensitivity in dealing with an anxious patient. COMMENTARY The most common cause of unilateral facial nerve palsy without a clear history of local injury is the condition of idiopathic acute facial nerve palsy ('Bell Palsy) Bell Palsy is of unknown aetiology and affects all ages and both sexes. Patients present with an acute or subacute onset over a few hours. Pain around the ear is followed by unilateral facial paralysis of lower motor neurone type, with complete or partial paralysis of muscles supplied by the facial nerve. The clinical features are consistent with a lesion due to inflammatory oedema and compression of the nerve within the bony canal of the petrous temporal bone. Clinical features of the lesion, if complete and all muscles equally affected are as follows (see illustrative figures): • Facial asymmetry is accompanied by loss of voluntary, emotional and associated movements. • The affected side of the face is immobile, the eyebrow drops, the lines on the forehead and nasolabial fold are smoothed out. • The palpebral fissure is wider due to the unopposed action of levator palpebrae. • Tears fail to enter the lacrimal puncta medially because they are no longer held against the conjunctivae and the eye weeps. • The direct corneal reflex is absent, but the patient appreciates the discomfort from testing and the indirect corneal reflex is present (the other eye blinks). Corneal abrasion and ulceration are significant risks. • Efforts to close the eyes cause the affected globe to roll up under the upper lid (Bell reflex). • The a/a nasi does not flare or dilate with vigorous breathing. • The lips stay in contact but cannot be pursed for whistling. When smiling, the angle of the mouth on the affected side does not move; and in repose 'wry-mouth' can be identified. • Hyperacusis in the affected ear can be troublesome when the patient is subjected to local noise. • During mastication food accumulates in the cheek and dribbling of saliva can occur from between paralysed lips. • The articulations of labial consonants (m, b, p) may be affected. 513 094 Performance Guidelines • Loss of taste sensation may be noted in the anterior tongue on the affected side. • The cosmetic and psychological effects of the disfigurement can be profound. • Patients with Bell Palsy are frequently concerned that they may have suffered a paralytic stroke. Pathologic Anatomy The facial nerve supplies muscles of facial expression from scalp to neck — from occipito-frontalis in the scalp to platysma below, and including those muscles governing movement of eyebrows, eye closure, mouth, cheek and nose. The major motor root of the 7th nerve originates in the pons from the motor nucleus and fibres run in the pons in an unusual curving course around the 6th nerve nucleus before leaving the anterior surface of the mid-pons to enter the internal auditory canal with the 8th (vestibulocochlear) cranial nerve. The motor root is joined at the internal auditory meatus by the 'sensory' root, which carries afferent taste fibres from the tongue and also efferent secretomotor fibres to the lacrimal and salivary glands. Somatic sensation to the face is subserved by the 5th cranial nerve, not the 7th. Within the petrous temporal bone the nerve runs laterally to the medial wall of the tympanic cavity before bending backwards abruptly (the genu). The facial nerve then runs downwards in the facial canal on the inner wall of the tympanic cavity, giving branches to the tiny stapedius muscle of the inner ear, and giving off the chorda tympani, before emerging from the stylomastoid foramen at the base of the skull. The geniculate ganglion is the relay station for the secretomotor fibres for tears and the site of the sensory root ganglion of the taste fibres. From the geniculate ganglion run the secretomotor fibres to the lacrimal gland and submandibular salivary gland. The autonomic sensory taste fibres are carried from the tongue with the lingual nerve (carrying ordinary sensation) via chorda tympani through middle and inner ear, to the sensory facial nerve root. Facial nerve lesions below the chorda tympani (e.g. in the parotid gland) will not affect taste. The chorda tympani leaves the nerve a few millimetres above the point of exit from the stylomastoid foramen, and runs between the layers of the tympanic membrane separating outer and middle ears, and then joins the lingual nerve to the tongue, and supplies the anterior two-thirds of the tongue with taste sensation as illustrated. The motor branches of the facial nerve break into a spray of branches and run through the parotid salivary gland before emerging from its anterior border to supply the facial muscles via temporal, zygomatic, buccal, mandibular, and cervical branches as illustrated. 514 094 Performance Guidelines f.m, s.f s.g. tn s.s.n. 7* m.n. rn T. s.r s b at g.gi.a.m. foramen magnum stylomastoid foramen submandibular ganglion taste nucleus - nucleus of tractus solitarius superior secretory nucleus 7th nerve motor nucleus motor root 'sensory' root stapedius buccinator chorda tympani geniculate ganglion internal auditory meatus CONDITION 094. FIGURE 5. Anatomy of facial nerve 515 094 Performance Guidelines Differential Diagnoses — other causes of facial nerve palsy • Patients with Bell Palsy are frequently concerned that they have had a stroke', or have a cerebral tumour. • Facial weakness due to 'stroke' is usually upper neurone in type and part of a hemi-paresis on the same side as the facial paralysis. Movements of the upper muscles to forehead and eyes (which are bilaterally innervated from the upper motor neurone) are spared, as may be emotional movements. However, an infarct in the pons may produce a nuclear (lower motor neurone) lesion of the facial nerve. • In Bell Palsy the motor lesion is confined to the facial nerve alone and is lower motor neurone in type. • If hearing loss or other cranial nerve lesions are associated with facial nerve palsy the diagnosis is more likely to be a cerebellopontine angle tumour (for example, auditory neurofibroma) or a vascular event from vertebrobasilar insufficiency. • If vesicles within the external ear or on the palate accompany the 7th nerve palsy the condition is viral herpes zoster infection affecting the geniculate ganglion, not Bell Palsy. This is the Ramsay Hunt syndrome, and occasionally other cranial nerves are also affected. Such patients are often elderly. Pain may precede the facial palsy and the associated herpetic eruption in the ear and sometimes on tongue or palate. Recovery of facial nerve function is rare. Prompt treatment with aciclovir may improve prognosis and diminish post-herpetic neuralgia. • If the nerve is affected within the parotid gland, this is usually due to a parotid malignancy giving partial or total lower motor palsy. Benign parotid tumours do not cause facial palsy. • Basal skull fractures of the petrous bone are another important cause of facial nerve palsy. CONDITION 094. FIGURE 6. Left-sided facial nerve palsy Face in repose: note widening of palpebral fissure due to unopposed action of the levator of the upper lid, smoothing of facial lines and failure of eversion of mucosa of patient's left lower lip ('wry-mouth') due to paralysis of depressor anguli oris. 516 094 Performance Guidelines CONDITION 094. FIGURE 7. Left-sided facial nerve palsy Attempted eye closure: note failure of left eye closure with rolling up of the eye under the upper eyelid, and accentuation of the 'wry-mouth' triangular deformity. CONDITION 094. FIGURE 8. Left-sided facial nerve palsy Obvious deformity when smiling: note immobile left eye and mouth musculature and absence of nasolabial fold. 517 094 Performance Guidelines CONDITION 094. FIGURE 9. Left-sided facial nerve palsy Attempting to blow out cheeks: note failure of left buccinator muscle with flaccid paralysis of patient's left cheek. The patient is unable to prevent air from escaping from the mouth when he tries to build up intraoral pressure. 518 095 Performance Guidelines Condition 095 Dysuria and urinary frequency in a 40-year-old man AIMS OF STATION To assess the candidate's approach to a first time urinary tract infection in an adult male patient. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You consulted this doctor today because of the gradual onset of dysuria and frequency of micturition over the last three days. The doctor has examined you (including rectal examination) and asked you to provide a urine sample which was checked in the practice laboratory. You are about to receive the doctor's advice about the problem. Questions to ask unless already covered: • 'What did you find in my urine?' • 'Can this infection be treated easily?' • 'Where do these bacteria come from?' • ‘Is this the same as my wife gets?' • 'Tell me exactly what tests I should have done?' • 'Why do I need these tests?' • 'Do you think I have something seriously wrong?' • 'How long will I need to take the medication?' • 'Could it occur again?' • 'What will the urologist do?' (Ask only if referral is advised) You are not overly concerned about your condition because your wife has suffered from occasional urinary tract infections over the years which have always responded well to treatment with antibiotics. She has had no other investigations other than urine laboratory tests. You expect to recover quickly after receiving antibiotics. If the doctor indicates that further special investigations are necessary followed by referral to a urologist, be surprised and express some reluctance to undergo these procedures. If the doctor handles your reaction satisfactorily agree to follow this advice. EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • This may appear to be a straightforward clinical situation but it requires care to avoid alarming the patient concerning the need for more investigations than just a urine culture • Give a clear explanation of the nature of the condition. • Obtain compliance in use of medication (clear instruction about frequency and duration) • Emphasise importance of followup. • Explain why further investigation is essential and obtain compliance for this. 519 095 Performance Guidelines Tell the patient what Is wrong A variety of terms may be used to describe a urinary tract infection but the candidate should explain that it is most likely to be in the lower urinary tract (bladder, prostate or urethra) rather than in the kidneys, because of the absence of fever and loin pain. Immediate management The candidate must advise that the midstream urine specimen collected today will be sent for culture and antibiotic sensitivity assessment. Choice of initial treatment — appropriate antibiotic — for example, trimethoprim 300 mg orally, once daily; or cephalexin 500 mg orally, 12 hourly. Urinary alkalisation may be used, for example, Ural® (sodium citrotartrate) 8 hourly. Duration of therapy is 14 days. Amoxycillin is often given but is inappropriate in this patient because of the penicillin sensitivity. Advise patient to drink extra fluids. The antibiotic therapy should be commenced today whilst awaiting the culture results. Phone with results when through. Early review if poor response to treatment. Followup of this episode by repeat microscopy and culture after completion of antibiotic therapy. Discussion of condition and advice about investigation Significance of a urinary tract infection in males. Usually associated with underlying pathology according to age group: • Children — congenital abnormality especially vesicoureteric reflux. • Younger adults — foreign body in bladder, sexually transmitted infection, including homosexual activity. • Older adults ~ calculus formation in kidney, ureter, or bladder; ~ prostatitis; ~ bladder polyps or carcinoma; ~ benign prostatic hypertrophy; ~ carcinoma of prostate; ~ urethral stricture; or ~ genitourinary tuberculosis should not be forgotten. • The clinical picture suggests a lower urinary tract infection. The main conditions to be excluded are urinary neoplasm and calculus and prostatic pathology. KEY ISSUES • Approach to patient. • Initial management plan. • Choice of investigations. • Patient education and counselling. 520 095 Performance Guidelines CRITICAL ERRORS • Failure to arrange urine culture before commencing antibiotic therapy. • Failure to advise the need for further investigations. COMMENTARY • Further investigation is essential to identify the underlying cause and to exclude malignancy. • These would be undertaken in a staged manner. • Urinary culture to define organism. Repeat culture after initial treatment. • Ultrasound of kidneys, ureters, and bladder. • Contrast enhanced CT of abdomen and pelvis. • Prostatic specific antigen (PSA) level. • Serum urea and electrolytes • Referral to a urologist who may arrange: ~ cystoscopy, ~ voiding cystourethrogram. 521 096 Performance Guidelines Condition 096 Eclampsia in a 22-year-old primigravida at 38 weeks gestation AIMS OF STATION To assess the candidate's ability to recognise that the grand mal fit is a sign of eclampsia, and the ability to manage appropriately this particular pregnancy complication in an 'out-of-hospital' situation. EXAMINER INSTRUCTIONS The examiner will have instructed the mother of the patient as follows: Your daughter has just had a fit in the waiting room. The fit occurred approximately 10 minutes ago and lasted three minutes. She bit her tongue, and had funny movements of her limbs, and then went off to sleep. The candidate will generally be expected to take an appropriate history from you as the mother in order to manage the case. The list of responses below is likely to cover most of the questions you will be asked. Your daughter has: • no past history of epilepsy, and has never had any treatment with antiepileptic drugs; • no hypertension, renal disease, or other medical problem in the past; • not mentioned any headaches or visual disturbances recently; and • noticed oedema of the legs for the last two weeks, but was otherwise well. Questions to ask if not already covered: • 'Why did she have a fit?' • 'Will the fit damage my daughter or her baby?' • 'Will she have any more fits?' • • 'What are you going to do with her now? Can I take her home?' If the candidate suggests hospital transfer, but does not detail what will happen to the daughter following admission to hospital, you should ask 'What treatment will they give my daughter in hospital?' 522 096 Performance Guidelines Examination findings to be given to the candidate by the examiner on request • Drowsy, but rousable. • Generalised oedema. • BP: • Pulse: 80/min and regular. • Reflexes: very active, clonus evident at the knees. • Abdominal examination: uterus enlarged to 38 cm (symphysis-fundal height), lax, and non tender. The presentation is cephalic, fixed in the pelvic brim, with three fingerbreadths palpable above the pubic symphysis. The fetal heart is audible and normal. • Central nervous system examination — apart from the conscious state and the active reflexes, this appears normal. There are no unilateral localising signs. 180/110 mmHg. Investigation results None done except office urine testing of specimen brought with her showed proteinuria (++++). Failure to ask for the results of urine testing would indicate inadequate care. , EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should advise the mother along the following lines: • The diagnosis is eclampsia, a condition which occurs late in pregnancy generally in women having their first baby. Providing it is well controlled, no longterm harm usually occurs to either mother or baby, although it is potentially very dangerous to both the mother and baby. • She will need to be transferred and admitted to hospital immediately, and delivery arranged as soon as her blood pressure and any further fitting are brought completely under control. • There is no point prolonging the pregnancy in view of the gestation of 38 weeks. • Prior to transfer to the hospital admission an anticonvulsant such as diazepam should be given intravenously in an attempt to prevent further fitting (oral therapy is inappropriate and NOT acceptable). • The likely care provided in hospital would be: ~ an intravenous drip to be inserted and magnesium sulphate commenced in appropriate dosage to try to prevent any further fits; ~ the blood pressure should be lowered with intravenous hydralazine or diazoxide — oral agents are ineffective and should not be used; ~ tests on patient should include: renal function tests, liver function tests, Hb and platelet count, and coagulation profile; ~ the fetus should be checked by cardiotocography (CTG); ~ monitoring of the patient should include: pulse, blood pressure, temperature, urine output, and frequent urine testing (predominantly for protein); and ~ the room should be prepared in case a further fit occurs with the facility to administer oxygen, to have a Guedel airway/padded spoon available to prevent her from biting her tongue, to have the facility to place her in Sims position, and to observe her in a slightly darkened environment. 523 096 Performance Guidelines • The mode of delivery will depend on her condition, and the cervical findings. If the cervix is very favourable, she should be induced and monitored closely in labour, probably with the use of an epidural anaesthetic for pain relief and blood pressure control. CTG monitoring of the fetus in labour is mandatory. If the cervix is unfavourable, consideration needs to be given as to whether induction is appropriate, after prostaglandin priming, or whether an elective Caesarean section is more appropriate. Obviously if the CTG is abnormal, Caesarean section is likely to be required. KEY ISSUES • Knowledge of the causes of fitting in pregnancy. • Ability to manage a patient who has had an eclamptic fit in late pregnancy and is not in hospital. CRITICAL ERRORS • Failure to diagnose eclampsia and recognise risk of this to mother and baby. • Failure to sedate, and failure to transfer her immediately to hospital. • Failure to outline the three principles of management in the hospital — sedation, lower blood pressure, and delivery of baby. COMMENTARY In this case the most likely diagnosis is eclampsia occurring in pregnancy. A history of previous fits should be sought, but it is unlikely that this is anything other than an eclamptic fit. It is important that the three basic principles of the management of eclampsia are performed or arranged. These principles are: prevention of further fits; lowering of the blood pressure; and arrangement for immediate delivery of the baby by the most appropriate route. Common problems likely with candidate performance are: • When taking the history, not being focused enough to the actual problem, but asking for information such as irrelevant past history, social history and so on. This just takes time to do, and reduces the time available for the remaining tasks. • Not asking whether she had had any fits before. • Not asking for appropriate examination findings, such as hyperreflexia. • Not requesting whether there was any proteinuria present. • • Failing to understand that any prolongation of the pregnancy is irrelevant as the gestation is already 38 weeks. Administering oral instead of intravenous hypotensive drugs to reduce the blood pressure. 524 097 Performance Guidelines Condition 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida AIMS OF STATION To assess the candidate's ability to make the correct diagnosis of gestational diabetes, and to appropriately manage the patient for the remainder of the pregnancy. The candidate should do this by taking a focused history, asking the examiner for the examination findings, and then advising the patient appropriately EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows The list of responses below is likely to cover most of the questions asked. • No family history of diabetes. • You have never been tested for diabetes previously. • No previous operations or illnesses • This is your first baby. • You are now 28 weeks pregnant. • Your ultrasound at 18 weeks was normal. Questions to ask if not already covered: • What do the blood sugar levels mean?' • 'Do I have diabetes?' • 'How bad is my condition?' • ‘What treatment will I require?' • ‘Will my baby be diabetic?' Examination findings to be given to the candidate by the examiner on request • The blood pressure is 120/80 mmHg. • No proteinuria. • • Uterus is enlarged to the size equivalent to a 28 week pregnancy (symphysis-fundal height = 28 cm). Cephalic presentation, head still mobile above the pelvic brim. • Fetal heart rate is normal. 525 097 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE It would be expected that the candidate would provide much of the following information. • The diagnosis is gestational diabetes • Consultation with a diabetic physician and consultant obstetrician is mandatory. • She should follow a special diet to keep the blood glucose during the day at less than 7 mmol/L. If this is not possible, insulin therapy will probably be necessary. • Test the blood sugar 3-4 times per day, especially about two hours after a meal. • The major risks to the baby are: ~ Macrosomia (large baby size) — do ultrasound at 32-34 weeks and probably deliver by Caesarean section if macrosomic. ~ Increased risk of fetal death in utero — therefore weekly CTGs should be performed until delivery, twice weekly if on insulin, the fetus is macrosomic or polyhydramnios occurs. These should be started at 32-34 weeks gestation. ~ Hyaline membrane disease if delivered prematurely — try to delay induction until after 37 weeks. Steroid therapy would improve fetal lung maturity, but will make gestational diabetes worse. • Risks to the mother — increased risk of pre-eclampsia. • Deliver at term at the latest, unless obstetric complications indicate earlier delivery is indicated. Monitor the fetus by continuous CTG in labour. Keep blood glucose levels stable in labour with intermittent insulin injections. Deliver by elective Caesarean section if macrosomic (> 90th centile for weight), breech presentation, or evidence of fetal distress. • The diabetes will almost certainly resolve following delivery. However gestational diabetes is likely in subsequent pregnancies, and there is a 30% risk of her developing diabetes later in life. Glucose tolerance should therefore be checked at least every 5 years for life. She must control any weight gain in the future. KEY ISSUES • Ability to recognise that the blood sugar results are diagnostic of gestational diabetes. • Ability to appropriately assess the control of the diabetes during the remainder of the pregnancy, and to appropriately manage the patient, in consultation with a physician and obstetrician. • Ability to recognise the need for insulin if the blood glucose levels are not reduced satisfactorily with diet alone. • Ability to recognise the increased risks to the fetus, and the need for close monitoring. 526 097 Performance Guidelines CRITICAL ERRORS • Failure to diagnose gestational diabetes. • Failure to advise diabetic diet and testing of blood sugar levels 3-4 times daily. • Failure to arrange for consultation with a diabetic physician and obstetrician. COMMENTARY This case illustrates the need for the candidate to recognise the diagnosis of gestational diabetes based upon a two hour glucose tolerance test. The most important aspects of the management of the case are to recognise the need for assessment of the blood sugars three or four times a day; the need to consider insulin if the blood glucose levels do not respond, and the need to include in the management of this patient a diabetic physician and an obstetrician. Common problems likely with candidate performance are: • When taking the history, not being focused enough to the actual problem, but asking for information such as irrelevant past history, social history and so on. This just takes time to do, and reduces the time available for the remaining tasks. • Failing to recognise a need for special fetal monitoring because of the increased risks to the fetus. 527 098 Performance Guidelines Condition 098 Bed-wetting by a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and handle the common problem of bed-wetting in a 5-year-old child. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You are the mother of Johnny who has a problem with bed-wetting nightly since the age of three years. You were initially exasperated by the wetting but now have accepted that the wetting is involuntary. You have not punished Johnny despite your exasperation. His general health is excellent, and he has had no major illnesses. He appears to be growing normally and is on the middle line of his graph for height and weight. Since the age of 3 years, he has always been dry during the day and never had any incontinence. He has never had a urinary tract infection. He is embarrassed and you and your spouse are very keen to help him control his wetting. His father wet the bed until the age of nine years. The tablets that were tried two years ago made no difference to the wetting. Johnny is going very well at school and enjoys his teacher. He has lots of good friends. You and his father are happily married and have no major stresses in your lives. Johnny has a 4-year-old younger sister who has been dry day and night since the age of two and a half. Questions to ask if not already covered: • ‘Is there something wrong with his kidneys or bladder?' • 'Does he need any investigations?' • ‘We have restricted his fluids after dinner at night and lift him onto the toilet when we go to bed. Should we continue to do this?' • 'What about when he is asked to sleepover at a friend's place — so far we haven't let him do this. Is there anything we can do for that?' • 'How does this alarm work if he has already passed urine and wet his bed before it goes off?'(If an alarm is advised) EXPECTATIONS OF CANDIDATE PERFORMANCE This scenario describes a 5-year-old boy with persistent primary bed-wetting from three years of age. He is otherwise well, has no daytime wetting or any other symptoms to suggest a pathological cause for his wetting. His height and weight are on the 50th percentile. The boy himself is very keen to be dry, and his parents are keen to help him achieve this. These are important points the candidate should appreciate. Amitriptyline (Tryptanol®) was tried about two years previously to no avail. Johnny is doing well at school and has lots of good friends. 528 098 Performance Guidelines The parents are happily married and under no major stresses. His 4-year-old younger sister has been dry day and night since the age ot 21/2 years. The candidate should enquire about family history; one parent was a bed-wetter until aged nine years. Before embarking on a plan of action, the candidate should proceed as follows: • Check the boy's urine by dipstix (Multistix®) testing, and a urine microscopy and culture. • Enquire about the child's growth percentiles, which are normal. • Ensure his blood pressure is normal. • Renal ultrasound may be suggested but is probably unnecessary unless there is a great deal of parental anxiety. Having excluded any organic pathology and having ensured that there are no serious emotional reasons to account for the symptom, the candidate should outline an ongoing plan of management. This should include: • Empathy with the exasperating nature of the condition particularly with the excessive washing of bedclothes and pyjamas, but enthusiasm for the interest the parents are showing in trying to help Johnny. • Reassurance that there is almost certainly no organic pathology present. • Advice that even though lifting and restriction of fluids have not been shown to be effective generally, if the parents are keen to continue this they should feel free to do so as it occasionally does help some children. • Outlining the plan of management including use of an enuresis alarm. Explain how the alarm works as a conditioning response to release of urine. • Explaining how to obtain the alarm (for example, through pharmacies [hiring], buying or through some Community Health Centres or Children's hospitals) • Discussing that the success rate is much higher if the child himself is motivated to become dry (as Johnny is), • Discussing a recording star chart and reward system. • Supporting and encouraging child and parent by regular frequent review to encourage the boy on even minor successes. • Explaining a plan of action for the use of arginine vasopressin (DDAPV®) by nasal spray when it is important to remain dry and avoid any embarrassment for school camps and sleepovers. Explain the safety of this substance if used only as directed. • Advice that the success rate with amitriptyline (Tryptanol®) is low. It can be a dangerous drug in overdose and is rarely used now. • Advice that even with the alarm it may be some weeks before success is achieved and the alarm should be persisted with for up to three months. A review appointment should be made two to three weeks after the alarm has started, to review the progress. KEY ISSUES • Empathy, support, and encouragement to both child and parent. • Enquiry about a family history of enuresis. • Exclusion of emotional stress at home or school. • Exclusion of organic pathology by the history and by arranging simple urine testing. • Advice about plan of action should be logical and clear. 529 098 Performance Guidelines CRITICAL ERROR • Suggesting a probable organic cause for the wetting and the need for invasive investigations. COMMENTARY This scenario describes a five-year-old boy with persistent primary bed-wetting from three years of age. He is otherwise well, has no daytime wetting or any other symptoms to suggest a pathological cause for his wetting. The candidate snould appreciate that the boy himself is very keen to be dry, and that his parents are willing to help him achieve this 530 099 Performance Guidelines Condition 099 Acute gout in a 48-year-old man AIMS OF STATION To assess the candidate's ability to manage an acute attack of gout and give advice about its prevention. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are suffering from severe pain in your right foot which began two days ago. You saw the doctor earlier today who diagnosed gout (which you have had before), and arranged for a confirmatory blood test. You have returned to find out the result and receive treatment. You are a 48-year-old taxi driver and usually keep in good health. You do not smoke but drink three or four stubbies of beer, after work, daily. No serious past medical problems but you are taking tablets for mild blood pressure diagnosed two years ago. You are overweight. You have no family or social problems. You are anxious to get relief from the pain which is preventing you from driving your taxi. You are somewhat irritated that you were asked to have a blood test, because this was not done during previous attacks which responded well to treatment. You have little knowledge about the cause of gout and are unaware that recurrent attacks are to be expected and can be prevented. You have not suspected that the blood pressure tablets could have something to do with gout, and are annoyed that you were not warned about this. Questions to be asked if not covered • 'How long before I can resume work?' • 'What causes gout?' • 'Can it do any serious damage to my system?' • 'What is the best treatment?' • 'Should I have any other tests?' • 'What about having a beer after work?' EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient It is essential to establish a satisfactory relationship with this patient because of the need for compliance regarding his use of alcohol and control of his weight, and to defuse irritation about having to have a blood test for this attack and finding out that the antihypertensive medication has been a precipitating factor. • Initial management plan — immediate ~ Discontinue diuretic and aspirin. ~ Specific treatment: - Nonsteroidal anti-inflammatory drug (NSAID) initially in high dose: e.g. indo-methacin 25 mg capsules — 50-75 mg immediately, 50 mg two hours later, 25 mg eight hourly for 48 hours, then 25 mg twice daily for one week, would be appropriate. Other NSAID such as naproxen or ibuprofen are also effective. 531 099 Performance Guidelines - OR prednisolone 25 mg orally, daily in the morning, reducing to zero over 7 to 10 days. - OR colchicine 0.5 mg tablets 2-3 immediately, then 1-2 every 4-6 hours or until diarrhoea occurs. Maximum dose 6 mg/24 hours. As pain reduces the dose of colchicine can be reduced to 0.5 mg twice daily. - Note that allopurinol and probenecid are contraindicated for an acute attack. ~ Additional measures: - Increase fluid intake. - Elevate and rest foot for 24-48 hours. - Paracetamol (Panadol®) can be used for additional pain relief if needed. - Warn regarding possible side effects of medication: indigestion and elevated blood pressure from indomethacin or prednisolone: diarrhoea from colchicine. - Suggest an alternative drug to reduce blood pressure (e.g. angiotensin converting enzyme inhibitor [note that all thiazides and Beta blockers may exacerbate gout]). - May return to work as soon as pain is relieved — should be within 48 hours. • Initial Management — Preventive ~ Ensure adequate intake of water. Do not take diuretics or salicylates. ~ Reduce weight. Reduce intake of alcohol. Avoid foods rich in purine (offal, tinned fish, shell fish and game). ~ Approximately eight weeks after this attack has subsided may commence allopurinol 50-100 mg daily, gradually increasing up to 300 mg daily (two strengths 100 and 300 mg tablets) ~ Check uric acid level after 4 weeks — aim to reduce below 0.4 mmol/L ~ Colchicine (0.5 mg b.d.) can be used in conjunction with allopurinol if gout recurs during initial therapy. ~ Further assessment of patient should include review of blood pressure, serum lipids, fasting blood sugar and urea and electrolytes. Other renal function tests are not indicated at this stage. X-ray of the affected area is not required. • Patient education and counselling ~ Gout is a metabolic disturbance with an inherited tendency in which there is decreased renal clearance of urate causing hyperuricaemia with deposition of urate crystals in joints, soft tissue (tophi) and urinary tract (urate stones). It is frequently associated with hypertension, dyslipidaemia, and Type 2 diabetes. Thiazide diuretics also predispose to diabetes. Gout: - Particularly occurs in the great toe following minor trauma. - Can follow any surgical operation. - Can be precipitated by alcohol excess, and diuretics which inhibit sodium reabsorption. - Is aggravated by diet high in purines. - Is prone to recurrence. - Exhibits a prompt response of the acute attack to appropriate treatment (24-48 hours). KEY ISSUES • Appropriate choice of drug therapy for initial management. • Appropriate patient education and counselling regarding prevention of further attacks. 532 099 Performance Guidelines CRITICAL ERROR • Failure to advise change of antihypertensive medication (thiazide diuretic). COMMENTARY Gout (uric acid arthropathy) may present as acute arthritis or be associated with a chronic destructive arthropathy. Most cases of primary gout are due to excessive synthesis of uric acid while one-third relate to reduced renal clearance of urate. Acute gout commonly affects the great toe metatarsophalangeal joint, although other foot joints and the ankle are frequent sites. It may affect any joint in the body or, unusually, it can present as a polyarticular arthritis mimicking other systemic rheumatic conditions. The joint can be extremely painful, red and tender and the patient may be intolerant of even a sheet touching the foot. If fluid can be obtained from an affected joint, it will contain needle-shaped crystals that are negatively biréfringent on phase-contrast microscopy. Plasma urate concentration may not be elevated in the course of an acute attack, so hyperuricaemia is not a necessary diagnostic criterion. CONDITION 099. FIGURE 1. Acute gout CONDITION 099. FIGURE 2. Chronic tophaceous gout It is important to treat hyperuricaemia in order to avoid chronic gouty arthritis, tophaceous gout and renal complications (calculi, chronic renal failure due to interstitial nephritis). Hyperuricaemia is commonly exacerbated by excess alcohol intake and drugs. It is common in clinical practice to come across an elderly patient who has been on longterm diuretic therapy with chronic tophaceous gout and renal impairment. This should be considered an iatrogenic disease. Hyperuricaemia is an independent risk factor for cardiovascular disease. Therefore, an attack of gout provides an opportunity for the prescriber to review the cardiovascular risk factors (for example, smoking, hyperlipidaemia, hypertension, obesity), and to recommend appropriate management. In this station, the candidate is confronted with a very common clinical problem, an eminently treatable condition and an opportunity, through patient education, to institute a longterm management plan to reduce the frequency of attacks. It also provides the practitioner with the opportunity to address significant lifestyle issues with the potential for improved cardiovascular health. 533 100 Performance Guidelines Condition 100 Request for repeat benzodiazepine prescription from a 25-year-old man AIMS OF STATION To assess the candidate's ability to identify benzodiazepine dependency and counsel the patient accordingly. EXAMINER INSTRUCTIONS The station assesses the candidate's awareness that longterm benzodiazepine use is a problem (abuse), capacity to recognise overuse in this case by simple calculation (dependency), and preparedness to intervene and address this with the patient. It also assesses ability to evaluate the problem further by taking a focused history, communication skills in engaging the patient and ability to make an appropriate management plan — including an awareness of potential problems following sudden cessation. A brief survey of mood is all that is required in this case. The history does not suggest any other psychiatric diagnosis except substance dependency. At five minutes, if candidates have not already done so, interrupt and ask them to give their conclusions and make their recommendation to the patient. At six minutes, ask candidates whether they would immediately stop the prescription and why. You may not need to ask this question if the candidate has already addressed this issue. The examiner will have instructed the patient as follows: You are a 25-year-old, divorced salesman. You were first prescribed this anxiolytic four years ago when your marriage broke down. At the same time, your business failed and you were having problems going for job interviews because you had lost so much confidence. You eventually found the anxiolytic was very good at helping you get off to sleep quickly, and you have continued to use the anxiolytic since. Your work, relationships and home life are generally okay now, but you expect this is at least partly because you can get to sleep without fail and feel calm throughout the day. Opening statement: 'This is just a quick one for you, Doc. I just need a refill of my sleeping tablets, thanks, and then I will be on my way'. If the doctor indicates in any way that you should not be taking the Serepax®, or that the doctor is going to stop or substantially change the dose immediately, respond as follows: ‘I know I need to continue the Serepax® because on occasions I have taken only half a tablet for a few days, or missed taking them for one to two days, and I ended up feeling edgy, jittery, shaky and was unable to sleep or concentrate on my work. On one occasion, I thought I was going to have a heart attack because my chest was pounding. As soon as I get back to my usual dose, I feel fine. I do not use, and have never used, any other drugs.' 534 100 Performance Guidelines You are generally in good health. You do not smoke and rarely drink alcohol. You have not had any serious illnesses, injuries or accidents, including car accidents. You have never had any fits, falls or faints or any loss of consciousness. You did feel depressed when your marriage broke up and your business failed, but that has been the only time. Give the following responses and answers to further questions: • When or if the candidate mentions addiction or dependency, say that you are aware of some information about these tablets being addictive, but you don't think it applies to you (for no particular reason), and also your symptoms on ceasing are evident to you that you have a 'real need'. • When, or if, the candidate asks about the schedule of your use. respond by saying that you use them only to get to sleep. • When or if the candidate goes on to demonstrate to you that you have used more than one per day in the past week, say that there has been extra pressure at work, and admit that you have taken a few extra. You can expect the candidate to pursue the issue of quantities used. If the candidate approaches this diplomatically, be cooperative in uncovering the overuse problem. If the candidate is critical or blaming, or wishes to refer you immediately to a substance abuse unit or report you to the Health Department, take offence and say you do not want to continue with the consultation: 'Just give me the script and I will go' or 'I'll sort this out myself. • When the candidate explains a proposal of a period of monitoring your use and moods or stress, followed by graded reduction, along with regular appointments, support and resource materials or groups, agree with this management plan. • If the candidate refuses to prescribe, take offence and respond as above: 'I'll sort this out myself. • If the candidate agrees to provide a prescription with no suggested measures or comments such as 'we will talk next time', accept that and say 'What days do you work. Doc. so that I can be sure to see you next time?' Be quite at ease and be pleasant. Provide your background history and the development of your habit in a straightforward way. Respond to questions about your present use as outlined previously. Questions to ask if not already covered: • 'So what's the problem with taking these tablets, really?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Take a focused history of the patient's use of the benzodiazepine anxiolytic (Serepax®) and history of other substance and alcohol use and patient mood. • Advise the patient about the problems of benzodiazepine dependency and outline a plan of management that includes a gradual reduction in use, along with regular appointments, support and resource material and followup. 535 100 Performance Guidelines KEY ISSUES • Identification and preparedness to address the issue of dependency and overdose. • Appropriate language and attitudes in taking the history and discussing the problem. • Knowledge of biological and psychosocial management of benzodiazepine dependency. • Awareness of the risks of sudden cessation, such as acute withdrawal states, fits, agitation, exacerbation of anxiety and treatment failure. CRITICAL ERROR - none defined COMMENTARY This station assesses the candidate's ability to identify inappropriate benzodiazepine use and dependency, and to counsel a patient appropriately. The doctor is presented with the problem of being drawn into maintaining a longterm benzodiazepine use habit, with clear evidence of over-use (approximately 75% greater consumption than the prescribed dose). Benzodiazepines are recommended for short-term use only. While they have some place in the longterm management of chronic severe anxiety, other treatments, including antidepressant medication and psychological treatments (relaxation techniques, cognitive behavioural or interpersonal therapies) must be applied first. Longterm prescription needs are to be closely supervised and monitored for over-use, such as in this case. This case challenges candidates in a number of ways. Chiefly, it requires them to actively and constructively intervene, not just to provide the prescription (with or without advice) or to just refuse the prescription, thus provoking the patient to seek out another source, or risking precipitating a withdrawal state. The satisfactory candidate, in addition to managing the immediate consultation needs, will be aware of community support and self-help groups. Candidates should demonstrate that they understand the problems of both prescribing further medication without any review or plan for reduction, and also suddenly stopping the medication. Thus, simply advising the patient that they will 'talk next time', or refusing to prescribe with no other measures put in place, are both unsatisfactory. Similarly, referring the patient immediately to a substance abuse unit would be unsatisfactory and counterproductive. 536 3-B: Clinical Procedures Peter G Devitt and Barry P McGrath 'The hand is the cutting edge of the mind.' Jacob Bronowski The term management implies an integrated approach to patient care, focusing on investigation and treatment. This section concentrates on aspects of management that involve practical aspects of patient care. There are certain procedures with which the commencing intern is expected to be fully conversant and competent. These include at least: • establishment of elective or emergency venous access for The junior graduate commencing infusion of fluids; internship is expected to be fully • venesection for collection of blood samples; • insertion and removal of a urinary catheter (male and female); • intramuscular, subcutaneous and intradermal injections; • cardiopulmonary resuscitation (CPR); • interpretation of ECGs and basic imaging films; • use of a glucometer: • use of inhaler, spacer and nebuliser; and • understanding of spirometry and pulmonary function testing. conversant and competent with certain core skills, including antiseptic and aseptic technique, basic first aid techniques and primary wound care. Graduates are expected also to understand the principles of more specialised clinical skills, and to be able to explain these clearly to a patient. There are other skills that the individual is expected to acquire progressively under supervision during internship and should have some understanding of at graduation. Some of these are ward-based skills and some may be learnt in the emergency or anaesthetic department. These skills include: • simple skin suturing; • use of a defibrillator; • maintenance of an adequate airway; • insertion of a nasogastric tube • performance of an electrocardiogram; • collection of a sample for arterial blood gas analysis; • central venous pressure measurement; • pleural aspiration and peritoneal tap (needle thoracentesis, needle peritoneocentesis); • nasal packing; • slit lamp examination; • anoscopy (proctoscopy/rigid sigmoidoscopy); and • endotracheal intubation 537 3-B Clinical Procedures Another group of skills are those which the intern will be expected to observe and perhaps perform under supervision, but not necessarily demonstrate fully independent competence at this stage of training. It is important that the principles of these procedures are observed and understood and can be explained to patients. These skills include, among others: • indirect laryngoscopy; • lumbar puncture; • use of a tonometer; and • advanced local anaesthetic and field block including intravenous local block (Bier), and epidural block commonly used in obstetrics. A fourth group of skills include those which are not considered suitable for those at intern level, but which may have been observed by individuals whilst medical students or interns. There is a common misconception that such procedures need to be learnt at internship, when in reality the procedures should preferably only be undertaken independently by individuals with already developed specialist skills. Again, the principles of these procedures should be understood at intern level, such that they can be explained to patients. These procedures include: • cricothyroidotomy; • insertion of a central venous line; • insertion of an intercostal draintube; • peritoneal dialysis/lavage; and • haemodialysis/haemofiltration. Missing from these lists are a number of tasks sometimes thought of as procedures, but which in reality should be considered an essential part of the examination of the patient. These include: • ophthalmoscopy; • measurement of blood pressure; • otoscopy; and • urinalysis. Specialist and generic endoscopic skills These are usually confined to performance by specialists in various disciplines and include: • nasolaryngoscopy, bronchoscopy; • upper gastrointestinal endoscopy - - oesophagoscopy, gastroscopy; • lower gastrointestinal endoscopy — flexible sigmoidoscopy, colonoscopy; and • arthroscopy, thoracoscopy, laparoscopy. This section contains some examples of procedures which the intern is expected to be able to perform competently and be able to explain to a patient. The following table is an AMC composite checklist of 'Clinical Procedural Skills'. Students are expected by graduation to understand the principles of all of these, and to be able to explain them clearly to a patient. Competence levels expected as regards performance thus varies between those they should be able to perform and interpret independently (A), perform under supervision and with guidance (B), or observe and understand principles (C). 538 3-B Clinical Procedures Many University Clinical Schools make use of similar student log books indicating acquisition of skills and certification of their performance under supervision of a clinical tutor. We are grateful to the University Clinical Schools of Adelaide, New South Wales and of Monash for access to their skills lists, which have been amalgamated into the AMC table. Other important core skills and principles often violated or overlooked relate to appropriate antiseptic and aseptic techniques, including such basic aspects as care in handwashing between each patient contact; and skills in regard to basic first aid techniques and primary wound care, together with knowledge of operating theatre protocols including donning of gowns, gloves and masks and simple splintage and plastering techniques Clinical Procedural Skills — Competency Expectations Final Year Key to Competency Levels A = ability to perform and interpret independently and explain principles to patient B = ability to explain principles, perform, and/or interpret with prompting and guidance C = observe and understand principles, explain to patient Core skills (Competency Level A) At the end of final year the student should be able to perform the following age-appropriate skills competently and without supervision Competency Level A Measure and record vital signs: oral, aural and axillary temperature/pulse/respiratory rate/blood pressure Testing of urine (urinalysis) Venepuncture (including knowledge of appropriate containers for common tests) Insertion of peripheral intravenous cannula Simulated administration of a drug intravenously Setting up of an intravenous infusion including blood 12 lead ECG — procedure 12 lead ECG — interpretation Use of auroscope/ophthalmoscope Basic first aid, including CPR Application of a simple dressing Basic trauma management Basic wound care including burns Basic life support on a mannikin Application and removal of a forearm plaster Insertion of a nasogastric tube Insertion of a urinary catheter (male and female) Removal of a urinary catheter Nasopharyngeal aspiration Administration of immunisation and knowledge of appropriate schedules Calculation of common drug dosages Administration and prescription of oxygen Give a drug orally 539 3-B Clinical Procedures Competency Level A (continued) Give a drug via eyedrops Give a drug sublingually Give a drug via an inhaler, a spacer and a nebuliser Give a drug rectally Give a drug vaginally Give a drug intranasally Give a drug transdermally Give a drug via intramuscular injection Give a drug subcutaneously Hand cleaning, asepsis, awareness of sterility and standard precautions Surgical scrub procedures Aware of occupational health and safety (OH&S) procedures about blood and body fluid exposure and needlestick Diagnose death, complete a death certificate and a cremation form Demonstrate knowledge of requirements for reporting deaths to the coroner Demonstrate knowledge of requirements for detention under the Mental Health Act Demonstrate knowledge of requirements for notification of infectious diseases Complete a Workcover certificate Write a discharge letter from a hospital to a general practitioner/local medical officer Write a referral letter to a specialist Write a hospital consult request Write an investigation request form Interpret standard laboratory medicine reports Interpret commonly used imaging (CXR, AXR, pelvis, spine and long bones) Specimen handling Write a prescription (including Authority and SP) — simulated Demonstrate use of relaxation therapy Lifting and patient handling skills Use of infiltrative local anaesthesia Simple nerve block, e.g. ring block/peripheral digits Suturing of a simple wound Remove skin sutures and staples Skin biopsy Wound swab Throat swab Skin swab Cervical smear/use of speculum Perform the following components of advanced life support on a manikin — intubation Understand principles of advanced life support on a manikin — defibrillation 540 3-B Clinical Procedures Supervised Core Skills (Competency Level B) Supervised core experience (at the end of final year student has performed or assisted with the age-appropriate skill under direct supervision). Competency Level B Normal vaginal delivery Arterial puncture Femoral venepuncture Management of epistaxis by nasal packing Syringe an ear Uncomplicated removal of foreign bodies from eyes, ears and nose Use of slit lamp microscope 541 3-B Clinical Procedures Procedural Skills (Competency Level C) Observed core experience (at the end of final year student has observed and may have assisted with the skill or procedure and is able to describe and explain it to a patient simply and clearly). Competency Level C Advanced trauma management, including defibrillation/revival Measurement of central venous pressure Insertion of CVP line Pleural tap, insertion intercostal catheter/chest drain — management of underwater drainage Abdominal paracentesis/diagnostic tap of ascitic fluid; peritoneal dialysis/lavage Suprapubic bladder tap Lumbar puncture and measurement of CSF pressure Simple skin excision Handling an aggressive patient Joint aspiration (including practice on a model) — knee, shoulder, elbow Endoscopy — upper Gl tract Colonoscopy Flexible sigmoidoscopy Colposcopy Fine needle aspiration cytological biopsy for common conditions, e.g. breast, thyroid and lymph node Liver biopsy Audiometry Post mortem examination (autopsy) Bone marrow biopsy Exercise ECG Echocardiogram Coronary angiogram and angiographic procedures Bronchoscopy Spirometry — formal lung function testing MRI and CT imaging Ultrasound (abdominal, musculoskeletal, breast and obstetric) Nuclear medicine scans Electroconvulsive therapy (ECT) Application of a lower limb traction splint Peter G Devitt and Barry P McGrath 542 3-B Clinical Procedures 3-B Clinical Procedures Candidate Information and Tasks MCAT 101-104 101 Resuscitation of a 24-year-old man after head and chest injury 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery 103 Evaluation of lung function by spirometry in a 22-year-old man 104 A suspected fractured clavicle in a 20-year-old man 543 101 Candidate Information and Tasks Condition 101 Resuscitation of a 24-year-old man after head and chest injury CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in the hospital Emergency Department A 24-year-old man is carried by his friends into the department, having just driven his car into a telegraph pole immediately outside the hospital. He is unconscious, barely breathing and with limited chest movement. He vomits as he is carried into the room. His forehead is bleeding from a head injury from being thrown into the windscreen. YOUR TASKS ARE TO: • Indicate what measures you would undertake to resuscitate him, describe these to the examiner and perform them on the manikin. • Following your initial resuscitative measures his colour improves initially, but another several minutes later it becomes very difficult to ventilate him even squeezing the breathing bag very firmly, and he becomes deeply cyanosed. Indicate to the examiner what further physical findings you would seek, and what measures you would then undertake. The Performance Guidelines for Condition 101 can be found on page 549 544 102 Candidate Information and Tasks Condition 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) on a surgical ward; you have been asked to see a middle aged patient who had a laparotomy for a perforated duodenal ulcer six hours ago. He has a nasogastric tube in position and an intravenous line administering 5% dextrose. Serum electrolytes and creatinine done prior to surgery showed no significant abnormality. Operative findings as recorded were an anterior wall duodenal ulcer perforation which was oversewn without complication. The nursing staff are concerned that the patient has not passed any urine since the procedure was completed six hours ago. The patient had been in good health up to the time of the perforation and had been in severe pain for 12 hours before the operation, and had vomited several times. He has had 500 ml_ of 5% dextrose intravenously since admission. He has a nasogastric tube in situ draining to the bedside. He does not have a urinary catheter. YOUR TASKS ARE TO: • Assess the patient, and determine the cause of his problem. • Initiate a plan of action: this will include the writing up of any drug, or intravenous or nursing orders. • Outline your plan and orders to the observing examiner. • You have six minutes for your assessment and two minutes to describe your management plan and diagnosis. . The Performance Guidelines for Condition 102 can be found on page 551 545 103 Candidate Information and Tasks Condition 103 Evaluation of lung function by spirometry in a 22-year-old man CANDIDATE INFORMATION AND TASKS You are seeing this 22-year-old man in a general practice for an examination for insurance purposes. You have completed the history-taking and the only finding is a history of mild asthma until the age of 11 years. There have been no symptoms in recent years and no need for treatment. You have examined the respiratory system which you find is normal. You are asked to evaluate the patient's lung function using a Vitalograph spirometer as illustrated below. You are also asked to determine the FEX^ (forced expiratory volume in 1 second) and FVC (forced vital capacity) and then compare these with normal values. After this you are asked to explain the results to the patient. YOUR TASKS ARE TO: • Perform spirometry on this patient. • Calculate the FEV, and FVC. • Compare the patient's FEV^ and FVC with predicted values. • Discuss the results with the patient. CONDITION 103. FIGURES 1-3. The Performance Guidelines for Condition 103 can be found on page 558 546 104 Candidate Information and Tasks Condition 104 A suspected fractured clavicle in a 20-year-old man. CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in an Emergency Department. Your patient is a young adult male who fell heavily onto the point of his right shoulder earlier today. He presented with pain in the area and you suspected a fracture of the clavicle on that side because of swelling, mild deformity and localised tenderness. An X-ray of the area has just been done. YOUR TASKS ARE TO: • Examine the X-ray provided. • Inform the patient of your diagnosis and outline a management plan and answer any specific questions asked by the patient. • Commence treatment using the materials provided. CONDITION 104. FIGURE 1. The Performance Guidelines for Condition 104 can be found on page 561 547 3-B Clinical Procedures 3-B Clinical Procedures Performance Guidelines MCAT 101-104 101 Resuscitation of a 24-year-old man after head and chest injury 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery 103 Evaluation of lung function by spirometry in a 22-year-old man 104 A suspected fractured clavicle in a 20-year-old man 548 101 Performance Guidelines Condition 101 Resuscitation of a 24-year-old man after head and chest injury AIMS OF STATION To assess the candidates knowledge and ability to clear the patient's airway, perform assisted ventilation, cardiac massage if necessary and circulatory support for patients with severe trauma. To suspect, diagnose and perform emergency decompression of a tension pneumothorax. EXAMINER INSTRUCTIONS EXPECTATIONS OF CANDIDATE PERFORMANCE A patient who has a severe combined head and chest injury needs urgent resuscitation: • Clear the airway — remove aspirate, vomitus. • Perform assisted ventilation — mouth to mouth, oral airway, ventilate with bag if available, consider endotracheal intubation. If initial improvement is followed by significant deterioration and inability to ventilate the patient with an endotracheal tube in place, the clinician must suspect a tension pneumothorax is present. Physical findings to be sought: Percussion and auscultation of the chest reveals tympany, absent or reduced air entry, supported by evidence of mediastinal and tracheal shift. This confirms the clinical diagnosis of tension pneumothorax on that side and necessitates immediate insertion of a large bore (18 gauge) needle into the second or third intercostal space anteriorly, followed by elective passage of an axillary intercostal underwater drainage tube. The candidate should indicate the tube connections to the underwater drainage bottle. KEY ISSUES • Knowledge of the AIRWAY, BREATHING. CIRCULATION priority sequence in management. CRITICAL ERRORS • Failure to follow an appropriate priority sequence in management. • Failure to consider a tension pneumothorax. • Failure to recommend immediate needle decompression thoracentesis. 549 101 Performance Guidelines COMMENTARY Emergency management of severe trauma (EMST) involves primary surveys assessing adequacy of airway breathing, and circulation by initial assessment; and correcting life-threatening complications by procedures such as those illustrated in this scenario. The possibility of neck injury must be born in mind, but adequate ventilation must be achieved or the patient will not survive. Manual holding of the neck to prevent any further injury during the airway management, is clearly necessary. 550 102 Performance Guidelines Condition 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery AIMS OF STATION To assess the candidate's ability to manage a common problem — postoperative fluid balance and monitoring. EXAMINER INSTRUCTIONS The examiner will arrange the station and will have instructed the patient as follows: The patient is a middle-aged man in pyjamas, lying in a hospital bed or on a trolley. A nasogastric tube is in position from nares to bedside, taped appropriately to the face, leading to a nasogastric bag containing 600 ml_ of 'gastric juice' (malt vinegar). An intravenous line and cannula is in place taped to run beneath a dressing to left forearm, from a full bag of 500 mL 5% glucose (dextrose) in water. The fluid balance chart and nursing observations sheet appended is at the foot of the bed This will show the following: 1. Pulse and blood pressure in the normal range since admission and surgery 6 hours ago. Temperature is normal. 2. The nasogastric drainage output is 600 mL since surgery (corresponding with the volume in the bag which has not been emptied since surgery). 3. Intravenous fluid intake since admission has been • 500 mL isotonic saline started during the operation and subsequently just finished. • Intravenous orders as currently written are ~ 500 mL 5% dextrose over 12 hours, then ~ 500 mL 5% dextrose over 12 hours then review The patient's abdomen has a gauze and plastic dressing over the upper abdomen to cover the simulated vertical upper midline incision. Analgesics have been ordered on an as required basis — morphine 10 mg four hourly sub-cutaneously. Instructions given to the patient are: You are recovering from surgery from a perforated ulcer. You have some abdominal pain but this has been reasonably controlled by an injection 30 minutes ago. You have not passed urine since the operation. If asked, you gave a specimen prior to surgery; you do not feel currently a need to pass urine. The nurses have asked the doctor to see you because you haven't yet passed urine. The doctor will look at your charts and examine you. You have a painful cut in the upper abdomen covered by a dressing and any undue handling will be distressing. You have a tube in your nose ostensibly passing to your stomach to drain the gastric fluids. You have an intravenous drip in your left arm If the doctor palpates your lower abdomen say that it is not particularly uncomfortable and you do not feel the urge to void if abdominal compression is performed. However, palpation of your upper abdomen will be painful as you have just had an upper abdominal procedure performed. 551 102 Performance Guidelines If asked other questions say you feel reasonably well apart from the pain in your wound, and you feel rather thirsty but appreciate that you cannot yet drink. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to check the nursing and fluid balance observations and note the absence of voiding in combination with minimal intravenous replacement over 6 hours since surgery and in the presence of continuing nasogastric losses. Optimal acquisition of data would be by checking intraoperative and postoperative fluid charts, to establish input since admission and to check for extrarenal losses via gastric tube. The patient should be asked if he feels like voiding. The normal vital signs should be noted; there are no concerning abdominal signs relevant to surgery. The bladder is not palpable, gentle suprapubic pressure and absence of desire to void would be checked by knowledgeable candidates. Checking that the jugular venous pressure is not elevated and examination of tissue turgor for signs of 'dehydration' would be expected (none is present). The JVP is normal and no peripheral oedema is present. Appropriate treatment would be to increase intravenous fluid intake after acquisition of all data, with presumptive diagnosis of insufficient fluid and electrolyte replacement. The preferred intravenous fluid to order initially would be an isotonic electrolyte solution (saline, Hartmann solution, 4% dextrose in 1/5 isotonic saline), rather than dextrose alone, but a dextrose bolus would be acceptable although not the preferred fluid. Immediate treatment should be intravenous saline 500 mL over 30-60 minutes or so, with review after this. These instructions should be stated and written. Some hospitals possess proprietary (ultrasound-based) equipment which the ward staff can use to make estimation of bladder volume. This will help determine if the failure to void is due to retention of urine or to oliguria associated with inadequate fluid replacement. Candidates may suggest passing a urethral catheter, which would be acceptable with review of amount obtained and subsequent urine output. Preferably one would review the patient after giving an initial bolus of fluid. If the patient has not produced any urine within an hour, a urethral catheter should be passed. Urine obtained would be measured for volume and, if available, a urinary sodium level should be sought to aid diagnosis. Complete anuria would be a highly unlikely finding under these circumstances, and the finding of a low urinary sodium level (less than 20 mmol/L) in a small volume of urine would confirm prerenal circulatory insufficiency with renal conservation of sodium and oliguria. In subsequent monitoring of his urinary output, one would aim at an output of more than 30 mL hourly. Appropriate responses are as outlined. In particular candidates should appreciate that appropriate volume replacement (after checking for signs of volume overload — venous filling, peripheral oedema, auscultate lung bases) would preferably be by increased intravenous electrolyte solution replacement (isotonic saline. Hartmann solution, 4% dextrose in 1/5 isotonic saline) rather than dextrose/water alone. Administration of a diuretic prior to fluid replacement would indicate a clear fail. If no commentary or plan is forthcoming by six minutes — the examiner will ask: • ‘What is your diagnosis?' • ‘What orders will you give?' 552 102 Performance Guidelines KEY ISSUES • Assess the candidate's ability to determine the most likely cause for apparent postoperative oliguria with failure of early voiding after surgery by examination of nursing and fluid balance data and patient assessment. • Assess the candidate's ability to take appropriate corrective action and to recognise the need for continued monitoring and review. CRITICAL ERRORS • Administration of a diuretic without previous fluid replacement. • Failure to order an increased rate of intravenous replacement of appropriate type. • Failure to suggest continuing review after trial of more fluids. COMMENTARY Surgical operations have the potential to upset the normal water and electrolyte balance of the body, in which daily intakes and outputs are usually finely balanced and equivalent, as shown below in an adult: CONDITION 102. TABLE 1. Water Input Ingested Liquids Water of food Water of metabolism TOTALS Water Output 1.500 mL 1,000 mL 100-200 mL 2.5-3 litres = = = = Urine Insensible losses Faecal losses 1,500 mL 1,000 mL 100-200 mL 2.5-3 litres This simplification is administratively and clinically convenient: • In normal circumstances measured ingested water balances and equals measured urine production; • unmeasurable water in food is balanced by unmeasurable insensible losses from lung and skin; and • unmeasurable water produced within the body, by metabolism of ingested foodstuff, is balanced by unmeasured water loss in faeces. Urine output can be monitored daily or more frequently. A urethral catheter is necessary in the severely ill or shocked patient. A urine output of 40-50 mL per hour is reasonable evidence of satisfactory renal perfusion; urine output relates closely to renal blood flow in shock states Accordingly, urine output monitoring is one of the most useful guides we have in following progress of shocked patients. A 24-hour urinary output of 1000 mL or greater is within the normal range. Early diagnosis of postoperative oliguria is extremely important. Incipient acute renal failure can often be recognised early and reversed. 553 102 Performance Guidelines Changes in Fluid Balance during the Postoperative Period There is increased secretion of many hormones after surgery (catecholamines, Cortisol and adrenocorticotrophic hormone (ACTH), aldosterone, antidiuretic hormone (ADH), glucagon, growth hormone) and decreased secretion of others (e.g. insulin). The net result is that both salt and water are retained temporarily by the kidneys. This results in a transient and minor fall in urine flow for 24-48 hours after major injury and a dilution of electrolytes in serum and extracellular fluid. Sodium is also retained, but not to the same degree as water, so sodium is also temporarily diluted. The reality of this is easily checked by looking at virtually any serum electrolyte measurement after an operation, and seeing that the levels of ions such as sodium often seem to fall below their normal range, and plasma osmolality is also lowered. Remember that this effect is a dilutional effect and does not imply a need for giving more ions — quite the opposite in fact, since ions are already being retained by the kidneys. After the first 24-48 hours, the hormonal effects on the kidneys progressively disappear, and the kidneys can be relied on to make good the electrolyte adjustments required by the body — provided they are given enough fluid and electrolytes with which to work. Postoperative Water Balance Obligatory water losses are around 1500 mL per 24 hours (1000 mL insensible loss from lungs and skin, 500 mL minimal obligatory urine volume). Obligatory water losses may increase after surgery because of tachypnoea or fever. However, renal losses diminish often to between 700-1000 mL in the first 24 hours. Therefore, 2.5 L per 24 hr is usually adequate fluid replacement for adults in the first 24 hours after surgery (not 1,5 litres as is currently ordered in this man). As the kidneys begin to excrete more water, the amount of fluid should be increased to approximately 3 L per 24 hours. This is the baseline replacement for adults of average spectrum of size and weight. But it must be remembered that any other losses (e.g. nasogastric suction), must be replaced in addition to the 2.5 or 3 L; and this patient has already lost an additional 600 mL of gastric aspirate. Postoperative Electrolyte Balance Sodium Renal excretion of Na+ diminishes in the first 24 hours after surgery due to increased aldosterone and Cortisol secretion so there may be no need to give Na+ in this period. However, unidentified losses of Na+ can occur with injury or surgery (third space losses); and because of the uncertainty, it is more common to see sodium being given than withheld during this period up to one litre daily, and usually this causes no problems. Nevertheless, it is well to remember that this is probably in excess to body requirements and sodium should be withheld or given with caution in elderly patients, or those with failing hearts. This patient has no such problems and we have evidence of continuing gastric electrolyte losses of sodium. Once the first 24 hours is past, then sodium requirements return towards normal, and a figure of 150 mmol per day is adequate (which conveniently is represented by 1 L of normal saline). With the hormone-driven retention of sodium in the first 24 hours, there tends reciprocally to be increased K+ loss in the urine. However, this loss is small, and not until after this first 24-hour period is it important to replace K+. Note also that potassium given intravenously 554 102 Performance Guidelines immediately after surgery will just tend to be excreted by the kidney. After the first 24 hours 2gm of K+ in a litre gives 26.8 mmol of K; and so if given in 3 L, provides around 80 millimoles K+ a day, which is quite adequate. Intravenous Fluids Used in Surgery a) 5% Dextrose in Water: This is isotonic (isosmolar) with extracellular fluid, and is therefore the solution to use if you think a patient is dehydrated (i.e. deficient in water alone — for example by fever or absence of normal intake) and needs water. Giving 500 mL of 5% Dextrose intravenously over a short period, say an hour, is a useful manoeuvre if you think dehydration (i.e. pure water deficit) is the cause of a patient's low urine output. This can be thought of as giving the patient a drink intravenously. This patient needs a drink of salty water, however — he is being 'de-salinated' by his previous vomiting and peritonitis and by continuing gastric losses. b) Normal (isotonic) Saline: This is 0.9% NaCI and in one litre contains approximately 150 mmol of Na+ and 150 mmol of CI"; so at 300 millimolar concentration it is roughly similar in equivalence to extracellular fluid — it might be regarded as unsophisticated extracellular fluid replacement. This form of fluid and electrolyte depletion (ECF) is by far the one most commonly seen in surgical patients, and gives classical signs (firm woody tongue, decreased tissue turgor, sunken eyes). c) 4% Dextrose in 1/5 normal Saline: This is an isotonic solution comprising 4/5 dextrose and 1/5 saline; 1/5 isotonic Saline (equals 30 millimolar Na) is mixed with 4% Dextrose to increase the tonicity back to that of plasma. Three litres daily of this solution gives 90 mmol sodium which is usually quite adequate for daily requirements. d) Solutions such as Ringer-Lactate and Hartmann solution use lactate to increase their tonicity and more closely mimic extracellular fluid composition. They also contain some of the other cations and anions of extracellular fluid (K, Ca. Mg. CI) in roughly the concentration found in extracellular fluid. Therefore, they can be regarded as sophisticated extracellular fluid replacement. However remember that lactate is metabolised in the liver, with the release of bicarbonate. Thus in acidotic situations it makes good sense to give such solutions; but not if the patient is alkalotic. e) Potassium-containing fluids: Potassium is the main cation of intracellular fluid. Potassium requirements are broadly similar to sodium. But in contrast to sodium, extracellular and intravascular concentrations of potassium are low (3-5 mmol/L). and high concentrations are cardioplegic and can cause cardiac arrest. So NEVER give potassium in a higher concentration than 30-40 mmol/L, and preferably do not exceed 26.8 mmol/L (2 gm KCI in 1 litre). f) Haemaccel: This is used in situations where there has been rapid blood loss and when it is important to maintain a normal blood volume while awaiting blood for replacement. It consists of sulphated gelatine (produced from crushed horses' hooves, so it can be allergenic) with an average molecular weight of 30,000 Daltons. It is more or less isotonic and the gelatine has a half life of between 30-120 minutes, so its use is very much an interim measure to swell blood volume. The patient needs isotonic replacement for suspected insufficient ECF ('Saline') replacement together with replacement of continuing losses (i.e. gastric aspirate), which can be thought of as roughly equivalent to the same volume of isotonic saline. Intravenous hydrochloric acid cannot be given readily, and gastric juice contains a lot of sodium as well as hydrogen ion and chloride. 555 102 Performance Guidelines Distinguishing • acute prerenal postoperative oliguria due to prerenal circulatory insufficiency from • established acute oliguric renal failure due to acute tubular necrosis, is very important, as the first responds to volume loading, and in the latter case the kidneys are unresponsive. Apart from the important clinical signs and the initial response to a bolus loading, help may be obtained from urinary electrolyte findings (Table 2). CONDITION 102. TABLE 2. Urinary findings expected in postoperative oliguric patient Prerenal oliguria (renal circulatory insufficiency) Urine sodium Low (< 20 mmol/L) Urine osmolality or specific High (> 1,500 mmol/L) (S.G > gravity 1020) High Urine urea and creatinine Intrinsic acute oliguric renal failure (acute tubular necrosis) High (> 50 mmol/L) Low (< 1,000 mmol/L) (S.G < 1050) Low The urine composition in the instance of intrinsic renal failure resembles an ultrafiltrate of plasma due to impaired tubular function. This would be a highly unlikely diagnosis in the current circumstances, with no preoperative evidence of pre-existing renal impairment, and no evidence of intraoperative complication. Composition of Abnormal Losses Seen in Surgical Patients Gastrointestinal fluids all contain significant amounts of sodium and varying amounts of chloride and bicarbonate (Table 3). For unsophisticated and usually satisfactory replacement of abnormal gastrointestinal fluids one can use simple isotonic 0.9% saline. The only caveats are with small children whose kidneys are not yet fully capable of handling sodium loads, and with elderly frail patients with cardiac insufficiency. CONDITION 102. TABLE 3. Gastrointestinal Secretions Daily Fluid (litres) Saliva 1.0 Gastric juice 1.5 Bile Pancreatic juice Intestinal juice 556 1.0 1.5 2.0 Sodium (mmol/L) 50 100 Potassium (mmol/L) 20 15 Chloride (mmol/L) 40 200 Bicarbonate (mmol/L) 50 100 150 150 5 5 5-15 40 40 110-150 40 120 5-30 - 102 Performance Guidelines Note that it isotonic saline is used to replace prolonged bowel fistula losses, deficiencies of potassium and of bicarbonate are likely to be induced so that more sophisticated intravenous fluids, including special hypertonic intravenous parenteral nutrition fluids delivered by a central line, may be necessary. For temporary intravenous fluid management over only several days, simple isotonic intravenous solutions given by peripheral limb lines are all that is usually required. 557 103 Performance Guidelines Condition 103 Evaluation of lung function by spirometry in a 22-year-old man AIMS OF STATION To assess the candidate's ability to perform and interpret spirometry in a subject with previous asthma. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 22-year-old accountant. You had occasional mild attacks of asthma until the age of 11 years. You required only occasional bronchodilator treatment with Ventolin®. You have had no symptoms since the age of 11 years. You jog regularly and play tennis without any limitation. You are otherwise very well. You have not had your lung function measured previously. Listen carefully to the doctor and do as you are asked. When performing the first blow do it incorrectly by taking less than a full breath in and blowing out slowly for six seconds before giving a maximal effort. These manoeuvres should be practised with the examiner before the start of the first candidate. If the doctor does not give you appropriate instructions repeat the same error. Only give a maximal effort if instructed to do this. Questions to ask if not already covered: • ‘What do the results mean?' • If told results are normal, ask 'Does it mean I no longer have asthma?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to: • Use a nose clip. • Insert a clean mouthpiece. • Advise the patient to: ~ undertake a maximum inspiration; ~ give maximum effort during expiration; ~ ensure expiration continues for six seconds, or until candidate comments that the technique was faulty when the effort can be abandoned; and ~ repeats the manoeuvre until acceptable and reproducible efforts have been achieved; reproducible efforts are less than 200 mL or less than 5% variation for both FEV1 and FVC. • Identifies FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity) correctly (do not penalise for use of wrong scale). • Compares patient's FEV1 and FVC with normal values and calculates FEV1 as a percentage of FVC. • Disposes of used mouthpiece. 558 103 Performance Guidelines • Explains test results which are very likely to be normal. Normal results do not indicate that asthma has remitted; they indicate that at present there is no evidence of airway obstruction KEY ISSUES • Approach to patient — gives clear advice and corrects errors with constructive advice. • Familiarity with test equipment • Performance of procedure or task — detects errors and obtains reproducible efforts. • Interpretation of investigation — accurately calculates FEV1 and FVC. • Patient counselling — explains test results. CRITICAL ERRORS • Failure to recommend maximal inspiration • Failure to recommend maximal expiratory effort. • Failure to calculate FEV1. COMMENTARY The diagnosis and ongoing management of asthma require objective measurements of reversible airways obstruction using pulmonary function tests. The diagnosis of asthma is usually confirmed by spirometry measurements before and after the administration of inhaled, short-acting β-agonist bronchodilator. Although spirometry is ostensibly a simple test that can be performed in a medical practitioner's office and requires the recording of a forced expiratory volume-time curve using a spirogram, there are some pitfalls that must be avoided to ensure that valid and accurate results are obtained. Patient education is critically important to ensure compliance and best effort by the patient. Forced expiratory volume measurement must be recorded from a state of maximal inspiration. All expired air must be captured and nasal air escape or escape of expired air around the mouthpiece due to poor sealing of the lips around the mouthpiece, or partial tongue obstruction of the mouthpiece, can give false readings The two key components of the test result are the forced expiratory volume that is produced in the first second (FEV1) and the percentage this contributes to the total expiratory volume or forced vital capacity (FEV1/FVC). Typical examples are shown in the figures. 559 103 Performance Guidelines CONDITION 103. FIGURE 4. Most patients with asthma will show FEV1 < 80% predicted normal value and FEV1/FVC < 80% predicted normal value plus a significant (>10%) increase in FEV1 after bronchodilator. The following factors are taken into account in determining predicted normal values: age, gender, weight, height, surface area. Some patients with asthma will have normal spirometry test results, but sensitivity of airways to bronchoconstrictor stimuli and additional pulmonary function tests, including lung volume and diffusing capacity measurements, can be assessed further in a specialised pulmonary function laboratory. CONDITION 103. FIGURE 5 560 104 Performance Guidelines Condition 104 A suspected fractured clavicle in a 20-year-old man AIMS OF STATION To assess the candidate's ability to recognise a fractured clavicle on an X-ray film of the shoulder area (the degree of deformity is mild so that open reduction/fixation is not indicated), and to advise and initiate appropriate treatment by clavicular restraint. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You fell heavily onto the point of your right shoulder earlier today. The area has been painful since. Movement of the shoulder increases the pain. You have sought medical advice — the doctor has examined you and arranged for an X-ray of your shoulder. This has just been done. The doctor will now discuss the injury and its treatment with you. Ask the doctor to show you the fracture on the X-ray. Opening statement ‘Is a bone broken, doctor?' Questions to ask unless already covered (answers in parentheses after questions): • 'How long will I need to keep the arm in the sling?' (Until review at two weeks) • 'Can I remove the sling to exercise my elbow?' (Yes) • 'What about in bed?' (Elevate shoulder and arm on pillows) • 'Do I have to have it X-rayed again?' (Not if clinical union proceeds normally) • 'Will there be any disfigurement?' (Minor residual bony thickening) • 'When will I be able to go back to work?' (Depends on work and progress in regaining use of arm — often 2-4 weeks) EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to diagnose the clavicular fracture and to begin appropriate conservative treatment with a supportive sling or other clavicular restraints. The candidate should: • Tell the patient what is wrong and what will happen including a time frame for treatment. • Commence treatment demonstrating skill in maintaining alignment of the clavicular fragments using methods which will pull the whole shoulder girdle upwards and backwards (figure of eight bandaging or clavicular restraint shoulder rings tied together at back): and which immobilise and support the shoulder by the use of a sling. A well applied sling elevating and supporting the arm would be the most appropriate form of treatment with this minimally displaced fracture. • Avoid complications by testing for excessive tightness of the bandage/rings, advising finger, wrist and elbow joint exercises, removal of the sling after 7-10 days, and the bandage/rings if used, after three weeks when there is clinical evidence of union beginning (unduly prolonged immobilisation can result in a stiff shoulder). 561 104 Performance Guidelines KEY ISSUES • • Ability to recognise fracture of clavicle on X-ray. Skill in treatment by optional use of figure of eight bandage or clavicular restraint shoulder rings; sling for arm and forearm (supporting shoulder). CRITICAL ERRORS • Failure to recognise fracture on X-ray. • Failure to apply some form of appropriate shoulder and arm support COMMENTARY Fractures of the clavicle are common in younger patients from falls on arm or shoulder. The usual break occurs at the midclavicle and the outer fragment is carried with the arm downwards and forwards, while the inner fragment usually rides up giving a step deformity. Healing is usually rapid with conservative treatment — nonunion can occur but is rare. Treatment consists of elevating and supporting the arm with a sling which helps relieve discomfort and helps to minimise displacement. Application of a sling is illustrated (Figures 2-5) Additional clavicular restraints can be used such as a figure of eight bandage, or shoulder rings tied together from behind to brace back the shoulders into the 'position of attention'. All of these tend to loosen quickly and to require frequent adjusting. Union is usually accompanied by a localised boss of exuberant callus. Remoulding occurs in the young with time and the cosmetic result is usually acceptable. Return of full arm function is also usual. 562 104 Performance Guidelines CONDITION 104. FIGURE 2. CONDITION 104. FIGURE 3. CONDITION 104. FIGURE 4. CONDITION 104. FIGURE 5. Application of a supportive sling 563 564 4 Integrated Diagnosis and Management (D/M> 4-A: Clinical Perspectives and Priorities Bryan W Yeo 'Experience is the mother of truth; and by experience we learn wisdom.' W Shipperton (1736-1808) INTRODUCTION Clinical perspective is an essential skill that every clinician must strive to develop. It is never fully achieved, but should be A 22-year-old man with central steadily improved and refined throughout the lifetime of the abdominal pain which shifts to clinician. Proper perspective facilitates patient management, the right iliac fossa, with avoids unnecessary delay, allows better cost-effective anorexia and local tenderness treatment and achieves better communication with the patient, and rebound tenderness at McBurney point needs an especially when the prognosis is poor. appendicectomy, and not a Common things are common. This must be kept in mind as it white count, CT or ultrasound helps priority-oriented management. Dysphagia associated scan of the abdomen or a battery with an oesophageal stricture could conceivably follow a of other unnecessary tests. This lightning strike to a sword swallower but is much more likely to basic maxim regrettably be due to one of two common causes — chronic reflux continues regularly to be oesophagitis or a carcinoma of the oesophagus. overlooked in hospital Pain in the right iliac fossa always raises the possibility of emergency departments. appendicitis. Episodes of spontaneously resolving nonspecific abdominal pain with minimal local signs are commonly seen in general practice, but persisting acute local pain with tenderness and guarding in the right iliac fossa of the abdomen is most likely due to one of three conditions — appendicitis, a tubal-ovarian problem (ovarian cyst, salpingitis, ectopic pregnancy), or a urinary tract problem (urinary calculus or infection). These should be considered first in the diagnosis before other less common causes (of which there are many). A 22-year-old man with central abdominal pain which shifts to the right iliac fossa, with anorexia and local tenderness and rebound tenderness at McBurney point needs an appendicectomy, and not a white count, CT or ultrasound of the abdomen or a battery of other unnecessary tests. This basic maxim regrettably continues regularly to be overlooked in hospital emergency departments. Perspective skills improve with accurate knowledge of the underlying anatomy and physiology. A forty-year-old woman with abdominal pain and signs of peritonitis in the right upper quadrant of the abdomen is most likely to have acute cholecystitis associated with gall stones. But also keep in mind a common condition such as appendicitis occurring in a less common site like the upper right quadrant. Simply diagnosing that a patient has 'gallstones' is not enough. The site of the gallstones is critical to the patient's condition and a priority in diagnosis. Correct siting determines the correct timing of surgical treatment with the least risk of serious complications. A patient with severe acute cholecystitis due to a stone obstructing the cystic duct should undergo cholecystectomy within five days of the onset of the attack. A patient with pancreatitis due 565 4-A Clinical Perspectives and Priorities to gallstones passing through the common bile duct is best managed initially with conservative treatment of the pancreatitis; cholecystectomy is performed when the pancreatitis has subsided in the second or third week of the initial admission. Thus, the particular complication caused by the gallstones will prioritise the timing of the surgery. Never is there a more important need for clinical perspective than in discussion with a patient who has surgery for a malignant disease. After resection of a colonic carcinoma, the subsequent development of malignant ascites associated with peritoneal metastases is an indication that the patient is unlikely to be helped by further surgery in the form of an open laparotomy. Furthermore, this later occurrence of ascites would have been predicted as a likely future complication after the first operation when the histopathology had revealed that the carcinoma had spread through the full thickness of the bowel into the omentum and pericolic tissue. Discussion of the prognosis with the patient after the first operation would be guarded and with discretion, based on the spread of the carcinoma identified in the histopathology of the resected bowel. Similarly, a patient with carcinoma of the pancreas and back pain due to lymphatic or perineural spread of the carcinoma is unlikely to be cured by a pancreatic

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