Year 5 Written Specialities Exam 2014
Feedback for students
The mean score for students taking the written specialities exam in 2014 was 75.76% with a range
45-92%. Areas where students performed particularly poorly are highlighted below.
General Practice
Students often had difficulty answering questions relating to management of common childhood
conditions including skin rashes and helminth infection.
In assessing rashes in children, fewer than half of the students knew that a simple nappy rash with
flexural sparing is likely physical rather than infectious in origin and should be treated with a barrier
cream such as zinc and castor oil. Students were much more aware that the presence of satellite
lesions was suggestive of fungal infection and correctly identified clotrimazole as appropriate
treatment in this situation. Very few students were able to deduce that pruritis ani/perianal pruritis
at night, without other bowel symptoms, was likely to be due to threadworms and should be treated
with mebendazole, usually given as a single dose with the option to provide a second treatment two
weeks later. Likewise only a minority of students were able to identify the correct treatment for
impetigo; this is a highly contagious skin condition presenting in children with small fluid filled spots
which may burst and crust over. It is caused by staphylococcus aureus or streptococcus pyogenes
and is usually treated with topical fusidic acid as a first line agent.
Other areas where performance was weak included assessment of a child with delayed speech
where many students failed to organise a hearing assessment before making an onward referral for
speech and language therapy, and in assessment of depression in an individual with learning
disability where students did not appreciate the importance of physical symptoms such as poor
sleep and weight loss in diagnosis.
Obstetrics and Gynaecology
With one exception, all questions were answered correctly by at least 50% of students sitting the
exam.
Of most concern was students’ failure to consider ectopic pregnancy as a likely diagnosis in a young,
sick woman with abdominal symptoms and a positive pregnancy test. Students should be aware that
diarrhoea is not unusual with an ectopic pregnancy if there is blood in the pelvis. A mildly raised
white blood cell count is normal in pregnancy and so does not necessarily indicate infection.
Students were asked for the most likely cause of a single episode of brown stained vaginal discharge
in an elderly woman. Very few correctly identified atrophic vaginitis. Whilst malignancies are clearly
of concern in post-menopausal women, atrophic vaginitis is much more common and should be
considered within the differential. In general students must remember to consider common benign
conditions within their differential. Cancer is a relatively rare condition but must be included in the
diagnostic process.
Many students were keen to offer iron supplements as a first line approach to management of a
pregnant woman with Hb 10.5, MCV 82 and MCH 27. This is a normal Hb in pregnancy and simple
advice about including dark green leafy vegetables, pulses, beans, nuts, seeds and brown rice in the
diet is the most appropriate response.
Students were confused about screening tests for virus infection in pregnancy. Most serological tests
looking for IgG antibodies identify prior infection (eg hepatitis B core antibody) or prior vaccination
(eg hepatitis surface antibody). The presence of IgM antibodies usually identifies active or recent
infection. Tests for active infection may involve testing for the presence of the virus by identifying
viral antigens (eg hepatitis B surface antigen) or DNA (hepatitis B DNA). The latter is not usually
requested routinely as it is an expensive test. These screening results are documented in every
pregnant woman’s handheld notes.
Students failed to recognize features of uterine rupture. This may be preceded by hypercontractility
of the uterus. The rupture results in fetal compromise with reduced fetal movements and
bradycardia. Rupture into the bladder may result in haematuria. Suprapubic pain is a classic
symptom.
Psychiatry
Students were not sufficiently able to distinguish between clinical presentations of different types of
dementia. They should be aware of features of vascular dementia, frontotemporal dementia and
Alzheimer’s disease. Only a minority of students made a correct diagnosis of Alzheimer’s disease
based on a history of poor memory, difficulty in word finding and difficulty in planning.
Students showed very poor judgement when asked about management of an agitated patient and
failed to think through the scenario sensibly. If called to a ward in this situation a junior doctor
would initially assess the patient, in a safe environment with another person present, before
telephoning a consultant or prescribing a tranquilliser.
Likewise students showed poor judgement in management of an unconscious patient without
capacity to consent to surgery. The involvement of close family members in decision-making is
crucial in such cases.
Many students failed to appreciate the importance of patient education when prescribing
medication for individuals with a chronic disease. This is important not only in psychiatry but in very
many other chronic conditions (diabetes, rheumatoid arthritis, inflammatory bowel disease etc)
where patients need to take long term treatments that may be unpleasant to administer (eg
injected) or associated with side effects or the need for regular monitoring.
Students did not always understand the role of the health visitor in advising parents on management
of minor behavioural problems in young children. Support and advice from an experienced health
professional is often all that is needed to help parents deal with sleep or eating difficulties in their
children.
Paediatrics
Students should understand more fully the impact of brain injury/disorders on children; these may
be associated with neurological defects but are frequently also associated with psychiatric
comorbidity.
Students should be able to distinguish between different causes of headaches in children and tailor
their investigation and management plan accordingly. Very few students identified early use of
paracetamol as the best first line treatment for mild migraine.
At the other extreme, when presented with a febrile child with neck stiffness and a history of
convulsions, very few students identified the need for a CT scan with many students opting to do a
lumbar puncture as a first line investigation. Where there is concern about an intracranial
abnormality a CT scan needs to be done prior to a lumbar puncture to reduce the risks of
complications associated with this procedure.
Overall students did not perform well in questions relating to infection. Fewer than half were able to
identify herpes simplex as a likely cause of blistering lesions, malaise and fevers as a complication of
childhood eczema. A smaller minority still were able to identify parvovirus as a cause of a febrile
illness with rash and arthralgias associated with subsequent still birth and hydrops foetalis.