Station 4 : Discharge

Communication_1

Yet another scenario from 2/2009 diet:


A lady
Smoker

Infective Endocarditis of prosthetic mitral valve
on 10th day of parentral antibiotics
Consultant plans to keep her in hospital for next 2 weeks

She has 2 kids at home,whom need support and
keeps on smoking in hospital premise.

Adamantly asking you to send her back home

Recently Released Book:OST

If you're confident you are well grounded in Clinical Medicine,
just skim the texts there to update yourself.

Station1:Chest Percussion

Clinical Method_Respiratory

A colleague who sit for the paces diet 1 in 2009 was criticized by an examiner that he made percussion of the chest far below the boundaries of the lungs.

How far should we percuss downward on back of the chest in Respiration Station?

• In quiet respiration, the lungs’ inferior
  margin travels around the thoracic wall
  following a VI, VIII, X contour

  (i.e. rib VI in the midclavicular line, rib VIII in the
  midaxillary line, and vertebra TX posteriorly).

STATION 2:Action Plan for DIARRHOEA

Station 2-Diarrhoea

Action Plan:
Follow standard history taking format sensibly.

• You are ……
• tell me more about the symptoms
• how frequent?any blood?
• still much the same or getting worse?
• any medication?help
• Cigarette
• Caffeine Alcohol
• Any change in period
• Any SoB etc.
• Diet

SOCRATES is useful mnemonics for associated PAIN.

• Site
• Onset: ? following infective episodes or travel
• Character? how would you describe
• Radiation
• Timing: ?wake up at night to go to loo, pain goes away after bowel
• Exacerbation:? diet? tried exclusion
• Severity

Preformed broad DDx should aid symptom analysis.
COLON vs MALABSORPTION vs SI

• infective
• inflammatory
• neoplastic
• ischaemic
• Irritable bowel

Alarm Symptoms will guide the speed and types of  INVESTIGATIONS.

• > 40
• Weight loss
• Bleed
• Family history

Think about BLOOD,STOOL,ENDOSCOPY,IMAGING
Address patient concern and welfare.

PACES 2010/3

from a candidate

Respiratory: ?bronchiectasis with R mastectomy and bilateral thoracotomy scars,

CVS: young lady with small L thoracotomy scar in the back, and asked “why SOB in pregnancy?”

Hx: longstanding SOB+ suddenly worse, FH of CVA, MI and PE,

Abdomen: PKD

Neurology: peripheral sensory neuropathy in diabetic

Ethics: explain to a patient  recently diagnosed coeliac disease!

Station 5:

1. diabetic w necrobiosis lipoidica,reached to the diagnosis but examiner not happy because I didn’t address her concerns.

2. 60 year old lady w painless LN in cervical area, said all possible malignancies, then pushed and said sarcoidosis and amyloid, think she had sarcoidosis.

What do you expect to be heard?

St. Jude

Station 1 : Issues in COPD

Station1 FAQ_issues in COPD

The most important factor in reducing long-term progression of COPD is to STOP SMOKING.

Patients must stop smoking and they should have support with this and the offer of buproprion or NRT.

(NICE, evidence level B).

PULMONARY REHAB

if functionally disabled by COPD

(usually MRC grade 3 and above)

A programme includes

• physical training,
• disease education,
• nutritional, psychological and behavioural intervention.

PACES 2011/1

PACES Carousel started in Station 3.
It went well.
Cranial Nv Examination:
Lt sided LMN VII Palsy was obvious.Then I looked for cause:auricles,mouth,parotid and neck.Next, I asked for smell,Vision and EoM.There was Nystagmas on Lt LGaze.He said Double Vision on Lt Lateral Gaze.Outer image disappeared on covering Rt eye(a bit confused to interpret at that time).Later, noted hard of hearing on Lt side.I went for Weber( again he said couldn’t feel it ) then for Rinne ( he cannot follow my instruction),After checking V sensation,I asked to Outstretch arms and finger nose tests.

I gave CPA tumor as Dx.
they asked me possible causes( including acoustic neuroma).Rx( Surg/Radio)


CVS:
Comfortable pt with AF,purpura over forearm,midline sternotomy & lateral thoracotomy scar.Metallic sound.
Gave Dx as Metallic Mitral Valve,Af on Warfarin,CABG ( When I was about to check legs,times up )
Asked: What U look for in JVP in Af (>absent a),HF Mx.
I was contented when I left that station.Examiners were nice.


Station4:Young lady,admitted with Joint pains.immunological test confirm SLE.blood and protein in urine.unwilling for renal biopsy,talk to her for renal biopsy.

I felt like I got scenario a bit late,went into the room without a strategy.
I was trapped myself into kidney biopsy prematurely.
she was unhappy for being kept in hospital for about 2 weeks without being explained about diagnosis. Other issue was concern about her study.
I did badly in that I should have go through 
1,her perception,
2.Break SLE Dx.
3.Explain/Apologize for not being properly informed during her stay in hospital 
4.then benefits of biopsy and procedure.
5.Conclude.


Examiner :
why she was angry to hospital?
What to to do next if she refused biopsy.


Station 5:
Straight forward:

1_RA ,Peripheral Neuropathy
Concern: Whether her condition got worse as Humira was stopped recently for pneumonia.
Complaint of SoB during interview.
Asked me what might be causes of SoB.
>> my answer was to look for problems related to Lung, Heart or Anaemia

2_Gradual Visual Loss both eyes,T1DM
Soft exudates ( preproliferatve ) without history of laser Rx.
I suspect some len opacities with intact red reflexes.
I explained to the patient referral to Eye doctor,photo of back of the eye and proper glucose control.
examiners asked DDx.(dysglycaemia/cataract/maculopathy etc.)


Station1:Resp: Mildly Clubbed ,Rt thoracotomy,trachea >lt ( in fact I’m not that confident ),
Dull left side.
L Pneumonectomy
I missed added sound on Rt base when they asked me to listen there again
(coarse crackles was my answer ).

• asked reason for operation.
• asked how to differentiate pleural rub and pericardial rub: I was nervous to hear that Q since it sounded unrelated to my answer!

I simply said ‘stop breathing’.


Abdomen: craniotomy scar,fistula scar over forearm( without thrill or bruit?? )transplant Kid, lobulated mass on other flank.
Ask me Standard Qs:

• PKD mode of transmission,screening,presentation,associations,how to retard progress of kid failure.
• SEs and caution about ACEI.

Station2:
tremor
slow movement
Interview reveals she had it when she put her hands on lap,
presented on movement,
disturb her ADL,
but not miss the point eg. on eating,drinking


little facial expression noted by her husband,
slowly progressed over a few months.
no memory loss, no depression but dysphagia +, not on anti psychotic
no postural drop on last visit to GP


Her concern : stroke
family ho tremor + ( i felt it as red herring )




After all,I felt that I might have cleared if I did smoothly in communication and Respiration Stations.
Now I m gathering energy to fight back again!


PS: successful in this attempt!


My Sincere Thanks to the Authors,Stephen Hoole et. al.,without their concise guide book, I would not have cleared MRCP.

Hands

List 5 Abnormal Findings in the hands.

What are the systemic correlation?

Examine this patient's Upper Limbs

• Scan the whole patient and look at:

  1_FACE,NECK,ELBOW & HANDS
  2_MUSCLE BULK,TREMOR & FASCICULATION
  3_Ask : Hold your arms out infront of you
  4_Test:TONE,POWER,REFLEXES
  5_Test: Coordination and Sensory Screen

  
  

  FINDINGS:

  • Face and Neck look normal.
    Arms and forearms are wasted,more marked proximally.
    No tremor or fasciculation is noted.
    And the patient can not outstretch both arms.

    Tone is reduced both proximally and distally.
    Proximal power 2/5,3/5 distally.

    All of the upper limb reflexes are sluggish.

    Sensation is normal.

    
    

Arm Drift

• FINDINGS:

  Downward Drift,Spreading of Fingers,Pronation of Wrist and Flexion of Elbow on RIGHT side.

  INTERPRETATION:

  ? Pyramidal Weakness
  ? Cerebellar Disease
  ? Pseudoathetosis

  
  

Station4:Consent

Casts:

Patient:Mr G Andrew,77
Carer: Mrs J Fawkes,eldest daughter of the patient
Supporting Roles:Your consultant,gatroenterologist,registrar,speech therapist

Setting:Station 4

Plot:
Dementia
Right Basal Pneumonia
Poor swallowing coordination
Poor nutrition
Failed NGT,Drips

Plan to insert PEG tube for feeding

TASKS:
1.Why PEG tube is being considered
2.Obtain consent from pt's daughter

Ryder & Freeman,vol 2,p 165

Investigating suspected anaemia

The patient

A 70 year old retired barber presented to his general practitioner with breathlessness on walking. A history of gradual onset of fatigue, lethargy, and exertional dyspnoea was elicited.

The patient was a non-smoker who had previously been well, took no medications or supplements, and shared a bottle of wine with his wife at weekends. He was not a vegetarian and took a good mixed diet.

Physical examination showed pallor of the conjunctiva and nail beds and mild oedema of the ankles. There was no hepatosplenomegaly nor were there any signs of iron deficiency (such as glossitis, angular cheilosis, or koilonychia). Anaemia was suspected.

An initial full blood count confirmed this suspicion:

Hb concentration was 76 g/l (normal range 133-167 g/l),

MCV was 110 fl (82-98 fl),

white cell count was 4.7x10⁹/l (3.7-9.5x10⁹/l),

neutrophil count was 1.4x10⁹/l (1.7-6.1x10⁹/l), and

platelet count was 182x10⁹/l (145-350x10⁹/l).

Serum creatinine was 98 µmol/l (60-125 µmol/l) and

serum ferritin was 875 ng/ml (20-200 ng/ml).

What is the next investigation?

The clinical history has already excluded relevant drugs and excessive alcohol intake. The following investigations should be performed:

• A repeat full blood count to confirm the initial count and to establish if the abnormalities are stable or progressive.
  
• A peripheral blood film.Many laboratories will automatically review a blood film when the blood count is as abnormal as in this patient, but it cannot be assumed that the blood film will have been reviewed.
  
• Vitamin B-12 and folic acid assays.
  
• Reticulocyte count—will be raised in haemolysis or bleeding.
  
• Liver and thyroid biochemistry.

Identification of hypothyroidism, liver disease, or deficiency of vitamin B-12 or folic acid in general practice avoids the need to refer a patient to a haematologist. On the other hand, referral is indicated if initial tests suggest haemolytic anaemia or a myelodysplastic syndrome.

Coeliac Disease

Recognition and assessment of coeliac disease in children and adults: summary of NICE guidance

Who should be offered serological testing for coeliac disease?

Offer testing to children and adults with any of the following signs and symptoms:

-Chronic or intermittent diarrhoea

-Failure to thrive or faltering growth (in children)

-Persistent and unexplained gastrointestinal symptoms including nausea or vomiting

-Prolonged fatigue

-Recurrent abdominal pain, cramping, or distension

-Sudden or unexpected weight loss

-Unexplained iron deficiency anaemia or other unspecified anaemia.

Advice to patients

• Inform people that testing for coeliac disease is accurate only if the person is eating a diet that contains gluten at the time of testing.
  
• Inform people that when following a normal gluten containing diet they should eat some gluten (for example, bread, chapattis, pasta, biscuits, or cakes) in more than one meal every day for a minimum of six weeks before testing.
  
• If a person is reluctant or unable to reintroduce gluten into their diet before testing refer them to a gastrointestinal specialist and inform them that it may be difficult to confirm a diagnosis of coeliac disease on intestinal biopsy.
  
• Inform people and their parents or carers that a delayed diagnosis of coeliac disease, or undiagnosed coeliac disease, can result in:
  

  -Continuing ill health
  

  -Long term complications, including osteoporosis and increased risk of fracture, unfavourable pregnancy outcomes, and a modest increased risk of intestinal malignancy
  

  -In children, growth failure, delayed puberty, and dental problems

  Serological tests
  

• All tests should be undertaken in laboratories with clinical pathology accreditation.
  
• Do not use IgG or IgA antigliadin antibody (AGA) tests in the diagnosis of coeliac disease.
  
• When clinicians request serology, laboratories should:
  

  -Use IgA tissue transglutaminase antibody (tTGA) testing as the first choice of test
  

  -Use IgA endomysial antibody (EMA) testing if the result of the IgA tissue transglutaminase antibody test is equivocal
  

  -Check for IgA deficiency if serology is negative (if the laboratory detects a low optical density on the IgA tTGA test, very low IgA tTGA results, or low background on the IgA EMA test)
  

  -Use IgG tissue transglutaminase antibody or IgG endomysial antibody tests (or both) for people with confirmed IgA deficiency
  

  Communicate clearly the results in terms of values, interpretation, and recommended action.

Chronic Cough

Case scenario

A 42 year old non-smoking woman presents with a three month history of cough after a coryzal illness. The cough is worse in the morning and rarely produces sputum.

She is not short of breath, and she has been taking an angiotensin converting enzyme (ACE) inhibitor for two years for hypertension.

common:

asthma,

chronic obstructive pulmonary disease,

postnasal drip,

gastro-oesophageal reflux disease (GORD),

drug (ACE inhibitor) induced

and

rare but more serious causes.

"Red flag" symptoms
In both smokers and non-smokers, certain features require early investigation:

• Copious production of sputum (indicating bronchiectasis)
  
• Fever, sweats, weight loss, haemoptysis (indicating tuberculosis, lymphoma, bronchial carcinoma)
  
• Considerable breathlessness with the cough (indicating heart failure, obstructive airways disease, fibrotic lung disease).

Clinical features to be elicited:

• Duration and frequency of cough
  
• Pattern of cough: productive or dry, nocturnal, postural, or associated with food
  
• Haemoptysis or chest pain
  
• Smoking history and exposure to dust
  
• Use of ACE inhibitors
  
• Red flags—for example, breathlessness, sweats, weight loss
  
• Absence of focal chest signs (including normal heart sounds)
  
• Results of spirometry or serial peak expiratory flow rate if asthma or chronic obstructive pulmonary disease is likely or if a first test of treatment fails
  
• Chest x ray if patient smokes or red flag is present; consider also if first test of treatment fails

Ref:Education > BMJ 2009;338:b1218, doi: 10.1136/bmj.b1218 (Published 24 April 2009)

Liver Transplant

How long do patients wait for a transplant?

In the UK, nearly a fifth of all listed patients die or are considered too sick before a graft is available.

Waiting times vary by country and reflect

donor numbers,

clinical caseloads,

recipient weight and

blood group

the organ listing or allocation strategies.

The sickest patients benefit most from transplantation.

Adults in the UK on average wait 95 days (www.uktransplant.org.uk/ukt/newsroom/fact_sheets).

Clinical management of patients on the waiting list aims to minimise new complications:

diuretic-precipitated renal failure, prompt treatment of infection.

Surveillance for varices and hepatocellular carcinoma

Thyroid Swelling

A 48 year old post-menopausal woman with

a diffuse thyroid swelling more than 10 years:

1.Issues to be covered:

• pregnancy,puberty
• where she lives
• any medications:antithyroid,Lithium,Amiodarone
• women in reproductive years or >65
• hard & fixed suggest malignancy
• tenderness in thyroiditis
• Ask hyper/hypo symptoms
• Ask 3Ds:dysphagia,dysphonia,dyspnoea
• When does she first notice the swelling?
• Any past history of irradiation
• Any family history of thyroid cancer,FAP
  

2.Examination

• Inspect the fully extended neck
• Ask to swallow
• Elicit Pemberton’s sign
• Palpate including cervical glands
  
• Auscultation
  

3.Management

• Immediate referral in case of suspected malignancy

• Perform TFTs and follow up to inform about the results

• Hyper:nearly always benign

• Nodule with normal TFT:Ultrasound scan and possible FNAC

REF:

Practice

10-Minute Consultation

Thyroid swellings

BMJ 2009;339:b2563
Published 13 July 2009, doi:10.1136/bmj.b2563

Requesting Assisted Suicide

A journalist in her 30s has been diagnosed as primary

progressive multiple sclerosis 2 years back.

Now she says :
In agony ,Like legs are on fire,take every last grasp of energy to get out of bed ,even swallowing is starting to get difficult ,very soon to lose sight,use of hand,power of speech and all likely scenario:choke to death.

she is accompanied by her partner who is willing to support her final decision:Assisted Suicide

She ask Who could help her to enjoy life with dignity and peace by means of assisted suicide?

Counsel her.

Hypogonadism

A man in his 40s
with a feminine voice
Sparse axillary and pubic hair
Small phallus and testes

What are the possibilities?
What cardiac conditions are associated?

Midline Sternotomy Scar

A lady in her 50s.

Present to you with recent SoB.

She has a mid line sternotomy scar.

What conjures up on your mind?