PACES resources,MRCP(uk) Practical Assessment of Clinical examination SKills

exam question

2010-06-19T05:36:00.000-07:00

examin this patient's arms and legs and arms and discuss your findings.

on examination this patient has symemetrical weakness and wasting in the proximal muscles.the patient is unable to rise from squating position.there is no other neurological signs.
the diagnosis is proximal myopathy.

what are the causes of proximal myopathy?
what is Gower's sign?
what is diabetes amyotrophy?

Pseudoxanthoma elasticum

2010-06-08T17:00:00.000-07:00

Chicken skin neck, axilla
Test:Punch bipsy – van Gieson stain shows fragmentation elastic tissue
Extensions.
Examine peripheral pulses
Fundus for angioid streaks
Complications: upper GI haemorrhage, visual loss, MI, stroke, claudication, miral valve prolapse, renovascular hypertension

read more

hemodialysis Vs peritoneal dialysis

2010-02-27T05:20:00.000-08:00

RENAL REPLACEMENT THERAPY
Haemodialysis:
blood from the patient is pumped through an array of semipermeable membranes (the dialyser, often called an 'artificial kidney') which bring the blood into close contact with dialysate, flowing countercurrent to the blood.

Peritoneal dialysis:
Peritoneal dialysis utilizes the peritoneal membrane as a semipermeable membrane, avoiding the need for extracorporeal circulation of blood. This is a very simple, low-technology treatment compared to haemodialysis.

hemodialysis requires patient to stick to a schedule and go to a facility to have the treatment while peritoneal dialsis can be done at home, at the time that's best for patient.
hemodialysis give superior electrolyte control but require more time travilling.
peroteneal dialysis have greater risk of infection and the process need to be performed 3 times a day.

cranial nerve examination

2010-02-26T17:06:00.000-08:00

lower limbs examination

2010-02-26T17:04:00.000-08:00

Wasting and fasciculation
Tone, power and tendon reflexes
Plantar responses
Coordination and fine movements
Sensory system:
First, ask whether feeling in the limbs, face and trunk is entirely normal
Posterior columns:
Vibration (using a 128 Hz tuning fork)
Joint position
Light touch
Spinothalamic tracts:
Pain: use a split orange-stick or a sterile pin
Temperature: hot or cold tubes
If sensation is abnormal, chart areas involved

upper limbs examination

2010-02-26T16:57:00.000-08:00

Wasting and fasciculation
Posture of arms: drift, rebound, tremor
Tone: spasticity or extrapyramidal rigidity
Power: 0-5 scale
Tendon reflexes: + or ++ normal; +++ increased: 0 absent with reinforcement

Breaking bad news

2010-02-25T17:17:00.000-08:00

Breaking bad news is a professional skill which is acquired by practice under supervision. It should give a clinician confidence and satisfaction rather than alarm, although it can never be painless.

The interview:
Opening:
• If possible, the patient should have someone with them.
• The interview should take place with everyone introduced, sitting in a quiet place.

Exploring and focusing:
• The doctor should find out if anything new has happened since the last encounter.
• What does the patient know and how does the patient react to it? In detail.
• The doctor should then introduce a warning that the news is bad: 'I'm afraid it looks more serious than we hoped.' Then the details.
• At this point the doctor should pause and allow the patient to think, and only continue when the patient gives some lead to follow. This pause may be a long one while thoughts go round in the patient's head, and is often accompanied by shutdown which makes patients unable to hear anything further until these thoughts settle down and allow them to re-emerge.
Only then should the doctor:
• Discover how much the patient is likely to be able to take in at this point - methods for finding this out are shown in
• Give the information without fudging, in small chunks and make sure that the patient understands each one before moving on.
• Be prepared for the patient to have disorderly emotional responses of some kind and acknowledge them early on as being what you expect and understand and wait for them to settle before continuing. The clinician must learn to judge which patients wish to be touched and which do not. You can always reach out and touch their chair.
• Watch out for shutdown; when it occurs, just wait. When the patient emerges it is best to deal with what they then say, and only after that take up the running.
• Keep pausing to allow the patient to think.
• Stop the interview if necessary and arrange to resume later.
• The clinician can emphasize that some things are fixable and others are not. A broad time frame can be given for the fixable aspects of care.
• No time frame is ever accurate for the unfixable, but the clinician must be prepared for the question: 'How long have I got?' and avoid the trap of providing a figure which is bound to be inaccurate. Rather stress the importance of ensuring that the quality of life is made as good as possible from day to day.
• The patient must be provided with some positive information and hope tempered with realism

Closing :
The clinician must be sure that:
• the patient has understood what has been discussed so far and that crucial information has been written down for the patient
• the patient knows how to contact the appropriate team member and thus has a safety net in place
• the next interview date - preferably soon - has been agreed, for what purpose and with whom
• other members of the family have been invited to meet the clinicians as the patient wishes
• written material and further sources of information are readily available
• everyone is bid goodbye, starting with the patient.

After the bad news is broken
Patients want to know if they are going to die and if so when? Will they be able to stay at home? Will they be in pain? Must they eat if they don't want to? Patients facing the end of life have different priorities from the clinicians, and need clear information about their pain and symptom control, the extent to which they can influence this and how long active treatment will continue. Settling family matters and completing unfinished business come high on their agenda, and must be reconciled with attempts at palliation or treatment, particularly if these are of uncertain benefit. It is the clinician's responsibility to mediate between the patient, other medical staff and the patients' relatives.

stroke

2010-02-25T16:11:00.000-08:00

in recent exam councelling realtives of a patient with stroke appeared may times.
(see record of precious experience)
its important to have simple definition, undersatand the classification and outcome/prognosis.

click to enlarge

Rheumatology in new station 5

2010-02-22T04:30:00.000-08:00

examples from recent exams:
-RA on methotrexate presented with SOB.
-RA back from long journey presented with swallon calf.
-RA C/O gritty eyes.

aproach:
quick enquiry about the RA, how long, how active , current Rx, regular F/U.
now assess the presenting problem.
what is the link with RA?
SOB (pul fibrosis, pnuemonitis as s/e of MTX)
swallon calf (repture backer's cyst)
gritty eyes (Sogren's syndrome)

review medication and PMHx

quickly assess RA, ? active ?sinovitis
examine the system of the complain (chest, calf, eyes)

explore what the patient main concern and reasure
epxplain what investigation and wahy.

hopefully you will be done by 6 min and able to present to the examiner.

any other thoughts?

examination of the thyroid status

2009-11-17T13:49:00.000-08:00

-observe the general composure:

normal,hyperactive,fidegty,restless.

-examine the hand:

shake hand with the patient,observe sweaty hand

check the pulse:brady/tachycardia,AF

look for thyroid acropachy(swallon fingers,clubbing,perioteal

new bone formation),palmer erythema.

assess for fine tremers of out streched arm

-examine the eyes:

observe from top and side

led lag/retraction

eye movement.

-examine the shin:

pretibial myxedema

-check for proximal myopathy

-check reflexes

-finish by asking the patient about:

temp preference

wt loss with increase apetite

bowel habits

palpitations

The New Marking System

2009-11-14T15:59:00.000-08:00

peripheral neuropathy

2009-11-12T04:39:00.000-08:00

clinicaly:

→Generalize wasting
→Normal tone
→Distal muscle weakness
→Absent ankles jerk with down going planters
→There is impaired sensation to light touch in stocking distribution
→There is impaired vibration and position sense up to the knees
→Describe the gate (sensory ataxia)
→No evidence of spinal surgery

Cause:
Motor, sensory or mixed.

Predominantly motor:
1-gullian Barre; acute/chronic
2-common peroneal nerve palsy
3-lead poisoning
4-porpheria

Predominantly sensory:
The most common cause is DM, other causes:
1-Alcohol
2-B12, B2 def
3-CRF
4-Drugs nitrofurantion/nincristine/cisplatin
5-leprosy
6-paraneoplastic

how would you investigate a patiet with peripheral neuropathy?

what is the assoiaction?

2009-10-25T14:23:00.001-07:00

describe the findings in both pcitures.

what is the assoication?

answers:

the skin in the neck shaws multiple yellowish papules and plaques arranged in a cobblestone pattern resembling "plucked chicken skin."

the fundoscopy shaw angioid streaks:broad, irregular, red to brown to gray lines that radiate from the area around the optic nerve.

what is the diagnosis?

what is your diagnosis?

2009-10-25T13:29:00.000-07:00

figure 1

figure 2

confusion can sometimes happened between laser photocoagulation sacrs(1) and retinitis pigmentosa(2).

remember in laser photocoagulation the sacrs rounded in shape and follow certain pattern.

retinitis pigmentosa:

usually described as : wide spread scuttered black pimentation in the prephery resmbling bony specules and the macula is spared.

certain conditions are associated with RP:

1-Laurance-Moon-Piedl:

AR
mental disability
polydactly
syndactly
hypogonadism
obesity

Refsum's syndrome:

AR
deafness
cerebellar ataxia
ichthyosis

Kearns-Sayre syndrome:

heart block
progressive external oophthalmoplagia.

what is the pathophysiology of retinitis pigmentosa?

records of PACES experience

2009-10-21T02:34:00.000-07:00

I thought it might be a good idea if doctors who attend the PACES exam give a brief account of their experience and cases.It would great help for others who are preparing.
I know it might be difficult to visit this site after you finish your exam,however if you think this is a good idea, please click on comment below and tell us.

Mitral regurgitation

2009-09-16T10:08:00.000-07:00

The most common cause is: Rheumatic heart disease

Other causes include:

Degenerative mitral valve disease

Left ventricular dilatation

Mitral valve prolapse

Papillary muscle dysfunction

Infective endocarditis

Hypertrophic cardiomyopathy

Connective tissue disease

Congenital

Symptoms

Dyspnoea
Fatigue
Palpitation
Odema/ascites

Signs

AF/atrial flutter
Apical PSM+thrills
Soft S1 ,apical S3
Pul venous congestion
Pul hypertension
Jerky pulse

Investigation

1-ECG

Left atrial hypertrophy

Left ventricular hypertrophy

2-CXR

Enlarge left atrium

Enlarge left ventricle

Pul venous congestion

Pul odema

3-echo

Dilated LA/LV

Dynamic LV

Structural abnormality of the mitral valve

Management

Medical:

Duretics

Vasodilator

Warfarin/digoxin

Antibiotic prophylaxis

Surgical:

Signs of progressive left ventricular dilatation.

1-moderate to severe symptoms despite medical therapy provided left ventricular function is adequate

2-ejection fraction <55%

3-Left ventricular end diastolic dimension >45mm, even in absence of symptoms.

Signs of severity

1-dilated left ventricular→displaced thrusting apex

2-S3→indicator of poor prognosis

3-Rt vent function reduced

Making DNR decision

2009-09-06T12:42:00.000-07:00

The overall responsibilty for a DNR decision rest with the doctor in charge

of the patient care.However, the opinion of other members of the medical

and nursing team, the patient and the patient's relatives should be

considered when making the decision.

The patient in this scenario is usually terminal. you should be able to

convey the grave prognosis and the reasons behind that.

Explain in the event of cardiopulmonary arrest , resuscitation is likely to

be unsuccessful. explain you believe the patient be kept comfortable with

dignity and self-esteem.explain this is in the patient best interest.

Convey that the resuscitation decision is been made by the approperiate

health authoruties and not by patient or relatives.

Describe a clear plan of palliative management.

ethical/legal issues raised in this case:

1-respect of the patient autonomy

2-disclosure of confidential information. in this situation, the

doctor does need the patient's consent to discuss his illness with his

wife or carer.

3-beneficence:duty to do good and moral obligation to do no harm.

not providing CPR would be equivlent to withdrawing life prolonging

treatment.

4-duty to act justly

5-legal aspects-detailed knowledage of medical law is not required.

driving when medically unfit

2009-09-06T11:34:00.000-07:00

This scenario is mainly about disclosure of confidential information.

the patient is usually newly diagnosed with epilipsy or diabetes (insulin in HGD).

the patient will usually have his own reason to continue driving.

you are expected to:

after establishing that the patient is still driving, explain this is illigal.

explain he is banned from driving for a certain period e.g 1 year for fit.

explain the insurance policy is now invalid.

explain the situation clearly in a non-patrinising manner whilst

reconizing the patient dilemma.

advice the patient ti inform the driving authorities.

remain calm in face of mild aggressive and emotional behaviour.

tell the patient if he does not inform the DVLA then you are acting

within reasons to inform them yourself.

before you disclose these information to the DVLA you should inform

the patient about your decision to do so.you shouls also write to the

patient to confirm the disclosure has been made.

ethical/legalissues raised in this case:

1-respect the patient autonomy (i.e the capacity ofthe patient to make

deliberated or reasoned decisions for himdelf and to act on bases of

those decisions).

2-disclosure of confidential information. in this situation, it is in

the best interst of the public if this information is handed to the relevant

authotrities.patient consent is not needed.

3-beneficence:duty to do good and a moral obligation to do no harm

4-duty to act justly

5-legal aspects-detailed knowledge of medical law is not required.

DVLA guidelines link click here

PACES New Station 5 Guide

2009-09-04T11:36:00.000-07:00

MRCP PACES new station 5 example

2009-09-01T18:51:00.000-07:00

New Station 5

Demonstration scenario: goitre

INFORMATION FOR CANDIDATES

• You will be asked to see two patients at this station.
The clinical information about one of these patients is given in
the box below. You should have a second sheet giving you
information about the other patient.

• You have 10 minutes with each patient. The examiners will
alert you when 6 minutes have elapsed and will stop you after
8 minutes.

• In the remaining 2 minutes, one examiner will ask you to
report abnormal physical signs (if any), your diagnosis or
differential diagnosis, and your plan for management
(if not already clear from your discussion with the patient).

Your role: You are the medical doctor on call.

Patient name: Mrs Jane Smith – age 33 years

This lady was admitted to the orthopaedic ward for a
carpal tunnel release operation.
She mentioned to the orthopaedic doctors that she has
swelling in her neck and they have asked for the opinion
of a physician. You were asked by your consultant to see
the patient and to assess the suspected swelling in her neck.

Your task is to assess the patient’s problems and address
any questions or concerns raised by the patient.

• You should assess the problem by means of a relevant clinical history
and a relevant physical examination. You do not need to complete the
history before carrying out appropriate examination.
• You should respond to any questions the patient may have, advise
the patient of your probable diagnosis (or differential diagnoses) and
your plan for investigation and treatment where appropriate.
• You have 8 minutes to complete the task.

INFORMATION FOR PATIENT

The doctors sitting the examination have been asked to assess your
problem. They will have 8 minutes to ask you about the problem and
any other relevant issues. They will also examine you. They should
explain to you what they think is wrong and what action should be taken
and answer any questions you have, for example about the diagnosis,
tests that may be needed, or treatment. One of the examiners will ask
them to describe any abnormal examination findings and give their
diagnosis. Your history is described below.

You are: Mrs Jane Smith – age 33 years
Your problem: swelling in your neck
You are in the orthopaedic ward and you mentioned to the admitting
doctor that your neck seemed swollen. One of the medical doctors has
been asked to see you about this.
You have been suffering from pain in your right forearm and a numb
or tingly feeling in your right hand – affecting your 3rd, 4th, and 5th
fingers. The aching in your arm is worse at night and you have found
it more and more difficult to get comfortable. The problem has been
present for several years and was worse when you were pregnant
with your daughter 3 years ago but improved for a time after that.
A trapped nerve in the wrist has been diagnosed. You are having
a short admission to have the nerve released.
You mentioned that you thought your neck was swollen when the
admitting doctor was examining you. You have not mentioned this to a
doctor before but your sister has been commenting on it for a few years.
Your sister is 38 and has an underactive thyroid.
You do not have any of the symptoms your sister had when her thyroid
was underactive. Indeed you feel well. Your weight is stable. Your skin
and hair are normal. You do not seem to feel the heat or the cold any
more than anyone else. Your bowel works normally. You do not have any
problem with swallowing. You should ask why your neck seems swollen
and whether there is something wrong with your thyroid gland. You should
ask if any tests are required and, if so,what these tests will be.

INFORMATION FOR EXAMINERS

Patient: Mrs Jane Smith – age 33 years
Examiners should discuss and agree the criteria for pass and for fail in the
competencies being assessed.
As a general guide, candidates would be expected to:

• Note the history of neck swelling and the family history of thyroid disease.
• Enquire about symptoms of disturbed thyroid function.
• Examine the neck and identify the smooth and symmetrical thyroid
enlargement. Note absence of bruit.
• Examine for signs of overactive and underactive thyroid gland and
confirmclinical euthyroid state.
• Confirm to the patient that her thyroid gland does seem enlarged but
reassure that the gland seems to be working normally judging from clinical
examination. Advise on appropriate further investigations.

The lead examiner should:
a) Advise the candidate after 6 minutes have elapsed that “You have two
minutes remaining with your patient”
b) Ask the candidate to describe any abnormal physical findings that have
been identified
c) Ask the candidate to give the preferred diagnosis and any differential
diagnosis that is being considered
d) Any remaining areas of uncertainty eg regarding the plan for
investigation or management of the problem may be addressed in any
time that remains.

form mrcpuk website

the ECG dance...Medicine can be fun!

2009-08-27T16:22:00.000-07:00

check out this site!

visual field defect,...where is the lesion?

2009-08-25T13:56:00.000-07:00

click on this link for visual field simulator.

be confident of detecting the common field defects in clinical practice:

1-Homonymous hemianopia

2-Bitemporal hemianopia

3-upper & lower quadrantic hemianopia

4-Scotoma

Homonymous Hemianopia:

the patient does not see one half of the visual field-left or right.

in left homonymous hemianopia the patient does not see the left half of the visual field.

the lesions producing homonymous hemianopia are either in the optic tract or radiation.

optic tract-->incongruous hemianopia

optic radiation -->congruous hemianopia

optic tract lesions may produced by : pituitary tumour, craniopharyngioma or meningioma.

opyic radiation lesions are usually due to tumor or infarction inthe middle cerebral artery territory.

visual cortex lesions produce a mcular sparing homonymous hemianopia and may occure with migrane and posterior cerebral ischemia.

Temporal Hemiaopia:

may be unilateral or bilateral.

usually due to chiasmatic compression.

when there is compression from above (craniopharyngioma) the lower fields are affected first and more.

Quadrantic field defects:

this is due to involvement of fibres sweeping from lateral geniculate body to the visual cortex.

the upper fibres sweep through the parietal lobe and lower fiber through the temporal lobe.

temporal lobe lesion--->upper quadrantanopia

pareietal lobe lesion--->lower quadrantanopia

Central Scotoma:

island of loss of vision surrounded by normal visual field.

common causes:optic nuritis and optic atrophy.

Eye movement...occular nerves lesions

2009-08-24T03:48:00.000-07:00

click on this link for eye movement simulator.

3rd carnial nerve:

main features:
Ptosis
Divergent steabismus
Dilated pupil
The eye is fixed in down and out position
Causes:
1.DM/BP (pupilary sparing 3rd nerve palsy)
2.Multiple sclerosis
3.Post comm art aneurysm
4.Truma
5.Tumor

6th nerve palsy:

main features:
Convergent strabimus
Impairared lateral movemet of the affected eyewith diplopia
Causes:
1.DM/BP
2.Raised intra cranial press
3.Multiple sclerosis
4.Acoustic neuroma

the sexual history taking

2009-08-23T10:40:00.000-07:00

http://www.youtube.com/watch?v=V5ouk1SJbOs

click on this youtube link to see sexual history taking clip

(embeding disabled)

we live in a culture that is , on one hand, charcaterized by lack of

information and secrecy about sex and on the other, by sexually explicit

entertainment and advertising.

despite its importance, most of us find "sexual history taking" is a

difficult topic to discuss with the patient.

to begin the patient's sexual history, use introductory statement

and transparency whic ease the transition to difficult topic.

example:

"I always include questions about sexual problems in my

routine history because the are so common, have you had any

if you find that you need to know more, i.e suspecting a sexually

transmitted disease, you need to find more about:

1-sexual oreintation.

2-number and regularity of sexual partners.

3-weather they are from same or opposite sex.

4-if the partner have any STD's.

"I need to know more about your sexual relationship in order to

understand your risk for certain disorder,..."

techniques for sexual history:

* use simple screening question to determine how much you

need to know.

*delaying this part of the interview until you know something about

you patient as a person.

*ensuring that you and your patient are using words that have the same

meaning.

*proceed from less intimate to more intimate questions.

*sequencing your questions from open-end to close-end depending

on the degree of details you need.

*using introductory and transparent statment to help the patient

understand why you are asking what might otherwise be interpreted as

intrusive question.

from:the medical interview by J L Coulehan and M R Block

facial nerve palsy

2009-08-20T17:21:00.000-07:00

Look for:
Forehead wrinkles
Nasolabial folds
Watch spontaneous movements –smiling, blinking
Ask pt to do:
• Show his teeth
• Whistle
• Close his eyes tight and try to open
• Look up the ceiling & look for symm movt
• Compare strength of fore head and lower face.
LMN lesion:
• In LMN facial palsy the whole half of the face
in the affected side is involved.
• Causes:
1. Idiopathic (Bell’s palsy)
2. Herpes Zoster
3. Parotid tumour
4. CP angle tumour
5. Skull fracture
Look for the cause in LMN lesion
• Look at the external auditory meatus
• Look for parotid gland enlargement
• Examine the tympanic membrane
• Check for hearing (hyperacusis)
• examine for taste
• Test urine for sugar

UMN lesion:
• In UMN facial palsy the upper part of the face is spared
(due to bilateral inervation of the nucleus)
• Causes:
1. stroke
2. Intracranial tumour
3. MS
4. vasculitides

history taking, Gastro interview

2009-08-18T14:15:00.000-07:00

note the steps:
introduction,
history of presenting compliant,
past medical history,family history,
drug and social history and then systematic review.
note the use of open and close ended questions,facilitation and summerization.
use the steps outlined in history taking section.
any comment?

Changes to PACES: Information for candidates, July 2009

2009-07-16T11:31:00.000-07:00

the royal college of physicians UK has announced significant changes to the PACES examination worldwide.

click here for more information

inspect...diagnose

2009-05-02T07:47:00.000-07:00

this lady has a short stature.
what is your diagnosis?
what this disorder due to?
what other features might be present?

about station 4...

2009-02-28T08:56:00.000-08:00

general outlines of station 4:
Ethics and law: definitions
1. Ethics principles
2. Competence
3. Capacity
4. Best interrest
5. Advance decision
6. Confidanciality

Common ethical dilemas/senario
PEG/AIDS
Fitness to drive/ euthanasia
Jehovah’s Witness/ brain stem death
Resuscitaion/DNR /organ donation

Communication
Dealing with challanging patient/situation:
Angry patient/angry relative/non-compliance/self-discharge
Breaking bad news:
Immediate: loss of loved ones
Non-immediete (chronic illness): cancer/MS/coeliac
Discussing clinical management:
Explaining diagnosis, investigation or treatment.
Discussing management or possible complications

How do we show empathy?

2009-02-28T08:46:00.000-08:00

The answer to this lies in learning to distinguish between empathy and sympathy.

So, what's the difference?
Sympathy: the act of imagining and interpreting the thoughts, experiences, and perspectives of others from our own lens (e.g. our history, experiences, priorities and values).

Empathy: the act of attempting to understand the thoughts, experiences, and perspectives of others from their own lens (e.g. their history, experiences, priorities and values).

Although subtle, the difference in effect between empathy and sympathy is significant. Following is an example, which magnifies the point:

A woman in labor tells her husband she is in a terrible amount of pain.
He says, "I know, I strained my back once."(sympathy - using his own limited lens).

A woman in labor tells her husband she is in a terrible amount of pain. He asks her, "Is this the worst pain you've ever felt?" Then he asks her to describe what it feels like, where the pain lies, and if there is anything he can do to help ease the pain.(The key to empathy: There is no "I" in empathy).

The patient experiences being seen:
'That last point made you look worried. Is there something more serious about that point you would like to tell me?'

The patient experiences being heard:
'I notice that you have talked about the death of your mother but could I ask you to tell me something about how your brother died?'

The patient experiences being accepted:
'I can tell you that most people in your circumstances get angry at some point, even with the people who have helped them.'

The clinician shows self-disclosure:
'I'm a bit like you. Whenever I get heartburn I think it's a heart attack.'

How to deal with angry Patient/Relatives

2009-02-28T08:36:00.000-08:00

Allow the patient to voice his anger
Acknowledge the problem
Express concerns; Make him feel you are genuinely concerned
Formulate a plan of action which is mutually acceptable to rectify the situation
Consider complete incident form
If the patient wishes to complain provide him with the contact information.

Quick Guides
When a Patient is Angry about Others
•Pause and be attentive
•Avoid being defensive
•Stay curious about the patient's story
•Acknowledge the difficulty of the interaction
•Find out the specifics of the story--encourage the patient to give the details
•Express empathy for the patient--acknowledge the emotion by name
•Make a statement guessing at the meaning behind the patient's anger and validate
•Take an action on the patient's behalf if possible. Be an advocate
•When possible, link the patient with the resources that can help
•Transition to purpose for the visit

Questions that might help to uncover the source of anger (fear, guilt or

uncertainity)

Rapport Building:
"I can appreciate how you feel."
"It concerns me that you feel so strongly about this."
"Tell me how I can make it easier for you."

Confrontation:
"You seem very angry?"
"It's unlike you to be like this."
"I get the feeling that you are upset with…"
"What is it that's upsetting you?"
"What really makes you feel this way?"

Facilitation, clarification:
"I find it puzzling that you are angry with me."
"So you feel that….."
"You seem to be telling me…."
"If I understand you correctly…"
"Tell me more about this."
"I would like you to enlarge on this point…it seems important."

"I agree that we must sort this out quickly as possible. I will

do everything I can, but it will help me if I know which aspect of how

you have been treated concern you the most of all"

Searching:
"Do you have any special concerns about your health?"
"Tell me about things at home."
"How are things at work?"
"How are you sleeping?"
"Do you have any special dreams?"
"Do you relate to any one who has a problem like you have?"

Good Medical Practice 2006

2009-02-28T08:07:00.000-08:00

About Good Medical Practice
Good Medical Practice sets out the principles and values on which good practice is founded; these principles together describe medical professionalism in action.
it is important to read review before the exam.

here is the link.

Stages of hypertensive retinopathy

2009-02-24T08:17:00.000-08:00

1-Arteriolar narrowing and tortuosity
Increased light reflex
"Silver wiring"

2-Arteriovenous nipping

3-Cotton-wool "exudates"
Flame and blot hemorrhages

4-Papilledema

are you fimiliar with British hypertension society guidelines?

diabetic retinopathy 2

2009-02-24T07:38:00.000-08:00

remember diabetic retinopathy is different from diabetic maculopathy.

clinical types of diabetic retinopathy:

1-non-proliferative DR
formally classified as:background retinopathy
pre-proliferative retinopathy.
NPDR is further classified to:
mild->microaneutysm,dot and blot hge in all 4 quadrants
moderate->4 blots in one qudrant &/or cotton wool spots.
severe->severe hge in 4 quadrants,
or venous besding in 2 quadrant,
or IRMA in one quadrant.
very severe->any 2 of severe.

2-proliferative DR:
in addition to NPDR there is neovasculaization.
this can be in the disc (PDR with NVD) or elsewhere (PDR with NVE)

Diabetic maculopathy:
retinopathy in and around the macula
usually in form of exudate or oedema
significant visual impairment.

advance diabetic eye disease:
include retinal detachment and vitreous haemmorrhage.

management:
NPDR mild ->annual screening
NPDR moderate ->non urgent ophthalmoloyg referal.
NPDR severe ->non urgent ophthalmoloyg referal.
NPDR very severe ->urgent ophthalmoloyg referal.
PDR ->urgent ophthalmoloyg referal.
muculopathy ->urgent ophthalmoloyg referal.

remember:tell the examiner that you would like to:
ask the patient about sight disturbance
diabetes control
evidance of other micro or macrovasculr complications of DM

for all you need to know click on this link of the royal college of ophthamologists.

about ankylosing spondylitis

2009-02-18T10:46:00.000-08:00

chronic inflammatory disorder of the axial skeleton.
strong genetic predisposition associated with HLA B27.
incidious nature,characerized by:
sacroiliitis,
inflammation of entheses,
formation of syndesmophytes.

traditional treatment begins with physiotherapy,regular use of NSAID's,local corticosteroids injections and sometimes sulphsalazine.

surgery has a place in manaement including fusion procedures or wedge lumber osteotomy.

TNF inhibitors has revolutionized the management of AS.
three drugs are currently available:
etanercept,infleximab and adalimumab.
treatment with TNF inhibitors should be considered for patients with persistantly high disease activity despite conventional tratments.

Question:AS is easy to spot in the exam.what are the steps of examination to score 4/4? what question you might want to ask the patient?

thyroid eye disease

2009-02-06T14:50:00.000-08:00

thyroid eye disease is a manifestation of Graves' disease but can occure in patient who may be hyper/hypo or euthyroid.

ask the patient about;

1-smoking (risk factor)

2-blurred vission

3-impaired perception of colour

on examination:

1-inspection:

Look at the eye when it is closed/from side,back

-Exophthalmoses:(protrusion of the eye ball)

-Look for cornea, conjunctiva

-chemosis

2- 2nd cranial nerve:

-visual aquity

-visual field

-relative afferent pupilary defect

-colour vision

3- 3rd/ 4th/ 6th cranial nerves:

Examine eye movements looking for

Opthalmoplegia (limitation of eye movement)

4- comment od led lag/retraction (thyrotoxicosis from any cause)

describe.
what featurs are specific to Grave's disease?

exam question.what is your diagnosis?

2009-02-04T07:55:00.000-08:00

describe.
what is your diagnosis?

exam question.describe

2009-02-04T07:47:00.000-08:00

describe the skin rash and the associated changes.

exam question

2009-02-04T05:58:00.000-08:00

examin the abdomen of this patient.(hint:note the scar)
how would proceed after inspection?

exam question

2008-06-26T15:32:00.000-07:00

click to enlarge.

a friend of mine had his exam recently.
he had a tall patient in station 5 and was asked to come with a diagnosis.
he was confused between Marfan's and Klinefelter's syndromes!
how would you differentiate?

Infective Endocarditis

2008-06-26T11:33:00.000-07:00

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What are the update in NICE guidelines March 2008 regarding prophylaxis against infective endocarditis?

click here for full NICE guidelines

Child-Pugh score

2008-06-25T10:42:00.000-07:00

click to enlarge.
what do you know about Rockall scoring system?

important acts to remember

2008-06-25T01:56:00.000-07:00

the mental Capacity act 2005:
this act provides a legal framwork for making decisions in relation to people who lack capacity.
link

the mental health act 2007:
this act provides a statutory framework, which sets out when patients can be compulsorily treated for mental disorder without consent,to protect them or others from harm.
link

the human tissue act 2004:
this act require consent to be obtained before a person's tissue can be stored and used.
link

the human fertilisation and emberyology act 1990:
this act privide legal framework across UK for all those involved in fertility treatment.
currently the parliament is considering number of amendments to the act.
link

the human right act 1998:
the right to life and the right to be free from degrading treatment.
link

systolic murmurs

2008-06-17T11:29:00.000-07:00

one of the common problems in the cardiology station is confusion regarding the systolic murmur.is is MR or AS?!! or may be VSD?
practicing is the only way.
here is a reminder:

click to enlarge

remember:
*practice,lestin to as many as you can.
*try to diagnose the valve lesion before you apply your stethoscope-attention to pulse character, BP loction of the apex.
*character of the murmur often more useful than its location.
*if you have no clue what is the diagnosis, describe your findings, you can still gain some points.

try to identify the systolic murmurs below!

systolic murmur 1

2008-06-17T11:22:00.000-07:00

what is the valve lesion?

systolic murmur 2

2008-06-17T11:18:00.000-07:00

what is the valvular lesion?

systolic murmur 3.

2008-06-17T11:15:00.000-07:00

what is the valvular lesions?

check list...severity and management

2008-06-17T08:51:00.000-07:00

click to enlarge

exam question 8

2008-06-14T15:44:00.001-07:00

what is the most likely diagnosis?
how would you manage it?

check list...remember

2008-06-14T11:04:00.000-07:00

click to enlarge

cerebellar syndrome

2008-06-14T08:35:00.000-07:00

Examination of the cerebellar system:
Check eye movement for nystagmus
“..Put your arms straight in front of you...”
Intension tremor
Diminished/rebound reflexes
Examine for coordination
Finger-nose test
Rapid alt movements
Check for dys synergia
Check for coordination in the legs
Assess gait, Assess speech
Examine fundi for optic atrophy

what are the causes of cerebellar syndrome?
read more

Hand examination

2008-06-13T13:18:00.000-07:00

Inroduce yourself
Explain about your task
Ask about any pain
Correct positioning of the hands e.g pillow
•inspect the dorum for:
Nails pitting,vasculitis,atrophy
Skin
Small muscle wasting guttering
Deformity (memorise them)
•inspect the palmer aspect for:
Pulp top
Erythema
Wasting of the thener and hypothener
Contracture
Scar of decompansation
•Back to the dorsum:
Palpate the joint for evidance of synovitis
Palpate the wrist
•Back to the palmer aspect:
Perform tenil test
•check the motor system in the hand:
“squeeze my fingers” C8 T1
“hold your fingers striaght” stop me from pending them C7
“spread your fingers”stop me pushing them togerther ulnar
“point your thumb to ceiling”stop me pushing it down median
•check sensation
•Feel for subcut nodules
•Assess disability

cardiovascular examination

2008-06-12T12:54:00.001-07:00

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follow these steps in CVS examination:

Introduction : Hello Mr Smith,

My name is Dr X ; I'm a medical SHO,

Can I examine your heart please?

Position : 45 degree

Is it sore anywhere?

Exposure: can you take your shirt please?

General inspection : stand back,

Ask the patient to take deep breath in,

Look is he comfortable at rest, is he SOB?

Look for catheter, peripheral oedema, GTN, OXYGEN,

Malar rash,Lip cyanosis, BP apparatus.

Hands : look for warm/cold

Clubbing

Splinter haemorrhage

Xanthoma

Tobacco staining

Arm: pulse (rate, rhythm, volume, character & synchronous) Radio-radial delay

Collapsing pulse (ask for pain in shoulder)

Radio-femoral delay

Brachial pulse & anti cubital fosaa scar.

Feel carotid pulse & comment on character.

Face:

eyes for paller, xanthlasma

Mouth for tongue, cyanosis

JVP

Inspection:

Comment on mid sternal scar/ mitral valvotomy scar.

Palpation:

Palpate for apex beat (count the apex beat from sternal angle.

comment on position and character? tapping/heaving/normal)

Palpate for heave on either side of sternum

Palpate for thrill in 2 ICS

Auscultation:

Start from the apex. Comment on s1-s2

Always sync with carotid pulse and also ask pts to breath

in and out to look for respiratory variable

If PSM of MR then radiate to axilla

If EDM of MS (if u cant here murmur then L lateral position with bell)

PALPATE APEX BEFORE AUSCULTATE.

If ESM of AS auscultate in apex, below sternum,

left 2^nd ICS, right 2^nd ICS, then to carotid pulse.

Comment on site of best audible.

If EDM ofAR auscultate in right 2^nd with pts leaning

forward with breath held in expiration.

when finished,

Thank the pt

Conclude by saying:

I would like to finish ex by

checking signs of heart failure

(auscultating lung bases, looking for hepatomegaly, pedal oedema and sacral oedema).

Checking BP.

Checking urine

the jugular venous pulse

2008-06-12T12:25:00.000-07:00

examine this patient's neck.
comment on the waveforms.
how to time the waves of the JVP with the carotid pulse?

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exam question

2008-06-12T11:48:00.000-07:00

what is the name of this sign?
what are the features of the underlying condition?
if you have asked to lestin to this patients' heart,what murmur would you expect?

click here to read more about this condition.

should score 4 in scar!

2008-06-12T11:30:00.000-07:00

lestin to the heart of this patient.
what is your diagnosis?(two possibilities)
this patient present with bleeding.what is the most likely cause and how would you manage it?

scar in cardiovascular station

2008-06-12T11:27:00.000-07:00

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examples regarding consent and capacity

2008-06-12T10:26:00.000-07:00

Examples from GMC

Consent: patients and doctors making decisions together.

Refusal of treatment:

C had paranoid schizophrenia and was detained in Broadmoor Secure hospital. He developed gangrene in his leg but refused to agree to an amputation, which doctors considered as necessary to save his life .the court uphold C’s decision.

→ the fact that a person has a mental illness does not automatically mean they lack capacity to make decision about medical treatment.

Right of a patient who has capacity to refuse life-prolonging treatment:

B was 43 years old woman who had become tetraplegic and who no longer wished to be kept alive by means of artificial ventilation .she asked for ventilation to be withdrawn but the doctors caring for her were un willing to agree to this.B whose mental capacity was unimpaired by her illness, sought and obtained a declaration from the court that the hospital was acting unlawfully.

→A competent patient has the right to refuse treatment and their refusal must be respected, even if it results in their death.

Right to refuse treatment even if it resulted in harm to unborn child:

S was diagnosed with pre-eclampsia requiring admission to the hospital and induction of labour, but refused treatment because she did not agree with medical intervention in pregnancy. Although competent and not suffering from a serious mental illness, S was detained for assessment under the mental health act .A judge made a declaration overriding the need for her consent to treatment, and the baby was delivered by caesarean section.

The appeal court held that S’s right to autonomy had been violated, her detention had been unlawful (since it has been motivated not by her mental state but by the need to treat her pre-eclampsia) and that the judicial authority for caesarean section had been based on false and incomplete information.

→A competent pregnant woman can refuse treatment even if that refusal may result in harm to her or her unborn baby. Patients can not lawfully be detained and compulsorily treated for a physical condition under the term of the mental health act.

Can you add more example?

Ethical values and patient care

2008-06-12T05:08:00.000-07:00

In dealing with your case scenarios in the examination, you must be able to communicate your argument with relation to four important ethical principles. The examiner will expect you to have an understanding of these:

1-Autonomy (self rule)
It is the capacity to think, decide and act on the basis of such thought and decision, freely and independently.

2-beneficence (promoting what is best for the patient)
This principle emphasises the moral importance of doing good to others.

3-non-maleficence (avoiding harm)
This principle state that we do not harm patients

4-justice
We must try to distribute limited resources (time, money, intensive care beds) fairly

ethics...impotrant definitions

2008-06-12T04:48:00.000-07:00

Ethics…important definitions

Competence:

The assessment of a patient’s capacity to make a decision about medical treatment is a matter for clinical judgement guided by professional practice and subject to legal requirements.

To demonstrate capacity individuals should be able to:

understand (with the use of communication aids, if appropriate) in simple language what the medical treatment is, its purpose and nature and why it is being proposed;
understand its principal benefits, risks and alternatives;
understand in broad terms what will be the consequences of not receiving the proposed treatment;
retain the information for long enough to use it and weigh it in the balance in order to arrive at a decision
Communicate the decision (by any means).

In order for the consent to be valid the patient must be able to make a free choice (i.e. free from pressure).

Capacity:

You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide weather to agree to, or refuse an examination, investigation or treatment.

You must only regard a patient as lacking capacity once it is clear that, having given all appropriate help and support, they can not understand, retain, use or weigh up the information needed to make decision or communicate their wishes.

In England and Wales, the Mental Capacity Act allows people over 18 years of age, who have capacity, to make a Lasting Power of Attorney appointing a welfare attorney to make health and personal welfare decisions on their behalf once capacity is lost.

The Court of Protection may also appoint a deputy to make these decisions.

Neither welfare attorneys nor deputies can demand treatment which is clinically inappropriate.

Where there is no welfare attorney or deputy the doctor may treat a patient who lacks capacity, without consent, providing the treatment is necessary and in the patient’s best interests.

The Act also requires doctors to take into account, so far as is reasonable and practicable, the views of the patient’s primary carer.

In Scotland, the Adults with Incapacity (Scotland) Act allows people over 16 years of age to appoint a welfare attorney who has the power to give consent to medical treatment when the patient loses capacity.

The Court of Session may also appoint a welfare guardian on behalf of an incapacitated adult.

Neither welfare attorneys nor guardians can demand treatment which is judged to be against the patient’s interests.

Where there is no proxy decision maker, doctors have a general authority to treat a patient who is incapable of giving consent to the treatment in question.

The Act also requires doctors to take into account, so far as is reasonable and practicable, into the views of the patient’s nearest relative and his or her primary carer.

In Northern Ireland, no person can give consent to medical treatment on behalf of another adult. As the law currently stands, doctors may treat a patient who lacks capacity, without consent, providing the treatment is necessary and in the patient’s best interests

Best interest:

A number of factors should be addressed when considering what the patient best interest is, including:

The patient’s own wishes and values (where these can be ascertained), including any advance decision;
Clinical judgement about the effectiveness of the proposed treatment, particularly in relation to other options;
Where there is more than one option, which option is least restrictive of the patient’s future choices?
The likelihood and extent of any degree of improvement in the patient’s condition if treatment is provided;
The views of the parents, if the patient is a child;
the views of people close to the patient, especially close relatives, partners, carers, welfare attorneys, court-appointed deputies or guardians about what the patient is likely to see as beneficial; and
Any knowledge of the patient’s religious, cultural and other non-medical views that might have an impact on the patient’s wishes.

Advance decision:

Advance refusals of treatment have long been legally binding under common law. Advance requests or authorisations have not had the same binding status but should be taken into account in assessing best interests.

Following the Burke case in 2005, it is accepted that there is a duty to take reasonable steps to keep the patient alive (e.g. by provision of artificial nutrition and hydration) where that is the patient’s known wish.

In England and Wales, advance decisions are covered by the Mental Capacity Act. Patients who are aged 18 or over who have capacity may make an advance refusal of treatment orally or in writing which will apply if they lose capacity.

To be valid and legally binding the advance decision must be specific about the treatment that is being refused and the circumstances in which the refusal will apply.

Where the patient’s advance decision relates to a refusal of life-prolonging treatment this must be recorded in writing and witnessed.

The patient must acknowledge in the written decision that they intend to refuse treatment even though this puts their life at risk.

In Scotland and Northern Ireland, advance decisions are not covered by statute but it is likely they are covered by common law.

An advance refusal of treatment is likely to be binding in Scotland and Northern Ireland if the patient was an adult at the time the decision was made (16 years old in Scotland and 18 years old in Northern Ireland).

The patient must have had capacity at the time the decision was made and the circumstances that have arisen must be those that were envisaged by the patient.

Confidentiality:

Patients have the right to expect that information about them will be held in confidence by their doctors.

In the legal perspective, it is in the public interest for the patient to be able to trust their doctor to maintain confidentialty.for this reason, this obligation is not absolute.

Information must be disclosed when there is statutory duty. Examples include:

notification of infectious disease
drug addiction
termination of pregnancy
birth and death
identification of a patient undergoing in vitro fertility treatment with donated gametes
identification of donor and recipient for transplanted organ
prevention, apprehension or prosecution of terrorist
police on request, name and address nut not clinical details
under court orders

Link:GMC:confidentialty

Gait

2008-06-10T07:30:00.000-07:00

identify the gait abnormality:

gait assessment:
1-ask the patient:"can you walk unaided?"
cerebellar dysartheria during his replay will give clue
stand beside him for support
2-observe the gait (see below)
3-note arm swing/clumssiness on turning back/sticky foot
4-ask him to perform heel to toe gait.
this will axacerbate ataxia/note the side of tendency to fall
5-ask him to walk on his toes/heels
6-Romberg's test.
feet together/assure steadiness/close eye/support
this will demonstrate sensory ataxia e.g dorsal column lesion

abnormal gaits:
wide based/arms held aside ->cerebellar disease

stiff/scissoring/wading throgh mud ->spastic paraparesis

ataxic/Romberg's positive ->sensory ataxia

festinant/shuffling/no arm swing -> Parkinson's

steppage/foot high ->foot drop

semicircle/cercumduction/pelvic tilted ->hemiplagic

speech

2008-06-10T04:34:00.000-07:00

click to enlarge.

what is the type of speech in these following videos?

expressive Dysphasia:(anterior or Broca's aphasia)

comprehension of the spoken and written words is normal.

expression is poor with impaired non-fluent speech.

receptive Dysphasia:(posterior or Wernike's aphasia)

there is difficulty in undrestanding the spoken and written words

while speech may be fleunt and grammatical with normal articulation.

however, it may lack meaningwith inapprpriate words or phrases

(paraphasia) or new words (neologism)

assessment of speech:
1-general questions
"my name is ...,what's your name?"
"where do you live?"
2-comprehension:
one/two step command
3-orientaion:
time/place/person
4-name familiar objects.
5-articulation:
repeat:"british constitutions"
6-perform AMTS

can you think of additional/alternative way to assess speech?
what is the definition of dyspasia/dyartheria?
what are the causes of dysartheria?

history taking guidance

2008-06-09T03:57:00.000-07:00

it is improtant to be aware how you will be marked in the history taking skills station:

click to enlarge.

PACES guidance notes (MRCP UK):
waht you have to do:
1-take history focused on the question raised in the referral letter and on additional important issues refealed by consultation.
2-incorporare details of the social history and the activities of daily living which are relevant to the case.
3-you are expected to agree a summary and plan of action for the patient at the end of the interview.
4-when questioned by the examiner over the last 5 minutes of the station,you must be able to state the problems elicited in the history and how you would manage them giving your reasons.

the examiners will assess you on:
1-an adequate knowledge of the medical condition in question,and their investigation and treatment.
2-did you communicate effectively with your patient in a tructured but flexible way using intelligible language and avoiding jargons?
3-did you establish good rapport with the patient?
4-did you show good judgement in your management?

suggested preparation to improve performance:
1-in the course of your work,take as many purposefull analytical histories as possible an practice always make a differential diagnosis,with the most likely diagmosis on the top.
2-practice quantifying patients' disabilities and associated problems and assess the importance of personal factors in their illness.
3-practce drawing up management plans for patients under your daily care and discussing these with senior colleagues.

exam question

2008-06-07T13:50:00.000-07:00

look at the eyes of this patient.
what is defferential diagnosis?

see this link

history taking

2008-06-06T13:03:00.000-07:00

opening the interview:
introduce yourself appropriately and explain your role.
maintain attentive body position,good eye contact.

clinician:
"come in..."
"Hello,..Mr Osbourne, is it?" shakig hand with patient.
"common have a seat."
"nice to meet you."
"my name is Mr Steven, am a Urologist."

the main complaint:
obtain and record the main complaint in the patient own words.
let the patient finish the opening statment.
start with open-end questions.

clinician:
"I wonder if i can ask you a little about why are you here?,...and what problems you have been experiencing?"
"ok..,do you want to tell me more about that?"
"ok..,are there any other problems associated with that at all?"
"is there anytthing else you think of at the moment?"

strive for interchangeable responces, such as silence and noding.
use summerization and clarification.

clinician:
"so..am gathering obviously that the waterwork is getting worse and also the tiredness issue..."

close-ended questions provide details and they are useful in trying to build the case for certain diagnosis.
the "wh-" questions describe the attributes of the patient's symptoms and specify the story.

clinician:
"first of all,..HOW long these symptoms have been a problem for you?"
"WHEN was the first time you noticed that there is a problem at all?"

facilitation;
clinicain:
"..and then,..you saw your GP I think,is that right?"

summerize and recab,
clinican:
"can I actually ask about the main symptom again, you mentioned...."

shaw empathy:
clinician:
"I can imainge that can be very inconvenient at times.."

getting the details.
clinician:
"can i ask you when you go, is it painfull to pass urine at all?"
"..have you noticed blood in you urine..?"
"..do you got bony pain or joint pain?"

re summerize:
clininian:
"if you dont mind can I just summerize...."

history taking skills

2008-06-06T12:50:00.000-07:00

Opening the Interview/Setting the Agenda

The Trouble with Physicians

In one study, physicians did not allow patients to complete their opening statements 69% of the time. The mean time until the first interruption was 18 seconds. Once interrupted, fewer than 2% of patients went on to complete their statements.

"Data are thus very much physician-determined, skewed toward problems that are biomedical in nature... It has been proposed that current interviewing practices are at odds with scientific requirements: They produce biased, incomplete data about the patient."

An Outline for the Opening the Interview

Setting the Stage

Goal: To establish a favorable context for the interview

Welcome the patient
Know and use the patient's name
Introduce and identify yourself
Ensure comfort and privacy

Chief Complaint/Setting the Agenda

Goal: To establish the agenda for the interview

Obtain list of all issues - avoid detail
- Chief Complaint
- Other complaints or symptoms
- Specific requests (i.e. medication refills)
Patient's expectations for this visit
Ask the patient "Why now?"

Eliciting the Patient's Story

Goal: To establish a good flow of information

Open-ended questions initially
Encourage with silence, nonverbal cues, and verbal cues
Focus by paraphrasing and summarizing

Transition

Goal: To smoothly shift into physician-centered interviewing

Summarize interview up to that point
Verbalize your intention to make the transition

An Outline for the Rest of the Interview

Prioritize Problems

This should be clear from the transition summary.

Pursue the Most Urgent Problem (History of Present Illness)

Move from general to specific
Flow from open-ended to closed-ended questions

Pursue Other Problems as Time Permits

Review of Systems

Past Medical History

Allergies/Adverse Reactions
Medications/Immunizations
Major Medical or Psychiatric Problems/Major Surgeries
Last Menstrual Period/Pregnancies/Contraception (if female)
Smoking/Alcohol/Caffeine/Other Drugs

Other History (as appropriate)

Family/Social History
Occupational History
Sexual History

Parkinson’s disease

2008-06-06T09:35:00.000-07:00

→Difficulty to start walking
→Quick shuffling gate with no arm swinging
→Difficulty to turn back

→Has expressionless face
→Low volume monotonus speech
→Has drooling
→There is titubation

→Pill rolling tremor
→Bradykinisia
→The arms showed lead-pipe rigidity at the elbow
Cog-weal rigidity at the wrist

→Gabellar tap is positive (Myerson’s sign)
→Signs are generally asymmetrical
→Hand writing show micrograghia

what comprise Parkinson's syndrome?
what are the causes of Parkinson's syndrome?
what do you know about Parkinson's plus syndromes?
talk about treatment and management.

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NICE guidlines June 2006

exam question

2008-06-06T09:05:00.000-07:00

look at this patient's face.
describe your findings.
what is your diagnosis?

if you picked the diagnoses,proceed as follow:
1-shake hands
2-inspect face carefully,note balding/wasting/ptosis/cataract
3-examin upper limbs/lower limbs:wasting and decrease reflexes
4-perform percusion myotonia
5-tell the examiner that you would like to examine for:gynaecomastia/testiculr atrophy.
6-ask the patient about dysphagia/recurrent chest infection/FHx
7-request investigations

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internuclear ophthalmoplagia

2008-06-06T08:57:00.000-07:00

click on the image to enlarge.

what are the causes of INO?
how would you investigate?

Carpal tunnel syndrome

2008-06-06T08:30:00.000-07:00

how would you confirm the disgnosis?

foot drop

2008-06-06T08:01:00.000-07:00

click on the image to enlarge.

foot drop is caused by weakness of the dorsoflexors of the foot and toes.

site and causes:
1-lumbosacral pluxus (pelvic malignancy)
2-sciatic nerve palsy (trauma,IM injection)
3-peroneal nerve palsy (what are the causes?)
4-neuomuscular junction(Myathenia Gravis )
5-muscles/myopathy(myotonic dystrophy)

what are the features of foot drop due to common peroneal nerve palsy?
1-wasting of the muscles in the lateral aspect of the leg
2-weakness of dorsoflexion +/- eversion
3-high seppage gait
4-loss of sensation in the lateral aspect of the leg and ddorsum of the foot.

eye examination

2008-06-06T07:20:00.000-07:00

usefull powerpoint presentation about eye examination.

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examine this patient's legs

2008-06-05T08:40:00.000-07:00

what is your diagnosis?
what is the mode of inheritance?

features:
wasting of the muscles of the calves and thigh that stops in the lower third of the thigh giving "inverted champagne bottle"appearance.
pus cavus
clawing of the toes
weakness of dorsiflexion
wasting and clawing of the muscles of the hand

look for:
lateral popliteal nerve thickening
enlarge greater auricular nerve
gate (high steppage gate due to foot drop)
ask about family history.

Stroke

2008-06-05T07:58:00.000-07:00

there is right UMN weakness of the facial muscles.the right arm and leg are weak with increased tone and hyper-reflexia.the right planter is extensor.
he is dysphasic and there is sensory inattension.
this is right hemiplegia.

I would like to finish my examination by:
examin the visual field for homonymous hemianopia
check for caroted bruit
pulse for AF/heart for murmur
check the BP
dip the urine for suger

what are the causes of stroke?
what are the risk factors?

how would classify stroke?
Bamford classification 1991:
1-total anterior circulation stroke TACS
higher cerebral dysfunction +
homonymous visual field defect +
ipsilateral motor and/or sensory deficit
2-partial anterior circulation stroke PACS
2 out of 3 of TACS or higher cerebral dysfunction alone
3-lacunar stroke LACS
motor stroke or sensory stroke or sensory-motor stroke
4-posterior circulation stroke POCS
ipsilateral CN palsy with contralateral motor +/-sensory deficit or
bilateral motor+/-sensory deficit or
cerebellar dysfunction

can you list the features that are helpful t localize the site of hemiplagia?

examin this patient's eye

2008-06-05T06:26:00.000-07:00

If you noticed ptosis, answer the following questions:
1-is ptosis complete or partial
2-is it unilateral or bilateral
3-is the pupil constricted ->Horner’s syndrome
Dilated->3rd nerve palsy
4-are extra ocular muscles involved?
5-is the eyeball sunken or not (enophthalmos)
6-is the light reflex intact (intact light reflex in Horner’s)

If the patient has Horner’s syndrome then proceed as follow:
Examine the supraclavicular area
Look for scar of cervical sympathectomy
Look for enlarge lymph nodes
Percuss for dullness (pancoast tumour)
Examine the neck
Carotid and aortic aneurysm
Tracheal deviation
Examine the hands
Small muscle wasting
Sensation
Clubbing
Ask about loss of sweating on one side of the face.
Look for evidence of brain stem vascular disease or demyelination

presentation:
this patient has miosis,enophthalmos and left ptosis.
this is left Horner's syndrome.

what is Horner's syndrome?
Horner syndrome results from an interruption of the sympathetic nerve supply to the eye, and is characterized by the classic triad of miosis (ie, constricted pupil), partial ptosis, and loss of hemifacial sweating (ie, anhidrosis).
Horner syndrome isn't a disease but a sign of an underlying — often serious — disorder

what are the causes of Horner's syndrome?

wasting of the small muscles of the hand

2008-06-05T05:56:00.000-07:00

click image to enlarge.
examin this patient's hand.
describe your findings.
what are the causes of unilateral/bilateral wasting?

there is bilateral wasting and weakness of the thenar and hypothenar in addition to dorsal guttering.there is no fasciculation.no evidance of Horner's syndrome.the patient is unable to unbutton his clothes.

exam question 7

2008-06-04T12:24:00.000-07:00

describe.
what is your diagnosis?
what other signs you would look for?

renal transplantation

2008-06-04T07:50:00.000-07:00

exam question:
patient with renal transplant and arteriovenous fistula,did not had palpable kidneys.
what are the causes of renal failure?
discussion about polycystic kidney disease(presentation/complications)

Polycystic kidney disease:
AD chromosome 16
Prevalence 1:1000
The third most common cause of CRF in the UK

see presentation below.
what are the most used immunosuppresive medications and its saide effects?

typical case

2008-06-04T07:45:00.000-07:00

click on the image to enlarge

look out for this in the abdomin station.
if you found it,you should score 4!

renal...

2008-06-04T07:40:00.000-07:00

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Abdominal Examination

2008-06-04T05:03:00.000-07:00

hepatosplenomegaly

2008-06-04T04:25:00.000-07:00

exam question:
hepatosplenomegaly,signs of chronic liver disease.
asked to discuss causes of portal hypertension.
asked about the management of a patient with acute hepatic encephalopathy.

causes of hepatosplenomegaly:
1-Infection:
Acute viral hepatitis
Infectious mononucleosis
Cytomegalovirus
2-Haematological disease:
Myeloproliferative disorders :CML,Myelofibrosis.
Lymphoproliferative disorders:CLL, Hodgkin's Lymphoma
Anaemia:Pernicious anaemia ,Sickle cell anaemia,Thalassaemia
3-Chronic liver disease and portal hypertension:
Chronic active hepatitis
4-Amyloidosis
5-Acromegaly
6-Systemic lupus erythematosus

another exam question:
anaemic patient with hepatosplenomegaly.
most likely diagnosis:myelfibrosis
discuss.

splenomegaly

2008-06-03T08:32:00.000-07:00

exam question:
young black man with massive splenomegaly.no lymph nodes.asked for the single most likely diagnosis.

causes for splenomegaly:
1-Neoplastic
Lymphoproliferative: CCL, lymphoma
Myeloproliferative: CML, myelofibrosis
2-Inflammatory
Amyloidosis SLE
Sarcoidosis RA
3-Infective
Glandular fever
Hepatitis
Chronic malria/Brucelosis
SBE
4-Others
PRV cirrhosis
ITP storage disease

in which conditions the spleen is massively enlarged?

another exam question:
large isolated splenomegaly,no anaemia,no lymphadenopathy.
what is the most likely diagnosis?
how would you investigate?

examination tip

2008-06-03T08:28:00.001-07:00

ascites

2008-06-03T07:40:00.000-07:00

exam question:
middle age male unwell with nausea and vomiting and abdominal distension,juandiced,ecchymoses,hepatosplenomegaly with ascites.had a urinary catheter.
asked to give various defferentials.
asked about investigation and management of ascites.

ascites is the pathological presence of fluid within the peritoneal cavity.
common causes:
1-liver cirrhosis with portal hypertension
2-malignacy
3-congestive cardiac failure

investigatons:
ascetic tab and send fluid for:
biochemstry
cytology
cell count,culture and gm stain

use the protein level to defferentiate between exudate and transudate.
exudate has protein content of 25g/L
serum-ascites albumin gradient correlate directly with the portal press.
SAAG gradient>11g/L indicate portal hypertension with transudate
SAAG gradeint<11g/L indicate exudate

lines of management:
1-bed rest ?of little value
2-soduim restriction
3-water restriction
4-diuretcs therapy
5-paracentesis
6-shunt

what are the complications of ascites?
what is the pathophysiology of ascites?

Asthma

2008-06-03T04:39:00.000-07:00

if you got a patient with asthma,you are likey to be asked about the stepwise treatment:
Step1
Short acting beta agonist as required
e.g salbutamoul PRN

Step 2
Short acting beta agonist as required
+ Standard dose inhaled corticosteroids
e.g salbutamoul inh PRN
Beclomethasone inh regular

Step 3
Short acting beta agonist as required
+standard dose inhaled corticosteroids regular
+long acting beta agonist regular
e.g salbutamoul inh PRN
Beclomethasone inh regular
Salmetrol inhalers regular

If no response, consider increase the dose of regular inhaled corticosteroids to the upper limit of standard dose.

Step 4
Short acting beta agonist as required
+standard dose inhaled corticosteroids regular
+long acting beta agonist regular
+6 weeks trial of one or more of:
Leukotrienes receptors antagonists
Modified released thiophylline
Modified released oral beta agonist

Step 5
Add prednisolone tab

what are the features of acute svere asthma and how would you manage that?
what are the indications for mechanical ventilation?

scar...again

2008-06-02T13:11:00.000-07:00

what is the name of this scar?
what are the indication for liver transplant?
what is the most likely aetiology in this patient?

Any patient with documented fulminant hepatic failure, decompensated cirrhosis, or hepatocellular carcinoma within defined criteria (no single lesion greater than 5 cm or no more than three lesions, the largest ≤3 cm) is a potential candidate for liver transplantation.
Any patient with one of the defined complications of end-stage liver disease (eg ascites, variceal bleeding, encephalopathy or hepatocellular carcinoma) and/or a MELD score of 10 should be considered for referral to a transplant center.

BSG guidelines for liver transplant, click here

the PACES liver

2008-06-02T13:05:00.000-07:00

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Addison's disease

2008-06-02T09:04:00.001-07:00

there is generalized pegmentation,most marked in scars,skin crease and buccal mucosa.

examin the abdomen for adrenal scar(Nelson syndrome)
check the BP lying and standing

how would you confirm the diagnosis?
Random cortisol
Short synacthin test (normal cortisol rise above 600 nmol/l or increase by 300 nmol/l)
ACTH level or long synacthin test

what is the most common cause?
mention other caues of hyperpegmentaion.
what is Schmidt's syndrome?

Cushing's syndrome

2008-06-02T08:41:00.001-07:00

this patient has a moon face with acne,there is truncal obesity and buffalo hump.the skin is thin with excessive bruising and there is purple striae in the andomen.there is proximal muscle weakness.

causes of Cushing syndrome:
Sustained over production of cortisol

Cushing syndrome (non-ACTH dependent)
1-Adrenal adenoma
2-Adrenal carcinoma
3-Glucocorticoid administration

Cortisol ^ , ACTH v

Cushing disease (ACTH dependent)
1-Pit dependent
2-Ectopic ACTH producing tumour
3-ACTH administration

Cortisol ^ , ACTH ^

NB, pigmentation occur with ACTH dependent causes

Features:
1)central obesity
2)hirsutism
3)recurrent infections
4)osteoporosis ( can cause vertebral collapse)
5)olegomenorrhoea
6)hypokalaemia (due to mineralocoticoid activity )
7)water retension ( ADH )
8)hypoglycaemia ( -ve to insulin )
9)hypertension
10)proximal myopathy and wasting

Investigations:

1-screening:
24 hrs free urinary cortisol
Mid night dexamethasone suppression test

2-cofirmation test
For +ve screening test
Depend on demonstration of inappropriate cortisol secretion not suppressed by exogenous glucocorticoid.
Normal individual suppress cortisol to less than 50 nmole/L
low/high dose dexamethasone suppression test

discuss the treatment/managment of this patient.

osteoarthritis

2008-06-02T07:58:00.000-07:00

examine this patient's hand.
desribe your findings.

there is Heberden's nodules at the base of DIJ and Buuchard's nodules at the PIJ.
there squiring of the first metacapal due to subluxation.
now assess functional status.
examin for hip and knee involvement.

what are the typical radiological features?
how would you manage this patient?

Psoriatic arthropathy

2008-06-02T07:19:00.000-07:00

asymetrical arthropathy involving mainly the DIJ.
there is pitting of the nail and onycholysis.
(look for patches of psoiasis in the skin)

radiological features:
1-fluffy periostitis
2-destruction of the small joints
3-pencil cup appearance
4-deformity

what are the different types of psoriaric arthropathy?
what are the lines of management?

Gout

2008-06-02T06:29:00.000-07:00

asymetrical swelling affecting the small joints of the hand (and feet),the joints are severely deformed.there are tophi formation in the halex of the ear.

its a metabolic disorder of purine metabolism,characterized by hyperuricaemia due to either overproduction or under excretion of uric acid.

main risk factors:
age
diabetes
high BMI (obesity)
high protein diet
high alcohol consuption
hypertension
hyperlipidaemia
family Hx
drug Hx

what the main clinical manifestations?
what is the defferential diagnosis?
how would you investigate this patient?
what are the lines of management?

exam question 6

2008-06-02T05:11:00.000-07:00

describe.
what is your diagnosis?
what other skin lesions associated with this condition?
what is the mode of inheretance?

exam question 5

2008-06-02T04:58:00.000-07:00

describe.
what is your diagnosis?
what questions would you like to ask?
read more about this condition

exam question 4

2008-06-02T04:27:00.000-07:00

describe your findings.
what is your diagnosis?
how would you investigate?
how would you treat this patient?

read more...

should score 4 in psoriasis

2008-06-02T03:12:00.000-07:00

describe your findings.
there are patches of psoriasis over the trunk of the body and the bony promenance.
the plaques are circular ,well defined adge with salivary scales.
there is no asymetrical arthropathy present.

what are the types of psoiasis?
1-plaque
2-guttate
3-pustular
4-erythrodermal

what factors can exacrebate psoriasis?
1-drugs e.g B blockers,ACE inhibitors,lithuim,antimalarials and alcohol
2-stress
3-infections
4-trauma to the skin
5-sun light

what are the lines of management?
no cure,only supportive treatment.
indication for treatment:
1-local symptoms
2-cosmoitc problems
3-both
goal of treatment:
to decrease the extent and severity of the condition to the point that it no longer interfer substantially with patient occupation,personal or social life.

therapy:
1-topical treatment
2-systemic treatment (phototherapy or systemic drugs)
read more

scleroderma

2008-06-01T14:24:00.000-07:00

the skin over the fingers is smooth, shiny and tight
there is digital ischemia and ulceration with pulp infarction and atrophy
there is dilated nail fold capillaries with nail fold infarct and ragged cuticle
there is calcinosis.
now comment on any features on the face.
what are the other organs involved?
what are the varient of scleroderma?
what are the lines of manahement?

read more.

exam questions 3

2008-05-31T16:23:00.001-07:00

look at this patient's leg.
describe the lesion.
what single test you want to do?
what other skin conditions associted with this condition?

scleroderma

2008-05-31T16:18:00.001-07:00

click on the image to enlarge