Archive for the 'Clinical Case Histories' Category
January 17th, 2010
Earlier in the week we posted the first 5 of our 10 most important things you need to focus on for your medical examination OSCE technique. Here are the final 5.
To recap, here is our 36-year old’s patient history and findings:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”
- Hands Normal.
- Pulse 80.
- No Signs in the face.
- BP 182/92 Pan systolic murmur left sternal edge.
- Otherwise NAD.
Tip 6. Group your thoughts logically every time
a) By the most likely causes
“The differential includes the following:…”
b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”
Tip 7. Let the examiners know you are finished every time
Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.
Tip 8. Acknowledge what you don’t know
If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.
Tip 9. Have a set way of presenting examination findings every time
Practice this, it is the same every time. For the above case here would be our example:
“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”
If you do this the same every time it will stop you making mistakes.
Tip 10. Thank and ‘look after’ your exam patient (and the examiners).
This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.
We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.
Hands Normal. Pulse 80. No Signs in the face. BP 182/92 Pan systolic murmur left sternal edge. Otherwise NAD.
January 11th, 2010
One topic that continually crops up in medical student questions is exam technique, and issues that can revolve around it. For this reason we have produced a list of the most important things you need to know.
This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.
Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.
Let’s consider the following features and clinical examination…
A 36 year old male gives the following history:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.
Your Examination Findings are:
- Hands Normal.
- Pulse 80.
- No Signs in the face.
- BP 182/92 Pan systolic murmur left sternal edge.
- Otherwise NAD.
Tip 1. Look professional
Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.
Tip 2. Organise your presenting posture to minimise nerves
This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.
Tip 3. Structure your presentation of medical terminology
This needs to be structured in the same was that you elicited the history. PC, HPC PMHx, for example:
Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…
Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!
Tip 4. Interpret as you go
Don’t be afraid to explain your interpretations as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”
Tip 5. Learn to summarise in one sentence
Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”
We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!
August 27th, 2009
Listen to this patient’s symptoms, that will encompass different clinical features. Then try and provide a differential diagnosis. Let Medical Educator guide you through the process to reach a conclusion of what is wrong with this patient.
Remember you can listen to more podcasts, get MCQs and EMQs, watch clinical skills videos, and download ‘one minute’ revision guides in the medical finals login area of the site.
January 19th, 2009
EMQ’s
EMQ’s are being increasingly used in research and papers have recently been published on their success in the USMLE. Its likely that many medical schools will adopt this N from many approach. An EMQ is simple: its a series of typically 6-10 answers, used a number of times with different question stems.They first cropped up in 1993 after work by Case and Swanson. Read more about EMQ’s and their development here.
Distracters
Distracters are being used to throw students off the scent, and in some ways discriminate from good and bad students. An example would be describing a history of a rash affecting the flexor surfaces and giving on e of the answers as psoriasis. Seeing the two together can lead to the assumption this is the correct answer. This is an example of a good discriminator, but EMQs can easily be written in such a way that the more capable student gets it wrong!
Take an example EMQ from our new section dedicated to them on the login site.
“A 64 year old homeless man presents after being found exposed under a bush shelter by paramedics. He is ‘tided over the night’ by the emergency department staff with an IVI of 5% dextrose. The next morning he is confused, and ataxic. On examination he has nystagmus. Which of the following is treatment is most likely to be effective?”
Students classically then have to pick from a range of answers:
- Aciclovir
- Ciprofloxacin
- Buscopan
- Omeprazole
- Gluten free diet
- Peg Interferon alpha
- Mesalazine
- Vitamin B Complex
Here’s the Answer from the main site:
“Nystagmus, and ataxia are features of cerebellar disease, with the addition of confusion this triad is suggestive of Wernickes Encephalopathy (vitamin B1 deficiency- thiamine). Risk factors: poor nutrition (+/- alcohol).
Thiamine is important in carbohydrate metabolism and the Krebs cycle: it’s vital to remember that dextrose presents a carbohydrate load, the excess of which cannot be effectively metabolised , leading to cell death.
Hence the treatment: Vitamin B complex: initially this is given as Intravenous Pabrinex © for 48-72 hours.”
The EMQ here does a number of things: You could use your knowledge of drugs alone to answer the question: An antiviral (acivlovir), quinalone antibiotic (ciprofloxacin), an antispasmodic (buscopan), a Proton pump inhibitor (omeprazole) a gluten free diet (!), etc.
Aciclovir would initially seem attractive for a possible encephalitis- there are some things that fit: confusion, other CNS signs? This is a form of a distracter-look at the history, and the role of the glucose drip.Here the answer has been worked through by correctly recognise the triad of opthalmoplegia, confusion and ataxia that isin keeping with the diagnosis of Wernickes.
So, we can see that EMQs look initially pretty intuative, but more are being written, and expect them to be coming to an exam near you soon.
You can work through some examples of EMQ’s to prepare for your medical finals with different question structures on the subscription section of our site.
December 17th, 2008
Our free trial has now been taken by international students. Our questions are deliberately tough. Why not try a sample of the questions from the site and see how you compare to the rest of the students sitting the questions.
Our current average on the trial questions (20 marks) is
46%
That’s because our questions are tough. They’re not about knowledge, but the application of knowledge, exactly what your medical school will be interested in when they set their own benchmark…
Try out questions like the one below on our free trial.
November 15th, 2008
A 38 year old female is diagnosed with breast cancer and having had a lumpectomy proceeds to have 6 cycles of chemotherapy.
PMHx: Asthma, Previous Intravenous drug user
SHx: Current smoker
She does not attend for her pre op chemotherapy clinic appointment, but nevertheless goes on to have the chemotherapy.
6 weeks into her chemotherapy treatment she becomes jaundiced and has the blood tests taken
The problem has not arisen as a result of an adverse drug reaction.
What is the most likely underlying problem that has caused her to be jaundiced?
October 24th, 2008
A 32 year old female presents with an expressive dysphasia to her GP. Her GP initially thinks it could be migraine as she recalls a mild headache. However, he explains to the patient that she needs to be seen in the hospital for a check up.
She has no visual symptoms, motor symptoms or other neurological symptoms or signs.
By the time she arrives in the Emergency department, her symptoms have entirely resolved.
O/E
Temp 36 o Celsius
BP 112/78
Sats 99% Air
GCS 15/15
Fingerprick Blood glucose 3.9mmol/l
On examination she has an entirely normal neurological examination. The rest of the general examination is unremarkable other than a soft systolic murmur.
Is there anything else to be done, or should she simply see her GP for a follow up and consideration of a referral to a headache clinic? If there is something to be done, what is it and why?
September 21st, 2008
The One Minute Case History
46 year old male presenting with a bit of joint pain
Also tells you he has premature “wear and tear” of his hands with no history of trauma.
There’s nothing much else to go on in the history other than the fact that he’s impotent.
His blood tests show a low FSH and a low LH.
His GP thought it all might be rheumatoid arthritis…
What’s the diagnosis people?