Table of Contents
Foreword — Joanna M Flynn Preface — Roger J Pepperell Contributors Editorial Committee Additional Contributors Acknowledgements Introduction — Vernon C Marshall Role of the Australian Medical Council (AMC) — Ian B Frank Construction, Scoring and Validation of Assessments — Neil S Paget The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format — Heather G Alexander How to Use this AMC Handbook of Annotated MCATs — Vernon C Marshall MCAT Format Example: Candidate Information and Tasks, Performance Guidelines 001 A cut to the thumb of a 22-year-old man MCAT Candidate Information and Tasks, MCAT Performance Guidelines; Five Principal Categories and Domains ix x xi

xvii 1 9 25 31 34 37 44

• 1-A Communication, Counselling, and Patient Education — Introduction: Alan T Rose ~ MCAT Candidate Information and Tasks 002-021 ~ MCAT Performance Guidelines 002-021 CIT DETAILS OF MCAT SCENARIOS 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 5 Counselling a family after sudden infant death syndrome (SIDS) 6 Hair loss in a 38-year-old man 7 An unusual feeling in the throat in a 30-year-old man 8 Pain in the testis following mumps in a 25-year-old man 9 Contraceptive advice for a 24-year-old woman 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 12 Thalassaemia minor in a 22-year-old woman

45 51-67 68-130 PG

53 53 54 55 56 57 58 58 59 60 61

69 72 75 77 79 81 84 87 90 92 95


CIT 13 14 15 16 17 18 19 20 21 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida A duodenal ulcer found on endoscopy in a 65-year-old man Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery Advice on stopping smoking to a 30-year-old man Excessive alcohol consumption in a 45-year-old man Type 1 diabetes mellitus in a 9-year-old boy Request for vasectomy from a 36-year-old man 62

PG 99

62 63 64 65 65 66 67 67

102 105 108 111 115 121 125 129

1-B Case presentations and summaries to Examiner — Introduction: Vernon C Marshall DETAILS OF MCAT SCENARIOS 022-029 Headache, neck lump, previous shoulder dislocation, dysphagia, low back pain, knee pain, abdominal discomfort, gastric ulcer with haemorrhage


2-A The Diagnostic Process — History-taking and Problem-Solving — Introduction: Reuben D Glass ~ MCAT Candidate Information and Tasks 030-043 ~ MCAT Performance Guidelines 030-043 DETAILS OF MCAT SCENARIOS 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Jaundice in a breastfed infant A convulsion in a 14-month-old boy Loud and disruptive behaviour of a 6-year-old boy Tremor in a 40-year-old man Headache in a 35-year-old woman Lethargy in a 50-year-old woman Syncope in a 52-year-old man A painful penile rash in a 23-year-old man Primary amenorrhoea in an 18-year-old woman A skin lesion on the cheek of a 50-year-old man A pigmented mole on the trunk of a 30-year-old woman An itchy rash on the hands of a 19-year-old woman Red painful dry hands in a 30-year-old bricklayer Swelling of both ankles in a 53-year-old woman


137 142 -154 155 -195 143 144 144 145 145 146 147 148 149 150 151 152 153 154 156 159 161 164 167 170 173 177 180 182 184 186 189 191


CIT • 2-B Physical Examination — Introduction: Vernon C Marshall and Barry P McGrath ~ MCAT Candidate Information and Tasks 044-057 ~ MCAT Performance Guidelines 044-057 DETAILS OF MCAT SCENARIOS 044 Assessment of a comatose patient 045 Recent onset of poor distance vision in a 17-year-old male 046 A painful rash on the trunk of a 45-year-old child-care worker 047 Acute low back pain and sciatica in a 30-year-old man 048 Fever and a recent rash in a 30-year-old man 049 A heart murmur in a 4-year-old boy 050 A knife wound to the wrist of a 25-year-old man 051 Multiple skin lesions in a Queensland family 052 Subcutaneous swelling for assessment 053 Examination of the knee of a patient with recurrent painful swelling after injury 054 Assessment of hearing loss, first noted during pregnancy in a 35-year-old woman 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 056 Assessment of a groin lump in a 40-year-old man 057 Eye problems in an aboriginal community • 2-C Choice and Interpretation of Investigations — Introduction: Reuben D Glass and Vernon C Marshall ~ MCAT Candidate Information and Tasks 058-064 ~ MCAT Performance Guidelines 058-064 DETAILS OF MCAT SCENARIOS 058 Positive test for hepatitis C in a 26-year-old woman 059 Diagnosis of 'brain death' prior to organ donation 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 061 An elbow injury in an 11-year-old schoolgirl 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman 063 Atypical ureteric colic in a 25-year-old man 064 Investigation for male factor infertility in a 25-year-old man

PG 196 -23 3 -29 6 235 241 246 248 252 255 257 264 274 280 282 286 289 293 297

218 234

219 220 221 222 223 224 225 226 228 229 230 231 232 233

312- 319 320- 342 313 314 315 316 317 318 319 321 325 329 331 334 337 340


CIT 2-D The General Consultation — Introduction: Barry P McGrath ~ MCAT Candidate Information and Tasks 065-073 ~ MCAT Performance Guidelines 065-073 DETAILS OF MCAT SCENARIOS 065 Acute chest pain in a 60-year-old man 066 Palpitations and dizziness in a 50-year-old man 067 Muscle weakness and urinary symptoms in a 60-year-old man 068 Aches and pains in a 62-year-old man 069 Lack of energy in a 56-year-old suntanned man 070 Recent haematemesis in a 50-year-old man 071 Anaemia in a 28-year-old pregnant woman 072 Acute vertigo in a 50-year-old man 073 Urinary frequency in a 60-year-old man 2-E The Paediatric Consultation — Introduction: Peter J Vine ~ MCAT Candidate Information and Tasks 074-077 ~ MCAT Performance Guidelines 074-077 DETAILS OF MCAT SCENARIOS 74 75 76 77 Neonatal jaundice in the first day of life Immunisation advice to the parent of a 6-week-old baby Dark urine, facial swelling and irritability in a 5-year-old boy Fever and sore throat in a 5-year-old boy 402 402 403 403

PG 343

347-354 355-396

348 349 350 351 352 352 353 353 354

356 363 368 371 374 377 380 383 394 397

401-403 404-416

405 408 412 414 417

2-F The Obstetric and Gynaecologic Consultation — Introduction: Roger J Pepperell ~ MCAT Candidate Information and Tasks 078-082 — MCAT Performance Guidelines 078-082 DETAILS OF MCAT SCENARIOS 78 79 80 Breech presentation in labour at 38 weeks in a 25-year-old woman Vaginal bleeding in a 23-year-old woman Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 420 420 421 421 422

419-422 423-435

424 427 430 432 434 436

081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 082 Vaginal bleeding after 8 weeks amenorrhoea, in a woman with previous irregular cycles 2-G The Psychiatric Consultation — Introduction: Frank P Hume ~ MCAT Candidate Information and Tasks 083-089 ~ MCAT Performance Guidelines 083-089

446-454 455-481


CIT DETAILS OF MCAT SCENARIOS 083 Medication changes for a 35-year-old woman with chronic schizophrenia 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 085 Poor work performance in a 30-year-old female police officer 086 Lifestyle stress in a 45-year-old man 087 Binge drinking in a 25-year-old man 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 089 Collapse of a 30-year-old woman on the way to a court attendance 447 448 449 450 452 453 454


456 459 463 466 470 474 478 483 483

• 3-A Management Objectives, Therapeutics, Prevention and Public Health — Introduction: Alan T Rose, Michael R Kidd and Ronald McCoy ~ MCAT Candidate Information and Tasks 090-100 ~ MCAT Performance Guidelines 090-100 DETAILS OF MCAT SCENARIOS 090 Acute right sided pain and haematuria in a 25-year-old man 091 Faecal soiling in a 5-year-old boy 092 Psoriasis in a 30-year-old man 093 Temporal arteritis in a 58-year-old woman 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man 095 Dysuria and urinary frequency in a 40-year-old man 096 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida 098 Bed-wetting by a 5-year-old boy 099 Acute gout in a 48-year-old man 100 Request for repeat benzodiazepine prescription from a 25-year-old man • 3-B Clinical Procedures — Introduction: Peter G Devitt and Barry P McGrath ~ MCAT Candidate Information and Tasks 101-104 ~ MCAT Performance Guidelines 101-104 DETAILS OF MCAT SCENARIOS 101 Resuscitation of a 24-year-old man after head and chest injury 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery 103 Evaluation of lung function by spirometry in a 22-year-old man 104 A suspected fractured clavicle in a 20-year-old man 543548544 545 546 547 489499490 491 492 493 494 495 496 496 497 497 498

-498 -536 500 503 507 510 512 519 522 525 528 531 534 537

-547 -563 549 551 558 561



PG 565 565

4-A Clinical Perspective and Priorities — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 105-112 ~ MCAT Performance Guidelines 105-112 DETAILS OF MCAT SCENARIOS 105 Abdominal pain and vaginal bleeding after 9 weeks amenorrhoea, in a 39-year-old woman 106 Recent insomnia in a 25-year-old man 107 Dandruff or head lice in a 6-year-old girl? 108 Recent orchidectomy for a testicular neoplasm in a 28-year-old man 109 Postnatal fatigue and exhaustion in a 28-year-old woman 110 Fundus greater than dates in a 26-year-old woman at 30 weeks gestation 111 Tiredness and anaemia in a 55-year-old woman 112 Colonoscopy findings in a 24-year-old man with chronic diarrhoea 4-B Life-threatening Emergencies — Priorities of Treatment — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 113-118 ~ MCAT Performance Guidelines 113-118 DETAILS OF MCAT SCENARIOS 113 A severely ill 4-month-old baby girl with fever 114 A lethargic febrile 2-year-old boy with a rash 115 Wheezing and breathing difficulty in a 5-year-old girl 116 Cuts to the wrist of a 25-year-old man 117 Severe postpartum haemorrhage in a 25-year-old primigravida 118 Emergency management of a snake-bite in a 20-year-old man 602- 608 609- 627 603 604 605 606 607 608 571 572 573 574 575 575 576 577 570 578

-577 -600

579 582 585 587 589 593 596 599 601

5-A Ethical and Legal Dilemmas — Introduction: Kerry J Breen ~ MCAT Candidate Information and TasKS 119-124 ~ MCAT Performance Guidelines 119-124 DETAILS OF MCAT SCENARIOS 119 A man requesting disclosure of his wife's medical condition 120 Obtaining consent for leg amputation in a 35-year-old man after a motor vehicle injury 121 Several bone fractures in a 9-week-old baby 633640634 635 636

610 612 614 618 622 625 628 629

639 659

644 647


CIT 122 A parent requesting sterilisation of her intellectually disabled daughter 123 Blood transfusion consent for a 33-year-old pregnant woman with severe APH at 7 months 124 End-of-life request from a terminally ill patient 638 639 637



652 655 661 661

• Preparatory Instructions — Roger J Pepperell 16 Station Trial Assessment ~ MCAT Candidate Information and Tasks T1-T16 ~ MCAT Performance Guidelines T1-T16 DETAILS OF MCAT TRIAL ASSESSMENTS 125 [T1] Meconium staining of liquor in labour in a 25-year-old primigravida 126 127 128 129 130 131 132 [T2] [T3] [T4] [T5] [T6] [T7] [T8] A heart murmur in a 5-year-old girl Vigorous vomiting by a 3-week-old boy Urinary incontinence in a 50-year-old woman Migraine in a 30-year-old woman Past history of hip dislocation in a 35-year-old man Tiredness in a 45-year-old man Review of lung function tests in a 65-year-old man with shortness of breath 133 [T9] Assessment of a 28-year-old primigravida at 34 weeks with fundus less than dates 134 135 136 137 [T10] [T11] [T12] [T13] Delirium in a 25-year-old man after a burn injury Chronic diarrhoea in a 45-year-old man Fever, irritability and ear discharge in a 2-year-old boy Review of cytology after aspiration of a breast lesion in a 28-year-old woman 138 139 140 [T14] Nocturnal hand discomfort in a 35-year-old schoolteacher [T15] An attack of asthma in a 25-year-old man [T16] Preparing a 30-year-old woman with suspected acute appendicitis for surgery 8 Station Trial Retest Assessment ~ MCAT Candidate Information and Tasks R1-R8 ~ MCAT Performance Guidelines R1-R8 DETAILS OF MCAT TRIAL RETEST ASSESSMENTS 141 142 143 [R1] [R2] [R3] Intravenous cannula insertion for antibiotic prophylaxis Heartburn in a 35-year-old man Spontaneous bruising and nosebleed in a 3-year-old boy 733 734 735 732 740 -739 -765 672 672 673 674 675 677 677 678 665 666 667 668 668 669 670 671 664 -678 679 -730

680 683 685 688 691 694 696 700

705 708 712 716 718 721 724 728

741 744 748




144 [R4] Nausea and vomiting in the first trimester in a 25-year-old primigravida 145 [R5] Visual difficulties in a 50-year-old man 146 [R6] Cognitive state assessment of a 50-year-old barman 147 [R7] Jaundice in a 25-year-old man 148 [R8] Assessment of prominent leg veins in a 38-year-old woman INTERACTIVE CLINICAL ASSESSMENT — OTHER METHODS AND OSCE MODIFICATIONS — Peter G Devitt and Heather G Alexander 149 Confusion and delirium after surgery in a 50-year-old man 150 Postoperative fever in a 45-year-old woman 151 The 4 station progressive OSCE

736 736 737 738 739

750 753 756 760 763 767

771 771

773 776 779 781 790 803 806 810 814 843 847 856 862 863 867 868

2. AMC Instructions to Standardised Patients and Clinical Examiners 3. MCC/AMC Clinical Task Categories; AMC Function/Process;
System/Region/Speciality; and Discipline classification MCATs with full Domain listing and AMC Anthology Reference MCATs by Discipline (Condition and page listings only) MCATs by System/Region/Speciality (Condition and page listings only) MCATs by Function/Process (Condition and page listings only) Suggested Additional Groupings of MCATs for self-test trial assessments Guidelines for further reading EPILOGUE INDEX


The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format
Heather G Alexander
The student is to collect and evaluate facts. The facts are locked up in the patient. To the patient, therefore, the student must go.' Abraham Flexner (1866-1959) Medical Education, a Comparative Study The MCAT is an integrated OSCE-style clinical examination where each candidate proceeds through the same number of stations — 16 stations in the full exam, 8 stations in the retest. CONTENT OF STATIONS At each station, two minutes are allocated for preliminary reading outside the room. An instruction sheet giving the candidate specific information and tasks required is provided. This introduces the candidate to the consultation setting and clinical situation. It may also include patient profile test results or an illustration. Specific tasks that the candidate will be asked to perform are itemised. A duplicate copy of the instructions is provided in the examination room. This is followed by eight minutes performing the required task in a room The aims of the with a standardised patient. When the candidate first enters the room, the station, the tasks observing examiner will check that the instructions for the station have that candidates are been read and will then introduce the candidate to the patient. The asked to perform, examiner will then observe the performance and record the the key issues and candidate's performance on a tailored mark sheet. The standardised assessment patient may be a real patient or a simulated patient (role player) who domains defined plays the role of either the patient or a relative. Doctor-patient for the station are communication performance contributes to the assessment and requires all closely aligned. a well-trained role player. Where scenarios are based on physical examination, the 'role player' may be a real patient.

FIGUREIII. History-taking

FIGURE iv. Commencing the Physical Examination

The aims of the station, the tasks that candidates are asked to perform, the key issues and assessment domains defined for the station are all closely aligned.


The MCAT scenarios developed for assessment purposes are designed to simulate closely real life situations within medical consultations. These may be in a general practice setting, a hospital emergency department, or a hospital inpatient or outpatient setting. Scenarios deal with different phases of illnesses. Diagnostic scenarios include the diagnostic phases of history taking, physical examination, and ordering and interpreting investigations. The management phases incorporate patient explanation and education, advice and referral, therapeutics and preventive medicine, clinical procedures and counselling. Scenarios are focused precisely so that the assessment domains, key issues and critical errors are accurately related to the station aims and the tasks set down in the candidate's instructions. Members of the AMC clinical examination panel suggest MCAT clinical scenarios based on their prevalence, seriousness, preventability and whether they can be simulated as real life situations within the inherent time constraints. Scenarios are thoroughly reviewed and approved by the multidisciplinary clinical panel prior to use. The current 16 or 8 station MCAT formats cover a broad spectrum of skills in clinical medicine, psychiatry, surgery, obstetrics/gynaecology, and paediatrics, including emergency, hospital and community practice medicine. MCAT MARKING In an MCAT, candidates are assessed at the level of a final year medical student, i.e. a doctor about to commence an intern year (PGY1). Mark sheets for examiner use. The examiner scores the candidate's performance on a mark sheet which specifies the assessment domains, key domains, and critical errors if appropriate. The assessment domains match the tasks outlined on the instructions the candidates receive during the two minutes preliminary reading. The marking domains are identified from among a total of 14 covering: • approach to patient and responses to patient's questions; • patient counselling and education; • history-taking; • physical examination choice and technique; • physical examination accuracy; • choice of investigations; • interpretation of investigations; • diagnosis and differential diagnosis; • initial management plan; • explanation of clinical procedure; • performance of clinical procedure; • familiarity with test equipment; • commentary to examiner; and • answers to examiner's questions, No single station is likely to have assessment in more than five of these domains. Each domain has a 4-point marking scale: • Very satisfactory Clear pass • Satisfactory Pass • Unsatisfactory Fail • Very unsatisfactory Clear fail


An example mark sheet is included later with the example MCAT 001. (see page 44) Critical errors are defined and derived from one or more of the key issues, when relevant. Not all stations have critical errors. If the candidate makes a critical error the candidate is very likely to fail that station, regardless of performance in other domains, unless performance in other domains is outstanding and the critical error is deemed possibly related to lack of time or misunderstanding of the task. MCAT performance is checked and reviewed by the Clinical Panel of Examiners after each use in an examination. All details, particularly presence and definition of critical errors, are reassessed and retained or modified in light of candidate performance and examiner feedback. Station failure would probably result from two or more 'unsatisfactory — fail' assessments or one 'very unsatisfactory — fail' assessment in a key issue domain, or from making a critical error in a key issue domain. After scoring each of the domains, the examiner will provide an overall (final) rating that is either 'Pass' or 'Fail' for each station. All 16 MCAT scenarios are of equal weighting and for each scenario there are only two outcomes — pass or fail. Candidates must obtain a pass in 12 or more of the 16 stations, including a pass in at least one paediatric and one obstetric/gynaecology station, to pass the MCAT as a whole. Candidates scoring pass levels in nine or less of the 16 stations, or with failures in all three of the paediatric or obstetric/gynaecology stations, fail the examination and must resit. Candidates who pass 10 or 11 of the 16 stations (including a pass in at least one obstetric/ gynaecology station and one paediatric station) will be eligible for a pass/fail Retest Examination of 8 stations. Retest candidates will be required to pass six or more of the eight retest stations to pass the examination. Candidates scoring five or less passes will fail and be required to resit the whole examination. Heather G Alexander July 2007


How to use this AMC Handbook of Annotated MCATs
Vernon C Marshall
'In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.' Sir William Osier (1849-1919) The MCAT self-test scenarios are arranged in groups under the principal categories and domains tested. In each instance the reader is provided with a synopsis heading, outlining the clinical problem/condition together with the information available to the candidate and details of the task to be undertaken, exactly as this appears in the MCAT examination. INSTRUCTIONS TO CANDIDATES You may wish to attempt to complete the tasks in each of the major categories before moving to the next group. If you would prefer to review tasks by system and region, or by discipline, the appropriate groupings of these are listed in later pages. Page numbers of individual MCATs are listed in the table of contents at the beginning of the book for easy reference. After reading carefully the information provided to you for each clinical scenario and the required tasks, jot down how you will approach this consultation, how you will advise the patient or relative of your findings and recommendations, and how you would structure responses to queries from patient or examiner. Then turn the pages to check your responses against the optimum Performance Guidelines, Examiner Instructions and Commentaries. Note the station Aims, Key issues and Critical Errors outlined. In this book the scenarios are grouped into five main categories. The groupings are to some degree artificial in that communication skills are relevant to all scenarios. For example, aspects of diagnosis, management, and patient counselling and education are frequently combined to varying degree, but the groupings are arranged to emphasise and categorise the principal domains even though most scenarios are assessed over multiple domains. The five groupings below condense the total of 14 domain assessments into five categories covering skills principally in: 1. Clinical Communication (C) — with patient, relative and observer, and including a number of domains: approach to patient, patient counselling/education, history-taking, commentary to examiner, answers to patient's or examiner's questions, explanation of procedure, case presentation and summary. 2. Clinical Diagnosis (D) — includes history-taking, technique and accuracy of physical examination, choice of investigations and their interpretation, diagnosis/differential diagnosis. 3. Clinical Management (M) — includes initial management plan, performance of procedure/task, treatment and prevention of disease, clinical procedures. 4. Integrated Diagnosis and Management (D/M) — includes clinical perspectives and priorities, life-threatening emergencies, integrative reasoning skills and clinical problem-solving. 5. Legal, Ethical and Organisational (LEO) — includes scenarios where ethical and legal issues are significant.


INTRODUCTORY GUIDELINES for candidates (see Table below) The MCAT self-test are provided at the start of each of the main categories and their scenarios are arranged domains. in groups under the After completing individual case scenarios you may find it helpful to principal categories revise your knowledge of similar and linked conditions by referring and domains tested. In to appropriate clinical texts and references. The AMC Anthology of each instance the Medical Conditions contains other self-test strategies for individual reader is provided with conditions. a synopsis heading, Try making up your own variations on the conditions tested, and outlining the clinical practise role playing and interactions with a colleague or in a group. problem/condition Once you are familiar with the mechanics and time constraints, together with the pace yourself through the trial examinations (one containing 16 information available to stations and one containing 8 multi-disciplinary stations), and the the candidate and other suggested groupings provided later in the book, under details of the task to be undertaken, exactly as simulated examination conditions. this appears in the The Editorial Committee hopes you find the examples helpful and MCAT examination. extends its good wishes for a successful assessment. SCENARIO HEADINGS FOLLOWED IN THE AMC HANDBOOK OF CLINICAL ASSESSMENT The MCAT scenarios and performance guidelines are set out in a standardised sequence as follows. Groups of self-test candidate information and tasks are arranged under principal categories and domains tested. Table 3 MCAT Introductory Guideline Scenario Headings CONDITION AND ID NUMBER A generic and non-diagnostic summary of the presenting symptom, physical sign or investigation result in diagnostic-type cases, such as: • Assessment of acute abdominal pain in a 30-year-old woman. • Assessment of a vesicular rash in a 50-year-old man. • Review of liver function test results in a 50-year-old man with jaundice. The diagnosis or most likely diagnosis in management/counselling-type cases, such as: • Management of shingles ('herpes zoster') in a 25-year-old woman. • Counselling the relative of a patient after recent major surgery.


Under this heading the background information and tasks are given precisely as they appear in the MCAT examination. Page references to the matching Performance Guidelines are given at the foot of each Candidate Information and Tasks sheet. Lists requested tasks for candidates.


Performance guidelines follow in similar category and domain groups linked to the preceding scenarios by ID number and page reference. PERFORMANCE GUIDELINES Principal category and assessment domains in detail; and classitication by function, system/region and discipline (see Appendix 3) are listed for each station just prior to the index. AMC Anthology of Medical Conditions reference is listed to aid further self-testing. The MCC/AMC Clinical Task Category is also listed. AIMS OF STATION A brief outline of station and assessment aims, matching the tasks. The expected responses and levels of performance required to complete the tasks successfully are outlined in the examiner instructions and commentaries. These provide the following: Instructions from examiner to standardised patient Candidate information and tasks and role player instructions are detailed and provided to examiners and standardised patients so that there is standardised behaviour across multiple patients. Cues assist in directing the consultation pathway. The instructions are set out using lay terminology to maintain realism, and outline: • Clinical setting — hospital emergency department, hospital ward or outpatient department, primary care facility, community practice office consultation. • Clinical situation — description of illness and symptoms and phase of the consultation. • Patient profile — age and gender, past history, family history, habitus, as relevant to the case. • Opening statement — one sentence provided as the patient's opening gambit. • How to play the role — advice on further responses, posture, gestures, affect, mood and ways to react to the doctor, including where the task is a physical examination. Questions to be asked by patient/role player — set down in a loose priority and which will depend on whether these have already been covered by the doctor/candidate. Any examiner questions or prompts to the candidate are also outlined, with the required responses. CONDITION AND ID NUMBER



These are clarified for the examiner and match the tasks and the domains.

These are selected from the assessment domains and expectations of candidate performance for each case and highlighted accordingly. These list significant errors likely to lead to a fail performance. This discusses and comments further on the condition, highlighting performance standards and common errors.



the edges of which have sealed after the initial bleeding which has now stopped. He is right handed. The patient injured his left thumb at work an hour ago. He was wearing cotton gloves. He is aged 22 years and works as an orchard labourer and fruit picker. The knife cut through the glove and cut the thumb as shown in the illustration below. Near the end of the eight-minute time allotted for your task. CONDITION 001.Condition 001 Candidate Information and Tasks Condition 001 A cut to the thumb of a 22-year-old man You are the Hospital Medical Officer (HMO) in a hospital Emergency Department. FIGURE 1. Bleeding was minor and controlled by a pressure dressing. You may ask other questions of the patient as you proceed with the examination and explanation. Knife wound to the left thumb The Performance Guidelines for Condition 001 can be found on page 40 037 . which has been removed for examination. the examiner will ask you one or two questions. YOUR TASKS ARE TO: • Examine him and assess the injury. The wound appears as a linear knife cut as shown. MCAT FORMAT EXAMPLE: Sample .EXAMPLE CASE SCENARIO: The following case scenario exemplifies the formatting for a combined Diagnosis and Management MCAT. He was pruning fruit trees today and the pruning knife slipped and he cut his left thumb. • Explain to him the nature of the injury and your recommended management.

SUMMARY OF STUDY TASKS Read the candidate information and task(s). Finally. Follow a similar process for the other MCATs. expectations of your knowledge and performance. before proceeding to read the performance guidelines. examiner and patient instructions and commentary which you will find on subsequent pages. preferably working with a colleague or group. and note the aims of the station. 038 . while another group member takes the role of examiner/observer. 113H.Sample-Condition 001 Candidate Information and Tasks CANDIDATE ADVICE You should: Prepare and document your responses and how you would approach this task. Your colleague reads the performance guidelines and plays the patient/relative. revise your knowledge of applied surface anatomy relevant to wounds giving risk to underlying structures and how you should check for local and distal effects of injury. The best way to develop proficiency in an MCAT assessment is to work in pairs or as a group. Revise the Anthology scenarios 113. Check for any deficiencies in your performance. Construct alternative scenarios for other wounds and self-test yourself on these (for example. For this MCAT about a thumb wound. Reread the introductions to the section in which the MCAT appears. Reinforce your understanding of the condition by completing other self-assessment tasks (for example from the AMC Anthology of Medical Conditions) and construct at least one other related task for solving. Test yourself thoroughly after reading the MCAT Candidate Information and Tasks. while you read the candidate information and perform the tasks. Then read the performance guidelines that follow. key issues and critical errors and other points raised in the commentary. Formulate and document a logical approach for responding to and solving the consultative problem given. injuries to radial nerve in the arm. one complete MCAT 16 station assessment and one complete MCAT eight station assessment are provided later in the book as examples of whole examinations for trial. 113J and 113K and complete the self-test exercises. common peroneal nerve in the leg).

Pace and test yourself through these. We hope that you will find the self-discipline and requirements to adhere to logical clinical reasoning pathways in approaching the wide range of clinical problems selected for this book will stand you in good stead. MCATs are similarly grouped into the relevant function and process and into system/region/specialty. surgery if you wish to use the book in this way. obstetrics/gynaecology. paediatrics.Sample-Condition 001 Candidate Information and Tasks Additional groupings of MCATs into further self-test trial examinations are also suggested at the end of the book. but throughout your subsequent career. Vernon C Marshall 039 . Keep practising within a group of your peers until fully familiar with the routine. For these latter groups. not just for assessment examinations. MCATs are often listed more than once when they cover more than one system or function. MCATs are also grouped into one of the principal disciplines of medicine. psychiatry.

the knife cut has severed the two extensor tendons to the thumb.Condition 001 EXAMPLE: Performance Guidelines MCAT FORMAT Condition 001 A cut to the thumb of a 22-year-old man AIMS OF STATION To assess the candidate's ability to use clinical reasoning skills to diagnose and manage important injuries associated with skin wounds. if the candidate has identified that a tendon injury has occurred. which you are unable to do. the examiner should ask: 'What are the names of the injured tendons?' (Extensor pollicis longus [EPL] and extensor pollicis brevis [EPB]) and 040 . Opening statement: • 'Will it be okay for me to go back to work tomorrow with a dressing over it now it's stopped bleeding. until specifically asked to extend each of the two end joints. Examiner's questions to candidate: • At the end of 6-7 minutes. you will accept the recommendations for operation. In this instance. and show the patient how to respond to requests to bend his thumb and testing of sensation as follows: • You have not yet noticed and should not volunteer any information about limitation of thumb movement. Doc?' Other questions to ask: • If the candidate/doctor diagnoses tendon injury with normal sensation. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The examiner will draw the linear cut with a red marking pen on the role-playing patient.Sample . and should ask about the operation 'Will I need an anaesthetic?' (Appropriate answer — Yes: regional block or general anaesthesia). • If no mention of a tetanus prophylaxis or antibiotics is made during the interview you will subsequently ask 'Will I need another tetanus shot?' (A booster dose of toxoid would be appropriate). • You had a tetanus booster shot about a year ago for a leg graze and were immunised against tetanus as a child. Sensation is normal.

CRITICAL ERROR Failure to test and identify the injury to the extensor tendons would comprise a clear and irremediable fail for this station at a very unsatisfactory level. providing the presence of tendon injury was diagnosed and appropriate advice given in other areas. EXPECTATIONS OF CANDIDATE PERFORMANCE Cuts and stabs of various types commonly present to emergency departments. such omission would most likely be corrected with subsequent specialist referral for surgery and anaesthesia. Explanation of treatment would optimally advise preparation for early surgery using local (field) block or general anaesthesia. what would you choose?' (Broad spectrum cover such as one dose of amoxycillin. Failure to mention antibiotic or tetanus prophylaxis would be unsatisfactory. Failure to name the tendons correctly would not necessarily be a fail performance. Diagnosis of injury to the two main long thumb tendons and recognition of the treatment requirements for primary surgical repair in this 'tidy' (clean contaminated) wound. KEY ISSUES Ability to identify deeper tendon injuries resulting from stabs or cuts. If no tendon injury has been identified just ask: 'If antibiotics are to be given. cephalosporin or other antibiotic). but would not be considered a critical error in the presence of a 'tidy' recent wound.Sample .Condition 001 Performance Guidelines 'Which joint does each tendon act upon?' (Interphalangeal [IP] and metacarpophalangeal [MP] joint respectively). Attending doctors must be aware of the anatomy of deeper structures at risk from injuries at specific sites and the methods of diagnosing such injuries. Antibiotic and tetanus prophylaxis would be appropriate. Failure to appreciate that the whole thumb extensor mechanism (involving two tendons) has been damaged would comprise a fail (unsatisfactory) in the domains of examination technique and diagnosis. 041 .

These tendons form the margins of the anatomical snuff box as illustrated. • Extensor pollicis brevis (EPB) is the lateral of the two thumb extensors. separating the thumb from the other digits in the plane of the palm. may be injured by cuts and penetrating injuries. often multiple or ridged like a stalk of celery. Cuts around the knuckle of the metacarpophalangeal joint are likely to sever one or both tendons. The patient has no obvious thumb deformity but is unable actively to extend either the metacarpophalangeal (MP) joint or the interphalangeal (IP) joint of the thumb. In this patient. 042 . EPL is the prime mover and sole extensor of the terminal (interphalangeal) joint. The tendons have been severed at the knuckle level of the metacarpophalangeal joint. EPB is the prime mover in extension of the MP joint and an accessory extensor of the CM joint. inserts dorsolateral^ into the base of the thumb metacarpal. EPB runs in the same synovial sheath as the tendon of abductor pollicis longus on the lateral surface of the radius and continues over the dorsal shaft of the metacarpal to insert into the base of the proximal phalanx. both EPL and EPB have been severed. EPL can also act as an accessory extensor of these joints. like other superficial tendons. radial abduction will be unaffected as APL has not been injured. The long tendon of EPL runs obliquely across the back of the hand after angulating around the tubercle of the radius (Lister tubercle) before inserting into the base of the distal phalanx. This stout tendon. The digital cutaneous nerves have not been cut and distal sensation is normal apart from tenderness around the cut. By passing across the metacarpophalangeal (MP) and carpometacarpal (CM) joints of the thumb. from radial to ulnar side).Sample . APL is the prime mover of radial abduction and extension of the thumb at the carpometacarpal joint. EPL.Condition 001 Performance Guidelines COMMENTARY The knife cut has severed the two extensor tendons to the left thumb {extensor pollicis brew's and extensor pollicis longus. In this patient. Extension of the joints of the thumb occurs from the actions of: • Extensor pollicis longus (EPL) the ulnar-sided of the two thumb tendons running on the dorsal aspect of the thumb. • Abductor pollicis longus (APL).

Normal Anatomy — Left hand and thumb The Examiner mark sheet for MCAT 001 follows.Sample . 043 .Condition 001 Performance Guidelines CONDITION 001. FIGURE 2.

□ □ □ [11 Serious errors or omissions in findings: reported findings not consistent with physical signs CRITICAL ERROR? Diagnosis not given. Optimal management plan. □ □ □ □ □ Unsatisfactory .significant errors of technique . well organised. CRITICAL ERROR? Serious errors or omissions in the answers given. Diagnosis inappropriate to the . oo Minor errors in answers to questions. GO O OVERALL RATING FOR THIS CANDIDATE FOR THIS STATION: PASS FAIL 044 . § 1 n ni — in O O •-. explanations of findings. or errors in explanations of findings.Candidate ID card sighted *-■ KEY ISSUE Choice & Technique of Examination.PASS Covers all essential aspects competently . Very poor organisation. Unclear and poorly organised. Clinical reasoning and diagnostic skills markedly deficient.FAIL Serious errors or omissions in technique. minimal errors or omissions. Serious omissions or errors in interpretations of findings. Minor errors in findings. CRITICAL ERROR? n X ZS cp o Tl Covered all essential Minor omissions Significant errors in aspects competently . Very Unsatisfactory . Significant errors in answers to questions indicating lack of in knowledge/expertise these areas.minimal errors or omissions. □ □ □ □ □ Satisfactory .PASS Minor technical faults but examination completed reasonably. Minor errors but did not interfere with an adequate initial management plan. Organisation and Sequence Did the candidate carry out an appropriate focused and relevant examination as per examiner instructions? •-■ KEY ISSUE Accuracy of Examination Did the candidate identify the physical findings accurately as per examiner instructions? •^ KEY ISSUE Diagnosis/Differential Diagnosis Did the candidate formulate and describe an appropriate diagnosis/ differential diagnosis as per examiner instructions? Very Satisfactory . clear.minimal errors or omissions. CRITICAL ERROR? T U) X < CD T 3 n 1 A 1 II X— 3 -i ^+ ( 1 A i1 o rr Identified most or all findings accurately.minimal or no errors or omissions. Significant errors which did interfere with an adequate management plan. Covered all aspects completely. KEY ISSUE Initial Management Plan Did the candidate formulate and describe an appropriate initial management plan as per examiner instructions? Answers to Questions Answers to questions asked by examiner? Covered all essential aspects competently . Wrong interpretations of findings. Wrong diagnosis could result in serious harm to the patient.ase. Logical. or complete unfamiliarity with the subjects asked.FAIL Candidate displays one or more of the following: .poor technique One or more significant errors in findings. Inappropriate management and/or management proposed is potentially harmful to patient. Diagnosis and differential diagnosis appropriate to the case even if not completely accurate.significant omissions . CRITICAL ERROR? Serious errors or omissions.

In these situations the patient's legal right to commentaries. English is not the first language for many IMGs. during affect either patient or doctor. auditory level. Impaired hearing may consultations. but are less readily assessed within the current AMC format. 15 March 1884. The AMC examination process places considerable emphasis on assessment of effective communication between candidate and patient during clinical consultations. Punch Cartoon. mute. Verbal communication depends on a mutual understanding of the language being used and the way it is articulated. I don't know much about his ability. ideas. The AMC examination assesses communication in the English language in a medical and clinical context. during discussions with relatives. 045 . speed. signals or writing. or outside agencies) requires the patient's case presentations and consent. Communication skills are employed to ensure that exchanges are readily and clearly understood. or effective communication when doctor and patient do not share the same language. COUNSELLING AND PATIENT EDUCATION Communication is the exchange of messages and thoughts by speech. Involvement of third parties (such as relatives. The role of the interpreter. friends. and during case presentations and commentaries. but he's got a very good bedside manner!' George du Maurier. Failure of communication is an important contributor to clinical situations of perceived malpractice and is the most important factor in a high proportion of medicolegal actions. Communication is the foundation on which medical consulting takes shape.Clinical Communication (C) 1-A: Communication. that's your doctor. This includes pronunciation. when discussions with required. Counselling & Patient Education Alan T Rose 'Oh. between candidate and Communication requires special techniques with patients who patient during clinical are blind. 1-A COMMUNICATION. is it? What sort of a doctor is he?' Well. confidentiality and privacy must be respected. is also critical. and during relatives. aphonic or aphasic.The AMC examination Exceptions are when the patient is an infant or is intellectually process places handicapped — communication is then with a relative or carer — considerable emphasis or when the patient is unconscious (including when on assessment of anaesthetised) or suffering from certain psychotic states. tone and the unique voice qualities and cadences of the speaker. emotions. supplemented by the practitioner's skill in physical examination and diagnostic reasoning. Exchanges involve the sharing of information. and empathy. Written communications are important for letters of referral and discharge summaries. but all IMGs are required to have adequate clinical communication skills in English by medical registration boards. Most medical consultations and activities require the doctor and patient to communicate rationally and effectively with each other.

History-taking There are two main methods. Similarly. 046 . Doctors practising in Australia require multicultural competence across all fields of medicine. Firstly. Although apparent irrelevancies may be brought up. The application of communication skills Effective communication is of most value when taking a history. and emoting) by either doctor or patient. although important. or one interpreted as such. providing patient education about the condition diagnosed. and satisfactory compliance with advice and treatment. Good communication skills must be accompanied by sound clinical skills. and for culturally and linguistically diverse groups. this method gives an opportunity for patients to reveal concerns initially unstated. the patient can be daunted from further enquiry. If the doctor retreats behind a professional fagade of a stilted and portentous style of speech. are not sufficient. Other personal factors can interfere with the doctor's use of communication skills. The term 'bedside manner'. or adopts a pompous or pretentious attitude. This is especially important when treating users of illicit drugs or dependent alcoholics. The (fortunately) rare physician serial criminal murderers have usually been superb communicators. Rejection by the doctor of a patient's attitude or behaviour engenders lack of understanding and trust. These can be modified and improved by education and self awareness. posture. Many clinical realities are unpleasant to both patient and doctor. Care and compassion should be evident but not forced or obtrusive. These concerns may explain their real reason for attending and why they have come at this particular time. Effective verbal and nonverbal communication in medical practice facilitates the establishment of empathy and rapport.Nonverbal communication (such as facial expression. Communication skills. giving advice about treatment. attitudes and professional behaviour. used to describe a doctor's communication skills. Value judgements of the doctor are best avoided or concealed. Transition from one to the other occurs depending on the clinical setting and progress of this phase of the consultation. The aim is to define the presenting problem to a point where the diagnosis moves from possible to probable to definite. so that time is saved and any frustrations felt by the doctor or dissatisfaction by the patient are minimised. also conveys messages as well as influencing the understanding of what is being said and its emotional context. Mention should also be made of the so-called 'difficult patient' whose underlying but sometimes unrecognised personality disorder reduces or eliminates the effectiveness of the communication skills described below. mutual understanding. Wide variations in clinical communication skills occur because of each individual doctor's inherent personality traits and individual approach to patients. and when discussing the patient's illness with anxious relatives or friends. was first used in a London 'Punch' cartoon by George du Maurier. silence. Special care is required in the case of Aboriginal and Torres Strait Islanders. the cultural characteristics of the patient (and of the doctor) can profoundly affect the quality of doctor-patient communication. trust and confidence. the nondirective or 'open-ended' approach: this allows and encourages patients to outline the problem ('tell their story') in their own way while the doctor listens with little interruption. education about the clinical condition. gesturing. counselling patients.

Confrontation can defuse an issue ('Wouldn't we progress better if we leave aside for the moment your previous dissatisfaction with treatment and try to work out how best to fix things now?') but should be used with care. This is appropriate in emergencies and. Listening is an essential basis of communication. 'being run down'. or has feelings of shame or guilt. these techniques are modified by the personality and instinctive behaviour of the doctor. embarrassed.This approach is most useful when the patient is consulting the doctor for the first time about undifferentiated symptoms such as 'tiredness'. or 'requesting a checkup'. Nonverbal communication is very useful in the nondirective approach and can replace some parts of the verbal component. when a patient's progress is being reviewed in followup. Facilitation uses nonspecific inviting or encouraging remarks. Using questions about pain as examples: open ended 'Tell me about the pain?' direct Where Is the pain?' closed 'Have you had this pain before?' leading 'The pain isn't severe?' A series of direct or closed questions is usually necessary to complete the history regarding occupation. The type of question used will change the direction of the interview. Facilitation is also a valuable nondirective tool. particularly from a patient who is anxious. As previously noted. 'bloating'. This approach is well summarised by the traditional term — history 'taking'. for example. 7 see'. In summary. Transition from nondirective to directive mode occurs when the doctor begins to ask direct or closed questions. 'tell me more about the pain'. Adequate time must be given and the doctor's nonverbal behaviour should indicate to the patient that the listening is attentive. The doctor takes early control of the interview by the use of a series of direct or closed questions. or 'uh uh'. 'I'm listening carefully'. expressing surprise by facial expression. Silence is not the same as listening. the following guidelines apply to history 'taking' from a patient presenting with a nonurgent diagnostic problem. The directive approach risks the omission of significant information. reticent. but the two modes are usually phased or overlap. Frequently initial aggression or anger from the patient is better deflected in the first instance. domestic habits. The use of a personal computer by the doctor in the consulting room while taking a history requires. Secondly. past and family illness. that the doctor's nonverbal behaviour assures patients that they are being 'listened to'. if the problem has already been well defined. medications. allergies and sensitivities. 'anything else?'. where relevant. closed or interrogative approach: this confines the patient to the doctor's agenda. 'go on'. Summarising briefly what the doctor believes the patient has said so far is often useful to confirm that mutual understanding at that point in the interview is present. who may not always be fully aware of their effect on a patient. 'sleeplessness'. The perceptive doctor attempts always to appreciate the patient's perspectives as well as the doctor's own. the directive. 047 . Silence may be the best response when there is an emotional or confrontational component in the consultation. for example. more than ever. Note-taking should be discreet and avoid distraction.

• use direct and closed questions to take control at an appropriate time. to supplement verbal communication. sexually transmitted infection. anxiety may reduce the efficiency of absorbing and understanding information. With loquacious and garrulous patients. dissatisfaction with treatment and feelings of grief or guilt — to mention only a few. it should be stated to the patient using both medical and lay terminology appropriate to the patient's understanding. and what forms treatment will take. The patient's knowledge and understanding of the condition should then be established so that education can be pitched at the correct level. and also to assure the patient of the doctor's continuing support. whether it can be treated. • listen carefully and attentively. direct questioning is essential to enable a focused history to be taken within the time period available. • briefly summarise what is being learnt or understood (or not) from the patient. • gradually increase control of the interview as it proceeds. An adequate level of understanding is the only basis on which patients can share the responsibility of decision-making about treatment and give informed consent. This includes the correction of incorrect beliefs and responses to the patient's questions. • use facilitation and open-ended questions to encourage the patient. the doctor should: • begin with an open-ended approach. even though these questions may not be asked directly. • take note of any display of emotion by the patient and respond appropriately. Handing out previously prepared written material is helpful for most patients but is no substitute for verbal education from the doctor. Communication skills are especially important when the patient has concerns other than those expressed in the first statement to the doctor. when they will recover and resume normal activities. Reassurance may be the only therapy that is necessary — unnecessary prescribing may follow if the doctor has not understood this basic need of the patient for reassurance. Failure to do so may allow patient anxiety to block the reception of other information. Many patients 048 . relationships. • use nonverbal communication. In many of the MCAT clinical scenarios. diagram or of printed notes. The use of a chart. Most will want to know if the condition is serious. Such hidden concerns may include fears of cancer. may be additionally helpful. Further information can be added at a subsequent consultation. serious illness in an unborn child or infant.Following the formalities (or informalities) of introduction. work capacity. heart disease. Initial reassurance should be given when appropriate ('I'm pleased to tell you that the biopsy showed no evidence of cancer'). Adverse information should be given in such a way so as to not destroy hope. Patient education Once the diagnosis has been made. • use indirect and reflected questions as appropriate. transition from open-ended to direct questioning needs to proceed expeditiously but tactfully because of time constraints. and • be alert to the patient's nonverbal behaviour. Patients will also differ in their interest and tolerance of information about their ailments. stroke. blindness. As previously stated. • limit direct questions early in the interview. Overloading the patient with information can be counterproductive and have unwanted effects including the creation of pessimism and anxiety.

and providing support and reassurance whenever possible. one type usually predominates according to the clinical situation. All require the use of communication skills. prescribing. Nondirective counselling begins with an accurate definition of the problem using the skills outlined under nondirective history-taking. usually with special training in psychological skills. and what to expect when a referral has been made.however still prefer to leave all decisions to the doctor. confrontation can be used to bring to the attention of patients their own responsibilities in aiding effective treatment. based on the options that have been discussed. This may involve other members of the patient's family. nondirective counselling is a special communication skill which involves more than patient education or giving advice about treatment. nonverbal. which may be indicated. Patients will also wish to know general details about any procedure which has been recommended. Neglect of these can have medicolegal consequences. It is essential for the doctor to maintain a nonjudgmental attitude throughout the process. Patients are then asked what course they intend to follow. is the final decision-maker and shares or accepts. additional special skills are required. Counsellors. However. The doctor then provides education about the problem including possible outcomes that are likely to follow alternative forms of behaviour or non-compliance by the patient. Doctors frequently need to give 'bad news' to patients and relatives. and are involved with bereavement and grieving responses. 049 . the dose and timing. which may also be written down for the patient. Certainty about followup arrangements. Allowing patients and relatives to work through their feelings by means of facilitation and attentive listening. Its objective is that the patient. Giving advice about treatment The wide ranges of treatments. Directive counselling is when straightforward advice or instruction are given to the patient. particularly after investigations or referral. either verbal. referral to another doctor or to a hospital service. there are two types: directive and nondirective. However. Patient Counselling Counselling is a term widely used in the community to describe the provision of support to individuals or groups who are experiencing significant emotional stress. when 'patient counselling' is used in treatment. expected effects including the most important side effects. Patients should not be left wondering what happens next. include giving simple advice. The process may occur rapidly or may take more than one consultation to work through. instead of the doctor. the use of allied health professional services. and significant adverse reactions. is required every day in clinical practice. attend survivors or observers of accidents and disasters and provide support. with unforced compassion and sympathetic understanding. If thought necessary. or written. should be made quite clear. The duration of intended treatment should be advised to the patient and opportunities for giving preventive advice taken whenever appropriate. in part or fully. particularly listening and the use of silence. In contrast. and counselling. Prescribing should be supported by a statement of the name of the medication. When counselling is the main component of treatment. responsibility for the subsequent course and outcome of the problem. minor or major procedures. As with other communication skills these may overlap or be used in an integrated way.

heavy drinking. using language that the patient understands (no jargon). and • Presenting a case analysis in summary to the examiner. and Obtaining verbal consent to proceed. Experienced examiners. Initial management plan • Describing an appropriate initial management plan. Other domains are usually assessed in sequential segments (for example physical examination follows history. counselling has shortcomings as do other techniques. have no difficulty in integrating communication components with those of knowledge and attitudes and other clinical skills.This skill is most useful in dealing with difficult behavioural problems such as smoking. but is always worth using — results can be surprisingly effective. parent or relative. marital problems and when dealing with anxious parents. who are themselves skilled in communication. eating disorders. and • Some scenarios have specific prompts or questions from the examiner. and so on). Diagnosis/differential diagnosis • Describing an appropriate diagnosis/differential diagnosis plan. Explanation of procedure • Explaining a procedure and its implications to the patient. Explanation. comfort. History • Taking an appropriately focused medical history. consideration. Commentary to examiner • Describing the findings of physical examination with appropriate commentary. drug use. Particular communication skills are also defined within the domains in current use in the AMC examination. Assessing communication skills Communication skills are assessed continuously throughout the whole of every case scenario and consultation. parent's or relative's questions. Answering patient's. 050 . diagnosis follows investigations. Patient counselling/education • Educating the patient/relative/carer about the condition. These are: Approach to patient • • • • • Empathy. Communication skills may affect performance in all domains. Checking for patient understanding. When the use of addictive substances is involved. and • Giving appropriate counselling. The number of domains being assessed in any individual MCAT rarely totals more than five. Each of the above domains (plus others such as technique and accuracy of examination 14 in all) attracts separate assessment by the examiner. Answering questions asked by the patient or examiner • Most scenarios include cued questions to the doctor by the patient.

patient compliance. patient education and understanding. as a result of the proper application of communication skills. empathy and rapport. diagnostic precision. The establishment of trust and confidence. and self-help lifestyle modifications are all facilitated when doctor and patient understand each other to an optimal level. Alan T Rose 051 . Counselling & Patient Education Conclusion The effectiveness of virtually all consultations is enhanced by the doctor's understanding and use of communication skills.Communication. appropriate prescribing.

Counselling and Patient Education Candidate Information and Tasks MCAT 002-021 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman Advice on neonatal circumcision for a couple expecting their first child Suspected hearing impairment in a 10-month-old child Counselling a family after sudden infant death syndrome (SIDS) Hair loss in a 38-year-old man An unusual feeling in the throat in a 30-year-old man Pain in the testis following mumps in a 25-year-old man Contraceptive advice for a 24-year-old woman Rape of a 20-year-old woman Cancer of the colon in a 60-year-old man Thalassaemia minor in a 22-year-old woman Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida A duodenal ulcer found on endoscopy in a 65-year-old man Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery Advice on stopping smoking to a 30-year-old man Excessive alcohol consumption in a 45-year-old man Type 1 diabetes mellitus in a 9-year-old boy Request for vasectomy from a 36-year-old man 052 .1-A Communication.

the wife pregnant with their first child. • Outline the steps involved in safe formula-feeding. but her mother told her recently that babies grow better with formula feeds. The Performance Guidelines for Condition 003 can be found on page 72 ] J 053 . She has heard a lot about the benefits of breastfeeding. She wants to discuss infant feeding with you. The Performance Guidelines for Condition 002 can be found on page 69 Condition 003 Advice on neonatal circumcision for a couple expecting their first child CANDIDATE INFORMATION AND TASKS A young couple. YOUR TASKS ARE TO: • Discuss the advantages and disadvantages of breast-feeding and formula-feeding with her. YOUR TASK IS TO: • Discuss with the couple the perceived risks and benefits of this procedure.002-003 Candidate Information and Tasks Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in an antenatal clinic. seeing a 28-year-old woman for her antenatal visit at 35 weeks of gestation. She is uncertain whether she should breastfeed or formula-feed her baby. have come to see you in a general practice to discuss with you the place of routine neonatal circumcision if their baby is a boy.

The pregnancy and delivery were normal. apart from a few upper respiratory infections. baby Helena. • Discuss your plan of management with the parent. She is crawling. does not walk yet. She babbles during assessment. seen with her mother. The Performance Guidelines for Condition 004 can be found on page 75 054 . YOUR TASKS ARE TO: • Ask the parent for additional relevant and focused history. Initial examination findings A busy infant girl who objects to being restrained by her parent. Otoscopic examination is normal. but pulls herself up to standing beside a small table. • Counsel the parent after you have obtained a further history. The parents are puzzled at the need for referral and seek information about further investigation and management. She is the third child in a healthy family and has been well. Your next patient is a 10-month-old female infant. The child presented to the nurse six weeks ago for review and general screening including hearing. The child's parents have never had cause to worry about her hearing.Candidate Information and Tasks Condition 004 Suspected hearing impairment in a 10-month-old child ( CANDIDATE INFORMATION AND TASKS ) You are working in a community health centre. who has been referred by the local child health nurse. No abnormal physical signs are present on general examination. The nurse was concerned that the baby has a hearing problem and wanted her checked by a doctor. • Explain possible causes of any suspected hearing loss to the parent.

The provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a Coronial autopsy. and his mother had advised you that he appeared normal and fed well from the breast just prior to his death. when he was thriving and developing normally and had commenced immunisations. over the next two days he apparently improved. • Counsel the aunt and family. Two days before his death you saw him again. this time with mild upper respiratory snuffles which were causing minor difficulties with breastfeeding. YOUR TASKS ARE TO: • Answer the questions of the aunt relating to the death of the infant. However. but is too distressed to ask any questions herself. You are unaware of any suspicious circumstances surrounding the death. You are counselling the family of a four-month-old male infant who was rushed to the Emergency Department of the local hospital the day before but was dead on arrival. The mother is also present. You had seen him for the first time two months previously. with his single mother.Condition 005 Counselling a family after sudden infant death syndrome (SIDS) CANDIDATE INFORMATION AND TASKS 1 You work in a general practice. The family members have attended to seek details of why the baby died and why an autopsy is necessary. The Performance Guidelines for Condition 005 can be found on page 77 055 . the aunt of the infant. The spokesperson for the group is the mother's sister.

The Performance Guidelines for Condition 006 can be found on page 79 056 . CONDITION 006. This 38-year-old male newsagent has just consulted you about recent (2-3 weeks) hair loss from the scalp. • Advise him about treatment. The findings are as depicted below. YOUR TASKS ARE TO: • Discuss the condition with the patient. You have completed an examination of the scalp. He is otherwise well with no significant past or family history. The patient is very concerned about possible future progression and wishes to ask you about the diagnosis and possible treatments. FIGURES 1 AND 2. One eyebrow is also affected.Candidate Information and Tasks Condition 006 Hair loss in a 38-year-old man CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital.

what is most likely to be found. YOUR TASKS ARE TO: • Take a focused history about his throat problem. He smokes 10-15 cigarettes daily and takes 2-3 alcoholic drinks only at weekends. . is married with two children. The Performance Guidelines for Condition 007 can be found on page 81 057 . • Discuss whether any investigations are necessary and if so. He is a previous patient of the clinic.Condition 007 An unusual feeling in the throat in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. He had a vasectomy two years ago and has had no serious illnesses. The examiner will then give you the examination findings. Your next patient is a 30-year-old man who is consulting you about a throat problem. • Discuss the most likely causes of the problem and its nature with the patient. parents and his siblings are well.

Advise the patient of the appropriateness of oral contraceptive pill (OCP) therapy. You had previously diagnosed mumps in the patient's five-year-old son. YOUR TASKS ARE TO: • • • Take a further relevant and focused history. The patient's other child. His face is slightly swollen. The patient has come to see you today because of a relapse of his fever associated with the onset of severe pain in his left testis. She knows that various types of pills are available and wants to know how to decide which is the most appropriate pill for her. It is very tender. Apart from a tachycardia.4 °C. YOUR TASKS ARE TO: • • • Advise the patient of the diagnosis. A 24-year-old woman has come to see you for advice as to the most appropriate pill she should go on for contraception for the next two to three years. The son has now fully recovered. The Performance Guidelines for Condition 009 can be found on page 87 058 . and asked him to see you in a few days time before returning to work. Ask the examiner about findings you wish to elicit on general and gynaecological examination. You are aware that the couple have contemplated having another child. is well. Answer any questions asked by the patient. The Performance Guidelines for Condition 008 can be found on page 84 Condition 009 Contraceptive advice for a 24-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. suggested paracetamol as an analgesic.008-009 Candidate Information and Tasks Condition 008 Pain in the testis following mumps in a 25-year-old man CANDIDATE INFORMATION AND TASKS Your next patient in a general practice is a 25-year-old man who consulted you five days ago because of painful swellings on both sides of his face associated with fever and malaise You made a confident diagnosis of mumps. which pill should be given. a little less than three weeks beforehand. The patient has a temperature of 38. aged three years. You have found the left testis to be swollen to twice the size of the right one. The right testis feels normal. there are no other abnormal clinical signs. Advise him about treatment and prognosis. You advised the patient to rest at home. and how it should be administered.

She has decided not to involve the police as the person concerned is known to her family. The Performance Guidelines for Condition 010 can be found on page 90 059 . Your patient is a 20-year-old university student who is brought to the Emergency Department of the hospital because she was raped by a man that she met at a disco and who offered her a lift home. • Advise the patient of the investigations required and the management you would propose.Condition 010 Rape of a 20-year-old woman CANDIDATE INFORMATION AND TASKS J You are a Hospital Medical Officer (HMO) in the Emergency Department of a metropolitan general hospital. • Ask the examiner about appropriate findings likely to be evident on initial general and gynaecological examination. YOUR TASKS ARE TO: • Take any further relevant history you require. She has had no previous operations or illnesses and no pregnancies. The rape occurred six hours ago after he had stopped the car in an undeveloped area.

However. The patient insists he has no symptoms and refuses to have any operative treatment. he is still concerned enough to ask you what will happen if nothing is done. whose father died of colon cancer. The Performance Guidelines for Condition 011 can be found on page 92 060 . Clinical notes: Biopsy of ulcerating tumour of rectosigmoid at 15 cm from anus. what complications may develop and how they would be treated.Candidate Information and Tasks Condition 011 Cancer of the colon in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. A 60-year-old man. CONDITION 011. You are not required to take any further history. • Address his concerns and counsel him about surgery. and would the surgery ever entail having a colostomy (which he dreads)? YOUR TASKS ARE TO: • Advise him what symptoms and signs may occur in the future.' Diagnosis: Adenocarcinoma of colon. FIGURE 1. This revealed a lesion shown in the photograph given to the patient (see illustration below). Biopsy report: The specimens show numerous fragments of a moderately well differentiated adenocarcinoma of the colon with invasion into the submucosal tissues. consults you following a screening colonoscopy. The biopsy report confirms an adenocarcinoma of the colon. The patient also wishes to know what are the prospects of cure if he changes his mind and has the lesion removed by surgery. The specialist who did the colonoscopy said the lesion was on the left side of the colon.

but the full blood examination showed a hypochromic microcytic anaemia of 108 g/L. Your next patient is a 22-year-old woman who recently had a self-limiting febrile illness. One of her father's brothers was reported to have died in childhood from an unknown cause. You suspected /j-Thalassaemia minor ('Mediterranean anaemia') and this has been confirmed by electrophoresis which showed an elevated Hb H2 level (4. Blood tests for IM were negative. The family history is that her mother. The mean corpuscular volume (MCV) was below normal (68 cubic microlitres — normal 80-101). The patient has returned to discuss her results with you. Serum iron and ferritin estimations were also normal. • Answer the patient's questions. father and brother are all alive and well. You are aware of her Greek descent and that she has just become engaged to be married. • Advise the patient what should be done now.3%).Candidate Information and Tasks Condition 012 Thalassaemia minor in a 22-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. Her fiance is also of Greek descent. The Performance Guidelines for Condition 012 can be found on page 95 061 . The patient is very worried about being told she is anaemic. She is now fully recovered. and as she is to be married shortly. which was suspected to be infectious mononucleosis (IM). You followed this up but there was no evidence of chronic blood loss (other than normal menstruation). YOUR TASKS ARE TO: • Explain the nature of the condition to the patient. is worried about the effects on any of the children she hopes to have. Her grandparents died in Greece and both were very old.

YOUR TASKS ARE TO: • Take any further relevant history you require from the patient. Your patient is a woman aged 24 years (para 0. The Performance Guidelines for Condition 014 can be found on page 102 062 . The Performance Guidelines for Condition 013 can be found on page 99 Condition 014 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus CANDIDATE INFORMATION AND TASKS You are working in the primary care facility of a teaching hospital. • Advise the patient on the management she will require before and during the next pregnancy. At the time of a previous assessment twelve months ago. which was complicated by deep vein thrombosis and a postpartum pulmonary embolus. • Advise the patient of the information she needs to be given for pre-pregnancy counselling. YOUR TASKS ARE TO: • Take any further relevant history you require. When assessed six months ago. there were no sequelae or symptoms and she had no signs of chronic venous insufficiency in the legs. She has come to see you for pre-pregnancy counselling as she wishes to conceive again. There are no abnormalities on physical examination and she is not overweight. who had one pregnancy 18 months ago.013-014 Candidate Information and Tasks Condition 013 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism CANDIDATE INFORMATION AND TASKS You are working in a general practice. she had ceased warfarin. a known diabetic for 15 years and well controlled on insulin. gravida 0). Your next patient is a 28-year-old woman. She has come to see you for counselling and advice about possible future pregnancies.

nor to arrange any further investigations. CONDITION015. You will not be expected to request examination findings. • Advise the patient. YOUR TASKS ARE TO: • Take any further relevant history.Candidate Information and Tasks Condition 015 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) working in a primary care clinic attached to a teaching hospital. of the relevance of the diagnosis and the subsequent management you would propose in this pregnancy. • Advise the patient of the care you would recommend in a subsequent pregnancy. in lay terms.FIGURE1. Your next patient is a 25-year-old primigravida who has just had an ultrasound performed at 18 weeks of gestation. which has revealed an anencephalic fetus (as shown in illustration below). A maternal serum screening (MSS) was done at 16 weeks and this had shown elevated levels of alpha fetoprotein. Anencephalic fetus at 18 weeks of gestation The Performance Guidelines for Condition 015 can be found on page 105 063 .

FIGURE 1. You recently referred a 65-year-old man with a history of self-medication for arthralgia and a subsequent six week history of epigastric pain and indigestion to a gastroenterologist who performed an upper gastrointestinal endoscopy. The Performance Guidelines for Condition 016 can be found on page 108 064 . The patient has come back to you seeking answers to several questions. CONDITION 016. ~ natural history and possible complications of the condition. The photograph is as shown. The endoscopist told the man he had detected a duodenal ulcer and gave him a photograph of the ulcer. YOUR TASKS ARE TO: • Discuss the endoscopic findings with the patient in terms of the: ~ pathogenesis of the ulcer. and ~ treatment options available to him. taken during endoscopy.Candidate Information and Tasks Condition 016 A duodenal ulcer found on endoscopy in a 65-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice.

you had told him that the 'best thing that he could do for his health would be to stop smoking'. The patient wishes to discuss this with you. YOUR TASKS ARE TO: • Assess his motivation to stop smoking. On his previous visit. The next patient is a 30-year-old man who has returned to your practice for followup following a recent chest infection.017-018 Candidate Information and Tasks Condition 017 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery CANDIDATE INFORMATION AND TASKS You are working in a general practice. • Discuss treatment options and general resources. • Answer any questions from the patient about the blood transfusion procedure. The patient has now come back to see you. as he has some questions and in particular. you are expected to follow up his response to your previous advice and counsel him further about tobacco cessation. The Performance Guidelines for Condition 018 can be found on page 115 065 . • Counsel him appropriately. Your next patient is a middle-aged man booked for a total hip replacement. At this visit. as he did not take in everything that was explained by the surgeon. You have examined his chest which is clinically normal. You referred him to an orthopaedic surgeon who has arranged elective surgery for his severely osteoarthritic hip. • Respond to any questions he may have. YOUR TASKS ARE TO: • Explain the principles and indications for preoperative blood collection and intra operative autologous blood transfusion. He is a smoker (20 cigarettes per day). The Performance Guidelines for Condition 017 can be found on page 111 Condition 018 Advice on stopping smoking to a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. is concerned about the risks of blood transfusion (if required) and would like to find out about using his own blood for the operation.

You told him that his use of alcohol appears to be excessive and you ordered liver function tests and a full blood examination. at work and socially. hypertensive 180/90 mmHg. At the previous consultation you established the following: • He is drinking excessively (at least five standard drinks every day). • He has a family history (grandfather) of alcoholism. • His sexual performance is impaired. • He has problems at work. • This is of long standing — at home.Candidate Information and Tasks Condition 019 Excessive alcohol consumption in a 45-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. • He has had two minor traffic accidents in the last year. You do not need to take any further history. and has hepatomegaly. You are about to review a 45-year-old businessman who consulted you two days ago about his drinking after seeing a TV program about the harmful effects of alcohol. He is seeing you today for the results of the tests which are as follows: Liver Function Tests Bilirubin Total ALP (Alkaline phosphatase) AST (Aspartate transaminase) GGT (Gamma glutamyl transaminase) Serum albumin Full Blood Examination This showed a normal haemoglobin level (145 g/L) with a macrocytosis and elevated mean corpuscular volume (MCV) of 106 fL (normal range 10-96) and some variations in red cell size and shape (anisocytosis and poikilocytosis). • Counsel him about his drinking. • Discuss the effects of the excessive alcohol consumption. The Performance Guidelines for Condition 019 can be found on page 121 066 . nor perform any examination. and • On examination he is overweight (BMI 28 kg/m2). Other features were normal. 14 umol/L 50u/L 45 u/L* 63 u/L* 32g/L (<20) (25-100) (<40) (<50) (32-45) YOUR TASKS ARE TO: • Explain the results of the tests to the patient. • He has trouble with his close family relationships.

and • He is not on any medication. He is asymptomatic across all his body systems. Physical examination is normal. related to the ongoing care of Roger's diabetes. as are his wife and two children. The Performance Guidelines for Condition 020 can be found on page 125 Condition 021 Request for vasectomy from a 36-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. • He is a senior constable in the police force. • His mother. including his scrotum. father and brother are well. This is his first presentation of insulin-dependent Type 1 diabetes mellitus. As the Ward HMO. There are no marital problems of any kind. His general condition is satisfactory. YOUR TASKS ARE TO: • Explain the sterilisation procedure and its consequences to the patient. • Answer the patient's questions and provide counselling accordingly. YOUR TASK IS TO: • Answer the queries the mother has. You have already obtained the following patient details: • He has been married for 12 years and has two children (a boy aged seven and a girl aged nine years). and he has already commenced insulin therapy and has stabilised with good blood sugar control. testes and penis. You have enquired about his past medical. He is not overweight. is admitted to the paediatric unit to which you are the Hospital Medical Officer (HMO). urinalysis normal. does not smoke but is a moderate alcohol drinker (three standard drinks a day).020-021 Candidate Information and Tasks Condition 020 Type 1 diabetes mellitus in a 9-year-old boy CANDIDATE INFORMATION AND TASKS A nine-year-old boy. family and social history (see below). You are seeing a man aged 36 years who indicates that he wishes to discuss vasectomy with you. Blood pressure is 120/70 mmHg. The Performance Guidelines for Condition 021 can be found on page 129 067 . • He has no known drug sensitivities. not requiring intravenous resuscitation. You believe that he is in good physical health. his mother has asked you for further information about his ongoing care in relation to his diabetes from now on. There is no need for you to take any additional history from the patient. Roger.

Counselling and Patient Education Performance Guidelines MCAT 002-021 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman Advice on neonatal circumcision for a couple expecting their first child Suspected hearing impairment in a 10-month-old child Counselling a family after sudden infant death syndrome (SIDS) Hair loss in a 38-year-old man An unusual feeling in the throat in a 30-year-old man Pain in the testis following mumps in a 25-year-old man Contraceptive advice for a 24-year-old woman Rape of a 20-year-old woman Cancer of the colon in a 60-year-old man Thalassaemia minor in a 22-year-old woman Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida A duodenal ulcer found on endoscopy in a 65-year-old man Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery Advice on stopping smoking to a 30-year-old man Excessive alcohol consumption in a 45-year-old man Type 1 diabetes mellitus in a 9-year-old boy Request for vasectomy from a 36-year-old man 068 .1-A Communication. Counselling & Patient Education 1-A Communication.

doctor?' Questions to ask if not already covered: • 'What are the advantages of breastfeeding? I would have thought it is easier to breastfeed. You have come to discuss this. rather asking 'Why do you think your mother made such a recommendation?' • Discuss that while breastfeeding is the optimal method of feeding the human infant. What do you think. ~ failure to establish lactation. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 28-year-old mother having your first baby. It also tests ability to discuss logically the advantages and disadvantages of the different feeding methods as well as testing knowledge on safe bottle-feed preparation. against the ideas of your mother with whose opinions you have to live.g. including: ~ illness in the mother. ~ possible illness in the baby (e. You realise that you may have to defend what the doctor says to you (about breastfeeding being advantageous). and your own previously held ideas about breastfeeding. 069 .' • ‘Is there anything special about breast milk? I always thought there was. Opening statement 'My mother feels that bottle-fed babies gain more weight than breastfed babies and therefore are more healthy. and that the majority of mothers successfully breastfeed. while knowing that this advice is contrary to her own feelings. avoiding comments like 'Where on earth did your mother get such an idea?'. which may be hormonally based. a variety of reasons may prevent breastfeeding in practice.' • 'Do you have to prepare bottle feeds in any special way?' • 'Are the formula feeds safe? I thought they contained cow's milk and what if you are allergic to cow's milk?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Be nonjudgmental. You now have only five weeks to go and although you always hoped to breastfeed your infant. This scenario tests the candidate's ability to identify the conflict the young mother has in trying to respect what her mother has told her. cleft palate).002 Performance Guidelines Condition 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman AIMS OF STATION To assess the candidate's ability to advise a young expectant mother on the advantages and disadvantages of breastfeeding and bottle-feeding. you have had some doubts about its value recently when your mother mentioned that formula-fed babies grow better than babies who have been breastfed.

from immunological constituents in breast milk including lymphocytes and antibodies. • Satisfactory explanation of the advantages and disadvantages of the different methods of feeding. and any excess discarded at the end of the feed. which can be harmful. ~ bottles and teats need to stored in solution (e. Discuss that formulas are designed to contain the same nutritional components as breast milk. ~ the fluid used to make the formula and to rinse the bottles should be cooled boiled water.002 Performance Guidelines • • • • ~ prematurity. the day's feed should be stored in the refrigerator. formula-feeding is a safe and very effective alternative.g. Discuss the specific advantages of breastfeeding: ~ the practical advantages of being able to feed almost whenever and wherever the baby wants it without having to prepare formula. ~ there is no place for any added scoops. If the former. which requires the mother to express regularly to maintain her supply. The candidate should stress the importance of optimal formula-feeding as follows: ~ sterility in preparing the bottle feeds is essential. and ~ heightened anxiety in the mother. Milton®). • Recognition that she is uncomfortable with what her mother has told her but is seeking reassurance and support for her own view which she feels is accurate. • Candidates should know how formula feeds are prepared. advise that weight gain is not the only criterion for success as excess weight gain in the first 12 months of life may in fact be detrimental in later life. ~ previous extensive breast surgery in the mother. • In response to her mother's comment. and ~ satisfaction derived from feeding the infant as well as the development of a close relationship with the infant. if followed these will produce the exact required concentration. although each feed can be made separately. 70 . ~ bottles need to be washed clean with a bottlebrush to ensure that all milk residue is removed. and ~ each feed should contain approximately 30 ml more than it is anticipated the baby may take. ~ only one day's feed at a time should be prepared in advance. Advise that there is no advantage of formula-feeding over breastfeeding. but that exact reproduction is difficult as the concentration and components of breast milk change throughout each feed. Explain that if for some reason breastfeeding is unsuccessful. to ensure continuing sterility. but the bottles need to be rinsed free of this solution prior to use. ~ increased resistance of the baby to infection. carry bottles around and without problems with sterility. ~ the day's requirements are best made up at the one time. KEY ISSUES • Empathic answering of this young mother-to-be's questions. ~ each can of formula has explicit makeup instructions on the side of the can or packet.

contraindications and techniques of infant feeding by breastfeeding and by formula-feeding is a requisite for all medical graduates as outlined and is an area where good communication skills are paramount.002 Performance Guidelines CRITICAL ERROR . indications. 071 .none defined COMMENTARY Ability to discuss impartially and accurately the relative merits.

Opening statement ‘We have come to discuss with you whether to have our baby circumcised. but can be selectively applied at a later age if this situation exists.003 Performance Guidelines Condition 003 Advice on neonatal circumcision for a couple expecting their first child AIMS OF STATION To assess the candidate's ability to give impartial advice about neonatal circumcision. Your family members have suggested that if the baby is a boy he should be circumcised. You have therefore come to discuss the process and learn what the advantages and disadvantages of the procedure are before making your own decision on the matter. and • realise that many are unaware of the actual process of circumcision and may ask for the procedure more as a ritual. You have no religious beliefs that dictate that circumcision must be done. and stress that the parents should consider the advantages and disadvantages of the procedure before making a decision. but some evidence suggests the risk of HIV infection is lessened by circumcision. the candidate would be expected to advise along the following lines: • The perceived advantages of routine neonatal circumcision commonly quoted are: ~ Reduced incidence of urinary tract infections (UTIs) in circumcised boys. routine general circumcision of all boys is not indicated to achieve this. • indicate that when religious grounds are stated as the reason for the procedure. ~ Reduction in the incidence of sexually transmitted infections (STIs) and HIV infection. these are generally respected. You are very unsure about this. The literature currently is divided on this issue. 072 .' Questions to ask unless already covered: • • • • • ‘What does the procedure involve?' 'What are the complications that can happen?' ‘What are the advantages of having it done?' 'Are there any times when it definitely should or shouldn't be done?' 'Has anyone looked into this in detail and come to any conclusions about it?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • give an impartial but informed explanation to the parents on the advantages and risks involved in routine neonatal circumcision. EXAMINER INSTRUCTIONS The examiner will have instructed the parents as follows: You are a couple who are expecting your first baby. While circumcision may assist the uncircumcised boy who is suffering recurrent UTIs. This remains a controversial point. During the discussion. as you cannot see any reason why circumcision is essential.

the candidate should indicate the appropriate care of the foreskin. and ~ if performed after six months of age.g. do not support routine neonatal circumcision. But poor penile hygiene associated with human papilloma virus infection is the major contributor in adults. epispadias). ~ inadvertent injury to the urethra. which is usually by about five years of age. • The candidate should be able to explain the procedure of circumcision and indicate that: ~ it is usually done under local anaesthesia. • Capacity to summarise that the recommendations of various national and international paediatric and paediatric surgical associations. and ~ inadequate expertise and facilities. . If asked. including septicaemia/meningitis (rare). ~ ulceration of the glans. haemophilia A). ~ sick infants.003 Performance Guidelines ~ Circumcision is indicated for phimosis or its prevention. ~ infection. • The recognised complications and disadvantages of routine neonatal circumcision should also be discussed and include: ~ haemorrhage. phimosis. Often. This is true only if all conservative methods of treatment have failed.2%—10%). The skill of the operator is obviously of paramount importance. not just in the neonatal age range. who have extensively reviewed the literature on the subject. ~ buried penis. The most common complication is haemorrhage. until the foreskin can be retracted easily. developing after birth. The complication rate has been estimated to occur with an incidence of between 1-5% (range 0. it is done under general anaesthesia. is secondary to inappropriate foreskin care and subsequent trauma and scarring. including jaundiced infants. ~ family history of a bleeding disorder or known recognised familial bleeding disorder possibility (e.anaesthetic complications. but these are figures at all ages. ~ chordee. ~ too much skin removed leading to unsatisfactory cosmetic appearance. • The candidate should also discuss the absolute contraindications to routine neonatal circumcision explaining each in turn: ~ hypospadias and other congenital anomalies of the penis (e. ~ Neonatal circumcision minimises the risk of subsequent development of carcinoma of the penis. and ~ secondary phimosis. 073 . KEY ISSUES • The ability to discuss in an unbiased manner the perceived advantages and disadvantages of routine neonatal circumcision. which is minimal. cancer being rarely seen in men who can retract and clean the foreskin.g.

They then request circumcision without any information about the procedure and hence the need for informed discussion to allow them to make a rational decision in the interests of their baby. The review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for neonatal circumcision as a routine procedure. the issue in the scenario is related to the secular trend towards routine neonatal circumcision of all males soon after birth. Unbiased up-to-date written material summarising the evidence should be made available to the parents. Circumcision in ancient Egypt Phimosis Many young parents are unaware of the issues involved and are often ill-informed by family members who recommend that their infant should have the procedure performed without any explanation as to although this tendency has reduced in recent times.003 Performance Guidelines CRITICAL ERROR . The Policy Statement on Circumcision from the Paediatric and Child Health Division of the Royal Australasian College of Physicians (September 2004) is recommended as an excellent summary with 78 references to the evidence for and against circumcision. but circumcision at any age. This has become more of a ritual rather than for any recognised medical indication.g. While circumcision for religious reasons has been done for many centuries. established phimosis in boys and men). 074 . However there are recognised medical indications for the procedure ( defined COMMENTARY This topic is one that has been controversial for many years. The decision should be left to the parents after a full and accurate discussion. CONDITION 003. This is available on the open website of the Royal Australasian College of Physicians under Policies (http://www. This scenario illustrates that medical practitioners are obliged to provide accurate information on the risks and benefits of routine neonatal circumcision and should attempt to avoid any personal bias. In fact there are many recognised complications of circumcision.racp. FIGURES 1 AND 2. not just routine neonatal circumcision.

You have been referred by the local childcare nurse for a suspected hearing loss in your daughter. you should ask — do you think further tests would help?' The candidate is expected to take a relevant history to determine if hearing loss may be present as suspected by the child health worker despite the good sign of babbling. and to provide succinct.004 Performance Guidelines Condition 004 Suspected hearing impairment in a 10-month-old child AIMS OF STATION To assess the candidate's ability to deal with suspected hearing loss in an infant aged 10 months and ability to appropriately counsel the parent. 075 . EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You have a 10-month-old girl called Helena. You and your husband are concerned as you feel baby Helena's hearing is normal. • Maternal problems in pregnancy — 'Were there any problems with the mother during pregnancy especially infectious diseases?' (none) • Perinatal problems — 'Were there any health problems with the baby during or soon after birth?' (none) • General development — 'Is the baby growing and thriving?' (satisfactory same as the other children) • 'Does the baby respond to sounds. Your responses to questions asked are outlined below. You will accept advice about referrals. accurate advice to concerned parents. the parents have noted no abnormalities in regards to her response to sound. The candidate should ask for history details as below (your response is indicated in brackets): • ‘Is there a family history of deafness?' (none). who have noted nothing amiss with her development or hearing. In regard to any of the above aspects. If referral is not suggested. including loud sounds?' (seems to hear them and respond) • 'Does the baby respond when called by her name?' (usually) • 'Does the baby turn towards the sources of the sounds?' (sometimes) • 'Does the baby respond to television?' (sometimes).

• Counselling with reference to early definitive screening for hearing. should be evaluated.004 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The history should cover most of the questions detailed above. features in the history which could be causative. is present to support this diagnosis. refer to appropriate specialist for further evaluation. Given a working hypothesis of possible hearing loss. COMMENTARY The candidate is expected to proceed from the cue of 'possible hearing loss' to assess whether other evidence. • Often it is the parents who recognise that there is something wrong. used in combination with appropriate knowledge-based clinical skills. • If there is a problem then the earlier the diagnosis the better. • Sensorineural hearing loss is less common but important to detect as early as possible. reassure and review hearing and early language development in about three months. However. • Distraction tests are only a screening tool and do not diagnose deafness. • Providing appropriate level of support and reassurance. 076 . such as failure to turn to sound. enquiry regarding features suggesting associated developmental delay is appropriate. The candidate should exhibit understanding for the parent's concern and provide guarded reassurance and support. KEY ISSUES • Appropriate history relevant to deafness. • If normal. the importance of early diagnosis and treatment of significant hearing deficit in this age group make referral for definitive diagnosis mandatory despite no other concerning features being present. The candidate should give the following advice: • Refer the child to a Paediatric Audiologist as soon as possible for more formal hearing assessment by an audiogram. In addition. The candidate should explain that: • Hearing loss is common in preschoolers — most cases are mild and transient due to conductive deafness from middle ear effusions. • Review following audiogram. Adequate communication skills in dealing with a concerned patient are essential. such as maternal illness in pregnancy. but the child health nurse is also a professional and her concerns must be followed up. • If abnormal. CRITICAL ERROR • Failure to refer for specialist assessment (audiogram) for definitive diagnosis. perinatal problems such as jaundice or drug administration.

apparently of SIDS. 77 . Many theories exist. the day before. but the child's history does not suggest this cause. Is there anyone we can talk to about this?' 'Should the snuffles have been treated?' EXPECTATIONS OF CANDIDATE PERFORMANCE Explanation of diagnosis The most likely cause of the child's death is SIDS. in a caring and sympathetic manner. Candidates should outline the statutory requirements (i. • the peak incidence occurs at about four months of age. notifying police and coroner). but none is proven. and • there are no certain causes known. overwhelming infection). The family members including the young single mother have attended to ask questions about the baby's death but the mother is still too distressed to ask them herself. You are the spokesperson of the family. EXAMINER INSTRUCTIONS The examiner will have instructed the relative as follows: You are the aunt of an infant who died. Andrew's snuffles were not a warning sign and there is no suggestion that any medical treatment would have influenced the outcome.005 Performance Guidelines Condition 005 Counselling a family after sudden infant death syndrome (SIDS) AIMS OF STATION To assess the candidate's ability in approach to the family and providing empathic counselling in this tragic situation of presumed sudden infant death syndrome (SIDS) where there are no suspicious circumstances. Explain that there can be other causes of sudden infant death (for example. Opening statement ‘We can't understand why Andrew has died!' Questions to ask unless already covered: • • • • • • ‘Why do the police have to be involved? Do they think my sister killed her baby?' ‘Why does he have to have an autopsy?' ‘When will we get further information and results of this?' ‘When can we arrange his funeral?' ‘We feel so alone.e. Candidates should explain what is known about SIDS along the following lines: • the frequency of SIDS has fallen from 1 in 500 live births to now approximately 1 in 1000.

• The Coroner will decide if an inquest needs to be held. which many Coroners are. COMMENTARY Empathy in communication is essential in these tragic circumstances. The caring practitioner will offer to keep contact with the grieving couple or parent until confident that this tragic event has been accepted. • Explain that tissues will be removed for further examination under the microscope. The caring practitioner will also offer to liaise with the Coroner on behalf of the parents. • Explain that the role of the Police Officer is to assist the Coroner — police are required to interview all people concerned including the baby's general practitioner.005 Performance Guidelines Immediate management following a death due to apparent SIDS — should be advised empathically as follows: • Explain that the police and the Coroner must be notified by law because Andrew's death was sudden and unexplained. 078 . and that autopsies are done by very experienced pathologists in an attempt to find out what causes SIDS. Liaise with support group in counselling the mother when results are available. All deaths under these circumstances must be reported to the Coroner and the police must take statements. • Offer to contact the Coroner later to obtain information on the initial findings after the autopsy has been performed or advise that the Coroner's office will contact the mother at a later date to giver further information. KEY ISSUES • Appropriate empathic explanation. • Offer to contact the local SIDS Support Group. • Explain the need for the autopsy in all cases. and to exclude other possible causes of death. but with SIDS this is generally not necessary. This is often the most distressing part of the process for young parents and should be explained carefully to the family why this process needs to happen by law. together with accurate knowledge of legislative requirements. • Offer to contact other family members for support for the mother. • Ability to explain the involvement of appropriate authorities and support groups. Future management Followup contact with family and with the Coroner/pathologist to confirm diagnosis. CRITICAL ERRORS • Failure to display empathy in counselling. if one is available. Several pathologists who perform these autopsies actually interview the parents themselves when the autopsy is completed. • Offering to arrange for continuing followup. and in this way is often able to receive preliminary reports if the Coroner is agreeable to them being released. • Failure to recognise and explain need for coronial notification and autopsy. contact and support with the family.

betamethasone dipropionate . Multiple injections are usually required. Past history is clear and there is no significant family history including baldness. The candidate should explain that: • Initial management is by topical medication which aims to stimulate hair regrowth. married. almost certainly alopecia areata. Become impatient if simple reassurance is the main advice given. 079 . The patient's questions should be answered directly with supportive explanation. You work long hours with the usual stress associated with running a small business. ~ Intralesional corticosteroid such as triamcinolone acetonide 10 mg/mL is useful for small areas on the scalp or eyebrows.006 Performance Guidelines Condition 006 Hair loss in a 38-year-old man AIMS OF STATION To assess the candidate's ability to deal with a cosmetic problem. Your general health is excellent and you do not smoke or use alcohol. with two children. and should explain the nature of the condition in such a way that the possibility of improvement or return to normal is emphasised but the natural history is unpredictable in individual cases. Any one agent should be used for 3-6 months before changing therapy. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 38-year-old male newsagent. for which treatment and prognosis are uncertain. Opening statement 'What is happening to my hair?' Questions to ask if not already covered: • 'Will I go completely bald?' • 'Will it improve?' • 'How long will it last?' • 'What can be done about it?' • ‘Is treatment effective?' • 'Should I see a specialist?' • 'Could it have anything to do with my glands? OR with my thyroid gland?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise that the patient has alopecia areata and is concerned about his appearance. The objective is to achieve patient understanding and acceptance of his condition based on correct information.g. You are concerned about the cause of the hair loss and are very anxious to have treatment and also to be assured of effectiveness of treatment. ~ Potent topical corticosteroid applied once or twice daily — e. You are worried about your appearance because of your contact with customers.05%. but otherwise have no social or family problems.

will eventually relapse.006 Performance Guidelines • • • • • ~ Topical dithranol applied once daily. ~ Topical minoxidil (5% lotion) applied twice daily in cases not otherwise responding (but has very limited effectiveness). verbal and nonverbal communication. Alopecia areata is a descriptive term for one or more discrete circular areas of hair loss. The condition is a chronically relapsing autoimmune disease with an extremely variable natural history. disguising the hair loss with a wig may be considered. CRITICAL ERROR . There may be a specific trigger such as a febrile illness or severe emotional stress (for example. Approximately 80% of patients. and good interpersonal skills should be displayed by the candidate. remain unaltered or enlarge and coalesce into alopecia totalis (whole scalp). Consideration of topical immunotherapy and ultraviolet phototherapy would require referral to a dermatologist. commencing at 0. the prospect of regrowth is diminished. the death of a family member). If the hair loss persists for years. as well as being honest and generating trust and confidence are particularly important in a chronically relapsing condition such as this which significantly affects the patient's appearance. 080 . Alopecia universalis is where there is complete hair loss from the whole body and is a variant of alopecia areata. Oral corticosteroids may be Mailed if topical treatment is ineffective. Less severe day-to-day stress is not considered to be a trigger. however. The aetiology is unknown. Patches on the scalp may regrow spontaneously.none defined COMMENTARY Alopecia is a generic term for hair loss. Some patients may require early referral for confirmation of the diagnosis and reinforcement of advice about the likely course. These areas can occur anywhere on the body including the beard area in males. sensitivity and perceptiveness. Appropriate language. but a family history is present in 20% of cases and there is a linkage with other organ-specific autoimmune diseases. • Place of topical and systemic treatment and prognosis. although the potential for hair regrowth always remains because the hair follicle is not destroyed. KEY ISSUES • Effective communication skills are very important in this case. • Showing empathy.5% increasing gradually to 2% (avoid eye contact). Followup arrangements should be made appropriately. In a case such as this scenario. tapering dosage downwards over two months. there is approximately a 33% chance of complete regrowth within six months and a 50% chance within one year. If the condition worsens. especially in females. The condition itself is stressful.

The examiner will have instructed the patient as follows: You are a 30-year-old man. EXAMINER INSTRUCTIONS Examiners should note that the scenario covers the initial consultation about the problem and that ongoing management is not being assessed.007 Performance Guidelines Condition 007 An unusual feeling in the throat in a 30-year-old man AIMS OF STATION To assess the candidate's ability to take a satisfactory history about globus pharyngeus disorder and to display perspective in selecting appropriate investigations. • you have excessive saliva. your voice can 'catch'. • you clear your throat repeatedly. There is: • no hoarseness of the voice. Opening statement ‘I keep getting a lump in my throat. usually until you go to bed. • no sore throat. there is definitely no difficulty swallowing solids or liquids which go down easily without discomfort. You smoke 10-15 cigarettes daily and only drink socially at weekends. 081 . happily married with two children. You are consulting the doctor about an unusual feeling in your throat. and • • • • it occurs mostly after your evening meal. and • your voice is otherwise unaffected. you swallow more often when you have it. and skill in counselling and educating a patient about the condition. cough or nasal discharge or discharge from the back of the nose into the throat (called postnasal discharge). Your parents and siblings are in good health and apart from vasectomy two years ago. it was very bad and you vomited. answer as follows: the feeling lasts 3-4 hours. • a few days ago. It feels like a knot. and your eyes water. • when your throat tightens. You have become concerned since the recent vomiting episode. Over the last 4-6 weeks you notice that: • your throat tightens up. You have had no previous worry about your health and you have no idea what the nature of your complaint is. if questioned.' Provide more information as follows: Without prompting: Present your symptoms in a straightforward manner. your past medical history is clear. but you now wish to have it thoroughly investigated.

there is a list of much less likely differential diagnoses for this patient. wife and children. His death is still on your mind. • no aggravation of symptoms brought on by lying down. You used to be close as children. as well as the thought of cancer at times. • are conscientious and hardworking but not a worrier. • believe you are in good health. • have no past history of anxiety or other psychiatric illness. You were upset by his death. You should now discuss the problem with the patient as stated in your tasks'. • never take time off work. ~ Bronchoscopy is not indicated. Other than gastrooesophageal reflux. any disturbance in general health and to reveal the patient's concerns about the cause of his cousin's death. chest pain or dizzy spells. appetite change. and You: • sleep well. EXPECTATIONS OF CANDIDATE PERFORMANCE • The focused history is expected to exclude dysphagia and hoarseness. have no other symptoms and do not take any medications. • Choice of investigations: ~ Laryngoscopy and pharyngoscopy must be done. ~ Chest X-ray with thoracic inlet views and barium swallow are acceptable. but no more than you would expect for normal grief. palpitations. • do not feel depressed or anxious. Alternatively. • feel fit. three months ago. • The diagnosis of globus disorder (subject to laryngoscopy) should be made. abdominal pain or regurgitation (water brash). and you grew apart. • have no particular worries about your everyday life. Examiners should use their discretion in assessing how the candidate describes this functional disorder to the patient. A cousin died from cancer of the larynx.007 Performance Guidelines • no loss of weight. but have felt annoyed in the past few months when having to work weekends — you feel you should be with your family. 082 . ~ Upper gastrointestinal endoscopy may be suggested for reassurance. but may not be directly stated to the patient. If the doctor reassures you without discussing the possibility of any investigations say: 'You don t seem to be taking my complaint seriously'. He had been a heavy smoker and drinker in adult life. and • usually enjoy work. if the doctor advises multiple investigations all of which are to be done at once say: 'Isn't there just a simple test to check my throat out?' Examiner statement When the candidate has completed the history or after five minutes the examiner should say: 'Physical examination of this patient is completely normal. • no shortness of breath.

myasthenia gravis. Globus pharyngeus disorder (globus hystericus) is a physiological symptom associated with altered mood states. ~ the condition is brought on by emotional factors. but not associated with any specific psychiatric disorder or necessarily requiring psychiatric treatment. the role of normal grief and worry about cancer being largely unrecognised. and polymyositis are other potential causes of dysphagia. Laryngoscopic view — normal vocal cords • Patient counselling and education: the correct diagnosis should be explained as most likely being a nonserious condition with transient change in sensation or function of the throat. FIGURE 1. • Failure to indicate to the patient that serious disease is extremely unlikely. and ~ investigations are unlikely to reveal any serious process. Elevated cricopharyngeal pressure or abnormal hypopharyngeal motility may exist at the time of the symptoms. carcinoma of laryngopharynx. myotonia dystrophica. oesophageal or cricothyroid web (sideropenic dysphagia). Skeletal muscle disorders. KEY ISSUES • Ability to take a focused history. CRITICAL ERRORS • Failure to request laryngoscopy or upper pharyngeal/oesophageal endoscopy. ~ the condition needs limited investigations which should be explained. 083 . Other causes of upper oesophageal or laryngeal compression are retrosternal goitre. The same sensation may result from gastro-oesophageal reflux or from frequent swallowing and mouth dryness. • Ability to discuss a probable functional disorder with a concerned patient. often grief. None is likely in this case.007 Performance Guidelines CONDITION 007. COMMENTARY This patient is presenting with recent onset of mild symptoms localised in the same anatomical region as his cousin's recent cause of death.

your infectivity (you have a wife and other younger son) and how long you will be away from work. which is inflammation of the coverings of the brain) • • • • • • • 084 . if we decide to?' (Yes. but he may still be infected from his father. You are anxious about possible sterility (you and your wife would like to have a daughter). prognosis and preventive medicine aspects. You are in quite severe pain and feel most unwell. and communication skills in dealing with an unwell and anxious patient. Sterility can rarely follow if both testicles are affected) ‘Will we be able to have another child. Questions patient should ask if not already covered (the candidate's expected response is in brackets): • • • • 'What is the connection between the mumps and this trouble?' (Doctor should explain how mumps virus is related to testicular problems — viral aetiology) ‘What can I take for the pain?' (Pain killers that contain codeine compound analgesics) 'Are there any antibiotics or other drugs for this condition?' (Not at this stage) ‘Will it affect both of my testicles?'(Unlikely. Unless the other testicle becomes affected. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You thought you were recovering from mumps. If he is not immunised. whether the other testis will also be affected. having noticed the onset of facial swelling about a week ago. You contracted the disease from your older son aged five years. The doctor has examined you and will now advise you about your condition. usually only one is affected. management. The younger son should be immunised if not already done) 'Are there any other complications of mumps?'(Very occasionally mild meningitis. he is unlikely to contract mumps from his brother. Be cooperative and willing to accept the doctor's advice if presented clearly. possible impotence. Function of the other testis is usually unaffected) When will I be able to go back to work?' (Depends on how rapidly the pain and swelling persists — about 7-10 days) ‘Why wasn't my son affected in this way?' (Orchitis — inflammation of the testicle — is extremely rare in childhood) ‘Will our younger son get mumps too?'(If he is immunised already with measles-mumps-rubella (MMR) vaccines. Analgesics (Panadol®) have had little effect. You are now consulting the doctor about a painful and very tender left testicle.008 Performance Guidelines Condition 008 Pain in the testis following mumps in a 25-year-old man AIMS OF STATION To assess the candidate's knowledge of mumps orchitis including natural history. he is at minimal risk. there would not be any expected influence on fertility. fertility is not likely to be affected) 'Will my sex life be affected?' (No problems anticipated) ‘What will happen to the testicle eventually?' (Possibly reduction in size. but usually remains fully functional.

Panadeine®. Immunoglobulin is not effective. The candidate should indicate that the patient's anxiety over testicular function (fertility and sexual activity) and infectivity to his younger child. until pain and swelling have subsided. • One attack gives lifelong immunity. • Advise general measures for a febrile illness — adequate fluids. the candidate should tell the patient the diagnosis. • Period of infectivity is from 6 days before swelling of face occurs till 9 days after. determine the patient's knowledge of the condition including any fears he may have. In counselling. • Provide information about immunisation for mumps — live attenuated vaccine combined with rubella and measles vaccines (MMR) is available. Immunisation is advised for all children after 12 months of age. KEY ISSUES • Confidence in diagnosing mumps orchitis. so his wife (if she has not had mumps) and younger son can still contract it from the father. • The risk of infectivity to other adults is very low. and rest.none defined COMMENTARY Mumps has the following associations: • The infecting organism is a paramyxovirus. • Infectivity is 50-60% (sufferer to unimmunised person). 085 . discuss these and reassure him appropriately. are recognised and that possible reduction in size of the left testis is not likely to be of any consequence to fertility. and its prevention by immunisation. application of heat. Torsion of the testis need not be considered under the circumstances. • Local measures — scrotal support. Panadeine Forte®). • Incubation period is 12-25 days (usually about 18). • Steroids can be used to relieve severe pain but have no other effect on the illness. spread by droplet infection or direct contact. this will not immediately protect the wife or son from patient's infectivity.008 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should be confident with the diagnosis of mumps orchitis and should state this to the patient. light diet. • Giving an adequate explanation of the condition including the infectivity of mumps. • Pain control — paracetamol with 8 or 30 mg of codeine (for example. • Recognising patient anxiety about possible infertility and impotence and giving appropriate reassurance. A sympathetic and reassuring manner is expected. Their use in mumps is controversial. However. Monovalent vaccine is not available. CRITICAL ERROR . with booster dose before going to school.

~ significant atrophy of testis occurs in 50% of cases. ~ onset is 3-4 days after the parotitis is subsiding. ~ sterility is rare — only if bilateral involvement. arthritis. and ~ Rare — encephalitis. ~ sexual performance is not affected after recovery. • Orchitis complicating mumps: ~ occurs in 20-30% of postpuberal males. 086 . ~ usually is unilateral. and ~ mumps orchitis does not predispose to testicular malignancy. pancreatitis and oophoritis in females.008 Performance Guidelines • Complications of mumps: ~ Common — orchitis and aseptic meningitis. Subsides over one week.

No hirsutes. work as a secretary and live alone. unexplained vaginal bleeding and focal migraines. breast cancer or abnormal bleeding. active liver disease or previous cholestatic jaundice. diabetes. oestrogen-dependent malignancies particularly breast cancer. using barrier contraception with condoms. but have a steady boyfriend. the following list of responses is likely to cover most questions: • You have no previous deep vein thrombosis. In response to specific questions.009 Performance Guidelines Condition 009 Contraceptive advice for a 24-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately assess and advise a patient requesting oral contraception. • Blood pressure has always been normal. cigarette smoking. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 24 years. Periods have always been irregular. and very irregular cycles or oligomenorrhoea. You have been in a stable monogamous sexual relationship with your boyfriend for the past 12 months. do not smoke and only drink alcohol occasionally. but the candidate is expected to ask specifically for the important relevant findings: • Blood Pressure 120/80 mmHg • Pelvic and abdominal examination no abnormality. Examination findings to be given by the examiner after the history are basically normal. • Pap smear normal six months ago. • You are not on any medications. You have never been pregnant and have no history of gynaecologic or medical problems. • You have no history of migraine. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: A patient wishing to take the oral contraceptive pill (OCP) requires the following assessments: • Exclude absolute contraindications on history. Need to exclude deep venous thrombosis. but are otherwise normal. active liver disease. occurring every 2-3 months. A wide variety of relative contraindications has been described including hypertension. 087 . • Breast examination normal. • Check for relative contraindications to see whether the therapy can be justified.

. should have been advised. missed pills and diarrhoea and the appropriate management of these: take the normal dose the following day. sore breasts in the first 1-2 cycles. • Patient starts in red sector at time of next period. the timing of its effectiveness and the likely problems during its use. It is also less costly than Microgynon 20®. a 50 ug oestrogen-containing pill such as Microgynon 50® should have been chosen. resulting in an increased metabolism of the hormones administered in the OCR ~ If she had been hirsute. ~ If she was still breastfeeding. [ KEY ISSUES • Ability to take an adequate history to exclude absolute contraindications to the OCP and facts that would influence the pill chosen. or previous oestrogen-containing pills have produced problems or she has had a previous thrombosis. • Need for followup in about three months. This is because these drugs increase liver enzyme activity. • In this instance. • Explain about breakthrough bleeding.009 Performance Guidelines • Choice of pill: ~ Choose a low monophasic dose oestrogen pill (such as Microgynon 30®). 088 .If she had been an epileptic or on an antituberculous drug.5/50®. • Common side effects — breakthrough bleeding for first three months. or with acne (consistent with polycystic ovarian syndrome) an oestrogen-dominant pill such as Ovulen 0. and take appropriate additional precautions depending on circumstances. and its dose. a low-dose oestrogen or triphasic pill would have been appropriate. or (probably more appropriate) Diane 35® if the patient can afford it. a low dose progestogen pill should have been chosen and a failure rate of 3% accepted. CRITICAL ERROR Failure to exclude absolute contraindications to OCP use. Contraceptive efficacy is satisfactory after seven hormone tablets have been taken. Because her cycles are irregular (oligomenorrhoea) it is probably better to choose a triphasic preparation such as Triphasil® or Triquilar® as these have less post-pill amenorrhoea associated than a monophasic constant dose pill. This is required to check the blood pressure and to advise her as to whether the pill prescribed needs to be changed because of persistent problems such as break-through bleeding. This has a low breakthrough bleeding and low failure rate. • Ability to advise a patient as to how to take the pill.

Any patient prescribed the OCP must have a full explanation of how to commence taking the pill. As part of the assessment of a patient who is to be prescribed the OCR the type of pill and its cost. Common problems likely with candidate performance are: • failing to advise patients as to when contraception will be achieved following the commencement of therapy. Appropriate advice along the above lines is required. and • failing to advise the common side effects.009 Performance Guidelines COMMENTARY A young woman needs to be fully informed of all the benefits and side effects and risks of taking the OCR She also needs to be carefully assessed to ensure that she has no condition making her unsuitable to take the pill. when it becomes effective as a contraceptive. an appropriate low dose oestrogen pill should be advised with a low breakthrough bleeding rate and low failure rate. Having excluded absolute and relative contraindications to use of the OCP (as is the case in this patient). and what to do if a pill is missed accidentally. Alternatively a triphasic preparation could be used which has less post-pill amenorrhoea. should be taken into account as part of the advice to the patient. 089 . • what to do if a pill is missed or the patient gets diarrhoea.

Penicillin (or azithromycin) and doxycycline should be given prophylactically. • The need to exclude sexually transmissible infections and get a baseline blood sample for HIV and syphilis. the rape followed a threat of severe injury if you did not comply. and are not on any medications at present. you have not been taking or using any contraceptive agents. you have had no previous operations. • you have no allergies to drugs or chemicals. Speculum examination is required to check that there are no lacerations in the vagina. to take swabs to exclude infections as indicated below and to collect a specimen for pathologic analysis. illnesses or pregnancies. The candidate should now discuss these with patient.Condition 010 Rape of a 20-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately assess and manage a woman who gives a history of having recently been raped. Questions patient to ask unless already covered (candidate's expected responses as outlined in expectations of candidate performance): • 'Has he caused me any harm?' • 'Will I be able to have children when I want to?' • 'Do I need any treatment now?' Initial examination findings to be given to the candidate by the examiner on request: • general examination: no evidence of bruising or trauma. but not for the last six months. No previous known pelvic infections. • vulva: looks normal — not bruised and not bleeding. and advise on management plan. and • speculum examination and PV have not yet been done. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to respond as follows: • • • • menses are regular and normal and your last menstrual period started ten days ago. • you do not use drugs of addiction. EXPECTATIONS OF CANDIDATE PERFORMANCE The history should have: • determined the date of her last menstrual period. A cervical smear and culture should be done for gonococcus and Chlamydia (or urine can be collected for polymerase chain reaction [PCR] analysis to exclude Chlamydia). The candidate should advise the patient along the following lines: • Explanation as to what examination is required and why. He did ejaculate into the vagina. 090 . and • noted that she was not on the contraceptive pill. • you have been sexually active in the past. No bleeding followed rape.

• The need to collect a specimen from the vagina to see if spermatozoa are present and keep the specimen for DNA analysis later. as well as the possible use of post-coital contraception to prevent conception. She should also be counselled that a review of testing in three months time will be necessary to follow up from the initial potential infection. • If the candidate prefers to refer the patient to a doctor in a rape crisis centre immediately. COMMENTARY This patient will need to be treated with great empathy and support. and she may well need the support of a social worker or a rape crisis counsellor. 091 . As she is in the late follicular phase of the cycle. but it would be appropriate to preserve any specimens collected in case she changes this decision. Screening for syphilis and HIV will need to be repeated in 1-3 months time. As she does not wish to involve the police at this stage. CRITICAL ERRORS • Failure to consider need for post-rape contraceptive methods and management. For legal purposes. should be given. By that time.010 Performance Guidelines • The need to prevent pregnancy. and that the time of the incident in her menstrual cycle should be established. Common problems likely with candidate performance are: • failure to review to exclude pregnancy and to arrange followup infection testing. KEY ISSUES • Ability to assess a patient who has recently been raped. Antibiotics should be given as prophylaxis against STI. • Ability to arrange the appropriate followup investigations and care. She needs a full explanation as to the reasons for your examination (to exclude trauma and STI). • Offer referral for rape crisis counselling with the rape crisis team or medical social worker. • The need to review patient in three weeks to check whether she has conceived. indicating what action would be expected from the staff at the rape crisis centre. reassurance about subsequent pregnancy should be possible. there may be no indication to collect forensic specimens. the Yuzpe method of the oral contraceptive pill (two doses of two tablets given twelve hours apart with associated metoclopramide [Maxolon®]. • Failure to consider use of prophylactic antibiotics to prevent pelvic inflammation with an STI. a summary as above must be given. She needs explanation that pregnancy might occur as a result of the rape. and • failure to arrange appropriate counselling. there would need to be a strict 'chain of security and continuity' of handling the specimen if the results are to be admissible in court. • Failure to refer to appropriate clinic or to discuss taking appropriate swab to exclude sexually transmissible infections (STI) and taking specimen for DNA analysis. and to review test results and decide if any need to be repeated. or high dose levonorgestrel [Postinor®]).

thank the doctor and ask him to arrange surgical referral. and that the biopsy confirmed that cancer was present.011 Performance Guidelines Condition 011 Cancer of the colon in a 60-year-old man AIMS OF STATION To assess the candidate's ability to counsel an anxious patient. You were advised about followup periodic colonoscopy. recently diagnosed with colon cancer. You have had no bowel symptoms. but you dread this prospect. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Your father died from bowel cancer in his late sixties. You recently attended for a further screening colonoscopy at your wife's insistence. whether any other treatment is possible. a temporary colostomy may be performed. including the clinical features of left colon carcinoma. and the likelihood of a colostomy being required. You have been advised that referral for early surgery is required. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to know the natural history and clinical presentations of left sided colon cancer as outlined in the commentary. 092 . Opening statement ' What will happen if I don't have surgery?' Questions to ask unless already covered: • • • 'What are the prospects of cure if I have the operation?1 ‘Is any other treatment apart from surgery possible ' 'Would I need a colostomy like my father had?' 9 At the conclusion of the interview if your concerns have been addressed adequately. and no general symptoms. You were shocked and upset when told by the gastroenterologist that a bowel lesion suspicious of cancer had been found. Knowledge of the clinical presentation and natural history of carcinoma of the colon is required. you wish to discuss matters with your general practitioner to check what is likely to occur if you continue to refuse surgery. and to address the patient's concerns appropriately. you did not attend for further studies after the first one five years ago. Now that the implications of the positive diagnosis have sunk in. but as you had no symptoms. which you were told was clear. and the necessity for urgent operation should acute bowel obstruction occur. in which case.

• Failure to advise need for urgent operation in the event of acute obstruction. bowel obstruction or tumour spread. COMMENTARY If surgery is not performed the tumour may become evident due to bleeding.011 Performance Guidelines KEY ISSUES • Discussion of natural history of left sided colon cancer if not treated. but would usually be temporary unless operation revealed extensive unexpected tumour spread. A colostomy may need to accompany emergency surgery at the surgeon's discretion. Carcinoma of the left colon may present with the passage of red blood mixed with the stools (or even bleeding apart from defaecation). If obstruction develops. then distension will follow with increasing pain. FIGURE 3. CONDITION 011. and ~ the general principles of surgical management for a rectosigmoid cancer. CONDITION 011. • The candidate is expected to know: ~ that urgent operation is necessary if acute large bowel obstruction with caecal distension ensues. CRITICAL ERRORS • Failure to counsel patient on natural history of untreated colon cancer. Bowel obstruction — gross caecal distension Metastatic carcinoma liver 093 . If acute complete obstruction ensues in the presence of a competent ileocaecal valve. FIGURE 2. Nasogastric tube suction and intravenous fluid replacement alone is incorrect management. increasing constipation. subumbilical central pain ensues with persisting constipation. or alternating constipation and spurious diarrhoea. The risk of rupture of the caecum means urgent operation is essential to decompress the bowel from the 'closed loop' obstruction.

and colostomy is not usually required. and should be advised in this concerned patient to facilitate informed consent for surgery. The prognosis after resection of colon carcinoma relates directly to the degree of spread of the carcinoma as indicated in Dukes classification: • • • • Stage A: carcinoma confined to the mucosa.011 Performance Guidelines Cancers commonly arise in premalignant adenomatous polyps. 094 . which can be followed by malignant ascites and peritoneal metastases. Spread of the tumour occurs by direct invasion through the bowel wall. 75-80% five year survival: Stage C: lymph node involvement. it would normally only be temporary. absence of anaemia and normal renal function. which significantly worsens prognosis. adjuvant chemotherapy has been shown to improve survival in selected cases. Stage B: carcinoma involves the muscle of the colonic wall. Perioperative prophylactic antibiotics can minimise infective complications of surgery. The likelihood of malignant change increases with increasing polyp size. In low left sided colonic cancer. Lymphatic spread in left colonic cancer. and Stage D: spread into the peritoneal cavity or by blood spread to the liver and beyond. Preoperative investigations normally check for general fitness for anaesthesia. 50% five year survival. If a colostomy is performed under conditions of elective surgery. Abdominal imaging by computed tomography (CT) can provide information regarding intra-abdominal spread as an aid to whether curative resection is likely to be possible. 25-35% five year survival. Blood spread occurs via the portal system to the liver and beyond. over 95% five year survival. Elective surgery on confirmation of diagnosis offers the best prospect of cure. is via epicolic. paracolic and preaortic nodes.

• Initial management plan: per day will more than meet the requirements of the mildly increased red cell turnover. which is very rare. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The doctor will discuss the results of the tests and will explain to you the implications of you being a carrier of the condition of / β -Thalassaemia. ~ Reassure the patient regarding the effect on her health. and the candidate's counselling skills in dealing with a sensitive issue involving her prospective spouse. Oral folic acid of 1 mg 095 . a supportive attitude and with guarded reassurance about present day management is expected. future children may be affected. ask: • Will this have any effects on our children?' • Should my fiance have any test done?' EXPECTATIONS OF CANDIDATE PERFORMANCE Candidates are expected to know that Thalassaemia is a recessive inherited trait so that the heterozygous (carrier) state gives Thalassaemia minor. its management. ~ Minimisation of anxiety by careful explanation. • Interpretation of investigations: The characteristics of / β -Thalassaemia minor include: ~ FBE — a symptomless hypochromic microcytic anaemia (rarely below 100 g/L) with decreased mean corpuscular volume (MCV) and usually normal red blood cell count (RBC). but there are inheritance implications which will depend on your fiance's genetic status. ~ diagnosis needs confirmation by serum electrophoresis (elevated Hb A2). unless the patient happens also to be iron-deficient.012 Performance Condition 012 Thalassaemia minor in a 22-year-old woman AIMS OF STATION To assess the candidate's knowledge of the Mendelian inheritance of / β -Thalassaemia minor. namely that if the patient's fiance is also a carrier. You should be reassured that the condition is not serious to your own health. If the doctor does not suggest testing your fiance. whilst the homozygous state results in Thalassaemia major. Iron therapy is not indicated. and ~ the anaemia does not respond to any form of iron therapy. with a significant risk of / β -Thalassaemia major. • Approach to patient: ~ This scenario deals with a sensitive issue.

Availability of antenatal diagnosis and management of pregnancy (including termination) if fetus is shown to have β -Thalassaemia major. β -Thalassaemia major is a rare. ~ Nature of this condition and possible consequences if conjugal partner also carries the trait. ~ This problem cannot be resolved at this consultation. but very serious. If the fiance is not a carrier there is no immediate problem. • Advise that fiance be tested for β-Thalassaemia minor 096 . India. In Australia. Initial management plan. and ~ homozygous inheritance: results in B-Thalassaemia major. • • Failure to advise that the prospective spouse should be investigated for carrier state. ~ Information about β -Thalassaemia major and risks of its occurrence in offspring if both partners are carriers. which are oxidised and result in premature red blood cell removal in the spleen. • Patient counselling/education: The candidate should counsel regarding the following issues: ~ Thalassaemia minor is a recessive inherited trait ('carrier' state). There is also haemolysis because the imbalance results in excess globin chains.012 Performance Guidelines ~ The candidate should offer to see her fiance to arrange appropriate testing. At the molecular level. and offer to refer the couple to a geneticist or haematologist. The underproduction of either alpha or beta chains results in a microcytic red blood cell. • • Patient counselling regarding inheritance implications. Failure to understand principles of Mendelian recessive inheritance. Meaning of ~ heterozygous inheritance: results in β -Thalassaemia minor. advise that the fiance consults his own doctor. Followup with patient and also fiance (if possible) is required after results of fiance's genetic status are known. including the Mediterranean region. there is a high prevalence of this condition in individuals descended from these regions. Thalassaemia is a common anaemia in certain areas of the world. congenital anaemia requiring lifelong transfusional support and patients with this condition also need treatment to avoid complications of iron overload related to the frequent transfusions. including how the carrier state is diagnosed. There is a markedly reduced life expectancy with devastating consequences for both the child and family. Suggest also that her brother should seek advice in regard to testing for the trait. The most important points being assessed are: • • Knowledge of Mendelian inheritance (what is a recessive inherited trait and what are its implications?). there are hundreds of globin abnormalities leading to either alpha-chain or beta-chain underproduction. although the couple should be advised to inform their children of the situation at an appropriate time. Southeast Asia and Africa.

097 . • If fiance is positive for β-Thalassaemia minor: Half the children of either sex will be carriers. • If fiance is negative for β -Thalassaemia minor. None should have β -Thalassaemia major. One in four children will have β -Thalassaemia major. ~ Explanation of carrier state is required (can affect male or female children) — each offspring will have an equal chance of being carrier or noncarrier (normal). diagnostic certainty. known risks and availability of antenatal diagnosis and safe termination procedures (unless this is not an acceptable option). The diagnosis of β -Thalassaemia major can be made by in utero genetic sampling at 12-14 weeks. they will need counselling about risks to fetus which are 1:4 for β -Thalassaemia major (25%) and 1:2 for β -Thalassaemia minor (50% — carrier status). • Management If the haemoglobin test for β -Thalassaemia minor in the fiance is negative: ~ No further action or tests are required. If both partners are carriers there is no cause for undue alarm because of increased awareness. Either sex can be carriers. Half the children of either sex will be carriers (β -Thalassaemia minor). She has the carrier state /J-Thalassaemia minor. which affects children of either sex.012 Performance Guidelines The pattern of inheritance is as illustrated. ~ If the fiance has a positive test for β -Thalassaemia minor.

β -Thalassaemia major: the slide shows microcytosis. CONDITION 012. hypochromia. anisocytosls. a normoblast and target cells 098 . Heterozygous alpha-Thalassaemia (which involves the alpha ( a ) chains) is also compatible with survival.Performance Guidelines Beta-Thalassaemia is a condition involving the beta ( β ) chains. however the homozygous state of alpha-Thalassaemia results in fetal hydrops and death-in-utero. FIGURE 3. with both homozygous and heterozygous states being compatible with survival to term but with major differences in outlook.

• You have now been off all treatment for 12 months. • There are no varicose veins. when the last one was complicated by a pulmonary embolus during the puerperium. • During the last pregnancy. Because of her previous deep venous thrombosis (DVT) and pulmonary embolus. • You have no family history of any clotting problems or thromboses. • You were treated with intravenous heparin for two weeks. but you do have occasional ankle oedema on the right side (the side of the previous thrombosis). 099 . followed by full dose warfarin therapy for six months. • Your previous delivery was a spontaneous vaginal delivery of a live male infant weighing 3550 grams. • You have had no previous DVT or pulmonary embolus apart from as outlined in the previous pregnancy. • Contraception: you are using condoms. Questions to ask unless already covered: • Will I get another deep vein thrombosis and pulmonary embolus?' • 'Do I need anticoagulant treatment during the next pregnancy? If so. what?' • ‘Is there any risk from anticoagulant treatment during pregnancy to my baby or me?' Investigation results No investigations have been done since you ceased warfarin therapy and none had been done prior to commencing anticoagulants after the pulmonary embolism. After this DVT in the right pelvic veins was diagnosed when the doctor performed a venogram. you were shown to be rubella-immune and took folic acid from before pregnancy and for the first 16 weeks. You had previously been on the contraceptive pill prior to the first pregnancy without problems. in full dosage.013 Performance Guidelines Condition 013 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism AIMS OF STATION To assess the candidate's ability to advise a patient of the appropriate management she should receive during her next pregnancy. she is at increased risk (probably at least 20%) of a repeat thrombosis in her next pregnancy. A small episiotomy was cut to facilitate delivery. • There is no shortness of breath currently. • You have had no trauma or operations on legs or pelvis. You did not breastfeed. The examiner will have instructed the patient to respond as follows: • Previous DVT and pulmonary embolus: your pulmonary embolus occurred on day three after the birth.

100 . neurologic problems in the baby and stillbirth. • • • • • • Ability to recognise that she is at increased risk of a recurrent thrombosis in her next pregnancy and requires at least low dose heparin during the puerperium if not for most of the antenatal period as well. Avoid prolonged immobilisation during pregnancy. fetal and maternal haemorrhage. and unlikely to affect clotting tests. although it is commonly used if treatment is continued postpartum. and it is safer to treat her throughout the pregnancy. anti-thrombin 3. in a dose of 20-40 mg 12 hourly (in the past it would have been common for heparin to be changed to warfarin. Recognition of relative risks and indications for heparin and warfarin therapy. has problems such as a 5% risk of teratogenesis when given in the first trimester and an increase in miscarriage rate. it is best to arrange induction at a time when the morning dose of heparin can be withheld. however. in full dosage. rather than allowing a spontaneous labour to occur in someone who has just had her dose of heparin. and factor V Leidin — these tests will screen for both inherited and acguired thrombophilias). There is a need to screen her for a clotting propensity (thrombophilia) prior to her becoming pregnant (tests should include the measurement of anticardiolipin antibody. anticoagulant therapy throughout the pregnancy and the puerperium should be advised. with the treatment being reinstituted after delivery. If a thrombophilia is identified. between 16 weeks and 36 weeks. and then from one week postpartum). Recognition of significant risks of warfarin during pregnancy. lupus anticoagulant. protein S. The treatment should therefore probably be started at about 14 weeks of gestation and continued until at least 4-6 weeks postpartum. Deliver in a controlled manner at about 38-39 weeks of gestation.013 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should provide the substance of the following information in lay terms: • • The pregnancy should be managed in consultation with a consultant physician or haematologist and an obstetrician. Take her folic acid therapy as on the previous occasion. Although the heparin dose is not full dosage. Optimal anticoagulant therapy is best given as subcutaneous low dose heparin in a dosage of 7500 units twice daily. Advising warfarin therapy throughout pregnancy. Failure to advise anticoagulant therapy at least for 4-6 weeks postpartum in the next pregnancy. she should still be treated with anticoagulants at least during the puerperium. Treatment with warfarin. For all of these reasons. or with a low molecular weight heparin such as enoxaparin. protein C. • • • • • Failure to screen for an inherited or acquired coagulation disorder. and consider using compression stockings by day throughout the pregnancy. Even if there is no underlying problem discovered. warfarin is not used during pregnancy.

as opposed to the risks of warfarin in pregnancy. However. The benefits of heparin must be carefully explained. • suggesting that warfarin therapy should be given throughout the pregnancy. which can be teratogenic if given in the first trimester. She must receive treatment to prevent a similar episode occurring in her next pregnancy. It is essential to exclude any acquired or inherited coagulation disorder. and is impossible to reverse quickly in the late third trimester when labour is likely to occur 101 . in any event. Common problems likely with candidate performance are: • failure to enquire about the particulars of the previous thrombosis/pulmonary embolism. It is also important that the anticoagulant therapy be continued beyond the birth of her infant for at least 4-6 weeks. she will need anticoagulant therapy for the majority of her next pregnancy.013 Performance Guidelines COMMENTARY This young woman has survived a life-threatening pulmonary embolus in a previous pregnancy.

Your vision has been good and kidney function has been normal. and the actions she should take to minimise the risk of potential problems. such as rubella antibodies. • • • Your diabetes was diagnosed at the age of 9 years (that is. The examiner will instruct the patient to reply. 15 years ago). Generally you are able to keep the blood sugar levels at 6-8 mmol/L. full blood examination (FBE). the effect of future pregnancies on her diabetes. that the baby is also at increased risk. • • • • Questions to ask if not already covered: • • • • 'Will I be able to have a baby?' ‘Will my baby be OK?' ‘Will the pregnancy adversely affect my diabetes?' 'How does the diabetes affect my pregnancy?' EXPECTATIONS OF CANDIDATE PERFORMANCE In general. You manage your own insulin dosages and test blood sugar levels three times a day. blood group.014 Performance Guidelines Condition 014 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus AIMS OF STATION To assess the candidate's ability to counsel a nulliparous diabetic woman about the effects of her diabetes on a future pregnancy. Your diabetes has been well controlled on insulin and is currently very well controlled on long-acting insulin given twice daily. but occasionally have hypoglycaemic episodes. You have never had a hyperglycaemic coma. as indicated below. indirect Coombs test or syphilis serology. that the pre-pregnancy counselling applicable to all pregnant women is also applicable to her. and that delivery at 38 weeks or sometimes earlier will probably be required. the candidate needs to advise her of the need to have very good blood sugar control prior to conception and during the pregnancy. 102 . that the risk of certain pregnancy complications are increased. when her history is being taken by the candidate. Your last review by the diabetic physician was 12 months ago. You have not had any of the other pre-pregnancy blood tests done. You have not been troubled with urinary infections or vaginal infections.

rubella serology. These tests should include blood group and indirect Coombs test. and a check of her optic fundi by her ophthalmologist. the pregnancy is more likely to be complicated by pre-eclampsia. delivery should be planned for 38-40 weeks in someone who has had diabetes for 15 years and is on insulin therapy. ~ Her insulin requirement will markedly increase and she will need to keep her blood sugars between 5-7 mmol/L to keep the fetal malformation rate to a minimum. Venereal Disease Research Laboratory Test (VDRL). so that she can make an informed decision as to whether she wishes to proceed. the routine tests which would normally be performed at the first antenatal visit are better performed prior to pregnancy. hepatitis screening. There is also an increased risk of unexplained fetal death-in-utero late in pregnancy and of respiratory distress in the baby after delivery. with assessment for peripheral neuropathy. 103 . and at 32 weeks looking for macrosomia. All of these matters need to be raised with the patient prior to pregnancy. and the macrosomia (large fetal size) rate to an acceptable level. It is particularly important to keep the blood glucose levels within the range of 5-7 mmol/L during the first trimester to reduce the risk of fetal malformation to an absolute minimum. and midstream urine specimen to exclude urinary infection. renal function (renal function tests and 24 hour urinary protein). If a Pap smear has not been performed in the last two years.5-1 mg per day from the time pregnancy is attempted until at least mid-gestation. ~ Despite adequate monitoring and care during pregnancy.014 Performance Guidelines Specific advice to the patient The candidate should explain that: • Pre-pregnancy counselling must take the form of assessment of her diabetic control and looking for any evidence of effects of the diabetes on target organs. Earlier delivery might be necessary if problems occur during the pregnancy. this should also be performed. and commence folic acid in a dosage of 0. full blood examination (FBE). Her haemoglobin A1C (HbA1c) should therefore be measured and her blood glucose assessments reviewed to ensure they are satisfactory. and during the remainder of the pregnancy to reduce the fetal and maternal complications (particularly macrosomia and unexplained fetal death). she could be advised to attempt to become pregnant. ~ In general. ~ The insulin requirement after delivery usually returns to pre-pregnancy requirements within 24 hours of delivery. • In addition. • Providing all of these are normal. polyhydramnios and macrosomia of the fetus. Any abnormalities found in these tests should be addressed prior to the pregnancy. • She should also be advised about the care which is likely to be required during pregnancy as follows: ~ Referral to a consultant obstetrician who will manage her in conjunction with a diabetic physician. even where the diabetes is well controlled. • Referral to her diabetic physician to check her general state is mandatory. ~ Ultrasound examination should be performed at 12 and 18 weeks looking for fetal abnormalities. ~ Iron and folic acid therapy should be continued throughout the pregnancy.

The most important advice that the patient should receive is that pre-pregnancy and pregnancy control of blood sugar levels is essential for an optimum outcome of the pregnancy. Failure to do pre-pregnancy blood tests (haemoglobin estimation. and failing to suggest that the pregnancy should be managed in consultation with a diabetic physician and a specialist obstetrician. but fall back to pre-pregnancy requirements within 24 hours of delivery. . • • Failure to ensure the patient is aware that her diabetic control prior to pregnancy should be good to ensure the risk of fetal abnormality is kept as low as possible. lack of knowledge that good blood-sugar controi reduces the risk of unexplained fetal death-in-utero and fetal macrosomia. blood group.014 Performance Guidelines KEY ISSUES • Ability of the candidate to counsel a diabetic woman. lack of knowledge that the insulin dose required will usually increase dramatically during the pregnancy. rubella antibodies and tests as above) and failure to recommend pre-pregnancy and early pregnancy folic acid therapy (routine pre-pregnancy counselling). The most important aspect of managing pregnancy in an established insulin-dependent (Type 1) diabetic is that the pregnancy must be managed in consultation with a physician specialising in diabetes and a specialist obstetrician. Common problems likely with candidate performance are: • • • • inability to advise the patient adequately concerning the special problems seen in pregnancy that can affect either the baby or the mother. about the care she will require and the methods of keeping the complication rate to herself and her fetus to a minimum. prior to a pregnancy.

and • there is no history of asthma or other contraindication to prostaglandin therapy. • if after explaining the diagnosis. Opening statement ‘Is there anything wrong with my baby?' Questions to ask if not already covered: • 'Can I have the pregnancy terminated?' — Ask only if the candidate informs you of the diagnosis but doesn't mention termination of the pregnancy being an option. The patient has the option to terminate the pregnancy forthwith. the candidate explains termination of the pregnancy as an appropriate action. The list of appropriate answers below is likely to cover most of the doctor's questions: • if asked about your periods.) in pregnancy. • your blood group is O positive. or asks you what you would prefer. • no family history of neural tube defect (spina bifida. You are seeing the doctor to discuss your recent ultrasound test. indicate they had been normal prior to the pregnancy. otherwise labour post-term is common. If the latter is chosen.015 Performance Guidelines Condition 015 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida AIMS OF STATION To assess the candidate's ability to appropriately counsel a patient found to have an anencephalic fetus at the time of an ultrasound examination at 18 weeks of gestation. the labour is likely to be premature. and if hydramnios occurs. 105 . the condition has been diagnosed unequivocally at the 18 week ultrasound as illustrated. • you did not take any folic acid in early pregnancy. The examiner will have instructed the patient as follows: This is your first pregnancy at 18 weeks. indirect Coombs test negative. The condition is always fatal soon after birth. answer: ‘I do not wish to continue with the pregnancy if this can be arranged'. or continue until labour occurs. Screening blood tests two weeks ago raised concerns about the fetal condition. • ‘Is this problem likely to occur again in a subsequent pregnancy?' • 'How can I prevent the problem from occurring again?' EXPECTATIONS OF CANDIDATE PERFORMANCE Diagnosi Fetal anencephaly is a developmental defect of the brain which occurs somewhere between five and eight weeks of gestation. In this patient.

Prostaglandin termination may take several hours — or even days — and results in uterine contractions similar to those experienced in labour. As the patient has indicated she should wish to have the pregnancy terminated. The most important aspect of managing this case is to understand the anxiety and disappointment of the mother. • • • • Ability to advise the mother: • • • empathically of the fact that her baby has a lethal abnormality. 106 . as this has been shown to reduce the risk of a neural tube defect Ultrasound examination in a subsequent pregnancy is imperative. This latter procedure has the advantage of being performed under general anaesthetic with the procedure being over when the patient wakes up. and of the methods available to reduce the recurrence risk of this abnormality Failure to: • • • recognise and advise the patient that this is a lethal abnormality to the baby: or determine the preferences of the mother in respect to termination of pregnancy. this needs to be discussed. There is also a possible need for curettage to remove any retained placental fragments. is somewhere between 2% and 5%. of the appropriate options regarding her further care in this pregnancy. and cervical damage resulting in subsequent cervical incompetence in any subsequent pregnancy may result when the procedure is done after 16 weeks ol gestation. the candidate should be positive in terms of prevention (folic acid) and screening tests in a subsequent pregnancy. or counsel the patient appropriately concerning management in a subsequent pregnancy. She will need considerable support and understanding when discussing the abnormality with her and the management of the termination of the pregnancy that she has requested.015 Performance Guidelines Advice expected to be given to the patient: • • The information concerning anencephaly should be given as indicated above. While helping her to deal with the extreme disappointment of the outcome of this pregnancy. or by the surgical procedure of dilatation and evacuation. Termination of the pregnancy could be performed by using prostaglandins. The risk of recurrence of a neural tube defect (NTD) such as anencephaly. followed by vaginal delivery of the fetus. Post-mortem examination should be performed on the fetus to check that no other abnormality is present that might influence the advice given concerning the successor otherwise of any subsequent pregnancy. Maternal serum alpha fetoprotein assessment is also useful as a screening test and should be performed at about 16 weeks of gestation in any subsequent pregnancy. This procedure is quite difficult except in expert hands. Folic acid administration (in a dosage of 5 mg per day) should be commenced prior to conception and continued until about 12 weeks of gestation. or spina bifida.

CONDITION 015. • Advising the patient that a suction curette would be the preferred method of termination. but asking for information such as the date of the last menstrual period. An understanding of the recent methods and timing of genetic screening in early pregnancy is required. • Advising that maternal serum screening at 11-12 weeks gestation in the next pregnancy would be appropriate to exclude another NTD. This just takes time to do and reduces the time available for the remaining tasks. FIGURE 2. This is not the case at 18 weeks of gestation. This test would be appropriate to assess the likelihood of a chromosome abnormality but an alpha-fetoprotein assessment at 15-16 weeks gestation is also necessary for recognition of a likely NTD. social history etc. but would not exclude spina bifida. Ultrasound showing anencephalic fetus 107 . although it would be appropriate for a pregnancy termination being performed at less than 15 weeks of gestation.015 Performance Guidelines Common problems with candidate performance are: • Not focusing enough on the actual problem when taking the history. may allow a diagnosis of anencephaly to be made. at 11-12 weeks of gestation. irrelevant past history. Earlier ultrasound examination.

can this relapse be prevented?' ‘Is the ulcer cancerous?' '’Would surgical treatment ever be required?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain that: • The majority of duodenal ulcers are a consequence of mucosal damage caused Helicobacter pylori and gastric hydrochloric acid. the patient will only require acid suppression to achieve ulcer healing. Questions to ask if not already covered by doctor: • • • • • • • 'Why have I developed the ulcer?' ‘Is it contagious? Can my family members be affected?' ‘'What treatment do I need to get rid of this duodenal ulcer?' ‘'Would those NuroferP tablets have anything to do with this?' ‘Is it likely to come back once it has healed? If so. You have had dyspepsia (epigastric pain after meals) for abo six weeks. omeprazole) plus antibiotics (clarithromycin or amoxycillin plus metr dazole given for 1-2weeks). The patient should replace ibuprofen alternative analgesia such as paracetamol. which you obtained from the pharmacist. pylori a gastric acid to gastric ulcer is less definite. which have not given much relief. The relationship of H. they d o n ’ t contribute to the development of the ulcer. The bacterial infection is not highly contagious to other family members. • Cessation of potential aggravating factors such as NSAID use and smoking is important. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a retired bank clerk. Management of peptic ulc depends on the underlying cause.016 Performance Guidelines Condition 016 A duodenal ulcer found on endoscopy in a 65-year-old man A I M S OF STATION To assess the candidate's ability to counsel a patient on the aetiology and complications duodenal peptic ulceration and the principles of management. provided the organism is eradicated (u breath test at six weeks). You have been taking Nurofen"1 table (ibuprofen). Whilst tobacco and alcohol may hinder the healing of ulcers. Non-steroidal antiinflammatory dru (NSAIDs) commonly contribute to peptic ulcer formation. pylori-related ulcer includes a proton pump inhib' (for example. the chance of ulcer recurrence is low. For NSAID-relat ulcers. triple ther (usually a proton pump inhibitor and two antibiotics) will heal more than 90% of ulc within one week of starting treatment and. followed by continued antisecretory therapy foruptoat of 4-8 weeks. i do not smoke or drink alcohol. 108 . • Recommended therapy for an H. Your general health has been reasonably good apart from some rec generalised aches and pains in your joints. For Helicobacter pylori-related ulcers.

pylori. with about 10% of patients developing complications (bleeding. is often successful in preventing further bleeding. most ulcers will spontaneously heal. From being a chronic. obstruction and for patients with severe. but more likely to persist in older patients with arterial medial sclerosis. Haemorrhage from peptic ulcers produces haematemesis and/or melaena. brought on by the breakdown of urea (through the enzyme urease) and formation of ammonium ions. Left untreated. The layer itself may be disrupted and acid allowed to infiltrate and damage the underlying mucosa. this bacteria surrounds itself in a neutral zone. About 70% are related to H. which require surgical intervention. With the advent of the proton pump inhibitors and the identification of the pathogen Helicobacter pylori. This change weakens the integrity of the mucous layer. • Knowledge of the usual medical therapy and risk factors for patients with peptic duodenal ulceration. In these patients. Surgery is indicated when excessive or persistent bleeding occurs and should be considered when blood loss exceeds 3000 mL. This is an important side effect of NSAIDs. cyclic AMP (cAMP) and several other agents. Malignancy occurring in a chronic peptic ulcer is uncommon (1-2% in gastric ulcer) but would need examination and monitoring to ensure permanent healing. To survive in the hostile acid environment. perforation or gastric outlet obstruction). Complications of peptic ulceration. The mucosal lining of the stomach and duodenum is normally protected from acid-attack and autodigestion by a layer of mucus. more so in men. management of peptic ulcer disease has undergone a considerable change in the last two decades. often after several months. the • Informing the patient that the duodenal ulcer is likely to be malignant. Thus peptic ulcer disease can be a lifelong problem. • Most patients can be managed with medical therapy and without surgery. Bicarbonate is also secreted from the surface cells to help with mucosal defence. • Understanding that surgery is required for perforation. Both mucus and bicarbonate secretion are modulated through the actions of prostaglandins.016 Performance Guidelines • Peptic ulcers are common. There are a number of ways in which the integrity of this mucous layer can be broken. persistent bleeding or intractable pain. each patient should be evaluated individually. Bleeding is usually self limiting. indolent problem. peptic ulcer disease is now a relatively benign and easily treated condition. However. endoscopic haemostasis using a heater probe or injection of adrenaline. gastric outflow obstruction and severe persistent bleeding. include perforation. This layer of mucus forms an 'unstirred layer' which is constantly replaced by secretion from the underlying cells. Replenishment of the layer can be interrupted through interference with prostaglandin synthesis and reduction in bicarbonate secretion. The most common mechanism of this kind of damage is brought about by the presence of Helicobacter pylori. but relapse. frequently requiring surgical intervention. 109 .

Urease test on biopsy with sample The existence of H. pylori. This has not proven to be the case. FIGURE 2. and the ulcer biopsied again if still present. If the ulcer does recur this is probably because the patient has become reinfected. from belief that this class of compound would be associated with a lower incidence of gastrointestinal side effects. the most likely aetiological factor will be an NSAID. 110 . If H. Duodenal ulcers are not associated with malignancy. pylori. mainly through the seminal contributions of B Marshall and R Warren from Perth. most peptic ulcers will be related to the presence of H. pylori and its role in peptic ulcer disease was only appreciated in the early 1980s. Treatment for 4-8 weeks will lead to H. to confirm the diagnosis. As part of the diagnosis. Ideally. the chance of recurrence is low. to test for the presence of H. pylori is absent. Treatment consists of withdrawing the NSAID and giving the patient an acid-suppressing agent for long enough for the ulcer to heal. If the initial ulcer was a duodenal ulcer. Provided this is done and the ulcer is healed. pylori eradication and ulcer healing in over 90% of cases. the likely cause of the ulcer is an NSAID. pylori is high in many communities — especially amongst those in lower socioeconomic groups — the rate of ulcer formation is still relatively low. The aim of the procedure is two-fold: first. and secondly. Whilst the prevalence of H. On a worldwide basis. all patients with a suspected peptic ulcer should have an endoscopy performed. If H. part of the treatment will be to eradicate the infection. pylori. leading to their receipt of the Nobel Prize in Medicine for 2005. A great deal of false expectation occurred with the development of the Cyclo-oxygenase-2 (COX-2) inhibitors (such as celecoxib). If the cause of the problem had been a gastric ulcer.016 Performance Guidelines CONDITION 016. any ulcer in the stomach must be biopsied to exclude malignancy. Australia. pylori is present. When a peptic ulcer is not related to the presence of H. success of treatment can be judged by relief of symptoms and a breath test to check for H. Helicobacter pylori associated peptic ulceration CONDITION 016. pylori eradication (if the infection was present in the first place). the patient should be endoscoped again. FIGURE 3.

017 Performance Guidelines Condition 017 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery AIMS OF STATION To assess the candidate's ability to explain the principles of preoperative blood collection for autologous intraoperative transfusion. • Blood can be stored safely for reuse within a few weeks (up to five weeks). two or more donations can be collected over the weeks prior to operation. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should display ability to counsel about the following issues: • The candidate is expected to explain the normal functions of bone marrow and blood. being a renewable tissue from the bone marrow) • ‘'Won't it make me very weak?' (Not significantly) • ‘'What are the advantages of my blood over blood bank blood?''(It is your own. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to ask questions of the candidate as follows (unless the matter has already been covered): The answers expected by the candidate are in brackets. where blood loss can be such as to require transfusion. and that blood is a renewable tissue with the main functions of oxygen transport to tissues and maintenance of circulatory volume. which is fully compatible). • The procedure removes the risk of disease transmission (particularly by viruses) or incompatibilities and allergies inherent in standard homologous blood transfusion from another donor. The blood units can then be stored and saved to be used during operation as whole blood or reconstituted red cells to replace operative blood loss requirements in operations (such as this patient is having) on large joints or blood vessels. so that one. Opening statement: 'Are there any advantages in using my own blood it I need a transfusion?' (Specifically minimising infective and incompatibility risks) Questions to ask if not already covered: • 'How long is the blood good for?' ( U p to five weeks) • 'How much do they take?' (Up to 2 litres over a period of 2-5 weeks) • 'Don't I need all my own blood?' (Your blood rapidly regenerates. Replacement of the red cells starts immediately after donation and the slight anaemia resolves within weeks as the blood cells are replaced. • Blood donors can give readily 10-15% of the blood volume (450 mL) and the fluid volume is rapidly replaced within hours from the body's reserves. 111 .

and although not entirely free of risk. Screening for HIV does not give absolute freedom from risk. CRITICAL ERROR COMMENTARY . In industrialised communities. who are to have a planned major elective surgical operation on a defined date some weeks ahead at which blood losses are expected to be moderate or high.017 Performance Guidelines • The procedure is recommended in patients with no medical contraindications to blood donation. There are strict guidelines for the administration and monitoring of blood and any adverse events are documented and reported. so there is always a possibility that the blood would be unavailable for use if the operation was inadvertently long delayed or cancelled for any reason. Blood is usually collected from volunteer donors only. screened for antibodies and cross-matched with the potential recipient. All blood samples are carefully screened for important communicable diseases. because the thinned blood flows more freely. Some countries will not accept donors who have come from countries where 'mad cow' disease has been identified. hepatitis B and C virus (HBV. Blood is only given to patients when strictly necessary. pulmonary embolism. The procedure of donation does not cause any increase in liability of operative problems or complications and the modestly lowered haemoglobin level causing temporary 'thinning' of the blood may be protective against thrombotic clotting complications such as deep venous thrombosis. The procedure would not necessarily remove all likelihood of requiring an additional non-autologous transfusion. heart attack or stroke. risks and principles of autologous blood transfusion. To explain the benefits. but will significantly reduce such prospects. as a window period occurs after primary infection until antigen is detectable and seroconversion occurs after several weeks. thus allowing for preoperative collection and storage including: ~ advantages of autologous over homologous blood transfusion: and ~ circumstances in which autologous transfusion may be considered. is rigorously supervised and a safe procedure in Australia. including human immunodeficiency virus (HIV). blood transfusion is now extremely safe. In Australia there is no remuneration or any form of inducement other than a demonstration of community spirit. Blood transfusion is used sparingly for elective surgery and otherwise healthy patients can tolerate haemoglobin concentrations down to 80 g/L.none d e f i n e d There are two components to the task: • • To provide education on the transfusion of blood and blood products. Donors are screened for high risk circumstances and the donated blood tested. • • • KEY ISSUES • Appropriate explanation of blood being a renewable tissue. which will depend on volume of operative loss. There will always be a risk of infection and of concern is the rare hepatitis G virus and the prion transmission agent responsible for Creutzfeldt-Jacob disease (CJD). Preoperative autologous blood collection for subsequent operative use depends on a verified and non-cancellable time for surgery. Non-autologous/homologous blood transfusion itself is used to save many thousands of lives each year. HCV) and syphilis. 112 . and the blood is grouped.

Intraoperative autotransfusion can be used in major trauma and vascular surgery. Other techniques that can be used include intraoperative autotransfusion (operative blood salvage) and erythropoietin. With pre-deposit autologous transfusion. The shelf life of allogenic blood is limited and although current techniques of blood transfusion are very safe. and long-term storage. or tumour. Collection and administration of blood for autologous transfusion is an expensive exercise. Stored blood at 4"C has a 'shelf-life' of up to five weeks. particularly single unit transfusions (Give blood by the gallon. intestinal content. Autologous blood transfusion is one such technique. providing the operative site is known to be free of bacteria. immediate availability. and it is likely that a substantial amount of blood will be lost during the procedure. particularly in the 1980s about risks of transmission of HIV infection. if the blood is not used for any reason. which reduces the risk of transfusion of viral infection and also of alloimmunisation and incompatibility reactions. deliberate preoperative haemodilution can be induced by removing one or two units immediately before surgery to be used during surgery to replace operative losses. A clinically effective red blood cell substitute would thus be beneficial in terms of universal compatibility. This contrasts to other communities. not by the gill). Several techniques can be used to avoid the need for bank blood. haemodiiute the patient with crystalloid and then use the freshly removed blood as required. such as USA. Recombinant human erythropoietin can be used to stimulate the body's own blood reserves prior to elective surgery. stimulated interest in avoiding or reducing the use of donor blood. The future: The use of allogenic blood will always involve the need for compatibility testing. Another variant on autotransfusion. Starting a maximum of five weeks before the planned procedure. where the use of autologous transfusion is more common (up to 5% in some regions). Major potential candidates are haemoglobin solutions and perfluorochemical emulsions. Concerns about the safety of blood transfusion. at which time around 70% of the red cells still survive normally. freedom of disease transmission. where blood transfusion is generally perceived as being safe. is to take off 1 L of blood immediately prior to operation.017 Performance Guidelines Autologous transfusion is only considered when: • • • the date of the surgical procedure can be virtually guaranteed: the patient's haemoglobin concentration exceeds 110 g/L (135 g/L in women). disease transmission from viruses is unlikely to be completely eliminated because of false negative results during the window period. In Australia and UK. Blood salvage techniques to collect and retransfuse blood lost during surgery can be employed. 113 . Alternatively. and where emergency surgery and pressures and operating list revisions make it difficult to set definite dates of elective surgery. as noted above. As the equipment required to run such systems is expensive. it cannot be put into the general donor pool and will be wasted. The technique can be considered for chronic renal failure patients who are anaemic and as a blood-saving strategy in major surgery. intraoperative autotransfusion does not usually make significant dollar savings over standard banked blood. patients can donate 2-5 units (of450mL) at approximately weekly intervals before elective surgery. the patient donates a unit (450 mL) a week and is given ferrous sulphate supplements. the techniques of autologous transfusion are applied only in a minority of cases. Because the donor (the patient) is not a standard blood donor.

and intravascular oncotic stability equivalent to that exerted by plasma proteins with oxygen-carrying capacity. chemically binds and carries oxygen (1 g Hb binds 1. Oxygen is unloaded from Hb in capillaries at 40 Torr. the tetramer. dextrans).017 Performance Guidelines The haemoglobin molecule. and simple balanced electrolyte solutions. Efforts to modify the tetramer to improve safety include polymerisation and other techniques. 114 . In the meantime. The unmodified tetramer is potentially nephrotoxic and vasoconstrictive. Continuing research into synthetic blood substitutes thus continues in an attempt to produce a non-toxic temporary fluid combining volume replacement. the major alternative volume replacement fluids available are albumin solutions. solutions utilising other colloids (gelatin.39 ml_ 02 and is fully saturated at ambient pressure).

Questions to ask if the topic has not already been covered by the candidate: • ‘Is it too late for me to stop? Is the damage already done?' • 'How easy is it to stop?' • 'Do / have to stop abruptly or can I just cut down gradually?' • 'Do hypnotherapy or acupuncture or alternative remedies like herbs or vitamins work?' • 'What are the risks/benefits of nicotine patches/gum or mood tablets? Are they expensive? What are the side effects?' • 'What should I expect by way of withdrawal symptoms? • ’Will the treatment affect my sex life?' • ‘Do I need to do a course or join a quit smoking group?' • ‘Is the desire to smoke inherited? Will I pass it on to my children?' 115 . Opening statement: Start the interview by saying: I've been thinking about your advice last time about my smoking. depending on the content provided.018 Performance Guidelines Condition 018 Advice on stopping smoking to a 30-year-old man AIMS OF STATION To assess the candidate's knowledge of nicotine-dependence and the ability to obtain relevant information to counsel the patient appropriately and to answer his questions about the withdrawal process and treatment options. and respond appropriately. You are engaged to be married and have attended your general practitioner as a followup to a recent episode of an upper respiratory infection associated with a cough. With your impending marriage. On the previous visit to your general practitioner. employed in a State Government Department. What can you do to help me?' Appear interested. Ask questions and seek clarification. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 30-year-old information technology specialist. You have been a cigarette smoker since your mid-teens and currently smoke 20 cigarettes a day (on average). you have been considering stopping smoking. I would like to stop. engaged and genuinely motivated at this time to stop smoking Listen carefully to the advice and information provided by the doctor. the doctor had briefly suggested that you should stop smoking for the benefit of your health.

on a scale from 'not at all' to Very much'). increase in appetite so that you may gain up to 3 kg over the next 12 months: cravings for sweet things. and cravings for cigarettes. the candidate should not only ask about the number of cigarettes a day the patient smokes. anxiety and difficulty concentrating. Withdrawal symptoms: • • • peak in intensity over the first four days of abstinence.018 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should display appropriate empathy. Questions which would be appropriate from the candidate to the patient are: • • • • • • • 'How many cigarettes a day do you smoke? 1 ‘How soon after you wake up do you have your first cigarette?' 'Do you find it difficult not to smoke in nonsmoking areas?' ‘Is the first cigarette of the day the hardest to give up?' ‘'What is your pattern of smoking during the day?' 'Do you smoke even if you are so ill that you cannot get out of bed?' ‘Have you tried to stop smoking for good in the past but found you could not?' The patient's answers to these questions will shape the advice that the candidate then gives. ADVICE ON NICOTINE WITHDRAWAL Within 24 hours of reducing or stopping nicotine intake you may experience: • • • • • • • • depression or otherwise feeling unwell. involves a long term. drop in heart rate over time. The patient is in the preparation' stage of behaviour change (planning to stop in the near future) and is hoping to learn 'action' strategies that will help him succeed in overcoming his dependence on nicotine. A 'yes ' response to the last question suggests that the patient will need help to stop smoking. About 5% of nicotine-dependent individuals can stop smoking unaided and less than 25% of people succeed at their first attempt to quit. hunger and weight gain may persist for a year or so. but focus more on the pattern of smoking during the day (smoking more in the first hours of waking is more significant and suggests a greater degree of dependence). 116 . most residual symptoms improve significantly within a month. When a patient smokes 20 or more cigarettes/day and has to have the first smoke within half an hour of waking up then the patient is likely to benefit from nicotine replacement therapy (NRT) or bupropion. rapport and enthusiasm for explaining the benefits and pitfalls of smoking cessation. Motivation to stop in this patient should be assessed by the candidate asking direct questions about his intentions and desire to stop (for example. In order to assess how dependent the patient is on nicotine. even lifetime struggle to achieve abstinence. Overall the successful quit rate is about 45% eventually. insomnia. restlessness and irritability. Cigarette dependence is a chronic relapsing condition which. once established.

acid drinks such as fruit juice should be avoided. Costs of NRT may influence patient choice. of the plan. carcinogens or carbon monoxide. weight gain or depression). • Review previous attempts at quitting and what went wrong! • Inform family and friends.018 Performance Guidelines KEY ISSUES • Counselling abilities. the following key elements into their counselling. then left between cheek and gum before being repositioned and chewed intermittently for up to 30 minutes. Smokers extract about 1 mg of nicotine per cigarette independent of the brand used. NICOTINE REPLACEMENT THERAPY (NRT) The aim of nicotine replacement therapy (NRT) is mainly to ameliorate nicotine withdrawal. Because nicotine is poorly absorbed from an acid environment. • Avoid alcohol. particularly other smokers. • Recommend starting or increasing physical activity and the importance of a balanced diet. Forms of NRT include: • NICOTINE GUM contains nicotine 2 or 4 mg per piece in a sugar-free resin base.g. COMMENTARY Principles of a tobacco cessation programme follow. although each cigarette may contain up to 14 mg of nicotine. but they are not accompanied by tar. • Anticipate and discuss likely individual pitfalls and difficulties (for example. Candidates should have a broad knowledge of the content. coronary artery disease or pregnancy). The gum should be chewed slowly. which is an important trigger for smoking. and incorporate most of. • Encourage the use of nicotine replacement therapy unless there are contraindications (e. 10 times a day. Neither patches nor gum give the arterial 'high' concentration of cigarettes and the overall dose of nicotine they provide is about 40% of that provided by cigarettes. and are expected to be aware of. KEY ELEMENTS OF CIGARETTE/NICOTINE WITHDRAWAL PROGRAMME The key elements of a cigarette/nicotine withdrawal programme include: • Set a definite QUIT BY date (within two weeks of making the decision to quit). but are generally cheaper than continuing to smoke. 117 . and similarly review coffee intake. • Aim for total abstinence — not just 'cutting down'. • Practise problem solving as a way of dealing with 'what do I do if/when'. Lozenges are an alternative. • Awareness of principles of a tobacco quitting programme. Mouth soreness or dyspepsia may occur. • Schedule followup visits and supportive phone calls. CRITICAL ERROR • Lack of awareness of the key elements of a nicotine quitting programme.

come in a variety of dosage strengths from 7 mg to 21 mg and in preparations designed to be used for 16 or 24 hours. Skin reactions or rashes may be severe enough to warrant discontinuation. There is no reliable evidence to recommend gum over patches or inhaled. and are used for 8-12 weeks. Patches are applied each morning on a rotational basis to non-hairy skin sites. All forms of NRT are effective as aids to stopping smoking. They are not available on the Pharmaceutical Benefits Scheme. Whilst NRT is effective by itself in achieving abstinence. Maintenance may last a further six months. OTHER SMOKING CESSATION STRATEGIES AND AIDS INCLUDE: • Bupropion (slow-release — Zyban®) is an atypical antidepressant with both noradrenergic and dopaminergic activity. badges and audiovisual and multimedia tapes in different languages are available through the various state health departments. each roughly doubling the chances of successfully quitting. ~ Sustained-release bupropion has been shown to be efficacious in producing abstinence in cigarette smokers either with or without adjunctive psychological interventions. but to common addiction pathways. The initial strength of nicotine dosage will depend on severity of dependence as well as average daily intake of nicotine from cigarettes. They are designed to release nicotine slowly through the adhesive layer of the patch to the skin and hence into the circulation. Nortriptyline 10 mg/day has also been trialled as an alternative to bupropion. • NICOTINE INHALERS are less popular. 118 . About 4 mg of nicotine is released by the device which is single use only and cannot be reused or recycled. • • • Clonidine is uncommonly used to moderate withdrawal symptoms. family and friends will increase the success rate. They may be used together but monotherapy is preferred. behavioural support from the doctor. which can supplement face-to-face counselling. ~ The standard treatment period is nine weeks which is subsidised under the Pharmaceutical Benefit Scheme in Australia. preferred by many patients. ~ It must not be prescribed during pregnancy. ~ Treatment starts at 150 mg/day for the first three days and then increases to 150 mg twice daily. insomnia and dry mouth are the commonest early side effects.Bupropion is absolutely contraindicated in patients with a history of epilepsy: and is relatively contraindicated when there is a history of Type 1 or 2 diabetes.018 Performance Guidelines • TRANSDERMAL PATCHES. which may mean 10 or more cartridges need to be used per day for up to 6 months. ~ Mechanism of action as an aid to smoking cessation is not related to its antidepressant action. stickers. ~ Nausea. . Pamphlets. Gaseous nicotine is released after deep inhalation through the mouthpiece of a plastic cartridge.

heart disease. Quitting at any age will give major health benefits and reduce your risk of tobacco related illnesses. • Carbon monoxide . stroke and lung disease. anxiety or other mental illness. Lower tar or 'light' cigarettes are not any better as you are likely to take deeper putts. and miscarriage and complications in pregnancy and labour. You will: • Breathe.018 Performance Guidelines General Health 0109 . a minimum of $2300 per year for a pack a day habit. Harmful ones include: • Nicotine . immune system and the health of your heart and lungs • Have fewer days of illness and fewer health complaints than continuing smokers • Provide a positive example for children and others • Save money. We know that stopping smoking can be Ï stressful. heart and brain with less oxygen. • Tar . FIGURE 1. Smoking by the mother is a major risk factor for sudden infant death syndrome (SIDS or 'cot death).contains many cancer causing chemicals. Passive smoking causes heart disease and lung cancer in non-smokers living with smokers. So if vou have suffered from an addictive drug and can make it hard.2004 SMOKING Quitting smoking is one of the most important actions you can take to protect yourself from chronic disease and early death. Smoking affects your immune system and is ■ cause of many other conditions such as blindness and osteoporosis. Smoking cessation pamphlet 119 . Harm to others Environmental tobacco smoke comes from both the burning end of a cigarette and from the smoke breathed out by a smoker. Do you know why you want to stop smoking? It's important to be clear about your reasons. Children exposed to passive smoking are more likely to suffer from health problems including asthma. but not impossible. This harms not just the jjf smoker. coughs and chest infections. It affects fertility levels in men and women and can lead to impotency in men. One in two lifetime smokers will die from their addiction. Pharmacy Serf Care is a program Society of Australia of the Pharmaceutical CONDITION 018. These are some of the best reasons to quit.replaces some of the oxygen in your blood. Health effects of smoking Tobacco smoke contains more than 4. to get the amount of nicotine you need. It also affects vour heart rate and blood pressure. Half of these deaths will occur in middle age. but also family members and coworkers. more often. speak to your doctor before quitting. to quit.000 chemicals. and/or are taking medication. leaving your muscles. Before you quit Chemicals in cigarettes change the way some medications work. meningococcal disease. and taste and smell food better within weeks • Improve vour circulation. Smoking increases the risk of cancer. With planning and determination you can quit and stay a non-smoker.

018 Performance CONDITION 018. Examples of some nicotine replacement therapies (NRT) available Guidelines 120 . FIGURE 2.

. You consulted this doctor two days ago. The doctor enquired about your use of alcohol and other concerns at length. The examiner will have instructed the patient as follows: You are a 45-year-old businessman who has become concerned about the harmful effects of alcohol. sequelae. • Discuss the effects of excessive drinking in counselling and educating the patient ~ Other physical sequelae on gastrointestinal tract. ~ Family problems. The doctor said your use of alcohol was of concern and asked you to have some blood tests. 121 .The candidate should make this clinical suspicion clear to the patient and explain that excessive drinking is also linked with his hypertension and excessive weight. elevated mean corpuscular volume (MCV) and macrocytosis should confirm the candidate's clinical suspicion of liver disease due to excessive harmful drinking. and skill in counselling a person who has been drinking hazardously over a long period of time. cardiovascular system and central nervous system. and then examined you. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate's approach to the patient should be nonjudgmental and supportive. including early presentation. You should be rather passive. but you considered yourself to be an 'average drinker' for your personal situation in life. drinker for many years. work problems. You have been a regular. Be complimentary about patient's initiative to consult about his drinking (this is positive and helps probability of compliance). as revealed from the history obtained at the previous consultation. exhibiting acceptance of the doctor's advice. sexual problem. The candidate should: • Explain test results and their interpretation ~ The elevated Gamma glutamyl transaminase (GGT) and Aspartate transaminase (AST). You have returned today to discuss the results. minor accidents. while showing a contemplative demeanour that suggests that you may not have made up your mind about modifying or stopping your alcohol intake. types of dependency.019 Performance Guidelines Condition 019 Excessive alcohol consumption in a 45-year-old man AIMS OF STATION To assess the candidate's knowledge of hazardous drinking. now daily.

K. Indicate availability to assess and treat any symptoms which may arise such as tremor. the candidate should: ~ suggest further consultation shortly. ~ hazardous: 5-6 standard drinks per day. As initial management. R. Stockwell.019 Performance Guidelines • The 'CAGE' or 'AUDIT' questionnaires could be applied during this I I hazardous alcohol 122 .. 2000.. or during counselling: ~ Cutting down on your drinking?: Annoyed by criticism of drinking?.list. Hulse. Screening for use and dependence in psychiatric in-patients using the AUDIT questionnaire. http://espace.R. M. Eye opener needed in the morning? ~ Alcohol Use Disorders /dentification Test. ~ Psychological (may apply to this patient). excitability and craving. sweating..B. • Discuss the significance of amount and duration of alcohol use in determining risk oi physical dependency. behavioural. G.R. sweating. work. ~ offer to see wife. hyperarousal through to delirium tremens). When conventional glasses/containers are used. Hallmarks of physical dependency include: ~ increasing alcohol tolerance (which decreases in later stages). Guilty about your drinking?. and Basso.curtin. • • • symptoms by further alcohol consumption. 1 • Counsel the patient about safe drinking using National Health and Medical Research Council (NHMRC) Guidelines for men: ~ low risk: less than 4 standard drinks per day. ~ The test results show that he is demonstrating clearly harmful and progressive effects of excessive drinking. • 1Curtin: Research Centres: University Research Institutes: National Drug Research and ~relief from withdrawal (benzodiazepine). and ~ harmful (high risk): more than 6 standard drinks per day. As followup management. Roydhouse. social and individual settings.. advise a period of abstinence to test presence and/or degree of physical dependency. Explain that excessive habitual consumption/dependence can be associated with target organ damage without psychological or social disorders and vice versa. emotional and cognitive sequelae of excessive alcohol use in family. ~ Physical (probably applies to this patient). ~ withdrawal symptoms (tremor. J. • Explain types of dependency: ~ Social (applies to this patient). T. the volume of each drink reduces as the strength increases. Saunders. or agonist Discuss the social.M. Adjustments must be made for the different strengths of beer because cans/bottles are the same size. • Counsel the patient that the test results show that his drinking level is above safe drinking levels: ~ A 'standard drink' contains approximately 10 grams of alcohol.

  Australia Pharmacy Serf Care is a program of the Pharmaceutical Society of CONDITION 019. and are  not elderly. alcohol problems affect the health and well being of many individuals. You do not need to  get drunk tor this to cause harm.2  Check the label All alcoholic beverages have the number  of standard drinks in the container on the  label. Alcohol ingestion guidelines 1 .  How much is too much? • Drinking at risky or high‐risk levels means  drinking many drinks in one day.Wml spirit nip I  300ml alcoholic soda 1. They are for people who  are not on medications. pregnant or breastfeeding.  families and communities. the levels  recommended in the guideline for the general  population should be reduced.  drinks in any one day  Number of alcohol‐free  days per week  1‐2  1‐2  What is a standard drink? The pictures below show the number of standard  drinks found in typical serving  containers. In Australia. Be careful ‐ glasses  of wine and spirits can vary  widely in size and alcohol  content. Many people drink in ways that put themselves at risk of alcohol‐related  harm.  • Hxcessive alcohol consumption can cause health  problems in the longer term. If you weigh  less than 60 kg for men or 50 kg for women.  Average number of  drinks per day  Men  4 or less  Women 2 or  less  Maximum number of  drinks per week  Maximum number of  28  6  14  4        1.8  . FIGURE 1. or are  about to drive or operate machinery. more  than eight standard drinks a day. You do not  need to do this regularly to cause harm. Use this to calculate the number of  standard drinks.  180ml average restaurant serve of wine   What do the Australian Alcohol Guidelines recommend? People who drink regularly (almost daily).  375ml full strength beer  Who are the Guidelines for? The Guidelines indicate the low‐risk drinking levels  for the general population. should see their  doctor before attempting to change their drinking  habits. do not have medical  conditions that are made worse by drinking.019 Performance Guidelines Self Help 0506-2004 ALCOHOL  Alcohol  can  interact  with  some  medications  and  certain  medical  conditions  can  be  made  worse  bv  drinking alcohol. The Australian Alcohol Guidelines recommend levels for low‐risk drinking.

order and emphasis offered by the candidate will vary and examiners will need to give a global assessment of the candidates interpretation of the test results and counselling skills with regard to hazardous drinking. 124 . • • • Interpretation of results of liver function tests (LFTs) and full blood examination (FBE). the next step in management is to test this assumption by asking the patient to try abstinence and see what happens. Advising a period of abstinence to establish type and degree of dependency. in which the type of dependency is uncertain at this stage. but that he can expect ongoing support in followup.019 Performance Guidelines ~ mention availability of Alcoholics Anonymous. The patient is likely to have true physical dependency. and ~ make clear to the patient that he has to come to his own decision about what to do. this case allows assessment of the candidate's communication skills and knowledge of counselling as the principal form of management in a behavioural problem. Explanation of effects of hazardous and harmful drinking. The content. Subsequent management will depend on the result and the willingness of the patient to accept and control the type and degree of dependency on alcohol. The above points serve as guidelines only. • Taking a judgmental attitude and blaming patient for his condition As well as knowledge of hazardous drinking. Weight reduction and control of hypertension will need to be undertaken but cannot be successful unless use of alcohol is modified.

This will ensure that the candidate has the opportunity to cover all of the questions in the allotted time. The questions chosen are similar to those asked by parents who are anticipating the problems that they may encounter in the months after initial diabetic education and discharge from hospital EXAMINER INSTRUCTIONS The examiner will have instructed the mother as follows: As many candidates have a tendency to refer any question they are uncertain of to a higher authority (for example. you should not accept that answer. Each question asked by the parent requires an answer from the candidate so that examiners should keep a close watch on the time. Satisfactory candidates will answer each of the following questions asked and cover most of the following points.020 Performance Guidelines Condition 020 Type 1 diabetes mellitus in a 9-year-old boy AIMS OF STATION To assess the candidate's knowledge of practical aspects of childhood diabetic care — which is not very dissimilar to adult Type 1 diabetic care — and the candidate's ability to answer queries of a concerned parent. she will be confident in handling her child's diabetes and in teaching other people with whom he will be in contact to understand and manage his diabetes. 125 . their registrar or consultant). and indicate to the parent to move to the next question if the candidate is either spending too much time on detailed information. but ask what sort of things the consultant is likely to say about that question. Questions to be asked by the mother (in this order) Opening Statement 'Will he need insulin injections each day from now on?' If the candidate indicates (correctly) that the child will require daily insulin. or does not provide the appropriate explanation. ask how often and then ask 'Who is going to be giving Roger's insulin from now on?' ‘How do I assess the day to day control of his diabetes?' 'What do I need to do about his school?' 'Will he be able to go to school camps? What should I do about them?' ‘He went to his first sleepover party a few weeks ago — could he still go on these now?' 'Can he play sport?' The above questions are designed not only to test the candidate's knowledge but ability to reassure the parent that with appropriate tuition.

FIGURE 1. Candidates should indicate that the Paediatric Unit staff and educators will ensure that parents are confident of drawing up and administering insulin before discharge. This is best left until teenage and when the child is ready to accept four injections per day. and perhaps an older sibling. These levels are usually assessed before each meal and before bed at night.020 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Opening statement/Need for insulin injections? The candidate should indicate that the child will be on life-long injections of insulin and should go on to describe that this is usually in a regimen of twice daily insulin injections consisting of a combination of a short-acting insulin and an intermediate-acting insulin to allow for a 24-hour cover. or if the child is unwell for any reason. This is usually adjusted based on a trend over several days rather than on a day-to-day basis. Q 3 Monitoring? The candidate should indicate that blood sugar levels are monitored several times daily by a glucometer (illustrated). The doctor should also indicate that urine testing for ketones should also be done if the blood sugar levels are persistently high. Similarly they should understand how and when to give glucagon. Glucometer kit for blood glucose monitoring 126 . when confident. to be able to review the blood sugar levels and to recognise if an adjustment in the insulin dosage is required. the details of which will be shown to the parent. CONDITION 020. This allows the clinician and the parent. and if necessary will arrange help at home from the District Nursing Service after discharge. should learn the injection technique in case of parental sickness or absence. Q 2 Who injects? The candidate should advise that both parents if available. At this age it is usually inappropriate for children to be on basal/bolus insulin regimen.

Q 6 Sleepovers? These should also be encouraged for reasons previously discussed. this should usually be at a home close to the child's home so that if necessary the child's parent may be able to call over and do the blood test as well as give the insulin in the evening and next morning. He will be excluded from some activities (for example. Management is related to the confidence and experience of the teachers involved and how comfortable the parents are with the teacher's knowledge. 127 . Similarly the school should be given phone numbers to ensure that the parents. parents are often encouraged to attend as camp parents and this would be appropriate for this family if one or other parent is able to do so. If the camp is in a distant town. The parent should be advised that the aim of the treatment and education program is to allow the child to live as normal a life as possible and Roger should be encouraged to participate in all the school activities. the child's general practitioner and if necessary the Hospital/Children's Ward can be contacted in an emergency. Some school camps have permanent staff who have children attend with a variety of medical conditions (for example. Similarly. The parent will also be advised to take every opportunity to review these important aspects of care with the school staff and to ensure that any new staff are made aware of the child's condition. supervising teachers with good clinical acumen are a prerequisite. Many camps for young children are held relatively close to the school district. A good candidate will mention that insulin doses may need to be adjusted prior to active sport to allow for the increased glucose metabolism associated with physical activity. and these staff are given special detailed instructions as to the complications and management of these conditions. Q 7 Sport? The parent should be assured that there is no reason why the child cannot play most sports. but the parent should be satisfied that the personnel involved are cognisant with the treatment for the child. With young children. The parent should be encouraged to enquire as to the knowledge of the staff involved. so that there can be a frank informative discussion on the child's management. blood sugar levels and telephone contacts. until the child is old enough and reliable enough to do these by himself. This usually is possible. which is highly likely to be known to the host family. Sleepovers should usually be at the home of a family who know the child and parents well. In an emergency most schools will contact the Ambulance service who will be capable of managing the situation on arrival. piloting an aeroplane).020 Performance Guidelines 0 4 School liaison? The candidate should advise that the parent should notify Roger's school of his diagnosis and indicate that the school will probably be visited soon after the child's discharge from hospital by the Ward diabetic educator in association with the parent to instruct the relevant school staff as to the important features related to possible complications at school (the most likely one being hypoglycaemia and how to detect and manage it). The Paediatric Unit. in conjunction with the parent will support the teachers by education and telephone support. epilepsy and diabetes). but a letter should be supplied to a local medical practitioner explaining the child's diagnosis and providing details of the insulin regimen. Q 5 School Camps? Management at school camps may vary often depending on the age of the child.

020 Performance Guidelines The candidate should be able to counsel the parent in a reassuring manner that parents will not be left entirely on their own in the management of their child. The emphasis in many of the answers should be allowing the child to lead as normal a life as possible. The key to success in these situations is whether parents are well educated in their child's condition and can confidently instruct others accurately in the management of the child. 128 . Most of the detail for this case is provided in the examiner's instructions. and that help is but a phone call away. if any. in lifestyle. Under most circumstances this can be achieved. so that school and social activities should be maintained wherever possible. Most candidates should be able to handle this discussion with ease and confidence by applying general principles in their discussion and this should comprise part of the overall assessment of the candidate. Families who achieve this are generally very successful in managing their child's diabetes confidently and appropriately. The scenario is designed to assess both the knowledge of the topic and the candidate's ability to provide accurate information in a reassuring manner to a parent who is trying to cope with a diagnosis. and the child is generally able to progress satisfactorily through childhood with minimal restriction. which to most parents is initially devastating and upsetting. Much of the advice to be given is • Ability to answer the specific questions of the parent accurately and sensibly CRITICAL ERROR • Failure to discuss symptoms and treatment of insulin-induced hypoglycaemia common sense in relation to the ongoing care of a person with diabetes and should not be a problem to the competent candidate.

success uncertain. and haematoma). and these reduce fertility. • 'Can it be done as a day procedure?' (Yes). test repeated on at least two occasions). not after recovery from operation). temporary discomfort. wishes to cease oral contraception because of weight gain. success is not 100%). 129 . • ‘What is actually done?' (Description of identification and division of vas). bruising. effectiveness. Your wife would prefer not to have a tubal ligation. • ‘Can the operation be reversed?' (Reversal requires microsurgery. A condom must be used until the result of the postoperative sperm count is known. recanalisation of vas can occur rarely). reliability. • 'How long afterwards can we resume normal sex?' (As soon as you are comfortable. • 'Are there any complications?' (Wound infection. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Your wife aged 34 years. and any adverse effect on your sexual performance. Because sperm antibodies can occur. You want a-vasectomy but have reservations about the operation because of possible complications. • 'Will I have a general anaesthetic?' (General or local used with sedation). She has taken 'the pill' since the birth of your son now aged seven years. Questions to ask unless already covered (the candidate's expected responses are in brackets): • ‘Is it 100% effective?' (No. its complications. You are happily married with a mutually satisfactory sexual relationship and neither of you wishes to have another child. • ‘Will my wife notice any difference?' { N o ) . who works as a secretary. • ‘Does my wife have to sign anything^' (Preferable if both provide written permission). reversibility and effects on sexual performance.021 Performance Guidelines Condition 021 Request for vasectomy from a 36-year-old man AIMS OF STATION To assess the candidate's ability to explain the surgical procedure of vasectomy. You have no extramarital relationships. • ‘What happens to the semen?' (Semen ejaculated but no sperm). even if the tubes can be connected satisfactorily. or wife should continue to use the pill until the sperm count is clear). • ‘How do you know it has worked?' (Semen analysis showing no spermatozoa after 20 or so ejaculations. You also have a daughter aged nine years. absence from work. • ‘Will there by any change in my sexual performance?' (No.

• Adequate explanation to the patient of the procedure and its followup.021 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • • • • Give reassurance about result of checkup (good health). Counselling • • • • Recommend involvement of patient's wife — offer to discuss procedure with her. patient education material (e. Royal Australasian College of Surgeons patient information brochure). Timing and effect on sexual activity/performance. Advise that she should preferably also give written permission. The candidate may have religious or cultural objections to contraception in general or vasectomy in particular.g. If so. Discussion of alternatives. This recognises the patient's right to seek the procedure and the doctor's right not to remain nvolved beyond this consultation. 130 . Postoperative sperm counts. candidates have been advised to inform the patient of their position at the beginning of the consultation. Provide information in a clear and concise manner. but to suggest appropriate referral after initial discussion. False reassurance that a vasectomy is easily reversed. Effectiveness and reversibility — although reversal is sometimes possible. Deal with patient uncertainties. • • • False reassurance that the procedure is 100% effective before at least two negative sperm counts. Explanation of the procedure • • • • • • Surgical procedure of vasectomy — how it is done. medical knowledge of the procedure is still expected together with the communication skills required in explanation. Use of diagram. condom or diaphragm with spermicidal). However. Permission of the patient's wife is not obligatory but is strongly advised by medical defence organisations.e. Inconvenience and complications. Refusal to discuss sterilisation. Be supportive and give honest advice about the procedure. Appropriate consent for vasectomy is required. vasectomy should effectively be regarded as a method of permanent sterilisation. Clarification that they need to use contraception until seminal analysis is negative. (i.

1-B: Case Presentations to Examiner Vernon C Marshall 'Begin with an arresting sentence. 131 . in between speak simply. Whatever the circumstances. clearly and always to the point. close with a strong summary.' William J Mayo (1861-1939) American physician Case Presentation and Discharge Summary scenarios 022-029 02 2 02 3 02 4 02 5 02 6 02 7 02 8 02 9 Headache Neck lump Previous shoulder dislocation Dysphagia Low back pain Knee pain Abdominal discomfort Gastric ulcer with haemorrhage Verbal Case presentation to an observing examiner or senior colleague is a fundamental part of clinical medicine. It may consist of an informal exchange of information between colleagues on a ward round or it may be a more formal presentation to an examiner or to a group in examination circumstances. it is essential that the listener's interest and attention are kept and that information is clearly accurately and sensitively transmitted. and above all be brief.

systems review. a biopsychosocial approach. Relevant data should be given in a systematic and concise form highlighting the presenting problem. practice in delivering summarised case presentations to an observing examiner (as could occur in an extended or composite station) is well worthwhile as an aid to improving your communication skills. It may consist of an informal exchange of information between colleagues on a ward round. Proceed to a narrative.1-B Case Presentations to Examiner CONDITION 022 CASE PRESENTATIONS A number of AMC MCAT communications with examiners will involve answering questions or prompts asked by the examiner to clarify points of diagnosis or management. begin with patient identification (age is essential) and reason for presentation. it is essential that the listener's interest and attention are kept and that information is clearly. centred on the individual patient's presenting condition and problem and the demographic and psychosocial environment. Alternatively. These usually require brief and succinct candidate answers. Whatever the circumstances. ' Examiner: 'Are any alternative diagnoses likely?' Candidate: ‘I think the clinical presentation fits tension headaches rather than migraine. or may be confined to one of these domains. accurately and sensitively transmitted. investigation findings. to best effect and in a logical manner. Verbal Case presentation to an observing examiner or senior colleague is a fundamental part of clinical medicine. or it may be a more formal presentation to an examiner or to a group in examination circumstances. 132 .’ Examiner: 'Please now advise your patient of the likely diagnosis and your management plans. risk factors. which may sequentially summarise examination findings. and to organising and presenting clinical reasoning skills in data acquisition. Example 022 Examiner: What do you believe is the most likely diagnosis from the information you have found so far?' Candidate: 'Tension headaches. If asked to describe what task you are doing as you proceed (such as performing a physical examination). and diagnostic and treatment plans. You may find it easiest to do this along disease-centred diagnosis approaches by succinctly summarising history. diagnostic and investigational plans and management — separately or sequentially. To summarise a patient's problem fully. with most of your communication interchange being with the standardised patient. the presentation needs to be given in such a way as not to upset the patient. If the patient is also present and listening. depending on circumstances. and evolving into a coherent whole. examination findings. may be preferred. assimilation and interpretation.’ In most of these multiple short assessments your oral presentation to the observing examiner will be necessarily brief. However. make sure you both describe and perform. I don't think a serious cause like temporal arteritis or raised intracranial pressure is likely.

: Example 026 Examiner: Please summarise your history and findings and your provisional diagnosis ' Candidate: 'The patient is aged 25 years and has had low back pain with sciatic radiation after a lifting strain at work two weeks ago. He has painful limitation of back movements and symptoms and signs suggesting lower lumbar nerve root impingement. I believe the most likely diagnosis is a lumbar disc prolapse with L5 radiculopathy'. Next I shall test reflexes and power. Example 024 Candidate: (To the examiner) 'The patient has had a past history of dislocated shoulder of his dominant right arm and my task is to assess the current status. 7 am now looking for muscle wasting. He walks with a painful limp favouring the right leg. 'and missing the obvious muscle atrophy which is present. neck and abdomen. probably a neoplasm. and the external ear for any primary pathology'. Example 025 Examiner: 'What is your provisional diagnosis?' Candidate: 'The patient is aged 60 years and has a history of progressive painless dysphagia for the past 6 months associated with weight loss. You have informed me that physical findings are noncontributory in the chest. I shall begin by inspection of contour looking in particular for wasting or deformity None is apparent (make sure you have looked). Example 027 Examiner: Please summarise your findings on physical examination so far'. the oropharynx and nasopharynx. / shall now test the range of active movements.. ' (To the patient) 'Please face me and move your arms as I do'. comparing these to the opposite normal side. 133 . He needs further investigation by diagnostic imaging or endoscopy. Then go ahead and do what you said you will do. so I shall order a contrast swallow now as well as arranging consultation for an endoscopy'. I think the most likely diagnosis is an oesophageal lesion.. He finds it difficult to bear weight on that side. I shall explain this to him and arrange appropriate referral and followup.. by not actually looking. Preliminary contrast imaging may help by identifying the site of a stricture and can show extralumenal aspects like extrinsic compression. One of the most common errors is failing to observe appropriately.. Examiner 'Please now advise the patient of your recommendations'. and painful to kneel or squat'.1-B Case Presentations to Examiner CONDITIONS 023-027 Example 023 Candidate: 'The patient has a lump in the right anterior triangle of the midneck which feels like a lymph node enlargement. Candidate: 7 was asked to examine the right knee area in this young man with a past history of twisting strain to his knee and persisting pain on its inner side. Examiner: 'Which of the two investigations would you choose?' Candidate: 'Endoscopy usually is most definitive. '. I shall proceed to examine the skin of face and scalp.

Example 028 Examiner: 'Please summarise the history you have obtained so far and your provisional diagnosis from the history'. 'She has a recent history of increasing abdominal discomfort and bloating related to meals over the past four weeks. Candidate: 'Mrs S is a 65-year-old widowed pensioner with a number of problems. The other knee appears normal'. and there is no local swelling. Joint stability is stable testing the collateral ligaments and cruciate ligaments. The pain is epigastric and diffuse without radiation. gastritis or reflux oesophagitis as a cause other abdominal discomfort. 'She has had rheumatoid arthritis. I cannot detect any joint effusion. She is currently on 5 mg prednisolone and Celebrex®. He has localised tenderness over the joint line anteriorly on its inner side. 'She was widowed 5 years ago She lives by herself and her three grown children live interstate. 'She had a myocardial infarction 10 years ago with no sequelae. Type 2 Diabetes: Non-insulin dependent diabetes mellitus was diagnosed 5 years ago. 'She has a number of relevant associated problems. Her rheumatoid arthritis has progressively worsened and has caused increasing difficulties in activities of daily living Examiner: How would you plan to proceed?' Candidate: Her multiple medical comorbidities and problems have been mentioned and are likely to be contributory to the presenting problem. ' The above is a good demonstration of a problem-based summary. 'She has always been overweight despite dieting. the deficiency is 15°. Gall stones should also be excluded by ultrasound. She has regular eye and foot and blood checks. She has occasional reflux of bitter fluid. with episodes of greater discomfort which have woken her from sleep intermittently. She gets some relief from a glass of milk. Examiner: What is your provisional diagnosis?' Candidate: 'Injury to the medial intraarticular cartilage'. 'She has a number of risk factors for peptic ulcer disease. There is no muscle wasting. I believe an upper gastrointestinal endoscopy will be needed to check for peptic ulcer. and has been told these are all satisfactory. patellofemoral friction is not painful. She is on diet and oral hypoglycaemics and blood sugar control has been good — BS 5-6 mmol/L. she has not vomited nor passed blood. 'There is a family history of diabetes and of coronary artery disease. affecting predominantly the hands. 'She has hypertension which has been controlled by an ACE-inhibitor. She remains on low dose aspirin.1-B Case Presentations to Examiner CONDITION 028 He cannot fully extend the right knee. for 15 years and has been treated with anti-inflammatory agents and steroids and has required periodic increased steroid dosage for exacerbations. and flexion range is normal. Patellofemoral mobility and tracking appears normal. She neither smokes nor drinks alcohol. 134 . There is no other relevant medical past history.

In a patient whom you have been treating as an inpatient.B • Paracetamol tablets two q. He had a past history of myocardial infarction in 1992 with no sequelae.1-B Case Presentations to Examiner CONDITION 029 Scenarios requiring presentation of diagnostic case summaries to the examiner are exemplified in Conditions 65 (chest pain) and 66 (palpitations and dizziness) as well as in scenarios in other sections. He will require long term acid inhibition medication. Inpatient dates: 13. DOB. He was haemodynamically stable on admission. Biopsy of the edge was performed which confirmed a benign gastric ulcer. He was begun on a proton pump inhibitor (omeprazole) and his steroids and NSAID were discontinued. aged 66years.2004 Title of problem Onset # 1 Gastric ulcer with haemorrhage ~ Haematemesis and melaena ~ Endoscopic fulguration Rheumatoid arthritis # Myocardial infarction Problem number 13. Dr S.2004 1988 1992 Status Active Active Inactive #1 Gastric ulcer with haemorrhage — haematemesis and melaena Mr B. .2004-20. He was discharged after being observed in hospital for a week without recurrence of bleeding. a 66-year-old pensioner. . #2 Rheumatoid arthritis Rheumatoid arthritis since 1988 affecting mainly the hands and wrist.d. Urgent endoscopy was arranged which showed a shallow gastric ulcer in the prepyloric region with a bleeding point which was fulgurated. At time of admission had been on prednisolone for past two weeks. stiffness and deformity causing loss of function. He presented with a history of having vomited blood on two occasions. Hospital Record No . has been taking anti-inflammatory drugs for rheumatoid arthritis diagnosed in 1988. Discharge Summary Name: Mr B.i. the communication required may be a written discharge summary Example 029 Copy of Discharge Summary to local medical officer.2.2.1937. 16. His medications have been Celebrex® with intermittent steroid courses for exacerbations.2. Prognosis is guarded in view of associated risk factors of arthritis likely to require resumption of anti-inflammatory and steroid treatment.8. Medications on discharge: • Omeprazole 40 mg daily • • • Gastroenterology outpatients one week Rheumatology clinic one week Local medical officer. Followup 135 . Referred to rheumatology clinic for advice on continuing management. and passed a tarry melaena stool earlier that day. Significantly disabled by pain.

136 .

anxious. clinicians tend to sentence or two of the presenting complaint? The combination review hypotheses either by of verbal and nonverbal information. who had an appendicectomy for appendicitis two years ago now presents with symptoms of an acute small bowel obstruction. This is essential in life-threatening situations. The child with an infection who is pale is unusual. It is important to check what the patient means by evidence. which have value in discriminating between one disease and another. 1996 137 . Australia. or by a comb I nation of methods. he is telling you the diagnosis. 'Framing the problem' is an art requiring practice to avoid going on a false trail. Good clinicians organise knowledge so they can quickly retrieve and use relevant data.' Sir William Osier (1849-1919) History-taking usually provides the most important diagnostic evidence. It is the starting point for action or information. For example. The soundness of the cause-andmost frequent error in the diagnostic process arises from faulty effect relationships of the triggering. by 1 grouping knowledge into 'chunks'. Diagnosis: A Brief Introduction.2 Clinical Diagnosis Reuben D Glass (D) 2-A: The Diagnostic Process — History-taking and Problemsolving 'Listen to the patient. which impresses the some form of rule. For example: a 45-year-old man. Oxford University Press. The careful clinician will ensure that less common but weightier causes — external hernia or colonic malignancy. by clinician when first meeting the patient. by considering the gathering. which would require corrective urgent surgery — are considered and excluded. For example. Where are we meeting? Is the patient male or female. The alert clinician also notes unexpected variations from a common pattern.probability. the pallor may result from the circulatory insufficiency of septicaemia. or between one group of diseases and another. or When solving clinical unconscious? What else do I see? What is the opening problems. relaxed. has been called the informally weighing 'dominant cue'. then does he have 1 Glass. The most likely and most common cause is adhesions. a child with fever is usually flushed. A number of cues are noted within seconds of meeting a patient. if a patient presenting after a motor crash is gasping for breath and has a weak pulse with one side of his chest moving less than the other. what was said. Obtaining this evidence requires the communication skills previously discussed in Section 1 Clinical Communication'. The dominant cue may provoke urgent action by triggering a process of pattern-recognition. which is close to an end-diagnosis. Experienced clinicians gather important evidence early in a consultation. In addition to recognising diseases by patterns. Reuben D. often groups of three items of information. they recognise groups of symptoms and signs. young or old. In such instances spontaneous resolution often follows conservative management. by triggering ideas from the clinician's memory.

and the patient may respond lno. to assess whether a problem may exist in another system or subject area. and the value of treating it. the clinician is mindful of the events that have influenced the patient's life. further evidence is gathered. It is often helpful to summarise the events that led to the patient's presentation for medical attention. otherwise it is rejected. their health and occupations. keeping in mind the likelihood of a disease. Thus abdominal pain may be due to an intra-abdominal cause. form part of a complete assessment. the background of the patient needs to be known. If so. the clinician usually develops a number of hypotheses — often three — about how the patient's symptoms might be explained. Then provisional hypotheses. 'acute appendicitis'). the hypothesis becomes active. Excessive reliance on pattern-recognition may lead to failure to consider diagnostic alternatives methodically. This involves a history of past illnesses. Experts 3onsider a number of possibilities and rank them. The ultimate refinement is called a 'differential diagnosis'. In a full consultation. are explored. which the cue suggests. The data is checked to see if it explains the various hypotheses. but the absence of a feature in history or examination may be of great diagnostic value. 'intra-abdominal mischief). Beginners tend to jump to conclusions too rapidly. This process occurs early in diagnostic :hinking. it's just I have to go often'. By repeating the information in unambiguous but nontechnical language to the patient. For example. until the evidence against it is overwhelming. the clinician's summary may trigger a further comment from the patient. to a measured consideration of hypotheses. If the dominant cue does not demand immediate action.2-A The Diagnostic Process — History-taking and Problem Solving a life-threatening tension pneumothorax requiring urgent needling? Pattern-recognition is also helpful in dealing efficiently with common diseases. On other occasions. Compiling a set Df active hypotheses often involves including some inclusive category (such as 'something 138 . This helps to ensure that the clinician understands what the patient meant by what he said. this clinician has avoided the traps of incorrectly mentally coding the dominant cue as 'polyuria instead of 'frequency'. leading to the presentation for medical attention. Screening questions. pattern-recognition mode of functioning. If the situation does not require immediate action. Rather than relying on question lists for system reviews. and to repeat this concisely to the patient. collecting the most critical information early in the interview. but are mainly ideas about disease groupings (for example. or result from referred pain due to intrathoracic or spinal causes. Most questioning attempts to elicit symptoms to support a diagnosis. only then allowing them to move to another hypothesis. processing a limited amount of information at one time in meaningful packets. During the diagnostic encounter. Groups of observations may raise the possibility of related diseases. Early lists of hypotheses nay include some specific diagnoses (for example. Problem-oriented questions probe a subject in depth when the dominant cue suggests that this is warranted. provided the clinician remains alert for deviations from the regular pattern. They structure data. the patient may have said 7 seem to have peed an awful lot lately'. The clinician may summarise this as 'you have been concerned about passing large amounts of urine'. and interpersonal relationships. The clinician changes from a rapid. about some important item that was not mentioned. considering one hypothesis at a time. These questions reflect a doctor's style. experienced clinicians choose questions that give the highest yield for the specific situation. I don't do much. enquiry about other family members. The first task is to elaborate details of the patient's presenting complaint and confirm that the dominant cue has been interpreted correctly.

It is also important to realise that the absence of a feature does not necessarily have the same leverage or weight as its presence: the relative value of each may be completely different. A common strategy is to alternate between questions aimed at confirming a hypothesis. Knowledgeable candidates will highlight discriminatory 'normal' findings in problem definition. by considering the soundness of the cause-and-effect relationships of the evidence. this means that hypotheses favour readily treatable or remediable situations even if they are unlikely (though even more if they are probable). clinical examination can be divided into problem-oriented and screening signs. Diagnostic errors arise when clinicians confuse populations with differing frequency of disease. Problem-oriented signs are best given in clusters. though the presence of these features is of little diagnostic value. The need for action depends on the likelihood of a disease. to give 'revised odds'. Here. An outline of pathways of diagnostic and management planning is shown in Figure 1. or negative findings can also be given in some detail. Diseases have a variety of forms and their manifestations often do not follow the typical textbook example. Thus evaluating fully the possibility of a rare disease that is amenable to treatment is important. which relate to disease groups. which serves until attention is drawn to that situation and is evaluated more fully. and the usefulness of the observation. the 'prior odds' of disease (chances of disease compared with nondisease) are expressed as a number or fraction. or by a combination of methods. Malaria may be the probable diagnosis of a febrile patient in a tropical area where the disease is endemic. however. where the initial idea and subsequent observations are given scores which are added. and others aimed at distinguishing it from other hypotheses. Sometimes absence of a feature — a 'normal' finding — may be of great value in differential diagnosis. although perhaps less important if treatment is unsatisfactory. consideration of each hypothesis may be divided into stages. but in a similar patient in a temperate zone. Logically. or if they involve 'high stakes' — that is. absence of anorexia or nausea is evidence against the diagnosis of appendicitis. Artificial methods can be used to analyse the process. not zebras — but the odds require revision in Africa. This is multiplied by the 'likelihood ratio' (chances of observation in disease. When solving clinical problems. Hypotheses remain active longer if they include common situations. A simpler method involves 'weighing the evidence'. Similarly. the clinician needs an awareness of the prevalence of the disease in the population. or 'leverage of the evidence'). normal. clinicians tend to review hypotheses either by some form of rule. the presence of a bruit over the thyroid is diagnostic of hyperthyroidism. is only weak evidence against the diagnosis. Thus stronger evidence is required for diagnosing a rare disease than for a common one. To determine the probability of disease. Experience provides a picture of the variations. For example. and the value of treating it. One method is 'revising the odds'. For descriptive purposes. more evidence will be required to confirm that diagnosis. As with history-taking. in contrast to 'normal findings' on screening. as this feature is absent in half of the patients with acute infarcts.2-A The Diagnostic Process — History-taking and Problem Solving odd'). by informally weighing probability. Thus sudden vomiting without preceding nausea is unusual and raises the possibility of intracranial disease. 139 . compared with nondisease. Thus severe crushing central chest pain associated with pallor strongly suggests myocardial infarction. The absence of a bruit. the absence of the 'classical pattern' is of limited diagnostic value. Diagnostic reasoning involves considering the value of items of information. Hoof beats usually imply horses. Less detail is generally appropriate in the screening component of the examination. however. potentially serious diagnosis. Before an observation is made.

2-A The Diagnostic Process — History-taking and Problem Solving Gathering clinical or laboratory information about a patient costs money — whether from doctor or patient time. For example. on others. requiring a candidate to deduce the diagnosis. In all cases. they may be asked to elaborate on a patient's history. two threshold levels of likelihood of disease are important. and explain the management to the patient. In deciding on patient management. or differential diagnostic possibilities. generally using role playing patients. or equipment. a normal leucocyte count should not be taken as a contraindication for surgery. Candidates should read and follow instructions carefully. no additional evidence is going to alter the treatment decision. if acute appendicitis is confidently diagnosed on clinical evidence. While some redundancy of information is appropriate when there is significant doubt or risk. inconvenience. Pathways in the diagnostic process are summarised in Figure 1. it needs to be obtained efficiently. While information must be complete for the purpose of deciding management. they may even be misleading. Reuben D Glass 140 . unnecessary investigations should be avoided. to examine a particular organ or system or region. no amount of new evidence would suggest that treatment is warranted. Below the lower level. the ability to achieve rapport with the patient is expected. At times. Examination candidates should recognise that questions have been designed to test skills in different aspects of the diagnostic process. Other scenarios may give all relevant information. Above the upper threshold. On occasions.

the clinician uses all these methods. Recognition of a typical pattern may be used for common problems. FIGURE 1. Rapid diagnostic pathway. Pathways in the diagnostic process. Examination scenarios are often designed to test one component of the process. In practice. 141 .2-A The Diagnostic Process — History-taking and Problem Solving SECTION 2-A. A full systematic enquiry is needed for complete patient care. essential for urgent solutions. □ □ Problem-oriented diagnosis generating and evaluating hypothesis. Arrange follow up if required □ Pattern recognition.

2-A The Diagnostic Process — History-taking and Problem-solving 2-A The Diagnostic Process — History-taking and Problem-solving Candidate Information and Tasks M CAT 030-043 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Jaundice in a breastfed infant A convulsion in a 14-month-old boy Loud and disruptive behaviour of a 6-year-old boy Tremor in a 40-year-old man Headache in a 35-year-old woman Lethargy in a 50-year-old woman Syncope in a 52-year-old man A painful penile rash in a 23-year-old man Primary amenorrhoea in an 18-year-old woman A skin lesion on the cheek of a 50-year-old man A pigmented mole on the trunk of a 30-year-old woman An itchy rash on the hands of a 19-year-old woman Red painful dry hands in a 30-year-old bricklayer Swelling of both ankles in a 53-year-old woman 142 .

The Performance Guidelines for Condition 030 can be found on page 156 143 .7 kg. • Discuss the results of investigations with the mother. You arranged investigations as set out below.9 kg. Helen is now two weeks old and was born at term by easy vaginal delivery weighing 3. Current weight is 3. Investigation results • Serum bilirubin ~ Conjugated: • Neonatal thyroid screening • Urine culture • Full Blood Examination (FBE) Total: 250 umol/L less than 10 umol/L normal sterile normal YOUR TASKS ARE TO: • Obtain any further necessary history you require. The mother has now returned with the baby to discuss the results and your advice about treatment. You should not take more than 2-3 minutes to do this. Baby is feeding well from the breast. Since discharge from hospital at eight days of age the jaundice has persisted and the mother is concerned.Candidate Information and Tasks 030 Condition 030 Jaundice in a breastfed infant CANDIDATE INFORMATION AND TASKS Baby Helen is brought to see you in a general practice setting. Examination findings The baby was active and clinically normal apart from the jaundice when you saw her yesterday. • Explain the diagnosis to her and advise about future management. The infant was treated with phototherapy for two days. She became jaundiced in the neonatal period starting on day three. Apgar scores were 9 and 10 (at 1 and 5 minutes respectively). as her mother is concerned about her continuing jaundice. both mother and baby being group O positive and no red blood cell (including enzymes) abnormality. Investigations then revealed no blood group incompatibility.

Indicate to the mother your probable diagnosis and a brief plan of management. Explain your diagnosis and subsequent management to the child's parent. has been brought in to the hospital Emergency Department by his parent following an episode at home the previous evening. who complains how active he is. He then went off to sleep and slept for the rest of the night. he was staring and did not respond to his name. Examination findings Benjamin is alert and normal neurologically.031-032 Candidate Information and Tasks Condition 031 A convulsion in a 14-month-old boy CANDIDATE INFORMATION AND TASKS Benjamin. The Performance Guidelines for Condition 031 can be found on page 159 Condition 032 Loud and disruptive behaviour of a 6-year-old boy CANDIDATE INFORMATION AND TASKS You are seeing a 6-year-old boy. He is in his second year at school. for the first time with his mother. YOUR TASKS ARE TO: • Take a focused history from the mother to determine the possible causes for the child's presentation. They noted that his body twitched all over for several seconds and the whole episode lasted 60 seconds. and while he was being cuddled. The • Performance Guidelines for Condition 032 can be found on page 161 144 . Jonathan. and his teacher has commented that he is disruptive and loud in class. YOUR TASKS ARE TO: • • Take any further history to ascertain the most likely cause for this episode. a 14-month-old boy. His parent explains that he had been unwell all day with a high fever (40 °C). He has a low grade fever and signs of an upper j respiratory tract infection.

• After completing the history.033-034 Candidate Information and Tasks Condition 033 Tremor in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. discuss possible diagnoses with the patient. • Request from the examiner the essential features of the physical examination you would look for in this patient as the next stage in diagnosis. The Performance Guidelines for Condition 034 can be found on page 167 145 . • Tell the patient what you consider to be the most likely diagnosis and what investigations. YOUR TASKS ARE TO: • Take a focused history about his condition. YOUR TASKS ARE TO: • Take a focused history from the patient. is consulting you in the Emergency Department of the local hospital about headaches. should be undertaken. if any. The examiner will inform you of the results. and any investigations you would arrange. You have not seen the patient before. a 35-year-old woman. • The examiner will then question you about the physical findings you would check to clarify the diagnosis. The Performance Guidelines for Condition 033 can be found on page 164 Condition 034 Headache in a 35-year-old woman CANDIDATE INFORMATION AND TASKS Your patient. Your next patient is a 40-year-old man who is consulting you because of a tremor ('the shakes').

Ask the examiner for the results you would wish to elicit on a focused physical examination. CONDITION 035.035 Candidate Information and Tasks Condition 035 Lethargy in a 50-year-old woman CANDIDATE INFORMATION AND TASKS You are consulting in a general practice setting. She looks apathetic and lethargic on first impression. YOUR TASKS ARE TO: • • Take a focused history. FIGURE 1. CONDITION 035. and indicate what further investigations you would require. Your next patient is a middle-aged widow (see Figures 1 and 2 below) who is presenting for a 'check-up'. • Give your diagnosis and differential diagnosis to the examiner. FIGURE 2 The Performance Guidelines for Condition 035 can be found on page 170 146 .

Your next patient is a 52-year-old technician who is consulting you about recent transient loss of consciousness. • Indicate to the patient how you would proceed in your further assessment of his condition. • Ask the examiner for the findings of the focused physical examination you would perform. The Performance Guidelines for Condition 036 can be found on page 173 147 . • Tell the examiner your diagnosis and the reason(s) for this.Candidate Tasks Information 036 and Condition 036 Syncope in a 52-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. YOUR TASKS ARE TO: • Take a history from the patient.

FIGURE 1. YOUR TASKS ARE TO: • • • Take a focused history to assess the presenting problem. A 23-year-old man presents with penile pain and a penile rash. The penis appears as in the illustration below. Explain to the patient your provisional diagnosis and recommended management. CONDITION 037.Condition 037 A painful penile rash in a 23-year-old man CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. The Performance Guidelines for Condition 037 can be found on page 177 148 .

YOUR TASKS ARE TO: • Take any further relevant history you require. The Performance Guidelines for Condition 038 can be found on page 180 149 . Your next patient is an 18-year-old woman who is concerned because she has never had a menstrual period.038 Candidate Tasks Information and Condition 038 Primary amenorrhoea in an 18-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. • Ask the examiner for relevant findings you wish to ascertain on general and gynaecologic examination. • Counsel the patient appropriately. • Advise the examiner of investigations you wish to order and your provisional diagnosis.

Explain to the patient your recommended management. FIGURE 1. The lesion appears as in the illustration below. CONDITION 039.039 Candidate Information and Tasks Condition 039 A skin lesion on the cheek of a 50-year-old man CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. YOUR TASKS ARE TO: • • • • Assess the lesion by a focused history and physical examination. The Performance Guidelines for Condition 039 can be found on page 182 150 . A retired 50-year-old builder presents with a skin lesion on his right cheek. Present your case summary and diagnosis to the examiner.

The skin lesion appears as in the illustration of her back shown below. YOUR TASKS ARE TO: • Assess the lesion by a focused history and physical examination. A fair complexioned 30-year-old schoolteacher seeks advice concerning a 'mole' on her trunk. FIGURE The Performance Guidelines for Condition 040 can be found on page 184 151 . • Explain to the patient your diagnosis and recommended management.Candidate Tasks Information 040 and Condition 040 A pigmented mole on the trunk of a 30-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. CONDITION 040.

FIGURE 1. Advise the patient about treatment. There are no other abnormal examination findings apart from the rash. The Performance Guidelines for Condition 041 can be found on page 186 152 . CONDITION 041. Explain the most likely diagnosis to the patient and how this can be confirmed.Candidate Information and Tasks 041 Condition 041 An itchy rash on the hands of a 19-year-old woman CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO) in a general medical outpatient clinic. YOUR TASKS ARE TO: • • • Take a further focused history. A 19-year-old female computer student presents with an itchy rash on her hands. The rash has been present for about one week and appears as shown in the photograph.

Candidate Tasks Information 042 and Condition 042 Red painful dry hands in a 30-year-old bricklayer CANDIDATE INFORMATION AND TASKS You are the Hospital Medical Officer (HMO) in a hospital primary care clinic. The rash appears as in the illustration below. and is on the front and back of both hands YOUR TASKS ARE TO: • Take a history about the presenting problem. • Explain to him your diagnosis and the possible causes of the condition. A 30-year-old man presents with red dry hands. • Outline your management of the problem. FIGURE 1. The Performance Guidelines for Condition 042 can be found on page 189 153 . CONDITION 042.

The patient you are about to see is a 53-year-old clerical worker who is consulting you about bilateral swollen ankles. Describe to the examiner the essential features you would look for in physical examination to confirm your provisional diagnosis. The Performance Guidelines for Condition 043 can be found on page 191 154 . as illustrated below. CONDITION 043. FIGURE 1. YOUR TASKS ARE TO: • • • Take a relevant history from the patient (you have five minutes to do this).Candidate Information and Tasks 043 Condition 043 Swelling of both ankles in a 53-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. \ Tell the patient your working diagnosis as to why the ankles are swollen after concluding the history.

2-A The Diagnostic Process — History-taking and Problem-solving 2-A The Diagnostic Process — History-taking and Problem-solving Performance Guidelines MCAT 030-043 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Jaundice in a breastfed infant A convulsion in a 14-month-old boy Loud and disruptive behaviour of a 6-year-old boy Tremor in a 40-year-old man Headache in a 35-year-old woman Lethargy in a 50-year-old woman Syncope in a 52-year-old man A painful penile rash in a 23-year-old man Primary amenorrhoea in an 18-year-old woman A skin lesion on the cheek of a 50-year-old man A pigmented mole on the trunk of a 30-year-old woman An itchy rash on the hands of a 19-year-old woman Red painful dry hands in a 30-year-old bricklayer Swelling of both ankles in a 53-year-old woman 155 .

Questions to ask unless already covered: • • • 'Does Helen need to go under those lights again?' ‘Is t h e r e s o m e t h i n g w r o n g w i t h m y m i l k . and you established breastfeeding successfully. on no medication. You are a healthy. You have always intended to breastfeed. ability to make an appropriate diagnosis and to convey this to the patient This is your first baby. She has gained weight and is having normal bowel actions — motions and urine are both normally coloured.030 Performance Guidelines The examiner will have instructed the parent as follows: Condition 030 Jaundice in a breastfed infant AIMS OF STATION To assess the candidate's knowledge of the causes of persisting neonatal jaundice. The diagnosis can be confirmed by suspending (not stopping) breastfeeding for 24-48 hours which will result in a fall in the serum bilirubin after which breastfeeding can be continued. This is acceptable but not necessary. No treatment is indicated and further phototherapy is not indicated. ask ' W i l l t h i s a f f e c t m y c a p a c i t y t o c o n t i n u e b r e a s t f e e d i n g ? ' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise the significance of the baby's unconjugated hyperbilirubinaemia and come to the most likely diagnosis (breastmilk jaundice) without need for further investigations. The condition is self-limiting and requires no treatment. Baby Helen has been normal in all respects since birth. Establishing that a well baby with persisting jaundice has normal-coloured urine and motions and no abnormality on examination virtually clinches the diagnosis. The candidate should explain that: • • • The most likely diagnosis is breast milk jaundice. breastfeeding mother. Emphasise that there is nothing wrong with her milk. • • The mother should be advised to express her milk in order to maintain lactation if temporary suspension of breastfeeding is advised. 156 . nonsmoker. s h o u l d I s t o p b r e a s t f e e d i n g ? ' If the candidate indicates that breastfeeding should be ceased for 1-2 days to see if the jaundice decreases.

• Accurate interpretation of important pathology results. that is. Jaundice that is manifest in the first 24 hours of life usually has a pathological cause and this must be sought. jaundice generally can be considered pathological if it occurs outside the above age range or is more pronounced than expected. With such a common condition. 1 . the latter often indicating a more significant aetiology. usually ABO incompatibility although there are several other more rare causes of haemolysis that may also present at this time (such as hereditary spherocytosis and glucose-6-phosphate dehydrogenase [G6PD] deficiency). • Insisting that the breast milk is unsatisfactory for the baby and recommending permanent cessation of breastfeeding. • Reassurance to mother that her milk is not harmful to her baby. for example. affecting at least 50% of full term infants and a significantly higher proportion of premature infants. There are many possible causes for prolonged jaundice which can usually be differentiated by whether the jaundice is predominantly u n c o n j u g a t e d or c o n j u g a t e d . Rh isoimmunisation is usually known prior to birth from the screening tests done on the mother during her pregnancy. The most common cause for this in our community is a haemolytic process. • Accurate explanation of the possible causes for the jaundice and logically excluding other important diagnoses. biliary atresia. The other extreme of the natural history of jaundice is prolonged jaundice. Generally termed physiological jaundice. jaundice that persists longer than the time when it would have been expected. • Not appreciating the significance of predominant unconjugated hyperbilirubinaemia and insisting that the baby has biliary atresia or haemolytic disease. guidelines are therefore required to determine what aspects of jaundice fall outside this physiological range.030 Performance Guidelines KEY ISSUES • Establishing that urine and stools are of normal colour. There are a multitude of causes for jaundice besides physiological jaundice and all must be considered before assuming that the jaundice has a benign origin. Usually physiological jaundice does not become obvious in full term infants until day three of life and by late day two in premature infants. Jaundice in the newborn is very common. However. this is an adaptation process to extrauterine life that takes some days to mature. Most physiological jaundice resolves by the end of the first week of life in full term infants and up to 10 days to a fortnight in preterm infants.

important clinical features that also would support this diagnosis Obviously the babies are breastfed. The cause is unknown. for example. Breast milk jaundice is a benign condition. The jaundice may persist for up to three months but over that time the baby thrives and remains well. This is rarely necessary and tends to give the message to young mothers that their milk is harmful to their infant. 158 . except for the jaundice. although it is thought to be due to a factor in breast milk that causes increased enteric absorption of bilirubin. are normal.030 Performance Guidelines Breast milk jaundice fits into the unconjugated variety but should be considered as a diagnosis by exclusion of the other important causes of unconjugated hyperbilirubinaemia. Their bowel motions and urine are normal colour. is entirely normal and important investigations to exclude other causes. a feature that must be determined when assessing these infants Physical examination. hypothyroidism. Breastfeeding should not be interrupted although some authorities indicate that the diagnosis can be confirmed by ceasing breastfeeding temporarily and demonstrating a significant fall in the bilirubin level. which is not true. which requires no treatment except explanation and support. There are. however. but are thriving and gaining weight well. with many theories expounded in an attempt to explain this phenomenon. Despite its persistence for many weeks in some infants it may disappear in just a few days in others.

but has had no further problems (this is potentially important information but should be provided only if the candidate asks). If asked about his development. He now seems well and is back to normal. • He has been well since birth and has not been sick until last night. • There is no family history of epilepsy. the candidate should question specifically to exclude any risk factors for epilepsy or recurrence. The examiner will have instructed the parent as follows You are the parent of 14-month-old Benjamin who had a convulsion with generalised twitching the previous evening. The candidate should: • Indicate that this is most likely a simple febrile convulsion population have a seizure associated with fever. reply that all has been normal. ' Questions to ask if not already covered: • 'Why would he have this episode?' • If the candidate indicates that this was a febrile convulsion. Opening statement Benjamin seems fine now that he is less feverish. including birth history developmental history. • His birth history was normal — born at term weighing 3600 g (good Apgar birth scores). • Explain that a febrile convulsion is a common reaction to fever in young children — about 3% of the 159 .031 Performance Guidelines Condition 031 A convulsion in a 14-month-old boy AIMS OF STATION To assess the candidate's ability to relate appropriately with the parent of a boy who had a febrile convulsion the previous evening. and family history of febrile convulsions or epilepsy. but you are concerned as to what the episode was as it frightened you when it occurred. You did not know what the episode was at the time but as he went off to sleep. and advising preventive measures. by taking a relevant history making and explaining the diagnosis. then ask 'what is a febrile convulsion?' • ‘Is this epilepsy? Should he have some medicine for this?' • 'Does he need to have any tests done?' • ‘Will it occur again?' • ‘What should we do if it does occur again or when he gets a high temperature?' EXPECTATIONS OF CANDIDATE PERFORMANCE Although this boy has had a simple febrile convulsion. • Your own younger sister had a similar episode when aged two years. you let him sleep and brought him in the next day to be checked.

a family history of epilepsy. A simple febrile convulsion is a common condition and candidates must be aware of risk factors that would suggest an alternative diagnosis of epilepsy should be considered: prolonged convulsion lasting greater than 15 minutes. 160 . a focal element. the dominant cue is the recognition of the change in sensorium in this child while he has a high fever. While epilepsy may be raised as a possibility. The scenario tests not only knowledge of a common condition. Candidate may mention the use of rectal diazepam for recurrent febrile seizures. but also skill in being able to impart a logical explanation in language that the parent can understand without causing alarm. Explain that such convulsions do not cause brain damage or subsequent epilepsy. Only around 3% of children who have had febrile convulsions subsequently develop epilepsy. This is the process of diagnostic reasoning. abnormal development before the seizure). the clinical features at the time. Appropriate education and reassurance. None of these features is present in this child and hence the diagnosis is clearly most likely to be a simple febrile convulsion. Pattern recognition leads to the likely diagnosis and should allow the candidate to make a definitive diagnosis and be confident in the advice given to the parent. prolonged convulsion. but immature brains are susceptible to the effects of high fever. as this is unnecessary. COMMENTARY In this scenario. Advise against any drug treatment (except an antipyretic). make this highly unlikely at this stage.031 Performance Guidelines • • • • • • • Emphasise that generally this is a benign condition. Give advice as to a 30% risk of recurrence especially in the first 24 hours after this episode and advise the parent what to do if it occurred again (tepid sponging and antipyretics when he is feverish). Point out that the condition commonly runs in families. The candidate should therefore recognise this as a simple febrile convulsion with an excellent prognosis. CRITICAL ERROR • Suggesting on the strength of this episode of a brief febrile convulsion that he has epilepsy. being mainly in the high risk group (positive family history of epilepsy. Explain that the fever is almost always caused by a viral infection. but this should be reserved for special circumstances and its use is not without risk. Any of these features would throw doubt on the diagnosis of simple febrile convulsion. It also requires reassurance and confidence in the diagnosis. Advice on preventive measures. • KEY ISSUES • • • Appropriate questioning and history-taking. Reassure that this is most unlikely to be epilepsy. or abnormal neurological behaviour in the child prior to the seizure. the normal appearance of the child when examined and absence of risk factors. a focal element to the seizure. which would usually manifest as an upper respiratory tract infection in an adult.

• He lives in a caring family and you have tried just about anything that anyone has suggested to help him.032 Performance Guidelines Condition 032 Loud and disruptive behaviour of a 6-year-old boy AIMS OF STATION To ensure that the candidate considers all other possibilities as to why Jonathan is behaving as he is. • His sleeping pattern since birth has been very bizarre with frequent waking. Listed below are suggested answers that you should provide in response to questions from the candidate. Home situation • He is the first in the family. which at times is disruptive to the rest of the class. The candidate is required to take a concise history from you to try to determine the possible causes for Jonathan's behaviour. Both teachers he has had in the first two years at school have commented on how disruptive he is in class. • His preschool teacher commented on similar behaviour. almost to the level that Jonathan has achieved. 161 . questions are grouped based on how the candidate may question you. The examiner will have instructed the parent as follows: You are the mother of Jonathan aged six years and are concerned about how active he is. • The description given by the teachers is exactly as he is at home as well. At six minutes. before concluding that he most likely has attention deficit hyperactivity disorder (ADHD). • Even as an infant he was a restless. For ease of response. The candidate will therefore be assessed on ability to ask pertinent questions that confidently exclude other important diagnoses. School progress • His reading and learning are behind the level of the other children in the class. • He is impulsive and often acts without thinking what the consequences might be. he has a four and a half-year-old sister who already is reading. • He tends to interrupt frequently and has great difficulty taking turns. Hyperactivity and other associated symptoms • Jonathan has always been very active from the time he walked (13 months). the examiner will indicate to you to ask the candidate what is the problem and how should Jonathan be managed. • He cannot concentrate on tasks for any length of time. • His teacher complains he never sits still and tends to wander around the classroom. as he is so boisterous. • He is easily frustrated and rarely plays at any particular activity for any length of time. • He constantly talks loudly in class. • He has trouble keeping friends. irritable baby who was difficult to feed.

Past medical history • • • • Physically well.032 Performance Guidelines • • • He tends to disrupt his younger sister's play. There are no parental interpersonal problems. When indicated by the examiner. It is not at all critical that the correct diagnosis is made. There is no family history of intellectual disabilities or deafness. encephalitis). He demands attention from you frequently. A visual or auditory problem. although he appears uncoordinated and constantly seems to run into things. You noticed very active movements even in utero compared to when you were pregnant with his sister. left school as early as he could to take up his apprenticeship and who found it difficult to study at Technical College (TAFE). Jonathan thrived and gained weight well. 162 . and what can we do about it?' EXPECTATIONS OF CANDIDATE PERFORMANCE This scenario is designed firstly to assess the candidate's ability to explore the reasons a ! child may present with hyperactivity. only mild and transient jaundice in the neonatal period. While it has been written to suggest ADHD. No serious illnesses (in particular no history of meningitis. development was normal except slow in speech development compared to his younger sister. Subsequent medical or physical illnesses including significant head injury. This is not a problem at work where he is supervised. but rather that the child's history is fully explored to exclude: • • • • • • Physical or congenital lesions. Pregnancy • • • You had a normal pregnancy. You consider your home situation to be very stable with both parents active in supporting each other and rearing the children. You have had his hearing and vision tested and were assured both were normal (give this information ONLY if asked). Difficulties in the child's adaptation to school. Family history • • • • • His father is a plumber who struggled at school. you should ask: ‘What do you think is causing this. the assessment is essentially based on whether the candidate approaches the problem in a logical manner. Reaction to unfavourable home circumstances or child rearing and family environment. Father is described by his own parents as being very similar to Jonathan at Jonathans age. exploring all other possibilities for the behaviour. Mother was previously a secretary for a builders' supply firm. Father even now tends to leave tasks unfinished around the home. Jonathan's birth weight was 3600 g at term after normal labour. No history of head injury. Behaviour secondary to neonatal problems. not being able to take 'no' for an answer which you are finding exhausting. good Apgar scores.

Monitoring progress over several consultations may be required to give a positive diagnosis of ADHD. Diagnosis is made from the pattern of behaviour. This presentation of childhood hyperactivity is common in both paediatric and general practice and skill is required to sort out the myriad of causes for the behaviour exhibited. and that stimulant medication is not the immediate treatment in this situation. without having explored the history for other causes. • Indicate willingness to review and monitor progress in a supportive manner.032 Performance Guidelines Importantly. • Suggest a neurodevelopmental assessment be performed with an experienced psychologist if possible. While behavioural modification is recommended. suggest having hearing and vision assessed (can then be told this has been done and is normal). • Briefly outline the management of ADHD by behavioural modification with or without stimulant medication. • Showing empathy with the parent's frustration. • Obtaining a logical and focused history to exclude various possible causes for Jonathan's behaviour. The doctor is often under great pressure to prescribe these medications at first visit and this should be resisted. This is done by a careful history exploring the child's past history. but the practitioner should monitor progress and make a critical appraisal as to the success or otherwise of this treatment and support the parent accordingly. The great majority of children presenting in this manner have major family dynamics problems and the scenario could easily have been modified to indicate this. CRITICAL ERROR • Coming to a premature conclusion of ADHD and recommending stimulant medication. However the current scenario is designed to indicate that a diagnosis of ADHD is by exclusion of all the other causes for this symptom. There are no specific tests available that make a diagnosis of ADHD. Parents should be supported to try exclusion diets if they are keen to institute them. provided history has been satisfactory). current developmental status. parents have often already arranged this prior to the consultation. a tendency for which has developed in the general community and is often the expectation of family members who have spoken with neighbours or read the lay press. and family and school situation. and also have often tried a variety of exclusion diets that in some cases may be helpful. • If hearing and vision have not been enquired about. • Having a clear approach to the management plan. the candidate should question as to similar behaviour in other family members (see note on father's history) In outlining briefly the probable diagnosis and plan of management. but overall are not. which can be confirmed by psychometric testing. the candidate should: • Give a logical explanation as to the possible causes for Jonathan's presentation having excluded organic pathology and indicate that ADHD is a strong possibility (the diagnosis of ADHD is not essential to pass. 163 .

stress makes the shakes worse. I can control the shakes by gripping things firmly. Sometimes I have trouble lighting a cigarette. so I thought I should see a doctor'. The newspaper shakes when I am trying to read it. Provide the following information without prompting: ‘I have had the shakes since my early 20s. In response to further questioning: 'It doesn't seem to bother me when I get up in the morning and doesn't stop me going to sleep. or writing. You like to have a 'few beers' especially at the weekends but never get 'drunk'. Seems to be when I am doing something with my hands like using a knife and fork. You smoke 10-15 cigarettes daily and drink up to five 375 mL cans of full strength beer on most days. gastrointestinal or urinary systems. It can go away for a few days then comes back. It happens when I get nervous about something. but admit to a diminished libido and difficulty in maintaining an erection if asked directly or if the doctor provides an opportunity for you to do so. The doctor will seek details of your symptoms and will ask questions about your health status. but only occasionally and of minor degree. You have always been a tense and nervy person. I feel much better after a couple of beers. Deny any other symptoms affecting the central nervous system. medical and social history. Opening statement 'I've got the shakes doctor. respiratory. ' • You have noted that your hands and fingers shake if you hold your arms out in front of your body. nor in walking. I don't have any stiffness and I don't have trouble moving from one position to another. My right hand is the worst. You are married with two teenage children. The examiner will have instructed the patient as follows: You are a 40-year-old man who has consulted a general practitioner complaining of the shakes'. No loss of weight.033 Performance Guidelines Condition 033 Tremor in a 40-year-old man AIMS OF STATION To assess the candidates skill in defining a presenting symptom of tremor. You work as a storeman. making a probability diagnosis from the history and selecting with discrimination which aspects of physical examination and investigations will clarify the diagnosis. Left hand is less affected and not until recently. Recently I heard something about Parkinson's disease which can cause the shakes. but it hasn't been a problem until recently (6-12 months). I spill my drink sometimes'. You have had no serious illnesses or operations. • • • • 164 . cardiovascular system. Sometimes my head shakes and often I spill my drink when I put a glass to my mouth. You may ask the doctor if your voice could be affected because you have noticed some shakiness in your voice. Shakes were first noted in your dominant right hand.

Her father had Parkinson disease. using appropriate communication skills Diagnosis must include benign tremor and alcoholic tremor. Questions from the examiner after six minutes with expected responses: • What are your differential diagnoses?' ~ Benign or essential tremor (familial).05. Other differential diagnoses such as an anxiety state. and have never had an injury or motor accident associated with alcohol use. cerebellar signs. • Approach to patient — establishing trust and confidence by having a non-judgmental attitude. cardiomegaly • 'What investigations would you advise assuming the physical examination to be normal?' ~ Full Blood Examination (FBE). the doctor controls the interview too early. admit to concern about Parkinson disease because of your grandfather. Past. He also used to get the 'shakes'. sister. Knowledgeable candidates will be reassuring because of their confidence in the likelihood of a benign tremor. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should assess the patient's tremor as follows: History (see patient instructions) By the process of listening (using an open-ended approach followed by direct questioning). You are ignorant of long term harmful effects of alcohol. by only asking questions and not listening to your story. If asked. thyrotoxicosis • 'At this stage what do you consider to be the most likely diagnosis?' ~ Benign tremor or alcoholic tremor • "What are the essential physical signs you would look for in this patient?' ~ Hepatomegaly and any stigmata of chronic liver disease. tachycardia. • You are anxious about the cause of your symptoms. just answer the questions asked. If. If the doctor facilitates your story and maintains an open-ended approach whilst you are giving details of the shakes'. effects of heavy drinking: Parkinson disease: cerebellar disease.033 Performance Guidelines • Family history: Father died from lung cancer aged 58 years. increased muscle tone. Mother died of stroke aged 62 years. however. to develop the two most likely diagnostic pathways: benign tremor and tremor associated with heavy drinking. possibly thyroid function tests. Discussion with patient after the history This may or may not be specific. wife and two children all keep in good health. It is included to assess the candidate's diagnostic approach to the patient. Parkinsonism and thyrotoxicosis are much less likely from the history. The same applies to your alcohol use: be reluctant to confirm or reveal the true level of your alcohol intake. liver function tests. • History — comprehensive but focused. listening to patient's concerns and being reassuring. family and social histories should be sought. continue to amplify your symptoms. 165 . You have never been charged with exceeding . He was a non-drinker. Your brother.

166 . with the largest peak in the second decade. Head tremor is also present in 40%. Patients with benign essential tremor often drink as a means of controlling the tremor as alcohol has an ameliorating effect in 50% of cases. Failure to advise liver function tests. with prevalence increasing with age. leading to a coarse tremor which can be disabling. An autosomal dominant family history is present in 50-60% of patients and the genetic basis is unknown. CRITICAL ERRORS Failure to indicate the most likely diagnosis is essential tremor. but thyroid function tests not essential. Age of onset is bimodal. Functional imaging reveals abnormal cerebellar activity and no histological or structural changes have been identified. although this is uncommon. tachycardia and cerebellar signs. COMMENTARY Essential tremor is one of the most common neurological disorders.033 Performance Guidelines Answer to examiner questions ~ Physical examination should include checking for hepatomegaly and stigmata of chronic liver disease. This would require further assessment with the investigations recommended above. the patient may also be suffering from the effects of prolonged heavy drinking. In this case. ~ Investigations — must advise liver function tests. and a smaller peak in the fifth decade. The characteristic finding is a postural and kinetic tremor of the upper limbs which interferes with fine manual tasks. With advancing age. Less commonly legs are involved or there is voice tremulousness. the tremor frequency often slows and amplitude increases.

exercise or position of head or neck. • You can continue to work and to do household duties during attacks. and now last longer. In response to questioning: • The headache has not increased in intensity — only in frequency and duration. You are concerned because in the past few months. knowledge of types and causes of headache and the essential components of an appropriately focused physical examination are tested. • You do not regard yourself as a 'nervous' type and have not noticed any change in your usual mood. photophobia. visual disturbance. • It feels like a tight band or pressure around or on top of your head. • It affects the forehead and both the temples and radiates to the back of the head. • They are not related to posture. the headache pain rates about 3 to 4. Use the following information to respond to the doctor's enquiries. • It usually starts in the morning and lasts all day. after your evening meal. or a dull ache. lasting for a few days. You have not seen this doctor before. Opening Statement ’I want to find out what is causing my headaches. • You do not often seek medical advice. for most of the day.' History without prompting: You have been suffering from intermittent headaches for at least five years. Examiner Instructions The examiner will have instructed the patient as follows: You are consulting the doctor about headaches. vomiting. They are temporarily relieved by Panadol®. attacks occurring irregularly every few months. getting worse by evening. Review of General Health • You consider your general health to be satisfactory. up to six a day at a maximum. that is. not interfering with sleep. the headaches have occurred more often. You have not previously sought advice. every few days.034 Performance Guidelines Condition 034 Headache in a 35-year-old woman AIMS OF STATION To assess the candidate's communication skills in defining the nature of the patient's headache. You are aged 35 years and work as a telecommunications manager. or associated with menstrual cycle. You have lost no time from work. • Your marriage and family life is satisfactory. not pulsating. • On a scale from 1 to 10. and with rest and local heat. • Headaches are not accompanied by nausea. 167 . In addition. • The pain reduces after taking Panadol®.

Communicate understanding and concern that there is a recent change in a chronic problem. Indicate the site of the headache (forehead. rush through work. You have a dual income and no financial problems. Nonsmoker. temples. Recognition of typical characteristics of tension headache. and have less relaxation time now. You are now seriously worried about having a cerebral tumour. Communication skills • • • Use of facilitation. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should assess the patient's headache along the following lines: History (see patient responses) • • • • • Characteristics of headaches. Cardiovascular examination must include blood pressure. Other Significant Information You are very busy. including assessment of severity. You recently saw a TV documentary about a person who had a cerebral tumour. THE EXAMINER SHOULD INFORM THE CANDIDATE THAT NO ABNORMALITIES ARE FOUND ON PHYSICAL EXAMINATION. active listening and relevant enquiry. Note that you are also at a peak in your family responsibilities. and facilitate disclosure of relevant psychosocial history and worry about brain tumour. Identification of relevant psychosocial and environment factors (lifestyle stress) Essential features which candidates should look for on physical examination (supplied from examiner on request) • • • Inspection of head and neck and testing for neck stiffness. Diagnosis/Differential Diagnosis • Tension headache (muscle contraction headache) is the most likely diagnosis. to fully define the nature of the headache and its associations. No known drug sensitivities. and occiput). You had previously been complacent about the headache. Menstrual cycle normal. Current medication — Panadol® (paracetamol) 500 mg 1-2 tablets to relieve headache taken not more than three times daily.034 Performance Guidelines • • Negative response to questions about all body systems except as already stated. Be prepared to be reassured by the doctor if history and physical examination are adequate. Alcohol is used occasionally at weekends. Identify acute patient concern that a serious cause may be present (cerebral tumour). You are a perfectionist by nature and are finding it more difficult to cope with all of the activities of your growing family. Recent change in chronic condition. Other diagnostic possibilities include: ~ Migraine. domestic and family duties. Appear worried and tense and display concern. Neurological examination may be limited but must include ophthalmoscopy. If not. press the doctor to have tests or be referred to a specialist. 168 .

~ Cervical spondylosis. Patient counselling • Headache is of muscle contraction type due to tension and associated with personality and daily pressures of work and family life. 169 . KEY ISSUES • Use of communication skills to elicit the most relevant and important points in the history. normal physical examination. ~ Raised intracranial pressure (excluded by history typical of tension headache and negative examination findings). COMMENTARY This case is deliberately set in a hospital Emergency Department where the time constraint matches the eight minutes allowed for the candidate to complete the focused tasks set. • Referral for computed tomography (CT) brain or magnetic resonance imaging (MRI) would detract from overall performance but is not a key issue especially if a patient requires additional reassurance that the headache is not due to a cerebral tumour. • Recourse to investigations (CT or MRI) unnecessary at this stage but allowable to diminish patient concern. • Investigations are not indicated. intensity etc. No special investigations are indicated at this stage.034 Performance Guidelines ~ Cluster headache. and encouraging the patient to tell the whole story including concerns and life situation. • Failure to indicate the most likely cause is tension headache and that a serious cause is most unlikely. X-ray skull is not indicated. duration. listening. CRITICAL ERRORS • Failure to request blood pressure and ophthalmoscopy findings. The candidate who takes immediate control over the interview by asking a series of direct questions about site. • Discussion and education about the role and function of investigations is indicated. may successfully reach the diagnosis of tension headache. • Arrange followup to assess therapeutic effect of this initial assessment. Reassurance should be strongly given with offer to follow up results of this first contact with the doctor. Referral to neurologist for opinion is acceptable. • Focused physical examination in a patient complaining of longstanding headache. patient concern about a serious cause and lifestyle factors. • Confidence in diagnosis of tension headache based on typical history. The initial response from the candidate should be to facilitate the history given by the patient with an open-ended approach. but is likely to overlook the patient's recent concern about a serious cause and miss the real cause (lifestyle factors) with two consequences: • referral for unnecessary investigations which also increases the patients anxiety about a serious cause. and • missing the opportunity to convert the diagnostic approach into the appropriate therapy by improving self understanding by the patient.

in response to appropriate history-taking. You are always constipated and this seems to be getting worse. lacking expression. but nevertheless positive manner. Opening statement 'My daughter wants me to have a check-up because she says I am always tired. Your responses are apathetic. but appropriate questions evoke correct responses. You respond slowly to doctor's questions. Do not be evasive. You have put on weight. Your memory is not good. You feel cold all the time. You are slow to react with a croaky. Your voice has become 'croaky' — people say it has changed over the past year. go to sleep during the day and can't be bothered talking to people. Your daughter says you are not interested in anything. You also feel lethargic. You have not felt well lately (be vague about the duration). Show paucity of body movements. You get constipated if you don't take Coloxyl® regularly. 170 . Your hair has become thinner. You feel weak especially your arms and legs. In response to other questions: • • • • • • • No history of thyroid surgery. You are able to manage your own personal care but everything is an effort and takes longer. The case is deliberately presented as an undifferentiated problem but the patient's initial unprompted statements should lead to the correct diagnostic pathway with confirmation of suspected hypothyroidism by a focused selective physical examination. You find it hard to concentrate. The examiner will have instructed the patient as follows: You are a 50-year-old widow. ' • • • • • • • • • • • • • Respond to the doctor's enquiries as follows — w i t h o u t p r o m p t i n g . Your periods stopped last year and were scanty and irregular for a year before that. thick voice and poor memory.035 Performance Guidelines Condition 035 Lethargy in a 50-year-old woman AIMS OF STATION To assess the candidate's history-taking skills and diagnostic acumen in a patient with the symptoms and signs of hypothyroidism. husky. Examiner Instructions This case requires the patient to reveal the symptoms of hypothyroidism in a slow and hesitant.

035 Performance Guidelines • Your joints feel stiff and the muscles are sore. • Aspirin irregularly for the rheumatism. Parents died from old age. • If asked. taken for about a year. • You wake up early in the morning and can't get back to sleep. • Past medical history and family history — nothing of note. • Appearance — as illustrated ~ Looks tired and dull. early dementia may be mentioned but should be considered unlikely. blood pressure 130/70 mmHg ~ Thyroid not palpable ~ Skin dry sparse axillary hair ~ Cold hands and feet ~ Power and tone reduced in arms and legs ~ Reflexes sluggish with delayed ankle jerks At six minutes the examiner will ask the candidate for the diagnosis/differential diagnosis and proposed investigation. • Investigations Must request thyroid function tests and full blood examination. EXPECTATIONS OF CANDIDATE PERFORMANCE • Diagnosis/differential diagnosis Candidate's response to examiner's request for the diagnosis: candidate should strongly suspect hypothyroidism as indicated by pattern recognition and from the patient's symptoms and signs. Other possibilities such as depression. coarse features and skin. ~ Overweight — BMI 29 kg/m2 ~ Pulse rate 56/min regular. anaemia. Key Issues • History • Choice and sequence of examination • Diagnosis/differential diagnosis • Appropriate investigations 171 . • Dioctyl sodium 120mg (Coloxyl®) 'for my bowel' 1 or 2 tablets daily. state that you have just come to stay with your daughter because you were unable to carry on living alone. • Answer in the negative to any other questions about your health except to indicate that you feel you are gradually going downhill. Current medication • 'Tonic' obtained from Pharmacist by daughter. • Physical examination — the examiner should give the findings for selective and specifically requested components of the physical examination. Expressionless face.

COMMENTARY Spontaneous atrophic hypothyroidism often gives gradually progressive symptoms as ir this case. Diagnosis is suspected by the constellation of symptoms and signs as exhibited in this patient and would be confirmed by elevation of serum TSH with lowered T4 levels. 172 . The pathology is destructive lymphoid infiltration of the thyroid gland leading tc atrophy with no visible enlargement. The condition is an organ-specific immune disorder and responds well to thyroxine treatment. beginning with a low dose (50 ug daily) and increasing slowly to the dose required to restore TSH to normal. associated with goitre.035 Performance Guidelines CRITICAL ERROR • Failure to consider hypothyroidism in differential diagnosis. or in some patients.

Opening statement ‘I was playing tennis yesterday when I suddenly blacked out. no vertigo. Anyway I woke up and felt that nothing had happened except for this graze on my elbow. The candidate should also know the essential components of a selective physical examination which should identify a probable cause and be able to specify the investigations which would confirm the diagnosis Examiner Instructions The examiner will have instructed the patient as follows: You are a 52-year-old technician who is consulting a doctor about recent transient loss of consciousness. • There has been no swelling of ankles.036 Performance Guidelines Condition 036 Syncope in a 52-year-old man AIMS OF STATION To assess the candidate's ability to take a focused history regarding transient loss of consciousness with possible causes in mind. • You get short of breath whilst playing and this has been more noticeable lately. • No one said anything about your colour. which sometimes comes on when you are playing. follow with this information: '/ was enjoying my usual Sunday morning game of tennis. • You don't feel it anywhere else. You have not had any previous fainting or dizzy spells • No convulsions or fitting from your friend's description. It was a hot day. • You had no loss of control of your bladder or bowel function during the attack. this has been noticed over recent months. You don't get short of breath lying down or at night. appropriate questioning: • You feel well today. They couldn't tell whether I was breathing or not and they said they couldn't feel my pulse. My friends thought I was dead!' If given the opportunity by the doctor. • This was the first such attack. • Negative responses to all questions reviewing body systems. Provide the following information in response to specific. • You also have some 'muscle soreness' in your chest. no headache. There was no warning and I must have 'come to' pretty quickly because my friends told me they were about to start pushing on my chest. You have attributed this to your age. 173 . but it is not severe and goes away when you stop playing tennis between games. I decided not to play on although I felt ok'. just across your chest. no disturbance of your vision. Before or after the attack you had no palpitations or awareness of heart beating abnormally. This occurs if a game is strenuous or prolonged and is a tight feeling. no numbness or tingling. I had been serving and the game was pretty fast — when I suddenly blacked out.

After six minutes ask the candidate the most likely diagnosis. • heart ~ prominent left ventricular impulse ~ apex beat not displaced ~ ejection systolic murmur (3/6) best heard over aortic area ~ radiates to neck and apex normal Neurological examination There are no other abnormal physical findings. 174 . You were told that it was in the 'high normal' range and advised to reduce intake of fatty foods. Because you were unaware of the details of yesterday's events (except for the graze on your elbow) and because you feel so well.036 Performance Guidelines Other significant information • • • • • Your last cholesterol check was three or four years ago when you last saw a doctor. Physical examination (provide these on request) Cardiovascular examination • • • • pulse blood pressure jugular venous pressure auscultation of neck 70/min regular 118/88 mmHg lying and standing normal . exertional dyspnoea and angina which raise a high index of suspicion of aortic stenosis. you are not unduly concerned. You are a mature middle-aged person without previous health concerns. social history or other information. After obtaining the results of the physical examination the doctor should give you an opinion as to the cause of your symptoms. then direct the candidate to discuss these with patient. Excluding symptoms suggestive of other causes. • • EXPECTATIONS OF CANDIDATE PERFORMANCE History • • Eliciting the triad of symptoms of syncope. If asked about your past history. habits. without proper enquiry from the doctor. respond as for yourself. Accept what the doctor says. particularly epilepsy (see differential diagnosis). No regular medication.systolic bruit (transmitted) over both carotid arteries at base of neck — loudest on right. The examiner should limit the candidate's requests for physical examination findings to the cardiovascular and central nervous systems (the latter is normal). Do not reveal the chest soreness or the excessive shortness of breath on exertion. family history. Blood pressure always normal.

and echocardiogram • Diagnosis must recognise that this patient's syncope has a serious underlying cause. including an eyewitness account. drugs.03 Performance Guidelines Diagnosis (opinion to patient) That the loss of consciousness was most likely due to an abnormality in one of the heart valves which requires investigation by ECG and echocardiogram (X-ray chest and full blood examination are addtionally acceptable). • Choice of investigations must include ECG. Taking a careful history. is critically important in syncope and can prevent inappropriate and costly investigations. cardiac arrhythmias (bradycardias and tachycardias). Causes of syncope include neurally-mediated syndromes (such as vasovagal/ vasodepressor syncope and carotid sinus syncope). An attack of syncope is associated with major morbidity such as fractures and motor vehicle accidents in 6% of cases. relationship with head turning or warning symptoms). • Examination must request pulse. • History must elicit details of syncope. The prevalence of syncope increases with age and can cause significant morbidity in the elderly. The candidate is expected to use appropriate questioning to try to exclude epilepsy and other neurological causes. The absence of palpitations is against the diagnosis of cardiac arrhythmia but this could still be a possibility on the history. accounting for 3-5% of attendances at Emergency • Failure to ask about cardiovascular symptoms. and minor injuries such as lacerations and bruising occur in about a third of cases. • Failure to request examination findings for both carotid and cardiac bruits. The history in this middle-aged patient with syncope has the important feature of coming on with exertion and against a background of cardiovascular symptoms of chest pain and shortness of breath pointing towards a cardiac cause. This middle-aged patient with syncope evinces the triad of symptoms classical of aortic stenosis. Departments and affecting 15-25% of the population over any 10 year period. presence of carotid and cardiac murmurs. blood pressure. 175 . autonomic failure syndromes). Syncopal episodes are common. exertional dyspnoea and chest discomfort. structural heart disease and cerebrovascular disease. It is essential to distinguish syncope from seizures and syncope caused by benign causes from syncope caused by serious underlying illness. orthostatic syncope (including volume depletion. Carotid sinus syncope and vasovagal/vasodepressor syncope may be considered as differential diagnoses but other features of these conditions are not apparent (for example. and referral to a cardiologist (may use term aortic stenosis with further explanation).

site and radiation are key findings that help to refine the diagnostic process. Hotter or loop monitoring and coronary angiography. in particular for features of aortic stenosis. The nature of the cardiac apex beat.036 Performance Guidelines The next step is a careful cardiovascular examination. and a request for details on the heart sounds and the cardiac murmur. electrolytes. The candidate is expected to look for evidence of structural heart disease. The most important investigations to perform in this patient are an ECG and an echocardiogram. ' 176 . A lack of understanding of the condition would be exhibited if a candidate requests a whole range of investigations such as: 7 would like to perform full blood count. moving on to an examination of the carotid pulses. The examination requested should be systematic. electroencephalogram. Referral to a cardiologist would be an appropriate step to take. its characteristics. starting with the peripheral pulse and blood pressure. blood glucose. carotid Doppler studies.

• It started as intermittent tingling. • There is no history of mental illness. • Sexual history — you have no steady partner. chlamydial. Patient counselling and education is important to reduce risk of transmission. doctor. gonococcal and HIV testing. This patient has penile herpes simplex. • Explain the Cause to the patient. You are heterosexual and you last had sex with a woman you met at a disco a week ago.037 Performance Guidelines Condition 037 A painful penile rash in a 23-year-old man AIMS OF STATION To assess ability to diagnose and manage genital herpes. ' You are a carpenter. 177 . and management advice should be: • Confirm diagnosis with virological testing. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement ‘I've got a problem with my penis. Testing for associated sexually transmissible infections as part of the differential diagnosis should include Venereal Disease Research Laboratory (syphilis). In response to questions from the doctor indicate that: • You have had no serious past illnesses and are on no medications. The patient also needs to be assessed in terms of other possible sexually transmissible infections. • Do not volunteer information about sexual behaviour unless asked specifically Questions to be asked of the candidate unless already covered: • ‘What is wrong with me?' • 'What is the cause?' • 'Can I pass it on?' • 'How can it be treated?' • 'Will I be cured?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to take an appropriate sexual history and to be able to identify the vesicular penile rash as most likely due to genital herpes simplex and to confirm diagnosis by viral testing. • You have no allergies. but is now constant. • You have noticed today a lumpy penile rash with blisters. Volunteer the following history without prompting: • You have had penile pain for two days.

HSV 2 is largely associated with genital infection and is most common in young. The infection appears at the site of virus entry. but share some characteristics. Counselling to reduce risk of transmission of any sexually transmissible infections is essential. Further investigations ~ The risk of other sexually transmissible infections. are treated with a five day course of oral aciclovir. but can occur anywhere on the skin. Epstein-Barr virus (EBV). Ability to take a sexual history and investigate possible concomitant sexually transmissible infections. wear loose clothing. Transmission is by vaginal. when severe. HSV 1 is more common and is usually acquired during childhood presenting most commonly as acute gingivostomatitis. Topical treatments can help symptomatic management: for example. sexually active adults. including HIV infection needs to be investigated. on the glans penis or penile shaft in men. CRITICAL ERROR Failure to assess for other sexually transmissible infections. The risk of infection increases with numbers of sexual partners. COMMENTARY Herpes Simplex Virus (HSV) is one of a family of herpes viruses. genital and anal areas for Chlamydia and other infections. HSV 1. analgesics. keratoconjunctivitis is a feared infection because it can cause scarring of the cornea and loss of vision. KEY ISSUES Ability to identify rash as herpes simplex. First clinical episodes of genital herpes. for which the patient should be screened. ~ This may involve swabbing oral. Perianal and rectal lesions can develop as a result of anal intercourse. lignocaine.037 Performance Guidelines • • • • • • Assess the risk of possible exposure to other sexually transmissible infections. Primary herpes simplex infections have an incubation period of 3-6 days but this may be longer. salt baths. In the eye. or similar agent. Antimicrobial therapy: reduces the length of illness and may decrease virus transmission. Ability to treat herpes infection. Condoms reduce the risk of transmission. varicella zoster virus (VZV). Supportive treatment: rest. HSV 2 and herpes zoster all establish permanent latency in sensory nerve ganglia following the primary infection. topical povidone-iodine. Counselling to reduce risk of further transmission of herpes simplex virus. HSV 1 and HSV 2 cause patterns of disease which differ clinically and epidemiologically. All testing needs to be done with informed consent. ice packs. oral or anal sex. which includes HSV 1 and HSV 2. or on the vulva or vaginal mucosa in women. cytomegalovirus (CMV) and human herpes virus 6. 178 .

• There may be associated fever. Systemic manifestations are uncommon. myalgia and local lymphadenopathy. These heal within a few days.037 Performance Guidelines During the first attack. the vesicles leave small red. • The rash is vesicular. • • • • Recurrence occurs in about 50% and may be associated with shooting pains in the buttocks and legs. HSV infection may be associated with other sexually transmissible infections. • After a day. painful ulcers. there may be a tingling and burning over the affected area. often occurring in crops. 179 L . Recurrences are also more frequent in presence of immunosuppression including HIV infection. • The first (primary) attack lasts around two weeks. Recurrences often occur at times of stress and tiredness.

You are now of similar height to peers from school. Breasts show Tanner stage 5 of puberty. Hymen intact. You have never been sexually active. but apparently perforate. Lower vagina above hymen appears normal. EXPECTATIONS OF CANDIDATE PERFORMANCE Pelvic examination per vaginum should not be done and should not be specified by candidate. Pubic and axillary hair also show stage 5. Blood pressure 120/80 mmHg. You are 18 years old. 180 . • • • • • You have no history of abdominal or pelvic pain. You have had no operations or significant illnesses. Vulval inspection — normal appearance. • • • • Her weight is 48 kg and she has normal height for weight. Your mother had her first period at the age of 17 years. ~ Pubic hair began to develop three years ago. Questions to ask unless already covered: • • • 'Why hasn't my period started yet?' 'All my friends at school started years ago. List of appropriate answers in response to likely questions • Evidence of pubertal changes: ~ You had a growth spurt three years ago. ~ Breast changes started three years ago. Will I ever have periods?' 'Will I be able to have a baby?' Examination findings from examiner These should be given to the candidate on request for specific components of the examination.038 Performance Guidelines Condition 038 Primary amenorrhoea in an 18-year-old woman AIMS OF STATION To assess the candidate's ability to define the cause of primary amenorrhoea in a young woman who has gone through an apparently normal puberty EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You have come to see the doctor because you are worried that you have not yet had a period. Your sister (aged 14) has not yet started to have breast development.

• Ability to define the most likely cause of primary amenorrhoea (delayed menarche). • She will be reviewed after investigations have been established as normal and again in 12 months time. estimation of oestradiol levels should be repeated. • Performance of pelvic vaginal examination as she is virginal. • Failure to reassure the patient and failure to advise review in 12 months time if a period has still not occurred. If a period has still not occurred. It is therefore essential to obtain an appropriate history. luteinising hormone (LH). The first period usually occurs two years after the first breast development.03 Performance Guidelines Investigations required • Ultrasound examination (abdominal-pelvic ultrasound. Noninvasive investigations will enable this patient to be reassured in the presence of other pubertal changes. Requesting that pelvic examination should be done would be a significant and potentially failing error. Pelvic (vaginal) ultrasound is also inappropriate • Failure to order hormonal analyses of FSH. Common problems likely with candidate performance are: • Failure to recognise that an apparently normal puberty is occurring. Other less likely possible causes are obstruction to the outflow of blood from the uterus to the exterior by an intact hymen or vaginal septum or an absence of development of the uterus. both in regard to her own history and that of other family members. Advice to patient (the candidate should convey the substance of what follows to the patient): • Reassurance that this is likely to be just a physiological delay in the first period as all else appears normal on examination. prolactin. • Failure to order abdominal ultrasound. not vaginal): to check the development of the uterus and vagina and to confirm that these are normal • Hormone tests: should order follicular stimulating hormone (FSH). Therefore the cause of the primary amenorrhoea is likely to be just a slight delay in the first period with everything else being normal. prolactin and oestradiol. but can be delayed for three years or longer as normal variation in menarche. • Ability to arrange the appropriate investigations. The investigations which have been arranged should confirm this. CRITICAL ERRORS • Inadequate history to evaluate current pubertal status. • Chromosome analysis is not necessary if uterus is shown to be normal and above hormonal levels are normal. Ultrasound examination is essential to make these latter diagnoses. This case illustrates the situation where a slightly delayed menarche can be a normal situation particularly where there is a familial trait. and oestradiol levels. 181 .

The most likely diagnosis is an ulcerating basal cell cancer and the most appropriate treatment is local excision with an adequate margin. followed by advice to the patient about treatment. • You have had a firm nodule on your cheek for a year or so. It tests accuracy of observation and ability to summarise the problem concisely. and should advise the patient accordingly. You are otherwise healthy and well with no serious past illnesses. It has recently developed an ulcer in the centre of it. Differentiating a basal cell cancer from a squamous lesion or other skin malignancies is less important than identifying the lesion as requiring appropriate histologic diagnosis after adequate excision. in this case basal cell carcinoma. which has slowly increased in size. Otherwise answer as for yourself. Opening statement: 'I've had this thing on my cheek for about a year doctor. The diagnosis should be straightforward. COMMENTARY This scenario has been arranged in the format of a summary case presentation to the examiner of a suspicious skin lesion.039 Performance Guidelines Condition 039 A skin lesion on the cheek of a 50-year-old man AIMS OF STATION To assess the candidate's ability to diagnose a facial skin lesion suspicious of basal cell carcinoma EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a builder aged 50 years. CRITICAL ERROR • Failure to diagnose that this is a 'suspicious' skin lesion needing excision. and has bled a little. 182 . Ability to identify and manage a 'suspicious' skin lesion. KEY ISSUES • • Ability to present a focused case summary. • You have no allergies and are on no medications. You think this may have followed you picking at it. ' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should recognise from the history and physical findings that this is a 'suspicious' lesion which requires excision. Most of your working life has been spent outdoors.

183 . occurring usually in people older than 35 years.They do not metastasise. or ear ('nothing burrows like a basal cell'). eye. . limbs (10%). ~ BCC occurs most commonly on sun-exposed areas: face (mainly). • Patients need to be educated about avoiding direct sunlight when the sun is at its strongest: wear a broad rimmed hat. neck. wear a shirt. and can occur in various forms: nodular. but can occur on covered areas as well. upper trunk.039 Performance Guidelines • Common clinical features of basal cell carcinoma (BCC) are: ~ BCC is the most common skin cancer comprising 80% of skin cancers. ~ Ulceration produces the characteristic 'rodent' ulcer as illustrated by this example ~ BCCs grow slowly over years. and use sun block cream when exposed. more frequently in males and in fair-skinned people. ulcerated. but local spread can cause problems with surrounding structures as they can spread deeply around nose. morphoeic. cystic or pigmented.

About one third of melanomas arise in pre-existing naevi. The examiner will have instructed the patient as follows: • • You are a 30-year-old schoolteacher. Removal of such naevi is important for melanoma prevention. Excluding melanoma by excision is critical to successful case management. and are on no medications. You have no allergies. appears to be related to brief intense sunlight exposure as well as effect of chronic exposure. Incidence is higher in fair-skinned people. Ability to manage pigmented skin lesions appropriately. You think you were born with it. should raise concerns about malignant change. but they have not changed. KEY ISSUES • • Ability to identify a 'suspicious' pigmented lesion. doctor. and have had no serious past illnesses. ' EXPECTATIONS OF CANDIDATE PERFORMANCE The presence of change in appearance and irritative symptoms in a previously stable pigmented naevus. You have a few other dark spots. • You are otherwise healthy and well. CRITICAL ERROR • Failure to suspect malignant potential. The incidence of melanoma is rising in Australia and around the world. 184 . especially in a large lesion with appearances suggesting a dysplastic naevus. The spot has become darker over the last few months so you thought you would have it checked out. EXAMINER INSTRUCTIONS This patient has a 'suspicious' pigmented skin lesion: a melanocytic naevus suggestive of a dysplastic naevus.040 Performance Guidelines Condition 040 A pigmented mole on the trunk of a 30-year-old woman AIMS OF STATION To assess the candidate's ability to diagnose a pigmented focal skin lesion and to identify a 'suspicious' lesion. You have had a dark spot on your back for many years. COMMENTARY Most pigmented skin lesions are benign. possibly at risk of malignant melanoma. Opening statement: 'It seems to have changed and become more itchy lately. The candidate should refer the patient for excisional biopsy.

this lesion should be excised. • change in colour (brown. black. pink. mainly on the trunk. • junctional and compound benign melanocytic naevi. Management: • In this case. • change in the border. Multiple dysplastic naevi carry a greater risk of malignant change. However. but excision is indicated if any diagnostic concerns. • dermatofibroma (sclerosing haemangioma). and • lentigines. and • other symptoms (itching). white and combinations of these colours).040 Performance Guidelines Most people have an average of 5-10 benign melanocytic naevi. • Most are stable and do not lead to melanoma. appearing usually on the trunks of young adults. variable colours — brown. • blue naevi. background redness. and not be treated by cryotherapy. the solitary dysplastic naevus may have no significant malignant potential at this stage. large. Differential diagnosis of pigmented skin lesions includes: • haemangioma (thrombosed). • dysplastic naevi. 185 . • change in surface. irregular pigmented naevi. because of the size of the lesion and the patient's concern. Dysplastic naevus syndrome is diagnosed because of the presence of multiple. ill-defined borders. tan. Development of satellite nodules and lymph node involvement are late signs. • pigmented basal cell carcinoma. red. blue. such as this patient exhibits. It is important to exclude malignant melanoma Signs indicative of possible malignant melanoma include: • any change in size of a presenting lesion (lateral spread or thickening). • Suspicious pigmented lesions should have complete excisional biopsy. Clinical features of 'suspicious' dysplastic melanocytic naevi include: • Large (> 5 mm) irregular moles. black. • pigmented seborrhoeic keratosis. • Lesions with irregular. irregular pigmentation. • bleeding or ulceration. • change in shape.

History.041 Performance Guidelines Condition 041 An itchy rash on the hands of a 19-year-old woman AIMS OF STATION To assess the candidate's ability to diagnose. ~ No known allergies. EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient. ~ No recent travel away from home. Be nonjudgmental about possible sexual transmission of scabies from boyfriend. but should advise the patient that diagnosis must be confirmed by taking skin scrapings from the lesions for microscopy. Display interest and intention to deal effectively with the condition. Scratch and rub the backs of your knuckles and between the bases of your fingers. ~ No past history of any serious illness. Answer the doctor's questions in a straightforward manner including about the relationship with your boyfriend. ~ Your boyfriend with whom you are sexually active has had a similar rash though not as bad and he has not sought medical advice about it. ~ Your hands have not been in contact with any irritants. as when washing up in hot water or bathing or showering. ~ The itch is worst at night and interferes with sleep. ' • • Follow with 'It started about a week ago and I can t stop scratching my hands because of the itch. Confirmation of diagnosis. ~ No history of mental or behavioural disturbance. ' In response to questions the doctor may ask: ~ You have not had anything like this before. • • 186 . ~ Your general health is excellent. Examiner Instructions: The examiner will have instructed the patient as follows: Opening statement 'I want to get rid of this rash on my hands. chemicals or plants. Provide reassurance that condition is simply cured and not serious. ~ The itch is intense and made worse by warming your hands. confirm and treat scabies. and to prevent recurrence. ~ No rash or itchiness elsewhere on your body. ~ No medication except oral contraception. Identify site and severity of itch and question about sexual activity after other possible sources have been excluded. Compliance with the whole of the treatment regimen should be obtained. Do not reveal this spontaneously. The candidate may diagnose scabies from illustration and history as given above.

The female scabies mite (illustrated below) burrows just beneath the skin in order to lay her eggs and then dies. In this case. especially if overcrowded. 187 . although this is now uncommon. ~ Application of permethrin cream or lotion 5% (Lyclear®) or benzyl benzoate emulsion 25% (Ascabiol®) to entire body from jawline down including nails. flexures and genitals. the condition is transmitted by close contact during sexual activity. • History — Ability to take an appropriate history including site and severity of pruritus and sexual partner as source of infection. The eggs hatch into mites which spread out across the skin and live for about 30 days. Commentary Scabies is a highly contagious infestation which is spread through close contact including sexual contact. Description of the scabies mite is expected with reassurance that the condition is not serious. • Management — Provide adequate advice for proper treatment and advise the patient to avoid intimate contact with boyfriend until he has been treated Critical Error • Failure to suspect scabies or to take action to confirm diagnosis. and advise the patient accordingly. A mite antigen in the excreta induces a hypersensitivity rash. • Patient education and counselling. ' The examiner should only state this if the candidate has mentioned the need for skin scrapings to diagnose scabies. • Management. • Diagnosis — Should advise microscopy of skin scrapings to facilitate diagnosis. Patient should advise boyfriend to seek medical advice. but benzyl benzoate lotion should be left on for 24 hours. ~ Avoid hot baths or scrubbing before application ~ Treat household contacts even if nonsymptomatic ~ Wash clothing and bed clothes in hot water and expose to sun to dry ~ Repeat treatment in one week if infestation is considered to be severe ~ Avoid intimate contact with boyfriend until he has also been properly treated Key Issues • Approach to patient — Ability to establish satisfactory relationship with patient to achieve compliance and cooperation of patient to get boyfriend to seek treatment. It is characterised by widespread inflammatory papules and severe pruritus and it can be endemic among school children and institutionalised older patients. Scabies can affect entire households.041 Performance Guidelines Examiner should intervene at this point by stating 'Please assume that the skin scrapings are positive for scabies. Leave permethrin cream or lotion overnight then wash off thoroughly. although very uncomfortable. and is readily treatable.

CONDITION 041. FIGURE 3. Scabies mite (Sarcoptes scabiei) CONDITION 041. axillae. The rash also can occur in web spaces. Penile scabies Clinical features include intense itching. after a shower). on elbows. or nipples of females. Diagnosis is confirmed by microscopy of skin scrapings. FIGURE 2. 188 . on male genitalia as illustrated. feet and ankles. worse at night and when hands and body are warm (for example. with an erythematous papular rash usually on hands and wrists.

with no serious past illnesses. You have no allergies. and have been working as a bricklayer/contractor for about a year. ' Following without prompting: Your hands have been itchy and dry for some months now. This patient has occupational contact dermatitis secondary to concrete exposure.Condition 042 Red painful dry hands in a 30-year-old bricklayer AIMS OF STATION To assess the candidate's ability to diagnose occupational dermatitis and advise an initial management plan. You are on no medications. You are otherwise healthy and well. and are getting worse. 189 . State if questioned about the relationship of rash to work: the rash definitely improved significantly after a holiday from work. Opening statement 'I've got problems with this rash on my hands. Your brother has skin problems but you are not sure what type. The rash is on no other part of the body. if the candidate has not identified the condition as contact dermatitis ask the questions: • • What is the likely cause of the condition?' 'How would you manage this condition?' The examiner will have instructed the patient as follows: You are aged 30 years. After 6 minutes.

grevillea. Management — explain to the patient that the rash will persist as long as there is exposure to cement although its severity may be reduced by the following initial management: ~ Wash only with water and avoid soap. • CRITICAL ERROR • Failure to suspect causal work association in diagnosis. Ability to manage occupational contact dermatitis. 190 . even after working with cement for many years. glues. epoxy resins. topical antibiotics. topical antihistamines. Diagnosis — should suspect allergic contact dermatitis and its cause in this patient from the history and from the physical findings as illustrated. dyes. rubber/latex. Consideration of cement as most likely cause of dermatitis. individuals can become sensitised to chromate salts at any time. Oral prednisolone is reserved for severe cases. While physical appearance of the skin can be similar to other forms of dermatitis. Confirmation of diagnosis is by patch testing by dermatologist (not essential). management and prevention. ~ Oral antibiotics may be required for secondary infection in severe cases ~ Consider using emollient agents for future prevention. ~ For cement dermatitis. poison ivy). Common trigger factors include cosmetic ingredients including perfumes and preservatives. KEY ISSUES • • • Ability to identify the type and cause of the dermatitis. chromâtes — as occur in cement and concrete). ~ Pat dry after washing ~ Apply topical corticosteroid cream to gain initial control. plants (rhus. metal salts (nickel sulphate. specific measures involve avoiding contact with wet cement: using barrier creams before putting on gloves (do not use barrier creams on damaged skin). COMMENTARY Allergic contact dermatitis is due to a delayed hypersensitivity reaction. acrylates. coral. In cement dermatitis. Trigger factors only affect some people. which involve palmar and dorsal surfaces of both hands. topical anaesthetics.042 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • • History — must elicit occupational history. rash site and exposure history are critical for diagnosis. using protective gloves when working and washing hands after being exposed to cement. primula.

' • You sleep well. • Regarding exercise: you gave up playing tennis about a year ago because you became very breathless for a short time after a rally and also you felt exhausted afterwards. • Recurring palpitations: for some years you have noticed that your heart seems to 'bounce around in your chest' particularly when you are going off to sleep (thumps and misses beats). You have not counted your pulse rate but you are sure that it is faster than normal. • No associated dizziness or blackouts. Your heart also seems to race after any strenuous exertion although this settles down after a few minutes. • No suggestion of a fever. If asked about chest pain in the past say ' Four years ago I had a bad pain in the centre of my chest. My ankles have never swelled up before'. knowledge of possible causes and the components of the physical examination necessary to reach a firm provisional diagnosis. • There has been no pain in your legs. ' Provide the following without prompting 'Over the past eight weeks my ankles have been swelling. but you find it hard to be sure. there is no discolouration of the skin. I usually notice this is worse at the end of each day. you may comment that this is why you haven't worried about the other symptoms. • No cough or blood in sputum. The pain lasted about two hours and I felt unwell for a few days afterwards. no chills or shakes. I was on holidays at the time. • If asked about shortness of breath: you believe that you are not as fit as you used to be because you become noticeably breathless when walking up stairs or hurrying. • You have not had any recent chest pain with or without exercise.043 Performance Guidelines Condition 043 Swelling of both ankles in a 53-year-old woman AIMS OF STATION To assess the candidate's ability to take a detailed history concerning swelling of the ankles. They have mostly gone down by the mornings. This passes when you rest. The examiner will have instructed the patient as follows: You are a 53-year-old clerical worker and are consulting the doctor about swelling of your ankles. 191 . Provide the following in answer to appropriate questioning • The swelling is the same in both lower legs. The doctor will take a history about this complaint but will not examine you Opening statement 'I have come to see you about swelling of my ankles. You have the feeling that it may not be regular at times. lying flat in bed: you do not snore.

apart from the short episode 4 years ago. You eat a normal. but do not disclose all of the cardiovascular symptoms without facilitation. 'After all. You have never had any kidney problems (for example. then you get 'puffed' You have noticed this over the past six months. You work for a large legal firm as a legal secretary. Blood pressure has been checked several times in recent years and was always normal. my father was 90 when he died'. You have never suspected that your various symptoms could be connected and would not have attended without the insistence of your spouse. You are not worried about heart trouble because you no longer smoke and. Past medical history • • • • No serious illnesses. No operations. Patient profile • • • • • • • You are married. do not have chest pain. prompting and appropriate questioning by the doctor. The only exercise you have these days is when gardening and this does not cause any problems. reply in the negative. Other instructions • • • • • Appear calm and not unduly concerned about your swollen ankles.Review of general health • • • You consider yourself to be in good health. Review of relevant systems • • Positive responses are confined to the cardiovascular system. You are not taking any medication. Be cooperative. as indicated above. No brothers or sisters. No history suggestive of rheumatic fever. You have attributed them to your age. In particular. blood in urine) or liver disease (jaundice). 192 . If asked other specific questions. no gastrointestinal symptoms including no rectal bleeding. Family history • • • Mother died aged 77 years (stroke). Father died aged 90 years. unless you are digging for more than a short time. You smoked 20 cigarettes a day from age of 18 years and stopped a year ago. You have not had a medical check-up recently. You have never suffered any serious ill health. well-balanced diet. Your spouse is well. You have three married children. Other significant information • • • • You are very busy at work. You drink three glasses of wine daily.

~ cardiac examination (apex beat and auscultation). causing inferior venacaval obstruction or bilateral lower limb deep venous thrombosis is unlikely but needs to be considered. encourage the candidate to do so • After five minutes. nephrotic syndrome or malignancy as most unlikely causes in this patient). but clearly time limitations will influence the choice and number • The history must at least cover key questions relating to possible cardiac. ~ respiratory examination (any reference to effusion. adventitious sounds or rub acceptable).043 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE History • This should include a reasonable number of questions detailed in the patient's advice above. tenderness. if the candidate has not already done so. hepatic and renal causes for the oedema. • If. 193 . Some questions out of each section should be included. • Other potential causes could also include hepatic and renal disease (consider cirrhosis. Examination • The examiner is not required to provide specific examination findings but should encourage the candidate to relate the examination findings sought to the previously stated diagnostic possibilities. ~ pulse rate and rhythm. ~ mucous membranes. • These should include: ~ temperature. heat). after five minutes the candidate has not started to discuss with the examiner some of the likely causes for the symptoms. ~ jugular venous pulse and pressure. spleen ~ inguinal region and lower limbs (symmetry of oedema. although candidates may indicate the tests required to confirm the proposed diagnosis. • Venous thrombosis. and ~ urinalysis must be requested or come up some time in the assessment. ~ liver. • Candidates are not expected to indicate the investigations required in this station. • Possible diagnosis given to patient after history must include cardiac failure as the most likely condition. instruct the candidate to tel the patient the working diagnosis. discolouration. ~ blood pressure. and then ask the examiner for physical findings to confirm this.

which is worse after prolonged standing and reduces with supine rest. As in this case. neural and hormonal responses. This station assesses the candidate's ability to take a comprehensive. there is often a coexisting history of left heart failure symptoms. Ability to state precisely what would be sought on physical examination and why. constrictive pericarditis).' A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic. cardiomyopathy). Pressure overload (hypertension. Heart failure is difficult to define.' A biomechanical definition is that the failing heart exhibits a reduction of power such that it cannot maintain a normal cardiac output without abnormal elevation of systemic and/or pulmonary venous pressures. Congestive heart failure can present in a subtle way with symptoms of right heart failure. Various definitions include the following: • A pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising tissues.043 Performance Guidelines KEY ISSUES • • • • Ability to take an appropriate history. aortic stenosis). such as bilateral leg oedema. Ability to explain to the patient why she has swollen ankles and shortness of breath. renal. It is very important in a patient with possible congestive heart failure not to be satisfied with this as a complete diagnosis. • • The underlying causes of heart failure are many and it is useful to consider these under the following group headings: • • • • • Primary myocardial disease (ischaemic heart disease. but to ask the questions 'Why has this patient developed heart failure? What is the underlying cause? This will require an understanding of the pathophysiology of heart failure. 194 . ventricular septal defect. but ordered and concise history in a patient with recent onset of bilateral leg oedema. Restriction of ventricular filling (hypertrophic cardiomyopathy. Volume overload (aortic regurgitation. Ability to provide a sensible differential diagnosis. high output states). such as exertional dyspnoea. mitral regurgitation. Obstruction to ventricular filling (mitral stenosis). It also examines clinical reasoning abilities in understanding the potential causes of leg oedema and proceeding in a logical way to accumulate the relevant positive and negative features of the history in order to form a satisfactory probability diagnosis.

hypertension. Atrial fibrillation is often a cause of diastolic heart failure because of the effects on ventricular filling with loss of the atrial systole and an increased ventricular rate. have hypertension and/or diabetes. the so-called 'backward failure'. Pitting oedema in CCF 195 . diabetes. FIGURE 2. ischaemic heart disease or a combination of these — the first presentation may be due to cardiac diastolic dysfunction where heart failure is caused by an increased resistance to filling of one or both ventricles. left ventricular hypertrophy. which in the great majority of patients is secondary to a longstanding problem with the left heart. In this patient. CONDITION 043. or underlying mitral valve disease. the presentation with leg oedema is an indication of right heart failure. With diastolic dysfunction of the left ventricle.043 Performance Guidelines In this station the patient presents with important history features of probable ischaemic heart disease and cardiac arrhythmia. the presentation is usually with breathlessness on exertion and episodes of acute pulmonary oedema. and this is particularly true in patients who are older. The onset of atrial fibrillation is often a precipitant of heart failure. In patients who have stiff (noncompliant) hearts due to age.

Whether one is examining the whole patient. medical practitioners in their attempts to become skilled clinicians must: • • • • • • have a good understanding of correct methodology.' Journal of the American Medical Association (1962) LOOK! MOVE! FEEL! LISTEN! MEASURE! COMPARE! INTERPRET! This aide-memoire comprises the seven champions of physical examination. A sound knowledge of clinical anatomy is an essential prerequisite. back. they form the basis of all physical examination techniques. Used in the correct sequence (and remember the above sequence. respiratory. well practised and logical sequence is essential. shock. the chest or the abdomen. • This introductory segment and the MCATs following provide selected examples of these techniques. and practise frequently. will confirm the diagnosis in the majority of consultations despite the plethora and utility of available investigations. etc) A sound knowledge of clinical physiopathology is an essential prerequisite. cardiovascular. an ordered. and practise. gastrointestinal. Skill development in physical examination is sequential throughout undergraduate medical education and extends into independent and specialist practice. In preparing themselves to be good noticers and good examiners of physical signs. hyperthyroidism or cardiac failure. clinicians should gain practice in: • • Pattern recognition: the ability to define and group a constellation of features in order to diagnose. Examination of multiple sites and areas logically. limbs) or a body system (integument. abdomen. assiduously develop the correct techniques. along with a careful history. Here one must concentrate on checking features — normal and abnormal-of the multiple local structures which comprise focal components of several body systems grouped at a common site. Like the acquisition of any skill. eyes first and foremost and only then fingers. be aware of the limitations of clinical signs. neuroendocrine). Sound technique facilitates accurate findings and diagnostic acumen. gastrointestinal. for example.2-B: Physical Examination Vernon C Marshall and Barry P McGrath 'One of the unexpected and disturbing results of the development of increasingly precise and useful diagnostic measures in the laboratory and X-ray departments is a significant and often alarming decrease in emphasis on the training of the medical student to perform with excellence the average comprehensive physical examination. chest. know the range of normality and what constitutes abnormality. hands and ears). but use adjuvant investigations thoughtfully and selectively. have the right equipment and know how to use it. Physical examination still matters and. the neck. a focal region (head and neck. Focused examination of an area or region such as a limb. sequentially and expeditiously to provide global assessment of a body system (cardiovascular. 196 .

accurate clinical summary. will confirm the diagnosis in the important aspects of pattern recognition. HIV). papular.Physical Examination 2-B Central to correct physical examination. • failure to spend time in general inspection of the patient. is the manner in which the examiner interacts with the patient. FIGURE 1. PHYSICAL EXAMINATION — REGIONAL EXAMINATION • The integument The skin is the largest body organ. Common problems that are observed in candidates undertaking physical examination include the following: • lack of empathy and skill in engaging the patient. • finding things that are not there. systematic approach. Acne vulgaris 197 . focal skin ischaemia in vasculitis. Atopic eczema is a blotchy ill-defined red macular rash which can progress to papule and pustule formation. and unique to the health domain. and along with a SECTION 2-B. fungal. Irritative contact dermatitis can be wet (intertrigo. Involvement of scalp or nails may occur (psoriasis). The distribution of the rash (e. majority of consultations. • missing obvious pathology by overlooking physical signs. nappy rash). pretibial erythema nodosum) and associated features (e. or viral (molluscum contagiosum. missing important signs along the way. • inaccuracy of sign characterisation and of measurements. lichenification and pigmentation. or dry and associated with hyperkeratosis. Physical examination still matters. Rashes are commonly allergic. FIGURE 2. vesicular or pustular. utility of available investingations. Skin rashes should be assessed as macular. • failure to develop a careful. despite the plethora and • causing undue discomfort to the patient. • incorrect techniques. give important diagnostic clues. herpes simplex and zoster. Flexural eczema SECTION 2-B. central clearing in fungal lesions). Infective rashes are legion and range through bacterial (impetigo.g. thus missing careful history. • a slipshod approach. itchy or nonitchy. irritative or infective.g. • over-interpretation. and • inability to provide a succinct. maculopapular. acne).

2-B Physical Examination SECTION 2-B. In Australia. benign and include benign melanocytic and other naevi. Most focal skin lesions are. Melanomas are the most serious lesions. FIGURE 3. seborrhoeic keratoses. Solar keratoses. and although mostly seen on the face and other exposed parts. FIGURE 4. so picking up dysplastic or premalignant lesions is important. however. and cherry angiomas (Campbell de Morgan spots). their incidence is increasing in Australia and in most parts of the world. Neurofibromatosis Type I — von Recklinghausen disease of nerves Note numerous cutaneous neurofibromas (molluscum fibrosum) 198 . are seen with increasing frequency with increasing age. Molluscum contagiosum SECTION 2-B. Basal cell cancers are the most common cancers. SECTION 2-B. particularly in higher latitudes and in fair-haired and pale-skinned individuals. By contrast squamous cancers are almost always confined to sun exposed areas. 'senile' melanocytic and purpuric freckling. Microsporum canis ('ring worm') Focal skin lesions are also of immense variety. malignant skin lesions are common. dermatofibromas (sclerosing hemangiomas). can occur anywhere. calluses and viral warts. FIGURES 5 AND 6.

Surroundings. SECTION 2-B. and relationships of the lump to its surroundings (which includes the regional nodes). Cough impulse. Shape. • Pulsation. Solitary cutaneous neurofibromas are also often found apart from the inherited syndrome. Fixity. The lump should always be layered' — is it in subcutaneous fat. and Ps.Physical Examination 2-B SECTION 2-B. The diagnostic features of most importance are site. • Fluctuation. and 'suspicious' with the latter two needing appropriately wide excisional biopsy. Colour. Critical features to note are the Ss. Ts. • Tenderness. Temperature. Portwine stains — cavernous haemangiomas Nodular portwine stain Cutaneous neurofibromas form part of the syndrome of von Recklinghausen disease of nerves (neurofibromatosis). 'clearly malignant'. The syndrome is usually readily identified by pattern recognition. Percussion. • Subcutaneous lumps These are mostly benign and often merely need accurate diagnosis and reassurance. FIGURE 9. and if so is it attached to overlying skin. It is usually possible following a focused and accurate history and examination to classify lesions into clearly benign'. • Contour. • Site. FIGURES 7 AND 8. Cs. Consistency. Transillumination. Fs. Congenital 'portwine' stains (cavernous haemangiomas) have a classical appearance and may become nodular with age. physical characteristics. Fields. Size. Compressibility. or underlying fascia and musculature? 199 .

vascular swellings and other subcutaneous lumps will be readily diagnosable if the above simple rules of focused assessment are combined with basic knowledge of local anatomy and likely pathologies. the abdomen or genitals). coughing. colon. The laryngopharynx and oesophagus are not accessible to your examining hands and fingers. Cytology is particularly useful in diagnosis and classification of lymphomas. 200 . laryngopharynx. attached to nearby bone or vessel or nerve. cytology commonly points to a lung. Hodgkin lymphoma SECTION 2-B. lymph node swellings. Cytology may be specific for melanoma. or testicular origin of the primary. Rarer lesions include chemodectomas such as carotid body tumours and neurilemmomas.The mobility of subcutaneous lumps in relation to their superficial and deep surroundings is important in picking up infiltrative rather than expansile enlargement. oesophagus. stomach. squamous neoplastic cells in a neck lymph node point to a potential primary neoplasm of skin. For example. bursae. If suggestive of adenocarcinoma. hernias. salivary glands. protruding the tongue. Most lipomas. in the abdominal parietes or intra-abdominal. The former is very suggestive of malignant or inflammatory fixation and fibrosis. The lump's 'mobility' or fixity helps in checking whether it is below deep fascia. cystic hygromas. SECTION 2-B. rather than from thyroid or stomach. and focal presentation of systemic lymphoid pathology. The most common swellings will involve lymph nodes. 'sebaceous' and other cysts. Nodal metastasis from papillary carcinoma thyroid Examination of a cytologic aspirate will often clarify the diagnosis and point the way for further diagnostic tests. FIGURE 10. sternomastoid 'tumour'). Careful application of the above techniques facilitates identification of the common head and neck lumps and their primary pathologies. or lung. but remember the importance of endoscopic evaluation in the diagnosis of occult primary neoplasms presenting as neck lumps. ganglia. and tensing underlying muscles such as sternomastoid or trapezius. thyroid. FIGURE 11. or developmental lesions (branchial cysts. • Head and neck lumps With neck lumps it is particularly important always first to observe the effects of movement: swallowing. With neck lymph node swellings always keep in mind the possibility of: • • lymphatic spread from areas outside head and neck (chest and lungs. Remember to examine the accessible nasopharynx and oropharynx. breast.

SECTION 2-B. and any abnormalities of skin and nails. Inspect carefully for deformities. carpal tunnel syndrome. Z-thumb. then probe deeper. bone and joint problems. musculotendinous disorders. boutonnière.). tendons and sheaths: Volkmann contracture (long forearm muscles) and short hand muscle contractures (intrinsic-plus deformity). trigger finger (stenosing tenosynovitis). swan-neck. ventral. pitting. SECTION 2-B. a large variety of dermatoses and nail changes. FIGURES 14 AND 15. and neurologic abnormalities. De Quervain tenosynovitis. Osier nodes in bacterial endocarditis • Subcutaneous fasciae: Dupuytren nodularity and contracture. rheumatoid arthritis (synovial thickening. etc. • Bones and joints: changes of osteoarthritis (Heberden and Boucher nodes. and vasculitis (nailfold capillaries). Test active and passive movements of each joint. mallet finger deformities). • Muscles. FIGURES 12 AND 13. neurotropic and occupational changes. digital). rheumatoid nodules. and ganglia (dorsal. A logical approach is to think successively of the various tissue layers. spontaneous tendon rupture (dropped finger. Palpate carefully and carry out clinical testing for vascular insufficiency. Hands in rheumatoid arthritis Rheumatoid nodules 201 . always checking active movements first. metacarpophalangeal subluxations and ulnar deviation fingers.Physical Examination 2-B • Examination of the hands and wrists This assessment will include structural and functional changes across multiple systems. and gout. infective lesions (Osier nodes. Common conditions encountered include: • Skin and nails: circulatory. checking for structure and function of each. carpometacarpal joint of thumb). thumb).

ulnar and radial nerve motor. and local and distal tendonj nerve and vascular effects. • Remember that any regional examination (for example. The aim is to provide guidance for a thorough examination of each system such that important signs are not overlooked Readers are provided with learning objectives for each system and a brief guide on how to prepare both themselves and the patient in order to conduct the system specific examination. and hook grips and opposition of fingers and thumb.2-B Physical Examination Nerves: check median. and| upper or lower brachial plexus lesions. A systems-based examination. chest. SECTION 2-B. This material is based on the Clinical Skills curriculum for Monash University Faculty of Medicine. and combing hair. limbs) necessarily involves assessment of several systems. palpate pulses. undoing buttons. abdomen. listen for axillary bruit)! With hand and wrist trauma. Functional assessment: test grip strength in dominant and nondominant hand: testl power. writing. Note the differing focused techniques required in performing an abdominal examination from examination of the gastrointestinal system PHYSICAL EXAMINATION SKILLS: EXAMINATION OF THE MAIN BODY SYSTEMS The structured approaches which follow provide succinct information on how to perform aq examination of each of the main body systems. by contrast.! differentiate peripheral nerve lesions from more centrally located cervical nerve root. check for proximal lesions (cervical rib. check dominant! arterial supply (Allen test). check for bone and joint injuries. precision. of head and neck. involves examination of several regions. Generic learning objectives • Conduct physical examinations across the following: ~ Integument (see previous description) ~ Neurological system and mental status ~ Cardiovascular system ~ Respiratory system ~ Gastrointestinal system 202 . Finally ask patient to perform everyday tasks of using a key. sensory and autonomic function. FIGURES 16 AND 17. Nursing and Health Sciences. Testing interossei function • • • Thenar atrophy Vessels: observe for vascular ischaemic digital lesions..

• sphygmomanometers will be available in all wards and clinics and other items will also be available for relevant stations. • Describe and use clinical reasoning skills.* • measuring tape.* • pencil torch.* • pins — these must be single use only and must not be hypodermic needles or diabetic lancets. • Involve patient in the process with clear initial explanation and stepwise instructions regarding what you are doing and why and what you wish the patient to do. • mini-mental state examination (MMSE) card. • Establish what difficulties and discomfort (especially pain) the patient may have before and during the conduct of the physical examination. best with a large-size rubber head). ~ Explain your status.* • Snellen chart for testing visual acuity. and avoid causing pain wherever possible.* • cotton wool. • Introductions: ~ Set the scene. Neurotips are excellent.* • reflex hammer (Queen Square pattern. • Demonstrate professionalism.* • 128 or 256 Hz tuning fork for vibration testing. but items starred you should have for personal use. Items marked with an asterisk are standard requirements for personal use • watch with stop watch or second hand.* • disposable tongue depressors. ~ Exhibit a human interest in the patient. Preparing the patient • Establish patient's level of communication capacity. What equipment is needed? Have your own basic set of items to aid in eliciting signs. • Show sensitivity to patient's modesty.* • stethoscope with capacity to detect low frequency (bell) and high frequency (diaphragm) sounds.Physical Examination 2-B ~ Haematological system ~ Endocrinological system ~ Rheumatoiogical system ~ Renal and urogenital system • Interpret and integrate history and physical examination findings to arrive at an appropriate diagnosis or differential diagnosis in commonly presenting complaints and conditions. health status and comfort. ~ Gain patient permission. 203 .

g. electroencephalography [EEG]. mini-Maglite® or : similar] is best) Visual acuity chart (Snellen) — the half-size 3 metre chart is the most practical for ward work Desirable • • • Ophthalmoscope 512 or 1. technically competent neurological examination. incling ~ mental status ~ speech . single proton emission computed tomography [SPECT].3. naming) ~ memory ~ visuoconstructional ability ~ executional ability ~ MMSE (for scaling) 204 . [e. nerve conduction studies [NCS]. Other objectives Demonstrate stage-appropriate knowledge of the selection and use of standard neurological investigations (magnetic resonance imaging [MRI].1 The neurological examination • Assessment of mental status ~ level of consciousness ~ attention (e. bend in centre. THE NEUROLOGICAL SYSTEM 1. 1.g. then bend tips at right angles to ft a serviceable 2-point discriminator) 1.3 Physical examination 1. lumbar puncture [LP]) based on the results of history and physical examination.gait ~ cranial nerves ~ limbs • Localise neurological disorders based on the results of physical examination.1 Objectives Objectives for a neurological examination • Perform a stage-appropriate. computed tomography [CT].024 Hz tuning fork for hearing tests Glasgow Coma Score card as an aide mémoire Usually readily obtainable • • Cotton wool (for corneal reflex testing) Large size paper clip (straighten.2 Preparation What specific equipment is needed? Essential • • • A red-topped pin for visual field examination A bright pocket torch (a focusing torch with a halogen bulb. digit span) ~ language (comprehension.2-B Physical Examination 1. electromyography j [EMG]. repetition. positron emission tomography [PET]. spontaneous speech.

size. strength of eye/mouth closure. FIGURES 20 AND 21. Trendelenburg test ● Cranial nerve examination involves ~ olfaction (not routinely tested. Right hypoglossal nerve palsy ~ observe for deformity/wasting/fasciculation/adventitious movements ~ tone (spasticity. FIGURE 19. extrapyramidal) ~ power ~ reflexes (tendon/cutaneous) ~ coordination and rhythm ~ sensation joint position/vibration pin prick/temperature 2-point discrimination 205 . nystagmus ~ palatal: sensation. tuning fork tests. otoscopy. anosmia usually due to olfactory nerve or bulb injury) ~ vision: acuity. visual fields (red pin). vertigo.Physical Examination 2-B ● Assessment of speech ~ dysphasia/dysarthria/dysphonia ● Observation of gait and posture ~ free gait and turning ~ tandem (heel to toe) gait ~ Romberg test ~ toe/heel stance and walk. Trendelenburg test SECTION 2-B. nystagmus ~ trigeminal: corneal reflex. jaw jerk ~ facial: facial movements. rising from squat or chair. FIGURE 18. symmetry. diplopia. trapezius ~ hypoglossal: tongue protrusion/fasciculation SECTION 2-B. Papilloedema ● Examination of the limbs SECTION 2-B. cough ~ accessory: sternocleidomastoids. cutaneous sensation. motor function. fundoscopy ~ pupils: shape. colour vision. reactivity (light and accommodation) ~ eye movements: smooth pursuit (H-shape). corneal reflex ~ hearing and balance: whispered voice. gag reflex/palatal movement.

character. THE CARDIOVASCULAR SYSTEM 2. murmurs — 4 sites ~ special manoeuvres for mitral.2-B Physical Examination 2. brachial. the vessel wall Measure and interpret blood pressure Observe the face. 2. 45 degree and sitting positions. symmetry. abdomen and lower limbs for signs of heart failure Examine the central (carotid and aorta) and peripheral arterial pulses and listen for bruits Provide an accurate summary of your findings 2. pulsations ~ feel apex beat.1 Objectives for a cardiovascular examination • • • • • • • • Inspect for general and peripheral signs of cardiovascular disorder Accurately record vital signs — pulse and blood pressure Assess the jugular venous pulse Perform comprehensive central examination of the heart Detect and differentiate normal and abnormal impulses. sclera and conjunctivae The neck ~ JVP: height. aortic murmurs • The chest ~ percuss and auscultate lung bases 206 .3.1 The cardiovascular examination • Observe general appearance . tongue. heart sounds and murmurs Examine the lung bases. thrills) ~ listen for heart sounds. rhythm.2 Preparation • Specific to the cardiovascular examination ~ have adequate exposure of the patient's chest wall ~ comfortably position the patient in the supine. feel and listen ~ trachea: position • The precordium ~ inspect for scars. waveform ~ carotid arteries.colour ~ respiration ~ peripheral swelling • Observe and feel the hands ~ colour ~ warmth • • • • ~ fingernails Feel and listen: the arterial pulse — radial: character. rate.3 Physical Examination 2. and over 4 valve sites (impulses.

feel. diaphragmatic dysfunction • Examine the thorax ~ the chest wall and spine ~ the lung fields ~ central cardiac examination • Assess JVP. respiratory distress • Accurately record vital signs • Recognise clubbing SECTION 2-B.1 Objectives for a respiratory examination • Inspect for signs of respiratory disorders. bony tenderness • Provide an accurate summary and interpretation of findings 207 1 1 . feel. and percuss spleen ~ look. and percuss liver edge (check for pulsation and movement with breathing) ~ look. liver. recruitment of accessory muscles. and listen to aorta ~ examine femoral pulses (radial-femoral delay) • The limbs ~ inspect skin ~ check for pitting oedema ~ check pulses and peripheral circulation ~ check venous system 3 THE RESPIRATORY SYSTEM 3. feel. the abdomen and lower limbs for evidence of right heart failure • Assess for metastatic disease — lymph nodes in neck and axillae. Finger clubbing • Recognise different breathing patterns ~ paradoxical. FIGURES 22 AND 23. asymmetrical.Physical Examination 2-B • The abdomen ~ look.

character and waveform ( c o r p u l m o n a l e ) ~ mouth/tongue (central cyanosis) ~ trachea (tug.1 The respiratory examination • • Look for use of sputum cup.3. inhalers. deviation) ~ lymph node groups • Cardiac examination ~ apex beat position ~ parasternal heave ( c o r p u l m o n a l e ) ~ heart sounds 208 . oxygen General inspection of patient ~ obesity/cachexia ~ inspired oxygen requirements ~ cyanosis ~ respiratory distress and ventilatory pattern • Inspect hands ~ nicotine staining ~ clubbing ~ peripheral cyanosis ~ metabolic flap ~ pulmonary osteoarthropathy • • Blood pressure — measure. Peak flow meter 3.3.2 Useful specific equipment • Peak flow meter SECTION 2-B. determine if there is paradox Head and neck ~ JVP height.3 Physical examination 3. FIGURES 24 AND 25.

normal and abnormal breath sounds (bronchial breathing) and added breath sounds (wheezes or crackles) ~ anterior chest — repeat lung fields examination ~ test for upper lobe expansion. rib crowding (anterior upper chest) ~ the lung fields (start posteriorly) ~ chest expansion — demonstrate symmetry/asymmetry. deformity. axillae and laterally (remember right middle lobe region) ~ percuss spine and spring ribs for bony tenderness ~ assess sacral oedema • Abdomen ~ liver span — look for ptosis. hyper-resonance ~ auscultation — vocal resonance.1 Objectives for a gastrointestinal examination • Inspect for general and peripheral signs of gastrointestinal disease • Accurately record vital signs (including lying and standing blood pressure) • Recognise ~ anaemia and hypovolemia ~ jaundice. kyphosis. barrel chest. symmetry ~ percuss over clavicles ~ percuss and auscultate upper chest. FIGURES 26 AND 27. ~ percussion — Compare sides for normality. feel for pulsatile liver • Lower limbs ~ oedema. check for flail segment. dullness. rashes • Bedside lung function testing ~ forced expiratory time (obstructive disorders) ~ counting time (restrictive and/or obstructive disorders) ~ peak flow measurement (special test) 4 THE GASTROINTESTINAL SYSTEM 4. ascites and signs of chronic liver disease ~ abdominal veins (Caput Medusae) ~ hepatomegaly and splenomegaly SECTION 2-B. Scleral jaundice Ascites — chronic liver disease 209 .Physical Examination 2-B • Thorax ~ chest inspection — scars.

xanthelasma ~ parotid glands ~ mouth: dentition and breath (fetor) ~ tongue 210 .2 Physical examination 4. anaemia. clubbing) ~ palms (erythema. FIGURE 28.2-B Physical Examination • Detailed assessment of the ~ abdomen ~ periphery • • • Assessment of JVP and heart for evidence of right heart failure Assessment for metastatic disease Summary and interpretation of findings 4. scratch marks ~ spider naevi ~ pulse and blood pressure • Inspect the face ~ eyes: jaundice. petechiae.2. single pillow. abdomen and chest exposed) General inspection of patients ~ jaundice ~ weight and wasting ~ abdominal distension and peripheral oedema ~ skin (pigmentation and bruising) ~ mental state (encephalopathy) • Inspect the hands ~ nails (leuconychia. Leuconychia • Inspect the arms ~ bruising. Dupuytren nodularity) ~ flap (asterixis) SECTION 2-B.1 The gastrointestinal examination • • Position the patient correctly (bed flat. anaemia.

spleen. SECTION 2-B.2. Grey Turner sign) SECTION 2-B. bruits. ~ distension or local swellings (inspect on deep breathing) ~ prominent veins ~ skin lesions and striae ~ periumbilical or flank discolouration (Cullen sign. outline of any masses) ~ deeper palpation (define masses. rigidity.2 The abdomen • Inspection ~ scars. herniae (inspect with coughing and straining before palpation). midline to left flank) ~ listen — bowel sounds. Dilated abdominal veins in portal hypertension Combined Cullen and Grey Turner signs in acute pancreatitis • Palpation ~ superficial palpation (tenderness. hums • Inspect the groin (seek patient's specific permission) ~ genitalia ~ lymph nodes ~ hernias 211 . kidneys.Physical Examination 2-B • Inspect the neck and chest ~ cervical and supraclavicular nodes ~ spider naevi ~ gynaecomastia and body hair ~ JVP 4. FIGURE 29. FIGURE 30. other abnormal masses) ~ measurement of organ(s) if enlarged ~ roll onto right side to palpate spleen • Percussion ~ visceral outline ~ ascites and shifting dullness (away from examiner. liver.

Spontaneous bruising and abdominal wall haematoma from warfarin Rectus sheath haematoma confirmed on CT 212 . axillary. abdominal.1 Objectives for a haematological examination • • • • • • • • inspect general appearance inspect the hands and face and eyes examine the lymph node groups: epitrochlear. facio-cervical. supraclavicular. FIGURES 31 AND 32.2-B Physical Examination • Inspect the lower limbs ~ oedema ~ bruising ~ neurological signs (alcohol) • Other ~ ask to perform a rectal (PR) examination ~ temperature chart ~ urine analysis — check this routinely for all systems 5 THE HAEMATOLOGICAL SYSTEM 5. inguinal assess for bone tenderness perform an abdominal examination examine the legs perform a urinalysis with dipsticks provide an accurate summary of your findings — oral and written 5.2 Physical examination • General appearance (position patient lying on the bed with one pillow) ~ geographical and ethnic origin — thalassaemia ~ pallor — anaemia ~ bruising — distribution and extent ~ jaundice — haemolysis ~ scratch marks/pruritus — lymphoma or myeloproliferative disorders SECTION 2-B.

gum hypertrophy — leukaemia especially acute monocytic leukaemia . anaemia of chronic disease ~ gout — myeloproliferative disorders ~ pulse — tachycardia ~ anaemic patients have increased cardiac output and compensated tachycardia because of reduced oxygen-carrying capacity of blood ~ purpura — macular bruising within the skin.Physical Examination 2-B • Hands ~ nails — koilonychia. spoon-shaped nails due to iron deficiency ~ pallor nail beds — anaemia ~ rheumatoid arthritis or other connective tissues disorders. lateral and medial • Face ~ eyes . jugular chain. brittle. iron deficiency anaemia .injection — polycythaemia conjunctival pallor — anaemia ~ mouth . Examiner's thumb can then be placed over the area that is proximal and anterior to the medial epicondyle ~ enlarged epitrochlear lymph node is suggestive of Non-Hodgkin lymphoma • Axillary lymph nodes ~ five main groups of axillary lymph nodes — anterior and posterior.gum bleeding .scleral jaundice — haemolysis .atrophic glossitis — megaloblastic anaemia. central. lymphoma or carcinoma 213 .haemorrhage — platelet or bleeding disorder . occipital. submandibular. posterior triangle. which can vary in size ~ petechiae — pinhead bruising on the dependent parts of the body ~ ecchymoses — large bruises • Epitrochlear lymph nodes ~ must always be palpated ~ place the palm of the right hand under the patient's right elbow. ridged. postauricular.Waldeyer ring — lymphatic tissue involving the tonsils and adenoids — enlarged in Non-Hodgkin lymphoma • Cervical and Supraclavicular Lymphadenopathy ~ sit patient up and examine from behind and in front ~ eight groups — submental. dry. preauricular and supraclavicular • Bone tenderness ~ tap spine ~ press ribs ~ gently press sternum and clavicle ~ enlarging marrow due to infiltration by myeloma.

acromegaly. hyperthyroidism. hypoglycaemia. percuss and measure ~ para-aortic lymph nodes ~ inguinal lymph nodes — transverse and vertical groups ~ testicular masses • Legs ~ bruising ~ pigmentation ~ scratch marks ~ leg ulcers — haemolytic anaemia ~ neurological abnormalities — vitamin B12 deficiency 6 THE ENDOCRINE SYSTEM 6. thyrotoxicosis.2-B Physical Examination • Abdominal examination ~ splenomegaly — palpate. hypothyroidism Vital signs — blood pressure (postural hypotension) and pulse (bradycardia/ tachycardia) 214 . Coarse facial features and skeletal enlargement characteristic of acromegaly.g.1 The endocrine examination • • General inspection: observe for features of specific endocrine disorders: e.1 Objectives for an endocrine examination • • • Inspect for general physical features associated with endocrine disorders Develop skills in symptom pattern recognition in endocrine diagnosis Identify typical appearances of patients with hypothyroidism.2.2 Physical examination 6. Addison disease. diabetes mellitus. FIGURES 33 AND 34. • • • Tailor the examination to the specific organ system Evaluate signs of hormone over-secretion or under-secretion Provide an accurate summary of your findings — oral and written 6. Cushing syndrome. Klinefelter syndrome and hypogonadism SECTION 2-B. percuss and measure ~ hepatomegaly — palpate. Cushing syndrome. acromegaly.

a c a n t h o s i s n i g r i c a n s . or uninodular ~ palpate lymph nodes from behind and from in front ~ feel for thrill.Physical Examination 2-B • Inspect and feel hands ~ overall size ~ length of metacarpals ~ abnormalities of nails ~ tremor ~ palmar erythema ~ sweating of palms • Examine axilla ~ loss of axillary hair. multinodular. FIGURE 35. plethora • Mouth ~ protrusion of chin ~ enlargement of tongue ~ buccal/lip pigmentation SECTION 2-B. Peutz-Jeghers syndrome • Neck ~ always look first and check effect of movements ~ examine for thyroid enlargement — smoothly diffuse. acne. skin tags • Inspect eyes ~ visual fields ~ fundi • Face ~ hirsutism/hairless ~ skin greasiness. listen for bruit over thyroid 215 .

gait and deformities Identify extra-articular manifestations of systemic rheumatologic/connective tissue disorders Compare sides in unilateral abnormalities and effects of dominant/nondominant hand in upper limb disorders 216 .1 Objectives for a rheumatological examination • • • • • • Perform accurate focused physical examination of joints. lipohypertrophy ~ hirsutism ~ external genitalia ~ central fat deposition • Legs ~ reflexes. hepatomegaly. monarthritic or polyarthritic Identify normal locomotor system anatomy and joint movement ranges. tendons. spine and face — identify evidence of arthritis and whether acute or chronic. masses. and anomalies including disorders of stance. striae. listen. feel. measure. compare and Interprettor identifying normal and abnormal findings Assess joints of limbs.2-B Physical Examination • Chest wall ~ hirsutism/loss of body hair ~ reduction in breast size/gynaecomastia ~ nipple pigmentation SECTION 2-B. FIGURE 36. purpura. move. Gynaecomastia • Abdomen ~ scars. tone ~ diabetic changes • Body mass index (BMI — kg/m2) 7 RHEUMATOLOGICAL/MUSCULOSKELETAL SYSTEM 7. cirrhosis. bones. muscles and bursae Follow sequence of look.

FIGURE 37.1 Objectives for a urogenital examination • • • • • • • • Positive Thomas test — left hip Perform accurate focused physical examination of male and female genitalia and identify abnormalities Perform abdominal. bacilluria Identify and diagnose sexually transmitted infections Vernon C Marshall and Barry P McGrath 217 . vaginal and rectal examination with accurate interpretation of signs Identify signs of acute and chronic renal insufficiency and their causes Perform focused inguinoscrotal examination with accurate interpretation Identify urinoscopy as a global screening test of wide utility Identify signs and sites of urinary infections Identify and diagnose sites and causes of haematuria. Knee joint examination 8 RENAL AND UROGENITAL SYSTEM 8.Physical Examination 2-B SECTION 2-B. FIGURE 38. SECTION 2-B. pyuria.

2-B Physical Examination 2-B Physical Examination Candidate Information and Tasks MCAT 044-057 44 45 46 47 48 49 50 51 52 53 54 55 56 57 Assessment of a comatose patient Recent onset of poor distance vision in a 17-year-old male A painful rash on the trunk of a 45-year-old child-care worker Acute low back pain and sciatica in a 30-year-old man Fever and a recent rash in a 30-year-old man A heart murmur in a 4-year-old boy A knife wound to the wrist of a 25-year-old man Multiple skin lesions in a Queensland family Subcutaneous swelling for assessment Examination of the knee of a patient with recurrent painful swelling after injury Assessment of hearing loss. first noted during pregnancy. in a 35-year-old woman Examination of a 20-year-old woman who dislocated her shoulder 6 months ago Assessment of a groin lump in a 40-year-old man Eye problems in an Aboriginal community 218 .

When found. • Towards the end of the examination (after approximately six minutes). only becoming a flatmate a week ago. The flatmate is unable to provide any history. and the patient is breathing without difficulty. The airway is patent. The Performance Guidelines for Condition 044 can be found on page 235 219 . • Tell the observing examiner what you are doing and why. The patient is now in the Emergency Department where you are about to do an examination. the patient was in bed and there was no explanation as to why the patient might have become unconscious. the blood pressure is stable (140/70 mmHg) and temperature is 37.5 °C. you will be required to provide the examiner with an assessment of level of unconsciousness.Candidate Information and Tasks 044 Condition 044 Assessment of a comatose patient CANDIDATE INFORMATION AND TASKS This young patient has been found unconscious this morning at home by a flatmate. a list of possible and likely explanations for the patient's unconscious state and the investigations you would arrange. This can be as you proceed or at the end of each component of your examination. YOUR TASKS ARE TO: • Perform an examination to determine the level of unconsciousness and to try to identify the cause.

Test the patient's visual acuity using the Snellen test chart provided and state your findings to the patient. He has asked you if he may be short-sighted like his father and his older brother.045 Candidate Information and Tasks Condition 045 Recent onset of poor distance vision in a 17-year-old male CANDIDATE INFORMATION AND TASKS You are working in a general practice. He wants to be tested to check for short-sightedness or any other problems. to ask whether he will need glasses or contact lenses. He can no longer read notices. scoreboards etc. street signs. The Performance Guidelines for Condition 045 can be found on page 241 220 . whether surgery can help and whether he should see an optician or an eye specialist doctor. Both eyes are affected. Your next patient is a 17-year-old apprentice who is complaining of poor distance vision of recent onset. You do not need to take any further history. YOUR TASKS ARE TO: • • • Examine the patient's eyes to exclude serious eye disease. at a distance. Explain the problem to the patient. He says this is most inconvenient and is gradually getting worse.

CONDITION 046. YOUR TASKS ARE TO: • Take a history about the presenting problem. (Near the end of the time allotted. • Explain your diagnosis and the nature of the condition to the patient. the examiner will ask you one or two questions).Candidate Information and Tasks 046 Condition 046 A painful rash on the trunk of a 45-year-old child-care worker CANDIDATE INFORMATION AND TASKS You are a medical officer in a hospital primary care clinic. The Performance Guidelines for Condition 046 can be found on page 246 221 . as illustrated below. FIGURE 1. • Advise the patient about management. A 45-year-old child-care worker presents with a painful rash on the trunk.

nor request any further examination findings. particularly flexion/extension and left lateral bending. The patient could not sleep last night despite taking two Panadeine® tablets (paracetamol 500 mg codeine phosphate 8 mg per tab). The pain is also felt down the side of the left thigh and leg and the outer side of the foot. YOUR TASKS ARE TO: • • Advise the patient of the most likely diagnosis and management required. and painful limitation of lumbar spine movements. Abnormal examination findings are: He has difficulty standing or walking on his toes on the left side. There is no need for you to take any additional history. The pain came on suddenly yesterday whilst lifting a heavy rock. He has severe limitation to left straight leg raising. All the information you need is detailed above. diminished left ankle jerk and diminished sensation to light touch on the outer aspect of the left foot. It is made worse by coughing and movement. The Performance Guidelines for Condition 047 can be found on page 248 222 . Your next patient is a 30-year-old self-employed landscape gardener who is complaining of disabling left sided low back pain. The patient has previously been in excellent health and has no other relevant past or family history. Counsel the patient about when he can return to work and any necessary modifications that may be required.Candidate Information and Tasks 047 Condition 047 Acute low back pain and sciatica in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. with a positive stretch test.

• Explain to the patient the possible nature of his condition and how you intend to proceed. FIGURE 1.048 Candidate Information and Tasks Condition 048 Fever and a recent rash in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital primary care clinic. a palpable spleen and generalised tender lympha-denopathy in the neck. an inflamed palate. CONDITION 048. Your other findings on physical examination were a fever of 38. A 30-year-old man who works as a fashion consultant in a clothing store is presenting to you with fever and rash. The rash appears as in the illustration below. The Performance Guidelines for Condition 048 can be found on page 252 223 . • Briefly discuss differential diagnosis and investigations with the examiner. YOUR TASKS ARE TO: • Take a further focused history from the patient. It is a generalised erythematous maculo-papular rash. onset two days ago.5 °C. axillae and groins. You have just finished examining him.

YOUR TASK IS TO: • Explain your diagnosis and further management to the child's mother. His parents feel he has no concerning symptoms. His general health and exercise tolerance are excellent and he is on the 50th centile for height and weight. He was taken to another doctor with a cold whilst the family were on holidays and a soft cardiac murmur was heard. A 4-year-old boy has been seen with his mother. The Performance Guidelines for Condition 049 can be found on page 255 224 . On examination you have confirmed a soft vibratory midsystolic murmur (grade 2/6) located between the lower left sternal edge and the apex. which varies with respiration. You have finished your history-taking and examination and are about to discuss things with the child's mother. His parents were asked to bring him to see the family doctor. There is no history of heart disease in the immediate family but a cousin had a hole-in-the-heart operation. to decide if anything further needs to be done.Candidate Information and Tasks 049 Condition 049 A heart murmur in a 4-year-old boy CANDIDATE INFORMATION AND TASKS You are working in a general practice. He has never been cyanosed. Full physical examination is otherwise completely normal.

The ambulance personnel described the wound as a nasty deep knife wound and its extent is illustrated in the photograph. You are about to examine the patient for evidence of damage to important structures. The patient you are seeing has presented with a history of a knife wound to the left wrist from an assailant after an argument in a pub. and why. Assume that the illustration represents accurately the extent of the skin wound. YOUR TASKS ARE TO: • Perform a focused and relevant examination to determine the likely extent of injury. Do not remove the dressing. The Performance Guidelines for Condition 050 can be found on page 257 225 . The wound bled profusely at first and was controlled by a pressure dressing which is still on the wound. • The examiner will ask you one or two questions at the conclusion of your commentary CONDITION 050. He has been brought to hospital by an ambulance. or at the conclusion of that segment of the examination. • Describe your findings and your diagnosis of the injuries to the examiner. FIGURE 1. Explain to the examiner what you are doing. as you proceed.Candidate Information and Tasks 050 Condition 050 A knife wound to the wrist of a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working as a Hospital Medical Officer (HMO) in a hospital Emergency Department.

3. CONDITION 051. The face of his 82-year-old father 4. comes to see you as he is concerned about his family members. FIGURE 4. The leg of his 56-year-old wife CONDITION 051. who lives with his family. FIGURE 2. CONDITION 051. 226 . The neck of his 50-year-old brother CONDITION 051. FIGURE 3. and whether attendance is urgent. A 58-year-old farmer. The farmer presents the following photographs showing: 1. having seen a television programme about skin cancer. FIGURE 1.Candidate Information and Tasks 051 Condition 051 Multiple skin lesions in a Queensland family CANDIDATE INFORMATION AND TASKS You are working in a general practice in a small country town. 160 km outside of town. He has taken photographs of his family's various skin lesions and asks for your advice about the need for them to seek medical attention. They are all very busy harvesting crops and will be so for several weeks. The lip of his 35-year-old son 2.

CONDITION 051. and which are likely to be malignant or suspicious of malignancy.Candidate Information and Tasks 051 5. The Performance Guidelines for Condition 051 can be found on page 264 227 . YOUR TASKS ARE TO ADVISE HIM AS FOLLOWS AFTER REVIEWING THE PHOTOGRAPHS: • Indicate which lesions are likely to be benign. FIGURE 6. • Indicate which member(s) of the family require(s) the most urgent treatment. The chest of his 52-year-old brother (who drinks a large amount of alcohol) 6. FIGURE 5. The face of his 22-year-old daughter CONDITION 051. • Indicate the mode of spread of any malignant lesions you diagnose.

052 Candidate Information and Tasks Condition 052 Subcutaneous swelling for assessment CANDIDATE INFORMATION AND TASKS You are working in a general practice. Tell the examiner the likely diagnosis. YOUR TASKS ARE TO: • • • • Perform an appropriately focused and relevant physical examination in order to determine the nature of the lump. The patient thinks it may have grown slowly over this period but not much change in size has occurred. but your princip task is to perform a physical examination and come to a diagnosis. Explain your findings and diagnosis to the patient and indicate what further evaluation and/or treatment is required. The Performance Guidelines for Condition 052 can be found on page 274 228 . The patient is not particularly concerned about it but is curious as to its cause. It has never been painful or otherwise symptomatic. Describe your findings to the examiner as you proceed. You may ask relevant questions of the patient during your examination. Your patient is seeking advice about a subcutaneous swelling which has been present for about 10 years.

you will be expected to present a diagnostic/differential diagnostic plan to the examiner. on occasion. This is the first time he has consulted a doctor about this problem. Between attacks of pain he can walk normally with only a minor feeling of pain on the inner side of the knee. He is. The Performance Guidelines for Condition 053 can be found on page 280 229 . which settles within 24 hours. and has had difficulty in straightening the leg fully. He fell on the knee and it became swollen and painful on the inner side. Since then he has had intermittent attacks of pain on the inner side of the knee with swelling. describing what you are doing and why. The swelling caused a painful limp for a few days and then subsided with easing of symptoms. and your findings. YOUR TASKS ARE TO: • Perform a focused and relevant physical examination of the knees. • After seven minutes. giving a commentary to the observing examiner as you proceed. apprehensive when twisting to the right. He is otherwise well.Condition 053 Examination of the knee of a patient with recurrent painful swelling after injury CANDIDATE INFORMATION AND TASKS The patient you are about to see in a general practice setting has a history of twisting the right knee six months ago when he caught his foot on a piece of broken pavement.

first noted during pregnancy. The Performance Guidelines for Condition 054 can be found on page 282 230 . YOUR TASKS ARE TO: • Take a further focused history concerning her hearing loss (limit this to one minute). including your findings. telling the examiner what you are doing. • Examine the patient and test her hearing. • Suggest to the patient what further action is indicated for her hearing loss. including a prognosis.^1 Candidate Information and Tasks 054 Condition 054 Assessment of hearing loss. which she first noted about midway through her pregnancy. She is otherwise well and her infant (breastfed) is thriving. • Inform the patient of the most likely cause of her hearing loss. • Tell the examiner the type of hearing loss present. in a 35-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice and your next patient is a young woman who gave birth to her first child one month ago. She is complaining of loss of hearing. It has become progressively worse since and affects both ears.

Candidate Information and Tasks Condition 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago CANDIDATE INFORMATION AND TASKS You are a Hospital Medical Officer (HMO). It was a typical anterior dislocation which was complicated by a nerve injury and was treated by closed reduction. The patient has returned for a check up at the hospital outpatient department. and that she would like to recommence playing basketball next season. • In the final two minutes you will be asked questions by the examiner. FIGURE 1. several weeks immobilisation in a sling. • Describe your findings to the observing examiner as you proceed. has told you the shoulder now seems to be working fine. YOUR TASKS ARE TO: • Perform an appropriately focused and relevant physical examination of the area. CONDITION 055. subsequent physiotherapy and a gymnasium programme. • Discuss future activities with the patient. Film of previous dislocation 6 months ago The Performance Guidelines for Condition 055 can be found on page 286 231 . Your next patient dislocated her shoulder playing competitive basketball six months ago.

You do not need to take any further history. without relevant past history and has no problems with lungs or heart. Your next patient is a 50-year-old man who works as a builder's labourer. The Performance Guidelines for Condition 056 can be found on page 289 232 .056 Candidate Information and Tasks Condition 056 Assessment of a groin lump in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are working in a primary care clinic attached to a teaching hospital. The lump is not acutely painful. Two weeks ago he felt a pain in his right groin after heavy lifting at work and a week later noticed a lump in the groin which had not been there before. bladder or bowels. CONDITION 056. Give your diagnosis and management plan to the patient. YOUR TASKS ARE TO: • • Perform a focused physical examination to assess the lump. FIGURE 1. He is in good general health. Discomfort is eased on lying down. but is uncomfortable on exertion or walking. which is illustrated below.

• Answer any questions that the nurse may have.Condition 057 Eye problems in an Aboriginal community CANDIDATE INFORMATION AND TASKS You are a doctor working in a general practice in a remote setting in the Northern Territory. You are about to see a nurse who has recently joined the staff of the general practice clinic. CONDITION 057. CONDITION 057. Figures 1 and 2 were photographs taken after everting the upper eyelid. The Performance Guidelines for Condition 057 can be found on page 293 233 . FIGURE CONDITION 057. FIGURE 4. • Explain to the nurse what disease is illustrated in the photographs. CONDITION 057. • Discuss with the nurse how the problem should be managed. YOUR TASKS ARE TO: • Study the photographs and describe the abnormalities to the clinic nurse. The nurse wants you to explain what can cause these appearances. In the upper two photographs the upper eyelid is everted. FIGURE 3. FIGURE 2. and what can be done about the problem in the local community. The nurse made a time to see you to discuss eye problems she has noticed in the local Aboriginal community. The nurse has taken digital photographs of eye problems that were noticed in a number of affected individuals (see figures below of four separate individuals). and its epidemiology.

2-B Physical Examination 2-B Physical Examination Performance Guidelines M CAT 044-057 044 Assessment of a comatose patient 045 Recent onset of poor distance vision in a 17-year-old male 046 A painful rash on the trunk of a 45-year-old child-care worker 047 Acute low back pain and sciatica in a 30-year-old man 048 Fever and a recent rash in a 30-year-oid man 049 A heart murmur in a 4-year-old boy 050 A knife wound to the wrist of a 25-year-old man 051 Multiple skin lesions in a Queensland family 052 Subcutaneous swelling for assessment 053 Examination of the knee of a patient with recurrent painful swelling after injury 054 Assessment of hearing loss. in a 35-year-old woman 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 056 Assessment of a groin lump in a 40-year-old man 057 Eye problems in an Aboriginal community 234 . first noted during pregnancy.

• Check your arms for evidence of intravenous drug abuse. • Examine you for neck stiffness (which you have). You are wearing shorts and T-shirt and are feigning unconsciousness and stupor on a hospital bed. • You are feigning a partially responsive coma. The examiner will have instructed the patient as follows: You are to play the part of a young person found in a coma in your flat this morning breathing without difficulty with a Glasgow Coma Score of 10 out of 15 (see following pages about Glasgow Coma Scale). reacting by localising to pain. • Examine your response to commands and painful stimuli. • Remain in this role throughout the examination. Localise pain when stimulated — move arms towards source of pain or withdraw limb if stimulated. When painful stimuli applied say 'piss off'. • Check your pulse and breathing.044 Performance Guidelines Condition 044 Assessment of a comatose patient AIMS OF STATION To assess the candidate's ability to examine and diagnose a patient presenting with coma. 235 . The candidate will probably: • Do a general examination looking for evidence of injury. Keep your neck stiff when candidate attempts to flex it. • Remember. your neck is stiff if flexion is attempted. Your responses should be: • Maintain your level of consciousness and responses as follows during the candidate's examination. ~ Best motor responses: no response to verbal command. ~ Eye opening: eyes should be closed. and with inappropriate verbal response when stimulated. with a Glasgow Coma Score of 10-11 out of the normal score of 15. breathing spontaneously. Blood pressure and temperature have been given as normal. In summary. ~ Best verbal responses: use of inappropriate words. and will open your eyelids to do this and shine a torch. Do not open them spontaneously or to verbal command but open them in response to painful stimulation. • Examine your eyes and pupils. or 'damn'or 'shit'. you are being examined to check the level of coma and possible causes for this.

Arrange immediate blood sugar estimation — this may be asked by the candidate as part of the examination. The candidate is expected to: • • • • • • • • • Examine for evidence of injury to the head or elsewhere. 'Name at least four possible causes of the coma?' Acceptable causes would be: ~ drug overdose ~ meningitis ~ cerebral vascular accident (subarachnoid haemorrhage) ~ diabetic hypoglycaemia or hyperglycaemia ~ head injury ~ psychiatric problem 3. Examine breathing pattern — no hyperventilation (as in a hyperglycaemic coma) or hypoventilation (as in a drug overdose) is present. in the Emergency Department. Examine pupillary size and response to light (direct and consensual). Check for pulse rate. advise that they are normal. which are normal. if the candidate wishes to look at the fundi or ear drums. Similarly. rhythm and character. ~ blood and/or urine for drug screen ~ serum electrolytes and blood glucose ~ oxygen saturation 236 . a comatose young person found in bed this morning. After six minutes.044 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is examining. Examine for evidence of intravenous drug use or insulin injection sites in patients with diabetes. who is haemodynamically stable. it should be done as part of the investigations recommended. the examiner will ask the candidate three questions: 1. Alternatively. indicate that there is normal eye closure to cotton wool testing. If results from CT/MRI are not available. If candidates say they are going to test the corneal response. 'What investigations would you do?'— all these are required urgently: ~ brain computed tomograph (CT) / magnetic resonance imaging (MRI) (if available-lumbar puncture generally should NOT be done until the results of head imaging are available. Examine eye movement by gently opening the lids. lumbar puncture using a 25 gauge needle would be appropriate in view of neck stiffness). Look for evidence of neck stiffness. 'What is the Glasgow Coma Scale level?' Answer: around 10-11 out of possible 15 (Table 1) 2.

~ No response to verbal command but response to pain. • Ability to provide an adequate differential diagnosis. The comatose patient has no verbal response. Coma is a state of deep unconsciousness where the patient shows no meaningful response to external stimuli. does not obey commands and does not open the eyes spontaneously or in response to command. ~Neck stiffness should be tested and identified. drug screen and blood sugar level. and other levels of deep unconsciousness. but the stuporous patient shows some response to painful stimuli. ~ The candidate should indicate appropriate knowledge of the Glasgow Coma Scale. are best graded on the Glasgow Coma Scale. Coma and stupor. • Ability to describe an initial investigation plan. • Failure to check for neck stiffness. 237 . and best verbal and motor responses to standard stimuli (Table 1).044 Performance Guidelines KEY ISSUES • Ability to perform a focused. Stupor is also a state of inaccessible consciousness without awareness. relevant and accurate examination to aid determination of the level and cause of the coma. If CT/MRI is not readily available. a lumbar puncture should be performed if there is no evidence of papilloedema. This has three elements: eye opening. ~ Mandatory investigations should include Brain CT or MRI. • Failure to determine reasonably the level of coma by the Glasgow Coma Scale score.

the lowest level.To painful stimuli Localises pain Withdrawal Abnormal flexion (decorticate rigidity) Extension (decerebrate rigidity) No response Best verbal response Oriented Confused conversation Inappropriate words Incomprehensible sounds No response TOTAL SCORE 6 5 4 3 2 1 5 4 3 2 1 Range of 3-15 SCALE 4 3 2 1 NOTE: A score of 15 represents a fully responsive and conscious patient. A score of 3 of course does not indicate 'brain death' or a 'vegetative state or any other prognostic features as a single reading Guidelines for neurological examination and conscious state chart are shown in Figures 1 and 2 1 . Glasgow Coma Scale score CRITERIA Eyes open Spontaneously To speech or verbal command To pain No response Best motor response . Clinical Problems in General Surgery. Butterworths 1991 238 .044 Performance Guidelines CONDITION 044. A score of 3. TABLE 1. 1Reproduced from Hunt P and Marshall V.To verbal command Obeys . a deeply comatose patient unresponsive to external stimuli.

CONDITION 044. Butterworths. Clinical Problems in General Surgery. 239 . Conscious state and head injury chart1 1Reproduced from Hunt P and Marshall V. 1991. FIGURE 1.

FIGURE 2. Guide to recording neurological observation chart1 1Reproduced from Hunt P and Marshall V. 1991 240 . Butterworths.044 Performance Guidelines CONDITION 044. Clinical Problems in General Surgery.

• examine the optic disc (bulging. the patient should be referred to an ophthalmologist. tonometry (intraocular pressure) and the pinhole test. If the unaided visual acuity is less than 6/12. injection. cataract and glaucoma will need to be excluded. Macular degeneration. paraesthesia) • eyeball (intraocular pressure. pallor) • cornea (ulceration) • anterior chamber (blood or pus) • sclera (jaundice) • orbit (tenderness. The examiner must check the myopic patient's visual acuity in each eye before the examination commences. The patient should have mild myopia and does not require any special instructions other than the knowledge of having his eyes tested and providing appropriate responses. dilatation of the pupils (appropriate view of the posterior chamber). 241 . The candidate is expected to describe the proposed use of the opthalmoscope to the examiner who will then say 'fundoscopic examination is normal'. exudates. EXPECTATIONS OF CANDIDATE PERFORMANCE Exclude serious eye disease The candidate should indicate that the following would be examined: • eyelids (ptosis.Condition 045 Recent onset of poor distance vision in a 17-year-old male AIMS OF STATION To assess the candidate's knowledge of myopia. • examine the retina (detachment. The pupil will not be dilated. A thorough examination of the eye will also include instillation of fluorescein (cornea). retraction of upper or lower lids) • conjunctiva (chemosis. haemorrhage. The pinhole test A pinhole test card should be placed in an obvious position and used by the candidate for both eyes If visual acuity is not improved by looking through a card with a 1 mm pinhole. new vessel formation). glaucoma) The candidate should indicate use of the ophthalmoscope to: • test the red reflex (to exclude cataract). blurring of margins): and • examine the macula (exudates). The doctor/candidate will explain and perform the procedures. the defective vision is not solely due to a refractive error. and ability to test visual acuity and distance vision using a Snellen test chart.

The chart. A 6-metre chart should always be employed for formal visual acuity testing. In fact. The numerator indicates the distance of the patient from the chart (e. for legal assessment of visual impairment. Being able to discern letters below this line shows increased visual acuity and if the individual can only decipher letters above this line. 242 .g. This is the visual requirement for a fighter pilot 6/12 — The visual requirement for a Driver's Licence in Australia 6/60 — Legal blindness. Acuity of this degree is referred to as normal vision. 6 metres). Visual acuity is expressed as a proportionate relationship between the subject's vision and a person with normal vision. Visual acuity is recorded in the form of a fraction but it is NOT a fraction in the mathematical sense of the word. the visual acuity is diminished. Preliminary office testing can employ a 3-metre chart.045 Performance Guidelines Test visual acuity The term 'visual acuity' refers to the clarity of vision (from the Latin acuitas or sharpness). Testing should be done as follows: • The patient faces a Snellen chart at 6 metres distance. With the onset of presbyopia. Testing visual acuity Visual acuity is measured using the Snellen chart. A person with 6/5 (20/15) vision can see objects at 6 metres (20 feet) that a person with normal vision sees at 5 metres (15 feet). Note that the Snellen notation applies only to distance vision. Formal testing requires a distance of 6 metres (20 feet). Such letters are found on one of the lower lines of the Snellen chart. A near-sighted (myopic) individual will have better visual acuity at close distance. Newsprint is N8 (8 point type). whereas a far-sighted (hyperopic) person will have better visual acuity at far distance. Because the visual nomenclature used does not représenta mathematical fraction. An individual with visual acuity of 6/6 (or 20/20 if feet are used) is just able to identify a letter whose height subtends 5 minutes of arc at the eye. The subject is asked to read from a Snellen chart. Visual acuity of 6/6 means that the test subject sees the same line of letters at 6 metres (20 feet) as that seen by a person with normal sight at 6 metres (20 feet). Normal vision is 6/6 (20/20). Visual acuity of 6/5 (20/15) vision is better than normal 6/6 (20/20). whereas 6/12 (20/40) vision means that the test subject sees at 6 metres (20 feet) what a normal person sees at 12 metres (40 feet). is placed 6 metres (20 feet) from the subject. usually in this country the American point-type. Near vision is recorded using font size. necessitating use of a large room or a small room with a mirror to adjust for the distance. with letters of different sizes on each of its ten or eleven lines. 6/30 is regarded as a 50% impairment. it is incorrect to say that 6/12 represents 50% of normal sight. displaying letters of progressively smaller size. and the denominator indicates the distance at which the normal eye can read the line. Thus normal reading vision is N5 (5 point type). Levels of vision 6/6 — Normal vision. near visual acuity diminishes and reading glasses are required.

the poorer the vision (6/12. the candidate should perform a pinhole test. and this is recorded as 'Hand Movements' (HM). • Examine each eye separately by using an occlusive card in a systematic way which includes asking the patient to read the lines backwards when testing the second eye. • Management options. this is recorded as 3/60. • The candidate should give findings to examiner in the conventional way. • Correct use of the Snellen test chart. etc). a light is shone in the eye and the patient is asked if he can appreciate the light. acuity is 6/60. the chart should be moved closer to the patient. normal vision being 6/6. the acuity is NLP (No Light Perception). he is asked to identify a moving hand. treatment. CRITICAL ERRORS • Failure to exclude serious eye disease. • Accuracy of examination (compare with examiner's findings). If the patient can point to the light accurately. If unable to see a moving object. this is recorded as 'PL with accurate projection'. If the top line can be read at 3 metres. • Diagnosis — must state myopia. 6/24. until the top line can be read. • Failure to mention myopia as a possible diagnosis. Ask the patient to hold a piece of paper with a 2 mm hole in it over the uncovered eye. the patient should correctly identify 3 letters to be regarded as having read the line. The smaller the ratio. In a line with 5 or more letters. 243 . • Patient counselling/education — cause. This manoeuvre utilises the 'pinhole camera effect' and results in an improvement in visual acuity if a refractive error is the cause of the diminished acuity. or short-sightedness or near-sightedness. 1 metre at a time. If the patient cannot see 1/60. The patient should be referred for refraction and prescription of glasses.045 Performance Guidelines • Explain procedure to patient: Start reading at top (largest) line of letters. need for periodic check of intraocular tension when over 40 years of age. • If the visual acuity is worse than 6/6. KEY ISSUES • Exclusion of serious eye disease with ophthalmoscope and pinhole test. If only the top line can be read. If the patient is unable to read the top line. The small numbers corresponding to the lowest line which can be read give the denominator — the distance in metres at which a person with normal vision can read the line. If the light is not seen. Explain problem • Nature of myopia. and this is recorded as 'Perception of Light' (PL). • Visual acuity corresponds to the lowest line which can be read.

foreign body. without the risks of surgical correction. The dioptre is the unit of measurement of the strength of a lens. The second number (if present). near-sightedness) or a positive number for a convex lens (hyperopia. although not relevant to this case. is an important and urgent clinical problem. As the refractive power of a lens decreases. Myopia can affect the accurate measurement of intraocular pressure.e.50 X 170'). but more commonly in late teens. cataract or macular degeneration) should be considered by the candidate Ophthalmoscopic examination and the use of the pinhole test cover these concerns at this stage of assessment of vision.g.045 Performance Guidelines COMMENTARY A comprehensive history and careful physical examination will provide a diagnosis in most common ophthalmic disorders. The fourth number is the additional correction needed to bring the focal point of the eye to the reading distance. The power is a negative number of a concave lens (myopia. both more common if myopia is severe. +3. the possibility of the patient's complaint of recent impaired vision being due to a serious cause (namely retinal detachment. glaucoma. The 'acute red eye'. Otherwise glasses will need to be worn. Contact lenses can be worn to correct myopia. The third number indicates the axis of the steepest meridian of the cornea (e. although an initial assessment by an ophthalmologist is preferable to exclude any other cause of visual impairment. The strength of a lens = 1/focal length. Less often the refractive power of the lens is too strong. The corrective lens can be prescribed by an optician. the focal length increases. The condition is readily corrected by the use of a concave (minus) lens. Myopia (near-sightedness or short-sightedness) is a common inherited condition which in most cases is due to the axis of the eyeball being too long so that the visual image is focused in front of the retina. The first number in a spectacle prescription designates the amount of myopia (minus numbers) or hyperopia (plus numbers). and therefore intraocular pressure should be checked periodically to detect chronic open angle glaucoma which is asymptomatic in the early stages. Thus a 4-D lens has a focal length of 'A metre. far-sightedness). 244 . Onset can be in childhood. The condition tends to worsen in early adult life and then stabilises. Although unlikely in this case. The prescription: The refractive error of the eye can be expressed in numeric terms. glaucoma and subconjunctival haemorrhage) are associated with pain and/or trauma and can be excluded on the history alone in this patient. indicates the amount of astigmatism. A lens of power of 1 dioptre has a focal length of 1 metre (i. A lens deviates light and the amount of deviation is proportional to the amount of curvature and the density of the lens. and particularly to myopes.00/-2. especially retinal detachment and macular degeneration. parallel rays of light are brought to a focus 1 metre from the lens). Reading is not affected much until middle age. Most of the causes of red eye (conjunctivitis. The power of the lenses necessary to correct vision is measured in units called dioptres (see below). inflammation ulceration. This applies to all patients. Corrective operations (excimer laser surgery) can produce excellent results by altering corneal curvature and thus the refractive power of the eye. This procedure is not without significant risk.

Sudden loss of vision is usually associated with a vascular or neurological problem and again. FIGURES 1 AND 2. as presentation of this disorder with an ophthalmological complication may occur. Some diabetics present with cataract. CONDITION 045. others with mature onset diabetes may present with poor central vision due to oedema of the macula. The assessment of the ophthalmoscope and pinhole test should exclude the serious disorders that can be associated with gradual visual loss (and others such as retinal detachment. Visual acuity charts (not to scale) 245 . cataract and macular degeneration). glaucoma. Diabetes mellitus must be considered. these types of problem are not relevant in the present case.

• You have had no serious past illnesses. You have no allergies and are on no medications. Describe the pain and the skin rash without prompting. You have had a burning pain over your lower chest and flank for a few days. • Diagnosis ~ Must make diagnosis of herpes zoster. You have noted no disturbance to any body system function). famciclovir or valaciclovir. Opening statement: 'I've had a pain in my lower chest and now there is this rash. You noticed today that you have developed a blistery rash that runs in a line around your chest and abdomen in the area where the pain started. EXPECTATIONS OF CANDIDATE PERFORMANCE • History ~ Typical history and rash (see Figure 1) of herpes zoster with prodromal preherpetic neuralgia. Do not volunteer the weight loss and associated recent tiredness unless questioned first about How has your health been in general?'or something along those lines. 246 . ~ Treat with antiviral medications if patient presents (as in this instance) within firs! 72 hours of the rash — aciclovir.046 Performance Guidelines Condition 046 A painful rash on the trunk of a 45-year-old child-care worker AIMS OF STATION To assess the candidate's approach to a patient with a dermatomal rash from herpes zoster plus weight loss and tiredness. You have been considering having a checkup but have no other symptoms. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a child-care worker in a kindergarten. you have lost 6 kg in weight over the past few months and have been feeling more tired than usual (you have nothing to add to this general statement. and you had not considered that there might be something seriously wrong until the pain and this rash appeared. • Initial management ~ Treat the rash with symptomatic measures such as calamine or cold compresses and a drying lotion. ~ Use analgesics with or without codeine. Must show concern over recent weight loss and tiredness. there is no relevant family history. In addition. which could be incidental but may be associated with underlying malignancy. These symptoms need to be further assessed. You are single and live by yourself. ' Answer questions about your condition as follows: • • • • You have been feeling a bit unwell for a few days.

After 5-6 minutes. if the candidate has not discussed these issues. COMMENTARY Herpes zoster (shingles) is caused by reactivation of varicella zoster virus (VZV) acquired originally through primary infection with chicken pox. • Occasionally patients may get rare complications including meningoencephalitis. • Diagnose herpes zoster/shingles • Management must consider use of aciclovir or other related antiviral drugs. Therefore appropriate infection control measures need to be taken including management of occupational and community contacts (for example. In this case. 247 . although occasionally this can be related to an underlying malignancy such as a lymphoma. • The condition is more common in people over 50 years of age. • The virus is found in the dorsal root ganglion. but that chickenpox can be acquired by those persons in close contact with the patient who have not previously had chicken pox. • Failure to assess implications for contacts in community and work settings. ~ Examine patient and perform investigations for any possible precipitating cause. the examiner will ask ~ 'Are there any unusual features of the condition in this patient? ~ 'How would you manage this particular patient?' KEY ISSUES • History-taking must elicit weight loss and tiredness. • Must advise further assessment regarding weight loss and tiredness and discuss implications of infectivity. the weight loss and tiredness demand further investigation (no details are required at this stage). • Post-herpetic neuralgia is an important sequel. leukaemia or immunosuppression including HIV infection. In most cases the reason for reactivation is unknown. affecting around 30-50% of adults aged 70-79 years. relationship of herpes zoster to varicella [chicken pox]).e. CRITICAL ERRORS • Failure to diagnose herpes zoster. • Failure to consider the possibility of an additional underlying cause in this patient. ~ Explain that the condition is only mildly contagious. she is a child-care worker in a kindergarten and young children and babies should not be exposed to vancella zoster virus). The incidence of post-herpetic neuralgia increases with age.046 Performance Guidelines ~ Monitor for the development of postherpetic neuralgia which may require further management. • Patient education and counselling ~ Explain the cause to the patient (i.

It hurts to move and to cough. Expect the doctor to 'do something' to get rid of the pain. H o w d o e s t h i s h a p p e n ? ' ( V e r y common. It came on when you lifted a heavy rock and you have not been able to work. likelihood of recovery is good).047 Performance Guidelines Condition 047 Acute low back pain and sciatica in a 30-year-old man AIMS OF STATION To assess the candidate's ability to diagnose and treat the problem of acute exertion-related low back pain and sciatica. Resist advice (irrationally) not to go to work even in a supervisory capacity because of important jobs needing to be finished. State dissatisfaction with level of pain relief — you could not sleep last night. ' W h a t e l s e c a n I t a k e f o r t h e p a i n ? ' (Panadeine forte03). H o w l o n g w i l l I b e a w a y f r o m w o r k ? ' (Depends on progress. If pain does not settle. Appear to be in severe pain . must be investigated by CT orMRI). He will explain the problem and what you have to do. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a self-employed landscape gardener aged 30 years. Usually settles rapidly with I adequate rest. 'Do / n e e d t o s e e a S p e c i a l i s t ? ' (Not at this stage. If so. Become compliant if the doctor explains the situation and gives appropriate advice. • • • • • • Show concern about how you are going to be able to work now and in the future. You could not sleep last night despite taking Panadeine® tablets. You have consulted this doctor because of the sudden onset of severe disabling pain in your lower back yesterday which moved down your left thigh and leg into your foot. related to stress on back whilst lifting). manipulation may worsen the condition). ' W i l l I a l w a y s h a v e a b a d b a c k ? ' { N o . 248 . off work for 1-2 weeks. ' S h o u l d I s e e a c h i r o p r a c t o r ? ' (Definitely not at this stage. but wil depend on progress).sit uncomfortably be restless. W i l l I b e a b l e t o l i f t h e a v y o b j e c t s i n t h e f u t u r e ? ' (Give advice on how to lift with gooi self-maintenance strategies). Questions to ask unless already covered (candidate's likely response is detailed in brackets): • • • • • • • • • W h a t h a s h a p p e n e d t o m y b a c k ? ' (Explain 'slipped disc' — intervertebral disc prolapse with herniation of nucleus pulposus — use of a diagram can be helpful). The doctor has taken your history and examined you. You usually keep in excellent health with no serious medical problems in the past. will be arranged if symptoms persist! ' C a n ' t I h a v e a n o p e r a t i o n t o f i x i t a n d r e l i e v e t h e p a i n ? ' (Usually not necessary.

• Ability to advise early rest and short term review. • Orthopaedic. swimming. • Expected course both short and long term — most resolve completely • A diagram would assist. • Indications for further investigation — lack of. Then needs CT orMRI. MR I preferred. • Emphasis on positive approach. but up and about as tolerated) • Pain-relieving medication — Panadeine®. • Ability to advise the patient about work practice modifications required to prevent a recurrence of the problem. • Physiotherapy — stretching and arching active mobilising exercises appropriate once initial symptoms ease. plain X-ray gives limited information only). • Subsequent physiotherapy and back-strengthening exercises. 249 . or incomplete resolution. slow. Panadeine forte® or similar (including NSAID). Immediate management • Adequate rest is essential (3-4 days rest at home. This is essential. neurological or rheumatologic consultation — will be required for lack of resolution. • Gentle traction may have a place in treatment if progress slow — would be advised after specialist referral.047 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Diagnosis and explanation of condition • Anatomy of lumbar spine (this is an L5/S1 level problem. and the value of walking. • Ability to determine the likely cause of the sciatica and to explain the cause to the patient. involving the S1 nerve root) • Causes of pain particularly disc prolapse with nerve impingement/irritation (radiculopathy). Preventive measures 'Back education' including advice regarding bending and lifting. • Avoidance of manipulation. • Adequate knowledge of the management of a patient with acute sciatica including what further investigations or referral are required and when these should be done. Future management Reassessment in short term (2-3 days). or there is continuing evidence of neurologic or muscle weakness (CT acceptable. • Need for investigation — this is particularly important if there is no improvement. Prognosis for recovery within a few weeks is good despite ankle jerk being affected.

250 . Confirmation of the diagnosis can usually be made by noninvasive imaging. and is influenced by cultural. referred back pain from intra-abdominal lesions. relapsing or chronic. socioeconomic and other personal factors in its incidence and persistence. extending usually from low back and buttock down the leg to foot and toes corresponding to sensory disturbance within the dermatomal distribution of appropriate nerve roots (most commonly L5 or S1 ).047 Performance Guidelines CRITICAL ERRORS • Failure to make correct diagnosis of a likely disc lesion. concentrating on the search for pointers of more serious pathology (malignancy. of which MRI is the most accurate. Distinguishing true radicular sciatic pain ('sciatica') due to nerve root compression requires symptoms of pain of lancinating or cramping type. but gives short term outcomes no different from placebo. electricity and magnetism (and surgery) are each difficult to separate from placebo and are prone to fashion and fetish. A major problem in spinal assessment is the fact that there is often a poor correlation between clinical presentation (the patient's history and examination finding) and the imaging findings. and sometimes with objective motor weakness and sensory loss corresponding to the appropriate motor nerve root. is thus one of the most common of all conditions encountered but precise pathology is very frequently lacking. the most likely diagnosis being compression from an intervertebral disc prolapse between L5 and S1. manipulation. Such a constellation of objective signs (as in this patient) is virtually pathognomonic and diagnostic of nerve root foramen compression (from intervertebral | disc prolapse. In such instances the precise pathology is indeterminable and no specifically diagnostic imaging or other test is available. or cauda equina symptoms such as interference with bowel or bladder control). it is hardly surprising that the condition and its preferred treatment remain controversial. sound/ultrasound. The portmanteau and nonspecific term 'Mechanical low back pain' is useful in that it codifies a very common condition from which almost all individuals will suffer at some time of their lives. with positive nerve tension signs. bone infections. acute and chronic. COMMENTARY Low back pain is a very common problem in Australian society. Imaging abnormalities will be found with increasing frequency in individuals with or without accompanying symptoms from their third decade onwards. but may become recurrent. facet joint arthropathy or other encroachments on the relevant nerve root or spinal canal). Clinical studies are possible and literature search and meta-analysis can be helpful and reveal (for example) that laser treatment of low back pain is free of concerning side-effects. The incidence increases with age and is more common in manual workers than sedentary workers. This case scenario has been chosen to exemplify the classical syndrome of nerve impingement radiculopathy. The outcome of physical treatments such as massage. Back pain may (or may not) follow an identifiable injury or strain as occurred in this patient Pain is usually self-resolving over a period of days or weeks. heat. light. and is expensive and not cost-effective. psychological. Against such a background. Back pain. Persistence of unrelieved pain after one month is an | indication of the need for a full history and examination (including diagnostic imaging). exacerbated by straining or coughing.

spinal fusion techniques for chronic low back pain are various. shortwave diathermy. or other radiological signs of lumbar vertebral spondylosis affecting the facet joints. However. Percutaneous semisurgical procedures (radiofrequency rhizolysis) also seem of little convincing long-term value. indicated in only a very small percentage of patients with low back pain and it is quite rare to demonstrate treatable new pathology in patients with chronic low back pain. results can seldom be guaranteed and persisting pain after surgery is common. MRI is the investigation of choice for defining spinal pathology when surgery is being considered. Plain radiographs for patients with persisting chronic pain rarely are of clear cut diagnostic value. which has lasted for more than a year. obesity and socioeconomic deprivation are commonly found in such instances. formal physiotherapy or chiropractic have not convincingly been demonstrated to have other than placebo effects. most cases of simple mechanical back pain due to musculoligamentous soft tissue strain injuries will resolve within one to two weeks with explanation and encouragement. Associated job dissatisfaction. adjacent vertebral marginal sclerosis and osteophytes. gas formation in the nucleus pulposus. 251 . Surgical techniques have improved in the small group of patients requiring surgery. transcutaneous electrical nerve stimulation. ultrasound. and patient education regarding good back strategies. but may show loss of disc height. Long-term treatments with laser.047 Performance Guidelines By contrast. acupuncture. however. depression. By contrast. and release surgery for focal major nerve root compressions confirmed by imaging can be dramatically effective. similar radiological signs or evidence of minor spondylolysis or spondylolisthesis are also present commonly in nonsymptomatic middle-aged or elderly people. Surgery is. The effects of repeated image-guided facet joint. aided where indicated by a short course of physical therapy concentrating on early mobilisation and an active exercise program. epidural or nerve root foraminal injections of local anaesthetic or corticosteroids are also disappointing in the long-term. early mobilisation without bed rest ( ' d o n ' t t a k e b a c k p a i n l y i n g d o w n ) and simple analgesics.

~ You have a fever and a sore throat. ' • Follow with: ~ You have been feeling unwell for two days. These must include HIV serology. The examiner will have instructed the patient as follows: Opening statement: 'I think I may have developed an infection. However. ~ The rash is all over your body. • In response to questions the doctor may ask: ~ The rash is not itchy. EXPECTATIONS OF CANDIDATE PERFORMANCE The key to diagnosis is the history of unprotected anal sex. You have also had a number of casual sexual relationships in the past six months. ~ You have 'aches and pains' throughout your body in the legs. Answer the doctor's questions honestly. ~ You have been in a sexual relationship with another man for two years and have been having anal sex without condoms for a few months now. such as infectious mononucleosis. Support for the patient should be shown when the possible seriousness of his condition is discussed. the most likely infection is with human immune deficiency virus (HIV) and this must be confirmed or excluded by laboratory investigations. arms and back.048 Performance Guidelines Condition 048 Fever and a recent rash in a 30-year-old man AIMS OF STATION To assess the candidate's diagnostic approach to a young man presenting with fever and rash of 48 hours duration with signs of splenomegaly and lymphadenopathy. Be very concerned about the possibility of HIV infection when this is mentioned. and is especially apparent on the face and trunk. ~ You have a headache and bright lights hurt your eyes. ~ No history of mental illness. ~ You do not use injectable drugs. ~ You have had no serious past illnesses or family history of relevance. ~ You have never had an HIV test in the past. Explanation to patient: his condition is possibly due to one of a number of viral infections. • • History: must obtain detailed sexual history. ~ You have previously considered your health to be good. 252 . and anxious to proceed with investigations at once. ~ You have no allergies and take no medications. no history of blood transfusion. Be open about your homosexuality but do not reveal this without specific questioning by the doctor. ~ You have also developed a rash over the past one to two days. • Approach to patient: the history should be taken and diagnostic possibilities discussed in a matter of fact and nonjudgmental way.

~ secondary syphilis.048 Performance Guidelines Informed consent is required for HIV testing: ensure patient has pretest counselling. CRITICAL ERRORS • Failure to consider HIV infection as a likely cause of this patient's presentation. D or E. 253 . ~ liver function tests. • Approach to patient must discuss informed consent for HIV testing. ~ cytomegalovirus (CMV). • Failure to discuss informed consent for HIV testing. rash. • Differential diagnosis must include HIV infection. referral to a specialist infectious diseases unit is required for management during seroconversion illness. ~ The examiner should intervene at this stage and say: 'We should now discuss the differential diagnosis and appropriate investigations. C. ~ rubella. ~ herpes simplex infection. ~ disseminated gonococcal infection. and ~ other viral infections. lymphadenopathy and splenomegaly. sore throat.B.C. ~ If HIV infection is confirmed. and ~ tests for hepatitis A. ~ hepatitis A. ~ toxoplasmosis.D or E. CMV infection and toxoplasmosis. B. ~ Venereal Disease Research Laboratories/syphilis serology. ~ Other tests are indicated (see differential diagnosis) and the candidate may mention other viral causes of this patient's fever. • Investigations — these are related to the differential diagnosis and should include: ~ full blood examination and Epstein-Barr serology: ~ tests for rubella. KEY ISSUES • History must include sexual history • Investigations must include HIV serology. ' • Differential diagnosis apart from HIV: ~ Epstein-Barr virus infection. ~ Laboratory tests may not be clear during time of acute seroconversion illness and may require consultation with HIV laboratory and/or specialist unit to manage his condition.

headache. such as occupational exposure. reuse of contaminated needles or other exposure. These symptoms usually last for less than two weeks. Neurological manifestations including headache and photophobia are common as well as transient neurological signs including peripheral neuritis and other central nervous system manifestations.048 Performance Guidelines COMMENTARY Diagnosis of HIV infection requires a careful history to identify potential high-risk behaviour and recognition of the constellation of clinical symptoms and signs. Key to diagnosis in this patient is checking for recent risk exposure history of unprotected oral or anal sex. maculopapular rash. 254 . Common symptoms include: fever. malaise. arthralgia. Other nonspecific viral sequelae such as mucosal ulceration. Acute symptoms are self-limiting. depression and irritability may persist after initial illness. The rash of acute HIV infection is usually an erythematous. The condition resembles infectious mononucleosis but is seronegative for infectious mononucleosis. Chronic lethargy. From 40-90% of patients who have acquired HIV infection will develop an acute febrile illness within the first six weeks of infection. photophobia and sore throat. myalgia. often sooner. desquamation and herpes simplex may also occur. night sweats.

KEY ISSUES • Ability to assess confidently the features of an innocent heart murmur. It is estimated that careful auscultation under ideal circumstances will detect an innocent soft murmur in over 50% of normal four-year-olds. 255 . So the usual task is to differentiate an innocent murmur from one due to an organic heart lesion.none defined COMMENTARY Cardiac murmurs in young children are very common. This is unlikely to show any abnormality and may be reassuring. or seem unconvinced. insist on referral and ask what tests might be performed. Rheumatic fever in our community is unusual these days unless practising in areas where large numbers of Aboriginal or Torres Straight Islander peoples are treated. Parents need reassurance that the child is normal and that normal physical activity is allowed. If not. EXAMINER INSTRUCTIONS Opening statement: 'What is the matter with my child?' The examiner will have instructed the parent as follows: You are the parent of an only child. Be prepared to accept reassurance if the explanation is adequate. depending on degree of parental concern. No concerning symptoms or signs are present which might suggest an alternative diagnosis.049 Performance Guidelines Condition 049 A heart murmur in a 4-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose an innocent heart murmur in a young child and to advise a concerned parent. puzzled and concerned at being told that the child may have something the matter with his heart. Hence medical facilities would be overwhelmed if all of these murmurs were referred for specialist assessment. • Avoidance of unnecessary extensive investigation. Primary care physicians should be confident in distinguishing innocent functional murmurs from those that are associated with an organic heart lesion. Referral to a paediatrician/paediatric cardiologist is only indicated if parents wish it. most likely of congenital origin. EXPECTATIONS OF CANDIDATE PERFORMANCE This is almost certainly an innocent murmur. and may then render unnecessary further referral to a cardiologist. It would be reasonable do to a chest X-ray and ECG. CRITICAL ERROR . The consultant would consider echocardiography.

radiating either to the axilla or neck.049 Performance Guidelines As in many situations in paediatrics. usually between the ages of five and seven years. The parent should be reassured of the innocent nature of the murmur and that the practitioner will continue to observe the child until the murmur spontaneously disappears. including echocardiography. If the parents are still concerned despite adequate explanation and reassurance. If necessary. If all features indicate an innocent heart murmur. associated with cyanosis. the paediatrician will refer the child to a paediatric cardiologist for full cardiological investigations. the murmur varies with posture and respiration. referring the child to a paediatrician who is skilled in assessing murmurs is acceptable. and associated with significant symptoms. has a normal exercise tolerance. 256 . an organic murmur may be: In determining the possible aetiology. the clinician should seek information along these ines to determine if any of these features exist in the history. and does not suffer from recurrent chest infections. and has no associated thrill. is well and thriving. and must perform a thorough examination. no investigations are warranted. and the murmur has no diastolic component. The child with an innocent murmur. which is an almost musical high-pitched murmur at the base of the heart with no radiation. In comparison. the diagnosis can usually be determined by a careful history and examination. is not cyanosed. associated with a palpable thrill. Physical examination reveals: • • • • • • • • a soft midsystolic murmur. loud.

fingers and thumb. 257 . you cannot move the other fingers towards the thumb (cannot bend fingers and thumbs inwards towards the palm). you have lost sensation and muscle power as follows: • Sensation to touch and pin over the whole palmar aspect of your hand. • If asked to do the movement of abduction of the thumb by lifting the thumb away from the palm. you cannot. the examiner. and you cannot move the thumb across the palm towards the base of the ring and little fingers. • You also cannot flex your wrist (bend it forward). The numbness and loss of feeling extends onto the back of the fingers and thumb. or to move your little finger away from the others. It bled a lot at first.050 Performance Guidelines Condition 050 A knife wound to the wrist of a 25-year-old man AIMS OF STATION To assess the candidate's ability to diagnose tendon and nerve injuries in a deep wound EXAMINER INSTRUCTIONS The knife wound is across the wrist just above the crease line as in the illustration and the candidate can observe this. Proceed to your examination to ascertain the extent of injury describing your findings to me. • You should hold your hand as depicted in the illustration so all the fingers and thumb are stretched out straight. over the nails and the end of the joint. • You can only move the thumb outwards and away from the other fingers in the plane of the palm. You lifted your arm to protect your face and he slashed your wrist with a knife. The examiner will indicate to the candidate 'The bleeding has been stopped by the dressing. You are able to stretch them out straight again if the candidate bends them forwards. When asked to flex your fingers and thumb. Specifically. • If asked to hold a card between your fingers. and unable to bend any of the three joints of your four fingers. but which you think made your hand feel numb. but are able to extend it (bend your wrist back). • If asked to put your thumb across to touch the other fingers. you are unable to do so at the end two joints of the thumb. You are unable to move your fingers freely. but your friends reduced this by local pressure and the ambulance staff put on a dressing which controlled the bleeding. you cannot. ' The examiner will have instructed the patient as follows: You have presented to the Emergency Department with a knife wound to the left wrist produced by an assailant after an argument in a pub.

'Why is he unable to flex the end joints of fingers or thumb?' ~ Answer: Because the long tendons have been damaged. all of the following flexor tendons. Knowledge of all of the individual muscle groups is not expected but candidates should be aware of the effects of median and ulnar nerve division and the appropriate tests (sensory and motor) to detect these. u l n a r i s . the examiner will ask: • • 'Why is he unable to hold a card between his fingers?' ~ Answer: Because the ulnar nerve injury has paralysed the interossei. Candidates should also be expected to recognise that the failure to flex the distal joints of the fingers and thumb are due to concomitant tendon injury. and of MP joint of thumb (flexor pollicis brevis) ~ abduction/adduction of fingers (interossei — ulnar nerve) ~ opposition — median and ulnar nerves ~ ulnar adduction of the thumb (adductor pollicis — ulnar nerve) • Sensory loss is of combined median/ulnar nerve injury. ( p a l m a r i s l o n g u s ) ~ finger flexors - f l e x o r d i g l t o r u m s u p e r f i c i a l l s to all four fingers (normally flexes proximal inter-phalangeal [PIP] joint) f l e x o r d i g l t o r u m p r o f u n d u s to all four fingers (normally flexes distal interphalangeal [DIP] joint) ~ thumb flexor: f l e x o r p o l l i c i s l o n g u s (normally flexes thumb interphalangeal [IP] joint). Candidates should achieve the diagnosis of combined median and ulnar nerve and flexor tendon injury. KEY ISSUES • Ability to correctly identify the structures damaged. interossei — ulnar and median nerves). which have been severed above the wrist: ~ wrist flexors: f l e x o r c a r p i r a d i a l i s . At the end of the candidate's commentary.050 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate is expected to diagnose accurately the deep and extensive injury to: • • • the median nerve the ulnar nerve. tendon and vascular injury. by an appropriately focused examination. • • Arteries — probably one or both. Candidates are expected to conduct a logical and systematic examination to detect nerve. Knowledgeable candidates may recognise that the dorsal cutaneous branch of the ulnar nerve has been spared. 258 . Neurologic effects — Paralysis of all thenar and hypothenar small muscles of the hand preventing ~ palmar abduction of the thumb ( a b d u c t o r p o l l i c i s b r e v i s — median nerve) ~ abduction of little finger ( a b d u c t o r d i g i t i m i n i m i — ulnar nerve) ~ flexion of metacarpophalangeal [MP] joints of fingers (lumbricals. but these injuries have not disturbed the viability of the hand. and not to the effects of nerve damage to median and ulnar nerves at the level of the cut just above the wrist. or at seven minutes.

so repeat the process there to check for ulnar nerve damage. carrying motor fibres to the intrinsic short muscles of the hand. is at this stage a much less important nerve. To confirm your suspicions. nerves and tendons. Of the three main nerves of the arm (median. glass breakages and other sharp items need careful evaluation to identify damage to important underlying structures. The important sensory and motor branches are given off after the nerves have entered the hand by passing under (median nerve) or around (ulnar nerve) the carpal tunnel. It runs to the back of the hand and fingers along the radial side of the forearm. Can the patient feel you touch here (with a blunt pin. sensory fibres to the vital grasping surfaces of thumb and fingers. see and feel the responsible muscle contracting. or wool. Clearly both nerves were at risk from the cut illustrated. by contrast. or your own finger)? The pulp of the little finger similarly is supplied by the ulnar nerve. The superficial terminal branch of the radial nerve. COMMENTARY Cuts to the wrist and hands from knives. runs a midline course throughout the forearm and lies in close proximity to the tendon of flexor digitorum superficialis running to the middle finger. Median nerve The pulp of the index finger is virtually always supplied by the median nerve. keeping the thumb inside the margin of the index finger so the thumb pushes straight up against resistance. is virtually always supplied by the median nerve just after entering the palm. the median and ulnar nerves run to the hand on the volar aspect of forearm and wrist. ulnar and radial). The radial nerve is thus unlikely to have been at risk. In checking for motor paralysis due to nerve injury. and if possible. think of the muscles innervated by the nerve distal to the injury. check that action. and autonomic sympathetic fibres subserving sweating and vasomotor responses. with the palm flat. Testing for damage to the other two nerves is usually easy and rapid with a cooperative patient. away from the palm and the other fingers. If you extend your thumb and tense the tendon of extensor pollicis longus you may be able to feel the terminal branch of the radial nerve crossing the snuff box superficial to the taut tendon by running your finger along the tendon. with no motor fibres. The median nerve. For median nerve. The ulnar nerve lies more deeply on the ulnar side of forearm and wrist flanking the ulnar artery on the surface of the deep long flexor muscle (flexor digitorum profundus). find an action which is performed by one muscle only. abductor pollicis brevis (APB). 259 . particularly major blood vessels. You test its action by asking the patient to move the thumb directly upwards. The ulnar nerve gives a dorsal sensory branch to supply the other one and a half or two ulnar digits. supplying sensation to the dorsum of hand and only the backs of the radial three digits for a short way along their length. now check the motor functions — the median nerve first. as its name implies.050 Performance Guidelines CRITICAL ERROR • Failure to identify the combination of nerve and tendon injury. the short abductor of the thumb.

can act as accessory flexors of the wrist. Only APB can perform it. or stuporous. he may of course be using deeper finger flexors. This can be demonstrated elegantly by sprinkling a starch powder over the skin and observing the colour change. Flexor digitorum superficialis (FDS) and profundus (FDP). These lie in three layers from superficial to deep. But don't of course expect wasting. they too will be paralysed. Next check for damage to the next important group of structures — the long tendons to the thumb and fingers and the tendons to the wrist. You can check these by asking the patient to flex his wrist. 260 . ring and little fingers flexes the proximal interphalangeal joints. this is easy and conclusive — but supposing the patient was drunk and uncooperative. in an acute injury. There are many other tests for other muscles supplied by the ulnar nerve — pinch test for adductorpollicis (Froment sign). Use two tests here — they will help remind you of the muscles involved. supplied by ulnar nerve by its deep palmar branch. If the nerve carrying them is cut. each with four tendons. having already made the diagnosis of an injured ulnar nerve at wrist level or above. In patients with longstanding carpal tunnel syndrome with median nerve compression affecting the motor fibres as they go through the tunnel the muscle may waste and atrophy as illustrated elsewhere in the book. corresponding to the site of the cut. • • Can the patient abduct the little finger away from the other fingers against resistance? This is done by abductor digiti minimi. the deficiencies seen in opposition (Sunderland sign). If he can do so. you can test the power and you can see and feel the muscle contract. • The superficial and deep long flexor tendons to thumb and fingers. which they also cross to reach the end of the digit The deepest tendons are prime movers of the most distal joints of thumb and fingers. In cooperative patients. and so on — but further tests are not needed. all supplied by the ulnar nerve. middle. The branch to the muscle is given off immediately after the median nerve enters the palm after passing under the flexor retinaculum. compared to the handful from median (conversely the sensory loss from median nerve injury is much more significant than from ulnar nerve damage). • The wrist flexors: ~ Flexor carpi radialis — the largest and most visible tendon ~ Flexor carpi ulnaris — the most ulnar sided ~ The inconstant palmaris longus between them. In this case you can still diagnose a nerve injury from effects on the sympathetic efferent fibres. or a young child. The ulnar nerve has a much greater effect on the motor function of the hand than does the median — it supplies at least a dozen important small muscles. In this instance no wrist flexion is possible. and the solitary tendon of flexor pollicis longus (FPL).050 Performance Guidelines That movement is palmar abduction. It is difficult to test their independent action becauseof the last and deepest layer — flexor digitorum profundus. these can act as accessory flexors of the more proximal joints. or the deformities arising from such wasting. ~ FDS — This group of four tendons to index. and cannot or will not cooperate with you. Also check if any differences can be seen or felt distal to the cut compared to the other hand — a small point but sometimes quite helpful. and the affected skin in the distribution of the nerve will be dry and unable to sweat. Can the patient hold a piece of paper between outstretched fingers? This is done by the interossei. which because they cross multiple joints.

no spontaneous movement against resistance is possible — all of these deep tendons have been severed. and you will find this confirmed when you test the ability of the patient to flex the proximal interphalangeal joint (which in the absence of action of FDP is left as the only muscle which can flex the joint). FIGURE 2.050 Performance Guidelines ~ FDP and FPL — Test the abilities to flex the end joints of the digits first — thumb index through to little finger. it is very likely that the more superficially placed flexor digitorum superficialis tendons have been also severed. This is because. In this patient. then ask them to flex the remaining finger at the proximal IP joint to a right angle as illustrated. it is possible to flex the index finger at its end joint independent of other fingers. But what if the FDP is not damaged? How can the action of flexor digitorum superficialis on the PIP joint be checked in such circumstances if the sole injury is to FDS? Answer: To test the action of the superficial finger flexors in the presence of intact deep flexors is a difficult task and needs a knowledge of the anatomical arrangements of the muscles. ring or little finger alone is rather difficult — the end joints of adjacent fingers tend also to flex. Note that with fingers extended. and preventing their movement. Hold down flat all fingers but one of a colleague. By restraining the long tendons of FDP to the other fingers. CONDITION 050. But to flex the end joint of the middle. You can easily check that FDP is not having any effect by flicking the terminal phalanx with your finger — note that the distal IP joint is freely floppy and the only muscle now causing flexion of the PIP joint is FDS. just as with the end joint of the thumb. because the flexor digitorum profundus is also cut and cannot confuse things by itself acting as a flexor of the proximal IP joint. whereas the other tendons are communally joined until just above the wrist This fact can be used to advantage to eliminate the influence of the deeper tendons of FDP to these three fingers on the proximal joint as follows — try this trick. and in particular. Identifying damage to the flexor digitorum superficialis in the finger is easy in this patient with a cut wrist. unless concentrating or holding them down. of the four separate tendons of FDP in relation to the muscle. the deep layer of flexor digitorum profundus. Testing for function of FDS alone 261 . Clearly given this finding. you have very effectively inactivated the remaining FDP tendon to the middle finger. the one to the index finger is virtually a separate muscle (flexor indicis).

050 Performance Guidelines An injury to the long flexor tendons should have already been suspected in this patient on inspection alone. because the imbalance caused by the unopposed natural resting tension of the finger extensors. In your patient (a trained role player) the fingers are extended instead of curled and the thumb is also extended. with all the long flexors cut. In the normal hand at rest. CONDITION 050. Figures 3 and 4 show position of rest from palmar and radial aspects CONDITION 050. This is the position of rest of the hand with a balanced postural tone of flexors and extensors. due to the injury to the median or ulnar nerves The branches to the extrinsic long flexors come off from much higher in the forearm and are unaffected by nerve injury at the wrist. 262 . These effects on the terminal joints are due to tendon injuries. Note position of fingers and thumb after long tendon injury The inabilities to move the terminal two joints of the fingers and the terminal jointot the thumb are not. and the whole hand looks very unnatural. has distorted the normal position of rest. and could not be. FIGURE 3. the fingers and thumb are progressively flexed into the palm from index to little finger with the thumb at right angles as illustrated. FIGURE 5. FIGURE 4. which can only affect the function of intrinsic muscles in the hand. CONDITION 050.

Treatment will necessarily require a subsequent intensive rehabilitation programme of initial rest. Finally the blood vessels — the very superficial radial artery and more deeply placed ulnar artery. which need not concern us further in this patient. but the anastomoses and collateral circulation across the wrist are very efficient and it is very unlikely that the hand will be grossly ischaemic even if both arteries have been divided. The final functional outcome will be very much influenced by his occupation — if he is a concert pianist. after checking that sensation to the back of the hand and proximal back of fingers is intact. with early mobilisation and supportive physiotherapy over many months. These latter signs are accentuated and even more obvious in patients with longstanding effects of muscle wasting. also note that he cannot flex the metacarpophalangeal joints of the fingers (or of the thumb). thoughts about vocational retraining should start early. confirming that radial nerve and dorsal branch of ulnar nerve have escaped injury. Fortunately this is a 'tidy' wound without major contamination and there is no contraindication to primary repair. These additional tests also give characteristic signs: on attempted ulnar adduction. pinch test of the thumb (Froment sign) and failure of opposition of little finger (Sunderland sign). supplied by branches from median and ulnar nerves in the palm. This action in the fingers is done by the lumbricals. These are very likely both to have been cut but vascular spasm and compression may have caused bleeding to stop. and this inability is due to the nerve damage. is: Severe deep knife wound of wrist severing all volar long flexor tendons to wrist and hand and severing median and ulnar nerves — a very severe injury requiring early reconstructive surgery.050 Performance Guidelines Moving proximally. The most superficial muscles are the wrist flexors FCR and FCU and PL. as are all the other tests for intrinsic muscle function testing thenar and hypothenar muscles and interossei apart from those we have already done. 263 . The patient cannot flex the wrist actively either because all of these are divided as well (plus the long finger and thumb flexors which can of course act as accessory flexors of the wrist as well as prime movers of their respective finger or thumb joints). The final diagnosis. Examine the colour of the fingers and test capillary refilling after pressure.

His wife. melanocytic dermal naevus and spider naevus) and do not have to be excised. Figure 5. BCC and melanoma) and should be excised. His son has a lesion suspicious of squamous cell carcinoma (SCC) of the lip. EXAMINER INSTRUCTIONS A careful history of how long the lesions had been present would normally be required. and which are suspicious of malignancy (SCC. The SCC. Widespread metastases can occur even from a small lesion. assuming diagnosis is confirmed by excision. 264 . the spider naevus and the melanocytic dermal naevus are benign and probably require just reassurance. The SCC and the BCC should also be removed without excessive delay. Figure 6. The photographs demonstrate: • • • • • • Figure 1. The excision of her lesion should not be delayed. The BCC only spreads directly. The prognosis is favourable if the depth is less than 0. His father has a seborrhoeic keratosis on his face. His 50-year-old brother has a lesion suspicious of basal cell carcinoma (BCC) of the neck.75 mm. Figure 3. EXPECTATIONS OF CANDIDATE PERFORMANCE The farmer is very concerned about six members of the family and has photographs of each of the lesions. by lymphatics and by blood spread. Figure 2. although this occurs slowly. His 52-year-old brother has a benign spider naevus of the chest. His wife has a lesion suspicious of malignant melanoma of the leg. but local infiltration may be extensive. who has the malignant melanoma. Malignant melanoma is the most serious of the lesions and spreads locally. even though she would prefer to delay treatment for several months because they are busy on the farm. The SCC spreads directly and mainly by lymphatics. The risk of spread is proportional to the depth of the melanoma seen on microscopic examination. this scenario focuses on pattern recognition from physical appearance. KEY ISSUES • The candidate should indicate which lesions are likely to be benign (seborrhoeic keratosis. His daughter has a lesion suggestive of a benign melanocytic dermal naevus of the face.051 Performance Guidelines Condition 051 Multiple skin lesions in a Queensland family AIMS OF STATION To assess the candidate's ability to diagnose a variety of common benign and 'suspicious' skin lesions and to advise on management. He has come in from his farm. Figure 4. are malignant The seborrhoeic keratosis. requires the most urgent treatment. BCC and melanoma. which is a long way from the town. which is benign. and occasionally by blood spread.

longstanding lesions are the most commonly seen pigmented skin 'moles'. FIGURE 8.051 Performance Guidelines CRITICAL ERROR • Failure to suspect that the wife's lesion is a malignant melanoma. seborrhoeic keratosis. FIGURE 7. Seborrhoeic keratoses occur in older people and are most often found on the trunk. junctional and compound) These are classified according to the site of the benign pigment-containing melanocytes. Clearly benign. Haemosiderin deposition in the plaques may produce a brownish-black colour. basal cell cancer. 265 . Benign melanocytic naevus Seborrhoeic keratoses ('seborrhoeic warts') Benign melanocytic naevus of neck These lesions arise from the epidermis as the result of proliferation of keratinocytes. and most can be confidently diagnosed. although they may be found on the face and scalp. Intradermal and compound naevi have melanocytes intradermally. or at both epidermal and dermal levels. malignant melanoma). CONDITION 051. Macroscopically they vary from a light or dark brown nodule (often containing hair. and that surgical excision should occur without delay. The lesions are raised or flat and plaque-like. spider naevus. COMMENTARY This scenario illustrates six of the most common focal cutaneous lesions seen in the Australian population (benign melanocytic naevus. a helpful diagnostic point — hairy moles are almost invariably benign). They are quite benign and their fissured. variegated. they are flatter than the other more mature naevi and may be wholly macular. They are often multiple. There is no dermal involvement and the keratoses are so superficial that they are often said to have a 'painted on' appearance. Occasionally the lesion may be situated on a part of the body that makes it prone to trauma. with a waxy texture. rough textured appearance usually allows confident diagnosis. but the only real reason for excision of a seborrhoeic keratosis is for cosmetic purposes. Junctional naevi have melanocytes at the junction of epidermis and dermis. Benign skin lesions: Benign melanocytic naevi (intradermal. CONDITION 051. squamous ceil cancer.

Pyogenic granuloma of palm Pyogenic granuloma of finger 266 . CONDITION 051. Multiple ones on the upper trunk. Treatment is by excision and curettage of the area underlying the granuloma. FIGURE 11. CONDITION 051. At the site of puncture of the skin there is a mass of rapidly growing granulation tissue which characteristically forms an exophytic growth. Papillomas Otherwise known as skin tags. CONDITION 051. papillomas may be found at any site and are either sessile or pedunculated overgrowths of skin seen frequently around flexural areas of axilla or groin. Multiple seborrhoeic keratoses of trunk Spider naevi Seborrhoeic keratoses of back These small lesions have a red central spot surrounded by flaring telangiectases. This may appear over a few weeks and bleeds easily on contact. Pressure on the central arteriole causes blanching. They may be excised for cosmetic reasons. or face can be stigmata of alcoholic liver disease. FIGURE 10. FIGURE 12. FIGURE 9. upper limbs. Pyogenic granulomas These lesions may arise in response to minor trauma.051 Performance Guidelines CONDITION 051.

but are identified by a central core of proliferating cells extending down into the dermis. As many verrucae will completely regress. a macroscopic appearance resembling a squamous cell carcinoma and spontaneous regression. CONDITION 051. The centre of the lesion ulcerates and may contain a plug of keratin. 267 . they are better left alone. FIGURE 13. Keratoacanthoma of face Fibrohistiocytic tumours: dermatofibroma. They are caused by the human papilloma virus and spread by sexual contact.051 Performance Guidelines Verrucae Verrucae are most commonly seen in children and are caused by viruses. if the lesions are asymptomatic. Histologically these lesions can resemble squamous cell carcinoma. A keratoacanthoma usually occurs on the face (often on the nose or ear) or hand and appears over the course of a few weeks. as the verruca is likely to return if the virus is not completely eradicated. Keratoacanthomas should be excised and sent for histologic examination to exclude squamous cell carcinoma. Accurate histologic diagnosis is usually possible if the whole lesion is provided. Those warts that occur around the genital and perineal regions are known as condyloma acuminata. xanthoma There is a considerable histological range of soft tissue tumours and the two benign lesions that may be considered of true skin origin are the cutaneous fibrous histiocytoma (dermatofibroma) and the xanthoma. only a small margin of excision is required. The site of the tumour and its rapid development should make the diagnosis. Histologically there is hyperplasia of the epidermis and increased keratinisation. Treatment can be difficult. They consist of raised and rounded keratinised projections above the skin surface. Those on the sole are commonly 'endophytic' due to weight-bearing. Common sites are hands and soles of feet. Keratoacanthomas These lesions are characterised by rapid growth. A dermatofibroma is a relatively common skin nodule and typically occurs on the legs of young or middle-aged women. The lesions may spread to adjacent sites or other individuals.

Appendage tumours Cylindromas (arising from sweat gland cells) and other skin appendage tumours are rare. Actinic keratoses appear as scaly lesions with hyperaemic bases that bleed easily with trauma. There is a build-up of excessive keratin in the epidermis and elastosis in the dermis. Fair skinned people living in the tropics and subtropics are most at risk. They may occur at any site on the body and the most common form is the xanthelasma. They can be treated by cryotherapy. to confirm the diagnosis. Premalignant neoplasms of skin: Actinic keratoses Actinic (solar) keratoses are the result of solar damage and are characteristically found on areas of the body most at risk of prolonged sun exposure. CONDITION 051. The lesions occur most frequently in older people and those who work outdoors. These soft. The back of the hand is a common site. Most are asymptomatic but they can be itchy and tender which is the usual reason for excision. Dermatofibroma of leg The lesions are usually raised from the skin surface and about 1 cm in diameter. application of a cytotoxic cream or excision. FIGURE 14. Xanthomas occur when an area of skin becomes infiltrated by lipid-filled macrophages or histiocytes. Multiple actinic keratoses of hands 268 . Treatment is excision. 15-20% of actinic keratoses will progress to squamous cell carcinoma. yellow plaques are characteristically found at the inner canthus of the palpebral fissure. Left untreated.051 Performance Guidelines CONDITION 051. The actinic keratosis represents a gradual dysplastic change in the epidermis and underlying dermis. FIGURE 15.

the suspicion of malignancy must always be uppermost in the clinician's mind when dealing with a skin tumour. FIGURE 16. They tend to occur in people over the age of 40 and are usually found on areas of the body subject to chronic exposure to the sun. Although not all skin tumours are neoplastic. particularly the face. Characteristically these tumours are found on the face above an imaginary line running from the corner of the mouth to the ear. The tumours are slow-growing and may take years to get to sufficient size to bother the patient. There is hyperplasia of the epidermis. a basal cell carcinoma will spread relentlessly and destroy all the surrounding tissues without ever metastasising. and muscle or nerve elements. By contrast. Basal cell carcinomas (BCC) This is the most common type of skin cancer and is almost totally confined to fair skinned people. The surface is keratotic and often crusted and fissured. Treatment is with cryotherapy or cytotoxic creams. Bowen disease of skin The skin is the largest organ of the human body and not surprisingly it is the most common site of tumours. Tumours can arise from any of the skin structures — epidermis. atypical epithelial cells are present and infiltration of this layer with pleomorphic malpighian and giant cells. Larger lesions and those that are suspicious or frankly malignant are best treated by excision. rolled edge which often takes on a pearly appearance. Skin grafting may be required. from a management perspective. Most basal cell carcinomas are the same colour as the adjacent skin. Malignant skin neoplasms 7 49333535 CONDITION 051. Left untreated. Malignant skin lesions are very common in Australia with a susceptible population and excessive solar exposure. be it pigmented or not.051 Performance Guidelines Bowen disease This is an unusual condition and presents as a scaly red plaque with clearly defined margins. Basal cell carcinomas are rare in Asiatic peoples and almost never occur in dark skinned people. The lesion is not related to solar damage and in some instances arsenicals have been implicated in the aetiology Bowen disease may occur on any part of the body and is a premalignant condition and represents squamous cell carcinoma in-situ. The tumour characteristically has a raised. melanoma and other skin malignancies are uncommon in indigenous Aboriginal peoples. connective tissue. but some are heavily pigmented and mistaken for 269 . dermis. Skin cancer is the most common malignancy in fair-skinned people. glands.

Morphoeic BCC Ulcerative BCC CONDITION 051. To minimise tissue loss. A margin of at least 1 mm of normal tissue is required. FIGURES 17 AND 18. psoriatiform. Radiotherapy is used for cancers in areas where surgical resection would be difficult and risk damage to surrounding structures. cystic. particularly for lesions on the face. producing the so-called 'rodent ulcer. sclerosing/cicatrising ('brush-fire'). Apart from nodular BCC (the most common presentation). a technique of serial slicing can be employed. The erythematous variety of basal cell carcinoma tends to occur on the trunk. ulcerative. The optimum treatment for basal cell carcinomas — and particularly for lesions greater than 1 cm diameter — is surgical excision. such as tear ducts and eyelids. Sclerosing BCC behind ear Pigmented BCC Small basal cell carcinoma can be treated by cryotherapy. 270 . comedoform and pigmented variations are commonly seen. The major disadvantage of these types of treatment is that no tissue is obtained for histological analysis.' Other morphological patterns of basal cell carcinomas include those resembling Bowen disease with a thin pink plaque (erythematous basal cell carcinoma) and those known as sclerosing tumours with white plaque and a fine pearly edge (morphoea carcinoma). the serial excision and immediate microscopic examination of the resected tissue will allow an intraoperative assessment of clearance of tumour in depth and width. There may be central regression of the tumour with ulceration. Larger basal cell carcinomas will require skin grafting a reconstructive surgery. Radiotherapy should not be used for lesions adjacent to cartilage. Whilst this is time-consuming. FIGURES 19 AND 20. CONDITION 051. topical chemotherapy or radiotherapy. which might undergo radionecrosis.051 Performance Guidelines melanomas.

Squamous cell carcinoma of lip SCC of ear Squamous cell carcinoma has a variable natural history. FIGURE 22. particularly prevalent in fair-skinned populations of tropical climates. Whilst basal cell carcinomas arise from the basal layers. but incidence is increasing in most countries. CONDITION 051. FIGURE 21. particularly the head and the hands and on the lips. Squamous cell cancers can also occur in scars or chronic ulcers (Marjolin ulcer). in contrast to BCC which occur in the retroareolar sulcus. CONDITION 051. with a 95% 5-year survival rate. the crucial difference is the ability of the former to metastasise. more common in exposed skin. but with excessive sun exposure in childhood. These cancers are usually seen in the older population. Prognosis worsens with increasing depth of invasion. Although the tumours do metastasise to lymph nodes there is no evidence that prophylactic lymph node dissection confers any benefit. bleeding. particularly in depigmented skin following scarring. occurring throughout adult life. 271 . As most of the tumours are sun exposure-related. while those that complicate Bowen disease tend to be more aggressive. Bloodborne metastases to lungs. nodularity or ulceration should be regarded as suspect and should be excised with an adequate margin Spread to regional nodes is common and markedly worsens prognosis. squamous cell carcinoma is also a disease of young adults. Those tumours that arise from actinic keratoses can be quite slow growing. Optimal treatment of squamous cell carcinoma of the skin is surgical excision. Sunlight is an important aetiological factor and solar keratoses and Bowen disease are precursors. they tend to occur on exposed parts of the body. Malignant melanomas The most malignant of all skin tumours. On the ears. Most squamous cell carcinomas occur in the fair skinned people. Whilst a squamous cell carcinoma can morphologically resemble a basal cell carcinoma. For those patients who undergo a curative resection. the prognosis is good. liver. invariably involve the lower lip. squamous cell cancers occur particularly on the outer helix.Squamous cell carcinomas (SCC) These are the second most common cancer of the skin. irritation. but these tumours are also found in darker-skinned people. squamous cell carcinomas arise from the keratinocytes of the epidermis. Any brown or black mole showing an increase in size. Several macroscopic types are recognised with progressively worsening prognosis. brain and small bowel are common.

Kaposi sarcoma 272 . The disease associated with AIDS and other acquired immunodeficiency states runs a more aggressive course. FIGURE 26. In its aggressive form the body may be covered in confluent. CONDITION 051. Kaposi sarcoma Classical Kaposi sarcoma is found in elderly males of Mediterranean or East European origin and tends to run an indolent course. FIGURES 23-25 • Hutchinson melanotic freckle (lentigo maligna melanoma) • Superficial spreading melanoma (most common type) • Nodular melanoma • Nonpigmented amelanotic melanoma. Kaposi sarcoma is a spindle cell tumour and is characteristically a multicentric angiomatous lesion of the skin.051 Performance Guidelines CONDITION 051. The lesions vary in appearance from nodule or macule to plaque and may be several centimetres in diameter. violaceous skin nodules.

slow growing and prone to local recurrence if not adequately excised. Localised cutaneous lesions can be treated with radiotherapy. The three are Merkel cell carcinoma. but only three need to be considered because of their similarity to basal cell carcinoma. In most instances the skin deposits will only become manifest after the primary disease has been diagnosed or treated. cryotherapy. Occasionally. Secondary tumours The skin is a common site of metastatic deposits. It may resemble a basal cell carcinoma. FIGURE 27. Malignant histiocytoma There are numerous other uncommon primary cutaneous tumours. Other primary cutaneous tumours Malignant histiocytoma (dermatofibrosarcoma protuberans) is a lesion with a tendency to biphasic growth spurts and local recurrence after excision. but gastrointestinal and pulmonary disease often occurs in AIDS-related Kaposi tumour. microcystic adnexal carcinoma and sebaceous gland carcinoma Merkel cell carcinoma is of neuroendocrine origin and is an aggressive tumour with a high rate of local recurrence. intralesional chemotherapy or topical retinoids.051 Performance Guidelines Visceral involvement is uncommon with the classical form of Kaposi sarcoma. both in its appearance and preferential distribution on the head and neck. particular for aerodigestive tract neoplasms. The other two tumours are rare. CONDITION 051. 273 . a cutaneous metastasis may be the presenting feature of an otherwise asymptomatic tumour of the lung or oesophagus.

bursae and tendon sheath swellings. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The case scenario is a real patient with a longstanding subcutaneous swelling — the findings and diagnosis are to be checked by the examiner personally prior to commencement of the examination. neck and bowel. Real patients should just answer questions as asked and will expect to be reassured about conservative treatment being offered. Opening statement: 'What is this lump?' EXPECTATIONS OF CANDIDATE PERFORMANCE Major points of technique and accuracy in examination are • Establishing the lump's physical characteristics — particularly contour and consistency. • 'Layering' the lump — is it in subcutaneous fat. nerve or blood vessels? • Does the lump pulsate and is this intrinsic or transmitted pulsation? • What are its attachments? Superficially is it attached to the skin and deeply what are the effects of tensing or contracting underlying muscles or tendons. Gas cysts do occur in lung. ganglion or bursa. or may have a thick lining. sebaceous cyst.052 Performance Guidelines Condition 052 Subcutaneous swelling for assessment AIMS OF STATION To assess the candidate's ability to perform an appropriately focused diagnostic examination of a subcutaneous lump. the fluid will almost always be a liquid. When brilliantly positive. 274 . ligament. but in a subcutaneous site. or branchial cysts) rather than pultaceous material or blood. or note advice about possible surgery. bone. a test often inadequately performed. • Is it a fluid-filled cystic lump? The most helpful test here will be whether it is transilluminable. and if the latter is it arising from muscle. or occasionally a less common diagnosis. tendon. and usually a clear serous liquid (such as in scrotal cystic swellings. it gives irrefutable evidence of contents being liquid or gas. A negative transillumination sign does not of course exclude a fluid collection as the cyst may contain a complex and viscous fluid. This test must be performed properly by correct torch placement behind the lump and must be done by suitably darkening the surrounds — turning off lights and covering with sheet or blanket as required. The lump will usually be a lipoma. attached to or beneath deep fascia.

ADVISE the candidate 'please counsel your patient about the lump. Test your knowledge of the prepatellar bursa. but not lipomas or ganglia. Try illuminating the finger and areas of normal skin to see the extent of normal transillumination of fat and other tissues. sebaceous cysts. in areas where the skin is thick and relatively fixed to deeper layers such as on the back of neck or scalp. ASK — 'I s there any significant risk of infection?' The answer is YES for infection complicating bursae and sebaceous cysts. This sign is sometimes easy to elicit and is accompanied by obvious skin dimpling or a punctum. such as those in breast or thyroid. merely effects of deformation. because the content is viscous or pultaceous keratin. and if this occurs when tested in several directions and in planes at right angles to each other. The lump must be capable of being fixed by two fingers at the perimeter while a third finger compresses it centrally. At the end of the candidate's examination. In deeper lumps. or a transmitted venous impulse. Lipomas and other soft compressible solids may give an impression of fluctuance. • Is the lump vascular? Candidates should not omit feeling for vascular pulsation. Remembering normal vascular surface anatomy makes egregious errors less likely — such as missing an aneurysm. but they do not exhibit true fluctuation. where neither transillumination nor fluctuation is relevant or possible. the test is equivocal and the clinician must rely on other findings such as contour and consistency to help diagnose subcutaneous lumps. the examiner will: ASK — 'What is your diagnosis?' ASK — 'I s there any significant risk of malignant change?'JUe answer is NO for lipomas. ' 275 . • Testing for fluctuation is often poorly performed also. or listening for a vascular bruit or hum. the semimembranous bursa and a Baker cyst: all are near the knee joint. the suprapatellar bursa. • Is the lump attached to the skin? If this sign is unequivocally positive. • Does the lump show emptying and refilling after compression or with joint movements? This important sign should alert the clinician to a possible bursal communication with an underlying joint and candidates should know which bursae are likely to communicate with which joints. or after five minutes. Lipomas are not transilluminably separate from surrounding fatty tissues. and to differentiate between lipomas and keratinous 'sebaceous' cysts. nor are most sebaceous' cysts transilluminable. but only some communicate with (or are part of) the joint synovium. • Ultrasound confirmation and positive yield of liquid on needle aspiration are definitively diagnostic of a cystic collection. then this again is irrefutable evidence of contained liquid (by virtue of the incompressibility of liquids which causes transmission of outside pressure in all directions). these techniques become the best diagnostic aids. the lump is very likely to be a 'sebaceous' cyst or one of its variants. the pretibial bursa.052 Performance Guidelines Candidates should familiarise themselves with the normal extent of transilluminability of other tissues. ganglia and bursae. like a pilomatrixoma ('calcifying epithelioma of Malherbe'). which vary rather like the scale of sonicity characteristics of an ultrasound. the anserine bursa. If the other fingers are displaced and expanded symmetrically. But often.

bursae and ganglia are also common. Sebaceous (epidermoid) cysts. tabulated and mobile swellings beneath the skin. Major errors in accuracy of findings. will be observed for technique and accuracy. • COMMENTARY The most common subcutaneous swelling is a lipoma. painless.052 Performance Guidelines KEY ISSUES The candidate should be able to: • Perform an appropriately focused and accurate physical examination of the subcutaneous lump. such as an obvious punctum. soft. CRITICAL ERRORS • • Very unsatisfactory examination technique. contour and consistency. and of appropriate clinical reasoning skills. FIGURE 1. vessels and nerves. ~ Knowledgeable candidates will be able to make a confident diagnosis and to counsel the patient briefly but appropriately. CONDITION 052. The station is however predominantly to serve as a test of technique and accuracy of physical examination. muscle and tendons. size. FIGURE 2. Distinction between sebaceous cysts and lipomas may be easy and aided by diagnostic clues. Display appropriate reasoning skills in making the correct diagnosis: ~ Most lipomas. ganglia and bursae will not be difficult to diagnose. Testing for skin and deeper attachments and for fluctuation and transillumination. Subcutaneous lipoma of back Subcutaneous lipoma under arm 276 . its physical shape. CONDITION 052. sebaceous cysts. joints. where appropriate. An appropriate and optimal examination will determine in which tissue layer the lump lies. and its relationship to adjacent anatomical structures such as skin. and knowledgeable candidates will recognise the differences and the potential risks of infective complications of sebaceous cysts and bursae. Subcutaneous lipomas (Figures 1 and 2) are slow growing.

They have several different causes. will have a central punctum. FIGURE 3.g. whereas an infected cyst should be incised and drained. FIGURE 6. Uncomplicated cysts may be enucleated. Multiple 'sebaceous' cysts of scrotum CONDITION 052. Traumatic implantation cysts tend to occur on the hands and fingers. implantation dermoid cyst. scalp or trunk. FIGURE 5. These cysts are often and mistakenly called 'sebaceous' cysts. pilosebaceous follicle cyst. Others will be found at the site of surgical scars. but not all. Some are inclusion or implantation cysts. They can occur at any age and at any site although they tend to be seen in older people and most often on the face. CONDITION 052. A keratinous cyst is a preferable term. which has a characteristic soft cheesy texture and offensive odour when infected (Cock peculiar tumour). traumatic in origin. CONDITION 052. FIGURE 4. An epidermoid cyst tends to be elevated and many. 'sebaceous cyst') Epidermal (epidermoid) cysts are common. Some epidermoid cysts are associated with hereditary syndromes (e. Gardner syndrome). The cyst is lined with squamous epithelium and full of desquamated debris.052 Performance Guidelines Epidermoid Cyst (keratinous cyst. A true sebaceous cyst is rare and arises from a sebaceous gland. These cysts may discharge or become infected. 'Sebaceous' cyst with punctum CONDITION 052. and others result from the occlusion of the pilosebaceous unit. with later excision. Large 'sebaceous' cyst of scalp 277 .

and have a round non-lobulated contour. Imaging may be necessary. CONDITION 052. 5 and 6) move with and not separate from the skin. Feel. Dermoid cysts are true hamartomas and develop when skin and skin structures become trapped during embryonic development. Ganglion of lateral aspect of foot 278 . Listen. those on the face and neck are usually evident at birth. They occur within any area of hair-bearing skin. however. They may also be found in the mouth and upper neck. Treatment is by excision. to assess the degree of involvement of underlying structures. The common ganglia — those around wrist or ankle — do not communicate with the adjacent joints. They are thin-walled cysts and contain fatty material and occasionally. often formed by cystic degenerative change in the fibrous joint capsule or fibrous tendon sheath.052 Performance Guidelines 'Sebaceous' cysts (Figures 3. 4. They are usually round. They may be made more prominent by tendon contraction or tensing and on joint movement. The other differentiations (skin attachment versus the subcuticular mobility of lipomas) are not always easy signs to detect in areas of thick skin like the back of the neck . Although these cysts can appear at any age. fluctuant and non-transilluminable with a smooth nonlobulated contour which differentiates them from lipomas. Those on the face occur mainly around the eyes and are often attached to the underlying periosteum. These are helpful diagnostic tests in the optimal examination sequence of: Look. such as at lines of fusion anteriorly in the midline and around the eyes in the head and neck. in subcutaneous tissues. Apart from the confusing use of this term. FIGURE 7. Ganglia (Figures 7. so their removal necessitates opening the joint or sheath.but 'sebaceous' cysts always have a focal point of skin fixation with or without a punctum. They are. Move. Dermoid cyst (congenital inclusion cyst. the dermoid cyst is a congenital lesion and those found in the skin and subcutaneous layer usually occur on the face. hamartomatous cyst) Dermoid cysts can be found as cystic tumours of the ovary or within the cranium and spine and for the purposes of this section. hair. 8 and 9) present as deeply placed subcutaneous lumps around joints or tendon sheaths. neck or scalp.

Many or most of these lumps require no active treatment other than reassurance. Olecranon Bursitis Double pathology — 'sebaceous' cyst of neck with submandibular salivary gland swelling behind it Candidates should show appropriate perspective in counselling. FIGURE 11. Some bursae communicate with joints or tendon sheaths. Knowing that the lump has been present for a long time without significant symptoms or change in character is reassuring and makes a benign condition most likely. FIGURE 10. 279 . CONDITION 052. FIGURES 8 AND 9. Ganglion of wrist — the most common site Bursae are cystic sacs between the skin and underlying bony prominences or they separate and aid gliding of adjacent tendons and ligaments. Subcutaneous lumps are very common and typical examples as indicated in the figures. CONDITION 052.052 Performance Guidelines CONDITION 052.

at the joint line. Checks patellofemoral mobility and tracking Checks integrity of ligaments appropriately: valgus and varus strain to slightly flexed joint for collaterals. anterior and posterior glide (drawer) test for cruciates — all of these are normal 280 . ensuring that the range of active movement is not exceeded. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should examine both knees: Expected technique of knee examination: • • • • • • • Checks stance and gait. You have difficulty in straightening your right leg fully and occasionally have apprehension twisting to the right. Since then you have had intermittent attacks of pain felt on the inner side of the right knee with swelling which settles within 24 hours. You are otherwise well and between attacks can walk normally with only a minor feeling of pain on the inner side of your knee. Checks active range of movement initially — flexion/extension (range/power) notes positive signs of inability to fully extend affected knee and medial joint tenderness Checks passive range of movement with care. Checks for tenderness at joint line and around margins over sites of attachments of collateral ligaments and patellar ligament Should identify tenderness anteriorly. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement: 'What is wrong with my knee?' You have a history of twisting your right knee six months ago when you caught your foot on a piece of broken pavement. You fell on the right knee which became swollen and painful on the inner side of the knee. • • You should complain of tenderness at the inner joint line anteriorly when the right knee is examined. on the inner aspect of the right knee.053 Performance Guidelines Condition 053 Examination of the knee of a patient with recurrent painful swelling after injury AIMS OF STATION To assess the candidate's technique of physical examination of the knee joint and the accuracy of examination. You cannot fully straighten the affected knee because of pain (a deficit of around 15 of extension). Checks for joint effusion (patellar tap' and 'bulge test' for cross fluctuation). The swelling caused a painful limp for a few days then subsided.

• cruciate ligament tears. • tears of the collateral ligaments from valgus or varus strains. Failure to test ligament integrity. KEY ISSUES • • Perform a focused and accurate physical examination of the knee joints (physical examination skills). 281 . recreational and sporting injuries giving: • injuries to the intra-articular cartilages (more commonly to the medial meniscus). Candidates should not omit examining the back of the affected knee. COMMENTARY The knee joint is the most complex synovial joint in the body. Examines back of joint (popliteal fossa) as well as front and sides. Occasionally candidates may mistakenly examine the normal knee instead of the affected one after asking the patient to turn over — a moderately serious mistake induced by nervousness and lack of concentration. Diagnosis/Differential Diagnosis • • • Probable injury to medial intra-articular meniscus (medial cartilage) Alternative: traumatic osteochondritis/synovitis right knee. Unacceptable: cruciate/collateral ligament rupture. and • chondromalacia or osteochondritis dissecans. • traumatic synovitis.053 Performance Guidelines • • • Checks quadriceps for strength and wasting Compares symptomatic side with normal side. Traumatic soft tissue internal derangements of the knee (IDK) are common after domestic. CRITICAL ERRORS • • Failure to test movements of the left knee to compare with the other (affected) side. Formulate a diagnostic/differential diagnosis plan appropriate to the clinical problem (clinical reasoning skills).

first noted during pregnancy. Your mother had operations for deafness on both ears many years ago. you have to have the television volume turned up (partner complains it is too loud): and you have noticed that you seem to hear a bit better when there is a lot of outside noise. EXAMINER INSTRUCTIONS Opening statement: 'What is wrong with my hearing?' The examiner will have instructed the patient as follows: • • • • • you gave birth to your first child a month ago. 282 . heavy metal music via earphones). Tuning fork tests: ~ When placed on top of your head say — 'same on both sides'. this has become progressively worse and is the reason for you consulting the doctor today. in response to the doctor's question. brother and sister are not deaf.054 Performance Guidelines Condition 054 Assessment of hearing loss. or industrial noise. masking your other ear — respond by saying that you CANNOT HEAR these sounds when they become soft. in a 35-year-old woman AIMS OF STATION To assess the candidate's knowledge of types of hearing loss and their differentiation on examination.g. Other points: • The examiner will NOT ALLOW the doctor to use the otoscope provided to examine your ear canals but will ask about its use and what conditions are being looked for. The doctor may ask you further questions about your hearing loss: • • • both ears are affected. it has no other special characteristics — 'just getting deaf: you have not had exposure to very loud music (e. and you have no other complaints. and • you have no past history of ear infections. Your father. The doctor is expected to ask you about a family history of deafness but provide this information only when asked. Candidates should indicate they will look for complete occlusion of the ear canal by wax (cerumen). • • Hearing capacity — the doctor will whisper numbers or words in your ear. your infant is breastfed and thriving. about midway during the pregnancy you became aware of reduced hearing. Regarding severity: • • • you have difficulty hearing the baby cry if he is not in the same room as you are.

The onset of bilateral deafness in a young woman during pregnancy is uncommon. Ability to explain to the patient the problem and its management. One is due to wax and is curable. CRITICAL ERRORS • • Failure to correctly use tuning fork in assessing hearing loss. KEY ISSUES • • Skill in use of tuning fork tests to define types of hearing loss — conductive versus sensorineural. Failure to advise a referral for audiometry and/or ENT opinion. say 7 can't hear that either'. father of Oscar Wilde We have made some progress in diagnosis and treatment since the above statement! This station is predominantly a test of skill in clinical assessment of hearing loss requiring that the candidate has a basic knowledge of types of hearing loss: conductive versus sensorineural. • The candidate should advise that referral for an audiogram or otolaryngological (ENT) opinion is necessary. The positive family history of a mother requiring surgery for her hearing loss points towards an inherited cause. When it can no longer be heard say 7 can't hear that anymore and when air conduction is tested. COMMENTARY 'There are two kinds of deafness. the other is not due to wax and is not curable. EXPECTATIONS OF CANDIDATE PERFORMANCE Ability to distinguish types of hearing loss (in this patient conduction loss due to otosclerosis).e. The stapes footplate becomes ankylosed in the oval window causing conductive type deafness. and that conductive deafness due to wax occlusion or other causes must be excluded. Patients may notice they hear more clearly in noisy surroundings. 283 .' The doctor may then repeat the test with the fork beside your ear. The condition can be treated by prosthetic stapedectomy and vein grafting. namely otosclerosis.054 Performance Guidelines ~ When placed beside your ear and then pressed on the bone behind your ear. say that 'the latter is the louder. The patient evinces conductive deafness due to otosclerosis. ~ If the candidate does the test in the reverse order (i. Respond accordingly after about 10 seconds 'can't hear it now'. tests bone conduction prior to air conduction) react as follows: 7 can hear that' (on bone).' Sir William Wilde (1815-1876). The onset of this condition is generally in early adulthood and may progress rapidly in pregnancy. The doctor should then press the tuning fork on the bone behind your ear to test bone conduction. Respond by saying 7 can hear that'. asking you to say when the sound can no longer be heard. to test air conduction. Deafness is a common problem in older people in our community.

Deafness may be due to impaired conduction of sound through a muffled middle ear (conductive or middle ear deafness). and then put it outside the meatus. The fork is placed on the centre of forehead in the midline. the vestibular and the cochlear components. Fibres from that body go to the medial geniculate body and the auditory radiation to the temporal cortex.054 Performance Guidelines The eighth cranial nerve has two functional parts. but not in conductive deafness. cochlear or brain (perceptive or sensorineural deafness). Hearing the fork louder on bone conduction (BC) indicates conductive deafness (BC > AC). RinneTest The vibrating tuning fork is placed on the mastoid. Afferent cochlear fibres from the inner ear pass through the internal auditory meatus and enter the upper medulla at the level of the inferior cerebellar peduncle to reach the dorsal and ventral cochlear nuclei. bone conduction becomes better than air. ask whether this is louder in one ear or equal. put the fork on the mastoid until no longer audible. Weber test This can be very useful in unilateral deafness. Few people now have a ticking watch. A tuning fork of high pitch (256 Hertz or greater) is used to compare hearing by bone conduction and air conduction. so the examiner stands to the patients side and whispers numbers. So in unilateral conduction deafness Weber test localises to the affected side. Occlude one ear with a finger or ear plug. Alternatively. It is important to note that there are bilateral connections in the cochlear nucleus and above. This excludes other nonacute causes of conductive deafness (such as wax. The most common cause is degenerative changes in the elderly. In nerve deafness the sound is heard better on the normal side. The cochlear branch subserves hearing. chronic otitis media). Hearing should first be tested clinically for each ear with the examiner's finger occluding the other ear. • Establishing type of deafness — conductive versus sensorineural. and the sound will become louder in the affected ear (conductive deafness). or to a lesion of auditory nerve. In nerve deafness air conduction remains better than bone conduction in the affected ear or ears. which are repeated by the patient. The sound will in normal individuals be heard again and will also be heard again in nerve deafness. then at the auditory meatus: and the patient is asked which is louder. retracting the ear upwards and backwards to straighten the canal. Fibres from these nuclei cross to the other side and end in the inferior colliculus. otitis externa. In middle ear/conduction deafness. Other causes include a fracture of the petrous temporal bone and an acoustic neuroma. Conduction deafness is caused by blockage of the ear canal and by damage or disease of the tympanic membrane or ossicular chain or fluid in the inner ear. The meatus. osteomas. in nerve deafness to the normal side. canal and drum are inspected with an otoscope. Air conduction (AC) is normally louder and is also iouder in nerve deafness. Normally air conduction is better than bone conduction. 284 . Sensorineural deafness occurs when there is damage to the cochlear nerve fibres anywhere from the inner ear to the cochlear nuclei. In this instance candidates will be informed that otoscopy is normal. Normally the sound is heard equally in both ears.

The condition is familial (autosomal dominant). Investigation by audiometry will be diagnostic. otosclerosis and Paget disease. or trauma (fracture of petrous temporal bone). drug ototoxicity. Patients may notice they hear more clearly in noisy surroundings. Knowledge of features of otosclerosis is required to identify the likely cause. acoustic nerve tumour. more common in women and worsens with pregnancy so that patients may present during pregnancy. whereas in perceptive hearing loss background noise worsens hearing. otitis media. A hearing aid is less effective for this condition and effectiveness gradually diminishes. as cortical radiations are bilaterally and diffusely represented in the temporal cerebral cortices. The condition can be treated by prosthetic stapedectomy and vein grafting. 285 . The stapes footplate is ankylosed in the oval window. Nerve deafness can be due to cochlear degeneration. Common causes of conductive deafness are wax.054 Performance Guidelines In bilateral conductive or bilateral nerve deafness the sound will be the same. Otosclerosis is a common cause of bilateral symmetrical hearing loss in adults. Unilateral nerve deafness must be due to a lesion of the nerve itself.

EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You dislocated your right shoulder six months ago whilst playing competitive basketball. You were told this was due to a nerve injury. Over the next month the feeling gradually returned and the power in the arm came back.055 Performance Guidelines Condition 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago AIMS OF STATION To assess the candidate's ability to perform a focused examination of the shoulder joint and of axillary nerve function. Near the end of the assessment. and by four months you were able to move the shoulder quite normally. the examiner will ask questions concerning shoulder function and what nerve was originally damaged. Questions to ask unless already covered: • • • • 'Am I able to restart sport in three months. You initially noticed you had an area of numbness (with loss of sensation) the size of your fist over the lateral side of the upper arm below the shoulder tip. Appropriate prompts could be used as follows if the candidate does not provide you with the information you require regarding returning to basketball. The dislocation was reduced successfully without anaesthesia at courtside. doctor?' 'Do I need any other tests done?' 'Would it help if I saw a specialist in Sports ' Medicine?' 'Is it likely to happen again?' 286 . You have resumed fully your normal activities of daily living and are keen to return to playing basketball when the season starts again in three months. Your physiotherapist and gym supervisor feel you are ready to return to this sporting activity but have suggested you get a final clearance from your doctor. and you couldn't raise or keep your arm above your head. You then began a graduated gymnasium programme under the supervision of your physiotherapist. The candidate will give the findings to the examiner and then will discuss things with you. By four weeks you were having active shoulder exercises out of the sling. Your current programme includes weight work and you have a full range of movements without loss of power as compared with the other side. Your shoulder will be examined by the candidate and it is now normal and without discomfort.

CRITICAL ERRORS • Inability to assess adequately the normal range of movement of the shoulder joint.055 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to check: • Range of movement — flexion. adduction. but failing to test for axillary nerve function would be a critical error and generate a fail assessment. particularly of deltoid muscle. or get your coach to do it for you). • 'Which nerve is at most risk from the usual type of shoulder dislocation?' (Axillary nerve). It would be advisable for you to have the shoulder strapped before each game to reduce the likelihood of a recurrence of the problem. extension. and you then should be able to do it yourself. KEY ISSUES • Examination of the shoulder area indicating the appropriate technique to be used to evaluate the shoulder and axillary nerve function. • 'Could you please now finish your discussion with the patient about her desire to return to sport?' (All seems satisfactory for you to return to playing basketball. If the candidate is unable to indicate which nerve is involved. • Failure to test the sensory and motor functions covered by the axillary nerve. the examiner will ask (preferred answers in parentheses): • 'Is shoulder function and movement now normal?' (Yes). 287 . Your physiotherapist will be able to teach you the best method of strapping. There is a small likelihood that the shoulder dislocation will happen again. • Display appropriate counselling skills when advising the patient concerning her desires to return to sporting activities. As knowing the name of the involved nerve is not a "KEY ISSUE" it would not mean a fail mark overall must be awarded. internal and external rotation and circumduction — all will be normal • Power of movement — normal • Scale of muscle power used: ~ 0 = nil ~ 1 = flicker ~ 2 = active movement possible but not against gravity ~ 3 = active movement possible against gravity ~ 4 = active movement possible against gravity and resistance ~ 5 = full power — absence of wasting. After six minutes. a very unsatisfactory mark should be given in the diagnosis category of assessment. abduction. which is supplied by axillary nerve • Sensation — now normal. • Giving inappropriate advice concerning the likelihood of recurrent dislocation.

and the capsule is more lax to allow freedom of full flexion and abduction. The axillary nerve runs between the muscles immediately below the capsule from front to back and is therefore at hazard from stretching injury in shoulder dislocations. and by the rotator cuff musculature that closely envelops the joint.055 Performance Guidelines COMMENTARY A dislocated shoulder is a common injury in body contact sports. just as it is to test sciatic nerve function before and after reducing a posterior dislocation of the hip (the most common hip dislocation). The major weak spot is below. The shoulder joint is the most mobile synovial joint in the human body. It is important to test for the integrity of the vulnerable nerve before reduction is undertaken and afterwards. and supplies sensation as the upper lateral cutaneous nerve of the arm. The common mechanism of dislocation is therefore displacement of humeral head from the glenoid downwards and forwards. The axillary nerve gives motor branches to deltoid and to teres minor. Protection is supplied by the overlying acromion and clavicle. where protection by surrounding muscles is less. 288 .

EXAMINER INSTRUCTIONS The real patients. as various swellings (such as varicocele. with a variety of groin lumps will play themselves. The examination should be thorough but gentle. full examination and definition of all inguinoscrotal lumps is best performed with the patient comfortably lying. The groin area needs to be exposed and the patient examined unclothed below the waist. as small hernias are often made more prominent when standing. Inspection and palpation of the area enable one to answer: • 'Is a groin hernia present?'A groin lump with an expansile impulse on coughing confirms the diagnosis in this case. and to diagnose and advise on management of a reducible groin hernia. • 'Is the hernia reducible?' Check this visually and by feel. The lump is seen and felt to expand uniformly and expansively when the patient coughs. however. saphena varix) may only be apparent on standing. It may be convenient to start with the patient standing. KEY ISSUES • Performance of an appropriately focused inguinoscrotal assessment with appropriate technique and accuracy CRITICAL ERRORS • Failure to display appropriate clinical skills in diagnosis of a reducible groin hernia • Causing significant patient discomfort by rough technique. COMMENTARY Inguinoscrotal lumps are very common and present throughout life from birth to old age. but usually the differentiation is clear. The history of onset of pain following a lifting strain and followed by a lump is very suggestive of a groin hernia. The impulse ceases and the lump lessens or disappears when he relaxes. apprehensive or modest patient it is best to start the examination with the patient lying supine. This lump's relations to the groin land- 289 . Examination with the patient standing should not be omitted. The examiner will check the physical findings prior to the assessment. and the appearance of the lump also supports this diagnosis. The patient illustrated has a reducible right inguinal hernia. Always ask the patient himself to reduce the swelling before you try — in lumps of long standing he will be much more adept than you! • 'Is it an inguinal or femoral hernia?' This question is mainly of concern to the treating surgeon. However.056 Performance Guidelines Condition 056 Assessment of a groin lump in a 40-year-old man AIMS OF STATION To assess the candidate's ability to perform a focused inguinoscrotal assessment. and with an anxious.

Right inguinal hernia CONDITION 056. FIGURE 4. When you feel the impulse it is clear that it is arising from the external (superficial) inguinal ring. Sometimes in obese people it is impossible to be quite sure clinically which type of hernia is present. FIGURE 6. • This patient's hernia is clearly an inguinal hernia. FIGURE 2. It arises from the external ring. FIGURE 7. Large left scrotal hydrocele 290 . Larger right femoral hernia CONDITION 056. CONDITION 056. Left inguinal hernia CONDITION 056. FIGURE 5.056 Performance Guidelines marks with an inguinal hernia are that the swelling is above the inguinal ligament and medially placed in regard to the pubic tubercle. has an expansile cough impulse and reduces on lying down. FIGURE 3. If the lump had come out from the region of the saphenous opening below the inguinal ligament and more laterally (4 cm below and lateral to pubic tubercle) it would have been a femoral hernia. the key to diagnosis. Bilateral femoral hernias CONDITION 056. Right femoral hernia CONDITION 056.

Bilateral direct inguinal hernias CONDITION 056. But if the hernia is a larger one. FIGURE 10. the answer becomes obvious. and the diagnosis is made at operation for hernias confined to the groin alone. The candidate must check that an inguinoscrotal lump reduces completely on lying down — there may in fact be two lumps — a reducible hernia coming down from above and an unreducible scrotal hydrocele below! CONDITION 056. which clearly extends well down into the scrotum. Varicocele 291 . is behind the spermatic cord. These present as small swellings confined to the groin which bulge directly forward through the enlarged external inguinal rings as illustrated. CONDITION 056. FIGURE 9. which is within the spermatic cord. Whereas the sac of a direct hernia. Bilateral large inguinal hernias. which never descends. FIGURE 8.056 Performance Guidelines • 'Is the inguinal hernia direct or indirect?' The brief answer is — often you cannot tell clinically. probably indirect CONDITION 056. Large right indirect inguinoscrotal hernia Patients with chronic obstructive airways disease and a chronic cough often develop acquired bilateral direct inguinal hernias. FIGURE 11. Only indirect inguinal hernias descend into the scrotum by virtue of the anatomy of the sac.

consider treatment. Both right and left sides must be checked — both inguinal and femoral orifices — to check that the hernia is unilateral.056 Performance Guidelines After having arrived at the correct diagnosis (a reducible right inguinal hernia). explaining that the benefits of surgery usually outweigh risks (of which a number exists). So. refer him appropriately. Additionally carefully check the spermatic cords/testes and their coverings to exclude an additional testicular swelling. or epididymal cyst. Feel femoral pulses and check that no abnormal lymph node enlargements are present. Do not forget to stand the patient up to check for venous swellings or small hernias Once a full diagnosis is made. Multiple pathologies are very common. it is likely to be appropriate in this manual worker. Although surgery is not obligatory for all hernias. 292 . the examination is not yet finished. hydrocele.

You have no previous experience of this type of work and in particular. to assess their knowledge of the disease. hand contact. its mode of transmission and measures used to reduce the risk of infection. and the vector of transmission (flies. with classical appearances of trachoma: • describe the agent responsible for the disease (Chlamydia trachomatis).057 Performance Guidelines Condition 057 Eye problems in an Aboriginal community AIMS OF STATION To assess the candidate's ability to interpret photographs of trachoma. • Knowledge and understanding of trachoma. • describe the changes in the photographs: • recognise that the condition is trachoma. and • describe some simple and appropriate measures that might be employed to reduce the risk of infection. EXAMINER INSTRUCTIONS The examiner will have instructed the nurse as follows: You are a trained nurse and have come to work in a small community in outback Australia. You have been in the community for a couple of weeks and have noticed that a significant proportion of the community appears to have eye problems. because of the setting of an indigenous Australian Aboriginal community. and their ability to advise on appropriate management of the condition. Questions to ask unless already covered: • 'Do you think these might all be due to the same problem?' • 'How does the infection get from one person to another?' (if infection is mentioned as a cause) • 'What will happen if the condition is not treated?' • 'Is this condition found anywhere else and how common is it?' • 'Is it preventable9 If so. You have taken photographs of some of these individuals and have brought the images to the community doctor so that you can get a medical opinion on the problems and how they might be managed. • understand the pathological changes produced by the organism. fomites). you have little knowledge of the diseases often endemic in remote Australian Aboriginal communities. 293 . KEY ISSUES • Interpretation of clinical photographs of eye changes produced by trachoma. how can it be prevented?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should be able to: • recognise that eversion of the upper eyelid facilitates diagnosis.

The diagnosis of trachoma is confirmed by the presence of more than 5 follicles. They lead to scarring after multiple attacks (dozens). the tarsal plate becomes distorted and entropion (turning in of the eyelid) develops and this results in trichiasis (misdirection of the eyelashes towards the globe). The scarring effects of infection develop in middle-age. The disease is usually transmitted by direct contact or fomites between children and their mothers. Scarring. which is followed by scarring of the tarsal conjunctiva. Chlamydia trachomatis. infection. Chronic irritation of the globe will lead to corneal abrasions. or others involved in the care of children. easily remembered by the acronym FISTO — • • • • • Follicles. A simplified grading scheme for trachoma which can be taught to and used by community health workers. Recurrent infection will cause chronic conjunctival inflammation. the Middle East. 294 . Inflammation. with inflammatory changes most apparent in young adults. and represent the sites of replication of the causative organism. which ulcerates and becomes infected and scarred. The active disease is usually seen in young children. Trachoma is caused by an obligate intracellular Gram-negative bacterium. was introduced by the World Health Organisation (WHO) in 1987. Candidates should be able to identify the stages of trachoma. The condition was known from ancient times as a contagious disease. and by flies. trachoma is the most common infectious cause of blindness and is a preventable disease.057 Performance Guidelines CRITICAL E R R O R • Failure to recognise trachoma COMMENTARY Globally. blindness. More than six million people are blind as a result of trachoma. Candidates should know that azithromycin is specific for the causative organism Chlamydia trachomatis. when the patients present with trichiasis and corneal opacity. Asia and Aboriginal communities of Australia. It is endemic in Africa. Poor facial hygiene facilitates spread by attracting flies and there are often recurrent bouts of infection within a family. and given the name trachoma (Greek). The resulting blindness is permanent. It is a disease of poverty and the marginalised members of society. As scars mature. meaning a 'rough' swelling. Trichiasis. opacification and finally. and Opacity of the cornea. Follicles are the sign of active trachoma infection. The scarring of the deep surface of the lid distorts the lid and results in lashes rubbing on the cornea.

at least one eyelash rubbing on the globe. 7) The candidate should be able to discuss public health measures.057 Performance Guidelines Grade Definition TF Five or more follicles seen on the tarsal conjunctiva of the everted upper lid. 4. • Surgery: identification of individuals in the community who might benefit from correctional eyelid surgery for trichiasis and entropion. or evidence of recent removal. 295 . Some practical advice for a community nurse would be along the lines of the SAFE strategy. (Figures 1. (Figures 3. Additional trachoma examples are shown below. obscuring the view of more thanhalf of the deep tarsal blood vessels on the everted upper eyelid. Improved cleanliness in sleeping areas with fly and dust control should be emphasised. Upper eyelid eversion to inspect for follicles facilitates early diagnosis. need to be educated about the disease. 4. and particularly affected families. personal and community hygiene will reduce the risks of infection. (Figures 3. obscuring at least part of the pupil margin. its mode of spread. (Figure 2) TT Trichiasis. 7) CO Corneal opacity. 5) Tl Intense inflammation of the upper tarsal conjunctiva. • Environmental upgrade: any improvement in water supplies. • Antibiotics: children should be examined (with eversion of the upper eyelid) for trachoma and all members of a family where there is active trachoma should be treated with oral azithromycin • Facial cleanliness communities. and that simple measures such as ensuring facial cleanliness will reduce the risk and severity of trachoma. (Figure 6) TS White lines of subconjunctival scarring visible on the surface of the everted upper eyelid. household sanitation. developed by the WHO.

FIGURE 7.057 Performance Guidelines CONDITION 057. Inflammatory follicles on the under surface of the upper tarsus (TF) in closeup CONDITION 057. FIGURE 6. Entropion with trichiasis (TT) and corneal opacification (CO) 296 . Inflammatory changes on the everted upper eyelid (Tl) CONDITION 057. FIGURE 5.

he must be in a position to put the right questions and to find the right methods for answering them.2-C: Choice and Interpretation of Investigations Reuben D Glass and Vernon C Marshall 'It is not of decisive significance whether the clinician confronts an overwhelming or a modest amount of material. TEST RESULTS AND THEIR IMPLICATIONS 297 . Major growth of special investigations has occurred in the fields of laboratory medicine and in organ imaging. but this is The test sensitivity is the percentage of patients k n o w n t o h a v e a usually not true. and must be alert to the possibility that an opinion given by another (or the data issued by a machine) is not always absolutely reliable and may occasionally be wrong. Clinicians sometimes make the same mistake. If the test result will not alter the patient's management. hearing and touch are used in making diagnoses and in formulating strategies of management. Previously. or potentially dangerous. redundant. Patients often assume that when a test is ordered. A frequent error is to suppose that a given test is equally useful for confirming or excluding disease. but this is usually not true. or helping to exclude the possibility of a disorder. profitable. if only he understands how to exploit it: in other words. The clinician who orders a test should always be mindful of the reason for its use. and to help in their choice and interpretation. More often. If the test result k n o w n t o b e f r e e of the disease. it will answer whether disease is present or not. useful. there is little point in ordering it. A test may be useful for helping to confirm. but will seldom give a perfect answer. mindful of the reason for The test specificity is the percentage of patients in that population its use. in whom the test proves negative will not alter the patient's { t r u e n e g a t i v i t y ) The down side of high specificity would be a high management. This short introduction aims to give a general idea of the circumstances in which special investigations are essential. Investigations play an increasingly important (though still not all-important) part in the practice of medicine. Life and Man Modern medicine relies considerably on the results of special investigations. one must compare the accuracy of several available tests to determine which is best. whose test proves positive ( t r u e p o s i t i v i t y ) The clinician who orders a down side of high sensitivity is a potentially high false positivity rate: test should always be the proportion without the disease who also test positive. the traditional stock-in-trade of the astute clinician has been the manner in which his unaided clinical senses of observation. The clinician in such instances often assumes the role of consumer. A frequent error is to suppose that a given test is equally useful for The performance of a test may be studied in a survey of a particular confirming or excluding population. disease. there is false negativity rate: the proportion with the disease who also test little point in ordering it. The histological diagnosis of cancer is the usual yardstick against which the performance of another less invasive test is measured. Diagnostic accuracy of any test will depend upon how well it performs in comparison with its performance against another so-called 'gold standard'. however.' Rudolf Virchow (1821-1902) Disease. But times and clinical practice have changed. The particular disease. Sensitivity and Specificity negative.

there is a very low chance that this negative result will give false reassurance (0. which need to be adapted for clinical use. the clinician wishes particularly to know the predictive value of the test: that is. which in example 1 which in example 1 which in example 1 which in example 1 is 18/ 38 is 960/ 962 is 20/ 38 IS 2/962 = 47% = 99. It has a lower sensitivity (90%). there is a very high likelihood that disease is absent (99. and is much less useful in confirming disease. Predictive values In considering individual patients with unknown disease status on presentation.000 patients affected with a disease. Results SECTION 2-C.8% = 53% = 0. Negative Predictive Value is the proportion testing negative who in fact do not have the disease. 298 . Test results in 1. Disease Present Test Positive Test Negative Total: 18 2 20 (a) (c) (a+c) Disease Absent 20 960 980 (b) (d) (b+d) Total 38 (a+b) 962 (c+d) 1.2-C Choice and Interpretation Investigations of The following examples explore these concepts: Example 1 A group of 1. Conversely. TABLE 1.2% false reassurance rate). (The false negatives comprise the 'false reassurance rate'). If it gives a negative result. and thus is very helpful in excluding disease.8% negative predictive value). (The false positives comprise the 'false alarm rate').000 patients is tested for the presence of a certain disease (Table 1 ). the likelihood of a positive or negative test confirming or excluding the disease. It misses 10% of cases with the disease and is more likely to be positive — and thus gives a false alarm — in patients without the disease (53%) than in those with the disease (47%). • • Positive Predictive Value is the proportion of persons testing positive who actually have the disease.2% The clinical interpretation of the test may be given as: The positive predictive value is a/(a+b) The negative predictive value is d/(c+d) The false alarm rate is b/(a+b) The false reassurance rate is c/(c+d) Implications: This test has a high specificity (98%). Sensitivity and specificity are epidemiological measures.000 (a+b+c+d) The sensitivity is a/(a+c) which in example 1 is 18/20= 90% The specificity is d/(b+d) which in example 1 is 960/980=98% Results of research studies are often presented in this way.

which will require further assessment (endoscopy) of those identified with a positive result. In colorectal cancer. This will increase the number of false positives and create anxiety for a greater number of patients who would subsequently be worked up to decide whether the test was truly positive for prostate cancer. As there is overlap between the values in healthy and diseased patients. and at high levels the risk of prostatic cancer being present is increased. This should not be confused with disease incidence: the number of new cases of the disease occurring in the population over a set time interval). Faecal occult blood testing for bowel malignancies is another example of a test with a relatively high sensitivity but poor specificity. In the highly specific test on individuals picked up by the sensitive screening test. in screening tests for prostate cancer. Biochemical tests are based on results from a healthy population sample. The ideal test should also be absolutely specific (the converse of sensitivity) — all people within the test group who do not have the condition will give a negative result. If a test had a sensitivity of 1 and a specificity of 1 its probability of error would be zero. Laboratory reports often imply that results falling outside two standard deviations from the mean are 'abnormal'. Implications: A highly sensitive test is an appropriate one for screening a population for an abnormality. can subsequently be taken care of by applying to the identified group a further test which is highly specific (but not so sensitive). and positive and negative predictive values would be 100%. The test has a range of levels. one in 20 healthy individuals would fit this category. Such reports should be treated with caution. a faecal occult blood test will not detect neoplasms which do not bleed. 299 . Reducing the cut-off level of the test to 2 ng/mL would increase the test sensitivity but reduce the specificity. No test absolutely measures up to all these ideals. The sensitivity is determined also by the biology of the condition. The fact that the test is not absolutely specific for the abnormality but also identifies a number of individuals. a positive result will effectively give a definite diagnosis. A negative result in a highly sensitive test will effectively rule out the diagnosis. It should be highly reproducible: the error within and between observers should be very low. as by statistical definition. Unfortunately. In such tests. Other relevant aspects of testing are the frequency and importance of a disease and its duration and natural history. specificity and sensitivity are likely to be inversely related. as they depend on the prevalence of the disease in the population (Disease prevalence: the number of people with the disease in the test population at the time of testing. In the prostatic example above the subsequent test would be a tissue biopsy confirming cancer.2-C Choice and Interpretation of Investigations The ideal test should have absolute sensitivity — all people within the test group with the condition will give a positive test result.). benign prostatomegaly etc. who are normal or have some other condition. measures of predictive value have limitations in clinical practice. the choice of a cut-off point between a positive and negative test result is artificial. With such an ideal test there would be no false positives and no false negatives. The ideal test should also be attended by a very low level of random or systematic errors of measurement. These results will usually have a Gaussian normal distribution bell-shaped curve pattern when plotted. a serum prostate specific antigen (PSA) level of 4 ng/mL is frequently used as the cut-off level. For example. A similar spread of results is obtained when examining patients with a particular disease. At lower levels more patients will be identified who have a condition other than prostate cancer (prostatitis.

the negative predictive value has increased to almost 100%. were spread about a population 10 times the size (10. TABLE 3.000. Test(T) Needle core biopsy Needle core biopsy Positive for cancer Needle core biopsy Negative for cancer Total Patients with cancer subsequently confirmed (D positive) 143 a 15 c Breast cancer 158 Patients found free of cancer subsequently (D negative) 2 b 440 d Benign Conditions 442 Total 145 455 600 300 .2-C Choice and Interpretation of Investigations The utility of a test is influenced by population differences. Suppose the same number of affected patients (20) with the disease illustrated in Example 1 in a population of 1.000 patients in a region of lower disease prevalence.2% (Table 2) Example 2 SECTION 2-C. Test results in 10.980 (b) (d) (b+d) Total 218 (a+b) (c+d) 9. TABLE 2. SECTION 2-C.000 — Example 2. Disease Present Test Positive Test Negative Total: 18 2 20 (a) (c) (a+c) Disease Absent 200 9.2% (compared to a prevalence of 2% in Example 1 ). with a disease prevalence of 0. Table 2): The prevalence of the disease is (a+c)/ (a+b+c+d) which in Example 1 is and in Example 2 is 20 1000 20 10000 = 2% (Table 1) =0. while the positive predictive value is now only 8%.782 10.000 (a+b+c+d) The test sensitivity (90%) and specificity (98%) are unchanged in Example 2 from Example 1 However. The predictive value of a positive test depends on the frequency of disease in the population Example 3: breast cancer evaluation The following table gives results of a highly specific test (T: needle core biopsy) performed in 600 women showing focal mammographie abnormalities. in this larger population.780 9. to diagnose or exclude the worst case disease (D: breast cancer). Test results for 600 women with focal mammographie abnormalities.

is a method of separating the characteristics of a population from the inherent value of a test. Likelihood ratios and scoring systems Use of likelihood ratios. This can be expressed mathematically as prevalence probability (a+c)/(a+b+c+d).2-C Choice and Interpretation of Investigations Sensitivity of test (true positivity) Specificity of test (true negativity) False Positivity Rate False Negativity Rate Positive Predictive Value Negative Predictive Value False Alarm Rate False Reassurance Rate Prevalence of breast cancer in test population Implications: a/( a+c) d /(b+d) b/ (a+b) c/( c+d) a/( a+b) d/(c+d) b/(a+b) c/(c+d) (a+c)/( a+b+c+d) 143 /158 440/ 442 2/ 145 15 /455 143/145 440/455 2/145 15/455 158/600 91% 99% 1% 3% 99% 97% 1% 3% 26% Positive and negative predictive values are seen to be strongly affected by the characteristics of the test (sensitivity and specificity) and by characteristics of the population (disease prevalence). 301 . or [(a)/(a+c)]/[(b)/(b+d)]. which may be considered as measuring the 'leverage' of a test. In assessing the result of a test. The likelihood ratio of a positive test is the frequency of a positive test in disease compared with its frequency without disease. after preoperative false reassurance. or (a+c)/(b+d) The usefulness of a test is measurable by the likelihood ratio. or more usefully here as 'prior odds'. Here 26% of those showing focal abnormalities on mammography (the original screening test) ultimately proved to have cancer. Core biopsy had very good (99%) positive predictive value. but not quite so good (97%) negative predictive values. the clinician should have an idea of the possibility of disease in the population. or approximately 50. The value in example 1 is thus [(18/20)]/[(20/980)]. which is the ratio comparing the number of patients with disease to the number of patients without disease. A small but not insignificant group (3%) had cancer found at operation done to remove the mammographie abnormality. the clinician may follow the following thought process: Depends on population Depends on test characteristics Before performing a test.

Now that the transplantation of cadaveric tissues has become a clinical reality. the unequivocal early diagnosis of brain death has demanded diagnostic tests of scrupulous and unparalleled stringency. 1 Glass. R. rather than the multiplication of odds and ratios. the likelihood ratio (negative) is the frequency of a negative test without disease. compared with a negative test in disease. compared with absent: In example 1. As will be seen in the book example relating to brain death. Oxford University Press. or chances that disease will be present. In example 2. In example 1. the prior odds of no disease were approximately 500:1. Relatively simple clinical problems can all too easily become lost sight of in the maze created by multiple investigations.02 x 50 = 1. If the test is negative. or [ d / ( b + d ) ] / [ c / ( a + c ) ] . revised odds are 0. Australia.. the revised odds against disease. where the prior odds of no disease were 50:1. especially in an ageing population. While some believe that addition of 'weights' in this way may parallel the clinician's thought processes more closely.e. Various scoring systems have been proposed. are now 500:1. Most disturbing of all is the prospect of a mistake in the distinction between life and death. This is not the reciprocal of the likelihood ratio (positive). it is almost inevitable that one or more will be reported as positive.002 x 50 = 0. revised odds are 0. Test Error The possibility of error in any test must thus always be considered. given a negative test. using addition of mathematically derived scores. Another important factor is that multiple deviations from normality are common in any individual. Implications: It should be noted that the likelihood ratio often has a different value for a positive or a negative test.2-C Choice and Interpretation of Investigations Multiplying the prior odds by the likelihood ratio gives revised odds. and because procurement of such tissues within a short time of death is essential to success. the likelihood ratio (negative) is [(960/980)/(2/20)] or approximately 10. In that example. if multiple diagnostic tests are applied to a given patient in a mindless scattergun fashion. the prior odds are 20/980. important or unimportant. 1:1 or a 50:50' toss-up. USEFULNESS OF TESTS1 The more tests that are performed on a patient the more likely it is that one or another will give a falsely abnormal result by pure chance. i. which follow a similar logic. or approximately 0. Di ag n os i s : a bri e f i n tr od ucti o n . These positive results may be true or false.002 in favour of disease (or 500:1 against). relevant or irrelevant to the patients problem. the prior odds are 20:9980 or 0.01 in favour of disease (or 10:1 against).D.02 in favour of disease (or 50:1 against). 1996 302 . a test will not be equally useful for confirming or excluding disease. So. In example 2. the revised odds are now 5000:1. note that virtually all the tests for brain death involve direct observation of the patient by at least two experienced clinicians rather than the application of potentially imperfect technologies. these systems have not been widely adopted.

Clinical examination was noncontributory. • the test's cost and availability. above the right kidney. The mass had smooth borders and appeared well encapsulated without any evidence of infiltration of surrounding structures. extrinsic to the posteroinferior right lobe of the liver. solid mass within the right adrenal gland. and to the right of. The left adrenal was normal and no other intra-abdominal mass or pathology was noted. which had resolved after four hours. inferior to the liver. FIGURE 1. and in the position of the right adrenal gland. (Figure 1 ) SECTION 2-C. and • whether the outcome of the test will influence the management of the patient's complaint.2-C Choice and Interpretation of Investigations Diagnostic utility of a particular test is thus determined by: • the prevalence and importance of the condition tested for. and superomedial to the right kidney. the inferior vena cava. 303 . (Figure 2) The mass was confirmed to be a focal 5 cm round. Case Example The following case study demonstrates the optimal integration of morphologic and functional imaging and biochemical investigations with diagnostic and management plans and pathways in a patient with an unexpected incidental finding on initial investigation. • the diagnostic accuracy of the test and how it compares to that of other well established tests. Ultrasound findings An abdominal CT was next done to delineate more accurately the pathology. and lateral to. An abdominal ultrasound was ordered with a provisional diagnosis of gallstones and associated biliary pain. A 66-year-old man presented to his general practitioner after an episode of right upper quadrant abdominal pain. The ultrasound showed a normal gall bladder and biliary system free of stones. • the invasiveness of the test and the risk to the patient from its performance. but revealed a focal round solid mass 5 cm in diameter. Intravenous and oral contrast material were used to enhance imaging.

both in their 80s. His father died of a stroke and his mother of gastric cancer.2-C Choice and Interpretation of Investigations SECTION 2-C. chest pain. There was no family history of hypertension. and were associated with thumping and pounding in his chest. The experienced clinician recognised that such a pattern would be consistent with catecholamine surges produced by an adrenal medullary tumour — a phaeochromocytoma. No such family history was obtained here. For the last 8 years he had noticed 'funny turns ' episodically. or was It an 'Incidentaloma '? Small benign adrenal adenomas of no clinical relevance are very common in patients of this age. These caused him to feel dizzy and nauseated. with associated parathyroid hyperplasia (C cells) and medullary thyroid cancer. but are mostly less than 2 cm in diameter. Removal is often advised for larger tumours even it nonsymptomatic. 304 . His prostate felt normal on rectal examination. Further detailed history with focused questioning was helpful. He had a past episode of a bleeding peptic ulcer 30 years ago (duodenal ulcer is associated with phaeochromocytomas) and minor symptoms currently of urinary hesitancy. Computed tomography (CT) of abdomen Was this adrenal mass relevant to his symptoms. and clinical examination of neck was normal as was the serum calcium level. and a throbbing in his head thai lasted for several minutes. FIGURE 2. He was referred for specialist opinion. This one is larger (5 cm) and masses of 5 cm or above are more suspicious of malignancy. Family history can be important in phaeochromocytomas associated with multiple endocrine neoplasia Type 2. dyspnoea or sputum and did not smoke (adrenal metastases from lung or other primary sites need to be remembered). He had no cough.

• Adrenal sex hormones from adrenal cortex: these may give virilisation in women. no hypertension. A battery of screening tests was ordered. The advent of nuclear medicine has enabled accurate preoperative functional imaging to confirm one or multiple sites precisely. or for adrenaline and noradrenaline themselves (normally 80% adrenaline and 20% noradrenaline). Open surgery required large incisions. • Mineralocorticoids from adrenal cortex: aldosterone excess (Conn syndrome). together with hypokalemia. This seems most likely from the history. Urine 24 hour analyses for excretion of adrenaline and noradrenaline were done in this case and were markedly elevated. although his blood pressure was normal on review. no evidence cardiac ischaemia no ventricular hypertrophy normal no abnormalities mild elevation • Specific urinary catecholamine excretion analysis can be for end products (VMA — vannylmandelic acid). a check for aldosterone effects was also done measuring plasma aldosterone. adrenaline 720 mmol/day (5-80). 305 . with high levels of both noradrenaline and adrenaline — noradrenaline 1160 mmol/day (45-600). Hypertension is the common association here. no body fat redistribution. 10% are at extra-adrenal sites. major surgical dissection of hazardous tissue planes. Hydrocortisone (Cortisol) levels were also normal. • Catecholamines from adrenal medulla (adrenaline and noradrenaline): phaeochromo-cytoma. and in the presacral area around the great vessels. • Full blood examination • Cardiovascular status • Echocardiogram • Electrolytes • Coagulation studies • Blood glucose normal. but the opposite adrenal always needs to be excluded as a source. There were no stigmata of hypercortisolaemia clinically — no moon face. as well as standard preoperative screening tests. As adrenal tumours may produce more than one hormone. It is designated the 10% tumour — 70% are bilateral. 10% are malignant. and inpatient stays of up to 2 weeks. and Conn and Cushing syndrome excluded. Modern endocrinological tests have high specificity and sensitivity.2-C Choice and Interpretation of Investigations The range of endocrine overactivities from an adrenal tumour can involve singly or in combination: • Glucocorticoids from adrenal cortex: Cortisol excess (Cushlng syndrome). Extra-adrenal tumours secrete noradrenaline only and are almost always associated with hypertension. All were within normal range. the urinary bladder. renin activity levels. and aldosterone/renin ratio. Thus the three most common adrenal tumours each can cause secondary hypertension. Hb 151 g/L ECG sinus rhythm. the retroperitoneum down to the pelvis. But was the tumour only at one site? Phaeochromocytoma often causes attacks of episodic hypertension only and can be at multiple sites. Initial screening urinary or serum analyses are most reliable following an episode of symptoms but do not of course localise the site of origin. Functional endocrine investigative studies were arranged. no cataracts. However hypertension may be episodic. The diagnosis of right adrenal phaeochromocytoma was thus definitively established. extended open laparotomy was required to check fully for other abdominal sites — the opposite adrenal. His electrolytes were normal. Previously. particularly with phaeochromocytoma. Again hypertension is a common association.

Only very large tumours. or evidence of tumours at multiple sites are contraindications to a laparoscopic approach. Laparoscopic surgery is particularly applicable to well localised functioning adrenal tumours. The test is specific and sensitive. Preoperative elective catecholamine blockade over a period of 1-2 weeks has now virtually eliminated the hazard of operative adrenal crisis due to a catecholamine surge with life-threatening hypertension. 306 . Excellent views are obtained. is injected. Adrenaline and noradrenaline stimulate a and /3 (vascular and cardiac) receptors. Functional nuclear scan for catecholamines. which is taken up by catecholamine precursors. Preparation of the patient for surgery now began. The operation was uneventful with removal of the right adrenal and its contained tumour. malignant tumours. Initial a-receptor blockade was begun with phenoxybenzamine.2-C Choice and Interpretation of Investigations Final investigation: Radionuclide localising scan Metaiodobenzylguanidine scan (MIBG): A radioiodine labelled agent (MIBG). followed by (1-receptor blockade (propranolol) after a-blockage had occurred. During surgery nitroprusside and phentolamine should be available to control bleed pressure swings precisely. SECTION 2-C FIGURE 3. separation of the tumour from major adjacent vasculature is facilitated. and rapid convalescence ensured. showing hot spot below liver on right The scan confirmed a single hot area at the site of the right adrenal with no activity in the left adrenal or elsewhere. His convalescence was straightforward with discharge from hospital within 2 days of surgery. Abdominal scintigraphy will localise the functioning tumour as illustrated (Figure 3). required hospital stay is reduced.

These can provide highly specific and highly sensitive identification of glycosuria. proteinuria. haematuria and other abnormalities. is non-invasive and effectively free from risk. and radionuclide tests. biliuria.2-C Choice and Interpretation of Investigations SECTION 2-C. Observer error has been reduced to a minimum by the development of user-friendly dipsticks. Modern technology has enhanced rather than diminished the utility of urinoscopy/urinalysis in diagnosis. Blood glucose fingerprick analysis. Urinary positivity for glucose will depend upon renal threshold. FIGURE 4. Temperature recording is easily performed and inexpensive. Medieval manuscripts used depictions of inspection of a urine flask (urinoscopy) as a convenient symbol of the medical practitioner — a convention based on clinical reality at the time. An elevated random blood glucose level over 11 mmol/L will effectively confirm the diagnosis of diabetes. 307 . It is a cost effective test that can and should be applied to almost all clinical problems. leading to precise diagnosis and focused surgery with every expectation of complete cure. Adrenalectomy specimen Diagnostic utility was appropriate in this instance for each of the carefully planned sequential investigations across a spectrum of imaging. Urinalysis This shares many of the performance characteristics of temperature measurement and can be applied at minimum cost to virtually all clinical patients. but very low in specificity. OFFICE TESTS USED IN PATIENT ASSESSMENT Body Temperature Measurement This test illustrates many of the points discussed. can be done accurately. it is extremely sensitive. biochemical. now also readily available by user-friendly office instruments (glucometer). The test is thus an excellent all round screening measure. In terms of detecting abnormality. Glycosuria and glycaemia here serve as complementary screening and diagnostic tests — high sensitivity screening augmented by specific diagnostic testing. A significantly elevated body temperature indicates (in the absence of factitious malingering) an organic inflammatory or infective ailment. allows rapid identification of hyperglycaemia and can often establish the presence of diabetes.

aiding diagnosis of peripheral arterial insufficiency. particularly if accompanied by menstrual irregularities. In many clinical consultations with women of childbearing age with abdominal pain. involves mammography. and other programmes. or venous obstruction and incompetence. The additional requirement of cost-effectiveness in achieving such goals often requires years of prospective study. Electrocardiograph/electrocardiogram (ECG) Previously a quite sophisticated test. measurement of blood pressure and serum lipids. The ultimate goal of such screening programmes is to diminish mortality by early detection of diseases. colon) and cardiovascular disease (coronary artery disease and stroke).2-C Choice and Interpretation of Investigations Urine tests for pregnancy diagnosis Another very widely used urinary test for office or home use. ECG is now increasingly available for on-the-spot office consultation and provides sensitive and specific information regarding cardiac rate and rhythm and cardiac function. complementing cardiologie history and examination. a spot urinary pregnancy test is prudent and often diagnostically helpful. Urine tests for diagnosis of ovulation time Home monitoring of urinary luteinising hormone (LH) antibody from 17 days before the expected period can detect the LH surge indicating that ovulation will occur within 24-36 hours. is urinary detection of human chorionic gonadotrophin (hCG) using monoclonal and polyclonal antibody test strips. arteriovenous shunting. In the wards they can aid physical examination to detect a full or empty urinary bladder in postoperative patients. 308 . Sensitivity and specificity progressively increase thereafter as the pregnancy progresses. plus the prevalence and importance of the disease in the community. Positive testing for pregnancy can occur from the first day of the missed period with a sensitivity of 25 mu/ml. used in our community to identify common life-threatening diseases (cancer of breast. The effectiveness of these programmes is determined by sensitivity and specificity of the tests employed and their cost. which gives results within a few minutes. faecal occult blood examination. Mass screening of populations. or by detecting persons who are at high risk of developing disease and introducing preventive strategies. Ultrasound/Doppler probes Hand held battery-operated ultrasound probes can be used to more accurately identify arterial or venous blood flow.

Of the many other causes. can be investigated by plain or contrast X-ray. isotope studies. migraine or cervical dysfunction/spondylosis. Plain X-rays will exclude serious bony lesions and may give evidence of soft tissue pathology. Contrariwise in patients with chronic low back pain. The place of investigations is confounded by the facts that degenerative change in discs and facet joints which could be associated with symptomatic pain are found in a significant proportion of nonsymptomatic individuals. Upper abdominal pain which is less urgent. but CT (or nowadays and increasingly. warning flags should be looked for in the clinical assessment to exclude temporal arteritis. With acute abdominal pain. Precise anatomical or pathologic diagnosis is often not possible. and leads directly to diagnosis and management of such causes as acute abdominal aortic aneurysm rupture. In this case surgery is the major and most urgent investigation.2-C Choice and Interpretation of Investigations USE OF INVESTIGATIONS IN CLINICAL PROBLEM-SOLVING: CHOICE OF INVESTIGATIONS Tests used to aid clinical diagnosis of the patients presenting problem should utilise discriminative strategies rather than the cumulative strategy of performing more and more tests in the hope that something will turn up. especially those aged over 40 years. and again MRI is likely to be more sensitive and specific. CT head scan is only required in the minority of instances. Chronic and recurring headaches are most usually due either to tension headache. Tests used discriminatively and with appropriate perception and perspective will enable the diagnostic process to move along appropriately focused lines to best advantage. Data collection from focused history and physical examination leads to the discriminative clinician asking the questions: • What is the patient's presenting condition? • What is the diagnosis? • What else could it be? • Have I enough certainty to stop testing and go on to treatment? • If more tests are required which are the best and in what sequence. no significant organic pathology is demonstrable in around 30% of patients. acute headache is often part of an upper respiratory tract infection presentation associated with other symptoms of general loss of well being. in diagnosing headache. MRI scanning) gives the most accurate assessment of soft tissues. endoscopy. subarachnoid haemorrhage and cerebral tumour. but ultrasound is usually the investigation of first choice in acute or chronic shoulder pain following injury. CT or MRI together with a host of biochemical and other laboratory tests. or chronic. However. A persisting headache is also an associated symptom secondary to a wide range of other conditions. when an intracranial lesion causing cerebral compression with increased intracranial pressure is suspected. Ultrasound is of limited use in spinal pain. If gallstones are thought to be the most likely pathology causing abdominal 309 . and despite its expense the latter investigation of MRI is usually the preferred investigation in chronic spinal pain. ultrasound is very observer-dependent. Low back pain and neck pain are most often due to temporary soft tissue musculo-ligamentous strains ('nonspecific mechanical back pain'). a small group of patients with a catastrophic syndrome of 'acute abdominal surgical emergency' requires urgent surgery with minimal preoperative investigations. ultrasound. and acute ischaemic strangulation of bowel. and over what time interval? For example. where the prevalence is likely to be at least 30%.

310 . displays the gallbladder wall and contents as well as the bile duct system and picks up many associated or alternative diagnoses (particularly in liver. a member of l-MED/MIA Network. The use of combined noninvasive modalities such as helical CT or magnetic resonance cholangiopancreatography (MRCP) can now provide high sensitivity and specificity with high resolution imaging. CT Angiography 2 Figures reproduced by permission of MIA Victoria. MSCT allows greater information to be gained due to the thinner multiplanar slices acquired. pancreas and spleen). kidneys. which can be reviewed in multiple planes or in three dimensions to give superbly detailed images as illustrated (Figures 5-9). Angiography SECTION 2-C. FIGURE 8. Ultrasound is noninvasive. SECTION 2-C. Spine Extremity Abdomen SECTION 2-C. FIGURE 9. SECTION 2-C. endoscopy is usually the best initial investigation and aided by biopsy can distinguish benign from malignant lesions. FIGURE 7.2-C Choice and Interpretation of Investigations pain ultrasound is the most appropriate first investigation. FIGURE 5. can be used both in emergency and elective situations.2 SECTION 2-C. Newer techniques such as multi-slice CT (MSCT) are becoming the examinations of choice for assessment of various body systems and organs. If peptic ulcer is thought most likely. Pain thought to arise from the pancreas is likely to require early CT. A Guide to Multi-Slice CT Scanning. FIGURE 6.

or subcutaneous lymph node swellings. Accurate cytology can point the way to a further appropriate sequence of diagnostic investigations.2-C Choice and Interpretation of Investigations In patients with jaundice. If the lump or skin lesion is clinically suspicious then the definitive investigation is often histological examination of an operative specimen. liver function tests are usually of limited value in diagnosing the cause of the jaundice. or by finding a papillary thyroid lesion in neck lymph nodes. Aspiration cytology gives cytological rather than histological diagnosis. In the examples which follow. Finally core biopsy by percutaneous needling is widely used and is the preferred diagnostic method for solid breast lumps and other deeper lumps where tissue diagnosis is required. Primary growths of pharyngolarynx and thyroid can be small and occult in association with larger nodal metastases. candidates should exercise care in the choice and interpretation of investigation in order to direct and focus diagnostic and management pathways. but they provide information which must be taken into account in formulating further diagnostic and management plans. in many instances no investigations are required and an accurate diagnosis can be obtained from the clinical history and examination. Ultrasound and helical CT or MRCP comprise investigative mainstays. Preliminary diagnostic investigations are often done to determine more accurately the physical nature of deep lumps. For focal subcutaneous lumps and focal skin lesions. Colonoscopy is preferred to diagnose mucosal lesions. Reuben D Glass and Vernon C Marshall 311 . Patients with suspected bowel pathology can be investigated either by radiology or endoscopy. Ultrasound can differentiate between cystic and solid lesions. Important investigations prior to surgical management include blood coagulation tests and tests of renal function. while CT or MRI will give more precise diagnosis. Once the decision is made that microscopic examination is necessary. but using flow cytometry and assessing surface receptors to differentiate subsets of T and B lymphocytes can diagnose and differentiate polyclonal and monoclonal lymphomas. as discussed in Section 4-A. Cytological studies may also demonstrate the likely origin of metastatic lesions by finding squamous neoplastic cells in a lymph node neck swelling. fine needle aspiration cytology (FNAC) is often a highly specific test. particularly for patients presenting with breast lumps (palpable or picked up by imaging).

2-C Choice and Interpretation of Investigations 2-C Choice and Interpretation of Investigations Candidate Information and Tasks M CAT 058-064 58 59 60 61 62 63 64 Positive test for hepatitis C in a 26-year-old woman Diagnosis of 'brain death' prior to organ donation Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer An elbow injury in an 11-year-old schoolgirl Sudden onset of chest pain and breathlessness in a 20-year-old woman Atypical ureteric colic in a 25-year-old man Investigation for male factor infertility in a 25-year-old man 312 .

The Performance Guidelines for Condition 058 can be found on page 321 313 . YOUR TASKS ARE TO: • Take a relevant history from the woman. • Advise her about subsequent management and likely prognosis. Your next patient is a 26-year-old woman who has been sent to see you because she was tested for hepatitis B and C and for HIV when she attended the Red Cross blood bank as a blood donor one week previously and was found to be hepatitis C positive. She has just been notified that she was found to be hepatitis C positive and advised to see her local doctor for further assessment.Candidate Information and Tasks 058 Condition 058 Positive test for hepatitis C in a 26-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. and had not been tested for any of these infections previously. She had never given blood before. Other blood tests were negative for both hepatitis Band HIV.

The Performance Guidelines for Condition 059 can be found on page 325 314 . The teacher has heard about 'brain death' and found the protocol below on the internet and printed it out. Next week a doctor from the Australian Kidney Foundation is going to speak at a class seminar to all the Year 11 students about organ transplantation and the donation of organs and tissues from donors who have died. Your next patient is a secondary school science teacher. Absent pain response in cranial nerve distribution 4. Vestibulo-ocular reflexes absent (no nystagmus) 7. Absent corneal reflexes 3. hypopituitarism • PaC02 > 50 mmHg ▪ No hypoglycaemia TESTS 1. Oculocephalic reflexes absent (no 'dolls' eyes' response) 6. He wants you to explain it to him in understandable language to help him comprehend the implications and facilitate his chairmanship. The teacher is to chair the seminar which has been titled The Gift of Life'.Candidate Information and Tasks 059 Condition 059 Diagnosis of 'brain death' prior to organ donation CANDIDATE INFORMATION AND TASKS You are working in a general practice. TABLE 1. PREDETERMINED CRITERIA BEFORE TEST • Core body temperature > 35 °C • No central nervous system (CNS) depressant drugs for > 48 hours (longer if CNS depressants given in large amount or for a long time) • No neuromuscular blocking drugs for > 12 hours • No endocrine problems. BRAIN DEATH Diagnosis to be made by two doctors independently including the intensive care consultant. Neither will be a member of the transplant team where organ donation is considered. Absent gag reflex on endotracheal tube movement 5. Pupils fixed and unresponsive to light 2. Arterial blood gases taken at 5 and 10 minutes. The results of examination must be recorded in the case notes or a suitable devised form. CONDITION 059. eg hypothyroidism. Brain death protocol. No spontaneous respirations after 10 minutes (patient ventilated on 100% oxygen at a rate of 4 breaths/min with a tidal volume of 7 mL/kg). Two groups of tests. YOUR TASK IS TO: • Discuss the subject with him and respond to his queries. preferably separated by 24 hours.

YOUR TASK IS TO: • Discuss her concerns with her and advise her on the future management you would propose. You ordered an ultrasound of the breasts in this young woman. also a patient of the clinic. surgery would not be required. You referred her to the female surgeon who treated her mother. She is worried that the lump may be malignant or will become so. and she could be observed clinically with periodic ultrasound assessments. had a Stage 1 breast cancer treated by mastectomy and axillary dissection five years ago and is well on follow up. The patient was also reassured that if this showed. She had no previous history of breast problems. Physical examination of the breasts was normal. and feels that just taking a piece of it will leave her still worried. which showed an impalpable. as expected. a benign lesion. The patient is unhappy with this advice and feels she would like the lump removed and has come back to you to discuss this further. Her 50-year-old mother. focal well-circumscribed solid parenchymal lesion in the right breast 1 cm in diameter consistent with a fibroadenoma. The Performance Guidelines for Condition 060 can be found on page 329 315 . who suggested an ultrasound-guided percutaneous core biopsy to confirm the imaging diagnosis of benign fibroadenoma.Candidate Information and Tasks 060 Condition 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer CANDIDATE INFORMATION AND TASKS Your next patient for office consultation in a primary care community practice clinic is for review of a 20-year-old single woman whom you saw four weeks ago with a complaint of cyclical mastalgia for the last six months.

You arranged for X-rays which have been taken and are shown below. The Performance Guidelines for Condition 061 can be found on page 331 316 . The elbow region was swollen. FIGURE 1. CONDITION 061. CONDITION 061. FIGURE 2. You are interviewing Emily's mother after examining Emily and her X-rays. There were no signs causing concern on examination of the hands. Answer questions from the observing examiner near the end of the interview. with marked pain on attempted movement. fell at school injuring her right elbow which is swollen and painful. painful and tender. Emily an 11-year-old schoolgirl.Candidate information and Tasks 061 Condition 061 An elbow injury in an 11-year-old schoolgirl CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. YOUR TASKS ARE TO: • • Advise the parent regarding diagnosis and treatment.

YOUR TASKS ARE TO: • • Examine and interpret the patient's chest X-ray. Explain to the patient the diagnosis and how she should be treated.Candidate Information and Tasks 062 Condition 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman CANDIDATE INFORMATION AND TASKS This young woman has presented to the Emergency Department of the local hospital with the sudden onset of right sided chest pain and breathlessness while walking to work. FIGURE 1. CONDITION 062. Her breathlessness is less now. The Performance Guidelines for Condition 062 can be found on page 334 317 . Physical examination of the chest showed no definite abnormality. She is otherwise in good health and is a nonsmoker. and is illustrated below. There is NO need to take any further history from the patient NOR repeat the physical examination. A chest X-ray has been taken.

a 25-year-old driver. He is now well and has been straining his urine but no calculus has been found. YOUR TASKS ARE TO: • • • Examine the IVP film. a diagnosis of atypical ureteric colic was made. Because the patient's urine tested positive for blood. The films are available for you to review (see below). CONDITION 063. Advise the patient about further management. The pain was controlled by an injection of pethidine. and give a commentary to the examiner. Abdominal examination was normal. Intravenous pyelogram The Performance Guidelines for Condition 063 can be found on page 337 318 . FIGURE 1. Explain the X-ray findings to the patient. but a formal report from the radiologist has not yet been received. A plain X-ray of the abdomen was normal so an intravenous pyelogram (IVP) was arranged. The patient is seeing you today to find out the result of the IVP. A few days ago your next patient.063 Candidate Information and Tasks Condition 063 Atypical ureteric colic in a 25-year-old man CANDIDATE INFORMATION AND TASKS You are a medical officer in the hospital followup clinic. previously in good health. attended the Emergency Department with very severe acute colicky mid-line lower abdominal pain.

Examined 30 minutes after collection by masturbation. felt normal in consistency. you found no abnormality on general or genital examination. His result is as follows: SEMEN ANALYSIS Collected after three days of abstinence.064 Candidate Information and Tasks Condition 064 Investigation for male factor infertility in a 25-year-old man CANDIDATE INFORMATION AND TASKS A married couple (husband 25. normal values in brackets Volume 6 mL Count 2 million/mL Motility 20% Velocity 20 microns/second Abnormal morphology 95% Antisperm antibodies nil (2-6 mL) (Greater than 20 million/mL) (Greater than 40%) (Greater than 30 microns/second) (Less than 80%) (Nil) The husband has come to see you today for the result of the semen specimen. Investigations arranged by you. His wife is aware of her results. Both testes were normal in size (20 mL estimated volume). • Advise the husband regarding the couple's fertility problem. and has patent Fallopian tubes. The husband's recent semen analysis is not normal. When you examined him previously. The Performance Guidelines for Condition 064 can be found on page 340 319 . She was unable to come today. wife 23 years) have been trying to conceive for the last 12 months. YOUR TASKS ARE TO: • Take a further relevant and focused history from the husband in regard to the results obtained. there was no indication of a varicocele or hydrocele. from a general practice setting. have shown she is ovulating each month. Examination of both the husband and the wife is normal.

2-C Choice and Interpretation of Investigations 2-C Choice and Interpretation of Investigations Performance Guidelines MCAT 058-064 58 59 60 61 62 63 64 Positive test tor hepatitis C in a 26-year-old woman Diagnosis of 'brain death' prior to organ donation Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer An elbow injury in an 11-year-old schoolgirl Sudden onset of chest pain and breathlessness in a 20-year-old woman Atypical ureteric colic in a 25-year-old man Investigation for male factor infertility in a 25-year-old man 320 .

321 . • You are taking the oral contraceptive pill (Microgynon 30®) and wish to have a child in about two years time. the likely long-term outcome. whether any treatment is likely to be helpful. The candidate will also be expected to provide you with information concerning the investigations now required to assess any potential adverse effect of the hepatitis C virus on your body and whether you have cleared the infection spontaneously. The following history is likely to be sought from you (give answers to specific questions as outlined below): • Information in regard to likely cause of the hepatitis C infection ~ You were an intermittent intravenous drug-user over a two-year period. and whether you are likely to spread it to another individual. ~ On occasions you had shared needles with a friend. skin changes. bowel function) reply that there have been no such problems. has lasted four years. You married your current partner two years ago. but last had a 'shot' about six years ago. and the need for notification of the disease. ~ You have never had a blood transfusion or given blood products ~ You have had two sexual partners in your life. the current one. ~ You never had a needlestick injury • You feel well. and then to appropriately advise the patient in regard to the mode of contracting the disease.058 Performance Guidelines Condition 058 Positive test for hepatitis C in a 26-year-old woman AIMS OF STATION To assess the ability of the candidate to take a focused history assessing the possible mechanism for her becoming hepatitis C positive. ~ No previous operations or illnesses. You have never been jaundiced. The first relationship lasted three years and the second. Advice concerning your subsequent management will also be given and the need for notification of the disease to the local state health department within five days. the likely possibility of transmitting the disease to other people. have a normal level of energy and no difficulties at work • In response to any questions about symptoms (such as change in appetite. change in weight. • You have no past history of clinical hepatitis. the tests required to assess the current activity of the disease. ~ No tattoos or body piercing ~ You work in a hospital as a cleaner. ~ No family history of hepatitis of any sort. • Your alcohol intake is 1 or 2 glasses of wine a day. abdominal discomfort. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The candidate will be expected to take an appropriate history from you to determine how the hepatitis C infection occurred.

bruising. LFTs and HCV PCR should be performed • • An HCV PCR should be performed to help determine if the patient has spontaneously cleared the infection. and whether the actual viral infection has spontaneously cleared. itch. appetite change. the candidate should explain to you that the infection is likely to have occurred as a result of your intravenous drug use.058 Performance Guidelines • • After taking your history. In any patient. You are likely to be advised that you need blood tests to define whether the infection has cleared spontaneously from your body (polymerase chain reaction [PCR] test) and whether it has had any effect on your liver function (liver function tests). (i. In this patient if ALT is normal on the first test. the patient can be reassured. Current status • • She has no current symptoms of liver disease: no tiredness. Counselling In counselling about hepatitis C and risk to the patient. If positive this will influence the care required in a pregnancy. the candidate is expected to know that hepatitis C is a viral infection transmitted mainly via infected human blood. Questions to ask if not already covered: • • • • 'Do I need to have any more tests?' 'Will I be able to have a baby?' 'Can anyone catch this infection from me?' 'Must you notify this to the health department?' EXPECTATIONS OF CANDIDATE PERFORMANCE History taking should include: • Information in regard to the likely cause of the hepatitis C infection as outlined in instructions to patient. Knowledge of these results will then determine what the subsequent risks to you are.e. the exposure was almost certainly at the time of intravenous drug use 6-8 years ago. leg swelling. 322 . abdominal discomfort. Investigations Investigations required are those to assess any effect of hepatitis C on her liver. Alcohol intake is moderate. the possibility of blood group immunisation due to the use of shared needles needs to be assessed by the indirect Coombs Test. In most patients the diagnosis is made only when the disease is established and chronic. given the likely exposure was many years ago. In addition to the above tests. In this patient. In order to best identify the risk of liver disease. if serum alanine aminotransferase (ALT) is persistently normal (three estimations over a six month period) the prognosis is good and it is likely no long-term adverse liver effects will ever be found. gastrointestinal bleeding. but further ALT monitoring should still be advised. liver function tests and a polymerase chain reaction test for hepatitis C virus [HCV PCR]).

Patient education The good candidate will seek to provide the patient with appropriate supplementary patient education material. if this has been given. • Advising the patient of a benign course of disease in all instances. Pregnancy should not be allowed until at least 6 months has elapsed after cessation of antiviral therapy. may be of use if there is significant fibrosis in the biopsy specimen. When the above aspects have been sorted out. Risk factors for hepatitis C infection include intravenous drug use (70%). There are no recommendations against breastfeeding. The risk of spreading this infection during sexual activity is extremely low. and that the sharing of needles is never done. The risks of tattoos. COMMENTARY Hepatitis C is a single stranded RNA virus. body piercing and intranasal cocaine are not well defined. including interferon and ribavirin. sexual exposure (-10%). sharing food or eating utensils. Counselling about hepatitis C and risk to others Prevention of infection of others can only be achieved by ensuring all people who come in contact with her blood take appropriate precautions. the oral contraceptive pill should be ceased and the pregnancy awaited. There is no risk of hepatitis C transmission by hugging.058 Performance Guidelines • If ALT is elevated. treatment with interferon within 3 to 6 months of infection can prevent chronicity in 98% of patients. However it is important to avoid sharing objects with potential for blood contamination. occupational exposure (3%). as antiviral therapy. 323 . such as razors and toothbrushes. If pregnancy is to be allowed. and there is little or no evidence that condom usage will be of value in protecting her husband from his very low risk of getting infected in this way. the risk of liver pathology. Ultimately liver failure and liver transplantation may be required in a small percentage of cases. The chance of the baby being infected by vertical transmission during the pregnancy is about 5% in patients who have a positive PCR for HCV. as this would be likely to result in hepatitis C infection in the recipient. KEY ISSUES • Taking a focused history in regard to determining the source of the infection. casual contact. due to the teratogenicity of the ribavirin. • Advising the patient appropriately regarding subsequent care. and the patient is also at increased risk of hepatocellular carcinoma. and the need to ensure blood transmission does not occur. The risk of vertical transmission is very low. The viral infection is established and chronic at the time of diagnosis in most patients. Hepatitis C is a notifiable disease — notification is confidential. referral to a gastroenterologist would be appropriate for full liver assessment. a decision can be made regarding the advisability of a pregnancy. blood transfusion (6%). unknown (-10%). CRITICAL ERRORS • Failure to recognise the need for LFT (ALT) assessments. including biopsy. kissing. If identified early.

of which 1-5% will develop hepatocellular carcinoma. 324 . The patient needs to be advised about the necessary investigations (blood tests for HCV PCR and LFTs) and why these are required. The station examines the ability of the candidate to take a focused medical history. monitored and treated. Good communication skills are required to address sensitive issues in a situation where the patient is likely to be very anxious. Counselling skills are evaluated as the candidate talks with the patient about the possible effects of the hepatitis C virus on her health and the potential of passing on the infection to others. and any effects on her health. and 20% will develop liver failure requiring transplantation. There is a good opportunity at this first consultation to establish a good rapport. Twenty percent of those with an elevated ALT will develop cirrhosis. Candidates should be aware that hepatitis C is a notifiable disease with confidentiality maintained. having just been informed about a potentially serious infection.e. to give some basic education about hepatitis C. to provide some reassurance about transmission risk.058 Performance Guidelines The natural history of hepatitis C infection is that 15-50% resolve completely with no adverse end result and normal liver function (i. and to set the scene for the next visit when the ordered test results will be discussed. relating to potential source of the infection. This station requires that the candidate has knowledge of the natural history of hepatitis C and how this infection is detected. PCR is negative and liver function and ALT are normal). LFTs and HCV PCR therefore need to be done to assign the patient to the appropriate group. The remaining 50-75% will have chronic infection (PCR positive).

• To assess the candidate's communication skills in public education by discussing and explaining aspects of cadaver organ donation in the context of brain death with a layperson.none defined COMMENTARY The candidate should be familiar with legislation in Australia (which is broadly similar to that pertaining in most developed countries) providing for legal certification of death by either of two methods: • permanent and irreversible cessation of heart beat and loss of cardiac function. lung. 325 . • Ability to discuss principles of cadaveric organ donation for transplantation CRITICAL ERROR . Removing organs once brain death has been diagnosed and certified improves significantly the prospect of immediate function of the organ graft in the recipient after revascularisation in its new host. and highly desirable in grafts of kidneys. EXAMINER INSTRUCTIONS The standardised 'patient' in this instance is a secondary school science teacher with enquiries as described. bowel and other tissues. of the diagnosis of brain death and its implications in gaining of consent for cadaver organ donation as outlined in the commentary. Responses and questions will depend upon the clarity of explanation and information from the doctor. KEY ISSUES • Ability to discuss principles of 'brain death' to a lay person. as an alternative to 'cardiac death' has important implications in transplantation of organs and tissues from a cadaver donor. pancreas. Immediate graft function is essential for successful heart and liver transplantation. and • permanent and irreversible loss of brain function The concept of 'brain death'. although not necessarily the detail. Questions to be asked unless already covered: • 'What does'brain death'mean?' • What are these predetermined criteria about?' • 'Can you explain these tests to me?' EXPECTATIONS OF CANDIDATE PERFORMANCE You would expect the imminent medical graduate to understand clearly the principles.059 Performance Guidelines Condition 059 Diagnosis of 'brain death' prior to organ donation AIMS OF STATION • To assess the candidate's knowledge of the principles of diagnosis of brain death and its certification.

cardiac arrest inevitably follows within 30 minutes or less unless ventilation is restored by artificial ventilation). involving successively the midbrain. testing reflexes subserved by cranial nerves 2 through 12 via their sensory and motor pathways. which in the presence of a responsive respiratory centre will stimulate spontaneous breathing. and the brain stem reflex arcs from highest to lowest level. kidneys and other organs. heart-beating cadaver with permanent and irreversible apnoea (cessation of spontaneous breathing) due to brain stem death. where the respiratory centre and cranial nerve origins are clustered. with absolutely no prospect of error. including a senior and experienced clinician. The criteria listed for diagnosis of brain death first require the appropriate clinical setting (usually massive head injury or a catastrophic stroke). so that loss of brain stem function is progressively confirmed from above downwards. Diagnosis of brain death is made by meticulous clinical observations and tests and does not require elaborate technology for certainty of diagnosis. Criteria for confirmation of findings is by two groups of tests separated by an appropriate period of observation. The doctor here has been put on the spot by the bluntness and directness of the science teacher's request. and confirmed by two independent doctors. whose respiration is maintained by artificial mechanical ventilation of the lungs. The tests then employed as listed in the criteria of brain death are diagnostic of destroyed and absent brain stem reflexes. minimises the critical time of 'warm' ischaemia before cold perfusion of the removed organs. and also in the functions of the brain stem. ethical and cultural issues which make empathie and 326 . continuing central nervous system paralysis from drugs or curare-like respiratory depressants. pons and medulla.059 Performance Guidelines Removal of organs from the brain-dead. Meticulous application of these defined and universally accepted worldwide criteria has ensured that brain death can be diagnosed clinically with absolute confidence and without any risk of misdiagnosis. The other criteria are the exclusion of other possible contributors to prolonged coma (hypothermia. and the presence of deep and totally unresponsive coma with permanent loss of function of the respiratory centre. The several criteria and tests listed outline the ways of ensuring that irreversible loss of function has occurred both in the higher cortical brain functions. Clearly the diagnosis of irreversible and permanent loss of brain and brain stem function must be an unequivocal and certain one. We need tests of absolute specificity and sensitivity. How should the request best be handled? It may be best initially to broaden the discussion into a general outline of the usual setting of cadaver organ donation and the tragic circumstances of sudden and unexpected death of a loved one highlighting the many sensitive human. Permanent irreversible apnoea (failure of spontaneous breathing) due to death of the respiratory centre is confirmed over a 10-minute interval in the presence of a high level of build up of carbon dioxide in the blood. so no spontaneous breathing can occur because the brain stem centre for breathing has been irreversibly destroyed (and in the absence of respiratory activity. or gross metabolic and endocrine disturbances). immediate function of the graft in its new host can be anticipated provided total ischaemic times after organ removal do not exceed the tolerated time periods for the individual organs — around 6 hours for hearts and up to 24-48 hours for liver. Thus.

Knowledgeable candidates will stress this fact. Knowledgeable candidates should be able to give a general description. its certification and its legal and ethical implications have been ratified by all major religions. and that the time of brain death is seen by theologians to equate with the time at which the soul leaves the body. with permanent loss of the capacity to breathe: • the various tests described are tests of these brain stem and higher functions to be certain that all are permanently and irreversibly destroyed over a repeated period of observation: and • all other potential influences on consciousness (like effects of drugs) have been eliminated with certainty. which would be more relevant than the specifics of agonochemical events and the specifics of tests used to diagnose permanent and irreversible death of the brain and brain stem. including the respiratory centre and consciousness centre. of brain death. but the request would come normally from an experienced senior member of the intensive care team. that: • all the vital brain stem centres have been destroyed. often quite detailed but not always appropriate in their perspective or application to the particular problem posed by the patient.059 Performance Guidelines compassionate communication between the treating and transplant medical teams and grieving relatives and next of kin so essential. similar to the above. requiring artificial feeding (and often respiratory assistance). so the condition presents as a totally unresponsive individual with permanent loss of consciousness. and not from a junior Hospital Medical Officer (HMO). the isolated table the teacher brought was presumably taken from a larger general account. 327 . It is also important to understand that brain death means death of the individual as surely as does recognition of death by cessation of heartbeat. The vegetative state comprises the condition of deep coma with present but ineffective spontaneous breathing and with retention of other brain stem activities and reflexes. In particular. In this instance. and responding to a variety of stimuli. This station is a rather extreme example of the increasingly common practice of patients presenting to doctors with printed internet reports related to their presenting problem. The essential principle is that the criteria and tests provide the legal basis for medical certification of the death of a person (because the brain is dead) even though other functions of the body (heartbeat and machine-driven ventilation) are still going on with the support of machines and transfusions so the person (who is now actually a cadaver) 'looks alive'. Initial discussion with the candidate could then be followed by a subsequent briefing in which the doctor could read up about the more specific details of diagnosis of brain death and the science and ethics of cadaver organ transplantation before meeting the teacher again. Objections from next of kin to obtaining consent for organ donation after certification of brain death are usually cultural and emotional and associated with fear of mutilation of the body. It is NOT brain death. Doctors should also know that the condition of brain death. Certainly all doctors should be conversant with the laws governing consent for donation given by the next of kin.

Doctors always need to employ great empathy and compassion in obtaining consent in indicating to the relatives of the brain dead individual what organs are to be removed for transplantation. and in answering direct questions from them in regard to these and other matters.059 Performance Guidelines Much confusion in the public mind was initially stimulated by misinformed or unsubstantiated. 328 . (but sensational) reporting of doctors removing organs from struggling and responsive patients in whom brain death was said to be wrongly diagnosed.

If not. • Sympathy for concerns of patient about cancer. • Reassurance that with a homogeneous lesion such as this. periodic followup with clinical and imaging reviews will be advisable because of her family history and her concerns. KEY ISSUES • Counselling and communication skills in dealing with an anxious patient. the surgeon would be likely to accede to her wishes. ask if you can have a second surgical opinion Opening statement: 'I think this lump should be removed'. you are prepared to change your mind. and if not.060 Performance Guidelines Condition 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer AIMS OF STATION To assess the candidate's counselling and educational skills in a patient with concerns about familial breast cancer risk. the biopsy could be relied upon to give a definitive diagnosis. and about continuing clinical and ultrasound monitoring. 329 . If the doctor's reassurances are clear and convincing. • Knowledge of pathology and natural history of breast fibroadenomas. • Reassurance that the biopsy takes several representative pieces and can save unnecessary surgery and avoid potentially unsightly scarring. • Reassurance that impalpable fibroadenomas are very common in nonsymptomatic women on imaging and do not reguire excision and that they are not cancers and do not become cancerous. reassurance of noninvasive nature of ultrasound monitoring: reassurance of noninvasive nature of ultrasound • Assurance that if patient is still concerned. • Whatever the patient decides. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are very worried that this lump could be a cancer You feel it should be removed so you don't have to worry about it anymore. Questions to ask if not already covered: • 'How can you be sure it's not a cancer?' • 'Isn't it likely to turn into a cancer'? • 'Can’t I just have it out and then forget about it? EXPECTATIONS OF CANDIDATE PERFORMANCE • Reassurance about likely benign diagnosis. she could be referred for a second opinion.

This young patient requires regular clinical screening and appropriate imaging. The risk is increased in the presence of family history of breast cancer in first degree relatives. and pathology all confirmed and negative for cancer). Pathology can be determined by fine needle aspiration cytology (FNAC) or by percutaneous image-guided needle core biopsy. This lesion is impalpable and both clinical findings (normal breasts) and imaging findings (typical ultrasound appearance of a benign lesion) already favour a benign fibroadenoma. even though she (the surgeon) correctly regards core biopsy and observation as the best option. No convincing evidence exists that benign fibroadenomas are premalignant. The surgeon's advice was therefore appropriate and concise. the lesion is virtually certain to be benign. The patient will require continuing periodic clinical and imaging review from her family doctor and surgeon. despite repeated reinforcement by the family doctor. as is the case here. Breast cancer is very common in Australian women and around 1 in 14 women will develop breast cancer in their lifetime. imaging.none d e f i n e d COMMENTARY The scenario illustrates a common problem. and that the natural history of fibroadenomas may be to remain unchanged. It is unlikely that the surgeon would not agree to this. The ultrasound ordered by the family doctor was appropriate as initial investigation. to increase in size or to regress. If the 'triple test' is negative. but she has not convinced the patient that it is the right plan. and pathological confirmation by biopsy is required additionally to make our reassurance quite positive ('triple test check' — clinical. Choice will depend on circumstances and availability of expert cytology and pathology services. but an appropriate core biopsy would take five or more representative samples and would be expected to give a definitively accurate diagnosis with minimal likelihood of either a falsely negative or falsely positive result. and with minimal morbidity in experienced hands. and much collateral evidence on screening programme followup suggests that they are not.' Benign impalpable (or palpable) fibroadenomas and other benign parenchymal lesions are very common in this age group. but core biopsy will give a tissue diagnosis and has higher sensitivity and specificity. clearly the best decision may be to agree to her own wishes that the lesion is removed. If this patient remains unconvinced and unhappy. Whether total excisional biopsy or partial core biopsy should be performed will depend on circumstances. Note that her original problem (cyclical mastalgia) has now been replaced by the more serious problem of 'I have a breast lump which could be cancerous' Her natural reaction (which might be the correct solution to the problem) is 'I want it out. This will require an image-guided needle localisation operation.060 Performance Guidelines CRITICAL ERROR . 330 . The utility of any advice regarding management is only relevant and helpful if patient acceptance is present. so is generally preferred. We know from mass screening that benign lesions occur throughout all stages of life. But these findings alone are no! enough.

dose for age. The parent should report earlier if hand or fingers swell further. She should sleep with arm supported on a pillow. initial treatment plan and followup in response to the questions along the following lines: (Expected responses in parentheses) • 'Is the arm broken?' (Yes. No anaesthetic will be needed. Can return to school when pain eases in a day or two). Emily.061 Performance Guidelines Condition 061 An elbow injury in an 11-year-old schoolgirl AIMS OF STATION To assess the candidate's ability to identify a supracondylar humeral fracture on X-ray and advise regarding treatment. Opening statement and questions from the parent: • 'Is the arm broken. • 'What treatment will she need?'(\Ne will apply a back slab/plaster/splint to the elbow with a bandage and sling. painful swollen right elbow. and that she is comfortable with the plaster and sling. There is minimal displacement and no complications. Subsequent unrestricted use of hand and fingers should be encouraged with self-maintenance finger stretches). She will need to keep the elbow in plaster for several weeks [4-6 weeks] as illustrated. • 'What about school and writing?' (Can write as soon as finger movements allow this. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: Your 11-year-old daughter. CONDITION 061. fell at school and now has a sore. Pain relief will be ensured by paracetamol as required. FIGURE 3. doctor?' • 'What treatment will she need?' • 'What about school and writing?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate would be expected to advise the parent and describe the diagnosis. She will need a first followup tomorrow to check plaster and fingers. Emily has fractured the arm bone [humerus] just above the elbow. X-ray after application of backslab 331 . She should get excellent results with full functional recovery). The candidate has finished examining your child and has examined the X-rays.

A serious complication to be watched for is injury to the brachial artery from the anteriorly displaced upper fragment. Unless circulation is clearly restored after reduction. CRITICAL ERRORS • • • Missing the diagnosis of fracture Failing to arrange appropriate review and followup. giving ischaemia of the hand and fingers shown by pallor. 332 . finger swelling or severe hand pain occur. Severely displaced fractures will require reduction under anaesthesia and similar splintage after alignment is checked. Understanding of potential complications in this type of fracture. and parents and patients advised to report earlier if symptoms of numbness. such ischaemia must be treated by open exploration of the fracture site and the injured artery with restoration of adequate blood flow by vascular surgery. Undisplaced fractures or those with minor displacements can be treated without need for reduction by immobilising the elbow using a padded backslab or plaster (leaving shoulder and wrist and hand free to move) in the position of function of partial elbow-flexion of around 100° flexion. COMMENTARY Supracondylar humeral fractures are common in children following falls on the arm or hand. KEY ISSUES • • • Recognition of fracture on X-ray. Emily would be expected to make a full functional recovery after this injury and did so as llustrated (Figure 4). otherwise Volkmann ischaemic contracture of forearm muscles can occur. Fortunately in the majority of cases. but circulation must always be checked by review after 24 hours. displacement is minor or alignment is readily corrected and no vascular complications are present. Understanding principles and practice of management of an undisplaced uncomplicated closed supracondylar fracture. Immobilisation is usually only needed in children for 4-6 weeks and active mobilising exercises then begin.061 Performance Guidelines The examiner should ask the following question at seven minutes: 'What complication is most to be feared in these fractures if they are displaced?' (Vascular njury to the brachial artery). insensitivity and absent radial pulse. Failure to know of risk of vascular complications in displaced supracondylar fractures.

FIGURE 4. 333 .061 Performance Guidelines CONDITION 061.

ask if you could be treated at home. Also indicate that you are concerned about the cause of the pain and what the doctor will do to relieve it. The candidate needs to reassure the patient and then explain how the problem will be managed. not made worse with every breath worse if you take a deep breath. upper chest. and moderately severe at onset. An irritating dry cough . Opening statement • 'I've got a bit of a pain in my chest and I feel a bit breathless' — indicate site of pain which is on the right below the clavicle and at the back in the same area.062 Performance Guidelines Condition 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman AIMS OF STATION To assess the candidate's ability to recognise the right-sided pneumothorax on the chest X-ray and explain the diagnosis to the patient. and admission to hospital may be recommended.not severe or distressing • • • • You also have: You are a nonsmoker and drink alcohol on social occasions only (2-4 standard drinks). Indicate area where pain is felt. The candidate must make the correct diagnosis. You were walking to work when the pain came on suddenly. a partial collapse of the lung. Be cooperative and answer the doctor's guestions without evasiveness You have a moderate-sized pneumothorax. also radiating to your shoulder tip. You were also breathless. If so. but easing now A feeling of breathlessness (not severe) at rest as well as on exertion. A chest X-ray has just been done at the local hospital and you are about to be informed of the result of this. You have no known drug sensitivities. The pain is: • • • sharp and stabbing (if asked it is not tight. 334 . explain it to you and how the problem will be managed Inserting a catheter to take the free air out of the chest is a possible response. You live 2 km from the hospital and there are several others at home most of the time. both back and front. heavy or gripping). EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You developed chest pain while walking to work.

whether symptomatic or not — drain. ~ If 25-30% or less lung collapse and persisting symptoms — drain. The pneumothorax is around 30% and her symptoms are currently mild. • The pain should be recognised as being of respiratory origin. This is a reasonable option in this patient. It would be prudent and reasonable to admit the patient overnight for observation and serial X-ray. KEY ISSUES • Correct interpretation of chest X-ray. 335 . Displaying clinical knowledge and skills • Aetiology of pneumothorax — rupture of bleb on surface of lung. Most recurrences occur within 12 months. It may need a formal chest drain. • Nature of pain associated with pneumothorax — possibly due to tear of adhesion as lung collapses. This is a moderate (25-30%) pneumothorax. ~ If greater than 30% collapse. • Associated breathlessness — depends on size of pneumothorax. Sending the patient home if she lives nearby is a less acceptable option with a pneumothorax of this size. The patient may fall into this category with observation.062 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Candidate should respond along the following lines: Response to patient • Pneumothorax is the diagnosis. • Confirmatory investigation — chest X-ray diagnostic. • Explaining the diagnosis and appropriate management to the patient. Inserting a catheter with a Heimlich valve is an option to be discussed should the pneumothorax increase in size. A pneumothorax of this size may not need active treatment. Demonstrating Communication skills • Reassuring approach to patient anxious about the cause of the pain. and the recurrence rate is approximately 35% on the same side and 10-15% on opposite side. CRITICAL ERROR • Failure to identify the pneumothorax on the chest X-ray. Recurrence is possible after spontaneous pneumothorax. rather than cardiac. confirmed by chest X-ray. • The general consensus regarding the need for intercostal drainage is as follows: ~ If 25-30% or less lung collapse and no symptoms — observe.

3) and chest CT (Figure 4) 336 . The common smaller size pneumothoraces are often difficult to identify on plain X-ray. Symptoms of breathlessness and local discomfort are proportional to the size of the pneumothorax which is often small. as illustrated. Elective intercostal catheter drainage is indicated for a large (> 30% chest volume) initial pneumothorax or progressive increase in size on serial X-rays. even with erect films and magnified views. FIGURE 4. FIGURE 3. in which case no active interventional treatment is required. CONDITION 062. CONDITION 062. FIGURE 2. Larger pneumothoraces.062 Performance Guidelines COMMENTARY Spontaneous pneumothorax is usually due to the rupture of a previously nonsymptomatic bleb on the pleural surface of the lung. CONDITION 062. Examples of pneumothoraces and haemopneumothorax on plain X-ray (Figures 2. are usually easy to identify.

There is no evidence of a calculus in either ureter on the single film available The candidate. The pain was relieved by an injection and has not returned. Inform future medical attendants of the renal abnormality. Ensure adequate fluid intake in future especially in hot weather. and give further advice about future management to the patient. The abnormal position of the right kidney must be described. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 25-year-old driver who has always kept in good health. • explain that the stone is likely to have been passed spontaneously. You were diagnosed as most probably having a stone in one ureter (the tubes which connect the kidneys to the bladder). 337 .063 Performance Guidelines Condition 063 Atypical ureteric colic in a 25-year-old man AIMS OF STATION To assess the candidate's ability to interpret an X-ray of an intravenous pyelogram (IVP). • 'Is the stone still in there somewhere?' • 'Will I get another stone?' • 'Is this kidney likely to develop a cancer?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should in commentary to the examiner interpret the IVP appropriately and indicate that the abnormality shown is a left-sided crossed fused ectopic kidney with separate calyceal systems and ureters. Be yourself. Report further symptoms. in discussion with the patient. explain the findings to the patient. Questions to ask if not already covered: • 'What does this mean for the future?' • 'Why is my kidney in the wrong place?'— ask this if the candidate advises you that your right kidney is not in its normal position. A few days ago you suddenly developed very severe lower abdominal pain for which you attended the Emergency Department at this hospital. This anomaly is obvious on the film. Today you are attending the follow up clinic for the result of the X-ray. An X-ray of your kidneys was arranged (IVP). should: • check and confirm that no stone has been found on straining the urine. No need to strain urine anymore. especially if suffering from an abdominal complaint. Avoid alarming the patient about the congenital renal abnormality. Estimation of serum calcium to exclude hyperparathyroidism would be appropriate. You were told to strain your urine but so far nothing has been found. Be more concerned about the kidney abnormality (which the candidate should explain to you) than about the possibility of a stone in the ureter. Reassure patient that on the X-ray there is no sign of any urinary calculus.

Ectopic kidneys One or both kidneys may be in an abnormal position. and may be accompanied in a male by the absence of the vas deferens on the affected side. The patient should be reassured concerning the future. COMMENTARY Although intravenous urography/pyelography (IVP) is now largely replaced by computed tomography (CT) when scanning for suspected urinary calculi. The kidney begins intrauterine development in the pelvis. uterine and vaginal abnormalities commonly co-exist. In 'pancake' kidney a single pelvic renal mass is served by two collecting systems and ureters. Unilateral renal agenesis (congenital absence of one kidney) occurs in about 1 in every 1000 births. The condition is congenital (present from birth) and variations in kidney position are quite common. Most ectopic kidneys are pelvic in position. Otherwise the renal abnormality is of no significance and needs no treatment except awareness of its presence in the case of trauma to the left side of the abdomen or left sided abdominal pain. explanation of renal abnormalities. KEY ISSUES • • • Interpretation of investigations — must identify abnormal position of right kidney on the X-ray. CRITICAL ERROR • Failure to describe abnormal position of right kidney. Initial management plan — no further action required as stone has most likely passed. and may be fused with the normal kidney or pelvic in site — as is this instance of crossed fused renal ectopia. Patient counselling/education — reassurance. or on the side of the normal kidney (crossed ectopia). and acquiring fresh blood supply from progressively higher blood vessels with exclusion of others as differential growth of body segmental somites occurs. Ensure patient awareness if any future abdominal pain occurs. 338 . Ectopic pelvic kidneys usually receive their blood supply from local vessels. or be felt on rectal or vaginal examination. In the female.063 Performance Guidelines • Patient Counselling/Education — the abnormal position of the right kidney would explain the atypical nature of the pain. in this case a urogram is used to assess the candidate's ability to interpret an X-ray finding which is quite obvious if anatomical knowledge is sound. the ureter of the displaced kidney often crosses to its own side and opens into the bladder in the normal position. and may present as a pelvic mass. Congenital anomalies of the kidney and its vascular and urinary drainage systems are relatively common: up to 10% of infants may be born with some anomaly of the genitourinary system. although warned that recurrence of renal/ureteric colic may occur if further stone formation occurs. An ectopic kidney may be on its own side. ascending to its adult position on the posterior abdominal wall by birth.

the kidneys being joined by an isthmus. If they come into contact and adhere. An abnormal site of the kidney with anomalous referral of pain can cause difficulties in diagnosis until functional imaging reveals the anomalous anatomy. 339 . a horseshoe kidney may result. penis and testis. constant and unremitting severe pain felt from the site of the kidney towards bladder. Anomalies of the urinary collecting and drainage systems can predispose to urinary obstruction from hydronephrosis or calculus. which the ureters need to cross to descend. Obstructive renal and ureteric pain (renal 'colic') is often an acute.063 Performance Guidelines As kidneys ascend from the pelvis they normally remain separate.

You have never had any testicular trauma. or undertake treatment if this will lead to an improvement in your semen specimen or achieve a pregnancy. You have had no surgery to your testes or inguinal region. 340 . per week. You are not on any drugs and have never taken any tablets except Panadol® when you have a headache. You do not smoke and have 3-4 glasses of alcohol. or the use of donor sperm not involving the use of IVF. You do not use saunas.064 Performance Guidelines Condition 064 Investigation for male factor infertility in a 25-year-old man AIMS OF STATION To assess the candidate's ability to advise a husband with an abnormal semen specimen of the subsequent evaluation and management required for the couple to best achieve a pregnancy. and the semen analysis does not improve with time it will be necessary for you and your wife to consider the place of IVF. You have had no contact with any chemicals. You have never used any drugs of addiction or hashish. or high fever. and what treatment is likely to be given in an attempt to achieve a pregnancy. List of appropriate answers: • • • • • • • • • • • • • • You are happy to have other tests done. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The doctor will generally be expected to advise you (the husband) of the significance of the semen findings. You had mumps when aged 10 years There was no testicular involvement (give this latter information only when specifically asked). If asked whether you and your wife would accept the use of IVF to achieve a pregnancy. If asked whether you would accept the use of donor sperm to achieve a pregnancy in your wife. If there is no reversible factor present. indicate 'no'. You work in an office writing computer programs for the banking industry. nor were you given antibiotics over the last three months (these could have resulted in the current semen specimen being abnormal). what further evaluation is required. indicate 'yes'. usually wine. You have never used anabolic steroids. You have not had any viral illness.

spontaneous improvement in the analysis is less likely. • A number of blood tests should be performed to provide information as to the likely reversibility of the problem. as detailed in the patient answers. • Knowledge of appropriate tests to assess him. • Ability to understand that a definitive cause is unlikely to be found. Pregnancy rate is about 20% per cycle of insemination. This would include at least the measurement of serum FSH and testosterone levels. • Intrauterine insemination using his poor semen sample has a very poor success rate (about 1-2% pregnancies/cycle of insemination). • Need for empathie counselling. The candidate should advise along the following lines. • One semen specimen is insufficient to make a meaningful prediction of fertility potential. Preferably three specimens obtained about three months apart are required. and of the possibility of improvement with time. • If the semen analysis improves spontaneously with time. • There is a place for the use of donor sperm and performing artificial insemination. IVF without the use of ICSI has poor results (about 2-5% pregnancy rate per cycle of transfer). 341 . • There is a definite place for the use of IVF. then clearly there is a problem which is almost certainly a major factor in the infertility. If these show the same findings as the first one. with intracytoplasmic sperm injection in the oocyte (ICSI). the possibility of achieving a pregnancy is increased.064 Performance Guidelines Questions to ask unless already covered: • • • 'Why is my test so bad?' 'Can't you do something to improve it?' 'If there are two million sperm present. why doesn t a pregnancy occur?” • 'Will a change in my diet help?' • 'Will IVF be required for all pregnancies my wife and I want?' Only ask this question if the candidate has already discussed the use of IVF. if this had been acceptable. EXPECTATIONS OF CANDIDATE PERFORMANCE The history should cover the likely causes of the abnormal semen specimen. KEY ISSUES • Need for appropriate history from husband. • There is no documented evidence for the use of hormone or other treatment. Use of donor semen is cheaper and more straightforward than other methods of treatment such as IVF. but the baby would not contain any of the husband's genetic material. This has a pregnancy rate of about 20-40%/cycle. • It is unlikely a cause of the abnormal semen specimen will be found. in improving the semen specimen. If the FSH is high.

as this is very effective and cheap. COMMENTARY In the advice to this young man. The comprehensive aspect of the counselling is based upon the assumption that a repeat specimen would show a similar abnormality. lack of understanding that one semen analysis's result is of little predictive value). Common problems likely with candidate performance are: • • • Failure to repeat the semen specimen analysis a few months later (i.e.064 Performance Guidelines CRITICAL ERRORS • • • Failure to advise that at least a second semen specimen (3 months after the first) must be examined. Failure to ask questions to define the possible causes of the abnormal semen specimen. Failure to understand that ICSI (within IVF) is the best method of achieving pregnancy using his genetic material. This test must be repeated 2-3 months later and preferably again after a further 3 months. it must be recognised that a single sperm test is unreliable as a basis on which to make a meaningful fertility prediction. although the child produced would not obtain DNA from the husband 342 . Failure to ask whether the use of donor semen would be acceptable. Failure to recognise that persisting severe abnormality of the semen specimen as currently obtained will result in a very low pregnancy rate.

its physical. psychological and social consequences. • Arrange referral to other clinicians or health workers appropriately. • using jargon. • lack of expressiveness in interviewer's body language or voice. • Reach agreement with the patient on a plan of management. closed questions. It can also motivate a patient to follow treatment recommendations. • Determine and evaluate the patient's physical and psychological symptoms. • excessive use of leading or loaded questions. The following are the broad objectives of a medical consultation: • Establish or build on an effective. • Provide advice on health promotion. Some commonly encountered problems during a clinical consultation are: • failure to observe common courtesies. clinical problems.' Louis Pasteur (1822-1895) Objectives of the medical consultation — How I Do It' The medical consultation is the cornerstone of medical practice. the vehicle for a patient's education about health promotion. A properly conducted consultation establishes an effective doctor-patient relationship.2-D: The General Consultation Barry P McGrath 'In the field of observation. • Identify abnormal physical and mental state signs. • Choose and interpret appropriate investigations. • failure to establish levels of comprehension and communication capabilities. • ignoring emotional réponses and concerns. chance favours the prepared mind. • vague or complex questions. • not discerning patient's ideas and beliefs about the problem. • Explain to the patient the nature of the condition. professional doctor-patient relationship. • Devise methods of relieving pain and suffering. • Define the clinical problem(s) — the patient's principal condition(s). • disjointed questioning. • abrupt topic changes. It is usually not a 'one-off encounter. • Reassure the worried well. the first consultation is generally followed by further consultation visits at variable intervals which can extend over many years. The consultation is the basis of the diagnostic and treatment formulations. 343 . • Reach the correct diagnosis (the doctor is progressively developing and testing hypotheses). • Institute treatment. • narrowing the focus of enquiry too soon. • overuse of directed. disease processes and test interpretations.

2-D The General Consultation Setting the scene for a medical consultation This may take place at any number of settings: general practice. are very important. disjointed questioning. privacy. A skilled medical interviewer will exhibit: • • • • • • • • • • • • • • • • • • • an encouraging. stroke). The interviewer. friendly demeanour and introduce themselves in a way that identifies their roles. good listening skills. physical disability (such as deafness. as soon as possible. blindness. Some failure to observe common courtesies: failure to establish levels of comprehension and communication capabilities: ignoring emotional responses and concerns. awareness of any discomfort. and note-taking that does not interfere with patient rapport. language or cultural attitude. will need to seek the patient's permission to conduct the consultation. a trainee). if a medical student or if not the patient's usual medical practitioner (for example. hospital ward. the doctor must respect the patient's safety. closed questions. Depending on the circumstances. It is critically important to establish. Attention should be paid to the interview setting (for example. physical and psychological well-being. the seating arrangement). vague or complex questions. Patient-related factors and doctor-related factors can influence doctor-patient communication. family member or friend. and specialist consulting rooms. with an underlying self-questioning approach: 'How can I connect with this patient?' Frequently a patient will attend with a partner. lack of expressiveness in interviewer's body language or voice. Communication skills First impressions. Establishing whether or not the patient wishes. using jargon. abrupt topic changes. overuse of directed. good eye contact. to proceed to interview in the presence of 'a significant other' needs to be established early. and narrowing the focus of enquiry too soon. Whatever the setting. warm and empathie manner. if there are any impediments to communication such as dementia. excessive use of leading or loaded questions. commonly encountered problems include: 344 . but again only with the patient's permission. dignity. the interviewer may seek to conduct the medical consultation with the patient alone initially and then subsequently involve the 'significant other' or family members. or indeed. alertness and responsiveness to nonverbal as well as verbal cues. as in most human encounters. The goals of the consultation will vary with the setting and the urgency of the clinical problem(s). An expert medical interviewer may adopt a variety of techniques. modesty. respect for patient's dignity. use of mainly open questions. Medical interviewers must be appropriately dressed. with a professional. not discerning patient's ideas and beliefs about the problem. if it is appropriate. nonjudgmental attitude. outpatient/ambulatory care. Emergency Department.

They are also addressed in a number of excellent text books and in many of the case 1. Mosby Inc. Com m u ni ca ti o n Skil l s f or M e di ci ne . R Boor (eds). hypothetic-deductive process. Me di cal C o ns ul ti n g Ski l l s-Beh avi o ur al an d I n te rp ers on al Di m e nsi o ns o f H eal t h C ar e Addison Wesley Longman Australia Pty. are considered. in some cases a new diagnosis is defined. Usually a list of alternative hypotheses. GJA Byrne (eds). Clinical reasoning in medical history-taking Clinical reasoning mostly involves an efficient. New York USA.2.4 scenarios. The diagnosis is often made early in the medical consultation. 3 M Mloyd. FIGURE 1. Churchill Livingstone. 4 T h e Cl i ni cal Enco u nt er: A G ui d e t o th e Me di cal I n te rvi ew an d C as e Pr es en t ati on .3. The process of problem identification is summarised in the accompanying figure SECTION 2-D. • Clinical examination often provides confirmatory information. Ltd. The following points are germane to the process of clinical reasoning: • Iterative nature of process: the diagnostic hypothesis is continually being strengthened refined. • Investigations provide the diagnosis in only about 10% of instances. St Louis Missouri 1999. ranked and further addressed Additional information is obtained from the physical examination and specific investigations which serve to confirm the diagnoses. St Louis Missouri USA. modified or totally reformulated on the basis of responses to questions. or differential diagnoses. Th e M edi c al I n ter vi ew — T he T hr e e-F u ncti on Ap p ro ac h . Mosby Inc.The General Consultation 2-0 These issues relating to communication skills are vitally important and are re-emphasised here. 345 . • 80% of clinical diagnoses are reached on the basis of history alone. determine their severity and effects and to exclude alternative (differential) diagnoses. 2000. Melbourne Australia 1997. 2 SA Cole and J Bird (eds). 1996. Process of problem identification 1 MR Sanders. C Mitchell.

aggravating and relieving factors .setting/context .site .time course .associated features • risk factors other medical problems: ~ related to presenting complaint ~ additional problems • • • • • • medication.quality/character .The General Consultation 2-D The structure of the medical history This is usually arranged along the following lines: • • basic information about the patient the presenting complaint: ~ history of the presenting complaint ~ description of the presenting complaint: . habits and allergies systems review past medical history family history social and personal history psychiatric history Barry P McGrath 346 .severity/intensity .

The General Consultation 2-D 2-D The General Consultation Candidate Information and Tasks MCAT 065-073 65 66 67 68 69 70 71 72 73 Acute chest pain in a 60-year-old man Palpitations and dizziness in a 50-year-old man Muscle weakness and urinary symptoms in a 60-year-old man Aches and pains in a 62-year-old man Lack of energy in a 56-year-old suntanned man Recent haematemesis in a 50-year-old man Anaemia in a 28-year-old pregnant woman Acute vertigo in a 50-year-old man Urinary frequency in a 60-year-old man 347 .

relevant and focused history. You are asked to see a 60-year-old man complaining of acute chest pain. Tell the examiner your provisional diagnosis and the reasons for this. Interpret the ECG to the examiner (the ECG will be given to you at about 7 minutes into this consultation). Present a summary of the patient's history for the examiner. Institute emergency treatment. CONDITION 065. FIGURE 1. YOUR TASKS ARE TO: • • • • • Take a concise.Candidate Information and Tasks 065 Condition 065 Acute chest pain in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. who will then give you the findings on physical examination which you request. The Performance Guidelines for Condition 065 can be found on page 356 348 .

CONDITION 066. He is lying down on a trolley. • Tell the examiner your differential diagnosis. You are asked to see a 50-year-old man complaining of palpitations and dizziness over the past three days.Candidate Information and Tasks 066 Condition 066 Palpitations and dizziness in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. The Performance Guidelines for Condition 066 can be found on page 363 349 . The symptoms are still present when you see him to take his history. • Interpret the ECG to the examiner (the ECG will be given to you by the examiner about 7 minutes into the consultation). relevant and focused history. He has not seen a doctor for the past 10 years and at that last assessment he was told his blood pressure was elevated. His current blood pressure is 150/96 mmHg. YOUR TASKS ARE TO: • Take a concise. who will then give you the findings on physical examination. FIGURE 1. • Present a summary of the patient's history to the examiner.

Briefly explain to the patient what you believe to be the cause of his symptoms and the first step in management (you are not expected to discuss treatment in detail). weakness and urinary symptoms. Ask the examiner for the findings of a selective and focused physical examination you would perform. The Performance Guidelines for Condition 067 can be found on page 368 350 . YOUR TASKS ARE TO: • • • • Take a history from the patient. Your next patient is a 60-year-old man who is complaining of tiredness.Candidate Information and Tasks 067 Condition 067 Muscle weakness and urinary symptoms in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. State to the examiner any relevant investigations you would order.

worsened by movement and is keeping him awake at night. but is now more definite pain but hard to describe. His appetite is not as good as usual. He s consulting you about aches and pains. He has felt much more tired than usual over the last few weeks. He thinks he may have lost a little weight and sometimes feels hot and slightly sweaty at night in bed. He has not played golf for a week. Since retirement two years ago he has been playing golf at least three times per week and thought that he may have been overdoing it. The examiner will give you the results and ask you questions about your provisional diagnosis and further investigations. You do not need to take any further history. • Advise the patient of your diagnostic and management plans. and you have just finished taking a history. The aching and stiffness is worse early in the morning and he finds it difficult to get out of bed because of muscle weakness and pain which improves during the day. Muscles feel 'as if they are losing their strength'. he has had a gradual onset of pain across the upper part of the back. YOUR TASKS ARE TO: • Specify to the examiner the essential features you would like to know from a focused physical examination of this patient. Pain is not relieved by aspirin or Brufen®.Candidate Information and Tasks 068 Condition 068 Aches and pains in a 62-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice You next patient is retiree and aged 62 years. especially after golf. At first the pain was just an aching feeling. In the past week or so his hips are also feeling stiff and sore. It is continuous. nor worsened by coughing. neck and shoulders which feel stiff. He has noted a little difficulty in lifting himself up from a chair. Pain is felt in the muscles but not in the joints. 351 . The Performance Guidelines for Condition 068 can be found on page 371 r . although these feel stiff especially after inactivity. which was as follows: Over the last six weeks. • Answer the questions put to you by the examiner. There is no radiation to the arms.

although he has just returned from holidays in Queensland and appears quite suntanned. Victoria. On the basis of the history you have just finished taking. tell the examiner what would be the most significant clinical signs you would search for on physical examination. The patient has given you a past history of a previous admission six months ago with a similar episode of haematemesis which settled spontaneously. The patient tells you that he has been trying to give up alcohol with limited success. An endoscopy was done and the patient was told there were dilated veins at the lower end of the gullet and was advised not to drink alcohol.Candidate Information and Tasks 069-070 Condition 069 Lack of energy in a 56-year-old suntanned man CANDIDATE INFORMATION AND TASKS You are consulting in a general practice setting in Melbourne. Explain your actions and what you are looking for to the examiner. This 50-year-old patient has presented having had a haematemesis of about 500 ml_ of fresh blood two hours ago. Advise the patient of your opinion about possible causes for his tiredness. The examiner will respond with these findings for this patient. and how you intend to proceed to make a firm diagnosis. Your next patient is a 56-year-old industrial chemist. you believe that the patient may have had a haematemesis from oesophageal varices with portal hypertension and chronic liver disease as the explanation for the current problem YOUR TASKS ARE TO: • • • Perform a relevant and focused physical examination of the patient. including office laboratory tests. After four minutes. relevant and focused history. You are not required to take any further history. He is complaining of tiredness. accompanied by a transient feeling of light headedness and sweating. • The Performance Guidelines for Condition 069 can be found on page 374 Condition 070 Recent haematemesis in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are an intern at the hospital Emergency Department. YOUR TASKS ARE TO: • • Take a concise. Describe your findings as you proceed. and his prior episode. The Performance Guidelines for Condition 070 can be found on page 377 352 .

and is on medications for control of hypertension and hyperlipidaemia. This 50-year-old man is consulting you about intense dizziness. has just been found to have a haemoglobin level of 80 g/L when tested at 26 weeks of gestation. • The observing examiner will then give you the significant findings on physical examination. He is a previous patient who is overweight. His wife drove him to the hospital. • Discuss your diagnosis and management plan with the examiner. YOUR TASKS ARE TO: • Take a focused and relevant history. The Performance Guidelines for Condition 072 can be found on page 383 353 . YOUR TASKS ARE TO: • Take any further relevant history you require. The Performance Guidelines for Condition 071 can be found on page 380 Condition 072 Acute vertigo in a 50-year-old man CANDIDATE INFORMATION AND TASKS You are working in a primary care facility attached to a teaching hospital. with a slight drooping of the left eyelid. • Ask the examiner about relevant findings likely to be evident on general and obstetric examination.071-072 Candidate Information and Tasks Condition 071 Anaemia in a 28-year-old pregnant woman CANDIDATE INFORMATION AND TASKS This 28-year-old pregnant woman. who is attending a general practice in which you work. He appears unwell and distressed. • Advise the patient of the tests required to define the most likely diagnosis and the subsequent management you would advise.

Ask the examiner what aspects of physical examination are most likely to confirm this diagnosis and any initial office tests you would perform. Your next patient is a 60-year-old man. Tell the patient your diagnostic conclusions. Today he is consulting you about urinary symptoms. YOUR TASKS ARE TO: • • • Take a focused history with regard to the presenting symptoms. The examiner will respond accordingly. He has attended the practice infrequently in the past.073 Candidate Information and Tasks Condition 073 Urinary frequency in a 60-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. what investigations are indicated and the reasons for these. • The Performance Guidelines for Condition 073 can be found on page 394 354 . Give the examiner a summary of the patient's presenting history with the most likely diagnosis.

2-D The General Consultation 2-D The General Consultation Performance Guidelines MCAT 065-073 65 66 67 68 69 70 71 72 73 Acute chest pain in a 60-year-old man Palpitations and dizziness in a 50-year-old man Muscle weakness and urinary symptoms in a 60-year-old man Aches and pains in a 62-year-old man Lack of energy in a 56-year-old suntanned man Recent haematemesis in a 50-year-old man Anaemia in a 28-year-old pregnant woman Acute vertigo in a 50-year-old man Urinary frequency in a 60-year-old man 355 .

As in clinical practice. oesophageal reflux or dysphagia. If no questions about your bowels. tiredness (two days). nausea. radiating to lower jaw.' Characterisation of symptom: Site: Severity: Time course: Context: central. aspirin. Myocardial infarct three years ago For blood pressure (enalapril/hydrochlorothiazide).065 Performance Guidelines Condition 065 Acute chest pain in a 60-year-old man AIMS OF STATION To assess the candidate's ability to take a medical history in an older male patient presenting to the Emergency Department with chest pain of two hours duration. whilst being aware of the patient's discomfort and the need to take steps to relieve this. No epigastric pain. Opening statement 'I have a very bad tightness in my chest. retrosternal. oxygen when given in Emergency Department sweating. alcohol intake 1 glass wine per day. the importance of taking a focused history to distinguish between cardiac and non-cardiac sources of chest pain. hypertension (3 years): high cholesterol (3 years). volunteer this information. Systems review: Past history: Drugs: 356 . the early performance of an ECG and its correct interpretation is a key step in the assessment of this patient. no association with respiration anginine. diabetes (5 years). severe 8/10 came on two hours ago. lipid-lowering agents Habits: Family History: Smoker until three years ago. The candidate needs to be aware of the potential seriousness of the situation. diabetes (metformin). Recent black bowel motions (five days). breathlessness overweight. Nil relevant. pain in left leg on walking 500 metres (1 year). this pain started when playing third set of tennis Aggravating factors: Relieving factors: Associated symptoms: Other health problems: none. central chest pain when walking on cold mornings for the past two months: short of breath on exertion and breathless at night (three days). steadily getting worse recent angina for two months. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You have acute and worsening chest pain. You are 60 years of age.

its time course. pulse rate 96/min and regular. Examination otherwise noncontributory EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient The candidate is expected to demonstrate professionalism. assess for thrombolytic therapy. Heart sounds dual rhythm. indicates he is diabetic. monitor pulse. Awareness of the potential seriousness of the situation as the history evolves still requires the candidate to be calm. glyceryl trinitrate and morphine. The cardiovascular risk factors must be determined. the patient has been asked to bring this to the candidate's attention. The presenting problem: Check out his medication list: Other cardiovascular risk factors: Other medical problems: Physical examination: Treatment starts immediately: fits pattern of acute myocardial infarction. probable melaena. fits pattern of acute myocardial infarction This is a medical emergency requiring management by an expert team (what is the candidate's role in the team?). sweaty older man with chest pain: urgent assessment needed: focus on key questions relating to possibility of ischaemic heart disease. previous acute myocardial infarction. claudication: smoker. anxious-looking. History-taking skills The candidate is expected to fully characterise the chest discomfort. If the history of recent 'black bowel motions' is not obtained by the candidate. ECG. What should the doctor be thinking? Meeting the patient: an overweight. high cholesterol. Blood pressure is 150/96 mmHg. blood pressure. Type 2 diabetes. This needs to be done in a sensitive and focused way. the context and associated symptoms. central obesity. no murmur. 357 . empathy and to seek relief of the patient's discomfort with use of oxygen whilst taking the history. including the past history of myocardial infarction. confident and reassuring.065 Performance Guidelines The examiner will provide physical examination findings to the candidate as follows: He is an overweight man of stated age who is in acute distress with pain and who is anxious and sweating. using a mixture of open-ended and direct questioning. The occurrence of this pain in the context of recent chest pain on exertion and breathlessness needs to be defined. hypertensive. hypertension. hypercholesterolaemia. There are no signs of heart failure. aspirin. commence oxygen therapy.

having had a prior myocardial infarct. ECG of patient Tests: confirm acute myocardial infarction. There are features of acute inferior myocardial infarction shown by the Q waves in leads II. A concerning symptom is his 5 day history of passing black bowel motions. and with risk factors of diabetes. In addition he has had exertional chest pain over the past 2 months and shortness of breath. in the central. CONDITION 065. which is suggestive of gastrointestinal blood loss. high cholesterol. orthopnoea and tiredness over the past few days. assess anaemia 358 . sweaty 60-year-old man with chest pain described as 'a very bad tightness'. anxious looking. III. AVF and ST segment elevation in these leads as well. rate 96/min. associated with shortness of breath. FIGURE 2. 8/10 severity. Interpretation of ECG The ECG shows the following features: • • Sinus rhythm. The patient is an overweight. sweating and partly relieved by anginine and oxygen. The pain came on when playing tennis and has been increasing steadily over the past 2 hours. radiating to the lower jaw but not to the arms. He is at very high risk of acute coronary ischaemia. The key features that suggest this diagnosis are the characteristics of the chest discomfort in a patient with significant risk factors and prior myocardial infarction. EC G findings need to be checked and anaemia considered as a precipitating factor.065 Performance Guidelines Ability to provide a concise clinical summary This should be along the following lines and reflect the manner in which a junior doctor would describe the key features of the history to a registrar or consultant. hypertension. retrosternal region. Diagnosis The most likely diagnosis is acute myocardial infarction.

• Diagnosis/Differential diagnosis — the candidate must consider the diagnosis of acute myocardial infarction and why noncardiac causes of the chest pain are less likely. • Interpretation of investigation — the most important findings on the 12-lead ECG must be defined: sinus rhythm. 4 MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20. et al. Ci rcul ati o n 359 . • Failure to define the main cardiovascular risk factors — prior myocardial infarction. COMMENTARY The patient's presentation is highly suggestive of an acute myocardial infarction. L anc et 2000. hypertension and hypercholesterolaemia. acute inferior myocardial infarction.536 high-risk individuals: a randomized placebo-controlled trial. MacMahon S.065 Performance Guidelines KEY ISSUES • Approach to patient — sensitivity to the patient's discomfort and a calm and professional manner. smoking. and an efficient ability to characterise associated symptoms and to define the context in which the symptom of chest pain has arisen. For hypertension and hypercholesterolaemia and a history of smoking. Di a be tes C ar e 2003. Smith S. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. The candidate needs to show an appreciation of cardiovascular risk factors. • Failure to correctly interpret the ECG features of myocardial infarction. The candidate should identify the potential significance of the history of melaena. Implications of the United Kingdom prospective diabetes 26 Suppl 1 : S28-32. http://www. • Commentary to examiner — a succinct summary which brings together the key features of the presenting complaint. Blood Pressure Lowering Treatment Trialists' Collaboration. Eastman R. the associated symptoms and the cardiovascular risk factors. the risk is also significantly increased. 2001. 6 Neal B.360:7-22 5 Genuth S.5. Lachin J.6.7 1 2 1 Management ot unstable angina guidelines. 356: 1955-64. Lebovitz H.heartfoundation. Wellington: National Health Committee. 100:1481-92. Klein R. Chapman N. Fuster V. Greenland P. the context in which it has arisen. Pasternak R. http://www. Lancet 2002. and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Type 2 diabetes mellitus is associated with a 10-fold increased risk of acute myocardial ischaemia. Type 2 diabetes mellitus. 7 National Health Committee revised guidelines for smoking cessation 2002. • The ability to take an appropriate and focused medical history showing an awareness of the likely causes of chest pain and the main characteristics that distinguish cardiac and noncardiac sources of chest pain. Effects of ACE inhibitors. Cardiovascular risk assessment A prior history of a cardiovascular event is the most important pointer towards a recurrent calcium antagonists. CRITICAL ERRORS • Failure to consider the diagnosis of acute myocardial infarction on the 2 Therapeutic Guidelines Cardiovascular Version 4 2003 3 Grundy SM. 3 . Kahn R.

thrombosis. V2-V6. If the coronary occlusion is not relieved. ECG changes and biochemical markers. This may cause sudden death from ventricular fibrillation. The acute coronary syndromes are differentiated on the basis of extent and duration of chest pain. 360 . FIGURE 3. They are divided into two syndromes: (1) associated with ST elevation on the ECG (ST elevation myocardial infarction. NSTEMI is differentiated from unstable angina on the basis of biochemical evidence of myocardial necrosis (elevated troponin level). V3 and loss of R waves across chest leads.065 Performance Guidelines Acute coronary ischaemia syndromes All the acute coronary syndromes share the underlying pathology of an atherosclerotic plaque which becomes active acutely with rupture of the plaque with resultant platelet adhesion. NSTEMI) associated with either ST depression. vasoconstriction and inflammation. myocardial infarction develops progressively over the next 6-12 hours. This is often associated with evolution of evidence of transmural myocardial infarction on the ECG as shown by the development of Q waves. Acute anterolateral myocardial infarction Features indicating acute anterolateral infarction are: • • ST elevation in leads I. The exact syndrome depends on the extent of thrombosis. aVL. the result is severe transmural myocardial ischaemia with ST elevation on the ECG. When the thrombus that occurs on a ruptured plaque completely occludes the coronary artery. STEMI) and (2) those without ST elevation (non-ST elevation myocardial infarction. and Q waves in aVL. The following figures give examples of different patterns of myocardial infarction: CONDITION 065. T-wave inversion or no changes on the ECG. V2. the degree of distal embolisation of platelet thrombi and the resultant myocardial necrosis.

V6 indicate postero-lateral infarction.065 Performance Guidelines CONDITION 065. and aVL. III. FIGURE 5. III. Acute inferior myocardial infarction Features of acute inferior myocardial ischaemia/infarction are: • ST segment elevation in II. FIGURE 4. Acute posterior-inferior myocardial infarction Features of posterior-inferior myocardial infarction are: • Q wave and ST elevation in inferior leads (II. CONDITION 066. aVF). 361 . and • The slow rate is also common in this condition. and • the prominent R waves in V1 (labelled C1) and Q waves with ST elevation in V5.

the context in which the symptom occurs. lungs or a musculoskeletal disorder.Central chest discomfort is a common presentation of cardiac disease. ' 'How severe is it — e. the jaw. the associated symptoms and the patient's predisposition to cardiac versus noncardiac disease based on an assessment of cardiovascular risk factors.g. A common sequence of enquiry would be as follows: • • • • • • 'What is the discomfort like? Describe it in your own words. but it may also be due to disease of the gastrointestinal tract. the neck. In taking a history relating to chest discomfort. a number of key descriptors needs to be defined to determine if its origin is cardiac ischaemia. the arms?' 'When did it start? How has it progressed? How long has it been present or how long did it last?' 'Does anything make the discomfort worse? Does anything make it better?' 'Do you have any other symptoms? Shortness of breath? Dizziness? Palpitations? Sweating? Nausea or vomiting?' In addition there are a number of questions that will be used in trying to determine if there is a non-cardiac cause: • • • • 'Do you get acid indigestion or reflux?' 'Was the onset of the discomfort related to a meal?' 'Does it hurt to take a deep breath?' 'Is the chest sore to touch?' 362 . The features of the chest discomfort/pain. a score out of 10?' 'Show me where you feel it? Does it go anywhere else — the abdomen. must all be considered. the back.

You have them now. You feel you have to lie down. the candidate needs to have knowledge of the causes of cardiac arrhythmias and the manifestations of different types of arrhythmias. rhythm. If asked to tap out the rhythm on the desk. You are on no medications. the nature of the arrhythmia (rate. 363 . Also critical to the assessment is an understanding of potential risk factors and précipitants of cardiac arrhythmias. There is no associated chest pain but you are mildly short of breath and sweat during and for a short time after each attack. provide the following information: • History of presenting complaints — The palpitations and dizziness seem to come on together. • Dizziness — This is a light-headed. Obtaining an ECG during an attack and its correct interpretation is a key step in the assessment of this patient. context) and the close association between the two symptoms. The attacks come on suddenly and stop suddenly. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are lying on a trolley in the Emergency Department. onset. There have been four attacks over the past three days. • Social history — You have a sedentary solitary lifestyle. Three of the episodes occurred after the evening meal and the fourth whilst driving. Underpinning the history-taking. • Palpitations . Careful history-taking is essential in assessing such patients. headache or nausea. • Family history — No significant family history of heart disease or cardiac arrhythmias. You are overweight with no recent change in weight. • Systems review There is no history of heat intolerance. near fainting experience which comes on within a minute of the palpitations and lasts for the duration of the attack. Bowel function is normal. offset. There is no flushing. each lasting for about two hours. give a rapid regular beat of about 150/min. drink 4 or 5 glasses of wine with the evening meal and 5 cups of coffee per day. • Habits — You smoke 20 cigarettes per day. nervousness or tremor. The candidate needs to define the attacks. You were brought to hospital by ambulance. Opening statement 'I've been getting attacks of palpitations and dizziness over the past three days. ' In response to specific questioning.066 Performance Guidelines Condition 066 Palpitations and dizziness in a 50-year-old man AIMS OF STATION To assess the candidate's ability to take a medical history in a patient presenting to the Emergency Department with episodes of palpitations and dizziness. Your job is stressful as a company secretary and the company you work for is restructuring. Nothing you have tried seems to stop the attack.These are described as a fast beating of the heart going into the neck.

ventricular tachycardia. Considering possible underlying causes for his attacks. approximately 150/min and regular. There are no signs of cardiac failure. which he describes as a near-fainting experience. He is currently experiencing an attack. In addition the candidate is expected to explore possible underlying cardiac diseases. but no chest pain. supraventricular tachycardia. alcoholic cardiomyopathy. obesity and sedentary lifestyle. He is also at risk of ischaemic heart disease because of his smoking. in this case particularly the possibilities of hypertensive heart disease or alcoholic cardiomyopathy. always accompanies the palpitations. There is no evidence on history to suggest thyrotoxicosis. 364 . • Ability to provide a concise clinical summary This should be along the following lines and reflect the manner in which a junior doctor would describe the key features of the history to a registrar or consultant. probably atrial flutter. Examination otherwise is noncontnbutory • Diagnosis The most likely diagnosis is paroxysmal atrial arrhythmia. the context in which they occur. He has a high alcohol intake and has recently been under stress at work. Heart sounds show dual rhythm with no bruits and are synchronous with the pulse. The specific features of the palpitations. The potential causes for this arrhythmia are hypertensive heart disease.066 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient The candidate is expected to demonstrate professionalism. Three of the attacks have occurred in the evenings after his meal and one whilst driving. the potential risk factors and précipitants are all important elements of this patient's history. • History-taking skills The candidate is required to carefully define the two symptoms and how they relate. 'The patient is a 50-year-old company secretary who presents with his fourth attack of palpitations and dizziness over the past 3 days. ' The examiner will provide physical examination findings to the candidate as follows: Physical examination He is an overweight. blood pressure is 150/96 mmHg. The differential diagnosis includes atrial fibrillation. they come on suddenly and stop suddenly and the dizziness. Each attack lasts approximately 2 hours. the rapid. The attacks are also associated with shortness of breath and sweating. The nature of the palpitations is that they appear to be rapid. Pulse is 150/min and regular. he has a history of high blood pressure but no known cardiac disease. The key features that suggest this diagnosis are the sudden onset and offset. regular palpitations and the rate. empathy and good communication skills. ischaemic heart disease or occult thyrotoxicosis. anxious man in some distress while sitting or lying on a couch.

Atrial flutter with variable block KEY ISSUES • Approach to patient — Sensitivity to the patient's discomfort and a calm and professional manner. 365 . the context in which it has arisen. FIGURE 2.066 Performance Guidelines • Interpretation of ECG The ECG shows the following features: CONDITION 066. the associated symptoms and the arrhythmia risk factors. • Failure to correctly interpret the ECG features of atrial flutter. CRITICAL ERRORS • Failure to consider the diagnosis of atrial tachyarrhythmia on the history. • Diagnosis/Differential diagnosis — The candidate must consider the diagnosis of atrial arrhythmia and the potential contributions of hypertension and alcohol. • Interpretation of investigation — The most important findings on the 12-lead ECG must be defined: atrial flutter with variable block. • Commentary to examiner — This needs to be a succinct summary which brings together the key features of the presenting complaint. • History — The ability to take an appropriate and focused medical history with careful definition of the symptom characteristics and showing an awareness of the likely causes and précipitants of cardiac arrhythmias.

It is important to determine whether this is regular or irregular and whether there are any associated symptoms. Wyse DG.066 Performance Guidelines COMMENTARY1 2 3 Palpitations are the symptom of an abnormal awareness of heart rate. A common problem encountered in older patients with hypertensive heart disease who develop atrial fibrillation is that the presence of a poorly compliant (stiff) left ventricle renders them quite intolerant to this arrhythmia. atrial fibrillation (AF) usually presents with an irregular ventricular rate of 160-180/min. Waldo AL. Isolated forceful beats ('thump in the chest') are usually caused by ectopic beats. where the natural history is not clear. Rarely conduction occurs 1:1. 366 . A comparison of rate control and rhythm control in patients with atrial fibrillation. DiMarco JP. Schron EB. Patients may progress from one to another. from 4:1 to 2:1 block). where there is loss of the contribution of atrial contraction to ventricular filling. Anxious patients may be aware of their normal heartbeat. atrial fibrillation tends to fall into one of three clinical patterns (the so-called 'three Ps'). Atrial flutter with 4:1 block In untreated patients with a normal AV node. It is often misdiagnosed as supraventricular tachycardia. giving a ventricular rate of 300/min and severe symptoms. rhythm or force of the heartbeats or some combination of these. leading to left heart failure. 347: 1825-33. and 1 2 3 Therapeutic Guidelines Cardiovascular Version 4 2003. Persistent AF (episodes persist for days or weeks unless active measures are taken to revert to sinus rhythm). Domanski MJ. et al. the rhythm. Atrial flutter usually presents with 2:1 atrioventricular block and a regular ventricular rate of 150/min. An example of atrial flutter with 4:1 block is seen in the figure below (Figure 3). underlying cardiac disease and patient characteristics. N ew E n g l and J o ur n al o f Me di c i ne 2002. Patients may be asymptomatic except when the rate changes (e. Much more frequently greater degrees of AV block are present giving ventricular rates of 100 (3:1 block) or 75 (4:1 block). Awareness of a fast heart rate usually occurs when this is of recent origin. These patterns are: • • Paroxysmal AF (episodes which come on suddenly and usually revert spontaneously within 48 hours). Note the characteristic saw-tooth appearance of the P waves. 274: 234-39. Patients may also report their heart 'misses a beat'. M e di cal Jo urn al o f Austr al i a 2001. Non-valvular arial fibrillation and stroke prevention. Apart from the first episode. usually due either to a compensatory pause after a ventricular ectopic beat or a nonforceful ectopic beat. Hankey GJ. It is important to ask the patient to tap out with a finger what is noticed when the palpitations arise. Older patients with impaired AV conduction can often present with lower rates. CONDITION 066. They may be due to a change in the rate. The development of symptoms in a patient with an atrial arrhythmia will depend on the rate.g. Rosenberg Y. FIGURE 3.

Atrial fibrillation It is important to identify and manage underlying causes of atrial tachyarrhythmias (for example. Patients with persistent and paroxysmal AF have at least the same risk of thromboembolism as patients with permanent AF. Note that the rhythm is irregularly irregular and that no P waves can be seen. The pharmacotherapeutic approaches to atrial fibrillation and flutter are very similar. however atrial flutter commonly responds very easily to a low energy direct current shock or to pace cardioversion and is often relatively insensitive to antiarrhythmic drugs. CONDITION 066.066 Performance Guidelines • Permanent AF (inability to sustain sinus rhythm for any length of time or decision made not to try to revert the rhythm). FIGURE 4. An example of atrial fibrillation is illustrated (Figure 4). atrial septal defect). thyrotoxicosis. Treatment of these two common arrhythmias needs to be considered under two headings: treatment of the arrhythmia itself and prophylaxis against thromboembolic complications. heart failure. mitral valve disease. hypertension. 367 .

Opening statement 'I'm feeling weak and tired which is not like me. but from a different doctor. Over the last six months you have also felt an increasingly strong urge to pass urine when standing up after sitting (e. respond as for yourself. No weight loss. So far you have not lost control or soiled yourself. You think that reduction in the amount of beer you drink after work from 4 to 5 glasses to 1 or 2 has helped. • In response to appropriate questioning: • The stream of urine is poor and you find it hard to finish. symptoms of prostatism and the patient's concerns about their cause. habits or social history. by telling the doctor that: • • Symptoms have only developed over the last six months or so. I'm also ha ving trouble with my waterworks. You also have had to pass urine more frequently at night. This is not constant and not severe. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows You are a 54-year-old newsagent. You have always kept in good health. The urine does not smell abnormally. family history. Passing urine is not painful. In particular. You have learnt to empty your bladder before going out or sitting for long periods. on getting out of your car or after watching TV for an hour or so). No marital. no cardiovascular or other neurological symptoms and no related symptoms such as tremor or stiffness. It gets worse towards the end of the day and you have attributed this to tiredness (long working hours) and increasing age. You still play tennis on Sunday but the power in your game has 'gone'.g. Your medication is hydrochlorothiazide 25 mg (Dithiazide®) each morning. • 368 . Other body systems are normal. Some nights you have to get up at three or four times and then have trouble in starting the passage of urine. while also being aware of the possibility of an adverse drug reaction. You have also had some cramps in your calf muscles. If asked about your past history. You have felt tired and have noted a feeling of weakness in your muscles over the past few weeks. • • Other significant information: • You commenced treatment for 'mild blood pressure' about eight months ago. with annoying dribbling. family or financial problems. You are on your feet all day in the newsagency. Sexual intercourse and ejaculation are not affected except for reduced frequency in recent years. if not interrupted by direct questioning. ' Follow this. All your muscles seem to be affected. The candidate should know the essential components of a selective physical examination and essential investigations to confirm the diagnosis and exclude other conditions.067 Performance Guidelines Condition 067 Muscle weakness and urinary symptoms in a 60-year-old man AIMS OF STATION To assess the candidate's ability to take a focused history regarding muscle weakness.

urgency and dribbling and medication (for hypertension — use of thiazide diuretic should be elicited). You have also thought of the possibility that your symptoms might be caused by your medication. EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient ~ Use of appropriate communication skills to define the salient points of the history. TABLE 1. • After obtaining the results of the investigations from the examiner. cramps. the candidate will briefly explain the cause of your symptoms to you. • History ~ Identification of muscular weakness. simply accept what is said. Patient concern about cancer should be recognised. Do not question the doctor. Features which should be sought: Urine office testing — normal on chemical testing 369 . If asked other questions. • Physical examination ~ The candidate should ask the examiner for certain findings based on diagnostic possibilities suggested by the history. urinary frequency. Examination findings General appearance Pallor Pulse Blood pressure Heart Abdomen Neurological examination (limited) power of limbs tone reflexes sensation degree of enlargement both lobes consistency tenderness surface nodularity/induration looks well absent 72/min regular lying 154/92 mmHg and standing 148/90 mmHg normal normal possibly slightly reduced normal normal normal moderate yes firm but not hard no smooth no PR —the prostate is enlarged.067 Performance Guidelines • You are very puzzled by your muscle weakness. You are also concerned about the urinary symptoms and worried that you could have prostate cancer. respond as for yourself. Results will be provided for specific requests as follows: CONDITION 067. • The doctor may not seek all this information.

Explanation to patient that the likely diagnosis is hypokalaemia (reversible) as the cause of muscle weakness together with benign prostatomegaly. Investigations of serum electrolytes (particularly potassium levels). Examination for pallor. ~ Enlargement of prostate is the cause of the urinary symptoms. Reassure that malignancy is very unlikely but that referral to a urologist is advisable for probable operative treatment. 370 . and his symptoms of musde weakness began after starting this medication. urine microscopy and culture and cytology. renal function tests. neurological (limited). Investigations including serum electrolytes and creatinine. abdomen. heart. FBE. fear of cancer. The other dominant cue is picked up by systems review giving the information that the patient has been on a thiazide diuretic for eight months. KEY ISSUES • • • • History-taking to identify weakness. prostatism. pulse and BP. ECG. which could be contributing to his muscle weakness and muscle cramps through hypokalaemia. Even so-called potassium-sparing thiazide diuretics can be associated with potassium depletion.067 Performance Guidelines • The following investigations should be suggested: ~ Serum potassium ~ Haemoglobin and full blood examination ~ Prostate specific antigen (PSA) ~ Microscopy and culture of midstream urine Explanation to patient ~ How low potassium due to use of a diuretic tablet for treatment of elevated blood pressure could be the cause of the weakness. COMMENTARY Muscle weakness and fatigue are common symptoms with multiple aetiologies. PSA. and caused potassium loss. CRITICAL ERRORS • • Failure to do rectal examination. current medication. In this scenario the first dominant cue is the association of tiredness and weakness with urinary symptoms. ~ Cease Dithiazide® and perform followup checks of blood pressure for further management. These latter symptoms and the signs of benign prostatic enlargement suggest bladderneck obstruction requiring further investigation and referral. and full blood examination would be mandatory in a patient of this age with symptoms as described. urine cytology and culture. The diuretic polyuria may have brought to light previously nonsymptomatic prostatic pathology. Reassure the patient regarding cancer. rectal examination. Failure to suggest appropriate investigations. Effects are fully reversible. which will include examination of tissue for cancer cells.

~ Rectal examination to check prostate — normal.068 Performance Guidelines Condition 068 Aches and pains in a 62-year-old man AIMS OF STATION To assess the candidate's knowledge of the clinical presentation of polymyalgia rheumatica and the way in which this diagnosis is confirmed or excluded. . normal 70/min regular 140/80 mmHg ~ Muscle groups of neck. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a retired office worker and will be advised by the candidate of the diagnostic and management plans. abdomen. ~ Examination of lymph nodes.Normal power and tone and coordination of movements. The examination does not reveal any specific diagnostic features but erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) would be expected to confirm the diagnosis. These show no abnormalities and a full range of movement. lymphoma. upper and lower limbs should be examined. 371 . the examiner will ask the candidate • 'What is your provisional diagnosis and differential diagnosis?' • 'What further tests will you advise?' • 'Please now give to the patient your diagnostic and management plans. neck. . particularly hands. shoulders. EXPECTATIONS OF CANDIDATE PERFORMANCE Physical examination findings to be sought: • Essential features of focused physical examination to be given to candidate on request by the examiner. Underlying malignancy should be a consideration. ~ Temperature ~ Pulse ~ Blood pressure 37 °C. ' Diagnosis/Differential diagnosis Polymyalgia rheumatica should be suspected from the history. carcinoma) — normal findings. trunk.Active movement of neck.Examination of joints. . and respiratory systems is expected to exclude any medical conditions that could possibly give rise to this constellation of symptoms (e. shoulder and trunk muscles causes discomfort.g. sacroiliac joints and hips. After providing results of physicai examination.

Management The candidate is expected to indicate to the patient that if the blood tests confirm the suspected diagnosis of polymyalgia rheumatica. The myalgia is symmetric and often begins in the shoulders. how it is given and monitored. There is often a disparity between the severity of myalgia reported and the physical findings. characterised by aching pains across the shoulders and upper back. may follow a viral infection and the dominant feature is incapacitating fatigue with other medical symptoms of subjective memory impairment. Differential diagnosis to be considered would include: ~ Chronic fatigue syndrome: This condition is a 'medically unexplained condition'. CRITICAL ERROR • Failure to request ESR and/or C-reactive protein. The incidence varies with ethnicity and these conditions are more common in people of Northern European descent. KEY ISSUES • • • Focused physical examination which must include musculoskeletal system plus rectal examination. specifically ESR and C-reactive protein. spiking fevers are rare. headaches. poor sleep pattern and often additional constitutional symptoms. lymph node tenderness. generalised muscle pains. poor sleep. and full blood examination (FBE). malaise and depression. CRP and FBE are normal. Polymyalgia rheumatica as the most likely diagnosis. shoulders and hip girdles. The diagnosis in this instance would be confirmed by investigations. then the patient is likely to have a good response to a limited course of prednisolone which may need to be given for up to two years. visual disturbance or pain in the jaw when eating. ESR. Muscle strength is normal but can appear diminished because of pain. The patient should be advised to report any severe headaches. postexertional malaise lasting more than 24 hours. 372 . ~ 'Fibromyalgia': Another of the 'medically unexplained' conditions. It is usually seen in younger patients. It is best viewed as a symptom complex resulting from interaction of physical and psychosocial factors. The ESR. skin tenderness. • • Treatment of polymyalgia rheumatica is with oral prednisolone. CRP and FBE tests are normal. but that any such treatment. Polymyalgia rheumatica commonly presents in middle aged or elderly patients with diffuse symptoms of muscle pain particularly in the neck. must await the results of the tests. COMMENTARY Polymyalgia rheumatica and giant cell arteritis are linked conditions of unknown aetiology. since giant cell arteritis can occur together with polymyalgia rheumatica. There are often constitutional symptoms including weight loss. initially in high dosage. Investigate with ESR and/or CRP.

lung cancer.068 Performance Guidelines ~ Polymyositis: This is an uncommon inflammatory muscle disorder that may be associated with an underlying neoplasm in older patients. A positive muscle biopsy is diagnostic. ~ Underlying malignancy: prostate. associated with some atrophy with disproportionate weakness. breast in females. ESR. 373 . CRP and FBE abnormalities may be indistinguishable from polymyalgia rheumatica but elevated creatine kinase and abnormal autoantibodies are characteristic. often commencing in the neck. shoulder girdle and proximal limb muscles. The most frequently encountered mode of presentation is the onset of painful muscles and proximal muscle weakness. multiple myeloma.

you thought due to your age.069 Performance Guidelines Condition 069 Lack of energy in a 56-year-old suntanned man AIMS OF STATION To assess the candidate's ability to diagnose the cause of tiredness and lack of energy in a 56-year-old man. hips and knees. The aches and pains are mainly in your shoulders. There have been no significant past illnesses. Opening statement 'I have felt very tired lately and for no apparent reason. In response to specific questions respond as indicated: • • • • • • • • • • The tiredness is constant and not improved by resting or sleeping (you sleep well). You do not smoke or drink any alcohol. You have just returned from holidays in Queensland. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 56-year-old industrial chemist. The muscles are not sore. 374 . Your sexual activity has been less than before. About three or four months ago you also noticed aches and pains in your joints which have persisted. The weight loss is 3-4 kg. You have also noticed palpitations at times — mainly when going off to sleep. You have noticed that you have developed a suntan even though you don't spend much time outdoors. There is no significant family history but you were adopted and know little about your parents. There is some tenderness and swelling in wrists and elbows and pains in the shoulders. and did not do much swimming on holiday. when your heart seems to speed up and miss beats for a few minutes at a time. You don't feel depressed In response to all other questions deny any other symptoms. ' Story in Detail Without prompting — you have felt tired and lethargic since you retired about a year ago You attributed this to a lack of mental stimulation from what was a demanding job. You also realised that you had lost some weight which is why you decided to see the doctor.

drugs causing photosensitivity (for example. The additional symptoms of palpitations. 5 cm enlargement of liver — firm nontender liver edge testes softer and smaller than usual for age positive for glucose. ~ Pulse ~ Blood pressure ~ Heart ~ Abdomen ~ Genitalia ~ Urine 375 . The examiner will respond to a request with the following specifics: ~ Distribution of hyperpigmentation — generalised over body but not mucos ~ Joints swelling and some tenderness of wrists. and ~ using direct and indirect questioning in a logical. certain antibiotics. porphyria. relevant and non-threatening manner. arthralgia and weight loss. malnutrition/malabsorption. indicate there is a multisystem disorder. amiodarone). Limitation of range of movements and tenderness of the shoulder joints irregular. phenothiazines. in the absence of other symptoms or significant past history. • History-taking — The candidate is expected to take a comprehensive history in a patient presenting with the symptoms of tiredness. • Choice of investigations — The candidate should indicate the need for: ~ full blood examination and erythrocyte sedimentation rate. their choice of investigations and/or referral will indicate the level of performance. However most candidates will require the examination findings to assist in the diagnostic formulation. psoralens. change in skin colour and loss of libido.069 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient — The candidate should show skill in: ~ listening and facilitation of presenting symptoms. cirrhosis. If the candidate does not recognise the significance of the constellation of symptoms and signs. atrial fibrillation. Details of treatment are not required in this case. elbows and knees. ~ creatinine and electrolytes ~ serum iron studies (especially transferrin saturation) ~ liver function tests ~ test for gene for haemochromatosis (HFE) gene If the candidate suspects haemochromatosis the next steps in the confirmation of the diagnosis should be explained to the patient. no signs of cardiac failure. Specialist referral would be expected for further assessment and management. hyperthyroidism. Cushing disease. Diabetes confirmed by random blood sugar of 12 mmol/L • Diagnosis/Differential diagnosis — The patient presents the classical clinical picture of haemochromatosis ~ Other causes of increased pigmentation — Addison disease. confirmed by office ECG 140/90 mmHg no additional findings. chronic renal failure. • Examination requests should be made for specific diagnostic features.

Repeated blood transfusions can cause secondary haemochromatosis. transferrin and transferrin saturation. testicular atrophy and hyperglycaemia make a clinical diagnosis possible. The homozygous state is present in 1:150 in Australia with 1 in 10 carriers (1 in 300 blood donors have iron overload) and is more common in people of Celtic or Northern European background. arthritis. joint pains and weight loss. liver. cardiac. plus testing for the gene for haemochromatosis (HFE gene). ferritin. Choice of investigations — these should be appropriate to the investigation of the multisystem disease. cardiovascular system. The candidate should indicate the need to examine the pulse. liver damage and pituitary failure. hepatomegaly. The critical confirmatory investigations are iron studies — serum iron. • • • CRITICAL ERROR . Choice and sequence of examination — examination of the joints and of the features of skin pigmentation is expected. and endocrine systems disorder should be sensibly discussed. Fatigue.069 Performance Guidelines KEY ISSUES • History-taking — the candidate is expected to exhibit appropriate history-taking skills and obtain the key features of the illness given the patients initial presenting complaints of tiredness. Typical manifestations are bronze skin pigmentation. cardiomyopathy. total iron binding capacity. arthralgia and abdominal pain are leading symptoms. However a consideration of the causes of the multisystem disease with skin pigmentation. 376 . This will require a systematic approach to history-taking and the multisystem nature of the complaints requires a comprehensive but concise history. while detection of atrial fibrillation. The primary form is an autosomal recessive condition.none defined COMMENTARY In primary haemochromatosis there is increased absorption of iron from a normal diet. diabetes (60%). known also as 'Bronze Diabetes'. abdomen and to look for evidence of endocrine dysfunction. Diagnosis/Differential diagnosis — the condition of haemochromatosis may not be apparent to the candidate on the history and examination findings.

In a patient with liver problems. They have just finished taking a history. You've been trying to give this up but you have had limited success. It is likely that the candidates will want to measure your blood pressure and feel the pulses in your arms. You have given a past history of a previous admission six months ago with a similar episode of vomiting blood which settled spontaneously. Once candidates indicate they would take the blood pressure. The HMO who has taken your history is about to examine you. and will be informed there is a fresh melaena stool on the glove. You were warned about the effects of continued drinking. face. On this occasion you vomited a large amount of fresh blood two hours ago — you think it might have been a pint or so (500 ml_). EXPECTATIONS OF CANDIDATE PERFORMANCE Candidates should first look for evidence of haemodynamic compromise (looking for evidence of hypotension and postural drop. the findings will be evident on examination. They are not expected to take a further history from you. and you were discharged after a few days.070 Performance Guidelines Condition 070 Recent haematemesis in a 50-year-old man AlMS OF STATION To assess the candidate's clinical perspective in examining a patient presenting to the Emergency Department with an acute haematemesis. As the bleeding occurred only two hours ago. they can be told that the BP is 110/70 mmHg and pulse 90/min. chest and abdomen. Your wife has driven you to hospital where the Hospital Medical Officer (HMO) has taken your history You are lying on the couch undressed to your underclothes and wearing a hospital gown. You felt temporarily faint and broke into a sweat. and will have been previously checked by the examiner. 377 . Candidates should indicate that they would do a rectal examination looking for a melaena stool. this assessment is particularly important. You have not vomited since. To check abilities to examine for evidence of chronic liver disease. pulse. peripheral perfusion). EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: The candidates have been told that you have vomited up a large quantity of blood two hours ago and they have been instructed to undertake a relevant physical examination. They will also examine your hands. You had an endoscopy through the mouth and you were told you had dilated veins at the lower end of the oesophagus leading into the stomach.

spiders. gynaecomastia. correctly position him supine with appropriate exposure to examine the whole abdomen. and a clinical evaluation of how well the periphery and vital tissues are perfused. Thus the physical examination must start with measurement of the blood pressure (lying and sitting. head and neck and upper limbs. cold and clammy. Failure to look for evidence of liver failure and portal hypertension. Make an appropriate examination looking for evidence of chronic liver disease (examination of hands — liver palms. Percuss for evidence of liver and splenic enlargement. if necessary) and pulse. Check for evidence of ascites. leuconychia. by palpation for shifting dullness or fluid thrill. oral cavity and tongue. if necessary. • CRITICAL ERRORS • • Failure to assess the haemodynamic state of the patient. testicular atrophy. the candidate should: • • Put the patient at ease. the physical examination must cease at this stage and the patient must be resuscitated. bowel sounds. 378 . portal hypertension (dilated veins and splenomegaly). ascites. Identification of the cause of the haemorrhage. Satisfactory commentary to examiner. This patient has had a large haemorrhage and the airway couid be compromised. Breathing. parotid enlargement. bruit. Palpate the abdomen adequately for hepatic and splenic enlargement. Is the patient shocked. Auscultate abdomen for venous hum. • • Assessment of the cardiovascular state of the patient and provision of prompt resuscitation. Circulation) of immediate resuscitation. • • • • • • • KEY ISSUES • • Performing a satisfactory physical examination pertinent to an episode of acute haematemesis in a patient in whom evidence of chronic liver disease should be sought Accuracy of examination will be a key issue for the mark sheet when a real patient is involved.070 Performance Guidelines After assessment of stable haemodynamic status as first priority. clubbing). easy bruising. groin. Examine for liver flap. so it is unlikely that there is a major problem with the airway or breathing. spider naevi elsewhere. with a shutdown peripheral circulation? If the patient is shocked. COMMENTARY In this important and common emergency room setting there are three issues the doctor must focus on: • Checking the ABC (Airway. In this scenario the patient appears fully conscious and is able to give a detailed history. Perform the examination in a logical sequence. Provide a logical description concerning the examination.

The assessment now concentrates on the technique and accuracy of physical examination as key issues. the hereditary haemorrhagic telangiectasia associated with the Osler-Weber-Rendu syndrome. for example. Occasionally. portal hypertension and bleeding oesophageal varices. In this emergency department scenario the emphasis is FIRSTLY on assessment of stable or unstable haemodynamic status in a patient with recent haematemesis. which is expected to be present. in which a real patient with liver disease is to be assessed after admission to the ward and institution of an intravenous drip while blood is being typed and cross-matched. Signs associated with chronic liver disease apart from hepatomegaly include nail changes (leukonychia). gynaecomastia and spider naevi. Although the patient's past history has suggested that the cause is alcoholic liver disease. a methodical examination may be undertaken to look for the cause of the haemorrhage. testicular atrophy. Abdominal distension — Ascites 379 . salivary gland enlargement. CONDITION 070. Portal hypertension may be manifest by the signs of hypersplenism (purpuric haemorrhage). splenomegaly and collateral venous channels. this should not be assumed as many patients with known varices will be bleeding from another cause. The examination should look for: • signs associated with chronic liver disease: • signs of possible liver failure. If the liver is failing. FIGURES 1 AND 2. The latter may be visible in the anterior abdominal wall as communications between the umbilical vein and the epigastric venous channels flowing back into the systemic circulation. and • any other clues suggesting a different aetiology for the haemorrhage.070 Performance Guidelines Provided the patient is stable. the physical examination will reveal other signs that might be associated with haemorrhage. Of more sinister import are the oesophageal mucosal collaterals that form between the portal and azygos systems through decompression along the left gastric (coronary) vein. Encephalopathy may have a variety of presentations. through to coma. the patient may have ascites and encephalopathic changes. • signs of portal hypertension. The instructions will in that case state that the patient is now haemodynamically stable and the emphasis of the task is to assess the patient for evidence of chronic liver disease. ranging from minor mental impairment and flap. Variations on this theme are also used.

and confirmed the period of gestation. No iron tablets have been taken during the pregnancy. You are Australian born as were your parents. and folic acid deficiency associated with a multiple pregnancy need to be excluded. and there is no Mediterranean heritage in the family You have not had a full blood examination (FBE) done before in this pregnancy. You did not take iron tablets during these pregnancies: your haemoglobin was always greater than 100 g/L when previously tested. Diet — you eat meat occasionally. Having made the appropriate diagnosis iron therapy should be prescribed. this showed a singleton pregnancy was present. No vaginal bleeding has occurred during the pregnancy. you have always lived in Southern Australia. You noted no excessive blood loss before or between pregnancies — periods have not been heavy. List of appropriate answers to questions • • • • • • • • • • Previous obstetric history — you have had three pregnancies during the last four years. You have had no bleeding from the bowel. and there has been no suggestion of malaria or hookworm infestation. You had an ultrasound examination at 18 weeks of gestation. you don't like green vegetables. There is no family history of /^thalassaemia or of anaemia generally.071 Performance Guidelines Condition 071 Anaemia in a 28-year-old pregnant woman AIMS OF STATION To assess the candidate's ability to define the possible causes of anaemia in pregnancy and to arrange appropriate investigations and advise the patient concerning the diagnosis and treatment. EXAMINER INSTRUCTIONS The examiner will instruct the patient as follows: The list of responses below is likely to cover most of the questions you will be asked. but other causes of anaemia including thalassaemia. You have a supportive partner who assists at home. The most likely diagnosis is iron deficiency anaemia due to the demands of three pregnancies in a short time interval. Questions to ask if not already covered: • • • • 'Why have I become anaemic?' 'Will my anaemia harm my baby?' 'Do I need a blood transfusion?' 'How quickly will my haemoglobin come up?' 380 . No postpartum haemorrhage.

• A satisfactory response to oral iron therapy should be able to be achieved well ahead of the time that delivery is likely. however the babies are usually smaller. or blood transfusion. Providing the anaemia can be treated satisfactorily. • Failure to administer oral iron therapy. In the absence of adequate treatment the placenta becomes larger.071 Performance Guidelines Examination findings to be given to the candidate from the examiner on request Apart from looking pale. • If the FBE suggests possible /Mhalassaemia minor. • Treatment with iron tablets should begin after taking blood for investigation (Ferro-Gradumet® or Fefol®). EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to patient (the candidate should convey the substance of what follows to the patient): • She needs an FBE to check on the form of anaemia which is present. general examination is normal. KEY ISSUES • Ability to evaluate appropriately a patient who has become anaemic during pregnancy. If the haemoglobin does not increase satisfactorily. along with a reticulocyte count. referral to a haematologist for advice concerning diagnosis and treatment would be appropriate. • Recommending blood transfusion at this time. • She requires assessment of her iron status — serum iron or ferritin levels should also be checked. Two tablets should be taken a day. haemoglobin electropheresis will also be required. there should be little effect on the pregnancy. The uterus is enlarged to about 4 cm above the umbilicus and measures 26 cm above the pubic symphysis. she should be warned about the possible effects of these in causing constipation and dark stools. 381 . Investigation results None has been recorded for this pregnancy other than the ultrasound. • Ability to commence treatment and arrange appropriate followup in such a patient. The haemoglobin should be checked again in two weeks. There is no need for parenteral iron therapy at this time. CRITICAL ERRORS • Failure to make a provisional diagnosis of probable iron-deficiency anaemia due to the demands of successive pregnancies.

It is also important to remember that blood transfusion is not indicated under these circumstances in mid-pregnancy. loss from other sites. and the assessment of serum iron or ferritin levels. Common problems likely with candidate performance are: • • Failing to focus on other causes of anaemia when taking the history — failing to ask about menstrual loss. Failing to arrange appropriate blood tests which would include haemoglobin electrophoresis if the anaemia is hypochromic and microcytic without evidence of iron deficiency. This is the most common form of anaemia under these circumstances and whilst other less common forms of anaemia should be considered. and failing to consider the possibility of thalassaemia minor. 382 . it is important to commence treatment for simple iron deficiency anaemia whilst awaiting the results of investigations.071 Performance Guidelines COMMENTARY This case illustrates a common problem of iron deficiency anaemia in a young woman who has had a number of pregnancies in a short period of time.

Give a full account of your symptoms unless interrupted by the doctor taking control of the interview at too early a stage. It's like being on a merry-go-round! ' Story in detail without prompting 'This morning just over an hour ago. You suspect that your taste has been affected). • No hoarseness (if asked about swallowing. ' 'My head felt as if it was exploding. • Everything seems to be moving and spinning around you. ' 'My wife got me into bed and then I felt sick and vomited. You are very concerned that you are having a stroke. I keep falling this way (indicate to the left). Appear apprehensive and agitated. It was like being very seasick. I had to lie very still or I wanted to vomit. Your blood pressure has been variable. Your speech has now returned to normal after initial slurring Review of general health Apart from being overweight and having treatment for high blood pressure and high cholesterol. • No persisting headache or neck stiffness. I was having breakfast when I felt a pain in the left side of my face (indicate the left side). • No previous episodes. I found it hard to get in and out of the car. So I rested while she rang you. let alone stand up. No more vomiting. you did feel that it was difficult to swallow your saliva. Then I started to feel numb up and down the other side of my body (indicate the right side) and I became so dizzy that I couldn't even sit up. Lipid levels stable. 383 . Lean towards your left side. but that feeling has now gone. you feel you have been in good health. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Opening statement 'I feel so dizzy that I can hardly stand up. and my speech was funny and slurred. If I turn my head to the side the dizziness gets worse. Hold firmly onto the desk or chair to keep yourself steady. involving the trunk and limbs.072 Performance Guidelines Condition 072 Acute vertigo in a 50-year-old man AIMS OF STATION To assess the candidate's ability to diagnose an acute vascular 'stroke' presenting with vertigo. • You still have a feeling of numbness down your right side. • The pain has gone from your face but the cheek (left) now feels numb too. Although you have just suffered a cerebral event your ability to give a satisfactory history is not impaired. Am I having a stroke?' In answer to the doctor's questions • You are feeling a little better now but would prefer to lie down.

but no motor weakness or other motor signs are present. the examiner will hand to the candidate a separate sheet giving an outline of physical findings as set out in the box below. Appreciation of pain and temperature sensation is reduced down the whole of the right side of the body below the face. After the history is finished. Family history • • • Mother died from stroke at 65 years. ~ Hyperlipidaemia identified about 6 years ago. You and your wife live in your own home.072 Performance Guidelines Social history You are married. You work as a postman. Vibration and joint position sense and light touch sensation are normal. You drink alcohol only occasionally. EXPECTATIONS OF CANDIDATE PERFORMANCE Abilities in communication skills and in diagnostic problem solving are required. Father was diabetic. ~ Both conditions have been well controlled. Nystagmus to the left on looking to the left is present. The skill required is in listening carefully. Current medication Norvasc® (amlodipine) 10 mg once daily (calcium channel blocker). pulse 80/min and regular. Hearing is normal in both ears. Avapro® (irbesartan) 150 mg once daily (angiotensin II receptor antagonist). Pain sensation to pinprick is lost on the left side of the face and the direct corneal reflex is absent. prompting or facilitating when necessary and leaving questions to confirm clinical suspicion until after the patient has finished. The main findings on neurologic examination are that he has an ataxic gait and postural unsteadiness without significant change on closing eyes. Power of the muscles of mastication is normal. Physical Findings Cardiovascular examination is normal — blood pressure 145/85 mmHg. 384 . A left Horner syndrome is present (ptosis. miosis of pupil). Lipitor® (atorvastatin) 10 mg once daily (CoA reductase inhibitor). died from heart attack aged 59 years. He has some incoordination of movement of the left arm and hand. You do not smoke. Cranial Nerves • • • • • • • Eye movements and pupil reactions are normal as is fundoscopy. This patient is able to give a very full picture of the onset of the condition. Major continuing health problems are: ~ Hypertension for about 10 years.

Advise that the patient has had a 'mild stroke' as suspected. • Ability to use clinical reasoning skills to explain neurological signs found on physical examination. • Appreciating the need for further assessment on an urgent basis. particularly loss of pain sensation to left face but to opposite side of trunk and limbs. This should include urgent assessment by a specialist physician/neurologist. but other potential causes of vertigo include • acute labyrinthitis • benign paroxysmal vertigo • Meniere syndrome • migraine • cerebral tumour • multiple sclerosis Response to patient and immediate management There is a need for immediate hospital admission. The cerebellum and brain stem are the areas involved. • Appreciation of cardiovascular risk in this patient. however. associated symptoms and signs and lack of further progression suggest vascular obstruction rather than haemorrhage.072 Performance Guidelines Presentation to the examiner requires diagnostic problem-solving skills about: • Causes of vertigo of sudden onset including stroke or transient ischaemic attack. • Knowledge of the clinical picture presented by obstruction of the blood supply to the brain stem and cerebellum. The inclusion of a neurological case of this complexity may be more threatening to candidates than other cases. recognises that the presence of neurological signs as described. Response to observing examiner The candidate should recognise that vertigo is of central brain stem/cerebellar origin rather than peripheral vestibular origin. Examiners are asked to take this into account when marking. • Choosing the investigation most urgently required. then a clear pass level would be achieved. Differential diagnosis All unlikely. 385 . but that confirmatory investigation is necessary. Its acute onset. It would be reasonable to reassure the patient about the future but to emphasise the need to pay attention to the underlying risk factors which will require ongoing management after recovery from this event. • Significance of crossed signs. is indicative of a brain stem lesion and realises that this is a serious disorder of cerebrovascular origin involving the cerebellum/brain stem and that it requires urgent investigation. If the candidate obtains a detailed history. makes a reasonable attempt at explaining the findings on neurological examination. well documented and should not be an unduly difficult diagnosis for a well prepared candidate to suspect from the history and confirm by the physical findings. in addition to nystagmus. The posterior inferior cerebellar artery (PICA) syndrome is.

Embolism is also possible. There is loss of pain sensation on the left side of the face. KEY ISSUES • • • Recognition of an acute cerebral vascular event affecting the vertebrobasilar system. in particular a disturbed gait) suggesting an acute cerebellar disturbance. most likely due to thrombosis of the vertebral artery. the sudden onset of vertigo has not been associated with tinnitus or hearing loss. Failure to advise hospital admission. in upper and lower limbs. Immediate management including appropriate investigation. so the vestibulocochlear system seems likely to be intact. without any weakness.072 Performance Guidelines Investigations Magnetic resonance imaging (MRI) should be advised associated with hospital admission.e. (where decussation of the uncrossed fibres of vibration and joint sense [and half touch] in the posterior columns occurs to join previously crossed pain and temperature fibres [and half touch] running in the spinothalamic tracts) as illustrated in Figure 1. True vertigo (a sense of rotation between patient and surroundings) is in this instance accompanied by ataxia (= Greek. Relationship of this episode to the patient's cardiovascular risk factors should be recognised. Data assimilation from history and examination. Other investigations can be undertaken later. A cerebellar source is also suggested by the motor incoordination. The combination of cerebellar ataxia and crossed sensory loss suggests a left sided lower midbrain and cerebellar lesion 386 . Appreciation that this combination of symptoms and signs implies brain stem/cerebellar disease. Problem solving ability • • Clinical reasoning skills. CRITICAL ERRORS • • Failure to recognise likelihood of cerebral/cerebellar vascular lesion. Understanding that the pathology is in the area of the vertebrobasilar arterial system. Knowledge of the disease process Recognition that the patient has had a serious cerebrovascular incident (i. 'stroke'). but in the trunk and limbs there is dissociated anaesthesia — sensation of pain and temperature is impaired on the right side All forms of ascending sensation for projection into the contralateral cerebral hemisphere come together at the level of the medulla. Computed tomography (CT) with CT angiography is also acceptable. What else is going on? Other clinical features suggest that a unilateral lower brain stem disorder is also present Sensory loss to pain is crossed between the face and the body. COMMENTARY In this scenario. without order. Knowledgeable candidates may recognise the likelihood of posterior inferior cerebellar artery (PICA) obstruction.

the cervical sympathetic outflow is interrupted. Figure 1 Sensory Ascending Pathways Are any other brain stem nuclei or long tracts involved? Yes.072 Performance Guidelines CEREBRAL HEMISPHERE Internal Capsule MIDBRAIN PONS V n.t ) Pain Temperature 1 /2 Touch Spinal Cord Condition 072. 1/2 touch cross in upper medulla Cuneate & Gracile tubercles medial lemniscus Spinothalamic tract (s. Descending excitatory sympathetic fibres to the cervicothoracic outflow are also concentrated in the medulla. Loss of sensation to the left cheek suggests that the left 5th nerve sensory pain nucleus is involved. with loss also of the corneal reflex. vibration. 387 . There is a left Horner syndrome (which fits a left sided lesion) catching the sympathetic head and neck outflow. Sensory. nucleus All sensation modalities now conjoined and contralateral Position.

a anterior communicating artery a s a anterior spinal artery __________________________________________________________________________ CONDITION 072.a.c. vertebral artery b.a.i. The anatomy of the blood vessels and cranial nerves is as illustrated (Figures 2-5).a. FIGURE 2.072 Performance Guidelines The findings fit a left posterolateral lower lateral medullary and left cerebellar lesion This would be explained by a focal infarct involving the vertebrobasilar system.e.i. basilar artery a. anterior inferior cerebellar artery p.e. nofthe carotid and its branches. posterior inferior cerebellar artery a. 388 .BLOOD VESSELS & CRANIAL NERVES va. -A MIDBRAIN PONS -----C MEDULLA VENTRAL VIEW .

A CONDITION 072. 389 . The absence of progression. arising from basilar or vertebral arteries. so an acute thrombosis affecting a left sided artery supplying cerebellum and brain stem is most likely (distal left vertebral artery). and sudden onset make a haemorrhagic stroke less likely. FIGURE 3. Knowledgeable candidates may recognise that this cluster of symptoms and signs is classical of thrombosis of the posterior inferior cerebellar artery (PICA syndrome).SECTION MIDBRAIN . The cerebellum and brain stem receive their blood supply via the superior and inferior cerebellar arteries. and other neurological problems. The relevant vascular and cross sectional anatomy is indicated in Figures 2-5 3rd & 4th nerve Colliculi Ascending contralateral sensory pathways Descending sympathetic fibres Descending ipsilateral upper motor neurone pathways 4 CROSS . cerebellopontine angle tumour. The patient has coexisting vascular risk factors. chronic petrositis. The differential diagnosis would include other causes of vertigo: Meniere syndrome. There are no cardiac arrhythmias to favour embolism. None is as likely as a vascular stroke.072 Performance Guidelines The acuteness of onset suggests embolism or thrombosis.

072 Performance Guidelines CONDITION 072. FIGURE 4. 390 .

CONDITION 072.SECTION MEDULLA .072 Performance Guidelines CROSS . The patient made a rapid recovery. FIGURE 5. The patient's MRI is shown and demonstrates a left sided focal cerebellopontine vascular infarction. MRI of patient's head showing left cerebellar and brain stem ischaemic infarction 391 . FIGURE 6.C CONDITION 072.

usually without tinnitus or deafness. Cerebellar incoordination — Various tests evince incoordination of upper and lower limbs 'past-pointing'. miosis. and other medullary brain stem nuclei may be affected.072 Performance Guidelines Cerebellar functions include ipsilateral stabilisation of motor movements and coordination and balance.sensory ataxia due to loss of position sense is worse in dark conditions. as is an ipsilateral loss of facial sensation to pain due to 5th nerve involvement. Associated cerebral sympathetic paralysis with an ipsilateral Horner syndrome (ptosis. or rhythmic flexion-extension of ankle. facial sensation loss of taste to side of tongue and motor weakness disturbance of hearing difficulties with swallowing dysarthria The PICA syndrome classically presents. Additional brain stem damage may be found. anhydrosis. and a tendency to fall to the side of the lesion. Differentiation of different causes of ataxia can be helped by associated symptoms . 'finger-nose tests' with eyes open or closed. with a dramatic onset of cerebellar signs with ataxia and vertigo. 'dysdiadochokinesia' on rhythmic pronation-supination. or alternate hand slapping. Loss of pain and temperature sensation from opposite (right) side of the body due to involvement of left spinothalamic tract is also seen. for example: • • • • • ipsilateral ipsilateral ipsilateral ipsilateral ipsilateral 5th nerve 7th nerve 8th nerve 9th nerve 10th nerve muscles of mastication. Dissociated anaesthesia (diminution of pain and temperature sensation with retention of touch and of other forms of sensation) is classical of a brain stem or spinal lesion below the pons. or knee-shin-ankle placement by other foot. Ipsilateral dorsal column sensory loss (position and vibration sense) below the injury Contralateral spinothalamic loss (pain and temperature) below the injury 392 . Ipsilateral upper motor neuron lesion paralysis below the injury. The gait of sensory ataxia from bilateral dorsal column loss with loss of position sense is by contrast a high 'stamping' gait with positive Rombergism (instability standing with eyes shut). enophthalmos) from medullary brain stem involvement is common. Cerebellar Disturbances cause: Cerebellar ataxic gait — with a staggering broad based gait like a drunken sailor. as in this case. and occurs most notably in Brown-Séquard Syndrome (hemisection of cord) with findings as illustrated (Figure 7): • • • • Focal ipsilateral lower motor neuron lesion at the level of the spinal cord injury.

072 Performance Guidelines CONDITION 072. 393 . FIGURE 7.

If so. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 60 years. No incontinence. The doctor may ask additional questions about you. straightforward. You also have concerns about cancer (your father had prostate cancer) and loss of sexual function. except for some embarrassment over sexual activity. respond as follows but do not volunteer all this information without appropriate prompting by the doctor. You also suffer from leg cramps. ‘I suppose I need new glasses at my age. You have felt thirstier lately and your mouth has been dry. knowledge of the symptomatology and confirmatory testing for maturity onset Type 2 diabetes and the investigations which should be undertaken in a recently diagnosed diabetic. No other symptoms suggestive of prostatism with bladder neck obstruction. Opening Statement: ‘I seem to need to go to the toilet to pass urine more often lately doctor. worse at night.073 Performance Guidelines Condition 073 Urinary frequency in a 60-year-old man AIMS OF STATION To assess the candidate's history-taking skills. Admit to recent deterioration in eyesight. You are consulting your general practitioner about urinary symptoms. Be pleasant. You are a previous patient but not well known to the doctor. and your feet have felt slightly numb. Normal stream. ' Review of relevant systems No other deviations from normal. no serious illnesses. respond as follows: Smoking habits: Alcohol use: Drug sensitivities Family history: Past medical history: Nonsmoker Two cans light ale daily Nil Father died from a stroke aged 80 years — also had prostate cancer.’ In response to the doctor's enquiries. Admit to feeling tired recently — 'Maybe I'm just worried. Mother in nursing home — Dementia. Over about the last three months you have been passing urine more often during the day and have to get out of bed to pass urine at least twice each night. if asked. No chest pain or breathlessness.' Admit to loss of libido and inability to obtain and sustain an erection over last 3-4 months. No dysuria. You have been worried that your symptoms are due to prostate trouble because of your father's history and recent publicity about prostate cancer Review of general health You have lost 4 kg in weight. but these should not be immediately revealed to the doctor. over the past three months. You are worried about prostate cancer. 394 .

without evidence of prostatic enlargement or nodularity. Result of 21 mmol/L effectively confirms diagnosis of diabetes mellitus. CRITICAL ERROR • Failure to test urine or measure random blood sugar at this consultation 395 . Neurological examination is otherwise normal. Genital and rectal examinations are normal. EXPECTATIONS OF CANDIDATE PERFORMANCE • Summarise the problems presented by the patient: ~ urinary symptoms. triglycerides. examination and office tests). • Appropriate further investigation of newly diagnosed diabetic. • microscopy and culture urine — checking for microalbuminuria. negative for protein. • glucose tolerance test to confirm definitive diagnosis (although the level of random blood sugar puts the diagnosis effectively beyond doubt). He has mild blunting of all sensory modalities in his feet. ~ numbness in feet and visual disturbance: ~ fear of cancer. creatinine and electrolyte levels. • full blood examination and erythrocyte sedimentation rate: and • prostate specific antigen (PSA) level indicated in view of his family history and concerns. weight loss. ketones (+).073 Performance Guidelines Physical examination findings to be given to the candidate from examiner on request He is significantly overweight with abdominal obesity. KEY ISSUES • Diagnosis of Type 2 diabetes mellitus by appropriate consultation (history. Low/High Density Lipoprotein (LDL/HDL) and ratio. ESSENTIAL OFFICE INVESTIGATIONS — TO BE PROVIDED BY EXAMINER WHEN REQUESTED Urinalysis — positive for glucose (++++). pulse is regular. • glycosylated Hb should be done as baseline. OTHER INVESTIGATIONS • urea. thirst. Blood pressure is 140/90 mmHg. • ECG to check for presence of undiagnosed ischaemic heart disease. • Request urinalysis and random blood sugar using glucometer. Random blood sugar should be done in the consulting room with glucometer. and ~ maturity-onset diabetes as the most likely diagnosis. ~ erectile dysfunction/reduced libido. • serum lipids — cholesterol. • Recognition of fear of cancer and sexual dysfunction.

sensory and visual disturbances. and erectile dysfunction. thirst. Urinary chemical testing and random blood sugar assessment applied to overweight adults over 45 years will pick up at least as many nonsymptomatic undiagnosed diabetics as are found on symptomatic presentation. weight loss. should raise suspicion of maturity-onset Type 2 diabetes mellitus. 396 .073 Performance Guidelines COMMENTARY The constellation of symptoms of polyuria.

the health of the children often is equivalent to those in developing countries — with high infant mortality. the paediatric history is usually given by a third person. Many medical practitioners admit to being rather frightened at the prospect of caring for children. Often with new arrivals. as the process is so different from that related to adults where the history is obtained from the patients themselves. deteriorate more rapidly than adults. Our capital cities in particular have people from many nations residing in them who have cultural beliefs and practices of which doctors need to be aware.2-E: The Paediatric Consultation Peter J Vine 'Children are not simply micro-adults. if untreated. who may or may not be a relative. unencumbered by a series of complicating past that a child is significantly ill events or of age-related disease. 1 Australian Bureau of Statistics 2005 is a skill that must be 397 . rheumatic fever). children also repair and recover quickly. It is imperative that if any child is not improving at a time when improvement is expected. While they do become ill quickly and. commonly a parent or caregiver. all of which have a profound effect on the development of the child as he or she progresses to adulthood. Refugee children come from other lands rather than our own. which may add yet another dimension to the consultation. Contrary to popular belief in some circles. Medical care and assessment of children is often a developed by anyone caring multidisciplinary process. a high incidence of conditions uncommonly seen in the urban populations (for example. Australia is a multicultural nation with 25% of the population being born overseas according to 1 the latest Census. but rather their needs are under the influence of a variety of variable factors. children are not just scaled-down adults. Except in the case of older children where the direct history from the child is most appropriate. but have their own specific problems. Other doctors are apprehensive at being able to perform an adequate examination of a child. an interpreter. before any formal examination is performed. Children in Australia have generally been spared the traumas experienced by their peers in third world countries. Nowhere else in medicine is it so essential to have expert observation skills than in paediatrics. Many children are first generation Australians born in this country to immigrant parents. Recognition of the features in the history and in the clinical signs that indicate that a child is significantly ill is a skill that must be developed by anyone caring for children.' Beta Schick (1877-1967) There are many very positive features about working with Recognition of the features children — they are much less complex than adults and usually in the history and in the under most clinical situations have only one presenting clinical signs that indicate complaint. the history is given by yet another intermediary. However within our indigenous populations. and a reduced adult life span. All of these influences therefore must be taken into account when consulting with children and these vary depending on the age of the child. or those torn apart and disrupted by war and natural disaster. Many diagnoses can be made just by observation of the child while the history is obtained. an immediate investigation into what might be complicating the situation must be instigated. and have their own problems related to this background.

The Paediatric Consultation 2-E While many illnesses seen in children also occur in adults (for example. While intussusception can occur in adults in later years. sexual or emotional. Emotional and behavioural problems are common and often relate to the child's life experiences. the spectrum of conditions seen by medical practitioners has changed dramatically over the last couple of decades. whether these relate to poor nutrition. the majority of children seen in clinical practice present with relatively minor complaints. Specific pocket handbooks with this information are published by several of the major Australian paediatric teaching hospitals. An example is the method of administering bronchodilator therapy in young children. The needs of children to develop their potential and to remain in good health are legion. Similarly intravenous and oral fluids are calculated on a mL per kilogram basis and need to be calculated carefully for each child. Rather than malnutrition. Churchill Livingstone 2003 p2. While the same medications are used. While we practise in a so-called developed country. In this country. whether it be physical. Australian law mandates that in each suspicious case. poor parenting skills. which must be considered in any infant presenting with colicky abdominal pain. Many primary schools arrange breakfast for their pupils as for one reason or another the children leave home for school having not eaten. poor socioeconomic circumstances. 'primary' intussusception is a very prominent condition in infants. Such situations are usually recognised from the history or the appearance of the child on examination. Beware of the listless infant or child who allows you to perform any examination you wish. Prescription of drugs is also different in children: most drugs are given on a mg per kg basis up to a certain weight and age. and adult practitioners need to be aware of management of this condition. There are also many conditions that are specific to children. harmful emotional environment or even deprivation. the needs of the child change. for example hypertrophic pyloric stenosis and cystic fibrosis — although the latter has now become an adult disease. The general practitioner is often an appropriate person to assess this situation. their methods of administration are very different. and the medical practitioner needs to be alert to this possibility. Unfortunately all too commonly children in our country are the subjects of abuse. asthma) the requisite skill is knowing the variations that must be considered in the child which will influence future management. but practitioners must always be vigilant for the circumstances when they should be considering more complex conditions specific to infants and children. 1 Some situations that may influence these are: • many children under two years of age participate in formal child care while parents work. Many parents find it difficult to provide for those needs. we still have a significant percentage of our child population who live in extremely adverse circumstances. to the detriment of the child's development. especially when the presentation is at odds with what is observed. secondary to a number of bowel lesions. As each year goes by. the relevant appropriate authorities are to be notified. many of the problems we see are related to inappropriate nutritional habits and inactivity leading to obesity. almost a necessity for maintaining a suitable income: 1 Practical Paediatrics Ed. As is typical of the industrialised countries. This is usually a very sick child. DM Roberton 5th Ed. MJ Robinson. with small volume spacers and masks designed for very young children. 398 .

which the practitioner should refer to a higher authority. Much of this may be related to the sociological change in child rearing. Many sites unfortunately are inaccurate and anecdotal. Children of today largely depend on artificial media for entertainment in their spare time — television. the task may involve coming to a diagnosis from the information supplied and then counselling a parent on the management of the child's condition. as young adults move freely around the country seeking employment. attention deficit disorder. examination and discussion with a parent of a child's problem can take considerable time. Detailed knowledge of rare conditions is not generally necessary. whether it is a physical or intellectual disability. The care of the disabled child. and • tobacco and/or alcohol use. but generally present with their downloaded information asking for explanation of the contents. The internet has revolutionised the practice of medicine.The Paediatric Consultation 2-E • the extended family in many communities is scattered and less accessible. a mentor to many practising Australian paediatricians and one of the forerunners of paediatrics in this country. as much of the consultation time of paediatricians in this country is taken up with oppositional defiant behaviour. many in two-parent families live in very unhappy circumstances. Often parents may self-diagnose based on this information. so that the practitioner must be very alert to this possibility. especially binge drinking. only certain aspects will be examined in any one scenario. 399 . A complete history. including paediatrics. How right he was. can often be a source of major conflict. where children from previous marriages live together. Having two 13-year-old females suddenly living together can be quite trying. but that behaviour problems. is common in teenagers. blended families. many of which require little if any intellectual skills and commonly have a strong base of violence and aggression. and other developmental behavioural problems. The physical and emotional needs of the growing child must therefore be kept to the fore when children are being assessed. Hence the practitioner's role often is to sift through this information and to give an accurate précis of the particular condition. but the support given to parents as they advocate for their offspring can be a major role asked of the practitioner. as the explosion of knowledge in these fields is occurring at such an alarming rate that it has outstripped the ability of most of us to keep up-to-date. Or it may be taking a focused history to determine the cause of the presentation. Dr Howard Williams of Melbourne. often falls to the primary practitioner for day-to-day events. Add to this a high divorce rate and the loss in many instances of the extended family and the scene may be ripe for acting-out behaviour. • one in five children will experience divorce of their parents before mid teens. Advice concerning screening procedures and genetics is also a common question. Years ago. used to urge his postgraduate students to be aware of 'the new morbidity'. The presentation of a child with an emotional problem can be quite varied and commonly may be organically based. • a significant percentage of children live in one-parent families. disrupted families and the effect on the children involved would be a major part of the work of the modern practitioner. In the AMC MCAT examination. electronic games. and most high school students are aware of where they can obtain cannabis and other drugs. as parents consult the internet for advice on conditions their children are reported to have. For example. cinema. • with the higher divorce rate. He stated that his generation had overcome much of the infectious disease morbidity and mortality with antibiotics and immunisation.

It can be seen then that working with children. whether it be neonate or teenager.The Paediatric Consultation 2-E Candidates therefore are assessed on their ability to relate to a worried parent of a sick child at a standard expected by the Australian community. are honest and much less complex than most adults. and the competent practitioner needs to be aware of these conditions in order to consider them. no matter how minor the complaint appears to be. The ability to counsel worried parents in an empathie manner is paramount for successful paediatric practice. Children are fun to work with. is generally quite ordered and rewarding if aware of the various factors that influence the development both physically and emotionally of the child. Peter J Vine 400 . while it can be a complex business. as well as being mindful and knowledgeable about the specific conditions that are peculiar to children. They do however have special needs and are afflicted by many conditions specific to their age group.

The Paediatric Consultation 2-E 2-E The Paediatric Consultation Candidate Information and Tasks MCAT 074-077 74 75 76 77 Neonatal jaundice in the first day of life Immunisation advice to the parent of a 6-week-old baby Dark urine. facial swelling and irritability in a 5-year-old boy Fever and sore throat in a 5-year-old boy 401 .

You will not be expected to take any additional history or ask for examination findings. The infant has been sucking well at the breast. Her mother wants to know what you would advise about immunisation because she and her husband have recently heard conflicting views expressed in the media. and was uneventful. She was given her first hepatitis B vaccination soon after birth. General examination of the baby reveals no abnormality. born 24 hours ago. Laura is the couples first child.074-075 Candidate Information and Tasks Condition 074 Neonatal jaundice in the first day of life CANDIDATE INFORMATION AND TASKS History You are asked to see an infant. You have obtained all relevant findings on history and examination. Examination Findings The infant is clinically jaundiced but otherwise well and active with no hepatosplenomegaly or other abnormal physical signs. Jaundice was noticed soon after birth. within the first 24 hours. The babe is breastfed and gaining weight normally. Delivery was at term. for jaundice. The Performance Guidelines for Condition 075 can be found on page 408 402 . YOUR TASKS ARE TO: • • Outline the current immunisation protocol you would recommend and what diseases the programme is protecting against. Discuss any concerns the parents have about immunisation. as part of routine postnatal followup. She is the first child of a healthy mother. The Performance Guidelines for Condition 074 can be found on page 405 Condition 075 Immunisation advice to the parent of a 6-week-old baby CANDIDATE INFORMATION AND TASKS Your next patient is baby Laura brought by her mother to a general practice at six weeks of age. The mother wants to go home as soon as possible. YOUR TASKS ARE TO: • • Ask the observing examiner for results of any investigations you consider necessary. The infant weighed 3700 g at birth. Advise the parent on diagnosis and management. by a midwife. whose pregnancy was normal. Jessica.

In the past 12 hours he has become restless and irritable. • Discuss with the parent your provisional diagnosis. which is dark in colour. although he is able to do so. YOUR TASKS ARE TO: • Indicate to the examiner the clinical examination you would perform to diagnose the problem. You do not need to take any further history. but has had no other prior illnesses. facial swelling and irritability in a 5-year-old boy CANDIDATE INFORMATION AND TASKS A five-year-old boy is brought to the Emergency Department because of swelling around the eyes. YOUR TASKS ARE TO: • Ask the examiner for the relevant physical findings you wish to elicit. • Explain your diagnosis and suggest management to the mother. The child had school sores (impetigo) three weeks ago. The Performance Guidelines for Condition 076 can be found on page 412 Condition 077 Fever and sore throat in a 5-year-old boy CANDIDATE INFORMATION AND TASKS Peter. The examiner will give you the results of the physical examination. He has only been passing small amounts of urine. Both parents are well. The child is an only child and has always kept in good health. You do not need to take any further history.Candidate Information and Tasks 076-077 Condition 076 Dark urine. He complains of an intensely sore throat and finds it sore when he swallows food or fluid. • Advise details of any investigations that are required and advise the parent of the treatment that will be needed. treated successfully with a topical antibiotic cream. a five-year-old boy is brought to you in a general practice setting by his parent with a fever of 40 °C that developed overnight. • Discuss with the parent any investigations you feel are necessary. The Performance Guidelines for Condition 077 can be found on page 414 403 .

2-E The Paediatric Consultation 2-E The Paediatric Consultation Performance Guidelines MCAT 074-077 74 75 76 77 Neonatal jaundice in the first day of life Immunisation advice to the parent of a 6-week-o!d baby Dark urine. facial swelling and irritability in a 5-year-old boy Fever and sore throat in a 5-year-old boy 404 .

microspherocytes. A Rh positive. you are confused and upset. The biochemist indicates that this is abnormal. Investigation results/details to be given to candidate by examiner on request Tests performed: • Mother's blood group • Infant's blood group • Infant's Hb • Blood film • Bilirubin 0 Rh positive. • You are well educated. The problem is compounded by the mother's disappointment.074 Performance Guidelines Condition 074 Neonatal jaundice in the first day of life AIMS OF STATION To assess the candidate's knowledge of causes of neonatal jaundice occurring in the first 24 hours after birth. • You insisted your obstetrician allowed you to have a natural childbirth with appropriate assistance from a midwife. and that you could go home on day two. Direct Coombs test strongly positive. Phototherapy is required. • Now that your babe has become jaundiced. She is a young professional woman who wanted a completely natural delivery and management and is disappointed that she is not allowed to go home as her infant requires treatment. and a strongly positive Coombs test. but will be needed for several days. you will accept the doctor's recommendations if they are given clearly and empathically. but below the range at which exchange transfusion is indicated. and resent medical intervention. and the appropriate management of the condition. 405 . and were recently a middle-level manager in a successful company. EXAMINER INSTRUCTIONS This scenario illustrates the common problem of ABO blood group incompatibility with the classic combination of a mother group O Positive and a baby A Positive. The baby's bilirubin level has reached a total of 250 umol/L at 24 hours of age. which should prevent further rise in bilirubin. • You believe childbirth is a natural phenomenon. The examiner will have instructed the parent as follows: • You gave birth to your first child 24 hours ago. Total 250 umol/L Conjugated 6 umol/L at 24 hours. • After appropriate discussion. 170 g/L.

~ Her eyes will be covered while she is under lights to protect her eyes ~ Baby is only under lights when not feeding and is sleeping. The technique of phototherapy. • • • • KEY ISSUES • • • Recognition of haemolytic disease of newborn and its immediate treatment. 406 . ~ Phototherapy may be able to be given in the room where mother is staying in hospital. ABO incompatibility would be the most likely cause. ' ‘Why do I need to stay longer in hospital? I want to go home. Consequence of severe neonatal jaundice and the need for phototherapy and monitoring. Empathie but realistic communication with new parent. but usually due to haemolysis consequence upon blood group incompatibility. its side-effects and reassurance regarding aspects which could cause anxiety: ~ Jessica's bowel motion may be a loose green/black colour while under lights. Arrange continued stay in hospital for mother and infant with facility for mother to continue breastfeeding. Exchange transfusion unlikely to be required but could be an option if jaundice worsens despite phototherapy. ' ‘Is treatment really necessary?' ‘What would happen if no treatment were given?' 'Are there any side effects of this light treatment?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain the following: • Jaundice occurring in the first 24 hours after birth is not due to immature liver function. In a primiparous woman. Followup developmental assessment and audiometry — not usually discussed at this first consultation.074 Performance Guidelines Questions to ask or statements you could make: • • • • • ‘I expected everything to be normal. ABO incompatibility — this has been confirmed by the tests done. Ability to relate to mother's disappointment with need for medical intervention. CRITICAL ERROR • Failure to recognise haemolytic disease of newborn and failure to advise phototherapy. • • • Excellent prognosis.

The crucial laboratory tests in establishing the diagnosis are examination of blood group of mother and infant. As it is readily treatable. and direct Coombs test. Jaundice occurs frequently in the neonatal period. The degree of haemolysis should be defined by measuring the infant's haemoglobin. The protocol states that hepatosplenomegaly is not present. and complications potentially avoidable. discussion of other haemolytic or nonhaemolytic causes of neonatal jaundice is not required once the problem is correctly framed as 'jaundice on the first day of life'. so-called 'physiological jaundice'. and excreted into the bile. the candidate is not only expected to make the diagnosis. but to provide information in a persuasive and lucid manner to justify medical intervention. the clinician needs to seek evidence confirming the existence of haemolysis and defining the degree of hyperbilirubinaemia. In this scenario. There is a diagnostic rule that 'jaundice on the first day of life is haemolytic unless proven otherwise' This originated in the days when Rh haemolytic disease was a common cause. Haemolytic disease is the most common cause of potentially dangerous neonatal jaundice. In the present scenario.074 Performance Guidelines COMMENTARY The dominant cue in this example is neonatal jaundice in the first day of life. but the clinical picture. The positive direct Coombs test confirms that the infant's red cells have been sensitised by antibody and establishes the diagnosis of haemolytic disease due to AO incompatibility. but does not exclude less dramatic forms of haemolysis. it indicates a pathological and potentially dangerous rise in bilirubin level. Conjugated bilirubin is not reabsorbed once it enters the intestinal tract. so immediate diagnosis and often exchange transfusion were required to avoid the serious complication of kernicterus or later nerve deafness. early diagnosis is mandatory. confirms the need for treatment with phototherapy. though simple transfusion for correction of the anaemia will rarely be required in AO haemolytic disease and is not needed here. This makes the severe intrauterine haemolysis seen in some cases of Rh haemolytic disease less likely. Bilirubin is derived from the catabolism of haeme proteins produced in the breakdown of red blood cells. combined with laboratory confirmation of an unconjugated hyperbilirubinaemia exceeding 240 umol/L. The candidate familiar with this rule will immediately refine the cue to: 'Jaundice on the first day of life. the serum bilirubin rises more slowly. and jaundice is not apparent on the first day. probably haemolytic' This scenario is an example of the need for pattern recognition where urgent diagnosis is required. while recognising the mother's disappointment. 407 . In deciding management and providing further confirmation of the diagnosis. the level of bilirubin is insufficient to warrant exchange transfusion. estimation of serum bilirubin level (direct-reacting and indirect-reacting) should be performed. but when seen on the first day of life. In the common. As indicated in the examiners' 'Performance Criteria'. Hyperbilirubinaemia is likely to reach a maximum level around the third day of life. To frame the problem more clearly. The scenario of a group O Positive mother and a group A Positive infant indicates the potential for the infant's blood to be harmed by maternal anti-A antibody. Unconjugated (indirect-reacting) bilirubin is converted in the liver to conjugated (direct-reacting) bilirubin. The jaundice of the affected infant could increase rapidly.

• Questions to ask unless already covered: • • • • • • • • • • 'What vaccines or injections will Laura need to be immunised with. You are widely read and take an interest in popular medical articles especially during your pregnancy. but very diluted. knowledge of side effects and the latest information concerning claims of associations with serious medical conditions. several versions of these combination vaccines are likely to be approved and thus variations as currently seen in the schedule will become more common. Laura. Is this available and do you advise it? EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should give the parent a succinct and accurate regimen for the immunisation that is currently recommended. with special reference to those given at two months. Can you do anything to ease the side effects?' 'I've also heard about a vaccine for chicken pox. You are taking the opportunity of the six week visit to have these concerns clarified. To reduce reliance on single suppliers. If uncertain. Because of this. Can we leave it out 9 ' 'What other side effects happen with these vaccines 9 ' 'What if we didn't give these vaccines — can't you just treat any infections with antibiotics anyway?' ‘I have a friend who goes to a homoeopath and he gives the same vaccines. Is that an alternative?' 'What about other alternative vaccines?' 'I've heard babies can get high fever and be guite sick after some of these injections. candidates should demonstrate familiarity with the basic principles of the immunisation 408 . EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: • • • You are the mother of a six-week-old baby. up to school age?' 'What problems might she have?' 'Are there any children who shouldn't have these vaccines 9 ' 'I've heard the whooping cough vaccine can cause brain damage. by mouth and there are no side effects. combination vaccines which will reduce the number of injections are expected and small variations to the schedule will be needed to accommodate these. Examiners should be aware that the recommended schedule has changed annually over the last several years as new vaccines have been introduced. In the future. You are an educated parent in a stable marriage. as you were concerned about some information you had read and heard about immunisation and its possible adverse effects. the candidate should be aware of the current NHMRC Immunisation Guidelines and how to access them.075 Performance Guidelines Condition 075 Immunisation advice to the parent of a 6-week-old baby AIMS OF STATION To assess the candidate's knowledge of the currently recommended immunisation programme in Australia.

chicken pox. pertussis (DTPa). the vaccination should be postponed until the child is well. mumps. may be vaccinated safely. WA. pneumococcus. • previous pertussis-like illness. measles. hepatitis B (hepB). Examiners should note that there are slightly different recommendations for the immunisation schedule from State to State.e. With a major illness or a high fever. tetanus. The following are NOT contraindications to any of the vaccines in the standard schedule: • family history of adverse reactions to immunisation. Children with minor illnesses. rubella (MMR). SA. but stress that these are few and minor and that vaccinations are safe. the candidate should discuss known side effects and how these can be reduced. • At 12 months: Measles. If the parent has no particular concerns. A simple febrile convulsion or preexisting neurologic disease are not contraindications to pertussis vaccine. oral or inactivated polio vaccine (O/IPV). but many authorities recommend that in such a case it should be administered in an area where resuscitative equipment is available and the child be observed for 4 hours. tetanus. • At 2 months and 4 months: Acellular diphtheria.influenzae type B (Hib). particularly for States other than the one in which they work. • family history of convulsions. MMR. These are encephalopathy within seven days of a previous DTP-containing vaccine or an immediate severe or anaphylactic reaction to vaccination with DTP. mumps. 409 . meningococcus (MenC): (hepatitis B [hepB]) in VIC. (hepatitis B [hepB] in NSW.5 "C. rubella (MMR). The following would generally be recommended: • At birth: Hepatitis B (hepB). Candidates should address specific concerns that the mother may have regarding possible side effects and the incidence of these. oral or inactivated polio vaccine (O/IPV). 7-valent pneumococcal conjugate vaccine (7VPCV). hepB. without systemic illness and providing the temperature is less than 38. QLD. oral or inactivated polio vaccine (O/IPV). polio. meningococcus. 7-valent pneumococcal conjugate vaccine (7VPCV). • At 18 months: Varicella zoster virus (VZV). TAS). pertussis (DTPa).influenzae type B (Hib). Live vaccines (MMR. tetanus. Hib. i. Candidates should discuss the few absolute contraindications to vaccination. measles. NT). pertussis (DTPa). 23-valent pneumococcal polysaccharide vaccine (23VPPV). Examiners should also be aware that the level of understanding expected should match the current edition of the immunisation handbook rather than vaccines introduced subsequent to publication of the handbook.075 Performance Guidelines schedule rather than detailed knowledge of precise recommendations. mumps or rubella infection. An anaphylactic reaction to egg is not a contraindication to MMR vaccine. Also stress the marked decrease in the incidence of side effects with the use of acellular vaccines for pertussis. • prematurity (immunisation should not be delayed). oral poliomyelitis. rubella. What is being tested in this scenario is whether the candidate is aware of the general principles for DTP. chicken pox) should not be administered to immunocompromised patients. • At 6 months: Acellular diphtheria. H. H. • At 4 years: Acellular diphtheria.

beliefs they have. Down syndrome). 410 . without domineering with their own personal feelings. Doctors should not hesitate to admit that they do not know a particular answer but should offer to seek the answer and communicate it at a later date.g. Candidates should state that there is no evidence for the efficacy of alternative (homoeopathic) oral vaccines given sublingual^ Latest vaccination now available for varicella-zoster virus (the cause of chicken pox) and meningococcus should be discussed and recommended. Candidates may mention the reported association of measles vaccination with autism The knowledgeable candidate will be aware that no association has been convincingly demonstrated and several studies show no link at all. including a single dose about 30 minutes prior to DTPa prophylactically and for subsequent immunisation if significant reaction with fever with first or second dose. Updated immunisation schedules such as the one illustrated are available from paediatric hospitals. cerebral palsy. Candidates should stress that many of these diseases are still prevalent in the community (e.g. Recommendation or acceptance of sublingual homoeopathic vaccines. pertussis. eczema. COMMENTARY This scenario is concerned with counselling a young mother on the advantages and disadvantages of immunisation. pneumococcal and meningococcal infections. 'snuffles'. This is a very common situation in general practice where patients will often attend to discuss with the doctor. and replacement corticosteroids. or to seek further information on a topic. contact with an infectious disease asthma. Candidates may suggest paracetamol for fever and pain after vaccination as necessary. over the age recommended in vaccination schedule.075 Performance Guidelines • • • • • • • • • • • stable neurological conditions (e. history of jaundice after birth. treatment with locally inhaled or low dose topical steroids. Explanation and accurate nformation regarding benefits of immunisation • Exploration of parental concerns. KEY ISSUES • • Knowledge of basic principles of current immunisation regimens. and varicella). treatment with antibiotics. recent or imminent surgery. atopy. hay fever. CRITICAL ERRORS • • Candidate provides wrong advice regarding contraindications to immunisation. This requires of candidates a sound knowledge of the topic and an ability to give the information to the parent in a manner that gives a balanced overview. child's mother is pregnant. Candidates should be aware of the absolute contraindications to the standard vaccinations and also the false contraindications which are so often quoted. child is breastfed.

CONDITION 075. 2006 411 . Immunisation schedule guidelines adapted from Royal Children's Hospital. FIGURE 1. Melbourne.

90/min regular. Questions to ask unless already covered: • • • • • • • • 'Why has this happened?' 'Will my son be all right?' 'What is going to happen now?' (If hospitalisation is recommended) 'What is going to be done to my son in hospital?' (If hospitalisation is recommended) 'What are they looking for with these tests?' 'How long will it take to get results?' ‘Is that really necessary?' If kidney biopsy is mentioned. normal. palpable just below the costal margin.5 °C. become even more concerned. This would include that the original skin streptococcal infection (impetigo) has triggered an immune reaction of the body against the organism and that this reaction is occurring in the kidneys causing a major effect on 412 . Nothing like this has ever happened before. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You are the parent of a five-year-old boy. normal. no ascites or pleural effusions. facial swelling and irritability in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to recognise that this child most likely has acute poststreptococcal glomerulonephritis (PSGN) which requires hospitalisation in view of hypertension and recent irritability. You are particularly concerned about the dark urine and swelling of the boy's face. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain the cause of the child's clinical picture in terms the parent can understand. No postural hypotension.076 Performance Guidelines Condition 076 Dark urine. strongly positive (++) for blood and protein. no oedema elsewhere. 36. normal. and without medical jargon. The child has never been really sick before. 'Why is blood testing not enough?' Relevant physical findings to be given to the candidate on request Resting blood pressure Temperature Pulse Periorbital oedema present Cardiovascular system Liver edge Optic fundi ENT examination Urine dipstick 145/90 mmHg. This illness is all very unusual and worrying.

• Penicillin therapy may be suggested — but is not essential • Renal biopsy is not needed for diagnosis at this stage. ASOT. KEY ISSUES • Diagnosis of acute PSGN • Ability to specify appropriate plan of investigations. 413 . Future management • Monitor blood pressure and renal function weekly/monthly/quarterly as needed as convalescence progresses. knowledge of the condition is important in considering the differential diagnosis of this child's symptoms. • Low protein. and salt and fluid retention that causes the swelling of his eyes and raised blood pressure. Tests to be ordered should include: • Urea and electrolytes. full blood examination Immediate management • Admission to hospital. • Antihypertensive treatment. • Daily weight. • Strict fluid balance and restricted fluid intake • Test all urine . low salt/high carbohydrate diet. inflammatory markers — C3. DNAase B • Urine micro and culture. the candidate should be able to arrive at the correct diagnosis and investigate and treat appropriately. • Development of coherent treatment plan CRITICAL ERROR • Failure to admit to hospital COMMENTARY This scenario involves diagnosis. from clinical signs and appropriate investigations. Hospital admission is desirable in view of the acute presentation and hypertension Investigations required will include blood and urine tests to confirm the provisional diagnosis of PSGN.four-hourly blood pressure and other vital signs. This then leads to a fall in urine output. so positive and sympathetic reassurance is required.076 Performance Guidelines their function. From the information given. • Long term prognosis is excellent with a very low incidence of sequelae. creatinine. C4. • Regular urinalysis (microscopic haematuria may persist for up to two years). and an empathie explanation of treatment. While classical poststreptococcal glomerulonephritis has become rare in many parts of Australia. Failing to do so puts the patient at risk.

There is no evidence of neck stiffness. rash or lymph-adenopathy elsewhere. Three-year-old sister at kindergarten is well. which the examiner will show to the candidate. and are concerned by his high temperature. no hepatosplenomegaly. blood pressure 110/70 mmHg. mother is at home. 9 9 414 . Your son has had no previous antibiotic reactions. Some investigations to confirm this are indicated. who has become unwell overnight with a very sore throat and has difficulty swallowing food and drink. Peter.077 Performance Guidelines Condition 077 Fever and sore throat in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and treat a child with tonsillitis most likely due to Group A β-haemolytic Streptococcus. Examination is otherwise normal. You are worried that Peter has that right?' How long will he take to get better?' 'Is antibiotic therapy reguired?' Examination findings to be given by examiner to candidate on request A flushed child. The appearance of his oropharynx and tonsils are shown in the illustration (Figure 1). Father is an office-worker. Temperature is 40 °C. tonsils acutely inflamed with follicular exudate. He most likely has an acute tonsillitis which should be treated with penicillin. EXAMINER INSTRUCTIONS The examiner will advise the parent as follows: You are the mother of a five-year-old boy. with moderately enlarged and tender cervical lymph nodes on both sides. pulse rate 110/min Tympanic membranes are normal on otoscopy. Family history Both parents are well. The candidate may suggest some basic investigations to help confirm the diagnosis. Questions to ask unless already covered: • • • • • • 'How would he get this infection ' 'Is he likely to get it again?' 'What causes this infection ' 'I've heard that this sort of infection can damage your heart or your kidneys or something . respiration rate 24/min.

Explanation of diagnosis Acute tonsillitis. probably streptococcal. Indicate that viral infection may cause similar features. Stress that a full course of 10 days penicillin treatment is required. Antibiotic therapy would not only treat the streptococcal sore throat but would probably reduce the likelihood of serious poststreptococcal complications.077 Performance Guidelines CONDITION 077. review and possibly seek other aetiologies. infectious mononucleosis) should be sought. the majority opinion would be that penicillin therapy is indicated because of the high likelihood of the diagnosis being streptococcal tonsillitis. and prescribe oral penicillin. 415 . Immediate management The candidate may wish to perform a throat swab for culture (appropriate but not obligatory). There is no need for any other investigations at this stage. If the candidate does not recommend antibiotic therapy the mother should ask whether antibiotics are needed. Future management Suggest review in few days or earlier if concerned and if the child has not responded as expected. Prescribe analgesics. and should also arrange for further review in a few days to ensure the expected recovery is occurring and if not. other aetiologies (e. Acute tonsilitis EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should enquire as to the important clinical findings on examination allowing confident diagnosis of acute tonsillitis. Reassure that with appropriate treatment this should resolve completely. Advise the mother of need for frequent fluids. If this is the case. most likely bacterial.g. A throat swab could help confirm this prior to antibiotic treatment. Although the problem might be viral and settle without antibiotics. as might acute infectious mononucleosis. FIGURE 1. The candidate should be able to explain in simple terms the diagnosis and its associated complications in a manner that the parent can understand. Check whether antibiotic reaction previously.

Adequate treatment plan. Failure to discuss followup and screening for other conditions if there is no initial improvement.077 Performance Guidelines KEY ISSUES • • • Appropriate examination interpretation. CRITICAL ERRORS • • Failure to consider streptococcal tonsillitis as the diagnosis. The scenario tests diagnostic acumen by showing how several conditions can be safely excluded because of the history and the time frame and gives scope to considering other diagnoses if the provisional diagnosis is not confirmed. 416 . COMMENTARY This scenario assesses the ability of the candidate to come to a logical conclusion as to the most likely diagnosis (acute bacterial tonsillitis) in this situation based on the information provided and knowledge of the natural history of disease processes. Appropriate explanation. with appropriate diagnosis.

all of the options of management which might be appropriate need to be provided to the patient. to follow through a particular treatment which might be appropriate. is mandatory. can result in the candidate being reported to the relevant medical board or health complaints commission. and ultimately to give the clinician informed consent to proceed with the option chosen. well need to do such assessments 417 . Where the clinician is not prepared. Personal beliefs should not restrict the matters discussed with the patient although they may affect what the clinician is actually prepared to do in terms of actual management.2-F: The Obstetric Consultation Roger J Pepperell and Gynaecologic 'Man endures pain as an undeserved punishment. the clinical abdomen of a pregnant woman. or scenarios used as part of the MCAT examination are much more focused perform a pelvic examination in the and restricted to fit in with time constraints. with perspective and with empathy and compassion. verbose and largely irrelevant. and has an obligation to offer to refer her to an appropriate physician who would provide the treatment she has accepted as being most appropriate.' Anonymous Although in clinical practice obstetric and gynaecologic consultations may Although it would be unusual for involve a consideration of a complex set of symptoms and history which can you to have to examine the include relevant past history. The scenarios reflect conditions actual clinical MCAT examination. on religious grounds. the candidate is again expected to show perspective rather than ordering a large number of irrelevant and inappropriate tests. and unless done in a manner which is acceptable to the patient. in terms she can readily understand. Some involve the candidate taking an appropriately focused history to enable on models which have been the diagnosis to be made. and if appropriate with her partner. In clinical practice today. Where investigations are required to assist in making a diagnosis or starting treatment. which should be able to be appropriately assessed and managed by a final you clearly need to know how to do year medical student or a doctor working as an intern in a public hospital or in such clinical examinations and may community practice. total time spent. the history-taking must concentrate on relevant issues and not be generalised. to enable her to decide which option she will accept. Some of the stations involve the candidate requesting the examination findings they would look for if assessing such a patient to allow the examiner to assess whether the candidate knows what examination findings are particularly relevant and important in assisting the candidate make the correct diagnosis in this circumstance. medical history and social history. the clinician has a responsibility to explain the options available to the patient. If the candidate needs to advise the patient on the initial management plan. this should be provided to the patient in lay language. particularly in obstetrics and gynaecology. and the history-taking will represent only a fraction of the for this purpose. In obstetrics and gynaecology. woman accepts it as a natural heritage. such as a pregnancy termination because the fetus has a lethal congenital abnormality. Because only eight minutes are allocated specifically designed and produced for the assessment. communication with the patient.

haemostasis and bleeding disorders. The various scenarios cover aspects of the female reproductive system including normal development and disorders of uterus. they clearly need to know how to do such clinical examinations and may well need to do such assessments on models which have been specifically designed and produced for this purpose.2-F The Obstetric and Gynaecologic Consultation Clinicians must preserve a nonjudgmental and supportive approach in discussion and must not impose their own religious or other nonmedical views on a concerned patient. tubes. fertility and contraception. pelvic infection. pregnancy. Although it would be unusual for candidates to have to examine the abdomen of a pregnant woman. obstetrical toxaemia and haemorrhage. abortion. or perform a pelvic examination in the actual clinical MCAT examination. vaginal discharge. Roger J Pepperell 418 . dyspareunia. menopause. ovaries. hormonal influences. vagina. labour.

2-F The Obstetric and Gynaecologic Consultation 2-F The Obstetric and Gynaecologic Consultation Candidate Information and Tasks MCAT 078-082 78 79 80 81 82 Breech presentation in labour at 38 weeks in a 25-year-old woman Vaginal bleeding in a 23-year-old woman Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles 419 .

Advise the patient of the probable diagnosis and subsequent management you would institute. She has developed vaginal bleeding after eight weeks of amenorrhoea. This patient is 3 25-year-old woman in her second pregnancy. and believes she is pregnant. including any further investigations you would arrange. Ask the examiner about the findings you would look for on general and gynaecological examination and the results of any tests you would expect to be available at the time you are seeing the patient. Your next patient is a 23-year-old nuliiparous woman who has been trying to conceive. The cervical dilatation is 4 cm. YOUR TASK IS TO: • Advise the patient of the possibilities in regard to subsequent management and the pros and cons of these. The Performance Guidelines for Condition 078 can be found on page 424 Condition 079 Vaginal bleeding in a 23-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a hospital Emergency Department. but do this briefly as the essential features have been provided above. YOUR TASKS ARE TO: • • Take any further relevant history you require. • The Performance Guidelines for Condition 079 can be found on page 427 420 . The previous pregnancy resulted in a normal cephalic vaginal delivery of a 4 kg baby at 41 weeks of gestation. You may take any further relevant history you require.078-079 Candidate Information and Tasks Condition 078 Breech presentation in labour at 38 weeks in a 25-year-old woman CANDIDATE INFORMATION AND TASKS You are working in the Emergency Department of a general hospital. at 38 weeks of gestation and is in early labour. The current pregnancy has been uneventful to date and the fundal height is 38 cm above the pubic symphysis at the time of admission in labour at 38 weeks. Vaginal examination unexpectedly reveals a breech presentation: the legs of the fetus are apparently both extended.

You have been looking after her pregnancy in a shared care arrangement in a general practice setting. All has been normal. • Advise the patient of the diagnosis and subsequent management (including any investigations you would arrange). • Ask the examiner about the findings you wish to elicit on general and gynaecological examination. She has come to see you in a general practice because she did not have a period following the last two courses of pills YOUR TASKS ARE TO: • Take a further focused history. She has returned to receive the results and any implications if the test is positive. The Performance Guidelines for Condition 080 can be found on page 430 Condition 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman CANDIDATE INFORMATION AND TASKS Your next patient is a 26-year-old woman who is now at 37 weeks of gestation in her first pregnancy. YOUR TASKS ARE TO: • Advise the patient of the results of the GBS test. and at 36 weeks you ordered a vaginal and rectal swab for Group B streptococcal (GBS) testing. This test has shown GBS organisms were detected in the lower vagina. • Advise her about the subsequent management you would advise There is no need for you to take any further history or to request any examination findings or investigation results from the examiner The Performance Guidelines for Condition 081 can be found on page 432 421 .Candidate Tasks Information 080-081 and Condition 080 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) CANDIDATE INFORMATION AND TASKS Your patient is a 30-year-old woman who is taking the oral contraceptive pill (OCP).

YOUR TASKS ARE TO: • Take a further focused history.| cological/obstetric examination. Her cycles are often irregular with the periods occurring at intervals of 4-8 weeks. • Ask the examiner about the findings you wish to elicit on general and gynae. including any investigations you would arrange. • Advise the patient of the probable diagnosis and subsequent management.Candidate Information and Tasks 082 Condition 082 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles CANDIDATE INFORMATION AND TASKS Your patient is a 25-year-old married nulliparous woman who presents to you in a general practice with vaginal bleeding after eight weeks of amenorrhoea. The Performance Guidelines for Condition 082 can be found on page 434 422 .

2-F The Obstetric and Gynaecologic Consultation 2-F The Obstetric and Gynaecologic Consultation Performance Guidelines MCAT 078-082 78 79 80 81 82 Breech presentation in labour at 38 weeks in a 25-year-old woman Vaginal bleeding in a 23-year-old woman Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles 423 .

~ Only a very small episiotomy was necessary. Does that cause any problems?' List of appropriate answers to questions by the candidate: • Your desires in relation to mode of delivery are as follows: ~ You would prefer vaginal delivery if possible but would accept Caesarean section if this is recommended as necessary or very much more preferable. ~ Your antenatal course in this pregnancy has been normal. Questions to ask if not already covered: • • • 'What are my options regarding delivery?' 'Are there any significant risks to the baby or me if I have my baby normally?' ‘What are the potential problems to the baby of vaginal delivery versus Caesarean section?' Examination findings The candidate may ask for specific components of the examination. ~ You had no problems with delivery of the first baby at 41 weeks of gestation. but no additional findings in addition to those outlined in the candidate's instructions need to be given.078 Performance Guidelines Condition 078 Breech presentation in labour at 38 weeks in a 25-year-old woman AIMS OF STATION To assess the candidate's ability to appropriately advise a patient concerning the advantages and disadvantages of vaginal breech delivery or Caesarean section when the fetus is found to be presenting by the breech in early labour at 38 weeks of gestation. despite the baby weighing 4 kg. Forceps delivery was not required. Investigation results None is to be provided or available. doctor. Opening statement: 'So it is a breech. as was your previous pregnancy. 424 . ~ There is no family history of diabetes or other problems. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: Breech presentation has not previously been diagnosed and all your tests and progress have been normal.

Vaginal examination as soon as the membranes rupture. arms or head. ultrasound examination will probably be difficult to arrange urgently Had the breech presentation been diagnosed prior to labour.breech presentation in early labour. 425 . This particularly applies where the baby is of normal size (between 2.078 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to patient (the candidate should convey the substance of what follows to the patient): • Diagnosis . type of breech presentation. However about 3-5% of patients do have problems during the latter stages of delivery due to difficulty delivering the legs. • As she is in labour.5 and 4. the current baby is being delivered three weeks earlier than the preceding one which means it should be smaller than the previous child • Cardiotocography (CTG) monitoring is necessary in association with breech presentation as there is an increased risk of cord prolapse associated with this abnormal presentation. the breech presentation is a complete breech or a breech with extended legs: the fetal neck is not extended. or if breech extraction was considered required to effect delivery because of fetal distress or inadequate progress. an attempt at vaginal breech delivery would be appropriate. KEY ISSUES • Ability of the candidate to advise and counsel a patient of the current options in regard to breech delivery by vaginal or Caesarean delivery. • A successful outcome of labour can be anticipated with the findings which are evident in this patient. is also mandatory. and whether the fetal neck was extended.0 kg). or a significant CTG abnormality occurred in the first stage of labour. ultrasound would have been of value to check fetal size. • Indicating to the patient that vaginal breech delivery is absolutely contraindicated despite her desires. • Caesarean section would be indicated if there was slow progress of labour. CRITICAL ERRORS • Failure to advise of the appropriate risks of vaginal breech delivery • Recommending that external cephalic version should be attempted despite the fact she is in labour. Although second babies are likely to be bigger than the first one. where labour occurs spontaneously and progresses at the appropriate rate. to exclude cord prolapse and confirm the type of breech presentation. and vaginal delivery is safe in selected patients. COMMENTARY Approximately 4% of all babies present by the breech. The type of breech presentation (extended legs) is a favourable one. and as she is keen to avoid a Caesarean section delivery. • X-ray pelvimetry is unnecessary in view of the size of her previous baby (4000 g) which was born at 41 weeks of gestation. and where the pelvic dimensions are normal.

some patients will still prefer a vaginal delivery. These aspects were well reported in the Term Breech Trial published in 2000. Caesarean section recommendation at this stage would be appropriate depending on the patient's responses and concerns after discussion. Despite this. and the general recommendation that all babies presenting by the breech should be delivered by Caesarean section. 426 . when she is clearly in labour. If the candidate suggests external cephalic version should be attempted at this time. Failure to advise that the risk of vaginal breech delivery is higher than that of delivery by Caesarean section with the risk being approximately doubled. In this patient it would be appropriate to recommend a trial of vaginal delivery with appropriate monitoring. Common problems likely with candidate performance are: • • Failure to advise of the actual care in labour which would be given. and the risks are higher than when the baby is delivered by Caesarean section.078 Performance Guidelines There are risks to the baby of vaginal delivery however. this is contraindicated and clearly WRONG. The recent trial of vaginal breech delivery as compared to Caesarean section delivery clearly showed the risk of vaginal delivery was higher than that associated with delivery by Caesarean section.

079 Performance Guidelines Condition 079 Vaginal bleeding in a 23-year-old woman AIMS OF STATION To determine the ability of the candidate to assess and appropriately manage a patient in early pregnancy with eight weeks of amenorrhoea which was then followed by vaginal bleeding. and had a urine pregnancy test which was positive. Light loss then. • Blood group O Rh negative. enlarged to the size of an eight-week pregnancy. Questions to ask if not already been covered: • 'Will my baby be OK?' • 'Can you give me something to make sure I don't lose this pregnancy?' • 'What will happen if I miscarry?' Physical examination findings to be given to the candidate on request General examination Pulse Blood pressure Pelvic examination Uterus Adnexae 80/min and regular. • You ceased the oral contraceptive pill (OCP) five months ago. • You have minimal pelvic discomfort. • Breasts sore and nipples tender for last six weeks — no reduction in these symptoms recently. no mass or tenderness Previous investigation results to be given on request Pregnancy test Blood group positive previously. confirmed on spot urine testing now. and have had regular menstrual cycles since then until recent amenorrhoea. Total loss is much less than a normal period. this is your first pregnancy. Bleeding seems now to have stopped. You checked via a chemist two weeks ago. no blood in vagina. O. • You and your husband have been trying to conceive since stopping the pill. Rhesus negative 427 . EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • Your periods are usually regular and normal and your last menstrual period was eight weeks ago. • No bleeding since last menstrual period until yesterday. 120/80 mmHg. You think and hope that you are pregnant. not distressed cervix closed and firm. retroverted.

with a good prospect of a continuing viable pregnancy. • Immediate Management • • Treat conservatively and rest. (Anti-D is often not available in Australia for a threatened abortion). the chance of a successful pregnancy is somewhere between 90% and 95%. Ability to appropriately investigate a woman with these symptoms. These findings would be expected to confirm and define the diagnosis of threatened abortion (miscarriage). to check the sac size. the diagnosis is a threatened miscarriage. If indirect Coombs is negative. Chance of successful outcome of pregnancy — prior to performance of the ultrasound the chance of success was only 50%. 428 . the pregnancy was in the uterus. The candidate should ask for these investigations to be done and should explain to the patient that if everything was normal. liquor volume. give anti-D if abortion occurs. No specific therapy is effective in improving the pregnancy outcome. and the presence or absence of fetal heart activity. Other investigations required: checking the haemoglobin and check indirect Coombs as patient is Rh negative. • She needs an ultrasound of the pelvis to enable the pregnancy to be sited. KEY ISSUES • • Ability to define the diagnoses needing to be considered in the presence of eight weeks of amenorrhoea. Failure to consider use of anti-D in view of Rhesus negative state.079 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE Advice to Patient The substance of what follows should be communicated to the patient in lay terms. CRITICAL ERRORS • • • Failure to confirm pregnancy by pregnancy testing Failure to arrange ultrasound to check site and viability of pregnancy. Providing the ultrasound examination is perfectly normal. and the fetal heart activity was present. to confirm the gestation.

• Failure of candidate to advise the patient of the likely prognosis for this pregnancy. uterine size was not asked for. social history etc. Ultrasound in this case will enable the viability of the pregnancy to be assessed. Common problems likely with candidate performance are: • When taking the history. the state of the cervix and the presence or absence of pelvic tenderness.079 Performance Guidelines COMMENTARY In all cases of bleeding in early pregnancy. The reliance upon ultrasound examination alone is inappropriate. This just takes time to do and reduces the time available for the remaining tasks. the most critical examination findings are those of uterine size. but asking for information such as irrelevant past history. • Failure to examine the patient appropriately (cervical closure or opening status was not requested. not being focused enough to the actual problem. possible signs suggesting an ectopic pregnancy were not asked for). 429 . thus enabling the patient to be reassured with a degree of confidence. following performance of the ultrasound examination and assuming confirmation of normal findings. The other aspect of this case is the fact that the patient's blood group is O Rhesus negative.

Since then they have been shorter and lighter. breast enlargement. You have not missed any pills in the last six months (give the information of progressive reduction in menstrual loss only in response to specific request from the doctor).080 Performance Guidelines Condition 080 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) AIMS OF STATION To assess the candidate's ability to take an appropriate history and to assess findings to define the cause of amenorrhoea developing while on the OCP. but lightly. but they have become lighter and lighter. No relevant past. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • • • You were married six years ago. family or social history You have never had a curettage. Initially the periods were normal. and then to appropriately counsel the patient. You have been on Microgynon 30® for six years. You will probably want to conceive in about two years time. When not on the OCP. No problems with sexual activity. your cycles were 28 days long and you bled for three days. or nipple discomfort (so nothing to suggest a pregnancy). usually active 3-4 times per week. medical. surgical. vomiting. You have been on the OCP since then. and no period occurred at all at the end of the last two packs of pills. No recent nausea. About six months ago the periods were only lasting for one day. Your menarche was at 14 years of age. • • • Questions to ask unless already covered: • • 'Does it matter if I don't have a period at the end of the pill month?' 'Will I be able to have a baby when I want to do so?' Examination findings given to the candidate on request: General and abdominal examination: normal Speculum examination: Pelvic vaginal examination: Adnexae: normal uterus retroverted and of normal size and mobility normal 430 .

431 . The other option would be for her to have a break from the oral contraceptive pill and use some other method of contraception. LH or prolactin levels is suggested. including her fertility. or a triphasic pill (Triquilar®). • A pregnancy is most unlikely but a p-hCG estimation should be done to confirm this for the patient. KEY ISSUES • Ability to diagnose the cause of amenorrhoea when on the OCP.080 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: • The diagnosis is endometrial atrophy due to the progestogen component of the OCP M (Microgynon 30 ). all will return to normal. The key to the situation is generally the history of gradual reduction of menstrual flow over a period of time prior to the complete cessation of withdrawal bleeding. • Ability to counsel the patient appropriately. The cause is due to a progressive endometrial atrophy (progestogen -induced) over the period of time the patient is taking the pill. a pregnancy test is appropriate to reassure the patient — as conception is possible whilst a patient is taking the oral contraceptive pill. • If she is really worried about the amenorrhoea. the pill could be changed to either a higher-oestrogen-containing pill (such as Microgynon 50®). If the assessment of oestradiol. COMMENTARY The reduction in the amount of of withdrawal bleeding whilst a patient is on the oral contraceptive pill is not uncommon. • Inadequate advice concerning the natural history of this symptom after cessation of the OCP. When the oral contraceptive pill is ceased. CRITICAL ERROR • Failure to perform a pregnancy test (/J-hCG) to exclude the unlikely possibility of a pregnancy occurring whilst taking the OCP. Common problems likely with candidate performance are: • Inadequate history concerning the progressive reduction in the menstrual loss whilst on the OCP. FSH. and the menstrual loss may increase. • There is no real problem with the progestogen-induced secondary amenorrhoea except for the anxiety it produces in the patient about whether she is pregnant. Whilst the likelihood of pregnancy is very low. this would suggest little or no insight into the cause of the amenorrhoea or the effect of the OCP on these hormone test results.

~ by the time the neonatal diagnosis is able to be made clinically in the infant. GBS cannot be eradicated from the vagina with certainty by treating with penicillin or amoxycillin during pregnancy. if mother is GBS positive. and is not given antibiotics in labour. and ~ the important principle is therefore to prevent the baby getting infected. Although a low risk situation. It is extremely unlikely that the baby will become infected under such a regimen. Questions to ask unless already covered: • • • • 'What are these GBS organisms?' 'Why are these bugs there?' 'Will these bugs do any harm?' 'Why don't you just give me antibiotics now and get rid of them?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should convey the substance of what follows to the patient: • The significance of GBS organisms in the vagina is: ~ the organism will not usually produce a problem for the mother. those with premature rupture of the membranes. consensus best practice is to treat all GBS positive patients during labour. ~ the risk of the baby becoming 'infected' under the above circumstances is 1% but this infection can be very severe. and 10-15% of pregnant women may carry this organism. at this stage of the pregnancy. to prevent fetal infection. Having found that she is GBS positive. • • • 432 . Some obstetric units only give antibiotics to 'high risk' patients in labour. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You will be advised of the results of the recent GBS screening and what the doctor advises in regard to treatment.081 Performance Guidelines Condition 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman AIMS OF STATION To assess the ability of the candidate to counsel a patient concerning the significance of the finding of vaginal GBS organisms late in pregnancy and the subsequent management required. such as those in premature labour. it may be too late to treat effectively and mortality is high. or where there is a maternal fever. You have no history of allergies to penicillin. it becomes important to treat the mother in labour. ~ the risk of the baby being colonised is 40-50%. and delivers vaginally. The antibiotic crosses the placenta and protects the baby. Candidates should be aware that such a management protocol does however put about 0. Treatment with parenteral penicillin should be commenced in labour or if membranes rupture prior to onset of labour.5% of babies at significant risk where the mother is GBS positive.

or when labour commences. It is important to know that approximately 10-15% of pregnant women will be colonised with Group B streptococcus organisms at this stage. • Counselling the patient as to why antibiotic treatment in labour is recommended. • Failure to advise antibiotic treatment of the pregnant woman if the membranes rupture. It is important to stress the serious significance of Group B streptococcal infection in the neonate. The critical aspect of the management of this situation is that antibiotics are given to the mother only when she presents in labour and not at any time during the pregnancy when the colonisation is discovered. use erythromycin. • Believing that treatment of an infected baby is so effective. risk to the mother but may affect the baby. It is important to counsel the mother that colonisation with this organism poses tittle. if any. 433 .081 Performance Guidelines • If allergic to penicillin. to protect the fetus from the risk of severe infection. • Believing antibiotic treatment of the mother is necessary now because of the adverse effects GBS organisms will have on her. COMMENTARY This case illustrates the now almost universal practice of routinely screening all pregnant women at 34-36 weeks gestation for the presence of GBS colonisation of the vagina. • Parenteral penicillin to the baby after birth is optional unless signs of infection ensue or in high risk situations (such as prolonged ruptured membranes). KEY ISSUES • Defining the management plan. that prophylactic antibiotic therapy to the mother in labour is unnecessary. CRITICAL ERRORS • Failure to advise patient of the significance of GBS organisms to mother and her baby. Common problems likely with candidate performance are: • Recommending administration of antibiotics during pregnancy (antenatally) and assuming that such treatment would eradicate the GBS organism.

No previous pregnancies. The bleeding was not related to any sexual activity. No medications. You do not usually identify midcycle mucus to recognise the time of ovulation. Last Pap smear was six months ago and was normal. You use condoms for contraception. Questions to ask unless already covered: • • • ‘Do you think I'm pregnant?' 'If I am pregnant. You have noticed some breast discomfort and nausea recently. Your periods are often irregular with cycles varying between four and eight weeks duration. why am I bleeding? Will the baby be OK?' ‘Is there any treatment to stop the bleeding?' Examination findings to be given to candidate on request Patient looks well but is overweight (90 kg) Blood pressure Pulse Abdominal examination Speculum Pelvic vaginal examination Adnexae 120/80 mmHg 70/min no mass or viscus palpable. Your last menstrual period was eight weeks ago and was normal. The current bleeding is minimal and bright in colour. No abdominal or pelvic pain has been associated with the bleeding. and is retroverted normal. no tenderness cervix closed and normal. No tissue has been passed. You have never had an abnormal smear test.082 Performance Guidelines Condition 082 Vaginal bleeding after 8 weeks amenorrhoea in a woman with previous irregular cycles AIMS OF STATION To assess the candidate's ability to appreciate the significance of vaginal bleeding in a woman with irregular cycles where early pregnancy is a possibility. some minimal blood loss uterus is not obviously enlarged. It commenced yesterday spontaneously and is like day two of the period. No past medical or surgical history of relevance. EXAMINER INSTRUCTIONS The examiner will have instructed the patient to reply to questions from the candidate as follows: • • • • • • • • • You are a 25-year-old married woman without previous significant illness. no tenderness 434 . Your blood group is O Rh positive. You would not mind if you were pregnant although you were not planning to become pregnant for another couple of years.

TFTs). enquire about pain. • When all of these results are known it will be necessary to review her. symptoms suggesting pregnancy. or whether she simply is having one of her longer. COMMENTARY This is a situation where bleeding occurs some eight weeks after a previous period but where the patient often has an irregular cycle when amenorrhoea may last up to eight weeks. CRITICAL ERRORS • Failure to consider non-pregnancy as well as pregnancy causes. the diagnosis is probably a threatened miscarriage. Therefore. The prognosis regarding the pregnancy can be discussed when it is known what the results are. check β -hCG level to assess usefulness of ultrasound examination. It is also important to remember that where pregnancy is proven not to exist. if present. 435 . and the gestation and due date. • If β -hCG is negative. It is therefore important to differentiate whether this woman could be pregnant. Common problems likely with candidate performance are: • Failure to take an adequate history to define the previous menstrual cycle frequency and to check for symptoms of pregnancy. further investigations for the irregular menstrual cycles should be considered. is progressing satisfactorily. and tests for pregnancy. • Ability to confirm or exclude pregnancy as a cause. therefore observe. • If β -hCG is positive and greater than 1000 U/L. The candidate should advise along the following lines: • The diagnosis is unclear from the history and examination. An appropriate plan of investigations would be: • β-hCG to check if pregnant. • Failure to describe appropriate management and investigative plans. and no hormonal therapy is likely to be of value. • If she is pregnant. and enquire about symptoms suggestive of pregnancy. hormonal tests to see if fertility treatment is required may subsequently need to be considered (such as FSH. • Failure to arrange ultrasound if pregnant and β -hCG is greater than 1000 U/L. irregular menstrual cycles. Investigations will need to be done to confirm or exclude pregnancy and then define whether the pregnancy.082 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE The history needs to define the normal cycle regularity and length. KEY ISSUES • Ability to evaluate a patient with bleeding after amenorrhoea. If periods remain irregular. the diagnosis is just a late period. PRL. • Failure to advise appropriate endocrine tests if she is found to be not pregnant and the irregular cycles persist. she needs an ultrasound to check the site and normality of the pregnancy. must be discussed in the management of this case. LH. • If β -hCG is positive.

Comprehensive and contemporaneous case notes are essential. If the interview is to be conducted in a language other than English. with the time constraints imposed. The patient should then be allowed to talk spontaneously and without interruption for several minutes. as are nodding. then a trained health service interpreter should be used rather than an accompanying relative or friend. depending on the sensitivity and intimacy of the information to be gathered. For trust and rapport to develop. greeting companions if the patient is accompanied and explaining how long they may have to wait and whether they will be interviewed. It is usual to interview the patient alone first and other informants afterwards. paying attention to the factual content whilst simultaneously monitoring the patient's verbal and nonverbal behaviour. The interview should commence with the history of the presenting complaint by asking an open-ended question such as 'please tell me about your problems in your own words'. the clinician should be able to establish whether the individual has a mental health problem or not. notes should be taken during the interview rather than relying on recall afterwards. the tasks are split and focused to allow completion in the time period allowed. Let the patient know from the outset how long the interview is likely to take and that you will be taking notes at some stage (which are confidential) Begin with basic census data: contact details. Experienced interpreters will repeat patient's replies word for word. whereas well-meaning relatives may paraphrase or substitute replies to compensate for confused or disordered responses. When using an interpreter. education. but when time is short it may be necessary to focus on the immediate problems at first and schedule a longer followup appointment to round off the evaluation.' Aloysius Sieffert (c. the nature of the problem and a plan for the most suitable treatment. even if they are obviously delusional or thought-disordered. A private setting is crucial with comfortable seating and ambience and freedom from interruptions. complemented by observation and mental state examination and supplemented by a physical examination and the interview of other informants when appropriate. Whenever possible. In the context of the AMC assessment. empathy and genuine respect for the individual's dignity throughout the interview. occupation and languages spoken. 1858) A psychiatric assessment is a structured clinical conversation.2-G: The Psychiatric Consultation Frank P Hume 'The care of the human mind is the most noble branch of medicine. Confidentiality is central. given the personal and intimate nature of the material to be talked about. introducing themselves if unknown. the clinician must display tact. but it is not absolute when the safety and interests of the patient or others are at issue. or in medicolegal consultations. A thorough initial assessment may take an hour or more to complete. Clinicians should begin by welcoming patients by name. hostile or paranoid it maybe sensible to defer note-taking until after the interview and limit the amount of factual information at the first interview. with the patient's consent. Encouraging the patients to 'go on' or 'tell me more are simple strategies to put them at ease. with the clinician maintaining appropriate eye contact. After the initial interview. expressing concern or repeating key 436 . If the patient is highly anxious. leaning forwards. agitated. direct your attention and your enquiries to the patient and not the interpreter. However note-taking should be delayed at the outset until the patient feels that he or she has the clinician's attention.

As the interview unfolds. • know how to set limits if patients become angry. then more directive questions aimed at clarifying symptoms and their evolution are used. values and beliefs about themselves. patients' cultural and spiritual backgrounds. overfamiliar or adulatory patients.2-G The Psychiatric Consultation phrases. family psychiatric disorders (and treatment) should all be recorded. tolerant and empathie when a patient becomes tearful during the interview. • gain sufficient trust to encourage an unwilling or suspicious patient to discuss relevant issues by displaying tact. anorexia. then the family history should be reviewed with a family tree or genogram developed as far back as the grandparents. disinhibited. formative influences. When there is time pressure or urgency to make treatment or admission decisions. After the history of the present complaint has been established. Accordingly. disorganised. grossly psychotic or dysphasic and for whom other informants will be imperative. The quality of the relationship of each family member with the patient and its stability over time. other people and the world may all be explored in the course of an assessment. asking for more specific examples of symptoms or experiences Interviewing is an active and dynamic process: initial hypotheses or rough ideas are modified continuously as more information is collected. intoxicated. parental occupations. blind spots and personal vulnerabilities. 437 . important relationships. you are accordingly less likely to react inappropriately to them A psychiatric assessment differs from other medical interviews in that more attention needs to be paid to the patient's psychological and social influences. boredom sexual excitement or ' r e s c u e ' fantasies in you. Comments which make patients realise that they are being listened to and understood will increase their confidence and deepen rapport. for example. explaining that because of time restraints it may be necessary to break into their flow of conversation from time to time to concentrate on the points that are important for planning treatment: • rapidly identify patients who are demented. family status and atmosphere. and recognising when patients arouse strong feelings of anger. • politely interject and refocus garrulous patients. hostile or abusive. their attitudes. disorientated. significant life events and their reactions to them. and • become aware of and monitor their own countertransference responses to particular patients. patience and encouragement: • be comfortable. familial diseases and illnesses. weaknesses. By being aware of your own prejudices. anhedonia. then the clinician may need to be more active or directive from the beginning and use more closed questions (requiring just 'yes' or 'no' answers) Good clinicians should be able to: • put an anxious patient at ease. • recognise and respect patient-clinician boundaries especially with dependent. A vertical time line can be used to summarise key events in a person's life from what follows (which is not comprehensive). ' s o y o u r s l e e p p r o b l e m h a s b e e n g e t t i n g w o r s e ? ' Avoid using specialised language: for example. insomnia.

deviations or fetishes. childhood deaths. Predominant mood: and whether stable or changing. early development and nutrition. • • Maternal pregnancy and birth: abnormalities. milestones. Children: stillbirths. satisfaction. occupation and personality of partner: quality and stability of relationship. Psychiatric disorders may change a person's personality. drug and alcohol taking. behaviour disorders and insomnia. family. arrests. hospitalisations. Forensic history: includes delinquency. current libido. incest. with details about treatment or not. Marital history: length of courtship. peer groups. Current life situation: involves a description of family. behaviours and physical characteristics that define a person as an individual to oneself and others. disappointments. fidelity.The Psychiatric Consultation 2-G The patient's personal history may begin with conception. but there may have already been significant family or parental events that have occurred that will influence their development and shape their destiny (e. attempts to give up and their effects on health. menstrual or menopausal symptoms and chronic physical illnesses including fatigue. self-critical. anxiety symptoms. promotions and the patient's reaction to them. maternal rape. as well as the patient. terminations. sedatives. age. relationships. caffeine. neurological disorders. can help to describe the following: • • • • Attitudes to others: in social. mood disorder. losses.g. attitudes to children and further pregnancies. satisfaction. analgesics or narcotics and whether prescribed or not. illnesses and hospitalisations: anxiety traits and behavioural problems. Relationships with neighbours. housing. previous relationships. assault or property damage including fire setting and arson. and rebellious.g. vain. miscarriages. Previous mental health: includes self-harm. IVF. realistic. Attitudes to self: e. sex. and the chronological history of use and the quantities involved and patterns of usage over time. diet and exercise. Adolescent pressures: puberty. examination success and age of leaving school. 438 . rigid. work and finances. employers and superiors. accidents. experience of bullying. competence. imprisonment. stimulants. critical. thus other informants. separations. bereavement. the Holocaust). self-conscious. • • • • • • • • • • Personality refers to the habitual attitudes. somatic concerns. divorce. obesity. Recent life stresses. health and temper tantrums of the surviving children. the prior death of siblings. domestic violence. ambition. age. sexual dysfunction. contraception. psychosexual identity and dysphoria. education and schooling. eating disorders. peers and colleagues. Occupational history in chronological order: training. Moral and religious attitudes: e. Gambling history should also be explored. permissive. Use and abuse of drugs and alcohol: includes tobacco. work and sexual relationships. cannabis. operations. immigration. head injury.g. convictions. work and financial circumstances. probation and any history of violence. experience in armed forces or war. violence or abuse. Past medical history: should include significant childhood illnesses which may have affected brain development or function. friends and relatives. social. fantasy life. rebelliousness. duration and severity of symptoms and periods of hospitalisation and outcome. Psychosexual development from childhood: sexual orientation. Childhood milieu: separations. learning difficulties.

mood. MENTAL STATE EXAMINATION Mental state examination is a History-taking deals with the past while mental state systematic review of the examination is a systematic review of the patient's present patient's present symptoms symptoms and observed behaviour during the interview. neologisms (made up words). Patients could be asked How do you feel in yourself?' or 'What is your mood like?' or ‘How about your spirits?' To assess depression ask about unhappiness. ‘Mood is to affect as climate is to weather’. body size. Affect is a more short-term and immediate feeling state and refers to what is observed by the clinician during the interview. response latency unusual sentence construction e.2-G The Psychiatric Consultation • Leisure activities: hobbies and interests. slowness.g. Dysarthria or dysphasia are noted. shame or guilt about the past and hopelessness about the future. essential elements of Recording mental state begins with: Appearance and behaviour psychiatric practice. posture. • Fantasy life: includes daydreams and nightmares. pessimism about the present. Common sense and experience should inform the clinician about what is relevant to each patient as a picture emerges during the interview. psychomotor function and general activity and social relatedness during the interview. mobility. to enable appropriate candidate assessment over a brief eight minute doctor-patient encounter. Clues to mood assessment arise from the patient's appearance. Orientation. quality. pressure. It is neither essential nor desirable to enquire exhaustively about all of the above with each patient. incorporated into the grooming. volume. hesitancy. physical. scenarios must be selective and focused with clear aims and guidelines. anxiety. dress. looseness. • Resilience: in the face of adversity. quantity and tone of speech are recorded. Mood and affect Mood refers to a person's usual or longterm feeling state. solo or team. creative. movement and facial expressiveness. 439 . Yoda the Jedi in Star Wars. It is a and observed behaviour cross-sectional view of the patient and is one of the essential during the interview. The form of the patient's talk is considered rather than the content: spontaneity. In structured assessments at undergraduate level. sadness. tearfulness. Speech The rate. repetitions and distractibility. Behaviour refers to cooperation. body language and gestures. coherence. hallucinations and medication may all influence appearance and behaviour. posture and behaviour. The principles of the mental state assessment can readily be A comprehensive. It is a elements of psychiatric practice. The principles of the mental cross-sectional view of the state assessment can readily be incorporated into the patient and is one of the examination of any patient. accurate and lifelike word-picture of how the patient looks in terms of appearance.

artificial or cartoon-like. or as //'they are acting a part or being like a robot. labile. Thought form Abnormalities of thought can only be inferred from what patients say or write and may be influenced by mood or psychosis. Depersonalisation and derealisation experiences are difficult for patients to describe. because they are determined to succeed and do not wish to be thwarted or prevented from doing so. and then progress tactfully: 'Have you ever felt so bad/desperate that you have wanted to end it all?' 'Have you ever thought of harming/or actually harmed. Patients who are depressed and suicidal may be alarmed and frightened by their thoughts and are relieved that someone cares enough to ask what they may be thinking about. nor does it put the idea into their heads. Appropriateness of affect means that the current emotional expression matches what is being said at the time. yourself?' 'Do you feel unsafe at the moment?' 'Do you feel desperate enough to kill yourself?’ ' Do you think you are suicidal?’ 'Do you have a 'Plan B'?' Asking about suicidal ideation or plans does not make patients suicidal. The range of mood should be described as normal. fabulous or famous?' Other mood states that may be specifically enquired about include anxiety. restricted or blunted. suspiciousness and perplexity. unwanted and unpleasant. Examples of disorganised speech should be recorded verbatim. but may feel it is the only solution to their anguish. anger. All or any part of the body may be involved and the feelings may be intermittent or persistent. lifeless.The Psychiatric Consultation 2-G To assess suicidal ideation. Loosening of associations is the classic formal thought disorder of schizophrenia. inventive. 440 . Manic patients speak very rapidly and their train of thought may shift repeatedly (flight of ideas). irritability. Most suicidal patients do not want to kill themselves and find the thoughts repugnant. Attempts to clarify with followup questions often only deepen the puzzle. A patient may say a lot but it is impossible to grasp the meaning of what is being said.. increased. They may describe feeling unreal or detached. Alternatively they may describe their environment as colourless. They are usually accompanied by anxiety and/or depression.. envy. but are always seen as alien. Some genuinely suicidal patients may deny being suicidal when asked. Depressed patients may have slowed speech with no rhythm or cadence and only give limited or monosyllabic replies after a pause and with a limited range of topics or themes. They may be difficult to interrupt and their flight of ideas may be triggered by a pun or a clang association — where the sound of a word is rhymed with another word midsentence to produce a different set of ideas. because there is a loss of the normal clarity and structure of thinking. emotionless and numb. The feelings may vary from mild to severe. begin with the first question. To assess elation or hypomania ask 'Do you ever/often feel in unusually good spirits?' 'Do you ever/often feel on top of the world or full of energy?' 'Do you ever/often get racing thoughts?' 'Do you ever/often go on uncontrolled spending sprees that leave you in debt?’ 'Do you often feel unusually confident. Also note whether it is constant or stable.

g. They have the full force and impact of a real perception and occur spontaneously and cannot be controlled or terminated by self-will... Schizophrenia may affect olfaction and taste. Paranoid (persecutory) delusions are the most common. guilty.. illness or religion). or when anxiety is high.. Grandiose.. Specific delusions about one's thoughts. Voices in schizophrenia may be single or multiple. amphetamine psychosis and affective disorder... germs.. They are recognised as being self-generated and nonsensical and usually deal with issues that the patient finds disturbing or unpleasant (e. jealousy.... or1 You 're the doctor. Usually the patient is referred to in the third person (he or she).. nihilistic. intrusive. It is influenced by mood: mania heightens perception. and cause irreparable harm to significant relationships in the patient's life.. rattles. music. faces. but can also occur in alcoholism. depression mutes sound and dulls colour.. often to the extent that the patient forgets what the question was... sexual. cultural... Subjectively... animals or scenes. irrational thoughts... withdrawal or broadcasting are pathognomonic of schizophrenia. dirt.. violence. Hallucinations are false perceptions in the absence of a stimulus.g. An illusion is the misinterpretation of a real stimulus and is more likely to occur when attention and concentration are unfocused. for example. An overvalued idea is usually a solitary abnormal belief which dominates a patient's life and causes disturbed functioning and suffering to the person or others. anxiety may intensify sound.. Auditory hallucinations are characteristic of schizophrenia. They may be simple: experience of bangs... impulses or images that persist despite efforts to exclude or resist them... but occasionally commands and orders are given in the second person (you)... you tell me!' Thought content A delusion is a false belief which is out of keeping with an individuals educational. A delusion may arise spontaneously (out of the blue).....The Psychiatric Consultation 2-G Circumstantiality infers a lengthy and garrulous response to a question. religious. transsexualism). religious and social background which is held with extraordinary and unshakeable conviction and absolute certainty. and referential delusions also occur. hallucinations are normal sensory experiences.. 441 . The patient's whole life may revolve around this one idea (e. involving either thought insertion. body dysmorphic disorder.. sex..' With my fingers and toes. Perception Perception is the process of integrating input either from the sense organs or from imagery and fantasy (which are self-generated). anorexia nervosa. Obsessional patients may be anxious not to leave any doubt about their replies and qualify and exhaustively explore every detail and nuance before they get to the point. or be a secondary response to a patient's mood hallucinatory experiences or false memories.. Obsessions are recurrent. To patients. it is indistinguishable from a true belief and it is not influenced by rational argument or evidence to the contrary.. control. Concrete thinking is a literal and restricted response to a basic question. hypochondriacal.. particularly of colours. argue with each other or appear to speak or echo the patient's thoughts out loud.. whistles or flashes of light: or complex: hearing voices. 'How are you feeling today?'.. Tangentiality is an oblique or irrelevant response to a straightforward question. whisper or shout or speak in normal conversational tone: give a running commentary on the patient's behaviour. as usual! ' .

Visual hallucinations usually signify organic illness and are uncommon in schizophrenia. Reliability Whenever there is any doubt about the veracity of the patient's account of symptoms or behaviour change and other autobiographical details. Rapport Rapport refers to the degree of relatedness between the patient and the clinician during the interview and is a measure of the quality of the communication and trust achieved. Insight depends next on the degree to which patients recognise that the phenomena are abnormal. It also encompasses attitudes to assessment. and finally whether patients are willing to have treatment or be hospitalised. education and intelligence.g. postconcussional states. phenomena that other people (including the clinician) have drawn to their attention. Orientation. Substance abuse (hallucinogens. other informants should be interviewed 442 . recent and remote memory should be tested. alcohol). Insight is not simply present or absent. bereavement) and when falling asleep or on waking up. Auditory hallucinations may occur in normal individuals under stress (e. sensory deprivation. but depends on the degree to which patients acknowledge. Difficulty in establishing rapport may be symptomatic of the patient's illness or the clinician's countertransference and lack of empathy. haptic (touch-related) or somatic hallucinations may occur in acute psychosis and often have a bizarre complexity. Rapport predicts whether a patient will engage in and continue treatment. should be performed. are more likely due to temporal lobe phenomena or neurological lesions of the olfactory pathways. concentration and short-term. attention. neurological disorders affecting the visual pathways or the occipital lobe. temporal lobe epilepsy and various forms of dementia may cause visual hallucinations. Cognition Cognitive function should be assessed briefly in every patient and interpreted in relationship to age. insight is usually absent or partial at best. usually occur together and although they may occur in schizophrenia or depressive disorders. If impairment is suspected or revealed. Tactile. Perceptions of heat. and their effect on personal functioning and relationships. They may be more indicative of benzodiazepine. have all been described. if appropriate. cocaine or alcohol withdrawal. the clinician's assessment of the patient's suicidalityand risk of violence to others should be noted and then acted upon. glue. touch. or may have a psychological or psychiatric cause. such as the Mini-Mental State Examination. water dripping (or blood or bodily fluids). visceral sensations of severe pain caused by 'knives' or 'demons': or of formication (the sensation of ants or insects crawling on or under the skin). mental disorder and treatment. Blind or deaf people may hallucinate images or sounds. then a more structured and objective review of cognitive functioning. or are aware of. In psychotic disorders. Insight Insight refers to the self-awareness of morbid experiences (symptoms).The Psychiatric Consultation 2-G In organic disorders and depressive states when voices are heard they may adopt an abusive or critical tone and use the second person or simple words or brief sentences. Risk Depending on the circumstances. Olfactory and gustatory hallucinations are rare.

• The interpretation of proverbs or sayings: for example. Patients with frontal lobe dysfunction score poorly. their scores are so low that progression cannot be assessed. Frank P Hume 443 . naming as many words as possible in one minute starting with the letter F. are all easily incorporated adjuncts to a more comprehensive screen of frontal lobe function. fruit or vegetables in one minute (10 or less abnormal). Since its publication in 1975 it has become the most commonly used instrument for bedside cognitive function screening. orientation and drawing. perseverate and become disorganised under the time pressure of these simple tests. table and chair. attention. Once patients reach the more advanced stages of disease or dementia. significantly thought-disordered or affectively distressed. Patients with Alzheimer disease may perform worst on recall. This applies particularly to patients who are cognitively impaired. Its purpose is not to make a diagnosis. 18-24 indicate mild to moderate impairment and scores of 17 or less indicate severe impairment. The MMSE was developed primarily to quantify cognitive functioning in elderly patients with delirium and dementia and may not be reliable in every patient in all situations. The thirty items in the MMSE measure orientation. easily administered. intoxicated. amnesia). socioeconomic status. right hemisphere disorders and frontal lobe deficits. registration (immediate memory). recall (short-term memory). Alternatively ask for as many examples as possible from semantic categories: such as animals. a bird in the hand is worth two in the bush'. child and dwarf. Better educated people may score well on the test despite having significant cognitive impairment. whereas subcortical dementias may primarily affect attention and concentration. education. THE MINI-MENTAL STATE EXAMINATION (MMSE) The MMSE was developed by Marshal Folstein and colleagues from the Johns Hopkins School of Medicine in Baltimore. has high inter-rater reliability and may be used to monitor progress or fluctuations in these disorders. The MMSE may be supplemented by specifically testing frontal lobe functioning via • verbal fluency tests: for example. language and visuo-spatial function Performance in the MMSE is affected by age. apple and banana. It may be useless at detecting focal cerebral lesions (aphasia. years of education. but to indicate the presence of cognitive impairment due to delirium. ethnicity and whether English is the first or second language. then S.g. It is brief. or list as many items as possible that can be bought in a supermarket (15 or less is abnormal). Once again allowance must be made for age. dementia or head injury. ice and glass: and • motor sequencing tests: either rapidly alternating hand movements or the Luria three-step hand movements: fist-edge-palm. disorganised.The Psychiatric Consultation 2-G to corroborate the history. ethnicity and command of English. It is essential to consider the performance profile of the subsets of the test as well as the overall score. Normal is 15 words per letter or 30 words in total for the three. Scores of 25-30 out of 30 are considered normal. then the letter A. 'a stitch in time saves nine] • similarities and differences: e.

Recall Ask the patient to name the three objects in Question 2 1Adapted from Folstein M.g. drolw = 3) 4.. Folstein S. Apple Repeat them until the patient learns all three. dlrow = 5.g. taking one second to say each. and McHugh P. then ask the patient to repeat them. 86. Ask patient to remember them Number of trials required to learn the answers 3. Enter the scores out of the maximum shown. 1. Orientation What is the Year? Season? Date? Month'? Day of the week7 Where are we 7 State City Suburb Hospital Floor (if at home. e. 444 . Psychiatric Research 12 pp 189-198. stop after five answers): deduct one mark per error Or (b) Spell WORLD backwards (e.The Psychiatric Consultation 2-G MINI-MENTAL STATUS EXAMINATION (MMSE) 1 Date of Examination: Name: Date of Birth: Sex: Handedness: Occupation (previous): Educational Level: General Remarks Hearing: Vision: Record exact replies. Attention/Concentration (a) Table Coin Serial Sevens (take 7 serially from 100 -» 93. J. 79. Registration Name three objects. the street number and name) 2. No half marks awarded. 1975..

object) 6. Language (a) (b) (c) Ask the patient to name the following as you point: 'pen'.5. or buts Have the patient follow a three stage command: 1 /2 /1 Take this paper in your right hand. Construction Ask the patient to copy this design /1 Score = /30 445 . Fold the paper in half.. ands. 'watch Have the patient repeat: 'No its. Put the paper down in your lap'. verb. /3 /1 /1 (d) (e) Have the patient read and obey the following: CLOSE YOUR EYES Have the patient write a sentence (containing subject...

headache and feeling 'jittery' in a 30-year-old bank clerk Collapse of a 30-year-old woman on the way to a court attendance 446 .The Psychiatric Consultation 2-G 2-G The Psychiatric Consultation Candidate Information and Tasks MCAT 083-089 83 84 85 86 87 88 89 Medication changes for a 35-year-old woman with chronic schizophrenia Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man Poor work performance in a 30-year-old female police officer Lifestyle stress in a 45-year-old man Binge drinking in a 25-year-old man Nausea.

Before doing so. The Performance Guidelines for Condition 083 can be found on page 456 447 . Due to recent adverse publicity and concern about the effects of longterm thioridazine on cardiac conductivity (as reflected in a prolongation of the corrected QT interval on the ECG). • Educate the patient about the risks and benefits of the newer atypical antipsychotics. you will need to discuss with her the risks and benefits of her current treatment and the risks and benefits of the commonly available atypical antipsychotics. • Respond appropriately to the patient's questions. A longterm patient of the practice has attended for a repeat prescription of thioridazine (Melleril®).Candidate Information and Tasks 083 Condition 083 Medication changes for a 35-year-old woman with chronic schizophrenia CANDIDATE INFORMATION AND TASKS You are working in a general practice. YOUR TASKS ARE TO: • Explain your concerns about continuing on thioridazine. • Explain the side effects of the most common atypical antipsychotics. The patient is a 35-year-old woman who has been receiving thioridazine 200 mg daily for chronic schizophrenia over the past 15 years. you wish to change her to a newer atypical antipsychotic. There is no need for you to take any further history from the patient.

YOUR TASKS ARE TO: • • • • Establish rapport.Candidate Information and Tasks 084 Condition 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man CANDIDATE INFORMATION AND TASKS You are the duty Hospital Medical Officer (HMO) in a busy city hospital clinic attached to the Emergency Department. The patient you are about to see is a neatly dressed. Reach a diagnostic conclusion. focused and relevant history. He appears to have a normal full head of hair as illustrated below. asking if they can be 'examined under a microscope'. The triage assessment states that he is worried that he is suddenly going bald because he has begun to lose his hair. He is single and lives at home with his parents. He appeared to be guite anxious and restless whilst waiting to be seen by you and the triage nurse has told you that he has visited the toilet facilities for lengthy periods of time on several occasions. He has brought some of his hair to the hospital to be examined to find out what the problem is and have treatment urgently' because he believes that his hair loss is affecting his 'prospects for promotion at work'. He admits to not having any social life and is a nonsmoker and nondrinker. Discuss management briefly with the examiner. well-groomed 29-year-old man who has brought an envelope containing some hair strands to the front desk. FIGURES 1 AND 2. The Performance Guidelines for Condition 084 can be found on page 459 448 . It is early evening. CONDITION 084. and discuss this with the patient. Take a sensitive. He has worked as a financial analyst in a merchant bank for the past six years.

Candidate Information and Tasks 085 Condition 085 Poor work performance in a 30-year-old female police officer CANDIDATE INFORMATION AND TASKS You are working in a general practice. • Inform the examiner of the three most likely diagnoses. which are often on the first day of a new set of rostered shifts. She has been having an increasing number of sick days. The Police Service has become concerned that she does not appear to be functioning 1 as well in the workplace. • Answer questions from the examiner about one or more of these diagnoses The Performance Guidelines for Condition 085 can be found on page 463 449 . for the State Police Service. The patient is a 30-year-old Police Officer who has been advised to seek medical help by the human services officer (staff counsellor). YOUR TASKS ARE TO: • Take a focused history — you have six minutes to do this.

Other family members attend your practice. the patient had come from particularly difficult meetings. mother alive and well. to get some sleep. including performing an ECG. Blood pressure today is 130/70 mmHg. but this patient has not previously consulted you. to monitor his general health. normally only used on long plane trips. all alive and well. and you have just completed examining the patient. the BP reading was high (160/80 mmHg) but eventually settled to normal levels. unrelated to exertion. The patient has come to see you after having insurance medical examinations at work. wife an artist Wife. but now he is worrying about having a heart attack and can't get that out of mind over the past couple of nights. The patient is upset by these findings.Candidate Information and Tasks 086 Condition 086 Lifestyle stress in a 45-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. and resting ECG are normal. It was recommended that he see a general practitioner. On those days. The patient has been told that cholesterol. although a worrier No serious illnesses or operations • None known None 450 . Father died aged 65 of a heart attack. Last night he took a sleeping tablet. three teenage children Finance Manager 3-5 cigarettes daily two whiskies/sherries most nights Not known Eldest of five siblings. and feels much better now—the patient is now thinking he may have been suffering from stress over the past couple of years. You have obtained the information as listed below in the patient profile. He did not really think of being a 'stress type' before now. No abnormality has been found. The insurance doctor said 'there was nothing to be concerned about really'. and that he may be 'just stressed'. This worry has been reinforced by several episodes of stabbing chest pain each lasting only a few seconds. but on two occasions in the last month when tested by the insurance doctor. blood sugar. believing that he has always been in perfect health. and has no symptoms except for headaches towards the end of the day. Patient profile Marital status Household Occupation Smoking habits Alcohol use Drug sensitivities Family history Past medical history Major continuing health problems Current medication Married.

The Performance Guidelines for Condition 086 can be found on page 466 451 . • Advise the patient of your diagnosis and proposed management. • Answer any questions the patient asks you.Candidate Information and Tasks 086 YOUR TASKS ARE TO: • Discuss his health condition and relevant matters with the patient.

heavy drinker during the patient's childhood. but has had frequent presentations for minor sporting injuries. sustained eight days ago in a fall at the pub after the football. intoxicated to the Emergency Department of the local hospital at 1:00 am eight days ago. She has alerted you to discuss the patient's drinking and parental responsibilities. He was taken. Your nurse has just removed the sutures.087 Candidate Information and Tasks Condition 087 Binge drinking in a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. the wound was repaired and he was discharged several hours later. He intermittently presents on Monday 'feeling seedy' requesting a certificate for the day off. well-healed. smokes 10 cigarettes per day. • • • • • • • • He regularly drinks heavily at the weekends. He is not taking any medication. He is generally a good and caring parent — he has no other regular help with child-care. but not to excess. His father was a violent. YOUR TASKS ARE TO: • • Discuss with this patient his pattern of drinking and its harmful consequences. He was briefly unconscious. there is no other drug history. Make appropriate recommendations for dealing with the problem. He is a 25-year-old sole parent of a six-year-old girl — the mother left soon after the girl's birth and there has been no contact since. He does not have any history of psychiatric illness. His relationship with his family is strained — they blame him for his wife leaving. The patient came to the practice today for the removal of sutures to a small scalp laceration. He is otherwise in good health. The Performance Guidelines for Condition 087 can be found on page 470 452 . This patient is well known to you. The patient works full time as a local delivery truck driver. and still drinks.

Candidate Information and Tasks 088 Condition 088 Nausea. She is complaining of severe nausea. She attended here two days ago. The Performance Guidelines for Condition 088 can be found on page 474 453 . headache and feeling 'jittery' in a 30-year-old bank clerk CANDIDATE INFORMATION AND TASKS Your next patient is a 30-year-old bank clerk. • Ask the examiner for the appropriate examination findings you require to assist in diagnosis. who is consulting you in the Emergency Department of a general hospital. The notes also state that she had been taking the selective-serotonin-release-inhibitor (SSRI) Prozac® (fluoxetine) 20 mg daily for depression for three weeks on the advice of her local doctor. headaches and the 'jitters'. • Counsel the patient about the likely cause of her symptoms. their treatment. An alternative SSRI —Zoloft® (sertraline) 100 mg daily was prescribed when she attended the Emergency Department. • Inform the examiner of your diagnosis. Brief notes in the Emergency Department patient record state that she was then complaining of back pain which was diagnosed as 'muscle pain'. without much improvement. YOUR TASKS ARE TO: • Take a further focused history related to this situation. and what you recommend with regard to further management of her depression.

and give your reasons for selecting the diagnosis. After two weeks in hospital she recovered the ability to walk. The charges related to embezzlement to cover the husband's gambling debts. • Provide a likely diagnosis to the examiner. She is a 30-year-old housewife who was fully active yesterday and carrying out her everyday life up until this morning. Also take note of the patient's general behaviour and demeanour. she was admitted to hospital. YOUR TASKS ARE TO: • • • Examine the lower limbs with attention to the neurological system — you have six minutes to complete your examination. She had collapsed on the way to court where her husband was due to appear on fraud charges. Report your findings to the examiner as you proceed. and investigations including computed tomography of the spine and head were reported as normal.089 Candidate Information and Tasks Condition 089 Collapse of a 30-year-old woman on the way to a court attendance CANDIDATE INFORMATION AND TASKS This patient was brought to the Emergency Department complaining of a sudden inability to walk. Answer the questions which the examiner will ask you about this problem. You have reviewed the case and found the patient presented with a similar condition a year ago at the time the fraud was first alleged. At that time. The Performance Guidelines for Condition 089 can be found on page 478 454 .

2-G The Psychiatric Consultation 2-G The Psychiatric Consultation Performance Guidelines MCAT 083-089 083 Medication changes for a 35-year-old woman with chronic schizophrenia 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 085 Poor work performance in a 30-year-old female police officer 086 Lifestyle stress in a 45-year-old man 087 Binge drinking in a 25-year-old man 088 Nausea. headache and feeling 'jittery' in a 30-year-old bank clerk 089 Collapse of a 30-year-old woman on the way to a court attendance 455 .

5 metres (BMI 29 kg/m2). It is a drug that has given you a mild dry mouth. Monitoring and followup during medication changeover. as you cannot afford to live anywhere else. but sceptical — unconvinced that you need medication at all. Listen carefully to what the doctor says about the new medication options and respond appropriately depending on what is said.083 Performance Guidelines Condition 083 Medication changes for a 35-year-old woman with chronic schizophrenia AIMS OF STATION To assess the candidate's ability to explain the need for antipsychotic medication change. Outlining the management plan as detailed in the commentary. so that when the doctor tells you it is time for a change. 456 . You are convinced that a family does live in your roof and you only take medication because your mother supervises this and insists that taking medication daily is a condition of you continuing to live at home. Obtaining informed consent for medication change. Explanation of benefits and side effects of recommended alternative medications. Describing the benefits and side effects of alternative medications. You cannot realistically move out. You have been taking thioridazine under protest for 15 years and your condition is relatively stable. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 35-year-old woman with chronic schizophrenia characterised by chronic paranoid delusions about being 'spied upon by people who live in your roof cavity'. blurred vision and constipation for years. you are socially isolated and rarely go out. Occasionally you can hear them whispering amongst themselves or 'operating a computet system that enables them to track you with electromagnetic radiation '. You have only limited insight into your illness. Your weight is 66 kg and your height is 1. Responding to patient's queries. Although you live at home with your aging parents. You are attending your general practitioner to receive a repeat prescription of your thioridazine (Melleril®). EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should advise the patient of the need for medication change by appropriately: • • • • • Outlining recent evidence linking her current medication with potentially life-threatening arrhythmias. you are relieved. KEY ISSUES • • • Explanation of risks of continuing current medication. Your only income is the disability support pension.

olanzapine. thyroid disease. amisulpride and quetiapine are available for prescription on the Pharmaceutical Benefits Scheme for schizophrenia. Blockade of cardiac potassium channels may be the mechanism and genetic factors may play a part. but weight gain and inappropriate dietary choice increase the risk further. but not cholesterol. Weight gain liability is not confined to the atypicals. as well as impaired feedback of the adipose tissue-leptin loop. Sedation. syncopal episodes. Australian prescribers were alerted to the recently established link between thioridazine and prolongation of the QTc interval of the heart. metabolic disturbances and hyperprolactinaemia. but olanzapine. heighten the prevalence of Type 2 diabetes especially in overweight or obese patients. Pre-existing cardiac pathology. Since 1992 there have been several atypical antipsychotic drugs available for prescription in Australia. Extrapyramidal toxicity with thioridazine is uncommon. The most important emerging side effects of the atypical agents are weight gain. may also be significantly increased by olanzapine.083 Performance Guidelines CRITICAL ERROR . There is an increased risk of Type 2 diabetes mellitus in patients with schizophrenia independent of treatment. This arrhythmia is usually self-terminating but can progress to ventricular fibrillation or sustained tachycardia. Triglyceride levels. severe bradycardia and many commonly prescribed drugs may all lengthen the repolarisation phase of the ventricular myocardium. Weight gain is not dose-dependent. cardiac arrest or death may result. but patients who were relatively underweight prior to treatment may put on the most weight.none defined COMMENTARY In 2002. but not rare. receptor (which also causes sedation) and antagonism at 5HT2A receptors. Their efficacy is equivalent to conventional 'typical' antipsychotics. Data about other atypicals are limited. Thioridazine has also long been known to cause lenticular opacities when used in high dosage for long periods. There is a danger of life-threatening ventricular tachycardia if the QTc interval is longer than 500 milliseconds. cerebrovascular disease. 457 . Atypical antipsychotics. But it is the anticholinergic effects which cause most subjective discomfort. quetiapine and risperidone (of the drugs available for prescription by general practitioners) are associated with faster and greater weight gain than typical antipsychotics. Women are at greater risk. The mechanism of weight gain may be blockage of the histamine H. which could trigger the polymorphic tachycardia known as torsade de pointes. The risk is less with risperidone and quetiapine. Dizziness. They are 'atypical' in the sense that their mechanism of action is not solely to block CNS dopamine D2 receptors and they are thus less likely to cause tardive dyskinaesia or other extrapyramidal syndromes. electrolyte abnormalities. by increasing insulin resistance. particularly olanzapine. Risperidone. Adolescents may be particularly susceptible to this side effect. postural hypotension and weight gain are other well known side effects.

because of the length of time on a typical antipsychotic. creatinine and liver function tests. full blood count. Nonspecific discontinuation symptoms may persist for several weeks after changeover. but it is available only through specialist clinics. electrolytes. a crossover period of 1-2 weeks is recommended by reducing the dose of the previous medication and gradually increasing the dose of the new medication. weight monitoring and an agreed exercise program are all essential elements of the preswitch counselling process. Once the decision has been made to change a patient from one antipsychotic to a new one. Risperidone. thyroid function. decreased libido. body mass index. There is an increased risk of relapse requiring hospitalisation during the changeover period and patients need to be warned of the above major side effects. including agranulocytosis. Prolonged uninhibited prolactin release may cause hypogonadism and decreased oestrogen and testosterone secretion. Hyperprolactinaemia. has the greatest risk of hyperprolactinaemia and hence amenorrhoea. is a laboratory finding and is not always associated with clinical symptoms. The decision to change a patient from a typical to an atypical antipsychotic depends on the risk/benefit ratio. blood pressure must be measured as well as a 12-lead ECG. should not necessarily be changed to an atypical agent just because there is a choice. These include: nausea. impotence and anorgasmia. which in turn increases cardiac morbidity and osteoporosis. headache. A patient on typical antipsychotics. fasting blood sugar and lipids. of the atypical antipsychotics.083 Performance Guidelines Hyperprolactinaemia is a well known side effect of typical antipsychotics due to removal of inhibition of prolactin secretion by hypothalamic dopamine receptor blockade. and gives an increased risk of breast cancer. Lifestyle and dietary advice. Clozapine is the atypical antipsychotic with the most adverse side effect profile. 458 . who is stable and whose symptoms have reached equilibrium with minimal side effects. any change toa newer atypical agent may require dose-titration over several weeks and doses towards the higher end of the therapeutic range may be necessary. then for a nonacute patient. galactorrhoea. In this patient. Amisulpride is the atypical antipsychotic most likely to cause extrapyramidal side effects. Baseline weight. Patients and caregiver need to be alert to the 'early warning signs' or relapse signature' symptoms which herald the return of acute psychosis. however. urea. prolactin. although it is claimed to preferentially block limbic dopamine receptors rather than those in the striatum. restlessness and an influenza-like syndrome.

Checking your facial appearance on a regular basis during the course of a day has now become part of your daily life. could be four hours a day on weekends.084 Performance Guidelines Condition 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man AIMS OF STATION This is primarily a diagnostic and communication skills station. They have become accustomed to you constantly asking them 'Howdo I look?' or. You have been with the company for six years since graduation from university. Then you began to notice facial skin flaws and different shades of pigmentation. shave creams and cosmetics in an attempt to treat or camouflage your skin defects. it is three years since your last promotion. pick at and constantly inspect the lesion in a mirror on an hourly basis. In the past decade. face packs. Although you are conscientious and reliable at work. 7s there something wrong with my face/skin/mouth/eyes/hair?' Their unfailing reassurance that there is nothing wrong with your appearance does not reduce your concerns as you are sure they are only saying that to humour you. hair styling and allergy-free soaps. Fellow cadets from your intake cohort seem to have left you behind. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are a 29-year-old financial analyst in a large city merchant bank. It is your main interest. you will concede that the total amount of time you spend checking your appearance in front of the mirror. touching. You avoid crowds and public transport to avoid embarrassment of strangers 459 . Since your adolescence you have been concerned about your appearance and grooming. assessing the candidates ability to take an empathie and relatively quick psychosocial history and to rapidly reach the correct diagnostic conclusion. If asked. Your concern for the care of your skin means that you do not like to socialise at parties or clubs where people may smoke. Your mother suffered from agoraphobia during her twenties before her marriage. It began with a belief that your face was asymmetrical which you believed was obvious to other people and this led to you checking your facial features in a mirror several times a day. The amount of time you spend monitoring your appearance is slowly increasing. but your career progress has stalled. you have spent a small fortune on male beauty treatments. examining and picking at almost every skin pore or hair follicle. Your explanation for this is that you are losing scalp hair and must be going bald and that it is your hair loss that has cost you your promotion. which you repeat three times a day. You have just had a performance appraisal interview and have once again been passed over for promotion. facial massages. It is a competitive environment. who are both school teachers approaching retirement. You still live at home with your parents. Whilst at work you can only do this every two hours for a few minutes. but at home and on weekends it may take you at least half an hour to complete a thorough inspection of your entire head and face region. Each mirror checking episode lasts several minutes with you having to reassure yourself that no new blemishes have appeared or that any existing blemishes are improving or fading. If you developed a pimple or shaving rash you would touch.

you have come to believe several things. The first is that the cumulative loss of hairs means that you are going bald and that the resultant change in your hair density and thickness is obvious to other people. Although it may only be one or two. As you do not trust your family general practitioner. If the doctor realises what your underlying problem is. then your irritability and exasperation may increase. If the doctor rushes to judgment and dismisses your concerns without tact. In this instance there are many obsessive compulsive disorder features. but be prepared to listen and interact appropriately. you've got to find out why I'm losing my hair!' ‘I want these hairs of mine examined under a microscope by a specialist! ' 'Let me show you where I'm going bald'. but is infrequently diagnosed because of the lack of awareness by clinicians and patients' secrecy about their bodily preoccupations. You avoid direct sun exposure. BDD is a condition that affects about 1% of the population. about diagnosis and treatment for your hair loss. Over the past few months you have been monitoring the number of your scalp hairs you have found on the floor of the shower cubicle after a shower. well dressed and have a full head of hair. You are certain that this obvious hair loss has influenced your employers not to promote you because to have employees with thinning hair is not good for the bank's image when dealing with clients. who has dismissed your concerns and said there is nothing wrong.084 Performance Guidelines subjecting your features to close scrutiny. You will be anxious and somewhat irritable. You do not smoke or drink alcohol. but you may be relieved that at last someone is able to encourage you to talk about them. These have been behaviours you have kept secret for years. How to play the role You must be neat. (It would be useful to have a small mirror as a prop) Opening statements • • • • ‘Doctor. After six minutes. Do not willingly volunteer history of your rituals or checking behaviour until asked. when objectively and clinically. If there is a mirror in the consulting room. you have sought a second opinion from an unbiased doctor at the city hospital closest to where you work. and the extent of your difficulties and hypochondriacal concerns is realised. then insist on showing the doctor your 'receding hair line' at an early stage of the interview. 'You've got to do something!' Your subsequent behaviour and emotional reactions will be shaped by the way the interview unfolds. effectively establishes rapport. Finding out that you have yet again not been promoted has driven you to seek advice. You will have an envelope with a 7 couple of strands of your hair in it. there is no supporting evidence. 460 . ' EXPECTATIONS OF CANDIDATE PERFORMANCE The patient has a form of Body Dysmorphic Disorder (BDD) presenting with the conviction of impending baldness. the examiner will interrupt the consultation and ask 'What is your provisional diagnosis? Describe briefly possible management plans to me. BDD is a form of hypochondriasis which is part of the anxiety disorder spectrum. then be defensive and sceptical. empathy or appropriate discussion.

eyebrows. Key questions the candidate should ask of the patient would be: • 'Apart from your hair. cheeks or head. Typical complaints commonly involve imagined or slight flaws of the face or head such as thinning hair.Text Revision Most individuals with this disorder experience marked distress over their perceived deformities. vascular markings. • Ability to communicate with a patient with body dysmorphic disorder. it may also be vague: 'a flat chest'. Other common preoccupations include the shape. hips. the person's concern is markedly excessive. abdomen. family relationships. ears. shoulders. From Diagnostic and Statistical Manual 4 . Knowledge about the effectiveness of the serotonin reuptake inhibitor antidepressants and cognitive behavioural therapy in this condition would be desirable. CRITICAL ERRORS . legs. or dysmorphophobia. Repetitive and 461 . acne. swelling. teeth. overall body size or body build and musculature). spine. lips. paleness or redness of the complexion. feet. buttocks. chin. Any other body part may be the focus of concern (the genitals. or general: 'I'm just ugly'. breasts. wrinkles.none defined COMMENTARY 'Body Dysmorphic Disorder. The preoccupation may focus simultaneously on several body parts and although it may be often specific: 'a hooked nose'. Many hours of the day may be spent thinking and worrying about their 'defect' and these thoughts may dominate their lives. hands. They find their preoccupations difficult to control and may make little or no attempt to resist them. social and public situations. friends. arms. is a chronic preoccupation with an imagined defect in one's appearance. jaw. mouth.084 Performance Guidelines The candidate will be expected to establish the diagnosis. leading to significant impairments in functioning and avoidance of work. eyes. job or other activities?' • ‘Do you wish to do anything about your concerns?' KEY ISSUES • Ability to take a focused psychosocial history and to come to an appropriate diagnosis. scars. as well as being aware of the common comorbid psychological disorders. Even if a slight physical anomaly is present. have you ever been very worried about your appearance in any other way?' • (If yes): 'Can you tell me what your concern was?' • 'Did this concern preoccupy you? Do you think about it a lot and wish you could worry about it less?' • 'What effect has this preoccupation with your appearance had on your life?' • 'Has it affected your social life. facial asymmetry or disproportion or excessive facial hair. size or some other aspect of the nose. eyelids. The preoccupation causes significant distress or impairment in the person s social. occupational and other important areas of functioning. the associated behaviours and the complications in this case.

Treatment must be continued longterm as relapse is common if treatment is discontinued. that contribute to their social isolation and intensify their suffering to the point of despair. camouflaging. They may then become litigious or violent. Perhaps women are more likely to focus on their skins. With the patient's consent. but remain dissatisfied with the results. obsessive compulsive disorder. The condition typically begins in adolescence. It is their self-referential ideas. Severe comorbid depression may need hopitalisation and/or lithium carbonate augmentation with antidepressants. substance abuse and avoidant personality disorder are highly prevalent. They are socially avoidant and will not willingly visit restaurants. their genitals and hair loss or excess. i. shame. cognitive challenge and restructuring. 462 . Augmentation with antipsychotics may increase the response rate. beaches or go to parties or functions because of their self-consciousness about their appearance. Social impairment is the norm. Major depression is the most common (60%) but social anxiety/phobia. excessive grooming. The course is chronic and relapsing. Insight is usually poor or partial and their beliefs may become delusional. The dosages need to be in the higher range and it may take three months to get a response. The most common associated behaviours are mirror-checking. exposure and response prevention. lips. but may not present or be diagnosed until the thirties. which have no or only minimal benefit. shopping centres. comparing the defect' with other people's body parts either directly or with pictures in magazines. can supplement drug treatment and increase response rates to over 80%. whereas men are more preoccupied with overall physique. Psychiatric comorbidity is universal. Cognitive behavioural treatments including psychoeducation. self-harm and sometimes suicide.e. family involvement in psychoeducation and treatment planning and supervision of response prevention strategies and the removal of mirrors from the family home may be valuable. as well as anxiety management training. The core irrational belief in BDD is that the person is somehow defective and unattractive and this is accompanied by low self esteem. The condition is common if it is looked for and asked about. constantly seeking reassurance and questioning others about their alleged defects or ugliness and then seeking dermatological or cosmetic surgical treatments. Trying to convince patients with entrenched ideas that their beliefs are irrational or that they look normal is unlikely to persuade them to accept psychiatric treatment or referral. Rarely patients perform their own procedures after consulting internet web sites. that other people are taking special notice of their 'defect' and will talk and gossip and laugh about it. There is a roughly equal sex incidence and similar clinical features. Reassurance that there are no visible defects has no lasting effect on their abnormal beliefs.084 Performance Guidelines time-consuming behaviours are undertaken to reduce their distress. and weight. Most patients with BDD seek costly dermatological or cosmetic surgical consultations and treatments. but 70% of patients report improvement. embarrassment and fear of rejection. touching. Management The specific serotonin reuptake inhibitor antidepressants and clomipramine are often effective.

It's also worse when I'm going back to work after some days off. • Been ill? ' N o t t h a t m u c h m o r e t h a n o t h e r s . insert the following into your first answer to them: ‘I didn't really want to come today. ' • What has been wrong? ' I ' v e b e e n f e e l i n g r e a l l y j u m p y a n d o n e d g e . ' • You are a police constable with a variety of service attachments in the field and at office tasks. and what the ramifications of the problem might be at this time or in the future. I am only here because the Police Service thinks I have a problem.085 Performance Guidelines Condition 085 Poor work performance in a 30-year-old female police officer AIMS OF STATION To assess the ability of the candidate to diagnose a stress-related depression associated with increased alcohol intake. at first say: ‘I d o m y j o b w e l l — t h e r e have been no complaints about what I do at work. ' • Days off when shift changes? ‘I guess I ' v e h a d o n e o r t w o d a y s o f f o n t h e l a s t f o u r times the shift changed. ' 463 . ' • When has the anxious feeling been worse? ' W h e n I t h i n k a b o u t t h o s e e x p e r i e n c e s . I was OK. • You live alone. When the candidate questions you further. I ' v e b e e n finding it hard to concentrate and just don't have any confidence. You should present as anxious and initially reluctant to admit that you are having difficulties at work. or when I have to deal with another situation where people might get hurt. but volunteer additional information only if appropriately led. ' — ' O n e d a y I h a d t o g o t o a f a t a l m o t o r vehicle accident where an adult and two children were killed. but haven't seen them much lately. I ' v e h a d s i x d a y s o f f i n t h e l a s t month. answer the following or similar questions directly. ‘Too b u s y a t w o r k . • You have l o t s o f f r i e n d s ' . To assess the ability of the candidate to determine when and why the problem started. No current romantic relationships. but my work colleague received serious injuries and he has not returned to work. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You do not wish to be examined by the candidate and resent having been advised to see the general practitioner by the Police Service's staff counsellor. ' • Your family is interstate. ' • When did this start? ' S i x m o n t h s a g o . The very next day I was called to an armed hold-up and both my work colleague and I were shot at by the offender. ' • If you are asked if there are any problems at work. • After candidates introduce themselves.

~ Nightmares of both incidents — most nights. ' What about your gun? 'I have not handed this in nor have I been asked to do so. or ~ social or occupational problems. Depressive disorder: adjustment disorder. major depressive disorder. 3. 2. ' Alcohol? Only answer direct questions 'Over the last six months my alcohol intake has increased from 1-2 glasses of wine per week to 6-7 glasses of wine each day on most days. NOTE: If the candidate has not identified alcohol dependence/abuse as a problem. ~ Racing heart (palpitations). ' Does your use of alcohol bother you? 'I am worried that I have to have a drink to control the anxiety. ~ potentiation of anxiety or post-traumatic stress disorder symptoms. ' If pressed further. 'What are the short term risks associated with the patient's current level of alcohol use?’ You should expect at least four of the following: ~ hangover effects — headaches. ~ worsening of mood/depression. ' Examiner's questions Towards the end of six minutes. ~ impaired decision-making: ~ accidents. breathing faster.085 Performance Guidelines • What is the anxiety like? Volunteer any two of the following features if asked a general question: ~ Feel terrified something awful will happen. add 'I have sometimes thought that life is not worth living. It's the only thing that helps me "unwind" after work and enables me to get to sleep. Appropriate responses are: 1. including with firearms. ' What does alcohol do for you? 'It relaxes me and lowers the anxiety. I don't want to end my life. tremor: ~ gastritis. anorexia. or just problem drinking. ~ impulsive acts — including suicide attempts. the examiner will ask the candidate to describe three conditions which should be included in the differential diagnosis. panic disorder or generalised anxiety disorder. these questions should NOT be asked. Next questions for the examiner to ask should be: • • 'What is a safe level of alcohol consumption for this patient?' Low risk = maximum of 20 grams per day (two standard drinks) and two alcohol-free days per week (NHMRC Levels for Women). ' Any plans to commit suicide or past attempts to harm yourself? 'No. ~ Can't watch television or read magazines with pictures or articles of car accidents or Police Officers being shot at. ' Suicidal thoughts? 'No. Instead ask 'Are there any other possible diagnoses?’ 464 . Alcohol dependence/abuse. • • • • • • • What will happen in the future? 'It is only a matter of time before I'm injured or killed in the line of duty. and perspiring a lot. Anxiety disorder: post-traumatic stress disorder. Never.

assess subjective mood and risk of suicide and. and the NHMRC recommendations of alcohol abuse. a pass mark is unlikely to be given. 465 . If they are not aware of at least four. particularly in this case. They should ask about the key features of post-traumatic stress. COMMENTARY This case concerns a patient with a work experience that has exposed her to severe stress. namely the fatal car accident and the shooting of her work colleague the next day. her access to firearms. Identifying the alcohol problem alone is insufficient for a pass. leading to an alcohol abuse problem to help relieve a post-traumatic stress syndrome with anxiety. • Knowledge of the causes of the problem • Knowledge of the short-term effects of alcohol excess.085 Performance Guidelines KEY ISSUES • Ability to take a focused history to define the potential cause of the current problem. Candidates should be familiar with at least four of the short-term risks or consequences of excess alcohol use and the NHMRC recommendations concerning alcohol consumption. CRITICAL ERRORS • Failure to identify the excess alcohol consumption. and also explore the factors that have led to the problem. She has a responsible job and failure to help her may also result in her colleagues or other members of the community being at risk. • Failure to ask about suicide. Candidates must both take an adequate history of alcohol consumption. The patient is also at risk of comorbid depression and suicide.

If candidates attempt to seek further history. Your spouse is usually very understanding. and resting ECG are normal. blaming work. and you would still enjoy all your usual activities if there was time to do them. and avoid taking tablets. blood sugar. You have been told that cholesterol. and you get irritated with your eldest son who dropped out of university last year. You have been more irritable at home. even a Panadol® if you have a headache at the end of the day. You have never thought about having serious physical illness. EXAMINER INSTRUCTIONS The candidate needs to have sufficient skills in evaluation of cardiovascular disease to recognise this is not ischaemic heart disease. the BP reading was high (160/80 mmHg) but eventually settled to normal levels. and people coming to see you for advice. On those days. You did not go on the family holiday this year for the same reason. you had come from particularly difficult meetings. You have never felt depressed. You sometimes feel like escaping. Since you were promoted 18 months ago. even with a bad cold or jetlagged from a trip.086 Performance Guidelines Condition 086 Lifestyle stress in a 45-year-old man AIMS OF STATION To assess the candidate's ability to recognise and to communicate to the patient. You have planned to retire at 55. No further prompts. you have been taking work home on weekends more frequently and there is a lot more pressure. and your spouse complains you criticise the children too much. but on two occasions in the last month when tested by the insurance doctor. examination or investigation of cardiovascular disease. but got mad with you about that and things have been tense the last few months. The only health problem you have noticed is more frequent headaches towards the end of the day. the examiner is to inform them (once) they are to proceed on the basis of a normal examination. common behavioural. psychological and emotional concomitants of lifestyle stress. The examiner will have instructed the patient as follows: You have been recommended to see a general practitioner to review your health after an insurance assessment. and 'just sits around playing music with his mates'. You work 12-15 hour days. You enjoy being challenged by work and sports. physiological. but think of it only being a few more years and anyway you feel happier at work than at home these days. It is just too noisy with three teenage children. and advise the patient accordingly. The candidate who pursues a physical cause to the exclusion of the psychological matters should be marked down. You never take a day off work. which you put down to eyestrain. and believe people who complain of stress 'just aren't motivated enough or don't work out their goals properly'. 466 . and to formulate and implement an appropriate immediate and preventive management plan. You feel rather shocked by what you have been told and by the way you have felt over the past couple of weeks. or at any time recognised yourself as being anxious.

086 Performance Guidelines You normally get on with a few hours sleep. why did I have those pains in my chest?' • 'What would help the most?' • 'What do you suggest I do?' • 'How long will this all take to make a difference?' • 'What happens if I need these tablets all the time to sleep? Are they addictive?' • 'What else can I do to sleep?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Inform the patient about common symptoms of stress. absence of leisure and exercise) and the compensatory measures which increase physical and emotional burden (alcohol and smoking. but started again smoking 3-5 cigarettes a day in the past 12 months because it helps keep you going through the day. both psychological and physiological. and sleep pattern). but do not labour the point. regular recreation. or unfit. You are more accepting of a straightforward solution (for example. You stopped smoking 15 years ago when your father. You have never worried about suffering your father's fate. and readily accept further investigations. Expect to be provided with an effective solution and definite results. sympathetic arousal causing blood pressure rise and initial sleep disruption. You have always eaten a balanced diet. but you are sure it is not your lack of interest that is the problem. You notice you are drinking more these days. but the last year or so you 'catch up with naps' on weekends. who was a very heavy smoker and ate badly. you walk up the stairs when you have time. except when on overseas trips and at business lunches. or cause a heart attack?' • 'If my heart is okay. • Identify for the patient the sources of stress (overwork. You never feel tired. Now. Seek reassurance about the risk of heart attack. reduced sleep). exercise. the sooner the better. • Reassure about nature of stabbing chest pain. You have gained a few kg over the past few years. You used to exercise regularly at the gym and with weekly tennis but have not done so in the last few years because you are just too busy at work. or some kind of a breakdown?' • 'Could it be the beginning of heart trouble. died at 65 of a heart attack. and running around with the children's activities on weekends. and seek advice regarding change. 467 . • Explain the mechanism of physiological symptoms — headaches resulting from muscle tension. You feel uncomfortable in an unfamiliar environment. you have slept badly. The last couple of weeks. if offered. often thinking through work problems once you are in bed. but do not consider yourself overweight. You consider yourself a moderate social drinker. Answer any questions from the candidate in a straightforward manner. because you have looked after yourself so well. and feel tired in the morning There is little time for sex. Questions to ask unless already covered: • Opening question: 7s this stress. and somewhat embarrassed about the problem. but acknowledge the stress levels and sources when identified.

on available information). propensity to overwork. Resume exercise. increase leisure activities. Recognition of the personality style enables realistic intervention — brief. Provision of an adeguate explanation about stress. behavioural and psychological seguelae and complications. with extension to include spouse for interpersonal/family issues. increased recreation through regular exercise. Reassurance about blood pressure and chest pain. Include the spouse in supporting lifestyle modifications and enable discussion of interpersonal and family issues. but in the context of promotion and increasingly complex life. increased intolerance and isolation. holidays. Modification of lifestyle — restrain working hours. healthy compensatory mechanisms such as pursuit of fitness and competitive sports have been discarded. including discussion with spouse Avoidance of intensive or invasive management. behaviourally or physically mediated. Management The essential management is to provide this patient with appropriately focused brief intervention to modify behaviours and lifestyle. chest pain. after engagement through adequate reassurance regarding physical illness. and sleep pattern). especially family demands.086 Performance Guidelines • • Educate about the negative role of stress in cardiovascular disease and mental health. and dysfunctional habits substituted. mental and interpersonal control. CRITICAL ERROR . such as a regular sleep pattern. Use of hypnotherapy for sleep disturbance (short-term) is acceptable but other measures are preferable. it has brought occupational and personal success. as well as relationship breakdown. labile hypertension. followed by education of the physiological mechanisms and identification of stressors.none defined COMMENTARY This patient has obsessional personality characteristics of perfectionism. alcohol and cigarette consumption. it is now being overused.g. KEY ISSUES • • • Patient counselling — explanation of diagnosis and patient education and initial management plan. Assist the patient in identifying realistic changes for healthier work/personal balance (e. and progressive muscle relaxation. As a coping style. The degree of dysfunction is sufficient to produce somatic and behavioural symptoms — increased headache. Initial management plan • • Appropriate advice regarding lifestyle change. The patient is stressed and does not have a psychiatric or physical illness. but intervention is now needed to modify those behaviours which increase risk of cardiovascular disease and psychiatric illness. Followup and ongoing monitoring of blood pressure and cardiovascular health is indicated. acute and chronic. and inflexibility (not personality disorder. its origins and its physical. 468 . including family pursuits — these are the interventions most able to be implemented.

• Ability to combine the tasks of identifying stressors. through using direct questions around the main activities of daily living and habits. currently anxious. with providing psychoeducation. but usually pragmatic and busy person in appropriate lifestyle change. and empathie listening. • Consideration to inclusion of spouse in further discussion.086 Performance Guidelines Communication skills • Ability to take this opportunity to engage a reasonably informed. 469 . • Attitude to alcohol and cigarette use should be nonjudgmental and proportionate to use.

The binge drinking pattern risks impaired judgement and injury to self and others.' • • • In response to specific questioning: • • You drink because it helps you unwind. Brief interventions such as this consultation provide a vital opportunity to initiate change in critical patterns of dysfunctional behaviour. Admit to being stressed by the demands of being a single parent and not being able to call on your family for help because they hold you responsible for your former partner leaving. faints. alone. Respond to further questions about the amount you drink. defensively — 'not any more than my mates at the club — don't do anybody any harm. • • • • • • • • 470 . to personal physical injury. by cost). social. some of which he has manifested in the past. You have had no period of abstinence longer than two weeks. or any other attempt to estimate it (e. Your mates said you were 'playing up'. You have not noted any change in tolerance. apart from minor injury like today. you admit this has happened before but rationalise your lapses by saying ' The girl is such a good sleeper. Now you no longer have a babysitter because the next door neighbour who has filled that role now refuses to do so because of the events last week. You do not have any fits. She had to go home and left your daughter asleep. You do have 'blackouts' (episodes of amnesia) quite often. but I'll listen to your lecture just in case!' You have no recollection of your fall. and makes you more sociable. or how much you had to drink. you need a break by the end of the week with work and taking care of your daughter. You do not have any symptoms of panic or phobia of any kind. EXAMINER INSTRUCTIONS This is problem drinking of a binge drinking type with consequential exposure to risk —in this instance. If specifically asked.g.' You do not feel anxious or depressed. relationship. You have never had any medical complaints. tremor and palpitations). The examiner will have instructed the patient as follows: Opening statement • (You are embarrassed and feel tense but attempt to make a joke of it) ‘I deserve this knock and the team lost! I think its put some sense into my head. neglect of parental responsibilities and potential harm to his daughter. are of illness. she never wakes and would never know. psychological and legal complications. Other potential problems. withdrawal symptoms (sweats. work. You regard yourself as a responsible and caring parent and had intended to be home. financial.087 Performance Guidelines Condition 087 Binge drinking in a 25-year-old man AIMS OF STATION To assess the candidate's ability to recognise the specific risks of the patient's drinking pattern and to counsel him accordingly.

no more than three days a week). especially about any risk or harm to your daughter or doubt about your parenting capacity. to a reminder that his father's drinking was associated with violence and family dysfunction. and that change is necessary. No other forensic history. The candidate should approach this by discussing this incident and injury and asking about any current problems or stresses. Questions which may be asked with appropriate responses • 'Are you saying I'm an alcoholic?' The candidate should indicate there are ranges of consequential problems to excessive drinking. including simply accepting this statement without comment. • Counsel the patient about the risks to his daughter and his relationship with and care of her. • 'Look at my father — he's always been a drinker and he's okay' There are various responses. or some introduction of relaxation techniques. KEY ISSUES • Discussion about binge drinking and consequential harm. you are prepared to listen to the advice and respond in a positive way to changing your drinking habits. You are embarrassed about your drinking problem being addressed directly and you are initially tense and defensive. and encouraging the patient to talk about his views about his drinking and other potential problems. However. • You have had one drink driving charge with no loss of licence several years ago. safe up to six standard drinks per day. or the option of controlled drinking (less feasible with a binge drinking pattern). • 'Howcan I relax if I don't have a few drinks with my mates?'The candidate could respond with an undertaking to discuss this further. Further instructions: You know this doctor quite well. • Be able to communicate concern in a nonjudgmental and nonthreatening way so as to maintain rapport and ensure engagement in ongoing review and case management. and generally feel comfortable here. • Advise reduction or cessation of alcohol use — discuss. EXPECTATIONS OF CANDIDATE PERFORMANCE • Recognise that alcohol overuse — binge pattern — is the primary problem. • Highlight risk to daughter — discuss potential referral to child protective services or equivalent. unless the doctor is unduly critical. for his own wellbeing and his daughter's. • Seek out whether there are any aggravating as yet undisclosed issues or current stressors.087 Performance Guidelines • You do not drink in the morning. • Discuss the problem and actual consequences. which the patient would want to avoid for his daughter. 471 . • Demonstrate knowledge of hazardous/harmful drinking levels (NHMRC guidelines for men. The candidate is expected to diplomatically but firmly advise that the patient has a habit of binge drinking on weekends. and binge type drinking is associated with increased risk-taking and acute harm events.

Rather than being punitive or restrictive.087 Performance Guidelines CRITICAL ERROR • Not addressing the issue of his daughter's wellbeing. there is a specific need to appropriately address the risk to the patients daughter which must include his responsibility for parental care and protection. especially identification of concurrent psychiatric illness which requires treatment in its own right. social. such as regularly missing work after weekends. and the responsibility of the doctor to monitor and ensure her wellbeing. She is potentially at risk of abuse by neglect. which is less likely to be associated with addictive/withdrawal symptoms than a daily drinking pattern. A good general practitioner will either have relevant pamphlets on hand or be able to print the information off line. legal and interpersonal problems. personality traits and other psychiatric illness. often rapidly. Incidents of accidental injury to self or others. environment. The symptom of a 'blackout'. including consideration of referral to child protective services. disinhibition and sexual or aggressive acts. including education. 472 . The evaluation of all of these elements is important in the individual case. and neglect of self or others are other frequent reasons for intervention. and of interpersonal and sociocultural factors which trigger or maintain the behaviour. Effectively intervening in such a problem requires identification of the reason for the adverse consequences. especially mood and personality disorders. medical. as well as possible child-minding options. In this case. the Department's caseworkers should be able to advise him about local child-care and parent support services. developmental. and more likely to be associated with injury and other social and interpersonal sequelae of impaired judgement and poor impulse control. assessment of other psychiatric. Sociocultural factors are also significant. the doctor may have a statutory obligation to inform an authority such as the Department of Families. Hazardous drinking of excessive quantities of alcohol intermittently is a subtype of alcohol abuse. Community Services and Indigenous Affairs of his daughter's situation. a brief period of amnesia without loss of consciousness during a drinking episode. The recognition of hazardous drinking depends less on an estimation of the quantity consumed than defining a pattern of drinking. is associated with the rapid consumption/absorption of alcohol and is a useful indicator of this pattern. to severe intoxication and consequential risk-taking. In addition to counselling this young man about his hazardous drinking. sensitive but frank communication about them and the underlying problem and appropriate offers of assistance. motivation for change and ongoing review. protection and care management in any way. Episodic neglect of financial. COMMENTARY Alcohol abuse and dependency are linked with genetic and developmental predisposition. occupational and social responsibility is common. Consider checking whether notification was made at the time of his presentation to the Emergency Department. Most communities will have single parent support groups and possibly men-only support groups which may be of interest to him.

For example.087 Performance Guidelines In addition to practical support. through her school he could advertise for part-time child support or pressure the partners of his team mates to care for his daughter during the game and its aftermath. Consider at what point should a clinician notify the local license-issuing authority about CONDITION 087. Alcohol content of standard drinks* 'Many thanks to Drug and Alcohol Services South Australia for this poster 473 . His drinking pattern may jeopardise his ability to drive and hence his livelihood if he should lose his driver's license or have a serious accident. this man would benefit from understanding simple problem-solving in relation to his daughter's ongoing child-care. FIGURE 1.

hazardous drinking. 473 .

088 Performance Guidelines Condition 088 Nausea. You have come back to the Emergency Department of a nearby general hospital because of severe nausea. headache and the jitters. You saw a doctor and mental health nurse and were told it was due to muscle strain'. elevated blood pressure. but on the other hand you think there may well have been some confusion over what was said to whom as they all seemed very busy and distracted and you felt a bit sorry for them and wanted not to bother them too much. You are prepared to follow the doctor's advice about further treatment. Your back pain has resolved. You think your appetite was improving before the nausea started. the examiner should advise to proceed with the tasks required. but do not want to have another reaction like this. Without prompting — go on and tell the doctor: 'Three weeks ago my local doctor started me on Prozac® (fluoxetine) 20 mg daily for a relapse of the depression I get. namely advising the patient of the diagnosis and management of both the immediate problem and her depressive illness. tremor. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows You are a 30-year-old bank clerk. Your opening statement to the doctor should be: ‘I feel awful doctor — I'm nauseated. They were more concerned with your depression and prescribed Zoloft® (sertraline) 100 mg daily. It didn't seem to be helping much'. you are relieved. It all started yesterday'. You are still sleeping poorly and waking about 4-5am. I've got a headache and a feeling of the jitters. You are wondering if the medication is the reason you feel so unwell. If the candidate has not started to ask for these findings six minutes into the examination. The candidate should ask for findings consistent with the serotonin syndrome. 474 . but will ask for appropriate examination findings from the examiner. You are angry that the hospital doctors did not warn you of this. You told them about being on Prozac® which you then stopped taking because you knew that both drugs were antidepressants. Two days ago you felt some back pain and attended the hospital Emergency Department. You have never had suicidal ideas but you remain pessimistic about the future and find it hard to concentrate at work. Your medication has recently been changed (see below). You have had no other symptoms and your last period was two weeks ago. headache and feeling 'jittery' in a 30-year-old bank clerk AIMS OF STATION To assess the candidate's ability to recognise that the history strongly suggests a mild serotonin syndrome. increased muscle tone and hyper-reflexia. You could say something like 'Could this happen again?' The candidate is not expected to conduct a physical examination. In answer to further questions which may be asked: • • • • You feel anxious and 'aroused'. increased pulse rate. When the candidate explains that this is the case. namely: sweating. You suffer from recurrent depression.

EXPECTATIONS OF CANDIDATE PERFORMANCE • Serotonin syndrome should be diagnosed. 25-30 mg. Often it is the doctor's helplessness that is being treated by the prescription because there is never enough time to establish why this patient is depressed on this occasion. CRITICAL ERROR • Failure to recognise the need to stop the Zoloft® (sertraline) medication. if the candidate has not told you to stop the treatment with Zoloft®. KEY ISSUES • Ability to diagnose the serotonin syndrome due to side effects of a Selective Serotonin Reuptake Inhibitor (SSRI) drug. COMMENTARY This scenario is a timely reminder about aspects of psychopharmacology.8 °C. • The appropriate advice regarding management is to stop Zoloft® (sertraline) and wait until the symptoms resolve. Blood pressure 130/80 mmHg She has a tremor. Side effects are common with most psychotropics because they may be prescribed too enthusiastically and in dosages that are inappropriately high. in about 24 hours. Not all patients with ' d e p r e s s i o n ' or depressive symptoms need antidepressants. regular. especially in management of ' d e p r e s s i o n ' which is a complex multifactorial complaint in our modern society. which has not yet had an adequate therapeutic trial in this patient. 475 . at a lower dose. and tone and reflexes in limbs are brisk and mildly hyperactive. The candidate should continue to treat the depression and should arrange followup with the Emergency Department or the patient's general practitioner the next day. her palms feel sweaty. As Prozac® (fluoxetine) has a long half life the candidate should recommend waiting at least another week before reintroducing sertraline. but like antibiotics they are often prescribed reflexly by doctors under time pressure as a ’quick fix – it can’t do any harm’ panacea for a patient in distress or in tears.088 Performance Guidelines Near the end of the exam. 36. you should ask ' S h o u l d I c o n t i n u e w i t h t h e c u r r e n t d o s e o f Z o l o f t ® ? ' Examiner will provide details of physical examination on request as follows: Pulse rate Temperature 90/min. Support will need to be provided for the patient during the 'washout' period as she is still depressed. and advise the patient to contact the after-hours service immediately if symptoms worsen. A reasonable alternative is to reintroduce fluoxetine. for example.

Often it is not symptoms per se that cause patients or relatives to seek treatment. Once the dosage increases then side effects and toxicity will increase significantly. ‘Is it fatal/terminal? Will I go mad/drop dead etc?' An effective initial consultation with a patient who is 'depressed which attempts a biological-psychologicalsociocultural approach and allows sufficient time for the patient to be listened to. These people are more likely to present at their peaks or troughs when they are symptomatic in response to a life event or ongoing environmental stress. Anxiety intensifies ALL symptoms including 'depression' and is accompanied by typically exaggerated and catastrophic cognitions about the conseguences and outcome of whatever is causing their distress. SSRIs are potent drugs even in low dosage. they will not tolerate scenarios like this one lightly. the dose will be increased or doubled again. then they will double the dose). As patients become better informed. At two weeks. the inexperienced or unaware clinician may recommend doubling the dose and seeing the patient a week later. when symptomatic (instead of being managed expectantly). Antidepressants and antipsychotics take 3 4 weeks to work. Their symptoms may be naturally or temporally transient. and they improve after a few days. really distressed {more must be better and will work faster'). Many people with 'depression' have mood fluctuations on a cyclical basis which are subthreshold or relatively mild. including antidepressants. When a patient has been started on an antidepressant and is appropriately reviewed a week later and reports no improvement. this is wrongly attributed to the increase in dosage and not the latent response to the initial dose. Patients deserve better and clinicians must ensure that they are aware of both the risks and benefits of the drugs they prescribe. Some patients are extremely somatically focused and will develop toxicity just by reading the package inserts about product information. or relief that the problem has been identified and that something is being done. Neither will their legal advisers. who influences the patient to attend the consultation. they and their clinician may mistakenly attribute their response to the medication. This will only enhance the effectiveness of whatever is subseguently recommended or prescribed. This patient feels aggrieved that she has been mismanaged and ill-served by the doctors who have unknowingly contributed to her serotonin syndrome. If the patient's symptoms improve within that time there may be other factors which explain the improvement. when there is still no major improvement or cure. will in itself relieve a major part of the intensity of the symptoms. if they are having ' a good day' they will skip a dose: if it's a bad day'.e. to be understood and to be taken seriously. Patients present to doctors when they are worried or anxious about symptoms or behaviours. 476 . By the third week when the patient reports some improvement at last.088 Performance Guidelines Another common error is to start with too high a dose if the patient is 'really. Most patients take such medications erratically or in fits and starts (i. such as reduction in anxiety or insomnia or the benefits of a sensitive interview with the discussion of issues and problems. This may commit them to a future psychological dependence on medication rather than learning to tolerate temporary oscillations in mood and biological symptoms by using nonchemical coping strategies. Some doctors and patients have become brainwashed by pharmaceutical companies into believing that any degree of distress or suffering reguires a chemical solution that is quick and effective (but freguently expensive and unnecessary). or someone else is. If these people (as patients) are then prescribed psychotropics.

irritability. in this case inadequate washout between a long half life agent (fluoxetine) and a high starting dose of a second SSRI (sertraline). labile mood).088 Performance Guidelines The serotonin syndrome is caused by excess serotonin in the central nervous system. cooling blankets). sweating.g. restlessness. Treatment is to cease the medication and provide symptomatic care (e. Hypertension. 477 . myoclonus. shivering and tremor and diarrhoea. fever. convulsions. commonly because of drug-drug interaction. The syndrome usually presents with changes in mental state (confusion. and death have been reported. hyper-reflexia. Referral to an emergency specialist may be necessary in more severe cases.

you say that you are a little worried for your spouse but have no concerns for yourself. but patient unable to stand or walk. and firmly decline to walk. The candidate must test: passive and active movement. behave in an unconcerned manner. which involves tests of movement and coordination of your legs. To make a diagnosis based on the neurological findings. When requested. and ask the following questions (appropriate answers in brackets): • • • 'What would you expect to find on sensory examination. At six minutes. You will not need to ask any specific questions to the candidate. observations of the patient's behaviour and the history provided. The examiner will have instructed the patient as follows: • • • • The candidate is to do a neurological examination of your legs and ask you to stand and walk. Candidates are not required to ask any further history from you. you are able to lift your legs. • • • • EXPECTATIONS OF CANDIDATE PERFORMANCE When the candidate commences any sensory examination. calm and cooperative. You have confidence in the hospital that they will be able to help and you will get better. ask the candidate to summarise the findings. aided or unaided. even with support. tone. but you cannot stand. the examiner will say that sensation does not need to be tested. follow the candidate's instructions in a straightforward way while you are on the examination couch — you are not required to simulate any dysfunction or discomfort. instruct the candidate to stop the examination. or asks to do this. Inconsistent findings should be noted by the candidate: normal active and passive movements in supine and sitting position. Be polite. and you cannot walk. If asked directly. • • Tone. indicate this is down-going. Exhibit a lack of concern for your condition.089 Performance Guidelines Condition 089 Collapse of a 30-year-old woman on the way to a court attendance AIMS OF STATION To assess the candidate's ability to conduct an examination of the lower limbs focusing on the neurological system. If the candidate attempts to test the plantar reflex. and sit over the edge of the examination couch. During the examination. given your findings thus far?’ (Normal sensation) 'What is your likely diagnosis?' (Somatoform conversion disorder or similar term) 'What has led you to that conclusion?' (Physical findings inappropriate for organic illness) 478 . coordination and should attempt to test gait. power. should they do so. and will be directed away from that course by the examiner. reflexes. Although your spouse is presently in court facing charges linked to his gambling debts. coordination and reflexes will be normal.

'an anxiety disorder' or other such ill-defined diagnosis. other than the most recent versions of the International Classification of Diseases — ICD10 or American Psychiatric Association DSM-IV. such as hysterical conversion. to correctly identify conversion disorder and also conduct an examination of the lower limbs. • Demonstrate familiarity with typically associated findings such as normal sensory examination findings. • Utilise a nonjudgmental approach. thus correctly linking the conversion disorder to the unresolved emotional conflicts around the impending fraud charges and the candidate's extreme shame and anxiety in regard to this. the examiner could ask: • What have you noticed about the patient's attitude and general behaviour and what does that signify?' • What is your understanding of the psychological reasons for this patient's presentation at this time?' The candidate should be able to: • Perform a systematic motor examination of the lower limbs. Anxiety/stress or other such diagnosis by itself is not an acceptable diagnosis. • Formulate a likely diagnosis. and the candidate has not commented on these features. it is unacceptable for the candidate to conclude the problem is 'stress-related'. Malingering is not an acceptable diagnosis because there is no personal gain. abnormal illness behaviour. KEY ISSUES • Ability to conduct an appropriate focused neurological examination of the lower limbs and identify a somatoform conversion disorder with abnormal illness (sick role) behaviour. abnormal illness behaviour and sick role behaviour are acceptable. • Recognise the presence of incongruous affect. Stronger candidates may present a more sophisticated diagnosis with formulation. in the face of abnormal illness behaviour. It is thus unacceptable for the candidate to do a cursory or incomplete neurological examination and equally. • Hypothesise that the 'belle indifference' and physical disability are defences against an overwhelming emotion such as anxiety. somatoform disorder. and its significance for diagnosis. being bland disconcern ('belle indifference').089 Performance Guidelines If there is time. It is an integrated station in that it is assessing both clinical skills in neurological examination and recognition of a psychiatric somatoform disorder. being a physical problem developing in an individual under stress: conversion disorder. 479 . sick role behaviour. CRITICAL ERROR • Failure to conduct a thorough neurological examination as instructed COMMENTARY This station assesses the ability of the candidate to recognise abnormal illness behaviour. Use of terms that are in psychiatric classification schemes. anger or shame.

in conversion disorder the motivation is unconscious and unintentional. a court appearance. but at a price. 'La belle indifference has no diagnostic validity and is nota criterion for diagnosis. These disorders are common and typically first present in general medical or neurological settings. thus reducing otherwise overwhelming affects (anger/rage. psychosis) and hence keeping the conflict out of conscious awareness ('primary gain'). anxiety. The psychological pathogenesis of a conversion symptom is that the individuals somatic symptoms represent a symbolic resolution of an unconscious conflict. With more thorough examination and modern sophisticated investigative technologies missed organic disease may occur in less than 10% nowadays. a job interview). Psychogenic paralysis is worse when patients consciously try to move a paralysed limb and are attending to the task. a family history of physical illness and hence role models and a fear of stigmatisation if psychological disorder is acknowledged. The external benefits of the symptom/illness behaviour may include avoidance or exemption from anxiety-provoking or threatening life experiences (e. Unlike malingering or the deliberate feigning or faking of symptoms of illness. The symptoms must cause significant distress. increasing age. alexithymia (lack of psychological mindedness). trauma or physical injury and does not conform to any known neurological damage pattern. lower social class. which is done consciously and with intent. or financial compensation ('secondary gain'). Her symptoms are confined to the voluntary central nervous system. show activation of inhibitory centres in the orbitofrontal and cingulate gyrus areas of the brain with associated nonactivation of the primary motor cortex.089 Performance Guidelines The common feature of somatoform disorders is the presence of one or several symptoms or physical signs that suggest an organic or physical illness but which are not explained by any medical condition. an exam. Presentations vary from mild to severe and may be symptom-focused (hypochondriasis) or sign-focused (conversion disorder). but improves when their attention is distracted. myasthenia gravis and idiopathic periodic paralysis could be considered. may all predispose to a conversion disorder 480 . Recent functional magnetic resonance imaging and positron emission tomography studies of lower limb psychogenic paralysis. impairment or predicaments in the patients social and occupational functioning. schizophrenia or panic disorder). they are improbable. This patient has a conversion disorder. The acute disruption in her ability to walk was not associated with any known infection. Whilst multiple sclerosis. Previous followup studies with conversion disorders suggested that 30% may subsequently develop organic central nervous system disease. depression. Typically the neurological findings are bizarre and atypical and do not conform to any known neurological disease. but may reflect the individual's beliefs about how neurological disease may present. Psychological factors associated with the drama and turmoil of her husband's court appearance are highly relevant. or repressed sexual conflict in the genesis of most instances of conversion disorder.g. or by another psychiatric disorder (e. or side effects of any medication or substance. Previous episodes of conversion disorder. an escape from responsibility. when patients were actively trying to move paralysed limbs. Diagnosis depends on a careful history and linking a significant life event or interpersonal stress temporally to the onset of the symptoms.g. nor is there any association with histrionic (or hysterical) personality traits. a wedding.

481 . should usually be prescribed in iow fractional dosages initially and increased very gradually to the normal therapeutic range. Patients should be told that their symptoms are real and genuine and that their neurological deficits result from loss of conscious control over the affected function due to a neurochemical disturbance. especially if the onset was acute. Up to 80% of patients make a complete or substantially complete recovery from an individual episode. as the weakness or other physical symptoms improve. Adjunctive psychotropics.Performance Guidelines Many conversion disorders resolve spontaneously over a short period of time. but 50% may relapse within 5 years. with physiotherapy as the mainstay of treatment. These patients have exguisite somatic sensitivity and may develop side effects just from reading the manufacturer's package inserts from any medication that is prescribed. An expectation of full and complete recovery is provided in conjunction with multimodal therapy. Patients with chronic or multiple sensorimotor disturbances may need treatment in specialised multidisciplinary units or psychiatric units. Other patients will need active rehabilitation. An essential part of the treatment is a therapeutic alliance and rapport that allows the patient to recover with dignity and no loss of face. Nontoxic technologies such as ultrasound and transcranial or direct muscle magnetic stimulation may produce dramatic 'cure' of paralysis. either as inpatients or as an outpatient. which may include cognitive behavioural treatments antidepressants and physiotherapy. usually an SSRI antidepressant and/or an atypical antipsychotic. examination and appropriate investigative workup). The underlying affects may then emerge and become more florid and obvious. with no specific treatment other than explanation and targetted suggestion (after a thorough history.

482 .

Prevention. carer. recommending a procedure. preventive care. Once the cause of the clinical presentation has been fully identified and treatment is about to begin. one may have to use techniques of 'selective attention' and 'selective neglect' whereby a conscious decision is made to focus on some problems. 483 . • emphasise preventive opportunities. and • provide appropriate support and reassurance. Separation of diagnostic and management phases allows parts of what would be regarded as a long case' in normal clinical practice to be completed within the time allowed. The ethical bounds of confidentiality must always be kept in mind. the emphasis is now on the formulation of a management plan by the candidate.3 Clinical Management Alan T Rose. and others with a low priority. onward referral. At that stage. and followup. and Ronald McCoy (M) 3-A: Management Objectives: Therapeutics. which may include patient education and reassurance. Management will often involve others beside the patient: a parent. In others the information provided directs the candidate to undertake investigations to facilitate diagnosis. a firm diagnosis may not have been reached so that the next step in management may be to proceed with investigations or referral. but not on others. In complex cases. Others provide sufficient information for the candidate to formulate diagnostic and management plans. • educate the patient about the condition. putting aside some for exploring at a later consultation. such as employers. or the patient may be returning for a second consultation with results of investigations now to hand. OBJECTIVES OF THE MANAGEMENT PHASE OF THE CONSULTATION ARE TO: • treat appropriately the patient and presenting condition. • involve patients as far as possible in the management of their own conditions and ailments.' H Sigehst (1891-1957) The term management can be used broadly to describe what the doctor does once the history and physical examination have been completed. arranging hospital admission. spouse/partner. & Public Health 'Disease has social as well as physical. Some of the illustrative management cases in this book begin with a statement of the diagnosis which is provided to the candidate. advice and counselling. chemical and biologic causes. • achieve compliance in therapy. the clinician may be confronted with numerous conditions to deal with some of which may be self-limiting. other family members or others. some insoluble. Michael R Kidd. prescribing medication. Thus.

if the illness is chronic or recurrent. or by supplying leaflets and brochures. When considering the degree of urgency of the referral it should be remembered that few patients feel they have minor problems in which long delays are acceptable.g. • ~ Preventive. Arrange followup — this may include an offer to see another member of the patients family. An offer to write the medical term down should be made. ultrasounds or scans. Prevention.g. AMI). ~ Longterm. ~ Supplement existing knowledge to a level appropriate to the needs of the patient and the doctor.3-A Management Objectives: Therapeutics. Herpes zoster/shingles). Not all are appropriate to every case. Candidates in the AMC clinical examination need to recognise that referral to a specialist is not sufficient action. Propose therapy within an appropriate timeframe. • Answer the patient's questions. Enclosing copies of relevant investigations and other medical reports is advisable. with the patient's consent. • Reassure the patient if the condition is minor. model. The doctor should exhibit tolerance to repetition of questions. which may be specific and may require lifestyle change. Hospital admission may be the most important action to be taken. and be prepared to repeat or complete the provision of information at a subsequent consultation. ~ Immediate. Referrals can be given to the patients to carry or sent separately. ~ The use of a diagram. unless the candidate indicates why the referral is necessary. ~ The medical term as well as the common or lay name should be given (e. and what action the specialist is likely to take. and Public Health THE MANAGEMENT PROCESS The following guidelines provide a sequence of steps for the management process. These may reveal misunderstandings which require further explanation. • • • • • 484 . ~ Patients are usually reticent to admit ignorance of a condition and need encouragement to make inquiries (because of concern about wasting the doctor's time). understanding and attitude regarding the condition. by what means and when. or advise the patient of appropriate serious concerns in a nonthreatening and supportive way. Refer as required to a medical specialist or allied health professional. including when no action is required. or the patient's X-rays. The standard of written referrals is often inadequate. and there will be different emphases according to the nature of the clinical problem. will often facilitate effective communication. ~ An anxious patient may not absorb detailed information adequately before being given time to consider the implications of an important or serious diagnosis • Establish the patient's knowledge. ~ Correct any incorrect beliefs. Educate the patient about the condition. Patients should leave the consultation with a clear understanding of whether the doctor wishes to review this episode of illness. Counsel the patient or relative as required (see also Section 1-A). The use of medical abbreviations should be avoided (e. Supplement and reinforce the information already given during discussion by providing written instructions. The doctor should: • Tell the patient the diagnosis.

it is important for the doctor to review these. Candidates are also referred to a series of publications entitled 'Therapeutic Guidelines'. The use of pharmaceuticals in therapy usually begins once a positive diagnosis has been made. each covering a different body system. dentists and pharmacists. biliary colic). and to inform the patient of the results. Candidates for the AMC examinations are advised to be familiar with the 'Schedule of Pharmaceutical Benefits' handbook updated three times a year by the Australian government and issued free to registered doctors. meningococcal septicaemia). Exceptions are where relief of severe pain is necessary before the diagnosis has been established or proven (renal colic. rather than by telephone. Prevention. at a subsequent consultation. Overlooking to inform a patient of serious adverse results can have medicolegal complications. prescription quantities and their cost to the government. Australians also self-medicate with 'over-the-counter' items available from pharmacies and health food or natural lifestyle outlets. THERAPEUTICS Therapeutics is the selection and use of pharmaceutical agents in the treatment and prevention of ill health and in the maintenance of an individual's health status. or by telephone or letter. Unexpected adverse results should be conveyed by further interview. and are invaluable aids. It contains a list of all subsidised pharmaceuticals classified by disease categories. Costs to patients are further reduced by concessions to certain income and age groups and ex-service personnel — 'safety net' levels also apply to individual's/family's annual expenditure on prescribed medicines. generic and trade names. Australians are fortunate to have a Pharmaceutical Benefits Scheme which provides federal government subsidies to patients for prescribed approved medicines (outside of public hospitals) by registered medical practitioners who hold a preserver's number issued by the federal health department. when a therapeutic trial using medication can confirm a strongly suspected diagnosis (gout. even when the patient has been instructed to ring to check for results and failed to do so. even life-threatening consequences (temporal arteritis. Some items require government approval before prescribing because of their high cost or risk of adverse reactions. or when medication is given before a diagnosis has been confirmed because early treatment is necessary to avoid serious. 485 . polymyalgia rheumatica). All these considerations have an effect on what pharmaceutical item is selected by the doctor for the treatment of a particular condition. awareness of possible drug interactions and the possibility of noncompliance. Knowledge by the doctor of the use of these substances by patients can assist in understanding the patient's attitude to sickness and health. and Public Health If investigations have been ordered.3-A Management Objectives: Therapeutics. similarities of actions. They contain regularly updated advice from dedicated consensus groups on the current therapy for most diseases. form.

Iatrogenic illness has steadily increased because of polypharmacy. Assessment of knowledge of therapeutics frequently takes place in management consultations The use of pharmaceuticals in therapy usually begins once a positive diagnosis has been made. The situation is compounded by patients attending multiple doctors. Polypharmacy is common in older age groups where several chronic conditions are being treated simultaneously. is the need to treat more than one condition in the same patient (e. as are databases on office personal computers. existing regimens are altered or dosages changed. Patients often attribute their recovery to medications rather than to spontaneous resolution. and because it is unethical for a pharmacist to ask a patient what diagnosis has been made by the doctor. This may include writing the instructions down. 486 . drug interactions. Always consider whether reactions. and were they helpful or did you have any side-effects?' 'Do you have any allergies to medications?' If a history of allergy is given. varies markedly. Pharmacists have limited capacity to detect inappropriate prescribing because patients use different pharmacies. updated six times annually and circulated to medical practitioners is a very useful guide to such effects. together with adverse reactions. side effects or drug interactions may be contributing to symptoms (for example. or cough from ACE inhibitors). Patients may also be uncertain which of their medications relates to which of their ailments and be mistaken about the timing or frequency regimens of their medication. and Public Health Patient perception of the effectiveness of medications (e. polymyalgia rheumatica). for example to penicillin. even life-threatening consequences (temporal arteritis. or when medication is given before a diagnosis has been confirmed because early treatment is necessary to avoid serious. and drugs which accentuate or decrease anticoagulant actions of warfarin. TAKING A 'DRUG' HISTORY Diagnostic consultations often require a 'drug' history. Patients may be confused when medications are added. and patient confusion over medication dosage. a diabetic patient who is hypertensive and has hyperlipidaemia). Of particular importance are the effects of some antibiotics on the efficacy of oral contraception. Exceptions are where relief of severe pain is necessary before the diagnosis has been established or proven (renal colic. or when a patient on longterm medication develops an acute illness which demands additional medication. Also important in considering drug therapy. the use of antibiotics for viral infections). Patients will not necessarily volunteer what medications they are on to a second doctor. The proprietary publication MI MS. allergies and idiosyncrasies which may be associated with the use of any medication. These shortcomings need to be understood by the doctor who must instruct the patient carefully.3-A Management Objectives: Therapeutics.g. establish details and severity to determine risk of anaphylaxis. Prevention. meningococcal septicaemia). as follows: • • • ‘Do you take now or in the past any prescription or over-the-counter medicines?' 'What for. even when referred for specialist care. asthma. biliary colic).g. when a therapeutic trial using medication can confirm a strongly suspected diagnosis (gout. The creation of medication lists on a patient's computer-generated medical record has not replaced personal communication and enquiry about medication from the doctor to the patient. claudication or cardiac failure from Beta receptor blocking agents.

hypertension) where therapeutic pharmacology is complex.3-A Management Objectives: Therapeutics. but also on aspects of patient behaviour. antiangina agents. nonsteroidal anti-inflammatory drugs (NSAIDs). together with antibiotics. 21 different system and function groupings are listed. The pharmaceutical companies employ many strategies for marketing their particular product to doctors. bronchodilator aerosols. diuretics. 487 . These decisions are either written or processed onto personalised numbered prescription forms supplied by the government. • Elderly patients — drug tolerance is reduced increasing risks of overdosage (e. Drug usage and dosage need modification in the following circumstances: • Pregnancy — drugs potentially harmful to the fetus. Fifty different generic products (classified into 22 different categories) are listed on the PBS for the treatment of hypertension. • The most commonly prescribed drugs cover a wide range. Most of these agents have several proprietary names. In the MIMS therapeutic classification index. • Impaired organ function — especially liver failure or renal insufficiency. ACE inhibitors. sedatives and anxiolytics. Often a wide range of therapeutic agents is applicable to a single condition (e. It is at the doctor's discretion as to how much of such information should be discussed with individual patients. indications. but pharmacists are required to offer this information to patients. postural hypotension from antihypertensives). must be avoided. A major objective of the doctor in therapeutics is to achieve patient compliance in the use of medication. and include blood lipid-lowering agents. route and time of administration and ensure that a sufficient supply (which may include repeats) is ordered. • Previous portal-systemic shunting operations. particularly those with teratogenic potential. These are the instructions which the patient takes to a pharmacy to obtain the medicine. Prevention. adverse reactions and interactions is available in 'Australian Prescribe? (also online) circulated free to all doctors in Australia by the Commonwealth Government. antihypertensives. sometimes in printed form. each with numerous (up to 14) subcategories. and Public Health The first step is for the doctor to select the correct therapeutic agents and name them by generic or proprietary name and then comply with any government restrictions on use decide on dose. side effects. The doctor's function of prescribing medication is a complex process dependent not only on knowledge of available therapies for specific diseases. As emphasised above it is the doctor's responsibility to be aware of significant side effects (unwanted symptoms from the drug. • Children correct dosage is especially important in infants and small children and must be individualised and based on weight.g.g. potential adverse reactions or drug interactions). proton-pump inhibitors. form. and to advise patients or relatives accordingly. More authoritative and referenced information about new drugs.

For example.racgp. social class and how connected people are to their communities. place of residence and migration. Recent Australian experience with SARS and related epidemics have emphasised the importance of knowing how to contact local public health authorities. and therefore each activity must be based upon sound research evidence of what is effective. Social and economic factors influencing health include: level of education. These guidelines only include activities of relevance where research has shown a demonstrated benefit. Candidates should be aware of how to contact relevant public health authorities in the event of requiring assistance and advice in issues of public safety. This involves looking beyond the individual consultation to the population of patients we serve. The opportunities for health are affected by where people live. Some groups have increased risk of diseases because of social or other factors. proactive in targeting preventive care most intensively to high risk individuals. Alan T Rose. their skills. Clinicians therefore need to understand which preventive activities are recommended as the costs may outweigh the benefits when assessed by carefully designed research studies. and is also exacerbated by poor access to preventive treatment and late intervention. Candidates can access Guidelines on Preventive Activities from the Royal Australian College of General Practitioners website (www.3-A Management Objectives: Therapeutics. anticipatory in routinely assessing the preventive care needs of their Candidates should know which diseases are notifiable to public health authorities and how they are to be reported. with many cases of chronic disease only diagnosed when complications are already present. and reaching all of their patients. The links between poor health and socioeconomic disadvantage include a relationship between mortality. their communities and lifestyles. especially those who are least likely to seek out assistance. clinicians need to be • • • • opportunistic in offering preventive care when patients present with other problems or concerns. To do this effectively can be difficult. Candidates need also to understand the special public health and preventive issues facing Aboriginal peoples and Torres Strait Islanders. The poor health of Aboriginal peoples and Torres Strait Islanders has many causes including social and economic factors and the history of colonisation. Michael R Kidd and Ronald McCoy 488 . and Public Health PUBLIC HEALTH MANAGEMENT Medical practitioners have a central role in public health and the prevention of disease To be effective in this role. clinicians must reach a large proportion of patients in their practice or community. One of the challenges for clinicians is to ensure access to preventive care for all their patients. Notification of infectious diseases is an important public health responsibility for all clinicians. income. employment status. to be effective in immunisation or screening. occupational status. Poorer health makes disadvantaged groups major users of general practice and they are also the lowest users of preventive care services. Each preventive activity uses up some of the clinicians' available time to spend with their patients.

and Public Health 3-A Management Objectives. Therapeutics. Prevention.3-A Management Objectives: Therapeutics. Prevention and Public Health Candidate Information and Tasks MCAT 090-100 90 91 92 93 94 95 96 97 98 99 100 Acute right-sided pain and haematuria in a 25-year-old man Faecal soiling in a 5-year-old boy Psoriasis in a 30-year-old man Temporal arteritis in a 58-year-old woman Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man Dysuria and urinary frequency in a 40-year-old man Eclampsia in a 22-year-old primigravida at 38 weeks of gestation An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida Bed-wetting by a 5-year-old boy Acute gout in a 48-year-old man Request for repeat benzodiazepine prescription from a 25-year-old man 489 .

090 Candidate Information and Tasks Condition 090 Acute right-sided pain and haematuria in a 25-year-old man CANDIDATE INFORMATION AND TASKS This 25-year-old man is being seen in the hospital Emergency Department with a first episode of severe right-sided abdominal pain. to the patient. The pain came on two hours earlier and was so severe that the patient writhed in agony unable to relieve his symptoms. The pain started in the right side of his back and radiated into his right groin and testicle. \ Determine the most likely diagnosis and discuss initial investigations with the examiner. You will not need to take any additional history. He has had no pain like this previously and has been in good general health. The Performance Guidelines for Condition 090 can be found on page 500 490 . Outline your management plan. He is now free of pain. There is no loin or other tenderness. There is no need for you to ask the examiner about any other findings on clinical examination. and any further investigations required. Physical examination findings are normal. You have just finished examining him. YOUR TASKS ARE TO: • • • Explain the diagnosis to the patient. except that his urine is positive for blood on chemical testing.

with foul-smelling semifluid faeces. a five-year-old boy. The Performance Guidelines for Condition 091 can be found on page 503 491 .Candidate Information and Tasks 091 Condition 091 Faecal soiling in a 5-year-old boy CANDIDATE INFORMATION AND TASKS Mark. because for the past six weeks he has been soiling his pants. • Ask the examiner for the appropriate findings on examination of the child which would be relevant to your diagnosis. His parent cannot tell you much about his bowel habits as he now attends to his own toilet needs when he feels like it. YOUR TASKS ARE TO: • Take a further focused history from the parent. with increasing frequency. It is now happening almost every day and he is being teased at school. • Explain your diagnosis to the parent and advise on management. is brought to see you in a general practice setting.

and in the scalp. over the sternal and lower back areas. You are seeing a 30-year-old man who works as a bank teller. The level of severity for this patient's psoriasis should be regarded as moderately severe. The photograph shows details of the skin lesions on the knees. It first appeared after a motor accident six months ago in which he suffered a fractured femur. The patient remembers that his father. They are raised. It has been getting steadily worse over the last few months with some improvement following the use of cream obtained from the local pharmacist (Egopsoryl TA®).092 Candidate Information and Tasks Condition 092 Psoriasis in a 30-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. Examination has revealed the typical lesions of plaque type psoriasis. The Performance Guidelines for Condition 092 can be found on page 507 492 . pink and covered with a silvery waxy scale. This has helped the rash on his body but not on elbows. CONDITION 092. The nails are not affected. YOUR TASKS ARE TO: • • Explain the nature of his condition to the patient Advise the patient about management. now deceased. He has consulted you about a rash on the extensor surfaces of both elbows and both knees. knees and in the hair. The plaques vary in size from a few mm to several cm. used to be bothered by a chronic rash. You are about to discuss the disease and its management with the patient. FIGURE 1.

You have just concluded your physical examination and are about to advise the patient of your diagnosis and management plans. Brief Patient Profile Married. • Advise the patient about management — both immediate and longterm. Has been taking Panadol® (paracetamol 500 mg) for the headache. Side view of right temple CONDITION Based on this information you believe that the most likely cause of the patient's symptoms is temporal arteritis ('cranial arteritis' or 'giant cell arteritis'). No significant past or family history except for occasional migraine. This could include any investigations you believe are necessary.Candidate Tasks Information 093 and Condition 093 Temporal arteritis in a 58-year-old woman CANDIDATE INFORMATION AND TASKS You are working in a general practice. FIGURE 1. to the patient. Over the last few days. The patient is normotensive. works as an accountant. and which is now constant. Nonsmoker. On physical examination you noted tenderness and tortuosity over the right temporal artery as illustrated. This 58-year-old woman has consulted you about the recent onset (two weeks) of right-sided headache gradually becoming more and more severe. The Performance Guidelines for Condition 093 can be found on page 510 493 . 093. the patient has also had a tight feeling in the muscles on the right hand side of the face when chewing. and its implications. YOUR TASKS ARE TO: • Explain the diagnosis. There were no other abnormal physical findings. Its pulsation cannot be felt as well as that of the temporal artery on the left. You do not need to take any further history.

and wishes to know the cause. The main issues to be addressed are patient counselling and management. The accompanying illustrations show the findings. Time should not be wasted taking further history or asking for any other physical findings. Respond to any questions asked by the patient. Smiling CONDITION 094. You have just completed taking a history from and examining a 40-year-old man who is very upset because of the sudden onset of paralysis of his face. He felt discomfort behind the left ear last night and on waking today found that the left side of his face would not move.Candidate Information and Tasks 094 Condition 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man CANDIDATE INFORMATION AND TASKS You are consulting in a general practice. what treatment and tests he should have and how long it will take to recover. FIGURES 1-4. The patient is very upset and concerned that this may be a stroke. The patients parotid salivary glands show no abnormality. You have made a confident clinical diagnosis of acute idiopathic facial nerve palsy (Bell Palsy') YOUR TASKS ARE TO: • • • Explain the problem to the patient. whether recovery will occur. He arranged an urgent appointment with you. Advise the patient of the management you would advise. Examination confirms a near complete left 7th cranial nerve facial palsy of lower motor neurone type. The Performance Guidelines for Condition 094 can be found on page 512 494 . There are no other abnormal neurological or other signs including normal ear canals and tympanic membranes. Blowing out cheeks These illustrations show his facial appearance in repose and with smiling and movements.

• Discuss the condition and answer any questions the patient may ask. There has been no urethral discharge and no history of extramarital sexual contact. He is aware that he is sensitive to penicillin but otherwise his past history. habits. Urine test strip The Performance Guidelines for Condition 095 can be found on page 519 495 . A midstream urine specimen was collected and the following office laboratory tests were done on the urine • Dipstix — positive for protein. including rectal examination of the prostate. FIGURE 1. • Microscopy of uncentrifuged specimen — shows large numbers of leucocytes and bacilli. The patient usually keeps in excellent health. • Advise the patient of your immediate management.Candidate Information and Tasks 095 Condition 095 Dysuria and urinary frequency in a 40-year-old man CANDIDATE INFORMATION AND TASKS This 40-year-old postman is married with two children and has consulted you today in a general practice setting complaining of the gradual onset of dysuria and frequency of micturition over the last three days. YOUR TASKS ARE TO: • Advise the patient of your diagnosis. family history. CONDITION 095. On examination the patient is afebrile and you found no abnormality on examination. leucocytes and nitrites: negative for blood. glucose and ketones. and use of medication have no relevance to this problem.

Advise the mother of the patient.096-097 Candidate Information and Tasks Condition 096 Eclampsia in a 22-year-old primigravida at 38 weeks gestation CANDIDATE INFORMATION AND TASKS This 22-year-old primigravida has been seeing you in a general practice clinic for her shared antenatal care since early in her pregnancy. YOUR TASKS ARE TO: • • • Take any further relevant history you require from the mother of the patient. Progress of her pregnancy has until now been normal. of the diagnosis and the subsequent management you would advise for her daughter.0 mmol/L). Advise the patient of the management you would give in the remainder of the pregnancy. Advise the patient of the diagnosis you have made. The Performance Guidelines for Condition 096 can be found on page 522 Condition 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida CANDIDATE INFORMATION AND TASKS This patient is a 34-year-old obese primigravida whom you are managing in a country general practice. She has had a screening glucose tolerance test performed at 28 weeks of gestation. No other investigations have been done apart from routine screening tests at the first antenatal visit which were all normal.5 mmol/L. She had brought a urine specimen with her to the appointment. YOUR TASKS ARE TO: • • • • Take any further relevant history you require. Ask the examiner about the specific findings you would look for on general and obstetric examination and any office test results which should be available to you. she has had a g r a n d m a l fit. Whilst in the waiting room along with her mother waiting to see you for her routine antenatal visit. two hour < 8.5 mmol/L and a two hour level of 9. This revealed a fasting blood glucose of 7.5 mmol/L (Normal levels — fasting < 5. She is now at 38 weeks of gestation. in lay terms. The pregnancy has been progressing perfectly normally until now. who is in the waiting room. This should be limited to 1-2 minutes only. The Performance Guidelines for Condition 097 can be found on page 525 496 . Ask the examiner for the findings you would expect on general and obstetric examination.

74 mmol/L) and for treatment. Over the past two days he has taken two or three aspirin tablets for the pain. The patient has always kept in good health apart from mild hypertension diagnosed two years ago for which he takes hydrochlorothiazide. is brought to see you in a general practice by his mother because of a bed-wetting problem. • Advise Johnny's mother how you will further assess and manage his condition. The Performance Guidelines for Condition 099 can be found on page 531 497 . which commenced two days ago.45 mmol/L. These have been diagnosed as gout. YOUR TASKS ARE TO: • Advise treatment of the acute attack.Candidate Information and Tasks 098-099 Condition 098 Bed-wetting by a 5-year-old boy CANDIDATE INFORMATION AND TASKS Johnny. The normal serum urate range for males is 0. Urinalysis is normal. worsening. but they now accept that it is involuntary and both parents are keen to help him in any way possible. The joint was swollen and felt hot. He has • been fully continent by day since he was three years old: and has • previously been treated unsuccessfully with nightly amitriptyline (Tryptanol®). The overlying skin was red and shiny and the joint was exquisitely tender. The wetting exasperated his parents initially. There is no need for you to take any additional history or perform any examination. throbbing pain in the right first metatarsophalangeal joint. The patient has returned to find out the result (which was 0. which occurs nightly.20-0. a five-year-old boy. Each time response to treatment was satisfactory. • Tell the examiner what relevant examination findings you would seek. severe. There is a history of previous attacks over the last two years. You took blood for serum urate estimation. • Discuss further management of his condition. The Performance Guidelines for Condition 098 can be found on page 528 Condition 099 Acute gout in a 48-year-old man CANDIDATE INFORMATION AND TASKS You are about to see a 48-year-old taxi driver who consulted you earlier today in a general practice setting about continuous. YOUR TASKS ARE TO: • Ask the mother for any further relevant history.

At that time. Outline to the patient the nature of the problem you have identified and proposed management. The patient has returned today for another prescription. The patient's mental state is unchanged. You saw this patient for the first time one week ago and provided a prescription for his usual sleeping tablet. Answer any questions the examiner asks you. 25 tablets. YOUR TASKS ARE TO: • • • Evaluate the situation by taking a focused history.100 Candidate Information and Tasks Condition 100 Request for repeat benzodiazepine prescription from a 25-year-old man CANDIDATE INFORMATION AND TASKS You are working in a general practice. you were satisfied there were no comorbid problems such as depression. the benzodiazepine oxazepam (Serepax®) 30 mg daily. The Performance Guidelines for Condition 100 can be found on page 534 498 .

3-A Management Objectives: Therapeutics. Therapeutics. Prevention and Public Health Performance Guidelines MCAT 090-100 90 91 92 93 94 95 96 97 98 99 Acute right-sided pain and haematuria in a 25-year-old man Faecal soiling in a 5-year-old boy Psoriasis in a 30-year-old man Temporal arteritis in a 58-year-old woman Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man Dysuria and urinary frequency in a 40-year-old man Eclampsia in a 22-year-old primigravida at 38 weeks of gestation An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida Bed-wetting by a 5-year-old boy Acute gout in a 48-year-old man 100 Request for repeat benzodiazepine prescription from a 25-year-old man 499 . Prevention. and Public Health 3-A Management Objectives.

'What happens if the stone does not pass?' (An instrument may have to be inserted to retrieve it). with episodes of increased severity each few minutes. The doctor has listened to your story and taken a full physical examination and you have given him a sample of urine for analysis. The doctor will explain to you the diagnosis and proposed management. The pain has now settled. and never experienced anything like it before. You have come to the Emergency Department and have seen the doctor. The investigations required are likely to include: • • • • • Culture of the urine to exclude infection. You are unlikely to have future problems. Most stones pass spontaneously. The pain was gripping. but have heard of kidney stones. The pain extended from the loin to your right testicle. You will be given strong painkillers for the pain in case it recurs. You have not heard about renal/ureteric colic or a stone passing from the kidney down the ureter (the tube between the kidney and bladder). but tests on your urine and blood will be done to check this. You have been writhing in agony with this pain. severe and constant. It may take one to two days to pass the stone. The candidate should explain that you have a small stone that is passing down your ureter. Fortunately it gradually eased and ceased after about 30 minutes.090 Performance Guidelines Condition 090 Acute right-sided pain and haematuria in a 25-year-old man AIMS OF STATION To assess the candidate's knowledge of the natural history of urinary calculi. and ability to diagnose and manage a patient with a recent history of renal pain associated with a stone in the ureter. Other blood tests and specialist referral may be required in followup. if the stone is still in the ureter). ‘How will I know if I have passed the stone?' (You will strain your urine). Questions to ask unless already covered and appropriate responses from doctor/candidate (Answers in parentheses after the question): • • • • • • ‘Do / need to be admitted to hospital?' (Not at this stage) 'Will the pain come back?' (Possibly. Examination of the stone after you have passed it to determine the type of stone present. 500 . 'When do I see you again?' (Followup in a couple of days for investigation results). EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are aged 25 years and about two hours ago you developed severe right-sided back and abdominal pain. 'Why did I get the stone?' — Ask this if the candidate suggests a stone is the cause of the pain. Imaging by computed tomography (CT) to define the size and site of the stone. An ultrasound of the kidney may be performed looking for evidence of blockage of the ureter caused by the stone.

bladder and urethra. 501 . and does not wax and wane intermittently in a sine-wave pattern. CRITICAL ERRORS • Failure to make a diagnosis of renal (ureteric) colic. urea and creatinine. KEY ISSUES • Diagnosis of renal 'colic'. • Providing an appropriate plan of management (including provision for further pain relief). ureters. constant. He may need an open operation. Refer to urologist if stone is not passed in 48 hours or pain recurs and worsens. • Check serum uric acid. This is the pattern of true 'colic'. but definitive imaging is by helical abdominal CT which will pick up very small stones. as seen in intestinal colic or uterine colic.090 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE • The candidate should indicate the pain is almost certainly due to renal colic. give pethidine or Panadeine forte® or a nonsteroidal antiinflammatory drug (NSAID). • Followup to check progress. No need for pethidine now as pain has gone. Although the term. is hallowed by long usage (as is biliary 'colic'). • Give patient a brief description (draw diagram) of the anatomy of the kidneys. renal 'colic'. rising through a crescendo of intensity. due to the fact a small stone is being passed down the right ureter. If pain returns. or ultrasound destruction if not passed spontaneously (depends on size and site of stone). with regular intervals of relief from pain in between episodes of cramping pain. COMMENTARY Renal and ureteric pain ('renal colic') frequently accompanies urinary calculi passing from kidney to bladder via the ureter. • Advise high fluid intake. and serum calcium. • Ultrasound to see if hydronephrosis is present is an acceptable and appropriate test. to identify the site of the stone and use for subsequent assessment. in neither instance is the pain usually of true 'colicky' type. Renal pain can vary in intensity but not with such cyclical regularity. • Failure to arrange appropriate investigations. • Check urine for infection. • Imaging by computed tomography (CT) abdomen or plain X-ray. • Pass all urine into a container and strain (save any stones found for analysis). • Explanation of the problem to the patient incorporating rapport with the patient and communication skills. probably due to a stone in right ureter. agonising pain which makes the patient writhe and change position in an attempt to gain relief. endoscopic removal. and then diminishing over a similar period. • Appropriate choice of investigations. Renal 'colic' is often an intense.

FIGURE 2. a common mode of presentation of parathyroid adenoma. so that treatment is usually expectant while providing pain relief for recurrence of pain. and persistence of pain without progress. The preferred investigation is a helical CT without intravenous contrast (as illustrated). CONDITION 090. Helical CT showing obstructing right ureteric calculus 502 . Radiolucent stones occur with hyperuricaemia and in some types of familial and metabolic calculi. and to the upper thigh.090 Performance Guidelines Renal (and ureteric) pain is usually recognised by its character as described above. It is prudent in each patient with a urinary calculus to check for hypercalcaemiato pick up cases of primary hyperparathyroidism presenting as renal calculi. Plain X-ray showing opaque ureteric calculi CONDITION 090. its site (which can be over a wide area from posteriorly and laterally in the loin and flank. Full investigation for a primary cause is mandatory in patients with a history of recurrent calculi. which will pick up any small stones and also identify urinary tract obstructions. iliac fossa and suprapubically). Most urinary calculi (80%) are radio-opaque so plain abdominal X-ray may be diagnostic (as illustrated). Pain can also radiate to the penis and testes. however small stones may be missed and differentiation from pelvic phleboliths impossible. Indications for intervention are large stones not likely to pass spontaneously. Investigations of presumed renal colic due to stone are by diagnostic imaging. The majority of stones will pass spontaneously. FIGURE 1. to the anterior abdomen. Associated urinary symptoms and the presence of blood in the urine (macroscopic or microscopic) help confirm the diagnosis. calculi associated with uncontrolled infection.

• His urine is normal and he has no daytime or evening urinary incontinence. Questions to ask unless already covered: • 'What can we do to treat this?' • 'Surely he must smell It when he does It in his pants? Doesn't he know he is soiling himself?’ 503 . EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: The doctor is required to question you further. Sometimes he hides his soiled underpants. • His general health is excellent. • There is no abdominal pain. • He is embarrassed by it. • He has not lost any weight. he enjoys school and he has lots of friends. seeking a possible cause for your child's soiling. • This has been occurring for the last six weeks or so. then the candidate is required to explain to you what is wrong and the principles of management. However he seemed to get over that with some laxatives. • His appetite is good and he has a well balanced diet with lots of fruit and vegetables.091 Performance Guidelines Condition 091 Faecal soiling in a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and manage the problem of encopresis in a young child secondary to constipation and faecal retention and to advise the concerned parent on management. • He is the elder of two children. His progress at school is excellent and he enjoys the teaching he has had this year • He has a good relationship with his younger sibling. Once the doctor has finished questioning you. the examiner will provide examination findings on your child. • Except for the recent teasing. He had an episode three months ago when his bowel motions were hard and difficult to pass and caused him bleeding and pain when he went to the toilet. • This is most unlike him as he was fully toilet trained by three. • He has had no vomiting. Below are a series of answers to possible questions you may be asked' • You are a very concerned parent about your child's constant soiling over the last six weeks. especially at school where the other children are calling him names. The home situation is very stable with both parents very active in the raising of the children.

and the child holds on fearing defaecation will be painful. Suggest regular toileting after meals for a set period of time. abdomen is soft. giving pain. Therapy needs to continue for many months to allow resolution of the megacolon and to ensure that the passage of motions is not painful. • • Interaction with patient • Explanation with appropriate language to parent to discuss the matters with the child. enema or suppositories. Behavioural technigues such as a star chart to reward successful defaecation should be encouraged. no other abnormality. • • • Management • • • Empty large bowel by whatever means necessary.g. Need for prolonged treatment and followup • 504 . faecal masses are felt in the lower guadrants.091 Performance Guidelines Examination findings — provide findings specifically requested • • • • • • • • a shy boy. anus appears normal. an egg timer is suitable for timing. Next objective is to maintain regular bowel habit by use of laxatives and faecal softeners. KEY ISSUES • • • Explanation of diagnosis Initial empting of rectum and colon. and so constipation with overflow is the most likely diagnosis. but faecal masses remain. emotional disturbances at home or school). Review to ensure constipation is not recurring. Explain that if this is not successful he may need oral gastrointestinal lavage (Golytely®). The constipation leads to chronic dilatation of the rectum and lower colon. None is apparent. Liguefaction of the faeces leads to soiling from overflow. Other aetiologies should be explored (e. and on rectal examination the rectum is packed with firm faeces. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should explain that: • The most likely diagnosis is chronic constipation which from the history is most likely secondary to the probable anal fissure he had three months previously. Try high dose oral laxative. See regularly to encourage and support parent and child in their efforts. with some faecal staining adjacent. no anal fissure is apparent. normal height and weight on 50th centile. The process often starts as an anal fissure.

• Provide adequate explanation of the processes involved for both parent and child with a plan of action to alleviate the problem. progress at school. riding with them the inevitable ups and downs towards success. preferably with illustrative drawings. relationship with peers. growth pattern. in the majority of cases. often with a delay in the passage of meconium. however. This should include a comprehensive explanation about how constipation has developed. further compounding the problem. The great majority of cases are nonorganic. that is they are related to an episode. • Explore any precipitating features. The aims of management are therefore to: • Exclude any possible organic pathology. and the like. toilet refusal and in many cases overflow encopresis. Young children may also develop a fear of the toilet during toilet training if they are required to perch on a toilet seat without support and this also may lead to deferral and subsequent constipation. constipation is secondary to an emotional upset or trauma. While organic conditions like Hirschsprung disease may need to be considered. COMMENTARY Constipation in young children is a very common problem presenting to primary care physicians and paediatricians alike. The hallmark of care of these children is a thorough and careful history which. and the doctor's role is to be supportive of the efforts of the parent and child.091 Performance Guidelines CRITICAL ERROR • Suggesting that sigmoidoscopy or colonoscopy is required at this stage. In many children. To achieve success is very time consuming in resistant cases. This may be more difficult to treat. if the child remains fearful of going to the toilet because of anticipation of pain and this compounds the situation leading to chronic constipation. The history should include a thorough enquiry into the child's environment. whether this is at home. Hirschsprung disease has usually presented by this age and usually has a history of constipation from birth. However. which may make the child wary of passing a bowel motion subsequently. Constipation can be associated with a mucosal tear or anal fissure which distresses the child. school or elsewhere. This can last for a varying length of time. Major problems may develop. If one is able to recognise this pattern early and treat it with faecal softeners allowing the fissure to heal. The history should include a thorough enquiry into aspects of the child's environment including diet. the family dynamics. general health. 505 . Treatment is essentially careful reassurance and explanation to parent and child of the nature of the condition. the episode may be short lived. Careful enquiry is necessary to seek information indicating that this may exist. From this information a likely diagnosis may be evident. if there is doubt or suspicion of this condition. will clarify the probable aetiology. in many cases associated with the passage of a hard stool. a paediatric surgical opinion should be sought to arrange bowel biopsies. if organic pathology is not suspected.

Once the bowel is empty the faeces are kept soft with faecal softeners. and are available as Clinical Guidelines from most major Children's Hospitals. In severe cases. It cannot be emphasised too much that the clinician's main role is the support of the child and family over the period of time required to achieve success. Without this support and encouragement. The programmes used are described well in standard textbooks. which preferably do not stimulate the bowel. This may vary from child to child. Parent literature is freely available and for the older children story books addressing the situation in terms they can understand are available. manual disimpaction under general anaesthesia may be necessary. or aperients from above. 506 . the programme is doomed to failure. Many methods are available and are often successful.091 Performance Guidelines The bowel however usually needs to be emptied of the retained faeces in the most painless and noninvasive manner possible. and a retraining program is instigated. particularly if toilet phobia is a major issue. This may need at times either simple faecal softeners or more vigorous treatment with microenemas.

cosmetically disturbing condition. answering questions directly. You have a scaly skin rash for which you have just consulted this doctor. • Aetiology. scalp and nails — but can involve other parts of the skin). You are hoping to receive reassurance that it can be cured. 507 . expected course. You find the ailment and the ointments distasteful because of the unpleasant smell and staining of clothing and you are worried your wife may become infected. • Point out that physical or emotional stress can cause flare up. Diet has no effect. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are suffering from psoriasis. You wonder whether you should see a skin specialist. which cannot be completely cured. Good effect of sunlight if not overexposed. The doctor has taken your history and examined you and will now discuss the condition with you. availability of treatments. Questions to ask unless already covered: • 'What causes this?' • 'Can it be cured?' • 'Will it spread to other parts of my body?' • 'I s it infectious?' • 'Can it affect my health in other ways?' • 'Could I pass it on to my children?' • ‘Does it have anything to do with my accident?' • 'I've heard that there is a chemist somewhere who can cure psoriasis?' EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • The candidate should show interest and concern. You are concerned that it may spread and wonder if a recent serious motor accident was the cause. Explanation of the diagnosis • Description of which parts of the body can be affected (extensor surfaces of elbows and knees. sternal and sacral areas. listen to and deal with the patient's concerns and give clear instructions. Use of sunscreen applications during summer.092 Performance Guidelines Condition 092 Psoriasis in a 30-year-old man AIMS OF STATION To assess the candidate's knowledge of psoriasis and its management. and the ability to counsel the patient about a chronic. associations. Exercise and reduction in alcohol intake may be beneficial. nature. prognosis. Psoriatic arthritis could be mentioned.

The candidate should include an offer to refer to a dermatologist. and recognition of when referral to a dermatologist should be made using a patient-centred as well as disease-centred approach. the patient should ask for more information about treatment and expect discussion of different types of local creams and lotions. • Management — Longterm • Monitoring of progress and repeats of medications are required. Counselling and explanation of diagnosis: must acknowledge chronic nature of psoriasis and that treatment can be demanding and will be prolonged. 508 .092 Performance Guidelines Management — Immediate • The candidate should exhibit a general understanding of the principles and modalities of treatment and that these are applied according to severity. backed up by clinical knowledge. Must be honest and supportive. Extent of treatment proportional to severity. This requires the establishment of trust and confidence. Exact details. strengths (except for steroids) and doses are not expected although candidates should indicate that these will be ascertained if required. Review during flare-ups with closer involvement if systemic therapy becomes necessary. generic or trade names. Management: knowledge of principles of different local measures. Review if secondary infection is suspected. Counselling • Ability to achieve patient understanding of the chronicity. CRITICAL ERROR • Failure to explain appropriate principles of treatment. • KEY ISSUES • • • Approach to patient: must listen to and acknowledge patient's concerns and provide support and encouragement. reassurance that the condition can usually be brought under control. Liaison with dermatologist. variability and difficult therapeutic nature of the condition. If this is the only management advice given. a willingness to listen to the patient's views about cause and treatments suggested by others. Despite this.

Occlusive dressings increase their effect. 509 . but disfiguring psoriasis may warrant the use of antimetabolites or immunosuppressants following the use of more potent topical corticosteroids. Harsh soaps should be avoided. Less when in combination (e. It can be drug-induced.g. large quantities for widespread rash. site and severity of the condition. Onset is most commonly between 10 and 40 years but can occur at any age. severe. Salicylic acid can be combined with tars and dithranol. chloroquine and hydroxychloroquine. Diet is not a factor. It is not infective and waxes and wanes in intensity. Phototherapy is also often used by dermatologists. trauma or emotional stress. There is increased epidermal cell proliferation. Beta blockers. There is no complete cure but in most cases psoriasis can be reasonably controlled with therapy. • For psoriasis which is widespread.092 Performance Guidelines COMMENTARY Aetiology of psoriasis is unknown but there is a familial predisposition. ~ Emollients for scaling or irritation. ~ Calcipotriol (a vitamin D derivative that regulates growth of keratinocytes). and it can be precipitated by infections. and emollients. Psoriasis affects 2-4% of the population.g. ~ Dithranol — an antiproliferative agent — is very effective. ~ Tars — anti-inflammatory but can stain and smell which are disadvantages. The lesions can become secondarily infected. e. or causing disfigurement or disability. mainly affecting the hands. Complicated or difficult cases need specialist care and open lines of communication between general practitioner. tars. any other medical attendants and the patient. lithium. emollients or a weak topical corticosteroid may suffice. • For mild to moderate plaque psoriasis — use topical therapy — dithranol. In mild cases. ~ Topical corticosteroids are more potent preparations for thicker lesions. dermatologist. corticosteroids. Psoriasis can be associated with a specific type of arthritis. with allantoin). keratolytics. with vascular proliferation and inflammation in the upper dermis. systemic therapy is indicated such as methotrexate or acitretin or cyclosporin. Treatment should be at an appropriate level for the type. ~ Keratolytics for lifting and softening thick scale such as sulphur and salicylic acid.

The patient should be commenced on oral prednisolone in high dose at first (60-100 mg). Politeness. A stronger nonopioid analgesic than paracetamol should also be prescribed. respect and consideration rather than an authoritarian approach should be demonstrated when discussing the threat of blindness and obtaining compliance with the use of corticosteroids. as she doesn't like the idea of steroids. 510 .093 Performance Guidelines Condition 093 Temporal arteritis in a 58-year-old woman AIMS OF STATION To assess the candidate's knowledge of the treatment of temporal arteritis and its most important possible sequel: visual impairment. The doctor should not withhold this information. Initial management plan An erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) should be arranged immediately with request for a same day report (this requires liaison with the patient who should contact the doctor later in the day). Referral to a surgeon with a view to temporal artery biopsy should be discussed and urgent referral to an eye specialist should be advised. Generating trust and confidence and giving the correct level of reassurance are also expected. EXAMINER INSTRUCTIONS The examiner will have advised the patient that she should ask about side effects of steroids and whether some alternative medication is preferable. Questions to ask unless already covered: • • • • • • • • • 'Could it be a migraine?' 'Are there any (other) complications?' 'Are you sure that my eyesight will be all right?' 'Should I see an eye specialist?' 'Isn't "cortisone" dangerous?' (If 'cortisone' or 'steroids' are recommended) 'What are its side effects?' 'How long will the headache last once treatment lasts?' 'How long will I be on "cortisone"?' 'Can this trouble affect me in any other way?' EXPECTATIONS OF CANDIDATE PERFORMANCE This can become an emotive situation for the patient after being informed of the nature of the condition and the possibility of severe visual impairment. which should be given with empathy and support. The doctor should listen carefully to the patient's queries and provide honest as well as accurate answers. She should also ask about further tests such as X-ray and whether the headache might just be a simple migraine.

Commencement of oral steroid therapy before completing investigations is indicated to reduce the risk of visual impairment. hypertension. • Must commence prednisolone therapy immediately. CRITICAL ERRORS • Failure to request ESR or CRP.093 Performance Guidelines Patient Education The aetiology and prognosis of temporal arteritis are obscure. Temporal arteritis may follow polymyalgia rheumatica in about 20% of cases. 511 . Resolution may take up to 2-3 years. • ESR or CRP must be ordered with urgent early report requested. especially in a case of this duration (two weeks). Vision is impaired in about 50% of patients at some stage. • Failure to commence prednisolone therapy. Maintenance steroid therapy in lower dose over 2-3 years may be required. which raises the possibility of steroid-induced complications of osteopenia. Concomitant use of H2 receptor antagonists should be considered in patients with a history of dyspepsia or peptic ulcer. followed in most cases by biopsy of the superficial temporal artery for confirmation because of the likely need for medium to longterm corticosteroid therapy. Once symptoms are controlled and ESR levels fall. diabetes and changed facies. COMMENTARY Although this is not a common disorder. referral to eye specialist and longterm nature of the condition. If blindness occurs it is usually irreversible. The condition is very responsive to corticosteroids which should be prescribed in high doses initially. Confirmation by ESR or CRP (usually markedly elevated) is essential. • Patient counselling and education is required regarding possible biopsy. KEY ISSUES • Skill in conveying unpleasant news to patient in an honest and supportive manner with guarded reassurance about the outcome. This patient should be seen again within 48 hours by which time significant resolution of symptoms should have occurred. A highly probable diagnosis is possible on clinical grounds alone. It is a manifestation of giant cell arteritis. Involvement of the ophthalmic artery or ciliary arteries may occur causing optic atrophy and blindness. the high risk of preventable blindness and response to early treatment makes it essential knowledge. the prednisolone can be reduced to maintenance levels (5-10 mg three times daily). The patient should be monitored closely by continuing review of symptoms and serial ESR levels.

~ May prescribe artificial tears. will accept the diagnosis and management plans. particularly reassurance that the patient has not had a stroke. ~ Investigations are not essential but CT head would be appropriate for reassurance in view of patient anxiety about a stroke. and skills in counselling an upset and anxious patient. ~ Wear patch over left eye at night.094 Performance Guidelines Condition 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man AIMS OF STATION To assess the candidate's knowledge of Bell Palsy. • 512 . There is no evidence that exercises or nerve stimulation aid recovery. but if informed and reassured appropriately. Antiviral drugs may also be given because of its presumed viral aetiology. because of possibility of incomplete or nonrecovery. Advise about immediate management: ~ Steroids are usually prescribed empirically: prednisolone 40-80 mg daily for three days then taper off and cease over the next seven days. its prognosis and its management. The cause is unknown but is consistent with inflammatory compression of the facial nerve in the temporal bone (probably viral). watch for symptoms of conjunctivitis and corneal injury. ~ Consider early referral to a physiotherapist as an aid to self-management strategies. EXPECTATIONS OF CANDIDATE PERFORMANCE You would expect the candidate to: • • Acknowledge the patient's distress about his appearance and to provide support and guarded reassurance. Referral is also appropriate for confirmation of management. ~ Referral to a neurologist should be offered for confirmation of diagnosis and possibly for nerve conduction studies. and 5-10% do not recover by the end of one year. First signs of recovery appear within two weeks. He is very concerned. Expected course — about 70% of patients completely recover within two months. An older patient age is associated with slower recovery. ~ Arrange continuing followup to monitor progress. Explain the diagnosis and natural history of the condition. About 20-25% take up to six months for full recovery. but they may support patient confidence in recovery. ~ Review within a few days for support and monitoring. EXAMINER INSTRUCTIONS The patient has the condition as illustrated.

• Tears fail to enter the lacrimal puncta medially because they are no longer held against the conjunctivae and the eye weeps. Offer referral to neurologist and physiotherapist. the angle of the mouth on the affected side does not move. the lines on the forehead and nasolabial fold are smoothed out. • The palpebral fissure is wider due to the unopposed action of levator palpebrae. • Hyperacusis in the affected ear can be troublesome when the patient is subjected to local noise. • Initial management plan — protection of eye and possible use of steroids and antiviral agents. providing support and guarded reassurance about recovery. emotional and associated movements. When smiling. • The affected side of the face is immobile. Patients present with an acute or subacute onset over a few hours. if complete and all muscles equally affected are as follows (see illustrative figures): • Facial asymmetry is accompanied by loss of voluntary. Clinical features of the lesion. with complete or partial paralysis of muscles supplied by the facial nerve. Corneal abrasion and ulceration are significant risks. • The direct corneal reflex is absent. but the patient appreciates the discomfort from testing and the indirect corneal reflex is present (the other eye blinks). the eyebrow drops. b. p) may be affected. 513 . • The articulations of labial consonants (m.094 Performance Guidelines KEY ISSUES • Approach to patient — acknowledging distress about his appearance. and in repose 'wry-mouth' can be identified. • The a/a nasi does not flare or dilate with vigorous breathing. Pain around the ear is followed by unilateral facial paralysis of lower motor neurone type. COMMENTARY The most common cause of unilateral facial nerve palsy without a clear history of local injury is the condition of idiopathic acute facial nerve palsy ('Bell Palsy) Bell Palsy is of unknown aetiology and affects all ages and both sexes. • Very unsatisfactory counselling skills displaying insensitivity in dealing with an anxious patient. • During mastication food accumulates in the cheek and dribbling of saliva can occur from between paralysed lips. CRITICAL ERRORS • Telling patient that complete recovery always occurs. • The lips stay in contact but cannot be pursed for whistling. stressing that complete recovery is usual (although not invariable). • Efforts to close the eyes cause the affected globe to roll up under the upper lid (Bell reflex). The clinical features are consistent with a lesion due to inflammatory oedema and compression of the nerve within the bony canal of the petrous temporal bone. • Patient counselling about prognosis and natural history.

From the geniculate ganglion run the secretomotor fibres to the lacrimal gland and submandibular salivary gland. and supplies the anterior two-thirds of the tongue with taste sensation as illustrated. The motor branches of the facial nerve break into a spray of branches and run through the parotid salivary gland before emerging from its anterior border to supply the facial muscles via temporal. Pathologic Anatomy The facial nerve supplies muscles of facial expression from scalp to neck — from occipito-frontalis in the scalp to platysma below. to the sensory facial nerve root. not the 7th. The autonomic sensory taste fibres are carried from the tongue with the lingual nerve (carrying ordinary sensation) via chorda tympani through middle and inner ear. Facial nerve lesions below the chorda tympani (e. and cervical branches as illustrated. before emerging from the stylomastoid foramen at the base of the skull. The chorda tympani leaves the nerve a few millimetres above the point of exit from the stylomastoid foramen. The cosmetic and psychological effects of the disfigurement can be profound. and giving off the chorda tympani. and including those muscles governing movement of eyebrows.g. zygomatic. which carries afferent taste fibres from the tongue and also efferent secretomotor fibres to the lacrimal and salivary glands. The major motor root of the 7th nerve originates in the pons from the motor nucleus and fibres run in the pons in an unusual curving course around the 6th nerve nucleus before leaving the anterior surface of the mid-pons to enter the internal auditory canal with the 8th (vestibulocochlear) cranial nerve. buccal.094 Performance Guidelines • • • Loss of taste sensation may be noted in the anterior tongue on the affected side. 514 . mandibular. and then joins the lingual nerve to the tongue. The motor root is joined at the internal auditory meatus by the 'sensory' root. and runs between the layers of the tympanic membrane separating outer and middle ears. in the parotid gland) will not affect taste. eye closure. The geniculate ganglion is the relay station for the secretomotor fibres for tears and the site of the sensory root ganglion of the taste fibres. cheek and nose. Within the petrous temporal bone the nerve runs laterally to the medial wall of the tympanic cavity before bending backwards abruptly (the genu). Somatic sensation to the face is subserved by the 5th cranial nerve. Patients with Bell Palsy are frequently concerned that they may have suffered a paralytic stroke. giving branches to the tiny stapedius muscle of the inner ear. The facial nerve then runs downwards in the facial canal on the inner wall of the tympanic cavity. mouth.

g.f s. tn s.nucleus of tractus solitarius superior secretory nucleus 7th nerve motor nucleus motor root 'sensory' root stapedius buccinator chorda tympani geniculate ganglion internal auditory meatus 094. 7* m.m.n.m. s.s. FIGURE 5.r s b at g.094 Performance Guidelines rn T. Anatomy of facial nerve 515 .n. CONDITION foramen magnum stylomastoid foramen submandibular ganglion taste nucleus . s.a.

If the nerve is affected within the parotid gland. or have a cerebral tumour. Recovery of facial nerve function is rare. However. auditory neurofibroma) or a vascular event from vertebrobasilar insufficiency. This is the Ramsay Hunt syndrome. smoothing of facial lines and failure of eversion of mucosa of patient's left lower lip ('wry-mouth') due to paralysis of depressor anguli oris. Movements of the upper muscles to forehead and eyes (which are bilaterally innervated from the upper motor neurone) are spared. Prompt treatment with aciclovir may improve prognosis and diminish post-herpetic neuralgia. Basal skull fractures of the petrous bone are another important cause of facial nerve palsy. and occasionally other cranial nerves are also affected. this is usually due to a parotid malignancy giving partial or total lower motor palsy. as may be emotional movements. Pain may precede the facial palsy and the associated herpetic eruption in the ear and sometimes on tongue or palate. Such patients are often elderly. • • • • • CONDITION 094. 516 . If hearing loss or other cranial nerve lesions are associated with facial nerve palsy the diagnosis is more likely to be a cerebellopontine angle tumour (for example. Benign parotid tumours do not cause facial palsy. not Bell Palsy. an infarct in the pons may produce a nuclear (lower motor neurone) lesion of the facial nerve.094 Performance Guidelines Differential Diagnoses — other causes of facial nerve palsy • • Patients with Bell Palsy are frequently concerned that they have had a stroke'. If vesicles within the external ear or on the palate accompany the 7th nerve palsy the condition is viral herpes zoster infection affecting the geniculate ganglion. Left-sided facial nerve palsy Face in repose: note widening of palpebral fissure due to unopposed action of the levator of the upper lid. In Bell Palsy the motor lesion is confined to the facial nerve alone and is lower motor neurone in type. Facial weakness due to 'stroke' is usually upper neurone in type and part of a hemi-paresis on the same side as the facial paralysis. FIGURE 6.

FIGURE 8. 517 . FIGURE 7. and accentuation of the 'wry-mouth' triangular deformity. Left-sided facial nerve palsy Attempted eye closure: note failure of left eye closure with rolling up of the eye under the upper eyelid. Left-sided facial nerve palsy Obvious deformity when smiling: note immobile left eye and mouth musculature and absence of nasolabial fold.094 Performance Guidelines CONDITION 094. CONDITION 094.

Left-sided facial nerve palsy Attempting to blow out cheeks: note failure of left buccinator muscle with flaccid paralysis of patient's left cheek. 518 .094 Performance Guidelines CONDITION 094. The patient is unable to prevent air from escaping from the mouth when he tries to build up intraoral pressure. FIGURE 9.

• Explain why further investigation is essential and obtain compliance for this. Questions to ask unless already covered: • 'What did you find in my urine?' • 'Can this infection be treated easily?' • 'Where do these bacteria come from?' • ‘Is this the same as my wife gets?' • 'Tell me exactly what tests I should have done?' • 'Why do I need these tests?' • 'Do you think I have something seriously wrong?' • 'How long will I need to take the medication?' • 'Could it occur again?' • 'What will the urologist do?' (Ask only if referral is advised) You are not overly concerned about your condition because your wife has suffered from occasional urinary tract infections over the years which have always responded well to treatment with antibiotics. EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient • This may appear to be a straightforward clinical situation but it requires care to avoid alarming the patient concerning the need for more investigations than just a urine culture • Give a clear explanation of the nature of the condition. You are about to receive the doctor's advice about the problem. • Obtain compliance in use of medication (clear instruction about frequency and duration) • Emphasise importance of followup.095 Performance Guidelines Condition 095 Dysuria and urinary frequency in a 40-year-old man AIMS OF STATION To assess the candidate's approach to a first time urinary tract infection in an adult male patient. You expect to recover quickly after receiving antibiotics. 519 . be surprised and express some reluctance to undergo these procedures. If the doctor indicates that further special investigations are necessary followed by referral to a urologist. If the doctor handles your reaction satisfactorily agree to follow this advice. EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You consulted this doctor today because of the gradual onset of dysuria and frequency of micturition over the last three days. She has had no other investigations other than urine laboratory tests. The doctor has examined you (including rectal examination) and asked you to provide a urine sample which was checked in the practice laboratory.

• The clinical picture suggests a lower urinary tract infection. ~ benign prostatic hypertrophy. or cephalexin 500 mg orally. Phone with results when through. trimethoprim 300 mg orally. for example. because of the absence of fever and loin pain. Followup of this episode by repeat microscopy and culture after completion of antibiotic therapy. Amoxycillin is often given but is inappropriate in this patient because of the penicillin sensitivity. The antibiotic therapy should be commenced today whilst awaiting the culture results. sexually transmitted infection. ureter. ~ bladder polyps or carcinoma. Ural® (sodium citrotartrate) 8 hourly. 12 hourly. Patient education and counselling. Choice of initial treatment — appropriate antibiotic — for example. • • Younger adults — foreign body in bladder. including homosexual activity. KEY ISSUES • • • • Approach to patient.095 Performance Guidelines Tell the patient what Is wrong A variety of terms may be used to describe a urinary tract infection but the candidate should explain that it is most likely to be in the lower urinary tract (bladder. Discussion of condition and advice about investigation Significance of a urinary tract infection in males. Older adults ~ calculus formation in kidney. ~ prostatitis. Urinary alkalisation may be used. Immediate management The candidate must advise that the midstream urine specimen collected today will be sent for culture and antibiotic sensitivity assessment. Choice of investigations. prostate or urethra) rather than in the kidneys. ~ urethral stricture. Early review if poor response to treatment. ~ carcinoma of prostate. or ~ genitourinary tuberculosis should not be forgotten. once daily. 520 . Usually associated with underlying pathology according to age group: • Children — congenital abnormality especially vesicoureteric reflux. Advise patient to drink extra fluids. Duration of therapy is 14 days. Initial management plan. The main conditions to be excluded are urinary neoplasm and calculus and prostatic pathology. or bladder.

• Failure to advise the need for further investigations. • Prostatic specific antigen (PSA) level. • Serum urea and electrolytes • Referral to a urologist who may arrange: ~ cystoscopy. Repeat culture after initial treatment. ~ voiding cystourethrogram. • These would be undertaken in a staged manner. • Ultrasound of kidneys. and bladder.095 Performance Guidelines CRITICAL ERRORS • Failure to arrange urine culture before commencing antibiotic therapy. • Contrast enhanced CT of abdomen and pelvis. 521 . ureters. • Urinary culture to define organism. COMMENTARY • Further investigation is essential to identify the underlying cause and to exclude malignancy.

you should ask 'What treatment will they give my daughter in hospital?' 522 .096 Performance Guidelines Condition 096 Eclampsia in a 22-year-old primigravida at 38 weeks gestation AIMS OF STATION To assess the candidate's ability to recognise that the grand mal fit is a sign of eclampsia. but does not detail what will happen to the daughter following admission to hospital. but was otherwise well. EXAMINER INSTRUCTIONS The examiner will have instructed the mother of the patient as follows: Your daughter has just had a fit in the waiting room. renal disease. She bit her tongue. Questions to ask if not already covered: • • • • • 'Why did she have a fit?' 'Will the fit damage my daughter or her baby?' 'Will she have any more fits?' 'What are you going to do with her now? Can I take her home?' If the candidate suggests hospital transfer. no hypertension. or other medical problem in the past. not mentioned any headaches or visual disturbances recently. Your daughter has: • • • • no past history of epilepsy. and noticed oedema of the legs for the last two weeks. and had funny movements of her limbs. The list of responses below is likely to cover most of the questions you will be asked. and then went off to sleep. The fit occurred approximately 10 minutes ago and lasted three minutes. The candidate will generally be expected to take an appropriate history from you as the mother in order to manage the case. and the ability to manage appropriately this particular pregnancy complication in an 'out-of-hospital' situation. and has never had any treatment with antiepileptic drugs.

with three fingerbreadths palpable above the pubic symphysis. There are no unilateral localising signs. and coagulation profile.096 Performance Guidelines Examination findings to be given to the candidate by the examiner on request • • • • • • Drowsy. this appears normal. blood pressure. Hb and platelet count. very active. to have a Guedel airway/padded spoon available to prevent her from biting her tongue. Generalised oedema. 80/min and regular. • She will need to be transferred and admitted to hospital immediately. and to observe her in a slightly darkened environment. Central nervous system examination — apart from the conscious state and the active reflexes. 523 . • Prior to transfer to the hospital admission an anticonvulsant such as diazepam should be given intravenously in an attempt to prevent further fitting (oral therapy is inappropriate and NOT acceptable). The presentation is cephalic. ~ tests on patient should include: renal function tests. Failure to ask for the results of urine testing would indicate inadequate care. ~ the fetus should be checked by cardiotocography (CTG). lax. Providing it is well controlled. and ~ the room should be prepared in case a further fit occurs with the facility to administer oxygen. and frequent urine testing (predominantly for protein). fixed in the pelvic brim. The fetal heart is audible and normal. although it is potentially very dangerous to both the mother and baby. a condition which occurs late in pregnancy generally in women having their first baby. ~ monitoring of the patient should include: pulse. • Investigation results None done except office urine testing of specimen brought with her showed proteinuria (++++). to have the facility to place her in Sims position. EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should advise the mother along the following lines: • The diagnosis is eclampsia. but rousable. liver function tests. urine output. . • The likely care provided in hospital would be: ~ an intravenous drip to be inserted and magnesium sulphate commenced in appropriate dosage to try to prevent any further fits. and non tender. clonus evident at the knees. temperature. and delivery arranged as soon as her blood pressure and any further fitting are brought completely under control. BP: Pulse: Reflexes: 180/110 mmHg. Abdominal examination: uterus enlarged to 38 cm (symphysis-fundal height). no longterm harm usually occurs to either mother or baby. • There is no point prolonging the pregnancy in view of the gestation of 38 weeks. ~ the blood pressure should be lowered with intravenous hydralazine or diazoxide — oral agents are ineffective and should not be used.

and failure to transfer her immediately to hospital. Failure to sedate. • • • • • 524 . after prostaglandin priming. These principles are: prevention of further fits. and the cervical findings. This just takes time to do. not being focused enough to the actual problem. Not asking for appropriate examination findings. Common problems likely with candidate performance are: • When taking the history. lowering of the blood pressure. COMMENTARY In this case the most likely diagnosis is eclampsia occurring in pregnancy. social history and so on. Obviously if the CTG is abnormal. and arrangement for immediate delivery of the baby by the most appropriate route. Failure to outline the three principles of management in the hospital — sedation. but asking for information such as irrelevant past history. CTG monitoring of the fetus in labour is mandatory. lower blood pressure. Ability to manage a patient who has had an eclamptic fit in late pregnancy and is not in hospital. Not asking whether she had had any fits before. and delivery of baby. It is important that the three basic principles of the management of eclampsia are performed or arranged. Administering oral instead of intravenous hypotensive drugs to reduce the blood pressure. Failing to understand that any prolongation of the pregnancy is irrelevant as the gestation is already 38 weeks. CRITICAL ERRORS • • • Failure to diagnose eclampsia and recognise risk of this to mother and baby. she should be induced and monitored closely in labour. Not requesting whether there was any proteinuria present. KEY ISSUES • • Knowledge of the causes of fitting in pregnancy. consideration needs to be given as to whether induction is appropriate. probably with the use of an epidural anaesthetic for pain relief and blood pressure control. and reduces the time available for the remaining tasks. or whether an elective Caesarean section is more appropriate. but it is unlikely that this is anything other than an eclamptic fit. such as hyperreflexia. If the cervix is unfavourable.096 Performance Guidelines • The mode of delivery will depend on her condition. A history of previous fits should be sought. If the cervix is very favourable. Caesarean section is likely to be required.

asking the examiner for the examination findings. 525 . • No previous operations or illnesses • This is your first baby. Uterus is enlarged to the size equivalent to a 28 week pregnancy (symphysis-fundal height = 28 cm). No proteinuria. Fetal heart rate is normal. The candidate should do this by taking a focused history. Cephalic presentation. and to appropriately manage the patient for the remainder of the pregnancy. • Your ultrasound at 18 weeks was normal. Questions to ask if not already covered: • What do the blood sugar levels mean?' • 'Do I have diabetes?' • 'How bad is my condition?' • ‘What treatment will I require?' • ‘Will my baby be diabetic?' Examination findings to be given to the candidate by the examiner on request • • • • • The blood pressure is 120/80 mmHg.097 Performance Guidelines Condition 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida AIMS OF STATION To assess the candidate's ability to make the correct diagnosis of gestational diabetes. • No family history of diabetes. head still mobile above the pelvic brim. and then advising the patient appropriately EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows The list of responses below is likely to cover most of the questions asked. • You are now 28 weeks pregnant. • You have never been tested for diabetes previously.

• • • • • The diagnosis is gestational diabetes Consultation with a diabetic physician and consultant obstetrician is mandatory. insulin therapy will probably be necessary. Deliver at term at the latest. Ability to recognise the increased risks to the fetus. She must control any weight gain in the future. 526 . or evidence of fetal distress. and there is a 30% risk of her developing diabetes later in life. Monitor the fetus by continuous CTG in labour. Glucose tolerance should therefore be checked at least every 5 years for life. Steroid therapy would improve fetal lung maturity. The major risks to the baby are: ~ Macrosomia (large baby size) — do ultrasound at 32-34 weeks and probably deliver by Caesarean section if macrosomic. Ability to appropriately assess the control of the diabetes during the remainder of the pregnancy. especially about two hours after a meal. However gestational diabetes is likely in subsequent pregnancies. She should follow a special diet to keep the blood glucose during the day at less than 7 mmol/L. breech presentation. the fetus is macrosomic or polyhydramnios occurs. ~ Increased risk of fetal death in utero — therefore weekly CTGs should be performed until delivery. Test the blood sugar 3-4 times per day. If this is not possible. The diabetes will almost certainly resolve following delivery. • KEY ISSUES • • • • Ability to recognise that the blood sugar results are diagnostic of gestational diabetes.097 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE It would be expected that the candidate would provide much of the following information. and to appropriately manage the patient. in consultation with a physician and obstetrician. ~ Hyaline membrane disease if delivered prematurely — try to delay induction until after 37 weeks. but will make gestational diabetes worse. • • Risks to the mother — increased risk of pre-eclampsia. Keep blood glucose levels stable in labour with intermittent insulin injections. Deliver by elective Caesarean section if macrosomic (> 90th centile for weight). twice weekly if on insulin. unless obstetric complications indicate earlier delivery is indicated. These should be started at 32-34 weeks gestation. Ability to recognise the need for insulin if the blood glucose levels are not reduced satisfactorily with diet alone. and the need for close monitoring.

but asking for information such as irrelevant past history. 527 . COMMENTARY This case illustrates the need for the candidate to recognise the diagnosis of gestational diabetes based upon a two hour glucose tolerance test. and the need to include in the management of this patient a diabetic physician and an obstetrician. social history and so on. • Failure to arrange for consultation with a diabetic physician and obstetrician. The most important aspects of the management of the case are to recognise the need for assessment of the blood sugars three or four times a day. • Failure to advise diabetic diet and testing of blood sugar levels 3-4 times daily.097 Performance Guidelines CRITICAL ERRORS • Failure to diagnose gestational diabetes. Common problems likely with candidate performance are: • When taking the history. This just takes time to do. and reduces the time available for the remaining tasks. not being focused enough to the actual problem. the need to consider insulin if the blood glucose levels do not respond. • Failing to recognise a need for special fetal monitoring because of the increased risks to the fetus.

He has never had a urinary tract infection. Is there anything we can do for that?' 'How does this alarm work if he has already passed urine and wet his bed before it goes off?'(If an alarm is advised) EXPECTATIONS OF CANDIDATE PERFORMANCE This scenario describes a 5-year-old boy with persistent primary bed-wetting from three years of age. His father wet the bed until the age of nine years. These are important points the candidate should appreciate. Since the age of 3 years.098 Performance Guidelines Condition 098 Bed-wetting by a 5-year-old boy AIMS OF STATION To assess the candidate's ability to diagnose and handle the common problem of bed-wetting in a 5-year-old child. Amitriptyline (Tryptanol®) was tried about two years previously to no avail. His general health is excellent. You were initially exasperated by the wetting but now have accepted that the wetting is involuntary. has no daytime wetting or any other symptoms to suggest a pathological cause for his wetting. and he has had no major illnesses. You have not punished Johnny despite your exasperation. Should we continue to do this?' 'What about when he is asked to sleepover at a friend's place — so far we haven't let him do this. His height and weight are on the 50th percentile. and his parents are keen to help him achieve this. EXAMINER INSTRUCTIONS The examiner will have instructed the parent as follows: You are the mother of Johnny who has a problem with bed-wetting nightly since the age of three years. He appears to be growing normally and is on the middle line of his graph for height and weight. Johnny is going very well at school and enjoys his teacher. Johnny is doing well at school and has lots of good friends. The tablets that were tried two years ago made no difference to the wetting. He is otherwise well. He is embarrassed and you and your spouse are very keen to help him control his wetting. he has always been dry during the day and never had any incontinence. Questions to ask if not already covered: • • • • • ‘Is there something wrong with his kidneys or bladder?' 'Does he need any investigations?' ‘We have restricted his fluids after dinner at night and lift him onto the toilet when we go to bed. 528 . He has lots of good friends. Johnny has a 4-year-old younger sister who has been dry day and night since the age of two and a half. The boy himself is very keen to be dry. You and his father are happily married and have no major stresses in your lives.

one parent was a bed-wetter until aged nine years. Explain the safety of this substance if used only as directed. 529 . • Exclusion of emotional stress at home or school. • Explaining how to obtain the alarm (for example. Before embarking on a plan of action. support. the candidate should outline an ongoing plan of management. • Reassurance that there is almost certainly no organic pathology present. if the parents are keen to continue this they should feel free to do so as it occasionally does help some children. This should include: • Empathy with the exasperating nature of the condition particularly with the excessive washing of bedclothes and pyjamas. and encouragement to both child and parent.098 Performance Guidelines The parents are happily married and under no major stresses. A review appointment should be made two to three weeks after the alarm has started. which are normal. • Enquiry about a family history of enuresis. His 4-year-old younger sister has been dry day and night since the age ot 21/2 years. • Advice that even though lifting and restriction of fluids have not been shown to be effective generally. • Advice about plan of action should be logical and clear. • Explaining a plan of action for the use of arginine vasopressin (DDAPV®) by nasal spray when it is important to remain dry and avoid any embarrassment for school camps and sleepovers. • Enquire about the child's growth percentiles. buying or through some Community Health Centres or Children's hospitals) • Discussing that the success rate is much higher if the child himself is motivated to become dry (as Johnny is). The candidate should enquire about family history. through pharmacies [hiring]. • Supporting and encouraging child and parent by regular frequent review to encourage the boy on even minor successes. Having excluded any organic pathology and having ensured that there are no serious emotional reasons to account for the symptom. • Ensure his blood pressure is normal. Explain how the alarm works as a conditioning response to release of urine. the candidate should proceed as follows: • Check the boy's urine by dipstix (Multistix®) testing. KEY ISSUES • Empathy. • Exclusion of organic pathology by the history and by arranging simple urine testing. • Renal ultrasound may be suggested but is probably unnecessary unless there is a great deal of parental anxiety. • Advice that the success rate with amitriptyline (Tryptanol®) is low. but enthusiasm for the interest the parents are showing in trying to help Johnny. • Outlining the plan of management including use of an enuresis alarm. and a urine microscopy and culture. to review the progress. It can be a dangerous drug in overdose and is rarely used now. • Discussing a recording star chart and reward system. • Advice that even with the alarm it may be some weeks before success is achieved and the alarm should be persisted with for up to three months.

and that his parents are willing to help him achieve this 530 . has no daytime wetting or any other symptoms to suggest a pathological cause for his wetting. The candidate snould appreciate that the boy himself is very keen to be dry. He is otherwise well.098 Performance Guidelines CRITICAL ERROR • Suggesting a probable organic cause for the wetting and the need for invasive investigations. COMMENTARY This scenario describes a five-year-old boy with persistent primary bed-wetting from three years of age.

EXAMINER INSTRUCTIONS The examiner will have instructed the patient as follows: You are suffering from severe pain in your right foot which began two days ago. would be appropriate. and are annoyed that you were not warned about this. indo-methacin 25 mg capsules — 50-75 mg immediately. You saw the doctor earlier today who diagnosed gout (which you have had before). 50 mg two hours later. • Initial management plan — immediate ~ Discontinue diuretic and aspirin. after work. You are overweight. You have little knowledge about the cause of gout and are unaware that recurrent attacks are to be expected and can be prevented. and arranged for a confirmatory blood test. and to defuse irritation about having to have a blood test for this attack and finding out that the antihypertensive medication has been a precipitating factor.099 Performance Guidelines Condition 099 Acute gout in a 48-year-old man AIMS OF STATION To assess the candidate's ability to manage an acute attack of gout and give advice about its prevention. You are somewhat irritated that you were asked to have a blood test. Questions to be asked if not covered • 'How long before I can resume work?' • 'What causes gout?' • 'Can it do any serious damage to my system?' • 'What is the best treatment?' • 'Should I have any other tests?' • 'What about having a beer after work?' EXPECTATIONS OF CANDIDATE PERFORMANCE • Approach to patient It is essential to establish a satisfactory relationship with this patient because of the need for compliance regarding his use of alcohol and control of his weight. You are a 48-year-old taxi driver and usually keep in good health.g. You have returned to find out the result and receive treatment. 531 . because this was not done during previous attacks which responded well to treatment. You are anxious to get relief from the pain which is preventing you from driving your taxi. ~ Specific treatment: . You have not suspected that the blood pressure tablets could have something to do with gout. Other NSAID such as naproxen or ibuprofen are also effective. You have no family or social problems. daily. 25 mg eight hourly for 48 hours. You do not smoke but drink three or four stubbies of beer. then 25 mg twice daily for one week.Nonsteroidal anti-inflammatory drug (NSAID) initially in high dose: e. No serious past medical problems but you are taking tablets for mild blood pressure diagnosed two years ago.

. .4 mmol/L ~ Colchicine (0. tinned fish. Appropriate patient education and counselling regarding prevention of further attacks. ~ Reduce weight. OR colchicine 0.Paracetamol (Panadol®) can be used for additional pain relief if needed. fasting blood sugar and urea and electrolytes. gradually increasing up to 300 mg daily (two strengths 100 and 300 mg tablets) ~ Check uric acid level after 4 weeks — aim to reduce below 0. • Initial Management — Preventive ~ Ensure adequate intake of water. . then 1-2 every 4-6 hours or until diarrhoea occurs. ~ Approximately eight weeks after this attack has subsided may commence allopurinol 50-100 mg daily.Can be precipitated by alcohol excess. Note that allopurinol and probenecid are contraindicated for an acute attack.OR prednisolone 25 mg orally.Elevate and rest foot for 24-48 hours. X-ray of the affected area is not required. Thiazide diuretics also predispose to diabetes. Other renal function tests are not indicated at this stage. . angiotensin converting enzyme inhibitor [note that all thiazides and Beta blockers may exacerbate gout]). Gout: . dyslipidaemia.Can follow any surgical operation.5 mg tablets 2-3 immediately.Increase fluid intake.May return to work as soon as pain is relieved — should be within 48 hours. and Type 2 diabetes. Do not take diuretics or salicylates. . .Is prone to recurrence.Particularly occurs in the great toe following minor trauma. - ~ Additional measures: . Reduce intake of alcohol. • Patient education and counselling ~ Gout is a metabolic disturbance with an inherited tendency in which there is decreased renal clearance of urate causing hyperuricaemia with deposition of urate crystals in joints. and diuretics which inhibit sodium reabsorption. 532 .5 mg twice daily.099 Performance Guidelines .d. Maximum dose 6 mg/24 hours. ~ Further assessment of patient should include review of blood pressure. reducing to zero over 7 to 10 days. .) can be used in conjunction with allopurinol if gout recurs during initial therapy. .Warn regarding possible side effects of medication: indigestion and elevated blood pressure from indomethacin or prednisolone: diarrhoea from colchicine.g. It is frequently associated with hypertension. .Exhibits a prompt response of the acute attack to appropriate treatment (24-48 hours). .Is aggravated by diet high in purines.Suggest an alternative drug to reduce blood pressure (e. soft tissue (tophi) and urinary tract (urate stones). Avoid foods rich in purine (offal.5 mg b. As pain reduces the dose of colchicine can be reduced to 0. serum lipids. KEY ISSUES • • Appropriate choice of drug therapy for initial management. daily in the morning. shell fish and game).

FIGURE 1. Acute gout commonly affects the great toe metatarsophalangeal joint. 533 . unusually. it can present as a polyarticular arthritis mimicking other systemic rheumatic conditions. This should be considered an iatrogenic disease. red and tender and the patient may be intolerant of even a sheet touching the foot. and to recommend appropriate management. the candidate is confronted with a very common clinical problem. obesity). It is common in clinical practice to come across an elderly patient who has been on longterm diuretic therapy with chronic tophaceous gout and renal impairment. The joint can be extremely painful. Plasma urate concentration may not be elevated in the course of an acute attack. It may affect any joint in the body or.099 Performance Guidelines CRITICAL ERROR • Failure to advise change of antihypertensive medication (thiazide diuretic). chronic renal failure due to interstitial nephritis). smoking. Hyperuricaemia is commonly exacerbated by excess alcohol intake and drugs. hyperlipidaemia. Therefore. FIGURE 2. Chronic tophaceous gout It is important to treat hyperuricaemia in order to avoid chronic gouty arthritis. to institute a longterm management plan to reduce the frequency of attacks. tophaceous gout and renal complications (calculi. it will contain needle-shaped crystals that are negatively biréfringent on phase-contrast microscopy. If fluid can be obtained from an affected joint. In this station. Hyperuricaemia is an independent risk factor for cardiovascular disease. so hyperuricaemia is not a necessary diagnostic criterion. Most cases of primary gout are due to excessive synthesis of uric acid while one-third relate to reduced renal clearance of urate. although other foot joints and the ankle are frequent sites. It also provides the practitioner with the opportunity to address significant lifestyle issues with the potential for improved cardiovascular health. CONDITION 099. an eminently treatable condition and an opportunity. COMMENTARY Gout (uric acid arthropathy) may present as acute arthritis or be associated with a chronic destructive arthropathy. hypertension. through patient education. an attack of gout provides an opportunity for the prescriber to review the cardiovascular risk factors (for example. Acute gout CONDITION 099.

It also assesses ability to evaluate the problem further by taking a focused history. and preparedness to intervene and address this with the patient. communication skills in engaging the patient and ability to make an appropriate management plan — including an awareness of potential problems following sudden cessation. interrupt and ask them to give their conclusions and make their recommendation to the patient. I feel fine. At six minutes. The examiner will have instructed the patient as follows: You are a 25-year-old. respond as follows: ‘I know I need to continue the Serepax® because on occasions I have taken only half a tablet for a few days. You eventually found the anxiolytic was very good at helping you get off to sleep quickly. and have never used. Your work. but you expect this is at least partly because you can get to sleep without fail and feel calm throughout the day.' 534 . if candidates have not already done so. EXAMINER INSTRUCTIONS The station assesses the candidate's awareness that longterm benzodiazepine use is a problem (abuse). relationships and home life are generally okay now. You were first prescribed this anxiolytic four years ago when your marriage broke down. any other drugs. ask candidates whether they would immediately stop the prescription and why. and then I will be on my way'. or missed taking them for one to two days. or that the doctor is going to stop or substantially change the dose immediately. Doc. jittery. At the same time. A brief survey of mood is all that is required in this case. and you have continued to use the anxiolytic since.100 Performance Guidelines Condition 100 Request for repeat benzodiazepine prescription from a 25-year-old man AIMS OF STATION To assess the candidate's ability to identify benzodiazepine dependency and counsel the patient accordingly. shaky and was unable to sleep or concentrate on my work. I thought I was going to have a heart attack because my chest was pounding. divorced salesman. capacity to recognise overuse in this case by simple calculation (dependency). Opening statement: 'This is just a quick one for you. You may not need to ask this question if the candidate has already addressed this issue. On one occasion. At five minutes. and I ended up feeling edgy. I just need a refill of my sleeping tablets. As soon as I get back to my usual dose. If the doctor indicates in any way that you should not be taking the Serepax®. The history does not suggest any other psychiatric diagnosis except substance dependency. thanks. I do not use. your business failed and you were having problems going for job interviews because you had lost so much confidence.

• When. along with regular appointments. If the candidate is critical or blaming. accept that and say 'What days do you work. • If the candidate agrees to provide a prescription with no suggested measures or comments such as 'we will talk next time'. including car accidents. followed by graded reduction. 535 . • If the candidate refuses to prescribe. support and resource material and followup. respond by saying that you use them only to get to sleep. take offence and say you do not want to continue with the consultation: 'Just give me the script and I will go' or 'I'll sort this out myself. Doc. but you don't think it applies to you (for no particular reason). but that has been the only time. • Advise the patient about the problems of benzodiazepine dependency and outline a plan of management that includes a gradual reduction in use. and also your symptoms on ceasing are evident to you that you have a 'real need'. the candidate asks about the schedule of your use. Respond to questions about your present use as outlined previously. so that I can be sure to see you next time?' Be quite at ease and be pleasant. really?' EXPECTATIONS OF CANDIDATE PERFORMANCE The candidate should: • Take a focused history of the patient's use of the benzodiazepine anxiolytic (Serepax®) and history of other substance and alcohol use and patient mood. You did feel depressed when your marriage broke up and your business failed. Give the following responses and answers to further questions: • When or if the candidate mentions addiction or dependency. agree with this management plan. Questions to ask if not already covered: • 'So what's the problem with taking these tablets. and admit that you have taken a few extra. take offence and respond as above: 'I'll sort this out myself. say that you are aware of some information about these tablets being addictive.100 Performance Guidelines You are generally in good health. or if. injuries or accidents. You have not had any serious illnesses. or wishes to refer you immediately to a substance abuse unit or report you to the Health Department. support and resource materials or groups. You can expect the candidate to pursue the issue of quantities used. along with regular appointments. be cooperative in uncovering the overuse problem. falls or faints or any loss of consciousness. Provide your background history and the development of your habit in a straightforward way. You do not smoke and rarely drink alcohol. say that there has been extra pressure at work. If the candidate approaches this diplomatically. • When the candidate explains a proposal of a period of monitoring your use and moods or stress. You have never had any fits. • When or if the candidate goes on to demonstrate to you that you have used more than one per day in the past week.

none defined COMMENTARY This station assesses the candidate's ability to identify inappropriate benzodiazepine use and dependency. Similarly. Longterm prescription needs are to be closely supervised and monitored for over-use. CRITICAL ERROR . including antidepressant medication and psychological treatments (relaxation techniques. thus provoking the patient to seek out another source. The satisfactory candidate. or refusing to prescribe with no other measures put in place. Appropriate language and attitudes in taking the history and discussing the problem.100 Performance Guidelines KEY ISSUES • • • • Identification and preparedness to address the issue of dependency and overdose. Chiefly. exacerbation of anxiety and treatment failure. and to counsel a patient appropriately. such as in this case. The doctor is presented with the problem of being drawn into maintaining a longterm benzodiazepine use habit. Candidates should demonstrate that they understand the problems of both prescribing further medication without any review or plan for reduction. cognitive behavioural or interpersonal therapies) must be applied first. referring the patient immediately to a substance abuse unit would be unsatisfactory and counterproductive. it requires them to actively and constructively intervene. not just to provide the prescription (with or without advice) or to just refuse the prescription. Thus. While they have some place in the longterm management of chronic severe anxiety. with clear evidence of over-use (approximately 75% greater consumption than the prescribed dose). 536 . fits. simply advising the patient that they will 'talk next time'. in addition to managing the immediate consultation needs. such as acute withdrawal states. Awareness of the risks of sudden cessation. are both unsatisfactory. Knowledge of biological and psychosocial management of benzodiazepine dependency. This case challenges candidates in a number of ways. will be aware of community support and self-help groups. Benzodiazepines are recommended for short-term use only. other treatments. or risking precipitating a withdrawal state. agitation. and also suddenly stopping the medication.

spacer and nebuliser. basic first aid techniques and primary wound care. There are other skills that the individual is expected to acquire progressively under supervision during internship and should have some understanding of at graduation. including antiseptic and aseptic technique. These include at least: • establishment of elective or emergency venous access for The junior graduate commencing infusion of fluids.3-B: Clinical Procedures Peter G Devitt and Barry P McGrath 'The hand is the cutting edge of the mind. • insertion and removal of a urinary catheter (male and female). conversant and competent with certain core skills. • anoscopy (proctoscopy/rigid sigmoidoscopy). focusing on investigation and treatment. • cardiopulmonary resuscitation (CPR). Graduates are expected also to understand the principles of more specialised clinical skills. • central venous pressure measurement. • maintenance of an adequate airway. internship is expected to be fully • venesection for collection of blood samples. • collection of a sample for arterial blood gas analysis. and to be able to explain these clearly to a patient. Some of these are ward-based skills and some may be learnt in the emergency or anaesthetic department. These skills include: • simple skin sut