Demonstration scenario: goitre

INFORMATION FOR THE CANDIDATE Scenario N°

MRCP(UK) PACES

Station 5: BRIEF CLINICAL CONSULTATION

Patient details: Mrs XX aged 33

Your role: You are the medical doctor on call

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

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

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

Referral text:

Clinical problem: This lady was admitted to the orthopaedic ward for a carpal tunnel release
operation.

She mentioned to the orthopaedic doctors that she has swelling in her neck and they have
asked for the opinion of a physician. You were asked by your consultant to see the patient and
to assess the suspected swelling in her neck.

Your task is to:

• Assess the problem by means of a brief focused clinical history and a relevant physical
examination. You do not need to complete the history before carrying out appropriate
examination.

• Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for
investigation and treatment where appropriate.

• Respond directly to any specific questions which the patient may have.

Any notes you make must be handed to the examiners at the end of the station
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INFORMATION FOR THE PATIENT Scenario N°

MRCP(UK) PACES

Station 5: BRIEF CLINICAL CONSULTATION

You are: Mrs XX aged 33

History of current problem

You are in the orthopaedic ward and you mentioned to the admitting doctor that your neck
seemed swollen. You do not have any of the symptoms your sister had when her thyroid was
underactive. Indeed you feel quite well.

Your weight is stable; your skin and hair are normal. You do not seem to feel the heat or the cold
anymore than anyone else. Your bowel works normally. You do not have a problem with
swallowing.

Background information

Past medical and surgical history

You have been suffering from pain in your right forearm and a numb or tingly feeling in your right
hand – affecting your 3rd, 4th and 5th fingers. The aching in your arm is worse at night and you
have found it more and more difficult to get comfortable. The problem has been present for
several years and was worse when you were pregnant with your daughter 3 years ago but
improved for a time after that.

A trapped nerve in your wrist has been diagnosed and you are having a short admission to have
the nerve released.

Family history
Your sister, who is 38, has an underactive thyroid.

Medication record

Current medications (if relevant)

You are on no medications.

Personal history

Relevant personal, social, occupational or travel history

You work as a typist and find that the pain and numbness of your hands is beginning to hamper
your work.

Occupational history
You are a typist.
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INFORMATION FOR THE PATIENT Scenario N°

Physical examination

Relevant clinical findings

There is a smoothly enlarged goitre. There is no bruit to hear. The gland does not extend below
the level of the manubrium. The patient is clinically euthyroid. There are also signs of bilateral
median nerve damage with reduced light touch sensation over the distribution of the median
nerves.

You have some specific questions for the doctor at this consultation:
- Why does my neck seem swollen?
- Is there something wrong with my thyroid gland?
- Are any tests required, and if so, what will these be?
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INFORMATION FOR THE EXAMINERS Scenario N°

DATE CYCLE
MRCP(UK) PACES

Station 5: BRIEF CLINICAL CONSULTATION

Examiners should advise candidates after 6 minutes have elapsed that “You have two minutes
remaining with your patient”. If the candidate appears to have finished early remind them how
long is left at the station and enquire if there is anything else they would like to ask or examine.
If they have finished, please remain silent and allow the candidate that time for reflection.

The Examiner should ask the candidate to describe any abnormal physical findings that have
been identified. The Examiner should also ask the candidate to give the preferred diagnosis and
any differential diagnoses that are being considered. Any remaining areas of uncertainty eg
regarding the plan for investigation or management of the problem may be addressed in any
time that remains.

Examiners should refer to the marking guidelines in the five skill domains on the mark sheet.

Examiners are reminded that, during the calibration process, the patient should be rehearsed
and specific aspects of the scenario that require clarification or emphasis should be discussed.
The boxes on the next page indicate areas of potential interest in this case which both
examiners should consider, along with any other areas they feel appropriate. Examiners must
agree the issues that a candidate should address to achieve a Satisfactory award for each skill
and record these on the calibration sheet provided. Examiners should also agree the criteria for
an Unsatisfactory award at each skill.

Continued on next page…

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INFORMATION FOR THE EXAMINERS Scenario N°

Problem: Goitre
Candidate’s role: Medical doctor on call.
Patient’s name: Mrs XX aged 33

Examiners are reminded that the boxes below indicate areas of potential interest, but are not intended as
absolute determiners of Satisfactory performance. It is for the Examiners to agree and record the specific
criteria they will assess the candidate on during the calibration process.

Clinical skill Key issues

Clinical Note the history of neck swelling and the family history of thyroid disease.
Communication Enquire about symptoms of disturbed thyroid function.
Skills (C)

Physical Examine the neck.

Examination (A) Examine for signs of overactive and underactive thyroid gland

Clinical Identify that the swelling in the neck is a smoothly enlarged thyroid gland.
Judgement Conclude that the patient is clinically euthyroid.
(E)

Managing Confirm to the patient that her thyroid gland does seem enlarged but
Patients’ reassure that the gland seems to be working normally.
Concerns (F)

Identifying Identify the smooth and symmetrical thyroid enlargement.

Physical Signs (B) Note absence of bruit.
Confirm clinical euthyroid state.

Differential Probable Diagnosis:

Diagnosis (D) →Early Hashimoto’s thyroiditis.

Plausible alternative diagnoses:

→Early multinodular goitre.

Maintaining
Patient Welfare See marksheet
(G)