PACES 8

Professor Izham Cheong, FRCPDepartment of MedicineUNIVERSITI KEBANGSAAN MALAYSIA

“Learning without thinking is useless. Thinking without learning is dangerous”

Confucious

WE’VE DONE IT AGAIN IN KOTA KINABALU

The PACES is coming round the corner again. Singapore will host it in June and Kuala Lumpur will do it in August. It was therefore a great pleasure to be asked to do a MOCK for the candidates in Sabah. We had a great time during the “clash-of-minds” of the short cases, history-taking and counseling sessions. The enthusiasm of the students brought out my best and made the tiring trip worth every moment I was there. The open expressions of gratitude on the final day was overwhelming (unfortunately I can’t say the same for many other doctors I’ve taught before!!). I hope my little effort will be enough to make the difference for some of them during the real thing soon. Many thanks to Dr Timothy who made all the arrangement. I enjoyed the hospitality very much. The PACES is not an easy examination by any measure but I’m confident you all are making the right preparation for it. Good clinical technique is a MUST, we hope you will pick up the signs, and with a little bit of oratory skill and a whole lot of “BLUFF-ALOGY”, I’m sure success will eventually come your way.Thank you for the being my students. The pleasure was all mine.

Station 1: Respiratory

This patient has exertional dyspnea.Please examine her chest.

1.What is the diagnosis?

2.What is the likely cause?

3.Can you ask her three questions that can support you diagnosis?

Diffuse lung fibrosis

Progressive systemic sclerosiswith lung fibrosis

Any Raynaud’s phenomenon?Any dysphagia?Any stiffness/tightness of the fingers?

Station1: AbdomenPlease examine this patient’s abdomen

You will have no problem detecting thehepatosplenomegaly without ascites.

Go through the motion of looking for stigmata of chronic liver disease, lympho-proliferative disease (nodes for lymphoma and CLL), myeloproliferative disease (anaemia, bleeding tendencies, sternal tenderness).

You should notice by now that the patient is hyperpigmented and has prominent forehead and cheek bone.

1.What is the diagnosis?

2.List three other features of this condition.

Thalassaemia with transfusion hemosiderosis

Diabetes mellitusArthropathyCardiac failure

Station 2: History TakingYou are the medical officer in the Gastroenterology Clinic.Please read the letter from the patient’s general practitioner.

6th May 2002Dear Doctor,RE: Mr. K RajendranThank you for seeing this 27 year old Indian studentwith a persistent “boil” in the perianal region. He hasjust returned from Australia where he is enrolled asa master student in the University of Sydney.He presented with chronic diarrhea 3 years ago and was diagnosed to be suffering from “non-specific-colitis”following investigation at the University Hospital. He hasremained well on sulphasalazine.His present problem started 2 months ago during thefinal semester of his study. He has seen his GP in Sydneymany times and has been advised to return home forfurther treatment.I shall be grateful if you can see him and advise on the further management.Thank you.Dr. HC Lee (MBBS)

Please take a history from the patient and prepare to discuss the problems and yourfurther management.

You have 14 minutes until the patient leaves the room, followed by 1 minute for reflection, before discussion with the examiners.

You are not required to examine the patient.

Begin by introducing yourself to the patient and then explaining to him the reason for the interview. Begin by asking him to tell you about the circumstances leading to the diagnosis of his “non-specific colitis” 3 years earlier. Ask for extra-intestinal symptoms that may support the diagnosis of inflammatory bowel disease (Crohn’s disease or UC). Determine any relapse over the same period. Clarify on his medications for the colitis. This will allow you to “break the ice” with the patient, to assess the “activity” of his colitis and more importantly, to determine whether his present problem is related to the underlying pathology.

Go on now to ask him for more information about his perianal boil – when, where, discharges, pain, blood, tenesmus, incontinence, what has been done – antibiotic, investigations in Sydney eg sinogram or fistulogram etc. Has it affected his studies and social life?

Does he think that his colitis is active presently? How many motions per day? Are the stool well formed or otherwise. Any mucus or blood? Ask some direct questions of extra-intestinal complications of IBD – arthritis, backaches, red-eyes, jaundice.

Turn you attention now to other possible causes of perianal boils. Always consider the possibility of gay bowel syndrome. Be sensitive otherwise you will not get the truth! A good approach is to tell the patient that you ask these personal questions of every patient as a routine because it can have a direct bearing on the diagnosis and treatment. Please show appropriate facial and body languages!! Any recent travels?

Quickly go into the psychosocial aspects aspect of the case now. It is particularly relevant in all chronic illness. Will he continue with his studies in Sydney? What family support has he got? Does he support anyone in the family. Is he married? What is the financial state of the family? Does he feel depress with his chronic ailment. If he can’t continue with his studies, what other options has he got? AND many more……….(This part of “doctoring” is poorly developed in local doctors - technically sound but emotionally void!!).

Always keep aside 2-3 minutes at the end of the interview to tell you patient what youthink is the present problem and what further investigations you plan to carry out to confirm or refute it. Sharing your opinion at this stage with the patient is not only reassuring but often therapeutic for the patient. If you fail to do so, you have not fulfilled the patient’s expectation. Most examiners would like to see this important quality of a doctor clearly demonstrated during the interview.

Finally ask if he has any extra information he wishes to share with you. Are there any other questions he would like to ask? Any other clarification?

Thank the patient and usher him out to the door.

Reflect for a minute and then turn to face the music!! Take a cue from a battle-scarred examiner here. Look confident and in control. Don’t wait to be asked but fire the opening- shot by summarizing and identifying the patient’s problem to lay the ground-work for the subsequent discussion.

“THE ART OF BEING WISE IS THE ART OF KNOWING WHAT TO OVER LOOK”

AS WISE AS AN OWL

Station 3: CVS

1.Examine the patient’s heart.The patient has a prosthetic mitral valve (metallic1st HS, normal 2nd HS) [Aortic valve prostheses givenormal 1st HS and metallic 2nd HS; In aortic and mitralvalve replacment, both 1st and 2nd HS will be metallic)).

Porcine and cadeveric heterografts do not cause metallicclicks.

2.What are the different types of prosthetic valves?

2.What are the complications of prosthetic valves?

3.Which patient should receive a bioprosthetic valve?

Mechanical valves The Starr-Edwards valve (caged-ball device with higher incidence of haemolysis) The Bjork-Shiley pivoted single-tilting disc valve (lower incidence of haemolysis) The St Jude valve which is a double-tilting disc valveXenografts Porcine valves Pericardial valves mounted on a frameHomografts These are cadaveric aortic and pulmonaric valves

ThromboembolismValve dysfunction – leakage, dishiscence and obstructonBleeding due to anticoagulantsHaemolysisInfective endocarditisStructural dysfunction – fracture, poppet escape, cuspal tear, calcificationNon-structural dysfunction – paravalvular leak, suture/tissue entrapment, noise

Patients unable to take anticoagulantsPatients not expected to live longer than the predicted lifespan of the prosthesisPatients > 70 years (particularly in aortic valve replacement)Woman in the childbearing age (to avoid the risk of warfarin therapy)

Station 3: CNSThis 65-year-old man has difficulty walking and poor vision 1/12.Please examine him.

1.Introduce yourself and then get the patient to walk. Observe the gait. Very often the diagnosis is apparent.

2.Comment on the gait. (click on LINK button) What do you suspect can be the reason for such a gait?

3.How would you clinically differentiate between the two possibilities

The patient is very unsteady on his feet dueto ataxia. With assistance, he is able tostumble forward but tended to fall. HisRhomberg’s test is positive.A positive Rhomberg’s test indicates that he hasEITHER sensory ataxia (e.g. peripheral neuropathy)or posterior column disease (e.g. tabes dorsalis)

Click for answer

Sensory and posterior column ataxia canbe differentiated by examining position and vibration sense starting in the big toes and then proceeding upwards through the ankles and knees. In posterior column disease, both will be loss/impaired in all levels of the joints whereas in peripheral neuropathy they will be loss only up to the level of the peripheral neuropathy. Joint position and vibration proximally will be intact.

It turned out that this patient has sensoryataxia. He has “stocking-like” neuropathyto the level of the ankles.

This is a picture of his arm and fundus.

4.What is the likely underlying cause of his peripheral neuropathy?

5.How can you diagnose this condition?

Waldenstrom macroglobulinaemia

Demonstration of a M-band in proteinimmunoelectrophoresis

Bone marrow

Proprioceptionat the bigtoe

Proprioceptionat theankle

Proprioceptionat theknee

Station 4: Communication Skills and EthicsYou are the medical officer on the ward.You are about to see Encik Ahmad.Please read the scenario below. When thebell sounds, enter the room to begin the consultation.

Encik Ahmad is a retired senior governmentofficer. He presented two weeks ago with haemoptysis and weight loss. CXR showed a mass lesion in the right upper lobe. Subsequent investigations confirmed he has small cell CA lung which is inoperable.

Your task is to explain to the patient ofhis lung cancer, the options for treatment, The possible side-effects of treatment and the survival prognosis.

You have 14 minutes until the patient leaves the room, followed by I minute for reflection before the discussion with the examiners.

You are not required to examine the patient.

This is a sad, frightening and emotional experience for the patient. No one is ever prepared for DEATH. Please be sensitive, and show the appropriate facial and body languages.

Begin by introducing yourself to the patient explaining clearly the reasons for the consultation today. Ask the patient if he wishes to have his family along today otherwise you will arrange to meet them separately.

We have been doing some investigations for your “bloody spits” and I’ve got some bad news to tell you. The bronchoscope examination and subsequent analysis of the tissue specimens we took showed that you have cancer of the right lung. The Xrays have also confirmed that your cancer is quite advance and inoperable. You should pause at this stage to allow the patient to compose himself before continuing with the consultation.

Are there any question you wish to ask me at this stage? How did I get cancer? What type of cancer do I have? Why am I inoperable? How can my type be treated? How long more will I live? You will respond appropriately.

Continue now by expressing how sorry you are to learn of his cancer. Explain to him that there has been many new advances in the treatment of lung cancers in the last few years and that you are optimistic that some of these new treatment will be made available locally for him. Continue by briefly explaining to the patient that there are a few types of lung cancers and most of them are related to heavy smoking in the past (as in the patient). In you case you have the type we call small-cell CA. The good news about this type of cancer is that it is quite responsive to chemotherapy even when they are advance and inoperable.My consultant and I have discussed your problem and we have decided that you will be best treated with a combination of……….. (I hope you know what is the recommended regimen otherwise you can’t counsel the paptient!!).

Some patients have had prolonged survival with this combination and we hope it will alsowork equally well in your case. However, I must warn you that there are some nasty side-effects with these drugs because they are so powerful. This may include going bald, multiple ulcers in your mouth, diarrhea, loss of appetite, nausea and vomiting, and higher risk for infection (because they suppress your wide cells and bone marrow). Fortunately, we have a lot of experience with these drugs and by careful titration of the dose, we seem to have avoided many of these problems in the past.

Doctor, I read that some lung cancers can be treated by radiotherapy? What about mine?Answer any queries to the best of your knowledge. In the event you are stuck because you lack the knowledge, don’t bluff or evade the questions. That will be FATAL because the examiners are also listening! Just tell the patient you need to check on the answer (books or consultation) before getting back to him.

“HE WHO ADMIT TO HIS IGNORANCE SHOWS IT ONCE, HE WHO HIDES IT SHOWS IT MANY TIMES”- in this case it may also be expensive too!!

Can I ask you for some information of your family. Is his wife alive and well? How many children has he got? Does any of the children stay with him. Do you have any existing financial commitment? Does his extended family and close friends know of his illness? Is he getting any emotional support from the neighborhood mosque? Is the family financially sound? Where do you stay? etc etc. (please don’t under stress these psychosocial aspect of terminally ill patients as no where else in the world emphasizes these aspects more than those trained in UK- in case you have forgotten, you should be reminded that the MRCP is a UK examination!!). How do you feel about your cancer? Is the family well taken care of if the treatment fails?

In the last few minutes of the consultation ask if he has any more questions. If no, explain to the patient the treatment schedule for chemotherapy. Reassure him that he will be supervised regularly by your team during the whole period. Tell him too that you will be happy to see any of his family members if they wish to seek further clarification of his illness and treatment.

Station 5Skin Examine these skin lesions.

1.What is the diagnosis?

2.What is the significance of these lesions to the physician?

Multiples lentigines

Look out for:a.Peutz Jeghers syndrome (usually around the lips)b.LEOPARD syndrome (lentigines, ECG abnormalities [conduction defects], ocular hypertelorism, pulmonary or aortic stenosis, abnormal genetalia [hypospadia, cryptochirdism]mental retardation, deafness)

c.Lentigines are also seen in association with cardiac myxomas and have been described in two syndromes whose findings overlap: LAMB (lentigines, atrial myxomas, mucocutaneous myxomas, and blue nevi) syndrome and NAME [nevus, atrial myxoma, myxoid neurofibroma, and ephelides (freckles)] syndrome. These patients can also have evidence of endocrine overactivity in the form of Cushing's syndrome, acromegaly, or sexual precocity (Carney’s complex).

Station 5Locomotor

Examine this patient’s hands.

You should not have problem recognizing that thepatient has tophaceous gout.

Proceed by examining the helices of the ears, olecranon bursae and Archilles tendons for tophi.Examine the feet particularly the 1st metatarsal joints.

Look for the sallow face of chronic renal failure. If present check the forearm for an AV fistula.

Cushingn’s features are common due to steroid use and should be noted if present.

Station 5Eye

1.Describe your findings. What is the diagnosis?

2.Can you suggest three causes of this finding?

3.What is the differential diagnosis?

There are mulitple patches of haemorrhagesand some exudates confined to the outer and upper quardrant of the retina.Some of the veins are dilated and tortous. The disc is normal.This is branch retinal vein thrombosis.

Multiple myelomaWaldenstrom’s macroglobulinaemiaHyperosmolar non-ketotic diabetic coma

Retinal vasculitis

Station 5Endocrine

This patient has a murmur in the heart.

1.What is the diagnosis?

2.What is likely reason for the murmur?

Acromegaly (if you can’t spot the diagnosis immediately, you should NOT be taking the MRCP!)List out quickly all the positive signs present – NO hiccups allowed!Proceed to look for a bitemporal visual field defect.Look out for surgical scars – transfrontal hypophysectomy.Look for evidence of MEN 1 (ask for history of renal stone [hyperparathyroidism]; peptic ulcer [gastrinoma];diarrhoea [ViPoma]; hypoglycaemia attacks [insulinoma];attacks of asthma and facial flushes [carcinoid tumor])Quickly look for features (symptoms or signs) ofhypopituitarism due to damage to the gland (by the tumoror surgery or radiation therapy)

Atrial myxoma. Its diagnosis should raise the possibilityof Carney’s complex which is an inherited autosomal dominant disease of multicentric tumors I many organsincluding pigmented nodular adrenal dysplasia (causingCushing’s syndrome, myxoid fibroadenomas of thebreast, testicular tomors, and GH-secreting pituitaryadenomas.