AMC Handbook of Clinical Assessment PDF

Table of Contents Foreword — Joanna M Flynn ix Preface — Roger J Pepperell x Contributors...

Table of Contents Foreword — Joanna M Flynn ix Preface — Roger J Pepperell x Contributors xi Editorial Committee Additional Contributors Acknowledgements xvii Introduction — Vernon C Marshall 1 Role of the Australian Medical Council (AMC) — Ian B Frank 9 Construction, Scoring and Validation of Assessments — Neil S Paget 25 The AMC Multidisciplinary Clinical Assessment Task (MCAT) Format 31 — Heather G Alexander How to Use this AMC Handbook of Annotated MCATs — Vernon C Marshall 34 MCAT Format Example: Candidate Information and Tasks, Performance Guidelines 37 001 A cut to the thumb of a 22-year-old man MCAT Candidate Information and Tasks, MCAT Performance Guidelines; 44 Five Principal Categories and Domains 1 CLINICAL COMMUNICATION (C) 45 1-A Communication, Counselling, and Patient Education 45 — Introduction: Alan T Rose ~ MCAT Candidate Information and Tasks 002-021 51-67 ~ MCAT Performance Guidelines 002-021 68-130 CIT PG DETAILS OF MCAT SCENARIOS 002 Advice on breastfeeding versus bottle-feeding for a 28-year-old pregnant woman 53 69 3 Advice on neonatal circumcision for a couple expecting their first child 4 Suspected hearing impairment in a 10-month-old child 53 72 54 75 5 Counselling a family after sudden infant death syndrome (SIDS) 55 77 6 Hair loss in a 38-year-old man 56 79 7 An unusual feeling in the throat in a 30-year-old man 57 81 8 Pain in the testis following mumps in a 25-year-old man 58 84 9 Contraceptive advice for a 24-year-old woman 58 87 10 Rape of a 20-year-old woman 11 Cancer of the colon in a 60-year-old man 59 90 12 Thalassaemia minor in a 22-year-old woman 60 92 61 95 i  CIT PG 13 Pre-pregnancy advice to a 28-year-old woman with previous thromboembolism 62 99 14 Pre-pregnancy advice to a 24-year-old woman with Type 1 diabetes mellitus 62 102 15 An anencephalic fetus diagnosed at 18 weeks gestation in a 25-year-old primigravida 63 105 16 A duodenal ulcer found on endoscopy in a 65-year-old man 64 108 17 Advice on autologous blood transfusion to a 55-year-old man awaiting elective surgery 65 111 18 Advice on stopping smoking to a 30-year-old man 65 115 19 Excessive alcohol consumption in a 45-year-old man 66 121 20 Type 1 diabetes mellitus in a 9-year-old boy 67 125 21 Request for vasectomy from a 36-year-old man 67 129 1-B Case presentations and summaries to Examiner 131 — 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 132-135 2 CLINICAL DIAGNOSIS (D) 137 2-A The Diagnostic Process — History-taking and Problem-Solving 137 — Introduction: Reuben D Glass ~ MCAT Candidate Information and Tasks 030-043 ~ 142 -154 MCAT Performance Guidelines 030-043 155 -195 DETAILS OF MCAT SCENARIOS 30 Jaundice in a breastfed infant 143 156 31 A convulsion in a 14-month-old boy 144 159 32 Loud and disruptive behaviour of a 6-year-old boy 144 161 33 Tremor in a 40-year-old man 145 164 34 Headache in a 35-year-old woman 145 167 35 Lethargy in a 50-year-old woman 146 170 36 Syncope in a 52-year-old man 147 173 37 A painful penile rash in a 23-year-old man 148 177 38 Primary amenorrhoea in an 18-year-old woman 149 180 39 A skin lesion on the cheek of a 50-year-old man 150 182 40 A pigmented mole on the trunk of a 30-year-old woman 151 184 41 An itchy rash on the hands of a 19-year-old woman 152 186 42 Red painful dry hands in a 30-year-old bricklayer 153 189 43 Swelling of both ankles in a 53-year-old woman 154 191 ii  CIT PG 2-B Physical Examination 196 — Introduction: Vernon C Marshall and Barry P McGrath ~ MCAT Candidate Information and Tasks 044-057 218 -23 3 ~ MCAT Performance Guidelines 044-057 234 -29 6 DETAILS OF MCAT SCENARIOS 044 Assessment of a comatose patient 219 235 045 Recent onset of poor distance vision in a 17-year-old male 220 241 046 A painful rash on the trunk of a 45-year-old child-care worker 221 246 047 Acute low back pain and sciatica in a 30-year-old man 222 248 048 Fever and a recent rash in a 30-year-old man 223 252 049 A heart murmur in a 4-year-old boy 224 255 050 A knife wound to the wrist of a 25-year-old man 225 257 051 Multiple skin lesions in a Queensland family 226 264 052 Subcutaneous swelling for assessment 228 274 053 Examination of the knee of a patient with recurrent painful swelling after injury 229 280 054 Assessment of hearing loss, first noted during pregnancy in a 35-year-old woman 230 282 055 Examination of a 20-year-old woman who dislocated her shoulder 6 months ago 231 286 056 Assessment of a groin lump in a 40-year-old man 232 289 057 Eye problems in an aboriginal community 233 293 2-C Choice and Interpretation of Investigations 297 — Introduction: Reuben D Glass and Vernon C Marshall ~ MCAT Candidate Information and Tasks 058-064 312- 319 ~ MCAT Performance Guidelines 058-064 320- 342 DETAILS OF MCAT SCENARIOS 058 Positive test for hepatitis C in a 26-year-old woman 313 321 059 Diagnosis of 'brain death' prior to organ donation 314 325 060 Breast biopsy concerns in a 20-year-old woman with a family history of breast cancer 315 329 061 An elbow injury in an 11-year-old schoolgirl 316 331 062 Sudden onset of chest pain and breathlessness in a 20-year-old woman 317 334 063 Atypical ureteric colic in a 25-year-old man 318 337 064 Investigation for male factor infertility in a 25-year-old man 319 340 iii  CIT PG 2-D The General Consultation 343 — Introduction: Barry P McGrath ~ MCAT Candidate Information and Tasks 065-073 347-354 ~ MCAT Performance Guidelines 065-073 355-396 DETAILS OF MCAT SCENARIOS 065 Acute chest pain in a 60-year-old man 348 356 066 Palpitations and dizziness in a 50-year-old man 349 363 067 Muscle weakness and urinary symptoms in a 60-year-old man 350 368 068 Aches and pains in a 62-year-old man 351 371 069 Lack of energy in a 56-year-old suntanned man 352 374 070 Recent haematemesis in a 50-year-old man 352 377 071 Anaemia in a 28-year-old pregnant woman 353 380 072 Acute vertigo in a 50-year-old man 353 383 073 Urinary frequency in a 60-year-old man 354 394 2-E The Paediatric Consultation 397 — Introduction: Peter J Vine ~ MCAT Candidate Information and Tasks 074-077 401-403 ~ MCAT Performance Guidelines 074-077 404-416 DETAILS OF MCAT SCENARIOS 74 Neonatal jaundice in the first day of life 402 405 75 Immunisation advice to the parent of a 6-week-old baby 402 408 76 Dark urine, facial swelling and irritability in a 5-year-old boy 403 412 77 Fever and sore throat in a 5-year-old boy 403 414 2-F The Obstetric and Gynaecologic Consultation 417 — Introduction: Roger J Pepperell ~ MCAT Candidate Information and Tasks 078-082 419-422 — MCAT Performance Guidelines 078-082 423-435 DETAILS OF MCAT SCENARIOS 78 Breech presentation in labour at 38 weeks in a 25-year-old woman 420 424 79 Vaginal bleeding in a 23-year-old woman 420 427 80 Cessation of periods in a 30-year-old woman on the oral contraceptive pill (OCP) 421 430 081 Positive culture for Group B streptococci (GBS) at 36 weeks of gestation in a 26-year-old woman 421 432 082 Vaginal bleeding after 8 weeks amenorrhoea, in a woman with previous irregular cycles 422 434 2-G The Psychiatric Consultation 436 — Introduction: Frank P Hume ~ MCAT Candidate Information and Tasks 083-089 446-454 ~ MCAT Performance Guidelines 083-089 455-481 iv  CIT Pfi DETAILS OF MCAT SCENARIOS 083 Medication changes for a 35-year-old woman with chronic schizophrenia 447 456 084 Demand for urgent treatment for 'sudden hair loss' from a 29-year-old man 448 459 085 Poor work performance in a 30-year-old female police officer 449 463 086 Lifestyle stress in a 45-year-old man 450 466 087 Binge drinking in a 25-year-old man 452 470 088 Nausea, headache and feeling 'jittery' in a 30-year-old bank clerk 453 474 089 Collapse of a 30-year-old woman on the way to a court attendance 454 478 3 CLINICAL MANAGEMENT (M) 483 3-A Management Objectives, Therapeutics, Prevention and Public Health 483 — Introduction: Alan T Rose, Michael R Kidd and Ronald McCoy ~ MCAT Candidate Information and Tasks 090-100 489- -498 ~ MCAT Performance Guidelines 090-100 499- -536 DETAILS OF MCAT SCENARIOS 090 Acute right sided pain and haematuria in a 25-year-old man 490 500 091 Faecal soiling in a 5-year-old boy 491 503 092 Psoriasis in a 30-year-old man 492 507 093 Temporal arteritis in a 58-year-old woman 493 510 094 Acute idiopathic facial nerve palsy ('Bell Palsy') in a 40-year-old man 494 512 095 Dysuria and urinary frequency in a 40-year-old man 495 519 096 Eclampsia in a 22-year-old primigravida at 38 weeks of gestation 496 522 097 An abnormal glucose tolerance test (GTT) in a 34-year-old primigravida 496 525 098 Bed-wetting by a 5-year-old boy 497 528 099 Acute gout in a 48-year-old man 497 531 100 Request for repeat benzodiazepine prescription from a 25-year-old man 498 534 3-B Clinical Procedures 537 — Introduction: Peter G Devitt and Barry P McGrath ~ MCAT Candidate Information and Tasks 101-104 543- -547 ~ MCAT Performance Guidelines 101-104 548- -563 DETAILS OF MCAT SCENARIOS 101 Resuscitation of a 24-year-old man after head and chest injury 544 549 102 Fluid balance assessment in a 50-year-old patient after abdominal surgery 545 551 103 Evaluation of lung function by spirometry in a 22-year-old man 546 558 104 A suspected fractured clavicle in a 20-year-old man 547 561 V  CIT PG INTEGRATED DIAGNOSIS AND MANAGEMENT (D/M) 565 4-A Clinical Perspective and Priorities 565 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 105-112 570 -577 ~ MCAT Performance Guidelines 105-112 578 -600 DETAILS OF MCAT SCENARIOS 105 Abdominal pain and vaginal bleeding after 9 weeks amenorrhoea, in a 39-year-old woman 571 579 106 Recent insomnia in a 25-year-old man 572 582 107 Dandruff or head lice in a 6-year-old girl? 573 585 108 Recent orchidectomy for a testicular neoplasm in a 28-year-old man 574 587 109 Postnatal fatigue and exhaustion in a 28-year-old woman 575 589 110 Fundus greater than dates in a 26-year-old woman at 30 weeks gestation 575 593 111 Tiredness and anaemia in a 55-year-old woman 576 596 112 Colonoscopy findings in a 24-year-old man with chronic diarrhoea 577 599 4-B Life-threatening Emergencies — Priorities of Treatment 601 — Introduction: Bryan W Yeo ~ MCAT Candidate Information and Tasks 113-118 602- 608 ~ MCAT Performance Guidelines 113-118 609- 627 DETAILS OF MCAT SCENARIOS 113 A severely ill 4-month-old baby girl with fever 603 610 114 A lethargic febrile 2-year-old boy with a rash 604 612 115 Wheezing and breathing difficulty in a 5-year-old girl 605 614 116 Cuts to the wrist of a 25-year-old man 606 618 117 Severe postpartum haemorrhage in a 25-year-old primigravida 607 622 118 Emergency management of a snake-bite in a 20-year-old man 608 625 LEGAL, ETHICAL AND ORGANISATIONAL (LEO) 628 5-A Ethical and Legal Dilemmas 629 — Introduction: Kerry J Breen ~ MCAT Candidate Information and TasKS 119-124 633- 639 ~ MCAT Performance Guidelines 119-124 640- 659 DETAILS OF MCAT SCENARIOS 119 A man requesting disclosure of his wife's medical condition 634 641 120 Obtaining consent for leg amputation in a 35-year-old man after a motor vehicle injury 635 644 121 Several bone fractures in a 9-week-old baby 636 647 VI  CIT PG 122 A parent requesting sterilisation of her intellectually disabled daughter 637 649 123 Blood transfusion consent for a 33-year-old pregnant woman with severe APH at 7 months 638 652 124 End-of-life request from a terminally ill patient 639 655 MCAT TRIAL EXAMINATIONS 661 Preparatory Instructions 661 — Roger J Pepperell 16 Station Trial Assessment ~ MCAT Candidate Information and Tasks T1-T16 664 -678 ~ MCAT Performance Guidelines T1-T16 679 -730 DETAILS OF MCAT TRIAL ASSESSMENTS 125 [T1] Meconium staining of liquor in labour in a 25-year-old primigravida 665 680 126 [T2] A heart murmur in a 5-year-old girl 666 683 127 [T3] Vigorous vomiting by a 3-week-old boy 667 685 128 [T4] Urinary incontinence in a 50-year-old woman 668 688 129 [T5] Migraine in a 30-year-old woman 668 691 130 [T6] Past history of hip dislocation in a 35-year-old man 669 694 131 [T7] Tiredness in a 45-year-old man 670 696 132 [T8] Review of lung function tests in a 65-year-old man with shortness of breath 671 700 133 [T9] Assessment of a 28-year-old primigravida at 34 weeks with fundus less than dates 672 705 134 [T10] Delirium in a 25-year-old man after a burn injury 672 708 135 [T11] Chronic diarrhoea in a 45-year-old man 673 712 136 [T12] Fever, irritability and ear discharge in a 2-year-old boy 674 716 137 [T13] Review of cytology after aspiration of a breast lesion in a 28-year-old woman 675 718 138 [T14] Nocturnal hand discomfort in a 35-year-old schoolteacher 677 721 139 [T15] An attack of asthma in a 25-year-old man 677 724 140 [T16] Preparing a 30-year-old woman with suspected acute appendicitis for surgery 678 728 8 Station Trial Retest Assessment ~ MCAT Candidate Information and Tasks R1-R8 732 -739 ~ MCAT Performance Guidelines R1-R8 740 -765 DETAILS OF MCAT TRIAL RETEST ASSESSMENTS 141 [R1] Intravenous cannula insertion for antibiotic prophylaxis 733 741 142 [R2] Heartburn in a 35-year-old man 734 744 143 [R3] Spontaneous bruising and nosebleed in a 3-year-old boy 735 748 Vii  CIT PG 144 [R4] Nausea and vomiting in the first trimester in a 25-year-old 736 750 primigravida 145 [R5] Visual difficulties in a 50-year-old man 736 753 146 [R6] Cognitive state assessment of a 50-year-old barman 737 756 147 [R7] Jaundice in a 25-year-old man 738 760 148 [R8] Assessment of prominent leg veins in a 38-year-old woman 739 763 INTERACTIVE CLINICAL ASSESSMENT — OTHER METHODS AND OSCE 767 MODIFICATIONS — Peter G Devitt and Heather G Alexander 149 Confusion and delirium after surgery in a 50-year-old man 771 773 150 Postoperative fever in a 45-year-old woman 771 776 151 The 4 station progressive OSCE 779 GLOSSARY OF TERMS AND ABBREVIATIONS 781 EPONYMS 790 APPENDICES 1. AMC Objectives of Medical Education 803 2. AMC Instructions to Standardised Patients and Clinical Examiners 806 3. MCC/AMC Clinical Task Categories; AMC Function/Process; 810 System/Region/Speciality; and Discipline classification MCATs with full Domain listing and AMC Anthology Reference 814 MCATs by Discipline (Condition and page listings only) 843 MCATs by System/Region/Speciality (Condition and page listings only) 847 MCATs by Function/Process (Condition and page listings only) 856 Suggested Additional Groupings of MCATs for self-test trial assessments 862 Guidelines for further reading 863 EPILOGUE 867 INDEX 868 Viii 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. FIGURE iv. History-taking 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. 031 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 032 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 033 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. 034 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 simulated examination conditions. undertaken, exactly as 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 A generic and non-diagnostic summary of the presenting symptom, AND ID physical sign or investigation result in diagnostic-type cases, such as: NUMBER 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. CANDIDATE Under this heading the background information and tasks are given INFORMATIO precisely as they appear in the MCAT examination. N AND Page references to the matching Performance Guidelines are given at TASKS the foot of each Candidate Information and Tasks sheet. YOURTASKS ARE TO: Lists requested tasks for candidates. 035 Performance guidelines follow in similar category and domain groups linked to the preceding scenarios by ID number and page reference. PERFORMANCE GUIDELINES CONDITION AND Principal category and assessment domains in detail; and ID NUMBER 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. EXAMINER These provide the following: INSTRUCTIONS 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. EXPECTATIONS These are clarified for the examiner and match the tasks and the OF CANDIDATE domains. PERFORMANCE KEY ISSUES These are selected from the assessment domains and expectations of candidate performance for each case and highlighted accordingly. CRITICAL ERROR(S) These list significant errors likely to lead to a fail performance. COMMENTARY This discusses and comments further on the condition, highlighting performance standards and common errors. 036 EXAMPLE CASE SCENARIO: The following case scenario exemplifies the formatting for a combined Diagnosis and Management MCAT. MCAT FORMAT EXAMPLE: Sample - 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. The patient injured his left thumb at work an hour ago. He is aged 22 years and works as an orchard labourer and fruit picker. He is right handed. He was pruning fruit trees today and the pruning knife slipped and he cut his left thumb. He was wearing cotton gloves. The knife cut through the glove and cut the thumb as shown in the illustration below. Bleeding was minor and controlled by a pressure dressing, which has been removed for examination. The wound appears as a linear knife cut as shown, the edges of which have sealed after the initial bleeding which has now stopped. YOUR TASKS ARE TO: Examine him and assess the injury. Explain to him the nature of the injury and your recommended management. You may ask other questions of the patient as you proceed with the examination and explanation. Near the end of the eight-minute time allotted for your task, the examiner will ask you one or two questions. CONDITION 001. FIGURE 1. Knife wound to the left thumb The Performance Guidelines for Condition 001 can be found on page 40 037 Sample-Condition 001 Candidate Information and Tasks CANDIDATE ADVICE You should: Prepare and document your responses and how you would approach this task. Test yourself thoroughly after reading the MCAT Candidate Information and Tasks, before proceeding to read the performance guidelines, examiner and patient instructions and commentary which you will find on subsequent pages. Follow a similar process for the other MCATs. The best way to develop proficiency in an MCAT assessment is to work in pairs or as a group. Your colleague reads the performance guidelines and plays the patient/relative, while you read the candidate information and perform the tasks, while another group member takes the role of examiner/observer. SUMMARY OF STUDY TASKS Read the candidate information and task(s), preferably working with a colleague or group. Formulate and document a logical approach for responding to and solving the consultative problem given. Then read the performance guidelines that follow, and note the aims of the station, expectations of your knowledge and performance, key issues and critical errors and other points raised in the commentary. Check for any deficiencies in your performance. Reread the introductions to the section in which the MCAT appears. For this MCAT about a thumb wound, 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. Construct alternative scenarios for other wounds and self-test yourself on these (for example, injuries to radial nerve in the arm, common peroneal nerve in the leg). Revise the Anthology scenarios 113, 113H, 113J and 113K and complete the self-test exercises. 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. Finally, 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. 038  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. MCATs are also grouped into one of the principal disciplines of medicine, obstetrics/gynaecology, paediatrics, psychiatry, surgery if you wish to use the book in this way. MCATs are similarly grouped into the relevant function and process and into system/region/specialty. For these latter groups, MCATs are often listed more than once when they cover more than one system or function. Pace and test yourself through these. Keep practising within a group of your peers until fully familiar with the routine. 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, not just for assessment examinations, but throughout your subsequent career. Vernon C Marshall 039 Sample - Condition 001 MCAT FORMAT EXAMPLE: Performance Guidelines 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. In this instance, the knife cut has severed the two extensor tendons to the thumb. 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, 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, until specifically asked to extend each of the two end joints, which you are unable to do. Sensation is normal. You had a tetanus booster shot about a year ago for a leg graze and were immunised against tetanus as a child. Opening statement: 'Will it be okay for me to go back to work tomorrow with a dressing over it now it's stopped bleeding, Doc?' Other questions to ask: If the candidate/doctor diagnoses tendon injury with normal sensation, you will accept the recommendations for operation, 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). Examiner's questions to candidate: At the end of 6-7 minutes, if the candidate has identified that a tendon injury has occurred, the examiner should ask: 'What are the names of the injured tendons?' (Extensor pollicis longus [EPL] and extensor pollicis brevis [EPB]) and 040  Sample - Condition 001 Performance Guidelines 'Which joint does each tendon act upon?' (Interphalangeal [IP] and metacarpophalangeal [MP] joint respectively). If no tendon injury has been identified just ask: 'If antibiotics are to be given, what would you choose?' (Broad spectrum cover such as one dose of amoxycillin, cephalosporin or other antibiotic). EXPECTATIONS OF CANDIDATE PERFORMANCE Cuts and stabs of various types commonly present to emergency departments. 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. 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. Explanation of treatment would optimally advise preparation for early surgery using local (field) block or general anaesthesia. Antibiotic and tetanus prophylaxis would be appropriate. KEY ISSUES Ability to identify deeper tendon injuries resulting from stabs or cuts. 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. Failure to name the tendons correctly would not necessarily be a fail performance, providing the presence of tendon injury was diagnosed and appropriate advice given in other areas. Failure to mention antibiotic or tetanus prophylaxis would be unsatisfactory, but would not be considered a critical error in the presence of a 'tidy' recent wound; such omission would most likely be corrected with subsequent specialist referral for surgery and anaesthesia. 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. 041 Sample - 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, from radial to ulnar side). These tendons form the margins of the anatomical snuff box as illustrated. The tendons have been severed at the knuckle level of the metacarpophalangeal joint. 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. The digital cutaneous nerves have not been cut and distal sensation is normal apart from tenderness around the cut. 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. 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. EPL is the prime mover and sole extensor of the terminal (interphalangeal) joint. By passing across the metacarpophalangeal (MP) and carpometacarpal (CM) joints of the thumb. EPL can also act as an accessory extensor of these joints. EPL, like other superficial tendons, may be injured by cuts and penetrating injuries. Extensor pollicis brevis (EPB) is the lateral of the two thumb extensors. 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. EPB is the prime mover in extension of the MP joint and an accessory extensor of the CM joint. Cuts around the knuckle of the metacarpophalangeal joint are likely to sever one or both tendons. In this patient, both EPL and EPB have been severed. Abductor pollicis longus (APL). This stout tendon, often multiple or ridged like a stalk of celery, inserts dorsolateral^ into the base of the thumb metacarpal. APL is the prime mover of radial abduction and extension of the thumb at the carpo- metacarpal joint, separating the thumb from the other digits in the plane of the palm. In this patient, radial abduction will be unaffected as APL has not been injured. 042  Sample - Condition 001 Performance Guidelines CONDITION 001. FIGURE 2. Normal Anatomy — Left hand and thumb The Examiner mark sheet for MCAT 001 follows. 043  Candidate ID card sighted Very Satisfactory - PASS Satisfactory - PASS Unsatisfactory - FAIL Very Unsatisfactory - FAIL T X *- KEY ISSUE Choice & Technique of Examination, Organisation and Sequence Covers all essential aspects competently - minimal errors or □ Minor technical faults but examination □ Candidate displays one or more of the following: Serious errors or omissions in technique. CRITICAL ERROR? U) 5 mm) irregular moles, such as this patient exhibits, appearing usually on the trunks of young adults. Lesions with irregular, ill-defined borders, irregular pigmentation, background redness, variable colours — brown, black, tan, pink. Most are stable and do not lead to melanoma, but excision is indicated if any diagnostic concerns. Dysplastic naevus syndrome is diagnosed because of the presence of multiple, large, irregular pigmented naevi, mainly on the trunk. 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); change in shape; change in colour (brown, blue, black, red, white and combinations of these colours); change in surface; change in the border; bleeding or ulceration; and other symptoms (itching). Development of satellite nodules and lymph node involvement are late signs. Differential diagnosis of pigmented skin lesions includes: haemangioma (thrombosed); dermatofibroma (sclerosing haemangioma); pigmented seborrhoeic keratosis; pigmented basal cell carcinoma; junctional and compound benign melanocytic naevi; blue naevi; dysplastic naevi; and lentigines. Management: In this case, the solitary dysplastic naevus may have no significant malignant potential at this stage. However, because of the size of the lesion and the patient's concern, this lesion should be excised. Suspicious pigmented lesions should have complete excisional biopsy, and not be treated by cryotherapy. 185 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, confirm and treat scabies, and to prevent recurrence. Examiner Instructions: The examiner will have instructed the patient as follows: Opening statement 'I want to get rid of this rash on my hands. ' Follow with 'It started about a week ago and I can t stop scratching my hands because of the itch. ' In response to questions the doctor may ask: ~ You have not had anything like this before, ~ No rash or itchiness elsewhere on your body. ~ The itch is intense and made worse by warming your hands, as when washing up in hot water or bathing or showering. ~ The itch is worst at night and interferes with sleep. ~ Your hands have not been in contact with any irritants, chemicals or plants. ~ Your general health is excellent. ~ No past history of any serious illness. ~ No known allergies. ~ No history of mental or behavioural disturbance. ~ No recent travel away from home. ~ No medication except oral contraception. ~ 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. Scratch and rub the backs of your knuckles and between the bases of your fingers. Answer the doctor's questions in a straightforward manner including about the relationship with your boyfriend. Do not reveal this spontaneously. EXPECTATIONS OF CANDIDATE PERFORMANCE Approach to patient. Display interest and intention to deal effectively with the condition. Be nonjudgmental about possible sexual transmission of scabies from boyfriend. Provide reassurance that condition is simply cured and not serious. Compliance with the whole of the treatment regimen should be obtained. History. Identify site and severity of itch and question about sexual activity after other possible sources have been excluded. Confirmation of diagnosis. The candidate may diagnose scabies from illustration and history as given above, but should advise the patient that diagnosis must be confirmed by taking skin scrapings from the lesions for microscopy. 186  041 Performance Guidelines Examiner should intervene at this point by stating 'Please assume that the skin scrapings are positive for scabies, and advise the patient accordingly. ' The examiner should only state this if the candidate has mentioned the need for skin scrapings to diagnose scabies. Patient education and counselling. In this case, the condition is transmitted by close contact during sexual activity. Description of the scabies mite is expected with reassurance that the condition is not serious, although very uncomfortable, and is readily treatable. Patient should advise boyfriend to seek medical advice. Management. ~ 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. Leave permethrin cream or lotion overnight then wash off thoroughly, 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. History — Ability to take an appropriate history including site and severity of pruritus and sexual partner as source of infection. Diagnosis — Should advise microscopy of skin scrapings to facilitate diagnosis. 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. Commentary Scabies is a highly contagious infestation which is spread through close contact including sexual contact. Scabies can affect entire households, especially if overcrowded, although this is now uncommon. It is characterised by widespread inflammatory papules and severe pruritus and it can be endemic among school children and institutionalised older patients. The female scabies mite (illustrated below) burrows just beneath the skin in order to lay her eggs and then dies. The eggs hatch into mites which spread out across the skin and live for about 30 days. A mite antigen in the excreta induces a hypersensitivity rash. 187 CONDITION 041. FIGURE 2. CONDITION 041. FIGURE 3. Scabies mite (Sarcoptes scabiei) Penile scabies Clinical features include intense itching, worse at night and when hands and body are warm (for example, after a shower), with an erythematous papular rash usually on hands and wrists. The rash also can occur in web spaces, on male genitalia as illustrated, on elbows, axillae, feet and ankles, or nipples of females. Diagnosis is confirmed by microscopy of skin scrapings. 188 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. This patient has occupational contact dermatitis secondary to concrete exposure. After 6 minutes, 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, and have been working as a bricklayer/contractor for about a year. Opening statement 'I've got problems with this rash on my hands. ' Following without prompting: Your hands have been itchy and dry for some months now, and are getting worse. The rash is on no other part of the body. You are otherwise healthy and well, with no serious past illnesses. You have no allergies. You are on no medications. State if questioned about the relationship of rash to work: the rash definitely improved significantly after a holiday from work. Your brother has skin problems but you are not sure what type. 189 042 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE History — must elicit occupational history. Diagnosis — should suspect allergic contact dermatitis and its cause in this patient from the history and from the physical findings as illustrated, which involve palmar and dorsal surfaces of both hands. Confirmation of diagnosis is by patch testing by dermatologist (not essential). 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. ~ Pat dry after washing ~ Apply topical corticosteroid cream to gain initial control. Oral prednisolone is reserved for severe cases. ~ Oral antibiotics may be required for secondary infection in severe cases ~ Consider using emollient agents for future prevention. ~ For cement dermatitis, specific measures involve avoiding contact with wet cement: using barrier creams before putting on gloves (do not use barrier creams on damaged skin); using protective gloves when working and washing hands after being exposed to cement. KEY ISSUES Ability to identify the type and cause of the dermatitis. Ability to manage occupational contact dermatitis. Consideration of cement as most likely cause of dermatitis. CRITICAL ERROR Failure to suspect causal work association in diagnosis. COMMENTARY Allergic contact dermatitis is due to a delayed hypersensitivity reaction. While physical appearance of the skin can be similar to other forms of dermatitis, rash site and exposure history are critical for diagnosis, management and prevention. Trigger factors only affect some people. Common trigger factors include cosmetic ingredients including perfumes and preservatives, topical antibiotics, topical anaesthetics, topical antihistamines, plants (rhus. grevillea, primula, poison ivy), metal salts (nickel sulphate, chromâtes — as occur in cement and concrete), dyes, rubber/latex, epoxy resins, glues, acrylates, coral. In cement dermatitis, individuals can become sensitised to chromate salts at any time, even after working with cement for many years. 190  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, knowledge of possible causes and the components of the physical examination necessary to reach a firm provisional diagnosis. 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. 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. ' Provide the following without prompting 'Over the past eight weeks my ankles have been swelling. I usually notice this is worse at the end of each day. They have mostly gone down by the mornings. My ankles have never swelled up before'. Provide the following in answer to appropriate questioning The swelling is the same in both lower legs, there is no discolouration of the skin. There has been no pain in your legs. 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. This passes when you rest. 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). Your heart also seems to race after any strenuous exertion although this settles down after a few minutes. You have not counted your pulse rate but you are sure that it is faster than normal. You have the feeling that it may not be regular at times, but you find it hard to be sure. No associated dizziness or blackouts. No suggestion of a fever, no chills or shakes. No cough or blood in sputum. You have not had any recent chest pain with or without exercise, you may comment that this is why you haven't worried about the other symptoms. If asked about chest pain in the past say ' Four years ago I had a bad pain in the centre of my chest. I was on holidays at the time. The pain lasted about two hours and I felt unwell for a few days afterwards. ' You sleep well, lying flat in bed: you do not snore. 191 Review of general health You consider yourself to be in good health. You have never suffered any serious ill health. You have not had a medical check-up recently. 'After all. my father was 90 when he died'. If asked other specific questions, reply in the negative. You have never had any kidney problems (for example, blood in urine) or liver disease (jaundice). Review of relevant systems Positive responses are confined to the cardiovascular system. In particular, no gastrointestinal symptoms including no rectal bleeding. Other significant information You are very busy at work. You work for a large legal firm as a legal secretary. The only exercise you have these days is when gardening and this does not cause any problems, unless you are digging for more than a short time, then you get 'puffed' You have noticed this over the past six months. Patient profile You are married. Your spouse is well. You have three married children. You smoked 20 cigarettes a day from age of 18 years and stopped a year ago. You drink three glasses of wine daily. You are not taking any medication. You eat a normal, well-balanced diet. Family history Mother died aged 77 years (stroke). Father died aged 90 years. No brothers or sisters. Past medical history No serious illnesses. No operations. No history suggestive of rheumatic fever. Blood pressure has been checked several times in recent years and was always normal. Other instructions Appear calm and not unduly concerned about your swollen ankles. You have attributed them to your age. Be cooperative, but do not disclose all of the cardiovascular symptoms without facilitation, prompting and appropriate questioning by the doctor, as indicated above. You are not worried about heart trouble because you no longer smoke and, apart from the short episode 4 years ago, do not have chest pain. You have never suspected that your various symptoms could be connected and would not have attended without the insistence of your spouse. 192  043 Performance Guidelines EXPECTATIONS OF CANDIDATE PERFORMANCE History This should include a reasonable number of questions detailed in the patient's advice above. Some questions out of each section should be included, but clearly time limitations will influence the choice and number The history must at least cover key questions relating to possible cardiac, hepatic and renal causes for the oedema. Venous thrombosis, causing inferior venacaval obstruction or bilateral lower limb deep venous thrombosis is unlikely but needs to be considered. Possible diagnosis given to patient after history must include cardiac failure as the most likely condition. Other potential causes could also include hepatic and renal disease (consider cirrhosis, nephrotic syndrome or malignancy as most unlikely causes in this patient). If, after five minutes the candidate has not started to discuss with the examiner some of the likely causes for the symptoms, encourage the candidate to do so After five minutes, if the candidate has not already done so, instruct the candidate to tel the patient the working diagnosis, and then ask the examiner for physical findings to confirm this. 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. These should include: ~ temperature; ~ pulse rate and rhythm; ~ blood pressure; ~ jugular venous pulse and pressure; ~ mucous membranes; ~ cardiac examination (apex beat and auscultation); ~ respiratory examination (any reference to effusion, adventitious sounds or rub acceptable); ~ liver, spleen ~ inguinal region and lower limbs (symmetry of oedema, discolouration, tenderness, heat); and ~ urinalysis must be requested or come up some time in the assessment. Candidates are not expected to indicate the investigations required in this station, although candidates may indicate the tests required to confirm the proposed diagnosis. 193 043 Performance Guidelines KEY ISSUES Ability to take an appropriate history. Ability to explain to the patient why she has swollen ankles and shortness of breath. Ability to provide a sensible differential diagnosis. Ability to state precisely what would be sought on physical examination and why. This station assesses the candidate's ability to take a comprehensive, but ordered and concise history in a patient with recent onset of bilateral leg oedema. 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. Congestive heart failure can present in a subtle way with symptoms of right heart failure, such as bilateral leg oedema, which is worse after prolonged standing and reduces with supine rest. As in this case, there is often a coexisting history of left heart failure symptoms, such as exertional dyspnoea. It is very important in a patient with possible congestive heart failure not to be satisfied with this as a complete diagnosis, 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. Heart failure is difficult to define. 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.' A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.' 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. 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, cardiomyopathy). Pressure overload (hypertension, aortic stenosis). Volume overload (aortic regurgitation, mitral regurgitation, ventricular septal defect, high output states). Obstruction to ventricular filling (mitral stenosis). Restriction of ventricular filling (hypertrophic cardiomyopathy, constrictive pericarditis). 194  043 Performance Guidelines In this station the patient presents with important history features of probable ischaemic heart disease and cardiac arrhythmia. The onset of atrial fibrillation is often a precipitant of heart failure, and this is particularly true in patients who are older, have hypertension and/or diabetes, or underlying mitral valve disease. In patients who have stiff (noncompliant) hearts - due to age, left ventricular hypertrophy, hypertension, diabetes, 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. 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. With diastolic dysfunction of the left ventricle, the presentation is usually with breathlessness on exertion and episodes of acute pulmonary oedema. In this patient, the presentation with leg oedema is an indication of right heart failure, which in the great majority of patients is secondary to a longstanding problem with the left heart, the so-called 'backward failure'. CONDITION 043. FIGURE 2. Pitting oedema in CCF 195 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.' Journal of the American Medical Association (1962) LOOK! MOVE! FEEL! LISTEN! MEASURE! COMPARE! INTERPRET! This aide-memoire comprises the seven champions of physical examination. Used in the correct sequence (and remember the above sequence, eyes first and foremost and only then fingers, hands and ears), they form the basis of all physical examination techniques. Whether one is examining the whole patient, a focal region (head and neck, back, chest, abdomen, limbs) or a body system (integument, cardiovascular, respiratory, gastrointestinal, neuroendocrine), an ordered, well practised and logical sequence is essential. Sound technique facilitates accurate findings and diagnostic acumen. Physical examination still matters and, along with a careful history, will confirm the diagnosis in the majority of consultations despite the plethora and utility of available investigations. In preparing themselves to be good noticers and good examiners of physical signs, clinicians should gain practice in: Pattern recognition: the ability to define and group a constellation of features in order to diagnose, for example, shock, hyperthyroidism or cardiac failure. Focused examination of an area or region such as a limb, the neck, the chest or the abdomen. 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. A sound knowledge of clinical anatomy is an essential prerequisite. Examination of multiple sites and areas logically, sequentially and expeditiously to provide global assessment of a body system (cardiovascular, gastrointestinal, etc) A sound knowledge of clinical physiopathology is an essential prerequisite. This introductory segment and the MCATs following provide selected examples of these techniques. Skill development in physical examination is sequential throughout undergraduate medical education and extends into independent and specialist practice. Like the acquisition of any skill, medical practitioners in their attempts to become skilled clinicians must: have a good understanding of correct methodology; assiduously develop the correct techniques; have the right equipment and know how to use it; know the range of normality and what constitutes abnormality; be aware of the limitations of clinical signs, but use adjuvant investigations thoughtfully and selectively; and practise, and practise frequently. 196  2-B Physical Examination Central to correct physical examination, and unique to the health domain, is the manner in which the examiner interacts with the patient. Common problems that are observed in candidates undertaking physical examination include the following: lack of empathy and skill in engaging the patient; Physical examination still matters, and along with a failure to spend time in general inspection of the patient, thus missing careful history, will confirm the diagnosis in the important aspects of pattern recognition; majority of consultations, despite the plethora and causing undue discomfort to the patient; utility of available investingations. incorrect techniques; failure to develop a careful, systematic approach; a slipshod approach, missing important signs along the way; inaccuracy of sign characterisation and of measurements; missing obvious pathology by overlooking physical signs; finding things that are not there; over-interpretation; and inability to provide a succinct, accurate clinical summary. PHYSICAL EXAMINATION — REGIONAL EXAMINATION The integument The skin is the largest body organ. Skin rashes should be assessed as macular, papular, maculopapular, vesicular or pustular, itchy or nonitchy. Rashes are commonly allergic, irritative or infective. Atopic eczema is a blotchy ill-defined red macular rash which can progress to papule and pustule formation. Irritative contact dermatitis can be wet (intertrigo, nappy rash), or dry and associated with hyperkeratosis, lichenification and pigmentation. Infective rashes are legion and range through bacterial (impetigo, acne), fungal, or viral (molluscum contagiosum, herpes simplex and zoster, HIV). Involvement of scalp or nails may occur (psoriasis). The distribution of the rash (e.g. pretibial erythema nodosum) and associated features (e.g. focal skin ischaemia in vasculitis; central clearing in fungal lesions), give important diagnostic clues. SECTION 2-B. FIGURE SECTION 2-B. FIGURE 2. 1. Flexural eczema Acne vulgaris 197 2-B Physical Examination SECTION 2-B. FIGURE 3. SECTION 2-B. FIGURE 4. Molluscum contagiosum Microsporum canis ('ring worm') Focal skin lesions are also of immense variety. In Australia, malignant skin lesions are common, particularly in higher latitudes and in fair-haired and pale-skinned individuals. Basal cell cancers are the most common cancers, and although mostly seen on the face and other exposed parts, can occur anywhere. By contrast squamous cancers are almost always confined to sun exposed areas. Melanomas are the most serious lesions; their incidence is increasing in Australia and in most parts of the world, so picking up dysplastic or premalignant lesions is important. Most focal skin lesions are, however, benign and include benign melanocytic and other naevi, calluses and viral warts. Solar keratoses, seborrhoeic keratoses, dermatofibromas (sclerosing hemangiomas), 'senile' melanocytic and purpuric freckling, and cherry angiomas (Campbell de Morgan spots), are seen with increasing frequency with increasing age. SECTION 2-B. FIGURES 5 AND 6. Neurofibromatosis Type I — von Recklinghausen disease of nerves Note numerous cutaneous neurofibromas (molluscum fibrosum) 198  2-B Physical Examination SECTION 2-B. FIGURES 7 AND 8. SECTION 2-B. FIGURE 9. Portwine stains — cavernous haemangiomas Nodular portwine stain Cutaneous neurofibromas form part of the syndrome of von Recklinghausen disease of nerves (neurofibromatosis). The syndrome is usually readily identified by pattern recognition. Solitary cutaneous neurofibromas are also often found apart from the inherited syndrome. Congenital 'portwine' stains (cavernous haemangiomas) have a classical appearance and may become nodular with age. It is usually possible following a focused and accurate history and examination to classify lesions into clearly benign', 'clearly malignant', and 'suspicious' with the latter two needing appropriately wide excisional biopsy. Subcutaneous lumps These are mostly benign and often merely need accurate diagnosis and reassurance. The diagnostic features of most importance are site, physical characteristics, and relationships of the lump to its surroundings (which includes the regional nodes). Critical features to note are the Ss, Cs, Ts, Fs, and Ps. Site, Size, Shape, Surroundings. Contour, Consistency, Colour, Compressibility, Cough impulse. Tenderness, Temperature, Transillumination. Fluctuation, Fixity, Fields. Pulsation, Percussion. The lump should always be layered' — is it in subcutaneous fat, and if so is it attached to overlying skin, or underlying fascia and musculature? 199 The mobility of subcutaneous lumps in relation to their superficial and deep surroundings is important in picking up infiltrative rather than expansile enlargement. 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, attached to nearby bone or vessel or nerve, in the abdominal parietes or intra-abdominal. Most lipomas, 'sebaceous' and other cysts, ganglia, bursae, lymph node swellings, hernias, 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. Head and neck lumps With neck lumps it is particularly important always first to observe the effects of movement: swallowing, coughing, protruding the tongue, and tensing underlying muscles such as sternomastoid or trapezius. Remember to examine the accessible nasopharynx and oropharynx. The laryngopharynx and oesophagus are not accessible to your examining hands and fingers, but remember the importance of endoscopic evaluation in the diagnosis of occult primary neoplasms presenting as neck lumps. With neck lymph node swellings always keep in mind the possibility of: lymphatic spread from areas outside head and neck (chest and lungs, the abdomen or genitals); and focal presentation of systemic lymphoid pathology. SECTION 2-B. FIGURE 10. SECTION 2-B. FIGURE 11. Hodgkin lymphoma Nodal metastasis from papillary carcinoma thyroid Examination of a cytologic aspirate will often clarify the diagnosis and point the way for further diagnostic tests. For example, squamous neoplastic cells in a neck lymph node point to a potential primary neoplasm of skin, laryngopharynx, oesophagus, or lung, rather than from thyroid or stomach. Cytology may be specific for melanoma. If suggestive of adenocarcinoma, cytology commonly points to a lung, stomach, colon, breast, or testicular origin of the primary. Cytology is particularly useful in diagnosis and classification of lymphomas. Careful application of the above techniques facilitates identification of the common head and neck lumps and their primary pathologies. The most common swellings will involve lymph nodes, thyroid, salivary glands, or developmental lesions (branchial cysts, cystic hygromas, sternomastoid 'tumour'). Rarer lesions include chemodectomas such as carotid body tumours and neurilemmomas. 200  2-B Physical Examination Examination of the hands and wrists This assessment will include structural and functional changes across multiple systems. A logical approach is to think successively of the various tissue layers, checking for structure and function of each. Inspect carefully for deformities, and any abnormalities of skin and nails, then probe deeper. Test active and passive movements of each joint, always checking active movements first. Palpate carefully and carry out clinical testing for vascular insufficiency, musculotendinous disorders, bone and joint problems, and neurologic abnormalities. Common conditions encountered include: Skin and nails: circulatory, neurotropic and occupational changes; a large variety of dermatoses and nail changes; pitting; infective lesions (Osier nodes, etc.); and vasculitis (nailfold capillaries). SECTION 2-B. FIGURES 12 AND 13. Osier nodes in bacterial endocarditis Subcutaneous fasciae: Dupuytren nodularity and contracture, carpal tunnel syndrome. Muscles, tendons and sheaths: Volkmann contracture (long forearm muscles) and short hand muscle contractures (intrinsic-plus deformity); trigger finger (stenosing tenosynovitis), De Quervain tenosynovitis; spontaneous tendon rupture (dropped finger, thumb); and ganglia (dorsal, ventral, digital). Bones and joints: changes of osteoarthritis (Heberden and Boucher nodes, carpometacarpal joint of thumb); rheumatoid arthritis (synovial thickening, rheumatoid nodules, metacarpophalangeal subluxations and ulnar deviation fingers. Z-thumb, swan-neck. boutonnière, mallet finger deformities); and gout. SECTION 2-B. FIGURES 14 AND 15. Hands in rheumatoid arthritis Rheumatoid nodules 201 2-B Physical Examination Nerves: check median, ulnar and radial nerve motor, sensory and autonomic function;! differentiate peripheral nerve lesions from more centrally located cervical nerve root, and| upper or lower brachial plexus lesions. SECTION 2-B. FIGURES 16 AND 17. Testing interossei function Thenar atrophy Vessels: observe for vascular ischaemic digital lesions, palpate pulses, check dominant! arterial supply (Allen test), check for proximal lesions (cervical rib, listen for axillary bruit)! With hand and wrist trauma, check for bone and joint injuries, and local and distal tendonj nerve and vascular effects. Functional assessment: test grip strength in dominant and nondominant hand: testl power, precision, and hook grips and opposition of fingers and thumb. Finally ask patient to perform everyday tasks of using a key, undoing buttons, writing, and combing hair. Remember that any regional examination (for example, of head and neck, abdomen,; chest, limbs) necessarily involves assessment of several systems. A systems-based examination, by contrast, involves examination of several regions. 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. 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. This material is based on the Clinical Skills curriculum for Monash University Faculty of Medicine, Nursing and Health Sciences. 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  2-B Physical Examination ~ 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. Describe and use clinical reasoning skills. Preparing the patient Establish patient's level of communication capacity. Introductions: ~ Set the scene. ~ Explain your status. ~ Exhibit a human interest in the patient. ~ Gain patient permission. Demonstrate professionalism. Show sensitivity to patient's modesty, health status and comfort. 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. Establish what difficulties and discomfort (especially pain) the patient may have before and during the conduct of the physical examination, and avoid causing pain wherever possible. What equipment is needed? Have your own basic set of items to aid in eliciting signs. Items marked with an asterisk are standard requirements for personal use watch with stop watch or second hand.* stethoscope with capacity to detect low frequency (bell) and high frequency (diaphragm) sounds.* pencil torch.* disposable tongue depressors.* measuring tape.* reflex hammer (Queen Square pattern, best with a large-size rubber head).* pins — these must be single use only and must not be hypodermic needles or diabetic lancets. Neurotips are excellent.* cotton wool.* 128 or 256 Hz tuning fork for vibration testing.* Snellen chart for testing visual acuity. mini-mental state examination (MMSE) card. sphygmomanometers will be available in all wards and clinics and other items will also be available for relevant stations, but items starred you should have for personal use. 203 2-B Physical Examination 1. THE NEUROLOGICAL SYSTEM 1.1 Objectives Objectives for a neurological examination Perform a stage-appropriate, technically competent neurological examination, incling ~ mental status ~ speech - gait ~ cranial nerves ~ limbs Localise neurological disorders based on the results of physical examination. Other objectives Demonstrate stage-appropriate knowledge of the selection and use of standard neurological investigations (magnetic resonance imaging [MRI], computed tomography [CT], single proton emission computed tomography [SPECT], positron emission tomography [PET], electroencephalography [EEG], nerve conduction studies [NCS], electromyography j [EMG], lumbar puncture [LP]) based on the results of history and physical examination, 1.2 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, [e.g. 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 1,024 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, bend in centre, then bend tips at right angles to ft a serviceable 2-point discriminator) 1.3 Physical examination 1.3.1 The neurological examination Assessment of mental status ~ level of consciousness ~ attention (e.g. digit span) ~ language (comprehension, repetition, spontaneous speech, naming) ~ memory ~ visuoconstructional ability ~ executional ability ~ MMSE (for scaling) 204  2-B Physical Examination 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, rising from squat or chair. Trendelenburg test Cranial nerve examination involves ~ olfaction (not routinely tested, anosmia usually due to olfactory nerve or bulb injury) ~ vision: acuity, visual fields (red pin), colour vision, fundoscopy SECTION 2-B. FIGURE 18. ~ pupils: shape, size, symmetry, reactivity (light and Trendelenburg test accommodation) ~ eye movements: smooth pursuit (H-shape), diplopia, nystagmus ~ trigeminal: corneal reflex, cutaneous sensation, motor function, jaw jerk ~ facial: facial movements, strength of eye/mouth closure, corneal reflex ~ hearing and balance: whispered voice, otoscopy, tuning fork tests; vertigo; nystagmus ~ palatal: sensation, gag reflex/palatal movement, cough ~ accessory: sternocleidomastoids, trapezius ~ hypoglossal: tongue protrusion/fasciculation SECTION 2-B. FIGURE 19.