SUMMARY NOTES FROM BOX HILL CLINICAL EXAM DAY, 2013

Notes from Ari Horton

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INTRODUCTION PEARLS Theoretical knowledge is not being tested in this exam Testing application of knowledge Criterion based exam... Reach a certain standard all pass!!!! If you are good you pass Is the candidate good enough to look after my child History and examination - thorough and insightful Synthesis and priorities - mature Investigation and management - 'that' patient Impact on patient and family - life living and more Overall performance – physicianliness No undeserving candidate can pass Logos, Ethos, Pathos Logic ethics emotion Passion performance and panache Reasoning cardio respiratory interaction Discriminator Level of difficulty Enthusiasm realism Apply knowledge to the patient How would you manage this patient For the patient the 3-4 most significant things for the patient Group drugs according to system Verbal and non verbal skills Line of action Show the examiners What you are doing look at them Mature professional analysis How you would manage patient not latest evidence… Investigations grouped and what expect to find and it's implications What interests you in the tests Analyze results do not just read it out If unsure please say so!!!! Do not lie!!!! Do not argue with examiners

Last summary gives lasting impression Record your presentation and review it with a colleague

LONG CASE PEARLS Think like a physician and think like an examiner Give the examiners what they want and what they expect Think like a physician They want you to be safe Rule out red flags Relevant negatives Relevant positive findings Use any opportunity to practice Practice cases not always realistic Do some cases as an examiner for colleagues Do you know your limitations, recognize them and with help manage other specialty conditions? Approach to patient is sympathetic and practical How the illness practically impacts on their life and their family and their prospects Do not spend too much time on the finer detail – how many steps, how they make dinner Know everything and indicate you have asked all the questions but do not spend too much of presentation on any single area Have you recognized what the main problem is for the patient What is the main medical problem in your eyes what do you ink is the main problem with your health? A genuine issue can be that the patient’s main concern differs excessively from the main issue you/examiners

identified Medications list first Genogram Pretty picture of illness trajectory Growth charts with multiple dots and trajectory as per mum! Do not be cocky They know more about examining than you do Full general physical examination and specifically systems that may be affected by their conditions Is there anything else about your health you think I need to know I would normally have … Remain sceptical patients are not always right about their diagnoses Stick to time Answer precisely and directly Don't ask for tests whose results you won't understand Sound as though you are interested in the patient and their management Never belittle patient or their management – it might have been that consultants decision!!! How would the investigation help you

--> would it rule out something important --> would it change management, prognosis or QOL --> would it relieve anxiety and improve outlook Another way of approaching this or another option for treatment would be? Keep the examiners interested Present like a news reader Do not go to fast that they can't keep up with you!! They need to take notes about you Use respectful eye contact Smile Respectful junior colleague Complications of treatment long ago, affect on life, education, friendships Sexual history Do not bully patients about sensitive topics Reasonable to say on first consultation with the patient I felt that it was a sensitive topic Would wait till more rapport and trust between us to delve into this issue further Patients main concern Deal with quickly Prioritize priorities Do not have an inaudible monotone!! Be a professional colleague They want to help you if they interrupt you Answer and move on Candidate won't stop talking vs Tell a story, allow them to ask you questions, when they see you know it they move on! Be aware of the over prepared candidate Rote presentation for any problem Examiner dreads multidisciplinary team Now I wish to discuss bone health - off putting!! Develop your own approach Variety Individuality Own approach to problems Wound in IBD patients pyoderma gangrenosum, necrobiosis lipoidica Malabsorption and nutrition Attempt at interpreting presentations with recurrent symptoms not supported by investigations - drug seeking, loneliness/isolation, psychological distress Intractable problems- realistically every thing has been tried and not likely this patient will change, prospect of losing weight are small Show thought about this patient and Their problems Would I want this person as my registrar or would you want your examiner as your boss

Broad and deep understanding of multisystem issues

LONG CASE PITFALLS Greatest test of maturity as young physicians Common sense approaches to most problems Formulaic doesn't work Serve the examiners a chocolate soufflé Common problems Discriminating information and nourishment Unusual conditions that you haven't heard of.... Catersall TH17 deficiency extraordinary test beyond me Patients extremely expert in their condition They are your guide, haven’t been exposed to this condition before Provenance how constructed guide your experience of the dish Not a medical student Question voracity of the history Asses for inconsistencies and incongruities What they say and what they don't say and what you know If you have a shit patient and poor historian then use it to your advantage Important to mention if the patient doesn't have a good understanding of their disease and the complexities this will result in EXAMINATION Relevance of examination Precision Tailored examination System that you know will have the pathology and examine it thoroughly Integrate all those signs including Subtle Signs Reflect on them Examine the rest of the patient thoroughly Don't be feeble You are the master in control of your destiny Do NOT race through the recounting of the examination findings This was indicative of ... and in this patient interpreted as severe given this and this The grade 3/6 systolic murmur heard loudest at the apex, harsh in nature, associated with a displaced apex beat, can be interpreted as a severe mitral regurgitation in the setting of a dilated cardiomyopathy especially given the mitral click This is something serious given the likely resultant left heart failure and will need intervention, as such I would review regularly and refer to the cardiologists for consideration of a mitral valve repair. Long smoking history and yet no signs of lung disease or ischemic heart disease and continues to run ultra-marathons Drug list is vital - do not forget it Dissect the difficulties of polypahrmacy and drug interactions Previous intolerances and allergies that will impact on patients management in the long term and their prognosis and experience ie an asplenic patient allergic to penicillin Risk of encapsulated organinsms with subpar or alternate prophylaxis

Golden ten minutes Think of forget me nots 30 mins history 20 mins exam 10 mins Golden 10 mins 2 outside room Stand back with a fresh ie on info gathered What is the big picture issues for this patient How do I put them together How do they interrelate Complete the problem list Plot out where the conversation is going to go With the examiners Do not restrict the problem list Synthesize the patients overall issues The patients greatest concern is this... But the problem that is the greatest risk to their health is this And they are not really aware of it And that in itself is a problem The complexity of the problem list Way to deal with 12 problems Introduce the problem – anchored by 1 or 2 words that explains what you think of the problem and how your going to deal with it Write the perfect sentence for each issue and how you’re going to deal with it You have covered it Use your information wisely Too much information than you really need Indicate that you have it all available at your fingertips Modulate your presentation Style Keep the examiners interested Avoid repetition Use varied language Avoid culture of denial Engender rapport and understanding Do not say patient denied They gave no history of There was no suggestion Avoid buzz phrases Be aware of your examiners they are on your side Drive the discussion do not lose control Foresee questions

Wrest control back With maturity comes responsibility Indicate how you would look after the patient in front of you Take ownership Engage them in their care Make it interesting for the patient Be purposeful and confident Wake up and say I deserve To move onto advanced training I am competent in this process Look forward to opportunity to demonstrate this to the examiners We are all nervous Do our best Always look forwards Physicianly skills

SHORT CASE PEARLS Understand what is being tested and why Learn and practice the skills to a level where you can do it timed and in stressful situation Basic clinical skills Not detailed knowledge Approach to patient Examination technique Accuracy Interpretation of findings Discussion of investigations Standard of 3rd yr basic trainee are you ready for advanced training Respectful and fluent manner Elicit the signs Interpret put in context of stem Significance of findings Practice shorts 1 per day Wide variety Practice with study group and assess each other Practice thinking like an examiner Be strict with time Look at marking sheet 7-8mins for ex Rest for questions THROW STEMS at each other Challenge the candidate to run thru exam for a particular stem, given them findings, interpret them, throw questions or tests at them Prepare all body systems Prepare all predictable stems Prepare for unexpected ?video yourself

Calibration Agree of physical findings Agree on expectations Formulate stem Approach to patient not diagnosis Talk about severity of illness and prognosis given physical findings Read stem carefully Remember key facts System vs problem Physically prepare (bag, hand wash) Think about your approach Stock statements about washing hands, introductions and repeating the stem to settle nerves step away from patient for good general examination Assess who has come with them and all objects in the room Move on quickly to what you have been asked to do quickly Be gentle and respectful Systematic Thorough Confident Rough or rude ----> fail Slick examination I'd like to reexamine the left knee reflex as I was unable to elicit it Not certain if absent or just technique Describe finds and try to put them in the context of the stem If things don't fit discuss your uncertainty Approach to problem and not single do If say something incorrect, correct yourself Restate stem and summarize overall impression Systematic presentation Most likely a problem of ataxia rather than weakness Salient findings and negatives to support assertion Problem based assessment Systematic presentation Positive findings Important negatives Not every finding Intents and synthesize as you go Working differential diagnosis How you will differentiate between them

If really confident begin with diagnosis Talk about signs that indicate severity, complications and signs of likely drug side effects Other possibilities would include I would do a WCC because it would aid prognosis and provide evidence of treatment side effects If less confident describe findings with possible dx with pros and cons for each ROSSCO SSS approach Repeat name and remember stem Observations Comment on well/unwellI have to check that in more detail Appropriately lit, undressed Ask them or mum to get ready Systematic exam What am I finding Signs of severity and relevant negatives Think about complications of disease and management as you go Would you like me to go ahead with that Am I ready to shoot I'm ready to present I'd like to summarize Or do I want to see some investigations first Engage examiners in a conversation about the patient you saw Speak slowly and clearly Sound confident, Compassionate and professional Good approach to problem/stem Targeted approach Severity and complications and possible prognosis Analyze any inconsistencies in hypothesis and findings Short case check list

SHORT CASE PITFALLS Confident in clinical medicine Contextual reality physicianly qualities Art science and reasoning Keep cool Listen to introduction Examination style and fluency Professional etiquette Bed side manner Professionalism Line of action Body language General conduct to help patient Circle of action

Focus on centre and scan left to right No back to patient ever Thoughtful examination Think on feet Look for corroborating clinical signs If I had more time I'd like to check in order to classify Synthesise Rarely signs do not add up Correlate physiology and signs Aortic stenosis and high systolic BP Widened Pulse pressure in Aortic Regurgitation, mitral regurg Not incompetence You may be incompetent but the valve is regurgitant Effort tolerance and lung signs (interstitial Lung disease) Diplopia John patten neurological differential diagnosis 2nd Buckles on shoes Difficulty walking AFO Charcot Marie tooth distal wasting, high arch foot, Look at rash and proceed Look at feet and proceed scleroderma Psoriasis, If time permits I'd Like to exam the lungs to look for oesophageal Easy but great discriminators A symptomatic cr 300 Foot drop radiculopathy or neuropathy Neurology Where what and what can you do about it 34yo IBD Necrobiosis lipoidica diabeticorum Foreshortening of fingers and toes Arthritis mutilans Weak hand UMN LMN Is the other hand wasted Is the food wasted Is the sensation intact Asymmetry can be even if systemic

Acoustic neuroma Seventh and eight nerve palsy Splenomegally Sharpen diagnostic skills Mitral regurg Darwin rheumatic In Australia degenerative, ischemic, Facioscapularhumeral dystrophy Proximal>distal Symmetrical/asymmetrical Pay very careful attention to the stem Comfortable and happy with what your doing

A GOOD CANDIDATE The gestalt of a good candidate Convey an impression Have control of how you come across Organized whole Don't play your cards too close to your chest Be open and honest Allow yourself to be examined How you think and how you work rather than what you know How solve this problem for this patient Decisive but also how you arrived at this decision Points for each step of working out Number of options Given his bradycardia I would try avoid a beta blocker But given microalbmuniuria and HTN I would commence an ace inhibitor Apply knowledge to this particular patient NOT style over substance Accurately elicit and Synthesise signs to an appropriate DDx Specifically assessing domains and allocating a score to each domain Accuracy and completeness Impact of illness on patient and family Guarded prognosis social isolation DO NOT BE GENERIC If find mental health issue be prepared to manage it! Depression or anxiety should be assessed appropriately

Huge impact on chronic illness and especially the patients major concern of her compliance long term implications What treatments are you on (not tablets, also inhaled, injected etc) What questions arrive from the case Can this patient go to school Can this patient play with other kids Impact or impinge on biopsychosocial Patients priorities Tailored management plan What investigations am I likely to be shown in this case What are likely questions Structure response in your head What will kill this patient Infection and immunosuppressive Transplant or surgery Sequencing management decisions First I would try then I would consider Behavioral control, cbt, removal of triggers, optimize sleep and nutrition, then try medication Is the patient happy to proceed with the management plan Are they able and safe to administer their own management plan Are they able to move on with their life and move out of home Are they dependent Will they need to be transferred to long term care in future What if parents unable to care for this patient Balanced physicianly person Systematic and target preparation Avoid multidisciplinary management team spiel Analyze medicines Renal failure Concerned of the PPI and risk of nephropathy I do not think he needs the and the risk outweighs the benefits for this patient No confessions – ie. I have never found JVP!!! Never pomposity Try and avoid jargon terms and acronyms Say high resolution CT not HRCT I would want to do a lumbar puncture which is a painful and risky procedure in this patient but i discussed this with the patient and we feel it would allow them to go back to school with confidence Never lie! I should have asked them as it would have provided Sort out chronic issues, optimize, They are pretty comfortable and stable We could consider changing their heart failure management If asked a scenario question give an analytical answer...

CARDIOLOGY MASTERCLASS Plenty of time Don't feel rushed General inspection BP take it! Adjust the bed, appropriate position The Stem Wash hands before entering room Helpful, make you think Symptom or sign Consider the stem in final assessment and summary Comment about symptoms in stem during examination or introduction Introduce self and thank patient (brief/polite) Unwell, breathless, cyanosed BP and auscultatory gap RF delay useful if HT patient Dysmorphic features Hands stigmata and clubbing Fingers and palms Radial pulse RR delay BP Face – dysmorphic features Praecordium Lateral scars and back scars Apex beat Thrills at Apex and base of heart Parasternal impulse Manoeuvrers bell at apex Mitral stenosis Left lateral position then Sit up then lean forward, AR Valsalva manoeuvre Respiratory exam sacral oedema TR pulsatile liver hepatojugular reflex Do not say resting comfortably in bed No signs of heart failure(know them and expand if asked)

CXR comment on heart size, surg clips wires, pacemaker, prosthetic valve, lung fields +\- lateral film ECG rhythm, rate, LVH, BBB Voltage criteria ECHO would help with Dx and severity Quantification of jet sizes Systemic and pulmonary pressures comparison No murmur consider MS, ASD, PHT Cyanotic cong heart disease Eisenmenger's Syndrome Avoid too long a list... Acknowledge mistake try revise dx Practice in clothes and with distractors Cardiology long case Very rare Discussing indications for surgery Qp:Qs > 2:1 Major areas of discussion Obesity, smoking, HT, diabetes, hypercholesterolaemia Renal protection, risk of restenosis Long term redo surgery Chronic disease discussion Anti platelet Management of diuretics Exercise rehab programs Weigh daily What do if breathless Reasons for deterioration anemia arrhythmia compliance with diuretics Defibrillator Left sympathectomy Dabigitran rivaroxiban Meds vs EPS Amiodarone and sotalol Defibrillators for recurrent VF Psychological implications of treatment Anti-tachycardia pacing Indications for valve surgery Replacement vs repair Choice of valve Monitoring how often review Advise patient about exercise and sport Could this patient manage anti coagulation in the future Antibiotic prophylaxis Latest guidelines

Complex cong heart disease with shunts and foreign tissue Beta blockers and Transplant Pulmonary HT Classification Endothelial antagonists Workup prior to treatment Don't confabulate

NEPHROLOGY MASTERCLASS Renal case is common Central, participatory, not relevant – If renal problem is primary or co-primary CKD GN Diabetes HT Classification of CKD Stages and progression Need for dialysis Dialysis vs Transplantation Type Satellite home and nocturnal Automated peritoneal dialysis Residual renal fn Weekly hours Number of years Type of access Complications of access Options at the end If last venous access it is their lifeline and management goal one is vessel protection Weight gains Dry/base weight Reflux nephropathy family surveillance and can skip generations Hypertension hypotension Hyperparathyroidism CKD MBD Nutrition and inflammation Exercise/activity Phosphate binders Vit D 25 OH plus 1,25 OH bit D Epoetin darbapoetin Mircera Statins ACEi ARB When to start dialysis Symptoms biochem fluid status/BP Education Family guilt Cultural factors Donation after cardiac death Donation after brain death

Extended criteria donation Rejection Cell mediated Antibody mediated Transplant JOURNEY Chronic allograft nephropathy Calcineurin inhibitors Recurrence of old disease or new disease History of other grafts Transplant is a supportive mx Part of ESKD management When to return to dialysis or conservative care Protocol biopsies BK virus Depression and social issues Honeymoon period Tacrolimus/cyclosporine IL2 inhibitors Renal toxicity Gum hypertrophy hirsuitism Pred Behaviour change Weight gain MMF Marrow suppression Gut disorders MMF taco and low dose pred Sirolimus everolimus Dyslipidaemia Bactrim PJP prophylaxis Valganciclovir CMV prevention Azathiprone and allopurinol interaction CMV Primary Reactivation BK virus first 6mths HSV EBV post transplant lymphoproliferative disorder ANZDATA Report Third nerve palsy APKD

ABDOMINAL EXAMINATION MASTERCLASS Read instructions carefully Examine like an undergraduate Present like a postgraduate 4 Discuss like a consultant 4-6 Once I knew the patient well I would offer counselling Save sub specialty knowledge for discussion and brownie points 6+ or 7 Approach with confidence and compassion keep them Comfortable thru the exam Ask for specific areas of pain or tenderness General observation Preliminary info Chronic liver disease Renal failure grey ArPKD ADPKD Cirrhosis young KF rings IVC obstruction superior epigastric vein into intercostal veins on sides of abdomen Caput medusae above and below central veinous dilatation around umbilicus Leukonychia Chemotherapy BMT Flat with one pillow Adequate exposure Tell the patient what you want to do

Renal artery Bruits if hard to control BP Extended exam Genitalia Back Left cervical region for node Poly cystic kidney Full flanks Uni/bilateral Scar from nephrectomy ?transplanted kidney Av fistula, tenkoff catheter, renal Bruits over transplanted kidney, recent biopsy mark Prioritize your signs Non-Invasive standard Ix Invasive Ix

RHEUMATOLOGY MASTERCLASS GALS rheumatological screening examination in long case Gait Arms Leg Spine Mobility is issue and function and falls risk

NEUROLOGICAL SHORT CASES – Cranial Nerves Always going to be difficult Task different every time Listen to the lead in and exactly what you've been asked to do Methodological exam primary focus Plus think on your feet and explore further Ataxia + UMN signs --> CN exam would assist in localization and diagnosis Directed to CN first Problems with vision Hearing or speech Directed elsewhere but move to cranial nerves 1 smell mention it will come back to it later Vision 2,3,4,5,6 Acuity time consuming, fundi time consuming Speech and swallowing Lower cranial nerves Expected to use ophthalmoscope appropriately Practice on colleagues Focus on optic disc Right to look at right Left eye to look at left eye Know the patients line of gaze that brings optic disc into vision Line between your eye and their eye to see disc 30degrees laterally Visual field testing Screen with finger wiggle first Map it out with red tip hat pin if defect found screen with both eyes open Exclude homonymus hemianopia and quadrantanopia red pin vital for para central Scotoma in MS Monitor size of physiological blind spot in BIH Bitemporal hemianopia craniopharyngioma, pituitary adenoma Eye movements

Know H diagram but not realistic See Diplopia up or down Work out which muscle is weakest LR 6 SO 4 ALL 3 DDx full or partial 3rd nerve palsy is first Recti are all straight muscles Work in the line of the orbit pointing outwards pull Cover test is only if you can't see what is wrong Diplopia in maximal position, then cover eye Peripheral image from faulty eye if say look left and left eye doesn't look left it is the faulty eye… no need to do cover test Alternating amblyopia Suppressed double vision as long term squint In cover test each eye independent all movements and if h is normal then it is not a muscle defect RAPD Inter nuclear ophthalmaplegia Saccadic horizontal movements slow eye compared to leading eye Parinauds syndrome Limited upgaze Convergence Beware partial third nerve palsy Corneal reflex Pledget good Test cornea not sclera Approach the eye from the side not in field of vision of patient Rest hand on cheek Go in like a crane Good discriminator Forehead affected so LMN lesion Hearing Is it impaired Is the hearing loss virtually complete Occoustic neuromas are fantastic short cases Lovely signs including scars NF 2 vestibular schwannoma Surgery results in complete sensorineural hearing loss plus combinations of ipsilateral Facial weakness Reduced corneal sensation Cerebellar signs Vestibular dysfunction Nystagmus

Lateralisations Right 12th tongue goes to right Palate to left Jaw to right Muscles are pulling jaw inwards so left working unopposed Jaw moves to right Speech Listen and decide Dysphasia table Broca Wernickes Global Cerebellar speech Mary had a little lamb it's fleece was white as snow Dysphonia Laryngeal palsy Bovine cough hough not cough Avoid foot in mouth disorder dont say dipshit stuff! LMN lesion I think it is Multiple sclerosis!

NEUROLOGICAL SHORT CASES – Peripheral Nerves Always in exam Great discriminator Symmetry is your friend Position is comfortable for you and for patient Test side to side Brachioradialis is same tract as biceps so if get brachioradialis but not biceps then just say UL reflexes normal Myotonic dystrophy Know what looking for Pattern recognition Neuro exam is always easier if you know what to look for If not systematic exam Do not faff – Purposeful movements 5,6 root, axillary nerve and deltoid C8, T1 lower brachial plexus Power MRC grading system Beware of antalgia pain restricts movement and makes power look incorrect Reflex Absent or present (cannot say absent unless jaw clench or clasp hands, pull/relax) Gendrassic reinforcement manoeuvre Hit reflex in the 6-7 milliseconds after motor potentiation goes down spine If missing reflex must explain

Pathologically brisk - need accompanying findings Sustained clonus or babinski is abnormal Brisk reflex with weakness or asymmetry is abnormal Pathologically depressed reflex or increased reflex Reflexes 1/2 Ankle 3/4 knee 5/6 biceps 7/8 triceps Light touch initial assessment of sensory deficit with cotton pledget Testing hypothesis Start from abnormal area and move towards normal area Teach on sternum first Say yes each time I touch you Causes of foot drop L5 root lesion Common perineal nerve lesion 1st/2nd toes is sensory distribution of common perineal nerve lesion If not look at L5 dermatome Fuzzy borders proximal nerve lesion 4-5cm unclear (C5 nerve root lesion) Crisp borders very distal nerve lesion 1-2mm border/crossover (distal finger nerve) Peripheral neuropathy Small fibers pain and temp first Large fibers vibration and proprioception is best Tap musically on my hand Quick screen to rule out Cerebellar rather than heel shin test Acquired peripheral neuropathy Myotonic dystrophy Muscular dystrophy CMT Wernicke deficit is acute Brocas stay chronically Sacral Stand on L5 Stamp on S1 Sit on S3 Shit on S4

RESPIRATORY EXAM MASTERCLASS We are not trying to trick you Enjoy if candidate does cases well Don't let it derail you Don’t let suggestions confuse you Positioning of the patient Bed head at 45 degrees top off towel on for modesty Scars Paradoxical abdo movements Cushingoid from steroids Spine for restriction Altered voice Asymmetric chest expansion Local pathology Breathlessness Provisional diagnosis and differentials Asterixis may take 45 sec (don’t look for 2 secs) Clubbing – yes or no Don't look for HPOA if not clubbed Position of trachea IMPORTANT (changes rest of exam) Warn It may be uncomfortable before you check (if pt surprised by it, lose marks) Cervical lymphadenopathy from behind Look for vocal resonance or fremitus but not both, sometimes neither MUST PERCUSS WELL AUSCULTATION areas represent each lobe Back upper lobe, Front Lower lobe, Middle Lobe and Lingulae are in axillae Say Normal/bronchial/reduced Crackles (fine ILD, medium LVF or coarse bronchiectasis or airway secretions) If clears with cough just airway secretions DO NOT USE CREPITATIONS, RONCHI or RALES Bilateral or unilateral How do you know difference between collapse vs consolidation vs pleural effusion? CXR is always of patient don't do beginning spiel But look at date Does CXR fit with your signs and findings and diagnosis (only important factor is TIMING – ie. Not current state of patient) ALWAYS AFTER CXR may ask HRCT chest Lung function tests Know your patterns Obstruction Restriction Mixed

Can't find FEV1 FVC FER DLCO Know what your looking for TSANZ Austin Spirometry How to interpret it David johns Keep your descriptions common Thick section CT – masses, cancer, consolidation HRCT Bronchiectasis or Pulm Fibrosis