PACES 2014 June Diet, Singapore

Station 4
The task was to speak to a Mr P Loh who the son of my patient Mr J Loh. Mr J Loh had been admitted to hospital with severe pneumonia. He had been having symptoms about 1 week ago, consulted a GP and was given antibiotics. He completed about 2 days worth of antibiotics and stopped because it gave him diarrhoea. When his son visited him a week later, he was noted to be drowsy and had shortness of breath. On admission to the hospital he had a right upper lobe pneumonia with type 2 respiratory failure. He was already given a trial of NIV. The task required me to (1) update Mr P Loh (2) explore the patient's premorbid and (3) discuss resuscitation status.

Seemed like a fairly straightforward case. For some reason I miscalculated the time and ended up being truncated abruptly in the middle of my summary section. I found out that the patient was a previous chronic smoker, likely COPD, had good functional capacity being ADL independent and community ambulant, and this was his first admission. I proposed intubation should the patient deteriorate further. The surrogate seemed to have many questions, asking about the risks and benefits of intubation, and there did not seem to be a definite conclusion. During the questioning, the examiner seemed to ask questions that were directed at leading me away from planning to go ahead with intubation. So, what if the son decides that he does not want intubation? What if there are not enough ICU beds? I held my ground and explained the necessary medical decision making process under the principles of beneficience. The examiner also asked me if I knew of any legislative ruling which may apply should the patient's son insist on max ward management. I was stumped at that. Am not sure if she was refering to the mental capacity act.

Station 5A
25 year old female, on OCPs, came in with monocular blurring of vision which has since resolved after 30 minutes.

When I saw blurring of vision my heart sank. FUNDOSCOPY. This will certainly be the end of my PACES. Had a few differentials and went in. Met Prof Raja (!!!) and some other UK examiner. History sounded like amarousis faugax. Bravely offered to do a fundoscopy in light that there was one sitting on the table next to me but was saved when the examiner said IT IS NORMAL. Weird also because I was going to allocate a significant amount of time to it. No clinical findings on examination - screening cranial nerves, pronator drift, UL and LL power and auscultated the carotids. No swollen lower limbs either. The only thing I left out was auscultation of the precordium, which I should have done on hindsight. I had little time left so I explained the problem being that of a nerve problem (DDX being AF vs optic neuritis) which did not require admission (low ABCD2 score) and required further investigations. Last question she had for me was, should I stop taking the OCPs? I was not sure about the causality but I told her to stop anyway. Questioning was directed at differential and further evaluation - which I gave amaurosis fugax and optic neuritis as my top differentials. The question I had in my brain was BUT SHE IS SO YOUNG?? I said I would do cardiac evaluation. When asked what I was looking for, I blurted out patent foramen ovale, after which the bell rang.

Station 5B
57 year old female, in your hypertension clinic, comes in with numbness in her fingertips.

This case was weird. Patient had a 3-4 month history of numbness in her finger tips with wrist pain. Wrist pain did not sound inflammatory. On gross inspection there was no obvious arthritic deformities. Medication list revealed that she was on carbimazole and propranolol. According to her, the symptoms started after she was put on these medications. I decided to bite the bullet and examine the neurology of the upper limbs. I was throw off when the biceps jerk demonstrated finger flexion, however there was no brisk triceps. The sensory testing, which I did in a very haphazard way, was in ALL finger tips, and did not conform to median nerve pattern. I FORGOT TO DO THE TINELS TEST :( I also did not do the thyroid exam, although I looked for tremor and also checked the pulse. Questioning was done by the UK examiner this time, and he did not look pleased at all. My differentials were cervical radiculopathy, or peripheral neuropathy related to hypothyroidism. I did not state bilateral carpel tunnel syndrome (another candidate said Tinels test was positive).

Break
As I sat in the 5 minutes waiting for my next station, I could not help but ruminate over the previous cases. Oh whywhywhy did I not do this, why did I say this. Whywhywhy. That went on for about one minute before I snapped out of it to prepare for my next station. Abdominal and respiratory system.

Station 1: Respiratory
Young boy 17 years old with chronic cough.
In the anterior chest I was actually very scared because (1) he was so young OMG what does he have and (2) I did not find anything in the anterior chest wall. I finally found some dullness in the back and concluded it was a right pleural effusion. The diagnosis was clear when the examiners nodded happily once I said it, and the discussion went all the way past Light's criteria, definition of empyema, etiologies, treatment regimens for tuberculosis, when to do pleural biopsy and finally differentials for a transudative effusion.

Station 1: Abdominal examination
Middle aged man with abdominal distension.
Clinical examination revealed spider naevi and a ?duputryens contracture over the right palm (looked a little weird though, like a little bit too off centre). No evidence of decompensation. The liver edge was palpable below the costal margin but the liver span was measured about 9cm. Presented as above, said the liver was not enlarged because the span was 9cm, but the examiner asked me if I was able to feel the liver below the costal margin to which I replied yes. Discussion was on clinical features of decompensation, causes of ascites in the patient, as well as surveillance monitoring for HCC.

Station 2: History taking
Note: This was a total disaster.

The stem was a referral from a GP for a 35 year old female with a known diagnosis of Type 1 DM at age 19 years old, who defaulted treatment for several years, and now returns with poorly controlled DM HbA1c of 10%. The task was to review the poorly controlled DM.

Now in retrospect the case was not that tricky. Well, in the 5 minutes I had outside, I was planning on finding out reasons for non compliance, complications and the works. However, when asked during systems review, the surrogate would reveal that she has this intermittent nausea and vomitting for 8-9 months. I cannot remember what my frame of mind was at that time, but I know that I kept thinking that my focus was on the DM and not so much the nausea and vomitting. As such, I ended up barking up the wrong tree. The questioning was honestly quite painful. I could tell that the examiner was trying very hard to guide me, pushing me for differentials about nausea and vomitting, for which I had not thought much about. After much egging, I finally offered hypocortisolism secondary to autoimmune adrenalitis in association with type 1 DM, as well as autonomic neuropathy. I never got to say gastroparesis before the bell rang. :(

Station 3: Cardiology
This patient presents with chest pain, please evaluate.

This patient had a midline sternotomy so I thought HURRAY valve replacement! Then I saw the CABG scar and felt sad. That said, in the midst of doing the examination, I thought I heard an occasional click. And another click. I wasn't sure, since there was a CABG scar, so I listened very very...very hard. Gritted my teeth and said mitral valve replacement. I was inclined to say aortic valve replacement as well, but the sound in the aortic area was very soft so I let that go. My presentation was very shaky though, because clearly I was not like 100% sure and all my signs were all over the place. The examiners never pushed me for any aortic replacement though, so I guess maybe not. Discussion went on to evaluation for this patient with chest pain, and also advice for warfarin and bridging with LMWH and infective endocarditis prophylaxis prior to dental surgery. Seemed alright.

Station 3: Neurology
This patient presents with feet numbness. Please examine the lower limbs.

When I saw the patient a lightbulb lit up in my head. I remember Yanru telling me about a famous patient in a particular hospital with charcot marie tooth and he is famous for coming for exams. When I saw tall angmoh man and a request for lower limb examination, I was like THIS MUST BE HIM!!!

The patient was sitting on the edge of the bed when I entered. In retrospect, I should have examined his gait first. Instead, I told him to lie down. He had very deformed feet, and also deformed hands on inspection. Many calluses. Paradoxically, the lower limb tone was not flaccid at all. In fact it was more hypertonic than anything. There was however no ankle clonus and reflexes were absent. The was a clear sensory loss of a stocking distribution until the midshin as well as loss of priopioception. I ended off by examining his gait, which he required the aid of a walking stick. I presented a case of peripheral neuropathy of chronic etiology in view of the deformities and marked wasting, for which I offered some differentials. CMT of course was my top differentials (in retrospect the patient was hearing impaired!!! Which is also seen in patients with CMT). I then rattled off a few more, B12 deficiency, alcohol, drug induced...the examiner kept pushing me more and more, and said that I was missing out one common one. At that time I had a mind block. He then asked me how I would investigate, which I answered by saying I would evaluate his fasting glucose for...DIABETES. And then the examiner smiled. The last thing the examiner said was, there is one other thing in his left foot that you have not mentioned...As I looked at his feet for the last time, I said, he has a hallux valgus deformity. The examiner clearly looked unimpressed and said, you do note that he has a missing 2nd toe right...AND THE FINAL BELL RINGS.

Remember this feeling

Capture. Now.