Ultimate Finals List - Writtens

1st paper (SBA path +)*
* Picture of ECG: was difficult choices were ectopic (supraventricular or
ventricular), capture or fusion beat
* X-ray pictures:
- ARDS in pancreatitis
- Mantoux test +ve/-ve
- Gram stain: group B strep, campylobacter
- Knee X ray: fractured? compound?
- Lumbar X ray: ank spond
- Hand X ray: rheumatoid hand
* Path pictures (mostly from Utah path site)
- mesothelioma
- pneumonia
- CLL or CML
- adeno/squamous oesophageal ca
- myeloma
- PE
- question on focal segmental glomerulonephritis
* Epidemiology questions: do questions on LAPT lite as these are very
similar and some have been transferred from T/F to SBA format.
* Picture of eyes: bilateral ptosis (hx consistent with myasthenia)
* Diagram of blood levels of antigens/antibodies in HIV (it's in baby Kumar
and Clarke) and ask to label one of the lines (although they ended up
withdrawing this question as wasn't printed well).
* Slide of giardia
* Picture of psoriasis and question surprisingly on pathophysiology of
psoriasis
* Detailed question about high dose/low dose dexamethasone suppression test,
length of test
* Question on gallstones and knowing significance that colour of gallstones
is yellow
* Many questions on interpreting sodium/potassium, ALP, Ca

*2nd paper*
* Do and know all questions from Moodle, 2 came up (question on hyoscine for
dying patient and question on lung function)
* AF management
* Scleritis
* Chronic supparative otitis media
* Pleomorphic adenoma
* CSF changes with viral encephalitis
* Polycythaemia - primary or secondary? Few questions on this.
* Paralytic ileus, causes
* Rx of hyponatremia: water restriction?
* Anal fissure
* Haemorrhoids
* Ulcerative colitis treatment
* Vomiting in adult: pyloric stenosis
* Lateral medullary syndrome
* Headache: cavernous sinus thrombosis
* Acute glomerulonephritis
* Carpal tunnel syndrome: hand pain in man with DM
* 1st thing would do in anaphylactic shock
* Acne treatment
* Woman with sores around mouth
* Breathlessness in GP setting: would give salbutamol?

Ultimate Finals List - Cardiology

Cardiology Stations

• CABG, heard no heart sounds initially, then listened again and again, then thought dextracardia, then got asked what sternotomy scar could indicate
• CABG, aortic valve replacement and systolic murmur, all due to alcoholic liver disease (?) // Gentleman with a very impressive nicotine stained beard! Plus AF, a raised JVP, midline CABG scar, clicking valve replacement and graft scars on his leg. We had to examine, report our findings and then state what drugs we would expect him to be on 
• Cardiology st: Pt looked well. Had midline sternotomy scar and click THUD which I could hear from end of bed. Pt had no other leg or arm scars. I said it was aortic valve replacement and talked about infective endo.Then time was up. I wish there had been time to recite the causes of AF!
• Cardio - prosthetic at S2, midline sternotomy. Asked about how I knew it was aortic. When I would replace the valve. Porcine vs prosthetic
• Cardiovascular- Patient with sternotomy scar. I couldn’t hear a metallic click (in fact he had incredibly quiet heart sounds) and started to panic when I looked for a scar on the upper thigh but couldn’t see one. So I presented and said if it was a CABG I would expect a scar which was not present. At that point the examiner pointed out a scar near the guy’s ankle! It turned out he had had a CABG and valve replacement (biological) and I was asked what valve was most likely to have been replaced and why. I didn’t know and guessed the mitral- wrong! I didn’t mind this station as it all seemed to make sense and the examiner was lovely.
• CVS – Aortic valve replacement, had collapsing pulse, asked for BP, examiner said 160/60 (wide pulse pressure). Auscultation revealed a click at S2, midline sternotomy scar also. Also a diastolic murmur heard with patient sat forwards in expiration. Asked for diagnosis and reasons for my thinking it is aortic regurgitation.
• CVS - Not 100% certain, CABG scar, and ankle scar, loud 2nd sound, but not metallic, I gave CABG and aortic (porcine) valve replacement (examiner said I did really really well). Unable to hear the mitral heart sounds (everyone found this).
• The patient had a large sternotomy scar and metallic sounding S2 and some people also heard a murmur and he had AF. I only mentioned the prosthetic valves and said it was a aortic valve replacement because of the position of the scar and because I heard it loudest in the aortic area. He seemed happy enough with that cos I saw him tick the pass box.

• Mitral valve replacement in a Marfans patient - then asked about JVP waves
• CVS - young afro-Caribbean lady with a midline sternotomy scar - when palpating for her apex beat I could hear the clicking sound of a valve replacement without even my stethoscope! Nice straightforward station - presented my case and gave some differentials as to the type of valve (mitral/aortic etc), examiner asked what else I would consider giving the patient (warfarin with INR between 3-4) and that was about it // Cardio – MVR – mechanical, heard from bedside!! Q’s on likely causes, warfarin

• CV - lady had clubbing and a metallic valve with massive midline sternotomy, which I thought was aortic valve replacement but now I think was pulm secondary to Fallot's. Asked about what I thought she had and why, and complications of valve replacement

• Cardiology – Radial scar with sternotomy scar and mechanical aortic valve!! Patient had a CABG replacement with the radial artery, and an AV replacement. REMEMBER if there is a scar on the radial side and NO pulse use the other hand, many people made the pulse up!!// CARDIO- the lead in was this lady has high cholesterol and hypertension, please do an cardiovascular examination. I had done a specialist module in cardiology so I was pretty confident with my murmurs, however, this lady had no murmurs, the only things I could find were quiet heart sounds in the aortic and pulmonary regions, and a very weak left radial, I presented my findings and was asked about the causes of a weak left radial, I started going through a list of things I had learnt and then I said possibly cardiac catheterisation via the right radial artery for angioplasty/stent insertion, I think that’s what he wanted as he didn’t ask me any more

• Cardio - difficult, very loud systolic murmur and obvious artifical valve sound (? ball and cage) loudest at left sternal edge, no radiation. Pt had massive sternotomy scar which looked like it had been re-opened at least once. Also thought she had a waterhammer pulse. Examiner asked me which valve, we had been told by numerous consultants that it would be either a mitral or an aortic pathology so I guessed aortic. Examiner didn't seem too bothered but asked me to look at her abdomen and arms, covered in what looked like multiple biopsy or cigarette burns - had no idea. Turns out pt was a former IVDU and thus it was tricuspid valve replacement - haven't met anybody else who got it yet, most people said mitral though

• Congenital cyanotic heart disease with a right-left shunt. I was asked about causes of central cyanosis.

• Cardio exam - irregular pulse in thin old man with rheumatoid hands, no peripheral oedema. JVP very elevated. Thrill over mitral valve. Systolic murmur, louder on expiration and leaning forward, radiated to carotids not to axilla. I said it was aortic stenosis, examiner guided me to mitral valve prolapse.
• Patient had AF and mitral prolaspe, I thought it was Aortic stenosis but the examiner was very nice and led me round to describing mitral prolapse. He then asked me about the pathogenesis of mitral regurg and how it caused LVF

• Some thought it was aortic stenosis but others thought it was mitral regurgitation. He had subconjunctival haemorrhage which they also wanted you to note and this tied in with his being on Warfarin

• CVS - AF and aortic stenosis. Causes, investigations and managament of aortic stenosis and asked about pulse deficit in AF

• Cardio – gentleman with a beautiful pansystolic murmur also heard at the apex but NOWHERE else. Almost too good to be true. Anyway he also had a pacemaker so had to discuss reasons why – big MI I suggested as likely although he was quite thin and the examiner seemed to enjoy taking a few of us along the HOCM route...
• cardio: excellent station...MR murmur, but apex was undisplaced, examiner asked: give me differentials of just systolic murmurs: MR, VSD, TR, AS, A sclerosis, PS....then he said one investigation: ECHO......y is his JVP raised if he doesn’t have oedema or crackles or other signs of HF....the bell went and I said not sure n he said ur right its difficult to say why!:)
• This was quite straight forward until the questioning. Examiner was again ridiculously nice. The case was mitral regurgitation. The examiner asked me to name the causes (which was fun!). When I said Marfan’s, the examiner asked me what valve is more commonly affected with Marfan’s, I said aortic and he nodded and smiled (see..nice!!!). Then when I said mitral valve prolapse, he also asked me the causes of mitral valve prolapse. He then asked what I would hear with a mitral valve prolapse, I said a mid systolic click and he nodded again. Then he asked me the clinical features of mitral valve prolapse, I think he was getting at signs of left ventricular failure. Then he asked me how many cusps the mitral valve has. I had a moment of madness when I said 2..er no 3....er no 2......about twenty times. He then asked me which cusp more commonly prolapses with mitral valve prolapse, I do believe the answer was anterior (because he told me) but I'm not repeating my answer here because I had a REAL moment of madness!!! Still passed though (despite the examiner laughing in my face).

• My CVS station was AS. Nothing much to say. maybe transoesophageal vs transthroracic echo, and when to have surgery
• Cardiovascular exam: Young Patient with audible clicking and midline sternotomy scar. Ejection systolic murmur radiating to the carotids. Asked about causes of aortic stenosis (marfan’s?)

• Blalock shunts

• Examine pulse, JVP, precordium of Harvey, mitral stenosis & tricuspid regurg // With Harvey, we were told that 'the patient has ankle oedema and bibasal crackles, please examine his precordium' .the murmur was pansystolic, radiating to axilla and was associated with S3 and S4. I said mitral regurg but the examiner kept pressing me saying 'but it can't just be mitral regurg, what is it?' I didn't understand and didn't get the answer, but after my time was up I asked what he meant and the answer he wanted was biventricular failure. causes of mitral regurgitation
• Harvey – cardiac murmur simulator – told to inspect and auscultate the precordium only without talking and then to present our findings. Was mitral regurgitation. Displaced apex beat, Pansystolic murmur @ apex radiating to axilla – s1 obliterated, s3 present giving short diastolic sound. Normal splitting in Pulmonary area, Normal in Aortic area and Tricuspid regurgitation at the tricuspid region - Asked Dx (chronic MR with TR due to R sided dilation). Ask what would do – look for signs RH Failure and do an echo. Asked re causes (I said Rheumatic heart disease, SBE, MV Prolapse and Pap muscle Rupture (although said last would be acute so no displ apex). Told under ECHO that the valve was normal – what is the cause ? No idea I guessed must have been cardiomyopathy. Bell went and as I was leaving I was asked what I would look for on Examination – I said signs of alcohol use?! No idea what he wanted there as I had already mentioned RH failure signs>?
• HARVEY cardiac patient simulator. He had dilated cardiomyopathy but most people said mitral regurgiation.

• CVS - aortic stenosis and mitral regurgitation

• There was a soft ejection systolic murmur which I said was a flow murmur, and he asked the other possible reasons that there could be a flow murmur but I didn't know so he moved on.

• HARVEY (mitral regurg and 3rd heart sound)

• 2 murmurs to trick me! mitral regurg and aortic stenosis both radiating loudly... everywhere, in a really talkative patient making it rather difficult to auscultate the pracordium!

• CVS: VSD

• Tetrallogy of fallot!!

• cardio - was asked to explain my understanding of pulmonary hypertension and right sided heart failure and how this might fit with the murmur

• cardio- great my cardio patient must of been ill so I got a normal medical student! no murmurs after all those hours of learning! however his intro led u to believe it may be hocm, however examination was normal. I was then asked why else he may have collapsed while playing football on a hot summers day. duh dehydration- I forgot to do cap refill!

Ultimate Finals List - History Stations

History Stations

• Take a history of abdo pain...he had renal colic and told me when the bell went his urine was pink! You had to specifically ask if there was blood in the urine/changed colour- otherwise he said it was all normal. 
• ... next station was a follow on...u had to ring up the hospital and on the phone refer ur patient n the doc on the line asks u why u referring and what management plan do u propose...pt had a family history of gout so I said to screen for that, analgesia and further investigations cos he was male // Telephone referral of the case - not sure what they wanted. Finished way early. Looked like an idiot again as asked to speak to the med registrar, so the examiner hiding behind the screen said he was the surgical reg.. oh I said.. no, I want you!! :S // Talk to a Dr on a fake phone, I didn't check who I was talking to - so I gave all of the info to the man who picked up the phone, which could have been anyone- so check! // He then asked you for a differential and what tests you wanted to do. They provided you with urine analysis results and examination results, which confirmed renal stones - no signs of inf, but haematuria, plus tenderness in the loins 

• Cough hx, due to ACEi, so never omit the drug history. Was even asked about why ACEI give you cough and ATR blockers don’t. I discussed a chemical building up in body, normally broken down, some people mentioned bradykinin specifically. I’m not sure how much technical info a patient would want to hear // but u must say at the end that well change ur antihypertensive medication and see if cough improves n if it doesn’t well call u back in for more tests. cos they waned u to discuss a management plan with the pt in the quest // Smoking history with 40 pack year history, hence differentials are ACEi cough and maybe some underlying cancer of the lung. 

• History - diabetes history from knowledgeable patient, asked about complications. Had no differential diagnosis to make. 
• Hx Diabetes Mellitus in 19 yo girl with abdo pain and weight loss

• Splenectomy + pancreatectomy, HCV + HIV etc. 

• Hx - Rheumatoid Arthritis. You get 5 minutes before you start but no info. So just wrote down headings and surreptitiously studied the patient for clues! History taking was fine, but I missed the clue about TB in the family - he didn’t want to go on biologicals because of the risk of TB reactivation. Also re chronic conditions make sure you ask about previous medications patient have been on rather than just the current ones. Presented a differential diagnosis at the end. I also forgot smoking and alcohol till I heard my neighbour ask about it swiftly followed by the next door cubicle too! Questions on how to monitor RA (Esr/ Crp I think) How to diagnose, Dmards, how to protect vs possible Tb reactivation. Cjd from biologicals possibility? Should people with RA have joint replacements? Was straightforward I think. // rheum arthritis, also going through MJ THREADS was important as patients had TB in the past and lots of people didn’t pick that up. Asked to present the hx then asked about differentials, what the drugs were Anti TNF therapy what it was, Ix I would do...I mentioned anti ccp and the examiner seemed very impressed. // History for 20 mins from pt then 10 mins of qus from examiner. Lovely patient with rheum arthritis and kidney failure. Then she went out and I was asked about her meds etc and differentials for her kidney failure. I then asked examiner what the cause of it actually was- he didn't know! So I think as long as you gave a differential, it was fine. // Others histories that came up: stroke, scleroderma examiner asked me about RA so known ur stuff about chronic conditions in particular!! she waned to know all the drugs she was on and their side effects especially steroids and she was also on etanercept so u must say u give it when 2 DMARDS including methotrexate have failed hence don’t forget to ask patient if they’ve been on methotrexate ever like I did!!

• Hx Adhesions 

• History - guy with MS. Needed to elicit that his main problem was urinary dysfunction 

• Peripheral vascular disease in a man who smokes and drinks a lot!!!! Take a good social history because most of his problem list was to do with this and I spent most of my time discussing his drinking and smoking with the examiner as opposed to his PVD. General questions I got asked about PVD was investigations and management (conservative, medical and surgical). In terms of his drinking, she asked me how I would know that he has problem drinking - eye openers, interference with work and social/family life, putting alcohol above all other priorities and if he's ever been admitted into hospital with an alcohol related illness. It turns out he's on iron tablets. You are asked how this relates to his drinking - GI bleeds? 
• hx - 25year history or arterial and venous disease. Discussion of all surgical options and complications of such disease

• SAH history (Know Cushing’s response) 

• Ankle swelling history - patient was on amlodipine 

• Focused history - Chest pain - given a short case scenario of a woman who presented with epigastric pain radiating round both sides 'like a strap' worse when hungry, not on any medication. ECG and cardiac enzymes show no features of MI. - take a history and then answer examiners questions - patient had no CVS symptoms other than the chest pain, but had features suggestive of peptic ulcer disease/GORD. - examiner asked: whats ur differential diagnosis (GORD/PUD/DUD); what further investigations could you do; and what the management would be if patient had PUD (examiner stressed MEDICAL management, didnt want any conservative management! hurried me along!) Overall comment: you don't have very long to do the history so it's important to focus in on the really important things eg. does patient smoke/drink lots of alcohol/use of NSAIDS important if suspecting PUD etc.. Triple therapy for treating H Pylori
• answer questions about PUD and its aetiology/risk factors/diagnosis/management - had to ask if taking any medication over counter cos only then she said NSAIDS and paracetomol.... . // As I was leaving I was asked what it was important to rule out – said cancer and that I should have asked the patient about weight loss. The examiner asked how I would investigate this possibility and I said endoscopy. 

• Patient had rectal bleeding and history of aortic dissection, bladder cancer and angina. Asked about bladder cancer. 
• Hx - Bleeding episodes PR twice yesterday on background of weight loss and increased diarrhoea with mucous in a 59 year old lady with an aunt who has just been diagnosed with colorectal carcinoma.
• ... Writing a referral letter to hospital re: PR bleed - write referral letter to Med Reg on call regarding an urgent referral for this woman – quite tight for time. 

• Hx lady with Marfans - presented with 12 year hx of back pain. Asked diff dx, then why you get lens dislocation and mx of patients with marfans. Examiner was impressed when I said genetic counselling. 

• history - a man with hypothyroid, this was annoying - presenting complaint was just increasing tiredness. eventually got to the fact that he had carpel tunnel as well. // TATT -  History of tiredness...pt is only tired absolutely no other symptom...okay this comes up yearly n we figured that last year she had a change in her diet so you had to ask in particular have you changed ur diet...but this yr when I asked that she said no...so I asked r u a veg and she goes yes for 20 yrs she’s been a veg!!! only other problem was weight gain in past 5 months...so hypothyroid??? but examiner didn’t ask any questions so still not sure what her prob was exactly.
• History station – tiredness. She was a vegetarian, taking vitamin tablets, recent weight gain, slightly depressed. Take a full focused history, and then give differentials (main were anemia, depression and hypothyroidism), then mention to patient you will take some blood tests looking for anemia and thyroid problems and will review her later at GP // Hx - tiredness (vegetarian and swollen glands and sore throat: ?infectious mononucleosis) - told her I would ix her for anaemia, TFTs, EBV, depression hx- tiredness. // Young girl with tiredness for 2 months, some bowel problems, a viral infection a few months ago, vegetarian (but had been all her life). No heat/cold intolerance or menstrual changes. No idea. He asked what bloods I would do at the end and I said Fbc but it wasn’t until I was on the tube home that I thought of TFTs! and to keep a food diary for review

• Some weird skin condition where the patient had what looked like multiple skin tags for a history taking station (not neurofibromatosis - it was really random, but the friend of mine who had this didn't know what either of these things was and still got a distinction, so I don't think they really care that much about you getting the correct diagnosis).

• Had to take a history from a guy who had been vomiting small amounts of blood for the past two days and who had a family history of gastric cancer which he was worried about but no other symptoms. He was taking shed loads of ibuprofen for a sprained ankle. Learning point: make time for the drug history!!!
• ... 10) Referral letter for above patient. This was a strange station, we had to refer the patient we had taken a history from for further investigation, the main issue here was time and getting all the patient details down.
• History station on Gastrointestinal stromal tumour. Viva mainly on upper GI bleeds, differentials, emergency treatment etc.

• Hx – Chronic Pancreatitis – asked differential, problem list, summary etc. + causes, Ix, differences between chronic and acute
• Hx - BPH
• ... Referral for patient above via telephone - examiner kept asking what else??

• Hx - Acute shortness of breath. O/E legs for swelling - signs of tension pneumothorax and P.E management.

• Hx station - Stevens Johnsons syndrome (doesn't really matter what the Dx is - just have to take a thorough Hx and then summarise, give DDx, problem list, management plan)

• History - IHD

• Hx - crohn's disease - Dx, Rx, prognosis, aetiology etc

• Hx - perianal abscess in lady with nonspecific colitis - causes, crohns, diabetes, COPD, Qs on diabetic Cx and Ix of colitis

• My history was really hard as the patient was jaundiced, but had left abdo pain, urinary frequency and a hx of diverticulitis. I couldn't put it together but stuck to my format for the history and it must have gone OK because my score was good in the end

• History of feeling odd with frothy urine and a rash - SLE // History of gentleman with recently diagnosed hypertension (i.e. that day) and urine dip showing nephritic syndrome. Nice history of two months increasing tiredness and joint aches and spotty red rash over legs and gluteals ... Can you guess what it is yet... Two questions – most likely diagnosis and which investigations // History from a person with hypertension, with protein and blood in urine. Does not have any cardiovascular risk factors...was kinda stuck because secondary causes such as phaechromocytoma and coarctation of aorta could not be ruled out. Turned out infact patient had a rash and diffuse joint ache. Other students said the patient had SLE?? Asked what 2 investigations would you do? Answer depended on what you got out of the history, I went for renal ultrasound and ECG. // Urinalysis with nephrotic syndrome picture - history taking of hypertension, haematuria and proteinuria. - You are a GP and a patient who has just moved house had just registered- has a urine dipstick and u get given the result - ++++proteinuria and ++blood He had swollen ankles and face and a rash on shine 2/52 agon ? Nephritic sx? Asked 3 Ix would do. . 
• Think most people like me fumbled around with renal failure as most likely diagnosis and said we'd like to do U&E, FBC, glucose, creatinine clearence... and prayed for the bell to go... I said SLE, although other people think it might have been IgA - who knows? // history of (i think) glomerolonephritis secondary to SLE. He didn't question my diagnosis anyway like he did with other people who said things like pyelonephritis, nephrotic syndrome. Asked to name three tests you would do eg urine culture, microscopy, U and Es, autoantibodies for SLE

• History station - obstructive jaundice

• Hx station: very long and complicated UC history from a real patient but they just wanted to see hoe you cope with taking a complicated history.

• I had a stable patient with diabetes brought on by steroids she was on for Crohn's. Quite straightforward Others had diabetes, SLE, and there was one with gauler's disease which noone had heard of!!

• Liver transplant history

• Hx - pt with lymphoedema and median nerve compression post-radiotherapy for breast cancer
• History of a 79 year old woman with a history of breast cancer. “Please talk to this woman regarding any problems she had with this diagnosis”. More psychological rather than medical but still talked briefly (in the history and with the examiner afterwards) about triple assessment, oestrogen receptor inhibitors, staging and grading and non-medical treatments for breast cancer.

• I got SLE (I almost cried). the patient had recently been discharged from hospital with heart failure, but I asked her every question under the sun (systems review in the best!) and she was feeling very well and had no rashes or anything. She mentioned that she sometimes gets "cold fingers" and the penny dropped after that. The examiner was really nice and asked me to present my findings as a problem list. I was then asked about the features of SLE and why this patient had heart failure. I said cardiomyopathy (which I think might have been wrong) and then pericarditis/pericardial effusion (which I think made more sense). I was asked about investigations for the patient and how often I would review this patient in clinic. I said monthly for the first six months then perhaps six months. I actually was making it up.

• History: (20 mins observed + 10 mins questions) This was ridiculous. My young patient was referred to clinic with recurrent shoulder dislocations and stretchy skin. She had long complicated history involving hyperextendible joints and operations for shoulder and broken tibia, fundoplication for GORD, arthroscopies. She had osteoporosis and secondary amenorrhea because of a pituitary adenoma. On many meds - remember to ask about doses and any side effects. Diagnosis was Ehler Danlos. Differentials include osteogenesis imperfecta, Marfans, pseudoxantha elasticum. Examiner then asked questions about ED - what type of collagen affected? how would you treat? referrals? At the end the examiner said he would never have expected to see an Ehler Danlos patient in finals and that he did not feel it was fair. I did ok though!

• History – 30 minutes station, 17 minutes history, rest of time questioning by examiner. I had history of elderly man with chronic fatigue and episodes of melaena. Main differential was colon cancer. Take a FULL history, you have 5 minutes before station starts to read the scenario and write whatever questions you may want to ask so use this time efficiently to write down differentials etc before you have even taken the history. Examiner then asks you to present the history briefly and then asks for differentials, investigations and a management plan.

• Other people had a scleroderma history (shortness of breath and skin changes so know that inside out).

• Remember they like chronic diseases for histories, like HIV (nasty one as you need to know about anti retrovirals and their side effects etc), rheumatoid, SLE, IBD (UC and Crohn’s is world famous history to come up). // Hx - HIV clinic please take Hx of lady with known HIV. Turns out she has a cough, so disuses differential/management afterwards with

• hx of woman who had lung ca 4 yrs ago, had to find out how this affected her life. I was only asked questions about things I brought up. for example, when asked what investigations I would do I said fbc to start looking for high calcium - I was asked how having cancer may raise your calcium. and how on a scan they may differentiate cancer from fibrosis due to previous radiotherapy

• long hx- Mine was on thyroid cancer- initially hypothyroid, then developed thyroid cancer & Mx. A nice history in comparison to what other people got. The questioning was relatively difficult, but the doctor was very nice and there's not much you can do to prepare for it anyway

• History – took history from patient with history of several valve replacements and infective endocarditis more recently. Then asked questions by examiner on infective endocarditis and valves etc.

• Long History station - was a little baffled by this at first, the instructions were just to take a full med history from this lady, who when I asked for her presenting complaint, said 'I don't know dear, I've come in today because I always come in for exams and the doctors asked me to'. But just moved onto her PMH etc and she had a lot to go through, to which I really had to rush by the end to get a complete history! But then the 10 min discussion I just presented my case (who had diabetes, AF, OA, cancer of the breast and skin, a stroke and a few other chronic problems) and then was asked how I would manage these different parts as a GP. Again

• Hx - Patient is new to GP practice. Please take her medical history. My patient just would not stop talking and kept going off on tangents. At 17mins, I was still on HPC. Had to rush through social hx. Moral: feel free to interrupt patients!!

• History of acute cord compression and a linked station with the next one being a telephone referral (which was actually really fun!)

MI & Liver Enzymes

Remember - does the investigation rule out/in? Dx

MI Enzymes

CK
- rises 3-6hrs after event
- only 50% pts show rise > ULofN @ 4hrs
- CK rises by over 50% over 12 hrs

CK-MB
- rises earlier than CK
- 3% CK-MB in skeletal muscle
- rhabdomyolysis = raised absolute levels
- better test = CK-MB/CK

+
Sys + ECG
CK-MB to confirm CK

Troponin

Myofibrillar protein fr damaged cells
- subtypes inc trop-T/trop-I
Measured at 12hrs post onset
Elevation persistent up to 10 days
Can indicate low-grade myocardial damage before infarction, requiring acute treatment
Good specificity

Liver Enzymes

ALT - cytosolic enzyme

ALP - biliary brush border enzyme
GGT - ribosomal test, x liver specificity

Enzymes

Raised Levels
*most significant finding
- increased synthesis/cell proliferation
- cell membrane damage
- cell death
- defective/slow blood clearance
Level increased can = extent of injury
Isoenzyme = greater tiss specificity

Enzyme profiles

1) tissue of origin
2) isoenz pattern in tiss
3) timing in relation to disease
4) lab availability

Normal variations of enzyme levels

1) Age/sex variation in reference range (ALP higher in adolescents)
2) Race (CK higher in afro-Caribbean)
3) Analytical interference (transaminases & LDH - haemolysis from red cells)
4) Renal failure (Amylase increased, as excreted renal-ly)
5) 'Macro enzymes' - binding of enzyme to immunoglobulin - lowers rate of degradation
- primary protein (immunoglobulin) disease eg myeloma
- temp
- *CK & AMY
- = req alt of Ix w/ documentation

Dx

MI
CK & CK-MB
troponin (non-enzyme)

x transamimases/LDH

Liver
ALT
ALP
GGT

Pancreatitis
Amy

Skeletal

CK for muscles
ALP for bone

Osteoporosis

Reduction in bone mass via loss of matrix
Excessive bone loss
Normal mineral:matrix ratio

Causes
Old age (post-menopause)
Endocrine
 - premature ovarian failure (early menopause)
- Cushings
- thyrotoxicosis
Drugs
Steroids
Heparin

Ix
pl Bone profile = normal
DEXA
- Identify fast bone losers
- Monitor therapy (HRT, bisphosphonates)

Osteomalacia

...aka rickets in children

Defective mineralisation of bone (calcium deficiency) + Increased osteoid

Causes
Dietary/Malab - Ca/vit D def
x Exp to sunlight
Disordered vit D metabolism
- renal Dis (decreased 1-hydroxylation)
- vit D-dep rickets (1alpha-hydroxylase def)
- a-convulsive therapy (induces metabolism)
Low phosphate (Renal Tubular Leak)

Ix
low sCa & PO4
high ALP (osteoblastic response) - interpret with age-related ref range
low circulating 25-OH cholecalciferol (?diet def)
elev sPTH (2ry HPThm)