Nocturnale

Exam venue: Kuala Lumpur
Examiners: Andrew Elder (Consultant Geriatrician) & Norella Kong (Consultant Nephrologist)
Lead Examiner: Norella Kong

Role: Senior House Officer in the Outpatient Clinic

28-year-old man with recent DVT on warfarin started 3 weeks ago. He had an argument with his girlfriend, which prompted him to overdose on his warfarin tablets. He presented to the clinic with a severe headache.

Task: Please assess and advise him accordingly.

I walked in and saw a healthy looking chap sitting cheerfully on the chair. I knew immediately this is a surrogate actor with no real physical signs. But I realized I could not afford to make any mistakes or worse make assumptions, so I treaded carefully just the same.

This was my first station and I was extremely psyched up. I put on my best professional air and kicked off the station with a resounding,”Hello, my name is Dr. X. I’ve been asked to have a look at you and I understand that you’ve been having this bad headache. Would you like to bring me through the problems in your words and we will go on from there?”

I probed his headache in detail within the timespan allowable (worst headache ever, no speech or visual disturbance, no limb weakness or neck pain/stiffness, no vomiting, no fever and no recent head injury). I then asked him why and how much he had overdosed, to which he answered,” Only one extra tablet yesterday.” I also enquired about any other additional medications that he was taking at that time.

I scanned through his skin for bruises (of course there’s none) and I made sure they watched me do this with some polished measures of showmanship. I proceeded to do a neurological examination. The examiner stopped me, “Let’s say there is no extrapyramidal signs to be elicited. Go on.” I went on to do CN examination specifically for 3rd nerve palsy. The examiner stopped me again saying,” No need for that, it’s normal.” I then proceeded to do a fundoscopy examination (no hemorrhages seen). I then went on to elicit for Brudzinski and Kernig’s sign to which it’s negative, by which time I have a few minutes left to wrap up the consultation (still on track with my timing which I have practiced adhering to perfection).

I pulled up a chair by the bed, not allowing the time constraint to disrupt my composure, sat down and asked him the inevitable question,”As we discuss this, many patients will have thoughts about what may be causing their symptoms. Are you worried about anything in particular?” I have practiced this ‘end-game’ routine quite painstakingly, so I knew I could use this to my advantage. I put up a concerned demeanor and told him what my plan is and what to expect next after allaying his fear in a few succinct sentences. He seemed satisfied. I shook his hands firmly and thanked him for the time.

I then turned towards the examiner and readied myself for the punches.

Things happened rather fast. You do not have the luxury of time to pause and think about the next step to take. Everything felt very instinctive and fluid.

Patient’s concern: Will I have to admitted to the hospital? Why?

Questions asked:

1. How would you investigate?
2. How would you manage?
3. Do you think the patient’s INR will be raised significantly?
4. What advice would you give the patient?

Overall comment: Walking out of the station, I have no idea whether I did well. The examiners’ poker facies is too difficult to judge. I really give my all and try and replicate what a safe doctor would and should do in a real clinical setting. I feel the cases presented were typically your bread and butter acute medicine material. This should be the focus of all future candidates facing this station.

Verdict: I kept thinking if I scored badly at this sub-station, what else had I missed? But in the end when the results were revealed, I performed better than I thought with a perfect score 14/14 .

Do you have any Station 5 Brief Clinical Consultation cases to share? Do post them on this thread on the comments column below or send them via the contact form here!