Tuesday, 1 September 2009

MRCP PACES new station 5 example

New Station 5

Demonstration scenario: goitre


• You will be asked to see two patients at this station.
The clinical information about one of these patients is given in
the box below. You should have a second sheet giving you
information about the other patient.

• You have 10 minutes with each patient. The examiners will
alert you when 6 minutes have elapsed and will stop you after
8 minutes.

• In the remaining 2 minutes, one examiner will ask you to
report abnormal physical signs (if any), your diagnosis or
differential diagnosis, and your plan for management
(if not already clear from your discussion with the patient).

Your role: You are the medical doctor on call.

Patient name: Mrs Jane Smith – age 33 years

This lady was admitted to the orthopaedic ward for a
carpal tunnel release operation.
She mentioned to the orthopaedic doctors that she has
swelling in her neck and they have asked for the opinion
of a physician. You were asked by your consultant to see
the patient and to assess the suspected swelling in her neck.

Your task is to assess the patient’s problems and address
any questions or concerns raised by the patient.

• You should assess the problem by means of a relevant clinical history
and a relevant physical examination. You do not need to complete the
history before carrying out appropriate examination.
• You should respond to any questions the patient may have, advise
the patient of your probable diagnosis (or differential diagnoses) and
your plan for investigation and treatment where appropriate.
• You have 8 minutes to complete the task.


The doctors sitting the examination have been asked to assess your
problem. They will have 8 minutes to ask you about the problem and
any other relevant issues. They will also examine you. They should
explain to you what they think is wrong and what action should be taken
and answer any questions you have, for example about the diagnosis,
tests that may be needed, or treatment. One of the examiners will ask
them to describe any abnormal examination findings and give their
diagnosis. Your history is described below.

You are: Mrs Jane Smith – age 33 years
Your problem: swelling in your neck
You are in the orthopaedic ward and you mentioned to the admitting
doctor that your neck seemed swollen. One of the medical doctors has
been asked to see you about this.
You have been suffering from pain in your right forearm and a numb
or tingly feeling in your right hand – affecting your 3rd, 4th, and 5th
fingers. The aching in your arm is worse at night and you have found
it more and more difficult to get comfortable. The problem has been
present for several years and was worse when you were pregnant
with your daughter 3 years ago but improved for a time after that.
A trapped nerve in the wrist has been diagnosed. You are having
a short admission to have the nerve released.
You mentioned that you thought your neck was swollen when the
admitting doctor was examining you. You have not mentioned this to a
doctor before but your sister has been commenting on it for a few years.
Your sister is 38 and has an underactive thyroid.
You do not have any of the symptoms your sister had when her thyroid
was underactive. Indeed you feel well. Your weight is stable. Your skin
and hair are normal. You do not seem to feel the heat or the cold any
more than anyone else. Your bowel works normally. You do not have any
problem with swallowing. You should ask why your neck seems swollen
and whether there is something wrong with your thyroid gland. You should
ask if any tests are required and, if so,what these tests will be.


Patient: Mrs Jane Smith – age 33 years
Examiners should discuss and agree the criteria for pass and for fail in the
competencies being assessed.
As a general guide, candidates would be expected to:

• Note the history of neck swelling and the family history of thyroid disease.
• Enquire about symptoms of disturbed thyroid function.
• Examine the neck and identify the smooth and symmetrical thyroid
enlargement. Note absence of bruit.
• Examine for signs of overactive and underactive thyroid gland and
confirmclinical euthyroid state.
• Confirm to the patient that her thyroid gland does seem enlarged but
reassure that the gland seems to be working normally judging from clinical
examination. Advise on appropriate further investigations.

The lead examiner should:
a) Advise the candidate after 6 minutes have elapsed that “You have two
minutes remaining with your patient”
b) Ask the candidate to describe any abnormal physical findings that have
been identified
c) Ask the candidate to give the preferred diagnosis and any differential
diagnosis that is being considered
d) Any remaining areas of uncertainty eg regarding the plan for
investigation or management of the problem may be addressed in any
time that remains.

form mrcpuk website

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