1. Using acid to cure a skin infection

Thomas S Fletcher was a surgeon at the Bromsgrove Workhouse, Worcestershire. One of his patients, young Henry Cartwright, died in 1842 after being immersed in potassium sulphate – in an attempt to cure “the itch”, or scabies.

2. Mistaking Tincture of Opium for Rhubarb

Mrs Elizabeth Galloway was suffering from inflammation of the bowels. To aid her recovery, she was given a tincture of rhubarb … Unfortunately, the druggist mixed up the wrong remedy; the cup contained laudanum [Tincture of Opium] rather than rhubarb. Mrs Galloway immediately worsened and the doctor was called… she later died.

3. Choosing the wrong bottle

Mary Ramshaw was knocked down and severely fractured her thigh. Dr Lumley was called, and prescribed both a mixture to take and an embrocation. Mrs Ramshaw’s daughter unfortunately administered the medicine from the wrong bottle and Mrs Ramshaw instantly began to convulse. Ten minutes later, she died. The embrocation she had accidentally been given contained belladonna (deadly nightshade).

You can read about more deadly disasters in the full article here.

The MPS regularly publish case reports as an aid to its members, to alert them to pitfalls that have caught their colleagues unawares.

Have you been privy to any first-term disasters? We would love to hear about them.

To recap, here is our 36-year old’s patient clinical cases of history and findings:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 6. Group your thoughts logically every time

a) By the most likely causes
“The differential includes the following:…”

b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”

Tip 7. Let the examiners know you are finished examining the clinical cases every time

Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.

Tip 8. Acknowledge what you don’t know

If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.

Tip 9. Have a set way of presenting clinical case examination findings every time

Practice this, it is the same every time. For the above clinical case here would be our example:

“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”

If you do this the same every time it will stop you making mistakes.

Tip 10. Thank and ‘look after’ your exam patient (and the examiners).

This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.

We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.

This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.

Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.

Let’s consider the following features and clinical examination…

A 36 year old male gives the following history:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.

Your Examination Findings are:

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 1. Look professional

Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.

Tip 2. Organise your presenting posture to minimise nerves

This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.

Tip 3. Structure your presentation of medical terminology

This needs to be structured in the same was that you elicited the clinical case history. PC, HPC PMHx, for example:

Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…

Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!

Tip 4. Interpret as you go

Don’t be afraid to explain your interpretations of the clinical cases as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”

Tip 5. Learn to summarise in one sentence

Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”

We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!

Remember you can listen to more podcasts, get MCQs and EMQs, watch clinical skills videos, and download ‘one minute’ revision guides in the medical finals login area of the site.

EMQ’s are being increasingly used in research and papers have recently been published on their success in the USMLE. Its likely that many medical schools will adopt this N from many approach. An EMQ is simple: its a series of typically 6-10 answers, used a number of times with different question stems.They first cropped up in 1993 after work by Case and Swanson. Read more about EMQ’s and their development here.

Distracters

Distracters are being used to throw students off the scent, and in some ways discriminate from good and bad students. An example would be describing a history of a rash affecting the flexor surfaces and giving on e of the answers as psoriasis. Seeing the two together can lead to the assumption this is the correct answer. This is an example of a good discriminator, but EMQs can easily be written in such a way that the more capable student gets it wrong!

Take an example EMQ from our new section dedicated to them on the login site.

“A 64 year old homeless man presents after being found exposed under a bush shelter by paramedics. He is ‘tided over the night’ by the emergency department staff with an IVI of 5% dextrose. The next morning he is confused, and ataxic. On examination he has nystagmus. Which of the following is treatment is most likely to be effective?”

Students classically then have to pick from a range of answers:

• Aciclovir
• Ciprofloxacin
• Buscopan
• Omeprazole
• Gluten free diet
• Peg Interferon alpha
• Mesalazine
• Vitamin B Complex

Here’s the Answer from the main site:

“Nystagmus, and ataxia are features of cerebellar disease, with the addition of confusion this triad is suggestive of Wernickes Encephalopathy (vitamin B1 deficiency- thiamine). Risk factors: poor nutrition (+/- alcohol).

Thiamine is important in carbohydrate metabolism and the Krebs cycle: it’s vital to remember that dextrose presents a carbohydrate load, the excess of which cannot be effectively metabolised , leading to cell death.

Hence the treatment: Vitamin B complex: initially this is given as Intravenous Pabrinex © for 48-72 hours.”

The EMQ here does a number of things: You could use your knowledge of drugs alone to answer the question: An antiviral (acivlovir), quinalone antibiotic (ciprofloxacin), an antispasmodic (buscopan), a Proton pump inhibitor (omeprazole) a gluten free diet (!), etc.

Aciclovir would initially seem attractive for a possible encephalitis- there are some things that fit: confusion, other CNS signs? This is a form of a distracter-look at the history, and the role of the glucose drip.Here the answer has been worked through by correctly recognise the triad of opthalmoplegia, confusion and ataxia that isin keeping with the diagnosis of Wernickes.

So, we can see that EMQs look initially pretty intuative, but more are being written, and expect them to be coming to an exam near you soon.

You can work through some examples of EMQ’s to prepare for your medical finals with different question structures on the subscription section of our site.

Our current average on the trial questions (20 marks) is

46%

That’s because our questions are tough. They’re not about knowledge, but the application of knowledge, exactly what your medical school will be interested in when they set their own benchmark…

Try out questions like the one below on our free trial.

PMHx: Asthma, Previous Intravenous drug user

SHx: Current smoker

She does not attend for her pre op chemotherapy clinic appointment, but nevertheless goes on to have the chemotherapy.

6 weeks into her chemotherapy treatment she becomes jaundiced and has the blood tests taken

The problem has not arisen as a result of an adverse drug reaction.

What is the most likely underlying problem that has caused her to be jaundiced?

She has no visual symptoms, motor symptoms or other neurological symptoms or signs.

By the time she arrives in the Emergency department, her symptoms have entirely resolved.

O/E

Temp 36 o Celsius

BP 112/78

Sats 99% Air

GCS 15/15

Fingerprick Blood glucose 3.9mmol/l

On examination she has an entirely normal neurological examination. The rest of the general examination is unremarkable other than a soft systolic murmur.

Is there anything else to be done, or should she simply see her GP for a follow up and consideration of a referral to a headache clinic? If there is something to be done, what is it and why?

46 year old male presenting with a bit of joint pain

Also tells you he has premature “wear and tear” of his hands with no history of trauma.

There’s nothing much else to go on in the history other than the fact that he’s impotent.

His blood tests show a low FSH and a low LH.

His GP thought it all might be rheumatoid arthritis…

What’s the diagnosis people?