A 44 year old builder presents with weakness over the past 48 hours.

A neurological exam reveals the following (N=normal):

Which of the following is the most likely diagnosis?

a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome

Leave your answers as comments, and we will give you the full professional medical answer in a few days!

Remember, for more MCQs check out our free question bank here.

A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’  however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.

Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.

PMHx

Previous history of skin psoriasis, treated with topical preparations only.

Drug history

Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)

Examination

You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.

Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination

Neurology:

Cranial Nerve Exam

Normal. Fundoscopy normal.

Mental Test Score:

Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8

Recent blood tests

What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.

A free subscription is on offer for what we judge as the best ‘free text’ answer to this question!

They look so fashionable they must be great for the modern day medical student. Right?

We here at medicaleducator.co.uk are currently checking out he use of predominantly free iPhone apps on for medical students. So what we would like are three things. Why not email us at iphone@medicaleducator.co.uk if you have a point of view on any of our points below. We’re keen to supply our users with a free iphone guide once we know what’s worth checking out. So we have a few questions….

1. Have you been refused access to any iPhone health resource because you are ‘only a student’ ? (something we’ve heard is getting more common- and is perhaps a little frustrating [we know you need the information most!]
2. Any apps that are really worth their weight in gold to budding students out there?
3. Anything you think is not worth the free download time?
4. Any recommended top apps?
5. Overall as medical students do you think an iPhone is worth the money in terms of the benefit it gives you?

We;’ll be covering a feature on a few of some of the apps that we like, and are currently using in our day to day practice. We’ll leave you with this…

I was using my iPhone to check a patients disease activity score (DAS) to check their eligibility for anti-TNF therapy- a biologic agent that is a powerful treatment for rheumatoid arthritis.  I think the patient thought I  was checking my text messages! It took a careful explanation to avoid an embarrassing incident.

A free subscription to the user who sends us in the most detailed answer to any/ all of the above. And if you can make us laugh heartily you might get one too. Check out our user guide coming soon too!

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

Trying to cater for the 140 countries that use the site and our growing list of >1000 registered users can at times be difficult. We asked one of our contributing registrars to comment on the forms of assessment:

Its a very interesting question if a single site can provide enough different content to suit the needs of different medical students. I think the best approach is to remain diverse in your tutorial and assessment methods on the site, which is something that medicaleducator manages to do. Obviously there’s a number of domains which could be improved, and that’s the big challenge.

When asking a newly qualified doctor about their own experiences we got a slightly different answer:

I dont think it makes any difference what you do, as long as you have some practice in the assessment method- I mean if you’re doing an MCQ, then that’s fine, you should have had some MCQ practice, same goes for an OSCE, but the knowledge you get from sites like these about key important things, that you might not understand, really helps you to get an overall grasp of whats going on.

One of the qeaknesses of assessment methods is the opportunity to use exam technique to help students perform well in OSCEs. James Bateman, one of the key contributors to the site has his own view:

I do see exam technique as an important issue, but for a different reason to many doctors.

An example of the format of the answers used in the site.

I’ve helped a large number of doctors (>20) sit complicated clinical examinations in tutorials of up to 3 doctors (for entry to specialist training). Its actually problems in techniques in fielding and answering questions that leads to the main problem, i.e. the doctors are being penalised for problems in the way that they answer questions.

Its a shame to see people not maximise their potential because of nerves. I do think that assessment methods used are robust (the evidence from the literature supports this), I do think that web based learning on the site will help people learn (as the meta-analysis by Cook DA et al in JAMA suggests).

So our reasons are as follows

1. Evidence based medical knowledge is transferable across continents in terms of pathophysiology, clinical assessment investigation, and treatment approaches
2. Almost all assessment by medical schools involve MCQ based assessments, a strong component of our approach. This can be useful practice, and any essay format or long answer question will still revolve around key medical facts.
3. Clinical examination skills as taught by a video format can help in both clinical and written examinations. Our questions also highlight clinical connundrums based on different clinical findings
4. A wide variety of delivery formats will help to provide students with the capacity to learn from multiple different domains
5. Detailed clinical answers to MCQ and EMQ question format will help in medical written assessments and other viva situations by providing the students with key clinical facts.

Medical Educator hopes to publish some interviews with UK based and US based medical students in the coming weeks, to see how their needs differ. We already have some US contributors. If you’re a student, and you’re like to get invovled in this, or are interested why not email interviews@medicaleducator.co.uk for further details.

Further Reading:

Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: a meta-analysis. JAMA. 2008;300(10):1181-1196 Full text here.

UMAP, one organisation currently working to standardise medical student exam question content across medical schools

It’s essentially the organisation which is writing/ collecting a bank of medical student exam questions for use in ‘high stakes’ examinations, such as medical finals.

UMAP’s description of their activities can be found on their website: On the site they describe themselves as follows:

UMAP’s aim is to improve quality in high stakes written assessments across UK medical schools. UMAP runs best practice item writing sessions where clinical and academic staff come together to learn about item writing techniques and to represent their subject area in the developing question bank.

UMAP QA process

Once written, questions move on to be quality assured at UMAP question review meetings which are convened at our partner schools. Staff members with experience in assessment and who are familiar with UMAP style and technique check each question and amend as necessary to ensure the highest accuracy and conformity to question writing principles. Questions are then ready for use and are listed as part of selection documentation available to our partner medical schools.

Schools are invited to select the items they wish to use and then confirm their selections to us. Schools later return results data in an electronic format which is then analysed and uploaded into the UMAP bank. A summary of this data is displayed within question selection documentation to enable schools to make informed, evidence based, item choices.  [Accessed 4.03.09 from http://www.umap.org.uk/about/]

From their site they cover about 14 medical schools and they run an active recruitment of Specialist Registrars to write questions for their bank, most recently to our knowledge in Birmingham at a West Midlands General Internal Medicine training day.

UMAP currently publish on their site that as of October 2008 they have over 2500 questions for use in the these high stakes examinations. They acknowledge that they seem to be lacking in a few key areas, however they are currently working to address this.

What do you need to know about UMAP as a medical student? Well probably not that much. In fact all UMAP really are trying to do is generate sensible MCQ questions that are fair, and are well written. They have a reasonably complicated list of rules that a number of ME’s contributors have been talked through at a number of different times: overall though its not rocket science.

• you shouldn’t be able to answer a question just by using the investigation result or the stem on its own (e.g. a big intro and then showing an ECG with complete heart block etc.)
• The questions are aimed at core FY1 knowledge
• You should be able to guess the likely options for the answer (again straight forward)

In principle, when UMAP look at the answers for any given question, they check that these same answers seem reasonable. They also like the same level of detail for both (for example the answers should all be of similar length).

What about the stem’s themselves: again UMAP make some sensible judgements including avoidance of medical jargon, avoiding using the same words in the questions and the answers etc. They should be readable and comprehensible.

So is there any technique involved? Well yes! Look carefully at results an investigations. Its clear that UMAPs strategy will be not to spoon feed the reader. For example if an important feature is tachycardia the question may read as follows

Ther pulse rate was 124 – Rather than mentioning the tachycardia directly, or showing a picture of an ECG

The same goes for investigation reults: e.g. K+ 3.0 mmol/l (NR 3.5-5.5 mmol/l) rather than ‘hypokalaemia’

All this means is that you have to look carefully at the investigation answers, and then draw conclusions. The rest is guesswork? Not really. Simple mathematics state that you should rule out the maximum number of wrong answers, and maximise your chance of success.

Medical Educator or its wuestion writers have not contributed any questions to the UMAP quesiton bank and have no formal or informal association with the organisation. We’d be interested to hear students comments and opinions about the work done by UMAP.

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.

Medical educator is expanding week on week and we’re hoping to provide relevant content for all our international users. We’ve now topped over 70 countries using the service, with the top 4 countries using our service to search for medical student exam revision services being the UK, USA, India and Canada.

Check out the world map below, the darker the shade, the bigger the proportion of users from that country.

Used in > 70 countries and Rising

But what do you think of it as students? These models are often costly, locked away and the actual face to face training you get with them is minimal. Is may be a good use of time and resources to train you, but do you feel it is effective in the institution you work in.

Also from an exam perspective:

• Do any medical students have any simulator topics they would like to be covered specifically in an exam situation (e.g. approach to pulmonary embolism)
• Have any students faced these simulators in an exam (excluding ALS stations)? As far as I’m aware although they’re used in an interview setting its not clear that they are ready yet to be rolled out across the whole curriculum

We’d be interested to hear comments and tips from students from the UK and also abroad