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This gentleman has abdominal discomfort. Examine his abdominal system.

Discussion::

     First lesson to be learned in abdominal examination is appropriate proper exposure. My friend failed this station because he insisted to expose his female patient in his MRCP PACES exam down to thigh. I would expose the patient up to just above the genitalia. Obviously you notice this gentleman’s abdomen to be grossly distended and there are multiple tattoos at his supra-pubic region. You also notice presence of jaundice, ascites (shifting dullness), clubbing and splenomegaly in this gentleman. You must always remember that beside making a diagnosis of chronic liver disease, you should try to find out the underlying cause for his chronic liver disease, some clues may help you.
If you find….

- parotid swelling, Dupuytren’s contracture – you may be dealing with alcoholism,
- skin hyperpigmentation- you may be dealing with haemochromatosis or iron overload due to multiple transfusions in Thalassemia patients ( although you are unlikely to see this in UK, you may be seeing this type of cases in developing countries),
- tattoos or punctum wound to suggest intravenous drug abuse- you may be dealing with Hepatitis B or C,

Common questions examiners will ask you,

1) What is Child’s grading of liver disease in portal hypertension?
(The mnemonic to remember BAPA + E- bilirubin, ascites, PT (INR) and albumin and encephalopathy)
2) What are the possible complications of portal hypertension?

Conclusion:

This gentleman has chronic liver disease due to Hepatitis B ( He is an ex- intravenous drug abuser.)

Extra points,

1) Remember that the commonest cause of chronic liver disease in Asia is chronic viral hepatitis whereas in UK is alcoholism.
2) Do not forget that Wilson’s disease also can cause chronic liver disease!
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You are the SHO in charge of the Infectious Disease clinic.

You are asked by the sister in charge of the surgical ward to see Dr Henry who accidentally pricks himself while taking blood from a HIV patient in the ward. Dr Henry just started his internship 3 months ago in the surgical department and he is very worried about this incident. He is waiting to see you to discuss about post exposure prophylaxis (PEP). You task is to explain to him about post exposure prophylaxis.
You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners.

Discussion:

     HIV is a very important topic in MRCP PACES exam. This is a common scenario in station 4 for MRCP PACES. Candidates should start off by expressing their empathy towards this event. Before going to the major task of any scenario in the exam, always remember the following rules,

ask about details of the event- in this case, you should ask Dr Henry about the time of the event, size of needle he was using, the depth of needle penetration and what was his action after the incident,
assess the patient’s understanding about certain issue, in this case, Dr Henry’s understanding about HIV/AIDS,
explain to Dr Henry the current problem/illness, in this case about HIV/AIDS including the disease progression, modes of transmission and possible treatment ,
assess Dr Henry’s risk to get certain infections such as HIV, Hepatitis B and Hepatitis C. Ask him whether he knows about his status and his previous Hepatitis B vaccination,
ask more about that HIV patient’s status -? on treatment,?CD4 count, any other medical problems such his ? Hepatitis B/ VDRL/ Hepatitis C status.
tell him you are there to help him and you certainly understand his feeling right now, (always remember that the strategy in exam is ……… reassure patient, reassure patient and keep on telling them you are there to help everyway possible!)
then inform Dr Henry briefly about PEP and maybe include some details about the possible side effects. (Do not try to show off to examiners by bombarding patient with very detailed information. This would make you to score less point!!)
also inform Dr Henry about your plan for his follow up, do not forget to ask his permission for HIV testing.

Last but not least, always ask patient whether they have any other issue to discuss. Actually in the real MRCP PACES, Dr Henry was just got married 4 months ago and he is very worried about his relationship with his wife. He is also worried whether he can continue to function as a houseman while waiting for his blood results. You must always remember that patients in MRCP always have some hidden agendas that they want to discuss with you. You may miss these issues if you do not ask them specifically!

Common questions examiners would ask you,

1) What is ‘window period’ for HIV infection?
2) How do you decide what treatment to be offered to Dr Henry?

Extra points:

1)PEP regime usually consists of combinations of three drugs!
2)To learn more about HIV PEP, click here !

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