2005, Hot Cases 2

The Clinical Section (hot cases) was conducted at the Alfred Hospital, Melbourne.
Nine  out  of  sixteen  candidates  passed  this  combined  section  (nine  out  of  sixteen  passed  the  hot cases  overall,  and  eleven  out  of  sixteen  passed  the  cold  cases  overall).  Candidates  should  listen carefully  to  the  introduction  given  by  the  examiners  and  direct  their  examination  accordingly.
Patients  were  usually  presented  as  problem  solving  exercises.  For  maximal  marks,  candidates should  demonstrate  a  systematic  approach  to  examination,  clinical  signs  should  be  demonstrated, and  a  reasonable  discussion  regarding  their  findings  should  follow.  The  twenty  minutes  available for  each  case  provides  ample  opportunity  to  discuss  related  investigations  and  plans  of management.
Exposing the patients should be limited to those areas that are necessary for that component of the examination, and in keeping with the modesty requirements of the patients. Candidates must show appropriate courtesy and respect to patients.
Cases encountered as hot cases included patients with:

·  Difficulty to wean after chest trauma (introduced as “isolated chest trauma. Why difficult to wean?”)
·  Extubation  after  a  stroke  (introduced  as  “admitted  following  a  stroke.  He  was  extubated  6 days  ago,  but  required  re-intubation  within  3  hours.  Fasted  overnight  for  consideration  of extubation.  You  are  taking  over  care  today.  Please  examine  and  determine  what  problems are and how you want to manage them.”)
·  Weaning  after  cardiac  surgery  (introduced  as  “cardiac  surgery  12  days  ago.  Slow  to  wean and  confused  post-op.  Readmitted  after  asystolic  arrest.  You  are  taking  over  care.  Please examine and determine hat medical issues exist and how you would manage them.”)
·  respiratory  failure  and  bone  marrow  transplant  (introduced  as  “10  days  of  increasing shortness  of  breath,  3  months  post  BMT  for  AML.  Arrived  in  the  unit  last  night.  Please examine respiratory system and suggest a diagnostic and management plan”).
·  sepsis (introduced as “presented with respiratory distress and shock 8 days ago after a 3 day prodrome of fever and malaise. Please examine and focus on possible sources for sepsis.”)
·  haemodynamically  unstable  after  cardiac  surgery  (introduced  as  “post-CABG  who  is haemodynamically unstable day 1 post-op. Please examine”)
·  Intracerebral haemorrhage
·  Out-of-hospital cardiac arrest

Comments  documented  at  the  time  of  the  clinical  examination  suggested  that  common  problems encountered  related  to  poor  examination  technique  (eg.  erratic/disorganised),  detection  and interpretation of clinical signs, and identification of clinically significant issues.

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