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graduate and postgraduate examinations.
cyanosed and mildly dyspnoeic at rest,with Ian Bickle takes us through this
They now feature in final examinations in fine late inspiratory crackles heard bilaterally the United Kingdom as they are thought to be valuable in assessing both the level andapplication of knowledge.
Approaching the EMQ
tom, sign, diagnosis, set of investigations, or a There are several processes to go through topic in basic sciences, EMQs assess the abil- ity of the candidate to process and evaluate To start with, identify clearly the theme, in this case finger clubbing. Then carefully read focus on how they should be approached.
example, the key points to take away are that the patients all have finger clubbing and that favourite—the clinical sign of finger clubbing.
you should choose the most appropriatediagnosis. This in itself implies that severaldiagnoses may be suitable, but one is supe- Theme: finger clubbing
rior, that is to say, most correct. Finally, you A—Alcoholic cirrhosis
must match each of the vignettes (1-5) with B—Congenital cyanotic heart disease
C—Cryptogenic fibrosing alveolitis
option may be used once, more than once, or D—Empyema
not at all. On occasion, more than one option E—Infective endocarditis
may be correct for any one vignette, but youshould choose the best option available.
F—Inflammatory bowel disease
G—Mesothelioma
which to some extent depend on your level H—Pulmonary abscess
I—Squamous cell carcinoma
J—Tuberculosis
vignettes—in this case clinical scenarios— The patients below all have clubbing of the fingers. Choose the most appropriate diag- available. Then, refer to the options and see if your preferred diagnosis or one of the differentials appears in this list. If you wrote Thailand presents to her general practitioner only a single answer down and it appears in (GP) with weight loss, malaise, and a produc- the option list it is very likely to be the cor- tive cough. Sputum culture after five days is (2) A 71 year old retired electrician pres- ents to his GP with pleuritic chest pain and Box 1: General approach to an
dyspnoea. After initial investigations, a com- puted tomography scan of the chest shows aright pleural effusion with lobular pleural (3) Read the first vignette and try to write ment feeling unwell with intermittent fevers (4) Select the correct answer from the list and weight loss. He is found to have a raised jugular venous pressure, a pansystolic mur-mur at the left sternal edge that is accentu- ated by inspiration, and a pulsatile liver.
in a munitions factory during the secondworld war presents to her GP with abdomi- potential options after reading the vignettes, haemoptysis, and weight loss. A chest x ray method that you might resort to when your film taken three years ago showed multiple knowledge of a particular theme is limited.
STUDENT BMJ VOLUME 10
NOVEMBER 2002 studentbmj.com
inal pain. These are likely to be due to hyper-calcaemia, a paraneoplastic feature of squa-mous cell carcinoma attributable to secretionof ectopic parathyroid hormone (PTH).
Hypercalcaeamia occurs more often in squa-mous cell carcinoma than in other subtypesof bronchial carcinoma. You have theanswer.
The following EMQ looks at the details of a specific diagnosis—hypertension.
Theme: secondary causes of
Cirrhotic liver
hypertension
A—Acromegaly
B—Coarctation of the aorta
Polycystic kidneys
C—Conn’s syndrome
D—Cushing’s syndrome
E—Diabetic nephropathy
series of biochemical, haematological, imag- Narrowing down the answer
ing, and other test results, which require F—Phaeochromocytoma
To make the task more straightforward, take advantage of all the information on offer.
G—Polyarteritis nodosa
Use the pointers offered in the vignettes to H—Polycystic kidney disease
would be difficult for any clinician to estab- I—Pregnancy
lish the diagnosis from the symptoms pro- return to the modified list for further more J—Renal artery stenosis
vided alone. In this type of question, the The patients below have all presented with assessor is looking for the ability of the can- caught by the distracters slipped into state- didate to interpret the list of results obtained appropriate diagnosis from the above list.
(1) A 61 year old man with diet controlled diagnosis, as you would do as a practising the clinical scenario of a 28 year old. This in type 2 diabetes mellitus and coronary artery itself immediately narrows the list down to disease develops asymptomatic hypertension.
The urine dipstick is strongly positive for half. The only likely conditions for someone Urine taken at 24 hours is negative for pro- of this age from the list of options are con- tein. Urea and electrolytes are normal. Treat- genital cyanotic heart disease, infective endo- ment with lisinopril is started, and the patient rate and concentration of C reactive protein is seen again a week later. Repeat blood tests are markedly raised for a young man, indi- show concentrations of urea of 19.2 mmol/l cating an inflammatory process. These are are also told that the patient has cardiovascu- and of creatinine of 287 [micro ]mol/l.
all pointing towards the option of polyarteri- tis nodosa. This answer is almost confirmed options further to either congenital cyanotic GP with fatigue and ankle swelling. Blood heart disease or infective endocarditis.
which is highly suggestive of this condition.
ogy. A pulsatile liver is a sign of tricuspid –35mmol/l, urea 6.9 mmol/l, Cr 84 [micro illustrate the use of a distracter. The patient regurgitation, which also causes a murmur ]mol/l. Plasma concentrations of adrenocor- scenario gives symptoms highly suggestive of at the lower left sternal edge. This is a right sided valve, and intravenous drug misusers (=4.8pmol/l). Plasma rennin is undetectable.
in the list above. Raised catecholamines are are predisposed to infective endocarditis also stated. According to the last sentence, affecting right sided valves. You have the shows a nodule of 1.2 cm in diameter in the the adrenals does not show abnormalities. A In vignette four, a much older patient is outlined. Again, you should extract the key hypertensive during a routine medical exam- pointers from this—she is 84 years of age, worked in a munitions factory and a chest x- delay, an ejection systolic murmur, and tor- candidate will recall that 10% of phaeochro- mocytomas exist in the sympathetic nervous plaques. All this suggests occupational expo- with a three week history of malaise, weight loss, abdominal pains, and ankle swelling.
Ian Bickle preregistration house officer, Royal Victoria
recall types of asbestos related lung disease— Urine dipstick is strongly positive for blood asbestosis (lung fibrosis). As only two of mmHg. Blood tests show a white cell count these appear in the options—squamous cell of 15.2x10/l, an erythrocyte sedimentation The studentBMJ would like to thank Wai-Ching rate of 67 mm/hr, C reactive protein 80g/l Leung, who is well experienced in this area, for narrowed it down to the last two. Now you GP with frequent, rapid palpitations associ- Prepared in collaboration with Pastest Limited.
complains of don’t help. Haemoptysis and ated with a pounding headache, sweating, and a feeling of impending doom. Measurements Feather A, Domizio P, Field BCT, Knowles CH, could weight loss. But there are other symp- of urinary catecholamines over 24 hours are Lumley JSP. EMQs for medical students. Volume 1.
toms too—polyuria, constipation and abdom- elevated on three separate occasions, but a STUDENT BMJ VOLUME 10
NOVEMBER 2002 studentbmj.com

Source: http://www.drcog.co.uk/sbmj406.pdf