graduate and postgraduate examinations.
cyanosed and mildly dyspnoeic at rest,with
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
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
not at all. On occasion, more than one option
may be correct for any one vignette, but youshould choose the best option available.
F—Inflammatory bowel disease
which to some extent depend on your level
I—Squamous cell carcinoma
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
method that you might resort to when your
film taken three years ago showed multiple
knowledge of a particular theme is limited.
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
B—Coarctation of the aorta
series of biochemical, haematological, imag-
Narrowing down the answer
ing, and other test results, which require
To make the task more straightforward, take
advantage of all the information on offer.
Use the pointers offered in the vignettes to
H—Polycystic kidney disease
would be difficult for any clinician to estab-
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,
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
NOVEMBER 2002 studentbmj.com
CONTROLE DE DOPAGEM R E G U L A M E N T O 2007/2008 1 - ATO DE DOPAGEM A luta contra o doping tem por finalidade a proteção da saúde psicofísica do atleta e a preservação da igualdade de oportunidades para todos, bem como a defesa da ética desportiva. A administração ou a utilização de qualquer substância - seja qual for a maneira de administrá-la ou os meios utilizado
Pablo Perel Personal Particulars Birth date: November 4, 1967 Nationality: Argentine Professional Experience: 2011-present: Coordinator Centre for Global Non Communicable Diseases, London School of Hygiene & Tropical Medicine. 2011-present: Senior Clinical Lecturer, Nutrition and Population Health Intervention Research Department, Epidemiology and Population Health Faculty, L