Transcript Novartis Case

ICE Survive
Phase 2
Integrated Clinical Examination
UNSW 2009
Assoc Prof Tony O’Sullivan
St. George Clinical School
Integrated Clinical Examination
• The objectives of the ICE is to assess:
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History taking and communication skills
Clinical examination
Clinical judgement & synthesis
Application of basic knowledge
Communication skills
Some basic management principles
– Make sure you review the objectives in the
student guide
– Barrier examination
Integrated Clinical Examination - format
• 6 stations - mix from all four Phase 2 courses
• 20 minutes each station (bell at 10 & 18
minutes)
• One examiner per station (one case per
student)
• Examiner interacts with student
• Grade given for 9 specific criteria
• Pass / fail is determined on an algorithm
Integrated Clinical Examination - format
• First 10 minutes: clinical component
– History
– Directed clinical examination
– Summarise findings and discussion
• Second 10 minutes: viva component
– Questions based on basic sciences, pathology,
investigations, microbiology, theory from a case
method tutorial etc
– Some discussion may occur
– Discussion on management will be on general
principles not specific treatment
QUESTION SAMPLE 1
Clinical and Communication Section (10 minutes)
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Patient with inflammatory bowel disease.
Age 25 – 70 years
Gender - either
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Parts of Phase 2 examined: HM
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Student Instructions
This is Mr Smith. He is 65 years old and has a history of bowel problems.
a. Please take a history of the patient’s gastrointestinal problems. This
should include information about his past management and the
medications he is taking.
b. Please ask the patient about how their disease has impacted on them.
c. Summarise the history to the examiner and provide a differential
diagnosis of the gastrointestinal problem.
QUESTION SAMPLE 2
Clinical and Communication Section (10 minutes)
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Patient with chronic liver disease
Age 25 – 70 years
Gender - either
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Parts of Phase 2 examined: HM
• Student Instructions
This lady has been unwell for some time.
Please look at her and examine what you think is appropriate.
Patient with chronic liver disease
hepatosplenomegaly (liver palpable, spleen palpable but not as
easy), spider naevi, jaundice.
Summarise your findings to the examiner and provide a differential
diagnosis of the gastrointestinal problem.
• VIVA SECTION SAMPLE 1: Pathology of metastatic
adenocarcinoma of the bowel
• Biomedical and Social Science Viva Section (10 minutes)
• Parts of Phase 2 examined: HM & AE
• A 61 year-old man with a 23 year history of ulcerative colitis
presents unwell with significant weight loss and anorexia. He has a
history of non-compliance with his medication and previously he has
been advised to undergo a colectomy. He had also noticed that he
was becoming jaundiced, associated with pallor of his stools and
darkening of his urine. He is noted to have an enlarged liver on
examination which is non-tender. His LFTs are shown below.
Liver Function Tests
Anal yte
Measu red
Value
Reference Interval
Bilirubin (mmol/L)
98
2-20
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Alkalin e Phosphatase
(U/L)
320
38-126
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Aspartate Tran samina se
(U/L)
130
<45
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Alan ine Tran samina se
(U/L)
155
<45
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g-Gluta myltransf erase
(UL)
485
<50
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Albumin (g/L)
30
33-48
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Globulin (g/L)
32
25-35
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Total Protein (g/L)
62
62-80
VIVA SECTION SAMPLE 1: Pathology of metastatic
adenocarcinoma of the bowel
Question 1
Comment on the abnormalities present on the LFTS.
Question 2
In view of the above clinical history, how would you interpret the
biochemical abnormalities in this man’s liver function tests shown?
Question 3
What further investigations might be helpful in determining the diagnosis
in this case? What are the possible differential diagnoses?
Question 4
Discuss with the examiner reasons why this patient may have been noncompliant with treatment.
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QUESTION SAMPLE 3
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Clinical and Communication Section (10 minutes)
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Patient with history of claudication and peripheral vascular disease.
Age 50 – 80 years
Gender – either
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Parts of Phase 2 examined: S&H, HM
Student Instructions
This is Mrs Smith. She has a 6 month history of pain in her legs which
comes on when she walks especially up hills. She has a 32 year
history of smoking. Lately she has noticed pain in her right foot
occurring at rest.
a. Please examiner the patient’s lower limbs from a vascular point.
b. Are there any dynamic movements that may help in the examination?
c. Summarise your findings for the examiner and provide a differential
diagnosis.
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VIVA SECTION SAMPLE 2: Discussion on risk factors for
atherosclerosis (10 minutes)
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Parts of Phase 2 examined: S&H, HM
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Instructions to student:
Question 1.
Describe to the examiner the possible risk factors which may predispose
to atherosclerosis in an individual.
Question 2.
Describe how these risk factors can be diagnosed in asymptomatic
patients?
Question 3.
Describe the metabolic syndrome (insulin resistance syndrome) and
relate its components to CVS disease.
Question 4.
Discuss some strategies to reduce two components of the metabolic
syndrome from a Public Health point of view.