Clinical Exams and the Quickest Way to Fail (or Pass)

Consider this made-up scenario: 

“Christina Matthews is a 24-year-old female who presents to the emergency department following an overdose of paracetamol. She has recently broken up with her boyfriend after finding out about his infidelity. She is currently training as a vet nurse but has few friends, having moved to this town with her now ex-partner a month ago. She is isolated and has been dating him since she was 13 years old.

Question 1: Discuss your initial management of Christina. (4 minutes)

Candidate A answers:

“I’d check her blood pressure, check her oxygen, umm, start some fluids, umm. Oh yeah, I’d check airway. Oh, that’s patent. Goodo. I’d definitely check levels for sure. Is her oxygen sats ok? It is? Righto. In which case I’d start N-acetylcysteine. The loading dose: 150 mg/kg IV over 1 hour. She’s overdosed and there’s psycho-social stressors, so I’d definitely do a mental state assessment. Have I checked blood pressure? If not, can I get that examiner please? I’d ask if she has active plans to end her life.”

Candidate B answers:

Initial Assessment and Stabilisation:

1. Airway, Breathing, Circulation (ABC):

   - Ensure the airway is clear, assess breathing, and check circulation. Administer oxygen if required.

2. Vital Signs:

   - Monitor her blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.

3. IV Access:

   - Establish intravenous access for the administration of medications and fluids.

History and Examination:

1. History of Ingestion:

   - Confirm the amount and time of paracetamol ingestion, and whether any other substances were taken.

   - Specific questions should include the time of ingestion, the number of tablets taken, their strength, and whether any other substances were consumed, including alcohol or drugs.

2. Physical Examination:

   - Conduct a thorough physical examination:

     - General Appearance: Observe for signs of distress, jaundice, and mental status changes.

     - Abdominal Examination: Inspect for distension, palpate for tenderness (especially in the right upper quadrant), and assess for hepatomegaly.

     - Neurological Examination: Assess for any changes in mental status, orientation, and level of consciousness.

     - Cardiovascular Examination: Check for signs of tachycardia, hypotension, and peripheral perfusion.

     - Respiratory Examination: Auscultate the lungs for any abnormal breath sounds.

Investigations:

1. Blood Tests:

   - Order liver function tests (LFTs), coagulation profile, electrolytes, renal function, and a paracetamol level (taken at least 4 hours post-ingestion).

2. ECG:

   - Perform an electrocardiogram to check for any cardiac abnormalities.

Specific Treatment:

1. Activated Charcoal:

   - Administer if the patient presents within 1 hour of ingestion and is fully conscious. Dose: 50 grams orally (may repeat if there are large or delayed ingestions).

2. N-acetylcysteine (NAC):

   - Initiate as an antidote to prevent liver damage. Dosing is based on the paracetamol nomogram.

     - Loading dose: 150 mg/kg IV over 1 hour.

     - Second infusion: 50 mg/kg IV over 4 hours.

     - Third infusion: 100 mg/kg IV over 16 hours." 

They look and sound very different right? Have a closer look – they cross off almost all the same points. Yet one is going to outright pass, and the other is going to borderline pass/borderline fail.

So, what is the difference?

The difference is structure. In almost all clinical examinations, examiners not only mark you on the specific content of what you say, but their overall feel of how you went. If they feel you are not confident, or “all over the place”, chances are they will mark you down, even if what you have to say is perfectly reasonable.

The most important thing that we hope to show you with PassGP is how to structure your answers – and how to pivot so that you know exactly what to do if you go on to get a random question which you haven’t prepared for. In the interim, practise your structure!