Medical Council of Canada

Case 3: 6-minute paired station – Raymond Bedford

Case 3: 6-minute paired station - Raymond Bedford

Objectives

  • Expert: Abnormal Liver Function Tests
Component 1 – Candidate instructions
Raymond Bedford, 34 years old, presents to your office after receiving a letter from an insurance company. The company denied Raymond life insurance due to elevated liver enzymes. He is frustrated about the denial and wants you to clear up what he thinks is a mistake.

Raymond’s test results are as follows:
Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
Alkaline phosphatase
Total bilirubin

230 U/L         (N = 18‐40 U/L)
225 U/L         (N = 17‐63 U/L)
110 U/L         (N = 38‐126 U/L)
26 μmol/L    (N < 26 μmol/L)

IN THE NEXT 6 MINUTES:

• OBTAIN A FOCUSED AND RELEVANT HISTORY

At the next station, you will be asked to answer questions about this patient.

GIVE TWO (2) LABELS TO THE EXAMINER.

 

Examiner checklist
Attempted
only
Completed
satisfactorily
 


1.0 Elicits symptoms of acute hepatitis
1.1 Right upper quadrant pain
1.2 Jaundice


2.0 Elicits symptoms of cirrhosis
2.1 Hematemesis or melena
2.2 Abdominal distention
3.0 Elicits history of alcohol use
3.1 Quantifies alcohol intake





4.0 Elicits risk factors for viral hepatitis
4.1 Intravenous drug use
4.2 Travel history
4.3 Unprotected sexual contacts





5.0 Elicits personal and familial medical history pertinent to liver disease
5.1 Family history of liver disease
5.2 Current medication use [including prescribed, over-the-counter and herbal]
5.3 Hepatitis B immunizations
Interaction Rating Scale
Interviewing skills
(one bubble only)
Inadequate performance
Marginal performance
Adequate performance
Superior performance
  • Gathers relevant biomedical and psychosocial information
  • Establishes a timeline or sequence of events
  • Elicits pertinent positives and negatives as they relate to the differential diagnosis
  • Uses open and closed-ended questions
  • Avoids jargon and leading questions
  • Clarifies and summarizes what the patient has said
Component 2 – Candidate instructions
  • Record your answer(s) to each question by filling in the bubble(s) in front of your answer(s) with pencil.
  • To change an answer, completely erase the bubble you do not want counted.
  • Only clearly filled bubble(s) will be scored. The following marks CANNOT be scanned: ×, √, 
  • If you fill in more bubbles than specified in the question, that question will be scored ZERO.
  • Ensure your candidate label is placed as indicated.
  • Initial in the box in the top right-hand corner of your exam sheet.
Raymond Bedford’s physical examination was normal. You ordered repeat tests of the insurance assessments. The results of the repeat liver enzyme tests are as follows:
Aspartate aminotransferase (AST) 254 U/L (N = 18‐ 40 U/L)
Alanine aminotransferase (ALT)
246 U/L (N = 17‐ 63 U/L)
Alkaline phosphatase 116 U/L (N = 38‐126 U/L)
Bilirubin (total) 24µmol/L (N < 26 µmol/L)
Albumin 37 g/L (N = 35‐50 g/L)
INR 1 (N = 0,9‐ 1,2)
Q1. Choose the THREE most likely diagnoses for the patient’s abnormal blood testing.
[Maximum of THREE answers]



 2


 2
 2





 1



1.1   Acute hepatitis A
1.2  Acute hepatitis B
1.3  Acute hepatitis C
1.4  Alcoholic hepatitis
1.5  Autoimmune hepatitis
1.6  Cholelithiasis
1.7  Chronic hepatitis B
1.8  Chronic hepatitis C
1.9  Cirrhosis
1.10 Fatty liver
1.11 Gilbert disease
1.12 Hemochromatosis
1.13 Hepatocellular carcinoma
1.14 HIV
1.15 Infectious mononucleosis
1.16 Primary biliary cholangitis
1.17 Toxin‐induced hepatitis
1.18 Wilson disease
Q2. Until further laboratory investigations are available, what advice would you give to the patient? [Maximum of THREE answers]
 3




 1




 1



2.1   Alcohol cessation
2.2   Antiretroviral therapy
2.3   Chelating agent therapy
2.4   Fluid‐restricted diet
2.5   No driving
2.6   No sharing of toothbrush
2.7   Notification of sexual contacts
2.8   Phlebotomy
2.9   Prednisone treatment
2.10 Protein‐restricted diet
2.11  Safer sex practices
2.12 Screening of family members
2.13 Sick leave
2.14 Ursodeoxycholic acid prescription
Q3. The patient is a hospital housekeeper. Based on the information available at this time, what is your public health notification responsibility? [Maximum of ONE answer]
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3.1    No responsibility to report this to public health
3.2   Flag medical record with infectious disease warning
3.3   Inform employer of patient’s medical condition
3.4   Inform motor vehicle licensing authority of patient’s medical condition
3.5   Inform occupational health service of patient’s medical condition
3.6   Inform other health care team members of patient’s medical condition
3.7   Inform patient’s wife about his medical condition
3.8   Inform union health and safety representative of the infection
3.9   Report this infection as an occupational‐related illness
3.10 Report this infection to the local public health authority
3.11 Require testing of patient’s wife and children for hepatitis infection

Maximum score: 15