ECG exam for Cardiac Technicians

I have just purchased these set of books on ECG during the American College of Cardiology Congress. It consists of a textbook that contains comprehensive ecg learning, plus a small pocket size ecg criteria book that makes quick and easy reference possible.
I think they will make great learning material for my Cardiology technicians. Especially because they are going for the ECG exam soon.
The textbook is quite straight forward, not very didactic. In fact it is presented in a very practical way with lots of exercise in interpreting ECGs. There are over 80 ECGs to test your skill, followed by pop quiz. The explanations are clear and concise. I think this is the most practical way of learning ECGs for doctors, medical students and other paramedics.

The conference is over, the learning continues

I just discovered the best alternative of attending a conference. You don't have to travel that long distance, no hassle, little cost. Just sit at home or work and 'attend' the conference online. This is for real.
For long they have got all this webcast that come with all those major conferences like ACC, AHA, ESC Congress, EuroPCR. However, I never explored fully into. I knew of the European one, that sell you a CD or package that contain most of the scientific session. However, it all make a stunning revelation when I discovered ISCIENCE, an ACC package that allow you to follow all of the sessions of the American College of Cardiology Scientific meeting. I said all, because, that's what they are offering. For the delegate, you get up to $700USD discount on limited period, the deadline was yesterday, so I purchased it and was utterly impressed.
Though they have yet to post me the complete package, immediately following payment I was able to get online to the program website. And bingo, I can watch every session, fully videod with slides, just like attending the conference physically. Fantastic! I have started to watch a few sessions - which I missed during the conference.
The good thing is, even if you don't go to the conference, you can still purchase this package, of course at much higher price. Perhaps, it is easier to get sponsorship to BUY the package, than attending the congress itself, as it cost only a fraction of the full sponsorship! Or you can buy at your own cost, still worth the money, one full year of education! What a comprehensive digital library of scientific presentations, containing over 300 hours of sessions, great video quality. Continuous learning made so easy now!

Final Year Exam: New curriculum, new exam, old examiners...

It's exam time again. The new FINAL MD exam format has been so much publicised, now is the test time. It's supposed to be more objective, fair and efficient too.

Today is my first day examining. The first surprised is, no more big group of examiners, like 4 or 5 examiners in a group, instead, each examiner group consists of just two examiners. I saw an anaesthetist paired with a Surgeon, so the lucky candidates will escape grilling by the Medical examiner. Anyway, in fairness, many of those experienced examiners are so capable that they can test candidate on their general medicine. I can testify this, as I am sitting with a veteran Paediatric Professor and she could have conducted the exam by herself as she could smoothly quizzed the candidate presenting General Medical case...

First candidate was detected early as a failure - for the reason that he 'found' large hepatosplenomegaly on a patient presenting with nephrotic syndrome, without any physical signs! Furthermore he claimed that the patient had generalised crepitations, which was negative.

The good thing about the long case exam this time, there are only two examiners for each group, so you got more time to ask the candidates. And second, you are also given the time to 'vet' the patient, just before examining the candidate.

WE later found this rewarding, as our third case was a very talkative patient (a musician) who turned out to have no active complaints, and on questioning was rather denial of any previous history apart from his repetitive narration of his cerebellar infarct.

We are also required to 'waitage' the marks ie out of the 6 section: History, Exam, Diagnostic ability, Investigation, Management, Interaction with Patient. Unlike the previous exam where all those sections more or less carry the same marks, this time around, it is up to the examiners to decide at the beginning of the exam, how much mark (out of 30) each of the section allocated. We are also required to document the Criteria for Passing ie what critical data or findings that must be presented by candidates, in order to deserve a Pass.

And I have heard about the 'Manned OSCE' too - basically a very much robotic exam. So, all candidates beware, sometime, there are many disadvantages when examiners are not allowed to interrupt or give hints - this could be good or bad depending on the candidates, and the cases. Therefore, each candidate must ensure they conduct examination with the appropriate approaches and techniques - as each of the technique may draw mark, leaving a particular part of exam means you will miss a mark. There, theoretically, a person, in his rush and enthusiasm of passing exam, perform a lot of unnecessary examinations, or repeat certain manouvers several times, and yet this will not disqualify him as long as he has performed all those in the examiners checklist!

I wish all the Year 5 candidates best of luck, may God help you and make it easy for you.

VIDEOS ON BASIC CLINICAL EXAMINATIONS

This St. George's University Online program on YouTube provides excellent series of videos on clinical examination, even history taking. I hope my students can look at them and give me feedback.
May I remind you ever again, there is no substitute to clinical, own personal experience. You will not become a good history taker, no clinical examiner, just by watching videos! So, watch, learn then apply.
The link is http://www.youtube.com/sgulcso#p/u/7/CrqNa9a9PZY. The St. George's link itself is at http://www.elu.sgul.ac.uk/cso/

MMED: Whose faults if candidates don't shine?

The MMED examinations were just over. Pass rate for Part I, II and III (UKM centre) were 63%, 76% and 100% respectively. Well done and congratulations to successful candidates. To the unfortunate ones, my advise: Failure is just another way of discovering how NOT to do things right. So, do look back, and ponder upon yourself. Start by looking at YOU, before thinking of the examiners and patients, or unfriendly-looking invigilators!

Though I have always been on the candidates' side, I have to admit, as we get more and more familiar with both undergraduate and postgraduate examinations, as examiners, I realise the very one quality that we badly need: being objective. So, beside having 'kesian' etc., we need to be objective. Furthermore, I begin to suspect, there may be relationship between bad examination performance and actual clinical practise - this is yet to be subjected to a longitudinal study...

So, basically as examiners, we need to be objective when it comes to assessing the candidates. During the exam of course, we even have to put aside our 'opinion' on candidates outside examination (ie a candidate may be excellent in the exam, but in the ward he or she is so-so but this should not influence our judgement). Weakness or failure in one particular aspect of examination does not automatically fail you. For example, an (external) examiner gave 8/10 marks to a candidate in the long case, when in actual fact she missed a gross hepatomegaly. He argued that she had made a thorough assesment, discussed the diagnosis and management well and answered all questions appropriately.

There are a few comments by the examiners, worth noting here. Surprisingly, in the Part II short cases, out of 30 candidates, there was only ONE candidate who passed ALL the short cases! Every other candidate failed at least one short cases, and most failed badly ie given a mark of 3. Many failed the CVS and Neurology stations. More surprisingly, many were discovered to display poor examination techniques, and missed gross physical signs like past pointing in cerebellar syndrome, or prothetic click in an MVR. There were a number of candidates who failed 2 short cases, total average score in short cases <50%,>50%, but still failed the overall exam because he failed 3 out of 4 short cases.

Calibrating the examiners - Has the gap narrowed or remains in status quo?

Hot Tip MMED exam

It was Sunday, Mother's day. And we also got a wedding to attend – one of our Department's senior staff getting married. And yet, we 'were forced' to congregate at UMMC early morning at 8am for the Exam Calibration. The event supposed to last the whole day, therefore ruling out the possibility of celebrating either of the above social occassions!

I intended to attend, but slightly off the starting time, expecting that the crowd will congregate slowly in view of Sunday. I was right - despite nearly losing my way driving on the new Duke's highway to PJ, I still managed to arrive just past 8.30am. As I steered my 4WD to the parking, I spotted a familiar maroon merc, no doubt I immediately recognised that a 'Hawk' and a 'dove' couple is on its way – so I know that, even if I was late, I was not the only one!

The purpose of this Exam calibration is to close the gap (disagreement/discrepancies) between examiners (in awarding marks to candidates), and hope that examiners will be more objective in marking the candidates, and hence come close to consensus. Sadly, I doubt if it achieved its objective, all I learn from this meeting is – there are those 'hawks' most of those prominent professors, who will stand by their views no matter what, so if I got paired with anyone of them, tough luck, I may end up agreeing with them. There were many 'doves' certainly, but I quickly found out that 'doves' may easily get 'eaten' away by the Hawks, therefore end up agreeing with them...

Let me give you a brief highlight of what's happening. We were given two cases – one long and one short. Each of us was instructed to mark the candidates. Then we split in groups, each group discuss the candidate and come to a consensus on the final marks. The results? Shocking...

First candidate – long case. A complex case of longstanding hypertension, developed resistant hypertension, only diagnosed with Conn's after nearly 30 years of treatment. Concurrent diabetes/IGT. The case was presented in comprehensive way. Candidate arrived at correct diagnosis. Assesment of patient in term of HTN complication, CV risk etc a bit deficient. I initially was a bit flustered and thought that he should be marked down, perhaps a borderline pass. But it all depends on 'prompting' the candidate. In the video, the examiners did not actually attempt to probe deeper into this. There were clear questioning on the social aspect, interpretation esp ECG (which the candidate was hesitant), but not so much on patient's assesment. Perhaps it was not a very good long case after all, but candidate could certainly do better.

Sow, how do the examiners mark him? The range of marks were 4 to 6 (4 – borderline fail, 6 – clear pass). A prominent Professor A gave him a mere 3, when asked to comment – he simply said:

I assess this candidate by comparing him to me. I do not think he is equal or better than me, no, not all.

I must make it clear that this is a postgraduate exam – all this candidate did was telling us story! An undergraduate candidate can do the same – what is the difference between him and a year 5 student – none. So, how can I pass him?

External examiner 1 – I passed him, gave him 5. I think there is patient factor here, we cannot confidently say that this candidate was not objective enough.

External examiner 2 – I initially gave him 4 (borderline fail) – he missed assesment of this patients risk eg. IHD, end organ damage etc., if they were negative, they were important negative. However, I also rely on local people, how you set the standard.

Prominent Prof. B – This candidate has not done anything – has not outlined the problem at all – he failed social assesment (simply because he forgot to ask patient about his wife's condition!). No comprehensive assesment of clinical organ damage, CV risk. Did not clarify, why patient still hypertensive post operatively. So I gave him 3!

'Doves' group – well, we think the candidate has addressed most of the problems, he did miss a few things like social aspect, important negative findings etc., but he got most of the stuff – we gave him 7!

Take home message – if you are a candidate – please pray you get those 'doves' then you will be safe or even a chance to get honours grade!

Err, yes, Prof. Wan did mention in his opening, a candidate approaced him and asked him, please, please Prof, pray for me. He replied, I prayed for all of my students. But the candidate insisted, please, make a special prayer for me. He was puzzled, so he asked for clarification. The candidate immediately replied – please, pray that I will not get Professor A in my exam! (A here did not refer to the earlier A above!).

Next were were shown a candidate performing on a short case. Mixed mitral valve disease, query IE. Previous mitral valvuloplasty, so the MS sign was no longer prominent.

Range of marks – again between 4 to 6. This time, only one group (that is mine!) awarded the candidate with a 6 – after finalising our initial score of 5.5.

Prof. B – This candidate should be failed, given a 3. He missed displaced apex (got it on prompting). He did not check RF delay (is there a need?), did not qualify how to accentuate a diastolic murmur (wow, sounded like a prominent cardiologist).

Prof. C – In fairness, he looked confident. He got the apex, on second prompting. His technique was good overall, we did mark him down for missing the apex, but his overall is clear pass, therefore we gave him a 6.

External 1 – We gave him 5.5, then we finalise by rounding the number, to 6. His overall performance is satisfactory, missing one or two things, but he showed confident techniques to elicit those signs.

External 2 – I gave him a pass (I can't recall whether he said 5 or 6) – his performace was satisfactory – good cardiovascular examination to a standard of a physician.

What about the 'doves group' (they were sitting at the same corner, so I conveniently put them in the same group). Surprisingly, perhaps after listening to prominent Prof. A words, they have now realised their 'naivity' and now prepared to go on the invasive. So, what did they say:

We gave him 4. He missed a few things. Assesment not very systematic. Caused patient discomfort, as he did not ask permission for the second examination. He also missed important signs like apex beat, and made up loud P2...

Take home message – don't pray you get a 'dove' in the exam – in case the dove has been brainwashed by the hawks!

At the end of the session, I approached Prof. C and aired my confidence and relief on her – Prof, glad to know that you are so fair, and going to pass most of our candidates...

Then I patted Prof. B's back, and remarked – I am sure you just did that for exercise, in the actual exam, I believe you are kinder and much more lenient! Perhaps, to defend himself, he simply said: In the exam .... I will smile a lot at them, but still give them a 3!

So, the lesson – there are three factors that influence your performance in the exam. They are: the patient, the examiners, and YOU. Two of them, you cannot change, it is entirely up to destiny which patients and examiners you will get. However, if you prepare to be the highest standard candidate, then you will sail through the exam, God willing.

In summary, I attached a table on Criteria of Assessment for Long and Short cases

LONG CASE

(remember, you will be marked on all of these aspects, be prepared!):

Only two markings (4 – borderline fail, 6 – clear pass) shown, the marks range between 0 – 10.

Clear Pass (6)

History – emphasis on appropriate details, appreciates subtleties, interpretes significant aspects of the history.

Exam – includes important relative negative signs, appreciates significance of more subtle signs

Synthesis & Priorities – Confidently identifies essential problems, shows maturity in recognizing lesser issues

Impact of Illness on Patient/Family – Shows persistence in exploring subtle psychological issues, or issues that impact on the patient or family

Management Plan – proposes appropriate management plan with good understanding of social impact lifestyle and psychological aspects of disease, good use of discriminating investigations, accurate interpretation of results

 

Borderline Fail (4)

History – Poorly organised, omission of some key issues, need to clarify important details

Exam – omission of some important physical signs

Synthesis & Priorities – Problems poorly prioritised, significant problems undervalued

Impact of Ilness – Fails to recognise some important aspects of the disease on patient or family, misses some aspect affecting functioning or reaction to illness

Management – Lacking confidence and including some errors in arranging a management plan, erratic and non-discriminatory use of investigations, errors in the interpretation of tests, lacking some apprectiation of complication of treatment

 

SHORT CASES

Again, you will be marked on the following aspects. (15 minutes each case, 4 cases)

Clear Pass (6)

Approach to Patient – Introduces oneself, preserve patient's modesty, request permission for sensitive aspects of examinations

Technique – Systematic, not smooth

Findings and Interpretation – Identifies all essential signs, correctly interprets all major findings

Diagnosis, Differential Diagnoses – Able to give diagnosis with confidence, able to carry out a satisfactory discussion

 

Borderline Pass (5)

Approach to Patient – Less than the above (vague!)

Technique –Not smooth, require prompting before proceeding to the next step

Findings and Interpretation – Require prompting

Diagnosis, Differential Diagnoses – Not confident with diagnosis

 

Borderline Fail (4)

Approach to Patient – Less than the above (what's the difference with Borderline Pass?)

Technique – not Systematic, require prompting on two occassions

Findings and Interpretation – require prompting on two occassions

Diagnosis, Differential Diagnoses – require prompting

 

Finally, very best of luck in your exam. I pray that you will be in your best form, get the right patient and the right examiners, so you will sail through the exam.

HOT TIPS FOR MMED

First of all, let me tell you the experience of sitting in a panel of 'MMED exam Vetting'. The panel is led by a senior Professor and members represent lecturers from all the three universities. Each of the University will be given 'assignment' eg. To pick a number of questions on Cardiology, Neurology etc. Each of those questions, be they MCQ, MEQ whatever, will be discussed. Here's how they select the questions.

First, the question must be easily understood by all the members present. If one of the members strongly object a question with good reason, most likely the question will be turned down.

Second, for MCQ for example, it should be 'answerable' by all the members in the panel. Generally if most of them think they can answer 3 out of those 5 items, the question is considered ok.

They will then go on to change wordings and phrasing of the question as necessary.

Where all the members are unable to explain certain doubts, they will either refer to 'Google' the material on the internet, or simply ring the respected specialtists to get clarification.

Sometimes they do change the questions completely, in order to make the question more 'understandable' and 'answerable'.

For MCQ, of course you understand what is called Bloom Taxonomy (I don't really, just know it superficially…). Each question can be given a grade of difficulty and whether it tests comprehension, deduction, logic etc. Good set of MCQs should contain mixtures of those.

What I am trying to put across here, is that, the examiners also have 'difficulty' in creating and finalising questions for the exam. Since all of them are Generalists and Specialists in their field, when it come to subjects beyond their specialty, their knowledge is probably just above an average MMED candidate! (Presumably their vast amount of experience in Medicine help them to understand things in broader sense…). Knowing this could be very useful, since then, you probably think that, no question is really difficult. If you find one as such, it is either you have not been studying (enough!) or that there are certain wordings or terminologies in the question that you need to understand deeper. Once this is overcome, you should be able (as an average performer) to answer at least 60% of the questions correctly. This applies to MCQ, MEQ, Problem solving etc.

Sample of MEQ

Unlike Problem solving, in MEQ information is presented in stage. You should answer each package on itself, ie based on the currently presented information. Basically, step by step approach. It is common that in MEQ, you will not have any clue of what is the final diagnosis till near the end. So, just go by the flow…

Package 1

A 45 year old lady was admitted due to chronic cough and difficulty in breathing. She was well until about three months earlier when she had productive cough and fever. She was admitted to a private hospital and treated as community acquired pneumonia. Her symptoms partially improve after one week admission.

She continued to cough with whitish sputum. There was no haemoptysis. She claimed has normal appetite but has lost about 7kg of weight. She is non-smoker. Her grandfather has pulmonary tuberculosis.

On examination, she was mildly dyspnoeic. She was not pale or cyanosed. Her temperature was 37.5C.There was no lymphadenopathy. There was fine crepitation heard over the right middle and lower zones. The left lung was clear.

1. Discuss the differential diagnosis
   

Your differentials should cover broad possibilities like unresolving pneumonia, cryptogenic organising pneumonia, atypical pneumonia, absess/empyema, Pulmonary TB and lung Ca

1. List 5 investigations that you would like to do at this stage. Give reason
   

Remember, at this early stage, you are talking about basic investigations that include things like CXR, ABGs, FBC, Blood/sputum cultures, atypical pneumonia titres and perhaps Mantoux

Package 2

A 45 year4 old lady à chronic cough and difficulty in breathing à loss of weight à crepitations over the right middle and lower zones.

The results of investigations were as follows:

1. Blood count
   
2. Hb 9.8
   
3. TWBC 8.6
   
4. Plt 250,000
   

2. ESR 110mm/hr

3. Arterial blood gases

pH 7.36

pO2 77

pCO2 38

HCO3 23

O2sat 91

1. Mantoux test 9mm at 72 hours
   

CXR:

Comment the above investigation results

Describe the abnormalities seen in the CXR

(Xray showing Alveolar opacification of the right lower zone obscuring the right hemidiaphragm and lower end of the right heart, suggestive of consolidation)

Package 3

A 45 year old lady à chronic cough and difficult in breathing à loss of weight à consolidation over the right lower zone

CT scan of thorax was performed

1. Describe the abnormalities in the CT scan
   

Massive right pulmonary consolidation involving right basal segments of the right lower lobe and middle lobe

1. State the differential diagnosis of the CT findings
   

Lung Ca, Connective tissue disease

1. State further investigations that you would like to perform
   

Autoantibodies, bronchoscopy and transbronchial biopsy

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe

The screening for connective tissue disease was negative.

Bronchoscopy and transbronchial biopsy was performed. The histology was reported as bronchoalveolar cell carcinoma.

1. State the stage of her lung cancer
   

Since it involves both lobes, this is advanced lung Ca stage 4

1. Outline the management of her lung cancer
   

Include everything from counseling the patient on diagnosis, counseling the relatives, palliative chemotherapy, treat underlying infection, manages her electrolyte balance etc.

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe à bronchoalveolar carcinoma

She agreed for palliative chemotherapy. While waiting for chemotheraphy to be administered, she suddenly develop sudden onset of chest pain. It was associated with worsening dyspnoea. On examination she was dyspnoeic and tachypnoeic. The blood pressure was 120/70 and HR 120/m. there was no new respiratory or cardiac findings on examination.

What is the most likely diagnosis?

Didn't know? Has got to be PE

State 3 further investigations that you would like to perform.

CXR, arterial blood gases, D-dimers, CTPA

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe à bronchoalveolar carcinoma à sudden onset of chest pain

Her ECG revealed sinus tachycardia. She is hypoxaemic. A CTPA confirmed a pulmonary emboli in the right main pulmonary artery.

Outline your management at this stage

This is on how to manage PE. Goes from option for thrombolysis to short and long term anticoagulant. Screen the peripheral limbs for DVT

PROBLEM SOLVING

A 50 year old man presented to the A n E Department. He had been unwell for the past 3 weeks with fever, night sweats, non-productive cough and loss of appetite. He woke up on the morning of admission coughing out red blood, feeling breathless at rest and unable to move his right foot fully.

Examination whowed he had a respiratory rate of 40 breaths per minute. Blood pressure was 140/80 mmHg, pulse 110 regular, temperature 39C. there wer multiple splinter haemorrhages in all fingers of both hands. His maxillary sinuses were tended to palpation. A soft systolic murmur grade 2/5 was heard at the left sternal edge with no radiation. There was bronchial breathing dound in the upper zone of both lungs. Power of right ankle dorsiflexion was 2/5. No rash or peripheral oedema was noted.

Hb 9.7

WCC 6x109

Plt 733x109

Na 138

K 5.5

Urea 29.3

Creatinine 344

Albumin 30

Ca 2.24

Alt 30

ALP 63

Urine analysis

Protein 0.25

Ery 22/ul

Leu 1/ul

Red cell casts found

CXR :

Consolidation with several cavitaging lesions measuring 3-4 cm in both lung apices

Blood cultures x 3 no growth

1. Give four important interpretations of the investigations shown (8marks)
   
2. State one complete unifying diagnosis
   
3. Suggest three further investigations to confirm the diagnosis, stating also the results you would expect (6)
   
4. Outline your short and long term management of this patient
   

1. Acute renal failure (Ca normal)
   

Glomeruolnephritis (RCC)

Cavitating pneumonia/pneumonitis

No evidence of bacterial infection

Normocytic anemia (1 mark)

1. Wegener's Granulomatosis (2) with renal (1) and pulmonary (1) involvement with mononeuritis multiplex of the right common peroneal nerve
   

1. ANCA testing – positive c-ANCA, positive also for proteinase 3 antigen
   

Renal biopsy – pauci-immune glomerulonephritis (+- crescents)

Nerve conduction studies – mononeuritis multiplex of right common peroneal nerve

Sural nerve biopsy – vasculitis of vasa nervorum

Echocardiography to rule out presence of vegetations/myxoma

1. Ensure adequate oxygenation
   

Fluid resuscitation with central venous monitoring

Careful monitoring of renal function

Renal replacement therapy if needed

High dose corticosteroids (either IV methylpred or oral pred 1mg/kg)

Cyclophosphamide (oral or pulsed intravenous)

Plasmapharesis

IV immunoglobulin

A 27 year old lady, G3P2 at 10 weeks pregnancy complained of acute onset of left sided weakness for 4 days duration. She had history of severe vomiting prior to the weakness. On the day of admission patient initially developed focal seizures involving the left upper limb and lower limb with secondary generalization, which lasted for few hours. Her 2^nd child was 6 months of age and she had no family history of epilppsy. Examination showed L hemiparesis. Other systems were unremarkable.

State 2 differential diagnoses

Ischaemic stroke – due to preeclampsis, HPT, SLE, antiphospholipid syndrome

Venous infarcts – due to sagittal sinus thrombosis

Space occupying lesion – tumour, abscess

Intracranial haemorrhage – AVM, aneurysm

State 3 investigations required for this patient

CT brain/MRI

Connective tissue screening

EEG

If CT normal – LP

State your immediate management

Control seizures – IV diazepam/phenytoin

Hydrate patient

Start anticoagulation

As for MCQs, questions that test knowledge per se, should be able to be tackled in a very straight forward way. It is either you know or not! Eg.

Regarding treatment for Heart Failure:

1. Addition of ARB on ACE-I improves prognosis
   
2. Digoxin reduces rate of hospitalization
   
3. Betablocker is contraindicated in NYHA functional class III
   
4. Calcium channel blocker increases cardiac death
   
5. Warfarin reduces risk of stroke
   

All of the above questions, are derived from clinica studies some of which as old as 15 or 20 years! Though you can make intelligent guest, one who has read reasonably extensively, and perhaps attended some of the cardiovascular symposium would have answers to the above within seconds. Correct answers are TTFTT.

Questions that test knowledge can be very straight forward (if you know) or can be 'difficult' one – if you have not enough grasp. In this case, perhaps you should limit your attempts with what you know, it's mostly safer that way. So, even if they are pure 'recall' test, they are not necessarily easy! Eg

Regarding management of severe sepsis

1. Clinical trials have failed to consistently demonstrate a difference between colloid and crystalloid in the treatment of septic shock
   
2. Norepinephrine has been sown to be superior to dopamine as a vasopressor in patients with persistent hypotension despite fluid resuscitation
   
3. Elevated serum procalcitonin levels is a good predictor to distinguish sepsis from nonseptic systemic inflammation
   
4. The time to initiation of appropriate antimicrobial therapy is a strong predictor of mortality
   
5. Combination therapy has been proven to demonstrate superior overall efficacy compared to monotherapy in gram-negative septicaemia
   

Like the question on digoxin in heart failure, stem B test our very fundamental grasp on daily clinical practice, since we mostly use NE over dopamine in septic shock. So those clinically orientated people will straight away answer True! However, all of these statements are backed by evidence, so it is either you know the evidence or not. If you don't, better not attempt it. If you know half-half, perhaps you can attempt it…correct answers TFFTF

In general, many of the less common diseases or syndrome for instance, if they are asked, the questions will be of those 'recall' type. They are seen as difficult, but if you have come across them or learn them somewhere, you are the lucky one. Eg

Tuberous sclerosis (err when did I last hear about this?)

1. Is inherited as autosomal recessive
   
2. Is characterised by the development of multiple hamartomas distributed at various sites throughout the body
   
3. Tends to affect bone marrow
   
4. The earliest visible sign is facial angioma
   
5. Mental retardation is a feature
   

Either you know or not, isn't it? Of note, the vetting committee usually will not allow statement like B to appear, because they are actually a combination of two sentences, therefore, if one part of it is false, the whole sentence becomes false. This is considered unfair to canditates. Same like in C, you will not come across answer like 'Tends to affect the skin, brain, eyes and bone marrow' – since, though this statement appears wholly true, the truth is now 'contaminated' by the eyes!! Correct answers for the above FTFFT.

Another example in rheumatology

Regarding viral infections and inflammatory arthritis:

1. Parvovirus B19 infection is known to lead to chronic erosive arthritis
   
2. The arthralgia of Chikunguya infection responds to corticosteroids
   
3. Infection with HIV improves rheumatoid arthritis activity
   
4. Infection with HIV improves psoriatic arthritis activity
   
5. Symptoms of reactive arthritis will improve is the original viral infection is treated
   

I hardly could recall the above, but it sounds like B is true, E is false. The rest…guestwork? Correct answers here TTTFF

While some questions test your knowledge plus deduction eg

Transfer of patients with ST-elevation MI to Percutaneous Coronary Intervention Centres should be considered in the following situations

1. When fibrinolytic therapy is unsuccessful
   
2. When cardiogenic shock occurs
   
3. Patients presenting less than 3 hours of chest pain onset
   
4. In patient presenting with large anterior infarcts, 6 hours from the onset of pain
   
5. In asymptomatic patients with late presentation
   

Some of this information can be obtained directly from the guideline, while others require your logic and deduction, understanding the pathophysiology of acute MI. Correct answers TTFTF

This one tests understanding:

A 78 year old man had sudden onset of right sided hemiparesis two hours ago. The following are true:

1. Hypertension is the most important risk factor
   
2. The presence of dysphasia indicates cortical involvement
   
3. Aspirin cannot be given before a CT scan of the brain is done
   
4. Recombinant tissue plasminogen activator (r-tPA) is indicated if the CT scan shows the infarct
   
5. Blood pressure of 180/90 mmHg should be treated with IV antihypertensive agent
   

Whatever it is, E definitely sounds false even to orginary laymen…correct answers TTFFF

Some do test mixture of scientific and clinical knowledge, almost a pure recall too, but it calls for your understanding of the subject eg

Regarding COPD

1. Best documented genetic risk is present of circulating inhibitor of serine protease
   
2. The risk for COPD in smokers in dose-related
   
3. The pattern of inflammation is characterised by neutrophils, macrophages and B-lymphocytes
   
4. Emphysema is most associated with gas exchange abnormalities than with reduced FEV1.
   
5. Pneumococcal polysaccharide vaccine is recommended for patients > 65 years old.
   

Correct answers TTFTT