Earlier this week we posed the question: A 27 year old woman presents to your ED with RIF pain and PV bleeding. She is sexually active and uses a Mirena device. Her only gynaecological and obstetric history is an incidental diagnosis of ovarian cysts as a 22yo. A urine bHCG is positive. Which of the following statements is true? A) this patient's symptoms are likely due to an ovarian cyst B) Because this patient has no documented history of PID an ectopic pregnancy is unlikely C) This patient's use of an intrauterine contraceptive device places her at an increased risk of an ectopic pregnancy D) This patient may have an ectopic probably caused by exposure to diethylstilbestrol It's a good example of a clinically based multi-choice question that should be featuring on the new exam. Now, knowing is NOT enough - you need to able to reason as well. In the old school of examinations, simply being able to answer a "which of the following" or "pick the odd one out" from a list of answers was enough. Now, knowing is NOT enough - you need to able to reason as well.
So let's take the question above. What can we reason? 1). The patient is pregnant, which leads us to believe the pregnancy is likely to be at the core of the diagnosis. In fact, it's highly likely that this patient has an ectopic pregnancy based on the information provided. At this point any non pregnancy related answers can be excluded. So: A) this patient's symptoms are likely due to an ovarian cyst Is off our list straight away, and we are down to three possibles. The mention of ovarian cysts is a distractor - if you are going to do well in the MCQ you need to be able to recognise them, and focus on the core issues in the question. 2). The patient has a significant risk factor for an ectopic, specifically the use of an IUD for contraception. She is sexually active and uses a Mirena device. Every word in the stem is significant, and therefore it's likely that the use of an IUD (a major risk factor for an ectopic) relates to her diagnosis. Looking through the possible answers, we see: C) This patient's use of an intrauterine contraceptive device places her at an increased risk of an ectopic pregnancy In the context of the information with which we have been provided this statement is indisputably true and likely is the correct answer. 3) At this stage we have arrived at a presumptive answer. Checking our two remaining stems we can see: B) Because this patient has no documented history of PID an ectopic pregnancy is unlikely and D) This patient may have an ectopic probably caused by exposure to diethylstilbestrol Thinking about each of these statements, we can realise that PID is simply one risk factor for an ectopic. This patient has another risk factor, and a presentation clearly consistent with the pathology, so we can discount (B) as untrue. If we think about (D) we notice the word "probably", implying a high chance of causation. Although diethylstilbestrol is classically listed as a risk factor for ectopic pregnancy, it has not been manufactured since 1997. The chances of a 27 year old being exposed to it would be extremely small, given that she would have been 9 in 1997. Even if you don't know when diethylstilbestrol was last made, a fairly heuristic approach to the question would intimate that it's much less likely than answer (C). So, (C) is the correct answer. People tend to regard MCQs as a fairly straightforward part of examinations, but here at fellowshipexam.com we think they are a detailed and highly complex method of examination. Being able to approach an MCQ with a sophisticated approach to reasoning is important for your exam success. We've just spent the last week looking at the MCQ process, so that our candidates have every chance of building up their knowledge and reasoning as they progress through the rest of the course.
0 Comments
Your comment will be posted after it is approved.
Leave a Reply. |
TAKE ME TO THE COURSE PORTAL!
The fellowship facultyWe work as emergency physicians, and teach, blog and write at resus.com.au Archives
July 2017
Categories |