Diagnosing what stares you in the face rather than the minutiae

I had a pretty sudden health setback in April, and I've decided to start writing about it. And I'm sharing something I've realised from the whole ordeal that I see in some of the candidates I've been coaching and training for the MEQ exams. 

The post is not for sympathy but to illustrate a common trap I see in MEQ and CEQ exam answers - providing something convoluted when the thing staring you in the face is what the examiners are expecting.

I hear a lot of "but what if there is a trick?"

Or,

"What if they want the things it might not be but they want us to mention them anyway?"

This is a real life example of why that doesn't work if you want to pass an exam.

In April I finally decided to do something about my painful right shoulder, rather than put up with it. I was diagnosed with a frozen shoulder and underwent a hydrodilatation.

As soon as the local anaesthetic wore off after about 48 hours, I was in agony. Having no experience with this procedure before, I didn't feel it was right, but I tried to wait.

I saw a GP about 5 days after the procedure who said I should go to ED as I'd had a needle stuck into my glenohumeral joint space and it would be way quicker to get it sorted there. She said it would be rare, but the one diagnosis she really didn't want to miss. So I went, despite how much I hate hospitals, and even more, being a patient. 

The ED doctor said my bloods were normal, (they weren't), and it would be overkill but I could come in for pain management.

The HMO who admitted me said because my CRP was elevated on presentation, and was continuing to rise, and that I'd spiked a temperature that afternoon, she was going with infection, and told me I had to stay in hospital. 

The surgeon who admitted me said infection was extremely rare so he ordered plain films to rule out a fracture or dislocation.

The physician who admitted me was sure it was an abnormal pain response (given I was female I suspect), or pseudogout. He charted prednisolone and diazepam, and ordered an ultrasound to search for crystals in the joint space.  

Guess who was correct?

Well the prize goes to the HMO who saw me on day 5 of admission and finally charted antibiotics. The following day I had an arthroscopy and shoulder washout for a staph infection with emerging sepsis (different surgeon).

And to a huge shoutout to the GP who first saw me and the 2 HMO's who were so thorough. They were all female. 

Three months later I am still not sorted and the whole thing has been a terrible ordeal. I'll spare you the details. 

As I said, I'm sharing this to get you to think about which doctor you want to show the examiner in the MEQ or CEQ exams. I totally understand we get presumptive diagnoses wrong all the time. I've done that myself. But when facts stare you in the face it's best not to ignore them. 

Show the examiner the thing that is staring you in the face when you read the MEQ vignette or the CEQ essay quote. Be confident enough to do that as you will be correct, no doubt. Take into account all the information in the MEQ or CEQ question, rather than think about what is not there.

After all, I had a needle stuck in my shoulder joint, developed excruciating pain, stiffness, a fever, and my CRP climbed to nearly 200. That would be in the MEQ question, not that I failed to tell anybody I slipped over and fractured my humerus or presented with a rip roaring case of pseudogout.

One of my MEQ essay questions involves a police officer who is presenting with emerging symptoms of PTSD, and you can tell that because I put him in a life threatening incident and described how he was presenting.  Some candidates offer a differential diagnosis of schizophrenia.

One of my favourite CEQ essay questions comes from a book titled "Great and desperate cures". So I'm expecting an essay that does mention cures that are great AND desperate. And I want an essay that discusses the idea of a cure in psychiatry. I know there are lots of potential marking domains but I still want an essay that discusses this. An essay that overstates the importance of the recovery model is going to annoy me. 

So, 4 weeks out, take time to consider, "am I offering everything I know about the psychiatry equivalent of acute shoulder pain?" Or I am taking the only opportunity to show the examiner that I am safe and competent. 

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