CASE 1: PRIMARY BILIARY CIRRHOSIS (FULLY DIALOGUED) 643
Case 1: Primary biliary cirrhosis
(fully dialogued)
Candidate: Good morning, my name is Dr. David Brown, thank you for agreeing to
participate in this exam.
Patient: No problem.
I might just quickly tell you that this exam is a very important part of our
training, and I only have a short time to gather as much information about
your medical history as possible. I may interrupt you from time to time, but
it’s only in the interest of getting the whole story. Please tell me if there is any-
thing I miss or anything you feel is particularly important. After the history, I’ll
examine you as well. Is that ok with you?
Sure, that’s fine doctor, go ahead.
Great, I’ll start by taking your full name, age, and where you’re from please.
Ms Sandra Murphy, I’m 45 and I’m from Dublin.
Ok Ms Murphy, may I ask you when and why you came into hospital on this
occasion?
Well I’ve been unwell for a long time really. I was admitted 3 days ago. I’ve
had liver problems for some time.
I see . . . But what was it in particular that made you come into hospital this
time?
I’ve just been feeling more and more tired. I can’t do anything at all.
I’m sorry to hear that. I’ll get back to that in one moment if you don’t mind –
you said that your liver was the problem. Have you been attending a consultant’s
clinic for this problem?
Yes I have – Dr. Cole . . . I usually see him about once a month. In fact my
GP called him up because he thought I looked dreadful, and I was told to
come into the hospital.
I see . . . were you ever told what was wrong with your liver?
He said it was primary biliary cirrhosis (PBC) about 4 years ago. He told
me it was to do with my immune system.
I understand. So you’ve been feeling very tired of late. Do you remember when
you last felt well?
I was actually doing pretty well until the last month . . . then I just started
getting progressively weaker.
0 Top Tips
• Try to ask one question at a time, otherwise the patient may not give
all the required information*!
(*Multiple questions may be asked in this sample case in the interest of
space.)
,644 CHAPTER 9 MRCPI
Is your appetite gone? Have you lost weight?
Yes, I just don’t have the taste for food, and I’ve lost about 1 stone in the
last few weeks.
Have you been feeling sickly or even vomited? And has your bowel habit
changed at all?
I feel a bit nauseated at the moment, but I haven’t vomited. My stools are
just the same.
Do you have any other complaints? Like pain, cough, fevers or itch?
Well I’m always itchy, but it is manageable. No pain, cough or fevers.
Do you have problems with a dry mouth or dry eyes?
Actually my eyes have been very dry recently too – I don’t know why
that is.
Any joint stiffness or pains?
Not particularly.
PMHx
Do you have any other medical conditions, Ms Murphy?
I have diabetes and high blood pressure.
When were you diagnosed with diabetes?
I was told that I only have mild diabetes about a year ago, it was picked up
by chance. I’m just watching my diet.
I see, so do you check your blood sugars or take medications for it? Have you
been seen by a diabetic specialist?
No, my GP takes care of it mostly.
Have you had your eyes checked within the last year?
No.
How about your blood pressure? Is it well controlled?
I’m not sure, I think so.
Have you had your thyroid function checked before?
I must have, but I’m not sure.
Ok . . . just a few more questions; have you had any other problems such as
with your heart, asthma or high cholesterol?
I used to have high cholesterol, but now I take a tablet for it.
Have you been admitted for any operations or other procedures?
Well I had a camera test to look into my stomach 2 years ago, but I wasn’t
kept in for it. And I had a hysterectomy after the birth of my third child.
Did the doctors remove your ovaries?
I don’t think so.
May I ask you what medications you take?
, CASE 1: PRIMARY BILIARY CIRRHOSIS (FULLY DIALOGUED) 645
In the morning I take aspirin 75mg, one tablet of ramipril, ursodeoxycholic
acid 250mg, colestyramine 2g, and Calogen®. I take another ursodeoxy-
choic acid 250mg at lunch and again at dinner. I take one more sachet of
the colestyramine and atorvastatin 20mg at night.
Do you know what dose of ramipril you take?
No, it’s just one tablet, sorry.
0 Top Tips
• It is likely that patients will use commercial names such as Questran®
and Ursofalk® instead of generic ones. It is important to present
generic names.
• Always check for a medication record at the end of the bed, and
enquire if this list includes any new medications which have been
commenced since admission.
• Patients may not recall all dosages, and it is acceptable to state this.
• If there is no record available, and the patient is not sure, prompt
them with questions such as: ‘do you take any blood pressure tablets,
water tablets, tablets for cholesterol . . . etc.’
Thank you. Do you take any over-the-counter medications or herbal remedies?
No.
Are you allergic to any medications?
Not that I’m aware of.
Ok, just a few more questions, we’re nearly there. Are you a smoker?
No, I never smoked.
How about alcohol, how many drinks would you have in a week?
I’d say on average about 4 glasses of red wine.
Are you working at the moment?
Yes I’m a librarian, but I’ve missed so much work because I’ve been unwell . . .
and I get paid by the hour which doesn’t help.
Are you finding it difficult to cope with finances because you are missing
work?
Actually I recently received an inheritance from an aunt, so I’m fine for
the moment.
I see. Are you married? Any children?
I got divorced 5 years ago, and I have 3 children living with me.
Ok. But do you feel like you need additional support at home at present?
No, my sister and her husband have been great, they help out loads with
the kids. In fact, my kids are staying with them now.
That’s very helpful. Do you have any family history of PBC?
Yes – two of my aunts on my mother’s side had it, one of them passed
away last year. She was 62.
, 646 CHAPTER 9 MRCPI
I see. Are your parents alive? Are they well?
My mother is healthy at 82. My father died at 40, I think it was a heart
attack.
I see. Is there any other medical illness in your family? Is there any history of
thyroid disease, diabetes or lupus?
My sister has diabetes, she was diagnosed about 4 years ago and takes
tablets.
Summary/recap
So Ms Murphy I’ll just quickly go over what you’ve told me to make sure I have
it right . . . you have a diagnosis of primary biliary cirrhosis for which you see
Dr. Cole. You had been relatively well until last month, after which you began
to feel excessively tired, lose your appetite, and lose weight. You also feel
nauseated, but haven’t been vomiting.
Have I missed anything or do you want to add anything more?
No I think you’ve covered it all really.
May I ask you then what has happened since your admission here . . . have
you had blood tests or scans performed?
I’ve been getting bloods done every day, but I don’t know what the results
are yet. I had a scan of my tummy today, and I’m waiting for the result.
I see. Have you been seen by a dietician, physiotherapist, occupational
therapist or social worker?
Yes, a dietician saw me and I’ve been given some extra drinks to take now.
Ok. You’ve been very helpful – I think I have asked all the questions I need for
now. Would you mind if I go on to examine you?
No problem, go ahead.
Examination
At this stage approximately 25 minutes should have passed, leaving you
with a further 20 for examination and preparation.
Examination should proceed in the format previously mentioned
(starting with general inspection and moving to the hands etc.). This
particular patient has liver pathology and therefore the following items
must also be specifically addressed:
Specific examination points
• General:
• Jaundice
• Icterus
• Spider naevi
• Pigmentation
• Scratch marks
• Hands:
• Clubbing
• Leuconychia
Case 1: Primary biliary cirrhosis
(fully dialogued)
Candidate: Good morning, my name is Dr. David Brown, thank you for agreeing to
participate in this exam.
Patient: No problem.
I might just quickly tell you that this exam is a very important part of our
training, and I only have a short time to gather as much information about
your medical history as possible. I may interrupt you from time to time, but
it’s only in the interest of getting the whole story. Please tell me if there is any-
thing I miss or anything you feel is particularly important. After the history, I’ll
examine you as well. Is that ok with you?
Sure, that’s fine doctor, go ahead.
Great, I’ll start by taking your full name, age, and where you’re from please.
Ms Sandra Murphy, I’m 45 and I’m from Dublin.
Ok Ms Murphy, may I ask you when and why you came into hospital on this
occasion?
Well I’ve been unwell for a long time really. I was admitted 3 days ago. I’ve
had liver problems for some time.
I see . . . But what was it in particular that made you come into hospital this
time?
I’ve just been feeling more and more tired. I can’t do anything at all.
I’m sorry to hear that. I’ll get back to that in one moment if you don’t mind –
you said that your liver was the problem. Have you been attending a consultant’s
clinic for this problem?
Yes I have – Dr. Cole . . . I usually see him about once a month. In fact my
GP called him up because he thought I looked dreadful, and I was told to
come into the hospital.
I see . . . were you ever told what was wrong with your liver?
He said it was primary biliary cirrhosis (PBC) about 4 years ago. He told
me it was to do with my immune system.
I understand. So you’ve been feeling very tired of late. Do you remember when
you last felt well?
I was actually doing pretty well until the last month . . . then I just started
getting progressively weaker.
0 Top Tips
• Try to ask one question at a time, otherwise the patient may not give
all the required information*!
(*Multiple questions may be asked in this sample case in the interest of
space.)
,644 CHAPTER 9 MRCPI
Is your appetite gone? Have you lost weight?
Yes, I just don’t have the taste for food, and I’ve lost about 1 stone in the
last few weeks.
Have you been feeling sickly or even vomited? And has your bowel habit
changed at all?
I feel a bit nauseated at the moment, but I haven’t vomited. My stools are
just the same.
Do you have any other complaints? Like pain, cough, fevers or itch?
Well I’m always itchy, but it is manageable. No pain, cough or fevers.
Do you have problems with a dry mouth or dry eyes?
Actually my eyes have been very dry recently too – I don’t know why
that is.
Any joint stiffness or pains?
Not particularly.
PMHx
Do you have any other medical conditions, Ms Murphy?
I have diabetes and high blood pressure.
When were you diagnosed with diabetes?
I was told that I only have mild diabetes about a year ago, it was picked up
by chance. I’m just watching my diet.
I see, so do you check your blood sugars or take medications for it? Have you
been seen by a diabetic specialist?
No, my GP takes care of it mostly.
Have you had your eyes checked within the last year?
No.
How about your blood pressure? Is it well controlled?
I’m not sure, I think so.
Have you had your thyroid function checked before?
I must have, but I’m not sure.
Ok . . . just a few more questions; have you had any other problems such as
with your heart, asthma or high cholesterol?
I used to have high cholesterol, but now I take a tablet for it.
Have you been admitted for any operations or other procedures?
Well I had a camera test to look into my stomach 2 years ago, but I wasn’t
kept in for it. And I had a hysterectomy after the birth of my third child.
Did the doctors remove your ovaries?
I don’t think so.
May I ask you what medications you take?
, CASE 1: PRIMARY BILIARY CIRRHOSIS (FULLY DIALOGUED) 645
In the morning I take aspirin 75mg, one tablet of ramipril, ursodeoxycholic
acid 250mg, colestyramine 2g, and Calogen®. I take another ursodeoxy-
choic acid 250mg at lunch and again at dinner. I take one more sachet of
the colestyramine and atorvastatin 20mg at night.
Do you know what dose of ramipril you take?
No, it’s just one tablet, sorry.
0 Top Tips
• It is likely that patients will use commercial names such as Questran®
and Ursofalk® instead of generic ones. It is important to present
generic names.
• Always check for a medication record at the end of the bed, and
enquire if this list includes any new medications which have been
commenced since admission.
• Patients may not recall all dosages, and it is acceptable to state this.
• If there is no record available, and the patient is not sure, prompt
them with questions such as: ‘do you take any blood pressure tablets,
water tablets, tablets for cholesterol . . . etc.’
Thank you. Do you take any over-the-counter medications or herbal remedies?
No.
Are you allergic to any medications?
Not that I’m aware of.
Ok, just a few more questions, we’re nearly there. Are you a smoker?
No, I never smoked.
How about alcohol, how many drinks would you have in a week?
I’d say on average about 4 glasses of red wine.
Are you working at the moment?
Yes I’m a librarian, but I’ve missed so much work because I’ve been unwell . . .
and I get paid by the hour which doesn’t help.
Are you finding it difficult to cope with finances because you are missing
work?
Actually I recently received an inheritance from an aunt, so I’m fine for
the moment.
I see. Are you married? Any children?
I got divorced 5 years ago, and I have 3 children living with me.
Ok. But do you feel like you need additional support at home at present?
No, my sister and her husband have been great, they help out loads with
the kids. In fact, my kids are staying with them now.
That’s very helpful. Do you have any family history of PBC?
Yes – two of my aunts on my mother’s side had it, one of them passed
away last year. She was 62.
, 646 CHAPTER 9 MRCPI
I see. Are your parents alive? Are they well?
My mother is healthy at 82. My father died at 40, I think it was a heart
attack.
I see. Is there any other medical illness in your family? Is there any history of
thyroid disease, diabetes or lupus?
My sister has diabetes, she was diagnosed about 4 years ago and takes
tablets.
Summary/recap
So Ms Murphy I’ll just quickly go over what you’ve told me to make sure I have
it right . . . you have a diagnosis of primary biliary cirrhosis for which you see
Dr. Cole. You had been relatively well until last month, after which you began
to feel excessively tired, lose your appetite, and lose weight. You also feel
nauseated, but haven’t been vomiting.
Have I missed anything or do you want to add anything more?
No I think you’ve covered it all really.
May I ask you then what has happened since your admission here . . . have
you had blood tests or scans performed?
I’ve been getting bloods done every day, but I don’t know what the results
are yet. I had a scan of my tummy today, and I’m waiting for the result.
I see. Have you been seen by a dietician, physiotherapist, occupational
therapist or social worker?
Yes, a dietician saw me and I’ve been given some extra drinks to take now.
Ok. You’ve been very helpful – I think I have asked all the questions I need for
now. Would you mind if I go on to examine you?
No problem, go ahead.
Examination
At this stage approximately 25 minutes should have passed, leaving you
with a further 20 for examination and preparation.
Examination should proceed in the format previously mentioned
(starting with general inspection and moving to the hands etc.). This
particular patient has liver pathology and therefore the following items
must also be specifically addressed:
Specific examination points
• General:
• Jaundice
• Icterus
• Spider naevi
• Pigmentation
• Scratch marks
• Hands:
• Clubbing
• Leuconychia
