Station - Instructions for candidate
You are a final-year medical student working with a GP in a suburban Perth practice. The GP has asked you to review a set of results before the patient is seen.
Abraham Akol, 52, saw the GP six days ago because his wife had noticed his colour had changed. The GP's consultation note and the results that were ordered are printed below. Abraham is in the waiting room and is feeling much the same.
| GP consultation note (6 days ago) | 52 M, bus driver. 1/52 yellow sclerae and skin, dark urine, pale stools, generalised itch worse at night, mild fatigue. No abdominal pain, fever, rigors, vomiting or weight loss. Completed flucloxacillin 500 mg QID x 7 days for cellulitis L shin, finished 3/52 before this visit; shin healed. No other medicines, herbs or supplements. Alcohol 2 beers/week. No travel, no IVDU, hepatitis B vaccinated. O/E: jaundiced, excoriations forearms and shins, abdomen soft non-tender, no hepatosplenomegaly, no ascites, no stigmata of chronic liver disease, alert. Plan: LFT, coags, hepatitis serology, FBC, lipase, abdominal US; review with results. |
|---|---|
| Observations at the visit | HR 76 /min, BP 128/80 mmHg, RR 14 /min, SpO2 98% on room air, T 36.8 degrees C, BMI 27 |
Results provided:
Liver function tests, coagulation and viral hepatitis serology (taken 6 days ago)
| Item | Value | Reference range |
|---|---|---|
| Bilirubin (total) | 140 micromol/L | <20 micromol/L |
| Bilirubin (conjugated) | 110 micromol/L | <5 micromol/L |
| Alkaline phosphatase (ALP) | 480 units/L | 30-110 units/L |
| Gamma-glutamyl transferase (GGT) | 620 units/L | <60 units/L |
| Alanine aminotransferase (ALT) | 95 units/L | <40 units/L |
| Aspartate aminotransferase (AST) | 70 units/L | <40 units/L |
| Albumin | 38 g/L | 35-50 g/L |
| Total protein | 72 g/L | 60-80 g/L |
| INR | 1.1 | 0.9-1.2 |
| Hepatitis A IgM | Negative | Negative |
| Hepatitis B surface antigen | Negative | Negative |
| Hepatitis B core antibody (total) | Negative | Negative |
| Hepatitis B surface antibody | 180 IU/L | <10 IU/L (unvaccinated) |
| Hepatitis C antibody | Negative | Negative |
Abdominal ultrasound and full blood count
| Item | Value | Reference range |
|---|---|---|
| Liver | Normal size (14 cm) and echotexture; no focal lesion | Normal |
| Bile ducts | Common bile duct 4 mm; no dilatation of the ducts within the liver | CBD <6 mm |
| Gallbladder | No stones; wall 2 mm; no pericholecystic fluid | Normal |
| Pancreas and spleen | Pancreas visualised, normal; spleen 10 cm; no ascites | Normal |
| Haemoglobin | 142 g/L | 130-180 g/L |
| White cell count | 7.8 x10^9/L | 4.0-11.0 x10^9/L |
| Eosinophils | 0.7 x10^9/L | <0.5 x10^9/L |
| Platelets | 260 x10^9/L | 150-400 x10^9/L |
| MCV | 89 fL | 80-100 fL |
| Lipase | 35 units/L | <60 units/L |
Your tasks are to:
- Interpret the results printed on your sheet and state your findings to the examiner.
- State your most likely diagnosis and the differential diagnoses to the examiner, with brief justification.
- Outline your initial management plan to the examiner, including what you would tell the patient, monitoring, referral and safety-netting.
- The examiner will ask you two questions at the end.
- You do NOT need to take a history or examine the patient; the GP's findings are on the sheet and the examiner can answer brief questions.
- You do NOT need to summarise to the examiner beyond the tasks above.
- Further results are available from the examiner on request.
This is a 10-minute station, with 2 minutes of reading time.