OETリスニング練習模試 6
Dictation
| M | : So Tereza, I see you made an appointment . |
| F | : Yes, that’s right. |
| M | : So let’s start off with you tell me a bit about when and how this all started. |
| F | : Well, it all started, I’d say about and I was late to work after sleeping through my alarm clock despite having had an early night. I remember that day clearly because it was the first time being late for work at years. |
| M | : That’s quite an accomplishment. And ? |
| F | : Well since then I’ve been feeling tired most of the time, . I mean, I’m struggling to make it through a full shift at work and I only work from 9am to 3pm. |
| M | : Yes, your hairdresser, right? |
| F | : Yes. So a couple of days ago, I fell asleep during my lunch break, and my manager told me to get checked out by the doctor. So that’s why I’m here. I also I’ve not got . |
| M | : So you mentioned being tired no matter how much sleep you get. you’re sleeping a day? |
| F | : I’ve been sleeping around a day, which is far more than than seven hours. I was sleeping a few months ago. I mean, it didn’t suddenly switch to 14 hours though. It’s just been gradually increasing over the last few months. |
| M | : What about the ? You wake frequently? |
| F | : I don’t remember waking frequently. I seem to sleep pretty well. |
| M | : Okay. And you mentioned a change in appetite. So when did it change? |
| F | : Well, my appetite is generally pretty good. But for the , it’s definitely decreased. I don’t feel nauseated or anything like that. No vomiting. I just seem to . For instance, I might have a piece of toast and then feel like I don’t need anything else for another six to eight hours. |
| M | : And any change in since you notice this change in appetite? |
| F | : No, my bowels haven’t really changed. I go on average once a day, and there’s no blood or anything. |
| M | :And the tiredness and change in appetite, how have you felt? |
| F | : I’ll be fairly well otherwise, no recent colds or anything like that. I sometimes feel hot and sweaty at night and I have woken up due to it on a few occasions. But at my age, right? I think I’m a little stressed about sleeping at work, but my mood is generally pretty good. |
| M | : And any ongoing medical problems? |
| F | : Yes, I have , but no other medical problems. I don’t take any medication. |
| M | : I have one last question. It might seem a bit weird, but please bear with me. Have you noticed any ? |
| F | : Hmm. Well,now that you mentioned that I have noticed a few weird bruises in random spots where I don’t remember hurting myself. There was one or two last week but this week there are about six. |
| M | : Yes, I can see multiple patches of potential bruising as well as conjunctival paler. But given your symptoms there are quite a few systems we need to examine. Particularly your gastrointestinal, given the reduced appetite and tiredness, the because of the night sweats and early satiety and your cardiovascular because of the tiredness.This is going to require quite a few studies to be performed. The start is a full blood count, blood film and coagulation studies. |
| F | : Do you think this is something? |
| M | : Hello Mrs Campbell, I am Dr black, so I see you have come with chest pain and some . |
| F | : Oh yes doctor. I just don’t feel quite right. I’ve had this pain in now, I’ve been feeling breathless. |
| M | : And how are you feeling right now? How bad is the pain? |
| F | : I’ve not had anything like this before but right now I’m feeling okay. I mean, I’ve got some niggling pain but it’s settling after some . And I’m not breathless at the moment. |
| M | : And so I’m going to ask a few questions about the chest pain. So the first question where is the chest pain and what kind of pain is it? Dull, sharp, crushing, constant or intermittent? |
| F | : Hmm. The pain is a of my chest. Nowhere else. It’s there all the time, and ibuprofen and paracetamol don’t take it away completely. I mean I would say it’s about at the moment. |
| M | : Does anything make it better or worse, such as deep breathing or leaning forward? |
| F | : Well, when the pain first started, I just sat on the sofa. And I’ve noticed it’s the breathing that bothers me more. I just feel I can’t catch my breath. Then when I take a , the pain is worse. Also I can just about get up the stairs at home but I have to sit down and rest. If I’m walking more than a couple of hundred meters, which is not like me at all. I’ve always been very fit. I mean I’ve never had any problem with . |
| M | : Have you ever had any other symptoms such as cough, fever, or wheezing ? |
| F | : No, I mean, I thought it might just be a chest infection at first, but I’m not had a and I’m not so I’m not sure. Definitely no wheezing. |
| M | : So Miss Campbell, you said you have no history of chest pain or heart problems. |
| F | : Correct. I’ve never had any heart problems in the past, although my mom had a heart attack at . As I said I’m normally very healthy. The only thing is I had a , but no complications and I was home within a couple of days. |
| M | : I see. So based on what you have told me about your recent surgery and other factors, you’re at risk for a . In order to be sure, we will need to run some tests. I’m going to order an ECG and CT pulmonary angiogram. |
| F | : What is that a pulmonary embolism? |
| M | : A PE as we call it involves a blockage of the pulmonary arterial tree by something that has traveled from elsewhere in the body through the bloodstream. Usually this is due to a from the deep veins and the legs. Symptoms include difficulty breathing and chest pain and clinical signs include a , which you’re not exhibiting yet, but are on the verge of, as well as tachycardia, which the ECG will show. |
| F | : Doc, would I need surgery to this? |
| M | : Rarely is an open pulmonary embolism performed. A is the most common type of management. In fact, while we work to confirm the diagnosis, we are going to start you on a , an anticoagulant commonly used for PE’s. Then once we get the imaging results we can make a final decision about what additional methods are needed to achieve .Any other questions before we get started? |
| F | : Yes, one more. If it is a pulmonary embolism, is this an ongoing problem or? |
| M | : Well because of your recent surgery, it is likely a provoked pulmonary embolism. The treatment will likely last . At that point, we would assess the risks and benefits of continuing treatment. |
| F | : Ummm…So….. |
| M | : So Tereza, I see you made an appointment because of tiredness. |
| F | : Yes, that’s right. |
| M | : So let’s start off with you tell me a bit about when and how this all started. |
| F | : Well, it all started, I’d say about three months ago and I was late to work after sleeping through my alarm clock despite having had an early night. I remember that day clearly because it was the first time being late for work at 30 years. |
| M | : That’s quite an accomplishment. And since that day? |
| F | : Well since then I’ve been feeling tired most of the time, regardless of how much sleep I get. I mean, I’m struggling to make it through a full shift at work and I only work from 9am to 3pm. |
| M | : Yes, your hairdresser, right? |
| F | : Yes. So a couple of days ago, I fell asleep during my lunch break, and my manager told me to get checked out by the doctor. So that’s why I’m here. I also I’ve not got much of an appetite. |
| M | : So you mentioned being tired no matter how much sleep you get. How many hours would you say you’re sleeping a day? |
| F | : I’ve been sleeping around 14 hours a day, which is far more than than seven hours. I was sleeping a few months ago. I mean, it didn’t suddenly switch to 14 hours though. It’s just been gradually increasing over the last few months. |
| M | : What about the quality of your sleep? You wake frequently? |
| F | : I don’t remember waking frequently. I seem to sleep pretty well. |
| M | : Okay. And you mentioned a change in appetite. So when did it change? |
| F | : Well, my appetite is generally pretty good. But for the last four to six weeks, it’s definitely decreased. I don’t feel nauseated or anything like that. No vomiting. I just seem to feel full quicker than usual. For instance, I might have a piece of toast and then feel like I don’t need anything else for another six to eight hours. |
| M | : And any change in bowel movements since you notice this change in appetite? |
| F | : No, my bowels haven’t really changed. I go on average once a day, and there’s no blood or anything. |
| M | :And aside from the tiredness and change in appetite, how have you felt? |
| F | : I’ll be fairly well otherwise, no recent colds or anything like that. I sometimes feel hot and sweaty at night and I have woken up due to it on a few occasions. But night sweats are normal at my age, right? I think I’m a little stressed about sleeping at work, but my mood is generally pretty good. |
| M | : And any ongoing medical problems? |
| F | : Yes, I have some eczema, but no other medical problems. I don’t take any medication. |
| M | : I have one last question. It might seem a bit weird, but please bear with me. Have you noticed any strange bruises? |
| F | : Hmm. Well,now that you mentioned that I have noticed a few weird bruises in random spots where I don’t remember hurting myself. There was one or two last week but this week there are about six. |
| M | : Yes, I can see multiple patches of potential bruising across the limbs and trunk as well as conjunctival paler. But given your symptoms there are quite a few systems we need to examine. Particularly your gastrointestinal, given the reduced appetite and tiredness, the lymphoreticular because of the night sweats and early satiety and your cardiovascular because of the tiredness.This is going to require quite a few studies to be performed. The start is a full blood count, blood film and coagulation studies. |
| F | : Do you think this is something? |
| M | : Hello Mrs Campbell, I am Dr black, so I see you have come with chest pain and some shortness of breath. |
| F | : Oh yes doctor. I just don’t feel quite right. I’ve had this pain in my chest for a week now, I’ve been feeling breathless. |
| M | : And how are you feeling right now? How bad is the pain? |
| F | : I’ve not had anything like this before but right now I’m feeling okay. I mean, I’ve got some niggling pain but it’s settling after some paracetamol. And I’m not breathless at the moment. |
| M | : And so I’m going to ask a few questions about the chest pain. So first question where is the chest pain and what kind of pain is it? Dull, sharp, crushing, constant or intermittent? |
| F | : Hmm. The pain is a niggling sharp pain on the left side of my chest. Nowhere else. It’s there all the time, and ibuprofen and paracetamol don’t take it away completely. I mean I would say it’s about 4 out of 10 at the moment. |
| M | : Does anything make it better or worse, such as deep breathing or leaning forward? |
| F | : Well, when the pain first started, I just sat on the sofa. And I’ve noticed it’s the breathing that bothers me more. I just feel I can’t catch my breath. Then when I take a deep breath, the pain is worse. Also I can just about get up the stairs at home but I have to sit down and rest. If I’m walking more than a couple of hundred meters, which is not like me at all. I’ve always been very fit. I mean I’ve never had any problem with lungs or heart. |
| M | : Have you ever had any other symptoms such as cough, fever, or wheezing ? |
| F | : No, I mean, I thought it might just be a chest infection at first, but I’m not had a cough and I’m not feverish so I’m not sure. Definitely no wheezing. |
| M | : So Miss Campbell, you said you have no history of chest pain or heart problems. |
| F | : Correct. I’ve never had any heart problems in the past, although my mom had a heart attack at 76. As I said I’m normally very healthy. The only thing is I had a hysterectomy three weeks ago, but no complications and I was home within a couple of days. |
| M | : I see. So based on what you have told me about your recent surgery and other factors, you’re at risk for a pulmonary embolism. In order to be sure, we will need to run some tests. I’m going to order an ECG and CT pulmonary angiogram. |
| F | : What is that a pulmonary embolism? |
| M | : A PE as we call it involves a blockage of the pulmonary arterial tree by something that has traveled from elsewhere in the body through the bloodstream. Usually this is due to a blood clot from the deep veins and the legs. Symptoms include difficulty breathing and chest pain and clinical signs include a low blood oxygen saturation, which you’re not exhibiting yet, but are on the verge of, as well as tachycardia, which the ECG will show. |
| F | : Doc, would I need surgery to this? |
| M | : Rarely is an open pulmonary embolism performed. A pharmacological treatment is the most common type of management. In fact, while we work to confirm the diagnosis, we are going to start you on a low molecular weight heparin, an anticoagulant commonly used for PE’s. Then once we get the imaging results we can make a final decision about what additional methods are needed to achieve adequate anticoagulation. Any other questions before we get started? |
| F | : Yes, one more. If it is a pulmonary embolism, is this an ongoing problem or? |
| M | : Well because of your recent surgery, it is likely a provoked pulmonary embolism. The treatment will likely last at least three months. At that point, we would assess the risks and benefits of continuing treatment. |
| F | : Ummm…So….. |
| F | : Hey, Mark. Good job, communicating with Mr Simmons. You did great job putting him at ease with the transfusion. |
| M | : Thanks,yeah, Mr Simmons has been through a lot, so I’ve tried to make an extra effort to take things slow as not to overwhelm him. |
| F | : That’s great. I just wanted to mention one thing. When you were collecting the initial blood sample, I noticed that you didn’t immediately copy the patient’s details from the identity bracelet onto the bottle. You waited to do it until later in the procedure. |
| M | :I did? And there are so many different steps in blood transfusion. Particularly when it comes to documenting and forms the initial blood sample with the form and then later documenting the time and date of infusion, as well as the monitoring. |
| F | : Yes, there’s a lot involved, which is why it is important to document every step, and to follow this procedure exactly so that you don’t forget anything. That way it is possible to go back later if there is a problem. Communication with patient is key. But patient safety always comes first. |
| M | : You’re right. Thanks for the reminder. |
| F | : So, Dr. Kyle. Now that we have carried out the cardio topography, we need to interpret it. So why don’t you get us started. |
| M | : Of course Dr. Adams. So the first thing we need to look at is defining the risk. So because of the mother’s gestational diabetes, we’re assessing this as a high risk pregnancy. |
| F | : Yes. And also because of the general absence of prenatal care, and the history of drug abuse. So what about contractions? |
| M | : Well, there were 2 in 10. And as far as the baseline rate of the fetal heart. It was within the normal range of 110 to 160 beats per minute at 120 beats per minute. So no tachycardia or bradycardia. |
| F | : But variability was not reassuring. What could be the cause of this? |
| M | : Hmm, well, the most common cause is fetal sleeping. And as we see no D cells, that is the most likely as well considering what I just said about there being no sign of tachycardia, and also since we are past 28 weeks. |
| F | : Right. So let’s see how long the baseline variability could be considered as non reassuring. Hmm… |
| F | : Just a heads up, the patient in bed 4 is quite upset. He’s been waiting here for a while, his wife still hasn’t shown up and from what I can get out of him, he has a history of anger management issues. |
| M | : Thanks for the info. I could hear him threatening to walk away and to file a complaint because he says no one wants to treat him. |
| F | : Yes,but he is in quite a bit of pain so not really an option. I tried contacting his wife again but no answer. I mean, when I talked to her earlier she didn’t seem thrilled to have to come down here. Of course, I didn’t tell the patient that but I’m sure he knows how long it should take his wife to arrive. |
| M | : Yes, and he is hurting and as a whole other set of reasons to be angry. Hopefully, getting him some pain relief will help to calm him down a bit. |
| F | : Yes, I hope so. So,… |
| F | : So arterial blood interpretation is something many medical students find difficult to grasp. I mean we’ve all been there. So today I wanted to provide a structured approach to ABG interpretation that will also increase your understanding of the relevance of each result. |
| So, to provide an overview, the real value of an ABG comes from its ability to provide a near immediate reflection of the physiology of a patient, allowing you to recognize and treat pathology, more rapidly. So here are the normal ranges for pH, PO-CO2, PaO2, HCO3 negative, and base excess. | |
| So before getting stuck in the details of the analysis, it’s always important to look at the patient’s current clinical status as this provides essential context to the ABG result. I’m going to go through a few examples to demonstrate how important context is when interpreting an ABG. | |
| So the first example involves a normal PaO2 or oxygenation in a patient on high flow oxygen. So this is abnormal as you would expect the patient to have PaO2 well above the normal range with this level of oxygen therapy. So the next…. |
| M1 | : Okay, Mr Jacobs. So we’ve discussed your medication, which included two inhalers, medication for anxiety, pain, diabetes, epilepsy and headaches and the vitamins you buy over the counter. The plan is to reduce your Diazepam by one tablet each day. And I’m going to call you to see how you feel that is going, and then review everything else again at your usual review appointment with the GP surgery. Do you have any questions about what we’ve covered in this consultation? |
| M2 | : So reducing Diazepam will make me less drowsy? |
| M1 | : Yes, that is correct. So for the next two weeks, you will only take one Diazepam tablets each day. |
| M2 | : Yes, I understand, one a day. |
| M1 | : Okay, so do you have any questions about anything we haven’t covered that I may be able to help with? |
| M | : Hello, I’m David, a foundation year one doctor calling from A&E. I’m calling about a patient called Jane Addams, a 62 year old lady who arrived 15 minutes ago with a suspected stroke and needs an urgent review by the neurosurgical team. |
| F | : Yes, please go ahead with the background. |
| M | : Mrs Adams presented with acute onset dyspnea, left sided limb weakness and inattention. Her past medical history includes a TIA, two years ago, hypercholesterolemia, and atrial fibrillation is anticoagulated and her admission INR is 4.8, a head CT demonstrates an intracerebral hemorrhage, in the right hemisphere with some associated mass effect, and midline shift. We’re currently administering bier block for the patient does appear to be becoming more drowsy. The patient appears to be neurologically deteriorating. Are you able to come and review the patient now? In the meantime, are there any other treatments or investigations you would want us to get started on? |
| F | : Hmm. Well, we…. |
| D | : Hello everyone. I’m here on behalf of this country’s Cauda Equina Syndrome support group that provides support education and practical advice to individuals affected by CES, and their families to provide some background and insight into this condition, for doctors who may encounter it. So let’s start off with a bit of background to make sure we’re all on the same page. |
| So, annually cauda equina syndrome or CES is believed to newly affect about one person per 33,000 to 100,000 people. At this point, patients’ gender, age and race are not thought to influence rates of CES. However, it is true that small case loads may limit insight into such relationships. Also, regardless of the epidemiology, it is important to remember that CES is a spinal emergency, necessitating quick and effective care to mitigate permanent neurological consequences. | |
| The disease itself affects the tail end of the spinal cord, the cauda equina. And when this anatomy is disrupted, a characteristic collection of symptoms emerge and must be urgently investigated to rule out CES. Patients may present with back pain, as well as pain, paresthesia, and numbness in the distribution of any lumbar or sacral dermatomes. In addition, some cases may present following trauma or episodes of mechanical stress. All such patients should be screened for red flag symptoms of possible CES, I cannot stress this enough. | |
| So, the red flags that point towards CES include bilateral sciatica, saddle anesthesia, bowel or bladder dysfunction. Most commonly, urinary retention and sexual dysfunction. As you start to conduct a history of the presenting complaint, you should ask about the onset and duration of the symptoms, the progression and the specific characteristics of the pain, including site onset, continuing versus intermittent radiation intensity and related symptoms. While I mentioned earlier that personal characteristics, such as gender, age and race are not thought to influence the occurrence of this condition, there are a set of causes. I mentioned them now as well you’re taking a patient’s history, you should ask about features which may point to an underlying cause of CES. | |
| So in general, the etiology of CES can be thought of as any factor which compresses the spinal nerve roots, and that includes lumbar disc herniation, spinal vertebral fractures, or subluxation, primary or metastatic malignancy spinal infection, such as meningitis or Pott’s disease. I intergenic, such as following spinal anesthesia post op hematoma or manipulation. So, back to taking the history of the presenting complaint in relation to infection, you should ask about fevers, night sweats, vaccinations, recent travel and local sources of infection and relation to it genomic, you should ask about recent surgery and localized collection of fluid around the lumbar spine. In addition to previous surgeries and hospitalizations, you should ask about recent trauma or heavy lifting during this part of the history taking. Another important aspect is family history of particular interest is any history of rheumatological disease, degenerative disc disease, osteoporosis, cardiovascular disease and malignancy. | |
| Following a thorough patient history, examination is necessary to identify the sacral dysfunction, if patients are complaining of the red flag symptoms I mentioned earlier. For patients who are not currently symptomatic of clear red flag symptoms, but a history with suspicious features is present, such as sudden onset back pain or sciatica or symptoms related to a possible primary cause of CES, examination is also necessary to identify, or rule out evidence of CES. So the said examination should include a lower limb neurological examination to assess tone, power, reflexes and sensation. The next part is a digital rectal examination to assess for saddle anesthesia, loss of para needle sensation, and a loss of anal sphincter tone. Finally, a brief abdominal examination should be done to assess for palpable bladder, particularly urinary retention. | |
| So now, let’s say you have a patient that has suspected CES. So based on clinical features, CES may be broadly categorized into two categories. Incomplete versus complete pathology, patients with incomplete CES will complain about urinary difficulties, altered urinary sensation, loss of desire to void, hesitancy and urgency. Patients with complete CES will demonstrate definitive urinary retention with associated overflow continence. However, regardless of the actual classification, prompt surgical referral and urgent further investigations are required. | |
| These investigations include an MRI of the spine. Ideally, within one hour of the patient presented. At a post void residual volume to assess the urinary retention. So patients with suspected CES should be… |
| M | : So today, we’re going to turn off focus from experts working on the front lines to interesting clinical trials, being done in the world of gastroenterology. Today’s guest, Dr. Julia Schneider is heading up such a trial. The aim of which is the effectiveness of two different dietary interventions for patients with Crohn’s disease. Please welcome Dr. Schneider to the program. Thank you very much for joining us, Dr. Schneider. |
| F | : It is a pleasure to be here. I don’t get a lot of opportunities to talk about my work outside of the lab. My teenagers just start to roll their eyes once I start talking about data analysis and clinical trial this and that. I think they like it, They.., I think they liked it better when I work directly with patients. |
| M | : Well, we are delighted to have you here. I was hoping that before getting into your clinical trial, you could give us some background about Crohn’s disease and current treatments for it. |
| F | : Of course. So Crohn’s disease is an inflammatory bowel disease that causes inflammation as the digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. Also the inflammation caused by Crohn’s disease, often spreads deep into the layers of affected bowel tissue, which is both painful and debilitating, as well as potentially life threatening. So you mentioned current treatments and so first I want to point out that unfortunately there is no known cure for crohn’s, but fortunately there are therapies that can greatly improves the signs and symptoms, and sometimes even bring about long term remission |
| M | : So, what does treatment look like for someone diagnosed with Crohn’s disease? |
| F | : Well, the disease affects people in a wide variety of ways. So at my health care institution, a wide array of specialists, with expertise in digestive diseases, as well as surgery, pathology, radiology and nutrition work together to provide care for Crohn’s patients. |
| M | : A holistic approach to medicine. So great to see it. One last question before getting into your research, what is the cause of Crohn’s disease? |
| F | : Well the exact cause remains unknown. Previously diet and stress were suspected, but now doctors know that while these factors may aggravate and bring on symptoms, they do not cause the disease. So a number of factors, such as heredity and a malfunctioning immune system, likely play a role in its development. For example, we know that Crohn’s is more common in people who have family members with the disease. So genes may play a role in making people more susceptible. However, it is important to point out that most people with the disease don’t have a family history of the disease. As for a possible role of the immune system, it’s possible that a virus or bacterium may trigger Crohn’s disease. This may seem strange considering we’re talking about the bowels but you have to consider that when your immune system tries to fight off an invading micro organism, an abnormal response causes the immune system to attack the cells in the digestive tract as well. |
| M | : Oh, interesting. There has recently been a lot more attention paid to the role of the digestive tract in the immune response. Definitely worth more investigation and discussion in future shows. So now tell us about your study. |
| F | : Well, as you said at the beginning, it is designed to compare the effectiveness of two dietary patients with bones. The first being the specific carbohydrate diet, and the other being the Mediterranean style diet. The two diets will be compared in terms of their ability to resolve, both the symptoms and bowel inflammation that characterize this debilitating disease. |
| M | : So, I think viewers are likely somewhat familiar with the Mediterranean style diet, due to all the media coverage of it lately, but perhaps not with a specific carbohydrate diet. Can you tell us a bit about it? |
| F | : Of course. So, it was developed by a pediatrician originally as a treatment for celiac disease, and then later others started to experiment with it in the treatment of other inflammatory bowel diseases. And it is a grain free diet that is low in sugar and lactose. So examples of prohibited foods on the specific carbohydrate diet include sugar, molasses, maple syrup and similar products. All grains starchy tubers like potatoes and turnips, and all milk and products high end lactose like mild cheddar and ice cream. |
| M | : Well, that includes quite a lot of foods. So what foods are allowed? |
| F | : Well, more than you might think. So, meats without additives, poultry, fish, shellfish and eggs certain legends like lentils, peas, peanut butter, lima beans, some types of cheeses, such as Colby and Swiss, homemade yogurt, most fruits, nuts and vegetables and most oils teas and coffees. |
| M | : Well, coffee is super important. And so, I understand that your study is in its early phases, and you’re currently looking for eligible participants. |
| F | : Yes, we have some very specific inclusion, as well as exclusion criteria for the study. So it is a bit difficult to find participants. So the main inclusion criteria is that the person have a documented diagnosis of Crohn’s disease and be of age, and the exclusion criteria include… |