9 August 2008 AMC Melbourne Clinical Exam Recall Medicine & Surgery Station one: TIA.

A 50yo man complains of blurred vision. Past hx: by-pass surgery 2ys ago, hypertension, DM, medication taken: Metformin, enalapril, simvastatin, aspirin 100mg o Task: hx, ask for physical examination results, Mx. o Further details from consultation: 1. hx: there are other 3 episodes during last week persisting for 5minutes. No weakness of the legs, no sensory loss anywhere. The role player keeps on telling me that may be she needs to change her glasses. The blurred vision was like a curtain coming down on the right eye and she couldnt see anything for 5minutes. No smoking, no alcohol, 2. on examination: pulse: regular, on right carotid artery carotid bruit is present. Neurological: normal. Fundoscopy: normal. 3. Mx: Admit to hospital, looks like TIA, do Ix: Doppler US of the carotid , CT, blood for lipids, cholesterol, FBE, ECG Treatment depends on Ix results. 4. Qs from the examiner: what are you expecting to see on CT scan? Why do you order it? What medication are you going to give? AMC feed back: Visual disturbance Station two: cellulitis of the leg. A 65yo woman presents with a swollen sore right lower leg for 2 days (picture provided). o Tasks: 1. hx 2. examine the lower limb 3. advise about Mx. o Further details: 1. picture: diffused redness on lower limb, no ulceration, no clear margins. 2. on Hx: last night she noticed small patch of redness, and in the morning this redness had increased, became itchy and painful. No obvious injury, no hx of DM or HT. Two days ago she was doing gardening and thinks she injured herself with a branch. 3. On examination, T: 38.6, other vital signs are normal. Inguinal lymph nodes are palpable and tender. Pedal pulse presents. Sensation is normal. Others are the same as the picture. 4. Ix: FBC, blood culture, blood sugar, wound swab 5. Mx: PC + flucloxacillin iv (may need admission)

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Give tetanus vaccine Elevate the leg Bed rest Review next day Qs from the examiner: Which bacteria is most likely involved? What antibiotics would you like to choose? Apart from antibiotics, what would be the other management? AMC feed back: cellulitis of lower leg

Station three, cardiovascular system examination(a real patient with heart murmur). 65yo man who is travelling overseas soon, presents to GP for a pretravel check up, he was told by other doctor that he had a heart murmur but he is asymptomatic. o Tasks: 1. perform physical examination 2. provide running commentary 3. no need for abdominal and lower limb examination o Qs from the examiner: 1. Is the murmur systolic or diastolic? 2. whats the Dx? AMC feed back: cardiac murmur Station four,cholesteatoma. 25yo man, who is a truck driver, presents to your GP clinic with ear pain for 3 days. No discharge. 3 episodes in the past with yellow discharge. Picture provided. (redness in tympanic membrane and some crystal substances deposits on the lower part of the ear drum)An otoscope and a tuning fork are on the table. o Tasks: hx, perform physical examination, Dx, Mx. o Details from consultation: 1. AMC book case 136, p674, 716 for otoscopy and Rinne test and Weber test. 2. Mx: Antibiotics for two weeks or longer? Recheck hearing test Refer to audiologist for audiometry Refer to ENT Dr for further Diagnosis and Mx if not response to antibiotics. AMC feed back:cholesteatoma of right ear Station five, pheochromocytoma(CT scan and blood results provided). Refer to AMC book page303. o Tasks: 1. Explain CT (see AMC book 303) to the patient 2. explain the condition 3. further Ix

4. answer patients questions o details from consultation: 1. Other Ix: cortisol, aldosterone are normal. 2. cathecolamines significantly increased. AMC feed back: Adrenal tumour Station six, inflammatory bowel disease. A 25yo man who is a computer worker presents with diarrhoea of 3 weeks duration. This is the 4th episode in the past 3ys. In the past, he was treated with antibiotics but has had no improvement. o Task: 1. take further hx 2. ask examination findings from the examiner 3. further Ix and Mx o further details from consultation; 1. on hx, diarrhoea was about 6 times a day, no steatorrhoea, but there had been some mucus and blood. The condition has been getting worse since yesterday. The patient had lost some weight and appetite. 2. on examination, GA and VS normal. Focus GI examination showed some tenderness on LIF and PR showed blood in the glove. No fistula, no haemorrhoids. 3. provisional Dx: inflammatory bowel disease 4. Mx: Further Ix: stool culture and microscope, colonoscopy Treatment will be according to the Ix results. AMC feed back: diarrhoea(recurrent) Station seven, Back pain. A 25yo man presents to your GP practice with back pain after lifting heavy box at work. On examination, no neurological findings were present. The only positive sign is tenderness in the paravertebral area. o Task: 1. explain condition to the patient (see patient education p118; Backache) 2. advise on further Mx 3. write a prescription for the patient o important: to explain lifting technique o to write a medication the examiner gave a paper with the place for the name, address and a place to write the medication AMC feed back: acute mechanical lower back pain Station eight, thyroid carcinoma. Your next patient in your GP surgery is a 25yo man, who has been seen by one of the other GPs in the surgery two wks ago when he presented with a small nodule in the right side of his neck. Your colleague took a history and examined the patient and came to the conclusion that it was most likely a lump in the thyroid gland and arranged U/S, isotope scan and a fine needle aspirate for cytology. He came today for the test results. The U/S revealed a single, solid nodule of about 1.5x2cm with changes consistent with a papillary carcinoma in the right lower part of the thyroid

gland. The iodine 131 radioisotope scanning demonstrates a cold nodule in the same area. The FNA confirms a papillary carcinoma. o Tasks: 1. explain the Dx 2. discuss the Mx options with the Patient. o Qs for the patient: 1. what will be the treatment? 2. whats the prognosis? 3. whats the complications after surgery? 4. future Mx: thyroxine and long term monitoring 5. how about chemotherapy or radiotherapy? AMC feed back: papillary cancer of the thyroid O&G: Station nine, Post labour eclampsia. Your are a resident in a country hospital. A woman in the labour ward has just had a fit one hour after the delivery of her baby. The seizure was controlled and now the mother is asleep. The husband is with her and wants an explanation. o Task: 1. talk to husband about the condition 2. answer his questions. o Questions from the husband: 1. what happened? 2. is this epilepsy? 3. will she have any more fits? 4. what are you going to do now? 5. what about a future pregnancy and how to prevent it? 6. can she breast feed the baby? AMC feed back: post partum eclampsia Station ten, Oligohydramnios IUGR: Dx + Mn (AMC c133, p672) AMC feed back: fundus less than dates Station eleven, secondary amenorrhoea - anorexia nervosa. 20s womans period has stopped for 12 months. o Task: hx, ask for physical examination results, Dx, Mx. o Further details: first period: 14yo. One year ago the period gradually reduced and stopped. jogging one and half hours per day. Only eat cereals and supplements. BMI 15. Other examination results are normal. o Further details: 1. prolactin, TSH, LH, FSH: normal 2. oestrogen: slightly low o Qs from patient: 1. what will happen to me? 2. how can I get my period back? 3. whats about my fertility? o Mx:

1. see dietician, psychologist for CBT and psychiatrist. 2. ongoing review AMC feed back: secondary ameonorrhoea Pae: Station twelve, febrile convulsion. GP setting. The mother of a 3yo child comes to see you because her daughter has had a fit for 2 minutes. Physical examination findings are normal. o Tasks: 1. further hx 2. Tell the mother about the condition 3. Further Mx o Details hx from consultation: 1. this was the 3rd episode which is related to a high fever from 18mths. The father has a hx of the same condition as a child. The mother is also concerned that her daughter shows some delay in her speech. No family hx of epilepsy. This time temperature is 38.5. 2. Mx: Explain that is a febrile convulsion and reassure. refer to audiologist for hearing test refer to speech pathologist for assessment o Qs from the mother: 1. Can it be epilepsy? 2. Can the audiologist diagnose epilepsy? AMC feed back: prolonged convulsion developmental delay Station thirteen, autism. The mother of a 3yo girl comes to see you because the staff at the childcare centre complained that the child has strange behaviour. o Tasks: 1. focus hx 2. tell the mother about the condition 3. further Mx AMC feed back: isolated speech delay Station fourteen, chicken pox and pregnant. A woman with 10wks preg comes to see you because her 5yo niece had rashes on the back (picture provided: blisters on the upper body). She has 2 children, aged 9mths and 6yo. o Task: 1. provide Dx from a given picture 2. advise mother about pregnancy and Mx about two children. o Further info: woman got chicken pox at 6yo. Her children had no symptom at the moment. o Qs: 1. can we give vaccine to young kids at 9mo? 2. how about pregnancy? AMC feed back: exposure to varicella Psy:

Station fifteen, adjustment disorder with anxious mood. A woman of 40yo complains about chest pain for about 3 mths. All Ix including ECG and blood tests are normal. While you were talking to her and told her it is not a heart problem, she suddenly begins to cry. She also insists that she know sits a heart problem. She is currently working and looking after her sister who has just had surgery. o Task: 1. take a hx 2. Dx and Mx. o Further details from consultation: 1. the daughter is 17yo, left school and living with her boyfriend who is not working. Mother thinks that the boy is a looser and doesnt like him. She is also worried about her daughters future. 2. The mother has no trouble with sleeping and eating. She doesnt have hallucination, no delusion or suicidal ideas. AMC feed back: psychosomatic chest pain Station sixteen, mania. A 23yo university student claims that she has important information to report to the United States president. He hasnt slept for a few nights and his performance is not good now. o Tasks: 1. mental state examination 2. summarise your findings to the examiner and 3. discuss differential Dx with the examiner. AMC feed back: elevated mood assessment.