Professional Documents
Culture Documents
Case 1
25y.o. Rh-ve woman Gravida 1 Para 1, 30 wks. of gestation came to ED complaining of vaginal bleeding and a little pain in her lower abdomen. Routine antenatal tests were normal, US at 18 wks. was normal.
The patient was hemodynamically stable. She developed bleeding in the morning and used 2 pads until was seen by me. The color of the blood was not bright. At the time of examination these bleeding nearly stopped and woman did not have any pain. She did not have any other complains and felt her baby kicking. Lady did not have any trauma, did not have intercourse, did not overstrain herself physically.
On PE: the patient was not in distress, VSs were normal, abdomen was not tender, fundal height was 30 cm, cephalic presentation, FHR was 140, PV- cervix was closed, spotting,uterus was not tender.
Provisional diagnosis: Mild placenta abruption ( <1/6 th of the placenta has separated; blood loss is usually < 250ml= light menstrual loss to heavy menses, no clots).
Management: Admission.
Bed rest for the period of bleeding and for 2-3 days
thereafter.
administered.
Case 2
28 y.o. lady has past medical history of 2 miscarriages at 8 and 10 wks of gestation. She came to your GP setting last week and you ordered some investigations.
Task: Explain results of investigations and further management. Information about investigations will be provided on request.
incompetence
11 Rubella status.
Management: Monitoring in high risk clinic ( needs referral). Stop smoking. Avoid sex intercourse until 12 wks of gestation. Do not travel. Do not overstrain yourself physically. Acupuncture. Every miscarriage increases the risk of further miscarriage by 5%(20%,25%).
My status: Passed.
Case 3
Paediatrics
Case 1
You work in ED. Your next patient is a 3 y.o. girl, who has been brought in by her dad, because she complained about a painful right leg. Girl was fine last night but when she woke up this morning she complained about pains in her
R. hip and difficulties to walk. Task: Focused history, physical examination, investigations, management.
Girl has always been well, active. No childhood diseases, no operations, no trauma. Normal pregnancy, normal delivery, normal development, immunisations up to date. 2 weeks ago she had a flu like infection with cough, sore throat and fever but got over very quickly without any medications.
On PE: The patient appeared well, not flushed, not in obvious pains. VSs
normal. Her physical examination was unremarkable except for her R. lower limb.
Inspection of her R. lower limb was normal, but there was marked painful limitation of active and passive movement in her R. hip mainly on rotation and abduction. Girl had marked limp and did not want to walk.
The more the child can rest, the quicker the recovery ( usually settles within a few days). Patients may have a relapse if they increase their activity too quickly.
Case 2
You work in GP setting. Your next patient is 12 mths old girl, who has been brought in by her mother because she had been unwell with fevers for the past 48 hours. She had vomited twice, but has had no diarrhoea. Dipstick of urine ( urine bag specimen) showed protein, nitrites, leucocytes.
Task: diagnosis, management. Explanation: Your child most probably developed condition which is called UTI. A UTI is an infection in the urine. It may affect the bladder and sometimes the kidneys. UTI is quite common, particularly in young children who are still in nappies. It is usually caused by germs from the poo, which are on the skin, get into the urethra ( the tube from which urine passes out of the bladder). This can happen to any baby and is not due to poor washing or changing.
Management: Hospitalization. Consultation of pediatrician. Microscopy and culture of urine specimen( supra-pubic aspiration or catheterisation). US ( to exclude urinary tract obstruction). Antibiotics: If oral medication is appropriate Trimethoprim 4 mg/kg BD or Cephalexin 15mg/kg TDS 2 If severe vomiting- Gentamicin 7,5 mg/kg IV daily and Penicillin 50 mg/kg IV 6 hourly.
For 1 week! Check antibiotic sensitivity and adjust therapy in 24-48 hours. If recurrent UTI- US and MCU, prolonged antibiotico-therapy.
This test involves putting catheter into the bladder through the urethra. Dye is injected through the catheter and X-ray pictures are taken. The test is done mainly to look for a condition known as urinary reflux ( VUR). Draw a picture and explain VUR.
Case 3
30 y.o. woman who has 2 y.o. son with Down Sd. came to your GP setting inquiring about further pregnancy.
Counseling: Incidence of Down Sd.- 1,4 per 1000 live births. Risk increases with maternal age. 30y.o.- 1:350; 35y.o.-1:250; 37y.o.-1:200; 40y.o.-1:100. Risk of 2-d child with Down Sd. is 1:100.
Screening tests: 1 US for measurement of nuchal translucency bw 11-13 wks. 2 Maternal serum test for B-hCG and PAPP-A bw 10-13 wks. 3 Maternal serum ( quadruple ) test: AFP+B
hCG+oestriol+inhibin A bw 14- 18 wks, can detect 85-90%. 4 CVS bw 9-12 wks ( if risk>1/200-250), can detect 100%. 5 Amniocentesis bw 15-18wks, can detect 100%, fetal loss
0,5-1%. Performance of CVS and Amniocentesis: Obstetrician will put a needle through your abdomen and womb under US to get sells of the baby from chorion or from the fluid around him/her and then analyse. By this procedure, woman can know the conclusive result whether the baby has Down Sd or not.
Psychiatry.
Case 1
You work in hospital. 17 y.o. girl and her family are suffering at the bedside of their mother who is in the terminal phase of liver disease. Girl was not able to speak any more
History: Q- Can you answer my Q-s by indicating with your head yes and no? A- Yes Q- Did it happen to you before? A-No Q- Do you have any other complains? A-No Q- Have you had any infections recently? A-no Q- Do you feel any discomfort or any lump in your throat? A-No Q- Can you cough? A-Yes, she did. Q- Any problems with your health? Are you on any medications ?
On PE: GA- normal. VSs- normal. Inspection of neck and LN- normal. Throat on examination with pocket torch and with spatula- normal (instruments were provided).
Explanation: There is strong link bw our brain and our body. Because you worry about your mum very much, your body reacts to this by making you unable to speak. This condition will disappear by itself with time.
Management: Consultation of Psychiatrist in hospital. Referral to psychologist for CBT. Referral for counseling.
Case 2
You work in ED. 30 y.o. man who was previously diagnosed with schizophrenia had a relapse 2 days ago . His GP prescribed Resperidone . He took 2 tab yesterday morning, 2 tab yesterday evening and 2 tab today in the morning. After this he started to feel dizzy , drowsy and to have headache.
The patient has had no nausea, vomiting, gastric discomfort, blurred vision, agitation, anxiety. But he had difficulties with sleep lust night. He does not remember what medication he took before for his condition. His health generally- OK. No smoking, no alcohol, no recreational drugs. Married, has 2 children, works as a seller.
On PE: GA- looked confused P=110, RR=18, BP(lying)= 120/85, BP(sitting)= 100/70 (postural hypotension).
Management: Hospitalisation. Stop taking Resperidone. O2. Monitoring. Chek blood drug level,ABG, BSL. Consultation of psychiatrist.
Q. from examiner: What psychiatrist will do? A. Psychiatrist may decrease dose of Resperidone or may change this medication for Olanzapine or Clozapine. AMC feedback: Side effects of anti-psychotic medication. My status: Passed.
Case 1 25 y.o. driver came to your GP setting for some advice regarding his epilepsy. The patient was sent to you by specialist who already prescribed Carbamazepin. He had several febrile convulsions in his childhood and 1 epileptic seizure 2 wks ago. EEG confirmed diagnosis.
Explanation: Epilepsy is the recurrent tendency to spontaneous, disordered electrical discharge in your brain manifestating as a seizures in your body. Draw a picture from Patient education. You are more prone to develop this condition, because of your past medical history of febrile convulsions, then other people.
2 It is not possible to drive (seek help in Centrelink to change work ). Restrictions range for driving from 1 mths to 2 yrs, depending on the seizures.
3 Avoid swimming alone. 4 Avoid physical exhaustion, stress, lack of sleep. 5 It is better to stop consumption of alcohol, because
it can interact with medicine or to cut down (patient drinks 1-2 stub of beer 3-4 days per week).
6 Regular checkups- to watch for any side effects of the medicine and to have blood test to check the level of drug in the blood.
Q. from the patient: Should I take this medicine for whole my life? A.- Once complete control has been established for several years, the medication can be gradually withdrawn and stopped.
Case 2
26 y.o. woman came to your GP setting. She had high BP checked in 3 occasions ( 135/85; 140/90; 145/90 ). She was not overweight and did not have family history of hypertension.
The patient started to have BP-problems 6 mths ago. She does not have any complains. Her high BP was found during regular checkup. Her health generally is OK. Woman is on OCP Microginon-30 for 3 yrs. She did not have any side effect of OCP before. Woman is not on any medications. The patient smokes 15 cigarettes per day and consume alcohol very rare; does not exercise, has normal diet, does not use recreational drugs. Her job is not stressful. She is in stable relationships with her partner and planning to become pregnant next 6 mths.
urine culture.
ECG.
Renal US.
Case 3
You work in GP clinic. Your next patient is 25 y.o. man with chronic diarrhoea for more than 6 mths.
2 weeks ago the patients condition got worse -he noticed some fresh blood on his stool and on the paper, no mucus, no fat. There is no abdominal pain or pain on defaecation, no nausea, no vomiting. Now he needs to go to toilet 3-4 times per day ( before- only 2 times per day), sometimes he wakes up at night time because of urge. Man lost 5-6 kg over 6 mths. He did not travel overseas, did not change his diet; his family history is unremarkable. The patient does not smoke, drinks 2-3 stub of beer per week; does not have any stress at his work place and home. He is not on any medication. There is no joints pain, no problems with eyes.
On PE: The patient looks pale, no jaundice. BMI= 20. VSs- normal. PE is
Sigmocolonoscopy.
Feacal fat.
TFT.
Total serum Ig A.
Ig A antigliadin antibodies. Endomysial antibodies. Tissue transglutaminase antibodies. Consider referral to surgeon, physician, dietician.
Case 4.
68 y.o. man came to your GP clinic, complaining of pain in his R. calf on walking , relived by rest. It is getting worse now. He smokes 15-20 cigarettes per day, drinks 2-3 stub of beer per day, has 2-3 days free of alcohol. The patient is on diuretics for his hypertension. His BMI- normal.
VSs: P=90, BP=140/ 85. After that I examined lower limbs for peripheral vascular disease: 1 Claudication on walking; 2 On inspection: no atrophic changes of skin, no color changes of calfs and feet, no ulcers, no swellings, no deformities, no visible veins, no muscle wasting, but there is absence of hairs; 3 On palpation: temperature- normal, no tenderness, capillary refill=5'', all pulses are present( femoral, popliteal, posterior tibial, dorsalis pedis ), no sensory changes, reflexes are normal (information provided by examiner ) ;4
Dopler US.
Angiography.
prescribe it now).
Q. from examiner: What is the differential diagnosis of calf pain? A. : DVT, Acute lower limb ischaemia, trauma, muscle pain due to diuretics,
Q. from examiner: What could be the causes of patient condition? A.: Atherosclerosis, embolisation. Q. from examiner: What surgeon will do? A.: Bypass graft or enderterectomy. DO NOT FORGET TO WASH YOUR HANDS AFTER PATIENT!!!
Case 5
You work in GP clinic. Your next patient is 38 y.o. woman with chest pain and coughing who had cholecystectomy 5-6 weeks ago. You saw her yesterday and ordered CXR. On PE: pale, in distress, SOB; VSs: T=37,7; BP = 135/85; RR-25-26; P= 94; Lung percussion and auscultation: dullness, reduced breath sounds and vocal resonance over R. lower lobe, pleural friction rub.
Task: Explain results of CXR (CXR will be provided by examiner ), management. You can ask some relevant Q-s.
On AP view of CXR I could see small amount of fluid on the R. side of the chest, but on the Lat. view I saw consolidation as well ( I was not sure about consolidation, so I did not tell about it, but after had regrets about this ). I explained to patient that she had a collection of fluid in the pleural space and
Short history: Woman now is in pain= 7-8 ( from 0 to 10 ), Panadol does not work, cough is getting worse; she feels high temperature ; after operation she was all right, but about 1 week ago developed SOB , cough, weakness; she used to be a severe smoker 2-3 y. ago; generally her health is OK.
Management: Hospitalisation.
O2
Pain relive.
CT scan ( to exclude Ca ).
ECG.
Consultation of physician.
Antibioticotherapy.
IV fluid
Q. from patient: Could it be a Ca of lungs? A.: Yes. Q. from examiner: What you can see on XR? A.: Pleural effusion on the R. side. ( consolidation ? ). Q. from examiner: What is you differential diagnosis?
Case 6
You work in GP clinic. Your next patient is 56 y.o. old women complaining of bloating and abdominal pain. You saw her yesterday and ordered ultrasound of abdomen (US was given with stem). US revealed 3 stones in gall bladder.
From description of US I explained to the patient that she had mild inflammation of gall bladder caused by gall stones. I asked if she was on any medication. She was taking Mylanta for bloating and Panadol for pain but it did not work. She did not have nausea or vomiting and any other complaints. I draw a picture of gall bladder with stones in common bile duct and explained such possible complications like billiary colic obstruction; cholangitis and
added infection.
Case 7
Condition 124, p 639 AMC handbook of clinical assessment. End of life request from terminally ill patient.
Case 8
Condition 137, p 675 AMC handbook of clinical assessment. Review of cytology after aspiration of breast lesion.