MELBOURNE, 9 FEBRUARY 2008

This recall has been written by two candidates. We both have passed 15 stations, but failed in different ones. One of the candidates failed the station with acute back and leg pain (sciatica), the other one failed postpartum haemorrhage. So, in order not to mislead you, only the candidate who has passed a particular station has written it.

Other stations we have written together so that you can obtain as fuII feedback about them as possible.

PSYCIllATRY

35 year old man is complaining of having funny movements of his lips and tongue for a couple of months which are getting worse and really bothering him. He has been on Haloperidol for more than ten years.

TASK:

• take relevant history

• Mx - immediate and long term (identify the aspects which you should deal with)

The patient takes haloperidol for many years without major problems until the facial movements started. He also claims that people are looking and following him on the streets and plotting something against him. When asked if he thinks that people are looking because of his lip movements, he said no, they are just following and plotting. He is fine at home where he lives alone (taking care of his own medication himself) and tends to stay there to avoid social interaction. He denies and suicidal thoughts and any chronic conditions, psychiatric illnesses that run in family or allergies He admitted of halving the dose of Haloperidol by himself, because of these movements. He also told me that he hasn't been to a psychiatrist since he has been diagnosed and he has been under my care since.

MANAGEMENT:

I first explained to him that the S/E that he is experiencing are due to Haloperidol and 1'11 try to help him to deal with them. I told him that I'm also concerned about him halving the dose of medication and those signs of illness that he started to experience afterwards (people following etc ... ). Most likely, it is a result of the dose reduction. I will refer him to a psychiatrist ASAP (getting on the phone right now), and his medication will be changed gradually. We call this cross over period where the dose of one medication is reduced whilst increasing the dose of the other. While we change the medication he may experience the worsening of his condition (breakthrough psychosis). I also added that because he lives alone the psychiatrist might consider admitting him to hospital to monitor his condition during the change from one medication to another. We finished earlier this station.

AMC feedback: Paranoid schizophrenia (relapse).

35 year old woman works in a managerial position with increased work load. She is very busy at work. Doesn't sleep well, anxious, has pains and aches everywhere (abdominal, headache, chest pains). She drinks 5 cups of coffee a day and smokes 15 cigarettes a day. There was a long list of investigations that had been done, including ECG, TFfs, colonoscopy? FBE, etc., which were all normal and she was diagnosed with Generalised Anxiety Disorder.

TASK:

• Talk to patient (you may ask some relevant questions)

• Explain

• Manage accordingly

C: Good afternoon Mrs. X, I have some good news for you.

P: What do you mean good news; I cannot sleep well and do not feel well.

C: we will address this issue but first I will tell you that all the investigations that we ordered for you have come back normal. But I do have some more questions for you. I understand that you are very busy at work and its quite stressful, could you tell me please your major concerns?

P: I cannot fall asleep for three or four hours. So what could be wrong with me?

C: The condition that you have, we call a generalised anxiety disorder in which emotional problems can actually cause physical symptoms to appear because our brain regulates all our bodily systems and organs.

P: is it so?

C: Yes it is. Tell me please about your situation at home?

P: At home everything is OK, my husband is very supportive. But I regret that we don't have any children as we are both very busy.

C: I see. First of all we have to address your coffee intake and cigarette smoking. It would be good for you to drink less coffee, I suggest that you choose an alternative such as juice, green tea or water.

P: I will try.

C: have you ever considered quitting smoking?

P: yes I have but my life is so stressful and my smoking helps me to get through the day.

C: on a scale of 1 to 10, where would you put your desire to quit smoking?

P: around 5.

C: Fair enough. We'll follow it up on our next appointment. There is another issue I'd like to talk to you about: it would be great if you could plan your work and rest so that you delegate part of your responsibilities to other people to reduce your stress levels.

P: Doctor, one of my friends who is a pilot, is taking some tablets that help him go to sleep. Could you prescribe them for me as well? He gave me couple of LIttau to try I have found that they are really good.

C: Could you tell me the name of these tablets?

P: Temazepam.

C: you know we are a bit reluctant to prescribe these tablets because they are drugs of addiction, but in some cases we can prescribe a short course of it when it is really required. But in your case relaxation techniques, yoga or mediation may really help you without the need of drugs.

P: But you said that I can have a short course of these tablets so can I have them?

C: As I said it is not out of the question but for now I would really like you to start on the relaxation techniques and lifestyle changes. I will also refer you to a psychologist.

P: what will the psychologist do?

C: CBT to help you to take things easier and understand the causes of the problem and the way to deal with them.

P: OK I'm happy with that. Finished early.

AMC feedback: Generalised anxiety disorder.

PAEDIATRICS

A five year old boy - Peter Day, is brought to see you in a general practice setting because he has been soiling his pants for the past couple of months. Now it happens every day and the parents are really concerned and not happy with the child.

TASK:

• Focused history from the parent.

• Ask examiner for the appropriate findings on the examination that would be relevant to your diagnosis

• Explain your diagnosis and advise the management.

C: could you tell me what seems to be the problem?

P: You know Peter is soiling his pants everyday, at school and at home as well and I am really not happy with this because he was toilet trained by 3.

© Could you tell me please if Peter has been under any stress like being bullied at school or any other emotional problems?

P: No I don't think so. He has not been bullied but he has started a new school 3 months ago and the children there are teasing him because he is stinky.

c. What about his general health?

P: He is generally healthy, no chronic conditions, normal growth and developments and not on any medications or possessing any allergies.

©What about his appetite, nausea, vomiting? Any weight loss? Fe ve { P: all normal, no problems.

©any problems with the bowel movements?

P: He had an episode of constipation about 3 months ago. ~what is his diet like?

P: He doesn't like fruits or vegetables, doesn't drink much water and juice and likes fast food.

@whatis your situation at home?

P: We are a very happy and stable family, but I am not happy with Peter now (she actually .JlChpitted that she punished him for soiling his underwear).

lGAs there anybody in your family on a special diet (to exclude Coeliac)?

P: Not at all.

PE: GA-normal, VS-normal, abdominal-no visible masses but there is a hard palpable mass in the left iliac fossa. For one candidate the examiner provided PR findings and for another candidate it was told that the mother and child were not happy to proceed with it.

I provided an explanation (with drawing) for her of the condition from patient education and told her that our management will be as follows. First of all we must pay attention to his diet, the more fibre the better, fruits vegetables, cereals and less junk in general. Also not to forget abou t the fI uids: plenty of water and fruit juices. In terms of medication, we' 11 start with the three day cycles. First day: Microlax enema, second day: Durolax rectal suppository, third day: Bowel stimulant laxative (like paraffin oil preparations). It can be repeated and the laxative continued. The purpose of this is to clean his bowel and establish regular bowel motions and to keep it regular. I would also like to say that it is very important for you to understand that it is not the child's fault so please try to be gentle with him and encourage him to go to the toilet and try his best after every meal. You may like to keep a diary with a star chart to encourage and support him.

E: How long till we see the result?

C: It needs some time but I expect to see significant changes in 4 weeks time. I will follow it up with you. This problem could persist over the course of a few months (6-12). If all these measures are not successful (which is very rare), we can refer you to an encopresis clinic.

AMC feedback: Constipation/Encopresis.

10 year old boy, overweight, complains of pain below the knee for about three months, he is a very active child, plays football and basketball, noticed that phys activity worsens the pain and also noticed that there is a lump below the knee.

TASK:

• History

• Explanation and management

From history:

Generally a very healthy boy, fully immunised, normal growth and development, no medication, no allergies, has pain for about three months. Now he avoids sports because pain is aggravated by this. (The other candidate has been told that the patient would be very upset if it was strongly suggested to avoid sports for a while in order to get better and that he is still training and playing ... )

Dx: Osgood-Schlatter Syndrome Management:

As it is a self limiting condition, the management is conservative in the acute period - rest and analgesics. In the future, gradual strctch exercises, £.hysiotherapy and graded return to full activity: Dad asked if he could play sports - yes but when pain subsides. He asked how long does it last - 6-12 months. Feeling that parent was concerned - mentioned possible X-Ray. In any case at this moment there is no need for any other treatment. He asked if other treatment is needed such as plaster cast or corticosteroids or immobilisation.- NO.1 mentioned about weight reduction.

We finished early.

AMC feedback: Osgood - Schlatter's disorder.

You are working in a hospital ED. Emily, an 11 year old girl still at school fell at school injuring her right elbow, which is swollen and painful. X-Rays are provided, you are with Emily's mother. After examining Emily, there were no signs causing concerns.

TASK:

• Talk to the parent regarding diagnosis and treatment

• Answer the questions

On the X-Ray it was a supracondylar fracture which was not really clear on the lateral X-Ray. Examiner first asked me to show the mother where exactly the fracture was on both films, After that I explained to the mother what had happened. Explained that our arm has 3 bones and showed the fracture just above the elbow. My major concern is the possible damage to the brachial artery in case of displacement. Right now the bones are positioned well and we'II just have to keep them this way. For that we will put a back slab and a collar and cuff or a sling. Please watch her carefully today, especially for any swelling, pallor or really severe pain in the hand or arm, in which case bring Emily back to the ED immediately. Otherwise I will see you tomorrow for a follow up. You can give her some Panadol for pain relief.

P: Can she go to school?

C: yes, after the pain subsides.

P: Can she write since she is right handed?

C; Not from the beginning, but she can still attend school and listen to the teacher. Later on, provided everything goes smoothly, Emily will go to see a physiotherapist. She will be taught little exercises and she wiJI be writing soon afterwards. We both finished this station earlier.

AMC feedback: Supracondylar fracture humerus.

ED setting. A 9 year old girl has been stung by a bee, experienced shortness of breath, swollen lips, tachycardic, BP-60/40. You are about to see a nurse and the mother of the child.

TASK:

• Give the nurse instructions of your management step by step.

• Explain the condition to the mother and answer her questions.

Start with ABC. Nurse quickly responded that it is done (as in the stem).

Please call a code blue. Then I asked if she is on oxygen and the nurse said she is. I told her to give her Adrenalin IM-O.Olmglkg in dilution I: 1000. She said OK and I asked about the vital signs to which she responded that BP is not available but she is not responding well. I told her to give more Adrenalin through IV if there is IV access but if not then administer the same amount as before 1M.

N: anything else?

C: Could you please establish IV line and give fluids.

N: how much fluid?

C: 1O-20mUkg as a bolus. N: Child is 30kgs

C: then give 300-500mL. N: Anything else?

C: I will consider steroids and antihistamine (Hydrocortisone lmglkg and PromethazineImg/kg).

N: ok Dr. The child is improving.

Now talk to the mother - very upset, especially after telling me that her daughter has been advised to see the allergologist already.

C: I talked about the very severe allergic reaction and the need for a good plan and management (first aid courses, anaphylactic kit, including Epipen, avoiding places where bees live, avoid bee products, referral to allergologist, medical alert bracelet and inform the school)

M: can we go home?

C: NO, we have to keep the child under observation for at least 8 hours because of the possible rebound effect.

AMC feedback: Anaphylaxis bee sting.

OBSTETRICS AND GYNAECOLOGY

28 year old lady presents to you in your general practice. 10 days ago she gave birth to her 2nd baby. The first child is a 4 year old, the baby is fine. She now has vaginal bleeding, changing her pads every 2 hours and she has already changed more pads within the last 24 hours than within her entire normal period. During delivery the episiotomy was done, the scar now is looking fine and healing.

TASK:

• Take further history

• Examine the patient

• Discuss the diagnosis, investigations and management.

From history:

NVD - 10 days ago, baby is fine, no problems after delivery, had some bleeding - 'lochia' after discharge from hospital but now she bleeds severely with clots, no chronic condition including bleeding disorders, non-smoker, non-drinker, no allergies, no medications and is currently breast feeding.

PE:

General appearance: not well

Vital signs: BP-Iow, PS-IOO, temperatnre-S'r.S, CVS, RS-normal.

Abdominal: involution of the uterus is not satisfactory and the uterus is a bit lax. PV: cervix is open and stream of blood in visible, digital examination-normal,

MANAGEMENT:

You will need to be admitted to hospital by ambulance. In hospital an ultrasound will be done. I suspect that your problem is related to the retained products of conception and the danger is that they could get infected and bleeding could be quite severe. I also mentioned other causes of

PPH: lacerations of the birth canal, coagulation disorders and uterine atony. If the ultrasound confirms this the gynaecologist will do D&C where the products of conception will be removed. Now I will give oxygen and insert an IV cannula.

Examiner asks something else?

I will commence the patient on antibiotics. Organise social worker jf nobody is available to look afte~.

Thepatient asked if she needs blood transfusion in hospital. My answer was no. Finished early.

AMC feedback: Secondary postpartum haemorrhage.

68 year old lady, presents to you with Pruritis Vulvae for 12 months.

TASK:

• History

• PE (photo provided on request)

• Investigations and management.

From History:

Patient has terrible itchiness down below which interferes with her daily life. Her nights are OK - doesn't wake her up. Generally a healthy woman - no medications, chronic conditions or allergies, last Pap smear - 3 years ago - normal, usually does regular Pap smears, not sexually active for 35 years, aware of self breast examination and does mammography every year. Period ceased at the age of 50. She was prescribed oestrogen cream that didn't help her.

PE:

All normal, picture of the external genitalia featuring scratch marks on labia majora, whitish plaques and broken skin. PV -norrnal.

Dx

Lichen Planus or Sclerosis.

DD:

Ca?

Management:

I will take Pap-smear, swabs for infection and refer her to 0&0 where the colposcopy and vulvoscopy will be performed as well as mUltiple biopsies of the lesions. If LP is confirmed then I would prescribe her a corticosteroid cream - patient was happy.

AMC feedback: Vulval itch.

Young primigravida - 41 weeks gestation comes to our GP clinic. All antenatal visits are normal, all tests and scans are normal, GTT and GBS done recently - normal. Worried that she is still not in labour.

TASK:

• Address her concerns

• Management

From history: h..l-t&-- ....... ~ ,

• All normal, Bl.Gr. A( +), all antenatal visits- normal, last ultrasound - 18 weeks - normal, no chronic medial conditions, no smoking, no alcohol, no allergies, no medications.

PE:

GI and NVS - normal Uterus: FH - 40 weeks

Cephalic presentation - FHR- normal Pv- cervix is closed.

All else - normal.

Management:

Explain to the lady that it is quite alright to be a week overdue. Our major aim is to make sure that you are OK and the baby too for which purpose we organise an ultrasound: to see how placenta is situated and measure the estimated fetal weight and amount of amniotic fluid; CTG: to see how your baby is doing. Depending on those fmdings, you will either wait a little more or your labour will be induced by using medications or by rupture of the sack with the amniotic fluid.

Another option is caesarean but it is the last resort .

Asked if everything is normal how long to wait, so I said for a couple of more days but you can consider staying at hospital from now because the labour is very close. (we finished this station earlier).

AMC feedback: Post dates pregnancy.

l\1EDICINE AND SURGERY:

45 year old lady come to your GP clinic complaining of ''nervousness''.

TASK:

• Take history

• PE findings from examiner

• Investigations and management

From history:

Husband complains about her Irritability and nervousness which she admits herself, On further questioning she mentions some palpations, diarrhoea (3 loose stools everyday), dislike of hot weather for 3 months, sweating even when its cold. No problem with steroids or drugs in her

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family. He was previously healthy, no exposure to radiation, no family history of thyroid problems, no allergies or chronic conditions. Appetite is increased but she has lost some weight.

PE:

As you see it - slim agitated woman, sweaty hands, fine tremor.

BP; normal. pulse: irregularly irregular: 100. Palpable enlarged thyroid - smooth - no nodules. CVS: widespread systolic-murmur (don't remember exactly), could be heard everywhere. Abdominal and respiratory are normal.

Diagnosis: Hyperthyroidism.

Management:

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FBE, TFl's, ECG, Radioisotope scan of thyroid, consider referral to endocrinologist which will prescribe medication that wilLdecrease.1he.1e¥-eLof-thyr.oid-hormones_--

Explained the condition to the patient.

AMC/eedback: Nervousness.

28 year old man presents to your GP clinic complaining of joint pain and wide-spread rash. Picture provided: rash on trunk and limbs, maculopapular with generalised erythema.

TASK:

• History

• PE

• Inform patient if any investigations are necessary.

From history:

Generally healthy young man, no chronic conditions, medications or allergies, recently travel1ed to QLD (camping where there was a lot of mosquitos).He returned just 1 week ago. He is in a stable relationship, not an IV drug user, no smoking, alcohol occasionally, no recent contact with person having similar symptoms. His family is fine. He is a mechanic but pain in join ts doesn't limit his work, other candidate was told that it does interfere and that he needed pain relief and sickness certificate.

Note: the patient did not volunteer any information, he only replied when you asked specific questions.

PE:

General appearance: rash as described, trunk and limbs. VS: normal but temperature: 37.8

All major joints and joints of the hand are swollen.

On abdominal examination: no hepatosplenomegaly. ~j~

Examiner asked about DD.

I said that main diagnosis was Dengue fever.

Also we should consider HIV but from history it is less likely.

Possibility of Ross River fever (It was the main Dx for the other candidate) Infectious mononucleosis and malaria. (but they are less likely then Dengue fever).

Investigations: FBE, viral serology for all of the above. I finished early.

AMC feedback: Joint pains and rash.

Post menopausal woman who had a L4 compression fracture presents to you at general practice. She has done bone densitometry; it shows -3 standard deviation bone loss.

TASK:

• Talk to the patient, explain

• Manage accordingly

I didn't have to explain the osteoporosis to the patient because when asked if she knows what it is she answered yes and she herself asked what to do about it. I said that we'll get to that a bit later and went on to ask her a series of questions.

From history:

She is 10 years after menopause which was OK but had a few hot flushes and didn't take HRT. She doesn't smoke or drink alcohol but drinks 5 cups of coffee a day and doesn't like milk and dairy products. Her only time spent exercising and being outside in the sun is a little bit of gardening. She doesn't have any chronic conditions or allergies and is not on any medications (including corticosteroids). Her sister and mum also had osteoporosis.

Mx:

Talked about the importance of decreasing the coffee intake, advised on exercise and sun exposure and tried to talk her into at least thinking about increasing dairy product intake but patient was really adamant. Then we talked about calcium, vitamin D, Bisphosphonate and Raloxifene. As she was 10 years after menopause, there was no point in giving her HRT. I did not mention about excluding Multiple Myeloma but I think that it was relevant.

Other candidate: When I said about the diet rich in Ca and diary products the patient said that she does not know how she will eat it because she does not like it. I offered a help of a dietician, the patient happily agreed.

I also mentioned about SE of bisphosphonates( nausea, oesophagitis).I said that in order to reduce the chance of SE she needs to swallow the pill with plenty of water 20-30 min before breakfast and remain upright for at least 30 min after taking it.

Also I talked about occupational therapist involvement to assess the her living conditions and to advise on necessary adjustments in her house in order to prevent further falls.

The patient and examiner were very friendly, they smiled a lot. It was my last station and when I entered the room the examiner said: you are our lucky last for today, do not worry about anything already, talk to you patient and after you can finally relax. What a great examiner! :-)

AMC feedback: Back pain and osteoporosis.

ED setting. A woman in her mid 20's presents with severe abdominal pain in RIF for a few hOUl'S. Nausea? Vomiting? Bowel motions - normal, no dysuria, LMP 4 weeks ago and she is onOCP.

TASK:

• Examine the abdomen

• Manage accordingly

First of all I asked if she wanted me to give her something for the pain to which she answered yes. Examiner then asked me of what I am thinking of giving her, to which I answered Pethidine and further questioned me to ask patient whether she had this type of pain killer before and how she reacted to it. Patient confmned that she had morphine a few years back and was completely knocked out by it. The examiner wanted to know whether I still wanted to give her anything. I said no and asked the patient to bear with me for a few more minutes whilst I proceeded to examine her. Examiner asked how to go about the PE.

After asking about GA and VS I will only do an abdominal examination because it looks like a

surgical emergency. First I looked then I asked where it hurts the most (RIF). Then the

patient reacted quite badly to even su erficial palpation even in LIF and she said that the pain in the RIF also increased. Guarding (+), rigidity (+ . I wanted to stop palpation but the examiner instructed me to go on t6 illicit tenderness at the Mc Burney point. PR and PV not done. Examiner asked about differential diagnosis: acute appendicitis, perforated peptic ulcer, PID, ovarian torsion, ectopic pregnancy or UTI. ? "

The only question from the patient was: Could it be just gastro?

Other candidate: Guarding and rigidity were (-) in my patient, but the patient had pain and tenderness over McBurney's point, Rovsing's and psoas signs were positive. When I asked about PR findings the examiner told me that it is tender on the right side.

I wanted to auscultate the abdomen, but the examiner said that it is normal on auscultation.

Then the examiner asked me about DD( which was the same with other candidate) and what investigations I would like to order. I said: FBC, U&E, urine microscopy and culture, pregnanC2}! test (the patient was on OCP, but I said that there is stiIl a slight chance of pregnancyf, US of abdomen and I also want the patient to be seen by surgical registrar asap. When I mentioned about US, the examiner asked what I want to see on it. I replied: signs of PID like salpingooophoritis... The examiner was happy. He said that I was on the right track and can go out now. Now you see that in different groups the same case could be presented with some variations.

AMCfeedback: Appendicitis (acute).

A 55 year old woman was accompanied to the ED by her husband. She complained of severe dizziness and inability to walk.

TASK:

• Take a focused history

• Ask the examiner for PE findings

• Discuss your diagnosis and management with the examiner

From history:

Patient started having pain in the left side of her face this morning, then started to feel numb in her right arm and leg and became very dizzy. She didn't complain of difficulty speaking and her swallowing is alright. She was so dizzy and nauseated that she vomited once; she becomes dizzier when she moves or turns her head. I asked the patient if I ask her to walk at that moment,

how she would go. She said that she would become dizzier and keep falling to the left. Patient is overweight and is being treated for high blood pressure and cholesterol, doesn't smoke and drinks socially (occasionally). She is on anti-hypertensive medication and Lipitor.

PE from the examiner (only given what you ask for):

Eye movements and pupils - normal, Nystagmus to the left, Horner syndrome (+) on the left. Muscle power is normal, pain sensation is reduced on left side of the face and right side of the body, couldn't check the cerebellar signs (patient was too unwell).

Other candidate: When I said that I want to check cerebellar signs the examiner asked to tell him exactly what signs I want to check. I said that I think it would not be possible to check gait for ataxia or to perform Romberg's test because patient is not well enough for this, but I want to perform the finger-nose test, alternating movements of the hands and the heel- shin test.

The examiner said that they all are positive on the right side of the body (patient is not able to perform them when the right side is actively involved).

On talking to the examiner I indicated that these are the signs of Lateral Medullary syndrome with posterior inferior cerebellar artery involvement. Immediate admission is required with urgent CTIMRI and neurological consultation. Finished early. Far too early.

Other candidate: when I mentioned CT scan of the head the examiner said that on CT you cannot see anything. Then I asked for MRI. The examiner answered that on MRI you can see ischemic infarction of the left side of cerebellar and brain stem. I said that it is consistent with my clinical diagnosis ( the same with the above candidate) ,I will admit the patient urgently and will consult a neurologist.

AMCfeedback: Dizziness (acute).

A 32 year old man presents to your GP practice complaining of low back pain and right leg pain. He is unable to sit and walking is difficult. The pain came on suddenly after lifting a heavy object. Previously has been in excellent health, no chronic conditions, no allergies, no medications.

TASK:

• Perform a physical examination of the back

• Give summary of the PE to the examiner

• Explain your diagnosis to the patient.

On PE findings were:

Had difficulty standing and walking on his heels (right side), back movements - extention, flexion and side tlexion are severely limited, the palpation of the spinous and tranversus processes is painful, couldn't perform the slump test because of the patient's i nabi 1 ity to sit. He had severe limitation to LSR on the right side, tone and power were all normal except for the right foot dorsiflexion, reflexes are preserved and the pin prick sensation is decreased in the L5 distribution on the right.

The examiner asked me to explain to the patient what's going on.

I explained about the vertebrae, the disks, the prolapse and the nerve/root involvement. Tried to touch on management but examiner stopped me telIing me its not my task and told me to wait outside as I finished the station earlier.

AMC feedback: Back and leg pain (acute).

A young male patient has been found unconscious at home by a flat mate who is unable to give any history. The patient is now in the ED.

TASK:

• Perform an examination (GCS)

• Tell the examiner what you are doing and why

• Provide the examiner with your assessment

• Differential diagnosis and investigations

There was a young male patient lying on the couch with his eyes closed. I did ask about the ABC and the examiner said its all OK. I said I'd like to check for the neck stiffness but I am concerned about a possible injury so I would like to secure the neck as well. The examiner said that the cervical spine was cleared as the CT was done. The neck stiffness was present. I also stated that I would like to check for any other injuries and look at the arms (IVDU?). Pupils- PERLA. Reflexes are normal.

GCS:

Eye opening: opens them in response to pain. Motor response: withdrew to pain.

Verbal response: inappropriate words.

My GSC score was around 10.

Examiner asked what could be the possible causes of the coma.

--Meningitis, drug overdose, alcohol overdose, SAR, DKA or hypoglycaemia. Examiner asked what investigations are necessary.

--Brain CTIMRl (after which I would consider LP), urine for drug screen, blood glucose and electrolytes and oxygen saturation and I also will take blood culture urgently and commence patient on antibiotics empirically, as the most likely cause of his coma is meningitis.

AMC feedback: Coma.

Good luck for everyone!!!

AMC CUNICAL EXAM RECALL

BRISBANE FEBRUARY 2008

1

AMC CLINICAL EXAM RECALL

BRISBANE FEBRUARY 2008

1. A 17 year-old girl with a known peanut allergy has had moderate episode yesterday.

TASK; advise her of the management.

This is a common station. Advise for the potential dangers of the peanut allergy, possibly associated allergies to other nuts, Epipen carrying instructions with explanation of contents and their use. Bracelet, referral to allergologist, advice for meticulous checking of any food for descriptive labels of traces of nuts, leaflet. The chance for the allergy to bum out over the years is small.

No questions from the role-player or the examiner. Peanut Induced Anaphylaxis

2. A young man with nausea, vomiting, and abdominal pain which started out as central but which moved to the right iliac fossa. There is guarding in the right iliac fossa on palpation.

TASK; explain the possible likely diagnosis, give differential diagnoses. Management.

The patient was told that the likely diagnosis is appendicitis. I explained additional examination/tests I would do to prove this, namely Rovsing, Psoas, obturator symptom. The differential diagnoses I mentioned were renal colic, mesenteric adenitis, Crohn' s disease. After that the conversation was about the forthcoming operation, why it was needed, possible complications, and the regime for care after the operation. This refers to case no. 140 in the Australian Medical Council Handbook of Clinical Assessment.

Initial Management Of Acute Appendicitis

3. Case no 113 in the Australian Medical Council Handbook of Clinical Assessment.

Sepsis (Paediatrics)

4. Case no. 79 in the Australian Medical Council Handbook of Clinical Assessment.

Here I nearly missed assessing the blood group for rhesus negative. The examiner prompted me, asking whether I had anything else to add, and I remembered and was saved.

Threatened abortion (O&G)

5. A young woman unsuccessfully trying to conceive has been seen by your colleague yesterday and now is in your consulting room with the investigation results, which are borderline anaemia, thyroid function normal, follicle-stimulating hormone low, and normal electrolytes. Her body mass index is 14.4; BP normal, without postural drop.

TASK; history, explanation of results, and management.

History- no problems at home, work or socially. She has been this skinny since her teens and claims to feci very comfortable. Not tired, has enough energy. lIas had no periods for several years. I missed asking about illicit drug use and hyperthyroidism symptoms.

I explained to her the connection between low BMI and failure to conceive, and the hypothalamus, pituitary and ovary interrelationships. T explained osteoporosis following

AMC CUNICAL EXAM RECALL BRISBANE FEB RUARY 2008 2

anovulation, and referred her for a bone density test. She was keen to start to eat so as

to conceive, and so was sent to a dietician, and to the community mental health service.

The examiner said nothing, but looked extremely grim. Anorexia Nervosa, Diagnosis

6. A woman with a previous caesarian section, who is now at 28 wks gestation, has been having vaginal bleeding, and has come to the emergency dept. She is rhesus positive.

TASK; focused history, examination findings from the examiner, management.

In the history I find that she has had an uncomplicated pregnancy till this moment. She does not abuse drugs and has undergone no recent trauma except possibly that she has had sex the previous night. Her morphology scan at 18 weeks showed the placenta to be in a low position. Presently, she is feeling well. She does not feel dizzy when she stands up ..

On examination, she is haemodynamically stable, with BP 120/80 and HR 70 or so. The abdomen is not tender. She is not in pain. The foetal HR was 140BPM.

I explained that this is probably a case of placenta praevia, and that I would urgently call the obstetrics registrar for an ultrasound examination and eTG to discover the reason for the bleeding, and to make sure of the baby's well-being. I admitted her because the bleeding may resume. I will NOT examine her vaginally (this would have been a critical error; because it may cause bleeding).

The role-player asked me about the mode of delivery. I answered, "If the case is placenta praevia, delivery will only be via caesarian section".

The young Indian examiner was hostile from the beginning, making angry exclamations when I mentioned wanting to check the vital signs in the first instance, and after that, continued to look angrily at me for whole duration of the station. Perhaps somebody had angered him before I arrived. In any case I will be surprised if I fail such an easy station.

Well, it happened that I did in fact fail this station.

It was because she looked so well and her vital signs were so stable that I didn't order a blood cross-match for a possible transfusion while waiting for the obstetrician to arrive, and this might have been the critical error.

Vaginal Bleeding At 26 Weeks Gestation (O&G) (Failed)

7. A ~,~ye'ar=om child with limping and pain in one leg.

TASK; history, examination results from examiner, differential diagnoses, diagnosis, management.

History; the pain began last night. There is no history of trauma, of easy bruising. The child's delivery and developmental history to this moment have been norma1. The father has not noticed the child to be hot. He had a respiratory tract infection, possibly flu, some ten days ago.

The examination findings from the examiner were; general appearance; normal, restricted and painful internal rotation and abduction in the hip. The child is not febrile.

I explained that this is probably a case of irri table hip, with this typical history of flu 10 days ago, and restricted hip movement. The differential diagnoses are avascular necrosis (Pedes Disease), septic arthritis, and perhaps, though unlikely, developmental dysplasia of the hip.

AMC CUNICAL EXAM RECALL BRISBANE FEBRUARY 2008 3

I would order C-reactive protein, erythrocyte sedimentation rate and full blood count

and X-ray of the hip, and I would refer the patient to the orthopaediatrician. Meanwhile, the child will need at least a week's rest.

30 seconds before the bell, the father turned to me and asked provocatively, "Are you sure that the problem is in the hip?" I felt somewhat panicked, and asked the examiner for the examination findings in the groin, knee and ankle. With a guarded smile, the examiner answered, "Normal". Then I replied that yes, I was certain that the problem was in the hip.

Transient Synovitis Of Hip - Irritable Hip (paediatrics)

8. Case no. 119 in the Australian Medical Council Handbook of Clinical Assessment.

A man wants to discuss his wife's condition. Patient confidentiality

9. Full page of text impossible to read in 2 minutes, describing investigation done on a man with abnonnalliver function test. He has a pacemaker fitted.

TASK; history. investigations from the examiner, management.

When I entered, I asked for permission to read for a little longer, and after 30 seconds started to take the history. The patient had never used any drugs that could damage the liver, or any alcohol. On questioning about his ancestry, he kept replying "Australian!" He reported no skin-colour change. Hepatitis serology tests were negative, as was monospot test. On the list of investigations given, there were normal Alkaline Phosphotase (no cholestas!s), but increased Alanine Aminotransferase (hepatocellular "damage). I asked for a serum iron study, and the examiner supplied an additional list with significantly increased ferritin and transferrin saturation. After that, it was easy. This refers to case no. 69 in the Australian Medical Council Handbook of Clinical Assessment.

The management; once weekly venesection 500rnl for at least 2 years, then every 2 to 3 months. screen 15t degree relatives for haemochromatosis.

Abnormal Liver Function Tests

10. Case no. 97 in the Australian Medical Council Handbook of Clinical Assessment.

A pregnant woman of 28 weeks gestation, with a positive Glucose Challenge Test result.

The scenario given was nearly the same as the above-mentioned Handbook case, with just the one difference that the blood-sugar levels after 2 hours were not so high, but rather were only 8-point -something.

After I began to take the history, the examiner stopped me to tell me that he was unable

to hear me. So I made my first mistake; instead of raising my voice, I moved my chair closer to his. This violated his personal space and ruined his preferred arrangement of the room. And then, after a time, asking about investigations, I said 'urinalysis'. and he said something like 'what?'. I mistakenly thought that he had not heard me and repeated 'URINALYSIS!', loudly. He looked insulted, and answered me with quiet venom

'What .... For .... ?'. of COli rse th is was a test for protein, but the damage. had been done. After that, I covered the case according to the book, except [or neglecting to ask [or foetal lie and presenting part, and I didn't advise the mother to test her blood-sugar levels 4 times daily, which was a critical error. (I thought this was needlessly cruel, given that the glucose levels were not so excessive).

Abnormal glucose challenge test (O&G) (Failed)

AMC CLINICAL EXAM RECALL

BRISBANE FEBRUARY 2008

4

11. A 3 year-old child has had a problem breathing through his/her nose (mostly mouthbreathes), night-snoring, and frequent upper-respiratory tract infections.

TASK; history, examination, investigations from examiner, diagnosis, management.

This has been happening for the last several months. There are no sleep apnoea episodes. Otherwise the child's development has been normal, has had all the proper vaccinations and is thriving. The child's father suffers from allergies .. The mother hasn't noticed any hearing problem in the child. The child does not take any medications.

On examination, there were difficulties with nose-breathing, with bilateral nasal secretion (not malodorous) and constriction. Otherwise the throat was given to be normal (via pharyngoscopy), as were the chest (via auscultation), and the ears (otoscopy).

The examiner was surprised by my attempts to view enlarged adenoids through the nose or via the indirect epipharyngeal route; it seems that this is not done in this country.

Following my past experience, I explained to the mother what I thought was the likeliest diagnosis, of adenoiditis, and that I would like to refer the patient to an ENT specialist for eventual surgery.

I perceived that neither the role-player nor the examiner were satisfied with what I had said. The role-player started to ask me about other possible management, and especially about anti-biotics, and in an attempt to salvage some success I answered that we could use an intranasal saline rinse, and then eventually antibiotics. But I forgot to ask for about pharyngeal post-nasal drip, or for a nasopharyngeal swab, or about enlarged cervical lymph nodes.

I felt that something had gone wrong. I mentioned that an allergy could be playing a role here, given the family history, and offered to arrange a skin-prick test. At this point, 20 seconds before the end of the station, the answer given by the examiner was 'not available'.1 think it was a mistake to send the child for prospective surgery without trying less invasive treatments first. I wonder whether perhaps they wanted me to speak mostly about perennial rhinitis, and about strategies for dust-mite reduction etc. I forgot to advise against smoking in the house as well.

See p 243 in the Royal Children's Hospital Paediatric Handbook Rhinitis (Paediatrics) (Failed)

12. Case no. 83 in the Australian Medical Council Handbook of Clinical Assessment.

A woman with chronic schizophrenia recently started a new medication, and gained 15 kg in 3 months. The role player was extremely convincing, and appeared to be authentic. I asked her PASS questions (Psychosis, Anhedonia, Substance Abuse, Suicide). She had no extrapyramidal side-effect symptoms, nor anticholinesterase symptoms. She had no decreased tolerance to cold. The name of the drug she has started 3 months ago was unknown to me (probably deliberately), and so 1 asked "is this OJanzapine'l". Examiner; "Yes". 1 ordered a blood sugar test, thyroid function test, a lipid profile. I forgot to ask for a serum prolactin test.

My management was to explain this common side-effect of the drug to the patient, and to give her the option to start diet and exercise (referral to dietician), or to consider a change of medication, urging her though, to take into consideration the probable side-effects of any eventual new drug. I told her that a change of medication could be carried out only by a psychiatris t, with gradually withdrawal from the old and introduction of the new. The examiner seemed want to hear something else about my management. at almost the

AMC CUNICAL EXAM RECALL BRISBANE FEBRUARY 2008 5

last possible moment, he said, "The psychiatrist could see her not earlier than in a

week's time. She's taking 20 mg of Olanzapine!". I thought for 5 seconds and said, "I can't change her treatment myself' (20 mg of Olanzapine, it turns out, is a normal dose, so this seems to have been a case of the examiner attempting to provoke me into making an error). But still 1 am not sure whether or not a GP is empowered to prescribe or change antipsychotics. Please check this.

Weight Gain Side Effect Of Antipsychotic Drug

13. Case 59 in the Australian Medical Council Handbook of Clinical Assessment.

The examiner was the lovely Dr Marshal, from the AMC examination video. You don't have to memorise the signs and tests for brain-death; the list is inside the room. The roleplayer only wants you to explain the logic of the tests.

Diagnosis Of Brain Death

14. A 50-something-year-old man with a history of 2 weeks of headache.

TASK; take history, a real focused examination, diagnosis, management.

1 questioned the patient about the nature of his pain; severity, duration, constancy, nausea, vomiting, blurred or double vision, history of similar symptoms, and about any history of drug abuse or trauma. I asked whether there had been any recent fever.

In the examination, 1 checked for neck stiffness, facial and pupillary asymmetry, and visual abnormalities. The pain was definitely in the temporal area, but pulsation of the temporal artery was present. I mentioned ophthalmoscopy and the examiner asked what 1 was checking for.

For the management of temporal arteritis, see case no. 93 in the Australian Medical Council Handbook of Clinical Assessment.

Headache

15. A middle-aged woman has had a black-out yesterday.

TASK; history, examination findings from examiner, differential diagnoses, diagnosis, management.

The patient has a history of good health, but yesterday, while playing tennis, she had fallen suddenly unconscious. She had no visual disturbances prior to the episode and was not disoriented after it. She does not use drugs and her BP is usually normal. She doesn't feel any numbness in her limbs and has no headache (I thought I knew what this case would turn out to be, but tried to hide this fact from the examiner, and so 1 didn't even ask about cardiovascular symptoms at this point).

After I offered to examine her, the examiner pointedly asked me, "Do you want to finish your history?". I asked about shortness of breath during exertion, palpitations, orthopnoea, swelling of the ankles.

The examination revealed a normal cranial nerve, no carotid bruit, and no displaced apex beat. There was no thrill, but there was a grade 3 systolic murmur over the aortic valve propagating to the carotid artery. I asked about the Valsalva manoeuvre to exclude hypertrophic obstructive cardiomyopathy.

I diagnosed aortic stenosis.

AMC CUNJCAL EXAM RECALL BRISBANE FEBRUARY 2008 6

The examiner asked me about differential diagnoses for syncope, and I mentioned Transient ischaemic attack, hypoglycaemia, epilepsy, orthostatic hypotension, vasovagal syncope, and hypotension-causing medications. I forgot to mention arrhythmia.

In the end, the examiner told me, 'You forgot, taking your history, something connected with aortic stenosis'. What did I miss?? The answer came to mind after the exam; ANGINA. But I would not have expected to fail for this kind of omission.

This refers to case no. 36 in the Australian Medical Council Handbook of Clinical Assessment.

Syncope (Failed)

16. A middle-aged man is concerned about the possibility of his contracting prostate cancer.

TASK; assess the risk of prostate cancer for this particular patient. Inform him about the prostatic screening strategy in Australia.

Upon my entering the room, the examiner asked me whether I had understood the test, and although I answered in the affirmative, he stood beside me and read to me the entire ~ ·L"rU-'V<... ~'n;I stem. Probably he was upset with the levels of comprehension of previous candidates.

- Att . 80i: b., Z¢ j ....

1i ' The role-player's father had had prostate cancer of> 70 years of age onset. The role-

- ~lq-'H~ player had not had any radioscopy and neither had he worked with toxins. I asked him carefully about bladder-outlet obstruction and haematuria, neither of which he had, but I neglected to ask about back-pain. The examiner wanted to hear specifically the triad of screening tests;

if Digital Rectal Examination

iii prostatic-Specific Antigen

iii! Abdominal Ultrasonography

The required content is on pages 77 and 11 02 in the latest edition of Murtagh.

Most decisive in this case was that at the end of the station, the role-player asked me to describe the advantages and disadvantages of prostate cancer screening.

My comments were that the benefits are as for any screening; to discover problems early. The disadvantage is inaccuracy; there are a lot of false negatives and false positives. And the patient is subjected to high levels of anxiety that can not necessaril y be relieved by favourable results, and may be needlessly stressed by an unfavourable one.

Carcinoma of the prostate

CONCLUSION

• More than half of the stations were from the Australian Medical Council Handbook of Clinical Assessment.

• The strong tendency in past exams for examiners to behave as observers remains stable.

• These particular examiners -and I have heard this about the Brisbane examiners- do not appear to feel obliged to provide any positive feed back after you finish, Most of them maintain stony faces, and this could seem very discouraging, especially if they have met you at the beginning of the station smilingly.

• There were two relatively young examiners, and they both failed me for - to my mindinsufficient reason (see the vaginal bleeding and syncope cases).

March 29th 2008 - Gold Coast Hospital

1. GP setting. A young mother brings in her little baby girl aged only 7 or Bwk. because the nurse found asymmetrical hip creases at 6wk postnatal check-up. Today she comes to see you for your advice. Task: lake focused Ax; Perform relevant physical examination on the model; Management

Hx










• Have you noticed any difference with your baby's hip joints? - no Any restricted hip movements? - no

Do you think she is in pain when she moves her hips? - no Is she your first baby? - yes

Was she born in a breech presentation? - yes Was it an elective CS? - yes

Any other complications during pregnancy and delivery? - no Is she putting on weight? - yes

00 you have any other concerns about her development? - no

Has anyone in your family had similar problem? - yes. my younger sister had problem with her hip when she was a baby and treated with plaster.

Do you know the exact diagnosis? - no

Ex

There was a model of baby girl (lower half body) on the table. I did not go through this case during my preparation. but I had a very vague impression about the topic and remembered there was a diagram in GP book. So I tried to move the hips forwards and backwards genlly. The mother asked me what I was looking for on the Ex. I explained there was dislocation on the right side.

Mx

Your-baby's right hip joint is not stable on the Ex. which means that she may have a condition called congenital hip dislocation (currently called developmental dysplasia of the hip). lt is more common in girls and has some risk factors such as breech presentation and family Hx. I need to refer your baby to paediatric orthopaedic surgeon for further Mx. The specialist will do Ix to confirm the Ox and probable plaster or splint to fix it. I appreciate that you bring your girl early to me. The outcome will be good if we can start intervention as early as possible. If left untreated. she will have walking problem when she grows up and possible osteoarthritis of the hip in the longterm.

Q from role-player

Why does it happen? - risk factors: female. breech and FHx

Do you think it is important to see a specialist? - yes. (I repeated what [ said earlier.)

Offer written info and follow-up No question from examiner.

(I finished the station earlier. I am not sure about the Mx. Pis check it)

AMC Feedback - Dislocated hip in an infant (Paeds)

2. GP setting. A 5-year-old boy is brought in by his father. He started feeling unwell since last night and had temperature at 40C. He also c/o sore throat.

Task: Ask Ex findings from examiner and Mx (no Hx needed)

The examiner was a very nice old lady. who let me ask a few more questions from the father. Hx

• How did it happen? - He has been well until last night. He c/o sore throat and has high fever this

morning.

• Has he had this problem before? - No

• How is his eating and drinking? - Not very well due to sore throat

• Does he go to toilet as usual? Any complaints? - No

• Have you noticed any skin rash? - No

• Does he hold his head In an unusual way? - No

• Have you noticed any ear discharge? - No

• Any complications during pregnancy and delivery? - No

• Any concerns about his development? - No

• Immunisation up-to-date? - Yes




Ex






• Does he go you school? - Yes, preschool Is he on any medication? - No

Is he allergic to anything, such as penicillin? - Not I am aware of.

GA - unwell, but still alert

VS - T 40C, mild tachycardia Skin rash and neck stiffness - nil Signs of dehydration - nil

ENT - nonnal ear tympanic membrane, a bit clear nasal discharge, throat (as soon as I asked about it, the examiner handed me a pic which was exactly the same as the one in the AMC book.)

CVS, chest and abdo - clear

Urine dipstick - not available

Mx

From Hx and Ex, I suspect that your boy has an acute tonsillitis, which is caused by strep A bacteria. I showed father the enlarged tonsils and yellowish pus in the pic. It is a common infection in young children and can be treated by antibiotics - penicillin. It is a 10--days' Tx, so even he gets better, he still needs to finish the full course of tablets. You can give him Panadol for his high fever. Let him drink a lot of water because he may get dehydrated. Sirep tonsillitis is very painful, so give him ice cubes and ice-cream to ease the pain. I believe he will love it.

I would like to see him in 2 days. If he does not improve in 2 days, I need to consider other possibility, such

EBV infection, also known as kiss'n di se. Strep tonsillitis is mainly a clinical Ox, so no Ix needed.

However, I V infection is suspected, further Ix will be considered.

Keep him at home for a few days, because strep tonsillitis is infectious. But once he gets better, he can go back to school. Do you have other kids at home? Yes, I have a liHle girl, 3-year-old. Is she well? Yes. Ok, keep him away from her as well. If you are concerned about your daughter, bring her to see me.

Any other questions?

- Does the infection affect any other parts of the body? - Serious complications are uncommon, but they may happen. The infection may affect his kidneys and heart.

Offer written info and follow-up in 2 days No questions from the examiner

(I finished it earlier)

AMC Feedback - Tonsillitis (Paeds)

,------------

3. GP setting. A father brings in his 2-week-old baby boy, who has had jaundice since day 3. There was no complication during pregnancy and delivery. Birth weight was 3.5kg. Mother's blood group is 0+ and baby's blood group is 0+. His total bilirubin is 220umo1lL, conjugated bilirubin is <10, comment: significant conjugated hyperbilirubinaemia. (I was confused by the comment in the stem. Conjugated bilirubin is <10, it is not a big deaL)

Task: Take relevant Hx and Mx

(Before I went into the room, I had thought it would be breast milk jaundice. However ... ) Hx

• Can you tell me more about your baby's problem? - He has had jaundice since day 3.

• Is it geHing better or worse? - no change, about the same

• Has he had any Tx for jaundice, such as phototherapy? - no

• Is he exclusively breastfed? - yes

• Does he put on weight? - he dropped a bit in the first week, but put on weight after.

• Does he have any vomiting? - no

• Have you noticed any color change of his stool and urine? - his stools are light color and urine is

dark.

• Any diarrhoea? - no

• Does he have any fever? - no

• Has he contacted anyone with hepatitis? - no

• Do you know his newborn screen test result? - it was normal

• Is he a full term baby? - yes

• Any concern about his development? - no

• Immunization? - I think it up-to-date

• Medication? - no

2

(Forgot to ask FHx of blood disorder) Mx

Your baby has prolonged jaundice. Because his blood test shows elevated conjugated bilirubin and you also told me his stools are light color and urine is dark color, I need to refer him to paediatrician for further Ix to rule out serious conditions, such as biliary system obstruction, hepatitis, and hypothyroidism. The father asked me what the specialist would do. I said he/she would repeat TFT, do imaging Ix and blood tests-to rule out the conditions I had mentioned.

He asked if there was anything wrong with breast milk. I said no. If we can rule out those serious conditions, prolonged jaundice may be simply due to breast milk. If that is the cause of jaundice, your wife can continue breastfeeding.

(In this station I knew I had to cover biliary atresia, because stool and urine color was abnormal anyway and there was elevated conjugated bilirubin, although [ thought it was not too high. But I should have explained more about biliary atresia.)

AMC Feedback - Neonatal conjugated hyperbilirubinaemia (Paeds)

4. ED setting. You are working in ED at a tertiary hospital. The ambulance officers bring in a 30/4Owk pregnant woman, who was involved in a MVA. She was sitting in the front seat with seatbelt, while her husband was driving. She is conscious and is able to sit up and talk to you. She brings her antenatal notes with her. Her antenatal check-up has been normal so far, including 18wk US. Her blood group is 0(-).

Task: Take relevant Hx; ask Ex finding from the examiner; Mx

Hx

(to the examiner) Before I take Hx, I would like to know if my patient is haemodynamically stable. - yes

I am very sorry to hear what happened to you. Are you feeling alright? Could you please teU me a bit about the accident? - it was half an hour ago. A car behind us hit our car when my husband was trying to change the lane.

• Was it on highway? Was it at high speed? - no, just on the street. It wasn't too fast.

• After smash were you able to walk out by yourself? - yes

• Do you have headache? - no

• Chest pain and SOB? - no

• Tummy pain? - no

• Have you had a gush of water running from the vagina? - no

• Any vaginal bleeding? - no

• Have you felt any uterine contractions? - no

• Do you still feel your baby's movements? - yes

• Is this your first pregnancy? - yes

• Have all the AN check-ups been normal? - yes

• What about your 18wk US? Did it show single baby with placenta in the normal position? - yes

• How is your general health? - good

• Any bleeding disorder? - no

• On any medications? - no

Ex









Mx GA - normal, conscious VS - normal

Chest - normal movement, no trachea deviation. normal breathing sounds CVS-normal

Abdo - slight tenderness in the pelvis, no uterine contraction, fundal height consistent with gestational age, not tense, cephalic position not engaged, audible fetal heart sounds

PV speculum - no bleeding or discharge, cervix is closed

Seat belt mark or bruises - nil

Active bleeding - nil

Fracture or deformity - nil

From the Ex, you and your baby are doing well right now. But I still need to keep you in the ED for observation for at least 24 hours. We need to perform CTG and US to make sure your baby is actually fine. CTG will be monitored for at least 4 hours. You just had a MVA, so both you and your baby should be monitored. US does not just check your baby, but also is used to detect any internal bleeding in your tummy

3

from your organs. Sometimes serious fetomaternal bleeding may happen sometime after the accident. So we have to be careful.

Because your blood group is 0 (-), you will receive anti-D injection to prevent bleeding complication in the next pregnancy.

My senior will come to see you. I will also check you up regularly. Inform nurse if you experience headache, chest pain, SOB, tummy pain, contractions, reduced baby movement or vaginal bleeding or discharge. (Then I stressed the importance of keeping her in ED for observation again. She was pretty pleased to accept this.) I said to the examiner I would like to do some lx, including group & hold and FMH test (Kleihauer test).

Do you want me to contact anyone for you? - no, thanks

Do you have any other concerns? - no, I just want to make sure my baby is ok.

Well, you are in a tertiary hospital. You and your baby will be looked after very well. (Surprisingly, she didn't ask about her husband.) My colleges are looking after your husband. Don't worry.

The role-player was quite happy.

No questions from the examiner.

(J finished it early)

AMC Feedback - Abdominal trauma in pregnancy (O&G)

5. GP setting. A woman in her 30s comes to see you because this morning she contacted a boy who has Rubella. She also thinks she may be pregnant

Task: Take relevant Hx and Mx

When did you contact the boy? - This morning Have you developed any fever or rash? - No

Have you had Rubella or received vaccine? - I am not sure When was your last period? - 10wk ago

Have you confirmed your pregnancy? - Not yet

Have you experienced any early pregnancy symptoms, such as NN and breast soreness? - yes How is your period like? - Not very regular

What do you mean? - Sometimes the cycle is 2 months If you are pregnant, is this your first pregnancy? - Yes

Is this your planned pregnancy? - No, but we have been trying, so no contraception Mx

There will be a few different scenarios depending on the results of pregnancy test and Rubella serology.

• j3-hCG (-), IgG (-), IgM (+) - mild illness, only supportive 1x. Don't go to work. Reportable disease)

• j3-hCG (-), IgG (+), IgM (-) - immunised .I SP..U

• j3-hCG (-), IgG (-), IgM (-) - repeat test in 2-3 wk, if IgM (-) again, have vaccination and avoid pregnancy for 3m

• j3-hCG (+), IgG (+), IgM (-) - immunised, safe to continue pregnancy

• j3-hCG (+), IgG (-), IgM (-) - can continue pregnancy, repeat test in 2-3 wk, avoid further contact, but no vaccination during pregnancy

• j3-hCG (+), IgG (-), IgM (+). - worst scenario, fetal damage in 90~ of affected pregnancies in first 8- 1Owk. Multiple and serious defects are common. This group of fetal abnormalities is called congenital rubella syndrome, including eye problem, heart disease, deafness, mental handicap, and delayed intrauterine development. If this happens, I will refer you to specialist considering termination, but the final decision is yours.

(I wrote all these scenarios down when I explained to the lady. That made it easy.)

Since your period is not very regular, we can repeat pregnancy test if it is negative this time. Offer written info and follow-up

No questions from the examiner. They both were very happy.

Hx









• AMC Feedback - Potential Rubella infection (O&G)

6. GP setting. A young lady comes to see you. She just had an ectopic pregnancy and was treated by laparoscopy. Tile lert lube WCiS removed and Ihe right tube looked normal during the operation.

Task: take relevant Hx and address pt's concerns

• How have you been since the operation? - Good

• Do you still have vaginal bleeding? - No

4


















Mx Was this your first pregnancy? - Yes Was it a planned pregnancy? - No

What type of contraception do you use? - I am on pills. Did you miss any tablet? - No

Why did you get pregnant then? - Possibly I did not take pills on time.

How is your period like? Any pain or vaginal bleeding in between? - Regular, no pain or bleeding Are you in a stable relationship? - Yes

Have you had multiple partners before? - No

Do you have any pain or discomfort during sex? - No

Any abnormal discharge or bleeding? - I had vaginal discharge a few months ago. Did you see doctor and receive Tx? - No, it recovered by itself.

Previous STD or PID? - No

When was your last Pap smear? - 6 (?) months ago, it was normal Any female organ disease? - No

Previous abdo surgery? - No

SIND-no

Medication - nil

Q: why did I have an ectopic pregnancy?

A: It is usually due to damaged tubes. Previous STD, PID or abdo surgery can make it happen. However in some cases there are no obvious causes. You had an episode of vaginal discharge, which was possibly a sign of infection. So I would like to take some swabs to rule out infections. (I am not sure if we need to do full STD screening here. I did not mention it in the exam.)

Q: I had only one tube now. How does it affect my future pregnancy?

A: Let me assure you that you still have good chance to have a normal pregnancy as you still have normal tube on the right side. The chance is about 60%. However, since you have already had one ectopic pregnancy, there is 20% of chance to have another ectopic pregnancy and 20% of chance to have a miscarriage.

Q: What should I do for the next pregnancy?

A: We need to rule out infection first. If clear, it is better to have a planned pregnancy. Practise safe sex and have a healthy lifestyle. Take folic acid for 3 months before pregnancy. If you miss a period, come to see me. I will do pregnancy test and US to confirm that it is an intrauterine pregnancy.

Q: How early can you confirm this?

A: Because your period is regular, fetal heartbeat should be able to be detected by US after 7wk of pregnancy. If not, we can repeat US soon after.

No questions from the examiner.

AMC Feedback - Recent ectopic pregnancy (O&G)

7. Delirium case - same as the one in the AMC book (after burn) AMC Feedback - Delirium

8. Male UTI - in the AMC book

AMC Feedback - Urinary tract infection

9. ED setting. A young uni student just had a fall. He has mild swelling, deformity and tenderness around right shoulder and clavicular area. X-ray has been taken.

Task: Explain the condition to the pt; Answer his questions; Mx the case using the material provided The questions from the role-player were the same as those in the AMC book.

The question not in the book:

Q: Can I write doctor? (Thif; question ls 5UPP05Cd to appear in the case or su~rtlt;ullt.Jyltlr JI.! 0)

A: You can write as soon as pain relieves and hand movement allow this, but try not to move your shoulder too much In the first few days.

In this case when the role-played asked me if he had to have x-ray again, I answered "possibly after a few weeks", because I could not remember the right answer. After I finished arm sling on the pt, the examiner said to me "earlier you mentioned that the pi needs another x-ray. Do you think it necessary?" I realized that I made a mistake. The examiner felt uncertainty in my answer and tried to help me. After a second, I said 'no,

5

I think it unnecessary since the patient only has mild deformity and if healing is good.' He then replied: 'Of course not!' ©

AMC Feedback - Fractured clavicle

10. GP setting. 60+ years old postmenopausal lady comes to see you because of L5 crush fracture. She had DEXA scan and her T-score is -3. F8G, calcium and ESR (?) are normal. Today she comes for the result.

Task: Take further history and advise management

• You had a lumbar fracture. How did it happen? - I tripped myself when I went upstairs.

• Did you have fall before? - No

• How is your appetite and diet? Do you have milk or milk products? - I just don't like milk and dairy

products.

• How much tea or coffee do you drink every day? - I have 5 cups of coffee everyday.

• Do you do exercise regularly? - No

• Do you have outdoor activities? - No, only do some gardening

• Menstrual and Menopausal Hx

Age of 1st period - I can't remember Regular period or not? - Yes

Age of menopause? - 10 yr ago Menopausal symptoms? - Nil

Are you on HRT? - No

Have you ever used OCP pills at young age? For how long? (I cannot remember how the role-player answered me.)

How many children do you have? - 3 children (?) Last Pap smear and mammogram - normal

• How is your bowel motion? - Normal

• Have you had weight change recently? Lumps or bumps in your body? - No

• Chronic medical diseases? - No

• Previous surgery? - No

• FHx - osteoporosis, bone and joint disease, cancer - nil

• SIND-nil

• Medication - nil Counselling

Osteoporosis is "bone thinning" because of oestrogen deficiency. The thinning makes the bones fragile so that they can break easily. Osteoporosis is found mainly in middle-aged and elderly women, after the menopause. Women at greatest risk are those who are thin and slight, smoker, drink alcohol, drink a lot of coffee, get little exercise, have little calcium in their diet, and lack hormones due to the menopause. I also would like to order some Ix to rule out 2nd osteoporosis (I am not sure if the examiner heard I said this. He did not ask anything in this station.).

Mx

a) Ufe-style changes: cut down your coffee intake; Moderate alcohol drink; Keep ideal body weight; Increases dietary calcium intake (milk and milk products, fish. nuts); exercise - brisk walking; sun exposure - 15-20 min

b) Medications

• Calcium and vitamin 0

• 8isphosphonates - they have SE of heartburn and oesophagitis

-take it 30 minutes before other food or drink is consumed and remain seated upright for 30 minutes after taking it.

c) Fall and fracture prevention

• General advice: Low-heel shoes, check eye sight. safety in bathroom

• OT referral- home risk assessment

When I felt I finished, I asked the role-played If she had any questions for me. She said: 'I have back pain.' I wasn't too sure what she meant. I said she could take simple analgesia for the pain and anti-osteoporosis might help it as well. She said: 'ok, doctor. You think the medication helps.' I could not think of anything else at that time. The bell rang. After I walked out, I thought I should have talked about her fracture. Well it was my first station. I was a bit nervous with my heart pumping heavily but still was able to lalk ill a normal voice. I just felt I talked too much.

6

• Can you tell me more about your problem? - I have this chest pain. It started suddenly half an hour

ago. I feel SOB as well.

• Have you had similar problem before? - No

• Where is the pain? - Here, central

• Does it go anywhere else? - No

• What type of pain? - The role-player could not describe it precisely

• Constant pain? - Yes

• Does anything make chest pain and SOB better, such as position or breathing? - No

• NN-no

• Headache - no

• Calf pain - no

• Feeling feverish? - No

• Cough or wheezing? - No

• Previous heart disease, asthma, or clotting problem? - No

• FHx of heart disease and clotting problem? - No

• Medication - no

Ex (I cannot remember too much now.) GA-unwell

VS-?

Chest - bilateral basal crackles (?) Heart - normal

Calf tenderness - nil

I said to the examiner I wanted to do ECG. He handed me one. I read it for a minute but could not see any ST elevation. I knew that massive PE has characteristic ECG feature but I could not remember. I was hesitated to say there was no ST elevation. Also because the patient was on heparin, which made me keep PE as my second Ox. I was struggling between AMI and PE. Eventually I said 'my provisional Ox is AMI, but PE is also very likely and needs to be ruled out. Other possible cause is pneumonia. I like to do cardiac enzymes.' 'What cardiac enzymes?' 'Troponin 1& T, CK, CK-MB.' The bell rang.

(I was not happy with my performance. I failed in this station.)

AMC Feedback - Chest pain and dyspnoea (acute)

13. Ectopic kidney - in the AMC book

Task: Give comments on the X-ray and diSCUSS it with the examiner; Explain x-ray result with the patient; Answer the patient's question and Mx

AMC Feedback - Atypical urinary colic

14. Migraine - in the AMC book AMC Feedback - Migraine

15. Postmenopausal IDA - in the AMC book AMC Feedback - Anaemia

16. GP setting. A middle age woman c/o chronic cough for 6 months. You organised bronchoscopy which doesn't show any abnormalities. The patient is here today for the result.

Task: Take psychosocial Hx and Mx

Hx

I have good news for you. Your bronchoscopy result comes back normal. which means you don't have underlying organic problem.

I would like to ask you a few more questions to find out the possible cause of your cough. Do you still have cough? - yes

Do you take any medication for it? - yes, XXX (I forgot the name), but not always works. Have you ever thought that your cough could be related to any emotional upset? - no

Any new avant or partfcularthing happened in your lift recently? - my husband left me 6 months ago. Do you have any children with him? - yes, 2 kids, but he doesn't let me see them.

Did your cough start after that? - yes

Do you think that could be related to your cough? - yes, possible

Do you feel hopelesslhelplesslworthle55? - no

Have you ever thought of harming yourself or others? - no How has your energy level been like? - as usual

Do you still enjoy things you used to? - yes

How is your appetite? Have you noticed any weight loss recently? - no How is your sleep? - normal

Have you been feeling especiaUy nervous or fearful? - no

Do you have close friends you can talk to? - yes Do you go out with them? - yes

Do you have financial problem? - no

How is your work? Do you still enjoy it? - yes, I love my job Any stress at work? - no

Good relationship with your colleagues? - yes

Have you had nerve problem before? - no

Is there any family member who has the similar problem? Any family history of nerve problems? - no

Do you drink alcohoUuse recreational drugs/smoke? - I drink 3-4 glasses of wine everyday at dinner Are you aware of safe limits of daily alcohol intake? - no

(Then I explained the safe limit and std drink to her briefly.)

Counselling

From what you told me, your cough is probably related to your emotional upset. It is well known our bodies are connected with our minds. Vllhen ppl are under a lot of stress, they may have physical complaints. For example, when students have exams, some of them may have abdominal pain or diarrhoea. It does not mean ppl have gastro problem. Under stress we are anxious and distressed. The symptoms are real and not imaged.

If you like, I can refer you to a psychologist, who is an expert in this area and will help you much better than me. It is better for you to have a 'talking treatment' such as cognitive behaviour therapy. It helps you to understand the reasons behind symptoms and to identify and deal with emotional issues.

Also I suggest that you can join some support groups, where you can meet some ppl with similar experience and you can share your experience with them and get advice.

Other methods: relaxation therapy, meditation, stress management and yoga

Re-stress the importance of reducing alcohol intake and arrange another appointment to discuss it. Written info and follow-up

AMC Feedback - Somatoform disorder

Comments:

I passed 15 stations except "chest pain and dyspnoea" case, which is No. 12 in my recalL It is expected.

My exam was actually not very difficult as you can see, but you never know what is gonna happen in your exam. Therefore, be well prepared. I only got through 2006 and 2007 papers, as you really cannot do much in 3 months' time. Some of stations in my exam probably appeared in 2004 papers or even earlier. So it is better to have a bit of background reading on these uncommon cases. Don't worry about how to perform these cases. It will come up by itself in your mind during exam.

My experience: well preparation + confidence + good luck

All the best to all of you!

9

ADELAIDE!t S APRIL!t 2008

PAEDIATRICS

1 . 3 yr old Jessica was brought to the ED as she is limping since this morning. She is having pain in the right hip. All the investigations were done in the ED and the child was sent to the paediatric ward where you are intern in the ward.

Take history from the father, examine the child, investigation findings from the examiner (you will be given the results which you ask for) and explain management to the father.

History: father told the child was limping since this morning. No fever, no trauma, activity normal, growth and development normal, appetite normal. H/O URTI 2 weeks back. Even now the child is playful and playing with her toys in the bed but not willing to move her right hip. Jessica did not develop any swelling or redness around the right hip joint.

OlE: General appearance: the child is playful Vital signs: normal

Right hip joint: no swelling or redness, the child cannot perform internal rotation and abduction at the right hip joint.

Investigations: WBC count: normal Platelet count: normal RBC count: normal Haemoglobin: normal ESR, CRP: normal X-ray right hip: nonnal

Ultrasound right hip: shows minimal effusion.

i -,

Management: your child is having a condition called transient synovitis or irritable hip. This happened in response to the URTI she developed few weeks ago. It will take 7 - 10 days for this to settle. During this time she needs to take absolute bed rest. If she starts to move around even before this period, then she may get relapse of this episode. So it is better to get her admitted in the hospital during this period because if she is at home she will be moving around and her pain will not be resolving.

AMC feedback: TRANSIENT SYNOVITIS OF HIP ~ IRRITABL.E HIP.

2. You are in the ED. 12 month old child was brought to the ED by her mother. She Is having fever since the last 2 days. Her activity and appetite

are a little bit decreased. You examined the child and she is having a temperature of 38.3 and the other vitals are normal and the physical examination is also normal.

You have done the bag urine specimen examination and it shows: nitrites ++++, leucocytes +++, no RBC.

Your task is to explain the diagnosis to the mother and further management.

Candidate: your daughter is having a condition called urinary tract infection. (Then I drew a diagram showing the urinary tract). So we need to admit her in the hospital and she needs to undergo further investigations.

First she will be seen by a paediatrician and he will be doing suprapubic aspiration to collect urine.

Mother: how it is done.

C: first ultrasound is done to see any residual urine and then under aseptic precautions a needle is introduced in the bladder area over the abdominal wall to collect urine. Once the urine is collected it will be sent for culture and sensitivity.

Mother: is it really necessary

C: Yes, to know exactly which organism is causing the infection because the bag urine on which we did the test earlier is prone for contamination and we can't rely on that specimen for culture and sensitivity.

Mother is really panicking now

C: Are you okay and do you need anyone to be with you.

Mother: I am really worried regarding all these things. I thought that she got a simple flu but now you are telling me all these investigations. I came here alone and my husband is at home taking care of my 5 yr old daughter .

./" C: No need to worry. First we will be starting her on broad spectrum antibiotics and when the culture report is back we can change the antibiotics according to the sensitivity ofthat organism .

..AC: Does your daughter have any drug allergy.

Mother: no.

C: we will start her on IV amoxicillin and gentamicin. She needs to be on these antibiotics for 14 days. ·Once her general condition improves we will change them to oral antibiotics

Mother: how long does she need to stay in the hospital?

C: until her general condition improves. It will around 2 or 3 days. But she needs other investigations like ultrasound and micturating cystourethrogram.

Mother: what are they?

C: we will be doing ultrasound initially to see ifany anomalies are present in the urinary tract. But MCV is done after infection subsides because if we do it now her infection might become even severe

Mother: what is MCV and why is it done and how is it done

C: MCV is done to rule out any ye~.i~9~J!r~t~rjp reflux. It is done by putting a urinary catheter and a dye is injected ami while the child is passing urine serial x-rays are taken to see the urine flow and whether there is any reflux back into the upper urinary tract and

also ifthere is any dilatation ofthe upper urinary tract. IfVUR is present, then the reflux of urine back into the kidneys damages the kidneys and may lead to a condition called reflux nephropathy which is quite serious. So we need to diagnose it early even before it damages the kidneys.

Mother: okay then

C: any other concerns Mother: no

AMC feedback: URINARY TRACT INFECTION.

3. You are in a general practice. Your next patient is a 30 yr old woman who gave birth to a child with Down's syndrome 18 months ago. Now she is planning to get pregnant again. She went to a geneticist and he explained to her that her chance of having again a child with Down's syndrome is 1 in 100. She is quite confused about that and wants to discuss with you. Talk to the woman and answer her questions.

Candidate: from the notes I see that you are planning to get pregnant and you went to the geneticist as well.

Role player: the geneticist told me that my chances of havi ng a child with Down's syndrome are 1 in 100. I didn't understand what he meant by that.

C: I will explain to you everything about that but can I ask you few questions R: yes

C: during your previous pregnancy did you have any investigations done or after the birth of your first child did they do any karyotyping.

R: they did some investigations but I can't remember them.

C: there are different causes for the occurrence of Down's syndrome. In your case the cause might have been meiotic non disjunction that's why the geneticist told you that your chances of having a child with Down's syndrome are 1 in 100. Non disjunction means during cell division of the egg the cell gets an extra chromosome in the 21 st chromosome so it is called trisomy 21. Anyway I will give you all the information regarding this to you so that you can understand clearly regarding that.

R: what should I do before getting pregnant? Do I need to take any medication?

C: there is no need to take any medication but take folic acid tablets 3 months before getting pregnant and 3 months after getting pregnant. But there are certain investigations called screening tests which find out your risk of having a baby with Down's syndrome. At 11 - 13 weeks of pregnancy we can do a test in which P APP-A and beta HCG levels in the blood are assessed.

In Down's syndrome the levels of beta HCG are elevated and that ofPAPP-A are decreased. Ultrasound scan is also done at 11 wks to see nuchal fold thickness. In Down's syndrome the nuchal fold thickness is increased.

Both the above tests combined together the chances of diagnosing Down's syndrome is above 90%.

Apart from this there is another test called triple test which is done at 16 wks of gestation. The triple test includes AFP, beta HCG, unconjugated oestriol. In Down's syndrome AFP and unconjugated oestriol are decreased and beta HCG is increased. There is another test called quadruple test in which apart from the above three components inhibin is also included. In Down's syndrome inhibin is increased . .)"'

All the tests which I told you now are only screening tests. The screening tests combined with your age indicate your chances of having a child with Down's syndrome.

If the screening tests are positive then we do the definitive diagnostic tests called chorionic villus sampling or amniocentesis.

R: when are they done?

C: CVS is done at 9 - 11 wks of gestation and amniocentesis is done around 16 wks of gestation.

R: what tissues they take when they do this procedure?

C: in CVS they take the placental tissue and in amniocentesis they take amniotic fluid which is the fluid that surrounds the baby.

R: how long will it take for the report to come?

C: for CVS it takes 48 hours for the report to come but for amniocentesis it takes about 2 weeks.

R: do these procedures have any complications

C: both the procedures have the risk of miscarriage. But the miscarriage rate with CVS is 1 % where as with amniocentesis it is around 0.5%.

R: ok. My husband is busy all the time with his job and I am not having time to discuss about this with my husband. Do I need to talk to him?

C: yes we need to discuss regarding all these things with your husband. Whenever he is having time both of you come together to me so that discuss about this.

R: thank you.

AMC feedback: DOWN SYNDROME.

OBSTETRICS AND GYNAECOLOGY

1. You are working in a GP practice. Your next patient is 25 yr old woman who had 3 miscarriages before at 8 - 10 weeks of gestation. She came to you previously and you organized some investigations for her. Today she came for the investigation results.

Your task is to take investigation results from the examiner (you will be given only the results you ask for) and discuss the future management with her.

FBE: normal

Ultrasound abdomen: uterus is normal, there are no fibroids or other structural anomalies, fallopian tubes and the ovaries are normal.

Lupus anticoagulant and anticardiolipin antibodies: normal Karyotyping of both patient and her husband: normal TORCH titres: normal

FSH, LH, Testosterone levels: normal HLA typing: normal

TFT: normal

Blood sugar: normal

C: the blood tests that we have done for you show that you are not having any abnormality. So, no need to worry regarding this.

R: can I have a baby again

C: yes, you can have a baby but when compared to the general population your chances are a little bit decreased. Because you had 3 miscarriages before, you have75% chance of having a normal baby.

R: will I have miscarriage again

C: your chance of having miscarriage again in the next pregnancy is about 3"'10. But there is no need to worry about that. Once you plan to get pregnant, we will be monitoring you closely and more frequently and I will refer you to a high risk clinic and the obstetrician will take good care of you.

R: do I need to take any medications

C: at the moment there is no need to take any medications and when you plan to become pregnant take folic acid tablets 3 months before getting pregnant and take it for 3 months after getting pregnant. Try doing some regular physical activity like going for walks and eating healthy food. At the very moment you think that you are pregnant you come to me so that we will organize some investigations like confirming the pregnancy by doing some blood tests like pregnancy test and also ultrasound scan.

R: one of my friends is also having the same problem but the doctor applied some stitch to her cervix. Do I need to have any stitch applied?

C: in your case there is no need to apply any stitch. The cervical suture is applied to people who have cervical incompetence and generally they will be having second trimester miscarriages. Cervical incompetence is a condition in which the opening of the cervix is not closed and the membranes around the baby will not be having enough support and they will rupture.

R:ok

C: do you have any other concerns R: no

AMC feedback: RECURRENT MISCARRIAGE.

2. You are in a GP practice and now you are seeing the mother of a 13 yr old intellectually disabled Rebecca.

Rebecca is going to school daily during the day time and sleeps at home. She is on carbamazepine and phenytoin since the last 18 months for epilepsy and her epilepsy is now well controlled.

Now her mother is concerned about contraception and she wants to discuss with you regarding contraception.

Your task is to take relevant history which you think is necessary and address her concerns.

(It is the same case from the AMC clinical book but the scenario is a little bit changed)

C: can you tell me in more detail about your concerns

Mother: you know Rebecca is a lovely little girl and she is going to school now and these days she is developing some changes in her body. She started to develop breasts and pubic hair. Even though she stays with me during the night the whole day she goes to school and I am worried like if some thing unfortunate happens and if she becomes pregnant. So I want to discuss about contraception.

C: Did she start getting periods

Mother: she didn't attain menarche yet

C: did you discuss regarding contraception with Rebecca and is she able to understand anything

Mother: I tried to talk with her regarding this quite a few times but she is not able to understand and I am scared that once she starts getting her periods she will not be able to take care regarding the hygiene and it will be a hard task for me to take care of her during those periods.

C: can I ask you a few questions Mother: sure

C: who is taking care of her medications? Mother: I am taking care of her medications. C: is she coping well at school

Mother: yes

C: do you have enough support to take care of her

Mother: yes. But can you give her some contraceptive pills

C: I know that you are very much concerned about your daughter. Once she starts getting her periods then I will prescribe some oral contraceptive pills. Because she is on antiepiieptic drugs she needs DC pills containing high dose of estrogen. She needs those which contain 50 micrograms of estrogens in the combined pills because the antiepileptic drugs interact with the DC pills and decrease their efficacy. They need to be taken daily. As you are already taking care of her other medications also you will not finding any difficulty giving them to her daily. Apart from the pills there are also other modes of contraception also like injections and implants.

Mother: that's fine but sometimes I think it would be better to get her sterilized. Can you arrange something like that for her to get her ovaries and uterus removed?

C: I think you might know what sterilization means.

Mother: yes

C: well the procedure for which you are asking me is a permanent method of not getting periods. Even though you are the parent and care taker of Rebecca you cannot give consent for this procedure. You can take care of her medications and give consent for the DC pills as well but for the procedure of sterilization you cannot give the consent on her

behalf. Even though Rebecca is intellectually disabled and cannot give consent for the procedure she has every right to be treated like other people and it will only be indicated ifit is in the medical interest of Rebecca. For such a procedure to be done we need to involve the Family court or the Guardianship Board.

Mother: then I would like to file a case for this

C: well if you are quite sure about that then you can go ahead. Mother: thank you

AMC feedback: CONTRACEPTION REQUEST.

3. You are in the ED. Your next patient is a 25 yr old primigravida who is 30 wks pregnant. Her blood group is A -ve. She is complaining of bleeding since the last 1 hour and the bleeding is bright red. She is also having abdominal pain. You examined her and her vital signs are normal. On abdominal examination, the abdomen is not tense but a little bit tender and the fetal heart sounds are normal. Vaginal examination is not done. Your task is to take history from the patient, tell her about the investigations that she needs and further management.

R: doctor, I am bleeding since the last hour. C: can I ask you few questions

R: yes

C: how was your pregnancy so far? Did you have similar episode previously? R: everything was normal until now

C: are you having any abdominal pain

R: a little bit

C: any contractions of the uterus R: no

C: are you feeling the fetal movements and did you observe any change like decrease in the fetal movements.

R: no, they are normal

C: do you have any dizziness R:no

C: what about the 18 weeks ultrasound scan and is the placenta in the normal procedure R: the 18 weeks ultrasound scan is normal. It is a single pregnancy and the placenta is in normal position.

C: did you have any miscarriages previously or any other procedures done on your private parts or on the uterus

R: no

C: any trauma to your tummy or any sexual intercourse before this bleeding episode. R: no

C: did you undergo any investigations at 28 weeks and did you receive any anti-D injection.

R: yes, I received a shot of anti-D at 28 wks gestation C: any bleeding problems previously

R:no.

C: now we will be arranging some investigations for you like ultrasound scan to see the position of the placenta or any other abnormalities of the placenta and the uterus. Apart from that we will do the CTG to see the condition of the baby whether the baby is at risk like whether the baby is normal or distressed.

We will send blood for cross matching and hold in case if you bleed again we need to keep blood ready to give you. We will send the blood for FBE and coagulation profile. We will be doing a test called indirect coomb's test in which they will see if you have developed any antibodies against your baby's blood cells. Another test called kleihaeur test is done to see ifthere are any fetal blood cells in your blood so that we can give you extra amount of anti- D inj ection depending on the amount of fetal blood cells.

R: can I go home?

C: no, you need to get admitted in the hospital for all these investigations to be done and I will ask my obstetric registrar to come and have a look at you so that he will be telling you what further management can be done.

R: what could be the cause for the bleeding?

C: the bleeding could be because of a condition called placental abruption in which the placenta gets separated from the uterine wall and can lead to bleeding so we need to do the ultrasound to see the degree of separation from the uterus. It can be due to placenta praevia in which the placenta is present in the lower part of the uterus covering the cervix but in your condition it is less likely as the 18 wks ultrasound scan is normal.

R: is my baby going to be alright?

C: it depends on your condition, If you continue to bleed and if the CTG shows abnormality then your baby will be at risk and then we need to deliver the baby. Even before that we might consider giving you blood transfusion and also steroid injections like betarnethasone or dexamethasone. The steroid injections are given to enhance the fetal lung maturity because the baby is just 30 wks old so that the baby will not find it difficult to breathe once it is born.

Do you have any other concerns?

R:no

AMC feedback: PLACENTALABRUPTION (MILD).

PSYCHIATRY

1. You are an intern in the ED. You are now seeing an 18 yr old girl who suddenly lost her voice. She came to you in the ED at about 3 AM in the morning. Her mother is also in the same hospital and she is undergoing treatment for her terminal stage cancer. They belong to a very religious Anglican Christian family. All the family members are praying for her mother and this girl lost her voice suddenly.

Your task is to take history (she will nod her head in response to your questions). examine her with the equipment provided on the table, and explain diagnosis and management.

Here the patient lost her voice suddenly. She did not have any sore throat, dysphagia, hoarseness of voice, regurgitation of fluids or any other medical illness. She is able to cough, make sounds and can say aaaahhh. She didn't have this problem previously. This is the first time that she developed this problem.

She is studying in college, no problems with her studies. No past history of any psychiatric or medical illnesses. Not on any medications, no allergies. No family history of psychiatric illnesses. She doesn't drink or smoke or use any recreational drugs.

On mental state examination, mood is normal, no hallucinations or delusions or thought disorder. No thoughts of harming herself or others. The orientation and memory are normal.

On the table tongue depressor, pen torch, jug of water and glass are provided.

On examination with the pen torch and the tongue depressor, uvula is in the centre and there is no redness or erythema of the throat. Examiner told that gag reflex is normal. On saying aaaahhhhh, uvula is in the centre. The patient can drink water and there is no pain or regurgitation of fluids on swallowing. The patient can cough.

The condition that you are having is called conversion disorder. What happens in this condition is that emotional symptoms are suppressed and in their place certain physical symptoms are manifested. In your case as your mom is having cancer and you are feeling depressed about that, what happened is that the emotional symptoms like anger, agitation and anxiety which occurred because of your suffering are suppressed and in their place you are manifesting with the physical symptom of loss of voice. So, no need to worry about that and I will refer you to a psychologist and he will he doing cognitive behavioral therapy and he will help you to cope up with the stresses that you are having at the moment and helps you to face them.

AMC feedback: PSYCHOGENIC DYSPHONIA.

2. You are a HMO in the ED. Your next patient is 25 yr old man who is complaining of dizziness since this morning. He had past history of schizophreniform disorder and took medication for that and it was well controlled. Now, his wife thinks that he had relapse of his condition and she thinks that he became more suspicious about everyone and took him to a GP. The GP prescribed him Risperidone. The patient was not quite sure about the dose the GP prescribed. He took 2 tablets in the night and 2 tablets in the morning. Since then he developed the symptoms of dizziness. He now stopped taking the tablets and came to the ED.

Your task is to take history from the patient, examine the patient (you will be given only those findings you ask for) and tell him the diagnosis and management.

The patient said that he developed dizziness since this morning. Whenever he is getting up from the chair or the bed he is feeling dizzy. There is no loss of consciousness or palpitations. There is no tinnitus. No other complaints.

Not on any other medication and no allergies. No history of any medical illnesses. His job is fine and he doesn't smoke or drink alcohol or use any recreational drugs. He doesn't think that he is having any symptoms of schizophrenia but his wife thinks that he developed a relapse. That's why he went to a OP and he gave him Risperidone and he took those tablets since yesterday. He doesn't know the dosage of the tablets that he took.

On mental state examination, mood is nonnal, no suicidal or homicidal thoughts, no hallucinations, delusions or illusions. Thought process is normal, orientation and memory are normal. Judgment and insight are normal,

On physical examination, vital signs temperature: normal, BP: 120/80 (lying) and 100/6q (standin.,g), pulse rate: 80/min (lying) and 112/ min (standing), respiratory rate: 12/min Rest of the physical examination is normal.

ECG is normal, No QT prolongation.

The symptoms that you have developed are most probably because of the Risperidone tablets that you have taken. The dosage that you told me appears to be above the range of the daily dosage of the tablet that needs to be taken. Risperidone causes a condition called postural hypotension when taken in a higher dosage. What happens in orthostatic hypotension is that the BP suddenly becomes low when you get up from the sitting to standing position. So I want you to get admitted in the hospital now and the psychiatric registrar will examine you and he might consider decreasing the dose of the dose of Risperidone that you are taking or he may change you to other medication.

At the end the examiner asked me a question: how will you exactly know how much dose he took?

I told him that I will ask the patient or ask his wife or do blood levels of the drug, but he was not satisfied. Then I told him that I will ask the GP who prescribed him the medication.

AMC feedback: SIDE EFFECTS OF ANTI~PSYCHOTIC MEDICATION.

MEDICINE AND SURGERY

1. You are in a GP practice. Your next patient is 25 yr old man who is recently diagnosed with idiopathic GTCS and he was seen by the neurologist and the neurologist started him on Tegretal (carbamazepine). The neurologist sent a referral letter to you telling you that he started the patient on anti epileptic drug and that the patient is a motor cycle courier driver and he is getting married very soon. Your task is to talk to the patient and answer his questions.

Explained to him about epilepsy and told him that we need to notify R T A that he is having epilepsy. He should not be driving until he is seizure free for about 3- 6 months. Then the patient asked me how he can earn money if he stops working and that he is getting married very soon. I told him that ifhe gets a seizure episode while driving then he is at risk of accident so it is better not to drive. Then I told him to discuss about his condition with his fiancee. Take medication regularly and he needs to take the medication until he is seizure free for 3 yrs.

Have regular follow-ups with the neurologist as well as the GP. Need to change his occupation and he is not eligible for certain jobs like working near deep sea or at heights or near heavy machinery. Avoid trigger factors like fasting, excessive physical activity, fatigue, looking at flashing lights, alcohol. Avoid some sports like swimming, rock climbing, deep sea diving and surfing.

Then I told him that his medication needs to be changed according to the response. Ifhe gets any seizure attack when he is at home his family members should know all the precautions to prevent him from getting hurt and they should call an ambulance if the seizure lasts more than 10 minutes and immediately take him to hospital.

AMC feedback: EPILEPSY -IDIOPATHIC.

2. You are in a GP practice. Your next patient is 28 yr old woman who is having high BP recordings on separate occasions. The readings are 158/100,154/98 and 148/94. She didn't have any past history of hypertension. She is of normal weight and the general appearance and physical examination of the patient are normal.

Your task is to take history from her, organize necessary investigations and future management.

Apart from the high blood pressure now, her general health is normal. She is not having any headaches, blurred vision, episodes of palpitations and tummy pains, no vomiting. No past history of any hypertension or any kidney problem. No family history of any medical illnesses. She is on the oral contraceptive pill since the last 3 years. She is not on any other medications. No hlo any allergies. She is a secretary in an office and no stresses in her life. She goes out for regular walks .. She doesn't drink alcohol but she smokes 15 cigarettes per day. She doesn't use any recreational drugs. She eats normal healthy foods with lot of veggies. She drinks only one cup of coffee per day.

We will organize certain investigations like FBE and haematocrit, urine analysis to check for any casts in the urine, serum electrolytes, blood urea, serum creatinine, serum cholesterol levels, blood sugar levels and RCG to rule out any secondary causes of hypertension.

From the history, you are having some modifiable causes of hypertension like the oral contraceptive pill and smoking. So stop taking the pill and instead of it you can use other forms of contraception like PoP, condom, depot provera or iinp~ts. Smoking can also

contribute for hypertension. So try to cut down on your smoking or stopping smoking is the best option. Eat healthy food and go for regular walks, With the above measures and

the life style modifications the BP will go down and I will review you in about in 1- 2 4 ,J..L,. • months. If during this period the BP doesn't come down or if you develop target organ

damage then you might need medication.

AMC feedback: HYPERTENSION.

3. You are a HMO in the ED. Your next patient is 25 yr old man who is complaining of diarrhoea. He is a computer analyst and he is happily married. Your task is to take history, take examination findings from the examiner and discuss diagnosis and differential diagnosis and arrange investigations for him.

In the history, the patient is having recurrent episodes of diarrhoea since the last few months and the present episode of diarrhoea since the last 2 weeks. Every day he passes 3-4 loose stools but since last night he passed 6 loose stools and it is associated with the passage of blood and mucus in the stools. There is no difficulty in flushing the stools. There is no foul smelling of the stool. He lost 5 kgs since the last few months and he is feeling hot since last night. There is no preference for hot or cold weather. His sexual history and drug history are normal. There is no family history of any bowel cancer or inflammatory bowel disease. He is not on any medications and he is not having any allergies. His job is very stressful but his family life is normal. He did not travel overseas recently and no possibility of food poisoning. He didn't see any doctor for this problem. No back pain, visual problems, aphthous ulcers or pallor. The diarrhoea is not related to any type of food.

On examination:

General appearance: no pallor or dehydration Vital signs: T 37.8, all others are normal

Abdominal examination: inspection is normal, superficial palpation is normal, on deep palpation there is maximum tenderness in the left iliac fossa, and percussion is normal and on auscultation the bowel sounds are increased. On PR there are no hemorrhoids or any palpable masses but there is tenderness and you can see blood on the tip of the finger. Rest of the physical examination is normal.

Provisional diagnosis: inflammatory bowel disease

DID: infective colitis, irritable bowel disease, carcinoma colon, celiac disease, malabsorption syndromes, thyrotoxicosis.

Investigations: FBE, stool examination tor ova, cysts and parasites and also for culture and sensitivity. colonoscopy to look any lesions in the bowel and take a biopsy, barium enema after the acute episode, celiac disease screen, TFT.

AMC feedback: DIARRHOEA (RECURRENT).

4. You are in a GP practice. Your next patient is 45 yr old woman complaining of bloating since the last few days. She came to you previously and you examined her. The physical examination is completely normal and you arranged some investigations for her. Blood biochemistry and liver enzyme levels are normal. You arranged ultrasound also for her. A picture of the ultrasound scan was attached on the wall. It is showing 3 gall stones. (It is the same picture from the anthology book)

Your task is to explain the ultrasound report to her by showing her what the problem is, discuss the management with the patient.

I started the station by explaining to the patient the ultrasound report showing her the 3 gall stones in the gall bladder. Then I drew a picture showing the liver, gall bladder, common bile duct, pancreas and the small bowel and explained to her the complications of gall stones that it can cause acute cholecystitis, chronic cholecystitis, acute pancreatitis, choledocholithiasis, acute cholangitis, gall stone ileus. Acute cholecystitis can lead to gall bladder abscess and perforation. I also explained to her the mechanism of formation of gall stones.

I said that I will refer her to a surgeon and the surgeon may consider doing surgery for her and it will be elective surgery rather than emergency cholecystectomy. The surgeon might consider doing laparoscopic cholecystectomy which is a key hole surgery and the surgeon will take the consent before the surgery that if any problem arises during the key hole surgery they might need to open the tummy. The procedure will be done under anesthesia. During the surgery they will be doing intra operative cholangiography to see if there are any other gall stones in the common bile duct. After the procedure you may need to stay in the hospital for a couple of days and will be discharged after that.

In the mean time told her to avoid fatty foods. But she asked me about any medication for this before seeing the surgeon. I don't know what exactly she was asking me for but I told her that there is no need for any medication unless she develops any pain.

Questions asked by the role player:

Where are the stones in the ultrasound scan report? What type of surgery is done?

Are there any complications during the procedure?

How long do I need to stay in the hospital after the surgery?

After the surgery can I develop the symptoms again or am I completely cured? Can you give me anything for this bloating before seeing the surgeon?

AMC feedback: INCIDENTAL GALL STONES.

5. You are working in general practice. Your next patient is 65 yr old man who is complaining of pain in his right leg since the last few days. The pain is increasing gradually. He likes to play golf and these days he is finding it difficult to walk in the golf course and he is getting pain in his right leg after walking for a few meters and it is relieved by taking rest. He has history of hypertension and he is on diuretic and ACE inhibitor. Apart from that his general health is normal. He smokes 15 cigarettes per day and he drinks alcohol occasionally. His 8MI is 30.

Your task is to examine the patient. tell the provisional diagnosis. organize investigations and discuss management.

General appearance: normal Vital signs: normal

CVS: normal, no carotid bruits.

Lower limbs examination: on inspection the skin of the lower limbs is normal, no color change of the limbs, no hair loss, no edema, and no ulcers.

On palpation, there is no temperature difference between the two limbs, there is no tenderness, CRT is normal, lower limb pulses are normal.

Buerger's test: is normal.

Auscultation: normal. There is no aortic or femoral bruit.

Provisional diagnosis: peripheral vascular disease (intermittent claudication) Differential diagnosis: lumbar spondylosis, benign cramps, osteoarthritis of knee

Investigations: Doppler ultrasound oflower limbs to look for the blood flow and calculate AEr, FBE and haematocrit, blood sugar, serum cholesterol, ECG.

Then I explained to the patient that it looks like PVD and all the above investigations need to be done. In the meanwhile life style modifications like maintaining normal body weight, avoiding fatty food, regular physical activity and stopping smoking.

Questions asked: h h' r

) 1- r.. .', ...... ..J '<.Q+~' seV"~("€" C ("Ot1I( be. atl'l"J''''

What is the significance ofbuerger's test? 11 (+ )V-.:. J ,,1tI

What is the significance of aortic or femoral bruit?

If the AB! is 0.25 what does it mean?

To whom will you refer him?

Will you stop the ACE inhibitor?

AMC feedback: LEG CRAMPS ON EXERCISE.

6. You are working in a GP setting. Your next patient is a 55 yr old woman who is complaining of right sided chest pain since the last few days. She had sigmoid diverticular disease and an abscess developed and the abscess was drained 6 weeks back. After that she was normal and now

she developed this chest pain. On examination, the chest movements are decreased, percussion note is dull and breath sounds are decreased in the right lower lobe. The vital signs are normal apart from temperature which is 38. You sent herfor some investigations and she is coming back to you with the x-rays.

Your task is to interpret the x-ray and explain the x-ray findings to the patient, discuss the investigations and the management with the patient.

When I entered the room, the role player gave me 2 x-rays, one is PA view and the other is lateral view. The x-ray showed pleural effusion on the right side. Then I explained to the patient that she is having pleural effusion.

The patient is not having any breathlessness or cough. She is not feeling hot either but her temperature is 38. She is just having chest pain on the right side.

Then I explained to her that it could be because of infection, connective tissue disorder, uremia, pulmonary embolism or malignancy.

Investigations:

FBE,ES~

Pleural fluid analysis: for microscopy and culture, biochemistry ECG,

Blood culture, UEC,

ABG,

Ventilation perfusion scan, CT - scan chest.

Then I referred the patient to the hospital and told her the management of her condition will depend on the investigation findings,

Questions asked by the role player:

What does the x-ray show? Can it he cancer?

Do I need to go to the hospital now?

AMC feedback: PLEURISY WITH EFFUSION.

7. You are in a GP setting. Your next patient is a 25 yr old woman who is complaining of cyclical pain in her breasts since the last few months. You arranged ultrasound for her and it showed a breast cyst. Then the ultrasound guided FNAC was done and the fluid was aspirated from the cyst and sent for analysis. Her mother was recently diagnosed with breast cancer at the age of 50 years

The ultrasound scan report showing the breast cyst and FNAC result showing that the cells are benign is attached to the wall in front of the room.

Your task is to explain the report to the patient and answer her questions.

It is the same question from the AMC clinical book. (Case no: 137). The role player asked the same questions from the book.

AMC feedback: BREAST LUMP.

8. You are a GP. You are seeing a 65 yr old woman with terminal stage pancreatic cancer. She is already on morphine for pain relief. You know all her husband and son who are also your patients. She knows that her cancer can't be treated and her pain is also increasing. She wants you to give some medicine so that she can end her life.

Your task is to talk with the patient and answer her concerns.

It is euthanasia case from the AMC clinical book. (Case no: 124). This is the only station that I failed.

AMC feedback: END OF LIFE REQUEST.

STUDY HARD AND DO ALL THE RECALLS. DON'T MISS THURSDAY CLASSES BY DR. WENZEL.

I THANK DR.WENZEL FOR HIS HELP AND SUPPORT TO THE IMGs. TRY TO PREPARE FOR ALL THE CASES WELL IN ADVANCE AND DON'T RUSH JUST BEFORE THE EXAM. STUDYING IN A GROUP AND DOING ROLEPLAY ARE VERY HELPFUL AND I AM LUCKY THAT I HAD A VERY GOOD STUDY GROUP. TRY TO RELAX THE DAY BEFORE THE EXAM AND HAVE GOOD SLEEP.

GOOD LUCK TO ALL OF YOU PREPARING FOR THE EXAM.

GOLD COAST 29 March 2008 **** JAY SAl SABA *****

GYNECLOGY:

l.Pregnancy at 32 wk gestation had an car accident where patient was sitting in the front seat. Came to Emergency. Manage the case.

2. A women came in con tact with a ch i I d( 12 months) who had Rubella, she thin k s that she is pregnant. Came to your GP. Manage the case.

J-

3.Women had Ectopic pregnancy in the left FoU Tube, had some type of operation, she also had corpus lut in her right ovary, Sml of fluid in the pouch of Doug, hcg level was ISOO.Came for your advice for future pregnancy.( the stem was large I could not re collect in correct way)

Q)Explain what is Ectopic pregnancy Q) Can I have pregnancy again

Q )when u will advice IVF

Q)Could they have done something to prevent operation.

PEDES:

1. Congenital Dislocation of Hip

2. Fever and sore throate in a 5 year old boy===Tonsillitis (403 AMC Clinical book)

3. 2 Weeks old child with raised conjugated bilirubin, child and mothe had 0 Rh negative blood group,otherwise normal.Manage the case.===Obstructive Jaundice.

PSYCHI:

l.Psychogenic Cough.

Patient had cough for last 6 months started after diverse.all invstigations are normal.Take Psch-social history and manage.

2.Delirium==(672 AtvlC Clinical booh)

MEDfCAL & SURGER:

1. Pt suddenly started to have SOB and Chest pain, she had Hip replacement 3 days back so, on heparin. Take history, explain to the patient the cause for SOB and chest pain, inv,

treatment, Read ECG and tell the diagnosis. Pulmonary EmoolV' .

2. Pt hand weakness of his left hand and left leg since morning( since yesterday morning I am not sure )but improved to some extent. Task to take history, ask examiner the

examination findings, order Invest, tell the diagnosis. TIA/Stroke.

3. Clavicle Fracture =(547 AMC Clinical book)

4.Migrain=(668 AMC Clinical book)

5.Anaemia in a old women===::;:(576 AMC Clinical book)

6.Ectopic Kidney===(31S AMC Clinical Book)

7. UTr in a 40 year old man

(495 AMC Clinical Book)

s. A 60 year old female, back pain x ray fracture spineDEXA -3.5, Task .History, explain the results and manage the case====Osteoporosis.

******"'************ GOOD LUCK: JAY SAl BABA **********************

Adelaide exam 2008 AMC clinical

1. A young lady 26 years of age was found to have high blood pressure when she went to donate blood at the Red Cross Society. The blood pressure readings were1501100 ... (three readings were given and all were high).

The examinations and all the investigations were normal.

Task

1. Take a focused history

2. Management

On history she was on Microgynon for the last three years. Never came for checkups after starting the pill. She was a smoker on 15 cigarettes per day. Not much of exercise. Alcohol 2-3 drinks over the weekend. She had healthy food habits. Job was not very stressful.

The pill was stopped as she was planning to get pregnant in few months time and advised condoms till blood pressure is sorted out.

2. A 4year old boy was brought to the emergency department by the father

_ because he refused to walk since morning after waking up. The boywas also complaining of some pain in the right hip.

The boy has come to you from the X ray department.

Task

1. Take focused history

2. Examination of the relevant system

3. management

On history boy refused walk after getting up in the morning. No history of trauma, no similar problems in the past.

There was history of upper respiratory infection 1-2 weeks ago and antenatal, natal, post natal and developmental histories were all normal.

General examination and vitals, no rise in temperature, pulse BP normal. Throat examination was normal.

Examination of hip joint all movements were restricted and no signs of inflammation of. the joint in terms of swelling or temperature rise.

Investigations FBC count normal, Urine normal. X-ray Normal

USG Mild joint effusion.

Management, Admitted the patient for further observation with the diagnosis of transient synovitis to be reviewed later if the situation changes. Rest and antiinflammatory with admission for 2-3 days to rule out septic arthritis.

3. A middle aged lady has abdominal bloating which is relieved by defecation and USG was done ( I am not sure about other investigations) and it showed the walls of the gallbladder was of normal thickenss, 3 gallstones were there, the CBO of normal diameter.

,.

Task

1. Explain the USG TIflci:"';gs to the ?::~:'=!1t.

2. Manage ( Referral to a specialist is not enough)

Talked about the findings already given about the USG, laparoscopic cholecystectomy. When she asked whether her symptoms could be due to this, then spoke a bit about ISS as well.

4. 30 weeks primi with Rh negative blood group have come to the emergency department with bleeding and mild abdominal pain.

On examination, cephalic presentation longitudinal lie, mild abdominal

tenderness 140/mt. Pulse and BP normal. .

Task

Take focused history

Order. necessary investigations Manage

Antenatal period normal .18 weeks USG normal, she took anti D injections at 28 weeks, GCT normal, Foetal movements normal. Bleeding was just spotting. Investigations done were FBC, Blood grouping cross matching, USG, CTG, indirect coombs test.

Admitted the patient gave AntiD , further management depends on USG and CTG findings.

5. End of life request from a terminally ill patient with pancreatic maE~nancy. Same question as in the AMC book but need to talk about pain management.

6. A schizophrenic patient was on treatment but stopped treatment 2 years ago. Recently she started having delusions were put on risperidone. Now she comes with dizziness after taking 2 tablets of risperidone in the morning and 2 in the evening. Now she has come to the emergency department.

Task

Take focused history

Do relevant examination Manage

She took more because she was confused about the dosage. There were no other symptoms related to dizziness.On examination only relevant finding was postural drop in BP.

Admitted her had to be assessed by psychiatry registrar to decide on whether she needs a change of medication or same medication at a lower dosage.

7. A 24 year old man who is a courier driver was diagnosed with tonic clonic seizures and was started on carbamazepine . He also had a similar episode when he was a child. He is planning to get married in a few months time.

Task

Talk to him about further management Answer his questions.

Advised him about change in profession, to take medicine reqularly, not to overdose incase a tablet is missed, side effects, drug Interactions, RTA regulations, sexual life, trigger factors, alcohol.

The patient asked when he can stop the medication.

8. Mother of a mentally retarded girl has come to you asking about the methods of contraception. She is an epileptic on phenytoin and ....

Talk to the mother about the options available. .

Same as in the book, but you need to talk about the pills, injectable progesterone. Towards the end she will ask about tubectomy and hysterectomy She has not started menstruation as yet.

9. An old man with pain in the calf muscles after walking 200m which is relieved after resting. He is also hypertensive on ACE inhibitors.

Task

Examine the relevant system and manage.

Vitals Pulse normal BP norma/.( It was not a real patient, so the examiner went on giving positive findings when u do the examination) .

On inspection he didn't say anything. On palpation he said the right foot was cold. No dorsalis pedis, posterior tibial, popliteal on the right side. Femoral pulse was present. No femoral or abdominal bruit.

Other leg had normal pulsations.

Neurological examination was normal.

Investigations FBC normal, ABI (Doppler) was 0.25 on the right side 0.9 on the left side.

Patient was a smoker, asked him to stop smoking, other life style modifications and referred him to vascular surgeon for arteriography.

10. A middle aged lady has come to the emergency department with right sided chest pain. She had undergone s!gmcild ct;"verticUiar a5scess-draliiage6diiys--

ago and was given.-Q(ophYlacbc imtlbl-~b.9.$.:; 0

A chest X-ray was taken ana'wilf6e-glven to you by the patient inside. Her temperature was 38.9; I don't know remember other findings.

Task

Explain the X-ray findings to the patient and manage.

Chest Xwray showed obliteration of the right costophrenic angle with some consolidation above it.

Admitted the patient did the investigations like full blood count, USG and antibiotics_

11. 26 years old woman had a down's baby and geneticist advised her that the chances of having a second baby with Downs was 1 in 100. Now she has come to you for pre pregnancy advice. Her husband has not come with her today as he is busy at work.

Told her about folic acid, antenatal tests, nuchal translucency, quadruple test.Chorionic villous biopsy, amniocentesis etc and early intervention when she gets pregnant.

Review with husband during the next visit.

/

12. FNAC report of a breast lump in a woman with family history of CA breast given as benign and you have to explain the results.

This is the same case as in the AMC book.

13. Daughter of a lady diagnosed with terminal cancer suddenly looses her voice while she was praying for her mother's recovery in prayer group. She is the one who leads the prayer in such meetings.

Task

Examine the patient using the things provided. Take history and manage.

Examination materials given were tongue depressor and torch. She will respond to your questions by nodding her head for a yes or no accordingly. Management was referral to psychotherapist and speech therapist.

14. A 26 years oldlady with three recurrent abortions all in the first trimester came to see you and you had ordered several investigations. No '

Ask the examiner for the investigation results and manage.

FBC, Torch, Renal functions, Anti phospholipid antibodies, Lupus antibody, Blood sugar, USG ... £§H,L!::1. Prolactin, Hysterosalpingogram,Chromosomal analysis. Every investigation that I asked for were all given as normal. .

General Pre pregnancy advice referred her to the specialist and high risk clinic

when she gets pregnant. .

15. 26 year old man with diarrhoea for 2 months has come for consultation. He also has lost weight after this.

Take history, examination and do investigations.

Bloody diarrhoea for 2 month. Formed non foul smelling stools. No overseas travel, No medications, using condoms, No family history, No symptoms of thyrotoxicos is.

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On examination everything was normal. Investigations ordered were FBC, Stooi culture and sensitivity, Urea and electrolytes, colonoscopy.

16. 12 months old Amy is having vomiting and high grade fever presented to the emergency department

Bag urine showed Nitrates 1·++, Bacteria +++.

Further history

Manage and further investigations.

First episode of UTI. Antenatal, Natal and postnatal history were all normal. No positive family history.

Admit the patient, Suprapubic aspiration for C&S . Start antibiotics and then change according to the report. IV fluids, Repeat culture after 3 weeks to confirm infection is fully treated. Then USG.

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