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April Melbourne 2009

April Melbourne 2009

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05/20/2012

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4th April 2009 Melbourne Psychiatry 1. You are an intern working in neurology ward.

A 20 years old female has neck spasm, migrane, dysmenorrhoea etc. and was diagnosed with somatization disorder. She had to quit her job due to the neck pain and move back to live with her grand parents. Her grand mother has recently diagnosed with Parkinson disease and needs her support for daily activity around the house. Patient has had MRI scan of the brain, which is normal. Your task is to 1. Take further history. 2. Explain the diagnosis. 3. Manage the patient. This was my first station. The patient has had 10 years history of neck pain. And worries that she has got MS. I asked histories and found she has this problem for 10 years. I explained to her the Dx and reassured her that all Ix have been done including MRI show that there is no evidence of MS. I reconfirmed to her the pains are real. Somatisation is functional problem. Not structural problem. Just like piano working but out of tune…. The bell rang. I couldn’t finish the station on time. The roleplayer said “sorry doctor”. The examiner said, “Gee that was quick”. I remember Dr. Wenzel’s tips and tricks – so I encourage myself that I still have 15 stations to play with! No worries. AMC feedback (Somatization disorder & agoraphobia) 2. A 60 y/o female with right lower abdominal pain for 6 weeks and lost 5kg in the last 6 weeks. She c/o tiredness. She does not drink alcohol or smoke. She went to see the doctor (P/E was normal) and was investigated; including, blood tests, gastroscopy and colonoscopy were normal. Today she came for the results. (GP setting) Task: Take psych Hx Give the patient your DDx Explain the nature of her condition. Hx: The RLQ abdominal pain for 18 months and getting worse in the last 6 weeks. Poor sleep and always wakes up at 3 Am and can’t go back to sleep. Appetite is not good and feels depressed because the doctor says she‘s not ill. Lost interest. Suicidal idea. No plan. Retired teacher. Good relations at home and husband is busy. Patient has no eye contact. She read the notes in front of her. Appear sad. I explain the Dx as major depression (according to criteria). She asked what I was going to do for her. I said “admission, psychiatry r/v, medication and/or ECT etc.” the examiner interrupted me “ this is not your task”. I said I just answered the patient’s question.

I finished the station early.travel advice. Frequent flyer. 3. Stable partner. LMP 6/52 ago. Similar episode one year ago. Trimethoprim prescribed for 3 days (need to write this on script. But patient will need post-bite immunoglobin if being bitten by a dog. The script is in front of me). I will check and let you know.AMC feedback: Major depression with agitation & somatic features Medicine and Surgery 1. There is a MIMS book provided. UTI 23 yo female P/W lower abdomen discomfort to your GP clinic Task: History (No examination) Diagnosis Examiner will give you another task Hx: Patient c/o lower abdo. "Do you have any questions?" Role-player said "NO". AMC feedback: Urinary tract infection . She is not pregnant. Conselling: As per GP book . Urine dipstick: Nitrates+++. The examiner came from my back and asked “can you please give advice for Rabies?" I said "I am not sure whether there is a pre travel vaccine for Rabies. Discomfort and pain while passing urine. Sexually active. The role-player seems happy and I asked." Both examiner and role-player seem happy. Leucocytes +++ Random BSL 6.0 Pregnancy test: negative Dx: UTI Management: drink plenty fluid. Conselling History: He is a businessman. Travel advice 40yo male come to your clinic before his travel Task: History. AMC feedback – Overseas travel risks 2. Will go to Bangkok and then to NY. afebrile. Past history of DVT which was treated with Warfarin. And advised patient that he needs Heparin prophylaxis. Duodenal ulcer Same as AMC handbook No question from examiner.

PE: As per Talley O Connor . PR examination: enlarged prostate. Wenzel's case. She comes to your GP clinic and ask for antibiotics. I will put catheter in and will send urine. an old gentleman was sitting on the bed.. Examination finding: dullness on percussion up to umbilicus. Mx: No need to do bladder scan.4. He is a truck driver. But the scenario has been changed a bit and easier than Dr. AMC feedback: Sore throat 6. The examiner said patient was ok and you should start from the first task. PSA and U&E as well. PE and Mx Hx: Recurrent ear infection. The role-player blinked eye to me and said THANK YOU DOCTOR. BPH 73yo male could not passing urine for 12hrs and presented to Emergency Department. refer to urology reg for further Ix. Task: Hx. Task: History Ask examination findings Diagnosis Management I did this case with Dr. Task: History Ask examination finding Management I entered the room. Hearing not well. symmetry and smooth. I asked good history. There is a picture of tympanic membrane on the wall. Viral infection Young lady P/W sore throat and feeling unwell for a few days.) The examiner was happy and said. “Do you know you can go out if you finish earlier?” I left the room. I started by taking history. AMC feedback: Acute urinary retention in an elderly man 5. I finished the station earlier (only spent about 4 min. 26 years old male presented to GP c/o discharge from R) ear. Wenzel a few weeks ago. Examiner asked what PSA is and what it is for? So please don't say abbreviation in your exam. Typical BPH history. I said to the examiner that I need to put catheter in to release the urine.

Task: Hx. No photophobia. Ix: FBE. Arrange a holiday. I finished early. Arrange investigation This is an orthopaedic exam. AMC feedback: Cholesteatoma of right ear 7. No menopause symptoms. Pap smear normal. barrier method etc. Dx & Mx So 2min per task. BSL. The patient is limping. Good working environment. cos if on lower dose. Period regular. IUD. I could not assess the swelling. . 65 yo lady presented with a few weeks R) hip pain Task: exam the patient. Depot injection. FSH. Simple analgesia. she gets breakthrough bleeding. She has to use microgynon 50. PE. I need to refer him to ENT surgeon. Pain tends to start later in the day. I finished early. She works full time as a manager. Like band at forehead. She worries that she may have brain tumor. Lipid. No history taken. AMC feedback: Headache O&G 1. Question from roleplayer: what is menopause? A: 12months no menses.I took history and told patient that most likely he got cholesteatoma. Tenderness on palpation at great trochanter. Improved on the weekend. Mx: not to be a perfectionist. HRT does not prevent pregnancy. ask Ix and Mx She is a mother of 2 children & has finished her family. As the patient was wearing short and couldn’t be exposed. LH. Happy marriage with 2 children. Ix: X-Ray AMC feedback: Examination of the hip joint (Trochanteric bursitis) 8. U/S normal Mx: I explained to her the indication and contraindication for HRT. I also explained there are other contraceptive methods that I can suggest such as Implanon. A middle age lady p/w headache to ED. LFT. She has had headache for a few months. 45 years old lady currently on microgynon 50 wants to know about HRT Your task: Hx. I took detailed history. Most likely tension headache. No question from patient or examiner.

She is conscious and able to sit at up and talk to you. U/S Kleihauer test. Obstetric reg. I finished early AMC feedback: High mobile head at term Paeds 1. ABC stable. Her antenatal check up has been normal so far. placenta high. you will watch a video showing a 10months old baby is coughing and turned blue. Mother asked: Can I bring the baby home? A: No. Your baby needs O2 in the hospital. Management After watch video inside the room for 10 sec. CTG. She sat in the front seat with seatbelt on while her husband was driving. Task: Hx. and baby ticking as usual. Anti-D I finished early AMC feedback : Abdominal trauma in pregnancy 3. Comes to your GP clinic for advice. Her BG is O negative. Arrange U/S to r/o other causes. no bleeding. PE. antibiotics for baby and family. She worries about her baby. She has no pain. . 26yo primigravida 40/40 pregnant. Mx Repeat case. As baby’s head is still 5cm above pelvis. O2.AMC feedback: On OCP wants to change to HRT 2. including 18/40 scan. 36/40 lady had MVA and presented to ED. I said this is whooping cough Mx: admit. Task: Diagnosis. I told her most likely she has CPD. R/v. Mx: Either CS or trial of labour. She brings her antenatal note with her. Mx All normal including 18/40 U/S. PE (ask). ED. A nurse is putting O2 mask onto the baby. reportable disease. Task: Hx. PE: All normal Mx: Admit.

Check breathing. Ambo brought a 10 years old girl in. I would also thank the previous many candidates who have written recalls. The nurse said that is why I ring you. Tips to pass the exam: 1. Since the child has frequent attack (3 attacks per week). She said OK. Today the father comes to your clinic. Dr. So every week get real exam feeling! Dr. He was discharged from hospital yesterday. ED in country hospital. . AMC feedback: Asthma – persistent synptoms I felt relieved after I passed the exam. GCS 7. which was normal. SO IMPRESSED. I said the patient needs urgent transfer by helicopter to do CTB. Then do 2nd survey. Put cannula in. I explained the action plan in detail (when well. fantastic!!! 2. I told nurse primary survey first. No bleeding. unwell etc. I said he needs to be on both reliever and preventer. AMC feedback: Pertussis 2. Take VMPF bridging courses. I said it is steroids. Father knows how to use medication and spacer. But doesn’t know what preventer is. disease would be more severe. I would like to thank VMPF – Alan. Put collar on. she fell from a horse. Attend Dr. No signs of pneumothorax. Wenzel and my study partners. AMC feedback: Falling off a horse 3. how can this happen? A: if not immunized.Mother asked: My child has had immunization. Task: You will be on the phone with nurse to tell her what to do. Doc. G&H. But I couldn’t see anything. I said I would ring to arrange now. Task: History Asthma action plan Asthma action plan is on the table in front of me. Try to be the Guinea pig and sit on the hot chair.) as written on the paper and what to do. The role players are very good.18m old child was diagnosed with asthma. Most examiners are very quiet and didn’t say a word in my stations. The nurse is in front of me. The child is unconscious. Some of them are junior doctors. I tried to look at performance sheets on nearly every station when I shook hand with examiners. Put O2 mask on. I told her need intubation. Pupil equal sluggish to light. Wenzel’s Thursday evening’s discussion.

Good partners for group study. Don’t study the day before the exam. Dress professionally on the big day. you will pass the real exam. If you can survive.Wenzel’s cases are much harder than real exam. I could not pass. Have a message before the exam. 3. 4. I was very lucky to have good partners and finished this exam ahead of you guys who are still waiting the placements. GOOD LUCK . 5. Attend VMPF trial exam. Without their help.

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