I have to say that i didn't expect the exam to be that difficult, though i prepared well (or at least i thought

i did). I also have to agree with one of the previous topics about the exam being unfair between the morning and the afternoon session, i had a friend in the morning session and i was in the afternoon; the cases were the same but the patients (role players) and the examiners swapped around, so u got different clues and different reactions and different prompting ( i will come to that in the stations).

1) OSA in a 3 year old child history of mild asthma, recurrent middle ear infections for 1 year and poor sleeping. mother was nice with me as was the examiner (in contrast to my friend in the morning session where they were very uncooperative). poor sleep at night, sleepy during the day, father has OSA, examination enlarged tonsils, retracted tympanic membranes, mouth breather, normal child otherwise with normal growth and percentiles (a bit on the tall side though). I told the mother it is likely enlarged of adenoids and tonsils and that he will need surgery for that, she was happy and asked me if it could be anything else , I said it might be linked to the fathers OSA but I am not sure what he has may be there is a familial element.

2) Slow progression at school 8 ys old boy , reported to have slowly progressed over the last 6 months in school, discuss with the mother. Again this was unfair distribution of role players where I got a very annoying role player , doesnt talk , answers very briefly and seems surprised by a lot of questions (like she is saying why are u asking this stupid question) unlike my friend in the morning who had a very nice role player who told him everything in the history without prompting. Basically in this station the boy had no medical history and he was progressing fine till 6 months ago and his parents had trouble and conflicts and financial issues, but I couldnt elaborate any history of possible child abuse though I repeatedly asked, I asked the mother if she was depressed (because she really looked so ) but she wasnt , so I told her that the conflicts between her and her husband is what is causing her sons slow progression and that I wanna see him and refer both her and her husband to a psychiatrist or a marriage counselor .

3) Iron deficiency anemia Repeated station of iron deficiency secondary to cow milk and the child being a (fussy eater) which the mother repeated about 15 times in the station.

4) placental abruption Another repeated station of vaginal bleeding at 30 weeks in an RH negative mother .

5) vaginal bulging mass and rash 54 ys old lady presented to u as she noticed a mass bulging from the vagina and there is rash around it Tasks Do everything u can think of History, examination, counseling, management Now this was an incredibly difficult station though it might seem easy because as things unfold u will find out u are dealing with three problems that u have to take history for, examine and provide management This lady had vaginal prolapse ( which is the obvious one) and when asked about her deliveries she said she had 2 big babies in the past and as soon as u hear that u say YES!! That is what caused ur prolapse and u will be happy to hear that she has big babies as this will give u a perfect explanation for the prolapse but this will make u miss the clue. And the clue is big babies + rash = Diabetes !!!!! (never thought about it , didnt mention diabetes in this station at all, which is obviously a fail item). And the last but not the least of her problems is atrophic vaginitis that she tried oestrogen creams for in the past with no effect SO u will have to counsel her about HRT after excluding the contraindications of course. I am not sure how the hell am I supposed to do all that in 8 minutes but I would for sure like to see any of the examiners take history , examine and provide management of 3 conditions which are not really that clear in history in just 8 minutes.

6) 65 ys old with recent forgetfulness and she had an operation for diverticulitis 9 months ago This was a nice happy old lady who didnt know what she was supposed to do in the station so she kept reading from her instruction while I was interviewing her. She basically came to see you because she is being teased by her family as she forget s recent things mentioned just minutes ago and she is afraid she has dementia as both her parents died of dementia. The task was to do a rapid cognitive assessment (or a term similar to rapid) but the point is u r not doing a full MMSE. I went to ask her the orientation Qs and she was fully oriented and I asked her the frontal dementia Qs and she answered very well so I was puzzled. Since I have read the stem I was trying to think what could cause Dementia AND Diverticulitis and I couldnt think of anything except alcohol , so I entered the station to basically counsel her about Wernickes Korsakoff amnesia and alcohol quitting stuff , so my first Qs was obviously (do u drink alcohol) and to my great frustration she didnt. After that history I told her she might have early Alzheimers but we will have to do tests for reversible causes B12, Folate , TFTs , Syphilis and brain imaging before coming to that diagnosis. When I discussed this with other candidates they said this lady had DEPRESSION not dementia and when they asked about depression they had positive responses from the role player. Now as a said earlier my patient was a really happy looking patient so I didnt think about depression at all (which is obviously a fail point as well) and I dont know why the hell they told u in the stem that she had operation for diverticulitis 9 months ago.

7) young lady , known borderline personality disorder , comes to hospital intoxicated after having cut her forearms. A repeat station of involuntary admission in a patient with deliberate self harm who was obviously too dangerous to go home on her own.

examination of rheumatoid arthritis hand They got a real patient with deformities He also had a knuckle replacement surgery scar Nice patient, normal examiner I think the only new thing about this station is the functional assessment so u have to ask the patient to do a key grip and write something (they had paper and pen lying there for u ). The other thing is that the examiner asked me what other joints can be affected and I mentioned the atlanto axial joint and she said what else , I said any joint of the body can be affected, like what ? she asks again and I go Hip? , I dont know what she wanted to hear but obviously not the hip.

9) Cellulitis AND PVD Elderly male coming to u with redness and pain in the right leg (a photo provided) , obvious cellulitis. That seemed like an easy station I talked about antibiotics and that he needed to come to hospital (he was feeling generally unwell) for IVs and excluded diabetes and trauma as the cause for cellulitis. I didnt think about PVD though but I finished the cellulitis stuff early so I asked the patient if he had any other complaints and the patient was nice enough to give me claudication symptoms (he also had a history of CABG I think) so I talked to him about that as well ABPI , angiogram , Bypass , etc In real life I never asked any of my patient with cellulitis about claudication , but may be I should start now.

10) MVA with a fractured Tibia , examine the leg Photo provided for an obviously swollen left leg with something like a blood clot in there. As soon as u enter the station the role player is screaming of pain , so u obviously have to give them some morphine and start your examination. The foot was neurovasculalry intact and I went to talk about further management ,

however I kept getting interrupted by the patient as he is in pain so I told the examiner that the pain is really out of proportion to the degree of fracture and I strongly suspect compartmental syndrome (I think he was happy with that). I mentioned the rest of the stuff, Xray, ortho reg, theaters, blood, etc I would think compartmental syndrome is a critical error here.

11) weight loss in a 40 ys old lady Weight loss of 7 Kgs in the last few months Take history, ask for examination, and mention the most important office tests u have to do. This was a really confusing station It was basically NORMAL No DM, No Thyroid, NO symptoms of malignancy, No Bleeding, NO depression , No GI symptoms at all, Diet the same, Appetite good. I dont know what they wanted in this station but I said we will do blood tests, imaging, tumour markers to exclude any sinister cause and then we will HAVE TO reassure her as nothing is abnormal.

12) RIF pain in a young lady A repeated station about the usual DD , it turned out to be torsion of ovarian cyst.

13) 45 ys old , brother had CABG and he came to u for assessment of cardiovascular risk He was obese , hypertensive, smoker, never did any tests for DM or Cholestrol and not on any meds This was a relatively easy station.

14) a young lady in a MVA with trauma to the left maxilla Task was to do a focused examination.

I went there with no clue to what I should do. It was a low speed MVA , got hit from behind by another car while stopping in the traffic lights , and she was not wearing a seat belt so she hit her face in the dash board. NO LOC, No Vomiting, No neck pain, No pain anywhere else apart from the left cheek (which had a painted bruise on it), patient looks well, not in distress at all . I palpated the maxillary bone and there was no fracture and I said I would examine the ear , the nose for any blood or CSF leak which she didnt have and the mouth for any bleeding or injured teeth. This took about 2 minutes and then I didnt know what to do. If I had this patient in ED I would have discharged her after that, she was perfectly normal. The examiner was quite nice though , he kept prompting me to do more examination We should check for mandible fractures and movement, EOM to check for any eye muscle injury, and examination of the trigeminal nerve for a possible lesion. Some candidates say this was a disguised way of asking u to do a cranial nerve examination . This was a totally new station to me and I really didnt have a clue.

15) scaphoid fracture Young lady , fell on her hand now coming with pain, examine , interpret X ray and counsel. Relatively easy, typical clinical examination of scaphoid # , nothing on Xray, so cast, and then repeat xray in 3 weeks and do a bone scan.

16) 40 something with GI symptoms Diarrhea, some bleeding, sticky stool, some temperatures, on and off for 3 years never had anything except stool samples. I said this is likely IBD either Crohns or UC and we will have to do colonoscopy and barium enemas and take some samples and counseled about treatment quickly.

My general impression Very tough exam. Is it a once off or is it a coming trend?

Will they adjust the results of the pass rate was 10% or so to make things look better ? I dont know All the best for the coming candidates Wish me luck with the results.

Another recall hi guys i got my result i passed 12 stations . i failed borderline personality disorder with wrist cut , scaphoid fracture , uterovaginal prolapse and cvs risk assessment . so dont follow what i did . =========================== i am gonna post 2 recalls today for what i passed . inflammatory bowel disease . it was an old case.The lady says that i have been to doctors but she wasnt an angry lady. she has diarroea for i think last 1 yr .It is of an on and lasts for 6 weeks at one time . She has tummy cramps .She was given medicine ,one was panadeine and other was i think one given for IBD ( irritable bowel) and that hasnt worked and its effecting her life . There was no stress .She felt tired and lethargic .SHe noticed some slime She noticed blood just one time ( the last one ).On exam every thing was ok except on rectal exam there was blood on finger .So i told her that she has got inflammatory bowel disease and pt edu stuff .I passed this case ================================== there was a picture of legs .on left leg there was bruising. Patient had an accident motor vehicle . When we enter the room there s a dressing on ot,s legs and we cant remove that just imagine that under the dressing the looks like the picture outside the room. Task was to examine his legs and give the commentary to the examiner .I dont remember rest of task . I went inside i said that i want bp and pulse . then i started with inspection about any bruising redness, swelling ,obvious deformity,his left foot (the injured one ) looked inverted in position . Pt had very tender leg . So i didnt check power ,reflexes ,tone . So i said that i will examine peripheral pulses. i said femoral and popliteal .examiner said.its present . Ex;its normal. C;then i checked dorsalis pedis and posterior tibial.and then i checked capillary refill ( although i dont know exactly how to do that just pressed finge r nail for a sec and then obserevd reddening .Then i checked sensations (pinprick and touch) on both legs and those were intact.i said i will like to do planter reflex (couldnt think of any thing else) E; no need. C. (talking to pt )its likely that your lower leg bones are broken. and i would like to have an x ray E; xray has been done but not available but you talked to radiographer on phone something like taht and he tells you that there is a # of tibia and fibula . C; i will give morphine with anti emetic then . then i made blunder by saying i would put a plster cast .examiner kind of jolted . he said plaster cast . Then i said ok i will

have a look at # and if there is displacement, we will do open operation and reduction and internal fixation under anesthesia.I had to tell it to pt .so i said you will be needing screws ,pins like things to hold bone ends together. Ex said look at the pic what do you think # would be like? I said it would be displaced #. C . i told pt you need to be admitted to hospital for atleast 7-10 days . E;what else you wannagive to him . C; ok we will give antibiotic .3rd generation cephalosporin . E; which one C; cephalexin . E; thats not 3rd generation but it doesnt matter . E; what else you wanna give . C; then i realized i have to ask tetanus status . pt said he doesnt remmber any thing . I said then you need tetanus booster . I passed this case

i will post recall one per day as i am so fatigued and still has flashbacks and post traumatic stress. Wosrt exam and best preparation in my whole life. session after noon. Scaphoid fracture ( ) A 25 yr old young man had a fall and pain in wrist Task .1.examine his wrist 2.ask xray from examiner tell pt what the proble is 3.Tell mangaemnt to pt No need to take history. First have to do inspection.then pt said his wrist is very sore. Then I carefully palpated wrist.and anatomical snuff box and did pinch test (oscs). Then I asked for xray . Icould see fracture of scaphiod bon e.Examiner asked where is # . I pointed out .I told pt about # and showed him .Told him Mx like rest , pain relief like panadeine and I will send you to orthopaedic dr fot scaphoid plaster and Ex said he is not here what will you do .I said ok I will do it for you ( I dont know wether I am right ). I told him extent of plaster and that he should move his fingers and elbows and elevation of arm . I was telling wrong about how plaster should cover the thumb so Ex wanted to know more .he asked where is the scaphoid bone on x ray .thanks God I knew it then he asked where is thumb .He said that thumb should be immobilizes uptil atleast I think distal interphalangeal joints . I forgot to tell about plaster care instruction . E;a physiotherapist is available in hospital do you thing he can put on plaster ? C;I dont know E;just for information yes he can C;this plaster need to stay for 10 days atleast . E.if there is no fracture that you can see. C;he still needs plaster for 10 days .then we will do an xray without plaster .may be then # becomes visible .and then immobilize it for 4to 6 wks.

Cellulitis AND PVD Elderly male coming to u with redness and pain in the right leg (a photo provided) , obvious cellulitis. That seemed like an easy station I talked about antibiotics and that he needed to come to hospital (he was feeling generally unwell) for IVs and excluded diabetes and trauma as the cause for cellulitis. I didnt think about PVD though but I finished the cellulitis stuff early so I asked the patient if he had any other complaints and the patient was nice enough to give me claudication symptoms (he also had a history of CABG I think) so I talked to him about that as well ABPI , angiogram , Bypass , etc In real life I never asked any of my patient with cellulitis about claudication , but may be I should start now. ============================================ I will just add that pt was on aspirin and ace inhibitor , C.you any past significant illnesses and operation . P no . C. why you take these medicines ? P. some breathlessness and discomfort previously . SEE the contradiction . WEll i did the same as above dr but i think what we all missed is asking DVT history . I read in oxford that these 2 conditions can coexist. But in PVD clots formation do happen as well . so guys who pass this station pls tell all of us how you performed

got some energy after breakfast Borderline personality disorder. I missed from her how many times she cut her wrist before? When she is stressed she cuts her wrists. ( so may be it has been going on for a while ) She had no depression hallucinations ,delusions,active suicidal plans,she knew she had problem and her judgment were ok , I forgot what she told about drug hx ?she thinks life is worth living and she has good things to look forward to . C;I will put you in touch with a dr who will help you ,he will give you insight in to your problem and do some behaviour congnitive therapy, P;are you gonna admit me ? c.yes at first you need to be seen by psychiatrist ( I dont remember in the stem it was rural practice with no urgent psychiatric emergency facilities I think . other cndidates pls confirm ,I dont know now if I can say to he rthat psychiatrist is gonna come and see you .)

p;they are gonna lock me up . c.bell rang .i hurriedly said there is no reason to lock you up .( I dont know if I am right or wrong as in the task we had to to suicide risk assessment and my assessment told me no active risk of further harm ) pls confirm .