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Paranoid schizophrenia 8. Anxiety/ depression 9. Haemochromatosis 10. Polymyelgia Rheumatica 11. Diabetes leg examination 12. Hypertension - physical examination 13. Leg cramp 14. Lymphoedema 15. Primary survey of trauma patient 16. Osteoporosis
Case 1nsion You’re seeing 3 year old Sarah one week after a hospital admission with an episode of asthma. This is her third episode in past two years. She has been prescribed terbutalin syrup (bracanyl) from the hospital. On examination her height and weight is in 50th percentile and can hear wheezing in her lungs. Task:z 1. Take relevant history 2. Explain the condition and your management to her mother In the history: No eczema or allerigies Wakes up about 3 nights per week with cough Uses terbutalin syrup once a week for exacerbations Gets cough if she plays too hard Mother is a smoker no pets Has an elder brother who has Asthma
FBE Hb 65g/L WCC 0. Explain you management to the mother Explain to the mother that I have bad news to tell and ask whether she needs someone with her. I summarised it saying need to identify what make her asthma worse and avoid them including mothers smoking and use of relievers and preventers. viral.I took too much time in taking history therefore ran out of time to tell my management. Explain the results to the mother 2. Is this a condition is severe? .6 Neutrophils 0. immunoglobulin or steroids. I failed this station and later found out that when you talk about spacer device they will provide you with one.2 Platlets 25 Blood film Normocytic Normochromic anaemia. Possible reason were indopathic. No abnormal cells seen His father is working overseas Task 1. AMC feedback Asthma Case 2 7 years old Tayler’s mother is in your practice to know about her sons recent blood results. She was happy to go on and I explained the results and told this looks like pancytopaenia and what it meant. drug related or may be leukaemia (but unlikely because the peripheral blood film doesn’t show any abnormal cells) Depending on the cause he can be treated with bone marrow transplant. He will be given antibiotics to protect him from infection and may isolate him from rest of the wards to protect him from catching any infections. Tell the probable diagnosis 3. He would under go a bone marrow biopsy which would be performed under anaesthesia to determine the cause of this condition. In hospital he will be managed by a haematologist. which you have to explain to the mother. You have ordered following investigations when you last saw him with multiple bruises and mild fever. Told her son needed immediate hospital admission for specialized care for this problem and it would be prudent to ask your husband to come back because you will need a companion to help you and your child through this difficult period.4 Lymphocytes 0. He might need blood and platelet transfusions if required.
drugs. If he gets another febrile convulsion which is more likely to keep him in a safe place. then bring the child to the hospital. Task 1. at the moment no treatment is needed. not to put stuff into the mouth. watch out for abnormal signs such as one side of the body moving or prolong fit or any hint of suspicion by the parents.Yes it is that’s why I am organizing prompt admission to hospital What can cause this condition? Viruses. I stressed this is not epilepsy and the chances of Sam getting epilepsy is only slightly higher than the normal population so nothing to be concerned at the moment. idiopathic (I couldn’t remember much) The bell rang!!!!!!!!!! AMC feedback Pancytopaenia Case 3 4 years old Sam was brought to the ED by his father after suffering from a fit like episode with a fever. Explained what parents can do at home to prevent it from happening. Therefore. Pamphlets to read…… My wife is pregnant and will that child have this problem as well? Yes high possibility due to 1st degree relative One of my friends who have epilepsy is taking a drug called Sodium Valproate. You have examined the child and diagnosed uncomplicated febrile convulsion due to a viral infection. Take relevant history 2. This is convulsion or fit due to abnormal firing of brain cell in response to the temperature changes in Sam’s body. Tell your management to him I greeted the medical student (Tom) and said I have good news and nothing to be alarmed at this moment. Now the child is ok. This occurs because Sam’s brain is still developing and is more sensitive to the changers compared to a mature person’s brain. does my child need any medication? No. Sam is doing fine and what you have witnessed is a febrile convulsion. Explain the condition to the father 3. your friend has epilepsy whereas your son has febrile convulsion. This does not mean he has any problems with his brain at the moment. AMC feedback Febrile Convulsion (this in the AMC DVD) Obstetric and Gynaecology . like paracetamol and tepid sponging if they feel he is going to get a febrile illness.
who will do the USS and suggest management options. Can it be anything else? With your history and examination this is the most probable cause. Cervix normal mass continuous with uterus no adenexial masses My probable diagnosis is fibromyomata (fibroid). Questions: Can I get pregnant? Depending on the position of the fibroid you may have trouble getting conceived. I did not offer pregnancy test as it is unlikely. I’ll refer you to gynaecolist. Probable diagnosis and management Regular periods Normal menstruation no heavy bleeding/pain/ discharge LMP 3 weeks ago Uses Condoms for contraception Stable partner no history of STIs or dyspariunia/dysmenorrhea Have gained about 2 kg during past few months No other medical or family history of concern Examination Avergae built. She has come back to repeat the test.Case 4 24 year old female had a pap smear done by one of your colleague 2 years ago. Depending on the position of the fibroid he will offer either surgery or watch and wait approach. Explanation: Benign condition commonly seen in reproductive age women. It is not a cancer. Vitals normal Abdomen mass extending from pelvis 2 cm above umbilicus. uniform and regular. While you are examining her you have found an abdominal mass extending 2cm above the umbilicus. if you get pregnant this might course you to have miscarriage or if you go till term may course problems with delivery of the baby and during the pregnancy it can cause problems like torsion or red degeneration which might lead to premature delivery or urgent surgery. Task: 1. To confirm the diagnosis need to do an USS. Take relevant history 2. Ask for examination findings( he will only tell you what you ask) 3. .
Task: 1. Left lateral Call for help Oxygen via face mask IV diazepam IV MgSO4 IV hydralazin to bring the BP slowly down Inform obstetric team as she will need emergency delivery Examiner said you have finished the station so go out side and wait…. Previously normotensive Ante natal period uneventfull.AMC feedback Mass found in lower abdomen Case 5 A 26 year old primigravida at 36 weeks presents to the emergency department with excruciating headache. Examiner told she’s now started to have a fit manage…. Explain your management History to differentiate SAH or Pre-eclamtic Severe pain 9/10 Generalized Gradual onset No visual disturbances Notices increase ankle swelling during past 2 weeks. all investigations and scans normal Baby is kicking fine. she is having pre-eclampsia and can going to eclamtic fits any time. Take relevant history 2. No vaginal discharge Examination: BP 170/110 Ankle oedema Exaggerated KJ/AJ + clonus SFH = POA = 36wks Cephalic head entering pelvis FSH + Urine ward test protein 4+ Management: I told this is an emergency.. You’re the attending HMO. Request relevant examination findings from the examiner (you will only be given what you ask for) 3. .
which is a good indicator of placental well being. Examiner hands you the GTT. Explain the results 2. lot of women with diabetes deliver healthy babies. Reading material. You’ll have more frequent clinic visits and more USS to check the baby’s progress. referral letter to dietician/endocrinologist/obstetrician AMC feedback Positive GCT (AMC book case) Psychiatry Case 7 A 30 year old Maria has come to your practice requesting for a letter to Department of Housing Authority to find her new accommodation. You will be seen by an endocrinologist and obstetrician. check ups and scans normal so far. Explain the management Explanation. Take relevant history 3. You’ll have to monitor blood sugar 3 – 4 times a day using a glucometer at home. and Indirect Coomb’s test. After 3 weeks if you can’t achieve good control with diet have to consider insulin for the rest of the pregnancy as the diabetes going to get worse as the pregnancy progresses. You’re having GDM History Strong FH of DM Average built No diabetic symptoms like polyuria/polydipsia/nocturia Healthy diet All antenatal investigation. . Now at 27 weeks she’s coming to receive her results to your practice. I will refer to a dietician for assistance. Hb. GCT: elevated (can’t remember the values) Hb: Normal IDC: Negative Task: 1. you may have GDM but need to do GTT to confirm it. Plan: First we’ll try diet to achieve glycaemic control. Your rest of the antenatal follow ups will be done in a special clinic.AMC feedback Eclampsia Case 6 A 24 year old primigravida visited you last week at POA of 26 weeks for GCT. Fasting and 2 hour glucose levels elevated. You do not need to worry as this is not an uncommon thing.
Delusion of persecution: She believes her former husband is causing all the current problems she is facing with her neighbours Hallucinations: Second person: she hears voices talk about her next door. (including the mental state examination) 2. Task: 1. live by herself and previously also stop medication on her own. She in your practice today to get a letter to Housing Authority for change of accommodation as she has been troubled by the neighbours. Take psychosocial history of this woman. She lives by herself. (She knows there is nobody living next door) She strongly believe the neighbours throw things into her house which she needs to continuously clean (this is causing her the dermatitis) No insight Good judgment and no suicidal ideas or plans She has stopped medication herself previously because she thought she was feeling well. She had nervous breakdown 4 years ago after separating from her husband. AMC feedback Paranoid Schizophrenia . She needs admission and if she refuses has to consider involuntary admission because she has paranoid ideations. DD: Acute psychotic attack Schizophrenia Drug withdrawal Brain tumour Examiner: What are you going to do about her? Need urgent assessment done on her and seen by a psychiatrist. Give your DDs History + Mental State: Well dressed Appears well groomed Normal mood Speech is normal Perception: Delusion of reference: She was watching a program on TV where she believes they discussed about her. She has stopped her medication 3 years ago.You have seen 30 year old lady several times during the past few weeks because of extensive contact dermatitis due to cleaning agents. Present your finds of MSE to examiner 3. loss of insight.
AMC feedback Mixed anxiety/depression – Atypical abdominal pain General Medicine Case 9 A 55 year old retired manual labourer has been referred to you by your colleague for your opinion regarding abnormal liver function tests. She is angry because the gastroenterologist has told her that IBD is due to stress and associated with brain/mind. What ever you tried to talk she would brat down on your neck and blaming you for all the misery this has caused her due to your inability to diagnose her condition for 4 years.Case 08 A young female who has been a patient of your clinic due to her long term bowel problems is here after her colonoscopy and gastroscopy. Task: 1. She has been suffering with these symptoms for 4 years. Explain the condition and answer her concerns 3. Take psychosocial history 2. Tasks: 1. Gastroenterologist has confirmed it was irritable bowel disease but failed to explain what it was and re-referred her back to you for further management. Arrange further management I knew what was happening in this station even before I went in as I could hear this young girl shouting at the candidates from my rest station. By the time I finish the station my ears were ringing and I just sat there hopelessly because I didn’t had any idea what I should do or say. I tried asking HEADS questions and this is what I found or hear while in the rest station She is 24 and works as an airhostess Have problems at home with boy-friend and also at work She is stressed to the max Smokes and drinks but no increase in recent times Not on any other drugs So still no idea how to get around it but I passed this station and in a friendly chat with an examiner said the expectation may have been for the candidates to sit there and listen to her and not get offended. This is the famous recall with a referral letter from GP Pt has pace maker for bradycardia Serology negative Never done drugs or alcohol Continuously elevated liver function for 2 years Results of GGT/ALT were given. Explain the results .
Request further investigations 3.Normal Diagnosis Haemochromatosis Explain that this can be controlled but can’t be cured Regular venesection Specialist care by gastroenterologist Watch out for diabetes Can cause cirrhosis if not managed properly which if happens will increase your chances of having a liver cancer Questions: What about my son. Give the diagnosis and explain the management Investigations: Serum iron studies. 3.Iron level. Trans ferrin saturation elevated HFE gene study . Gradually getting worse for couple of weeks Now the pain is in his hips and upper thigh as well. does he need a test? No need if he is below 40 as we can’t prevent him from getting this if he carries the gene. Take focaused history Ask for relevant physical examination findings from the examiner Request relevant investigations Give the diagnosis and management plan History: Pains started in back of the shoulders not in the shoulder joint. Ferritin. 4. Also symptoms only manifest in late 40’s and above. Never had similar pains. . Good news is people can have normal life expectancy with good management of the condition with minimal complications AMC feedback Abnormal liver function tests JMPE 5th 250 Case 10 A 60 year old retired accountant is in your practice because of gradually worsening aches and pains in his body. then gets better and again worse in the evening. But advice the son about the risk if the disease and beware of it. Task: 1.Homozygous for C282Y gene RBS .2. Worse in the morning. No arthritis or joint problems in the past. 2.
Explain your findings and reasons while examining the LL to the examiner Examination: I started by saying longstanding DM would have Macro and microvascular complication and this is what I am going to look for and elicit during the examination. Similar on hip as well CVS and RS normal.Not on any medication. osteoporosis) Examination: Normal BMI. FBE Gastroscopy and colonoscopy Diagnosis: Polymyalgia Rhuematica Management: Oral Prednisolne + Osteoporosis prophylaxis Rhuematology referral Educate about warning signs of temporal arteritis. Acute pain relief with paracetamol and NSIADs AMC feedback Aches and pains AMC case 68 Q351 A371 Case 11 This middle age woman has long standing DM. Hasn’t lost any weight. No headaches. visual problems or mastication problems No family history of similar condition or malignancy Non alcoholic and non smoker No other medical or surgical problems (including gastritis. Healthy looking Vitals normal Pain on shoulder girdle not on the joint. CRP. PR prostate normal. Examine her LL in view of finding complications of longstanding uncontrolled DM 2. Abdomen no masses. Task: 1. Stood up the patient for inspection Quadricep wasting Pigmentation Charcot’s joins (loss of proprioception) VV . The BSL control is poor through out the life. No point tenderness over spine Investigation: ESR.
He ask me to show him how I would look for them. AMC feedback Diabetes – complications Case 12 A 30 year old gentle man has found to be having a blood pressure of 170/100 during a routine medical check up. Use the 128 one no sensation until tibia. Explain your further management to the patient Examination: I started by saying the examiner that I am looking for cause for secondary hypertension in the young man with strong family history of cardiovascular disease. When I came to abdomen he asked what I want look for I said kidneys. General appearance looking for Cushin or acromegaly Started by feeling for pulse (rate. forgot to listen for brui in the tummy. rhythm. . Once I did it the examiner was impatient and was rushing me through rest of the examination. therefore I explain I would ballot for them to feel whether they are enlarged (polycyctic). Vibration both 128 and 256 tuning forks were there. She had stocking type sensory loss. Bell rang!!!!!!! Want get time to do everything therefore my advice select what you want to do or what you think is most important in this station and do it first and then go for the rest. Do relevant physical examination. character and volume) Any R – R delays or R – F delays indicating Co-arctation of Aorta BP when requested I was asked to measure it using a wall mounted BP apparatus. Task: 1.Healed ulcer scars or ulcers While standing Romberg’s test for proprioception Palpation: Temperature CRFT < 2 Nail and nail fold hygiene Ulcers between toes and on the sole of the foot All the pulses of the lower limbs Sensation: Looking for stocking type sensory loss using the mono filament. (explain what your looking for the examiner as you go) 2. This was repeated three times during the past few weeks and still high. Role player was a medical student. Family history: Mother died of a stroke at 50 years and father had a myocardial infarct at 45 years. The filament was on the back of the knee hammer so I check the reflexes at the same time which was normal.
Told him you may be having secondary hypertension and I need to find the cause if I am to bring down your BP. He gets it on his calves when walking. Then he told the ABPI in Left is 0.25 and Right 0. colour. Do relevant examination of the limbs. He used to a around of golf very week which he is unable to do now. therefore where do you think the obstruction is? Either in external iliac or common iliac artery Since you couldn’t feel both where do you think the problem is? Abdominal Aorta Good. hair when the examiner interrupted and said go ahead palpate and tell me what you find. Recently the distance he could walk without getting the leg pain has significantly shortened. You didn’t felt any pulses up to femoral artery. He smokes 30 cigarettes per day On an ACE inhibiter for his hypertension Task: 1. The bell rang!!!!!!!!!!!! After the exam I found out everybody was asked to check the BP and some struggled to do so. what can be the cause? . AMC feedback Hypertension Case 13 A 50 year gentlemen is in your practice because of his worsening leg pains. He asked me to show him how to do the Berger’s test which I did. He had a surgical scar from a bypass surgery on his left leg. I said I want to do Berger’s test and ABPI.Then told me to tell what further investigation I would do to the patient. He told me it’s in the medial side of the thigh. Palpation I couldn’t feel any of the lower limb pulses in either legs. Explain the reasons for the findings This was a real patient. Questions: What do you think he is having? Peripheral Vascular disease Where do you think the problem is according to history? Superficial femoral Good. (You’re not required to examine the hear) 2. First would like to do and USS of you abdomen to look for you kidneys and the renal arteries. Now show me where the superficial femoral artery runs? Which I was not sure and I showed him the lateral aspect of the thigh. therefore my advice is learn it as I believe this station was to check your examination technique nothing else. scars.9. As usual I proceeded to inspect the lower limbs muttering the mantra of pigmentation.
Tell me how rapidly did the swelling got worse? Over few weeks Does it hurt? No (There was a picture as well which shows a lymphoedema arm) I need to rule out DVT and for which I need to do a Doppler and CT scan.Aneurysm Very good. If the tests are negative and most likely with the information you may be having lymphoedema. How would you know you’re right. . Tell her you diagnosis and explain it 2. This a complication of removal of lymph nodes from your arm pit during your mastectomy. What is your management of this patient? Need urgent vascular surgical referral Your vascular surgeon is not available for months advice the patient regarding the management till then? Need to stop smoking. Now she has come with increasing swelling of her left hand. You have notice some telengetaciae in her left axial and chest. I can help if you’re willing Do moderate exercise as you can tolerate. Task: 1. Since then she had radiotherapy and chemotherapy. This would improve the blood supply to the leg Cardiology opinion on management of hypertension and ACE Inhibitor (I was not sure whether to stop or not) The bell rang!!!! AMC feedback Leg cramps on exercise Case 14 Mrs A is 48 years and was diagnosed with breast cancer three years ago and had mastectomy done o her left side. This condition is similar to what we get in lower limbs and you are more at risk to get it in your arm because of the surgery and complications due to radiotherapy. Talk about the management No further history taking is required Explanation: With the information I have gather it looks like this may be either lymphoedema or DVT. show me how you would look for an AAA? I showed him how to look for an expansible pulsation Excelent.
where you have specially trained physiotherapist to do special physic to your arm so the fluid can be drained out into the body. Perform primary survey 2. listened and felt breathing. I looked. This is lymphoedema. it was clear Breathing. Examiner: Show me how you would place the collar? I showed how to do it Then air way. Task: 1. You need to where compression bandages at all times due to the risk of DVT Don’t let the arm get sun burnt or injured during house hold chores Don’t allow to check BP. There was cervical collar. Hudson mask. What are you going to do? .. Suggest immediate managements needed When I went in I was shown all the equipment I should be utilizing during the management. If it is severe there is micro surgery which can correct the lymph drainage. There was a medical student lying in the bed covered with a bed sheet I started by say I would follow DR ABC and check the air way (I forgot to check for response at this point) I said before doing anything I would like to stablize the cervical spine using the cervical collar.Other than arteries and veins there is a third vessel system which we call lymphatics which drains fluid from tissue. You are the attending HMO. Here are some reading materials about this condition. Examiner: Good show me how you would do it? I need someone to keep the head and neck in-line till is pass the collar under the neck. Examiner: Left chest is not moving with breathing. There is specific clinic for this in the breast clinic. He was brought to the emergency department by his friend who was riding with him. AMC feedback lymphoedema/upper limb Case 15 A 25 year old man was herding the sheep on a motor bike when he accidentally hit log and fell down and hit his head. Any questions you would like ask? Role player Is this a cancer? Most likely not but it is one of the possibilities that we have to exclude. draw blood or put cannulas in this hand. Because of the surgery and the radiotherapy the drainage of lymph is obstructed causing it to accumulate in you arm. tubing……. He has lost consciousness for 5 minutes. Good news is that we can control it and treat it but not necessary cure it. Request immediate investigations 3.
Menopaused for 18 years Never took HRT No PV bleeding/ wt lost/ bowel habit change/ bone pains Don’t like diary products . Task: 1. chest and pelvic x-rays and CT brain I was told I have finished the station early so go out side and wait. Take focused history 2. She has under gone a DXA scan which revealed T -3 score. Tell the diagnosis and management History: Got the fracture while trying to get off the bed. Examiner: SaO2 94% in room air and you can ask the patient for the deterioration. AMC feedback Primary survey of trauma patient Case 16 A 68 year old menopaused lady was investigated for a back pain and found to have a fractured thorasic vertebra. Asked whether his is progressively feeling difficult to breath. I asked whether the there is any pain which was and arranged pain killers. Examiner: What next? Cardiovascular Examiner: Anything else before that? Ohhh I am so sorry I need to put oxygen via mask Examiner: Ok assume you have done that and go on to the cardiovascular Need to feel for carotid pulse for volume and rate and BP Examiner: Pulse 110 and BP 100/60 Patient is haemodynamicaly unstable. I thought I have failed this as you must have noticed I have done things wrongly but for my amassment I have passed this station. he said no I am alright. Examiner: What other investigations do you need? Cervical. Same time would like to connect him to the monitoring and arrange base line blood investigations. Her FBC ESR and UFR are normal.I need to exclude tension pnuemothorax as it is life threatening Examiner: How would you do that? Listen to lung for breath sounds and check whether patient is deteriorating. Examine: Ok Listen for BS? I listen for the sounds using the steth Examiner: How do you know patient is deteriorating? Decrease in SaO2 and by asking the patient. Need two wide bore cannulas in both hands and start fluid resuscitation. This is the first time. She has come to gather her results today from her general practitioner.
Do you have any questions? Can this be cured? I am I having a cancer? No can not be cured but can be control to the limit where you’ll be able to lead a normal life with reduce risk of fractures Didn’t get to answer the second question as the bell rang…. Ca and Vit D supplementation. Help to produce Vit D in the body Keep up the good habits Medical management would include drugs like bisphosphonate. my advice to everybody who is sitting the exam is to improve the communication skills because this is more about how you would communicate you medical knowledge to a lay person. Good Luck!!!!!!! and mind my spelling and grammar mistakes . This helps to prevent fractures and falls Dietician for dietary advice regarding fortified foods with vit D and Ca Increase out door activities which would expose you to sun light. Presumably due to the fact I didn’t alleviate her worries about a cancer. which is thinning or sponging of the bone due to lost of female hormones in your body following menopause. alcohol and smoking Most likely osteoporosis.Not much out door activity Family history of osteoporosis in her mother at 80 No medical or surgical co-morbidities.. Strontium and raloxifen Explained what each drug does. Not on any medications. AMC Feedback Osteoporosis Thank god finally the nightmare was over and can look forward to building my medical career in Australia now. Looking back. I have thank my study partner for all the help and also all the other friend who supported me and encourage me during these few months. Therefore keep doing the role plays. This station I failed…. Said here are some pamphlets to read. Management: Talked about Physiotherapy to improve bone thickness and muscle strength.
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