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22th November 2008 Melb retest 1. 2. 3. 4. 5. 6. 7. 8.

Diabetes foot examination Abdominal examination Painless haematuria Chronic diarrhoea in 9mth old child PV bleeding after 8 weeks amenorrhoea Adrenal tumour Pethidine request SOB pneumonia

1. This middle age woman has long standing DM. The BSL control is poor through out the life. Task: 1. Examine her LL in view of finding complications of longstanding uncontrolled DM 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. Stood up the patient for inspection Quadricep wasting Pigmentation Charcots joins (loss of proprioception) VV Healed ulcer scars or ulcers While standing Rombergs 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. She had stocking type sensory loss. The filament was on the back of the knee hammer so I check the reflexes at the same time which was normal. Vibration both 128 and 256 tuning forks were there. Use the 128 one no sensation until tibia. 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. AMC feedback Diabetes complications

2 AMC case 70 Q352 A377 Abdominal examination 3

A 60 y.o man, who is c/o hematuria for 3 weeks, came to GP clinic. He has past Hx of renal colic. Task: take relevant Hx for 4 min, ask exam findings, arrange Ix, Dx, DDx, Mx Hx: Mr. X, I understand you have trouble with your waterworks. Could you tell more about it? Do you pass water more frequently? How often do you pass water? Do you pass water at night? Do you have any sense of incomplete emptying? Do you still have strong stream? Is there any dripping at the end of urination? Do you pass small amount of urine more frequently? Do you have any burning pain when you pass water? Can you hold your urine or you have to rush? Have you noticed that any blood in urine? Is it at the start, middle or end of the urination? Did you have any injury in your private parts or groin or hip? Do you have any bleeding from the other parts of your body? Did you ever experience pain in your loin or tummy before? Did you travel overseas recently? Did you eat large amount of beetroot recently? Have you ever diagnosed with STD before? Is there any Hx of bleeding disorders? Is there any family Hx of bleeding disorders? Is there any Hx of strong sports or jogging? Have you ever had kidney problems or stones before? Have you ever diagnosed with UTI before? Are you on any medication like blood thinning pills? Do you have any pain in your other parts of your body? How is your appetite? Have you lost weight recently? Do you have any family Hx of cancer? Have you ever diagnosed with cancer before? Smoking? Alcohol? Recreational drugs? Exam: GA, vital signs, BMI, rash, pallorness, all LNs in the body, chest, heart, abdomen, any loin pain, tenderness, mass? PR. There is palpable bladder, on percussion- 3 cm dullness. Urine dipstick. Ix: FBE, coagulation profile, PSA (before PR), U&E, Urine M/C/S, U/S, referral to urologist for cystography. They may decide to do prostate biopsy.

Dx: Bladder Ca DDx: Urinary calculi, stone, infection, trauma, BPH, kidney disease, bleeding disorder, discoloration due to foods (beetroot).
4 12 months old baby brought in to your GP practice by his mom. He has been suffering for ongoing diarrhoea for the last 6 weeks; he was investigated by other doctor who is now overseas. Stoll microscopy showed no parasites or bacterial growth. Initially was 10kg now is 9.2kg. Still complaining of offensive diarrhoea and excoraited buttocks. Otherwise he is well. Take focused history from the mother. Explain the Dx, and manage appropriately. Coeliac disease 5
A married woman mid 20's comes to you (GP) with 8 weeks of amenorrhoea and sudden onset of bleeding. Has H/O miscarriage 1 year ago. Task : Take history and discuss with patient..(allowed to ask examiner for investigations) diagnosis and management spontaneous abortion

A middle aged woman, who is c/o abdominal pain with headache, came to GP clinic. You arranged U/S; a photo was given on the door and showed 5 cm mass on adrenal gland. Today she came for the result. Task: explain the result, Hx, ask exam findings, Dx, Mx 2006 nov melb Dx: Phaechromocytoma Read CT Scan by yourself Hx: Mrs. X, before I explain the result, Id like to ask some Qs. Could you describe me your tummy pain? Is it constant or does it come end go? Where is the pain exactly? How severe is the pain, 0-10? Are there any relieving or precipitating factors? Have you had this for the first time? How long does the pain last? Are there any accompanying symptoms such as nausea, vomiting, sweating, tremors or headache? Do you have any chest pain or palpitations? What about your bowel motions? What about your waterworks? Have you lost any weight or gained weight? Have you ever diagnosed with cancer before?

Do you have any striates on your tummy? Do you have any abnormal hair or sopts in your skin? Have you ever diagnosed with HBP before? Do you have any muscle weakness? Is your urination in big amount? (Cons disease, poliuria) Are there any changes in your periods? Is there any family Hx of cancer or tumor especially in the kidney like phaechromocytoma? Do you have any problem with your thyroid gland? Exam: GA, vital signs. BP sitting/standing, regularity of pulse, BMI, distribution of fat, buffalo hump, striate, hirsutism, all LNs in the body, thyroid, chest, heart, abdomen, any mass?, lower limb edema. Urine dipstick for sugar. Ix; 24 hour urine collection for creatinine, total adrenaline, noradrenaline, VMA and metanephrine, plasma metanephrine, serum parathyroid hormone to rule out hyperparathyroidism as a part of MEN, serum calcitonin level, chromosomal screening for mutations, consultation of ophthalmologist for retinal angioma, MRI to exclude cerebellar hemangioblastoma (Von Hippel Lindau). Plasma ACTH and dexametasone suppression test (Cushing). Serum rennin and ALD (Cons disease).

If CT and MRI dont show paeochromocytoma, MIBG (metaiodobenzoilguanidine) test for confirmation. Metanephrine is not affected by stress, motion or anxiety. Plasma catecolamines or metanephrine must be measured both standing and sitting. In normal patient, there wont be a change. If there is phaechromocytoma, CAs will increase but metanephrine will not change. Surgery is the treatment of choice. Preoperative cautions are mandatory to prevent hypertensive crisis during operation.

Start alpha blocker (phenoxibenzamynie) 7-10 days before operation. After alpha blockage, start beta adrenergic selective blockage. Volume expansion with N/S. Give last alpha blocker in the morning before operation.
AMC feed back: Adrenal tumour 7 A lady comes to A & D Department asking pethidine for pain relief of his abdomen pain. You are surgical registrar and you found no any surgical conditions. O/E, nothing was wrong. Task: Talk to the pt and give the immediate Mx On Hx, pt said she is on pethidine for 5 yrs on/off. Only pethidine help her relieve the pain. You try panadal, but pt said it didnt help him During this station: pt kept asking: What can you do now? What can you give to me?

Stem: ED setting. Young male, SOB for 2 days. Task: Hx, ask for Ix result, and Mx Patient was lying on bed, pretending to be SOB. I offered him oxygen first, and asked examinor whether vitals are ok. Hx: - SOB for 2 days, gradually onset - R lower chest pain when taking deep breathing - Cough & yellowish sputum for last couple of days - No history of injury - No palpitation - No calf pain - No smoking - Previous healthy O/E: - Vitals normal - Trachea in middle - R lung base crackles, bronchial breathing sound, also dullness on percussion I asked for CXR, and examinor gave me CXR straightway after I mentioned it. It shows R lower lobe consolidation. Not sure about middle lobe. Mx: Abs. Role player asked which Abs. I said if you dont have allergy, penicillin. He said he is allergic to penicillin, then which Abs. I said erythromycin, but now I think its wrong should be cefataxime. Qs from role player: Do I need to stay in hospital?

How long do I need to take Abs?