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1. You are a surgical intern in the ward. A middle age woman was admitted and had her cholecystectomy. She has the complication of pulmonary embolism. Patient is now stable and all her treatments have been arranged. Her husband is now coming to see you. Tasks: Talk to her husband and answer his questions. The role-player appeared stress and loss of his concentration from time to time. Questions from the role-player: Why does this happen? What’s the complications? When will she go home? Is there any thing I need to pay attention after she come home from the hospital?
Before I started, asked clarifying question with examiner, “I assume the patient agrees to disclose her confidential information to her husband…” “Yes, you can talk to him.” The role-player appeared stressful and kept asking questions like why this happened and what’s the complication, ect. Later, he demonstrated not taking message for several time, like avoid eye contact and looked away. So, I had to check his feedback by saying “are you alright, sir?” and told him “I understand this is worrying you but the good news now is every thing is under controlled.” “If you don’t understand, please let me know and I will repeat”. I didn’t explore his family circumstance in details. The Patient didn’t have the stocking shocks, was obese and on OCP, no history of diabetes. I didn’t remember whether she was on other medications. So I explained to husband about her treatments: Staying in ward in the next couple of days; already in Heparin infusion and using another blood thinning pill called Warfarin. The role-player asking all the old questions, like“When will she go home?” “After next two or three days when her pain is settled and the Warfarin kicks in, her drip will be stopped and she can go home.” “Is there any thing I need to pay attention after she come home from the hospital?” I mentioned to him about the narrow therapeutic window of Warfarin, about blood test with her GP follow up, her diet and medications when she is taking Warfarin. Also, I mentioned about safety issue like ensure that she is not knocking at hard things, as it will easily cause bruise. And “if she has any bleeding like bleeding in her gums and heavy period, she needs to see her GP or come to the emergency immediately”. Gave the husband patient education sheet and mentioned to him that his wife was having one, as the nursing educator in the ward was seeing her at moment. There is no question from the examiner, Dr Gya.
2. GP Clinic. A 43 (?) yo lady presenting with heavy bleeding for 6 months. She had her D & C done at the beginning, which an endometrial biopsy and blood tests were all done and normal. Her also had her PAP smear done last year, which was normal. She is not on the pill. You have ordered some blood tests and the results – Hb 7.0, LFT, U&E, TFT were all normal. (I couldn’t remember if there was any iron studies.) Task: Talk to the patient about her condition manage the case. Comments and Questions from the role-player: I don’t want to have blood transfusion, Doctor. What are you going to do, if all these medical treatments do not work?
” “I don’t want any blood transfusion. “The diagnosis is dysfunctional uterine bleeding”. PE unremarkable. it’s very much unlikely. 3. except Anaemia. “Do I need to remove my womb?” “No”. Felt tired but no loss of appetite.” The cat was quiet. He had been on NSAID for a long time for his back pain (I forget its name).Do I need to remove my womb? Her Periods lasted for eight days and heavy with clots. no tiredness. antifibrolytic agent. No PHx. I started with greeting to the patient and passed his specialist’s message (apology) to him. I am calling the ambulance. if all these treatments are not working?” I told her about another D&C and recheck uterine USS and hysteroscopy. Had two children. explained to her in lay words. “But this ablation will be done only if you have finished your family. I also advised the patient about healthy life style. it is very unlikely to have a cancer. He had a gastroscopy yesterday. and offered the patients a triple treatment. Talked to her about hormone treatment..…” “Can I not go?” “because your haemoglobin is low. GP setting. However. He asked you to talk to the patient and manage his condition. Pyloris positive. I forget to pay some attention to few unclear but yet readable letters in the image. “Could it be an cancer?” “No. A 35 year old builder presents with abdominal pain for two years. Patient had alcohol and smoking history and was a hard working builder. but it’s for preventing the clot from dissolving. she demonstrated that she felt relieved.. and “D&C may not work in your case (recurrent). Do you have any chest pain.” “I do. He telephone you later and sent the image to you. to be 100% sure. “I just don’t want to remove my womb”. no post coital bleeding between periods. She had no pain at all. stop alcohol in this stage. so. I explained to the patient about the diagnosis as a peptic ulcer. Your condition is a benign one. I will check the Mims to find out its name. My younger son is 12 years old.” I replied after asked his symptoms – no weight loss. Tasks: Explain the diagnosis to the patient and manage the case. You are in a good safe side. doctor. “This is an emergency situation. I will organise some blood tests and imaging tests like ultrasound to check you liver and other abdominal organs. A large grey-yellowish patchy area with the rest of the image not very clear.” So in this case I didn’t go more assertively to advise her about blood transfusion.. I forget if there was any FHx. reduce stress. Not on any medications. “I couldn’t remember the name of this medication at this moment. to be honest. .” “All right. mood was ok. Not on the pills as husband using condom. No itchiness in genital area.” “What are you going to do. no loss of appetite. I mentioned about endometrial ablation. but explained to her about iron study and supplement. short of breath or dizzy spells?” “No. stop smoking. no any other pain apart from the back pain which had been there for a long time. “Your specialist had took some tissue from your stomach and we are still awaiting for the pathology report. Questions from the role-player: Could it be a cancer? Do I need another gastroscopy? Very poor image which was like one downloaded from the internet with very low resolution. I am going to admit you to the hospital right now. “to help your body produce more blood”. The specialist was called away due to an emergency. you need to have blood transfusion. which shows a large ulcer and H.
it’s finished now. See you LATER. So. However.” Just about ten seconds before the bell rang. Tasks: Instruct the patient to do spirometry and analyse the result. and the light in the switch was on. I kept my smile and English-style eye contact with him to demonstrate my confidence. But because your ulcer is a bit bigger than usual. My response might be just over-sensitive. but I assume it likes a ECG machines. which you keep my confidence to facilitate my performance in next station. Relationship. suicidal ideation and psychotic features . Suicidal. schizophrenia. you can ask me questions to find out my limitation and decide whether I failed. judgement. This was my first time to see a spirometry machine indeed.I mention about the breathing test four weeks after the anti finished. The role-player interrupted me. in this case. Tasks: Take a history and manage the case.other anxiety disorders such as PTSD. Employment and/or Education. Questions from the examiner: What is your Ddx? What’s else? What’s else? I used the HEARDS as my framework to take his history. PTSD. “Do I need another gastroscopy?” “Generally speaking. no need. I asked him questions about his insign.. depression. its operation would be very similar". organic disorder. “doctor. as this was a psy case. I will check his pancrease…” I tried to fill the gap.” The machine was placed on the table. I explained to the patient that I need you to take a deep breath. and think about what I didn’t covered. I started thinking why he behaved like that. As an health professional graduated in Australasia and having working in Australasia for a long time. 5 You are seeing a young man who comes to you for a insurance check up. . The use your mouth to hold this mouth piece (the tub). The AMC feedback stated that I passed this station. 4 Typical “king” case. Like other candidate did. "Make sure it's sealed properly without leaking any air out from both sides then brow the air into the tub as fast and as hard as possible. He has a history of asthma. it might be better to just go back to the basic and give him a list of DDs." .. Drug and alcohol. or just a cross-cultural reaction. Basically nothing was particular. no drug and alcohol issues. he had to walk around for three times. except . His school performance was worsened due to the fact that every time when he read or mentions the word "king". I will check with your specialist. There is a tub like one used in a humidifier. “no worries.the examiner kept asking about differential diagnosis. the Indian examiner suddenly interrupted me. (Home. You can simply fail me by not telling me. Non-smoker. or alternatively. but luckily. drug and alcohol issues/ induced psychosis (which we need to have blood tests to confirm it although history did not support that).” The bell rang. which details was exactly the same as what presented in the previous recalls. It's all set up.. he acted in neither way. I think. except the roleplayer didn’t get up and walk around for three times. I plugged the mouth piece into the ventilation tub. this sort of thinking kept fleshing back. infection. like drug and alcohol induced psychosis. A mouth piece the same as what we use in the peak flow meter was separately placed on the table. A young Uni student comes to see you. and do his “ritual things”. schizophrenic form disorder. depression. I knew most of the stamps well. before I started. I felt his way wasn’t a supportive way. I answered in a way of differentiating each possible diagnosis and it took quite a while . “Anyway. psychotic conditions like acute psychosis. this is an duodenum ulcer!” “Ok. On the other hand. Appetite. In the next few stations. “Thank you”. which was distinct from what our lecturer in the weekly class normally do. I mention to the examiner that I did not use "this specific type of spirometry machine. I used my two hands to shake his hand to thank him for his assessment. Smoking and Sex).non of them was identified. brain tumour.
The result was about 0. sweeting. She didn’t see any doctor but took Panadol only by self. "we need to do it for another two times. No question from the examiner. On examination. shaking and palpitation over the last two to three weeks. if you like. A middle age business man.” “Please wait for a while. paused. "no need. When it he finished. keep going. who works in an insurance company. 6. she would probably have an ERCP which would attempt to use an basket to remove the stone. The role-player first time did not follow instruction to blow as fast as possible. LFT. You do not have an asthma attack at moment. A typical cholangitis case which has been in the previous recalls. She had a cholecystectomy some years ago. “That’s why she needed to be admitted quickly”. but the role-player told me. presenting in you GP practice. but it’s interesting that the AMC diagnosis did not touch the correct diagnosis. Asked about all histories. the paper rolled back to its starting point again and pin returned to its initial position pointing to zero second.” The recording uses a specific paper for spirometry. feeling hot. “Because it’s normal. keep going." While he started blowing air into the machine. palpitation as well as the pain in right upper quadrume. shaking and palpitation. he blowed. lipase. Congratulation for having a good lung function. and clotting profile. I will analyse the result for you. GP setting.6 L and TVC was 4. advised to keep her Nil by Mouth.6 L. Once he started blowing into the tub. and then I will analyse the best one. doctor. complaining with diarrhoea for the last 6 months. Manage the case.” “Can I have my insurance?” “It’s up to your insurance company ti interpret. the trend line rose slowly. Start with asking her pain questions . “it’s all done.10/10 severe pain. also I turned over and talked to examiner.” No question from the examiner. U+E.6 or >0. I asked the role-player to do as described above. what was indicated if the result was < 0. She was sweeting. it would be Flagyl and another board spectrum antibiotic as per therapeutic guideline. because if we don’t keep it under control soon. But your lung function is good. You are seeing a 60 years old lady who presenting with abdominal pain. but other candidate did. paused for several time. the recording paper with a pin on top of it automatically started running. USS and CT scan. I also explained to him. he had the last asthma attack at 11 year old. like FBE. so I offered her pain killer first after asking allergy history. "keep going. the consequences could be nasty” (possible complications). Drew a picture and talked to her if there was a stone found in the lower part of her common bile duct. Tasks: History taking. 7. Talked to her that she will be given strong and combined antis. blood culture if temp high. I mentioned to him. sweeting. Tasks: Take a history. then “I am going to ring the ambulance and send you to the hospital. “I will send a copy of your report to your insurance company. and liver was 2 am palpatable.8. blowed. Talked to her what going to happen in the hospital: blood tests. it would get sepsis and abscess.9. So. Ask examiner about the examination findings.” “I don’t have asthma. instead. and let the bile to drain into the duodenum. then tired the paper off and gave it to me. I advised her this is cholangitis (in lay words). “it is normal”." He did it the one more time only.” Further history. So I did not need anything else to analyse it. I asked him to relax and take a rest. not diabetic. so I didn’t repeat after offer him Ventolin.I attend to touch the switch of the machine. The FEV1 was 3. . her right upper abdomen was quite tender. That patient had a periodic abdominal pain over the last two to three weeks. it's all set up already".
Funny setting. I explained to him in lay words. which presented in recalls several times already. 6 to 7 times a day. when discussed with him about the management later I forgot to highlight its importance. 8. Patient had been diarrhoea for the last six months. Not sure what rationale for such setting . so blood tests to exclude chronic pancreatitis. Tasks: Discuss with mother about diagnosis and manage the case. No recent overseas travel. “The diagnosis is exclusive diagnosis”. “we will discuss it later” but indeed.Discuss with the patient about the diagnosis. avoid smoking and stop alcohol. I forgot to ask him about his medication. but drinks alcohol and he knows the safety limits. Comments from the role-player: I am actually using Imodium. I forget to ask him about recreational drug and sexual history to exclude conditions like HIV infection. He does not smoke. No constipations. if it is still not under control. You also noticed the child has bruise in her cheeks. Doctor. Told him about healthy life style. always watery stool. I could give you some medication like Imodium. colonoscopy to exclude other disease like diverticulosis and Chron‘s disease. “You have a condition called irritable bowel syndrome”. No Family history and cancer history.” Bell rang. It was an unexpected pregnancy. no mucus. stool culture for pathogens. Questions from the Mother: Can you treat her then let me take her home? Can I go with my child to the hospital? Are you going to take my child away from me? A typical child abuse case. No existing medical/surgical problems. You do not have to take the history. no blood. Stress level in his job and family life all “fine”. I mentioned to him he might need to stop it. Emily is look after by her mother and her boyfriend. A six months old baby Emily was brought in by mum who stated that the child had a fall from the cot which an x-ray was taken and shows a green stick fracture in upper one third of the humerus. please refer to other candidate’s recall for more information.” “I have already on it and it doesn‘t work. “After these. Mum is a part-time worker. Discussed with him about the management.Was because the examiner had impaired hearing or some thing else. hypothyroidism. I didn’t mention and also not sure if it might be better to put Coeliac disease listed as a Ddx due to the current change to public awareness recently. key issues as listed in Murtagh’s book: Told the patient to keep note to find out if there is any factor like specific food would trigger his diarrhoea. teenager mother. . I didn’t pass this station. Manage the case. examiner dominate the table and left the candidate and role-player to sit beside him. Mother trust her partner. She is born from her single.
7. So what happen is. Her father is not mum’s current boy friend. 5. which she pretended not understood. which she did not react much neither.” The role player kept telling me she loved her child and asking “are you going to take my child away from me?” I replied to her “I am not the right person to decide. They will ask you questions as well. “Can I go with my child to the hospital?” “Yes. but I did feel there might be some issues I did not explore well yet. her affect could be quite flat. She did not drink or smoke but her partner does. I am concerning about your child’s safety. you could. Mum stated she was able to cope well and she loved the baby. He was unemployed. The role player was a Chinese/Asian lady who demonstrated less western teenager’s cultural identity. AMC Definition of Stations: 1.” I mentioned about the Department of Human Services and Gate House Centre.” Talked to her about social worker visits. I directly told her I suspect child abuse. Her affect remained flat. that you child will be assessed by the paediatricians and social workers who are specialised in this area. I understand this is also difficult for you. “I am going to ask some more history and just to role out the family situation. 8. In psychiatric perspective. I will ring them and ask her to come with the ambulance and go to the hospital with you. 3. 2. the social worker will to give you information and assistance you need. Pulmonary Embolism Menorrhagia . Emily was born in 26 weeks of gestation.” The examiner said “go ahead”. But this has to be arranged and approved by the hospital social worker. Please check with other candidate’s recall. then talked to the examiner the I would notify the Department of Human Services. Can you treat my child then I take her home?” “No. 6. so I did. Mum was very trust him. I started with telling her “this is an non-sustained injury”.I talked to examiner first. I an not sure was it the stamp required for the role player.DUB Duodenum Ulcer Obsessive-Compulsive Disorder Lung Function by Spirometry Jaundice Diarrhoea (Chronic) Child Physical Abuse . I talked to her I am going to ring an ambulance to admit your child to the hospital. They will discuss with you in the hospital after her assessment. and was in hospital for 3 months and discharged to her mother 3 months ago. “It just a simple fracture. You can also have a legal representative. No question from the examiner. It is my duty of care to the Royal Children Hospital. Then. 4.
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