Adelaide 5th of April 2008 Obstetrics and Gynaecology Case 1 25y.o. Rh-ve woman Gravida 1 Para 1, 30 wks.

of gestation came to ED complaining of vaginal bleeding and a little pain in her lower abdomen. Routine antenatal tests were normal, US at 18 wks. was normal. Task: Focused history, physical examination, management. The patient was hemodynamically stable. She developed bleeding in the morning and used 2 pads until was seen by me. The color of the blood was not bright. At the time of examination these bleeding nearly stopped and woman did not have any pain. She did not have any other complains and felt her baby kicking. Lady did not have any trauma, did not have intercourse, did not overstrain herself physically. On PE: the patient was not in distress, VS"s were normal, abdomen was not tender, fundal height was 30 cm, cephalic presentation, FHR was 140, PV- cervix was closed, spotting,uterus was not tender. Provisional diagnosis: Mild placenta abruption ( <1/6 th of the placenta has separated; blood loss is usually < 250ml= light menstrual loss to heavy menses, no clots). Management: Admission. Bed rest for the period of bleeding and for 2-3 days thereafter. US and CTG - for baby monitoring, confirmation of diagnosis. If the condition settles completely and tests of fetal well-being are satisfactory, the woman can be discharged home and will be followed carefully until delivery. Because she is Rh-ve- Anti-D gamma globulin should be administered. AMC feedback: Placental abruption ( mild ). My status: Passed.

25%). The cause of miscarriage was unknown. Stop smoking. AMC feedback: Recurrent miscarriage. Management: Monitoring in high risk clinic ( needs referral). lady has past medical history of 2 miscarriages at 8 and 10 wks of gestation. . 6 Genetic consultation to exclude chromosomal abnormalities 7 Test for human leucocyte antigen ( HLA ). Task: Explain results of investigations and further management.Case 2 28 y. She came to your GP setting last week and you ordered some investigations. Information about investigations will be provided on request. Do not overstrain yourself physically. 10 BSL to exclude poorly controlled DM. All tests were normal. 9 Anticardiolipin antibody test. Acupuncture. uterine septa). Do not travel. cervical incompetence. Diagnosis: Recurrent miscarrier (1 trimester). 11 Rubella status. 8 Lupus Anticoagulation test. 5 Hormonal profile to exclude PCOS. Every miscarriage increases the risk of further miscarriage by 5%(20%.o. 4 TFT to exclude poorly controlled thyroid diseases. Avoid sex intercourse until 12 wks of gestation. Investigations: 1 PV examination to exclude uterine myomata and cervical incompetence 2 US examination to exclude uterine malformations ( submucosal myomata. 3 STD and TORCH infections screening.

Girl was fine last night but when she woke up this morning she complained about pains in her R. 2 weeks ago she had a flu like infection with cough.p 637 AMC handbook of clinical assessment. Paediatrics Case 1 You work in ED. Normal pregnancy. no operations. Investigations: 1 FBC . no trauma. My status: Passed. Inspection of her R. Your next patient is a 3 y. hip mainly on rotation and abduction. blood culture 2 US of the hip 3 X-ray of the hip X-ray was normal. investigations.o. lower limb. active. Task: Focused history. Girl had marked limp and did not want to walk. physical examination. immunisations up to date.( on request) Diagnosis: Transient synovitis/ Irritable hip. Her physical examination was unremarkable except for her R. but there was marked painful limitation of active and passive movement in her R. who has been brought in by her dad. because she complained about a painful right leg. Girl has always been well. AMC feedback: Contraception request. lower limb was normal. Management: Admission. Condition 122. not in obvious pains. On PE: The patient appeared well. Case 3 A parent requesting sterilisation of her intellectually disabled daughter. No childhood diseases.My status: Passed. normal development. US showed synovial effusion. VS"s normal. sore throat and fever but got over very quickly without any medications. girl. . hip and difficulties to walk. management. normal delivery. not flushed.

It may affect the bladder and sometimes the kidneys. . For 1 week! Check antibiotic sensitivity and adjust therapy in 24-48 hours. Analgesics. Patients may have a relapse if they increase their activity too quickly. Task: diagnosis. The test is done mainly to look for a condition known as urinary reflux ( VUR). US ( to exclude urinary tract obstruction). who has been brought in by her mother because she had been unwell with fevers for the past 48 hours. but has had no diarrhoea. Antibiotics: If oral medication is appropriate Trimethoprim 4 mg/kg BD or Cephalexin 15mg/kg TDS 2 If severe vomiting. Mobilisation. prolonged antibiotico-therapy. Explanation: Your child most probably developed condition which is called UTI.US and MCU. This can happen to any baby and is not due to poor washing or changing. AMC feedback: Transient Synovitis of Hip. Dipstick of urine ( urine bag specimen) showed protein. Draw a picture and explain VUR. Your next patient is 12 mths old girl. If recurrent UTI. She had vomited twice.5 mg/kg IV daily and Penicillin 50 mg/kg IV 6 hourly. nitrites. leucocytes. Consultation of pediatrician. Micturating Cysto-Urethrogram( MCU) explanation: This test involves putting catheter into the bladder through the urethra.Irritable Hip. particularly in young children who are still in nappies.Gentamicin 7. Case 2 You work in GP setting. Dye is injected through the catheter and X-ray pictures are taken. Management: Hospitalization.Observation. management. the quicker the recovery ( usually settles within a few days). The more the child can rest. Microscopy and culture of urine specimen( supra-pubic aspiration or catheterisation). It is usually caused by germs from the poo. get into the urethra ( the tube from which urine passes out of the bladder). My status: Passed. which are on the skin. Bed rest. UTI is quite common. A UTI is an infection in the urine.

Case 3 30 y. can detect 100%. can detect 85-90%. 35y. woman can know the conclusive result whether the baby has Down Sd or not. fetal loss 0. 4 CVS bw 9-12 wks ( if risk>1/200-250). 40y.o. Risk increases with maternal age.-1:100. Risk of Down Sd. Psychiatry. Task: Counsel the patient. By this procedure.o. Girl was not able to speak any more after she heard her mother screaming in pain a while ago.. Counseling: Incidence of Down Sd..18 wks.-1:200. 37y. 17 y. 2 Maternal serum test for B-hCG and PAPP-A bw 10-13 wks. Task: Focused history.5-1%. 3 Maternal serum ( quadruple ) test: AFP+B hCG+oestriol+inhibin A bw 14. 30y. woman who has 2 y.o.1:350. My status: Passed. Performance of CVS and Amniocentesis: Obstetrician will put a needle through your abdomen and womb under US to get sells of the baby from chorion or from the fluid around him/her and then analyse. in normal population is 1:600-700. diagnosis. is 1:100. can detect 100%. AMC feedback: Down Sd. . girl and her family are suffering at the bedside of their mother who is in the terminal phase of liver disease.o. 5 Amniocentesis bw 15-18wks. management.o. Screening tests: 1 US for measurement of nuchal translucency bw 11-13 wks. son with Down Sd. Risk of 2-d child with Down Sd.1.o.-1:250. came to your GP setting inquiring about further pregnancy. My status: Passed. physical examination.o.4 per 1000 live births.AMC feedback: UTI. Case 1 You work in hospital.

Explanation: There is strong link bw our brain and our body.Can you cough? A-"Yes"." Yes" Q.History: Q. This condition will disappear by itself with time. Throat on examination with pocket torch and with spatula. My status: Passed. Case 2 You work in ED.normal.Do you have any other complains? A-"No" Q.Can you answer my Q-s by indicating with your head "yes" and "no"? A. she did.Do you feel any discomfort or any lump in your throat? A-"No" Q. management. VS"s. your body reacts to this by making you unable to speak. Referral to psychologist for CBT.Have you had any infections recently? A-"no" Q. Referral for counseling. .normal (instruments were provided). Because you worry about your mum very much. He took 2 tab yesterday morning. physical examination. 30 y. drowsy and to have headache. Inspection of neck and LN. recreational drugs? A-"No" On PE: GA. alcohol. Diagnosis: Conversion disorder. After this he started to feel dizzy . man who was previously diagnosed with schizophrenia had a relapse 2 days ago .Any problems with your health? Are you on any medications ? Any operations before? A-"No" Q. AMC feedback: Psychogenic dysphonia. Task: Focused history. Q.normal. Management: Consultation of Psychiatrist in hospital.Smoking. His GP prescribed Resperidone .normal.Did it happen to you before? A-"No" Q. 2 tab yesterday evening and 2 tab today in the morning.o.

Medicine and Surgery. AMC feedback: Side effects of anti-psychotic medication. depending on the seizures. Case 1 25 y. Management: Hospitalisation. The patient was sent to you by specialist who already prescribed Carbamazepin. O2. He had several febrile convulsions in his childhood and 1 epileptic seizure 2 wks ago. 2 It is not possible to drive (seek help in Centrelink to change work ). works as a seller.The patient has had no nausea.ABG. regularly. anxiety. Explanation: Epilepsy is the recurrent tendency to spontaneous. gastric discomfort. BP(lying)= 120/85. Monitoring. blurred vision. driver came to your GP setting for some advice regarding his epilepsy. no alcohol. then other people. disordered electrical discharge in your brain manifestating as a seizures in your body. Chek blood drug level. No smoking. has 2 children. BP(sitting)= 100/70 (postural hypotension).OK. His health generally. agitation. Otherwise PE was unremarkable. EEG confirmed diagnosis. He does not remember what medication he took before for his condition. BSL. from examiner: What psychiatrist will do? A. RR=18.o. advice accordingly. because of your past medical history of febrile convulsions. no recreational drugs. Patient education: 1 Take Carbamazepin tab. Consultation of psychiatrist. Stop taking Resperidone. You are more prone to develop this condition. On PE: GA. Married. But he had difficulties with sleep lust night. Restrictions range for driving from 1 mths to 2 yrs.looked confused P=110. Psychiatrist may decrease dose of Resperidone or may change this medication for Olanzapine or Clozapine. vomiting. Q. My status: Passed. . Task: Explain condition. Draw a picture from " Patient education".

lack of sleep.Once complete control has been established for several years. Her health generally is OK. 7 Wear a special bracelet to worn about your condition. The patient smokes 15 cigarettes per day and consume alcohol very rare. 6 Regular checkups. She was not overweight and did not have family history of hypertension. Urine tests: Urinalysis for protein and glucose. because it can interact with medicine or to cut down (patient drinks 1-2 stub of beer 3-4 days per week).o. Task: Focused history. the medication can be gradually withdrawn and stopped. management. Life stile modifications ( exercising. does not use recreational drugs. 5 It is better to stop consumption of alcohol. . Q. 4 Avoid physical exhaustion. has normal diet. Her high BP was found during regular checkup. Quit smoking ( give her "QUIT KIT" and organise next appointment to discuss this problem).to watch for any side effects of the medicine and to have blood test to check the level of drug in the blood. Her job is not stressful. stress. She did not have any side effect of OCP before. does not exercise. Woman is on OCP " Microginon-30" for 3 yrs.3 Avoid swimming alone. from the patient: Should I take this medicine for whole my life? A. 140/90. Management: Stop OCP and use condom until ready to be pregnant.idiopathic. Case 2 26 y. She is in stable relationships with her partner and planning to become pregnant next 6 mths. She does not have any complains. AMC feedback: Epilepsy . reducing salt in diet ). My status: Passed. microscopy. Woman is not on any medications. The patient started to have BP-problems 6 mths ago. She had high BP checked in 3 occasions ( 135/85.. 145/90 ). woman came to your GP setting.

CRP. man with chronic diarrhoea for more than 6 mths. glucose. management. Consider referral to physician. Followup in 1 week and 3 mths time. 2 weeks ago the patients condition got worse -he noticed some fresh blood on his stool and on the paper. Management: Stool microscopy and culture. He did not travel overseas. ECG.o. There is no abdominal pain or pain on defaecation. no vomiting. Total serum Ig A. Now he needs to go to toilet 3-4 times per day ( before. sometimes he wakes up at night time because of urge. Case 3 You work in GP clinic. The patient does not smoke. Biochemical tests: potassium. cholesterol ( total. Feacal fat. Task: Focused history.urine culture. HDL. uric acid. no fat. does not have any stress at his work place and home. PE is unremarkable except PR. He is not on any medication. his family history is unremarkable.fresh blood on the gloved finger. AMC feedback: Hypertension. LDL). Upper GIT endoscopy.normal. FBE. My status: Passed. TFT. BMI= 20. Sigmocolonoscopy. . physical examination. VS"s. drinks 2-3 stub of beer per week. did not change his diet. no jaundice. ESR. creatinine. Your next patient is 25 y. no problems with eyes. Renal US. There is no joints pain.only 2 times per day). On PE: The patient looks pale. urea. no nausea. no mucus. Man lost 5-6 kg over 6 mths. sodium.

Task: Physical examination. Differential diagnosis: Inflammatory bowel diseases. diagnosis. chronic pancreatitis/ cystic fibrosis.normal. calf on walking . cancer. no tenderness. BP=140/ 85. hypothyroidism.profile. but there is absence of hairs. 68 y. drinks 2-3 stub of beer per day. Meckel's diverticulum.Ig A antigliadin antibodies. no visible veins.o. man came to your GP clinic. start exercising. Stop smoking. haemorrhoids. diverticular disease. posterior tibial. My status: Passed. no sensory changes.normal. physician. no color changes of calfs and feet. PE: GA. Provisional diagosis: Chronic lower limb ischemia . His BMI. lipid. Case 4. fissure in ano. polyps. After that I examined lower limbs for peripheral vascular disease: 1 Claudication on walking. has 2-3 days free of alcohol. Endomysial antibodies. Tissue transglutaminase antibodies. dietician. complaining of pain in his R. all pulses are present( femoral. irritable bowel Sd. management. 3 On palpation: temperature.normal. Check BSL. AMC feedback: Diarrhoea ( recurrent ). no swellings. relived by rest. popliteal. dorsalis pedis ).4 Performance of Buerger"s test. no muscle wasting.25. He smokes 15-20 cigarettes per day. Management: Control of high BP. It is getting worse now. capillary refill=5''. no ulcers. It was real patient. 2 On inspection: no atrophic changes of skin. no deformities. 5 ABI=0. VS"s: P=90. Consider referral to surgeon. reflexes are normal (information provided by examiner ) . . The patient is on diuretics for his hypertension.coeliac disease. FBE ( exclude polycythemia and thrombocytosis ).positive ( examiner words ).

P= 94. embolisation. but after had regrets about this ). DM changes. Case 5 You work in GP clinic. cough is getting worse. DO NOT FORGET TO WASH YOUR HANDS AFTER PATIENT!!! AMC feedback: Leg cramps on exercise.: Atherosclerosis. VS"s: T=37. she used to be a severe smoker 2-3 y. but about 1 week ago developed SOB . from examiner: What surgeon will do? A. Angiography. from examiner: What could be the causes of patient condition? A. Acute lower limb ischaemia. else ). but on the Lat. (Examiner wanted to hear smth. lower lobe. Short history: Woman now is in pain= 7-8 ( from 0 to 10 ). pleural friction rub. varicose veins. My status: Passed. You saw her yesterday and ordered CXR. Aspirin 150 mg per day ( examiner said that I can"t prescribe it now).o. You can ask some relevant Q-s. side of the chest. view I saw consolidation as well ( I was not sure about consolidation.: Bypass graft or enderterectomy. Your next patient is 38 y. Lung percussion and auscultation: dullness. BP = 135/85. generally her health is OK. I explained to patient that she had a collection of fluid in the pleural space and draw a picture for her. Q. from examiner: What is the differential diagnosis of calf pain? A. woman with chest pain and coughing who had cholecystectomy 5-6 weeks ago. she feels high temperature . On PE: pale. cough. reduced breath sounds and vocal resonance over R. so I did not tell about it. after operation she was all right. RR-25-26. O2 . SOB.Dopler US. trauma. Q. management. Panadol does not work. Management: Hospitalisation. muscle pain due to diuretics. Q. ago. Referral to vascular surgeon. weakness. Task: Explain results of CXR (CXR will be provided by examiner ). in distress.7. On AP view of CXR I could see small amount of fluid on the R. : DVT.

from patient: Could it be a Ca of lungs? A.: Yes. old women complaining of bloating and abdominal pain. cholangitis and added infection. I asked if she was on any medication. CT scan ( to exclude Ca ). Ventilation/ perfusion lung scan ( to exclude PE ). I draw a picture of gall bladder with stones in common bile duct and explained such possible complications like billiary colic obstruction. From description of US I explained to the patient that she had mild inflammation of gall bladder caused by gall stones. from examiner: What is you differential diagnosis? A.: Pleural effusion on the R. Antibioticotherapy.: PE. side. IV fluid Q. management. ECG. ABG. You saw her yesterday and ordered ultrasound of abdomen (US was given with stem). Pneumonia. pericarditis. AMC feedback: Pleurisy with effusion. Diagnostic aspirate of effusion . Consultation of physician. Pethidine) Arranging of operation during upcoming week (explain . She did not have nausea or vomiting and any other complaints. culture. Ca. Your next patient is 56 y.o. pneumothorax. She was taking Mylanta for bloating and Panadol for pain but it did not work. Q. Q. from examiner: What you can see on XR? A.Pain relive. Case 6 You work in GP clinic. Task: explain result of US. FBE. ( consolidation ? ). Management: Refferal to surgeon Pain relieve (Panadine. US revealed 3 stones in gall bladder. My status: Passed.

My status: Passed. AMC feedback: Incidental gall stones. AMC Feedback: end of life request. Review of cytology after aspiration of breast lesion. My status: Passed. My status: Passed. laparoscopic operation techniques and postoperative complications). Case 8 Condition 137. . p 639 AMC handbook of clinical assessment.preoperative preparation. End of life request from terminally ill patient. p 675 AMC handbook of clinical assessment. AMC Feedback: Breast lump. Case 7 Condition 124.

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