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1. SIDS (see AMC Handbook of Clinical Assessment) Scenario and Qs asked by the role player were exactly the same as the publication. AMC Feedback: Sudden Infant Death Syndrome 2. A 2 year old child with cough of 4 days and now worse at night. Recent URI in the family. Fully immunised, previously well. There is a 6-week old sibling at home apart from his parents. On PE: The child is well, alert, active, and afebrile, not in any form of distress. When you checked the throat and touched the palate, the child started coughing with an inspiratory stidor. No need to take history. Tasks: • Explain your possible Diagnosis • Advice on plan of management I started by saying that there are several possibilities. One is that it can be a viral cough, an allergic cough (because the cough is primarily nocturnal) or a para-pertussoid cough which is a cough similar to pertussis but the organisms causing it are not necessarily pertussis (i.e., Bordatella parapertussis, Mycoplasma, Chlamydia). But I could sense that the role player was not happy with my answer. So I said, at the bottom of my list is pertussis. Then the role player suddenly became interested in my diagnosis. I continued to say that immunisation does not afford a 100 percent protection that is why there is a need for booster doses later on in life. If he gets infected with pertussis despite immunisations, it would be a modified symptom and not the typical text book presentation of pertussis. I would need to get some swabs from the nasopharynx to confirm the diagnosis. If this is Pertussis these are the following things that need to be addressed. • A reportable case. • He would need to have some erythromycin which is the drug of choice (or any of the macrolides – clarithromycin, roxithromycin). At this point the examiner asked me to whom will I give the erythromycin to. First, I said to the patient, to reduce his infectivity but that this would not necessarily alter the clinical course. Secondly, all household contacts need to have prophylaxis treatment. I am particularly concerned with the 6-week old baby since he would not have any protection because of the lack of transfer of maternal antibodies. Thus this 6-week old should receive prophylaxis Rx and should be immunised with DTPa which can be safely given as early as 6 weeks. This immunisation however, does not give immediate protection. I would need to follow up the 6-week old closely. With the 2 year old, it should not be a big problem on him having had 3 initial doses of DTPa and therefore his clinical course will be modified and not as severe as when he is not immunised. Q (question) from the role player. Where could he have gotten this? I said from someone who harbours the organism in the nasopharynx. I wasn’t able to clarify that the parents can have waning immunity and could have harboured this in their throats/nasopharynx. Also, I forgot to ask if the child is in childcare. If he
water leaks etc. Tasks: • Take further relevant history from the patient • Ask examination findings from the examiner • Tell the patient about your management plan.N. Lives 80km from the hospital. I asked her blood group and she said she does not know. the child carers’ nasopharynx should be checked if they carry the organism (potential source of infection) and should be treated and excluded from child care as well. I then asked any issues during this pregnancy. Gen appearance. After making sure that there is no placenta praevia.cord prolapse happens.. A multigravid is now in your clinic and is 38 weeks pregnant.2kg if I remember right). You find out that she has a transverse lie. placenta praevia can prevent a baby from positioning itself normally thus I would like to rule this out by doing an ultrasound (and a CTG to check on baby). Dipstick urine. general health . PROM +/.can’t recall. these are the options: • Admission to hospital. • Lastly. ready for any potential complications i. She said she had 3 babies. I said it is unlikely that you have an Rh-ve blood group but we can check that later.ok. • Second. I asked about their birth weights (3. Then I asked about her previous pregnancies. and presentation. Because we are quite far from the hospital and also because she is already at term (38 weeks).5kg to 4. I explained that she has a transverse lie and there are several reasons for this. The patient should also be exempted from childcare temporarily until at least 5 days of erythromycin/clarithromycin Rx. There is the potential for the baby to return to its original transverse lie position again. • The first one is a small pelvis and this causes cephalopelvic disproportion CPD – this is unlikely in her case as she has had 3 previous pregnancies with relatively large babies who were all vaginally delivered thus her pelvic passages have been tested for adequacy. VS then went straight to the obstetric examination. we can also gauge the amount of amniotic fluid because too much amniotic fluid can also cause the baby to move around easily. baby kicking. FHT. 18 week scan – any abnormalities. contractions. we can attempt to gently externally rotate the baby with a double setup – meaning. . immediate delivery just in case a cord entanglement. Labour pains. I first asked current pregnancy issues. AMC Feedback: Pertussis 3. the most probable cause of her transverse lie is the previous 3 pregnancies she had with relatively large babies causing her uterus and abdominal wall muscles to be stretched more than usual thus allowing more room for the baby to move around easily. with an ultrasound.e. fundic height. I asked her if she had injections (anti-D) . bleeding. I examined the patient. • Third. having ruled out pl. placenta praevia etc – role player said baby was normal and that she does not know any information on the placenta. Then I asked pre-eclampsia Qs (questions). praevia and polyhydramnios from the ultrasound. manner of delivery and any previous issues like diabetes.is.
The examiner was very happy and said that was an excellent discussion. I asked about issues during pregnancy. • I will arrange that she be transferred immediately and if possible by air ambulance while stabilising her. I talked on the following issues: • That she is in active labour and since the baby is just 26 weeks old she needs to be admitted in a hospital which is capable of handling a baby of this age. o Bed rest when in hospital. although CTG ‘s interpretation may not by accurate since baby is still premature o A fibronectin test may be done but I did not emphasize much on this. I asked about trauma and possible reasons for the premature labour. Speculum showed the cervix to be 3cm dilated. Then I asked her if she had leaking bag of water or vaginal bleeding. o She needs to have an ultrasound to rule out abruptio and chorioamnionitis (both contraindications for tocolytics) and CTG. I started by asking the character and severity of the pain. intact bag of water.whether there were any abnormalities and whether the placenta was low or not. it was spontaneous. She asked me if I had any obstetrics training. o We hope we can delay (until at least the second dose of steroids) or stop progression of labour by giving her tocolytics. I finished this station early. I was already thinking of at least 2 differentials: abruptio placenta or premature labour. 18 week ultrasound . She has abdominal pain for 3 hours. blood group. ideally in a neonatal intensive care unit. longitudinal lie. AMC Feedback: Premature labour . AMC Feedback: Transverse Lie 4. She said as far as she knows they were normal. Examiner asked me what tocolytic do I intend to give. o While awaiting transfer. Abdomen showed compatible FH with age of gestation. I continued to ask about regularity (every 5 minutes) and duration (around 2 minutes) and figured out it was the start of labour pains. Your next patient is a 26/40prim. PE • Manage the case While reading the stem outside the room. she needs to have a drip in with a first dose of steroids to be given for the baby’s lung maturity. She said no. I said none. Task: • History. There was none.• Schedule for a caesarean section because it would not be feasible for a vaginal delivery on a transverse lie. I said calcium channel blockers. VS were normal. correct date. On PE. You are working in a country hospital which is 300 km from the nearest neonatal intensive care unit. normal FHT. She described it at intermittent contractions. I just mentioned it in passing.
Will need to follow her up for progress. As I recalled this station post exam. She said she is with a steady partner for the past couple of years or so (no sure of the duration) and has had 2 previous relationships. A young female with recurrent greenish vaginal discharge. If positive for Gardnerella or Trichomonas she would need to be treated with metronidazole. General health including diabetes. I had the following differentials in my mind: Pneumothorax.N. Paps smear 2 years ago N. PV examination was normal. Then I said that I will have to do swabs. Cervical ectropion. some blood tests. Never been pregnant. has always been normal. Before I went to management. I asked if she is sexually active. pain (none). I told him I will have to rule out Trichomonas. A 35 year old female with sudden onset of difficulty of breathing. VS especially temperature . Even then I still asked for no cervical excitation? Or adnexal tenderness? The examiner answered with a firm “Nomal”. I curiously asked the patient if there was any swab/culture taken before when she was treated by my colleague. that is the best thing I’ve heard today! Any masses and tenderness in the abdomen – none. Asthma . Pulmonary embolism. I explained that I know that she and her partner are exclusive to each other and they use condoms but I need to check this (STI) still. I feared that I might have done a critical error by totally ignoring the cervical ectropion which was seen on speculum examination. – general appearance normal. Periods regular. Speculum examination – greenish yellow vaginal discharge which is foul smelling. LMP 3 weeks ago. monthly. The examiner brightened up and said. Your colleague treated her with antifungals and doxycycline but discharge is recurrent. fever (none). No previous STI. I asked if it was alright to be asking some sensitive and personal Qs. relation to menstruation (no). Gardnerella and will also test for Candida. Pericarditis. P. I passed this station though. Also. Task: • Take a history • Examine the patient • Advise on plan of management I started by asking her details of her vaginal discharge – smell (foul).E. Not on any medications and no allergy to medications. I will need to also do a Paps smear on her too since the last one was 2 years ago. Then I said I’d like to focus my examination on the gynaecological aspect.5. AMC Feedback: Green vaginal discharge 6. N. Tasks: • Take a history • Examination • Management plan When I was reading the stem outside the room. Contraception – condoms. dysuria (none). She said no. Pneumonia. Examiner asked me what I was thinking. she should continue on practicing safe sex. Then depending on the results I will have to treat her. I also asked the patient’s permission to test her for STI – including high vaginal swabs for Chlamydia and Gonorrhoea and to complete my STI screen.
either with the standard heparin or LMWH plus an overlap with warfarin because it takes time for warfarin to take effect (around 4-5 days for INR to be at least 2-3). I started by asking the patient. AMC Feedback: Shortness of breath 7. Physical examination: I think the only abnormality is the slight increase in respiratory rate. No heart racing. I will have to request the following: FBE. He got small calculi in his gall bladder. no liver disease before. A 60yrs old male patient. I was also planning to pin down the diagnosis in the first 5 Qs I will throw to the role player. He had haematemesis due to oesophageal varices. pancreas was normal. What can you expect in the ECG? In severe PE. Finished early. Then I asked medications (OCP and other DVT risk factors –recent surgery. Factor V Leiden. smoking. He had a pacemaker inserted a few years ago. no calf tenderness (I couldn’t recall if there was). How will she be treated? I said she will need to be started on heparin. viral serology normal doesn’t drink alcohol. She will also need to have a V/Q scan. thrombophilic markers both for hereditary – protein C. No fever. (Long stem) . Examiner commented . How long will she be treated? I said 6 months. coagulation profile (what do you mean. I got excited so I immediately said she needs CTPA (CT pulmonary angiography). He asked what will happen in hospital. She said she just arrived from New York 5 days ago (or less than a week ago). sputum and colour –yes. Is this progressive – No. tell me about it? She said. referred by his previous GP to see you – new to the area. brown (Aha! I have narrowed my differentials to either pulmonary embolism or pneumonia). homocysteine and acquired – lupus anticoagulant and antiphospholipids. I said that she needs to have immediate hospital admission as I am highly considering pulmonary embolism. I then asked recent long travelling. That was what I was waiting for. further down my list were: AMI and Dissecting aneurysm. Dear Doctor Would you please see this patient? His liver function has been abnormal for 2 years. Though this is the gold standard of diagnosis. He feels tiredness.(because of the relatively young age of the patient). S. I said. I asked her if this was the first time this happened – Yes. No leg swelling.don’t you think that this is too invasive as an initial investigation? Oh yes. General health – good. aPTT). The examiner asked what else? I said an ECG too. If she was coughing – yes. Cardiopulmonary exam – N. he remarked. Then heparin will be ceased once warfarin kicks in. The examiner was sitting very close to me and seemed very pleased. he asked – I said PT/INR. No chest pain. yesterday in the office (clerical job) she suddenly felt this shortness of breath. you can have Q3T3S1 but you may also have a normal ECG if PE is not severe. family history) – none. I asked her what she did in the plane – she said she slept most of the flight time.
As soon as I said this the examiner handed me the result. he asked. he asked. However. renal function etc. pituitary and in fact can deposit in any organ causing its dysfunction. some hormones from pituitary deposits. Will I live to be 70? Well. we have to test your wife first. Transferin saturation increased. which means he has received one recessive gene each from his parents. The treatment is aimed to bring down the iron load by doing phlebotomies around 500 ml every week for 1-2 years (read JMurtagh) then if levels are acceptable.Task: • Ask the examiner about Ix result • Explain the patient to the result. What about his siblings. Then I went on to say that your iron stores are very high which supports what I was initially thinking thus I would need to do some genetic testing for the gene. I will have to do some iron studies. I briefly explained that you have to have a pair of the recessive gene to have haemochromatosis and that one gene inheritance is considered a “carrier” of the abnormal gene and should not cause any clinical significance to that person. Perhaps a referral to a liver specialist will be necessary in the future for the possibility of a liver biopsy. There are other parts in the stem regarding history but I could not recall them. I don’t think you have to take any more history from the patient apart from clarifying Qs. AMC Feedback: Abnormal Liver Function Tests 8. . He will need to have regular follow up. And of course continued specialist referral for the heart and long-term follow up should be advantageous for his health. Her father had colon carcinoma at 58 years old. If your wife does not carry the gene. Homozygous for C282Y (+). I said. then the worst case scenario is that your children will have inherited one HFE gene and that should not be a problem to them. it is recommended to have their future partners tested because of the possibility of having affected children. heart. It is an inherited disorder. gallbladder and maybe some other organs too which we will need to investigate. I will also have to test him for other organ dysfunction such as diabetes from pancreatic involvement. A 48 year old lady came in for her biopsy results which showed adenocarcinoma of the colon. It is a condition with a disturbance in iron metabolism such that excess iron accumulates and deposits in organs such as the liver. I’d like to do some tests to rule out a condition which we call haemochromatosis. the frequency drops down to every 3-4 months. That it is a good thing that we detected it now and that we can do something about it. Ferritin increased (1500). I started by saying that he has multiple organ involvement namely the heart. I said that since you came from one set of parents. H63D (-) I asked him if he knows anything about haemochromatosis. I said that depends on the degree of organ involvement. What will happen to his kids. they have to be tested for iron studies and the HFE gene. pancreas. The examiner handed me a second laminated paper. liver.
her friends and what her hobbies were. The biopsy results showed that she has carcinoma of the colon (at this point I tried to look at the stem to see which part of the colon but I don’t understand why I couldn’t see the part that is involved. First of all I asked her if she came for the results of her biopsy and she said yes. I asked her if she would want someone to be with her before I explain the condition and if she would want me to go further. What about her siblings. I asked about her social life. I drew the different stages 1-4 and the degree of involvement (I-mucosa. E – Education. she can’t sleep.bowel wall and LNs.Task • • • s Explain the results of the biopsy to the patient Advise on management Answer the patients Qs. Does she need colostomy like her father? I said. I told her that I have some disturbing news. she may need it but it may just be temporary especially if it is in its early stage. The examiner was very quiet. AMC Feedback: Carcinoma of the rectum 9. IV. A – Activities. Economics (work and finances). I said that your siblings need to be investigated with faecal occult blood in the stools and colonoscopies. She was previously treated with antidepressants before. . That she had to leave home and she is now renting out a unit with some friends with whom she shares the bills.liver mets and other organs) and their respective prognosis (Dukes Staging in AMC book p94). I said yes and the use of adjuvant chemotherapy +/. stage I. Then I said that they will need to have surveillance colostomies done when they reach their 40s or alternatively a bit sooner since some authorities recommend it to be done 10 years earlier from when a first degree relative was diagnosed to have the carcinoma (in her case around 38 years old for her children) . What will happen to her kids? I asked how old were they (I think they were in their teens). That. How are things at home? She mentioned that the family is dysfunctional. She said that she has a double job and shifts from one work to the other in a day. II. III.maybe it was the “nerves”). She said she feels down. i. On a piece of paper. I finished early. I screened for “HEADS”. For the meantime their diet should be rich in fibre.e.unless they have symptoms. A young female came to your GP to ask for antidepressants again.bowel wall. She said she does not socialise much as work keeps her busy. She asked if surgery is the only treatment. if treated early. Several issues happening (could not remember exactly what). the 5 year survival rate is >90-95%.XRT in selected cases improves overall survival. Tasks: • History • Management I started by asking why she thinks she needs antidepressants.. H – Home environment. I explained to her that the earlier we treat the better. A middle aged woman was in the room waiting. most days a week.
as he changed the lanes while driving without obvious reason and almost caused MVA. Assessment of a Comatose patient (AMC Handbook of Clinical Assessment) There were 3 people in the room. Tasks: • Take further history • Do at least one test to assess his cognitive function.. the examiner and an observer. • Antidepressants have certainly a role but only when all means mentioned before have been exhausted. Drugs. • I briefly mentioned sleep hygiene (read JMUrtagh). low score in attention. no need to repeat MMSE (assume it was accurate) . I asked about risk factor of harming herself and others – none. Then I explained to her that giving an antidepressant is not the only solution to her problems. • That she needs to socialise and find ways to relax and go out with friends and family. I asked about delusions. His children also report that his behaviour has changed recently.Middle age man has come to your clinic. She said it is unaffected. I will be happy to arrange for that. 2 weeks only to prevent dependency) just to break the cycle of anxiety and lack of sleep. • Cognitive behaviour therapy and meditation techniques can certainly help. hallucinations. AMC Feedback: Anxiety and Depression 10. I asked her about sleep – what was bothering her. A patient lying comatose on the bed. Then just to complete the psychiatric assessment. I could no longer remember the reason why an antidepressant was previously prescribed on her – but I know she did not have any major depressive symptoms previously including suicidal thoughts.drugs. Last time you did MMSE and it was 25/30 (page with report was provided on the wall. Her general health has been good. S – Sexual activities. I asked her if she is sexually active – No. if there was anything that keeps her awake.e. there is no harm in trying a short-term sleeping tablet (i. • I will follow things up with her to see how she is going. • If she still has a problem coping. his wife is worried about his strange behaviour recently. • If her finance is an issue. recall sections). AMC Feedback: Coma 11. Should she wish to have a family counselling session with me. – None. cigarette – none. That she needs to cut down on her working hours because she is overworked and tired and unable to get enough sleep. we may have to tap on community resources to help her out temporarily while she overcomes this situation. alcohol. I asked about coping mechanisms. • That the cornerstone of management is in her lifestyle change. etc. She said she just cannot sleep and wakes up unrefreshed. I asked about eating.D – Depression. Suicide risks.
The role player was unable to do the interpretation of the saying “a stitch in time saves nine” and also found it difficult to do the motor sequencing test of the “fist-edgepalm”. worry too much and that there is nothing wrong with him. you finished your task and can wait outside.. Read page 443 of the AMC handbook under the title “MMSE may be supplemented by specifically testing frontal lobe functioning via. how much. mood. First I commended the patient for coming to see me to talk about his alcohol consumption. work. Tasks: • History • Talk to the patient regarding issues with his alcohol consumption • Investigations and plan of management There were again 3 people including an observer. activities/exercise. I also asked about past medical history and general health. I asked about home situation. mood. He denies any change in his behaviour.any relationship issues? . Thus I asked the patient and he could do this. how often – I gathered that it was way too much in excess of the recommended. He tried hard but kept repeating words he already used. he does not know why and that he thinks they.nothing significant. I asked the examiner if there was time to do words beginning with F’s in one minute. Smoking. Also he drinks different kinds of liquor.e.A man who sees you about his alcohol consumption.• Discuss your diagnosis with the examiner. He asked me the basis for this. hard drinks. Does he know where he is at the moment?Orientation Qs. AMC Feedback: Frontal Dementia 12. driving offence . but he said. tumours etc. I said he probably has frontal lobe dementia. especially his wife. medications were all non contributory. I was about to explain the possible causes of frontal lobe problems such as vascular deficits/infarcts. home and work situations. Then the examiner interrupted and asked me for the diagnosis. and activities . I said that he has borderline MMSE 25/30 and that he is unable to do the tests I’ve done on him which can only mean that he has some form of frontal lobe deficits. • C-A-G-E Qs • “HEADS” check (as in the case above) i. The examiner answered that I have plenty of time.” I did exactly what was on this outline. Then I moved forward to do my second task.. I asked the following: • Alcohol consumption – what kind. wine and beer.. does he drink because he is in a lot of stress? –mood and suicide risks .Yes. I asked him general Qs on dementia like does he think he is forgetful and has he ever found difficulty in his way home. I started by asking the patient the reason why his wife and children are concerned with him.None • Did he get in trouble with the law because of his drink driving – yes.. alcohol. He said. An elderly man around 60 was in the room. don’t worry about that.
I said that the good news is that there is no LN involvement and that the depth is 0. the tumour excision did not indicate clear borders.4mm. Melanoma is the third commonest skin malignancy in Australia and is related to prolonged sun exposure. One standard drink is equivalent to 10g alcohol. a school teacher had this mole for many years and noted it recently to be itchy thus a biopsy was done. . Since there are different liquors he takes. I advised on the following: • Re-excising the tumour with clear margins of normal tissue – referral to a surgeon (or dermatologist) to do this. HPN. cholesterol. I have to check this margin as I remember them to be so in squamous and basal cell carcinoma but wasn’t sure if this applied to melanoma (further readings post exam – 1cm clear margins). LFT’s. No history and examination required. • I can arrange for him to have some blood tests like – FBE with red cell indices. BSL. ideally I said 3-4mm of clear margins. Q from the patient: What advise do I need now as an immediate plan? I was thinking of what he meant and I was about to address the issue of drink driving but the bell rang. B12 and folate levels. The usual cut-off depth is 0.diminished General health – weight. diabetes. The patient. Tasks: • You are to explain the biopsy result to the patient. smoking and recreational drugs Motivation to stop – he said he is not sure yet but just came to ask. I advised on the following • That his alcohol consumption is beyond the harmful effect of 4 standard drinks/day with 1-2 days free/week.A biopsy report of a melanoma with depth of involvement of 0. • Advise on management. cholesterol and ECG • I can arrange counselling for him or if he wants I can arrange for further consultation with him and his wife for counselling and support should he decide to withdraw. • That alcohol can have harmful effects on his physical. social and psychological aspects of his life. • In the end. No lymph node enlargement.4 mm thickness with tumour extending to the lateral margins (couldn’t recall which site of the body). I will give him a reading material on the equivalent of one standard drink of the different liquors he takes.• • • Libido .75mm which could affect prognosis. I told the patient the disturbing news of the biopsy result. However. A picture was outside the wall. • It would be nice to mention alcoholics anonymous which I forgot to do. it is still up to him to decide on what to do with his alcohol consumption and that we are here to help him out. AMC Feedback: Excess alcohol consumption 13.
myopathy (proximal muscle weakness). the prognosis is excellent if the depth is just 0.methotrexate. There is also the possibility of using steroids. He should also regularly inspect his skin himself and report early for any skin change. I said yes. swelling and stiffness in both hands recently. in RA.• • • • Although LN involvement was not seen. which is the “cushion” at the end of the bones in the joints. I enumerated the DMARDS . This was my very first station. Task: • Explain the diagnosis to the patient. sulfasaline etc. Her mother has rheumatoid arthritis. However. a violinist in an orchestra. AMC Feedback: Melanoma 14. diabetes. the use of steroids is limited only to flares and are of short courses usually. I still would want to have some scans (CT) to make sure that no other LNs are involved in other sites. The role player said she does not like the use of steroids because of the ill effects on her mother. starting from simple analgesics to stronger ones. Therefore I said if you feel too strongly against it then we can use NSAIDS such as Ibuprofen. You suspected that it's rheumatoid arthritis. With modern day medicine and new drugs which we call DMARDs we can markedly delay and hopefully prevent further progression of the disease. ESR and RF. But she was still hesitant. • Counsel the patient and answer her questions . . There was a very nice middle-aged role player who smiled and nodded her head when I said the answers she wanted to hear. gastric irritation. Inflixamab. LFTs and CRP ESR. Although we usually recommend a step-up approach in pain management. etc. we can use DMARDs in the early phases of treatment. I will definitely follow you up closely with your steroid use. cyclosporine. Early referral to physiotherapist and rheumatologist is the key to prevent further disease progression. You prescribed ibuprofen and run some blood tests for ANA.A 50 years old lady. Wear wide brim hat. She said “but I’ve been using this already with not much relief”. It has an autoimmune component as well as genetic predisposition. I said bone marrow suppression and liver dysfunction that is why she needs to have regular check of her FBE. azathioprine. mood changes and long term effects of osteoporosis. the complications of steroid use are well recognized such as. • • Examiner asked about the side effects of DMARDS. Then we can also try Aspirin plus Panadeine (Panadol Codeine) combination. It is an inflammatory condition eroding cartilage. long sleeved top and use sun protection lotion. to counteract the effect of cytokine (thought to be a mediator in RA) can also be used.4mm and no LN involvement is seen. with pain. Referral to an oncologist for possible chemotherapy if LN involvement is seen. However. RF to monitor her disease progression as well. Avoid prolonged sun exposure. The results showed that she has early rheumatoid arthritis. He would need to be followed up on a regular basis for progress report and also to regularly check the skin for suspicious lesions. • I explained that she has RA and that this is a chronic condition with flares and quiescent phases.
weakness – yes. forearm and hands.none. Then I proceeded to do shoulder examination testing for powers (against resistance) of abduction and adduction. extension. biceps.no. There was obvious weakness of all movements of the right side. Numbness. rotation to the right and left. The examiner said I finished my task and that I can step outside. Tasks: • History no more than 2 minutes • Do your examination and investigation • Dx There was a middle aged woman with a hospital gown seated already for my examination. I said conservatively. lateral flexion. Then I asked for the patient to do neck movements extension. we can talk about HRT on another consult to weigh the risks and advantages of using this and we can also talk about the use of bisphosphonates and dietary advice on calcium or supplements. She would need to have baseline bone scans (bone densitometry was what I was actually thinking but I said bone scans). Examiner was hurrying me up to proceed to examine the patient. There was tenderness around the C6C7 area. swelling. and adduction. AMC Feedback: Prolapsed cervical disc with radiculopathy. There was limitation in all the movements. Then I went to palpate the spinous process from the base of the occiput down the cervical spine.Examiner asked what potential risks would the use of steroids do to this patient given her age – 50. Bell rang. 16. The examiner kept on hurrying me up to examine the hands. triceps. extension. flexion. A sibling had a recent bout of gastroenteritis. forearm and hands. I was also comparing it to the right side which seemed to be unaffected. I had limited testing for finger flexion. Middle aged woman complaints of pain on the right arm. I was quickly asked how I would manage the patient. wrist flexion. she said yes. I started by saying ideally I will have to expose the shoulders to check for asymmetry. I did not get to examine the sensory and reflexes as the examiner cut me short and asked what investigations I would request.A previously well 5 months old brought to you by the father because of sudden onset of intermittent screaming with few episodes of vomiting. Tasks: . I asked her to tell me about the pain and she indicated pain in the arm. Then I moved to the back of the patient and talked about looking for any deformities swelling. Any pins and needles? Not exactly. I will refer for physiotherapy. abduction. He handed me an MRI picture of the cervical spine which showed a prolapsed disc. Any history of rheumatoid arthritis. etc. Any neck pains. Then I checked for paravertebral tenderness. Any trauma. The examiner said you don’t have to expose anything. Examine the patient as is. General health.non contributory. I said since I was considering cervical spondylosis I would request for an MRI. AMC Feedback: Rheumatoid arthritis 15. I said osteoporosis. muscle atrophy. there was none. However.
The exam in really “nerve-wrecking”. . I advised on nil by mouth and what they will do in the hospital such as IV fluid. colour and character of stools. I advised on the possibility of intussuception (explained what it is) and that the baby needs to be admitted to hospital because of the suspected diagnosis. Relax the day before and do not read anymore while waiting for your turn whilst in quarantine (especially for the group in the afternoon). Just when you think you have a good grasp of the commonly repeated cases. UTI. vomiting. It just adds more pressure to an already stressed out brain. small gut obstruction. Think of a few differentials and keep on talking while ruling out the others and ruling in the most probable diagnosis. it was still surprising to see unfamiliar cases. possibly either gas or contrast enemawhich can be both diagnostic and therapeutic . In hindsight. It is possible that this was completely unexpected by some candidates and could have affected the low passing rate (35%). I discussed about going to theatre if the enema measures fail to reduce the intussuception. If you know them you would at least be able to talk about it and not be caught by total unawareness. early surgical referral. urine tests etc. Rectal exam was normal. AMC Feedback: Incarcerated Hernia (the only station I failed) Comments: This candidate has reviewed almost 350 cases (including the 150 cases from the AMC publication). Past medical history was uneventful. I couldn’t help but develop doubts in my diagnosis and my approach because they were modified in such a way that I have to think further and not fully rely on the diagnosis given in the recalls. There were 4 modified cases from the recalls. I would have gotten an obvious diagnosis of incarcerated/strangulated hernia if only I had checked the groin area. meningitis. PE Advise diagnosis and plan of management My first thought was intussuception because of the typical clinical picture. I also asked for fever.• • • History. So I asked Qs pertaining to this such as: how is the infant in between episodes. Some exams will have very familiar repeated cases thus probably contributing to the relatively higher passing rates. This particular exam had a lot of unfamiliar cases and only 2 cases came out from the book published. You will never know what cases will come out in the exams. Try to know the cases by heart in all their aspects because they can appear in different “shapes and sizes”. A few of the cases were not exactly how we expected it to come out as in the previous recalls. There were 2 new cases to me which I have not encountered in my recalls at all. I should have also asked for the groin examination. abdominal xrays. any obvious straining when he wees . blood tests for FBE and electrolytes. PE: nothing contributory. Examiner asked me my differentials: I said volvulus.none. He was noted to be pale in between episodes.
Be observant to the role plays during the class because you will learn something from them even if the candidate performed badly or excellently. You will pickup very precious “survival tips” which you can apply in your preparation for the exams and during the exam day itself. Cheers All. Get the most out of this class. It is also a good way to establish networkings with people who are in the same situation as you are. It is freely given by a kind hearted person who wants to help us IMGs (a rare precious opportunity). We happen to be just ahead of you in passing the clinical exams but soon enough you will also be in the same situation and we will be criss-crossing our paths again in the future.Dr. Listen carefully to the testimonies of those who passed. Hope this recall helps! . All the best in your endeavours. Wenzel’s (Couldn’t thank you enough Dr Wenzel) class has a very good simulation of what happens in the exams.
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