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Trial AMC Exam

OTD Program
PMIT Inc
The Real AMC Exam
• 20 stations
– 16 active; 4 rest
• Pass = 12/16 Provided 1/3 Paediatrics & 1/3
O&G station passed
• Re-test: 10 or 11 passed
• Fail: < 10 passed
Today’s exam
• 8 stations:
– Emergency (injured arm)
– Surgery (post-op dysuria)
– O&G/GP (CIN II)
– Medicine (stroke)
– GP (knee pain)
– Paediatrics (D&V)
– Psychiatry (aggressive patient)
– Rest
The purpose of this session
• To provide constructive feedback on each
station
• To allow you to assess your own strengths
and weaknesses
• To stimulate discussion about the cases
1. Injured arm
• You are the surgical intern and are assessing
a young child who injured his arm after
falling from a tree. There is no significant
past medical history. Examination reveals a
deformed arm, and there are no other
injuries. There is no distal nerve or vascular
injury at this time. An x-ray has been
obtained which is displayed. You are about
to talk to the child’s parent.
Injured arm
• Your tasks are to:

Explain the diagnosis to the parent


Explain the management
Obtain informed consent for the procedure
• Diagnosis – displaced supracondylar
fracture
• Management – MUA and application of
POP
Common errors…
• Wrong Dx – disloc instead of #
• Wrong Mx – eg GA in DEM, Not reading
the instructions beforehand
• Incomplete or avoidance of discussion of
risks / complications
2. Post op dysuria
• You are the evening intern covering the
surgical unit. You are asked to see this
patient who is 2 days’ post laparoscopic
cholecystectomy. The patient had been kept
in hospital because of pain. The nursing
staff have just called you because the
patient has a fever.
Your task is to:
• Take a brief directed history from the
patient (3 minutes)
• Ask the examiner for the examination
findings(2 minutes)
• Discuss with the examiner your diagnosis &
management plan (3 minutes)
• Note: you will not be required to examine the patient. You
will need to ask the examiner for any specific examination
findings.
• Features in the history: feeling better during
the day but “poorly” this evening, hot and
cold, shivering, burning when passing urine
• Exam findings: need to ask for findings
relating to typical post op fever – wound
infection, phlebitis, atelectasis. Patient was
dry.
• Diagnosis – UTI related to urinary catheter
insertion
• Management – urinalysis, MC&S,
antibiotic, increase fluids
Common errors…
• History disorganised, and too brief
• Unecessary invasive procedures
• What about urine dipstick?
3. PAP smear
• You are working in general practice. You
are seeing Joanne, who had a routine Pap
smear with another doctor in the practice
last visit. She has presented for the results.
The PAP smear has come back as
“abnormal cells, likely CIN2”.
Your tasks are to:
•Take a brief history
•Explain the results and answer
any of the patient’s questions
•Explain your management
• History to include: previous gynae
history, obstetric history, sexual
history, contraception, social & family
history, alcohol, smoking
• Explain what the abnormal cells are,
reassure that its not cancer
• Management – refer to gynaecologist
for colposcopy
Common errors…
• Failed to explain that PAP smear is a
screening test – treated it as if it was
diagnostic
• Poor description of the progression from
CIN1 to Ca
• Poor explanation of the management
4. Stroke
• You are the intern on a medical unit. Mr Faraday is a 73 yo
male who has been on your ward for 2 days following a
massive stroke. The CT scan showed a large amount of
intracerebral haemorrhage with midline shift. He was
previously quite well and fully independent, and lived
alone following the death of his wife 3 years ago.
• He has had fluctuating levels of consciousness for the time
he has been in hospital. Today he is deeply unconscious
and his breathing is becoming laboured.
• Mr Faraday’s son Tom has arrived from overseas and you
are meeting him for the first time.
Medicine
• Your task is to:
– Explain to Tom the diagnosis and the
prognosis.
• Establish rapport and work out what
Tom knows already
• Explain the diagnosis in plain English
• Explain that Mr Faraday is dying
• Answer questions sensitively
Common errors…
• Poor knowledge of prognosis and
management of this scenario
• “Fence sitting” – need to be unequivoal
about death
• Inappropriate management eg ITU
5. Knee pain
• You are working in general practice and your next
patient is a young netball player who presents
complaining of left knee pain. She has complained
of “clicking” in her knee for the last few months,
and has presented for review.
• She cannot recall a specific injury, and she is
otherwise well. She does not think the knee “gives
way”, and on one occasion it locked in mid
flexion.
General Practice
• Your tasks are to:
– Perform a knee examination
– Describe the most likely diagnosis to the
examiner
• Knee examination (eg as per Talley and
O’Connor) – function, look, feel, move,
stress
• Diagnosis – most likely a medial meniscus
injury
Common errors…
• Poor, or lack of structured approach to
examination
• Most forgot function (walk), ROM and
patellar apprehension
6. Child with D&V
• You are working in a hospital emergency
department. You have just examined
Jessica, a 2year old girl who has had
vomiting and diarrhoea for the last 24
hours. Her parents have brought her to
hospital because they are concerned about
her not drinking enough.
Your tasks are to:
• Take a history

• Ask the examiner for examination findings

• Advise the parent of the diagnosis and your


management
• History – brown watery diarrhoea, 10-
12 times, not eating, not taking much
fluid and vomiting what little goes
down back up, has been a bit hot, no
wet nappies today, increasingly drowsy
over the last few hours, immunisations
up to date, no PMH
• Exam findings – looking blank, PR
160, RR 28, T 37.9, capillary refill 3
seconds, dry mucus membranes, dry
coated tongue, reduced skin turgor
• Diagnosis – viral gastroenteritis with
significant dehydration
• Management - supportive approach,
admit for nasogastric (preferably) or iv
fluids
Common errors…
• Inadequate history
• Failure to identify hydration status
• Poor understanding of appropriate
management
• Poor communication with mum
7. Aggressive patient
• This patient has been brought to hospital by
the police in an agitated state, with
aggressive and violent behaviour. Medical
staff have since settled him/her down.
• You are the psychiatry RMO and you have
been asked to assess him with a view to
psychiatric admission.
Your task is to:
• Assess the patient

• Discuss your management plan with the


examiner
• Patient is confused, disorientated and
lacks any insight. Exhibits
misinterpretations and delusions

• Important to realise that the patient is


delerious and that there is an
underlying medical cause which
requires investigation and treatment
Common errors…
• Failed to assess orientation
• Got stuck on “psychosis”
• Admit Psych ward, Rx with BDZP
Tips:
• Work together
• Practice, don’t just read
• Talley and O’Connor for examination
• Start thinking of an “English” word for
every medical one that you use
• The next bridging course…

Royal Hobart Hospital


th
7 October 2006