1)GP, complaining of lump in front of the neck which moves with deglutition.

Having that for

6mths. Initially tender but not now.
Tasks: explain the dx and ddx, mention invx u would like to do to ur patient and possible
management

Approach :Midline Structures:thyroid, larynx and LN and then concentrate on thyroid

when I entered I told him that I know that you are bothered about this lump in your neck but is it ok if I
ask you a few questions. He said no problem. Asked a few questions about thyroid, larynx etc. but he
replied in negative for everything . I realised that he must be instructed to do so as history taking is not
in task. So I took pen and paper and started with explaining midline structures. thyroid , larynx and
lymph node but since it moves with swallowing most likely thyroid then explained a bit about thyroid.
even in thyroid there could be many causes like cyst or a growth which is overfunctioning or under
functioning or a growth that’s nasty . All this while I was drawing or scribbling something .For this we
need to do some test like basic bloods along with thyroid function tests. Explained abit about thyroid
function test. Then will do ultrasound and Guided FNAC. Explained FNAC . Specialised tests like
thyroid scan and thyroid antibodies may be required as well . Explained a bit about them .checked
understanding.

2)GP, going to see a patient 1yr 6 mths brought in by mum. Mum no concern. Local nurse
worried abt weight gain. Wt chart and height chart given. Height is good. Wt grows well till 6
mths, become stuck from 6 mths and now below 3rd centile.
Tasks: history, explain the condition
Approach: FTT cluster. A) decreased or faulty intake — fussy eater, too much cow milk are AMC
cases b) decreased absorption— cealiac disease is amc case c) increased utilisation- hyperthyroid
and DM — not AMC cases d) psychosocial issues— single mother this is a AMC case.

Yes this is a recall if I am not mistaken . This belongs to the FTT cluster so ask all the questions in
this cluster like intake issues diet cows milk+ve . Fruit juices , fussy eater, +ve decreased absorption
issues so go in detail about bowel habits, consistency , blood mucus in stools etc. take BINDS for all
peads cases ask are you a happy family and role player will tell you everything even without asking
any further.no significant past history or family history. Single mother no job no support. When
explaining I said generally when we plot the chart we expect that the line will be parallel to the rest of
the growth lines that you see but for your child it is dropping down. Mentioned all the reasons Mx was
not in task but even if it was I would not have reported to CPS instead the mother required lots of
support. Yes this is a recall if I am not mistaken . This belongs to the FTT cluster so ask all the
questions in this cluster like intake issues diet cows milk+ve . Fruit juices , fussy eater, +ve decreased
absorption issues so go in detail about bowel habits, consistency , blood mucus in stools etc. take
BINDS for all peads cases ask are you a happy family and role player will tell you everything even
without asking any further.no significant past history or family history. Single mother no job no
support. When explaining I said generally when we plot the chart we expect that the line will be
parallel to the rest of the growth lines that you see but for your child it is dropping down. Mentioned all
the reasons Mx was not in task but even if it was I would not have reported to CPS instead the mother
required lots of support. Mentioned fussy eater , too much cow milk intake and psychosocial. Issues
for FTT

3) GP, 42 yrs old lady complaining of indigestion.

Tasks: history, dx and ddx, explain invx u would like to do

Approach: GERD And its complications

This case of a 42 yr old man with indigest and long history of GERD i dont remember anything else.it
was history PEFE ddx and inx. No Mx . outside i thought about GERD and its complications and
thought this is mot likely ca. When i eneterd this person was holding his stomach. I asked if there is
pain he said no just bad indigestion. Started with HOPC about indigestion( Onset, severity, course,
continous or intermittent, anything makes worse better --+ve was antacids which intially worked not
working anymore) then asked about associated GI symptoms + ve change in colour of stool so
explored more about bowel motion , FOBT done ever keeping ca colon in mind. Then asked about
consitutional symptoms no fever but positive loss of weight which was significant5 kg then asked
about what treatment received for GERD and who was following him up and any
complications.personal history was positive for significant smoking and alcohol . Said its detrimental to
gerd and will have to address this. Nothing positive in past or family history . In PEFE + ve was left
supraclavicular LN and DRE showed dark stools. dont remember anything else . Ddx said sorry looks
like nasty growth most likely ca oeosphagus due to long stnding GERD but could also be ca colon
need to refer you urgently for upper gi endoscopy and colonoscopy . Explained about it .will also do
some bloods like FBE to see if you anemic etc. had plenty of time so told him i will advise you about
lifestyle changes examiner said that is not in task so said i will give something for indigestion.
Examined laughed and told me thats management again dont go there. So thanked and left ,

4) ED, pt having chest pain characteristic of angina from time to time. Long stem given. Getting
pain with exercise, walking uphills and not relieved with omeprazole. Pt. taking omeprazole and
ibuprofen for back pain. Family history of heart attack in dad and stroke in mum.
Tasks: ask pefe, dx and ddx, give management

Approach: My approach was either this two things chest pain and Malena are related or not related
yes i will not forget this case as it was my first station . Lot of history given outside with chest pain
which radiated to jaw etc suggesting ischemic pain and also had Malena and was taking painkillers.
My approach was either this two things chest pain and Malena are related or not related and I have to
do focused cvs and abdominal exam so for PEFE asked everything started with vitals to assess
hemodynamic stability yes had postural drop , pulse was normal not irregular rest ok CVS no positive
findings and abdomen not sure but I think there was tenderness . drE had blood Or dark stools don’t
remember.so for ddx to patient I said that from my findings most likely this is chest pain angina due to
anemia as you are taking painkillers since long time and have Malena or it could also be that your
chest pain and dark stools are two different problems ie chest pain is due to blood supply getting
compromised due to block somewhere and we will have to investigate the bleeding also. mx said I will
move to resus area and do a quick ECG . If there are ischemic changes will start MOnA and I am also
giving cardiology and GI referral for your bleeding.will also send bloods as you may be anemic and
drew something while explaining. es also the usual admission start on iv fluids since he had postural
drop so was hypovolemic

5) 8 mnth old child crying for 6 hrs father very worried task hx dx nd ddx

Approach: irritable child head to toe

Yes there was this lady with a doll and pretended to comfort the child and was really worried. outside
was the baby is irritable and crying for 4 hours . I dont remember any other history. When i went in
asked hemodynamic stability examiner said you have to find that out.i thanked him and then
comforted the lady, started with crying questions, ( is it first episode, is it continous or intermittent ,
was there any trigger factor any trauma , was the baby alright before this episode started or was the
baby sick, are there any associated factors like drawing up of legs, baby turning blue or pale while
crying, child was turning pale while crying + ) irritable baby r/ o everything from head to toe Including
lumps or bumps anywhere .Head - meningitis, ENT, RS and CVS, abdominal was in detail with poo
details , urine details, including change in colour, odour, consistency , number ) then asked well baby
questions, BINDS,travel history. brother was sick with gastro+ . Ya there was no PEFE which was an
indication for taking detailed and good history. I gave a ddx with i need to r/ o intussusception first but
could also be gatro which the child got from brother, UTI less likely child does not have fever, could be
strangulated/ incarcerated hernia i need to examine the child etc, mentioned child abuse as ddox as
well said I need to look for injuries on child, mentioned colic as ddx but said unlikely As this is not age
for presentation and this is a first episode of crying

Comforted the lady saying whatever it is we will take good care of the child and asked about the other
brother as well. Ddx could be anything in this case as the only + ve thing was child turning pale while
crying

6) GP, pt having night sweats, 2LNs palpable at groin, and some features of lymphoma. Very long
stem. Tasks: perform haenatological examination, give pdx and ddx (no positive findings except groin
nodes)

Approach: hematological system

Yes there was lots of lymph nodes, lymphomas and hemat exam that i actually thought i am
hallucinating. First case lady with bilateral inguinal lymph nodes. You have examined the lymph nodes
and gone out and come back to do rest of exam. long stem with negative night sweats, no allergies,
bites etc .case was perform hemat exam and give ddx . Took consent . for got to handwash. The role
player was supergeneral ap helpful . She gestured to me that wash your hands and the examiner had
a smile. So to cover up i said remember i have examined your groin and then went out. I have already
washed my hands and not touched anything but since you are concerned i will wash my hands
again...examiner smiling even more.follow hemat format. General apperance . told examiner i would
like to do vitals . Examiner said normal. start with hands epitrocheal LN, then axillary both sides, Face
frontal bossing, eyes , mouth , neck cervical LN, clavicle tenderness, listened to heart, abd palpate for
tenderness. Hepatosplenomegaly, then examined legs for rash, skin changes etc, nothing positive
gave ddx lymphoma, said cannot rule out viral or bacterial etiology from exam And history. Will need
investigations

7) I can only remember the second case faintly as there was lot of lymph nodes and lymphomas. This
was a man with lump in neck of about 3 to 4 months cants remember for sure. Either you or colleague
has examined and found out that it is cervical lymph nodes enlargement. Ask PEFE, Ddx and invx.

Approach: All causes of LN enlargement

Asked examiner everything that was possible in step wise format. general apperance.. examiner you
are looking at him right now. Vitals normal ,PICKLE asked abt pallor, icterus and lymph nodes . When
i mentioned lymph nodes he asked what in lymph nodes so had to mention all groups in cervical,
axillary, inguinal lymph nodes . cant remember so clearly but he had only bilateral cervical nodes.
Then asked specifically about cervical in detail like largest node, consistency was firm , mobility were
mobile nor fixed, tenderness non tender, any skin changes above them none, then asked about BMI
and wt of patient . Asked if i have previous wt to compare if any loss of wt, skin rash none. Then
asked about focused abd exam any tenderness any hepatospelnomegaly none. Then said with
consent, privacy and chaperone would like to know if testes size is normal as lymphoma can involve
testes and lastly asked to listen to heart and lungs. ddx was most likely lymphoma but cannot rule out
infectious etiology so in investigation asked to do FBE.. inflammatory markers EsR, CRP, baseline
LFT and RFT, LDH and b2 microglobulin as prognostic markers for lymphoma, but said the most
important investigation would be LN biopsy which would help in diagnosis and also tell me about the
type of lymphoma as they all have different prognosis. Also said if it turns out to be lymphoma i will
sent to specialist who will do furthur investigations like CTscan for staging chest x ray etc . If it is not
lymphoma we will have to look for infectious etiology by doing viral serology. Drew diagram and
expalined a bit about LN and lymphomas

8) doctor at primary care center. Talk to the care giver at some centre because one of the residents
he is taking care of acting strange. Has been dxed with schiz for 5 yrs. Now auditory hallucination +,
delusion of grandiosity +, delusion of persecution +, no idea of harming himself or others.
Tasks: take further focused history, explain the condition, explain the necessary Mx

approach was to take a good psychosocial history quickly( psychotic symptoms, depressive
symptoms and HEADSsS)

he had command auditory hallucinations from God, was currently not suicidal or homicidal, was
having grandiose delusions, living at this care facility and going for treatments himself, on risperidone
has stopped taking it since 2 weeks. I asked why did he stopped taking treatment anysideeffects of
risperidone in short. The caretaker said none.he stopped as he believes he does not need any
treatment at all.i asked do you know what symptoms he had when he was first diagnosed with
schizophrenia ?are the symptoms now any different from previous symptoms. She said she does not
know. my ddx was most likely relapse of schizophrenia due to medication non compliance. But since
we do not have previous case notes it may also be a new onset schizophrenia with completely
different symptoms from the previous episode. Mx I said he is getting Commands from god so he can
be risky to himself or others anytime hence needs admission. Questions from caretaker he would not
like admission I said I am sorry as I have to admit under mental health care act which means
involuntary admission Caretaker He does not like hospitals can we treat under community treatment
order I said i said we will keep his wishes into account and community treatment order CTO is
possible but the criteria are stringent like he needs a constant companion who would take
responsibiltiy for his treatment including medication compliance

9) ED, 10 days post partum bleeding and fever

Task: perform PE, findings to examiner, explain pdx and ddx to patient

Approach: all causes of post op fever and secondary PPH

10) ED, CT scan of haemorrhagic stroke. Pt taking perindopril for high blood pressure and aspirin. No
injury or trauma history. Been living together happily with husband
Tasks: explain the findings to the husband, dx and possible risk factors in the patient including the
prognosis with reasons.

Approach: 5 C approach to counselling

Karens case. Prognosis will remain guarded but too early for comment on whether she will be in
vegetative state

11)) low back pain examination. Dx and ddx.

Approach: Back exam—look , feel , move and special tests and neurology

+ve S1 sensation loss and SLR +ve, protective posture +ve, restriction of ROM , Mentioned acute
mechanical back pain with disc prolapse as likely cause

12) GP, pt complaining of lack of sleep and irritable and tired

Tasks: history, give dx and ddx

Approach: quickly rule out tiredness (HEMIFADS) questions and lack a bit of psychosocial
history(depressive symptoms, psychotic questions and support at home), sleep questions(difficulty in
falling, maintaining sleep or early morning awakening , do you feel refreshed after a sleep, )

she had nightmares. So ask about what are these nightmares about. (Have been as a strategist in
afghanistan and experienced very war, now avoiding all things concerning abt war, flash backs and
vivd dreams),once I understood this is PTSD so explored all the PTSD core symptoms(Avoidance,
hypervigilance , reexperiencing ) DDX most likely stressor related disorder namly PTSD but could
also be an anxiety or a mood disorder.

13)friends told that he has parkinsons, Tasks: perform examination give dx and ddx to patient

Approach: Tremor Exam and all causes of tremor

I am very sure this was a real parkinsons patient who was well controlled on medication ( mask like
facies +, walking well, had micrographia, no slow movement, slow speech +, tone a little bit increased,
glabellar -ve.

Ddx : this is most likely parkinsons but could also be normal aging or thyroid problem

14) ED, seeing a patient with rash, has urti 10 days ago, started limping 3 days ago and now joint pain
and tummy pain.
Tasks: explain the dx and ddx,arrange invx, possible mnx.

Approach: all causes of rash

Failed this very simple HSP case. All key steps done , approach –5 , choice of inx 4 , DDX -4 , patient
counselling 3 global 3

I will be kicking myself for this case as in patient counselling I kept referring to liver instead of kidney.
I realised my mistake and apologised to patient but by that time I was toast for the examiner. Missed
opportunity for a perfect score.

15) 30 weeks pregnant, GP, 4th pregnancy. Tests show hypochromic microcytic anaemia.
Tasks: take further focused history, ask pefe, give dx, mx
Approach: Iron deficiency anemia or Thal to confirm with iron studies. Iron deficiency causes—
decreased intake-diet, decreased absorption—malabsorption states, increased loss through
bleeding, increased demand –pregnancy , breast feeding

+ve vegetatrian, decreased spacing between pregnancies

16))STI screening. GP, 27 yrs old lady came to ur gp wants to know how she can know whether she
has contacted with STI. She also wants to know about her new partner. No sexual rship with the new
partner yet. Both have been active in the past. So they want to know either of them has contracted
any STI. She claimed that her new partner would also be ready to do any tests.
Tasks: further focus history, ask PEFE not more than 5 min for these 2 tasks, counsel according to
her concern.

Approach: 5 Ps and extensive STD counseling

Karens case if not mistaken