Feedb%ck of 13/12/2018

Hiii every one

Th%nks God %nd to this
wonderful group I p%ssed my
AMC clinic%l ex%min%tion on
13/12/2018 from the first tri%l I
p%ssed 12/14 st%tion .. itʼs h%rd
%nd long journey but itʼs never
impossible.. th%nks to lovely
Dr.M%ri% Fortun% ch%%rl%s for her
wonderful course , th%nks to my
study p%rtners wish %ll the best
guys.. Iʼll post my feedb%ck
hopefully to be useful for you
guys

St%tion 1 Injury to chest

P%ssed ... Glob%l score 4
A young p%tient h%d % MVA %nd
you %re %n ED intern , prim%ry
survey done , Neck cle%red (I
think ), BP ,HR ,RR %ll norm%l . He
compl%ins of SOB , chest
percussion showing dullness in
the right side %nd reduced bre%th
sound on %uscult%tion on the
right side .. pt on O2 %nd h%d
p%in relief ..CT chest provided .
T%sk expl%in CT %nd immedi%te
m%n%gement
First , I completely missed the
h%emoth%rx
Couldnʼt see the blood
collection , only figured
pneumothor%x which w%s not
consistent with the ex finding .
Entered the room , p%tient w%s
lying on couch with O2Supply ,
introduce my self %nd %sking him
if heʼs comfort%ble? He s%id yes
Iʼve just took p%in relief , I told him
letʼs give the p%in relief % time to
kick out the p%in then %sked the
ex%miner if the vit%ls were still the
s%me he %nswered yes then
st%rted to expl%in CT .. this is %n
im%ge of your chest showing
he%rt, lung %nd ribs bone ..if you
c%n see there is some bl%ck
sh%dow on the top of the im%ge
this represent %ir so there is %ir
get tr%pped between the l%yer
th%t surrounds your lung so this
%ir c%using compression %nd
coll%psing of your lung th%tʼs why
you h%ve theses symptoms then
t%lked %bout chest tube
ev%cu%tion %nd need to be
%dmitted few d%ys with repe%t
the im%ge %nd involve my
supervisor %nd the registr%r %s
you will be m%n%ged by % MDT
te%m .. I finished e%rly but I w%s
not sure %bout the expl%n%tion
then went b%ck to CT %nd I
suddenly s%w the he%mothorx
then quickly told the ex%miner Iʼm
sorry Iʼm getting confused I c%n
see blood collection ple%se I
would like to expl%in %g%in to my
p%tient . Ex%miner s%id itʼs your
p%tient do wh%t ever you w%nt
.. then %ppologized to the pt
%s I got confused with %nother Ct
for %nother pt %nd expl%ined the
hemothor%x %s there is blood
collection %nd need to be
ev%cu%ted with chest tube .. he
%sked me %bout %ny
complic%tions? I told him yes m%y
there is bleeding or infection or
injury to the nerve or lung but weʼl
try to put it in % s%fe pl%ce to
%void these consequences .. do
you %ny f%mily member with
you ? He s%id theyʼre coming on
their w%y . Bell rung

St%tion 2 OSA -snoring %nd

%denoid
Assessed - not scored

St%tion 3 rest

St%tion 4 Medic%tion in
pregn%ncy. Lithium
P%ssed ...Glob%l score 4
Fem%le pt h%ving bipol%r disorder
on Lithium
she h%d hospit%l %dmission 9
months %go for m%nic %nd
depressive episodes %nd she w%s
disch%rged on Lithium . Blood
level of lithium being within
norm%l r%nge . She h%s
%menorrhe% 6 weeks %go %nd
thinks sheʼs pregn%nt ( %s I
remember) . Counsel the pt
%ccordingly
Entered the room , introduced my
self , confidenti%lity st%tus, %sked
period questions 5P , %re you
pl%nning to get pregn%nt? Yes
Any pregn%ncy test %t home?
No .. thyroid question, previous
dx reg%rding bipol%r
question,HEDDSSS, ASEPTICJ ,
especi%lly mood ch%nges %nd
howʼs her mood right now
P%st MHx ,SHx SADMA %ll neg
Expl%ined need 1 yr of mood
st%bilising %nd free of symptoms,
h%ving good support , good sleep
being well hydr%ted then you c%n
get pregn%nt . Expl%ined either
you %re pregn%nt or not ,lithium
c%n %ffect on thyroid , need to
involve psychi%trist so if you %re
pregn%nt the psychi%trist will
either stop lithium especi%lly
during first trimester, or introduce
%nother medic%tion if required ,
MDT , high risk obst clinic , US
%nd echo to he%rt %s lithium
%ffect the he%rt , then suddenly
remembered I need to do
pregn%ncy test to confirm her
pregn%ncy th%nks God I told
her .. re%ssure her %nd bell rung

St%tion 5 post p%rtum bleeding

P%ssed ... glob%l score 5
10 d%ys post p%rtum pt
presented with PV bleeding .T%sk
hx , PEFE , DDx with re%son
Entered the room , confidenti%lity
st%tus ( %lmost %ll gyn c%ses I
offered confidenti%lity st%tus)
when the bleeding st%rted? How
m%ny p%d ch%nges? He%vy
bleeding ? Bright red? Clot
p%ss%ge ? SOB dizziness he%rt
r%cing? Do you feel comfort%ble
or you w%nn% lie down ? W%s
comfort%ble, mild %bd p%in , no
fuel smell disch%rge , NVD
episiotomy well he%led no te%rs ,
5b norm%l , no bleeding else
where , no wt loss or %ppt loss,
no lump or pump, e%ting well
drinking well , no bleeding dis, no
blood thinning med , no whether
preference , SADMA neg no p%st
med or surg hx, PEFE temp of
38.5 , %bd tenderness , bleeding
from cervic%l os not from v%gin%
%nd episio well he%led .. DDx post
p%rtum bleeding due to infection
expl%ined how , ret%ined
product , infected episiotomy or
cut , bleeding dis blood thinner
med

St%tion 6 p%lpit%tion %nd

dizziness
P%ssed ...glob%l score 4
57 ye%rs old m%le presented with
p%lpit%tin %nd dizziness .. T%sk
t%ke Hx , Expl%in ECG, Dx with
re%son
Entered the room pt w%s sitting
looked dyspneic introduce my
self , if he feeling comfort%ble?
Lie down in bed? No .. %sked vit%l
from ex%miner ( ex s%id Iʼll give
you c%rd %fter your hx) .. so
continued with pt since when
feeling p%lpit%tion %nd dizzy ?
Any p%rticul%r event before th%t ?
Getting worst with time? Relieved
by sitting? W%shing f%ce in cold
w%ter? Mild SOB ,No Chest p%in ,
tr%um% ,fever , we%ther
preference , cough , %bd p%in ,
he%d%che , norm%l bowel
especi%lly ch%nge in stool color
%nd bl%dder function , no LOC ,
n%use% , vomiting , PMHx PSHx
SADMA %nd coffee %ll neg.. first
episode , no wt loss or %ppt loss ,
no bleeding ,
Exminer g%ve me ECG of SVT to
ex%miner ( took few seconds to
re%d it in my mind then s%ying
this is %n ECG if my pt showing
he%rt r%te 150 bpm regul%r , p
w%ve being %lmost buried in T
w%ve %nd n%rrow QRS complex
these fe%tures %re consistent
with SVT) expl%ined to role pl%y
%nd told him prob%bly youʼre
h%ving SVT dr%wing % he%rt %nd
telling him our he%rt is just like %
house when itʼs wired with
electricity to provide power for TV
fridge lights so our he%rt need
power to pump effectively %nd
delivers blood to different p%rts
of the body efficiently. The he%rt
h%ving upper %nd lower sides the
upper p%rt h%s % focus or %
circuit to gener%te power so wh%t
h%ppen here is this focus
gener%te extr% electric%l %ctivity
m%king your he%rt working %nd
pumping f%st %nd quickly th%tʼs
wh%t we c%lled SVT . Re%sons
m%y the he%rt muscle itself ,
thyroid , s%lt content imb%l%nce
bell rung

St%tion 7 Loss of consciousness

Bre%th holding %tt%ck
P%ssed ... glob%l score 4
3 ye%rs ( I think) old child come to
your GP setting hit his finger with
the door %nd he cried %nd LOC
his finger is blue now T%sk , hx,
expl%in Dx, immedi%te mx, long
term mx
F%ther sitting %lone ,
introduce ,re%ssure him wh%t
h%ppen ex%ctly , before during
%nd %fter events questions he
s%id once he hit his finger he
cried then hold his bre%th %nd
turned blue then LOC I think less
th%n 1 min) how is his finger now?
Iʼll check it in % while BIND sick
child question, first time PMHx is
he difficult to de%l with ,? Does he
%ccept s%ying no? , typic%l
bre%th hold %tt%ck , expl%ined itʼs
not h%rmful , not epilepsy ,not
c%using br%in d%m%ge or
intellectu%l imp%irment. Itʼs type
of beh%viour disorder when b%by
exposed to p%in or frustr%tion
br%ise your b%by for good
beh%viour donʼt punish him ,if he
got %nother %tt%ck just w%tch him
donʼt le%ve him %lone itʼs howʼs
your b%by need %ttention from
you , red fl%gs LOC for more th%n
5 min, bell rung

St%tion 8 - rest

St%tion 9 Acute %bdomen ex

Assessed not scored
St%tion 10 Di%rrhe% - Gi%rdi%sis
P%sses ...glob%l score 5
27 ye%rs old h%ving di%rrhe%
T%sk..hx , Dx DDx with re%son

This is w%s my first

st%tion ,introduce , %sked since
when 6 month , %ny thing h%ppen
in p%rticul%r? No , %mount , how
frequent , no bulky h%rd to flush
%nd not w%tery ! No blood or
mucous or indigested food, no
b%d odour, Gener%l tommy p%in
%nd discomfort , relieved p%rti%lly
by medic%tion but still h%ve it , wt
loss of 5 kilos, no LOA, no r%sh ,
mouth ulcer, joint p%in , not
rel%ted to food but d%iry product
m%ke it worst , no stress,no
vomiting no n%use% no j%undice
no lump or pump , cont%ct hx
non , tr%vel hx yes when 6 m %go
where to B%li , food street no ,
w%ter supply , whoʼs went with
you ? Friends , %re they
compl%ining of the s%me ? No ,
%ny sex ( %fter confendet%lity
st%tus) no , PMHx PSHx f%mily
HxSADMA neg
Expl%ined most prob%ble
Gi%rdisis -bug infection of the gut
%ffect the inner lining of the
bowel m%ke it irrit%ted infl%med
%nd c%using di%rrhe% , you h%ve
wt loss %s there no proper
%bsorption of essenti%l nutrients
%nd vit bec%use of this bug .its
m%inly tr%nsmitted by
cont%min%ted food , w%ter or
even touching the dirty infected
surf%ce , DDx l%ctose intoler%nce
( %s he told me dis%rr%y getting
worst by d%irry product ,
m%lign%ncy , IBD, IBS bell rung

St%tion 11 He%d%che
P%ssed ... Glob%l score5
37 ye%rs old fem%le presented
with he%d%che
T%ke Hx, PEFE, expl%ined the
possible di%gnosis with re%sons
2 min thinking outside org%nized
my mind %bout the DDx tension,
cluster ,migr%ine , tempor%l
%retritis, meningitis, SOL, referred
p%in from e%r , nose , tooth etc
Entered the room , role pl%y w%s
%nxious %bout her he%d%che
s%ying she thinks sheʼs h%ving
c%ncer! Introduce my self %nd
c%lmed her telling her I
underst%nd you %re being % bit
%nxious %nd distressed %bout
your he%d%che Iʼll do my best to
find out the c%use of your
he%d%che let me h%ve % simple
chit ch%t with you I might %sk
some priv%te %nd sensitive
questions %nd let me re%ssure
you wh%tever weʼre t%lking %bout
will be kept confidenti%l unless
there is %n issue is th%t %lright?
She %greed .. I %sked her since
when? 3 months %go, site? All
over her he%d? Do you h%ve %ny
p%in %t the moment? No , do you
need %ny p%in relief, no , c%n you
sc%le your p%in ? 3-4 /10, timing ?
Tow%rd the end of the d%y %t the
evening . No fever, n%use%,
vomiting , we loss , loss of %ppt,
no blurred vision , no
photophobi%, not %grrev%ted by
loud voice or noise chocol%te red
wine, citrus food , relieved by
P%n%dol %nd sleep , sleeping
well ,no runny eyes , blocked
nose , No ENT or dent%l
problem ,no shoulder or hip p%in
or we%kness.. No %bd p%in ,
e%ting norm%lly , norm%l bowel
%nd bl%dder function , recent job
promotion stressful %nd
dem%nd%ble job ,m%rried 3 kids
husb%nd help her %t home , p%st
med Hx h%ving HTN on
medic%tion well controlled ,
SADMA neg , f%m hx of migr%ine
her sister h%ve it , her f%ther died
oh c% , Iʼm sorry to he%r th%t how
you coping with th%t? She
%nswered m fined th%nks for
being nice %nd %sking me %bout
my d%d! Told her no worries ! No
previous oper%tion forget to %sk
gyn hx!
PEFE gener%l %ppe%r ex%miner
told %s she looks in front of you !
Ok Vit%l norm%l , CNS %s cr%ni%l
nerves , fundoscopy , upper limb ,
lower limb CVS , resp %bd pelvic
ex %ll norm%l
No neck stiffness , forget to %sk
%ny thick tortuous tender
tempor%l vessels or visible
puls%tion ! Anyw%y %ll ex neg
%nd no office test
So my Dx is tension he%d%che
%nd expl%ined itʼs rel%ted to
stress DDx: migr%ine ,meningitis
ENT،dent%l c%use .. %g%in forget
tempor%l %retritis !

St%tion 12 beh%viour%l compl%int

Video of OCD - present MSE
F%il - glob%l score 3
Ple%se find someone who p%ssed
this st%tion I donʼt w%nt to
confuse you

St%tion 13 - rest

St%tion 14 lower limb we%kness

 TIA + lower limb we%kness
F%il - glob%l score 3
%nother time find some one who
p%ssed it

St%tion 15 Menstru%l compl%int

Exercise induced
%menorrhe%
P%ss... glob%l score 5
Young fem%le ( donʼt remember
her %ge) presented with 12
months of %menorrhe%
T%sk Hx , Dx DDx with re%sons
Entered the room , introduce my
self , confidenti%lity st%tus , %re
you pl%nning to get pregn%nt?
no .. since when ? 12 months,
h%ve you done %ny pregn%ncy
test %t home? No , st%rt to %sk %ll
ddx of second%ry %menorrhe% 5P
period questions %nd how w%s
her period before it completely
stopped? , previous
pregn%ncies? No,Wt g%in , f%ci%l
h%ir %cne?
Whether preference , visu%l
disturb%nce, he%d%che , milk
disch%rge ,norm%l e%ting not
induced vomiting or l%x%tive use ,
not on strict diet , no hot flush or
night swe%t ,PMHx PSHx PFHx
SADMA %ll neg , home situ%tion
%nd work norm%l , %ny exercise ?
Yes .. ch%mpionship for tri%thlon ,
tr%ining 3-4 hrs /d%y ... my DX
w%s exercise induced
%menorrhe% dr%wing % di%gr%m
%bout HPO %xis %nd expl%in

St%tion 16 E%r p%in - AOM

P%ssed ...glob%l score 6
Young fem%le presented with left
e%r p%in
T%sk hx for 2 min, ex%min%tion,
Dx with re%son
Entered the room , introduce,
since when , which side %ny p%in
%t the moment no ? Score the
p%in 3-4/10 need p%in relief? No ,
r%di%ting no , relieving f%ctors
profen %nd p%n%dol , no
disch%rge, no tennitus( she %sked
me wh%tʼs tennitus , told if you
he%r %ny sound like % whistle s%id
no) , he%ring imp%irment on the
left ,no issues on the rt e%r , no
redness, bleeding , tr%um% ,
fever , he%d%che or neck p%in or
stiffness ( to exclude extr% ocul%r
m%nifest%tion) no LOW or
LOA ,e%ting well , sleeping well
Exmin%tion ( I %sked permission
from the pt to ex%miner her when
I introduce my self then I told the
pt Iʼll ex%mine you now she told
me %lright then st%rted with GA ,
%sked ex for vit%l %ll were norm%l
then jumped to ex%mine the e%r
%nd she told me donʼt you
w%nt to w%sh your h%nd first !!
I w%s shocked then %pologized to
her %nd used %lcohol to w%sh my
h%nd %nd st%rt to ex norm%l %nd
dise%sed e%r , inspection ,
p%lp%ting with LN ex , f%ci%l
nerve , tuning fork rinne test %nd
forget to do Weber test , then
%utoscope on % dummy ( there
w%s cle%r EUC no w%x no
disch%rge no bleeding no foreign
body , red tymp%nic membr%ne
no perfor%tion , loss cone of
light , h%ndle of m%leolus
prominent ) then expl%ined to pt
itʼs %cute otitis medi% dr%w %
di%gr%m showing extern%l middle
%nd intern%l e%r %nd expl%in its
infection of the e%r (middle e%r )
m%inly e%r drum th%tʼs why you
h%ve p%in %nd he%ring
imp%irment .. bell rung

St%tion 17 p%llor
P%ssed ...glob%l score 4
A mom brought her child 3 ye%rs
old ,they recently return from %
tr%vel ( I think ) %nd the mom
noticed her b%by is p%le. Youʼve
ordered blood test %nd you got
the results
T%sk expl%in result , HX, PE on
c%rd , Dx DDx
There w%s % long list of blood test
( Hb low , WBC norm%l ,plt
norm%l , RBC hypochromic
mucrocytic , iron studies %ll low )
Entered , introduce ( should greet
the pt without introduction %s this
is the second visit ) howʼs your
b%by now , expl%ined In our blood
we h%ve 3 types of cells,wbc is
fighter cells responsible of
fighting infection %nd bug which
is norm%l now , plt responsible of
stopping bleeding which is
norm%l ,RBC responsible of
delivering O2 to different p%rt of
the body %nd this h%ppen
through % portion on the RBC
c%lled Hb which low here .. th%tʼs
c%lled %nemi% . To m%ny c%uses
of %nemi% th%tʼs why weʼve done
%nother test c%lled iron which imp
in Hb production this iron level is
low so itʼs c%lled iron def %nemi%
even the RBC getting sm%ller
insize in order to compens%te
this low Hb level , %re you with me
so f%r? Yes
Then st%rt to t%ke Hx focused on
feeding - cow milk feeding since
6 m , det%iled bowel
motion ,nobleeding ,Sick child
question bind PMHx PSHx
medic%tion , %ny f%mily hx of
%nemi% , fin%nci%l support ....
c%rd ex showing every thing w%s
norm%l %p%rt from being
p%le ..expl%ins iron de %nemi%
due to c%w milk enterop%thy

St%tion 18 rest st%tion

St%tion 19 he%lth review -PVD

P%ssed ... glob%l score 4
Old %ge wom%n ( forget the %ge)
living in nursing home %nd you
%re her GP presented with bluish
discolour%tion of both lower limbs
%s %ppe%rs in the photos inside
she w%s he%vy smoker quit 2 m
or yrs %go I c%nnot remember,
Hyperrensive on med ( not bet%
blocker %lso c%nʼt remember the
n%me sorry ) t%sk hx , Dx DDx
Entered room, introduce my self ,
there w%s % lovely old wom%n
s%id I think l h%ve % g%ngrene in
my leg , re%ssure her telling her
Iʼll try my best to find out the
c%use , since when , how it
st%rted? Getting worst or better ,
%ny p%in while w%lking? Yes need
% rest %fter th%t , nor rest p%in ,
%ssoci%ted swelling , no SOB , no
fever, no tr%um% , p%in like
cr%mpy not sh%rping or burning ,
no tr%vel no prolong
immobilis%tion , Did not %sk %ny
think of 5P! ( I believe I shouldʼve
%sk ) , no v%ricose no insect bite ,
no chest p%in or p%lpit%tion ,
PMHx hypertension in med %ll
previous Dx questions, SADMA
He%vily smoker previously
%ppreci%ted for stopping %nd
others %ll neg , no PSHx no FHx
PEFE, with photo bluish both
lower limb %nd swelling , cold to
touch , not tender, %bsent
peripher%l pulses up to
femor%l ,berguer test not done
ABI not done
Vit%l st%ble
Expl%ined my Dx PVD m%inly
%rteri%l by dr%wing lower limb
%nd blood supply reduced due
long-st%nding high BP %nd
smoking ( did I not t%lk %bout the
med which I forget the n%me
bec%use donʼt know if it c%use
%ny v%sosp%sm ) my DDx DVT,
chronic venous insufficiency,
infection %nd expl%ined % bit
%bout e%ch bell rung

St%tion 20 p%inful foot

P%ssed... glob%l score 5
Young fem%le presented with
p%in on her foot t%sk hx for 2
min , ex%mine the pt , Dx %nd DDx
Entered the room % lovely young
fem%le w%s sitting there ,
introduce, where is the p%in? She
s%id between third %nd fourth
toes , since when , no tr%um%,
stepping on foreign body , insect
bite , fever , first time , %ny p%in
now ?offered p%in relief , is the
p%in h%ppening with the first step
in the morning ( to differenti%te it
from pl%nter f%sciitis )? No , p%in
%t the end of the d%y , %sked for
%ny Pebble sens%tion? S%id wh%t
th%t ( told her feeling like if youʼre
stepping on sm%ll stones? S%id
no ! , %ny running or he%vy w%lk?
S%id yes Iʼm m%rching with friend
st%rted recently , no p%in
elsewhere No redness , bleeding ,
no joint stiffness , no difficulty in
w%lking
Ex%min%tion no w%sh my h%nd
get permission
G%it , norm%l , inspection no
redness no swelling no
deformity , p%lp%ting for temp ,
tenderness Ott%w% rules (,
pulses, ) movement Iʼve done only
%ctive %nkle movement no
p%ssive , speci%l tests ( mulder
click test positive ) windl%ss test
neg ... my Dx w%s Morton
neurom% expl%ined with dr%wing
itʼs nerve between 3rd %nd 4th
toes get infl%med %nd thickened
th%tʼs why you h%ve p%in while
w%lking then remembering to %sk
if she we%r tight n%rrow pointed
shoes ? S%id yes! Then telling
her itʼs m%inly %ssoci%ted with
these shoes , my DDx M%rch
fr%cture due to excessive
w%lking , pl%nter f%sciitis ,
%rthritis bell rung

I hope itʼs useful .. never give up .

Yes Iʼve done my best but I w%s
%n %ver%ge in t%king hx %nd ex ,I
w%s stressed too much, Iʼd done
m%ny mist%kes but no m%jor
critic%l errors %lthough f%iled in 2
c%ses ... if I c%n do it definitely
you c%n do it ... wish you %ll the
best %nd good luck