Station 1-Relapse of Schizophrenia(PASS)

Approach-6, Hx-5, Management-6, Global score-5

Stem: 40+ yrs old female behaving unusually. Previously dx withs chizo
+ve:auditory hallucinations-save the world, stopped medications-feels like she doesn’t need them,
no psych visit for past few years, grandiosity+, does cone-(I did not know what that meant,I asked
what she meant-she said Marijuana),gets disability pension
Took complete psychosocial hx, previous schizo dx-what treatment and whether admission needed.
Discussed that she will need to be admitted and reviewed by psychiatric team. She agreed with the
plan

Station 2-Foot Examination (PASS)

Approach-7, Examination-4, Global score-4
Hind foot examination.
Stem:60+ yr female, previously played sports. Foot pain at the back of foot, now worse. Task: PE
with anatomical landmark to the student
WIPE, Ask for Pain and offer pain killers.
Look feel move. Pulses, CRT
Ottawa rule and all other points on the foot.
Movements, power, reflex.
Special test-Windlass, calcaneal squeeze, mulders, Thompson to check for achilles, talar tilt test, ant
drawer test etc

Station 3-Break

Station 4-Seizure in child(PASS)

Approach-5, hx-5,DDx-5, Global score-5

5 yr old child with seizure for 8 mins previous two history of febrile convulsion brought in
ED.now stable but drowsy. bsl 4.6, temp 37.1, BP 82/50 Task: history,diagnosis with reason
+ve: 2 febrile convulsions when he < 1 yr old , Fam hx of grandmum having febrile seizures
as a child.
Asked when-before, after and during the episode questions.He has seen this happen.
Ruled out head injury, hypoglycemia, fever, dehydration,head injuries, hypoxia, CVS
disorders, infections. Dad was concerned about epilepsy. Fam hx of seizures, heart issues,
diabetes. Birth hx and how his growth and general health was. Any stressors?
Diagnosis: I said it is just the first episode and we still need to find the cause. I said we
cannot call it epilepsy yet. I also mentioned that I cannot come to a conclusion as to what
the diagnosis is and will do further investigations to rule out causes for the seizure including
blood test-FBE, ELFTs to check for electrolyte dist, ECG,Urine dipstick etc(Basically tried to
rule out all infections) and will discuss with a senior doctor regarding imaging. I also
mentioned that the BP seems low

Station 5- GAD(PASS)
Approach-7, Counselling-6, Management-6, Global score-6
Man 40+ feels worried all the time without major life stresses All investigations done-Nil
findings. You diagnosed as GAD. Task-Explain GAD and Management.
Explanation-Based on my assessment you have something called GAD. Have you heard
about this before.( Yes, But I don’t know what it means). Sure let me help you with that. It is
one of the anxiety disorder quite commonly seen, it is an excessive uncontrollable worry
without any major life stress. The exact cause is unknown but is said to be related to
decrease in a calming chemical in the brain. It presents with excessive worrying, irritability,
sleep disturbance, concentration difficulty etc. It also presents with physical symptoms such
as headaches, tiredness, muscle pain etc. Are you with me so far( Yes Doctor).
Mx- Lifestyle modifications, relaxation techniques like yoga, meditation, sleep hygiene,
referral to psychologist for talk therapy, if it does not work, will refer you to a specialist who
might decide to put you on medications. I asked if he had any questions.(He asked-Can I use
Lorazepam ?), I asked if he has used it before and tried to rule out dependane. (Yes, used
once, had good sleep,got it from friend, he said he uses it regularly, no script), adviced on
first trying sleep hygiene, explained in detail regarding the same, explained how he could
get dependant on the meds. He was happy and said yes I will give these things a try!

Station 6-Rubella in Pregnancy (PASS)

Approach-6, History-6, Investigation-7, Patient counselling-5, Global score-6
Stem-32 yr old lady, is your next patient at your GP clinic. She appears concerned as she had contact
with a child, having rubella at the kindergarten where she works as a teacher.Hx, Mx.

Performance- HISTORY-When exposed.

-Rubella confirmed in the child or not.
-Previous h/o rubella or h/o vaccination.
-Symptoms now-fever, sore throat, lumps/bumps around head or neck, rash.
-Periods-LMP,regularity,how long, severity, any pain.Pregnant tested by UPT+ve
-Sexual history-sexually active or not, stable partner, previous pregnancies/ miscarriages,
contraceptive use,PAP smear, Other M/S history,SAD

Explanation:Rubella is an infectious disease caused by a bug which is a virus.Relatively mild disease

but if infected during early stages of pregnancy complications may occur. Could affect baby
producing serious side effects like blindness, deafness, heart defects, limb defects and intellectual
defects.(congenital rubella syndrome).
IGG+ve IgM-ve:Immune and safe to continue pregnancy
IgG-ve, IgM+ve-infected:terminate pregnancy as 1 option, if decides to continue then complications
as above. Notify. Supportive measures. Notify DHS.
Igg-ve, IgM -ve: Need for repeating in 3 weeks. Can continue pregnancy for now .Seroconversion.
Explained vaccination and that cannot be taken now since pregnant. Also said that since this is her
first visit and no antenatal tests have been done- we may do the first sem ones, I said depending on
the results, we can look after you during your pregnancy if you wish to continue.
Station 7-Warfarin counselling (PASS)
Approach-5, History-5, Counselling-5, Global score-5

Stem: A 50 something old man was there as be had been sent by the surgeon to you (registrar) pre
op review for Inguinal Hernia surgery scheduled for 6 days from today. He was on Metformin,
Atenolol and Warfarin. Was on Warfarin for AF.

I assessed compliance, bleeding from anywhere and also asked if he is nervous about the surgery.
Fam Hx. Reg doc visits etc.Somehow the risk I assessed for this case was high, I do not remember
what gave me the 2 score to consider it as high risk and I counselled him accordingly with option of
bridging therapy.(Did not ask for any current stroke symptoms, just went with the flow)

Station 8-Break

Station 9-Pilot

Station 10-BCC(FAIL)
Approach-2, interpretation of investigation-4, pt counselling-2,Mx-2, Global score-2
Stem- 60+ Female had a lesion on forehead biopsied-which showed BCC-was extended to 1
peripheral margin.No lymph node spread.
Task-Explain results, Management plan

I am shocked at the result for this one. I couldn’t have been any more considerate or polite or
empathetic. This was a case I considered as a definite pass and had a really good response from the
roleplayer as well. I counselled her as breaking bad news case while giving her time to understand
things and repeating well so that she is with me, however I did feel like she wasn’t very shocked and
reacted very casually. On asking if she has any specific concerns, she said I am worried that it will
leave a scar on my face-I counselled regarding referral to a plastic surgeon who would look at the
cosmetic side while liasing with her cancer doctor. Out of all my stations, this station was one where
I thought I might get the highest scores and had an amazing rapport with the patient.

Station 11 -IDA PE (PILOT)

6 yr old All iron deficiency anemia lab result. Hb low. mcv low. ferritin low. hb electrophoresis
normal. wbc normal plts normal.explain investigations to mom.what findings will you find related to
result. Explain examination.

I did this as complete haematological examination+looked for all lymphnodes and signs of
bleeding+Growth chart+signs of dehydration. Did not do PR exam in this one.

Station 12-CVS Examination (FAIL)

Approach-5, Choice, technique, organisation and sequence-4, Explanation of procedure-3, Global
score-3
Stem-60+ yr old man who has peripheral edema, SOB on exertion and Orthopnea. Explain PE to
student focusing on CVS examination.
Firstly, this was one examination I have done regularly on patients and had performed in front of my
senior doctors at the hospital I was working just a couple of days before my exam. So again failing
this station was as surprising as the BCC station. Must have made some major mistakes to get a fail
in this one, but wasn’t able to find out what that was.

Performance: Full CV Exam:

WIPE: pt in 45 degrees
GA: dyspnoea, cyanosis
Hands: cyanosis, pallor, clubbing, splinter, crt
hemorrhage, Osler’snodes, Janeway lesions

Arms: pulse, radio-radial/ radiofemoral delay, BP (postural drop)

Eyes, Pallor, Jaundice, Xanthelasma, Fundoscopy – Hypertension
Mouth: Central cyanosis
Neck :JVP( explained the process of measuring with action as well as using the white paper present.
Asked understanding at every step. Student seemed to understand and watched carefully. After
every step I asked if he understood and if I should move on to next)Also explained Hepatojugular
reflex-> Press liver, increased JVP.

Carotid Pulse:Location
Chest
Inspection– Scar, swelling, rash, redness, deformities, pulsations
– PMI (point of maximal impulse) → 5th ICS mid clavicular line
-Pulsations
Palpation: Apex beat, thrill, heave
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Auscultation- Same location as above.
I also mentioned about accentuation murmurs- I asked if he wants to know how it will be done-he
said, if you think you will have time, you can say it. I said I would also like to do a quick resp system
examination and listen to bibasal crackles at the end(did not mention location for bibasal crackles)
I went on to quick abdomen exam-Organomegaly, mass, bruits etc.
Then went ahead with peripheral edema, sacral edema.

Station 14-Lichen sclerosis (PASS)

Approach-4, Hx-5, Diagnosis and DDx-4, Management-4
60 year old came with itchy vulva
+ve-has itching for 2 yrs, worse since past few months, dyspareunia,on Thyroxine(for graves), On Vit
D-Has osteoporosis.
I was very happy about the stem and was very confident initiialy but as I started taking the history,
the roleplayer was not certain about a lot of questions and had a straight face throughout. Could not
build a good rapport throughout, no matter how hard I tried!
She did not give positives for any post menopausal symptoms, but her mood seemed to be swinging
and she had this itching, she said that she has dyspareunia and said it is due to cuts in the vagina
while having sex(I though atropic vaginitis at this stage. She said she has used Canestan in the past
which had worked for her but doesn’t remember why she stopped,she said maybe because it
stopped working.I asked if she has any discharge/smell and she said I has never noticed any but not
sure. She gave a positive for Graves disease (I thought about autoimmune and therefore the Lichen
sclerosis. I asked any flaky appearance (She replied I will show u in a while). Meanwhile I took all
other history and she had not been put on any hormonal replacement.

Now comes the picture(light was reflecting on the picture as if the picture was taken from a glossy
book)-I think I am really blind cause I could not see any vulval rash at all!!I so wanted to say it is
definitely Lichen sclerosis but couldn’t see the white flakes! Did see some whitish discharge-not
curdy though. I said I will have to examine further to give a concrete diagnosis as I cannot see the
vagina in this picture of vulva which is very important to confirm. There are a few dx in my mind
after the hx and picture-Lichen sclerosis, Atrophic Vaginitis, Candidiasis. Mentioned swabs. Gave
treatment options for each of my DDx!

Once I came back, I read the questions in which most people had mentioned Lichen sclerosis. Maybe
it was really that, but I couldn’t see that or confirm it, I only mentioned what I could see. Did not get
good scores, maybe it really was lichen sclerosis!

Station 15- Gout in knee (PASS)

Approach-7, Dx and differentials-7, Choice of investigations-6, Management-7 Global score-7
(all findings given in scenario). Pt on thiazide if I am not wrong Task: explain, investigations and shot
term management.

Gout is a metabolic disturbance in which there is decreased uric acid clearance from Kidney resulting
in deposition of uric acid crystals in joints, soft tissues and kidney.
Cause- these crystals accumulate either due to reduce kidney clearance or excessive synthesis & uric
acid in the body.Its common condition usually runs in families, more common in men and pt who are
overweight, consume excess alcohol, purine rich food-red meat,fish etc. Some medications can also
contribute to it .Its frequently associated with HTN, increase lipid,DM type 2. Symptoms-
swelling,redness and painfull during flareups.
Mx-Investigations: Xray, Aspiration, (Mentioned bloods but did not say to check uric acid, not sure if
it was given in the stem, Thought it must be a critical error!)
Discussed regarding alcohol and all risk factors. This patient ate red meat regularly. So adviced
regarding the same as well+ Indomethacin- SE discussed+Mentioned allopurinol after 8 weeks of
settled (Although only short term mx was asked, I did realize that I covered even the long term ones)
Start Indomethacin,change of BP medications(Referred to his usual GP for the same)

Station 16- Post op delirium (PASS)

Approach -5, Investigation interpretation-6, Accuracy of exam-4, Dx and DDx-6, Global score-5
Stem: Long scenario with preop assessment long list given with alcohol intake all preop
investigations, post op assesment done. Task:Tell brother preop and Postop findings.Diagnosis ,ddx.
To be honest I have no idea what they meant by accuracy of examination as we weren’t supposed to
do any. I did read out the investigations done and what still needs to be done with all DDx in
mind.The diagnosis I said could be alcohol withdrawal but I cannot say that with certainty yet as
most of the post op assessment said that it could not be done due to the patient’s agitation. I
mentioned I will do further assessment when possible and calm him at this stage. I mentioned all the
causes- hypoxia, electrolyte disturbance, infections, hypo/hyperlglycemia, medications etc.
Station 17- Scarlett fever(PASS)
Approach-6, Hx-7, Dx and DDx-6, Mx-5, Global score-6
Stem: 7 yr old with sore throat rash and fever. All examination findings were given after 4 mins of
history. Task-Hx, Diagnosis and management.
+ves mild dehydration, fever(started yesterday),sore throat today, rash on trunk,arm and thigh
(started today)-red,blanchable, red pharynx, swollen tonsils,not itchy. As soon as one of the words in
the description of the rash said ‘Rough’, I remembered my rural rotation where I almost missed a
sandpaper rash and a very knowledgeable consultant diagnosed it as Scarlett fever on first sight. I
gave the diagnosis as Scarlett fever. Said it is a bacterial rash .In my management I mentioned blood
test,swabs(must have mentioned covid, resp swabs and viral swabs),and said I would lie to start with
antiobiotics-methylpenicillin+PCM +fluids+rest. Discussed about slowly trying to start giving food
and not force feeding.I also mentioned school exclusion for 24 hours after starting antibiotics.

Station 19-Allergic Rhinitis(PASS)

35 ye old woman, runny nose. Tas-Hx, diagnosis and Mechanism of action
+ve previous hx of asthma, has had flu vaccine before, 6 months since this started. Moved to new
house. Has moved to new house with carpet few months ago. Timeline correlates.

Station 20-Eye PE(PASS)

Stem- Stem-EYE PE. Pt came with B/L Red Eyes. Task: PE. Name instruments and how you will use
them Approach-6, Choice, technique, organisation and sequence-6, Familiarity with test
equipments-6, Global score-6
Did complete eye examination including fundoscope, Cranial nerves etc, missed Slit lamp and
thought it was a critical error.