I passed AMC Clinical Exam on 4th October 2017 with overall score of 14/16.

This group was

very useful during my preparation. I read many detailed recalls I found in the group file
section initially, to get an idea about the exam. So, this is my attempt to help others.
Please be careful how you use recalls, do not try to memorise tasks or positive findings. This
may narrow down your approach and the examiner will sense this. Better to read around all
the topics that have come up so far and have your own general approach in history taking /
asking PEFE / IX / explaining DDs /MX etc. So, in the exam you never go back into somebody
else’s recall but into your own medical knowledge. My recalls are in no way perfect as for
the scenario or what I did in the tasks. (but I tried my best 😉) I have forgotten so many
details by the time I recovered enough to write this.
In all the cases, I greeted the examiner and patient and asked vital signs to check for stability
when appropriate, but did not repeatedly type these to save time. Whenever a concern
came up in history I stopped and addressed that. Showed empathy whenever its needed.

AMC CLINICAL EXAM 04 OCTOBER 2017- RECALLS

Psychiatry
1. Mood disorder- Pass
Scenario

You are a GP. Patient is a 30-year-old lady, who has had an enquiry in workplace regarding a fraud,
was cleared already. Now complains of feelings of guilt, low mood, LOA, early morning waking, etc.
for 6weeks. (Enough lengthy details were given to definitively diagnose major depressive episode.)

Tasks:

 Take relevant further history

 Explain your diagnosis to patient
 Explain management to patient

Take relevant further history

Role player was much older looking lady, observed - normal appearance/ behaviour/speech. Gives
ready answers in detail. I asked few points to elaborate on her mood and symptoms such as sleep
(wakes early morning-cannot fall back into sleep)/ appetite/ anhedonia (present), not enjoying
friends company, do not go out/ still strongly feels guilt despite no case against her anymore/
problems at workplace? Cannot remember all her replies.

Most importantly - has she ever had suicidal ideas/ plans or past attempts? No/ Any passing
thoughts of same? (I sometimes wish I never wake up from sleep...but never thought of killing
myself.) / Any family history of suicide? No

No psychotic features...
Not excessively anxious.

SAD negative.

Lives alone. No family support. No partner. Financially ok, but reluctant to work now.

She generally gave me the idea that she has good insight into her condition. I appreciated that and
the fact that she came looking for help..

Explain your diagnosis to patient/ Explain management to patient

Explained most probable diagnosis as ‘major depressive episode’ possibly triggered by the events at
her workplace. Explained her symptoms and how all these points to this diagnosis and explained
about pathophysiology a bit. Very common condition and effective treatment available. You are not
going to feel like this all your life. I do not remember if I gave any DDs here or whether it was in the
tasks.

Treatment involves SSRI and psychologist referral for CBT. Stressed that SSRIs take at least 2weeks to
show any change in condition, in the meantime her symptoms may escalate. She may need
psychiatry referral later, but I will also follow her up frequently and regularly. Told her that I am
worried as she lives alone and no support available (faintly remember she said she had a friend who
lives near). Gave her a number that she can call 24/7 if she has any suicidal ideas and need help/ she
can go to nearest ED. Alert her friend also. Stressed that psychotherapy is also very effective.

 3 out of 4 key steps were covered.

1. Assessment of change in behaviour - Pass

Scenario

22-year-old male brought by his father due to behavioural changes. Had psychotic symptoms 18
months before and diagnosed as schizophreniform disorder.

Tasks:

 Take relevant history

 Advice patient on probable diagnosis with reasons

Take relevant history

Approached as to why his parents are upset. (I keep to my room.) Why? (I hear voices.)

What do they say? (Can’t remember his responses, but that was about galaxies and universe and
some change in the world in which he has a big role to play.)

How long has this been happening? (Quite a while… / he did not give a specific answer.)

Do they ask you to do something? (No, they just discuss among themselves.)

Any suggestions in these discussions, of hurting yourself or anyone? No

Do you see them? No

Feel, see or smell anything strange? No

Do you think life is worth living? (Of course.)

Ever thought of suicide? No

No thought insertion/ withdrawal. He thinks people in TV/radio are talking about him sometimes.

Non-smoker/ not using alcohol/ used (mentioned the name of a strange street drug -can’t
remember which) before the previous admission but never after discharge.

What happened at that time/ symptoms seems to be same. Antipsychotics tailored off and with
drown sometime back.

Home: Supportive parents and brother / no partner

Worked previously. Stopped because he has more important mission now. 😉

When asked what was his idea about medical treatment for this - showed insight, said the pills
worked well last time.

Judgement fire in the room question- showed good judgement.

(Patient was frequently distracted by voices during our conversation/ so I had to wait and ask my
question again. Noticed that he was not talking with the voices nor disturbed by them.)

Advice patient on probable diagnosis with reasons

You are having acute psychotic episode again probably due to relapse of schizophreniform/
schizophrenia as diagnosis depends on duration of symptoms. Psychiatrist evaluation necessary for
definitive diagnosis.

A common condition… Can be due to illicit drug use but he denied it.

Can’t remember much about the discussion though. He was surprisingly interested, even when I
described increased dopamine in brain as the cause.

 All 3 key steps covered.

OBS/GYNAE
1.Bleeding -Pass
Scenario

10 days post-partum. Delivery history was given. Complete placenta. Episiotomy done. Was ok till
today. Bleeding for 2 hours.

 History for 3 min

 Do relevant physical examination
 Explain most probable diagnosis to patient.
Role player looked depressed. I felt that I did not understand the case fully. But it seems I have
covered all five key steps – only scored 3 in history though. When short history and PE both involved
need to practice how to manage time. I got anxious about saving time for PE and took a too short
history I think.

HISTIRY FOR 3 MIN

No further important addons to given delivery history. Rest of the history went something like-
Started bleeding bright red blood 2 hours before, 2 pads fully soaked so far. Mild lower abdominal
pain. No dizziness/ Fever? Feels cold/ Waterworks-OK/ Bowel habits-OK/ episiotomy wound healing
well -no discharge /Mild breast tenderness/ Breastfeeding satisfactorily established/ baby is fine and
easy to look after/ good support at home

Examination

Commented on general appearance/ vitals: Normal except -Temperature high- (examiner)/ pallor-no

Head to toe exam done. Only found mild suprapubic tenderness. Uterus- asked from examiner for
findings: 12 weeks size / firm.

Speculum exam: Epis healing/ Blood+/ Cx: no abnormal findings

Vaginal bimanual exam: Uterus 12 weeks/ non-tender.

Said I would do urine dipstick- Normal

Explain most probable diagnosis to patient

Endometritis causing secondary bleeding

Drew diagram and explained.

2. Vaginal bleeding - Pass

Scenario

Post-menopausal bleeding 2 days.

 History
 Focused examination from examiner
 Explain most probable diagnosis to patient.

C/O brownish discharge 2 days.

Menopause 15 years before no bleeding till 2days back. Used 2 pads so far. No abdominal pain. Last
pap smear 2 years back. (Told her we’ll have to do it today.)

Not sexually active for years. No previous vaginal discharge. No fever/ LOA/LOW

Waterworks and bowel habits normal.

Never been on HRT. No menopausal symptoms. Never had breast lumps/surgery.

Assessed for risk factors of endometrial ca. 3 children. No family history of endometrial (womb) or
colon cancer. Not taking any meds. (esp. tamoxifen), no evidence of PCOS in the past history. Not
used OCP…

SAD-no

PEFE:

All normal except blood in vagina/ not coming from OS. Atrophic vagina. Said I will do a PAP smear
during speculum exam. When asked for BMI, examiner said she is as you see her -role player was
quite lean.

Diagnosis:

Atrophic vaginitis is most probable diagnosis. Explained the effect of estrogen on integrity of
epithelium………. And explained her examination findings…

At her age endometrial carcinoma is the most important diagnosis we want to rule out with this
presentation, (she got anxious- so added as she does not have any of the risk factors apart from
being post-menopausal and age, so atrophic vaginitis is the most probable) but cancer should be
excluded with a transvaginal USS, and PAP smear test before giving her above diagnosis.

 4/4 key steps covered.

3. Antenatal care
Scenario:

You are a GP. Seeing this patient for the first time. 30year old female 12 weeks POA, your colleague
had done antenatal bloods. Patient had come back for results. Usual GP not available today. You will
be given a card inside the room with investigation findings.

Tasks:

 Explain results to mum.

 Explain management. Immediate and long term.

I was expecting something like rubella or varicella positive. So, it was shocking to see HIV positive
(Antigen and antibody). Even before you finish reading Ix card patient talks to you asking how are
the tests. I decided to handle it as a breaking bad news case (I myself was still in shock!) and asked if
she knew what tests were done. (no)

I summarised that they’ve done blood group (…+ve) and some checks for certain infections that are
important in pregnancy. Rubella and varicella is negative but there is one concerning result……
waited for a while... Did you know HIV test was done? I don’t remember the specific words I used
but said that she is HIV positive, and waited for that to sink in … She acted very worried but did not
cry (there was a tissue box, but I did not give it to her.) …. Then I said something to show empathy…
and gave hope saying that HIV is not what it used to be, as nowadays there are very effective
antiretroviral drugs…
Then I asked her I can explain things in more detail regarding her further care now or does she wish
to wait or want someone else to be present. She said its ok to continue.

Then I assessed her knowledge on this stated this does not mean she has AIDS… Asked a bit of
history- gathered that she has had casual partners before current long-term partner but always used
condoms in those encounters. Baby was unplanned but now they are happy to have the baby.

IV drug abuse – when she was a teenager shared needles!

Current smoker and drinks alcohol (not much) – Addressed then and there but postponed more
discussion 😊 Felt overwhelmed as so many issues kept coming up. ☹ I think she was already on
folic acid…

Management:

Will refer her to high risk pregnancy clinic where infectious disease specialist and obstetrician will
look after her with frequent clinic visits. They will do further testing to confirm HIV and see the viral
load as well. More Ix to check for other STI and blood borne viruses. Possibility of vertical
transmission explained but it’s not a must and means of minimising the risk will be discussed with
her and starting of antiretroviral drugs will be considered by ID specialist.

I totally forgot her partner or contact tracing…so I thought I lost the case, but with a worried patient
being led by her reactions is more important than covering all the points I think. I had to talk slowly
and show my empathy on and off, so this takes time…😉

 All 4 key steps covered.

PE
1. Osteoarthritis of knee – Examination - Pass
Scenario

52-year-old with knee pain. No history of trauma. Cannot remember the stem much.

Tasks

 Examine the knee giving a commentary to examiner

 Diagnosis and differentials to patient

Patient was standing in the room. So, started with gait which was normal but patient complained of
pain while walking.

Did the knee exam as in the Geekimedics youtube video.

Positive findings:

On inspection he had a red colour very minor skin rash which I mentioned just to show I am a very
keen observer 😉, but on palpation when he complained medial and lateral joint line tenderness, I
looked more closely and found soft swellings on either side of right knee- left knee normal… so I
admitted my mistake and commented on this.
No other positive findings. Special tests also negative but tenderness was quite generalised in the
joint.

Diagnosis/ DD

Osteoarthritis is most probable diagnosis. Told him it’s a degenerative condition……

Gave gout, pseudo gout, RA, patellofemoral pain syndrome, septic arthritis (said this is very unlikely)
as DD.

 All 5 key steps covered.

2. A painful foot - Pass

Scenario

A middle-aged lady c/o foot pain.

 Focussed history
 PE
 Diagnosis to patient with reasons

Shooting pain in forefoot first noticed on a jogging trip. Can’t remember duration. No trauma/
swelling/ joint pain. No pain in other joints. Can’t remember much as I took a hasty history.

PE:

Look/ feel/ move/ special tests/ vascular /sensory

Positive findings: Pain on squeezing metatarsals, ……………test for Morton neuroma positive

Showed that I am excluding stress fracture of 5 th metatarsal/ plantar fasciitis / tarsal tunnel
syndrome, mentioning these during examination.

Checked light touch sensation (looked around for cotton bud examiner was amused and asked me to
do with finger) and checked distal pulses as well.

Diagnosis: Morton neuroma. Explained with a diagram.

Said I have excluded other possible diagnosis (above).

 2/2 key steps covered

3. Health review - Pass

Scenario

Young lady, c/o diarrhoea for 2 days- vomited twice today.

 History
  Do physical examination looking for hydration status and abdominal examination with
presentation to examiner
 Diagnosis and DDs to patient

Watery loose stool. Cannot remember much details in history, but it all sounded like a viral
diarrhoea. Nothing alarming in history. No travel history. SAD-no

PE

No positive findings on checking for hydration status, but when asked if she feels thirsty she said
yes/ dizzy-no.

Normal vitals given by examiner

Abdomen- Only positive finding was generalised mild tenderness on deep palpation. Bowel sounds
normal.

Diagnosis: Gastroenteritis most probably viral, with mild dehydration.

DDs: Salmonella/ Giardiasis/ Food poisoning/ Food allergy / Intolerance / Side effect of
medication…..Bell rang

 ¾ key steps covered.

4. Scrotal swelling - Fail

Scenario

 Scrotal swelling over months.

 Examine with reasons give most probable diagnosis and DDs to patient.

I failed this case probably due to wrong diagnosis + many other things. I could not watch a good
video for this PE in my preparation. Please refer to someone who passed😊.

MEDICINE AND SURGERY

1.Headache - Pass
Scenario
40-year-old male patient comes to your GP. Has had headaches since adolescence.

 Relevant history
 Explain most probable diagnosis and other diagnosis to the patient with reasons.
Patient gave a TYPICAL text book history of migraine since adolescence self-medicated with
ibuprofen up to now (it works most of the time), never sought medical help before. No red flag
symptoms present. (Not increased with coughing, sneezing/ not associated with eye movement,
blurred vision, stiff neck, rash, malaise/ no neurological signs/ no sudden severe) Excluded other DDs
but diagnosis of migraine was quite clear. (When asked if anything about headache changed, to see
why he came this time, said it’s getting worse now. Any other worries? His cousin was diagnosed
with brain cancer recently. (Now started to show anxiety. Do I have cancer too doctor??? Had to
address this showing empathy and explaining his symptoms are quite different from that of brain
tumour.)

General health good. No significant past illness/medications. SAD -nothing significant. He is an

accountant had some worries at workplace. Can faintly remember that he had a family history of
migraine too (brother).

Explain most probable diagnosis and other diagnosis to the patient with reasons

Explained typical pattern of migraine pain. Tried to explain a bit of pathophysiology about vessel
dilatation etc. Explained other diagnosis like cluster headache/ tension headache/ brain tumour for
long standing headache, but said infectious causes (sinusitis/meningitis) also considered but unlikely.
Ran out of time to finish.

 3/5 key steps covered.

2. Shortness of breath - Pass

Scenario

A young girl in her 20s presented with respiratory symptoms- you are HMO -ask examination findings
and any available investigations from examiner and explain the condition to patient and DDs.

PEFE

Asked GA/ VS with O2 saturation/ general inspection (don’t remember details - not much positive
except increased respiratory rate), then straight into respiratory system examination: Chest
expansion reduced R/S. Vocal fremitus and resonance increased. Bronchial breathing in R/ middle
zone with few crepts. No rhonchi.

Asked for CXR examiner gave 2 x rays- lateral and AP with typical R/ middle lobe consolidation
(pneumonia).

Asked for some other Ix which were not yet available at the time.

Explained diagnosis to patient

Pneumonia R/lung cause is probably bacterial. “She said I thought it happens to old people!”.
Explained its more common in old age but can happen in your age specially after viral URTI then
secondary bacterial infection. I think there was a hint on this in the scenario as well. Showed the
patient the areas of consolidation in x ray and corelated it with symptoms.

Explained DDs Saying there are other causes of shortness of breath and respiratory symptoms that
are less likely to be the cause here. Viral infection/ TB/ DVT (PE)……………
Please make sure you practice how you explain DDs to patient as this is the new trend in AMC
Clinical. I did not practise this well and it made me feel awkward in the exam. I did not know how
deeply I should go into this explanation... For an example when I said tuberculosis role player asked
what is that? Deep vein thrombosis- what is that? …Then you may run out of time if you go on
explaining one less likely diagnosis too much…

 4/4 key steps covered

3. Altered conscious state - Pass

Scenario

A truck driver in ED admitted with episode of?? Syncope. Long term Type2DM on treatment with
Metformin. Some weeks before had an infection and found to have increased blood sugar levels,
therefore specialist added another drug. Already received treatment and now blood sugar normal.

 Explain to patient diagnosis and further management.

Did not take breakfast today. Has a habit of skipping meals due to work.

Explained management:

Hypoglycaemic drugs, if taken without meals, will invariably cause this problem. So, prevent it by
taking regular meals/ keeping a healthy snack near him all the time. Explained warning symptoms of
hypoglycaemia (hunger, sweating, shaking, palpitations…) and once detected need to act quickly.

Patient is used to checking blood sugar with glucometer, so if level below 4, asked to take 15g of
simple sugar -with a fruit drink/ snack (keep these in pocket) as soon as hypo detected. Wait for 15
min and check blood sugar again, if still below 4 take another 15g. If more than 4 then take low
glycaemic snack (wholemeal sandwich/ fruit or regular meal if meal time). Explained that prolonged
hypoglycaemia can cause coma state/ death. His family members should know how to use Glucagon
injection if he is unconscious. Explained sternly the risk of driving the truck with hypo attacks, risk to
himself and other road users. Needs to check his BSL before driving (should be more than 5). Need
to keep sugary snacks to use if he becomes hypo… He asked can I drive home? I got in trouble here
so thought for a while and said we will monitor BSL hourly, in the meantime I will discuss with my
seniors regarding his fitness to drive, will get back to him later….

Early follow up afterwards. His previous high sugar levels may have been due to infection at the
time, so asked him to regularly check and record his BSLs and will refer to his usual endocrinologist
to reconsider medication and further assessment.

 All 4 key steps covered here.

4. Bleeding - Fail
Scenario
52year old man with rectal bleeding, a topic I’ve read very well. Tasks were history, explain to
patient examination that you will do and management.

When reading outside I remember thinking- How do I do this? Should it be like “I will check your
general appearance, vital signs etc.“ I went in and took a lengthy history/ gave DDs …Then forgot
about examination and went into management. I think you only have to tell about PR/ proctoscopy
as it was a case of haemorrhoids. I think I have misunderstood a task here. Always keep the paper
given in front of you and complete all the tasks.

 ¾ keysteps covered.

PAEDIATRICS
1.Collapse - Pass
Scenario

15year old girl presented with sudden loss of consciousness. She has an ECG done soon after. This will
be provided after completing other tasks.

Cannot remember tasks that well. I think history and explain the diagnosis to patient. I was paralysed
by previous case where I did not complete tasks.

Started with asking for vital signs from examiner. Vitals stable, pulse regular, no postural
hypotension.

Collapsed at school. Asked details of the incident but cannot remember in detail. I think she
collapsed while sitting, no warning signs. History of exertion + but some time before the incident????
Loss of consciousness for one min. Witnessed. Nothing to suggest seizures. Nothing to suggest
cardiac cause in history. No indication of vasovagal. No trauma/ fall. No recent illness /fever. Now
feeling completely fine. This was the 3 rd attack. First similar attack occurred one month before.

LMP 10 days before, normal menstrual bleeding. Never been sexually active. Never used SAD. Social
history unremarkable. Asked for permission and offered confidentiality before asking sensitive
questions as she is an adolescent.

Family history of similar symptoms or sudden unexplained death is very important here. I can’t
remember any positive responses.

Medication history nil of note.

PEFE

All normal.

Asked for ECG : Shows Prolonged QT interval.

Explained: Probably a congenital abnormality with electric impulse conduction in heart. Explained
how electrical impulses control heart activity and how we record it in this ECG strip. This condition
makes her prone to arrhythmias resulting in collapse. Used simpler words in explanation. Mentioned
it is potentially dangerous and need further management. (Did this all the while wondering why do
they ask us to explain this to a teenager in one or two minutes when it took me such a long time to
learn all these.) 😊

 4/4 key steps covered.

2. Loss of consciousness - Pass

Scenario

2 year old. Loss of consciousness 30sec. Mother comes to see you. Child now well.

Tasks:

 History
 Relevant PEFE
 Explain diagnosis to mother
 Explain management

It was a typical history of breath holding attack- jammed finger on car door/ cried / turned blue /
LOC / no convulsions / better soon after / now quite well. First episode. No family or personnel
history of epilepsy. No behavioural/ social issues. No fever or significant illness recently. BINDS
normal……. Did explanation and management tasks as in
http://www.health.vic.gov.au/edfactsheets/downloads/breath-holding-in-children.pdf please refer
to it. Got 6s and 7s for all domain scores here, as this one was very straightforward.

PEFE: Examiner said all normal and child is happily playing now.

Mother had concern about epilepsy. Need to address that and reassure.

3. Abdominal pain -Pass

Scenario:

You are a HMO - ED (in a rural or regional hospital). 3-month-old infant had vomited twice today and
cries excessively. Father has brought the baby.

Tasks

 History
 Relevant PEFE
 Give diagnosis/DD
 Explain management to father

Approached with stability question as this is an emergency. Results were quite ok as I remember.

In history you find a previously healthy infant being increasingly irritable from yesterday, crying

excessively 6 hours. Asked pattern of cry, drawing up of legs? no. Vomited twice. Once greenish
as I remember. Refuses feeding now. Last feed few hours before (exclusively breastfed). No fever.
Not lethargic or drowsy. No rashes. Bowel habits not changed. Urinary habits- normal. When asked
about number of nappies and whether they were wet like usual – he said all that is normal.

BINDS normal /thriving well / previously had infrequent posseting like symptoms but never had this
type of vomiting. Did not notice any abdominal distension.

Brother had gastroenteritis recently.

PEFE: Went on starting with does he look ill? Irritable/ drowsy? VS? Asked specifically for CRF/ cold
peripheries/ mottled skin. I faintly remember he had latter two. Not too sure. Got no other signs of
dehydration. No rashes.

Abdominal exam: Inspection -distension??? (Not sure). Palpation /percussion / auscultation /

Genitalia- all normal. When mentioned on hernial orifices examiner gave a picture that looks like
inguinal hernia. Asked is this reducible? Examiner said no.

Other systems normal.

Explained diagnosis as inguinal hernia that has got obstructed causing symptoms of bowel
obstruction.

DD: can’t remember what I mentioned at the time. May be Gastro / bowel obstruction due to
volvulus- malrotation/ pyloric stenosis/ GERD/ UTI / intussusception…..

Management: Mainly stressed that this is potentially fatal if not treated surgically ASAP. Explained
ischemia/ bowel necrosis on obstructed site / perforation / peritonitis very concisely, but I think this
was too much as I ran out of time for this case. Reassured that we will send to nearest tertiary
hospital with necessary facilities as soon as possible after stabilising the patient. Prognosis very good
with prompt treatment. Started explaining IV cannula/ Ix etc. in immediate management but the bell
rang.

 4/4 key steps covered.