13th October recall

I could pass this tough exam fortunately! And it was really long journey for me to clear this
important step of my life. I am really tankful for all the help and support from my enormously
supportive family and friends without whom I could not make it obviously. I tried to share the details
of cases in my own experience during the exam situation as well as narrating what went on during
each station as I think it could be of prodigious help for the ones who sit the exam to have some
understandings about each station details and circumstances. There are still some details of my
faulty performance so I have written what I have done in real exam case and once the feedback
comes true I will update it for you. I found detailed recalls very helpful and am very thankful of
others who shared their experiences previously cause this exam is all about experiences and tips and
tricks not only knowledge!....So I just want to do my turn! I hope it is of beneficial point for you and
keep me in your pray please!

1. You are in GP, a Lady with 35 weeks old pregnancy presented to you with
headache.

Task:Hx, PEFE, Dx to the patient with reasons.

I entered room after introducing myself I asked haemodynamic stability? Examiner said what you are
looking for? Bp: 180/100, PR: 80 regular, RR:NL, Temp:37 I said I want to secure two IV line and stat
dose of labetalol IV line and transfer the patient to the treatment room while I am taking history
from my patient.

Hello Jilly? I am… one of the doctor in this GP. Where is your HA exactly (all around the head) When
did it start? It was there for couple of days but today it is more severe. How sever it is?(7-8) Do you
want pain killer?(yes) no allergies?(no) I will arrange a painkiller for you.

Just quick questions: BOV?tummy pain? trauma?discharge? BLD? (no) swelling on legs? Baby
kicking?(yes) no hx of HTN DM… this is first pregnancy and no miscarriage before. All the antenatal
tests were positive( sweet drink test, U/S 18 wks was NL). If you are OK I want to ask some
questions from my colleague?

Dear examiner, Is there any pallor, jaundice, dehydration in my pt's general appearance?(no)

Any change in V.S? Bp is now 150/90 all others the same.

I want to systemically do examination mainly focusing on abdomen. Neurological examination of

upper and lower limb? Tone(inc) reflex(brisk) power(nl) sensation(nl) ophtalmoscopy? (Blurring of
disc margins) Cardiovascular and respiratory (NL). As for the abdominal examination, in inspection
any scars?bruises? Dilated veins?(no) In palpation, tenderness?(no) Lie(longitudinal)
Presentation(cephalic) FH(34cm) FHR(150). I want to do per-vaginal examination with the consent of
the pt and presence of the chaperon. Just inspection and speculum (OS closed) thanks I won't go
further. Urine dipstick? ++Protein, Nitrate -,BSL AND ECG?No ECG no CTG no BSL available(he got
cranky I think:D) OK thank you examiner I go back to my patient.

Jilly during hx and px most likely you have condition called pre-eclampsia have you heard of it
before? This condition more common in first pregnancies and runs in family can be due to smoking
recreation drugs(not sure that was only my performance)… So some particles produced in placenta
attaching the baby to the womb( drew picture) are going to other places in body causing vessel
damage and kidney damage as well specifically brain vessel that is why you have high blood pressure
that is serious condition please do not worry you are in safe hand that is why I want to send you to
hospital to be checked as you may develop seizure and…Bell rang

Feedback: Third trimester Complication, PASS(G.S:5)

Key steps:2,3,4 &5: Yes, 1 :No

Hx:4

Choice and technique of examination and organization and sequence:5,

Dx/DDx:6

2. Young woman came with 4 episodes of recurrent ulcers on vulva over

12 months

Tasks: Hx, Tell the pt the Most likely diagnosis,Csl

(Very kind Asian examiner!)

In hx, the pt was having unsafe sex with several men, No symptoms at the moment no rash, ulcer,
pain, discharge or bld. Pap smear 18 month before (NL) (period was regular and no bld between no
pregnancy before no PID she is on pill (COC).

So I said the most likely condition you are having is called Genital Herpes ulcer have you heard of it
before? It is kind of viral infection. Firstly, it enters the body and stays in the nerves in our body
thence it is activated due to the exhaustion or infection or pregnancy or even with pill and obesity
and it gives the symptoms of rash ulcer itchiness and discharge. This can be happened in your
partners as well as this is sexual transmitted disease so I need to visit your partners to examine and
treat them as well. Meanwhile, I want to run some investigation to rule out other STI like HIV,
Syphilis, HBV, HCV and take swab for bugs like chlamidia and gonorrhea and obviously confirm the
Herpes with T-zanc test if there is any. At the moment I will not start medication for you I wait for
the result and review you once result back if any was positive we treat you with 3 days of Acyclovir
and then once weekly for 6 month-period. It is important to over this period have safe protected sex
with condom and be cautious about the hygiene and wipe yourself from front backward. Have warm
bath sitz and if symptoms occurred, apart from medication I prescribe lignocaine gel which can help
to decrease the amount of your pain. I don't notify DHS now but I need to notify if any of STI
screening came back positive. We can later talk about other options of contraceptive methods like
Implanon or devices and so forth about which I can give reading materials if you want…
Feedback: Vulval complaint, PASS(G.S:5)

Key steps:1,2,3 and 4: Yes

Approach to patient:6

History:5

Dx/DDx:6

Patient counseling and education:5

3. A young woman has come to ED due to sever abd pain. PT was weakly
positive and LMP was 8 wk ago.

Task: Px, Most likely dx with ddx to the pt with reasons.

Inside, there were a clock and a sphygmomanometer on the table. Washed my hand introduced
myself. I started assessing V.S. Pulses as soon as I was checking examiner said it is NL. (Asian
examiner, he was checking the technique from close distance and was telling the result like he was
whispering!:)) Bp was NL as well I said no sunken eyes no dry mucosa no pallor. Then I started
abdominal exam by inspection( no dilated veins no scar no bruises no mass obviously) I said first I
check auscultation to prevent inadvertent changes(NL bowl sound). In palpation, started from left
side and went to right side just tenderness on RLQ no rebound no guarding. I said because you have
pain I won't do percussion and deep palpation to check organ enlargement. Then I did Morphie
sign(-) Obturator and psoas and Rovsing sign(all NL)Renal angel tenderness(-) I said dipstick and
bsl(not available) Then I asked for DRE and PV with consent of the patient and presence of the
chaperon.

Examiner gave me the card which was saying right adnexal mass which was tender to touch but no
CMT and size of uterine was enlarged.

To patient, I mentioned: Regarding the hx and px most likely you have condition called ovarian cyst
have you heard of it? (drew pic) it is fluid –filled sac formation in ovaries but it can be EP which fetus
and product of pregnancy can be formed in tube( fallopian tubes) instead of womb which is serious
condition. It can be also a kidney stone or appendicitis which is a swelling at the end of your small
bowl. Also it can be mittelschmerz which is an inflammation in small bowel however it is unlikely due
to your age of pregnancy as it is happening in young girl in the middle of menstrual cycle. We need
to do U/S to confirm but most likely it is due to the ovarian cyst. Bell rang.

Feedback: Substance abuse, PASS(G.S:6)

Key steps:1,2,3 &4: Yes

Approach to patient:6

Choice and technique of examination and organization and sequence:6,

Accuracy of examination:5

Dx/DDx:5

4. A 6 Y/O Peter was brought by Ben( Indian roleplayer) with severe knee
pain from 2 days before , due to which the pt could not bear weight
and walk.

Task : Hx, PEFE, Investigation to patient, Most likely diagnosis and ddx with
reasons to pt.
There was a history of viral infection few days back and trauma during a fall in a basketball field. No
fever no Abdominal pain no rash no joint pain or bone pain on other parts of the body. BINDS NL no
specific PMH his grandma had RA.

Px: GA: Pallor, Jaundice, dehydration(-) Growth chart NL no LAP

V.S no fever, Systemical exam focusing on the limbs comparing both but on right leg is there any
swelling or erythema or bruises or bowing of legs?(no) On palpation of knee tender to touch?
Patellar tap? Buldge? In Movement?knee ROM restricted?(no) then I remembered the hip…I said in
hip again in inspection the same questions. ROM in internal rotation and abduction was restricted. I
mentioned about Roll's test and it was positive. The Urine dipstick and BSL was not available.

I said look from the Hx and Px the most likely condition that you have is called tenosynovitis have
you heard of it before? No actually it is inflammation of the outer layer of bones of hip joint. That is
why I want to investigate it with U/S and X-ray and FBE to rule out infection with inflammatory
markers. Other possibilities are Perthes disease (which is important to be ruled out) and SCFE and
Trauma and OSD which are less likely due to the age and the hx and px of your child still u/s can help
us to find the cause.

For now I kindly ask you not to move and bear weight with the affected leg and use the crutches for
it and I prescribe pain killer as well as cold compress. Normally we expect to see the resolution of
your symptoms in 7 days. Bell rang I said I want to see you in 6 month as well to rule out Perthes!

(Still I am not 2 sure about Perthes and T.S in this case so I look forward to my result and feedback)
Feedback: Joint Pain, PASS(G.S:7)

Key steps:1,2 and 3: Yes

History:6

Choice and technique of examination and organization and sequence:7

Choice of investigation:7

Dx/DDx:7

Mx:6

5. A 3 y/o boy was brought by mother Bredith because she was worry
that her child is not eating properly and there were a growth chart of
the baby for the length and the weight separately. The former was on
30% and the latter was on 10% after falling from 50% over 2
consecutive months.

Tasks: take Hx, Explain the condition and tell the most likely diagnosis.
I was so stressed in this case and really was confused about the tasks so please ask other people
about it. Surprise I passed this case which I thought I will fail!!contrary to ear examination case!

I asked about the N/V/D was not there not hard to flush not sticking to pants. No fever no cough
SOB. Waterworks was fine. Mother said she divorced 6 months back and she is so alone and her
child is not eating well as he refuses to eat while she offer the foods. I asked whether she has
anybody to help her she said no. The role player was not happy at all. I mentioned the most likely his
condition is due to being fuzzy eater which is important this time to be investigated as he is not
gaining weight then I explained the growth chart but she was not happy yet. I said I need to do some
investigation to rule out other possibilities like fever diarrhea celiac and so on. (I should have said
this is FTT and ruled out child abuse)

Feedback: FTT, PASS(G.S:5)

Key steps:1,3 and 4 Yes…2:No

Approach to patient:4

Choice and technique of examination and organization and sequence:4

Dx/DDx:5
 6. An 18 month y/o boy John was brought with his father Lindsy due to
his pallor and investigations which was: Hb:low, WCC: NL ;Neutrophil
NL, Lymphocytes NL, Eosinophil NL, Plt NL, Blood film was Hypochromia
and Microcytosis. Iron level: Low, Ferritin: Low, Sat Ferritin: low.

Tasks: Hx, Explain the Results, PEFE(card will be given), Most likely dx and
Mx.
The RP was so careful about what I am saying (he was my previous exam RP in previous exams!:D
and his name was the same(Lindsy) and I really hated him( to somewhat due to PTSD) but I tried to
focus on my tasks but yet it affected my performance). I asked about causes of diarrhaea bld?no
Diarrhea? No hard to flush? Stick to pant? Floating pu? No waterwork was NL his diet was only chips
and 5-6 bottle of milk that was all. No worm infestation no itchy back passage no change in skin of
backpassage no N/V/D. BID apart from N were NL. Happy family. No skin lesion or rash.

I asked about the PE card: the examiner gave me the card which was NL completely.

I explained the result in a lay man term and said the condition that you are having is most likely due
to excessive consumption of bottle milk and it can cause diarrhea with some bleeding( he said but he
does not have any bleeding at the moment I said there can be tiny bleeding which is not visible in
stool. And then said we must put you on Hydrolyzed formula and wean him off from milk and I need
to run some investigation to rule out other possibilities like celiac and hypothyroidism and bleeding
disorder and infections. (I should have talked about the iron supplement but I totally forget abt that
due to my PTSD I should say)

Feedback: Pallor, FAIL(G.S:3)

Key steps:1,2 no,3 Yes,4:Yes, 5:No…

Interpretation of Ix:3

History:2

Dx/DDx:3

Mx:3

7. The young patient has come to your GP as he has ear pain for 2 days.

Task: HX, relevant examination, most likely diagnosis.

The Asian role player (RP) that I thought was medical student was there. I started history. No
discharge no loss of hearing obviously no trauma no swimming frequently no spinning around no
dizziness occupation was secretor in bank. Previous infections? Yes he was treated with amoxicillin
couple of time (I should have asked about increase of the hearing in noisy area and noticing the TV
sound and exposure to loud music and…) No PMH.

As for PE, having introduce myself as well as washing my hands, I started by inspection. No skin tag
erythema discharge on helix antihelix tragus and pinna area. I started by palpating mastoid and
tragus and drawing back the ear to look for any pain none was there. Otoscopy exam: perforated ear
drum+ erythematous and whitish materials in ear. Weber test: localized to left ear. Rhinne test was
the same on both part and AC was better than BC!!!!!!! I did check that double time with 2 different
techniques but the result was the same. Facial nerve quick screening was NL no LAP.

I mentioned the most likely condition is chronic infection of your middle ear due to previous
infections that you have it can be also Chlosteatoma which is again infection of the middle ear with
skin changes in the middle ear that can go to other structures in brain which is risky.

Feedback: Ear Pain, FAIL(G.S:3)!!! I thought definitely I passed the case!

Key steps:1 &2: Yes…but 3&4:No

History:4,

Choice and technique of examination and organization and sequence:4

Accuracy of examination:2

Commentary to examiner:4

Dx/DDx:1

8. The young man woke up in the morning with the asymmetrical face. He
is worried about having stroke.

Tasks: Px of facial nerve and relevant examination to rule out the cause of his
symptoms.

Tell the patient the most likely dx and ddx with reasons.
I started with introduction, Washing hand and the consent. Inspection: I said(pointing at the picture)
I can see naso-labial fold is smoothed and palpebral fissure is narrowed and asymmetrical no ulcer
Keratitis no conjunctivitis. Then I went for facial nerve. And the examiner showed the pictures then
asked what is this? I said in this way the patient could not keep blowing from pursed lips instead so it
is deviated to the other side. I did inspection of ear no rash no vesicle no erythema then otocsope
the examiner said it is NL. And I said there is no tuning fork and… examiner said weber and rhinne is
NL. Then I said I want to check for the 9th nerve open mouth say ah examiner said it is NL as well.
Thence I said I want to check 10th nerve and 11 said NL.I said OK I want to check the parotid gland.
There is no lump no tenderness in palpation. Later I wanna check inside mouth with gloves examiner
said NL. I said I wanna check LAP later.

Look John what you are having is called Bell's palsy. What's that??? I can't imagine how it is
concerning for you but let me tell you it is not serious although it looks scary. It is due facial nerve
damage. Due to many theories, one of them is a viral infection but mostly the cause is unknown and
70% of pt will be OK after 2 months so please do not worry. Other conditions can be brain tumor
which is unlikely due to my examination. It can be due to parotid gland that you have but again less
likely and stroke is another one. Bell rang( I forgot to talk about Ramsy-haunt syndrome)

Feedback: Altered appearance, PASS(G.S:6)

Key steps:1,2,3 and 4 Yes

Approach to patient:6

Familiarity with test equipment:6

Choice and technique of examination and organization and sequence:6,

Accuracy of examination:6

Dx/DDx:6

9. 55 y/o man have come to your GP with shakiness in both hand more on
left…he has this symptom for many years getting worse recently. He
takes alcohol which can helping a bit. He is concerned about having
Parkinson disorder as his family succumb to one.

Task: Px upper neurological, relevant neurological exam, tell dx and ddx with
reasons to the patient by giving running commentary to the examiner.
Introduced myself washed hand asked for consent.

RP was sitting behind the table. I asked to walk few steps examiner said it is NL don't assess gait and
don't make patient stand. I said OK I want to check Romberg test as well examiner said NL. I started
by hand. No muscle wasting no nicotine stain no palmar erythema and sweaty hand. Obvious tremor
on both hand. No flapping tremor. Radial Pulses were NL bilaterally. In Head I asked the patient to
stand I did Pull's test I said negative as in parkinsonism pt will fall back with few steps backward with
this test. I said now I want to check eyes. No exophthalmos, No lid lag, I forgot to mention mask face
and Glabella tap!!!!!:(

Then I went for thyroid inspection I said there is no enlargement no skin changes. Then I saw a glass
of water. I asked the pt to take a sip of water. His hands were severely shaking I said sorry I annoyed
you let me help you. Then with consent of patient I went to the back starting palpating the thyroid
nothing was there positive no lump no nodule no pain no warmness asked pt to swallow. Then I said
now do tap on table like playing piano examiner said what is that I said piano tapping test! And said
finger to nose and twiddling and micrographia however mistakenly I said this is micrographia instead
saying there is no micrographia!!!:(

I forgot Dysdiadochokinesia!! I want to finish my examination with Abdominal examination and lung
and heart and cranial nerve examination.

So I said look the problem that you have is called benign essential tremor have you heard of it? It is
muscular problem not serious which is running in family and not parkinsonism. Still other condition
like alcohol consumption as well as hyperthyroidism and liver disease can be there but I have ruled
them out in physical examination. However I want to rule them out with investigations as well.

Feedback: Shaky hands, PASS(G.S:4)

Key steps:1,2;NO..3 and 4 Yes

Approach to patient:5

Choice and technique of examination and organization and sequence:4,

Accuracy of examination:3

Dx/DDx:4

10.A young man with hx of chronic schizophrenia came to ED. Not taking
his medication as he think God is inside him.

Task: take psych history tell the patient your psychiatric assessment as well
as his risk assessment.
He was great actor! Hardly could I stop myself smiling when he was deepened in his role! I took Hx.
No LOA NO LOW NO sleep problem Mood was elated and he said I am happy that I can save the
world. Auditory Hallucination was positive as he could hear the God talking to him no one else. No
tactile hallo was there no visual. He was taking Marijuana but could not afford buying alcohol and
smoking. Delusion of grandeur and persecurity as he was thinking that they want to prevent him
from helping God(who?? He did not know…)no reference no broadcasting delusion. No suicidal
thought no plan no mean. He did not medical help and if find fire in the room he will remove it to
other place by God's hand!... Cognition was intact. No weather preference no constipation no head
trauma no CP no heart racing or SOB…

For MSE I was confused how to tell the patient all the jargons so I did it whatsoever ganna happen! I
had no time left. I said well-dressed well-groomed! He was not as other said!:(…behavior is
cooperative and maintaining eye contact. Speech tone and rate and rhythm is not affected. Mood is
elated congruent to the affect. He has auditory hallo but no tactile or visual. Thought form , there is
a flight of idea but no tangentiality. Thought content involved persecurity delusion as well as
grandeur. Rapport is OK. Reliability is OK still I need collateral hx. Insight is abnormal and cognition is
intact and judgment is poor. Risk is moderate to severe as the pt is hallucinated with no insight and
doesn’t take his medications. That is why I want to admit you in hospital and call mental health team
to come by and visit you! Bell rang!

Feedback: Behavioural disturbance, PASS(G.S:4)

Key steps:1 No2 ,3,4&5: Yes

Approach to patient:3

Hx:4

Dx/DDx:4

11. A middle aged woman has come to your gp clinic. Bp is not controlled
as she is forgetting to take her medications. She is excessively
consuming alcohol and her MMSE is impaired assessed by one your
colleague. Recent memory is impaired while remote one is intact.

Tasks: Hx, console and address the problem of bp control accordingly.

She had no HA, no cp, no dp, no sob, no BOW, no bowl movement problem, no problem with
waterworks. For alcohol she tried to quit it but it was not successful and she is forgetting to take her
medications. Mood was OK no LOA, LOW, sleep was OK( with confidentiality mentioned).
I said regarding your problem I am concerned about your alcohol consumption and want to focus on
it but your medication is important. So first of all I want to arrange another consultation with you for
alcohol consumption. Briefly it is better idea to drink non-alcoholic drinking and refraining from
areas that trigger you and I refer you to alcohol anonymous group and there are lots of support
group as well (I tried anonymous dr it is not working) I said OK so if you are OK I want to send you to
counselor as well to talk further about your concerns. Actually the condition that you are having is
called Wernicke Korsakoff which damages your brain due to alcohol consumption and it causes
forgetfulness as well in your case because you are forgetting taking your blood pressure lowering
medications. I want to start you on thiamine as well while I arrange a district nurse service for you as
you do not have anybody to help you with your regular medications and there is dosette box that
can help you to stick to you medications. I need to run some investigations to rule out other
conditions as well (the examiner said no Ix Stick to your task!)

Feedback: Substance abuse, PASS(G.S:4)

Key steps:1,2 &3: Yes 4:No

Approach to patient:4

Hx:4

Counseling and education:4

12.The middle aged man has come to you because he has sob and you
have the chest x-ray with AP and Lateral view of the patient.

Tasks: take Hx, explain the x-ray to the pt and tell dx and ddx with reasons.
I went in introduced myself. The RP was nice middle-aged man and I think he looked like a real
patient. He had no hx of lung disease. His sob is getting worse while he was walking. No cough, no cp
no LOW and LAP, no hx of travel to overseas (he has not travelled to anywhere since 15 years ago)
no leg(cuff) pain, no hx of contact to anybody with viral infection or respiratory infections, no
smoking, no alcohol, he doesn't need pillow while sleeping ( normally use 2 pillow but it is not
increased) no sob during sleep, no leg swelling, no problem with waterworks and BM were present.
He had been working in coal factory however he is now retired. He has HTN and Hyperlipidemia for
which he is taking medications (some people were shown his medications but he did not show me
his medications however they were alendronate and perindopril and atorvastatin which were not
really specific to his problem now) he is regular with his medications. No family hx of lung cancer.

I said I have your cxr in my hand these are 2 views of your chest taken. One is from front and the
other from lateral. These are your shoulder, rib cage and collar bones. Black area is normally due to
air in lung. This whitish area you can see is abnormal due to its specific pattern. There are some LN
which are responsible for fighting against the bugs in the helium part of your lung (showed the area)
which is enlarged as well. This can be due to some conditions like tissue disorders called sarcoidosis.
But what I am thinking of is Mesothelioma as you have being exposed to coal previously so there are
some membranes around your lung called pleural membrane which are affected in this case due to
that lack of sharpness in this area (showed on pic). Normally there is an angle at the base of lung
which is called costophrenic angle which in your case is not that sharp that we expect it to be and it
is blunted actually. It can be due to nasty growth there or accumulation of fluid or blood which can
be due to infection or mesothelioma or sarcoidosis and so on.

Feedback: SOB, PASS(G.S:4)

Key steps:1 No2 Yes ,3 No 4 Yes

Approach to patient:6

Hx:4

Interpretation:4

Dx/DDx:4
13.Middle aged woman has come to ED due to pre-dialysis assessment.
And ECG has been taken shown in the stem. Bp: 130/80, Palse 60 and
irregular, temp: NL, RR: NL.
Tasks: Take relevant hx, Explain the ECG to the examiner, Ask from relevant
investigation from examiner, Tell the diagnosis to the patient with the
reasons.
I entered and introduced myself. There was a nice RP. No Vomiting but the patient was nauseated.
NO cp or sob or cough no problem in waterworks but the patient has diarrhea. No AB no other PMH
and FH. Her medication: Prindopril, Ca bicarbonate , Calcitriol.

I told the pt if you are OK I want to talk with my colleague regarding your problem. So I said dear
examiner, This is 12 lead ECG and I can say the rate is 60 and sinus as there is p wave before QRS
complexes and it is narrow. Axis is NL and I can appreciate that T wave is tented and there is a strain
of ST interval. The most likely condition regarding this ECG is Hyperkalamia( examiner said OK)then I
asked for investigations. Examiner said what you are looking for? I said: Na, K, Mg, Ca level and RFT.
Na was 145 and K was 6 and RFT was impaired( I don't remember the exact numbers). Thanks
examiner. I turned to the patient. I said your ecg has some problem which is due to high amount of
potassium in your blood which are the electrolyte and chemicals in your body. Also Na is decreased
and your kidney function is impaired. This is due to many causes. One of them due to kidney failure
that you are having( I did not mention ARF on CRF!!:(..) the other condition is due to your medication
which is perindopril and the other one is due to diarrhea that u were having causing your symptoms
of nausea and heart arrhythmia. Bell rang.

Feedback: Occasional palpitation, PASS(G.S:4)

Key steps:1 Yes2 No ,3 Yes 4 Yes

Approach to patient:5

Hx:5

Interpretation:4

Dx/DDx:4

14.A young woman comes to your practice due to her problem with
asthma control. She is on Budesonide 200 mcg twice a day. The nurse
checked her technique which was good.
Task: Take hx to assess her severity of her problem. Address her problem
regarding acute management!
I entered the room and introduced myself and she was really nice RP as she calm me with her
positive and cooperative attitude which really helped me as I was enormously stressed due to
previous stations. She had 2-3 times night attacks during the night. And daily attack every day but
she can eat and talk with no problem however she has problem with exercise these days. She is
smoking 10 cig per day for 10 years( I said that is too much we have talk about it next consultation
OK?) Yup… No allergy to pollens, linens, perfumes, food, no skin changes. She was a lawyer and has
so much stress these days that is why she is smoking more frequently. No family hx of asthma. No
medications. She has enough support at home and no problem socially, drinks alcohol occasionally.

I said regarding your asthma control it is very important to decrease the amount of smoking I need
to arrange another consultation to talk about your smoking habits. But do you want me to briefly
talk about it? She said yes….I said Ok there are NRT in forms of nicotine gum and patch and champix(
varnecilline) I give you 2 week to think about it with reading materials and then come back to talk
about it. There is quit line and lots of support group for you available. Meanwhile I want to add
Floxitide to your puffer!!!( I totally forgot she is on Budenoside) as your asthma is moderate to
severe and needs to be contolled. As for your exercise I put you some medication called intal which
you can use it before exercise as normal and regular exercises are important for you. As for you
stress devote some of your time to Yuga and meditations if you have specific concerns I can refer
you to psychologist as well.. I said can you show me how you use puffer because there was a puffer
on table she said your nurse checked that and she was happy with that…I said so I am happy now as
she is as good as me!… bell rang!....I did not talk about action plan and PFM!!! And I did not explain
about asthma pathologies and mechanism…and I think we should start prednisolone for this
patient…but main things is smoking here to be addressed. I am not sure for this case…

Feedback: Health review, PASS(G.S:4)

Key steps:1 ,2,3 and4: Yes

Approach to patient:6

Hx:4

Dx/DDx:4

Patient counseling:4
 15.A young male comes to your GP due to severe back pain after lifting an
object 2 hours ago.

Task: take Hx for 4 minutes! PEFE, explain ddx and most likely dx.
Having entered I introduced myself and asked whether the pt needs painkiller? He said no I am fine
now. He lifted a rock without squatting instead he was bending forward. No trauma. No PMH of joint
disease. No medication. No Fhx of joint diseases. He has tingling in his left leg. No trauma to leg. No
stiffness in morning. He had the similar attack 2 years ago. He is worker in mine… and it is affecting
his job as he can’t work now. No involuntary BM and urination.

PEFE: Gait( heal walking toe walking squat NL)Inspection: no stepped deformity, no muscle wasting,
no scoliosis, no erythema, lore doses is normal. In palpation; tenderness on lower part of lumbar
spine, no inc temp. Slump test and Schober test is not available. ROM is decreased in all movements.
I want to do neurological exam of lower limb. In inspection, No muscle wasting no bruises no
fasciculation. ITPRCS: Tone is NL, Power is NL, Reflexes of Knee is compromised. Sensation of little
toe is not intact. Coordination is NL.(I forgot to mention SLR!!!!!).I said I want to check DRE to check
to anal tone with consent of the patient( not available)

I said the condition that you have is called Disc prolapse have you heard of this? (Drew pic), there is
a cushion between your lower back bones called nucleus pulposus which is most likely between L4-
L5 bones prominence. It is ruptured some time due to sudden lifting and bending movements like
your case thence it puts pressure on the nerves surroundings and causes this tingling and pain you
have in your legs. Other condition like inflammation around that cushion or just mechanical back
pain or spondyloartheropathy which is chronic condition not related to your case here.

Feedback:PASS(Global score:4)

Key steps:1,2,3 Yes…but 4:No

History:4,

Choice and technique of examination and organization and sequence:6,

Dx/DDx:4

16.The middle aged woman in ED has upper abdomen pain.

Tasks: Hx, PEFE, Ix , Dx ddx

The patient did not need painkiller. Pain started 2 hours ago now is better. On RUQ it is going to
back. Not relieved when leaning forward or not related to bowel motion. It is started after eating
fatty food. No sob no cp no dp no palpitation. She had these symptoms years ago as well relieved by
itself. No waterbrush or bitter taste at the back of the tongue, no heartburn was present. No N/V/D.
No PMH, No FH of cancer in digestive system.
PEFE: GA: no pallor no jaundice no Dehydration. BMI NL. Focusing on abd:inspection NL, Palpation
only tenderness on RUQ no rebound or rigidity. No organomegaly No morphie's sign positive.
Inguinal orifice NL Auscultation NL. No percussion due to pain. DRE not available. Lung and heart are
NL.

Ix: U/s, FBE, U&E, CT, LFT ECG CXR,I don't ask for amylase lipase as at the moment I am not
suspecting pancreas dis

Most likely you have condition called gall bladder stone. Drew pic. Still it can be due to heart, lung,
pancreas, liver, stomach so that is why we do ix. But this condition is due to stone formation due to
fat deposition and accumulation and formation of stone there causing obstruction of neck of the gall
bladder as well as causing dilatation of gall bladder and due pain. Are you with me?...Bell rang.

Feedback: Abdominal pain, PASS(G.S:4)

Key steps:1.2.3 & 4 :Yes

Hx:4

Choice of Ix:4

Dx/DDx:4