20th September 2018 (retest) recall with feedback

Station 1 : Recurrent falls (PASS)

70 years old male comes to your GP clinic because of fall which happened yesterday.
Tasks : Focus History.
PE card will be provided.
Dx and DDx with reasons.

Approach :
I greeted the patient & asked him whether he’s comfortable or not and is there any concern?

History :
This is the 3rd time of fall. No loss of conscious in each time. All of them are similar. He says once, he
slipped on the small stones & fall. The other time was he bumped into sth and fall. Don’t remember the
other one but he’s not injured. In asking general health, he’s got Type 2 DM for many years & he’s on
Metformin. No changes in dose or medication. No history of recent illness. BSL is not regularly checked,
do not go to specialist regularly, seemed not well controlled. When asked about complications, he denies
all. He also tells he’s got knee pain (OA) and he’s on OTC pain killer. Apart from that, there is no
problem with hearing, vision, no h/o stroke, heart problem, other joint problems, no features of postural
hypotension.

PE Card : GC – well
VS – Stable (BP on lying, standing not given)
Eyes – microaneurysms +
Heart – normal
Sensation on limbs – loss in gloves and stocking appearance
Both knees – acutely inflamed, tenderness +, reduced active and passive movement
Office tests – BSL – 18 or 24 mmol/L
I don’t remember whether UDS and ECG given or not.

Dx and DDx :
I explained that DM is not well-controlled and caused complications like loss of sensation in all 4 limbs
and eye problems which can lead to slip and fall. But reassured that u don’t have other complications like
ur heart is fine. Ur kidneys are doing well. Another condition is OA knee. Then I gave other DDx that I
excluded in h/o.

Station 2 : Limb pain (PASS)

4 years old boy brought to your GP clinic or hospital ( not sure ) by mom because of pain in his
Right forearm since yesterday.
Tasks : History taking
Ask PE from examiner.
Order Inx from examiner.
Explain Dx
Management plan

Approach :
I greeted both mom and the child. Offer pain killer to him. Asked her is there any concern?
History :
This is the first time. Then, I started with pain questions. Pain started last night but worsen this morning.
The child does not cry a lot. On asking how did it happened, mom says he was playing with his elder
brother last night and may be he got injured back then. No h/o fall. No redness but swelling +, no
deformity. No features of complications like changes in colour or sensation of fingers. No h/o pre-existing
joint problem. On social h/o, she’s single mom with 2 kids. She can cope well and she’s financially
secure. She works part-time, but she send her kids to child care while she’s going for work. (I
intentionally left BINDS as there are so many tasks but later I regret it as this could be the case of abuse.)

PE : GA – in pain
VS - stable
GC - I forgot to ask
I said I’d like to examine the painful area as well as both UL comparing each other. On
inspection, there was a swelling in Rt forearm but no redness and no deformity, no skin color changes. On
palpation, temp normal, pulses normal, CR normal, there was tenderness around the swollen area.
Sensation normal. Movement of the joints normal. Other systemic examination normal. No bruises all
over the body.

Inx : I ordered Xray. There shows the buckle #.

Dx : Buckle # ( I explained it on the xray )
Mgt : I reassured her that it is not serious and that the sensation and blood flow of his hands are
intact. This can be managed effectively. I’ll give him pain killer. Then , will give a back slab to stabilize
the area and it should be there for like 2-3 weeks, meanwhile I’ll give him medical certificate. I asked is
there anyone who can take care of the baby apart from you? She says their grandmother. She says I
should’ve brought him last night, my bad. Then, I reassured her that I know that she’s doing her best and
it’s not late, baby’s doing fine, you’re such a good mom…and so on. I told her that pls make sure he
moves his fingers and told about the redflags, gave reading material. (not sure)

Station 3 : rest

Station 4 : Breast Lump PE (FAIL)

27 years old lady c/o breast lump on Rt breast. Her mother was Dx with breast Ca.
Tasks : Examine the breast on dummy provided.
Dx, DDx
Further investigations

Approach :
I greeted the patient, asked her is there any concern? She says what would u like me to concern with a
serious facial expression. I was surprised.

PE :
Then I took consent from her and started examination. ( needed to wear gloves ) I did according to what I
practiced, and I found a lump on Rt upper outer quadrant which is around 2*3 cm in dimension, hard in
consistency, not mobile. Then, a small bell rang.

Dx/DDx :
I told her that I suspect Breast Ca according to nature of the lump. Then gave other DDx like FA breast,
fibroadenosis, traumatic fat necrosis, breast cyst, breast abscess which are less likely.
Inx : USG, FNAB
Then, I forgot to examine Axillary and cervical LN and was counseling her about CA breast. Then in the
last minute, it just pop up in my mind so, told the examiner that I’ll examine axillary LN and time’s up.

Station 5 : Abdominal Pain (FAIL)

You’re HMO in ED, 27 years old lady with 32 weeks pregnany comes with severe abdominal pain
which started this morning. This is her 3rd pregnancy.
Tasks : History
Ask PEFE
Dx with reasons.

Approach :
I greeted the patient. Offered her pain killer as patient seems very painful. Then I checked vital signs and
examiner said BP 90/50 mmHg, PR 100/min. When I told that I would like to do resuscitation, examiner
said no management needed.

History :
Asked about pain questions. This is the 1st time, the pain is very severe and she felt it all over the tummy.
No radiation. Nothing makes it better or worse.
Then asked DDx - Does not look like contraction. No bleeding or watery discharge from down below. No
history of injury. No fever, nausea, vomiting. No problem with poo and pee. No history of fibroid.
Then I asked about ANC which is unremarkable. I forgot to ask about fetal kicking.
Past Obstetric H/o - she delivered both babies normally and they’re fine. Everything was unremarkable.
PMH and PSH – PMH is unremarkable but she had laproscopic appendicectomy when she was young.
Social h/o – unremarkable.

PE :
GA – patient is in pain
VS – the same
EYES – slight pallor +, no jaundice
CVS, RESP – normal
ABDOMEN - Inspection - laproscopic scars in RIF.
OBSTETRIC exam - FH is 36 cm. The abdomen is tense & tender. Cannot feel the fetal parts well. FHS
cannot be heard.
VE – no bleeding or discharge. Bishop score – unfavourable.
BST – UDS shows protein 3 or 4 +
Reflexes – intact.

Dx : Abruptio placenta with IUFD ( i was explaining the condition to patient by drawing a pic that her
womb size was larger and which is tense and tender….then the bell rang. I need to rush & tell her that it’s
due to abruptio placenta and your baby might be probably dead. Then I came out. )

STATION 6 : Shortness of breath (PASS)

60 years old lady comes to your GP clinic for investigation results. Previously she c/o cough with
sputum, & SOB. She is a former courier driver. She used to be a heavy smoker but now she quitted
smoking. Her BMI is quite high. Her SPO2 is 93%.
Pulmonary function test - Moderately severe COPD.
CXR - Hyperinflated lungs
Taks : Explain Dx
Tell her about your management plan.
Also tell her measures to improve pulmonary health.

Approach :
I greeted patient and asked her whether she’s comfortable or not.
Dx : I told her that her results came back and all pointing towards a condition we call COPD. Then
explained her with a drawing.

Management :
I followed the pneumonic COPD X. firstly, I asked her whether she’s taking any medication for her
problem and she said no. Then, I said I’ll prescribe you inhaler medication which u can use whenever you
have symptoms and explained her briefly about how to use it. I appreciated her for quitting smoking and
told her to avoid passive smoking as well as polluted areas because this condition is caused by inhalation
of dusts, smokes and fumes and is most likely due to your previous occupation and smoking. Now that
you don’t have exposure to these anymore so, it’s very good for you. Then told her to reduce weight (diet
and exercise), and advised about vaccination. For pulmonary health, I’ll liaise you with physiotherapist
who’ll teach you breathing exercise which you can also do at home. I forgot to tell her about O2 therapy.
Also tell her about exacerbation of COPD and redflags. Reassured her and told her about supports. Time
left so, just repeat & summarize the important points again.

STATION 7 : Health Check (PASS)

30 years old lady who says she has some kind of thought problem in a health survey. Today she
came to your GP clinic to discuss about that.
Tasks : History taking
Dx with reasons

Approach :
I greeted the patient and asked her any particular concern? She said these thoughts are troubling her a lot.

History :
I asked what kind of thoughts? She said she had recurrent thoughts of her ex-husband having sex with
another woman and because of that, she couldn’t sleep well. I asked more about sleep problem. It was
non-specific. I asked how long has it been going on? She said it’s been for a year or so. This is the 1st time
for her. I asked is there any other thoughts? She said no. I asked OCD questions and all positive. When I
asked did you try something to get rid of the thoughts? Then she said when she count from 1 to 7, it goes
away.
I excluded other DDx like other anxiety disorders, depression, PTSD and so on. No features of depression
and she did not have any major stressful events 1 year back.
When it comes to HEADDSS, she lives alone, can cope well, was divorced (don’t remember when), no
contact with family members? Father also passed away years ago, no problem with job & financially
secure, no smoking, alcohol drinking, no drug usage.

Dx : I explained her about OCD then said it can be treated effectively. Then told her other DDx but
they’re less likely in you with reasons.

STATION : 8 rest
STATION : 9 Headache PE (PASS)

60 years old male c/o left sided headache for months, he also had aches & pain and loss of 3 kg. His
VS today are Temp normal, BP 140/90 mmHg, the rest normal.
Tasks : Perform PE of head and neck. Explain your findings to examiner.
Dx and DDx with reasons to patient.
( There were tongue depressor, torch, otoscope and fundoscope on the table. )

Approach :
I greeted the patient and asked him whether he’s in pain and offered him painkiller.
I told him that I’m going to examine your head & neck, and so on…

PE :
Washed my hands.
Inspection - Eyes, ENT (with torch and tongue depressor), face especially temporal area – unremarkable.
Palpation – I started on eye balls, then patient c/o pain when I press over left temporal region, no pain
over sinuses, and on opening the jaws. No cervical spine tenderness as well.
I proceeded to examine 2nd CN. I looked for Snellen chart & asked examiner, he said VA normal. Then I
did VF which is normal. I took fundoscope and explained patient what I’m going to do, but I couldn’t find
the switch. xD after some time, examiner said normal. Then the small bell rang.

Dx : GCA, explained about it. (didn’t tell about PMR)

DDx : it could be due to raise BP but yours is not that high. Can also be due to TMJ dysfunction, dental
problems, ENT infections, eye problems, migraine, brain tumor but less likely.

STATION 10 : Abdominal pain (PASS)

37 years old lady comes to your GP clinic for biopsy report. Previously, she c/o abdominal pain (
don’t remember other symptoms ) I think she had family h/o bowel cancer. So Sigmoidoscopy was
done and took biopsy from the growth which is 10cm from anal verge showing adenocarcinoma.
Tasks : Explain Dx
Further investigation with reasons.
Management plan ( details not required )

Approach :
I greeted patient. Asked her whether she comes here alone? How would she expect the result?

Dx :
I told her that the result came back and shows that you have bowel cancer. Then, asked her to take her
time, offered tissue and water. Patient was a good actor. She was teary and surprised but she kept talking
about how she feels right now instead of being silent. I reassured her.
After some time, I explained her about the condition with a drawing. Then told her that we need to do
further inx to look for any spread.

Inx :
Blood tests – tumor markers
CXR – because it can spread to lungs
CT chest, abdomen – because it can spread to lungs & organs inside tummy
Bone scan for similar reason
I was hesitated to do colonoscopy, then I didn’t tell about it.
( it was awkward to tell the reasons according to task because patient seemed stressed when I tell about
the spread, so needed to reassure her whenever possible. )

Management :
We’ll treat you with team approach like….
Main option is Surgery but other options like RT and Chemo are available which depends on staging and
decision of specialist.
I explained about surgery with drawing, and temporary colostomy, and their purpose, good points, bad
points, and stoma nurses.
Reassured her and asked her is there any Q? she said how can I think of Q in this situation.
Then, I kept reassuring and highlighted some important points in management.