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Adelaide 13th September 2008

Paediatrics:
Case 1 Youre seeing 3 year old Sarah one week after a hospital admission with an episode of asthma. This is her third episode in past two years. She has been prescribed terbutalin syrup (bracanyl) from the hospital. On examination her height and weight is in 50th percentile and can hear wheezing in her lungs. Task: 1. Take relevant history 2. Explain the condition and your management to her mother In the history: No eczema or allerigies Wakes up about 3 nights per week with cough Uses terbutalin syrup once a week for exacerbations Gets cough if she plays too hard Mother is a smoker no pets Has an elder brother who has Asthma I took too much time in taking history therefore ran out of time to tell my management. I summarised it saying need to identify what make her asthma worse and avoid them including mothers smoking and use of relievers and preventers. I failed this station and later found out that when you talk about spacer device they will provide you with one, which you have to explain to the mother. AMC feedback Asthma Case 2 7 years old Taylers mother is in your practice to know about her sons recent blood results. You have ordered following investigations when you last saw him with multiple bruises and mild fever. FBE Hb 65g/L WCC 0.6 Neutrophils 0.4 Lymphocytes 0.2 Platlets 25 Blood film Normocytic Normochromic anaemia. No abnormal cells seen His father is working overseas Task

1. Explain the results to the mother 2. Tell the probable diagnosis 3. Explain you management to the mother Explain to the mother that I have bad news to tell and ask whether she needs someone with her. She was happy to go on and I explained the results and told this looks like pancytopaenia and what it meant. Told her son needed immediate hospital admission for specialized care for this problem and it would be prudent to ask your husband to come back because you will need a companion to help you and your child through this difficult period. In hospital he will be managed by a haematologist. He might need blood and platelet transfusions if required. He will be given antibiotics to protect him from infection and may isolate him from rest of the wards to protect him from catching any infections. He would under go a bone marrow biopsy which would be performed under anaesthesia to determine the cause of this condition. Possible reason were indopathic, viral, drug related or may be leukaemia (but unlikely because the peripheral blood film doesnt show any abnormal cells) Depending on the cause he can be treated with bone marrow transplant, immunoglobulin or steroids. Is this a condition is severe? Yes it is thats why I am organizing prompt admission to hospital What can cause this condition? Viruses, drugs, idiopathic (I couldnt remember much) The bell rang!!!!!!!!!! AMC feedback Pancytopaenia Case 3 4 years old Sam was brought to the ED by his father after suffering from a fit like episode with a fever. Now the child is ok. You have examined the child and diagnosed uncomplicated febrile convulsion due to a viral infection. Task 1. Take relevant history 2. Explain the condition to the father 3. Tell your management to him I greeted the medical student (Tom) and said I have good news and nothing to be alarmed at this moment. Sam is doing fine and what you have witnessed is a febrile convulsion. This is convulsion or fit due to abnormal firing of brain cell in response to the temperature changes in Sams body. This occurs because Sams brain is still developing and is more sensitive to the changers compared to a mature persons brain.

This does not mean he has any problems with his brain at the moment. I stressed this is not epilepsy and the chances of Sam getting epilepsy is only slightly higher than the normal population so nothing to be concerned at the moment. Explained what parents can do at home to prevent it from happening, like paracetamol and tepid sponging if they feel he is going to get a febrile illness. If he gets another febrile convulsion which is more likely to keep him in a safe place, not to put stuff into the mouth, watch out for abnormal signs such as one side of the body moving or prolong fit or any hint of suspicion by the parents, then bring the child to the hospital. Pamphlets to read My wife is pregnant and will that child have this problem as well? Yes high possibility due to 1st degree relative One of my friends who have epilepsy is taking a drug called Sodium Valproate, does my child need any medication? No, your friend has epilepsy whereas your son has febrile convulsion. Therefore, at the moment no treatment is needed. AMC feedback Febrile Convulsion (this in the AMC DVD)

Obstetric and Gynaecology


Case 4 24 year old female had a pap smear done by one of your colleague 2 years ago. She has come back to repeat the test. While you are examining her you have found an abdominal mass extending 2cm above the umbilicus. Task: 1. Take relevant history 2. Ask for examination findings( he will only tell you what you ask) 3. Probable diagnosis and management Regular periods Normal menstruation no heavy bleeding/pain/ discharge LMP 3 weeks ago Uses Condoms for contraception Stable partner no history of STIs or dyspariunia/dysmenorrhea Have gained about 2 kg during past few months No other medical or family history of concern Examination Avergae built. Vitals normal Abdomen mass extending from pelvis 2 cm above umbilicus, uniform and regular. Cervix normal mass continuous with uterus no adenexial masses

My probable diagnosis is fibromyomata (fibroid). Explanation: Benign condition commonly seen in reproductive age women. It is not a cancer. To confirm the diagnosis need to do an USS. Ill refer you to gynaecolist, who will do the USS and suggest management options. Depending on the position of the fibroid he will offer either surgery or watch and wait approach. Questions: Can I get pregnant? Depending on the position of the fibroid you may have trouble getting conceived, if you get pregnant this might course you to have miscarriage or if you go till term may course problems with delivery of the baby and during the pregnancy it can cause problems like torsion or red degeneration which might lead to premature delivery or urgent surgery. Can it be anything else? With your history and examination this is the most probable cause. I did not offer pregnancy test as it is unlikely. AMC feedback Mass found in lower abdomen Case 5 A 26 year old primigravida at 36 weeks presents to the emergency department with excruciating headache. Youre the attending HMO. Task: 1. Take relevant history 2. Request relevant examination findings from the examiner (you will only be given what you ask for) 3. Explain your management History to differentiate SAH or Pre-eclamtic Severe pain 9/10 Generalized Gradual onset No visual disturbances Notices increase ankle swelling during past 2 weeks. Previously normatensive Ante natal period uneventfull, all investigations and scans normal Baby is kicking fine. No vaginal discharge Examination:

BP 170/110 Ankle oedema Exaggerated KJ/AJ + clonus SFH = POA = 36wks Cephalic head entering pelvis FSH + Urine ward test protein 4+ Management: I told this is an emergency; she is having pre-eclampsia and can going to eclamtic fits any time. Examiner told shes now started to have a fit manage. Left lateral Call for help Oxygen via face mask IV diacepam IV MgSO4 IV hydralazin to bring the BP slowly down Inform obstetric team as she will need emergency delivery Examiner said you have finished the station so go out side and wait.. AMC feedback Eclampsia Case 6 A 24 year old primigravida visited you last week at POA of 26 weeks for GCT, Hb, and Indirect Coombs test. Now at 27 weeks shes coming to receive her results to your practice. GCT: elevated (cant remember the values) Hb: Normal IDC: Negative Task: 1. Explain the results 2. Take relevant history 3. Explain the management Explanation, you may have GDM but need to do GTT to confirm it. Examiner hands you the GTT. Fasting and 2 hour glucose levels elevated. Youre having GDM History Strong FH of DM Average built No diabetic symptoms like polyuria/polydipsia/nocturia Healthy diet

All antenatal investigation, check ups and scans normal so far. Plan: First well try diet to achieve glycaemic control. Youll have to monitor blood sugar 3 4 times a day using a glucometer at home. I will refer to a dietician for assistance. After 3 weeks if you cant achieve good control with diet have to consider insulin for the rest of the pregnancy as the diabetes going to get worse as the pregnancy progresses, which is a good indicator of placental well being. You will be seen by an endocrinologist and obstetrician. Your rest of the antenatal follow ups will be done in a special clinic. Youll have more frequent clinic visits and more USS to check the babys progress. You do not need to worry as this is not an uncommon thing, lot of women with diabetes deliver healthy babies. Reading material, referral letter to dietician/endocrinologist/obstetrician AMC feedback Positive GCT (AMC book case)

Psychiatry
Case 7 A 30 year old Maria has come to your practice requesting for a letter to Department of Housing Authority to find her new accommodation. You have seen 30 year old lady several times during the past few weeks because of extensive contact dermatitis due to cleaning agents. She had nervous breakdown 4 years ago after separating from her husband. She has stopped her medication 3 years ago. She in your practice today to get a letter to Housing Authority for change of accommodation as she has been troubled by the neighbours. Task: 1. Take psychosocial history of this woman. (including the mental state examination) 2. Present your finds of MSE to examiner 3. Give your DDs History + Mental State: Well dressed Appears well groomed Normal mood Speech is normal Perception: Delusion of reference: She was watching a program on TV where she believes they discussed about her. Delusion of persecution: She believes her former husband is causing all the current problems she is facing with her neighbours Hallucinations: Second person: she hears voices talk about her next door. (She knows there is nobody living next door)

She strongly believe the neighbours throw things into her house which she needs to continuously clean (this is causing her the dermatitis) No insight Good judgment and no suicidal ideas or plans She has stopped medication on her on previously because she thought she was feeling well. She lives by herself. DD: Acute psychotic attack Schizophrenia Drug withdrawal Brain tumour

Examiner: What are you going to do about her? Need urgent assessment done on her and seen by a psychiatrist. She needs admission and if she refuses has to consider involuntary admission because she has paranoid ideations, loss of insight, live by herself and previously also stop medication on her own. AMC feedback Paranoid Schizophrenia Case 08 A young female who has been a patient of your clinic due to her long term bowel problems is here after her colonoscopy and gastroscopy. Gastroenterologist has confirmed it was irritable bowel disease but failed to explain what it was and re-referred her back to you for further management. She has been suffering with these symptoms for 4 years. Tasks: 1. Take psychosocial history 2. Explain the condition and answer her concerns 3. Arrange further management I knew what was happening in this station even before I went in as I could hear this young gal shouting at the candidates from my rest station. What ever you tried to talk she would brat down on your neck and blaming you for all the misery this has caused her due to your inability to diagnose her condition for 4 years. She is angry because the gastroenterologist has told her that IBD is due to stress and associated with brain/mind. By the time I finish the station my ears were ringing and I just sat there hopelessly because I didnt had any idea what I should do or say. I tried asking HEADS questions and this is what I found or hear while in the rest station She is 24 and works as an airhostess Have problems at home with boy-friend and also at work She is stressed to the max

Smokes and drinks but no increase in recent times Not on any other drugs So still no idea how to get around it but I passed this station and in a friendly chat with an examiner said the expectation may have been for the candidates to sit there and listen to her and not get offended. AMC feedback Mixed anxiety/depression Atypical abdominal pain

General Medicine
Case 9 A 55 year old retired manual labourer has been referred to you by your colleague for your opinion regarding abnormal liver function tests. This is the famous recall with a referral letter from GP Pt has pace maker for bradycardia Serology negative Never done drugs or alcohol Continuously elevated liver function for 2 years Results of GGT normal/ALT increased were given. Task: 1. Explain the results 2. Request further investigations 3. Give the diagnosis and explain the management Investigations: Serum iron studies- Iron level, Ferritin, Trans ferrin saturation elevated HFE gene study - Homozygous for C282Y gene,H63D gene, RBS - Normal Diagnosis Haemochromatosis Explain that this can be controlled but cant be cured Regular venesection Specialist care by gastroenterologist Watch out for diabetes Can cause cirrhosis if not managed properly which if happens will increase your chances of having a liver cancer Questions: What about my son, does he need a test? No need if he is below 40 as we cant prevent him from getting this if he carries the gene. Also symptoms only manifest in late 40s and above. But advice the son about the risk if the disease and beware of it. Good news is people can have normal life expectancy with good management of the condition with minimal complications

AMC feedback Abnormal liver function tests Case 10 A 60 year old retired accountant is in your practice because of gradually worsening aches and pains in his body. Task: 1. 2. 3. 4. Take focaused history Ask for relevant physical examination findings from the examiner Request relevant investigations Give the diagnosis and management plan

History: Pains started in back of the shoulders not in the shoulder joint. Worse in the morning, then gets better and again worse in the evening. Gradually getting worse for couple of weeks Now the pain is in his hips and upper thigh as well. Never had similar pains. No arthritis or joint problems in the past. Not on any medication. Hasnt lost any weight. No headaches, visual problems or mastication problems No family history of similar condition or malignancy Non alcoholic and non smoker No other medical or surgical problems (including gastritis, osteoporosis) Examination: Normal BMI, Healthy looking Vitals normal Pain on shoulder girdle not on the joint. Similar on hip as well CVS and RS normal. Abdomen no masses, PR prostate normal. No point tenderness over spine Investigation: ESR, CRP, FBE Gastroscopy and colonoscopy Diagnosis: Polymyalgia Rhuematica Management: Oral Prednisolne + Osteoporosis prophylaxis Rhuematology referral Educate about warning signs of temporal arteritis. Acute pain relief with paracetamol and NSIADs

AMC feedback Aches and pains Case 11 This middle age woman has long standing DM. The BSL control is poor through out the life. Task: 1. Examine her LL in view of finding complications of longstanding uncontrolled DM 2. Explain your findings and reasons while examining the LL to the examiner Examination: I started by saying longstanding DM would have Macro and microvascular complication and this is what I am going to look for and elicit during the examination. Stood up the patient for inspection Quadricep wasting Pigmentation Charcots joins (loss of proprioception) VV Healed ulcer scars or ulcers While standing Rombergs test for proprioception Palpation: Temperature CRFT < 2 Nail and nail fold hygiene Ulcers between toes and on the sole of the foot All the pulses of the lower limbs Sensation: Looking for stocking type sensory loss using the mono filament. She had stocking type sensory loss. The filament was on the back of the knee hammer so I check the reflexes at the same time which was normal. Vibration both 128 and 256 tuning forks were there. Use the 128 one no sensation until tibia. Bell rang!!!!!!! Want get time to do everything therefore my advice select what you want to do or what you think is most important in this station and do it first and then go for the rest. AMC feedback Diabetes complications Case 12 A 30 year old gentle man has found to be having a blood pressure of 170/100 during a routine medical check up. This was repeated three times during the past few weeks and still high.

Family history: Mother died of a stroke at 50 years and father had a myocardial infarct at 45 years. Task: 1. Do relevant physical examination. (explain what your looking for the examiner as you go) 2. Explain your further management to the patient Examination: I started by saying the examiner that I am looking for cause for secondary hypertension in the young man with strong family history of cardiovascular disease. Role player was a medical student. General appearance looking for Cushin or acromegaly Started by feeling for pulse (rate, rhythm, character and volume) Any R R delays or R F delays indicating Co-arctation of Aorta BP when requested I was asked to measure it using a wall mounted BP apparatus. Once I did it the examiner was impatient and was rushing me through rest of the examination. When I came to abdomen he asked what I want look for I said kidneys. He ask me to show him how I would look for them, therefore I explain I would ballot for them to feel whether they are enlarged (polycyctic), forgot to listen for brui in the tummy. Then told me to tell what further investigation I would do to the patient. Told him you may be having secondary hypertension and I need to find the cause if I am to bring down your BP. First would like to do and USS of you abdomen to look for you kidneys and the renal arteries. The bell rang!!!!!!!!!!!! After the exam I found out everybody was asked to check the BP and some struggled to do so, therefore my advice is learn it as I believe this station was to check your examination technique nothing else. AMC feedback Hypertension Case 13 A 50 year gentlemen is in your practice because of his worsening leg pains. He gets it on his calves when walking. Recently the distance he could walk without getting the leg pain has significantly shortened. He used to a around of golf very week which he is unable to do now. He smokes 30 cigarettes per day On an ACE inhibiter for his hypertension Task: 1. Do relevant examination of the limbs. (Youre not required to examine the hear) 2. Explain the reasons for the findings This was a real patient. He had a surgical scar from a bypass surgery on his left leg.

As usual I proceeded to inspect the lower limbs muttering the mantra of pigmentation, scars, colour, hair when the examiner interrupted and said go ahead palpate and tell me what you find. Palpation I couldnt feel any of the lower limb pulses in either legs. I said I want to do Bergers test and ABPI. He asked me to show him how to do the Bergers test which I did. Then he told the ABPI in Left is 0.25 and Right 0.9. Questions: What do you think he is having? Peripheral Vascular disease Where do you think the problem is according to history? Superficial femoral Good, Now show me where the superficial femoral artery runs? Which I was not sure and I showed him the lateral aspect of the thigh. He told me its in the medial side of the thigh. You didnt felt any pulses up to femoral artery, therefore where do you think the obstruction is? Either in external iliac or common iliac artery Since you couldnt feel both where do you think the problem is? Abdominal Aorta Good, what can be the cause? Aneurysm Very good, How would you know youre right, show me how you would look for an AAA? I showed him how to look for an expansible pulsation Excelent, What is your management of this patient? Need urgent vascular surgical referral Your vascular surgeon is not available for months advice the patient regarding the management till then? Need to stop smoking; I can help if youre willing Do moderate exercise as you can tolerate. This would improve the blood supply to the leg Cardiology opinion on management of hypertension and ACE Inhibitor (I was not sure whether to stop or not) The bell rang!!!! AMC feedback Leg cramps on exercise Case 14 Mrs A is 48 years and was diagnosed with breast cancer three years ago and had mastectomy done o her left side. Since then she had radiotherapy and chemotherapy. Now she has come with increasing swelling of her left hand. You have notice some telengetaciae in her left axial and chest. Task: 1. Tell her you diagnosis and explain it

2. Talk about the management No further history taking is required Explanation: With the information I have gather it looks like this may be either lymphoedema or DVT. Tell me how rapidly did the swelling got worse? Over few weeks Does it hurt? No (There was a picture as well which shows a lymphoedema arm) I need to rule out DVT and for which I need to do a Doppler and CT scan. This condition is similar to what we get in lower limbs and you are more at risk to get it in your arm because of the surgery and complications due to radiotherapy. If the tests are negative and most likely with the information you may be having lymphoedema. This a complication of removal of lymph nodes from your arm pit during your mastectomy. Other than arteries and veins there is a third vessel system which we call lymphatics which drains fluid from tissue. Because of the surgery and the radiotherapy the drainage of lymph is obstructed causing it to accumulate in you arm. This is lymphoedema. Good news is that we can control it and treat it but not necessary cure it. There is specific clinic for this in the breast clinic, where you have specially trained physiotherapist to do special physic to your arm so the fluid can be drained out into the body. You need to where compression bandages at all times due to the risk of DVT Dont let the arm get sun burnt or injured during house hold chores Dont allow to check BP, draw blood or put cannulas in this hand. If it is severe there is micro surgery which can correct the lymph drainage. Here are some reading materials about this condition. Any questions you would like ask? Role player Is this a cancer? Most likely not but it is one of the possibilities that we have to exclude. AMC feedback lymphoedema/upper limb Case 15 A 25 year old man was herding the sheep on a motor bike when he accidentally hit log and fell down and hit his head. He has lost consciousness for 5 minutes. He was brought to the emergency department by his friend who was riding with him. You are the attending HMO. Task: 1. Perform primary survey

2. Request immediate investigations 3. Suggest immediate managements needed When I went in I was shown all the equipment I should be utilizing during the management. There was cervical collar, Hudson mask, tubing.. There was a medical student lying in the bed covered with a bed sheet I started by say I would follow DR ABC and check the air way (I forgot to check for response at this point) I said before doing anything I would like to stablize the cervical spine using the cervical collar. Examiner: Good show me how you would do it? I need someone to keep the head and neck in-line till is pass the collar under the neck. Examiner: Show me how you would place the collar? I showed how to do it Then air way, it was clear Breathing, I looked, listened and felt breathing. Examiner: Left chest is not moving with breathing. What are you going to do? I need to exclude tension pnuemothorax as it is life threatening Examiner: How would you do that? Listen to lung for breath sounds and check whether patient is deteriorating. Examine: Ok Listen for BS? I listen for the sounds using the steth Examiner: How do you know patient is deteriorating? Decrease in SaO2 and by asking the patient. Examiner: SaO2 94% in room air and you can ask the patient for the deterioration. I asked whether the there is any pain which was and arranged pain killers. Asked whether his is progressively feeling difficult to breath, he said no I am alright. Examiner: What next? Cardiovascular Examiner: Anything else before that? Ohhh I am so sorry I need to put oxygen via mask Examiner: Ok assume you have done that and go on to the cardiovascular Need to feel for carotid pulse for volume and rate and BP Examiner: Pulse 110 and BP 100/60 Patient is haemodynamicaly unstable. Need two wide bore cannulas in both hands and start fluid resuscitation. Same time would like to connect him to the monitoring and arrange base line blood investigations. Examiner: What other investigations do you need? Cervical, chest and pelvic x-rays and CT brain I was told I have finished the station early so go out side and wait. I thought I have failed this as you must have noticed I have done things wrongly but for my amassment I have passed this station. AMC feedback Primary survey of trauma patient

Case 16 A 68 year old menopaused lady was investigated for a back pain and found to have a fractured thorasic vertebra. She has under gone a DXA scan which revealed T -3 score. Her FBC ESR and UFR are normal. She has come to gather her results today from her general practitioner. Task: 1. Take focused history 2. Tell the diagnosis and management History: Got the fracture while trying to get off the bed. This is the first time. Menopaused for 18 years Never took HRT No PV bleeding/ wt lost/ bowel habit change/ bone pains Dont like diary products Not much out door activity Family history of osteoporosis in her mother at 80 No medical or surgical co-morbidities. Not on any medications, alcohol and smoking Most likely osteoporosis, which is thinning or sponging of the bone due to lost of female hormones in your body following menopause. Management: Talked about Physiotherapy to improve bone thickness and muscle strength. This helps to prevent fractures and falls Dietician for dietary advice regarding fortified foods with vit D and Ca Increase out door activities which would expose you to sun light. Help to produce Vit D in the body Keep up the good habits Medical management would include drugs like bisphosphonate, Ca and Vit D supplementation, Strontium and raloxifen Explained what each drug does. Said here are some pamphlets to read. Do you have any questions? Can this be cured? I am I having a cancer? No can not be cured but can be control to the limit where youll be able to lead a normal life with reduce risk of fractures Didnt get to answer the second question as the bell rang.

This station I failed.. Presumably due to the fact I didnt alleviate her worries about a cancer. AMC Feedback Osteoporosis

Thank god finally the nightmare was over and can look forward to building my medical career in Australia now. I have thank my study partner for all the help and also all the other friend who supported me and encourage me during these few months. Looking back, my advice to everybody who is sitting the exam is to improve the communication skills because this is more about how you would communicate you medical knowledge to a lay person. Therefore keep doing the role plays.

Good Luck!!!!!!!
and mind my spelling and grammar mistakes