AMC Orals Brisbane 26th of July O&G

1. AMC feedback: Pre-pregnancy counselling diabetic AMC assessment book condition 14 (P62, 102) 2. AMC feedback: Urinary incontinence/stress incontinence Scenario: A fifty-five year old lady comes to your GP complaining of urine leakage. She is overweight. Tasks: Take relevant Hx, ask examiner the physical findings and Mx. AMC assessment book condition 128 (p668, 688) When I stepped in the room, the examiner stressed the pt was obese. Then the role player gave the typical presentation of stress incontinence with the past 3 deliveries, one of which was aided by forceps. She denied past history of UTI, DM, HRT use and other aggravating factors like chronic coughing and constipation. Pap smear was up to date. Examination findings revealed atrophic vaginal change and positive pad test without cystocele, rectocele or uterine prolapse. Urine deepstick was unremarkable. Then I explained to the pt the likely diagnosis could be stress incontinence. However, mixed incontinence was not uncommon. I need to organise some investigations like urine C&M, BSL and urodynamic study. If the diagnosis was confirmed, there were several things we could do. I drew a picture and said the treatment options included pelvic physio, operation such as colposuspension to lift and strengthen the neck of the bladder. Life style modification was also very important, like weight reduction, prevention of chronic constipation and coughing. I would refer her to incontinence clinic. Before the bell rang, I also added local estrogen cream if there was no C/I. 3. AMC feedback: Urinary retention Scenario: Eighteen year old young lady comes to ED complains that she has been unable to pass the water for a couple of hours. Tasks: Take a relevant history, ask PE from the examiner and manage the case. When I went inside, there was a lovely young lady sitting in the chair. After introducing myself, I got to know her name was Anna. Me: When did it happen?

Anna: Oh, it started several hours ago. Me: I can see you feel uncomfortable, so do you want me to help in emptying the bladder now? Anna: I am fine. Me: Could you pls tell me more about your symptoms? Anna: Oh, I feel sore in my private area and cannot pass the water. Me: Have you noticed any discharge from there or vagina? Anna: No Me: Before this episode, everything was all right? Anna: No problem before Me: Has it happened before or is it the first time? Anna: The first time. Me: Any other symptoms: burning sensation when you pass the water before this? Tummy pain? Fever? Muscle soreness? Anna: No to all the above Qs. Me: What about your general health, any kidneys or bladder problems? On any medications? Anna: No to all the above Qs Me: Can I ask some sensitive Qs? Anna: Yes? Me: Are you sexually active? How long have you been with the partner? Do you have any other relationships? Do you use any contraceptive methods? Any similar symptoms for your partner? Anna: Yes, three months, no other relationships. No contraception. Dont know about him. Me: Have you ever been diagnosed with any STI or PID? Anna: No Me: Pap smear? Anna: No Then I turn to the examiner: Examiner: What do you want to know? Me: GA and V/S, especially Temperature. Examiner: all normal and Anna feels uncomfortable for you to touch the tummy, you can see the ulcers and blisters around the vaginal area. I smiled and said to the examiner: Pls can I take the swab from the ulcer and send to lab? Examiner smiled: of cos you can. Pls talk to Anna what you are going to do. I turned to Anna: Anna, it looks to me that you have the genital herpes. I have already taken the sample and sent it to lab. I understand that you are in great pain, so let me help you to get relief first. I am going to use a syringe to aspirate your water out from your tummy. It is gonna be a little bit sore, but I will do it quickly. Is that all right for you? Anna: Pls. doc. Thank you. Okay, now I am comfortable now.

Me: That is good. Then we have further Mx for you. Since it started several hours ago, I can prescribe you some anti-viral mediation and pain relief gel. You can use them for a couple of days. Also it is very important for me to suggest a full STI screening test. As this condition itself is transmitted by sex. So for the best interest of you, I strongly suggest you to have it done. Do you reckon? Anna: That is fine, but what about my bf? Me: It is recommended too for your bf to have this screening. Pls talk to him and if possible, bring him here to see me. Anna: I will. So doc, will it happen again? Me: It may recur, but if that is the case, it will be less frequent and less painful. Anna: Thank you, doc. Then I talked about some other things, like safe sex, pap smear, from 18 years old or two years after being sexually active, whichever comes later. Also HPV vaccination is free for her.

Paeds
1. AMC feedback: Febrile toddler with slight pyuria Scenario: You work in GP setting. Your next patient is 18 months old girl, who has been brought in by her father because she had been unwell with fevers for the past 48 hours. She had vomited twice, but has had no diarrhoea. Dipstick of urine (urine bag specimen) showed protein, nitrites, leucocytes. Tasks: Talk to the father about the management. Me: How is your daughter now? How is her eating and drinking? How many nappies have you changed so far? How about temperature now? Any rashes on the body? Father: The Tm is 37.4 now. She is all right. Tell me what is the problem? Me: Weve got your daughters bag urine test back. There are some abnormal findings. Father: What does it mean? Me: It may indicate the infection involving the water-passing system (I drew a pic), but there is also the possibility of contamination by the outside. As you know, there are lots of bugs around the private area. Father: Okay, so what will you do? Me: Because we do not want to miss the possibility of infection as it is for your daughters best interest. What I am going to do is to refer your child immediately to the hospital. What medical staff will do in the hospital is to take the clean urine out directly from the bladder (I pointed the bladder in the pic). This is called Superpubic

aspiration. It is gonna be a little bit sore for your child, but it is very quick and you can accompany her. The sample will be sent to the lab for culture and other tests for the purpose of medications. Pls do not worry, in the hospital your child will be very well looked after by the specialist. Father: Will my child need admission? Me: It depends. As I have mentioned, if the bag urine test this time is false positive, which means contamination, then your daughter can go back home after SPA. But, if SPA sample is positive, then the specialist will make the decision what to do at that time. If that is the case, most probably your child will be put on antibiotics for a couple of days. The specialist may also consider the further Ix for the child after the recovery, like U/S and Miturating cystourethrogram (I drew a pic to explain how MCU would be done). Father: Okay, I understand. Me: Any Qs? Father: No, you have explained everything. 2. AMC feedback: Torsion of testis Scenario: ED setting, an 8 year boy was brought in by his anxious father because of acute abdominal pain and feeling unwell. Tasks: Take relevant history, ask physical finding and manage the case. After greeting the father, I was told the abdominal pain started a couple of hours ago and the kid felt quite sick and looked miserable. His temperature was normal and bowel and water worked fine previously. He was healthy before and was not on regular medication. When I turned to the examiner for physical findings, the nice lady asked me how you went for physical examination. C: How about GA and VS. E: he looks miserable and is in pain. VS are still within normal range. C: I want to focus on abdominal examination. I start from inspection, looking for any mass, peristalsis, groin hernia and scrotum. E: there is a right scrotal swelling, and the testis is high and horizontal. On palpation, the right scrotum is quite tense. The bowel sounds are present. Then I explained the condition to the father, saying the affected testis was lacking of blood supply due to twisting. The urgent admission and surgery would be needed to restore the blood supply and to fix bilateral testes to prevent recurrence for both sides. The father was quite concerned about his sons fertility. I said that you were a good father and brought your child to hospital at the early stage. The experts would try their best to save his testis. Your kid will have good chance to recover fully.

Both the father and examiner did not ask any questions, I left earlier. 3. AMC feedback: Breath holding attack Scenario: An anxious father came to your GP clinic concerning about his 2-year-old sons condition. His son was crying and holding his breath for few seconds after his finger has been injured by the car door. Tasks: take relevant history from the father, Dx and explain to the father. After taking the history, I made the Dx as breath holding attack and explained to the father that its kind of temper tantrum. It would not be harmful to the childs brain and his development. It was not epilepsy which the father was quite concerned about it since his uncle had it. I explained to the father that what to do in case it happened again. Gave the advice on how to manage in the future which all could be found in the patient education.

Psych
1. AMC feedback: Bulimia nervosa - management Scenario: A young girl with DM type 1 was going to be discharged from ED after being treated for DKA successfully. The nurse required you to talk to her as she found the girl skipped the insulin purposely. You got to know this girl had binge-purge eating habit, also tried to control the weight by using laxatives. Tasks: explain the diagnosis and its effect on her body to the pt, and manage the case. (No history taking) As soon as I greeted her she said: doc, pls do not tell my GP about this, otherwise he must be very angry at me. I answered the conversation between you and I today will not be out of this room. I explained she got Bulimia nervosa, which was a kind of eating disorder. People with this condition had overvalued idea about eating and body image. It is very common in young people, as some people tend to use this way to cope with the stress in their life. I also took a little bit history. She was a hair dresser, doing well with her colleagues and parents. She had no suicidal idea and had not used any drugs. I convinced her that what she had done was harmful to her health, especially skipping insulin potentially might endanger her life. Her eating habit also affected her heart, skin, period, bones, blood system, stomach, teeth and food pipe. She said her periods were ok. What about laxatives? I told her it could cause electrolyte imbalance and also resulted in constipation from a long run. Then I mentioned family meeting, dietician and psychiatrist involvement. Specifically, CBT or sometimes some medications might be needed. CBT would help her to correct the overvalued idea about the eating habit and body image.

Then the role player asked: what is the difference between a psychologist and psychiatrist? I answered: both of them can do the talking therapy, which is CBT but the psychiatrist can also prescribe the medications. At last, I mentioned the follow up and written information. After that, I realised I forget to say that she need to be assessed by the psychiatrist before being discharged! 2. AMC feedback: A request for bilateral breast reduction Scenario: A 28 yo lady wants to have breast reduction operation done. Tasks: Counsel her. Pls notice that referring to the specialist is not enough, you must state the reason for that. When I stepped inside, I noticed this lady lacked of eye contact and looked at the ground. Me: Pls could you tell me why you want to have this done? Roleplayer: I am unhappy, very unhappy. Me: Why? Roleplayer: My husband is going to divorce me. I think maybe after this operation I will feel better. At this moment, I began to know this was a psychy case. Then I asked the typical depression Qs. She had the following features: feeling down for over two weeks, early waking up, lack of interest of life, sex drive decreased and no suicidal ideas/plans. She had no delusions or hallucinations. She had no features of anxiety. She drank 1-2 glasses of wine everyday(I specifically asked the glass size and told her about the safe level). Past physical hx and mental illnesses were negative. Other stresses: father passed away several months ago, mother also passed away long long time ago and stressful job. Then I screened her for grief Qs, all negative. Then I counselled her, saying the possible Dx could be depression. Then talked about relaxation techniques, sleep hygiene and psychiatrist review. I could not see whether she was pleased or not with my performance. My tears were almost out when she repeated: I am very unhappy. She was a very good actor with Queens accent. So I spoke very softly and the examiner had to move her body close to me.

Med & Sur

1. AMC feedback: Adrenal tumour Scenario: A middle aged lady was found to have a 5cm size abdominal mass on her CT and her BP was confirmed to be elevated. Tasks: Take relevant Hx, ask examination findings from examiner, explain CT to the pt and manage the case AMC assessment book P 303-307

(Pls read the book carefully as all of the answers are between the lines in the book). After I greeted the role player, I started to explain the CT scan briefly. This pt had several episodes of headaches and palpitation, of sudden onset, lasting about 10 minutes, without obvious trigger factors. The pt did not complain of skin colour change chest pain, SOB, visual problem, dizziness, ankle swelling, loss of consciousness, tummy pain or weight loss. Her bowel and water worked fine. She was previously healthy and family history was unremarkable. Examination findings: high BP, which was 180/110. There were no signs for Cushion syndrome, no irregular pulse, no JVP elevation, no fundi change, no displacement of apex beat, no crackles in lung fields, no abdominal mass palpable, no abdominal bruits, no ankle oedema. And urine deep stick was negative. Then I said, based on the clinical features and CT scan, you had a tumor in the adrenal gland. Most likely it was pheochromacytoma which might explain your symptoms. In medical field, we call pheochromacytoma 10% tumor. 10% familiar, 10% spreading outside adrenal gland, 10% malignant and 10% bilateral. We need to order further investigations to confirm the diagnosis, such as urine VMA, catecholamine, bone scan and some blood tests to exclude other DDx such Conns disease and Cushion syndrome. Mx: refer to surgeon for operation as the size reached 5cm. Also if it is the case, you would be given some medications prior to operation, blocker and blocker. I stressed the point that blocker should be first! 2. AMC feedback: Shortness of breath Scenario: A 45yo man complains of SOB for 3months. Tasks: take relevant Hx, PE from the examiner and give the Mx. First I screened him on PE Qs (cough, sputum, travelling Hx), all negative. Then I asked CVS (chest pain, how many pillows at night, ankle swelling), PHx of liver and kidney problems, all negative. Further Hx included: profession (he worked in a timber shop), smoking (two packs for over 10yrs), general heath are FHx are negative. Then I turned to the examiner asking for PE. The examiner immediately asked me: which system you want to know? I said: Respiratory system. He said a lot of things, trachea, vocal fremitus, tactile fremitus, breath sound..Actually all of his words did not get into my mind! At that moment, the only info I grasped was the breath sound disappeared at the left lower chest. After finishing this, the examiner immediately asked me to talk to the pt (time controlling was very important for this case as I noticed the examiner helped to shorten the time for PE). I then drew a pic talking about the pleural effusion and

offered the referral to hospital for further Ix. The most important Ix was called pleural tap (then I explained in the pic). I also mentioned the possible Dx including the nasty things. The bell rang on my last word! 3. AMC feedback: Dementia of Alzheimer type Scenario: A middle aged woman comes to your GP clinic. Her father was Dx with Alzheimers disease by the specialist recently. Her relationship with her father is tense. Tasks: Listen to her concerns and answer her Qs. Daughter: I do not want to look after my father, as you know I am very busy at work and I do not have a good relationship with him. Me: Okay, I understand it must be very stressful at this. We have aged care assessment team. It includes a lot of people who are going to look after your father together. We need to assess him, what level of support he need, whether he is going to nursing home, respite care, residential care or private hospitals. Geriatrician, the specialist will assess your fathers health and also possible medications. My role as a GP is to regular follow him up. Occupational therapists will assess your father safety issue, the bright lights at night, rails at home, steps in the yard and other modifications at home. Physiotherapists will assess your fathers mobility, whether he need walk stick or wheel chair. Social workers are also involved. If he cannot cook, we will arrange meals on wheels, if he is not able to wash clothes, we will arrange the people to help on that. Pls do not worry, we will look after your father together. I will come and visit your father, I want to talk to your father, to initiate the assessment for your father. Can I ask does your father drive? Daughter: No, he does not drive. Can my father have depression? Me: It is possible. For people with dementia, they may have depression. Sometimes we also call depression pseudo-dementia. But pls do now worry, I need to assess him, I need to do MMSE on him. After assessment, if that is the case, we can put him on some meds. It is too early to say at the moment. Daughter: Will I inherit the dementia from my father? Me: It is difficult to say, there is a very rare type which may run in families. But normally it happens at a very young age. Regarding this issue, the specialist will explain more to you. 4. AMC feedback: Weakness in left arm and leg Scenario: 65yo female comes with left arm and leg weakness from this morning comes to your GP clinic. Tasks: Ask proper Qs, Ex findings and Mx

My Qs were as follows: How did it start? when you went to bed last night, completely normal? Any difficulty in talking? Any headache, visual problems? Any tingling sensation? Have you ever had stroke? Ever had this before? Any family members with CVD, heart attack, stroke? What are known medical conditions? Any known medications? I take warfarin. You take warfarin? Why ? Have you had something called AF? Your heart must be irregular? How long on warfarin? How often do you check INR? When was last time? Months ago. What was the finding? 2-3 Well, The role player volunteered that she had lost 6kg over the last 3 months. I asked a few more Qs. Her appetite and exercise lever were the same and did not feel stressful. Then turned to examiner: Pulse rate is irregularly irregular, other Vitals (-) Cranial nerves (-), no carotid bruits Pupil equal, active or reactive (-) Upper and lower limb motor sensory and tone, reflex: all decreased at the right side I want to find out plantar reflex: R down, L upper going Then I told the examiner: upper motor neuron lesion on the right side. I talked to the pt: I am sorry to tell that you may have stroke. I am going to tell you what is stroke, stroke could be bleeding, could be clots, in your case, and both are possible. Pls do not get upset about it. The first thing is to go to ED and have a CAT scan done. Also INR need to be done immediately. Depending on the results, docs are going to Mx it. Regarding your weight change, I am not sure. But we need to organise some investigation to find out underlying causes. The bell rang! 5. AMC feedback: Anaemia AMC assessment book condition 111 (page 576, 596) 6. AMC feedback: Abdominal pain (Acute) AMC assessment book condition 140 (P678, 728) 7. AMC feedback: Chest pain AMC assessment book condition 065 (P348, 356) 8. AMC feedback: Epilepsy idiopathic Scenario: 25 y.o. female courier who is going to get married came to your GP setting for some advice regarding his epilepsy. The patient was sent to you by specialist who already prescribed Carbamazepin. Tasks: Explain condition, advice accordingly. Explanation: At this station I dominated the conversation. I kept talking and talking according to the draft in my mind.

Epilepsy is the abnormal electric discharge in the brain, which causes the abnormal movements of the body. It is very common in our society, 1 in 100 (in this exam, I mentioned a lot of figures as I felt it might make the pts feel better if knowing his/her specific condition is common. Luckily I tried to remember all of these figures before the exam) Several issues I have mentioned: 1. Take the medication regularly 2. Have good sleep everyday, avoid stress and mood swing, better off the alcohol. 3. Be careful of the interactions among the medications, so need to tell the future doc and pharmacists beforehand 4. Be careful of the interactions with food, like grape juice. The written info will be given regarding this. 5. Action plan will be given for the acute attack. Not only for herself, but also for the family members. 6. Safey and job. Need to change the job, not be able to be commercial driver, but it is possible to drive the private car after being further assessed by the neurologist in the future. A lot of safety issues mentioned: swimming, climbing, diving, travelling 7. Medi-alert/bracelet 8. Follow up: especially initially drug concentration need to be monitored 9. Offer to see the partner and the plan for future pregnancy There was time left, so the roleplayer asked more about the future pregnancy. I brought all pre-pregnancy advice for epileptic women here (of cos I mentioned the figure again, 3% risk for the baby if one parent is idiopathic epilepsy) like folic acid and morphologic U/S.

Comments: We would like to thank Dr Wenzel from the bottom of our hearts for his support and help to all IMGs. He has trained us to be as local graduates, which is a precious treasure for our future career. This was a great exam and the following Thursday after this exam was the happiest day in our lives! We believe you will have the same feeling in the future. Please remember Dr Wenzels words, this is a patient-centred exam. During the exam, making the role-players happy is of utmost importance. They will lead you through easily if they want to. Be well prepared before the exam and you will feel confident on the day. Do not study the day before the exam. A warm shower and a good sleep are the best warm-up for the big day. On the big day, a light meal before the exam is important. Do not overeat. During the 2min reading time, try to make a good plan for the counselling before entering. If you are not happy with one station, remember to cheer yourself up after it. I use the words by Dr Wenzel you are allowed to fail 4 stations, so keep going, keep going, who cares one station! It is really very effective! Good luck, everybody! 10

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