Clinical recall 17 May 2008 Melbourne

1. SIDS (see AMC Handbook of Clinical Assessment) Scenario and Qs asked by the role player were exactly the same as the publication. AMC Feedback: Sudden Infant Death Syndrome 2. A 2 year old child with cough of 4 days and now worse at night. Recent URI in the family. Fully immunised, previously well. There is a 6-week old sibling at home apart from his parents. On PE: The child is well, alert, active, and afebrile, not in any form of distress. When you checked the throat and touched the palate, the child started coughing with an inspiratory stidor. No need to take history. Tasks: Explain your possible Diagnosis Advice on plan of management I started by saying that there are several possibilities. One is that it can be a viral cough, an allergic cough (because the cough is primarily nocturnal) or a para-pertussoid cough which is a cough similar to pertussis but the organisms causing it are not necessarily pertussis (i.e., Bordatella parapertussis, Mycoplasma, Chlamydia). But I could sense that the role player was not happy with my answer. So I said, at the bottom of my list is pertussis. Then the role player suddenly became interested in my diagnosis. I continued to say that immunisation does not afford a 100 percent protection that is why there is a need for booster doses later on in life. If he gets infected with pertussis despite immunisations, it would be a modified symptom and not the typical text book presentation of pertussis. I would need to get some swabs from the nasopharynx to confirm the diagnosis. If this is Pertussis these are the following things that need to be addressed. A reportable case. He would need to have some erythromycin which is the drug of choice (or any of the macrolides clarithromycin, roxithromycin). At this point the examiner asked me to whom will I give the erythromycin to. First, I said to the patient, to reduce his infectivity but that this would not necessarily alter the clinical course. Secondly, all household contacts need to have prophylaxis treatment. I am particularly concerned with the 6-week old baby since he would not have any protection because of the lack of transfer of maternal antibodies. Thus this 6-week old should receive prophylaxis Rx and should be immunised with DTPa which can be safely given as early as 6 weeks. This immunisation however, does not give immediate protection. I would need to follow up the 6-week old closely. With the 2 year old, it should not be a big problem on him having had 3 initial doses of DTPa and therefore his clinical course will be modified and not as severe as when he is not immunised. Q (question) from the role player. Where could he have gotten this? I said from someone who harbours the organism in the nasopharynx. I wasnt able to clarify that the parents can have waning immunity and could have harboured this in their throats/nasopharynx. Also, I forgot to ask if the child is in childcare. If he

is, the child carers nasopharynx should be checked if they carry the organism (potential source of infection) and should be treated and excluded from child care as well. The patient should also be exempted from childcare temporarily until at least 5 days of erythromycin/clarithromycin Rx. AMC Feedback: Pertussis 3. A multigravid is now in your clinic and is 38 weeks pregnant. Lives 80km from the hospital. You find out that she has a transverse lie.

Tasks: Take further relevant history from the patient Ask examination findings from the examiner Tell the patient about your management plan. I first asked current pregnancy issues. Labour pains, contractions, baby kicking, bleeding, water leaks etc. Then I asked pre-eclampsia Qs (questions). I then asked any issues during this pregnancy; 18 week scan any abnormalities, placenta praevia etc role player said baby was normal and that she does not know any information on the placenta. Then I asked about her previous pregnancies. She said she had 3 babies. I asked about their birth weights (3.5kg to 4.2kg if I remember right), manner of delivery and any previous issues like diabetes; general health - ok. I asked her blood group and she said she does not know. I asked her if she had injections (anti-D) - cant recall. I said it is unlikely that you have an Rh-ve blood group but we can check that later. I examined the patient. Gen appearance, VS then went straight to the obstetric examination, fundic height, FHT, and presentation. Dipstick urine- N. I explained that she has a transverse lie and there are several reasons for this. The first one is a small pelvis and this causes cephalopelvic disproportion CPD this is unlikely in her case as she has had 3 previous pregnancies with relatively large babies who were all vaginally delivered thus her pelvic passages have been tested for adequacy. Second, placenta praevia can prevent a baby from positioning itself normally thus I would like to rule this out by doing an ultrasound (and a CTG to check on baby). Third, with an ultrasound, we can also gauge the amount of amniotic fluid because too much amniotic fluid can also cause the baby to move around easily. Lastly, having ruled out pl. praevia and polyhydramnios from the ultrasound, the most probable cause of her transverse lie is the previous 3 pregnancies she had with relatively large babies causing her uterus and abdominal wall muscles to be stretched more than usual thus allowing more room for the baby to move around easily. Because we are quite far from the hospital and also because she is already at term (38 weeks), these are the options: Admission to hospital. After making sure that there is no placenta praevia, we can attempt to gently externally rotate the baby with a double setup meaning, ready for any potential complications i.e., immediate delivery just in case a cord entanglement, PROM +/- cord prolapse happens. There is the potential for the baby to return to its original transverse lie position again.

Schedule for a caesarean section because it would not be feasible for a vaginal delivery on a transverse lie.

The examiner was very happy and said that was an excellent discussion. She asked me if I had any obstetrics training. I said none. AMC Feedback: Transverse Lie 4. You are working in a country hospital which is 300 km from the nearest neonatal intensive care unit. Your next patient is a 26/40prim. She has abdominal pain for 3 hours. Task: History, PE Manage the case While reading the stem outside the room, I was already thinking of at least 2 differentials: abruptio placenta or premature labour. I started by asking the character and severity of the pain. She described it at intermittent contractions. I continued to ask about regularity (every 5 minutes) and duration (around 2 minutes) and figured out it was the start of labour pains. Then I asked her if she had leaking bag of water or vaginal bleeding. She said no. I asked about trauma and possible reasons for the premature labour. There was none, it was spontaneous. I asked about issues during pregnancy, correct date, blood group, 18 week ultrasound - whether there were any abnormalities and whether the placenta was low or not. She said as far as she knows they were normal. On PE, VS were normal. Abdomen showed compatible FH with age of gestation, normal FHT, longitudinal lie. Speculum showed the cervix to be 3cm dilated, intact bag of water. I talked on the following issues: That she is in active labour and since the baby is just 26 weeks old she needs to be admitted in a hospital which is capable of handling a baby of this age, ideally in a neonatal intensive care unit. I will arrange that she be transferred immediately and if possible by air ambulance while stabilising her. o While awaiting transfer, she needs to have a drip in with a first dose of steroids to be given for the babys lung maturity. o She needs to have an ultrasound to rule out abruptio and chorioamnionitis (both contraindications for tocolytics) and CTG, although CTG s interpretation may not by accurate since baby is still premature o A fibronectin test may be done but I did not emphasize much on this. I just mentioned it in passing. o We hope we can delay (until at least the second dose of steroids) or stop progression of labour by giving her tocolytics. Examiner asked me what tocolytic do I intend to give. I said calcium channel blockers. o Bed rest when in hospital. I finished this station early. AMC Feedback: Premature labour

5. A young female with recurrent greenish vaginal discharge. Your colleague treated her with antifungals and doxycycline but discharge is recurrent. Task: Take a history Examine the patient Advise on plan of management I started by asking her details of her vaginal discharge smell (foul); pain (none); relation to menstruation (no); fever (none); dysuria (none). I asked if it was alright to be asking some sensitive and personal Qs. I asked if she is sexually active. She said she is with a steady partner for the past couple of years or so (no sure of the duration) and has had 2 previous relationships. Contraception condoms. No previous STI. Paps smear 2 years ago N, has always been normal. Never been pregnant. Periods regular, monthly. LMP 3 weeks ago. General health including diabetes, N. Not on any medications and no allergy to medications. P.E. general appearance normal. VS especially temperature - N. Then I said Id like to focus my examination on the gynaecological aspect. The examiner brightened up and said, that is the best thing Ive heard today! Any masses and tenderness in the abdomen none. Speculum examination greenish yellow vaginal discharge which is foul smelling. Cervical ectropion. PV examination was normal. Even then I still asked for no cervical excitation? Or adnexal tenderness? The examiner answered with a firm Nomal. Before I went to management, I curiously asked the patient if there was any swab/culture taken before when she was treated by my colleague. She said no. Then I said that I will have to do swabs. Examiner asked me what I was thinking. I told him I will have to rule out Trichomonas, Gardnerella and will also test for Candida. I also asked the patients permission to test her for STI including high vaginal swabs for Chlamydia and Gonorrhoea and to complete my STI screen, some blood tests. I explained that I know that she and her partner are exclusive to each other and they use condoms but I need to check this (STI) still. Then depending on the results I will have to treat her. If positive for Gardnerella or Trichomonas she would need to be treated with metronidazole. I will need to also do a Paps smear on her too since the last one was 2 years ago. Will need to follow her up for progress. Also, she should continue on practicing safe sex. As I recalled this station post exam, I feared that I might have done a critical error by totally ignoring the cervical ectropion which was seen on speculum examination. I passed this station though. AMC Feedback: Green vaginal discharge 6. A 35 year old female with sudden onset of difficulty of breathing. Tasks: Take a history Examination Management plan When I was reading the stem outside the room, I had the following differentials in my mind: Pneumothorax, Pneumonia, Pulmonary embolism, Pericarditis, Asthma

(because of the relatively young age of the patient); further down my list were: AMI and Dissecting aneurysm. I was also planning to pin down the diagnosis in the first 5 Qs I will throw to the role player. I started by asking the patient, tell me about it? She said, yesterday in the office (clerical job) she suddenly felt this shortness of breath. I asked her if this was the first time this happened Yes. Is this progressive No. If she was coughing yes; sputum and colour yes, brown (Aha! I have narrowed my differentials to either pulmonary embolism or pneumonia). No fever, No chest pain, No heart racing. I then asked recent long travelling. She said she just arrived from New York 5 days ago (or less than a week ago). I asked her what she did in the plane she said she slept most of the flight time. Then I asked medications (OCP and other DVT risk factors recent surgery, smoking, family history) none. General health good. Physical examination: I think the only abnormality is the slight increase in respiratory rate. Cardiopulmonary exam N. No leg swelling, no calf tenderness (I couldnt recall if there was). I said that she needs to have immediate hospital admission as I am highly considering pulmonary embolism. The examiner was sitting very close to me and seemed very pleased. He asked what will happen in hospital. I got excited so I immediately said she needs CTPA (CT pulmonary angiography). Examiner commented - dont you think that this is too invasive as an initial investigation? Oh yes, I said. Though this is the gold standard of diagnosis, I will have to request the following: FBE, coagulation profile (what do you mean, he asked I said PT/INR, aPTT), thrombophilic markers both for hereditary protein C, S, Factor V Leiden, homocysteine and acquired lupus anticoagulant and antiphospholipids. She will also need to have a V/Q scan. The examiner asked what else? I said an ECG too. That was what I was waiting for, he remarked. What can you expect in the ECG? In severe PE, you can have Q3T3S1 but you may also have a normal ECG if PE is not severe. How will she be treated? I said she will need to be started on heparin, either with the standard heparin or LMWH plus an overlap with warfarin because it takes time for warfarin to take effect (around 4-5 days for INR to be at least 2-3). Then heparin will be ceased once warfarin kicks in. How long will she be treated? I said 6 months. Finished early. AMC Feedback: Shortness of breath 7. A 60yrs old male patient, referred by his previous GP to see you new to the area. Dear Doctor Would you please see this patient? His liver function has been abnormal for 2 years. He feels tiredness, no liver disease before; viral serology normal doesnt drink alcohol. He had a pacemaker inserted a few years ago. He had haematemesis due to oesophageal varices. He got small calculi in his gall bladder, pancreas was normal. (Long stem)

Task: Ask the examiner about Ix result Explain the patient to the result. I started by saying that he has multiple organ involvement namely the heart, liver, gallbladder and maybe some other organs too which we will need to investigate. Id like to do some tests to rule out a condition which we call haemochromatosis. I will have to do some iron studies. As soon as I said this the examiner handed me the result. Ferritin increased (1500), Transferin saturation increased. Then I went on to say that your iron stores are very high which supports what I was initially thinking thus I would need to do some genetic testing for the gene. The examiner handed me a second laminated paper. Homozygous for C282Y (+), H63D (-) I asked him if he knows anything about haemochromatosis. It is a condition with a disturbance in iron metabolism such that excess iron accumulates and deposits in organs such as the liver, heart, pancreas, pituitary and in fact can deposit in any organ causing its dysfunction. It is an inherited disorder, which means he has received one recessive gene each from his parents. I briefly explained that you have to have a pair of the recessive gene to have haemochromatosis and that one gene inheritance is considered a carrier of the abnormal gene and should not cause any clinical significance to that person. The treatment is aimed to bring down the iron load by doing phlebotomies around 500 ml every week for 1-2 years (read JMurtagh) then if levels are acceptable, the frequency drops down to every 3-4 months. I will also have to test him for other organ dysfunction such as diabetes from pancreatic involvement; some hormones from pituitary deposits; renal function etc. He will need to have regular follow up. What will happen to his kids, he asked. I said, we have to test your wife first. If your wife does not carry the gene, then the worst case scenario is that your children will have inherited one HFE gene and that should not be a problem to them. However, it is recommended to have their future partners tested because of the possibility of having affected children. What about his siblings, he asked. I said that since you came from one set of parents, they have to be tested for iron studies and the HFE gene. Will I live to be 70? Well, I said that depends on the degree of organ involvement. That it is a good thing that we detected it now and that we can do something about it. Perhaps a referral to a liver specialist will be necessary in the future for the possibility of a liver biopsy. And of course continued specialist referral for the heart and long-term follow up should be advantageous for his health. AMC Feedback: Abnormal Liver Function Tests 8. A 48 year old lady came in for her biopsy results which showed adenocarcinoma of the colon. Her father had colon carcinoma at 58 years old. There are other parts in the stem regarding history but I could not recall them. I dont think you have to take any more history from the patient apart from clarifying Qs.

Task

s Explain the results of the biopsy to the patient Advise on management Answer the patients Qs.

A middle aged woman was in the room waiting. First of all I asked her if she came for the results of her biopsy and she said yes. I told her that I have some disturbing news. The biopsy results showed that she has carcinoma of the colon (at this point I tried to look at the stem to see which part of the colon but I dont understand why I couldnt see the part that is involved- maybe it was the nerves). I asked her if she would want someone to be with her before I explain the condition and if she would want me to go further. I explained to her that the earlier we treat the better. On a piece of paper, I drew the different stages 1-4 and the degree of involvement (I-mucosa, II- bowel wall, III- bowel wall and LNs, IV- liver mets and other organs) and their respective prognosis (Dukes Staging in AMC book p94). That, if treated early, i.e., stage I, the 5 year survival rate is >90-95%. She asked if surgery is the only treatment. I said yes and the use of adjuvant chemotherapy +/- XRT in selected cases improves overall survival. Does she need colostomy like her father? I said, she may need it but it may just be temporary especially if it is in its early stage. What will happen to her kids? I asked how old were they (I think they were in their teens). Then I said that they will need to have surveillance colostomies done when they reach their 40s or alternatively a bit sooner since some authorities recommend it to be done 10 years earlier from when a first degree relative was diagnosed to have the carcinoma (in her case around 38 years old for her children) - unless they have symptoms. For the meantime their diet should be rich in fibre. What about her siblings. I said that your siblings need to be investigated with faecal occult blood in the stools and colonoscopies. I finished early. The examiner was very quiet. AMC Feedback: Carcinoma of the rectum 9. A young female came to your GP to ask for antidepressants again. She was previously treated with antidepressants before. Tasks: History Management I started by asking why she thinks she needs antidepressants. She said she feels down, she cant sleep. I screened for HEADS. H Home environment. How are things at home? She mentioned that the family is dysfunctional. Several issues happening (could not remember exactly what). That she had to leave home and she is now renting out a unit with some friends with whom she shares the bills. E Education, Economics (work and finances). She said that she has a double job and shifts from one work to the other in a day, most days a week. A Activities. I asked about her social life, her friends and what her hobbies were. She said she does not socialise much as work keeps her busy.

D Depression, Drugs. I asked her about sleep what was bothering her; if there was anything that keeps her awake. She said she just cannot sleep and wakes up unrefreshed. I asked about eating. She said it is unaffected. I asked about coping mechanisms- drugs, alcohol, cigarette none. S Sexual activities, Suicide risks. I asked her if she is sexually active No. I asked about risk factor of harming herself and others none. Then just to complete the psychiatric assessment, I asked about delusions, hallucinations, etc. None. Her general health has been good. I could no longer remember the reason why an antidepressant was previously prescribed on her but I know she did not have any major depressive symptoms previously including suicidal thoughts. Then I explained to her that giving an antidepressant is not the only solution to her problems. That the cornerstone of management is in her lifestyle change. That she needs to cut down on her working hours because she is overworked and tired and unable to get enough sleep. That she needs to socialise and find ways to relax and go out with friends and family. Should she wish to have a family counselling session with me, I will be happy to arrange for that. I briefly mentioned sleep hygiene (read JMUrtagh). If her finance is an issue, we may have to tap on community resources to help her out temporarily while she overcomes this situation. If she still has a problem coping, there is no harm in trying a short-term sleeping tablet (i.e., 2 weeks only to prevent dependency) just to break the cycle of anxiety and lack of sleep. Cognitive behaviour therapy and meditation techniques can certainly help. Antidepressants have certainly a role but only when all means mentioned before have been exhausted. I will follow things up with her to see how she is going. AMC Feedback: Anxiety and Depression 10. Assessment of a Comatose patient (AMC Handbook of Clinical Assessment) There were 3 people in the room. A patient lying comatose on the bed, the examiner and an observer. AMC Feedback: Coma 11.Middle age man has come to your clinic; his wife is worried about his strange behaviour recently, as he changed the lanes while driving without obvious reason and almost caused MVA. His children also report that his behaviour has changed recently. Last time you did MMSE and it was 25/30 (page with report was provided on the wall, low score in attention, recall sections). Tasks: Take further history Do at least one test to assess his cognitive function, no need to repeat MMSE (assume it was accurate)

Discuss your diagnosis with the examiner.

An elderly man around 60 was in the room. I started by asking the patient the reason why his wife and children are concerned with him. He said, he does not know why and that he thinks they, especially his wife, worry too much and that there is nothing wrong with him. He denies any change in his behaviour. I asked him general Qs on dementia like does he think he is forgetful and has he ever found difficulty in his way home. Does he know where he is at the moment?Orientation Qs. I asked about home situation, work, mood, and activities - nothing significant. I also asked about past medical history and general health. Smoking, alcohol, medications were all non contributory. Then I moved forward to do my second task. Read page 443 of the AMC handbook under the title MMSE may be supplemented by specifically testing frontal lobe functioning via.... I did exactly what was on this outline. The role player was unable to do the interpretation of the saying a stitch in time saves nine and also found it difficult to do the motor sequencing test of the fist-edgepalm. I asked the examiner if there was time to do words beginning with Fs in one minute. The examiner answered that I have plenty of time. Thus I asked the patient and he could do this. He tried hard but kept repeating words he already used. Then the examiner interrupted and asked me for the diagnosis. I said he probably has frontal lobe dementia. He asked me the basis for this. I said that he has borderline MMSE 25/30 and that he is unable to do the tests Ive done on him which can only mean that he has some form of frontal lobe deficits. I was about to explain the possible causes of frontal lobe problems such as vascular deficits/infarcts, tumours etc, but he said, dont worry about that, you finished your task and can wait outside. AMC Feedback: Frontal Dementia 12.A man who sees you about his alcohol consumption. Tasks: History Talk to the patient regarding issues with his alcohol consumption Investigations and plan of management There were again 3 people including an observer. First I commended the patient for coming to see me to talk about his alcohol consumption. I asked the following: Alcohol consumption what kind, how much, how often I gathered that it was way too much in excess of the recommended. Also he drinks different kinds of liquor, hard drinks, wine and beer. C-A-G-E Qs HEADS check (as in the case above) i.e., home and work situations- any relationship issues? - Yes; activities/exercise, mood; does he drink because he is in a lot of stress? mood and suicide risks - None Did he get in trouble with the law because of his drink driving yes, driving offence

Libido - diminished General health weight, diabetes, cholesterol, HPN, smoking and recreational drugs Motivation to stop he said he is not sure yet but just came to ask.

I advised on the following That his alcohol consumption is beyond the harmful effect of 4 standard drinks/day with 1-2 days free/week. One standard drink is equivalent to 10g alcohol. Since there are different liquors he takes, I will give him a reading material on the equivalent of one standard drink of the different liquors he takes. That alcohol can have harmful effects on his physical, social and psychological aspects of his life. I can arrange for him to have some blood tests like FBE with red cell indices, B12 and folate levels, LFTs, BSL, cholesterol and ECG I can arrange counselling for him or if he wants I can arrange for further consultation with him and his wife for counselling and support should he decide to withdraw. In the end, it is still up to him to decide on what to do with his alcohol consumption and that we are here to help him out. It would be nice to mention alcoholics anonymous which I forgot to do. Q from the patient: What advise do I need now as an immediate plan? I was thinking of what he meant and I was about to address the issue of drink driving but the bell rang. AMC Feedback: Excess alcohol consumption 13.A biopsy report of a melanoma with depth of involvement of 0.4 mm thickness with tumour extending to the lateral margins (couldnt recall which site of the body). No lymph node enlargement. A picture was outside the wall. The patient, a school teacher had this mole for many years and noted it recently to be itchy thus a biopsy was done. No history and examination required. Tasks: You are to explain the biopsy result to the patient. Advise on management. I told the patient the disturbing news of the biopsy result. Melanoma is the third commonest skin malignancy in Australia and is related to prolonged sun exposure. I said that the good news is that there is no LN involvement and that the depth is 0.4mm. The usual cut-off depth is 0.75mm which could affect prognosis. However, the tumour excision did not indicate clear borders; ideally I said 3-4mm of clear margins. I have to check this margin as I remember them to be so in squamous and basal cell carcinoma but wasnt sure if this applied to melanoma (further readings post exam 1cm clear margins). I advised on the following: Re-excising the tumour with clear margins of normal tissue referral to a surgeon (or dermatologist) to do this.

Although LN involvement was not seen, I still would want to have some scans (CT) to make sure that no other LNs are involved in other sites. Referral to an oncologist for possible chemotherapy if LN involvement is seen. However, the prognosis is excellent if the depth is just 0.4mm and no LN involvement is seen. He would need to be followed up on a regular basis for progress report and also to regularly check the skin for suspicious lesions. He should also regularly inspect his skin himself and report early for any skin change. Avoid prolonged sun exposure. Wear wide brim hat, long sleeved top and use sun protection lotion.

AMC Feedback: Melanoma 14.A 50 years old lady, a violinist in an orchestra, with pain, swelling and stiffness in both hands recently. Her mother has rheumatoid arthritis. You suspected that it's rheumatoid arthritis. You prescribed ibuprofen and run some blood tests for ANA, ESR and RF. The results showed that she has early rheumatoid arthritis. Task: Explain the diagnosis to the patient, Counsel the patient and answer her questions . This was my very first station. There was a very nice middle-aged role player who smiled and nodded her head when I said the answers she wanted to hear. I explained that she has RA and that this is a chronic condition with flares and quiescent phases. It is an inflammatory condition eroding cartilage, which is the cushion at the end of the bones in the joints. It has an autoimmune component as well as genetic predisposition. With modern day medicine and new drugs which we call DMARDs we can markedly delay and hopefully prevent further progression of the disease. Although we usually recommend a step-up approach in pain management, starting from simple analgesics to stronger ones, in RA, we can use DMARDs in the early phases of treatment. I enumerated the DMARDS - methotrexate, cyclosporine, azathioprine, sulfasaline etc. Inflixamab, to counteract the effect of cytokine (thought to be a mediator in RA) can also be used. Early referral to physiotherapist and rheumatologist is the key to prevent further disease progression. There is also the possibility of using steroids. The role player said she does not like the use of steroids because of the ill effects on her mother. I said yes, the complications of steroid use are well recognized such as, gastric irritation, myopathy (proximal muscle weakness), mood changes and long term effects of osteoporosis, diabetes, etc. However, the use of steroids is limited only to flares and are of short courses usually. I will definitely follow you up closely with your steroid use. But she was still hesitant. Therefore I said if you feel too strongly against it then we can use NSAIDS such as Ibuprofen. She said but Ive been using this already with not much relief. Then we can also try Aspirin plus Panadeine (Panadol Codeine) combination.

Examiner asked about the side effects of DMARDS. I said bone marrow suppression and liver dysfunction that is why she needs to have regular check of her FBE, LFTs and CRP ESR, RF to monitor her disease progression as well.

Examiner asked what potential risks would the use of steroids do to this patient given her age 50. I said osteoporosis. However, we can talk about HRT on another consult to weigh the risks and advantages of using this and we can also talk about the use of bisphosphonates and dietary advice on calcium or supplements. She would need to have baseline bone scans (bone densitometry was what I was actually thinking but I said bone scans). The examiner said I finished my task and that I can step outside. AMC Feedback: Rheumatoid arthritis 15. Middle aged woman complaints of pain on the right arm, forearm and hands. Tasks: History no more than 2 minutes Do your examination and investigation Dx There was a middle aged woman with a hospital gown seated already for my examination. I asked her to tell me about the pain and she indicated pain in the arm, forearm and hands. Any pins and needles? Not exactly. Numbness, weakness yes. Any neck pains, she said yes. Any trauma- no. Any history of rheumatoid arthritis- none. General health- non contributory. Examiner was hurrying me up to proceed to examine the patient. I started by saying ideally I will have to expose the shoulders to check for asymmetry, muscle atrophy, swelling. The examiner said you dont have to expose anything. Examine the patient as is. Then I moved to the back of the patient and talked about looking for any deformities swelling, etc. Then I went to palpate the spinous process from the base of the occiput down the cervical spine. There was tenderness around the C6C7 area. Then I checked for paravertebral tenderness, there was none. Then I asked for the patient to do neck movements extension, flexion, lateral flexion, rotation to the right and left. There was limitation in all the movements. Then I proceeded to do shoulder examination testing for powers (against resistance) of abduction and adduction, biceps, triceps, wrist flexion, extension. The examiner kept on hurrying me up to examine the hands. I had limited testing for finger flexion, extension, abduction, and adduction. I was also comparing it to the right side which seemed to be unaffected. There was obvious weakness of all movements of the right side. I did not get to examine the sensory and reflexes as the examiner cut me short and asked what investigations I would request. I said since I was considering cervical spondylosis I would request for an MRI. He handed me an MRI picture of the cervical spine which showed a prolapsed disc. I was quickly asked how I would manage the patient. I said conservatively. I will refer for physiotherapy. Bell rang. AMC Feedback: Prolapsed cervical disc with radiculopathy. 16.A previously well 5 months old brought to you by the father because of sudden onset of intermittent screaming with few episodes of vomiting. A sibling had a recent bout of gastroenteritis. Tasks:

History. PE Advise diagnosis and plan of management

My first thought was intussuception because of the typical clinical picture. So I asked Qs pertaining to this such as: how is the infant in between episodes; colour and character of stools; vomiting. He was noted to be pale in between episodes. I also asked for fever; any obvious straining when he wees - none. Past medical history was uneventful. PE: nothing contributory. Rectal exam was normal. In hindsight, I should have also asked for the groin examination. I advised on the possibility of intussuception (explained what it is) and that the baby needs to be admitted to hospital because of the suspected diagnosis. I advised on nil by mouth and what they will do in the hospital such as IV fluid, early surgical referral; abdominal xrays, possibly either gas or contrast enemawhich can be both diagnostic and therapeutic ; blood tests for FBE and electrolytes; urine tests etc. I discussed about going to theatre if the enema measures fail to reduce the intussuception. Examiner asked me my differentials: I said volvulus, small gut obstruction, UTI, meningitis. I would have gotten an obvious diagnosis of incarcerated/strangulated hernia if only I had checked the groin area. AMC Feedback: Incarcerated Hernia (the only station I failed) Comments: This candidate has reviewed almost 350 cases (including the 150 cases from the AMC publication). Just when you think you have a good grasp of the commonly repeated cases, it was still surprising to see unfamiliar cases. There were 2 new cases to me which I have not encountered in my recalls at all. There were 4 modified cases from the recalls. I couldnt help but develop doubts in my diagnosis and my approach because they were modified in such a way that I have to think further and not fully rely on the diagnosis given in the recalls. Think of a few differentials and keep on talking while ruling out the others and ruling in the most probable diagnosis. You will never know what cases will come out in the exams. Some exams will have very familiar repeated cases thus probably contributing to the relatively higher passing rates. This particular exam had a lot of unfamiliar cases and only 2 cases came out from the book published. A few of the cases were not exactly how we expected it to come out as in the previous recalls. It is possible that this was completely unexpected by some candidates and could have affected the low passing rate (35%). Try to know the cases by heart in all their aspects because they can appear in different shapes and sizes. If you know them you would at least be able to talk about it and not be caught by total unawareness. The exam in really nerve-wrecking. Relax the day before and do not read anymore while waiting for your turn whilst in quarantine (especially for the group in the afternoon). It just adds more pressure to an already stressed out brain.

Dr. Wenzels (Couldnt thank you enough Dr Wenzel) class has a very good simulation of what happens in the exams. Be observant to the role plays during the class because you will learn something from them even if the candidate performed badly or excellently. Listen carefully to the testimonies of those who passed. You will pickup very precious survival tips which you can apply in your preparation for the exams and during the exam day itself. Get the most out of this class. It is freely given by a kind hearted person who wants to help us IMGs (a rare precious opportunity). It is also a good way to establish networkings with people who are in the same situation as you are. All the best in your endeavours. We happen to be just ahead of you in passing the clinical exams but soon enough you will also be in the same situation and we will be criss-crossing our paths again in the future. Cheers All. Hope this recall helps!