Recalls 15

th
june 2013, Adelaide

Thanks to Dr. Wenzel. Without your support, my success was not possible. You gave me courage to do
this exam. Here I would sincerely advice everyone. Try hot seat. My first experience of sitting on hot seat
was a NEAR FAINT Experience. But after that I started to take challenge and finally started to enjoy the
hot seat, so on the day of exam, I was just relaxed. Adelaide experience was a good one for me, coz I
passed. But I must say that all examiners and role players were simple expressionless. No smiles, no
yes and even no Nos no thumbs up from anyone. Infact when I asked them, do u wanna know
anything more, most of the role players replied in an expressionless way.. No and started to look down. (
a very awkward situation for me) I finished some cases just in 5 or 6 minutes, and some just on time.
There were 3 to 4 cases from book, 9 cases from Dr. Wenzel hot seat and 3 old recalls. Nothing new or
unusual.
Thanks to God for HIS Blessings.
Thanks to Dr. Wenzel for his continuing support. May Allah always bless you and keep you healthy and
safe.
Thanks to my hubby, my kids who really sacrificed during my exam prep, my parents, and my friends.
Started from case 19 ( so I knew it gonna be psychiatry)
Q. 5o plus female with some forgetfulness.
Take history
Do MMSE only orientation and memory testing. No need for full MMSE
Give DD and explain the condition.
2 min thinking Dementia/ Al zheimers and to R/O organic causes.
Satrted with confidentiality.And explored the history.Asked q abt dementia, weather pref, head injury,
metabolic problems.
Family h/o of alzheimers + so I got clue and asked more questions abtalzhiemers. Which were clinical
features of early dementia
Poor recent memory
Impaired acquisition of new information or new skills
Mild anomia (not remembering names)
Personality changes ( e.g. withdrawn, irritable, difficulty in social interactions)
Minimal visuospatial impairment (tripping easily)
Inability to perform sequential tasks
Impaired orientation to time, place and person
Inability to care for oneself
Nothing was positive in her.


Did MMSE .. I asked orientation..she was very well orientated in every thing. I then registered with 3
things. I checked language and the lady replied. Sorry doc, im not prepared for this question. So I
omitted all together attention and language and asked about recall of 3 names, which she remembered
very nicely.
So I told her that keeping in view her family history, I wann do complete mmse on her, in next consult
and also I wanna rule out, organic causes so I will do some blood tests now and then on next visit will do
complete mmse. I told her that it seems to be minor forgetfulness and alzheimers is just a diagnosis of
exclusion, which means that I need to rule out all other possibilities. At this stage it doesnt look like
alzeimers so I will do complete mmse in next visit.
Will do review with blood reports, and gave reading material. Will refer to experts if reqd.
Lady was happy. No question from anyone.
AmcFeed back minor forgetfulness

Case 20 Gynae
Post menopausal woman with incontinence..book case but it was maily urge incontinence.. and very
slight stress incon. So I talked and explained the same way as in book.
Role player asked about treat, so I started with life style modifications and step ladder approach of Rx.
reduce wt, kejel exercise to stergnthen the pelvic muscles, pessary, slings , medications, and surgeries. I
covered both stress and urge but gave more stress on urge incontinence.
Amc feedback..urgeincon

Case 1 medicine
50 plus man with abnormal LFTs. HepA B And C serology is negative. He is non alcoholic. Referred by
another GP to me for further evaluation. Past h/o pacemaker +. And some gall bladder problem.
Do further investigations and ask the results frm examiner.
Explain the condition
Further management
(hmmmmmmm I know this case and can bet on this case. It is only hemochromatosis. A typical recall)
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 hemochromatosis. I will have to do some iron studies. As
soon as I said this the examiner handed me the result. Ferritin increased (1500), transferrin
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 +. Then I asked
for liver biopsy which also showed some iron deposits and some more stuff..cant rem.

I asked him if he knows anything about hemochromatosis. 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 hemochromatosis
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 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. I asked the examiner that I would like to do ECG and sugar levels also, but
examiner smiled and said..they are not yet available.:)

I told that it is very imp to check your kids.. 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. I advised to
check his siblings also. I said that since you came from one set of parents, they have to be
tested for iron studies and the HFE gene.
it is a good thing that we detected it now and that we can do something about it. And of course
continued specialist referral for the heart and long-term follow up should be advantageous for
his health.
Finished in 5 min.
AMC FEEDBACK ABNORMAL LFTS ..



Case 2 paeds
Book case type 1 DM in 5 years old boy. Talk to worried father. Answer his questions.
Only diff was that child was well oriented with BSL 21, and well hydrated, ketones only 2+.

Started the same way as book. I asked any family history of DM 1 or colieac disease. Father told yes
mother has colieac disease. Then I told that gene which causes colieac dis and type 1 DM are same. So
father asked. So mum has given this problem to son. I said, lets put it this way that gene which causes
coeliac dis and DM 1 are same. So he smiled at me. And then started looking at his questions. I told all
the things as in book. Father was worried about giving insulin. So I told you will be explained by diabetic
nurse how to give insulin. Also I mentioned that thanks to new technology, nowadays insulin pumps can
be used which deliver insulin on timely basis. Finished in 6 minutes. No question from anyone.
AMC FEEDBACK DM1 IN CHILD Rest station 3.
Drank water as I was so thirsty talking continuously in 4 stations

Case 4 surgery
papillary thyroid ca, a confirmed case on USG, FNAC, and radioisotope scan.
Breaking bad news
Treatment
(Easy one, Thanks Dr. Wenzel)bcause we just did this case in Dr. Wenzels class, so im copying the same
here. I did exactly the same but when I paused after breaking bad news, the role player said, hey doc,
why u are not telling more. I said, ok and then when I asked do u need water .. he said im not thirsty,
you go ahead.HAhhaha what bad news was that ) this was a male pateint
Your next patient in your GP surgery is a 28 year old woman, Jennifer,
who has been seen by one of the other GPs in the surgery two weeks
ago when she presented with a small nodule in the right side of her
neck. Your colleague took a history and examined the patient and
came to the conclusion that it was most likely a lump in the thyroid
gland and arranged U/S, isotope scan and a fine needle aspirate (FNA)
for cytology.
Jennifer comes today for the test results.
The U/S revealed a single, solid nodule of about 1,5 x 2 cm with
changes consistent with a papillary carcinoma in the right lower part
of the thyroid gland. The iodine-131 radioisotope scanning
demonstrates a cold nodule in the same area.
The FNA confirms a papillary carcinoma.
Your tasks are to:
1. Explain the diagnosis to the patient
2. Discuss the management options with the patient

HOPC: (no further history taking is expected!)
As above. There is no other significant history for papillary carcinoma although head and neck radiation
in childhood has a higher incidence of thyroid cancers and the family history is important in medullary
cancers

EXAMINATION:Physical examination is also rarely helpful in differentiating benign and malignant
nodules, unless there is evidence of invasion of other structures in the neck (eg, hoarse voice) or
enlarged regional lymph nodes, which suggest malignancy. Normally one finds a palpable, firm, and
nontender, painless nodule in the thyroid area.


Papillary carcinomas are the most common thyroid cancer. They are either encapsulated with minimal
invasion into the surrounding normal thyroid tissue or unencapsulated with invasion of adjacent thyroid
or perithyroidal structures. They are often multicentric, and bilateral in a third of cases. The most
common sites of metastasis are regional lymph nodes (50%) and, less commonly, the lungs (less than
5%).
Following surgery, papillary carcinoma has an excellent prognosis, despite the presence of lymph-node
metastases in 5%20% of patients and distant metastases in 10%15%. Ten-year survival is 80%95%.
Factors that worsen prognosis include male sex, advanced age, large tumour, poor differentiation, local
invasion and distant metastases.
Initial management is surgical, with total thyroidectomy (postsurgical radioisotope scanning usually
shows residual thyroid tissue) indicated for any malignancy with diameter > 1 cm. If cancer size is less
than 1cm, if it is unifocal and if there is no evidence of lymph node involvement lobectomy or subtotal
thyroidectomy is recommended.
Thyroidectomy should be performed by an experienced surgeon, as this reduces complications, such as
hypoparathyroidism (calcium problems) and recurrent laryngeal nerve palsy (hoarse voice, vocal cord
paralysis).
Lymphnode resection is indicated when nodes appear to be grossly involved.
Systemic treatment with radioactive iodine-131 is only indicated in case of metastatic spread. I.e. after
surgical thyroid removal, the patient waits around 46 weeks to then have radioiodine therapy. This
therapy is intended to both detect and destroy any metastasis and residual tissue in the thyroid. The
treatment may be repeated 612 months after initial treatment of metastatic disease where disease
recurs or has not fully responded.
Other radiation and chemotherapy are not indicated in papillary ca because of limited effect!
The patient will require lifelong thyroid hormone replacement therapy


It is important to refer the patient to a specialist surgeon and to explain the operation to the patient.



Additionally I mentioned about thyroglobulin protein specific for thyroid to check as follow up.
AMC FEEDBACK PAP THYROID CA COUNSELLING



Case 5Gynae a typical recall
A 28 wkspreg with h/o bleeding. G 3 with past history of Csection.
Take history
Examination findings frm examiner
Further investigations, and management
Examiner was quiet sleepy.
Started with asking if my pt is hemodynamically stable..Yes, you can start with history.
So I started asking about planned preg and congratulating her. Then asked all quesabt type and amount
of bleeding. Bleed was minor and now stopped. Past USG showed some low lying placenta. Hmmm a
clue she gave herself . I asked about any sexual activity. Ans was yes after which the bleeding started.
Then explained the condition with drawing abt 4 types of plprevias. Asked her deliver preference.Told
causes of placprevia.
Also told the absence of pain is often regarded as a
significantdistinquinshing factor between placenta praevia and placental abruption, but 10% of
women with placenta praevia will have a coexisting abruption.

Other common causes:
Marginal bleeds - 60%
Show - 20%
Cervicitis - 8%
Trauma - 5%
Important but rarer causes include cervical cancer, vasa praevia and genital infections
Any women bleeding from the genital tract after 20 completed weeks gestation should be
reviewed by
a registrar following initial assessment.
Note the amount of vaginal blood loss, but bear in mind the possibility of a concealed abruption.
Gentle abdominal examination I asked the examiner the following:
ABCDE OF pat which was all normal. Vitals were stable. When I asked SPO2, then examiner
shouted as if he woke from sleep and said SPUTUM in this patient?????. I politely said, sir im
asking pulse oximetry, not sputum. Then he said normal( believe me my accent of English is not
bad at all, and I cantunderstand why he misunderstood SPO2 as sputum.)
Abdominal exam
symphysis fundal height
lie
presentation, level of presenting part above the pelvic brim (may indicate placenta praevia)
uterine tenderness, irritability / activity / tone (may indicate abruption)
auscultate fetal heart rate; the abnormality or absence of which, if confirmed, may indicate a
major abruption.
MANAGEMENT
Degree of resuscitation and urgency will depend upon the clinical findings.
Admission for observation
CTG
Blood taken for full blood picture, group and hold / cross match. If the estimated blood loss is
greater than 200ml or there is suspicion of placental abruption consider a coagulation screen.
Anti-D immunoglobulin administration if the woman is Rhesus (D) negative.
If the woman is Rhesus negative a Kleihauer test should be performed to quantify the magnitude
of the feto-maternal haemorrhage and ensure an adequate dose has be given
I avoided vaginal examination until the location of the placenta is known. Information
regarding placental location will usually be available from previous ultrasound scan reports,
otherwise a realtime ultrasound scan should be performed.
Arrange review with obstetric registrar.

AMC FEED BACK BLEEDING IN 28WKS PREG

Case 6
Abnormal Lipid profile in 38 yrs old male, with normal BSL, and Normal BP, but BMI 30, sedentary
lifestyle and + family history.
Explain the reports
Take further history and counsel the pat with further treatment plan.

Again an easy one.
I told him about CVS risk factors. Expalined all of them in same order.
CVS RISKS
ABCDEF S
AGE/ ALCOHOL
BLOOD PRESSURE/BMI
CHOLESTEROL AND CIGARETTES
DIET/ DM AND DRUGS
EXERCISE LACK
FAMILY HISTORY
STRESS
TREATMENT (Hyperlipidaemia):
Life style modifications and step ladder approach
Referred him to dietitian, exercise programs etc

1. Weight loss and life style:
diet
reduce fat intake, especially saturated fats (dairy products and meat), substitute with
poly- or unsaturated fats (vegetable and fish oils). Avoid fast food or junk food,
increase high fibre foods like fruits and vegetables and eat fish. Limit processed
carbohydrates e.g. pastry , biscuits, white bread. Increase unprocessed carbohydrates
like fruit, vegetables, pasta, whole grain cereals and bread. Minimise salt intake.
regular exercise (at least 20 min 3 times per week to level of perspiration or mild
breathlessness)
reduced alcohol intake



2. Monitor lipid levels after 2 and 6 months!!!!

3. Lipid lowering drugs: Statins, Cholestyramine
Only after at least 6 weeks trial of diet! GI side effects are common with nausea, flatulence,
dyspepsia, constipation, diarrhea and abdominal pains. CAVE liver function!!!
AMC FEED BACK DYSLIPIDEMIA Case 7 psychi
Somatization disorder. Pat already diagnosed, but refused to see the psychiatrist. All tests normal.
Always complain of neck pain. You are an intern working in neurology ward. A 20 years old female has
neck spasm, migrane, dysmenorrhoea etc. and was diagnosed with somatization disorder. She had to
quit her job due to the neck pain and move back to live with her grand parents. Her grand mother has
recently diagnosed with Parkinson disease and needs her support for daily activity around the house.
Patient has had MRI scan of the brain, which is normal.
Your task is to
1. Take further history.
2. Explain the diagnosis.
3. Manage the patient
Started with confidentiality. The patient has had 10 years history of neck pain. And worries that she has
got parkinsons dis. I asked history and found she has this problem for 10 years. I explained to her the Dx
and reassured her that all Ix have been done including MRI show that there is no evidence of parkinson.
I reconfirmed to her the pains are real. Somatisation is functional problem. Not structural problem
I told that I do bel that your pain is real and I want to help you to get rid of this, but I need your help in
this regard. You have to see the specialist. They are so trained to treat such problems and im sure that u
will be fine with it. Explained CBT and role of SSRI in somatization dis.
Told her that People with somatoform disorders are not faking their symptoms. The pain and other problems
they experience are real. The symptoms can significantly affect daily functioning

She happily agreed to see the psychiatrist gave reading material and talked abt social support.
AMC FEEDBACK SOMATIZATION DISORDER

Case 8 rest station. Drank water again. And rushed to toilet

Case 9 Acne vulgaris
Easy case .im copying Dr. Wenzels notes as I did almost the same. Finished in 6 minutes.
Your next patient is a 16 year old William Slater who
has suffered from facial skin problems for the last
12 months and it is not getting better. (See
provided picture)

YOUR TASK IS TO:
To take a history
Examine the patient
Arrange for appropriate investigations
Discuss the diagnosis and management with the
patient
HOPC: Will noticed about one year ago a few blackheads and whiteheads (comedones),
and circumscribed, solid elevation of the skin with no visible fluid, varying in size from a pinhead
to 1 cm (papules). Over the last few months they have become worse and spread all over his
face, forehead and also on his shoulders. Sometimes he accidentally scratches the papules and
they then become infected and crusty. Recently he also developed pimples (pustules, small
elevations of the skin containing cloudy or purulent material usually consisting of necrotic
inflammatory cells. These can be either white or red.)


PHx.:unremarkable

FHx.: his father had severe acne as a teenager

SHx: high school student, lives with his parents and two younger sisters, no problems, no alcohol, non
smoker, no recreational drugs, NKA.

EXAMINATION: except for the obvious acne he looks quite well and healthy, normal vital signs.


DIAGNOSIS: ACNE VULGARIS

Acne vulgaris is a common skin problem, affecting most adolescents and
many adults with formation of comedones, papules, pustules, nodules,
and/or cysts as a result of obstruction and inflammation of pilosebaceous
units (hair follicles and their accompanying sebaceous oil gland). It most
often affects adolescents.


Diagnosis is by examination. Treatment is a variety of topical and
systemic agents intended to reduce sebum production, infection, and
inflammation and to normalize keratinization.

Pathophysiology:
Acne occurs when pilosebaceous units become obstructed with plugs of
sebum and desquamated keratinocytes, then colonized and sometimes
infected with the normal skin anaerobe Propionibacterium acnes or
Corynebacterium acne They produce lipase with the result of free fatty
acids which can provoke inflammation or infection.
Comedones, uninfected sebaceous plugs impacted within follicles, are
the signature of noninflammatory acne. They are termed open or closed
depending on whether the follicle is dilated or closed at the skin surface.
Inflammatory acne comprises papules, pustules, nodules, and cysts.
Papules are circumscribed, solid elevation of skin with no visible fluid,
varying in size from a pinhead to 1 cm. They can be either brown, purple,
pink or red in colour. The papules may open when scratched and become
infected and crusty
Pustules occur when active P. acnes infection causes inflammation
within the follicle. Nodules and cysts occur when rupture of follicles due
to inflammation, physical manipulation, or harsh scrubbing releases free
fatty acids, bacteria, and keratin into tissues, triggering soft-tissue
inflammation.
AETIOLOGY:
The most common trigger is puberty, when surges in androgen stimulate
sebum production and hyperproliferation of keratinocytes. Other triggers
include hormonal changes that occur with pregnancy or throughout the
menstrual cycle; occlusive cosmetics, cleansing agents, and clothing; and
humidity and sweating. Associations between acne exacerbation and diet
(eg, chocolate), inadequate face washing, masturbation, and sex are
unfounded. Some studies question an association with milk products.
Acne may improve in summer months because of sunlight's anti-
inflammatory effects. Proposed associations between acne and
hyperinsulinism require further investigation.

Symptoms and Signs:
Cystic acne can be painful; other types cause no physical symptoms but
can be a source of significant emotional distress. Lesion types frequently
coexist at different stages.
Comedones appear as whiteheads or blackheads. Whiteheads (closed
comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in
diameter; blackheads (open comedones) are similar in appearance but
with a dark center.
Papules and pustules are red lesions 2 to 5 mm in diameter. In both, the
follicular epithelium becomes damaged with accumulation of neutrophils
and then lymphocytes. When the epithelium ruptures, the comedone
contents elicit an intense inflammatory reaction in the dermis. Relatively
deep inflammation produces papules. Pustules are more superficial.
Nodules are larger, deeper, and more solid than papules. Such lesions
resemble inflamed epidermoid cysts, although they lack true cystic
structure.
Cysts are suppurative nodules. Rarely cysts become infected and form
abscesses. Long-term cystic acne can cause scarring that manifests as
tiny, deep pits (icepick scars), larger pits, shallow depressions, or areas
of hypertrophic scar.

.

DIFFERENTIAL DIAGNOSIS:
Rosacea (in which no comedones are seen)
corticosteroid-induced acne (which lacks comedones and in
which pustules are usually in the same stage of development)
perioral dermatitis (usually with a more perioral and periorbital
distribution)
andacneiform drug eruptions.

Acne severity is graded mild, moderate, or severe based on the number
and type of lesions:

Classification of Acne Severity
Severity Definition
Mild < 20 comedones, or < 15 inflammatory lesions, or < 30
total lesions
Moderate 20 to 100 comedones, or 15 to 50 inflammatory lesions,
or 30 to 125 total lesions
Severe > 5 cysts, or total comedone count > 100, or total
inflammatory lesion count > 50, or > 125 total lesions

Prognosis
Acne of any severity usually remits spontaneously by the early to mid-
20s, but a substantial minority of patients, usually women, may have
acne into their 40s; options for treatment may be limited because of
childbearing. Many adults occasionally develop mild, isolated acne
lesions. Noninflammatory and mild inflammatory acne usually heals
without scars. Moderate to severe inflammatory acne heals but often
leaves scarring. Scarring is not only physical; acne may be a huge
emotional stressor for adolescents who may withdraw, using the acne as
an excuse to avoid difficult personal adjustments. Supportive counseling
for patients and parents may be indicated in severe cases.

MANAGEMENT :reducing sebum production, comedone formation,
inflammation, and infection:
Support and counseling:factual patient education about acne
(see above) and acne should not be dismissed as minor problem
but dealt with in a sympathetic manor and the patient should be
reassured that treatment is available!

Mild inflammatory acne:
a) unblock the pores (follicular ducts)with benzoyl peroxide,
sulphur compounds, salicylic acid (5-10%) or retinoid acid
(tretinoin) gel, creamor lotion, improvement should happen
in 1-2 months!
b) Topical antibiotics (clindamycin, erythromycin)


Moderate acne:as above and the addition of oral antibiotics
(tetracyclin, clindamycin, erythromycin, doxycyclin) for 3-6
months. Consider oral hormones (combined OCP) for female
patients.
Severe cystic or recalcitrant acne:
Oral isotretinoin(Roccutane, teratogenic, photosensitivity!!!)

Affected areas should be cleansed daily, but extra washing, use of
antibacterial soaps, and scrubbing confer no added benefit. Changes in
diet are also unnecessary and ineffective, although moderation of milk
intake might be considered for treatment-resistant adolescent acne.

How various drugs work in treating acne.


Treatment should involve educating the patient and tailoring the plan to
one that is realistic for the patient. Treatment failure can frequently be
attributed to lack of adherence to the plan and also to lack of follow-up.
Consultation with a specialist may be necessary.

Scarring: Small scars can be treated with chemical peels, laser
resurfacing, or dermabrasion. Deeper, discrete scars can be excised.
Wide, shallow depressions can be treated with subcision or collagen
injection. Collagen implants are temporary and must be repeated every
few years.






Same pic was given.
I talked abt treatment as life style modifications and then step ladder approach. Gave reading material
and talked abt social support.
Expressionless roleplayer and examiner. Just looking down and trying to stop their yawning
No question from anyone.
AMC FEEDBACK ACNE VULGARIS

Case 10
Examination of 10 days old baby
Take brief 2 min history and then examine
(thanks Dr. Wenzel, we just did this case 2 weeks ago in classs)
History was first planned preg hey congrats..:) a big smile on everyones face
SVD, uncomplicated, no problems in preg. Mild jaundice on day 3 now resolved. BINDS questions. Breast
fed, baby. Passing wee and poo normally.
It was a cute doll wrapped in sheet.
I took the doll and said awww cute baby and every one smiled. It was a real cute doll
Im copying drwenzels notes for that. I did almost the same but forgot few things. Started with head
circum and length.then vitals Then head and neck / Eye for red reflex and ENT exam. Ruled out cleft
palate, then neck and heart for murmers and chest and abdomen. Checked genitalia and checked for
cong hip dislocation.
I told the examiner that im assuming that baby is normal/ and she gave me a lovely smile. THE only
examiner who was constantly smiling at me

HEAD AND NECK:
1. swelling, haematoma (boggy swelling present from birth, cephalohaematoma which is
subperiosteal and limited by suture lines, usually does not require any treatment.
Subaponeuritic / subgalealhaematoma is more extensive and can lead to hypovolaemia
and often is a neonatal emergency!), size of fontanelles.
2. abnormal shape (premature fusion of sutures, craniosynostosis)
3. head circumference (micro / macrocephaly)
4. clefts of lip and /or palate
5. periauricular sinuses, ears (low set), external auditory canals
6. swellings, cysts or sinuses in the neck (thyroid, branchial cleft malformations)
7. the eyes red reflex! (cataract, glaucoma or retinoblastoma)
8. cystic hygromas, goiters, branchila arch remnants, torticollis

CHEST:
1. respiratory rate (35-60), central cyanosis, nasal flaring, costal recession (laboured breathing)
2. cardiovascular: peripheral pulses (100-160), auscultation of the heart




ABDOMEN:
1. anterior abdominal wall defect (exomphalos, gastroschisis), a simple paraumbilical hernia does
not require treatment at this stsage.
2. abdominal distension (?enlarged organ, intestinal obstruction, atresia, Hirschsprungs disease)
3. umbilicus should be clean and dry
4. genitalia: patency of anus, hypospadia or epispadia and especially testicular position in the
scrotum, hydrocele, torsion. Ambiguous genitals?


HIPS: for congenital hip dislocation (Ortolani and Barlow test)

BACK:
1. myelomeningocele (spina bifida, hairy patch or lipoma on lower back)
2. sacrococcygealteratoma

SKIN AND MUCOUS MEMBRANES: Mongolian spots (blue-black pigmented areas),
Urticaria, heat rash, milia (white pimples)



MUSCULOSKELETAL:The extremities are examined for deformities, amputations (incomplete or missing
limbs), contractures, and maldevelopment. Brachial nerve palsy due to birth trauma may manifest as
limited or no spontaneous arm movement on the affected side, sometimes with adduction and internal
rotation of the shoulder and pronation of the forearm.

NEUROLOGICAL ASSESSMENT:
1. spontaneous movement: frequent
2. posture: flexed arms, extended legs
3. upper limb tone: resists lifting of arms
4. lower limb tone: resists hip abduction, popliteal extension
5. truncal tone: attempts to straighten back when lifted prone
6. tendon reflexes: brisk, some clonus common
7. Moro (startle) reflex: abduction and extension then adduction and flexion
8. Suck reflex: a pacifier or gloved finger is used to elicit this reflex
9. Rooting reflex: Stroking the neonate's cheek or lateral lip prompts
the neonate to turn the head toward the touch and
open the mouth.
10. Response to objects: fixes and follows bright lights
11. response to sounds: quietens or startles



MEASUREMENTS: weight, length and head circumference should be plotted on a standard growth
chart.
AMC FEEDBACK EXAM OF NORMAL BABY

Case 11 obs
Primi 40 wks with unengaged head
History
Investigations
Management

Started again with asking history about 6 Ps..congratulating her as it was first and planned preg.
Everything was normal so far.
Told about It's much more common for second and subsequent babies not to engage until you
go into labour, than it is for first babies.
It is that your baby's head is free-floating, or high in your pelvis, rather than 'dipping' into your
pelvis or partially engaged.Explained with drawing.
In primis head engage at 37 weeks, but in multi it enagages with onset of labout.
Causes of free head
In many cases it is because the baby's head is not in the best position for birth yet. If
baby's head is well flexed, ie chin tucked on his chest and he's facing your back or your
right kidney, then he's in the best position for birth. If his head is not well-flexed, ie his
chin isn't tucked in, or if he's in the occiput posterior position, ie he's facing your
tummy, then it's harder for his head to fit into your pelvis. Thus it could well be that he
hasn't wriggled down yet because the position he's in means it's too tight a fit, and
when he *does* get into the right position, he'll settle down nicely. This is the most
likely case of non-engagement.
Cephalopelvic disproportion (CPD) - baby's head too big to fit through the pelvis - true
cases are thought to be rare in developed countries unless the mother has suffered
from pelvic injury or deformity. Asked about any previous traumas or fractures of pelvis.
Answer was no
Placenta Praevia - low-lying placenta. Have you had any scans during the pregnancy? If not then
you could have one to check that the placenta is not stopping the baby descending into your
pelvis
Any fibroids, or history which might suggest them? Like a low placenta, they might be blocking
the baby's exit route; again, a scan can eliminate this possibility
OK, so what does it mean if the head is high at term, for your first baby? Well, if the head is still
free-floating when you go into labour, then you do have a higher chance of ending up with a
caesarean for slow progress. HOWEVER, the vast majority of women whose first babies are
completely unengaged when they go into labour, will still have a vaginal birth
RISK FACTORS
SLOW PRGRESS
CORD PROLAPSE

Patient was happy in end as I said that im referring you now to obstetrician
No question from anyone.
AMC FEEDBACK UNENGAGED HEAD AT TERM


Case 12
Barium meal pic was given outside. It was apple core lesion. History was 65 + female with
constipation. She previously took some codeine tab for some pain which worsened her
constipation. Explain barium meal findings and ask history and mange and further investigation.

Started with explaning by drawing what is apple core lesion and the causes. Then asked about
her history of wt loss, altered bowel habbits..all were no. no family history of colon cancer. She
was a very nice role player. Guided me by asking herself questions about colon ca. I told her
that my diagnosis is not yet colon CA, im just saying that it could be one reason of this apple
core lesion. Then she asked, if it is CA, what u will do. I said, colonoscopy, biopsy, blood and
stool tests. Then she asked, lets assume, it is CA colon, what next. I said that after staging
cancer we operate it. Explained role of surgery and chemo. She asked what next if u cut my
colon. I told about colostomy bag. But then again I said, that it is far down the track to talk
about colostomy. Lets first refer you for colonoscopy and do more tests, then only we can come
to conclusion. Finally she smiled at me
Finished on time. And while going out, I told here is some reading material for you.
AMC FEEDBACK COLON CA COUNSELLING

Rest station 13..
Case 14 book case of 47 Sciatica but altered to Radiculopathy. Here the patient didnt have any
tingling or pain in his leg..just severe pain in back after lifting something heavy
Examination showed spasm of paravertebral muscle.
Explain the condition
Write prescription
Manage and counsel
Easy one.
Asked the examiner if I could relieve his pain first..he said no need. He took the medicine.
Explained same like book. Made drawings.
Gave prescription of panadine forte.
Refered for physio and back strengthening exercise.Explained him how to lift heavy weight by
bending knees.
AMC FEEDBACK LOWER BACK PAIN ..

Case 15 Pleural effusion
Short question.A young 30 yrs man with aches and pains and weight loss.
Take history.
Investigations
D/D
Started asking about all weight loss questions, weather preference, more thirsty or passing
more urine, diarrhea, breathing problems,cough, joint problems, dieting, any excerise,
depression, any medication, any fever all answers were NO.
I was like..oh God everything is no.. what to ask now. So I asked, any thing u wanna tell. He said,
yes 2 weeks back I took augmentin for sinusitis. (again I thought, augmentin or even sinusitis
related to weight loss NO WAY) finally it clicked in my mind. Any history of travel. He said
Yes..( ohhhthankssss) again I asked any shortness of breath , cough or fever.. answer was
nooooooooooo
I didnt waste time after that and turned to examiner for examination findings. She was so
sweet, she started telling me herself in detail..my dear vitals are ok except for temp 37.8. on
inspection of chest, moving less on left side, percussion dull note on left side and aus some
crackles. Rest of exam is normal. I thanked her and turned to role player and made the drawing
of pleural effusion and told that ill do some blood tests, and chest xray and this fluid test to find
the reason of your problem. Looks like pneumonia but other possibilities also I told.
AMC FEEDBACK GENERAL MALAISE

Case 16 paeds
Croup
A 3 year old boy in Gp clinic with severe cough.Started with mild fever and runny nose.Now
breathing with effort.
History, examination findings from examiner, manage
A veryvery serious examiner. And a very sleepy roleplayer, who was just trying to stop his
yawning.
Typical history of croup.
Examination findings were positive insp stridor, tracheal tug + with nasal flaring. So I told I will
give straight away steroidsdexamethasone and then some nebulization with adrenalin latter
on.. And will shift in ambulance to Emergency. I told it looks like moderate to severe attack,
caused by parainfl virus. Croup child needs minimal handling. Let him sit the way he wants to.
Role player asked any antibiotics. I said no as it is viral.
AMC FEEDBACK CROUP
Case 18
Anterior knee pain.
22 year female with pain in left knee since 6 weeks.plays hockey.
History,
Examination findings from examiner
D/D
Answer her questions

No History of trauma, fall, fever, or contact injury. No arthritis problem. Plays a lot of hockey. I
asked her BMI as, she was quiet obese may be around 28 BMI, but examiner said she is 21 BMI.
Examination finding was all normal except for pain over patella and patellar apprehension test
+. All other tests, hip exam and rest all normal.
I told it might be Chondromalacia patella, or osteochondritisdessicans. Patellofemoral
instability but I wann do xray, USG and MRI.
Rx is step ladder approach. Use pain killers nad some chondroitin sulfate to strengthen your
cartilage. Explained her what about cartilage and its problem.Told her about role of
physiotherapy to strengthen her muscles around knee. Should take some rest
She asked , can I play sport. I told lemmeruleout first other things, then yes u can with knee
caps and supports.
The only examiner who said Good to me in the end.
Some ppl mentioned it as patellar sublaxation. Some as bursitis (which was wrong)as there was
no redness or increased temp over joint.
I didnt mention sublaxation of patella. So I dont know. Waiting for amc response..

AMC FEEDBACK CHONDROMALACIA PATELLA
Rest station 18 exam over cant believe it.

Best of luck to everyone.