13 november

1.

GP setting
Case: a man in his 30s complaining of shortness of breath. Task was: obtain
history, ask physical examination findings from examiner, inform the patient of
probable diagnosis and suggest investigations

Performance: wen I entered the room an aussie roleplayer was sitting there. As it
was my first station so I was bit tensed but I tried very hard to control my
nerves. After introducing myself to role-player I asked open ended question :
how can I help you? He responded that he has shortness of breath from few
weeks and he also noted phlegm . when I asked about the quantity of phlegm he
said its not much. No hemoptysis, no wheezes, no cough, no chest pain, no
throbbing of heart, no liver disease, no kidney disease, no swelling of limbs. He
denied any weight loss. No lumps or bumps. He said his father had emphysema
but there is no family history of lung cancers. He was a smoker who smokes
around 15 cigarettes in a day and was an occasional drinker.

After taking history I couldn’t think of any diagnosis though I had few
differentials in my mind. I asked examiner about physical findings, he handed me
a sheet of the physical findings:

General appearance normal

Vital signs – normal, no fever
Chest – air entry decrease on left lower lung base and vocal fremitus also
decreased in that area. No added sounds.

After reviewing his findings I explained him that I suspect there may be some
fluid accumulation in your lungs. I drew a diagram and explained about
pulmonary effusion(the roleplayer seemed very interested in my explanation).
Then I said that I need to do Xray to confirm it and if it shows pleural effusion we
will find out the cause and treat it. then I gave my d/ds copd, lung cancer,
pulmonary edema, heart failure, kidney failure. I also suggested that spirometry
may be done.

I did not explain management because the task was only to tell diagnosis and
suggest investigations.

2
EMERGENCY DEPARTMENT SETTING
Case: adult male who was previously diagnosed with schizophreiniform disorder
has presented with dizziness. He was started on resperidone by the psychiatrist
about 4-5 days back.
Task: take history, ask findings from examiner and suggest management
Performance : wen I entered the room a young boy in his 20s was sitting there.
He was looking restless and his body was bit shaking. I asked him about his
problem. He said he has been ffeling dizzy from past 2 days. wen he gets up from
sitting to standing position, he tends to fall. No spinning of environment. Mood
was okay. No suicidal ideation. He said he has been experiencing some strange
things. He saw some vans with cameras around his apartment and those vans are
keeping an eye on him. He denied any missed dose or doubling of dose.
Judgement and insight was intact.

I asked the examiner lady about patient’s gait and instead of telling the gait she
said ok go ahead. I got little confused because the task was not to perform any PE
but instead ask findings from examiner. Then I asked the patient to take few
steps. His gait was ok. Then I asked her about any tremors or signs of
parkinsonism. She said no. (I COMPLETELY FORGOT TO ASK BLOOD PRESSURE)

Wen I started explaining the cause of dizziness to patient I suddenly

remembered that I didn’t ask BP . so I asked her and she gave me standing and
sitting reading obvious of postural hypotension(THANK GOD SHE DIDN’T SCOLD
ME FOR NOT ASKING IT BEFORE). Wen I explained patient that your dizziness is
due to resperidone side effect, he asked – but these medications are supposed to
make me better??? Then i said – of course but dizziness is the common side
effect of this medicine and can even occur with normal dosage and its usually
seen within 1 week of starting the treatment.
Then I said that ur BP is bit unstable so I will admit you in emergency
department for OBSERVATION and call the psychiatry registrar. If he decides to
change the medication then you may have to get admitted for 2 weeks. Explained
about crossover period too.

3
GP SETTING

30 year old man presented with complain of diarrhea from 2-3 months.
Task; history, ask findings from examiner, tell probable diagnosis and
investigations.

Performance: the role player was bit troublesome was examiner was very nice
Asian man. I started with introduction and open ended question. He said he is
having diarrhea from past 2-3 months. Wen I asked about volume of stools he
replied sarcastically that I did not measure it. then I directly asked is it bulky or
watery? He said neither of these. I got bit offended. Anyways then asked any
smell, flatulence, bloating. He denied all. No travel history. No prior antibiotic
usage. I asked about blood and slime in stools . he said yes he has both. Wen I
asked about any stress in life. He said he is very busy at work and his diarrhea
started at the same time wen his worked load increased over a period of 3
months. (HE WAS TRYING TO MISLEAD ME BUT I KNEW THAT ITS NOT DUE TO
STRESS). Then I asked about weight loss. He said yes he has lost some weight but
he is not complaining about it. instead he is happy to lose some weight.(AGAIN
TRYING TO MISLEAD). The I ruled out infections, thyroid disease, hiv etc. he was
non drinker but a smoker from 10 years.

Finally asked examiner about physical findings but instead of asking specifically.
He read out all findings at once for me. (THANKS FOR SAVING MY TIME)

GENERAL APPEANCE – looks pale

Abdomen – only finding was slight tenderness all over on palpation.
PR- skin tags

I explained that depending on yr his and PE it seems that u have IBD. The I
explained wat it is. I said there could be other reasons for yr presentation : celiac,
thyroid, food related, infectious, colon cancer etc. the role player AGAIN TRIED
TO MISLEAD ME. Oh god!!! . He specifically asked me about Celiac diasease
instead of asking more about IBD. I explained wat celiac disease is.
Then I suggested referral to specialist for colonoscopy and biopsy and order
other baseline investigations.

4
HOSPITAL(ED) SETTING

This was the station wen my tough time started and I completely screwed up this
one.
Case: 18 month old child brought by mother because he was having difficulty in
breathing & swallowing along with stridor.

Performance: I entered and asked examiner is the patient stable? He said yes.
Then I asked mother about the problem of her child. She was crying. She said my
child has difficulty in breathing. He also has cough from past 1 day I guess. She
said there is noise wen he breathes. The difficulty and noise developed
overnight. No wheezes . mild fever. Immunization was up to date. Growth and
development was normal.

I asked examiner about physical findings. He said child looks irritable.

SPO2 – 93%
TEMP-38
PR was bit high and BP was normal. RR was also bit high but I don’t remember
exactly.

No redness of throat. No muscle retractions. Chest was clear. Inspiratory sridor

+.

I got completely confused and I said its croup and explained management of
croup.

Now after discussion with others, it is believed that it was epiglottitis.

This was a totally new case for me. I didn’t read the causes of difficulty in
swallowing in children b4 therefore I had complete thought block in this station.
Please refer to other candidates’ recalls as well.

GP setting
Case : 24 years old and 20 weeks pregnant lady came to visit you because she
wants to have planned cesarean section

Task; take relevant history, discuss the merits and demerits of cs and answer
patients questions

Performance: I explore her reasons that y she wants cs. She said because it
simple and she will not have any pain.
Explained about indications of cs and complications and risks of cs. Then I said
that it can be said at this time that u need a cs. It depends on how yr pregnancy
approaches and if u develop any contraindication to normal delivery then u have
to undergo cs. Still its yr choice. But if u r consistent with having cs then at 34
weeks I will refer u to obs for more detailed discussion.

The lady didn’t ask me any other question and gave me a sweet smile.

6
HOSPITAL SETTING
Case: 60 year old man had surgery of colon 2 days ago. Now he is breathless. He
has a past history of hypertension from 15 years abd was on antihypertensives.
The srgery was uneventful and there were no complications.
The charts were given
1. intake/output chart – intake was considerably higher than output(sorry
don’t remember the exact figures)
2. vital signs – no fever, pulse rate was bit high, spo2 was low and BP=
155/90

Task: ask physical findings from examiner

Interpret the charts
Explain the probable diagnosis
Outline the management

Performance: when I entered an old man was lying on the couch. He was on
oxygen through nasal cannula and was looking distressed. When I entered I
asked examiner about any signs of dehydration… LOL I was so anxious that it just
came out of my mouth. The examiner laughed and said no dehaydration.
Then I asked about any edema he said no. he said jvp is enlarged. Then I asked
about heart and chest. Heart exam was normal except S4 was heard. In chest he
told me that there are widespread crepts.
I turned to the patient and assured him. Then I said that probably you have
accumulation of water in your lungs and that is the reason it has become hard for
you to breathe. I will make you sit upright and put you on oxygen through mask.
Then I said we will give u diuretics to remove the excessive water. Explained the
cause of pulmonary edema and suggested nitroprruside to lower the afterload
and preload of the heart. Then i turned to the examiner. Examiner was so so nice
that he asked me to read the tasks again to make sure that I m not missing
anything. Oh god!!! I missed the interpretation of charts. Then I discussed the
charts with examiner and bell rang.

7
GP Setting
50 year old man complaining for sharp pain in the left groin region from few
weeks. No other medical history was given.

Task: Perform PE
Explain diagnosis and differential diagnosis

Performance: a nice gentleman wearing a gown was sitting on the chair. I

greeted him and ask him to remove gown. Instead he asked me can I just pull it
up . I said ok.
I did whole examination of his HIP. On gait trelendenberg sign was positive and
trelendenberg test was also positive. Thomas test positive on left side. All
movements of left side were painful and reduced especially internal rotation.

I explained him that you may have osteoarthritis. I explained wat it is and how it
occurs. Wen I started explaining him the management the examiner interrupted
me and said that management is not your task. Then I again elaborated the
osteoarthritis explanation.

8
CASE: 7 year old girl complaining of headache from past 2 days. also has fever
and sore throat.

Task: Take history

Ask findings from examiner
Management

Performance: I totally messed up this one and couldn’t reach the right diagnosis.
Please refer to other recalls as I don’t want to misguide you by giving you wrong
information.

9
Case: 65 year old lady living in nursing home. She did not attend the usual church
ceremony in the mornings. The nurses complained that she is using
“inappropriate words” and not able to understand whatever is said to her.
Task:

Do MSE (I WAS SHOCKED WHY R THEY ASKING TO DO MSE OF A CONFUSED

PATIENT. HOW WILL I DO IT??? )
Give reasons of her confusion
Suggest management

Performance : An old chinese lady lying on the couch. I started with Introduction.
And then MSE. Whatever I asked her she replied with the word “rubbish”.
Rubbish for mood, rubbish for suicidal ideation, rubbish for strange experience. I
got so nervous. In fact whole MSE was RUBBISH. She wasted the whole time. I
got so furious with this scenario.

I told all the causes of confusion to examiner. And wen I was about to explain
management. The bell rang!!!!

10
RURAL HOSPITAL SETTING

Case: 25 year old and 32 weeks pregnant lady complaining of gush of fluid from
her private parts. Her blood group was O+.

Task: History, Ask physical examination findings and explain management

This one was a straightforward case of premature preterm rupture of

membranes. I took history. Asked about pain, discharge, rash, fowl smell,
bleeding etc. then ruled out the risk factors of PPROM.

On asking examiner gave me relevant findings, nitrazine test was positive. I said I
will take swabs. He replied that swabs have been taken

Then I explained wat is PPROM. Ordered ESR/CRP. Arranged transfer. Gave her
steroids and antibiotics. Explained y I am giving u these meds. Explained that
USG and CTG will b done in hospital. I also said that u may be given tocolytics if
contractions begin b4 the completion of steroid therapy.

11

GP SETTING
Case 35 year old man complaining of numbness in his soles and lower part of leg.
He is a chronic drinker. All investigations were done. BSL were normal but LFTs
were elevated.
Task: perform neurological examination of lower limbs
Explain the cause and give dds

Performance: I performed neurological exam of lower limb. His sensations were

reduced down below the knee and so was vibration and proprioception. I
explained him about peripheral neuropathy and said that its coz of your excess
alcohol. Also gave other dds – diabetes, b12 def, uremia due to kidney failure.

12
HOSPITAL SETTING
28 year old female admitted to hospital with severe abdominal pain that started
2 hours ago and now have become more worse. No nausea/vomiting. The
abdomen is distended and patient is constipated from yesterday.

Task:
DO PE of abdomen
Give dds and management.

Performance: when I entered the room a young lady was lying on the couch. I
introduced myself and offered painkillers. Then I performed Physical
examination. To my surprise, she distended her tummy by taking deep breath.
Wen I started palpation, her tummy was so hard to palpate (FOR A MOMENT I
FELT THAT I M DEALING WITH A REAL PATIENT). Then I did percussion to rule
out pneumoperitonium. It was tympanic. I was about to check bowel sounds that
examiner interrupted and said bowel sounds cannot be heard.

Then I said that most likely ur presentation is because of rupture of any part of
viscera. So it’s an emergency and I have to admit you and get you ready for
surgery. I will call the surgeon to access you further. Kept her NPO. Put NG.
Started iv fluids. Also explained about the need of antibiotics. I asked the lady
whether she is alone or not. She said she has come alone. So I offered to call her
husband on her behalf.
When I was done , examiner asked me what can be the other causes. I said bowel
rupture, perforation of peptic ulcer, appendix perforation, complete obstruction
of bowel.

13
GP SETTING
Case: 65 year old lady complaining of vaginal bleeding that occurred a week ago.

Task: take history

Ask findings from examiner
Suggest management
Performance: a very nice old lady sitting in the room who greeted me with a big
smile. I asked about the episode of bleeding and took history according to 5ps.
Excluded any trauma and bleeding problems. Asked about past HRT. She said she
is not sexually active. The bleed was usdden and very slight. Was red in colour.
she had the bleed for first time. No weight loss, no lumps or bumps, papsmear
was done 12 months ago and was normal.

Examiner gave me the findings : no signs of trauma on inspection. On speculum

no dischare, no bleeding, thin friable vagina. No mass can be seen on the cervix.
Bimanual exam: uterus size n shape was normal. No tenderness.

I explained the patient all the causes of postmenopausal bleed: atrophic vagina,
endometrial cancer, endometrial hyperplasia, cervix cancer. Referred her to
gynaecologist. Explained about USG, hysteroscopy&biopsy. Offered review after
results.
I had time so I talked about the management of each problem.

14
HOSPITAL SETTING
2 year old boy brought by mom because he was gagging.
Task: take history and suggest management
Performance : I asked the lady about gagging. She said it started about 2 hours
ago and he is still gagging. Asked about cough, fever, noisy breathing which she
denied. Wen I asked about foreighn body, she said she suspects that he had
swallowed a button battery of one of his toys. When I asked about the size of the
battery, she pointed that it was the size of 10 cent coin.

I explained the need of xray and explained that management will depend on the
site where the battery is lodged. Explained the management according to the site.
Then examiner interrupted me and said that xray is clear. My tough time started
now. I explained the mom that most likely it has passed(this was my mistake,
shouldn’t have said that). I should have referred her to ENT/PEDS. Anyways I
don’t think that I passed this station. Please refer to other recalls.

15
GP SETTING
Case- 55 year old lady came to Gp clinic because she has a nose bleed . the nurse
did the nasal packing and the bleeding has stopped now.
Her vitals are

BP- 140/90
PR- 75/min
RR-16/min
TEMP- 37.4

Task: Take history

Explain diagnosis and management
Performance: I ruled out all the causes of nasal bleed(well written in Karen).
There was no cause except hypertension that she had from few years and was
taking antihypertensive for it. she said her BP normally remains under control.
She was taking Aspirin from past 3 days coz of headache. There was no bleeding
disorders in the family.

I explained about epistaxis, its causes, gave epistaxis action plan, booked another
consultation for her headache and asked her to stop aspirin and take
paracetamol instead. Ordered FBE and clotting studies(just in case)

This case is very well written in Karen. Please refer to Karen notes for this case.

16
Hospital setting

It was a typical case of fever in immunocompromised(HIV POSITIVE) patient.

AYOUNG BOY WITH HOT AND COLD FEELING. managed as atypical pneumonia
in immunocompromised patient.