Amc Clinical Sample Questions 3k4y1c

3 June 2006, Melbourne ( retest) Question 1: A young student has a heart murmur coming and going, he comes to you as a GP for diagnosis. He has no cardiac symptoms, no SOB. Everything is normal, no family history of heart problem. General health is fine. Tasks: 1. do a cardiovascular examination. ( please do not cover abdominal examination and lower limbs examination.) 2. present what you have found to your examiner. 3. present your diagnosis to your examiner and answer examiner. My approach: do the physical examination following the textbook. It was a medical student with no murmur at all. Questions from examiner: 1. what other physical examination do you want to do? ( I stopped after I auscultated role player.) valsava examination. 2. if a patient has a murmur coming and going, what do you think? – functional murmur? Question 2: A young student presents with dry cough, mostly in the morning or at night, general health ok, non smoker. Tasks: 1. do a respiratory examination, 2. report your finding to your examiner. 3. answer examiner‘s question. My approach: Again, follow the textbook‘s instruction. It was a medical student with no positive finding. I told the examiner that there was no positive finding. Then she asked me what was the diagnosis- asthma. Immediately she asked me what else I wanted to do. I said spirometry. She handed over a spirometry result: FEV1 decrease, FVC decrease, after bronchodilator, FEV1 increase but lower than normal, FVC increase but lower than normal. I said it was consistent with the diagnosis with asthma. Question 3: (same question from April Melbourne 2006) A young lady driver has a few car accidents because she can not see the car coming from the intersection. Please do a visual examination. Tell your examiner what is your finding. Make a diagnosis and management plan. Please note that MRI is the gold standard of diagnosis. Question 4: (same question from November, 2005, Melbourne) You are an ED intern, a 45 years old man presented with right upper quadrant abdominal pain for 6 hours, nausea but no vomiting, this is the first attack. On examination: temperature 38.3 C, other vital signs normal. 1. please explain to your patient what is the most likely diagnosis 2. do the essential investigation. 3. management plan Question 5 A young student presents with poor sleeping, examination is coming, he is worried about the exam. Recently, his father ed away unexpectedly due to heart attack. Please take a history, Counsel this patient, Make a management plan My approach: I asked all the questions related to depression anxiety, such as drinking, eating, weight, sex drive, usual interest, the impact of his father‘s death on his life. and also the past psychiatric history, drug and alcohol history, medical history, social history including performance at school, family relationship, employment, Explain to him: the reaction of bereavement. Emotional , Management: sleeping pill, medical certificate, psychologist counselling. Question: how should I use sleeping pill, what is the prevention of heart problem.

Question 6: A 2 year old girl presented with headache, fever for 2 days, father is concerned, he brought his daughter to your GP setting, Her father has family history of migraine. Please ask for examination finding from examiner. ( no further history taking) Manage this case. My approach: ask for general appearance. Vital sign, ENT, any rash? Neck stiffness, kernig sign? Other system. – only phalangitis, and bulging ear drum. Sign of dehydration, not drinking well _ from father, but examiner said baby looked well? My management plan: Explain to father that it may be viral infection however I can not exclude meningitis or other serious infection, so please observe and send to ED if rash, fever increase, drowsy, not drinking well or eating well. Question 7 24 years old lady presents with vaginal bleeding 2 hours after 8 weeks amenorrhoea. General health ok. She is obese. You are a GP. Please take a history Ask for physical examination. ( investigation not available) Discuss with examiner about your management plan. My approach: she is not planning for family, partner is using condom, she is not on pill, bleeding more than usual. LMP 8 weeks ago. Regular period, no pain, no STD history. No family history of bleeding tendency. Not on any regular medication. PAP smear 6 months ago, normal result. No pregnancy history. No abortion history. Now she has no abdominal pain. Only per vaginal bleeding. Has stopped now. Physical examination: haemodynamically stable. No tenderness or mass in pelvic, speculum: os close, no bleeding, no polyps or ulcer. Examiner asked: what is your diagnosis if beta HCG positive? Threaten miscarriage. What other investigation do you want? – U/S What if beta HCG negative? Polycystic ovarian disease. Or other bleeding tendency, or problems in the uterus such as PID…. Question 8 61 years old bricklayer(male) presents with two years history of back pain and thigh pain? (not bilateral or which side) Past history: osteoporosis Your task: 1. history taking 2. ask for physical examination finding 3. your provisional diagnosis and management plan my differential diagnosis: 1. sciatica – fracture or disc prolapse – malignancy or osteoporosis 2. osteoarthritis 3. claudication 4. trauma? I asked the history carefully, first, pain question. Then I asked during the last two years, has he been to any doctor? He told me that a doctor told him that he had got spondylosis of spine (x-ray) then I knew it might be osteoarthritis. Then I asked examiner the hand examination and shoulder, neck, back, hip, knee etc… The examiner told me : heberdon nodes on hand.. Then I got a clue…… Management x-ray and referral to rheumatologist… I am not sure I am right or not? AMC MELBOURNE 29/04/06 I never realized how difficult it will be to make a recall after the exam. I do not all the tasks and some of the examiners questions. Stems were also much longer. So please be careful when you read these questions and find your own answers!! NEW QUESTIONS

1.18 y.o patient comes to your GP practice for insurance purposes. He had asthma when he was 11. TASK Do spirometry, calculate FEV1, FVC and ratios. Discuss results with the patient. To answer properly I‘d look up for spirometry from http://www.nationalasthma.org.au/html/ma..._spiro.asp Video is there FEV1, FVC interpretation, (normal values were provided by examiner) Pt asked one question – Do I have asthma? Other candidates had Normal result of spirometry and reassured the pt 2. Photo dorsum of hand. (Not from AMC book –scaly lesions on whole dorsal surface of hand, red).Pt is a brick layer started new job 6 months ago, comes to your GP practice TASK- take Hx, discuss condition with patient. Rash has been there for 3 months, 3 months after he started his work, at work does everything with hands, no gloves. Rash very itchy, holidays made it better. Pt loves his job. Brother has psoriasis (to confuse you). My answer: dermatitis. Examiner expected to hear oral steroids as tx , not only topical steroids and gloves as protection. I told the role-player he does not have to change the job, which he liked. The examiner asked about complications. (My answer cellulitis, treat with oral Flucloxacillin after checking BSL and lymph nodes) I‘d read at least from Murtagh and Pt‘s education re: this topic 3. 50 y o patient wants some advice about loosing weight,BMI 34, Cushing, hypothyroidism excluded. She will ask you about medications. TAKS – discuss with patient. No further Hx My answer –still talked re:Family (anybody with diabetes, angina, CVA?- she said no). Reassured-, very good and important that you came, good decision. Spoke re:cardiovascular risk factors Explained the risk of increased weight –heart, DM, CVA again. Advised re: Diet ,offered dietician. Exercise (all the info from Pt‘s Edu and http://www.heartfoundation.com.au) And spoke about osteoporosis if she does not exercise No smoking and, safe levels of alcohol Re medications :said don‘t know much about, only they can give you high BP. She was not interested anyway (in contrast to the stem!!!) Loose your weight slowly, in a sensible way. Examiner asked about surgery – Lap banding of stomach 4. 50y o man problems with vision, can‘t see the signs when driving car signs on the left and right bumping into things and people. You‘ re GP. TASK – Examine eyes.tell Dx, What other investigation would you do. (looks like old question – Myopia –Mel NOV 2004), but in this exam the man is 50 y.o.…. My answer: role-player helped me, saying I can‘t see from LEFT and RIGHT. Examination Snellen chart- normal, Visual fields- bitemporal hemianopia Fundoscopy-examiner said normal. Accommodation – couldn‘t see a thing but said normal Pupils reflexes –examiner said normal. Eye movement – Normal Examiner asked Summarise findings – Bitemporal hemianopia. What‘s the cause – brain tu, possibly optic chiasm. What other tests?- I said CT and P, BP, full neuro examination and baseline bloods. Look up Talley.-Theory-from the book, Examination from the DVD- invaluable for any examination (only hip& back not there) 5. 41 weeks (can‘t possibly primi ) in labour. Station 0. Baby in OTposition, cervix effaced , 3cm dilation. ed meconium. You‘re GP working inObs Ward of countryside hospital – no obstetrician available. TASK- Take Hx from patient, ask examination findings, discuss situation wih pt. (Similar to Syd SEPT 2005, or Syd MAY 2004 but changed) 5. A lot of Interactions with the examiner at this station which makes it harder. My answer: I asked how long in labour – Pt said 3 hrs, are you comfortable – dehydration, pain, - pt NO ANcare, esp DM ( sweet drink at 28 weeks) – pt all OK Contractions? – examiner said every 3-4 min,getting stronger

Examiner said Manage I said - call another DR in Hospital for 2nd opinion. Check pt GA,hydration, P, BP, T, -Put CTG (examiner said– reactive) and LEAVE IT ON. -Fetal scalp electrode- Examiner not available- countryside. -Asked re:meconium Examiner green , you can‘t tell thick or thin -I want to re-examine pt- exclude cord prolapse, asses cervix, presenting part. examiner – cervix 10cm now, baby between OT and OA,station +1 talk to pt Talking was reassurance- canal for baby open, baby turning into good position, moving down. Green stuff ed but does not mean there‘s a problem (41 weeks), I‘ll keep an eye. Examiner also wanted to hear - suction airways of baby, augmentation not required. Similar case in Greer – Problem based Obs&Gyne. OLD QUESTIONS/PAST RECALL PAPERS INCOMPLETE and CONFUSING 6. 50 y o women postmenopausal come to your GP practice for the results. Result of microcytic anemia attached NO further Hx to be taken. TASK ask examiner examination findings, Discuss condition with pt (same as Syd MARCH 2005 Retest) 6. I asked for iron studiesExaminer gave me a paper --low Fe, low ferritin, high transferrin, low Fe saturation.Obvious IDA I asked for tissue transglutaminase for celiac – Examiner – normal and nothing else available. Talk to pt. I explained IDA, maybe due to diet,maybe other cause. The woman did not want any tests. The case was really ―dealing with difficult Pt/convince her to have the test‖. Explained why loosing iron maybe diet, maybe ulcer,maybe sth more serious, we have to find the cause. Pt asked- Can it be sth else??-Not likely we need to find the cause. Can you give me Iron? – OK, may improve your symptoms, but still need to find the cause. Colonoscopy/gastroscopy invasive but done under sedation so you will comfortable, no pain. If losing iron due to ulcer it‘s easily treated, if sthn else/sthn nasty better to know early. Go home/ speak to husband/come back with decision in few days. You really need the tests. IDA from P.Devitt 7.30 yo woman on O no period for 2 months, comes to you as GP. NO Ix result available TASK further Hx, discuss condition with pt. (same as Adel SEPT 2004,but hidden points were Pt is 85kg, wants to be pregnant in 2 yrs) 7. HX – on Microgynon 30(forgotten to ask for how long!), did not loose/put on weight recently, now 85 kg, periods regular before, no headache/vision probs/nipple discharge, no dry skin/cold intolerance, no acne/funny hair on face/Fhx of PCOS,no gyne procedure, does not .smoke, no meds only Pill. I have to ask you sensitive qq- Did you have sex over last 2 months. Yes. PE – Examiner all Normal Pregnancy test- unavailable My answer : explained – exclude pregnancy first , if negative don‘t worry, 2 months not significant, no test necessary now If you concerned we can stop Pill and wait (use barrier protection) or change Pill to higher estrogen or Triphasic. Other option I‘d recommend - continue same Pill (as 2 months no period- no reason to worry), see if period back and loose weight over next 2 yrs. You‘re overweight pregnancy MAY be complicated by high BP and DM. Pt asked ―Will I get pregnant‖- We have to exclude pregnancy now and wait for period to come back. See me in 2-3 weeks. 8.You‘re intern ED, women came 3 days ago-previously on Prozac stopped 3 days ago, started on Zoloft. Today she‘s vomiting, jittery, dizzy. TASK- take further history, PE from examiner, discuss condition with Pt. ( same as Syd AUG 2003) 8. Still confusing this question, in taking Hx I repeated what was in stem, Pt unwell on Prozac before given Zoloft, unwell today. Did not take any other meds. PE – P-normal, BP no postural drop, not dehydrated, CVS< RESP>ABDO NAD, brisk reflexes Urine no ketones. Ix not available. I explained all due to SE of antidepressant, there‘s sthn we call serotonin synd, but usually when 2 antidepr. mixed from different groups, these 2 are SSRI‘s . So my Dx is SE of antidepressant. Examiner- what will you write in chart? Iv line, Nsaline, Metoclopramide.

Pt asked I can‘t sleep. I answered I‘ll ask senior (did not know if I could give Valium) 9. You‘re GP. Your patient was 29cm at 30 weeks, now 4 weeks later she‘s 30 weeks. Figures may have been different but still decreased growth around 28/34 weeks TASK-take further Hx, ask PE and Ix, discuss results with Pt. (Similar to Syd May 2004) 9. In Hx no headache, blurred vision, tummy pain, no hx of infection, ANCare normal –USS 18 weeks, sweet drink 28 weeks. Good diet, no smoking, no iv drugs. baby kicking less (I forgot to ask how many kicks/day now!!!) PE – P,BP normal Heart sound 140/min. urine dipstick no protein I asked for Ix - CTG (examiner says reactive), Doppler (examiner-what you're looking at? - S/D ratio, which artery ?- umbilical) BPP - (examiner- which parameters you're looking at ?) tone, breathing etc USS - examiner says- baby 10th percentile asymmetric What's your Dx? - IUGR Talk to Pt. Started explaining and bell rang. Funny other candidates got Small for Dates from Ix, to others examiner said- NO Ix available. This question still confusing. IUGR from Greer. OLD QUESTIONS REPEATED 10. 2 y o boy brought by father to your GP practice 50km from Hospital. Boy had sore throat last 2 days, today drowsy, dehydrated, P-high, BP low, T-40, petechial rash, no neck stiffness. Photo from AMC book. TASK - explain condition to father, manage the case. (same as Mel FEB 2006 !!) 10. My answer: it's urgent, so I'll explain very briefly. Blood poisoning, very dangerous if not treated,same bug as the one causing meningitis. Any allergies to penicillin? Pt - NO I do iv line, take blood for culture, give benzylpenicillin 600mg iv, call Ambos, call Registrar in Hospital. You' re wife pregnant? Pt -No. OK, so you'll both need meds for prevention 2 tabs. daily for 2 days. Think if anyone kissed, shared food with child over last 10 days. I also need to notify DHS. Very good you came, very important, hope the child will be fine. Pt asked- can it be sth else? Not likely as child really sick needs to go to ED now, you can go with the child in ambulance. Guidelines RCH 11. Father of 5 months old boy comes to your GP practice re: lumps in Rt groin and another one around belly button. Lumps come and go. TASK explain diagnosis and manage the case (same as Mel NOV 2005) 11. My answer: good you came, you child has 2 hernias-weakening of muscles in tummy, explained about testis traveling from tummy to scrotum,channel did not close, can be dangerous if bowel gets stuck outside. I am calling surgeon now, for appointment as early as possible. Operation possibly within 2 weeks re;lump in groin,about lump around belly button surgeon will decide if he will repairs both together. Normally the one around belly-button can wait until 2/4 years If baby crying upset, check tummy if lump-hard - go to ED ASAP. Pt asked any SE of anesthetics.? Every medication has SE, but benefit outweighs risk. 12. Mother 4 weeks baby comes to your GP practice, says baby vomiting everything after feeding. Put on weight since was born. She wants to change to bottle feeding. TASK take further Hx, PE, discuss mx with mother (same as Adel OCT 2005) 12. Hx -Baby vomiting not on further questioning not so much, only a bit on the clothes, she props baby up after feeding . Baby hungry 1 hr after feeding (other candidates got 2-3 hrs) then settles. Vomit only milk – no blood or green stuff. Child happy, development OK, put on weight. Did not feel any lump. PE – normal, no lump in tummy. Still send you for USS to exclude pyloric stenosis if result OK baby has reflux. I explained gastro-esoph. reflux/draw a picture/, very common, gets better with time. Can last up to 9 months. Pt asked Am I doing sth wrong?Continue breastfeeding as breast milk better for baby and not the cause of this problem. You can thicken feeds with Carobel/Gaviscon, keep baby prone 30-60min, elevate the bed 20degrees, and give smaller, more frequent

feeds. Pt asked - complications of Reflux? – Bell rang GORD – from Pt‘s Education 13.40 yo woman (2 episodes of headaches with nausea, photophobia, had CT scan done excluded brain tu), comes to our GP practice for advice. TASK- explain migraine, discuss further mx (same as Syd AUG 2004) 13. My answer: Good news, the stress may be gone,as you have no cancer, what you‘ve got is migraine. Explained re:vessels closing and opening. Different causes, usually multiple factors, Chinese food, red wine etc., so write a diary. Pt was teacher a lot of stress in life. Management – Aspirin(asked if no pain I tummy)/ Metoclopramide if not better Ergotamine (asked her no probs with heart or BP) Prophylaxis not required as yet. Migraine from Murtagh 14. Young man comes to ED 2nd episode of severe pain in the back, pain radiating to groin, went away now. 1st episode 2 months ago. TASK take further hx, ask Ix, discuss Dx with pt (same Syd MARCH 2006!!) 14. Pain occurred suddenly, very severe, pt moving around to make it better No change in urine color. Ix asked for dipstick, KUB and helical CT, Dr Gya showed CT with stone. Explain the pt - sediment in urine, stone builds up around pain,pain happens when stone moving. Dr Gya- what‘s mx. Stone is 5mm. Answered borderline, maybe pt goes home and wees thru mesh, or lithotripsy. I‘ll take blood tests and ask consultant. Can he go home? Consultant will decide. (better answer was ―not sure as he has not ed the stone last 2 months‖) Where do you refer? To surgeon. Renal colic from P. Devitt, Senanyake- Common Cases, Pt‘s Education 15.Shoulder examination GP setting. Basketball player had anterior dislocation 6 months ago, comes for check up. TASK- examine shoulder give running commentary, answer questions. (same Syd MARCH 2004) 15. Examined the shoulder as from DVD , everything normal, Apprehension test, impingement test negative Asked for pin to check patch on the deltoid (examiner says normal) Questions from examiner- Which nerve? Axillary Which muscle for abduction? Deltoid Pt asked can I play? Yes but no dunking Examiner asked where you refer? Sport medicine Clinic What do you do for recurrent ? Bell rang. 16. Young women gave birth to child 4 weeks ago, has another baby 30months. Recently unwell, tired (can‘t what else) You‘re GP TASK talk to mother, discuss condition(same as Syd JULY 2004) Pt tired no time for herself, husband ive, appetite, sleep, energy down, interest gone, mood low. No hallucinations, dos not think baby has special power, no hx of depression in past. (some candidates got 10kg weight loss). (I forgot risk assessment!) Dx explained Postnatal depression/we don‘t know why it happens,/maybe hormone changes. Common - happens to 1/7 women after birth Come back with husband, try to find time for yourself, see old friends, relaxation, Pt does not want to see counselor, psychiatrist. Still referred her to PANDA Pt asked – should I breasfeed? Up to you - breast milk good for baby, but takes a lot of your energy so you‘ll have to think and decide. Come back in few days if not better maybe start antidepressant RECALL 29th APRIL 2006 MELBOURNE 1. Post Natal Depression The 28 years old woman came to your GP practice after delay 4 days from appointment. She just gave birth to baby 6 weeks ago has another 10 years old child at home. She complains doesn‘t have enough energy and can‘t organize herself. Take relevant history Explain the condition to the patient Management

2. Iron Deficiency Anemia Woman 48 years old menopause came to your clinic to get result from her blood test (attached, suggested iron deficiency anemia). Ask relevant history Explain the condition to the patient Management 3. Side effect of antidepressant Woman came to ED feels nausea, vomiting, jittery and unwell. She‘s been on fluovoxetine for 3 years and then she came to ED. The doctor gave her Sertraline. Take relevant history Management 4. Septicemia Father of 4 years old child came to your surgery because his child looks very ill, fever and developed rash (as picture in AMCQ book page 118).O/E GA: looks ill, VS: BP 100/60 Temp : 40 degree RR: 98 Explain the condition to the patient Management You know the song guys, explaining condition to the patient, notify health department, prophylaxis for household . 5. Renal stone 28 years old came to your surgery after having severe abdominal pain 2 hours ago. The pain radiates to his right groin and testicle. He had similar pain 2 months back. Explain the condition to the patient ,Order the necessary investigation, Management Examiner in this station was very nice. I explained to the patient about stone in his urine age. I said to examiner I want to order for FBE, U&E, MSU culture and microscopy, abdominal X-ray. Examiner asked: • What else the investigation you need to order? CT KUB • What stones do you think it is? Calcium, Phosphate and Uric acid. • What from the blood you want to look? (Examiner pointed the stones so I understand what he wants) Serum Calcium and Phosphate. Role player asked : • Why do you think I‘ve got this condition? Because there‘s possibility that you didn‘t drink enough water. • What else? (Examiner stopped him and said okay you finished earlier you can wait outside. 6. Management of migraine The woman 38 years old came to your surgery with severe headache and vomiting. She had a history of migraine 2 months ago. The CT brain result doesn‘t suggest any tumor. Take relevant history (no more than 2 minutes) Explain the condition to the patient Management I congratulated the patient and explained to the patient about enlargement of blood vessel on the scalp and tried drawing the picture as well. Then I gave her an advice about lifestyle modification reduce wine, caffeine, smoking, cheese, etc and paracetamol and antiemetic tablet. Examiner asked: • What if she doesn‘t get better? I‘ll refer to neurologist and they might give her sumatriptan or ergotamine. You as a GP can give her she said. 7. Bitemporal hemianopsia The man 48 years old came to your surgery. He complained of having visual disturbances. Two days ago he had accident because he didn‘t see a truck coming from the side of the road. Examine the patient eyes Order necessary investigation I checked for the visual acuity, visual field and funduscopy.That real patient had visual lost on the lateral side. I said to the examiner that he has bitemporal hemianopsia probably due to compression of optic chiasm. (Pituitary adenoma) Examiner asked: • What are the sign you looked on the patient? • What investigation you want to order? FBE, prolactin level, blood sugar, lipid profile, CT brain, 24 hour serum cortisol level, TFT,…. • What else? I wasn‘t sure about this station because examiner kept asking what else? Then the bell rang.

8. dermatitis The 32 years old man came to tour surgery. Presented with hand (the picture attached: swelling with sign of dermatitis and infection between the fingers) Take relevant history Explain the condition to the patient Management From history the patient said it came suddenly, he doesn‘t have any allergy, hay fever or asthma, as well as family history of those conditions. He is a builder and recently he worked with cement. I explained to him that he had an allergy probably due to cement complicated by bacteria. I gave him prednisolone and antibiotic. I talked about referring him to allergic clinic to have a test done and avoidance to the materials that you allergic to. Then report to your employer regarding his condition. There‘s possibility that they‘ll move you to another department Role player asked: • How long you going to put me on antibiotic? I haven‘t answered and bell rang….. 9. Gastrooesophageal reflux. The mother of 1 month old baby came to your surgery because the baby always vomits after feeding. The baby grows and develops well. Mother thinks there‘s something wrong with her milk. Take relevant history Ask examiner examination finding Management I took further history, the baby‘s well so far. Then explaining about GE reflux and drawing a picture. I reassured mother that‘s nothing wrong with the baby and the breast milk. And role player asked are you sure that‘s my baby‘s okay? Bang! I realized I forgot to do PE. I said sorry to examiner then asked GA,VS, ENT, heart and lung, abdominal examination. All normal. Then I said to the patient your baby‘s normal, usually this condition will clear up by itself when solid is introduced abut 6 months old. If the condition doesn‘t get better you can add corn flour to your milk or gaviscon. I‘ll follow her up in 1 week, but if you have any concern come back to see me. 10. Examine the shoulder and nerve injury. The 18 years old student playing in basketball competition. He had shoulder dislocation on the right and nerve injury. He already had an operation fixing it up 6 months ago. He came to your surgery asking you when he can go back playing basketball again. Examine the patient Advise the patient about returning to the competition The examiner was really old and very nice. I started examine the shoulder. Examiner asked: • What nerve could be injured? Axillary nerve. Go on examine the patient. I examined for sensation on deltoid muscle and power (abduction) • What else? The bell rang… I was thinking about radial nerve as well, but not sure. So please check the books. 11. The woman 26 years old came to your surgery complained of stopping her period after two courses of oral contraceptive pill. Ask relevant history Ask examiner examination finding and order necessary investigation Explain to the patient From further history the woman stopped her period suddenly, doesn‘t have tummy pain and vaginal discharge. No past history of STD, Hypertension, DM. Family history (-). I asked examiner for Pregnancy test urine and blood, FBE, TFT, FSH, LH, prolactin level, swab. Examiner said good but they are not available. Huh? Okay, I said to the patient I‘m waiting the result of the test I ran. If there‘s abnormality I‘ll refer you to specialist straight away. If they come back normal we‘ll wait for another 3 months if your period doesn‘t come I‘ll refer you to sp. It could be due to stress or side effect of O. I wasn‘t sure about this case. Check it again in the book. 12. You are HMO in Obstetric and Gynecology department. 41 weeks primigaravida came to ED. She is in labour. O/E cervix dilated 3 cm LOP (in the morning LOT, means tranverse) and meconium stained. ObsGyne registrar and consultatnt are not there. You have to manage her by yourself. Ask relevant history Ask examiner about examination finding Manage the patiet 13. Primigaravida woman 28 years old came in for routine check up. Four weeks before you checked fundal height 26 cm. Now she came to you and her fundal height 30 cm

Take history Ask examiner examination finding and order the necessary investigation (Examiner only will give you what you ask) Manage the patient 14. Weight reduction Woman 43 years old BMI 33. She came to you for advice on weight reduction Advice the patient Answer patient questions regarding medication to lose her weight. 15. Umbilical And Groin Hernia A father of 4 months old baby came to you complaining of a lump in his right side of the abdomen as noticed by the father in the bath comes and go, otherwise the baby is fine.O/E : There‘s umbilical hernia 1cm, both testis are in the scrotum Ask few clarifying questions Manage the condition I explained and drew a picture as usual. Then referring the patient to a surgeon and saying possibility of twisting if it‘s not corrected and should be in two weeks time. The umbilical hernia, it‘ll reduce by itself when the child gets older but if it doesn‘t when the child 5 years old, need to have operation done and don‘t put anything on it. 16. Spirometry 28 years old man with a history of asthma came to you. He has symptom free for 2 years. He hasn‘t been using ventolin in the past 2 years. Do spirometry Explain to the patient the result compare to the expected value I gave up in the middle of this station so definitely I failed this station . I had no idea at all. Felt really bad. Read it in the Talley o‘Connor. Clinical Exam Melbourne Feb 11, 2006 O&G 1- 25 yo female patient with more than ten years‘ history of DM type 1. Task: Pre pregnancy counselling Pt asked: - How would DM affect my pregnancy? - Should I keep taking Insulin? - What are the effects on my baby? - Would I need a CS? Examiner asked: - What kinds of blood test are you going to order? 2- Young university female student wants to start taking O. Task: O Counseling Pt asked: - What type of O is suitable for me? - Any side effects associated with O? 3- A primi 38 wks had a convulsion while sitting in the waiting room with her mum to see you, a remote GP. Task: Manage this pt and answer the questions raised by her mum Her mum asked: - What‘s wrong with my daughter? - How are you going to deal with my daughter? - Any harmful effects on my daughter or her baby? Paediatrics: 4- Young mother comes to see you, a GP, enquiring about circumcision. Task: Counselling Pt asked: - What are the benefits of circumcision? - What are the contra-indications? - What are the complications?

5- A 9 yo child is just diagnosed Diabetic type 1. His father wants to know more about it. Task: Counseling. Father asked: - What‘s the management to my son? - Does my son need insulin for the rest of his life? - Can my son go to camp with school? - How about him overstaying with his mates on weekends? 6- You, a GP working at remote area, are seeing a young boy who presented with fever and rash (Picture is presented). Task: Management and counselling his father Examiner asked: - What is your provisional diagnosis.? (Septicaemic Meningitis) - What‘s your management? - If allergic to penicillin which AB would you give? - If it‘s hard to establish iv access, what are you going to do? Psychiatry: 7- Young female comes to see you just because her parents asked her to do so. She denies any abnormality. Task: Hx, Dx, and Mx Examiner asked: - What‘s your dx? Why? (Anorexia Nervosa) - Would you it this patient? Why? 8- 1st episode acute Psychosis: nurse noticed wrist injury, lives with 3 friends Note: no more hx required - Patient wanted to go home to sleep - Patient has auditory hallucination - No suicidal ideations - Very agitated and swears all the time - No insight Task: Focused hx and mx. Patient asked: - Can you give me something to get some sleep? Examiner asked: - What do you think he has? - Would you it him? - What if he refuses to be itted? - What will you give him? - What are the side effects of Haloperidol? Medicine 9- A 60 yo lady has been told by a previous GP that she had a murmur, she wants to travel oversees. Task: Examine her CVS and report to the examiner your findings. Dx: Aortic Stenosis 10- A 67 yo lady wakes up in the morning with weak Rt arm and slurred speech that lasted for one hour (TIA case) Task: Examine the relevant system/s 11- An asthmatic patient was at a party last night and tried walnut butter for the first time, He gets swollen lips and difficulty breathing, and then gets better after taking Ventolin. Task: Counseling Patient asked: - Am I going to get these reactions every time I have walnut butter? - What else should I not try? - Is there a way to cure or prevent these reactions? - Can I go camping? 12- 45 yo male patient, referred by his GP to see you, feels tired, cardiac problems, abnormal of live function test, bradycardia, non alcoholic, no hx of dark urine, Task Ix, Dx, Mx, Dx: Haemochromatosis

Surgery 13- 50 yo male patient with a swelling in his scalp Task: examine, Dx & advice on management. Dx: Lipoma 14- 65 lady had pain for 3 hrs in the morning and bloody diarrhoea, nausea, Hx of AF and appendicectomy Task Hx, DD Mesenteric artery occlusion / ischaemic colitis 15- An obese male presents to you with pain in the left lower chest, Task: Hx, DD Pneumothorax / pleurisy / PE / Pneumonia / MI 16- A middle aged patient fell of his motor bike and fractured his clavicle, Task: Management. Patient asked: - Can I ride my motor bike? - Can I drive my car then? - How can I have a shower? Examiner Asked: - What are you going to do for him? - How to do the sling? - For how long should the patient use the sling? Melbourne 11/02/2006 Medicine 1./ Heart examination. 2/ A woman came to you because she had slurred speed and upper limb weakness 2 hours ago. Now, she is normal. Your tasks are: • To do physical examination? • To discuss the DDx and tests that should be done to confirm the diagnosis with the examiner? You do the upper limb examination and talk to the patient for 1 second to prove she does not have any speaking problem. The diagnosis is TIA and to differentiate with other causes, e.g. heart block, hypoglycaemia. 3/ A 35 yo man came to you because he has developed the chest pain that only radiated to his left arm and his neck. The painful area is in the border between the left chest and abdomen. Your tasks are. • To take the history? • To take the physical examination and order the tests to have DDx? The symptom is only the pain radiating to the left arm. The rest is normal. The physical sign has not been detected any abnormal sign. So, DDx are a) Angina or MI → ECG, troponin enzyme. b) PE or pneumothorax→ chest X-ray and CT scan. CTscan is the best since it can prove PE or pneumothorax quickly and accurately. c) Herpes zoster 4/ A man comes to you since right after eating the nut, he developed throat irritation that was subsided after inhaling antihistamine (I cannot the name of medication). Your tasks are: • To discuss with him about his problem, as well as another serious problem? • MX? This is a case of nut allergy. You must refer him to the immunologist. You also warn him about anaphylactic shock with serious symptoms and signs, talk to him about epi-pen, the information of nut allergy in the wallet or bracelet to let the ambulance officer knows his nut problem. Q: Will I allergy with other food? A: It‘s very good question but the specialist will discuss with you when you meet him.

5/ A man has migrated to a new area. He comes to you with liver enlargement. The US show fatty liver. He does not drink, and smoking. Your task are • To take the history? • To ask the physical examination and test results from the examiner? • DDx? This case is haemachromatosis→ because he also has a heart problem and serum iron increased?????- I was not very good for this case. Surgery 1/A woman comes to the hospital because of a serious abdominal pain. Her faeces is brown colour. Your tasks are: • To take the history? • To ask the physical examination, the test results from the examiner? • Mx? The woman has 9/10 abdominal pain. Her abdomen is totally distended and rigid. She did not take aspirin or NSAIDs or other medication that can cause gastric bleeding. She only has taken the medication for her heart. Her pulse is irregular- irregular →gut necrosis. It will be confirmed by CTscan and barium enema without preparation. Mx: 1. Call surgeon to it to theatre (critical error if you do not know). 2. Morphine, fluid and other resuscitation. 3. Blood tests and others for preparing surgery. 2/ A man has had a lump in his head for 2 years. Your tasks are: • To do physical examination? • To give DDx? It is a case of lipoma. You must explain to the patient that the lump is not likely to be a cancer lesion because he has had for 2 years and you cannot find out any lymph nodes in his neck and head. Removing it and studying under microscope will give an accurate answer. Refer to specialist. 3/ Clavicular broken bone with X-ray film that is very clear cut. Your tasks are: • To explain the problem? • To discuss the complication and Management? • To perform the sling? Paediatrics 1/ A 2 yo boy comes to you because of hypotension, cold temperature, and rash that is illustrated in the picture. He has no neck stiffness. Your tasks are: • To explain to his father what has happened to him? • Mx? This is a case of septicaemia. Explain to his parent about the disease. Then, you will call ambulance immediately. During waiting for the ambulance, you draw out his blood into the tube, and then inject ceftriaxone 50mg/ kg (explain why you do not use penicillin because of the anaphylaxis in some people.) Q: During waiting the ambulance, if the boy‘s vein collapses, what will you do? A: Fluid transfusion into the tibia, and IM antibiotic are the basic procedures in the country-side clinic. Q: What else will you do? A: I will inform to the authorities and prescribe rifampicin to his relative. Q: What is the S/E of rifampicin? 2/ A new case with 2 examiners. A boy who develops DM has been discharged. Your tasks to discuss with his father are: • What is the kind of DM in his son? • Mx • Complications? How to avoid? Patient education is a good source. You must say his son‘s life will be normal if the son follows the advice from the specialist, the dietician and physiotherapist (very important to keep BMI in the normal range). He can go out to camp, to play sport with his teachers‘ notice. Talk briefly about the complication, e.g. hyper/hypoglycaemia. Discuss short and long acting insulin briefly and leave the answer for DM specialist since he will prescribe short or long acting insulin. Do not scare when you see 2 examiners. Like this case, it was easy to talk.

3/ A mother comes to you because she want her male baby will have circumcision? Candidate should ask what she knows about the circumcision? The mother will say she has heard from her friend. Candidate must say circumcision is not common procedure in Australia any more. Obstetrics & Gynaecology 1/ The DM young woman comes to you because she wants to conceive. She has used insulin for a long time and her DM has been controlled very well. She has just married. Your tasks are: • To take history? • Counselling? • To discuss what she wants to know? During the conversation, she is normal, no problem occurs. Then, she asks Q: Can I conceive? Yes Q: What should I do? A:I will refer you to DM clinic since you need a DM specialist, a dietician as well as a physiotherapist to prepare you for your pregnancy? Q: What will happen to me during the pregnancy if DM is not controlled well? Q: What will happen to my baby if DM is not controlled well? 2/ A young woman comes to you because of contraceptive pill. Your tasks are: • To discuss what she wants to know? • If she wants, you can outline other contraceptive methods? You must discuss about the S/E, complication of the pill. Do not forget to make sure she is not pregnant. Q: Can you choose the pills that are suitable for me? A: I cannot. I will introduce the advantages and disadvantages of every kind of contraception pills. Then you select the pill that is the most suitable for you. Q: Which kind of pills you will prescribe for me? A: I will prescribe the lowest dose of pill for you, such as microgynon 20. 3/ A 35th week pregnant woman got the convulsion in the outpatient clinic. Now she is conscious. Your tasks are: • To take the history and to explain what happened to her mother? • To take some signs and symptoms from the examiner? • To manage the situation? The mother said her daughter had had antenatal care very carefully without any abnormality, esp. blood pressure or proteinuria. She did not contract with epilepsy or hypoglycaemia. The examiner says every thing was not available yet. You must know the rule in this case that is the pregnant woman must be treated as a case of eclampsia until you can prove other causes, esp. epilepsy or hypoglycaemia (see that rule in the eclampsia topic from the royal women hospital website). Psychiatry 1/ A teenager girl comes to you because of tiredness. Physical examination is normal. Your tasks are • To take the history? • To report the psychiatric problems to the examiner? • To diagnose and manage the case? This is a case of anorexia nervosa in the young girl who eats 3 meals/day with only vegetable. She thinks her thighs are quite big. She has had amenorrhoea. Her BMI is 15 and the signs of dehydration. Otherwise is normal. Report to examiner about her behaviour during the conversation, e.g. not eye , she tried to cover her body. The important sign from the examiner is dehydration. So, Dx is anorexia nervosa and you must it her immediately to hospital because of dehydration. 2/ A man who develops psychotic problems with hallucination, delusion and illusion. He was itted to hospital because of the laceration in his left wrist. Now, he wants to go home and sleeps with sleeping medication. Your tasks are • To Talk to the patient to find out the problems? • Mx and to discuss with the examiner about his condition? Introduction, then you should talk to the patient to satisfy 3 things: • You are here to help him. • You do everything to calm him down. • You persuade him hardly to stay in the hospital. The performer disagrees and always wants to go home with sleeping pills. So, talk to the examiner about his risk of suicide (he cut his

wrist before he was itted to the hospital), then you call CAT team to it him involuntary to the hospital. Q: During waiting for CAT team, if the patient becomes violent, what will you do? A: I will stay with him during waiting CAT team. If he becomes violent, I will run away because I must be safe first. When I have more people (Ideally, 6 people (in Murtag)), I will come back to inject haloperidol to him. Q: How to limit the S/E of haloperidol? A: I have to use the minimum dose. 11-Feb 2006 Clinical Examination Melbourne Paediatrics 1. 38/40 pregnant woman comes to see you as a GP and asks about neonatal circumcision. Task: Tell your patient about the medical opinion and answer her questions. 1st pregnancy, no religious reason. Just husband had it done when he was a child. Q ‗s from the role player: What are the disadvantage and advantage of circumcision? What are the contraindications? When is the best time to have it done? Q‘s from the examiner: If the patient insists on having it done for her child, what are you going to do? Answer: it is patient‘s choice. I‘ll refer……. Circumcision 2. You are a HMO in the hospital. A 9 yrs old boy is just diagnosed of type I DM. He is still in the hospital. Task: talk to the father and answer his concerns. Have you heard about DM? – yes. My uncle is a diabetic. I know what it is. I just want to know how long he needs insulin. Can my child have normal life? Can he go for camping? How about playing sport in school? Diabetes Type I Juvenile – counselling 3. GP setting, 50 km away from city. A father brought his 2 yrs old child to see you. Temp 40‘c. rash (picture from AMC‘s MCQ book page 118). Over the lase a few hours, the child was not interested in eating, lethargy and drowsy. No neck stiffness. No history taking and physical examination. Task: manage the case. Q‘s from examiner: If the child is allergy to penicillin, what will you do? The child is dehydrated, how are you going to give fluid? – putting IV cannula. What else? –intraosseous infusion. Lethargic febrile 2 yr old O& G 1. GP setting. You were interviewing a mother of 38/40 pregnant lady who just had a fit in the waiting room. Now she is not fitting, but a bit drowsy. Task: talk to the mother, take the focus history and ask examiner the finding, manage the situation. History and examination findings: 1st episode of fit. BP 180/110, urine dipstick – protein +++. Q‘s from examiner: If you don‘t have Mg SO4, what are you going to give her? Q‘s from the mother: Can she have any fit again? Any dangers to the baby? Will she have high blood pressure after delivery?

Are you going to the hospital with her? Eclampsia 2. GP setting. A 24 yrs old lady, married, asked for different types of O. Task: history taking, ask examiner the physical finding and give her advice. In this case, no CI of O. She can have combined O. Tell her 7 day‘s rule, not protecting her from STD Contraception request 3. GP setting. A 26 yrs old has 15 yrs history of well controlled IDDM. She wanted to get pregnant. Task: give her advice and answer her questions. Q‘s from the role player: I want to know how DM affects my pregnant and how pregnant affects my DM. If I become pregnant, are you going to look after me? Q‘s from the examiner: When are you going to refer her to endocrinologist, before pregnant or after? What do you need to check before she becomes pregnant? Pre-pregnancy counselling – diabetic Psychiatry 1. GP setting. A mother of 16 yrs old girl concerned about her daughter‘s weight. Last week the weight was 45kg but now is 40 kg. Now you are seeing the girl. Task: Take a history and ask examiner the finding Tell examiner about your diagnoses and the management. Finding —BMI 14, fine hair, dehydration, postural BP drop. No Ix result. Anorexia nervosa 2. GP setting, a young man had a right wrist injury and lived with other young people. You did a limited mental examination as f ollowing. He had problems with his previous employer, poor sleep, lack of insight, denied any suicidal ideation. He was having hallucination and paranoid. (long stem). No more history taking and examination. Task: manage the case. Q‘s from the examiner: What do you think about the diagnosis? Patient refuses to go to hospital, what are you going to do? Under which law you can it the patient? While you are waiting for ambulance, what medication are you going to give? – Diazepam. Which route? -im. For other symptoms, which medication are you going to give? – Haloperidol. This is a young man, if you give haloperidol, what do you expect? – Extrapyramidal side effect. What medication to revert it? What are you going to do if the CAT team comes late? Psychotic episode with violence – crisis management Medicine and Surgery 1. GP setting. A middle age lady wants to go for overseas and comes for check up. She has heart murmur for several years, which was told by her previous GP. She was asymptomatic. Task : do the physical examination and tell the examiner about you diagnosis. Pansystolic murmur at the mitral valve area. Q‘s from examiner: What is the cause of MR? Cardiac murmur 2. One hour ago a 46 yrs old lady had a difficulty in speaking and weakness in right arm. When she was in the waiting room the

symptoms resolved. Patient ‗s mother had a stroke. Task: examine the relevant systems. Dysphasia & upper limb weakness 3. GP setting. A patient has a lump for several years. Slightly increase in size and asymptomatic. Task: take a focus history and do an examination. Q‘s from examiner: What else do you need to examine? – lymph nodes. Can it become cancer? What is the complication of the lump? – infection How do you remove it? Subcutaneous lump 4. GP setting. A patient comes from other city. A letter from his previous GP said that his LFT‘s was abnormal. He was not an alcohol drinker, had no history of infectious liver disease. He had permanent pacemaker insertion a few years ago for the bradycardia. LFT‘s was GGT , ALT,AST all increased. You have ordered some tests. Task: ask the examiner about the Ix result and talk to the patient. Q‘s from the examiner: How often is the venesection done? What diet? How about the siblings and children of the patient? Abnormal liver function tests 5. A young man had a history of eczema and asthma. Last night in the party after eating a walnut he started having wheezing, SOB and urticaria. He had peanut allergy at 7, 9 and 17 years old. Your diagnosis was nut allergy. Task: Explain to him about the diagnosis and how to prevent it happening again, what he can do next time. What test do you confirm the diagnosis. Q‘s from role player: If it happens again, call an ambulance first or give Epipen first? Nut induced anaphylaxis 6. HMO in ED. A 35 yr old man complains of left chest pain. Task: history taking and give your DDx. Pleuritic chest pain 7. Acute abdomen pain. Task: take a focus history. (pt on Digoxin, some bright red blood in the stool) Ask examiner the finding ( irregular pulses, generalised tenderness of abdomen, slight rebound, occasional bowel sounds.) Tell what you are going to do Acute abdomen 8. A 25 yr old man fell on outstretched hand. You did the examination. There was tenderness over the right clavicle. Task: read X ray Tell what you are going to do and manage the condition with the materials provided. All materials included a sling and the ones for figure 8. Q ‗s from the role player: How long do I have it on? – 3 weeks Do I have a lump over the collar bone? Can I go to work? Fractured clavicle

12/11/2005 Melbourne AMC Clinical exam Recalled by Ling Medicine and Surgery 1. A 40 years old lady, an important player in orchestra, C/O pain, sausage swelling and stiffness in both hands recently and was tested for ANA, ESR and RF and the results showed that she has early rheumatoid arthritis. Today she comes to you (a GP) for the result and tell her your Mx. Patient was shocked and knows that it‘s a very severe situation because her mother is 62 y/o and has RA for many years ( I explain early stage, modern medications and more therapy will keep the function well, it varies individually, various ranges. I will refer you to the rheumatologist‘ and totally forgot the magic words: early intervention and multi-disciplinary team management. Questions: Can I continue my career (yes) What medications you would give me ( first Brofen and take rest) She said, I really can‘t take any rest, any other medication can relieve the pain quicker steroids-she‘s shocked, ‗Dr, no steroids. My mom took it and I know there are a lot of SE. (Yes, but in short term. It should be OK, but anyway I will refer you to the specialist.) Give leaflet and suggested the Internet. This case looks easy but I was not sure the details of the Disease- modifying agents. (I failed this station.) 2. A 28 y/o male fell his Left wrist on the floor yesterday and still sore today. He came to ED and you‘re a ED HMO. Task: focused P/E, order your Inx and Mx On P/E, tenderness in the sniffbox-------I‘ll do a X-way Examiner asked what‘s your possible Dx? (scaphoid #) Here is the X-way ( it‘s a scaphoid #). This is a picture from AMC which is too clear to be missed. Talk to the patient. (I explained and refer him to the Orthopaedics surgeon) His Qus:  What are they going to do for me? (They will put a plaster for you)  How long do I need to have it ( about 6-8 weeks. But they will assess you regularly. First they may see you in the next 24 hours to check the plaster, the blood circulation and then they may check in 2 weeks when the swelling fades away and sometimes the bone may die because of the poor blood circulation.)  You mean my hand will return to normal after 8 weeks. (It depends. The surgeon will look after you and I think you will be fine.) (Then I asked ‗Do you have any other concerns) No. Then examiner remaindered me to wash my hands. 3. Poorly-controlled DM for several years comes to you for check up. Do relevant P/E on his lower limbs. You may be interrupted by the examiner because of time saving. Examiner asked:  what do you want to check first (peripheral vascular disease), Go ahead. (I did inspection and palpation for pulses.)  What‘s other change? （peripheral neuropathy）,Go ahead ( I started with pain sensation check for stocking distribution which disappeared below the mid-tibia, then vibration loss below knee and also proprioception loss on both big toe ts on a role player. I hesitated and asked whether I need to do the power and tone. Do as you want. (So when I was doing the reflexes the bell rang). 4. A 60 y/o male, who is your infrequent patient, came to you (GP) today wanted to enquiry about his wife because he found she is getting more forgetful recently. His wife, a 60 y/o lady, your frequent patient, was seen by you 3 days ago, complaining that her husband found her more forgetful than before. You took Hx and P/E her and found she was normal. Task explore the husband regarding the marital issue Response to the husband‘s concern From the beginning, he complained his wife and asked ‗what did you find wrong with my wife. She didn‘t tell me anything about it‘ (I am sorry I can‘t tell you any thing about your wife‘s condition without her written permission. It‘s patient‘s confidentiality.) o ( he‘s not happy) Why not? I am her husband. It‘s me to look after her all the time? (I can understand. But I can‘t. What do you find wrong with your wife?) o She ‗s terribly forgetful, a lot of trouble. I am afraid she may make fire at home when she cooks. I think she needs to stay in hostel. Doctor, I should do something earlier to put her on the waiting list.( I understand. But it must be assessed by the Aged Care Assessment team. I can‘t do the assessment.) o I know. That‘s why I came to you. I need your referral. (Oh, terrible case.) o (I know. But about this issue should ask your wife to make the decision. She is conscious now. She has the right to make her own decision) (This time he didn‘t come back straightaway. And I can ask Qu: How about your relation with your wife?) o Quite good. We‘ve been married for 30 years. Sometimes, ups and downs, but I think every couple are the same. (Do you think it is as fresh as before, like the early time?) o ( Laughing) No, Dr, we‘ve been married for 30 years already. (Do you have any children? How do they think about your wife?) o They agree with me. (I gave up the marital issue. Can you come to see me next time with your wife together?) o I don‘t think she would come. Last time I force her to come. (Anyway, I can‘t give you any information about your wife. I have to repeat again and again. Finally the bell rang.)

5. A 60 y/o male C/O episodes of palpitation and dizziness recently. His BP 155/96. I can‘t the other details. (? ED or GP setting) Task: focused Hx P/E and Investigation from examiner Read an ECG at 7th minute This is a quite confusing case. I think I asked too much Hx. Hx, Palpitations sometime happen at night, not related to exertion, no chest pain (?). no tinnitus and spinning feeling. No target organ damage symptoms (visual problem, SOB, pain in calf or body weakness). No Hx of heart attack or stroke or thyroid disease. No medications. Smoking by 20/day and alcohol by 4-5 glasses of wine since teenage. drinking a lot of caffeine. P/E: Bp155/96, p150, regularly, heart and lungs are all normal. Examiner asked: What‘s the likely cause (Tachycardia) Which one (maybe sinus tachycardia, not sure). How is the ECG? (ECG was given. It‘s an atrial flutter.) Which degree of the block(4 to 1).( bell rang)． 6. A 51 y/o came to ED with severe right upper abdo pain. Task: focused Hx , DDx Answer patient‘s Qu Again, a typical acute cholecystitis case. 7. A 30 y/o male came to ED, C/O terrible headache since yesterday and getting worse. Task: focused Hx P/E from Examiner Mx Qu: What‘s the reasons for my headache？（DDx）( Then talk to the examiner) P/E (T: 38.5℃, neck stiffness, no rashes)  What are you going to do for the patient (consult my Reg or senior Dr. it the patient, give AB.)  What investigation( FBE, Blood culture)  What else? (CT head). Why? (Rule out bleeding). No bleeding, what else? (lumber puncture). What tests are you going to do with the fluid (pressure, bacteria staining, culture and biochemistry). OK, patient has a Qu.  How is about my two kids (9 and 11 years olds) ( I will give all your family rifimpicin for prevention), The bell rang. I hadn‘t finished the whole Mx ( Notification). 8. A young male had bloody diarrhea for 6 months and had colonoscopy done today. Unfortunately, the surgeon just said the changes exist in the whole large bow which suggests ulcerative colonitis without giving a report. The patient brought the picture of his colon change to you (a GP). Task：talk to patient. Explain ( lifetime situation, multidisciplinary Mx, it can be well-controlled) it to hospital at this moment. Qu from role player:  How about my diet ( low fibre diet)  Any operation now ( not this moment, sometimes may need surgeon)  Can it be other situations according to the picture? (the picture suggests inflammation, can be caused by infective inflammation, like germ infection or Crohn‘s disease. But the distribution of the inflammation can tell the difference).  What‘s the complications (bleeding, perforation and higher risk of bowel Ca. Other organs can be affected, such as eye problems, mouth ulcer, skin changes and liver problems. O+G 9. A 28 years old lady come to you for advice of next pregnancy regarding that se had an abortion 2 years ago. Task: relevant Hx adverse effect to the next pregnancy and evaluation。  I asked and give possible effect on the future pregnancy:  how many weeks of pregnancy（14/52）, which hospital (RWH)，  any fever after that(no),when get her first period after the procedure( a month)；  any check up by any obstetrician (Yes), How about the periods since then ( as normal as before, about 4 weeks a cycle).  Blood group (―O‖ negative), Any anti-D after the procedure (not sure),  same partner (yes),  Any diseases: DM, HTN, Blood clotting problems, smoking, alcohol drugs  Qu from role player: Will it affect my fertility? 10. A 50 y/o lady C/O hot flush and irregular periods for 11 months. No weight loss or discharge. Two children (20 and 22 y/o). All P/E are normal. Task: Mx (no further Hx and P/E) I was on the wrong track and gave her O, so I fail this station easily and completely.

11. (GP setting) A 25 y/o Ph D student was 8 weeks of pregnancy. She complained right lower intermittent abdo pain for a week. Task: focused Hx, P/E and Inx from examiner, Mx  Hx: A dull pain at 5-6/10, no fever, no discharge, no burning sensation or frequency ing urine, no diarrhea, no pregnancy reaction symptoms.1st pregnancy, planned, no PHx of PID or STD. Pap smear is normal. no smoking or alcohol.  P/E: Vital signs are normal. Only superficial tenderness in the right lower abdo. US: normal pregnant sac in uterus, which is compatible with 8 weeks of gestation. A cyst of 5 cm was found in the right ovary, not torsion, not ruptured. Speculum P/E: Os is closed and PV P/E showed tenderness in the right adnex.  Mx: I will refer you to the obstetrician. Patient asked:- They will remove the cyst now? (I don‘t think so). Paediatrics 12. Immunization advice for a mother with a 6 weeks old child (her first child). The child is all normal with P/E and growing well. Role player‘ Qu:  First she asked me to talk through the schedule of vaccines from 6 weeks to pre-school  Is there any reaction after the vaccines ? (Yes, some children may have mild fever or unwell). －How to prevent it? (Paracetomal).  What is the complication of Pertusis vaccine (encephalopathy). Is there any condition you should not give vaccine (Children with encephalopathy caused by pertusis must not be given any pertusis vaccine)  Some parents suggested to use diluted protein (a natural way of immunization). Is that the same as the immunization schedule (I haven‘t heard this before and not sure its effect but I will check this for you.  Then she told me she has no Qu for me. I said that ‗I am not sure about the diluted vaccine. Is it recommended?‘ The examiner told me ‗No, but you said you will check the book for her. So that‘s fine 13. A young mother bought her 4 years old daughter to your suburban clinic, C/O that her daughter has some rashes in her genital area in the last several weeks and it‘s getting worse. She devoiced for a while and looking after her daughter. At weekend her daughter stays with her ex-husband but she refused to go there yesterday. She suspected her daughter was sexually abused by her ex-husband. She has a new boyfriend moved in 5 months ago. Task: Give the mother your Mx plan. (It looks easy. I need to call Gatehouse now. The question here is how to explain this 2-3 sentence in 8 minutes. I kept repeating that they will take Hx, do P/E and do Investigations. Not sure what else they want.) 14. A father came to you, worrying about his 5 months old son. He found one lump in his right groin area, which comes out when he‘s crying and goes back when he‘s sleeping and another lump in his tummy button Talk to the father about the Mx (totally repeated case) Psychiatry 15. A 60 y/o lady with right lower abdo pain for 6 weeks and lost 5 Kg in the last 6 weeks. She went to see the doctor (P/E was normal) and was investigated, including, blood tests and colonoscopy, which are normal. Today she came for the results. ( GP setting) Task: Take HX for the psychiatry cause Give the patient your DDx Explain the nature of her condition and Mx. Hx: The RL abdo pain for 18 months and getting worse in the last 6 weeks. NO particular event 6 weeks ago. Poor sleep and always wakes up at 3 Am and can‘t go back to sleep. Appetite is gOOD sAMARITIAN - Guest Posted: Thu Sep 28, 2006 4:43 pm Post subject: --------------------gorani Guest Posted: Fri Sep 29, 2006 12:53 pm Post subject: -------------------------------------------------------------------------------all of the following are the signs of Ischaemia of the lower limb EXCEPT: A .Ulcer at Halluces B .Intermittent claudication c .Rest pain d. Ulcer above medial malleolus *** e .Hair loss on lower limb 2. A painful lump in the groin of sudden onset in an otherwise healthy young man is MOST LIKELY to be? a. Direct Inguinal hernia b .Indirect I