MELBOURNE, 9 FEBRUARY 2008 ‘This recall has been written by two candidates. We both have passed 15 stations, but failed in different ones. One of the candidates failed the station with acute back and leg pain (sciatica), the other one failed postpartum haemorrhage. So, in order not to mislead you, only the candidate who has passed a particular station has written it. Other stations we have written together so that you can obtain as full feedback about them as possible. PSYCHIATRY 35 year old man is complaining of having funny movements of his lips and tongue for a couple of months which are getting worse and really bothering him, He has been on Haloperidol for more than ten years. ‘TASK: = take relevant history + Mx immediate and long term (identify the aspects which you should deal with) ‘The patient takes haloperidol for many years without major problems until the facial movements started. He also claims that people are looking and following him on the streets and plotting something against him. When asked if he thinks that people are looking because of his, lip movements, he said no, they are just following and plotting. He is fine at home where he lives alone (taking care of his own medication himself) and tends to stay there to avoid social interaction, He denies and suicidal thoughts and any chronic conditions, psychiatric illnesses that run in family or allergies He admitted of halving the dose of Haloperidol by himself, because of these movements. He also told me that he hasn't been to a psychiatrist since he has been diagnosed and he has been under my care since. MANAGEMENT: first explained to him that the S/E. that he is experiencing are due to Haloperidol and Y'll try to help him to deal with them, I told him that I’m also concerned about him halving the dose of medication and those signs of illness that he started to experience afterwards (people following ...). Most likely, it is a resuit of the dose reduction. I will refer him to a psychiatrist ASAP (getting on the phone right now), and his medication will be changed gradually. We call this {ross over period where the dose of one medication is reduced whilst increasing the dose of the other. While we change the medication he may experience the worsening of his condition (breakthrough psychosis). I also added that because he lives alone the psychiatrist might consider admitting him to hospital to monitor his condition duri medication to another. We finished earlier this station. AMC feedback: Paranoid schizophrenia (relapse). 35 year old woman works in a managerial position with increased work load. She is very busy at work. Doesn’t sleep well, anxious, has pains and aches everywhere (abdominal, headache, chest pains). She drinks 5 cups of coffee a day and smokes 15 cigarettes a day. ‘There was a long list of investigations that had been done, including ECG, TFTs, colonoscopy?. FBE, etc., which were all normal and she was diagnosed with Generalised Anxiety Disorder,TASK: + Talk to patient (you may ask some relevant questions) + Explain = Manage accordingly C: Good afternoon Mrs. X, I have some good news for you. P: What do you mean good news; I cannot sleep well and do not feel well. C: we will address this issue but first I will tell you that ail the investigations that we ordered for you have come back normal. But I do have some more questions for you. I understand that you are very busy at work and its quite stressful, could you tell me please your major concerns? P: I cannot fall asleep for three or four hours. So what could be wrong with me? C: The condition that you have, we call a generalised anxiety disorder in which emotional problems can actually cause physical symptoms to appear because our brain regulates all our bodily systems and organs. P+ is it so? C: Yes itis. Tell me please about your situation at home? P: Athome everything is OK, my husband is very supportive. But I regret that we don’t have any children as we are both very busy. C: Lsee. First of all we have to address your coffee intake and cigarette smoking. It would be good for you to drink less coffee, I suggest that you choose an alternative such as juice, green tea or water. P: Iwill try. C: have you ever considered quitting smoking? : yes Ihave but my life is so stressful and my smoking helps me to get through the day. C: ona scale of 1 to 10, where would you put your desire to quit smoking? P: around 5. C: Fair enough, We'll follow it up on our next appointment. There is another issue I'd like to it would be great if you could plan your work and rest so that you delegate part ities to other people to reduce your stress levels. P: Doctor, one of my friends who is a pilot, is taking some tablets that help him go to sleep. Could you prescribe them for me as well? He gave me couple of thei to try I have found that they are really good. C: Could you tell me the name of these tablets? P: ‘Temazepam.C: you know we are a bit reluctant to prescribe these tablets because they are drugs of addiction, but in some cases we can prescribe a short course of it when it is really required. But in your case relaxation techniques, yoga or mediation may really help you without the need of drugs. P: But you said that I can have a short course of these tablets so can I have them? C: As I said it is not out of the question but for now I would really like you to start on the relaxation techniques and lifestyle changes. I will also refer you to a psychologist. P: what will the psychologist do? C: CBT to help you to take things easier and understand the causes of the problem and the way to deal with them. P: OK I'm happy with that, Finished early. AMC feedback: Generalised anxiety disorder. PAEDIATRICS AA five year old boy — Peter Day, is brought to see you in a general practice setting because he has been soiling his pants for the past couple of months. Now it happens every day and the parents are really concerned and not happy with the child. TASK: + Focused history from the parent. + Ask examiner for the appropriate findings on the examination that would be relevant to your diagnosis + Explain your diagnosis and advise the management. C: could you tell me what seems to be the problem? P: You know Peter is soiling his pants everyday, at school and at home as well and I am really not happy with this because he was toilet trained by 3. ©iCouid you teil me please if Peter has been under any stress like being bullied at school or any other emotional problems? P: No Idon’t think so. He has not been bullied but he has started a new school 3 months ago and the children there are teasing him because he is stinky. C: What about his general health? P: He is generaily healthy, no chronic conditions, normal growth and developments and not on any medications or possessing any allergies. ©)What about his appetite, nausea, vorniting? Any weight loss? Fave « B: all normal, no problems. @©any problems with the bowel movements? P: He had an episode of constipation about 3 months ago. ©what is his diet like? P: He doesn’t Tike fruits or vegetables, doesn’t drink much water and juice and likes fast food. ©what is your situation at home? P: We are a very happy and stable family, but I am not happy with Peter now (she actually tied that she punished him for soiling his underwear). is there anybody in your family on a special diet (to exclude Coeliac)? P: Not at all.PE: GA-normal, VS-normal, abdominal-no visible masses but there is a hard palpable mass in the left iliac fossa. For one candidate the examiner provided PR findings and for another candidate it was told that the mother and child were not happy to proceed with it. I provided an explanation (with drawing) for her of the condition from patient education and told her that our management will be as follows. First of all we must pay attention to his diet, the more fibre the better, fruits vegetables, cereals and less junk in general. Also not to forget about the fluids: plenty of water and fruit juices. In terms of medication, we'll start with the three day cycles. First day: Microlax enema, second day: Durolax rectal suppository, third day: Bowel stimulant laxative ( like paraffin oil preparations). It can be repeated and the laxative continued. The purpose of this is to clean his bowel and establish regular bowel motions and to keep it regular. I would also like to say that it is very important for you to understand that it is not the child’s fault so please try to be gentle with him and encourage him to go to the toilet and try his best after every meal. You may like to keep a diary with a star chart to encourage and support him. low long till we see the result? : It needs some time but I expect to see significant changes in 4 weeks time. I will follow it up with you. This problem could persist over the course of a few months (6-12). If all these ‘measures are not successful (which is very rare), we can refer you to an encopresis clinic. AMC feedback: Constipation/Encopresis. 10 year old boy, overweight, complains of pain helow the knee for about three months, he is a very active child, plays football and basketball, noticed that phys activity worsens the pain and also noticed that there is a lump below the knee. TASK: © History * Explanation and management From history: Generally a very healthy boy, fully immunised, normal growth and development, no medication, no allergies, has pain for about three months. Now he avoids sports because pain is aggravated by this. (The other candidate has been told that the patient would be very upset if it was strongly suggested to avoid sports for a while in order to get better and that he is still training and playing...) Dx: Osgood-Schlatter Syndrome Management As it is a self limiting condition, the management is conservative in the acute period — rest and analgesics. In the future, gradual stretch exercises, physiotherapy and graded return to full aglivity. Dad asked if he could play sports — yes but when pain subsides. He asked how long does it last — 6-12 months. Feeling that parent was concerned - mentioned possible X-Ray. In any case at this moment there is no need for any other treatment. He asked if other treatment is needed such as plaster cast or corticosteroids or immobilisation.- NO.I mentioned about weight reduction. ‘We finished early. AMC feedback: Osgood — Schlatter’s disorder.‘You are working in a hospital ED. Emily, an 11 year old girl still at school fell at school injuring her right elbow, which is swollen and painful. X-Rays are provided, you are with Emily’s mother. After examining Emily, there were no signs causing concerns. TASK: «Talk to the parent regarding diagnosis and treatment * Answer the questions On the X-Ray it was a supracondylar fracture which was not really clear on the lateral X-Ray. Examiner first asked me to show the mother where exactly the fracture was on both films. After that I explained to the mother whet had happened. Explained that our arm has 3 bones and showed the fracture just above the elbow. My major concern is the possible damage to the brachial artery in case of displacement. Right now the bones are positioned well and we'll just have to keep them this way. For that we will put a back slab and a collar and cuff or a sling, Please watch her carefully today, especially for any swelling, pallor or really severe pain in the hand or arm, in which case bring Emily back to the ED immediately. Otherwise I will see you tomorrow for a follow up. You can give her some Panadol for pain relief. P: Can she go to school? C: yes, after the pain subsides, Can she write since she is right handed? C: Not from the beginning, but she can still attend schoo! and listen to the teacher. Later on, provided everything goes smoothly, Emily will go to see a physiotherapist. Sho will be taught little exercises and she will be writing soon afterwards. We both finished this station earlier. AMC feedback: Supracondylar fracture humerus. ED setting, A 9 year old git! has been stung by a bee, experienced shortness of breath, swollen lips, tachycardic, BP-60/40. You are about to see a nurse and the mother of the child. TASK: * Give the nurse instructions of your management step by step. * Explain the condition to the mother and answer her questions. Start with ABC. Nurse quickly responded that it is done (as in the stem). Please call a code blue. Then I asked if she is on oxygen and the nurse said she is. Itold her to give her Adrenalin IM-0.01mg/kg in dilution 1: 1000, She said OK and [ asked about the vital signs to which she responded that BP is not available but she is not responding well. I told her to give more Adrenalin through IV if there is IV access but if not then administer the same amount as before IM. N: anything else? C: Could you please establish IV line and give fluids.N: how much fluid’? C: 10-20mL/kg as a bolus. N: Child is 30kgs C: then give 300-500mL. N: Anything else? C: Lwill consider steroids and antihistamine (Hydrocortisone mg/kg and Promethazine- mg/kg). N: ok Dr. The child is improving. Now talk to the mother ~ very upset , especially after telling me that her danghter has been advised to see the allergologist already. C: Ttalked about the very severe allergic reaction and the need for a good plan and management (first aid courses, anaphylactic kit, including Epipen, avoiding places where bees live, avoid bee products, referral to allergologist, medical alert bracelet and inform the school) ‘M: can we go home? C: NO, we have to keep the child under observation for at least 8 hours because of the possible rebound effect. AMC feedback: Anaphylaxis bee sting. OBSTETRICS AND GYNAECOLOGY 28 year old lady presents to you in your general practice. 10 days ago she gave birth to her 2™ baby. The first child is a 4 year old, the baby is fine. She now has vaginal bleeding, changing her pads every 2 hours and she has already changed more pads within the last 24 hours than within her entire normal period. During delivery the episiotomy was done, the scar now is looking fine and healing. TASK: ‘© Take further history © Bxamine the patient * Discuss the diagnosis, investigations and management. From history: = 10 days ago, baby is fine, no problems after delivery, had some bleeding — ‘lochia’ after discharge from hospital but now she bleeds severely with clots, no chronic condition including bleeding disorders, non-smoker, non-drinker, no allergies, no medications and is currently breast feeding. PE: General appearance: not well Vital signs: BP-low, PS-100, temperature-37.8, CVS, RS-normal. Abdominal: involution of the uterus is not satisfactory and the uterus is a bit lax. PY: cervix is open and stream of blood in visible, digital examination-normal. MANAGEMENT: ‘You will need to be admitted to hospital by ambulance. In hospital an ultrasound will be done. I suspect that your problem is related to the retained products of conception and the danger is that they could get infected and bleeding could be quite severe. I also mentioned other causes ofPPH: lacerations of the birth canal, coagulation disorders and uterine atony. If the ultrasound confirms this the gynaecologist will do D&C where the products of conception will be removed, ‘Now I will give oxygen and insert an IV cannula, Examiner asks something else? 1 will commence the patient on antibiotics. Organise social worker if nobody is available to look after ‘The patient asked if she needs blood transfusion in hospital. My answer was no. Finished early. AMC feedback: Secondary postpartum haemorrhage. 68 year old lady, presents to you with Pruritis Vulvae for 12 months. TASK: + History + PE (photo provided on request) + Investigations and management, From History: Patient has terrible itchiness down below which interferes with her daily life. Her nights are OK ~ doesn’t wake her up. Generally a healthy woman — no medications, chronic conditions or allergies, last Pap smear ~3 yeats ago -- normal, usually does regular Pap smears, not sexually active for 35 years, aware of self breast examination and does mammography every year. Period ceased at the age of 50. She was prescribed oestrogen cream that didn’t help her. PE: All normal, picture of the extemal genitalia featuring scratch marks on labia majora, whitish plaques and broken skin. PV-normal, Dx Lichen Planus or Sclerosis. DD: Ca? Management: Iwill take Pap-smear, swabs for infection and refer her to O&G where the colposcopy and yulvoscopy will be performed as well as multiple biopsies of the lesions. If LP is confirmed then I would prescribe her a corticosteroid cream — patient was happy. AMC feedback: Vulval itch.‘Young primigravida - 41 weeks gestation comes to our GP clinic. All antenatal visits are normal, all tests and scans are normal, GIT and GBS done recently - normal. Worried that she is still not in labour. TASK: + Address her concerns = Management From history: Feta. hn + + All normal, BLGr. A(+), all antenatal visits- normal, last ultrasound — 18 weeks ~ normal, no chronic medial conditions, no smoking, no alcohol, no allergies, no medications, PE: Gland NVS - normal ‘Uterus: FH — 40 weeks Cephalic presentation ~- FHR- normal PV- cervix is closed. Alllelse - normal. ‘Management: Explain to the lady that itis quite alright to be a week overdue. Our major aim is to make sure that you are OK and the baby too for which purpose we organise an ultrasound: to see how placenta is situated and measure the estimated fetal weight and amount of amniotic fluid ; CTG: to see how your baby is doing. Depending on those findings, you will either wait a little more or your labour will be induced by using medications or by rupture of the sack with the amniotic fluid. Another option is caesarean but it is the last resort Asked if everything is normal how long to wait, so I said for a couple of more days but you can consider staying at hospital from now because the Jabour is very close. (we finished this station earlier). AMC feedback: Post dates pregnancy. MEDICINE AND SURGERY: 45 year old lady come to your GP clinic complaining of “nervousness”. TASK: + Take history + PE findings from examiner + Investigations and management From history: Husband complains about her irritability and nervousness which she admits lciself, On further questioning she mentions some palpations, diarrhoea (3 loose stools everyday), dislike of hot weather for 3 months, sweating even when its cold. No problem with steroids or drugs in her Ppaatthieg on Hoe wee « palpabesbion , Heenan + weullaitn eypenmre Wreath pret herenet, + femnity, hy + eappatihe | ot 2 ta nerabitain hana 2 OL. 5 Ee Beep,ion, no family history of thyroid family. He was previously healthy, no exposure to radi increased but she has lost some weight. problems, no allergies ot chronic conditions. Appetite i PE: As you see it~ slim agitated woman, sweaty hands, fine tremor. BP: normal, pulse: irregularly irregular: 100, Palpable enlarged thyroid — smooth — no nodules. CVS: widespread systolic-murmur (don't remember exactly), could be heard everywhere. Abdominal and respiratory are normal. Diagnosis: Hyperthyroidism. Management: ists, PNAD FBE, TFTs, ECG, Radioisotope scan of thyroid, consider referral to endocrinologist which will prescribe medication that will decrease the level of thyroid hormones. Explained the condition to the patient, AMC feedback: Nervousness. 28 year old man presents to your GP clinic complaining of joint pain and wide-spread rash. Picture provided: rash on trunk and limbs, maculopapular with generalised erythema, TASK: + History + PE + Inform paticat if any investigations are necessary. From history: Generally healthy young man, no chronic conditions, medications or allergies, recently travelled to QLD (camping where there was a lot of mosquitos).He returned just 1week ago. He is ina stable relationship, not an IV drug user, no smoking, alcohol occasionally, no recent contact with person having similar symptoms. His family is fine. He is a mechanic but pain in joints doesn’t limit his work, other candidate was told that it does interfere and that he needed pain relief and sickness certificate, Note: the patient did not volunteer any information, he only replied when you asked specific questions. PE: General appearance: rash as described, trunk and limbs. HF Rees Hilfe, VS: normal but temperature: 37.8 All major joints and joints of the hand are swollen. On abdominal examination: no hepatosplenomegaly. bywpadimp-ty . Examiner asked about DD. Isaid that main diagnosis was Dengue fever. Also we should consider HIV but from history it is less likely. Possibility of Ross River fever (It was the main Dx for the other candidate) Infectious mononucleosis and malaria.(but they are less likely then Dengue fever).Investigations: FBE, viral serology for all of the above. I finished early. AMC feedback: Joint pains and rash. Post menopausal woman who had a L4 compression fracture presents to you at general practice. She has done bone densitometry; it shows -3 standard deviation bone loss. TASK: » Talk to the patient, explain * Manage accordingly I didn’t have to explain the osteoporosis to the patient because when asked if she knows what it is she answered yes and she herself asked what to do about it. I said that we'll get (o that a bit later and went on to ask her a series of questions. From history: She is 10 years after menopause which was OK but had a few hot flushes and didn’t take HRT, She doesn’t smoke or drink alcohol but drinks 5 cups of coffee a day and doesn’t like milk and dairy products. Her only time spent exercising and being outside in the sun is a little bit of gardening. She doesn’t have any chronic conditions or allergies and is not on any medications Gncluding corticosteroids). Her sister and mum also had osteoporosis. Mx: Talked about the importance of decreasing the coffee intake, advised on exercise and sun exposure and tried to talk her into at least thinking about increasing dairy product intake but patient was really adamant. Then we talked about calcium, vitamin D, Bisphosphonate and Raloxifene. As she was 10 years after menopause, there was no point in giving her HRT. I did not mention about excluding Multiple Myeloma but I think that it was relevant. Other candidate: When I said about the diet rich in Ca and diary products the patient said that she does not know how she will eat it because she does not like it. I offered a help of a dietician, the patient happily agreed. Talso mentioned about SE of bisphosphonates( nausea, oesophagitis) I said that in order to reduce the chance of SE she needs to swallow the pill with plenty of water 20-30 min before breakfast and remain upright for at least 30 min after taking it Also I talked about occupational therapist involvement to assess the her living conditions and to advise on necessary adjustments in her house in order to prevent further falls. ‘The patient and examiner were very friendly, they smiled a Jot. It was my last station and when I entered the room the examiner said: you are our lucky last for today, do not worry about anything already, talk to you patient and after you can finally relax, What a great examiner! :-) AMC feedback: Back pain and osteoporosis. ED setting. A woman in her mid 20’s presents with severe abdominal pain in RUF for a few hours. Nausea? Vorniling? Bowel motions — normal, no dysuria, LMP 4 wecks ago and she is on OCP.TASK: Examine the abdomen © Manage accordingly First of all | asked if she wanted me to give her something for the pain to which she answered yes, Examiner then asked me of what I am thinking of giving her, to which I answered Pethidine and further questioned me to ask patient whether she had this type of pain killer before and how she reacted to it. Patient confirmed that she had morphine a few years back and was completely Knocked out by it. The examiner wanted to know whether I still wanted to give her anything, I said no and asked the patient to bear with me for a few more minutes whilst I proceeded to examine her. Examiner asked how to go about the PE. Afier asking about GA and VS I will only do an abdominal examination because it looks like a surgical emergency. First I looked......then I asked where it hurts the most (RIF). Then the patient reacted quite badly to even superficial palpation even in LIF and she said that the pain in the RIF also increased. Guarding (+), rigidity (¥). I wanted to stop palpation but the examiner instructed me to go on tO illicit tendemiess at the Mc Burney point. PR and PV not done. Examiner asked about differential diagnosis: acute appendicitis, perforated peptic ulcer, PID, ovarian torsion, ectopic pregnancy or UTIL P\) ‘The only question from the patient was: Could it be just gastro? Other candidate: Guarding and rigidity were (-) in my patient, but the patient had pain and tendemess over McBumey’s point, Rovsing’s and psoas signs were positive. When I asked about PR findings the examiner told me that itis tender on the right side. ‘I wanted to auscultate the abdomen, but the examiner said that it is normal on auscultation. ‘Then the examiner asked me about DD( which was the same with other candidate) and what investigations I would like to order. I said: FBC, USE, urine microscopy and culture, pregnanc test (the patient was on OCP, but I said that there is still a slight chance of pregnancy), “abdomen and I also want the patient to be seen by surgical registrar asap. When I mentioned about US, the examiner asked what I want to see on it. I replied: signs of PID like salpingo- Sophoritis. The examiner was happy. He said that I was on the right track and can go out now. Now you see that in different groups the same case could be presented with some variations. AMC feedback: Appendicitis (acute). A. 55 year old woman was accompanied to the ED by her husband. She complained of severe dizziness and inability to walk. TASK: * Take a focused history * Ask the examiner for PE findings * Discuss your diagnosis and management with the examiner From history: Patient started having pain in the left side of her face this morning, then started to feel numb in her right arm and leg and became very dizzy. She didn't complain of difficulty speaking and her swallowing is alright. She was so dizzy and nauseated that she vomited once; she becomes dizzier when she moves or turns her head. I asked the patient if I ask her to walk at that moment,how she would go. She said that she would become dizzier and keep falling to the left. Patient is overweight and is being treated for high blood pressure and cholesterol, doesn't smoke. and drinks socially (occasionally). She is on anti-hypertensive medication and Lipitor. PE from the examiner (only given what you ask for): Eye movements and pupils — normal, Nystagmus to the left, Horner syndrome (+) on the left. “Muscle power is normal, pain sensation is reduced on left side of the face and right side of the body, couldn't check the cerebeltar signs (patient was too unwell). ‘Other candidate: When I said that I want to check cerebellar signs the examiner asked to tell him exactly what signs I want to check. I said that I think it would not be possible to check gait for ataxia or to perform Romberg’s test because patient is not well enough for this, but I want to perform the finger-nose test, alternating movements of the hands and the heel- shin test. ‘The examiner said that they all are positive on the right side of the body ( patient is not able to perform them when the right side is actively involved). On talking to the examiner T indicated that these are the signs of Lateral Medullary syndrome with posterior inferior cerebellar artery involvement. Immediate admission is required with urgent CT/MRI and neurological consultation. Finished early. Far too early. Other candidate: when I mentioned CT scan of the head the examiner said that on CT you cannot see anything. Then 1 asked for MRI. The examiner answered that on MRI you can see ischemic infarction of the left side of cerebellar and brain stem. I said that it is consistent with my clinical diagnosis ( the same with the above candidate) ,1 will admit the patient urgently and will consult a neurologist. A 32 year old man presents to your GP practice complaining of low back pain and right leg pain. He is unable to sit and walking is difficult. The pain came on suddenly after lifting a heavy object. Previously has been in excellent health, no chronic conditions, no allergies, no medications. ‘TASK: «Perform a physical examination of the back + Give summary of the PE to the examiner + Explain your diagnosis to the patient. On PE findings were: Had difficulty standing and walking on his heels (right side), back movements — extention, flexion and side flexion are severely limited, the palpation of the spinous nd tranversus processes is painful, couldn't perform the slump test because of the patient’s inability to sit. He had severe limitation to LSR on the right side, tone and power were all normal except for the right foot dorsiflexion, reflexes are preserved and the pin prick sensation is decreased in the LS distribution on the right. ‘The examiner asked me to explain to the patient what’s going on.