4th April 2009 Melbourne Psychiatry 1. You are an intern working in neurology ward.

A 20 years old female has neck spasm, migrane, dysmenorrhoea etc. and was diagnosed with somatization disorder. She had to quit her job due to the neck pain and move back to live with her grand parents. Her grand mother has recently diagnosed with Parkinson disease and needs her support for daily activity around the house. Patient has had MRI scan of the brain, which is normal. Your task is to 1. Take further history. 2. Explain the diagnosis. 3. Manage the patient. This was my first station. The patient has had 10 years history of neck pain. And worries that she has got MS. I asked histories and found she has this problem for 10 years. I explained to her the Dx and reassured her that all Ix have been done including MRI show that there is no evidence of MS. I reconfirmed to her the pains are real. Somatisation is functional problem. Not structural problem. Just like piano working but out of tune. The bell rang. I couldnt finish the station on time. The roleplayer said sorry doctor. The examiner said, Gee that was quick. I remember Dr. Wenzels tips and tricks so I encourage myself that I still have 15 stations to play with! No worries. AMC feedback (Somatization disorder & agoraphobia)

2. A 60 y/o female with right lower abdominal pain for 6 weeks and lost 5kg in the last 6 weeks. She c/o tiredness. She does not drink alcohol or smoke. She went to see the doctor (P/E was normal) and was investigated; including, blood tests, gastroscopy and colonoscopy were normal. Today she came for the results. (GP setting) Task: Take psych Hx Give the patient your DDx Explain the nature of her condition. Hx: The RLQ abdominal pain for 18 months and getting worse in the last 6 weeks. Poor sleep and always wakes up at 3 Am and cant go back to sleep. Appetite is not good and feels depressed because the doctor says shes not ill. Lost interest. Suicidal idea. No plan. Retired teacher. Good relations at home and husband is busy. Patient has no eye contact. She read the notes in front of her. Appear sad.

I explain the Dx as major depression (according to criteria). She asked what I was going to do for her. I said admission, psychiatry r/v, medication and/or ECT etc. the examiner interrupted me this is not your task. I said I just answered the patients question. AMC feedback: Major depression with agitation & somatic features

Medicine and Surgery 1. Travel advice 40yo male come to your clinic before his travel Task: History. Conselling History: He is a businessman. Frequent flyer. Will go to Bangkok and then to NY. Past history of DVT which was treated with Warfarin. Conselling: As per GP book - travel advice. And advised patient that he needs Heparin prophylaxis. The role-player seems happy and I asked, "Do you have any questions?" Role-player said "NO". The examiner came from my back and asked can you please give advice for Rabies?" I said "I am not sure whether there is a pre travel vaccine for Rabies. I will check and let you know. But patient will need post-bite immunoglobin if being bitten by a dog." Both examiner and role-player seem happy. I finished the station early. AMC feedback Overseas travel risks

2. Duodenal ulcer Same as AMC handbook No question from examiner.

3. UTI 23 yo female P/W lower abdomen discomfort to your GP clinic Task: History (No examination) Diagnosis Examiner will give you another task Hx: Patient c/o lower abdo. Discomfort and pain while passing urine. Stable partner. Sexually active. LMP 6/52 ago. She is not pregnant. Similar episode one year ago. afebrile. Urine dipstick: Nitrates+++, Leucocytes +++ Random BSL 6.0 Pregnancy test: negative Dx: UTI Management: drink plenty fluid. Trimethoprim prescribed for 3 days (need to write this on script. The script is in front of me). There is a MIMS book provided.

AMC feedback: Urinary tract infection

4. BPH 73yo male could not passing urine for 12hrs and presented to Emergency Department. Task: History Ask examination finding Management I entered the room; an old gentleman was sitting on the bed. I said to the examiner that I need to put catheter in to release the urine. The examiner said patient was ok and you should start from the first task. I started by taking history. Typical BPH history. Examination finding: dullness on percussion up to umbilicus. PR examination: enlarged prostate, symmetry and smooth. Mx: No need to do bladder scan. I will put catheter in and will send urine, PSA and U&E as well. Examiner asked what PSA is and what it is for? So please don't say abbreviation in your exam. refer to urology reg for further Ix. The role-player blinked eye to me and said THANK YOU DOCTOR. AMC feedback: Acute urinary retention in an elderly man

5. Viral infection Young lady P/W sore throat and feeling unwell for a few days.. She comes to your GP clinic and ask for antibiotics. Task: History Ask examination findings Diagnosis Management I did this case with Dr. Wenzel a few weeks ago. But the scenario has been changed a bit and easier than Dr. Wenzel's case. I asked good history. I finished the station earlier (only spent about 4 min.) The examiner was happy and said, Do you know you can go out if you finish earlier? I left the room. AMC feedback: Sore throat

6. 26 years old male presented to GP c/o discharge from R) ear. He is a truck driver. There is a picture of tympanic membrane on the wall. Task: Hx, PE and Mx

Hx: Recurrent ear infection. Hearing not well. PE: As per Talley O Connor I took history and told patient that most likely he got cholesteatoma. I need to refer him to ENT surgeon. No question from patient or examiner. I finished early. AMC feedback: Cholesteatoma of right ear

7. 65 yo lady presented with a few weeks R) hip pain Task: exam the patient. No history taken. Arrange investigation This is an orthopaedic exam. The patient is limping. I could not assess the swelling. As the patient was wearing short and couldnt be exposed. Tenderness on palpation at great trochanter. Ix: X-Ray AMC feedback: Examination of the hip joint (Trochanteric bursitis)

8. A middle age lady p/w headache to ED. Task: Hx, PE, Dx & Mx So 2min per task. I took detailed history. She has had headache for a few months. Like band at forehead. Pain tends to start later in the day. Improved on the weekend. No photophobia. She worries that she may have brain tumor. She works full time as a manager. Good working environment. Happy marriage with 2 children. Most likely tension headache. Mx: not to be a perfectionist. Arrange a holiday. Simple analgesia. I finished early. AMC feedback: Headache

O&G 45 years old lady currently on microgynon 50 wants to know about HRT Your task: Hx, ask Ix and Mx
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She is a mother of 2 children & has finished her family. No menopause symptoms. Period regular. She has to use microgynon 50. cos if on lower dose, she gets breakthrough bleeding. Pap smear normal. Ix: FBE, LFT, BSL, Lipid, FSH, LH, U/S normal

Mx: I explained to her the indication and contraindication for HRT. HRT does not prevent pregnancy. I also explained there are other contraceptive methods that I can suggest such as Implanon, Depot injection, IUD, barrier method etc. Question from roleplayer: what is menopause? A: 12months no menses. AMC feedback: On OCP wants to change to HRT

2. 36/40 lady had MVA and presented to ED. She sat in the front seat with seatbelt on while her husband was driving. She is conscious and able to sit at up and talk to you. She brings her antenatal note with her. Her antenatal check up has been normal so far, including 18/40 scan. Her BG is O negative. Task: Hx, PE (ask), Mx Repeat case. ABC stable. She has no pain, no bleeding, and baby ticking as usual. She worries about her baby. PE: All normal Mx: Admit. Obstetric reg. R/v. CTG, U/S Kleihauer test. Anti-D I finished early AMC feedback : Abdominal trauma in pregnancy

3. 26yo primigravida 40/40 pregnant. Comes to your GP clinic for advice. As babys head is still 5cm above pelvis. Task: Hx, PE, Mx All normal including 18/40 U/S. placenta high. I told her most likely she has CPD. Arrange U/S to r/o other causes. Mx: Either CS or trial of labour. I finished early AMC feedback: High mobile head at term

Paeds ED, you will watch a video showing a 10months old baby is coughing and turned blue. A nurse is putting O2 mask onto the baby. Task: Diagnosis, Management
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After watch video inside the room for 10 sec, I said this is whooping cough

Mx: admit, O2, antibiotics for baby and family, reportable disease. Mother asked: Can I bring the baby home? A: No. Your baby needs O2 in the hospital. Mother asked: My child has had immunization, how can this happen? A: if not immunized, disease would be more severe. AMC feedback: Pertussis

ED in country hospital, Ambo brought a 10 years old girl in. she fell from a horse. Task: You will be on the phone with nurse to tell her what to do.
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The nurse is in front of me. The child is unconscious. I told nurse primary survey first. Put collar on. Put O2 mask on. Check breathing, which was normal. No signs of pneumothorax. Put cannula in. G&H. GCS 7. I told her need intubation. She said OK. Then do 2nd survey. No bleeding. Pupil equal sluggish to light. I said the patient needs urgent transfer by helicopter to do CTB. The nurse said that is why I ring you, Doc. I said I would ring to arrange now. AMC feedback: Falling off a horse

3.18m old child was diagnosed with asthma. He was discharged from hospital yesterday. Today the father comes to your clinic. Task: History Asthma action plan

Asthma action plan is on the table in front of me. Since the child has frequent attack (3 attacks per week), I said he needs to be on both reliever and preventer. Father knows how to use medication and spacer. But doesnt know what preventer is. I said it is steroids. I explained the action plan in detail (when well, unwell etc.) as written on the paper and what to do. AMC feedback: Asthma persistent synptoms

I felt relieved after I passed the exam. The role players are very good. Some of them are junior doctors. Most examiners are very quiet and didnt say a word in my stations. I tried to look at performance sheets on nearly every station when I shook hand with examiners. But I couldnt see anything. I would like to thank VMPF Alan, Dr. Wenzel and my study partners. I would also thank the previous many candidates who have written recalls. Tips to pass the exam:

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Take VMPF bridging courses. fantastic!!! Attend Dr. Wenzels Thursday evenings discussion. SO IMPRESSED. Try to be the Guinea pig and sit on the hot chair. So every week get real exam feeling! Dr. Wenzels cases are much harder than real exam. If you can survive, you will pass the real exam. Attend VMPF trial exam. Good partners for group study. Without their help, I could not pass. I was very lucky to have good partners and finished this exam ahead of you guys who are still waiting the placements. Dont study the day before the exam. Have a message before the exam. Dress professionally on the big day.

GOOD LUCK