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Brisbane, 11th October 2008

1. Cranial nerve Exam in Head injury 2. Viral rash with arthralgia 3. PROM, 30 weeks 4. Urge Incontinence 5. Celiac disease 6. Fever in Neonate 7. Bee Sting 8. Panic attack 9. Antipsychotic side effect 10. ? Peritonsillar abscess with trismus 11. Breaking Bad news (Bowel Ca) 12. Iron Deficiency Anaemia 13. Post op Fever 14. Multinodular goitre 15. Pneumonia 16. CVS risk factors 1. Euthyroid multinodular goitre Yong girl in her 20s, 2nd presentation to your GP, previously saw your colleague who organized blood test and US. The results are as below: TFT with normal TSH and T4 US showing multinodular goitre. Task: Discuss treatment and its complications with patient. It was an easy case but the exam stress makes even simple things very hard. I went inside, greeted patient and told her the blood results. As she is euthyroid I would not start any medicines on her. I asked her about various symptoms to see if she is having any problem. She was wearing scarf around her neck and was worried about the cosmetic appearance, nil other complaints. I advised her regarding referral to endocrinologist and surgery and complications like: Infection, Bleeding, Injury to laryngeal nerves causing hoarseness, Damage to Parathyroid glands. I also told her that I will follow her further and arrange TFT in future to make sure she is not having hyperthyroidism and in that case I will start anti thyroid drugs like PTU and carbimazole. I was not confident in my approach and examiner asked me if i would like to do some tests. I said anti-thyroid antibodies and then I stopped and said they are for Graves not MNG. Probably he was hinting me on FNAC or nuclear scan but none of them crossed my mind and I did not mention a word about it. Could someone please tell me if it coud be critical error not to further investigate. But I did refer her to specialist. Management of Euthyroid Multinodular Goiter Multinodular goiter, a relatively common condition, has a multifactorial etiology and demonstrates a female predominance. Most multinodular goiters are slow-growing and asymptomatic. These require no operative intervention unless there is a suspicion of

malignancy. Patients with multinodular goiters present for medical management predominantly due to cosmetic concerns or compression of adjacent structures, most notably the trachea, the esophagus, or the large veins of the neck. These patients require a thorough clinical assessment, including noting the position of the trachea, checking for the presence of inspiratory or expiratory stridor, and distension of neck veins or dysphagia. If a dominant nodule is present then fine-needle aspiration is indicated to rule out malignancy. Current evidence suggests that the incidence of unsuspected malignancy within multinodular goiters may be higher than previously reported. As stated, the indications for treatment of a multinodular goiter include compression-induced symptoms, hyperthyroidism, suspected malignancy, and, in some instances, cosmetic concerns. Suppression has been attempted by various clinicians using exogenous T4 (e.g., Synthroid). The likelihood of affecting the size of the multinodular goiter, however, is exceedingly small with T4 suppression. The therapeutic use of radioactive iodine has also been proposed by some clinicians. However, unless the patient has a hyperfunctioning nodular goiter (Plummer's disease), radioactive iodine does not represent appropriate management of these patients. Surgical resection represents the treatment of choice for the majority of patients with multinodular goiter. Options include selective resection of the pathologic tissue, bilateral subtotal thyroid lobectomy, and total thyroidectomy. It has been our policy to perform a total thyroidectomy for patients with multinodular goiter with bilateral disease, or total lobectomy with resection of the isthmus in the minority of patients who have a unilateral nodular goiter. We and others feel that total thyroidectomy can be performed safely and with a morbidity comparable to that of lesser resections. A subtotal thyroidectomy has the potential for the development of recurrent goiter and the increased surgical morbidity associated with reoperation, or, in the case of an unsuspected malignancy, the possibility of performing a less than adequate resection. Although subtotal resection can be performed if the surgeon is less experienced and concerned about potential complications (such as recurrent laryngeal nerve injury), a total thyroidectomy is certainly a reasonable procedure and a more definitive treatment for this disease.

2. Simple case of examining head and CN in patient who came after MVA. He is stable now and spine is ok. No further Hx, only examination. I started it really well and I think I spent oo much time looking at the head for lacerations, bruises, sinus tenderness, and asked examiner re otoscopy and fundoscopy, which he said was normal. Rest I could not finish and bell rang when I was about to test 9th and 10th nerve. Do you think the examiner would fail me for not completing the task. I will send you more soon Please if someone could advise me Getting our result tomorrow but cant stop thinking about it.

3. Q: Young man in late 20s presented with cough and SOB for few days. Also complained of chest pain. Sputum rust coloured. Feeling hot and cold. Temperature was 38.something,O2 saturation 93%,tachycardiac and tachypneic. Task: Focussed Hx Ex findings from examiner Ix and Mx My differentials were pneumonia, pneumothorax, pleural effusion. On Hx, it sounded more like pneumonia. He was non smoker, nil other significant medical history. On asking the examiner about Ex finding, there was reduced air entry in rt middle lobe with percussion dullness in the same area. Nil wheezes , Crepts? Xray was given on asking and it had a clear picture of middle lobe consolidation. I advised that it is pneumonia, need to admit him because of poor saturation. Start IV antibiotics and rest Ix like sputum and blood test. Imp: Ask about allergy as he was allergic to penicillin, so I said ceftriaxone and one more antibiotic to cover atypical pneumonia. I passed this station.

4. Q: A man in his late 30s presented with fever and polyarthralgia with a generalized maculopapular rash all over body(picture provided). Task: Focussed hx, Ix, Ex and Mx It is very important to think about DD when you are outside the room so that you dont miss anything in history. My differentials were IM, HIV, Hepatitis, Ross river virus. IM: no sore throat, on Ex no findings in ENT, no hepatomegaly, no splenomegaly. HIV and Hepatitis: no abnormal sexual Hx, happily married man, no IV drug abuse, no loss of appetite, no weight loss. Ross river Virus: Hx of recent travel to North Australia last week, unwell since then. All joints were tender but no arthritis like deformity. Lymphadenopathy? Ix: FBC, Serology for Hepatitis, EBV and ross river virus. Mx: antipyretics, pain killers, ample fluid, good diet. Important to follow him up so I said I would like to see you soon after your results are back and if your condition gets worse, come to see me immediately. No antibiotics required as yet. I passed this station.

5. Q: Peritonsillar abscess. It was a young female, C/o sore throat for few days, painful swallowing, GP gave antibiotics but not getting better. Task; Hx, Ex, Ix, Mx.

It was a typical History of sore throat. Febrile with high temp. LN palpable. Examiner provided a picture of throat on asking about examination. The picture was not clear and the examiner said it is hard to open the mouth fully. The picture showed only rt tonsil and uvula. The tonsil was red, big and bulging but no pus. Looked like an abscess. I advised to admit the patient as the abscess needs to be drained. To start IV antibiotics. Other blood tests ordered.

6. Q: A young girl coming for prescription of anti-psychotics as she had run out of the medicine. On presentation, you saw tremors. She was recently admitted to hospital for severe depression with severe delusion. Task: Focused Hx and Ex and Mx. I did not do this too well but I passed. Because of previous severe attack, it is important to admit and change her medicines because of relapse. Ex for EPS includes checking tone, power and reflexes of the arm and gait. Prepare it well but the examiners are nice and I think they can see that you know what you are doing and saying.

Paediatrics 1. Q: 4 year old boy bib father after bee sting. Vitals normal, swelling of the leg where bee stung and generalized itchy rash. Had previous episode of bee stung where he only developed swelling of the feet. Nil allergies, nil other medical problem. In the scenario it was not mentioned if it is a GP set up or ED. So be cautious. Task: Immediate management and subsequent management I went inside, shook hand with father and examiner. Asked examiner about vitals and he said child is stable. I told father i would like to keep him in observation for 4 to 6 hours as his condition might get worse. Give him anti histamine for allergic reaction. It is not anaphylaxis but only allergic. Subsequent Mx same as for anaphylaxis. Gave Epipen and advised father that as 2nd episode was worse than 1st one, it is possible that the next one could be even worse. gave alert bracelet, education regarding protection from bees, make sure no bee nests near playing areas.

2. Q:18 month baby with failure to thrive that is weight and height less than normal. Nil medical problems. task: Hx, Ex, Ix and Mx The scenario was changed for different candidates. The role player gave the history relevant to Coeliac disease and to others it was more like cow milk enteropathy. For me it was typical coeliac disease. Started since weaning. Likes toast, less milk. Family Hx of brother in law on special diet since childhood. It is imp to advise mum that confirmatory Ix is biopsy besides

other blood test and stool culture. Fully immunized. Mx is special diet, refer to dietician and gastroenterologist for biopsy and further management. It is a lifelong condition and has to avoid wheat/oat/rye/barley. (AMC feedback: celiac disease)

3. Q: 4 month baby bib mother because of temperature and lethargic, irritable, reduced feed. Peripheries are botchy and not well perfused. Task: Hx, Ix, Ex and Mx. The mother was very weird and rude. On asking about immunization she said "what is that". I said they are the injection given to babies to prevent serious infections. She was totally ignorant about it and said whatever. It is a typical sepsis case. I told mum that she her baby is at serious risk, especially cos he is not immunized. She said, "are you blaming me for that". I was really scared that I should not have said that. But I handled the situation well saying I am not blaming you but its just that she is at high risk. After she is well, I'll follow you for her immunization as it is not too late. When I advised that she needs to go to the hospital now, she said I've travelled so far to see you and now I have to catch another train. She was not happy about it. Then I suggested that I will call the ambulance. She was happy. I think she was giving me hint to call the ambulance. Regarding IV antibiotics i said that if ambulance is going to be long I have to give him antibiotic now and take the bloods too. Overall a typical case from AMC handbook but with immunization problem.

Obs and Gyne 1. Q: Post vaginal hysterectomy. Inpatient, 3rd post op day, Spiking temperature today. Task: Hx, Ix, Ex and Mx I was not expecting to pass this station but thanks to the examiner. The patient was very worried that she was recovering well and how come she had sudden temp. There were notes provided regarding physical obs, urine output and fluid input. No urinary symptoms, chest clear. On examination there was tenderness in the suprapubic region but no mass palpable. Per speculum exam normal. I did not ask for PV examination and did not order ultrasound. But I did mention, there could be some infection at the surgical site. I will order some blood test and will see you soon. Examiner asked how soon, I said when the blood results are back, in couple of hours. I must have been really lucky to pass this station. Other candidates said it was a case of pelvic abscess. But please ask someone else.

2. Q: Premature rupture of membrane at 30 weeks in primi mum. Leaking clear fluid.

Task: Hx, Ex, Ix, Mx It happened yesterday after sex. Little amount of fluid oozing out. No contractions, baby moving. No blood. Antenatal serology normal. US Normal. On examination, vitals stable, SFH corresponding to Gestational age. Head not engaged. FHR 100 and movements present. It was a GP setting and I asked for CTG which was not available. I advised pt to go to the hospital now. She will have an U/S to check amount of amniotic fluid and biophysical profile of baby. If it is minor leakage and rest is all normal, she will be discharged and I will follow her weekly with U/S coz it is important to keep an eye on amount of fluid loss. But if the leakage is more baby has to be delivered and she will be given steroids to mature the lungs.

3. Q: Urge incontinence Typical history with sudden urge to pass urine and she cant control it. Some symptoms of stress incontinence as well. No prolapse and vaginal examination normal. I advised that I will refer her to specialist for urodynamic studies and physiotherapist. After her urodynamic studies are back, we will discuss further Mx.