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AMC Clinical Exam Recall 8 Sep 2008 Melbourne Retest

1. You are a surgical intern in the ward. A middle age woman was admitted and had her cholecystectomy. She has the complication of pulmonary embolism. Patient is now stable and all her treatments have been arranged. Her husband is now coming to see you. Tasks: Talk to her husband and answer his questions. The role-player appeared stress and loss of his concentration from time to time. Questions from the role-player: Why does this happen? Whats the complications? When will she go home? Is there any thing I need to pay attention after she come home from the hospital?
Before I started, asked clarifying question with examiner, I assume the patient agrees to disclose her confidential information to her husband Yes, you can talk to him. The role-player appeared stressful and kept asking questions like why this happened and whats the complication, ect. Later, he demonstrated not taking message for several time, like avoid eye contact and looked away. So, I had to check his feedback by saying are you alright, sir? and told him I understand this is worrying you but the good news now is every thing is under controlled. If you dont understand, please let me know and I will repeat. I didnt explore his family circumstance in details. The Patient didnt have the stocking shocks, was obese and on OCP, no history of diabetes. I didnt remember whether she was on other medications. So I explained to husband about her treatments: Staying in ward in the next couple of days; already in Heparin infusion and using another blood thinning pill called Warfarin. The role-player asking all the old questions, likeWhen will she go home? After next two or three days when her pain is settled and the Warfarin kicks in, her drip will be stopped and she can go home. Is there any thing I need to pay attention after she come home from the hospital? I mentioned to him about the narrow therapeutic window of Warfarin, about blood test with her GP follow up, her diet and medications when she is taking Warfarin. Also, I mentioned about safety issue like ensure that she is not knocking at hard things, as it will easily cause bruise. And if she has any bleeding like bleeding in her gums and heavy period, she needs to see her GP or come to the emergency immediately. Gave the husband patient education sheet and mentioned to him that his wife was having one, as the nursing educator in the ward was seeing her at moment. There is no question from the examiner, Dr Gya.

2. GP Clinic. A 43 (?) yo lady presenting with heavy bleeding for 6 months. She had her D & C done at the beginning, which an endometrial biopsy and blood tests were all done and normal. Her also had her PAP smear done last year, which was normal. She is not on the pill. You have ordered some blood tests and the results Hb 7.0, LFT, U&E, TFT were all normal. (I couldnt remember if there was any iron studies.) Task: Talk to the patient about her condition manage the case. Comments and Questions from the role-player: I dont want to have blood transfusion, Doctor. What are you going to do, if all these medical treatments do not work?

Do I need to remove my womb?

Her Periods lasted for eight days and heavy with clots. She had no pain at all, no post coital bleeding between periods. Not on the pills as husband using condom. No itchiness in genital area. Not on any medications. Felt tired but no loss of appetite, mood was ok. Had two children. No PHx, I forget if there was any FHx. PE unremarkable, except Anaemia. The diagnosis is dysfunctional uterine bleeding, explained to her in lay words. This is an emergency situation. I am going to admit you to the hospital right now. I am calling the ambulance, Can I not go? because your haemoglobin is low, you need to have blood transfusion. I dont want any blood transfusion, doctor. All right,... Do you have any chest pain, short of breath or dizzy spells? No. So in this case I didnt go more assertively to advise her about blood transfusion, but explained to her about iron study and supplement, to help your body produce more blood. Talked to her about hormone treatment, antifibrolytic agent. I couldnt remember the name of this medication at this moment, to be honest, but its for preventing the clot from dissolving. I will check the Mims to find out its name. What are you going to do, if all these treatments are not working? I told her about another D&C and recheck uterine USS and hysteroscopy, and D&C may not work in your case (recurrent). Do I need to remove my womb? No, I mentioned about endometrial ablation. I just dont want to remove my womb, she demonstrated that she felt relieved. But this ablation will be done only if you have finished your family. I do. My younger son is 12 years old. The cat was quiet.

3. GP setting. A 35 year old builder presents with abdominal pain for two years. He had been on NSAID for a long time for his back pain (I forget its name). He had a gastroscopy yesterday, which shows a large ulcer and H. Pyloris positive. The specialist was called away due to an emergency. He telephone you later and sent the image to you. He asked you to talk to the patient and manage his condition. Tasks: Explain the diagnosis to the patient and manage the case. Questions from the role-player: Could it be a cancer? Do I need another gastroscopy?
Very poor image which was like one downloaded from the internet with very low resolution. A large grey-yellowish patchy area with the rest of the image not very clear. I forget to pay some attention to few unclear but yet readable letters in the image. I started with greeting to the patient and passed his specialists message (apology) to him. Patient had alcohol and smoking history and was a hard working builder. I explained to the patient about the diagnosis as a peptic ulcer, and offered the patients a triple treatment. I also advised the patient about healthy life style, reduce stress, stop smoking, stop alcohol in this stage. Could it be an cancer? No, its very much unlikely. I replied after asked his symptoms no weight loss, no tiredness, no loss of appetite, no any other pain apart from the back pain which had been there for a long time. Your specialist had took some tissue from your stomach and we are still awaiting for the pathology report. Your condition is a benign one. You are in a good safe side, so, it is very unlikely to have a cancer. However, to be 100% sure, I will organise some blood tests and imaging tests like ultrasound to check you liver and other abdominal organs.

I mention about the breathing test four weeks after the anti finished. Do I need another gastroscopy? Generally speaking, no need. But because your ulcer is a bit bigger than usual, I will check with your specialist. Just about ten seconds before the bell rang, the Indian examiner suddenly interrupted me, doctor, this is an duodenum ulcer! Ok, in this case, I will check his pancrease I tried to fill the gap, and think about what I didnt covered. Anyway, its finished now. See you LATER. The bell rang. Thank you, I kept my smile and English-style eye contact with him to demonstrate my confidence. I used my two hands to shake his hand to thank him for his assessment. On the other hand, I started thinking why he behaved like that. As an health professional graduated in Australasia and having working in Australasia for a long time, I felt his way wasnt a supportive way, which was distinct from what our lecturer in the weekly class normally do. You can simply fail me by not telling me, which you keep my confidence to facilitate my performance in next station, or alternatively, you can ask me questions to find out my limitation and decide whether I failed. However, he acted in neither way. In the next few stations, this sort of thinking kept fleshing back, but luckily, I knew most of the stamps well. My response might be just over-sensitive, or just a cross-cultural reaction. The AMC feedback stated that I passed this station.

Typical king case. A young Uni student comes to see you. Tasks: Take a history and manage the case. Questions from the examiner: What is your Ddx? Whats else? Whats else?
I used the HEARDS as my framework to take his history, as this was a psy case. (Home, Employment and/or Education, Appetite, Relationship, Drug and alcohol, Suicidal, Smoking and Sex). I asked him questions about his insign, judgement, suicidal ideation and psychotic features - non of them was identified. His school performance was worsened due to the fact that every time when he read or mentions the word "king", he had to walk around for three times, and do his ritual things, which details was exactly the same as what presented in the previous recalls, except the roleplayer didnt get up and walk around for three times. Non-smoker, no drug and alcohol issues. Basically nothing was particular, except - the examiner kept asking about differential diagnosis. I answered in a way of differentiating each possible diagnosis and it took quite a while - other anxiety disorders such as PTSD, psychotic conditions like acute psychosis, schizophrenia, depression, drug and alcohol issues/ induced psychosis (which we need to have blood tests to confirm it although history did not support that), . I think, it might be better to just go back to the basic and give him a list of DDs, like drug and alcohol induced psychosis, depression, PTSD, schizophrenic form disorder, organic disorder, brain tumour, infection,... Like other candidate did.

You are seeing a young man who comes to you for a insurance check up. He has a history of asthma. Tasks: Instruct the patient to do spirometry and analyse the result.
This was my first time to see a spirometry machine indeed. So, before I started, I mention to the examiner that I did not use "this specific type of spirometry machine, but I assume it likes a ECG machines, its operation would be very similar". The role-player interrupted me, no worries. It's all set up. The machine was placed on the table, and the light in the switch was on. There is a tub like one used in a humidifier. A mouth piece the same as what we use in the peak flow meter was separately placed on the table. I plugged the mouth piece into the ventilation tub. I explained to the patient that I need you to take a deep breath. The use your mouth to hold this mouth piece (the tub). "Make sure it's sealed properly without leaking any air out from both sides then brow the air into the tub as fast and as hard as possible."

I attend to touch the switch of the machine, but the role-player told me, "no need, it's all set up already". I asked the role-player to do as described above. Once he started blowing into the tub, I mentioned to him, "keep going, keep going, keep going." While he started blowing air into the machine, the recording paper with a pin on top of it automatically started running. When it he finished, the paper rolled back to its starting point again and pin returned to its initial position pointing to zero second. The role-player first time did not follow instruction to blow as fast as possible, instead, he blowed, paused, blowed, paused for several time. So, the trend line rose slowly. I asked him to relax and take a rest, "we need to do it for another two times, and then I will analyse the best one." He did it the one more time only, then tired the paper off and gave it to me, its all done. Please wait for a while, I will analyse the result for you. The recording uses a specific paper for spirometry. So I did not need anything else to analyse it. The FEV1 was 3.6 L and TVC was 4.6 L. The result was about 0.8. it is normal, so I didnt repeat after offer him Ventolin, but other candidate did. I also explained to him, what was indicated if the result was < 0.6 or >0.9. Because its normal. You do not have an asthma attack at moment. I dont have asthma, doctor. Further history, he had the last asthma attack at 11 year old. I will send a copy of your report to your insurance company, if you like. Can I have my insurance? Its up to your insurance company ti interpret. But your lung function is good. Congratulation for having a good lung function. No question from the examiner.

6. GP setting. You are seeing a 60 years old lady who presenting with abdominal pain, sweeting, shaking and palpitation over the last two to three weeks. She had a cholecystectomy some years ago. Tasks: History taking; Ask examiner about the examination findings; Manage the case.
A typical cholangitis case which has been in the previous recalls, but its interesting that the AMC diagnosis did not touch the correct diagnosis. Start with asking her pain questions - 10/10 severe pain, so I offered her pain killer first after asking allergy history. That patient had a periodic abdominal pain over the last two to three weeks, sweeting, shaking and palpitation. She didnt see any doctor but took Panadol only by self. She was sweeting, feeling hot, palpitation as well as the pain in right upper quadrume. Asked about all histories, not diabetic. On examination, her right upper abdomen was quite tender, and liver was 2 am palpatable. I advised her this is cholangitis (in lay words), advised to keep her Nil by Mouth, then I am going to ring the ambulance and send you to the hospital, because if we dont keep it under control soon, it would get sepsis and abscess, the consequences could be nasty (possible complications). Thats why she needed to be admitted quickly. Talked to her what going to happen in the hospital: blood tests, like FBE, U+E, LFT, lipase, and clotting profile; blood culture if temp high; USS and CT scan. Talked to her that she will be given strong and combined antis, also I turned over and talked to examiner, it would be Flagyl and another board spectrum antibiotic as per therapeutic guideline. Drew a picture and talked to her if there was a stone found in the lower part of her common bile duct, she would probably have an ERCP which would attempt to use an basket to remove the stone, and let the bile to drain into the duodenum. No question from the examiner.

7. A middle age business man, who works in an insurance company, presenting in you GP practice, complaining with diarrhoea for the last 6 months. Tasks: Take a history;

Discuss with the patient about the diagnosis; Manage the case. Comments from the role-player: I am actually using Imodium, Doctor.
Funny setting, examiner dominate the table and left the candidate and role-player to sit beside him. Not sure what rationale for such setting - Was because the examiner had impaired hearing or some thing else. Patient had been diarrhoea for the last six months, always watery stool, 6 to 7 times a day, no blood, no mucus. No constipations. No recent overseas travel. I forgot to ask him about his medication. No existing medical/surgical problems. He does not smoke, but drinks alcohol and he knows the safety limits. I mentioned to him he might need to stop it, we will discuss it later but indeed, when discussed with him about the management later I forgot to highlight its importance. Stress level in his job and family life all fine. I forget to ask him about recreational drug and sexual history to exclude conditions like HIV infection. No Family history and cancer history. You have a condition called irritable bowel syndrome, I explained to him in lay words. The diagnosis is exclusive diagnosis, so blood tests to exclude chronic pancreatitis, hypothyroidism, stool culture for pathogens, colonoscopy to exclude other disease like diverticulosis and Chrons disease. I didnt mention and also not sure if it might be better to put Coeliac disease listed as a Ddx due to the current change to public awareness recently. Discussed with him about the management, key issues as listed in Murtaghs book: Told the patient to keep note to find out if there is any factor like specific food would trigger his diarrhoea. Told him about healthy life style, avoid smoking and stop alcohol. After these, if it is still not under control, I could give you some medication like Imodium. I have already on it and it doesnt work. Bell rang. I didnt pass this station, please refer to other candidates recall for more information.

8. A six months old baby Emily was brought in by mum who stated that the child had a fall from the cot which an x-ray was taken and shows a green stick fracture in upper one third of the humerus. You also noticed the child has bruise in her cheeks. She is born from her single, teenager mother. It was an unexpected pregnancy. Emily is look after by her mother and her boyfriend. Mum is a part-time worker. Tasks: Discuss with mother about diagnosis and manage the case. You do not have to take the history. Mother trust her partner. Questions from the Mother: Can you treat her then let me take her home? Can I go with my child to the hospital? Are you going to take my child away from me?
A typical child abuse case, which presented in recalls several times already.

I talked to examiner first, I am going to ask some more history and just to role out the family situation. The examiner said go ahead. so I did. Emily was born in 26 weeks of gestation, and was in hospital for 3 months and discharged to her mother 3 months ago. Her father is not mums current boy friend. Mum stated she was able to cope well and she loved the baby. She did not drink or smoke but her partner does. He was unemployed. Mum was very trust him. The role player was a Chinese/Asian lady who demonstrated less western teenagers cultural identity. I started with telling her this is an non-sustained injury, which she pretended not understood. Then, I directly told her I suspect child abuse, which she did not react much neither. In psychiatric perspective, her affect could be quite flat. I an not sure was it the stamp required for the role player. I talked to her I am going to ring an ambulance to admit your child to the hospital, then talked to the examiner the I would notify the Department of Human Services. It just a simple fracture. Can you treat my child then I take her home? No, I am concerning about your childs safety. It is my duty of care to the Royal Children Hospital. So what happen is, that you child will be assessed by the paediatricians and social workers who are specialised in this area. They will ask you questions as well. I understand this is also difficult for you, the social worker will to give you information and assistance you need. You can also have a legal representative. I mentioned about the Department of Human Services and Gate House Centre. Her affect remained flat. Can I go with my child to the hospital? Yes, you could. But this has to be arranged and approved by the hospital social worker. I will ring them and ask her to come with the ambulance and go to the hospital with you. The role player kept telling me she loved her child and asking are you going to take my child away from me? I replied to her I am not the right person to decide. They will discuss with you in the hospital after her assessment. Talked to her about social worker visits. No question from the examiner, but I did feel there might be some issues I did not explore well yet. Please check with other candidates recall.

AMC Definition of Stations: 1. 2. 3. 4. 5. 6. 7. 8. Pulmonary Embolism Menorrhagia - DUB Duodenum Ulcer Obsessive-Compulsive Disorder Lung Function by Spirometry Jaundice Diarrhoea (Chronic) Child Physical Abuse