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ADELAIDE, 5 APRIL, 2008

PAEDIATRICS
1. 3 yr old Jessica was brought to the ED as she is limping since this morning. She is having pain in the right hip. All the investigations were done in the ED and the child was sent to the paediatric ward where you are intern in the ward. Take history from the father, examine the child, investigation findings from the examiner (you will be given the results which you ask for) and explain management to the father. History: father told the child was limping since this morning. No fever, no trauma, activity normal, growth and development normal, appetite normal. H/O URTI 2 weeks back. Even now the child is playful and playing with her toys in the bed but not willing to move her right hip. Jessica did not develop any swelling or redness around the right hip joint. O/E: General appearance: the child is playful Vital signs: normal Right hip joint: no swelling or redness, the child cannot perform internal rotation and abduction at the right hip joint. Investigations: WBC count: normal Platelet count: normal RBC count: normal Haemoglobin: normal ESR, CRP: normal X-ray right hip: normal Ultrasound right hip: shows minimal effusion. Management: your child is having a condition called transient synovitis or irritable hip. This happened in response to the URTI she developed few weeks ago. It will take 7 10 days for this to settle. During this time she needs to take absolute bed rest. If she starts to move around even before this period, then she may get relapse of this episode. So it is better to get her admitted in the hospital during this period because if she is at home she will be moving around and her pain will not be resolving. AMC feedback: Transient Synovitis of Hip Irritable Hip. 2. You are in the ED. 12 month old child was brought to the ED by her mother. She is having fever since the last 2 days. Her activity and

appetite are a little bit decreased. You examined the child and she is having a temperature of 38.3 and the other vitals are normal and the physical examination is also normal. You have done the bag urine specimen examination and it shows: nitrites ++++, leucocytes +++, no RBC. Your task is to explain the diagnosis to the mother and further management. Candidate: your daughter is having a condition called urinary tract infection. (Then I drew a diagram showing the urinary tract). So we need to admit her in the hospital and she needs to undergo further investigations. First she will be seen by a paediatrician and he will be doing suprapubic aspiration to collect urine. Mother: how it is done. C: first ultrasound is done to see any residual urine and then under aseptic precautions a needle is introduced in the bladder area over the abdominal wall to collect urine. Once the urine is collected it will be sent for culture and sensitivity. Mother: is it really necessary C: Yes, to know exactly which organism is causing the infection because the bag urine on which we did the test earlier is prone for contamination and we cant rely on that specimen for culture and sensitivity. Mother is really panicking now C: Are you okay and do you need anyone to be with you. Mother: I am really worried regarding all these things. I thought that she got a simple flu but now you are telling me all these investigations. I came here alone and my husband is at home taking care of my 5 yr old daughter. C: No need to worry. First we will be starting her on broad spectrum antibiotics and when the culture report is back we can change the antibiotics according to the sensitivity of that organism. C: Does your daughter have any drug allergy. Mother: no. C: we will start her on IV amoxicillin and gentamicin. She needs to be on these antibiotics for 14 days. Once her general condition improves we will change them to oral antibiotics Mother: how long does she need to stay in the hospital? C: until her general condition improves. It will around 2 or 3 days. But she needs other investigations like ultrasound and micturating cystourethrogram. Mother: what are they? C: we will be doing ultrasound initially to see if any anomalies are present in the urinary tract. But MCU is done after infection subsides because if we do it now her infection might become even severe Mother: what is MCU and why is it done and how is it done C: MCU is done to rule out any vesico- ureteric reflux. It is done by putting a urinary catheter and a dye is injected and while the child is passing urine serial x-rays are taken to see the urine flow and whether there is any reflux back into the upper urinary tract and

also if there is any dilatation of the upper urinary tract. If VUR is present, then the reflux of urine back into the kidneys damages the kidneys and may lead to a condition called reflux nephropathy which is quite serious. So we need to diagnose it early even before it damages the kidneys. Mother: okay then C: any other concerns Mother: no AMC feedback: Urinary tract infection. 3. You are in a general practice. Your next patient is a 30 yr old woman who gave birth to a child with Downs syndrome 18 months ago. Now she is planning to get pregnant again. She went to a geneticist and he explained to her that her chance of having again a child with Downs syndrome is 1 in 100. She is quite confused about that and wants to discuss with you. Talk to the woman and answer her questions. Candidate: from the notes I see that you are planning to get pregnant and you went to the geneticist as well. Role player: the geneticist told me that my chances of having a child with Downs syndrome are 1 in 100. I didnt understand what he meant by that. C: I will explain to you everything about that but can I ask you few questions R: yes C: during your previous pregnancy did you have any investigations done or after the birth of your first child did they do any karyotyping. R: they did some investigations but I cant remember them. C: there are different causes for the occurrence of Downs syndrome. In your case the cause might have been meiotic non disjunction thats why the geneticist told you that your chances of having a child with Downs syndrome are 1 in 100. Non disjunction means during cell division of the egg the cell gets an extra chromosome in the 21 st chromosome so it is called trisomy 21. Anyway I will give you all the information regarding this to you so that you can understand clearly regarding that. R: what should I do before getting pregnant? Do I need to take any medication? C: there is no need to take any medication but take folic acid tablets 3 months before getting pregnant and 3 months after getting pregnant. But there are certain investigations called screening tests which find out your risk of having a baby with Downs syndrome. At 11 13 weeks of pregnancy we can do a test in which PAPP-A and beta HCG levels in the blood are assessed. In Downs syndrome the levels of beta HCG are elevated and that of PAPP-A are decreased. Ultrasound scan is also done at 11 wks to see nuchal fold thickness. In Downs syndrome the nuchal fold thickness is increased. Both the above tests combined together the chances of diagnosing Downs syndrome is above 90%.

Apart from this there is another test called triple test which is done at 16 wks of gestation. The triple test includes AFP, beta HCG, unconjugated oestriol. In Downs syndrome AFP and unconjugated oestriol are decreased and beta HCG is increased. There is another test called quadruple test in which apart from the above three components inhibin is also included. In Downs syndrome inhibin is increased. All the tests which I told you now are only screening tests. The screening tests combined with your age indicate your chances of having a child with Downs syndrome. If the screening tests are positive then we do the definitive diagnostic tests called chorionic villus sampling or amniocentesis. R: when are they done? C: CVS is done at 9 11 wks of gestation and amniocentesis is done around 16 wks of gestation. R: what tissues they take when they do this procedure? C: in CVS they take the placental tissue and in amniocentesis they take amniotic fluid which is the fluid that surrounds the baby. R: how long will it take for the report to come? C: for CVS it takes 48 hours for the report to come but for amniocentesis it takes about 2 weeks. R: do these procedures have any complications C: both the procedures have the risk of miscarriage. But the miscarriage rate with CVS is 1% where as with amniocentesis it is around 0.5%. R: ok. My husband is busy all the time with his job and I am not having time to discuss about this with my husband. Do I need to talk to him? C: yes we need to discuss regarding all these things with your husband. Whenever he is having time both of you come together to me so that discuss about this. R: thank you. AMC feedback: Down syndrome.

OBSTETRICS AND GYNAECOLOGY


1. You are working in a GP practice. Your next patient is 25 yr old woman who had 3 miscarriages before at 8 10 weeks of gestation. She came to you previously and you organized some investigations for her. Today she came for the investigation results. Your task is to take investigation results from the examiner (you will be given only the results you ask for) and discuss the future management with her. FBE: normal Ultrasound abdomen: uterus is normal, there are no fibroids or other structural anomalies, fallopian tubes and the ovaries are normal.

Lupus anticoagulant and anticardiolipin antibodies: normal Karyotyping of both patient and her husband: normal TORCH titres: normal FSH, LH, Testosterone levels: normal HLA typing: normal TFT: normal Blood sugar: normal C: the blood tests that we have done for you show that you are not having any abnormality. So, no need to worry regarding this. R: can I have a baby again C: yes, you can have a baby but when compared to the general population your chances are a little bit decreased. Because you had 3 miscarriages before, you have75% chance of having a normal baby. R: will I have miscarriage again C: your chance of having miscarriage again in the next pregnancy is about 35%. But there is no need to worry about that. Once you plan to get pregnant, we will be monitoring you closely and more frequently and I will refer you to a high risk clinic and the obstetrician will take good care of you. R: do I need to take any medications C: at the moment there is no need to take any medications and when you plan to become pregnant take folic acid tablets 3 months before getting pregnant and take it for 3 months after getting pregnant. Try doing some regular physical activity like going for walks and eating healthy food. At the very moment you think that you are pregnant you come to me so that we will organize some investigations like confirming the pregnancy by doing some blood tests like pregnancy test and also ultrasound scan. R: one of my friends is also having the same problem but the doctor applied some stitch to her cervix. Do I need to have any stitch applied? C: in your case there is no need to apply any stitch. The cervical suture is applied to people who have cervical incompetence and generally they will be having second trimester miscarriages. Cervical incompetence is a condition in which the opening of the cervix is not closed and the membranes around the baby will not be having enough support and they will rupture. R: ok C: do you have any other concerns R: no AMC feedback: Recurrent miscarriage. 2. You are in a GP practice and now you are seeing the mother of a 13 yr old intellectually disabled Rebecca. Rebecca is going to school daily during the day time and sleeps at home. She is on carbamazepine and phenytoin since the last 18 months for epilepsy and her epilepsy is now well controlled.

Now her mother is concerned about contraception and she wants to discuss with you regarding contraception. Your task is to take relevant history which you think is necessary and address her concerns. (It is the same case from the AMC clinical book but the scenario is a little bit changed) C: can you tell me in more detail about your concerns Mother: you know Rebecca is a lovely little girl and she is going to school now and these days she is developing some changes in her body. She started to develop breasts and pubic hair. Even though she stays with me during the night the whole day she goes to school and I am worried like if some thing unfortunate happens and if she becomes pregnant. So I want to discuss about contraception. C: Did she start getting periods Mother: she didnt attain menarche yet C: did you discuss regarding contraception with Rebecca and is she able to understand anything Mother: I tried to talk with her regarding this quite a few times but she is not able to understand and I am scared that once she starts getting her periods she will not be able to take care regarding the hygiene and it will be a hard task for me to take care of her during those periods. C: can I ask you a few questions Mother: sure C: who is taking care of her medications? Mother: I am taking care of her medications. C: is she coping well at school Mother: yes C: do you have enough support to take care of her Mother: yes. But can you give her some contraceptive pills C: I know that you are very much concerned about your daughter. Once she starts getting her periods then I will prescribe some oral contraceptive pills. Because she is on antiepileptic drugs she needs OC pills containing high dose of estrogen. She needs those which contain 50 micrograms of estrogens in the combined pills because the antiepileptic drugs interact with the OC pills and decrease their efficacy. They need to be taken daily. As you are already taking care of her other medications also you will not finding any difficulty giving them to her daily. Apart from the pills there are also other modes of contraception also like injections and implants. Mother: thats fine but sometimes I think it would be better to get her sterilized. Can you arrange something like that for her to get her ovaries and uterus removed? C: I think you might know what sterilization means. Mother: yes C: well the procedure for which you are asking me is a permanent method of not getting periods. Even though you are the parent and care taker of Rebecca you cannot give consent for this procedure. You can take care of her medications and give consent for the OC pills as well but for the procedure of sterilization you cannot give the consent on her

behalf. Even though Rebecca is intellectually disabled and cannot give consent for the procedure she has every right to be treated like other people and it will only be indicated if it is in the medical interest of Rebecca. For such a procedure to be done we need to involve the Family court or the Guardianship Board. Mother: then I would like to file a case for this C: well if you are quite sure about that then you can go ahead. Mother: thank you AMC feedback: Contraception request. 3. You are in the ED. Your next patient is a 25 yr old primigravida who is 30 wks pregnant. Her blood group is A ve. She is complaining of bleeding since the last 1 hour and the bleeding is bright red. She is also having abdominal pain. You examined her and her vital signs are normal. On abdominal examination, the abdomen is not tense but a little bit tender and the fetal heart sounds are normal. Vaginal examination is not done. Your task is to take history from the patient, tell her about the investigations that she needs and further management. R: doctor, I am bleeding since the last hour. C: can I ask you few questions R: yes C: how was your pregnancy so far? Did you have similar episode previously? R: everything was normal until now C: are you having any abdominal pain R: a little bit C: any contractions of the uterus R: no C: are you feeling the fetal movements and did you observe any change like decrease in the fetal movements. R: no, they are normal C: do you have any dizziness R: no C: what about the 18 weeks ultrasound scan and is the placenta in the normal procedure R: the 18 weeks ultrasound scan is normal. It is a single pregnancy and the placenta is in normal position. C: did you have any miscarriages previously or any other procedures done on your private parts or on the uterus R: no C: any trauma to your tummy or any sexual intercourse before this bleeding episode. R: no

C: did you undergo any investigations at 28 weeks and did you receive any anti-D injection. R: yes, I received a shot of anti-D at 28 wks gestation C: any bleeding problems previously R: no. C: now we will be arranging some investigations for you like ultrasound scan to see the position of the placenta or any other abnormalities of the placenta and the uterus. Apart from that we will do the CTG to see the condition of the baby whether the baby is at risk like whether the baby is normal or distressed. We will send blood for cross matching and hold in case if you bleed again we need to keep blood ready to give you. We will send the blood for FBE and coagulation profile. We will be doing a test called indirect coombs test in which they will see if you have developed any antibodies against your babys blood cells. Another test called kleihaeur test is done to see if there are any fetal blood cells in your blood so that we can give you extra amount of anti-D injection depending on the amount of fetal blood cells. R: can I go home? C: no, you need to get admitted in the hospital for all these investigations to be done and I will ask my obstetric registrar to come and have a look at you so that he will be telling you what further management can be done. R: what could be the cause for the bleeding? C: the bleeding could be because of a condition called placental abruption in which the placenta gets separated from the uterine wall and can lead to bleeding so we need to do the ultrasound to see the degree of separation from the uterus. It can be due to placenta praevia in which the placenta is present in the lower part of the uterus covering the cervix but in your condition it is less likely as the 18 wks ultrasound scan is normal. R: is my baby going to be alright? C: it depends on your condition. If you continue to bleed and if the CTG shows abnormality then your baby will be at risk and then we need to deliver the baby. Even before that we might consider giving you blood transfusion and also steroid injections like betamethasone or dexamethasone. The steroid injections are given to enhance the fetal lung maturity because the baby is just 30 wks old so that the baby will not find it difficult to breathe once it is born. Do you have any other concerns? R: no AMC feedback: Placental abruption (mild).

PSYCHIATRY
1. You are an intern in the ED. You are now seeing an 18 yr old girl who suddenly lost her voice. She came to you in the ED at about 3 AM in the morning. Her mother is also in the same hospital and she is undergoing treatment for her terminal stage cancer. They belong to a

very religious Anglican Christian family. All the family members are praying for her mother and this girl lost her voice suddenly. Your task is to take history (she will nod her head in response to your questions), examine her with the equipment provided on the table, and explain diagnosis and management. Here the patient lost her voice suddenly. She did not have any sore throat, dysphagia, hoarseness of voice, regurgitation of fluids or any other medical illness. She is able to cough, make sounds and can say aaaahhh. She didnt have this problem previously. This is the first time that she developed this problem. She is studying in college, no problems with her studies. No past history of any psychiatric or medical illnesses. Not on any medications, no allergies. No family history of psychiatric illnesses. She doesnt drink or smoke or use any recreational drugs. On mental state examination, mood is normal, no hallucinations or delusions or thought disorder. No thoughts of harming herself or others. The orientation and memory are normal. On the table tongue depressor, pen torch, jug of water and glass are provided. On examination with the pen torch and the tongue depressor, uvula is in the centre and there is no redness or erythema of the throat. Examiner told that gag reflex is normal. On saying aaaahhhhh, uvula is in the centre. The patient can drink water and there is no pain or regurgitation of fluids on swallowing. The patient can cough. The condition that you are having is called conversion disorder. What happens in this condition is that emotional symptoms are suppressed and in their place certain physical symptoms are manifested. In your case as your mom is having cancer and you are feeling depressed about that, what happened is that the emotional symptoms like anger, agitation and anxiety which occurred because of your suffering are suppressed and in their place you are manifesting with the physical symptom of loss of voice. So, no need to worry about that and I will refer you to a psychologist and he will be doing cognitive behavioral therapy and he will help you to cope up with the stresses that you are having at the moment and helps you to face them. AMC feedback: Psychogenic dysphonia. 2. You are a HMO in the ED. Your next patient is 25 yr old man who is complaining of dizziness since this morning. He had past history of schizophreniform disorder and took medication for that and it was well controlled. Now, his wife thinks that he had relapse of his condition and she thinks that he became more suspicious about everyone and took him to a GP. The GP prescribed him Risperidone. The patient was not quite sure about the dose the GP prescribed. He took 2 tablets in the night and 2 tablets in the morning. Since then he developed the symptoms of dizziness. He now stopped taking the tablets and came to the ED.

Your task is to take history from the patient, examine the patient (you will be given only those findings you ask for) and tell him the diagnosis and management. The patient said that he developed dizziness since this morning. Whenever he is getting up from the chair or the bed he is feeling dizzy. There is no loss of consciousness or palpitations. There is no tinnitus. No other complaints. Not on any other medication and no allergies. No history of any medical illnesses. His job is fine and he doesnt smoke or drink alcohol or use any recreational drugs. He doesnt think that he is having any symptoms of schizophrenia but his wife thinks that he developed a relapse. Thats why he went to a GP and he gave him Risperidone and he took those tablets since yesterday. He doesnt know the dosage of the tablets that he took. On mental state examination, mood is normal, no suicidal or homicidal thoughts, no hallucinations, delusions or illusions. Thought process is normal, orientation and memory are normal. Judgment and insight are normal. On physical examination, vital signs temperature: normal, BP: 120/80 (lying) and 100/60 (standing), pulse rate: 80/min (lying) and 112/ min (standing), respiratory rate: 12/min Rest of the physical examination is normal. ECG is normal. No QT prolongation. The symptoms that you have developed are most probably because of the Risperidone tablets that you have taken. The dosage that you told me appears to be above the range of the daily dosage of the tablet that needs to be taken. Risperidone causes a condition called postural hypotension when taken in a higher dosage. What happens in orthostatic hypotension is that the BP suddenly becomes low when you get up from the sitting to standing position. So I want you to get admitted in the hospital now and the psychiatric registrar will examine you and he might consider decreasing the dose of the dose of Risperidone that you are taking or he may change you to other medication. At the end the examiner asked me a question: how will you exactly know how much dose he took? I told him that I will ask the patient or ask his wife or do blood levels of the drug, but he was not satisfied. Then I told him that I will ask the GP who prescribed him the medication. AMC feedback: Side effects of anti-psychotic medication.

MEDICINE AND SURGERY


1. You are in a GP practice. Your next patient is 25 yr old man who is recently diagnosed with idiopathic GTCS and he was seen by the neurologist and the neurologist started him on Tegretal (carbamazepine). The neurologist sent a referral letter to you telling

you that he started the patient on antiepileptic drug and that the patient is a motor cycle courier driver and he is getting married very soon. Your task is to talk to the patient and answer his questions. Explained to him about epilepsy and told him that we need to notify RTA that he is having epilepsy. He should not be driving until he is seizure free for about 3- 6 months. Then the patient asked me how he can earn money if he stops working and that he is getting married very soon. I told him that if he gets a seizure episode while driving then he is at risk of accident so it is better not to drive. Then I told him to discuss about his condition with his fiance. Take medication regularly and he needs to take the medication until he is seizure free for 3 yrs. Have regular follow-ups with the neurologist as well as the GP. Need to change his occupation and he is not eligible for certain jobs like working near deep sea or at heights or near heavy machinery. Avoid trigger factors like fasting, excessive physical activity, fatigue, looking at flashing lights, alcohol. Avoid some sports like swimming, rock climbing, deep sea diving and surfing. Then I told him that his medication needs to be changed according to the response. If he gets any seizure attack when he is at home his family members should know all the precautions to prevent him from getting hurt and they should call an ambulance if the seizure lasts more than 10 minutes and immediately take him to hospital. AMC feedback: Epilepsy idiopathic. 2. You are in a GP practice. Your next patient is 28 yr old woman who is having high BP recordings on separate occasions. The readings are 158/100, 154/98 and 148/94. She didnt have any past history of hypertension. She is of normal weight and the general appearance and physical examination of the patient are normal. Your task is to take history from her, organize necessary investigations and future management. Apart from the high blood pressure now, her general health is normal. She is not having any headaches, blurred vision, episodes of palpitations and tummy pains, no vomiting. No past history of any hypertension or any kidney problem. No family history of any medical illnesses. She is on the oral contraceptive pill since the last 3 years. She is not on any other medications. No h/o any allergies. She is a secretary in an office and no stresses in her life. She goes out for regular walks. She doesnt drink alcohol but she smokes 15 cigarettes per day. She doesnt use any recreational drugs. She eats normal healthy foods with lot of veggies. She drinks only one cup of coffee per day. We will organize certain investigations like FBE and haematocrit, urine analysis to check for any casts in the urine, serum electrolytes, blood urea, serum creatinine, serum

cholesterol levels, blood sugar levels and ECG to rule out any secondary causes of hypertension. From the history, you are having some modifiable causes of hypertension like the oral contraceptive pill and smoking. So stop taking the pill and instead of it you can use other forms of contraception like PoP, condom, depot provera or implants. Smoking can also contribute for hypertension. So try to cut down on your smoking or stopping smoking is the best option. Eat healthy food and go for regular walks. With the above measures and the life style modifications the BP will go down and I will review you in about in 1- 2 months. If during this period the BP doesnt come down or if you develop target organ damage then you might need medication. AMC feedback: Hypertension. 3. You are a HMO in the ED. Your next patient is 25 yr old man who is complaining of diarrhoea. He is a computer analyst and he is happily married. Your task is to take history, take examination findings from the examiner and discuss diagnosis and differential diagnosis and arrange investigations for him. In the history, the patient is having recurrent episodes of diarrhoea since the last few months and the present episode of diarrhoea since the last 2 weeks. Every day he passes 3-4 loose stools but since last night he passed 6 loose stools and it is associated with the passage of blood and mucus in the stools. There is no difficulty in flushing the stools. There is no foul smelling of the stool. He lost 5 kgs since the last few months and he is feeling hot since last night. There is no preference for hot or cold weather. His sexual history and drug history are normal. There is no family history of any bowel cancer or inflammatory bowel disease. He is not on any medications and he is not having any allergies. His job is very stressful but his family life is normal. He did not travel overseas recently and no possibility of food poisoning. He didnt see any doctor for this problem. No back pain, visual problems, aphthous ulcers or pallor. The diarrhoea is not related to any type of food. On examination: General appearance: no pallor or dehydration Vital signs: T 37.8, all others are normal Abdominal examination: inspection is normal, superficial palpation is normal, on deep palpation there is maximum tenderness in the left iliac fossa, and percussion is normal and on auscultation the bowel sounds are increased. On PR there are no hemorrhoids or any palpable masses but there is tenderness and you can see blood on the tip of the finger. Rest of the physical examination is normal. Provisional diagnosis: inflammatory bowel disease D/D: infective colitis, irritable bowel disease, carcinoma colon, celiac disease, malabsorption syndromes, thyrotoxicosis.

Investigations: FBE, stool examination for ova, cysts and parasites and also for culture and sensitivity, colonoscopy to look any lesions in the bowel and take a biopsy, barium enema after the acute episode, celiac disease screen, TFT. AMC feedback: Diarrhoea (recurrent). 4. You are in a GP practice. Your next patient is 45 yr old woman complaining of bloating since the last few days. She came to you previously and you examined her. The physical examination is completely normal and you arranged some investigations for her. Blood biochemistry and liver enzyme levels are normal. You arranged ultrasound also for her. A picture of the ultrasound scan was attached on the wall. It is showing 3 gall stones. (It is the same picture from the anthology book) Your task is to explain the ultrasound report to her by showing her what the problem is, discuss the management with the patient. I started the station by explaining to the patient the ultrasound report showing her the 3 gall stones in the gall bladder. Then I drew a picture showing the liver, gall bladder, common bile duct, pancreas and the small bowel and explained to her the complications of gall stones that it can cause acute cholecystitis, chronic cholecystitis, acute pancreatitis, choledocholithiasis, acute cholangitis, gall stone ileus. Acute cholecystitis can lead to gall bladder abscess and perforation. I also explained to her the mechanism of formation of gall stones. I said that I will refer her to a surgeon and the surgeon may consider doing surgery for her and it will be elective surgery rather than emergency cholecystectomy. The surgeon might consider doing laparoscopic cholecystectomy which is a key hole surgery and the surgeon will take the consent before the surgery that if any problem arises during the key hole surgery they might need to open the tummy. The procedure will be done under anesthesia. During the surgery they will be doing intra operative cholangiography to see if there are any other gall stones in the common bile duct. After the procedure you may need to stay in the hospital for a couple of days and will be discharged after that. In the mean time told her to avoid fatty foods. But she asked me about any medication for this before seeing the surgeon. I dont know what exactly she was asking me for but I told her that there is no need for any medication unless she develops any pain. Questions asked by the role player: Where are the stones in the ultrasound scan report? What type of surgery is done? Are there any complications during the procedure? How long do I need to stay in the hospital after the surgery? After the surgery can I develop the symptoms again or am I completely cured?

Can you give me anything for this bloating before seeing the surgeon? AMC feedback: Incidental gall stones. 5. You are working in general practice. Your next patient is 65 yr old man who is complaining of pain in his right leg since the last few days. The pain is increasing gradually. He likes to play golf and these days he is finding it difficult to walk in the golf course and he is getting pain in his right leg after walking for a few meters and it is relieved by taking rest. He has history of hypertension and he is on diuretic and ACE inhibitor. Apart from that his general health is normal. He smokes 15 cigarettes per day and he drinks alcohol occasionally. His BMI is 30. Your task is to examine the patient, tell the provisional diagnosis, organize investigations and discuss management. General appearance: normal Vital signs: normal CVS: normal, no carotid bruits. Lower limbs examination: on inspection the skin of the lower limbs is normal, no color change of the limbs, no hair loss, no edema, and no ulcers. On palpation, there is no temperature difference between the two limbs, there is no tenderness, CRT is normal, lower limb pulses are normal. Buergers test: is normal. Auscultation: normal. There is no aortic or femoral bruit. Provisional diagnosis: peripheral vascular disease (intermittent claudication) Differential diagnosis: lumbar spondylosis, benign cramps, osteoarthritis of knee Investigations: Doppler ultrasound of lower limbs to look for the blood flow and calculate ABI, FBE and haematocrit, blood sugar, serum cholesterol, ECG. Then I explained to the patient that it looks like PVD and all the above investigations need to be done. In the meanwhile life style modifications like maintaining normal body weight, avoiding fatty food, regular physical activity and stopping smoking. Questions asked: What is the significance of buergers test? What is the significance of aortic or femoral bruit? If the ABI is 0.25 what does it mean? To whom will you refer him? Will you stop the ACE inhibitor? AMC feedback: Leg cramps on exercise.

6. You are working in a GP setting. Your next patient is a 55 yr old woman who is complaining of right sided chest pain since the last few days. She had sigmoid diverticular disease and an abscess developed and the abscess was drained 6 weeks back. After that she was normal and now she developed this chest pain. On examination, the chest movements are decreased, percussion note is dull and breath sounds are decreased in the right lower lobe. The vital signs are normal apart from temperature which is 38. You sent her for some investigations and she is coming back to you with the x-rays. Your task is to interpret the x-ray and explain the x-ray findings to the patient, discuss the investigations and the management with the patient. When I entered the room, the role player gave me 2 x-rays, one is PA view and the other is lateral view. The x-ray showed pleural effusion on the right side. Then I explained to the patient that she is having pleural effusion. The patient is not having any breathlessness or cough. She is not feeling hot either but her temperature is 38. She is just having chest pain on the right side. Then I explained to her that it could be because of infection, connective tissue disorder, uremia, pulmonary embolism or malignancy. Investigations: FBE, ESR, Pleural fluid analysis: for microscopy and culture, biochemistry ECG, Blood culture, UEC, ABG, Ventilation perfusion scan, CT- scan chest. Then I referred the patient to the hospital and told her the management of her condition will depend on the investigation findings. Questions asked by the role player: What does the x-ray show? Can it be cancer? Do I need to go to the hospital now? AMC feedback: Pleurisy with effusion. 7. You are in a GP setting. Your next patient is a 25 yr old woman who is complaining of cyclical pain in her breasts since the last few months.

You arranged ultrasound for her and it showed a breast cyst. Then the ultrasound guided FNAC was done and the fluid was aspirated from the cyst and sent for analysis. Her mother was recently diagnosed with breast cancer at the age of 50 years The ultrasound scan report showing the breast cyst and FNAC result showing that the cells are benign is attached to the wall in front of the room. Your task is to explain the report to the patient and answer her questions. It is the same question from the AMC clinical book. (Case no: 137). The role player asked the same questions from the book. AMC feedback: Breast lump. 8. You are a GP. You are seeing a 65 yr old woman with terminal stage pancreatic cancer. She is already on morphine for pain relief. You know all her husband and son who are also your patients. She knows that her cancer cant be treated and her pain is also increasing. She wants you to give some medicine so that she can end her life. Your task is to talk with the patient and answer her concerns. It is euthanasia case from the AMC clinical book. (Case no: 124). This is the only station that I failed. AMC feedback: End of life request. STUDY HARD AND DO ALL THE RECALLS. DONT MISS THURSDAY CLASSES BY DR.WENZEL. I THANK DR.WENZEL FOR HIS HELP AND SUPPORT TO THE IMGs. TRY TO PREPARE FOR ALL THE CASES WELL IN ADVANCE AND DONT RUSH JUST BEFORE THE EXAM. STUDYING IN A GROUP AND DOING ROLEPLAY ARE VERY HELPFUL AND I AM LUCKY THAT I HAD A VERY GOOD STUDY GROUP. TRY TO RELAX THE DAY BEFORE THE EXAM AND HAVE GOOD SLEEP. GOOD LUCK TO ALL OF YOU PREPARING FOR THE EXAM.