AMC Clinical Exam Brisbane 24 February 2007

1. A businessman who heard about harmful effects of excess alcohol use and want to consult with you. (Counseling) : It was my second station and the first station was a rest station. There was a young gentleman who was the role player. After introducing myself to examiner and role player I as ed him how I could help him. !e told me he is a businessman and the other day heard about problem drin ing and now is concerned about his drin ing and wants some more information. I started to as how much has he been drin ing. "or example what you usually drin and how many drin s a day and when he was not sure about daily drin s I as ed about wee ly drin s. !e told me he drin s about #$ drin s a wee . Then I started to as about CA%& 'uestions and if he drin s during the day( or if he feels if he need any drin to settle. )y as ing the specific CA%& 'uestions I let the examiner now I am aware of the approach to the problem. Then I tal ed about health problems and social conse'uences of drin ing too much and then I explained about safe drin ing le*els and what is a standard drin . !e as ed if Alcohol already caused any damage to his body and I said we will now after some in*estigations. &xaminer as ed me what in*estigations+ I said some blood tests li e ")&( ,"T( and li*er -./ at first. Then I explained about a couple of points about benefits of safe drin ing (because I had extra time other wise I already mentioned them briefly) and as ed the role player if he has any more 'uestions or concerns. !e was happy and no more 'uestions. I ga*e him some written information and arrange for a follow up appointment in few days and also offered him to 0oin some support groups if he thin s it is difficult for him to reduce the le*el of drin ing. Then I as ed the examiner if he has any further 'uestions and he said no. I left the room before ring. I passed this station. 1

1. 2ash and allergic reaction on hands of a construction wor er. (3x and 4x) There was a picture and hands with rash and crusts and swollen on the door. There was a young role player in the room who said he has this rash for few months. And it is only on his hands (both of them). !e said they are itchy. I as ed what his 0ob was and he said construction wor er. I as ed if he changed his 0ob recently and he said yes. I as ed if the rash started after his change and he said yes. I as ed about any pre*ious treatment and allergies and tried to exclude and other exposure. Then I tal ed about wor safety stuff li e glo*es and goggles. And he said he does not use them. Then I told him it is an allergic reaction and needs treatment. I explained for him the best treatment is a*oidance and ad*ise him to change his 0ob. &xaminer said he can not change his 0ob. Then I said then you should discuss with your boss to do another duty which minimi5e the exposure and need to wear safety wears li e glo*es. As treatment I ga*e him oral antihistaminics and steroid cream (the picture was *ery se*ere reaction) and I warned him about /& of medications. I also told him to come bac for follow up as he may need some antibiotics if the wounds get infected. I ga*e him some written info about allergy and as ed if he has any other concerns. !e was happy and examiner did not ha*e any 'uestion. This station was also a short one. I passed this station. #. A child with meningococcal infection. 4other is worried. &xplain diagnosis and management.(4x) "rom the beginning you could say it was meningococcal meningitis from the history on the door. I the scenario it was said there were 1 other young children at home.

I introduce myself to examiner and the role player. I told her( her son has 4eningococcal meningitis and as ed her if she nows what it is. /he said yes( she heard about that. I explained the disease briefly and told her we will hospitali5e her son and gi*e I6 fluid and antibiotics and he may need to stay in hospital for few days. /he as ed me if I will transfer him to a larger hospital (7n scenario it said you are in a country hospital). I said not at this stage because we ha*e pediatrician at this hospital who can manage this disease. )ut she as ed again. This usually means I am on a wrong tract and I need to send the son to a larger hospital( but because I already insisted on eeping him in our hospital and told her we ha*e pediatrician I could not step bac . /o I reassure her we ha*e good pediatricians here and they can ta e care of her son and if we need to I will transfer her son to a larger hospital by air ambulance A/A8. Then she as ed me her son had immuni5ation so why he is sic . I explained about different strains and limitation s of the *accine that we ha*e. Then I as ed about child care and any other persons at home and she said yes he goes to child care. Then I explained about prophylaxis for young children at home and child care staff and children and about notifying the authorities. /he as ed if her son will sur*i*e and I reassured her. I as ed about any concerns. 9either she nor the examiner as ed any further 'uestions. I passed this station. :. ;ellow<brown *aginal discharge in a post menopausal woman. /exually acti*e. 3x and 4x) There was a woman in the room with the examiner. I introduced myself to both and as ed her to tell me more about the discharged. /he said it is a yellow<brown discharged and she has this problem for 1 months (I am not sure about the length of the complaint) she said she has itches. /he denied any specific smell. /he was not on any medication (no !2T). /he said she is sexually acti*e but denied the same symptoms in her partner.

I as ed for examination findings and examiner told me she had greenish discharge. I got confused because on scenario it said yellow< brown and the examiner said green. I was thin ing of bacterial *aginitis or atrophic *agina or = I could not ma e up my mind and I lost the tract. I am not sure how I managed her but I was not happy with the station myself. It was the only station I failed. >. 2heumatoid hand examination. 2eal patient. (examination) I was a real elderly patient in the room with almost all signs of 2A on his hands. ?hen I entered the room he already put his hands on a pillow and I started to explained was I saw one by one( following hand examination pathway on Talley @ 7AConnor 363. I finished early and had a chat with the examiner. )oth examiner and patients were friendly. I passed this station. B. immuni5ation schedule and side effects (Counseling) It was a *ery easy and strait forward station. I as ed the role player who was a young lady what she wants to now about the immuni5ation and she said all *accination from birth to school age. I started to explain the current schedule. I new the schedule by heart but if you want you could get a copy of it from the examiner. After I finished with the immuni5ation schedule she as ed about any side effect and I explained about possible minor side effects li e minor fe*er or tenderness on the site of in0ection. Also I explained about rare /& li e anaphylactic shoc . Then I explained contraindications (it was not the tas but because I new them and I had time I explained them to manage the time.) I also told her the new *accines ha*e less /& and I explained about ?hooping cough *accine (old and new ones). Then she as ed what if the baby is not immuni5ed. And I explained about the difference. The examiner was *ery happy with my explanations and than ed me and wished me good luc . I finished this station early. I passed this station.

C. :1.:$ pregnant( in labor( in a country hospital. 4econium satin but e*ery thing else normal. 4anage the patient. (4x) There were 1 ladies one examiner and one role player. The role player was a post term pregnant woman in labor in a country hospital. /he had #.> cm dilation at admission and now (after #$ minutes it was : cm). I as ed about past history and any medications and allergies. I as ed about antenatal care and any abnormalities. I as ed about any obstetrician follow up. I as ed about her -./. I as ed about any abnormality( discharge= (?hate*er you can thin of) and all was normal. Then I as ed the examiner about the examination findings and she said what specifically I want. ?hate*er I as ed was normal except she had meconium staining. I as ed if the membrane is ruptured and she said yes right now. I as ed about cord prolapsus and she said no. I as ed for CT% findings( was normal( -./ findings was normal( "!2 was 11>.min. I as ed about cephalo<pel*ic proportion which was 7D. And at the end examiner said what will you do now+ I said I consult with an obstetrician and she said Ethe obstetrician say go ahead and deli*er the baby. ?hat will you do now+F I was confused. &xcept meconium staining e*erything seemed to be normal but I could not get any clue from examiner or role player *oice or facial expression to now if I am in the right direction. I said if e*erything is 7D and obstetrician says go ahead( I will go ahead and deli*er the baby. The bell rang but I was not sure if I passed this station or not. "ortunately I passed this station. G. )eha*ioral change in >G year<old. 44/& 1>.#$ (test sheet presented). 3o another test and gi*e your diagnosis. (3x) There was a long scenario and a complete 44/& report on the door but I did not ha*e time to read the 44/&. /o first I thought they want me to perform the 44/&( and I was confident that I will do it. I started to as the patient the ice brea ing 'uestions and then 44/& 'uestions. )ut examiner interfered and said 44/& is done and the result is here and hand the result to me. And as me to do another test. I did not really now what they

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want. I started to as 'uestions to exclude depression (pseudodementia). Then I as ed the same 'uestions of the 44/& in a different format. I new it was not the answer but I had to say something and I could not sit there mute. Then examiner as ed me which part of the brain is affected. And I said fronto<temporal because there are many beha*ioral changes. Then suddenly I remember the cloc face test for frontal dementia. ?hen I said I would do cloc face test( examiner smiled and said do it. 9ow I new it is the answer and I was more relaxed. I did the test and as I expected patient could not put numbers in right position and I said I thin he has an early fronto<temporal dementia. I passed this station. H. 7xa5epam addiction in a young man. (3x and 4x) A young guy was sitting in the room and I as ed him how I can help him and he said he is bac for some prescription. I as ed few 'uestions and I understand he is on oxa5epam and he ta es #x#$mg oxa5epam a day for last wee and is bac for some more. I as ed some 'uestions to establish the diagnosis of dependency. !e said he needs them to sleep and after I pushed him he said he cant sleep with out them. !e said he would be anxious if he does not ta e them. !e denied getting prescription from other doctors. !e denied alcohol or other drug abuse. Then I as ed about his 0ob and stressors and family relations and social support. Then I explained for him that I thin he has drug dependency. "irst he refused to accept the diagnosis but after I explained the signs of dependency he did not deny any more (but he did not accept either). Then I told her we will manage this problem together and I will refer him to a drug and alcohol dependency center. I ga*e him some written info and arranged an appointment to see me in a couple of days for follow up. &xaminer as ed me if I gi*e him any more medications or stop it. I said I gi*e him a different ben5o with a lower dose (for example for 1<# days) otherwise he may ha*e withdrawal syndrome. I passed this station.

1$. Inade'uate asthma management in a young child. "ocused brief history and write action plan. (4x) It was case of a child who uses his relie*er se*eral times a day and still has few &3 admissions. I started to as mother about the history and the trigger factors but suddenly the examiner interrupted me and said it is not your tas . 3o your tas . At this moment I was so disrupted that it too a few seconds until I could say any thing. Then I stated to explain for her that her child does not get ade'uate medication and that is why he has these problems. I told her I would gi*e her an asthma action plan and add another puffer which is a pre*entor to her childAs medications. At this stage she pulled out a printed action plan with some blan parts and ga*e it to me. I started to fill in the blan s as I explained for her what a pre*entor is and how it wor s and how her son should ta e it. Then I as ed if she needs me to show her how to use the puffer but she said she nows. &xaminer as ed me if I need to as ed any other 'uestions and I said no. the examiner as ed me why did not you as ed about trigger factors and I said I was going to but you stopped me. !e did not say any thing and bell rang. I passed this station also. 11. "emale who had her first deli*ery as C./ and now wants her 1 nd deli*ery as *aginal. Answer her 'uestions. (Counseling) I introduced myself to examiner and the role player as usual. /he as ed me she was pregnant and it was her second pregnancy. /he was planing to ha*e her second deli*ery as *aginal deli*ery. !owe*er she had her first as C./. I was not sure about the answer. )ut I started to use common sense. I told her as the uterus is a muscular body and will under go a huge tension and pressure during labor( there is a possibility of a rupture in the uterine wall as the scar tissue which is there after C./ is not as flexible as the rest of muscular uterus. Then I said that I am not 1$$I sure how big the ris is and I will refer her to an obstetrician for a second opinion and antenatal care. /he was happy and then examiner as ed me what happens if the uterus ruptures+

I said it will bleed and it can be life threatening for both mother and baby. &xaminer was also happy about this. I passed this station. 11. "emale had cholecystectomy B.11 ago. 9ow has 2-J pain for few wee s and fe*er. 3iagnose and manage. (3x and 4x) After introduction I as ed her more about the history. I as ed when she had cholecystectomy did they remo*e any part of biliary duct or only the bladder and she said only gall bladder. I also as ed about any complications after operation and there was none. Then I as ed the examiner about the examination findings. !e said she is 0aundiced and tender in 2-J. /he was febrile and generally unwell. Then the examiner as ed me about my diagnosis. I said it can be a new stone formation in biliary system that causes 0aundice. Also it can be subphrenic hematoma or also it can be right lower lobe atelectasis as a post op complication (later when I thin about it I understand it was wrong because it was B.11 post op( but in the room I did not thin about it). Then I said because she is febrile a strong possibility is an infection li e cholangitis. Then examiner as ed me what else can it be+ I did not ha*e any more ddx. that includes fe*er and 0aundice. I had to say something and the most reasonable ddx in a middle aged or old lady with 0aundice that I could thin about at that time was neoplasm of head of pancreas. I said this and examiner wa*e his head in supporting my opinion. Then he as ed about management and I said to diagnose first I do an abdominal -./ and then if necessary CT abdomen. I also do some blood tests li e ")&( -@& and ,"T. )efore I go any further into management the bell rang and I had to lea*e. I passed this station. 1#. !ad pel*ic operation (drainage of sigmoid abscess) B.>1 ago. 9ow has pleuritic chest pain. !as K<ray with her. 3iagnose and manage. (3x and 4x) I as ed about the nature of pain and radiation and relation with breathing and mo*ement and any cough or phlegm and /7) and also if it started suddenly of built up slowly. /he had cough and sharp C8. /he did not gi*e any further info.

The CK2 showed a consolidation on right side (can be the left( I am not sure) and a small amount of pleural effusion. I started to explain for patient about the K2 finding. And I concluded it is pneumonia and the reason can be an aspiration during operation. And I will send her to hospital for further assessment and probably I6 antibiotics. The examiner as ed me can aspiration pneumonia occur B.>1 after operation. I understand it is not the answer they expect but I had to manage the situation. /o I said it is not *ery li ely and there are other ddx. li e 8& that can happen after pel*ic operations. Then examiner smiled and said go on. Then I turned to patient and continued. I said( as I told you before I am going to send you to hospital for further assessment which also may include a d<dimer test and according to the setting a 6J scan or CT8A. And I explained about the 8& and what these tests were. &*ery body was happy in the exam. I passed the station. 1:. Cut to the wrist. !and examination.(&xamination) It was an easy station. A young guy with a dressing on wrist. ;ou need to do hand examination. "inding were sensory loss on ulnar area and function loss of : th and >th finger. 3o not forget to do tendon examination and paper grab examination for ulnar ner*e. Lust follow Talley @ 7AConnor 363 The role player was acting *ery well and I was not allowed to open the dressing. I passed this station too. 1>. "ather died of 4I. explain the 4I to the daughter and answer her 'uestions. (Counseling) A young lady was sitting in the room as role player and loo ed sad. I introduced myself and as ed her how can I her. /he said she lost her father and they told her it was heart attac . )ut the report from coroner says a different thing. /uddenly I started to thin it is a medicolegal issue and I was about to get confused. Then she continued. It the report it says her father died of myocardial infarction due to atherosclerosis. At this time I recogni5ed it is a simple counseling. And it was important to remember there she was my patient not his dad.

I started to explain what 4I means and how atherosclerosis forms and how it causes heart attac . I left enough time to her to digest the information and as ed if she had any 'uestions. /he as ed about her possibility of ha*ing a heart attac . I explained for her that she has a family history and it is a ris factor. I also told her about oter ris factors li e being male( old age( smo ing( obesity( high cholesterol( !T( 34(= I told her we canAt change some ris factors li e age or family history( but we can modify the rest. I tal ed about weight lose (she was obese) and exercise and smo ing and chec up for !T and cholesterol and 34. I ga*e her some ad*ise about health diet and ga*e her some written info. I as ed her to see me again soon to discuss her impro*ement. I passed this station. 1B. B$ year<old man with hematuria for #.>1. 8!x of renal colic. 3iagnose and manage. (3x and 4x) There was an elderly role player in the room. I introduced myself and as ed about his complaint. !e said he has hematuria but no pain (or not much pain( I do not remember but the answer pushed me away from renal colic). !e said he has fre'uency and when I as ed more( he said he has dripllng and he feel he canA empty his bladder. I as ed about other symptoms of )77 ()ladder 7utlet 7bstruction). There were mostly positi*e. Then I as ed about examination findings. I had to as smooth regular surface. I told the patient that I thin he has a )77 and I explained for him what it was and what are the possible reasons. I told him howe*er I donAt thin he has a Ca prostate (I should not ha*e said this) but I would li e to do some tests li e 4/-( 8/A (and I then turn to examiner and said I collected blood before 82 exam) and pel*ic -./ and refer him to urologist for further tests which may include a cystoscopy for hematuria and biopsy of prostate. I ga*e him some written info about )77 and told him to go to &3 in case of acute retention. &*ery body was happy. I passed this station. what I was loo ing for. !e had minimal abdominal tenderness and palpable bladder and on 82 exam there was enlarged prostate with

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