6

th
April 2013 Melbourne Afternoon Group (Blue)
O & G
1. A 68 YO female ame to !our G" lini omplainin# of ra$h %ith $e&ere ithine$$ 'o%n belo%
for the pa$t 2 !ear$. You %ill be $ho%n a photo b! the e(aminer.
)a$*$+ )a*e hi$tor!,-e$ribe the ra$h of the photo to !our e(aminer. proee' aor'in#l!.
.i$tor!//// 0he ha$ been $ufferin# thi$ on'ition for 2 !ear$. 0he ha$ trie' Oe$tro#en ream but
it 'i' not help. 1o feature of hi$tor!, no menopau$al feature$, no '!$pareunia. "ap $mear reentl!
'one an' it %a$ normal. 0he ha$ 3 *i'$.
"h!$ial 2(am...0al! le$ion$ on labia ma3ora..., no $in#$ of infetion, atrophi feature$(4)
Other $!$tem e(amination$ are normal.
2(planation....5t i$ a *in' of 'ermatiti$ 6uite ommon in !our a#e. 5t i$ *no%n a$ lihen $lero$i$.
5 %ill #i&e !ou h!'roorti$one ream %hih %ill be &er! helpful, an' for the ithine$$, 5 an #i&e
!ou antihi$tamine. But %e 'o ha&e &er! important i$$ue to be a''re$$e'. )hat i$ !ou nee' to be
re&ie%e' b! a #!naeolo#i$t, to ta*e a $mall piee of t7$ from it to rule out aner beau$e $ometime
it oul' be a preur$or le$ion of 8a 9ul&a. 5 'o not mean that !ou %ill ha&e aner but %e 3u$t ma*e
$ure that it i$ not aner. : u happ! %ith thi$; <.
Feedback : Vulva Itch (Passed)
2. )hi$ 2= !ear/ol' primi#ra&i'a h' a normal &a#inal 'eli&er! b! mi'%ife 20 min$ a#o in a
ountr! 'i$trit ho$pital in %hih !ou are a .MO an' urrentl! on all for Obe$tetri untit.
)he "re#nan! ha$ been perfetl! normal. )he e$timate' bloo' lo$$ at 'eli&er! %a$ onl!
2=0 ml. .o%e&er 1=00 ml of bri#ht bloo' ha$ been pa$$e' in la$t 1= min$ an' the or' i$
$nappe' in the &a#ina. )he mi'%ife 3u$t phone !ou to a'&i$e !ou of the$e fat$ an' a$* !ou
to ome an' help %ith the patient>$ are. 0he ha$ #ot 5M O(!to(in 10 ? $oon after the
'eli&er!.
Your )a$*$
2(plain the patient about the on'ition.
A$* the e(aminer about the e(amination fin'in#$ an' !our mana#ement.
"t i$ alert an' on$iou$ but ha&in# lo% B" an' rapi' "ul$e$. 0o 5 mentione' that 5 %ill re$u$itate
her b! #i&in# flui' an' probabl! bloo' after 'oin# the bloo' te$t$ (@B8, 8oa#ulation profile,
Groupin# an' mathin#).
)hen 5 a$*e' the e(amination fin'in#$ fou$in# on ab'omen an' &a#inal e(amination( ?teru$ i$
flabb!/ 2 to 3 m abo&e the umbiliu$ an' annot in$pet &a#ina 'ue to the or'). Other
e(amination$ %ere normal.
5 e(plaine' the pt that $he ha$ #ot a on'ition alle' retaine' plaenta that mo$t probabl! 'ue to the
poor ontration of the uteru$. )he other rea$on i$ the fat that the plaenta i$ a'here' &er! 'eepl!
to the uteru$. )hen 5 al$o tol' her that her B" %a$ lo% 'ue to e(e$$i&e bloo' lo$$ for that $he mi#ht
nee' bloo' tran$fu$ion althou#h %e #a&e her plent! of flui'.
)hen 5 tol' her that %e %ill #i&e her O(!toin infu$ion to ma*e her uteru$ ontrat better an'
normall! plaenta $houl' be 'eli&ere' %ithin 1= to 30 min$ after the bab!>$ 'eli&er!. 2(aminer
a$*e' me that ho% 5 %oul' 'o to ma*e uterine ontration better. 5 an$%ere' that %e an tr!
O(!toin infu$ion, then 5M er#ort or "9 pro$ta#la'in. )hen 5 ontinue' to e(plain the pt that %e
mi#ht probabl! nee' to ta*e the plaenta out manuall!. 0he a$*e' me if 5 %ill be 'oin# the
proe'ure on m! o%n. )hen 5 remember imme'iatel! an' tol' her 5 %ill all ob$tetri re#i$trar to 'o
that a$ 5 am 3u$t .MO. ( ho% nie $he i$)
At that time e(aminer a$* me %hether the proe'ure %ill be 'one in labour room. )hen 5 an$%er
that %e %ill $en' her in O) an' manual remo&al %ill be 'one un'er $hort GA b! the ob$tetri
re#i$trar.
)hen e(aminer a$*e' me if blee'in# i$ not ontrolle' e&en after plaenta 'eli&er!, %hat 5 %ill 'o.
5 $ai' that 5 %ill fin' out the au$e of blee'in# e# tear in &a#ina, in$petion of plaenta for
ompletene$$ to rule out :"O8. )hen he tol' me !ou 'on>t fin' an! rea$on, %hat 5 %ill 'o. 5 $ai'
%e mi#ht probabl! thin* of the other rea$on li*e -58 an' 5 a$* him a#ain the blee'in# i$ lotte' or
not.
)hen 5 $ai' %e mi#ht thin* of 'oin# laparotom!, then 'oin# uterine arter! or internal ilia arter!
li#ation or h!$teretom! if in'iate'. )hen the ob$er&er a$*e' me %hat 5 %ill 'o if pt ha$ -58. 5
$ai' 5 %ill #i&e her fre$h bloo' or @@". )he bell run#.
( 5 mi$$e' to pa$$ urethral atheter )
Feedback: Primary Postpartum Haemorrhage (Passed)
3.2A!ear/ol' primi#ra&i'a ome$ to !ou to 'i$u$$ about her 'eli&er! at 20 %ee*$ of pre#nan!. .er
frien' ha$ 'eli&ere' a bab! b! B080. 0he al$o hear' that ha&in# B080 pre$er&e her pel&i mu$le$,
an' her &a#inal %all %ea*ne$$.
Your )a$*$..
)a*e the hi$tor!.( All in&e$ti#ation ha$ been 'one an' all normal) for 3 minute$ ( "h!$ial
e(amination i$ not nee'e' to be 'one)
8oun$el about B080 9$ normal 'eli&er!.
.i$tor!... "rimi#ra&i'a , planne' pre#nan!, too* O8" before, "A" $mear reentl! 'one an'
normal. 1o ompliation$ $o far 'urin# pre#nan!, feel bab! mo&ement normall!, Bloo' #roup O4,
1o blee'in# '7o, no pre&iou$ $ur#er!, 1o 'ru# aller#!
8oun$ellin#... Ce 'on>t normall! reommen' B080 %ithout 'efinite in'iation$ a$ it ha$ ma! ri$*.
5t i$ an operation 'urin# %hih a $mall ini$ion i$ ma'e on !our tumm! %all an' ut the uteru$ to
ta*e out the bab!. 5t i$ 'one un'er anae$the$ia an' $he %ont *no% or feel it. But there are $ome ri$*$
e#, ri$* of GA7BA li*e lo% B" an' $ho*, aller#i reation, blee'in#, in3ur! to near b! or#an in
tumm!, infetion, lon#er ho$pital $ta!, inrea$e ri$* of "2, bab! ha$ a ri$* of tran$ient apnoea atta*
a$ $eretion$ form the lun#$ not $6ueeDe' out. )he benefit i$ an pre$er&e pel&i mu$le <
:e#ar'in# 9a#inal 'eli&er!, lo% ri$* of blee'in# an' infetion$, $hort ho$pital $ta!, 1o% %e al$o
offer total pain relief 'urin# normal 'eli&er! (2pi'ural )
5 %ill #i&e !ou $ome rea'in# material$ to *no% it better...
)hen role pla!er a$*e' me an!thin# el$e...
5 tol' her that B080 limit the number of 'eli&erie$ ( ? an ha&e onl! 3 hil'ren)... Bell run#.
5 mi$$e' to tell her that ompliation$(?terine rupture) 'urin# the future pre#nanie$.
Feedback: Request for elective aesarea! "ectio! (Passed)
8hil' .ealth
A.You are in G" an' a = !ear/ol' bo! %ho reentl! omplain of ha&in# fre6uent urination an' be'
%ettin#. .e i$ %ell 'eh!'rate' an' no other $peial omplaint$. ?rine 'ip$ti* $ho%e' =4#luo$e,
an' 24Eetone. B0B 23 mmol7'l.
)a$*$
2(plain the on'ition of the hil' to the father.
An$%er hi$ father>$ 6ue$tion.
2(plain about !our mana#ement plan for him.

2(planation... 1o $peial hi$tor!, no fe&er, no &omittin#, hil' i$ %ell. 5 e(plaine' that !our $on
ha$ a on'ition alle' -iabete$ an' a$*e' him ho% muh he *ne% about -M. .e $ai' no. )hen 5
tol' him that in our bo'!, panrea$ $eret a hormone alle' in$ulin to *eep bloo' $u#ar le&el normal
in the bloo'. 5n !our $on a$e, in$ulin i$ not $erete' enou#h to ontrol bloo' $u#ar le&el that>$ %h!
hi$ B0B i$ &er! hi#h an' the ell$ annot u$e $u#ar. 0o the ell$ u$e' other thin#$ li*e fat an' *etone
i$ e(rete' a$ a b! pro'ut. A$ a re$ult, %e ha&e foun' #luo$e an' *etone$ in hi$ urine. )hat *etone
an 'ama#e hi$ bo'! or#an. @ather a$*e' me %hat i$ the rea$on. 5 $ai' %e 'on>t *no% 'efinitel! !et
an' probabl! hi$ bo'! pro'ue a hemial alle' antibo'! to atta* the ell$ in panrea$ %hih
pro'ue in$ulin.
:e#ar'in# Mana#ement, 5 %ill refer him to ho$pital, %e nee' a'mi$$ion. .e %ill be treate' b!
pae'iatriian$ an' the! %ill ta*e the bloo' for @B2, ?&2, B0B,.... 1o% he mi#ht ha&e eletrol!te
imbalane that nee' to be ur#entl! orrete' b! #i&in# him 59 flui'. )he mo$t important thin# i$ to
lo%er hi$ #luo$e le&el, %e %ill #i&e him 59 in$ulin. One on'ition i$ $ettle' 'o%n %e %ill #i&e
him 08 in$ulin. 0ometime he mi#ht al$o ha&e infetion$ in hi$ bo'! %ith thi$ on'ition. 0o %e
mi#ht nee' to ta*e bloo' or urine ulture.... an' treat it.
@or lon# term, he %ill nee' in$ulin life lon# to ontrol hi$ $u#ar, normall! t%o time a 'a! b! #i&in#
08. Chen he i$ 'i$har#e the 'otor$ from ho$pital %ill teah !ou ho% to #i&e in$ulin 08. )o
monitor hi$ $u#ar le&el he mi#ht nee' to 'o B0B te$tin# 3 to A time$ a 'a!. Be al$o a%are of
h!po#l!aemia < then the bell run#.
Feedback: #e$ly diag!osed child diabetes mellitus(Passed)
=.G" $ettin#, 18month$ ol' bab! %a$ 'i$har#e' from 2- !e$ter'a! %ith the 'ia#no$i$ of a$thma
%ith &entolin inhaler. Mother 'oe$ not *no% ho% to u$e &entolin inhaler an' $paer. (Bon# $tem$)
Your )a$* <.
)a*e the hi$tor! for $e&erit! a$$e$$ment of hi$ a$thma not more than 3 min$
A$$e$$ the tehni6ue ho% mother #i&e &entolin to him
A'&ie ho% to u$e $paer an' &entolin to mother.
.i$tor!.... infre6uent intermittent atta*, 3 time$ of atta* %ithin 6month$, fe% 'a! an' ni#ht
$!mptom$, ne&er u$e' &entolin before, not *no% tri##er, an pla! ati&el! %ithout ha&in# 0OB,
father ha$ #ot a$thma %hen he %a$ !oun# but no% #re% out of it, no $mo*er at home, #oo'
&entalation, no onern about #ro%th an' 'e&elopment, immuniDation up to 'ate... (9entolin puffer
an' 0paer are on the table but no ma$* on $paer)
A$$e$$ment... $he pre$$ &entolin 3 time$ $trai#ht into puffer an' $he $ai' $he 'ont *no% ho% to u$e
it.
5 $ai' the %a! $he 'i' i$ not orret. )o u$e $paer an' puffer effeti&el!, $he $houl' ma*e orret
hoie of ma$* that ha$ to o&er the hil'>$ no$e an' mouth not too bi# or $mall. 0ha*e &entolin
puffer before u$in# it. 5f it fini$he$, !ou annot hear the $ha*e or nothin# %oul' be relea$e' %hen
!ou pre$$ puffer. )o u$e it after $ha*in# puffer, attah to the $paer,put the ma$* on hi$ fae then
pre$$ puffer one time an' let him to ta*e A breath$ then #i&e him another 'o$e...
)hen $he a$*e' me ho% $he an ta*e are of $paer. 5 $ai' 3u$t %a$h $paer 2 to 3 monthl!, 'ont
%ipe or bru$h then let it air 'r!. )hen 5 e(plaine' her to #i&e puffer %hene&er the hil' ha$ 'r!
ou#h, %heeDin# or 0OB.
)hen 2(aminer a$*e' me to tell her about the $ummar! of m! hi$tor! an' %hat to 'o. 5 tol' her that
her hil' ha$ #ot a$thma atta* intermittentl! an' infre6uentl!. )hen 5 e(plaine' her a$thma ation
plan %hat to 'o %hen he i$ %ell, %hen he i$ un%ell an' 'urin# the atta*.
Cell mean$ intermittentl! an' infre6uentl!, u$e &entolin prn.
?n%ell mean$ fre6uent 'a! an' ni#ht a$thmati atta*, 3 time of &entoline u$e 'urin# a %ee*,....
.e mi#ht nee' to u$e pre&enter at that time an' a$* her to ome ba* to me...
-urin# a$thmati atta*, u$e &entolin A(A(A if not relief, 'ial 000.
5 $ai' 5 %ill #i&e opie$ of ation plan to her...
)hen 5 %a$ bout to tal* a$thma tri##er$ , then the bell run#..
Feedback:%&plai!' demo!strate a!d check use of (ro!chodilator )*I a!d spacer (Paediatric)
6.Boo* a$e 8on'ition F6 A"0G1
.i$tor!.. the hil' ha$ #ot $*in ra$h on hi$ hee* 2 %ee*$ a#o, it impro&e b! it$elf %ithout an!
me'iation$.
Feedback: Haematuria i! a child(Passed)
Me'iine an' 0ur#er!
F.Boo* a$e 8on'ition 33... Beni#n 2$$ential )remor %ith hea&! alohol 'rin*in#
Feedback: +remor (Passed)
8.Boo* 8a$e 8on'ition AA... A$$e$$ment of a omato$e patient
"o$iti&e fin'in#$ < G80 8 to G, ne* $tiffne$$, inrea$e tone an' *nee refle( on ri#ht lo%er limb.
Feedback: oma (Passed)
G.68 !ear/ol' la'! fell on her ri#ht out$trethe' han' an' #ot the pain an' $%ellin# on her ri#ht
%ri$t. 0he &i$ite' !ou in 2- an' H ra!$ ha$ been 'one. ( H ra!$ piture %a$ #i&en)
)a$*
(a) 2(plain the fin'in# of H ra!$ to the patient.
(b) -i$u$$ !our follo% up an' mana#ement plan %ith patient.

@rature on the 'i$tal en' of ri#ht ra'iu$ an' an#ulation %ith po$terior 'i$plaement an'
impation an' thi$ i$ al$o alle' olle>$ frature. 2(aminer a$*e' me %hat el$e 5 $ee in the H ra!$. 5
'i' not $ee an!thin# el$e an' arpal bone$ are intat. 0o 5 $ai' 5 'ont $ee an!thin# el$e an' 5 oul'
not $ee arpal bone$ learl!. 5t i$ probabl! 'ue to poor 6ualit! of photo. (After e(am 5 ima#ine if
there mi#ht be o$teoproti feature in that)
)hen 5 tol' her that 5 am #oin# to 'i$u$$ %ith orthopae'i re#i$trar. .e mi#ht ome an' a$$e$$
!ou then %ill 'o re'ution un'er anae$the$ia (0hort GA) an' put the pla$ter on. 2(aminer a$*e'
ho% far "O" #oe$.5 $ai' from metaarpophal#eal 3oint to belo% elbo% in $emi prone po$ition an'
arm $lin#.
)hen 5 $ai' %e %ill 'o rehe* H ra!$ an' $he ha&e to be follo%e' up b! a G" or me in 2Ahr$. But
if $he e(periene pain, olour han#e$, numbne$$..... , ome ba* here. Ce nee' to remo&e the
pla$ter... )hen 5 mention ph!$iotherap!..... an' $he %ill $ta! %ith that for A to 6 %ee*$ 'epen'in# on
her on'ition. 5f it i$ not heale' until that time, $he mi#ht be $ta!in# %ith that up to 8 %ee*$ or
lon#er.
5 al$o mention about o$teopro$i$()hinnin# of the bone$) an' a$* her %hen $he #ot to menopau$e
an' if $he #ot .:). 0he $ai' no. )hen 5 $ai' there mi#ht be o$tepro$i$ an' $he mi#ht #et -2HA
$an 'one. 5f $he ha$ O$teopro$i$, $he ma! #et bi$pho$phonate an' enoura#e her to eat more
alium, 9it -, 'o more e(eri$e, $un e(po$ure....
Feedback: olles fracture of the $rist(Passed)
10.You are .MO in 2- of a rural ho$pital. A =0 !ear ol' la'! %ho i$ on 'ial!$i$ ame an' &i$ite'
!ou for the omplaint of palpitation. .eart rate i$ F=. )he piture of 28G ha$ been $ho%n
(9entriular )ah!ar'ia). (Bon# $tem)
Your )a$*$,
(1)-e$ribe 28G fin'in# to e(aminer.
(2))a*e fou$e' hi$tor! not more than 3 min$.
(3)A$* in&e$ti#ation from e(aminer.
(A)2(plain !our mana#ement plan to the patient.
2(aminer i$ "rof Iohn Muta#h. 5 a$*e' him if m! patient %a$ thermo'!namiall! $table or not.
.e $ai' her &ital$ %ere #i&en in the $tem. (Atuall! onl! .: %a$ mentione' %hih i$ F=) an' a$*e'
me to proee'...
5 $ai' %i'e omple( J:0 omple( %ith re#ular heart beat. 5t i$ 9entriular tah!ar'ia.
.i$tor!... #ettin# 'ial!$i$ one 3 'a!$. .er 'ue i$ tomorro%. 0he i$ not feelin# %ell an' palpitate'
$ine !e$ter'a!. 1o faintin#, no 'iDDine$$, no he$t pain,...., no fe&er.... Gettin# 'ial!$i$ o&er 3
!ear$.... ta*in# me'$... (a li$t of me'iation$ %a$ $ho%n b! the patient)
Chen 5 a$*e' @B2 ( normo!ti normohromi anaemia), B0B normal , ?&2 ( E4 F.2, lo% 1a,
hi#h reatine an' urea ) M# an' 8a not 'one !et...
)hen 5 tol' the patient that her pota$$ium le&el i$ &er! ni#ht no% an' it i$ affetin# her heart. 0o
her heart i$ beatin# abnormall! an' it i$ *no%n a$ 9). 5t i$ a $eriou$ on'ition an' it an lea' to a
ri$i$. 0o !ou %ill be un'er our ob$er&ation an' put on ar'ia mornitor. )o protet !our heart, %e
%ill #i&e !ou 59 alium #luoronate. )o lo%er E4 le&el, %e %ill #i&e !ou 5n$ulin an' #luo$e, 1eb
9entolin an' re$in to 'erea$e E4 ab$orption from !our bo%el.
)he mo$t important thin# %e nee' to 'o i$ ur#ent 'ial!$i$. Ce %ill refer !ou to neare$t ho$pital
%hih ha$ 'ial!$i$ failitie$. 0he a$*e' me if $he an #o an' 'ri&e there. 5 $ai' no an' %e %ill
arran#e ambulane ur#entl! to tran$fer her to 'o 'ial!$i$. <.
Feedback: Hyperkalaemia i! %"R* (Passed)
11.=3 !ear/ol' la'! ome$ to !our G" lini omplainin# of 0OB o&er a perio' of time.........
)a$*
)a*e hi$tor! not more than = min$
A$* "h!$ial e(amination fin'in#$ from e(aminer.
-i$u$$ !our mana#ement plan %ith the patient.
.i$tor!... 0OB o&er 6 month$, #ettin# %or$e, 0OB on e(ertion but an 'o 'ail! ati&itie$, no
orthopnoea, no paro(!$mal noturnal '!$pnoea, no oe'ema, but 'r! ou#hin# (4), no %ei#ht lo$$,
no fe&er, no appetite han#e, no he$t pain <.. 0he ha$ been $mo*in# o&er 30 !ear$, 3= i#arette$
per 'a!, $oial 'rin*er, no other po$iti&e hi$tor! .
2(amination+ 2(aminer #i&e me a ar' ontainin# the fin'in#$... 'erea$e breath $oun' an' &oal
re$onane on ri#ht lo%er $i'e of the he$t %ith 'ullne$$ on that area. 890 e(amination i$ normal.

Mana#ement+ You are probabl! $ufferin# from a on'ition *no%n a$ pleural effu$ion. 5 %ill e(plain
a bit more about that. 1ormall! there are t%o la!er o&erin# the lun#$. 5n !our a$e there i$ a flui'
olletion bet%een the$e t%o la!er$ an' it i$ *no%n a$ pleural effu$ion %hih ompre$$ on !our
lun# that>$ %h! !ou oul' not breath properl!. )o onfirm thi$, %e nee' to 'o 8H:. Another
po$$ible au$e i$ infetion in !our lun#.
Ce ha&e one more important i$$ue to be a''re$$e'. )hat i$ the un'erl!in# au$e. "leural effu$ion
happen$ $eon'ar! to un'erl!in# au$e %hih %e nee' to be 'i$o&ere'. 5n !our a$e %e nee' to
rule out mali#nan!(8aner in the lun#). 0o 5 am #oin# to or#ani$e $ome in&e$ti#ation$ li*e @B2,
?&2, <.. 8) $an an' probabl! bronho$op!. 5 %ill al$o a'mit !ou to ta*e the flui' out from the
pleural a&it!. Ce an al$o 'o $ome te$t li*e plural flui' anal!$i$.
0he a$*e' me $he i$ ha&in# lun# aner. 5 $ai' 5 'ont $a! $o but there i$ a po$$ibilit! beau$e of her
lon# term $mo*in# hi$tor!. <
Feedback: "hort!ess of (reath(Passed)
12. 2= !ear/ol' man %ho i$ .59 po$iti&e ame to $ee !ou a$ he i$ ha&in# $ome hot an' ol' feelin#
o&er a fe% 'a!$.
)a$* <
)a*e .i$tor!
A$* ph!$ial e(amination fin'in#$ from e(aminer
Mana#ement plan.
.i$tor!.. .e i$ homo$e(ual,'ia#no$e' %ith .59 o&er = !ear$, not ompliane %ith A:), mi$$e$ la$t
.59 lini appointment, not *no% hi$ 8-A $tatu$. .a&in# fe&er %ith hill an' ri#or, no urinar!
$!mptom$, no ab'ominal pain, 'r! ou#hin# %ith 0OB on e(ertion (4) o&er a %ee*, no ra$h.1o
other po$iti&e fin'in#, a%are of $afe $e(, hi$ partner i$ fine, aller#i to peniillin. 1o )B ontat, no
reent tra&ellin#.
"h!$ial e(amination+ )emperature i$ o&er 3G>8 %ith GAK 0aO2, All other e(amination$ are
normal. 1o renal an#le ten'erne$$, no abnormal breath $oun', urine 'ip$ti* normal.
Mana#ement+ 5 tol' him that he i$ mo$t po$$ibl! $ufferin# from infetion in the lun#$ %hih %e
alle' pneumo!$ti pneumonia ("8"). @or that 5 %ill a'mit !ou to the ho$pital. )here $ome bloo'
te$t$ (@B2, ?&2, <), 8H: %ill be 'one. )o onfirm the 'ia#no$i$ %e an ta*e the $eretion from
!our phar!n( an' 'o "8:. @or the infetion, %e %ill put !ou on 8otrimaDole %hih i$ antibioti
orall!. 5f the infetion i$ not re$pon$i&e, %e %ill han#e to 59 antibioti.
)he mo$t important thin# i$ to ta*e A:) a$ thi$ infetion too* plae a$ !ou 'i' not ta*e anti&iral
therap!. )hen e(plain 'ifferene bet%een .59 an' A5-0 an' ho% important the ompliane %ith
me'iation$ i$.
.e a$*e' me %hat are the other po$$ible au$e$. 5 $ai' there are ouple$ of thin#$ li*e )B, other
he$t infetion$ li*e A&ian 5ntraellularlae omple(.... Bell :un#.
Feedback: Fever i! a! immu!o,compromised patie!t(Passed)
13.A A= !ear ol' patient &i$ite' !our G" lini omplainin# of upper ab'ominal pain. .e %a$
reentl! 'i$har#e' from 2- %here he %a$ treate' for ab'ominal pain an' ?00 $ho%e' #all $tone$.
1o% he i$ $ufferin# from inrea$in# ab'ominal pain.
)a$*.
.i$tor!
"h!$ial 2(amination
Mana#ement
.i$tor!... pain i$ A/=710, in epi#a$trium, ra'iate to ba*, no nau$ea an' &omitin#, no fe&er, no
3aun'ie, no urinar! problem, no han#e in olour of urine an' $tool, no ithine$$, no %t lo$$, no
appetite han#e, <.. $mo*in# about 1= i#arette$ for 20 !ear$, ta*in# 5buprofen for ba* pain <..
"2 <. All fin'in# are normal
Mana#ement... 5 $ai' it i$ probabl! 'ue to "?-(Ga$triti$ or uler in the $tomah) althou#h he ha$
#ot #all $tone. )he rea$on i$ he i$ ta*in# 5buprofen %hih ha$ irritation effet on $tomah. 0mo*in#
i$ al$o a$$oiate' %ith thi$ on'ition.
@or thi$, 5 %ill #i&e !ou a pre$ription of ""5 an' M!lenta < )he mo$t important he $houl' 'o it to
$top ta*in# 5buprofen. 5 al$o enoura#e !ou to on$i'er to 6uite $mo*in# an' 5 am here to help !ou
for that %e an 'i$u$$ later about that. 5 %ill al$o or#ani$e $ome 5n&e$ti#ation$ to rule out $ome
other au$e$. Ce %ill 'o @B2, B@), ?&2 < an' ?00 ab'omen to rule out #all bla''er au$e$,
28G to rule out heart atta* an' OG0 $ope an' . p!lori te$t to onfirm the 'ia#no$i$. -epen'in#
on the re$ult he mi#ht nee' to ta*e antibioti$. <...
Feedback: -allsto!es or Peptic .lcer(Passed)
1A.8F !ear ol' man 'ia#no$e' %ith 8a olon an' 'i' $ur#er! to'a!. )he aner i$ $prea'in# to the
%hole ab'omen an' li&er. You are .MO in $ur#er! %ar'. .i$ 'au#hter i$ a nur$e %ho 'oe$ not
%ant to her father *no% about hi$ on'ition.....8on$ent ha$ been #i&e to 'i$u$$ the i$$ue %ith hi$
'au#hter. ( lon# $tem)
)a$* <
)al* to the patient 'au#hter
)he role pla!er *eep$ tal*in# that $he i$ &er! %orrie' about her father on'ition. 0he 'oe$ not %ant
to *no% her father hi$ on'ition. .er father u$e' to be a $tron# an' in'epen'ent man. 6 month$ a#o
her mother 'ie' an' he i$ a bit 'epre$$e'. 0he thou#ht he oul' han'le thi$ $ituation.0he %ant$ me
to hol' the 'i$lo$ure to her father until patholo#! re$ult ome$ out. 5 $ai' $o $orr! to hear hi$ father
$tor!. Ce %ill a$$e$$ hi$ re$pon$e... 5f he i$ %ell orientate' an' %ant$ to *no% about hi$ on'ition 5
%ill ha&e to 'i$lo$e the operati&e fin'in#$. 2&er! patient ha$ a ri#ht to *no% their o%n on'ition
an' in&ol&e in the 'ei$ion of further mana#ement plan. 5 %ill al$o arran#e famil! meetin# if he
allo%$ to 'o $o.
)hen $he a$*e' me to hol' the 'i$lo$ure for 2A hr$ a$ he 3u$t #ot $ur#er! to'a! an' thi$ ba' ne%$
%oul' be impat on him.... 5 $ai' 5 an $ee ho% muh thi$ $ituation i$ har' for her an' her famil!. 5
al$o tol' her that her father i$ &er! lu* to ha&e $uh a &er! arin# an' lo&in# 'au#hter li*e !ou. 5
al$o appreiate' her onern an' heere' her up. 5 al$o trie' to tal* other mana#ement plan li*e
palliati&e are. 0he $ai' $he i$ a plliati&e are nur$e an' $he *no%$ e&er! *in' of $upport an'
$er&ie$. +(
But 5 tol' her that 5 %ill a$$e$$ him $oon an' if he full! reo&er$ from GA, %ell orientate' an' a$*$
me about the operation 5 ha&e to 'i$lo$e him. 5 al$o tol' her that before 'i$lo$ure 5 %ill a$* the
permi$$ion from him to #et her aroun' u$ li*e famil! meetin#. <
0he $ai' $he 'o$e not a#ree an' %ant me to hol' 3u$t for 2A hr$...
5 faile' to on&ine her an' 5 *eep$ tal*in# about patient ri#ht an' 'e$ire....
@inall! $he $ai' 5 am not happ! %ith !ou an' then Bell run#.... +(
Feedback: olo! a!cer cou!selli!g(Failed) as I e&pected
1=. A0 !ear/ol' patient %ho ha$ been 'rin*in#..... .You ha&e $een him la$t %ee* an' inrea$e' BM5
an' B" 1F07G=mm# an' other$ normal. You arran#e' $ome in&e$ti#ation$
@B2.. 'erea$e M89
B0B... 1ormal
B@).. inrea$e GG)
One more left < %hih i$ normal.
)a$*..
2(plain the re$ult$ to the patient.
A$* the e(amination fin'in#$ from e(aminer
-i$u$$ mana#ement plan %ith the patient. (1o hi$tor! ta*in# re6uire')
2(planation.... )he te$t re$ult$ are not &er! ba'. Beau$e of hroni alohol 'rin*in#. )he li&er i$
affetin# a bit $ho%in# inrea$in# one enD!me$ from the li&er, $iDe of :B8 i$ inrea$e.
2(amination.... All normal e(pet B" 1F07G=mm.#.
Mana#ement... 5 ha&e e(amine' !ou an' e&er!thin# i$ normal e(pet hi#h B". 5 ha&e notie' that
!ou ha&e been alohol a bit too muh. )hen 5 a$*e' him 8AG2 6ue$tion$. Aor'in# to that he i$
not alohol 'epen'ent. 0o 5 tol' him that 'rin*in# alohol i$ one of the ontributin# fator$ for hi#h
B". 5 al$o mentione' that to re'ue' alohol to the $afe le&el an' e(plain %hat the $afe le&el i$.
)hen he a$*e' me %hat i$ one $tan'ar' 'rin* of alohol. 5 $ai' it 'epen'$ on t!pe$ e#, one bottle
32= ml of beer i$ one $tan'ar' 'rin* of alohol. 5 al$o $ai' life $t!le han#e$ ( re'ue alohol,
e(eri$e, 'iet et).5 tol' him that he $houl' 'o tho$e thin#$ fir$t for a fe% %ee*$ unle$$ hi$ B" i$ not
%ell ontrolle' %ith tho$e mea$ure, %e %oul' on$i'er to put him on me'iation$ for .)1.
.e al$o a$*e' me if he oul' ta*e me'iation %ithout re'uin# alohol 'rin*in#. 5 $ai' %ithout
that mea$ure, %e %ont be able to ontrol B". 5 al$o mentione' other effet$ of alohol li*e $oial,
ai'ent$ an' other health i$$ue$.
Feedback: /lcohol use a!d sequelae(Passed)
16. 2F !ear$ ol' "h- mathemati$ $tu'ent han#e' her the$i$ title from >formula.... > to >
or#ani$m.....>. .er $uper&i$or $ent her to be a$$e$$e'..... ( lon# $tem) 0he 'oe$ not ha&e pa$t
p$!hiatri illne$$e$.
)a$*...
)a*e the hi$tor! an' a$$e$$ her mental $tatu$.
2(plain her about her illne$$ an' the ri$*$.
One 5 ame in an' #reete' her, $he *ept tal*in# non $top that $he i$ $peial an' 'oin# re$earh
about or#ani$m <.... 0he i$ not $leepin# &er! %ell, ha&e full of ener#!, no $uii'al7homii'al
i'eation, u$e' to be in $table relation$hip %ith her hu$ban', ha&e man! partner$ no% 'ue to her
the$i$ title,no feature$ $u##e$ti&e of 0)5, $pent a lot of mone!, her mother ha$ #ot $ho* therap! for
p$!hiatri illne$$ fe% !ear$ a#o, no 'ru# u$e$ reentl!, no alohol, no ai'ent$, 3u'#ement i$ fine,
%ell orientate', .... ( )!pial hi$tor! for mania)
5 tol' the e(aminer that 5 %ill a$* 8A) team to a$$e$$ her for ho$pitali$ation. 0he $ai' mana#ement
i$ not !our ta$*.
5 tol' the pt that her moo' i$ 6uite ele&ate' an' thi$ on'ition i$ alle' aute mania. 5t oul' be
'ue to other on'ition$ li*e 'ru# u$e$ althou#h !ou 'i' not $a! that $o. Other 'ifferential 'ia#no$i$
are 'ru# o&eru$e$, aute p$!ho$i$, bipolar 'i$or'er ( 5 e(plain them in la! man term ).
)hen $he a$*e' me %hat are the harm$. 5 $ai' *illin# or harmin# other$, 0)-70)5, ai'ent$ ,
finanial ri$i$, 'ru# an' alohol i$$ue$....
Feedback: /cute )a!ia(Passed)


5 pa$$e' 1= out of 16 $tation$ an' faile' a olon oun$ellin# $tation a$ 5 e(pete'.
)han* !ou -r Ma3i', the be$t teaher %ho 5 e&er met an' -r CenDel for hi$ *in' effort for 5MG$. 5
am &er! lu* to ha&e tho$e #reat teaher$.
5 al$o pa! m! #ratitu'e to m! frien'$ from 9M"@ #roup$ e$peiall! 2liDa Yu, B!nn %ho al%a!$
#i&e$ me #oo' $u##e$tion$ an' 'i' role pla!.
M! $u##e$tion i$ to 'o role pla! a$ muh a$ !ou an. 5f !ou 'o $o, pratie at lea$t A $tation$
$trai#ht, not one b! one. 5t %ill #i&e !ou #oo' $tamina. 5 'i' not feel tire' or onfu$e' in the e(am.
5 feel &er! omfortable throu#hout the e(am. -onLt memori$e the note$ an' reall$. ?n'er$tan'in#
the onept$, 'ealin# the role pla!er$ in a #oo' manner onfi'entl! an' #oo' ommuniation are
important.
Goo' Bu* for all....
Eo Eo