FEBRUARY 25, 2012 ADELAIDE

CLINICAL EXAM RECALL

MEDICINE AND SURGERY
AMC HANDBOOK CASE
ASTHMA IN A 25 YEAR OLD MAN (CONDITION 139)
In this case, the puffer, peak flow meter and spacer were placed in a shelf behind my seat.
In the middle of consultation, I asked for them and than got up to get them. The rest of
the case was same as the book.
AMC FEEDBACK

ASTHMA, OCCUPATIONAL RISK

CASE 2
A 20 years old basketball player came to the ED with sudden pain in his right arm
with swelling since yesterday. It happened while he was playing and pain is not
relieved with simple painkillers.
Task
Take history
Ask examiner for physical examination findings.
Give your most likely diagnosis and management plan to the patient.
From the stem I knew that its a case of upper limb DVT. The role player was a medical
student and examiner was very nice.
I started taking history on the following lines.
Can you please tell me a bit more about it ( I was playing yesterday and all of a sudden I
felt pain in my arm and now its quite swollen )
How severe is it from the scale of 1 to 10 ( 6 or 7, and I offered a pain killer )
Can u point out where exactly is this pain ( started in the upper arm but now generalized )
Did u injure your shoulder or arm before this ( no )
Is it for the first time (yes)
Is is progressive or settling down ( getting worse )
Any thing increasing it (activity)
Any thing decreasing it ( nothing )
Is swelling increasing also (yes)
Chest pain, shortness of breath(no)
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Did you notice any insect bite or injury in the recent past (no) ( to rule out cellulitis)
Fever in the recent days (no)
Any problem with the other arm(no)
How is your general health besides this ( good )
Any bleeding disorder (no)
Any recent surgery (no)
Past history of DVT, cardiac dz, stroke or any other serious illness (no)
Taking any medications and known allergies (no)
Family history of DVT (no)
Smoking (no)
Alcohol( socially)
I would like to ask the examination findings from the examiner with your
permission(yes)
Positive findings were;
Swollen, tender left arm and forearm
No signs of inflammation and no breach in the skin
No cyanosis
I was trying to examine other systems also but he said in a cold voice, hey, the whole arm
is swollen and what else are you looking for. Why dont you manage this problem and I
quickly said thank you to him and got ready to regurgitate DVT management.
I summarize it as follows.
Most likely you are having a condition called as upper limb DVT.
It is a condition in which a clot is formed in your vessels that carry the blood to your
heart and I drew a diagram to explain it. It needs immediate management to stop its
progress and for that reason you will be admitted in the hospital.
You will be seen by a specialist to start you on drugs like heparin and warfarin.
These drugs will help to dissolve the clot and prevent its reformation. But before that we
need to confirm it by doing some investigations.
FBE ,ESR, CRP ( rule out cellulitis)
Doppler ultrasound of the arm
LFTS, clotting profile
Thrombophilia screening ( if positive, life long treatment )
Heparin will be started and when INR ( a test done to measure the thinning of blood that
helps us to adjust the dose of warfarin to prevent further clots or bleeding) will reach 2 -3
you will be started on warfarin and heparin will be stopped. The treatment will continue
for 3- 6 months as decided by the specialist .

Talked about side effects of warfarin ( bleeding, bruising, dark colored stools, its
interaction with other medications)
Take warfarin at the same time each day and best is to keep a diary.
Elevate the arm and wear compression sleeves.
Regular reviews and follow ups.
Any questions ( no, you explained all)
Thank you and the bell rang after a few seconds.
AMC FEEDBACK PAINFUL SWOLLEN RIGHT ARM
CASE 3
60 year old patient presented to your GP clinic. She is diabetic for the last 15 years
and is well controlled on medications. She is consulting you to discuss about a
problem with her feet ( there was a diagram that showed bilateral bunions) .
Task :
Take history
Ask for examination findings from the examiner
Discuss with the patient what it is and how will you manage this condition.
I opened the door and it was Dr Wenzel as the examiner. The role player was a graceful
lady in her sixties with a lovely smile and after introduction I asked how can I address
you.
My name is Veronika, doctor.
Okay Mrs Veronika (and she was so pleased to hear this), can you please tell me a bit
more about your problem.
She slipped the picture infront of me that showed bilateral bunions. She wanted to know
about this condition because it was bothering her while walking.
Since when you are having this problem( for a long time but its getting worse now)
Do you wear tight shoes ( not now but when I was young)
And what about now ( yes, I wear comfortable ones)
How much this condition is affecting your life( it s difficult for me to walk as it is
painful)

I also understand from my notes that you are suffering from diabetes ( yes, for last 15
years)
Are you taking medications regularly(yes and I am doing fine with it)
Do you check your blood sugar level regularly(yes I do)
Did you ever had any break in the skin of your feet that we call ulcers (no)
I would like to explain you what it is and how can we manage this condition. ( before you
do that, would you like to know about the examination findings, Dr Wenzel prompted)
And there were no positive findings on the exam except the bunions.
Office urine dipstick and blood sugar level were normal.
I started my explanation by drawing a diagram. The bony protrusion of the bent big toe is
pushed out beyond the normal straight line of the foot and forms the lump that we call a
bunion and you have them on both of your feet. The deformity of the big toe is called as
hallux valgus.
There is a bag of fluid overlying this lump(bursa) which if gets inflamed because of the
pressure problems can get infected and this can be a serious problem especially in
diabetics.
She got my point and I moved on to the management.
It is very important for you to wear comfortable shoes to prevent any further deterioration
of this problem. It is also going to prevent ulcer formation on your feet because of
diabetes. For proper foot care, I will refer you to podiatrist.
Wear a thick adhesive pad around and over the bunion.
She was more interested in surgery so I mentioned that surgery is one of the option and is
reserved for severe cases and you can be considered for it. The results of surgery are
excellent. The surgeon will remove the abnormal bony enlargement of the first toe to
restore the normal alignment of the toe joint under anesthesia.
Will it done on both feet together or one by one( I said, one by one)
What are the complications of surgery, she asked;
Bleeding / haematoma
Infection / sepsis
Anaesthesia related complications
I finished well in time. When I was leaving the room, Dr Wenzel gave a smile and wished
me luck. What a great person he is !
AMC FEEDBACK BUNIONS IN AN OLDER PATIENT

CASE 4
A 60 year old man presented to your GP clinic with complain of pain in his legs
while walking that settles down after taking rest. He is a known case of hypertension
and take medications for it. He smokes 20 cigarettes per day for the last twenty
years and has a family history of heart disease and diabetes although he is not
diabetic and never had heart attack or stroke.
Task
Do relevant physical examination and give running commentary on it
Talk to the patient about your diagnosis and management plan.
After reading the stem, I revised peripheral vascular disease examination for the few
precious seconds that I was left with before entering into another trial and error situation.
I was greeted by the examiner and introduced myself to a very feeble but nice old man.
Didn t wash hands( should have done that of course) and explained to the patient what I
will be doing in the next few minutes.
Exposed and started with inspection from abdomen to toes( No visible pulsations, scar
marks, ulcers, cyanosis, any discolorations and amputations. He had muscle wasting of
both lower limbs, had loss of hair and shiny skin)
Palpation both limbs ( capillary refill time was normal I suppose, no ulcers between toe
nails, didnt check temperature and oedema, was not able to feel dorsalis pedis, posterior
tibial and popliteal. I got a bit upset, jumped to femoral, put my hands approximately
inbetween ASIS and pubic symphysis on both sides and before feeling it, louldly said
both present.. u dont do it friends. No pulsations of AAA.
Quickly auscultated for AAA, renal and femoral bruit( none present)
Did Buergers test and it was negative( honestly speaking, my patient didnt have enough
blood in his circulation to come to the threshold level of PVD exam and I was more
worried for the very fact that if I touched him with a slight force, he will scream and it
will be all over. Having said that, he was a very nice person and was trying to help me in
every possible way.
Continued and mentioned about AB index but didnt ask for its values ( another big
mistake.. hope you will not repeat it)
Finished the exam, forgot to cover the patient again( will you do the same. Ofcourse
not)

Told the patient that most likely he has peripheral vascular disease. Although my exam is
inconclusive but due to the typical history of leg pain while walking, relieved by rest and
the cardiovascular risk factors mentioned in the stem, I need to investigate him further
and discuss the treatment measures ( he didnt say anything)
I will do FBE (anemia), BSL, lipid profile, urea/creatinine and electrolytes, LFTs, and
ECG.
First step is to address the risk factors in the stem and advice him to do regular exercise,
stop smoking, eat a healthy diet and so on.
I will refer you to vascular surgeon(what will he do, he broke the silence)
He will do a test called as angiography to see the blockage in your vessels and might put
a stent or do a bypass surgery to relieve the obstruction(ok)
At the same time, the bell rang and I came out. I totally forgot about the examiner. Even
when I was going out, I didnt bother to have a look at him. Why should I be now?
Other useful information is,
Start statins and aspirin, change medications from beta blockers to ACE inhibitors.
AMC FEEDBACK

LEG CRAMPS ON EXERCISE

CASE 5
A 60 years old man presented in the ED with symptoms of nausea, vomiting and
confusion for the last couple of days. He is a known patient of chronic renal
failure(CRF). He is taking furosemide and lisinopril whose dose was increased by
his doctor a week ago. He is also suffering from gout for which he is taking
indomethacin. On examination his blood pressure is low.
Task
Take history
Ask for investigation results from the examiner
Ask for ECG from the examiner
Advise the patient about further management plan
This was my first station, I had a shaky start, went well in the middle part of the
consultation and ended with a disaster that took me away from getting a pass in this
station.

I started with the history after introducing myself;

You have nausea, vomiting and confusion. Can I know a bit more about your problem
( yes doc, I am getting confused since the last week as I am not able to concentrate well. I
had an episode of vomiting and most of the times I feel nauseated)
What was the color of the vomit, any blood in it( no blood)
You have CRF, when were you diagnosed ( it was more than 5 years I think)
Do you have regular chekups (yes)
Since when are you taking these drugs( for last few years for high blood pressure)
Why their dose was increased( dont remember what he said)
Did you had dialysis before (no)
The points that I missed in history were;
Since when you are suffering from gout
For how long are you taking indomethacin
What about your waterworks
When did you pass urine for the last time (for oliguria or anuria)
Any complications of CRF
Any previous hospital admissions
I moved forward for investigations. The examiner gave me a paper in which;
Urea and creatinine
FBE

very high
anemia

I asked for ECG ( tall T waves, when I saw them, I said hyperkalemia (and I felt as I have
just woke up from a slumber sleep because things started making sense to me)
I turned to the patient and explained that his kidney function is deteriorated as he is a
vulnerable patient for this kind of insult because of his CRF. This ECG is showing
hyperkalemia and its an electrolyte abnormality that needs immediate attention and
intervention. For this reason, he will be admitted in the nephrology unit of the hospital
now and I will arrange an urgent consultation with the nephrologist( the examiner and
role player also got interested after witnessing a spark in the ashes). Your blood pressure
needs to be restored by passing an IV line and giving fluids and specialist will assess your
condition and the drugs that you are taking, their dose will be decreased and it is going to
be decided by him or her.
Oh doctor, I feel so lonely. I will be alone here( i will call your partner if it is alright with
you, I said still shaking and sweating. He was happy for himself but he didnt offer
me to call my partner to wipe off my sweaty forehead but he gave me a clue while
imaginating his partner on his side.doc, do u think dialysis will be done on me)

Yes Mr Martin, hyperkalemia is one of the indication for the dialysis and examiner wrote
something on the paper. ( I also mentioned about calcium gluconate, I am not sure if I
was right)
It was time to go, the bell rang, I stood up from my seat and took a stride towards the
door when examiner asked me a question;
What will you do with the drugs( he was holding his pen firmly because he had to put a
tick some where and he was giving me the last chance)
My mind didnt lit up and I went on by saying, specialist will decrease the dose of these
drugs and went out to read the next stem
MY MISTAKES
Completely ignored the indomethacin (NSAID) to stop it.
ACE inhibitor also needed to be stopped ( cause hyperkalemia)
I didnt give the diagnosis ( Acute renal failure )
The examiner was very nice person and same was role player and they wanted me to pass
but the pressure of the exam didnt let me to talk about the common things.
Here is some additional information on this case provided that, please go through the
other recalls of colleagues who have passed it.
INDICATIONS FOR DIALYSIS
Acidosis
Encephalopathy ( this patient was going towards that)
Hyperkalemia (this patient had it)
Fluid oveload
Pericarditis
Other things to look for;
Bleeding ( gastrointestinal because of uremia induced platelet dysfunction)
Anemia ( decreased erythropoietin)
Hypocalcemia
So the questions you can ask in the history are;
Changes in your heartbeat or loss of consciousness ( hyperkalemia causes rhythm
disturbances)
Swelling of your legs or other parts of your body ( fluid overload )
Shortness of breath( fluid overload)

Tiredness or lethargy (anemia)

Muscle cramps ( hypocalcemia)
Itching ( increased phosphate because of poor excretion)
Ask about diabetes and polycystic kidney disease as causative factors of CRF.
AMC FEEDBACK

ACUTE RENAL FAILURE ON TOP OF CRF(FAIL)

CASE 6
35 years old lady comes to your GP clinic. She is complaining of abdominal pain and
bloating. Stool examination and colonoscopy were done and came out to be normal.
Task
Take the relevant history
Explain the diagnosis and management to the patient
Role player was well prepared about this topic and was helpful.
So can you tell me a bit more about it( pain in tummy with bloating)
Since when you are having this problem(last 6 months)
Where exactly is the pain(generalized)
How severe is it ( 4-5)
Anything increasing it (spicy food)
Anything decreasing it(not sure)
Did you take any medications for this pain(simple pain killers but not helpful)
Does this pain wake you up at night(no)
Does anything increase or decrease the bloating( not sure what she said)
Nausea or vomiting(no)
Alternating diarrhea and constipation(yes I have constipation sometimes but no diarrhea)
Any bleeding from the back passage(no)
Did you notice weight loss and tiredness(no)
How is your appetite(good)
How much this problem is affecting your life( she took a big sigh and said, I am fed up
and want to get relieved from it)
Any stresses at work or at home(sometimes at work)
Smoking,alcohol and drugs (not significant)
From the history you are most likely suffering from a condition called Irritable Bowel
Syndrome.
Irritable Bowel is the sensitive bowel & causes abdominal pain and disturbed bowel
actions. Our mind and body are connected with each other so when our mind is upset or
under stress, it can affect the bowel. Please do not worry, it is a harmless condition.

Good news is that all your investigations are normal that means you dont have any
disease in your gut (she leaned forwards and was listening carefully) but having said that,
I can understand that your pain and concern is real and is also affecting your life.
She laughed and said, atleast somebody acknowledged my problem and after that she was
sitting relaxed on the chair and was quite easy going through the rest of the consultation.
In management, I summarize what I said;
Its not a cancer or any other organic disease
Make a food diary. Avoid spicy foods. Note any thing that bring your symptoms and its
avoidance is the best treatment.
Fibre rich diet will help for constipation and bloating
Maintain a healthy life style and do regular exercise
Manage stress at your work and home and take time out for relaxation
I can give you some anti spasmodics to relieve your symptoms but these are not for
treatment
Anti depressants can be given for a short period if these measures fail.
Referral to the psychologist is also one of the option to manage stress in your life
I finished early and went out to wait for the bell to ring.
AMC FEEDBACK IRRITABLE BOWEL SYNDROME
CASE 7
A young man presented to your GP clinic for an advice on travelling overseas.
Task
Take history
Talk to the patient about the travel risks and manage the case
I started the history with a smile;
So you will be quite excited about your trip, can I know a bit more about it(its a business
trip and I will stay for some time in Thailand and then leave for US) he was not excited
about it at all.
For how long, may I know( a month)
Will you be going alone or with your friends( with my partner)
Is it for the first time(no I am a frequent traveller)

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Have you been vaccinated before( no, is it important) yes, I will talk about it in a short
time
Do you have any plans for bushwalking or any other activity like camping (no)
Do you know about safe sex(well, that s something everybody knows I suppose)he was
quite surprised by this question
Do you have travel insurance(yes)
Do you have any medical issue at the moment(no)
I was sensing that I am missing something quite important here and luckily out of
nowhere I asked, do you have any previous history of DVT ( oh my God, he started
rattling off like a parrot about his previous episode of DVT one year ago and its
treatment, the examiner put a tick in the sheet infront of him)
Was that the only episode(yes)
Was it associated with pulmonary embolism(no)
Are you still on treatment(no)
Any pain in your legs, chest or shortness of breath after that(no)
Did you travel after that episode of DVT(no)
Smoking, alcohol ( not significant)
PRE TRAVEL ADVICE
Update vaccination status may include typhoid, hepatitis A, B, yellow fever,
meningococcal vaccine(after checking with WHO schedule for the area you are
travelling)
ADT (if >10 years since last dose)
Malaria prophylaxis Doxycycline 100 mg daily 2 days before travel, during the entire
stay until 4 weeks after coming back
Avoid mosquito bite, apply skin repellent creams, wear long sleeve clothes, avoid
wearing dark coloured clothes
Travel kit bandage, dressing, water purification tablets, sunscreen, topical analgesics,
topical antifungal cream, antacids, antibiotics, rehydration mixture gastrolyte.
DVT prophylaxis before travelling
DURING TRAVEL
There is a risk of DVT in long flights >6 hours
Move around and do regular leg exercises in the plane
Avoid alcohol
Drink plenty of fluids
Take care with food and water hygiene to avoid travellers diarrhoea
Always practice safe sex to avoid sexually transmitted infections
Never walk barefoot at night
Always carry a vaccination certificate

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Better to have and keep any document of any known health problems
Try to sleep and rest at a transit stop to reduce jet lag on arrival at your destination
ON RETURNING BACK
See me again to discuss any health related issue
I will give you written materials/pamphlets
Any questions (no)
Thank you.
AMC FEEDBACK OVERSEAS TRAVEL RISKS
CASE 8
A 40 years old man comes to your GP clinic with intermittent hoarseness of voice for
last few weeks. He is a school teacher and is concerned about this problem.
Task
Take history
Ask for physical examination findings from the examiner
Talk to the patient about your differential diagnosis
The role player was a casual young guy and not a medical student. Neither he was a real
patient and was only answering what exactly he was asked for. I started by history;
Can you tell me a bit more about it ( repeated the stem)
When exactly you noticed this change ( for the last few weeks)
Is it for the first time you are having this problem ( yes)
Do you use your voice a lot or speak loudly while teaching( yes doc, I think because of
teaching I am having this problem) this was actually a distractor I believe.
That can be one of the reasons, I added.
Recent fever or cough (no)
Any episode of viral infection(no)
Any problem with swallowing or breathing (no)
Weight loss, poor appetite,weakness (no)
Any surgery in the neck region(no)
How is your general health besides this( good)
Past history,family history,medications,allergies(no findings)
I asked for smoking ( I smoke 20 cigarettes a day for the last 20 years)

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Without wasting a single moment, I replied, well John, smoking is not good for your
health. I would like to arrange another consultation with you to talk about its harmful
effects on health if it is alright with you( he stretched his lateral rectus muscle towards the
examiner and casually said, okay) I knew I have fired at the right spot.
Alcohol (socially)
To my surprise, everything including chest and ENT examination was normal.
I turned to my patient and explained that it can be;
Laryngitis (less likely)
Voice abuse ( can be a possibility)
Laryngeal, lung or any other nasty growth because you have a long smoking history and I
need to rule it out as my first priority even though you dont have any positive physical
findings. I will refer you to the ENT specialist for laryngoscopy and do your chest x ray
to look for any findings. If required I will also refer u to a respiratory physician to do the
further tests like CT scan of the chest.
I will follow you up once I get the investigations result. And I will talk about smoking in
the next consultation.
Any question (no)
I finished and came out well with in time.
AMC FEEDBACK

HOARSENESS

PSYCHIATRY
CASE 1
A 50 year old man is in your GP clinic. His wife visited you and gave the history that
he changes the lanes while driving and is having behavioral problems at home( very
typical history as in the previous recalls). Now he is in your clinic because his wife
insisted him for a check up. MMSE was already done and a separate sheet of
MMSE was there which showed (0/3 in recall and 0/3 in the test where we ask the
patient to take the paper in his hand, fold it into two and put on the table). The rest
of MMSE was normal.
Task
Take further history from the patient
Assess his cognitive function by doing relevant tests ( but dont repeat MMSE)
Talk to the examiner about the diagnosis

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The role player was a good actor and was a difficult patient right from the start. I
introduced myself and asked him, how can I address you ( why do you want my address).
I didnt get it and asked, sorry how can I call you ( you want to call me, why ) ok, what is
your name (John, he replied).
Your wife is concerned about you. Can I know why ( I dont know)
Did you notice any change in your behavior at home( no)
Any problem at work
Do you find it difficult to come back home from work
Do you have a problem with your memory
For all these questions he didnt answer correctly. He was having short term memory
problem as he was forgetting my questions while answering.
I also asked about head injury, any episode of stroke or heart attack which he denied.
I thought I should stop now and continue with my examination. I drew a clock ( clock
face test) which he was not able to draw. I also did other tests for frontal lobe
examination that are in the AMC Handbook.
I concluded that its frontal lobe dementia and as expected the examiner asked me the
reason for it( this is the deciding moment of this station to get a pass or fail that I learnt
from the previous recalls) so I continued as follows;
History given by his wife is relevant to dementia
My history proves that he has severe memory deficit and his understanding of complex
language is impaired
MMSE also shows memory issues and his poor performance of difficult functions
And I further added to rule out depression, B12 deficiency, HIV, Syphilis,
hypothyroidism, stroke,tumor, CVS problems and alcohol abuse.
When I talked about the rule outs, he started flexing his neck for the first time during the
whole case. I extended mine and went out of the room after the bell rung.
AMC FEEDBACK FRONTAL DEMENTIA
CASE 2
17 year old girl in your GP clinic who is concerned about her weight. She has also
some issues with her mother and her school performance is affected because of this.
Task
Take history

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Ask for physical examination findings from the examiner

Give your diagnosis and management
I started with confidentiality and took a complete history for eating disorders and it was
quite clear that it was a case of anorexia nervosa. When I finished the history, the
examiner who was looking at me with big eyes over her glasses, asked me to move on if I
have finished the history.
I repeated what I had already asked from the role player to her. She replied, well, you
assume that you have asked for weight loss but actually you didnt . I didnt say anything
to her but I was disappointed by her remark. How can I say something that I didnt ask
forI moved on without much interest and finished early and left the room without
bothering about getting passed or failed in this station.
I failed but didnt argue with her. Not every examiner is nice and thoughtful in this exam!
Please consult other recalls for this case.
AMC FEEDBACK ANOREXIA NERVOSA(FAIL)

PAEDIATRICS
AMC HANDBOOK CASE
A LETHARGIC FEBRILE CHILD WITH A RASH (CONDITION 114)
AMC FEEDBACK SEPTICAEMIA

CASE 2
8 month old baby brought by his mother to your GP clinic for immunization. It was
delayed by 2 months because of his grandmothers funeral. He is arching his back
when sits and mother is concerned about this.
Task
Take history
Ask for examination findings from the examiner.
Discuss the most likely diagnosis with the mother.
When I read about arching of the back, I knew that its gonna be a cerebral palsy case. The
role player was a medical student and quite cooperative. I went smoothly right from the
start till the end and the important points that I covered were;

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I asked the baby s name after introducing myself.

Can u please tell me a bit more about it ( stem repeated and mother was concerned. I
reassured her that she is in safe hands and said sorry for her mothers demise)
Before immunization, I would like to ask few questions from you(yes)
Is John your first child (yes)
Was it a planned pregnancy (yes)
Ok , is he able to sit or stand with support(no)
Did you notice that he is crossing his legs when u hold her (no)
When did he start to crawl ( looked at the examiner and wasnt sure)
Can he speak and say one or two words ( no)
Does he respond to the sounds (yes)
Was his hearing and vision checked after birth (yes and that was normal)
How was your pregnancy ( I had an infection during pregnancy)
What was that ( dont remember what she said)
And how was delivery( normal vaginal delivery)
Was it full term or preterm (full term)
Was John fine after birth ( No, he was admitted in the nursery for a week because he was
not able to breathe normally when born)
Do you know about the condition he had ( no)
How is his health since than (good)
What about previous immunizations and growth charts (normal)
How is his feeding ( breastfeeding and normal)
Any family history of developmental disorders(no)
With your permission, I would like to ask for the examination findings from the examiner
(yes)
Positive findings were;
Increased tone and brisk reflexes on neurological examination
Growth charts were normal
Rest of exam was normal
Well Mrs X, John is most likely having a condition called as cerebral palsy. It is a
condition in which there is a defect in the baby s brain and most likely it has occurred
either due to the infection that you had in pregnancy or because he was not able to
breathe normally ( lack of oxygen) after delivery and was admitted in nursery. It affects
posture & movement and unfortunately not curable. John will need life-long support and
care.
I will refer you to the specialist for further assessment of this condition and than we can
give you the definite diagnosis.
Role player : You mean its quite serious.
Yes it is unfortunately because it is associated with certain complications like mental
slowness and joint problems and others including many systems of the body.

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But you will be having a lot of support because John will be under supervision of a
multidisciplinary team which includes me as your GP, neurologist, paediatrician,
physiotherapist, occupational therapist and social worker. Any complication will be dealt
accordingly and I will also give you contact numbers of available support groups. I know
you are loaded with information to add in your anxiety but the bottom line is that in any
circumstances you and John will be taken care of and help will be just a call away from u.
I will be liasing with the specialist and follow you up on regular basis.
Any other question ( no doc)
Thank you and I finished early.
AMC FEEDBACK SPASTIC DIPLEGIA
CASE 3
A 7 month old baby brought by his mother because she noted a lump in his groin
and another at the belly button. It was clear from the stem that these are umbilical
and inguinal hernias although their names were not mentioned. On examination, left
sided testicle is also undescended.
Task
Counsel the mother and manage the case.
While entering into the room I was not quite sure what I will be talking about so I left it
to the role player to lead me towards the important points to cover. So after introduction,
I started with the open ended question.
Can you tell me a bit more about it ( I have noticed two lumps, one in groin region and
another at the belly button. These protrude when he cries but normally they are not there.
I have also noticed that his one of the testicle is not palpable. I am quite concerned and
want to know about it.
I drew a diagram and gave her the diagnosis of umbilical, inguinal hernias and
undescended testis. Before I said anything else, she asked me a question.
So doc, what is hernia?
It is a condition in which part of intestines or other tissues like fat in the abdominal cavity
protrude through a weak spot in the abdominal wall.

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She followed by asking a series of questions and I tried to answer precisely what she was
asking for and in summary I covered the following important points.
Umbilical hernia usually disappears gradually. Most disappear by the age of 12 months
and the larger ones usually disappear by the age of 4 years. No treatment is required at
the moment. One question that she asked me was;
Doc, my mother told me that if we put a coin or tape around it, will it help ( it is not
recommended because it can compromise the blood supply of herniated organs
(strangulation) so please avoid it.
Referral to the specialist will be required if hernia is still present at age of 4 years.
I am more concerned about the inguinal hernia. It can lead to incarceration ( cannot be
pushed back into its place) and secondly it can proceed to strangulation ( constrict the
blood vessels and can cause the death of the tissues).
For these reasons I need to refer him to the specialist ASAP for its surgical correction.
THE 6-2 RULE
Birth to 6 weeks
( surgery within 2 days)
6 weeks to 6 months ( surgery with in 2 weeks)
Over 6 months
(surgery with in 2 months)
Undescended testis coexists with indirect inguinal hernias in 90 percent of cases.
It also needs to be fixed by orchidopexy ( optimal time is 6 12 months of age)
If we dont fix it, the fertility can be reduced. It s more susceptible to injury and there is a
risk that it can turn into a nasty growth.
So the bottom line is, I will be referring (John) to the surgeon who will fix the inguinal
hernia by closing the defect and will bring back the testicle to its original place in the bag.
He might also consider to close the defect at the belly button in the same go but the final
decision will be made by him and will discuss all the options with you.
Any other question( no). In this station the role player wanted to get a very basic
explanation of the medical conditions in lay man terms and that was the main focus of the
station. I was at ease because I was just answering in the simplest possible way with the
help of a diagram and was not putting forwards my thoughts in the first place.
Before I said thank you to her, the bell rang and I ran out to try my luck in the next
station.
AMC FEEDBACK
UNDESCENDED TESTIS, UMBILICAL HERNIA AND
RIGHT INGUINAL HERNIA IN INFANT

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OBS & GYNAE

AMC HANDBOOK CASE
N & V IN FIRST TRIMESTER ( CONDITION 144)
It was a bookcase of hyperemesis gravidarum with additional information of first
trimester small amount of bleeding that has stopped and the patient is Rh negative.
AMC FEEDBACK

HYPEREMESIS GRAVIDARUM

CASE 2
A 35 years old pregnant lady comes to your GP clinic for her first antenatal checkup
as she is 10 weeks pregnant. She drinks heavily and is a smoker for the past 10
years.
Task
Take history regarding her smoking and drinking habits.
Talk about their effects on her pregnancy and manage the situation.
It was a new case as far as I know but we have book cases and recalls of smoking and
alcohol issues so that knowledge made my life quite easy in this station.
There is some additional information in this case to help you prepare it in a good way.
After introduction, can u please tell me a bit more about it( came for pregnancy check up)
Is it a planned pregnancy(yes)
CONGRATULATIONS !
Is it your first pregnancy(yes)
I would like to ask you a few more questions about your smoking and drinking habits, if
it is alright with you(yes)
For how long are you drinking( for a long time)
How much are you drinking per week( moderate to heavy)
Do you drink a lot on the weekends(no)
What type of alcohol do you drink(wine)
Do you drink alone, partner or with friends( partner)
Are you aware of safe level of drinking(no)

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How long can you go without alcohol( not even a day)

Do you need it to steady your nerves(yes)
Does it help you to go to sleep.
Do you drink when you get out of the bed in the morning.
Any symptoms of agitation, sweating,nausea and shakes(no)
Any problem at work(no)
In family relations(no)
Any financial problems(no)
Problems with law
CAGE questions
Have you ever tried to quit(no)
Do you know about the effects of alcohol on pregnancy(no)
How many cigarettes do you smoke in a day( a few daily)
For how long( for a long time, not sure what she said)
How soon do you have your first cigarette when you wake up
Do you find it difficult not to smoke in non smoking ares(yes)
Have you tried to stop it in the past(no)
Does your partner smoke(no)
Past history of serious medical condition
Folic acid (no)
Any other illicit drugs(no)
I would like to talk about the effects of alcohol and smoking on your pregnancy.
ALCOHOL ON BABY
Passes down through placenta easily and broken down slowly.
Can cause fetal alcohol syndrome( main cause of mental retardation in babies)
Vision and hearing problems
Learning, emotional and behavioral problems
Low birth weight
Birth defects that include heart, face, eyes and other organs of the body
ON PREGNANCY
Increased risk of miscarriage and premature birth.
SMOKING EFFECTS ON BABY
Nicotine,tar and carbon monoxide can decrease oxygen for the baby
Low birth weight
Increased chest infections like asthma, pneumonia and ear infections
Increased chances of SIDS with both smoking and alcohol

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ON PREGNANCY
Ectopic pregnancy, placental abruption, still birth.
So you can imagine how badly these substances affect the pregnancy so its in the best
interest of you and your baby to stop them. There is no known safe level alcohol use in
pregnancy ( what can I do doc if I want to stop)
Understand its effects and admit it as a problem
Strong motivation is the key to success
Establish clear and realistic goals and I will help you implement them
Choose a quit day for both alcohol and smoking if possible for you
You can experience withdrawl symptoms and contact me immediately when you have
them
I can arrange a family meeting to ask your partner to quit and team up with you
Avoid situations where you usually drink or smoke
Deal with stress with healthy way like exercising, meditation, and other relaxation
techniques.
I will refer you to AA , will give u reading materials and numbers of support groups
Do the investigations that we normally do on the first antenatal visit
Will follow you up and get the feed back about our plan in the next consultation
Any other question(no)
Thank you. I finished this station well in time. The focus was not on how difficult it
would be for the patient to stop both of these substances but an overall approach to
manage substance abuse in pregnancy.
AMC FEEDBACK ALCOHOL EXCESS IN PREGNANCY
CASE 3
A 30 years old lady comes to your GP clinic complaining of dysmenorrhea for the
last 5 years. She has tried OCPs but the pain is not relieved.
Task
Take history
Ask for physical examination findings from the examiner
Give your diagnosis and management plan.

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From the stem I had an idea that most likely its a case of endometriosis but I had some
other differentials like chronic PID and fibroid to rule out.
The role player was a medical student. I started with the history along the following lines;
Can you tell me a bit more about it( I have a dull lower tummy pain for the last 5 years
that starts 3-4 days before my periods, increases in intensity during the periods and settles
when they are over)
How severe the pain is( 4-5) and I offered a pain killer.
Does it radiates to any other place(no)
When was your LMP
For how long and how many days( it was normal)
Any episode of abnormal bleeding(no)
Are you in a relationship(yes, stable partner)
Painful intercourse( yes)
Pain while passing stools(yes,sometimes)
And what about your water works( normal and no pain)
Do you have kids(we tried but couldnt conceive)
Ever had unprotected intercourse(no)
Any episode of STDs (no)
For how long are you taking pills(last 5 years)
Any other contraceptive used like IUCD(no)
Did you notice any mass in your tummy(no)
Recent fever, nausea, vomiting(no)
What about Pap smear(done last year and normal)
How this pain is affecting your life( she was almost to cry. I feel terrible, please do
something for me. The examiner flexed his neck in applause and gave a smile)
Past history of any pelvic surgery(no) to rule out pelvic adhesions
Medications, allergies,smoking, alcohol and any positive family history( nothing
significant, she wanted me to move on)
With your permission, I would like to ask the examiner the findings of your physical
examination(yes and another little smile from the examiner)
I concentrated on the abdominal and pelvic examination. The positive findings were;
Uterosacral ligament nodularity and tenderness
No palpable mass (fibroid) and rest of exam normal
I said thank you to the examiner and proceeded by explaining endometriosis to the patient
with the help of a diagram. In this condition the tissue lining your womb is deposited in
unusual locations by backing up of menstrual flow into the fallopian tubes, ovaries,
abdominal cavity or other organs in the body.
Talked very briefly about the retrograde menstruation as one of the theories been put
forward to explain the phenomenon.

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Referred to the specialist for laparoscopy ( gold standard) and explained what it is.
Gave the options for the treatment that will be considered by the specialist.
Medical option is Danazol (drug of choice) and laser surgery via laparoscopy can be
performed.
Gave reading materials, offered family meeting, talked about support groups, and follow
up on regular basis.
When I was finished she asked me a question;
Is pregnancy going to be helpful for this condition( yes, because in pregnancy you will
not have periods so it will help)
Any other question (no) and I finished well in time.
AMC FEEDBACK CHRONIC DYSMENORRHOEA IN A 25 YEAR OLD
My best wishes to all the colleagues who will be appearing for this exam. It is important
how well you are prepared before the exam and it is a must to perform well on that day.
Dont skip important findings from the stem, get the right clues from the role players and
the examiners and give a word to important stuff related to the case by speaking out
rather than thinking silently.
I want to thank all my friends who have helped me during the preparation. My special
thanks to Dr Wenzel and Alan Roberts who have helped and guided me when ever I
spoke to them. We are lucky to have them with all their experience and kind hearts.
Please refer the books if you have a doubt on the information provided although I have
tried to include useful points to make this recall more fruitful.
Be calm, nice and safe and all the best !

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