3rd March, 2017.

Thanks for the grace of god and to someone who I have come across and taught me without
notice.
Station 10
Typical BDD recall case.30 year old lady sent by dentist because of concern of callosities.

History 4 mins,
Explain PDX to patient,
Other two possible diagnosis, and
Mx

I started the case by talking about how she was doing today and why she came here. As the case
is seemingly known case I directly offer confidentiality.
Then I ask why her dentist send her?
I directly go to Wt and Bulemia Questions( including BMI and choosing the 3 drawing. She
choose the biggest one, here important question is how she feel after vomiting and she felt good
and that relieved her guilt every time she do it) all positive
Brief 5P and all normal
Other differentials, like Anxiety disorder, OCD, BDD, Panic, PTSD, all negative
HEADS including brief Depression Questions, all negative

Explain Bulemia + Reassurance + appreciation for telling me

Other possible conditions… BDD, OCD, but less likely in you

Mx--Lets do it together …
Refer to psychologist for CBT
Ref flag, blood in vomitus
Reading material
Reassure
Always recheck pt. understanding after every task.
Follow up closely.

(Passed)

Station 1
35 year old lady comes back for paps smear test .HSIL with HPV+.

History,
Explain condition and causes,
Mx and implication of management to patient

Patient acts as a stubborn and less educated patient, very sensitive patient with sensitive Qs!

On history, Patient ask directly the result and I said I will discuss after asking brief questions
Confidentiality *
No safe sex previously, currently stable partner,
When I ask what about previously, she became agitated so I said its ok and I missed previous
relationship.
No family history, want to get pregnant in one year, OCP taking, no family history of cancer, no
features of cancer, previous papsmear test done 2 years ago was normal .
I forgot to mention Gardasil vaccine.
On explaination she ask about everything. What is papsmear /why done/what cell changes/why
grading/what is HPV/why did she get it / Is it cancer /colposcopy ?

Mention according to latest guideline : Colposcopy and biopsy +/- local treatment based on
finding cryo/laser
After 6 months: colposcopy+ papsmear..
after 6months :papsmear +HPV if normal, then 1 year later again
If for 2 consecutive times normal, it will go back to 2 yearly papsmear as routine.

I missed implication of Mx.

One of my frineds mention that as colposcopy will be done, better not to get pregnant until
everything is normal

I missed implication as time out.

I missed to mention Gardasil vaccine as well in Mx.

(Failed)
Comment : ( I think in this case, when studying old questions, patient is good to discuss.
Question is simply explaining the conditions and discuss, then I might have done it well!.
Considering everything, there is one station with a patient agitated and screwing up in every
exam. At that time, be careful do the job as quickly as you can and choose the words as simply as
you can as you can see well because it was many tasks ,and sensitive patient at the start of
conversation. )

Station 2
75 year old man present with tummy pain on lower tummy. First time presenting with
pain. No previous medical or surgical history.

History,
Ask PE,
Mx to patient

Typical urinary retention case with BPH symptoms. But when I ask patient, he was confusing
about pee and poo and looking at examiner and then he said normal. So I kept asking other
systemic questions….
No features of cancer. No family history. No herpes rash, no injury to bladder or back problem,
no nausea or vomiting .
So I couldn’t find the Dx and directly carried out PE
The examiner only provided me only you ask.(urge to void on pressure on abdomen ,dullness on
mass ,bowel sound normal, prostate enlarge on PR but no blood on examining finger )
Explain about catheterisation and admit to find out the cause with the help of urologist.
Medication and Surgery will be followed if necessary in order not to happen again. Likely to
happen again as chance of recurrence is high. Patient seems tired as well just smile and nodding
head . Time out and I have no time to say, 6R eventhough I gave reassurance.

(failed )
Comment: (In this case, History is a bit long as I couldn’t find out Dx, may be patient is
confusion about the data, always looking examiner to answer yes or no. So not enough time in
Mx. Eventhough I have answered the Mx like above. I failed)

station 3 : Rest station

Station4:
Middle aged lady present with tummy pain, loose motion and vomiting one time containing
food materials. Nausea .Lost of appetite .Dark and brown stool present but no blood. No recent
travel history. No previous medical condition and surgical condition. Did not have any family
history of cancer. Some other information were provided in the question but no positive
history given.

Assess dehydration status,

Perform focus abdominal examination ,
Tell examiner about the findings,
Mention PDX,DDX to patient

I had a hunch that this is all about AGE but task is do PE, quite weird!
Introducing and washing hands
GA is good and when ask VS examiner let me do it yourself according to the task
Obese woman was lying on the bed, with gowns.
There is a tongue depressor on the table
I need to check hands to assess limbs and cold peripherals, capillary refill, comparing both sides,
then I mention I will examine Pulse rate,( a watch was given on table)
skin turgor on back of hand and slightly slow return ( I said as it was)
RR and T were given by examiner.
BP need to be measure by yourself
No sunken eye, check the eyes for pallor, and check for dry mouth. All negative.
Then I summarized there is no signs of dehydration.

PE focus on tummy, Ask the woman to remove the gown and she was just wearing a sport bra.
Inspect the abdomen was usual. Reassure the patient before touching her checking tender area.
light palpation normal, on deep palpation tenderness present on whole abdomen, exclude signs of
perforation, did obturator and psoas, no organomegaly, no renal angle tenderness as well.
No rebound, so I skip cardiac and live dullness
Auscultation was normal.
mention examiner to further exclude perforation will do vaginal and PR examination which was
normal
Explain to the patient about Gastroenteritis and recheck her understanding,
Mention ddx: Gastritis, Other Bacterial diarrhoea like typhoid, hepatitis, perforation less likely

(Passed )
Comment: Always asking her if she understood and moved to next task
Always asking for permission to do PE in evey step and explain why to do!

Station 5:
55 year old lady with hoarseness of voice. Teacher for years. No known medical history. No
regular taking medication. No stress.

History 6 mins,
Ask PE,
Explain PDX to patient, and DDx
Investigation to patient

The patient had real hoarseness of voice

Symptom analysis: for 3 weeks now, slightly progressive, loss of weight and appetite negative,
No association with pain, fever, work as teacher and had to use more voice lately,
smoking history present and had to ask detail about it 30 cigarettes a day smoking for 30+ years
and tried quitting previously but failed, no surgery ,no lump
asking severity like swelling, no swallowing difficulty, no family history of cancer, no stress.
I also added any facial weakness and hand weakness.

PE: As routine asking starting from GA, VS and systemic examination

BMI
Postivie findings on Respiratory examiation: Reduce air entry on left side, dullness at lower
zone, the rest normal, No facial weakness, no bone tenderness, no weakness of hands, no neck
swelling, CNS normal, indirect laryngoscope not available

PDx: Nasty condition in lung because abnormal findings in your lungs!

DDx: Vocal abuse but less likely because ….
Vocal cord palsy, TIA, Vocal cord polyp, nodule,
Tonsillitis, pharyngitis, peri-tonsillar abscess
Thyroid problem
GORD

INVx: Based line test FBE (to exclude infection),ESR(inflammatory markers), TFT(to exclude
thyroid causes), CXR to check and exclude infection and suspicious cancer lesions
Chest CT and Bronchoscopy if necessary
No need to do direct laryngoscopy because it was surely from lungs.
(passed with all 6 in keep step and domain)
Always asking her if she understood and moved to next task
Always reassure whenever her experession change
Station 6
Mother of 8 months child came to GP, because of cough for 18 days.
He was healthy previously.

History,
Ask PE,
Explain Dx,
Exaplin Mx to patient

Mother was very nervous and restless when enter room. Haven’t even introduced myself to her
yet and she started restless. Calmed down her and reassure her and she started talking all about
the symptoms. She also make sound of whooping cough, after excluding all other causes and
DDx…(smoking history nil in parents, no antibiotics allergy, Home condition, Environment,
trigger factors for asthma, Family Hx)

Father had similar symptoms before the child has it.

Severity: child is stable, eat and sleep well, play well, no breathing problem, no signs of
respiratory distress.

BINDS normal,

PE, Dehydration status, Wt chart

No rhonchi, wheezing nor stridor.

Explain about Whopping cough, possible contact from father, but since son is stable not to worry
so much and can handle at home.
Dx clinically but may need to confirm diagnosis via Naso pharyngeal swab, antibiotics to child
and house hold members not to kill bugs but to shorten infectious period, inform DHS.
6R
(passed 5)
Comment: During history, some patient always asking son’s condition and showing their
anxiety, so kept on reassurance multiple times.

Station 7
25 year old lady with repeated ear infection, gradual hearing loss on one side.

Perform examination,
Comment the findings to examiner
Mention condition and exaplin with reasons
Other DDx
Greeted the examiner, just as i am gonna wash hands, the examiner told me to wear gloves.
There is a dummy to examine orthoscope beside the patient .Introduce the patient and usual ask
vital signs,
Inspection around external ear. use torch to look for discharge and inflammation of ear, nose and
throat. all normal.
loss of hearing on the left side. the patient was sitting close to the wall and not much space to do
hearing test. I ask her which side loss of hearing before starting the test, she said left side, Start
from normal right side whispering asking her to close her left ear but she said she cant hear
because I was staying on the left side and testing her other side .Moved to her right and she said
can hear, moved back to left cant hear.
Rinne test bone >air on left side.
Weber test lateralisation to left side,
Ortoscope examination with dummy, use the ear piece, turned on the ortoscope and placed it at
the external ear opening pulling the ear outwards and upwards on dummy

The ear was filled with wax like fragments throughout and the tympanic membrane was not
visible so I just mention the comment what I saw directly during examination.
PDx : conductive deafness because ear structures cannot vibrate to receive sound.
With drawing.
DDx: wax impaction, cholesteatoma, recurrent OM, Otosclerosis, pagets disesase, osteoma

(passed 5)

Station 8 rest station

Station 9
55 year old lady present with chest discomfort for a few months duration.

History,
Ask PE,
Exaplin the condition to patient,
Other possible causes to patient

Introduction!
I checked stability before starting the history.
The patient was not currently in pain.
Previous repeated episodes. Chest discomfort, 5-6/10 severity, agg. by activity, during running,
relieved on rest, no radiation, no associative features: sweating nil/pallor nil/raising of Herat beat
nil.The patient thinks she has reflux condition.
ABCDEFS normal apart from family history for heart condition. Father has AMI bu survived.
Reassure that sorry for your father but it was good to know he was well now.
No GI causes. No features of cancer. No travel history. No regular taking mess. No systemic
problems

PE: given card: showing baseline blood tests, all normal.

I explain about angina.
Mention DDx system by system.
Commnet: Although there is not task for Inves I mention a few and the examiner did not stop
me. We have to consider heart causes as first priority.

(passed)

Here is outline about AMC

 Relax all the time.
 Treatment patient like a real patient (patient centre), though situation is making up!
 Gasp the facts in old questions analysis, after getting this, you will not be fooled around
during the exam and you have virtual experience to face upcoming unseen questions.
 Before doing cases, 2 minutes thinking is very important. So you need to train that just
before every cases.
 Keep doing cases around 4 to 6 cases a day
 Listening the cases when your friends are doing, about 6 cases.
 Assess what you have done in the daytime at night
 If doubtful, look up only facts from the notes( Karen, JM) and reproduce with own
language.
 Keep every usage simple, less conjunction and short to the point because of no time to
beat around the bush! ( So Management discussion should be within 1 or 2 minutes,
do it with timer)
 Just before 7 days to exam is the golden time, just discuss with friends, like group
discussions to facts, and do PE with less doing cases.
 Lastly, do enjoy your practice sections with friends in a sense of not being about
humiliation and centre of laugh, but learning new things and clinical experience in each
role play, which improves not only your interest in professionalism but also care of
patients in the not too distant future!

All the best wishes!