Brisbane 8th May 2010

(The comments in the boxes belong to another candidate)

Paediatrics
Q.1\ AMC book -condition 20Questions asked by the role player: 1. What is DM? My father has DM, is it the same one? Me: No, the one your father has is called Type 2 and it is different from the one ur son has which is called type 1 DM .Type 1 DM occurs at younger age in which there is less insulin production from the pancreas which is responsible for regulation of the blood sugar in our body. This occurs due to destruction of the pancreas possibly due to autoimmune condition (our immune system attacks our own cells). 2. Will he need insulin for the rest of his life? Yes 3. Who will give him the injections? 4.How?Here I think I misunderstood the role player coz I thought she asked me to explain the method of giving an injection so I wasted a precious time to explain that. I believe we just need to tell her about the site of injections, the number of times a day......... 5. What about increasing or reducing the dose? Who will decide that? Me: The specialist will decide that which will be based on several readings of the blood sugar....I explained about the glucometer and monitoring of the blood sugar. 6. What should I do in case of hypoglycaemia? 7. What should I do in case of hyperglycaemia? 8. What about sport? In this case I always reassured the mother coz she was so anxious..... However I could not finish my task on time so when the bell rang I told the examiner while going out that I need also to talk about school and camping. AMC feedback- Diabetes type 1 juvenile-counselling (Paediatrics) -PASSED

This case is exactly same as the AMC book... but the mother was worried and needed reassurance and was asking about the cause of DM......Passed

Q.2\ A father brought his seven year old daughter who is complaining of recurrent headaches. Task: Hx, ask the examiner for the examination findings and management? (My D.DX included the following: Tension headache, Migraine, Meningitis, Haematoma after a fall, Brain tumour ,Others like Infection such as viral or chest infection ,Visual problem ,Sinusitis and hypoglycaemia ) History - I do understand that u r here today coz of ur daughter? Could u please tell me more about it? (He did not volunteer useful information so I start to ask questions) -How long? 4 months -Where? Like a band around her head. -Does she skip school coz of it? No -Does it affecting her daily activities? (I cannot remember what he answered) -does she complain from this every day? No -Is it there all the day? It starts in the morning and (I think he said until the evening) -What about the weekends and holidays? No -What relieves the headaches? May be Panadol -Is this the first time? Yes -Is it getting worse? Yes Then I started to ask questions to exclude my D.DX -Any family history of migraine? My sister has migraine -any family history of brain tumour? No -Does she vomit? Any nausea? Does the light hurt her eyes? No -Any fever? Wt loss? No -what about lying or bending? Do they relieve or worsen the headaches? No -Any weakness in her legs or arms? No -Any history of recent fall or head injury? No -Any recent infection? Sinusitis? No

-Does she skip breakfast? No -Is she enjoying her school? No, coz there r many students there who r bullying her and make fun of her and she is very upset about that. I tried to talk to her teacher about that several times but we could not do anything about it. -does she love her teacher? Yes -What about her school performance? (I cannot remember what he answered) -Can I ask some personal questions? Yes -What about the situation at home? Very good -r u happily married? Yes -Any interpersonal problems between u and ur wife? No -R u both having enough time with her? Yes -Any financial problems? No -Any other siblings at home? Yes (I cannot remember the age) -How is the relationship between them? Very good Then I finished my history taking with the usual BIND questions (birth and pregnancy, immunization, nutrition and development)...All were normal Also asked about general health, medication and allergy...All normal Examination -General appearance, well or unwell? Looks well -growth chart? Normal -Vital signs? (I cannot remember the exact numbers but they were all normal) -Rash? No -Fundoscopy? Normal -ENT? Visual acuity? Sinuses? Normal -Neck stiffness? LAP? No -Chest and heart? Abdomen? Normal -Neurological examination? Normal

Management Mr x, from what u have told me and from the examination, ur daughter has Tension headaches due to the stress that she has at school. Our body and mind r connected together and when our mind is upset, our body can respond in different way and in ur daughters condition it is the headaches. The headache is real and genuine. It is not serious and we have a lot to do about it. First of all I need to talk to ur daughter and also we need to arrange family meeting. Also we will arrange social worker to go to school to talk with the teacher coz the most important think to treat these headaches is to remove the stress. Also it will be a good idea if u can take her for a holiday. I forgot to refer her to paediatric psychologist as the bell rang when I was talking about the management but I told the examiner when I was going out that I have more to talk, He laughed and said I know :)!!! The role player here was so anxious after telling him the diagnosis so asked him if he has any concern, he said, could it be brain tumour. I told him I am very happy with my examination and it is very unlikely to be something serious but if u like I can refer u to a paediatrician for a second opinion AMC feedback Headache-tension (Paediatrics) -PASSED

I referred the child to psychologist; but the role-player asked Is that necessary? And what the psychologist will do? So I explained that the psychologist is expert to deal with similar situations and he will help your daughter to identify the stress in her life and teach her how to deal with it. Other management Social worker, school involvement, family meeting and ongoing support from me.....Always at the end of each case the 4 R: Refer, Review, Red Flags and Reading materials.......Passed

Q.3\ A six month old baby brought by his mother .He has diarrhoea about 5 or 6 times and vomiting about 4 times (I cannot remember the exact no.). Task: Hx, ask the examiner about the examination findings and management? History -I do understand that u r here today coz of ur son? Could u please tell me more about it? (Again she did not volunteer useful information so I started to ask questions)

-How long? 24 hours -Is the diarrhoea watery or semi-formed? Watery -What colour? (I cannot remember) -Any blood? No -Is it explosive? No -Is this the first time? Yes -What about the vomiting? Colour? Milky -Is it projectile? No -Any blood? No -Any fever? He is a little bit hot -Is he feeding well? I breast feed him and it is a little bit less than before -From 0 to 100%, how will u rate his feeding? Probably 80% to 90% -what about wet nappies? A little bit less -From 0 to 100%? Also 80% to 90% -Any rash? No (to exclude meningitis) -Is he crying a lot or looks irritable? A little bit -Does he draw his legs or look pale when he cries? No (to exclude intussusception) -Does he cry when he passes water? No (to exclude UTI) -Have u travelled recently? No -Does he go to child care? No -Any contact with similar condition? His brother (4 years old) has similar episode 4 weeks ago .Now he is well. Then I asked about BIND...The mother said that he has not had the 4 month shot for some reason (I cannot remember why) so I told her it is important to immunise him coz it will strengthen his immune system and help him to fight against diseases. Beside it contains vaccine against rota virus which is the main cause of diarrhoea in children....She accepted my advice and she was very willing to have her baby immunised.

Examination -General appearance? Normal -Growth chart? Normal -Signs of dehydration (fontanelles, sunken eyes, dry mouth, skin turgor and CRT)? All normal -Vitals? I cannot remember the exact no. But they were all normal except the temp. Was 37.7 -Any rash? No -ENT? Normal -Neck stiffness? LAP? No -Chest, heart ?Normal -Abdomen? Starting by inspection? Normal....then by palpation for masses and pain? Normal Bowel sounds? Normal -Inguinal orifices? Normal -Urine dipstick? Normal -excoriation of buttock? No Management Mrs x, from what u have told me and from the examination, ur son has gastroenteritis most likely due to viral infection....It will resolve by itself within 3 to 4 days. There is no specific treatment or antibiotics coz it is viral infection. The most important thing is to prevent dehydration. So I would like to refer him to the hospital for observation for few hours and oral rehydration solution until the vomiting settles down.... (Here the mother asked if she can manage that at home)I told her Yes u can but I would like to see him in 6 hours time to re-examine him coz babies at this age can easily get dehydrated. So continue breast feeding but frequently and in smaller amount .Also give him ORS a mouthful amount every 15 mins. During this period if u noticed that he is unwell, does not feed well or less wet nappies or u r worried for any other reason, bring him ASAP to me or to the ED. Also coz this type of diarrhoea is contagious so try to keep him away from his brother and make sure u wash ur hands after changing the nappies or before handling food. I also gave some written materials.

Then the mother asked me if she can visit her cousin who has 3 children, I told her that she can but she needs to keep her baby away from them..... AMC feedback Gastroenteritis (Paediatrics) -PASSED

I gave the mother options either taking care of the child at home (if she can) and I need to review him in 6 hours, or I can refer her to hospital where her child will be assessed and then discharged when he is feeling better....encourage breast feeding and immunisation.....4R..... Passed

Obs & Gynae.

Q.4\ A 28 year old woman comes to ur GP, she has a positive pregnancy test at home after nine weeks of amenorrhea ...Her periods are irregular. Her pap smear was done 6 months ago and it was normal. This is her first pregnancy...Her next antenatal visit is in 2 months time so she has been told to visit her GP for initial Investigations. Task: Counsel her about the initial Ix she needs until that time and answer her questions. I talked about the following: Congratulations for ur pregnancy. I do understand that this is ur first pregnancy? (Yes).have u started taking folic acid? (No).So first of all we need to confirm the pregnancy here in our office .Also it is important to start taking folic acid for the first 12 weeks of pregnancy. We need to do routine initial antenatal tests which include the following: 1. FBE &Hb, BG & indirect Coombs test. 2. Rubella and varicella immunity status. 3. After ur permission, screening tests against certain STDs including HIV, VDRL for syphilis, hepatitis also we need to take some cervical swabs for Chlamydia and gonococcus infection. 4. Midstream urine C&S for UTI. Also if u like we have screening test for Downs syndrome that we offer for any pregnant woman although u r still young. We will also do U/S to confirm the date of pregnancy coz ur periods were irregular (I am not sure if I should have said that or not but I had a plenty of time so!!!!) The role player asked me if there is any other medication she should take. I saidiron but first we need to check ur Hb level (I am not sure if this was what she wanted to hear)

Also she asked me if she should continue her job as she is a teacher? I said It is up to u but let us first check ur immunity status against Rubella and chicken pox. if u r immune it is safe but if it is not it is important to stay away from children especially the first 3 months coz it is the critical period for the development of baby... I believe the critical errors in this case r most probably to offer downs screening ... OR very less likely to arrange U\S to confirm the date of pregnancy since her periods r irregular OR to arrange varicella Ab screening coz I know a candidate who failed this station and he did exactly like me apart from the above 3 things. AMC feedback Investigations during pregnancy (O&G) -PASSED

I offered all the antenatal care Ix mentioned above, but I did not offer Downs screening, early U/S or Varicella Ab screening. I mentioned, as you are a childcare teacher its important to avoid contact with ill children or children with fever...... Failed

Q.5\ AMC book condition -64The differences were the following: 1. Task includes examination 2. In the examination I asked the following: -General appearance? Normal -BMI? Normal -Secondary sexual characteristics (axillary hair, beard, gynaecomastia)? Normal -Chest and heart? Normal -Abdomen? Normal -Inguinal orifices? Normal -Genitalia (Inspection: pubic hair, scrotum, any swelling.....Palpation: can I feel both testes, spermatic cord, size of testis, any swelling)? Both testis r present and of normal size but there is a small swelling in the right side.... (So I asked the examiner about the CCC of the swelling?)It is not tender, feels like bag of worms, can get above it, and disappear when lying down... (Here I should have asked also about transillumination and may be others but I was in a hurry as I wanted to finish my task) -Urine dipstick and BSL? Normal 3. I advised the patient as in the book but I also told him u have a swelling in the scrotum most likely it is called varicocele which is dilated veins like varicose veins in

the legs .It can be related to ur problem but do not worry coz it is a treatable condition so I will refer u to a surgeon for that. He accepted my advice without any comment and then I completed my task according to the book. AMC feedback Primary infertility (O&G) -- PASSED
I just did as the above candidate and as the AMC book.....Passed

Q.6\A woman in her 50s (I cannot remember the exact age), comes to ur GP complaining of a lump going down on and off mainly with sneezing and straining. Task: Hx, ask examiner for examination findings and management. History -I do understand that u have been complaining of a lump from the down below? Could u please tell me more about it? I have this lump on and off for months now but it is getting worse now. -Is it there only when straining? Yes -does it disappear by itself? Yes Here the role player said I had my womb removed 13 years ago. Actually she surprised me when she said that coz I was almost sure it is uterine prolapse. So I continued my history taking... -Can I ask why u had ur womb removed? Coz of heavy bleeding. -Any complication after the operation? No, everything was normal until months ago when I had this lump. -Any problem with passing water? No, completely fine. -Any bleeding? Discharge? No -Can I ask some personal questions?Yes,please -r u sexually active? Yes, I am married -does this lump affecting ur sexual activity? Yes, it makes me feel uncomfortable. -Any bleeding after sex? No -Have u had any HRT before? No -What about ur pap and mammogram? Done regularly and normal -How is ur health in general? Fine

-any wt loss or loss of appetite? No -do u have any cough? Constipation? No - Do u have children? Yes 2(or three) -What about the deliveries? All NVD and without any difficulties. -Do u smoke? No -Alcohol? Socially -Some people used recreational drugs, have u ever used them? No -Any chronic illnesses? No -Any medication? Allergies? No

Examination -General appearance? Normal -BMI? 28 -Vitals? Normal -Chest and heart? Normal -Abdomen? Starting by inspection? Normal......Palpation, any masses, tenderness? No -Vaginal examination after patients permission, starting by inspection, any lump? No... -then by speculum examination, any discharge? No -Then I would like to ask the pt to strain, any lump? Yes, the vagina comes down... -Then I would like to use Sims speculum in left lateral position and ask the patient to strain again to look for cystocele or rectocele? Normal -Urine dipstick and BSL? Normal Management Mrs x, from what u have told me and after examining u, it seems that u have vaginal wall prolapse (Actually the right thing to say is Vaginal vault prolapse and I knew that but it just did not come out so I just said wall prolapse...also I drew to the patient and explain the condition but please read more about it as I have no enough information and I am not sure if what I said is correct or not).

Coz u had ur womb removed, this can leave the vagina unsupported and with age the ligaments become weak.....this is not serious but with time it can get worse and might lead to ulceration. We have conservative treatment and surgical....so what treatment do u prefer?(The pt. says she wants to find a final solution to the problem so I said:)so we need to refer u to a gynaecologist who will do further assessment and most likely will decide an operation. but life style modification is also important and u need to lose wt, walking for 30 mins every day, healthy diet( I am not sure if we need to talk about pelvic floor exercise ,actually I did not have time as the bell rang!!) AMC feedback Vault prolapse after hysterectomy (O&G) -PASSED

Psychiatry
Q.7/ A very long stem of a women has 2 children, 2 months old and 30 months old, presented to u one week ago with a history of tiredness ,wt loss and inability to sleep. She is always worried about her baby as he might die from SIDS .She thinks life is not worth living but she does not have infanticide idea. U arranged Ix for her one week ago including FBE, TFT and (many others that I cannot remember) all were normal...Today she comes to ur GP for the result. Task: Take focused hx, counsel the pt about the treatment in details? This is a very weird station as when I was outside I thought it is definitely severe postnatal depression that needs urgent admission...beside I was wondering what else I should ask this patient as the stem is too long and I did not have enough time to read it carefully so I can figure out what else they need so I just decided to follow the usual psych hx except things provided in the stem. History -Hi Mrs x, we have received the results back and I am pleased to tell u that all of them r normal. So can I ask u few questions to clarify the problem? Yes(here I was surprised that the role player actually was a happy young female, and no signs of depression at all so I said to myself may be she is not a good actress!!!!) -How was the pregnancy and labour? All fine, no problems at all. -How is ur mood? Not good, feeling tired (I cannot remember the exact words) -what about ur sleep? Cannot sleep, feel anxious -What about ur sexual desire? Reduced -Do u go out with friends? No, do not have time -Do u have enough support? My husband is very supportive

-What about ur family? They r interstate -Do u work? No -Were u working before or do u want to start a job? No -Any financial problems? No -Do u think life is worth living? Yes!!!!!..............Here the role player really surprised me so I said But I do understand from ur notices that u do not think life is worth living!...She smiled and said That was before but now I do understand that I have responsibilities and I should take care of my children!!!! -Do u smoke? Do u drink alcohol? Drugs? No -Do u see or hear things that other people cannot? Do u think someone is trying to follow u or spying on u? Do u think TV is talking about u ?Do u think that u have special powers? No -If u r in a cinema and there is a fire, what will u do? Run away -Do u think u need a medical help? Yes -Do u have any past hx of any illnesses or psychiatric illness? No -Any family hx of psych illnesses? No Management Mrs X, What u have is a condition calledpostnatal depression..It can happen to women after deliveries and it is treatable. So please do not worry. What Id like to do is to do admit u to the hospital for further assessment.(Here the role player said that she does not want to be admitted to the hospital and me personally I did not find any reason for admission as she was smiling ,no suicidal ideas, she just needs some help so I said....) OK then, I will refer u to psychiatrist ASAP for further assessment and for CBT which is a type of talking therapy based on weekly sessions. It will help to identify the stress and deal with it. Also the psychiatrist most likely will start u on antidepressants medication. The role player askedwhat about breast feeding. I saidThis depend on the type and dose of medication .There r medications that r suitable for breast feeding, however the best will be decided by the specialist...Then I said: Also we need to arrange a social worker and also liaise with the local community nurse for any help u need.....Also beside my support and regular follow up, we have good support group that u can talk to them, share ur experience and have good advice. Also Id like to arrange family meeting ...Here the role player interrupted me

and said Yes, what about my husband, I am really worried about him coz he is very concerned about me...I answered I will talk to him but please do not worry about that coz they r there to support us and they r happy to do that ...I think I should have said something better than that but that what came to my mind at that moment......Then the bell rang!!!!!!!!!!!!!! AMC feedback Major depressive episode-post partum phase- -PASSED

In the stem they mentioned that a depression Questionnaire was done to that patient and it showed that she was depressed... The role-player did not seem depressed to me and she was somewhere between depression and anxiety, but I decided to go with what I know (post-natal depression)... I admitted the patient who refused in the beginning, but she agreed when I explained to her that it is important and necessary to admit her and to be assessed by a psychiatrist... I also asked to talk to the husband and check both of her children... I reassured that her condition is common and has good outcome with treatment... support group and social worker....Passed

Q.8\ A thirty something woman comes to ur GP asking about her father who has recently diagnosed with Alzheimers disease .She is a very busy solicitor. She is very concerned about her father and she has many questions to ask. The daughter has her fathers permission to ask about his condition. (I think also that a CT scan was done to the patient and showed atrophic changes)... Task\ Answer her questions. The role player asked the following questions: 1. What is Alzh. Dis.? Me\It is a type of dementia where there is wasting of the brain cells, which in turn can affect the brain function. The early features of this disease are disturbance of thinking and short term memory. It also causes personality changes. This will worsen slowly and gradually with time .It can lead to severe memory disturbance, the person might even forget the names of his family. The person might also neglect himself and this lead to malnutrition and increase risk of accidents at home or outside. 2. When they dxed him with this dis...r they 100% sure? No, basically Alzh. Dementia is a dis of exclusion. By that I mean exclusion of other correctable causes. It is true that we can see some changes on the CT scan, however the only definite dx is after death of the affected person and examining the tissue of the brain under the microscope. 3. Can it be depression coz my mother passed away 6 months (or one year) ago?

Well ,Depression by itself can be presented as dementia and sometimes it is called pseudodementia so it is important to exclude it before diagnosing dementia. But Those with Alzh. can get depressed especially at early stages of the disease coz they can recognise their disability ,but please do not worry about that ,he will be assessed by a psychiatrist and I will follow him up regularly. Also we have good medication for depression in case he needs them. 4. What can be done now? First of all, he needs to be assessed by the aged care assessment team; this team is composed of a geriatrist, psychiatrist, social worker, occupational therapist, and physiotherapist. He will be assessed by them to determine his degree of dependency and assess his eligibility for the services that we can offer. So the geriatrist might prescribe some medication for him that will delay the progress but will not treat the illness as this disease is unfortunately progressive and it is not treatable. The occup. Therapist will assess the house and assess his needs, for example, he might need a big clock, rails to prevent falling, remove any loose carpet and a list of things as a remainder. The social worker will arrange some people to help him in washing clothes in case he needs and meals on wheels and many other services as well. The physiotherapist will assess his ability to walk and might provide him with walking aids. 5. Is it better to put him in a nursing home coz I am very busy and I cannot take care of him? Well, the ACAT will decide that after further assessment...The options that we have r: 1st option, treat at home if he can cope with that and this is a good option as the environment is familiar to the pt .He will be assessed regularly by me and the ACAT so we wont leave him alone. 2nd option is to put him in a nursing home in case he needs that. And at any time if u change ur mind, u can take him to ur home and take care of him but u will not be alone and there is respite care that will help u to take a break and have some rest. While I was talking about that the bell rang so I have not had the opportunity to talk about ability to drive (as we need to assess his brain function and if it is well he can

drive, otherwise he cannot and his licence should be suspended) and also to give some reading materials. AMC feedback Dementia of Alzheimer type -PASSED

Examination
Q.9\ AMC book condition 102The differences were the following: 1. On the wall outside the room, there is an attached paper includes a chart of the vital signs of the patient since the operation....I believe they were all normal. 2. Also in the question, the bladder was assessed by U\S probe and it showed little amount of urine (a number was given). 3. The task was to examine the patient and write a management plan.(When I went inside the room, the examiner asked me if I understood my task, I said yes, I need to start examining the patient without taking any hx?He said Well u r the first candidate to do that!!!!! :) 4. The pt was a young female lying on bed with a NG tube attached and fluid(as described in the book) 5. Then he asked to give a running commentary while examining the pt so I told the examiner My examination will include assessment for urine retention, signs of dehydration and signs of over hydration..He answered Good........Then I started to examine the pt and straight away I started to examine the abdomen by pressing on the bladder and asking the pt if she has any desire to void for which she said no....Actually with any examination it is better to start with the general app. and vitals then the rest but I FORGOT................Then I started to look for the signs of dehydration and here the examiner asked me what I am looking for ,I said (while I was demonstrating that) sunken eyes, dry mouth, skin turgor and CRT and again I forgot to say the vitals!!!However they were already measured by the nurse......Then while I was starting to look for signs of over hydration, the examiner interrupted me and asked me to write my notes. 6. The examiner asked to explain to him what I had written so I said I will give the pt 500 ml of N\S in 30 or 60 min and then review the patient...The examiner asked me how I will monitor the pt, I said The vitals and repeating my examination but he really did not seem satisfied with my answer and a little bit upset and he said something like the vitals r not that useful to monitor such patients so I said by putting a catheter and he was happy with this answer but I told him that I was going to do that if the pt did not pass urine after 30 to 60 min ( As in the book ) but he answered No, u should do that

from the beginning so I agreed and I did not argue with him coz HE IS THE BOSS !!!! 7. Then he asked me how much fluid I will give for the rest of the day so I answered as in the book. He asked me to write that as well. 8. Then he asked me what if the pt did not pass urine after 60 min, here my answer was I will take a sample of urine and send it to the lab to differentiate between pre-renal cause or renal cause and I explained what I will measure in the urine.....And again he was not satisfied with my answer and after trying to repeat the same answer in different ways( coz I really did not know what he wanted me to say) the bell rang and at that moment I said I will check for urine retention and here he said yes that what u need to do and I went out.................But after thinking of that after the exam, I asked myself Why do we need to check for urine retention and a catheter is already there?!!!!!!!!!!!!!!!!!!........................In this station either I did not understand the examiner or he did not understand me!!!!!!!! AMC feedback Post operative oliguria -- PASSED

Q.10\ A 50 something man, come to ur GP complaining of pain during walking which relieves after rest. He is a smoker (heavy) and on ACE inhibitor for HPT. (I cannot remember if there were other risk factors in this case). Task: Perform physical examination (u do not need to examine the vitals or the heart) and outline ur management plan.

I think the pt here was a real pt. and he was wearing a gown. 1. I started by asking the pt to walk few steps (I think we do not need to do this step so double check that please)... 2. Inspection: There was a midline longitudinal scar on the abdomen and another one on the inner side of the upper right leg...I asked the examiner if I can ask the pt about them he nodded yes .Here the pt said that for the abdomen it was for AAA and for the leg it was for a clot removal. 3. Temp. and CRT. 4. All the pulses were palpable (No expansile impulse for aorta, femoral pulsation and others were intact as well) .However it really took me long time to feel one of the femoral pulses. 5. After finishing that, the examiner started to rush me and asked what else, I said Auscultation for bruit and I showed him where quickly (abd aorta, iliac, femoral, adductor hiatus and popliteal) .He answered No bruit

6. Also I said burgers test and ABI but he did not asked how to do that and he asked about my provisional diagnosis for which I said PVD Then he shocked me when he smiled and said the bell rang...actually I did not hear it and I said to him that I still need to manage the patient but he smiled and while he was guiding me to the door I said with a loud voice to the pt u need to quit smoking, life style modification and referral to a vascular surgeon...They both laughed loudly.!!!!!!!!!!! .........This was a very funny station. AMC feedback Leg cramps on exercise -PASSED

I was asked how to perform burgers test, D.DX (I think we need to say neurological cause such as sciatica, spinal canal stenosis and peripheral neuropathy)...Passed

Medicine & Surgery Q.11\ AMC book - condition 68 The only difference is that we also need to take hx and to give D.DX....and when I was going to tell the examiner (after asking him about the examination findings) about my D.DX and the test to confirm that, he stopped me and asked me to tell the pt about it....So I rattled off the D.DX to the pt. but when I asked her if she wanted me to explain each one to her she said no need( What a nice lady, she wanted to save my time)..When I was going to explain the treatment the bloody bell rang again so I quickly said while going out that the treatment is steroid.!!!!!!!!! AMC feedback Aches and pains -PASSED

Q.12\ AMC book condition 139 The only difference is to explain to the pt how to use the peak flow meter ......he said he know how to use the puffer.........There were a puffer and a peak flow meter provided on the table . Also I wrote the management plan on a plain paper as there were not any management plan papers when I asked the examiner about it. The patient asked me about the dose and type of steroid tablets. AMC feedback Asthma -PASSED

Q.13\ A 30 or 40 something old tram driver, comes to the ED complaining of chest pain for few hrs. Task: Hx for 4 mins, ask the examiner for examination findings and management.

When I entered the room ,the examiner said to me that I have 3 mins to ask hx so I asked him to stop me after 3 mins coz I will forget and continue asking question ..He smiled and said ok History - I do understand that u r here today coz u have been having pain in ur chest? Could u please tell me more about it? I have been having this pain for few hrs now (I cannot remember how many exactly) and it travels to my back and shoulder. It is getting worse now. -How did it start? Suddenly without doing anything but I had flu days ago.( The role player was very kind to volunteer this info. However she was answering all my questions directly and nicely). -Is it there all the time? Yes -Could u describe the pain? (I cannot remember what she answered) -From 1 to 10, 1 is the minimum and 10 is the maximum, how would u rate the pain? 6/10 - Anything worsens the pain? When lying or with deep breathing. - Anything relieves the pain? When leaning forward. -have u ever had chest pain before? No -Any SOB, Cough, palpitation, leg swelling, dizziness, fever? No -How is ur health in general? Perfect -Any chronic illnesses such as DM, HPT, high cholesterol? No -Do u smoke? No -Alcohol? Socially -Some people used recreational drugs, have u ever used them? No -Any medication, allergies? No

-Any recent travel? No -Is ur chest sore to touch? No

Examination -general app.?She is in pain -VS and O2 sat.?Normal (I cannot remember the exact numbers). -heart? any thrill by palpation? No.....heart sounds? Normal... -any added sounds or murmurs? There is a noise ............I asked the examiner if it is a rub? He said YES -Any signs of heart failure? No -Lungs? Normal -Abdo.?Normal -Leg swelling? No Any Ix available? No.....I think the examiner asked me about my provisional dx and I answered My provisional dx is acute pericarditis but I need to exclude MI coz every chest pain is MI until proven otherwise

Management Mrs x ,from what u have told me and from the examination findings, most likely u have a condition called Acute Pericarditis which is inflammation of the covering of the heart. It can follow a viral infection....Pericarditis by itself is not serious and it is self limiting condition but it can lead to serious complication such as pericardial effusion and temponade which r collection of fluid that may affect the function of the heart.... First of all we need to do ECG to confirm the dx . Also I would like to admit u to the hospital and u will be assessed by cardiologist .The following ix will be done as well: -General blood test such as FBE, HB, inflammatory markers. -Cardiac enzymes to exclude MI -CXR to pericardial effusion -ECHO to exclude effusion.

The treatment includes high dose of NSAID such as Ibuprofen every 4 hrs and regular monitoring to detect any complication earlier. The role player asked the following: -How long do I need to stay in the hospital? Me\Probably few days but it depends on the severity and the progression of the condition. -Could it be heart attack? (The role player was a bit concerned about the chest pain) Me\It is unlikely but we still need to perform some tests to exclude it. Please do not worry coz u will be managed in good hands. AMC feedback Pain in the chest, back & shoulder -PASSED

Q.14\ A 70 years old man present to ur GP clinic complaining of recurrent falls...He had stroke four years back with weakness of the right upper and lower limbs. Task\ take a detailed history for 4 mins, ask the examiner for the examination findings, d.dx and management.

History This was my first case and I put the following d.dx when I was outside the room(Neurological-epilepsy ,TIA-......CVS-structural or arrhythmic-....postural hypotension-medication and DM-.......hypoglycaemia......vision ,hearing and balance.......alcohol.....musculoskeletal such as joint problems.....psych. as depression .....Environmental as messy house). - I do understand that u r here today coz u have been complaining of recurrent falls? Could u please tell me more about them? (The role player did not volunteer any new info so I started to ask questions). -When was the first one? Few months ago (I think 6 months ago) -How many times? 3 or 4 times -Have u sustained any injuries? Just few bruises. -What were u doing before the fall? It happen when I get up for e.g. in the morning when I get up from the bed. -Did u feel dizzy before u fall? Yes

-Did u lose conscious? No -any problem with speech, swallowing, weakness in the arms or legs (apart from the one u have)? No -Any palpitation, chest pain, SOB? No -have u been passing water a lot? Or feeling thirsty lately? No -Any problem with vision, hearing? No ...I said ok we will check them. -Any joint problem or pain? No -Do u skip meals? No -How is ur health in general? Any wt loss or loss of app.?No, I am fine -Do u live alone? Yes -can u manage things by ur self? Yes -Any walking aids? No -What about the environment at home? It is a little bit messy. -Any medication? (The role player here who was an old age man gave me a small card with names of drugs written on it...... angiotensin 2 receptor antagonists, diuretics and amitriptyline but I cannot remember the names of the antiHPT medication). -Do u have HPT? Yes for few years -Is it well controlled? I check it every now and then and it is ok -I can see that u r on amitriptyline, do u have depression? Yes since my wife passed away 9 months ago. -I am sorry to hear that, and how do u feel now? Fine. -Any other illnesses such as DM, heart problems? No -Do u smoke? No -Alcohol? socially - Some people used recreational drugs, have u ever used them? No

Examination -General app. And BMI? Normal

-Vitals including BP lying and standing?(I cannot remember the exact numbers but the pt had low postural hypotension) -Fundoscopy? Any HPT changes or papilledema? Normal -Carotid? Any thrill or bruit? Normal -Chest and heart? Normal -Neurological examination?(here the examiner asked me what I want to examine exactly so I started with the gait, cerebellar signs, cranial nerves ,upper and lower limb examination including tone ,power ,reflexes ,sensation and coordination)..The findings was hypertonia and hyperreflexia on the right side but the power reduced.....I cannot remember what the examiner told me about the gait. -here the examiner told me the rest of the examination is normal and I should talk to my pt. but still I asked about vision ,hearing ,BSL and musculoskeletal...The examiner said it is all normal ( with a smile that meant do not ask anymore when we said the rest of examination is normal!!!!!!! as Dr.Wenzel always says that but we still ask !!!!!!!!!! )

Management Mr x ,It seems that the most likely cause is postural hypotension which sudden reduction in BP when changing position from lying to standing..The most likely cause in ur case is the antiHPT medication that u r on (Other candidate said that amitriptyline also causes that) so it is important to change ur medication.....Other causes of the recurrent falls could be due to loss of balance coz of the stroke that u had 4 years back or due to depression and loss of concentration. So I would like to refer u to fall clinic for further tests and...............Here the bell rang and I did not have the opportunity to say occupational therapist to visit ur home and physiotherapist which I believe is important to mention ....This was my first station and I realized here that I am very slow and I need to be quicker ,however I could not achieve that in most of my stations but what I could do is to continue talking especially the main and imp points until I go out and the examiner closes the door . AMC feedback Recurrent falls -PASSED

I mentioned referral to fall clinic, physiotherapist, occupational therapist and installing an alarm in your house because the patient lives alone.... and of course changing the medication...Passed

Q.15\ A 30 or 20 something lady came to ur GP clinic complaining of constipation and pain the lower left abdomen for few months.....u arranged some tests like

colonoscopy, sigmoidoscopy, blood tests and TFT and others ( I cannot remember the exact ix) ,all of them were normal..She came today for the results. Task\Take a focused hx, D.DX and management In this case I tried to ask a little bit about the pain and constipation and to focus more on the social hx.... History -Hi Mrs X, we have received the results back and I am pleased to tell u that all of them r normal .This means that u do not have any organic or serious illness but I still need to ask u few question to try to find the cause, is that fine with u? Yes. -Is the pain always there? No, it is every now and then -Does it travel anywhere else? No - Anything relieves the pain? When I open my bowel or pass flatus -Anything worsens or brings up the pain such as certain food? yes when I eat certain food like broccoli and also red wine.......(I cannot remember the answers in this case including other pain questions like the severity but it was typical of Irritable Bowel Syndrome as in the previous recalls.) -What about the constipation? (Again I cannot remember the details) -Do u have any diarrhoea in between? No -Do u use any laxatives? No -Can I ask u some personal questions? Yes -How is the situation at home? I am married and I have 2 kids (I think teens) -Any financial problems? No -R u happily married? Yes -Any problems with the kids? No but I always like everything to be perfect at home, clean and tidy -What about ur family, friends? Do u work? (I cannot remember the exact answer but nothing specific) -Health in general? Sleeping? Mood? Fine -Any chonic illnesses? Any medication? Smoking? No - Alcohol? red wine ( I think with evening meals)

- Some people used recreational drugs, have u ever used them? No -any family hx of similar problems, relatives on special diet or cancer? No

Management Mrs X, It seems that the most likely cause is a condition called Irritable Bowel Syndrome. Other causes could be Celiac disease but it is very unlikely and we can do some screening blood test for it. (Here I really did not know what else to say about the D.DX as I had not read in the previous recalls about a D.DX in this case!!!!So I just continued my management and the examiner was just listening without any word.).....Have u ever heard about Irritable bowel syndrome? No Well the bowel of some people r sensitive to some external and internal stimuli such as certain food and stress coz our mind and body r connected to each other and when our mind under stress ,our body can respond in different ways ( I am not sure if we should say that here),...This will lead to different symptoms such as pain , constipation and s.t. diarrhoea. This is not serious at all .It is not cancer and it does not lead to cancer so please do not worry a lot about it. This condition is chronic .it comes and goes and it may disappear for years. It is not treatable but controllable condition however we still have a lot to do about it The most imp thing in the management is life style modification and preventing the contributing factors so try to avoid the causative food such as broccoli and red wine and try to make a diary and write down the food that can worsen the symptoms. High fibre diet and plenty of water is imp. I can refer u to dietician if u like. Also relaxation is very important to relieve the stress such as yoga and meditation. Try to be less than perfectionist. For medication I can prescribe u some medication such as mebeverine and peppermint oil but these medication is to control the symptoms and not to treat the condition...and please try always to stay away from the laxatives as it can cause lazy bowel in the future...... (Here the bell rang and I did not tell the pt about the red flags, reading materials, review!!!!!!!!) AMC feedback Constipation -PASSED

Q.16\ (The famous lymphoedema case) A 50 something woman came to ur GP clinic complaining of swelling in her left arm and forearm (I think the hand was not involved...Also a photo was provided)). She has a hx of breast cancer years back and she was treated with mastectomy and axillary clearance followed by radiothearapy. Task\ explain the condition to the pt and management...Referral to specialist is not enough.

Explanation Mrs X, most likely u have a condition called lymphoedema; Have u ever heard about it? No Well Mrs X, our body composed of three types of vessels ,arteries ,veins and lymphatic vessels which carry a type of fluid called Lymph from the body back to the blood and these vessels r connected by lymph nodes( I drew that to the pt.).... Lymphoedema occurs when the lymph accumulates in the body due to destruction or blockage of the lymphatic vessels. In ur case it might be due to the surgery itself and the clearance of the axillary lymph nodes in the armpit or it could be due to the radiotherapy or less likely due to recurrence of cancer itself. Other causes of this swelling r DVT (a clot in the vein) and infection...so we need to do some tests such as some blood test as tumour markers, CT scan to detect any recurrence and Doppler U\S to exclude DVT. (I cannot remember if I told the pt about referral to vascular surgeon for lymph angiogram to confirm the dx and I am not sure if this test is available or not or if it is right to mention it so please check this) For the management, I will refer u to lymphoedema clinic and we will work as a multidisciplinary team (specialist, physiotherapist, nurse and me as ur GP)...The aim of the treatment is 2 things. Firstly is to reduce the swelling and secondly is to prevent infection as the skin here is very liable to be infected. To reduce the swelling, we need to use compression bandage day and night, also massage and try to keep ur arm elevated...The physiotherapist will help u with that. To prevent infection, it is important to follow certain tips: -avoid sunburn. Insect bite. -Always wear gloves when working in the garden or washing dishes as the skin can easily get injured. -Do not let anyone to measure BP in this arm or to give u any injection or to take blood. -Use emollients to moisturize the skin. -Take care with nail clipping or hair removal. This treatment is usually successful however we still have surgery as a last resort...(here the examiner was very surprised about this info and he asked me what type of surgery, I really did not know what to say coz I just know from the course in the VMPF that there is a surgery ..So I told the examiner that once I watched that on a TV report about 2 women, one in the US who was treated conservatively and the

second one in Sweden who was treated by surgery...Actually I did not lie and I really watched that before..So the examiner nodded his head and said ok maybe it was due to?!!!I did not understand him) I forget to tell the pt about red flags and if there is any redness or signs of infection to come back immediately for antibiotics. I finished this case earlier and I asked the pt if she has any further questions, she again asked me if it could be cancer and I repeated the same answer. The examiner here who was a very nice one asked me again to summarise my management so I repeated the same answer but he asked what else and I repeated the same things...I do not know what he wanted to hear from me ...Then we chatted a little bit then he asked me to wait outside...This is the only case that I waited outside!!!!!!!!!! AMC feedback Lymphoedema \upper limb -PASSED

Dear colleagues, - I tried to remember and write whatever I could, however do not rely on the answers of the recalls completely as we may forget to write important and vial things...Always compare the recalls and choose the best answer. -I would like to say a big thank you to the staff and all teachers of VMPF long course..... -Also I would like to thank Dr.Wenzel so much for his great and priceless efforts. -Thank u to the previous candidates who wrote the recalls for us as these recalls were a vital element to study in order to pass this exam. -my exam was in Brisbane...The examiners there just sit and listen to u...Actually they neither give u hints nor mislead u ...The role players did the same ......But always listen well to the role player and his concern and questions and answer accordingly. -Please study the AMC book very well ...as u can notice we had 5 cases from the book although they were a little bit modified.... -I believe the stations in the exam were in the following order: 1. Recurrent falls. 2. Headache-tension (paeds).

3. Rest station. 4. Lymphoedema\upper limb. 5. Investigations during pregnancy (O&G) 6. Aches and pains. 7. Major depressive episode-post partum phase-. 8. Rest station. 9. Asthma. 10. Diabetes type 1 juvenile-counselling (Paeds). 11. Primary infertility (O&G). 12. Leg cramps on exercise. 13. Rest station. 14. Constipation (Not sure) 15. Post operative oliguria (not sure) 16. Pain in the chest ,back and shoulder(not sure) 17. Gastroenteritis (Paeds)(not sure) 18. Rest station. 19. Dementia of Alzheimer type. 20. Vault prolapsed after hysterectomy (O&G).

GOOD LUCK FOR ALL..........................................................................................