AMC Clinical 2009 Recalls
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7th Feb Melbourne 2009 1: Generalized anxiety Young female had palpitation and chest pain had her ECG and all test done everything came normal. On history she is smoking and her sleep has impared due too too much work load, has recently started new business. ( AMC feed back, generalized anxiety) . Task take history, explain to the patient what is it and why it is happening and manege the case . (wanted to hear epinephrine and norepinephrine effect. 2: Permanent sterilization: Youg female taking OCP and doesn’t not want to take any longer wants to dicuss with you the permanent sterilization method. Task: Discuss the method Advantages and disvantages Questions: does it affect on my menstruation, weight and sexual performance and failure rate. 3: ADHD : same as AMC handbook 4: Fever: young female has been getting fever since 3 months probably associated sweats. Task: take the history , ask examination findings from examination and order the investigation It was a differential diagnosis and organizes investigation accordingly. On history she had a travel history scratches on the body and splenomegaly 5: Ca colon : Barium Xray explain the Xray findings to the patient , he had diverticulosis and had been constipated on and off .Answer the questions asked by patient and Examiner: I t was bit hard and tricky I was going to say diverticulosis but patient dragged me on the right side asking could it be cancer, what investigation to confirm and examiner asked that how you will know if it has spreaded. 6: Headache: father is concerned about his 5 year old son who is getting headaches. Task take history, ask examination findings from examiner , diagnosis and manage the case. Father asked are you sure it is not tumour. Headache was related to school situation. 7: Iron deficiency anaemia : Father has been concerned about his 2 year old son. Discuss the blood results with the father. Take the relevant history and management. I was given the growth chart plot the chart and tell to the father if his growth is ok.
8: Arm swelling: young boy was playing tennis notice sudden swelling in her arm : Task ask the relevant history , diagnosis and what investigations you will do? On examination no redness and tenderness just painful and pitting oedema I said thrombosis Examiner questions: Where do you think the clot is? When you send the patient to emergency then what you will write down in your notes?
9: Large for dates: fundus height larger than the dates : Task ask the relevant history examination finding from the examiner and management.
10: Sciatica: same as AMC hand book
Task: take history ask examination findings from examiner, explain to the patient what it is and management. Question asked by examiner which nerve root is affected (single nerve root not the not the whole segment of sciatic nerve. Examiner continuously asked which nerve root I want to know the single nerve. 11: Travel advise: young boy is going to Bali in couple of days who needs your advise what he should do before he flies . 12: Abruptio placenta (concealed bleeding) : 30 weeks (probably) pregnant lady came in the emergency dept complaining for the severe pain in her tummy. Task take the history, ask the examination findings from the examiner, explain to the patient what it is and how you are going to manage. 13: Examine the hands : make your diagnosis I was asked to examine the hand and rt hand was acutely infected and tender. I was confused as everything was normal on the left side finding were positive only on rt side therefore I though I should touch the Rt hand. But do not forget to mention and act on that (when it hurts please let me know I will cease the examination must remember). 14: Chest pain: Middle aged man came to the emergency dept complaining of pain in the chest. Task take the history: Ask the findings from the examiner,what investigations you will do : In the history he had all the risk factor, drinking alcohol, smoking taking meds for diabetes and he was obese aswell. 15: Benzodiazepine overdose: Take the history asses the mental status. The girl did not have any positive history except she has been taking marijuana with friends. Otherwise no depression, no suicidal idea . she was very hard patient she was not happy when I told her to stay in the hospital she said I want to go back and I just took the tablets to get good sleep and I am not that mad to kill myself. Hard one. 16: Terminally ill patient explain the palliative care: The daughter is concerned about her father who has pancreatic cancer wants to know about palliative care, no one lives with her father how can we assist her father in order to provide him a quality of life until he is alive. She wants to know each and everything before she goes away as she lives in other city. Examiner : patient can’t eat anything what you will do ? February 2009 Recall – Different version 1. inferior MI in a 60 year old man with significant risk factors. Take History and discuss management 2. Pale 9 month old came for review of blood tests. Resuilts show iron deficiency. Take a history and discuss diagnosis and management. Child still on cows milk and no solids. 3. 26 year old with lower back pain sudden onset whilst at work. Take history and request examination findings and discuss management. Sciatica 4. 33 year old female with 2 children wants sterilisation, discuss and answer her questions. 5. Travel advice to a young jounalist travelling to asia 6.Examination of hand in apatient with osteoarthritis 7. 70 year old came for resuilts of barium enema. Discuss the resuilt and management plan. Report states narrowing in descending colon.
8. 17 year old brought in after a drug overdose now stable, do a mental status examination and discuss your management plan 9. 23 year old Primigravida presents with sudden onset lower abdominal pain at 38 weeks. Take a history and discuss management. Placenta abruption, unstable and no fetal heart. 10. 34 year old female who presents with recurrent fevers for the past three months. Take a history, request examination findings and discuss mangement.-Lymphoma 11. Father enquires about 6 year old daughter with recuurent headaches.-Tension type and bullying at school. 12. Mother with 6 year old child desruptive at school. Take history and discuss management. ADHD 13. 24 year old clerk with swollen arm. Take History and request examination findings and discuss management plan. Every thing negative in history. 14. 23 year old primigravida large for dates at 32 weeks . Take a history and request examination findings and discuss management. Large for dates but normal afi 15.daughter of 70 year old with advanced pancreatic ca wants to know about condition and management- patient has given consent for disclosure. 16. A woman with Generalised anxiety disorder, smokes 15/ day and drinks a lot of cough. Discuss management
March 2009, Adelaide case 1: a 6 months old child recently came from overseas trip has low haemoglobin and 6 weeks history of diarrhoea. take history , ask for examination findings and counsel mother. buddies whenever dealing with a paediatric case always remember three things to ask : immunization, growth chart and diet history. the child had anemia with falling off the weight for age. fully immunized. very fussy in eating. diarrhoea started 6 weeks ago and is continuing. stools semiformed in nature with no blood. stools not bulky. no history of any recurrent infection, genetic disorder in the family. examination findings : pallor ++, no organomegaly, protuberant abdomen with muscle wasting. no findings in urine. choice of investigation: CBE, sweat chloride test, Hb electrophoresis to rule out thal., stool microscopy and culture to rule out any parasitic infection. Differential diagnosis: 1. dietary anemia secondary to poor oral iron intake. 2. protein energy malnutrition( unlikely) 3. parasitic infestation (recent oversease trip to tropics). 4. cystic fibrosis 5 malabsorption syndrome ( unlikely as it doesnt give anemia). case 2 : examination of a swelling on the face , just anterior to right ear , dermoid. case 3: 23 year old girl with RIF pain, beta HCG positive, simple cyst 5.5cm on right ovary. case 4: postnatal depression (typical from AMC book). case 5: 6 weeks old child with 1 day history of diarrhoea, counsel father. case 6: 24 year old female, LMP 20 weeks back, uterine size 30cm, was on overseas trip, no investigations done. counsel and manage. case 7: coeliac disease. case 8: bitemporal hemianopia, eye examination. case 9: anorexia nervosa case 10: 59 year old man with prostatism , undergoing TURP, counsel. case11: 6 year old child with limping , perthe's disease vs transient synovitis of hip. case12: pneumothorax (typical from AMC book). case13: 60 year old lady with lethargy, history and examination findings, investigate ( wait till monday as this one was tricky and it was not hypothyroidism). case14: 60 year old recently diagnosed with rheumatic arthritis , violin player, counsel. case 15: 22year man, fell off from motor bike, 15 mins unconcious, perform primary survery and counsel the patient and organize relevant investigation. case 16: 62 year old lady, profuse vaginal discharge , brownish yellow( case of atrophic vaginitis but rule out malignancy by hysteroscopy). Discussion of cases: case 2 discussion: 6 month old baby, presented to ED after having diarrhoea. take relevant history , ask for examination finding and counsel the mother. This case was not as straight forward as it looks like and as i had mentioned before that whenever there is a paediatric ase always take proper history.
the history is that 6 month old baby has been having diarrhoea for past 2 days, listless, fussy, crying and difficult to handle. feeding fine.60th percentile for weight and length. diarrhoea profuse , 8 to 10 motions. no blood. 2 siblings had mild diarrhoea 3 days back but self limiting. baby is fussy but drinking fine and not lethargic. BUT THERE IS A DECREASE IN NUMBER OF NAPPIES CHANGED SINCE YESTERDAY. when asked for immunization BABY IS NOT IMMUNIZED AS SOMEONE TOLD THE MOTHER THAT HOMEOPATHIC VACCINES ARE AS POTENT AS NORMAL VACCINE. EXAMINATION FINDINGS: FUSSY BABY. VITALS NORMAL. SKIN TURGOR NORMAL, FONTENELLE NOT DEPRESSED AND EYES NOT SUNKEN. MUCOUS MEMBRANES DRY. REST OF THE GENERAL PHYSICAL EXAMINATION UNREMARKABLE. URINE DIPSTICK: KETONE POSITIVE in this case i counselled the mother that baby has to have immunization and i will refer the case to immunization nurse. also baby is mildly dehydrated secondary to rota virus infection and can be managed at home but since there is suspected decrease in urine output as well as urine ketone positive so i will not be very comfortable at sending him home at this moment but will monitor his urine output along with hospital based rehydration and if everything is normal he can be sent home. also, there is no danger to baby's life if water, salts are replaced appropriately as virus wont pose a danger to his life but dehydration will. then when i asked her do u have any more questions : she asked " would immunization could have prevented this episode?" i said no but immunization is important as it prevents other more life threatening diseases. case 3: 23 year old female , 20 weeks pregnant, has been overseas with no investigations done in the past. the current uterine size is 30cm, rest of the general physical examination normal. talk to mother and manage. well guys the basic mistake which we all do in this case is that we assume that its polyhydroamnios and formulate a plan according to that and thus we are given a unsatisfactory mary, which doesnt mean a fail, but increase the chances of fail if we commit further mistakes. now whenever dealing with a aussie pregnant female always remember following things: always ask blood group. always ask about immunization. always ask weather the pregnancy was planned or unplanned. always ask weather she had any antenatal checkup and if not then organize blood group, CBE, rubella antibodies level, VDRL, gonorrhoea serology, HIV and if Rh negative then get a coomb's indirect and urine microscopy and culture. always ask about previous pregnancies and outcomes. now this female is 20 weeks pregnant, not been investigated and has a uterine size of 30cm, thus she is large for gestational age and not polyhydroamnios. i told the mother that your uterine size is greater than expected for this gestational age and most common case for this is wrong dates. ( with this statement the examiner was overtly happy as if became so emotional that she was about to kiss me and say bless you my child "bravo" haha). now i told that but we have to rule out more sinister causes which can give you the increased uterine size : polyhydroamnios secondary to neural tube defects, GI abnormalities, infection. Blood group mismatch giving hydrops fetalis ( unlikely as mother is O positive and its her first pregnancy) twin pregnancy diabetes uterine fibroids
first thing is that since you havent had any investigations done i would like to do all the antenatal investigations . secondly i need to organize a ultrasound to rule out twins, hydrops, fibroids. will do a glucose challange test to check for deranged BSL. will review in few days time , as soon as the blood results and ultrasound are back and if required refer you to obstetrician. the examiner was happy and so was patient.
March 2009 cases list Adelaide
1. Postnatal depression 2. Anorexia nervosa 3. Ovarian cyst 4. Plyhydramnios 5. Atrophic vaginitis 6. Knee pain/ irritable hip 7. Diarrhoea 8. Anaemia ( due to ?) 9. Pneumothorax 10. Rheumatoid arthritis 11. Pleumorphic adenoma 12. chr. diarrhoea 13. Trauma Mx 14. Visual problem 15. Prostate BPH 16. Infective endocarditis
Sydney 4th April, 2009 Case 1 (Pertussis) A mother brings her 4 month old daughter who has been suffering from cough for 2 days. She turns blue when she coughs. A 2 seconds’ video of her coughing was shown in that station. Task: Take the history from mother. Tell her your diagnosis and management.
Case 2 (Asthma- persistent symptoms) A baby is suffering from asthma, uses Ventolin inhaler but with no effect. She has been hospitalized with an attack of asthma. Task: Talk to his mother about management.
Case 3 (Falling of a horse) A nurse calls you on telephone from a rural hospital & telling you that a 10 year girl fell from a horse and had been brought to hospital unconscious. Talk to her over phone and answer her queries.
Case 4 (Abdominal trauma in pregnancy) A 30 week pregnant lady comes with an H/O RTA (mild injury). Task: Talk to her. Ask examination findings from examiner. Talk about management.
Case 5 (On OCP wants to change to HRT) A 45 years lady is using Microgynon-50 for the last 15 years. She comes to your GP and is asking advice from you about changing it to HRT. Task: Talk to her and answer her questions. Ask investigation finding from examiner. Advice her about what to do.
Case 6 (High mobile head at term) A 40 weeks pregnant primigravida comes to hospital. On examination foetal head is high above pelvic brim (5/5) which can be felt. Task: Ask physical exam findings from examiner. Talk to her about management.
Case 7 (Headache) A 45 years old lady comes with an H/O headache for 6 months. Task: Take a brief history from her (3-4 minutes). Ask examination/investigation findings from examiner. Tell her your diagnosis & management.
Case 8 (Major depression with agitation & somatic features- assessment) A 35 years (?) lady comes with an H/O various physical problems for 10 years (Abdominal pain & others I forgot). She consulted doctors many times, lot of investigations done and all findings normal. She had been referred to a psychiatrist & he diagnosed as “Somatisation disorder”. She doesn’t want to any psychiatrist referral. Task: Take history and explain management to her.
Case 9 (Somatization disorder & agoraphobia) A 65 years lady comes with mild abdominal pain, for which she saw a doctor and investigations done and result normal. She is scared of having cancer. Task: Take details history from her and manage her case.
Case 10 (Cholesteatoma of right ear) A 25 years old truck driver comes with H/O right earache for 2 days. He had a similar episode 2 years ago. Task: Take a brief history from him. Do the relevant examination.
Manage the case according to your diagnosis.
Case 11 (Examination of the hip joint- trochanteric bursitis) A 54 years old man comes with right hip pain. Do the hip examination. This is a complete examination station. You don’t need to take any history or ask investigation findings from the examiner.
Case 12 (Overseas travel risks) A 35 years old executive is flying overseas soon. Task: Counsel her about travelling.
Case 13 (Acute urinary retention in an elderly man) A 74 years old man comes with an H/O urinary retention for 12 hours. Task: Take history from him. Ask physical examination findings from examiner. Talk to patient about management.
Case 14 (Urinary tract infection) A 26 years lady comes with H/O urinary frequency for 1 day. Task: Take history from her. At the end of taking history examiner will give you a task. Do it.
Case 15 (Sore throat) A 20 years old man comes with sore throat for 3 days. Task: Take history. Ask P/E findings from examiner. Talk to patient about your diagnosis and treat the case.
Case 16 (Duodenal ulcer) A 30 (?) years old man has H/O of abdominal pain. A gastroscopy has been done and finding is “An ulcer in the proximal duodenum”. Task: Talk to him about gastroscopy findings and management.
BRISBANE MAY 2009
1. Roughly 55 male had a transient loss of vision in one eye(not sure now which one) while watching TV yesterday. It resolved completely later on. Previous hx of HTN and a few other co-morbid conditions, though all stable. he comes to you today. Perform relevant examinations, discuss ur d/d with examiner and suggest recommendations in managment or further investigations. mid aged man was sitting on couch. already shirt off. chair lying nearby had certain items for examination (torch, hammer, pins, cotton etc). the examiner told me to examine the patient. I was very confused, however thought better of starting with cranial nerves. he asked me to skip details and just do relevant examination. I checked his visual acuity- long standing bad vision in rt eye, left eye fine. light reflexes normal. i didnt do any further eye exams frm here on, and went straight on to gag reflex- normal. I asked for findings on chest auscultation. he talked of added sounds all over chest. no carotid bruits (he made me check carotid bruits). time was running out , he asked me for a differential. I mentioned TIA. In managment I was going to mention CT , but couldnt as time ran out. 2. anne is 4 month old kid , had cold 2 days ago. She was warm last night. Mother brings her to ED today, coughing, snuffles, not feeding well. take some history, ask for ex. findings, give ur provisional diagnosis and further management. Mother told me that anne was quite warm for 2nd day now. dry cough, though not in episodes. not related to feeds, crying. baby feeding less. lesser wet nappies. no excessive drooling. temp 40 degrees celsius, resp rate very fast. pulse raised with BP somewhat normal, though towards normal range. no rash, neck stiffness. baby consc. inspiratory wheeze and fine crackles. substernal/subcostal recession. I suggested acute bronchiolitis and immediate admission with bld cultures, IV line, stabilization of hydration status, oxygen and antibiotics. I ruled out epiglottitis and whooping cough as well. 3. James is 4 yrs old. Bed wetting at night. No previous treatment/intervention. Father wants to discuss re further evaluation and managment. James has been wetting his bed at night. upon enquiry, father also had the problem till age 6 , resolved without treatment. no treatment tried with james so far. normal developmental history. no other positive findings. i counselled re ALARM stretagy, using a tricyclic. father was wanting some reassurance re ongoing response modification stretagies, and that how long would it take before james is dry. 4. Mother of a previously healthy 8 yr old boy Shane says he has been reported by school teacher of day dreaming fr the last 4-6 wks. Ask mother questions, evaluate further, give your likely differential and further plan of action. mother tells me that his teacher reported him sort of day dreaming for last few wks, with decline in his performance as well. mother denies reporting any such thing at home. no conduct disorder signs- gets along well with everyone, has friends. sleep/ appetite fine. no one has spoken to the kid himself who is 8 yrs of age. I asked the kid to be reviewed as well. i mentioned to continue follow up to rule out absence seizures, but apart from that, given that mother herself wasnt too concerned about anything at this stage, i just told them to observe him closly at home and to report to us anything if they r concerned, that we will however rule out absence seizures
5. mid aged man with a hx of HTN, and heart condition has been displaying mildly deranged LFTS for sometime . Recently relocated to ur area, and previous gp sent you the last set of LFTs for further follow up. Also attached is an USG report of abdo. patient is negative for past drug abuse, needle use, sexual contact, doesnt drink alcohol or smoke. he has been tired lately but no other complaints. explain the results, discuss further managment with patient. This was a vague station. there was no clue. you were not supposed to take any history, just interprete the deranged lfts and USG report and tell the patient of further recommendations/managment. his lfts were midly deranged and there were gall stones in GB on USG report. he only talked of being more tired of late, but nothing else. his HTN and heart condition was under control and USG also reported normal pancreas and liver otherwise. I counselled him straight on for cholecystitis and regarding removal of GB. i told him he will do an array of tests to prepare him which will include all baseline bloods, CXR, urine , ECG etc. They asked me wat else. i ended up asking for CT abdo as well, but couldnt think of anything else. patient kept on seeking reassurance that doc i just want to make sure nothing sinister is going on and i am well. later on outside i was informed that when investigated on the lines of hemochromatosis, the examiner would give a bad iron study result as well. all in all it wasnt a straightforward scenario 6. 21 yrs old boy comes with a painless scrotal swelling which has been causing some apprehension. Not sure about the time duration its been there(probably few wks). Transilluminable, you can reach above the swelling. no need to examine or further hx. discuss ur diagnosis based on this data and further managment. i was quite confused here. i thought of it as hydrocele. i said it would need aspiration and we shall send fluid for investigation. patient asked would it be operation, i said yes. patient was concerned for sterility.i said no need. i tried to rule out vericocele there as well . examiner asked wat else to be done. i thought of USG. he asked for any particular order of USG and aspiration. i suggested first USG. n the reason for usg was to view scrotal contents for abnormalities. also mentioned ruling out melignancies. examiner asked wat will u do . i replied b hcg and alpha fetoprotein. 7. 21 yrs old male drama artist had a sudden paralysis of lower limbs last night at his flat. Evacuated by his flatmate who doesnt know the patient too well. No report of any other symptoms as in loss of consc. or anything else. Do a neurological exam of lower limbs, report your findings to examiner , a differential and answer any questions by the examiner. no further hx needs to be taken. drama artist. I started examination by inspection. nothing wrong there. normal tone. power 0/5 in all parts of lower limbs. sensation for fine touch and pain impaired below knee bilaterally. just as i was to commence vibration, examiner asked me to comment on my findings. I did mention that i would ideally like to complete the exam with rest of sensory and reflexes. he asked again for my findings. i mentioned anaesthesia below knee and loss of power in both limbs and that tone was normal and no abnormality on inspection. examiner asked for d/d. i said CVA, cord compression, conversion disorder. examiner asked what would i expect in reflexes in conversion disorder, i said normal reflexes. bell rings.
8. patient a young female with a previous history of c-section, now pregnant again, and wants to have a normal vaginal delivery. counsel, appropriate history, ask the examiner about relevant information from notes from previous labour ending in c-section. ask for current findings on examination. no current investigations available. young lady in twenties. tells me she had a previous pregnancy which ended up in c-section following a 14 hr labour as her baby went into distress. pregnant again and wants to make sure she delivers the baby vaginally. very insignificant past history where i did ask about pap smears, contraception hx, menstrual hx etc. no medical conditions to warrent any extra attention. upon askin examiner for info frm past episode, all he could give was that after 14 hrs of labour CTG showed baby in distress and hence c-section was performed. no info provided re exploration for cord prolapse or anything else. no info whether anyone tried to expedite the delivery. i reassured the patient that as she was a primi that labour got prolonged, that it was likely for her labour to be shortened this time, and also that we could augment it to be more speedy. also counselled her on importance of routine ante-natal check up and to be on a lookout for signs of any deterioration. she was quite compliant with instructions 9. 52 female patient presents to gp to get results of tests done for menopause as had been having hot flushes and oligomenorrhea. discuss the results of tests, counsel re: HRT and suggest an appropriate treatment. Patient asked me about the results. i told her she is in menopause as i ahd results of FSH, LH showing menopause. she asked me for info re HRT. i told her it will alleviate her hot flushes and other associated symptoms. mentioned slighly increased risk of ca breast, and she wanted to discuss that. counselled her re regular follow up re that. i also emphasized on the importance of a healthy lifestyle including good balanced diet and exercise. she asked what tablets. i mentioned estrogen preparations , either transdermal or tablets depending on her preference , as she had an intact uterus. situation with pap smear to continue. 10. young spray painter, admitted to ICU yesterday following acute asthma attack, was commenced oral prednisolone this morning after requiring hydrocortisone and aminophylline. PEFR around 450 (expected at least 650) . still minimal wheeze audible. wants to b discharged. counsel him appropriately, tell him of your suggestions, further treatment and follow up. Repeat station. i advised the patient that ideally we would want him to stay for atleast 01 more day, and if he still wants to be d/c that he will be doing it against medical advice. explored his knowledge of his condition and counselled him on that this is not the end, that appropriate treatment if not commenced, he is at risk of having relapse. told him what asthma is and what can aggravate it. mentioned his spray painting as a possible factor. i told him that he will need to take oral prednisolone for the next 5 days at least and then could be weaned off them(book says no need to wean off). also informed him about a regular steriod inhaler and for short term augmenting it with a b agonist. told him he would be referred to asthma clinic , resp physician where they will provide him with asthma managment plan for him where in the long run he will be able to titrate his treatment according to his symptoms. also mentioned to wash mouth frequently when using steroid inhaler and that spacers are also available. also cautioned about sports and other physical activities having an impact on asthma.
11. Mid twenties lady presents seeking anti-depressant as feeling low lately.. was trialled on ATD's few yrs ago, though stopped taking it after some time. discuss with her further
managment after taking appropriate history. Girl said she was prescribed anti-depressants 2 yrs back n she only used them for a few wks , that they probably helped to some extent, however she was fine afterwards. didnt remember wat antidepressant it was. this time , recent relationship breakup and difficulties at home. she works. describes mild to moderate depression, however no suicidality. insightful and good judgement. finding it hard to go to sleep but sleeps well otherwise. mild anhedonia. appetite well. finds it relieving to speak to people. wants to get onto an antidepressant as thinks it might help this time. counselled re the prospect of psychological input and i offered her a referral to psychologist and also a probable connection to local mental health services if required. as she could assure safety, i was happy for her to give psychotherapy a go, and then consider antidepressant later if initial therapy dint help. she was happy with same. 12. a support worker from a disability support house is here to discuss regarding a patient with DOWNs syndrome living at the hostel who has been significantly withdrawn, staying in bed till late in the morning. discuss with him the case further and suggest appropriate management. supported accomodation worker told me that the patient was not himself the last couple of wks. teary, labile, withdrawn, spending more time in bed in the mornings, not motivated to do anything , and few episodes of behavioral outbursts. denied any manic episode in past. no prev similar incident. no known family hx of mental illness. drug and alcohol hx negative as well. support worker was concerned for patients health however informed that he is still managable at the accomodation. i advised that i will be arranging a full organic work up to rule out any organic cause. i will probably start him on an anti-depressant with again a probable augmentation by a mood stabilizer. i will also involve DADAC services(dual diagnosis services). support worker happy with same.
13. patient had a laparotomy 6 hrs ago for deudenal ulcer. All was well pre op and operation was uneventful. patient consc alert and oriented. didnt pass urine in last six hrs. glucose 5 % I/V in place.patient doesnt report any distress yet. examine the patient, write down your orders accordingly as what needs to be done. no further history. ask examiner for clinical findings. Repeat from amc book. examiner showed me the patient lying in bed(with a wide grin on her face !!!). i was asked to start examining the patient. i started with hands. examiner asked wat could i look for in hands. i said turgor...he asked HOW...i pinched on skin and examiner was happy. further on, i asked for bp n pulse. checked eyes for pallor, checked into oral cavity, and examiner informed me of dry tongue(while patient continues to grin!!!). i asked for JVP and i was informed not visible. i said i will examine tummy. examiner said go ahead ..i was taken aback as i wasnt expectin to get that permission. however, she uncovered herself appropriately, and i did deep n superficial palpation. nothing to find. examiner asked me how else would u look for a distended bladder. after some thought, i said i might do with percussion and examiner looked like as if he was looking for the magic word( i am terrible with examinations!). he asked ok wat else now. i mentioned that patient is in post op oliguric state secondary to dehydration. I said i will give i/v saline or hartmanns solution 500 ml initially to see if she gets an output or not. examiner encouraged me to use a bit more then that and we went on to 1000 ml in 1 hr. i said i will pass a cathetar and collect urine . i will also take into account any other losses. in this whole thing i forgot to actually document or write anything anywhere, and i actually i couldnt see any setting where i
could write down things nor did the examiner showed or flinched any muscles at my not doing any such thing. 14. young female presents with acute urinary retention for a few hours, in pain. assess appropriately, limited history. ask for examination findings and suggest managment. This was a strange one. young lady had urinary retention for past 15 hrs or so and was in terrible pain(yet again a wide grin on face!). i was asked to take relavant history and there was nothing on the history. pain was fixed continues in the lower abdo with no radiation while she hadnt passed urine. no previous history. inspection examination normal apart frm distended bladder. PV exam revealed a swelling somewhere causing bladder obstruction. i further asserted on gynaecological hx but nothing given. i decided to initially pass a cathetar and relieve her of this retention, arrange an USG to look for this swelling. i think i did mention fibroid as a potential cause, but said i will be going by what the specialist would conclude. i obviously spoke of a referral to gynae. 15. 55 female had a biopsy of somwehere around recto sigmoid junction, suggesting adenocarcinoma after suspicious colonoscopy. Counsel re treatment necassity, and what treatment its going to be. tell her about the procedure /operation and subsequent care / follow up. 55 female diagnosed with bowel tumour on biopsy following suspicious colonoscopy. i told her of the results and the fact that she would require surgery. explained how it would involve removing part of bowel and that she might have a temporary opening of bowel out on tummy , she knew of colostomy and identified it. asked me of risks associated. i counselled her about pre -op , intra op situation , probable complications after operation incl haemorrhage, infection, thrombosis. also mentioned associated inc risk of ca breast and the fact that she needed to alert her 1 yr younger to her brother for a follow up as well. 16. mid aged lady, presents with central chest pain going to back and left shoulder. appropriate history, managment. It was a bit strange. lady presented to ED with chest pain for about two hrs , central radiating to left shoulder and back. no nauseas, vomiting, shortness of breath. pain wasnt sharp, was rather dull. execerbated by cough, she mentioned a chest infection few wks ago. no other relieving aggrevating factors. no prior hx of any ailment nor any other significant thing on hx. her pulse was a bit high, bp normal n m forgetting a bit, but i guess somewhat high temp as well. i asked for findings on examinations. nothing significant on respiratory as well as CVS. i said i will offer pain relief, do ecg, bloods, CXR initially and go on frm there. time run out there
AMC CLINICAL RETEST MAY 30, 2009. 1) Fever + rigors and chills in 35 something lady Pyelonephritis on examination. Inconclusive history 2) Examination of actual pt of Rheumatoid Arthritis Interpretation of findings and discussion of Extra artiular features 3) Newly diagnosed DVT in a pt on HRT Manage and explain diagnosis and management Hard to avoid medical jargon in this case 4) Monthly breast pain in a 35 year witl pre - menstrual s/s and 1st degree relative with breast CA.Never had breat screen before Task manage and discuss with pt She had cyclical mastalgia Needed explanation it is not CA Also mammogram and scan as on hi risk Both examiners very old and very very nice 5) Breech presentation in a 32 week pt Inform the pt about the presentation , explain and outline management Pt a young girl who was a poor actor and i could nt stop smiling on her poor acting during the exam 6) Mother of child with falling grades in school I realized the examiner and actor slightly varied the scenario on every candidate. So every body got a slightly different hist . Examiner was a bit rude in the start and i realized it is difficult station On history after an extensive hist including behavious , family , parent , school , development financial and social history the only thing which the pt indicated was that they have some financial problems with the recession and that so also with a lot of disinterest and very briefly. Counselled on financial and behavioural problems and offered to see her again with the child. Examiner very pleased at the end of the session and i sneaked while he was marking and found he is passing me in all the boxes on his sheet. Examiner shook my hands on the way out and gave a big smile. 7) Schizophrenia pt dec dose of haloperidol from BD to OD Having tardive dyskinesia manage and counsel pt no suicidal ideation c/o delusions
8) Central chest pain ECG = Anterolateral MI Also h/o malena Present case to examiner no t supposed to discuss management
ADELAIDE 22ND AUGUST 2009 – AMC CLINICAL RECALL
1. A 60 Y OLD MAN CAME WITH LEG PAIN. HE WAS FEVERISH AND UNWELL. Photo was outside the door. There was no history of diabetes. Task – take hx and manage the case. (cellulitis). 2. 14 y old girl has been diagnosed with type 1 diabetes at the age of 8. she skipped some insulin injections. Her mum was not happy with her eating habits. Mood was okay with 50 kg wt and in history there were no other symptoms of anorexia nervosa. Task – talk to the patient. 3. A 45 year old man with hx of 3 episodes of right abdominal pain. The last time it was a few hours ago. Each attack lasted for a few hours. The patient was rolling over in pain but it settled y itself. Task : History, diagnoses and management. 4. A 3 y old child had diarrhoea. Treated with garstrolyte in the hospital and now he is okay. Diagnosed with salmonella. Lives with parents and 7 y old sister. They just came back from a holiday. Task: talk to the parents. 5. 30 week primigravida BP 170/110 PR 80 protiens 3 +. She is in your practice which is 200 kms away from the hospital. O/E fundoscopy was normal. Reflexes brisk. Task – hx and manage the case. 6. 50 y female diagnosed with DM for the last 10 years. Poor sugar control. Do examination of her lower limbs and manage the case. ( loss of sensation above both knees) 7. A 45 y old lawyer had 2-3 episodes of chest pain and had fainted. Pain radiated tot he jaw. Got chest pain with shortness of breath when walking up the stairs. Father died of heart attack at the age of 53. Mother died from stroke at 71. No h/o smokng but drinks more than usual. Doesn't know about BP or cholesterol. On history he had a long history of epigastric pain and had been taking medications for this. His motion colour has changed since last week. On examination hear and chest were clear but he was pale and had severe hepatomegaly. Task: history and manage the case. 8. 25 y old female. 12 month h/o of amenorrhoea. Pregnanc test is negative. There was no h/o polycystic ovarian disease or anorexia nervosa. She had a miscarriage 12 months ago. Task: hx, investigatins and management. 9. 70 y male suddenly developed hemiplegia. Has a pace maker and patient is in hospital for about 10 hours. BP was 200/90, PR 80 regular. Talk to his wife and explain your diagnosis and management plan. 10. You did a MMSE on a 50 year old and found she had memory loss. Patient has a h/o of post partum depression. The medical student is in the ward and asked you to explain the chart of the patient to him and tell him the possible cause of her memory loss. The student asked - could it be psychoses. Explain the possible causes. 11. 18 month old child brought to the ED by his mum. Photo was there showing swollen lips and utricaria. Task : relevant history, manage and talk to the mother ( Peanut allergy ). 12. Primi 14 weeks pregnant. In the first ante natal visit you found that she is Rh negative. Talk to the mother and manage the case.
13. 38 y old female has palpitation . She also complained of abdominal pain and headache . Many episodes. Her husband lives with his new girl friend and has left her. Talk to the patient and manage the case. 14. A 45 year old businessman drinks daily. P 140/90 BMI 29. abnormal LFTs. Task: explain the test results and counsel the patient about his drinking. 15. 25 y old female lifted a heavy box and has had shoulder pain for 2 days. Task examine the shoulder, diagnose and answer the examiner's questions. Most movements were restricted due to pain – abduction, elevatione. Empty can test was positive (supraspinatus injury). Questions – what is the other name for this injury – rotator cuff injury/ impingement sydnrome. What is the inverstigation of choice – ultrasound. 16. 25 year old woman diagnosed with papillary carcinoma thyroid after FNAC. Task – tell the patient about the diagnoses and manage. Q – does it run in family? Do any other members of the family need to be investigated? Do I need chemotherapy?
ADELAIDE AUG 2009 : CASE LIST
1. Secondary ammenorrhoea after D and C 2. Rh negative lady in first trimester for counselling 3. Severe Preeclampsia 4. Acute Allery – Peanut Allergy 5. Uncontrolled diabetes – conselling 14 y old girl 6. Bacterial Gastroenteritis – salmonella 7. Alcohol abuse – from AMC book 8. Renal Colic 9. Somatisation disorder 10. Papillary carcinoma of thyroid gland 11. Chest pain and fainting – anaemia and pallor and typical cardiac pain 12. Acute stroke – explanation to family 13. Type II DM – leg examination and conselling 14.. Lower limb cellulitis with PVD 15. Shoulder examination – post traumatic rupture of rotator cuff. 16.. MMSE – Acquired brain damage – AMC book. SYDNEY AUGUST 2009
1.70 yrs old man 3 times fall all related to getting up quickly 6 beers / day for long time heart attack- only medication 1/2 asprin Hx & DD
2. 26 yrs old female SOB for 2 days- sudden onset came from interstate to visit her sister first time at your gp Hx Ex Mx only +ve findings irregular pulse & 6 cups of coffee 3. child abuse 4. fussy eater 5. fall from horse 6.8 week amenorrhea, mild blding , lower abd pain Hx Ex Ix Mx 7. Primary amenorrhea 8.26 yr lod on valporate and wants to become preg. 1st time Mx 9. Phaeochromocytoma 10. Talar dislocation and spiral fibular fracture. talk to the pt 11. LOW 5kg, constipation, RIF pain colonoscopy and upper gi endoscopy all normal Hx DD Mx Findings early morning waking, loss of interest, LOA, No suicidal thought 12. lady travelled Malasia one month ago Hx ex Ix Mx Hx-cough,clear sputum for 1mon, irregular fever ,malaise , tired, night sweats,LOW Ex- lung R/base cracles, percussion reduced, vocal fremitus reduced 13. alcocholic pt- do relavant Ex 14. Nurse checked 6/18 - visual acuity, no improvement in pin hole task- Ex,Mx findings temporal field lost opthalmoscopy - pale & flat disc 15Nrse checked 3 episodes of HT. smoking +,ocp+ Hx,Mx 16 Lymphoedema
SEP 2009 Retest Melbourne 1) You are working as a RMO in a country hospital, one baby was just delivered and you examined the baby find some features similar with DOWNS syndrome, photos were pasted on the door. Task explain the condition to mum and further mx. The mother was telling—my baby is gorges isn’t it Dr ? Yes it is, I have examined your baby and I found some unusual features which are compatible with Downs syn, I am sorry to say that you are having a baby with Downs Synd. Mother was crying with tears, I told her it is not your fault, it can happened to anybody unfortunately it happened to you, have you heard about this condition, she said she saw in TV know about MR of these babies, her baby too is going to have MR. I told her don’t worry a lot about at this stage, we can’t predict the severity of mental retardation it vary from individual. I will explain what is DOWNS it is an chromosomal disorder duo to aging of the mother. Normally we have 46 chromosome in our body from our parents 23 from mum 23 from dad but in DOWNS the 21 chromosome there is an extra chromosome trisomy 21 due to this extra chromosome they have different signs and sym of Downs syd. She said she is 23 and did 18 weeks scan even though why she has this, I told her some time it can happened to younger women also, we don’t do diagnostic test for young women and missed it in ANC after birth only we can diagnose this I am very sorry for you, it is common in normal population 1:600. Nowadays we have effective education and behavioral mx strategy to this children, they can learn and have employment later in their life, they also going to have developmental skills like learning, motor development, problem solving skills but they are slower than normal children. I am going to refer to pediatrician to confirm the diagnosis by blood test. They need early eye hearing check and speech and language therapy. They have some health concern like CHD, hypothyroidism, hearing and visual problem, intestinal obstruction, we need to check all of that .Mother was still crying, I told her you feel shock and helpless, it is understandable and I also feel shock for you, don’t worry you are not alone I will put you in touch with Downs Syn association and community support counseling and introduce one Downs syn child family, you can contact and see how they are cope and manage with the child, usually the children are not aggressive easy to handle, they like music and dance well, depending on the MR severity they are independent in later life.(If the mother says I don’t want to take this child with me, say Don’t need to make a decision now, you are in shock now every body feel like this, think about with your husband you will change your mind later I will arrange counselor for your family, still don’t want we will have foster care and adoption)To me she accepted to take with her. I will arrange an another appointment talk about more about this now you can’t take it all in once I will give you the reading materials you can read it at home if you have any concern please contact me. I will put you in high risk clinic in next pregnancy there is a chance of 1:100, need to do screening and diagnostic test. DOWNS SYND 2)60 year old man came for the results of LFT, he is having chronic cough, increase yellow sputum production with chest tightness. He has stopped smoking one year ago.He is a truck driver. Explain the results and further mx, explain how to use the spacer. It is an AMC book case. Thank you for coming the results, is it the first time have you had this test? Yes Do you know why we do this ix? No. We assessing your lung capacity and function before and after given the bronchodilator drug
which help to open up the airway. FEV1 is how much air you can blow out in 1st sec, FVC is how much air you can blow out as possible as you can, it should be more than 20% improvement after the drug, unfortunately in your case it shows only 11% improvement, it means the airway is getting damage progressively and irreversibly due to chemical irritation to mucous membrane and mucous production of inflammatory response and block by mucous plug. RV was increased, this means after we blow out the air from lungs there are some air stays in the lung, in your case it is more than normal because the lung lost its elasticity and difficult to expel all the air out, same as TLC was increased due to the same reason and obstruction, we call it emphysema. CO diffusion capacity was reduced- this is a waste product of respiration it should be eliminated from lungs, but due to the loss of elasticity and obstruction the lining lost its capacity to diffuse into the blood stream and remains in the lungs. He asked is it cancer dr—We would not diagnose cancer from this IX, for that I will do other IX like CXR, CT chest if you have sym and signs like LOA. LOW blood in sputum, do you have these? NO. Don’t worry about this at this stage I will check on it. I appreciate that you have stopped smoking, then the sym wont progress and better to avoid environmental and work related dust, because you are a truck driver. I will refer you respiratory rehabilitation to improve lung function, chest physio Do some regular walking in clean air daily as you can comfortable, take nutritious food to improve your quality of life, try to avoid contact with sick people, take 5yearly pneumococcal vaccine and yearly influenza vaccine. You need to have regular follow up. I will give you bronchodilator and ipratropium combine inhaler as well as steroid inhaler bcos you are having increase sputum and cough, you need Augmentin as well, are you allergy to any medication? No. Depending on your oxygen saturation(less than 65%)continuous home oxygen more than 16 hours per day will help your symp, because you stopped smoking we can arrange for that. Finally I explained how to use the spacer, and examiner asked me if he does not have spacer how to use the inhaler, I explained it as well( 10 sec hold the breath is important) COPD 3)50 year old man had TKR 5 days ago, and developed confusion and agitation, he is on Morphine for pain, he is taking alcohol long time 6 cans per day. AMC book case but here they have done some IX and Ex on pt MMSE –decrease orientation, recall, attention, Hb 11.5, LFT totally deranged specially GGT bp 130/80 Task talk to your registrar about further mx Good morning Mr x I have gone through the case note and examined this gentlemen I suspect he is having delirium after operation and I would like to find the causes and do ix for that, it can be hypoxia—O2 saturation, ABG and CXR, sepsis—blood and urine culture, wound swab US ABD, underlying medical condition dementia, hyper and hypo thyrodism, hyper parathyroidism, metabolic and electrolyte imbalance—hypo and hyper glycemia, uremia, Ca Mg Po4, BUSE, alcohol and drug with withdrawal(opioid, narcotic) BP and Hb are normal so unlikely hypotension and anemia. I highly suspect alcohol withdrawal bcos pt is taking long term and abnormal LFT. Registrar asked how are you going to manage? I would like to stop morphine and give diazepam, O2 , Thiamine, glucose infusion Monitor the pt in calm and quiet room with protection of noise and visual disturbances (night and subdue light), same nurse take care him during the shift, explained the procedures, and perceptions which he has clearly before they do. Frequent visit of family member and friends, keep familiar things from home to his room, try to avoid bladder and bowel fullness to avoid urinary catheter. Examiner asked me do you want to ask any que from your registrar I just asked him did I miss any Ix or Mx which need to do this pt, he said everything is ok, then the examiner ask the registrar do
you want to ask her any que, the registrar was smiling. Delirium after operation. 4)23 year old male came with the hx of painless testicular swelling and discomfort for 2 weeks, Ex—found nontender scrotal swelling, can get above transilluminable, testis and epididimis can’t be separated. Explained the condition and further Mx no need to take hx and ex. Good morning Mr. x I have examined you and found some fluid accumulation between your scrotal wall and testis, we called this condition as hydrocele, have you heard about this? No. It can be just benign fluid formation due to infection, injury or trauma, or nasty growth in testis so I will arrange US first to differentiate benign and malignant, if it is benign we will aspirate it and send it to pathology to exclude infection and treat with antibiotics, recurrence benign hydrocele will be managed by sclerosant injection to stop formation and last option surgery. If it is nasty lesion urologist will remove your testis through the groin, to prevent the implantation of tumour cells in scrotum and it different lymphatic spread, don`t worry a lot at this stage, even it is malignant we can manage it very well, you came early and it has a good prognosis, we will follow up with tumour markers alpha fetoprotein, beta hcg, ct chest and abd to exclude secondaries, beginning fup 3monthly later less frequent. You need radiotherapy as well, before that we will collect your sperm and store for the later fertility, because radiation will affect the sperm, don`t worry all are temporary side effect during radiation. Better to do self testicular examination monthly after warm bath, if you find any lump immediately contact me. SCROTAL SWELLING. 5)60year old male has LLQ pain, constipation and weight loss 6kg in 6months duration, he had blood test and endoscopy colonoscopy everythings were normal take a psychiatric hx and DD. Hello Mr x I have a good news for you all the ix turned as normal there is no nasty lesion or any chronic condition, you will be a good relief of that, pt said I still have pain and constipation Dr. It does not mean you don’t have these symp, all your sym are real and I agree with you, I would like to ask some more que why you do still have these, is it ok? Yes. Could you tell me were there any unusual things happened 6 months before like, did you loss anyone who you love, any financial problem, any accident operation, he said he retired 6 month before now staying alone at home, wife is working, his children are faraway and busy with their life. Do you enjoy your hobbies, interest and out going as previous? He is not playing golf as before, don`t want to mix with his friends, want to stay at home, How is your sleep and appetite? Poor appetite, awake early morning and difficult to go back sleep again, Do you loss confidence and feel guilty or thinking the life is not worth full and hopeless? I have lost my confident and not feeling guilty or ending of life. Some people when they are stress they can hear or see images even nobody around themselves was it happened to you? No. Do you avoid any places if you go you will get panic attack or anxiety? No, do you have any bad dreams or flashbacks? No. Do you experience that thoughts are taken from your mind or you felt that thoughts are putting in your mind? No. Do you feel some one spying you or people are against you? No. Do you have a thought of harming your self or others? No. Do you think you have a problem that need to be treated? No If you smell a smoke when you are in a cinema what will you do? I will ran away. Do you know where are you now? Hospital, What is the day and time? He answered correctly. Alcohol, smoking, recreational drug hx negative. No previous or family hx of mental illness. When people are mentally unwell and stress the body can express the sym like pain, body ache, hyperventilation and palpitation, you can see our head is above the body and control the other parts of body, if the mind is not in our control it produces some physical symptoms and some chemicals in the brain is not in sufficient amount , it has to be replaced by externally. E.g. if blood FE is not in sufficient amount we will get anemia like this if the chemical is not in enough amount
we will get depression, every body feels some depression now and then when they are stress or not well but in your case you are over depressed it can’t be control by yourself and don’t fight with it without support, you need a professional help. I will give you some sleeping hygiene method, go to sleep at regular times like 9pm to 7am, do some regular exercise in the morning, don’t take your dinner too late and too much, have a light dinner, warm milk before go to bed, don’t drink coffee or alcohol in night, use your bed room only for sleep, don1t read books or watching TV in the bedroom, comfortable bed, and good temp in the room, if you can’t sleep in particular time in the bed get up and do some work or read books out side the room and when you get sleep go to bed rather than just lying in the bed without sleeping. DD—Depression with somatic disorder, Adjustment disorder Major depression with agitation and somatic disorder 6) 40 yo female present with flush and flu like symp Take hx, ex and Dd. Hx—She had chills and rigor, sweat in nights and fever in the morning for last 1 week, whole body ache feeling un well, nausea and vomited 2times, no joint pains no lumps and bumps in body, no sore throat, headache present, no resent travel hx, no contact with sick people, pain in left loin, no radiation, no sob, chest pain, no cough, no dysuria, hematuria, frequency, constipated last 2days, no p/h of UTI, renal stone or renal disease, no F/H of renal problem, periods regular, no pregnancy sym, using condom, pap smear normal no significant p/h, NKDA, Smoking alcohol recreational drug—negative. Ex- Tem 38c, pr 80 regular, BP 120/80, ENT normal, no CLN enlarged, no pallor, chest—no murmur Lungs clear no added sound No liver or spleen enlargement, On deep palpation left loin tender( renal angle tender ) kidney not balatable, No suprapubic tenderness, PV normal, urine deep stick –positive for nitrate, leukocyte RBC, no glu. DD pyelonephritis, Renal stone I am going ti admit you now in hospital, you are having a condition called pyelonephritis, it is an infection in the kidney, it is little bit serious condition, you need IV antibiotics until your symp subside and continue with oral for 2 weeks, before thst I will do midstream UFR mcs. After 3 weeks another MCS to confirm clear infection, and special IX US ABD and Pel, MCUG,IVUand urologist referral to exclude urinary abnormality. Chills and Rigor. 7)23 yo female came with 4th attack of monoliasis , she took some medication for that it does not help much, take relevant Hx, ex mx She had 4th time in 6 month duration, she is irritated with this, no discharges, itchy It is not before or during her periods, no urinary symp, no frequency, no dysuria, no thirst, no polyphagia, no other allrgy in body, her periods are regular no preg symp, she has been on OCP for 6years, no children yet, sexual hx, she has regular partner, no STI or PID in the past , no casual partner, her pap smear was normal, she in not on steroids, or not taking any antibiotics Ex BMI normal, no temp PR BP normal no skin allergy signs, no pallor, Ht Lungs normal, ABD non tender no mass or organomegaly, PV no rash no discharge no ulcer, speculum only white patches no discharege. Other ex we have to do, cervical swab for candidiasis, trichomonas, bacterial vaginosis, chalamydia and gonorrhoea, Urine deep stick for glu nitrate leucocyte, RBS Urine MCS She had nystatin cream and pessary before, I told you are having recurrent candidiasis it can be
precipitated by OCP, DM so I would like you to stop OCP for a while and use condom, will see how is response, I will give you Flucanazole oral tab weekly for 6 month and exclude other STI Infection, UTI and DM as above. Some LSM, like use cotton underwear, loose pants wash and wipe front to back, void urine when your bladder is full, don`t hold it long time, don’t sit long time, take a walk frequently, if you go for swim change wet dress quickly, don’t use tampon, vaginal douche or deodorant, use sodium bicarbonate bath. Recurrent Moniliasis 8. 50year old lady with 5th attack of leg weakness, she has DM for 20years.Hx, EX,MX She had 5th episode of leg weakness, this time she had a fall, so I ask about any head injury or LOC, bleeding, all were negative, no slurred speech, no dysphagia, no visual blurredness, no other body part weakness or numbness, no head ache, giddiness, SOB, chest pain, palpitation. Now she is well with out weakness, no loss of balance. She has DM taking medicine for that blood sugar control is good, PB normal No high cholesterol or AF F/H of CVD, CAD is positive, she is smoking for 20years, no alcohol hx, NKDA, No recreational drug, no regular exercise, no stress EX, no obvious weakness in body, BMI 28, PR regular 78, BP 130/90, normal, heart no murmur no added sound, carotid no bruie JVP normal, lungs clear, abd normal, no aortic bruie or femoral bruie or renal artery bruie, peripheral pulses present, CNS—Cranial nerves normal, fundscopy normal, UL, LL tone power reflex coordination sensation all normal. urine deep stick negative for glu, protein, ketone, nitrate leukocyte. You are having mini stoke and it is an emergency any time you can develop Stroke, have you heared about this, there is a block by blood clot in the arteries or fatty plaque formation due to excessive cholesterol in the blood and brain not get enough blood supply from that arteries, depending on the which part of brain damage the symptoms will appear. I am going to admit in hospital by ambulance, there you need ix MRI brain, carotid dopler US Bld test RBS, lipid profile, coagulation study, ECG, If there is no bleeding you will be given aspirin and continue for life long, seen by neurosurgeon. I would like to arrange another appointment to talk about quit smoking, it is an important risk factor and it affect almost all organ in our body, I will give you the contact, you need to have good control of BP, GLU. Choles, referral to ophthalmology, RFT And podiatrist. Do some regular exercise like 30 min walking, take more fiber contain complex cho food avoid sugar, oily take away food, dietician referral. When you are on Aspirin don’t take NSAID, if you have PUD sym bleeding come to hosp immediately. Recurrent leg weakness in DM patient
AMC Clinical Recall – October 2009, Melbourne 1. Young lady has had a grand mal fit. She has h/o epilepsy in childhood. Last fit before this attack 6 yrs ago. Been to a neurologist and has done CT head, EEG, etc. She has been diagnosed with idiopathic GTCS. Started on carbamezepine. She is currently using microgynon 20 as a OCP. She wants to concieve. Works as a courier. Neurologist concerned about driving. Sent her to GP for further advice. Advice patient regarding her work and about pregancy. Answer her questions. 2. 3 and half year girl. Parents and teachers says that she does not get involved much and prefers doing things by her self. Only child. o/e NAD. Talk to parents, take relevant history. Diagnostic impression and management. 3. Young 19 y old girl. Pain in vulva. Inability to pass urine. History, examination findings from examiner. And manage. 4. 12 y old boy active basketball player c/o pain right knee and thigh since yesterday after playing. Been having similar pains on and off since last 4 months with occasional limping. Hx, ask examiner about examination findings, interpret investigations. And manage. 5. Young guy with knife injury to right wrist. Examination of hand and Mx. ( cut on the wrist ventral aspect and medially in the ulnar nerver area. Not extending across) 6. 40 – 50 yr old lady admitted in GP Mx unit to manage her Diabetes milletus. H/o of DM since 10 years. Resent BSL high. Hb1AC >11%. Now admitted for starting insulin. Examine her lower limb and interpretation of findings to examiner. 7. Daughter of patient has come to talk to you. The patient had passed away with acute MI. Patient's wife is known to you but has not come today. Daughter has come to talk to you. She wants to know how and why her father died. He was apparently healthy till now. CVS risk factors. 8. 24 y female been to her beautician to get her hair done. She was told that there is increased hair on her face that might need medical attention. She has come to talk to you in the GP practice. Hx, ask examination findings, inv and manage. 9. 30 y old female complaining of cough. Had recent URTI 6 months ago. Other symptoms settled but cough is persisting. Has been seperated from Partner for 6 months. Investigated by respiratory physician, ENT – NAD. Talk to patient and advice about management. 10. 60 y male with aches and pains. History, ask examination findings and manage. 11. 24 y female last seen by LMO 9 weeks ago for amenorrhea. Amenorrhea for 9 weeks. Her periods generally irregular. Last period was 3 months ago. She has done urine beta HCG which is positive. Taken an appointmet at the hospital antenatal clinic. Given appointment in 2 months. She has come to see you in your GP practice. Advice on what investigations are necessary for her from now till 2 months time. Answer patients questions.
12. 5 y old oy brought to ED in a rural hospital by parents. Boy was well today morning. Suddenly in the afternoon became febrile, lethargic, decreased interest and responsiveness. History, ask examination findings and manage. 13. 30 year old school gym instructor with c/o hoarseness of voice since few weeks. Hx, ask examination findings and advice management. 14. Young girl known borderline personality disorder. Known to mental health team brought to hospital by ambulance as she has had multiple cuts to wrists and thighs which did not need sutures. She was also intoxicated with alcohol. No 24 hours psychiatric cover in hospital. It is 10 pm now. Do risk assessment on the patient. Advice patient on your initial management.
AMC CLINICAL – NOV 7, 2009 SYDNEY 1. 8 Week old child complain of crying Task – Take detailed history for 6 minutes Advise mother about management Young mother first born. Complaining that child is crying a lot. More during the night. Feeding alright. Some amount of vomitting after feeds. No fevers. Growth and development satisfactory. No concerns during pregnancy and post pregnancy till birth. I asked all the history related to the baby. Physical examnination: all normal. No abnormalities. No signs of injuries. I had almost exhausted all my history. The role player was a young girl however she did not give me any hits. The examiner was also just a passive spectator. Suddenly I realised that I had forgotten to ask about the mother. I asked her – how she was coping. She said she was doing alright. However she feels that the baby is not feeding well.So she is feeding the baby several times of the day. She even got up and fed the baby. She had no signs of depression. I wanted to ask more. However ran out of time. Other history – supportive family, no depression, no h/o mental illness, no suicidal ideation. I failed this case. I should have explored the mother's angle as well. People who treated this case as Post natal depression/blues/maladjustment failed either. Mother was coping well. However being the first born mother was overtly anxious. AMC – Irritable baby – History (Paediatrics) Essentially normal baby with maternal anxiety. Essentially a paediatric case but have to r/o psychiatric aspect too. From other candidates who passed Key issues are her husband just left her after birth, and her breastmilk not enough. Solutions are: if not support (only her mother), social worker support, and community nurse coming home to teach techniques of breastfeeding. Show your empathy and supportive attitude, baby is fine, nothing wrong
2. 24 Year old female complains of vaginal bleeding. 8 weeks amenorrhoea. Task – take history, Physical examination, investigation, management. Same case as in recalls. 8 weeks amenorrhoea. Bleeding post amenorrhoea. Small amount. Asked if any clots, patient was not sure. Symptoms of pregnancy positive. Not trying to get pregnant. Not on OCPs or contraception either. No pain or cramping sensation. No sex or trauma involved. No signs of haemodynamic compromise. Blood group A +ve. Periods normally irregular once in 2 months or more. No breast tenderness or other signs of pregnancy – morning sickness etc. Urine Beta HCG positive. 10,000 units or something like that. Can't remember.
Physical examination: When I asked how the patient was – haemodynamic compromise: examiner said the patient is the way she is sitting in front of you. P/A: soft non tender. P/V no active bleeding. Cervix closed. I forgot to ask about adnexal tenderness. (might have been tender in the right). Other examination unremarkable. No breast tenderness. I said the urine Beta HCG is positive. So it means that she could be pregnant. I will do some blood tests – Serum Beta HCG and arrange for an ultra sound. If the ultrasound confirms pregnancy then it is pregnancy and she will be treated as pregnancy. I she is pregnant then we will have to do all other tests that are done as a part of the antenatal work up. The role player asked me about ultrasound. What will I be looking for in ultrasound. I said it will be abdominal and transvaginal. Was not sure what she wanted. For some other candidates – the examiner gave Ultrasound finding saying a cyst in ovary. Anyway, I said it could be threatened haemorrhage but we will have to wait for the investigations. However I failed this case. I think I did not rule out and say ectopic pregnancy as one of the causes PV bleed which is important. AMC Diagnosis – PV bleed. 3.
50 year old man with red painful leg. Picture provided. Task- take history, explain your management to the patient. 50 year old man. Developed red patch on the right leg and he feels it is hot. No history of wound, injury or trauma. Not a diabetic, but has not had a blood test in a while. Feels feverish. This started 3 days ago. No complaint of any bleeding, discharge or itching from the spot. No swelling, numbness or pain in the calves. No history of DVT. No similar complains in the past. There is family history of diabetes. No other complains. On examination – a picture was provided with a red patch on the right leg on the anterior and medial aspects. The margins were clear. It was clearly a case of cellutitis. The examiner told that there is local rise in temperature. Rest of the findings as in the picture. No calf tenderness. Pulses palpable. He told me to the condition and management to the patient. I said that it is most likely to be cellulitis. However we have to rule out DVT. He would benefit from hospital admission for investigation and IV antibiotics. It is most likely to be caused by Staphylococcus. I asked him if he was allergic to anything. He said no. I said I will take bloods – FBC, CRP, ESR, Blood culture and also do Blood sugar, lipids and EUC. To rule out diabetes and since he had not had a check up. USG to r/o DVT. Also would start him on IV Flucloxacillin. He would need it for a 3-4 days and depending upon the inflammatory markers and clinical condition he can be shifted to oral antibiotics to complete the course of a minimum of 2 weeks. He was doubtful about getting admitted. But I said that it would be better for him to get admitted for IV antibiotics. I asked him if he had any family. He said he lived alone. I told him that he would benefit from at least 1-2 days of hospital stay. If he wants after the investigations are complete we can send him home on IV antibiotics under community nursing. But it would be ideal for him to get admitted. And that I would need to review him again with all he blood results and to check the progress. He was happy with management and was ready to get admitted. He said – 'Give me some time to pack my bags'. Diagnosis – Cellulitis Lower Limb 4. 26 year old woman complains of hardness of hearing after delivery of her baby. Task – take brief history for 1 minute, physical examination, management. Finds difficult to hear since delivery. It is in both ears. Finds that she has to turn the TV vol up to hear better. Asked whether she heard better in noisy surroundings, she said no. No history of trauma, ear infections or use of medications like gentamicin. Family history of similar problems is
positive – sister has similar problems Examination – there were 4 tuning forks that we had to choose from. I chose the 256 hz one. Performed Rinne's test – air conduction lesser than bone conduction. Not able to hear the tuning fork when placed near the near canal but can hear when placed on mastoid. Weber's test – Equal in both ears. Otoscopy – not done but asked to look for wax and tympanic membrane. The examiner said Okay. ( note – when you try to activate the tuning fork, it is better to strike it on the heel of your shoe and test it by placing against your ear, striking it against your palm or elbow may not work and it might be painful) Explained to the patient that she had conduction deafness most probably – otosceloris. Explained it by drawing a diagram. Told her the need to confirm diagnosis by doing a audiogram and ENT specialist consultation who might decide to do a surgery – prosthesis with vein graft. She asked whether this problem will get better with itself or by medications – No. Will her children get it – autosomal dominant, so a genetic pattern to it is seen. Diagnosis: Otosceloris/ Hearing Loss 5. Mother comes to you complaining that her 18 month old child is not talking well. Task – take further history, physical examnination, management plan to the mother. 18 month old child not talking. Mother anxious. Child just muttering a few unintelligible phrases. Growth and development normal till now. No infections. No ear infections, no history of trauma or accidents. No ear injury. Antenatal history – No use of any drugs or any illness in the mother. Asked about rubella and gentamicin Post natal – premature baby. Requiring phototherapy. Had jaundice. One sibling. Normal. Not problems. I was not sure about the normal milestones. So I asked the mother about the first child. She said the first child started talking at 12 months of age and she said that this child has not yet started talking. No family history of deafness or any speech disorders. Mother was concerned about Autism. Physical examination: Normal healthy looking baby. Growth chart given when asked. Normal. Ear – dull tympanic membrane. No wax. Nose and throat – NAD Other systems – normal. Management- told the mother that the child's speech is delayed possibly because there is some problem with the child. This could be because of the hearing defect. I will have to arrange the baby to have a formal audiogram and also referral to a ENT specialist. Mother wanted to know that could jaundice after birth have caused it. I said yes. Could it be autism? I said at this stage it looks like the baby has some hearing problems that has delayed speech. She wanted to know if it could be cured. I said we have to wait for the investigations and the opinion of the specialist. He will be able to advice about further management. Diagnosis: Hearing Loss or Autism. 6. 30 year old man went to donate blood. BP was found to be elevated BP 170/100. Three consistent readings were elevated. Patient smokes ten cigarettes a day and moderate drinker of alcohol. Not on any medication. Family history of heart disease and hypertension. (long stem – cannot recollect the entire stem, details of family, social and occupational history were given).
Task – perform focussed physical examination Explain further management to the patient. I was not at all organised. However the examiner was very helpful and was observing my every step. I gave a commentary as I went along as best as I could. I performed general examination – looking for BMI. Pulse rate. BP in all four limbs. Checked the CVS Endocrine – Thyroid and cushings. Eyes – fundoscopy. Urine dipstick – looking for glucose, protiens. ECG Finally after I had finished examination, the examiner asked me to advise the patient. I said we have to do some investigations – EUC, Blood glucose, Lipid profile, TFTs, serum cortisol level etc. If no cause is found then it meant that it is essential hypertension. The patient wanted to know if we will start medications. I said we will try to control it with diet and exercise. And if that fails then we may have to consider medication. But that will be later. I was not at all satisfied with the way I went. I was not organised but I guess I covered everything. The examiner was a nice person and tried to help me and put me back on the track when I started doing some unecessary examinations. I passed this case. Diagnosis - Hypertension 7. 50 year old female complains of dizziness and dysphasia. Weakness in the right upper and lower limbs. Symptoms have resolved while waiting in the GP clinic. Task – Perform focussed physical examination. At the end of 6 minutes the examiner will stop you. Explain your diagnostic impression and management plan to the patient. Same case as in the AMC hand book. Did P/E as per the handbook. However forgot to do co-ordination tests and gait and balance. All findings were normal. No bruit in carotid arteries and no sensory loss or weakness. Cranial n. 5,6, 7, 8. 9. 10 normal. No e/o horners sydnrome. At the end of 6 minutes the examiner stopped me and asked what was my management. I told her that she had what we call a 'TIA'. A mini stroke. The symptoms have resolved. But she needs to get admitted to Hospital for investigation. We will do a CT scan of the brain and also blood tests – FBC, Euc, Blood sugars, Lipids. Carotid dopplers. And we will also start her on Aspirin and a statin. Also the neurologist will come and review her. Further management would be on the basis of the investigation findings. Diagnosis – Dysphasia and upper limb weakness. Essentially TIA. 8. 24 year old female patient calls you at 4 a.m in the hospital ward complaining of abdomen pain. She has been seen by your registrar regarding this and no cause was found. She is insisting that her pain can get relieved by only morphine and she is insisting that she be given it for her pain. Task – Talk to the patient – history and further management It was a young Chinese girl. I started by introducing myself and asked her what was wrong and what woke her up at 4 a.m? She told me that she has severe pain in her tummy. When asked about the PQRST of the pain she said it is generally all over and it is pretty bad. She has had it for 2 years now. She takes morphine and it settles. She said that each time she has such a pain, she goes to the medical centre and the doctor gives her script of morphine and then she is alright. I asked her whether she was investigated for this pain. She said that she had all tests including colonoscopy and
they were all normal. I asked her whether she has the reports. She said yes. Her bowel function was normal. She had no regular GP. Physical examination done by Registrar was normal. I told her that the senior doctor has examined her and he feels that there is no obvious cause for this pain. I told her that her body had become dependant on morphine and so she was experiencing this sort of pain. She got angry and asked me – Am I a junkie? I said no. Her pain is genuine and we need to solve it and sort it out. I further asked her about any addiction. None at all. Her family – she had a daughter but she does not live with her. She lives with her grandmother. She is single and is on a pension. I told her I emphatise with her condition and that her problem is genuine. I will organise for her to get investigated to find the cause of the pain. At the same time we need to address the issue of morphine. I said that there is a group of specialists who will deal with this. I avoided mentioning Drug and Alcohol. I said they will devise a plan for you to bring you off the dependance of morphine. She asked me that is for later, what about the pain for now. I said that I will not give her morphine. However there are other non opiate analgesics that will help with the pain. I said we will try NSAIDS and I will give her an injection of Ketorolac ( toradol ). This may give her some relief. I will review her some time later to see how she is going. I further said that her pain is genuine and we will try to help her in every way possible. I asked her how does that sound. She said that is fair enough and is willing to give it a try. AMC Diagnosis – Chronic Pain. I dealt this case as Chronic pain with opiate dependance. 9. 60 year old female has come to you about a lump in the right breast. Picture provided. Right breast higher than the left. Nipple inverted. No signs of lyphoedema in the picture Task – History, Ask for Physical examination findings, Talk about your management plan. There was a picture of the the breast outside the room. The right breast higher than the left. The nipple was inverted and there seemed to be some amount of lyphoedema changes but not clear. I asked history. Important points was that this had started slowly. Never had a mammogrom or breast check up. Family history positive. Said she had been getting increasingly short of breath. The patient was very afraid and kept on asking me from time to time whether it was serious. She also said that there is family history of heart disease. I asked further examination findings. The examiner asked me to say what I saw in the picture. No axillary lymphadenopathy. I asked about the other finding. The examiner said you tell that patient what you will do. I said that I will do a thorough physical examination. Starting with the breasts. Since she was short of breath. I will check her CVS and Respiratory system. Looking for signs of any heart failure pedal oedema etc. She was very afraid and said that she is all alone, no family. She asked me if anything could be wrong with her heart. I said that I can understand her worries. I am there for her for support. I will arrange investigations like ultrasound, mammogram and then biopsy. If the biopsy it positive for breast cancer then we will have to do a CT scan for further staging. I said that I will be referring her to a specialist for further assessment. She asked me whether it was breast cancer. I said possibly but we have to wait for the investigation results. Till that time I cannot say anything in definite. She said that she was afraid. I said I will arrange support for her and I will be there with her all through this difficult period of her life. The examiner and role player were happy. He said Shukriya ( thank you in Hindi ) as I was leaving the room. AMC – Advanced breast cancer. 10. 23 year old female come to you with pain abdomen lower abdomen radiating to the groin. Pain is subsided now. A CT was done.
Task – Interpret the CT scan. Talk to the patient about your diagnostic impression and management plan. Same case as in the recalls. The CT scan showed a horse shoe shaped kidney. The examiner wanted me to explain the CT scan. Which I did. The role player asked me if it could be cancer. I said not likely. I said that the pain could have been because of a stone that you would have passed. However we will do some tests like EUC, TFTs and CMP. The patient should be aware and the abnormally positioned kidney. She should be careful especilally with contact sports. The examiner asked what sort of contact sports. I said – kick boxing. They both started laughing. The examiner asked me so what if I have a million dollars. Can I give it to her. I said by all means. She will be very lucky. There was still some time. So we made some small talk and when the bell rang I went out. Everyone seemed to be in a good mood in this station. Diagnosis – Congenital renal abnormality 11. 45 year old female complaining of pain abdomen. Presented in ED. Task – take further history. Physical examination findings, talk about management plan. Same case as in previous recalls. Right upper quadrant pain. With some nausea and vomitting. Now settled. No radiation. Constant. No aggravating or relieving symptoms. No such pain in the past. No history of gall stones till now. No ulcers. No history of heart disease. Pain still there, about 6/10. Started suddenly. Did not eat a heavy meal. No chest pain. No SOB. Physical examination: Pain right upper quardrant. Tender. No rigidity, no gaurding. ECG – Normal. I said that it looks like acute cholecystitis. We will have to get the surgeons to come and see her. We will keep her nil by mouth. Put a canula and take baseline bloods and start her on fluids. Arrange for a ultrasound abdomen. The surgeon may decide to do a surgery to take the gall bladder out. It may be most probably by lapsoscopy. It depends upon the surgeons assessment. I asked if any concerns. She said no. AMC Diagnosis – Upper Abd pain and rigors. 12. A 20 year old patient has been brought to your GP practice by his parents. He says that he has a specific information for the US president. Task – Take history, Present your diagnostic impression and finding(mental state examination) to the examiner with DD. 20 year old boy brought to GP practice by the parents. He was very agitated. He had been to a music festival yesterday and it suddenly dawned on him that he has this mission to save the US president. Continuously talking. Saying that he had some important information for the american president and he had to go. He was answering questions but was really agitated. No insight and judgement. No suicidal intent or ideation. When I asked about drug usage he was not clear and became annoyed. I told the examiner – 20 year old boy agitated. Dishivelled and untidy to look at. Continuously talking. Unable to obtain full history. No insight or judgement. DD – Acute psychosis secondary to most possibly drug usage. Mania, Bipolar illness, Pre existing mental illness – schizophreniform disorder. AMC Diagnosis – Elevated Mood assessment
13. 10 year old boy presented to GP practice with headache. Task – take further history from the father, physical examination findings (only those specific investigation finding that you ask for will be givne) , explain management plan to the father. Headache since the past few weeks. Mostly in the mornings. With vomitting. No fever, no visual disturbances. No aura. Growth and development normal. No other medical illnesses. No history of trauma or head injury. Family history of migraine positive. Physical examination: Healthy looking child alert oriented. Obs stable. Afebrile. I asked for Fundoscopy: Given a picture of the fundus – it did not look normal. ? Papilloedema. ENT – Normal. CVS – Normal. No rash neck rigidity. Management: I told the father the the fundus did not look normal. It looked like papilloedema. But I will get it confirmed by the senior doctor here. The examiner asked me if I was sure about this. I said that I am a junior but this does not look normal so I will get the findings confirmed. The examiner asked me to tell the father the plan – I said that the fundus looks abnormal. If my senior confirms that it is papilloedema. Then it might be because of raised intracranial hypertension. We need to take a CT scan. And further referral to a neurologist. It could be serious. The examiner asked me what if normal. I said if the fundus is normal then it could be migraine and we need to keep a watch on the headache. I will also give some pain relief since paracetamol was not helping, I will give something stronger like nurofen or paracetamol with codiene (painstop syrup). We also need to study the pattern of the headache. However I said that we need to rule out the serious cause by taking CT scan. I asked the father how does this plan sound. He said, that seems reasonable. The examiner was alright. I was worried because I wasn't sure about the papilloedema, but I passed the case. I guess, it was because I did say that I will rule out papilloedema, intracranial hypertension and do a CT scan. Thus keeping the patient safe. AMC Diagnosis – Child headache raised ICP 14. 24 year old woman has presented to your GP practice with 12 month amenorrhoea. Task – take further history physical examination findings Management History of 12 months of amernorrhoea. Periods have been normal prior to that. Complaint of some pain in the tummy. Dull pain. I asked if there is any pattern to it. She said it comes every month. I asked whether it was approx at the same time as when she got her periods previously. She said yes. Also some amount of slight brownish discharge. No complain of excessive hot or cold. Not on any medications. No breast tenderness. No history of pregnancies in the past. History of D and C more than a year ago. Feels that the period have stopped after that. Physical examination: P/A – slight tenderness lower abdomen. PV – NAD Urine dipstick – Beta HCG negative. Other examination unremarkable. I said that most possibly the periods have stopped because she might have developed adhesions post D and C which is called Asherman's syndrome. However we need to confirm the diagnosis by doing a ultrasound of the uterus. If the diagnosis is confirmed the we need to refer her to a gynaecologist who will do a hysteroscopy for further management.
AMC Diagnosis – Secondary Amenorrhoea 15. 35 year old woman comes to your GP practice complaining of tiredness. Your colleague ordered some blood tests. The reports are here. FBC – HB (decreased), MCV (decreased) and blood film report provided. No other reports are available. She has come to you today to discuss the blood reports. Task - take further detailed history for 6 minutes. Explain management plan to the patient. Same case as in previous recalls – Fe deficiency anaemia. I ruled out hypothyroidism, any bleeding – from the gut and excessive periods, diet and cancers.weight loss. Diabetes and dementia. I said that we need to do some investigations FBC, EUC, TFTs and stool examination (faecal occult blood test). Also we need to find out the source of bleeding for which we need to do a colonoscopy and upper GI endoscopy. I will also give her dietary Fe supplements. I will be reviewing her regularly with all the the results. AMC Diagnosis - Anaemia 16. Patient comes to your GP practice with 41 week pregnancy primi. Pregnancy has been uneventful till now. 34 week scan normal. All antenatal blood tests normal. No DM/HTN. GBS swab was done at 34 weeks which was normal. (long stem) Task – take further history Physical examination findings Explain your diagnosis and further management plan to the patient. Same case as previous recalls. Post dates pregancies. 41 weeks. Dates confirmed. Pregnancy normal till now. Ultrasound 34 week normal. No big baby or CPD. No fibroids. No malpresentation. Baby kicking. P/E – Normal lie presentation. Fetal heart sounds normals. No signs of poly hydramnios or oligo hydramnios. CTG – reactive. Management: I said that it is already 41 weeks. We will have to deliver the baby because it is post dates. We will have to admit the mother in hospital. Arrange for a USG to r/o big baby, placental abnormalities or CPD. If everything is normal the delivery will be induced using prostaglandits to ripe the cervix. I asked her whether she had bronchial asthma or any other medical problems – nil. There is no point in prolonging the delivery. We will keep a watch of meconium staining of liquor in which case we will have to suction the nose and mouth and oropharynx and visualise the vocal cords. If everything is well then the delivery will go uneventfully and everything will be fine. The mother agreed to get admitted to the hospital. AMC Diagnosis – Post date pregnancy. Good luck to everyone. You need to be very thorough with all the recalls. This is not an easy exam. The cases are mostly repeated but we need to be very thorough. We have to have all the facts on the tips of our fingers. So that we can recall them inside the room during the 8 minutes. Only repeated study and role play will help. We need to constantly go through the cases in our mind. Thanks for all the previous AMC candidates who have recalled their papers. We all should help each other. And do recall all your papers and pass them around. Thank you and Good luck!