3rd May 2008 Sydney

Paediatric 1. You are working in GP practice. You are counselling the mother of four month old male infant who was suffering from mild upper respiratory snuffles which causing minor difficulty with feeding. However, over the next two day he apparently improve and his mother had advised you that he appeared normal and feed well prior to his death. You are unaware of any suspicious circumstances surrounding the death.

Task: counsel the mother and ask her permission to do the autopsy And answer her questions. This case is similar to AMC Clinical handbook page 55 AMC feedback SIDS 2. A father of 18 month old boy come to your GP concerning about his son refusing to eat and not growing well. Task: ask focus Hx from the father Ask Ex finding from the examiner Discuss the Dx and Mx plan with the father.

Hx: How long have you identified this problem? 3-4 wk Does your child still breast feeding? No, he stop breast feeding at 1 year. he start solid food since the age of 6 months. what kind of food that your child eat? He drinks milk a bottle per day and he likes to eat jelly and sweets. At meal time he just eat a few mouth then he run away. Who is taking care of your child feeding? My wife Do you have other children? Yes, she eats normally If you compare your child to the other kid at the same age, do you notice if there is any different? I dont know Hows your child development like? Normal His vaccination is up to date? Yes

Is there any problems with your child? No Hows your relationship in your family, financial problems? No, we are a happy family Does he have any past history of any illness? No

Ex: GA and VS are normal All the rest of Physical Ex are normal How is his growth and development? Examiner gave growth chart. Weight is 25% and height 25% are normal Dx: Depending on the Hx and Ex, I dont find any obvious abnormality with your child. The growth chart shows that your child is growing well. So please dont worry. I think that this is the condition we call fussy eater. So, please dont punish or force him to eat. Just encourage him to eat regularly three times a day and dont offer him too much sweets and junk foods between meals. When he feels hungry, hell eat definitely. So I will review him in one month. Q from Father :Does he need to be hospitalized? No. Is there any tests to be done for him? No. Q from Examiner: Can you give him tonic? No, it is not necessary. AMC Feedback : normal child/maternal anxiety

3. You are in GP. Father of 7-year-old girl, Jessie, comes to see you because of fever, sore throat and runny nose for a few days. This morning she complains of headache and so she is kept away from school. Task: Ask focused history from the father. Ask Examination findings from examiner. Manage the case.

History: How long does your child have this problem? Two days ago, it started as flu like symptoms with fever and sore throat, but this morning she complained of severe headache and she refused to have her breakfast. Does she vomit? No.

Is she playing normally? Yes Does she feel sleepy all the time? No Do you notice rashes or lumps on her body? No Does she cough? No Is there any loose motion? Normal Is there any tummy pain, pain in urination? No. Does she still have fever? Yes, she feels hot. Does she have the same problem before? No Is there any discharge from ears? No. Is there anyone in family have the same problems? No Whats her growth and development? Normal Hows about vaccination? Up to date Does she have any past history of any diseases? No Ex: GA she is playing with her toys beside you. VS: T 38.4C, PR and BP are normal. No dehydration, neck stiffness, rashes and lumps ENT Ex : tympanic membrane is injected both sides but not bulging and no discharges Tonsils are not enlarged but the throat is slightly red. The rest of examinations are normal. Mx: Depending on the history taking and examination, your child has a condition we call URTI. It is mainly caused by the virus. So it is not serious. At this stage, Ill give your child Panadol to lower down the fever, relieve sore throat and headache. I also advise you to give her more fluids to drink and also keep an eye on her at home. If her condition is not improved and she develops any change in conscious level or become lethargic, pls bring her to the hospital immediately. Q from father : Does she need any investigations? No, not at the moment. Does she need any antibiotic? No, as it is mainly caused by virus, she doesnt need antibiotic at the moment. Can it be migraine? If she has family history, it can be migraine also.

Father says I have got migraine. Then I answer yes, then it can be migraine.

AMC Feedback : Headache(acute)

4- Hyperemesis gravidarum AMC Clinical book page 751 exactly the same 5- A parent requesting contraception for her intellectually disabled daughter AMC Clinical book page 637 exactly the same 6- ED setting. You are working in ED at a tertiary hospital. The ambulance officers bring in a 30wk pregnant woman, who was involved in a MVA. She was sitting in the front seat with seatbelt while her husband was driving. She is conscious and able to sit at up and talk to you. She brings her antenatal note with her. Her antenatal check up has been normal so far, including 18wk scan. Her BG is O negative. Task: take relevant HX, ask Ex finding from the examiner and Mx

Hx: I would like to know is she haemodynamically stable or not? Yes, shes haemodynamically stable. When did you have this accident? An hour ago. How do you feel now? A bit nervous and worried about my baby Do you have headache, blurred vision, nausea and vomiting? Do you have SOB and chest pain? No Any tummy pain? Yes, slightly on the seatbelt line Do you notice any contraction in your tummy? No Do you feel your baby is still kicking? Yes Do you notice any bleeding or discharge from your private part? No Did you do any prepregnancy screening? Yes, all are normal Do you attend antenatal follow up regularly? Yes Is there any abnormality? No Did you get any anti D prophylaxis? Yes, at 28wk

Do you have any known medical conditions? No Are you on any medications? No

Ex: Everything is normal apart from slight tenderness over the seatbelt line. Mx: From the examination, you and your baby are doing well. but I still want to make sure everything is alright, I would like to admit you in the hospital for 24 hours for observation. At the same time, I also organise some Ix like Abd US, CTG, indirect coomb test, Kleihauer test. You will need extra anti D injection depending on Kleihauer test. I will also inform obstestrician to look after you. After 24h if everything is normal you can go home but if you feel that your baby is not kicking or moving, any pain or contraction in tummy or any bleeding or discharge from your private part. Please come back immediately. AMC feedback: Abd trauma in pregnancy

Psychiatry

7- Insomnia and grief response in a 25y uni student AMC Clincal book page 572 8- Cognitive impairment of 50y woman who work in the bar Exactly the same AMC Clincal book page 737. But they changed MMSE finding, the patient was disorientated, registration was good, impaired recall and the rest were normal.

Med & Surgery

9- you are in the ED, a 50y man is complaining sudden onset of chest pain an hour ago. Task: take Hx, Mx the condition and answer the examiner questions When I went In a young man was lying on the bed. There were oxygen mask, cannula and drip set with 1l bag of NS on the table beside the bed. I asked whether the patient is hemodynamically stable or not? The patient is in front of you

I said as the patient has SOB and chest pain, first I would like to move the patient to the resuscitation room, and ask the nurse to give oxygen, put iv line, do EKG and put on monitor. Then I ask the patient about his pain. The pain was started an hour ago in the central of his chest radiating to his left jaw, shoulder and hand. It was constricting in nature with SOB. Its the first time and very severe. Then the patient collapsed. So I called code blue and started on CPR as the patient is witnessed collapsed and check the ECG. The examiner gave ECG which showed VT, then I connected the patient with bipolar defibrillator and gave 200J. Then I checked the monitor and ECG again. Keep doing CPR. The examiner gave another ECG. It showed sinus rhythm and inferior myocardial infarct. Then the patient gained conscious. The examiner asked what you are going to do now. Then I have to give the patient IV morphine 10 mg , metocloperamide, GTN sublingual, Aspirin if not give by paramedics, take blood for CKMB, troponin , U and El, FBE, Lipid profile, Uric Acid, inform the cardiologist.What the cardiologist will do? Since it is STEMI, he will do coronary angiogram and PTCA.

AMC Feedback : Cardiac arrest

10-Dysphasia and upper limb weakness You are in ED. 60-yr old man complained about difficulty in speaking and right upper limb weakness an hour ago. His symptoms resolved while he is waiting in ED. Task: Perform the focussed Physical Examination. Answer the examiners question. When I went in, the examiner asked what you are going to examine. Cardiovascular System and Neurological system. GA normal. VS BP- 140/90, T-normal, RR-normal, PR-do urself, PR- 80/min, regular , no AF,normal character, moderate volume,no radio-radial , radio-femoral delay. I will do cranial Nerve Examination. All normal, had to do Facial Nerve Examination and Upper limb neurological Examination. Then listen for carotid bruit and do CVS, normal. Lower limb neurological Examination is normal also. Q from Examiner: What is your Diagnosis? TIA Where is the lesion? As he had right upper limb weakness and dysphasia, the lesion is in Left parietal lobe.

AMC Feedback : Dysphasia and upper limb weakness

11- Shoulder Assesment Exactly the same in AMC Clinical Handbook pg 231. 12-Swelling of Ankles Exactly the same in AMC Clinical Handbook pg 154.

13-Thalassaemia minor(Beta) Exactly the same in AMC Clinical Handbook pg 61.

14-Urinary Frequency Exactly the same in AMC Clinical Handbook pg 354.

15-DVT You are in GP. 30 yr old man who was on OCP for 5 years complained of lower limb pain which become worse when she plays tennis.. You did Doppler USG and now she came back for results. All physical examinations are normal. USG : thrombus in left popliteal vein, extending to left superficial femoral vein but not occluded. Rt lower limb veins are normal. Task: Explain the results and short and long term management to her. I explained her that she had got a condition called DVT, got blood clot in her left lower limb vein. So she is needed to be hospitalized and need medication to break down her blood clot. She also need to undergo some investigations especially thrombophilia screening to rule out acquired and inherited tendency to get blood clot and Platelet, APTT and INR before she is started on LMWH and Warfarin. She also needs to take long term blood thinning tablets for 3 to 6 months and put on compress stocking for 2y. Then I also explained about things to follow up, side effects, interaction medications when taking warfarin and future travailing prophylaxis. She also need to stop taking OC pills also.

16-Chronic Leg Ulcer Picture given venous ulcer in medial malleolus

You are in GP. A 50 yr old woman complained of chronic leg ulcer in letf lower limb. She has diabetes and it is under control. Task : Take history, Do physical examination and give differential diagnosis How long have you had this ulcer? Many months Do you remember how it happened? While I was doing gardening. I got a small scratch then it becomes bigger and bigger. Did you visit any doctor or take any medications? No Now do you have any fever? No Do you notice is there any discharge? No Any change in colour? Yes, around the ulcer Is it in pain? Not really Is there any dilated veins on your legs? yes Hows your DM, is it well control? Yes Is there any numbness or reduce sensation on your legs? no Do you have ever had any pain in your legs while you are walking? No Do you have any past Hx of legs injury? I had a left leg fracture since last 10 year, since that its well. Hows about clot in your lower limps? No Are you on any medications? No Do you smoke or drink alcohol? No

Ex: GA and Vs are normal I would like to see the patient ulcer by inspection and palpation? The examiner gave me the photo exactly the same Anthology book. It was venous ulcer with varicose veins. With Palpation, the tissue around ulcer was warm, all the pulses were present. Lower limps neurological examination was normal. Office tests ( random blood sugar and urine dipstick ) were normal.

After my examination, I think that it most likely you have a venous ulcer on your left leg. But it less likely an ischemic ulcer or an ulcer caused by osteomyelitis. Also talked about Mx but actually it wasnt the task.