MELBOURNE, 9 FEBRUARY 2008 ‘This recall has been written by two candidates. We both have passed 15 stations, but failed in different ones. One of the candidates failed the station with acute back and leg pain (sciatica), the other one failed postpartum haemorrhage. So, in order not to mislead you, only the candidate who has passed a particular station has written it. Other stations we have written together so that you can obtain as full feedback about them as possible. PSYCHIATRY 35 year old man is complaining of having funny movements of his lips and tongue for a couple of months which are getting worse and really bothering him, He has been on Haloperidol for more than ten years. ‘TASK: = take relevant history + Mx immediate and long term (identify the aspects which you should deal with) ‘The patient takes haloperidol for many years without major problems until the facial movements started. He also claims that people are looking and following him on the streets and plotting something against him. When asked if he thinks that people are looking because of his, lip movements, he said no, they are just following and plotting. He is fine at home where he lives alone (taking care of his own medication himself) and tends to stay there to avoid social interaction, He denies and suicidal thoughts and any chronic conditions, psychiatric illnesses that run in family or allergies He admitted of halving the dose of Haloperidol by himself, because of these movements. He also told me that he hasn't been to a psychiatrist since he has been diagnosed and he has been under my care since. MANAGEMENT: first explained to him that the S/E. that he is experiencing are due to Haloperidol and Y'll try to help him to deal with them, I told him that I’m also concerned about him halving the dose of medication and those signs of illness that he started to experience afterwards (people following ...). Most likely, it is a resuit of the dose reduction. I will refer him to a psychiatrist ASAP (getting on the phone right now), and his medication will be changed gradually. We call this {ross over period where the dose of one medication is reduced whilst increasing the dose of the other. While we change the medication he may experience the worsening of his condition (breakthrough psychosis). I also added that because he lives alone the psychiatrist might consider admitting him to hospital to monitor his condition duri medication to another. We finished earlier this station. AMC feedback: Paranoid schizophrenia (relapse). 35 year old woman works in a managerial position with increased work load. She is very busy at work. Doesn’t sleep well, anxious, has pains and aches everywhere (abdominal, headache, chest pains). She drinks 5 cups of coffee a day and smokes 15 cigarettes a day. ‘There was a long list of investigations that had been done, including ECG, TFTs, colonoscopy?. FBE, etc., which were all normal and she was diagnosed with Generalised Anxiety Disorder,TASK: + Talk to patient (you may ask some relevant questions) + Explain = Manage accordingly C: Good afternoon Mrs. X, I have some good news for you. P: What do you mean good news; I cannot sleep well and do not feel well. C: we will address this issue but first I will tell you that ail the investigations that we ordered for you have come back normal. But I do have some more questions for you. I understand that you are very busy at work and its quite stressful, could you tell me please your major concerns? P: I cannot fall asleep for three or four hours. So what could be wrong with me? C: The condition that you have, we call a generalised anxiety disorder in which emotional problems can actually cause physical symptoms to appear because our brain regulates all our bodily systems and organs. P+ is it so? C: Yes itis. Tell me please about your situation at home? P: Athome everything is OK, my husband is very supportive. But I regret that we don’t have any children as we are both very busy. C: Lsee. First of all we have to address your coffee intake and cigarette smoking. It would be good for you to drink less coffee, I suggest that you choose an alternative such as juice, green tea or water. P: Iwill try. C: have you ever considered quitting smoking? : yes Ihave but my life is so stressful and my smoking helps me to get through the day. C: ona scale of 1 to 10, where would you put your desire to quit smoking? P: around 5. C: Fair enough, We'll follow it up on our next appointment. There is another issue I'd like to it would be great if you could plan your work and rest so that you delegate part ities to other people to reduce your stress levels. P: Doctor, one of my friends who is a pilot, is taking some tablets that help him go to sleep. Could you prescribe them for me as well? He gave me couple of thei to try I have found that they are really good. C: Could you tell me the name of these tablets? P: ‘Temazepam.C: you know we are a bit reluctant to prescribe these tablets because they are drugs of addiction, but in some cases we can prescribe a short course of it when it is really required. But in your case relaxation techniques, yoga or mediation may really help you without the need of drugs. P: But you said that I can have a short course of these tablets so can I have them? C: As I said it is not out of the question but for now I would really like you to start on the relaxation techniques and lifestyle changes. I will also refer you to a psychologist. P: what will the psychologist do? C: CBT to help you to take things easier and understand the causes of the problem and the way to deal with them. P: OK I'm happy with that, Finished early. AMC feedback: Generalised anxiety disorder. PAEDIATRICS AA five year old boy — Peter Day, is brought to see you in a general practice setting because he has been soiling his pants for the past couple of months. Now it happens every day and the parents are really concerned and not happy with the child. TASK: + Focused history from the parent. + Ask examiner for the appropriate findings on the examination that would be relevant to your diagnosis + Explain your diagnosis and advise the management. C: could you tell me what seems to be the problem? P: You know Peter is soiling his pants everyday, at school and at home as well and I am really not happy with this because he was toilet trained by 3. ©iCouid you teil me please if Peter has been under any stress like being bullied at school or any other emotional problems? P: No Idon’t think so. He has not been bullied but he has started a new school 3 months ago and the children there are teasing him because he is stinky. C: What about his general health? P: He is generaily healthy, no chronic conditions, normal growth and developments and not on any medications or possessing any allergies. ©)What about his appetite, nausea, vorniting? Any weight loss? Fave « B: all normal, no problems. @©any problems with the bowel movements? P: He had an episode of constipation about 3 months ago. ©what is his diet like? P: He doesn’t Tike fruits or vegetables, doesn’t drink much water and juice and likes fast food. ©what is your situation at home? P: We are a very happy and stable family, but I am not happy with Peter now (she actually tied that she punished him for soiling his underwear). is there anybody in your family on a special diet (to exclude Coeliac)? P: Not at all.