MELBOURNE 28 February 2005

Case 1: Circumcision

A 35 weeks pregnant female comes to your GP enquiring about neonatal

Circumcision. Talk to the mother about advantage and disadvantage. Question asked
by the examiner, what age is best for circumcision and how long will stay in the
hospital? Is it compulsory?
Notes:
- It is done mainly because demanded for cultural reasons. Some want the child to
be like father
- Generally doctors’ advice against it because every unnecessary operation should
be avoided and has risks and some say foreskin has a protective role.
- Usually foreskin fully retracts by age 5 and you should clean the cheesy material.
If not fully retracted by age 10 then consultation needed.
- Medical indications: Very tight foreskin (phimosis) which is prone to infection,
Sometimes infection can cause tightness which cause small opening and difficulty
passing urine, Usually more than one or two attacks of infection means that action
is required, Foreskin that cannot be pulled back (stuck foreskin)in older boys.
- Timing: It is best performed when the baby is not wearing nappies.

Case 2: Febrile Convulsion

A 2 years old child had a convulsion about a few hours ago which lasted for about 10
minutes and was generalized. After the episode the child was a bit drowsy but now
she is fine BP and PR is normal. Child had otitis media for the last 2 days and has
been pulling her ear. temperature was 38C the child is fully immunized and active and
playful. You are a medical officer in emergency department on the hospital.
Take a relevant history from the mother, rule out meningitis head injury, explain the
diagnosis to her.
Tell her the further management and prognosis.
Question asked by the mother, what is febrile convulsion, can she get again and can
she get epilepsy? It is affect her intellectual capability?
Notes:
- A febrile convulsion is a common condition where a child has a fit that is brought
on by a high temperature. Their growing brain is more sensitive than mature
people.
- They are very common and can affect any normal child and usually do not cause
brain damage or epilepsy. Nothing can be done to  prevent the convulsion from
occurring
- If happened again: The most important thing is to stay calm - don't panic, Place
your child on a soft surface lying on his or her side or abdomen, Do not put
anything in their mouth, Do not try to stop it, Remember to time how long it lasts.
 - If it was more than 5 minutes or the child didn’t wake up after that call the
ambulance, otherwise you should see a doctor as soon as possible. Drive with
your car only if there are 2 adults.

Case 3: Breast feeding& Formula feeding

A 32 week pregnant female has come to you to talk about breast feeding and formula feeding.
Her mother’s opinion is that children fed a formula are much healthier and grow better when
compared to breast fed children. Talk to her about the advantages and disadvantage of breast
feeding and formula feeding. Question by examiner how you make formula ready for
feeding? Another question by examiner what will happen if child is put on formula feed and
found to be allergic to it. Is there substitute available?

Notes:
- Breastfeeding: Complete nutrients for the first 6 month, Protection against
infection and allergies, Less vomiting and diarrhoea, It changes to suit each stage
of baby’s growth, It’s convenient and always has the right temperature, Never
goes off and costs nothing, Doesn’t need sterilization, Can help to lose extra
weight, can help the womb to get back into normal size, It has close physical
contact, Antenatal classes available---------Bad points: Sometimes can cause
painful breasts, cracks, engorgement and you are the only one who is responsible
for feeding.
- Formula feeding: Although its impossible to make the exact composition, it’s the
best second option, it has good and bad points: Not as much protective, It doesn’t
make the child healthier, needs sterilization, Expensive, but your partner can help
you feeding the baby. Regarding nutritious value there is no doubt that
breastfeeding is better.
- Cows' milk infant formulas are all very similar, so babies are unlikely to do better
on one than the other. Soy formulas have no cows' milk protein or lactose and
may be used for various health problems. (thick formula is for reflux)
- Some notes about Reflux:
- http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?
p=114&np=304&id=1790

Case 4: Placental abruption

A 30 wks Rh-ve pregnant female comes to the emergency department of the hospital
complaining of bleeding per vaginal. She has a little bit of pain in her lower abdomen
as well. On examination the uterus was not tender but it was soft.
BP and PR were normal FHS was 140; you are a medical officer in the hospital take a
relevant history explain the diagnosis and manage the patient. Start by asking for
hemodynamic stability. (Patient was hemodynamically stable).
 Question by patient: risk to her baby if she delivers now as she only 30 weeks.
Question by examiner what will be your management if the CTG shows absent FHS.

Notes:
- First thing to ask is vital signs
- Abruptio: Shock out of proportion with bleeding, constant pain, tender and tense
uterus, normal lie and presentation, FH is absent or decreased, coagulation
problems, Beware of pre-eclampsia, DIC and anuria
- Increased risk of PPH in abruptio and previa
- Always Admit
- If stable check for FBE, crossmatch, Rh, Coagulation and fibrin degradation
products, U&E and FMH (feto-maternal haemorrhage) test
- If diagnosis is previa then mom should be in hospital till delivery
- If abruptio and bleeding stopped and no fetal distress then may go home after anti-
D
- If bleeding severe or fetal distress then Delivery
- With recent technology nearly 100% of babies >=30 weeks will survive, but they
need special care in incubator by paediatrician. Some risks of prematurity are:
RDS, periventricular malacia and haemorrhage
- Remember steroids before 34 weeks for lung maturity

Case 5: Eclampsia

You are a medical officer in the countryside base hospital called you for episiotomy
repair. On reaching there you find that the lady was unconscious and had generalized
convulsion a little while ago blood lost at the time of delivery was 300-400ml. the BP
and urine examination in the antenatal period was completely normal. She is not
epileptic. Her husband is there to talk to you. Take the examination findings from the
examiner and ask for relevant investigation. Explain to the husband your diagnosis
and further management. Asked from the examiner whether ABC have been taken;
care of BP, reflexes. BP was 160/100 and reflexes were exaggerated. I asked for
following investigations: FBE including platelet count, clotting profile, serum uric
acid, LFT, U&E, urine proteins and complete examination. Explained to the husband
about eclampsia. Called for air ambulance. Explained the need to transfer to a
tertiary level hospital. Started on IV hydralazine and mentioned that she will be given
Magnesium in the tertiary level hospital.
Notes:
- BP>170/110 requires prompt treatment
- Your wife has pregnancy induced high blood pressure which sometimes causes
fits even after delivery. She should be closely monitored in a hospital for BP and
fit control. It sometimes affects kidneys, liver and blood system. Usually resolves
10 days after delivery. Cause is not clear but is something to do with placenta
insufficiency and compensatory increased BP.
- Symptoms: headache, visual disturbances, epigastric pain, vomiting and increased
PR signs: increased Cr, decreased Platelet,
 - 5-10mg Hydralazine, given intravenously as a bolus over 5-10 minutes, then by
continuous infusion at 5mg/hr, with adjustment of rate to maintain BP <160/100
every 30 minutes until BP 140/90 to 160/100
- MgSO4 commenced (as per protocol) and continued as an infusion (in the HDU
unit). 4 mg bolus over 10 minutes then 1 gr/hr maintenance

Case 6: Tubal legation

A 38 year’s old lady comes to you to talk about sterilization procedure. She has three
children age nine, five and two years. All of children are healthy. She is on OCP. Talk
to the patient why she wants to do sterilization, explain the procedure of surgery and
tell to the patient what is advantage and disadvantage of tubal legation. Because she is
not happy with contraceptive pill, if she not choose tubal legation what is other option
is best to do? Talk about IUD, condom or vasectomy.
Notes:
- There are 2 tubes which extend from womb to ovaries. The sperm and egg meet in
this tube and then transferred to uterus. In this procedure these tubes are cut off or
blocked. This stopes the sperm from reaching the egg.
- Its done under GA through a small cut (operation) or a special tube (a cut about 1
cm). Two methods are: ring or clip and cut&tie
- 1-2 days stay
- Very effective (1/200 failure)
- No weight gain or menstrual change
- Reversion success rate between 30-80 %, but you should consider it as permanent
and irreversible and you should think about it.
- Vasectomy: Small operation in which the two vas tubes are cut and tied. This
blocks the flow of sperm. Under local or GA can be done. 30 minutes. Two cuts in
scrotum (bag). 1 in 500 failures. 2 month after operation should have a sperm
count. No effect on sexual life. Normal sex after 5 days but use a method.
Sometimes has infection or bleeding or sperm granuloma which all will settle with
treatment. 40% reversal success rate. Should be regarded as permanent. Be
definite about decision.
-
Case 7: Postnatal Adjustment Disorder?

A 28 year’s old lady comes to your GP set up complaining that her heart rapidly beating,
which she has been experiencing for the last 3 months after the delivery of her baby. Another
GP in your clinic examined her CVS last week and found everything was normal her ECG
shows sinus tachycardia TFT’s was normal. Other relevant investigations done at that time
were also normal.
Take history explain your diagnosis and differential diagnosis. Based on her history she
doesn’t like going outdoors, the pregnancy was planned and she has a supportive husband;
she has a low mood and no suicidal idea.
Notes:
- Complete history including sleep, appetite, energy, memory, concentration,
enjoying activities, delusions, hallucinations and anxiety symptoms.
- Differential: postnatal adjustment disorder, postnatal depression, Anxiety
- Support, reassurance and counselling
- Group psychotherapy, couple therapy, Postnatal depression support group
- If suicidal or child harm ideas then hospitalization.
- Medication
- Beware of psychosis
- Some advices: avoid getting tired and rest, Voice out your problems with a good
listener, Accept help, Allow your partner to help

Case 8: Paranoid schizophrenia

52 years old female had a breakdown 4 years ago because of some work place problem
now she staying alone in house. She took some medication for allergic contact
dermatitis otherwise her health has been fine she has not been on any other
medication. She came to your GP set up asking for a latter to the housing department
that she is being annoyed by her neighbors and claiming neighbour plotting against
her and hearing neighbour voice which is talking about her bank account. Take a
relevant psychiatric history for 6 minutes. Tell your diagnosis and differential.
Notes:
- History taking: 1. History of present illness: a. The problem b. Precipitating event
c. Risk assessment 2. Past history 3.Family history 4.Social and personal history
5. Mental State Exam 6. Differential
- MSE: 1.General description 2. Mood and Affect 3. Thought 4. Sensorium 5.
Judgement and Insight 6. Speech
- R/O of medical illness is very important in elder age. Brain CT and U/A
- Drug history very important in social history
- Team approach is necessary with family members and psychiatrist
- Acute phase usually needs admission
- Remember support groups and psychotherapy
- Paranoid SZP: Delusions with preservation of cognition and affect

Case 9: Gout

A 45 years old taxi driver comes to your GP set up with complaining of pain redness,
swelling in the right big toe on the first metatarsophalangeal join. This is the second
time he is having such an attack. He is moderately obese and non smoker but drinks
about 4-5 standard beer per day. He has been on anti hypertensive therapy (diuretic)
for the last few years. His general health has been fine otherwise. Ask for relevant
history from the patient and ask investigation from examiner; explain your diagnosis
 and further management to the patient.
Question by patient when he can go to work and question asked examiner when you
will start allopurinol-(when acute attack finished start that for long term control and
prophylaxis). Side effect of that are headache, stomach pain, skin rash, occasionally
nerve damage and enlargement of liver.
Notes:
- You have Gout which is a type of arthritis that is caused by uric acid (A waste
product from body) crystals getting caught in the space between joints. The tissue
around the joints becomes inflamed and tender and painful. Sometimes kidney
cannot cope with the load of uric acid produced in the body and this causes an
increase in blood uric acid level.
- A hereditary factor is involved. Associated with high BP and obesity, rich foods
and alcohol, some drugs (diuretics), injury, surgery and starvation.
- Its curable but if not controlled may cause kidney problems (stones).
- Bed rest, hot compress
- Rules of moderation: restrict food high in purines, reduce alcohol (2 standard
drink a day), well-balanced diet, plenty of water, weight control, comfortable
shoes, regular exercise (not strenuous), don’t take your worries to bed
- Acute attack: Indomethacin, colchicine (causes diarrhoea) or steroids
- Diagnosis: joint aspiration X-ray: punched out erosions
- Allopurinol side effects: Rash and severe allergic reaction
- Intraarticular steroid after aspiration and culture
- Ring block

Case10: Polymyalgia Rheumatica

62 years old female comes with complain of vague aches and pains in her body. Take
further history, ask for the examination findings and what are the investigations you
would like to do? Give your diagnosis and deferential diagnosis.
On history you have to rule out problem whit shoulder joint, neck pain, headache,
(temporal arteritis), polymyalgia rheumatica and trauma. Question by the patient what
is polymyalgia rheumatica and in what medication you put me on?
Notes:

- Polymyalgia rheumatica is a rheumatic disorder that is associated with moderate

to severe muscle pain and stiffness in the neck, shoulder, and hip area. Stiffness is
most noticeable in the morning. This disorder may develop rapidly--in some
patients, overnight. In other people, polymyalgia rheumatica develops more
gradually. The cause of polymyalgia rheumatica is not known; however,
possibilities include immune system abnormalities and genetic factors. The fact
that polymyalgia rheumatica is rare in people under the age of 50 suggests it may
be linked to the aging process.
 - Polymyalgia rheumatica may go away without treatment in 1 to several years.
With treatment, the symptoms of polymyalgia rheumatica are quickly controlled,
but relapse if treatment is stopped too early.

- Giant cell arteritis, also known as temporal arteritis and cranial arteritis, is a
disorder that results in swelling of arteries in the head (most often the temporal
arteries, which are located on the temples on each side of the head), neck, and
arms. This swelling causes the arteries to narrow, reducing blood flow. Early
treatment is critical for good prognosis.

- PMR: It is symmetrical, early morning stiffness, maybe with anorexia, weight loss
or malaise, restriction of movement of shoulders and hips, maybe better later in
day

- TA: unilateral throbbing headache, temporal tenderness, loss of temporal artery

pulsation, jaw claudication (pain with mastication that resolves with rest but
returns after a period of chewing), biopsy is diagnostic

- FBE, ESR, CRP

- Prednisolone 15mg for PMR and 60mg for TA tapering to 5 mg for at least 2
years, relapse common, Remember azathioprine and methotrexate

Case 11: Acute Appendicitis

A young female comes to your GP set up with pain in the RLQ and her temperature
was 38.5 and had been vomiting for the last 24 hours. Take history, ask for
examination finding, investigation and explain the management to the patient. On
history and examination finding you have to rule out appendicitis, salpingitis, and
ectopic pregnancy, torsion ovarian cyst.
Notes:
- Salpingitis: Lower abdominal tenderness + cervical motion tenderness + adnexal
tenderness + one of these (high temp, high WCC, purulent discharge, high ESR or
CRP, presence of gonorrhoeae or Chlamydia). Patient is usually sexually active
- Ectopic pregnancy: check for urine hcg or β-hCG + vaginal bleeding + missed
period
- Torsion: patient looks ill with severe pain radiating to back, flank an repeated
vomiting, no temp

Case 12: Palliative care

A 50 years old female was diagnosed with inoperable bowel cancer about a few
months back. Some days back she presented with intestinal obstruction when she was
 admitted in the hospital and an entero-enterostomy was performed. Now she had
severe pain in her lower back and lower tummy region which was not relieved by
panadeine forte. On per rectal examination tumour deposits were found in the pelvis.
Liver was normal. She has come to your GP set up to talk about pain. Talk to her and
explain the further management. Spoke to her about the cancer progressing and
infiltrating the nerves leading to severe pain. Explained to her that prognosis is not
good and cancer is no longer in the curative stage. Talk about palliative care. Question
by the patient: Am I going to die? And asked by examiner: Is there any thing else you
could give to the patient for pain relief besides morphine?
Notes:
- After explanation about cause of the pain speak about palliative care: This is a
multidisciplinary team approach to provide the best possible quality of life for
you. It’s running by me, nurses, social workers, cancer support group and your
family. We will address every complaint appropriately to make it comfortable for
you as much as possible.
- Before answering to “am I going to die?” ask the patient that how much she
knows about her problem and whether she is ready to hear bad news or she wants
to be with her family members to hear about it.
- Pain relief and medications remember Fentanyl patch, Hydromorphone,
Methadone, Oxychodone and Tramadol. In neuropathic pain remember
Amitriptyline, Carbamazepine and Gabapentin. Ketamine is also a resort.
- In neurological pressure (like spinal) remember steroids.
- Continuous sc infusion of morphine is an option.
- Address anorexia with metoclopramide and steroids. Constipation with
Cloxyl/senna, bisacodyl, rectal suppositories, microenema or enema. Shaw’s
cocktail. (peristaltic stimulants not bulking agents)
- Terminal death rattles: hyoscine or atropine
- Dyspnea: tap, morphine, steroids
- Terminal distress: First exclude reversible causes like constipation, urinary
retention, faecal impaction or drugs then consider clonazepam or midazolam.
- Vomiting: if due to morphine give haloperidol otherwise metoclopramide

Case 13: Alopecia areata

A 28 years old female presented to your GP complaining of loss of hair from her scalp
and eyebrows. Below in the photograph taken of her scalp, showed patchy hair loss
throughout the scalp with normal hair in between. Ask for examination and
investigation findings from the examiner. Explain your diagnosis and further
management to the patient. Examination finding – any scaling, erythema, scaring
exclamation mark, and hair features of hypothyroidism (not positive finding).
Exclamation mark was positive. Investigation: FBE, Urine C/E, TFT’S, wood’s lamp
examination (all normal). Explained alopecia areata (patient education and GP).The
 management, prognosis referred to skin specialist. Question asked by examiner: any
other medication can be given besides Minoxidil or not?
Question by the patient: can stress lead to this problem? And she eats a lot of cheese
and milk can this lead to hair loss? And will she lose all her hair?
Notes: refer to Sydney 4th June

Case 14: Benign Prostatic Enlargement

A middle aged man comes to your GP with difficulty in passing urine for the last few
weeks. Take a further history; ask for examination findings from the examiner. Tell
the investigations you would like to do. Explain the reason, why he is experiencing
these symptoms. I took a detailed history to rule out: DM, UTI, Benign prostatic
hyperplasia and carcinoma of prostate, kidney disease and stones. History given was
very much suggestive of prostatic enlargement. Patient was also drinking lots of
water. Examination findings were suggestive of benign prostatic enlargement
(moderate degree). Investigation: FBE, urine, U/C, blood sugar, PSA. (All were
normal). Explain – benign prostatic enlargement asking the cause of the symptoms.
Remember referral to specialist who might consider biopsy.
Notes:
- All the questions about water work. ( what, when, how long, how often, difficulty
initiating, dribbling, stopping and starting, suddenly or gradually, night, stream,
volume, blood, colour, smell, burning, any pain like flank pain, bowels)
- Drug History: Antidepressants, Cough or Cold mixtures, Antiparkinsons, Atropine
and hyoscine compounds + smoking and alcohol
- History of UTI, DM (when was the last time checked sugar) or cancer in the
family or renal stones.
- Investigations: FBE, MSU, U&E, BSL, PSA, U/S transrectal preferred, Needle
biopsy.
- Prostate gland: A brownish gland that surrounds the opening of the bladder and
beginning of urethra. BPH is not dangerous. May cause acute retention, UTI,
stones. Treatments are nonsurgical and surgical. Third of the cases can be
controlled without surgery.
- Advices: Cut down alcohol, Avoid fluids before sleeping, get up immediately at
night, don’t hang on, and make sure bladder is empty by waiting.
- Drugs: Alpha blockers: Prazosin, Trazosin, Phenoxybenzamine and 5-alpha-
reductase inhibitors: finasteride ( urine flow improves by 3 month)
- Surgery: TURP Complications: rarely incontinence for 2 days, Impotency is very
rare, Avoid sex for 3 weeks, backward ejaculation, sometimes infection and
bleeding (drink lots of water), can return to full function in about 4 weeks

Case15: Post operation Anuria

A young man underwent repair for his perforated duodenal ulcer a few hours back in
the hospital. He was put on fluids starting a few hours before the operation. Following
 the operation he has been on bed, the nursing sister calls you. You have looked at his
fluid chart which is as given below. On further questioning the nursing sister says that
he has not passed any urine. Fluid intakes are only about 500ml during this whole
period. Nasogastric tube aspirate is 600ml. Task is to examine the patient and write
down your instructions in the fluid chart provided.

Examination: vital signs of dehydration and normal temperature and normal blood
pressure. The patient was mild dehydrate, suprapubic was not tender and bladder was
not distended, the patient was not catheterised.
Question asked by examiner- what the cause is. (Ans. Less fluids have been
administered).

Question: write down the instructions. Sixty per cent of the body is made up of fluids.
The patient’s body weight was about 70kg and has been roughly10% dehydrated.
Thus the patient requires 4.2 to 5 litres of fluid in 24 hours. (0.6 x 0.1 x 70 =
4.2 Litres – divided by 8 + 8 + 8 hourly) Give one litre of normal saline I/V in hour,
check urine out put to be 40-50 ml/hour (investigate of blood urea creatinine and
electrolytes). If kidney functions and urine out put are good, start another litre in a
two hours and next litre give in a 4 or 5 hours and we continue one litre of 5%
Dextrose in eight hours and another litre of 5 % Dextrose in the last eight hours.
Check urine out put hourly.
Maintain TPR charting and give potassium when urine out put is normalized.
Question asked by examiner: all these fluids have been infused; patient complains of
pain in his abdomen and is still not passing any urine. What would you do?
An: catheterize. (After check by cystometer)
Notes:
- Deficit therapy is usually 3-5 % of body weight in the presence of dehydration and
oliguria (about 2-3 L)
- Two rules of thumb should be applied in prescribing parenteral therapy for fluid
and electrolyte deficits. The first is that for most problems, half of the calculated
deficits should be replaced in a 24-hour period, with subsequent reassessment of
the clinical situation. The second is that a fluid or electrolyte abnormality should
take as long to correct as it took to develop.
- 70 kg guy maintenance is about 3 L per day. He has about 5% deficit so 3.5 L. So
today he needs about 4.5-5 L fluid (N/S first and 5% dextrose at the end). Start 1
L statim and the rest during 24 Hour. Check U&E after this 1 L. Insert catheter
and keep output to 0.5 ml/kg/day. If output is returned then start K (20-30
mmol/L).
- Check vital signs frequently.

Case16: Coma
You are called to a unit by a boy whose flatmate suddenly collapsed. Airway is clear
and breathing movements are normal. BP, PR and temperature are normal. Examine
the patient. Tell the examiner the investigations you would like to do. Give four
differential diagnoses.
Examined the patient according to Talley, performed the GCS. The GCS was nine and
neck stiffness (make sure there is no injury).
Investigations: full blood examination, urine C/E, LFT, TFT, KFT, blood sugar, CT
scan of brain, LP, blood for toxicology.
DDx: 1-Sub arachnoid haemorrhage, 2-Meningitis, 3-Hypoglycaemia, 4-Drug over
dose.
Question by examiner, what is contraindication of LP? (SOL, Infection in the site,
optic disc oedema in fundoscopy as blurring of margins) Another question is it brain
CT effect on the CSF or not?