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AMC resit Melbourne 4June 05

Question: 1 (SURGERY)

Middle age man has a swelling on the right side of his neck. Picture ( AMC anothology
book) . You have perfonned FNA, it came out to be squamous cell carcinoma.

Your task is to examine the pt.

What relevant physical examination you will do

Discuss the differentials with the examiner. How would you manage the patient?

( This was my fIrst station and I was not so warmed up, I went in and in examine the
swelling on the patient and then minute after that examiner interrupt me and ask me what
other examinations you would do, I said look for lymphadenopathy in the neck, the he let
me examine the neck. Examiner ask me where do you think that the primary is from and
I said defInitely lungs, skin and then he said what else he gave me a prompt that this man
has been smoking for 15 years, what else then I said throat (pharynx) he ask what else
would you to fmd out primary.

Bell rang he still ask me few questions about the other relevant investigations would you
do in this case and its management. I mentioned Broncoscopy and I didn't ask for Chest
xray.

Squamous cell CA

Question 2: (GYNAE)

54 year old woman has a vulval swelling for the 12 months and it had gradually increased
in size. It was a very long stem ...

The task was to ask relevant history, management.

My reply I went in I think that the lady patient was gynaecologist, so there were two
examiners in this station.

I ask all the history and was trying to fInd out the site nature of swelling and any other
assoc symptoms and also her past gynae and sexual history, she told me which was a hint
that she had 10 pound babies in the past. She is otherwise healthy, no STD, pap smear
nonnal.
I ask the examiner the examination fmdings which he said there is a complete prolapse
along with cystocele.

This question is also from Anthology book page 341

Management was all about referral and different options about the operations.

Various degrees of prolapse.

Question 3 (psych)

This was again a long stem

17 year old girl who had sustained a full thickness burns and has been to your unit and
you are the intern, she has all the initial management of burns and she is on 1mg of
morphine every hourly along with usual IN replacement. She started having nightmares
for the last 3 days and her appetite has also decreased that she also complains that the
nurses are trying to harm her and injecting drugs.

You task is to take brief history, do the relevant MSE and discuss the differentials and
also manage the patient.

I went in after taking a brief history and MSE , the girl was oriented to time and place and
she was having nightmares of the incident and she could not sleep and was jumpy, she
was hallucinating during the day time on odd occasions ..
She was not suicidal or homicidal.

My differential were no PTSD and may be delirium sometimes rare in burns.

I rattle about the management and reassure her about what is going on and briefly discuss
the management.

The trick about morphine be the cause of her hallucinations no. Img of morphine every
hourly124 hours PRN is the correct dose.

Question 4:( General Practise mS)

52 year old woman who had a long term history of constipation comes to see you as
she has been thoroughly investigated in the past three months and her
gastroscopy, FBE, Colonoscopy were all normal. She complains of bloating and
wind, is tender in left iliac fossa.

She has come to see you again

-------------------------------------------_ ... . -

Please take relevant history, explain to the patient what would you do to manage her.
Lots of students interpret as anxiety but my reply after taking the detail history was
dietary habits were poor and her bowel habits were irregular and she takes over the
counter laxatives , no smoking and drinking but she complains that whenever she eats
broccoli or beans she get bloating and wind and pain in her lower abdomen.

She does not work.

I also ask about thyroid and weight loss.

My reply was to correct her constipation by being regular and start with simple measures
like adequate fibre and plenty of water and exercise and also appointment with dietitician
to identify the food which she is sensitive towards. I explain to her about the IBS
possibility and joining the support groups etc.

She was quite happy when I mention dietitician she said that I quite like it, so I got that as
a hint, did not label her as anxiety disorder.

Question 5 (Examination station)

Examination of hands and explain about your differential to the examiner.

Dr Sedal was the examiner. He was very kind.

Please 'again refer to Anthology, the woman had exact features of Rheumatoid Arthritis
as given in the picture self explanatory

Question 6 (Paediatrics reccurrent Otitis Media with Effusion)

This question has very long stem, I could not finish reading in 2 minutes.

4 year old girl has recurrent Otitis media she also had been given Amoxil by you for 5
days. She has mild grade temp 37.1 and lately her mother has noticed that she snores a
lot and breath from mouth at night.

On examination she had bilateral effusion and also tonsil are enlarged.

Task is to talk to the anxious mother.

I did not do every well as I had to read again inside and examiner looked at my name
twice.

I explained very quickly about the Otitis media and recurrent episodes and URTI.
I reffered the child to paediatricianlENT as during the history mother told me also that
child has problems with her hearing and she wanted to her child hearing tested formally.

She also wanted to know all the options of treating OME.

By the way I mentioned about long term prophylactic antis, gromets etc .Possibility of
adenoidectomy left it to paediatrician.

Question 7 (Surgery fractures of lower end of fibula)

My Gya was the examiner

There were pictures of the ankle joint with # of lower end of fibula which was minimally
displaced.

Task was to explain the [mdings to patient.

Mr Gya ask questions about wight bearing and follow up.

Question 8 ( Insulin induced hypoglycemia)

57 year old was type 2 diabetic and recently commenced on insulin and you have booked
the appointment for him to Diabetic educator next week he is on protaphane 20 units
B.D. This morning he had brief episode of being very dizziness, nausea, sweating. Light
headedness, his friend brought him to your clinic urgently .

task is to take relevant history what test would you do in your clinic and how would you
manage the patient.

There were again 2 examiners there.

Patient told me that he went for a long walk longer than his usua130 minutes and he had
only 2 biscuits to eat and after that he took his normal shot of insulin his pre test BSL was
5.2.

He had a brief episode of light headedness he did not lost his consciousness. His friend
gave him some coke to drink but he still feells very dizzy and sweaty.

I quickly inquire about his knowledge of hypo and hyperglycemia. I ask the examiner if I
can do random BSL she said it is 3.2. I said I would give the patient a glucose drink, she
said what else I said IN line with 50 percent glucose and she said can you do something
else before you do invasive procedure of putting cannula in , so I remember from Doctors
Bag there is always glucogon available so I said I would give him injection of glucagon
and then examiner was happy.

/
She ask me what would you tell the patient not to take his night dose on insulin tonight.

Well it was bit tricky so I said the patient needs awareness of hypoglycemia and effects
of delayed hypoglycemia with exercise. There is also a single episode of hypo so I am
going to talk to my colleague about the dose for tonight.

I think that patient needs 24 hours monitering, Bell rang.

Good luck to you all.

The exams was not tough but not easy either all the examiners were very helpful and they
give you lots of cues.