Uploaded by Emenike Muonanu

KT-FEB to DEC 2019 (1)

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20th, 21st, 26th, 27th, 28th Feb 2019
20th Feb 2019
1. Man with urinary retention now coming for routine exam do focused abdominal exam and dre on
mannequin
2. Breast exam female 62 coming with lumps. 18 months ago, everything was normal there were 2
lumps in left breast
3. Knee exam of old lady having pain on walking mainly on left I found crepitus on passive movement
4. Man, with giddiness do relevant exam
5. Counselling regarding immunisation old recall
6. Ulcerative colitis counselling
7. Lady taking temazepam for 1 year now coming for refill and low mood
8. Lady coming with tearfulness husband died 4 months ago 6 mins history give dds
9. Acute mechanical back pain sensory loss on lateral side dd case with history
10. Placental abruption with IUD no fatal heart rate hx pefe dds
11. Lady 52 years coming with discomfort in feet hx give ddx not sure about this one everything was
negative just alcohol history
12. 3 weeks facial pain electrical shock like hx pefe dds it was trigeminal neuralgia
13. Delirium case daughter coming to discuss moms condition 400 km from hospital 74 year old lady
she had lobar pneumonia and on polypharmacy address her concern give causes and management
14. 12-year-old with psychogenic cough hx dds
15. Biliary atresia
16. urge incontinence
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21st Feb 2019
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Another Feedback (21st Feb 2019)
1. 30 year old lady presents with feeling Feverish for few months.
Task- History for 5 minutes. PEFE card from examiner. Tell your DDs and Dx with reason.
History - Fever- last 3 months, did not measure, low grade, with Night Sweat, Itching with no LOA,
LOW, L n B. Asked all systemic infection query from Head to toe- nothing positive. No sore throat. No
travel. No significant sexual hx. No Jaundice – all jaundice qs with negative answers. 5Ps (as
reproductive age) No positive SADMA
PEFE I think 2/3 about 3 cm cervical LN, Firm Rubbery in consistency. Rest all normal
DDs: Chronic Infection-TB, Sarcoidosis, Nasty growth-like Lymphoma, Leukemia
My Dx with reason: Lymphoma- nasty growth of blood, might present with similar feature. As from
your hx- you are feeling feverish, night sweat, itching and from the PEFE- Few LnB are present in
your neck which are showing some characteristic feature. So it could be a possibility But it is very
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difficult to confirm dx with only Hx and PEFE. It needs several tests to come to a conclusion. Reading
material.
2. 35 years old lady, 4th gravida, now at 36 weeks of gestation- presents for regular check up in your
GP clinic. (Probably she was not my regular patient.) She is regular with all her ANC checks. 18 weeks
USG was normal. Everything up to date and normal. Task- Do obstetric examination. Explain your
finding to the patient.
My Approach: Upon entering, a lady was sitting in a chair.
I introduced myself, asked her was it a planned pregnancy- she said yes, so congratulated her.
Whether she had any complain at that moment- no. I told her that today my task is to examine your
tummy to see how the baby is doing by checking baby’s heart rate and position.
Also with your consent I would like to request my examiner to be my chaperon to perform pelvic
examination. (Examiner said-No need to do PV, only abdomen you can examine)- Ok
I told examiner I would like to wash my hand – he said you can directly put on gloves cause it’s very
hard to put on gloves in wet hand.
The patient exposed the manikin beside her in the bed- it was only a gravid abdomen.
I did an overall general inspection-it was normal.
SFH-35 cm with a measuring tape, gave running commentary to the examiner, he said it’s fine for a
36 wks pregnancy.
FHR: a little clock was there, I used my stetho. It was clearly audible. I counted for 15 seconds and
told examiner it’s in normal range.
Lie- I felt like transverse lie so I told my finding accordingly
Presentation: I could not appreciate any presenting part.
Explanation to patient - I have done my examination. Baby is growing well, heart rate is good. But in
examination I felt like the baby might be in a horizontal position rather than a more common Head
Down position at this moment. It can be due to because of your previous 3 pregnancies for which
your womb might become a bit lax. There could be some other causes but as you are regular with all
your ANC checks and considering your previous test reports other causes like DM, big baby or
malformation seems unlikely.
I would like to confirm by USG and specialist referral.
Examiner told me- anything else u want to check?? I told -PV?? He said no. Then I said Vitals?? He
said-what’s in vitals? I said- BP. He said –yes, u can check. I put the cuff and bell rang. Could not
finish checking BP.
(Outside there was some vital parameters already given so I didn’t ask at 1st place…anyway managed
to pass the case)
3. 50 Years old man admitted to the hospital with cough and SOB 3 days back. Vitals given outside.
Some hx was there as well but can’t remember now.
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Task: Do respiratory examination. Tell patient your DDs and Dx with reasons.
I entered the room. An elderly patient with some real findings were there. He was sitting on the
patient bed which was really high for me to do examination. So after WIPE, I requested the patient
to come to a chair next to the bed to perform examination properly. Both the patient and examiner
happily agreed. Idid examination from back only.
On inspection- the right shoulder was slightly elevated, there was some redness in the skin, a deep
dimple was there in the back. I gave running commentary and told everything I found. Air entry I felt
a bit reduced on the lt side.
Palpation: Trachea-central, Apex beat-couldn’t feel even in leaning forward so said probably behind
rib. Chest expansion: reduced on lt, Vocal fremitus: reduced at left apex.
Percussion: Dull on lt upper zone
Auscultation: Reduced on Lt upper zone, Vocal resonance reduced on the same area.
I asked about V/S-same as mentioned in stem, no LAD, stopped smoking few years back.
DDs: Asthma, COPD, Occupational lung disease, Malignancy
Dx with reason: From my examination I could appreciate some abnormality in our upper part of left
chest. Your chest is moving less on that side, when I tapped it’s a bit dull I felt and I could hear the
breath sound reduced on that part than the rest of the chest. So based on that I am suspecting there
could be a chance of some nasty growth in that area but only history is not sufficient to come to any
conclusion. It needs some investigation to find the cause and specialist referral to confirm.
4. A 40 year old lady with DM lives in rural area, currently visiting Melbourne. Presents to ED
because of sudden drowsiness (I forgot the exact term for this case). She was on both Insulin and
oral hypoglycemic agent and regular with her check ups.
Task: History, Immediate Mx, Long term Mx.
My Approach: I entered the room and saw a lady was sitting in a chair and she was sweating heavily.
It made me alert immediately and I asked examiner about hemodynamic stability and BSL. Examiner
told me as mentioned in the stem BSL is 3.1. I then told him that I would like to shift my patient to
resuscitation cubicle, will give her 6 jelly beans, continuously monitor her vitals and check BSL after
15 minutes. Also I would like to call my registrar to have a look.
Then I asked my patient how r u feeling now?? She said much better after the jelly beans. I told her
while taking history at any point if you feel any dizziness or fatigue please let me know.
Hx: Is it the 1st time you are feeling this way? Did u take insulin at night? Had breakfast? Checked BSL
this morning?-yes. It was 6.5. So what happened next?
Went to shopping had to walk a long way. So exercise induced Hypoglycemia.
All routine qs for DM, specialist visit, feature of any complication, knows about hypo or not? Roughly
other system qs in short
Immediate Management: Explained hypoglycemia
She got this due to sudden exertion. I will now call registrar and endocrinologist for review of
medication. BSL and vitals we are continuously monitoring.
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Long Term Management: Explained early S/S of hypoglycemia
Rule of 15 for Hypoglycemia and hypoglycemia kit, Caution while driving, Regular F/U with specialist,
LSM, 4 R
5. Young lady presents with lower tummy pain during menstruation. Task- Hx for 5 minutes, PEFE,
Tell dds and Dx with reason to the patient. Typical endometriosis case
PEFE- discomfort on CMT, rest all normal
Told dds- PID, Primary dysmenorrhea, adhesion due to previous surgery but very unlikely here.
Explained endometriosis with positive findings from history and examination. 4R
6. Heartburn case same as Handbook case 142
7. 40 year old lady with known renal insufficiency admitted in the hospital because of nausea and
vomiting. She was taking NSAID for gout, ACEI and frusemide for hypertension. A long scenario was
there. Patient was already given fluid and started on treatment.
Task: Hx for 3 minutes. Ask for investigation and explain to examiner. Explain condition to patient.
My approach: The patient was lying in a bed, holding a plastic container as if she is going to vomit. I
introduced and then as usual told her I need to ask some findings from the examiner.
I asked examiner about vitals and dehydration. He specifically asked me how do you check
dehydration? I asked about eye, tongue, skin turgor- so it was moderate dehydration. Vitals were
normal.
Hx - I asked her detail about vomiting, diarrhea, urination to establish dehydration. I knew it was
hyperkalemia so asked related features like muscle weakness. Most things were already mentioned
in the stem. So just asked whether she is having any CVS feature now.
Investigation: I asked for ECG and Blood investigations. Examiner handed me over the ECG and s.
electrolytes report. Hyperkalemia with high uric acid and creatinine.
Explain to the patient: She was having hyperkalemia with moderate dehydration on top of chronic
renal insufficiency. Explained each part: kidney prob-taking ACEI+NSAID=high K,
vomiting+frusemide=dehydration
High K can be life threatening so I’ll immediately call my registrar and specialist to modify treatment
plan and manage hyperkalemia.
8. Vaginal prolapse with candidiasis- same as Karen. History, PEFE, Investigation, Explain to patient.
9. You are a family physician of a farmer who is having fear of contamination. Task- History for 5
minutes. Tell DDs and Dx with reason.
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My approach: I assured confidentiality. Then asked about his thoughts. He was having fear of getting
contamination for last couple of months and needed recurrent washing of his stuffs. On asking he
told me he was having 4 other thoughts at a time along with the contamination thoughts. He told
me all 4 where there were obvious obsession and compulsion features. He knew these thoughts
were irrational. His uncle also had similar thoughts and acts. These all started after the drought for
which he was having issues returning the bank debts. No previous history of mental disorder. No
thyroid feature or head injury.
DDs: GAD, Panic disorder, Adjustment disorder, Phobia
Dx with reason: OCD with all positive features present in this patient
10. PE station: Back pain. Task: Relevant examination. Tell DDs. Dx with reason.
My approach: Young man, back pain started after heavy lifting. I asked him about any
bowel/bladder problem to r/o cauda equina. Then offered pain killer-WIPE-checked gait-he had
difficulty walking so told him to lie down.
I started with ITPRCS approach. Examiner told me T,P normal, R-reduced on lt ankle, S-loss along S1
distribution, I checked with cotton and pin.
DDs: Cauda equina, Sciatica, Radiculopathy due to disc prolapse
Dx wih reason: Radiculopathy with disc prolapse
11. Father of a 11 year old school girl presents to your GP clinic because she was having a neck lump.
Task: History for 5 minutes, PEFE, Dx with reason.
My approach: Asked about the lump detail and the dad showed me typical enlarged thyroid shape
mass in the neck. Asked all feature of thyroid problem specially school performance, hoarseness of
voice for hypothyroidism, any LOA/LOW/LnB for malignancy. All negative.
PEFE: Diffuse bilateral firm enlargement of thyroid, Pamberton’s sign negative, rest all normal.
Dx with reason: Enlargement of thyroid most likely due to Hashimoto which is common in this age
group. She is having only enlargement now but from your history and PEFE I could not find any
feature of thyroid hormone imbalance at this point. But need to confirm by investigation and
specialist referral for proper management.
12. PE station (Pilot) : Genital examination of a young man for STI. Task: Genital examination. Explain
your further management.
A manikin was there. After confidentiality, consent and chaperon, WIPE- Inspection: all normal with
retracted penis, normal scrotum, no discharge
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In the trolly next to the bed there was a torch and folded paper so I checked transilumination along
with all the things we do for scrotal examination.
Explain the patient about STI screening things in detail including DHS notification, safe sex practice
etc.
13. (Pilot) - Mother of a 15 year old girl with known cystic fibrosis presents because of poor school
performance. History. Explain the growth chart and another chart I forgot. Management
Here the problem was some family issue. The lady got separated from husband 2 /3 months back.
Now she is upset, not taking proper care of daughter. Kids are upset with mum and not talking to
her. The girl was not doing physio properly, had recent hospital admission for chest infection, mum
kept saying-she is teenager now , capable of taking care herself.
Explained the both the charts. It was easy.
Management: Refer mum to psychologist. Referred daughter to CF clinic and child psychologist
If possible arrange family meeting. Single mother support group. Social worker.
Not sure about involving child protection authority.
14. Lady with abdominal pain and USG of cholelithiasis
15. Limping child (Spider bite?)
16. Crying baby /post natal depression Hand book case 109
26th Feb 2019
1. Acute Knee Injury - Predominant assessment area – Diagnostic formulation
A middle aged lady presenting with acute knee pain. Task – history, PEFE, DX and DDx to patient.
GS – 4
Approach – 4
History – 4
Choice and technique of examination – 5
Dx and DDx – 4
Intro, offer painkiller (patient was lying on the bed with pillow under her knee on right side)
History – patient was squatting down and when her daughter called her, she stood up and twisted
the knee. Got swelling and pain soon after that. Patient pointed the pain on medial side of the
right knee. Otherwise – unremarkable.
On PEFE
Inspection – swelling +, no redness, fixed flexion deformity +, locked in mid flexion of right knee
joint.
Palpation – tenderness on medial side of knee
Movement – Restriction of movement +
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Special tests – Patella bulge and tap test, apprehension test, anterior drawer and posterior drawer
test, varus and valgus test all negative.
When asked for apley grinding and mc murrey for meniscus, examiner said cannot be performed
because of fixed position and pain, and also patient refused to do it.
Dx – medial meniscus injury
DDx – other ligament injury, fracture, infection, chondromalacia patella, etc
2. Behavioral Complaint - Predominant assessment area – History Taking
An engineering student came here as his counselor advised him to see you. He has poor school
performance and fall in grades. Previously he was of average student.
Task – take psychiatric history from patient. Explain Dx and DDx to patient with reasons.
GS - 4
Approach to patient - 5
History - 4
Dx and DDx – 4
Patient was sitting in stooping posture, wearing a hat and looking downward all the times.
History – Introduced myself, offer confidentiality and show sympathy first. (There must be some
reasons for this poor school grades and I will try to help you in any way I can, etc). After that,
patient opened up about things like he has broken up with his girlfriend 6 weeks back, feeling
down for about 1 month, cannot rate on scale of 10 but it was really low. (in a soft voice and slow
speech) He even cried during conversation. There were tissue box, water bottle and cups nearby.
So I offered them. Let him take some time for a few sec.
-asked about other depressive features according to DSM criteria (sleep, appetite, concentration,
energy, weight loss, suicidal idea, anhedonia where most of them were positive but without
suicidal idea)
-Asked Delusion, Hallucination, thought insertion and withdrawal, insight, judgment according to
MSE – all Nil
-Cognition – Time, place, person – all good
-Asked about HEADSS and if he has support or someone to talk to. (I don’t remember exactly but I
think his family and friends are aware of this situation)
-SADMA – nil
Short Bell Rang. Examiner asked me to explain the dx to patient.
Dx – mild to moderate depression. But it is a good thing that he has support and no suicidal
ideation.
DDx as depressed phase of bipolar disorder, drug induced, schizophrenia, hypothyroid, anaemia (I
forgot to tell adjustment disorder in ddx)
Told him this is a manageable condition and will address his concern definitely and some empathic
words….
Note: This was my first station and I was really nervous. I had recall bias and thought this was the
case of OCD with King word while reading the stem. So I lost for a while when patient told me
about broke up. So I just followed the MSE format in this station. But forgot to ask about OCD and
other anxiety features.
3. Post operative Complications - Predominant Assessment Area – Diagnostic Formulation
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A middle aged woman recently delivered her first baby with Emergency CS (due to poor progress
of labour – 8 hr). Today is 2nd post op day. Vitals Chart is given – T – 38.4C, others normal. She was
given enoxaparin.
Task – History, Ask PEFE, Explain Dx and Ddx, advise her before discharge from hospital
GS – 4
Approach to patient 4, History 3,
Choice and Technique of Examination – 5
Dx and DDx – 5
Mx plan - 4
History
Ask if mom and baby are doing fine, any problem with breastfeeding,
Explain that fever +, so need to find the source of it.
Asked about discharge from down below, abdominal pain, UTI features, breast pain, leg pain, pain
and swelling at cannula site. Other general well being questions.
I forgot to ask details in discharge like foul smelling. I just got the information of some red color
discharge. No tummy pain. Others – perfectly fine.
PEFE
GA, VS- the same, Heart and lung - clear
Abdomen – incision clean and dry, uterus just below the umbilicus (again forgot to ask about the
consistency L), just slight tenderness in lower tummy.
Pelvic exam – no cervical motion tenderness, unremarkable
Urine dipstick – leucocyte 1 +, RBC + (I was really confused here with UTI as examiner mentioned
leucocyte)
Breast, leg and cannula site – all normal
Dx and DDx
Due to my anxiety, I missed important information like discharge details and uterine consistency.
Therefore, I told many possibilities like endometritis, UTI, DVT, mastitis, thrombophlebitis, post op
atelectasis, incision site infection.
Mx
Inform seniors, will do further investigations like urine test and USG. And give her antibiotics.
After fever drops, she will be able to go back home.
Give advice like baby vaccination, lactation and regular follow up and also offer for contraception.
Though I wasn’t sure of the diagnosis, luckily I passed this station thanks to examiner.
Another recall - Post op fever Key-4,5,4,5,4
Baby delivered yesterday c section. Want to go home. she is on enoxaparin for dvt profilaxis.
Observation chart givem outside. (temp increasing.other vitals normal). Tasks- hx, pefe, dd and dx,
mx in brief
Asked abt baby. she is fine. then asked about post delivery fever couses - nothing positive except
some vaginal discharge. Ex positive for uterine fundus at umbilicus, few bleeding + brownish
dishcharge. Said endometritis+retained placental parts. Will inform obs team. may need Ab and
ERPC. Didn’t mentioned about enoxaparin.
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4.
Mental
Health
Assessment
Predominant
assessment
area
–
Management/Counselling/Education
University student with some maniac features given on the stem (feeling happy and elated,
energetic etc)
Task – History, dx and ddx with reasons, Mx plan to patient
GS – 5
Approach -4
History -4
Dx and DDx – 5
Mx plan – 5
I also asked like in depression case with MSE approach with HEADSS.
Positive findings were high mood, energetic, multiple sexual partners, practiced safe sex
sometimes, no drug use, unsure about alcohol?) At the start of conversation, patient mentioned
that teachers at university are not qualified enough to teach them and need to replace them.
Patient was really cooperative and looked really happy. :D
Told Dx as acute mania (explained in layman terms in association with her symptoms)
DDx – maniac phase of bipolar disorder, schizophrenia, psychosis, drug induced, anxiety disorder,
hyperthyroid etc.
Mx – need to be assessed by psychiatrist. After confirmation of dx, patient might need to take
some medication to improve the symptoms,
Patient asked me do I really need to take medication, any other option available?
Any reason that you don’t want to take? Medications are really effective for this kind of condition
and we only give if benefits outweigh the drawbacks and make sure that there is minimal side
effects. also mentioned CBT and support are available. But definitive tx will be decided by
specialist. Explained in a very careful way so as not to insult the patient. (I don’t remember if I
mentioned about alcohol cessation or not)
5. Abdominal Distension - PAA – Examination
A middle aged man patient has undergone elective herniotomy for right sided inguinal hernia 6 hr
ago. Now complaint of abdominal pain.
Task – Perform abdominal examination, Explain Dx and DDx to patient
GS – 4
Choice and Technique of examination – 4
Accuracy of examination – 4
Diagnosis and DDx - 4
I was totally unorganized in this case. I’ll just share what I did during examination.
There was a dummy on examination table. Patient was sitting aside wearing a gown.
Introduced myself. I was about to wash hands but they put a notice over hand wash area to use
gloves. (three sizes available)
Expose the gown over the dummy. There was a dressing over the right inguinal area.
Started with Inspection – abdomen moves with respiration, no flunk fullness
I asked the examiner if allowed to remove the dressing to check incision site. (not remember what
the examiner said, may be it was normal)
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Ask the patient to cough, ask whether it is painful or not, he said painful. (I mentioned rebound
tenderness present, Examiner asked me did u mention rebound tenderness? Patient just coughed,
how would u know whether it was rebound or not) He said something similar like that. So I was
alarmed. Okay Then. So I just mentioned hernia orifices are intact. :D
Palpation – (always ask the patient to point the painful area first), Patient said unsure.
Said I’ll try to be gentle and did light palpation. (Tenderness in SPA +). (honestly the dummy feels
slightly different than human body, so I couldn’t differentiate much whether there is a mass or
not, but it feels slightly tense in SPA region)
I pressed in SPA and asked if there’s any urge to void. (No). Is there any urination after the
surgery? (No). I asked examiner if there’s any catheter inserted after the operation? (he said go
ask your patient). Patient said No.
I did deep palpation for liver and spleen and the percussion. I didn’t percuss over SPA as I didn’t
feel a real mass over there. I percussed over chest for obliteration of liver and cardiac dullness.
Then listen to bowel sound.
I didn’t do any special test here as I could think of only whether it was bladder retention or post
op complication like leakage or injury to nearby structures.
I asked examiner to check private areas to check any vesicles or ulcers. Any discharge. All nil.
Explained to patient – most likely to be bladder retention. Others – could be leakage for suture
sites, bleeding, injury to other structures. Patient was so nice, he seemed to understand well. :D
Then I remembered I need to do proper rebound tenderness again. I asked examiner that can I
perform again? He said ask your patient again. Patient approved. while I was doing rebound
tenderness, Bell rang. Thank both of them.
Note: Examiner couldn’t hear me well. I needed to repeat and speak louder here.
Another recall - Post op abdominal pain. Key-4,4,5
Old patient underwent R/ inguinal hernia repair 6 hours ago complaining of tummy pain. Task –ex
for 7 min, explain the DDx and diagnosis
An old man sitting on the chair near the be d. A manikin on the bed. I did some general ex on
patient like checking temp and pallor. (not even checked BP or pulse) then straightly went to the
abdominal ex. Superficial non tender. Deep suprapubic and umbilical tenderness+ I felt hardness
and distention on those areas. I squeezed little bit and asked weather he get the feeling to pass
urine. he said yes. I asked examiner that I want to check penis and do PR cause I’m suspecting
distended bladder. He said they are normal. Checked for bowel sounds and wound. Those are ok.
Explained the patient he has distended bladder due to urine retention. Most probably due to lack
of locomotion and pain. Surgical wound infection, intestine obstruction, acute gastroenteritis,
adjacent structure damaged said as DD and said they are unlikely according to the examiner
findings.
6. Dysuria - PAA – management/counseling/education
Dysuria – Key-6,7,7,6,5
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a man at 40es c/o dysuria for few days. Circumcision done . urine dipstick results given. Blood+,
protein+, nitrites+, leucocytes+ (NOT MENTIONED ABOUT KETONE BODIES) PENICILLIN ALLERGY+
TASK - HX , explain the DDx with ix u would order. Outline the mx plan.
Few days hx of dysuria. Frequency and nocturia. No LUTS .SEXUAL HX, SX, Med hX, uneventful. No
DM feature .no cancer, BPH hx no fx.
Said according to the dipstick mainly UTI. Reason for UTI could be DM , STI, PROSTATE PROBLEM,
BLADDER CA, calculus disease. Nephrotic and nephritic mentioned as other dd.
Order UFR and culture, PSA, USS KUB, RENAL FUNCTION TESTS, FBS.
As management said will give Ab (nitrifuranton or trimethoprine due to penicillin allergy) will
manage accordingly if underline cause found. Take plenty of water.
7. Visual Problem - PAA – Examination
A man with past history of Hypertension and DM came here for sudden onset of double vision.
Task – Perform PE, Dx and DDx to patient
GS – 5
Approach to patient – 6
Choice and Technique of examination – 5
Familiarity with test equipment – 5
Accuracy of examination – 5
Dx and DDx – 4
I had this bad habit of recall bias. Again thinking this might be the case of mono ocular diplopia
with retinopathy changes.
Inside – Greet the examiner, wash hands. Started with Inspection of the eyes
Then do palpation for eyeball muscles tenderness.
Visual acuity tested with Snellen chart. All Good.
Visual field test with red tip pin. Normal.
Then I explained about fundoscope. (put some eyedrops to dilate pupil, dim the light, etc.)
Fundoscope was on the table. (I switched it on and adjusted the lens for some time :D) Examiner
stopped me and said fundoscope normal. (Damn, I was expecting some abnormality).
I proceed for 3rd, 4th, 6th CN examination – direct and indirect light reflex, accommodation reflex –
all normal.
Diplopia – patient had diplopia when I moved my finger to his left side. I asked whether the two
images are vertical or horizontal to each other. Patient confused and looked at the examiner. He
said it’s just double vision. It’s okay.
Then I tested one eye after another. The diplopia gone. So I mentioned binocular diplopia present.
I forgot if I asked for slit lamp and IOP measurement or not. But I asked for color vision chart.
(examiner said normal)
I started explaining about binocular diplopia in layman terms again. It took some time and I only
got to say the causes like eyeball muscle weakness or 3,4,6 CN palsy. Bell rang.
Another recall - Eye examination Key-4.5,5,5,5
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old patient with uncontrolled DM complaining of diplopia. Task-do eye examination for 7 min,
explain DDx
First checked visual acuity with snellan. (it was hang on the wall) vision 6/6 B/L.
Then did visual field. Pupil check-N .then check eye movement. Left lateral sided diplopia was
there.i asked to close one eye and diplopia was disappeared. Then checked fundus –N.
SAID NEED TO DO THE SLIT LAMP EXAMINATION AS WEL.
Explained binocular diplopia and lateral rectus muscle palsy as the most probable reason. Most
probable cause for it is uncontrolled DM. other causes like brain tumors, strokes also mentioned
as reasons for lateral rectus palsy.
8. Back Pain - PAA – History taking
A man presenting with acute severe low back pain. Task – history, PEFE, Dx and DDx to patient.
GS – 4
History 4
Choice and technique of examination – 3
Dx and DDx – 4
Patient was lying on the bed. Offered Painkiller. He said already taken.
Start with Pain History – very severe. He had an episode of renal colic and this was the 2nd most
painful one after that. The pain went down the left thigh from back. It started after lifting a heavy
weight in a shopping center. No associated weakness nor tingling numbness sensation.
No history of direct injury to that area. No bone or joint problem.
He has past history of hypercholesterolemia so taking medication. (may be atorvastatin)
Other history – unremarkable.
PE
GA, VS, BMI (I think 26?)
Local area – no injury, no deformity
Restriction of movement of back +
Tenderness + in Low back (not in paraspinal area)
SLR 40’ on left side, 60’ on right side.
Faber’s test –ve, Lower Limb neuro (tone, motor, power, reflex, sensation all good)
I forgot slump test.
Dx – sciatica
DDx – other lumbar radiculopathy like lumbar disc prolapse, spinal canal stenosis, ankylosing
spondysis, injury, fracture, mononeuropathy, muscular pain etc.
Another recall - Acute back ache Key-5,5,5
old patient c/o acute back ache since today morning. Task-take short hx, pefe, explain the
diagnosis and DDx.
Old man was lying on the bed. He did some lifting of heavy box today morning and felt a sudden
back pain following that. now difficult straight his back. No weakness or numbness in the legs.no
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bowel, bladder incontinence. While I’m asking the hx suddenly he said “dr. I’m worried about
aneurysm. my father died from aneurysm last month. I showed some sympathy and asked where
was the aneurysm. He said in the abdomen. Then I realized he talked about AAA. So I took short
hx which is relevant to AAA. He has high cholesterol and only on diet control. No tummy pain. no
any other diseases.
Examination-ROM of low back limited in all direction. No reproduction of numbness of leg with
lateral movement of the back. SLR positive for both sides. Left leg 60’ and right leg 40’.
Neurological examination otherwise normal.
Said mostly mechanical type back pain. disc prolapse little unlikely cause bilateral sciatic nerve
compression uncommon. SLR limitation in both legs most probably due to the mechanical pain.
Because he does not have any sensory symptoms of the legs. Other DDx are ligament tear,
vertebrae #, muscle sprain. Finally talked about his further ix to exclude AAA and said will repeat
cholesterol level as well.
9. Vaginal Bleeding - PAA – diagnostic formulation
57 years old lady presenting with vaginal bleeding last week. USG and blood tests were done and
results given below.
Hb – 130, USG – endometrial thickness 11mm, others normal
Task – History, PEFE, Dx and DDx to patient.
GS - 5
History – 5
Choice and technique of examination – 4
Interpretation of investigation – 6
Dx and DDx - 5
History – asked bleeding and 5 Ps (past Obs history, pills (HRT), pain in tummy or after intercourse,
pap smear, partner)
+ve findings – bleed for 5 days, which happened last week, now stopped, only soaked a few pads.
No SOB or anaemic features, Menopause for 5 years, 1st time bleeding after menopause, pap
smear stopped 5 years back. Mild discomfort on sexual intercourse. other history – unremarkable.
PE
GA, VS, BMI
Anaemia (not remember the findings)
CVS and lung – normal
Abdomen – clear
Pelvis – normal except uterus bulky, atrophic changes +
Dx – endometrial hyperplasia (in post menopausal woman, it is expected that the lining of the
womb should be less than 4-5 mm, now in your case it’s 11, so it is thickened. Called hyperplasia,
but it can sometimes mask the underlying cancer, so need further investigation like taking tissue
sample from womb, but this will be decided by specialist. I explained further mx in short)
DDx – Ca endometrium, Ca cervix, polyp, myoma, cervicitis, vaginitis, bleeding disorder, blood
thinning medication
While I was explaining Ca cervix, examiner interrupted me, said pap smear was taken during Pelvic
examination and it showed normal. :D
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Another recall - Post menopausal bleeding Key-5,5,5,4
56 years old lady. USG done endometrial thickness 8 mm. Task-hx ,pefe, explain dd
Menoupouse 5 years ago. bleeding few days. 1-2 pads per day, fresh blood. No tummy pain.
Sexually active. Mid pain with sex intercourse, pap done 5 years back. Was normal. No hx of
cancers,not on drugs,All other hx negative.
Pefe-mild aneamia+,ab ex-N, mild vaginal atrophy,cervix-N , uterus little bulky( as I remember)
dd-talked abt endometrial hyperplasia,ca, cervical polyps /ca/erotions and atrophic vaginitis as
dd. Mainly talk abt first 2 dd.
10. acute fever - PAA – examination
Young male presenting with fever and painful swallowing x 1 week?
Task – perform PE, Dx and DDx to patient.
GS – 4
Approach to patient, examination, familiarity with equipment, accuracy of examination, dx and
ddx – all 4
Patient was sitting on bed with gown. Patient didn’t say a single word throughout the
examination.
There was a one sided head dummy on the other table with otoscope, otoscope specula, tongue
depressor and torch given.
Greeting, Hand washing, start with inspection on face, eye, and ENT.
When I was about to check throat, examiner showed a pic of tonsillitis with white exudates.
Uvular in midline.
I checked external ear and then perform otoscopic examination on dummy. (you need to choose
the largest specula, but what I saw is all the covers were of the same size). Frankly, I could not see
properly, but it is likely to be red tympanic membrane, but I mentioned like it’s normal :3)
I asked the patient if he has any hearing problem. (no) so I skipped hearing test. (I think I
mentioned the reason for skipping it)
Then palpate on mastoid for tenderness and for cervical lymphadenopathy, (1-2 tender cervical
LNs +ve, soft in consistency)
I asked for other LN enlargement and rashes all over the body. (nil)
I am not sure if I asked for splenomegaly finding for EBV and indirect laryngoscopy for epiglottitis
That’s all I can remember for this station.
Explained the dx of bacterial tonsillitis (I didn’t mention OM), DDx – viral tonsillitis most likely EBV,
other viral infection like herpes, epiglottitis, pharyngitis, STD
Another recall - Acute fever +saw throat Key-5,4,5,4,4
young man complaining of fever and saw throat for few days. unable to eat and drink due to pain.
Task - relevent examination + ear examination. Explained DDx.
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Young boy was in the bed. Did not talk a single word. only head nodding for my questions. I check
temp by putting my hand on his forehead. It was normal then look for pallor, icterus rashes. Then,
did cervical lymphadenopathy. examiner said tender cervical lymph nodes positive. Then checked
axillary lymph and said need to check inguinal lymph nodes. Examiner said they are normal, then
went for the throat examination. I forgot to put gloves. when I asked him to open his mouth
,examiner showed me a photo of throat. (same photo of the hand book case) I explained it to the
patient. uvula not deviated, tonsillar enlargement +with exudate.
Then when for the ear ex. asked for hearing, webar and rinne. examinar said normal. then did
inspection and palpation of the ear on dummy and then did the otoscopic examination to the
dummy. hypereamic TM was there. no discharges or perforations. Explained as mostly u have
bacterial tonsillitis +ACUTE OTITIS MEDIA.
DDx-glandular fever. irritant tonsillitis due to chemical burn. STD due to oral sex. but those are
unlikely according to the ex.
11. Periodic Health Review - PAA – Examination
A middle aged man was about to donate blood, but BP is high on different occasions.
Task – CVS examination, Dx and DDx
GS – 5
Approach -5
Choice and technique of examination – 5
Accuracy of Examination – 5
Patient Counseling/education – 4
Greet, Hand wash, Patient already in 45’.
I will examine today to find the cause and effect of high BP in you.
Start examination with hands (pallor, cyanosis, clubbing, pulse – rate, rhythm, volume, character,
equal on both sides, radiofemoral delay) (sweet examiner helped me with the clock, she held the
clock near me J)
I think I mentioned I will measure the blood pressure at the end of examination.
Then Eye (pallor, jaundice, hypercholesterolemia features) and mouth and neck for thyroid gland
enlargement. No cushingnoid face.
Proper CVS examination on chest –
Inspection – visible pulsations, deformity, etc
Palpation – locate apex beat, palpable thrills in all 4 areas
Auscultation – in 4 area, check pulsus deficit
Check neck for carotid bruit and pulsation, JVP
I would like to listen to back for basal crepts (I think examiner skipped that), so I proceed with
abdomen, she said inspection and palpation all normal. But you can proceed if you want.
I asked I would like to lower down the bed. She said examine in this position.
I listened for aortic, renal and femoral bruit.
I would like to check Lower Limb for any pitting oedema. Examiner said Not present.
Then I check the BP. BP cuff was detached from the pumping balloon. I wasted some time trying to
reattach it. While I was putting the cuff on pt’s arm, short bell rang. Examiner said one min left.
You can explain.
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I continued measuring the BP quite fast. (actually should have switched to next task) BP was like
160/70. May be I was wrong in measuring as other candidates mention that BP was normal in that
case. :(
Explained that most likely to be essential hypertension. Sometimes can happen secondary to
hyperthyroid, RAS. Then times up.
Another recall - CVS EX - Key-4,4,4,4
45 old patient found to have high BP in several check-up in several places. Task- CVS ex 7min,
explain the condition with DD.
Patient was in the bed with 45’ angle. We have to measure the BP. BP 140/80. Then, did
examination according to the tally o’ corner (not done all the parts). I did not have time to explain
the condition. just said he has high BP. Mostly essential HT
12. First Trimester Complication - PAA – Diagnostic formulation
11 weeks pregnant woman, G1, come to clinic for vomiting. Antenatal Invx done – all normal. USG
scan – Not done/result not come back yet.
Task – history, PEFE, Dx and DDx with reasons to patient
GS - 5
Approach – 4
History – 4
Choice and Technique of Examination – 4
Dx and DDx - 5
History
Vomiting and BPV +, fresh blood, not contain vesicles nor tissues. No dizziness, SOB, no tummy
pain.
Previous menstrual cycle – regular, LMP – 11 week
Took folic acid, pap smear normal,
No injury to tummy, No bleeding disorder, BTM
PE
Uterus 16 weeks size, os closed, Urine dipstick – ketones +
Otherwise, unremarkable.
Explained Dx – threatened miscarriage, hyperemesis gravidarum, twin pregnancy, H mole, wrong
date, incomplete miscarriage, UTI, GE
Another recall - First trimester complaint Key 4,4,4,5
11 weeks pregnant lady come with vaginal bleeding, dating scan not done yet. all the first
antenatal ix normal .nausea and vomiting+. Task; hx, pefe, dd and diagnosis.
Asked about bleeding - 2 tea spoons fresh blood. started yesterday.no tummy pain.
Haemodynamically stable. No hard particles, no grape like structure, no other discharge. no
truma, no bleeding disorder. all other negative. Didn’t ask about ix results since its mention in the
stem. Vomited several times
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Pefe - general–N ,abdomen uterus felt at umbilicus leval. non tender. Speculam –mild bleeding
from os .os closed uterus bulky as 18 weeks. Mild dehydration+, ketone bodies +v (asked one by
one)
dd- Said as multiple pregnancy with threaten miscarriage, trophoblastic disease or wrong dates
with threaten miscarriage + hyperemesis.
13. Falls - PAA – history taking
72 year old male, brought in by daughter, due to fall.
Task – History, Explain Dx, DDx to patient with reasons
GS - 6
Approach to patient - 4
History - 5
Dx and ddx – 7
History
3rd episode of falls, all 3 times were associated with position changes. Patient explained all
episodes scenarios.
Before fall, he had lightheadedness, some grayish vision +, no LOC, no weakness after fall, no
headache, No SOB, No chest pain,
No past history of head injury, heart problem, DM nor Hypertension, No bone and joint problem,
Not taking any medication
All other history – nil
Dx – postural hypotension (also explained causes like aging, or consequence of DM etc, we still
need to confirm and find the cause of postural Hypotension)
DDx – vasovagal syncope, Heart rhythm problems and structural diseases, IHD, Hypoglycemia,
epilepsy, Head injury, stroke, mini stroke, infections inside the brain, etc
I left early in this case, got a lot of time here.
14. Feeding problem - PAA – Mx, counseling, education
Breast feeding - Key-6,6,6 - Task -take short hx and counseling- HB Case
15. Burn - pilot
A hot noodle soup fell accidently over the 2 year old baby and brought to ED by father.
Task – History, PEFE card will be given, Dx and Mx plan to father.
History – child was sitting and reaching the noodle soup on the table. Then it fell. Father run the
water over the chest and brought to ED as soon as possible. Child is crying very much. Mother is
on the way to hospital. Other history unremarkable. I suspected child abuse and ask the
possibility, father denied.
PEFE card– blisters and erythematous area present over the chest, about 11 % of Body surface
area, airway not involved. (a drawing of human body with spotting of the burn area on card), pain
score – 10/10
Mx – I mentioned it is superficial burn, appreciate father for bringing in here asap. need
admission, will inform seniors, effective pain mx, dress the area, investigation for fluid and
chemical balance and will replace if necessary, AB cover if directed by specialist, will involve CPA if
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anything suspicious to prevent further incident (said something like that as I couldn’t put down
the idea of child abuse :D, luckily this was pilot)
16. Hemoptysis - pilot
Middle aged man presenting with coughing up of bloods. Task history, explain dx and ddx to
patient.
+ve findings –
He just came back to Australia a few weeks back. Cough up blood for the first time last week.
Fresh blood. Amount – about a cup/spoon (I forgot)
Past travel history to Cambodia for work, kind of office work, cough very occasionally, night
sweats and weight loss present, but no appetite loss, (symptoms + for 4 months)
No heart symptoms, other voice changes and difficulty swallowing – nil,
No smoking history, no cancer history, no lumps or bumps over body, no history of similar
problems in workmates or family
SADMA - nil
Told Dx as TB,
DDx – CA lung, Other infection like pneumonia, heart failure, throat erosion, bleeding disorder
27th Feb 2019
1. Change of consciousness - Pass
GS: 6
Approach: 6
Interpretation of investigation: 6
Dx/DDx: 6
Patient Counselling/Education: 5
HMO at ED. A teenage boy was brought in by father because of fever, headache, drowsy,
hallucinations, changes in behavior. He also had an attack of fits.
On PE, T – 37.8 C, no neck stiffness
Inv were done, FBC – high WBC
ESR, CRP – high
BSL – normal
CT brain – normal
Drug screening – pending
Lumbar puncture – WBC increased with lymphocytes – 90%
Glucose – normal
Protein – a little bit raised
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Patient’s father is here to talk about his son’s condition.
Tasks: Explain the PE findings to father
Explain the Inv results to father
Dx, DDx
Implications of the condition.
Greeted the father of patient.
Reassured him – I know you must be very worried of your boy. His VS at the moment is good. We
will also make sure that he is fine and kept him monitored.
Then I explained by linking the findings on PE & history with Inv results in detail.
Dx – Viral Encephalitis
DDx – Tuberculous meningitis, Bacterial meningitis, Viral meningitis, Haemorrhage, tumour,
abscess, hypoglycaemia, drug overdose
(Gave reasons why they are less likely)
Implications – if left untreated, the condition might get worsened; recurrent seizures, fall, head
injury.
Since he is at the hospital, we will make sure none of these happen to him.
Reassure
Always recheck understanding
Another Feedback - 20 year old boy brought to ED after behaving inappropriately and having a
seizure attack. Vital signs are given (stable, but not too good) Invx were done. FBC - high WBC,
ESR,CRP - high
Blood Glucose – normal, Urine RE – Normal,CT ( Head) – normal, Lumbar Puncture - WBC increase
with 90% lymphocyte , I don’t remember the rest ( I'm so sorry for that)
Urine and Blood Drug screen – pending. Patient's parents are here.
Task : explain patient's father about the investigation result , PDx and DDx
-ask about power of authority ( yes)
-what do you know about your son's condition , reassure
-explain about investigations well ( explain everything,please don’t just focus on LP,that's the
main task)
-I gave the diagnosis of Encephalitis , DDx - meningitis ( viral,bacteria) , other causes of fits (
epilepsy,hypoglycaemia,drug,brain abscess,brain tumour,etc.)
-impl
Approach - 5, Interpretation - 6 , Dx/DDx - 4 ( I wasn't able to interpret whether it was viral or
bacterial at that time, I only said encephalitis ) , Patient Counselling - 5
2. Behavioural change – Pass
GS: 6
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Approach: 6
Dx/DDx: 6
Counselling/Education: 5
You are a GP. The next of kin of a 80 years old woman, who has been diagnosed with lobar
pneumonia and heart failure, is here to see you. Patient is on a number of medications, antibiotics
and others (I can’t remember). Patient is being agitated, disorientated, talking and shouting in
Greek. VS given – SpO2 93% on 4L of O2.
Tasks: Explain the condition with reasons to next of kin.
Explain possible reasons of the condition.
Discuss Mx plan.
Greeted the next of kin of patient.
Explain it is because of a condition we called Delirium, which is a state of cloudy consciousness,
and patient is not orientated to time, place and person.
That is why your mother is behaving like this.
Possible reasons
There are a number of reasons which can lead to this. In your mom’s case, according to the notes,
probably because of low oxygen in blood – hypoxia, Pneumonia – infection of lung tissue, Heart
failure
Others like – septicaemia, side effects of medications, drugs & alcohol withdrawal, electrolytes
imbalance
Mx
Your mother needs to be admitted to the hospital.
I’ll have the psychiatrist team & seniors informed.
At the hospital, the team will run some Inv and correct if any of them turns out to be abnormal.
Review the medications & adjust if necessary.
In the meantime, her VS will be monitored.
Most importantly, her room need to be quiet and the light need to be dimmed; make sure the
objects kept in the room are familiar to her; only people who are closed with your mother should
stay with her.
At this point, the role player asked “Should we talk to mother in English or Greek?”
I asked, “In which language do you guys usually communicate with?”
RP said, “in English, my mom can speak English fluently”.
I said, “since she is familiar with English, then talk to her in English”.
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RP doesn’t seem to be satisfied and said, “but Dr, my mom’s first language is Greek”.
I said, “Ok, so it would be better if you can speak in Greek with her”.
Another Feedback - Approach - 5 , Dx - 6 , Patient counselling/education - 5
80 year old Greek lady was admitted to hospital yesterday for basal pneumonia, she is a smoker.
She was given antibiotic and was getting better, but now she is getting restless and acting
aggressive. She is a fluent English speaker but now she is only talking in Greek. Talk to the
daughter. Task : Explain Dx and possible causes, Explain immediate management of her condition.
-Dx - Delirium, causes - hypoxia due to pneumonia, other respiratory causes like
atelectasis,PE,COPD, plus all other causes ( hypo,hypoglycemia,natraemia,volaemia, heart causes,
brain causes, infections, drug, alchohol withdrawal,etc.,I gave like 15 causes)
Mx - we will try to calm her ( might need sedative) , let her stay at a private room, make sure the
light and noise are minimum, monitor continously, familiar face like family member to be with her
all the time, if not, one-on-one nursing (if possible same nurse all the time)
Daughter ask "what language should I use to talk to her,greek or english?" I said Greek because it's
her first language so she will be more familiar in it. " Can I be with her in the room?" I said yes,it's
better because she will be more calm when she sees her daughter,etc.
Then, we will run some investigations and liaise with specialist and treat the underlying cause
according to findings.
3. Hand problems – Pass
GS: 6
Approach: 4
Choice & Technique of exam:, organisation and sequence: 5
Accuracy of Examination: 6
Diagnosis/DDx: 7
You are a GP. A 35 years old man, complaint of pain around left elbow and tingling, numbness on
the left hand.
Tasks: Perform upper limb neurological examination
Dx, DDx
(Cotton wool, tooth prick, hammer given)
Greet the patient.
Explain & take the consent for PE. Ask whether he is comfortable at the moment.
Wash hands
General appearance, VS
Look – normal
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Feel – temperature – normal
Tenderness – whether any painful area? (No) so I skipped
Then I started the neurological exam: of upper limb
(compare & start with the normal side)
Tone – normal
Power – shoulder abduction, elbow F, E, wrist F, E, thumb, fingers opposition, grip - all normal
Sensation – loss over left ring & little finger
(according to dermatone with cotton wool)
I forgot to check the bicep & tricep Jerks.
Special tests – Tinel test over left wrist for carpal tunnel $ - negative
Tinel test over left cubital tunnel – positive
Dx – Cubital tunnel $ - explain
DDx – carpal tunnel $, nerve impingement under the armpit, or over the neck like cervical
spondylosis, cervical disc prolapse
Another Feedback - Approach - 5 , Choice & technique - 4 , accuracy of examination - 5, Dx/DDx, 5
24 years old complaint of pain around elbow and tingling and numbness in hand
Task - perform examination , Dx to patient.
-greet,wash hand,consent
-ask him which side(right side), which specific area in hand ( he said I don't know there is tingling
in hand)
-he is sitting on bed, I put the pillow in his lap and ask him to put his hands on pillow
-inspection of both hands and elbows ( normal)
-palpation of both hands and elbows ( temp, tenderness)
-sensation of hand with cotton wool ( ulnar,median,radial nerve) ( loss in ulnar +)
-power of ulnar,median,radial ( all normal)
-tinel test on cubital tunnel and carpal tunnel ( + in cubital tunnel)
-elbow flexion test ( - )
-Dx - Cubital tunnel syndrome
DDx - carpal tunnel syndrome , peripheral neuropathy
-Wash my hands and go out
Side notes - I forget to do phalen test but you should do it.
-some said they don’t get positive findings on tinel test on cubital tunnel ( please please make sure
that you tap on the right spot because I was doing at the wrong spot for so long and only know the
correct one 4 days before the exam, please find the reliable source now and check whether you
are doing it right)
-elbow flexion test might be negative because it has to be done at least 1 min to 3 min to
reproduce the symptoms
-don’t forget to wash your hand before and AFTER examination
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4. Leg swelling - Approach - 5 , History - 5, Dx/DDx - 5
Middle aged man complaining of leg swelling
Task - History, PEFE, Dx/DDx.
History - for around 1 month, both legs, up to his calf, worse at the end of the day, becoming
worse
- facial oedema + in the morning ( no other oedema in other part of the body)
-no pain,fever,redness,insect bite,injury
-breathless on doing exercise but not too much, not breathless at rest, no inhibtion of daily
activities due to this , no orthopnoea, sleep with one pillow , no waking up at night due to
breathlessness
-has to go to toilet at night more frequently and it's annoying for him , no other urinary symptoms,
no recent flu or any infections
-no jaundice,not alchoholic
-no allergy,normal nutrition
-no hypertension,no DM
PEFE - card is given
BP - 150/90mmHg, PR - normal , SpO2 - normal, RR - normal
Urine dipstick - Protein (+++), Leucocyte (-) , Nitrite (-) , RBC (-)
Dx - Nephrotic syndrome
DDx - Chronic renal disease, Congestive heart failure
- Chronic liver disease, Cellulitis , DVT , Injury, Angioedema, Nutritional deficiency
Side notes - I was convinced it's heart cause until I saw the PEFE card, my mind was blank but I told
him it's probably kidney disease and he ask me what kidney disease, then I said it can be nephrotic
syndrome because of the very high protein in urine and facial oedema)
5. Incomplete Miscarriage – Unscored
You are a GP. 27 years old lady complains of vaginal bleeding.
Tasks: History, PEFE, Dx, Ddx
Checked stability – VS - stable
History – happened this morning, have to used to 2 pads, no blood clot, no vesicles, no tissue,
tummy pain + initially but not now
Severity – not dizzy, no cold, clammy extremities
LMP 8 weeks ago, pregnancy test done at home +ve
PEFE – VE – no active bleeding
On SSE – os open, tissue present at os
BME – uterus 6weeks size, no cervical motion tenderness, adnexa clear
Dx- incomplete miscarriage
Ddx – threatened miscarriage, H.mole, Ectopic, bleeding disorders, side effects of blood thinning
medication
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6. Weight loss – Pass
GS: 5
Approach: 6
Interpretation of Inv: 4
Dx/DDx: 6
Choice of Inv: 5
A 80 years old woman comes to your GP for the result of investigations done in the last visit when
she complained of dyspepsia and weight loss. She has history of cholecystectomy 2 years ago. On
PE, liver is enlarged.
Inv shows – HB reduced, MCV, MCHC reduced
CT abdomen is given – multiple black shadows over the liver
Tasks: Explain the test results to patient
Dx, DDx
Tell the patient further Inv you would like to do.
Explain Inv
Explain anaemia, CT abdomen – explain identification, quality, normal anatomy, we expect the
surface of liver to be smooth, but we can see multiple blackish shadows over your liver, that’s why
I am thinking of the nasty condition, which is the cancer inside the liver
Patient looked shocked and started to cry – offered tissue & asked if she want some water,
showed loads of sympathy
Asked if she is ok to continue the conversation, she said ok
Continued explanation – the cancer is more like spread from a primary source, we called it
secondary metastasis
So we will need to find out this primary source, draw diagram & explain
It can be from the stomach, upper or lower bowels, pancreas, lungs.
Inv – blood test like tumour markers, LFT, RFT, gastroscopy, colonoscopy, liver biopsy, CXR
From now on you will be managed with a multidisciplinary team.
Patient was crying throughout the conversation, reassured her
Another Feedback - Global score – 4 Approach - 5 , Interpretation - 3 Dx - 4, Invx - 4
80 year old woman came to the GP one week ago due to some complaint ( weight loss or
indigestion) and you order some investigation. Now,she came for result.
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FBC - anaemia + , CT (Abd) - Liver mets +
Task : Explain the investigations, Dx, Invx
-I recall the reason she came here and explain FBC result first,then the CT.
-Dx - Secondary liver mets from primary cancer elsewhere ( lots of sympathy like any breaking bad
news case, water,tissue)
-Invx - CT (Chest,Pelvic,Head), Tumour markers, Upper and Lower GI endoscopy, PET scan, other
basic
7. Failure to conceive – Pass
GS: 4
Approach: 5
History: 4
Counselling: 4
You are a GP. A 30 years old woman trying to get pregnant and it has been 12 months. Today she
come for CST which is normal. Husband is away for work currently.
Tasks: History
Explain possible reasons
Further management including investigations
History
Offered confidentiality
First marriage for both of them, no child before
Both are healthy, no problem with sexual intercourse like pain & bleeding
Husband comes back from work only one week in a month
Not aware of the best time to conceive
Period is normal, every 28 days, regular
no history of STI or gynaecological procedure
Ruled out hyperthyroid, exercise, anorexia nervosa, prolactinoma, PCOS, POF – all negative
Cause – probably because the time you have sex doesn’t meet with the fertile period, infrequent
intercourse
Mx
First, to make sure you don’t have any problem, I would like to run some Inv for you, like day 21
progestrone, TFT, prolactin, USG
From now on, you will need to have more frequent sex, at least twice per week.
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Awareness of the fertile period is important, which is the around 12-14 days before the next
period.
You can check this by measuring your body temperature, which tends to increase during the fertile
period.
Or checking the discharge from down below – becomes increase in amount, wet, clear, stringy &
lubricative
Or you can simply check with an ovulation kit.
I’ll see you again when the results are ready & please bring your partner in the next visit.
We can try this method up to a year, and unfortunately if this doesn’t work, we can help you in
many other ways.
Another Feedback - Approach - 5 , History - 4, Counselling - 4
29 year old woman come to your clinic because she has been trying to conceive but fails to do so.
Task : History, Explain possible causes, Invx,Mx
History - trying to be pregnant for one year, never been pregnant, husband hasn't done any test
for infertility before, husband doesn't have any kids too.
-not aware of fertile period, husband away for work, only come back for 5 days a month, but have
frequent sex during that time
-no positive finding for PCOS,primary ovarian insufficiency,stress,eating,exercise induced,
asherman's,hyperprolactinaemia
Cause - not being aware of fertile period and infrequent sexual intercourse
Invx - Day 21 progestrogen to make sure you are ovulating, USG to detect any abnormality,
hormones like prolactin,testosterone,oestrogen, TFT ( I forgot to mention FSH,LH)
Mx - I explain about the fertile period ( when you are ovulating, highest chance of getting
pregnant)
There are some methods to detect it, 1.ovulation kit ( buy from pharmacy and start checking for
ovulation from 11th day of the cycle) 2. Basal body temp method ( buy BBT thermometer and
check the BBT every morning before getting out of bed, rise in 0.2 to 0.3 degree indicate ovulation)
3. Cervial mucus method (check cervical mucus everyday, when it's clear and stretchy like eggwhite it's fertile).
Come to next consultation with husband because it's very important to manage both partner
together.
Sex 2-3 times/week is suggested if trying to conceive. She said my husband is away,what to do? I
said I'll try to help with this too (time run out before I can say more, I'm thinking if he can comes
back during the fertile period that would be helpful but I didn't get chance to say that) the
roleplayer was a very pleasant lovely lady.
8. Abdominal pain – Fail
GS: 2
Approach: 3
Choice & Technique: 3
Accuracy: 0
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Dx/Ddx: 2
You are HMO at ED. 25 years old female, complain of abdominal pain. She also has frequency &
burning pain on urination. She is sexually active, on OCP, boyfriend also uses condom. LMP was 3
days back.
Tasks: Perform PE
Dx, Ddx to patient
When I entered the room, patient is already lying on the bed.
Intro, Explain & take consent, wash hands, ask whether she need painkiller
Check VS – T – around 38 C, others – normal
Check for dehydration – no sunken eyes, no dry lips or coated tongue, skin turgor normal, pulse
rate – regular
Then I start the abdominal examination with (on patient)
Inspection – normal
Palpation – light – tenderness over right lumbar region
No rebound tenderness, No rigidity, No guarding
No pain on coughing
Deep – no liver or spleen enlargement
I skipped the percussion as no feature suggestive of perforation
Special tests – Murphy sign negative
Psoas test, Obturator test – negative
Short bell rang & I quickly checked for the bowel sound – present
I have no idea of what the Dx is, so I told the patient, you are having fever, symptoms on urination
like pain & frequency – I think you are having the infection and inflammation of kidney,
pyelonephritis.
Another possible cause could be UTI.
Bell rang, I thanked the role player & examiner.
(A friend told me she asked for urine dipstick – RBC positive, VE is normal
Maybe I should have checked for kidney ballotable or not on deep palpation and renal punch test)
Another Feedback - Approach - 3 , Choice of technique - 2, Accuracy - 1, Dx - 1
17 year old girl complain of lower abdominal pain for 3 days, worsens now, has fever, vomit and
has loose motion as well. On COC,period are regular.
Task : Perform examination, Dx/DDx to patient .
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I was so sure it is appendicitis when I read the case outside. I went in and failed this case
miserably. It's my second case in exam and examination station are not my strong suit. I was so
flustered and lost all my sense of sequence or deduction or any brain functions in that case.
I ask examiner vital signs and he said normal
Inspection - lying on bed,in pain, offer painkiller ( examiner say temperature is 38 degree and he's
sorry for saying normal before)
Palpation - I asked her where is the pain ( she said all over her tummy) , on light palpation ( she
said pain in right upper and middle quadrant) no pain in RIF , I said I will skip deep palpation
because she is in pain, no rebound tenderness, Rovsing sign - , bowel sound +
(that's it, that's all I do, my mind was blank all throughout the station)
Dx - Peritonitis due to burst appendix according to your story
(they said Urine dispstick ( which I didn't ask) has RBC + , the diagnosis is probably UTI or Renal
stone,I guess)
9. Late Pregnancy complications – Fail
GS: 2
History: 3
Choice & Technique: 2
Dx/Ddx: 3
You are a GP. A pregnant lady had made an urgent appointment to see you.
Tasks: History, PEFE, Dx, Ddx
History
She noticed some fluid coming from her down below, clear & watery, not foul smelling, no fever
No bleeding, no tummy pain, no contraction
Baby kicking as usual, this is her 3rd pregnancy
When I asked her how are the previous children – she doesn’t want to answer
(I should have reassured her & asked again – where there are positive findings
First one – terminated, second one – miscarriage due to cervical incompetence and cervical
cerclage still + now)
No urinary incontinence, no urinary symptoms
Pregnancy – 37 weeks (Patient said her period is regular before she gets pregnant & has confirmed
her pregnancy with Dr and early scan was done)
all AN tests are normal
Short bell rang, so I moved on to PEFE (I missed a lot of positive points)
PEFE
GA – anxious and looked worried
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VS – stable
Obstetric exam: - no tummy pain, no contraction
FH – 34cm**, single fetus, longitudinal lie
head presentation, not engaged
FHS – normal
VE – inspection – discharge +, no bleeding
SSE – discharge +, os is closed
so I asked for swab test, nitrizine blue test, fibronectin test – all are pending
BST – UDS – normal
BSL – normal
Dx – I said PROM, rupture of membrane before onset of labour
(I think it should be PPROM?)
DDx – chorioamnionitis, UTI, urinary incontinence
(I forgot to mention true labour & false labour)
Another Feedback - 26 year old woman at 35 weeks of pregnancy complain of losing fluid from
down below. Task - history, PEFE, Dx.
History - large amount,this morning,no bad smell,clear.
No urinary symptoms
3rd pregnancy this time, 1st- termination, 2nd - miscarriage due to cervical imcompetency and
cervical cerclege done ( cervical cerclege still + now)
Bad pap smear result 5 years(?)and cone excision done.
Normal pregnancy so far.
PEFE - vitals normal, GA - normal
Obstetric exam - normal FH,FHS,Lie,Presentation
Pelvic exam - Inspection - clear discharge + , no offensive smell
-Stertile speculum exam - os is close, while I'm asking is the cervical cerclege still present , the bell
rang.
History - 3, Examination -3, Dx - 0
Please make sure that you don't waste time on history and non-essential stuffs like I did.
10. Adolescent Health – Pass
GS: 4
Approach: 4
History: 3
Commentary to Examiner: 4
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You are HMO at ED. 15 years old male who had binge drinking last night, alcohol level now is 0.2%.
VS – stable.
Tasks: Take medical and psychosocial history
Present key issues and risks regarding adolescents to the examiner.
History
The role player is sitting on the bed, bending both knees, keeping them close to his chest, doesn’t
seem like he wants to talk & wants to go home.
Introduced to him and told him would like to have a talk with him & if everything is fine, we would
like to discharge him.
Offered confidentiality
Alcohol – started drinking 1 year ago, how frequent, where, with whom, increase in tolerance,
awareness of safe level (no)
No withdrawal symptoms, no dependency
Doesn’t use any recreational drugs nor smoke
No problem with law
No social problem, no family problem
No medical issues, generally healthy
HEADDSS – family – good & supportive
Works a part time job, no financial problem
A uni student, no problem with school performance
Activity - good
When asked about sexual activity, he said, ‘I don’t think you need to know about this’
Reassured him & asked again, but still he didn’t answer
So I said, ‘It is totally ok if you don’t want to talk about this & I just want to make sure that you
don’t have any problem like STIs, You can open up to me when u feel like it’.
Mood – good, no anhedonia, no idea to harm himself
Appetite, sleep – good
No problem with concentration
Hallucination – negative
Commentary to Examiner
Dear examiner, I would like to present a case of 15 years old *name*,
He was admitted because of binge drinking last night, no withdrawal symptoms, no dependency
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Apart from alcohol, no smoking or recreational drug use
No health issues, no problem with law, social & family, no financial problem
Family is supportive, which is a very good thing
Uni student, doing well at uni
No feature of depression
He poses some risks of alcohol dependency, alcohol related health problem & school expulsion.
Examiner asked, ‘will you discharge him?’
I said, ‘Yes, if possible, I would like to arrange someone to pick him up.’
He will need to be followed up for alcohol counselling in the future to prevent the unwanted
implications of alcohol drinking.
Another Feedback – Approach - 4, history -3 , commentary to examiner - 3
15 year old came to ED yesterday night with alcohol intoxication, you're HMO at ED
Task : History , Discuss with examiner about psychiatric and medical conditions of this patient and
its implications ( or something similar to this sentence)
History - Confidentiality, Are you alright right now? ( he said I'm ok, I want to go back home now)
What happened last night ( I went out with my friend and have a drink,it's not serious)
appetite - normal , mood - good , suicide - no,no tendency,no past history, I ask about
hallucination and delusion - he said I'm not crazy.
Home situation - good, good support from parents
Education - okay
Activities - okay
Drug - no , alcohol - yes, sometimes on weekends, but not much, smoking - yes,sometimes
Sleep - normal
Sex - I didn't ask
Past medical and surgical - normal
Medication - using inhaler for wheeze ( I ask him,were you diagnosed with asthma,he said I don't
know I have wheeze and use inhaler, how long - since young, regular? When I have wheeze )
Discuss with examiner - He asked do you think we can discharge this patient ? ( yes, because no
suicidality and good support)
-he is a minor and drinking and smoking - so it's a problem ( we should arrange counselling for that
)
-he probably has asthma and smoking - so it's quite worrying ( we should follow him up with GP
for that)
(My friend said she focus more on alcohol and went into details with alcohol drinking and
counselling and passed the case)
(I didn't know what to ask in history and wasn't confident and it shows. When you're clueless, the
examiner just knows)
11. Shortness of breath - pass
GS: 4
Approach: 4
Choice & Technique: 5
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Interpretation of inv: 4
Dx/DDx: 4
You are an intern at the hospital. A middle aged man who recently had a surgery complains of
shortness of breath. 3 charts given – VS chart – SpO2 low, RR increase, intake output chart day 1 –
total 4000 ml intake and 1280ml output, day 2 also given – clearly also the intake exceeds the
output. Medication chart – clexane, frusemide, ramipril.
Tasks: Interpret the charts given to the examiner
Ask PE findings from the examiner
Dx to the patient.
When entered the room, patient is lying in propped up position, on IV drip.
Introduced, told the examiner, ‘I would like to stop the drip since patient is having SOB,’ and
examiner did this for me.
Then examiner said, ‘do you want to look at the chart again?’
He handed me one chart after another – I explained, interpreted the findings on the chart.
I said I would like to give oxygen to my patient since SpO2 is low – examiner said Ok, we will have
it done.
PEFE
GA – as you can see, VS – stable
Signs of dehydration – nil
CVS – normal
Resp – dullness on percussion, bilateral basal crepitation
Abdomen – wound looks good
No palpable mass
No oedema or pain over legs
PR – no prostate gland enlargement
Dx – acute pulmonary oedema due to fluid overload
Explain to the patient – we will be giving oxygen so you will feel better.
There is retention of fluid inside the lungs since the body fails to excrete the excessive fluid – APO.
This is totally manageable. I will inform my seniors of your condition, we will need to strictly
control the input of fluid, if necessary, we will also increase the dose of frusemide, to help excrete
the fluid.
Another Feedback - Approach - 5, Choice of technique,organization - 5 , Interpretation - 5 , Dx/DDx
-5
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middle aged patient has operation yesterday and now becoming breathless, the charts are given (
Vital signs chart, Intake-Output chart where intake is so much more than output, Drug charts)
patient has underlying hypertension or some heart condition and was taking medication.
Task - Discuss the charts with examiner and patient condition, Dx.
Patient is lying on with chest propped-up in 45 degree and IV line present and drip running.
I greet the patient and examiner and excused myself to stop the drip now. The examiner did it for
me. Then examiner take out the charts and say let's discuss.
Vital signs chart - Here on VS chart, the temp is quite normal since the day of operation, BP and PR
has been pretty stable too, but see here Dr, the RR has been increasing since last night and SPO2
has been falling since then. So,I gave us the clues that there is something wrong with his CVS or
RS.
Drug charts - After checking that this is the right chart for this patient,Mr.something. I see that he
is having ( name of drugs given in chart) and the nurses has been giving the right drug at right dose
at right time as well. But here, the dose of frusemide is missed.
Intake-output chart - there is the gross imbalance between intake and output because the intake
is this much and output is this much. Especially the IV drip has been given excessively.
Dx - Acute pulmonary oedema due to fluid overload ( I didn't give any other DDx)
He said please explain this to patient.
I ask him how are you feeling right now, he said I'm getting a little better now.
I think you are having condition called APO, where there is excessive fluid in lungs. It is due to the
pressure increase in vessels supplying lungs caused by heart failing to pump out blood. Since you
have underlying heart condition and also the intake we gave after the operation is high,it leads to
this problem. I'm sorry it happens to you, but we will make sure you are alright.
What will you do? I will call the senior and also the heart specialist and he will look after you, we
will also make sure your intake-output is balanced. It's very good that you are in this position(
please don't lie flat for the time being, he said yesss,I feel better when I'm like this,I can't lie flat)
12. Cough – Pass
GS: 4
Approach: 4
Interpretation of Inv: 5
Dx/DDx: 5
Mx: 4
You are a GP. 50 years old woman complains of SOB, cough with sputum. She was a smoker, but
has already stopped it. Her BMI is also raised.
Spirometry results given: FEV1, FVC, FEV1/FVC – reduced
TLC, RV – increased
DLCO – reduced
(normal value, pre BD, post BD, predicted % given)
Tasks: Interpret the result to the examiner
Explain Dx, Mx plan to patient
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Interpretation to examiner
This is the spirometry result of 50 years old, *name*
Comparing with the normal value, FEV1, FVC, ratio – all are reduced
So they are checked again after giving the bronchodilator to differentiate from asthma, and there
is less than 10-15% increase after the bronchodilator – which means the airway obstruction is not
reversible.
TLC, RV are also increased – therefore, this is chronic obstructive pulmonary disease.
DLCO is also reduced – probable emphysema.
Examiner asked me to explain to patient.
Dx to patient – chronic obstructive pulmonary disease – explain
Mx
Appreciate the patient has already stopped the smoking.
Stay away from people who smoke, fumes, dust.
Will give you bronchodilators to dilate the airway so that you won’t feel SOB.
I found that your BMI is quite high. Since this can have a big influence on COPD, we will need to
help you reduce weight, for that, I can liase with dietician for you and please do some exercise.
Yearly flu vaccination.
Physiotherapist will teach you breathing exercise to improve your lung functioning.
I noticed you are having cough with sputum, I will give you some mucolytics for that.
This condition needs lifelong follow up to make sure your condition is under control. Also let your
family members know about your condition, so that they can help you with this.
Red flags – increasing SOB, increased or more purulent sputum – means exacerbation
If any of these, notify family members & go to ED, need urgent treatment
Another Feedback - Middle age woman,ex-heavy smoker came due to cough, did spirometry,now
come for result
(spirometry findings given outside the room just like book case)
Task - Interpret the result to examiner, Dx to examiner , Dx and Mx to patient.
-Interpret the results
This is the spirometry result of Ms.something. She was a heavy smoker and now quitted, she
complaints of cough, the result shows decrease FEV1 and FVC as it's only (number) compared to
normal's (amount), so it indicate the presence of obstructive pulmonary disease. So since the 2
main causes are asthma and COPD, we need to see if there is reversibility with ventolin inhaler but
here it shows there is only 3 or 5 % increase after inhaler,it's very unlikely to be asthma and favors
the Dx of COPD. And we also did DLCO and it's reduced as well,so I think it's emphysema.
Dx to patient - COPD ( I didn't particularly mention emphysema to the patient)
Mx - I explain in COPDX approach as John Murtagh's book. I also mention support group,etc.
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Approach - 4 , Interpretation - 5 , Dx - 5 , Mx - 4 ( I wasn't very clear in explaining management,I
got lost in COPD)
13. Breast swelling - pass
GS: 5
Approach: 5
Choice & technique: 4
Accuracy: 5
Diagnosis/DDx: 5
You are a GP. 50 years old man, complains of bilateral breast enlargement. He is a chronic
alcoholic, has hypertension and on ramipril.
Tasks: Perform physical examination
Dx, DDx
Entered the room. Role player was sitting on the edge of the bed.
Explained & got consent, washed hands.
Start with the hands – clubbing, leukonychia, onycholysis, fine tremor, flapping tremor, rashes,
bruises, spider naevi, proximal myopathy
Face – cushingnoid face, eyes – pallor, jaundice
Parotid gland enlargement
Nose bleeding, gum bleeding
Neck – thyroid gland enlargement
Chest – spider naevi
(no positive finding)
With the patient sitting, breast examination
Inspection – in 4 positions – hands on side, leaning forward, raising both hands above the head,
hands pressing on waist – no visible mass, no dilated veins, no skin changes, no swelling over the
armpit, no accentuation of any mass on different positions (bilateral breast enlargement +)
Palpation – ask the patient to put the corresponding hand at the back of the head
all 4 quadrants in zig-zag method + under nipple and areola – no pain, no palpable mass
ask patient to squeeze the nipple – no discharge
Axillary LN (-)
Cervical LN (-)
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Told the examiner, would like to check the abdominal examination for liver, spleen enlargement,
ascities – none of them present
Private area – no scrotal mass, no testicular atrophy
Per rectal – no piles
BMI – 32
Dx – bilateral breast enlargement in man, we called it gynaecomastia
There can be a number of reasons for this, in your case, I noticed your BMI is high; obesity is the
most probable cause for you. Others are like – anabolic steroid, cushing syndrome, hyperthyroid,
chronic liver disease, testicular cancer, breast cancer (gave reasons why they are less likely)
Another Feedback - Approach - 4, Choice of technique - 3, Accuracy - 3, Dx/DDx - 4
Middle aged man complain of breast enlargement. He is on ramipril for hypertension. He is a
heavy drinker.
Task - Perform physical examination, Dx/DDx to patient.
-patient looks a little disoriented to me ( when I come in, he said 'another doctor has come' and he
looks quite drunk to me) I was confused.
-he take off his top after I said about exposure and leave it on floor, I tried to pick it up, he
said,leave it.
-I focus on chronic liver disease features on examination, no abnormal findings
-on breast exam - no lump,examiner say there is bilteral enlargement of breast +
-BMI - 32
Dx - I said it's due to medicine you are taking but there are many possible causes and I mentioned
them especially on liver disease.
( I forgot to do Lymph node examination and to look for thyroid condition in examination, and did
inspection of breast AFTER the palpation and forgot to mention obesity as the cause , examination
stations are really quite unforgiving , if you don’t practice enough, you got stressed and forgot
everything)
14. Body odour – Unscored
You are a GP. 9 years old girl brought in by mum, because of body odour.
Tasks: History, PEFE, Dx with reasons
History
For months already
I thought it would be encoparesis or enuresis (no wetting or soiling)
No skin infections.
Armpit hair, pubic hair – noticed by mom
No excessive sweating
Personal hygiene – good, regular showering, changing of clothes
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Child is coping well, eat well, sleep well, thriving well
Being teased at school, child is aware of herself,
But no depression, school performance is good
Home situation – good
PEFE
GA, VS – good
Growth chart – growing well
Tanner stage – 4
CVS, respiration, abdomen – all normal
DX – probably because your girl is going into puberty, there might be some hormonal changes,
that’s why having body odour
This can be mx – deodorant, take more care of personal hygiene
Another Feedback - Mom came today because of bad body odour in her daughter, 9 year old girl.
(PILOT CASE)
Task - History, PEFE, Dx,DDx
History - How long ( months ) , what kind of smell ( I don’t know but it's quite bad) I ask about
encoparesis, enuresis (both no)
-personal hygiene ( good,shower frequently but body odour still +)
-excessive sweating (NO)
-is it bad breath (No) , from down below ( No)
-how about at school ( other people are making fun of her because of that)
-good support at home, mom is quite solid
-no depression in kid though ( she is embarrassed but the grades are okay and she has friends)
PEFE - Vital signs - normal
Dental - healthy
CVS+RS+ Abd - normal
Inspection of vulva - (tanner stage 4 development of pubic hair- examiner said this as soon as I say
inspection of vulva, I did not ask for it) no discharge , no sign of infection
DDX - encoparesis, enuresis, poor hygiene,halitosis, excessive sweating, vaginal infections ( I had
no idea what is happening and thank god it's pilot)
Some say it's phenylketouria and I think it makes sense. tanner stage 4 in 9 years old. (tanner 4 is
found in 13 to 15 years old) so it's precocious puberty associated with PKU,I guess. And PKU
causes bad body odour and bad breath.
15. Hay fever - Pass
GS: 6
Approach: 6
History: 5
Mx plan: 5
40
Inv: 6
Counselling: 6
You are a GP. 30 years old lady, who is a school teacher, complains of runny nose, nose block and
red, watery eyes. Her father has asthma, mother has hay fever, and sibling has either hay fever or
asthma. She was excluded from school because of severe symptoms.
Tasks: Take history regarding the medication she is taking
Immediate management to patient
Further investigations to patient
Further management to patient
The role player was wearing sunglasses.
History
Taking antihistamine – but only relieved her watery, red eyes
Decongestant – only relieved the block nose
Steroid spray – good & take away her symptoms, but it is too pricey
The symptoms have been a long time, worse during the spring.
Immediate Mx
I understand steroid spray works for you, I will prescribe you with an affordable brand.
Oral antihistamine
As for the decongestant, please stop using it, because it is not good for long term usage due to
some side effects.
I will give you saline drops which can help with nasal blockage.
At this point, examiner asked, ‘Dr, will you give steroid only when the patient has symptom or
continuously?’
I said, ‘I will ask the patient to use it regularly during the hay fever season (spring)’.
Further Inv
FBC – to check eosinophil, cells which might be elevated in allergic condition
Refer to allergic specialist to identify triggers with allergen test.
Further Mx
As soon as you know when triggers you are allergic to, try to avoid them.
Keeping a diary can also help.
Stay healthy by eating healthy meals, sleep well, exercise.
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I will see you again after the allergen test.
Reading materials, recheck understanding
Another Feedback - 28 years old school teacher came because of worsening nasal discharge,nose
block and watery eyes ( plus other hay fever features). It's been present for long time but worse
this spring. She has taken medications for this but not get better.
Task : history about the tried treatment for this condition , advise about the method to relieve the
symptom promptly , Further investigation you would like to do, further Mx.
She is wearing sunglasses and using tissue and has red nose.
History - are you comfortable right now, I'm sorry that must be very irriating for you ( she said yes,
especially I'm very embarrassed during classes)
how long ( she said very long, every year) did you go to doctor for this, what did you take? ( she
say many including anti-histamines) ( but she hasn’t tried steroid yet) ( I only used like 1-2 mins for
history)
Method to relive the symptom - I suggest steroid ( I told steroid only for short time and to relieve
quickly) I also suggest the saline wash method ( can buy at pharmacy, saline from one nostrils and
it will clear the nose. I also mention saline drop to both nostrils
Invx - Allergy test with allergy specialist since it's very very important to avoid trigger and you
have tried many medications and havent worked well. Also some blood test like Full blood count
to look into your blood since sometimes it's associated with increase in certain blood cells. Also
inflammatory markers.
Mx - avoid trigger, increase immune, use medication when worse, see you after allergy test.
Approach - 4, History - 6, Mx - 5, Invx - 7, Patient counselling - 5
( I was 101% sure it's pilot case when I walk in, but it's scored. I have never seen this case before in
my life, so please don't give up thinking it's pilot, attempt every case to your best ability)
16. MSE video – Fail GS: 3 Commentary: 4 Accuracy: 3
30 years old married nurse, was brought in by her husband because he found out she was
attempting to drink a full bottle of tablets. She feels guilty for the death of a patient in the ward.
Tasks: watch video and present MSE findings the examiner
Patient does not maintain eye contact, teary, cried while answering questions
Speaks slowly & hesitantly, but gave appropriate answers
Mood is minus 1
Auditory hallucination +
Delusion of guilt +
Insight, judgement, cognition not assessed
(I guess I failed this station because I accidentally mentioned the things that are not assessed)
Another Feedback - 30 something nurse has been brought to ED because her husband found her
trying to hang herself. She has been involved in the case of the investigation of patient's death
some time ago but the coroner has cleared her for that case.
Task - observe the video, present MSE to examiner.
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Video - messy hair, wearing t-shirt and no eye contact. Has delusion of guilt and hallucination +.
Has plan to suicide. Give -1000 on mood scale.
Commentary to examiner - 4 , accuracy of examination - 4
Side notes - please make sure to not add things that are not asked in the video ( for example, don’t
said judgement seems to be impaired if they don’t specifically ask in the video, just say judgement
is not properly assessed) , and don’t forget to say risk,rapport,reliablity at the end, and don’t
forget to mention patient presenting condition before saying ASEPTICJ3R.
1. Osteoarthritis of knee - examination
28th Feb 2019
Case: Middle age/Old age. Restriction in ROM of knee since last 6 months or so, getting worse with
time. Especially restricted in climbing stairs.
TASK :
Physical exam 6mins, give running commentary to examiner
DDs to patient with reasons
POSTIVE FINDINGS: (Real patient)
Look: Generally overweight, slight SOB
Gait: Slow, seemed antalgic, unable to squat
Feel: Both knees swollen, especially right. Temperature normal.
Move: Global restriction of movements. Painful if done passively. Crepts on passive positive.
Special Tests: None positive. I did all tests except for meniscal injury as patient had difficulty lying
prone and examiner asked me how u will do it, so I just explained it to him.
Dx: Osteoarthritis most likely
DDs: every single thing that I ruled out during examination I said here. Including chronic conditions
and trauma.
2. Obesity
Father has come to meet you, I think regular follow up of asthma. I have made the asthma action
plan already today and I am satisfied with asthma control. Follow up with asthma specialist has been
done as well. Asthma diagnosed in earlier years. Age is like early teenage. Right now I am
concerned about his weight gain. About 5 readings were given of both height and weight(at birth, 8
months, 2 years, 5 years etc till the latest one). I don’t remember if the readings were given outside
in the stem or inside.
TASK:
Plot growth and height chart according to findings given in stem and explain findings to patient
History
Counsel
POSTIVES:
Height chart: normal centile since birth
Weight chart: Increasing steadily since birth. Now above 97th centile
History: only responded to questions, no open ended answers. Diet not healthy. No exercise or
school activites, later dug and found out parent does not let him do exercise because worried it will
cause asthma attack, so I offered specialist review for addition of preventer before exercise. Whole
family eats unhealthy, role player seemed pretty fit but I asked him what do you think about your
weight, he said he has always been overweight. I counseled about SNAP(smoking, alcohol, nutrition,
43
physical exercise) for the whole family then. Family meeting. School trainer. A lot of what I said was
according to how the role player responded and his concerns.
3. Abdominal Pain - PILOT. I can’t remember what it was.
4. Smoker Health Review
Patient has come for review of his investigations T score -2.37 and
Vitamin D lower than normal, he has history of COPD for a long time which is not controlled.
TASK: Interpret investigations. Manage and counsel. (PASS)
I started with greeting as usual and started explaining the results. I
said Osteopenia and the patient asked me if it is the same as
Osteoporosis, I said “Well, it is similar but not exactly the same,
osteoporosis is the more severe form and if we don’t do anything for the osteopenia it can lead to
osteoporosis in the future, which carries higher risk of fracture with minor or no trauma”, patient
seemed to be happy with the response. He was smoker for a long time and his COPD was not wellcontrolled, he was using steroid inhaler as well. Then I drew a diagram, smoking > worsening of
COPD > using more steroid inhaler > worsening of osteopenia.
Then I said “We need to break this chain, starting from smoking, I will arrange a meeting to talk
about that and also arrange a referral to respiratory specialist, and possible change in medication,
since the vitamin D is also low we need to start you on supplements, along with that some changes
in diet, have more vitamin D rich foods” mentioned some like nuts and seeds, fish,… and offered
referral to dietician and recommended about sun exposure with caution (slip, slop, slap), explained
about SNAP and importance of weight bearing exercise. That’s all I can remember now.
5. Dirrhoea
Middle aged lady c/o diarrhea since 6 days. TASKS: History 6 mins, DDs with reasons to patient
POSITIVES: non bloody, no mucus. Liquid. 6 bowel movements per day. No other organic complaints
related to diarrhea head to toe. Went to Bali, got travel advice but didn’t follow and ate from
outside. had diarrhea once before in life when 6 years old because ate food at a party and all people
there got diarrhea. That resolved in about a week.
DDs: I gave non malabsorptive DDs first( first mentioned infective) then malabsorptive.
6. Head Trauma
MVA. Young woman, primary survey done. Collar and neck cleared. Vitals stable. Picture of
periorbital ecchymosis given.
TASKS: Relevant Physical Examination. DDs to patient.
INSTRUMENTS INSIDE: cotton, snellen chart(it was like in a corner of the room I am glad I looked for
it. It was a small one to be hand held at 1 metre, which I measured as one arm distance). Tongue
depressor maybe.
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POSITIVES: as soon as I entered patient said “my head hurts here doctor. Why is my head hurting so
much?”
Examination I did detailed of Secondary survey (HEENT), CN 2 3 4 6, CN 5 7 8 unless examiner asked
to skip forward, he did so very frequently.
He let me do complete inspection and palpation, let me do complete eye examination. On ear and
CN 8 he said normal, on nose he said normal, throat he let me do and then said all of the things u
looked for are normal. When trying to find otoscope and opthalmoscope in the room he said not
available, so I just mentioned what I was going to look for like vitreous hemorrhage etc etc, and he
said okay all of those are negative.
Patient had pain on right side of head, global restriction of eye movements. Other than that all
negative.
DDs: I mentioned according to emergency levels: I have ruled out basal skull fracture bc of…..I have
ruled out Orbital floor fracture bc… I drew a diagram for all this.
Then I mentioned all the hemorrhages.
Then I said most likely you have trauma to tissues around the eye, and that’s why the pain. But
specialist review needed and investigations need to be done.
Another Feedback - I was not very organised in this station because the role-player distracted me
with fidgety hands.
He had peri-orbital ecchymosis, I started with examination of the
head look, feel then went for feeling all around the orbit, there were mild tenderness, all this time
role-player was fidgeting and I got confused and decided to do neurological exam as well, started
with gait then examiner told me to read my task again! then jumped back to eye examination and
did all, acuity, field, movements and asked for diplopia which was not present, mentioned
ophthalmoscopy. examiner said normal, checked sensation of the face and mouth for any sign of
trauma or broken tooth as well, mentioned otoscopy and examiner said normal. I only had time to
say two differentials and bell rang, I said subconjunctival haemorrhage explained what it is and then
said orbital floor fracture and went out.
7. Assessment of change in behavior
Old patient of schizoaffective disorder brought by parents due to change in behavior recently and
has stopped taking medications.
TASK: Watch MSE video 4 mins. Present MSE to examiner 4 mins.
MSE video is very clear, very clearly audible and understandable. The screen is of big size and close
to the candidate. Paper and pen given to note things down.
POSITIVES: auditory hallucinations (command), Delusion of grandiosity, Thought insertion, Homicidal
Ideation, No Insight, High risk.
As 4 mins is a good enough time I included a small introduction of the patient according to the case
given. Then ASEPTICJRRR.
Another Feedback - I wrote ABSEPTIJCS on paper and quickly added positive finding which were:
dressed appropriately, wearing a cap, pressured speech, visual and auditory hallucinations, thought
form tangential and flight of ideas present, delusion of grandiosity and persecution present (I did
give reason for all these to the examiner), insight impaired, not suicidal but mentioned might harm
others if the voice tells him to. then I presented MSE as ISBAR format in assessment I mentioned
ABSEPTIJCS then RRR( rapport, risk, reliability)
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8. Weight Loss
9. PILOT - It was about preoperative counseling for a man about to undergo some elective colorectal
procedure due to maybe cancer. I don’t remember why he was about to have the procedure. Meds:
Warfarin, 2 Antihypertensive, Statin
TASKS: Take history relevant to his medications.
Tell Examiner about how you will manage his medications, and what “practical advice” you will give
to patient before the procedure.
10. Dental Compliant – Bulimia Nervosa
Patient referred to you from his dentist because of dental carries and calluses over knuckles. BMI
right now is within normal range. Rest physical examination normal.
TASKS: History 6 mins. DDs.
POSITIVES: Patient needed a lot of support, confidentiality and motivation to talk. No open ended
answers. Stressed because of people’s remarks that he is fat. Understands now that his weight is
within normal limits. Lost 10 kgs in 1 year. Head to toe all organic causes of weight loss negative. All
answers to Bulimia SCOFF positive.
(Do you ever make yourself sick because you feel uncomfortably full? Do you worry you have lost
control over how much you eat? Have you recently lost more than one stone in a three month
period? Do you believe yourself to be fat when others say you are too thin? Would you say that food
dominates your life? )
All answers to anorexia negative.
DDs: I mentioned Bulimia first (very sensitively with a lot of build up, patient was already so down I
was feeling pity on him to be honest). Then anorexia, then all organic causes and psych causes like
depression and why they are unlikely.
Another Feedback - Started with greeting and confidentiality, patient was not worried and said he is
only there because his dentist asked him to. Started with HOPI: asked about binge eating, induce
vomiting, using laxative, fasting, excessive exercise and diuretic use. Then ruled out organics then
asked about mood, sleep, appetite and suicide, then asked about complications of bulimia
(electrolyte imbalance, dizziness, arrhythmias, callus on knuckles, osteopenia, change in
hair/skin/nails) then asked what he thinks about his body and if he checks mirror frequently, then
asked about differentials, then started explaining the condition by saying it’s normal for people to be
worried about their weight however it becomes a problem when it is affecting your health and then
talked about the complications.
11. Vomiting
Child vomiting continuously since last night. Diagnosed case of cystic fibrosis since birth. X-ray of
Ileocaecal Obstruction was given.
TASKS: Take history 3 or 4 mins. PEFE. Explain X-ray to patient. DDs to patient.
POSITIVES: vomiting whatever being given to child. 9 months old.
tummy seems distended to father. Compliant to all cystic fibrosis meds. Specialist follow up done
closely. No change in environment recently. Stool not passed since last night.
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PEFE: pain, pale, abdomen distended, fecal masses palpable. I don’t remember what examiner said
about auscultation of bowel. Rest all systems and examination normal
I explained X-ray to patient and told all DDs at the same time. What features are positive drew a
diagram and explained.
DDs: DIOS secondary to CF, then all other causes of intestinal obstruction and vomiting in child
(atresias, intussusceptions, hirschsprung etc), and then non serious pathologies like infections. The
diagram I was making saved me a lot of time to explain the DDs in this case.
12. Health Review
A 22 year old (not sure exactly) lady came for prescription of
contraceptives
Inside the room role player was siting, poker face, not very cooperative.
I started with confidentiality, then asked why she decided to take
pills, and if she know anything about other methods as well, which
she was not interested, I asked about contraindications of OCP which were absent, I asked generally
“do you have any medical
conditions?” she said no, then asked PMH, FH, SADMA, then I said ok. you are suitable for taking pills
and explained her how to use it, forgot about MOA, mentioned side effects, 7 day rule, missed pill
and side effects, what to do if vomited - Emergency pill, also that it does not protect from STI and
condom needs to be used because some people may carry STI asymptomatically, she had also taken
Gardasil and Hep-B vaccine, then said you need to be careful because It can interact with other
medications like OTC and and here I asked do you use any medications? and she said yes for my
epilepsy!!! I was stressed at this point and I didn’t have much time, I quickly said it’s Ideal to switch
to other contraceptives like Mirena or Depo provera, but she insisted she wants pills, and I said ok if
you prefer pills we need to give you higher dose to make sure it is effective because epilepsy
medications decrease the effect of OCP, gave her red flags, I didn’t have time to refer her to
specialist and didn’t also get to ask her more about how control her epilepsy is, but luckily I passed.
13. Limb weakness
Transient weakness in left lower limb. Old age. HTN. BP given and is normal. UL neuro, CNs and LL
sensation has already been done and normal.
TASKS: Physical Examination of Lower limb. Relevant Physical Examination. DDs.
Instruments: Clock, hammer, stethoscope
I did Pulse, BP mentioned what was given already, then Lower limb Inspection, Tone, Power,
Reflexes. Examiner was listening to whatever I was saying very attentively in this case, and checked
everything I did so closely that I thought this might be a real patient. He checked where I was
checking the reflex response, so I just said for his satisfaction “looking for knee reflex in Quadriceps,
ankle reflex in gastrocnemius”. He even checked where I was striking the hammer and how the
reflex was. Thankfully this patient’s reflexes illicited very well. He listened and ticked off when I was
saying the nerve roots in power and reflexes.
On plantar reflex examiner said “they are upgoing”
Then I did CVS quick inspection and palpation. Then when I started using stethoscope he again
started examining closely. (I felt like seriously? I have to do whole CVS?), but well thankfully I had
done LL neuro exam pretty quick and I had time to do complete auscultation and carotid bruit. After
I completed auscultation he said the findings you are looking for are negative.
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DDs: I drew a simple diagram about brain and blood vessels to brain and how one of them could
have closed temporarily or permanently. Explained a little about ischemia and hemorrhage. Said you
have HTN and it’s a risk factor.
14. Antenatal Care
38 or maybe 32 weeks pregnant woman. All antenatal care up to date and normal except for last
visit which she missed.
TASKS: History 3 or 4 mins. PEFE. Do SFH yourself. Tell causes to patient.
POSITIVES: everything normal in history and PEFE. They changed the findings for this case between
candidates, for some it was larger for dates and for some it was smaller, or maybe we all just
measured differently, which I think is most probable.
I made a critical error in this case, after I asked PEFE I was like okay so I am continuing the
examination I don’t need to wash my hands, and I started doing SFH without washing hands. Yes, it’s
a beyond idiotic and silly mistake. I judged it wrongly. I failed this case. Not a surprise for me.
Another Feedback - 32 weeks primigravida, did all the antenatal check ups and all normal, missed
her last visit because of her aunt’s funeral. Task: History, PEFE, measure SFH yourself, tell causes to
patient.
Started with greeting and said sorry about your loss then started my history with asking if pregnancy
is planned which was I congratulated patient and asked all check-ups so far (blood test before
pregnancy, dating scan, sweet drink test) every thing normal, then asked 5P, then asked about third
trimester complications ( water leak, bleeding, decrease baby movement, contractions, fever, pain,
headache, tummy pain) non positive, then asked for diet during pregnancy any pets at home and
SADMA then family history of any small or large baby or chromosomal abnormality, then asked
blood group and how far she lives from hospital also asked if she has her family around. In PEFE I
honestly don’t remember what I asked for but everything was normal, then washed hands, warmed
them and grabbed tape, examiner got close to observe at this stage, measured with non-centimetre
side to avoid bias, then looked at centimetre side, it was
28 cm. then started describing for patient: everything is ok there is
only one thing I’m a little concerned about, when you are 32 weeks
pregnant we are expecting your tummy to be between 30-34 cm but when I measured it was 28 cm,
which means it is smaller than It
should be, then explained all causes one by one: wrong dating, genetic or anatomical disorders,
TORCH, PROM, problems with the
placenta, diabetes, smoking I was so stressed I didn’t say the word
IUGR. Then checked patient understanding, and said I didn’t find the exact cause and we need to do
more investigation to find out and manage you accordingly.
15. Headache
Father has come because he is worried about his child’s headache.
TASKS: History 6 mins. DDs.
POSITIVES:
All organic causes and findings of headache negative. It took about 3 mins to rule out all organic
causes. When entered HEADSSS, it was headache due to bullying at school. Really had to dig out the
history. And after finding out the cause after about 4 mins into history, then role player said actually
several other students in school are being harassed as well. So it was a little bit of counseling
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regarding bullying as well. Rest all psychosocial was negative.
DDs: bullying/stress first. Then psychosocial causes. Then all organic causes.
Another Feedback - Greeting and asked about patient concern, he said his nephew has recently been
diagnosed with brain tumour that’s why he is so worried about his daughter having headache, I said I
try my best to find out what’s wrong today and for that need to ask some Qs, he agreed.
Started with SOCRATES
pain was all over head, doesn’t know about character, no radiation,
doesn’t know about aggravating or relieving factors, more severe at
the end of the day, didn’t notice any change during weekend, never
woke her up from sleep, then asked Qs for differentials:
Meningitis: fever, neck pain
Referred pain from eye, ears, tooth, throat, TMJ, sinusitis
SOL: early morning vomiting
Migraine: light or sounds bothering her, FH of migraine
Stroke: FH of blood clotting
all negative then asked about home, everything ok and happy family then asked about school and he
said they called from school a couple of time for her severe headache. Then asked if he is aware of
any bullying he said YES, apparently her classmates tease her a lot. Then quickly asked PMH and FH.
Then started to explain my diagnosis as: I think her headache is related to what’s happening at
school, our body is pretty complicated so when we get stressed our body will sometimes present
that stress with a symptom, some people get diarrhoea, some people feel their heartbeat, and some
people, like your daughter get headache (he seemed to like how I explained, nodding constantly)
what she is experiencing is real and distressing and we need to do something about it (although
management wasn’t my task I said “ bullying is not acceptable at all and I would like to involve
school as well, some counselling sessions would be really helpful) then started to tell all DDs one by
one and why I ruled them out emphasising on tumor because he was worried about that. Dad
seemed pretty happy at the
end.
16. Counseling
A patient has been diagnosed as having abscess secondary to diverticulitis. Surgeon has said that he
will be given IV antibiotics for 3 to 4 days, and if he doesn’t respond he will undergo surgery.
TASKS: Take a history regarding concerns of the patient. Give a summary of the concerns to the
patient. Counsel the patient.
POSITIVES: hats off to this roleplayer. His acting made me become empathic easily.
He was crying when I entered. He only said one concern when I entered. I had to probe him again
and again. Like, any other concern at all, I am here to help you, you can share anything, etc etc..
First concern: I am concerned for the operation. I am going to die. Is it necessary?
Second concern: I am on blood thinners due to a stent placed in my heart. They will stop my
medication for this surgery. If you stop this medication I am going to have a stroke and if you don’t
stop this medication then I am going to bleed to death. I die both ways.
Third concern: Colostomy is dreadful! I am going to have a colostomy bag for the rest of my life
Then I still probed further. Then came the fourth concern:
Fourth concern: Doctors are saying its elective and safe, but my mother died during elective
operation as well! They were operating on her for cancer.
Counselling: Tissue and water was given. All my communications skills I poured into this case. That is
pretty much all the patient needed. For technical things like colostomy I drew a diagram and told
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him how it might not be necessary, and temporary if needed to be done. When I drew the diagram
the examiner came near and checked what I was drawing, and then I realized oh yeah this is a role
player and this is an exam. Hehee, this roleplayer was too good it seemed real. For medications told
about bridging, he asked about heparin and details. When I told about bleeding reversal medications
for heparin he was happy. To reassure I said I will arrange a call between the surgeon and your
cardiologist, then he became satisfied. Rest was counseling about concerns one by one.
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6th, 7th, 21st, 22nd, 26th, 27th, 28th March 2019 Recalls
6th March 2019
1. Pulled elbow history and management.
Stem: a two-year old could not move his arm for 2 hours after a
pulling on his elbow. No fall, no other injury, history insignificant. Px
local tenderness in lateral elbow, no other findings. Explain the
diagnosis to parent and examiner asked you to show how you would
do next
2. Post operative shortness of breath. Charts given. Possibly pneumonia.
3. Chest pain. Father had heart attack. ECG normal. Dx, DDx with cause.
4. Pain tingling and numbness of left shoulder and arm in a patient with mastectomy done few
years ago due to left breast cancer. Possibly cervical radiculopathy.
5. 36 weeks pregnant lady comes 30 minutes after MVA. Focused history, PE and Invx.
6. Father of a 4year old girl with asthma, eczema and egg allergy comes to discuss influenza
vaccine. Take history and explain about the vaccine.
7. PVD examination.
8. Post coital bleeding in 32 years old. Do an examination on a dummy.
9. MSE of mania. A physiotherapy student comes with plans to save the world with guidance from
the God.
10. An aged man comes with cough and runny nose. Do a respiratory examination.
11. Post natal blues. Crying baby for 4 hours no feeding or pooping. Intussusception.
12. Diarrhoea of a 27 years old for past 2 years on and off. No alternate constipation. Blood with
watery stool.
13. 47 years old with 5 episodes of bleeding in past 3 months.
14. HRT counselling.
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15. Warfarin counselling.
16. Preoperative medical management of an AF diabetic patient on warfarin metformin and
atenolol
7th March 2019 retest
1. Health review (PASS)
Approach to patient 4
History 4
Dx/DDx 4
GS 4
67 years old lady diagnosed with temporal arteritis some months ago presents with tiredness and
LOW.
Task – History 7min, D and DD
Greet examiner and patient. Introduce, ask her about the PC and showed some empathy. I
decided to use the HEMIFADS mnemonic. Then I went to PMH and DH which is when she took out
a card showing the Prednisone that she has been taking for past few months. I asked her about
compliance to which she said that she stopped taking 6 weeks ago. Also asked if she has an issues
with vision which was negative. Got into the social history, lives alone by the beach, not working,
no smoke, social drinker. Said she was busy taking care of mom that why she forgot to take meds.
Thanked her for the history, told her most likely it’s because the steroids were stopped suddenly,
could also be cancer, thyroid disease, diabetes, infection, anemia. Told her not be alarmed. These
are just my thoughts and need to do further tests to confirm. Asked her if she wants me to
address anything else. She told me that she was good and bell rang.
2. Breathing difficulty (PASS)
Approach to patient 4
History 4
Interpretation of investigation 3
Dx/Ddx 3
GS 4
10 month old child present with one week cough. CXR done.
Task – Hx , explain X-ray to father, PE on card, Dx and DDx
Hx – Asked the cough questions- duration, freq, pattern of cough (he told me chid has bouts of
coughing followed by vomiting and baby also turns blue), reported a dry cough as well, no noisy
breathing, no nasal flaring, no fouls smelling discharge from nose, nil problems with growth, ni
recurrent chest infections, nil fever, nil rash, no similar episodes in the past, father noted that
child had decreased appetite but child otherwise well and active, sister had cough few weeks ago,
6 month immunization missed, mom smoking outdoors, antenatal and birth hx normal, PMH and
DH normal. Showed some empathy to the father. Social hx was ok, there were a happy family with
good financial background. Told him that I can arrange smoking counselling for mom if interested.
Thanked him for history and told him to excuse me while I look at the PE card.
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Examiner gave me the PEFE card and vitals were good and RS exam was normal. I explained what
was on the card to the patient and told him there was nothing of significance.
Then I explained the X-ray. X-ray looked like the one below.
I told him that X-ray has some infiltrates which may be an infection or it could be normal. Didn’t
tell him anything about the ‘shaggy heart’. Wondering if that’s why I got 3 for explanation.
Told him most likely child has pertussis or whooping cough based on the history of cough and ill
contacts. Caused by a bug and treated with antibiotics. It could also be pneumonia, croup,
bronchiolitis, viral URTI and then I told him why I don’t think it is those. Reassured him and bell
rang.
4. Shoulder Pain (FAIL)
Choice and technique of exam 4
Accuracy of exam 3
Dx/DDx 3
GS 3
Old man fell and hit Right shoulder.
Task – PE, D/DDx
Was surprised about this station cause I thought I got all the findings for this exam and I gave my
dx and ddx. During the exam, my examiner did interrupt me a few times to tell me to speak clear,
speak louder etc so maybe that’s what resulted in the failure.
I introduced myself, got permission, offered pain killers. Then I hand sanitised my hands (very
messy, I used almost 2 pieces of paper towel to get it off).
Gen look- nil distress, male sitting comfortably
Look at the shoulders- symmetrical, nil deformities, nil scars, nil swelling, nil skin changes, nil
wasting of deltoid, nil wasting of scapular muscles, nil winging of scapula (asked him to push
against wall)
Feel- temperature was normal throughout. Then I felt both shoulder joints and patient reported
tenderness at the anterior joint line of right shoulder. Went to back and palpated thoracic spine
and medial aspect of scapula.
After this, I focussed my exam to the right shoulder.
Move- patient had limited ROM for abduction and forward flexion at right shoulder. Everything
else was normal. Resisted movements- painful during abduction and int and ext rotation normal.
Special test- empty can positive, Neer sign positive, pain arc positive. Skipped axillary nerve
neurology since time was running out. Also, skipped Apleys scratch. My role player was a bit laid
back so everything took some time.
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Told him most likely I am suspecting rotator cuff tendinitis or impingement syndrome which is
compression of some tissues at the shoulder. It could also be dislocation, fracture, OA, RA. We
need to confirm with X-ray and further invx. Thanked the patient and left.
I am wondering if I got the examiner irritated or if it’s the finding. I don’t know.
4. Change in behaviour (PASS)
Commentary to examiner 4
Accuracy of examination 4
GS 4
22 year old male patient present with altered behaviour. Past history of head injury and 4 days
coma. Slow recovery. Alcohol abuse +.
Mse + part of MMSE video 4 min (mixed findings of both test).
Present MSE to examiner. No dx or Mx.
I started at this station. At first I thought it was pretty straightforward case I have practised it
before. I went in and realised the video focussed a lot on MMSE -_-.
Video – male patient wearing a white T-shirt (appropriately dressed), well groomed, aggressive,
not cooperative. Was not making eye contact. Seemed disinterested during the interview.
Speech- increased r ate and volume (patient was shouting at times)
Mood and Affect- I can’t recall if it was discussed in the interview
Nil abnormalities in perception
Nil abnormal thought form
Thought content- Paranoid delusion or delusions of reference
Insight- poor
Judgement ok
Cognition (this was the annoying part)- oriented to time, place and person, registration ok but not
in order, poor recall and attention and calculation. Language and construction not assessed.
I gave a brief intro about the patient then presented the MSE and MMSE findings. Also said, there
was poor rapport, high risk to himself and others and not reliable (cause he was not cooperative)
Examiner told me that if I feel that I have finished, I can leave. I told him that I will stay and
enjoyed 2 minutes of awkward silence.
5. Antenatal Care (PASS)
Approach to patient 6
Interpretation of inv 5
History 3
Counselling 4
GS 4
Pregnant lady, antenatal test done, come for results.
Task – Explain result, necessary Hx, further Mx.
So results sheet was actually part of the stem. FBC was normal, Blood grp O+, syphilis non
reactive, varicella and rubella IGM negative and IgG positive, HepB sAG negative, then HIV
antibodies positive.
I decided to start the consultation by building some rapport, asked her if its 1st pregnancy,
planned, how she is feeling, told her I have results with me and if she wants anyone to be in the
room with her.
Started giving her all the good news first (very slowly) then I broke the HIV news. Another
excellent actress. She cried a river for next 30 seconds. I made sure I shut my mouth and offered
her tissues. When she stopped crying, I offered her a glass of water and if she wants to continue
54
the consultation. Told her I will be happy to rebook the consult if she wants. She told me to go
ahead.
Explained that I will need to ask her some questions before I explain and she nodded.
History- currently in stable relationship with male partner for a few years now, had multiple
sexual partners before, used IV drugs before but has quit for a while now, no blood transfusions,
asked if she or her partner been tested or treated for STIs which was negative. Asked her about
any weight loss, sweating, diarrhoea, rash which was negative. Took a quick antenatal history, 1st
pregnancy, no miscarriages, regular menses, pap smear not done, nil nausea or vomiting, nil PV
bleeding, nil PV discharge.
Then explained to her about HIV and how its transmitted and that it affect immune system. Told
her there is no cure but good thing is there are meds and lots of support available. Meds help to
reduce presence of virus in body and prevent transmission to baby. Told her she will be managed
by MDT which will include GP, OBGYN, and infectious dx specialist. Gave her a description of what
each doctor will do. ID specialist will start meds called ARVs and if taken properly baby may not
get HIV. Will need to do blood tests before ARVs and during pregnancy (didn’t specify viral load or
CD4) regularly and will be monitored very closely. Can arrange talk therapy with counsellor if u
want to ventilate ur emotions. May be delivered by C section but will be decided by specialist.
May not be able to breastfeed and donate blood in future. Keep reassuring. Told her that she can
stop me at any time. I kno it’s a lot of information to take in. Due to time, didn’t get to say inform
partner, contact tracing and notify. Was really focussed on closing the interview properly and
reassure.
6. Rash (PASS)
Approach to patient 6
Dx/DDx 4
Patient counselling 3
Management 4
GS 4
Young lady with skin rash for few hours. Picture give urticarial rash on back and hands. Recent Hx
of URTI but no AB. Itchy +. No FH of atopy. No recent new food or cream/soap. No signs of
anaphylaxis. All other hx was of no significance. There were 2 pictures given.
Task – explain the causes of the rash, mechanisms, Dx, DDx, Further Mx.
55
Outside the station, I was reading the case, looking at the pictures and feeling absolutely clueless.
So I went in and greeted the examiner and role player who was itching. She continued to itch for
the entire 8 minutes. I did offer her meds for the itching.
Started taking a history and my examiner told me not to take one and to move on with my tasks.
Really, I was trying to kill some time. So I explained to the lady that more than likely the rash is
due an allergic reaction to something she came in contact with. I told her that the notes were not
suggestive of a particular cause but it could something in the environment, food or new clothing,
lotions or soap. Unlikely that it could be due to the virus as rah would have affected the entire
body. Since I was clueless, I decided to give her some differentials so I told her it could also be
atopic dermatitis where immune system attacks skin, seborrheic where oil glands in the skin are
hyperactive, can also be due to insect bite, meningococcemia. For all my DDx, I told her why I
don’t think she has that condition. In terms of the mechanism, I told her that for an allergic
reaction, skin is very sensitive to certain substances like the ones mentioned above so this can
result in the immune system to overact and cause the rash and itch.
For mx, (it only got worse), I told her that I am the intern here so I would need to discuss this with
my senior first…but most likely we would give u some antihistamines to help u with the rash, may
also give u steroids IV as well but that will be based on my senior. Gave her reassurance that we
will follow her up closely, and review her frequently. She can always come in if she needs to see
one of us. Asked her if she wants me to go over anything. Gave her some red flags, reading
materials. I still had lots of time left and I just stayed in the room till the bell rang.
I thought this case was a goner. But I passed it somehow. After the exam, I looked up urticaria and
there seemed to be lots of articles from RACGP, NPS and ASCIA so check those out guys.
7. Breast lump (PASS)
Approach to patient 4
Choice and technique of exam 4
Dx/DDx 4
Choice of investigations 4
GS 4
57 years male with R/S breast lump for 1 month. History of alcoholism but no clinical features.
Task - PEFE, D and DDx, further Mx
My examiner was pretty strict with this case. I basically asked for everything and he gave me the
findings based on my requests. No information was given voluntarily.
First thing I did wa greet the role player and the examiner. I actually met this role player in my last
exam. He is really chill. I told him that I understand that he has a lump on the right breast and that
if he could excuse me for a few minutes while I get some examination findings from the examiner
and I will be right back to him.
First I asked for general appearance which was normal. Then I went straight to inspection of the
chest wall where I asked for skin changes, scars, swelling, asymmetry, skin dimpling, puckering,
nipple areola complex which were all normal and no nipple discharge. Palpation Findings were 2
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by 1.5 cm HARD lump close to the R nipple, lobulated, non tender, immobile. No LN (even for this
question….examiner asked me which LN I am looking for lol) . Thanked the examiner for the
findings. Did wonder if he was annoyed with me cause he did ask me a few times “What exactly
are you looking for” I went back to my patient and thanked him for his patience and told him that
I’m a bit concerned that it might be breast cancer since lump was hard but I don’t mean to alarm
him and we need to do further tests to confirm. Then like a robot, I told him that I am considering
other diagnoses like breast cyst, fat necrosis, fibroadenoma (lol….possible but very rare),
papilloma. Role player asked me what a fibroadenoma is. I told him it’s a non cancerous lump
which is rare in males. Then I told him I want to do some further tests on him which will include
xray of the breasts called a mammogram, ultrasound of the breasts to see if there is any fluid in
the lump or solid. After that, if there is fluid, we will take out some of this fluid for testing and if its
solid, we will do a core needle biopsy where we use a needle to obtain tissue and send the tissue
for testing. I will also arrange some basic blood investigations. Based on the results, I may have to
refer you to a surgeon. I told him that I understand that it’s a lot of info for him and if he wants me
to go over anything again. He told me that he is good. I reassured him and told him not to worry
and that we will take good care of him and review him with results.
8. Headache (PASS)
Approach to patient 6
History 5
Choice and technique of exam 5
Dx and DDX 6
Mx 4
GS 6
40+ lady with headache at GP. Accountant. She came to the GP for a certificate
Task – History, PEFE only what we ask ,Dx and DDx, Mx .
I entered the room. My patient was on lying down on the bed looking very distressed (painful).
Excellent actress, her face was flushed and she was sweating. I wish I could nominate her for an
Oscar. I did this entire station standing up at her bedside. I offered her painkillers prior to my hx
which she refused.
For my history, I had a set of differentials in my head so I asked the questions accordingly. Asked
the pain questions first (SOCRATES) Headache since yesterday evening, getting worse, Fever+,
neck stiffness +, no skin rash, no photophobia/phonophobia, no vomiting, no discharge from eyes
or nose, no pain behind eye, no trauma, no lumps and bumps on the body, nil weight loss, no
toothache, no facial pain, nil problems with vision, nil cord like structure at the sides of the scalp,
no limb weakness, speech and swallowing ok, no stress, occasional alcoholic, no FH related to
headache DDx, recent History of rhinitis
Ex – temp. 38.5 C , BP 140/85 or 95, neck stiffness+, fundoscopy not done, No other neurological
finding and other system normal. Thanked examiner.
Went back to patient and told her that I believe she has a condition called meningitis. Told her
that it is an infection of the lining of the brain. Quite serious. It could also be migraine, temp
arteritis, cluster headache, tension, refractive errors, sinusitis, dental caries, SOL, trauma (I only
gave 4 DDx) told her that I need to hospitalize her (she asked me why), told her that we will need
to do further tests in hospital to confirm her diagnosis and may need to give antibiotics through
the veins. Tests include bloods and also lumbar puncture where we take some fluid from the spine
to confirm dx. Also need to monitor in hospital for complications. Told her not to worry and that
we will take good care of you. I know u came for a certificate but unfortunately, have to
hospitalise and it’s in your best interests. I am going to arrange transport to hospital and inform
the medicine specialist at the hospital for transfer.
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21st March 2019
1. Low Back Pain (Assessed, Not Scored)
Old man, having low back pain, history of heavy weight lifting present, also known case of HT
Tasks- perform PE, Dx, DDx.
Positive findings- restricted movement in all directions, worse on the left side, SLR test positive,
sensory loss at S1
Dx- slipped disc involving S1 nerve root
To know more about this case, please read handbook condition 047.
(The patient has hypertension and one more CVS risk factor (I cannot recall what it is), so I looked
for the features for PVD during inspection of legs. That is why in this station, I can only tell Dx and
2 DDX. Luckily, this is a pilot case)
Another Recall (PASS) - 50 years old man lifted an object and his existing back pain got worse.
Perform relevant PE
Introduction +WIPE, Looked at the shoes- ok, Assessed Gait- painful
Back exam, No erythema, muscle wasting, Posture normal, Curvatures- normal lordosis &
kyphosis, no scoliosis
Feel- I’ll feel for your joint . if it causes any discomfort I’ll stop at anytime. temperature for
discositis- normal, central vertebraà paravertebral muscles- for muscle spasm-+ Sacroilliac
joints- no tenderness
Move- 6 movements- ALL restricted
Special tests- SLRT positive. I just started lifting like 10 degree. Patient complained of pain
Lower limb neuro- L5/ S1 or both affected I don’t remember.
to finish my exam, I’ll do complete neurovascular exam. Forgot to mention PR!
DDx- sciatica , trauma/fracture/ contributory muscle strain. Unlikely to be infection such a
discositis
2. Confusion (PASS)
Global 4
Approach 5
Interpretation 4
History 3
Dx and DDX 4
Your patient is John, he is agitated and confused at hospital. Urea, Cr and electrolytes are done.
Na, Cl and osmolarity is reduced. (these parameters are written in bold letters) Others - normal.
Tasks- make a phone call to the nurse at hospital and explain the result to the nurse
Obtain necessary information from the nurse. Tell the nurse Dx and DDx
I needed additional 1 min for reading this question inside the room.
There was no one inside the room.
There was a phone on the table.
After I finished reading, then I pressed 1 to call the nurse.
I introduced myself and checked her identification.
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I told her that John has hyponatremia and hypochloremia.
Also, the osmolarity is reduced. Apart from that, other parameters are normal.
To know more about John, I’d like to ask you a few questions.
Is it ok with you?
Firstly, how is he right now? (Confused)
Is he stable right now? How about his GCS? (sorry, I forgot the answers)
Does he have any know medical problem? (like what doctor?)
Like hypertension, diabetes? (The patient has some cardiovascular risk factors and for which he
has been taking some medications, the med include water pills, statins, aspirin, and beta blocker)
Does he have heart failure? (I am not sure doc)
Any SOB? Can he lie down or need additional pillow to lie down? (No / can lie down)
Any changes in water works? (not sure)
Any Headache? Any history of head injury? (No)
Any fever? (no)
Any History of stroke? ( Yes, he was admitted to the hospital due to stroke )
Then, I moved to another task. I told her that John is having delirium due to electrolyte imbalance.
I think it is associated with the water pill he has been taking. It could also be due to stroke. And
the other possible causes are heart failure, infection, hypotension, hypo or hyperglycemia, renal
failure, liver failure, head injury (I got the history of stroke at the end of history taking)
Another recall (PASS) - You are a GP and you receive a call from the head nurse at the local NH
where your supervisor consults. The nurse has already faxed the lab results of an elderly resident
to the clinic as he’s confused and irritable.
The patient profile - Mr. John Smith 65 years Medication- Hydrochlorothiazide for HTN,
Aspirin/Atorva
Ser. Osmolality
Ser Sodium
Ser. Pottasium
Ser. Chloride
Ser.Magnesium
Anion gap
eGFR
118mmol/l
265 mmol/kg
Normal
Normal- high end
Normal- high end
Normal
normal
Tasks: call the nurse and explain the test results. Obtain any relevant history & explain the
possible causes for the condition.
My approach
Hi I’m Dr S, a GP from the clinic, calling you regarding a fax been sent through to my supervisor.
Who am I speaking to? I’m sorry the treating doctor’s attending a meeting at the moment and I’m
going to take care of the patient. Could you confirm the name and the DOB of the patient please?
Can you please ask someone to check the BP, HR, RR, T, Sat for me please?
I have gone through the test results you’ve sent me. The results show the levels of salts and
overall concentration of dissolved particles of the blood. The salts excepts for the sodium is in the
normal range. Cl- is in high end, K- is in high end. The sodium level is very low. We medically call it
severe hyponatremia. The concentration of blood salts is low. This we call hypotonia. So this is
Hypotonic hyponatraemia! Thiazide is a drug which can cause low sodium levels. This is probably
the most likely cause for his confusion. This is a medical emergency. I’ll ask the staff to arrange an
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ambulance for Mr. Smith immediately and meanwhile I’d like to get a brief history to find out
more causes for his confusion.
Delirium screen Qs
Apart from those drugs in the fax any other medication? Blood thinners, any beta blockers? - NO
Emotional changes- NO
Any infection- recent cough & cold, changes in waterworks & bowel works?- NO
Any recent fall/ trauma/injury?-NO
SAD -NO
PMHx- kidney disease? Liver disease? DM? Thyroid? - NO, Heart failure? - NO
With given information, since there’s no signs of infection/injury/ existing kidney disease/ heart
failure; most likely he’s having hypotonic hyponatemia due to Thiazide. However, to come to a
definite diagnosis we need to assess him to check his hydration status. ( nurse- he’s been drinking
well) (me- I see, but will check his hydration status). Also, we need to check his urine osmolarity
and urine sodium levels.
3. Palpitation (PASS)
global -6
approach -6
history -6
dx/ddx -6
A lady (~25yr) who is anxious and having palpitation.
Tasks- take history. Tell Dx and DDx.
Hi! I am Dr. ---, one of the doctors here.
Nice to meet you, Tricia.
Are you comfortable right now? (doc, I am having palpitation)
In order to find out the exact cause, I’d like to ask a few Q to you.
Is it all right with you?
I asked her a few Q about palpitation. (still having it, happen suddenly, first time)
Can u tap over the table according to your heart beats? (very fast, but regular)
She has anxiety according to the Q, so I asked whether she is anxious person or not? (yes, for a
long time )
How is your mood? (fine)
How are things at home/ work? ( no stressor)
Have u noticed any neck swelling? ( yes )
How long? ( 4 weeks )
Do u think u are more anxious about things during these 4 weeks? ( yes )
Apart from that, have u noticed any other symptoms? (like what?)
Any weight changes? ( weight loss despite good appetite)
How are ur pee and poo? ( constipation +)
Any hand tremor? Sweating?
Any episodic headache?
Any panic attack? Any SOB?
Any eye changes? (no)
Any muscle pain?
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I’d like to know about your period. ( regular, normal)
Any known medical problem like hypertension or heart failure?
Do u smoke?
How about coffee? Alcohol?
Thank u for ur story, Tricia.
Is there anything u’d like to add to ur story?
According to ur story, I am suspecting the condition we call it hyperthyroid.
Do u have any preformed idea about that?
I’ll explain u with the drawing. - - - When the thyroid gland in front of the neck is hyper functioning, it can produce these kinds of
symptoms.( swelling, palpitation, anxiety, etc.)
Your symptoms could be due to other cause like GAD.
It could be due to pheochromocytoma, a problem at the structure which is at the top of kidneys, panic attack, other
anxiety related disorders such as PTSD, mood problem, alcohol, coffee, heart problem.
Another Recall (PASS) - 25 years old lady presented with increasing anxiety for the past two
months. History, Dx.
Anxiety , Palpitation+ appetite- good but weight loss unintentional, sensitivity to heat+, sweating+
muscle aches, skin thining, periods- I think was ok, don’t remember. Eye signs – negative , no
bowel changes, No feeling of neck mass , no difficulty in swallowing or drinking. No tummy pain,
jaundice, No recent infection, No chest pain, sob. Anxiety screening- mood, sleep, recent life
chabges or adjustment problems- no , no phobias, do you consider to be always a nervous person
– no. SAD- none caffeine- not much. PMHx- no heart conditions/ DM no any autoimmune dz,
hepatitis, pheochromocytoma. FHx- thyroid problem- positive. PPsychHx- GAD or mental health
related issues- none
Dx- hyperthyroidism- grave’s, autoimmune thyroiditis, goiter-MNG/ toxic, medication- unlikely,
Unlikely to be pheochromocytoma, GAD, cardiac disease
4. Hand Problem (PASS)
Global -4
History -5
Organization -5
Accuracy -5
DDx -4
A young man with known case of schizophrenia, now presenting with tremor.
He is on risperidone and other med. Also, his current mental condition is provided in the stem
Tasks- History taking not more than 3 min, Perform Hand PE, Dx, DDx.
Since the mental problem and his med were provided in the stem, I skipped all the Q related to
those. In history taking, I only asked about DDx.
How long has it been?
Do you have any neck swelling? (no)
How about recent changes in weather preferences?
Any weight changes in you?
Any difficulty in maintaining the balance? (no)
Any history of head injury?
Can I ask you Q about your personal life? ( all neg )
Do you drink?
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How about smoking?
How about coffee drinking?
How is your mood these days? ( good )
I can see that you are on the risperidone, how long have you been taking that?
Do you think this problem developed after taking the med? (yes)
Anyone in your family who have the same condition? ( no)
It took me 2 mins to ask these Q. Then, I moved to another task.
In order to find out the exact cause, I still need to examine you.
My examination will involve looking at your hands, feeling you and making some movements.
Is it all right with you?
Then, I washed my hands.
At that time, the examiner asked me whether I understood the tasks or not for 3 times.
So, I checked the tasks again and said yes.
I have no idea why she kept asking me that Q.
According to the task, I only performed hand examination.
The patient has pill rolling tremor at both hands.
Do have pain in your hands right now? I need to assess your muscle tone.
There is rigidity present on assessing the tone of upper limbs.
Can you twiddle your hands? ( cannot perform very well)
Can you pls act like ur playing a piano? ( cannot perform very well )
Finger nose test ( also impaired though this is not cerebellar case)
Rebound phenomenon ( normal )
Disdiadochokinesia ( impaired)
When I tried to assess reflex and sensation, the examiner stopped me.
I didn’t assess micrographia in this station.
I asked for the postural hypotension before inspection of hands.
Tremors could be due to a number of reasons.
But what I am suspecting in your case is parkinsonism which might be related the med you are
taking now. We call it drug induced parkinsonism, affecting both hands.
It could be due to Parkinson disease affecting some parts of the brain, Hind brain problem, Benign
essential tremor, Thyroid problem, Alcohol, Coffee, Anxiety or mood disorder.
Another recall (PASS) - You are a GP. You are about to see a middle aged man who was diagnosed
with some psychotic features. He’s on Risperidone and mitazepine and was admitted in hospital
last weekend his mood has improved. He’s now in your practice for follow up. He’s otherwise
healthy. Perform PE focusing on upper arm ONLY. State your Dx.
When I went in, patient was having tremor and patient was confused in giving me findings. My
DDx:
Action - BET, Thyroid, Alcohol, Anxiety
Resting – Parkinsonism, Parkinson’s ds, Cerebellar
H/o - Tremor SORTSARA
When it occurs? Onset? Only in hand r do u feel whole body shakes?
Anything makes it better or worse? (rest/ alcohol)
Is it present at rest or during working?
Exclude D/D
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Parkinson’s - Is it associated with dryness of mouth, constipation, unsteady gait?
Associated with weather preference, voice change, wt gain? (Thyroid)
Any jaundice, liver prb (CLD)
Any medication? What medications u r taking?
SADMA - how much alcohol do u drink? Does it affect ur shakes?
Social – do u have any support at home?
Psych – Are u anxious worried about something?
How wud u describe ur mood? Do u think life is worth living?
Family h/o tremor, parkinsons
DETAILS OF SCHIZO –
Since how long
What were the symptoms you had when are first diagnosed with Schizophrenia. Snakes
crawling on his tummy?
Do you experience the same now?
Do you think that your condition is under controlled now?
Are you taking the medications at the prescribed dose regularly?
Other side effects of Risperidone:
Do you feel dizzy when you get up from bed?
Any milky discharged from the nipple?
Any dryness of the mouth?
I checked gait and loss of arm swing and all negative
Start with upper limb exam - Tone, power all normal except patient gave me cog-wheel rigidity
which made me confused. There was no hammer and cotton in room and I asked examiner so she
said not required. i did special tests: Coordination (dysdiadokinesia, finger nose test), Twiddling
test, Play piano, Micrographia - All negative and then I checked tremor- flapping tremor, intention
tremor and resting tremor, all negative. I ended up saying complete by thyroid, abdominal exam
and glabellar tap. I explained patient that it is medicinal induced and other DDx which I mentioned
above and bell rang. I should have said the word parkinsonism but I did not in stress.
5. Abdominal Pain (FAIL)
16 year old girl with abdominal pain. Tasks – History, PEFE, Dx, DDx
I failed this case because I didn’t complete the last task. The bell rang during my explanation of Dx
(PID) to patient. Zero in Dx/ddx.
Positive findings- regular period, 28 days cycle, LMP-25 days back, Started sexual life, has a stable
partner
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PEFE- foul smelling vaginal discharge, cervical tenderness
The patient told me “I think I have a stomachache.”
And I spent too much time on excluding the upper abdominal pain DDx.
The examiner showed me the middle zone of the abdomen when I asked for the site of
tenderness.
This also confused me a lot.
(Please always think about the possibility of OG case in every reproductive women.)
Another Recall (PASS) - 25 years old lady comes with abdominal pain. Relevant history, PEFE, Dx.
Pain questions- SORTSARA, PK
5Ps- multiple partners- positives, condoms- not sure what she said Sexual historyVaginal discharge positive- yellowish/greenish, no rash, no LOA, LOW
PEFE- speculum- forgot what he said, Per vaginal discharge- +, Cervical motion tenderness -+ I
think uterus was not enlarged, PT- negative
Dx- PID
6. Contraception ( FAIL)
>18 year-old university student come to your GP for contraception. She wants microgynon 30.
Tasks- take history, PEFE, Counsel the patient.
I got 3 marks in patient in organization and counselling.
4 marks in approach and history taking.
Positive findings- she brought the pills with her
Known case of asthma and on inhaler
No absolute/relative contraindications
No epilepsy, No PCOS features
Another Recall - University student comes to your GP seeking advice on starting the pill.
Take relevant history, PEFE, Counsel
Hi I’m S, taking care of you today Ange. How are you?
Starting statement- I’ve brought a pill card (There were around 3-4 ATM size cards. No pills.
)which I got from my friend and says she’d like to take the same. I see…. Great! Thanks for the pill
card Mary I’ll have a look at it!
Before I prescribe would you mind me asking few questions to see if it’s safe for you to be on the
pill. During my consultation I’ll be asking you sensitive question. Will that be ok?
Periods-regular, LMP, bleeding in between periods? Are you sexually active? Gardasil?
Head to toe screen- migraine? Fits?; strokes?( infantile/any); heart dz? breast lumps? liver dz? Leg
clots/clots anywhere? SADMA?
PMHx- HTN/DM/ Cancer of any organs? Any other? I have asthma – I didn’t ask anything regarding
asthma as I thought it’s not a absolute C/I for prescribing pill. Some candidates have asked how’s
ypur asthma managed
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PE- GA-I forgot BMI, VS- BP- normal, CVS- dual heart rhythm with no murmurs/thrills/hives? – yes,
RS- b/l air-entry with no added sounds? Yes, Abdomen- soft non-tender, no organomegaly/
distention? – yes, Calf- tenderness? –no With consent & presence of chaperone- Breast- Normal
Counseling- I took the cards she brought and started explaining to her! Two types of pills. 21
Active pills with hormones (E+P synthetic version of female hormones) and 7 dummy pills with
sugar/ iron. Active pills stop releasing eggs from ovaries and makes changes in womb and
secretions to prevent fertilization. I forgot to ask when do you want to start the pill? You may take
the pill first day of next period. Forgot to tell she could take at any time with 7 days barrier
method. Take one pill/day at the same time. Once you start follow the arrows as indicated. after
21 days you’ll get periods. If you miss a pill, <24hours- take the missed pill immediately & continue
with the rest as usual. If you miss >24 hours- take the recently missed pills immediately, keep
going with the rest and need to use a barrier methods for 7 days. In case if you miss the pill >24h
and you are at our third week, please skip he dummy pills and start taking the new pill pack after
finishing the third week pills. I must tell you pill is a good contraception method, however its not
100% preventing getting pregnant. 99% and it doesn’t prevent you getting STDs. Condoms has to
be used for protection. S/E Break through bleeding, tummy upset- will settle with time. Will
Review in 3/12 – BP & weight. Reading material.
7. Leg pain (FAIL)
GP, over 60 year-old female with calf pain while walking uphill. No pain at rest. History of DVT on
the right side. She is hypertensive, taking b-blocker. She is a heavy smoker since last 20 years.
On PE, BMI-29, BP- 140/80, Gait-normal. Peripheral pulses are absent on the right side. Left sidenormal. ABI- 0.7 at right leg. Burger test-negative.
Tasks – Explain the findings and diagnosis to patient, DDx, Further investigations, Management.
Frequently asked old recall Q.
But I didn’t pass the case.
Please check other recall feedbacks.
Another recall (PASS) – 65 years old lady presented with 2 months history of right leg pain on
walking which is improved with rest. She’s a smoker for the past 10 years. She has HTN for which
she’s taking Metoprolol & Aspirin. She’s got previous history of DVT on the right leg. ABI been
done – 0.7
Tasks: Explain the test results to her. Explain the management plan.
Key points1. DDX- LVANS (explained later)
2.stop b-blocker
3. stop SMOKING.
4. Doppler usg to exclude DVT
5. other general tests and general mx, especially weight loss.(high BMI)
6. Finish it within time ( My weakness was time mx)
I entered the room. Examiner introduced me to my patient and said that " Do you understand
your tasks? You can have a look at the screen and the paper again. "
[ I would say some examiner took my time to describe all of these . Most of them were very slow
speaker. This introduction would take time around 30 secs to 50 secs. It's better to practice and
finish all tasks within 7 mints while doing role-play. No more talking after the beep at 7 mints. I
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had poor time mx, so my friend suggested me to practise like that. I would say this idea helped me
a lot.]
I didn't introduce my name again as I have seen this patient earlier according to stem. Pt was old
and overweight male: Are you in pain atm? (no) . Okay. Then, I said that as I had already taken
history and examined you, now I would like to say what could be the causes and reasons
associated with it. Would you like me to address any specific concern first, before I proceed
further? (doc, I want to know why I'm having this?) . Okay. Most probably you have a condition
called Peripheral Vascular Diseases, Have you ever heard about this? (NO)
I drew a leg picture and drew some lines to indicate blood supplies. I said there are few vessels
like different pipe-lines that kind of act as a drainage system of our body. One of them, we called
arteries, supply oxygen and blood to our muscles. But you know there are few factors that can
alter their functions, such as high blood pressure for long time, some medication such as Bblocker, high levels of fats in the blood and smoking ; these factors can make your vessels narrow (
I did a gesture by my hands :D) and block the blood supply just like dirt in water can block waterpipes. Whenever you are walking, there is actually more need of oxygen in your muscles, which
your arteries are unable to carry through. That can lead to damage of your muscle cells which in
turn leading to pain while walking. Does any of these make any sense to you? ( Pt was nodding his
head) . I'm sorry to say that I couldn't even feel the pulses in your right leg until your groin. But let
me reassure you this condition is manageable and we will do our best to help you.
However, there are few things in my mind that could be associated with it as well. As I mentioned
earlier, there are few other vessels in our body. I scribbled again some lines in the paper.
L- (lymph nodes)-lymphangitis ( no fever, no insect bite, no trauma)
Lymphedema ( no swelling around legs)
V- (Vein)-any clots in your vein, we called it DVT
A- (Arteries)-PVD
N- (Nerve)-neuropathic pain
S- (Skin)- cellulites, ulcers, insect bite.
I would like to do some invx to exclude these causes1. some blood tests to know if there's any infections are going on or not, any problem with your
kidney and liver, fat levels in your blood .
2. Doppler usg to check any clots in your leg.
3. Angiography to check the narrow arteries.
Further MX
1. I said; I'm really worried about your long standing smoking habit (Pt mentioned himself , yeah
50 years) . As we discussed earlier, smoking is one of the major reason for your calf pain. Have you
ever thought about quitting smoking? (I tried to quit). I said excellent. This time you can definitely
do it. I will do another consultation regarding this. I'll give you some reading materials regarding
how much beneficial is quitting smoking.
2. I would liaise with specialist regarding your anti-HTN medication(b-blocker) as we have to stop
it and put you on another medication.
3. Please opt for some healthy diet as well as we know that high fats in blood are associated with
your calf pain. I would like to send you to dietician for your diet chart.
I was going to talk more about exercises, weight loss but Bell Rang!!
I thanked the pt and examiner and came out of the room.
8. Headache
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Global -4
Approach -4
Dx/ ddx -3
Education -4
Management -3
ED, intern, ~25 year- old lady with severe headache. She had similar 8-9 attacks in the past.
Vomiting and photophobia present. Some blood tests and imaging tests are done and all are
normal.
She is a happily married teacher with two children. No stress at home or work. No relationship of
headache to period. She is not on the contraceptive pill. Non smoker, Drinks 2-3 standard alcohol
Tasks- tell your Dx and DDx. Counsel the patient.
I think you might have migraine.
-What is that doctor? Explained about it, also mentioned about the trigger factors
Others include meningitis, encephalitis, ENT infection, tension headache, head injury, SOL, stroke
etc.
I explained those in layman terms and with reasons.
Told her I am really glad that all the tests are normal.
During the attack, stay in quiet and dark room.
Since you have quite severe headache, you might need the medication such as ergot or
sumatriptan.
The patient looked really confused. And we’ll arrange the med for u, you don’t have to memorize
the names. Also, you are having this headache recurrently, you might need med to prevent this
from happening again. And again, I mentioned the med names like beta blocker, methylsergide.
We will arrange that for you also. Also told her OC pill and migraine, and modify the trigger factors
present in her case. Reading material. Recheck understanding. Red flag
( I didn’t mention about aura. The examiner stopped me every time I asked Q to the patient.
You are not allowed to ask Q in this station.) *** please read the Handbook condition 129
9. Scrotal swelling (PASS)
Global - 5
Approach -5
Sequence -5
Accuracy -5
Dx/Ddx -5
A young man with scrotal swelling.
Tasks- perform physical examination, Dx and DDx.
Introduced
Are you comfortable right now?
Take consent from the patient, after explaining the examination steps in details.
The examiner told me not to wash the hands but put on the gloves.
Performed a proper scrotal examination on dummy.
Positive examination findings- left scrotal is bigger than the right
There is a ulcer like growth when retracting the foreskin
Left testis is bigger than normal size and consistency is quite hard compared to the right one
Others- unremarkable (no tenderness, no discharge, transillumination test is also neg)
Dx- cancer but this is just my working diagnosis
Others- epididymo-orchitis, hydrocele, hernia, varicocoele, epididymal cyst ( with reasons)
I also mentioned about the investigations for him to confirm the diagnosis.
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(The examiner helped me a lot during transillumination test. He helped me cover the private part
with a blanket. I didn’t have to use all the steps in SPIKE approach because the patient said it’s ok,
I am all right.)
Another Recall (PASS) - Scrotal lump - Young man presents with a painless lump on his testis for
two months. Do PE with running commentary to the examiner.
Consent- I’m S. one of the doctors at the GP gonna to take care of you this morning. I’ need to
carry out examination of genital area including penis, testicles, surrounding area and tummy. Is
that ok with you? Dear examiner can you be the chaperone? Yes. Are you happy for me to
proceed. Yep! WIPE, dummy examLook - On examination of lower abdomen and groin area- there’s no scars, skin changes, masses,
distention. On examination of the penis no obvious discharge, rashes, vesicles, ulcers. On scrotal
exam no erythema,rashes, scars,vesicles, bruising/ swelling .
Feel- any pain anywhere? On retracting the penis there is an erythematous irregular rash, no
phimosis. Non-tender temperature normal. There is a hard lump on right testis, irregular, can get
above the lump. Trans- illumination positive. No pain in epididymis. Spermatic cord nontender
with no masses.
I’d take the temperature chart , do DRE and through abdominal examination
Dx- there are possible causes for the swelling John. This lump could be a harmless / a lump of
concern with malignancy. I was thinking what to tell next. It was my last station. I said testicular
cancer & hydrocele
10. menstrual complaint (PASS)
Global -4
Approach -4
History -3
Technique of examination, sequence -4
Dx/ddx -4
A middle aged lady, history of tiredness, now come for test results.
the result of HMA is given. Iron studied – not done.
Tasks – history, PEFE, Dx, (DDx???)
Asked symptoms of anaemia, assessed severity
Diet – normal healthy diet
Generally healthy, no known medical condition
Normal bowel habit, no weight loss, No fever, No travelling history
Australian, not from middle-east or SEA
Period- heavy period, need to use many pads. Blood clots+
No history of short interval between pregnancies
The last child was born many years ago. No abdominal pain or mass, No problem with intercourse,
No bleeding disorder, Not taking blood thinning med
PE- except from pallor and bulky uterus, there is no abnormal findings. No features of heart
failure, no murmur, abdomen – normal, uterus- soft in consistency, no tenderness, no mass,
smooth surface
Explained her the test result- HMA (according to tasks- this is not necessary)
Dx- IDA due to heavy period
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Others- IDA could be due to a number of reasons, can be due to inadequate iron in diet, gut
problem
The bell rang!!
I spent too many time on explaining the lab test. (I forgot to ask the duration of heavy period)
Another recall (PASS) - Iron deficiency anemia a young lady was feeling tired and FBC results given.
Hb-Low MCV-low MCHC-low PLT & WBC normal. Tasks: History, Explain the Cause and invx result.
It was written outside lab reports that it was hypochromic micro anemia.
History _i asked 3 question for tiredness (vegetarian,anemia, UTI, pneumonia) and then I asked
anemia questions (NSAID+ which she takes two times a month, period have increased from 4 to 7
days , pregnancy – 3 kids with 2 years gap) and results all negative. No bleeding in stool, blood
vomiting, Australian origin, does not bleed from minor trauma, blood group A+, no itching of
passage at night, 5P normal.
In Mx _ I explained her blood report, RBC, WBC, Platelet and their functions and told her the
causes could be NSAID induced, pregnancy issue as less gap, could be fibroid so I will order TVS
and iron study , it can’t be thalassemia coz she is austral origin but I will rule out with special blood
test and bell rang.
Another recall (PASS) - Iron deficiency anemia a young lady was feeling tired and FBC results given.
Hb-Low MCV-low MCHC-low PLT & WBC normal. History, PEFE, Explain the Cause for her and
further management
Hi Jessica, thank you coming to see me to discuss your test results. How are you today? Alright!
let’s go through the test results .there are three types of blood cells white blood cells- to fight
infections mainly, red blood cells- to carry O2 and platelets to stop bleeding. your wbc and
platelets are normal. However the RBC smaller and paler than usual , Hb – a part of RBCs an
oxygen carrying protein is less. You are most likely having a condition called iron deficiency
anaemia. Would you mind me asking questions to find the cause for it? Aussie, no Mediterranean
background. Eating veggies and fruits mostly, chicken one meal per week. No h/o coeliac or any
absorption problem. Heavy periods menorrhagia 6 fully soaked pads per day. LMP 2-3 weeks ago.
On PE, pallor CVS BP normal HR rhythm all normal no murmur. RS normal Abdomen-Normal , PRnormal, PV- uterus slightly enlarged
From what you are describing and PE –most likely your IDA – is due to inadequate intake of iron
rich food such as red meet, then excessive periods due to an underlying cause as I found the
womb is a bit enlarged. We’ll do some blood tests – clotting profile to see if there’s any bleeding
disorder and will do USS to get an image of womb. Iron tabs- allergy? S/E- constipation, tummy
upset. Refer to OG, R/V, reading material
11. Health complaint (PASS)
Global -4
Approach -4
History -3
Dx -4
Mx -4
A young lady wanting to have nose surgery. Tasks - history taking, Counsel the patient.
The patient covered her nose with her hand all the time.
There was a mirror on the table. Typical case of BDD.
Want to have nose surgery because it is too ugly. But other people think her nose is ok.
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Repeated mirror checking + Do u have any other body parts that u are not satisfied with? (no)
No eating disorder, Weight normal, Mood normal, No stressor at home or work.
Everybody concerns about their body appearance. But it is not quite all right when it is affecting
your daily life. We call it BDD. That’s why I want u to have a talk therapy with the Psychologist
first.
You will not be satisfied with the result even if you have the surgery. If u have the thought of
having a nose surgery even after the talk therapy, at that time I’ll arrange a meeting with the
plastic surgeon.
Is it ok? (patient said YES)
Another Recall (PASS) - Young lady has come to see you to get plastic surgeon referral to fix her
nose. History, Dx, Mx.
Hey I’m S, your doctor today. How are you? Ah doc I need to get my nose fixed. I see! Well let’s
see what can be done to help you as best as I can Jenifer. Do you get stuffy nose? Sob? Bleeding?
Previous operations of nose? Would you mind if I ask you some questions ( confidentiality). Since
when you feel like that? Did any one say anything about your nose? Apart from nose, have you
ever been worried about your appearance in any other way? No. Does this concern preoccupy
you? Do you wish you could worry about less? Yes what effect has this preoccupation with your
appearance have on your life? Do you think other people talk about it? Anxiety cluster questionsare you an anxious person? Do you worry a lot? You have control over your worries? Any
thumping of heart, palpitations- + she gets this when she’s socializing. No agoraphobia or any
other phobia. How long? Few months Depression qs- SEAIGCPS, Social history- asked home,
occupation, partner, SADMA stresses? PMHx, PSHx, PPsychHx - none
Well Jenifer we all want to look our best. However in some cases the desire to look good can
occupy our thoughts and time too much. As a result some people get an idea that ther’s
something wrong with their bodies. This looks like what has happened in your case. I forgot to tell
the Dx as body dismorphiis disorder as I jumped for treatment! Yet seems I have passed this case.
Talk therapy wih a psychologist- psychoeducation, cognitive challenge. And also as you feel
discomfort to socialize the psychologist will help you with social skills. With consent we can
involve the family. Reading materials, Review.
12. Hand pain (PASS)
Global -4
Approach -4
Technique -5
Accuracy -3
Dx/ddx -4
Old lady with hand pain. Tasks -perform hand examination, Functional tests, Dx, Ddx.
Real OA patient
Offered pain killer
Empathy***
Redness and nodules over the DIP, Both hands, Deformity present, Tenderness at DIP joints
Restriction of movement due to pain, Functional tests- impaired due to pain
Dx- OA
DDX- RA, SLE, psoriatic, gout, trauma Explained width reasons
(didn’t mention heberden nodes. Also my interpretation of findings for functional tests are not
quite clear)
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Another Recall (PASS) - 65 years old lady presented with pain in her hands. Perform relevant
examination of hand & assess the functional ability if the hand.
Hi I’m S. your doc today going to take care of you, WIPE, Let me give you a pillow so that you’’l feel
comfy!
Look- did both hands
Dorsal side- On examination of dorsal wrist, MCP, PIP- there’s no erythema, scars, muscle wasting.
ulnar deviation- on MCP, no visible z deformity/ swan neck deformity- on PIP, no visible nodes on
DIP, no sausage shaped fingers, no psoriatic pitting nails
Palmar side- No scars, erythema, muscle wasting.
Feel- Real patient- started feeing both hands examiner said left is normal – only do the right side
Any pain anywhere? Let me know if I should stop please.
Dorsal- base of the thumb tenderness- +, carpometacarpal tenderness -+ PIP& DIP- nodes -+
Palm- no tendon thickness, nodules
Move- Wrist- active F/Ex, MCP- F/Ex, Thumb- Ex/F/Abd/add/opp, DIP& PIP tendon separately
checked
Function tests( coins, keys all given) Grip strength, Key grip, Opposition strength , write with the
pen
Elbow exam- erythema-+, there were no nodules though.
I don’t remember doing median nerve –Phalen test for complications for OA- but I passed with a
good score! Thank you!
Dx- OA, DDx- RA, GA, PsoA,Trauma. Washed hands.
13. chest pain (PASS)
Global -4
Approach -5
History -3
Sequence -4
Interpretation -4
Dx/ddx -6
Old lady with chest pain. Tasks – history, PEFE, Ask investigations from examiner, Dx, DDx.
Check stability. Offered painkiller
Q about chest pain- central, sharp pain, radiate to left shoulder, 1st time
No CVS risk factors at all except her advanced age
Recent flu infection+, no more flu right now
no heart burn
no other cardinal symptoms of CVS and respiratory systems
no rash over the chest
PE- scratching sound in pericardium
ENT- normal
Respiration normal
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ECG showed normal rate and rhythm, ST elevation with upward concavity in most of the leads (but
not all the leads)
Told the Dx (pericarditis) to examiner
Dx to patientDDX- MI, IHD, lung infection, gullet problem, trauma, and herpes Explained with reasons and in
layman terms
Another recall (PASS) - You are an intern at ED. 45 year old man presented with chest pain. Take
history, PEFE ask specifically, Ask relevant Invx and explain the Dx.
In this case I asked pain q related to heart, lung, mental cause and costochondritis. In PEFE
examiner did not gave me anything positive neither pericardial rub nor muffled heart sound. I
asked ECG in which it was pericarditis so I explained ECG to examiner and my DDx to patient –
Pericarditis, MI, Angina, PE, Pleuritic, Pneumothorax, Costochondritis, Trauma
Another recall (PASS) - A man sitting on bed bending forward.
Hi Ryan, I’m S, an intern going to take care of you. Vitals stable to continue history. I’ll kindly ask
my nurse to arrange 12 lead ECG and do bloods for cardiac enzymes.
Pain question- I directly asked all the symptoms for pericarditis. Pain- middle of chest for few
hours, 6-7/10, worse on taking deep breath in, stabbing, are you bending forward because you
feel better that way? What will happen if you lie down - getting worse doc. pain radiationshoulder, on& off or continuous asked.
Associated – vomiting, sweating none, NO- sob, cough, tummy pain, dark stools
PMHx- recent viral infection , no chronic diseases, no HTN, no DM, no Hyperlipidemia, no IHD, no
clotting problems, no malignancies, no DVT/ PE, no recent trauma, no autoimmune / connective
tissue problems PSHx- none, SAD- negative, FHx- cardiac disease- none
PE- GA- not clammy, sweating, VS- BP-normal, HR- normal, I’ll do the focus CVS - friction rub on
l/lower sternal border?-positive he said, JVP- not increased pulse paradoxus- absent, muffled
heart sounds-absent. RS- decreased breath sounds-no, crackles- no. Abdomen- organomegalynone. Extremities- calf tenderness/ pitting edema- none. ENT to check if the viral infection
resolved- yes Musculoskeletal- press on ribs for pain? No
Invx- I’d like to do bloods – cardiac markers, FBE- WBCs, CRP, blood gases, RFT, ECG, CXR
That’s all I have -ECG- handed over and I was asked to interpret it- wide spread ST elevation,
absence of reciprocal ST depression
Dx- Hi Ryan you have a condition called pericarditis- pericardium is the two layers that surrounds
the heart they are inflamed. Causes are infection- most likely the recent viral infection has caused
this. Other causes trauma/ surgery/ autoimmune diseases, heart attack it’s unlikely.
14. Measles (Assessed, Not scored)
Infant with maculopapular rash(photo-provided), ED, He is on feeding tube because of feeding
difficulty. The baby looks quite ill according to the photo.
Tasks - take history from father, PEFE, Dx, DDx, Mx.
Father looked really concerned. Asking me a lot of questions. Duration- a few days
I skipped some Q about rash as the photo was provided.
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Fever + Feeding problem+ Really unwell + No family history of similar problem +
Immunization- not up to date
PE- low grade fever, unwell, dehydration
On ENT examination, the examiner told me there are white rashes inside the mouth.
I asked other Q very quickly as I found the pathognomonic sign of measles (Koplik spot)
Dx - measles
DDx – meningococcemia, Chicken pox, Other viral rash, Allergy
Explanation: Viral infection, Supportive Rx, Reportable disease, Vaccination preventable disease
Can be fatal due to serious complications (I didn’t mean to scare you)
Need Rx and observation at hospital
Another recall - You are an intern at ED. 9m old baby Lilly was BIB her father as she had fever and
rash. She’s been given fluid at ED and she’s febrile and having a rash as you can see in the photo
given below. Take history for 5 minutes, PEFE, Advic e the dad further management (short term
and long term)
There was picture outside the room ,in which baby had NG tube and all over the body there was
red rash .when I went inside, father was very happy and did not know what was happening so to
all my questions he said I am not sure, I asked any discharge from nose, ear, pulling of ear, BINDS,
fever, distention of abdomen, feeding history. Positive (fever but he does not know how high is
fever, and feeding has decreased as well as wet nappies)
PEFE - 39 degree fever, no neck stiffness and dehydration present and what all I am looking in
dehydration in child, rest all normal.
In management – I told septic work up but as for now take blood for culture n urine test and gave
Ab and send to hospital to rule out foci of infection and rest septic work up from Karen and father
was v happy. I asked if he has any financial issue and if there is any other child at home, I had
enough time and I finished early. My DDx: Meningococcemia, Pneumonia, UTI, Tonsillitis, Ear
infection, Meningitis
Another recall - Measles / Measles meningitis You are an intern at ED. 9m old baby Lilly was BIB
her father as she had fever and rash. She’s been given fluid at ED and she’s febrile and having a
rash as you can see in the photo given below. Take history for 5 minutes, PEFE, Advice the dad
further management.
On history - fever for four days developed this rash since yesterday. First in the face then trunk
and generalized rash all over. BINDS ok except immunization. Dad doesn’t believe in
immunization. No breastfeeding. Goat milk given. Asked if he could go home now? I said Lily
seems so unwell and we need to rule out all the serious infections and complications before we
can discharge sir!
PEFE (I asked if he’s drowsy- he said lethargic) turgor diminished, vitals T 38, rash - Maculopapular,
blotchy and red, non-itchy. ENT-inflammation of tympanic membrane & throat , Koplik spots on
buccal mucosa positive. Nose- runny, CVS, Respiration, Abdominal, Genital area- all normal.
Hi Lily seems to have a very common childhood infection called Measles, a viral infection.
However, she seems to be unwell suggesting complication of measles such as Measles meningitis. I
need to run some blood tests to confirm this. meningococcal meningitis another type can present
with rash and fever too. Will be ruling out that. Infection prevention can be avoided by vaccinating
the child. I’d like to arrange a consultation with you to discuss about immunization once she
recovered.
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15. Abdominal pain (PASS)
Global -4
Approach -5
History -5
Sequence -3
Dx/ddx -5
A young lady with abdominal pain.GP
Tasks – history, PEFE, Dx and DDx
In the stem, there is no information about pregnancy.
Actually, the patient is pregnant. Her tummy is really distended. Typical case of preterm labour.
Frequently asked recall Q
Pain- suddenly, progressive, on and off, Fetal kicking very well, No discharge per vaginal
No history of DM, infection, PE
No fever, vomiting, No trauma history, AN care +, Bowel and urine – normal, Generally healthy.
PE- contractions +, FHS+, os open 3cm, no liquor pooling, no rigitidy, fetal lie, presentation- all
normal Others – normal ( no bruises, reflex, fundoscope, office tests, no point tenderness on
abdomen etc.)
Dx- preterm labour
DDX- preeclampsia, abruption placenta, injury, appendicitis, UTI
Another recall (PASS) - You are a HMO in a rural hospital. A lady with complaints of abdominal
pain. Hx, PEFE, Dx.
When I was outside, I did not know she was pregnant so I had other DDx in my mind but when I
went in, I saw she was pregnant so I was shocked and I changed my question pattern.
My DDx – Preterm labour, PROM.
Causes of preterm - UTI, pre-eclampsia, trauma, recent sex, medication induced, Infection, DM,
multiple baby, multiparity.
All negative so when I took PEFE from examiner, I told I will take swab, I explained patient my Dx
and though Mx was not my task still I told that I will transfer to hospital and do basic blood tests
and infection markers to rule out infection and gave her tocolytic and steroid and in hospital, they
will do USG, CTG and inflammatory markers repeat, call her family and ask for any kid at home.
examiner did not stop me so I spoke Mx and DDx and I had enough time.
Another Recall (PASS) - You are a HMO in a rural hospital. A pregnant lady 32/40 comes with
complaints of abdominal pain. History, PEFE, Dx.
Pain Qs- SORTSARA- on & off, gets every 10 minutes. No discharge. No bleeding. Previous obs
history unremarkable. Bloods done- normal, scan- normal. I asked the EDD- she doesn’t know. So
I just went with POA. PEFE- os open
Dx- premature delivery
16. Discomfort (PASS)
Global - 4
Approach -5
History -5
Sequence -3
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Investigations -4
Dx/ddx -5
~10 year-old- boy, a spastic quadriplegic, living at care center
Care giver concerns that he cries a lot when moved.
Tasks - take history from care giver, PEFE, Ask investigations, Dx, DDx
He is known case of CP
Unable to speak, or walk since birth, Cries or screams a lot when moved, Happening for a few
weeks
Living at the care center, Visited to his parents a few weeks back, No history of injury, No fever
PE- GC – normal
There is a bruise over one leg. Others- all normal except CP features
Asked for X-ray- the examiner gave me a card stating that there is a spiral # (not X ray)
Then, I explained the baby spiral #.
It is an uncommon condition. A simple fall or minor injury will not cause this kind of #.
Told him I am suspecting Non accidental injury. That’s why I need to seek help form CPA.
Another Recall - A carer of 9 years old quadriplegic boy comes to your GP as the boy keeps crying.
Relevant history, PEFE, Invx, Probable Dx.
Child is crying since weekend. Did something happen on weekend? Who did take care of him on
weekend? Was with parents. Do they usually come to see him? I’m not sure I’m new. The carer
who came in doesn’t know much as there’s another carer to look after him. Did you ask the carer
if something happened? No. any recent fall? did you happen to take care of him recently-no Any
fever- no, is he drowsy? Dehydrated? Runny nose/cough?- no, ear discharge-no,
waterworks/bowel works changes- no, growth – poor , feedinig difficulties due to quadriplegia.
PMHx- of any disease? – no
PEFE- GA- spastic quadriplegia, poor growth, VS- normal, CVS- dual heart rhythm, no murmurs, RSb/l air entry with no added sounds, Musculoskeletal –bruises/ swelling/ rednesss/ signs of NAI?
The examiner gave me the card then. There was redness, swelling bruising on tibial shaft on one
leg.
Ix- lower leg XR - Spiral # tibia. Osteopenia was written somewhere
Fracture can happen d/t brittle bones. I can see he has fragile bones from the investigations. We
call it osteopenia. Where bones can get broken easily. Bone health depends on diet and exposure
to sunlight. Does he get enough sunlight? Minimal handling doc! However, I’d like to talk to the
regular carer and his parents as well to rule out possible NAI.
22nd March 2019
1. 17 years old female patient with urinary frequency and burning sensation during passing urine.
Task: H/O, PEFE, Dx, DDx.
I failed this case. May be my approach was not good enough. Also I was bit confused in this
station, don’t know why.
In history patient was having lower tummy pain. Also she added pain just after sexual intercourse
.I was then confused if it’s endometriosis /PID. I asked about sexual history .this is her 1st partner.
It’s her 1st episode of such pain . Period hx was normal ,No renal stone type hx, No fever , pain
SORTSARA not much helpful.
75
On PEFE everything is normal .On abdomen – only suprapubic tenderness. On P/V- nothing
significant. On Urine dipstick- nitrites, leucocytes ++ (which made me sure about UTI)
I said my dx as UTI. Drew a picture showing total urinary system and told could be infection
anywhere but most probably could be the bladder due to the location of pain. Also said about PID,
Endometriosis as D/D. I didn’t mention about arranging any investigation as management was not
the task, but it’s one of my weaknesses which I couldn’t correct still inside the exam rooms.
Another recall - Young lady has urinary difficulty. Task: History, PEFE, Dx & DDx.
17 years old young female patient with urinary frequency and burning sensation during passing
urine. It was her first episode. In history she had little discomfort in lower tummy, started sexual
life few weeks/months back, unprotected sex with single partner (sometimes), otherwise well. No
h/o fever, joint pain, no URTI, no vulvar rash, no blister. No lump in vulva. No vaginal discharge.
No travel history. No lumps and bumps. No past and family h/o renal disease. No foreign body,
she didn’t put any new cosmetics over there and no h/o eczema. I took 5P, STD history, past
history and SADMA.
PEFE- No dehydration, normal vitals. On systemic examination everything was normal except the
mild lower tummy tenderness. None positive in pelvic examination.
Urine dipstick shows: blood +, leukocyte+, nitrate+
I didn’t mention any confirm dx. I drew a pic showing urinary tract system. Then explain the test
result. I told it could be infection of urinary tract affecting any parts of the pic I had drawn. It could
be infection in bladder, kidney parenchyma, ureter etc. I told it could be associated with renal
stone also. I told her it could be STD or Connective tissue disorder too. So, I need to evaluate u
further and need to do further investigations. I uttered few more differentials but cannot properly
remember now.
2. Newborn baby vomiting, drowsy. Task: take history from
midwife, PEFE, ask examiner for investigation, Dx / Ddx with
reasons.
Assessment Domain
Domain Score (see key
below*)
History
5
Choice & Technique of examination, organisation and sequence
5
Choice of investigations
5
Diagnosis/ Differential diagnoses
5
First I thought it’s a neonatal sepsis case. So In history, Asked about vomiting in details-projectile
vomiting, normal curdy milk, not green, not foul smelling. No fever, No rash. Asked about Delivery
Hx- Was it a long standing PROM which may cause sepsis. Whether mother antibiotic during
delivery (as sepsis was in my mind) Everything seems fine. Then I thought it’s not sepsis.
In PEFE -mild dehydration, mild distension of abdomen. Others findings were normal. Office tests
not done. I also asked about feeding test done or not (for distention I thought about Pyloric
stenosis). It’s negative.
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On investigation asked about FBE,ESR,CRP, Xray Abdomen and Usg. Then the midwife gave me a
Xray of double bubble sign Xray of Duodenal atresia. I mentioned the name to midwife and
explained it a sign for duodenal atresia. My ddx were infection in blood, urine bag, chest but no
copmplaints like that so less likely.At last mentioned about Congenital hypertrophic pyloric
stenosis.
The x ray was similar to this one.
3. Foot pain sudden, for 2 days, picture given inside, not outside (Gout),
Task: H/O, PEFE, Tell investigation to examiner, D/D to patient with reasons
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Choice & Technique of examination, organisation and sequence
4
Diagnosis/ Differential diagnoses
4
Choice of investigations
4
This was my Last station. Patient was quite helpful and jolly. It made my station quite relaxed. DDx
s were Gout, Insect bite, cellulitis, DVT, RA, OA, Pseudogout.
I started with pain questions SORTSARA. Pain was typical in great toe. Any trauma hx, Any insect
bite, any travel hx, calf pain, calf swelling. General hx- medication, HTN, DM. I have tried to take
hx as handbook.
On PEFE - nothing much significant.
On Investigation asked about FBE, Serum UEC, Serum uric acid crystals, if possible xray of joint.
Then mentioned about DDX as above.
Another recall - Middle aged man has foot pain. Task: History taking, PEFE, Dx & D/D,
Investigation.
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It was a gout case. A middle age man sitting in a chair inside the room. He said he was doing
gardening and then this pain started. So, I offer pain killer to him. In history I excluded trauma,
rheumatoid arthritis, insect bite, other CT disorder. After history and pefe I explained my dx, d/d
to him and also about the investigations that I wanted to do.
4. 7 years old child, tired, teacher told he seems distracted all the time
Task: H/O, PEFE, D/D with reasons
Domain Score (see key
below*)
Assessment Domain
History
4
Choice & Technique of examination, organisation and sequence
4
Diagnosis/ Differential diagnoses
4
In history, father was very cooperative (may be because it’s my first station) Just by asking about
presenting complaints he said by himself that baby snores at night.I asked about difficulty
breathing, Cough, Runny nose. Also asked whether he can finish a task or always in hurry (ADHD
was in my mind ).Asked about sneezing ( allergic rhinitis) , ear pulling, sore throat. He said 2/3
times antibiotic course in a year, poor school performance. Well Baby qs, Tiredness & sleepiness
during the day. BINDSMA qs in very short way.
In PEFE, again forgot to ask about growth chart (my weakness) examiner gave me mouth
breathing, Crowding of teeth. Red swollen tonsil on ENT exam, others were normal.
I started explaining with picture about OSA . Bell rang. Couldn’t mention about my DDx. But
Alhamdulillah and also thanks to that good examiner I have passed this case.
Another recall - 7 years old child has some school problem. Teacher told he seems distracted all
the time.
Task: H/O, PEFE, D/D
In history, dad told that teacher complained that his child seemed distracted all the time and had
poor school performance. No learning/ speech delay. No behavioural problem. No vision problem.
Further query father said school results are low because child felt tired most of the time. Then I
started with HEMIFADO and then BINDS. No infection history, no lumps & bumps, no night sweat,
no recent travel, no endocrine or metabolic finding. No h/o heart surgery. No bone pain, no rash,
no medication history. But he had h/o otitis media 2 times at past & took medication at that time.
Child had some difficulty in swallowing/ sore throat. He snored at night and there was pause in
breathing. Mother had snoring problem too.
PEFE- Growth chart, vitals normal. Enlarged tonsils, redness in tympanic membrane but no
discharge. Otherwise normal.
I drew a pic showing upper airway, then time was over. I only able to say OSA & tonsillitis.
5. Lady with left breast tenderness, swollen, gave birth to a baby few weeks back, breastfeeding.
Task: H/O, PEFE given on card, tell diagnosis and management
78
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Diagnosis/ Differential diagnoses
5
Management plan
3
I have FAILED this case though I got quiet a good score. Here I couldn’t overcome my weakness.
While doing role play I used to forget mentioning about investigations to r/o other issues. Here I
did the same. Most probably that’s the reason. Also patient mentioned about feverish feeling. I
should have atleast arranged FBE,ESR,CRP for patient. I didn’t mention about that. I said about
antibiotic, cabbage leaf as in Karen, Antipyretic, Also reviewing patient to go for USG if needed
later. Guys please try to work on your weaknesses please.
Another recall - Young lady with breast tenderness & swelling. She was feeling feverish but didn’t
measure temp at home. No problem in water work, no tummy pain, no vaginal discharge, no
cough & cold, no sore throat. No calf pain. No medication history. She established breast feeding
and said felt pain while feeding her baby. There was redness over breast skin, hot to touch and
nipple tenderness too. No lumps & bumps in body.
Dx – Lactational mastitis, I said breast abscess & postpartum fever causes as d/d.
I told investigations and management as like karen notes.
6. Urticaria case picture given. Task: H/O, D/D (PASS)
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
5
Diagnosis/ Differential diagnoses
4
In history Lady was quite jolly. I started with sympathy. Patient appreciated that. She told it has
started from back, then spread to whole body, itchy, otherwise well. Rash Hx-Nothing significant.
Asked about Allergy risk factor qs, Family Hx of allergy- Father and sister has allergy issue or
asthma don’t remember properly. No pets, carpets, none smokes at home. Asked about any
trauma by any chance ( thinking about cellulitis), Any eczema, Were the rashes dry or not (
psoriasis). Actually I was looking for ddx in my mind. Then stopped there with these DDx. Asked
any other health issues- Nothing significant.
So started with Next task. Appreciated patient as she has come to see the doctor. Then told
urticaria ( pt told she doesn’t understand), then I mentioned Hives. Told positive family hx as a
cause. Also mentioned about other ddx. Also pt asked about Mx ( as I had time in my hand) I told
about Antihistamine, Red flags.
Another recall - Rash present in young lady from yesterday. Task: H/O, Dx & DDx.
79
A young lady had itchy rashes all over the body since yesterday. Initially started from the back.
The rashes were gradually increasing. There was no history of fever, recent URTI, bleeding or
oozing from the rash. No h/o insect bites. No travel h/o, no contact h/o. No lymph node
enlargement. No involvement of airway. No systemic involvement. There was no h/o asthma, hay
fever, eczema. No similar incident in the past. No medication h/o. But has F/h of hay fever. No
personal h/o allergy. No past h/o kidney disease etc. She was Non-smoker. I took full allergy h/o,
exclude d/d and in short 5P. Occupation h/o & SADMA.
Dx urticaria/ hives. D/D I told Contact dermatitis, Medication allergy, CT disorder, Postviral rash,
eczema (I have a couple of d/d, but can’t remember all now).
I drew a pic of skin layers and explained the dx. Explain in a straightforward way why I exclude
other d/ds. Assure her a lot.
7. Mother worried about daughter, she caught her watching porn, mother is very shocked.
Take history, address her concern, make management plan for key issues (task was exactly like
this)
In history, otherwise daughter is well, good relationship with mother, good school performance.
Took brief history for mother as well but mother didn’t mention about any significant
anxiety/stress.
8. Patient’s complaint was difficulty in swallow. Thyroid examination and relevant examination,
tell D/D
(In examination thyroid normal)
Again I thought I have failed this case as there’s torch to use .Others were hammer, may be
stethoscope (actually I don’t remember)
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
Choice & Technique of examination, organisation and sequence
5
Accuracy of Examination
4
Diagnosis/ Differential diagnoses
4
80
I did as usual PE , suddenly I noticed torch. I really didn’t know what to do with torch on Thyroid
PE. I checked exophthalmos, lid lag, lid retraction, ophthalmoplegia. My heart started pounding.
But I have to use it by any chance. So I started looking for pupillary reaction which I don’t know
whether it’s right or wrong. But I passed this case.
Another recall - Neck Examination. Task: Do relevant examination, Diagnosis & D/D
Inside the room there was a middle-aged lady, expressionless, sitting on a chair. Can’t correctly
remember now but she complaints abt a lumpy feeling in the neck. She had f/o of thyroid disease
something like that. I talked with her initially to make her comfortable. Then I took permission,
wash my hands and started from GA and then hand, eye and thyroid and so on. As you all know
the steps of thyroid examination, I did the same. No positive findings except course, dry skin. I told
few d/d like hypothyroidism, thyroiditis, thyroid nodule (unlikely) & cyst. Told her I need to take
detail h/o and if needed will do few investigations to confirm the dx.
9. 12 month old baby with convulsion, now stable. Task: H/O, PEFE, tell Dx and Mx to mom.
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Choice & Technique of examination, organisation and sequence
6
Diagnosis/ Differential diagnoses
5
Patient Counselling/ Education
4
In history mother gave Hx of typical febrile convulsion. This lady hardly can speak in English. I
asked about convulsion Hx in a bit detail. Before, during and after style.Fhx of epilepsy, missed
meals, loose motion hx, fever Hx. Any cough, SOB, runny nose Hx. Only fever was positive may be,
can’t remember properly. Well baby qs, BINDSMA qs.
In PEFE, everything as usual .I just added CNS, ULNE, LLNE with that. Office test I asked- nothing
was positive.
Mx I mentioned that it’s febrile convulsion as little brains are very sensitive to temperature. I tried
to assure and showed sympathy that it can happen again, but not injurious to little brain. I told Mx
as Karen- what mother can do when kid will have another convulsion, Paracetamol whenever kid
has fever. Also mention about red flags.
Another recall - A 1/1.5-year-old boy was brought to ED by his parents. He had convulsion at home
while watching tv. This was the 2nd time he had such convulsion. In previous occasion the
convulsion was not serious in nature. No URTI. Boy had fever for two days may be. But now stable.
The Convulsion lasted for 1 min, after that child went to sleep. No tongue bite, no pee & poo. No
rashes and neck stiffness. No headache, no vision & hearing problem. No vomiting. No h/o head
trauma. No h/o diabetes, no skip meal. No f/o seizures. No one in family has epilepsy.
No positive finding in PEFE.
Dx- Febrile convulsion. D/D- Epilepsy, Meningitis, Head trauma, Brain infection/abscess(very
unlikely)
81
Assure mother a lot. Explain her the dx febrile convulsion and other d/ds. Tell her in short how she
can manage this incident at home and when to come hospital.
10. A lady with short of breath, cough, haemoptysis. Vitals given, o2 sat 91%, you started oxygen
already
Urine and sputum sample given. Task: Perform urine dipstick test, write down findings, tell
possible causes to patient
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
Performance of procedure
4
Interpretation of investigation
3
Diagnosis/ Differential diagnoses
4
I read this case may be only once or twice, but not as a recall as it didn’t come in 2018, just sliding
through a slide. I tried to do as much as I remembered. For procedure pls try to follow the Geeky
video. That’s really a good one.
For Dx/DDx I just mentioned Infections in lung which has travelled to kidney. Also I mentioned
problem in kidney system as well. Some candidates told it could be goodpasture syndrome. But I
didn’t mention about that.
11. MSE video of mania, then present findings to examiner with reasons, no need to tell diagnosis
Domain Score (see key
below*)
Assessment Domain
Commentary to Examiner
5
Accuracy of Examination
4
Here I mentioned MSE as ABSEPTICJ RRR. I finished earlier, then examiner asked me – do you want
to add anything? I got confused what to add more? Did I miss anything? Tried to check in mind.
Then told pt doesn’t have any suicidal ideation and on asking about recreational drugs use she
didn’t reply anything directly.
12. Patient came with irregular bowel movement and per rectal bleeding. Do focused abdomen
examination and per rectal examination, tell D/D. (FAIL)
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
5
Choice & Technique of examination, organisation and sequence
4
Accuracy of Examination
5
Diagnosis/ Differential diagnoses
0
82
On examination, I started from Hand as a normal abdomen examination. Finished examination
well and DRE. But may be examiner didn’t like my ddx- Diverticular disease, Haemorrhoids, Anal
fissure, polyp. Just because of the Ddx I lost this case.
Another recall - Inside room there was a healthy middle age person. It took a while for me to
examine him as I’m a short, thin girl. There was some pigmentation and a scar mark over his
tummy. Otherwise palpation, percussion and auscultation were normal. No anal fissure in per
rectaI examination. I found his prostate gland was little enlarged with smooth surface.no other
positive findings. Cough reflex negative. No blood in my finger. I did all the steps I believe. As
soon as I finished my examination the time was over. So I couldn’t get any chance to say any dx
and d/ds. I just told hemorrhoid.
13. GDM case. 27 weeks pregnant lady, OGTT result- 2 hours after result was high. Task- interpret
result, talk about Mx plan, 6 week postpartum period Mx.
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
6
Interpretation of investigation
6
Diagnosis/ Differential diagnoses
6
Management plan
6
In this one I tried to follow as handbook case for key points. I made sure patient was
understanding everything in every few moments. I mentioned about high risk pregnancy clinic,
dietician for diet chart to reduce blood sugar, asked to check it regularly, then after few weeks if it
doesn’t work properly then specialist can start with insulin. Risks to herself and risks to baby.
Tertiary hospital delivery.
For 6 weeks postpartum check-up I told patient about her check-up and also baby’s one.
Before leaving room, examiner looked very happy.
Another recall - Obstetric case, 27 weeks, OGTT done, 2 hours post prandial high, fasting normal
(as far as I remember). No diabetes before.
Task: Explain investigation finding, Dx & D/D, Tell management plan including postnatal period
Inside room there was a 27 week+ pregnant lady sitting on a chair. She was anxious. I asked how
is her pregnancy going so far & congratulate her. Ask about her understanding regarding the
investigations. Explain her the result.
Dx- GDM (Explain it in simple term and why this can be happened to a pregnant woman)
D/Ds- Previous undiagnosed DM (I could not remember whether I mentioned anything else or not)
Tell her what’s my aim of glucose level throughout the pregnancy. Why it is important to treat
this, what are the effects of high glucose in mom and baby in short.
Tell her the management plan. Review by the MDT. Lifestyle modification now & throughout
pregnancy f/up plan. If not controlled by lifestyle modification then specialist might consider to
start insulin. After delivery it will resolve in most of the cases but still we will do follow up after 6
weeks of delivery. Reading materials
83
14. Respiratory examination, then tell findings to patient with D/D
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
5
Choice & Technique of examination, organisation and sequence
5
Accuracy of Examination
3
Diagnosis/ Differential diagnoses
1
Here I told whatever I have found – Patient had scoliosis, decreased chest movement, vocal
fremitus increased on right side, percussion node dull on right side, breath sound diminished on
right side.
For Ddx I mentioned pneumonia, pneumothorax, fibrosis, collapse.
Another recall - I follow all the steps of respiratory system examination. I started with hand, vitals,
eye, mouth, neck and then chest. Examiner told me to skip some step most of the time, that’s why
I was able to mx my time. I found barrel chest and some pigmentation. There was decrease vocal
fremitus, vocal resonance and air entry on left middle and lower zone. Normal percussion node.
Breath sound was normal with no added sound. I just said whatever I really found.
Dx- COPD (probably but not sure)
D/D- Asthma, Pneumonia/Consolidation, Ca (unlikely)
15. (Unscored case) Diabetic female, taking insulin, went for shopping, felt unwell, about to fall,
now stable, ECG given, I think there is ST elevation. Task: H/O, interpret ECG to examiner, tell D/D
to patient.
No chest pain in history, could be silent MI.
16. Truck driver, her employer told her to see doctor, because she was not feeling well. Task: H/O,
D/D.
(PTSD case, In stem, no clue of accident, after asking specifically she told about accident, a man
was killed in that accident, then typical PTSD history)
26th March 2019
1. 20 years old female came because she wants to get pregnant and wants to avoid any problems
like in the birth of her previous delivery.
Task- Hx, tell her causes of why it happened in previous delivery, tell her about future pregnancy
and management.
FAIL
84
Positive- She had an 18month old child via emergency. C-section as her labour was not
progressing. Baby’s weight was 4.1kg.
5Ps- using OC pils for now.
Details of previous pregnancy- No complications, all normal, No mention of small pelvis during any
antenatal visits, No DM, baby 4.1kg, she mentioned baby being back to back during labour- I think
meaning occipital-posterior position. She had an emergency c/s transverse low incision.
SADMA Fhx- GDM, DM, Large babies- nothing positive
Told her it could have been because of her large baby that she had to undergo emerg: c/s or could
be due to CPD… Drew a diagram and explained… said we will look into CPD and rule that out… will
monitor next pregnancy for GDM and large baby.
Told that this is called as VBAC and it is possible and since she desires a normal delivery we will try
to achieve that but due to previous c/s she is at risk of uterine rupture and increase chances of
c/section so labour will be monitored..
Reading material
Didnt ask height of partner/patient
Didnt mention that ocipito-post position of baby being a cause of progress of labour
Didnt ask any complications with previous c/section
2. 4 month old baby vomiting. Task- Hx, PEFE on card, Dx, Mx
PASS
PEFE normal + growth chart normal- GORD
4 month old, vomiting after feeds, white color, no smell, no discolouration, not projectile, no
fever, yellow discolouration of skin, bowel/ waterworks normal, no ENT problem. No
irritability/drowsiness, breast fed baby on demand.
BINDSMA- nothing significant
Told about GORD. Drew diagram and explained. Gave a lot of reassurance as she said is tired of
doctors telling her its nothing serious to worry about. Told her many babies have this problem.
Will get better with time. Keep baby upright after feeds, burp half way between and after every
feed. Avoid overfeeding. Gets better after starting solids. If baby is showing signs of readiness for
solids consider starting solids. Can try gaviscon sachets if very troublesome.
85
Reassure.
Reading material.
Didnt mention any complications of reflux- aspiration, ulcers, inflammation, dehydration
3. Young pt. Recently diagnosed with epilepy 4 months back. Had 1 seizure 4 years ago but no
work up was done and was fine after that. Had a grandmal seizure 4 months ago and started on
carbamezipine 100mg bid. Her license was cancelled. Now came as she wants to regain her license
back.
Task- Hx, address her request to get her license back.
PASS
Positive in hx- not taking medicines regularly, binge drinking on weekends
Hx- had seizure 4 years ago, doesn’t remember anything about it, the one 4 months ago was at
home, her mom was there, gen tonic clonic seizure, no tongue biting, no incontinence, started on
medicine… no seizure since but often forgets to take medicines in the morning due to hurry to go
to uni… asked about side effects of medicine- she mentioned nausea but it was not too
troublesome...drinks alcohol on weekends- binge drinking
SADMA, Fhx- no fhx of epilepsy
Told her that since its only been 4 months we have to wait until 6 months completed after
medicines started and her having no fits… but in order to make sure her fits stay under control she
needs to be compliant with them,,,
See her again in a few months and reassess her then to get her license back to her
Told her precautions regarding staying away from water, fire etc
What to do in case of seizure.
Regular review with specialist. Told Red flags
4. Lady got punched in the face with bruise on cheek, neck cleared already. Task- P.E, DDx
PASS
Positive- bruise on right cheek, anaesthesia on cheek, diplopia upward outward gaze
86
Started with inspection of face, eyes, nose, mouth, ears
Palpation of head, spine, paraspinal muscles, face
Neck movements
Optic nerve exam- normal, light reflex + accomodation- normal, fundoscopy- normal (told by
examiner about fundoscopy)
Otoscopy-normal, hearing tests- normal (otoschopy and hearing test results told by examiner)
3,4,6 nerve exam- diplopia
5th nerve- anesthesia of cheek (cotton and toothpick were there)
(Ran out of time, couldn’t do motor of 5th nerve or 7th nerve exam)
DDx- told her about orbital floor fracture… drew a pic and explained… told abt compression of
nerves or muscles due to the fracture or swelling… Time finished… quickly mentioned will do CT to
rule out all causes
5. Pt taking temazepam for 1 year. Task- Hx (psychosocial), Tell reason for insomnia, maybe mx
too (i’m not sure)
FAIL
Positive in hx- Mild depression, dependent on temazepam, no stress at the moment, just difficulty
with sleep
Didn’t really say why he started temazepam in the first place. Just said he had sleep issues. Even
after saying confidentiality statement he didn’t say much as to why he was having sleep trouble.
Mood was a bit low, sleep problematic- trouble initiating sleep- he takes his medicine and lies in
bed at 9-9.30 but it takes a long time to fall asleep, then even after going to sleep he wakes up
often in the middle of night, wakes up late in morning, appetite ok, anhedonia, passing thoughts
of suicide and as to why am I even alive but never thought much into it or made a plan for it.
Works 3-8 at a daycare and job is good. Lives with his parents. Coffee x 2 a day.
SADMA- only few drinks occasionally.
Forgot to ask questions about dependency on temazepam. And also he doesnt get along with
parents according to other candidates but I didnt get that in hx.
He said he worries what will happen if he stops taking it.
Reasons for insomnia I told about mild depression, and taking temazepam for so long.
Told about reading material for sleep hygiene and considering switching temazepam to another
medicine and then tapering it off.
87
Counsellor for talk therapy.
6. Middle aged guy, nose bleed. Already soaked through many handkerchiefs, nurse has done
some nasal packing. BP- 140/90, Task- Immediate mx of nosebleed, Hx, Causes, Mx
PASS
Positive in hx- HT, uses steroid nasal spray for allergic rhinitis
Told him to keep head straight, pinch his nose tightly and ice pack on nasal bridge for 5 mins. Then
check after 5 mins. If still bleeding do it for another 5 mins. It stopped bleeding in a few min :)
First episode, sudden, was at work and started, no sudden change in temp, no nose picking, no
trauma to nose,
HT- takes ACEI for it
no bleeding disorder, doesn’t bleed/bruise easily
SADMA- nothing significant except takes steroid nasal spray for allergic rhinitis, no blood thinning
meds
No Fhx of clotting problems
Cause- Nose is very vascular and even minor trauma and issues can cause nose bleed. In you
probably due to steroid nasal spray leading to thinning of nasal skin, and HTN, DDX- nose picking,
changes in temperature.
Next time it happens, do the same as I just taught you, if it doesn’t stop after a while then come to
ED immediately will consider doing packing, or cautery if needed. Can use saline drops and
vaseline to keep nose moist.
Forgot to mention not to blow your nose for next 12 hrs, sneeze with open mouth, if it’s very dry
use humidifier at night or doing a coagulation screen.
7. CVS risk assessment, brother had angioplasty. Task- Hx, PEFE, CVS risk, Invx.
PASS
Risk factors positive- Smoker, alcoholic, bmi-30, never had BP, cholesterol, BSL checked, sedentary
lifestyle, unhealthy diet, Fhx of heart disease in brother and mother.
88
Took relevant history:
Alcohol +ve
Blood pressure- never checked, BMI-30
Choleterol- never checked
Diet- unhealthy, Dm-never checked BSL
Exercise- nil sedentary lifestyle
Smoking +ve
Problem with bowel, waterworks- none
Drugs, medications, allergies- none
Fhx- of heart disease in brother + mother
Forgot to ask abt stress in hx. Also abt chest pain, sob, palpiations, numbness, weakness.
PEFE- checked BP twice- both times was high, other vitals normal
BMI- 30
Didn’t ask UDT, BSL, ECG, fundoscopy.
Asked for risk assessment chart- not available
Wrote down the ABCDEFS.
Explained all the positive risk factors in the and just quick brief ways to manage/monitor those.
I/V- FBE, Lipid profile, BSL, LFTs, UEC, ECG.
8. Rural hospital setting. Tertiary hospital 400km away. No CICU available here. Long full page
length stem given. Was unable to read full question in 2 mins. 50s male chopping wood and having
pain on arm and chest, brought to hospital. ECG given. Need to talk to wife about further
management. No transfer possible. Vitals were given in stem.
Task- Explain ECG to examiner, explain further management to wife (you can ask the wife
questions if you need to know anything for mx)
PASS
89
ECG- Anterio-septal stemi
Ecg of XYZ patient taken today due to pain in his left arm and chest showing rate of 65-70bpm,
regular sinus rhythm, normal p wave before QRS, QRS normal, ST elevation in v1, v2, v3, v4. (After
telling all this examiner asked me what else? I didnt know what else to say!)
Asked wife if she had SPA.
Told her what her husband is having is called MI, told her about it and why it happens. Told her
that it is an emergency condition and we will do immediately MONA- he was already being given
oxygen, so mentioned morphine and metoclopramide, then sublingual nitrates, aspirin.
Ideally PCI should be done, but since it is not available and tertiary hospital is so far, I will get a
senior to come and have a look at him and we will consider doing thrombolysis after ruling out
contraindications. Told her about thrombolysis a bit.
Then said once he is stable, we will start him on regular aspirin, ACE, B.blockers. Told about rest
and followup.
Didnt mention checking troponins or other blood i/v and repeat ecg.
9. 6 year old child with sore mouth. Pic given.
Task- Hx, PEFE, Dx, Mx
PASS
Positive- Herpes stomatitis- Painful sore mouth, lesions outside lips and tongue seen, aunt had
some sort of a cold sore
6 year old child, complaining of sore around her lips and then her mouth later… painful, no
discharge, no bleeding, no itching, no hx of any hot drink, no hx of trauma, no hx of change of
lotions/cosmetics, very mild fever, otherwise well, no ENT symptoms, not eating so well now due
to pain, but drinking well, hydrated, still going to school, no hx of contact at school, hx of aunt
visiting with a sore of lips, BINDSMA normal.
PEFE- vitals and growth chart normal, Pic of tongue given. No discharge from rash. No signs of
dehydration. No ENT findings. No neck nodes palpable. No rash anywhere else. No other
significant finding.
Dx- Herpetic ulcers due to virus herpes simples. Contagious.
90
Mx- Lignocaine gel- local anesthetic, supportive care, maintain adequate hydration, no going to
school, hygiene measures to prevent spread at home, reassure.
Red flags. Reading material
10. Lady with excessive bleeding during menstruation since last few months, family history of
thyroid and HTN.
Task- Do relevant examination on patient, ask examiner if u want to know anything else on PE, Tell
patient Dx, Ddx
PASS
Positives- Did vitals, thyroid exam on patient, abdominal and pelvic exam told by examiner as
having irregular mass in uterus
Started with bp, pulse.(forgot to ask for postural drop)
Then hand examination looking for signs on anemia and thyroid
Commented on bruises and petechias on arm to rule out bleeding disorder
Then did eye exam for anemia and thyroid changes, nystagmus/diplopia.
Mouth exam for pallor and dehydration
Neck exam for thyroid
Abdominal findings given by examiner- enlarged uterus to 12/14 weeks, irregular mass arising
from pelvis, no tenderness, pelvic inspection and per speculum normal, per vaginal irregular
uterine mass felt, no tenderness, no adnexal tenderness
Dx- Fibroids, other causes can be thyroid, bleeding disorder, blood thinning medications
(Didnt ask UDT, BSL, UPT)
11. Young guy with rash on lower limbs. Pic given. Task – Hx, PEFE on card, Dx, DDx.
PASS
Positive- sorethroat and fever a week ago, PEFE- petechial rash on lower limbs, few lymph nodes
in neck, Dx- ITP, DDX-HSP, Meningococemia, trauma, allergy etc.
91
Hx- rash since few days of lower legs, bilateral, no painful, no itching, up to knees, sudden onset,
no discharge, no hx of trauma, no hx of contact with anything, no hx of change of cosmetics, hx of
sore throat and joint pain and malaise a week ago, no joint pain now, no tummy pain, no problem
with bowels or waterwards.
PEFE- vitals normal, pic of petechial rash on lower limbs- non tender, non balanchable, few neck
nodes palpable
Dx- ITP- will do blood test to see level of platelets and decide treatment plan then. DDX-HSP,
meningococcemia, trauma, allergy
12. Old aged male came because his friends think he has parkinsonism.
Task- Do relevant PE, DDX
PASS
WIPE.
Started with gait- stooped posture, otherwise normal.
Tandem gait- he had trouble and was falling
Could stand on heels and toes
rhomberg- negative
Hand- pulse-normal, pallor -ve, koilonychia -ve, onycholysis -ve, palmar erythema- mildly, fine
tremors +ve, flapping tremors -ve
Bicep reflex- normal
Eyes- thyroid eye changes, nystagmus, glabbellar tap- all normal
Mouth-no drooling, british constituion, baby hippotamus- no slurred speech, no hypophonia
Neck exam for thyroid
Dysdiadochokinesia- normal
imaginary piano- normal
opening door knob- normal
(Forgot to do tone, intentional tremors- past pointing)
92
Positive was stooped posture on walking, problems in tandem gait, fine tremors.
Ddx- Essential tremor, Cerebellar lesion, thyroid, parkinsons
13. 37 Lady with breast pain.
Task- Relevant Hx, Breast examination on dummy, DDX- No mx
PASS
Postives- cyclical breast pain, just lumpiness/nodularity on breast, no obvious lump.
Pain about 4/10 on both breasts, since few months, comes on few days before periods, settles
after a few days of periods, relieved with panadol, no obvious lumps, no nipple discharge, no
redness or rash, no hx of trauma to breast, No fhx of breast ca, gynae ca
Breast exam on dummy- no lumps, just a bit nodularity/lumpiness all over the breasts, no axillary
nodes, no neck nodes
Ddx- cyclical mastalgia, breast cyst, fibroadenoma, breast ca
(Forgot to mention fibroadenosis as Ddx)
Didnt ask 5P’s, SADMAC
14. New patient came for routine antenatal checkup, all ok so far. Task- Hx, PEFE, Ddx or reasonsno mx
PILOT
Positive- 40 wks, first pregnany, everything normal so far, no abnormality on PEFE, head not
engaged, mobile, ballotable
Hx- first pregnancy, planned, 40 weeks, everything ok so far, no issue in any ANC or i/v, ultrasound
at 8, 12 and 20 week normal- single baby, no issues with placenta, everything normal, papsmear
normal, baby well kicking well, no bleeding, pv, tummy pain, discharge down below
PEFE- vitals ok, FH- 40cm, lie longitudinal, presentation- cephalic, not engaged, head fully
ballotable, fetal heart tone 140bpm
pelvic inspection- normal
per speculum- normal, os closed
93
Told her that normal due date is around 40 weeks but in first pregnancies can be bit later, so you
are going past your due date now and on examination the baby also seems not to be engaged,,,,
drew diagram and told abt engagement… so It could be either due to CPD, large baby, unlikely due
to placenta previa or fibroids as would have come up in previous exams… but will need refer to
monitor baby more regularly now with ultrasound and ctg as after 40 weeks the placenta might
not be sufficient for the baby and can lead to many complications and if after a week or so you’re
still not in labour specialist can consider induction or c/section depending on condition.
Didnt ask height of patient. Should have said we can wait till <42 weeks for spontaneous labour
then consider induction or c/section
15. Lady with RUQ pain for 6 months, hx of cholecystectomy few years ago. PILOT
Task- HX, PEFE on card, Ddx
PILOT
Positives- Pain not related to food, 10kg unintentional weight loss in 6 months, loss of apetite, fhxbrother with bowel cancer. PEFE-Hard non-tender 2cm enlarged liver
RUQ pain for 6 months, I think 6/10 in intensity, there all the time day and night, relieved partially
by panadol, exagerated by nothing, no relation to food, no yellow discoloration of skin, no
waterbrash, sob and not feels well while gardening, loss of 10kg in 6 months, loss of appetite, not
feeling well, fatigue and tiredness
Hx of cholecystectomy few years back, was well after that, no complications until 6 months ago
when this pain started.
htn on atenolol, hypercholestrolemia- managed by diet
FHX of brother with colon cancer
PEFE- vitals ok, liver hard and enlarged
DDX- I’m worried about a nasty growh or a cancer as u had so much LOW, LOA, have a fhx of
cancer and u have this pain as well, other things can be a stone due to high cholesterol, stricture
due to previous surgery (ran out of time)
16. Video MSE Recently diagnosed pt. of shizophreniform
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PASS
Introduction---Appearance- Dishelleved hair and appearance, wearing sunglasses
Behaviour- Fidgety, co-operative
Speech- Pressured speech, increase rate, volume normal
Emotion- She said mood was okay but pressured and seemed congruent to affect.
Perception- Auditory hallucination, no visual or taste hallucinations
Though- form- flight of ideas
Thought content- delusions of reference, delusions of grandiosity, delusions of control
(not assessed- thought insertion/withdrawal, persecutory/paranoid- but seems a bit paranoid
while answering some questions)
Insight- no
Judgement- not assessed
Cognition- normal
Risk- no risk to self, but risk of others
Rapport- was not able to build rapport with the patient
Reliability- hx seems reliable
27th March 2019
1. URINE DIP STICK: PASS
Global score 4
Performance of Procedure 3
Interpretation 6
Differential Diagnosis 6
I never prepared for Urine dip stick and only did it once in my course.
Case: 64 Year old man who has recently started developing swelling both his legs which is now
extending up to his knee. He has come to his GP where a Urine sample has been collected. He
doesn’t have diabetes or cardiac problem. BP around 130/90. It was a long stem and most of the
history given was negative.
Task: Perform Urine Dip stick. Interpret and record the results. Give DD to the examiner.
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I was clueless as to what lies ahead, went inside, who showed me the trolley, where there was a
stand with test tubes filled with liquid, some of them were yellow, and some were cloudy white.
On the table there was tissue paper and a small table clock which I observed later. The hand
sanitizer was covered with a tag saying to use gloves without using the sanitizer. I took out the
strip, dipped in to the sample which the examiner gave me. I was unsure as to how long I should
dip it so I left it in the tube for good 20 seconds (Mistake). Removed stick and placed it on the
tissue paper for a while and then read the results. Proteins were +++ and rest were negative. I
removed the gloves and discarded them along with strip. Examiner gave me a sheet to fill; it had a
chart with 2 columns. I just had to write negative or positive in front of the substances. Then I gave
him all the DD, like nephrotic, nephritic, renal failure, CCF, Auto immune, DX like SLE, Vasculitis,
and Long term standing. Then explained my strongest suspicion was nephrotic and gave him
reasons. Finished in 4 mins and sat there waiting for the bell to ring. I didn’t do it properly yet I
passed because of my interpretation and DD. Please look up for it as it is really easy station to pass
if you have done it a couple of times.
Another recall - LEG SWELLING
GLOBAL SCORE 5
PERFORMANCE OF PROCEDURE 5
INTERPRETATION OF INVESTIGATION 7
DIAGNOSIS/ DIFFERENTIAL DIAGNOSES 4
TASK: PERFORM URINE DIPSTICK, DX AND DD
EVERYTHING WAS GIVEN IN A TRAY INSIDE THE ROOM.
-CLOCK
-URINE BOTTLE
-STRIP
DID EXACTLTY AS MENTIONED IN YOUTUBE. PLEASE DO LOOK INTO YOUTUBE FOR COMPLETE
DETAILS.
WASKED HAND. USED GLOVES. ASKED FOR PERSONAL PROTECTIVE EQUIPMENTS (PPE LIKE
APRONS AND GOGGLES AND MASK) BUT SAID NONE AVAILABLE . SAID OK. THAN CHECKED THE
URINE JAR AND CONFIRMED THE PATIENT DETAILS. EXAMINER SAID THE DETAILS ARE CORRECT
PROCCED WITH THE PROCEDURE. CHECKED THE STRIP EXPIRY DATE AS WELL.
THAN DIPPED THE STRIP IN URINE AND TOOK OUT QUICKLY AND KEPT IT ON THE TISSUE PAPER.
THAN CHECKED FOR COLOR CHANGE. GIVEN NICLEY ON YOUTUBE PLEASE DO HAVE A LOOK.
FOR ME IT WAS PROTEIN 3+ OTHERS NEGATIVE SAID
DX: NEPHROTIC SYNDROME
BELL RANG
Another recall - Old man has come with bilateral leg swelling. He never had chest pain or
hypertension. Today his BP
150/90 .
96
Task: perform dip stick test and give ddx
Perform the procedure:6
Interpretation of investigation: 3
Ddx:6
GLOBAL SCORE 5
Approach: I entered, no patient was present in this station. Examiner show me all instruments and
sat on the corner of the room. I stared with wearing gloves, did inspection of urine, open the lid
and
pretend to smell urine for odour, then dip the stick and keep it horizontally for 1 min. there was a
clock inside the room. After one minute I saw readings , there was a paper on the table to write
the
positive findings. I saw the stick and throw it in the bin along with gloves. I stared writing then I
noticed that I shoudnt throw the stick until writing but it wasn’t possible to pick up stick from bin
again Jso I rely on my faith and write whatever I got. For me positive was protein3+ and glucose
2+
I wrote the findings and said heart failure as my first ddx. Then liver failure, renal failure,
nephrotic
syndrome, uti. Again finished early and I said why I was thinking it is heart failure.
2. RESPIRATIORY EXAM: FAILED
CASE: Young guy preparing to run for a marathon and while warming up felt a sharp chest pain
which didn’t subsided with Panadol. Pain is aggravated by breathing and he has BIB to ED by
friend
TASK: Perform Resp exam. Ask for relevant INX. Interpret INX and explain to patient. Give DD
There were too many tasks for 7 mins, I went inside, washed my hands and offered pain killers,
took consent and started my examinations from hands just like Geeky medics but the examiner
kept saying skip. He wanted me to just do chest, I went to the chest and only did the front, as the
patient was a very good actor and was breathing heavily, turning red and showed as if he was in
too much pain. I completed my examination, everything was normal; I asked examiner for CXR
which he gave. I expected to find pneumothorax, in the CXR, yet the x-ray looked like
Bronchopneumonia. I was stressed and started using medical jargons in explanation. After that I
had no time for DD and thus failed.
TIP: No matter what the x-ray show, always explain patient in simple terms, don’t take time for
yourself to interpret, just start talking with patient and give DD alongside. Things might be
unpredictable in exam.
Another recall - CHEST PAIN
GLOBAL SCORE 4
Choice & Technique of examination, organisation and sequence 4
Accuracy of Examination 4
Interpretation of investigation 4
Diagnosis/ Differential diagnoses 4
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TASK: DO PE, ASK INVS, EXPLAIN AND GIVE DX AND DD
YOUNG BOY RECENTLY HAD A RTA AND AFTER THAT COMPLAINING OF CHEST PAIN AND
DIFFICULTY IN BREATHING.
WIPE APPROACH! SHOWED EMPATHY SAID SORRY FOR THE ACCIDENT THAN TOOK CONSENT.
ASKED IF HE HAS ANY PAIN.
THE MISTAKE I DID WAS STARTED EXAMINATION FROM THE FRONT AS PATIENT WAS SITTING WITH
MASK ON AND WAS ON THE SIDE OF BED. DIDN’T WANTED TO DISTRESS HIM BUT LATER ON
REALISED COULD HAVE ASKED HIM TO STEPPED DOWN WHICH I DID FOR EXAMINING FROM THE
BACK.
QUICKLY DID ALL. EXAMINER DIDN’T SAY ANYTHING. GAVE NO POSITIVE FINDINGS.
THAN ASKED FOR XRAY. EXPLAINED A BIT AND SAID PNEUMOTHORAX THAN BELL RANG. EXAMINER
ASKED ME POINT OUT PNEUMOTHORAX AND THE LUNG LINES.
I DID HE WAS HAPPY AND PASSED ME J
PE: STARTED FROM VITALS, PALPATE THE TRACHEA.
CHEST: INSPECTION , PALPATION, PERCUSSION AND ASCULTATION
DIDN’T CHECK VOCAL FREMITUS BUT DID VOCAL RESONANCE.
FOR ME EVERYTHING WAS NORMAL AND EXAMINER DIDN’T GIVE ME ANY POSITIVE FINDINGS.
3. FEEDING PROBLEM: PASSED
GLOBAL SCORE 4
APPROACH TO PATIENT 5
HISTORY 4
PEFE 4
DD 4
9 MONTH OLD BOY COME TO GP, DUE TO RASH AROUND HIS MOUTH OUTSIDE AND INSIDE PHOTOS WERE GIVEN
(URTICARIAL RASH AROUND MOUTH)
TASK: HISTORY FROM MOTHER, PEFE, DIAGNOSIS AND DD.
SHOWED EMPATHY TO MOM. APPRECIATED HER FOR BRINGING HIM IN. RASH AROUND THE MOUTH
SUDDENLY ASKED IF SWELLING OF TONGUE / DIFFICULTY IN BREATHING. NONE. 1ST TIME. NEVER
HAPPENED BEFORE. ASKED WHAT WAS HE DOING AT THAT TIME. SAID WAS HAVING LUNCH AND HIS
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BROTHER GAVE HIM EGG TO EAT. NEVER HAD EGG BEFORE
NO FEVER. NO RASH ELSEWHERE. BINDS NORMAL. HAPPY FAMILY. H/O ATOPIC DERMATITIS. NO H/O
ALLERGIC RXN TO FOOD BEFORE
PEFE: GAVE A PICTURE OF RASH ( VERY SIMILAR TO DOWN BELOW)
DX: EGG ALLEGRY
DD: ALLERY TO OTHER FOODS, ATOPIC DERMATITIS, INSECT BITE
Another recall - FEEDING PROBLEM: Passed
Global score 5
Approach to patient 5
History 5
PEFE 5
DD 5
Case: 9 month old boy come to GP, due to rash around his mouth outside and inside photos were given (urticarial r
TASK: history from mother PEFE and diagnosis and DD.
Mother was deeply concerned and worried, on history she told me that she has started solids and has more interes
some stuff from his brother’s plate during breakfast. It was pretty difficult to get mother to give me these details. I
details, I also asked about if the baby has eaten anything to which she said NO, but when I asked about the breakfa
name foods like peanut, shell fish and eggs (Bingo) she said yes which made me happy.
She then told me upon triggering that it has happened in the past too and subsided quickly. Then I asked her about
was a long history. Then went for PEFE, the examiner was fast gave the entire findings negative, only pointed to the
and gave DDX with reasons. Burns, Egg allergy, Food Allergy, Dermatitis (irritant/contact), herpes, insect bite, scho
now.
Another recall - 11month Child came with rash on face. Task: hx, pefe,ddx
Approach to patient: 5
Hx:6
Choice of examination:6
Ddx:6
99
GLOBAL SCORE 6
Approach: I was thinking egg allergy as my first ddx as I practised this case before. After entering I
greeted mother and mother said rash for the first time, never happened before, not
itchy,oozy,scaly,no previous food allergy,no other allergy, no PHX fo allergy, FHX of asthma hay
fever,she didn’t give me any single positive findings other than rash, time wasrunning out and I was
nervous. Then I stared leading questions. Did he eat anything in the afternoon- she said I don’t know
LI asked any egg allegy- noLanyone feed him egg-yes his elder brother J. Exclude sign symptoms
of anaphylaxis (SOB, lip swelling, tongue swelling,Loss of consciousness-all negative) quickly asked
binds and move to next task.
PEFE: all normal except rash on face. I asked every system and examiner ran me by saying normal.
Ddx: egg allegy, anaphylaxis (unlikely), atopic der, seborric (unlikely at this age and due to location)
4. MENTAL HEALTH ASSESSMENT. MANIA(FAIL)
GLOCAL SCORE 3
CASE: A UNIVERSITY COUNSELOR HAS SENT A STUDENT FOR ASSESSMENT TO YOUR GP AS SHE IS BEING DIFFICULT
DISRUPTIVE AND HER PERFORMANCE IS DECLINING.
APPROACH 4
HISTORY 3
DX 3
DD. 3
MAINTAIN CONFIDENTIALITY. ASKED ALL PSYCHOSOCIAL HX. SADMA
DX: MANIA
DD: SUBSTANCE ABUSE, BPD
DON’T KNOW WHAT WERE THEY LOOKING FOR L
Another recall - Mental health Assessment.
Global score 7
Approach to patient 6
History 7
Differential Diagnosis 7
Case: a university counselor has sent a student for assessment to your GP as she is being difficult and disruptive and
diagnosis and DD.
In this station I took complete history MSIGECAPS+ABSEPTICJ The patient has flight of ideas, very rapid speech whic
asking general questions like how is her university going, about her friends and family, and if she works and about h
counselor is worried, she replied that she is completely fine and doesn’t know why the counselor is worried about h
simultaneously; all were different subjects and was not working (supported by parents), recently going to a lot of p
that she doesn’t need any sleep (typical mania history with multiple sexual partners every night). I gave my DD, the
100
slowly and said that because I can see that you are a bit disturbed and are having more energy than usual, I suppos
your brain or a condition called Mania. I explained mania as a mood disorder. DD explained each, bipolar, psychosi
parties, hypomania, and medication related. Got really good score as I was empathic.
5. CHLAMYDIA: GS 5
APPROACH TO PATIENT/RELATIVE 5
PATIENT COUNSELLING/ EDUCATION 5
MANAGEMENT PLAN 5
CASE: FOOTBALLER GUY HAS RETURNED FROM PLAYING IN UK, HAD SEXUAL CONTACT WITH A FEW
FEMALES WHICH WAS UNPROTECTED. HE HAS SEEN YOU A WEEK BEFORE AND YOU SEND STI SCREEN
TEST WHICH ARE NOW OUT AND THE PATIENT HAS COME FOR THE RESULTS. ALL WERE NEGATIVE AND
CHLAMYDIA WAS POSITIVE. TASK: EXPLAIN RESULTS AND ITS IMPLICATIONS TO THE PATIENT.
GREETED.
ASKED HOW IS HE DOING. I HAVE THE RESULTS. WILL EXPLAIN IN DETAILS. ANY QUES DO NOT HESITATE
TO STOP ME. 1ST GAVE GOOD NEWS. THAN TOLD HIM ABOUT CHLAMYDIA +VE. TOLD HIM IN DETAIL.
IT’S A STI CAUSED BY BUG CALLED CHLAMYDIA DUE TO UNPROTECTED SEX IN HIS CASE.
NOTIFIABLE DISEASE BUT WILL MAINTAIN CONFIDENTIALITY. FOR NOW WILL GIVE HIM ANTIBIOTIC
AZITHROMYCIN. SAFE DRUG WITH NO SIDE EFFECTS.
WILL NEED TO REPEAT ALL THE BLOOD TEST AGAIN AFTER 3 MTHS DUE TO WINDOW PERIOD.
PRACTICE SAFE SEX FOR FURTHER PROTECTION.
FINISHED BEFOREHAND. ASKED IF ANYTHING ELSE HE WANTS TO KNOW. HE SAID THAT’S FINE.
THANKED AND LEFT.
Another recall - Chlamydia: Fail
Case: Footballer guy has returned from playing in UK, had sexual contact with a few females which was unprotecte
STI screen test which are now out and the patient has come for the results. All were negative and Chlamydia was p
Task: explain results and its implications to the patient.
The patient was all sleepy and not interested in this station. I asked a few questions before telling the results, he in
partner one year back and was sexually inactive until the trip. He usually uses protection otherwise but not during
STI. I explained his results, explained what Chlamydia infection was and that it is treatable with antibiotics, stressed
sure), told him about epididymo-orchitis, if untreated, discharge from the penis, then it can also be transmitted to
treated, hepatitis B vaccine and that I needed to redo HIV test after 12 weeks to make sure it is negative. Also expla
antibiotics for 5 days. He asked me about side effects of these antibiotics, I was blank and couldn’t answer him bac
notification and contact tracing.
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Another recall - Young male has come after STI screening (stem was quiet long, I am trying to recall some) he
recently visited overseas where he had casual sex partners but practise safe sex with the help of
condoms. He didn’t take any blood transfusion, no hx of tattoo and piercing. His general heath is
good. Investigation report- gonorrhoea, HBV, HCV,HIV negative but chlamydia positive.
Task: 1.explain inv 2. Counsel accordingly ( no hx taking)
Approach to patient:6
Patient counselling: 6
Management: 6
GLOBAL SCORE 6
Approach: it was my first station and I was very nervous. I entered and greeted the patient, he was
cheerful man. I stared with rapport building and gave positive results first saying ‘ur HBV reports
turn out negative that’s amazing’ he was very happy. At last gave chlamydia positive. Have u ever
heard about it. It’s a sexually transmitted infection caused by chlamydia trachomatis (don’t bother
about the name) don’t worry it’s a treatable condition, patient was bit worried and I stared giving
reassurance by saying I found that u always use condom and didn’t have tattoo and blood
transfusion hx ( all given in hx) that’s a very good thing. I will refer u to specialist who will give u AB
azithromycin SD (at this point ask AB allergy) and we will recheck you after AB. We will repeat HIV
test after 3 months because of window period ( he was again worried and I gave reassurance). I am
ethically obliged to inform DHS but don’t worry I will only trace your contacts in last 6months, will
not disclose your informations.Finished case early .thanked patient.
As there was no history taking so I didn’t mention Confidentiality at first and remembered after 2-3
minutes and mentioned at that time.but better to mention at first.
6. HEMATURIA CASE (PASS)
GLOBAL SCORE 4
APPROACH 4
HX 4
CHOICE & TECHNIQUE OF EXAMINATION, ORGANISATION AND SEQUENCE 4
DX AND DD 5
THE PT WAS AROUND 60 AND HAD RED COLORED URINE A FEW TIMES. ON ENQUIRING HE GAVE ME
ALMOST ALL BPH FEATURES LIKE FREQUENCY URGENCY, NOCTURIA, DRIBBLING. HE GOES TO LOO
2-3 TIMES EVERY NIGHT. NO LOSS OF WEIGHT. NO LUMPS OR BUMPS. NO BLEEDIND DISORDERS.
NO FEVER. NO TRAUMA. NO H/O CANCER IN FAMILY
PEFE: ALL GOOD
PER RECTAL EXAM: ENLARGED PROSTATE, SMOOTH, NO NODULES, MEDIAL SULCUS PALPABLE,
FIRM IN CONSISTENCY, NON TENDER.
DX: BPH (EXPLAINED WITH FIGURE)
DD: UTI , STONES, CANCER
102
Another recall - HEMATURIA CASE-------PASS
Global score 5
Approach 4
Hx 5
Dx and dd 5
I am sorry as I don’t remember the stem for this case but it was a case of hematuria. The pt was around 60 and had
gave me almost all luts like frequency urgency, nocturia, dribbling. He goes to loo 2-3 times every night.
On examination from examiner I got enlarged prostrate without any malignant feature( you have to ask all the feat
examiner wanted to know all) rest all was normal. Pt was on aspirin and an antihypertensive which I don’t rememb
I gave many ddx in this case
Uti, stones in kidney ureter and bladder, complicated bph with stones in bladder, nephritic, blood thinners, bleedin
picture to exp stuff.
Another recall - A man has presented with blood in urine. Sorry the hx was long and I couldn’t remember all.
Task:take hx, pefe,ddx
Approach to patient:4
Hx:4
Choice of examination:4
Ddx:5
GLOBAL SCORE 5
Approach: I started asking bleeding questions, then obstructive ( weak stream,hesitancy,dribbling,
incomplete evaculation) and irritative (frequency,urgency,nocturia,burning) questions, occupation,
sexual history, PHx of stone,FHX,SADMa. Positive was all obstructive features.
PEFE: started from abdomen –all normal, DRE (examiner asked what r you looking for) I said
inspection, and prostate findings. He gave BPH findings(soft enlargement of prostate, median sulcus
palpable, no pain.no nodule) rest all normal.
DDX: draw pic and say BPH and explain it. DDX- ca prostate, prostatitis, ca bladder,ca kidney,trauma,
bleeding dis, medication.
7. WRIST CUT EXACT HB EXAMINATION(PILOT)
8. TREMOR EXAM (PASS)
APPROACH TO PATIENT/RELATIVE 5
CHOICE & TECHNIQUE OF EXAMINATION, ORGANISATION AND SEQUENCE 5
ACCURACY OF EXAMINATION 5
DIAGNOSIS/ DIFFERENTIAL DIAGNOSES 5
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CASE: A 65 YR. OLD GUY WHO HAS COME TO YOUR GP BC HIS FRIEND THINKS HE HAS PARKINSON’S.
DO PHYSICAL EXAM, GIVE DDX, VITALS ALL NORMAL,
INSPECTION: MASKED FACIES, PIN ROLLING TREMOR
GAIT: SHUFFLING
HAND: TONE NORMAL, REFLEX NORMAL
COORDINATION NORMAL
PAINO TAP TEST NORMAL
TWIDDLING TEST NORMAL
MICROGHAPIA +VE
GLABELLA TAP +VE
NO SLURRED SPEECH
DX: PARKINSON’S
DD: CEREBELLAR ATAXIA, TRAUMA, TUMOR
I FORGOT TO DO THESE EXAMINATION:
DIDN’T CHECK FINE TREMOR
DIDN’T CHECK ROMBERG TEST/ FALL TEST
DIDN’T CHECK FOR NYSTAGMUS.
Another recall - TREMOR EXAM….PASS
GLOBAL SCORE 5
APPROACH 4
EXAMINATION 5
DX AND DD 4
CASE: Some 65 yr. old guy who has come to your gp because his friend thinks he has Parkinson’s.
Do physical exam. Give ddx.
What I did was I examined the patient’s gait, then examined him while standing for stooped
posture and Romberg’s. Patient had normal gait but was stooped. He had hypomimia and then I
started my examination from hands for thyroid and cld signs and fine and flapping tremors. Asked
him to write on a page and then asked him to say two sentences about his breakfast today. Then
asked him to pretend piano and opening imaginary door knob, rapid alternate movements, and
then went to his face for glabellar tap test and then checked eyes for thyroid and neck for thyroid
enlargement and then told the examiner that I would like to do upper limb motor exam. She said
do it, I started with tone, it was cog wheel rigidity in elbow movement and as I started power the
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examiner said give your ddx as u r running out of time. I gave my ddx to the pt with some exp for
each
Bet, Parkinson’s, alcohol related cld, thyroid, neurological like cerebellar damage.
9. NECK PAIN {PASS}
GLOBAL SCORE 5
TECHNIQUE OF EXAM, ORGANISATION AND SEQUENCE 5
DX AND DD 5
MX PLAN 5
CASE: Middle aged female came with neck pain which she got 2 days back after picking some
heavy stuff.
Ask pe findings from examiner. Explain pt your dx and dd. Tell her about further mx.
I went inside the examiner was very old and had some hearing impairment as he wanted me to
repeat stuff so I started saying out stuff loudly and near his ear. The pt was a very fat lady sitting
on the couch with hospital gown on and her one arm held by the other, she was a very good
actress as she showed too much pain and was breathing heavily. I reassured her and gave her pain
killer. Kept on asking her if she is alright. I asked the examiner complete upper limb motor exam as
well as sensory, range of motion and spurling test (he asked me what’s that, I explained and told
him that its special test for cervical radiculopathy, then he said its positive) he gave me sensory
loss along c8 and t1(not sure about t1 though). I asked rest of the systems to which he said all are
normal.
I went to the patient and drew a picture to explain the cervical radiculopathy and then gave all the
ddx as fracture of the vertebral bodies compressing nerve, osteoporosis, and osteoarthritis with
bony spurs, disc slip, tumors compressing nerve or Mets. Also gave ddx for neck pain like muscle
strain sprain, wry neck, inappropriate posture, radiation of pain to neck from chest or other sites,
thyroiditis, for hand pain and loss of sensation I said it can also be due to carpel tunnel, tarsal
tunnel, fractures, oa, sa, pa, ra.
Patient was unhappy but examiner was smiling at the end. I gave her painkiller and asked her to
lie down with arm raised and I’ll put some cold pack over her neck meanwhile the ortho specialist
will be here and we will go for a mri scan with his consent and will see what further mx can be
done based on results, usually conservative mx is done with painkillers and rest and physio but if
pain is too much some numbing agent can be injected and if nerve is badly compressed sx can be
done.
Another recall - Young lady came due to neck pain after lifting heavy object.
Task: 1. Ask examination findings from the examiner 2. Explain dx 3. Management
Choice and technique of examination, organisation and sequence-4
DDX-4
Choice of inv-4
mx-4
GLOBAL SCORE-4
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Approach: i entered and saw a lady was sitting on a chair, she was not able to move her neck. I
offered pain killer, seek permission for examination and asked examiner the findings based on
cervical spondylosis. Positive findings were restricted neck movement in all direction, numbness
and
loss of sensation at C8 and T1. I asked shoulder examination which was normal, rest of the
examination one by one all normal. Turned to patient and describe cx radiculopathy due to disc
prolapse and gave dd ( muscle strain, RA, spondylosing arthropathy, trauma, fracture which is
quiet
unlikely). Management was PRICE and sed to specialist for MRI and further management. Again
finished early and dead silent in the room.
10. PELVIC EXAM …FAIL
I’m not sure about this station the female was postmenopausal and she was having some bleed
for last two days. I had to do pelvic exam and then explain her possible dx and ddx and further inx
and mx.
I went in and there was a dummy which was covered. I greeted the pt asked her if she was in any
pain, had any sob or dizziness. Went to the examiner for vitals, to which he said that they were all
okay and I should proceed to the examination. I explained the procedure to the pt and asked her if
she wanted to pee before, she said its ok. Washed hands and wore gloves. I removed the sheet did
inspection of vulva and vagina and proceeded with speculum exam. Inserted speculum with
xylocaine and opened it. Commented on walls and cervix. Everything was ok but I commented on
what I wanted to see, examiner kept saying negative. Some ppl from my exam said that the cervix
was lower than usual and it was prolapse but I don’t think so. After I removed the speculum, I said
I want to do bimanual exam. Examiner said its normal and I should proceed to next task. I cleaned
the dummy with wipe and covered it with sheet, told the pt that there might be slight bleeds and I
can provide with a panty liner for her, she thanked me. I gave all ddx of post-menopausal bleed Inc
atrophic vaginitis, cervical polyp or cancer, endometrial hypertrophy, endometrial cancer, fibroid,
bleeding disorder and blood thinners. Drew picture and explained each nicely. Told her I’ll go for a
transvaginal us and as she was on estrogen patch she might have overgrowth of her womb lining
in absence of progesterone, I explained. Referred her to the gynecologist and send for blood tests
inc basic ones. I must have missed few things in this station which I am unable to think atm. I GOT
2 in choice and technique of examination and I did exactly like geeky medics.
Another recall - PELVIC EXAM
(Global Score :6)
MIDDLE AGED LADY HAVING BROWINSH VAGINAL BLEEDING SINCE COUPLE OF WEEK AND IS
TAKING HRT. PE, DD
APPROACH TO PATIENT/RELATIVE 6
CHOICE & TECHNIQUE OF EXAMINATION, ORGANISATION AND SEQUENCE 6
ACCURACY OF EXAMINATION 6
DIAGNOSIS/ DIFFERENTIAL DIAGNOSES 4
INSIDE WAS A VERY CHEERFUL OLD LADY SITTING ON THE CHAIR. I GREETED THE EXAMINER AND
THAN GREETED THE LADY.
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WIPE APPROACH. EXPLAINED THE STEPS OF EXAMINATION. TOOK CONSENT. PROPER EXPOSURE
AND POSITION. CHAPERONE
GOOD AFTERNOON KATIE, I AM DR. NISHA, ONE OF TH EDOCTORS HERE. I KNOW THAT YOU ARE
HERE BECAUSE OF VAGINAL DISCHARGE. REGARDING YOUR CONCERN I NEED TO EXAMINE UR
PRIVATE PART THAT WILL INVOLVE ME LOOKING AT UR DOWN BELOW, USING SPECIAL
INSTRUMENT CALLED SPECULUM( IT WAS KEPT ON THE TABLE AND JUST POINTED OUT IT) AND
INSERT MY TWO GLOVED FINGER . WILL THAT BE OK? FOR THE EXAMINATION PURPOSE YOU
NEED TO EXPOSE URSELF BELOW THE WAIST INCLUDING UR INNERWEAR. I DO UNDERSTAND
THAT IT MIGHT BE VERY UNCOMFORTABLE FOR YOU. I WILL MAINTAIN THE PRIVACY
THROUGHOUT AND ALSO A CHAPERONE WILL BE ARRANGED AS WELL. SO WILL THAT BE OK? IF
YOU ARE READY CAN YOU PLEASE GO BEHIND THE CURTAIN , UNDRESS URSELF, LIE ON UR BACK
WITH KNESS BEND AND FOOT AT THE EDGE OF THE BED AND LET ME KNOW WHEN U ARE READY.
AND ANYTIME IF YOU FEEL UNCOMFORTABLE JUST LET ME KNOW, WE CAN MODIFY OR STOP THE
EXAMINATION.
WAS ABOUT TO WASH HAND, PATIENT SAID NO NEED JUST PUT ON THE GLOVES. IOOKED AT
EXAMINER HE SAID FINE.
I DIDN’T SAY LOOKING FOR. I JUST SAID THERE IS
INSPECTION: NO RASH , VESICLE, DISCHARGE OR BLEEDING
SPECULUM : NOW I AM GOING TO INSERT THE SPECULUM. THIS MIGHT BE UNCOMFORTABLE BUT
TRUST ME IT WON’T BE PAINFUL. I JUST NEED YOU TO TAKE DEP BREATHS IN AND OUT FOR ME.I
WILL ALSO USE THE GEL FOR EASY INSERTION. CERVIX LOOKS HEALTHY. NO DISCHARGE OR
BLEEDING. VAGINAL WALL IS HEALTHY . NO DISCHARGE OR BLEEDING OR THINNING.
PER VAGINA:NOW I AM GOING TO INSERT MY TWO GLOVED FINGER. EXAMINER SAID ALL
NORMAL DON’T HAVE TO DO . J
DD: ATROPHIC VAGINITIS: THIN VAGINAL WALL
ENDOMETRIAL HYPERPLASIA: THICKENEING TO INNER LINING OF WOMB
ENDOMETRIAL CANCER: CANCER OF INNER LINING OF WOMB
CERVICAL CANCER: CANCER OF MOUTH OF WOMB
CERVICAL POLYP
Another recall - Postmenopausal lady has come due to brownish vaginal bleeding. Patient is taking
HRT ( name was
mentioned which I forget) for osteoporosis.
Task: 1. Do pelvic examination 2. Do relevant examination 3. Ddx
Approach to patient:5
Choice of examination: 4
Accuracy of examination:5
DDX: 4
GLOBAL SCORE 5
Approach: I am not good in physical examinations so these are my nervous stations. While reading
the question I was thinking to say endometrial hyperplasia as my first ddx as patient is taking HRT.
I
entered the room. The lady was very good. After finishing WIPE I wear gloves and stared
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examination as she exposed dummy while talking. I didn’t turn on the light which roleplayer
showed
me. I finished inspection which was normal. Put jelly on speculum and did PV which was normal
according to me. Tried to put my finger examiner said no need to do this it is normal LI was
expecting enlarge uterus. Then asked relevant examination of rest of the abd which was normal,
breast examination as patient was taking HRT-normal.
DDx: as I couldn’t find any positive findings so I drew a diagram and point out all the possible ddx (
atrophic vaginitis, vaginal infection, cx polyp, cx cancer, endo hyperplasia, endo cancer, trauma)
11. SHORTNESS OF BREATH {PASS}
GLOBAL SCORE 6
APPROACH 5
HX 6
PEFE 6
DX AND DD 5
CASE: very long stem. Some old man who lives in rural area and has a farm had an mi 1 yr back for
which thrombolysis was done. He did not follow up with the gp after two times and did not go to
the cardiologist in tertiary care as advised by gp. Too many details given and I was unable to read
the whole stem.
Hx, pefe, dx and dd
I went in; there was an old guy with a beard sitting. As I did not complete reading the stem, I
started reading in front of him as if I was confirming the notes. This always helps in long stems. He
told me that he is the sole carer of his farm and cows and has no time to go see the cardiologist. I
asked him complete sob hx ruling out resp, psych, anemia, thyroid etc. he gave me typical CCF
history with dec walking distance recently and paroxysmal nocturnal dyspnea and orthopnea. I
was happy and went for pefe. In pefe I asked for all CCF features and all were positive. Jvp raised,
murmur of mitral regurg, enlarged heart with shifted apex, gallop rhythm, positive hepatojugular
reflux, and edema up to mid shin.bi basilar crackles. I explained the patient in easy language about
CCF drew a picture and gave only 2 other ddx inc copd and pneumonia. I was scared I’m going to
fail with these ddx but the examiner passed me.
Another recall - SHORTNESS OF BREATH {PASS}
GLOBAL SCORE 4
APPROACH 5
HX 5
PEFE 5
DX AND DD 4
MIDDLE AGED MAN COMPLAINING OF SOB ON/ OFF SINCE COUPLE OF MONTHS. HAD MI A YEAR
BACK AND UNDER MANY MEDICATIONS. WHEAT FARMER.
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ON HX, SOB ON EXERTION, NOCTURNAL DYSPNEA USING A LOT OF PILLOWS. LEG SWELLING. NO
CHEST PAIN. COUGH ON AND OFF. NO WEIGHT LOSS. NO LUMPS OR BUMPS. SMOKES. NO FEVER .
PEFE: VITALS NORMAL
RESP: B/L BASAL CREPITATIONS
CVS: RASIED JVP, +HEPAOJUGULAR REFLEX , MURMUR +
REST NORMAL
DX: HEART FAILURE EXPLAINED WITH FIGURE
DD: COPD, DIDN’T GET TIME TO SAY OTHER DDS.
Another recall - 47years old man came with shortness of breath. He had history of heart attack
2years back and
admitted in rural hospital. He refused to transfer to tertiary centre at that time so he was treated
with thrombolytic at that time. During last 1 yr he is having SOB and it has increased now.
Task: 1. Take hx 2. PEFE 3. DDX
Approach to pt: 4
Hx:4
Choice of inv:5
Ddx:4
GLOBAL SCORE 5
Approach: All SOB cluster of questions (positive was- he uses 3 pillows for better sleep at night,
SOB
on waking, relieved at rest,bilateral leg swelling), Phx,FHx,SADMA-nil
PEFE: I stared with resp though I already knew Its heart failure case. Resp –examiner asked what
do
u want to know specifically, I said crepitations which was present. CVS- JVP raised,S1,S2 ,S3
audible,
apex beat in the axillary line,no murmur, ABD- again asked what do u want to know specifically, I
said tender hepatomegaly which was negative. B/L pitting edema present.
DDX: heart failure, MI, pneumonia, pl effusion, pul embolism, pneumothorax , GORD (unlikely),
trauma.
12. ANTENATAL CARE {PASS}
GLOBAL SCORE 5
APPROACH 4
HX 5
COUNCILLING 5
CASE: 42 OR SOMETHING was the age of the pt and she has just done her pregnancy test at home
and found it to be positive. Now she is here at your gp for advice.
Hx and counseling
The patient in this case was not at all worried about anything. She was very happy as she has just
started a new relationship a couple of years back and she and her partner wanted a child. It was
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planned and so I congratulated asked typical hx and then asked her 5ps and everything was ok, no
prior pregnancies. I proceeded to counseling and made a time line on a page dividing it into 3
trimesters and gave her all the risks that were there to her and her child in each and also gave the
soln simultaneously. Referred her to hrpc and also did all first visit tests. Explained about downs
screening and gave her precautions regarding food, alcohol, smoking etc. I ran out of time and was
speaking all the way till the bell rang.
Another recall - ANTENATAL CARE
GLOBAL SCORE : 5
APPROACH TO PATIENT/RELATIVE 4
HISTORY 5
PATIENT COUNSELLING/ EDUCATION 5
40 YEARS OLD LADY DID UPT AT HOME. POSITIVE RESULT. CAME FOR ADVISE.
TASK: HX, PEFE CARD, COUNSELLING.
GREETED. ASKED IF IT WAS A PLANNED PREGNANCY. SAID YES THAN CONGRATULATED HER AND
APPRECIATED FOR COMING IN. THAN 5PS AND SUPPORT.
1ST PREGNANCY. NO ABORTIONS OR MISCARRIAGES. STABLE RELATIONSHIP. USED TO TAKE OCP.
NO STI. GOOD SUPPORT. TAKING FOLIC ACID. NO SIGNIFICANT MEDICAL PROBLEM.
PEFE: ALL NORMAL EXCEPT BMI 32
COUNSELLING: 1ST CONFIRM PREGNANCY BY DOING UPT IN THE CLINIC. IF CONFIRMED WILL REFER
HER TO HIGH RISK CLINIC. TAKE FOLIC ACID TILL 3 MONTHS OF PREGNANCY. WILL DO ALL ANC
BLOOD TEST.
BMI ON HIGHER SIDE. NEED TO MAINTAIN A HEALTHY BODY WEIGHT. WILL REFER TO DIETICIAN.
DUE TO HIGH AGE CAN NUMBER OF RISK ON HER AND THE BABY
ON HER: HIGH BLOOD PRESSURE, HIGH SUGAR LEVEL, PREECLAMPSIA, PRETERM
ON BABY: DOWN SYNDROME.
WILL DO BLOOD AND USG TEST AT 11 WEEKS TO LOOK FOR DS AND REPEAT THE BLOOD TEST ON
18 WEEKS. COULDN’T TALK MUCH AND THE BELL RANG.
Another recall - A lady has come to you with home preg test positive, this is her first day of ANC.
Task: 1.hx 2. Ask PEFE from examiner 3. Management
Approach to patient:5
Hx:4
Mx:4
GLOBAL SCORE 4
Approach: when I read the question outside I was very happy that its ANC counselling case, straight
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forward what I practised a lot. After entering I was in shock. Patient was almost 100kg, I thought its
pregnancy with obesity case. I stared with normal ANC hx from Karen. Nothing positive .
PEFE card : all normal expect weight 100kg
Management: I spoke all ANC blood tests, ANC visits, tests during pregnancy but I forget to mention
high risk pregnancy clinic though I mentioned considering your weight I will refer you to the
specialist. Talked about healthy food habit and rest all from Karen ANC counselling.
13. PYLONEPHRITIS {PASS}
GLOBAL SCORE 5
APPROACH 4
HX 5
PEFE 5
DX AND DD 5
CASE: I don’t really remember the stem but it was some 30 yr old female feeling week and
lethargic since last few days. Very vague with no indications of pyelonephritis. Hx, pefe, dx and dd
I went in where there was a female with a shawl covered over her showing that she was feeling
cold and had a tissue in her hand (nice actor). I asked her hx in which she told me that she has
fever around 39 to 40 since last 2-3 days. Vomited once this morning. She was taking panadol for
it. I started digging for the reason of fever and asked everything from head to toe with sexual hx.
She told me that she has burning micturition. Rest was all negative.
I went to the examiner who gave me all negative except fever 40 and tachycardia 92. I asked about
abdominal exam in which I think, he gave flank pain. Rest was all ok. I went back to pt drew a
picture explained about pyelonephritis, uti, stones with infection, cystitis and some irrelevant
other ddx.
Another recall - FEVER AND CHILLS
GLOBAL SCORE 4
Approach to patient/relative 4
History 4
Choice & Technique of examination, organisation and sequence 4
Diagnosis/ Differential diagnoses 0
42 YEARS OLD LADY FEELING FLUSHED SINCE COUPLE OF DAYS.
ASKED IN DETAIL ABOUT FLUSHING. GAVE NOTHING POSITIVE IN HX. ASKED ABOUT FEVER SAID
HAVEN’T MEASURED. SAID SHE FEELS HOT SOMETIMES AND SOMETIMES COLD. AND STRESSED
DUE TO IT. NORMAL BLADDER AND BOWEL. NO WEATHER PREFERENCES. NO STRESS. NORMAL
PERIODS. I WAS DESPERATE TO GET SOMETHING BUT NONE SO JUST MOVED TO PE.
PEFE: TEMP 40
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ABDOMEN: FLANK PAIN, RENAL ANGLE TENDERNESS +
REST NORMAL
UDT: NITRITIES +, BLOOD+, WBC+
DX: PYLEONEPHRITIS
DD: THYROID PROBLEM, ANXIETY, STRESS
Another recall - A lady has come with hot flushes for few days (only this much)
Task: 1. Hx 2. Pefe. 3. Ddx
Patient approach:5
Hx:4
Chice of examination and techniques:4
GLOBAL SCORE 4
Approach: after reading the question I was thinking of perimenopausal woman and formulate my
hx
according to this. After entering I stared hx taking on that way but turned out different . patient
has
hot flushes for few days, present all the time, periods are normal, no pill, partner stable, have kids.
I
was started panicking at that time due to lack of positive findings. Then asked head to toe
symptoms
where she gave positive for burning sensation of urine, I was happy, quickly asked uti symptoms
all
positive. Fever (39 she measured). Malaise, LOA, no blood in urine. I asked frequency, urgency all
negative except burning. Past hx: honeymoon cystitis,FHX, SADMA-nil
Pefe: asked ABD (inspectipn, palpation, auscultation) I forget to ask renal angle tenderness which
was positive, suprapubic tenderness was negative, rest of the examination was normal.
Ddx: I draw diagram and said it is UTI, where infection could be in bladder, ureter, kidney,
considering your hx I think its in kidney as ur temp is 39 and ur having chills. Bell rang.
14. PORNOGRAPHY (PASS)
Global score 4
Approach 4
Hx 3
Counseling 4
Case: mother has recently found her 13 or 14 year old watching porn and is really worried about it.
Take history. Council the pt and make appropriate plan (I was unsure about the plan thing as in
recalls no one wrote about it)
I went inside where there was a lady with a big flower in her hair and looked worried. On asking
she took around a minute to tell me the whole story that she went to her room to get some stuff
and she was watching porn on her laptop and as soon as she saw her mom she just shut the laptop
close. Next day the mom checked the laptop again in her absence and found that she was
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watching porn. Now the girl is not speaking to the mom and was tearful on contact with the mom
while going to school this morning. I was happy that she told me all this without asking.
I asked her all psych ques regarding her daughter. Ruled out any mental disorder or anxiety in
mom. Ruled out child abuse, drug usage, pear pressure in the daughter’s case. All her friends are
from nice families who know each other. Everything was ok in hx.
I then started counseling and told her that it’s normal to be inquisitive about sex and untouched
and un discussed topics like these. I told her that she should talk about it to the child. She said “we
are a very religious family”. I told her that it’s good to adhere to religious beliefs but its imp to
discuss sex and sexuality with kids or else they will find out from sources that are not appropriate
for them. I told her that she needs to tell the girl about safe sex, value of respect, consent and care
in intimate relations. I also stressed that she should tell the child that porn is unreal and is
dramatization and does not depict real life relations in any way. Watching porn excessively can
cause problems and unhealthy relations and expectations in future. I told her that I can arrange a
meeting with her as well. I spoke too much, showed empathy and care but still I just passed, which
shows that there is something more they expect us to talk about.
Another recall - Famous pornography case
Approach to patient: 5
Hx:5
Counselling:5
GLOBAL SCORE 5
Approach: mother was very anxious, I stared with reassurance, as she is my reg patient I stared
saying nice to meet to again. Maintain confidentiality and started. Mother was very worried. Gave
reassurance that its normal according to her age, they should have an open chat with daughter, if
they cant then I can arrange family meeting but before that I want to see her alone. Arrange
counsellor. I noticed mother was still very anxious so arranged counsellor for her as well. At that
time she said thank you doctor.
15. FEVER IN A CHILD {PASS}
APPROACH 5
HX 6
EXAMINATION 6
DX AND DD 6
CASE: Child was around 4 and was febrile for past 5 days. I don’t remember exact stem but outside
I thought its meningitis. Hx, pefe, dx and dd
I went in where there was a young guy standing. He showed worry and was asking me what was
wrong with the baby. I told him to calm down and ill check with the baby. Went to the examiner
to ask for vitals who said that I should carry on with the hx and child was ok for now. I reassured
the father and started hx mainly focusing on meningitis. When I asked for rash he said that he has
rash all over the chest. I asked more questions and found it was Kawasaki dx as the child had red
eyes, dry chapped lips, red palms and sole and had high grade fever for 5 days. For fever the
parents took him to the gp who said its viral infection and sent him home. Father was angry on the
gp as well. Rest of the hx was fine. I went to the examiner who gave me all the features of
Kawasaki. I ruled out scarlet fever, meningitis, measles, varicella, sepsis, itp. Went back to dad told
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him all the ddx with explanation and drew a picture. Said that you need to go to hospital soon, no
mx was needed.
Another recall - KAWASAKI ( FAIL)
GLOBAL SCORE 3
APPROACH TO PATIENT/RELATIVE 4
HISTORY 4
CHOICE & TECHNIQUE OF EXAMINATION, ORGANISATION AND SEQUENCE 4
DIAGNOSIS/ DIFFERENTIAL DIAGNOSES 2
FATHER CAME IN WITH CHILD. HIGH FEVER SINCE COUPE OF DAYS NOT RELEIVED BY PANADOL.
RASH SINCE YESTERDAY. DECREASE IN NUMBER OF WET NAPPIES. LETHARGIC. RASH MAINLY ON
TRUNK WITH DESQUAMATION ON PALMS AND SOLES
PEFE: TEMP 40
MACULOPAPULAR RASK WITH DESQUAMATION OF PALMS AND SOLES.
STRAWBERRY TONGUE PIC GIVEN ON ENT EXAM. DITTO DOWN BELOW
NO NECK RIGIDITY
REST NORMAL
DX: GAVE SCARLET FEVER BUT ITS KAWASAKI.
Another recall - Child has come with 39deg fever for 5 days,
Task: hx,pefe.ddx
Approach to patient:5
History:6
Choice of examination:5
Ddx:6
GLOBAL SCORE 6
Approach: after reading this case I was sure it is Kawasaki so I thought to ask question based on
this.
It proved time saving for me. After entering I greeted the father, ask fever question and
straightaway
went to Kawasaki sign symptoms question (skin desquamation, strawberry tongue,rash
presentasked
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rash question bit here whether itchy,oozy,scaly but not much), the asked relevant-neck
stiffness, appetite,well baby questions, pee, poo which were normal, PHX,FHX,contact hx, BINDS,
anyone smoke infront of child-all normal.
Pefe: GA-alert, VS- temp 39.5, neck stiffness negative, tongue –examiner gave me picture of
strawberry tongue, skin desqua-present, rash present.rest normal
DDX-kawasaki,scarlet,bac infection, viral infection, meningococcal.
16. (PILOT) YOUNG BOY WITH ACNE. TOOK ANTIBIOTIC FOR A YEAR NOW ON RETINOIDS.
TASK: HISTORY, TELL ABOUT THE IMPACT, S/E OF RETINOIDS
INSIDE WAS A MAN WEARING HOODIE AND COVERING HIS FACE WITH THE CAP. HE WASN’T
MAKING ANY EYE CONTACT HAD A LOW TONE VOICE.
I SAID SORRY FOR WHAT HE WAS GOING THROUGH. ASK MOOD QUESTIONS. FORGOT TO
MENTION CONFIDENTIALITY. EVERYTHING NORMAL MAYBE BECAUSE I DIDN’T TALK ABOUT
CONFIDENTIALITY.
HE WAS BEING BULLIED AT SCHOOL SO DIDN’T WANT TO GO TO SCHOOL.
I SAID STRESSED DUE TO ACNE. NOT GOOD FOR HIM. IT CAN CAUSE MORE HARM TO HIM. REFER
TO PSYCHOLOGIST FOR TALK THERAPY. WILL TALK AT SCHOOL FOR BULLY AS IT IS NOT
ACCEPTABLE. WILL ARRANGE FAMILY MEETING AS WELL.
ON SIDE EFFECTS I WAS BLANK SO DIDN’T SAY ANYTHING ON IT.
28th March 2019
1. (pass) 6 years old girl bib mother has c/ o headache for 6 months
Task: Take history from mother, PE card from examiner; Explain the most probable cause of
headache and differential diagnosis to mother with reason.
All pain questions - Findings she gave me: Pain on back of head, feeling nauseated when in pain
no vomiting no fever, Misses school due to pain, Similar pattern on weekdays and weekends
No concerns regarding growth and development
Have other siblings, Family history mother suffers from migraine, Doing well in school
When I asked about home situation she told Home situation is not the same as I am divorced 8
months ago. I asked about her relationship with daughter. I asked is she going to see her father
She said yes she is seeing father every 2 weeks. Immunization – up-to-date
Asked the examiner for card.
Told mother that examination is done
Explained her all the findings that were on card one by one and it is normal
Then explained her it’s most probably tension headache due to change in her circumstances at
home. Not sure whether DDx was a task or no
Asked about her understanding at the end. Thanked examiner and role player
Another Feedback: Headache in a 6 year old girl. Take history, tell Dx, DD to father. Predominant
assessment area: history taking. Pass
History: I asked Site, Onset, Radiation, Time (how long it lasts, frequency, timing pattern),Severity,
Aggravating Relieving factors, Associated symptoms --- positive were: headache in occipital area,
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since 6 months, 2 times in a month, relieved by a taking a nap, kids panadol, aura+, aggravated
by sth I forgot, has vomiting with it, no diurnal variation, no weekday/weekend variation. How is
her health in general health, questions, BINDS, Home/ School situation, Family history -. Recently
parents separated, otherwise all good at school, no suggestions of abuse. Father also has
headaches.
Dx migraine with reasons DD: tension, meningitis , trauma, refractive error, sinusitis, tumor- told
why not and reassured.
2. (pass) 67 years old male with haematuria for 4 weeks came to clinic.
Take history, Findings from examiner, Explain the provisional and differential diagnosis.
Old man sitting on chair, Started with all related questions of haematuria
I asked any problem in starting stream of urine. He said yes
I asked how long. He said long time.
He is known hypertension on aspirin and 1 other medicine
No pain no trauma, No fever, first episode, Retired.
Then is asked the examiner for PE: vitals normal
I went to abd exam-No tenderness no masses
Examiner said there is some dullness in super public area
I asked for DRE: He said enlarged Prostate smooth firm
Asked that quickly want to review CVS and respiratory - Examiner said normal
Then came back to patient said on history and examination I’m suspecting that u have a
condition called BPH , have u ever heard about it he said no.
Then I took the paper and pen and explained him about BPH
Then after that told other differential as well with reasons.
Asked about the understanding of patient.
3. (pass) 27 years old female came to your clinic for Re prescription of OCP nurse checked her
BP it was high rechecked after some time still high nurse gave her BP apparatus and
asked to monitor at home she came back and monitoring at home had all high
readings 2 years ago when OCP started her examination was normal
Task: Take relevant history, Tell her most probable cause of her high BP, Tell her your immediate
management plan.
When I said hello to patient she asked me dr, how is my blood pressure?
I introduced myself to patient. Said I’m concerned about your BP need to asked you some
questions regarding your condition.
Started with 5P period regular no previous pregnancy in stable relationship Pap smear-done
Then asked about family history for hypertension not sure what she said. SADMA.
Started explaining her that as your last examination at the time of starting OCP was
normal and I couldn’t find any significant history as well so your HT is caused by
pills as every medication has side effect so this high BP is side effect of OCP
Told her that my immediate management plan is to stop OCP and I’ll continue
monitoring your BP for 2 weeks if BP still high need to do investigation to rule out other causes
Asked her are u aware of other methods of contraception, she said dr what are my
Options? Then explained her about barrier method, IUCD and POP.
Said I’ll give you some reading material and she can discuss with her partner and
for time being continue with barrier methods will discuss with her about further
contraception asked about the understanding and bell rang.
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Another Feedback: Lady with elevated blood pressure in her 30s, stem mentioned her use of OCP
and BP normal before it was started. History, tell possible cause and reasons.
PASS predominant assessment area- management/ counseling/ education.
History: When was her last BP recorded , any symptoms of high BP like dizziness/ headache/ chest
pains.
Asked questions to r/o secondary causes of high BP. TRACKPADS mneumonic. Thyroid causes- any
weather preference, weight change? Renal artery stenosis, Aorta coarctation- any claudication?
Conn’s disease- nocturia, muscle cramps? Polycystic kidney disease- lumps in tummy?
pheochromocytoma- headache, sweating, palpitations? Drugs- alcohol/ steroids/OCP use? Stress?
Past medical, Family, Personal history, SADMA- all normal
Told possible causes in simple terms I explained more about OCP induced hypertension that
caused by effect of hormones and that I would refer to specialist to stop and change the
contraceptive and is reversible after stopping.
4. (pass) 5 years old child bib father with pain and limping on right leg seen in ER some blood test
were done along with X-ray. Take history, Examination findings from examiner, Ask for blood test
and X-ray. Explain X-ray to father. Explain most possible cause.
Asked history for pain and limping, Ruled out all differential
He didn’t give any positive findings in history.
Then I asked examiner about finding, General appearance examiner said boy is lying in bed playing
on mother‘s mobile with slight grimace when moving leg.
Vitals normal, Then started about lower limb exam. No findings on look feel.
I asked about movement. Examiner asked where u want to see movements
I said I’ll start with hip and then do knee joint. He said which movements are to specifically
interested in. I said abduction and internal rotation. He said both limited on right side
Asked to quickly review heart and chest he said normal. Then asked about the investigation
Examiner handed over a paper with 3 x-rays.
On paper HB , ESR and platelets were mentioned that were normal told father that blood test for
your child were normal. Then I saw the X-ray all 3 films were showing perthes disease.
Took 1 of the X-ray and started explaining the father. Started from the normal side
Told him everything looks fine on this side then explained effected side in X-ray
there was typical cobble stone appearance. Told him the cause for the condition but I didn’t
mention the name ‘perthes disease’. Checked understanding
Then examiner asked me what is the name that u will give to this condition.
Told him that this is called perthes Disease
Bell rang thanked examiner and roleplayer
Another Feedback: Pain in limb of a 4 year old boy. History, PEFE, x ray from examiner- explain to
mum.
All pain questions (SORTSARA), asked dd questions- any recent flu, trauma, fever, general health,
skin rash/ tummy pains, lump/ bump anywhere, home situation? BINDS, family history
PEFE: General appearance normal, vitals stable, inspection of limb no obvious swelling/
deformity/ redness/ signs of trauma, palpation- normal temperature, minimal tenderness over left
hip, range of movement (examiner asked which movement want to check )impaired especially
abduction and internal rotation, unable to stand/ assess gait.
Xray was clear picture of perthes disease blood report was given- normal.
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Explained mum that perthes disease- when head of thigh bone in the hips is diseased and showed
her in the xray comparing to the opposite side it looks irregular and in pieces. It is common in ages
4-8.
5. (pass) 20 years old girl came with c/o abdominal pain for 1 week pain around 6 in intensity was
intermittent earlier now became continuous associated with nausea no vomiting
Patient has regular menstrual cycle of 28 days last period was 7 weeks ago pregnancy test
at home was weakly positive vital normal.
Perform abdominal examination do running comentry to examiner what u r doing
Explain patient most probable cause and differential. diagnosis with reasons.
I entered the room young girl was lying in bed
Showed some sympathy asked about pain she said 6 asked about pain killer she said
she had it a while ago. Explained her about the examination took consent wire gloves and then
asked most tender area she pointed to RIF. Then completed the abdominal exam with
commentary to examiner. Told examiner that I have completed examination he said what u want
I told want to inspect hernia orifices and then want to do pelvic exam. He handed me a paper with
pelvic examination finishing : Inspection normal, Speculum exam-Normal, On bimanual exam -Not
sure about CMT
Uterus slightly enlarged
Small mass in right adnexa
Then told the patient that on your history and exam I’m suspecting ectopic pregnancy
Asked her if she knows anything about ectopic she said no. Took paper and pen
Draw uterus and tubes and explained about ectopic
Then told that abdomen is full of organs so any organ present in this place can give her pain
Said can be due to intestinal cause appendix renal, ovarian can be due to trauma.
Bell rand thanked examiner and role player
Another Feedback: 7 weeks amenorrhea, pain in Right iliac fossa since 1 week more since 2 days.
Urine pregnancy done was weakly positive. Do relevant examination, pelvic examination with be
given, tell DD to patient. PASS
Began by asking how bad is the pain and offering pain killer. General appearance- looked in pain
but not in distress. Took pulse, BP, forgot temperature. Inspected for pallor, dehydration, CRT.
Abdomen: inspection – no distension, all quadrants moving with respiration, no visible mass/
peristalsis, asked patient to cough for any rebound tenderness – absent, superficial palpationtender in RIF, no palpable mass, Mc burney point tenderness +, psoas sign/ obturator sign
negative, percussion omitted due to pain, auscultation- bowel sound present, no bruit.
Said I would examine the hernia orifice, DRE and pelvic examination.
Examiner gave pelvic findings- cervical os closed, uterus size ??? right adnexal mass present, no
cervical motion tenderness, no bleeding.
DD to patient: Unruptured ectopic pregnancy where pregnancy is outside womb, could be normal
pregnancy along with appendicitis, pregnancy with ectopic pregnancy, pregnancy with PID/
ovarian cyst explained with reasons.
6. (pass) U r working in a regional hospital where a Young lady with at 34 or 35 weeks of
gestation came with watery vaginal discharge came and delivered in emergency by midwife
Delivered a baby Apgar score was ok wt 2.5 kg. Shifted to nursery, On head box 40 % oxygen with
some grunting, O2 sat 95 %, Other vitals also given.
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Take history from mother, Explain her abt the condition. Tell her about your further management.
Role player asked me dr I’m worried about my baby, Reassured her
Asked her how is she after the delivery any pain or heavy bleeding
No previous h/o vaginal discharge, Regular antenatal check up, 3rd pregnancy, No trauma, Rest I
can’t recall now. Then told her that baby is supposed to deliver at 38to 40 wks, As u have
delivered earlier so baby is not fully matured to adjust in outside environment. Explained abt
surfactant, Told her that baby is in safe hands doing well. But need to shift him to tertiary care
hospital where specialized staff and consultant who deals with new born will be available to look
after him. They might pass Iv line might go ahead with some blood investigation and might
plan to give him surfactant. Checked understanding asked if she want to know anything she said
dr will my baby be ok, Reassured her again.
Another Feedback: Preterm delivery at 35 weeks, baby respiratory problems. At present, baby
vitals ok with oxygen, no murmurs.
Take history, possible causes, tell on going treatment.
DD: meconium aspiration syndr, transient tachypnea of newborn, respiratory distress syndrome,
tracheoesophageal fistula, congenital heart disease, pneumonia, rare causes. PASS
Empathy- sorry that this has happened. But we are doing our best and at the moment baby is
doing okay. Would it be ok to ask a few questions to help us find the cause?
History- Asked about pregnancy- how was it, gestational age confirm, did she receive any steroid
before hand, baby kicking well before hand? Any bleeding/ fever/foul discharge/ rash in mom...
OGTT was normal, bug test was due.
Asked about the labour- mode of delivery- vaginal, how long (it was very quick 4 hours) as soon as
the water broke, color of liquor? Any assistance needed
Past history- DM,HTN, Smoking history, Family history of heart conditions
Described above causes individual. I mentioned transient tachypnea first- said as the labour was
quick, liquor was clear and he is beyond 34 weeks this is likely, but it is more common after CS.
Next RDS- in babies less than 34 weeks, liquid called surfactant is not good in quality and quantity
so lungs cannot work properly but mostly in less than 34 weeks. MAS unlikely as liquor was clear.
Heart disease- less likely as examination it seems ok. Similarly others…
Ongoing treatment- senior doctors are taking care- giving oxygen in NICU, monitoring his
breathing and oxygen, heart rate, temperature. Will do x ray, once breathing settles may start
breastfeeding and you can stay with him. For now NG tube/IV fluids. With xray- guides us what
may be wrong. And treat accordingly like surfactant, antibiotics. If not improving may need further
assistance in breathing with intubation but it seems unlikely right now.
Any questions? We will keep you updated. Any one you want me to call?
7. (pass) Young lady at 32 wks of pregnancy cake to your clinic with her hand held pregnancy
Notes. Her regular gp is not available. Her hand held notes state that her labs were ok sugar test
normal blood group. positive 18 wks usg normal. She came for her regular antenatal check up
And u r seeing this patient for the first time.
Take relevant history, Ask findings from examiner except fundal height that u have to take
yourself. Explain patient the possible causes of her condition.
I entered the room young girl was sitting on chair
Greeted both examiner and role player
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Started history: Fetal movement ok, 3 trimester complications questions asked, Skipped the info
that was given in stem. Then asked about the family history of diabetes she said no.
I forgot the question that I asked her and she said I have some discomfort for last 1wk now
Then asked examiner about findings
General appearance ok, Vitals normal
Said I will do SFH but will u pls tell me about the lie and presentation of fetus
Examiner said it’s difficult to asses the fetal lie and presentation but it’s longitudinal
and cephalic I asked fetal heart rate he said normal
I asked about any uterine contractions palpable he said no
I asked about the office test he said normal
Told the patient that I’ll examine her tummy she said yes doctor it’s ok
Then measured her fundal height using measuring tape provided examiner was
standing beside me showed her that fundal height is 40 cm
Asked the patient to come back
Started explaining her that her fundal height should he 32 cm but it’s much more than expected
Than started explaining her that this is most probably due to polyhydraminos told
her other possibilities as well like mistaken date that is least likely as she has regular
check ups. Fibroid uterus is also least likely as her 18 wk USG was not showing any problem
Then quickly told her abt the causes of poly. Checked about understanding
Bell rang thanked role player and examiner
Another Feedback: large than date third trimester. History, take fundal height, PEFE, causes to
patient. PASS
History: Rapport- you must be very excited.
How is pregnancy so far? She said going well but her friends said she seems to be larger than
expected.
Was dating scan done? Yes Was it singleton pregnancy? Yes Did she take the folic acid? Yes Was
this first pregnancy? Yes. Any breathing problems/ abdominal pain/ pv
discharge/bleeding/fever/rash- all no just discomfort. Exposure to cat litter/raw meat no.
Antenatal Blood tests? USG at 18 weeks? OGTT all normal.
Past history- DM, fibroids no
Family history- DM, cancer no
SADMA all no
PEFE- all given were normal
Take fundal height: while was moving to the bed it was taking time so I asked if she has thought
about any names.
Height was larger than date. Forgot the exact measurements. Examiner was close and asked me
the measurements.
Then explained that the belly is larger than expected at this point in pregnancy , the baby’s heart
rates are normal and on examination everything else seems to be ok but we do need to rule out a
few things.
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Explained causes for large for date - polyhydramnios, wrong date, multiple pregnancy, DM, viral
infections, sometimes problems with baby’s development but that would be usually be picked up
in 18 week scan. Explained giving explanation and reasons.
8. (pass) 57 years old lady came with lump and rash. Take history both for lump and rash
examination findings on card from examiner. Explain patient about her condition.
I was so confused outside as the stem was so confusing
Entered room greeted roleplayer and examiner
Started with history: Typical Karen case
I asked about any past history she said no, I asked about DM
She said now after u asked me I think I might have diabetes
Prev 3 pregnancies she was GDM all babies were around 4 kg at the time of birth
1 delivery she had ventouse deliver with multiple vaginal lacerations
Post menopause for 7 years, Asked about menopausal symptoms
She said she has some dyspareunia and she is using estragen cream
Then I asked examiner for card
On card: Vitals normal, Other all systems normal
On pelvic inspection: Rash noted. Cervical os at the level of introitus
Anterior and posterior vaginal wall prolapse
On straining the uterus lies outside the vagina
Office test: BSL 12 mmol, Urine dipstick glucose 2 +
Told the patient she has few problems. ‘ ll be explaining her one by one.
Started with diabetes. Told her that she is having undiagnosed diabetes mellitus as blood sugar
level is high and glucose in urine as well this issue needs to be addressed first.
Then told her about candidiasis that is also due to underlying DM said that I’ll give her
medication for local application. Then explained about the uterovaginal prolapse
Told her that due to difficult deliveries and after menopause she had experienced
this problem. Told her that loss of hormones from body after menopause have contributed to this
Told her that definite treatment is surgery but after good blood sugar control
Bell rang thanked role player and examiner
Another Feedback: 50s lady, complaining of lump and rash . Take history, pefe card will be given,
explain to the patient like causes. PASS
Asked about lump – it was prolapse case, asked all questions such as – duration, when does it
come out (standing/ sneezing/ straining?), does it go back , any pain/ discharge/bleeding/tummy
pains/ burning wee.
Asked about rash- site, duration, itchy, discharge, pain, changes over time? Any new product
used? Etc
Asked 5 Ps- positive were she was multipara, one was prolonged labour with assisted delivery ,
post menopausal
Asked post menopausal qs- urine incontinence, mood/hot flushes, back pains, mammography ,
bowel changes - constipation..
Asked past medical/surgical, family history of cancer , Smoking
PEFE: everything was given: positive were: utero vaginal prolapse+, rash over the groin, BSL was
12. Explained to the patient: individually 3 findings what they were. Then explained why prolapse
occurs. Told the possible causes of rash as – fungal infection/allergic/traumatic/ viral
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9. (pass) 40 years old male is in your clinic. her wife saw a program on TV regarding the adverse
effects of alcohol and asked the husband to consult doctor because of this.
Take history, Explain the patient about the adverse affects of alcohol. This is handbook case
History taking is same. The second task is only to explain the adverse effects no counselling
needed.
Another Feedback: Oppurtunistic health review. Patient came because wife asked him to go due
to his excessive drinking . History, counseling regarding effects of alcohol. PASS
History – asked all questions like handbook case plus SADMA, past medical, family history,
HEADSSS; patient in precontemplation- denies that his drinking is harmful to him.
Counselling- effects of alcohol in all systems of body individually. Asked how he feels about thatsaid that he wasn’t aware of this. Then said I will give reading materials…..
10. (pass) 40 years old male came to u with complaint of chest pain.
Take history, Examination findings from examiner (u will only be provided with the findings u will
ask for ) Tell patient about most probable cause and differential diagnosis with reason.
Started with sortsara, Pain on right side of chest at the level of nipple, Started gradually since last
night, Tingling or burning in nature, Felt feverish last night, Pain scare 6 or 7, First time, No other
symptoms, Teacher by profession, Non smoker, Drinks on weekend, No weight loss and lumps and
bumps, Then asked the examiner for findings.
General appearance examiner said as u see vitals - normal
Local exam no lesions no rash or ulcers tender to touch
I asked respiratory and CVS and then office test not available
I forgot to ask about lymph nodes. Then came back to patient
Explained about shingles And other causes of chest pain. Checked understanding
Bell rang
Thanked examiner.
Another Feedback: Middle age woman with chest pain right side. History, PEFE, explain patient
likely diagnosis and its causation, DD. Pass
History: pain for one day, moderate severity, on right side in a line, aggravates when something
brushes against the skin, but no rash so far. Otherwise everything negative, no SOB, cough, fever,
racing heart, no GI symptoms, respiratory symptoms. Asked all DD questions (cardio/ respiratory/
GI/anxiety/ costochondritis, herpes zoster)
PEFE: vitals stable. tenderness along nipple line on right side chest and back, no rash/ breast
normal, chest/cvs normal
Diagnosis: herpes zoster- viral infection in patients who have had chickenpox, the virus lies
inactive in nerves and sometimes reactivates due to illness/ low immunity. I asked her did she
have chickenpox as a child, she said yes. It was clear herpes even if no rash as history was typical
of dermatomal pain before rash appears, and the stem also mentioned to explain the causation of
diagnosis so it was a hint.
DD of chest pain: Cardiac like MI/ pericarditis/aortic dissection, respiratory like
pneumonia/pneumothorax, GI like PUD, GORD, Musculoskeletal- costochondritis/trauma, anxiety
giving reasons why not.
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11. Mse video of depression- boyfriend after breakup with girlfriend. Watch video and present
MSE to examiner. PASS
According to ASEPTICJ, RRR. All pointed to depression. Quickly wrote down the mneumonic and
took notes while watching. Presented same findings, can look at notes.
12. 67 years old lady came to your clinic with pain in her both hand and this pain is interfering with
her daily activity. Perform hand examination and functional examination. Tell diagnosis and DDs
to the patient. (PASS)
Use pillow. Asked where the pain is and took permission to examine.
On Inspection patient had swelling over right distal interphalangeal joint 2/ 3rd finger. Slight
deformity of that joint 2nd finger. No other obvious deformity, muscle atrophy, no nail changes,
no bruising/ signs of trauma, scar marks, no claw hand/ contractures, elbow- no rheumatoid
nodules/ psoriatic patches.
Palpation: pulse, temperature over swollen joints, then started palpating every joint of hand,
examiner said tender only on swollen area.
Move: wrist, finger and thumb movements- normal.
Special test: Finkelstein’s negative, tinel/phalen negative. Examiner told me to skip nerve
examination.
Functional –used all the provided items. I asked her to use the paper clip with affected hand, write
her name with the pen, pick up the coin, open the cap of a container, act like opening lock with
key. In all these she was not using the 2/3rd fingers.
Dx: RA. DD: OA, gouty arthritis giving reasons. Missed trauma/ septic arthritis and other probably
that’s why got a low score in differentials.
13. Lithium travel advice - 36 years old lady came to your GP clinic known case of bipolar disorder
for 10 years, on lithium planning for trip to mountains in India. Taking lithium(dose given). All her
vaccination is up to date. Her last attack of mania was 5 years ago.
You have taken history about his mental status- seems fine. Task: take history about his
medication. Give advice regarding travel. PASS
Started by saying you must be very excited.
I mentioned that with previous history he seems to be doing ok but need to ask some questions
about medication. He had been taking lithium for 6 years, last relapse was maybe 1 year back,
dose was increased since that time, asked the dose and times. He takes it every day on time and is
compliant. His last visit to specialist was 1 month back and he did not ask for travel advice then.
I asked for side effects of lithium- thyroid, weight gain, thirst, urine changes. If blood levels were
checked. Doesn’t take alcohol/drug.
Asked where travelling, how long, with whom, any prophylactic medications/vaccines taken.
For advice I mentioned the general advices for travel: before, during and after. Specifically: take all
the medication needed for the time plus some extra. Take the prescription and letter to local GP.
Divide the medicine in the luggages in case one is lost. Take it regularly on time (forgot about the
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time difference as he was going to india), take enough water and sleep as it can affect him. Try not
to stress as much. Review with specialist asap before he goes. Take a friend or tell the group
leader about the condition if he can. Asked about antimalarials and mentioned to be careful with
OTC drugs as they can interact with lithium so ask pharmacist/local GP. If he feels unwell/ harmful
thoughts--- see Dr immedicately. Take local GP, emergency numbers.
Closed off by saying have fun and enjoy your vacation!
14. 57 yr old man with PR bleeding few weeks. Take consent from the patient and perform
abdomen exam on patient and per rectum examination on mannequin, Tell the investigations
needed. Pass
Took consent for abdomen exam; then PR examination- explained exam, position, chaperone (just
like geeky medics video on youtube).
Abdomen: On inspection no obvious distension, all quadrants moving equally with respiration, no
scar marks, striae, bruise, dilated veins. On palpation soft, non tender, no palpable mass, no
liver/spleen palpable, on percussion abdomen tympanic so skipped shifting dullness. On
auscultation abdomen sounds heard. I mentioned I will also check hernia sites and other signs of
liver disease.
(I followed geeky medics PR examination video on youtube and look out for positive finding- here
positive was a lump was palpable laterally—I didn’t describe the lump as I got nervous I just
mentioned it but you should describe it). Also mentioned Proctoscopy to examiner.
Investigations to patient: There could be few conditions leading to PR bleeding so we need to run
some tests. First, Hb to see blood levels, Platelets, LFT as sometimes liver problems, Colonoscopy
(patient specifically asked me why to do this, when I said nasty growth he asked me what nasty
growth so had to mention to r/o cancer) . I explained colonoscopy as a procedure done by
specialist, may need a CT/USG of tummy depending on the findings of colonoscopy and specialist.
15. (non-scored) 50+lady saw his GP with c/o pain in her tummy on examination GP found a hard
mass in epigastrium and requested CT scan. After reviewing the report of CT he asked the patient
to see specialist with a copy of CT scan. You are intern in hospital and seeing the patient.
Take relevant history. Explain the CT to patient. Explain her what can be the possible cause and
most probable causes.
16. (non-scored) 56 years old lady came to ER with (forgot presenting complaint) no past
significant history. ECG done in ER shows atrial fibrillation. This is the first time patient is having
this condition.
Tell patient what is Atrial fibrillation and what has caused it.
What further investigation u are going to do and why.
And explain her about the most probable medical management of atrial fibrillation.
(Referral to specialist for further management will not be acceptable at this station)
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3rd, 4th, 5th, 9th, 10th, 11th, 16th, 17th, 18th April 2019 Recalls
3rd April 2019
1. Leg pain DVT? Picture given History, Dx, Causes.
(another recall - PVD and leg infection picture given History and DDx)
2. Short of breath- COPD? PEFE, Invx, Dx, DDx CXR provided, Spirometry-not available
(another recall – CXR: emphysema, explain to patient give DDx)
3. MSE video Watch 4 min. Present, No dx asked. (Depression)
4. Knee exam PE, Dx, DDx. (Meniscus test positive)
5. GGT raised PE, Dx, Causes.
6. Bleeding PV post-menopausal atrophic? PE, Dx, Causes.
(another recall- positive finding polyps)
7. 8 years old child d/c from hospital because of acute asthmatic attack Trigger: infection, exercise.
Now on preventer. Explain spirometry. Dx. Write AAP. Tell SE of medication.
8. Feeling Hot and cold. HIV positive. Medication incompliance - History, PEFE, Dx, DDx
Feeling unwell. Fungal infection in mouth? High temperature
HIV with opportunistic chest infection: History and explain (new case)
(I took detailed history along the line of d/ds you already mentioned. I didn't ask about GIT infection
and toxoplasmosis.)
In history - he had high grade fever, dry cough, rigors and chills. no chest pain, no neck pain, no
discharge from ear, no rash, no travel history, positive history of contact: girlfriend had same
problem. Non-compliance with medication, haven’t seen doctor for last 1 year, no symptoms of UTI,
bowel normal, no diarrhea, no discharge from down below. No weight loss, no lumps or bumps.
Examination i asked: GA, vitals, dehydrated, ENT, lymph nodes, listened chest - it was N, neck
stiffness negative.
My explanation: Mr X, as you know you are diagnosed with HIV which means human
immunodeficiency virus. I will explain you in simple words. It affects immune system which is body's
defense system. So now defense system is week and body can’t fight with simple bugs. Don’t worry
it’s a common presentation. One of the bugs is pnemocystitis carini. Don’t worry about the name,
you made a very good decision to see me today. I am going to send you to hospital. They will start
you on antibiotics straightaway after doing couple of tests. You are in safe hands, do you want to call
someone. I still left with time so i asked him do you wanna ask something. He asked about
pnemocystitis. I then explained him a little bit about pneumonia and said it’s my most likely
diagnosis (I thought it was a hint from role player so said so). Also said still needs to exclude some
other causes. You will be seen by specialist. I would advise you to keep up with your future follow
ups. He said thanks doctor I will now.
(I didn’t mentioned CD 4 count. Although i passed but still adding it will give you more marks)
9.
Bulimia case. Feeling tired History. Counsel.
10. Baby headache for 4days History, PEFE, Dx. Inflammation in ear, runny nose, pharyngitis, no
pus, GA well.
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11. Farmer, drought. MSE - OCD features present.
12. Low back pain History, PEFE, Dx.
13. Request induction of labor- History, PEFE, Counsel. (2016)
14. Baby unwell (septicemia?) History, PEFE, Dx.
15. Jaundice 7 days old, sick child DDs and history- Biliary atresia
16. Dry cough fever 7 years old child = viral cough
17. Dysphagia and Weight lost = esophageal Cancer(2016)
18. Post cholecystectomy- pre-discharge assessment PE case (new case)
4th April 2019
1- Substance abuse, suicidal then MSE
(She was taken 10 tablets diazepam (5mg) because her boyfriend left her. It was 10th attempt. She
was happy that boyfriend will come back after that. History and MSE need to take and explain
examiner what you think and to patient what is wrong with her. No Mx.)
Another Feedback : Borderline Personality (Unscored)
20s/F took 10 tabs of meds due to fight with partner. She's stable and feels ok now, wants to go
home.
Task: Take psychiaric Hx, Dx, DDx.
2- ISBAR rectal bleeding
(PR bleeding. On Social History: smoking 20 cig and cocaine Occasionally. Big stem, need to tell
further Mx.)
Another Feedback : ISBAR Diverticulitis (Unscored)
Whole patient info given.
Task: Refer the patient, immediate management
(Just read the whole patient info though but just the pertinent ones)
Good morning I'm Dr. Jan, an intern in this institution. May I know whom I'm talking to? Dr.Stark. Ok.
Good day Dr. I would like to refer a patient of mine, Mr.___, 60/M, came in with a chief complaint of
hematochezia. Few days prior to consult patient developed hematochezia associated with dizziness.
Persistence of symptoms prompted consult.
This is a known hypertensive for __years, CAD last (__year), Osteoarthritis maintained on aspirin,
statins, and with reported chronic NSAID use.
There's a family history of breast cancer on maternal side.
Patient is a smoker and occasional alcoholic beverage drinker.
Upon arriving to the ER, patient 's vital signs were ____. On PE, patient is noted to be pallor,
abdomen was soft… DRE was ... otherwise other examinations were normal. VS as of now is stable,
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he was hooked to IV line (mention whatever's done in the ER). Laboratories such as CBCPC etc which
revealed ... (mention pertinent results).
Our working impression is LGIB probably secondary to bleeding diverticulitis. I would like you to
inform the gastro department for colonoscopy.
Do you have any questions? Do you want me to repeat anything? Thank you.
examiner says "if you remember anything just tell me."
After a few minutes...
Oh!! and Please maintain the patient on NPO and give PPI. Please monitor the VS continuously and
take note of any changes in the pattern of symptoms like abdominal pain, profuse bleeding. Hold his
medications of aspirin and NSAIDS. Thank you. Examiner says very good.
3- Assessment of change in behavior (Schizophrenia)
30s/M, known case of schizophreniform for 4 months, brought in due to change in behavior
Task: Hx, Psychiatric Hx, Present MSE
GS 4
Approach, commentary, accuracy, dx/ddx: 4
In this case the patient cannot get hold of the reality. So I just asked everything ruling out any
organic cases like infection, thyroid, head trauma, usage of drugs. Past hx of schizophreniform when
was he diagnosed, did he take any medications for it religuously. SADMA.
Then moved on to confidentiality and psychiatric hx such as Mood, Sleep, Appetite, Guilt, Energy,
Cognition, Delusions (Persecution, flights of ideas) and Hallucinations ((+)Auditory), Judgment,
Orientation to time, person and place.
Reported MSE:
Intro: This is a case of Sam 30/M brought in by his parents due to change in behavior. He was a
known case of schizophreniform for 4 months, stopped taking his medications. He started to have
changes in behavior hence brought here.
ASEPTICJ
Rapport not established with poor reliability hence i need to do collateral history from the relatives.
This is moderate to high risk, I would like to call the CAT team for reassessment.
4- Menstrual Abnormality (PCOS)
20s/F, Irregular menstruation
Task: Hx, PEFE, Dx, DDx
GS: 5
Hx: 4
Choice & technique: 5
Dx/DDx: 5
Intro
5Ps:
Period: Menarche, Interval, Duration, Associated sx like dysmenorrhea
Partner, Pills, Pregnancy, Pap: None
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Associated sx & DDQs:
Weather preferences, fever, lumps or bumps, changes in weight (increased), acne (+), frequency to
the loo, waterworks, bowel movement.
PEFE:
VS & BMI: Overweight
GA: Pallor, Lymphadenopathy, edema, signs of dehydration (-)
Face and neck: Acne, No mass on neck/ signs of thyroid enlargement
Abdomen: No skin changes, obvious mass, scar marks, no tenderness, tympanitic all over,
normoactive bowel sounds
Pelvic examination with consent and chaperone:
On inspection: No rashes, discharge, obvious mass or enlarged lymph nodes.
*Patient is a virgin so I stopped.
Office Test: UDS, BSL, Pregnancy test
Based from my Hx and PE, I'm considering that you have a condition called Polycystic Ovarian
Syndrome. Do you know what its is? (Draw ovary with multiple cyst). This is why you're having these
symptoms. This is common and treatable. Usually it coincides with blood sugar problem. Other
conditions could be thyroid problem, infection (I forgot other differentials I gave). I will refer you to
the specialist to confirm with some tests specifically an abdominal/rectal ultrasound and some blood
tests to rule out other causes.
For now, please adapt a healthy lifestyle, try loose weight by 10%, eat healthy. Once the specialist
confirm PCOS, she might give you pills to regulate your cycle. Any questions? Are you happy with the
plan? Review, red flags, reading materials.
5- PVD history, diagnosis
(He had a pain on Rt calf. Task: History, PEFE. DDx. No Mx. On History: He had a pain during 6 month
and had difficulty to walk even 50m. Better with rest. No skin discoloration, no edema, no ulcer. No
travel History. On PEFE- all normal, ABI- not done yet.)
Another recall - 50s/M, pain on leg. Task: Hx, PEFE, Dx/DDx
GS: 5
Hx: 4
Choice & technique: 5
Diagnosis/DDx: 5
Intro
Pain Qs: When? Where? Right leg Sudden/progressive? When do you notice that the pain is
prominent? walking especially uphill. Continuous or on & off? On a scale of 1-10 how painful its is?
how would you describe the pain? Does it go anywhere else in your body? Anything that makes it
better or worse? Did you do anything about it? Are you in any pain right now? No.
Associated sx: skin changes and color changes in the leg, chest pain, numbness and swelling of the
leg
DDQs: DOB, funny racing of the heart, trauma, weakness in any part of the body? None
Past Med Hx: HPN, DM, Lipid problem?
Family Hx, SADMA
PEFE:
VS, BMI
GA: Pallor, lymphadenopathy, edema
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Leg: Skin changes and color, edema, warm or cold to touch, pulses, CRT, no tenderness on palpation,
Homan's sign, Buerger's test
Chest and Lungs: Air entry equal, No murmur and arrhythmia
Office test: ECG, BSL
Based from my Hx and PE you have a condition called PVD (draw leg with vessels), in this condition
fats deposit at the sides of your vessels making it friable and hence the blood supply is affected
where it is deposited hence the pain whenever you walk. Other likely condition could be DVT. Other
causes of leg pain could be trauma, infection which are very unlikely in your case. We will confirm
this by doppler ultrasound and some other blood parameters. Once with results I would refer you to
the specialist. He might start you with medications such as statins to dissolve and stabilize the
plaques. Do SNAP, Review, red flags, reading materilas. Any questions? Are you happy with the plan?
6- Neonatal esophageal/duodenal atresia with X-ray
(On Antenatal US was Polyhydramnios, Apgar 9/10. Milky vomiting after 8 hrs. On PEFE all normal,
no blood in anus. X-ray similar to esophageal atresia. Need to explain X-ray, history from nurse.
PEFE. Immediate Mx plan)
Another Feedback : Vomiting (TEF/ Esophageal atresia)
8 hour old baby, vomiting. Chest AP xray given. Stable VS. Talk to the nurse in charge who inserted
the NGT.
Task: Hx, Explain xray, Dx/DDx, Mx
GS: 5
Hx: 5
Choice & Technique: 5
Interpretation of investigation: 5
Dx/DDx: 4
Mx: 5
Hi I’m Dr. Jan, I’m the intern in charge. I believe you were in charge with our patient, can you please
tell me more about it. Well doctor he’s been vomiting since I started feeding him.
Vomiting questions:
Can you please describe the vomitus? What’s the color, amount? Just milk.
Does it occur after every feed? Yes.
Is the vomitus going away from the body (projectile)? No doctor, it’s just flowing from his mouth.
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Do you think he’s satisfied after feeding? I think no doctor.
After every feed what is his position? Lying flat.
Associated symptoms:
Have you noticed any fever, abdominal enlargement? Unusual color of the baby? Did he pass BM?
No.
BINDSMA questions
Do you know if there’s any eventful thing that happens during the mother’s pregnancy? Do you
know if he’s born term/preterm? Normal or CS? Was resuscitation done?
NGT questions:
Were you successful in placing the NGT? I think yes
Do you know why you were asked to place an NGT? (I forgot his answer)
Ok this is the X-ray, this is the lungs, heart. Now, do you see this white thing? This is the NGT,
supposedly it should go straight however it coiled. Ideally the food pipe is like this (I drew esophagus
and stomach) in the patients case I’m considering that this is a condition of tracheoesophageal
fistula (I drew the different types H type, K type, h' type etc) a condition where there is a wrong
connection between the windpipe and the foodpipe along the way or no connection of the food pipe
at all (esophageal atresia). It can present like this. That is why when you tried to insert the NGT it
coiled and whenever you feed him he vomits. This is common with preterm. Other unlikely cause is
duodenal atresia however unlikely due to the xray given.
Does the mother know? No doctor. Have you talked to the father? No. Ok I will explain it to the
parents later. For now, I’m gonna refer this to the pedia and surgery team and we'll do further
imaging to be sure.
You did a good job so don’t worry it’s not your fault that the NGT coiled. I want you to hold any
feeding in the baby and insert IV line for his nutrition. Make sure to maintain his VS within normal
limits. Do you have any questions? “Is there anything that I should know?” I think I told you
everything you should know but once the surgery and pedia team decides I’ll inform you as well.
Thank you.
7- Puberty Menorrhagia
17/F, vaginal bleeding. Task: Hx, PEFE, Dx/DDx.
GS: 4
History: 4
Choice & Technique: 4
Dx/DDx: 4
1. Intro and asked about hemodynamic stability but all normal
2. Asked 5P's
Period: just recently, lasting for more than 5 days now(?) Uses 2-3 regular pads per day not fully
soaked, no dysmenorrhea, blood is bright red in color, no clots, no tissues, or grape like structure.
No offensive odor. (I can't remember if this is the patient's first period.) This was the first time it
happened.
(Have you started your sexual life?)
Partner: none
Pregnancy: none
Pills: none
Pap smear: no
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Asked about associated symptoms like abdominal pain (-), dizziness (slight), easy fatigability (-)
Asked about differentials like weather preferences (-), fever (-), weight change (-)
3. Family Hx: No same history and no bleeding disorder
4. Past med Hx: No other diseases like hypertension, diabetes, lipid problem
5. SADMA: Non smoker, non alcoholic bev drinker, not on any kind of meds like blood thinners, no
previous operation from down below or previous hospitalization, no allergies to meds.
PE:
Gen appearance: slight pallor, no lymphadenopathy, edema, or signs of dehydration
VS: Normal but BP was borderline (if I remember it correctly)
Abdominal examination: No skin changes, no tenderness, no organomegaly, tympanitic all over
Pelvic examination:
On inspection: No rashes, skin changes, there is slight bleed, non-clotted, bright red, no offensive
odor.
I stopped here since she's a virgin.
To complete with office test:
pregnancy test, BSL, UA all normal
Explain:
Based from my Hx and PE, most likely it is a condition called puberty menorrhagia where there are
menstrual irregularities specifically profuse bleeding which usually happen during puberty. This is
common if with family history of the same disease however it's not in your case. There could be
other causes like thyroid problem however you don't have those symptoms, it could be an infection
however you didn't have fever and the bleed doesn't have any offensive odor. Other unlikely cause
could be bleeding disorder however you said you don't have any family history, or this could happen
if you’re taking any blood thinking medications but you said you didn't.
So what are we gonna do now is, do some blood examination first to check the level of your red
blood cells since you're having dizziness already and slight pallor. I can give you medications to help
stop the bleeding (tranexamic acid, I can't remember if I said this drug exactly). Once with results I'll
give you a ring. However, if symptoms persist and the bleeding is more profuse, and any changes in
the pattern of symptoms, please don't hesitate to come back. By that time I might refer you to the
specialist.
I'll give reading materials.
8- HTN on perindopril, tired, over-weight, doesn't sleep well
(Patient hypertension came for a review. Also complain about tiredness. Nurse BP 135/85. On
history, no signs of Hypertensive emergency. So moved on DDx of tiredness. He's got OSA.)
Another Feedback - Health Check (OSA)
40s/M, Tiredness. Task: Hx, Dx, DDx.
GS: 4
Approach: 4
Hx: 4
Dx/DDx: 4
Hi! Good morning! Im Dr.Jan, I undertand your concern about tiredness. Can you please tell me
more about it? Well doctor, I have noticed I'm becoming tired recently.
Any particular time of the day that you are tired? I noticed I'm tired for the whole day.
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You get tired even upon waking up? Yes.
Is this the first time that it happened? Yes
DDx Qs:
Do you have any weather preferences? Any fever? Unintentional changes in weight? Chest pain,
funny racing of the heart? No
Do you still enjoy the things you usually do? Yes
Systemic Qs:
Headache, Lumps or bumps, DOB, Chest pain, change in skin color, changes in BM and waterworks?
None
PMHx:
Any medical conditions i should be aware of like DM, Lipid problem? Any previous hospitalizations,
dental procedures? None
PSHx: Anyone with similar symptoms at home? Travel anywhere? Recent tattoo/piercing? No.
FHx & SADMA Qs
(At first I'm not sure what this was, I ran out of differentials, then it hit me...)
Oh! Has anyone told you that you snore? Yes doctor. (Oh that yes! music to my ears LOL
*hallelujah*)
Do you feel sleepy even upon waking up? Yes.
Based from my history taking, I think you have a condition called Obstructive sleep apnea. Do you
know what it is? OSA is a condition where you have narrow neck area or enlarged tonsils. Whenever
we sleep the tongue relaxes impeding with the airway hence the snoring (I drew the head on lateral
view). So there's not much oxygen going to the brain that is why you don't feel refreshed even after
complete hours of sleep. Other conditions that I was considering were thyroid problem, infection,
heart problem (I stated why not). I'm gonna do physical examination then refer you for a sleep study
to confirm. Lifestyle modification. Reading materials, Review.
*I wasn’t able to elicit increased BMI and was not able to mention the relationship of hypertension
and OSA
*I forgot to ask his line of work
9- Post cholecystectomy wants discharge early
(A lady post cholecystectomy op. The surgeons want to discharge on day 3. Patient ask to be
discharged sooner. History, PEFE,Mx? Forgotten.
Everything was perfect on history. Reason she wants to go home. She has a mum at home. 85yrs.
PEFE: Everything marvelous, UDT- RBC + Discharge?)
Another Feedback - Post operative assessment
30s/F, day 3 (?) post cholecystectomy, wanna go home. VS given all stable, on IV antibiotics. Patient
was given blood thinners (?)
Task: Hx, PEFE, Assess if patient can go home
GS: 5
Approach 5
History 5
Choice & Technique 5
Patient Counselling 5
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Intro
Asked: Wind, water, wound, thrombophlebitis, DVT, bowel movements, flatus.
Do you have any idea why were you given the meds for blood thinners? None
Past Med Hx: Unremarkable
SADMA
PEFE:
VS (stable)
General appearance: Pallor, icterus, cyanosis, lymphadenopathy, edema, signs of dehydration (all
negative)
Chest and lungs: equal air entry, no added sounds
Abdomen: wound healing well without any discharge, No distension, erythema. No tenderness on
light and deep palpation. Normoactive bowel sounds
Extremities: Check for erythema, edema, pulses
To complete with UDS, ECG, BSL
Based from my history and PE, everything seems well. Your vital signs are stable, the wound is
healing pretty well. I'm sure you really want to go home so I will consult my senior if you can go
home, he might reassess you again. We might shift you IV meds to oral one. Do you have anyone
who will accompany you if you go home? None doctor, my husband is at work. Do you want me to
call anyone to accompany you? No. So for now, we want to make sure everything is well before
letting you home. I'll make sure that all the laboratories are normal. I suggest to have someone with
you when you go home to help you at home. Are you happy with the plan? Yeah I think so doctor.
10- Hand examination-Rheumatoid
Another feedback – Wrist tenderness + both ulnar and radial area
11- Ear examination - Hearing Complaint (Conductive Hearing Loss)
40s/F, hearing problem. Task: Do Ear PE, Dx, DDx
GS: 4
Approach: 5
Choice: 4
Accuracy: 4
Dx/DDx: 4
Hi! Good morning! I'm Dr. Jan, I'll be taking care of you today. I'm tasked to do some PE on you, it
may involve look, feel, move some parts of your body but if you feel uncomfortable just tell me and i
will modify my examination. (Reciting these while washing hands)
Are you in any kind of pain? No.
VS: stable
Quick history: When did it start? What side is affected? Right. Sudden or progressive? Any
discharge? Any ringing sound? Did you do anything about it? First time?
(I always start with normal side)
On general inspection, patient is seated comfortably not in apparent distress.
On inspection of both ears, Both are patent, I cannot appreciate any mass, swelling, redness,
deformity, discharge. On palpation, no tragal tenderness.
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Whisper Test
Weber Test
Rinne Test
Next I would like to check your inner ear with a scope if that's alright. I'll be careful don't worry.
(Gets otoscopy and assembled it, using the small earpiece)
(On the dummy) I'm gonna pull your ears up and back and will be very gentle.
Report: Ear canal is not erythematous, no discharge. Tympanic membrane is intact, not bulging
without any perforations but with slight erythema, cone of light is appreciated.
Based from my history and PE, I'm considering you have a condition called Acute otitis media. It is an
infection of the middle ear because I saw some redness on your tympanic membrane (draw). Other
condition could be Ear wax, mass (I forgot what differentials I gave but not much). What we're gonna
do is refer you for formal hearing test. I can give you some ear drops for the infection. Review,
Reading materials. Red flags.
12- Hematological examination: Inguinal LN, night sweats, tattooing
(Patient with tiredness LOW, LOA. On examination Inguinal LN enlarged rubbery. PE: Not asked to
examine scrotal.) Lymphoma
13- Rubella exposure in pregnancy investigations, management
Station 16: Antepartum care (Rubella in Pregnancy)
20s/F, exposure to rubella. Task: Hx, Counsel
GS: 5
Approach: 4
History: 5
Choice: 5
Counselling: 4
Good day I'm Dr. Jan, I'll be taking care of you today. So I understand you're concerned about having
an exposure with rubella. Can you please tell me more about it.
Rubella questions:
-When and where were you exposed? Few days back, one of my students have it.
-Was it a confirmed case of rubella? Yes
-Do you have any symptoms recently like fever, cough, throat pain, rashes? None
-Do you have an updated immunization?
-Have you had rubella before? No.
5Ps:
Period: delayed
Pregnancy: + UPT, first pregnancy if ever, no check ups yet, planned
Partner: stable, with good support
Pills/Contraception: No
Pap/HPV: updated, normal
Past Med: unremarkable
Family Hx: unremarkable
SADMA: Normal
Counsel:
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Congratulations on your pregnancy! Since this is your first check up we need to confirm your
pregnancy if that's alright with you. We'll run some antenatal tests as well which I'm gonna discuss
to you later.
First, I would like to address your concern regarding rubella. Do you know what rubella is? No.
Rubella is caused by a bug causing rashes and some flu like symptoms. It may look mild in your case
however I'm worried that it could be harmful for your baby. It could lead to eye, hearing, brain and
heart problem. (Patient had the usual worried reaction)
I know you are worried about this but let me walk you through on what's gonna happen.
We'll run some test and there are 3 scenarios: (drew the table)
1. IgG + IgM - : this means that you're immunized and nothing to worry about.
patient interrupted me asking "so doctor is this a blood test?", "Yes it is", I answered.
2. IgG - igM +: you are infected. Now in this case you have an option to not continue with the
pregnancy. OR I can refer you to high risk pregnancy clinic and we'll do more frequent tests to check
for complications.
3. IgG - IgM- : you are not immunized, but not yet sure if you're infected or not, hence we'll repeat
the test and see if we fall back to scenario 1 or 2 after several weeks
Do you have any questions? None. Ok, if it turns out positive, I need to report this to the department
of health for statistic purposes alright? For now we'll do all the antenatal check ups which involve
blood workups (tried to roughly enumerate it) and ultrasound. Once with results I'll give you a ring.
Please watch out for any changes like fever and the like or if any problems do not hesitate to come
back. If you need a time off from work I can give you a medical certificate especially if there's a
recent case in school. Thank you.
14- Failure to thrive: Celiac disease
15- Amlodipine, Congestive heart failure in COPD
(Patient COPD SpO2 91% comes to you with bilateral ankle swelling. COPD well controlled.
DDx of ankle swelling (liver, renal, DVT, cellulitis, insect bite, etc)
History- no signs of heart failure, PEFE- border of the heart can't be assessed.
Said Amlodipine and HF can be the cause. Review again.)
Another Feedback- Leg swelling (Right sided HF secondary to COPD)
50s/M, leg swelling, known hypertensive and with COPD for years, controlled.
Task: Hx, PEFE, Dx/DDx
GS: 4
Approach 5
History 4
Choice and technique 3
Diagnosis/ DDx 4
Intro
Leg swelling Qs: When? Where? Sudden/gradual? Progressive? Swollen in the morning or in the
evening?
COPD Qs: Controlled, maintenance, last attack, last seen by pulmo
Associated Sx & DDQs: Leg pain, Chest pain, DOB, Orthopnea (+), swelling of any parts of the body
like abdomen, eyes, changes in waterworks, BM, trauma, any skin cuts, fever
135
PMHx: COPD controlled can’t remember last attack, HPN
Family Hx & SADMA: On hypertensive medication
PEFE:
VS, GA
Chest: (My apologies, I can't remember)
Extremity: Grade 2 bilateral pitting edema
Otherwise all normal (JVP not increased, abdomen not distended/ no organomegaly, no facial
swelling, lungs normal no effusions)
Office tests: ECG, BSL, UDS
There could be several causes of leg swelling it could be from the heart, kidney, liver, or just locally
from the leg like infection, trauma. In your case I'm suspecting that it could be from the heart due to
your long standing COPD and hypertension. However we need to confirm this by doing further tests
like 2Decho, blood workups like CBCPC, renal profile, lipid profile, liver profile. Once with result I
would like to refer you to the specialist. If you notice any changes in the pattern of symptoms like
progression of the swelling, DOB and the elike please do come back. Review, reading materials.
16- Child with microcytic anemia, growth chart, all examination normal except systolic murmur,
diarrhoea FTT. History, Dx, DDx.
(Child with anaemia: Microcytic. So it’s iron def: History - a bit picky at food, loose stool +, hard to
flush+, on some exertion child became blue, murmur +, recurrent URTI+. So many reasons. But i
didn’t get the time to tell the DDx)
Another Feedback - Thalassemia (Failed- did not finish)
Toddler age, Blood test: Hypochromic, microcytic anemia with elliptocytes
Task: Explain blood examination, History, PEFE card, Dx/DDx
*growth chart will be given to you to explain* There's a decreasing trend to weight and height
however not more than 2 standard deviations to be FTT
5th April 2019
1. A man came to you as his friend concerned that he may have Parkinson’s Disease.
Task:
1.
2.
Do Physical Examination with running commentary
Give your Diagnosis with reason
+ve Finding: Short Shuffle gait present, Cog wheel rigidity present, Glabellar Tap Positive
(Another recall - nothing was positive except gabellar tap and micrographia. No tremors at all)
2. Volleyball player came with both side knee pain for 6 weeks.
Task:
1.
Perform Physical Examination
2.
Give your Diagnosis and D/D
+ve Findings: Clerk Test +ve. Findings were similar to Chondromalacia Patallae
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(Another recall: Knee examination - Patellar tendinitis
6 months history of pain in both knee pain on kneeling down. Sport girl university student.
Task: PE and DDx with reasons)
3. Middle aged man came with foot pain which started few weeks ago after he did hiking.
Task:
Perform Physical Examination
Give your Dx/DDx
+ve Findings: 4th & 5th Metatarsal tenderness present.
(Another recall: foot examination: don’t know stress fracture or Morton’s neuroma
45 years old man complaint of foot pain since 6 months. History of bush walking and camping for all
so long. No history of injury.
Task: History and PE and diagnosis with reason)
4. 6 years old child came in GP center with fever (38.4c), difficulty of swelling, Lymph node palpable,
Follicular exudate present, rash present (Rash is non blanchable, elevated, palpable), Tonsillar
enlargement present, not dehydrated. Father was very worried as he was thinking -could it be
meningitis or not.
Task:
1. Explain most probable diagnosis to patient with reason (No DDx).
2. Explain its implication
3. Manage the patient
(Another recall: 8 years old child presented in GP with rash congruent on his while body. Tongue
coated. Febrile unwell flushed. Conjunctive eye normal. Perioral pallor and tonsils are enlarged with
exudate plus cervical lymphadenopathy.
At home there are two more children.
Task: tell diagnosis with reason. Tell the management to the father)
5. A man comes with breast lump (it was in right side, lobulated, hard lump, just beside the nipple,
1.5 cm, mobile).
Task:
1.
2.
3.
PEFE
Give most probable Dx/DDx with reason
Give Investigation with reason
(Another recall - 35 years old man comes with complaints of lump in his breast. No relevent medical
and surgical history. Accountant drinks occasionally. Task: PEFE, Dx, DDx with reasons.
137
On PEFE : 2*2 mobile lump in the outer upper left quadarent. And patient was overweight. That’s all.
Chest was symmetrical.)
6. A middle aged woman is in the Alcohol Rehabilitation Center who used to take lots of alcohol for
long time, now stopped and in rehabilitation process. She is diabetic and was on insulin but now she
stopped taking insulin because she has financial issues and also for fear of injection. Today’s BSL is
15mmol/L.
Task:
1.
Do MMSE
2.
Why will you do it?
3.
Mention your D/D for your finding.
+ve Finding: Orientation, Recall, Attention were affected.
(Another recall: HB case of injury to the brain secondary to chronic alcohol abuse. Patient is in the
abstinence phase of alcohol quitting since 3 weeks. She is here for her cognition state function
checkup.
Task: do MMSE. Explain what it is and perform, tell normal and abnormal findings to the patient and
the reason for the abnormal findings)
7. Patient for Pre-Operative Assessment, Taking Hydrochlorothiazide. investigations done and given.
Potassium -Low, Anion Gap -Normal, chlorine- low, Increase bicarbonate.
Task:
Take History
Find the Cause
Explain the investigation
(Another recall: 57 years old man presented to know his report of pre anesthetic assessment as he
scheduled for inguinal hernia repair. All investigations - normal. Just K: 3.4 slight reduced with
slightly reduced chloride and bicarbonate. (Thiazide induced electrolytes imbalance)
Task: explain reports to the patient and take history and tell DDx with reasons.
History- Patient is known hypertension and on thiazide since 6 years. Increase urinary frequency and
wakes up one time at night for pee. Otherwise normal healthy. No history of reduced fluid intake,
vomiting, nausea, diarrhea. No symptoms.)
8. Bulimia nervosa case – Patient referred from dentist came with Dental caries and Self- Induced
Vomiting.
Task:
Take History
Give Dx/DDx
Give Management
138
9. A patient came to you for advice on quitting smoking. His father was recently diagnosed with
lungs cancer due to smoking. His motivation was 10 out of 10. Never tried to quit before so haven’t
experienced withdrawal symptoms before. He finds difficult to give up early morning cigarette and
also giving up smoking during sickness.
Task:
1.
2.
3.
Take History for 3 min
Tell the benefits of not smoking
Give a management to the patient
10. Pregnant lady came with 6 weeks amenorrhea. All pregnancy investigations have been done
except U/S. She is having excessive vomiting. On examination- Fundal height is as size of 8 weeks of
gestation. UDT- Ketone is positive. (Hyperemesis gravidarum)
Task:
1.
2.
3.
PEFE
Explain Investigation
Give Dx (Hx and Mx was not part of the task.)
(Another recall: 22 years old pregnant lady presented with nausea and vomiting. List of
investigations given. Including rubellia IgG positive means immune already. Antenatal test all normal
including infectious screening.
Task: history in 6 minutes and tell DDx with reasons)
11. Lady came with 3 days old child (post-partum). Fully breast fed baby. Want to discuss about
contraceptive methods. She wants to take another baby within 2 years.
Task:
1.
2.
Take History for 3 min
Advice the patient
12. A middle aged woman came with a neck lump (right side) for 2 weeks. Her friend noticed the
lump. She doesn’t have any symptoms. Only some discomfort in the neck and a feeling of
obstruction in the neck during sleep. She has cough as well.
Task:
1.
Take History
2.
Give Dx/ DDx with reason
(Family history of goiter positive and she has no symptoms except feels lump with mild dysphagia
and dry cough No symptoms of thyroid. No LOW, no LOA.)
13. ED, 3 years old baby came with fever, cough, lethargy, not eating and drinking well, temperature
high. CXR given. Consolidation present in right side of xray. (Pneumonia)
Task:
1. Take History x 3 minutes
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2. PEFE
3. Explain X-ray
4. Dx/DDx with reason
(Pneumonia - Superimposed Bacterial on viral infections. CXR has hazziness on the right lobe of the
lung. All lungs was hazzy. Mother asked me to point it which lobe of the lungs)
14. 47 years old woman came as she wants HRT. She used to take OCP since 30 years of age but
stopped for last 5 weeks because of its harmful effects. She had breakthrough bleeding after that
and resume her normal period. Investigations are done and given. All tests are normal (including
FSH,LH,Cholesterol,TSH,BSL) except she is not having periods for last 5 weeks.
Task:
1.
2.
3.
Take History
Explain Investigations
Counsel the patient
15. MSE Video – Borderline Personality Disorder (Typical History- repeated cut injury for stress relief,
she takes Dope)
Task:
1.
2.
Present MSE
Assess risk
16. A single woman came for Benzodiazepine prescription. Recently she doubled the dose of her
medication from 5mg to 10mg to reduce stress as her kid is having leukemia. She is taking for 3
months and dependent on it. She understands that it is a problem and wants to solve the problem.
Task:
1.
2.
3.
Take History
What will you do and why would you do that?
Give Management
9th April 2019
1) SOB in 7 week old baby , not feeding well – History, PEFE, Dx. (History – home birth, no
immunization, PEFE – murmur, gallop rhythm, Basal crepts, Dx – I said congenital heart failure and
other possibilities) (Another recall - VSD with CCF)
Another Recall - Your next patient in GP is a 10 day old by brought in by mother she has been crying
a lot and seems restless. (Pilot)
Task: History, PEFE, Dx to mother, Further Mx plan to mother.
I entered the room, reassure her as she looked restless.
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Check the vital sign of the baby and the examiner told me stable.
History – tell me about the problem? (the baby looked restless and crying a lot these days, especially
after breastfeeding) how about at rest or sleep? (she looked a bit restless but more while
breastfeeding) any consultation with doc about this problem before ? (no)
Can suck the breast well? (not much) pee and poo?( normal but seem a little bit reduce pee these
days) is the baby turn blue? (yes)
Fever? Cough?noisy breathing? (no)Sleep well ? (yes)
Any problems during delivery ? (delivered at home, no check up yet, no immunization yet, no
problem during the AN care, this is the first baby)
PEFE
GA- restless
VS – all in normal range , except spo2 – 93%, RR – increase
No special facies
GC- normal range
Dehydration status- normal
CVS – no cardiomegaly, no visible apex beat, but hear murmur but cant differentiate between
systolic or diastolic murmur
Heart failure features present – basal crept, liver 3 cm, pitting oedema on leg, no sacral oedema,
Resp exam: - basal crepts only
Bedside test – not available
I explained with drawing diagram. Marie, thanks for bring the baby as soon as you noticed the baby
didn’t look well. I also noticed the baby looked restless and when I did the examination, I can hear
some abnormal sound in the heart. Draw the diagram and could possibly that there is problem in the
wall between the left and right chambers. This is only my working diagnosis and might need to
workup as investigations to find out exact cause. I can hear some fluid in the base of lungs and liver
is 3 cm enlarge , all are due to the heart is not pumping very well and increase fluid in the lungs.
The baby is now stable at the moment and I will refer the baby right away to the tertiary hospital
and there will be specialist team who will access the baby for further Mx.
As investigation, they will do imaging- ECG, chest x ray, echo to find out exact cause, blood test- FBE
, organ fun: test. If any problem in the heart, the specialist with do corrective surgery after stabilizing
the condition.
Do u want me to inform ur husband about this condition? (she told me she will do herself)
She looked satisfied.
Bell rang.
141
Another Recall - A mother comes to your GP clinic with her 6 weeks old baby who is refusing to eat.
Task: History, PEFE, Dx and dds.
Hi my name is Dr Qureshi I will be looking after you and your baby today. So how can I help you?
My son is refusing to eat since tha past few days.
Is he breastfed ? Yes
Have u tried to formula feed him? No
Have u noticed any ulcers in his mouth? No
Is there any other concern? Yes he cant breathe when he is feeding that’s why he wont feed.
Does he have problem of breathing otherwise? Yes he is always seem to be catching his breath
Is it the same when he is asleep? Yes
Have you noticed he turns blue? No
Number of wet nappies? Decreased. Only 1-2 a day
BINDS: Birth: Where was he born? Born at home
Did you have a midwife? Yes
Did he cry after birth? Yes
Immunization? Done til now
Nutrition: He isn’t feeding well since the past few days
PEFE: General Appearance Normal, No cyanosis
Vitals Bp 90/60 RR 120/min Pulse 150/min
Dehydration status: mildly dehydrated
Chest: Tracheal tug, subcostal recession, accessory muscle use , nasal flaring (some were positive I
don’t remember exactly)
Auscultation: Bilateral crepitations
Heart: gallop rhythm, there is a murmur but cannot tell the details.
Abdomen: hepatomegaly, 3 cm, below the costal margin
Low limbs oedema –
Dx: Heart failure with respiratory involvement
Dds: VSD, Congenital Heart disease
2) Placenta previa - bleeding no tummy pain, previous c-section. History, PEFE, Invx and Mx.
Another Recall - Pregnancy complication
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Your next patient in GP is 32 year old woman with 28 week of gestation. G3 P2+0.
1st baby normal delivery, 2nd baby LSCS. AN care done up to 26 weeks and blood test were given and
all normal including blood group A, Rh +ve but didn’t mention about the imaging.
She came today as she got some bleeding and came to consult to you.
Social history and other information are given.
Task: Focus history taking not more than 3 min. PEFE, Advise the patient about the condition. Mx.
When I enter, I check the stability first. The examiner told me the vital signs that I wanna know and
normal range.
Opening statement “ I got some bleeding today and very first time for this pregnancy and I got this
bleeding just after the sex”.
I ask about bleeding in details, check shock symptoms, pain, discharge.
And I ask about the AN care , imaging. She told me that the doctor mentioned that she got low lying
placenta. Apart from that all others are normal.
PEFE
GA – normal
VS – normal
No dehydration
Abodmen examination è normal and no tenderness
VE à inspection – some stained of blood, no discharge and speculum è clear and skip Bimanual
examination
Bedside à not available
I returned to the patient. I sticked to the task and tell the bleeding is due to sex and explained her to
avoid sexual activity till the delivery. She told me she will follow the advice XD
It is very important since you got low lying placenta and can casue bleeding and decrease blood flow
to the baby.
I mentioned I need to refer her to EM for monitoring for few hours and will do CTG and USG
urgently.If you and the inv: are normal è you are good to discharge and will see u in frequent visit. I
asked how far away from hospital? 15 min drive. If you or baby is not normal, we will take further
action and might need to treat you like if excessive bleedingè Blood transfusion and urgent
delivery.
Bell rang.
Comment: I think I don’t mention like “APH until proved otherwise and didn’t take seriousness about
the low lying placenta”
Global score 3
Assessment Domain
Domain Score (see key
143
below*)
History
4
Choice & Technique of examination, organisation and sequence
3
Diagnosis/ Differential diagnoses
2
Management plan
3
Comment: Dx/ DDx is not asked in the task as much as I remember. It is mentioned as only advise to
the patient.
Another Recall – (PASS) A 26 year old patient present to the ED with vaginal bleeding. She is 28
weeks pregnant. Her blood group is O positive.
Task: History, PEFE, Management.
Hi my name is Dr Qureshi. Please excuse me for a moment. Dear Examiner is my patient
hemodynamically stable? Yes her vitals BP 120/80 and Pulse 70/min
So X can you tell me what happened? Oh I started bleeding few hours ago
Onset: How did it start? Any trauma? Any intercourse? Yes we had intercourse and I realised my bed
was soaked in blood
How much pads have u used? 2-3
Any clots? No
Any dizziness? Shortness of breath? Chest pain?
Bleeding from anywhere else? Rectum, ear nose? No
How were your antenatal checkups? All normal
U/S report at 18 weeks? 1 baby and placenta was not in the right place
Sweet drink test? Normal
Regular checkups? Normal
Feeling the baby kick? yes
Previous pregnancy? Yes , Mode of delivery? C-sec (risk factor)
Pap smear: Upto date
Pills: None
Partner: stable relationship no history of STI
SADMA: None
PEFE
General Appearance: A bit anxious
Vitals: Normal
144
Chest: Normal
Abdomen: Fundal Height: 28 weeks
Fundal lie: longitudinal
Presenting part: cephalic
FHS: 160/min
No tenderness
PV examination: only inspection and per speculum blood was seen
Any bruising on the body particularly limbs? No
Management: I will be admitting you into the hospital. Take bloods to do FBC, UEC, LFT’s
Coagulation profile and arrange blood just incase. I will refer u to have an U/S and CTG done to
check the baby and placenta. According to the grade and severity , the specialist may decide to opt
for an emergency C-sec if your baby is in distress. If the baby is fine she may opt for elective csec or
give a trial of labor if grade 1 or 2. Please note that at any time if you do not feel the baby moving ,
please notify the doctors asap or you have more bleeding.
Assessment Domain
History
5
Choice & Technique of examination, organisation and sequence
4
Diagnosis/ Differential diagnoses
5
Management plan
5
3) Behavior disturbance
Your are MO in ER, your next patient in ER is a middle aged man brought in by police who was
wandering in the street with barefoot, he has been previously Dx with schziophreniform disorder
and didn’t not take medications. The police noticed that his actions are weird (?talking to someone
when there is no one around) and ask you to assess him.
Some other medical history are already given in the stem.
Task: Take psychosocial history. Explain risk to the patient.
When I enter the room, greet and reassure, confidentiality first.
During the conversation, I assess non verbal appearance first.
The appearance of him is fidgeting and not looking at me and seemed to be distracted by something.
He looks a bit restless. Voice okay, but fast and co-op okay.
Asked him do you know why you are now in ER? I would like to ask you some history concerning
about your personal life as well as medical history. Would that be okay?
Pt: “Doc, I need to go as I need to save the prime minister and the world. I have a very important
task to perform.”
145
This sounds interesting and can you tell me more about that? I will make sure this will be a quick
conversation.
How long have you been having this important mission? (6 months already)
Have you consulted with doc before? (a long time ago yes, but during last 6 months NO)
Then, he acted like he was talking to sb. I ask May I know with whom are you talking right now,
David? (to God)
Can you see him? (no)
Can he touch you? (no, I hear only voices god talking each other and giving me mission)
David, this will be a little weird but I need to ask you this.
I assess him orientation (Time, place , person – all normal)
Do you think these thoughts and missions are being inserted into you? (no)
Do you think sb is trying to hurt u? (No)
Are you superior to others ? (yes , I have to save the world)
Do you think media has a strong meaning to you (no)
Do you think ur thoughts are being broadcasted to the others ?(no)
Any thoughts to harm urself or others ? (of course not, my mission is to save life)
Why do u think the world and minister are in danger? (the aliens are trying to make a mission)
How’s ur mood these days – any low or high mood? ( I m okay)
Do u think u have medical problems that might need medical attention ? (no)
What will you do if fire break out in this room? ( I will put off fireè by what means are u going to
put out?- I forgot his response)
With whom are u living at the moment? (alone, wandering around)
where are your family members? (he left out)
Job ? (no job)
How’s ur financial ? (got a support from the state)
Any using drug? (he asked me what kind of drug u mean? è I asked him back are u using any
recreational drugs like dope, marijuana ? he told me yes.) when is the last time u use ? yesterday
I noticed that you have a medical problems that has been Dx as mood problems. Do u aware urself?
(yes) are u taking any meds for that? (no)
Smoking, alcohol, relationship, sex ? (all no)
Why not taking it (I don’t need it )
146
Do you mean you don’t take even single dose or stopped without consultation? (just took for some
days and he is okay and stopped it)
Thanks him and tell him about his risk
“David, thanks for your co-op and answering patiently all my questions. What we concern about is
your health. What we found according to your story is that you have some risks like wandering
around with bare foot which I will check it later again for you about ur feet, hearing some voices
giving you mission to save life. I do trust these are real for you, but what I concern is that you might
get hurt self or the others unintentionally. There is no family members or anyone else to give you
support too
Another thing is that you have using some recreation drugs that might have worsen the mood
problems.
Would that be okay if we want to make sure u are safe by admitting you ? He said sure, do as it is
good for me.
Any family members do u want me to contact?
The examiner stopped me not to do further Mx.
Finish early è waiting in room for 1 min . during that time, I reassure him back he is safe and tells
him the importance of compliance for his well being.
Global – 5
Approach to patient/relative
4
History
5
Diagnosis/ Differential diagnoses 5
Another Recall – (Fail) A woman was seen wandering on the streets and police brought her into ED
because she had a laceration on her hand and claimed God was talking to her. Her appearance is
dishevelled, she is a known schizophrenic. Task: History, Risk assessment.
Hi my name is Dr Qureshi and I will be looking after you today. Can you tell me what happened?
She said she can hear God talking to her and giving her commands. I asked her since how long she
has been hearing it? She said 2 months. Asked her about her previous symptoms when she was
diagnosed with schizophrenia: 2 years ago, medications: She stopped them because she was feeling
better, specialist reviews No, any medical illness No
How is your hand? Its better thanks
Appearance – dressed appropriate with weather, no abnormal posture, maintained eye contact
(it was already given In stem she is dishevelled)
Speech: She was speaking in high volume, quality clear, make sense but fast
Mood: Elated, she felt great
Can you hear feel or see things other people don’t? God is great he is talking to me even now
147
At anytime do feel your thoughts are being withdrawn from your mind? (Thought withdrawal) (no)
or someone trying to insert some ideas into your mind? (Thought insertion) (no), do you think your
thinking is being broadcast? (Thought broadcasting) (no), does the news in TV or newspaper hold
special meaning to you? (Delusion of reference) No. Do you think people are trying to spy on you or
harm you? (Delusion of persecution/paranoia) (no), are you afraid of certain thing or places?
(Phobia) (no)
Insight: Do you think you need help? No
Cognition: Do you know where we are? At the hospital. What is the date? 9th Arpil
Judgement: If there was a fire in this room what would you do? Run out
Reliability: Patient’s history seems reliable
Rapport: I developed good rapport with patient
Risk: No harm of hurting herself
Who do you live with and what do you do for a living? I live at a hostel and don’t work or study. I
receive payments from centrelink
SADMA: Marijuana since few months
Risk Assessment : In terms of risk assessment, she is having some risk as she does not want any
medical attention and is having auditory hallucination. Most probably Relapse Schizophrenia
Approach to patient/relative
5
History
4
Diagnosis/ Differential diagnoses 2
Dx and dds weren’t even a task ! I don’t know why I failed this. Though I did mention that she is
having relapse and is non compliant with her medications
4) Ear exam – conductive hearing loss: Cholesteatoma
Another Recall - Your next patient in GP is recurrent pain and infection of left ear . no ear discharge
at the moment. other info history esp previous attack is given.
Task: PE, Explain Dx and DDx. Explain the cause of Dx
Greeted the patient and asked him any pain and offer the pain killer. Explained the procedure and
wash my hands.
Inspectionè the patient is sneezing and no ear discharge and no redness around the ear .
Palpationè no tenderness around the ear
Crude hearing test impaired on left side.
I started the examination of tuning fork .
Rinne test èair conduction is better than bone on right side and bone conduction is better than air
conduction on left side.
148
Weber test è no lateralization
Otoscopy è explained the procedure and commented to the examiner. There is no ear wax and I
can see intact tympanic membrane but redness seen and bulged.
I forgot LN examination and nasal inspection (even though no speculum is given), no watery eyes.
I explained as acute OM ,
DDx è OM with perforation, cholesteatoma, middle ear effusion and infection, wax and otosclerosis
Please check it with the one who passed this.
Global score – 3
Approach to patient/relative
4
Choice & Technique of examination, organisation and sequence 3
Familiarity with test equipment
4
Accuracy of Examination
4
Diagnosis/ Differential diagnoses
5
Another Recall (Pass) - A middle aged woman comes with difficulty hearing and ear pain in her left
ear since a few months.
Task: Perform Examination. Dx and DDx.
Hi my name is Dr Qureshi and I will be having a look and feel of your ear. Is that alright with you.
Sanatised my hands as it was stated on the dispenser.
There was a dummy with half face on the table so examiner said to perform on it
On inspection there is no Dysmorphic feature Scars Redness Discharge Colour change Mastoid area
for redness or discharge or vesicles
On palpation there was no tenderness
Explain about Otoscopy that is an instrument used to look inside the ear and asked for permission. I
attached a sterile speculum and mentioned that I need to pull your ear upward, outward and
backward. I commented on Otoscopic findings: No Light Reflex,excessive wax or excessive hair
redness discharge , no cholesteatoma was present no bulging or perforation of Tympanic membrane
as it wasn’t clear. It was some what blurry so I suppose it was ear wax
Whisper Test
•
Explain the patient about the test
•
Start with the normal ear
•
Mask one ear and say some numbers on the other ear
•
Ask the patient to repeat
•
First at almost 20cm distance then 40 cm distance
She had difficulty recalling the number I said in left ear at 40cm
149
Rinne’s Test
•
Explain about the test
•
Take tunning fork (512Hz)
•
Check the vibration on the sternum if patient can feel
•
Produce the Vibration
•
Start with the normal ear
•
Check it on mastoid bone followed by in front of the ear
•
I asked her if she could still hear the vibration, she said no for left ear but right she could
•
Comment upon your findings
Weber’s Test
•
Explained about the test
•
Checked the Vibration on the sternum
•
Produce Vibration and put it on the forehead
•
Asked the patient where he/she can hear better?
She had conductive Hearing loss- Lateralize to abnormal ear
Turning test
•
Explained about the test
•
I am going to check your balance
•
Can you please close your eyes and march on the spot for me?
She did it fine
Can you please smile for me? Normal
Dx: she is having conductive hearing loss and ear wax found on otoscopy
DDs: Choleastatoma, CSOM, Otosclerosis
Assessment Domain
Approach to patient/relative
4
Choice & Technique of examination, organisation and sequence
4
Familiarity with test equipment
4
Accuracy of Examination
3
Diagnosis/ Differential diagnoses
4
5) Knee exam – pain everywhere – osteoarthritis
Your next patient in GP is 60 year old man complained of knee pain for 3 weeks.
Task: PE, Running commentary, Dx, DDx to patient.
150
Real patient, he is sitting on the chair.
Greeting, explain, wash my hands, offer the pain killer.
I commented that a middle aged man is sitting on the chair but he seems to be overweight. I ask the
examiner about BMI. He told me not available and not measured yet.
I ask my patient to walk. “He has normal gait and can walk without walking aids but in slow pace”.
The patient refused to do squat. I handed and support him to the bed and he rested on the bed and
put pillow just under the knee.
Inspection è there is 3 abrasion (size is about 1 cm) found on the shin bone of the left side. (I
commented what I see) nail are not healthy and brittle. There is no signs of inflammation.
Palpatiionè there is non specific tender medial, lateral and over the knee, more tenderness on
medial side. Apart from that, there is no tenderness over the quadriceps muscle, tendon insertion
and tibial and fibula bone.
Temperature is normal.
Moveè active knee flexion and extension è normal on both side.
Special test è
Patella tap, bulge è negative
Clark test è told me painful
Patella tilt è negative
While performing Varus and valgus testè he told me painful
Anterior and posterior drawer test è negative
Mac Murray and Apley grinding test è the examiner told me it’s painful and to skip it.
I washed the hand and explained him that he got OA even though some special test are positive for
his case.
Other DDx: Collateral ligament injury, cruciate injury, meniscus injury, osteochondritis, fracture, OM,
septic arthritis
I told him to reduce weight since it has much effect on the knee as a piece of advice and he told me I
will make sure he will follow my advice ^^
I finished 30 sec earlier and I asked him whether he want back to the chair and If so, I offer the help
to him. He is satisfied with the help.
Bell rang.
Global - 4
Assessment Domain
Domain Score (see key
below*)
151
Approach to patient/relative
5
Choice & Technique of examination, organisation and sequence
4
Accuracy of Examination
4
Diagnosis/ Differential diagnoses
5
Another Recall (Pass) - Middle age/Old aged man with left knee pain since last 6 months or so,
getting worse with time. Especially restricted in climbing stairs.
TASK : Physical exam 6mins, give running commentary to examiner. DDs to pt with reasons
Hi my name is Dr Qureshi and I am going to examine your knees today. This will involve looking
feeling and performing special tests. Is that alright with you? Yes
DO you need any painkiller? No I’m fine thanks
Looked around the room for any crutches or walking aid.
Washed my hands and request the patient to walk. Commented on gait being antalgic
I asked him to lie down and roll up his pants
On inspection No muscle wasting, Slight redness. Noswelling. (supra patellar bursa ) Deformity (
Varus- OA, Valgus- RA) Extension deformity Flexion deformity,scars Skin changes.
Feel
•
I start from the normal side and compared with the affected leg.
•
. Tenderness i. Patella ii. medial joint line iii. lateral joint line iiii. popliteal region v. head of
fibula - from head of fibula palpate all the way down to lateral malleolus looking for
tenderness then go to medial malleolus then follow the shin and palpate all the way to the
tibial tubercle (in Osgood Schlatter, tibial tubercle is tender) vi. Quadriceps tenderness vii.
ASIS to lateral part of patella - Iliotibial band tenderness. Tenderness in whole joint
•
Bulk of the quadriceps muscles.
•
Temperature. Slightly raised
•
Patellar tap. Held the thigh with one hand and pressed patella down with the thumb of the
other hand.
•
Bulge sign. Held the thigh with one hand and moved with the back of your hand on the
lateral and medial side to look for small effusions.
•
Crepitus. Kept one hand on the knee and with the other hand flexed and extended the knee.
•
Pulse (Popliteal).
Move
•
Started from the normal side.
•
Asked him to flex and extend himself
•
Then I did it passively
•
Extension
152
•
Flexion
•
Collateral ligaments, >5 degree is abnormal. He had pain when I tested for medial collateral
ligament
•
Special Test
•
Anterior drawer test for anterior ligament
•
Posterior drawer test for posterior ligament
•
Clarke’s test : Held the superior pole of the knee with the web of your fingers and asked
Patient to contract quadriceps as if they were extending the knee .
•
I mentioned ideally I would do Appley’s grinding test but examiner said patient is in pain
•
Asked the patient to roll over and lie on his tummy looking for any Baker’s cyst.
I mentioned I would like to examine 1 joint above and below
Dx: Osteoarthritis as he had pain all over joint, tender, raised temperature and ROM were all
painful.
DDs: Septic arthritis, Mechanical Injury , RA,
Approach to patient/relative
4
Choice & Technique of examination, organisation and sequence
5
Accuracy of Examination
5
Diagnosis/ Differential diagnoses
4
6) Thyroid exam - lady postmenopausal hot flashes, weight gain, family history of thyroid + Task –
Tell possible causes and PE. (Another recall – Hypothyroid examination)
Another Recall - Menopause examination
Your next patient in GP is a 48 year old lady complained of nervousness and irritable these days. She
has hot flushes and night sweat and LMP – 1 year ago. She gained Wt these days.
All other medical history , social history are given.
Task:
Explain the most possible causes to her first.
Examine the patient to find out for the casue and dx.
Dx and DDx
I entered into the room. I saw a lady sitting on the chair.
Maria, thank you for your story and I’ve taken history from you. According to it, there are some
possible casues that have crossed my mind. That might include
-
Thyroid problems, there is a gland in front of neck essential for metabolism. When increased
hormone, it can happen just like ur case
Menopause – decreased level of female hormone, most possible cause for you and common
at ur age
153
-
Medication but u are not taking any meds so less likely
So I need to examine you to be able to find out the cause.
Explained what I’m going to do and get concern and wash my hand.
I start from
Vital signs (all normal)
General appearance (calm) and I commented what I see à she is fidgeting
Hand ( clubbing, onycolysis, fine tremor, palmar erythema, pulse for volume, rhythm back,
vitiligo)
Eye (upper and lower eye lid visible or not, eyeball protusion from side and back view, lid lag,
loss of wrinkles of forehead or not, opthalmoplegia, accommodation reflex)
Hand and eye è ALL NORMAL
Neck (front è no visible neck gland, trachea is in midline, no tenderness)
When I’m about to examine from back, the examiner stopped me and she told me no visible
neck gland and asked me what I’m going to do next. She gave me finding
I told her
Nervous system (tone, power, reflex, clonus) Normal
Abdominal exam: (inspection, organomegaly) NAD
VE examination (inspection è normal, speculumà dryness present on vaginal wall as well on
cervix, otherwise healthy and normal, no mass, no urine leakage during coughing , bimanual VE
positive finding è anteverted uterus with 10 week size , anterior , posterior fornix normal and
clear, no tenderness)
CVS and resp: è normal
Bedside test – urine RE not available
I missed 10 week size as I’ve been focusing about dryness and got menopause finding.
I’ve already examined you and thanks you so much for your co-op. According to the
examination, your thyroid is normal, when I did down below exam, I can see that there is some
features of menopause like dryness . In your story, you complained of irritable and hot flushes.
Bell rang.
Global score - 4
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
Diagnosis/ Differential diagnoses
4
Choice & Technique of examination, organisation and sequence
4
Accuracy of Examination
4
154
Patient Counselling/ Education
4
Another Recall (Fail) - A 52 year old lady has come to you GP clinic with complains of inability to
sleep, weight gain , and tiredness
Task: Perform Physical Examination. Dx and dds.
Hi my name is Dr Qureshi and I will be having a look and feel at different parts of your body mainly
your hands and neck. Is that alright with you? Yes
I washed my hands
General appearance: Patient looks a bit overweight and has some puffiness under her eyes
Hands: Looking for tremor, koilonychia, erythema , sweating
Pulse: Normal given by examiner
BP: Normal given by examiner
Eye signs of thyroid disease: lid lag, lid retraction, exophthalmos, Ophthalmoplegia Did "H" and ask if
there is double vision. Also I asked for Visual acuity and visual field . examiner said normal
Would you mind taking a sip? Thyroid is moving with swallowing
Would you mind bringing your tongue out? There is no movement of the thyroid with tongue
protrusion (thyroglossal cyst)
Palpation Check temperature of thyroid : Temperature is normal on both sides. No obvious increase
in the temperature of the thyroid
Would you mind taking a sip? Palpated the thyroid if it's moving with swallowing
I'm just going to palpate your thyroid, it might feel uncomfortable, please bear with me ,Palpated
one lobe at a time, Pressed on one thyroid lobe, and with the other hand, palpated the other lobe
There are no nodules, masses, cystic lesions
Thyroid bruit : negative
Palpated lymph nodes ▪ Submental ▪ submandibular ▪ Preauricular ▪ Post auricular ▪ Supraclavicular ▪
Anterior cervical ▪ Posterior cervical
Asked to check respiratory: Examiner said all normal
Abdominal and PV examination: All normal except atrophy of vaginal walls . I specifically asked
Bimanual Examination and any masses per abdomen
Looked for pretibial myxedema: Examiner said normal
As I was approaching reflexes: Examiner said normal
Asked patient to cross arms on chest and stand : she did it perfectly well
DDx: Hypothyroidism , menopause, depression
155
Assessment Domain
Approach to patient/relative
5
Diagnosis/ Differential diagnoses
4
Choice & Technique of examination, organisation and sequence
6
Accuracy of Examination
5
Patient Counselling/ Education
2
I thought I passed this station and again good score in all but 1 domain.
7) 15yrs old fall from bike. Now blood in urine and pain in left lumbar region. PE, Dx, DDx with
reasons
Another Recall - Abdominal injury examination (Pilot)
Your next patient in ED is a 17 year old boy who complained of blood in the urine for last 2 hours. He
was riding a bike this morning and fall down from the bike and didn’t get obvious injury. But he
noticed changes in urine color of red after the accident and came to you.
Otherwise, his vital signs are stable and given in the stem.
Task: Perform examination. Explain the pt Dx and DDx.
I greeted the patient and asked any pain and offer the pain killer.
I turned back to the examiner and check the vital signs is the same as in given stem or not. I assured
the pt he is stable.
Explain the procedure and wash my hand.
I started from checking the obvious injury and dehydration status (meanwhile the examiner stopped
me and told me no dehydration)
I asked the pt to expose the gowns and look for inspection
Inspection -> no obvious injury, Cullen signs, Gray Turner’s sign negative, flanks are not full, no
obvious mass,
Palpation à no guarding, righidity, temp – normal, no palpable mass, no tenderness on light
palpation
On deep palpation – no organomgealy, pain present when kidney is blotted on the left side.
Asked any radiation of pain after that è no
Auscultation – no bruit and can hear the bowel sound
Asked the pt to sit up and did the renal angle tenderness à positive
I asked the examiner and requested to check for hernia orifice, testicular examination, and perineum
and PR => all normal.
Bedside test à urine RE – blood 3+, others nil
I explained the pt as DDx
156
When I did the examination , I noticed that you have pain in the kidney area of the left side and the
special test is positive. You might remember I collect the urine sample and did the bedside test and
showed there is some traces of blood in the urine. All these are pointing out that u are likely to have
kidney injury during the bicycle accident.
Other DDxà draw the pic and explain possibly that it can be injury to the ureter, urine bag, urethra
and penis. Present of blood in urine can be due to stones present in the urinary tract system but less
likely. Pain in the left side can be due to injury to the colon and other nearby structures but less
likely according to the findings.
I reassured and got 1 min standing and reassure the pt. Bell rang.
Another Recall - A young teenager has come to the ED with fall from a bike and has pain under the
left ribcage with red urine
Task: Perform Abdominal Examination, Dx and dds.
Hi my name is Dr Qureshi and I will be examining you today. Is that alright with you? Yes
Washed hands
Exposure: Ideally I would like to expose from xiphisternum to mid thigh. Can you please lift your
shirt? Yes
Are you in pain ? would you like a painkiller? No I already had it
When I started Vitals and GPE examiner said stick to your task
Inspection : No bruising, distension, visible veins, scars
Palpation: Superficial : I palpated the injured quadrant last. Mild tenderness
Deep: : I palpated the injured quadrant last. Mild tenderness
Percussion: All resonant
Auscultation: Bowel sounds positive
DRE: Negative
Perineum: Check for bloody discharge from penis or any injury? No
Urine dipstick: 3+ RBC’s
DDS. I drew the urinary system and said there could be injury to kidneys , ureter, bladder or penis
because there is blood in urine. Other possibilities are injury to spleen, intestines, ribcage
8) Acute cholangitis – RHC pain (Another recall - upper tummy pain aggravates with moving and
fever- history, PEFE, Dx (i mentioned pancreatitis, cholangitis and all others)
Another Recall - Your next pt in ED is a middle age who came with tummy pain. She has been the
pain for a day. Task: Focus history, PEFE, Dx and DDx.
Greeted the pt and offer the pain killer. Check the vital sign first – temp increased, other within
normal range
157
Pain in details (positive finding – pain in RHC and this is recurrent attack, no radiation, no special
time)
Fever (fever , high grade)
No yellowish discolouration
Vomiting (nil)
Pee and poo (normal)
Abdominal injury (nil)
Medication (taking the medications for the thyroid, the doc just mentioned that she has increased
thyroid)
No CVS and rep symptoms
Other medical problems and diet (NAD)
PEFE
GA- in pain
VS – same and nothing changes
Dehydration status – no dehydration
Abdominal examination – inspection – flank not full, no signs of injury, abd moves with respiration,
palpation – light palpation – tenderness present in RHC, no rigiditiy, no guarding, special test –
murphy sign - +ve , deep palpation – no organomegaly, Bowel sound heard
PR –not done
Bedside testing – not available
I explained the pt as recurrent cholycysitits and draw the diagram.
As DDx I explained cholangitis, cholangiohepatitis, basal pneumonia, gastritis, abd injury, medication
induced problem (as she mentioned she mentioned taking meds for thyroid which could possibly
explain fever for levothyroxine) , pancreatitis
Got 30 sec free time in the room.
Bell rang
Global score - 4
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Choice & Technique of examination, organisation and sequence
3
Diagnosis/ Differential diagnoses
4
Another Recall -A middle aged man presents in the ED with abdominal pain.
158
Task
History
PEFE
Dx and Dds
Hi my name is Dr Qureshi and I will be taking care of you today. Before we start , do you need any
painkiller? The Nurse already gave me
Since how long? Last few hours, started at night while sleeping
Onset: Sudden
Severity: 9-10
Characteristic: Dull
Radiation: Just to the back
First time? No happened once before
Fever? No, Nausea/ vomiting? No, Noticed pee or stool change in colour? No, Noticed change in
colour of skin? No, Lumps/bumps/ loss of weight/ loss of appetite? No
Any food from takeaway? No
Shortness of breath/Chest pain? No
Travel history? None
SADMA : Occasional drinker
PMHx: None
PEFE:
General appearance: Anxious PICCKLE : negative
Vitals: Normal
Chest and heart: Clear bilateral vesicular breathing and heart sounds normal
Abdomen: Inspection Scars/distension/redness/bruising/ negative
Palpation: Tenderness on superficial and deep palpation in RHC
McBurney point tenderness Negative
Organomegaly: Negative
Percussion: Resonant
Auscultation : BS +
Dx: Acute Cholecystitis
Dds: Acute cholangitis. Hepatitis, pancreatitis, pneumonia
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Approach to patient/relative
History
4
Choice & Technique of examination, organisation and sequence
4
Diagnosis/ Differential diagnoses
4
9) Restrictive lung disease spirometry results given. Take history for breathlessness, PEFE on card, Dx
Your next patient in GP is 52 year old pt Damiel who came to visit last week for SOB for 2months.
You did blood test which are in normal range and did spirometry and data is given in tabulated form.
It is hard to see it at a glance.
Task: Explain the spirometry result to examiner
Comment about the Dx according to spirometry. Take brief history from pt. Explain the dx to pt.
I didn’t remember the value
But FEV1 is reduced in before and after BD
FEV1/FVC is INCRESAED compared with predicted volume.
TLC and RLV is increased.
I failed this station and please refer back to other candidates. Global score – 3
Dx – Restrictive lungs disease
(+)ve finding – smoking for just few months and stopped smoking 10 years ago,
Retired now, has worked as car driver for more than 15 years but he denied inhalation of fumes and
gases.
Another Recall (Fail) - A middle age man comes with complains of shortness of breath for past few
months. Spirometry was done. SpO2 is 92%
Task: History, Interpret the result, Dx and dds.
Hi my name is Dr Qureshi and I will be taking care of you today. I see that you had the spirometry
done. The results are back but before I explain them , I need to ask a few questions. Is that alright?
Yes
For how long have u been short of breath? Few months
Is it getting worst? Yes
Do u have it at night as well? Not particularly
Anything that makes it better or worst? No
Any cough? Yes
Dry or productive? Dry
Chest pain? No
Fever? No
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Loss of weight? No
Any lumps or bumps anywhere? No
Hoarseness of voive? No
Travelled anywhere? No
SADMA: Smoked cigarettes for 15 years but quitted
PMHX: none
Fhx of lung diseases? None
Interpretation of result:
Spirometry is the test that assesses your lung function. FEV1 is the amount of air you can breathe
out in 1 second after a deep breath. FVC is the total amount of air you can breath out forcefully after
a deep breath. Then we make a ration of these FEV1/FVC. The FEV1 and FVC are both reduced as
well as the ration which slightly increased after we gave you the inhaler, These point to a restrictive
pattern it means your lungs are not receiving enough air
DDX : restrictive lung disease, COPD asthma
NB: I completely stuffed up this case which I regret but it was probably because it was near the end
of the exam. I gave wrong dds, I knew Asthma and COPD are Obstructive pattern. I did ask him
occupation which I forgot but he never mentioned asbestos, maybe I should have dug in more. I
knew I would fail this case. Please study spirometry in detail. I did it so well before exam and made
my own notes. Now I regret it but at the end of the day I passed
Assessment Domain
Approach to patient/relative
5
Interpretation of investigation
2
History
4
Diagnosis/ Differential diagnoses
2
10) Old lady back pain fracture of bone History, PEFE, X-ray to patient (Another recall: Wedge
fracture, history, investigation from examiner and explain to patient. tell dx and causes and ddx)
Another recall - Your next patient in GP is an elderly woman complained to back pain in sudden
during the supermarket shopping last week and went to GP for consultation. You ordered the
imaging X ray of the back and the result is now ready.
Task: take brief history. Get X ray from the examiner and explain it to the patient. Further Mx.
I greeted the patient, a very nice lady named Trisha sitting on the chair. She is very cheerful lady.
Trisha nice to meet you back, I do know that you came here last week for back pain and how’s right
now?
She told me that “I have experienced back pain several times but never felt severe like this before. It
was in sudden and very sharp when I bent to pick up and the pain went straight from back to the
leg”.
Do you want me to prescribe pain killer for you? She told me it’s okay
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Trisha, I have taken X ray last week and the result is now ready but I need to ask you some questions
and would that be okay?
Pain in details
Weakness? Tingling and numbness? Pee and poo? è all normal
When was the last menstrual period? (I am now 80 and it was last 35 years back)
any hot flushes and night sweat ? (No) mood ? (okay)
have you taken any hormonal containing pills? (No)
how about other meds? (no)
diet? (usual diet) does it contain bone promoting food? (she asked me what is bone promoting food?
è just like fish, milk, seeds? (yes but in normal amt)
job ? (retired)
sport or any activities (sedentary lifestyle and cant move and even walk well due to this pain)
alcohol, smoking , recreational drug? (no)
coffee? (yes è 5 to 6 cups per day)
LOW? LOA? (no)
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I thanked her and asked the examiner for the X ray.
He handed me and looked at it.
Trisha, this is the X ray taken last week and confirmed your identification. This is taken from side
view.
You can see that this rectangular boxes are back bones. But right here, it becomes a triangular
shaped one which we call is compressed fracture. That’s why you are in pain. Normally, bone can be
seen as white on X ray but as you can see, the intensity of white of bone is lessen right here
compared with normal one which means that you are likely to have osteoporosis which we call bone
thinning. But this is not confirmed for bone thinning and btw, have you done any bone scan before?
(no) how about taking any previous x ray? (she told me yes , “I have taken once very long before”)
I asked the examiner for old X ray for comparison. He told me not available today.
I headed back to the pt. “Trisha, I’m sorry that we cant retrieve back yet for old x ray but I will look it
back in old medical record system and compared with it, discuss u later”
But at the moment, there are some we need to test you, would that be alright?
That might include doing investigation – bone Dexa scan for bone thing, blood test (chemicals like Ca
and phosphate) , organ fun: test for you.
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We need to modify your lifestyle back – diet – eat more bone promoting food, will give reading
materils about this later, graded gradual ex: after the pain goes off, tone it down or cut down ur
coffee drinking behavior.
I will give u pain killer to take it.
Do let your doc: know about ur condition and I will also liase with physio for some ex: these days.
Are you happy with my plan?
Bell rang.
Global score - 5
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
5
History
5
Interpretation of investigation
7
Diagnosis/ Differential diagnoses
5
Another Recall (Fail) - 65 year old lady comes to see you in your GP clinic complains of back pain for
few months. X ray given,
Task: History, Interpretation of Xray. Dx and dds.
Hi my name is Dr Qureshi and I will be looking after you today. I see you have some back pain ,
would you like a painkiller now? No I’m fine
So can you tell me more about the pain?
Grade 1-10 ….. 6-7
Site : Middle back
Characteristic: Stabbing
Onset: few months ago, suddeny
Course: getting worst
Aggravating factor: bending
Relieving factor: painkiller
Associated factor: no numbness, no pain in leg, normal defecation and pee, no lumps bumps, no
weight loss, no other joint pain
Menopause: 10 years ago
Pap smear upto date: yes
Mammography uptodate: Yes
SADMA: Alcohol occasional, specifically asked about steroids No
Exposure to sunlight: Very rare because of fear of melanoma
Dairy intake: Very little
Interpratation of Xray
This is an xray of your back , as you can see there is some difference in the composition of this
bones. There is a fracture here
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Dx. Osteoporosis
DDS Sciatica , Bone cancer
I failed this station though I had explained the x-ray . The examiner came up to the table to even see
where I was pointing the fracture
Assessment Domain
Approach to patient/relative
6
History
7
Interpretation of investigation
0
Diagnosis/ Differential diagnoses 2
11) ECG patient dizziness tachycardia I think prolong QT interval (Another recall – SVT ECG, Explain
to examiner. Take history and explain to patient)
Another Recall - Palpitation
Your next pt in ED is a middle aged woman came to you because she felt palpitation for 2 hour.
Vital signs given and stable.
Task: Focus history, PEFE card from examiner, Get the investigation from the examiner.
Comment on ECG to examiner. Explain dx and implication.
I entered the room, greeted the pt and check the stability first. The patient is stable.
History
Palpitation in details – duration, special time, are you having it at the moment? è can u tap on the
table for me ? (this morning, no special time, she tapped on table and it’s regular but fast)
Vomiting, pee and poo (NAD)
Recent change in weather preference, fever, weight gain (NAD)
Mood these days? Any acute attack these days ? anything precipitating this attack? (NAD, it came
itself)
CVS symptoms in details (NAD)
Previous medical and medication history – NAD
Period – regular
Diet – normal and ex: - active
Coffee drinking- 4 cups to5 cups per day
Work – no stress at work, home – supportive, no problems
PEFE card
GA- stable
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Vital signs – BP 110/70, HR is 120/ min regular, other stable
CVS – NAD ,
Resp: NAD
The examiner handed me ECG when asked. I asked the identification and confirmation for this pt,
the examiner confirmed me back.
I explained as atrial flutter in details in format for the commentary.
I explained by drawing a diagram. This is a heart and the heart rhythm is usually controlled by the
special tissue what we called SA node. In your case, your heart beat is not contracting effectively
either in the problem of special tissue itself or in the electrical circuit pathway. Reassured her back
and need to study in details with further investigation to find out the exact cause.
I explained cause and triggering factor and DDx in combined for this – thyroid, fever, ex: , existing
heart problems, anxiety, heart congenital anormaly, medication
P.S: ECG that I got seems to be different from the others since some of the candidates had given dx
as SVT.
Global score – 5
Approach to patient/relative
6
History
5
Interpretation of investigation
5
Diagnosis/ Differential diagnoses 4
Another Recall (Pass) - A middle aged woman has come to the GP practice with history of
palpitations Task: History, Ask for ECG, Interpret ECG, D/Ds.
HOPI: Hi my name is Dr Qureshi and I will be taking care of u today. Can you tell me since how long
have u had the palpitations : 2 months
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Can u please tap it for me?
Has it increased since the beginning? No
Anything that makes it better or worst? No
Associated factors ; Chest pain, SOB , Cough, cold/hot intolerance . light headedness, LOC, weakness
in limbs, slurred speech , any previous recordings of BP,
Are u an anxious person ? No
SADMA : Alcohol occasional . 1-2 cups of coffee a day
PMH: Nothing positive
FHX: Positive for CHD
ECG : Rate 180/min , regular , narrow QRS complex, missing P waves
Dx SVT
DD/s IHD, thyroid, Alcohol, caffeine, anxiety , pheochromocytoma
Assessment Domain
Approach to patient/relative
5
History
5
Interpretation of investigation
5
Diagnosis/ Differential diagnoses
4
12) 15 years old boy last night alcohol intoxicated admitted now. Take medical and psychological
history and present findings and risk assessment to examiner, safe to discharge?
Another recall - Adolescent health
This is the same scenario as my friend who took on 27th Feb and I copied and modified the finding
that I got.
You are HMO at ED. 15 years old male who had binge drinking last night, alcohol level now is 0.2%.
VS – stable.
Tasks: Take medical and psychosocial history
Present key issues and risks regarding adolescents to the examiner.
History
The surrogate is sitting on the chair and no eye contact.
Reassured and confidential and he told me he wanna go home.
Alcohol – started drinking 1 year ago, how frequent, where, with whom, increase in tolerance,
awareness of safe level (no), didn’t know about Standard drinking level and I mentioned I will explain
later
No withdrawal symptoms, no dependency
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Doesn’t use any recreational drugs nor smoke
No problem with law
No social problem, no family problem
No medical issues, generally healthy
HEADDSS – family – good & supportive
no financial problem and his family paid for his tuition fees
A uni student, no problem with school performance
Activity - good
When asked about sexual activity, he said, ‘this is my personal life and you don’t need not to know
this”
No reply even after the reassurance.
Mood – good, no anhedonia, no idea to harm himself
Appetite, sleep – good
Global score - 4
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Commentary to Examiner
4
Another recall (Pass) - You are HMO at ED. 15 years old male who had binge drinking last night,
alcohol level now is 0.2%. VS – stable.
Tasks: Take medical and psychosocial history
Present key issues and risks regarding adolescents to the examiner.
Hi my name is Dr Qureshi and I will be looking after you today. Whatever we discuss here today will
remain between me and you . I wont breech the confidentiality unless there is a risk of harm to
anyone. Do you understand? Yes
So can you tell me what happened? I was at a party and we had couple of drinks and I passed out.
Is this the first time it happened? No it happened a few times.
Do you know the safe limits of drinking? No
Have u increased the intake since you started? Yes
Do you feel nervous ,anxious, palpitation , difficulty sleeping when you don’t drink? No
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Have you ever been in trouble with the law? No
Has your school performance been effected? No
How is you sleep pattern? Normal
Lost appetite? No
Hows your mood? I’m fine
Can you concentrate well as you used to do? Yes
Any thoughts of harming yourself or anyone else? No
Do you know where you are? Yes. The hospital
Can you tell me the date? 9th April 2019
Do you think you need help? Yes
Im going to ask a few questions which may sound a bit silly but they are routine questions.
Do you hear feel or see things which other people don’t? No
How is the situation at home? Who do you live with? My mother and siblings. My parents separated
and we have financial difficulty
How is your health otherwise? I m fine except I use an inhaler before exercise
Since how long have u been using it? A couple of years.
Have you been visiting your specialist? Yes
SADMA : None
Discuss with examiner - He asked do you think we can discharge this patient ? At this stage I would
like to discuss with my senior as he needs proper alcoholic councelling and review by medical
specialist. He is also having issues at home as the finances are right so maybe ask centerlink for
assistance
Assessment Domain
Approach to patient/relative
5
History
4
Commentary to Examiner
5
NB: I had only given a read to a feedback from February exam recently and this was my last station. I
was drained but I stuck to my approach of alcohol counseling and passed luckily. At one time I was
blank and didn’t know what to do in this case
13) Immunization counseling - Mom not willing for immunization of 6month old because she is
having cold no high fever. also read that it can cause fits and MMR can cause autism
169
Another recall (pass) - A mother doesn’t want to do immunization for her 6month old daughter.
Task: History, Councel.
Hi my name is Dr Qureshi. I will be your GP for today. So may I know why you don’t want your
daughter immunized? She has been having a runny nose for the past few days and I have heard so
many side effects
What sort of side effects? That mmr causes brain damage and autism. I read it on the internet
As far as I have read there is no association of MMR with autism which is a behavioural disorder rather
or brain damage.
Previous Immunization : None
Other children immunised? Yes
Any other illness or allergies? None
Birth: NVD at term , heal prick done
Immunization: not done
Nutrition: Eats well
Developmental: Sitting, grasps objects
I can understand your concerns as parent. Immunization is an important part of child’s development
as it protects against many viral and bacterial diseases like MMR DPT Polio Hepatitis B and meningitis
which are given at different times. Moreover some of them can be quite dangerous such as meningitis.
Nowadays there is an outbreak of measles which can be harmful itself as it can cause lung infectuons
too. So rather than taking the risk its better to immunise your baby. Its good to know that your other
kids are immunised.
Many of the diseases have been contracted when children visit countries where these diseases are
common such as south east Asian countries. So incase you plan to visit these countries it will be better
if your child is already vaccinated
I can give you some reading material which outlines the whole schedule and its also written in the blue
book your baby must be having
Are you happy to go along with it? No she is sick
Well we can give her the shots after she recovers.
No but she is going to be very fussy.
Well we can give her some pain relief like Panadol or neurofen before and after the shots which will
minimise her pain. Do note that there can be some redness and swelling at the site
How does that sound? I will think about it
OK so you can come again and we can discuss it again.
NB; The role-player wasn’t satisfied much and I didn’t know what else to say. I tried to cover main
diseases covered by them and S/E of immunization. Please refer to other feedbacks of someone who
scored better.
Assessment Domain
Approach to patient/relative
4
History
3
Patient Counselling/ Education
3
Another recall (Pass) - Your next patient in GP is a mother who came to consult to you about
immunization. Her daughter has chest infection last week and got feverish. She gets better and the
nurse has advised her to give shots to her daughter but the mother has refused to give
immunization. Task: explain and discuss about the complaints and refusal of immunization
I greeted her and ask how the child is doing at the moment.
Any fever? Noisy breathing? è she told me her daughter gets better
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The nurse told me that you don’t wanna give shots to your daughter and may I know why?
“I heard that the immunization can cause brain damage that I heard from other mothers at the
playground and from the internet article”
Any other concern? “ I also heard MMR can cause autism”.
Any other thing else? She told me that’s all.
Marie, I can see that you are worried about your daughter but we gave immunization to prevent
common communicable diseases prevalent in the community. We have made sure that
immunization is safe and has passed through several trials which have proved safe to administer to
the children.
It will prevent common strains of infections but if in case of happened of infection like flu, it will
shorten the duration and lessen the severity of the disease.
Another thing is that the research and the trial has proved that there is no linked of MMR with
autism.
Before immunization, we will examine your daughter head to toe examination and measure whether
she still has fever or not. We will give shots when she is safe and okay.
Just after giving immunization, we will monitor an hour at the clinic. If in case of happening
anaphylaxis, we have medication kept in ready .
But she responded us “I’m still doubtful that the efficacy of immunization and whether it prevents
the infections as I don’t see anyone happening of catching infections nearby me” .
I responded “Marie, we don’t see any cases of serious cases of infections near around us due to the
benefits of immunization. In some developing countries, there are some children who don’t get a
chance to give shots to children and in worst scenario, we can see some catching infections like
poliomyelitis resulting in stiffness of the hands and leg. We don’t want anyone happening around us
and that’s why we give a shot.
How’s right now after our discussion of immunization? Are you happy to give shots to your
daughter? She told me she is not ready to decide.
I reassured her that it would be difficult for you to make a decision at a time after brief discussion.
Take your time and I will give reading materials to you. But we just want to make sure your daughter
free from diseases that can be prevented by immunization. Discuss with your husband and I’m
happy to explain you back if there is any doubts. Bell rang.
Global score – 4
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
History
4
Patient Counselling/ Education
4
14) Post natal depression – History, Mx
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Your next pt in GP is a 32 year old woman who delivered the baby 10 days ago. She came up to you
back for the routine check up. The baby is perfectly okay but she is worried about her baby and she
didn’t look well. She delivered the baby alone while the husband is away from her. She has no
delusion and haullucination. She looks teary at that time. She has no risk of harming herself and the
others.
Otherwise, her physical health is healthy and there is no previous history of mental problems.
Task: Take focus pyscho-social history. Explain about the condition to her. Explain further Mx plan.
I entered the room and the patient looks teary. I offered the tissue and I thank her for opening up to
her about her story but I need to to know more about how you are doing right now to be able to
give you help. Offer confidentiality
Psycho- asked her mood, sleep, appeitite, harm to herself and baby, any affect on her daily activity,
any guilty feeling towards something?
Insight – okay
Alcohol, smoking, drug – NAD
1st baby? (yes) any problem during delivery and pregnancy ? (No)
How do you think about her baby? Do u think she gets ill? (she is worried that the baby gets ill)
Social – where is ur husband at the moment? (now he comes back and with the baby at the moment
outside the consultation room) any other family members or friends beside you? (No)
Thanks for opening up to me.
I can see that you are worried about your baby but I have already examined the baby. He is perfectly
healthy. You are a good mother and you seek help when you don’t feel okay. Right now, I will be
right beside you to give all support you need. According to the story, I noticed that your mood is not
good these days and felt helpless. This is what we called post natal blue, very common in mothers
who just delivered the baby, especially with 1st pregnancy.
As a GP, I’m going to see u regularly how you are doing as well as the baby. I will take care both of
you. Would u mind if I talk about your condition to your husband so as to give help if he knows more
about u? (yeah its okay) Let’s start with talk therapy with me and if after few sessions with me and
need more help I will liase with the counsellor. The door is always open to you, Amy. You will feel
better if you open up to someone instead of feeling self alone. I will be alonw throughout this
journey.
Do you need any help with house chores? (No at the moment). How about financial ? (I’m secured).
If necessary, I can liase with social workers and center link for you. For your husband, I can write the
paternal certificate leave to give u help,how does it sound to you?
I will see u in next 5 days. If you are not okay with some talk therapy with me or either with
counsellor, we will seek medications for you. Do u agree with my plan?
She told me yes. 1 min left and reassure her again. Bell rang.
Global score – 4
Assessment Domain
Domain Score (see key
below*)
172
Approach to patient/relative
4
History
5
Diagnosis/ Differential diagnoses
3
Patient Counselling/ Education
4
Another recall (Pass) - A woman comes to your GP clinic who feels miserable. She had a baby few
weeks ago, she has issues sleeping, loss of appetite and is tearful
Tasks History. Diagnosis/ DDS. Counseling.
Hi my name is Dr Qureshi and I will be taking care of you today. Whatever we discuss here will
remain confidential between me and you.
So tell me whats been happening? Well I had a baby recently and no I feel miserable.
How is your baby doing? He is fine
Have u recovered from your delivery ? Yes
How is your mood? I feel very low
How is you sleep? I cant sleep at night and wake up a lot. I m so sleep deprived
Have u lost interest in the activities which you used to find pleasurable? Yes
Do you have any guilt? No
How is your energy level? Low
How is your concentration levels? Very low
How is your appetite? I have lost it
Have u ever tried to hurt yourself? NO
I am going to ask a few routine questions which you may find silly. DO you hear see or feel things
other people don’t? NO
Do you have enough support? No My husband is a truck driver and he is away most of the time. We
recently moved interstate.
Do you have other family members or friends around? NO
Any other children? No
Any fever, excessive bleeding from below, cough , burning micturition? No
PMHX: None
Diagnosis : Most likely you have a condition which we call as Post natal depression. Its very common
for women to experience it after birth. The symptoms point to it and some factors such as no
support favor it too.
Counseling: First of all I know its quite a lot for you to take care of yourself, your baby , house chores
especially with no support. I’m going to arrange a social worker to help you around. You can make
173
friends in you neighborhood and visit local community clubs. Keep yourself busy and look after
yourself and the baby. If you don’t feel better I can refer you to a psychologist
Assessment Domain
Approach to patient/relative
5
History
3
Diagnosis/ Differential diagnoses
5
Patient Counselling/ Education
4
15) Prostate cancer Gleason 7 with UTI results explains what implications and Mx (old recall)
55 yr old man who initially presented to your GP with frequency, urgency and pain when passing
urine was referred by you to a urologist because you found on the pr examination an enlarged
prostate.
The urologist sends you a letter with the results of a range of investigations he has initiated:
1. MSU showed growths of e.coli
2. PSA 6 ng/ml ( <4ng/ml normal, 4-6 ng/ml intermediate, >10 ng/ml high)
3. The core biopsy with 8 samples from the prostate was positive for adenocarcinoma
4. Gleason grade 7
5. A cystoscopy did not reveal a bladder neck obstruction
6. the whole body radioisotope scan did not show metastases
7. CT pelvis and spine did not show any tumour outside the prostate capsule (stage T2) The urologist
mentions that he explained to patient that there was cancer but he suggested to see you for further
counseling.
Tasks:
1. Explain results and its implications
2. Discuss treatment options and counsel patient
3. Mx of the patient as a GP
I explained the result starting from UTI and explained and whenever there is UTI in male, we need to
find out the underlying cause. Then explained PSA , biopsy and cystoscopy and CT step by step.
For implications è frequent UTI, AROU, stone formation, spread to nearby structures like bladder
and colon, lymph node, bone and brain and reassured that there is no spread and CA in within the
prostate.
For UTI as a GP ,I am going to give you Abs for 14 days followed by retesting ur urine sample to make
sure u are completely cured. Any Ab allergy?
For Tx options, I referred and made a booking back to specialist for MDT approach.
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Tx options è watchful waiting with frequent monitoring, blood test and imagaing, Sx, +/- radio,
chemo and hormonal.
Depending on the condition, the surgeon will discuss in details about options and your decision will
be respected for Tx.
I explained common Sx tx option if the specialist and you have decided for this è bleeding,
anaesthesia risk, retrograde ejaculation.
For me as a GP, aim is to prevent frequent infection and frequent monitoring and will liase with
specialist.
Global – 5
Domain Score (see key
below*)
Assessment Domain
Approach to patient/relative
4
Interpretation of investigation
4
Patient Counselling/ Education
5
Another Recall (Pass) - 57yo male with hx of recurrent dysuria, micturia had been seen by your
colleague who on PR found enlarged prostate and sent to urologist. The patient has gone to
urologist who did:
Urine c & s: Normal
cystoscopy: obstruction of urethral neck, prostate adenocarcinoma (gleason 7)
PSA-10
Bone CT: no tumors, pelvic and abdominal ct with no presence of tumors other than the prostate
which is confined to the capsule
Tasks: Explain the examination results. Explain its implication. Explain treatment options.
Hi my name is Dr Qureshi and I will be with you during this Consultation. So do u remember you had
the tests done? Yes
Would you like to call someone to be with you today? No thanks I’m fine . I just want to know the
results
What are your expectations? I just hope everything is good
OK so I have some good news and bad news.
You see these results it shows that your urine is clear of any infection.
PSA levels are bit high. PSA is a protein that is produced by the cells of the prostate gland and enters
the bloodstream. It is used to detect the early stages of prostate cancer
Cystoscopy shows obstruction and enlarged prostate
CT scan shows no other organs involved except the prostate
175
Gleason score 7 means its moderately invasive So I drew prostrate with the kidney, ureter and
bladder. I explained that it is a walnut shaped organ which produces a part of semen. You have the
cancer in this organ. Gleasons score means how invasive this cancer is. 7 means it is moderately
invasive
There are many treatment options for this and has a good outcome. If we don’t treat it on time, it
may spread to the bones, intestines and liver making it more difficult to cure
Are you getting me? Yes
Treatment options:
1. Surgery
2. External beam radiotherapy
3. Brachytherapy
4. Watchful waiting with regular followup—rare as he is young 57, no co-morbidities and moderate
grade of cancer.
I said we will approach your treatment plan in a multidisciplinary team manner.
Then went for details
Surgery is key hole under anaethesia. We will do an anaesthesia eligibility check up for you before
we proceed with surgery
EBRT—localized radiotherapy with covering of other body parts
Brachytherapy—injection of anticancer drugs locally
SESurgery
Injury to surrounding organs rare as expert surgeons will perform
Retrograde ejaculation, infertility- explained and mentioned whether he had completed his family.
He said Yes
Incontinence, impotence
I will arrange a follow up with the specialist. I know this must be a lot to take in but we can have
another meeting to discuss the options again and bring your partner in next time.
Assessment Domain
Approach to patient/relative
4
Interpretation of investigation
4
Patient Counselling/ Education
4
16) Secondary amenorrhea (exercise induced)
Your next pt in GP is a 16 year old girl who complained of lack of period and her mother brought her
to consult to you. Task : History, PEFE, Dx and DDx to patient
176
I greeted her and I saw the she is sitting on the chair.
I asked her mother whereabouts and she told me she is waiting outside.
I offered confidentiality and reassurance not to be shy.
I asked first about
Period ?
(lack of period for 1 year, before 1 year any period? è at first she told me No period, but during the
discussion phase, she mentioned back that she got period starting from age of 12 years)
Partner? (Nil)
Age of her mother and aunt period? (I asked this since she told me she has no period once before)
Hormal Pills? (No)
Weight? (normal)
Diet and ex:? (normal diet but doing ex:? ) what kind of ex? (dancer , 10 hr practice per day, she is
practicing from the contest, not aiming to lose weight) , water pills? (nil)
Other Medication ? (no)
Any hairy growth on face and acne? (no)
Vision disturbance and LOW and LOA? (all normal)
Sx procedure before and any woman problem? (no)
Stress these days and occupation? (student and no stress at all apart from the dancing contest)
Alcohol, smoking, drugs? (all no)
PEFE
GA – normal
Vital signs – normal
Vision – normal
No hairy growth and acene
BMI-19
Abdominal examination – NAD
VE – inspection – clear, NAD, I skipped BM and sterile speculum
I explained that she is having lack of period due to exercise she has been practicing a lot,
Normally, the mensturation is controlled by the female hormone what we called estrogen and
progesterone.
177
In ur case, the stress and ex: a lot have the effect on the part of the brain what we call pitituary
master gland which controls the ovary to produce normal female hormone.
Other ddx : PCOS, hormonal pills, diet, weight, other stress, Sx procedure, pituitary adenoma
Global score -4
Domain Score (see key
below*)
Assessment Domain
History
5
Choice & Technique of examination, organisation and sequence
4
Diagnosis/ Differential diagnoses
4
Another recall - Hi my name is Dr Qureshi and I will be taking care of you today.
So how can I help you? Well my mum is worries because I haven’t had my periods for a few months
Is this the first time it has happened? Yes
When did you get your periods ? At the age of 11
Are they regular and for how long do you have it ? Yes 28 days cycle and 6 days
Any excessive bleeding or pain during your period? No
Any discharge from below? No
Are you sexually active ? No ( didn’t ask remaining P’s because there was no point)
Any weather preferences ? no (thyroid )
Any milky discharge from breasts or visual disturbance? No (pituitary )
Any excessive hair growth or acne? No (PCOS)
Any gynaecological procedures ? No
How is your typical diet ? Mostly eat salads because I want to stay healthy
How much do you exercise? I am a personal trainer so I work almost 12 hours/ day
How is your mood today? I feel great
SADMA : Negative
PMH: None
PEFE
General Appearance and BMI : Normal 17 BMI
Vitals : Normal
CVS : Normal
178
Respiratory : Normal
Breast staging : Tanner stage 4
Abdominal : Normal
PV Inspection : bits of hair and developed
Diagnosis :
Secondary Amennorhea due to excessive exercise but other possible causes can be Thyroid,
pituitary, PCOS,
(I had this case in my previous exam and I failed it. Glad that I passed it this time)
Assessment Domain
History
4
Choice & Technique of examination, organisation and sequence
5
Diagnosis/ Differential diagnoses
4
10th April 2019
1. Vomiting (Paed)
Hx: as I remember baby is just a few months old, I started asking for CCVO, is it projectile or fall in
the body (fall in the body), associated sx/ ddx question: fever? Crying while urinating, distention of
abdomen? Iritability? Straigthening of the legs/paleness when crying? Any prob with bowel mvts?
Hyperpigmentation? - all negative, well baby questions- all normal, BINDS, heel prick test- all good
PE- all normal
DDx: I said all the dds and say why I rule out them
179
Not pyloric stenosis as no mass on PE, not projectile
No surgical abdomen such as intussuception, appendicitis as negative in hx
Not infection such as UTI, meningitis as no fever and negative in hx
Not CAH as it is pick up in the first few days of life
Lastly I reassure that its GERD and will be ok in time but need to observe, if persist beyond 9 mos
need to see a specialist.
2. MSE video (Pilot)
Very long stem which I havent finish reading but, outside you know that its MSE,
In the video man is very angry about his situation, about his life, about the police, about his gf
(complaining of the snoring neighbor in the ward, complains about everything) I cant remember the
case as I havent read the whole scenario. When ask if suicidal he said before but not now.
Maybe other candidates can talk about it fully
3. Vaginal Discharge
Hx of vaginal discharge, CCVO ,is there blood? Itchiness?, fever?, 5Ps particularly sexual history, as
far as I remember sexually active and is stable long term relationship. Pain during coitus? HPV, I cant
remember what she answer, Waterworks? Bowel mvt? asked for DM, antibiotic, steroids all that can
predispose to candidiasis.
On speculum I did swab, all look good except from discharge, cervix and vagina looks healthy
As I remember I don’t say a definitive diagnosis but I say all the possible causes of Vaginal discharge,
starting with infection, parasite- trichamonas, fungal- candiasis, bacteria- bacterial vaginosis, most
probable is bacterial vaginosis, but needs to confirm on the swab that was taken. Usually seen in
sexually active person. Since patient is on stable relationship I chose this. Cervical infection but
unlikely as cervix is healthy, atrophic vaginits but healthy vagina.
4. Health Review - Hypertension
Patient came in for the result of the ambulatory bp monitoring, and youll discuss the about the
result and the possible complication, has family hx of DM and heart attack. PE increase BP
So I start with discussing the result, and explaining that increase BP can lead to a lot of complication
such as stroke, heart attack, blindness, kidney failure, heart failure. That is why it is necessary to
control the BP, have a check with the eye and kidney specialist and make sure that the other risk
factor were controlled. I started with age (unmodifiable) BMI, increase BP (which what he has now)
Cholesterol(I discuss about plague formation), I appreciate that he don’t smoke coz its also a big risk
factor, I said we need to check the blood sugar as he have family hx, coz a comibination of high BP
and sugar and cholesterol is not really good. I told about exercise 5 times a week 30 minutes walking
etc. and stress at work home. So basically I just talk about this stuff and go around it again and again
till the bell rang.
180
5. Behavioral Complaint – OCD
A college student that was brought by school cordinator due to failing grades, because he cant pass
the project on time. I started by asking why do u think u where brought here then confidentiality,
then some statement like don’t worry im here to help you, he answered because he failing, and ask
why? Because he make sure that he do all the things perfectly, I started asking about OCD question,
like is there any unwanted thoughts in his mind that make him do uneccesary habits, he said about
the KING thing, I ask him what did u do if that comes to your mind?, he said he try to make things
perfect. I ask if it he think its uneccessary and affects him. He said yes. Is there any other ritual he
does like frequent does like frequent handwash etc. said NO
After I finish with OCD question, I proceed with Mood sleep appetite, suciadal, then ask about
delusion halluciation, cognition, judgement, headss ( I cant remember if there a dysfunctional family
in this case, everything was rumbled in my mind) but if yes probably parental divorce, not fxhx
mental ds, no substance abuse
I talk about OCD, I said could be because of the divorce.
He ask me what will I say to the school coordinator, I said everything here is confidential I’m not
going to tell what we have discuss unless he give consent about it.
6. Abdominal pain – (Cholelith)
Hx ask for the SIQORA, then dds question
Biliary colic- is there any pain after heavy meal?
Cholecystitis- any fever? Nausea, vomiting? Excessive sweating?
Cholangitis- fever? Chills and rigor? Yellowish skin?
Gallstone ileus- greenish yellow vomiting? Abdominal distention? Constipation?
Peptic ulcer- long term medication for pain? Pain increase after food or empty stomach?
GERD- waterbrash? Metallic or sour taste? Heartburn?
Pancreatitis- pain radiate to the back? Relieve by bending forward? Any alcohol intake? Previous
bindge drinking
Pneumonia- shortness of breath? Cough? Phlegm? Fever
Renal colic- loin pain, groin pian, any waterworks issue
Acute Cholangioma- wt loss, loss of appetite?
Post- Cholecystectomy syndrome- any past history of surgery (cholecystectomy)
MI- chest pain? splenic abcess- any trauma on left side
Mesenteric ischemia- diarrhea, palpitation? Heart prob?
Diverticulitis- fever? Blood stool?
Then SADMA
181
Then I just discuss all the ddx and rule it out depends on his answer to my question.
In this case my patient has cholelithiasis, no fever no yellowish discoloration, pain related to food,
no pain meds taken, pain radiating to the back at times, normal bowel movements, no distention, no
cough and colds, no cold sweat.
7. Respiration PE
Patient is an old man, real patient with chest deformity at the back, with wheezes, I hear some
crackles so I also mention that, and smells cigarette.
I made sure I say to the patient what im going to do before I do it.
I started with the general inspection, no respiratory distress then elaborate about it, not cachexic, no
hoarness, the I said ill inspect the hand, cant see nicotine stain, no clubbing then check for wrist
tenderness, no flapping tremors, the I said ill proceed to check in face, no pallor, no signs of ptosis
myosis anhydrosis, no oral cyanosis, no mass on the oral, then I said ill go at his back to check for
the neck lymphnodes,
Then I proceed to respi exam, start with inspection posteriorly, I was shocl that there is deformity on
left chest, I put my hands on his lower chest to check for the symmetry, then ask the patient to
breath in, the I said ill check for vocal fremiti he needs to say 99 (for the running commentary I said
normal) then I said Im just goin to percuss to check for the sounds (I actually don’t know if I elicit the
sound accurately coz im just really percussing) lastly I said I’ll listent to his chest and just breath in
when I ask him (I said I here crackles on upper lobe and wheezes on the rest).
I would like to proceed on checking the anterior part but the bell rang.
The on my dx/ddx, I said, you he smell smoke, and ask if he is smoking he said yes and ask how long,
long time already, so I said im thinking of obstructive lung disease and then mention about asthma
and copd, but because of his smoking its more towards COPD, although it could also be asthma, to
confirm we need to do spirometry test. I also mention about the possibility of restrictive lung
diseases such as, occupational lung disaeses, but since we havent have any test we cant totally rule
it out.
I say I cant totally rule out malignancy too as smoking is a risk factor to lung malignancy.
8. Exercise induced Amenorrhea
patient is a ballerina
I ask about the LMP if slowly become scanty, then procced with ddx, 5Ps said not sexually active but
I haven ask if virgin,
I ask about the PE depending on the ddx but not the taner stage, and I do rectal exam which I
shouldnt have done, when ask why, I was so dumb to say looking for nodularity (totally wrong) so I
know I messed up with this after I realized how wrong I am for saying nodularity.
9. Breathing difficulty – (Paed)
182
This is my first station, I thought I messed it up, because my structure jumble (but I tried to follow it)
luckily I passed. This is a station assessing the history, so ask all the ddx
Patient is a 9 yr old known asthma come in due to worsening cough, been using salbutamol but not
working. When ask about ddx: travel, immunization (he is up to date), hay fever, eczema, triggers to
asthma, heart (normal on PE) fever: negative (time for the hx taking is long, I didn’t get positive
result that will give me the diagnosis clearly.
On PEFE clear nasal discharge only, other ENT is normal but ask everything in ENT and chest. Picture
showed red eye injection (blood vessel bled) examiner says probably due to coughing hard.
Because I didn’t clearly got the diagnosis in hx, I go around the bush saying Im thinking of a number
of possibility for chronic cough, I said we can consider this as chronic as is more than/2 weeks
already. im thinking of pertusis but hes up to date in immunization so im doubting, tb but no travel,
could still be asthma but im thinking why salbutamol isnt working, was also thinking of heart but not
in PE, I didn’t finish coz bell rang. (so I really don’t know the diagnosis)
10. RA - Pilot
It’s a pilot case, patient has office job as typist, now having patient on hands joints and having hard
time typing, so on a sick leave so ask about SIQORA, and pain anywhere else, when the pain started
and how it subside, family hx, mother has the same issue and when ask what was the diagnosis she
said RA, then ask about the associated sx, fever, diarrhea, eye prob, wt loss, waterworks
–
RA- do you feel any joint pains once waking up, stiffness
–
OA- do you feel any pain after the day
–
Sepric arthritis- do you have any fever?
–
Trauma/ fracture- any trauma
–
Fibromyalgia
–
Malignancy- wt loss, night sweat, loss of appetite
–
Trauma
–
SLE- any rashes face, urine prob?
–
Dermatomysitis- any rashes on skin? Sausage shape
–
Scleroderma- hand color changes
Then need to ask the examiner about the lab test, I said cbc, esr crp, rh factor, anti ccp, liver and
kidney test
then I explain all the test result to the patient saying it looks like RA like what ur mom does,
explained that its having inflamation in the small joints and as of now this inflamamtion if not cured,
it can cause further damage to the joints, that’s why specialist needs to see her. I was thinking or
other causes which I ruled out in the information she gave me. I discuss all about it till the bell rang
11. Unconsciousness PE
183
I started with introducing myself and made sure that I explain things to her before I do it.
Can you pls open you eyes for me, do you know whats your full name , do you know where are we at
the moment? Whats the date today, can you grab my fingers and squeeze them? Wiggle you toes for
me pls. im just gonna give you a little bit of pressure. (tell your GCS assessment) , in this case its 9 =
E1- close all the time, V3- inappropriate words, M5- can localized.
Im just gonna examine the pupils, it will give you a little discomfort but pls bear with me, both eyes
are conjugate and looking on the same direction, there is no nystagmus, no ocular clonus, pupils are
equal and reactive to lights.
I have check the GCS and the pupils and I wanna know the blood sugar level and temperature.
Im done with the disability part, know I want to proceed on exposure, start checking from the head (
palpate)
There is no bulge, depression or crepitation in any of the frontal pariental temporal or occipital
areas, no midline neck crepitation, no c spine crepitation, I cannot appreciate any stigma of basilar
scalp fractures, no no rhinorrhea, no otorrhea, battle sign, epistaxis, I cannot appreciate any smell of
alcohol, acetone, fetohepaticus, I would like to check for the neck stiffness, ideally the head of the
bed should be flat, I can appreciate neck stiffness. Now I just want to complete the exposure part by
having a look of the rest of the body, extremities is negative for needle prick marks, no asthma,
diabetes, epilepsy bracelet, no open wounds, the chest is moving simultaneosly with his respiration.
Abdomen is moving on respiration, no signs of trauma no chest and abdomen.
I would like to proceed on my secondary survey, I would like to focus on all systemic examination,
mainly focusing on neurology exam. I would like to check for the tone ( rolling the wrist, elbow and
shoulder) (rolling the toes, knees,) – I forgot to check for reflex
Then I proceed with ddx: infection (in this case there is neck stiff ness) such as menigitis,
encephalitis, could be drug induced but unlikely, could be metabolic encephalopathy such as DM
enceph but need to wait for Blood sugar report, could be kidney or liver failure that cauz enceph but
we still have to wait for blood check, then I mention all the necessary blood test. Could be trauma
but no signs, could be hypoxia but respi is normal. That’s what I remember so far that I said.
12. Recurrent Respiratory problem (Rhinitis)
A child (can’t remember the age) has been having colds for so long already (recurrent). No meds
given, parents is concern.
On hx I ask about ddx: asthma(-) hay fever eczema (-) fever, cough (-) foreign body (patient is not
neglected) child care (+) smoking at home (+) BINDSMA (-) mother has growth chart when ask only.
heel prick (-) patient is normal, so be very friendly to role player nothing is serious.
PEFE: normal
So I reassure the patient, give ddx saying what im thinking of a lot of possibility like viral colds, its
very normal at this age they could get it 8-12 times a year and wont be having problems. They have
low immune system and child can pass it in child care. Allergic rhinitis is a possibility so I advise pls
stop smoking, its really bad for the heath and can affect your kid also. Just try hard for this. Could be
bacterial to but good hes not having fever. you said hes been looking after, which is good coz foreign
body is a possibility. As long as kid is growing eating well playful nothing to worry but im happy that
you bring him to me to be check. Then say all the nice things until the bell rang.
184
13. Knee PE
Patient came due to knee pain,- Chondromalacia patale
I say everything that Im goin to do before doing it, like im going to start on inspection (then do
inspection on anterior posterior lateral) im going to proceed to palpation, pls excuse me for my cold
hand and let me know any pain, then continue asking is this painful, repeat it while doing palpation
and look at his eyes (everything is good) Im going to check for the movement ok, pls bend your knee
and move it to your chest, then im just goin to do a passive movement to feel for crepitation, let me
do I by myself etc. (normal) then im goin to proceed to special test, then did all the special test while
saying what it is for
Special test
1. Patellar tap (large effusion)
2. Swipe test/Bulge test (small effusion)
3. Patellar tilt test (patellar tendinitis)
4. Clark test (chondromalacia patellae/Patello-femoral test)
5. Apprehension test (subluxation of patella)
6. Anterior drawer test (ACL)
7. Posterior drawer test (PCL) Varus test (MCL)
8. Valgus test (LCL)
9. Apley Grind test/McMurray test (Meniscus)
To complete my examination, I would like to examine one joint above which is the hip joint, and one
joint below which is the ankle joint. And I would like to do a full neurological examination of the
lower limb.
Then I say all the ddx and explained why its chondromalacia patale as clark test is positive.
14. Leg Pain - PE
I messed this up as I havent elicit positive on PE, havent ask pulse (which is decrease according to
other candidate), burger test, ABIndex
I explained PVD all the risk factor and say other ddx but not really good. I get lost when the examiner
says normal to all the things I ask, in the end I really don’t know what to explain, coz everything was
normal. Basically I missed to ask the important things.
15. Primary Post-partum Hemorrhage
Task ask examiner about PEFE, explain whats happening to px, give mgt
185
So in this I think we should be doing DRSABC protocol which I havnt done, but I pass. So my case
goes like this.
PEFE: ask about ddx pertinent positive: DIC- bruises; trauma- trauma; atony- if uterus is contracted,
retained products- placenta still there (it was given in the stem.)
Explaination; I said you are bleeding coz placenta is there and needs to get extracted, seniors are
coming to extract it, but that’s only one of the causes of vaginal bleeding, im thinking initially of
laceration also but on PE is all good, we need to check the blood as problems in the blood we call
disseminated intravascular coagulation is a possibility, then I discuss about RBC, WBC, platelet and
tell about whats happening in DIC, atony can be a possibility, where in uterus is not contracting, if
the placenta is extracted and bleeding continue then theres a possibility of taking the uterus out or
on specialist decision they might consider ligating the blood vessel, so it on the specialist hands, but
while waiting for them to come we will have to massage ur tummy and can u pls play with your
nipple as it helps to relaese a hormone what we call oxytocin, responsible for contraction of the
uterus, and then I remember we need to put IVF then bell rung.
16. Headache
Task is get psychosocial Hx, PEFE
Patient presented with headache around the temporal area, I quickly ask about SIQORA and
vomiting then because its psych, I started asking for stress and she talks a lot (cant remember the
stress) about her workmate/ work partner issue at work. She keeps thinking about it. So I quickly go
to psychosocial hx, for mood, appetite sleep, all affected. And feels guilty. (I didn’t fnish the hx taking
as she talks a lot and shes depress so im so slow too so bell rung.
On PEFE I ask all about the ENT, ddx of headache
Then on dx, I said im thinking that the cause of your headache is the stress that is goin on right now,
I see how you were totally affected by the situation, I would like you to be seen by specialist/ do
mediataion etc (mgt not included) as when our mind is stress it could manifest in our body, in some
people it could be difficulty of breathing, stomach pain, chest pain but in ur case its head ache. Just
talk a lot, I actually cant remember everything but I said u might be having depression or adjusment
disorder because of the situation ur frend is having etc but im pretty sure it not something organic
and more of stress related. I just repeated thing again and again till the bell rang.
11th April 2019 retest
1. Headache- probably tension type, History, DDx
Tension headaches with the usual Normal CT brain, chronic headaches for 10 years, Gastro Sx and
recently broke up with boyfriend. Get History to rule out other causes and explain Dx.
Asked history to describe (SOCRATES) and rule out –
Malignancy (loss of weight and appetite), migraine (photophobia, phonophobia, nausea), temporal
arteritis (scalp tenderness), visual difficulties, sinusitis……..
Firstly, showed empathy by saying that you have been suffering with these pains and investigations
do not seem to reveal anything.
186
Then explained that this is not a new thing and we see a connection between mind and body.
Difficulties causing stress can cause discomfort in the body that cannot be appreciated on
conventional medical investigations.
Then asked does she appreciate any connection of her recent worsening of long term headache with
a stressful situation at professional or personal level.
Then patient revealed her stressor and I explained that it is worsening of tension headache.
2. Adult with purpuric rash: PE, DDx
PE of the haematological system for a male/26 with petechiae on buttocks and LL. Recent History of
URTI. ?ITP
3. Lower limb sensory exam- Alcoholic peripheral neuropathy - PE DDx
Pain in the leg. Stem indicative of alcohol induced peripheral neuropathy. PE with DDx.
Greet
Consent
Wash hands
Offer painkillers after ruling out allergy
Do PE to rule out all causes of leg pain and not getting swayed in single direction by stem
Gait- regular, heel walk, toe walk
Inspection – for injury, inflammation, mass, varicosities, ulcer
Palpation- temp, tenderness, pulses, CRT
Sensations- I did touch and pain on all dermatomes, vibration, joint position (I did not see any
monofilament around)
I could not say DDs- I mentioned alcoholic neuropathy and bell rang.
4. Child URTI – History, PEFE, DDx, management
Septic child 14 months old boy brought in by father, for workup. Only positive finding of vomiting
and fever. PEFE showed pharyngitis and moderate dehydration. Take History, explain DDx and do
Invx.
5. Diarrhea DDx, Mx (Antibiotic induced)
67 years old Male with diarrhea x 3/7 and 6 episodes a day and has been treated with amoxicillin for
bronchitis. History of gastritis and on pantoprazole. Get History x 2 min, explain Invx you plan to do
and Mx.
187
I quickly ruled out common causes of diarrhea like infective (vomiting, eating out, fever?), lactose
intolerance (related to milk?), IBD (blood, mucus?), Coeliac disease (related to particular food)
Asked relationship with antibiotic and if bronchitis is better.
Ix- toxin for clostridium difficile, microscopy, stool culture and sensitivity, electrolytes, RFT
(explained what we are looking for in all)
Plan- I will first stop amoxicillin and wait for investigations to initiate another antibiotic if necessary
(forgot to mention the name metronidazole), also explained how to maintain hydration status.
6. USG report - fluid in POD, ovulation, gall stones - explain, Mx
USS of middle-aged to old lady who presents at mid-cycle with abdominal pain ---- showing gall
stones, corpus luteum and free fluid in POD. Report also says appendicitis cannot be rules out.
Explain USS with differentials, current Mx and future Mx.
Greet
Explain all 3 findings- Ovulation, Gall stones, Probability of appendicitis.
Differentials – apart from above 3- constipation and gaseous distention, food allergies,
gastroenteritis
Current and Future Mx- Some investigations in blood, stool, urine to rule out any severe cause. If
patient is stable, she may be discharged with pain medications and red flags and provided she stays
close to the hospital. If investigations indicate appendicitis it may be managed conservatively or
surgically. Gall stones if asymptomatic may also be managed medically.
7. Herpes in pregnancy - History, PEFE, Dx
Herpes simplex in Primigravida at 20 weeks of gestation. Hospital records down so take relevant
History, PEFE and possible causes.
Quick Hx- How are u feeling? regular check ups? USG? Any abnormalities? Any fevers during
pregnancy? Bleeding? Fetal movements? Bleeding?
C/O tingling/pain below- it has happened couple of twice before and no h/o recent exposure
PEFE- gen app, vitals, pallor?, auscultate heart and lungs, fundal height, fetal lie- current
presentation, fetal HR if doppler is available, pedal edema. In presence of chaperone and with pts
consent id like to do a pelvic examination. Inspection- vulva- skin- signs of injury, rash, redness ?
speculum examination if patient is not uncomfortable – looking for injury, rashes, laceration,
discharge, appearance of cervix…
(multiple vesicular rashes present on vulva)
Possible causes- recurrent herpes
8. Fluid overload post op breathlessness- interpret, PEFE, explain
Post op patient for bowel surgery. Observations so far to explain to examiner. Patient was
tachycardic, tachypnoeic, hypertensive, saturating at 90% in RA.
188
Drug fluid charts. Total input 10L and output 2.08 L
Drug sheet was marked as NG (not given) postop: So lasix 40 mg wasn't given, ramipril also not
given. Clexane administered. Ask PE from examiner and explain results to examiner with proposed
plan of Mx. Also tell patient what she is having. She had all the features of HF and was anuric.
After introduction and greeting I took permission to have a look at the obs chart to draw all essential
inferences. Then explained to the examiner that urine output is less than 30ml an hour which is
concerning and input in past 24 hour has been more than 6L which is much more than what is ideal
for a patient of hypertension and cardiac disease.
I asked PEFE in sequenceGen app
Vital signs
Auscultation of heart and lungs (basal crepitations in lungs, 4th heart sound on auscultation)
ascites, sacral and pedal oedema?
explained situation to the patient
Mx- Administer oxygen. I would stop fluids and ask cardiologist and nephrologist to review the
patient. Probably a higher dose of Lasix is needed. Asked the patient to stay propped up in order to
feel more comfortable.
16th April 2019
1- Eye PE - Bi-temporal hemianopia
Man, in 50s, came with progressive diming of vision. (Fail)
(Since stem mentioned diming of vision, during my 2 minutes time, I didn’t really think about
bitemporal hemianopia rather was thinking about peripheral causes of chronic vision loss like
changes from cornea to retina)
Findings: VA ↓ on right eye.
Asked for Ishihara chart- examiner said not needed.
Asked for Amsler grid chart- examiner said not needed.
Loss of temporal vision field of left eye.
Others said there was temporal vision filed loss on the right too, but I couldn’t appreciate that.
Fundoscopy picture a little bit blurry printed on paper, looked normal to me.
This combination of diming of vision, ↓ VA on right eye, temporal visual field loss on left (± left)
puzzled me and couldn’t conclude what it was. Please check with one who passed the station.
2- Child with recurrent colds : 2-year-old boy having recurrent upper respiratory tract infections,
mom is concerned.
189
Task: Hx, PE card, counseling. (Pass)
Findings:
6-8 episodes of runny nose, occasional cough in the last year.
No personal and family h/o allergies.
No high fever, sob, lethargy or drowsiness.
No sick contact or travel.
BINDS – normal.
No passive smoking at home.
PEFE card – normal.
Mentioned 6-12 times a year is normal for young kids. Discussed passive smoking is a risk factor.
Advised Panadol, adequate rest, plenty of fluid with food rich in vitamin C, good hygiene. To keep
immunization uptodate and avoid sick exposure. Red flags.
Another Recall (Pass) - 2 years old boy having repeated upper respiratory infections and father is
here to see you. Task history for 3 minutes. PE on card Counseling
Approach to patient/relative……4 History…..4 Patient Counselling/ Education…..5 Global score 4
d/d outside…. Recurrent colds, asthma, cystic fibrosis, immunocompromised, allergic rhinitis,
inside young man with multiple peircings on ears and nose is sitting and timer was present on the
table, when I sat on the chair he started the timer.. open ended question and then I just fired all the
relavant questions without wasting time. Father first statement…He is having repeated infections
and I am concerned, do we need to do more investigations or not? How many infections….6 in a
year. What are the symptoms during those. Runny eyes and runny nose, mild fever no sore throat.
Family history of allergies….negative Any cough sputum….neg Any time high grade fever….neg Any
lethargy or drowsiness…neg BINDS…. All normal No child care. No sick contact. Pee poo normal.
Happy baby at home. Examination on card…. Growth charts normal, respiratory normal.
Counselling….6 to 12 such infections are normal in a year, as baby is growing and his immunity is
developing so they get such infections. But as he is growing fine, his weight and growth is normal, his
immunization is uptodate, his diet is all well then there is nothing to be concerned about. We call
this conditions as recurrent URTI/colds. For now, there is no need to do any investigations cause
baby is fine but yeah anytime if his fever goes very high, his appetite decreases, or he is having any
difficulty in breathing and he seems lethargic, you must take him to emergency department. Reading
material.
3- Child - fussy eater - 10 months old boy, picky eater, mother concerned. Task: Hx, counsel the
mother about the condition.
Findings: Picky on food. Doesn’t like most of the foods offered.
Child likes yogurt but 2-3 spoons a day only.
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When asked about growth and development, mother showed growth chart and 4 values of different
weight at different ages were on 97th percentile.
Counselled the mom saying everything looks normal, babies are picky in this age and will outgrow.
Encouraged to offer appealing varieties of food and be considerate about the amount that baby can
eat.
4- Hip pain PE – osteoarthritis
Approach to patient/relative…..5 Choice & Technique of examination, organisation and
sequence…..5 Accuracy of Examination…..5 Diagnosis/ Differential diagnoses……6 Global score….6
47 or 57 year old man presented with pain in hip for last 9 months probably during working. Can’t
remember the exact stem. Task…examination for 6 minutes Diagnosis and dd
My d/ds outside…. Osteoarthritis (old man chronic pain), trochenteric bursitis, adductor tendinitis,
previous posterior hip dislocation. There was a young man inside lying down in so much pain, doing
full on acting of severe pain. I asked pain scale, offered pain killer and started my examination WIPE
(wash, introduce, physical exam) Gait …. Normal Trendlenburg test ….positive on right side.
Inspection Limb length measurements… true and apparent normal. Palpation normal Temperature….
normal Active movements…. All restricted on right side Passive movements …. All restricted on right
side Special test…. Squeeze test…negative Thomas test ….negative Faber test….demonstrated on left
side…couldn’t perform properly on right side due to pain. Redress himself like verbally.
I drew diagram and explained in layman’s term that it's a wear and tear injury of the joint called
osteoarthritis…and then explained all other dds mentioned above.
5- Hand PE - osteoarthritis
Lady in her 70s, came with chronic hand pain. (Pass)
I’m not sure if there was any deformity of hand, Bouchard or Heberden nodes. (for me they were
not obvious)
Tenderness of thumb and index finger joints. No effusion.
↓ ROM and painful.
Function test with key, urine bottle and coin which had been kept right behind the consulting table
so don’t see if you don’t look for it.
Function test was slightly limited.
Tinel, Phalen, Finkelstein – negative
Another recall (Pass)- 50 plus women having pain in hand or something like that… Perform physical
examination Check functional abilities of patient.
d/d outside …..OA, RA, mainly and if needed can add scaphoid fracture, psoriatic arthritis and others.
Quite old lady was sitting inside and she was real patient. I did WIPE Started my examination
Inspection…. Positive finding ….small deformity of DIP joint, probably haberdens nodes. Slight
muscular wasting. Palpation…tenderness on DIP joints positive. All movements at wrist and fingers
normal. All thumb movements normal. Phalen test normal Flexor digitorum superficialis/profundus
normal Opposition grip…normal Sqeeze fingers….normal Then I moved on to functional test… There
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was jar, pen, coin, key. Checked all one by one… She was able to do all this but slowly and bit
restricted. I explained osteo as main diagnosis and rheuma as my dd only.
6- Acute abdomen- ovarian cyst - 16 year girl, left sided abdominal pain, 8/10 pain in lower
quadrant, going to back. She was sexually active, her periods two weeks ago and use protection for
sex. In bimanual examination - left iliac fossa mass and tenderness.
Diagnosis and DDx - Ovarian cyst rupture, PID, Round ligament strain.
Another recall - ABDOMINAL PAIN (? OVARIAN CYST TORSION): UNSCORED
Young lady lying on bed. Task: Hx, PEFE, Dx with reasons.
Findings: LLQ pain, severe 8/10, sharp, for last 24 hrs, sudden onset, continuous
LMP 2 weeks back, partner using condom, not planning for pregnancy.
No previous pregnancies/miscarriages.
Would get midcycle pain but not this severe.
No fever.
No pv discharge.
No nausea, vomiting, bloating.
Gradasil, HPV/PAP uptodate.
Bowel bladder normal.
Tenderness on left iliac fossa.
Bimanual exam: CMT negative, normal uterine size, tender adnexal mass on left.
UDS: WBC positive. (I forgot if there was RBC positive too).
UPT: negative.
I think there was no DDx as a task, and I got positive WBC in UDS, couldn’t relate those findings and
said I’m not very sure at the moment but most likely ovarian cyst torsion so I need further workup.
(luckily, it was PILOT).
Another recall - 16 year old girl presented with pain on lower tummy. task… take history PEFE (have
to ask) Diagnosis and dd. d/d outside…. Appendicitis, ectopic pregnancy, ovarian cyst, round
ligament strain, pyelonephritis, pelvic inflammatory disease, bowel obstruction. Young girl sitting on
strature, Asked pain scale….8/10 Allergies nil Offered pain killer. SORTSARA Site … left ilac fossa.
Onset …. 12 hours ago now worsens. Radiation… to the back. Timing… continuous.
Severity…8/10. Aggravation…with time. Relieving factor… nil. Associated symptoms…burning on
passing urine. No nausea vomiting. Bowel habit normal. Last menstural cycle….2 weeks ago. Sexually
active, stable partner, protective intercourse, not pregnant. Gardasil vaccine taken. Any pain in
between periods… nil. Then many more questions which I could think of that time considering my
differentials. Physical Exam…. General appearance…as you see. Vitals…. Temperature were slightly
high. Rest were normal. Signs of dehydration…nil Focused abdominal examination…. Tenderness
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positive on left ilac fossa, no gaurding and rigidity. Auscultation normal. Pelvic Exam (with consent of
patient and presence of chaperone. On inspection… no visible discharge or bleed, Per speculum…
vagina and cervix healthy, cervical os closed, Bimanual….uterine size normal, no tenderness, Left
adnexal mass and tenderness positive. Office test…. Urine dipstick for uti and pregnancy negative.
I made a diagram of uterus, fallopian tubes, ovary and mass and then explained, it could be ovarian
cyst as my main diagnosis and then other above mentioned d/ds.
7- Acute abdomen- cholangitis Task: Hx, PE card, Dx/DDx (Pass)
Findings: Middle aged lady was lying on the bed.
RUQ pain, constant, 5/10, non-positional.
Feverish, Husband has noticed yellowish discoloration of eye.
Urine a bit darker.
H/O indigestion after fatty meal for some time.
No bloating, diarrhea, vomiting.
No chest pain, heartburn.
No risk factors for hepatitis.
No LOW, LOA.
No significant past medical surgical hx.
PE card: Fever, jaundice
Said most likely acute cholangitis and other DDx of RUQ pain.
Another Recall - patient presented with epigastric pain which started last night. Task… history
Physical examination on card. Diagnose and dd.
Approach to patient/relative…..4 History…….5 Diagnosis/ Differential diagnoses……4 Global score….
4.
d/d outside…. Acute pancreatitis, cholecystitis, cholelithiasis, cholangitis, peptic ulcer, acute gastritis.
History …SORTSARA. Positive findings. She gave me typical pain of pancreatitis…. Epigastric pain
peircing through chest and going to back. But when I asked about urine colour and stool colour, then
she said yes urine colour has been darker. Stool colour change she hasn’t noticed. I asked about
yellowness of skin, then she said yes my husband says my eyes looks yellowish. And then I took all
the relevant history.
Physical examination on card…. Right epigastric pain. Urine dark. Jaundice positive.
I explained my d/ds…. Made a diagram and explained cholecystitis, cholangitis and the ones
mentioned above.
8- Contraception counseling
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24-year-old lady came for contraception advice. Task: Hx, counselling (Pass)
Findings: No h/o migraine, epilepsy, stroke.
No h/o HTN, ACS.
No h/o active liver disease.
No h/o of breast, endometrial cancer.
No h/o DVT or thrombophilia.
No h/o PID, ectopic pregnancies.
Got pregnant last time while compliant on COC.
She doesn’t want any sort of pills.
She also doesn’t want IUD as one of her friends had PID while on IUD.
She was ready to go for Implanon so explained about it.
Another recall - 22 year old lady presented for contraception advice. Task history PE on card
Counseling
Approach to patient/relative …..5 History…..4 Patient Counselling/ Education…..5 Global score ….5
Outside thinking….okay she’s a 22 year old so I’ll ask all the contraindications of ocp and then I’ll
prescribe, and I’ll also ask what she has been using up till now.
There was a young lady sitting inside, I introduced and asked from the case notes I can see that you
are here for contraception advice, could you please tell me more about this. Patient:Yes doctor I
have a baby and now I want contraception. ME: Alright. What kind of contraception were you on
before having a baby. Dr I have been on microgynon 30 and then I fell pregnant. Okay. Did you by
any means missed any pills or have you taken it properly at right time?? Yes dr. All 5 p’s. Sadma
Support at home Then I said, okay before we discuss the contraception options, can you tell me for
how long you don't want to have another baby? She said 3 years. Is there any particular
contraception in your mind? No Alright… PE on card…. Everything normal. Then I discussed.
POP(mini pill) Implanon (thin rod for three years) Depo provera (injection every three month)
Mirena (intrauterine device for 5 years) I explained in lil bit details, and asked what do you think
you’d like for you? Dr I don't want to insert any device as my friend says it can cause cause some
infection in womb, I am intrested in implanon. Then I explained mechanism of action and some side
effects of implanon, reading material, review. Assessment Domain
9- DM counseling – Middle aged lady, came for routine checkup last week, UDS showed glycosuria so
doctor ordered FBS and HBA1c and results were 8.1 mmol and 6.9% respectively.
Task: explain the results, condition and its implications to the patient.
10- Heart murmur in pregnancy- RHD (mitral stenosis) Task: Hx, PEFE, Dx/DDx.
Pregnant lady on regular ANC. Up until last visit everything was normal. Today she came for routine
ANC visit. Gestational age wasn’t given in the stem.
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Findings:
During 2 minutes thinking, I thought it was a case of transverse lie but as I started history taking, role
player mentioned that on her last visit, doctor had noticed heart murmur. So, I immediately had to
reorganize my history.
LMP 10 weeks back. First pregnancy. No exaggerated symptom of pregnancy.
Taking folic acid, all ANC blood results normal. Received Gardasil. HPV/PAP uptodate.
When young had fever, joint pain, got antibiotics for some time but discontinued by herself and lost
follow up visits.
No fever, chest pain, funny racing of heart, sob, dizziness.
No weather preferences.
No h/o heavy period or blood loss of from other sites.
Not an anxious person.
No IV drugs.
Loud S2, low pitched rumbling diastolic murmur.
Another Recall (Pass) - A pregnant lady has presented to you, you have not seen this patient before,
all the test has been normal with previous gp. Task…. Take history PEFE…(only the findings will be
given to you for which you ask) Diagnosis and D/d
Approach to patient/relative…..4 History…..4 Choice & Technique of examination, organisation and
sequence…..5 Diagnosis/ Differential diagnoses…..5 Global score - 5
In this question, they have not given the age of gestation. So, I thought it could either be first
trimester complications like hyperemesis gravidarum, molar pregnancy, multiple pregnancy, anemia,
thalasemia. Or it could be third trimester problems, preterm labour, pre eclampsia, abruptio
placenta or prom.
So I went in, started history with open ended question and asked about her age of gestation first…..
she said ten weeks. So now the third trimester d/ds already ruled out.
Asked about confirmation of pregnancy…. Strip test at home. Further antenatal screening was also
done and was normal and then she said my previous gp has said I have some murmur in my heart.
Then I asked more about it, when it was diagnosed…she said it was diagnosed in childhood. Asked
about any fever during childhood, cant remember what she said. Then asked about her recent
pregnancy, early symptoms of pregnancy, any exaggerated symptoms, any tiredness and shortness
of breath of exertion like while walking (because of murmur/heart condition of Mitral stenosis)… she
responded negative. 5 P’s support family history PMH Physical exam…. General appearance… any
Pallor, Icterus, cyanosis, clubbing, Lymph node enlargement, edema?? Examiner… negative. Vitals
normal Focused cardiac examination Inspection…. Any previous scar …. No Any visible heave…. No
Palpation…. Apex beat… not displaced Palpable heave or thrill….negative
Auscultation…. Do I hear any added sound any murmur? Yes you hear a murmur. Position… 5th
intercostal space… Degree of murmur…. 3/6 Character of sound…. Rumbling Radiation…. Negative.
Raised Jvp… negative. Carotid bruit…. Negative
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I made a diagram, and explained mitral stenosis, Gave d/d as infective endocarditis, aortic stenosis,
innocent murmur and gave reasons why they are unlikely.
11- Post natal depression
It was a very long stem, more than half a page, Woman presented after the birth of a baby, you have
seen this patient one week ago and she has low mood and many other symptoms were given,
patient denied of any psych symptoms, now she has come back to see you after a week.
(so it was around 3 weeks after the birth of a baby) task…history for 4 minutes. diagnosis
management.
Approach to patient/relative……5 History…..4 Diagnosis/ Differential diagnoses…..4 Patient
Counselling/ Education……4 Global score 4.
Confidentiality, Very sad woman sitting inside, a good role player, looked quite sad and depressive. I
introduced and started history. Its her first baby. Firstly I asked about organic stuff, 4 B’s… bladder,
bowel, birth canal, breast. After that psych history. Low mood….positive Anhedonia….positive, she
said I don't find time to enjoy activities as I used to. Baby always cries and I feel like I am not a good
mother. Not enough support…husband always working. Have to do everything on her own. No
suicidal ideation. No ideas of harming baby. No delusions and hallucination, No previous history of
such symptoms. SADMA negative Baby doing well, she said, nurse says he’s fine and gaining weight. I
reassured her many times in between by saying, “you are an amazing mother, its not easy managing
everything on your own as you are a first time mother, but you are still doing great as your baby is
thriving well and though you don't have enough support still you are doing your best.’’
Diagnosis… Postnatal Depression…explained what it is, how common it is and its symptoms.
Management …. Psychiatrist referral for formal assessment and treatment, he might give you some
medications.
She asked… dr I am breastfeeding my baby so can I continue breastfeeding on medicines, I said no.
Psychologist review for counselling. Family meeting with husband to arrange support at home. Social
worker to help you as you also need some relaxation. And then I asked, how does that sound to you?
Are you okay with this plan? She said, yeah doctor if you think that is good for me then I am okay.
12- Sleep Problem (?Depression - Pass)
28-year-old man, sleeping problem, taking temazepam 10mg daily over a year.
Task: Hx, Explain the reason of sleeping problem. Mx.
Findings: Difficulty falling asleep and wakes up early in the morning.
No flashbacks/nightmares. No significant traumatic event.
Hasn’t increased the dose. Not sure about withdrawal symptoms because he has never skipped the
medicine.
Low mood. Anhedonia. Lack of energy. Unable to concentrate. Psychomotor retardation.
Not an anxious person. 2 cups of coffee daily.
No weather preferences. Rest of the psychosocial hx – negative.
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Counselled the sleep problem is due to depression. Mentioned addressing depression will solve the
sleep issue. Discussed about sleep hygiene. CBT, family meeting, psychiatrist if needed. Tapering of
temazepam over a period of time. I didn’t counsel this case with 5A approach of benzo dependence.
13- Pelvic exam with Pap smear collection - 27-year-old lady came for pap smear.
Task: perform pelvic exam and PAP smear on Mannequin with running commentary to the examiner.
Findings: Inspection of vulva and vagina: normal
On sterile speculum: vaginal walls and cervix looked normal.
Took sample using cervical broom and rotating it clockwise 5 times, stored the sample in the
container with liquid medium, labelled the container.
Examiner didn’t allow to proceed with bimanual examination.
14- Cervical Radiculopathy -NECK PAIN (CERVICAL SPONDYLOSIS/C6 RADICULOPATHY)
A lady in 50s, sitting on chair. Task: Hx, PE card, Dx/DDx.
Pain: first time, few days, constant, dull, radiating to left upper limb, not responding to Panadol.
Tingling and numbness of thumb and index finger.
No headache, blurring of vision.
No morning stiffness.
No fever, rash.
No difficulty combing hair.
No trauma.
No dysuria.
No tummy pain or diarrhea.
Computer analyst
PE Card: Neck: stiff, restricted ROM
Decrease elbow flexion and wrist extension; sensory loss outer forearm, thumb and index finger.
While I was explaining the diagram of possible cervical spondylosis and radiculopathy, role player
said I can’t see doc because I can’t bend forward, then I had to lift the paper up and explain her.
Another Recall - Woman presented with neck pain. Take history, PE on card Diagnose and DDx
Approach to patient/relative 5 History 4 Diagnosis/ Differential diagnoses 5 Global score. 5
d/d outside… already had an idea that it would be cervical radiculopathy/ spondylosis. d/d
osteoarthritis, trauma, pancoast tumor, spondylitis,
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I went in, introduced, patient was sitting very stiff and in pain. Painscale Pain killer… she said its fine.
Pain on left side of neck, started yesterday, going to arm, Did whole sortsara. When I asked about
weakness, she said yes of hand. Numbeness and tingling was also positive of few fingers of hand,
probably c8, t1.(not sure either was c6, c7 or c8, t1) Asked about early morning stiffnes. Skin
tightness. (one autoimmune condition) Everything else negative. PE on card All the positive findings
were present like weakness and numbness and tingling of respective dermatome.
Made a diagram of cervical spine and explained cervical radiculopathy and other d/ds.
15- Lisinopril induced chronic cough - CHRONIC COUGH (LISINOPRIL INDUCED/GERD)
Middle aged lady, c/o dry cough x 1 year. Task: Hx, PEFE, Dx/DDx
Findings: Cough: dry, constant.
No fever, runny nose, sore throat.
No chest pain, sob.
No facial/forehead pain.
No h/o recurrent chest infections.
No h/o allergy, asthma, COPD.
No swelling of limbs.
No h/o travel.
On lisinopril x 1 year for HTN. (role player took a paper out of the pocket and said the medication
name)
Has heartburn and water brass.
No loss of weight or appetite.
No lumps and bumps.
Nonsmoker.
Another recall - A 40 plus woman presented to you with complaints of cough for past one year. Take
history Diagnosis and d/d
Approach to patient/relative-5 History-4 Diagnosis/ Differential diagnoses…..4 Global Score …..4
Outside thinking…. I was happy that woman is older, must be a smoker and now copd. Well I
remembered all cough related d/ds in my mind and went in.
Started History. Dry cough for one year. No sputum. No shortness of breath. No fever. (for
pneumonia) No known allergies. No asthma or hay fever
No repeated chest infection. NON SMOKER….( and I was like what it is then) Was completely fine
one year back. No weight loss. No lumps and bumps. when I asked about any past medical history
and I also particularly asked has anything specific happened one year ago. She said yeah doctor I
have been diagnosed with high blood pressure. I asked, are you taking any medications for that??
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She opened a paper chit and said yeah I am taking Ramipril. Then I asked, when you started this
medication…. She said one year ago. Me … do you think these symptoms started after you started
taking this medication…. Dr I am not sure. Then I completed my history with all the relavant d/ds and
then
Explained about dry cough, that it is most probably a side effect of the medication which you are
taking. Then explained other d/ds like copd, pneumonia, bronchitis, asthma, emphysema and why
they are unlikely.
16- Chronic cough with 6kg weight loss and hemoptysis CXR given- opacity in left upper lobe:
Chest xray of a 50 plus woman was given outside… presented with complaint of cough with sputum.
Task… take history considering your differentials for 4 minutes (something like that ) Explain xray to
the patient. Explain your d/ds
Approach to patient/relative….4 History…..4 Interpretation of investigation…..4 Diagnosis/
Differential diagnoses……5 Global score - 5
outside thinking…. Lung cancer, copd, bronchioectasis, tb, sarcoidosis, pneumonia,
secondries/metastasis to lungs.
History Detailed cough history …. Cough for around a year… sputum which was firstly yellowish and
now having blood streaks. No fever. Weight loss of 10kg in 6 months. No history of asthma No
repeated chest infections. No copd history.
Recent travel to europe …. Took all vaccinations before going. No nocturnal dyspnea. No lumps
bumps. No numbness or tingling in arms(to rule out pancoast) Smoking….has been a chronic smoker
of 20 cigrettes or one pack for 20 to 25 years I guess and now have stopped. No other complaint. No
difficulty in breathing.
After that I explained xray in a typical way. This is an xray of your chest….explained while pointing
out ribs, collar bone, heart shadow, black air in lungs and then finally opacity. Can you see over this
side some white opacity which we are not seeing on the right side, this is not normally present, I am
concerned about this. Checked her understanding in between. Patient:Yeah doctor, I can see that,
what is this? Explained about any nasty growth called cancer as she has been splitting blood streaks
and has weight loss and all the dd’s mentioned above.
17th April 2019
1- BEHAVIOURAL CHANGE (DELIRIUM) (PASS)
Approach to patient/relative : 5 Diagnosis/ differential diagnoses : 4 Patient counselling/education: 5
Stem: Elderly lady without previous mental illness, admitted & treated for pneumonia & heart
failure. Day 2 of admission, she got confused & starting speaking in Greek. Long stem about vital
signs etc. Tasks: - Counsel the daughter about her condition - Explain about possible DDx causing this
condition - Explain behavioural & medical management
Thoughts during the 2 minutes: This sounds like delirium. Mnemonic PINCHME. Counsel with writing
& diagrams.
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Flow: Entered the room. Greeted the patient’s daughter. Asked her how she & her mother was.
Asked who was the primary caretaker at home. Talked to her about delirium (acute confusional
state), many causes: PINCHME. Pain, infection & ICB, constipation, hypoxia hydration, metabolic
problems, electrolytes & environment. Talked about how any of these could cause her current
status. She kept saying she’s worried, I kept giving her assurance (don’t worry, I’m your doctor, let
me do the worrying). Told her about behavioural management (calendar, clock, get her hearing aids
& glasses if any, minimise noise, will request same nurse to attend to her). She then suggested we
call her mother’s GP to come see her. I thanked her for the suggestion, saying it’s good, since her
mother usually sees the GP. Asked her if she could get her siblings to come see her. Medical
management (remember management includes investigations) I spoke about how it depends on the
investigations we will run. As I had time, I went through the PINCHME mnemonic and how we are
going to rule out each (for eg., imaging tests like a CT brain if evaluation reveals it to be necessary,
blood tests, urine test), since there is a fever we might consider antibiotics. She did ask if there’s
anything we can do (two times she asked this) now, since her mother is quite agitated, but I said it’ll
depend on the cause.
Afterthoughts: I forgot to mention giving safe dosage of sedation with monitoring
Another Feedback: PASS
Entered the room, greeted the patient and examiner. Doctor whats happening with mum? . I
understand this must be distressing for you but let me assure you she is being taken of by my seniors
and nurses ok? Ok doc so why is my mum suddenly so aggressive and shouting in Greek. Before we
continue let me introduce myself my name is Anish and I’ll be your doctor today. Before I ask you a
few question, is it ok if I can my examiner something? Sure doc. Hello examiner does (the daughter
name) have power of attorney for her mum. Examiner said- u can ask the daughter that yourself. Ok
thank you examiner. So (daughters name) are you the one making decisions for your mums
treatment. Yes doc. Ok great. So ill just explain to you whats happening with you mum ok- she is
having something we call as delirium. Have you heard of that? No doc what is it? Ok so what
delirium is acute confusional state which can affect some behavioral problems. There are many
causes for it such as (I started listing different causes) the daughter interrupted me saying doc but
whats my mums cause. I was like (shit whats her cause) blank, I said give me a moment please, ill try
to find it on her records to show u haha used this to read the stem again properly. There was an
awkward 15-20 secs of silence. I saw vitals temp borderline, SpO2 93 and BP and HR abnormal. I
went with that. In your mothers case what I’m suspected is hypoxia or infection. These are usually
the most common cause aswell. Explained about hypoxia and infection a bit. Then went into Ix: FBC,
ESR/CRP, LFT, TFT, urea and creatinine and electrolytes and BSL- we’ll do these just to confirm ok.
Now I understand this is very much distressing for you but let me assure you we are all here to help
you. Ive informed my seniors and specialist. She is being moved into a separate cubicle and will be
taken cared off by a nurse shes familiar with. Now I also want you to be with her. When people are
in delirious state its always better if people they know are with them. It calms them down to a
extend. But my mums shouting in Greek at me aswell. I understand it is very hard to care for a
delirious person but she needs your support now. Should I speak to her in Greek or English. Try to
speak to her in Greek, its always better when someone talks in our mother tongue. Makes us feel
more safer and connected especially when we are in a foreign country. Ok. Now I will be asking the
nurses to restrain her but let me reassure you this is for her own good and also for the safety of
yourself, staff and also mum aswell. Ok? Is that alright? We are doing the appropriate management
right now for ur mum but what Im concerned about is you. How are you handling all this? Im ok doc,
Im so stressed. I understand, I’ll tell you what, ill arrange a social worker to help you ok. Is that ok?
Im always here to help you, if you need any help, let me know ok I’ll be happy to oblige. Any kids at
home? Any financial strains? No doc but thanks for asking. Is that ok? Any questions about your
mum? No doc. bell rang.
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2- Throat and Ear exam - Swollen lymph nodes and sore throat
21 year old patient presented with sore throat and fever and he is having ear pain. Vitals given
outside. 1.Do relevant physical examination 2.Explain DDx to the patient.
AMC feedback-Acute fever-PASS Approach to patient/relative -4 Choice & Technique of
examination, organisation and sequence-4 Familiarity with test equipment-4 Accuracy of
Examination-4 Diagnosis/ Differential diagnoses-4 GS-4
Greetings WIPES Checked the peripheries for pulse, CRFT and rash,then proceed with the
examination from head. Checked lymphadenopathy. There was positive lymphnode enlargement.
When I asked patient to open the mouth examiner gave me a picture like this.
I explained the picture-bilaterally enlarged and reddened tonsils with a exudate.no uvula deviation.
Did ear examination on the mannikin. It was left ear. Tympanic membrane was reddened. I did not
do any hearing tests. I explained the dx to the patient as acute otitis media due to acute bacterial
tonsillitis. (using a diagram said that our middle ear and back of the throat is connected with a tube
and infection can spread from throat to the ear.) DDx-Bacterial, Viral (EBV)tonsillitis, pharyngitis,
Quinsy, irritant exposure, Reflux disease as possible causes for sore throat.
Another Feedback: ACUTE FEVER (PASS)
Approach to patient/ relative : 4 Choice & technique of examination, organisation, sequence : 4
Familiarity with test equipment : 5 Accuracy of examination : 4 Diagnosis/ differential diagnoses : 3
Stem: 20 y/o man presents with throat pain & fever x 48 hours, with ear pain.
Tasks: - Perform relevant examination - Explain DDx
2 minutes while reading: thought of throat exam, lymphadenopathy, chest, ears.
Flow: WIPER. Did it in a polite manner. As I asked him to open his mouth, the examiner showed a
picture of exudative enlarged erythematous tonsils. When I went on to his ears, I talked about
inspection (any scars, discharge, deformity), checked for tenderness by pressing the tragus & lightly
pulling the pinna). Then put my otoscopy into the mannequin. Explained my findings (no foreign
body, no bleeding or discharge, no ear wax, tympanic membrane intact with cone of light, not
retracted, slightly bulging with redness. I changed the otoscopy tip to examiner the ‘imaginary’ other
side, examiner then said the other side was exactly the same. I explained about peritonsillar abscess
with bilateral acute otitis media. DDx acute tonsillopharyngitis, acute tonsillitis, acute pharyngitis,
said could be a tumour (as tumours often DDx infections)
Afterthoughts: maybe I should’ve mentioned Ludwig’s angina? The diagnosis was so obvious I could
only talk about the provisional. Bad. Guys, always try to come out with differentials before entering
the room.
Another Feedback: PASS
Young male with fever, difficulty swallowing for 2 days, tired/unwell for 2 week.
Relevant PE, Examine Ear on dummy and Dx
2 min: ok so ENT examination- remember to check resp chest aswell
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Bell rang: WIPE, Checked the face- commented on eyes- runny/red/congested, came to nose- no
discharge/bleeding/nasal septal defect. Mouth- open the mouth please, examiner is there a tough
depressor- on the desk. Ok ill use the depressor to look inside the mouth (after I said the examiner
gave me a pic) enlarged tonsils with pus point, commented how uvula looks a little out of place but
myt be due to enlarged tonsils and also commented on congestion. Then said not parotids swlling
and cant appreciate any swelling over the neck. Ear examination- did otoscopy- ear drum red bulging
and congested, no discharge or bleeding or wax or rash. Checked the lymphnodes- tender cervical
Lns and also listened to chest. Then explained to the patient:
A/c bacterial tonsillitis with otitis media (drew image of mouth, Eustachian tube and ear) said
infection of the mouth- you tonsils are immune gland will help fight the infections but in ur case it
itself is infected hence enlarged and oozing pus. This infection travelled through your tube
connected mouth and ear hence cause infection of ur ear drum. DD: viral and quinsy and EBV- I
explained by its not these. Bell rang
3- Respiratory exam - Middle age man presented with cough and SOB for 6 months duration. 1.Do
relevant examination 2.DDx (Fail)
Greetings. WIPES. Start from hands. There was clubbing. Checked HPOA, dorsal guttering. Face- Did
respiratory examination from front. There was basal crepitation more in right side. DDx-COPD,
Bronchiectasis, atypical pneumonia.
Another Feedback: Pass
Approach to patient/ relative : 5 Choice & technique of examination, organisation, sequence : 4
Accuracy of examination : 5 Diagnosis/ differential diagnoses : 1
Entered the room, friendly gentleman in hospital gown, lying supine 45 degrees propped up. Hi sir,
I’m xxx, your doctor today. May I please know how you’d like me to address you? Hi Mark, I was
given the task to examine you today. What this entails- looking at, feeling with my hands, and
listening to your chest wall with this stethoscope. If it’s okay with you, I’d like to report my findings
to my examiner as I examine you. Is there anything you’d like to ask? Any pain anywhere? Great, I’ll
go wash my hands (I put alcohol rub on my stet as well, and mentioned), please make yourself
comfortable. (Almost forgot to ask him to sit on the chair for smoother examination.)
Did from peripheral. Examined for finger clubbing, Scamroth’s sign (the examiner asked me what I
was doing, & if clubbing was present or not), the usual, not to forget the eyes for Horner’s
syndrome, cervical lymphadenopathy, trachea. Went on to the usual respiratory examination (IPPA:
inspection palpation percussion auscultation), I did posterior first then anterior. found no significant
abnormalities. I reported in detail: vesicular breath sounds, equal air entry at all zones, no rhonchi or
crepitations heard. The examiner then asked me to tell my DDx to the patient, I panicked & said
heart failure, maybe pneumonia, the ball rang, I said pleural effusion as I got out.
Afterthoughts: I missed COPD, asthma. Or atypical pneumonia. Or occupational/ restrictive lung
disease. But I’m glad to see my other domains got me a pass despite a score of 1/7 in DDx.
Another Feedback: PASS
I didn’t complete this station. Could only say one DDx. Real patient
WIPE, General appearance- no dyspnea and cyanosis or no respiratory distress (signs of COPD),
accessory muscle use, intercostal or subcostal recession. Hands- no Nicotine staining, Cyanosis,
clubbing +. Arm- pulse and Blood pressure- asked the examiner- normal. Face- eyes (pallor, horner
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signs (ptosis, miosis and anhidrosis)), Mouth (no central cyanosis, red/ enlarged tonsils) no signs of
allergic rhinitis (nasal crease). Neck- JVP- normal. Trachea position- normal. Lymphnode- normal
Chest-Inspection. chest shape, deformity- +. No scars and normal chest wall movement. Palpationchest expansion normal. Percussion (fold the arm and elevate the elbow)
-dullness- in doubt ( cause I got dullness in ant chest). Auscultation- breathing sounds decreased on
left lower lobe. vocal resonance- decreased on left lower lobe.
Ideally I would like to complete my examination by doing anterior chest (examiner told me to do itthat’s were my calculations went wrong haha)- found dullness in lower lobe left side.
Ideally id like to do CVS examination. DD- all I said was could be carcinoma… bell rang
4- Pelvic exam – 60 year old lady presented with heavy dragging like sensation and passage of small
amount of urine with coughing and sneezing. Task - Do relevant physical examination. Explain
Dx/DDx to the patient.
AMC feedback-Urinary difficulty-PASS Approach to patient/relative-6 Choice & Technique of
examination, organisation and sequence-6 Accuracy of Examination-7 Diagnosis/ Differential
diagnoses-6 GS-6
Greetings Introduction. Pleasant smiling lady and an Asian examiner was there. W-GLOVES IPES I
explained the procedure to take the consent. I am going to examine your private area to find out the
cause. This will include -I will look at your private area and I will insert my two gloved fingers to
check the neck of womb, and I will insert a special instrument to see the neck of the womb. I will use
gel to reduce the discomfort and I will only do the examination with your consent and there will be a
chaperon. But anytime if you feel uncomfortable feel free to stop me. I specifically ask whether
there is any lump coming out from private area. if so I have to do the examination in sims position
with sims speculum. She said no. I said during examination you have to bend the knee and have to
keep the legs apart. Also mentioned about the exposure. Did the examination on mannikin. On
inspection-I am looking for the appearance of the labia majora, minora, any bleeding, discharge or
rash. any visible lump at vulva.
Separate the labia and asked patient to cough and checked for demonstrable stress incontinence.
Examiner said positive.it was hard to separate the labia in the manikin. I inserted the speculum after
applying gel on it. Asked the patient to take a breath while inserting. Throughout the procedure I
was reassuring her. I told I will be gentle but anytime if you feel pain please let me know. Then
commented on the cervix and os. Slowly removed the speculum. Examiner said no need to do VE. I
explained the condition -most likely you are having a condition called stress incontinence. I drew a
diagram. Expalined possible causes like menopause and lack of oestrogen, birth trauma,
constipation, chronic cough.Explained other possible causes like UTI and vaginal dx.
Another Feedback – (PASS)
Entered the room, greeted the patient and examiner. “Hello my name is Anish and I’ll be your doctor
today. I understand you are having some urinary problems, is that correct”. Yes doc I am stressed
and worried. Idk what to do? Ok I understand this must be distressing for you but it is ok for me to
ask a few questions? Sure doc.
Asked questions to differentiate b/w stress and urge incontinence and prolapse.
Ok thank you for that, now Id like to do a pelvic examination on you is that ok? Sure doc. Alrighty,
Jane/Mary (I think) I’ll first explain to you what I’ll be doing ok. Now before that let me reassure you
, we do have our examiner acting as my chaperon. Is that ok examiner? Sure. Ok so what I’ll be doing
in this examination is first I’ll have a look at your vulval and vaginal area ok to see if theres any
abnormalities there. Is that alright? Sure doc. Next (I picked up the speculum), see this- this is an
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instrument called speculum. What I’ll do is insert this speculum in your vagina to have a look inside
your vaginal canal to look for any abnormalities. Let me assure you this is not painful but it may
cause you some discomfort. Is that ok? Ok doc. After that I’ll be inserting two of my fingers (showed
the finger) into your vagina to feel for any abnormalities. Again I’ll be as gentle as possible ok. Ok
doc. Alright, now wat I want you to do is go behind the curtain and remove your pants including your
undergarments. There is a sheet on bed, please cover yourself and call me when you are ready. Ill
just wash my hands and put on gloves. Alright could you please expose the area.
Position: ok now let me reassure you examiner is here as the chaperon and if you are uncomfortable
at any point please let me know, I’ll stop right there and we can pick it up from there. How does that
sound? Sure doc. Could you please bend your knees, keep both heels together and let your knees
drop to both sides (a frog shaped position). Ok now ill have a look, if you are uncomfortable please
let me know ok? Ok thank you doc.
Im looking over the vulval and vaginal area-not rash, discharge or bleeding, I can visualize some
urine drops around the vagina. Now looking over the pubic region- looking for abnormal hair growth,
swelling, skin changes and rash- none present.
How are you mary? Are you doing ok? Good thank u doc. Ok well now I’ll be inserting this speculum.
Let me reassure you again it wont be painful but it may cause you some discomfort. Ok? Sure doc.
Examiner is here as a chaperon and if u are uncomfortable at any point let me know ok? Sure doc.
I was going to insert the speculum (examiner said- put some gel on the speculum)- Im so sorry
examiner, thank you for reminding me. I applied some gel and as I was going to put it in I kept
speaking and reassuring the patient. Mary take deep breaths for me, Its going in ok, deep breaths,
deep breaths, how are you, may I continue? Im good doc. Ill just fix the speculum and great its in
position. You are doing great mary. Ill just have a look inside ok? Sure doc. Cervix healthy, no bulging
over ant and post walls of vagina, vaginal walls healthy. Strain down for me please. Examiner said
leakage of urine +. Thank you examiner. Thank you mary, u are doing great. We are done ok, Ill just
remove the speculum. Deep breaths for me as I remove it. There we go its out. Mary thank you for
being so cooperative and u did great. Ill just put the speculum away. Now like I said before I’ll be
inserting my fingers to have a feel for any abnormalities inside. Ok? Examiner said skip.
DDs; From your Hx and examination what I believe you are experiencing is something we call stress
incontinence. Explained with images and then said urge incontinence and prolapse and sti as DDs
5- Lower limb neuro exam - Middle aged man presented with pin and needle sensation in lower
limb. He is a strawberry pluckier. 1.Do relevant physical examination. 2.Dx/DDx
During the 2 minutes I thought this may be common peroneal nerve injury because usually
strawberry pluckier will get it with repeated squatting
AMC feedback-Walking difficulty-PASS Approach to patient/relative-4 Choice & Technique of
examination, organisation and sequence-5 Accuracy of Examination-4 Diagnosis/ Differential
diagnoses-3 GS-5
Greetings. WIPES Started with the gait. There was high stepping gait. Asked the patient to come back
to the couch. Patient lie down so did not asked sit on the couch again. But sitting position is better.
Deformity will be clearly visible and easy to elicit inability of dorsiflexion and eversion. Did lower
limb examination, but examiner said to skip vibration and reflexes. Sensation according to the
nerves Anterior tibial-1st web space, Peroneal-dorsum patch, post tibial-sole. Explained the
condition to the patient with a diagram. There are two bones in the leg. Outside bone is
fibula.common peroneal nerve runs superficially around the neck of this bone.so can be easily
damaged. DDx-Sciatica, neuropathy ,trauma, spondylosis.
Another Feedback: WALKING DIFFICULTY (PASS)
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Approach to patient/ relative : 5 Choice & technique of examination, organisation, sequence : 5
Accuracy of examination : 4 Diagnosis/ differential diagnoses : 2
Stem: Adult man with history of prolonged squatting at work cutting flowers. Tasks: - Perform lower
limb exam - Explain DDx
Flow: Greeted, washed hands, consent etc. Started with gait, had high steppage gait (I think the
roleplayer did the wrong side because after that he switched sides during supine examination?).
Then did the usual look feel move. Did hip flexion extension abduction adduction quickly, knee
flexion extension, then ankle. Had weak dorsiflexion. Sensory loss (cotton & toothpick) at the
dorsum of the foot as well. Reflexes normal. Palpated one side @ neck of fibula but forgot to do the
other side. Told patient it’s likely a common peroneal nerve injury because of the features. Said
could be any pathology (bony growth, bone fracture, other growths) along the nerve running down
from hip to toes, likely fracture of neck of fibula.
Another Feedback – PASS
You are a GP and your next patient is male (forgot name) presents to your clinic with c/o pins and
needles on his right foot for past 1 day. He is a strawberry picker by profession. He doesn’t have any
significant past medical history.
• Perform physical examination
• Tell the pt about your most likely Dx and DDx
Two Min: footdrop pe, sensations only Nerve wise
Entered the room, greeted the patient and examiner. “Hello my name is Anish and I’ll be your doctor
today. I understand you are having some problems with the foot, is that correct? yes doc. Ok well I’ll
be doing an examination over your foot to find out the main cause. It will inolve me looking,
touching and doing some tests over your foot. Is that ok? Sure doc. Great could you please expose
the area while I wash my hands.
Mr Jones seems to be likely comfortably, doesn’t appear to have any obvious pain or distress and no
Protective posture
Check the gait- Are you able to bare your weight?yes doc. Would you be able to take a few steps for
me? High stepping gait. Romberg’s sign – to differentiate between sensory ataxia and peripheral
neuropathy. Look (Please lie down on the bed). SWIFT à Swelling, Wasting of muscles, Involuntary
movements, fasciculations and Tremors.I cannot appreciate any stigmata of peripheral vascular
disease.Ulcers, Skin color changes, Loss of hairs, Shiny skin. Feel- Temperature on both feet normal.
Tenderness- Checked the forefoot, midfoot and hindfoot of both sides- no tenderness. Circulation Checked the Capillary refill time of both feet and Checked the pulse- dorsalis pedis and posterior –
tibial. All normal
• Sensation – got the findingings for deep and common peroneal nerve.
• TIP à tibial nerve – Inversion and Plantar flexion
• Sensation of tibial nerve is checked on the sole of the foot
• Superficial peroneal nerve – eversion
• Lateral and dorsal aspect of foot
• Deep peroneal nerve – dorsal flexion
• Sensation over the first web space between toe and 2nd toe
Movements Of the Ankle- all normal ( which confused me a little)
• Point them up – dorsiflexion
• Point them down – Plantar flexion
• Move your feet away – eversion
• Bring them together – Inversion
I forgot the special tests
Said what I got to the examiner.
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I explained it was Common peroneal nerve injury. After examining you, what you might have is most
likely common peroneal nerve palsy aka strawberry picker palsy. There is a main nerve at the back of
buttocks to the back of the thigh and at the level of the knee it divides into 2 branches- common
peroneal and tibial. I think in your case it is the common peroneal nerve that is compressed at the
level of the knee. Because you are a strawberry picker, you squat to pick the strawberries which can
cause compression of the nerve at the level of the knee. Initially it would pose no problems but since
you do this constantly, repeated irritation of the nerve may cause damage ( I wasted too long
explaining what foot drop is with pictures and drawing etc). Other possibilities are . bell rang ( I was
very upset cause this was a case I should’ve known like back of my hand) but yea idk where the time
went but still passed it.
6- Child with prolonged coughing - 4 or 5-year-old child with chronic cough. Facial congestion with
the cough and has a positive contact hx. 1.Tell your diagnosis to the mother 2.Implication of the
condition 3.Management.
AMC feedback-Cough-PASS Approach to patient/relative -3 Diagnosis/ Differential diagnoses-4
Patient Counselling/ Education-3 Management plan-5 GS-4
Greetings. Introduction. Outside it was a long stem which suggestive of whooping cough. So after
building a rapport I explained the diagnosis to the mother. Explained the nature of the condition and
course of the disease and possible complications like subconjunctival h’ge and brain h’ge. but
reassured. Mx Start on antibiotics, Treat the contact, vaccination younger siblings, notification, stay
away from child care.
Another Feedback: COUGH (PASS)
Approach to patient/ relative: 4 Diagnosis/ differential diagnoses: 4 Patient counselling/education: 4
Management: 3
5 y/o child with prolonged coughing. Mother is concerned, last week discharged after review,
initially came because of coryzal symptoms. Now coughs with facial congestion. Has ? inspiratory
noise. Dad had been coughing for 1-2 weeks too.
Tasks: - Counsel condition to the mother - Explain management to the mother
Flow: Greeted the patient’s mother. Asked about the cough (LORD SANFARO). Asked BINDS esp.
vaccinations. Asked about ill contact, if child still fed well, was still active. Any other concerns. Talked
about likelihood of this being pertussis. Talked about how it’s called the 100 day cough, its clinical
course (coryzal phase, paroxysmal phase, convalescent phase), the bacteria involved, how it’s
curable with antibiotics, management depends on severity & hydrational status, ability to feed etc.
Mother queried for a bit regarding my diagnosis, since her child was vaccinated according to the
schedule. I told her vaccinations reduce the risk of getting a disease, & the severity if the child gets ill
with a particular disease. So in her case I said good that the vaccination is likely to reduce the
severity. (Another candidate posted their recall as psychogenic cough, I don’t know how it went..)
Management I talked about lifestyle modifications & pharmacological agents. Needed to notify, take
time off school (child wasn’t schooling yet so I diverted, talked about how they should avoid other
immunocompromised children or pregnant women). Talked about antibiotics, said I’d check with
seniors & the national ABx guideline, but azithromycin being the likely agent involved. Might need
to prophylactically treat other family members as well.
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Counselling of any condition: 7C’s Condition Commonality Classification Cause Course Complications
Cure
Another Feedback: COUGH (PASS)
Entered the room, greeted the patient and examiner. “Hello my name is Anish and I’ll be your doctor
today. I understand you came for an appointment last week is that correct? Yes doc. So tell me, how
is he? Is he improving at all? No doc its getting worse, hes always tired, Asked a few cough questions
to confirm pertussis and asked who all are in family? Father, herself, the child and a little brother.
Little bro is 6 weeks old.
DD:
From history and examination your child most likely have a condition called pertussis have you heard
about it? (Drew a pic of lung) it is an infection of the lung. It is contagious, spread by tiny droplet of
fluid when coughing or sneezing, usually presents with coughing followed by whooping and
vomiting. other possibilities are pneumonia; lung infection by another bugs, Bronchiolitis; viral
infection causing inflammation of small airways that delivered air to the lung or upper respiratory
tract viral infections, but unlikely from history and examination.
What I would like to do now is do some investigations? Is that alright? Yes doc. FBC,
nasopharyangeal swab and the main ones I want to focus on. Once we get the results we can
confirm it, alright. Now for treatment, make sure the child drinks a lot of water, I will prescribe an
antibiotic. notifiable disease so I need to notify to department of health services. Now this is not a
life threatening condition for you husband or son but I do want to stress that it is quite dangerous
for your little guy. Whats his name sorry? (I forgot) alright so now I want to focus on making sure
(the little guys name) doesn’t get this disease ok. So hygiene is very important. Him the little guy
away from his brother and father till their coughs are controlled. Make sure the patients personal
items are isolated for the baby doesn’t play with them. His immunizations?? Not sure doc. Well
anything u havnt understood. Im always here if you need me to clear any doubts. bell rang.
Forgot about prophylaxis and red flags
7- Intermittent abdominal pain – 47 years old man presented with intermittent abdominal pain x
6weeks. History, PEFE, Dx/DDx
Approach to patient/ relative : 4 History
: 5 Diagnosis/ differential diagnoses : 4
Flow: Patient’s abdominal pain was mainly suprapubic. He also had unintentional loss of weight, PR
bleed @ toilet paper. I told colon cancer as my provisional diagnosis. Then ran my mind through DDx
suprapubic pain: UTI, bladder mass, other colon problems, almost forgot to mention but thankful
that I mentioned IBD as well.
Should’ve mentioned also all common causes of PR bleed: haemorrhoids, fissures, diverticulitis.
8- Nervousness - 52 years old lady presented with nervousness. 1. Hx 2. Provisional dx/DDx.
AMC feedback-Anxiety-Pass Approach to patient/relative -4 History- 5 Diagnosis/ Differential
diagnoses-5 GS-5
Patient was flushed and was sitting on the edge. She was very nervous. Greeted her and introduced
myself. History Duration-couple of months -no proceeding events prior to onset Onset-gradual and
worsening Nothing makes it better or worse DDx • Menopause-LMP 2weeks back •
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Hyperthyroidism-No weather preference, weight loss+, loose stools+ • Hypoglycaemia-No hx of DM
• GAD
I could not find any positive finding. • Panic attack • Arrhythmias
No
positive finding. • Pheochromocytoma Family hx and SADMA-normal. Ask psychosocial hx with
confidentiality-negative I explained all the above DDx in simple term. She asked me what is the
cause for this? I said may be hyperthyroidism as I could not find any other positive thing. But AMC
gave the feedback as Anxiety.
Another Feedback- ANXIETY (PASS)
Approach to patient/ relative : 4 History
: 4 Diagnosis/ differential diagnoses : 4
Flow: Lady had anxiety, irritability, night hot flushes, loose stools. Explored SSx of menopause,
hyperthyroidism, & GAD. Told her these 3 DDx with menopause as my provisional Dx because of her
age & features.
9- Nurse upset after patient died – Nurse was brought by her partner as she was attempting to
suicide. A Child, who was in under her care died with meningococcaemia. She was cleared from the
fraud. History, Dx, DDx to examiner, Tell the risk assessment to examiner. - Depression with suicide
attempt
10- Painful lump down below – 27 years old girl presented with a painful lump H/o PEFE Dx/DDx
AMC feedback-Painful lump-PASS Approach to patient/relative-5 History-4 Choice & Technique of
examination, organisation and sequence-5 Diagnosis/ Differential diagnoses-5 GS-5
Greetings. Introduction She was in pain and offered pain killers. Site -private area. Duration -couple
of days, recently increased in size. No hx of trauma. Asked detailed sexual hx.5Ps. PEFE Examiner
gave a picture like bartholin cyst.
DDx-Bartholin cyst, Abscess, sebaceous cyst, haematoma, Trauma, tumour,lipoma
Another Feedback: Pass
Approach to patient/ relative : 5 History
: 5 Choice & technique of examination, organisation,
sequence : 5 Diagnosis/ differential diagnoses : 4
Thoughts during the 2 minutes: What? Where is the lump? Guess I’ll have to make do & be accurate
in my asking once I enter.
Flow: Friendly Asian lady. Asked where the lump was. Said down below. Asked if it was the first time,
any fever, discharge. Any sexual activity, STI symptoms. Any relation to menses. Increasing in size,
pain, affects urination/ bowel motions, UTI SSx, any bite previously, same problem in partner.
Contraception, alcohol usage, etc.
PEFE: erythematous lump outside the border of the vulvovaginal area. Way below, which is why I
didn’t put Bartholin cyst as my provisional. Examiner asked if I wanted to ask other things, to which I
said vital signs, & signs around the mass. Fluctuant: yes. So my thoughts went towards an abscess.
I said DDx: perineal abscess (I was then worried if they heard me wrong: perianal), infected Bartholin
cyst, other unlikely causes: infected lipoma, sebaceous cyst.
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11- Headache –Young lady presented with headache for few months. 1.Hx 2.PEFE 3.Dx/DDx
AMC feedback-Headache-PASS Approach to patient/relative-3 History-4 Diagnosis/ Differential
diagnoses-5 GS-4
Greetings Introduction Pain question-SOCRATES-Typical migraine headache with photophobia. And
aggravated with certain food. DDx question Family hx of migraine/tumour, SADMA DDx-Trauma,
Tumour, Cluster, tension, Glaucoma, drugs, referred pain from mouth, ear, neck,
Another Feedback: HEADACHE (PASS)
Approach to patient/ relative : 5 History
: 4 Diagnosis/ differential diagnoses : 6
Stem: Adult man presents with ? chronic headache. Tasks: - Take history - Explain DDx
Thoughts during the 2 minutes: ready to explore all primary and secondary headaches.
Primary: cluster headache, tension headache, migraine headache. Secondary: high ICP (tumour,
abscess), cervicogenic headache, URTI, glaucoma, acute otitis media
Flow: Took LORD SANFARO history on the headache. Location/ Onset/ Radiation/ Duration/
Severity/ Associated symptoms/ Nature/ Frequency/ Aggravating factor/ Relieving factor/ Offset.
Found out the features fit those of migraine, but ruled out all red flags as well- awakening from pain,
blurring of vision, nausea vomiting, pain worse in the morning, FHx brain tumour. Straight forward
case, explained my provisional because of the features the patient told me; explained possibility of
all other headaches: I mentioned everything, saying headache could be from any of these.
Another Feedback: HEADACHE (PASS)
Lady coming with headache. Hx and DDx à guys I got a 7 in approach here
2 mins- thought of DDs
Entered the room, greeted the patient and examiner. “Hello my name is Anish and I’ll be your doctor
today. I understand you have a headache, is that correct? Yes doc. Tell me more about this please.
Painkillers? SIQORAA. Headache DD questions- Respiratory infection, Tension headache (stress at
work), Migraine (all positive)n/v, Photo or phonophobiaà Do bright eyes/loud noises hurt your
eyes and ears? Aura- sparkling lights before you get a headache? , SAH and intracranial
haemorrhage à (initially occipital pain then generalized? trauma, vomiting)? No. TIA, Stroke à any
weakness? Loss of consciousness? Slurring of speech? No. Temporal arthritis- Screening Qsà Do
you have tender cord like structure on side of the head? Blurring of vision? Pain worse on chewing &
combing? No. Neoplasia- Loss of weight? Loss of Appetite? Lumps and bumps? Cluster Headache
(watery eyes and runny nose).Trauma (any h/o hits/injury to head). Meningitis à fever? Sore neck?.
Sinusitis à facial pain?. Otitis media à ear pain or discharge? All no
In the end I explained migraine as Dx- drew a head, with vessels and said certain stimulants cause
the vessels to dilate (meaning increase in size) causing you to have headaches. Then said DDs and
explained why its not them. I then spoke to patient asking how are you, are you happy with the Mx,
anything u didn’t understand and Im always here if you need any help, hows everyone at home, all
ok etc etc till my bell rang.
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12- Hypertension compliance issue – 37 years old patient diagnosed with hypertension and was on
treatment. Recently came for flu shot and found to have high blood pressure. 1.HX 2.Counsel the
patient.
AMC feedback-Medication management.-PASS Approach to patient/relative-4 History-4 Patient
Counselling/ Education-4 GS-4
Greetings Introduction. Asked about diagnosis of htn Non-compliance factors-doctor factor, drug
factors and patient factors-he has moved to Melbourne recently so busy with new job and other
stuff so forgot to buy the drugs. Complications of htn-nil SADMA Counselling. Explained what is
hypertension using a diagram of heart. Complications which may be not obvious now but can
happen if it is not controlled for a long duration. Life style modification. reading materials. review.
Another Feedback: MEDICATION MANAGEMENT (PASS)
Approach to patient/ relative : 5 History
: 4 Patient counselling/ education : 5
Stem: 37 y/o man with essential hypertension, issue with compliance. Came for influenza
vaccination, nurse told him to get a review because of high blood pressure.
Tasks: - Take targeted history pertaining to the issue - Counsel accordingly
Thoughts during the 2 minutes: to find out why he wasn’t compliant- forgetful/ cost/ side effects/
feel fine so he thought he was okay
Flow: Cooperative lad. Greeted, asked if he felt ok now, who diagnosed him with essential
hypertension. Tried to probe around possibility of 2ndary HTN but he said his GP ran tests. Had
family history of hypertension. I told about the dangers of hypertension. Said he was surprised to
hear me call hypertension a silent killer. I reassured him, explained what I meant- usually people feel
fine, until a complication happens- stroke, heart attack. Found out it was because he moved 5-6
months ago, didn’t get any referral letter, so he forgot about it. Felt fine. Management I talked about
the importance of BP control via lifestyle factors & pharmacological management (he said he
stopped smoking recently, blah blah. Appreciated him for that. Talked about the risk factors as a
whole, not just BP. Said I’ll get his info from his GP if it was okay with him. Will run ECG & blood tests
again since the last one he had was 6 months ago.
Alcoholism/ BP BMI Boy or girl (gender)/ Cholesterol/ Diet & DM/ ECG & Exercise/ FHx/ Smoking
&Stress
Afterthoughts: Forgot to mention hypertensive urgency.
Another Feedback: MEDICATION MANAGEMENT (PASS)
2 mins: non compliance causes- drug related, doctor related and patient belief
Hey mate, my name is Anish and I’ll be your doctor today. How may I help you today? Well I don’t
know doc, the nurse said I have high HTN. Oh no well I’ll ask a few questions o we can get to the
bottom of this. Is that ok? Sure doc. Just before that I just want to let you know, what we talk about
here will be confidential unless harmful to you or anyone else. Ok? Sure doc.so I understand you
were diagnosed with essential hypertension, is that correct? Yes doc. Could you tell me more about
this please.
He gave me a story about diagnosis by a doc at his hometown. I asked are you taking meds? He said
no. Is there a reason why? Oh no reason doc, I recently moved to Melbourne 6 months back. I had a
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stash of meds then but ran out 4 or 5 mths back. And since I was healthy, I thought itd be alright,
plus I was really busy with the move and work.
Ok I understand it can be busy with the new move, tell me how is Melbourne treating ya? Its good
doc, I like it. I asked about home and work and stress. I ruled out drug related, doctor related and
patient belief causes aswell. Ruled out financial strains aswell. None present. SADMA, family Hx, past
mx and Sx.
Well just before I go into what I want to do, I just want to confirm if your previous doc explained
about essential HTN.He said sth which I forgot, can you explain to be doc. (drew a pic of heart)
explained how essential HTN is high BP without any known cause. Explained what we call HTNincreased pressure on the vessel walls etc etc- picture helped. Now I know you are healthy now
which is great news but I do want to stress on the fact of controlling HTN. Very imp cause otherwise
it can lead to complications in the future. Such as heart failure, stroke etc. are you with me? Yea doc,
I didn’t think it was that serious. (he looked worried) Hey (called his name), im sorry if I scared you
but let me reassure you these are incidents far in future if we don’t control your BP. This is very
much controllable so ill restart you on some anti HTN and refer you to cardio so we can be on the
safe side. I understand you are busy with life but try to make some time for your health kk, SNAP etc.
13- Chest pain (Pilot). History, ECG, Invx from examiner, Dx, DDx.
Middle age (around 50) man presented with squeezing type chest pain for like 2 hours duration. He
was having similar episodes on and off for 6 months duration. 1.Hx 2.PEFE 3.Explain investigation to
the examiner 4.Explain dx to the patient Before entering the room, I thought it was a case
myocardial infarction and surely there will be ECG of MI to interpret. But I was wrong. Greeting.
Introduction. Chest pain question -According to SOCRATES Site-Epigastric ,gradual onset and
worsening, no associated factors. There was no features suggestive of MI. Asked all the DDx
question. PEFE-Normal. Asked for ECG from the examiner. It was completely normal. I was bit
hesitate to say the diagnosis at once. Explained all the DDx for chest pain in simple terms. I said most
likely you have condition called GORD and explained it. Then patient said pain aggravate with spicy
food. DDx-MI, Angina, Acute pancreatitis, Trauma, Costochondritis, aortic dissection.
14- Snake bite (Pilot) – Young man presented to the emergency department after a snake bite. First
aid done.crepe badage has applied. 1.Take a short hx of 3min 2.PEFE 3.Interprit the investigations
Greetings Introduction What was doing at that time? Did you see the snake? Any symptom of
systemic envenomation? Double vision any limb weakness, breathing difficulty, bleeding
manifestation, UOP? all normal. Only pain and swelling at leg. Examiner explained the physical
examination findings-he said only swelling and mild redness over the bite site, other examination
normal. Examiner was really supportive person. Interpret investigation There was increased INR and
APTT and high WBC other investigations normal. I said the snake venom has effected blood clotting
mechanism that is the cause for high INR and APTT were increased.CK level and RFT -normal
Another Feedback: Young man got bitten by a snake. First aid applied by father, brought to the ED.
Tasks: - Take history - PEFE - Interpret investigations to patient - Explain diagnosis
Asked if he saw the snake (to rule out other creatures), if he saw the colour & shape of the head. Bit
once or other sites as well? What happened in detail: where he was, bitten where, any bleeding, any
fall, trauma to head. Asked about complications in symptoms of envenomation: double vision,
weakness, bleeding from cannula sites.
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Patient had a tourniquet (used a belt) and a splint on, to which I commented what is this? They
mentioned tourniquet, I said I don’t think this should be here (but management was not part of the
tasks, so I just mentioned). His right antecubital fossa had a gauze, I asked why, and the examiner
said the cannula site started bleeding (yay I asked that in the history).
I was given the investigation results. Explained high INR & PT (means blood is thin, easy to bleed
hard to clot) probably due to snake venom effect on blood, low Hb (low red cell content that carries
oxygen to body parts) from bleeding. Other parameters were normal but I explained 1 by 1: white
cell normal means right now not suggestive of infection (yet), platelets normal (this helps blood
clot). I forgot what else they showed. Explained the need of sending more investigations: ECG, CK.
The bell rang and I realised I didn’t say the diagnosis, so as I left I said envenomation. The examiner
said well done as I left (I think it’s because I explained envenomation as I interpreted the
investigation results to the roleplayer), so it already was fine.
15- Secondary PPH -32 year old female patient, post-partum day 10.It was a normal vaginal delivery.
Presented with PV bleeding and fever. 1.Take Hx 2.PEFE 3.Dx/DDx 4.Mx
PASS Approach to patient/relative -5 History-5 Diagnosis/ Differential diagnoses-4 Management
plan-4 Gs-5
Greetings Introduction Asked whether vitals are stable. Bleeding question-duration, no of
pads,colour, Asked all the post-partum question. (BUBBLESHE) Breast-Breast feeding, breast pain
Utreus-lower tummy pain, delivery-placenta delivered completely Bladder-dysuria, frequency Bowelopen or not Lochia-colour, odour Episiotomy scar-healing, any pus dx Sexual activity-dyspareunia
Homan sign-Features of DVT-leg swelling, redness Emotion-Sleep, mood
PEFE-temperature -39, offensive vaginal dx+ DX-Endometritis-inflammation of the inner lining of the
womb DDx-Retained products, DIC, Trauma, bleeding disorder. I said only causes for secondary PPH.I
did not tell causes of post-partum fever though I asked them in the hx. Mx Need to admit to the
hospital for IV Abx
Another Feedback: POST PARTUM BLEEDING (PASS)
Approach to patient/ relative : 5 History : 6 Diagnosis/ Differential diagnosis : 5 Management : 6
Stem: Lady, para 2, SVD 10 days ago, uneventful intra-partum & post-partum days; comes with
heavy vaginal bleeding. Tasks: - Take history - PEFE - DDx
Thoughts during the 2 minutes: Sounds like secondary PPH, must explore the commonest cause of it;
could it be puerperal sepsis?
Flow: Greeted the patient, asked in detail- antenatal history, intra-partum, post-partum. Any
discharge/ fever, amount of bleeding, bleeding diasthesis, symptoms of anaemia. Asked her how her
baby was doing, if breastfeeding was ok. Said she had fever. Asked questions to find source of fever
(UTI, URTI, episiotomy wound breakdown/ dehiscence).
PEFE I was given, stable vitals except for a fever.
Explained secondary PPH (I wrote the diagnosis, told her what each word meant). Vs primary PPH.
Likely secondary to endometritis seeing she’s got bleeding & also fever.
Another Feedback: POST PARTUM BLEEDING (PASS)
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HMO (I don’t remember age) Woman comes with bleeding per vagina and fever (im not sure if fever
was there or not or if I asked in Hx). She had given birth 10 days back. She had a normal delivery and
baby is healthy. Hx, PEFE, Dx/DDx, Mx
2 min: just thought of DDs and Hemodynamic stability
Bell rang:
Entered the room, greeted the patient and examiner. “Hello my name is Anish and I’ll be your doctor
today. I understand you just had a delivery, is that correct? Yes. Well congratulations are in order
thank you doc. So tell me, how may I help you?’’ She explained about bleeding. I asked CCVO. Pads?
(1 or 2 fully soaked). Any contents? Placenta shown? Clots? Dizziness, tiredness? Blood group?
Tummy pain? (she said yes)- went into SIQORAA for tummy pain. fever? Yes. Have you recorded?
No.
Preg q’s: normal delivery, no complications. No predisposing conditions. Episiotomy done?? Nope.
Any tears or breaks in birth canal. Any bleeding after delivery? No. placenta shown? Yes.
SADMA
Baby Qs’and breastfeeding Qs.
PEFE:
Temperature around 38/39, other vital signs within normal range,
P/A: soft, non-distended, uterus? 10cm, tenderness +
Pelvic examination: inspection unremarkable
Speculum examination: vaginal wall normal, cervical os opened (1cm)
Bimanual examination: Ut size increased + tenderness +
office test: UDS and BSL - Normal
Thank you examiner
Explanation:
From your history and PEFE, couple of things are going through my mind. On top of my list is
something known as endometritis. Have you heard of this before? No doc. I drew a Ut picture and
apologised for my bad drawing and said this is your inner lining of uterus. We call it endometrium, In
your case whats happened is there is infection of this lining. This is what we call as endometritis. Can
be due to organisms in vagina coming in contact with lining in labour. I was also thinking of RPOC,
episiotomy wound or lacerations in canal. Bleeding disorder or medications. Admit. Ix- said it all FBC,
culture, ESR etc etc. IV line. Inform senior and specialist. Antibiotics. Assessed understanding and
just spoke about general measures.
16- Ureteric colic with CT - Middle age man presented with right side loin to groin pain. It was colicky
type pain. CT scan was given outside. Task : Explain the CT scan to the patient. Explain acute
management to the patient.
AMC feedback-Abdominal pain-PASS Approach to patient/relative -5 Interpretation of investigation4 Management plan-5 Global score -5
This is the CT picture of your tummy. In CT scan, bone appears in white colour and tissues appear in
grey colour. Can you appreciate this white dot like thing. I am suspecting a stone in your ureter-it is a
tube that connect the kidney to the urinary bag we called bladder(drew and explained) Acute
Management Will give you a strong pain killer. Management will depend on the size and the site of
the stone. If it is a small one most likely it will pass spontaneously. You have to pass urine to a
container and strain while passing urine. We will not give much fluid during the hospital. Specialist
will see you and decide on further management. Once discharge ensure to take high fluid intake
and gave dietary advices.
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Another Feedback: ABDOMINAL PAIN (PASS)
Approach to patient/ relative : 4 Interpretation of investigation : 4 Management plan : 4
Stem: Patient had loin-to-groin pain, seen by the ED already, now pain-free. CT done.
Tasks: - Explain CT findings to the patient - Explain acute management, & other plans to the patient
Thoughts during the 2 minutes: sounds like ureteral stone Divide my management answers into:
lifestyle, pharmacological, surgical.
Flow: Confirmed patient details on the image of CT shown. Told him left & right which side. Told him
skin, lots of bowels around. And the two different ureters, one showing white round mass. Told him
about the limited 2D view of this one slice. But this image shows the stone being 5mm (pointed at
the scale meter on the film as well).
Explained investigations we will run: blood tests like FBC (to check for infection in white cell count),
renal profile (to check for evidence of kidney injury), CRP (infection), calcium & uric acid (as
possibility of causing risk of stone formation). Urine tests (UFEME, cultures). Didn’t mention USG for
hydronephrosis as I thought CT was sufficient.
Told him indications of admission: intractable pain, sepsis, acute kidney injury, solitary kidney (this
image doesn’t show but unlikely, will see).
Acute management: now pain free, could be that the analgesia has taken effect, or the stone has
passed. Besides analgesia, straining, hydration as well. Possibility of using alpha-blockers to help
strain. Advised to pee into cup or onto the floor to catch the stone, could send for analysis see what
type of stone it was, therapy then could be tailored accordingly.
Talked about recurrence. Explained about surgical management depending on location & size, might
need PNL/ ureteroscopy/ ESWL/ nephrostomy stent in the future if recurrent & big & failed medical
therapy.
Another Feedback: PASS
Guys this is the ureteric colic case. Ct scan was present. I don’t remember much of what I said.
Hx- SIQORAA, fever, nausea, vomiting, r/o some acute abdomen
CT scan – explained CT – said theres a stone here. Drew a picture of stomach to show an
approximate level. Causes of this stone- I said increased cholesterol or calcium levels, dehydration
etc.
Mx- I said admit. Call senior and specialist. Ix- FBC, ESR, crp etc etc. Urine dipstick. Xray by specialist
to check the stone position or if its gone. IV fluids, said about size of the stone determines what the
specialist will do. If small enough, it will pass by itself so drink lots of fluids and rest. But if large
enough (I didn’t mention any cms) the specialist might do certain surgeries to remove the stone.
What surgeries doc? It depends on the specialist really but he might introduce radiation to break the
stones or insert a small tube to break it. Ok? Any questions? Ill arrange for medical certificate if you
need it. I forgot what else I said but I did talk to the patient bell rang
18th April 2019
1- Women working as a nurse in rural hospital presented after dating scan which
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shows a twin pregnancy with each fetus having a separate amnion and chorion. This is her
second pregnancy and first one was uneventful NSVD all normal. Too much details given.
You work at a clinic where shared antenatal care is given.
Task - further relevant history x 3min and counsel her for further Mx.
My performance
History- I asked focus history only because too many details given and didn’t know what to
ask. RP was excited and happy. I asked NV, pain bleeding discharge, partner supportive,
have family support too, previous delivery all normal, PMH – no preeclmpisa, no gestational
diabetes. Medication – folic acid only.
SAD – not significant, no Family history of twins.
Counsel – explain what is dichorionic diamniotic (DCDA) twin pregnancy. Favorable
outcome. But still this is high risk pregnancy. Need MDT care with frequent AN visits and
more scans like doppler USG to check babies’ growth.
(Here, I didn’t mention exactly how many AN visits or what AN tests she needs. Just mention
about sweet drink test, bug tests along with regular BP, body weight and urine checks)
Possible risks are - big tummy, preeclampsia, excessive NV, preterm delivery, RDS in babies,
obstructed labour, cord prolapse. Offered Elective CS which is safest, suggested to delivery
at tertiary. She refused saying want to be with family here at rural hospital where she
worked. So I explored more but she didn’t give any particular reason. Persuaded again
repeating the risks. Towards the end, she still refused. So I said it’s a bit early and take your
time discuss with partner and see me again.
Approach to patient/relative 4
History 6
Patient Counselling/ Education 5
Global score 5
Your reference
History
o Was this a planned pregnancy? Is this your first pregnancy?
o Was this a natural conception, or did you go in for artificial methods of conception?
o How is your pregnancy going so far?
o Are you experiencing any problems such as tummy pain, bleeding from down below,
burning or stinging on passing urine, fatigue, headache, blurring of vision & swelling,
fever/malaise?
o Have you started feeling the babies kicking?
o During the early weeks of pregnancy, any exaggerated vomiting, any nausea?
o Did you do all your antenatal tests? How were the results?
Routine first visit tests
o FBE
o Blood group and antibody screen
o Rubella antibody status
o Syphilis serology
o Midstream urine
o Chlamydia
o HIV
o Hepatitis B and C serology
o Varicella
o Cervical cytology/Pap smear
o Screening for Down syndrome (if >35 years old)
Ultrasound at 18 to 20 weeks?
o General well-being questions:
o Are you taking your folic acid? When did you start taking it? (folic acid 0.5mg/day 3
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months before and 3 months after)
o Are you eating a healthy balanced diet? Do you drink a lot of fluids?
o Are you taking any vitamin or mineral supplementation?
o Any change in appetite? Have you noticed weight gain/loss?
o Do you have a regular exercise routine?
o Do you open your bowels regularly? Any problems with your bowels?
o Are your influenza and pertussis vaccinations up to date?
o Any family history of multiple pregnancy?
o SADMA
o Do you smoke?
How long have you been smoking? How many per day?
o Do you drink alcohol?
What kind? How often? How much per session?
o Do you take any recreational drugs?
What kind? How often?
o Do you take any prescription or over the counter medications?
What medication? For what reason? Who prescribed it?
o Do you have any known allergies?
Do you take any medications for this?
o Any past history of any medical illness especially clotting problems (thromboembolic
disease), diabetes, epilepsy, thyroid problems, or high blood pressure?
o Do you have good support?
o Have you done your pap smear? What were the results?
Diagnosis and Management
How are you feeling about your pregnancy?
There are different types of twin pregnancies. The type that you are having is more
favorable because each of the babies has a separate placenta as well as a separate bag of its
own. These are actually independent twin pregnancies, and usually carries a better
prognosis. It is very likely that these could be non-identical twins.
I know that you are a bit concerned about this pregnancy, but let me reassure you that
many women who have twin pregnancies go through a normal pregnancy and will have
healthy, normal babies. But we need to monitor you as well as the babies for certain
complications. The complications we have to look out for you are first, anemia, you can feel
a bit tired and exhausted as the pregnancy goes by; there is also a risk of high blood
pressure and pre-eclamptic toxemia where there is a sharp rise in blood pressure with
leakage of proteins into the urine; there is also a higher chance of developing Diabetes
during pregnancy; also as your tummy will be a bigger towards the end of your pregnancy,
you may feel a little short of breath and experience back pain; you may also have
antepartum hemorrhage or bleeding during pregnancy, cord prolapse, and a greater risk of
postpartum hemorrhage. The complications in the babies are: low birth weight,
intrauterine growth retardation of one baby, birth defects, and malpresentation. But we will
monitor you and your babies for these complications. I will refer you to the high risk
pregnancy clinic for better management. You need to go for more frequent antenatal
checks: every 2 weeks until 28 weeks and weekly until you deliver. During each visit, your
weight will be recorded and your BP will be monitored. A sweet drink test will be done at 28
weeks to check for any Gestational Diabetes, a repeat blood test to check for anemia,
ultrasound screening every 2 weeks from 28 weeks, CTG to look at the wellbeing of the baby
twice a week from 34 weeks, and a bug test will be done as well.
Delivery will be planned at 38 weeks. There are two options for you: one is to do a Csection,
and two is a normal vaginal delivery. However, normal vaginal delivery can be done
only if certain criteria are met:
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o The first baby should be in cephalic presentation
o The second baby should be less than 500 grams compared to the first baby (if the
second baby is big, it will obstruct the passage of the first baby)
The delivery should be done in a tertiary hospital, under the guidance of a specialist.
Continuous monitoring of the babies will be done via CTG during the delivery.
How far are you living from the hospital?
It is better to stay near to the hospital during the last weeks of pregnancy because there is a
greater chance of you going into premature labor because of this twin pregnancy.
You need to take a healthy balanced diet, and take iron, calcium and folic acid supplements.
Just in case you develop tummy pain, bleeding and excessive discharge from down below,
blurring of vision, headache, excessive vomiting, regular painful contractions, please go to
the ED immediately.
It is always advisable to maintain kick charts for the baby as well so we can monitor the
wellbeing of the baby.
Another Feedback - You are a gp??/ hmo in rural region. A middle age woman in her second
pregnancy recently had a ultrasound as for her routine antenatal checkup. Usg result showed that
dichorionic diamniotic twin pregnancy.
Task history. counsel her about further management.
Approach 5, History 4, Patient counselling 5, Passed 5
- this case was a shock to me as i didn’t prepare for it. On 2-minute thinking time, i mainly
focussed on theory as this case was a new to me.
- When i entered the room, there was a happy woman sitting. I greeted her and asked if she
has any idea about the result. She replied ‘yes’. So i congratulated her. I spend 30 to 40
seconds on congratulation as i dun know what to do next.
- Then i ask her history according to 5P excluding period, pep smear, pills.
- Then asked about previous pregnancy— it was uneventful, delivered vaginally.
- She wishes to deliver vaginally if possible.
- Then i asked about early pregnancy complication like Nausea, vomiting, breast tenderness,
bleeding from her down below and anaemia symptoms
- Then closed the history by asking routine antenatal questions like immunisation, blood
group, investigations, support and so on.
- I forgot to ask about family history of twin pregnancy and fertility drugs.
- As for the counselling part, i drew a line and divides pregnancy to 3 parts and told possible
complication and how we are going to prevent.( in fact i was telling routine AN care)
- As for the twin pregnancy specific complications—anaemia, more nausea and vomiting,
abdominal discomfort, swelling of legs, SOB, PE, prolonged labour and so on
- I forgot to mention about malpresentation, twin to twin transfusion, malnutrition in one of the
twins
- Sent her to high risk pregnancy clinic.
- Told her about delivery options— i strongly suggested her to deliver at the tertiary hospital
via C.S.
- ( after the exam, one of my friends told me that it is still possible to deliver vaginally under
certain criteria. So check on it)
- I told her that i will refer her to specialist for further counselling and management as i dun
know much about twin pregnancy( guessed that helped in this case )
- The patient was really cheerful in this case so i felt relaxed , smiled and laughed a lot with
her.
- I still had time left even after that so i summarised the management and reassure her a lot.
Another Feedback - PASS (Global 5)
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Hx/ Patient knows about the condition already and happy about it. Patient already has 1 child
previously. Has enough support from husband and family. No excessive nausea and vomiting. No
tummy pain. No discharge/blood from down below. No family history of twin, IVF, or hormone.
Explain about dichorionic diamniotic with picture. There is 2 placenta and 2 amniotic fluid. The good
news is woman with twin pregnancy can deliver normal and have healthy babies. However there is
some effect of the twin to pregnancy. For mother, there is a risk of hyperemesis gravidarum which is
an excessive nausea and vomiting, DM, Pre-eclampsia, and prolonged/obstructed labour. For the
baby, there is a risk of IUFD, IUGR of one of the baby, twin-twin transfusion, and malposition (explain
a little bit of these condition). Because of all of these condition, we classify the pregnancy to high
risk pregnancy and will be taken care by the multidisciplinary team. We will do more often follow up.
Then I continue explaining about the delivery. It is possible to have normal vaginal delivery, however
the delivery has to be in the tertiary hospital because it has to be under supervision of the specialist.
(patient didn’t say anything until I mentioned this). She said she wants to deliver in the country
hospital. I asked why, and she said because she’s a nurse and working in the country hospital. I said I
understand, she must know all of the worker that work in the country hospital and wants to deliver
there. However, because of some risks during delivery, we will need obstetrician. She asked “what is
the risk again?”. I said obstructed labour may happen that will lead to SC. That’s why we need to
have operation room and complete instrument ready during that time and the country hospital
doesn’t have that facility.
In the end I said that this is just one of the risks, just in case. The delivery might also be normal with
vaginal delivery. And this is also too early to say, we have to check the condition of the mother and
baby closer to the delivery. The decision is up to you, but I need to inform you what might happen
and usually we will suggest to deliver in tertiary hospital. Please discuss it with your husband and
your family and if you want to come here together with them, I can explain it again.
2- Patient after shoulder surgery became violent and throwing things. Some PE findings of
hyperreflxia, hand shakes and some others given. Vitals OK.
MSE history present. DD.
My performance MSE history – patient complained that this place is filthy because there’re cockroaches
everywhere. I consoled her that I’ll address this issue definitely. Now I want to asks some
questions for her wellbeing. ?confidentiality – I’m not sure if I said this or not.
I started with hallucination as this was her complaint -visual + and feeling on herself (no
auditory- said I hear you talking). suicide homicide thoughts (not answered), mood (not
answered), orientation (date only impaired. Knows place as she said this filthy hospital), SAD
+ alcohol (said she takes wine or sherry something everyday) lives alone. Remaining
HEADSS.
RP showed anxiety and irritability. She didn’t answer most of the questions and preoccupied
with tissue box and cockroaches which made me very uncomfortable and awkward. Didn’t
have time to explore more and I guessed I should proceed.
MSE Presentation very disorganized. But I tried to address all ASEPTICJ RRR including those
like thoughts which I couldn’t assess. Insight loss as she’s not aware of what’s happening to
her. Judgement – she said where’s the fire which I didn’t know how to interpret. Rapport
not good, not reliable. Risk is intermediate to high because she’s lost insight and been
violent with active hallucinations.
DD – DT d/t alcohol WD is most likely. Others include hypoxia, infection, hyperthyroid,
dementia getting worse, drug SE. I finished early and examiner asked did you check your
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tasks which made me puzzled and checked again. But I did cover all and just sat there.
I thought I’d fail this station.
Approach to patient/relative 5
History 4
Accuracy of Examination 5
Diagnosis/ Differential diagnoses 4
Global score 5
Your reference
History
1-Approach
-when you enter there will be a patient sitting and holding a pillow trying to hit cockroaches.
Calm her and reassure her. I will call the cleaner to clean the room.
-do you know why you are here? Do not worry I will explain to you. You had a shoulder
dislocation and just went through a surgery
-do you have pain right now? (No)
2-Confidentiality
everything we gonna talk will be between you and I unless there is a harm to you or to
others.
3-Hallucination
-I can see that you are hitting cockroaches. Where are they? (All over, the place is very dirty)
- do the cockroaches crawl on you or on the table? (Yes, go away)
-do you hear things that others do not?
4-Dellusion (all negative)
-do you think someone is following you or spying on you?
-do you think someone is trying to harm you?
-do you believe that you have a special power
-do you think thought are inserted in your mind? Withdrawn from your mind?
-do you think your thoughts are broadcasting through TV or radios?
5-Mood history
-How is your mood ? How do you feel today? anytime you feel high?
-have you lost interest in things you used to enjoy?
-have you ever thought of harming yourself or others? (no)
-how is your sleep? Do you have difficulty getting to sleep or you wake up early in the
morning and have difficulty to get back to sleep?
-how is your appetite?
-have you lost weight recently?
-do you find it difficult to concentrate on things? Do you feel guilty?
-do you think other people’s action or behavior are directed towards you?
5-cognition
-where are you right now?
-do you know who I am? (Doctor)
-what is the day of the week?
6-Insight: do you think you need a professional help? (No)
7-Judgement: let us suppose there is fire in this room, what would you do?
8-HEADS
-who do you live with? Any stress? (alone)
-if alone: if ever had a partner? / if young how about your siblings or parents?
-what do you do for living? Any stress? / how about your performance in UNI? Any stress?
-SAD (couple of alcohol before she had a surgery)
-social activities
9-General
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-previous and family hx history of mental problems/ PMH/ PSH/ medications
MSE summary steps
1-short Intro
I would like to present MSE of Jill a 57 years old woman who was behaving strangely post
surgery.
2-Appearnace
-dressing: wearing appropriate to weather. -grooming: unkempt.
3-Behaviour
-Body posture
-eye contact
-cooperation
4-Speech
-Rate: pressured/ fast
-volume: high
-tone: high
5-Mood and affect
-mood: what the patient tells you
-affect: what you observed in your patient
Patient described his mood as----and the affect that I am observing is congruent with the
mood.
6-Thought form: is linear
7-Thought content: no delusion or obsessions
8-Perception
-experiencing visual and tactile hallucinations as she is seeing cockroaches and telling that
they are crawling on her.
9-Congnition: no oriented to time but oriented to place and person.
10-Insight: impaired
11-Judgement: impaired
12-3R
-rapport: I could build rapport with my patient all throughout the consultation.
-reliability: history is unreliable; I need to look into her case notes for PMH, PSH, operation
chart and Ix.
-risk: no risk of suicide (I think not sure)
Dx: most likely patient is having post op delirium. There are many causes it could be alcohol
withdrawal, which is the most likely. Need to rule out electrolyte disturbance, hypoxia, hypo
or hyperglycemia, medications, infections.
3- Indigestion for 4 months on mylanta with weight loss and melena and stomach/ cancer
Task : History, PEFE on Card, Dx with reason, DDx
(History – smoking(+) alcohol(+) and 5kg weight loss in one month.)
My performance
History - Asked indigestion (what do you mean by it? He said burning dull pain), red flags
(LOW +, Vomited once, food only, bowel dark? Not sticky not black like tar). Had history of
reflux but no reflux now, Mylanta didn’t work at the moment, anemia -, SOB -, dysphagia -,
SAD + smoker, takes beer, stressful job, takeaway food. No family history of GI cancer.
DD - said reflux oesophagitis explained with diagram. Others – PU, ?cancer, pain from heart
and lungs.
Approach to patient/relative 6
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History 4
Diagnosis/ Differential diagnoses 4
Global 4
Your reference
History
1-Indigestions questions
-I can see that you have troubled by indigestion, so what do you mean by digestion? Can
you tell me more? (Discomfort in tummy)
-do you have any pain in your tummy? Any heartburn? (No, but like burning)
-for how long? Sudden or gradual? Constant or come and go? Getting worse?
-site and radiation (pointed to epigastrium)
-does anything make it better like sitting up position or antacids? (Yes antacids Mylanta
initially worked but now not)
-anything makes it worse?
-is it associated with food? (yes)
2-Associated symptoms (Dysphagia, vomiting, distension, bowels, bladder, LOW, LOA, L&B,
jaundice, fever)
-any difficulty or pain during swallowing?
-have you had any vomiting or vomited blood? (yes but no blood)
-any abdominal bloating or distension?
-has your bowels habit changed recently? Any diarrhea, constipation or alternating D&C?
Have you seen blood in your motions? Have your bowel motions been black? (yes no blood
but black motions)
-how is your waterworks?
-have you lost weight recently without dieting? Any loss of appetite? Any lumps or bumps?
(lost 5 Kg)
-any change in the color of the skin or eyes?
-any fever?
-chest pain, SOB, palpitations, dizziness?
3-General questions
-PMH
GERD: (since when, on what medications, regular checkups) (long time history of GERD)
peptic ulcer
colon cancer
hepatitis
-PSH
-SAD (heavy smoker and alcoholic)
-diet (spicy food, fatty food, coffee) (+ve takeaway food)
-family history
PEFE card
1-General appearance DR PJL, BMI , Oedema
2-V/S
3-Focus abdomen + DRE
4-office tests (UDT, BSL, ECG)
(positives are pallor, Left supraclavicular LAP, DRE dark stool; in one feedback just pallor)
Explain
-from history and examination there are several possibilities why you have indigestion:
(Draw diagram)
-It could be esophagitis or an inflammation of the food pipe due to long standing GERD.
-Could be due to ulcer developed in the stomach or food pipe as you have vomiting, black
stool and discomfort in your tummy.
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-Could be due to nasty growth of the food pipe or esophagus, as you have a history of
weight loss, stool color change and examination showed LAP, pallor, and this what I am
suspecting the most likely cause. However, I am not telling that you definitely have it
because we still need to do some investigations in order to know more about the cause of
the indigestion.
-Others could be liver disease, inflammation of the bowels or pancreas but less likely.
Investigations
1-upper GIT endoscopy: is a procedure that allows to look at the inside lining of your
esophagus, your stomach, and the first part of your small intestine (duodenum). A thin,
flexible tube called an endoscope is used. inserted through your mouth and then gently
moved down your throat into the esophagus, stomach, and duodenum. if they saw anything
suspicious they will take a sample from
2-Colonoscopy: is a tube attached to a camera pass through the back passage to check the
inside of the bowels if they saw anything suspicious they will take a sample from it to be
examined under microscope.
3-FBC, LFT, UCE, Lipase and amylase
4-ECG
Another Feedback - Middle age woman comes to your GP clinic with indigestion
Task Take history for 6 mins
Tell possible ddx with reasons
Approach 4, History 3, Ddx 5, Passed with 4
- A lady with history of indigestion for nearly 6months off and on, comes with worsening of
symptoms.
- When asked about it, the patient will not tell the history willingly unless you dig hard enough.
- She had a history of heart burn for many years and taking mylanta which is not working well
now.
- Diet history points out that she is high risk to develop GU, PU.
- She also mentioned loss of weight in recents months
- I failed to asked about lifestyle stress, malaena and anaemia symptoms in history. I guessed
thats the reason why i got 3 in history.
- Then i followed ddx questions.
- Then explained ddx first one being cancer then followed by reflux disease, GU, PU, stricture
due to prolonged reflux( i just slipped my tongue), cholecystitis, MI and others that i can
think of at that time.
Another Feedback - PASS (Global 4)
Hx/ Patient has indigestion last couple of days, not help with Mylanta. His colleague has the same
problem and treated with antibiotic. Vomit 1x yesterday, food. Patient has GERD for a long time.
Don’t have problem swallowing. Urination and bowel movement has no problem (other candidate
said there’s black stool, but I didn’t asked specifically for black stool so patient just said its normal).
Loss of weight 5 kg past month, he thought because of the stress at work. Lately he has been eating
takeaway food because he has to keeps travelling for work. Don’t usually consume spicy food.
Smokes 1 pack/day. Drink 6 beers/day. Patient can’t eat big meal at night. Sleep with 1 pillow. No
chest pain.
PEFE card/ all normal
There are a couple of possibilities of the cause of your tummy pain. Can be because of gastric ulcer,
duodenal ulcer, but I’m afraid you might have a nasty growth since you had lost of weight past
month. Patient asked what is nasty growth. I said nasty growth is cancer, but I don’t know for sure
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now. From the physical examination everything is normal, but you have lost 5 kg last month and this
is a red flag for me. I’m scared it could be esophageal cancer. But again, we don’t know for sure and
we have to do investigation to rule this out. Other possibilities can be a stricture or a hiatal hernia. I
explain each dd with one sentence each and with a drawing.
4- man with feeling unwell for 4 days take history and tell Dx, DDx.
History: stuffy nose, Now no fever, no sore throat, no ear pain or discharge, have dry cough and
wheeze with rest of chest - normal. He has asthma and had allergy to pollen and grass but stopped
puffer 5 years ago and mom had allergic rhinitis and kid now has flu.
My performance
History – Role player sniffing and using tissues as I went inside.
Asked more about unwellness. Said that having cold a few days back and now, breathing
difficulty, wheezing (RP used this word), chest tightness, sleep ok, no snoring, asthma
history +, using partner’s Ventolin puffer which relived symptoms. Have cat as pet. Allergic
to pollen or grass. (RP emphazied too much on asthma and all pointing towards asthma
flares) But he/she didn’t have asthma attack since childhood and not taking any medication
for asthma. No travel history. Partner and child also had cold at the same time.
SADMA – smoking positive in partner I think. Family history of atopy present.
DD – asthma flares, viral infection, pneumonia, TB (unlikely as it’s uncommon in Australia). I
still had some time left so I asked more this and that. Only when I asked any other
symptoms like ache and pain in body (No), headache (No, but I have pain in face around
here pointing towards maxillary sinus! OMG)
It could be sinusitis (bell rang).
Honestly, I had no clue what this case was. So I just followed RP lead.
Approach to patient/relative 4
History 4
Diagnosis/ Differential diagnoses 4
Global score 4
Another Feedback - You are a GP, a middle age man comes to you because he is unwell for a few
days. History for 6 mins. dx/ ddx.
Passed 5 – each 5
- When i entered the room, a middle age man is sitting on the chair, wipping his nose with
tissue frequently.
- He spoke really fast in that station( may be he was instructed to do so)
- On history, he was having nasal discharge and blockage for a few days
- I needed to dig a lot in this case as he was not opening up.
- After asking for a minute, i knew it was a case of asthma.
- He noticed noisy breathing, SOB. His child recently had a history of bug infection.
- His home was full of risk factors for asthma like dust, fluffy toys, dogs and so on.
- As for the past history, he had previous history of asthma for that he used ventolin. He gave
up playing hockey because of that.
- As for the personal history, he smokes cigarette occasionally
- Then i explained to the patient that he was having acute attack of asthma which was
triggered by the same infection his son got a week earlier.
- Then i told him that it can be triggered by other factors like dust, pet fur, smoking( offered
smoking counselling)
- As for the ddx— hay fever, nasal polyp, Copd, viral and bacteria infection.
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- This case is about how you explore the history, he will not tell you anything unless you ask
specifically.
Another Feedback – PASS (Global 5)
Patient c/o runny nose, cough, and wheeze
Clear discharge from the nose 4 days. Cough is dry
Wheeze when walk upstairs
Patient has asthma when kid, but controlled. Don’t need any medication, unless last couple of days
patient has been using her partner’s ventolin because it helps with the wheezing.
No fever, no ear pain, no sore throat
No history of travel
No lost weight and lost of appetite
No chest pain
No SOB when sleep
I asked specifically if she has pain on the sinus cavity (I pressed my own sinus cavity to showed her,
and asked if she feels pain around this area. I mentioned because there is no PEFE, I cant check it
myself.)
Explain that she has viral URTI, most likely sinusitis because she feels pain around her maxilla. And
this URTI causing the flare up of her asthma, that’s why she has the wheezes.
Other possibilities can be bacterial URTI, tonsillitis, pneumonia, bronchitis. Can also be heart
problem because she felt SOB when go upstairs, but less likely since there is no other symptoms.
In the end I just reassure her that this is manageable. I will do some physical examination to make
sure that she has sinusitis the prescribe medications.
5- You are an intern in a rural hospital. 7/9 years old boy was diagnosed with ?leukaemia. He
was given chemotherapy and finished it a week ago. Now he comes with complaints of URTI
and fever39C. His father is accompanied him. Tertiary hospital is 200 Km (not sure) from
your place.
TASKS- Ask examiner for examination findings (u will be given only what u have asked for)
Talk to father about initial management plan
My performance
PEFE - no positive pefe (asked head to toe to screen infective foci, no UDT done) except
congested eardrum, mild pharyngitis.
Management – Explained about fever but couldn’t find any source of infection. I’m
concerned because of his special situation in which chemotherapy weakened his immune
system. Empathy. For admission, transfer to tertiary (air lift, PIPER, MDT – specialist
paeditirician, oncologist, infectious disease specialist, social worker, counsellor etc,. IV ab iv
fluid and full septic screen- blood with cultures, CT, CXR, UMCS, lumber puncture).
Roleplayer appeared very worried and felt sorry for his son. I said a few words to show
empathy but he still in held his head in hands. Here, I only focused on fever but totally
forgot to mention a bit of underlying condition.
Global score 7 – all 7
Your reference
Neutropaenic Fever
You are an intern in a rural hospital. 7 years old John was diagnosed with lymphoblastic
leukaemia. He was given chemotherapy for 6 months and finished it a week ago. Now he
comes with complaints of URTI and fever39.His father is accompanied him. Tertiary hospital
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is 70KM from your place.
TASKS
Ask examiner for examination findings (u will be given only what u have asked for)
Talk to father about your concerns and initial management plan
Explanation
Introduce to patient.
Dear Examiner,
I wanted to know the general appearance of the John.
Any Pallor, jaundice, rash, neck stiffness, signs of dehydration, signs of skin infection- No
Vitals signsPulse: 100/min, regular
Temperature: 39 C
Respiratory rate- 14/min,
Blood pressure-110/70
Any postural drop- no
Saturation-93%
Lymph node enlargement- cervical, axillary, inguinal- No
Ear Examination- normal/tympanic membrane congested
Nose and throat examination- Pharyngeal erythema
Respiratory System- Normal (If asked- then INSP-increased work of breathing, subcostal
recession, dullness, vocal resonance and fremitus, auscultation finding)
Cardiovascular system- Normal
Abdominal Examination- Normal
CNS examination- Normal
With consent of parent, axilla, groin and genital examination- Normal ( to detect abscess
and skin infections )
Office test- Urine dipstick, BSL
( finding results are according to one of the recall )
Explanation
Mr XY, I have examined john and he has got fever. There are many causes of fever. It can be
even simple viral infection also. Normally our blood contains cells called White blood cells.
These are very important to fight against infections caused by bugs. But as your son was on
chemotherapy, these medication can decrease the number of WBC in our body and making
us susceptible for severe infections. So even though I could not find any focus of infection, I
am concerned about the severe infection in John and if left untreated it can lead to life
threatening infection in blood which is medically called as sepsis. But do not get concerned,
it is good that you have brought John early and if we start treatment early we can control it.
So I will call the Paediatric registrar (If available in hospital) and we will do investigations to
find the focus that is called septic screen. We will take blood for investigations like Full
blood examination (to find the count of WBC), UEC, LFT, Inflammatory markers, blood
culture (to find infection in blood),cheat Xray. After taking blood, I will give board spectrum
antibiotics according to specialist's instruction and Paracetamol for fever. We will also take
urine for urine to find infection in it. As I said before, the John’s condition can get severe, so
the specialist can decide to transfer the child to tertiary hospital where the facility is better
(If no specialist, tell will refer to tertiary hospital). In the tertiary hospital, John will be taken
care by team of many specialist doctors together called as Multidisplcinary team. The
oncologist, paediatrician, microbiologist, residents and specially trained nurses will be there
for him. They will take meticulous measures for infection controls to prevent spread of
infection. We will also be in contact with the team regarding the investigations results. I can
understand this is very stressing for you, we do as much as we can. If you want we can
inform your partner and call her. (If have other children, we can provide support and can
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arrange a social worker). We will also arrange an ambulance to shift John to tertiary
hospital.
Do you have any other concerns? Thank you for seeing me. I will be here with John until
ambulance arrive. Meanwhile, if you have any question, don't hesitate to ask me.
Another Feedback - You are HMO in rural hospital. Child brought in by dad because he is
having high fever. He is previously diagnosed as leukaemia and
received chemotherapy recently ( a week ago i think). Now he is not
doing well—lethargic and drowsy.
Task PEFE. Management
Choice technique of examination 5, Dx ddx 4, Mx 4, Passed 4
- When i entered the room, a worrying dad awaits me. I tried to reassure the dad and ask PE
from examiner
- GC- drowsy
- Vitals— temp 39, other vitals stable
- No pallor, jaundice, cyanosis, dehydration
- GC— normal
- On system examination, mild redden tympanic membrane on right and slight enlarged tonsil
was found.
- I asked all systems that can have infection and all were normal but forgot to ask about neck
stiffness.
- All office tests were not done at that moment
- Then i explained to the patient that the boy is having serious infections due to the side effect
of chemotherapy which can lower the one of the blood cells that defend against infection
called WBC. It can either be due to septicaemia which is presence of infection in the blood
most properly got it from ear infection or due to cancer itself as it can reduce immunity.
- Then i told father that the boy needed to be admitted to tertiary hospital to be treated right
away.
- I mentioned about possible investigation like septic screening , antibiotic and arranged
ambulance and call doctors from tertiary hospital and explained about possible management
at hospital.
- I haven’t mentioned about febrile neutropenia although it is an old recall case.
Another Feedback - PASS (Global 7) All 7
PEFE- GA: flushed, but reactive
VS: T 39
Growth chart: all above 50th percentile
Ear: membrane tympanic injected, not buldging
Nose: runny discharge, no polyp
Throat: injected, can’t see tonsil
Lymph node: no enlargement
Chest: heart sounds normal, lung sounds equal, no additional sounds
Abd: lax, non tender, bowel sounds normal, no organomegaly
Limbs: no rash
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Urine dipstick: not available
FBE: not available
I finished with the history and physical examination. Now I will give him 1 injection of antibiotic then
send him to the tertiary hospital. At the moment I can see that he has URTI, but it also can be other
things such as pneumonia – infection of his lung, UTI – infection of the urinary tract, and meningitis –
infection of the lining of the brain.
We need to do some investigations. Since he had chemo 1 week ago, this condition can be expected
in 14 days after chemotherapy.
He is in a condition we called septic. Sometimes in child we don’t know the focus of infection. We
can find URTI now, but maybe there’s other source of infection.
(Father covers his face with his hands so I stopped and offer him water and tissue. Then asked him if
he wants me to continue).
Don’t worry it’s good that you bring him here so we can take care of him.
Then I mentioned we need to take some blood to check for FBE and blood culture, take urine sample
to check for UTI, do chest x-ray, and LP. I explained we will insert a small needle to the back bone to
take a little bit of fluid and check if there’s any infection of the brain.
I will send him to the tertiary hospital with air ambulance since we’re 200 km from the hospital. But
don’t worry, I will call my senior and your son will be taken care by the specialist paediatrician. All of
the procedure also will be done by the paediatrician. You can go with him to the hospital.
6- PE – hearing loss getting worse over few months without pain, discharge (no symptoms of
infection)
Tasks - Ear exam and explain Dx/DD
(otoscope and tuning forks, cotton wools given)
General appearance – patient comfortable.
Inspection (no facial asymmetry, there’re some flakes in ear cannal, ear discharge, redness,
also on mastoid) and palpation (did briefly only) at the same time.
Did whisper test (left side loss), Rinee (bone conduction better than air conduction on left
side) and Weber (hear better in left ear) (I chose the smallest tuning fork without checking
Hz to save time. Tips here – regarding tunning forks, for ears use the shortest forks given
which is 512Hz. Memorize as ears are short. For vibrating sesnsation check on limbs, use
tallest fork given. Memorize as limbs are long. It’s not buzzing at first, found conductive loss
in left side). Roleplayer was very cooperative and nice. On otoscopy, left ear (ear wax seen,
TM can’t be visualized), CN5 7 check (because they gave cotton wools, I used it to check
facial sensation. It was necessary because as soon as I explained to RP and he closed his
eyes immediately before I asked him. So, obviously, he was instructed to do so.)
Dd – conductive loss due to wax, ear inf, viral, nerve (I should have included all DDx of
conductive loss like otosclerosis, cholestetoma but I forgot)
Approach to patient/relative 6
Choice & Technique of examination, organisation and sequence 6
Familiarity with test equipment 5
Accuracy of Examination 6
Diagnosis/ Differential diagnoses 6
Global score 6
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Your reference
Examination Method
Ear examination consists of inspection and palpation, otoscopy, tuning fork assessment,
testing hearing and peripheral vestibular examination. In some cases lower cranial nerve
assessment is indicated.
Inspection
1-Inspect the position of the pinna and note its size and shape.
2-Look for deformity an obvious accessory auricle (separate piece of cartilage away from the
pinna), cauliflower ears (haematomas from recurrent trauma, which obscure the normal
anatomical features of the pinna) and bat ears (protrusion of the ears from the side of the
head)
3-Note any scars or swelling around and behind the ears.
4- Look for erythematous(redness) inflammation externally and any obvious ear discharge.
5- Inspect the auditory meatus and outer ear.
6-Then look for signs of gouty tophi (nodular, firm, pale and non-tender chalky depositions
of urate in the cartilage of the ear, specific but not sensitive for gout).
7- Look to see if the patient is wearing a hearing aid; if so, remove it.
Palpation
1-Palpate the pinna for swelling or nodules.
2-Pull down the pinna gently; the manoeuvre is often painful when there is infection of the
external canal.
3- Feel for nodes (pre- and post-auricular)
Otoscopy
1- Otoscope examination of the ears requires use of an earpiece that fits comfortably in the
ear canal to allow inspection of the ear canal and tympanic membrane.
This examination is essential for any patient presenting with an upper respiratory tract
infection, any symptom related to the ears, dizziness, facial weakness or head injury.
2- Always examine both ears! The correct technique is as follows.
3- Ask the patient to turn his or her head slightly to the side,
4- then pull the pinna up, out and back to straighten the ear canal and provide optimal
vision.
5- Stretch out the fingers of your hand holding the otoscope to touch the patient’s cheek, to
steady the instrument and to prevent sudden movements of the patient’s head.
6- When examining the patient’s right ear, the otoscope is preferably held in a downward
position with the right hand, while using the left hand to pull the pinna. An alternative
position involves holding the otoscope upwards, but there is a risk that if the patient moves
suddenly injury is more likely to occur.
7- Look at the external canal for:
- any evidence of inflammation (e.g. redness or swelling) or discharge.
- There should be no tenderness unless there is inflammation.
- Earwax is usually white or yellowish, and translucent and shiny; it can be moist or hard and
impacted. It may obscure the view of the tympanic membrane.
- Blood or cerebrospinal fluid (watery, clear fluid) may be seen in the canal if there is a
fracture at the base of the skull.
- In patients with herpes zoster, there may be vesicles (fluid-filled blisters) on the posterior
wall around the external auditory meatus.
8- Inspect the tympanic membrane (ear drum) by introducing the speculum further into the
canal in a forward but downward direction.
- The normal tympanic membrane is a pearly grey colour.
- It is ovoid in shape and semi-transparent.
- The upper fifth is called the pars flaccida and the lower four-fifths are called the pars tensa.
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- The handle of the malleus is often visible near the centre of the pars tensa.
- From the lower end of the handle a bright cone of light should be visible: the light reflex.
The presence or absence of the light reflex is not a sensitive or a specific sign of disease
- Note the colour, transparency and any evidence of dilated blood vessels (hyperaemia—a
sign of otitis media.
- Look for bulging or retraction of the tympanic membrane. Bulging can suggest underlying
fluid or pus in the middle ear. Retraction means a reduction in pressure in the middle ear
and is a sign of a blocked Eustachian tube.
- Perforation of the tympanic membrane should be noted.
Hearing assessment
1-Wisper test
- to test hearing, whisper numbers or words such as ‘mark’ or ‘park’ into one of the patient’s
ears while the other ear is distracted by movement of your finger in the auditory canal or
the canal is occluded by pressure on the tragus.
- It is important to stand behind the patient to prevent lip reading.
- Then repeat the process with the other ear.
- With practice, the normal range of hearing is appreciated. If a patient says he or she is
deaf, or the whisper test is positive, formal hearing testing (audiometry) is indicated.
2- Traditionally, Rinné’s and Weber’s tests are performed if deafness is suspected, but these
are not very useful screening tests:
A. Weber’s test: place a vibrating 512 Hz fork at the centre of the patient’s forehead. Nerve
deafness causes the sound to be heard better in the normal ear, but with conduction
deafness the sound is heard better in the abnormal ear.
B.Rinné’s test: place a vibrating 512 Hz tuning fork on the mastoid process. When the sound
is no longer heard move the fork close to the auditory meatus where, if air conduction is (as
is normal) better than bone conduction, it will again be audible.
Causes of deafness.
Unilateral nerve deafness may be due to:
(1) tumours, such as an acoustic neuroma;
(2) trauma, such as fracture of the petrous temporal bone; or
(3) vascular disease of the internal auditory artery (rare).
Bilateral nerve deafness may be due to:
(1) environmental exposure to noise;
(2) degeneration, such as presbyacusis;
(3) toxicity, such as aspirin, gentamicin or alcohol;
(4) infection, such as congenital rubella syndrome, congenital syphilis; or (vi) Ménière’s
disease. Brainstem disease is a rare cause of bilateral deafness.
Conduction deafness may be due to:
(1) wax;
(2) otitis media;
(3) otosclerosis;
(4) Paget’s disease of bone.
Another Feedback - GP, an old aged man comes with hearing loss on the right side for some time.
Task perform examination to assess hearing. tell findings and dx and ddx
Approach 6, Choice and technique 5, Familiarity with equipment 5, Accuracy of examination 5, Dx
ddx 6, Passed 5
- i was given 2 tunning forks, otoscope , dummy on table.
- I greeted the patient and asked him whether he wants me to louder my voice or not.
- Then performed proper ear examination
- Started with look— any discharge, vesicles, old scar , mastoid process and any
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inflammation.
- Feel— around ear area for any tenderness
- Then checked the ear with otoscope on dummy— it was filled with stuff that looked like ear
wax. GET familiar with the equipment
- I asked examiner whether i could do ear toilet to look inside, and he said no.
- So i presented findings to examiner that i could’t appreciate any tympanic membrane as it is
blocked by ear wax.
- Then i performed whispering test and rinne and weber respectively.
- The patient told me wrong answer on the normal side like bone conduction is better on
normal side( may be his mistake ).
- So i just told the normal findings on non affected side
- As for the rinne and weber, i had used 256Hz instead of 512Hz. Then i realised that and told
examiner that i should have used 512hz. He told me do whatever you think it is necessary.
The time was running out so i didn’t do the test again with 512Hz.
- Then i explained to the patient that he was having condition called conductive deafness. Of
course i used diagrams to explain it. The underlying reasons is due to ear wax impaction.
- For ddx—chronic ear infection, rupture tympanic membrane, middle ear effusion and
sensory deafness.
Another Feedback - PASS (Global 6)
Inspection: no redness, no swelling, ear looks symmetrical, no bruises
Palpation: Press mastoid, pre-auricular – no pain. Pull ear – no pain.
Did autoscope to dummy. Warned the patient “sorry I will pull your ear a little bit”. Dummy’s ear is
full of wax, cannot see membrane tympani.
Then continue with hearing test (I forgot to do whisper test).
Did Rinne, patient was confuse at the beginning. Examiner told me to do it again. Result on the left
ear BC>AC.
Weber – lateralisation to the left.
(It was really hard to make the tuning fork vibrate, the examiner finally said try to hit it to your
knee).
I would like to finish the examination with checking the lymph node. Examiner said no cervical
lymphadenopathy.
Then I drew the ear and start explaining. Most likely you have a conductive hearing loss and most
likely it’s due to wax since I can see a lot of wax in your ear cannal. Other possibilities are infection,
tympanosclerosis, cholesteatoma, otosclerosis, or sensorineural hearing loss such as acoustic
neuroma, meniere disease, labyrinthitis or also can be because of your age presbyopia. I explain one
sentence for each condition.
Don’t worry this is a manageable condition. We will clean the wax, and if after that you still have the
hearing loss then we might have to send you to the specialist to do the audiogram.
7- vision loss Ameurosis fugax. Detail history given along with vitals including BP (all ok)
Tasks – do PE to check eye function and relevant system. Explain causes to patient.
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I went straight to visual function tests after commenting on general
appearance. Did VA (6/9 not sure about distance. So I let the patient sit on my chair and
read the chart), VF, light reflex, accommodation reflex, eye movements, fundoscopy. All
normal. For CVS, listen heart sounds and carotid bruit (forgot to palpate carotid pulse) but
couldn’t palpate heart properly as patient not exposing properly. Just did palpation over her
top through the gown.
Explained AFugax as temporary loss of blood supply to the eye and time’s up. Didn’t explain
any other differentials.
Scenario: Visual problem Grade: Pass
Assessment Domain Domain Score (see key below*)
Approach to patient/relative 3
Choice & Technique of examination, organisation and sequence 4
Familiarity with test equipment 1 (I think the examiner was not happy with the way I did
visual acuity but who knows!)
Accuracy of Examination 5
Diagnosis/ Differential diagnoses 4
Global score 4
Your reference
1-WIPE:
the same approach of introduce yourself, explain what you are going to do and why then
take consent and wash your hands.
2-inspection
Eyes inspection
-ptosis
-swelling
-redness
-watery eyes
-size, shape and symmetry of pupils
face inspection
-facial symmetry
-prominent or dilated temporal artery
3-palpation
-feel for temporal artery tenderness
Note/ in the exam inspection and palpation will be normal
4-Visual acuity
notes/
-say ideally I’d like to keep it 6 m away from the patient. If Snellen was on wall or through a
mirror.
-for the exam keep it 3 m on one arm away from patient if the Snellen chart was hand-held.
-ask about glasses because patient should wear glasses if so.
-patient should cover one eye at a time.
-only let the patient to read one line (for example the next last line)
*I’d like to test your visual acuity. Do you usually wear glasses?
*if you could cover one eye with the palm of your hand and read this line?
*now if you could cover the other eye?
*good thank you.
Note/ in the exam visual acuity will be normal
5-Visual field
notes/
-patient should take off glasses if present.
-doctor should sit on the same level as the patient.
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-red pin half way between the dr and the pt.
-cover one eye at a time (both doctor and patient).
-ask the patient to look at your nose and let you know when he sees the pin comes into
view.
*Now I’m gonna test your visual field if you could cover the right eye for me with the palm
of your hand. I’m gonna cover my opposite eye.
*keep looking into my nose and tell me when you see this red pin come into view? (if nor
red pin you can use your fingers and ask when you first see my fingers moving)
*now if you cover the o
Note/ in the exam visual field will be normal
6-Light reflex
-now I’d like to test your pupils by shining a light with this torch is that ok for you?
-just keep looking at my nose? Thank you
-test both direct and indirect reflexes
note/ in the exam light reflex will be normal
7-accomodation
-now I’d like to test the ability of your eyes to focus. If you could look at a point on the wall
behind me and now look at the pen.
-the pupils becomes convergent and constricted
note/in the exam accommodation will be normal
8-eye movements
-test both eyes
-H pattern with red pin
-ask for double vision
-look for 3 things (restriction of eye movements, diplopia, nystagmus)
*I’m gonna assess the movements of your eyes. First of all do you have any double vision at
the moment?
*if you could keep your head still and I’d like you to follow my finger and let me know if you
have any double vision throughout the exam.
in the exam there will be normal eyes movements, no double vision or nystagmus.
9-ophthalmoscope/fundoscopy
-assemble it
-adjust the light size and color
-adjust the lens you are looking to
*choose the smallest light size, yellow color. And choose zero lens.
-hold it like a pen, perpendicularly
-Take permission: I would like to test the back of your eyes with this fundoscope this might
need me to be at times close to you.
-remove your glasses and patient’s glasses
-make sure you are on the same level with the patient
-ask the patient to focus on a distant object
-test the right eye of the patient with your right eye and vice versa.
Note/ when you start doing it the examiner will give a picture of fundus the picture shows
silver wiring, AV nipping +/- papilledema
10-other relevant examination
-complete other cranial nerves: examiner will say normal
-vital signs especially pulse and blood pressure.
-feel and listen for carotid: examiner will say normal
-CVS exam with stethoscope: examiner will say normal
-I’d like to complete examination with both upper and lower limb neuro. Examiner will say
normal
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Dx and DDx
1-Amaurosis fugax: this is a symptom of a condition called transient ischemic attack or mini
stroke causing transient loss or blurring of vision. It happens when the blood flow from one
of the arteries supplying the eye is blocked mostly by a piece of plaque or small clot then it
resolves spontaneously by itself. There are certain risk factors like high blood pressure,
diabetes etc.. and fundoscope shows some changes of the back of the eye related to high
blood pressure.
2-hypertensive retinopathy: vascular damage of the back of the eyes due to high blood
pressure
3-diabtic retinopathy
4-temporal arteritis: no prominent TA or tenderness
5-Carotid stenosis
6-migraine
7-space occupying lesion
Another Feedback - You are HMO, an old lady comes with sudden loss of vision this morning. Now
she can see well. Past history— high bp, high cholesterol, and many things that i couldn’t
remember.
After all, this case was TIA (eye) examination
Task perform eye examination. Perform other related examination.
explain findings and diagnosis and differentials to the patient.
Approach 5, Choice and technique 4, Familiarity with equipment 4, Accuracy of examination 5, Dx &
ddx 5, Passed 4
- as soon as i entered the room, a nice old lady was sitting on the chair. She seemed to be
having fun and happy at the same time.
- I greeted her and said sorry for her visual loss. I reassured her that she is in safe hands and
do not need to worry.
- Then perform PE
- All normal— visual acuity, visual field, fundoscope, light reflex, accommodation reflex, eye
movements
- I had some trouble opening fundoscope but luckily i was told how to open it up by previous
day candidate. So thanks to him, i can open it well. Even though if you dont know how to
open it, examiner will help you and you will not fail. So do not worry about that.
- Examiner waited until i had opened the light, adjusted focus on fundoscopy. Then told me it
was normal. So it is better if you are familiar with equipment.
- Then i checked her face for any signs of giant cell arteritis and felt carotid pulse and listened
to it. After that i listened to heart sound and ask examiner for full neurological examination
and ECG. She replied all normal right now.
- Then i told her it was called mini stroke and serious as it can happen again in the near future.
- for ddx- while i was telling her about temporal arteritis, time was up.
Another Feedback - PASS (Global 5)
Greet the patient. Explain that I will do examination to find out the cause of the loss of vision. Asked
quick question regarding loss of consciousness, weakness on arms and legs, everything is negative
and the vision is back now. Then I asked patient to sit down on the bed.
GA is normal. Asked for vital sign, I don’t remember is its normal or hypertension.
Inspection: no facial asymmetry, no redness or swelling around the eyes.
I used torch to check pupil, PEARL normal.
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Visual acuity: there is a wall Snellen chart (I’m not sure if it’s 3 meter or 6 meter) then asked patient
to read lowest line possible. Normal
Visual field: normal
Eye movement: normal
Funduscopy: I said to check the funduscopy I need to dim the light. Examiner said no need today.
Then while I’m doing funduscopy, examiner said funduscopy is normal.
After this I said, ideally I would like to do CVS examination. Examiner said its your patient you do it
yourself. So I asked the patient to lie down, bed still flat so changed it to 45o.
I did auscultation of the heart and carotid.
Ex: What are you looking for? Me: carotid bruit
Ex: what is the finding? Me: No carotid bruit.
I would like to finish my examination with the neurological examination of upper and lower limbs
(normal) and full cranial nerve (normal).
Then started explaining what you have most likely is amourosis fugax. There is a blockage on the
vessel of your eye but now it’s dislodge. It’s a type of stroke. Patient looked shock when I mentioned
stroke. Then explained that this is not stroke. Other DDs can be stroke, TIA, CRAO. Didn’t have time
to explain more DDx.
I forgot to check for pulsation on temporal area, do palpation of the eyes, and didn’t have time to
mention Temporal Arteritis as DDx.
8- Back pain for 2-3 days. History PEFE Dx DDx (Patient carried a heavy stone, now has LBP)
Sciatica as s1 and s2 lost sensation, SLR +ve, all others are negative
My performance
History – asked pain Qs and sciatica features (pain on lifting heavy load, shooting
downwards, took Panadol, mechanism – lifted bending back, occupation?, rule out cauda
equina – bowel bladder control ok, no numbness around back passage, inflammatory
reactions, previous history +, no LOW no LOA, no stiffness in other joints. No allergy.
PEFE – General appearance Ok, vitals Ok,
LL – ITPRCS
SLR + both side (left side is at 30’ and right side is better but I couldn’t remember the exact
figure given by examiner), S1 dermatomal sensation loss. DRE – normal anal tone.
DD – disc prolapse explained with diagram but I forgot to mention the term sciatica, muscle
strain, fracture, OM, Septic Artheritis, Ankylosing Spondylitis, Rheumatic Arthritic.
History 5
Choice & Technique of examination, organisation and sequence 5
Diagnosis/ Differential diagnoses 6
Global score 6
Your reference
A young male comes to your GP due to severe back pain after lifting an object 2 hours ago.
Task:
-take Hx for 4 minutes
-PEFE.
-explain ddx and most likely dx
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History
1-Back pain questions
-I understand that you are complaining of back pain so how severe is it from 1-10 1 is the
least 10 is the most. I would like to give you painkillers so do you have any allergy to any
medication?
-I understand that the pain started 2 hours ago. Can you tell me more about it?
Has it started suddenly or gradually?
What were you doing before the pain started? (He lifted a rock without squatting instead he
was bending forward.)
Is it constant or does it come and go?
Is it getting worse
-could you show me exactly where the pain is? (Buttock, thigh, leg)
does it go anywhere else?
-can you describe it for me?
-does anything make it worse? (Coughing, sneezing, leaning forwards)
-is it getting better with rest?
-has this happened before? (2 years ago)
2-associated symptoms
-is it associated with stiffness? Is the pain and stiffness worse in the morning?
-have you had any tingling, numbness, or weakness in your legs?
-any fever, LOW, LOA? Tiredness, does the pain wake u up at night?
-any trauma?
3-Cauda equine symptoms
-have you lost control of your urine? Or felt inability to empty your bladder?
-have you lost control of your bowels motion?
-any numbness in the lower back or private area?
-have you had difficulty obtaining or maintain an erection?
5-General
-do you take any medications? Steroid use?
-PMH (joint problems)? PSH? FHx?
-have you travelled recently?
-what do you do for living?
-how does the pain affect your life or job?
Differential diagnosis
1-mechanical back pain (gradual onset, no neuro signs or symptoms, no recent minor injury)
2-sciatica (pain radiates down leg beyond knee)
3-cauda equine (severe pain, urine retention or incontinence, faecal incontinence, saddle
paraesthesia, leg weakness).
4-fracture of vertebral body (sudden onset, trauma, steroid use, known osteoporosis,
tenderness over vertebral body)
5-spinal canal stenosis (pain on walking, improves by bending)
6-ankylosing spondylitis (pain at rest)
7-abscess (immunosuppression, fever, worse at rest)
8-malignancy( LOW, LOA, worse at rest, sleep disturbed, persistent > 4 weeks)
Physical examination findings from examiner
1-GA, VS
2-Gait
3-look (SSSDW).
4-feel (tenderness).
5-move (ROM)
6-neuro (tone, power, reflex, sensation)
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7-SLR.
8-DRE (anal tone)
Explanation
-from history and examination, you most likely have a condition called sciatica, have you
heard about it?
-draw diagram; these are your back bones and between each bone there is a cushion we call
disc, in your case the disc slipped out of its position causing compression on a nerve passing
here that what causes your back pain.
-This usually happens due to stress on your lower back after heavy lifting or sudden
inappropriate movement.
-let me assure that this is a common, not serious condition and its usually self limiting and
goes away in 2 weeks.
-there is no need to do any further Ix or refer to a specialist.
Management
-I will prescribe you painkillers to help with your pain, refer to specialist for MRI.
Rest and will give you medical certificate. but Keep moving around within your comfort
limit.
-what you need to do is some bed rest just for a short period not more than 2 days, just to
relieve the pain because prolonged bed rest actually prolongs the pain.
-the most important thing is to stay gently active and this will help your back to recover,
stop your back becoming stiff and your muscles from weakening and allow you to return
you to normal activity ASAP.
-refer you to physio for short course of stretching and strengthening muscles exercise. Once
the pain is ceased.
-Lifestyle modification;
-reading materials, review in 2 days.
-work: advise about proper bending and lifting heavy objects. Keep back straight when
lifting things and bend your knees. Don’t lift anything more than 10kg alone.
Another Feedback - You are HMO in ED, a middle age woman comes with acute onset of low back
pain. History. PEFE. Dx/DDx.
History 6, Choice and technique of examination 6, Dx and ddx 6, Passed 6
- when i entered the room, there was a woman in pain lying on bed.
- She seemed to be in much pain so i offered painkillers and showed sympathy.
- Then asked history. She had that pain while lifting a stone by bending the back. Ever since
then she was having pain.
- Location — low back pain, so intense that was affecting her life, travelled to buttocks and
thigh. Did not know about relieving and aggravation symptoms.
- No pins and needle sensation, no weakness, no bowel symptoms or urinary symptoms.
- No direct injury to back. No loss of weight and appetite.
- Pass history of low back pain present but it disappeared by itself
- Then PEFE
- I asked the examiner like i was performing PE on low back pain
- He asked me how to perform SLR test before giving answers
- I forgot to ask about slump test and shober test.
- ( i also forgot to ask about reflex in neurological examination. Luckily, the examiner
overlooked that)
- Then i asked him that i wished to check for anal and bladder involvement but he told me that
you dont need to.
- After that i told the patient that she was having a condition called siatica by drawing with a
diagram
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- As for the ddx— PID with lumbar raticulopathy, spinal canal stenosis, musculo liagamental
injury, direct injury to the back.
- Time was left in that case so i reassured her a lot in the remaining time.
Another Feedback - PASS (Global 5)
Hx/ Patient works as a landscaper. Moved heavy things a couple days ago, but getting worse now.
Pain shooting down to the foot. I asked which leg, patient pointed left one. Lying down bakes it
better, bend forward makes it worse. No problem with urination and bowel movement.
PEFE/ I asked for back examination. LOOK is normal. CRT (examiner asked what is CRT – so better
not to use the abbreviation in the exam), pulse, temperature, tenderness all normal. Movement is
restricted because of the pain to all directions. Then I asked for SLR test. Examiner asked which leg
you want to perform. I said I would like to do on the left leg first, then the right leg. Left leg:
restricted up to 30 degrees, right leg is normal. Then I continue with neurological examination.
Sensation: loss on the outer part of the calf and the side of the foot. Tone normal. Power normal.
Reflex: ankle jerk reduced.
I drew the backbone then explained that there is mechanical and non-mechanical back injury. He
experienced the non-mechanical back injury. Specifically disc prolapse because of the test is positive
and it affected the sciatica nerves. So this is sciatica due to disc prolapse. Other DDx can be muscle
spasm/mechanical back injury, spinal stenosis, and ankylosing spondylitis.
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29th, 30th, 31st May 2019
29th May 2019
PE
1. SOB and chest pain young patient respiration PE only. Read X-ray to both. Dx with reason (most
likely pneumothorax)
Another Feedback - A 20-25 years old man came with SOB. Task – PE, Inx, D/Dx (PASS)
Hi, I’m Dr. Moe. One of the doctors today. I checked VS first, did Resp: exam from back.
I told I need to do CXR and examiner gave me 2 CXR. I explained these CXR to patient and examiner
came close to me how I explained in CXR & where I pointed out.
Gave D/Dx & a bit of management (spontaneous pneumothorax, tension pneumothorax d/t trauma,
pneumonia, pulmonary embolism, anaemia, pleural effusion).
Another Feedback - chest pain – PASS - 4
Pneumothorax in young man - Same HB scenario given outside.
Front - Inspection tracheal palpation
Back - Inspection palpation percussion auscultation
Skipped vocal fremitus did vocal resonance.
Felt decrease vocal resonance on left side and mentioned - Don’t know whether it was right or not.
Not expecting to pass this as examiner was not happy with my performance.
And I asked x-ray without mentioning that I would do same from front.
Explain x-ray to patient and explain what pneumothorax is and spontaneous pneumothorax.
2. DM neuropathy - Hba1c and RBS increased. Do neurological examination sensation mostly. Ddx.
Another Feedback - 50+ yr man came with tingling and numbness. Clearly stated that he is diabetic &
has poor control. Task PE & D/Dx. (PASS)
Hi, I’m Dr. Moe. One of the doctors today. I asked patient to walk (examiner told me that it is fine &
to proceed). I did Romberg Test (It is normal). Ask patient to lie down & do inspection on the feet
(there were some brown patches on shin, I also included it might be diabetic dermopathy).
Palpation-Temperature, Pulse, then I checked sensation in details.
-Monofilament was given & no cotton wool given.
So I checked on sole & on dorsum for sensory level with monofilament (+ for the glove and stocking
pattern below knee level). I also said I will do dermatomal level and examiner told me it’s alright.
-I’d like to check for pin prick as well (I only told it).
-Check vibration (it was normal).
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-Check proprioception (lost under knee level).
-Reflexes are normal.
Complete with SLR test. Full neurological examination upper & lower limb, CVS.
D/Dx- DM peripheral neuropathy, Alcoholic, B12, Cerebellar Lesion, Nerve entrapment at back, CPN
entrapment.
Another Feedback - painful feet PASS - 5
Diabetic neuropathy - Real patient with chronic venous insufficiency
Gaiter area discolouration
Did look swift as well as ssrrmd
Feel ttpcneuro
Pulses normal.
Neuro monofilament 5 pressure points
Sensation dermatomal L45S1 on feet all neg then did glove n stocking till mid shin
Vibration sternum with consent plus did big toe, medial malleolus, tibial tuberosity positive
Proprioception just big toe that was negative
Reflex time finished just mentioned will do but like to skip and move on to next task.
Dx: diabetic neuropathy, Alcohol, B12, PVD
3. Tingling hand patient mostly night, Do upper neurological exam. Ddx.
Another Feedback - A middle aged lady C/O hand discomfort for few months. Tasks – PE & D/Dx.
(PASS)
Hi, I’m Dr.Moe. One of the doctors today. Do you have any pain at the moment or just discomfort?
She said it’s just discomfort. It was a Carpal Tunnel Syndrome (+) sensation loss in median nerve
supply area. D/Dx – Carpal T$, Ulnar nerve entrapment at wrist, elbow & brachial plexus level.
Another Feedback - Hand discomfort - Carpel tunnel syndrome PASS - 5
Wipe painkillers. Look swift ssrrmd
Feel temp tenderness palpated joints wrist to neck quickly
Pulses radial CRT quickly, Neuro TPRS
Checked tone in shoulder elbow wrist
Power c5 c6 c7 c8 t1 all normal
Skipped coordination
Sensation cotton wool n pin prick loss in c6 c7 interpreted it as median nerve distribution
“Didn’t think about used or unused items and even discarding toothpick or cotton after use”
Was thinking of pen touch outside but forgot inside
Did prayers sign (I know it’s reverse prayer sign but she gave me positive prayer sign don’t know
why)
Did Tinel positive at wrist, Negative at elbow.
Reflexes did bicep reflex on one side got it she gave all normal after that
Dx carpal tunnel
Draw flexor retinaculum and median nerve passing through closed compartment
Told compressed pregnancy or hypothyroid
Could not find time to tell ddx.
Thought examiner could fail me in this because I missed imp point pen touch card or froment sign.
4. hernia operation post op, Abdominal pain. Abdominal PE on dummy
Dull on lower tummy percussion (urinary retention)
Another Feedback - A post-op patient for Hernia came with tummy pain. Tasks – PE and D/Dx.
(PASS)
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Hi, I’m Dr.Moe. One of the doctors today. I did acute abdominal pain approach – asked about VS,
patient had taken pain killer already, Patient had pain in suprapubic area but when I pressed on SPA,
there was no urge to pass urine, wound is clear, no d/c.
In this station, the examiner asked me about percussion note (I told dullness) but I felt like he was
unsatisfied with my answer. I thought I’d fail that case, but he gave me accuracy score 5.
My D/Dx- acute retention of urine, trauma, UTI, Bleeding around surgical wound (unlikely)
Another Feedback - Abdominal pain (PASS – 6)
My performance was same like passed candidates
But I didn't perform the organ palpation.
Wipe >inspection asked to remove bandage examiner asked what will you find in 6hrs old wound
(obv nothing). Then he said it's normal >light palpation> auscultation bowel sounds present
Deep palpation avoiding area of pain
Bladder percussion
Bladder palpation asking for urge answer was No to my astonishment.
DRE normal
Hernia orfices "how will you check it" cough and looked opposite side and umbilical area
Forgot genitals.
Asked examiner for catheter he said no.
Told as urinary retention (anesthesia irritation infection-didn't mention any cause but you guys
should)
Paralytic ileus but bowel sounds present
Int or ext Wound dehiscence
Collection of pus or blood
N I also didn’t like the way I checked hernial orifices. As we avoid cough or increase abdominal
pressure in newly operated patient. Please ask someone for this. But as it was a case of inguinal
hernia so there is possibility of hernia on the other side may be that's why he was explicitly asking
about hernial orifices.
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Gyn
5. recurrent genital herpes - history of previous rash in vagina. Now burning pain on micturation
Mx and dx you can add few STI counselling.
Another Feedback - A young lady came to u with pain in private area. Tasks- H/O and D/Dx. (PASS)
History – Hi, I’m Dr.Moe. One of the doctors today. I asked about pain in details (typical history of
recurrent Herpes Inf & she is not having Herpes Inf at the moment).
D/Dx Ques, 5P Ques (Not always use condom, I think more than 1 partner during last 6 months), risk
factors, SADMA
D/Dx – Recurrent Herpes, Trichomonas, Bacterial Vaginosis, other STIs, Bartholinitis
Explained a bit about D/Dx and STI screening with consent & if (+) for other STIs, need to take Rx &
partner tracing, educate safe sex practice and told her to take medication for prolong period if it
happens again & told some general counselling & check her understanding.
Another Feedback - Valvular complaint – PASS - 4
Stem: young female had 3rd episode of ulcers on genitalia. Task: Hx, Ddx, Counselling.
I had herpes in mind, told confidentiality, Asked about nature of ulcer- pain discharge, fever, itchy,
anywhere else similar ulcer. Partner? Safe sex? Weight loss, lumps bumps, periods, pregnancy
Inside the room when I asked her if she is in pain or anything, she said right now she doesn’t have
anything at all. But she had previous episodes of ulcers on genitalia. now she wanted to get herself
checked that why did she have those ulcers and any other serious problem going on because she has
started a new relationship recently.
So I took history of the ulcers (1st episode was very painful later episodes were not that bad)
Had 3 or 4 sexual partners previously. Was on the pill so didn’t use condoms all the time.
All other things negative
Explained her the ulcers are related to HSV and it’s an STI and causes of flare up
Then told other sexually transmitted infections and that need to do complete STI screen including
some blood tests, urine tests. Cervical swabs and if any active ulcer swab of that she said no I don’t
have any at the moment. Explained in blood will be doing HIV as well and that I need your written
consent.
DDx- said herpes, chancre, chancroid. Safe sex education and Reading material.
Another Feedback - VULVAL COMPLAINT (5 4 4 4)
A young lady with prior history of genital ulcer around 4 episodes , has come to seek you advice .
Tasks: history, Diagnosis, Further management /counseling
I entered and greeted the patient who was a pretty young girl and asked her concern, she
immediately replied I have had these ulcers and I want to know more about them , I told her you
have done the right thing to come here and assured her that I am going to find out the cause and
will do my best to help her. Asked her can you tell me more about the ulcers (it was mentioned in
the stem that she does not have any ulcers at the moment ) she volunteered most of the
information like number character of ulcer, it was only limited to her private area, it did not bleed
but was painful, did not develop significant fever, she further added that I had trouble passing urine,
there was no discharge or abdominal pain associated with it. The first episode was most intense
lasted a couple of days (she had to pass urine under water during that time) rest of the episodes
were milder, upon inquiry she told that she did not seek any medical advice for these.
I then appreciated her for telling me all about it ensured confidentiality and took detailed sexual
history (it’s the key point here) she had multiple sexual partners when asked about safe sex practice
she said I take hormonal tablet so only sometimes condoms are used
Asked about current partner and if there are any symptoms in him.
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Her monthly cycles were regular, pap ( she said I never had any which sounded unusual to me I said
I’m going to arrange one for you) she never got pregnant before and had nothing significant in
medical history .
Diagnosis: recurrent ulcers due to genital herpes (a sexually transmitted infection) which she
acquired due to unsafe sexual practices ( I drew a picture and explained )
Counseling: Started with safe sex practice advice as this has been the reason she got them and
elaborated it . I then focused on telling her the STI screen, she said I don’t know about it doctor? I
explained all the tests urine blood samples and swabs are to be taken and her written consent is
necessary for that, briefly told her about all Sexually transmitted infections including HIV. She was
extremely cooperative, nodded and said she is willing to do these tests. Gave reading material too. I
finished early as I did not go deep in to history (plus the role player volunteered quite a lot of
information that saved my time)
In order to avoid the awkward silence in the room I said your ulcers could have been due to other
causes ( syphilis, papilloma, chancroid and one other differential that I cannot seem to recall) told
her why they are unlikely. plus told her what to do in case she again gets the ulcers.
6. Patient 20 weeks pregnant wants CS not vaginal delivery. TORCH screening not done on time on
hx
Tell risk benefits of CS and further mx plan.
Another Feedback - A woman in her first pregnancy (I forgot gestational age) came to your GP to
discuss about C-section. Task – History and Counselling (Roleplayer was wearing dummy belly).
(PASS)
History- Hi, I’m Dr.Moe. One of the doctors today. Congrats her pregnancy as it is planned.
I asked about complaint & reason for it (she wants to know all about it, no specific reason).
Asked about blood test and blood group(she told me she didn’t know her bld group but I’m not sure
for that answer), USG & so on(until her gestational age).
-SADMA
Counselling -told her about Indications of Elective CS & Emergency CS(told only 4 points for each).
-Complications & Disadvantages of it
-Advantages of Vg Delivery
-Explained about Pain issue
-Explained about Incontinence issue
Told her to take time to discuss with your husband and family, I could manage Specialist Visit for her
in further visits if she still has concern.
Another Feedback - I passed with all 4
After welcome patient, I confirm patient’ concern, so asked reason. Patient said avoiding pain + easy
way heard from neighbor.
Then I asked 5 P Qs (all negative), previous surgery, antenatal Qs.
Next come to Counseling:
explain CS with a draw, It’s a surgery so give more details about risks/side effects: anaesthetic,
bleeding infection injury to other organ, recover slowly... so not easy to recover
Then comparing :draw 2nd column about nature birth, it’s advantages: short pain, recover quickly,
less complications
Make sure patient understanding.
Mentioned consult specialist rather than neighbour.
In Mx I just said one sentence as bell rang, I was stressed and thought would fail this station as didn’t
finished Mx. Should mention further antenatal care and arrange future specialist counselling.
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Regarding natural birth+pain, mentioned about medication, epidural and it’s very effective for pain
relief. I spent a bit of time in hear so a little left on MX.
7. vaginal discharge yellow brown
Speculam atrophy vagina
Stable relationship but not used condom
Dx atrophied vaginitis with ddx
Another Feedback - 50+ years female came with vg d/c. Tasks H/O, PEFE & D/Dx. (PASS)
In this case, I tried to elaborate on my D/Dx, but I was too focused on each D/Dx and could only give
3D/Dx & my time ran out. So I didn’t give too many details in later cases but I tried to present at
least 4 D/Dx in other cases.
In History, I asked about the discharge related questions (it was a typical case of atrophic vaginitis).
D/Dx Ques for allergy, UTI, CA, DM
5P + Risk Factors
SADMA
PEFE GA, VS, BMI – High , Abd exam, Pelvic exam-Inspection, sterile speculum exam with swab
taking, BME Office test-UDS & BSL
D/Dx- Atrophic Vg explained more about it, Allergy, UTI, time ran out
Another Feedback - Vaginal discharge – PASS -5
In history I Missed pap mammogram STI asked in the end some of them. 3-4 pads of brownish
discharge, no weight loss lumps bumps CA history, or family history
5Ps HRT use sexually active. Dyspareunia+, BMI - high
Med sx history
Pefe: positive of atrophic vaginitis. Bimanual inspection normal.
Dx was atrophic vaginitis plus hyperplasia or CA Give all dds from down below cervical uterine
Paeds
8. pain on right leg 4 years boy after waking from sleep with tummy pain but No UDT available.
Rash on ankle photo no blanchable but looks like both insect bite and HSP confusing.
Another Feedback - A father came in because his son C/O sudden limb pain and worried about it.
I felt uncomfortable in this station because I needed to repeat a lot of questions to roleplayer.
Tasks – H/O, PEFE, D/Dx. (PASS)
Hi, I’m Dr.Moe. One of the doctors today. I reassured father and any pain killer for his son.
I asked about how did it happen, any previous history, was he able to walk/not.
I need to ask more pain Ques (that’s why I got only 3 in H/O).
D/Dx Ques – trauma, fever, bleeding H/O, tummy pain, well baby Ques.
Prevalence of poisonous animals near his house (like spider, snake). BINDS, happy family
PEFE – GA, VS, Gait
Examiner gave me 2 photos of bite area (I could see some sweating on the skin).
I forgot to ask details about bite marks after receiving photos (might be reason for score 3).
I quickly asked lower limb exam & the examiner told me other systems are normal.
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D/Dx – Explained about my D/Dx & a bit of management. I told poisonous bite (spider, snake, ant,
bee sting), trauma, bleeding disorder (unlikely).
Even if there was no task for management, I told a bit of it like we will monitor him, he will be seen
by a senior and specialist, he is in safe hands now, if needed, we will admit him. We will test with
venom kit and if needed, he will be given anti-venom. Rechecked understanding (I told exactly the
same in this case, I think that’s why I passed this station).
Another Feedback - LIMB PAIN ( 4 4 4 4 )
A boy aged 5 ( or maybe 3 ) has been crying after waking up from his nap . father is here to talk to
you
Tasks: history, PEFE, DX DDX( ASSESSMENT AREA)
MY APPROACH : the role player started with the statement “he has been crying since he woke up
“ reassured him and asked him to tell me what was the child doing before he went to sleep . the
boy was playing in the garage( or backyard ) where mum was cleaning , woke up and crying due to
pain in leg . the father said I am not sure if he fell or had any trauma before that . the child’s leg
did not seem warm to him and he said he has seen some bite marks but no discharge , no fever ,
joint pain , vomit , no rash anywhere. I very briefly asked about BINDS . NO prior history of allergy
, vaccination was up to date .
PEFE : GA ( the child was sweating ), VITALS ( Heart rate was high , BP NORMAL , NO FEVER ,
RESPIRATORY RATE WAS FINE )
ALL SYSTEMS : UNREMARKABLE
LEG : A picture was given it was of poor quality very blurry and vague , it showed bite mark and
local sweating that’s it )
No office tests were available.
DX. I said insect bite then said could me due to spider most likely or other bugs elaborated that a
bit , gave other differentials cellulitis ( no fever ) , trauma / fracture ( no swelling n bruising ) ,
Septic Arthritis , OM , allergic reaction , stated why they are unlikely .
The role player displayed great amount of concern and kept asking me if his child is going to be ok,
I tried my best to be as empathetic as I could.
9. Burn with coffee in 18 months baby -10% erythematous on chest. Mx and hx.
Another Feedback - A woman (Aunty of a baby/child, forgot age) came to hospital with complaint of
burn injury to her nephew. Tasks – H/O & counselling. (PASS)
Hi, I’m Dr.Moe. One of the doctors today. First, I would like to check VS (stable, burn surface area
less than 10 %, I think it’s on the chest area).
I asked about the burn in details (how it happened, is it the first time, any other area, was he well
before accident happened). The first aid measure was already done when I asked roleplayer because
she called an ambulance and did first aid according to the instructions. I appreciated her & also
reassured her that baby is in stable condition now and asked her relationship with baby. She said she
is his aunty and asked about the parents, she told something but I forgot (no concerning points, she
already informed parents and they are on their way to hospital).
She was with baby when the coffee cup was spilled onto baby’s chest as the baby was trying to take
the cup.
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I asked about well baby Ques, BINDS, happy family.
Mx & Counselling – I told her we will monitor the baby although he is stable right now. I think I need
to admit the child (that’s why score 3), I will liaise with my seniors and told a bit of burn Mx.
Need to be more careful next time esp handling hot drinks. I felt like I needed to tell one more point
but I couldn’t think of it at that time. In my scoring graph, the average score is 3.5 and my score is at
4, that’s why I passed the station. Thanks to the examiner.
Another Feedback – Burn PASS -4
Expecting to fail because I was focusing too much on the accident rather then managing it.
Was asking baby’s aunt again and again about incident home situation. Manage as per RCH
But it was <10% mentioned usually we don’t admit it but I would like to admit n call my senior
(intention was suspicion of NAI but didn’t tell anything to aunt)
Got 3 3 in management and patient education
Did mention about social worker and stuff for any help at home
But did not talk about reading material for home safety.
Didn’t mention word superficial burn because of lack of conc.
As it was mentioned in PEFE card as erythema
No previous burns or bruises (ruling out NAI still I was adamant to include this in my main mx don’t
know why.. again lack of conc
Another Feedback - She specifically asked me will the child develop a scar? – superfacial burn, don’t
worry about scar…
10. child 11 years with not sitting properly but rest examination normal. Take social history from
parents and Dx and mx.
Another Feedback - A woman came to you to do a check-up for her child (maybe 18 months)
because the child just started bubbling or rolling (I forgot details). Tasks – H/O, PEFE, Explain. (FAIL)
I’m not sure of this case, pls check with other passed candidates.
Hi, I’m Dr.Moe. One of the doctors today. In history, developmental milestones was normal for fine
motor and social area. No trauma history, BINDS normal, heel prick test was done & normal. Both
parents are working in a hotel with management level & they sometimes took their child the
workplace. (I have no clue related to that point)
PEFE – the child has no features of hypothyroid, Down’s $, tone was normal, growth chart was
normal as well, PEFE clearly states most things are within normal range.
Although I asked about D/Dx in PEFE, I didn’t say out loud to patient which things I had excluded for
your child like Hypothyroid, D$, CP. I only said that it might be delayed speaking & walking. We need
to do some tests & I’ll liaise with my seniors as well. We’ll do frequent monitoring & follow-ups for
your child.
Another Feedback - CHECK UP ( 5 4 4 3 )
An 11 month old kid with a very detailed history given regarding his milestones , all were normal
except that he is unable to sit unsupported ( I am not certain as maybe or may not be another delay
was mentioned but I remember this only, my Apologies ) Tasks : take history from parent and social
history ( it was mentioned specifically ) PEFE, Dx, ddx, Management
My APPROACH : Inside was a nicely dressed lady as the mom I was supposed to talk to, she had a
pretty cool vibe about her. I greeted her appreciated her for coming to see me regarding her kid and
asked her concern, she said I don’t have any concern it’s my Aunt who thinks there is something not
right about my kid. I asked what exactly is the aunt bothered about ( any behavioral or
developmental issue ) she said my Aunt thinks he’s not like her kids as they used to be at her child’s
age .
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I then held the question paper that sated all the child’s milestones and checked with her very briefly
that I can see you have already mentioned all of these about your child so I will quickly go through it.
Then took the history regarding child’s birth, her pregnancy ( it was her first ) Child’s birth , feeding,
immunization, any allergies or significant illnesses, head injury, abnormal posturing ( there was
nothing positive ), child was thriving well on growth charts .
Social history: a happy family, both parents work in a hotel and the child was taken care off by hotel
staff (weird right!!) I very politely inquired to which she said we are satisfied with it, also the child
seems really happy with both of us and she made it sound as if she has the happiest family in the
world. lol!!
A detailed PEFE card was given showing no abnormality in any systems
Neurological examination: unremarkable
Time to tell her what is going on, honestly I was very unsure I stared by saying CP and then had a
look at the card again and apologized profusely , just mentioned I’m suspecting some delay though I
still have to refer for further evaluation, I only uttered Cerebral Palsy ,head injury and
Hypothyroidism as differentials didn’t get the time to explain them but now that I remember I did
say it all could be normal too but to be on the safe side the child must be evaluated properly , bell
rang !
Med and surgery
11. SOB 67yrs old women farmer. Hx n ddx.
Needs pillow and PND, f/h of heart problems and own h/o HT DM and cholesterol high.
Another Feedback - An old woman is having SOB. Task – H/O and D/Dx (PASS)
H/O – Hi, I’m Dr.Moe. One of the doctors today. Asked abt SOB in details. Asked D/Dx Ques, Risk
factors, FH, SADMA (Positive H/O was she’s a farmer and is living in a farm house, cardiac symptoms
are (+), LOW & LOA (forgot her answer).
D/Dx – Heart failure (first priority), Occupational Lung ds, CA lungs, COPD
Sorry, I forgot other D/Dx that I gave, I checked patient understanding.
I left about 1 min in this case, just sitting in front of patient awkwardly.
Another Feedback – SOB PASS -4
History got 5 ask all points and typical SOB history
Family history of heart problem in brother and deaths positive
Wheat farm worker, Medications paper ace statin +?
Dx heart failure draw, Ddx occupational, Missed ACEI induced cough as dry cough was there ddx
4score
12. acute upper abdominal pain with a pot in hand for vomiting.
Pt was in bed lying down so ruled out pancreatitis and pericarditis.Pain on deep breathing .Ddx and
Dx
Another Feedback - A woman came to hospital with tummy pain. Tasks – H/O and D/Dx. (PASS)
Hi, I’m Dr.Moe. One of the doctors today. The roleplayer was lying on bed, I checked VS (stable),
offered pain killer after checking allergy. She was having pain in epigastrium-gave typical H/O of
pancreatitis-having some vomiting & was holding a plastic bag/jar in her hands (I totally forgot about
that jar and in my mind I was automatically thinking it was for her vomiting), asked pain questions,
D/Dx questions, binge drinking (+), asked some risk factors, SADMA.
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D/Dx – acute pancreatitis, gastritis, trauma, cholecystitis, hepatitis (with a bit explanation for each &
time ran out).
Another Feedback - Abdominal pain PASS – 4 Pancreatitis
1-Is my patient hemodynamically stable (VS and O2 Sat)
2-Pain questions-severity (painkillers + she denied but still she was in pain, onset? Sudden or
gradual? Constant or come and go? Getting worse? (2-3 hour ago, sudden, constant, getting worse)exact site and radiation? (epigastrium, radiate to back) -character? Does anything make it better like
sitting or leaning forward? (relieved by leaning forwards) does anything make it worse like
breathing, coughing, movement or fatty meal? (worse on lying down) If it is the first time? Or any
other type of pain on right side (gall stones) LMP
3-associated symptoms-missed vomiting(other were saying it was there)-Bowels and bladder (esp
colour)-fever, rash and recent infections-LOW, LOA, lumps and bumps-yellowish Discoloration of
skin, itching-chest pain, SOB
4-General questions-Past medical history (gall stones, stomach ulcer, hyperlipidemia, DM, HTN-past
surgical history -medications -Smoking, ALCOHOL yes
Any binge drinking? She wasn’t happy giving this info to me and said 1 or 2 bottles last night
Causes of pancreatitis (GET SMASHED)-gall stones –ve, ethanol +ve
Dx pancreatitis several reasons gall stone not in you, Alcohol most likely
Ulcer, gastritis, GERD, esophagitis, MI, pneumonia, Cholecystitis, stone, hepatitis, trauma
13. diarrhoea- for 6 months Pilot Travel to Bali and took street food 8 months ago. Giardiasis and ddx
Another Feedback - A woman came with tummy pain. Task- H/O & D/Dx – asked pain detail Ques,
diarrhea (+), features present for all D/Dx of diarrhea differentials (Giarrdiasis, Coeliac d/s, IBD,
Antibiodic, Cancer (unlikely).
Another Feedback - “As this is a chronic diarrhoea, I need to put DDs of Chronic diarrhoea, such as
Coeliac, giardiasis, amoebiasis, IBS, IBD, Causes of malnutrition and malabsorption such as previous
gastric surgery, hyperthyroidism and psychogenic.
Inside, young male was sitting comfortably.
Me: I’m so sorry to hear about diarrhoea. Is it ok if I ask you few questions to come to diagnosis so
we can help you better. Patient: ok.
Me: Can you please tell me more about your diarrhoea?
Patient: Got this diarrhoea since last 2-3 months. (that’s all he said)
Me: How many times a day (4-5) (I think patient said not every day, I may be wrong), color (yellow),
consistency (watery sometimes semi liquid), Any blood (no, to rule out amoebiasis, IBD), float on
water (yes), difficult to flush (sometimes), any mucus (no), weight loss (mild, I don’t remember how
much). Any food relation such as wheat, barley, rye (no), any medication to relieve (no)
Me: R you taking any antibiotics (no), weather preference (no), alternative constipation with hard
ribbon pallet like stool and diarrhoea (no, to r/o IBS).
Me: any work or family stress (no, to r/o psychogenic and IBS)
Me: any gastric surgery (no).
Me: Any recent overseas travelling?
Patient: yes, Bali, 3 months earlier.
Me: Where did u stay? Patient: In good hotel. me: where did u eat Patient: Mostly hotel.
Me: Did you eat street food or drink non- bottled water. Patient: no
(here I got confused as I have made up my mind for Giardiasis)
I asked about present, past and f/h according to Karen’s s here I had lots of time because of history
and Dx and DDS only.
Dx: Me: from the history, I believe you are suffering from condition called giardiasis, have u heard
about it? Patient: No
Me. It’s an infection from a bug called giardiasis. It is transmitted by faeco-oral route. You may have
got it from food in Bali. Although you have not eaten outside it is still possible to get it.
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There could be other conditions, these are all less likely such as Amoebiasis, other bug but less likely
as u don’t have any blood in stool, Coeliac disease where u are sensitive to gluten (less likely because
it does not occur after certain food), IBD less likely because no blood in stool, IBS less likely due to
lack of stress and constipation, thyroid less likely due to no symptoms for thyroid disease.
Global: 6 (4,6,6) Key steps: all 5 Yes
14. 25-30 years old man is feeling unwell and came to your GP. Task – H/O and explain. (PASS)
Hi, I’m Dr.Moe. One of the doctors today. The roleplayer was continually blowing his nose during
consultation. He got runny nose for months and had H/O of Asthma and took puffer for it. He had
this runny nose esp in winter months. I asked about relevant respiratory symptoms. He has a cat and
vacuum his carpet regularly. He already took medications for his symptoms but was not relieved. It
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was affecting his daily life. I asked about smoking h/o (didn’t remember his answer). I think family
h/o (+). I went according to the flow but my h/o was not too organized.
Counselling and management
D/Dx – Hay Fever, Asthma, Chronic sinusitis, medication
I explained about his condition & some pathology of it, told him he needs to get rid of risk factors
because he’s having some of it.
I will check his medications (technique & doses), if needed, will refer to specialist for his condition
and to allergen specialist as well. Checked his understanding.
Another Feedback - Young female real patient. Tasks were Hx and Dx ( as far as I remember ). I got 5
in all domains assessed.
My findings from Hx : runny nose, itchy nose, sneezing, itchy /watery eyes
Patient moved house , previous house no carpets, new place carpets (positive).
Also patient has a cat and started to sleep with her pet (same room).
Patient is known asthmatic on PRN Ventolin, no steroids.
Tried antihistaminics, didn’t really work for her.
Started to cough night time, doesn-t get enough rest .
Postnasal drip (feels secretions that cannot take out at the back of her
pharynx)
Besides these findings I’ve asked; “ Do you have an asthma plan, Tx ?” Well controlled?
Are you known to be allergic /seasonal allergies? Did you get allergy testing?
Anyone else in your family/partner with the same symptoms?
I started with open question after introducing myself.
The patient was cold to me but she was ok, answering my questions. She truly looked distressed so
it was real patient.
I said, from the history and because you have these symptoms for a while and you are asthmatic it
looks like you are suffering from allergic rhinitis. It is common for asthmatic people to experience
this and the postnasal drip, I can imagine how hard it must be but don’t worry this will resolve by
avoiding the triggers which in your case seem to be sleeping with your cat during the night and it
might also be the carpets . It is well known that allergic rhinitis, asthma and postnasal drip can get
worse /flare up from the dust mites that the carpets contain . Please, consider this and think about
taking away the carpets or treat them /clean the well.
It could be just common cold, sinusitis, conjunctivitis, seasonal allergies, upper respiratory infection,
nasal polyps but is unlikely in your case.
I would also like to refer you to an allergy specialist so he might run some tests for you. I will work
out an asthma plan for you as well so you can get better sleep and have it more in control. It looks
you are experiencing an asthma flare up at the moment.
The patient looked sad and she said something about feeling sorry not to have her pet in her
bedroom. I said “I can imagine it must be hard but unfortunately this has to be done in order to feel
better “. You will feel better once you remove the triggers.
Some info: postnasal drip- excess mucus that accumulates and drips down the back of the nose
and throat. This is a symptom, can be caused by cold temperatures, dry air, hormonal changes,
chemical irritants and nasal sprays. I think this symptom is a key word in this station.
Also I think it’s important to start in here by explaining allergic rhinitis -is caused by a reaction of the
body ‘s immune system to an environmental triggers (dust, molds, polen, grass, trees, animals).
Asthma and allergic rhinitis are related health conditions.
Remember the triad -Samter’s triad – NSAIDS sensitivity (aspirin) –asthma - nasal polyps
FOR TX – VERY IMPORTANT – get rid of the causative agents.
Psych
15. MSE schizophrenic patient
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Mood black hole and congruent with effect.Reacting to unseen stimuli and auditory hallucinations
Keep sleeping pills. Dx was not in task but present MSE
Another Feedback - MSE video case – it was a pilot case, the conversation was very clear. The
patient was having hallucination and a bit depressed. I go with ABSEPTICJS RRR approach. It was
clearly stated in Ques Stem, no need to give D/Dx. So I just told to admit patient due to the risk.
Another Feedback - MSE depression
So case was a guy standing in a video. May be some room in AMC centre. Clearly suicidal. Diagnosis
was not required was major depression. Have some guilt towards his parents. Past and future plans
positive
16. mania- patient doesn’t like to sleep. Talk fast student in university, increased sexual activity
Doesn’t need help. Thinks he knows everything.
Mx— admit and psychiatric review and antipsychotic with mood stabilizer
Another Feedback – PASS – 4 Mental health assessment -Mania has given outside.
Ask all foundation questions but in a filtered way not to repeat info. Management was main domain
of assessment.
Admission, Senior, Organic work up mention all Ddx.
1st time, Antipsychotic or lithium, CAT
Mania, psychosis, actively suicidal shouldn’t leave the premises.
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Another Feedback - A young female, I think a university student C/O maniac features (I didn’t
remember exactly). Tasks – H/O, D/Dx & Mx. (FAIL)
Hi, I’m Dr.Moe. One of the doctors today. In history, roleplayer gave me many information
voluntarily acting like she was having high mood, giving all positive -/s of mania.
D/Dx – mania, manic phase of bipolar disorder, hypomania, substance abuse
Mx – I didn’t admit the patient, I just referred to specialist (I think that’s why I failed).
30th May 2019
1) Change in behavior - Patient was diagnosed with schizophrenia last year and was taking
medication now having bizarre behaviour tasks - Hx and dds. (PASS – 5 each)
Outside I heard a laugh and I was like don’t know what she is going to do with me but I
thought I will stay composed
I went in and greeted, patient was a nice girl sitting I started how can I help you, (please
this is a very important question, let your patient talk , don’t save your time by saying I
know you have this problem , you will save time but lose the station)
She said my parents are worried about me, I asked what is their concern? She said I have
been able to hear thing and messages.
So here I gave her confidentiality and said what are those messages she said something, I
said are the voices asking you to certain taks? Or giving you commands? She said no I have
been chosen by God.
I said is this what happened before? Were you getting same messages before? She said
they are making more sense now, I asked do see or feel something as well which others
can’t, no
I asked when was the last time u visited your specialist - year ago
Why left medication - don’t need it. Any side effects – no.
Any problem purchasing medicine – no I don’t need medication.
Who used to give you medication – can’t remember her reply
Then I completed my ASEPTIC IJRRR
Only delusion of grandiosity and insight was lost rest was all normal
No suicidal ideation and no drugs good support by parents
So I started giving dds.
I said relapse of schizophrenia but because I don’t have notes from your previous doctor so
I’m not sure. Could be new onset schizophrenia but again we need notes from previous
doctor.
Mania, Bipolar disorder, Drug induced psychosis.
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2) Obesity - plot on growth chart (weight & height) for 10 years child with controlled
asthma and sedentary lifestyle, counsel the parents accordingly.
The same question that kid was diagnosed with asthma has an updated action plan which is
working well, came for normal checkup. PASS - 6
I went in, greeted them , mum was almost lying in her chair, examiner gave me graphs for
weight and height.
I plotted them with caution but very quickly because I wanted to save time for
conversation
He started with 40th centile at age 4 but at age 12 he reached more than 97th centile
So I started explaining mum that I’m happy with height chart but now look at this weight
chart, can you appreciate these band of lines, she sat down and stared looking on it, and
said yes, I said we normally expect kids to be under these line if someone is above or below
its not good, if below lowest line its failure to thrive and if more than 90 it’s overweight and
when more than 97th its obesity.
Then I explained initially your child was fine then he kept on increasing in his percentile first
he became overweight and now he has crossed 97th centile. And has become obese, she
said really, I thought it was in our bones we all are like this, I said then we will talk about
your rest of family as well.
I asked diet she said mostly take aways. Exercise no because of fear of asthma. Watching
TV all the time. I said first I will refer all of you guys to dietician. And you will have to start
cooking at home because these take aways have too much processing and calories which
are not good, please cook at home and use vegetables and fruits
Start going out for a walk as a family this will help u spend time together and your health
will also improve.
Let him do activity but give him a puff before it, but activity does not mean he starts gym
next day, just start with walk and then keep on increasing.
I’m happy with action plan still if u find any problem please come back.
3) Obstetric Examination - Passed GS 4
The patient came for her regular antenatal checkup, as she is new in this town, Do
examination and I don’t remember the rest of tasks.
Greeted and said I know you are new here, how are you doing, do you like this place baby
kicking any pain or discharge? Then put on gloves and started with her hands looked for
pallor
Then eyes for pallor then tummy Inspection>>>obvious bulge in tummy no other positive
finding Then started palpation first superficial palpation Then checked fundus, then lower
pole then all 4 manouvres, it was oblique lie, I said that then palpated for back then I
listened to fetal heart, examiner gave me the clock again and I tried to count heart beat but
I could not count in stress so I just gave random beat of 140, she what? I said its 140. She
said ok then, I forgot fundal height.
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Then I said I will finish my examination with pelvic examination, she said ok do it, I checked
dummy there was no pelvis there , I said there is no pelvis she said that what is the point
why do you want to do it then, I was like ok.
Then went to the patient told her normally baby is lying with head down but in your case
baby is lying obliquely it could have been transverse lie but it’s not, I said besides this
everything is fine heart beat is good and you don’t have a problem so I will just refer u to
the specialist to have a look on you she might decide to do external cephalic version in
which they will put some pressure on tummy to rotate the baby but totally depends on
your condition and decision of specialist, if done may still lead to caesarian section and if
we do nothing and baby does not change position himself then we can’t go for normal
delivery, it will be a caesarian.
4) Neck lump in adult (midline, firm, nontender) hx,pe and ddx
5) Atrial Fibrillation Counselling - A lady who had high blood pressure had some racing of heart, was
brought to the hospital and ECG was done which show atrial fibrillation. Explain patient what is AF.
What are the causes for her condition. Tell her what will be the next step in management, only
referral to specialist is not sufficient. (PASS – 5,5,4,5,5)
I went inside and greeted the patient and asked how are you doing, she said I’m good, I said plz
excuse me bcz you were having some racing of heart so let me confirm if you are stable enough
right now to continue, examiner said she is stable. So I told her we did your ECG which is electrical
rhythm of the heart like current running in our house our heart is run by current as well, I drew
normal ECG and said usually ECG is like this then I drew AF and told in your case, ECG waves are very
close, can you appreciate this? She said yeah, Then I drew a diagram of heart which was very poor
so I said I’m sorry for this picture so forget about this I will explain you with my hands, I said that
normally our heart beats like this (I opened and closed my hand) but in your case your heart is
beating like this, (and showed tremors of my hand) she picked it and said ohh its basically tremors of
the heart, I said yeah I really appreciate your understanding (this word did not come to my mind ) so
I said there can be many reasons for this, I see you have high BP are you using any medication for
that? She said I was but then my BP became normal so I left them, I said were explained by your
doctor how you have to continue your medication? She said no. I said BP medication need to be
taken lifelong no matter how much your BP is under control, the day you leave medication your BP
will come up high again, she said ohhh I was not told like that. I said don’t worry we will manage
that for you because high BP can damage your heart so probably this is the reason you got a fib.
Then in implications I told this a fib causes heart to work like a blender so there is too much
blending of blood in your heart which is going to make clots and then these clots can go anywhere
in your body. I tried a drawing again like I tried drawing of body but it was bad again so I said plz
forgive this poor drawing I tell you anyway clots can go in your brain and your gut and every other
organ of body and stop the blood supply, she became worried so I said don’t worry we are here to
take care of you and won’t let that happen. So I am going to refer you to specialist who is going to
do an echo of your heart which is basically an USG they might do some basic bloods to have a look
on them and the will do USG of your neck vessels , and then they will start your treatment. If
specialist thinks he wants to control rate of your heart he will start you on b blocker but if he thinks
it’s your rhythm which need correction first he will start u on amiodarone, but whatever it is they
will start u on heparin injection and warfarin as well to keep your blood thin because it’s prone to
clotting. After some days they will stop heparin and continue warfarin for long time but bcz warfarin
can make blood too thin as well and your heart can cause clotting so we have to maintain a thin
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equilibrium where your blood will be just perfect, not too thin n not too thick n we will keep
checking your INR to make that sure. You will be given BP medication as well bcz controlling ur bp is
very imp. Checked understanding.
6) 45 years old lady has some problem in her knee. Task - Knee Examination. Ddx. PASS - 5
Greeted and washed hands (people always say that sanitizer makes hand too wet, so
please don’t keep hand under it for long just put it under and take it back, it will only give
you few drops to complete the ritual)
So I started with gait – normal. Squatting - painful
Inspection from front and back – normal
Then asked to lied down. Palpation – normal
Movements active – normal, Passive - Crepitus on left knee
Then I said now I’m going to do special tests.
Examiner said when you are doing it you have to talk to me about findings.
I told him she has problem with squatting and crepitus is positive.
Then I did all the tests patellar tap, swipe test, valgus n varus, Patellar apprehension, Clarke
test, patellar grind Appleys grind test All normal
I told most likely you are having osteoarthritis of knee which is wear and tear of knee with
time, could be rheumatoid, Chondromalacia, Ligament rupture, tendon injury.
7) Shoulder PE (after falling down)/ rotator tear/ Dx,Ddx to patient.
A 45 year old lady had an accident yesterday since then she is not able to move her arm
Do relevant examination. Give DDx. (PASS -5,5,2)
Actually the stem was too much twisted and I could not figure out if I had to do shoulder exam or
clavicle exam so I went in and started with clavicle inspection and then shoulder, I mentioned there
is no tenting of skin, no step deformity, no obvious bruise no active bleeding , then on inspection of
shoulder right shoulder is lower than left one( she was standing like that) curvature of spine intact.
On palpation I kept everything very gentle as I was scared she might have a fracture because of
accident, I palpated clavicle and shoulder joint and then scapula.
Then started the movements. She was taking almost a minute to move her arm, I kept on saying
sorry everytime she would moan, she could not move her arm above head, I told every positive
finding. Once finished I started doing passive movements which because of her pain I did very slowly
and gently and kept on saying sorry which wasted all of my time and when I said now I will do special
tests examiner said give your DDx
As I could not do any special test so I had no diagnosis in hand I said: Shoulder dislocation, Fracture,
Rotator cuff tear, Supraspinatus impingement And surprisingly I passed it.
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8) cerebellar signs PE( real patient), frequent falls, DDx
It was a long stem saying patient had been drinking 6-7 glasses of beer for pas many years and now
she is unable to walk. Her upper limb examination is done and lower limb sensations are normal do
relevant examination on lower limb. Give dds. PASS - 5
I started with gait, patient was very unstable I stayed with her and then I said you are
clearly not able to maintain your balance so please lie down I’m going to skip Rhomberg
test
I did inspection, there were some dilated veins, and discolouration on legs and skin was
pale
Did tone. When I said I’m gonna check power examiner said its normal. Did reflexes which I
think were normal. And did heel knee shin test which came positive
Gave dds: Cerebellar ataxia because of excessive alcohol, told u have been drinking a lot
which damages the back of our brain called cerebellum and this is causing unsteadiness
Could be alcoholic neuropathy but les likely bcz your senses came out normal
Could be diabetic neuropathy but less likely
Brain tumour but least likely
9) Frequent headache in 10 years old girl + papilledema pic
10) 5 years chronic cough (yellow sputum), adult, nonsmoker, bank accountant, no travel
hx, no meds hx... all negative... Hx, ddx
Another Feedback - A 25 years old male with cough comes for checkup. Task – Hx, Dds
PASS – 5,5,4
I went in n greeted and I think this is the only station where I introduced myself, then I
started with cough - Since when - 5yrs, Dry or sputum - white sputum, Any blood - once or
twice, Any fever – no, What time – morning
Then I ruled out dds
Lying flat or pillows at night, Swelling on feet, Chest pain, Travel, Any discharge at back of
throat, Any blocked nose, Any hx of asthma, eczema hay fever, Any sneezes or runny nose
repeatedly, Any acid coming to your mouth, Any particular days, Occupation, Pain in face,
Lumps and bumps, Weight loss, loss of appetite, Family history of lung cancer -No
So then I started telling dds
I think most you have asthma because of morning cough and sputum but it cannot be
confirmed on the basis of this conversation, we need to investigate further then told all the
dds and told them they are least likely.
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Dds: CHF, GORD, SINUSITIS, ALLERGIC RHINITIS, TB, CANCER, OCCUPATIONAL LUNG
DISEASE, HABITUAL COUGH, PSYCHOGENIC COUGH, IRRITANT COUGH
11) Grief + DDX ( teary man after his wife death)
12) A 65 year old male came with bleeding from back passage for last 2 weeks. Hx. Dds (PASS – 4,5,4)
I greeted the patient and asked him how are you? Surprisingly he said I’m good doctor how are you?
Then asked him how can I help you?
He told about this bleeding from back passage
I said don’t worry, I know it’s distressing for you but I’m here to help you out
Since when, how much? Is it on stool? Mixed with stool? It was on stool? Any pain? no
Any lump coming out yes
I asked if remains there or goes back à goes back
Any discharge? Any weight loss? Loss of appetite? Lumps n bumps? NO
Any rash on body? Any problem with eyes? Any diarrhea?
Any medications? à aspirin positive
Any bleeding from anywhere else in body or family history of bleeding problems
Constipation?
Diet?
Bowel habits? Family hx past hx of cancers all negative
Ddx : Hemorrhoids most likely
Anal fissure but less likely cz no pain
Cancer less likely cz no symptoms
Ulcerative colitis less likely cz no symptoms
Bleeding disorder
Blood thinners
13) Kid with fever and sore throat/ post chemotherapy.
14) DKA (young female/ sleepy and tired) hx,PEFE ,Dx& ddx
15) young female in severe pain and acute urinary retention( Fibroids)/ hx, PEFE, Dx and ddx, Mx
(P.S: do catheterisation FIRST after excluding blood in urethra post trauma/ herpes vesicles
and give pain killers THEN start taking hx and pefe)
Girl who came with pain in abdomen and she has been given pain killer. Hx, Pefe, Dds. PASS
-5
As it was general abdominal pain I could not think much outside so I decided to go in and
see where exactly is this pain.
The patient was a young girl sitting on couch, greeted her n asked for pain killer
And gave morphine with metochlopramide. Then I started with pain - Where >>>
suprapubic
How bad – 8, Going anywhere no, when was last time u did pee? 12 hours ago.
I said excuse me plz I want to relieve your pain first so that you can be comfortable.
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Asked examiner that as my patient did not pee for last 12 hours I wanna do abdominal
palpation he said there is a mass till umbilicus, percussion >> dull
I said I want to inspect pelvis with patient’s consent if any rash he said no
So I will pass a catheter and send urine for investigations.
He said ok this has been done for you now talk to your patient again.
So I completed siqora of pain then started with her sexual history
Partner stable, safe sex using condoms, only one partner, only vaginal route everything was
clear in sexual history.
Asked about dragging sensation in tummy/ heavy periods - no
Lumps n bumps wt loss à No, Family hx of female related cancers à no
So went for examination -Started with GA examiner said as you see
Temp - normal, BP – normal, Lymph nodes – negative, Cachexia signs - negative
Abdomen: I did Inspection palpation percussion then did pelvic examination - inspection
speculum à -ive then bimanual , here examiner said u already drained the bladder right , I
said yes , he said ok then there is a mass on bimanual palpation of size of an orange no
tenderness.
no dipstick no blood sugar available. Thanked and went back to patient - told her as you
were unable to pass pee it was because something is not letting your wee come out of the
body it could be because of herpes when we can’t pee because of pain but less likely, I
found a mass inside your womb we call it as fibroid, it’s not a dangerous thing but because
of pressure it was not letting wee out, could be tumour less likely.
16) Antenatal counselling A lady came for probably a checkup at 8 or 9 weeks of pregnancy and we
had to tell her investigations for first check up and tell her preventive measures. Healthy patient.
31st May 2019
1. 27yr old computer programmer feeling stressed tired and not well these days- hx, dd (PASS)
2 mins Thinking:( Depression, PTSD, OCD, Lifestyle Stress, work stress, Organic
History: Confidentiality
Can you explain me more about stress? = feeling worried excessively (then I put Anxiety in DD)
+ve Finding= feeling worried excessive for few weeks, throughout the day and night, continue and
getting worse, affected sleep( hard to initiated as well as mention sleep but no snoring, no
nightmare, no flashback) general feels worry no specific situation or time or place) increased in work
nowadays and not able to cope at work
Anxiety= pt is an anxious person for a long time, feels flushes when he is worried, palpitation +ve,
mind goes blank when he try to concentrated at work, tremor +ve
Depression (mood, guilt, anhedonia, energy, suicidal ideation) = negative
Still enjoy the life
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Detail hx of Hallucination/ delusion= negative
SADMA=nil
HEADSSS= had a good support, no recent issues with family, friends, partners
Organic= fever/ headache/ chest pain/ SOB/LOC/change in weight/weather preference / body colour
change/diarrhea/ constipation = all negative ( that’s all I could remember in hx)
Diagnosis/DD= I explain about GAD, then gave a DD of Lifestyle stress, Panic disorder and organic
(Thyroid, DM, Infection) and explain why these are less likely.
Note: forgot to asked OCD and BDD in history.
Another Feedback - 27 years old IT guy feeling very stressed lately. - Hx - Dx and DDs (Fail - 4,4,3)
Confidentiality. Asked him to tell me more about the stress. He said he was feeling very stressed for
the past month or so. I asked if there was anything that happened during this time and he said no.
So I detailed MSIGECAPS + HEADSSS + WATCHER + weather preference + SADMA - he is usually
happy, but always very concerned about the future and about what other people thinks, struggles to
fall asleep and sometimes wakes up early and doesn't sleep again. Concentration isn't great lately.
Worries a lot, has always been like that. Tense as well. No triggers. No phobias. Happy with a new
girlfriend. I gave GAD as a Dx and DDx hyperthyroidism, panic disorder, depression and just normal
stress, but said it's very unlikely.
2. 6 years old girl brought by father due to c/o headache. Task Hx, PEFE, Dx with reasons and DD.
(PASS)
2 mins Thinking outside (URTI, sinusitis, orbital cellulitis, trauma, meningitis, encephalitis, tumour,
Psychological, migraine)
History: Symptom assess: SORTSARA: Headache since 6 months, on/off all over the head, severity
5/6 already had a pain killer, no radiating/ shifting, aggravated by light +ve, relieve after taking rest,
associated with nausea but no vomiting/ blurring of vision, pain at any time during day or night.
Fever/running nose/ cough/ fits/weakness/swelling around eye/rashes/diarrhoea/trauma= all
Negative
No pain at any other part of body, no contact hx, No allergy hx or any triggering factor
PMHx: nil
Family hx = Father had a migraine
Child eating well, growing well
BINDS= Normal
Stress= happy growing child, no issue within family or at school, socializing well
PEFE: everything was normal including growth (height/weight), RS, CVS, CNS
Diagnosis/DD: I explain about migraine and link with family hx. Explain about triggering factor and
reassure him regard her PE which shows everything normal then gave a DD of Tension headache due
to family stress, bullying at school, and other dd as above and explain why they are less likely.
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Another Feedback - I asked all SOCRATES questions + DDs questions (infection, trauma, teeth, ear,
social Hx) + BINDS + PMHx + FHx. Patient had nausea and vomiting, liked to stay in a dark room,
father has migraines and got divorced 6 months ago. Good relationship with mother. PEFE all
normal. I gave Dx migraine but also mentioned tension headache, infection and trauma as DDs. Pass
- 5,5,5
3. Pt with Shaky hands thinks of having parkinsonism. Pt vitals and gaits were already assessed.
Task: PE of upper limb neurological examination and relevant examination and DD (PASS – 5,6,6,6)
WIPER
PE:
GA: Patient was nodding his head frequently, but no any ataxic movement of body
Inspection:
Resting termers/ fasciculation/pin rolling termers/ wasting/ flapping termer): all negative
Fine tremers +ve , intentional termers +ve ( confused)
Tone(normal), Power(normal), Reflexes( normal), coordination( dysdiadokokinesia / Past pointing)
he gave me +ve finding so I get confused , sensation (Examiner said no need to do)
Then I went for face and neck for thyroid lump
No ataxic movement/ asymmetric / dropping of eye lid
Then I did some specific test
Nystagmus (negative)
Speech (normal)
Glabellar (normal)
Micrographia(Normal though pt was shaking a lot)
And tell examiner that I will like to complete my examination by doing all cranial nerves examination
and lower limb neurological examination and thyroid examination
Diagnosis: I was so confused of finding so I gave essential tremor and I also explain him that I have
found some finding which called a cerebral sign so need to refer to specialist and do some
investigation such as CT scan of head to make sure everything is ok. Then gave DD: Anxiety, Thyroid,
Parkinson,
Note: Though I score good mark but not sure about the finding as I got a mixed finding
Another Feedback - Tremors. Real patient. Both hands but worse on the right hand. Normal gait gave
on stem. Worse on stress. - PE - Upper limb neurological examination and relevant examination - Dx
and DDs. Pass - 5,5,6,5
GA + VS (given on stem). WIPER. Started with UL neuro: Inspection (commented on NO pill rolling
tremor or tremors at rest), then did tone (normal), power (normal), reflexes (normal) - I said I would
like to check sensation and the examiner said: "this is a neurological examination, Dr - made me
understand I could skip/I was wrong), then did coordination (tremor) + disdiadokokinesia (tremor),
no flapping tremor, tremor on outstretched hands. Piano test normal, tremor on writing but no
micrographia. Checked quickly face for exophitalmos, checked eye movements and patient had
nystagmus! (I asked if there was any findings and the examiner said: as you can see. The guy had a
bit of nystagmus, so I commented on that). Did glabelar tap and the examiner asked for finding, I
said "he doesn't blink". Asked for office tests as well - not available. As Dx I gave essential tremor.
Said it was benign and runs in the family (the guy shakes A LOT, I felt horrible saying it was a benign
condition). Said it's manageable. As DDs I have Parkinson's, CLD, hyperthyroidism and some drugs
SE. No management. This examiner was very cranky all the time and rude.
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4. Facial trauma exam - Guy punched in the face. There was a big bruise on the right side of face
involving eye and cheek. Task: PE and Dx with reasons, DD. PASS - 4,3,4
I started asking if he wanted pain killer. WIPER. Did inspection, commented on the bruise under right
eye. Said I was to check conjunctiva for any haemorrhage. Did a brief and gentle palpation - he said
there was pain on the bruise. Did CN 2, 346, 5, 7 - she asked me to stop when I said 8. Only findings:
loss of sensation on the bruise and double vision on eye movements. I said there was an orbital floor
fracture that could have injured/compressed some nerves that are responsible for the face sensation
and movements. Drew a picture (horrible). I was stuttering.
5. Old Lady with HTN on metoprolol, previous knee surgery 20 years ago - had DVT at the time.
Smokes. C/o pain on right calf when walking, relieved with rest. Pulse not palpable till femoral on
right leg but left leg pulse normal , Buergers negative. ABI 0.7. BP 150/90. BMI 26 (PASS)
Task - Explain Dx to the patient with reasons + DDs
Order further Ix and explain further management and its outcome
Explain impact on further management to patient.
I draw a diagram of leg and explain 3 type of vessel Artery, veins and LN and explain thoroughly PVD
( condition, course, cause, complication) explain all triggering factor from patient hx, ( smoking,
HTN, BMI) and link with all the finding such as not palpable pulse, ABI index 0.7. DD: DVT, cellulitis,
trauma and explain why they are less likely
Mx: need to refer her immediately to the specialist and do investigation such as FBC, Lipid profile,
Coagulation profile, Doppler of leg and if needed then they might go for a procedure called
angiography to confirm the diagnosis and check the severity( explain how it is done). Explain the
need to maintain lifestyle ( focus towards smoking) booked another appointment for smoking, Good
food ( refer to dietitian), regular exercise within the barring level of pain, reduce weight( BMI 26),
lipid lowering if needed and not sure if I maintain about aspirin . Reassure that still it can be
manageable and need regular review, managed in MDT. If not managed now tissue of leg will not get
enough oxygen and die which may lead to amputation. Gave a red flag (night
pain/tingling/numbness but forgot about change in colour of leg skin), referral, review
Note: Forget to maintain about surgery option and did not explain about complication in more detail
Another Feedback - Pass - 4,3,4,5 Patient with HTN on metoprolol, previous knee surgery 20 years
ago - had DVT at the time. Smokes. C/o pain on right calf when walking, relieved with rest. Buergers
negative. ABI 0.7. BP 150/90. BMI 26. - Explain Dx to the patient with reasons + DDs - Order further
Ix and explain further management - Explain impact on further management to patient
I gave peripheral vascular disease as Dx and DVT, trauma, infection as DDs. I explained PVD and
explained her ABI was 0.7 and it was concerning. I told her I needed her to stop smoking asap (she
said: as soon as possible?!!!), and I explained the implications of smoking in PVD - complications like
limb ischemia and necrosis (I got very confused). Told her she needed to exercise and lose some
weight. Ix: bloods + D dimer, coag profile and US doppler of lower limbs. I told her I would like to
refer her to the cardiologist to optimize her BP medication and manage the PVD as well, because her
ABI was 0.7. talked a lot about MDT approach (specialist + dietician + me) and LSM.
6. 70 yrs patient admitted 2 days ago with pneumonia. She has HTN and had DVT years ago. She was
stable yesterday then from this morning she is c/o SOB. A big observation chart was given out side.
Task:
1 Explain fluid chart and obs chart to examiner
2 PEFE (only give what you ask)
3 Explain Dx to patient and initial management (I think so, not sure) (PASS – 6,5,7,7)
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As I enter inside, I told examiner that I start explaining the chart I would like to stop the fluid, give
oxygen to pt. examiner said you can proceed
Then I focus on explaining the chart which had shown clearly +ve balance of more then 1000ml over
24 hrs (Note: there was both oral intake and if fluid so have to add both of them)
Temp: normal constantly
Pulse: Gradually raising up in the chart
BP: Gradually raising up in the chart
Spo2: Gradually dropping down in the chart
So I explained accordingly
PEFE: GA: Dyspneic, Vitals: as shown in the chart, Oedema +ve(facial puffy, b/l lower limb upto knee,
sacral oedema)
RS: Inspection: ok, Percussion: B/L dullness till mid zone, Auscultation: B/L Basal crepitation upto mid
zone, vocal resonance: increased
CVS: Normal, Abd: normal(no hepato/splenomegaly, no fluid thrill, no shifting dullness) rest of all
normal
Explained: I clearly in laymen term explain fluid overload leading to pulmonary edema and link with
her SOB then also explained other possibility such as congestion lead to HF, LF, KF or septicaemia
due to infection and said they are less likely. And also, reassure her, explain quickly about the
management (need to give diuretic, refer to specialist, continue oxygen therapy, strictly monitoring
intake and output charting).
Another Feedback - Pass - 6,4,6,7 I immediately put patient on O2 as her SatO2 was 90%. Then I
started explaining the fluid chart to examiner, said that her input was way higher than her output.
Then explained the obs chart one by one - said that the SOB was matching the increase in her BP and
PR, and it was probably due to stress and effort. Said that her temperature was getting better which
was a good sign that the abx were working. Then I asked about the PEFE: GA + any oedemas in any
part of the body (there was edema in both lower limbs up to the knee and on genitalia), went to
chest examination: inspection ok, percussion dullness on both lung bases, auscultation bibasal
crepitations. Asked CVS S1, S2, ?S4 audible, rest is normal. Abdominal examination no tenderness,
no masses, no dullness, bladder was empty. No calf tenderness. So I explained to the patient that
most likely she was receiving more fluids IV than what she needed, and that we need to balance the
amount we receive and the amount we lose (urine etc), and that she probably accumulated some
water in her lungs and that's why she was having SOB. I also said I didn't think it was any urine
retention, or infection as her pneumonia was getting better, or CCF. I didn't mention the words
pulmonary oedema.
7. Primi 10 weeks pregnant lady having nausea and vomiting for 1 week with lower abdominal pain
and feeling of hot since yesterday. All ANC normal so far, NO h/o STI.
Task: Hx, PEFE, DX and management
2 mins Thinking: UTI, AGE, pyelonephritis, PID, appendicitis, diverticulitis, Hyperemesis gravidarum
(early/ twin/ molar pregnancies), cholecystitis, cholangitis (if upper abd Pain)
History - Start with pain and offer a pain killer
Asked all pain question SORTSARA and other Hx: Fever/ dysuria/increased frequency/ nocturia/ pain
is radiating to back: positive
Nausea/ Vomiting: at any time/ excessive and multiple time since few days but able to tolerate food,
now feeling dizzy, weak, tired
Rest of other history PMH/ FH/ Contact Hx/ Gyn & obs all normal
PEFE - GA: Ill looking, Vitals: temp.: 39 pulse: more then 100,
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Dehydration: (asked what you are looking for so I said eye, tongue, lips, extremities, skin) then he
told me mild- moderately dehydrated
Abd: lower abd. Tenderness and renal angle tenderness positive.
Rest of other systemic examination normal
Office test: BSL normal
UDT: Leucocyte/ nitrate/ ketones (positive) blood trace
Dx - I draw a diagram of Urinary tract and explain about UTI most likely infection of the kidney called
pyelonephritis link with her symptoms along with present of ketones and explain its correlation with
dehydration due to excessive nausea/ vomiting and gave DD as above
Management - Explained that she need to be admitted in hospital, will seen by specialist, need to do
rehydrate with IVF, antibiotics and antiemetic ( if needed) then need to do blood investigation (
explain all), urine R/e and C/s. explain regarding regular check of blood and urine for ketones( forgot
to maintain about electrolytes) during the time of hospital stay . Reassure her, ask for the support
Another Feedback - Pass - 5,5,6,4
I asked all pain questions + associated sx +DDs questions and she had a fever, dysuria, frequency and
pain radiated to the back. In PEFE she had a high fever, lower abdominal tenderness, no dullness,
renal angle tenderness positive. All other systems normal. BSL normal and UDT + leuco, +ketones,
+nitrate and trace of blood. I told the patient she had pyelonephritis, drew the picture and
explained. Said I had to admit her to the hospital, send the urine for culture, order some bloods
including blood culture and start her on IVABx - didn't say start on IVF. Said I was going to ask an
obstetrician to go to and see her just to make sure everything was ok with her and the baby. And
that she was going to be ok after the IVABx start working and that she probably would be discharged
on POABx.
8. 57 yrs woman with diarrhea. Task: Hx, Dx/ DDs.
2mins Thinking (Acute: AGE, UTI, Amoebiasis/ giardiasis, pseudomembranous colitis, diverticulitis,
acute Hepatitis, Chronic: Lactose/ cow milk protein intolerance, coeliac disease, IBD, IBS, cancer,
Thyroid)
History: I asked all the history according to my dds.
Positive findings: Diarrhoea since 2 days, multiple times/ watery to semi solid/ smelly/pain while
defecating/ mucus but no blood/ feeling feverish
H/o sore throat 5 days ago and taken amoxicillin till yesterday and finish the dose already
H/o travelled to bali and 4 wks ago and ate street food.
No H/o contact, No FHx, or any drugs a part from antibiotics
Dx/DD I explain 1st pseudomembranous colitis and its relation to antibiotic and also explained it
could be Amoebiasis/giardiasis or AGE as pt had been to bali so told him need to do stools R/e and
C/s to confirm and if needed then treat with metronidazole .Then explain about other DDs as I
maintain above and explain why they are less likely.
Another Feedback - Pass - 5,6,6 I asked all questions detailing the diarrhea + DDs + PMHx + FHx.
Positives: started 4 days ago, felt feverish, no blood but had some mucus, not explosive. Has some
cramps just before going to the toilet. Multiple times a day. No vomit/nausea. No weight loss.
Traveled to Bali 4 weeks ago and ate street food. Her husband is fine. No stress, no FHx of IBD, but
mother had bowel cancer. I gave giardiasis as a Dx but said it could also be an acute viral
gastroenteritis. Said it's unlikely that it's IBS, IBD or bowel cancer. I really wasn't sure if it was
giardiasis or acute viral gastroenteritis.
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5th, 6th, 7th, 12th, 13th, 14th, 18th, 27th, 28th June 2019
5th June 2019
1. Telephone call with midwife mx of postpartum haemorrhage. You are in the ward 5 min from
the delivery suit. Ask history, Initial management, DD to midwife over phone
There was a phone that rang, I answered and then a midwife start talking to me about a patient that
delivered 30 min ago, NVD placenta also delivered complete. Baby is fine, mom has bled 1.5L so far.
Uterine atony, midwife unable to asses perineum due to haemorrhage. Tachycardic and a bit
hypotensive.
I asked her to call code pink, 2 IV lines one with fluids and one with oxytocin, uterine massage,
misoprostol and ergometrine. While I arrive to assess perineum, she can also have a tear and be
bleeding from there.
Make sure placenta was complete, IDC in.
Can’t remember what else I said.
PASS – Approach – 5, History – 4, Examination technique and sequence – 5, Dx/DDx – 4, Mx – 6
2. 9 month old brought in by mum with fever: 38 deg.
Take hx (not eating solids but breastfeeding as usual, only fever +, everything else
normal)
Ask PEFE (all PE normal: only Urinalysis: nitrites +, lymphocytes+ protein+, no RBS)
Explain dx to mum with reasons
3. 12 year old girl brought in by mum with cough for 6 months. Trial of antibiotics and
asthma medications done. No response. Long list of Investigations: all bloods-ve, CXR:
no findings. Spirometry done and normal.
Take history from mom and Dx/DDx to mother and explain her condition.
PASS Each -4
The mom was very upset, as I said hi. She said, doctor you must find out what is going on with my
daughter.
I asked about the cough, it was dry, all the time. Disturbing her at school. She got a letter from
school about the cough. No at night. More after the girls came back from the weekend with her dad.
Mom and dad divorce 6 months ago and now take turns for weekends. Has other two kids, they are
fine.
No fever, no chest pain, no dyspnoea, she can do sports.
No other diseases. All vaccination ok. No pets, or any allergies in the family.
Then I explain her that there are many things than can cause cough. Problems in the lung, in the
heart, infection, problems in upper respiratory system. She doesn’t seem to have any of those.
However, as she mentioned it gets worse after seeing her dad. How do you think is she coping with
your divorce? I don’t know, I haven’t talk to her about that. What about your other kids? Ah they are
fine.
Then I said everyone reacts different to stressful situations, it’ll be worth to chat to her. I think her
cough is probably the way she is reacting to the situation and not being able to express it in a
different way. I think she has psychogenic cough. Does it make sense to you? She said yes
4. (PILOT) 22 year old brought in by friends with SOB, dizziness and chest tightness an hour ago
in a movie theatre. Some history of marijuana use+, social drinker. No other sig history.
Take history (worries about having the breathlessness again)
Explain dx and other differentials with reasons.
Another Feedback – 22 years old chest tightness while watching movie. Ask hx and explain Dx
Several times this has happened to her. I said they were panic attacks.
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5. 32 year old unwell since yesterday. One episode of vomiting yesterday morning.
Take hx (fever, tummy pain- not pointing to any specific area- pain relieved on passing
motion, brown watery loose stools for 2 days, one episode vomiting, urine: dark
coloured, sick contacts: his son had similar loose motion just for one day- four days ago,
son’s now fine, no SADMA)
Ask for PEFE Card (card says left iliac fossa and epigastrium deep tenderness, and fever
37.8 or thereabouts, all other systems negative I think)
Explain dx and other differentials.
Another Feedback – 28 years old feeling unwell in the last 2 days. Take history. PE from a card or
from examiner (I can’t remember) Explain patient DD.
Entered the room, greeted examiner and patient.
“Jane” so you haven’t been feeling well lately. Can you tell me what is happening?
I’ve been having diarrhea and just feeling off in the last 2 days?
Before that were you completely fine? yes, it’s been only in the last 2 days.
Tell me more about the diarrhea, how many times a day? (I can’t remember what she said, probably
4-6 times or so.)
Is it liquid or just soft stool? Initially soft and now liquid.
Any blood or mucus? No
Any bad smell? Yes, like poo!
Oh yes you are right, I meant very bad offensive smell? No
Any tummy pain? yes, like cramps Any vomit? No
Fever? I have felt very hot Have you taken anything for that? No
Any weakness or body aches? Yes Any other symptom? Yes I also have sore throat
What do you do? Something like office work (can’t remember)
Have you travel recently? No I’ve been working
Who do you live with? My husband and my little kid
Any one sick at home? Yes my son had the same thing a week ago
How is he feeling now? He is completely fine, it only lasted for one day.
oh kids are pretty amazing, they get cure almost immediately but is not the same for us.
She laughed and said totally true. Apart from this do you suffer from any important disease? Blood
pressure? Sugar? Any problems with your bowels? No
Anyone in your family with any of those? Bowel cancer? No
Do you smoke? No Alcohol? No Recreational drugs? No Any medicines? No
Any previous surgeries? No Any chance you could be pregnant? No, we use condoms
And your LMP? Two weeks ago
PE: pretty much unremarkable, I think a little fever and only some tenderness all-over the abdomen.
Can’t remember well
So I said, listen I think you are probably having the same thing as your son. I think you are having a
viral infection and that is why you have all the symptoms you have. It is very unlikely that you have
any bacterial infection, or things like shigella or giardia, which are other types of infections. I also
don’t think you have any gastrointestinal disease, like BID or BIS. I don’t think you have any food
allergy or anything like that. So most likely is just a virus passing by your family at the moment.
PASS – Approach - 4, History - 5, Dx/DDx – 6
6. 33 year old young man comes with cough and blood in phlegm yesterday.
Take history (cough 4 months, when I asked if anything happened 4 months ago he said
no, when I asked towards end of hx if any travel, he said yes, cough started before he
left Cambodia, no sick contacts, got worse in the last week, unintentional weight loss +)
Explain diagnosis and differentials
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Another Feedback – 45 years old Female coughed up blood at dinner.
Take History explain the possible cause and other causes. PEFE.
All the cough questions, one episode with blood, night sweats and weight loss.
Works in humanitarian work in Cambodia, arrived three weeks ago and since then not feeling well
All the other questions negative.
I said TB as my first diagnosis and requested her to used protective mask while in there.
It can also be cancer, but she didn’t smoke or had any exposure to anything
She kept asking what else could it be? So I said a very bad pneumonia, trauma, or very rare diseases
like sarcoidosis.
We need to run some test to find out exactly what it is, but I think most likely TB.
PASS – Approach – 4, History – 5, Dx/DDx - 6
7. Pilot case – 55/72 year old male had acute urinary retention 6 hour after hernia surgery. Needs
catheterisation. Task : Take consent for procedure. Explain procedure to patient.
Gather the equipment needed to perform the catheterisation.
(Foley’s catheter, sterile pack, sterile gloves, gauze, saline on table)
All the equipment was there, several sizes. I just explained the patient and took all the things I
needed. I was going to setup the table and the examiner said don’t open anything just select what
you need. So I did.
8. 72 year old man comes to you with headache and ____.
BP: 140/88mm Hg and PR: 90 pm given in stem.
Perform relevant examination (as I said I’d like to do Cranial nerves PE, examiner took
up card and began to read out findings, fundoscopy normal, she asked me to do otoscope, I
put on speculum and started explaining otoscopy to patient and examiner said its
normal, proceeded with temporal arteries PE, checked ENT- did use tongue depressor
and did cervical lymph nodes check)
Explain diagnosis and differentials.
Another Feedback – 68 years old man with chronic headache sometimes throbbing and jaw pain
on chewing. Do PE. Explain implications of your findings to patient.
I started with inspection of head, no signs of trauma, no obvious deformity, no asymmetry in face.
No ocular or nasal discharge. No conjuctival erythema.
Then I palpate the full scalp, no pain. Tender over the temporal area in one side.
I examine eye movements, accommodation, peripheral view. I was going to do fundoscopy and
examiner said normal. Then I was going to assess ear with otoscope she said normal. Then I asked
him to do neck movements and palpate cervical spine, nothing there. Listed for carotid bruit.
Then I did proximal power in arms and asked patient to stand up while holding his body, checking for
polymyalgia rheumatic.
Then I said, there are many reasons to have headache, in your case, it’s nothing from your eyes, of
infections…then I realised I didn’t look into his mouth. Then I said I just remember that I would like
to look into your mouth as well, would that be ok? He said yes, I did it and said, yes as I suspected is
all normal there. I think you are having some signs of temporal arteritis. Its an inflammation of one
of the vessels that run in your head (I show him where). The problem is not actually the headache,
but it could have potential serious implications, like loosing of your vision. This is why I think you
should start treatment right away with steroids in higher dose and then we wait until get results
from a biopsy to confirm your diagnosis. If you feel your vision in changing, please come back to me
or ED so we can act promptly. He said ok doctor.
PASS – Approach – 5, Technique – 4, Accuracy – 4, Dx/DDx - 4
9. Serotonin syndrome. Mirtazepam started 2 days ago, Escitalopram 6 weeks ago.
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Take hx. (Patient in distress: pain, sweaty, fever, examiner asked what pain relief I would like to
give. I said I’ll start with panadol- later may require morphine)
Explain diagnosis and management.
Another Feedback - 35 years old male with long diagnosed depression on escitalopram, recently
another GP added mizatrapine, since this morning feeling restless, fever, anxious and unwell
Task : History, PEFE or from a card (can’t remember), DD and initial management.
I asked about his disease, when was diagnosed, all the depression questions including suicidal risk,
hallucinations. He said that lately he was feeling off, not able to sleep and lack of energy, that is why
the GP added the new medication. Well supportive environment. No alcohol, smoking or drugs.
PEFE all the serotoninergic syndrome findings were present. I explained he his diagnosis, told him
that we need to stop all medications and I need to send him to hospital. He asked me, is that really
necessary? I said, yes, you need to be monitored closely, it can be just this, but it can progress with
seizures and get worse. I explained him about the washout period and the need for support during
that time. PASS (Approach-5, History-5, Counselling-6, Management-6)
10. 22 year old male brought in by friends to ED. Acute change in behaviour, inappropriate,
words and confused. Can’t remember SADMA. All PE done and normal. NO NECK
STIFFNESS. Sons agreed to let me talk to mum.
Long list of investigations done: Bloods -ve Urine drug screen pending. All Ix negative except for
lumbar puncture: Protein high, Lymphocytes high, glu normal.
-Explain hx and PE to mum
-Explain dx and differentials and reasons
Another Feedback - It was a very long stem, almost two pages. 22 years old male had seizure, some
hallucinations and behaviour change. Brought by friends. He was in a party last night, feeling unwell
with cold like symptoms in the last 2 weeks. Vitals stable, no neck stiffness, CT brain normal, BSL 4.5,
lumbar puncture - normal sugar, high WBC with Lymphocyte. Toxicology screening pending. Father
just arrived to ED, he wants to talk to you.
Explain examinations and results to father. DD to father.
I greeted father of patient and ask him what did he know so far, he said not much. I was just told to
come here that my son was having seizures. So I said, that’s correct. I want to let you know that he is
stable at the moment; we have run several investigations that I would like to discuss with you. First
you know that he was feeling a bit sick since a couple of weeks, so perhaps those were just the initial
symptoms of something bigger to come. Then he also developed some change in behaviour and
recently seizures, that is why his friends brought him over.
These types of symptoms can be cause by many things, that is why we have done so many
investigations. We did a CT scan, an image of his brain which is normal, therefore there are no
masses or haemorrhages or signs of trauma to explain what he has. We did a sugar test, that is also
normal, so he is not having a hypoglycaemic crisis. We also did a toxicology screening, the results are
still pending and I’ll keep you update on those, we know he was partying yesterday, so perhaps he
has consumed any alcohol or drugs that can explain his symptoms.
More importantly we have done a test of the liquid around his brain and it is showing signs of
infection, by the characteristics of it, looks like a viral infection, but it is quite severe, as his is having
the symptoms he has. This is probably meningitis an infection around his brain or more specific
encephalitis as he is having more severe symptoms.
As I said he is stable and I’ll take you to see him soon, is there anything you want me to explain you
better? He said no doctor, thanks.
PASS
Approach to patient/relative 6
Interpretation of investigation 4
Diagnosis/ Differential diagnoses 4
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Patient Counselling/ Education 4
11. 12 months amenorrhea patient is unconcerned, husband brought her in. Pregnancy test -ve
yesterday. Take hx. Explain dx. Management
Another Feedback – 28 years old woman Amenorrhea for one year, patient is not concerning her
husband asked her to see a doctor. Take hx and explain Dx.
Patient healthy it was exercise induce amenorrhea. She was training for a triathlon, running,
swimming and using bike for several hours every day. Some weight loss, hasn’t increase her food
consumption despite increase training.
No previous pregnancies, no other diseases else.
All gynaecological hx unremarkable
No alcohol, no smoking, no medications
PASS – History – 4, Dx/DDx – 5, Management - 4
12. 66 year old woman comes with breast lump she found yesterday.
Explain examination to her. Perform PE on the dummy. Dx and DDx to examiner with reasons.
(Single hard lump in left outer quadrant of left breast, Examiner told me cervical ln -ve, perform
axillary ln: single hard ln+ in left axilla)
Another Feedback - 68 year old woman felt a lump in her breast and is coming to be assess.
Patient was adopted and has no knowledge of her family history (or something like that)
Perform PE. Explain DD to the examiner.
Entered the room, greeted examiner and patient.
I understand that you felt a lump in your breast, I would like to examine you to have a better idea of
what is going on, would that be ok with you?
I will look at your breast, feel the tissue including your axilla and ask you to do some movements, it
shouldn’t be painful but it might be uncomfortable. Can you please sit on the bed and remove your
gown? (while wearing gloves-There was a sign of the soap saying don’t wash hands, used gloves)
The role player uncovered the manikin and sat it down, she was sitting in a chair next to the bed
with a gown on.
I don’t see any asymmetries, no obvious lumps. The colour of the skin is even, no dimpling, no
retraction. Both nipples look fine, not inverted, no secretion.
Can you please put both hands behind your head? The role player did that.
I don’t see any changes on the skin, no new retractions
Can you please bend forward? The role player tilted the manikin.
Again, no new changes on the skin.
Can you please lie down with your hands behind your head, I would like to feel the lump and the rest
of the tissue? Let me know if is too uncomfortable. The role payer moved the manikin.
I started palpated the left breast and felt the lump, so I asked, is this what you felt at home? She said
yes. So I said, ok, let me feel the rest of your breast to see if there is anything else and then I’ll come
back to it. She said ok. I continue palpating the left breast fully and then the right one, there were no
more lumps. I went back to the lump and ask for a measuring tape (not available) so I said, there is a
firm lump about 2-3cm in size and about 4 cm from the nipple in the left external quadrant. Mobile,
no fixed to the skin, smooth borders.
I asked the patient to squeeze both nipples, she did it on the manikin. I said no secretion on
expression of nipples.
Then I said, I will feel your lymph nodes. I did supra and infraclavicular and all axillar (lateral, medial,
anterior, posterior and apical). There were none palpable, so I said that.
Then I thanked the patient and I said, you can wear your gown again. I’ll discuss with the findings
with the examiner.
I said, I have examined “Jane” (forgot her name), a 68 years old patient who felt a lump on her left
breast. On examination I also felt the lump, it has benign characteristics, possible a fibroadenoma,
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however she is 68 and we don’t have access to her family history so I also need to rule out breast
cancer. I think she should have a mammography and a biopsy of the lesion.
PASS – Each -5
13. Patient came with two times high BP. Perform cardiovascular examination. Explain dx with
reasons
Another Feedback - 42 years old patient found to have high BP while donating blood.
Relevant PE. Explain patient implication of your findings.
Hi “John” they found your BP to be high while you were donating blood and I will like to take it again
and fully examine you to see what is happening. Would that be ok with you? (while washing hands)
John is comfortable in the bed, no signs of respiratory distress
Can I see your hands please? I don’t see any pallor, no clubbing, no peripheral cyanosis, no nails
changes. There is not palmar erythema or sweat. Capillary refilled is less than 2 sec.
I started taking his pulse, he had very cool tattoos all over his arms, so I said that I really like your
tattoos, he smiled and said thank you. The examiner handed me a watch, I took pulse in both arms
at the same time, she said assume they are both the same, you can take only one hand. So I did that
and said, your pulse is about 70 per minute and is regular, no radio-radio delay, which is good. I
looked at the examiner and said, ideally, I will also do radio-femoral delay, she said is not present.
Then I took his BP (I had to ensemble the whole thing), so I apologised and told the patient, sorry I
have to put all this together, give me a minute. Then I took it manually and then with stethoscope. I
said, it is normal at the moment. Examiner asked me, what did you found? I said 100/70. Then I said,
I would like to measure also standing up and, in all limbs, examiner said is all the same.
Then I look at his face and said, no pallor, no exophthalmos. In the neck, no obvious masses, no
increased in thyroid gland. I palpated carotid pulses and the listed to carotid bruit and thyroid bruit. I
said, JVP not visible.
Then I said, can you please remove your gown? I would like to assess your chest? so he did. I said,
chest shape is normal, no scars, no visible pulsations. While palpating, no parasternal hive, no trills,
the apex beat is at (I measure the spaces) and said on the 5th with the midclavicular line. Then I
listened to all points in silence when I finished, I look at examiner and said I listened to mitral,
tricuspid, pulmonary and aortic points, there are normal heart sounds, no murmurs, no S3 present.
Then I said I would like to put the bed flat, the examiner asked me what I wanted to do. Then I said I
want to palpate the abdomen and listen to aortic and renal bruit, she said all normal.
Then I went to the legs, no edema and peripherical pulses present, while palpating dorsal pulse.
Then I said than you John you can put your gown back. Listen today I found your BP completely
normal and all your examination is unremarkable. Perhaps the day you were donating blood you
were a bit stress out by the situation, or it can be that you are actually having high BP, just not today.
The problem is that even if your BP is high you won’t feel pretty much any symptoms, so it is worth
to get it check several times to make sure it is not high.
PASS – Approach - 5, Technique - 4, Accuracy - 4, Counselling - 4
14. 25 year old woman well controlled SLE for 5 years. Wants pregnancy in the next 6 months.
Take hx. Explain what further investigations you will do. Immediate management.
Another Feedback - SLE for 5 yrs. Last specialist visit 6 months ago where RFT and Ab checked and
normal. On regular prednisolone. She wants to get pregnant. Take Hx, PEFE, tell her immediate
management.
I started asking her about her desire to get pregnant, enough support. She said that may be in the
next 6 months, supportive partner. I said it is a great idea to get check before hand, especially with
your condition. Many women with SLE can have successful pregnancies and since she was in such a
good control I was very confident it was going to be possible.
Discuss about her SLE, diagnosis, flares, management, using of medication, side effects.
All the gynae history, menstrual periods, actual contraception. CST, all those things
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On PE all normal.
I explained her the risk of having SLE, increase risk of miscarriage, once pregnant preeclampsia, if she
has anti-ro and anti-la fetal cardiac defects (I think she has those negative) I said I will order those
anyway. Referral back to rheumatologist, to be sure.
Referral to gynae and when all results back, then she can stop using contraceptives.
I ordered all the ANC bloods, I told her which ones. Also all the SLE and thrombophilia screening.
Started her on aspirin and folic acid.
PASS – Approach – 5, History – 4, Exam – 4, Investigation – 6, Counselling - 6
15. 55 year old has been diagnosed of diverticulitis. Turned into an abscess? Surgery needed
and surgeons say may do surgery in next 2-3 days. You are intern.
His atrial fibrillation is well controlled and he is on apixaban. Also atorvastatin and atenolol. He
is concerned about bleeding and very worried.
Ask about his concerns (What if I bleed to death? What if I have stroke? I don’t trust the
surgeons. My cardiologist not available right now it’s the weekend, can’t get hold of him.)
Summarise his concerns to him.
Explain how you will address his concerns.
Another Feedback – 72 years old man history of high BP and AF with acute diverticulitis and abscess.
Admitted in the wards with IV antibiotics for 24hours if fails, surgery may be considered. Taking
antihypertensives and apixaban.
Talk to patient and address his concerns.
Patient was very worry about surgery, he was diagnosed with high BP and AF long time ago in good
control and the acute diverticulitis since today. Afraid of stroke (some family member had one-I
forgot who), scare of surgery (someone he knows died in an elective surgery). Afraid of colostomy
(his neighbour has one).
I just keep reassuring the patient that he might not even need surgery, the majority of patients
resolved with AB, however if needed, we’ll liase with his cardiologist regarding his medications.
Possible putting him on bridging therapy although is more for people on warfarin and since he was
on apixaban maybe no so necessary. Regarding the colostomy I said it’s very unlikely but it happens
it will most likely be a temporary one.
He was relieved at the end I keep asking is there any other concern, and then he keep bringing more
and more things until finally he said, no those were all my concerns. Then I said, oh well you have a
lot on your plate, no wonder you were son concern, I’m happy to chat again later. Let’s hope you
don’t need surgery. He was happy with that.
PASS – Approach – 6, History 3, Counselling 4
16. Active 13 year old with pain below both her knee caps. Active in sports and been intensively
training for a tennis tournament in the last week.
Perform relevant PE
Explain diagnosis and differentials with reasons
Another Feedback - 13 years old ongoing knee pain specially while going down stairs. Do PE and
explain DD to patient. PASS – Each 6
Said hello to patient and examiner.
I can see that you’re having some troubles with your knee recently, which one is it? Both
I would like to examine you, to have a better idea of what is going on? Would that be ok? Sure
It’ll involve looking at your knees and I’ll ask you to do some movements for me, probably a bit
uncomfortable. Are you in pain at the moment? No (while washing hands)
So what I would like you to do if stand up please facing me. Patient did that. Thanks
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I don’t see any obvious deformity in your knees or any signs of trauma. No scars, no evident
efussion. No genuvalgo o genuvaro. Looking form the side, no hyperextension and from the back no
bakers cyst.
Can you please walk toward the wall and come back? Your gait is normal, no antalgic gait.
Can you please squat for me? The general power of your legs seems fine.
Now I would like to lye down please, I’ll have a feel of your quadriceps. Tone is fine, no tenderness
on palpation. Let me know if any point is tender, then I palpated all the knee join. He mentioned
pain on the tibia tuberosity in both knees. I look for effusion with patellar tap, then I look for bulging.
I did patellar test. Then I did movements of knee. Then I did test for all ligaments and meniscus, all
normal.
Then I said, thanks. The good new is that both your knees are stable, all the ligaments are intact also
you have a good range of movements. I only found one tender spot here (showed him were) which
makes me suspicious of a disease that I can’t remember the name, something like Osgood
something, I’ll look it up for you, it’s a fancy name…he laughed. (I’m bad at names). It is a very
common problem in active kids like you, when you start growing, the growing plates pull this bone
here and with activity it makes little traumas and minifractures in the bone and that is why you have
the pain. I was also thinking of patellofemoral syndrome or tendinitis or trauma, also an infection of
your knee, but as I said the rest of your exam is normal.
6th June 2019
1. Patient taking Valium TDS after son diagnosed with ALL but now in remission. Task – H/o Mx and
Counselling
Approach to patient/relative 5
History 5
Patient Counselling/ Education 3
Management plan 4 PASS GS 4
Approach – Empathy from the start (Even when son is in remission), 5As (Ask, Assess , Advice, Assist,
Arrange)
H/o – Ask – How long, How much, Why taking, who gave the valium
Assess – Tolerance, Dependence, Withdrawal, Motivation
Mood Q? Suicidal?
Past MH h/o?
SADMA + HEADS
Counselling (Advice) – Explained that in long run it’s bad (Respiratory depression, sudden death)
need gradual withdrawal if stopped suddenly – fits (I felt I rushed this part and used too many
medical terms hence 3)
Management (Assist & Arrange) - Gradual reduction of dose over period of time aiming to
completely stop in a few months’ time. Limited supply will be prescribed. Need filling frequently.
Expect withdrawal signs – if fits – call ambulance.
Sleep hygiene advice, Exercise, Diet. Arrange – Psychologist for CBT and Relaxation, Social worker,
Family meeting and mention Rehab if all methods fail.
At the end, wish your son a speedy recovery!
2. Female patient age around 50 years acute abdomen with some diarrhoea and fever. Task PE &
Diagnosis D/D.
Approach to patient/relative 4
Choice & Technique of examination, organization and sequence 4
Accuracy of Examination 4
Diagnosis/ Differential diagnoses 5 PASS GS 4
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Approach – WIPE, Offer pain relief after asking for allergy, HD stable? I asked the patient if it’s ok to
lie her bed fully flat (as the head end had an angle of about 20 degrees) – she refused . Can you point
me where exactly the pain is – she goes all over the tummy
Examination – I made running commentary even if the task did not ask for it.
Inspection – Scar swelling erythema distension movement with respiration
Palpation – As per any acute abdomen all 9 quadrants. Superficial first . Then deep palpation. Don’t
forget the Renal angle tenderness. (Positive LIF tenderness and voluntary garding)
Percussion - Percussion tenderness over LIF after informing patient that it will hurt a bit. (Examiner
came closer to check that)
Auscultation – I Rubbed the diaphragm of my steth (in an attempt to warm it up) before listening for
bowel sounds. (I commented that I am checking for the bowel sounds – because even if it is obvious
the fact that it is present on the patient I wanted to know whether examiner will say otherwise.)
Then I mentioned that to complete my examination I would like to get consent for checking Inguinal
hernia orifices, PV, PR Exams with Female Chaperon. – Then examiner said DRE – no blood.
Then I requested for BSL, ECG, Urine dip and possibility of getting erect X-ray chest – Examiner
frowned and said not done.
Diagnosis & DD – I explained Diverticulitis as diagnosis and DD – Diverticular abscess, perforation
bleeding, Colitis, Gastroenteritis, Left sided appendicitis, Left ureteric stone with UTI, least likely to
be left ovarian pathology. Bell rang !
Thanked examiner – washed my hands and ran out of the room.
3. 20 year old female comes to GP want to get a plastic surgery referral for her nose. Task Hx likely
Dx and Mx.
PASS GS 4 – Each 4
Approach (Upset girl with part of her hair over the face to cover her pretty nose) – Empathy and
Confidentiality
Hx – Nose questions – When noticed the big nose? Is it getting bigger progressively? Did anyone
commented ? Any treatment? How has it affected your daily life, Any other body part concerned
about? Do you often check self in the mirror? (She pretended to be crying – offered tissues)
Mood Sleep Appetite and Suicide questions as per psych history
SADMA & HEADS
Diagnosis – Explained that there are indications for plastic surgery but when I look at you don’t have
any gross abnormality of the nose that needs correction. Explained Body dimorphism – preoccupy
about appearance. If persist will lead to low self-esteem and fear of rejection.
Management –Offered Psychologist for CBT, Advice to remove mirror , Will review again, but if you
still concerned will give a referral to a plastic surgeon.
(In this case I couldn’t find any trigger that led her to come to GP suddenly. I felt I may have missed
something in the history. – passed family member? Broken affair? Abuse? ). I remember she stopped
crying eventually.
4. 34 weeks pregnant. Usual GP not present. Coming for Checkup. Task PE Dx.
Choice & Technique of examination, organization and sequence 4
Accuracy of Examination 3
Diagnosis/ Differential diagnoses 2 FAIL GS 2
Approach – (There was a real pregnant woman and a manikin in the room and when I look around
hand held clock, steth, measuring tape, BP with cuff.)
WIPE – need to wear gloves.
Today I’m going to examine you and your baby, looking feeling and performing some special tests.
I’ll be gentle as possible, if you feel any discomfort please tell me. If you want to empty the bladder
first please do so. My nurse will ask for a sample of your urine. A female chaperone will be present
throughout my exam.
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Examination – General – I would like to start by doing Ht Wt BP and PR (PR with hand held clock. BP
with the cuff – I totally screwed up this. I couldn’t inflate the cuff and then this old Examiner came
and then he advised me to put it other way and then the cuff wouldn’t deflate ….the drama made
me lose time and after finally checking BP moved on to Face) Comment Pallor Icterus, Chloasma.
Manikin Abdomen – Inspection – Distended with linea nigra and stria gravida, No visible contractions
Palpation - SFH - > 34cm (Cannot remember exactly how much) On lateral grips and Lie – I thought I
felt it as a Transverse lie. Certainly wasn’t engaged.
Auscultation – I mentioned that ideally I should be palpating mothers pulse simultaneously while
listening to FHS. I just had time to keep my steth bell above the umbilicus of manikin and was
listening to 15 seconds… bell rang!
As I was leaving I said FHR is around 140 and diagnosis is Transverse lie with Large for gestational
age. I even forgot to remove my gloves coming out of the station. then a Martial came and took the
gloves off me while I was reading the next station’s stem.
I was so crossed with myself as I prepared for this station so much before Exam. Did not expect to
fail. Please see another candidate’s notes. Someone who has passed this.
5. 30 year old male with Headache. HR and BP given. Task Hx Dx and DD
Approach to patient/relative 6
History 6
Diagnosis/ Differential diagnoses 7 PASS GS 6
Approach – offer pain killers
History – Pain questions – LOTRADIO – Unilateral, feel the attacks are progressive . Started from
teen years. Alcohol make it worse+. (Suggestive of migraine and not Tension headache)
D/D questions – Fever, neck stiffness, Rash, Photophobia (Meningitis/SAH) – Photophobia+
Pain around eye (Cluster headache)
Red eye, blurring/reduced of vision (Glaucoma)
Cough, sore throat (Upper Respi Infection)
Sneezing, runny nose (Sinusitis)
Ear pain discharge, pain behind ear (Otitis media, Mastoiditis)
Wt loss, LOA, Lumps and bumps, fits (space occupying lesion)
Trauma, assault, MVA (Post-concussion syndrome)
Past hx – Migraine, DM, Stroke, Polycystic Kidney Disease, HTN – (Malignant HTN)
Family h/o – Migraine +, HTN, Stroke, PKD
SADMA & Diet – Caffeine, cheese Red wine (There was some trigger among these other than alcohol
– I can’t recall unfortunately)
HEADS – Computer use, TV / noise/light environment – (patient said bright light was uncomfortable
and dark makes better)
(I can’t remember exactly in this station whether I had to ask for the Temperature and examiner
gave me an examination card or not ?)
Diagnosis – Migraine – explain no exact cause – believed to be dilatation of blood vessels and trigger
factors are….
D/D - explained how everything I have mentioned above within brackets are unlikely in his case I just
had enough time to finish and bell rang . Patients and examiners body language looked as if they
look satisfied.
6. Few months old child with h/o cough and Difficulty breathing . Task Hx PEFE Dx Immediate Mx
Approach to patient/relative 5
History 6
Choice & Technique of examination, organization and sequence 6
Diagnosis/ Differential diagnoses 7
Management plan 7 PASS GS 7
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Approach – As I entered upset dad asks me what’s wrong with the child. I honestly got a bit mad
there. I mean how would I know without hx. So without saying anything I turned to examiner and
asked for Vitals & sats. She politely said you will know them after the history. Then I introduced
myself and said that’s what I’m here for and would like to know a bit about the child if that’s all right
with him. Then he complied
History – ENT Qs – N- Noisy breathing, Runny nose, sneezing E – pulling ears? T - cough?
LRTI Qs – Increase work of breathing? Musical sound from chest?
D/D Qs
Chance of swallowing something /aspirate? (Foreign body)
URTI Qs (already asked above) – (Viral induced Wheeze)
Fever? (pneumonia/Bronchiolitis)
Difficulty breathing while feeding, scalp sweating, swelling over back? (Heart failure)
Well baby Q s – (Feeding was down and wet nappies reduced+)
Past h/o – Similar, Sick contact, Travel h/o, Day care. Eczema, Heart ds
Family h/o – Atopy – Asthma, Eczema, Hay fever
BIND h/o – Congenital heart defect /Xd? APGARS – needed NICU for ventilatory support at birth?
-Nutrition – BF/Formula – usual intake/d and how much it is reduced now ? (>50% dec+)
SADMA and HEADS – Smoker in house? Pets? Dust mite pollen? How mom and dad coping?
PEFE – ( Dehydrated + , SPO2 91% , RR increased+ , B/L wheeze +, Tracheal tug+, Recessions + )
Asked even if negative for – Murmurs, Femoral pulse sacral edema
Diagnosis – Bronchiolitis – Reversible airway obstruction. common due to RSV...Day 2-3 is worse
respiratory distress and arrest the main compilation . Unlikely to be pneumonia at this stage.
Management – Admit, NO Antibiotics as its viral, Need high flow oxygen, if no oral tolerance of feed
through NG tube – help deflate stomach and the feeds can be given. Need monitoring in ward.
Can rarely complicate later on – Intubation and ICU care. But rest assured bub is in good hands.
7. Unconscious Patient in ED . Your senior has done DRABC already. Tasks - Assess GCS,
Relevant PE with running commentary,Give at least 4 DDs.
Choice & Technique of examination, organization and sequence 6
Commentary to Examiner 6
Accuracy of Examination 6
Diagnosis/ Differential diagnoses 6 PASS GS 6
Approach – First of all I am glad that I took the 7 day intensive course with ARIMGSAS.
As I entered there was a young woman eyes closed with nasal prong oxygen pretending to be
comatose. I have to say the Indian Examiner was very welcoming too. He gave me a GCS chart and
asked me to proceed. I saw that there are torch, ophthalmoscope, knee hammer, otoscope .
GCS – COWS Q – Can you hear me? Open your eyes. What is your name? Squeeze my finger Then I
told examiner – I will now elicit for pain by squeezing patient’s index finger. He said proceed . When I
squeezed patient s index finger – she opened her eyes and pushed my hand away and told me to
F*#K off! - So for me E 3 V3 M 4-5 (as it can be localize/withdraw ) I got a GCS 10/15
Examination – Head to toe with running commentary
Head – no bruise skull depression or evidence of trauma Ears – No battle sign , From otoscope – no
hemotympanum Nose – with torch no septal hematoma ,no CSF rhinorrhea , no epistaxis, Want to
look inside mouth – Examiner ask what are you looking for – I said alcohol smell , fetor hepaticas,
acetone breath, blood – all not present . The eyes -Pupils, reflex, with torch, Fundus with
ophthalmoscope. (Examiner was assessing the familiarity.) Then proceeded to the neck – first felt for
any deformity and I told I want to exclude neck stiffness – Examiner asked me to show how its done .
So I held her head with both hands and passively rotated to both sides and up and brought chin to
chest. Then told no JVP rise. Chest – move with respiration , I did not go to expose the chest – I just
said would like to see if spider naevi , bruises and palpate for possible rib fractures and will not do
auscultation assumingly its done as part of the primary survey . Abdomen – move with respiration,
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no distension, dilated veins, Palpate to see for garding rigidity, Deep palpation liver and spleen, loin
balotability. Auscultation for bowel sounds. Upper limbs – IVDU, needle marks, bracelets, bite sting
marks . Roll wrist elbow shoulder (Forgot to do reflexes) Lower limbs – bite sting marks, Roll knee
and ankle. Then Examiner asked me to show how to check for reflex – then I took the knee hammer
and elicited knee jerk -it was normal. The he asked me is there anything else I would like to know?
Then I asked for Temperature and BSL (Both normal)
DD –Head injury, Meningitis, Encephalitis , SAH , Drug overdose , Encephalopathy – drugs, hepatic,
uremic, CO2 Narcosis , Syncope due to sudden cardiac arrest, ectopic pregnancy , rupture AAA,
Hyperglycemia/Hypoglycemia/DKA /Myxedema Coma, Septic shock , Dehydration/bleeding with
hypovolemic shock, Anaphylactic shock….Bell Rang – thanked examiner and left .
8. Female in her 20s coming for the 4th time for recurrent thrush that’s been going on for 3
months.Task Hx , PEFE , Mx.
History 3
Choice & Technique of examination, organization and sequence 5
Management plan 3 FAIL GS 3
Approach – A pissed off patient, she is asking what’s going on. I apologized as this is the 4th visit to
same GP (me) I told her I understand your frustration. But I need to understand whether I missed
something. Ensured confidentiality. So can I ask a few questions from you? But throughout she was a
bad patient answering me in like “whatever” attitude.
History – Discharge Q – CCVO, Itchy rash, fever, abdominal pain?
5Ps – Use tampon or pads? Left a tampon? Chance of pregnancy? Pill how long? PAP/Gardasil?
Past h/o – DM? Family h/o DM?
SADMA – Anxiety? Steroid use? Antibiotic?
PEFE – BMI – Normal , BSL – not done
Vitals – NAD
Chest – NAD
Abdomen – NAD
Pelvic exam with consent and in presence of chaperon inspection – Discharge+, Scratch marks +,
Rash. Speculum – Any mass, Removable Foreign body. Bimanual – No adnexal mass. Swab with
consent for fungal studies.
Management – Check BSL, stop pill– change to condom, send the swab to microbiology oral
fluconazole, avoid tight undergarments ….Bell rang
I knew I’ll fail this case .But in hx other than the obvious fact that she is on pill I can’t think of
anything else to ask. I thought my hx was spot on. Then On examination other than the discharge
and redness there was no other findings. In management however I forgot to mention it’s not an
STD but to avoid sex /toys/tampons/douche / bubble bath and further follow up with results.
9. RMO in surgical ward. Female Post lap cholecystectomy D1 fever -obs chart T 37.9 Other obs –
normal range. Task Focus Hx, PEFE, Diagnosis & Mx
Approach to patient/relative 4
History 4
Choice & Technique of examination, organization and sequence 5
Diagnosis/ Differential diagnoses 4
Management plan 3 PASS GS 4
Approach – As I entered the room the patient on bed asked me when can she go home? I greeted
her and told her that I am here to make sure that she is safe before discharge.
History –how are you feeling?
Any fever? – No +
D/D Qs post op fever
Cough? SOB? (Pneumonia/aspiration, Atelectasis)
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Abdominal pain? (Urinary issues? Bowel issues? UTI with or without constipation)
Pain over wounds, drain site any oozing? (wound infection)
Pain over cannula site (Thrombophlebitis)
Pain or swelling over Calf muscles (DVT)
Past h/o – DVT/PE, Lung disease, DM
SADMA and HEADS
PEFE – T mild low grade fever +, cannula site, for evidence of infection, Chest – no murmurs but b/l
crepitation+, no ronchi , b/l equal air entry, Abdomen – soft , no infection over wound sites, No calf
tenderness or swelling . No ankle edema.
Asked for urine dip – NAD BSL, ECG – not done
Diagnoses – Atelectasis – Day 1 fever + bi basal crepts – explained lung collapse -especially the bases
D/D – Pneumonia, UTI, Wound infection, Thrombophlebitis, DVT
Management – This was my last station and I was so tired and wanted to get this over and done. So I
just hurried along saying – Atelectasis is my provisional diagnosis – you need to stay in hospital
more, you need chest physiotherapy, monitoring with oxygen sometimes bronchodilators. But I
need to discuss with specialist whether we need to do X-ray, repeat bloods with culture and urine
culture and wound swab to exclude infection and to start antibiotics. Sorry for keeping you like this.
bell rang. thanked patient and the examiner .
10. MSE video -Plumber with Schizophreniform illness . Stopped taking his meds. Brought by partner
for change in behavior. Present MSE to examiner.
Commentary to Examiner 4
Accuracy of Examination 3 FAIL GS 3
Approach – My worst nightmare. No matter how hard I try I never get this properly. Maybe I’m
destined never to pass MSE. The big screen was about to start the video when I started jolting down
ASEPTICJRRR.
At Start of the video this man who appeared to be talking to someone. He was dressed ok but he
was wearing a cap opposite. Then he was maintaining good eye contact and mid-way turned his cap
to front. He was talking a whole lot of gibberish, Russian spying, Harry potter, I couldn’t really
remember what he was on about.
During the video he had some auditory and visual hallucinations, delusions of grandiose, paranoia
and possible homicidal tendency which he won’t tell whom. (Can’t remember now whether he said
his mood high or low)
After the Commentary to the examiner with a poker face. there was an awkward silence. I was trying
to think whether I missed something. Then I told examiner I’m trying to think whether I have missed
anything. Then the examiner asked anything on thought form? But before I could tell anything the
bell rang.
I guess had I known the answer to that he might have consider giving 4 for Accuracy and pass this
station.
I’ve seen lot of recalls from previous candidates who has successfully passed MSE stations. But
almost all of them have a global score of 4
So I really don’t know how to present an MSE and get a good score of 5 and above.
For this station please see some other pass candidate’s answer.
11. Father brings his 2 years old child as he is worried child not putting weight. Task Hx PEFE Dx Mx
Approach to patient/relative 4
History 4
Diagnosis/ Differential diagnoses 4
Patient Counselling/ Education 5 PASS GS 5
Approach – My first physical patient /patent’s father of exam. As I entered the examiner greeted me
and I was happy and as a reflex I tried to shake hands with the patient’s father. This guy gave me his
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hand and quickly withdrew it. It was very uncomfortable. so I panicked and ask whether he has
brought the Red/Blue book of growth charts. He looked confused and Examiner handed me the
growth charts – The latest weight was in 3rd percentile and it has only dropped from the next centile
above.
Hx - How long have you noticed for?
DD questions of FTT causes
1. Inadequate intake – 1.Content less – Can you describe his daily diet? 2.Coecific feeding – does he
eat with family members at the table? 3. Cleft palate – Similar problem in the past
2. Inadequate absorption -1. Chronic diarrhea – Fever? vomiting? Tummy pain? Diarrhea? 2.Chronic
pancreatic insufficiency – Foul smelling diapers? 3. Chronic Liver ds – Pale poo, yellow eyes, itchy
yellow skin? 4. Coelic ds – Pale skin?
3. Excessive calorie burn – 1. Congenital heart ds – Blue spells tired easily? 2. Chronic respiratory
illness & CF – cough SOB recurrent flu? 3. Cystits – strong smelly urine? Blood?
4. Congenital causes (BINDS) – Antenatal infections? , Birth defects? Congenital errors of metabolism
– Heal prick abnormal result?
(I forgot to ask for rest of the BIND questions – Development – any concern with millstones? Family
history of similar problem? Anyone on a special diet? )
5. Psychological factors – 1. Caregiver stress – parental depression/relationship issues 2. Cooperation
not enough – partner supportive? 3. Cannot afford – Financial? 4. Child abuse – anyone else looking
after him?
PEFE Card was given by examiner – All normal
Diagnosis – Most likely he is a fuzzy eater – He is at an age of independence . I cannot see any
Infection, Heart & liver lung gut or birth defect causing this. Then showed the Growth chart where
his weight stand at this point. (prove its not a very convincing drop)
Management – Offer variety of food, colourful food. If refuse – don’t force/punish, small frequent
meals and dine with family at the table. Let him feed self. Involve him in preparing food. (Father
seem ok with explanation and agreed with everything I had to say. I forgot to refer to a dietician)
12. Female with Long term SOB and tiredness. FBC and film – Microcytic hypochromic with low MCV.
(Can’t remember other by products in the film)
Approach to patient/relative 5
Interpretation of investigation 5
History 6
Diagnosis/ Differential diagnoses 6 PASS GS 6
Approach – Friendly female patient form the start. Greeted and told I have results. let me explain.
Interpretation – Show IDA. Blood has 3 components. White blood cells fight infection – Normal in
yours. Platelets act as sealing agent stop bleeding – Normal in you. Hb is a particle containing Fe
which take oxygen from lung to all body tissues. In your case it’s a bit low explaining why you got
those symptoms. Also makes size of red cells to shrink too – evident on blood film and MCV.
History – Number of causes for this. So I need to find out exactly what ‘s causing it.
IDA Q – Difficulty swallowing? (Plummer Vinson Xd), Heart burn Gastritis Blood vomit? (PUD/GORD),
Abdominal pain? Distension? Diarrhea? Bulky frothy poo? (Malabsorption Xd), PR Bleed? Malena?
LOW LOA lumps and bumps? (Malignancy)
D/D Q -Unexpected gum bleed, Bruising Blood in urine (Bleeding disorder), Menstrual ho –
Menorrhagia? Intermenstrual bleeds? (Menstrual ) LRMP? Chance of pregnancy? (Pregnant),
Past medical/surgical – scopes? , surgery ? Bleeding disorder?
Family h/o anemia? bleeding ds? Mediterranean heritage? (Thalassemia)
Diet h/o – Strict Vegan? .
SADMA – medication – Blood thinners? NSAIDS + - (Chronic use of ibuprofen for ?backpain)
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Diagnosis – Explained with diagram of stomach – barrier for acid get thinned with chronic use of
NSAIDS causing very micro bleeding which made you loose blood and hence iron making you
anemic. If left bad for the heart as increase work load, can get stomach ulcers – perforation .
DDx – unlikely to be above mentioned in brackets with reasons. I forgot to mention Pb poisoning and
Sideroblastic anemia as ddx
13. 21 month old brought by mom complaining unable to walk. Task Hx Mx
Approach to patient/relative 4
History 2
Diagnosis/ Differential diagnoses 2 FAIL GS 2
This station I was surprised when I failed it because I actually thought I did well in this one. I knew a
few milestones by hand and was remembering them before entering.
Approach – Pleasant mom greeted
History – Delay walking Q– when did you first notice?
BIND Q- Pregnancy/Birth Q - ANC check-ups? TORCH infections? IUGR?
Prolong resus at birth? APGARS? Birth defects? Delivery trauma?
Development Q – (Gross) Lift head by 3mo Sit with support by 6mo Crawl by 9mo?
(Fine) Grasping by 6mo Hand to hand transfer by 9mo? Pointing by 12mo ? Early hand dominance
before 18mo?
(Language) Cooing by 3mo? Babble by 9mo? 1st word by 12mo?
(Social) smile by 3mo? Recognize mom by 9mo? Bye bye by12mo?
Well baby Q?
Family h/o delay walk? +
HEADS
(Surely this history worth more than score of 2 right ?)
PEFE Card – all normal except for mild hypotonia of both legs/thigh
Diagnosis – Either I wasn’t paying much attention to patient’s answer or I wasn’t doing the right
thing. My diagnosis was Delay Motor Maturation
D/D – Global Dev Delay , Cerebral palsy , Muscular dystrophy , Congenital defect , Syndromic baby
Bell rang – thanked Examiner and the patient.
14. 42 year old female completed family on pill want to change to Mirena .Task relevant Hx, PEFE,
Explain Mirena coil and counsel patient.
PASS GS 4 – Each 4
I really thought I screwed this station up. I barely remembered reading Cu IUD and knew a little
about Mirena (In spite of recent recalls kept coming regarding Mirena)
The only bit I read was from OSCEstop.com - which compare all contraceptive methods in a table
format.
Approach – Friendly lady in GP practice, Examiner was also a nice young Asian examiner. Greeted
both and to my surprise on the table was a model of Female reproductive system section with
already inserted Mirena with string.
History – Why do you want to change? (Can’t remember exactly what patient said)
5Ps – How long pill? Stable partner? Pregnancy? Period? PAP?
CI for IUCD – PID? STD? undiagnosed PV bleed? Uterine abnormality?
CI for hormone – HTN, Heart ds, Liver ds , Migraine, DVT/PE Strokes Cancer
Family h/o – Migraine, clots, Breast Ca
SADMA – smoke, other medications
PEFE – BMI, Vitals, PICCLE, Thyroid, chest breast, Abdominal exam, PV exam with chaperon and
consent – All normal . Urine Pregnancy test – not done BSL – not done
Counselling – Explained it’s a T shaped device containing hormonal contraception
M.O.A. – Device – Spermicidal effect by inflammatory reaction
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-Progesterone – Stop ovulation, thin endometrium, Incr. Cervical mucous thickness
99% effective, last for about 5 years if put within 1st 5 days of start of period.
Risk/Side effects – Infection, perforation, bleeding, expulsion (device)
Weight gain, Headache, breast pain (Progesterone)
Then I used the model and explained all female anatomy (Examiner came close to check what I was
doing) I pointed at the string and told this bit will be felt through vagina – need checking
Monthly then bell rang. Thanked both patient and examiner. Really lucky to pass this station.
15. PILOT Hip Pain in 40 year old female for 3 weeks after running. Afebrile . Task – Hx Dx DDx with
reasons.
Approach: Offered painkillers.
Hx: Pain Q: LOTRADIO – Location was lateral hip. Activity worsens the pain, and rest makes it better.
Associated Q: swelling, fever, reduced ROM, numbness, weakness??
DDx Q: Fever? Redness?
Trauma?
Rash? Muscle pain?
LOA, LOW? Lumps and bumps?
Past medical Hx: arthritis, RA, gout, psoriasis, SLE, Osteoporosis, surgery?
Family Hx: arthritis?
SADMA
Dx: I drew the lateral hip and pointed at the likely diagnosis of trochanteric bursitis
DDx: fracture, osteomyelitis, OA, RA, gout arthritis, psoriatic arthritis, muscle strain, tendinitis,
polymyalgia rheumatica.
16. Hematuria in a 60 yr old male. Hx PEFE and Dx & DDx
Approach: Greeted both examiner and patient. Asked examiner BP, pulse rate, postural drop.
Hx: hematuria Qs (when did you 1st notice? is it at the beginning/throughout/ending?)
Associated Qs: any pain? Dizziness? SOB?
DDx Qs: Tummy pain? Loin pain? Any urgency, burning, frequency?
Any trauma? Scopes? Surgery?
Beetroot, red lollies?
Recent URTI?, Coughing blood?
LOW, LOA, lumps and bumps?
Any nose or gum bleeding? Or skin bruising?
Past Medical Hx: bleeding disorder? PKD? Kidney stones? Heart disease? HTN? BPH? Ca?
Family Hx: Kidney stones? bleeding disorder?
SADMA: smoking? Alcohol? Blood thinners?
HEADS: Occupation (when I asked, he said he’s retired, but I overheard another candidate that day
saying he was exposed to some chemical, but not too sure about that).
PEFE: Positive findings were; mild left loin tenderness, and on DRE enlarged smooth prostate with
well defined median sulcus.
Dx: I still favored the possibility of left RCC given the history of painless hematuria, and left loin mild
tenderness.
DDx: Bladder Ca, PKD, Renal stones, cystitis, bladder papilloma, BPH, prostate CA, PSGN, IGA
nephropathy, trauma, bleeding disorder, blood thinners.
7th June 2019
1. Cough and sob in a 3 years old boy for 24 hours. Father is very anxious, pacing around the room Foreign Body
2. Breast lump – PE
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3. Respiratory examination – PE, for SOB
4. Peripheral nerve entrapment in upper limb - Cubital Tunnel Entrapment
5. 34 weeks pregnant lady with headache - Pre-eclampsia turning into eclampsia
6. CT liver metastasis with microcytic hypochromic anaemia
7. 72 years old lady with haematamesis and mild epigastric pain going to back - Peptic ulcer
8. 28 years old male with dysuria - Sexually Transmitted Infection – Chlamydia / Gonorrhoea
9. Pap smear- HPV 16 positive
10. 37 years old wants hysterectomy (menorrhagia for 6 months)
11. Post natal blues / irritable baby
12. MSE video
13. 9 months old baby with crying and vomiting since this morning- Intussusception
14. Unwell lady for a month - Hepatitis
15. 3 years old boy with generalised jerking of limbs - Idiopathic seizure
16. Medication chart - Pneumonia
12th June 2019
1. TESTICULAR TORSION:
Father of 13 years old boy is in the ED to talk to you about his son condition, pain and swollen
scrotum. Task : HX, PEFE, Explain the DX and discuss immediate management and investigations.
(positive findings on examination no trauma history just playing basketball )
2. PALPITATION:
27 years old male presented with awareness of heartbeat , he is concerned about having heart
attack. Task : HX, DX and DDx.
(family history of heart attack in his father but the father is doing well , stress at work , and drinks
lots of coffee. No other abnormalities.)
3. OCP COUNSELLING:
Minor 15 years old in your GP clinic for OCP counselling .
Task: Hx, PEFE, counsel her accordingly.
4. PSYCHIATRIC VIDEO
23 years female with new behaviour recently, she keeps remembering her mother who passed away
last year in car accident. No previous mental history, past Medical history of hypothyroidism.
Task: Dx and DDx, Discuss immediate management.
5. anaphylaxis - peanut intake history f/h of asthma , atopy n hay fever
Another Feedback - SKIN REACTION :
Young boy presented with swollen lips and itchy rash , picture is given outside ( Rash covers the face
and the shown part of the neck ), now the swollen has subsided only the itching and the rash persist.
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Task : HX, Talk to the parents about the most likely DX.
(positive for eating a bit of his sister peanut butter sandwich.)
6. BURN :
2 years old baby BIB her mother after spilling hot noodles soup on her chest.
Task: HX, PEPE on card, there was a figure with marked burned surface area over the chest if 13%
Discuss immediate management.
7. HIV RESULT POSITIVE IN PREGNANT WOMAN
young pregnant woman in your GP clinic for her antenatal check results.
Results were given outside. Rubella, syphilis , Hep C , ep B , Hb and ultrasound at 18 weeks are all
normal. Blood group O Rh negative. HIV test positive.
Task: Explain the results. HX. Counseling accordingly.
8. PAINFUL URINATION : DYSURIA.
Middle age male presented with painful urination.
Task : History. Explain DX and DDX.
(positive was frequency, drippling , hesitancy, and dysuria. Change in urine colour and smell.)
9. LYMPHOMA :
Young male feels feverish . Task : HX, PEFE on card, DX and DDx.
(night sweating +, enlarged non tender cervical LNs and enlarged spleen.)
10. ULCERATIVE COLITIS COUNSELLING :
Young female is at your practice today for reviewing of her Results of colonoscopy in which the
result is UC. Task: Explain the results. Discuss the management.
11. WARFIN COUNSELING
A lady has been scheduled for elective colostomy for sigmoid cancer in 3 weeks time . PT is on
warfarin with INR with the therapeutic level.
On ramipril for hypertension.
On lipid lowering agent, arorvastatin.
Task : Short HX ( within 3 minutes) Pre Op Assessment before sx and discuss about warfarin
counseling.
12. GYNAECOMASTIA
Middle age male with bilateral breast enlargement, mentioned in the stem outside that he's on
ramipril, smoker and drinks beer.
Task : Preform PE , DX and DDx.
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13. FACIAL TRAUMA
Young male with MVA, being stabilized and neck clearance has been done, picture of of red
conjectiva given outside.
Task : Preform PE, Tell the PT your DX.
14. DRUG INDUCED PRAKINSONISIM :
Young lady has recently been put on Risperidone.
Task : Short HX ( in three minutes ). Preform PE to the hands , arms and elbow ! DX .
15. BACK EXAMINATION
young male presented with backache after lifting heavy object.
Task : Preform PE, mention in the stem that you don't need to do sensation! DX and DDx.
16. ELEVATED BLOOD PRESSURE IN PREGNANT WOMAN:
Young pregnant woman presented with two reading of high blood pressure 150/100 with 15
minutes apart between the two readings , earlier in the pregnancy blood pressure was normal of
120/70. Nurse asks you to review the pt.
Task : Hx, PEFE, DX and DDx.
(Pregnancy induced hypertension -no positive pre eclampsia finding, only high BP)
13th June 2019
1. HYPOGLYCEMIA
PASSED: GLOBAL SCORE 4
STEM: Patient felt unwell while shopping. BSL was mentioned in stem, it was less than 4. (clue)
TASK: Hx, Mx, causes.
FEEDBACK:
Patient told me in detail about her unwell feeling. In hx, she skipped her breakfast and recently her
dose was increased too. I don’t remember whether she was on insulin or medications. I asked her
Hypoglycemia symptoms (LOC, Palpitations, tremors, anxiety etc) and causes (skipping of meal,
recent increase of Activity, change of dose, any infection) Diabetic complications etc
Explained her about hypoglycemia in layman terms, explain her all causes with other causes of
unwell feeling like Silent MI etc .
Management: I advised her not to skip any meals after medication or insulin in order to prevent
recurrent episodes and what to do in case of any repeat episode. Same jelly beans, juice and followed
by meal. I asked her about driving too and again advised not to go with low BSL for driving.
Explained her about Hypopack (GLUCAGON) and asked her to bring her family members so that I can
explain to them about Hypoglycemia symptoms and how to inject glucagon in case she loses her
consciousness. I also focused on other complications of diabetes like Heart, vision, kidney and advised
her to be in regular follow up with GP and regular maintenance of Blood sugars.
Another Feedback PREDOMINANT ASSESSMENT AREA - MANAGEMENT/COUNSELLING/EDUCATION
Scenario: Treatment complications Grade: Pass Global score: 5
Stem: A lady in her 50s, presenting to ED after feeling dizzy while shopping with her husband.
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Hx of DM
Vitals normal
BSL 3 mmol/L
Tasks: Hx, Dx, DDx and immediate and long-term management plan.
MY APPROACH:
- Hemodynamic stability
- Reassuring and comforting the patient. I told her I will immediately give her a sugary drink to raise
her BSL (I did not say how much) and recheck her BSL after 15 minutes. If it is high enough (I did not
say the level
), I will give a snack of complex carbs to sustain your blood sugar at the desirable
level (I did not say any numbers).
- Hx. Of presenting complain: She did not lose consciousness or posture. She felt drowsy and her
husband rushed her to the ED. +ve racing of the heart and sweating. an hours ago. Sudden. First
time. Had an apple for breakfast. Had her meds after that. Did not have any alcohol before the
incident. Walked for 2 hours in the mall (unplanned activity).
DM Hx. Had DM type 2 for 5 years. Was only on oral antidiabetics (metformin and Gliclazide). Her
BSL got higher lately. The GP added Insulin (glargine) only before sleep a week ago. Good control
since then. Eye and kidney check up-to-date. Specialist visit every year. Compliant to medicine and
follow ups. Does not keep a BSL diary.
DDx: weather preference, fever, dysuria, occasional racing of heart, Hx of HTN, Hx of stroke.
Well-being: mood, sleep, bowel habits
SADMA
- Dx: Hypoglycemia. Causes are no carbs in the breakfast and unplanned physical activity which
caused her medications to lower the blood sugar level to a dangerous level.
- DDx: hyperthyroidism, alcohol intake, infections, arrhythmia, cerebrovascular accidents. (small
explanation about each).
- Management:
Re-explained the immediate management. Told her I will send blood for some investigations and
perform an ECG.
Long-term: Instructions on carbs in her diet, eating before medications, unplanned activity, alcohol
intake, snack in her hand bag, alarming symptoms of hypoglycaemia and what to do then, BSL
diary, five to drive.
- A lot of reassurance.
- I asked her if she has any questions. She said no but do you have anything else to tell me. So, I
repeated the management plan again.
2. PE : PYELONEPHRITIS
PASSED : GLOBAL SCORE 4
STEM: Young patient having abdominal pain for few hours/days don’t remember but clue was in
stem mentioning about burning urine sth like that.
TASK: Exam, DDX
2 min thinking: not to miss washing hands, vitals, DRE, pelvic and special test
FEEDBACK:
So in all physical examination stations, I washed my hands simultaneously while introducing myself
to the patient. Asked her pain severity and offered pain killers, she was given pain killers I think.
Asked examiner about vitals, she was running fever on asking temp. Commented on her general
appearance and did inspection. Nothing was positive on inspection. Then did superficial and deep
palpation of all 9 quadrants. Every time when she grimaced with pain, I said sorry. I dint check for
liver span because she had pain on right flank but I checked for spleen and turned her too. I even did
percussion and auscultated for bowel sounds. In special tests, I first and foremost checked for Renal
Angle Tenderness, asked her if she could sit, she was very nice and cooperative, she let me do that
and it was positive on right side. I did all signs for appendicitis and they were neg. I completed my
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examination, thanked patient and asked examiner about pelvic exam, hernia orifices. I forgot to
asked DRE here. Pelvic exam was normal. I asked office test too.
DDX: explained to her about pyelo, stones, appendicitis, gynecological causes.
Another Feedback PREDOMINANT ASSESSMENT AREA - EXAMINATION Scenario: Abdominal pain
Grade: Pass Global score: 4
Stem: A 20-year-old woman presenting to your GP with abdominal pain for 2 days. (long stem).
Feverish.
Regular periods. Sexually active. In a stable relationship. Uses both condoms and OCP. LMP was a
week
ago. No Medical or surgical Hx of note.
Tasks: Relevant PE in 6 minutes. Dx and DDx with reasons.
MY APPROACH:
- Hemodynamic stability
- Assured the patient that I checked her vitals and she is stable now.
- WIPES
- Asked about site of pain. (I did not ask about severity or offer a pain killer)
- Abdominal exam:
Inspection
Palpation (superficial and deep). Measured liver span. Spleen unpalpable. Kidney
ballottement. Rt. Renal angel and suprapubic tenderness +ve. McBurney tenderness and
Rovsing sign -ve.
Auscultation for bowel sounds, abdominal aorta and renal arteries.
- Pelvic exam (from examiner) no cervical motion tenderness, no adnexal mass or tenderness. No
bleeding or discharge.
- No Hx required was written with the tasks but I asked the patient about chills, shakes and dysuria
while examining her. She answered with NO. I think she was not trained on any Hx and answered
from her head. My advice is when they say “no Hx required”, do not ask about Hx. It might turn
out misleading.
- Office tests: UDS (+nitrates, WBC, RBC). Pregnancy test -ve (the examiner smiled when I asked
about it. FYI, in ectopic pregnancy, a woman can have a bleeding that starts and stops and can be
mistaken for a period.). BSL normal.
- Dx Pyelonephritis complicating a UTI (I explained)
- DDx: appendicitis, ectopic pregnancy, abortion, PID (I explained with reasons).
3. TIREDNESS – TB?
STEM: it was very short stem! patient feeling tired and lethargic.
FEEDBACK: I failed this station so ask someone who passed it.
POSITIVE FINDINGS: She travelled somewhere and throughout 8 mins, she was saying that she has
pain while coughing. She had dry cough, night sweats and weight loss. I followed STEAI approach for
tiredness. My ddx were TB, other respiratory infections and all tiredness causes.
Another Feedback PREDOMINANT ASSESSMENT AREA - HISTORY TAKING
Scenario: General malaise Grade: Pass Global score: 4
Stem: a 50sh lady who complains of tiredness for 6 months is coming to your GP practice for
consultation. No Hx of HTN or DM.
Tasks: Hx in 6 minutes, PEFE on a card, Dx and DDx.
MY APPROACH:
- Opening: Sorry about your problem. I will do my best to help you.
- Hx:
- SOCRATE for tiredness. The patient said she felt tired since she came back from Cambodia
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(I felt I was being tricked by bringing up the travel Hx so early. So, I did not pursue the
travel Hx at once).
- Later on, the patient brought up Cambodia again. So, I started asking about it. What
activities did you enjoy? Sight-seeing. Who did you travel with? Husband. Does he have a
similar problem? No. Did you eat any street food? Yes. Any GIT problems back then? Any
misquotes bite? No. I offered confidentiality and asked about unprotected extra-marital sex
while traveling? No.
- Any history of STIs? No. HIV Qs. No
- Hepatitis Qs. No
- Night sweat and night fever? YES. LOW and LOA? YES (6 kg in 6 months). Bumps or lumps?
No. itchiness and scratching? No. Cough? YES. She also said she had pain in her right chest
that travels to her back. It is TB and not lymphoma
- Menorrhagia and bleeding from orifices? No.
- Weather preference? No.
- Water works and bowel habits. Normal.
- Mood and sleep. Normal.
- PHx and SADMA
- PEFE card: I did not ask for it because I did not read this task. I knew after the exam that there was
a PEFE card READ YOUR TASKS WELL.
- Dx: TB (explained). I told her the pain in her right chest could a collection of pus and we need to
investigate more to establish the diagnosis. I said it is a NOTIFIABLE DISEASE and once the tests
turn out positive, the lab will report the results to the DHS who will trace her contacts without
disclosing her identity and her confidentiality will not be breached.
- DDx: lymphoma with reasons, HIV and hepatitis (just mentioned). I exhausted my time explaining
the Dx and why it is most probably not lymphoma that I only mentioned HIV and hepatitis after the
bell rang as I was leaving the room. YOU CAN TALK AFTER THE BELL WHILE YOU ARE LEAVING,
THEY’LL MARK YOU FOR IT.
4. SHORTNESS OF BREATH
PASSED : GLOBAL SCORE 4
STEM: there was a detailed chart with FEV1, FVC, FEV1/FVC Pre and Post bronchodilator..
I don’t remember the other details of stem sorry.
TASK: interpret findings to patient, Take Hx, DDX
2 min thinking: I was so confused with pre post readings, I couldn’t decide about obstructive or
restrictive
FEEDBACK:
Entered the room, examiner checked the ID, Greeted the patient and started explaining FEV1, FVC
And RATIO definitions and while explaining I realized it was restrictive lung Disease..
Took hx for Shortness of Breath
SIQRAA
when did it start? Is it getting worse? Is it your first time?
Are you short of breath at rest or only on exertion? Anything that aggravates or relieves it?
I remembered SOB cluster as heart, lung, anemia, blood loss and stress.
So asked 4Ps quickly Pneumonia, pleural effusion, Pulmonary Embolism, Pneumothorax
TOPES (Travel, Occupation, Pets & Carpets, Exposure to sick person, Smoking)
For Occupation I specifically asked : What have been your job till now?
Bcz he told me first that he was retired atm, then he told me he worked at a factory where some
metal was boiled and it was very nasty sort of work..
Smoking he already had quitted so I appreciated him again and again.
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DDX; I drew lungs on paper, excused for bad drawing lol , explained causes of restrictive Disease as
Asbestosis, silicosis, Pleural effusion, pleural diseases, nasty growth/cancer of pleura, in the end
even mentioned COPD as a cause too but less likely
Another Feedback PREDOMINANT ASSESSMENT AREA - HISTORY TAKING
Scenario: Shortness of breath Grade: Pass Global score: 4
Stem: A 74-year-old man has SOB for 3-4 months. He is in your GP practice. He had a spirometry
done at a mall in a campaign by the National Asthma Council Australia. The results are
Baseline
Post-bronchodilators
Observed
% Predicted
Predicted
Observed
% Predicted
Predicted
FVC (L)
78%
78%
FEV1 (L)
FEV1/FVC
83%
84%
PEF (L/sec)
PS.: I do not remember the rest of data, but this is the table as it appeared in the exam.
Tasks: Explain the results to the patient, Hx, Dx and DDx with reasons.
MY APPROACH:
- Hemodynamic stability.
- Assured the patient that I checked his vitals and he is stable now. Asked about any SOB or pain
right
now. He said none.
- Explaining the spirometry:
-What is it for? A lung function test. Further explanation of FVC, FEV1 and their ratio. His
results show restrictive lung disease (because FEV1/FVC is normal as it is above 80% while
FVC is below the normal figure of 80%) which means a STIFF lung. Results didn’t change
after bronchodilator which supports the diagnosis. Checked understanding all along. USE
SIMPLE WORDS.
- Hx:
-SOCRATE. I forgot to ask about orthopnoea (I am not sure if I asked does SOB change with
posture!).
-DDx. Questions: cough, fever? No. Travel Hx or DVT? No. LOW or LOA? No. Lumps or
bumps? No. Chest pain?
I was fixated on the Dx and investigations’ results that I could not ask very well about the
DDx. Beware that the DDx requested in AMC CLINICAL is for the patient’s complain not
for the PE findings or the investigations’ results.
- Occupation? Retired. What did you do before retiring? A Gardner. Before that? Taxi driver.
Before that? I worked in an asbestos factory and it was dusty and horrible and I could not
continue. COLLEAUGEs WHO DID NOT PURSUE THE OCCUPATION FURTHER, DID NOT GET
TO THE ASBOSTOS FACTORY. ASK IN DETAILS IF YOU HAVE A Dx IN YOUR HEAD.
§PHx, FHx and SADMA
- Dx: Asbestosis (explained what it is and its effects on the lung)
- DDx: other restrictive lung diseases like: pulmonary hemosiderosis and interstitial lung disease.
Obstructive lung diseases: asthma (I forgot to ask about in the Hx and I asked here), emphysema
and COPD. Heart failure (I forgot to ask about heart conditions or leg swelling, so I asked here and
the patient told me I had an ECG 2 months ago and it was normal, I told him that is really good to
hear and this means you have no heart problems - EMPATHY). I said I was also suspecting lung
cancer at the beginning but now I have no reason to consider it because you do not have any LOW,
LOA or bumps or lumps in your body, though, I still have to order some tests just to be sure
(whenever you mention cancer in the DDx after actually excluding it from the Hx and/or PE, you
have to reassure the patient immediately and tell him that you’ve excluded it because you do not
have “THIS or THAT”. Still, I will run some tests to be sure. EMPATHY - COMMUNICATION SKILLS -
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BEING A SAFE DOCTOR).
5. CONCEALED PLACENTAL ABRUPTION
PASSED: GLOBAL SCORE 6
STEM: don’t remember the gestational age but she came with abdominal pain. TASK: Hx, PEFE, MX.
FEEDBACK: So here patient was in severe pain, throughout 8 mins, she was writhing in pain and was
doing perfect acting.
I offered her painkillers after asking about allergies. moved to examiner, asked vitals, I think she was
not vitally stable so started her on IV lines etc
Now asked pain questions SOCRATES, ruled out abdominal pain ddx,
Stones, UTI, pyelonephritis: water works, blood in urine
Appendicitis, Bowel obstruction: last time opened her bowels
OBS HX: her antenatal visits, tests, scans were normal, she was not feeling kick of baby (important
question) asked about bleeding, discharge, contractions but nothing was there.
Thanked patient, asked pefe
Positive findings were her abdomen was tensed and tender, fundal height was increased compared
to gestation age, and Fetal heart sounds were not heard. When I asked about urine dipstick, protein
were there which made me confused for preeclampsia so I asked examiner about neurological
findings like reflexes and fundoscopy but they were normal.
Turned to patient, since fetal movements and sounds were not there, I tried to do it as Breaking bad
news but examiner dint let me do it instead she interrupted me, “ don’t do counselling here”
Anyways, I explained about abruption, mentioned about admission as its an emergency
Started mentioning investigations as I mentioned US and CTG, examiner again interrupted me and
said investigations confirmed fetal death. So I said I wil call senior obs gynae registrar, first they
would stabilize your condition, if its stable we will induce and can go for normal delivery otherwise
we have to do emergency C/section.
Another Feedback Scenario: Abdominal Pain Grade: Pass Global score: 4
Stem: A 20sh lady who is 28 (around this number) weeks pregnant comes in to the ED with severe
abdominal pain started 3 hours ago. Her ANC checks are up-to-date. She had no problems during the
pregnancy so far. She has two kids who were delivered vaginally after normal pregnancies.
Tasks: Hx, PEFE, request investigations’ results from the examiner, Dx, DDx and Mx.
MY APPROACH:
- Hemodynamic stability. HR was 120 and BP was 90/65.
- Assured the patient that I checked her vitals and she is stable at the moment and told her I will take
good care of her.
- Hx:
- Pain SOCRATE - severe (8/10) - I asked about allergies and told her I will have the nurse
administer her a pain killer. The role player appeared to be in severe distress, so BE
EMPATHETIC AND REASSURING AS MUCH AS YOU CAN.
- Asked about baby kick. -ve
- Pre-eclampsia Qs. -ve
- Nausea, vomiting, fever, gush of fluid from down below, bleeding down below, cramps that
come and go, discharge from down below. -ve.
- Burning micturition, frequency and urgency. -ve.
- I offered confidentiality and asked about trauma to tummy or down below. -ve. (According
to Intimate Relationship Violence (IRV) RACGP guidelines, every pregnant woman must
be screened for IRV whenever possible. Preferably, offer confidentiality before asking
about possible IRV.)
- PHx and SADMA.
- PEFE:
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- General and vitals
- Abdominal exam:
1. Tenderness all over the abdomen. No localized tenderness.
2. Fundal height 4 cm higher than GA.
3. No foetal heart sounds by auscultation.
- Pelvic exam (consent and chaperone):
1. No bleeding, discharge or gush of fluid
2. No signs of trauma
3. Speculum: Cervix closed.
4. I do not think I asked for PV.
- Other systems: Normal.
- UDS: normal. BSL: normal
- Investigations:
- I requested vaginal US and the examiner corrected me “You mean abdominal US”.
1. Absent foetal heart beats.
2. I asked if the placenta was separated. Yes
3. I asked if there was a hematoma behind the placenta. Yes.
ASK ABOUT EVERY DETAIL. COLLEAGUES IN THE EXAM ONLY ASKED ABOUT FOETAL
HEART BEATS AND DID NOT GET THE REST OF INFO.
- Dx:
- Abruptio placentae (I did not say “Concealed”). Explained. I asked if the husband was here
and if she needed him to be with her. She said “yes, please”. I told her “unfortunately, the
baby’s heart beats are absent. I am very sorry to tell you that the baby is not alive”.
SILENCE for seconds while the role player cried. I was going with SPIKE for breaking bad
news but he examiner told me to stick to my task.
- I gave preterm labour, PPROM, PID, UTI as DDx
- Mx:
- I told her that I will shift her to the treatment room, insert 2 wide-pore canulae, take blood
for investigations including blood group, matching and holding and administer 1 L of NS.
Call the obstetric specialist who will prepare her for a C-section to deliver the baby and the
placenta and stop the bleeding. I said I will also order FBE, LFT, UAE, Creatinine (I forgot
coagulation profile).
- Reassurance again.
6. PE: VISUAL PROBLEM
STEM: young pt had problem in vision since few weeks/months more on one side.
TASK: check visual acuity, do relevant examination of eye, explain patient about most probable
cause.
2 min thinking: So It was my first station and all anxiety huhh..
After the exam I realized after listening from other candidates that I could not do very well in this
station as I dint notice Pin hole on table and dint do it at all. I was expecting clear fail in this station
but to my surprise, PASSED with GLOBAL SCORE 5
FEEDBACK: I went in, again same greetings and washed hands simultaneously, patient was very
good, helping and smiling, I did detailed inspection of the eyes, checked for anemia, jaundice,
entropion, ectropion, etc.
Then I checked visual acuity. The chart was on wall, thanked patient after each and every task.
Checked visual field but forgot to report findings to examiner because anxiety, first station. But
anyways told to examiner after finishing WHOLE examination.. LOL
Took fundoscope and again took good half to one minute tried to adjust it but I couldn’t and
examiner came and helped me. That again made me stressed out, checked pupils, direct/indirect
reflex, accommodation reflex, eye movements. Findings were short sidedness (Myopia) more on one
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side than other. I explained very quickly :-D and completed before time, I dint even give any ddx
here hehe
Another Feedback PREDOMINANT ASSESSMENT AREA - EXAMINATION
Scenario: Visual problem Grade: Pass Global score 4
Stem: A 74-year-old man is complaining from decreased vision in his right eye over the last 5
months. No HTN or DM.
Tasks: Measure VISUAL ACUITY
Perform relevant eye examination in 7 minutes
Dx and DDx.
To be honest, this is the station I was certain I’d fail because it is the only station I did not finish. I did
not
say anything in the Dx and DDx except “It could be anything from the cornea to retina” while I was
leaving
the room after the bell already rang. And if it was simple math, my score in the domains would have
gotten
a global score of 3 which is a fail score. So, it is not simple math.
MY APPROACH:
- WIPES
- I started with visual acuity. The Snellen chart was on the opposite wall around 3 metres away from
the patient who was setting right against the chart. The chart was hanged at a low place on the wall
at the same level of the patient while sitting. The Snellen chart used was the modified one (smaller
by half and is tested at 3 meters distance). I asked the patient to cover his Rt eye with the palm of
his hand and tested each eye separately. I asked him to read the smallest line possible (this
sentence is in Talley O’connor book). I made some mistakes that costed me time.
- I did the test while I was sitting in the chair next to him → WRONG
1. I could not see the letters from my chair. I had to stand next to chart and asked the
patient to repeat the test → time wasting
2. I forgot to tell the patient not to “Squint” (using accommodation reflex) which I
noticed he was doing after standing next to the chart. → if you do not look at the
patient while he is reading the chart, you will not notice that he is
accommodating to see better.
3. I forgot to report the result to the examiner and he asked me to comment while I
examine the patient, so, I went back to the chart and told him the results (Rt 6/18,
Lt 6/9).
- I used the pinhole to test visual acuity again. I only tested the right eye which is a mistake
because you have to check the left eye too. I told the examiner “IT IS NOT AN ERROR OF
REFRACTION AS IT DID NOT IMPROVE WIRH THE PINHOLE TEST”.
- I tested the visual field. I gave adequate instruction (fix your sight on my nose, do not move
your head, neck or eyes and when you first see my moving finger let me know) but the role
player did another mistake (I believe it was deliberate). When I switched hands on my eye
to test the nasal field, he moved his hand to cover the other eye. I told him keep covering
the same eye because I need to test each eye separately. I commented “Visual fields were
normal”.
- I forgot to request Ishihara chart to test colour vision.
- FUNDOSCOPY was funny. I told the examiner that I need to exclude glaucoma before
applying a pupillary dilator and dim the room to do the fundus examination. The examiner
told “we are not going to apply the pupillary dilator or dim the room, but show how you
will do the exam!” (to be honest, I had fundus exam done for me before, but It was the first
time to hold a fundoscope in my hand). I could not light it. So, I held the fundoscope in my
hand and pretended to examin the right eye with my right eye (this is most probably what
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he was looking for. That you do not struck the patient’s nose with yours
) but he came
in and lit the fundoscope for me and the light flashed in my direction
. So, I simply said
with a smile “I was holding it the other way around”. He did not smile!
- I told him I will test cranial nerves starting with 3rd, 4th and 6th. At first, he told me to skip
cranial nerves, then said “Do it”.
- I tested light reflex. Instructions to patient are always crucial. I commented “DIRECT AND
CONSEQUENTIAL LIGHT REFLEX IS NORMAL IN BOTH EYES. MARCUS-GUNN SIGN IS
NEGATIVE IN BOTH EYES”.
- I tested eye movement. AGAIN, YOU HAVE TO GIVE GOOD INSTRUCTIONS. I told him not
to move his neck or head and follow my finger with his eyes only. If he feels double vison or
pain at any point, let me know. I commented “EYE MOVEMENTS IN BOTH EYES ARE
NORMAL, NO SQUINT OR NYSTUGMUS”.
- The examiner told me to skip the rest of cranial nerves and asked what else do you want.
- I requested “UL and LL neurological examination, Carotid auscultation and CVS
examination”. He told me all normal.
- Bell rang without saying any Dx or DDx. I said “It could be anything from the cornea to retina” on
my way out.
7. GASTROENTERITIS IN CHILD (PILOT)
Diarrhoea for 2 days in an 18-months child. GP practice.
Tasks: Hx, PEFE, Dx, CLINICAL ASSESSMENT and DDx.
It was a case of GE. Clinical assessment criteria are: skin turgor, CRT and weight loss.
8. SWALLOWING DIFFICULTY
PASSED : GLOBAL SCORE 4
STEM: patient was having pain and difficulty in swallowing
FEEDBACK: I don’t remember much here sorry , positive findings were loss of weight, he was only
taking liquid diet. He was a patient of GERD, was using antacids I think but it was not helping much.
Don’t remember about smoking alcohol hx,
Ddx I mentioned as esophageal cancer, gerd complications stricture etc, neurological causes of
dysphagia.
Another Feedback - PREDOMINANT ASSESSMENT AREA - HISTORY TAKING
Scenario: Swallowing difficulty Grade: Pass Global score: 4
Stem: a 50sh man complaining of PAIN with swallowing for few months. GP practice. (short stem).
Tasks: Hx, Dx and DDx.
MY APPROACH:
- Asked the patient how he is feeling now. EMAPTHY and REASSURANCE.
- Hx:
- Is it pain only or difficulty? Difficulty two. For both fluids and solids. SCORATE.
- DDx. Chest pain, SOB and racing of the heart? No. Nausea and vomiting? No.
- Heartburn and water brash? Sometime and he used to take over the counter antacids. No
relation to meals. Not increasing at night or sleeping after eating. Is not affected by chillicontaining
foods.
- Tightening of the skin, bluish discolouration of fingers and toes?
- LOW, LOA, bumps or lumps? No. he said he gained weight (4 Kg in last 8 months).
- Water works and bowel habits? Normal.
- PHx. He said he has HTN. I asked about medication? He said he is not compliant. I told him
“It is not good for your health not to take the HTN medication because you would
develop complications from HTN” → WRONG
I did not follow on the non-compliance issue and later on I felt I was judgemental. I thought
I would not pass thus case because of these points.
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- FHx of similar conditions -ve.
- SADMA.
- Dx: I said “From your answers, I am not really sure what the cause of your problem is. I am leaning
to GORD supported by your Hx of heartburn and increased weight lately but I still have to run some
tests to exclude other causes.”
- DDx: Angina, ascending aortic aneurysm, scleroderma, hiatus hernia, peptic ulcer (explained each).
9. BREATING DIFFICULTY
GLOBAL SCORE: 6
Stem: it was paeds OSA case, child was admitted in hospital I think, there was an oxygen saturation
chart with one plane having oxygen sat and other plane with snoring at night times. There was also a
lateral neck xray showing narrowing.
TASK: hx, PEFE, explain charts and xray and most probable cause.
In this station, examiner was very old and was not hearing properly. So during PEFE, i had to repeat
many times loudly. In hx same questions about loss of concentration, repeated ear infections, runny
nose, sore throat. Role player told me that they were told by previous doctors that tonsils were
enlarged. Snoring was positive too, dont remember about ear infection in hx, he dint notice any
behavioural change particularly. problem was there when the child was only 6-9 months of age. In
Pefe, i asked about adenoid facies, but examiner was not getting me, I asked crowded teeth, mouth
breathing then he told me positive.. ear examination , both tympanic membranes were bulging i
guess, I asked about tonsils, they were enlarged too but adenoid he said we cant check on simple ENT
exam . I explained about OSA and its causes, explained the chart properly and explained the xray, ( i
was explaining on ppr sheets on table, but role player asked me to explain on screen may be bcz of
examiner..) while I was explaining neck xray, examiner specifically asked me about narrowing.. i think
management was not the task but i still mentioned about ENT specialist referral and removal of
tonsils and adenoids after acute phase of illness would be over.
Another Feedback PREDOMINANT ASSESSMENT AREA - DIAGNOSTIC FORMULATION
Scenario: Breathing Difficulty Grade: Pass Global score: 5
Stem: An 18-month-old child brought by his father to the ED yesterday because of breathing
difficulty.
The baby was admitted for URTI and pulse oximetry readings were taken over night. A lat. Head and
neck
X-ray was performed upon admission and is displayed.
P.S. These photos are very close to the one I got in the exam.
Tasks: Hx, PEFE, explain investigation displayed to the father, Dx and DDx.
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MY APPROACH:
After I went in and the examiner checked my ID, I looked at the role player who talked rapidly
“Doctor, Doctor, how is my son doing? I am very worried about him”. I told him “Please, come down.
I will
check on your son now”. I looked at the examiner again and asked about the vitals which were all
normal. I
looked at the role player and said “I’ve just checked on your son. He is stable right now and is being
taken
care of. Can we discuss his situation further?” He said yes. So, I introduced myself and started the
history.
- Hx:
- SOCRATES for the fever and breathing difficulty.
- Question about OSA due to enlarged adenoids (recurrent ENT infections, sleep disturbance,
always tired in the morning, sleepiness and lack of energy by noon)
- DD. Asked about AOM (ear pain and pulling on the ear), meningitis (rash and neck pain), tonsillitis
(sore throat and difficulty swallowing), epiglositis (cough and drooling of saliva), croup (barking
cough and noisy breathing), pertussis (cough that ends up with a whoop, vomiting or bluish
discoloration episode).
- Well-being questions
- Contact history
- BINDS (vaccination up to date)
- Medication and allergy
- PEFE:
- General appearance, General exam, growth chart (non-toxic, no LN and no rash)
- Dehydration signs: None
- Dysmorphic features: -ve adenoid facies
- Vitals: stable
- ENT exam: enlarged congested tonsils, no stridor
- Neck: no rigidity
- CVS and chest are normal
- Abdomen: normal
- After consent from father, genital, hernial orifices and peri-anal examination: normal.
- Explanation of investigations:
- X-ray: lateral view of head and neck. Air is black, bone is white and grey is tissues. Column of air
behind the nose and mouth is narrowed.
- Sleep study: the X axis is time and the Y is oxygen saturation (which is how mush oxygen present
in the blood and is supposed to be 94% and higher). There are multiple drops during the night to
around 60% (showed on the graph). I think that the airway folds when the child sleeps because he
has enlarged ADENITIS (I said adenitis instead of adenoids at the start, I said the right word later
on during the explanation).
Dx:
- Large adenoids leading to OSA (I explained both again).
DDx:
- The bell rang. I said CROUP and EPIGLOTITIS on my way out.
10. BEHAVIOURAL COMPLAINT FAIL
STEM: young girl with low grades and she was sent by her university to GP
2 min thinking: I was thinking about all possibilities cz different cases came with the same stem.
OCD, mania, depression
FEEDBACK: I dint notice her non-verbal cues actually bcz she was sitting and looking downwards, she
was very slow. She was showing low mood by her acting but still I spent some time ruling out about
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OCD. Positive in hx was breakup from his boyfriend and she was considering him his soulmate. I
asked HEADSSS and ASEPTIC but I forgot organic ddx in hx. She cried in between too and I offered
her a glass of water which was near her but she refused and offered her tissues which she took. She
dint have suicidal ideation, no hallucination or delusion.
DDX: I explained her about depression in layman terms and said m glad you don’t have suicidal
ideation, other ddx I said mania, there I remembered I forgot to ask her organic ddx, I asked them
quickly and while I started to explain those organic dx, bell rang.
Another Feedback PREDOMINANT ASSESSMENT AREA - HISTORY TAKING
Scenario: Behavioural complaint Grade: Fail Global score: 3
Stem: GP practice. A young woman was referred by her university teacher because of change of
behaviour.
Tasks: Hx, Dx and DDx
MY APPROACH:
She said she was feeling low because her boyfriend dumped her 6 weeks ago. I asked the ASPETIC J.
Looking back, the interview with the role player felt like interrogating a criminal. May be because I
was
tired or did not practice psychiatry enough, I could not correlate with the patient well and my
questions
were blunt and even sometime rude. With a psychiatry patient, it is better to use a third person
pronoun
instead of asking sensitive questions directly and bluntly.
I asked her in the exam if she wants to hurt herself, her ex-boyfriend or his current girlfriend! When I
should’ve said “People under stress might think about hurting themselves or other people, Would
that
be right in your case? Did you ever think of harming yourself, your ex-boyfriend or his current
girlfriend?”
I did not give a good psychiatric DDx. I only said depression and anxiety (the diagnosis was
adjustment
disorder and I did not even mention it in the DDx). I focused on organic DDx.
11. ACUTE KNEE INJURY (MENISCAL TEAR)
PASSED : GLOBAL SCORE 4
STEM: it was clear from stem that it was acute knee painful condition.
TASK: HX, PEFE, DDX
FEEDBACK:
Hx,. again offered pain killer, allergies. Plz never miss the allergy question. Pain questions SOCRATES,
he told me he was playing with child I guess when his knee got twisted. Role player was lying on bed
with a sheet covering his legs. To me he was neither showing painful expressions nor smiling.
Examiner here was also sleepy and he had covered his face with his hands most of the times. Lol. I
ruled out ddx, asked about joint problem, fever; swelling (positive) , low, loa, insect bite,
PEFE: LOOK FEEL MOVE AND COMPARE BOTH KNEES
I asked about all special test, patellar bulge was positive I think. Rest like patellar tilt, Clarks test etc
were negative and for valgus varus, anterior & positive drawer and aplays grinding test examiner
said can’t be done.
DDX: drew diagram on page and explained meniscal tear, ligament injury, fracture, osteoarthritis,
rheumatoid arthritis, septic arthritis and osteomyelitis, bite etc
Another Feedback PREDOMINANT ASSESSMENT AREA - DIAGNOSTIC FORMULATION
Scenario: Acute knee injury Grade: Pass Global score: 5
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Stem: A 20sh old man complains of SUDDEN Rt knee pain that started 6 hours ago. I do not recall if it
was GP or ED. Some other irrelevant information (long stem).
Tasks: Hx (in 4 minutes), PEFE, Dx and DDx
MY APPROACH:
- When I first read the stem, I thought it is a PE station. So, I started revising the KNEE PE in my head.
When I got to the tasks, I found out it is no PE. I was a bit confused because it is a sudden pain case
so it
must be an injury and I was wondering how to fill the 4 minutes history.
- Hx:
- Introduced myself. Onset and I asked the patient if anything specific happened just before the
pain started. He told “I twisted my knee”. I asked what happened exactly and he elaborated. I felt
confused again because he gave the diagnosis and I missed asking the rest of SCORATES. I did not
ask about the severity of pain.
- After 10 seconds of awkward silence, I decided to ask about fever and other DDx (although was
not convinced).
- I asked about fever, rash, other joints involvement, prior joint problems, red urine, any Hx of
recent URTI, any vison problems, any Hx of knee injury before this incidence. All negative.
- Well being questions.
- Past and family Hx
- SADMA.
- PEFE:
- General exam, BMI. Normal.
- Dehydration signs: None
- Vitals: stable
- Local examination: I said I will compare both knees and examine the Rt ankle and hip too.
Inspection, palpitation and movement. Special tests: Apply grinding test +ve. When I was doing
the special tests, the examiner kept telling me that this move or this is “very painful”. I forgot to
offer analgesia!
- Rest of examination normal.
- Office tests normal.
- Dx:
- Meniscal tear (explained)
- DDx:
- I explained other types of knee injury.
- I was hesitant to say the usual DDx,, but I had plenty of time.
- I said it could be septic arthritis or osteomyelitis but you do not have fever or hotness of the joint
(The examiner smiled at this point).
- Osteoarthritis (tear and wear)
- HSP and RA
12. FAILURE TO CONCEIVE
PASSED : GLOBAL SCORE 4
FEEDBACK
Same old recall, in stem it was already mentioned that husband has to go for work somewhere
Same hx, she was not aware of fertile period, frequency of intercourse was reduced too, I rule out all
causes by PEAS F
(Period, pill, Partner, PCOS, premature ovarian failure, pituitary tumor, Exercise, endocrine, eating
disorders, endometriosis, Asherman syndrome, stress and fibroid)
Same counselling Explained about fertile period and how to determine that. Ovulation kits, calendar
and mucus method. Asked to increase freq of intercourse, Mention investigations, Asked to take her
husband in next visit to test him as well.
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Another Feedback PREDOMINANT ASSESSMENT AREA - MANAGEMENT/COUNSELLING/EDUCATION
Scenario: Failure to conceive Grade: Pass Global score: 4
Stem: GP practice. A 40sh old woman complains of failure to conceive. Her husband is working in
mines and goes away for 3 weeks and come back for 1 week.
Tasks: Hx, Dx and DDx
MY APPROACH:
- Hx. 5Ps, LMP was 2 weeks ago and her husband has just left for his work yesterday. Well-being.
DDx questions. Past and family Hx. SADMA.
- Dx. Infrequent intercourse. I talked briefly about ovulation times. I recommended using an
ovulation kit.
- DDx: PCOS, Premature ovarian insufficiency, hyperprolactinemia, stress or eating related,
Asherman syndrome.
13. WRIST INJURY
PASSED : GLOBAL SCORE 4
FEEDBACK: There was a patient with a glass piece and blood on one of his hand. Washed hands,
introduced, Rule is check arteries, nerves, tendons and bones. On inspection, there was no abnormal
hyperextended hand so i commented on that.
Arteries : i wanted to check pulse but i was confused how to do that , in anxiety I wore gloves and
examiner asked me what are you doing, i mentioned to check pulse, he asked how can you check
pulse here huhhh.. so removed gloves , i checked CRT and commented on colour of hand. Nerves:
Median nerve was damaged. Tendons: on checking tendons, examiner interrupted and made me
confused a lot. I wanted to chk wrist movements. He said its obvious his wrist was in a flexed position
so flexors are fine, I checked movement of fingers and thumb. I think he was not able to flex and
oppose his thumb. But i dont remember sorry about tendons findings. I was about to check pen touch
and card holding, he dint let me do that too. That by checking movements you already checked it.. In
last , he asked me findings. I said median nerve and he was constantly asking me which tendons, and
dont know I got blank, dint remember name of tendons.. and finally bell rang.
Another Feedback –
PREDOMINANT ASSESSMENT AREA - EXAMINATION
Scenario: Wrist injury Grade: Fail Global score: 2
Stem: A 20sh year old man has fallen on glass door and is presenting to the ED with a cut in the
wrist. The paramedics put a bandage on it. It was removed in the ED under-supervision. The patient
is stable right now.
Tasks: Physical examination, Dx and DDx.
After comparing what I did to a passed feedback, I failed this station because of one thing I did. I
moved the pillow that the patient rested his hand on without telling him. He told me then “please,
do not move the pillow without telling me” and I knew I failed it on the spot.
14. MEDICATION CHART (PILOT)
this was my worst station and many thanks to Almighty Allah it was a pilot station,
STEM: There were three drugs mentioned outside, pantoprazole, some ace inhibitor and
paracetamol..
TASK: fill the chart, and explain your prescriptions to examiner
FEEDBACK: I had no clue what and where to write about 3 drugs, i wasted a lot of time just
panicking. There was a paper bag which contained medicationz. I opened and took out medications.
In anxiety i dint check medication boxes but once I turned them, there were doses etc mentioned.
Anyways, i dint check handbook properly. But I think there was no book mark there. I was filling the
last drug paracetamol and examiner came near to me and said u r running short of time and bell
rang in sometime.. i was not able to explain prescription to examiner even.
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Another Feedback - Medication chart.
A lady coming to stay the night in the sleep study ward. She brought in her medication.
Tasks: Fill the medication chart (in 6 minutes) Discuss the chart with the examiner (2 minutes)
The medications were in a brown bag and they were Panadol, Ramipril and pantoprazole.
15. PORNOGRAPHY
FAILED!
Don’t know what they want in this particular station!!
Another Feedback –
PREDOMINANT ASSESSMENT AREA - MANAGEMENT/COUNSELLING/EDUCATION
Scenario: Counselling Grade: Pass Global score: 4
Stem: GP setting. A 40sh year old mum is consulting you about her daughter that is 13. She caught
her daughter watching pornography.
Tasks: Hx, Counselling.
MY APPROACH:
- Intoduction.
- Hx: The mother walked on the daughter as she was seeing something on the laptop and the girl
closed the lid suddenly. She told the girl to open the computer so that she can see what she was
watching. The girl opened the lid briefly and she saw the pornography. She was shocked and the girl
felt ashamed and didn’t talk all night. In the morning the girl was tearful when she was leaving to
school. The mom didn’t mention following her to school. They have a good relationship. The child is
a lonely child and the father has a good relationship with the girl too. she didn’t have any problems
of any kind she didn’t have any history of abuse (I offered confidentiality before asking about abuse).
no change in behaviour and no change in the school performance. She had friends and she had a
good relationship with them.
She wasn’t sexually active. she didn’t have a boyfriend. The mum didn’t speak with the girl about sex
before I asked about the gardasil vaccine, she said that she had given it to the girl. I asked the
mother about her own mood and her sleep pattern if she has any concerns in general. If she is a
perfectionist or if She worries a lot about trivial things and other OCD questions. All answers were
no.
- I started counselling. I told the mother that this is the age teenagers start exploring things specially
sex I told her that she should hear about it from the mom not from her friends because she could
have wrong information or have an abnormally high or false expectations specially from the porn. I
talked about porn addiction and she told me that the girl only watched that twice because she
checked the history on the laptop when the girl left this morning. I said the girl should be educated
about safe sex, about contraception and about consent and it is better to hear it from the mother
rather than friends and peers because children may do things out of peer pressure that they do not
want to do. I told her that you can bring the daughter over so that I can discuss that further with her
and if the girl wants, we can have a family meeting to discuss any concerns or problems she has. The
mother asked me if she was a bad mother and I told her no, of course not. I think that you are a
great mother that you came to discuss your concerns about your daughter and that you are worried
about her and this is a great thing you are doing. Asked if she has any questions or other concerns.
16. POSTPARTUM CHECK UP
PASSED: GLOBAL SCORE 4
I haven't read this PE from anywhere and any notes. May be it came previously but it was new for
me.
STEM: it was clear that she came for postnatal visit, hx was taken, u checked baby and baby is doing
well too, On hx, it was mentioned that she started sexual activity recently and having pain during
intercourse.
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2 min thinking: I was clueless and couldn’t get time to think much, I just revised 7Bs and decided to
go with the flow.
FEEDBACK:
As I entered, I noticed patient was lying on bed and just beside her, there was BP apparatus as well
as clock. So I commented on general appearance, took her BP, Pulse, I dint check for anemia,
jaundice but it can be done as well. Then I asked about breast exam in detail from the examiner,
everything was normal, then I did detailed abdo exam, there was no
tenderness and no findings for uterus. Then I asked examiner about Pelvic examination and she gave
me atrophic vagina, rest was normal. Then I was confused what should I do, so I asked patient about
support to rule out postnatal blues and in the end, asked examiner about DVT. And Urine dip stick. I j
ust explained her about lactational atrophic vaginitis by relating hormones, I guess I mentioned few s
entence regarding Mx too but had not given any ddx.
Another Feedback PREDOMINANT ASSESSMENT AREA - EXAMINATION AND EXAMINATION
Scenario: Post-partum check-up Grade: Pass Global score: 4
Stem: GP setting. A 25-year-old lady is coming for a post-partum check-up. She had a baby 6 weeks
ago. It was a difficult prolonged delivery and the forceps was used to help deliver the head. She had
an episiotomy. She noticed that she has started to leak urine as she loughs. She also had pain during
penetration in her first intercourse post-partum but none thereafter. The baby is doing well and had
been checked yesterday.
Tasks: Perform relevant PE in 6 minutes (No further history is needed), Dx and DDx.
MY APPROACH:
- This was my first station in the exam. Outside, I was thinking I will find a pelvic dummy and perform
and pelvic examination. So, I started revising pelvic exam.
- I walked in and there was no pelvic dummy.
- PE:
- WIPES
- I decided to start with abdominal examination. I focused on excluding UTI. All negative.
- I finished abdominal PE and looked around the room, I saw a stop watch and
sphygmomanometer. I measured the BP and pulse in 15 seconds and reported them to the
examiner.
- I asked the lady about her breasts. Any engorgement, tenderness, hotness or tenderness. Any
nipple fissures or bleeding. All negative. I was stuck and could not figure out how to proceed.
- After 10 seconds of awkward silence, the examiner asked me what else do you want to do.
- I told her I want to do pelvic exam. She said what do you want. So, I said the consent and
chaperone. I started with inspection (forgot to check the episiotomy scar) and there were no signs
of atrophic vaginitis. Performed cough test. Was positive for urine leakage but negative for
prolapse. I asked for speculum examination and repeated the cough test to exclude any uterine
prolapse. No uterine prolapse. I asked for PV. All normal and adnexal masses or tenderness.
Cervical excitation was negative.
- I asked for office tests. UDS, BSL, pregnancy test. All negative.
- Dx and DDx:
- I said that she has stress incontinence and explained what it is and its causes (prolonged and
instrumental delivery in her case).
- I mentioned UTI, PID, urge incontinence as DDx.
- I forgot to mention lactational atrophic vaginitis as a cause of her dyparonia.
14th June 2019
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1. Recurrent falls/ postural hypotension - 65 years old man presented to the GP clinic with history of
a fall that happened this morning. Task- Take relevant Hx. Tell dx with reason and dds. PASS - 5
PositivesHad fall spontaneously this morning while working in garden, I asked whole fall cluster, nothing was
significant. no chest pain,funny racing, flushing, blurring, no LOC, Pt is diabetic having metformin,
well controlled, hypertensive-antihypertensive, lipid lowering meds, NSaid for back pain. Had fall 2
times before too while getting up from bed. didn't hit head. no f/h/o of heart disease, no sign of
stroke or neuropathy.
Dx i told postural hypotension and explained mechanism of it as reasons then I said whole fall cluster
dds.
2. CVS examination murmur - You are in GP, 30 year old man came for check up before he increase
his health insurance. He was told by his previous GP one year ago that there was abnormal heart
sound murmur in his heart. Tasks - Do relevant PE. Explain findings to patient. PASS – 6
As usual old CVS PE case, started with hand, BP, eyes, neck, complete CVS, base of lung, abdomen
for hepatomegaly, pedal oedema-nothing was positive.
I explained may be that time you were running some temperature or infection, now its cleared up so
no noisy heart sound I found. told DDx - Valvular heart disease, IE, anaemia, thyroid. Easy case!!
3. 56 year old lady admitted to hospital after diagnosed with pericarditis. All investigations are
cleared and she was started with neurofen 200mg twice daily. Now she wants to talk to you as her
pain is not controlled and she wants more pain relief. She is otherwise healthy apart from her back
pain for which she has been taking - Morphine, codeine, gabapentin, paracetamol, neurofen.
Task- Hx, Counsel the patient, manage her pain.
PASS – 5, Approach 5, History 4, Counselling 5, Management 5
I had no idea about this case as I found it came once in blue moon and I tried to get rid of it but I
couldn't. No one could give me any feedback as it was pilot station that time, even I sent this case to
some tutors as well, but no reply.
Anyway I'm writing my approach and positives- Lady was in severe pain, already diagnosed with
pericarditis. As all info was given in stem, I tried to go into bit detail of each and every symptoms and
meds. I didn’t ask whole pain ques as it was diagnosed. I again poured my all empathy here rather
than knowledge.
This was more about counselling. she has been taking all of these meds for long time. healthy
otherwise. asked general ques- diet, exercise, SADMA, Period, support etc all normal. then I came to
counselling quickly as I realised counselling would be key in this case rather than Hx. I told her that I
believe her and her pain is real I understand. I made my tone as low as possible. She replied-yes doc
only you seem to be very caring, I liked you. No one is listening to me. I gained confidence at that
point. then I proceeded further. Now dear, as you are having pericarditis, I explained what it is and
best meds for it is given already which is neurofen as its mostly viral.
Now still you are having pain it could be due to couple of reasons1.As you are having all of these pain medication for long time sometimes what happens it makes the
nerve that supplies pain sensation of your organs to become sensitized. I willingly avoid addiction or
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dependence word as it might panick her making it hard for me to control her nerves. she smiled and
replied yes could be
2. Sometimes pericarditis can be bacterial too in that case you might need antibiotics along with
neurofen, but its unlikely.
Management- I'm very junior dr (told twice) Marie, I can't easily change, add or reduce any
medication without my seniors advice. I am going to arrange a consultation with him soon. there are
couple options available(i didn't have clear idea)
-Increasing dose, changing meds, changing frequency, PCA, TENS, others: heat pack, relaxation, sleep
hygiene, counsellor (kept in mind dependency)
4. Cystic fibrosis with intestinal obstruction - 9 months old baby boy BIB mom with vomiting for last
1day. He is a Known cystic fibrosis case since birth. Tasks- Hx, PEFE, Explain X-ray, Diagnosis and DDs.
PASS - 5
I followed vomiting cluster simply. positivesvomited 3times,not green,no blood.1st time,not projectile,no wt loss,no fever,sob,cough,no
diarrhoea,no bloody stool, constipated sometimes,didn't pass poo for last 2days.no smelly
nappies,doesn't cry while passing wee, no lump and bump,happy family,no birth defect,BINDS
normal.
Pefe-all normal,just mild dehydration,absent BS,fecal mass in RIF
X-ray was SBO with visible fecal mass in RIF. I explained it.
dx-said SBO known as DIOS,a complication of Cystic fibrosis because of sticky mucous
everywhere,they cause stools to be more sticky and accumulate in gut causing obstruction.
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DDs of vomting- meningitis,pneumonia,gastro,uti,GORD,obstructed hernia,intussusception
5. CKD with hyperkalaemia - Middle aged woman has come to ED due to pre-dialysis assessment.
Complaining of palpitations. Nurse did ECG which shown in the stem. Bp: 130/80, Pulse 60 and
regular, temp: NL, RR: NL. Tasks: -Take relevant hx. Explain the ECG to the examiner. Explain
investigation to examiner. Tell the diagnosis to the patient with the reasons.
GS-5, Approach to patient/relative 4, History 5, Technique 5, Investigation 4, Diagnosis/ Differential
diagnoses 5
PositivesNausea, diarrhoea, palpitation for last week. Had kidney impairment and taking dialysis regularly.
Regular with drs visit. taking Perindropil and frusemide for high BP. recently added ibuprofen for
back pain. In ECG- Tall tented T waves.
along with blood results of s electrolytes- hyperkalemia, s UEC-deranged
Explained hyperkalemia, tripple whammy, ARF on CRF
6. PE abdominal and DRE, male with previous urine retention - 50 year old man coming to your
practice for examination as he had retention of urine recently and was relieved. Task- Do Abdominal
examination on patient. Do DRE on manikin provided. Explain findings to patient. PASS – 5
I started with GA, vitals,anaemia,then whole abdomen-all negative, hernial orifice, vesicle for
sti,urethral meatus for blood-negtive. Took consent and positioned pt for dre, wore gloves, exposed
dummy and did inspection no fissure,tags,beeding,hemorrhoid. ask if there is any pain before
inserting finger. explain what i'm going to do,used lubricant,asked to take deep breath, rotate
finger,got prostate enlarged,median sulcus prominent,no pain,no nodule,firm,not fixed,checked anal
tone,checked finger upon withdrawing-normal. Thanked him,wiped dummy and covered. drew &
explained BPH and how it caused retension. other causes-ca prostate, uti,prostatitis, stone in
bladder or urethra, sti-herpes, urethra rupture.
7. Video of behavioural and anger issues in a guy on admission (PILOT)
You're about to see a consultation video between a doctor and a patient who has undergone
shoulder surgery today and now acting weird in post op room. long details were given.
Task- watch video for 4mins. give diagnosis and reason. Investigations you're gonna order to find out
causes. DD's.
Again another stupid case. After seeing video written in ques I thought it'd be MSE. but they're
asking straight forward dx!! anyway video was awkward. they didn't follow any format, neither MSE
or MMSE, it was more like general conversation. only finding I picked up was he was very angry and
was complaining a lot about being in hospital. They made it complicated by adding that he had
suicidal attempt before and now also has. It was mixed. but I myself decided to say delirium as its
common after operation.
Dx- acute confusional state or delirium
reason i couldn't say much other than saying patient is agitated and angry.
Inv I said all delirium screeningFBC,ESR,CRP,BSL,UEC,ABG,ECG,CXR, abdo xray,LFT,TFT,urine MCS, hearing and vision check,CT
scan,LP if needed
DDs- I said all causes of confusion using DEMENTIA mnemonic and added acute psychosis,
Mania,schizo,anxiety,panic
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8. Pulled elbow - 4 years child BIB mom in GP setting, with not using right upper limb. Tasks: history,
PEFE, Demonstrate acute management. PASS – 5, History 4, Examination 4, Dx/DDx 5, Counselling 5
I kept in mind about accidental,non accidental injury- fracture,dislocation.developmental problem,
cellulitis,insect bites.
Positives- not using arm since this morning when went to shopping mall, upon further asking
revealed- she was sitting in floor,not getting up,demanding for ice cream,showing tantrum. no
fall,no beating,happened first time,happy family,BINDS normal. she tried to pull her up when
daughter was not listening to her. She was so guilty for whatever happened. I kept reassauring
throughout station. Appreciated her for bringing her here as she is very good mom.
In pefe - no bleeding bruising,holding arm in protective posture,in pain. not allowing to do palpation
or movement. vascular and neuro intact. No other sign of injury anywhere in body.
Management - I followed RCH for demonstrating the reduction manuevoure. I drew elbow joint then
explained pulled elbow. In mx I said i'll give pain relief to your baby before i do it,to make her more
relaxed you can keep her in your lap. You're an amazing mother. then i demonstrated using my own
arm-pronation to supination then flex. I kept reassauring that its nothing serious,she will be fine
after doing it. but still i'll keep her here for 30mins to see how she goes. she would start playing most
probably. If she's still in pain or can't move arm I'll send her to hospital for further assessment by
senior and by doing tests like xray. Don't feel guilty there is nothing wrong that you have done to
her. But next time lift her up by holding below armpit rather than holding hands. She smiled :-)
9. PPROM @ 35wks - 28 year old pregnant lady coming to the ED at midnight because of feeling
uncomfortable. Tasks- Take Hx, PEFE (Examiner will give you whatever you're asking specifically),
Explain Dx (No mx required). PASS – Each 6
Outside I was confused about weeks of pregnancy and made up my mind about few cases. if 1st
trim, could be bleeding,vomit,varicella,rubella. 2nd trim-cervical incompetence, 3rdeclampsia,PE,preterm labour,PROM,Placental problem,DFM,Post dated pregnancy!!! They didn't
even put complain properly,discomfort???
Positives1st ques-what do you mean by discomfort??? dr I'm leaking fluids. now I got my case!!
asked all fluid ques, 3pads soaked, no blood or green colour, no tummy pain or contraction, baby
kicking well, PE ques negative, asked routine preg ques-Normal. 3rd pregnancy. 1st one she did
abortion,2nd was miscarraige.Had cone biopsy due to abn pap result I didnt expect it. I had to ask a
lot to get these info. suture is there stillI. asked risk factors ques-PROMIS,nothing positive :-(
In PEFE all normal in general. PV- clear fluid, pooling in post fornix. nitrazin not available,i took swab
to r/o infection-pending. other than slight edema of leg.
Counselling- dx was PPROM, i drew and explained. she was soooo anxious for baby that i spent 1min
only to calm her down, was reassuring a lot in between too though mx wasn't a task. I said all risk
fac,but she was asking what's in her positive. that time my mind went blank and was struggling but
said i didn't get anything particular but suture can predispose, infection word didn't come to my
mouth!! she was so so happy at the end and said Im so grateful dr you made me comfortable and m
not worried now, That moment I felt that I passed it.
10. Drug chart severe cellulitis -You are an intern in ED, Julia 4yrs old girl BIB mom and diagnosed
with severe cellulitis of her left arm. You are asked to prescribe antibiotics to her and also
appropriate analgesic for her pain. You will be given 4 antibiotics and 4 analgesic to choose
appropriate one from each and place then in medication order chart for nurses. Julia is 20kg and her
height is normal. Task- Identify correct antibiotic and pain relief for her. Calculate doses according to
body weight. Order them in medication chart. PASS – Each 6
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It was a complete blunder as we never did med chart for peds by calculating doses and again needed
to choose one meds from each 4!! In MIMS there were 8 bookmarks where normally they put 1 or
2!! It was so time consuming to go through all the pages to find desired one. Anyway I managed to
finish it within time.
Antibiotics were- Ceftriaxone, flucloxacillin, amoxycillin, cephalexin.
Analgesic- morphine, codeine, paracetamol, ibuprofen
I chose flucloxacillin and paracetamol, put them as regular meds as there was no PRN section :-P
11. Menorrhagia (fibroids) PE - 29 year old Diana presents to your GP clinic with excessive blood loss
for last couple of months during period each month. Today she is here to get checked.
Tasks- Do relevant PE. Tell dx and dds. PASS –All 6 (except Approach – 5)
I started with hand, checked pulse(counted 30 sec) CRT temp. I said i want to check her BP. examiner
pointed towards BP apparatus and I wanted to do. but you never know what can happen to you
during exam, while i asked for it she took few sec to show it, it was in a corner of room in the
meantime my mind become distracted and i forgot about checking BP though she has shown me!!!
rather i started checking any bleeding bruising in skin!!I was regretting later.
Checked eyes, tongue, did thyroid exam, LN, heart auscultation. then did whole abdomeninspection, palpation, skipped percussion, did auscultation. Examiner gave finding of a mass in SPA.I
ask for if could get below mass-no, so I said mostly pelvic mass.
Wanted to do PV, examiner stopped me and read out PV finding- uterus is 14 weeks size, rest were
normal.
Explained-fibroid, told dds-hypothyroid,adenomyosis,endometriosis,any polyp,nasty growth in cervix
or uterus, bleeding dz,blood thinners,trauma,infection of womb.
12. Back examination sciatica - 37 year old man, got sudden onset of low back pain while lifting
heavy weight. Tasks: Do P.E. Give DDx.
GS-5, Approach – 5, Technique - 5, Accuracy - 6 Diagnosis/ Differential diagnoses 4
PositivesPatients gait was so painful, he took ages to get on and off from couch, wasted my 2mins in taking
off his gown and get back to bed. no pain on palpation. all movements were restricted due to pain. i
said i'll do schober test at the end, examiner didn't tell anything to skip. i checked neuro of LL. while
checking sensation patient said feels bit less on little toe? not absense of sensation with both cotton
and pin prick. i started SLR, which was restricted below 30 degrees. Patient screamed loudly. so i left
it there. this was my first PE station and I ran out of time, I explained radiculopathy can be due to
wear and tear, vertebral slip or fracture while going out of room. couldn't say other dd's
301
-Neurologic pain which is reproduced in the leg and low back between 30-70 degrees of hip flexion is
suggestive of lumbar disc herniation at the L4-S1 nerve roots.
-Pain at less than 30 degrees of hip flexion might indicate acute spondyloithesis, gluteal abscess, disc
protrusion or extrusion, tumor of the buttock, acute dural inflammation, a malingering patient, or
the sign of the buttock.
-Pain at greater than 70 degrees of hip flexion might indicate tightness of the hamstrings, gluteus
maximus, or hip capsule, or pathology of the hip or sacroiliac joints.
13. Hay fever management (PILOT) - 27 years old female with runny nose for couple of days.
Tasks- 2 min history about what treatment or medication she had taken. Acute management of her
symptoms. Suggest Investigation and Future mx.
Positives- Taking decongestant Otrivin for 2 weeks, anti histamin, tried steroid,helped her but it was
costly. having runny nose mostly around winter every year.
acute mx- talked about steroid spray but within her capability, said I will check PBS list and suggest
cheap but effective one for 3-6 months, talked about anti histamin every night, saline wash, steam.
forgot to stop decongestant!!!!! i was panicked about it after exam thinking it as key point,luckily
turned out to be pilot.
14. Uncontrolled Type 1 DM prenatal counselling - 26 year old Bella comes for getting your advice
regarding getting pregnant. She is diagnosed with DM since she was 15 years old. Her DM is
controlled with insulin. Tasks- Take relevant hx, PEFE, counsel accordingly.
GS-4, Approach to patient/relative 4, History 5, Examination 5, Counselling 3
Positives1st pregnancy
302
DM cont with insulin. went to specialist 3months back. HBA1C was 11 that time. no dm
complications, not measuring BSL regularly, never had hypo or hyper. on further ques, works at
cattle industry as chef, has cattle at home too so I became concerned about listeria and toxo.
PEFE all normal, bsl wasn't done
Counselled about bsl control, regular 3-4 times monitoring, talked about hba1c, sent to specialist,
talked about inc insulin requirements during pregnancy but couldn't finish this station, couldn't talk
about TORCH infections and complications of DM in pregnancy, so got low mark in counselling.
15. PTSD - You man sent by his workplace manager for assessment of his behaviour lately.
Tasks- Take history. Explain dx to patient.
Approach to patient/relative – 5, History – 4, Diagnosis/ Differential diagnoses 4, GS-4
Positives- 2 weeks hx of feeling anxious, can't concentrate, not going for driving, went to holidays for
relaxation, still feeling same. can't sleep-nightmare, flashbacks, avoidance, hypervigilance, LOA. had
an accident 2weeks back and a pedestrenian died in front of him, since then he's feeling low. Rest
non significant.Dx- PTSD. dd's were not a task but I still said.
GAD,Panic,Phobic,stress,coffee,thyroid,pheochromocytoma
16. Spontaneous Pneumothorax - 21 years old man presented to ED with sudden severe chest pain
on left side for last 1hr. Pain started while playing rugby. You're an intern at ED.
Tasks- Take relevant history, PEFE(Examiner will only provide whatever you're asking for),
Diagnosis/DDs (no mx required) PASS – 4, History 4, Examination 4, Dx/DDx 5
positives- Offered pain killer
Sudden pain while playing, pt was sitting with O2 mask,too hard to understand, very good actor. pt
was thin and young so i was taking it as risk factor. I asked ques keeping all chest pain dds in mindcardio,respi,anxiety,anaemia,trauma. pt couldn't take deep breath bcz of pain and was gasping. I
checked HDS in beginning was fine.
Pefe- BMI-17, movement restriction on left side on inspection, reduced expansion, hyper
resonant,reduced breath sound. trachea placed centrally. CVS normal.
Dx-spontaneous pneumothorax, drew and explained rupture of blebs on the surface of lung,
common in tall thin man. said all other dds. but was reassauring a lot as patient was in pain and
SOB.As mx wasn't a task I didn't go further other than o2 and pain killer and mentioned calling
senior.
18th June 2019
1. TIA Male 60s, acute onset of unilateral leg weakness for 20 minutes. Now all normal. Upper limb
neuro, cranial nerves and sensorineural examinations were done. Now you are asked to do the
remaining examination.
Task: perform lower limb neuro PE, relevant PE to find the possible causes, tell Dx to pt
Another Feedback - You are HMO at ED. Your next patient is 60 years old male with acute onset of
unilateral right leg weakness for 20 minutes. Now all normal. Upper limb neuro, cranial nerves and
303
sensorineural examinations, gait were done and all normal. Now you are asked to do the remaining
examination.
Task-perform lower limb neurological PE
- relevant PE to find the possible causes
- tell Diagnosis and DDx
My approach
In the room, there is an old man lying on the bed.
Introduce
WIPER approach
I was stupidly doing the temperature, capillary refill time and pulse. Then the examiner reminds me
about the task. So I start again with Tone, motor, power, reflex. Everything was normal.
After that I did JVP, carotid bruit, CVS auscultation.
Explanation
I did thorough examination and didn’t find anything abnormal. So most probably due to TIA.
It is due to transient blockage of the blood supply to the brain.
DDX-stroke but in case of stoke the patient will have some residual deficit
-migraine in some migraine associated with weakness
Bell rang. I thought I lost this case, fortunately I pass.
Global score-4 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
5
Choice & Technique of examination,
4
organisation and sequence
Accuracy of Examination
3
Diagnosis/ Differential diagnoses
4
2. Hand exam (real patient) Female 60s, hand pain. Task: Hand examination including hand function,
Dx/DDx to pt. Key, cup, coil, pen provided.
Another Feedback - You are a GP. Your next patient is 60 years old lady with bilateral hand pain for a
few months. Task-perform hand examination with function assessment, diagnosis, differential
diagnosis to patient.
It was a real patient. She is so friendly and co-operative.
But I failed this case and don’t know why.
Global score-3 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
3
Choice & Technique of examination,
4
organisation and sequence
Accuracy of Examination
3
Diagnosis/ Differential diagnoses
3
3. Mild depression with ?PTSD refer from counselor mom died 2 years ago due to pancreatic cancer,
patient said I should be depressed 2 years back Nightmare about mom death avoidance flashback
Only mild depression Task-ho, dx with reasons
Another Feedback - Female 20s, referral letter from colleague. She is “feeling lost her way” for past
2 weeks.
Task: Hx 7 mins, Dx to patient.
(+) depressed mood for 2 wk, no difficulty concentrating, not suicidal, eating sleeping good, no
delusion/hallucination, insight & judgement ok. Mom passed away 2 yrs ago, this month is her
304
anniversary of passing away. Coping well 2 yrs ago after mom’s death, no sadness then, only feeling
angry towards her dad (family drama happened). Now reconcile with dad. Good support.
Another Feedback - You are a GP, your next patient is 22 years old girl. She is “feeling lost her way”
for past 2 weeks and was referred by school counselor for possible depression and need for
medication. There is description of letter that the patient written.
Task-history for 7 minutes, diagnosis with reasons
The patient said I should be depressed 2 years back.
What happened 2 years back? That when my mom died
I am sorry to hear about that. How did your mom pass away? Pancreatic cancer
Did you feel guilty about her death? No. there is nothing I can do
Do you avoid going to place that remind you of your mom? Yes
Any sleep problem? Yes
Any nightmare? Yes, nightmare about my mom
Any memories that you want to get rid of? Yes, I had flashback about my mom
Suicidal idea? No
These are all the positive finding I can think of.
I said it could be mild depression.
4. Young lady, Not taking medications for 4 months. Known hx of schizophreniform.
Task-MSE Present MSE Dx DDx to examiner Relapsed schizophreniform
(+) lady insisted on going to see Putin, keeps busy as if talking to someone, auditory hallucination >1
voices (not conversing each other), no visual/tactile, delusion of grandiosity & thought insertion. I
forgot the rest, sorry.
Another Feedback - Young lady with history of schizophreniform disorder, not taking medication for
4 months brought in by mom. She is well orientated.
Task-MSE, present MSE to examiner, diagnosis, differential diagnosis to examiner with reasons
A-well groomed
S-normal tone, volume
E-she said normal
P-Auditory hallucination (she turns her head and talking in the air for several times)
T-delusion of grandiosity +, other thought content not sure
I-impaired
J-said fire cannot break out as there is smoke detector in the room
C-well orientated
R-no suicidal risk
Recreational drugs-I have tried marijuana once a long time ago, but I don’t like the taste
Home situation-live alone
Global score-3 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
4
Commentary to Examiner
4
Accuracy of Examination
3
Diagnosis/ Differential diagnoses
3
5. Female 20s, painful sexual intercourse. Task: Hx, PEFE, Dx to patient. Endometriosis
(+) painful all throughout, no postcoital bleed, no discharge, painful period since 14 starting from 5
days before period and throughout the period, since started on ocp pain gets better, afraid partner
might leave her. (+)PE: nothing + except tenderness on douglas pouch during DRE
305
Another Feedback - You are a GP. Your next patient is 22 years old lady with painful sexual
intercourse.
Task-History, PEFE, Diagnosis, differential diagnosis.
I understand from the note that you are having problem with sex. Would you mind share me more
about that? Yes doctor, I have painful sex, it was so bad that we need to stop.
How long? Superficial or deep penetration? Deep
Any bleeding after sex? No
Any fever? Any discharge? No
What about your period? Was it regular? Yes
Day of bleeding, day of cycle? 4/28
Any pain during the period? Yes, it started 5 days before the period and throughout the cycle
How long has it been?
Any pain when defecation? No
Have you ever pregnant before? No
Are you on any type of contraception? OCP
Do you have stable partner? Is he supportive to you? Yes
General health-good, regular medication-no
Smoking, alcohol, recreational drugs? No
PEFE
General appearance-well
Vital signs-good
Pallor, jaundice? No
Focus on abdomen examination
Inspection-any distension, scar
Palpation-tenderness, organomegaly, any mass
Auscultation-bowel sound-normal
Vaginal examination
Inspection-atrophic changes, bleeding, discharge, vesicle? No
SSE-os-closed, condition of vaginal and cervical wall-healthy
BME-uterus size, cervical motion tenderness-no
-adnexa tenderness, nodularity-slight discomfort in adnexa
PR examination-any tenderness-no
Explanation
Look, most probably you have a condition called endometriosis. Let me explain you with drawing. A
layer of womb called endometrium cell are present outside of the womb, it can be in the ovary, the
space between womb and back passage, ligament.
It could be due to other causes like adenomyosis, myoma and atrophic changes.
Global score-6 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
4
History
6
Choice & Technique of examination,
4
organisation and sequence
Diagnosis/ Differential diagnoses
5
6. PPROM - rural GP Female, 30s, 30wk primi, in rural hospital 200km from tertiary centre.
Presenting with vaginal fluid loss. ANC given all normal. Blood group O+.
Task-Ho PEFE DX MX
(+) clear fluid, 6 pads soaked, no blood/discharge, baby still kicking well, no contractions/pain, no
fever, no injury to the tummy. (+)PE: no uterine contraction/tenderness, FH 28 cm, longitudinal,
cephalic, engaged 3/5, FHR ok, pooling of clear liquor, cervix os open.
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Another Feedback - You are a GP in rural clinic. Your next patient is 30 years old lady with 30 week
pregnancy came with watery leakage. Regular ANC all normal. Blood group O+.
Task: History, PEFE, Diagnosis, Management
In the room, there is an anxious lady sitting on the chair. She didn’t wait for my introduction and
start talking about the watery leakage. Doctor, I think my water broke.
Ok, Mary, I understand that you are very worried at the moment.
First let me introduce myself, my name is May, one of the doctor from this GP.
Since when did you notice the water leakage? 2 hours ago
Is it continuous? Yes
How many pads did you use? 6
Were they totally soaked? Yes
Any bleeding or discharge? No Was it foul smelling? No
Any tummy pain? No Any injury to tummy? No
How your waterwork and bowel? good
Increase frequency of urination or painful urination? No
Is the baby kicking as usual? Yes
Any headache? Blurring of vision? No
How is your general health? Good
Any abnormal investigation result that I need to aware of? Like blood test, ultrasound? All good
How your partner? Is he supportive to you? Yes
How far is your home from the hospital? 200Km
PEFE
General appearance-look anxious
Vital signs-all stable
I will focus on abdominal examination.
Inspection-any visible contraction? Scar? Bruises? No
Palpation-fundal height-28cm, FHS-140, lie-longitudinal lie, presentation-cephalic, contraction-No
I will do vaginal examination with my patient’s consent and present of chaperon.
Inspection-bleeding, discharge, vesicle-No
SSE-os-open 3cm?
-liquor pooling? Yes
Then I would like to take swab from it and send for investigation. Done
I will skip bimanual examination as we are in the rural clinic.
Explanation
Look Mary, I did thorough examination on you. According to your history and physical examination
finding, I am thinking about a condition called premature ruptured of membrane.
Let me explain you with a drawing. Water should be broke at the time of labour, but in your case it is
broke before the onset of labour. Fortunately, your baby is well at the moment, I can hear the heart
sound very well.
Do you understand me? Yes
One thing I am worried about is sometime labour followed after the rupture of membrane.
So for the management, I will send you to the tertiary hospital where there is specialist and
adequate facility to take care of you and your baby.
At the hospital, specialist will do urgent ultrasound and CTG to make sure the baby is ok.
Some baseline blood test like FBC, ESR, CRP.
There is a test called fetal fibronectin which can detect whether the lobour will follow or not.
I have taken swab from your down below and send for the investigation as well.
Check understanding, offer question.
Global score-4 Assessment Domain
Domain Score (see key below*)
History
3
Choice & Technique of examination,
4
307
organisation and sequence
Diagnosis/ Differential diagnoses
Choice of investigations
Management plan
4
5
3
7. Endometritis - Female postpartum vaginal bleeding day 2. Fever +. Had episiotomy, placenta
delivered completely. Currently breastfeeding & planning to do so until 12 months. Task: Hx,
Perform PE, Dx with reasons.
(+) bright red, 6 pads, no clots, no smell, lower tummy pain+. Breast, Bladder, Bowel, Baby, Blues all
good. (+)PE: lower abdominal tenderness, firm mass 2 cm below umbilicus, cervical os open, blood+.
Another Feedback - You are HMO at ED. Your next patient is 25 years old lady 10 days postpartum,
came with vaginal bleeding.
Task-History, PEFE, Diagnosis with reasons.
Introduction
Check stability
Since when? 2 days
How many pads? 6 pads totally soaked? yes
Color? Bright red clots? Yes foul smelling? No any discharge apart from blood? No
Apart from bleeding from down below, any bleeding from other parts of the body? no
Do you feel dizzy, raising of heart beat, sweating? No
Any fever? Yes measure the temperature? Chill and rigor? No
Tummy pain? No
How your baby? All good
Did you breastfeed or bottle feed the baby? Breastfeed any problem? No
How’s your waterwork and bowel? Good
How did you delivery the baby? NSVD placenta complete? yes
Was any wound made in your down below? Well healed now? Yes
How’s your appetite and sleep? Mood? Fine
How’s your general health? Good
Any family history of bleeding disorder? What about in you? No
Are you on regular medication for any reason? No
Home situation? Husband supportive to you? Yes PEFE
General appearance-unwell
Vital signs-stable, fever 38.5
Pallor, jaundice? No
Focus on abdominal examination
Inspection-distension, scar? No
Palpation-light palpation any tenderness?
Here strange thing happen. Suddenly examiner asked me to wash hands and do the examination. I
was so shocked, thought I did the wrong task but not the case. Anyway I did the light palpation, the
examiner was beside me watching me how to do it. When I palpate the SPA, the role player says it’s
painful. Then, the examiner said all right. Here are your findings.
No organomegaly, no palpable mass. What would you like to know?
I said I would like to do vaginal examination with patient consent and chaperon.
Inspection-bleeding, discharge? Bleeding present
SSE-os-close, bleeding-no active bleeding, vagina and cervical wall are stained with blood.
BME-uterus-lax, tender, size? Lax and tender
Any adnexa tenderness? No
Quickly assess the CVS and respiration. Clear
308
Bedside test- urine dipstick test to rule out infection-not available
Explanation
Look, according to your story and physical examination finding, you have a condition called
postpartum bleeding due to endometritis. Let me explain you with drawing. It is infection and
inflammation of a layer of womb called endometrium. It is not uncommon condition in women with
recent delivery. It could be due to infection from the back passage or from the blood stream. Or it
could be due to retained placenta.
There are many causes for bleeding. Like injury, bleeding disorder, blood thinning medication.
Global score-5 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
5
History
5
Choice & Technique of examination,
5
organisation and sequence
Accuracy of Examination
5
Diagnosis/ Differential diagnoses
4
8. 4 years old child with Loud snoring starting from birth Recurrent ear infection, tonsillectomy +
Growth 50th centile Task-Ho PEFE Dx with reasons
Another Feedback – Boy, 4 year old BIB dad bcs of snoring. Task: Hx, PEFE, Dx to dad.
(+) periodic apnea, daytime sleepiness, perform well at kindy but seems tired all day, recurrent ear
infections & tonsilitis, had bilateral tonsillectomy, mouth breathing since baby, no problem with
swallowing, weight ok.
Another Feedback - You are a GP. Your next patient is 4 years old child with loud snoring.
Task-History, PEFE, Diagnosis with reasons.
I understand from the note that you child had problem with loud snoring, would you mind share me
more about that? Yes doctor, I noticed that my child is snoring, he snore louder than my partner,
that why I concerned about that.
Since when did you start notice it? Since he was born
Do you think it is getting worse? Yes
Did you child complaint about headache? No
How does he look like these days?
Do you think he feel fresh after he woke up from sleep? No, he is sleepy
Do you think he is tired? Yes
Any day time sleepiness? Yes
How many hours did he sleep? (I forgot the answer, but it is adequate)
His appetite? The same
Any fever? Rashes? no
Any recent cough and cold? Yes he had a couple of weeks ago
Did he get treatment for it? Yes we went to GP, prescribe antibiotic
Did he complete the treatment? Yes
Any ear infection? Yes, a few times
Have he checked his hearing? no
Any tonsillar enlargement? He had his tonsil removed a few years ago becos of recurrent tonsillitis
B-only child?
I-immunization status? Up to date
N-tell me more about his nutrition? He ate everything we ate
D-satisfied with growth and development? Yes
S-social-are you guys happy family? Yes
Financial stable? Yes
309
Thank you very much for your information. Is there anything that you want me to know? No
I will talk with my examiner and I will come back to you.
PEFE - General appearance-well
Vital signs-stable
Growth chart-50th centile
Rash in the body? No
I will focus on ENT examination.
Is there any redness or inflamed area? No
Is there any finding for adenoid gland? Not available
Any lymph node enlargement? No
I will quickly checked CVS and respiration system. Clear
Thank you examiner. I will get back to my patient.
Explanation
Look John. I have thoroughly checked your baby.
According to information you provided and physical examination finding, I am thinking about a
condition called Obstructive sleep apnoea. Have you ever heard of it before? No
It means there are pause of breathing during the sleep. Because of pasue of breathing, there is no
enough oxygen supply to the brain. That why your baby is not feeling fresh after he wake up and
feeling tired. Do you understand me? Yes
So there are common causes for this condition, 1st one is obesity but your baby weight is in 50th
centile, so less likely. 2nd is tonsilar enlargement but your baby have his tonsil removed a few years
ago, so unlikely. 3rd is adenoid hypertrophy, it is a gland present at the back of the neck, we cannot
see it with naked eye. Need to do x ray to find it. I am thinking about that in your child.
Check understanding, offer question? No
Global score-3 Assessment Domain
Domain Score (see key below*)
History
2
Choice & Technique of examination,
3
organisation and sequence
Diagnosis/ Differential diagnoses
4
(Adenoid Face – Crowded teeth, open mouth, sunken eye, loss of nasolibial fold)
9. Newborn 2 days old baby with Vomiting since 2 hrs ago. Ward HMO talk to the nurse.
Task: Hx, PEFE, X-ray interpretation to nurse, Dx to nurse.
(+) vomiting milk at first, then billous, few times, baby appear hungry, not dehydrated, haven’t pass
meconium, tummy distended, heel prick test not done. (+)PE: no signs of dehydration, no
dysmorphic feature, distended abdo, BS vague, anus+, no meconium X Ray-Bowel obstruction
Another Feedback - You are HMO at neonatal unit. You have to talk to the nurse about the 2 days
old newborn with vomiting. NSVD. X ray is provided.
Task-history, PEFE, X ray interpretation to nurse, Diagnosis with reasons.
My approach
Introduction
Check the vital signs first.
Since when? Last night
How many times? 3 times How soon after feeding? A few minutes
Did he look hungry? No, look irritable
Content? Milk color? Greenish yellow any blood? I am not sure as I am not on duty last night
The vomitus go away? Not sure
Any fever or rash? no
Can the baby sleep well? Yes
How is pee? Reduced amount poo? Not pass first stool
Breastfed or bottle fed? Breast fed
310
PEFE
General appearance-look irritable
Vital signs-stable
Signs of dehydration-no
Focus on abdominal examination
Inspection-distension? Slight distension
Can I see any visible peristalsis? No
Palpation-tenderness, organomegaly-no
Auscultation-Bowel sound-vague
I would like to inspect the anus whether the anus is patent and any meconium stain? Patent, no
meconium stain
I would like to test feed. (Not available)
I would like to introduce the tube to exclude the esophageal atresia. (Not available)
I will check for features of Down’s syndrome. No
X ray (similar but more bowel dilatation +)
Here is X ray of baby x. start with normal first. Then here we can see dilatation of bowel all over
here. So it is most likely due to intestinal obstruction.
Bowel obstruction can be due to small bowel or large bowel obstruction.
And the role player asked what could be the reason for her patient?
I said as the baby hasn’t pass meconium, it could be due to Hirsprung’s disease.
The role player look pleased and said good.
The role player asked what could be other causes?
I said duodenal atresia, oesophageal atresia.
Bell rang. Thanks role player and examiner.
Global score-4 Assessment Domain
Domain Score (see key below*)
History
3
Choice & Technique of examination,
4
organisation and sequence
Interpretation of investigation
4
Diagnosis/ Differential diagnoses
4
10. You are a GP. Your next patient is an 11 year old girl bib father because of neck swelling.
Task-History, PEFE, Diagnosis and differential diagnosis.
My approach
Introduction
How can I help you today? Well Sarah has a lump in front of the neck
How long has it been? A few months
Do you think it is getting larger? (I am not sure about the answer)
Where is the lump exactly? Point to in front of the neck
Did you feel the surface? No
Any redness or ulcer over the lump? no
Did Sarah complaint about pain? No
Any problem with swallowing? No Any SOB? No
Any fever? Any recent cough and cold? No (not sure about the answer)
How does Sarah look like these days? Is she still active and playful? Yeah doctor
How about her appetite? Same Lose weight? No
Any weather preference? No
How about her poo and pee? Any changes? No
B-only child? One sibling
Anyone in the family have similar problem? No
I-up to date
311
N-good nutrition
D-satisfied with growth and development
S-happy family? Yes
Financial problem? No
Thank you very much for your information. I will talk with my examiner and get back to you.
PEFE
General appearance-well
Vital signs-all good
Growth chart-good (forget the centile)
I will focus on neck examination.
Inspection-any lump? Yes there is a lump in front of the neck.
Does it move with deglutition? Yes
Move with tongue protruding? No
Any redness or ulcer over the lump? No
Palpation-I would like to know the size, shape, surface, consistency, tenderness? (smooth surface,
firm, non-tender, lower margin palpable)
Any thrill? No
Any cervical lymph node enlargement? No
Quickly assess cardiovascular and respiration system? Clear
Reflex-normal reflex, proximal myopathy-nil
Eyes sign-nil
Explanation
(At this point, I don’t know how to give diagnosis. I was thinking about the thyroglossal cyst.)
I explained by saying it could be thyroiditis because it is the most common causes in Australia.
Do you have any idea about it? No
Draw a picture, let suppose this is our neck, there is a butterfly shaped gland in front of our neck
called thyroid gland and it is responsible for producing the hormone called thyroid hormone. Thyroid
hormone is required for our body metabolism. In your child case, it is inflamed.
It is the infection and inflammation of thyroid gland.
But it could be due to other causes.
Like Grave’s disease it is an autoimmune condition.
It can be due to prominent nodule of the multinodular goiter. It could be due to lymph node,
sebaceous cyst which is coming from the skin, lipoma which is coming from fat tissue. But according
to the story, these are less likely.
Check understanding, offer question
Global score-4 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
4
History
3
Choice & Technique of examination,
5
organisation and sequence
Diagnosis/ Differential diagnoses
5
Another Feedback – (FAIL) Neck swelling for 3-4 months in a child. On middle of neck, not increasing
size, not painful, no redness, no weight loss, no fever, no difficulty swallowing, child is active & well
at kindy, no recent infection, no recent travel, no contact, no past med/surg hx, no family hx. (+)PE:
bilateral (1 each) firm, non-tender & mobile swelling at anterior triangle. I told the father possibility
of harmless lymph node enlargement, nasty growth called lymphoma, LN tuberculosis.
Another Feedback – I handled it as Hashimoto and passed. If you asked, he would have given you hx
of diabetes in the auntie.
312
11. 50 yrs old lady Urine color changes scratch mark history of cholecystectomy 8 months ago weigh
loss LOA Task: Hx, PE on card, explain DDs to patient.
Dark brown color urine and pale stool jaundice (+), tummy pain (center), no fever. UDT bilirubin +++
Another Feedback – You are a GP. Your next patient is 56 years old with urine color changes. (didn’t
mention whether male or female)
Task-History, PEFE card, Diagnosis, differential diagnosis.
In the room, there is a lady sitting on the chair.
Introduction
How long? Few weeks
What kind of changes? My urine turn dark brown color
Is it present in every urination? Yes
Is it present throughout the urination or at the start or at the end? Throughout
Any pain when passing urine? No increase in frequency? No
Do you notice frothy urine? No
How about your poo? My stool became pale
Any foul smelling? No
Do you feel itchy all over the body? Yes I need to scratch a lot
Did anyone comment you that you look pale or yellow? My partner tell me my eyes are yellow
LOA, LOW? Yes was it intentional weight loss? No
Any fever, aches and pain? No
Travel recently? Any blood transfusion? Enjoy body piercing and tattooing? No
Let’s me ask you some private and sensitive question.
Are you sexually active? Yes stable partner? Yes practice safe sex? Yes
General health? Good regular medication? No
Any surgery done before? Yes removed my gall bladder 8 months ago
Reason? Becos of gall bladder attack and the doctor told me it need to be removed
Alcohol, smoking? No
Occupation? Financial secure? Yes
PEFE card
General appearance-well
Vital signs- stable
BMI-22
Deep jaundice +, pallor –, scratch mark +
Abdomen-distended, no organomegaly
Urine dipstick- bilirubin +++
Explanation
According to your story and physical examination findings, look like you have cancer called
cholangiocancinoma. The patient bounce back and said cancer. Yes, based on the story I need to
consider it as you lose weight and other findings are suggested of it. But this is just my working
diagnosis and need investigation to confirm it. Let me explain you with a picture. There are other
causes like pancreatic cancer, cholangitis inflammation of bile duct, cholangiohepatits inflammation
of bile duct and liver, hepatits just inflammation of liver, gastritis inflammation of stomcah,
pancreatitis inflammation of gland call pancreas.
Global score-5 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
5
History
5
Diagnosis/ Differential diagnoses
5
313
12. Middle age male frequency burning sensation and painful urination Long stem all normal except
UDT rbc 3+ protein 1+ leuko + nitrites 1+ Task- explain dx DDx Causes for ur dx Initial management
plan and further management plan.
Another Feedback – You are a GP. Your next patient is 30 years old man with frequent urination and
painful urination. No fever. Long stem. He has no history of sexual promiscuity. No underlying kidney
problem. Abdominal examination normal. No discharge from the penis. Did DRE and prostate size is
normal. He has penicillin allergy. Urine dipstick shows RBC++, protein+, nitrites+. (similar to book
case)
Task-explain diagnosis, differential diagnosis
-causes for your diagnosis
-initial management and further management plan
My approach
Introduction
According to your symptoms, we did examination and some test. Let me explain your condition.
It is called urinary tract infection. Let me explain you with drawing. It is the infection and
inflammation of the part of the urinary tract. Sometime it is associated with sexually transmitted
infection but you don’t have any history suggestive of it but still I need to consider it.
DDx-stone in the case of stone you will have some severe abdominal pain
-prostatitis-inflammation of prostate
-BPH-enlargement of prostate
-sometime cancer of the prostate as well (the patient really surprised when I mention cancer)
-benign growth or cancer of the bladder
-in young child, we also consider congenital abnormalities of the urinary tract
These are all the things I am thinking about. To be honest, it is not common for man to have urinary
tract infection. We have to find out the cause of the infection.
For the management, we will do some more tests. To confirm the diagnosis, we will do urine culture
and sensitivity, for the stone, ultrasound or CT scan, for the prostate, PSA after one week, for the
bladder problem, a procedure called cystoscopy will be done.
And further investigations would be needed but it depends on the result. We will manage you
accordingly.
So, I will prescribe the antibiotic. As you have penicillin allergy, I will prescribe ceftriaxone. You need
to take it for 2 weeks. You need to take it according to prescription and complete the course. We will
change the antibiotic after the C&S result come out. You need to do urine C&S again after
completing the antibiotic to make sure infection is clear.
For the prevention, you need to drink a lot of water. Do not hold urine and pass urine frequently.
Global score-5 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
4
Diagnosis/ Differential diagnoses
4
Patient Counselling/ Education
3
Choice of investigations
5
Management plan
5
(RACGP - Trimethoprim, Cephalexin, Amoxycillin/clavulanate, Norfloxacin)
13. Breast cancer 5 years ago, surgery and axillary lymph nodes clearance tamoxifen taking Now
came with neck pain especially flexion tingling sensation in right lateral border of forearm and
thumb index fingers No organomegaly no lymph node enlargement chest clear Task-explain dx DDx
Prognosis for your diagnosis. Management plan.
Another Feedback – Female, 60s? tingling sensation of outer side of left forearm. History of left
mastectomy for breast cancer, now on tamoxifen. Long stem, can’t remember everything.
Task: explain Dx, implication, Mx.
314
14. DKA 17 years old girl with feeling unwell Features of DM present blood sugar level-34mmol UDTglucose 4+ ketone 2+ or 4+ ECG not available Task-ho PEFE dx with reasons
Another Feedback - You are a GP in rural clinic with limited fascility. Your next patient is a 17 years
old farmer with feeling unwell so that she cannot keep up with her work.
Task-History, PEFE, diagnosis with reasons.
In the room, there is a lady lying on the bed.
Introduction
I will check your stability first.
Tell me more about it. I feel really unwell doctor.
Since when? Few months
Getting worse? Yes Relieved by rest? No
Any fever? Muscle aches and pain? No
Any loss of weight? Yes, I lose weight despite I ate a lot
Do you feel unusually thirsty these days?
Do you have to pass urine more frequently these days? Yes what about at night? 2-3 times at night
Pain when you pass urine? No
Any problem with vision? Yes, I cannot see well, blurred
Any tingling or numbness sensation? Any chest pain, SOB? No
General health? Good
Family history of DM? No
Alcohol, smoking, recreational drugs? No
PEFE
General appearance- unwell
Vital signs-BP 110/70, PR 100, RR-24, SPO2 96% Fever-nil
BMI-not available?
I will quickly assess CVS and respiration system. Clear
Abdominal examination-tenderness, organomegaly, kidney ballotable or not? All good
Neurology examination-normal
Neck-thyroid gland enlargement? No
Bedside test-BSL-34mmol
Urine dipstick test-glucose 4+, ketone 2+ or 4+
ECG-not available
Explanation
The reason why you are feeling unwell is due to DKA.
It is the complication of type 1 DM. to be honest it is an emergency condition and we need to do
immediate management. Please don’t worry too much, we will do everything to help you.
Global score-5 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
5
History
4
Choice & Technique of examination,
5
organisation and sequence
Choice of investigations
4
Diagnosis/ Differential diagnoses
5
15. (PILOT) You are an intern at surgical department. Your next patient is 60 years old lady with
history of colon cancer and had done colectomy and chemotherapy. She had routine check-up with
specialist. But CT shows multiple metastasis (no CT provided). She had already informed about the
condition but she wants more information. Hb% 96, MCV low.
Task-Tell her about the condition
315
-implication for your diagnosis
-management plan
My approach
When I entered the room, there is a teary lady sitting on the chair.
I started with introduction. Hello, my name is May, one of the intern doctors in this surgical unit.
I understand that you are very stressed about your condition. Do you need more time for your
feeling? I know it is very hard for you. And the patient said yes doctor and dropped a tear. I offer
tissue and water. But the patient refused. The patient said I am really concerned about my
condition. Yeah, I will explain you about that and addressed all of your concerns.
I explained about blood test first and then told her about spread of cancer to liver.
Consequence of the condition is liver failure which means liver cannot function properly. You will get
some problems with digestion, bloating and jaundice etc.
Management plan-you will be managed by MDT approach. This will involve surgeon, oncologist, well
trained nurses, social worker, etc. if you have financial problem, I can liase with centrelink as well.
The treatment are mainly chemotherapy and radiation, if possible surgery as well. But all of these
are decided by specialist. Are you with my so far? Yes
Do you have any question for me? No
So every treatment has side effects.
Like for chemotherapy, hair loss, taste problem (didn’t mention about weak immune)
For radiotherapy-skin changes, irritate the skin
For surgery-infection, bleeding, injury to nearby structures But all of these are minimized with expert
hands.
Reassurance, check understanding
Are your family members aware of your condition? If you want, I can arrange for family meeting as
well.
Have around 2 minutes extra time.
Thanks both role player and examiner.
16. Female 30s, intermittent headache. Task: Hx, possible DDs to patient.
(+) left sided, few months ago, dull, from the temple radiating to whole left head, each attack last ?
mins, taken ibuprofen only little relief, move to dark room, aura+. Migraine
Another Feedback - You are a GP. Your next patient is 30 years old lady with recurrent headache.
Task-History, Diagnosis, differential diagnoses
I understand from the note that you have recurrent headache. Are u in pain right now? No
Ok, you can tell me anytime if you are uncomfortable.
How long? A few months
Do you think it is getting worse? Yes more frequent during these days, previous it was 2 monthly,
now monthly
Is the nature the same during these few months? Yes
Do you think it is expected? I don’t know
Where is the pain exactly? The patient point to right sided and said it started from the back of the
eye and spread to the left head
How long does it last in each attack? A few hours
Was it like band like sensation? No
Anything that make it worse? I think when I drink wine, it is worse, so I stop drinking it for a while
Anything that make it relieved? Ibuoprofen with little relieved
Is the light bothering you during the attack? Yes
Do you have to stay in the dark and quiet room when you had headache? Yes
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Any symptoms before the headache? No
Do you hear any strange sound or light flashing or zig zag line? Light flashing
Any nausea or vomiting? Yes I vomit during the headache
Was it forceful? No
Any lacrimation or running nose? Any fever and rash? Any recent cough or cold?
Is it associated with chewing? Any dental problem? No
How your vision? Ok
LOA, LOW? No
How your general health? Good
Let’s me ask you some private and sensitive question.
When was your last period? 2 weeks ago
Are you on any types of contraception? OCP
How long?
Smoking, recreational drugs? No Regular medication? No
Occupation? Manager stressful? Yes
Home situation? Husband supportive to you? Yes
Financial problem? No
Explanation
According to your story, I am thinking about a condition called migraine. It is due to dilatation of
vessel of the head and some chemical changes as well.
DDx-cluster headache associated with lacrimation
Tension headache-associated with stress and band like sensation around the head
Brain tumor-LOW LOA forceful vomiting
Meningitis encephalitis-no fever
URTI-no recent viral infection
Sometime dental problem and eyes problem called glaucoma
TM joint problem-no problem with chewing
Global score-5 Assessment Domain
Domain Score (see key below*)
Approach to patient/relative
4
History
4
Differential Diagnosis
5
27th June 2019
1) Insomnia with stress?
GP 22yr Female yawning and tiredness x a few weeks. Task: History, PEFE, Dx, DDx
(sleep problem, stressful, coffee drinking, no OSA findings, mood is normal) I can’t explore any
positive findings in this case. (my first station)
Another Feedback – 19 years old girl tiredness and yawning. History, PEFE on card, Dx, DDx
Another Feedback: Lethargy : Fail
17 year old with tiredness. Asked by mom to visit doctor. Task h/o and ddx
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There was a young girl who kept on yawning. On h/o 6hrs of sleep and stress as she is in 12th grade
due to assignment. Rest all negative.
I couldn’t say sleep deprivation as ddx.
I gave hypothyroidism, stress, infections, chronic fatigue syndrome as ddx.
This was a clear cut case of sleep deprivation which I was unable to tell in my differential.
2) Conduction deafness (bilateral) with repeated ear infection? (Pilot)
GP 2years 9mth Male concerned by mom because the baby started saying only six words yet.
audiogram done, many info given, but not finished reading. Task: PEFE, interpret findings of
audiogram, Dx (have no idea about audiogram findings)
3) GCA - Headache PE
GP 50 years Male unilateral throbbing headache, chewing pain, a few weeks? Task: PE, Dx, DDx
(tenderness in Right temporal area, others are normal)
Another Feedback: Headache: (Pass)
A 45 year old man came with head which is increasing over few weeks. Task : Physical examination
and DDX.
Did headache examination as mentioned in Marwan notes- case 129
Positive: tenderness over left temporal region.
DDx: Most likely Temporal Arteritis, then I mentioned migraine, sinusitis, tension headache,
trauma(unlikely), cluster headache.
4) Nephrotic syndrome
GP 50 years Female bilateral leg swelling, a few weeks/days? Task: History, PEFE on card, Dx, DDx
(Increased frequency, nocturia, frothy urine, puffiness of face, history of hypertension? controlled,
urine DPT protein-3+, RBC(-), BP 140/90
Another Feedback: Leg swelling (Pass)
318
Elderly lady with swelling in both legs. Task H/o, PEFE, DDX
Asked all related questions to leg swelling, SORTSARA , then injury? Insect bite? Bush walking? Does
it reduce while resting? Any shortness of breath?
Positives on Hx: early morning puffiness on face as well, CVS – normal, Urine dipstick – proteinuria
3+
DDx: Nephrotic syndrome most likely, nephritic syndrome, cellulitis, pvd, trauma, heart failure (these
were the ddx I gave)
5) Acute gouty arthritis
GP 40/50 years Male right foot pain for 2 days, no history of trauma, history of hypertension taking
ARB, thiazide , BP well controlled, history of alcohol drinking 4-6 SD , BMI 25 Task: PEFE, Dx , DDx,
Explain implications and initial Mx
Another Feedback: Foot pain: (Pass)
Global:4 - Handbook case of gout.
A 40’s old man came with foot pain. Drinks 5-6 beers per day and is on Hydrochlorothiazide.
Task: Hx, PEFE, Immediate and long term management.
On examination the examiner will give you a picture of gout. Immediate management:
Indomethacin, stop hydrochlorothiazide and alcohol counselling to reduce the amount of beers and
long term management allopurinol and lifestyle modification.
6) Stroke
ED 72 years Female sudden onset of weakness of left sided weakness (arm+leg), Task: History, PEFE,
Dx, DDx, Invx?
(Residual weakness+, no slurred speech, funny feelings on leg? , no vision problem, history of
hypertension taking treatment regularly (atenolol, apixaban, losartan?), heart disease+ (AF)
Another Feedback: Limb Weakness: (Pass)
319
A 70+ year old lady came with limb weakness. Task H/o and DDX
I entered the room and there was an old feeble lady.
On H/o taking : Fall, atrial fibrillation +ve and she is on apixaban and anti-hypertensive. Asked all
recurrent fall ques, no blurring of vision, slurring of speech or headache.
I gave ddx, stroke – ischemic and haemorrhagic, SAH, cervical spondylosis(unlikely).
7) Acute mania (Pilot)
ED 17 years Female university student, brought by mom because of calling to police about her
daughter, she has been withdrawn 22000$ from bank account, gambling problem +, elevated mood,
restless, lack of sleep for 2 weeks. Now she was given medication like sedation? now at hospital
under care. Task: Psychiatric, psychosocial history from mom, explain her daughter's most likely Dx/
DDx, immediate Mx.
(previously healthy, no history of low mood, no history of drug use, no medical problem, single
mom, financial problem because of spending money a lot by her daughter, history of depression in
her grand mom)
8) Major depression with high risk of suicide
GP? 30 years Female married nurse, brought by husband because of not going to work for six weeks,
he found she was going to take all the tablets from the bottle to end her life, Task: Watch MSE video,
present this to examiner giving your reasons
Another Feedback: Mood change (Pass)
A 30-year-old nurse BIB husband as she was found to hang by herself. She was cleared by coroner in
a case she was accused, the death of a patient A 4 min video is played. Your task is to present MSE to
examiner.
Positive in video: gloomy, no eye contact, unkempt hair middle aged lady. Hears auditory
hallucinations, hears someone calling her “murderer” repeatedly. Is guilty as she still feels that she is
the reason for the child who died in the clinic. In second half of the video she starts crying. Couldn’t
assess cognition, judgement & insight. But mentioned that she lost her insight as she didn’t want
help.
320
9) Counselling for contraception
GP 47 years Female for contraceptive options, has 3 children, youngest one 17 years old, taking OCP
for long. Task: History, counsel.
(Reason: not want to take regularly, forgetful to take, busy, no preferred type, family complete)
Another Feedback: Contraception (Fail)
A 47 year old lady taking COCP, all normal. Periods are becoming lighter.
I mentioned all types contraception, but missed to say that she might reach menopause even though
I asked about mood changes in Hx and other perimenopause symptoms. Missed to mention surgery
(sterilization as an option as well)
10) Secondary PPH due to Endometritis
GP 25/30 years Female recently delivered a baby 10 days ago, present with BPV for 2 hours, baby is
fine. Task: History, PEFE, Dx, Invx?
(fever+ , no anaemic symptoms, no tummy pain, NSVD, no complication, placenta complete, PEFE:
temp 38.4, abdomen : uterus 16 weeks size tender, BPV+ Os slightly open, no foul smelling
discharge, no tissue piece, UDS normal)
Another Feedback – History, PEFE, Management.
Another Feedback: Vaginal Blood Loss(Pass)
A 27 year old lady came postpartum 10days with vaginal bleeding. Task Hx, PEFE, DDX
Entered room made sure hemodynamically stable, then examiner reminded me that management is
not my task.
Asked all bleeding ques, except forgot to ask episiotomy, asked about placenta , 36 weeks GBS,
bleeding disorders, blood thinning medicationsetc.
PEFE all was normal, except for TEMP: 38.9 and bleeding from vagina, 16weeks uterus size
DDX,: Endometritis(drew and explained). Retained POC, lacerations, bleeding disorders, trauma.
321
11) Disc prolapse
ED 30 years old Male lifting heavy weight c/o LBP sudden onset, can’t walk well, Task: History, PEFE,
Dx, possible causes, DDx
(not first time, previous months ago?, resolved spontaneously, this time tingling numbness on from
buttock down to leg, painful walking, PEFE: tenderness over lower back, restriction of movement in
all directions, SLR Right 30 degree, slump test (+), power normal, sensation reduced on dorsum of
foot lateral toes, reduced ankle jerk, right side)
Another Feedback – Sciatica
Another Feedback: Back pain (Pass)
A 40’s year old man presented with back pain. Task Hx, PEFE and ddx
Asked SORTSARA, then any weakness for which he said it is present. No bowel or bladder
dysfunction. Happened at work when he was lifting something heavy.
PEFE: mild tenderness over lumbar region and L5-S1 dermatome sensation diminished. Ankle reflex
also diminished. Cannot do schober’s test as the patient is unable to move. SLR –ve.
DDx: L5-S1 radiculopathy (most likely), sciatica, mechanical back pain, cauda equina syndrome,
trauma.
12) Right renal colic
GP? 30 years Male, right abdominal pain for 1 day, Task: History, PEFE, Dx/DDx, Invx
(colicky pain, from back to front spread along inguinal ligament, no fever, no other urinary
symptoms, PEFE: renal angle tenderness right+, DRE : BPH grade 1 soft, UDT RBC+++ , others normal)
Another Feedback: Abdominal pain (Pass)
An elderly man came with right sided pain increasing since yesterday. Task: Hx, pefe, DDX and
management.
Hx: no pain while urination, no problem in initiating urination, passed urine just before coming, mild
nausea, no vomiting.
322
Positive: right sided pain travelling towards groin.
On pefe: flank tenderness +ve
Urine dipstick: Haematuria +ve
Vitals all stable
DDX: Ureteric colic most likely, pyelonephritis (no fever) so unlikely, BPH unlikely, appendicitis
unlikely(psoas sign, rovsing sign all negative.
Management: Admission. Pain killers, scan to see the size, position of the stone. And asked the
patient to strain urine.
13) Acute epiglotitis/ ALTB
ED 9 month old boy b/in by dad because the baby has been running nose for a week?, barking
cough, inspiratory stridor, difficulty in breathing x one to two days, history of going to day care
centre yesterday, immunization complete) Task: history, PEFE, Dx, Mx
(reduced feeding, less change in nappy? , looks irritable, growing well, PEFE- sitting still, mild
respiratory distress, inspiratory stridor, lungs clear, cervical lymphadenopathy, temp 38.2 degree,
throat not examined) Some said its whopping cough case.
Another Feedback: Cough (Fail)
Croup case: Failed due due to mismanagement, by mistakenly told antibiotics instead of steroids.
Barking cough and inspiratory stridor positive.
14) Tranverse lie? – Obstetric PE
GP 30 years old Female 37 weeks pregnancy, routine AN visit, patient is well, previous visits are
normal, G3/4?, NSVD, Task: PE, Dx, (dummy exam) (Transverse lie- SFH 37cm,Fetal head right side,
Fetal buttock- left side, FHS heard) some said its large for date, I’m not sure in this case.
Another Feedback: Antenatal care (Pass)
A 37-week old pregnant lady came for antenatal check-up. Do PEFE and tell ddx.
323
Positives in my exam was: BP: 125/85 (need to put cuff and start measuring examiner will tell the
finding) cephalic ppt, longitudinal lie, head mobile, SFH: 38cm so told it can +/- 2cm. FHR: 140bpm,(it
was hard to hear). Ddx: Normal pregnancy, will keep monitoring.
***Some people got transverse lie, large for gestation and also small for gestation.
15) AAA
GP 65 years Male routine health check up in last visit mass in abdomen, ordered CT abdomen,
patient is well, no symptoms at all, history of hypertension taking med, plan to go for caravan trip
one or two weeks later Task: Explain CT abdomen (only photo provided, no report, no dimension
available), Dx, possible implications, Mx
(AAA , patient concern: wanna go to specialist only after trip)
Another Feedback – CT metastasis explanation, counselling and management.
Another Feedback: Abdominal swelling (Pass)
An elderly man came to your Gp clinic and you noticed an abdominal mass. CT scan and contrast X
ray was ordered. The results are here. Explain the results. The man wants to go for caravan trip. He
was a chronic smoker, stopped 5 years ago.
Task: Interpret the results, explain the contributing factors and management
324
Somewhat similar picture was given.
No measurement was given. Explained as abdominal aortic aneurysm. Contributing factors, High
blood pressure and smoking (appreciated him as he stopped smoking).
My management wasn’t good. I just told, will call radiology to find the size of the aorta and manage
accordingly. Will send to specialist for further follow-up. And explained if its below 3.9 cm will follow
up, and if more than 4.9 cm need to do surgery. (but was scored 3 for MX)
325
16) Hyperthyroidism PE
GP 40? Male feeling restless agitated, weight loss 3kg,Task: PE, Dx , DDx (restless, tremor of hands,
fine tremor, no neck swelling?, no eye changes, warm and moist hands, no AF, proximal myopathy+,
increased ankle jerks)
Another Feedback: Nervousness (Pass)
A 57 year old man with nervousness. Vitals were given outside. Temp: normal, PR:100
Task: Physical Examination, DDX.
I entered the room there was an anxious man. He was trying to enact as if he had exophthalmos. I
commented on general appearance, started with pulse rate, but got PR 68bpm. Then went on to do
tremors – positive, he tried to give me positive lid lag and proximal myopathy.Did thyroid
examination as per geeky medics video. I missed reflex in this station. Then gave my differentials –
Drew a thyroid gland and explained it could be hyperthyroidism due to grave’s disease (I apologised
for medical jargon) , goitre, thyroiditis, palpitations due to heart condition such as AF and anxiety as
one of the ddx as well.
28th June 2019
STATION 1 KNEE EXAMINATION
PAA:EXAMINATION
GS-5
Approach to patient-5
Choice and technique of examination-5
Accuracy of examination-5
Diagnosis and DD-5
QUESTION: middle aged, obese man with bilateral knee pain x 6 months
1: perform examination of knee
2: tell diagnosis and DD to the patient
MY APPROACH: I knocked the door, greeted both examiner and patient. Introduced myself. Patient
was an overweight man, middle aged,cooperative,sitting on a chair. Examiner had no expressions.
Washed my hands, explained that today I am asked to do the examination of your knee in view of
your pain. This will involve me making you walk,have a look and feel of your knee,and doing some
movements. Is that ok with you? During my examination if you feel any kind of pain,please let me
know,I will stop there. Shall I give you some painkillers?
326
I started with gait,it was painful,so I didn’t make him walk more(I kept on saying take your time,I
don’t want to hurt you). Then I did the inspection, I asked him to satnd there, and I walked around
to see knee from front,sides and back.Inspection had no significant findings. Then I asked him to sit
on the bed and moved to palpation. No local rise of temperature, medial joint line tenderness was
there on both sides,more on the right. Patellar tap showed some effusion. I did sweep test. I said I
will skip measuring quadriceps bulk for now as there is no obvious wasting I can see. Clark test ,
patellar apprehension test ,patellar tilt were all negative. I did anterior and posterior Drawer test
,varus and valgus stess test on both knees,all negative. Examiner asked me to skip Apleys grind test
as it was painful. Thanked patient, washed my hands.
DD: Then I explained most probably from your symptoms and my examination, you are probably
having OSTEOARTHRITIS of both knees, more on the right. This is basically wear and tear occurring in
your knee joint due to long term use and obesity also is a risk factor,but this is manageable,so don’t
worry. I also want to consider other possibilities like some problems with the knee cap like patellar
tendinitis,patellofemoral syndrome but they are unlikely on my examination. Infection of bone or
joint also possible, but unlikely as they will have more symptoms. Some injury to the supporting
structures of knee joint are also a possibility but are excluded by my examination. Can be RA too, an
inflammatory condition. Bell rang, thanked them both and left.
STATION 2: ABDOMINAL PAIN
PAA:EXAMINATION
GS-4
Choice and technique of examination-5
Accuracy of examination-4
Diagnosis and DD-4
QUESTION: Middle aged lady with acute onset of abdominal pain,fever with chills. No jaundice,no
problem with urination.
1. Do examination of abdomen
2. tell diagnosis and DD to the patient
MY APPROACH: I knocked the door, greeted both examiner and patient.Patient was lying on bed
covering herself with the blanket.washed my hands,explained what I am going to do,gained consent
and offered pain killer. She said she just had the pain killer. I started with general inspection,patient
was obviously in pain,hands,eyes,mouth-all negative. I mentioned lymph node and chest
examination for spidernaevi , examiner said normal. Moved to abdomen. Inspection nothing
positive,she was an obese lady breathing heavily but was cooperative. Palpation showed no local
rise of temperature, tenderness on right hypochondrium,no organomegaly. I said I will skip
Murphy’s sign as patient is in pain. (Patient was in too much of pain that she was saying ahhh…when
you reach close to upper abdomen. So I was saying sorry all the time, explaining everything I am
doing,making sure she is comfortable). Percussion showed no dullness or organomegaly. While I was
about to do the auscultation,examiner said bowel sounds are normal.i said I would look for hernia
and do per rectal examination,examiner said normal. I didn’t mention or do renal angle tenderness
here, I could have done that.Thanked patient and washed my hands.
DD: got a pen and paper and explained liver and biliary system and said most probably it is
cholangitis in view of the typical pain and chills. It is manageable,don’t worry. Other possibilities are
327
cholecystitis,choledocholithiasis,hepatitis,gastritis,pancreatitis,pneumonia,MI. Diagram made
explanation easier and time saving. Bell rang, thanked both and left.
STATION 3:REST
STATION 4:INGUINAL SWELLING(PILOT CASE)
QUESTION: Elderly male with swelling in the right groin region
1:take relevant history
2:tell diagnosis and DD to the patient
MY APPROACH: Greeted both examiner and patient,both were nice.In history,I aasked about the
details of swelling –it was there for some months,no trauma prior to that,not painful,not itchy,size
remained the same.Upon asking he said it is disappearing while lying down,not extending towards
scrotum, he was a chronic smoker, having chronic cough and constipation.Sexually active,no
features of STI,no significant past history.Symptoms of BPH present.
DD: I said hernia and explained what it is. Other DDs are lipoma ,sebaceous cyst,inguinal lymph
node,explained each in simple terms and said now I will do examination on you and we will figure
out what it is.
Thanked both examiner and patient.
STATION 5:LETHARGY
PAA:HISTORY TAKING
GS:4
Approach to patient:4
History:4
choice and technique of examination:4
Interpretation of investigation:4
diagnosis and dd:4
QUESTION: 5 year old boy brought in by his father due to tiredness.
1.take history
2.PEFE
3.tell diagnosis and DD to father
MY APPROACH: Greeted both examiner and role player. RP was having a long
hair,cooperative,examiner was also nice. In history, I tried to ask what he means exactly by feeling
tired, for how long has he been like this,tried to rule out organic causes keeping HEMIFADS in mind.
Assessed HEADS by offering confidentiality. Covered BINDSMA,pee and poo. IN history, to be honest,
I didn’t get a clue.Thanked patient.
PEFE:General appearance,vital signs,Growth chart,ENT,Neck-thyroid swelling,lymph node,chest and
heart examination,abdomen,hernia orifice-all normal except for pallor. Office test showed glucose in
urine and trace ketones in a card .
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DD: I know it is hard to see him being tired like this,but on examination everything seemed to be
normal except for some lack of haemoglobin which is correctable.but in the urine test done here, I
could see glucose,so most probably it is DM(I didn’t say DKA as such). I was about to say other DDs,
but father looked worried.so I explained that eventhough DM is a long term condition it is quiet
manageable with insulin injections,he will be fine. Then bell rang,I somehow said I want to consider
other possibilities like infections,nasty growth, we will rule them all out by proper workup.
STATION 6: FUNNY TURN
PAA: HISTORY TAKING
GS:5
Approach to patient:4
History:4
diagnosis and dd:5
QUESTION: 17 year boy came with funny turn
1.take history
2.tell diagnosis and DD to patient
MY APPROACH: greeted both examiner and patient. Examiner was fine. Patient was very
cooperative young boy.In history I asked about the details of fit he had. This was the first time, he
was about to grab something from the fridge, suddenly had funny movements all over the
body,lasted for 30 seconds, didn’t loose consciousness, no tongue bite,no incontinence. After that I
tried to rule out DDs,asked about fever, recent vomiting/diarrhoea,increased urinary frequency and
all. No significant past history. SADMA revealed binge drinking last night. He said it was the first time
he had a binge drinking. I didn’t go into details of HEADS, I should have done that.
DD: I explained fit as abnormal electrical activity most probably due to binge drinking. Did a bit of
alcohol counselling here, asked have you thought of cutting down , he said yes, I said I will book you
for another consultation so that we can talk about it in detail, don’t want to stress you at this
moment. Other possibilities are infection of brain covering or brain itself,but very unlikely as you will
be having fever and more symptoms in that case . Or can be due to abnormalities in hormones or
salt level in body too, we wil rule them out too by doing blood tests. Can be caused by medicines or
illicit drugs too, but not in your case , or seizure disorder(epilepsy), but highly unlikely as you are not
having any family history. I finished this station earlier, thanked both examiner and patient and left
the room early.
STATION 7 ERECTILE DYSFUNCTION (PILOT CASE)
QUESTION: elderly male patient with uncontrolled DM, on insulin, now presenting with erectile
dysfunction.
1. History
2. PEFE on card
3. Tell DD and Talk about the desirable intervention
MY APPROACH: Both examiner and patient were very cooperative. In history I tried to follow the
questions from Karens for ED. Asked about any trauma, any signs of STI, any recent relationship
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problem. Asked about diabetes , follow up with specialist, any diabetic complications. No other
significant past history. no smoking/alcoholism.
PEFE on card showed sensory system in lower limb affected, urine dipstick showed high glucose.
Thanked examiner and explained to patient that this ED is also associated with the DM as some
nerves serving the private parts are being affected. So the ultimate solution is to control diabetes. So
I will refer you back to the specialist and also to dietician so that he will tell you what all to eat
during each meal. Also I want to consider other possibilities like some problems with the blood tubes
supplying your private parts, STI, emotional factors. THEN again I went back saying that the only
solution is to get DM under control. thanked them both and left the room.
STATION 8:REST
STATION 9:ANTENATAL CARE
PAA:DIAGNOSTIC FORMULATION
GS:4
History:4
choice and technique of examination:4
diagnosis and dd:4
management plan:4
QUESTION: gravida 4 lady, at 30 weeks, came for regular ANC,to get her blood reports, which
showed microcytic hypochromic anaemia.
1:expain the report
2.take history
3.PEFE
4.Tell diagnosis and management
MY APPROACH: this was my first case in exam. I knocked the door,inside was very nice patient and a
nice examiner. I greeted both of them, she has been my regular patient. So I said good to see you
again, how are things. She wanted to discuss the reports first. I explained each component, iron
study was not done. So I said most probably this is iron deficiency anaemia, we will confirm it by
doing iron study,if by any chance it comes as normal we will have to do another test in your blood
known as electrophoresis to know ether it is thalassemia, and checked weather she had
mediteranian lineage, she denied. Then I went into detailed history,made sure that no current
problem with this pregnancy. Covered 5P.she had 3 kids already without much spacing, I asked how
they are doing at home and all. Also she was a vegetarian. No features of malabsorption or bleeding
problem.
PEFE-everything was normal. I started from general appearance,vital signs,
weight,pallor,icterus,assessment of SFH,lie,presentation,fetal HR, other system, examiner said
patient denied pelvic examination. Thanked him.
I explained to patient that it is probably iron deficiency anaemia, we will confirm it by doing iron
studies. Frequent deliveries and diet made her succeptible. In diet please add green leafy vegetables,
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dates and all and can refer her to dietician. reaassured her and said that she will be started on iron.
Bell rang, Thanked both and left.
STATION 10:FACIAL PAIN(FAIL)
PAA:DIAGNOSTIC FORMULATION
GS:3
Approach to patient:4
History:3
choice and technique of examination:3
diagnosis and dd:3
QUESTION: Middle aged lady presented with right sided facial pain for some weeks
1. History
2. PEFE
3. Diagnosis and DD to patient
MY APPROACH : Knocked the door,greeted both ,patient was cooperative, examiner had no
expressions. I asked about the details of pain after offering pain killer. She explained it as electric
shock pain, severe,situated close to corner of mouth, not increasing on talking or chewing, painkiller
gives some relief. I tried to figure out DDs afterwards.no pain or discharge in ear, no trauma, no
insect bite, no parotid swelling,recent fever. No significant past history/SADMA.
PEFE everything was normal. I covered general appearance,vital signs,pallor,icteus,lymph nodes, eye
,ear examination,parotid swelling and systemic examination.
Explained to patient that it is probably trigeminal neuralgia, explained that it is the pain affecting
one of the nerves supplying face arisisng from brain as you are having the typical pain. Also want to
consider other possibilities like temporomandibular joint problems, unlikely here as the pain will be
aggreavted by opening mouth and chewing. Also it can be problem with ear ,inflammation of a
salivary gland, but unlikely from my examination. Bell rang,thanked both and left.
STATION 11:FEEDING PROBLEMS
PAA:MANAGEMENT/COUNSELLING/EDUCATION
GS:5
Approach to patient:5
History:5
counselling/education :5
QUESTION: 28 weeks, primi ,came to discuss about breastfeeding and bottle feeding
1.take focused history
2.counsel the patient
MY APPROACH: Knocked the door, pleasant patient. Congratulated on pregnancy, asked any
bleeding or discharge down there,tummy pain,blurring of visison,headache,edema,all investigations
so far have been normal. Assessed weather she has enough support.Appreciated that she came to
discuss her concerns. Refer to HB for this case, I followed the same format. I basically praised
advantages of breastfeeding, difficulties with bottle feeding, and also the conditions in which
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breastfeedind is not possible.she was concered of getting mastitis and sleep problems while feeding.
I reassured her. I said you have plenty of time left still, go back home and think about what I said,I
will give you reading materials as well. Don’t stress out, with kids your life is going to be more
beautiful, I can tell you as I am having two and so on.
STATION 12: BEHAVIOURAL COMPLAINT
PAA:HISTORY TAKING
GS:7
Approach to patient:7
History:7
diagnosis and DD:6
QUESTION: uni student sent by counsellor for recent fall in grades
1.take history
2.diagnosis and DD to patient
MY APPROACH: Knocked the door,greeted both. Young , beautiful lady started crying,offered
tissues, reassured her, confidentiality given. I tried to be as empathic as I can, it was not difficult as
RP was acting really well. So I went into details, asked about why does she think she was sent,about
falling grades,and asked directly anything happened prior to all this, she opened up her breakup with
boy friend. I said sorry, don’t feel bad about yourself, if he has left you,he does not deserve you. So I
was just being spontaneous, thanks to RP for her acting skills. Covered HEADS,SIGECAPS,
hallucination,delusion,insight,past/family history,organic causes,SADMA. Positive findings were low
mood,anhedonia,decreased energy,decreased social interaction,no suicidal tendency.
Diagnosis I said depression,DDs were adjustment disorder,acute stress,dysthymia,BPD-depressive
phase, generalised anxiety disorder. She looked very releived and said thank you so much doctor for
explaining everything as bell rang.
STATION 13:REST
STATION 14:BREAST PAIN
PAA:MANAGEMENT/COUNSELLING/EDUCATION
GS:4
Approach to patient:4
History:4
diagnosis and DD:4
Managemet:4
QUESTION: young lady,some weeks following first delivery, came with pain in her right breast
1.take history
2.tell diagnosis to patient
3.advise management
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MY APPROACH: patient seemed irritable due to her pain, was not that cooperative. Tried to
reassure and congrarulated on baby,enquired about baby,all good.went into pain details, pain on
the right breast, no swelling or discharge,asked weather baby is being properly attatched to
breast,taught about it, no swelling,no cracks. Mild fever present. no significant past/family
history/SADMA. Mood is fine,no features of depression.
I said lactational mastitis, explained what it is, may be due to poor attatchment, cracks are being
formed through which bugs enter from baby’s mouth or mother’s skin. Reassued her, told that I wil
give you pain killers,paracetamol for fever and antibiotics. Drink plenty of water, keep feeding from
the same breast, milk down towards nipple while feeding, refrigerated cabbage leaf helps. Also I will
run some basic blood investigations FBE,ESR,CRP. Review in 3 days, if not improving can do USG to
rule out abscess/pus collection. Reading material regarding proper attatchment. Finished this case
early,thanked them both,and left the room.
STATION 15:LEG PAIN (FAIL)
PAA:DIAGNOSTIC FORMULATION
GS:3
Approach to patient:4
History:5
interpretation of investigation:2
chice and technique of examination:4
diagnosis and DD:3
QUESTION: 9 year old boy, brought in by mother with limping on the right side for few months, xray
oh hip and knee given.
1.take history
2.PEFE
3.expain Xray to parent
4. diagnosis and DD
I FAILED THIS CASE BECAUSE I COULD NOT FIGURE OUT SCFE FROM XRAY
MY APPROACH: Greeted both, both were nice. Went into details of pain,no trauma/insect bite
before it happened, pain on right hip and knee,no recent URTI,no problem from birth,no
fever/redness/swelling/bleeding prolems,BINDSMA nothing significant. No relevant past/family
history.
PEFE: General appearance,vital signs,growth chart—weight on 97 th percentile said by examiner.
ENT-normal,hip and knee examination-movements of hip are restricted especially abduction and
internal rotation, skin normal. Other system normal.
I exaplained Xray seemed to be normal,but I don’t want to give you wrong info,so I will confirm with
my senior and let you know,
I said SCFE possible in view of his pain and over weight. Explained what it is, gave other DDStransient synovitis,DDH,Perthes disease, Osteomyelitis,septic arthritis,HSP,bleeding
disorder,fracture,insect bite and why they are unlikely.
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BUT NONE OF THEM HELPED ME COVER MY LACK OF KNOWLWDGE ON INTERPRETING THE XRAY.
STATION 16:IRREGULAR PERIODS
PAA:MANAGEMENT/COUNSELLING/EDUCATION
GS:4
interpretation of investigation:4
choice of investigations:4
patient counselling/education:4
QUESTION: 45 year old female with irregular periods, coming to GP, to collect her reports, and to
know weather she can be started on HRT
1.explain investigations to patient(given outside itself-FSH,LH.CERVICAL SCREENING)
2.order other investigation you think are necessary
3.tell her weather she can be started on HRT
Greeted both of them. Introduced myself ,she enquired about the results. I explained that hormones
are in the perimenopausal phase, cervical screening to rule out cervical cancer is normal and no HPV
infection. When asked about LMP, she said she cant remember when was it.She had some hot
flushes, no mood issues or dyspareunia. Then I tried to rule out all the contraindications of HRT like
migraine/stroke/heart disease/liver disease/undiagnosed vaginal bleeding,breast CA/endometrial
CA/DVT. She had nothing abnormal. I said we will do FBE, LFT,mammo, transvaginal USG with
endometrial sampling,ECG. And if everything comes to be normal, you can be started on HRT. And
said that HRT also cant be given for a longer period as it has some side effects,can give you some
reading material to read about HRT.Finished early,thanked both, and left the room.
STATION 17:COGNITIVE IMPAIREMENT
PAA:EXAMINATION
GS:5
Approach to patient:4
explanation of procedure:4
Performance of procedure:5
interpretation of investigation:4
QUESTION:
regularly
young male, chronic alcoholic, found to have increased BSL too,not taking insukun
1.explain and perform MMSE
2.tell DDs to patient
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MY APPROACH: knocked the door, greeted both, patient was a bit irritable.MMSE paper given by
examiner.
I talked a bit about his alcoholism and BSL just to maintain a rapprt.I explained to patient that this is
just a screening test to assess your orientation nd memory and all. It does not confirm anything. We
will have to do further assessment if something is abnormal. He agreed.
I followed ORARLC format. He had problem with registration,had some 3 tries, also with recall. He
seemed to be irritable and sleepy. I kept calm and said don’t stess out,take your time, do you need
more time??
I explained my findings to him, and said can be probably due to his alcoholism, then bell rang, I
somehow said also want to rule out depression,dementia,drug induced and ran to next station.
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10th, 11th, 12th, 24th, 25th, 26th July 2019
10th July 2019
1. Eye exam on lady with diplopia (PASS)
Did complete exam of eye
INSPECTION: told same things exactly as hb case of myopia (45)
no EYEBALL TENDERNESS, no PARASTHESIA
checked VISUAL ACUITY. Chart was on wall.it was 6/12 I think. I dnt remember exactly. Asked
examiner about pinhole she said no nedd of that proceed further
checked VISUAL FIELD: no deficit
checked LIGHT AND ACCOMODATION reflexes : normal
checked H movements.. uniocular diplopia on lateral gaze
ischihara chart not available
turned on OPTHALMOSCOPE. ( I was not able to turn it on dnt knw why may be I got confused..
examiner helped me thats why gave 2 in familarity with equipment but passed overall due to good
score in other domains) jus checked red reflex examiner stopped and said findings are normal
Dds: diplopia due to DM( patient was diabetic) 6th nerve damage lateral rectus weakness
myasthenia gravis trauma tumor
2. Abdomen exam and DRE on man with PR Bleed, dx, ddx (PASS)
PR bleed with blood on tissue paper. Do relevant abdominal and DRE. N tell investigations to patient
(no Dds)
this examination is same that I failed in my previous attempt due to time constrains actually it is v
tricky and lengthy so I had to be v quick this time but still passed with margin global score of 4 ;-(
In this exam never do whole abdominal exam u cannt finish in time the hands arms face abdominal
and dre ..always do focused abdominal to rule out abdominal causes of PR bleed which are just 3
..CRC, IBD and CLD
GA ( patient was at 45 degree so asked him to lie flat) : no cachexia, no abdominal distension, no
jaundice
VITALS :BP with postural drop pulse
HANDS: no clubbing (IBD) no leukonychia (CLD) no kilonychia (IDA due to bleeding) CRT normal
ARMS: no sctrach marks, needle marks , no petechiae bruise (CLD), no psoriatic rash (IBD)
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FACE: pallor positive given in stem, no jaundice
MOUTH: no mucosal dryness( dehydration due to bleed), no angular stomatitis
ABDOMEN: did inspection, superficial and deep palpation and palpated for liver ( all normal).did not
feel for spleen or kidney..did not percuss at all even did not asculatate..even u can skip feeling for
liver bcx its not imp regarding Dds
DRE: did same as geeky medics..patient was having haemrrhoids which are seen and felt as rounded
structures on dummy
INVESTIGATIONS: I first told about Dds( although not in tasks) then inves
FBE
Iron studies
Proctoscopy
Colonoscopy with biopsy( patient was old aged so rule out CRC)
LFTs
3. Hand exam and test of function on lady with months of hand pains – OA real patient (PASS)
INPECTION: heberdon and bouchard nodes were there( I was a little bit confused on inspection but I
commented about nodes then before palpation I asked patient which site is more painful she
pointed at the same sites where nodes were visible so I got happy that I told right thing)..
TENDERNESS: palpated each and every joint , also chckd for palmar tendon crepitu, thenar
hypothenar muscle wasting and dupytren contracture and felt elbbow for rhematoid nodules.
MOVEMENTS: checked only active movements of wrist (flexion, extension, radial deviation, ulnar
deviation)
checked both active and resisted (power) movements of thumb and fingers (I chcked all mov like
active and power at same time e.g asked patient to point thumb towards ceiling chcking active
thumb abduction and then dnt let me push it down checking power and same for all other
movements)... then checked passive movemnts of wrist, thumb and fingers(I dnt knw whether all
movements are necessary or not but I got 6 score in technique and accuracy both)
PRACTICAL MOV: coin, urine jar and key was there so checked all.
Dds
OA RA septic arthritis psoriatic arthritis...could not say more
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4. 9 weeks old with sudden crying since last 4 hours – Intussusception
History and DDs. NO PEFE (PASS)
Father was there said baby is crying all of a sudden for few hours..episodic crying not turning blue or
white..normally a calm baby had 1 or 2 episodes of vomiting as well no fever no change in color of
urine but decreased no of wet nappies did not tell anything about stool color so overall vague histry
but I asked about sorethroat to rule out HSP as cause of intussusception then he said yes last week
but no rash..so it was again confusing but still I was sure it is intussusception due to HSP
Dds Intussception acute otitis media uti strangulated hernia
so told all Dds of acutely srying baby but got 4 in Dds bcx should have told about other Dds of
vomiting in child as well.
5. 32 years old lady with PV Bleed following amenorrhoea (PASS)
history PEFE investigations...no Dds
On history 6 weeks amenorrhea with breast tenderness but just little bit bleeding not much and mild
abdominal discomfort. took detailed history
forgot what examiner said in PEFE but UPT was not available
although Dds was not task still I first told Dds then investgations
Implantation bleed threatened abortion(confused between 2 bcx mild bleeding and mild abdominal
discomfort.. so told about both)
Incomplete abortion trauma bleeding disorder hydatiform mole PID ectopic pregnancy
Investigations : B-HCG T/V ultasound urine M/C TORCH screening Blood grouping and cross matching
STI screening plus others
6. 72 years old man with recurrent falls. only histry PEFE and DDs. (PASS)
Case of recurrent falls I think 3 times but everthing was normal on histry ruled out stroke epilepsy
vision hearing problem dementia
arrthymia all other CVS causes hypoglycemia OA/RA no DM no significant past histry no regular med,
no disease Ruled all other possible causes of recurrent falls but got nothing so was v v
confused..then at last asked family histry then he told about some heart disease of father but was
not sure of diagnosis so he just said some heart disease so I got a clue that it miht be heart disease
..nothing else on histry
PEFE everthng was normal Except BRADYCARDIA ( heart rate 54) everything else normal and asked
about Ecg..examiner said not available so confused
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Dds..was v vague so told first about CVS causes long QT syndrome was my provisial so told patient
about this first and explained bcx it is congenital and bradycardia is common then other CVS causes
and other Dds
7. 6 weeks old child crying frequently from day 3 since discharged home with mum – Evening Colic,
stressed mother
It was a typical case of infantile colic and postnatal depression. History Dds. (PASS)
Mother was v sad complaining of baby cryibg a lot. It was mentioned in the stem that baby was
checked by nurse and perfectly fine and mother was looking v sad and depressed so before and
immediately after entering room I got to know that it was more for mother rather than baby. Took
histry for both baby and mother but more for mother complete psychoscial histry. She was having
low mood not going out with friends and all features of depression but no hallucinations no
delusions and no intention to kill baby Told dds of postnatal depression, postnatal psychosis ,
postnatal blues, thyroid and other dds of organic diseases for mother and told about infantile colic.
Could not say about other dds of baby but got global score 6 in Dds
8. 52 years old man with anxiety and feeling of lump at back of his neck; perform thyroid exam
The scenario was patient is having neck lump which he thinks that it moves with deglutition. Having
positive family histry of thyroid as well. Do examination and dds. (PASS)
It was the same case that came in my previous exam as well. Entered room Introduced myself
meanwhile washed hands Adjusted chair of patient so that I can examine by standing behind
Commented on general appearance GENERAL APPEARANCE ; On general appearance patient is
sitting comfortably, no anxious agitated look, normal build, appropriately dressed according to
weather.
VITALS: There was no watch around to calculate pulse. I asked examiner about vitals and BMI . He
just shrugged the shoulders pretended that he does not know. I was a little bit confused but
proceeded further.
HANDS: no clubbing, no brittle nails, no sweating, no dry coarse skin, no palmar ertyhema no palmar
pallor, no fine tremors, no thyroid acropatchy
FACE; no obvious sweating, no periorbital edema, no loss of hair from outer third of eyebrows, no
xanthelasma
No MACROGLOSSIA
No HOARSNESS
No exophathalmos, no lid lag, no lid retraction ( did not chck for ophathalmoplegia)
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NECK INSPECTION: no skin change ,scar mark, no redness, no swellng even on deglutition and
tongue protusion
NECK PALPATION: temp, tendernesspalpated for thyroid and felt on deglutition and tongue
protusion everthing was normal, no swelling, felt for cervical and SCL LN as well
PERCUSSION: no retrosternal extension of goitre ASCULTATION: no thyroid and no carotid bruit
PEMBERTON SIGN : negative
KNEE JERK REFLEX: normal on right side, about to do on left side but examiner said normal
no PRETIBIAL MYXEDEMA
No MEDIAL MALLEOUS EDEMA
HEART ASCULTATION: started but examiner said normal
Checked for PROXIMAL MYOPATHY at end
OTHERS: ecg, neurological examination( both not available)
DD: as everything was normal nor did examiner told any finding so was confused about Dds so first
told GLOBUS PHARYNGEUS and explained. Then told dds of thyroid like cyst, adenoma, thyroiditis,
solitary nodule, mng and CA and explained them a little bit( dnt knw what was the diagnosis but got
5 in dds)
9. Video psych case; girl with unstable relationship and recurrent self-harm. Listen to video, dx, risk
assessment and steps to confirm dx. (PILOT)
There was a video. tasks were tell examiner diagnosis, Dds, steps t confirm diagnosis n tell examiner
about suicidal and homicidal risk..it was written that donot present MSE
in video no particular format just random questions..wrist cut..issue with boy friend..all suggestive of
borderline personality disorder told Dds in risk assesment I think it should ne told by SAD PERSONS
scoring dnt knw about steps to cnfrm
This was all from me what I remembered..sorry for what I forgot but u guys are welcome for any
further quiry and question..Best of luck for all..Do pray for me :-)
10. Woman day 2 post op C/section, following prolonged labour. Now wants review for d/c. Take
additional history, PEFE, Dx, Ddx – Endometritis (PASS)
In the stem it was written that C section was done and vital charts were given in which there was
rise in temperature on 3rd day not on first day. U have to tell patient about discharge. History PEFE
Dds management
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Took detailed history of casues of post op fever No cough, chest pain(atelectasis) Mild abdominal
discomfort, when asked about vaginal bleeding she gave a very vague ans..she said I dnt knw how
many pads a day and how much bleeding (endometritis) no burning micturition (UTI) no pain at
canula or wound site(septic thrombophelibitis) no calf pain (DVT) breast feeding but no redness
mass in breast In PEFE everything was suggestive of endometritis and trace of proteins in urine
dipstick
Dds :same Dds which I ruled out
Management : Detailed investigations and treatment for endometritis and regarding discharge I said
you should have stayed more and will cnfrm frm my seniors and specialist as well.
11. 52 years old man with strangulated and incarcerated hernia with bowel obstruction. Patient had
AMI and stent 3 months ago and on ramipril, Clopidogrel and aspirin. Patient is concerned about his
risk of bleeding . Talk to patient and carers his concerns. Patient asked what to do about medicines
and if surgery can be delayed. This is a pilot station without examiner.
12. 27 years old lady returned from USA 2 days ago. Right calf pains and USG confirmed popliteal
vein DVT. Explain result to patient, dx, ddx and advise on further management.
13. Mechanical pain. Tell diagnosis and fill the medical certificate
It was a typical scenario of mechanical lower back pain..neurological and other exam normal..all
given in stem ..tasks were diagnosis/dds, management and sick certificate..
so explained patient about conditin by making diagrams..Dds were sciatica, trauma, CA, fracture,
ankylosing spondylitis, cauda equina syndrome and other..explained all
then told about treatment both short and long term..he was a builder so told about correct
technique to lift weights in future( got from internet) plus other treatment
Sick certificate was v easy to be filled..regarding leave for how many days I was confused.. he was
builder so I gave leave for a week..frm 10th july to 16th...after coming home I thought I did mistake I
should have given less rest but I got global score 7 in medical certificate so I think I wrote the right
thing.
14. 6 months old baby cough for 1 week turning blue- History, PEFE, X-ray
15. Post-menopausal uterine prolapse with rash (PASS)
Same old scenario of post menopausal uterine prolapse with candidiasis due to DM
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histry, pefe, Dds
took detailed histry.same case as karens case..Dds I told as uterine prolapse cystocele rectocele
enterocele urethrocele
16. Post-partum Depression
11th July 2019
1. Breathing difficulty (fail)
I thought I did really well in this station and turned out I badly failed
Although it is my first station and I was nervous since it is kind of counselling station, the patient was
smiling and so easy to reassure. She is too sweet. I finished early in this one.
I kept checking her if there is any concern she said NO.
You are an intern in rural hospital which is about 200 or 300km away from tertiary hospital. Middle
aged lady just gave birth to a baby like hours ago at 30 weeks of gestation after PROM (duration not
given). Baby is having breathlessness.
On PE, no fever, No murmur on CVS examination
other findings given ( I don’t remember exactly )
Senior assessed the baby and gave head box oxygen and SPO2 is 98%
Baby is stable.
Your senior wants you to tell the mother about the condition of the baby
Tasks -History not more than 2 min. Dx and DDx with reasons. Mx.
I went in and young lady was lying and smiling instead of looking anxious
She asked me what happened to my baby
I told her your baby is having some problem with breathing but this is common in prem baby and it is
well manageable, your baby is in safe hands ( I reassured a lot and she keeps smiling and said “oh it
is a relief”)
h/o – I asked duration of PROM ( she said she doesn’t know)
Color of liquor ,anything like yellowish or foul smelling (she is not sure but doctor didn’t mention
anything like the liquor is dirty)
Mode of deli- Vaginal with no complication
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Antenatal history- fever and infection- NO and everything was fine
Complication during pregnancy- No
It’s her first baby
I asked where is her husband and if she wants her husband near her right now
She answered it’s ok and he is waiting outside
Dx and DDx- acute respiratory distress syndrome (since your baby is prem and lungs is not mature)
Transient tachypnea of newborn (more common in LSCS)
Pneumonia (but your baby doesn’t have fever)
Heart failure (no murmur)
Meconium aspiration (less likely)
Mx- we need to manage your baby at 3’ hospital
We will contact PIPER team( I told her who will involve in that team)
I told her what specialists and trained nurses will do at tertiary hospital (about continuous
O2,surfactant, breathing machine if necessary, feeding, temperature adjustment, infection)
I told her I will also explain our plan to your husband
And I asked her if she wants to accompany the baby to 3’ hosp
She said yes if possible
I will ask my senior to assess you and if he thinks u are fit enough you can go with your baby
Approach- 4, History 4, Dx ddx- 1, Mx 1
Please check this station from the candidates who passed!
Another Feedback - Breathing Difficulty (PASS)
You are an intern in Level 2 hospital. A lady gave birth to a baby at 34 WOG after PROM (duration
not given).Baby is having breathlessness.
On PE, no fever, No murmur on CVS examination.
Your senior registrar is currently assessing the baby and the baby is put on head box oxygen and
SPO2 is 98%
Baby is stable now.
Your senior wants you to tell the mother about the condition of the baby.
Tasks -History not more than 3 min, Dx and DDx with reasons. Mx
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Mother was lying supine on bed so went straight towards bed and stood by the side of bed during
whole 8 mins. Lots and lots of empathy that this has happened but not to worry as baby is being
looked after by senior doctors and is currently stable.
Took history about labour which was quick like in 2 hours after rupturing her membrane at home
which was like 10 mins from hospital, liquor was clear, NVD no assistance needed, No history of
trauma, sexual intercourse,bleeding,discharge, rash in past 24-48 hours, no fever. Did not receive
any steroids at hospital during labour.
Pregnancy was normal with all Inv and visits NAD, No significant family history of PTL, Heart
conditions, LBW babies. No Dm/HTN/smoking history.
Explained about all causes of breathelesness in New born like RDS, TTN, TEF, CHD, HF, Pneumonia,
MAS. I told TTN can be the cause here as labour was quick but it commonly occurs after LSCS. Then
told about RDS which commonly occurs in <32 WOG and LBW babies which can be the most likely
cause here as you are 34WOG and explained about immaturity of lungs and surfactant. RP asked me
what is surfactant, I told her some chemicals in lungs which help babies to breathe properly which
normally develops after 32-34WOG. I explained why other causes are unlikely in her baby but still
need to assess him properly and monitor him regularly.
In mx, I told her we are doing our best to make him come out this situation as soon as possible.
Senior doctors are looking after him. He is getting oxygen, his temperature is being maintained,
seniors might give him IV Abs as to protect him from infections, till he is alright he will be fed by NG
tube or IV (If its difficult for you as you are not able to breastfeed him right now, I arrange a meeting
with lactational nurse who will guide you about what to do when you are not bf your baby). If his
condition is not improving at our hospital, we might have to refer him to bigger hospital by NETS
where even more senior doctors will look after him and try to find the cause and address that. If its
due to RDS, they might give surfactant from his wind pipe to make his lungs work properly but it will
all depend upon senior decision. I will make sure doctors there know about your baby and ready to
receive him.
Do you want me to call your partner? I will make sure you get in touch with senior doctors here who
will explain more about the baby.
This was my last station. I was completely exhausted but managed to finish this case right on time.
Global Score: 5, Approach to patient/relative 5, History 4, Diagnosis/ Differential diagnoses 5,
Patient Counselling/ Education 5
Another Feedback – RDS - FAIL
Preterm baby was delivered and now baby has shortness of breath. You are speaking to the mom.
Task: Hx, d/d, Mx
Approach:
Mom was lying in the bed so please dont go and sit in the chair and take the case.Take the paper and
stand next to the mom i believe that is an essential step here.I started off by asking routine post
delivery questions (5Bs).Then i asked about the pre delivery,during delivery questions.One very
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important thing i missed was the steroids.Also quickly asked family hx and previous pregnancies as
well as any hx of asthma,smoking,and cystic fibrosis.Then i gave her the differentials of RDS,Cystic
fibrosis,bronchiolitis,acquired lung infections,meconium aspiration and said that its most likely RDS
and i explained that in detail.I said that we need to do an Xray as well as routine investigations to
rule out all the dd.As for the mx i mentioned referal to specialist and most likely administration of
surfactant by them along with chest physio.
As for this case im not quite sure why i failed.I thought i did okay but unfortunately i failed.I dont
think they are so strict to fail me just because i didnt ask about the steroids.I probabky didnt build a
good rapport.
2. AN care counselling (Pass)
Pregnant woman in 1st trimester came for AN blood test results.
In the result, FBE normal
Blood group and RH status O (+)
hep b and c (-)
HIV both antigen and antibody (+)
Syphilis (-)
Rubella – Ig G (+)
Tasks- explain result. History to find out the causes of her problem. Counsel about her condition.
Patient was active and curious about the result,acting like she was clueless
I gave her warning shot like if she comes together with any relatives or family members today-No
Any idea which tests we did - she said all routine tests
How is her expectation for the results- she hopes it’s okay
She became anxious and asked me what is wrong
I explained her the results ( I told her the normal tests first )
She looks really shocked and speechless when I told her HIV is positive
I reassured her a lot and if she wants any private moment, I can get out of this room. But I want you
to know that I am here for you and u can tell me whatever going on your mind. Offered her water
and tissue. She said she doesn’t know what to do. Yeah I can understand that you might be shocked
by this but nowadays medical facilities in Australia are very advanced, we hav a lot of medications
for HIV. She said she wants to know
1st bell rang
History- multiple partners (+) unprotected sex (+)
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IVDU- (-)
Transfusion (-)
Body piercing, tattooing (-)
Ever diagnosed with STI (-)
It was an unplanned pregnancy
Mx- MDT in high risk pregnancy clinic
CD4 count and viral load will be checked
will give you ART but the type of medication will be chosen by specialists
LSCS will reduce the risk of transmission ( she hasn’t thought about deli option)
No breastfeeding ,formula feed is better
baby will be given ART for first few months after delivery
better bring ur husband to check his blood test for HIV and other STI and to use condom to prevent
other STI in the future
I forgot to mention notification to DHS
(I didn’t reassure her a lot in counselling because examiner told me to hurry up
But rechecked understanding a lot)
Approach 6, Explanation of results 6, History 5, Counselling 3, Overall 4
Another Feedback - Antenatal care (PASS)
Pregnant woman in 1st trimester came for AN blood test results
In the result, FBE normal.
Blood group and RH status O (+) hep b and c (-)
HIV both antigen and antibody (+)
Syphilis (-) Rubella – Ig G (+)
Tasks- explain result
History to find out the causes of her problem
Counsel about her condition.
This was my first station. I was trying to control my nerves. When I entered, greeted the examiner
and roleplayer. Introduced myself and told her I will explain the results and before that if she has any
concerns for me to address. She said no doc I want to know the results. I asked her do you know why
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we did the test. She said yes its routine tests for pregnancy. I did not follow BBN format here and
explained all normal results first about normal FBC, blood group, no syphilis and immune to rubella.
She asked me what do you mean by immune dr and I had to explain what immune means( less
chance of you getting that disease as body can effectively fight againt that inf).Then I broke the news
by telling unfortunately HIV result came out to be positive. Then I stopped, gave her time to sink in
the news. Then I explained her about HIV and AIDS difference and then she became a little relax.
Took her permission to ask sensitive questions to find out the cause of this and ensured
confidentiality as well. Then asked all detailed sexual history (Multiple partner in past+), blood
transfusion, IV drug, tattooing. Also asked about any complains of rash, wt loss, lumps and bumps
recently. I also asked few questions regarding pregnancy, all routine questions.
In counselling, I told her we need take care of you and your pregnancy as well. MDT approach. Refer
her to Infection specialist, they will start on ART and monitor viral load. For preg, high risk clinic and
will have more visits and follow up with CD4 and viral count. If viral count less than cutoff
throughout preg, very less chance of baby being hiv positive. Also mode of delivery depends upon
viral load and decided by specialist. No breastfeeding. Baby also given ART for first month as decided
by MDT team.
At last, reassured her a lot, support group, Anonymous notification to DHS, contact tracing and
asked her to talk to her partner and we need to test him as well.
I forgot to mention we cant do amniocentesis, fetal scalp sampling like procedures as risk of
transmission.
Global Score: 4, Approach 5, Interpretation of results 5, History 4, Counselling 4
Another Feedback - HIV IN PREGNANCY-PASS
Pregnant lady came for routine ANC and inv showed HUV positive.All other inv normal.
Task: explain inv,hx, mx
Approach:
First explained all the normal results in the end i said that unfortunately HIV test shows positive
finding.Gave her couple of seconds to fake in the news.I explained HIV and said its not AIDS yet.Kept
reassurinng her and told gave her confidentiality before i took hx.In Hx i briefly asked about current
pregnancy and any hx of misscarriages.Turns out it wasnt a planned pregnancy.Then i asked detailed
sexual hx.Also touched on any travel tattooing or piercings.Then i moved on to management.I said
high risk pregnancy clinic,mdt and stuff.Also said that theyll start her on antiviral and keep
monitoring her cell count.Delivery will be C-sec and no breast feeding after surgery.Also mentioned
DHS.
Patient was very scary in this case thank god i passed.My advice is since there are a lot of tasks here
dont dwell on throwing so much empathy because you need to mention all the key points.Also dont
go on explaining about HIV.And i realized i forgot to ask about the HIV symptoms.Please dont forget
to ask.
3. Respiratory examination (FAIL)
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An old man with breathlessness and cough for many months.
Tasks perform PE
dx ddx to examiner
There was a real patient. I did chest examination from back and then examiner asked to do in the
front as well but I was saved by the mini bell and went on to tell dx/ddx as Copd, Asthma, ILd, OLD,
bronchiectasis, Lung ca, Less likely pneumonia, pe, pneumothorax.
On examination I could not find any positive findings except decreased BS on right lower zone. May
be I was not accurate enough, that’s why I got 3 in accuracy and it made me fail this station I guess.
Global Score: 3, Approach 4, Choice and technique 4, Accuracy 3, Dx/Ddx 4,
Another Feedback - (Pass)
An old aged man with breathlessness and cough ( duration not mentioned)
Tasks perform PE, commentary to examiner, dx, ddx.
I think this is real patient
PE-get consent
General appearance
Checked vital signs – stable
Inspection- hands-no nicotine staining, no clubbing, no tenderness in wrist joint( no feature
HPOA),no warm and moist hands, no palmar erythema and pallor, no flapping tremor
of
Face- no pallor, no jaundice, no subconjunctival suffusion, no nasal flaring, no features of horner’s
syndrome, no cyanosis)
chest from front – chest wall deformity(-), accessary muscle working (-)
checked trachea shift and apex beat
chest from back – spine deformity (+) examiners checked sth in his paper when I said this
palpation and percussion- I think all increased but I didn’t believe my findings and said these are
normal
auscultation- I was about to say ronchi but turned out I said no wheezing
no other added sounds
I said I would like to check for heart failure signs
Examiner told me to say ddx here
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When I was examining the patient, I was about to say restricted lungs disease first becuz of spine
deformity, but I said COPD and asthma first
When I said it can also be due to occupational lungs disease, bell rang
I wasn’t satisfied with my performance here but luckily I passed
Approach 4, Choice and technique 4, Accuracy 3, Dx 4, Global 4
Another Feedback - PASS
Patient came with cough for some time.
Task: do PE, d/d
Approach:
WIPER approach and asked for vitals first.Proceeded to check hands,face and also checked for lymph
nodes.Then inspection of chest i noticed his posture was drooping a bit so i mentioned that.Then
commented on trachea and respiratory distress signs.Then checked spine also.Then checked
expansion on mammmary area,supraspinatus area and infra spinatus.Then palpation i did vocal
fremitus.I found that its slightly reduced on L side.Percussion same findings.Vocal resonance also
reduced in L side but no added sounds.thanked the patient and gave my dds as pleural effusion,Ca
lung,pneumonia,TB,fibrosis,lumg collapse
I wasnt sure about this case because i thought my findings were wrong.But i dont think they care
about the findings its more about the technique.
4. FIBROID-PASS
30 y/o came with heavy menstrual bleeds. Task: Hx, PEFE, D/D, Investigations.
Ensured confidentiality.Asked full period hx,sexual hx,associated symptoms,personal history.Ask all
the questions for your dds like fibroid (lump,pee or poo issues,pain during periods) endometrial
hyperplasia (heavy bleeds,bleeds after intercourse) Ca Cervix (nulliparity,multiple sex
partners,menarche age,smoking or any habits) ,ovarion tumours,endometriosis,bleeding disorders,
polyps, trauma,IUCDs or any contraceptions.Coming to pefe the usual pefe and ask detailed pelvic
examinations with DRE.Examiner mentioned that uterus is 14weeks.I thought it was endometrial
hyperplasia (it was my last case i wasnt thinking straight) so i told her it could be that.But thank god i
said that it could be fibroud as well or a Ca.So we need to to all inv like transvaginal usg,pelvic
usg,probably biopsy,hormonal studies,FBE LFT RFT, as well as tumour makers.
I thought I’ll fail for sure since i mentioned endometrial as my main dx but thank god i mentioned
the others.
Another Feedback - PASS
Middle age lady with irregular period for months
Tasks :History, PEFE, Dx and ddx, Investigation.
History- period became heavy which was previously normal, now amount becomes larger, duration
of period longer
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But no pallor, no dizziness or tiredness
No mass on her tummy
No discharge
No trauma history
No irregular bleeding between each period
No mass on down below
No tummy pain
No Nausea, vomiting, breast tenderness
LMP was three weeks ago
Sexual history- hasn’t been active for months
I asked when you were sexually active, is there any pain or blood during sex, No
Not on any medication or pills
No blood diseases in her and family
Never dx with STI
Pap was ok
Any family history of cancer No
Personal history of gynae problem No
Never done any surgical or procedure to tummy and down below
No children
Poop and pee ok
PEFE- slight pallor present
Abdomen normal
Pelvic examination- uterus size larger about 10 week size
Other findings normal. (I didn’t do urine pregnancy test)
dx- myoma
ddx- endometriosis, STI, DUB, Blood Thinning Medication, CA cervix, Bleeding disorder
Invx- FBE esp Hb, BT, CT, LFT, RFT, U & E, USG
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History- 6, PEFE- 5, Dx DDx- 4, Choice of invx- 6, Overall- 6
Another Feedback (PASS) -Typical menorrhagia history with increasing amount, clots and days of
bleed(5-6 days bleeding) but no pain since few months, no trauma, no medication history, no
bleeding and clotting disorder, sexual history NAD, pap normal, ocp used as contraception in past, 2
children, both NVD, no complications, no surgeries, no fever, no rash, no sti, no mass in tummy, no
lumps and bumps, no cancer or thyroid history in her or family. Also asked about mood, family
support.
PEFE: pallor mild. Abd NAD. Pelvic exam…uterus size was 12 wks non tender irregular.
I drew uterus in paper and explained about fibroid and how it causes more bleeding during periods.
Told other ddx as DUB, Polyp, Blood thinners, Bleeding disorder, Sti, Thyroid related, lastly told
cancer as well.
Inv: FBE, U&E,LFT, Pelvic USG, Coagulation profile and explained why to do each inv.
Global Score: 5, History 5, Choice and Technique 5, Dx/Ddx 5, Choice of Investigations 5
5. Shortness of Breath (PASS)
50 old years old female came with SOB for few months which is getting worse
Tasks : History, PEFE, Dx and DDx to patients.
The RP was really helpful and showing her name card in front of me all through the station so that I
don’t utter wrong name.
I took all detailed SOB history. She gave me history similar to heart failure like sob on exertion ,lying
down and climbing stairs, increased number of pillows, with green/pinkish sputum but no leg
edema, blue face, mass in tummy, no family history of heart condition. No fever, no travel, no
contact history, not on any meds, no bleeding disorder, no trauma, no allergy history or asthma. She
was smoker for 30+ years more than 40 cigg/day but left 6months back. I appreciated her for that.
She also gave history of some wt loss as her clothes were loose but wt not measured but no lumps
and bumps.
Up until now, I was thinking its probably HF or Lung ca.
PEFE: No any features of HF but decreased BS on left mid zone, some crepts as well, dullness to
percuss, vocal resonance increased. No hornors or weakness in hand.
Dx/ddx: I drew diagram of lungs and told all causes of chronic cough like: Copd, Bronchiectiasis,
Asthma, Heart failure, pleural effusion which can be due to inf and other causes. At last, I told with
your smoking history and wt loss history, I am more concerned about some cancer of lungs so as not
to scare the pt I told I still need to confirm the cause by doing further inv and I am not quite sure
right now.
Global Score: 6, Approach 6, History 5, Choice and Technique 6, Dx DDx 5
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Another Feedback -CA LUNG-PASS
Old patient came with hx of progressive SOB. Task: Hx PEFE dx/ddx
Approach:
First asked the patient if shes comfortable and checked vitals.Then proceeded to ask the usual SOB
questions.She had typical Ca lung hx of LOW, hemoptysis,sob,smoking.PEFE i asked for the usual
things and also asked if any horners signs are present.Then gave her dx as Ca lung most probably but
also said that im not sure i still to confirm it with help of specialists.Then mentioned all the possible
dds for sob.
Patient was nice in this case plus its a straightforward case so no issues.
Another Feedback -PASS
45 year old male came with SOB for few months which gets worse
Tasks – History, PEFE, Dx and DDx.
History- he said he can’t sleep at night because of this
Lying makes it worse- yes
Activities make it worse
Taking rest makes it better
Other features of heart failure- no ( cyanosis, swelling, urine output)
No fever, no night sweats
Cough (+) and I am not sure but sth like pinkish sputum (+) but no foul smelling or yellowish sputum
(-)
No weight loss
Appetite good
Sick contact (-)
Travel history (-)
Hypertension (+) and well controlled
Smoking history (+) for many years
Clot problem (-)
Any flu symptoms before these (-)
Kidney problems (-)
Any history of cancer (-)
PEFE- BP- 140/80, Others stable
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resp exam-dullness in left lower zone
VF, VR increase in lt lower zone
Breath sound- increase in lt lower zone
No signs of heart failure
dx- pleural effusion ( which can be caused by infection, auto immune disease, cancer)
pneumothorax, pneumonia, heart failure, asthma, COPD, TB, Pulmonary Embolism
I said in your case pleural effusion is caused by cancer of the lungs as u have strong history of
smoking (reassured after that)
Approach 4, History 4, PEFE 4, Dx/DDx 5, Overall 4
6. Middle aged man who was forced by his wife because she saw about the harmful effects of
alcohol on television and worried about him
Tasks: history to find out his alcohol drinking habit. Counsel him about the adverse effects of alcohol
I appreciate him for coming to me
I am not here to judge you or blame you but I’m concerned about your health since alcohol drinking
can have some negative effects on our health
History - He has been drinking since he was a teenager.
About 7-8 cups of alcohol
Enjoy all the different types of alcohol
No history of binge drinking
No history of fits, hypoglycaemia, aspiration, unconsciousness or hospitalization
General health good except hypertension and increased fat level
BMI normal
No yellowish discoloration
No accident or crimes
But driver license has been detained becus of drink driving
Relationship with wife, children good
No recreational drugs usage
No smoking
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Work performances and rs with workmate all good
I asked some of CAGE questions- he denied all
Financially secure
Never been tried to quit alcohol
Reason to start drinking- because everyone is drinking
Sexual life- good
No withdrawal symptoms
Counselling- he has no idea about effects of alcohol
I said effects on physical health ( liver, BP, Fat level, sexual health, nerves, fits, hypoglycemia,
unconsciousness, hung over ), mental health( more likely to get mental problems, perception,
delirium tremens which is life threatening ,more prone to smoking, recreational drugs)
Social (work performance, relationship problems, impulsive behaviours, crimes, accidents)
Reassured that there are a lot of support groups to help quitting alcohol drinking
Asked his motivation level- I don’t remember how he response
I told some brief about how we will help him but I focused more on effects of alcohol because of the
question)
Provided with reading materials
approach 4, history 5, counselling 6, overall 5
Another Feedback - ALCOHOL COUNSELLING – PASS
Ensured confidentiality first.Then asked amount of alcohol consumed,smoking,and usual alcohol
questions.Then assessed tolerance,dependance,withdrawal questions including CAGE.Then i asked
about effects of alcohol on family,law,work,personal health.Pt had been caught for drink and
drive.He wasnt dependant on alcohol nor has he had any withdrawals.So i told him that hes not
dependant as such but he still needs to gradually cut down and told all the side effects of alcohol
along with benefits of stopping.
Pretty straightforward case just dont be judgemental.
Another Feedback - FAIL
I asked by 5A approach after ensuring confidentiality. Only drink driving was positive with some kind
of hangover sometimes. No withdrawal, tolerance, CAGE negative, knows about safe limit.
I counselled systematically about effects of alcohol physically, mentally, socially and economically.
Rp was not so cooperative. I picked his drink driving charge and counselled around that. I don’t
know what I need to add in this case with my scoring.
Global Score: 3, Approach 4, History 4, Patient Counselling 5
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7. Febrile Convulsion - PASS
GP clinic-I forgot the age of the baby (2 years I think). Mother brought the baby who just had a fit
attack which lasted only about 6 seconds this morning. Tonic clonic seizure, Now baby is well and
stable. Tasks history, PEFE, dx and ddx, Mx.
Appreciate mom for bringing son to clinic. You’ are a great mother blah blah :P
History- baby had his breakfast this morning and had a good sleep last night
Suddenly became stiff
Tonic clonic in all 4 limbs
No wetting in his pants
No tongue biting
First time
A bit drowsy after recovery but now he is like nth happened
A bit feverish( she is not sure) but no difficulty in breathing, no ENT infection, no cough
No sick contact
No head injury
No family history of epilepsy
Not on any medication
No rash
No nausea, vomiting
Poop and pee fine
General health good
Immunization is up to date
PEFE- temperature is 37.8
No signs of head injury
Other systemic examination are normal
Neck stiffness- no
RBS. Normal
Dx febrile convulsion
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Ddx- but fit attack can be due to other things like hypoglycaemia, Meningitis, Head injury, Epilepsy
Mx- the mx is just to lower down the temperature I will give anti fever medication
You can do tepid sponging
give him enough nutrition and fluid for quick recovery
in case of further attack – left lateral position
don’t splash water
make sure there is nth in his mouth
red flags ( to bring the baby if further fits occur), review, reading material
Approach 5, history 4, PEFE 4, Dx/DDx 4, Counselling to patient 4, Overall 4
Another Feedback - PASS
Child brought by mom because she believes he had an episode of fits. Right now child is stable.
Task: Hx PEFE D/D Mx
Greeted the mom and told her not to worry as child is in safe hands and is doing fine right
now.Asked the usual questions for fits.Mainly ruled out epilepsy,brain
tumour,meningitis,trauma.Child was fitting for 4 mins and had uprolling of eyes.Just one
episode.Asked BINDS question and family hx of brain tumor or epilepsy.Also touched on contact
with any one sick.Coming to PEFE asked for the usual PEFE and also asked for any stigmata if
downs.Dont forget fundoscopy for papilloedema and also ask for rash.Chilld had only fever on PEFE.I
told her its most likely febrile convulsion with all the dds.I said right now send for all routine septic
work out.Then i said right now ill just administer antipyretics and he should be fine but i still need to
refer to pediatric spl hell decide if further action is needed.Also need to monitor the child for a bit
Another straightforward case but my advise is dont directly say its febrile convulsion for sure and
your son is totally fine.just mention specialists and let them handle.
Another Feedback (PASS)
Father was quite worried, needed lots of reassuring that right now baby is doing alright and playing
happily. Appreciated him that he did the right thing bringing him here and that he is a responsible
and caring father. Took consent to ask few questions to find out the cause of seizure for his little
one.
In history, it was typical first episode GTCS seizure which occurred all of a sudden while he was on
bed playing lasting about 10 seconds, no tongue bite, no wetting of pee or poo, he gave me history
of some kind of frothing and up rolling of eyes. Some kind of drowsiness afterwards but no
weakness. NO trauma, No missing of brekky, NO epilepsy history in family, not on any meds, med
and sur history NAD. Baby was having some kind of flu like illness with mild temp. No vomiting, no
problem with pee and poo, no rash, no excessive crying, no contact history, no pulling of ears or
drawing up of legs, happy family. BINDS normal. PEFE: NO neck stiffness, no congested TM or
pharynx, No signs of trauma, no weakness in any part…All system normal but temp was little
increased. RBS, urine all normal.
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In counselling, I started by saying with your history and examination, I could not find any abnormal,
everything seems to be normal and that’s a good thing. What he had today is called febrile
convulsion, and explained by drawing diagram about fever can decrease threshold to seizures in his
age group and this is quite common at his age and he will grow out of it after 5years. I said other ddx
like trauma, hypoglycemia, brain infections (meningitis, encephalitis), epilepsy and why these all are
less likely. Then, I told him seizure can occur again if he is having fever so main mx is to control fever.
So advised him about tepid sponging and Panadol during fever. If seizure occurs, don’t panic, do not
try to stop it, if possible make him lie on side, don’t put anything in mouth. Gave red flags and fact
sheets about febrile seizure
Global Score: 4, Approach 5, History 4, PEFE 4, Dx/DDx 5, Counselling to patient 5
8. Altered conscious state -Pass
An old aged lady went unconscious in the shopping mall this morning brought in by ambulance. RBS
was 3.4. she was given glucagon injection and now stable
Tasks : History, Dx and ddx.
Very sweet lady was in the room asking me what just happened
I will explain to you about ur condition but are you comfortable right now? Yes
You were just found unconscious and we checked ur sugar and it is low but now u are stable
I would like to ask you a few questions
History - She has type 2 DM
Was taking metformin and gliclizide which was added three months ago
Taking some other lipid lowering agents too
Last time seen by specialist was three months ago
Blood tests were done at that time and eyes and Kidneys are ok
Havnt had breakfast this morning because she was in rush
And was in the shopping mall for hours
Dizzy and became sweaty before she fell down
I think it was not her first time but I m not sure
Bmi increased
No head injury
No nausea, vomiting, loose motion
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General health- apart from DM all good
No alcohol drinking
No infection
Pee and poop ok
dx- hypoglycaemia ( can be caused by newly added medication, skipping meal, excessive activity,
binge alcohol drinking, kidney disease and told her which ones are unlikely)
she looked very satisfied with my explanation
and other ddx of unconsciousness – epilepsy, electrolyte imbalance, head injury, s/e of medication
Approach 6, History 6, Dx DDx 7
Another Feedback – PASS
An old aged lady had LOC in the shopping mall this morning brought in by ambulance. RBS was 3.2.
she was given glucagon injection and now stable.
Tasks : History, Most likely and Possible Causes to the patient.
The Rp was very cooperative and so was the examiner. Rp was lying supine on bed so went to stand
by the side of bed. Took consent to ask questions to find out the cause of her LOC.
She said she was going to have party with her frens that night so she hurriedly went to shopping for
her dress this morning without eating brekky but taking her DM medications. It was a straight
forward case of Med induced Hypoglycemia after skipping brekky. She was on Metformin and
another sulfonylurea which I cant remember right now. I told her most likely due to med and not
taking brekky, u had less glucose in blood and brain and that’s why lost consciousness. Hypoglycemia
can also be due to skipping of your normal meal, binge alcohol, excessive exercise, stress, etc. There
can be other causes as well and I tried to rule out all causes of syncope cluster---before, during and
after---- trauma, epilepsy, stroke, brain inf, postural/vasovagal syncope, electrolyte imbalance, heart
conditions and why these are unlikely in her.
I had lots of time remaining in this station. I told her about mx as well, examiner did not stop me and
I went on explaining signs and symptoms of hypoglycemia, importance of taking regular med and not
skipping meals, rule of 15, medi alert bracelet, hypopack and advice about checking blood sugar
before driving. While going out of the room, I wished her enjoy your party with your friends tonight
and have a blast. Both RP and examiner laughed at that point and I said thank you and left.
Global Score: 6, Approach 5, History 6, Dx ddx 6
Another Feedback -PASS
Pt was lying on the bed so please stand next to the pt.Pt was very nice and cheerful so i was joking
around with her.I asked her the routine pre/during/after fall questions.She skipped her
meals,carried couple of bags and is on 2 meds for DM as well as medications for cholesterol and
HTN.So in my dd i mentioned that it could be due to either one of those reasons.
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This case patient was very friendly.I couldnt come up with a reason for her attack so i mentioned all
the possibilities
9. Hip pain - FAIL
An old aged man comes with hip pain for months. Tasks - perform PE, dx, ddx
I forgot to wash my hands in this station
Got consent. General appearance
Inspection – gait is ok. Trendelumberg test positive
I found measuring tape on the table and I got confused and accidentally told the examiner that I
would like to do Schober test
Then I remember it was for back pain and I said sorry I won’t do that
While standing, having look at the back of the legs for deformity, muscle wasting, injury,
inflammation
Told the patient to lie on his chest- checked for any pain at hip area
Did hip extension passively- not reduced
Having look at the legs and hip again after asking him to lie on his back
Checked temperature
Tenderness- I touched about many times around the hips but pt doesn’t have any pain
Pulse is intact
Hip movements all reduced due to pain (internal rotation and external rotation can’t be performed
since pt refused)
Patient refused to be performed Patrick test too
Fixed flexion deformity present
Thomas test positive
Squeeze test positive
Pelvic compression test negative
Measured true length and apparent length- the same on both side
Asked for any abnormal sensation he said no
Dx ddx- OA, adductor tendonitis, Ostetitis pubis, Trochantric bursitis, Femoral fracture - Explained
all with drawing.
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Approach 4, Choice and sequence 2, Accuracy 3, Dx ddx 4
Another Feedback -PASS
Same examination technique as in Tally book and geeky video I guess. Introduced, took consent,
explained what I am going to do, pain relief, washed hands, and asked patient to undress himself
from waist to below and would provide chaperone if needed. Assessed gait—antalgic gait but heel
toe walking normal, cannot squat Look—NAD
Trendelenberg test--- positive on right side
Feel--- NAD
Now asked RP to lie down on bed Apparent and true length (measured with tape which was on
table)—no discrepancy
Move---all movement active and passive limited due to pain Squeeze test—negative
Thomas test--- No FFD
I said I wont proceed with FABER test as my patient is complaining of pain in both active and passive
movement.
Told examiner I would like to complete my examination by doing back exam and knee exam and also
full LL neurological exam.
For DX/ddx, I told OA right hip and explained by drawing and asked if patient is clear or not. Then
told it could be RA, Trochanter Bursitis, Adductor Tendinitis, Fracture, Dislocation, Septic arthritis,
Gout, Any connective tissue disorder and Due to some back problem, nerve problem and explained
to him why these are less likely in his case.
Global Score: 4, Approach 5, Choice and sequence 4, Accuracy 4, Dx/DDx 4
Another Feedback - OSTEOARTHRITIS PE-PASS
Patient came with history of stiffness in joints gets worst throughout the day and relieved with
NSAID. Task: Do PE, D/Dx
Approach:
WIPER initially then i checked gait and did trendelenberg which was positive. On inspection i
checked for any asymmetry and wasting. Then asked pt to lie down and palpated along join line for
tenderness. Asked for femoral pulse. Then moved on to movements. Patient had pain in all
movements. I hesitated to do extension but examiner said do as you wish so i did that as well.
Special test i checked for adductor tendinitis, faber (was positive and please ask where the pain is)
and thomas test showed fixed flexion. As i was doing this i realized there was a measuring tape on
the table. So in the end i quickly measured ASIS to medial malleolus and when i did this examiner
came close to have a look. I mentioned only 3 DDs and bell rang.
I thought ill fail this case since i did measurements in the end and only mentioned 3 DDx but thank
god i passed.
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10. Feeling Unwell - PASS
Middle aged lady feeling unwell, malaise and nausea after travelling (may be Thailand or Asian
country I didn’t remember. Sorry L)
Question was a very long stems mentioning she is not sexually active, No insect or mosquito bites
during trip. Appendicetomy done at age 8. No fever, And other negative findings.
Tasks – PEFE, explain Invx results, Dx.
PEFE- jaundice (+)
no pallor, No fever, No rash, No joint pain, No tonsillitis or ENT infections, No lymph node
enlargement, Abdomen- liver enlarged, Other systemic examination- normal
BMI – normal, Urine bilirubin- 2+, No UTI
I asked investigation result from examiner and he gave me a sheet of paper
Liver enz are all increased.
FBE- Hb and platelets are normal. WBC increased.
I explained the results to the patient.
Dx- hepatitis A
could also be hepatitis B , C
could be other infection elsewhere in the body like pneumonia, UTI, IE, cancer elsewhere,
lymphoma, other viral infections and vector borne disease but less likely
Approach 4, Choice and technique of examiner 5, Interpretation of results 4, Dx and DDx 5, Overall 5
Another Feedback - PASS
A middle aged lady feeling unwell, malaise and nausea after travelling to Phillipines.
not sexually active during trip. No insect or mosquito bites during trip. Appendicectomy done at
young age. No fever. And other negative findings.
Tasks – PEFE, explain Invx results to patient, Dx /Ddx to patient.
I first introduced myself to the RP and asked her consent to examine her (although it was PEFE) and
then proceeded to ask PEFE.
PEFE--- icterus +, vitals stable, other NAD
ABd exam---- No tenderness but Hepatomegaly+
No signs of CLD/Portal HTN/or any acute abd features
Other all systems NAD
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Office test---UDT- Bilirubin 2/3+, others NAD
INV results: WBC – slightly elevated, Hb and platelets normal
HEP B and C Negative
LFT all deranged except ALP was normal.
I thanked the patient for her patience and started explaining the blood results. During explanation, I
was asking few relevant history as well just to make patient engaged in conversation. I told about
normal results first and then drew liver and told about deranged liver functions. Also, explained
about UDT results.
I explained her most likely its liver problem that is some kind of inf we call Hepatitis. As her HEP b
and C are negative, that’s good thing. Most likely it could be Hep A/E as she gave me history of
eating street food and water in Phillipines and explained her about it fecoral route of transmission. I
said there could be other reasons as well like any other inf in her like uti/pneumonia/bowel, can be
due to her GB, can be due to thyroid gland, Anemia, or any cancer. Also can be due to any viral flu
like illness and explained to her why these are less likely in her.
Global Score: 4, Approach 4, Choice and technique 4, Interpretation of results 5, Dx/DDx 5
Another Feedback - HEPATITIS-PASS
Long stem outside but the important points were that pt had nausea vomiting,travel hx,not
immunized,no hx of unsafe sex or needles exposure.
Task:Ask pefe from examiner, interpret the investigations to patient and give dds
Approach:
I asked the usual PEFE with emphasis on abdomen.Positive findings were fever jaundice and
hepatomegaly.Examiner then gave me a set of inv which showed disturbance in LFT.So i told that
most likely liver is effected and it could be hepatitis since findings were evindent and also with no hx
of immunization she cpuldve got it during travel.Other dds were gastroentritis,stone in gall
bladder,HIV,Viral infections and so on
This case was again straightforward but be mindful while explaining and dont bombard the patient
with too many things.And while explaining the investigations most it willl sound roman to the
patient so my advice is after quickly running through the inv just tell the pt that i know these are all
medical jargons but what it essentially means is that your liver is effected
11. Change in behaviour – PASS
A girl brought in by family members due to change in behavior. Has been diagnosed with
schizophreniform six months ago and didn’t take medication
Tasks watch the video and present it to the examiner.
In the video she is wearing sunglasses. Hair was messy.
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Acting like talking to someone through her hands( she used her hands as a ph or walkie talkie)
Auditory hallucination present but no visual and tactile
Saying that she was on mission ordered by god
Insight judgement impaired
Suicidal idea denied
But about harming others, she said she was not sure it depends on the situation
Presented to the examiner in ASEPTICJRRR approach
Examiner is very nice
Commentary to examiner 3, Accuracy of examination 4
Another Feedback - (PASS)
Positives in video were: Patient was unkempt with messy hair, talking irrelevantly through her hand
made microphone(she used her own hand as microphone) to someone.
Mood was ok and congruent.
Speech was not pressured or low.
Auditory hallucination + (talking to someone), Command Hallucination +
Delusion of reference + (newspaper, TV talking about her after she does something ordered by that
someone)
Insight impaired
Judgement not assessed.
No suicidal ideation
Rapport was not satisfactory as she was not giving answers to all questions asked
Reliability is poor and collateral history required.
Risk is there as she could do anything ordered by that someone. (Harm others if ordered by that
someone)
When I was about to tell dx/dxx, examiner stopped me. I finished early and stayed there mute for
about a minute.
Global Score: 4, Commentary to examiner 4, Accuracy of examination 4
Another Feedback - VIDEO MSE-PASS
Long stem.Pt had hx of schizo in the past and non compliant with medication.
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Task: Present MSE.
Approach:
The usual mse video case but please pay attention to the everything very closely and ONLY say
whatever you see.In this case there was auditory hallucination and delusion of grandeosity.She also
had loosening of association.Also patient is at risk of harming others.
I was very scared of this case because i failed this on my first attempt.Just remember to give a brief
intro before telling MSE
12. Abdominal Pain – FAIL
Long stem describing a woman who came with abdominal pain, vomiting, no fever after
cholecystectomy days ago. Motion was not passed for one day or something like that
Task Perform PE, ask investigations from examiner and comment the finding, Dx/DDx.
On PE, tummy dummy was given
Distension present
Not moved with respiration
No tenderness on both light palpation
Generalized pain on Deep palpation
Bowel sound increased
Murphy sign negative
Mac burney point tenderness negative
PR examination- no bleeding no mass
No hard stool
Invx was intestinal obstruction
I present it is erect abd xray front view
Sign of obstruction present
I will attach the xray in the comment session
Dx ddx intestinal obstruction( I thin post op ileus would be more appropriate), Cholecystitis,
Appendicitis. I didn’t remember well what I told more about ddx
Choice and technique 4, Accuracy 2, Interpretation of inv 3, Dx ddx 3, Overall 3
Another Feedback – Abdominal Mass (PASS)
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A middle aged man with history of constipation who came with acute abd pain, vomiting, no fever,
flatus and poo not passed for few days.
Vitals were given outside which were stable. Also, it was mentioned no pallor, icterus and no signs of
dehydration.
Task Perform PE, Ask Investigations from examiner and comment the finding, Most likely causes to
patient
èSame examination technique as in Tally book and geeky video. Introduced, took consent, explained
what I am going to do, pain relief, washed hands, and asked patient to undress himself from nipple
to thigh and would provide chaperone if needed.
There was a dummy and RP was sitting on the chair.
As all vitals, GA was given outside, I did running commentary that as all were stable, I would proceed
directly to focused abd PE.
The RP removed cloth from dummy and exposed it. Inspection— inspected from 2 sides of the bed
at abd level,, nothing was positive
I asked pt to cough and there was no pain anywhere.
Superficial palpation---- all normal, no tenderness Deep palpation—no tenderness
I palpated some kind of mass like thing in rt lower quadrant and told it could be some bowel mass or
liver enlargement. I tried to do liver span but no tape so just left it.
No splenomegaly, no ballotable kidney.
I quickly did percussion for any fluid but negative.
Bowel sounds were increased. ( can hear bowel sounds in dummy)
I told as no rovsing and no mc burneys point tenderness, I wont do psoas /obturator test.
I forgot to do Murphys.
When I said, I would do hernial orifices, examiner said do it and I did cough impulse and tried to do 3
finger( zeimann test) in dummy but was difficult to perform in dummy.
For DRE, examiner gave me empty rectum.
Then bell rang and I asked inv like--- FBE, LFT, Serum amylase/lipase, USG abd and pelvis, XRAY abd
erect and supine. At that very time, examiner handed me abd xray and asked me to interpret to him.
It was typical bowel obstruction supine xray with dilated small bowels. Examiner asked how can you
say its small bowel. I said as dilated bowels are centrally located with prominent valvulae
conniventes and no haustra seen, its most likely small bowel and there is some kind of obstruction
distally to it.
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Dx/ddx to patient: I again asked for pain and offered pain relief .I took a pen and paper, drew bowel
diagram and explained to patient about bowel obstruction and causes for it like constipation,
stricture, mass, adhesions, surgery, worms. I told him I could feel some kind of mass in your tummy
which could be bowel enlargement, liver enlargement or some nasty condition like bowel cancer as
well. I need to confirm the cause by doing further inv and consulting senior doctors.
Global score and each – all 4
Another Feedback - INTESTINAL OBSTRUCTION PE-FAIL
Pt came with c/o constipation and abdominal pain
Task:Do PE, interpret X-ray to examiner, give dds to pt
Approach:
Usual WIPER approach.There was a mannequin so i had to perform PE on it.i did the usual inspection
to check for any mass,bloating,trauma.Palpation first checked each quadrant for superficial
pain,then deep pain.Then checked for hepatomegaly.I actually could palpate the liver so i mentioned
that but i forgot to check the liver span.Then k checked the spleen.Then i checked for mcburneys
and murphy sign.Moved on to percussion.And finally auscultated for bowel sounds and i could
clearly hear increased bowel sounds so i mentioned that.Finally i asked DRE from examiner with
consent of patient and examiner said rectum was empty.Then he handed the xray and there was
clear large bowel obstruction.Then i told the patient its an intestinal obstruction.Since patient had
some hx of weight loss i mentioned it could be a carcinoma.Then i mentioned other dds like volvulus
divertivulosis mesentric ischemia polyps and few others.
I have no clue why i failed. I thought ill pass this case.I did forget to ask about vitals since and since
there was a mannequin i didnt even touch the patient even to check for pallor so maybe thats why
13. Dental Complaint – PASS - Typical bulimia nervosa patient case referred by dentist.
Tasks history, Dx and ddx, Management.
I think this case is a bit straight forward. The thing here is time management because you need to be
good in approach so you have to talk and reassure a lot
U also need to ask history ( as u know, psych cases need to be asked a lot of history)
In telling dx, you have to make sure not implying the patient that she is crazy or having mental
problem
And mention ddx which are less likely
Mx is also included
History- induced vomiting after binge eating
Concerned about body weight for one year
Not chose any circle when I drew him three circles
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Laxative usage present
Spend about three hours in gym
Bmi is around 23 or 24 which is normal
No one comments or teases her about her weight
No concern with other body parts
One year back,her bf moved oversea and she is now in LDRS which makes her miss him so much
She feels lonely
No effect on work performances
Good relationship with work mates and friends , also hang out
Not having much contact with family members and she is living alone
No signs of depression
Insight judgement good
No perceptive symptoms
No past history of mental problem
Alcohol drinking present only occasionally
Smoking also present
No use of recreational drugs
Dx bulimia nervosa ( related with the stress that her bf moved. When ppl feel lonely or stressed,
they became unsatisfied of their life, their body weight, their body image.)
Ddx anorexia nervosa, BDD, depression, Schizophrenia
Mx- I just told her to see with counsellor who will gave him CBT and tips about how to deal with this
problem. will give medication if necessary but in most of the cases, CBT helps a lot. About boyfriend
thing, you can visit him.
Approach 5, History 4, Dx DDx 4, Mx 2, Overall 4
Another Feedback - PASS
Patient went for dental check-up and dentist referred her to you.
Task: History, Tell what investigation to do and mx.
Ensured confidentiality. Same approach as in karens. Pretty straightforward case. Dont forget to ask
mood sleep appetite and suicidal thoughts. Also don’t forget delusions or hallucinations. I also asked
about periods. Investigations first I asked to send for urine dipstick, BSL, ECG. Then followed by FBE
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LFT RFT with electrolytes TFT. Management I just spoke about CBT and referral to dietician, physio
and psychologist. Also mentioned support groups.
This was a straightforward case again just don’t get confused with anorexia and also rule out all the
organic causes.
14. Contraception – PASS
18 year old girl coming for OC pill which she brings the empty card from her friend. She will start
sexual life very soon.
Tasks – History, PEFE, Counsel about the type of pill she wants to know.
History- I excluded medical diseases
She has asthma which is well controlled with Ventolin
LMP two weeks ago, regular and normal
Never had sexual activity before
Her bf is her classmate
No smoking, alcohol
Not on any medication
She already had Gardasil vaccine I appreciated
On PEFE- I examined breast, abdomen, calf tenderness
BMI normal
Counselling – I told OC pills action, missed pill management, how to take it, some immediate side
effects like nausea, vomiting, irregular bleeding in first few months which will resolve
Other things like hypertension, weight gain, acne
Will review her in few days to find out if she is ok with taking oc pills
To prevent STIs, use condom
Appreciate her for using Ventolin regularly and glad that her asthma is well controlled
Forgot to tell her about to use condom in first 7days
But provide her with reading materials
If she wants to know other types of contraception, I can arrange another counselling sessions
Red flags- if vomiting or loose motion within two hours after taking pill, repeat it
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Approach 5, History 6, PE 5, Couselling 6, Overall 5
Another Feedback - Contraception (PASS)
It’s also famous OCP counselling case. Here please use the empty packet of OCP to explain to
patient, please don’t just draw on paper and explain. Use the material provided to explain.
Appreciated her that she came for advice before using it.
Took history of all 5P and for contra indications of OCP and nothing was positive.
PEFE all normal (I asked for UPT even though she gave me history of not starting sex life)
In counselling, I used the empty pack and drew on paper as well.
Explained about MOA, how to use it, what to do when missed and during vomiting and diarrhea, side
effects, advantages and disadvantages, need to check LFT after starting in few months. This case is
quite long. I was not able to say all things, was telling everything in bits and pieces.
Global Score: 4, Approach 5, History 4, PEFE 4, Couselling 5
Another Feedback - OCP ADVICE-PASS
First ensured confidentiality. Then the next thing i did was i asked her which method she prefers and
she showed me a strip of combine OCP. then i asked period hx, sexual hx (she was a virgin) personal
history and habits and then ruled out all the contraindications for OCP. PEFE first thing i asked was
BMI then routine PEFE. Since shes a virgin be mindful to stop at inspection of pelvis and don’t forget
to check for DVT. Office test though she claims to be a virgin i still sent for UPT.I told her about the
dose, method, missed pills, side effects of the OCP and kept asking if she understood. And i told her
I’ll give her the pills once i do a STI screen and send for some inv.
This case just be aware of the time since its quite long and also while taking hx instead of mixing the
contraindications i mentioned it separately saying now I’m going to ask you couple of questions to
make sure you don’t have any contraindications for OCP. This was examiner wont miss out on any
key points
15. Pertussis (PILOT) - Father brings 6 month old baby due to prolonged cough for since 1 week.
Tasks: History, Dx/DDx, Mx.
16. Tiredness (PILOT) - A middle aged man with feeling of fatigue for few months.
Tasks: History, Explain possible causes to the patient.
This was the station without examiner. In my personal view, I felt the examiner was himself acting as
a role player in that station.
12th July 2019
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1. MSE from video give findings. Delirium after head trauma and alcohol abuse
Another Feedback: MSE video: 22 years old man, few years ago had MVA, and 4 days spent in coma,
now problems with assault and also. Aggressive, partially cooperative, impaired insight. Most of the
video MMSE were asked. No dx
Scenario: Change in behaviour: Task present MSE findings to the examiner
Commentary to Examiner 5, Accuracy of Examination 4
A young man (late twenties early thirties) came to see because his mother wants him to. He had
been observed to have disturbed behaviour after head injury. He had continued drinking after the
injury.
I started writing down the heading of MSE before the video played so I don’t forget anything. I
started stating it to the examiner also heading wise he appeared to be well rested neatly dressed not
according to weather though (as he was wearing a tee and it was very cold that that :/ I explained
this reason as well). I said his behaviour was cooperative responding to questions maintain eye
contact with occasional anger outburst. (He punched the table during the interview by getting
agitated over something I don’t remember). His mood although not clearly asked or stated appeared
to irritated and fluctuant during interview ( I said that because although he was responding well to
questions, he was irritated and angry at time with a bit of careless attitude as there was no insight).
Thought form is linear as he is responding well to asked question. Thought content no delusions
obsessions or suicidal ideation noted however patient was not directly asked about his suicidal
thoughts. There was no thought possession and no hallucinations. In cognition he was oriented in
time place and person he had poor concentration and attention span and short-term memory was
impaired. Although the interviewer did conduct full MMSE it isn’t my task for today. Patient lack
insight and although no direct question about judgment was asked I believe it might be impaired too
(due to his irrational mood variations)
In the end I had still time left so I asked the examiner anything else he would like me to explain n he
said u tell me. So, I just said although MMSE was conducted it isn’t my task. Also I started telling my
possible diagnosis of acute psychosis due to head injury or alcohol or combined cause leading to
brain oedema. Again, diagnosis isn’t really my task either.
2. Diabetic neuropathy PE, dx, D/D
PE sensory on LL, no findings. Hx of DM, poor control + burning sensation in legs
Another Feedback – Painful Feet
Approach: 4, Choice & Technique of examination, organisation and sequence: 1, Accuracy of exam: 1
Dx/DD: 4 (Failed)
Patient in stem was an old lady admitted in ward with raised BSL levels I guess HbA1c was also give
and was raised and now complaining of pain in feet. Task was neurological examination.
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so I entered greeted the patient introduced myself and explained why I am here and explain the
examination I have to perform today and that I will try my best not to cause any pain. sanitized my
hands. Offered pain killers. Lady was old and cooperative. I started as a diabetic examination which
pissed off the examiner (who was a bit rude btw) I inspected feet in between toes as well, checked
temp, capillary refill and pulse (dorsalis pedis) the examiner stopped me and asked me to read my
task again. Which was only neurological exam. So, I examined touch with cotton whisk by first letting
her know how it felt on sternum also asked to close her eyes during exam. Checked in distribution of
peripheral nerves. Both sides. Checked pin prick by tooth pick apologized if it gets uncomfortable.
Same way by giving test stimulus on sternum and asking to close eyes. Then vibration and
proprioception same way, (didn’t check or mention two-point discrimination or monofilament
touch) checked ankle jerk as percussion hammer was there :/. More than allotted time was
consumed to I told Dx quickly to pt that there were no positive findings but the most likely cause of
this pain is raised blood sugar for which she is been admitted. Other causes like alcohol and B12
deficiency depend upon history but less likely. Bell rang I ran out. Examiner was very unhappy n
angry I felt.
3. Mania. University student girl with outbursts in class increasingly argumentative and cause
disturbance. Psychosocial history, explain to the patient Dx and Dds.
Another Feedback - Mental Health Assessment Approach: 5, History: 5, Diagnosis / DD: 4
Patient was a young girl university student of psychology. You are the university counsellor and the
patient was reported to you by his psychology professor due to causing increased disturbance in the
class (for like 2 months). Professor talking to the student has not made situation any better.
I entered the room greeted the patient and introduced myself. The patient started going on talking
non stop at a rapid speed and not making much sense. She clearly looked like a case of mania. I
couldn’t get her to stop talking so I sat there spell bound looking at her. She stopped after a while
and explained her my purpose of seeing her today is because her professor has reported some
increased disturbance in the class and how does she view the situation. (she told she think she has a
higher intellect than the rest. All the class in stupid. And she should be placed in an advance class
again talking rapidly and excessively) I asked I see that must be very frustrating (and she went on
blabbering again) I asked her how long she is feeling like this (2 months) I asked rest of questions of
mania. How is her general mood like (hi) for how long (two months) if this feeling comes and goes or
stays all the time (stays all the time) are there any days she feels down (no) has his excited state
even happened before in her life (No) has she difficulty falling a sleep (yes) appetite (not changed)
difficulty in concentration (don give appropriate Ans) shopping sprees lately (yes going branded
shopping for mom a lot) in a relationship? (no broke up I don’t remember how long ago she said I
couldn’t understand n didn’t want to waste time on asking again as she would go on rambling and
waste my time with each question asked) increased sex drive (yes have been partying a lot lately
with various diff sex partners) drugs alcohol or smoking (Alcohol while patying) I asked now
questions for schizophrenia if she see or hear strange things (no). If she thinks people are conspiring
against her (No). I asked if she had any anxiety issues before (No). If she has ever been diagnosed
with any psychological of behaviour problems (NO) family history of such problems (No) so I ruled
out schizo, anxiety, Bipolar, Depression, OCD personality traits. Didn’t know wat else to rule out.
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Now I was trying to find a cause. breakup as per my understanding was quick some time back n
probably not related. I asked about how was growing up like. If she suffered an emotional loss. If she
had troubles at school and if she lived with her biological parents or else trying to find history of
abuse as a child. (no sig finding to any of these questions.
I gave my DD same as above most like mania, can be anxiety however rest I mentioned that are less
likely. I explained her that I m a university counsellor but if would really help us a lot to understand
her situation better if she agrees to meet a psychiatrist, I refer her too. She wasn’t convinced by me
that she has any problem and kept shrugging her shoulders like whatever. I tried my best though.
4. Peak expiratory flow meter for young man. demonstrate, measure, plot patient’s findings on
chart, explain findings to patient, and Dx
Scenario: Cough (Fail)
Approach: 4, Explanation of procedure: 3, Performance of procedure: 3, Interpretation of
investigation: 1, DX/DD: 4
A young non smoker healthy male came with wheeze and difficulty breathing (I think they
mentioned in stem that it was seasonal) and task was to determine Peek expiratory flow rate. After
demonstration. Plot readings on graph. Explain the graph to patient and what it means. Tell
diagnosis.
I entered greeted patient introduced myself ad asked how may I help. (he said he has been referred
for this test) I told I am aware that he has seasonal resp difficulty recently and is healthy otherwise.
If there is anything I should know or he wants to discuss before we start the procedure (No) I
explained from the flow meter that this will measure your lung capacity and help us determine the
base line from where we determine a medication plan n hope to improve also that it’s a simple test
and he could do that at home as well regularly to keep a check on his lung function. Now I told that
he would have to sit relax back straight feet touching the ground. Put this devise in the mouth after
taking a deep breath in as far in as he can. Close lips around the devise to make a seal make sure no
air leaks but in the devise. Take a max breath out as hard and fast as he can. Asked him if he
understood. He repeated the procedure by telling what he understood. I demonstrated the
procedure. Asked if he is ready and asked him to perform. Took 3 readings from him. Now his
readings were so low that I got so confused and said to examiner I don’t know how to plot on the
graph and I am afraid I might be doing something wrong :s than I just sat there looking at them and
told well I am goanna fail this. Then I was like lets at least do the last task so I said that although I am
unable to perform this test today for which I deeply apologize. I might need the help of my senior to
have a better grasp at the procedure and will perform again with their help. However, from history
his most likely diagnosis is asthma. Explained what that is. Told him that other possibilities like COPD
lung infection and lung fibrosis and atelectasis are very less likely as he is a healthy young man with
no history of smoking. I explained along with performing this test again we might have to perform
another similar test called spirometry before confirming the diagnosis and starting management.
I did not repeat the procedure after inhaler though.
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5. Herpes simplex. 6 years old girl come with sore throat, Picture of child’s mouth with vesicles on
lips given outside. Take history, PEFE (throat with white patches on palate and tongue – Candida?)
Dx, Mx.
Scenario: Sore Mouth - Approach: 5, History: 5, Choice and technique of examination organisation
sequence: 5, Dx/DD: 5, Mx: 3
Patient was a child presented with vesicular rash around mouth 2 days I think. Picture was given.
Task as above.
I asked how long he had rash. On any other part of body. Increased or spread since first noted.
Itching bleeding or oozing (Nil). Fever (I think low grade). Lethargy (Nil). Irritability. Sore throat
recent or current (Nil). Cough. Joint swelling (Nil). Appetite (Normal). First time he had this or ever
happened before. Asked about any pee or poo problems in terms of frequency and colour change
particularly as well as smell (nil). Goes to child care (no) goes to school. Contact with anybody with
similar symptoms (grand ma or aunt I guess with similar rash visited) I asked if she was kissing child
on the mouth (yes) Birth immunization growth Hx. Allergies. Past medical or surgical Hx. Family Hx of
eczema etc.
Physical Examination from Examiner: Asked to check vitals of baby. Dehydration. Eye examination
for any redness and periorbital swelling. Running nose increase sweating? (all nil) oral cavity
examination (gave pic showed white coated tongue no oral ulcers) cervical Lymph nodes. Asked for
chest auscultation (examiner said rest of examination below neck is normal)
I said most likely its herpes simplex as patient had contact with adult. In adults it’s a recurrent
disease which can spread. Other possibilities like chicken pox, Scabies, hand foot mouth disease,
measles etc is very less likely.
I advised plenty of fluids. Antiviral might be prescribed (depending on condition :/ I completely
forgot the management of HS so was just beating around the bush) consultation with a
paediatrician. And avoid contact on secretions as contagious. Didn’t advise anything about school or
paracetamol or ice wrapped in cloth application or avoidance of triggers. Told if condition gets worse
like irritable lethargic absolute refusal to feed or high grade fever come back. Asked if understood
and have any more questions for me.
6. Diagnosed patient of asthma on salbutamol and one more drug now increased frequency of
reliever and night attacks. Hx, explain cause, management (patient was smoking)
Another Feedback: Asthma exacerbating- long stem with nights attacks, already given that longstanding asthma, no changes in work or home environment, technic of administrator medication
already checked and good. PFM in normal range after broncholytic.
Scenario: Cough Approach: 4, History: 4, Dx/DD: 4, Counselling/education: 4
Patient was a young female diagnosed with asthma for like 10 years or so came with frequent
exacerbations now. Also attacks at night time. (and some more detail about the frequent attacks
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that I don’t remember). She was on salbutamol and some steroid inhalers already. Task were as
above
So, since she was a diagnosed case of Asthma for a long time, I focused my hx on finding out the
cause only. I started with asking about the medication if she is taking regularly as prescribed. How
long have the exacerbations been started (2months I guess don remember though) I asked if it is
seasonal (no) if she has recently moved from another city or area (no) pets (no) carpets and dust
control (she is aware and had done that already) any emotional stress (no) lives alone or relationship
(alone) job (police) stressful (yes a bit but just as always. no recent increase or unusual stress at
work) smoking (yes) alcohol drugs allergies (nil) past medical or surgical hx not sig other than
asthma. Family hx of asthma present.
I said its most likely frequent exacerbations of asthma itself most likely due to smoking itself. I said
other Dx like COPD lung fibrosis and infections are very less likely. I would like to have her evaluated
by pulmonologist but we might add some preventer (I explained preventers and relievers) most like
some steroids may be oral. I didn’t take any names as I totally went blank. I explained how asthma is
increased sensitivity of airways from irritants in environment and smoke and tobacco are the biggest
of those so asthma patients are particularly advised not to smoke at all. It would be the best decision
for her health if she quits. Offered help and support for smoking quitting and informed about
patches and quit help line too. Told quitting alone might control the exacerbations and medical
treatment might not be necessary. Also, if any stress is causing this smoking habit (she was smoking
for 2 months only) we can also devise alternate stress management strategies. How does she feel
about that? She was willing to quit. I asked if she understood and have any further questions. I had a
bit of time so started on asthma action plan and emergency numbers but bell rang as soon as I just
mentioned it and couldn’t explained this further.
7. UTI 17 years old girl. Take history, PEFE, Dx and advise. (she was a return traveller from europe,
increase frequency and burning micturition, in a regular relationship and on OCP. Urine dip stick
showed blood ketone and leukocytes)
Another Feedback - Urinary Difficulty
Approach: 4, History: 4, Choice & Technique of examination, organisation and sequence: 4,
Diagnosis/ DD: 3
The girl came with urinary difficulty was I guess 17 years old as far as I remember.
I greeted her introduced myself and ask her to tell me in detail the reason for todays consultation. As
I was already suspecting the possibility of Honey moon cystitis and she was under 18 I assured and
confidentiality and that she has all the legal right to obtain medical help with preservation of her
privacy.
I asked how long she has been experiencing. Asked about difficulty pain (yes) blood (no) in urine.
How long. Fever (NO). Abdominal pain (no) rashes on body esp. down parts. History of prior URTI.
(no) if this is first attack or has happened before (first time) ever diagnosed with DM. Any other
significant medical or surgical history (No). any discharge from down below. Smelly or itching on lady
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parts (No) if sexually active (yes) stable relationship (yes for 6 M) and urinary or genital symptoms in
partner (No) contraception (OCP) LMP (2weeks back) Any recent travel (yes to Europe ) stayed in
main cities of remote areas (I think she didn’t say remote areas) any unprotected sex there (NO)
Smoking alcohol allergies medication (NONE)
I asked about vitals, pallor jaundice, dehydration, oral cavity inspection, abdominal examination
rashes, bruises, scratch marks, area of tenderness organomegaly bladder distension. Genital
examination inspection normal, per vaginal and speculum can’t be done (don know why) asked for
PR as well I guess was normal. Urine dipstick was positive for blood and leucocytes.
I said most likely UTI. Can be PID or sexually transmitted illness but less likely. However, explained to
her that as she is on OCP which does not protect from STD it is always a possibility. A stone or
variable anatomy of kidney can also predispose to infections. However, it is fairly common in
sexually active girls her age without any other underlying cause. One of the causes can be back
washing/ Cleaning and poor toiletry conditions esp. during her foreign trip. And that genitalia should
be properly cleaned with separate wipe for front and back passage. Changing undergarment
regularly etc. That’s all I remember so far. There might be some more generic questions I might
have asked which I can’t recollect now.
8. Acute abdomen. PE and tell dx and D/D (lower abdomen all tender no mass nothing else positive,
she had 38.7 temp. no urine test available. LMP 3 weeks back)
Another Feedback: PV: adnexal tenderness without mass, on DRE: tenderness, no blood.
Another Feedback: Abdominal exam of young lady - no bowel sounds, tenderness in lower abdomen.
Pelvic - tenderness in adnexa. Give ddx
Another Feedback: Abdominal Pain Global score and Each - 5
Patient 35 yrs female had pain abdomen 2 days and exacerbated for one day presented in ED. (this
much scenario I remember only)
So, I greeted introduced and cleaned my hands asked for consent. Exposure. started with asking
vitals. Pallor jaundice dehydration and oral cavity inspection. Then started inspection of abdomen at
bed side level of patient and foot side. Asked about pain or area of tenderness (lower abdomen) I
said I will try to be as gentle as possible. Superficial palpation. (tender both iliac fossa) Deep
palpation. checked rebound tenderness at RIF. Explained and apologized in advance (was positive)
no guarding or rigidity. No organomegaly. Auscultation normal and percussion I did not do as i did
not see any indication (bladder was not enlarged and no distension of abdomen was there also
patient was in pain). On asking patient if she can lean on one side so I can examine the back (for
kidneys) patient said it was too painful to turn so I told her lets just skip that we don’t have to. asked
about exposing inguinal area checked for hernia lymph nodes and femoral artery pulsations. Asked
for genital examination and PR. The findings examiner gave was rt and lf adnexal tenderness on
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Vaginal examination and PR as well. Ankle oedema was negative. Asked for urine dipstick (don
remember what examiner said) I asked LMP from the patient (was like 3 weeks back)
I said most likely DX can be PID, however other possibilities like appendicitis diverticulitis ovarian
abscess and ruptured ovarian cyst can not be ruled out. Also said pregnancy test is needed although
its jus 3 week LMP still possibility of ectopic or ruptured ectopic cannot be ruled out.
9. Tiredness in middle age lady, FBE done - hypochromic microcytic anemia - italian + heavy periods.
On PEFE - pale on GA and bulky uterus. Task: interpret results, ask Hx, tell Dx and D/D
Another Feedback - Menstrual Difficulty Approach: 5, Hx: 4, Examination: 3, Dx/DD: 4
Stem given outside was a middle age lady came with tiredness and complete blood pic was given
which showed Microcytic hypochromic anaemia.
I greeted the patient introduced myself and asked about the reason of consultation. asked about
how long she is experiencing tiredness (2-3months I guess). Asked about wt loss, breathlessness,
Palpitations, night sweats, sleep problems, bleeding from gums urine stool (change in colour),
bruises on body, bleeding disorders, menstrual hx (menorrhagia) LMP, IMB, Dysmenorrhria, PID,
STD, Pelvic surgeries, family Hx of malignancies, ethnicity, SADMA
Exam findings from examiner: vitals, pallor jaundice, oral cavity examination, cervical lymph nodes,
bruises or rashes on skin, abdominal exam Inspection palpation for tender areas or masses esp. in
pelvis, inguinal and genital examination. Speculum and PV examination, (for some reason examiner
told me can’t be done :/) PR. Patient was pale and examiner didn’t give me any other positive
findings.
I said most likely diagnosis is iron def anaemia due to menorrhagia n I would follow u up with iron
studies and referral to Gynaecologist as it is imp to find what is causing this menorrhagia, will
provide with supplements, other causes can be thalassemia or sideroblastic anaemia and that she
doesn’t need to worry about names, though less likely v might run thalassemia test as well. Can also
be deficiency of iron in diet or loss from gut due to malabsorptions or some gut disease or loss from
urine. All these causes are less likely as her symptoms are mainly related to gynaecological system
for which we would do a thorough work up to find out the cause (I was mainly focused on causes of
iron deficiency anaemia as a case, it causes and all, rather than as a menorrhagia case primarily so I
didn’t go into details as to what is causing this menorrhagia and just said cause of menorrhagia Is
imp to find out so I will book a consultation with gynae)
10. Influenza vaccine counselling - Take history, advise. (Allergic to egg, has asthma)
Immunization (Fail) Approach: 4, History: 3, Counselling: 3
So, in scenario there wasn’t much given. Just that patient about 5 6 years (don remember exactly
but old enough to have completed his primary immunization) came with his father for flu shot.
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Task to take quick relevant history (I guess for 3 min) and counsel the patient about the flu shot.
So, I greeted the father asked the child’s name and confirmed his age. Asked him his reason of
consultation today and any particular concerns. He said just for the flu shot and didn’t stated any
concern. Father wasn’t very cooperative at all would only tell what u ask specifically. I asked about
birth immunization any reaction to previous primary immunization(no) mile stones. Any history of
encephalitis or fits. Any recent fever or sore throat. Any medical or surgical history (he said no) I
asked about egg allergies specifically myself (said yes) asked about anaphylaxis (no) asthma (yes
recently diagnosed) eczema(yes) . any medication child is on apart from asthma (no) family history
of allergies. I didn’t know what else to ask.
So I started explaining that flu shots are free of cost for vulnerable groups. Little Henry might be
vulnerable not only due to age but also due to recently diagnosed asthma your physician might want
to prevent the exacerbating factors as much as possible. I talked about egg allergies although father
wasn’t concerned, that previous vaccines had an element of egg product which is not the case with
the new vaccines so there are not significant chances off allergic reaction to vaccine however we
would like Henry to stay in the facility with resuscitative facility for 20 min after shot just to be safe. I
talked about it covers endemics but not pandemics (explained wat that is) and also that influenza is
a viral disease and the virus change every year to shot is given yearly. Also told there is still a minor
chance of getting influenza in small percentage of children. And that it does not prevent against
common cold (so runny nose and sore throat can still happen)
I asked if he understood and have any further questions. He said no just if u think I should know
anything else. I got that I might be missing something but I didn’t know what else to tell. Didn’t talk
about side effects of vaccine or any hx of Guillain barre syndrome
11. Headache (pre-eclampsia) Lady with 3rd trimester. Take history, PEFE, Dx and D/D (she had
headache blurring vision and pedal edema all rest normal. urine had proteins)
Scenario: Third trimester complication (Fail)
Approach: 6, Hx : 4, Choice and technique of exam organisation sequence: 2, Dx/DD: 4
Patient was a young female in 3rd trimester came with headache I think :S
I entered cleaned my hands. Greeted and introduced myself. Asked how can I help. How long
headache, where exactly, nature of pain, radiation, constant or come n go, anything bring it on, any
other symptoms like blurring of vision, double vision, watering of eyes or nose, painful chewing,
ankle edema, discharge from down below, high blood pressure during or before pregnancy,
antenatal check-ups, Scan, any problems during pregnancy like infections, if taking prenatal vit, DM,
stress. Sleep disturbance,support at home If this is first pregnancies, any miscarriages, method of
contraception used before conceiving (don’t remember anything else) past medical history and
allergies.
Asked about vitals (hi BP), anaemia, jaundice, facial oedema, dehydration, oral cavity, (I didn’t ask
about examination of scalp of face otherwise) ankle oedema. abdominal examination, inspection any
bruises or rashes stria palpation any area of tenderness masses, fundal ht, lie presentation of foetus,
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tenderness of uterus, inguinal and genital examination, speculum and PV. Urine complete (showed
proteins)
Dx was preeclampsia explained wat it is. Told we need to act promptly before it gets worse into
eclampsia. Told other causes like stress, temporal arteritis, hypoglycaemia, lack of sleep (all less
likely) this is all remember.
12. ECT counselling – without examiner (PILOT)
13. Breast pain - PE of breast with short hx and Dx, d/d (Patient had cyclical mastalgia, no lump)
Approach: 4, Choice Technique organisation & sequence of Exam: 4, Accuracy of exam: 5, Dx/DD: 5
Patient was a 35year old lady came with breast pain. I remember a short history was allowed from
which I gathered that her pain was cyclical I did ask about any lumps and nipple discharge Use of
OCPs, pregnancies and live births if any family hx of CA breast and ovaries or colon. Smoking and
alcohol. I greeted the patient, introduced myself, seek consent, explained appropriate exposure and
technique of exam and need for chaperon. I asked area of pain and that I will start from normal
breast first. Cleaned my hands. Proceeded on the dummy. inspection from front, hands on hips and
press, lean forward, hands behind the head. Inspection of axillae as well. palpation. Informed again
that I will feel around the normal breast first. Palpated all quadrants axillary tail and squeezed the
nipple to see for discharge. Did the same with troubling breast. No positive findings. Examined both
axillae. Supraclavicular nodes. Percussed the spine. Likely DX was cyclical mastalgia, others were
fibrocystic disease, costochondritis, muscle spasms, referred pain, lung pathology and suspicious
growth all of which I said very less likely.
14. DVT after air travel. Task explain findings of duplex USG, dx, and management
Scenario : Leg Pain Approach: 5, History: 4, Dx/ DD: 4, Management: 4, Counselling: 4
Patient came with ultrasound report showing deep vein thrombosis in lower leg. Task was to take
quick relevant hx. Explain result of ultrasound and dx to patient. Mx and counselling.
I started asking what was the reason for her undertaking this test/ initial symptom. (I think she said
leg pain) I asked duration. Extent of and intensity of pain. Swelling. Redness. Fever. Walking
difficulty. Respiratory difficulty. If this is the first episode. I asked her LMP. Her relationship status.
Any chance that she could be pregnant. Method of contraception. Particularly hx of OCP. Hx of air
travel (she jus came back from a long-haul flight after which she developed this leg pain). Family
history of blood clotting in veins (mother had DVT twice. once during pregnancy and once without).
Ever diagnosed with bleeding or clotting defects(no). any medical or surgical Hx particularly
gynaecology or hip surgery (no). smoking alcohol medications and drugs (nil).
That’s all I remember asking in Hx.
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I explained the ultrasound and clotting of blood in deep leg veins. made a diagram. Explain it can
cause life threatening conditions like Pulmonary embolism (explained what is that) so treatment
should be started right away. Explained reason can be the recent air travel which is a common cause.
Also familial as mother had two attacks. Some blood tests need to be done to rule out clotting
tendencies. Explained pregnancy test also needed to be done as its both a risk factor of DVT as well
as a contraindication to warfarin one of the treatment. Told her we need to do some specific blood
test PT APTT INR at the start of medical therapy. Explained about heparin and then transfer to
warfarin with daily INR check to keep btw 2-3. Told about duration of treatment. Avoiding pregnancy
when on warfarin as it is teratogenic. Regular follow up during the course of treatment with
frequent INR. Told about warning signs to report immediately id bleed from nose gums in urine and
stool (dark colour or fresh) and bruises on body. Ask if she understood and had any further questions
for me. Told about hand outs and reading material.
15. (PILOT) Post-menopausal lady with aches and pains - Very nice old lady with pains and aches all
around spine and shoulders. On PEFE: No tenderness spots, but ROM in all joints. Polymyalgia
rheumatica??
16. 4 month child non-bilious vomiting GERD. (after feeds. Growth is good.no decrease in wet
diapers no fever. No distension.) Task history, PEFE card – all good, dx, D/D, management
Another Feedback - Approach: 4, Hx: 4, Dx/DD: 4, Mx Plan: 4
4 months old baby came with vomiting. Don’t remember much about this scenario at all but would
write what I remember.
I entered greeted and introduced myself to the mum. Asked about the reason of consultation today
and anything particular that any other particular concerns. so the complaint was vomiting only. I
asked how long, how much, contents, colour, projectile or not, how much time after feed. If on
formula or breast milk. Any drooling of saliva, any tummy distension, constipation, colour of stool,
no of stool, consistency of stool, colour of pee and no of wet diapers, other associated complaints
like fever, stiffness, lethargy, drowsiness, any recent sore throat, rashes, cough, excessive crying
during pee or otherwise. Hight and wt percentile. Any contact with sick child or adult. Birth Hx,
Pregnancy with the baby, immunization, mile stones, help at home, how’s mother coping.
Didn’t find anything positive. Us that baby through up some milk after feeds otherwise healthy and
happy. I remember that baby was breast fed.
I gave Dx of reflux/ posseting explained what it means. Other possibilities can be intestinal
obstruction or infections like urine lung or brain infections and gastroenteritis all of which very
unlikely. All less likely.
Advised burping the baby after feeds. Asked if she would like any social support if she has difficulty
coping (as partner did night shifts and wasn’t much available) told about warning symptoms if
appear report back immediately.
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24th July 2019
1 – Emptiness Syndrome (Pilot)
2 - Abdominal Pain ( Fail )
Middle aged woman complained of abdominal pain for 6 months.
She has done lots of investigations – everything showed normal.
The specialist already dx her with IBS but her symptoms are still present and now she come and
consult to you concerning with that.
Tasks - Psychosocial history. Give one more dx. Counsel the patient
This was my first station and I felt really anxious and my history was disorganized.
Please make sure ASEPTIC+ Headdss and Risks in psychosocial history.
She had lots of stress in history which i cant recall exactly and some said smoking history positive for
that we have to add in mx.
I told dx as stress related ones only after that somatoform disorder.
I failed this case plz follow the passed feedback.
Predominant assessment area –Mx/Counselling/Education
Approach 6 , History 3, Dx/DDx 2, Pt education 2
3 - Antenatal Care - PASS
GP, Middle aged lady with 36 weeks of pregnancy come for ANC.
She was regular patient of your collage but didn’t see you before.
AN Invx done USG showed normal. OGTT normal.
Tasks – History, Ask PE from examiner, Measure SFH, Dx/DDx to patient.
History – First pregnancy planned one
No late pregnancy complication
Did ANC regularly & results normal
Confirmed by home pregnancy test and early scan done
No history of twin preg, no fertility drugs
No history of DM and family history of DM
No contact with pets and took folic acid regularly
PEFE – I asked from peripheral to central- Normal
Focus on Obs Exam – No contraction, no scar and dilated viens
Cant assess fetal parts easily on palpation
FHS 148/mins , not engaged yet
Then I washed my hands and measure FH and SFH - 40cm.
Asked about fluid thrill and examiner said u cant do it on dummy.
Then I went to pt and explained her condition is large for date most probably due to polyhydramios.
But can also be due to other conditons like placenta previa, twin pregnancy, big baby, wrong date
with reasons why it is not and causes of polyhydramios but can complete all.
Predominant assessment area – Diagnosic Formulation
Approach – 5, History – 4, Choice and technique of exam – 4, Dx/DDx - 4
4 - (Visual Problem) - FAIL
A 65 year old man complain of vision problem. He has history of DM and hypertension.
Tasks – PE, Dx and DDx to pt.
It’s the usual examination of CN 2nd and 3rd,4th ,6th.
He has diplopia in left eye and I asked him to cover one of his eye side by side. The double vision
disappear when he cover either eye.
I failed this case because of unfamiliarity with fundoscope. I really confused and didn’t see where to
open the lightsoure. And when mentioning the red reflex the lightsoure was at my side :D
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Examiner told me hey urs is opposite .. only after that I said sorry and turn the light soure to patient
side :D really awkward..
Gave Dx as binocular diplopia but didn’t explain the patient about that terms why it is like this and
just told him because of diabetes as diabetes retinopathy and ddx as CN palsy, Mysthaenia Gravis,
Multiple sclerosis .
Predominant assessment area – Examination
Approach – 4, Choice and technique of examination, organization and sequence – 4, Familiarity with
equipment – 3, Accuracy of examination – 4, Dx/ Ddx - 2
5 - Mental Health Assessment (Mania) - PASS
University student with some manic features given in stems (typical mania features)
Tasks - Psychosocial History, Dx and DDx, Mx plan to patient.
Typical manic patient with pressure speech mentioning the teahcers are not qualified enough to
teach them.
Positive findings – high mood score as 100, no need to sleep, energetic, superior to others, multiple
sexual partners, spend money alots , no drug or alcohol usage, no feeling down in the dump before,
no hallucinataion and delusion. I forgot wherether I asked orientation and delusion history or not. no
organic symptoms and home is supportive. No depression symptom.
Dx mentioned as mania explained her conditions associated with her symptoms and other DDx
bipolar disorder, schizophrenia, psychosis, Drug induced, GAD and other anxiety disorders,
hyperthyroid, head injury, etc.
Mx – need to be assessed by CAT team including specialist and need to be admitted . Specialists will
start on medication. Pt asked me what medication does she need to take? I said antipsychotic
medication and she asked any side effects of medications. I really forgot weight gain
,hyperlipidaemia and hypergycaemia and so on. Just mentioned general side effects like nausea,
vomiting, headache and blurring of vision but specialist will adjust medications and benefits
outweigh drawbacks.
Predominant assessment area – Mx/ Counselling/Education
Approach – 4, History – 4, Dx/DDx – 4, Mx - 4
6 - Giddiness -PASS
57 years old man complain of giddiness. In question .. the duration was given like 3 hours but I m
not sure for that and mentioned like buzzing sound present. ( Tuning fork and Pen touch given )
Task – PE, Dx/DDx to patient.
The patient was lying on bed and like he was having intense dizziness.
I showed sympathy to patient and if he can’t stand with it, plz don’t hestitate to tell me during the
examination.
I asked him to walk a few steps he said he can’t move because of the dizziness. Then I did Inspection,
Direct and Indirect Light Reflex and movement of the eyeball – no diplopia and opthalmoplegia.
Examiner showed me nystagmus photo on ipad.
Then I did 7th CN Examination – Normal
I asked patient wherehter he can sit or not.. he said ok dr… I can.
Then 8th CN Examinaton – Inspection – No discharge , no redness and swelling
Screening Test – I had to do from front of patient as patient was sitting on the bed. I said examiner I
would like to do it from the back of patient. It showed Normal on both side. I told examiner I would
like to skip Rhinne and weber. Examiner said me it’s up to you then I did it as the instruments were
given :D Both showed Normal.
Then asked 5th, 9th , 10th CN –Normal
Upper and Lower Neurological Exam – Normal
Special Test as Hallpike Test .. Examiner told Normal.
I become confused and don’t know how to give dx.
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I mentioned Dx as BPPV explaining in layman terms with reasons
2nd one as Meniere but no hearing loss .. less likely
Acoustic Neuroma
Acute Vestibular Neuronitis
PICA with reasons
Predominant assessment area – Examination
Approach – 5, Choice and technique of examination, organization and sequence – 4, Accuracy of
examination – 4, Dx/ Ddx - 5
7 - Headache -PASS
6 years old child brought in by dad because of Headache for 6 months
Tasks History, Dx/DDx, Explain the reasons to dad.
History - Headache at the back of the head for 6 months
Headache during the weekdays
No radiation
Better after sleeping
Took Panadol but headache still present
Sensitive to light but no history like zigzag line, better in quiet dark room, dad has migraine
No dental infections, No repeated flu infections, no fever at the moment, no head injury and injury
to neck, no weakness, n and vomiting, no LOW and Appetite
Parents divorced 8 months ago. Contact with mum – go and see with her on weekends. No bullying
history at school, no medical history
I confused whether to give dx as migraine or tension headache but
I mentioned it as Stress related headache called Tension Headache because of the issues of the
parents with mind body axis. And mentioned 2nd one as Migraine which we have to think about and
other DDx as upper respiratory tract infection but unlikely, dental problems , head injury, SOL and
brain tumour but not likely with reasons and mx as CBT and family meeting.
Predominant assessment area – History Taking
Approach – 4, History – 4 Dx/DDx - 3
8 - Urinary Frequency -PASS
5 yr old man who initially presented to your GP with frequency, urgency and pain when passing
urine was referred by you to a urologist because you found on the pr examination an enlarged
prostate. The urologist sends you a letter with the results of a range of investigations he has
initiated: 1. MSU showed growths of e.coli 2. PSA 6 ng/ml ( <4ng/ml normal, 4-6 ng/ml
intermediate, >10 ng/ml high) 3. The core biopsy with 8 samples from the prostate was positive
for adenocarcinoma 4. Gleason grade 7 5. A cystoscopy did not reveal a bladder neck obstruction
6. the whole body radioisotope scan did not show metastases 7. CT pelvis and spine did not show
any tumour outside the prostate capsule (stage T2) The urologist mentions that he explained to
patient that there was cancer but he suggested to see you for further counseling.
Tasks: 1. Explain results and its implications 2. Discuss treatment options.
It’s the usual recall.
Please don’t forget to treat UTI first with urine C and S after antibiotic course.
I explained the result one by one on the paper and its implications and treatment options with
diagrams.
Predominant assessment area – Mx/ Counselling/Education
Approach – 4, Interpretation of Invx: - 4, Patient Counselling and Education - 4
9 – Lower Limb Examination ( Fail )
65 y/o presenting with tingling and numbness sesation and leg pain. Walking uphill. Has history of
DM,HTN, hyperlipidemia. Vital signs were given. Tasks – PE, Dx and DDx.
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I got confused whether to proceed DM or PVD exam at outside.
Tuning fork, Monofilament, Cotton wool,?Hammer were given.
Washed hand and expained the pt about the procedure.
Asked the patient to walk .. Examiner said gait was normal.
Then Inspection – no redness, deformity
Bunion present on both feet, bluish discolouration near medial malleolus present, no ulcer , no
callosity and fungal infection.
Palpaion – Temperature, Pulse and CR – Normal
Tone –normal
Movement of the hip and knee – Normal ( I did it but examiner didn’t stop me L)
I don’t know what to proceed and I asked for
Burger Test and ABI – examiner said normal with upset face.
And I even did straight leg raising test which may not be necessary.
Only after that the most important one – I did DM examination L
Sensation – normal both cotton wool and monofilament at soles
Vibration - loss till ankle level
Propioception – I don’t remember exactly wheter I did it or not.
I don’t have time to do reflex as examiner told me to do next task.
But I run and took the cotton wool to scratch from sole to knee and examiner looked angry and said
that I told u to go next task . I said sorry and mentioned Dx and DDx to patient. Examiner looked alil
bit angry LI better listen to her words .
Mentioned DX as DM peripheral Neuropathy and DDX as PVD.
Timeup L
Predominant assessment area – Examination
Approach – 5, Choice and technique of examination, organization and sequence – 3, Accuracy of
examination – 4, Dx/ Ddx - 4
10 - Confusion - PASS
GP, Old age man living in nursing home. Nurse called to you for investigaions results that was done
because the patient had confusion, irritability and drowsiness.
Task: explain the test result to Nurse History for 3mins and Explain about the causes of the
conditions.
Investigation: *Na: 120 K: normal HCO3: normal *Cl: 72 (reduced) *Anion gap: 17 (normal: 8-16
mEq/L) *Urea: 6 (normal: 7 to 20 mg/dL) *Creatinine: 0.5 (normal: 0.6 to 1.2 mg/dL) eGFR: normal
*Cal osmolarity: ?270 (normal: 275–295 mosm/kg)
Inside the room, there’s no examiner and a phone to call to nurse was given in that u have to press
1 when u r ready to talk with the nurse.
Introduced your name and position to nurse and asked patient name and nurse name.
Then explained about the result one by one to the nurse.
I didn’t explain details in layman terms as it’s the nurse and u can use medical terms like
hyponatremia, hypochloremia. I forgot how to explain osmolarity and asked nurse do u know what is
osmolarity,right? She said yes and I skipped it :D
History – patient became agitated and confused for 2 weeks
- No infections features – no fever,cough and cold
- No UTI infecitons, no chest pain,sob and fast breathing
- No alcohol history, no surgery
- MED taken – Hydrochlorothiazide, Aspirin, Atovastatin,Metoprolol ( Asked dose in details) –took
according to dr prescribition, no change in dose
- Nausea and vomiting present 2weeks back
- NO DM and Thyroid History
- NO weakness and CNS features,No head injury
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- No Hallucination,Delusion,Depression features
Expain the causes as hyponatremia because of Nausea, vomiting and thiazide medication.
Other DDx of delirium with reasons .
Predominant assessment area – Diagnostic Formulation
Approach – 5, Interpretation – 5, History – 5, Dx/DDx - 5
11 - ( Palpitaiton ) -PASS
27 years old lady come to ur ED where you are working as HMO. She complains of anxiety and
palpitation for last 2months.
Tasks- History, Tell her Dx and DDx.
History - palpitation for 2 months off and on
No Chest Pain, SOB, no pallor
LMP 2 weeks ago, no menorrhagia
Weather preference present, Weight loss, Agitated and anxious for 2 months.
Family history of thyroid problem
No Blurring of vision, episodic headache
Anxiety disorders – Unremarkable
Coffee drinking – 2 cups per day since long time ago
No Alcohol, smoking and drugs
Dx – Hyperthyroid
Pheochromocytoma
Se of medications
Coffee, Alcohol
Heart problems
GAD , PTSD, Panic, Phobia
Predominant assessment area – History Taking
Approach – 3, History – 4, Dx/DDx - 4
12 –AN Care - FAIL
Middle age lady at 36 weeks of pregnancy come for routine ANC.
Tasks – PE, Dx and DDx.
I failed this case. Please follow the passed feedback.
13 – Pilot
ED, 3 weeks old baby come with breathlessness, everything seems to be alright at birth weight
97th centile and then reduce gradually, Now about 50th centile.
Tasks – History, PefE, Explain X-Ray to examiner. ?Dx and DDx to mum.
+ve findings - breathlessness off and on
No scalp sweating No cough No Vomiting No abdomen dissension
BINDs - Normal and I asked delivery history she said normal may be I didn’t explore details.
PEFE - no fever, VS Normal
Respiration - reduce left vbs, Dullness on left lower lung field
CNS- reduced tone on one side
CXR provided - increased left diaphragm
(I’m not sure with this case and I really didn’t do well. These are all I can recall)
14 – Neck Pain
Middle age man came with neck pain which he got 2 days back after lifting heavy object.
Tasks – PE findings from examiner. Order investigations, Explain Dx and DDx, Initial Mx.
The patient was sitting on the couch with hospital gown on and one of the arms hold by the other. I
offered pain killer and then ask PEFE.
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PEFE – no redness, swelling , deformity
Tenderness present at ? paraspinal area
I did upper limb neuro exam and sesation – Loss at thumb and index finger.
I forgot to do Cervical loading test and Spurling Test.
The rest of examination – Normal
I explained the patient invx as cervical xray, CT and MRI. If needed, nverve conduction study by
specialist.
Dx as Cervical radiculopathy wih disc prolapse
Cervical spondylosis, Spinal canal stenosis, Injury, RA, OA, Muscle Strain
Mx with PRICE and specialist assessment. ( Bracing may be needed. I forgot it)
Physiotherapist and education for neck pain and also to be aware of the back in heavy weight lifting..
Predominant assessment area – Mx/Counselling/Education
Choice and technique of examination, organization and sequence – 4, Dx/DDx – 4, Choice of Invx – 4,
Mx - 4
15 - Health Review (PASS)
9 years old girl brought in by mom because of body odour.
Tasks – History, PEFE, Dx and Counsel.
History – child had bad body odour for? Normal body development +
- No fever, no medicatons taken
- Personal hygiene good, no much perspiration
- Change clothes regularly, shower twice aday
- No history of DM and family history
- No injury or fungal infection
- No food like ginger,onion,garlic
- Home situation family supportive
Bully history at school present
- No features of depression
PEFE - GA – Fine
BMI –Normal
Tanner stage 4
NO features of infection at armpit
Private are with consent just inspection - Normal (I better ask Feet odour)
Other systemic normal
BST Urine dipstick normal, BSL – normal
Explained Dx as precaucious puberty because of hormonal changes.
Causes – infection, se of medications, personal hygiene, food prefernaces and mentioned preventive
measures and personal hygiene and usage of Alum, deodorant for it. Arranged Family meeting with
school consellor because of bullying. Showed sympathy.
Predominant assessment area – History Taking
Approach – 4, History 4, Choice and technique of examination, organization and sequence - 3
Dx/DDx - 4
16 – Abdominal Pain (PASS)
18 years old girl come to ED with abdominal pain. Tasks – History, PEFE, Ask Invx from examiner,
Dx/DDx.
When I entered into the room, the patient was sitting holding her hand on her tummy. Showed
sympathy and asked to offer PK. Check Stability of patient
Then asked about the pain –showed with her hands holding on RHC region. 7-8/10, no radiation,
persistent, no aggrevating or releving factor.. so I clarified RHC pain like Hepatobiliary-yellow
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coloration of skin,itchiness, poo and pee color, GS history, association with food, perferance of food,
Pancreas like position changes, alcohol history, pervisous similar history, Chest Pain , Cough,
Stomach previos history and any burning sensation – nothing showed positive.
Then asked LMP and she said 7 weeks ago. OMG!! I asked any breast tenderness –yes. Any
possibility of pregnancy – longing for it.
Partner supportvie.
Any dischare ? Brownish discharge present. Not foul smelling.
Then PEFE + findings in VE Inspection – brownish discharge
SSE –os closed, cervical and vg wall health
BME – uterus size normal
Cervical motion tenderness – strong
BST - urine UCG test +ve
Urine dipstick test –ve
Asked Invx; from examiner
Serum Beta HCG – 2700
Imaging (USG) - empty uterus
Mentioned the patient dx as Ectopic pregnancy explaining with diagrams showed sympathy and told
specialist will come now to assess your conditions and u need to be admitted to hospital.
Other DDx as PID.
Time up.
Predominant Assessment Area – Diagnostic Formulation
History – 5, Choice and technique of examination, organization and sequence – 4, Choice of invx- 5
Dx/DDx - 5
25th July 2019
1. Middle age women history of appendectectomy 10 years ago, came with abdominal pain and
nausea and vomiting
Task-do pe on dummy , present x- ray to examiner and tell dx and ddx to patient
Greet, WIPE, General app, Vital recheck, Inspection – mildly distended and flank fullness +,
tenderness on umbilical area, BS + but increased(inspection, Palpation – light and deep, Liver and
spleen, BS, I forgot to do rebound, then I told examiner I ll do other special test for tender ness like
murphy, mcburney point, rovsing signs as I don’t have time to do all, urine dip stick and pr normal,
xray-I told multiple loop of bowel with striae ( Valvuli Connivente) on bowel wall across the bowel
caliber consistent with small bowel obstruction. I only got chance to tell the patient sbo likely due to
adhesion and mal rotation as ddx.
Check glove size better use large or xl
Nausea vomiting GS-4
Choice & Technique of examination, organization and sequence 5
Accuracy of Examination 4
Interpretation of investigation 5
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Diagnosis/ Differential diagnoses 5
2. 32 years old G3P2 37 week came for anc. Task-Do pe on dummy and tell condition
Greet, wipe, general apperance , vital pulses check, Bp examiner said 120/70, start with anaemia and
jaundiac, Inspection, 9 region palpation, fdh- 34 cm, lateral grip-tranverse lie, and lower pole empty,
no contraction, fhs 125 to 130 (I only checked for 15 second and multiply with 4 and didn’t check
mother pulse at same time that ‘s why only 3 in accuracy so please check full 1 mins and check
mother pulse at the same time), speculum normal, UDS normal.
I only got to explain about transverse lie.
Antenatal care GS-4
Choice & Technique of examination, organization and sequence 4
Accuracy of Examination 3
Diagnosis/ Differential diagnoses 4
3. Young man came with ho of viral illness 2 weeks back. Now petechial rash on lower limb.
Task- Pe and tell dx ddx.
Greet wipe, vital, general, hand, iv mark, epitrochlear nodes , scratch mark, eye- pallor jaundiac, gum
hypertrophy, tonsil (hold tongue depressor and torch), strawberry tongue rash, LN neck and axillary,
Abdomen for LS and paraaortic, Inguinal LN, UDS DRE and LL for rash, examiner give you picture that
show on task (describe the picture).
I told ITP-explain Immune mediated mechanism briefly, Meningo, Scarlet fever, Allergy, Bleeding do,
Leukemia, Lymphoma.
I forgot about neck stiffness palm and sole rash genital for sti to rule out others ddx
Rash GS-4
Approach to patient/relative 5
Choice & Technique of examination, organization and sequence 4
Accuracy of Examination 4
Diagnosis/ Differential diagnoses 5
4. Spotting on Panty. 27 years old. Came with above complain. Task- Ho pe and Dx ddx.
Greet vital check and ask about the spotting (said after sex, otherwise no signs of anaemia) PPPP
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CA Bleeding disorder or meds, trauma, PE VE- red circular lesion at cervical os but otherwise normal.
UTP UDS normal.
Ectropian, infection, Trauma, CA, Bleeding med or disorder.
Abnormal Bleeding GS-5
Approach to patient/relative 5
History 4
Choice & Technique of examination, organization and sequence 4
Diagnosis/ Differential diagnoses 5
5. 27 years old came for post-partum 6 weeks check-up.
Task-Ho tell what to do next and further investigation
Greet, Ho – pregnancy – investigations normal except OGTT + so was on insulin. Now stop since
delivery, No other problem like polyhydramios or difficulty labor, I forgot to ask heel prick, term or
preterm, wt 3.9 kg, deliver at hospital vaginally, some tear at vaginal but heal well, no resuscitation,
everything ok with baby, no Neonatal ICU or admission, immunization not yet started, growing well
and breast feed well. No current symptoms of DM. No other post partum problem, mood ok, no
fmh, brief HEADSSS all good
So I told her we need to recheck the OGTT now and 5 yearly after that. For baby check up and
immunization. Post partum contraception. And also order some base line blood test now for mother
as she said a bit tired.
(Better to add SNAP and advice about next pregnancy like pre pregnancy investigation for better
score)
6 weeks post-partum review GS-4
Approach to patient/relative 4
History 4
Choice of investigations 4
6. 46 years old lady came with pleuritic chest pain, Sob and dry cough. Initial assessment, Bp 130/90.
PR 100. Temp 37.8. Spo2 99. Xray was done. Ho of Post cholecystectomy with abscess which was
drained 6 weeks back. Was done open sx and pneumatic stocking, ceftriaxone was given for one
dose? I can’t recall it how many dose.
Task-Explain xray and dx ddx and order more investigations from examiner.
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Greet, check vital, and explain the xrays (PA and Lateral) as Pneumonia with possible lung abscess on
right side( One of the feedback said it was splenic abscess on left side so I was preoccupied with
abscess so just said whatever you see ), and other causes- pulmonary embolism, pleuritic, Lung CA,
occupational lung disease. I requested cbc esr crp lft ue and blood culture and urine cs and ct chest,
and pleural aspirate. (Better add CT PA, Ddimer)
Chest pain GS- 4
Approach to patient/relative 4
Interpretation of investigation 4
Diagnosis/ Differential diagnoses 5
Choice of investigations 3
7. Hand pain for few weeks and can’t use them. Task-Do hand pe functional assessment and dx ddx
Greet, Wipe, Look feel move, nerve function ( no sensory item for exam and said normal) paper clip
bottle and key, can’t do most of them, pain + on MCP thumb, dip and pip and mcp on some digits
(no typical findings for each dx oa or ra)
So I gave oa and ddx as ra psoriasis carpel tunnel inflammation of tendons
Hand Pain GS-5
Approach to patient/relative 6
Choice & Technique of examination, organization and sequence 5
Accuracy of Examination 4
Diagnosis/ Differential diagnoses 6
8. Laparoscopic cholecystectomy? Post op day2 initial plan was to discharge after 72 hours.
Pneumatic stalking ambulating on heparin. Vital chart all stable.
Task-Ho and pe from examiner and talk about dc plan with patient.
Greet, Ho wind water wound walk iva, all normal, he want to go home as mother is 87 and can’t take
care of herself, I told him social worker and said she doesn’t like other people as she can’t speak
English, greek. Pe all normal uds few leukocytes, I told him as it might be UTI or reaction due to
surgery but still need to make sure that safe for home, inform senior and do investigations as urgent
sample, Social worker and interpreter for her mother if needed.
Post Op assessment GS-5
Approach to patient/relative 5
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History 5
Choice & Technique of examination, organization and sequence 5
Patient Counselling/ Education 4
9. Nose bleeding since this am, 49 years old, (fail)
Task-Demonstrate how to stop bleeding, short history and further management.
Greet, Vital, I have to press on patient nose with glove she has been telling that nose is still bleeding
all time. (I forgot the icepack application due to anxiety as feedback said tell the role player how to
do it rather than do it yourself) So I told her that IVA cbc gmx clotting lft, Call senior for posterior
packing if needed, then mini bell rung, HO as usual stuff, Trauma picking, ca, urti, bleeding disorder/
meds, she is using steroid spray for hay fever for 10 years? Some dizziness. So I told her about bp
and spray that might cause this bleeding. (I don’t know I am telling the further mx if bleeding is not
stop while I showing the method). Please check with passed candidate.
Dizziness GS-3
Performance of procedure 2
History 4
Diagnosis/ Differential diagnoses 4
Management plan 3
10. 9 years old girl come with headache father concern .
Task-ho pe dx with reason and ddx.
Greet, same old headache question, Migraine, Meningitis, CA, Trauma, ENT, Psychogenic.
Band like sensation, can’t grade the pain scale, feel better on weekends, no other positive, school
grade falling, and bully at school. PE card normal. So I give the stress related headache as due to
above facts, ddx
Headache GS-4
Approach to patient/relative 4
History 4
Diagnosis/ Differential diagnoses 4
11. MSE (fail)
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University student, refered by coordinator for falling grade and not finish assignment in time.
Broke up with his girlfriend. Mood 3 to 4, concentration, sleep, I didn’t see assessment of perception
I might miss it but I mentioned that I need to review it. No judgment nor insight was assessed, no
conigtion, no sucide of homicide but he said he don’t want to wake up and don’t want to continue
his days. Kind of difficult to present as most are not positive.
Behavior Change GS-3
Commentary to Examiner 4
Accuracy of Examination 3
12. Alcohol intoxication in 15 years old college student. Alcohol level is 0.2.
Take Psychosocial history. Discuss with examiner for assessment and significant finding.
Same as old recall, Role player did not cooperative (as usual)
Ask about alcohol drinking pattern, tolerance, CAGE, effect on social family education legal issue any
trigger factors for drinking, Brief ASPECTICJ, RRR, HEADS
exercise induced asthma+ which is well controlled, Financial issue and separate from father when
young due to divorce. No other risk. Binge drinker for one time. 3 positive. Presentation is not so
good due to my anxiety.
Adolescent health GS-4
Approach to patient/relative 4
History 4
Commentary to Examiner 4
13. 35 years old man ho of depression, on escitalopram 20 mg bd, recently gp put him on
mitrazepem and he is feeling awful with sweating nausea vomiting abdominal cramp, T 38 HR 100,
BP 140/90, Neurology exam was normal.
Task-Ho and tell dx further immediate mx.
Same old recall, Drug symptoms, rule out other fever thyroid, Short mse and admit specialist review.
Investigations- cbc esr crp ue lft tft Blood and urine c/s. IVA IVF antipyretic dx cyproheptadine
cooling blanket, stop meds and reintroduce slowly. (He ask me if we stop med, he is worry that his
mood disorder might get worse- I told him that we will reintroduced slowly, and there are other
method like CBT, now we need to treat the acute condition as this is serious but we can manage)
Fever GS-5
Approach to patient/relative 4
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History 5
Patient Counselling/ Education 5
Management plan 5
14. 87 years old lady ‘s daughter came for change in behavior and confusion.
Ho of mild dementia, lacunar stroke, High bp on captopril vit d and calcium.
Task- Ho PEFE and tell possible causes to daughter. (Pilot)
Onset for 3 days, wet her self, fever + 37.8? at home, urine foul smelling, aggressive, memory
problem got worse, confuse, hallucination (-), delusion (-), FU regularly with specialist, compliance
with me, last investigation was 1 months ago which are normal. Other negative on history.
I didn’t finish the task. UTI.(Pilot) Old recall. Luckily it was pilot.
Examiner was not good. She only gave PE finding that you want to know as you can’t ask all finding
to rule out other causes of dementia. It took a lot of time in PE. (Vital, Systemic signs for infection,
CNS, Fundo, UDS was not available, RBS, MSE, Neck stiffness, liver flap jaundiac)
15. 45 years old man came for check up. Brother had bypass surgery.
Task-Ho PEFE and tell the risk to patient and further investigation.
Same old recall ABCDEF. Mother passed away due to heart attack (found out on history and I gave a
lot of empathy). Desk job. Use car to go to work. Lack of exercise, Junk food as no time to cook,
stressful job, drink alcohol 3 u per day for 4 days in week, 10 cigarette per day for 20 years, never
check cholesterol level, BSL normal 10 years ago.
PE- BMI waist circumference-110 cm vital – BP 150/90, no signs of hypercholestrolnemia,
fundoscopy, Carotid bruit, CVS, renal bruit, ( forgot PVD exam), BSL and UDS normal. I told him
about positive risks and I spend time unnecessarily in this section and Couldn’t finish the last task
(investigation)
Periodic Health Review GS-6
Approach to patient/relative 5
History 5
Choice & Technique of examination, organization and sequence 5
Patient Counselling/ Education 6
Choice of investigations 0
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16. 23 years old mother brought her son 3 months old due to crying continuously. She and her
partner are university students with difficult time. Some bruises on baby ‘s cheek.
Task-Ho and tell possible causes or cause? and further management. (Pilot)
Same old recall, said baby fall one time. Denied abuse or abuse by husband. Both parent are having
difficult time and husband get drunk sometime. No family support. When I said possible cause
mother said “you mean I am hurting my baby “, Cps inform (she stood up and she want to go home
so I have to counsel her while I am also standing) , admit for investigation and treatment as well as
safety (use proper words for safety and non-accidental injury rather than abuse) specialist, reassure
for helping all family member. (new station without examiner).
26th July 2019
Station 1
Pilot (without an examiner)
A 2 year old girl came with jaundice. On USS splenomegaly +, Blood reports
given nicely on a chart Hb 60, MCV low, reticulocytosis +, spherocytes +,
AST ALT slightly elevated as I can remember.
Task – Explain blood reports to the father
Tell the diagnosis
Tell the investigations
Explain management
Entered the room and the role player checked my ID and told me ‘I am the father,
you can now talk to me’.
Explained the blood report and red cell indices and the blood picture.
Diagnosis hereditary spherocytosis, where the red cell shape becomes round
unlike normal biconcave red cells. Because of the abnormal shape spleen destroy
these cells.
During my explanation I asked whether this was the first time she developed
yellowish discolouration. He said at around 6 months also she had this condition.
I totally forgot osmotic fragility test. Only told LDH levels. I will refer her to a
heamatologist; she will arrange some other enzyme tests to rule out other
conditions.
Most probably they will decide on splenectomy as longterm management.
Explained about little bit of post splenectomy follow up.
Station 2
Scenario - Abdominal pain
Predominant assessment area – Hisotry taking
A 16-year-old girl came with abdominal pain for 2 days.
Task – History
PEFE
Dx with reasons
Asked pain score and offered painkillers.
Pain – site lower abdomen, not radiating, no increasing or decreasing factors,
aching like pain, no nausea vomiting, feverish but not measured temperature.
First time having this type of a pain.
Periods – LMP 2 weeks ago
Pap/Gardicil – ?vaccine taken
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Pregnancy – nil
Partner – history of multiple partners.
Pills/ contraception – sometimes missed to use condoms
PEFE – temperature 38
Abdominal tenderness lower
Pelvic Ex – discharge from Os (told that I want to take a swab to send for culture)
Bimanual Ex – uterus normal size, adnexal tenderness +, no masses
Office tests – UPT, UDT not available
Diagnosis – explained in detail about PID since she has Hx of multiple partners with unsafe sex
Station 3
Rest station
Station 4
Pilot station
27 year old lady comes with concerns on weight gain. BMI 27. Has past
history of anorexia nervosa at 15 years of age and hospitalized and
managed to regain weight. Has kids and been on OCP as contraceptive after
the youngest child.
Task – Take history mainly on diet and weight
Explain the cause for her weight gain
History
Weight – during past 5 years weight had been gaining.
Diet – she thinks she is taking a healthy diet, some binging but no laxatives
(because she thinks that those are not good for health) or vomiting after binging.
Normal physical exertion
No features of BDD
No depression
No symptoms of hypothyroidism
SADMA - nil
5 Ps – on OCP for 5 years
DDx – OCP as the main cause
Bulimia
Depression
Hypothyroidism
Station 5
Scenario – shortness of breath
Predominant assessment area – Diagnostic formulation
A spirometry chart given of a 70 year old male who complains of shortness
of breath.
FEV1/FVC ratio reduced
FEV1 reduced, less than 12% change after bronchodilator
Cant remember the all values, but everything directing towards a
restrictive pattern.
Task – Explain the report to the examiner
Take short focused Hx (3 min)
PEFE
Explain the diagnosis to the patient
Explained the report to the examiner all the values one by one.
History – symptoms are there for about few months. No orthopnea, PND. Mild
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dry cough was there as I can remember. No lumps or bumps, LOW, LOA. No
history of asthma. Smoking stopped at 22 years before getting married. Worked
as a courier not retired. I asked specifically what type of work he did, but did not
get a clear answer. Asked specifically whether he has exposed to passive
smoking or any broilers or any dusty environment, No.
PEFE – positive findings were bi basal fine crepitations
Explained the most possible cause as interstitial lung disease/ fibrosis due to
chronic exposure to something, which I could not identify from the history.
DDx – asthma, COPD, lung CA but unlikey
Station 6
Scenario – health review
Predominant assessment area – history taking
Young lady comes with itchy rash over hands and back. 2 pictures given
outside like below.
Task – take history
Explain Dx and DDx
Patient was scratching her hands, offered medication but rejected.
History – can’t remember whether this was the first time. Started from hands
then trunk. Increased with hot bath last night. Had some relief with cold packs.
No fever, SOB. No PHx or FHx of asthma.
No contact Hx of insects, no change in lotion or cream or other allergens. No hx of
food allergy or drug allergy.
SADMA
Explained Dx as urticaria commonly called as hives.
Explained bit of pathophysiology of urticarial rash (about histamine)
Other DDx – drug/ food allergy, insect bite, allergy to any cosmetic but unlikely
from the Hx
Station 7
Scenario – pre pregnancy councelling
Predominant assessment area – hisotry taking
A lady visits GP to discuss regarding her 2nd pregnancy. Has an 18 month
old baby.
Task – take hisotry (4min)
Councel regarding pregnancy
Nothing about previous delivery mentioned on the stem more than that.
History – previous LSCS. She has not brought the diagnosis card or any records.
Does not know the exact indication, done by whom. But said that she was in
labour room for many hours and doctors have told that baby’s position was not
normal. No fetal distress. No history of GDM, PIH. Does not know whether it was
CPD/pelvic assessment was good. No complications after surgery. Now on OCP
and have regualr cycles. Now likes to go for a NVD.
Counceling – appreciated for coming to discuss about her 2nd pregnancy.
Explained that I would like to go through her past records to find out the exact
cause for the LSCS. And adviced regarding folic acid for 3 months before
conception and to stop OCP when she is ready to get pregnant. Once pregnant,
will do basic Ix and refer her to high risk clinic. The specialist will assess her
previous records and if the indication was something persisting like inadequate
pelvis, they might decide on 2nd LSCS, or else she can go for NVD in a tertiary
hospital. Follow up at GP and reading materials.
Station 8
Rest station
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Station 9 - Fail
Scenario – abdominal pain
Predominant assessment area – management/councelling/education
Around 30’s lady comes with abdominal pain. Now pain settled. USS scan
performed. USS picture given outside (same like below)
Report – gallstones in gall bladder, no fluid around gall bladder
Free fluid in POD
Appendix not visualised
Task – explain the report to the patient
Explain management
Explained everything about gall stones and told that she had a biliary colick most
probably. Definitive management as elective cholecystectomy. She is worried
about surgery because her mother had undergone emergency cholecytectomy
and ended up with an ugly scar. Reassured that will not happen here since this is
an elective. If we do not do the surgery can develop complications like
cholecystitis and obstructive jaundice.
Told that we will keep an eye on appendix too.
Totally forgot about DDx for free fluid in POD and did not explain it.
Station 10
Scenario – sleep complaint
Predominant assessment area – management/councelling/education
A lady has been taking tamezepam one tablet for 2 years. Now came to take
the prescription from the GP.
Task – take history
Explain management
Role player told, ‘doctor please give me the prescription so can go back quickly’
History – started tamezepam due to difficulty in getting into sleep. Now 2 years.
Has been taking only 1 tablet, never increased the dose, but now 1 tablet is not
enough. Never missed a dose, so never experienced withdrawal effects.
Sleep – can sleep long hours and has affected her job
Sleep hygeine – no caffeine or physical exertion in the evening
Mood – low, no other significant features for depression. Her facial expressions
were like depressed
Not much work stress, living with parents
No symptoms of hypothyroidism
Councelling – she is at risk of dependance for tamezepam since one tablet is not
enough now. Appreciated for not increasing the dose. Refer her to a psychiatrist
and they will change into a long acting drug and then gradually reduce the dose.
Refer her to psychologist for talk therapy have some relief. I will follow up
regularly, reading materials.
Station 11 - Fail
Scenario – first trimester complication
Predominant assessment area – diagnostic formulation
A lady in her first pregnancy from a rural area comes with per vaginal
bleeding at 12 weeks. GP has asked her to undergo dating scan but she has
missed the scan.
Task – focused hisotry
PEFE
Explain Dx and DDx
History – first pregnancy, planned. Bleeding watery like, not clots or grapes like
material. Nausea vomiting present and that day morning vomitted 5 times. Can
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manage to drink but LOA. No abdmonial pain. Regualr periods. Pap upto date.
PEFE – vitals normal
Abdominal Ex – Nl
Pelvic Ex – os closed, bleeding mild, cervix normal
Bimanual – uterus 16 weeks, no adenexial masses or tenderness
Office tests – urine ketones +, BSL nL
Explained diagnosis as hyperemesis + threatened miscarriage, could not tell
‘may be due to twins’. Will admit her to hospital and arrange USS to confirm
dates. Other possibilities complete miscarraige, Hmole, ectopic
Station 12
Scenario – Heartburn
Predominant assessment area – management/councelling/education
Middle aged man came to GP to discuss about his endoscopy report which
was done due to heart burn.
Report findings – sliding hernia, H pylori excluded, no evidence of
oesophagitis or ulcers.
Task – short Hx (3min)
Explain the report and Mx
History – for about 2 weeks he is having these symptoms. When lying down gets
the acid taste. Recent weight gain. Diet mainly fatty food. Smoking ? alcohol +.
Explained the report and reassured on the things which are not present. Drew a
picture of upper GIT and sliding hernia.
Management – I will give PPI to reduce acid production (then he said that’s good
thank you doctor) explained about SNAP, stop smoking, limit alcohol for
standard drinks and explained about the standard limit. Limit fatty food because
it takes time to empty the stomach. Have some physical activity to reduce weight
because weight gain is also a risk factory for reflux.
Station 13
Rest station
Station 14
Scenario – knee examination
Predominant assessment area – examination
An old lady complains of increasing knee pain for 2 weeks.
Task – Knee examination
Explain Dx and DDx
Took consent for knee examination. Asked which side affected more, left side she
said.
Gait - Nl
Look – from back, sides and front NL
Feel – normal temperature, no joint line tenderness
Move – active movements not restricted, passive movements left side
crepitations felt.
Special tests – clark test, patella tilt, valgus varus, anterior posterior drawers
negative, when trying to do appley grinding test examiner said no need.
Diagnosis as osteoarthritis
Other DDx – patella tendinitis, meniscal injury, ligamnet injury but unlikely
Station 15
Scenario – abnormal bleeding
Predominant assessment area – examination
A lady comes to the GP due to bleeding after sexual intercourse. She has
done pap smear 3 weeks ago and has come as normal. She is on OCP.
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Task – take consent for pelvic examination
Do pelvic examination
Explain the Dx and DDx
On table speculums and Pap smear kits were there with gel packet.
Took consent for pelvic examination and speculum Ex and explained regarding
privacy, chaperone, hand washing. Since she has undergone pap recenlty and
normal report I told her specifically that Im not going to do PAP smear.
Examined the dummy.
Inspection – NL
Speculum – asked her to take a deep breath and told that I’m gonna separate the
labia and insert the speculum slowly and reassured. When sperating the
speculum told her about that and reassured. Fixed the speculum.
Inspection – cervical ectropian present, no other cervical growth
While removing the speculum told her that I am doing it slowly and asked her to
take a deep breath. Vaginal walls normal.
Bimanual – examiner said it was normal.
Thanked the patient and disposed the speculum and offered her tissues to wipe
her private area.
Drew the picture on paper and explained cervical ectropian why it occurs. Told
her that I will refer her to gynaecologist and they might go for cauterization. To
exclude other possibilities inside uterus I will arrange USS.
Other DDx – cervical polyp/ cancer, endometrial polyp/ cancer
Station 16
Scenario – feeding problem
Predominant assessment area – diagnostic formulation
A 11 month old baby brought by his father to the GP with a rash round his
mouth( pic given like this with baby’s face)
Task – history
Dx and DDx
History – rash appeared today. Only around the mouth, not increasing the area of
the rash. No fever or SOB. When asking whether he had a new food today, father
told baby’s elder brother has fed him some egg which he has not eaten before. No
previous Hx of rash like this as I remember. No change of soap or creams or
contact with other allergens, drugs or insect bites. Picky eater?
BINDS – NL
Strong family Hx of atopy and eczema
Dx – rash due to egg allergy
DDx – drug allergy, cosmetic allergy, insect bite but unlikely
Station 17
Scenario – dental complaint
Predominant assessment area – hisotry taking
A young man referred by dentist due to recurrent dental problems. He has
got calluses over his knuckles.
Task – take Hx
Explain diagnosis
Role player said ‘doctor, I’m here because my dentist asked me’. But he was
smiling always with a happy face.
History – Diet normal, not much sugary diet but sometimes eat icecreams.
Concerns about the body and wants to have a good body. No one has commented
about his boy as big built or anything. But does not look in the mirrors always
(not BDD). Not worried about other body parts. To maintain body he controls
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diet, but sometimes loses control and over eats, then feels guilty, and tries to
vomit. (Clear Hx of bulimia).
Mood – NL
No anhedonia but does not go out with friends much.
Perception and delusions – Nil
Insight – said I don’t know
SADMA – family Hx of depression in mother
Diagnosis – bulimia
Other DDx – depression, BDD, OCD, unhealthy diet causing reccurent caries
Station 18
Rest station
Station 19 - Fail
Scenario – health review
Predominant assessment area – examination
Middle aged man came with one episode of PR bleeding. On and off
constipation.
Task – take consent for abdominal examination and DRE
Do abdominal Ex and DRE
Explain the Dx and DDx
Asked for vital signs. Took consent for abdominal examination and DRE.
Abdominal Ex
Inspection – no surgical scars, petichial rash was present (it was an artificial rash
marked with a marker)
Palpation – no LIF tenderness
Percussion – NL
Auscultation – BS NL
To complete Ex I said I want to examine hernial orifices and genital – no need
DRE
Inspection – no fissures, on straining no lumps coming out
DRE – anal tone NL, prostate NL size and consistency, mucosa movable, no lumps
palpable, on straining no lumps coming down. No contact bleeding.
Thanked the patient.
I started with DDx so ran out of time to tell the diagnosis. Please tell the Dx first.
DDx – haemarrhoids (but no lumps –examiner did not tell anything), anal fissure,
rectal polyp, recal CA, diverticular disease, colon CA or polyps
But most possible Dx is a bleeding disorder (because of the petichial rash - ?ITP)
May be my diagnosis was wrong.
Station 20
Scenario – abdominal distension
Predominant assessment area – examination
Old lady from aged care centre coming with Hx of abdominal distension.
She is taking laxatives for a long time. Bowel not opened for 2 days.
Vomiting +. Patient is unconscious and accompanied by the carer.
Task – take consent for abdominal Ex
Do abdominl Ex on mannikin
Explain the xray to the exmainer
Explain the diagnosis to the carer
Took consent from carer
Abdominal Ex – inspection Nl
Palpation – hard lump like thing in RHC, epigasatrium (could not
appreciate guarding or rigidity or tenderness)
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Percussion – can’t remember
Bowel sounds – increased, it could be heard from the dummy
without stethoscope
Examiner gave the supine abdominal Xray – large bowel dilated without
haustrations, I saw fecal matter like thing in the pelvis. It did not have a coffee
bean appearance for me (for volvulus)
I am really poor in interpretation of abdominal xrays
I said toxic megacolon :/
Explained it to the carer.
I thought I would fail this station.
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8th, 9th, 10th, 21st, 22nd, 23rd August 2019
8th August 2019
1- Middle age male with upper tummy pain. (Remote marking station)
Task - History taking no more than 5 minutes, Possible conditions (Dx and DDx to patient with
reasons), Initial investigations and give reasons.
History - Epigastric pain for 2 hours radiating to back relieves with leaning forward 10/10 in scale
2- 54 years old woman comes with hot flushes and 5 kg weight gain task: do and ask relevant PE, dx
and ddx to pt.
(Did thyroid PE and asked PE rest only positive finding was dryness of vagina no like sclerosis did
speculum examination but forgot bimanual examination)
Another Feedback - Lady around 50 years old with mood swings, shaking and sleep problems.
Task: Explain the possible differentials to the patient. Do relevant examination regarding the
symptoms. Tell possible dx and differentials to the patient.
3- Small town Pregnant woman comes with generalise abdominal pain.
Task: Take history, PEFE, Possible Dx with reasons to the patient, Management.
History - 26th weeks of pregnancy generalise abdominal pain becomes more frequent and tense, no
bleeding nor watery discharge, no headache blurred vision edema, feels baby’s movements no
urinary symptoms
PEFE - vitals stable, uterine size 26 cm, tender, forgot to ask baby’s heart rate, no bleeding or
discharge on pelvic examination cervical is open 3 cm no discharge.
Management - condition said premature labour no PMR mentioned admitting and transferring
patient forgot to give tocolytic)
4- MSE from video 4 min mania patient. Task: Present MSE to examiner. no dx no mx.
5- Chronic diarrhoea Task: Take history and Investigation, counsel patient, dx, ddx.
History - Abdominal pain and bloody sticky diarrhoea for 2 years becomes worse in 2 months
Dx/DDx - Mention about ulcerative colitis, Crohn disease, IBS unlikely no infectious findings forgot to
ask travel history
6- Counseling case - Patient uses warfarin due to AF metformin and beta blocker. 3 weeks later - will
undergo surgery discuss medication INR 2.5 and BP was normal HBA1C was 6.5
(swapped to clexane ceased warfarin)
7- A lady in her 50s with hand pain. Task - Do physical examination and do functional test. Possible
diagnosis and differentials to the patient.
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(+heberden nodules and finger deviation on right 2 finger, no RA features, movements restricted and
painful can’t do pinching and can’t do undoing button ) osteoarthritis, RA, psoriatic arthritis etc.
8- Old man with pain with walking 100 m he has to stop previous history of DVT and PTE 20 year
back) no DVT signs now. Berger test was negative. ABI was 0.7, smoking for long time. Task: history
dx ddx and Invx and counselling.
(Mentioned about peripheral artery disease and illustrated vein talked about)
Another Feedback - A man in his 50s complaint of pain in the calf after walking 100m.
BMI 26, ABPI 0.7, Smoking history, Hypertension with regular medication.
Task - Explain the possible Dx and differentials to the patient. Tell the further investigation that you
would order. Further management in the future and explain outcome of the condition and after
management.
9- Burn injury to 18 month old boy on the chest less than %10 superficial uncle was taking care of
the toddler first aid done at home and paramedics gave intranasal fentanyl. Task: brief history, PEFE,
Dx and management.
10- Disorientated old lady. Cockroaches around the room with hallucinations.
Take mental status examination. Present the findings to the examiner. (was seeing cockroaches and
feeling on the skin as well)
11- Middle age woman kindergarten teacher comes with positive home pregnancy test planned
baby, first pregnancy, periods 4-6 weeks time, wasn’t taking folic acid, LMP was 9 weeks ago. Task :
Antenatal counselling, order Invx forgot blood type
Another Feedback - Lady come to the GP for counselling regarding her pregnancy. She has antenatal
visit at 16 weeks of her pregnancy. LMP 9 weeks ago and pregnancy test done with a test kit.
Explain the investigations for 1st antenatal care that you are going to do for her.
Explain her about the preventive measures throughout her pregnancy. (similar in task)
12- Old women diagnosed with temporal arteritis done biopsy 2 months back. Now, c/o tiredness
Task: history -6 minutes, dx, ddx with reasons (lady stopped taking steroids by herself I think was
Addison)
13- Middle age man c/o breast lump. Task: PEFE, Investigation and management. (lump was 1.5 cm
and irregular surface) No testicular finding No gynaecomastia, did breaking bad news spikes protocol
Another Feedback - A man in his 40s (maybe) complaint of breast lump. You have taking all the
history. Task: Ask PEFE. Most likely diagnosis to the patient and differentials. Explain to the patient
about the investigations that you are going to do.
14- quadriplegic 9 years old boy comes with career from nursing home, carer wasn’t the permanent
carer looking for temporary to boy, boy was agitated and screaming.Task: history, PEFE, request
investigation from examiner (everything was negative except spiral fracture on tibia on report there
was no x ray and bruising on skin) was abuse case dx and ddx and mx
15- 25 years old man c/o painful rashes on groin area new sexual partner not using condoms
negative past medical history of STI doesn’t know partner’s STI statue. Task: history, PEFE and
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Investigation and Management (Photo show ulcers on penile shaft no discharge from meatus,
counselled about other STI offered screening forgot to offer partner screening )
Another Feedback - Male in his 20s with painful rash on the genitals.
History. PEFE. Dx and DDx to the patient.
16- Sore throat, difficulty with swallowing, enlarged tonsils with exudates, temp was 39. Task: do
relevant PE on patient and do ear examination on mannequin (on throat exam exudative enlarged
tonsils, forgot to mention on uvula deviation + Lymphadenopathy on anterior neck rubbery and
tender mobile, no splenomegaly no neck stiffness, on ear examination both tympanic membranes
were red but intact) Dx DDx.
9th August 2019
1. Asthma and overweight child – Tasks: plot growth chart including BMI (4 mins), talk with father to
explain causes and management plan.
Another Feedback - (Obesity) I failed this station.
You are a GP. You have to talk to father of 12-year-old boy with known case of asthma who
is here today for routine follow-up. Weight and height measurements were done. Patient
enjoys eating junk food and sugary drinks, watching TV all the time and refuse to do any
physical activities. Parents don’t let him get involved in school activities to avoid having
asthmatic attacks.
Task: Plot weight and height on the given chart (4 minutes)
Explain findings to his father and give advice.
Positive findings: normal height, increasing weight and BMI 28 currently. (Father is sitting
with a can of coke on the table.)
Chart is similar to this one. For BMI, it is unlike in this chart. The box for BMI is separately at
the upper right corner of the chart. Two charts, one for height and another for weight given.
Another paper with weight and height measurements according to age was also given.
What I filled was age, weight, height, BMI. Given measurements were plotted on the chart.
For advice, I told him that junks food are not good for health and he should encourage his
son to do physical activities. I will liase with dietitian and give you information regarding
exercises. For asthma flare, I will refer the boy back to his specialist. He can have puffer
before doing activities to prevent attacks. Addressed his coke drinking habit and offered
another consultation to explain more.
Another Feedback - Obesity (pass)
GP 12 yrs old boy who has asthma came to see u for regular check up. Hx of asthma but asthma was
well controlled.Father is here.
Tasks:
1. plot wt and ht chart
2. explain the charts
3. Counselling
Approach: Went in and greeted and told i will come back after having a look on the charts...then
plotted all those things...guys pls don’t forget about plotting BMI..I didn’t see it first time and
examiner asked me to do that. otherwise it was very easy.
Then explained about charts...I didn’t utter about word OBESE...i just told weight is outside the
healthier range of weight and i am bit concerned about that. Then regarding
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counselling..appreciated dad for coming...he was reluctant..was not making eye contact but i was
trying to make that..he was holding a coke can ..i told the causes of obesity at first...most common
cause is improper balance between food and physical activities..others are hormonal,medications
but less likely Asked if he is with me so far...he told yes...then said as i am concerned about rate of
weight gain so we need to work on it..we will work together as a team..you will be the prime
motivator for him. He nodded...asked about diet...fast food,take away food....then asked about
family diet ..all family members used to take fast food,take away food.. Told about dietitian for
whole family, its not about dieting but to maintain a healthier diet plan. Then told about
exercise,told dad that just start with walking ..you can go for a family walk then increase day by
day.you don’t need to go to gym at the first day.Dad was expressionless but nodded. Appreciated
that asthma is controlled.Before exercise i can give him inhaler. Involvement of school teacher and
so on....finished with 4R,family meeting etc.
Performance of procedure-7, Dx /Ddx- 3, Patient counselling and education: 5
There was no task regarding dx and ddx but they marked on it...don’t know why.
Another Feedback - (Fail)
GP 12 yr boy who has asthma came to see u for regular check up( something similar).asthma was
well controlled.talked with father.boy likes to stay indoor,watching movies all the time,eat
unhealthy food, sedentary lifestyle(+)
Task- plot wt and ht chart ,explain,give advice to dad.
On the table , there are two charts; wt and ht chart (we have to plot the BMI in wt chart as well)
My performance- I only plot wt and ht at the age of 12yr. I forgot to plot for other ages bcoz I
thought they are unnecessary at that time(maybe the main reason I failed).According to wt chart, his
wt is more than 97 th centile but for ht ,it was within normal. then explained to dad.
Advice- appreciate for coming here, but he looked disconcerned. Told him for having good asthma
control. Told some risk related increased body wt such as heart ds,hypertension, dm,reflux ds, not
only asthma….so, important to control body wt by doing lifestyle modification.liase with
dietician.doing exercise like walking exercise about 30mins.let him do outdoor activities as well. (on
the table, one coca cola bottle was present and he kept drinking it while we had conversation) so
told him to follow LSM as well including family member bcoz he has obese family history. Do family
meeting .then bell rang. I didn’t have a chance to talk more about asthma.
Performance of procedure-2 Dx Ddx- 2 Patient counselling-3
(I know I’ll surely fail this case bcoz I didn’t have good rapport with him ☹)
2. Hypochromic microcytic anaemia in child with failure to thrive (Growth Chart) and diarrhoea
Mum brought growth chart and wants to be explained.
Task: explain results (FBE) and take relevant history (3mins), PEFE on card, Causes and Investigation.
PEFE on card: 2/5 grade soft systolic murmur in the left sternum
Another Feedback – You are a GP. You have to talk to mother of 9-year-old (not sure) boy who looks
tired after coming back from a trip. Blood tests were arranged showing:
Hemoglobin: Reduced
Red cell count: Normal
White cell count: Normal
MCV: Reduced
Platelet: Normal
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HMA with elliptocytosis
Task: Explain results and take history for 3 minutes
PEFE card will be given Diagnosis, Differential Dx, Further investigation
Positive Findings: Patient’s mother has growth chart which shows normal height, declined in weight
for last 2 measurements. Gives history of tiredness for 6 months and repeated chest infection. The
child is on normal diet. PEFE card shows pallor. CVS ex: G2/6 mid-systolic blowing murmur on left
upper sternal edge.
Hi, I am Dr XY from this clinic. Nice to see you today, Hannah. I understand that you are here
for your boy’s blood result. First, may I know how he has been doing? (He looks tired and it
has been for 6 months, doctor. Can you please explain me about the growth chart first?
Weight and height measurements were done just recently.)
Alright, Hannah, let me explain you about blood result first.
What we did was checking blood cells and the result showed that red cell number is
reduced and size is small and color is faint. This is what we call HMA in medical terms.
White cell count and platelet level turn out to be normal.
Do you understand so far?
Now, let me have a look at the growth chart. For height, it is increasing year by year. So, it is
satisfactory. But for weight, Hannah, I am afraid to tell you but it declined from the previous
year.
I’d like to ask you a few questions as well.
Can you tell me about his diet? Any favourite meal? Does he drink cow’s milk a lot? (No. He
is on normal diet.)
Can I know his ethnic origin? Is he Australian born?
Any bleeding from his body?
What is his general health like? (He has repeated chest infection.)
PEFE card shows pallor. CVS ex: G2/6 mid-systolic blowing murmur on left upper sternal
edge. Other findings also given which I couldn’t recall.
I mentioned causes of HMA as DDx: IDA, Thalassaemia, lead poisoning, sideroblastic anaemia,
anaemia of chronic disease.
For investigations, I mentioned iron study, Hb electrophoresis, lead level, LFT, RFT,
Echocardiogram.
I failed this station. I missed to mention coeliac screening and failed to ask bowel habits on
history. Maybe that’s the reason.
Another Feedback – PASS Approach to patient-4, History-4, Dx /Ddx-4, Choice of investigations: 5
GP ,young boy looks pale.recently came back from holiday. did some investigation. Mom is here to
discuss about test results. Hb% reduced, MCV, MCHC reduced. anisopoikilocytosis and elliptocytes +.
Tasks: 1. explain results 2. History 3.explain dx and ddx 4. order invx u would like to do to pt.
Approach: Greetings...asked about how was the holiday...mum was worried about her
son...I reassured. Explained results one by one...told about microcytic hypochromic anaemia
and all the causes like IDA, thalassemia and chronic disease
History: diet...cows milk, vegetables, red meat...any bleeding from anywhere,
pee, poo (history of chronic diarrhea...then bulky stool, odor, blood, stick to
the pan, floats on the toilet...all were positive. Asked about any relation with
food. Family history of same kind of condition...ethnicity...chronic
disease..general health...BINDSMA, contact history, child care.
Diagnosis: I gave the most likely diagnosis as IDA due to coeliac disease and
other causes like inadequate diet, bleeding, thalassemia and chronic disease
Investigations:
1. Iron profile to confirm IDA
2. Coeliac screening
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3. Stool analysis
4. Other blood tests after having the above three investigations to rule out
the other causes
There was growth chart. The height chart was normal...wt chart was
downgrading...and crossed 1percentile line...So I told it was normal...as it
wasn’t crossing two lines...and asked about understanding...Mother was
happy and I reassured...told about 4R
Another Feedback - (Fail) Approach to patient-4, History-3, Dx Ddx-3, Choice of invx-3
GP young boy (I think) who looks pale. recently came back from somewhere,So,did investigation for
him.Now,mum is here to discuss about test results.Hb% reduced,MCV, MCHC
reduced.HMA(+).anisopoikilocytosis and elliptocytes (+).
Task- explain results briefly,history ,explain dx and ddx ,order invx u would like to do to pt.(also there
is wt and ht chart on the table, she keeps asking about it)
My performance- explain results quickly & I also told her about wt and ht chart ,(but I couldn’t recall
whether it is normal or abnormal),then she looks satisfied.On h/o,her son is pale,no other feat of
anemia.diet –eat everything( not sure yet),forget to ask cow milk.no pee and poo prob.no fever .no
inf feat.no tummy pain.BINDS- normal.well baby question-all good.no family h/o of special
diet.family origin-australian.generally healthy.no bleeding disorder.no chemical exposure.i forgot to
ask about travel h/o.social h/o-normal.
Dx Ddx- I dun know about the dx but I said IDA due to diet,Malabsorption prob like coeliac, IBD,inf:
,bleeding prob. Could be due to thalassemia,b12 folate,chronic blood loss,metabolic d/or.
Invx- iron study,hb electrophoresis,blood test for b12 folate.(forgot to do coeliac screen & stool
test).
In this station, there r many tasks and I couldn’t explore properly in history taking.As predominant
assessment area is diagnostic formulation, they ‘ll surely fail u if we cannot find out dx.
3. Obstructive Sleep Apnoea child. Tasks – History, PEFE, Dx, DDx.
PEFE: mouth breathing mucus in nose, enlarge tonsil, tympanic membrane dull.
Another Feedback - You are a GP. Your next patient is a 12-year-old boy brought in by his mother
because of being tired and distractable for a certain duration (not sure).
Task: History, ask PEFE, explain diagnosis.
Positive findings: snoring, mouth breathing, hearing and school performance – normal,
repeated ear infection (last attack – just recently).
PEFE – general appearance looks sleepy, mouth breather, ENT ex: dull tympanic membrane,
mucous discharge inside the nostrils and clear throat, Oph ex: no conjunctivitis. Hearing not
assessed.
Another Feedback - Hi, I am Dr XY from this clinic. Nice to see you, Mary. What can I do for you
today? Can you please tell me more about what had happened to John? (His teacher told me that
he looked drowsy in the class.)
When? Do you notice that at home as well? (Yes, sometimes he looks sleepy.)
What else the teacher mentioned? (Nothing particular.)
Apart from that, do you notice anything special?
Snoring? Mouth breathing? Pause of breathing? (Yes for snoring, not sure for mouth
breathing and pause of breathing)
How long? How often? Every night? Everytime when he sleeps? Getting worse?
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Looks sleepy and drowsy during the daytime? (Yes.)
How is his general health? (Fine.)
Any ear infection or chest infection? (He had repeated ear infection.)
How often? (3/4 times this year) Get treated? (Yes.) Last attack? (Just recently.)
Any problem with his hearing? (No.) Does he respond to you whenever you call him? (Yes.)
What about his school performance? (Not bad.)
Does he look pale these days? Do you think his skin looks dry? Any history of constipation?
Does he talk loudly in class? Does he disturb other students in the class?
(These questions are for DDx of tiredness and distractablity : anaemia, hypothyroid, ADHD.
But I couldn’t remember whether I asked these or not.)
BINDS MA
GA : looks drowsy; I asked any features of adenoid facies and was told patient is a mouth
breather, no crowding of teeth.
VS : normal
GC : normal
ENT : dull tympanic membrane on otoscopic examination; clear mucous discharge inside
nostrils; throat looks normal
Hearing : not assessed
Eyes : no conjunctivitis
Other systemic examination (CVS, Resp) : normal
Hi, Mary, I have just finished examining John and I suspect the reason for his symptoms is
due to the condition what we call OSA. Do you have any idea about that?
It means there is some kind of obstruction along the airway which prevents the air from
entering the system. As a result, oxygen supply to the brain is reduced causing drowsiness
and sleepiness. Also because of that, the child snores a lot and breathes through his mouth.
That might be related to his repeated ear infection. I will draw a picture to explain in more
details. As I am about to do so, the bell rang. I failed to mention OSA due to adenoid hypertrophy.
Another Feedback – (PASS) History-5, Choice and technique of examination-5, Dx Ddx- 5
GP school teacher noticed a young boy looked distracted all the time. talk with mum.
Task- History, ask PE, Dx with reasons.
My performance- young boy looked distracted for 2-3mths.looked sleepy & unfreshed. snoring at
night. mouth breathing+, no pause of breathing, bmi-normal, no hearing & vision prob, no speech
prob, no behavior changes such as autism, h/o of repeated ear inf+ but treated, tonsillitis+, but no
fever now, no voice change, no diff in breathing, no L/N enlargement, no thyroid prob. School
performance-good. BINDSnormal, well baby Q- ok, no other medical & surgical h/o.family h/o of
snoring + in dad.
PE- tonsillitis+, no uvula deviation, eye and nose-clear, ear- dull tympanic membrane on otoscope ( I
don’t know what it means .maybe inflamed tympanic membrane) :P , no L/N enlargement, no
adenoid
facies,mouth breathing+,no feat of respiratory distress,no thyroid feat.other systems- normal.
Dx- OSA with tonsillitis due to repeated ear inf.( explain with reasons).
Another Feedback – School problems (Pass) GP school teacher noticed a young boy looked
distracted all the time. talk with mum. Tasks: 1. History 2. PEFE 3. Dx with reasons.
Approach: As it was last station i was so tired.Examiner told me oh doctor r
u tired?I tried to laugh.
Greetings and started to take history...duration, previous episode...tiredness..mom said yes..school
performance..was not that good. Hearing ,speech, recent behavior change, recurrent RTI, ear
infection was positive. Asked about sleeping, snoring positive, stops breathing during sleeping,
BINDSMA, PMHX,FHX...passive smoking, allergy,asthma
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PEFE: bilateral tonsillar enlargement and mouth breathing...others are normal
Dx/ddx: OSA due to tonsillar enlargement...drew and explained.others are
enlarged adenoid, jaw problem, muscle problem, nasal obstruction
Also told about other causes of tiredness ?HEMIFADO
History-3, Choice and technique of examination-4, Dx Ddx- 4
Don’t know why got 3 in hx ...i thought i asked about pretty much everything.
4. Pelvic examination: patient on HRT for 10 years, brown discharge spotting. Task: Get consent for
pelvic examination, perform, Dx, DDx.
Your next patient in GP is 62-year-old female patient complained of spotting of blood from
vagina. Last Pap smear was 18 months ago. Patient is taking HRT for 10 years.
Task: Obtain consent from patient and perform pelvic examination on the female model
provided. Explain diagnosis and differentials to your patient.
Hi, I am Dr XY from this clinic. Nice to see you today, Monica. I understand that you notice
some bleeding from your down below. For that, I am going to examine you.
Examination will involve having a look at your private area, inserting a plastic device and
introducing my two gloved fingers into your down below. This might be a bit uncomfortable
for you. I will be really gentle throughout the examination. If you want me to stop, you can
let me know. As this is a sensitive examination, I am going to examine you in a private room
and examiner will help us to be a chaperon. Do you agree to proceed? Any questions for the
examination?
Would you like to empty your bladder first before we begin?
So, let’s get started. I will go and wash my hands and wear the gloves.
Please lie down on the bed and remove your undergarments. Please bend your knees.
Please keep your heels close to your buttocks. Please spread out your legs.
I will have a look at your private area first.
On inspection, no bleeding, no discharge, no scratch marks, no atrophic changes, vulva looks
normal.
Now, I am going to insert this plastic device what we call speculum. I will apply lubricants
first before I introduce. Please breathe in and out deeply for me. If you want me to stop, you
can let me know anytime. I will insert it really slowly and gently. (Please make sure you
insert the speculum while closing and open the blades after it has been inserted.. Please
don’t forget to get light source as well)
On SS examination, os is closed and its multip os. No bleeding from the os. No atrophic
changes. Cervical and vaginal wall look healthy. (Please remember to remove the speculum
after making sure the blades are closed.)
(During the exam, I just removed the speculum without noticing the blades are still open and
patient shouted at this point. Only at that time, I remember to close. I said sorry and told her
that I will close and remove the speculum.)
I mentioned about taking CST but was told not necessary.
When I am about to do BME, examiner told me to stop.
After that, I checked incontinence of urine by asking to cough and by separating the labia and it was
unremarkable. I offered patient tissue to wipe her private area. You can wear your gown back,
Monica. Thank you so much for your cooperation.
Monica, I couldn’t find any abnormal findings on examination.
Now, I’d like to explain you about possible causes for the bleeding.
I think the most probable reason in you is because of side effects of HRT.
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It can be due to atrophic vaginitis which means down below become dry as a result of lack of female
hormones. Other possibilities are endometrial hyperplasia which means thickening of inner lining of
the womb. In case when there is benign growth or cancer arising from lining of the womb, what we
call endometrial polyp or cancer, there can be spotting like you have. When patient is taking BTM or
patient has underlying bleeding disorder, similar bleeding can occur.
Another Feedback - (Pass) Approach-5, Choice and technique of examination-4, Accuracy of
examination-5, Dx Ddx-3
GP 67yr old lady came with brownish vaginal discharge. She has been taking HRT.
Task- Perform vaginal examination, explain Dx DDx to pt.
My performance- take consent, call chaperone,prepare proper screening & adequate lighting for
her,then exposed herself.
On inspection- no dc,no bleeding,no ulcer,no atrophic changes,labia majora seems to be normal.ask
her to cough- no leakage of urine & no lump.
On speculum pe- no dc , no bleeding,no ulcer, no growth,no atrophic changes, cervical & vaginal wall
are healthy.(ask for taking swab-examiner said no.)
No bimanual examination was performed.
Dx Ddx- atrophic vaginitis,bacterial vaginosis,fungal inf, cervical poly&CA, cervicitis,C A
endometrium,allergy.(forgot to tell side effect of HRT.So, got only3 in Dx)
Another Feedback - (Pass) Approach-5, Choice and technique of examination-4, Accuracy of
examination-5, Dx /Ddx-4
GP old lady came with brownish vaginal discharge. She has been taking HRT.
Tasks: 1. Take consent from patient and Perform vaginal examination 2. explain Dx DDx to pt.
Approach: Greetings, consent...WIPER...followed Greeky medics..
Inspection all normal.
During speculum asked pt to strain down and to give a cough...all were normal. Started to do
bimanual examiner told normal.i did not wipe the manikin but covered properly.I forgot to dispose
the speculum...i thought I will fail the station...but luckily i passed.
Dx/ddx: Atrophic vaginitis,ca cervix,polyp,endometrial
hyperplasia,cancer,HRT
5. DM, burning sensation and pain on calf while uphill. Task: lower limb examination, Dx, DDx.
Your next patient in GP is 50-year-old male patient with known case of diabetes complained
of burning sensation on both feet and pain on calf muscles while walking uphill.
Task: Perform examination and comment your findings to your examiner.
Explain diagnosis and differentials to your patient.
Positive findings: Vibration sense – patient can only feel touch sensation on big toe and
medial malleolus on both feet, intact on both shins.
Fine touch, monofilament assessment and reflexes are normal.
Cotton bud, hammer, monofilament and tuning fork are provided.
Introduced. Obtained consent. Washed hands. Explained roughly about examination.
I started with gait assessment but was told to skip.
On inspection of legs, no muscle wasting, no muscle fasiculation. Skin looks normal, no pallor,
no cyanosis. Hair distribution is normal. No fungal infection between the toes. No ulcer or
callous formation at pressure points.
Checked tone. (Normal)
Checked fine touch with cotton bud according to dermatone. (Normal)
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Checked monofilament on 10 points. (Normal)
Checked vibration. (Patient can only feel touch sensation on big toe and medial malleolus on
both feet, vibration intact on both shins.)
Checked knee and ankle reflexes. (Normal)
(I forgot to check proprioception.)
Asked examiner that I’d like to check peripheral pulses and Buerger’s test. And was told not
necessary.
I asked BSL and fundoscopy as office tests.
Tom, thank you for your cooperation. Now, I’d like to explain you about possible causes for
your symptoms.
According to the examination findings, I think what you are having is what we call peripheral
neuropathy which means small nerves in the legs and feet are damaged. It can in turn be due
to several different reasons. In your case, it can be due to consequence of DM.
Other possibilities are due to excessive alcohol drinking, B12 and folate deficiency.
PVD is also another possible cause.
Another Feedback - PASS - Approach to patient-4, Choice and technique of examination-4, Accuracy
of examination- 4, Dx Ddx-4
GP Middle aged lady with h/o of DM compliant of tingling and numbness
sensation of legs. Pain was during walking uphill.
Task- 1. Perform LL examination 2. Dx, Ddx to patient
Approach: I went in and greeted ...asked about painkiller...comfortable or not...WIPER as
usual..started with gait..examiner said normal...then look..positive was shiny skin..loss of
hair...bunion on both feet...no ulcers Then feel for temperature ,tenderness,pulses...i found ADP was
absent on both sides and told about that...pos tibialis were present on both sides CRT was
normal..then did monofilament ..was normal...vibration was impaired up to med malleolus as far i
can remember...proprioception normal...now reflex...the hammer was new for me..i practiced with
different hammer so i was worried a bit...and first time it slipped from my hand...at that time
examine moved and started marking and I thought i am gonna fail this station..all reflexes were
normal..then moved for tone and power examiner said normal..asked about burgers test was
negative...forgot to ask about bruit.
Ddx i told diabetic neuropathy as most likely dx and alcohol ,vitamin b12 def...forgot to tell about
PVD ...i was not happy with my performance but luckily i passed...examiner was good i think...
Another Feedback - PASS with each 4
GP Middle aged lady with h/o of DM compliant of tingling and numbness sensation of LL . As far as I
remember, there was no pain.(some said pain present while walking uphill)
Task- Perform LL examination, Dx/Ddx to pt.(old recall)
On the table- jerk,cotton wool,monofilament, tuning fork.
My Performance- WIPE, starts with inspection- no redness,no swelling, no gross deformity but hallux
valgus(+),hair sparse,no ulcer,no callosity,no pressure sole, no fungel inf. Then,temperature,CR and
pulse-normal. Then,I examined LL with every items over the table, only vibration sense loss, others r
normal. I forgot findings about proprioception.
DX Ddx- DM neuropathy,alcoholic neuropathy,b12 folate deficiency,nerve impingement at back,
injury etc.
6. Chronic lymphocytic leukaemia with night sweating and weight loss. Tasks – History?, PE and
summary findings to patient, causes for night sweating and weight loss.
Another Feedback –(Pilot Station)
Your next patient in GP is a 62-year-old male patient with known case of CLL who is here for
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6 monthly follow-up and for annual influenza vaccine. He recently complained of tiredness,
weight loss and night sweats but no bleeding menifestations.
Task: Perform examination and comment your findings to your examiner.
Explain to your patient about the findings of the examination and causes for his current
symptoms.
Tongue depressor and stethoscope were given.
Introduced. Took consent. Washed hands. Explained roughly about examination.
Started from peripheral.
No pallor on nails, no leukonychia. No bleeding menifestations. No pallor, no jaundice. No
epistaxis. No bleeding from ears. No gum bleeding, no gum hypertrophy.
No bony tenderness on sternum.
Liver and spleen are not palpable.
LN: cervical, axillary, epitrochlear (Wore gloves before examining LN.)
PR (Examiner told me unremarkable.)
Examination all normal to me.
John, thank you so much for cooperation. I couldn’t find any abnormalities on examination.
But I see that you have some symptoms. I am sorry but I think the leukaemia has relapsed.
To make sure, I am going to arrange a couple of investigations including blood tests for you.
Another Feedback – (pilot) PE Station
GP Middle aged man who was already diagnosed with CLL, he has h/o of night sweat and wt loss.
Task-Perform examination, explain condition to pt.
My Performance- WIPE, start with hand, face and neck including cervical , supraclavicular,
epitrochlear l/n, then proceed to abdomen. When I checked his tummy, I noticed tummy distension
with mass in epigastrium probably splenomegaly. But, I said no mass in deep palpation (how stupid I
was ☹) and I think this is real pt. then, I moved to lower limb including groin & popliteal l/n.no
positive findings apart from splenomegaly.no bony tenderness, then I asked PR and axillary l/n from
examiner-all normal. Then bell rang and I missed the last task, but luckily, it was unscored ☺☺
7. Lateral epicondylitis. Arm pain PE, Dx, DDx
Your next patient in GP is 30-year-old male patient complained of pain on right arm.
Task: History for 3 minutes and perform focused examination.
Explain diagnosis and differentials to your patient.
Positive findings: Pain on lateral part of right elbow around olecranon. Occupation – worked
at a café and had to use the coffee machine.
Patient showed the painful area around olecracon. Actually that was lateral epicondyle. I
had no idea during the examination.
What I checked was inspection, tenderness, peripheral pulse, CRT. Tone and power of upper
limbs. Upper limb sensation. Tinel test for cubital and carpel tunnel syndrome. Cervical
spine TDN.
Bell rang and no time to explain Dx, DDx.
Another Feedback - (Pass) History-3, Choice and technique of examination-4, Accuracy of
examination-4, Dx ddx-4
GP middle aged man c/o painful right arm. Task:History,perform PE,Dx,Ddx to pt.
My performance- h/o of painful right arm for 2-3 weeks I guess. I asked pain Q properly. No swelling,
redness, deformity & no muscle wasting, no skin & nail color changes, no T&N sensation, no injury,
occupation- dun remember.no PMH, No SADMA.
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PE- WIPE, starts with inspection- no abn. Palpation- pain (+) on right lateral epicondyle. Temp, pulse,
CR –all ok. Movement- active & power –all good. I proceed special test for lateral epicondylitis
(cozen test) but I didn’t do properly bcoz I was so confused at that time. But, luckily, I passed ( really
thanks to examiner in this station ☺☺)
Dx Ddx- lateral epicondylitis ,medial epicondylitis then bell rang.
Another Feedback - (Pass) History-3, Choice and technique of examination-4, Accuracy of
examination-4, Dx /ddx-4
GP middle aged man c/o painful right arm. Tasks: 1.History 2. perform PE 3.Dx/Ddx to pt.
Approach: greetings...offered pain killer..pain SOCRATES ..pain on elbow ..no swelling,redness...no
hx of fall /injury...insect bite..no systemic symptoms...asked about occupation he told about
something which I cannot remember and i asked does it involve with repeated hand movement..he
said yes...then i thought about lateral epicondylitis...others are normal.
Then WIPER starts with look...- no abn..carrying angle normal.on feel..pain(+) on right lateral
epicondyle. Temp ,pulse, CRT normal. Movement active & passive normal .I tried to proceed for
special test but couldn’t do it properly...I didn’t practiced it before exam as it didn’t come in the
exam for long time. But managed to pass somehow.
Dx /Ddx- lateral epicondylitis , injury, fracture, insect bite, septic arthritis ,osteomyelitis
8. Placenta Previa - (Pregnancy complication) You are an intern at the city hospital. Your next patient
is 32-year-old pregnant lady who is in her 28 weeks of gestation complained of BPV. This is her third
pregnancy. G1 – Normal uneventful delivery G2 – LSCS (Breech presentation) Task: History, ask PEFE,
explain diagnosis and further management.
Hi, I am Dr XY from this hospital. Nice to see you today, Amy.
What can I do for you today? (I noticed some bleeding from down below.)
I am sorry to hear about that, Amy. Are you feeling comfortable right now? To make sure
you are stable, I am going to check with my examiner.
Dear examiner, may I know my patient’s VS? (VS given: all normal, no features of shock)
Amy, I have checked your condition and you are stable right now. I would like to ask you a
few questions. If you feel uncomfortable, please let me know.
Can you please tell me what exactly happened on you?
When did it start? (Just recently.) First time during this pregnancy? Did you have to use
pads? How many pads did you use? Are they all soaked? Any clots or tissues in the
bleeding?
Do you notice any other symptoms?
Anything like dizziness or ROHB?
Any discharge from your down below? Any tummy pain? Any fever?
I understand that you are now in 28 wk pregnancy. How is your pregnancy going so far? Do
you feel the baby kicking?
Did you go to ANC regularly? Do you remember blood test results? 18 wk USG scan? (low
lying placenta) Any subsequent scan done afterwards? 26 wk SDT?
So this is 3rd pregnancy. Can you please tell me about the previous pregnancies as well?
How did you deliver them? Any problems during pregnancy and delivery?
GH?
SADMA
Thank you for your information, Amy. I am going to examine you and I’ll get back to you
later.
Dear examiner, I’d like to know my patient’s GA.
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Are VS the same?
I will start with obstetric examination.
On inspection, any scars? (LSCS scar) any bruises? (No.)
On palpation, any TDN? (No.) Any contractions? (No.) FH? (28cm) Number, lie,
presentation? (Single baby, longitudinal lie, cephalic presentation) Is the baby engaged yet?
(No.)
I will listen to FHS. (loud and clear, 150 bpm)
I will proceed to vaginal examination with my patient’s consent and with the presence of 3rd
person.
On inspection, any bleeding or discharge? (Introitus is stained with blood.)
On sterile speculum examination, is the os open or closed? (closed) Any bleeding from the
os? (Yes.)
I will BME as I suspect APH.
I’d like to do UDT as office test.
Amy, I have finished examining you. I could hear the baby’s heart sound really well. You are
also stable right now.
I’d like to explain about the reason of the bleeding. This is what we call, APH which means
bleeding in 2nd half of pregnancy. In your case, placenta is attached at the lower part instead
of normal insertion at upper part of the womb, medically what we call placenta previa. This
might be related to the previous operation since the placenta is attached at the previous
incison site. Do you understand so far?
For management, you will need to get admitted. I will arrange admission. I will inform
women specialist and seniors to come and assess you.
Some blood tests such as basic blood tests, blood grouping, organ function tests will be
done for you. Most importantly, we are going to do USG over your tummy to confirm the Dx
and CTG to check baby’s heart rate and the contraction of the womb.
After assessment by specialist, steroid will be given to boost up baby’s lung maturation if
necessary. We are going to monitor you closely. You will be fine soon, Amy.
Another Feedback - PASS with each domain 5
GP lady comes with vaginal bleeding. 3o weeks i think. 3rd pregnancy.it was
a long question...many info were given...can’t remember the others.
Tasks: 1. History 2.PEFE 3.Dx and Mx including invx.
Approach: introduced and greeted ..asked about comfortable or not...went to examiner for hemo
stability...was normal.
Hx: bleeding CCOV...hx of trauma, baby kicking, 5P, ANC questions, all were normal but 18 weeks
USG had low placenta. Asked about late preg complications question, blood group was given
outside, SOB, chest pain, tummy pain, dizziness all negative.
PEFE: only bleeding in inspection and bimanual Others normal.
DX and mx: placenta prevails...drew and explained, told about grading. it’s a serious condition but
reassured as baby is fine so don’t worry. need to admit and call the senior. further inv. USG and CTG
Mx depends on grading but mostly C/S. Asked about support. if i need to call anyone for her.
reassured again.
Another Feedback - PASS with each domain 5
GP lady comes with BPV. 32 nd or 30 th wk preg, this is her 3 rd pregnancy.1 st baby was born by
NSVD ,2 nd baby was born via CS (I forgot the reason. All info about babies were given.So, I skipped
Q regarding previous babies). Task-History,ask PE,explain Dx and Mx including invx.
My performance- build rapport and check vitals first, ask for any dizziness ,she said she is fine. BPV+
(I didn’t remember detail info about bleeding),no feat of anemia,preg Q-all normal.AN care- all
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normal. AN care test-all good.no other 3 rd stage complications.blood gp-O +ve,immunization –
updated.no PMH,husband supportive.
PE- scar +,others- all normal apart from bleeding. I did obstetric and VE but skipped Bimanual.
DX- placenta previa.
MX-refer to hospital. Specialist ‘ll assess her.monitor her condition.do invx such as
FBE,HB%,PLT,BT,CT,G&M Rh,coagulation profile,LFT,TFT,RFT,USG,CTG to check baby’s condition and
placenta.consider giving steroid bcoz of risk of preterm delivery.told her safest MOD is CS but she
has no preference about MOD. then bell rang
9. You are a GP. Your next patient is 22-year-old female university student who moved recently to
your area. She is here today to ask about oral contraceptive pills. Task: History for 6 minutes and
counsel about management.
Hi, I am Dr XY from this clinic. Nice to see you today, Cindy.
What can I do for you today? (I am here for prescription of pills, doctor.)
Cindy, it’s really nice that u came here first before you start to take the pills. Today, I’d like to
ask you some questions about your overall health whether you would be suitable to take the
pills or not. Some questions might be a little bit private and sensitive. Will that be okay for
you, Cindy? (Sure.)
Any special reason why you chose these oral pills over other available alternatives? (My
friends use it and they recommend, that’s why)
Have you ever tried any contraception before? (No.)
Let’s talk about your period, Cindy.
When was your last period? Is it regular? How many days of cycle and days of bleeding? Any
pain or bleeding between the period?
Have you started your sexual life? (Yes.) Any problem with intercourse like pain during
intercourse or bleeding after sex? Do you practise safe sex? (Sometimes.)
Have you ever been pregnant before? Any history of miscarriages?
Are you following the cervical screening programme? (Not yet.) That’s fine, I am going to
explain you about that later on.
May I know about your general health? Have you ever been diagnosed with clotting
problems/ liver disease/ migraine/ breast problems/ womb problems? (No.)
What about in your family members? Anyone who has breast cancer or womb cancer? (No.)
SADMA
Patient told me that she is on antiepileptics (I forgot the name she told me.)
How long have you been taking? (Forgot duration.) Take regularly? (Yes.) When were you first
diagnosed with it? When was last attack? Regular follow up with specialist? (Yes.)
Thank you for the information, Cindy.
Now, I am going to explain you about the pills. Before that, may I know how much you know
about that?
(Before I explained, I asked the examiner whether the pills are available or not. I was told not
so I just drew the diagram with 4 rows with 7 pills in each.)
Medically, we call these combined oral contraceptive pills, in short, COC. It contains two
female hormones namely oestrogen and progesterone. For these kinds of pills, it is really
important to take them regularly at the same time everyday which means patient’s good
compliance is necessary.
As I understand, you have been taking AED. Actually, Cindy, these medications are good for
controlling epilepsy but it can interfere the efficacy of COC. That’s why we usually increase
the dose 50 micrograms in such patients, instead of 30 micrograms which is the usual dose.
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Do you understand so far?
Also, for these pills to show full effectiveness, it usually takes 7 days. So, if patient wants to
start on first day of period, that’s fine. But in case when patient wants to start on day other
than day 1, patient needs extra precaution which is to use condoms for initial 7 days.
As good compliance is important, please make sure not to miss taking the pills. If that
happens, please contact ASAP. I will also give you some leaflets regarding what to do in case
you missed the pills.
In patients taking these pills, period can be irregular and sore breasts can happen. But these
last only for a couple of weeks and they disappear with time.
In some patients, BP can go up so I am going to see you 3 months later to check your BP again.
Do you wish to start the pills right now? Or you can also take your time to have a think at
home. See you again when you have made your decision.
Another Feedback – PASS Approach to patient-5, History -5, Patient counselling and education: 6
GP Young lady came to see u bcoz she wants to take OCP. Tasks: 1. History 2. counsel.
Approach: greetings...appreciated and thanked for coming...confidentiality statement...
History: 5P, contraindication of OCP, PMHX, FHX , SADMA ...smoking 5/6 sticks per day, was on
antiepileptic medication. ...then asked about epilepsy. last attack. dose ,frequency of meds. etc
Counselling : told about pill ...M/A...missed pill,with diarrhoea/vomiting.. Side
effects...advantage...disadvantage...doesn’t protect from STI.... Offered another session for smoking
told few things about smoking.. Will give her high dose pill as she is on medication and told why. 4R
Didnt refer to specialist...review