2/4/2011—Brisbane
O&G
Station 20
GP setting: 30-year old female has been trying to conceive for 12 months and come for
pregnancy advice. On physical examination: height is 1.51 m and BMI is 40, BP and BGL is
normal
Tasks:
Take history <3 minutes and counsel the patient
It was my first station and a new topic as well. I thought about the stem outside the room
and two issues immediately came to my mind: 1. infertility and 2. pregnancy complications.
History:
5 Ps: Period was regular without any pain. Her husband used condom before. Stable
relationship. Denies any pregnancy or miscarriage. Pap smear was up to date.
System R/V: NAD
PMHx: Nil. Not on any medication nor allergic to anything.
After taking history, I mentioned to the patient that there were two issues for her due to her
excessive weight. 1. She would have problem with getting pregnant; and 2. If she became
pregnant, I would have to refer her to High Risk Clinic (remember Dr Wenzel tells us to think
aloud). Those two things were in my mind at that time. The role player was very nice that
she asked me about what could be wrong if she was pregnant. I briefly mentioned a few
possible complications for her and her baby (Refer to the Royal Women’s Hospital clinical
practice guidelines for details. There is a special chapter called obese maternity woman:
management). I recommended her to lose weight before getting pregnant and she asked
me how she could lose weight. The bell rang after I talked about diet and exercise. I didn’t
have time to touch on medication and surgery, which is another separate recall topic.
AMC feedback: Pre-pregnancy counselling of an obese woman (passed)
Station 5
GP setting: Young female around 30 years old complains about urinary problem and she has
history of two vaginal deliveries.
Tasks:
Take history
Ask for physical examination findings
Manage your patient
This is a modified AMC book case 128. The differences were she only had features of stress
incontinence, denied smoking, had history of constipation. She was on POP but otherwise
healthy. I did P/E per book case and there was no prolapse. Then I recommended life style
management first including pelvic floor exercise, wt reduction and constipation
management. The role player asked about medication and surgery. I told her that some
medication such as oxybutynin could help for those who had urge incontinence but not for
her. Surgery was not recommended for her at this stage.
AMC feedback: Urinary incontinence (passed)
Station 11
GP setting: middle aged female patient has been trying to conceive for last 12 months but
no success. Your task is to counsel the patient.
This was an old recall of female infertility. The patient had infrequent sex 1-2 per month and
no history of STDs. Although infertility was more likely due to infrequent sex, you still need
to know about all the investigations. The role player asked about investigations for the
examiner.
AMC feedback: Primary infertility: unknown cause (passed)
PAEDIATRICS
Station 2
GP setting: father brought his 5 yr old boy due to excessive thirst and frequent urination.
BGL is very high (30).
Tasks:
Explain to the father your diagnosis
Short and long-term management
This was a combination of f DKA and book case 20 (Refer to old recalls). The role player
asked lots of questions which require good understanding of DKA (Study Dr. Wenzel’s note
well).
AMC feedback: Newly diagnosed child diabetes mellitus (passed)
Station 10
GP setting: Mother brought her 6 weeks old baby girl to see you due to vomiting.
Tasks: Take history and manage the patient.
This is an old topic of GORD but modified with oesophagitis. During history taking and
physical examination, I excluded DDx: pyloric stenosis, gastro, increased ICP, bowel
obstruction and UTI. Mother mentioned there was trace of blood in the vomitus indicating
oesophagitis. I told her to do simple measures first and add PPI if not working.
AMC feedback: Gastro-oesophageal reflux with oesophagitis (passed)
Station 16
GP setting: 5 weeks old baby is brought in by his mother due to refusing feeding and SOB.
Tasks:
Take history
Ask physical examination finding
Manage the patient
HOCP: Mother said her baby was not feeding well for last week and got worse today. He
refused feeding and had difficulty breathing today. Denied cough, fever, rash and diarrhoea,
but had no urine output today.
System R/V: He’s never been sick prior to this.
BIND questions: Pregnancy was uneventful and mother had home delivery which was
nature vaginal delivery by a midwife. All of the antenatal checkups were normal. No
concern has been raised regarding development.
P/E (You need to ask specific signs, otherwise the examiner will ask you what are you
looking for.)
GA: sick looking baby, well perfused, nil signs of dehydration, no cyanosis.
VS: RR is 70/min, PR is regular. Sorry I can’t remember the rest or maybe they were not
significant.
ENT: NAD
CVS: heart murmur can be heard but can’t tell whether it is systolic or diastolic.
RS: Bilateral basal crackles
Abdo: NAD
Lower limbs: no oedema.
Then the mother asked me what I think of her baby. I told her that I highly suspected her
baby had pulmonary oedema due to possible heart failure. I mentioned urgent transfer to
ED and further investigation Echo to confirm the diagnosis. The possibility of VSD had been
discussed with her and her baby might need surgical repairing for that. Reassurance had
been given to the mum that the result of surgery was good.
AMC feedback: respiratory distress (passed)
Psychiatry
Station 7
GP setting: You took some blood from a patient with end stage renal failure last time. A list
of blood result given: HB 100, High Cr and Ur, K is 5.8... Pt usually has dialysis once a week.
Tasks:
Explain the result to the patient and take history
Tell the examiner your diagnosis and DDx
Manage the patient
The patient was a middle aged female. I followed the task but she said she was not
interested in the result at all and refused to have dialysis. I asked why. She told me that she
was worried about her sister who had the same problem as her and died 20 years ago. I
asked about HEADSSS questions: she lived with her husband and two teenage children.
Everything was fine at home but she didn’t talk about her feeling with them. Her mood is
low and lost interest. Nil smoking/Alcohol/drugs. Nil family or past history of mental illness.
Appetite and sleep were poor. She felt tired but I could not remember other details. She
denied suicidal ideation, cold intolerance, palpation and dizziness. At some point, the
examiner asked me what was my diagnosis and I answered depression but I had to do some
investigations to rule out organic causes. Then the examiner asked me to talk to the patient.
I told her that I would like to take some blood from her and organise a family meeting for
her. She would need treatment accordingly if there were any organic causes. She might
change her ideas after talking with her family down the track. Antidepressants may have to
be considered but I have to check with renal specialists. At the end, the patient agreed by
nodding her head.
AMC feedback: Depressed mood (passed)
Station 19
GP setting: Young female nurse has been diagnosed obsessive-compulsive disorder by your
colleague. She is worried about catching “warts” and developed dermatitis.
Tasks:
Explain the diagnosis to your patient
Provide psychoeducation to the patient
The patient was a young female role player wearing gloves. I explained that OCD was one
type of anxiety disorders and after that I mentioned two main features of OCD. Then I asked
about HEADSSS questions. I told her that I would like to refer her to a psychiatrist. She asked
me what a psychiatrist would do. I mentioned CBT and possible SSRI. Based on book case
84, I expanded CBT in details. The last question she asked me was about her job. She was
happy with my answer that she could start from part time and increase her workload
gradually.
AMC feedback: Obsessive-Compulsive Disorder (passed)
Surgery
1.GP setting: A patient came back to for US result : aortic artery is 5.3 cm in diameter and
he is planning for a trip for 4 weeks
Tasks:
Explain the result
Manage the patient
This is a straightforward case of AAA. Please refer to previous recalls.
AMC feedback: Abdominal aortic aneurysm (passed)
2.You are a resident on a surgical ward. Your patient is 55 years old female who is day 5
post-hip replacement. She had heparin for 2 days post-op and fluid intake is 3 L in last 24
hours. Now complains of SOB.
Tasks:
Take history
Ask for physical examination findings from the examiner
Order investigations
Diagnosis and DDx
Hx:
She complained of SOB for one hour and there was also chest tightness, which were getting
worse. Denied cough, cuff pain, sweating, palpitation, dizziness. She mobilised after the
operation.
System R/V: not significant
PMHx: arthritis
Not on medication or allergic to anything.
S/A/D: Nil
P/E:
GA: patient is in distress.
VS: BP: 100/60, T 37.5. Pulse regular and the rest are unremarkable
CVS/RS/ABDO/Lower limb: NAD
Wound/ IV site: Nil sign of infection
Urinalysis: NAD
Investigations: FBE, U&E, ESR, CRP, blood culture, cardiac enzymes, D-dimmer
ECG, CXY, CTPA or VQ scan
Once I mentioned ECG, the examiner handed to me the ECG which was not significant. I told
the examiner that I highly suspected PE and I didn’t have time to mention my ddx, which I
think the examiner got it from my history taking and investigations.
AMC feedback: Chest pain and dyspnoea (acute) (passed)
3. GP setting: A male patient c/o leg pain after walking about 200 meters and he is on ACEI
for his HT. He is a heavy smoker as well.
Tasks:
Perform the lower limb examination on the patient
Manage the patient
This was a repeated case of PVD and the role player was a real patient, who appeared in our
recall from Brisbane for last May. I did the examination per Talley O’Connor. I couldn’t feel
popliteal pulses and Burger test was positive. I mentioned neurological examination but the
examiner told me there was no need to perform it. I wasn’t entirely sure about the
examination findings and I didn’t have time to tell the patient to start low dose Aspirin.
AMC feedback: Leg cramps on exercise (passed)
Medicine
1.GP setting: 35 yr old female patient comes to see you for blood result. Her father has
cardiac problems and mother has DM. A list of blood result was given: Chol 7.5 HDL 1.2, BGL
Normal and the rest can’t be remembered.
Tasks:
Explain the result
Manage the patient
This was a repeated case. After explaining the result, I advised her regarding life style
management and f/u in 6 weeks. If the second blood test in 6-week time was still high,
medication would need to be added.
AMC feedback: Hyperlipidemia (passed)
2.GP setting: 55 years old female patient c/o SOB ( this is the shortest stem in my exam)
Tasks:
Take history
Ask for examination finding
Manage the patient
This is a repeated case of pleural effusion DDx case. Please refer previous recalls.
AMC feedback: Shortness of breath (passed)
3. ED setting: Male patient c/o indigestion which turned out to be chest pain. Refer this case
to book case 65.
AMC feedback: Acute myocardial infarction (passed)
4. GP setting: middle aged female patient was diagnosed Essential HT by your colleague and
treated with ACEI. She stopped the medication herself and today her BP is 160/100.
Tasks:
Explain the complication of HT
Manage the patient
This was a new and strange case. At the beginning, I tried to clarify to the examiner whether
the secondary causes of HT were excluded or not, but the examiner said all the information
were given and she couldn’t provide anything more.
I also asked the patient whether she had tried life style management before starting
medication. She said no. I really had doubt at that time, but I chose to trust my colleague’s
previous diagnosis. I asked the patient why she stopped the medication. She said she
stopped for 6 months due to running out of prescriptions. At this point, I got the conclusion
that the patient didn’t take HT seriously. Then I talked about all the complications of HT and
told her to continue the medication. Also her BP had to be monitored frequently and she
told me that she could monitor it at her work place. She seemed satisfied with my answer,
but I failed this case. This case might appear simple but I think there could be traps. Please
refer other people’s recalls.
AMC feedback: Non-compliance with anti-hypertensives (failed)
5. GP setting: 17 years old male comes to see you due to skin rashes. There are two pictures
hanging next to the stem which are from MCQ book.
Tasks:
Take history and management
This was a case I studied a long time ago. I know the diagnosis was acne vulgaris when I saw
the pictures, but I couldn’t remember the name of medication for it. After taking history, I
talked about skin care and offered medication for 3-6 months. The role player asked me
whether the medication was effective and I gave him a positive answer. The problem was
that I still had some time left and the examiner asked me the name of the medication. My
mind was blank and I told him that I couldn’t remember the name. I found a MIMS on the
table next to me and asked whether I could use it. The examiner was nice and allowed me to
use it. But I couldn’t find the name of the medication before the bell rang.
AMC feedback: Acne vulgaris (failed)
I could have done so much better when I think back but I am very happy about the result
because in the exam my performance was not 100%. I would like to thank everyone who
helped and encouraged me during my exam preparation. It is nearly impossible for me to
pass the exam without the support from my family and friends. I would like to thank my
VMPF bridging long course tutors and particularly Dr Wenzel, whom I have known for
nearly four years. He is such an unbelievable doctor who has done so much for IMGs and
set an excellent example for all of us.
26th February 2011 Adelaide
1.
56 y old gentlemen come to your GP for a consultation and advice. Take focused history, explain you
Dg to the patient and organise further investigations.
When I’ve started taking history the patient’s first complaint was that he has some unspecific upper
abdominal pain and he thinks is because he has gallstones. Apparently he had a friend who has his gall
bladder removed and this prompted him to go and have his gall bladder checked and was told that he has
gall stones. On further questioning – he never had abdo pain or discomfort, or bloating, or jaundice …or
any symptoms that might have suggested gall stones.
About the pain- unspecific, upper abdo, relieved by glass of milk.
PHx: nothing specific, usually fit and healthy
FHx: nothing significant
Meds: no regular meds but has been taking Nurofen lately because he hurt his back when trying to lift
something and was given Nurofen by some other Dr.
My Dg was peptic ulcer or gastritis and I based any further Ix around this Dg, so I’ve mentioned that he’ll
need r/v by gastroenterologist, he will also need gastroscopy, will have to stop taking Nurofen. As he was
persisting on the gallstones issue I tried to draw a picture and explain where they are and that number of
people have them and are completely asymptomatic and most of the time are not cause of any problems.
The bell rang as I was half way through.
Some other candidates mentioned PPI, guess it’s a good thing to do, I didn’t because Mx was not in the
task.
AMC feedback: Gallstones or Peptic ulcer PASS
2.
Middle aged male pt, comes for foot examination and further advice/management. This was real pt
and did not have dorsalis pedis pulses on one leg
PHx: T2DM
It is the diabetic foot examination station, everything will be provided, the examiner will rush you through
the examination just so you could have more time to counsel the patient and suggest further
investigations and management. The main point is to ask when was he last seen by endo/physician and
request HbA1c, FBE, UE, LFT, ophthalmology and nephrology r/v.
I personally think that my physical examination was very poor but guess I did well on the management
part.
AMC feedback: Type 2 diabetes mellitus PASS
3.
Young patient who is known to be HIV positive comes to your GP with a complaint of severe cold like
symptoms and cough for the past few days.
The role player was coughing the whole time, but was really good, he told me that he has been like that for a
few days, and has stoped working (works as a chef in a restaurant). On questioning he will tell you that he is
HIV positive for the past 5y but hasn’t had his CD4 checked for several years as has been feeling well.
Think this was a counselling station where we were expected to tell him that he probably has Pneumocistis
carini chest infection (if you don’t mention the pathogen he will specifically ask for it). I also mentioned that he
needs to have blood test done to check CD4 count and assess progress, he also needs a referral for an
infectologist for proper assessment of AIDS and start of antivirals. He will also ask about work arrangement,
should he tell his employer……
AMC feedback: Fever in immuno-compromised patient PASS
4.
12 year old girl run the school marathon and fainted once she finished. Now in ED, you are actually
talking to the mother who is worried and wants’ someone to explain what is the cause and what is
the further management. Take history, ask for findings and answer questions.
When you start asking questions the mother will tell you that she is perfectly fit and healthy, no issues, normal
delivery and development, nothing specific in home, has other siblings, all fit and healthy. She did prepare for
the marathon but usually eats healthy and whatever mother prepares, not obsessing about diet…… When
asked about the collapse she said once the girl finished she set down on the ground to rest and collapsed when
tried to get up. Mother will also mention that she was very anxious about the run, so didn’t eat her breakfast
or drink much before the start. When you ask the examiner for findings he’ll say BP 110/80 and 90/60, BSL 3.5,
HR 78 afebrile, no heart issues, no focal neurology.
My Dg was just a simple reaction to stress, overtiredness resulting in a postural drop. I suggested short stay in
ED, IV fluids, give her something to eat and drink as BSL was borderline, have ECG, check bloods and will r/v in
1-2 hours.
Some of the other candidates mentioned HOCM, not sure if this is right or wrong, I didn’t as it looked to me as
a simple vaso-vagal reaction, having said that I never asked about family history of heart problems, sudden
death ect. No harm in doing that
AMC feedback: Adolescent vasovagal syncope PASS
5.
Picture on the wall of venous ulcer. The pt is a middle aged female who comes to your GP as she has
this annoying ulcer on her leg for few weeks, it’s not healing and she thinks it’s getting even worse.
Take focused history, ask for findings and suggest further management.
On history taking she has T2DM and had DVT on the same leg wile ago. She hurt her self while gardening.
When asked for findings told – as you can see on the picture, than I asked if there were any pulses – yes, any
discharge – yes.
My advice antibiotics, take swab and regular dressings. Explained that it’s due to the diabetes as well as the
previous DVT, will take long to heal and the best management is to prevent infection, have good circulation
and do regular dressings. Will do one now and will organise district nurse to visit regularly at home.
AMC feedback: Chronic leg ulcer
PASS
6.
Young female, 10 weeks pregnant comes to your GP practice complaining of abdominal pain and
vomiting. Take focused history, ask examiner for findings, answer questions and organise further
management.
On history taking – she’s being felling well up until yesterday, pregnancy was spontaneous, expected, no issues
until now or nausea. The pain is in the lower abdomen unspecific, non-cramping, dull, she also has pain in her
left loin and had burning and stinging sensation when passing urine.
On findings – febrile, HR 80, on MCU proteins, blood and leucocytes, office pregnancy test positive. She looks
flushed and feels sick. On palpation abdomen is soft, bowel sounds present, tenderness in lower abdo and
loins.
My mistake – I forgot to ask for vaginal examination (exclude ectopic). The examiner tried to prompt me and
asked is that all you need to know?????
My response – looks like upper UTI, likely pyelonephritis, explained what it is, that she needs to be admitted
for urine cultures and IV antibiotics for a 1-2 days and than changed to orals. I asked if she is allergic to
anything and gave her the possible treatment options. Also mentioned that in ED they might decide to do an
US.
Again the pt tried to prompt me by asking what will they look for on the US? My stupid response- changes in
the kidneys, signs of hydronephrosis…..
Questions form pt – will the antibiotics hurt my baby, what antibiotics will I need, for how long???
AMC feedback: abdominal pain in early pregnancy PASS
Still surprised how I passed because in my view not excluding ectopic is a critical error, but maybe because I
did refer to hospital and mentioned US???
7.
You are the HMO on the ward, a med student has just done an MMSE 17/30 and wants’ to talk about
the results.
The pt is a 40 something female who scored poorly on concentration and recall. There will be hips of
questions, but the main points are:
Can’t establish Dg solely on MMSE, only a screening test for cognitive impairment; will probably need to
repeat it; dementia – frustrated if they can’t concentrate and answer properly; depression – don’t care;
delirium – pore score on orientation; if suspecting frontal lobe/vascular dementia add more tests (motor
repetition, name as many objects/animal in 1min, similarities and differences, all in AMC book).
AMC feedback: Teaching a Folstein MMSE PASS\
8.
Father of a 1.5y old child comes to you because his son is coughing for more than 10 days. Ask history
and answer questions.
Can’t remember more from the stem but is a typical Pertussis station.
Questions – what is it?, How did he get it? How will you diagnose/know for sure? How do we treat it? What
about us and our 4y old? Can we go and visit friends? For how long do you treat?
Make sure you ask what the cough looks like, changes day or night, is the child playful and cheery when not
coughing, who looks after child, is he in child care, is he eating and drinking….? Also make sure you advice
about feeds, stop when coughing, risk of aspiration, make sure is not vomiting, treatment with Clarithromycin
for 7 days, I actually said 7-14, same for family, other child vaccinated and will probably have only mild
symptoms, better if not visiting for a while because he is contagious….
AMC feedback: Pertussis PASS
9.
Young female, think it was 25, comes to your GP because she found a breast lump in her left breast.
Take focused history, ask for findings, advice further management and answer pt’s questions.
Typical breast lump question and the examiner was really nice, he actually greeted me in-front of the door and
said this is an easy one.
On history she only found it, not painful it’s on the external upper quadrant, she is quite anxious as her mother
had breast cancer, she’s otherwise fit and healthy not on medications. On examination there is a 1cm lump
that is mobile, non tender, not fluctuating, not red or inflamed…..
Basically have to advice FNAB and US because she is only 25, advice on risks because of family history and
explain further management (yearly checks, self examination every 2-3 months and mammography after she is
40).
AMC feedback: Breast lump (fibroadenoma) PASS
10. 32 weeks pregnant female comes for an antenatal check-up, she just found out the baby is in breech
presentation. Talk to the pt, explain and answer questions.
Straight forward station, she said everything was OK so far (must ask about all antenatal screening/visits/test),
she has another child (vaginal delivery). She doesn’t know much about breech so have to explain what it is, the
three types of presentation and the options available is (trial of vaginal if legs fully extended or fully flexed, or
caesarean if footling). There is always a risk of slow progress with vaginal trial so must be psychologically
prepared that may need CS eventually. There is also the possibility of external rotation latter in pregnancy…. I
started by asking her does she have any preferences about the delivery and think the examiner quite liked
that. (There was an observer in the room and they kinda nodded to each other and smiled )
AMC feedback: Breech presentation PASS
11. 35 y old male comes to you GP with a macroscopic haematuria. He also had a sore throat few days
ago. Take focused history, ask examiner for findings, advice further management and answer
questions.
This was a really confusing station, first because it looked like PSGM but it was an older pt, and according to
the numbers it was supposed to be a peads station.
On history taking – he is usually fit and healthy, this happened all of a sudden, no pain just blood in his urine,
no fever, but he feels that his face is a bit puffed. He had sore throat for couple of days, still soar but didn’t see
anyone about it. My differentials were PSGM, maybe trauma, stone, some sort of nephropathy. I was leaning
towards PSGM so focused all my further instructions in that directions. Told him that although macroscopic
hameaturia is unusual for PSGM he still needs admission for full investigation, check MCS, culture, throat
swap, blood FBE, U&E, C4, C3, ASOT, US, strict fluid balance, BP control, maybe antibiotics depending on swap
and blood results.
He wanted to know what is it and I did my best to explain PSGM, the examiner asked me to summarise what
investigations I want once admitted.
AMC feedback: Haematuria
PASS
Pls note that one of the other candidates said that the pt told him this was his second presentation and he felt
it was IgA nephropathy. Maybe you should also have a look at other recalls.
12. Psych station, young man comes to your GP because he wants a referral for plastis because he thinks
that his nose is too big and is the reason why he can’t progress in life.
Funny station because he actually took a small mirror from his pocket and was trying to explain what is wrong
with his nose. The funniest thing about this station was that the role player actually did have big nose
Anyway, this is question from the AMC book, have a read there, but the main think is that you should avoid
giving him a referral and suggest psych r/v, family meeting…..
AMC feedback: Body dimorphic and social anxiety disorder PASS
13. Middle aged female comes to your GP because she has problems with the “nerves”. Take focused
history, ask examiner for findings and advice further management.
Typical thyrotoxicosis/hyperthyroidism station. Not much I can tell – on history try to exclude psych issues,
menopause, always ask for bowel motion, sweating, weather intolerance, appetite, weight gain/loss,
palpitations, ask for family history of autoimmune conditions… Mx check ECG, bloods, FBE, UE, TFT explain that
will most likely need meds for a prolonged period of time….
AMC feedback: Nervousness
PASS
14. Mother of a 9 months old baby comes to you for a regular check up, she wants’ to know if her son is
progressing as he should. Take history, draw growth chart and discuss any issues/answer questions.
On history the child is fine, eating and drinking, if you ask milestones they are OK for the age, she says that he
is a bit agitated sometimes, but generally OK. When you actually do the chart will realise that up till 3 month
right in the middle for weight, but latter there is a progressive decline, and now on 9 months he is on the
lowest border, only 10%o. When asked about his food and any diarrhoea, he eats everything including bread,
toast, cereals, ect; started solids from age of 4 months, he does have few loose bowel motions every day but
she copes well with that and thinks he’s not distressed by that. I thought it was Celiac disease and focused my
further Mx in that direction. Tried to explain what CD is and why I suspect this is the case and how we make
the Dg. Told her that he needs an assessment by peads, he will need specific antibody tests and if positive will
need special diet. I also explained that it meant he has a life long condition that can be easily managed by diet,
but if not managed can lead to serious complications. At the end I asked if she has any questions and she said
it’s too much to digest. Now looking backwards think I should have given her more time to absorb all info and
ask if she has questions, or if anything is unclear, instead I just kept talking for few minutes.
AMC feedback: Infant with poor weight gain PASS
15. Middle aged pt is admitted to ED with confusion for more than 12h, now he is incomprehensible and
you are supposed to take history from his wife, ask for findings, give differentials and explain
questions, don’t talk about Ix or Mx.
Really weird station, not much I can tell because I failed this one. On history nothing much, all of a sudden he
become confused, non drinker, usually healthy, no trauma…. Findings HR90, T 38, everything else is normal (no
bloods, no CXR, no CTB….)
My differentials were trauma, delirium, infection; than she asked what kind of an infection, I did mention
acute brain sy, meningitis, chest, maybe even a UTI presenting as delirium. However I didn’t mention
encephalitis
AMC feedback: Encephalitis FAIL
Please note the candidates who did mention encephalitis were asked how he might have gotten it?
16. 18 y old girl comes to your GP because she wants Implanon. Take history, advice and answer
question.
Again not much I can say as I failed this station as well. These were the most dreadful 8 minutes in my life as I
knew I will fail even before I entered; I knew nothing about Implanon. The only thing I knew was that it’s a rod
inserted on the inside of the non-dominant arm and lasts for 3y. I was so confused and uncomfortable, so
when the role player asked me if she can have it done today I forgot even what I knew – that it’s a surg
procedure and she’ll need to be booked in.
AMC feedback: Implanon counselling FAIL
My advice – read everything there is about OCP and HRT because you WILL get a question about one of the
two
So there it is, I passed 14/16, quite happy with the outcome. I only studied actively for 1 month, did not get
much time off from work so had to use my annual leave. I’ve been through the AMC book and the recalls 20082010. I did try to study around the topics a bit, not just memorise recalls. That’s why I was a bit “stingy” with
this recall; think it’s always better to prompt candidates to actually look for more. I only used Mourtagh and
Oxford and think it’s more than enough.
Few tips:
-
-
don’t just read recalls, broaden your knowledge by reading a bit more because topics are the same
but questions wary slightly
be confident. I actually made some mistakes and missed some important things on examination, but
maybe because I was confident in my differentials, Dg and further Ix and Mx think I still passed some
stations
if you can’t find a study group don’t stress, I had to study alone ( have a 2y old boy and had to run
back from work, than there was always something on the weekend, so couldn’t really fit with a study
group). However always try to speak out loud, when you just go through the questions in your mind
you’re not practising and will most definitely be short in time, or will forget something.
-
Wenzel’s classes are also wonderful, unfortunately a bit difficult to attend to if you are working.
Nevertheless if you have a chance go to at least few, I’ve only been to 3 but found them to be really
useful
All the best
CLINICAL EXAMINATION – MELBOURNE 19TH MARCH 2011.
1. You are in GP clinic. A 52 yo man who has smoked 20 ( or 10) cig/day for 20 years, come for check
up because of chesty cough.
- Perform respiratory examination.
- Summarise the case to the examiner.
This is my 2nd station ( my 1st station is Rest station!). Outside the room, when I tried to outline
what I will focus when doing physical examination I only reminded myself: don't forget signs of Lung
cancer ( Horner's syndrome, hand examination for nerve root compression...). And I totally forgot
COPD.
I entered the room. After greeting the examiner and the Pt, I made a quick glance to the Pt and try
to guess if this was a real Pt (but I could not).
There are no abnormal signs on PE but nicotine stain on right fingers. By mistake, I checked vocal
resonance with a stethoscope! Fortunately I realised it was wrong so I checked it again with hands.
At the end, when I was mentioning Horner syndrome' signs, Pancoast syndrome's signs the examiner
rushed me to check PFM. In a hurry, I connected the mouth piece to the device, asked the Pt to do
PFM. He did it wrongly. I asked him to repeat. Time almost ran out. I ran the commentary quickly
and ordered some Ix: chest X ray, CT scan.... The examiner suddenly asked me to wash my hands. I
was so panic and wondered if i missed anything. Anyway I still washed my hands and the bell rang.
AMC feed back: respiratory examination.
2. A 24 yo student comes to your clinic, c/o headache which started this morning.
- Take relevant, focus Hx.
- Find out PE from examiner who only gives you the clinical findings which you're asking for.
- Give provisional diagnosis.
- Mx.
Outside the room, I thought maybe it is tension headache, migraine... But when I came into the
room. The Pt is a young man lying on the bed, suddenly I changed my mind: is it SAH?
I greeted the Pt then asked if he needs pain relief. The examiner said: no, he's OK.
"PAIN" questions: Pain 3-4/10. No specific type or location. No neck pain. No other symptoms.
Past Hx of migraine, 3-4 times last year. This pain is different from the previous ones. No Hx of
contact, no stress related, no head injury.
PE: No rash. T 37.5, BP normal. FO: not available. Neck stiffness +. When I asked for Koernig,
Bruzinski, Babinski signs, the examiner looked happy.
Provisional Dx: Meningitis maybe due to Meningococcus, HI. I told the Pt he needs to admit to
hospital for further Ix and management. He was not allergic to PNG so I gave him PNG. I mentioned
about notifiable disease and prophylactic ABT for close contact. The examiner smiled and asked me
who is close contact. I turned to the Pt: whom do you live with? Girlfriend! Then I said his girlfriend
needs Rifampicin for prophylaxis. I asked if he had any concerns he said no. Then examiner asked me
to go out.
AMC feed back: Acute headache.
3. 4 yo girl was discharged from hospital 3 days ago after an asthma attack. She is fine now but
mother wants to know about asthma action plan. She comes to ask about it at your clinic.
- Discuss about the girl's condition. Explain Asthma action plan.
- Future Mx.
When I entered the room I saw asthma action plan on the table. I was very happy and I grabbed it.
To be honest, at that time I was so confused and could not trust my memory ( !) although before the
exam I tried to memorise asthma action plan.
I asked the mother about her daughter's condition, how she is now, how she goes with the
medication... The mother asked me: which medication? I said the tablets (I means the
corticosteroids orally). She replied: all is OK.
I said if I can ask her some Qs. Then I asked Hx of asthma of her daughter: when Dx, how frequent,
medication.... Trigger factors, Fa Hx... The mother was also asthmatic but has settled now.
I started to expl what asthma is ( draw the pic). With the asthma action plan in hand, I said this is
symptom based plan the stared from WELL, UNWELL....When I finished I asked if she can follow me
she replied so far it's OK.
I explained about reliever, preventor ..... Then I said at this stage your daughter only needs reliever
medication (because she has only 2 attacks in the last 6 months). I asked if she gave the medication
via spacer or puffer and if she know how to use it. She said: spacer but not sure how to use. Then I
said via space is the best way to give reliever at this age and showed her how to use it correctly. She
ask how about her daughter's condition in the future? I said she may grow out of asthma as your
case. Then she smiled.
Finally I reminded the mother to avoid trigger factors and to realise red flag symptoms. Bell rang
when I just finished.
AMC feed back: Chronic asthma.
4. A 64 yo lady coming to your clinic c/o lower back pain. She was Dx with chronic lower back pain
for years. Recently she has groin pain.
- Take Hx.
- Give Dx.
When I read the senario, i was so nervous whether it is 2 symptoms of 1 disease or 2 different
diseases. Suddenly bell rang and I had to enter the room.
The Pt was sitting on the chair. I asked if she need pain relief. She said no.
PAIN Qs: lower back pain for years, did not getting worse recently. Right groin pain for last 4 days.
Appears when she walks for a distance. Settle in few minutes after she stop walking. No calf pain. No
lump in groin. No other symptoms. No other medical condition.
PE: Everything was normal. No tenderness on tenderness along the spine. No muscle wasting, no
swelling, no deformities on right leg, Knee normal. Trenderlenburg +ve (so it could be : OA, gluteus
medius weakness, NOF fracture). Thomas test -ve. Examiner asked what Thomas test means – check
fixed flexion deformity of the hip for ex in OA..
I was panic because I could not reach to the Dx. If it is OA? but why OA has the symptoms like
intermittent claudication. If it is sciatica? but the Pt confirmed: no pain at the back of thigh or leg, no
abnormal sensations. Then I asked for Burger test, the examiner said it's not available.
When I was ordering for Ix: X ray, Doppler US.. the bell rang!
At the rest station I kept thinking about the case. My performance was not good, I took a lot of time
for Hx as I could not find any cue for Dx. I felt so upset about myself. Anyway I reassured myself I
have a right to fail 1 in 4 stations! :-)
AMC feed back: hip pain.
5. The long Hx of the elderly lady who has been Dx with schizophrenia. Recently she refuses eating,
taking medication... Medical Tx has failed. The psychiatrist decided to have ECT for her condition.
Her son comes to your clinical asking for ECT. He has been given a consent from his mother.
-Expl ECT.
-Discuss with the son and answer his Qs.
I said usually we do not dislodge one's medical condition to others. At the time, the examiner looked
at me nervously as if I did not understand the task. I understood his feeling then I continued: as your
mum has given you a consent so I will talk to you about her condition and Mx plan. I could see the
relief on the examiner's face!
Then I did the case as Dr Wenzel's notes. Firstly, I said about indication of ECT. Then I told him the
whole procedure: anaesthetic assessment, Pt will be under GA. Some electrodes will be put on the
scalp and electrical current will be used for Tx. During that time, Pt may have jerking movements,
don't worry. She wont feel them at all because she is under GA. He asked me are you sure she is not
in pain. I said yes. Then I said about SE: headache, dizziness, forgetfulness. But they are temporary.
You see, now your mother is not in a good condition, she becomes self neglected. She refuses to eat
and drink, her health will be deteriorated soon. After assessing carefully we think ECT is the best
choice of Tx now. .He looked happy. I added if we compare the benefits outweigh the disadvantages.
I finished early. The examiner asked me: if I finish my task then I can go out. I was not sure whether
my performance was bad or I missed anything. Then I replied my task is discuss with the son so I
would like to stay here if he wants to ask me more. They both laughed. Then the examiner asked me
you'd better to go out.
AMC feed back: ECT.- procedure, indications, effects.
6. A 70 yo lady c/o back pain. X ray was done and showed crushed fracture at L4. Bone density -3.
She comes today for the result.
- Discuss, expl the results.
- Plan Mx.
I greeted the Pt then asked if she is in pain. She said she OK. Then I asked Hx
- Any trauma, injury.
- Menopause: when, any symptoms of menopause. Still sexually active, any complaints. Pap smear,
mammography...
- Malignancy symptoms; night sweat, weight loss, lumps in the body...
- Diet: milk, diary product.
- Exercise, sun expose...
- Smoking.
- Fa Hx.
I explained her that there are 2 issues:
- Spinal fracture: pain Mx, rest on firm mattress... physiotherapy, occupational therapy.
- Bone thinning: Needs more Ix to r/o other diseases: RF, multiple myeloma, hyperparathyroidism.
Then I mentioned about life style modification: stop smoking, healthy diet, take diary product,
exercise...
Give some medication: Vit D, biphosphonate ( how to use, SE..), SERM. I did not mention about HRT
because her menopause was 20 years ago!.
AMC feed back: osteoporosis.
7. A elderly man had operation few days ago for bowel obstruction. The surgeons found that there is
a tumour in pelvis and some spreading to mesentery, liver. They decided to leave the tumor and did
colonostomy. The biopsy post op has confirmed colon carcinoma. The Pt now comes to your clinic
c/o abdominal pain and ask about his condition.
Answer the Pt's Qs.
Outside the room, I wondered if this is breaking bad news or if it is complication post op because the
Pt c/o abdominal pain.
I asked the Pt how severe the pain is, if he needs pain relief, any other symptoms.. he said no. At
that point I though it would be a case of breaking bad news. Then I asked if he comes alone... When I
stopped for a while for his relief, surprisingly he pushed me to continue. I said your case will be Mx
by MDT, the oncologist will arrange further Ix: CT scan, bone scan to find out where the cancer
spread to. About the pain, there are a lot of options depending on the severity ( I mentioned about
step wise of pain Mx in J.Murtagh book). He asked me how long he can live. I said it's too early to
say, be optimistic, the quality of life is more important the quantity of life... He insisted he wanted to
know how long he can live. I was reluctant to say but at that time the examiner told me loudly: how
long he can live? I was so panic. I turned to the examiner and said for colon cancer at this stage, I
mean Duke D, 5 year survival rate is 25 - 30%. Then to the Pt, I said we will try our best to give you a
comfortable life and the outcome would be different from person to person. Finally the bell came. I
escaped the room.
AMC feed back: Carcinoma of colon ( recurrent, advanced)
8. At the small countryside hospital, 12 month old child suddenly refuses to stand on his legs when
his mother holds him by his sides to support him to stand as usual. The child was healthy previously.
Father brings his child to the hospital.
- Take Hx.
-Ask PE
- DDx.
- Mx.
All Hx about pregnancy, delivery were normal. No flu like symptoms recently. No trauma, injury.
Immunisation up to date.
Father had no idea about where the pain is, any redness, swelling...
PE: T 39. Crying when touched to right leg. Swelling at right knee. Not sure about effusion as child
did not cooperate.
My provisional Dx is septic arthritis. However I needs to rule out osteomyelitis.
Refer the child to the tertiary hospital where the paediatrician will do further Ix; FBE, blood culture,
knee aspiration for microscope, culture, bone scan. We also start with IV ABT.
Examiner asked why do you send the Pt to the hospital? you are in the hospital now. I did not forget
the senaerio, I replied this is a countryside hospital, I'm afraid if we don't have the facilities to follow
up the case as many severe complications may happen esp septicaemia and the child is only 12
month old. How long for ABT? Because the child < 5 yo, ABT should be 3 weeks IV when then 1 week
orally ( I'm not sure) When I asked the role player if he has other concerns, the examiner asked me:
do you think you have finished your task. He did not look happy. I took a quick glance to the paper
task and found that I did mention all the tasks! Why did he look so cold? As I had no more
information to talk so I turned to the role player again and asked if he could arrange for his child's
admission. He said yes. I said I will arrange NETS ( National Emergency Transport Service) to transfer
the child to the tertiary hospital and also social worker will support him if anything in need at home.
Examiner then asked me: where does the bacteria come from? Well, they could come from skin
infection, throat infection, sometimes we are not able to find out their origin. So next time if your
child has skin lesion, sore throat... pls bring him to see the doctor.
AMC feed back: Septic arthritis.
9. A 50 yo man, chest pain. Last time he had stress test done which showed ST elevation ( I forgot
which leads). Today he comes for the results. His records are: BMI 35, BP 130/80, Cholesterol 6.,
smoking 10 cig/day.
- Expl to the Pt his test results.
- Plan Mx.
I asked if he is OK, any chest pain now. He said he is OK now.
PAIN Qs.
Risk factors of CVD Qs: diet, body weight, BP, Hx of DM, hypercholesterol, Stress.. Fa Hx of DM, HT,
sudden death...
Then i expl about the test and its purpose. I drew the pic to expl coronary artery's function.
I said about Mx plan based on life style modification: A( alcohol), B ( BMI, BP), C( smoking), D ( diet),
E ( exercise). About medication: statin would be consider if there is indication as in his case if
cholesterol increases up to 6.5.
The role player asked me: are you sure if I follow your advice I will have a healthy life? I nodded my
head and said surely, you will. He laughed. I don't know why whenever they laugh I become anxious
and panic. So I wondered what else he wanted. Luckily, he said: do I need an operation? I realised I
missed something. I said it's too early to say about op. I will refer you to a cardiologist he will
perform Ix to find out where the blockage is by injection dye. Then he will decide whether you need
op with stent or graft. They smiled and asked me to go out.
AMC feed back: Angina pectoris.
10. 4 yo girl whose parents have separated for last year. For the last 4 days the mother has noticed
rash in her vulva after the child came back for her father's place. The child also refuses to come to
her father's place. The mother suspects sexual abuse.
Take relevant Hx.
Ask examiner PE.
Talk to the mother about her concerns.
The role player was a Chinese medical student. She looked really upset. After I greeted her, she
started sobbing. Then she continuously told me about her suspicion, blamed her ex, asked me to
help her to keep the child with her, prevent the father from doing his custody.
Outside the room, I thought this is child abuse but at this point I wondered if this is a case of mental
disease ? Depression because her acts were exaggerated. So I started asking Hx with HEADS Qs. No
specific findings. Then I ask about the child: the only child, was healthy, growth and development –
normal. This is the 1st time she has this condition. Child stays with father 3 days/week. He does not
smoke, drink, has no new partner. No financial problem in both sides.
PE from the examiner: Child looks normal, VS – normal. No other signs of trauma: bruising, old
fracture, deformities. Rash in vulvar area. No bruise, no laceration, no scratched marks, no vaginal
discharge.
Then I expl to the mother that I suspect this is non accidental injury. However I will take the pictures,
swab for evidence and Ix to r/o condition likes: infection, eczema … which are less likely. The child
will stay in the hospital which is the safest place for her at the moment. You can come with her at
any time. I also report the case to CPU, CSA... they will help her as much as they can. I will contact
social workers they will help you if there is anything in need. The mother still looked upset and
started to cry. She said: you're not going to help me to keep the child with me, don't let her come
with her father. Again, I was confused! Why did she still upset after my explanation? Then I gently
touched her hand and said pls calm down and think positive. We are here to help you. It is my
responsibility to look after your child's health. The CPU, CSA will try their best to solve the problem.
Event family court may involve. She was still upset but the bell rang and I have to go.
AMC feed back: Sexual abuse.
11. In GP clinic, a 24 yo female student, c/o RIF pain for last few hours.
- Take Hx.
- Ask examiner PE.
- Provisional Dx, Ddx.
After greeting the Pt, I asked the examiner if my Pt is haemodynamically stable. He smiled and said:
good, she is stable.
PAIN Qs: RIF, 3-4/10, no radiation, no other symptoms.
5P: not has children yet, trying to conceive for last 3 months, LNMP 3 weeks ago, lighter than
normal, Pap 6 months ago – normal. Has no idea about breast US. No past Hx of STD, doesn't know
about blood group, no Hx of miscarriage, no Fa Hx of female cancer.
PE: T 37.2, BP 110/60. Tenderness on RIF, no rebound tenderness. Mc Burney: not clear. I forgot
asking about Rosving's signs, psoas, obtulator signs. Speculum ex: no bleeding, no discharge. Os
normal, close. Uterus: retroverted, normal size. Tenderness on RIF and Douglas porch. Urine dipstick
-, pregnancy test +.
I told to the Pt due to your last period is abnormal, your pregnancy test +, your abdominal pain so
most probably you have ectopic pregnancy. I needs to admit you to hospital where the gynaecologist
will do Beta HCG quantity and US to find down the location of the foetus/ sac. When the Dx is
confirmed there are 2 options of Tx: medical Tx ( I mentioned indication) or surgical Tx. Outcome is
very good. I drew the pic and said your chance to have pregnancy is 60%.
The role player asked me if she have appendicitis. I said the DDx are appendicitis, ovarian cyst
torsion, PID which are less likely. Don't worry, with further Ix we can r/o the Ddx. I asked if she has
other concerns. She said no. I finishes early.
AMC feed back: Probable ectopic pregnancy.
12. 18 or something lady who was admitted to hospital due to DKA. She was Dx DM type I at 15 yo
and on Insulin. Recently she usually skipped the meals because she thinks she is fatty.
Discuss about her condition.
Firstly I assured her about confidentially. She looked happy and said pls dont tell my GP!
I start with taking short Hx: how is her DM, well controlled? Check up? Any complications.
Then I asked about her current condition: is she OK now. And HEADS Qs: no stress, no family
conflicts, no any specific thing. She skipped the meals because she want to be thinner. She also self
induces vomiting and uses laxative to keep good body image. Then suddenly she asked me: doctor,
do you think eating too much and getting fatty are good for health. I smiled with her and said: you
are right, we should not eat too much but need to have healthy diet and keep body weight in normal
range.
Turn to the examiner, I asked if I can ask some PE. How is her BMI? He said she is there, you can see.
Then I asks BP, any dropped BP – no. Heart rate – normal. Any signs of dental decay, callous on
fingers..- nothing. No anaemia, no epigastric pain. I forgot to ask about menstruation.
I asked the role player if see know about DM I. She said no. I exp what it is ( pancreatic gland does
not produce enough Insulin …). That's why we give Insulin inj to control BSL. Due to low BSL after
Insulin inj, if you skipped the meals you may suffer from severe complication. Apart from that due to
self induced vomiting, using laxative you may have: dental decay, inflammation/ rupture of the foot
pipe, callous on fingers and most important is electrolyte disturbance. Loss of potassium can affect
to the heart and cause critical condition. Your condition is called bulimia nervosa. It's a kind of
abnormal behaviour. I will refer you to see the psychologist who will talk to you ( CBT) and the
dietitian who will give your a good advice about healthy diet. Finally I said I think there are too many
information for you today so I print some hand out for you to read at home. Here is my card. You can
call me if you have any concerns.
Then I asked if she needs to ask anything. The examination told me: you told her everything. On the
way I went out, the bell rang
AMC feed back: Bulimia nervosa.
13. A 24 year old lady who is at 10 week of pregnancy came to your clinic to ask about Down
syndrome because her cousin just gave birth a Down baby.
- Take relevant history.
- Counselling her.
I started by greeting the Pt. She looked anxious. When I was asking history, she seemed to be in a
rush to know about Down syndrome. However I still tried to ask full Hx.
About current pregnancy so far: This is her 1st pregnancy. No difficulty in conceiving. Has not had
antenatal check up yet. Has symptoms of early pregnancy. No abdominal pain, no vaginal bleeding/
discharge. Not yet taking folic acid. No idea a bout blood group.
Hx: Medicine: healthy. No DM, HT, SLE, bleeding disorder, clotting disorder.
Ob & Gyn: no STD, no miscarriage. Regular period. Pap's – normal.
Fa Hx: no DM, HT... No Hx of congenital abnormalities except the above newborn baby.
Then I asked her if she know anything about Down syndrome. She said no but asked if it is
hereditary. I said it is not hereditary disease, it's congenital abnormalities due to abnormal
chromosomes. Then I expl about 23 pairs of chromosomes. The 21st have 3 instead of 2
chromosomes. Briefly mentioned about physical abnormalities and consequent complications. The
Pt looked really panic now ( I wondered if it is my mistakes to talk about these bad things!)
I quickly reassured her. Nowadays we have a lot of antenatal screening tests as well diagnostic tests
for Down syndrome. Screening test: 1st trimester: PAPA, B- HCG, US: nuchal thickness at (11 – 13
week), 2nd trimester: AFF, B HCG, Oestradiol, Inhibin A. Diagnostic tests: CVS ( 9 – 11 week, result in
2 days, miscarriage 1- 2%), amniocentesis ( 14 – 16 week, result in 2 weeks, miscarriage 0.5%). She
said: if Down baby has confirmed do I need to have abortion? Well Down syndrome is actually not a
significant condition. Depends on the type of chromosomal abnormalities: totally or partially ( I
wanted to mention about mosaic type.... but don't know how to exp them in lay terms) baby may
have a mild or severe symptoms. Good things is they are lovable, compliant …. So actually, there is
not a indication for abortion in all cases. Finally the choice is yours. She looked relieved. So I
concluded: pls take folic acid right now and continue up to 12 week pregnancy. I will arrange all the
antenatal tests for you plus some screening tests for Down syndrome. As your Fa Hx, your case will
be follow up at high risk clinic. When I ask her if she has any concerns, she said no. I still have time,
when the examiner ashed me to go out, suddenly the role player asked: can you tell me the
incidence of Down baby in my case? I said: for normal population, before 35 yo, incidence of Down
syndrome is 1/700. But I don't know the incidence if the cousin gets Down baby, I will ask my
seniors. She smiled the bell rang.
AMC feed back: explanation of fetal abnormality screen.
14. A well known case: a 40 something yo man who had pace maker put in few year ago came to GP
clinic c/o tiredness. No alcoholism. LFT has been done : increased GGT, ALP. US of abdomen showed
some changes of liver ( I forgot). The GP has written a referral to the specialist for further
management.
- Exp about the result to the Pt.
- Ask the examiner PE.
- Which Ix would the specialist order? You will only be given the result of which you ask for.
- Give Dx and discuss with the Pt about further Mx.
I greeted the Pt then ask how he is today. He said he is tired. Then I asked if he feels comfortable. He
said he is OK. Then I grabbed the copy of the senario, showed it and expl to him 1 by 1. I said: GGT,
ALP are liver enzymes. The increased levels mean there is some damage to the liver cells. Also US
showed some abnormalities in the liver. I said I will ask the examiner about PE to see how the
disease is going on then continue talking with him.
PE: Pt – alert. No confusion ( hepatoencephalopathy), no skin discolouration. No jaundice. VS –
normal. No parotic enlargement. No spider naevi, no carput medusa. Chest, heart – normal. Heart
rate – regular. Liver enlarged 2 cm below the costal margin. When I asked about density: hard or
soft, about the border: rough or smooth, hepatic jugular reflux... Not clear. No supraclavical LN, no
collateral veins. PR: no specific findings. Flapping tremor: -ve.
Ix : I asked if I have iron study, the examiner immediately gave it me, ferritin serum – increased, TIBC
– decreased, transferrin saturation: increased.
Then I expl to the Pt; most probably he has the condition called haemochromatosis. It is a genetic
disease. Due to high level of Fe, there are many complications which depends on where Fe is going
to accommodate. For ex: It can affect to heart – as your case, affect to joint: joint pain, affect to
pancreas: bronze DM, affect to testis; atrophy, affect to liver: liver cancer which may be a concern in
your case. Dont worry the gastroenterologist will do biopsy to see if there is nasty growth in your
liver.
Mx; Giving blood 500ml every week meanwhile follow up iron tests. When the level back to normal,
giving blood every 2 – 3 weeks
When I asked if he has any concerns he said no. Then suddenly my memory is switched on, I said
because it's genetic disease, it would be a good idea if your sibling, children have a genetic check.
The examiner said: you seem very interesting with this topic. Then he ask me if I think I finished my
task. I said I'm not sure but my task is to discuss with the Pt so I dont know if he wants to ask me
anything. The examiner gave me the other paper with : C282Y, H63D. He asked do you know it. I said
they are 2 mutations of gene disorder in haemochomatosis. He looked happy but the role player
said: I dont know anything. They both laughed then the examiner said: you'd better go out. I finished
early.
AMC feed back: Abnormal liver function test.
15. A 32 yo lady came to your clinic, wanted to know about sterilisation. Husband, 36 yo, is happy
with their decision. They have 3 kids ( forgot ages). Counselling.
I stared: I knew from the notes you want to ask me about sterilisation. Can I ask you some private Qs
before we discuss? She said yes. Then I asked: Period, Pap, Pill, Pregnancy … About the pill: what
kind, how long, any complication, follow up: BP, weight..., any complaints ( no).
Family situation: no family conflicts, healthy children. Marital status: happy. General healthy: good,
except operation for complicated appendicitis with a long scar next to the mid line.
I asked of she know about sterilisation, from which sources. I drew the pic then explained how
sperm and egg meet together. I said the whole procedure of sterilisation. Usually it will be done with
keyhole surgery but in her case may be normal abdominal operation as she had previous op. I
emphasised: successful rate is not 100% due to reconnection, and no prevention for STD. At the end
of the day if she changes her mind, wants to have baby, needs to have micro operation: successful
rate if 60% with hight rate of ectopic. Then I advised if the is no complaint with pill she can continue
with it or try others: depoprovera, implants, IUD ( I said about route, advantages, disadvantages of
each method) Examiner asked what kind of IUD, I said: Minera, Cooper 375. Finally, I also mentioned
about male sterilisation which is more simple.
When I ask if she has any concerns, she said no. Then I said you dont need to be in a hurry, go home,
think carefully if you want more information I will give you hand out.... I finished early.
AMC feed back: request for Sterilisation.
16. At GP clinic, the young lady suddenly has calf pain. She has 2 relatives diagnosed with DVT. This is
the 1st time she has this condition.
Take relevant history.
Order Ix. Expl to the Pt about Dx.
Mx
I asked all risk factors of DVT: no travel by flight, no pregnancy, no pill, no Hx of DVT, or fracture or
immobilisation, no varicose, no smoking, no obesity. No night sweat, weight loss, no lumps, bumps
on the body recently. Sister had DVT. Cousin also had DVT. Both are fine now. In general, she is
healthy, not on any medication esp female hormone. No Hx of other diseases; SLE... Current
condition: no SOB, no cough, no chest pain.
Ix: Doppler US: thrombosis at level of left lower leg, D dimer, thrombophilia screening test, ANA,
coagulation profile....:not available.
Epl: I drew the pic of the leg, expl about the role of venous system. Due to clot in vein, blood can not
get back to the heart. Trapping of blood causes pain. The most dangerous is this clot can dislodge
and travel to other organs: lung ( PE), brain ( stroke)...They are critical conditions. That is why we
needs to order further Ix.
Thrombophilia screening for Tx: If there is Fa trait, Tx will be long life.
Coagulation profile: INR for follow up Tx.
Refer to haematologist who will put her on Heparin 1mg BD inj and Warfarin orally. When INR 2-3
stop Heparin and cont with Warfarin. Examiner asked what kind of Heparin, I said low molecular.
Then I mentioned about SE of medication: bleeding gums, red urine, black stools... Needs to come
back immediately. And intereaction of medication: pill, Nexium, Antacid.. cause decreased INR,
Corticosteroid, Rulide, Aspirin … cause increase INR. They looked happy and did not ask me anything.
I was about to run to the next station. The examiner said you finished your exam. Good luck! At the
time I realised that was my last station!
AMC feed back: DVT
I tried to write in details what happened in the exam so you can roughly know about the real
situation. Apart from knowledge, the more appropriate you can manage to response to the
examiners' Qs or the role player acts the better outcome you can get, I think. Study hard, practise
repeatedly then everyone can make it. Best wishes to all of IMG candidates who is struggling for
AMC exams. Please help each other because we still have many other exams. Passing this exam is
just the end of the beginning.
AMC Clinical Examination 19 March 2011,
Melbourne
O&G
(1) 24 years old girl with her first pregnancy at 10 week gestation came to your
GP clinic to ask about Down syndrome. She is concerned about this because
her 32 years old sister gave birth to a baby with Down syndrome. She has
already decided not to continue this pregnancy if she found that her baby has
Down syndrome.
Task: take focused history; manage the case and counsel the patient
accordingly.
History taking
How are you today? The RP said I am good.
As far as I know, you want to get information about risk of Down syndrome, is that correct?
Yes.
Before we get to that point, I would like to ask you some questions, related your pregnancy,
and is that O. K? She said o. k.
I asked her how your pregnancy is so far. Have you already seen the doctor and done all
blood test? All results were normal.
Are you taking folic acid? Yes.
Do u have any medical problem that I should aware of? No.
Do u smoke or drink alcohol?
Are you on any medication? No.
Is there a genetic problem in your family apart from Down syndrome, cleft lips or cleft
palate? No.
Explanation and answer the questions
Then I asked her what you know about Down syndrome and explained to her about Down
syndrome. It is a genetic disorder that associated with advanced maternal age however it
mostly occurs below 35. In general population, the risk of having a Down syndrome baby is
1:600-700 but the risk increase with age and if there is family history of Down syndrome.
I explained that there are 2 sets of tests available: one is screening and the other is diagnostic.
The advantage of Down syndrome screening tests is that they only require a blood test from
the mother and an ultrasound to check the neck thickness of the foetus, so there is no risk to
the pregnancy. The first one is triple test (USG, PAPP, and BHCG) which is done during the
first trimester (typically at 11 to 13 weeks of pregnancy) and the second, quadruple test is
done during second trimester (4 markers in your blood which are either protein or hormone).
, if they are higher or lower than normal, it can be suspected for Down syndrome.
If both tests are negative, it is less likely to have a Down baby. On the other hand, if both
tests show abnormal results, you will be then put in a high risk group and need to have
another test done, which is a diagnostic test which is nearly 100% accurate to detect Down’s
syndrome. There are two tests available which are invasive procedures and require putting a
needle into the uterus or placenta and removing some fluid or tissue. Chorionic Villous
Sampling which is done at 11-13 weeks and the results will be back in 48 hours. But it
carries1% risk of miscarriage , and Amniocentesis which is done at15-18weeks and need to
wait for 2 weeks to get the result and which carries 0. 5% risk of miscarriage (1:200).
I asked RP do u understand what I am explaining to u so far or do u have any concern?
Then RP asked me "Do you still offer me diagnostic tests if the screening tests are negative?"
I said, screening tests for Down syndrome cannot tell for certain whether your foetus actually
has Down syndrome; rather, they tell you whether there is a low or high risk that the foetus is
affected. However, a diagnostic test can tell for certain if the foetus has Down syndrome or
not. Since you have family history of Down syndrome and you do not wish to continue the
pregnancy if you found your baby carries this gene, I would like to offer you the definitive
tests.
But the decision to have diagnostic tests depends on your wishes. There is no right or wrong
choice; you can decide what is best for you and your family. You can discuss with your
husband and I can arrange another meeting with both of you. If you want I can refer you to
obstetrician who can explain to you about the chance of having baby with Down syndrome
and about the invasive procedures in detail.
AMC Feedback: Explanation of foetal abnormality screen (passed)
(2) 22-year-old lady came to ED with right sided abdominal pain since last
night.
Task: Take history, ask examination finding from the examiner,
Order necessary investigations and explain your management plan to the
patient.
My DDx of pain in RIF: Appendicitis, Threaten abortion, Ectopic pregnancy,
Twisted ovarian cyst, PID, UTI
History taking
I asked examiner whether my patient is haemodynamically stable or not. He asked me again what
you want to know. I said BP, PR, T _all normal.
I offered the RP painkiller but she said it’s ok.
Then I asked all pain questions: pain started suddenly last night, around right lower part of the
abdomen and radiate to the back, 6/10, not relieved with anything, not associated with fever,
nausea and vomiting, no discharge or blood from the vagina.
I asked about waterworks and bowel motion. She mentioned as normal. When asked about the
LMP, it was about 3 weeks ago, regular, moderate amount, and no pain. She is married and not
on any contraception because they are trying to conceive.
When I asked about the symptoms of pregnancy, she denied. No past history of STD/PID also. Have
u ever been pregnant before? She said no.
When I asked RP, have u done a pregnancy test, the examiner said it was positive.
PE
Since I have known the vitals, I went for focus examination of the abdomen and pelvic. Pain in RIF,
no rebound tenderness, all tests suggestive of appendicitis–negative (no need to ask but want to
make sure). No renal angle tenderness. Pelvic examination: no discharge on inspection and os is
closed on speculum examination, but on bimanual examination, there was tenderness in the right
culs, Ut size is normal.
Urine dipstick normal. Quantitative BHCG and USG results were not available.
Explanation and Management
Then I explained to the patient. According to the history, the examination findings and the test
result , there is a high possibility that you have what we call “Ectopic pregnancy” that is a pregnancy
outside your womb, this can be in the tubes between your womb and ovaries as in most cases or
inside the tummy, which is very rare. As the pregnancy is not in the usual place, it cannot continue
to term. I understand that it is very disappointing for you.
Now you need to be admitted to the hospital where you will be seen by obstetrician; she or he will
make a definite diagnosis by laparoscopy or key hole surgery. First you will be put to sleep, and
then they will insert a tube with lens through a small incision in your tummy, and have a look at
your womb and tubes. Treatment will depend on the size of the sac, viability of the foetus, level of
BHCG. Depending on this, the obstetrician will decide either to inject medication or remove the
foetus by operation. Although the doctor will try to preserve the tube, there is still chance that they
need to remove the tube in case it is damaged.
Do you have any questions that you want to make clear? Can I become pregnant again?
Yes, you can as there will be one tube and ovary left even if the affected tube will have to be
removed. But still there is a chance of having ectopic pregnancy in your future pregnancy. (If tube
need to be removed, there is a chance of having pregnancy every alternate month.
AMC Feedback: Probable ectopic pregnancy (passed)
(3) 35- year- old woman came to your GP clinic because she wants to discuss
about sterilization. She has 3 children and has been taking oc pills for a long
time.
Task: take focused history, ask physical examination findings from examiner
and counsel the patient sterilization and other contraceptive methods suitable for
her.
History taking
I introduced myself and said from your notes I understand that you want to discuss about female
steralization. Before we come to this point, may I ask you a few questions? RP said it’s ok.
I asked the reason why she doesn’t want to continue to take oc pills anymore.
She said “I do not want to introduce all these hormones into my body and I will continue to be
sexually active for another 20 years. So I do not want to use any hormones for more than 20 years.
Since I have completed my family, I want to do the sterilization.
When was your LMP? It was 2 weeks ago.
Can you tell me about your period? It was regular and heavy before taking pills, but now regular and
normal flow after taking pills.
Have you ever been diagnosed with STD/PID? She said NO. When was your last papsmear? 6months
back-normal
Do you have any past medical problems? Have you undergone for surgery? Yes, it was a very
complicated procedure since appendix was burst. Then she continues to talk about that procedure
in detail.
At that time I did not realise that why she kept saying about appendectomy rather than sterilization.
Anyway I continue to ask her about her last Pap smear (normal), any medication that she has been
taking (nothing except pills), any relationship problem(no). On physical examination, the examiner
said all normal except there is a paramedian scar on abdomen.
Then I offered her different methods of contraception.
Depo Provera (this is the injection form and need to inject every 3 months).
I do not want to go to the clinic every 3 months, besides this is also hormone. Implanon (It is like a
small stick which will be put under the skin of the arm)
And last for about 3 years.
(Mirena)_can last for 5 years suitable for those with heavy period No
Male sterilization-Her husband does not want to have this.
Explain it’s a permanent procedure, method, failure rate, possibility of Rejoining. It will not protect
from STD, so u need to use condom. Reverse process is very difficult and involves complicated
surgery (about 50% can be pregnant with high risk of ectopic pregnancy. Regarding the procedures,
it is usually done with laparoscopy but in your case since you have the scar, I will refer you to the
gynaecologist to discuss further about the procedure.
RP asked me what about my period after sterilization.
It will not change.
AMC Feedback: Request for sterilization(passed)
Paediatric
(1) 12 month old child, refuse to stand for 24 hours, presented to ED with her
father.
Task: take focused history; ask examination findings from the examiner,
investigation and management.
History taking
I asked the RP, from your notes I understand that your daughter refused to stand for 24 hours. Can
you tell me more about it? RP said it happened all of a sudden and the child was crying excessively
that’s why he brought her to ED.
I asked can she walk properly before. Yes.
Has she been crying all the time or at particular time (like when u touched her limb). Yes when I was
changing her clothes and holding her limbs, she cried a lot.
Any trauma to the limbs. No.
I forgot to ask whether there are any swellings in either of the limbs.
Is she feverish? Yes, high fever for 48 hours.
Any viral I illness before? Any fits, noisy breathing, discharge from ear & nose (No).
What about water works (does the child cry when passing wee) and bowel motion? Normal.
How is her general health so far?(healthy child)BIND Normal.
Physical Examination
General appearance (drowsy/alert) _child looks ill.
Vitals (39C) ENT examination_ normal.
Respiratory /CVS/Abdominal examination _normal. Lower limb examination what do u wants to
know? I asked can the child stand(NO), bruise, deformity, swelling, temperature , tenderness
(Examine joint above and below) there is a swelling , redness , tenderness in left knee joint and
other finding are normal.
Explanation and Management
I explained to the RP: From history and examination, I am thinking a couple of possibilities. Septic
arthritis , osteomyelitis and transient tenosinovitis. But most likely your child has a condition called
septic arthritis that is inflammation of the joint due to infection through the blood. Your child need
to be admitted to the hospital where she will be seen by ortho registrar.
She will be put on antibiotics after taking blood sample to find out the causal organism, then joint xray, chest x-ray, other necessary investigations depending on the initial results
RP asked: Is my daughter condition serious?
Yes, but with immediate treatment and proper care, she will be ok.
How long does she need to take antibiotics?
IV for 2 weeks followed by oral for 3 to 4 weeks depending on your daughter
condition. Doctor will switch to the most appropriate drugs once blood result came
back. Why did it happen to her? Bell rang
AMC Feedback: Septic arthritis (passed)
(2) 4 year old girl went to ED yesterday due to acute attack of asthma followed
by upper respiratory tract infection. Today, Father came to your GP clinic for
follow-up.
Task: take focused history, and explain the management plan to the father.
History taking
From the notes I noted that the child got the acute attack of asthma yesterday? Can you tell me
more about it?
What did the doctors gave her?
When was she diagnosed with asthma? (3).
What treatment is he taking? Ventolin
How do you give him ventolin ( 2 puffs with spacer ).
I know how to give the medicine. ok I will check it later.
Do you know how frequent you get the symptoms? 4 attacks within 8 months.
What happens in between the attacks?
Do you have symptoms between the attacks? Yes.
How many days in the week does he have the symptoms? 3 to 4 days
Does he have symptoms in the evening? How many nights does he have the symptom? 4 nights
How is his sleep? (Can sleep well)Has he ever been admitted due to severe asthma? No. Just went to
ED.
How often does he get admitted?
What do you think is the reason or what triggers her asthma? Viral infection , Flu, pets, smoking.
Is he allergic to anything else?
Explanation
Then said, I will give your daughter ventolin only.
Ask to avoid triggering factors and wash the spacer as well
If the child need ventolin more than 1 day a week
Advise about activity and growth of child
I gave Asthma action plan – 3 copies
Advice to stick the copy at the fridge
Explain what to do when the condition become worse.
Wherever you go – Bring asthma action plan
Always bring reliever, spacer
I failed this station because I did not add steroid which is very important. Although RP gave me
hints to add steroid I could not respond. (this is my last station).
AMC Feedback: Chronic Asthma (failed)
(3) Mother of 4-year-old girl, who has separated from her husband, comes to
your GP clinic as she noticed the rash in the vulva area of her daughter. She
thinks that her Ex husband is abusing her daughter as the girl who has been
visiting her father refuse to go back to her father’s house.
Take relevant history, physical examination and manage the case.
History taking
I asked the RP about her concern. She thinks that her ex husband is abusing her daughter. Why do
you think like that? She said her daughter does not want to go back to her father place and she
noticed the rash in the vulva area of her daughter. Ok, I understand your concern but before we
come to this point, can I ask you a few questions. Yes. Start with the detail history of rash (site,
onset, and colour), itchiness, vesicles, ulceration, bleeding, discharge, and trauma. Similar rash in any
other part of the body. What about her water work and bowel motion? Normal. Have you noticed
any abnormal behaviour like strange posture? No. How is her interaction with friends and with you?
Fine. With whom is she living apart from you? (my boyfriend). How’s her relationship with your
boyfriend? (Good) he is a nice person. Has she got any allergic history? SAD questions for all.
Physical examination:
GC –alert and happy. Any bruise, rash, scar (all over the body) _No.
External genitalia_rash (no bleeding, no ulcer, no discharge)
Explanation and Management
Based on history and examination, I could not find any evidence suggestive of sexual abuse. There
could be other possibilities like (foreign body, allergy, and valvovaginitis). But I understand your
concern for your daughter so I will refer her to child protective service. They have a team where
many people involve –doctors, police, and social workers. They will examine your daughter
thoroughly and take sample from your daughter private part. They will also interview you, your exhusband and boyfriend. If you want I can offer you the support group. We will try our best to give
you the best possible help to solve your problem. I will follow you up. Bell rang
AMC Feedback: Sexual Abuse(passed)
Psychiatry
(1) 50-year-old woman, with long standing history of depression, has been
admitted to the hospital for severe depression with psychotic features. She has
been on antidepressant but not responding well to this medication. So,
psychiatrist has decided to do ECT.
Task: Explain to the daughter about the indication, the advantages and
disavantages of ECT.
History taking
Hi Ms …. , I am Dr…. . I understand that you are here to discuss about your mother condition. Yes.
Ok, I will explain about your mother condition and the treatment she will need. Psychiatrist has
decided to do ECT (electroconvulsive therapy).
Have you ever heard about that? No, what was that?
ECT is a short wave given with electrodes from which current passes to the brain that induces a
seizure. The purpose is to change the level of chemical in the brain.
RP asked me it sounds dangerous? I said it is safe and effective. It is given with general anaesthesia
along with muscle relaxant. So the patient needs to fast before doing this procedure. She might feel
confused, headache after waking up.
Only in one condition like if there is any mass or recent haemorrhage, where we can’t do this
procedure. So we will do CT of head first to exclude this.
RP: What do you mean my mother can have another condition?
I said we just want to exclude whether is there anything in her brain that can increase the pressure
in her brain. She seemed to be confused. Then I said this is part of the procedure.
RP: Then she asked why they decided to give ECT to her mother. I said since your mother is not
responding to medication, not eating nor drinking or not caring herself, she has psychotic features as
well. So she can harm herself if we do not control her condition very well.
Since we cannot wait for 4-6 weeks for the antidepressant drugs to kick in, this is the most effective
way of treating her depression.
RP: Why did not they give ECT if the response is good? Why did doctors treat her with
antidepressant without doing ECT previously?
We decide to give only to those who have indication like severe depression and suicidal ideation(like
in your mother case). Otherwise, we only use antidepressant to control mild to moderate
depression.
RP : Will my mother condition be cured after giving ECT?
We uusually give 6-9 sessions of treatment to patient. But, sometimes people respond after
3-4 sessions.
RP: What do you mean by respond? I mean if her condition improved after giving ECT, we
will consider continuing or not. Number of treatment given will be decided by psychiatrist.
RP: Are you sure that my mother condition will be completely cured after receiving ECT? I
said the condition will be improved but not cured so she will need to take antidepressant. It
depends on individual patient, if u have concerned I can arrange meeting with psychiatric to
clear any doubt.
I could not convince to RP and the bell rang.
AMC Feedback: ECT (failed)
(2) 18-year-old with DM type1 has been in hospital because of DKA.
Normal weight. She has a history of binge eating, use laxative and history of
self induced vomiting after binge Eating. Now she is ready to be discharged.
You are a HMO of that hospital.
Task: Explain her about the eating disorder she has and counsel her about the
management.
This is exactly same recall with opening statement “Are u going to tell my GP about this’’
I ensure her about the confidentiality. Explained her everything.
But when I came out of the room I realised that I forgot to mention the name of this condition
(bulimia nervosa) which is one of the task.
AMC Feedback: Bulimia nervosa (failed)
Medicine & Surgery
(1) 60-year -old man went to the hospital where stressed ECG test was done
and it was found to be positive for ischemia showing ST segment changes
(probably anterolateral segment). The patient records were given. He has
history of smoking for 20 years. Blood pressure is 130/80 mmHg, cholesterol is
6 mole/l. Now he is on anginine. His BMI >35.
Task: Explain to the patient, the results.
I started this station with explanation of the result…
Mr … from your notes, I understand that you are here to discuss about the test results.
Am I correct? Yes.
Your stress ECG result shows that you have a condition called angina pectoris.
It is a condition where people present with chest pain due to shortage of oxygen to heart muscle. It
occurs due to deposition of fat like substance in the coronary vessels resulting in narrowing of blood
vessels that supply to the heart. It can be due to several factors, so we need to control risk factors
first.
Lifestyle modification:
The first one is alcohol since you do not drink alcohol which is good.
Second, blood pressure is also within normal limit which is again very good. But your BMI is about
35 which fall into the category of obesity. So I will refer you to the dietician first to work out on a
diet plan and I would like to suggest you to do exercise like brisk walking but not at the moment. For
that I would give you the contact of the trainer, they will assess you and give you the exercise
program within your limit. Aim for body weight is between BMI 20-25. Hopefully we will try to
achieve that level gradually with diet and exercise. If not, then we will consider using medication. I
also found that you have been smoking . . . cigarettes/day for over 20 years. Since cigarette smoking
is one of the risk factor for your condition.
Would you like to consider stopping smoking? Ok,
I will arrange consultation to quit smoking.
Cholesterol level is 6mmol/l (slightly high), but I need to order lipid profile to check other lipid and
will control the level with diet. Then, if failed, we may start you on certain medication which lower
cholesterol called statins.
Do you have any concern?
Is my condition serious? Not at this moment if we control all these risk factors aggressively, we can
prevent serious outcome. So, I will refer you to the cardiologist, he will do necessary investigation
and depending on the result – the cardiologist may decide next step.
Then RP asked me can I have sex, yes but once your condition has stabilized. But I would like to
advice not to use drug like Viagra.
Bell rang. Could not say anything more.
Feedback: Angina Pectoris(passed)
(2) 50-year-old man comes to your GP clinic that has been referred to you by
another doctor with the complaint of tiredness. He is non alcoholic. He has
inserted pacemaker for bradycardia, abnormal LFTs (ALT -raised, Alkaline
Phosphate-slightly increase), Bilirubin-normal, Viral serology-Negative, USG
showed slightly enlarged liver, small gall stones,
Task: Ask further investigation, counsel the patient depending on the results.
From this referral notes, I understand that your previous GP ordered some blood tests because you
complained of tiredness. And the results showed that your liver enzymes are increased, but the
viruses that can attack the liver and causing raised liver enzymes are not found.
The USG showed small gall stones and slightly enlarged liver.
You have inserted pacemaker for heart problem. Since you have raised liver enzymes without
drinking alcohol and not having viruses in the body, I am thinking about the condition called
haemochromatosis. But I still need to confirmed this by ordering iron study (at that time examiner
gave me the result), yes it showed serum ferritin and transferring saturation is increased, which
means storage of iron in the body is high.
But I need to order HFE gene study (examiner gave me another card) which showed C282Y is
positive.
So I explained to the patient that my suspicion of haemochromatosis is confirmed by this test. I
asked for blood sugar level, first examiner said not available then said 8mmol/l (I guess no other
tests are available). I asked RP do you have any idea about this condition (haemochromatosis).
The Rp said NO.
It is a genetic condition where there is a defect in the gene which helps to regulate the amount of
iron absorbed from food. Because of this defect the body absorbs too much iron which deposits in
different organs if not detected and treated early, skin (pigmentation), liver (cirrhosis), heart
(rhythm problem), pancreas (diabetes_DM), testis (atrophy, loss of sexual drive).
That's why people of this condition usually complain of fatigue, lack of energy, abdominal pain, loss
of sex drive, and heart problems.
Treatment is simple, just to remove 500ml of blood every week until iron level goes back to normal
Treatment cannot cure the conditions associated with hemochromatosis, but it will help most of
them improve, which leads to a normal life expectancy.
However, if cirrhosis (scarring of the liver), has developed, the future outcome might not be good. I
will refer you to the specialists, hepatologist; he/she will do biopsy (taking the tissue sample from
the liver).
Do u have children? He said no.
Do u have siblings? Yes
I said all siblings (first degree relative) should do blood tests to see if they have the disease or are
carriers. Gall stones are just incidentally found. For this I will refer you to the surgeon with whom u
can discuss about the treatment option.
Examiner asked do u think the raised liver enzyme could be due to gall stone.
I said no.
AMC Feedback: Abnormal Liver function Test(passed)
(3) 22- year- old young man came with severe headache. You are HMO at the
ED of the hospital.
Task: Take history, ask physical examination from the examiner and explain
diagnosis to the patient.
DDx of headache: migraine, tension headache, tumor, haemorrhage (trauma), cervical spondylosis,
sinusitis.
History taking
I asked the patient “Are u comfortable to answer my question or do u want me to relieve your pain
first. ”RP said its ok.
Then I started with pain questions where, onset, severity, radiation aggravating or relieving factors.
[Pain around the head for 2 days, severe, not relieved with pain killer, no nausea &vomiting, no fits
but sensitive to light].
Any trauma recently (No).
Any pain in neck? (NO).
Any problems with the sinuses. Any weakness in any part of the body. Any similar attack before? All
No.
Any contact with sick patient recently. NO
Physical Examination
GC: conscious & ill, No rashes. Fundoscopy (can’t see properly due to flashing light, need to dim the
light?), Neck stiffness (positive), Kernig sign (Negative). Neurological examination (Tone, power,
reflexes) - All normal Urine dipstick (normal)
Examiner asked me to talk to the patient about the diagnosis.
Explanation
From history and examination results, the most likely condition you have is what we called
meningitis (inflammation of the covering of the brain), but I still need to rule out some lesion in the
brain (tumor).
He asked me what else; I forgot to mention (haemorrhage).
You need to be admitted to the hospital. Is my condition serious? Yes.
I thought that it is just normal headache, s o I was staying at home.
At the hospital, you will be seen by neurologist and will order CT scan, (to rule out the condition that
can increase intracranial pressure), blood culture, FBC, Blood glucose, ESR, CRP.
Then, they will consider to do LP if CT normal.
You will be treated according to the results.
AMC Feedback: Headache (acute) passed
(4) 50 years old, gardener, complains of long standing back pain and groin pain.
Take history; ask for examination findings and discuss your management to
your patient.
I started with pain question:
Pain around groin area, deep seated pain, severity 6/10 , no radiation, no pins and needles
sensation.
Back pain, for a long time, diagnosed with lumbar spondylosis. Relieved with physiotherapy now,
back pain is not that much giving him trouble.
Groin pain which occurred after lifting something. Pain aggravated by climbing stairs, not with
walking or sitting. Not relieved with pain killer.
Besides No history of trauma.
He has no other medical problems.
Examination findings will be provided which u asked for. I asked BMI (as u see), posture, gait,
movement, power, sensory, special tests. Results were limitation of Abduction, Adduction, IR, ER,
Flexion, but Extension-normal.
Tenderness at the vertebral column (not specific) No fix flexion deformity, Straight leg raising normal. Sensory and reflexes were normal.
I explained to the RP that from history and examination findings, I think you have a condition called
osteoarthritis, but at the same time I need to rule out hip dislocation & fracture (which are less
likely), and sciatica (less likely). I will order x ray & see is there any arthritis changes or fracture or
dislocation) If not could be nerve problem.
So if necessary I will refer, bell rang.
Could not say anymore.
AMC Feedback: Hip Pain (Passed)
(5) A 50 years old female was diagnosed with ca caecum about a few months
back and surgical procedure was done (entero-enterostomy). Few days back, she
presented with intestinal obstruction when she was readmitted to the hospital
where operation was done again to relieve obstruction. But there were some
cancer cells left in the pelvic. Now she had severe pain in her lower back and
lower tummy region which was not relieved by pain killer. Physical
examination showed tumour has spread within the pelvic and is now in
incurable stage.
Task: Counsel the patient.
Breaking bad news: As usual
AMC Feedback: Carcinoma of colon (recurrent, advanced) passed
(6) 70 year-old lady with L4 compression fracture and back pain with t score -3
(DEXA scan), come to your GP clinic for result. Take history, explain the
nature of the result and counsel her regarding management.
I asked the RP about the risk factors (body weight, cigarettes smoking, alcohol drinking, exercise,
calcium in her diet, taking cortisone and HRT, family history).
Her body weight is normal.
She has had menopause for 15 years but not on any hormonal therapy, or on any medication such as
prednisolone.
She has no history of hypertension and diabetes mellitus, thyroid and renal disease.
She does not smoke but consumes 2-3 drinks of alcohol a day.
The patient doesn't like milk, dairy products and doesn't do any exercises. Last Pap smear was done
_ year’s back which was normal and mammogram done 6 months back that was normal too. Family
history
I explained to her about the results. DXA scan which can predict an increased risk of osteoporosis
and fracture showed t score -3 which means you have a condition called osteoporosis. Do you have
any idea about this? It is a condition leading to thinning of bones with reduction in bone mass due
to depletion of calcium and bone protein so that they become weak and brittle and prone to
fractures. It is found mainly in middle-aged and elderly women, after the menopause where the
body (ovaries) stop producing female hormone called oestrogen which is important for forming
bone mass. Another reason is lack of Ca in the diet and lack of activity.
What I would like to do now is I will give you the pain killer to relieve the pain first, Take regular
weight-bearing exercise such as walking (e. g. Brisk walking for 30 minutes 4 times a week).
RP asked me do I need to do exercise now. No
I will refer you to specialist for fracture. You need to take rest till pain subsides. Then you will be
put on bisphosphonates and calcium supplements. I advice her to limit alcohol drinking within safe
level. Encourage her to take dairy products and provide her pamphlet containing the lists of
products and the amount she need to take.
Any concern? RP asked me can there be other cause for this fracture. Then I said yes I will refer you
to the specialist to rule out a condition called multiple myeloma.
AMC Feedback: Osteoporosis (passed)
(7) 55 year old lady presented to GP with the complaint of swelling and pain
around lower part of right leg. Mother and sister have DVT. She is taking
HRT.
Task: Take further history, ask for investigations and explain immediate and
future management.
AMC Feedback: DVT (passed)
(8) 60-year-old man, chronic smoker, recently becoming more and more SOB
on walking up hills.
Task: Do complete respiratory examination within 6 minutes and present
your findings to the examiner.
AMC Feedback: Respiratory Examination (passed)
Sydney 9th March 2011, morning session.
1. A middle age woman has major depression with psychosis and suicidal idea
not responding to antipsychotics and antidepressants. She is in hospital now
and the psychiatric team decided to give her ECT. Her daughter is concerned
about procedure and sees you in GP office. Tasks: explain the procedure, its
indications, advantages and disadvantages, address the concerns of the
daughter.
I explained ECT-the use of electricity to correct the chemical imbalances that
cause your mother’s symptoms. It is performed under general anaesthetics.
We apply the electrodes on the head, then deliver electrical activity that cause
convulsion and correct the problem.
It is indicated when the patient has severe mental illness not responding to
medication such as major depression, acute psychosis and is at risk of
harming themselves or other people, and it is the case of your mother. Also
indicated when patients cannot take medications because of other medical
problems.
Advantage: quick method to help the patient.
Disadvantages: temporary memory loss, which may be persistent, risks of
anaesthetic drug reaction.
Questions from the role player:
It looks terrible on movies, is it sore? – Yes, it looks more terrible than it is.
We work together with psychiatric team and anaesthetic team; make sure
that your mother is not suffering. She will be put to sleep and when she
wakes up, everything is done. She would not feel sore when she has the
procedure.
- Will my mother loose her memory and cannot recognise her children? –
She may have temporary loss of memory but will recover with time. Only a
small chance that memory loss may be persistent. We need to consider
the benefit of treatment and its side effects.
I did not know what else to discuss as I covered these points within 3-4
minutes. I asked the role player several times – whether she has any other
concerns. She said no.
I failed this station and did not know why.
-
Feedback: ECT- procedure, indications and effects
2. A young lady with type 1 diabetes admitted to hospital because of DKA. A
ward nurse said she has confessed to skipping insulin and inducing vomiting
after having heavy meal. Psychiatric review confirmed that she has bulimia
nervosa. Her weight is normal. She is now stable and about to be discharge.
Task: take relevant history, explain the diagnosis and management.
I addressed confidential issue before taking history.
She has supported family; she is working, no financial problems. She has had
a good relationship with her partner but was upset when he gave nice
compliments to the dress of another girl who looked much skinnier than her.
Since then, she has tried to lose more weight by diet because she thinks that
she is too fat. Sometimes she eats excessively and induces vomiting because
of feeling guilty. Sometimes skipped insulin and thinks it works. No excessive
exercise, no depressed mood, sleeping normal, appetite normal, no delusion
or hallucination, no suicidal idea. Periods have been regular.
I said your weight now is normal and you do not need to lose more weight. I
understand you are very concerned about your weight and that concern
affects your health. She asked why? – Because if you try to induce vomiting
there is an increased risk of tooth decay, unstable blood sugar levels, and
electrolyte imbalance that can lead to death. Skipping insulin can also worsen
diabetes control. I’d like to refer you to a counsellor who can help you to cope
with your concern; also refer you to a dietician who can give advice on good
diet.
She was happy with my advice but at this stage she said I don’t like to see
psychiatrist. I said – if you don’t want to see a psychiatrist, that’s OK but at the
stage that you cannot cope with the anxiety about your weight, your diabetes
can not be controlled well, the psychiatrist can give you medications to reduce
the anxiety about your weight.
She looked happy but… I failed this station unexpectedly.
Feedback: Bulimia Nervosa
3. A 3 year old girl was discharged from hospital 2 days ago because of asthma
attack. Her father comes to see you today in GP practice for following up.
Tasks: take relevant history, write asthma action plan and explain to the
patient.
On history, the patient has had asthma since she was 1.5 years and has been
treated with ventolin puffer when she has symptoms. At the moment, she has
had regular day and night symptoms, including cough, SOB, wheezing. She
also has symptoms when playing. There were no known allergies, eczema, no
carpets, no pets, no smoker at home. On discharge from hospital, she still has
3 days of prednisolone tablets to go. There was a stack of asthma action plan
forms on the table. I took one after asking the examiner and filled it up. I
added daily corticosteroid inhaler apart from ventolin and explained what to do
when well, unwell, get worse, asthma attack. Time ran out when I was
explaining 4×4×4. The examiner was very nice, gave me her empathic smile
when I had difficulty explaining 4×4×4 strategy in the last seconds.
Feedback: Asthma (paed)
4. A mother of a 4 year old girl came to see you in GP practice, complaining that
her daughter does not want to go to her ex-husband. She noticed some
redness in the vulva and suspected sexual abuse. Task: Take relevant
history, ask physical examination and manage the case
The mother was very angry. The baby refused to go to her father’s house for
couples of weeks after coming back from her father’s house. She did not tell
what has happened. The baby’s parent separated one year ago and she live
with her mom the new partner. Her father at the moment also lives with his
new partner. Her development has been normal.
On examination, the baby was playful, no positive findings apart from mild
redness and swelling in the vulva area. The baby’s mother asked: do you
think that her father abused her? I said that could be one of the possible
causes. Other possibility is inflammation of the skin, a common condition at
this age. However, I will refer your baby to child protection unit, there are
people that can examine your baby, take swab from the vulva to confirm the
diagnosis. They will also come to interview those related to caring for your
baby such as you, your partner, your ex-husband and his partner, and me as
well. I expressed empathy to her concern with reassurance of being
supportive to her. I finished this station early after 3-4 minutes- nothing else to
say…
Feedback: Sexual abuse (paed).
5. A father of 2 year old girl came to ED because his daughter cries when he
tries to pick her up. Tasks: take relevant history, ask physical examination
findings from examiner and explain differential diagnosis and management to
the patient’s father.
On history, the baby has been well until now, normal development. Today she
refused to walk. She is feverish. No other symptoms.
On examination, she is 39oC, no dehydration, no blotchy cyanosis. Hip
examination normal, knee examination: red and swollen left knee, limited
range of movements.
I explained the diagnosis of septic arthritis, with osteomyelitis as the
differential diagnosis.
For management: this is an emergency condition, baby needs hospital
admission, we will put a canula for her, take blood for investigations, call
orthopaedic registrar, arrange X-ray of the knee. Treatments involve
antibiotics for at least 3 weeks after taking joint fluid for investigations; she
may need operation to drain the knee joint.
Both examiner and role player were happy.
Feedback: Septic arthritis (Paed)
6. A 35 year old woman comes to see you to ask about sterilization.
Tasks: take relevant history, ask for physical examination, give diagnosis (?),
explain the procedure and other methods for contraception.
The patient has had 3 children, no significant obstetrics and gynaecology
history. She has had laparotomy for appendix abscess long time ago, very
keen on sterilisation and does not want to discuss other options.
Physical examination revealed a scar on the abdomen due to previous
operation, other examinations was normal.
I explained about tubal ligation procedure, the risks of anaesthetics. Refer her
to gynaecologist to consider whether keyhole surgery is suitable because she
has the risk of adhesion due to previous operation.
She asked about the failure rate- I said 1 in 200.
I finished early.
Feedback: Request for sterilisation (O&G)
7. A young woman comes to ED because of severe abdominal pain. Tasks: take
relevant history, ask for physical examination, give diagnosis, differential
diagnosis and management.
When I entered the room, the patient looked in agony because of pain. She
held her hands on the right iliac fossa; gave history of pain with sudden onset,
felt a little bit faint, pain was constant, no radiation, severity 8/10, nothing
could help to relieve the pain, no nausea/vomiting, no problems with bowel
motions or water work. She had stable partner, LMP 7 weeks ago, no
contraceptive methods, no previous pregnancy or STD, recent PAP smear
normal, no pain/bleeding on intercourse, no vaginal discharge or bleeding.
She was otherwise healthy.
On examination, vital signs normal, suprapubic tenderness, McBurney, psoas
signs, Rovsing sign negative, no loin tenderness, Speculum examination:
cervix close, no discharge. Bimanual examination: uterus size normal, cervical
excitation negative, no adnexal mass or tenderness. Urinary pregnancy test
positive.
I said most likely you have ectopic pregnancy, cannot rule out appendicitis,
threatened abortion. You needs hospital admission. We’ll put canula, take
blood for serum B-hcg , preoperative assessments, blood group and cross
match, transvaginal US, call gynaecology registrar, prepare operating theatre,
may need operation. There were no questions from the role player and
examiner.
Feedback:Possible ectopic pregnancy (O&G)
8. A young woman at 10 week gestational age comes to see you in GP setting.
She is concerned about having a baby with Down syndrome as recently her
sister just had a newborn baby diagnosed with Down syndrome. Task :
counselling the patient
The woman was very anxious about her pregnancy. She said- I don’t want to
have a Down baby, is there any way to detect it early so that I will not
continue the pregnancy.
I said yes, there are some options for you to detect Down syndrome during
pregnancy. Because you are under 11 weeks of pregnancy we can arrange
Ultrasound at 11th week to see the presence of increased thickness of the
space behind the baby’s neck. This combines with some other blood tests
such as B-Hcg, pregnancy associated protein A taken at the same time can
detect 90% Down syndrome. The other option is doing blood tests at 16th
week including B HCG. Estradiol, alpha fetal protein. These tests are used to
screen for Down syndrome. If the tests suggest that you may have Down
baby, we need to confirm diagnosis by either taking a sample from placenta at
11th week or taking fluid surrounding baby……..
She asked:
- Is there any risk for those procedures? – The risk of abortion is less than
0.5% for amniocentesis and less than 1% for CVS.
-
Are the tests accurate to detect Down syndrome? _yes, most likely but
there are no test can give 100% accuracy to diagnose Down syndrome. (I
knew my answer was risky but anyway I passed this station).
- If the tests confirmed that I have Down baby and I don’t want to continue
pregnancy- can I terminate it? By which way?- If it is the case, I will refer
you to the gynaecologist to discuss more about termination. Generally
under 16 weeks, we can do suction; above 16 week, we induce labor.
Feedback: Explantion of fetal abnormality screen.(O&G)
9. GP setting, a middle man has had chest pain, SOB on exertion. On
examination, he has BMI 35. Cholesterol 6.0, no hyperglycaemia, Stress test
showed ST depression Task- explain about investigations, diagnosis and
management to patient.
I explained about the investigations; referred him to a cardiologist to consider
angiography and other procedures such as stenting, bypass surgery. I spent
a lot of time to explain about cardiovascular risk factors (smoking, overweight,
hyperlipidemia…) and did not have time to start him on statin, aspirin, GTN….
while waiting for the specialist consultation.
I failed this station.
Feedback: Angina pectoris.
10. A middle age female patient came to see you in GP Office complaining of left
hip pain.
Tasks: take relevant history; ask physical examination from examiner, give
provisional diagnosis and further investigations.
In this station, Dr Wenzel was the examiner. The patient has had hip pain
recently (I cannot remember for how long). Pain felt in the lateral part of the
groin, no radiation, worsens when walking, reduces with rest, develops
gradually, no tingling, numbness, weakness of the leg, no previous injury to
the hip, no morning stiffness, no fever, and no weight loss. No significant
illness in the past except “arthritis” on fingers (PIP and DIP joints). No other
joint pain. Not on any medication; non smoker.
On examination: left hip joint has pain on movement, limited range of internal
rotation and abduction. No abnormality on neurological examination.
My provisional diagnosis was osteoarthritis. I explained it to the patient and
arranged X-ray of the hips.
There were no questions from the role player and examiner, who gave me a
big smile when I finished.
Feedback: Hip pain.
11. A 70 year old woman who has developed severe lower back pain and XRay
shows compression of lumbar spine (L4L5). DEXA bone scan -3SD. Tasks:
take relevant history, explained to patient about the diagnosis, provide
management.
On history, the patient still has pain, no previous illnesses, non smoker, not on
any medication, no weight loss, no fever, no tiredness recently. Systemic
reviews of symptoms were all normal. The patient does not take any dairy
products, no exercise, not much outdoor activities. Menopause more than 10
years; last Pap’s smear 2 years ago normal. Mother had osteoporosis at the
age of 80s.
I explained about the diagnosis, offered further investigations including bone
scan, blood tests, urine tests to rule out multiple myeloma and other
malignancies.
For management, I gave her pain killers, biphosphonate and mentioned its
side effects, how to use, advice on dietary, referral to dietician for advice on
good sources of Calcium rich foods, exercise to strengthen the muscles,
referral to occupational therapist to make sure safe home environment to
prevent falls.
The role player nodded her head but said nothing.
Feedback:Osteoporosis.
12. A middle age woman developed lower leg pain and swelling after a long trip
comes to see you in GP office. She has been on HRT. Her mother and sister
has had DVT. On examination her leg is swollen and red with pitting oedema.
Tasks: take relevant history, ask examiner for investigations, explain
diagnosis and management.
On history, pain developed suddenly, she had been fit and healthy, no
diabetes, hypertension, no smoking, no previous leg injury, not on other
medication apart from HRT. Her sister had DVT after having delivered her
baby; her mother had DVT because of …. (I cannot remember now, please
check other recalls).
For investigations, I asked for Doppler US, the examiner nodded his head and
said “positive”. ABI normal range.
I explained the diagnosis of DVT and the associated risks, recommended
hospitalisation in which she will have bed rest, blood tests for coagulation
profile, thrombophillia screening, introduction of Heparin and Warfarin at the
same time and relevant daily blood tests, stop heparin when INR reaches
therapeutic range, stop HRT or use the other form because of high risk.
Questions from the role player:
- Duration of using warfarin- Depends on the thrombophillia test results , 36 months or lifelong.
- Therapeutic range of warfarin – [2-3]
Feedback: DVT.
13. A middle age man comes because of SOB developed gradually. He has been
a heavy smoker, about 2 packs a day. Task: perform comprehensive
respiratory examination and give diagnosis.
This was a real patient. I performed respiratory examination according to
Talley and O’Connor. He had no Horner’s syndrome, no cervical
lymphadenopathy, positive finding included expiratory wheezing on over the
lung fields. When I was listening to the chest, the examiner said you have 30
seconds for examination. I quickly said- I’d like to do PEFR test. The examiner
said – do it! The instrument was provided on the table with disposable
mouthpiece. The patient performed it correctly at the second go. The
examiner then stopped me and said other repeating gave consistent results,
and then he told me to interpret the result which indicated 120 ml. I said-there
is evidence of airway obstruction and I’d like to perform the PEFR test after
bronchodilator to confirm COPD. He asked me what is the other bedside test?
– I said spirometry. He nodded his head with satisfaction. The bell rang.
Feedback:Respiratory examination.
14. A long stem with complicated details which indicated colon cancer previously
operated but now having peritoneal cavity spread, free fluid inside the
abdomen, no liver metastasis. The patient was a woman on middle age.
Tasks: explain the diagnosis and management.
I gave breaking bad news steps by steps. She took it quietly and asked what
the available treatments for me were. I said most likely chemotherapy and/or
radiotherapy. Treatments mainly to reduce symptoms that she may have such
as bowel obstruction with colostomy; pain with pain management… we work
together in team including oncologist, surgeon, pain management specialist,
community nurse, social worker… to help you. You do not need to stay in
hospital all the time, just 1-2 days if you have chemotherapy/radiotherapy to
follow up the side effects.
She asked:
- How long will I live..? It is different among individuals, many people with
this condition live longer than they have expected. We will help you to
enjoy activities as much as you can.
I also suggested cancer screening for her children.
Feedback: Carcinoma of colon (recurrent, advanced)
15. A young patient with headache developed 24 hrs ago. She is now in ED.
Tasks: take relevant history, ask for physical examination, and explain
possible diagnosis and management.
On history, the patient developed headache for one day, on over the head
with soreness in the neck. Pain was constant with 8/10 severity, no radiation,
feeling hot, no nausea or vomiting, no visual disturbances. Systemic reviews
were all negative.
Physical examination: Temp 39oC, BP normal, neck stiffness positive,
fundoscopy not available. Other examinations were normal.
I explained to the patient the possible diagnosis of meningitis, could be also
subarachnoid haemorrhage, brain tumor. She needs hospital admission for
having CT scan of the brain to exclude increased intracranial pressure,
lumbar puncture, blood tests to confirm diagnosis. Treatments include
antibiotics and symptoms management. The patient asked- what is CT scan,
lumbar puncture?
Questions from examiner:
- What are you looking for in CT scan?- Brain tumor or evidence of
increased intracranial pressure.
- CT scan and lumbar puncture - Which one you give first? Why?- CT scan
first to exclude increased intracranial pressure, because of the associated
risk of coning of the brain.
- What is the other test apart from CT scan to check ICP? – Fundoscopy.
- What would you expect from lumbar puncture?- Biochemistry change
including level of glucose, protein; numbers of white blood cells, culture for
the responsible bacteria.
The examiner was happy with my answers.
Feedback:Headache (acute).
16. You are in GP practice. A patient just comes to your area with referral letter
from his previous GP. From the stem and the letter, you can see he has had
pace maker, persistent abnormal liver function tests (increased AST, ALT,
GGT), hepatitis A,B,C serology were all negative, abdominal US shows
abnormal liver consistent with cirrhotic change.
The patient has had healthy lifestyle, no alcohol consumption.
Tasks: explain the tests to the patient; possible diagnosis, order other tests to
confirm diagnosis and management
I explained about the test, explained the provisional diagnosis as
haemochromatosis and order Iron studies, genetic test, liver biopsy. The
examiner gave me result cards only for the tests that I have requested.
Iron studies show transferrin saturation 85%, increased ferritin.
Genetic tests reveal C282Y positive, C63D negative
Liver biopsy shows fibrotic change grade 2.
I said – you have some level of liver scarring as the result of
haemochromatosis. We will need to take blood every week to reduce iron
load, and the gastroenterologist will consider liver transplantation when your
liver is not working properly.
Because this is a genetic condition, your first relatives will need screening
tests.
The examiner looked happy.
Feedback: Abnormal liver function tests.
AMC Clinical Exam Recall 2nd April 2011
Station 1
Total cholesterol 7.3, HDL- normal, but lowish, LDL and TG high
BP: 140/85, unhealthy diet, Father CABG, mother DM, non-smoker, social drinker
Task:
History, counsel regarding hyperlipidaemia
Candidate 1 (Adelaide) Status: Passed
Just CVS risk assessment (modifiable and non-modifiable) station and counselling; All
positive risks were given as in the stem, social drinker, non-smoker, no exercise; just the RP
wants to know more about healthy diet and reassurance + referral to medics and start on lipid
lowering agent
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Hyperlipidemia
Station 2
T1DM, GP, 7 yo male, 1 wk h/o lathergic, noturia, urine sugar +, ketone+, BSL 23, but, PE
completely normal and the child is well at this stage.
Task:
Explain about the result and management. (no more history or PE)
Candidate 1 (Adelaide) Status: Failed; don’t know why
Modified book case
Newly diagnosed T1DM, need to refer to hospital, r/v by paeds, do some fasting blood:
fasting BSL, Lipid, Insulin Assay, Explain about DM, RP asked me what dose ketone stand
for and the significane (ketone means dehydration in your son, and bcoz sugar is osmotically
active and draws water, he’s got increased frequency and amt of urine and also there might be
some electrolyte imbalance causing him weak and lathergic and that’s why he needs to go to
the hospital and assessed by paeds, but, not definitely necessitate admission since he’s
physically well at this stage.) If confirmed, he needs to be closely monitored, BSL 4 times a
day, insulin injection for life long (mum and dad are primary carers of the boy), but, don’t
worry too much, ppl live with this condition and with proper monitoring and control, he can
lead normal life, and he can also play sports and no specifically restriction of activities, also
warn about hyper and hypo-glycemia and glucagon, blah, blah, blah, the RP wants to know
all the Q in book case and show interest in Ketone and hypoglycaemia and glucagon
injection.
Candidate 2 (Brisbane) Status: Passed
Quite similar but I explain more about DKA and to exclude that the boy needs to go to
hospital and reviewed by specialist. The patient’s questions are quite similar to the book case.
AMC Feedback: Newly diagnosed child DM
Station 3 - Rest
Station 4
Day 5 postop DDx, PE
50+ lady, day 5 post-op for total knee joint replacement surgery, had 2 days of heparin subcut
5000 BD and prophylactic ABx post op. Now complain of SOB, sweaty, anxious.
Task:
History for 3 mins, asked PE findings from examiner (only give what you asked for), Invs
and Dx (not management)
Candidate 1 (Adelaide) Status: Passed
When I went into the room there’s a lady lying on the bed in hospital gown, the examiner
greeted me and I started to ask whether my patient is vitally stable or not and he said she’s
stable.
Day 5 post-op, not much walking post-op bcoz of pain
Sudden SOB, sweaty, anxious for last 2 hours, asso: chest pain-> central, no radiation, no
N+V, no recent H&M, no cough, no calf pain. 1st time having this kind of problem
PMHx: otherwise well apart from knee arthritis. NKDA, no meds apart from aspirin, no
significant FHx.
Then, I asked for PE findings. The examiner looked strict at first sight and asked me what I
would like to know. So, I asked for general appearance which is anxious and sweaty. Vitals,
Temp- afebrile, PR- 110/min, BP slightly lowish, SaO2 89% on RA (then, I asked the
examiner whether my patient has the IV cannula insitu since she is not vitally stable and I
would like to start her on oxygen 2L via NP and start to give her IV Fluid (then, I asked the
patient again that she doesn’t have any heart failure and the patient said no). Then, the
examiner, just gave me the rest of the physical examination findings which are all normal
(normal wound site, no calf tenderness, no signs of chest infection)
Then, he asked me my DDx.
I told him 1. AMI 2. PE 3. Septicemia, then, he asked me what are you going to do next and
asked me to tell the patient? So, I explained my patient that your SOB and Chest pain worries
me and I would like to take ECG, CXR and I would like to take some blood from you and run
the blood for Full blood count to look for trace of infection, baseline renal and liver function
test, and also, coagulation studies including D-Dimer since I’m afraid you might also have
the condition where there’s a blood clot formation in your leg veins and dislodged into the
blood stream and obstruct the major artery supplying the lungs and the patient looks a little
bit worried. And so, I told the patient, not to worry too much and in the meantime, i’d like to
give you some O2 to relieve your SOB and start on fluid. Then, the examiner, interrupts me
that what was your first DDx (stupid me forgetting troponin even until that time :P), So, I told
him that my first DDx was AMI and then, he asked me what investigation would you like to
do to confirm that Dx. Then, I know that I forgot Cardiac enzyme and I wanted to laugh at
myself and told him I would also like to run Troponin. Then, he asked me the normal value
for troponin. I answered < 0.04 and he said the result came back like that and so, what is your
first DDX now. So, I told him that now, PE is my first Differential so, he asked me what
would you like to do to confirm PE and I told him I’d like to do ECG which will show Sinus
tachycardia and S1Q3T3. He smiled and then, he gave me the ECG and asked me to interpret
that. So, I presented the ECG (this is the ECG of Ms. X, age 50 yr, HR around 120/min, sinus
rhythm, tachycardia, and I can appreciated S1Q3T3, but, I cannot find any ST or T segment
changes. Then, he asked me what else invs? D-dimer which will be raised by thousands, but,
to confirm that I need to do CTPA. He smiled and then, the bell rang.
I felt very good after that station bcoz the examiner, the observer and also the RP looked
strict at first, but, actually, the examiner was very helpful and said thank you very much and
also, the RP gave me a very big smile afterwards 
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Chest pain and dyspnoea (acute)
Station 5
30 yo, P2, 4 mo post partum, came to your GP for wetting problem, Ht and weight was given.
Task:
History for 3 mins, PE from examiner (will only give what you ask for), Dx and mgt to the
patient.
Candidate 1 (Adelaide) Status: Passed
I went into the room and congratulated the RP for the baby and asked if everything’s well
with her and baby. She said apart from the wetting problem, she’s coping well and the baby’s
fine.
Q. How long you’ve been having this problem? Since before this baby born, for about a year
now, gradually worsening and concerns bcoz she’s still young.
Q. Is that worsened when you cough or strain? She said yes, esp;ly when coughing and
sneezing
Q. When you wet yourself, is the amount a lot or just a little bit? Just a little bit
Q. Do you need to rush to the toilet when you need to go? No
Q. Do you have any other problem with the waterworks, like burning sensation, stingy pain
or fever? No
Q. How about the bowel? Fine
Q. any N or V? No
Q. Can I ask you some sensitive question? Yes
Q. Ask about 5P and all normal.
Q. How about your babies and deliveries? All normal vaginal delivery and both of them >=4
kg, no prolonged labour or prolonged hospital stay.
Q. Any past surg or gynae procedures? No
Q. Any past illness, sugar, blood pressure, lipid problem? No
Q. SAD? No
NKDA, not on regular meds
PE: Normal general exam and system r/v, BMI 30
With the patient consent, PV exam -> Demonstrable stress incontinence + and also, slight
anterior vaginal wall prolapsed
Bed side UA, BSL normal
Then, I explained to the role player that she’s having a condition what we called stress
incontinence (incontinence mean that you cannot control your waterworks so well and stress
mean when there is increase stress or pressure in her tummy like coughing or sneezing). She
seems to have understanding with my explanation and I told her that the most likely cause of
her problem will be due to the big babies she had and overweight might also contribute to
that. Then, I told her that I will refer her to the gynaecologist and she will be reassessed again
and treat accordingly. The possible treatment option will be starting with general measures
(it’s good that you don’t smoke and keep that good habit, exercise, including the pelvic floor
exercise) and also, there’ll be option like vaginal pessaries, and also surgical option. I asked
her whether she’s okay if she needs surgery and she asked me back what do I think? So, I told
her that I suggest we will start with conservation measures and if not we can consider surgery
and I try to tell her the 4 surgical procedures for GSI, but, the bell rang at that time and then, I
realized that I didn’t specifically told her to reduce weight.
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Urinary Incontinence (Passed)
Station 6
50 year old lady you are seeing in hospital OPD with complain of 2 wk ongoing SOB (the Q
is that short)
Task:
History for 3 mins, DDx, PE from exmr, Mgt plan
Candidate 1 (Adelaide) Status: Passed
When I entered into the room, the RP said the examiner hasn’t returned yet, and asked me to
start with her. So, I introduced myself and asked history from her. She’s feeling breathless for
about a month, but, worsen in 2 weeks and said that now even with daily chores and walking,
she’s SOB. But, no SOB at rest, no orthopnoea or PND. No chest pain, dry cough as usual
(smoker), no phlegm, no recent LOW or LOA, no stress, system r/v normal. Smoker 20/day
for about 15 years.
The examiner came back after about 2 mins, quietly sitting and then, after i’ve finished my
history taking, he pointed me the next task and so, I told him my DDx: Heart Failure, COPD,
LRTI and then, he gave me the PE result sheet. Vitals- normal, CVS: normal. Lungs, dullness
on percussion on right lower zone, reduced AE, Vocal fremitus and resonance Reduced. And
then, he pointed me the next task and pointed at the RP. So, I started to explain the RP that
from my Hx and PE, you are having a condition what we called Pleural Effusion, in which
fluid is trapped between covering of the lungs, which might be result of infection,
inflammation somewhere or nasty growth itself. So, I need to refer you to the medical
specialist and do CXR first to confirm the Dx and then, do the aspiration of the fluid to
examine under microscopy to make sure it’s origin. Then, the RP asked me you mean nasty
growth is that cancer? and she looked worried. So, I told her that it is not yet confirm as the
cause, but, it is one of the possibility and we do need to exclude this by doing the aspiration,
which is also kind of therapeutic since the fluid compress your lungs and cause you SOB (by
taking the fluid out, the tension will be relived and you’ll feel better, but, the medical
specialist will decide how long they’r gonna put the chest tube in) and if confirmed, the
medical specialist will proceed to some other investigation like bronchoscopy and biopsy,
etc.... and the bell rang
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Shortness of Breath
Station 7
40 or 50 year old lady came back to your GP, after seen by Nephrologist. She was recently
diagnosed as having ESRF and neprhologist suggested that she needs to have Renal Dialysis.
Blood test were done, results given,
FBE: Hb- mild anaemia, but > 100
UEC: ESRF picture (urea 35, Cr >500, K 5.3, blah blah blah)
CMP: ESRF picture
Task:
History, Tell the patient about Dx and DDx and Management.
Candidate 1 (Adelaide) Status: Passed
I was confused at first since the stem looks so so medical...... but the station is 7
I went in and greet the patient ( she’s holding a tissue paper and there’s glass of water in front
of her-> making me even confused coz i think about breaking bad news about ESRF) and ask
how she’s doing. She said not good and she said she did not want the treatment.
Q. Do you know your condition well Latifa? Yes
Q. Do you understand that you’ll need the renal dialysis for the rest of your life? Do you want
me to explain you more about the treatment? She said she understands well, but, she doesn’t
want the dialysis and she doesn’t want to be machine dependent and don’t want to go to the
hospital 3 times/week. And also she said she was explained by the nephrologist about the
treatment and again she repeats that she doesn’t want the dialysis. Makes me confused again
and I asked the examiner whether renal transplant is the available option. The examiner told
me that do your best with the provided information.
So, I talk to the patient that there’s also option of kidney transplant and i’ll discuss with the
nephrologist about that and let her know. The RP just repeat again that she doesn’t want
dialysis. I feel a bit frustrated and then, I decided to ask the psych question from that stage
since it is the psych station (if it’s not psych station, I’m going to tell her that it’s her choice
and we’ll respect her choice and refusal of treatment, blah, blah, blah)
Q. Well, Latifa, I understand that it’s frustrating to face this chronic illness and hear about the
invasive treatment (actually, I’m frustrated :P), but, before we discuss further, can I ask you
some questions first and some of these questions are also sensitive and I’d like to assure
privacy. RP said yes.
Q. How’s your mood? Not good Q. Feeling low or depressed? Yes
Q. Do you have any idea to harm yourself or others or end up your life? No
Q. Sleep? Difficult to fall asleep
Q. Sex? Not interested in it
Q. involvement of regular activity? Not anymore
Q. LOA? Yes
Q. any recent weight loss? Yes about 10 kg in 1 or 2 months
Q. Insight, Judgement -> intact
Q. No perceptual symptoms
Q. SAD -> no
Q. Home and Family -> supportive, but, RP doesn’t want to be a burden
Then, I explained the RP.
Latifa, I know that you are facing a very difficult period of time and I understand that you
don’t want to be a burden to your family and you don’t want the treatment although dialysis
is the best possible option for you at this stage and with dialysis, your lifespan can be
extended about 5 years and increase the quality of life to at life to your days. However, I
think your condition is more serious than this. According to what you’ve told me, I suspect
you are having a condition what we called major depression with somatic features, where you
have the depressive illness and as the result of that your body is also facing difficulty in
falling asleep and LOA, LOW, etc.... So, at this stage, I need to refer you to the psychiatrist to
start you on antidepressant medication and also psychologist to help you cope with your
stress. Also, I will arrange the religious and spiritual group to help you and also social worker
involvement for your family since you are also worried about being a burden to your family.
And, I’ll also discuss with the nephrologist about the option of kidney transplant. Are you
okay with the management? She said yes, and she repeated again that she doesn’t want the
dialysis. Then, I felt blessed that the bell rang at that time.
I forgot to mention the possible differentials, but, I don’t even want to think about this now.
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Depressed Mood
Station 8 - rest
Station 9
Intern in ED, 55 yo man, epigastric discomfort, anxious, sweaty.
Task:
History for 3 mins, PE, Present the case to the examiner as if you are presenting the case to
your registrar or consultant and most likely Dx and ask only one most important invs and
interpret the invs to the examiner.
Candidate 1 (Adelaide) Status: Passed
The RP looks anxious and SOB. So, I started by asking the examiner if my patient is vitally
stable and he said yes and told me to start my task.
Hi, X, My name is .... I’m the intern working in this ED. From the notes I understand that you
are having pain in your tummy, can you show me where exactly it is? Then, the RP point
around the central chest. Then, I ask for pain Qs. Started about 2 hours ago at rest, Central
chest pain, squeezy tight radiating to jaws, SOB+, Sweating +, N+, no V, No recent H&M,
No fainting or dizzy spell, no weakness of limbs, not the first time having this pain. Had heart
attack 2 or 3 years ago, did not have any invasive treatment or angiogram, doesn’t know
about Echo at that time.
PMHx: DM, HTN, Hyperlipid - all present and on regular medications including aspirin and
compliant
No recent surgery or travel, no calf pain
No family hx of sudden death, Hx of DM in mother
I forgot to ask about SAD bcoz I needed to rush through my hx fearing that I would run out
of time.
Then, I asked the general appearance, vital signs (unable to perform postural BP). He is
vitally stable at that stage. PR- regular. No pallor, J or cyanosis, JVP NE, Resp: normal, no
crepts or added sound, CVS: normal, no mur mur, Abdo: normal. No calf tenderness or pedal
oedema. Bedside UA: normal
Then, I told my examiner that I would like to present the case. The gentleman I’m seeing now
is 55 year old Mr.X, who came in with 2 hour history of sudden onset of central chest pain,
blah blah blah......... He’s got the significant background of previous heart attack 2 or 3 years
ago, but, he did not have any angiogram done at that time. He also has co-morbidities of DM,
HTN and Hyperlipidemia. He’s on medication for his diseases and claimed to be compliant.
However, he did not have any history of recent travel or surgery. Examination-wise, apart
from SOB, anxious and sweaty looking, he’s vitally stable, JVP is not elevated and systemic
examination is normal. Therefore, my provisional diagnosis at this stage is Acute Myocardial
Infarction and I’d like to arrange ECG. Then, the examiner asked me what are my points for
diagnosis? Cardiac sounding chest pain, significant BK of heart attack, then, he interrupted
me asking what are the risk to this patient. Age, Male gender, Previous history of heart attack,
Co-morbidities for CVS risk including DM, HTN and Hyperlipidemia (I forgot to ask about
SAD and stress, but, look, hx taking was only allowed for 3 mins and I didn’t feel guilty for
that). The examiner said OK and showed me the ECG. So, I present the ECG to him again.
This is the ECG of Mr. X, 55 yr old gentleman, sinus rhythm, PR around 90/min, No
widening of QRS, ST segment elevation in II, III, aVF which are inferior leads and also in
chest leads V1 and V2, anterior leads with reciprocal changes in I and aVL. Therefore, this is
the case of ST elevation Myocardial infarction. Then, he asked me how old do you think the
infarct is? Very recent within 6 hours. Why? ST segment elevation and hyperacute T
changes. Then, he asked me what will the old infarct show? Q wave and he asked me to find
Q wave in the ECG which I’m not so sure. So, I just told him that I think there’s 2 small
square of Q in lead III and then, he asked me what does the Q wave mean? I’m not so sure at
that stage again and told him that previous infarction and he asked me what else and I really
don’t know more and lucky that the bell rang that time 
Candidate 2 (Brisbane) Status: Passed
Same as above! But the examiner didn’t ask detail about ECG finding.
AMC Feedback: Acute myocardial infarction
Station 10
4 wk old BIBM, crying, vomiting sometimes
Task:
History, PE, Dx and management.
Candidate 1 (Adelaide) Status: Failed as expected
This is the most wired station.
When I entered into the room, the RP is middle aged lady who looked so so frustrated and
tired (about to cry with red eyes) carrying a baby (doll). If this is psych station, I can tell from
the look that this is postpartum depression/psychosis. However, this is paeds station.
So, first, I congratulated her about the baby and asked whether she’s coping well and has
some support from home. She said her husband is supportive but, both of them are so tired
because the baby is crying, vomiting all the time since birth. This is the second baby (first
one is about 3 years old and well), planned pregnancy, no prolonged hospital stay, uneventful
delivery. The baby was vomiting since birth varying 2 to 3 times or more, sometimes
postfeed, sometimes, not, now more often. Vomitus: milk, not projectile, no bile, but, some
blood curds/streaks present recently. Also, diarrhoea about 2 to 3 times/day. However, did the
baby check with clinic which was normal growth. Baby’s still responding well. Had
immunization at the hospital. Home situation; fine, no financial problem. The history is just
wired. To my knowledge it doesn’t fit into any of the possible Differentials -> infantile colic,
irritable baby, GORD, HOPS or DA, ?child abuse
PE: unremarkable, growth chart: normal, bedside UA: normal
I don’t know what to say at that stage. However, since the baby’s vomiting some blood, I
thought I should refer to the hospital. So, I told the RP that it is reassuring that the baby’s
growing well and PE was normal. However, since the baby’s vomiting some blood, I’d like to
refer the baby to the hospital. Then, the RP asked (looking angry), what will they do? The
paediatrician will reassess the baby and if necessary some blood test and USS. But, I’d like to
reassure you that the baby might be having problem as simple as irritable baby. Then, she
asked me why the baby’s vomiting a lot...... I felt so confused and I couldn’t concentrate well
at this station so, I couldn’t give her the answer at that time, but, I told her that’s why I’d like
to have the second opinion from the paediatrician and the bell rang..... felt relieved
So So wired 
Candidate 2 (Brisbane) Status: Passed
I started to explain the Mom that I suspect a condition called reflux but we still need to
exclude other important causes. So, I would like to refer your baby to hospital. Then I
reassured her don’t worry too much because the baby is growing well and PE was normal. At
Hospital, your baby will be reviewed by specialist and they will arrange required
investigation like some blood test and USS and treat accordingly.
She asked me why there is blood streak and so I explained that due to repeated vomiting,
there might be tearing at the end of gullet. Then, she asked me why the baby’s vomiting a
lot...... Bell rang!
AMC Feedback: GORD with oesophagitis
Station 11
25 or 30 yr old lady, came to your GP concerning about infertility. She had check up with
gynae about 3 years ago for her period pain and invs had been done and turned out to be
normal.
Task:
History, management
Candidate 1 (Adelaide) Status: Passed
Hx for both patient and partner- all normal (no previous child or STI in both), apart from
infrequent sexual activity: only 1-2 times a month (the RP cannot give the reason, why this
happen). So, I asked her whether she knows about the ovulation period. She said she only
heard about that, but, don’t know exactly what it is and asked me to explain. So, I explain
from the importance of timing for fertility and the need for the ovum to form the baby and I
told her how to find out about her ovulation period (her period is totally normal and regular,
so, day 14..... basal body temp, cervical mucous, blah, blah blah.....)
For management, I told her that I will see her husband also and take hx, PE and possibly,
semen analysis. However, at this stage, we can see how we go by timing the sexual activity
d/r ovulation period. And I’ll regularly follow you guys up and if no satisfactory progress,
will refer to Gynae again for further management.
Any other concerns? She said she’s fine, but, one Q-> will I need to take some fertility pill? I
told her not at this moment and the bell rang.
Candidate 2 (Brisbane) Status: Failed
Quite the same as above but I failed this station. I don’t know why?
AMC Feedback: Primary Infertility: unknown cause
Station 12
55 + year old male patient comes to your GP for pain in lower limbs during walking. He has
history of chronic smoking.
Task:
Physical Examination
Candidate 1 (Adelaide) Status: Passed
Burger’s test is the main point they want
Candidate 2 (Brisbane) Status: Passed
Peripheral Vascular Disease (real patient)
Reduced temperature, loss of dorsalis pedis and posterior tibial artery pulsation
Burger’s test (examiner asked me how to do Burger’s test)
Ankle brachial index (examiner asked me the normal value)
Abdomen examination for any mass or lesion
AMC Feedback: Leg cramps on exercise
Station 13 - Rest
Station 14
Police officer, ~30 yr of age, previously Dx as essential HTN, now came back for removal of
suture, BP 165/100, stopped taking medication for 6 months (was on perindopril), recent
blood test: UEC, Lipid, Sugar- Normal.
Task:
Assess patient’s compliance to medication and counsel the patient
Candidate 1 (Adelaide) Status: Passed
She was diagnosed as having HTN while she was interstate about 3 or 5 years ago. At that
time, she had difficult time period, lots of stress at work and family. She was compliant
initially, but, because of the job nature, she started to miss the medication and experienced no
difference and so, stop taking it. However, she did not suffer from the side effects of the
medication. About 1 month after stopping the medication, she checked the BP at work place
which was normal which reassured her and then, decided to stop taking it. She has family h/o
of HTN in her mother, dx in later life. She thinks she’s too young to have HTN and too
young to be on life-long medication. Apart from stress, no other CVS risk factor, no
symptoms of HTN at all.
I don’t even know how to manage it since she checked her BP after stopping meds, currently
no symptoms, blood tests- normal. However, I started to explain her the risk HTN will
impose on her and immediate risk of death or stroke and requirement to be compliant. I also
refer her again to the physician for reassessment. Throughout that station, I didn’t blame her
or antagonize her wishes, but, also I didn’t recommend her to stop the medication and also, I
advise her on life style changes, stress relaxation techniques.
Again wired station.
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: Non-compliance with anti-hypertensive
Station 15
17 y o boy came to your GP, he is known to you and healthy boy. Now, seeking some advice
regarding the following condition. Picture given showing acne.
Task:
History, Management
Candidate 1 (Adelaide) Status: Failed
I went in and greeted the patient asked how can I help him. He told me that he just came
today because of the acne. He had that for about 2 years now and since he grew older, it’s
quite embarrassing and so, wonders whether I could help him or not. I appreciated his
concerns and asked him whether he tried some measures or medications regarding this. He
said yes, the pharmacy gave him some cream and not working and that’s been about a month
now. Then, I asked him about HEADSSS since he’s teenager and all are negative. He’s
generally healthy and parents are supportive; however, he feels embarrassed about this and
has difficulty in dating girls. NKDA.
Then, I told him that I understands his concerns and understands that’s very embarrassing
problem for the teenager. But, I told him not to stress too much about it and we can sort this
out. Then, I explained him that acne is mainly due to hormonal changes during pubertal life
or sometimes unknown reasons. It is not related to hygiene. Please don’t stress yourself since
it is not your fault or due to your hygiene. Just relax and staying cool is the first measure and
avoid the facial scrubs coz that might erode your skin. And do you know the name of the
cream the pharmacy gave you. He said yes, I wrote that down for you, which is Benzoyl
peroxide (i’m really not familiar with that). However, I advised him to stop it since it’s been a
month and obviously not doing it’s job and it might also cause some erosions (i’m totally not
sure with this thing, please check yourself). Then, I told him, sometimes, acne is associated
with some infection, so, we can also try antibiotics. He looks interested and asked me what
medication. Again, I’m not so sure, so, I told him that I’ll check with my senior, but, I think
it’s doxycycline. Are you okay with that? He said totally fine. And I’ll also follow you up in
1 weeks’ time to check the progress. If not improving, I’ll refer you to the dermatologist for
some advices and he would start you on steroid cream (again, not sure). But, for the last
resorts, we can also give you retinoic acid and you’ll be fine with that because it has some
adverse effects on girls, but, you are a boy and should be fine. Then, I asked him any other
concerns, and he said will he have scars afterwards. Good question! Totally not. You might
have very tiny scars, but, you won’t be disfigured at all. Then, he asked me his mum said the
acne is due to chocolate and he wonders about that. So, I told him it’s just depend on personal
preference, if you like it, you can eat it and there’s no documented effect of chocolate on
acne. Then, the bell rang and again, felt relieved.
Candidate 2 (Brisbane) Status: Passed
I reassured him that his condition is called acne vulgaris and most acne usually settles by age
of 20 years. I advised him to stop Benzoyl peroxide. He asked me the possibility of scars on
his face after resolving his problem and I answered highly unlikely. Then, I told him I want to
give him some antibiotics. At that time, the examiner asked me what antibiotics will you use
and I said Doxycycline (actually I’m not sure ) Then I explain about general measures (Diet
– to avoid too much chocolates and spicy foods as there is some casual relationship in some
people and how to wash face gently with normal soap). He looks happy. And I’ll also follow
you up in one week time and if it is not well improved, I’ll refer you to the dermatologist
specialist to get advices. Bell rang!
AMC Feedback: Acne Vulgaris
Station 16
HMO in rural hosp. 6 wk old BIBD, problem with feeding for 1 week, poor suckling today.
Task:
History, PE, Mgt
Candidate 1 (Adelaide) Status: Passed
First born child, delivered at home, no immunization at delivery, previously well since after
birth. Poor feeding for a week, now poor suckling today. No fever, snorty nose, not sure
about cough, seems to struggle for breath today. Reduced amount of wet nappies (only 1 for
today, which is not really wet). Looks uninterested and lathergic. No family problem, No
possibility of abuse.
T 36.5, RR 70/min, O2 sats: not done, tracheal tug and IC indrawing +, cannot hear the heart
sound well bcoz of fast breathing, bilateral basal crackles + Hepatomegaly 5 cm
So, I headed towards Respiratory Distress, most probably bronchiolitis, however, there’s also
possibility of pneumonia. Put on O2, put a line in, take blood including cultures, talk with
paeds specialist in tertiary hospital, arrange CXR and arrange for transfer. In the mean time,
O2 and IV Abx if the specialist suggests so. Also, D/W father about importance of
immunization. I also told the father that he or his wife or both of them can accompany the
baby to the tertiary hospital.
The examiner asked me, what if you observe the baby in your department for about 4 hours
and no signs of improvement, what would you like to consider on examination? I really
didn’t know what she meant at that time. Then, I started to procrastinate around the possible
diagnosis. Then, the bell rang. Later on, I realized that she was asking for Heart Failure as
DDx. However, I couldn’t really think that much at that time and also, it was my last station
(just an excuse :P)
?? Heart Failure ?? Bronchiolitis or LRTI
Candidate 2 (Brisbane) Status: Failed
PE:
T 36.5, RR 70/min, O2 saturation: not done, Chest indrawing +, Both systolic and diastolic
murmur +, bilateral basal crackles + Hepatomegaly 2 cm
So, I think it is heart problem (heart failure) and so explaining about this. Admission and
manage as heart failure. I failed this station so please check other recall. I failed as I did not
tell differential diagnosis like bronchiolitis!
AMC Feedback: Respiratory Distress
Station 17
60 yo man planned for caravan trip in 4 weeks’ time. Came to you for check up and you
found abdominal mass and arranged USS which confirmed AAA 5.3 cm. The patient came
back today for result. BK h/o HTN on perindopril.
Task:
Explain the result and management plan to the patient.
Candidate 1 (Adelaide) Status: Passed
This is exactly the same as previous recalls. This is my first station and my examiner is Dr.
Wenzel 
My voice was shaky for first minute, but, I managed to control myself 
Candidate 2 (Brisbane) Status: Passed
When I enter the room, there is 60 year-old gentleman sitting there. But I explained his
condition. Your biggest blood vessels which distribute the blood from your heart to all parts
of your body now become dilated. We don’t know the exact cause but there are risk factors
such as family history, age, smoking, hypertension and diabetes. There is the risk of rupture
especially if it is more than 5 cm.
He asked me can he go to trip and do operation after that. I told him that I won’t recommend
you to do so because there is the risk of rupture. If you go for the trip and rupture, your wife
call ambulance and even if we do urgent operation, the chance of successful operation is very
low (just 10%). I told him that if we operate now, the chance of success is 95%.
Then he wants to know whether he will be ready to go for the trip in next 4 week if he did the
operation right now. I told him that, I am not sure. It depends on your condition. But he wants
yes or no answer. So I told him that, I am sorry I don’t know but I can ask the surgeon and
can tell you back.
Then he asked me what operations they will do? I told him that, it might be putting a stent
from your vessel at your thigh or they might do open operation and put a graft at the site of
dilated part…Bell rang!
AMC Feedback: Abdominal Aortic Aneurysm
Station 18 - Rest
Station 19
30 yo nurse came to you where you work as a GP. She was seen by your colleague a week
ago. She has repetitive intrusive and irresistible thoughts of washing her hands very
frequently because she thinks her hands might be contaminated and transmits infection to
patients or family member. PE and invs were done and she was diagnosed as having OCD
(they give the definition of OCD in the stem). She is feeling anxious and frustrated and now
thinks whether she can have some time off from work.
Task:
History, Management plan
Candidate 1 (Adelaide) Status: Passed
I went into the room, greet the patient. She was quite a nice lady, wearing rubber gloves.
C: Hi, how’r u going, Geraldine?
RP: I’m fine, but, I feel very anxious and frustrated about this problem and as a nurse, I’m
afraid I might transmit infection to the patients. I couldn’t help thinking about that and keep
on washing my hands several time and keep on wearing the gloves.
C: What area of speciality r you working? RP: just general (actually, she wasn’t prepared for
this Q)
C: So, do you think it’s rational to keep on washing the hands or this idea just drive you mad?
RP: I know it’s irrational, but, I just can’t help.
C: Okay, I understand. It’s kinda very frustrating, isn’t it? RP: yes.
C: However, it’s really good that you know it’s irrational and try to resist the thought and
sought some help. Apart from this thought, do you have other preoccupying thoughts?
RP: no
C: do you used to be a worrier/anxious person? RP: sometimes, but, lately, worries a lot.
All the other psych Q, she responded No. Insight (+), Judgement (+), No suicidal idea, lives
with family and husband’s very supportive and concerns about her problems, no financial
problems
Then, I started to explain about the management plan.
Well, Geraldine, the problem you’re having, which is OCD, THEN, the RP interrupt me
asking What is that problem? I was surprised that the RP did not know the problem yet coz I
thought she already know her problem and just come back for follow up and asking for some
time off. However, I explained her what is OCD again. She was quite okay with the
explanation. However, she’s afraid that she might be crazy. So, I reassured her. This is just
the kind of anxiety disorder and you’ve got your insight and judgement and I’d like to
reassure you that you are not going crazy at all. (Then, she looks relieved.) For the
management, I’d like you to relax and reduce the stress, don’t bottle things up, talk with your
friends or husband who are supportive and caring. Also, I’d like to refer you to psychologist
and do some CBT which is a talking therapy and he’ll also do special procedure called
exposure and response therapy. Then, the RP looked interested again and asked me what is
that. I told her that he will create a simulative environment and make you exposed to the
situation where you would like to wash your hands very much and he’ll help you to get over
that situation. Also, I will regularly follow you up and if your condition is not responding
well, I can also refer you to the psychiatrist to start you on antidepressant, SSRI (i asked her
whether she knows the medicine or not and she said she heard about it) and with the
combination of SSRI and CBT, the prognosis is pretty good. Finally, I asked her whether
she’s happy with the plan and she said yes, and then, she asked me whether that will be
beneficial if she has some time-off from work, which I’ve totally forgotten. I told her that it’s
a good idea to have a timeoff and have the therapy, refresh herself and that will be beneficial
to herself and also, the family, colleagues and also the patients coz if she’s so stressful and
anxious at work and home, that will make the situation worse and then, she looked happy and
the bell rang.
Candidate 2 (Brisbane) Status: Passed
Same as above!
AMC Feedback: OCD
Station 20
25 or 30 year old lady came to your GP for AN care advice. She is wondering whether she
could have your care in part of joint care with the hospital outpatient clinic. PE: normal, BMI
40.
Task:
History, Counsel the patient regarding AN care advice
Candidate 1 (Adelaide) Status: Passed
The stem sounded simple; however, I went into trouble with this station.
I greeted the patient and asked her how can I help her. She said she would like to have some
AN care advice from me. So, I asked her whether she already checked up with hospital OPD
and she said no, she said she’s planning to have a joint care. I asked her whether she’s
pregnant now and she said no. There are also no signs of pregnancy on history.
So, I started to ask 5P
Period: about 13 yrs of age, been regular, normal amount, no dysmenorrhoea
Partner: married, no h/o STI, stable relation
Pills: no contraception and then, I asked her how long they’ve been trying to get pregnant and
then, she said about 12 months now and couldn’t get pregnant. (At this stage, I was shocked
wondering whether is this station ANC or Infertility.)
No previous pregnancy or miscarriage, Normal pap smear
Sexual activity about 3 times/week, knows briefly about ovulation period. Partner has
previous relations, but, not known to have STIs or children or orchitis or injury.
Then, I don’t know what to ask for since if it is infertility station, I couldn’t find the cause
apart from obesity, however, she doesn’t have other features of PCOS (regular period, no
acne or hirsute), and her general health is perfectly well.
So, I started to talk to her that to have the AN care, if you need to be pregnant and you’ve
been trying for 12 months and no success. So, I would like to refer you to the gynaecologist
to check you up and he/she will reassess you and will do some USS of the womb and some
blood tests. And also, I would like to see your partner and assess him and do semen analysis.
Also, I advised her to reduce the weight because she falls into obesity group and the RP
didn’t seem to be happy with weight reduction. However, the bell rang at that time and I felt
relief because I’m not so sure about the task and there’s no hint from the RP or examiner
about my task. I didn’t even have the chance to talk to the RP about the AN care process
when she’s pregnant or didn’t have the chance to arrange the urine pregnancy test.
With this station, the RP is not hinting at all and she just answered in very short sentence
regardless of whatever I asked her and I needed to dig very details to have the information I
want. When I walked out of this station, I was pretty sure that I would fail this station.
ANC advice + infertility (?obesity and infertility)
Candidate 2 (Brisbane) Status: Passed
Same as above! I explained her also the effects of obesity especially on pregnancy and
fertility. So, I advised her to reduce weight. I explained Life style modification, Medications
and also surgical methods to reduce weight.
AMC Feedback: Pre-pregnancy Counselling of an obese woman
After I got the feedback, I can’t believe that I pass all O&G :P..... However, I feel blessed that
I passed one Paed station. Anyway, at the end of the day, the main concern is to pass the
exam, which doesn’t necessarily reflect how good you are in actual working environment
(just reflect how well you perform in that 8 minutes of agony) and get yourself fully
registered.
I’d like to wish everyone good luck with the AMC 2 exam. I also would like to remind you
all that this recall is just written to the best of my knowledge and I cannot guarantee that the
information are correct. But, I do really hope that this will be of some benefit to the
candidates preparing for the AMC2 exam.
With this opportunity, I want to thank my family and friends, especially my study partners
(Dr. Aung and Dr. Myo) and the last, but not the least, Dr. Wenzel. CHEERS!
Retest 28 May 2011 Melbourne
Station 4
60 year old man came to consult you, his GP regarding to screen for prostate cancer because his 75
year old friend at local rotary club had been recently diagnosed prostate cancer.
Task:
History, counsel and discuss the risks and benefits of prostate cancer screening
This is my first station; I was a bit uncertain when reading the stem, which was a bit unfamiliar to me
(no in my recollection of recalls). The history showed that his father also had prostate cancer but
died from a heart attack at the age of 80. The patient has some symptoms of BOO but no other risk
factors except his father’s prostate cancer history. Then I wanted to get the correct dx by asking for
PE findings but the examiner told me to stick to the task so I told the patient that I needed to
examine him to assess the size, shape, consistence and presence/absence of nodules. Then I
explained that prostate cancer is a slow growing tumour and people dies with prostate cancer rather
than died from it. Currently RACGP does not recommend screen for prostate cancer but considering
you have a family hx of prostate cancer so if you are worry we can perform simple blood test (PSA)
and US. He asked me what the risk for the screening, I explained to him that DRE does not hurt
although a bit discomfort for him, PSA is a simple blood test and US just a probe to give away some
signals to detect the prostate gland. I had not mentioned about biopsy because I did not want to
alarm the patient unnecessary. There were not questions from the examiner and the patient was
happy.
Station 5
25 year old woman had a CS over two years ago now is 7 weeks pregnant, she came to enquire
whether she can have a normal vaginal delivery.
Task: Hx, PE and answer her questions
After went through the first station feeling reasonable ok, I was a bit comfortable when I was
reading the stem. I started the history by congratulating her second pregnancy, then asked about
the previous pregnancy especially the details with the CS, which was done with low vertical cut over
2 years ago in a tertiary hospital with no complication because of failure to satisfactory progress of
labour. No other surgery history and contraindications for vaginal delivery. PE showed nothing
except an old horizontal scar in her supra-pubic area. She then asked whether she can have vaginal
delivery although admitting it was too early to discuss it. I then explained that there is no
contraindication for vaginal delivery and point out the risks associating VBAC, therefore depending
on the progress of pregnancy, vaginal delivery can be attempted but this must be done at a tertiary
hospital where emergency caesarian section facility is available and no oxytocin should be used. The
patient was happy.
Station 6
Middle age woman with long term diabetes recently developed numbness on her lower limps
Task: Perform relevant lower limp examination
It was an old recall but usually including further investigations and management. When I came in the
lady was already lying in the bed with the leg exposure up to knee level, I asked for permission and
said I already washed my hands as there was no antiseptic gel or tap & sink around. When I asked
the patient whether she felt any pain or numbness, she did not understand or unexpected my
questions but the examiner told me to carry on the examination. No abnormality on inspection but
no pulses in both dorsalis pedis and posterior tibial but popliteal pulse presented. Proprioception
only presented in knee level and other sensory tests (pain, light touch, vibration) lost just above
ankle level. There were two tuning forks with the 256 Hz obvious on top while the much smaller 128
Hz one was covered by cotton wool and hammer so I needed to look for it. I finished the
examination early but the examiner asked ‘what are you going to do now?’ I asked for clarification:
‘Do you mean in term of investigations and management?’ ‘No, just in term of physical examination’
I was sure then as I thought I had done everything in the lower limp so I answered ‘I would like to
check her eyes for diabetic retinopathy.’ The bell rang.
Station 7
50 something old man has been suffered abdominal pain, constipation, diarrhea and lost 5 kg in two
months, investigations including gastroscopy and colonoscopy are normal.
Task: hx dx and management
I forgot this is psych station when I was reading outside the room so I was thinking what dx would be
responsible to these symptoms if both gastroscopy and colonoscopy are normal, pancreatitis? liver
cancer? Etc but could not come up any answer then I suddenly realized the magic 7 just before the
bell rang for entering the room, I was still worrying about his weight loss when I got in the room. I
took the history by asking HEADS, depression and psychotic questions as well as substance abuse
and general health. Because of the stress from work as a teacher a couple months ago, he, now
retired, presented predominately anxiety symptoms with sleep disturbance, weight loss and reduced
appetite. His mood is “ok, kind of isolation rather than low” and libido & interest slightly reduced but
no suicidal or homicidal or substance abuse or psychotic features. I was not sure about the
psychiatric dx at that time as it did not fit into particular category such as major depression,
generalized anxiety disorder or adjustment disorder according to DSM IV criteria. So I decided going
to the safer option and told him that he got an irritable bowel syndrome. I then explained the body
and mind relations, reassure the benign nature (not malignancy) of the condition and offer
counselling, CBT, reading materials and regular following ups.
The role player was reluctant to give clear answers to my questions such as “life is not worthy living,
hurting yourself or somebody else, how is your mood like, etc?” When asked whether he was happy
with the plan of management, his reply was “Only when you say so!” so I did not feel well when the
bell rang. I talked to a few of my fellow candidates after exam with the same or different role players
and they all said the anxiety was the main feature so I was surprised that the feedback of Major
depressive episode.
Station 8
Rest station
Station 9
Book case 132 (page 671 and 700)
I just did this case in the trial exam one week before the exam so I was confident with the task.
However after asking me whether I am understand my task, the female examiner did not want to
give me the sheet with the results of the pulmonary function test by asking “Do you really need this
sheet?” I then started by explain the test results using that sheet and some drawings but as soon as I
completed the spirometry test the patient immediately asked “What have I got, doctor and what can
be done?” I quickly mentioned what the lung volumes and diffusing capacity mean then went on to
explain the dx, its causes and management according to the book and John Murtagh. Then the
patient asked me whether she has a lung cancer, I reassured her that as far as she continues staying
off smoking her chance of developing cancer is reduced but I forgot to mention to do CXR to rule out
that unlikely possibility if one has not been done in previous 12 months.
I then asked the examiner whether I should show the patient how to use the medication before the
6th minutes (she did set the alarm for the 6th minutes) and she said yes. There was a large cone shape
spacer packed in a box, a bag of mouthpiece resembling the empty toilet rollers and Vetolin puffer
on the desk. I demonstrated the 4x4x4 method with the spacer. I completed the task before the bell
rang but I was worrying this station about the exam as I forgot to mention to do a CXR, which could
be the critical error.
Station 10
Book case 47 (page 222 and 248) but includes taking hx, PE and Mx
The patient was lying on the bed but the examiner was at another side of the room so I bended over
at the bedside to take the history that was similar to the one in the book. I was not sure whether I
need to perform PE so I only took a very brief hx. The examiner waved me over to another side the
room then asked me what I want to know in PE, so once I said I would like to exam the lumber area
and low limps but starting with inspection. He then gave me all the examination finding from
inspection, palpation, movement, special tests and tone, power, reflexes, sensation and
coordination. The patient has slightly scoliosis to the left and limited movement in all direction of
lumber joint with local tenderness in L5 and S1. SLRT only 30° in the left and left ankle jerk
diminished and sensory loss in lateral side of left feet.
I then returned to the bedside to tell the patient that he got a “ S1 disc prolapsed” and explained it
by drawing a diagram. He then asked whether further test is required and “No this moment. I will
give you some analgesic for pain relief, you need to rest in bed for a couple days but need to get up
to move around and start physiotherapy after that” I then reassured him that most of these cases
will resolve completely without serious consequences. He then asked how long he will be away from
work, I said I will give you a medical certificate for a couple days but I will see you again then to
reassess your condition at this moment you are definitely off work for a couple days. There was no
questions from the examiner and the patient seems happy.
Station 1
Middle age woman complained visual disturbance for three times since last weeks. She has
hypertension and hyperlipidaemia and on a list of medication including aspirin, statin and ACE
inhibitor or β-blocker. She also had an angioplasty/bypass before and family hx of DM
Task: Hx PE & Management
In history, she has amaurosis fugax (curtain coming down) but no other symptoms such as verbal
problem and weakness of limps. PE showed BP 150/100 P100/min but regular, second degree
hypertensive changes in fundoscopy and carotid bruit. So I explained the dx is TIA and requires
urgent admission for further investigations such Dopple carotid US, CT/MRI of the brain, ECG, TOE
and blood tests. The role player asked “Will it happen again?” “Many patients who have TIA will
have stokes soon after TIA, this is why you need to go to hospital immediately and to prevent it
happens. Do you have any other concerns?” “No, doctor, thank you very much!”
Station 2
30 year old woman who has an 18 months old child with Down’s syndrome now is 7 weeks pregnant.
She and her partner went to geneticist and were told that the chance of having another Down
syndrome child is 1 in 100.
Task: Answer the questions from the mother
I was reasonable comfortable when I was reading the stem because we had argued a few times for
this case since it reappeared in March 2011 exam. “What does 1 in 100 mean?” I explained the
chance of developing Down syndrome in normal pregnancies in different ages and pointed out she is
about 10 times higher risk than the normal pregnancies. She was a bit worry Then I explained the
screening and diagnostic tests and their benefits & complications. She seems not very happy so I
wanted to find out what exactly her concern is, i.e. whether they do not want another baby with
Down syndrome that was happen in old recall. She told me that her partner does not want to talk
about this matter but she still want another baby who with Down syndrome or not. I offered to see
her partner, or joined consultation and simple literature to take home for her and also mentioned
the support group for Down syndrome as well as ongoing support/following up. She was happy and
no further questions.
Station 3
Rest, I finished my exam with a glass cold water and good feeling about the exam.
It was such relief when the result came out. Everyone I know who took this exam passed. All the
examiners except one who did not shave my hand and the role players except one who is major
depressive are very helpful and encouragement comparing to my full exam in another place. So just
like Dr. Wenzel said that retest is not a bad result although you have to go through PTSD first.
I would like to express my gratitude to Dr. Wenzel, all my teachers in different hospitals, all my
lecturers in VMPF long course, my various study partners, and of course, family and friends for their
generous supports and ongoing assistance. I won’t be here without them!
Scenarios AMC Perth 21.05.11, written in retrospect
Biliary colic (passed)
RUQ pain. History and clinical findings given. Task was to explain the most likely
diagnosis (biliary colic). Prior to starting I offered the patient some pain relief. I
explained all the possible differentials and then management. The patient wanted to
know the plan from here (could he be discharged or not, how long would he have to
be off work.)
Chronic liver disease (passed)
Only real patient in exam. Very clearly hat liver disease. Task was to examine the
patient.
Clinical and U/S confirmed IUGR (passed)
Explain causes and management. I could not remember all causes and if it was
necessary to further investigate. This case is a bit of a blur. I managed to be
reassuring to the patient (at least I think I was) and list quite a few causes. I made
sure she was properly followed up.
Croup (passed)
Fairly straight forward. Explain management. Question from the examiner: Could it
be something else?
Delirium (passed)
Aboriginal woman refusing dialysis. Task was to do a mini mental test and then
manage. Outcome of the mini mental test was that she was delirious (clearly
disoriented). Patient appeared depressed. I completely forgot to ask about drug
history. I managed to convince the patient to be admitted and mentioned in the last
minute that she needs further investigations. I think I could have handled this case
better, as I ended up telling the patient she needs a psychiatrist (which is only
appropriate once an organic cause for delirium is excluded.) I did think this all the
time but did not voice this to the patient. It must have looked quite bad ,-)
Diabetes mellitus in four year old (passed)
Setting in GP practice, young kid presents with bed wetting (if I remember rightfully).
Through history it becomes clear there is polydipsia. Asking for investigations: Urine
dipstic positive for sugar. Patient clearly needed urgent referral to hospital. Father
asked a few questions, including what would be done in hospital and would his son
need insulin forever.
Dyspareunia (passed, unsure why)
I clearly struggled with this one and thought I had failed. Setting was in a GP
practice, task to take history and ask for examination findings. Young recently
married woman, previously no problems with intercourse, now dyspareunia.
Implanon some time ago.
I think it was vaginitis secondary to chronic candida infection. I failed to illicit this in
the history and could not put 2 an 2 together after I was given the examination
findings (“white specs on vaginal exam”)
End of life request (passed)
As per AMC book, exactly the same.
Headache acute (passed)
Setting ED. Patient had sudden onset of headache. History photophobia. Exam: BP
normal. Febrile, some neck stiffness. No rash. Otherwise normal neuro exam. My
diagnosis was meningitis. (I assume I was right given I passed). After making sure
the patient had adequate analgesia I explained further management (my approach
was CT and then LP. Antibiotics as soon as possible after tests, unless there were
significant delays to get tests organized).
Obesity (passed)
GP practice. Routine follow up for asthma. You the Gp notice the child is more than
chubby. Task was to chart growth charts and explain significance to father. Child had
gained a lot of weight and was above the 95% percentile (prior was normal). From
the history it was evident that the Kid loved Take Away Food and had no exercise
(preferred computer games), so the weight gain was probably life style related. I
suggested a referral to a dietician and lifestyle changes. The dad asked me but what
about his “glands”. Not sure if I was required to do further testing....
Pancreatic pseudocyst (passed)
GP, patient with bloating. Recent procedure mentioned in stem. Taking the history it
became evident, that patient had recently undergone ERCP. After finishing the
history and examination, the examiner asked me to interpret a coronal CT image
which showed a LUQ collection. I called it that. I feel a little ashamed to admit, that I
did not click: ERCP + collection in LUQ = Pancreatic pseudocyst.
I thought it could also be an enlarged spleen. I think it would have been fairer to have
multiple slices of a CT to be able to localize neighbouring structures (I would have
been able to spot the spleen). I passed, unsure why.
Psychosomatic chest pain (passed)
Lots of investigations done, no cause found. Turns out patient has sister with heart
trouble. Took a psychosocial history and asked for depression. Explained it is highly
unlikely this is somatic chest pain, but would refer her to a cardiologist if she wanted
this. I further made clear, that I think a lot of what was happening in patients life was
to do with lots of social stressors, including sisters illness.
Sore throat and rash (passed)
Take history and explain reason for rash. Image shown showed maculopaular rash,
onset after taking Amoxicillin prescribed for sore throat by GP. Diagnosis. Drug
reaction to Amoxicillin on a background of likely glandular fever.
Transient visual loss due to thrombembolism (passed)
Task take history and examine. Everyone do not forget to examine the
cardiovascular system after doing your neuro exam.
Turner syndrome (passed)
Primary amenorrhoea in a 18 year old. Appearance scribbled down on a piece of
paper (as clearly the role player did not look this way): Short stature and something
else. No webbed neck. Task to take history and ask for investigations. Thus far not
too hard. But the big question is, how do you explain Turners to the patient. How do
you manage (do you give hormones, can a person with Turners become pregnant?).
I was not sure, especially about pregnancy, I thought maybe there was a new fancy
way of hormone treatment to facilitate pregnancy, even though I seemed to
remember pregnancy was not possible.
Lets put it this way, I do not think I came across cleverly.