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.