recall brisbane may 2010

8/4/2019 Recall Brisbane May 2010

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Brisbane 8th May 2010

(The comments in the boxes belong to another candidate)

Paediatrics

Q.1\ AMC book -condition 20-

Questions asked by the role player:

1. What is DM? My father has DM, is it the same one?

Me: No, the one your father has is called Type 2 and it is different from the one ur

son has which is called type 1 DM .Type 1 DM occurs at younger age in which there

is less insulin production from the pancreas which is responsible for regulation of the

blood sugar in our body. This occurs due to destruction of the pancreas possibly due

to autoimmune condition (our immune system attacks our own cells).

2. Will he need insulin for the rest of his life? Yes

3. Who will give him the injections?

4.How?Here I think I misunderstood the role player coz I thought she asked me to

explain the method of giving an injection so I wasted a precious time to explain that.

I believe we just need to tell her about the site of injections, the number of times a

day.........

5. What about increasing or reducing the dose? Who will decide that?

Me: The specialist will decide that which will be based on several readings of the

blood sugar....I explained about the glucometer and monitoring of the blood sugar.

6. What should I do in case of hypoglycaemia?

7. What should I do in case of hyperglycaemia?

8. What about sport?

In this case I always reassured the mother coz she was so anxious.....

However I could not finish my task on time so when the bell rang I told the examiner

while going out that I need also to talk about school and camping.

AMC feedback- Diabetes type 1 juvenile-counselling (Paediatrics) -- PASSED

This case is exactly same as the AMC book... but the mother was worried and needed

reassurance and was asking about the cause of DM......Passed


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Q.2\ A father brought his seven year old daughter who is complaining of recurrent

headaches.

Task: Hx, ask the examiner for the examination findings and management?

(My D.DX included the following: Tension headache, Migraine, Meningitis,Haematoma after a fall, Brain tumour ,Others like Infection such as viral or chest

infection ,Visual problem ,Sinusitis and hypoglycaemia )

History

- I do understand that u r here today coz of ur daughter? Could u please tell me more

about it? (He did not volunteer useful information so I start to ask questions)

-How long? 4 months

-Where? Like a band around her head.

-Does she skip school coz of it? No

-Does it affecting her daily activities? (I cannot remember what he answered)

-does she complain from this every day? No

-Is it there all the day? It starts in the morning and (I think he said until the evening)

-What about the weekends and holidays? No

-What relieves the headaches? May be Panadol

-Is this the first time? Yes

-Is it getting worse? Yes

Then I started to ask questions to exclude my D.DX

-Any family history of migraine? My sister has migraine

-any family history of brain tumour? No

-Does she vomit? Any nausea? Does the light hurt her eyes? No

-Any fever? Wt loss? No

-what about lying or bending? Do they relieve or worsen the headaches? No

-Any weakness in her legs or arms? No

-Any history of recent fall or head injury? No

-Any recent infection? Sinusitis? No


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-Does she skip breakfast? No

-Is she enjoying her school? No, coz there r many students there who r bullying her

and make fun of her and she is very upset about that. I tried to talk to her teacher

about that several times but we could not do anything about it.

-does she love her teacher? Yes

-What about her school performance? (I cannot remember what he answered)

-Can I ask some personal questions? Yes

-What about the situation at home? Very good

-r u happily married? Yes

-Any interpersonal problems between u and ur wife? No

-R u both having enough time with her? Yes

-Any financial problems? No

-Any other siblings at home? Yes (I cannot remember the age)

-How is the relationship between them? Very good

Then I finished my history taking with the usual BIND questions (birth and

pregnancy, immunization, nutrition and development)...All were normal

Also asked about general health, medication and allergy...All normal

Examination

-General appearance, well or unwell? Looks well

-growth chart? Normal

-Vital signs? (I cannot remember the exact numbers but they were all normal)

-Rash? No

-Fundoscopy? Normal

-ENT? Visual acuity? Sinuses? Normal

-Neck stiffness? LAP? No

-Chest and heart? Abdomen? Normal

-Neurological examination? Normal


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Management

Mr x, from what u have told me and from the examination, ur daughter has Tension

headaches due to the stress that she has at school. Our body and mind r connectedtogether and when our mind is upset, our body can respond in different way and in ur

daughters condition it is the headaches. The headache is real and genuine. It is not

serious and we have a lot to do about it.

First of all I need to talk to ur daughter and also we need to arrange family meeting.

Also we will arrange social worker to go to school to talk with the teacher coz the

most important think to treat these headaches is to remove the stress.

Also it will be a good idea if u can take her for a holiday.

I forgot to refer her to paediatric psychologist as the bell rang when I was talking

about the management but I told the examiner when I was going out that I have

more to talk, He laughed and said I know :)!!!

The role player here was so anxious after telling him the diagnosis so asked him if

he has any concern, he said, could it be brain tumour. I told him I am very happy

with my examination and it is very unlikely to be something serious but if u like I can

refer u to a paediatrician for a second opinion

AMC feedback Headache-tension (Paediatrics) -- PASSED

Q.3\ A six month old baby brought by his mother .He has diarrhoea about 5 or 6

times and vomiting about 4 times (I cannot remember the exact no.).

Task: Hx, ask the examiner about the examination findings and management?

History

-I do understand that u r here today coz of ur son? Could u please tell me more

about it? (Again she did not volunteer useful information so I started to ask

questions)

I referred the child to psychologist; but the role-player asked Is that necessary? And what

the psychologist will do? So I explained that the psychologist is expert to deal with similar

situations and he will help your daughter to identify the stress in her life and teach her how

to deal with it. Other management Social worker, school involvement, family meeting and

ongoing support from me.....Always at the end of each case the 4 R: Refer, Review, Red

Flags and Reading materials.......Passed


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-How long? 24 hours

-Is the diarrhoea watery or semi-formed? Watery

-What colour? (I cannot remember)

-Any blood? No

-Is it explosive? No

-Is this the first time? Yes

-What about the vomiting? Colour? Milky

-Is it projectile? No

-Any blood? No

-Any fever? He is a little bit hot

-Is he feeding well? I breast feed him and it is a little bit less than before

-From 0 to 100%, how will u rate his feeding? Probably 80% to 90%

-what about wet nappies? A little bit less

-From 0 to 100%? Also 80% to 90%

-Any rash? No (to exclude meningitis)

-Is he crying a lot or looks irritable? A little bit

-Does he draw his legs or look pale when he cries? No (to exclude intussusception)

-Does he cry when he passes water? No (to exclude UTI)

-Have u travelled recently? No

-Does he go to child care? No

-Any contact with similar condition? His brother (4 years old) has similar episode 4weeks ago .Now he is well.

Then I asked about BIND...The mother said that he has not had the 4 month shot for

some reason (I cannot remember why) so I told her it is important to immunise him

coz it will strengthen his immune system and help him to fight against diseases.

Beside it contains vaccine against rota virus which is the main cause of diarrhoea in

children....She accepted my advice and she was very willing to have her baby

immunised.


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Examination

-General appearance? Normal

-Growth chart? Normal

-Signs of dehydration (fontanelles, sunken eyes, dry mouth, skin turgor and CRT)?

All normal

-Vitals? I cannot remember the exact no. But they were all normal except the temp.

Was 37.7

-Any rash? No

-ENT? Normal

-Neck stiffness? LAP? No

-Chest, heart ?Normal

-Abdomen? Starting by inspection? Normal....then by palpation for masses and

pain? Normal

Bowel sounds? Normal

-Inguinal orifices? Normal

-Urine dipstick? Normal

-excoriation of buttock? No

Management

Mrs x, from what u have told me and from the examination, ur son has gastroenteritis

most likely due to viral infection....It will resolve by itself within 3 to 4 days. There is

no specific treatment or antibiotics coz it is viral infection. The most important thing is

to prevent dehydration. So I would like to refer him to the hospital for observation for

few hours and oral rehydration solution until the vomiting settles down.... (Here the

mother asked if she can manage that at home)I told her Yes u can but I would liketo see him in 6 hours time to re-examine him coz babies at this age can easily get

dehydrated. So continue breast feeding but frequently and in smaller amount .Also

give him ORS a mouthful amount every 15 mins. During this period if u noticed that

he is unwell, does not feed well or less wet nappies or u r worried for any other

reason, bring him ASAP to me or to the ED.

Also coz this type of diarrhoea is contagious so try to keep him away from his brother

and make sure u wash ur hands after changing the nappies or before handling food.

I also gave some written materials.


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Then the mother asked me if she can visit her cousin who has 3 children, I told her

that she can but she needs to keep her baby away from them.....

AMC feedback Gastroenteritis (Paediatrics) -- PASSED

Obs & Gynae.

Q.4\ A 28 year old woman comes to ur GP, she has a positive pregnancy test at

home after nine weeks of amenorrhea ...Her periods are irregular. Her pap smear

was done 6 months ago and it was normal. This is her first pregnancy...Her nextantenatal visit is in 2 months time so she has been told to visit her GP for initial

Investigations.

Task: Counsel her about the initial Ix she needs until that time and answer her

questions.

I talked about the following:

Congratulations for ur pregnancy. I do understand that this is ur first pregnancy?

(Yes).have u started taking folic acid? (No).So first of all we need to confirm the

pregnancy here in our office .Also it is important to start taking folic acid for the first

12 weeks of pregnancy. We need to do routine initial antenatal tests which include

the following:

1. FBE &Hb, BG & indirect Coombs test.

2. Rubella and varicella immunity status.

3. After ur permission, screening tests against certain STDs including HIV, VDRL for

syphilis, hepatitis also we need to take some cervical swabs for Chlamydia and

gonococcus infection.

4. Midstream urine C&S for UTI.

Also if u like we have screening test for Downs syndrome that we offer for any

pregnant woman although u r still young.

We will also do U/S to confirm the date of pregnancy coz ur periods were irregular (I

am not sure if I should have said that or not but I had a plenty of time so!!!!)

The role player asked me if there is any other medication she should take. I saidiron

but first we need to check ur Hb level (I am not sure if this was what she wanted tohear)

I gave the mother options either taking care of the child at home (if she can) and I need to review

him in 6 hours, or I can refer her to hospital where her child will be assessed and then discharged

when he is feeling better....encourage breast feeding and immunisation.....4R..... Passed


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Also she asked me if she should continue her job as she is a teacher? I said It is up

to u but let us first check ur immunity status against Rubella and chicken pox. if u r

immune it is safe but if it is not it is important to stay away from children especially

the first 3 months coz it is the critical period for the development of baby...

I believe the critical errors in this case r most probably to offer downs screening ...

OR very less likely to arrange U\S to confirm the date of pregnancy since her periods

r irregular OR to arrange varicella Ab screening coz I know a candidate who failed

this station and he did exactly like me apart from the above 3 things.

AMC feedback Investigations during pregnancy (O&G) -- PASSED

Q.5\ AMC book condition -64-

The differences were the following:

1. Task includes examination

2. In the examination I asked the following:


-BMI? Normal

-Secondary sexual characteristics (axillary hair, beard, gynaecomastia)? Normal

-Chest and heart? Normal

-Abdomen? Normal

-Inguinal orifices? Normal

-Genitalia (Inspection: pubic hair, scrotum, any swelling.....Palpation: can I feel bothtestes, spermatic cord, size of testis, any swelling)? Both testis r present and of

normal size but there is a small swelling in the right side.... (So I asked the examiner

about the CCC of the swelling?)It is not tender, feels like bag of worms, can get

above it, and disappear when lying down... (Here I should have asked also about

transillumination and may be others but I was in a hurry as I wanted to finish my

task)

-Urine dipstick and BSL? Normal

3. I advised the patient as in the book but I also told him u have a swelling in the

scrotum most likely it is called varicocele which is dilated veins like varicose veins in

I offered all the antenatal care Ix mentioned above, but I did not offer Downs screening, early U/S or

Varicella Ab screening. I mentioned, as you are a childcare teacher its important to avoid contact with ill

children or children with fever...... Failed


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the legs .It can be related to ur problem but do not worry coz it is a treatable

condition so I will refer u to a surgeon for that. He accepted my advice without any

comment and then I completed my task according to the book.

AMC feedback Primary infertility (O&G) -- PASSED

Q.6\A woman in her 50s (I cannot remember the exact age), comes to ur GP

complaining of a lump going down on and off mainly with sneezing and straining.

Task: Hx, ask examiner for examination findings and management.

History

-I do understand that u have been complaining of a lump from the down below?

Could u please tell me more about it? I have this lump on and off for months now but

it is getting worse now.

-Is it there only when straining? Yes

-does it disappear by itself? Yes

Here the role player said I had my womb removed 13 years ago. Actually she

surprised me when she said that coz I was almost sure it is uterine prolapse. So I

continued my history taking...

-Can I ask why u had ur womb removed? Coz of heavy bleeding.

-Any complication after the operation? No, everything was normal until months ago

when I had this lump.

-Any problem with passing water? No, completely fine.

-Any bleeding? Discharge? No

-Can I ask some personal questions?Yes,please

-r u sexually active? Yes, I am married

-does this lump affecting ur sexual activity? Yes, it makes me feel uncomfortable.

-Any bleeding after sex? No

-Have u had any HRT before? No

-What about ur pap and mammogram? Done regularly and normal

-How is ur health in general? Fine

I just did as the above candidate and as the AMC book.....Passed


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-any wt loss or loss of appetite? No

-do u have any cough? Constipation? No

- Do u have children? Yes 2(or three)

-What about the deliveries? All NVD and without any difficulties.

-Do u smoke? No

-Alcohol? Socially

-Some people used recreational drugs, have u ever used them? No

-Any chronic illnesses? No

-Any medication? Allergies? No

Examination


-BMI? 28

-Vitals? Normal


-Abdomen? Starting by inspection? Normal......Palpation, any masses, tenderness?

No

-Vaginal examination after patients permission, starting by inspection, any lump?

No...

-then by speculum examination, any discharge? No

-Then I would like to ask the pt to strain, any lump? Yes, the vagina comes down...

-Then I would like to use Sims speculum in left lateral position and ask the patient to

strain again to look for cystocele or rectocele? Normal

-Urine dipstick and BSL? Normal

Management

Mrs x, from what u have told me and after examining u, it seems that u have vaginal

wall prolapse (Actually the right thing to say is Vaginal vault prolapse and I knew

that but it just did not come out so I just said wall prolapse...also I drew to the patient

and explain the condition but please read more about it as I have no enoughinformation and I am not sure if what I said is correct or not).


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Coz u had ur womb removed, this can leave the vagina unsupported and with age

the ligaments become weak.....this is not serious but with time it can get worse and

might lead to ulceration. We have conservative treatment and surgical....so what

treatment do u prefer?(The pt. says she wants to find a final solution to the problem

so I said:)so we need to refer u to a gynaecologist who will do further assessmentand most likely will decide an operation. but life style modification is also important

and u need to lose wt, walking for 30 mins every day, healthy diet( I am not sure if

we need to talk about pelvic floor exercise ,actually I did not have time as the bell

rang!!)

AMC feedback Vaultprolapseafter hysterectomy (O&G) -- PASSED

Psychiatry

Q.7/ A very long stem of a women has 2 children, 2 months old and 30 months old,

presented to u one week ago with a history of tiredness ,wt loss and inability to

sleep. She is always worried about her baby as he might die from SIDS .She thinks

life is not worth living but she does not have infanticide idea. U arranged Ix for her

one week ago including FBE, TFT and (many others that I cannot remember) all

were normal...Today she comes to ur GP for the result.

Task: Take focused hx, counsel the pt about the treatment in details?

This is a very weird station as when I was outside I thought it is definitely severepostnatal depression that needs urgent admission...beside I was wondering what

else I should ask this patient as the stem is too long and I did not have enough time

to read it carefully so I can figure out what else they need so I just decided to follow

the usual psych hx except things provided in the stem.

History

-Hi Mrs x, we have received the results back and I am pleased to tell u that all of

them r normal. So can I ask u few questions to clarify the problem? Yes(here I was

surprised that the role player actually was a happy young female, and no signs ofdepression at all so I said to myself may be she is not a good actress!!!!)

-How was the pregnancy and labour? All fine, no problems at all.

-How is ur mood? Not good, feeling tired (I cannot remember the exact words)

-what about ur sleep? Cannot sleep, feel anxious

-What about ur sexual desire? Reduced

-Do u go out with friends? No, do not have time

-Do u have enough support? My husband is very supportive


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-What about ur family? They r interstate

-Do u work? No

-Were u working before or do u want to start a job? No


-Do u think life is worth living? Yes!!!!!..............Here the role player really surprised

me so I said But I do understand from ur notices that u do not think life is worth

living!...She smiled and saidThat was before but now I do understand that I have

responsibilities and I should take care of my children!!!!

-Do u smoke? Do u drink alcohol? Drugs? No

-Do u see or hear things that other people cannot? Do u think someone is trying to

follow u or spying on u? Do u think TV is talking about u ?Do u think that u havespecial powers? No

-If u r in a cinema and there is a fire, what will u do? Run away

-Do u think u need a medical help? Yes

-Do u have any past hx of any illnesses or psychiatric illness? No

-Any family hx of psych illnesses? No

Management

Mrs X, What u have is a condition calledpostnatal depression..It can happen to

women after deliveries and it is treatable. So please do not worry. What Id like to do

is to do admit u to the hospital for further assessment.(Here the role player said that

she does not want to be admitted to the hospital and me personally I did not find any

reason for admission as she was smiling ,no suicidal ideas, she just needs some

help so I said....)

OK then, I will refer u to psychiatrist ASAP for further assessment and for CBT which

is a type of talking therapy based on weekly sessions. It will help to identify thestress and deal with it. Also the psychiatrist most likely will start u on antidepressants

medication.

The role player askedwhat about breast feeding. I saidThis depend on the type

and dose of medication .There r medications that r suitable for breast feeding,

however the best will be decided by the specialist...Then I said:

Also we need to arrange a social worker and also liaise with the local community

nurse for any help u need.....Also beside my support and regular follow up, we have

good support group that u can talk to them, share ur experience and have goodadvice. Also Id like to arrange family meeting ...Here the role player interrupted me


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and said Yes, what about my husband, I am really worried about him coz he is very

concerned about me...I answered I will talk to him but please do not worry about

that coz they r there to support us and they r happy to do that ...I think I should

have said something better than that but that what came to my mind at that

moment......Then the bell rang!!!!!!!!!!!!!!

AMC feedback Major depressive episode-post partum phase- -- PASSED

Q.8\A thirty something woman comes to ur GP asking about her father who has

recently diagnosed with Alzheimers disease .She is a very busy solicitor. She is very

concerned about her father and she has many questions to ask. The daughter has

her fathers permission to ask about his condition. (I think also that a CT scan was

done to the patient and showed atrophic changes)...

Task\ Answer her questions.

The role player asked the following questions:

1. What is Alzh. Dis.?

Me\It is a type of dementia where there is wasting of the brain cells, which in turn can

affect the brain function.

The early features of this disease are disturbance of thinking and short term

memory. It also causes personality changes.

This will worsen slowly and gradually with time .It can lead to severe memory

disturbance, the person might even forget the names of his family. The person mightalso neglect himself and this lead to malnutrition and increase risk of accidents at

home or outside.

2. When they dxed him with this dis...r they 100% sure?

No, basically Alzh. Dementia is a dis of exclusion. By that I mean exclusion of other

correctable causes. It is true that we can see some changes on the CT scan,

however the only definite dx is after death of the affected person and examining the

tissue of the brain under the microscope.

3. Can it be depression coz my mother passed away 6 months (or one year) ago?

In the stem they mentioned that a depression Questionnaire was done to that patient and it showed that she was

depressed... The role-player did not seem depressed to me and she was somewhere between depression and

anxiety, but I decided to go with what I know (post-natal depression)... I admitted the patient who refused in the

beginning, but she agreed when I explained to her that it is important and necessary to admit her and to be

assessed by a psychiatrist... I also asked to talk to the husband and check both of her children... I reassured that

her condition is common and has good outcome with treatment... support group and social worker....Passed


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Well ,Depression by itself can be presented as dementia and sometimes it is called

pseudodementia so it is important to exclude it before diagnosing dementia.

But Those with Alzh. can get depressed especially at early stages of the disease coz

they can recognise their disability ,but please do not worry about that ,he will be

assessed by a psychiatrist and I will follow him up regularly. Also we have good

medication for depression in case he needs them.

4. What can be done now?

First of all, he needs to be assessed by the aged care assessment team; this team is

composed of a geriatrist, psychiatrist, social worker, occupational therapist, and

physiotherapist. He will be assessed by them to determine his degree of dependency

and assess his eligibility for the services that we can offer.

So the geriatrist might prescribe some medication for him that will delay the progressbut will not treat the illness as this disease is unfortunately progressive and it is not

treatable.

The occup. Therapist will assess the house and assess his needs, for example, he

might need a big clock, rails to prevent falling, remove any loose carpet and a list of

things as a remainder.

The social worker will arrange some people to help him in washing clothes in case

he needs and meals on wheels and many other services as well.

The physiotherapist will assess his ability to walk and might provide him with walking

aids.

5. Is it better to put him in a nursing home coz I am very busy and I cannot take care

of him?

Well, the ACAT will decide that after further assessment...The options that we have

r:

1st option, treat at home if he can cope with that and this is a good option as the

environment is familiar to the pt .He will be assessed regularly by me and the ACATso we wont leave him alone.

2nd option is to put him in a nursing home in case he needs that.

And at any time if u change ur mind, u can take him to ur home and take care of him

but u will not be alone and there is respite care that will help u to take a break and

have some rest.

While I was talking about that the bell rang so I have not had the opportunity to talk

about ability to drive (as we need to assess his brain function and if it is well he can


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drive, otherwise he cannot and his licence should be suspended) and also to give

some reading materials.

AMC feedback Dementia of Alzheimer type -- PASSED

Examination

Q.9\AMC bookcondition 102-

The differences were the following:

1. On the wall outside the room, there is an attached paper includes a chart of

the vital signs of the patient since the operation....I believe they were all

normal.

2. Also in the question, the bladder was assessed by U\S probe and it showedlittle amount of urine (a number was given).

3. The task was to examine the patient and write a management plan.(When I

went inside the room, the examiner asked me if I understood my task, I said

yes, I need to start examining the patient without taking any hx?He said

Wellu r the first candidate to do that!!!!! :)

4. The pt was a young female lying on bed with a NG tube attached and fluid(as

described in the book)

5. Then he asked to give a running commentary while examining the pt so I told

the examiner My examination will include assessment for urine retention,signs of dehydration and signs of over hydration..He answered

Good........Then I started to examine the pt and straight away I started to

examine the abdomen by pressing on the bladder and asking the pt if she has

any desire to void for which she said no....Actually with any examination it is

better to start with the general app. and vitals then the rest but I

FORGOT................Then I started to look for the signs of dehydration and

here the examiner asked me what I am looking for ,I said (while I was

demonstrating that) sunken eyes, dry mouth, skin turgor and CRT and again

I forgot to say the vitals!!!However they were already measured by the

nurse......Then while I was starting to look for signs of over hydration, the

examiner interrupted me and asked me to write my notes.

6. The examiner asked to explain to him what I had written so I said I will give

the pt 500 ml of N\S in 30 or 60 min and then review the patient...The

examiner asked me how I will monitor the pt, I said The vitals and repeating

my examination but he really did not seem satisfied with my answer and a

little bit upset and he said something like the vitals r not that useful to monitor

such patients so I said by putting a catheter and he was happy with this

answer but I told him that I was going to do that if the pt did not pass urine

after 30 to 60 min ( As in the book ) but he answered No, u should do that


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from the beginning so I agreed and I did not argue with him coz HE IS THE

BOSS !!!!

7. Then he asked me how much fluid I will give for the rest of the day so I

answered as in the book. He asked me to write that as well.

8. Then he asked me what if the pt did not pass urine after 60 min, here myanswer was I will take a sample of urine and send it to the lab to differentiate

between pre-renal cause or renal cause and I explained what I will measure

in the urine.....And again he was not satisfied with my answer and after trying

to repeat the same answer in different ways( coz I really did not know what he

wanted me to say) the bell rang and at that moment I said I will check for

urine retention and here he said yes that what u need to do and I went

out.................But after thinking of that after the exam, I asked myself Why do

we need to check for urine retention and a catheter is already

there?!!!!!!!!!!!!!!!!!!........................In this station either I did not understand the

examiner or he did not understand me!!!!!!!!

AMC feedback Post operative oliguria -- PASSED

Q.10\ A 50 something man, come to ur GP complaining of pain during walking which

relieves after rest. He is a smoker (heavy) and on ACE inhibitor for HPT. (I cannot

remember if there were other risk factors in this case).

Task: Perform physical examination (u do not need to examine the vitals or the

heart) and outline ur management plan.

I think the pt here was a real pt. and he was wearing a gown.

1. I started by asking the pt to walk few steps (I think we do not need to do this step

so double check that please)...

2. Inspection: There was a midline longitudinal scar on the abdomen and another

one on the inner side of the upper right leg...I asked the examiner if I can ask the pt

about them he nodded yes .Here the pt said that for the abdomen it was for AAA and

for the leg it was for a clot removal.

3. Temp. and CRT.

4. All the pulses were palpable (No expansile impulse for aorta, femoral pulsation

and others were intact as well) .However it really took me long time to feel one of the

femoral pulses.

5. After finishing that, the examiner started to rush me and asked what else, I said

Auscultation for bruit and I showed him where quickly (abd aorta, iliac, femoral,

adductor hiatus and popliteal) .He answered No bruit


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6. Also I said burgers test and ABIbut he did not asked how to do that and he

asked about my provisional diagnosis for which I said PVD

Then he shocked me when he smiled and said the bell rang...actually I did not hear

it and I said to him that I still need to manage the patient but he smiled and while he

was guiding me to the door I said with a loud voice to the pt u need to quit smoking,

life style modification and referral to a vascular surgeon...They both laughed

loudly.!!!!!!!!!!! .........This was a very funny station.

AMC feedback Leg cramps on exercise -- PASSED

Medicine & Surgery

Q.11\ AMC book - condition 68 -

The only difference is that we also need to take hx and to give D.DX....and when I

was going to tell the examiner (after asking him about the examination findings)

about my D.DX and the test to confirm that, he stopped me and asked me to tell thept about it....So I rattled off the D.DX to the pt. but when I asked her if she wanted

me to explain each one to her she said no need( What a nice lady, she wanted to

save my time)..When I was going to explain the treatment the bloody bell rang again

so I quickly said while going out that the treatment is steroid.!!!!!!!!!

AMC feedback Aches and pains -- PASSED

Q.12\ AMC bookcondition 139

The only difference is to explain to the pt how to use the peak flow meter ......he said

he know how to use the puffer.........There were a puffer and a peak flow meter

provided on the table .

Also I wrote the management plan on a plain paper as there were not any

management plan papers when I asked the examiner about it.

The patient asked me about the dose and type of steroid tablets.

AMC feedback

Asthma -- PASSED

I was asked how to perform burgers test, D.DX (I think we need to say neurological cause such as

sciatica, spinal canal stenosis and peripheral neuropathy)...Passed


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Q.13\ A 30 or 40 something old tram driver, comes to the ED complaining of chest

pain for few hrs.

Task: Hx for 4 mins, ask the examiner for examination findings and management.

When I entered the room ,the examiner said to me that I have 3 mins to ask hx so I

asked him to stop me after 3 mins coz I will forget and continue asking question ..He

smiled and said ok

History

- I do understand that u r here today coz u have been having pain in ur chest? Could

u please tell me more about it? I have been having this pain for few hrs now (Icannot remember how many exactly) and it travels to my back and shoulder. It is

getting worse now.

-How did it start? Suddenly without doing anything but I had flu days ago.( The role

player was very kind to volunteer this info. However she was answering all my

questions directly and nicely).

-Is it there all the time? Yes

-Could u describe the pain? (I cannot remember what she answered)

-From 1 to 10, 1 is the minimum and 10 is the maximum, how would u rate the pain?

6/10

- Anything worsens the pain? When lying or with deep breathing.

- Anything relieves the pain? When leaning forward.

-have u ever had chest pain before? No

-Any SOB, Cough, palpitation, leg swelling, dizziness, fever? No

-How is ur health in general? Perfect

-Any chronic illnesses such as DM, HPT, high cholesterol? No

-Do u smoke? No

-Alcohol? Socially

-Some people used recreational drugs, have u ever used them? No

-Any medication, allergies? No


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-Any recent travel? No

-Is ur chest sore to touch? No

Examination

-general app.?She is in pain

-VS and O2 sat.?Normal (I cannot remember the exact numbers).

-heart? any thrill by palpation? No.....heart sounds? Normal...

-any added sounds or murmurs? There is a noise ............I asked the examiner if it is

a rub? He said YES

-Any signs of heart failure? No

-Lungs? Normal

-Abdo.?Normal

-Leg swelling? No

Any Ix available? No.....I think the examiner asked me about my provisional dx and I

answered My provisional dx is acute pericarditis but I need to exclude MI coz every

chest pain is MI until proven otherwise

Management

Mrs x ,from what u have told me and from the examination findings, most likely u

have a condition called Acute Pericarditis which is inflammation of the covering of

the heart. It can follow a viral infection....Pericarditis by itself is not serious and it is

self limiting condition but it can lead to serious complication such as pericardial

effusion and temponade which r collection of fluid that may affect the function of the

heart.... First of all we need to do ECG to confirm the dx . Also I would like to admit uto the hospital and u will be assessed by cardiologist .The following ix will be done as

well:

-General blood test such as FBE, HB, inflammatory markers.

-Cardiac enzymes to exclude MI

-CXR to pericardial effusion

-ECHO to exclude effusion.


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The treatment includes high dose of NSAID such as Ibuprofen every 4 hrs and

regular monitoring to detect any complication earlier.

The role player asked the following:

-How long do I need to stay in the hospital?

Me\Probably few days but it depends on the severity and the progression of the

condition.

-Could it be heart attack? (The role player was a bit concerned about the chest pain)

Me\It is unlikely but we still need to perform some tests to exclude it. Please do not

worry coz u will be managed in good hands.

AMC feedback Pain in the chest, back & shoulder -- PASSED

Q.14\ A 70 years old man present to ur GP clinic complaining of recurrent falls...He

had stroke four years back with weakness of the right upper and lower limbs.

Task\ take a detailed history for 4 mins, ask the examiner for the examination

findings, d.dx and management.

History

This was my first case and I put the following d.dx when I was outside the

room(Neurological-epilepsy ,TIA-......CVS-structural or arrhythmic-....postural

hypotension-medication and DM-.......hypoglycaemia......vision ,hearing and

balance.......alcohol.....musculoskeletal such as joint problems.....psych. as

depression .....Environmental as messy house).

- I do understand that u r here today coz u have been complaining of recurrent falls?

Could u please tell me more about them? (The role player did not volunteer any new

info so I started to ask questions).

-When was the first one? Few months ago (I think 6 months ago)

-How many times? 3 or 4 times

-Have u sustained any injuries? Just few bruises.

-What were u doing before the fall? It happen when I get up for e.g. in the morning

when I get up from the bed.

-Did u feel dizzy before u fall? Yes


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-Did u lose conscious? No

-any problem with speech, swallowing, weakness in the arms or legs (apart from the

one u have)? No

-Any palpitation, chest pain, SOB? No

-have u been passing water a lot? Or feeling thirsty lately? No

-Any problem with vision, hearing? No ...I said ok we will check them.

-Any joint problem or pain? No

-Do u skip meals? No

-How is ur health in general? Any wt loss or loss of app.?No, I am fine

-Do u live alone? Yes

-can u manage things by ur self? Yes

-Any walking aids? No

-What about the environment at home? It is a little bit messy.

-Any medication? (The role player here who was an old age man gave me a small

card with names of drugs written on it...... angiotensin 2 receptor antagonists,

diuretics and amitriptyline but I cannot remember the names of the antiHPT

medication).

-Do u have HPT? Yes for few years

-Is it well controlled? I check it every now and then and it is ok

-I can see that u r on amitriptyline, do u have depression? Yes since my wife passed

away 9 months ago.

-I am sorry to hear that, and how do u feel now? Fine.

-Any other illnesses such as DM, heart problems? No

-Do u smoke? No

-Alcohol? socially

- Some people used recreational drugs, have u ever used them? No

Examination

-General app. And BMI? Normal


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-Vitals including BP lying and standing?(I cannot remember the exact numbers but

the pt had low postural hypotension)

-Fundoscopy? Any HPT changes or papilledema? Normal

-Carotid? Any thrill or bruit? Normal


-Neurological examination?(here the examiner asked me what I want to examine

exactly so I started with the gait, cerebellar signs, cranial nerves ,upper and lower

limb examination including tone ,power ,reflexes ,sensation and coordination)..The

findings was hypertonia and hyperreflexia on the right side but the power

reduced.....I cannot remember what the examiner told me about the gait.

-here the examiner told me the rest of the examination is normal and I should talk to

my pt. but still I asked about vision ,hearing ,BSL and musculoskeletal...The

examiner said it is all normal ( with a smile that meant do not ask anymore when we

said the rest of examination is normal!!!!!!! as Dr.Wenzel always says that but we

still ask !!!!!!!!!! )

Management

Mr x ,It seems that the most likely cause is postural hypotension which sudden

reduction in BP when changing position from lying to standing..The most likelycause in ur case is the antiHPT medication that u r on (Other candidate said that

amitriptyline also causes that) so it is important to change ur medication.....Other

causes of the recurrent falls could be due to loss of balance coz of the stroke that u

had 4 years back or due to depression and loss of concentration.

So I would like to refer u to fall clinic for further tests and...............Here the bell rang

and I did not have the opportunity to say occupational therapist to visit ur home and

physiotherapist which I believe is important to mention ....This was my first station

and I realized here that I am very slow and I need to be quicker ,however I could not

achieve that in most of my stations but what I could do is to continue talkingespecially the main and imp points until I go out and the examiner closes the door .

AMC feedback Recurrent falls -- PASSED

Q.15\ A 30 or 20 something lady came to ur GP clinic complaining of constipationand pain the lower left abdomen for few months.....u arranged some tests like

I mentioned referral to fall clinic, physiotherapist, occupational therapist and installing an alarm in

your house because the patient lives alone.... and of course changing the medication...Passed


23/27

colonoscopy, sigmoidoscopy, blood tests and TFT and others ( I cannot remember

the exact ix) ,all of them were normal..She came today for the results.

Task\Take a focused hx, D.DX and management

In this case I tried to ask a little bit about the pain and constipation and to focus moreon the social hx....

History

-Hi Mrs X, we have received the results back and I am pleased to tell u that all of

them r normal .This means that u do not have any organic or serious illness but I

still need to ask u few question to try to find the cause, is that fine with u? Yes.

-Is the pain always there? No, it is every now and then

-Does it travel anywhere else? No

- Anything relieves the pain? When I open my bowel or pass flatus

-Anything worsens or brings up the pain such as certain food? yes when I eat certain

food like broccoli and also red wine.......(I cannot remember the answers in this case

including other pain questions like the severity but it was typical of Irritable Bowel

Syndrome as in the previous recalls.)

-What about the constipation? (Again I cannot remember the details)

-Do u have any diarrhoea in between? No

-Do u use any laxatives? No

-Can I ask u some personal questions? Yes

-How is the situation at home? I am married and I have 2 kids (I think teens)


-R u happily married? Yes

-Any problems with the kids? No but I always like everything to be perfect at home,

clean and tidy

-What about ur family, friends? Do u work? (I cannot remember the exact answer but

nothing specific)

-Health in general? Sleeping? Mood? Fine

-Any chonic illnesses? Any medication? Smoking? No

- Alcohol? red wine ( I think with evening meals)


24/27

- Some people used recreational drugs, have u ever used them? No

-any family hx of similar problems, relatives on special diet or cancer? No

Management

Mrs X, It seems that the most likely cause is a condition called Irritable Bowel

Syndrome. Other causes could be Celiac disease but it is very unlikely and we can

do some screening blood test for it. (Here I really did not know what else to say

about the D.DX as I had not read in the previous recalls about a D.DX in this

case!!!!So I just continued my management and the examiner was just listening

without any word.).....Have u ever heard about Irritable bowel syndrome? No

Well the bowel of some people r sensitive to some external and internal stimuli such

as certain food and stress coz our mind and body r connected to each other and

when our mind under stress ,our body can respond in different ways ( I am not sure if

we should say that here),...This will lead to different symptoms such as pain ,

constipation and s.t. diarrhoea. This is not serious at all .It is not cancer and it does

not lead to cancer so please do not worry a lot about it. This condition is chronic .it

comes and goes and it may disappear for years. It is not treatable but controllable

condition however we still have a lot to do about it

The most imp thing in the management is life style modification and preventing the

contributing factors so try to avoid the causative food such as broccoli and red wineand try to make a diary and write down the food that can worsen the symptoms. High

fibre diet and plenty of water is imp. I can refer u to dietician if u like.

Also relaxation is very important to relieve the stress such as yoga and meditation.

Try to be less than perfectionist. For medication I can prescribe u some medication

such as mebeverine and peppermint oil but these medication is to control the

symptoms and not to treat the condition...and please try always to stay away from

the laxatives as it can cause lazy bowel in the future...... (Here the bell rang and I did

not tell the pt about the red flags, reading materials, review!!!!!!!!)

AMC feedback Constipation -- PASSED

Q.16\ (The famous lymphoedema case) A 50 something woman came to ur GP clinic

complaining of swelling in her left arm and forearm (I think the hand was not

involved...Also a photo was provided)). She has a hx of breast cancer years back

and she was treated with mastectomy and axillary clearance followed by

radiothearapy.

Task\ explain the condition to the pt and management...Referral to specialist is notenough.


25/27

Explanation

Mrs X, most likely u have a condition called lymphoedema; Have u ever heard about

it? No

Well Mrs X, our body composed of three types of vessels ,arteries ,veins andlymphatic vessels which carry a type of fluid called Lymph from the body back to the

blood and these vessels r connected by lymph nodes( I drew that to the pt.)....

Lymphoedema occurs when the lymph accumulates in the body due to destruction or

blockage of the lymphatic vessels. In ur case it might be due to the surgery itself and

the clearance of the axillary lymph nodes in the armpit or it could be due to the

radiotherapy or less likely due to recurrence of cancer itself.

Other causes of this swelling r DVT (a clot in the vein) and infection...so we need to

do some tests such as some blood test as tumour markers, CT scan to detect anyrecurrence and Doppler U\S to exclude DVT.

(I cannot remember if I told the pt about referral to vascular surgeon for lymph

angiogram to confirm the dx and I am not sure if this test is available or not or if it is

right to mention it so please check this)

For the management, I will refer u to lymphoedema clinic and we will work as a

multidisciplinary team (specialist, physiotherapist, nurse and me as ur GP)...The aim

of the treatment is 2 things. Firstly is to reduce the swelling and secondly is to

prevent infection as the skin here is very liable to be infected.

To reduce the swelling, we need to use compression bandage day and night, also

massage and try to keep ur arm elevated...The physiotherapist will help u with that.

To prevent infection, it is important to follow certain tips:

-avoid sunburn. Insect bite.

-Always wear gloves when working in the garden or washing dishes as the skin can

easily get injured.

-Do not let anyone to measure BP in this arm or to give u any injection or to take

blood.

-Use emollients to moisturize the skin.

-Take care with nail clipping or hair removal.

This treatment is usually successful however we still have surgery as a last

resort...(here the examiner was very surprised about this info and he asked me what

type of surgery, I really did not know what to say coz I just know from the course in

the VMPF that there is a surgery ..So I told the examiner that once I watched that ona TV report about 2 women, one in the US who was treated conservatively and the


26/27

second one in Sweden who was treated by surgery...Actually I did not lie and I really

watched that before..So the examiner nodded his head and said ok maybe it was

due to?!!!I did not understand him)

I forget to tell the pt about red flags and if there is any redness or signs of infection to

come back immediately for antibiotics.

I finished this case earlier and I asked the pt if she has any further questions, she

again asked me if it could be cancer and I repeated the same answer.

The examiner here who was a very nice one asked me again to summarise my

management so I repeated the same answer but he asked what else and I repeated

the same things...I do not know what he wanted to hear from me ...Then we chatted

a little bit then he asked me to wait outside...This is the only case that I waited

outside!!!!!!!!!!

AMC feedback Lymphoedema \upper limb -- PASSED

Dear colleagues,

- I tried to remember and write whatever I could, however do not rely on the answers

of the recalls completely as we may forget to write important and vial things...Always

compare the recalls and choose the best answer.

-I would like to say a big thank you to the staff and all teachers of VMPF long

course.....

-Also I would like to thank Dr.Wenzel so much for his great and priceless efforts.

-Thank u to the previous candidates who wrote the recalls for us as these recalls

were a vital element to study in order to pass this exam.

-my exam was in Brisbane...The examiners there just sit and listen to u...Actually

they neither give u hints nor mislead u ...The role players did the same ......Butalways listen well to the role player and his concern and questions and answer

accordingly.

-Please study the AMC book very well ...as u can notice we had 5 cases from the

book although they were a little bit modified....

-I believe the stations in the exam were in the following order:

1. Recurrent falls.

2. Headache-tension (paeds).


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3. Rest station.

4. Lymphoedema\upper limb.

5. Investigations during pregnancy (O&G)

6. Aches and pains.

7. Major depressive episode-post partum phase-.

8. Rest station.

9. Asthma.

10. Diabetes type 1 juvenile-counselling (Paeds).

11. Primary infertility (O&G).

12. Leg cramps on exercise.

13. Rest station.

14. Constipation (Not sure)

15. Post operative oliguria (not sure)

16. Pain in the chest ,back and shoulder(not sure)

17. Gastroenteritis (Paeds)(not sure)

18. Rest station.

19. Dementia of Alzheimer type.

20. Vault prolapsed after hysterectomy (O&G).

GOOD LUCK FOR ALL..........................................................................................

recall brisbane may 2010

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