AMC clinical adelaide march 21 2009

Discussion in 'AMC Clinical Exam' started by surgeonortho, Mar 28, 2009.

  1. surgeonortho

    surgeonortho Guest

    hi guys and gals i appeared in the Adelaide exam and passed it. This exam was a mix of cases , some easy and some difficult but as usual all the clinical scenarios has direct bearing with Murtagh. so read murtagh well along with your AMC clinical handbook.

    the clinicAL scenarios are as follows:
    case 1: a 6 months old child recently came from overseas trip has low haemoglobin and 6 weeks history of diarrhoea. take history , ask for examination findings and counsel mother.

    buddies whenever dealing with a paediatric case always remember three things to ask : immunization, growth chart and diet history.

    the child had anemia with falling off the weight for age.
    fully immunized. very fussy in eating. diarrhoea started 6 weeks ago and is continuing. stools semiformed in nature with no blood. stools not bulky.
    no history of any recurrent infection, genetic disorder in the family.

    examination findings : pallor ++, no organomegaly, protuberant abdomen with muscle wasting. no findings in urine.

    choice of investigation: CBE, sweat chloride test, Hb electrophoresis to rule out thal., stool microscopy and culture to rule out any parasitic infection.

    Differential diagnosis:
    1. dietary anemia secondary to poor oral iron intake.
    2. protein energy malnutrition( unlikely)
    3. parasitic infestation (recent oversease trip to tropics).
    4. cystic fibrosis
    5 malabsorption syndrome ( unlikely as it doesnt give anemia).

    guys i will post details of all the cases over time as i gotta work now. i have a off on monday so will post more details.
    anyways i am posting all the cases which came.

    case 2 : examination of a swelling on the face , just anterior to right ear , dermoid.
    case 3: 23 year old girl with RIF pain, beta HCG positive, simple cyst 5.5cm on right ovary.
    case 4: postnatal depression (typical from AMC book).
    case 5: 6 weeks old child with 1 day history of diarrhoea, counsel father.
    case 6: 24 year old female, LMP 20 weeks back, uterine size 30cm, was on overseas trip, no investigations done. counsel and manage.
    case 7: caeliac disease.
    case 8: bitemporal hemianopia, eye examination.
    case 9: anorexia nervosa
    case 10: 59 year old man with prostatism , undergoing TURP, counsel.
    case11: 6 year old child with limping , perthe's disease vs transient synovitis of hip.
    case12: pneumothorax (typical from AMC book).
    case13: 60 year old lady with lethargy, history and examination findings, investigate ( wait till monday as this one was tricky and it was not hypothyroidism).
    case14: 60 year old recently diagnosed with rheumatic arthritis , violin player, counsel.
    case 15: 22year man, fell off from motor bike, 15 mins unconcious, perform primary survery and counsel the patient and organize relevant investigation.
    case 16: 62 year old lady, profuse vaginal discharge , brownish yellow( case of atrophic vaginitis but rule out malignancy by hysteroscopy).

    i hope this is enough of a scholarly diet for 2 days. i promise i will give all the details of each and every case. if any queries just ask and i shall answer to best of my abilities.
    kind regards.
  2. surgeonortho

    surgeonortho Guest

    case scenerio 2

    case 2 discussion:
    6 month old baby, presented to ED after having diarrhoea. take relevant history , ask for examination finding and counsel the mother.

    This case was not as straight forward as it looks like and as i had mentioned before that whenever there is a paediatric ase always take proper history.

    the history is that 6 month old baby has been having diarrhoea for past 2 days, listless, fussy, crying and difficult to handle. feeding fine.60th percentile for weight and length.
    diarrhoea profuse , 8 to 10 motions. no blood.
    2 siblings had mild diarrhoea 3 days back but self limiting.
    baby is fussy but drinking fine and not lethargic.
    BUT THERE IS A DECREASE IN NUMBER OF NAPPIES CHANGED SINCE YESTERDAY.

    when asked for immunization BABY IS NOT IMMUNIZED AS SOMEONE TOLD THE MOTHER THAT HOMEOPATHIC VACCINES ARE AS POTENT AS NORMAL VACCINE.

    EXAMINATION FINDINGS:
    FUSSY BABY.
    VITALS NORMAL.
    SKIN TURGOR NORMAL, FONTENELLE NOT DEPRESSED AND EYES NOT SUNKEN.
    MUCOUS MEMBRANES DRY.
    REST OF THE GENERAL PHYSICAL EXAMINATION UNREMARKABLE.

    URINE DIPSTICK: KETONE POSITIVE

    in this case i counselled the mother that baby has to have immunization and i will refer the case to immunization nurse.
    also baby is mildly dehydrated secondary to rota virus infection and can be managed at home but since there is suspected decrease in urine output as well as urine ketone positive so i will not be very comfortable at sending him home at this moment but will monitor his urine output along with hospital based rehydration and if everything is normal he can be sent home.
    also, there is no danger to baby's life if water, salts are replaced appropriately as virus wont pose a danger to his life but dehydration will.

    then when i asked her do u have any more questions : she asked " would immunization could have prevented this episode?"
    i said no but immunization is important as it prevents other more life threatening diseases.

    OK GUYS AND GALS WILL POST MORE SCENARIOS TOMORROW BUT BLOODY HELL ATLEAST POST SOME REPLIES OR ATLEAST I DESERVE A THANKS. NOW THE NEXT POST WILL DEPEND ON THE NO. OF THANKS I RECEIVE.
  3. guest8

    guest8 Guest

    thank you very much, I believe you passed already
  4. guestSOS

    guestSOS Guest

    Thank you, looking forward for your further deatils
  5. David-

    David- Guest

    thanks for the above illustrated posts , pl.continue to post for all the future aspirants. I am sure you have already passed the above exam,wies u all the best ,David-
  6. eagle

    eagle Guest

    thanks

    thanx a lot.though u dont see a lot of thanx,thousands are thankful to u in their hearts.im doing it very shortly.so pls send them as soon as you can
  7. eagle

    eagle Guest

    chronic diarrhoea

    hi,
    didnt you consider giardia infection and coeliac disease in the differential diagnosis? did you pass that station?
    because its likely that anaemia and diarrhoea is co-related?
  8. surgeonortho

    surgeonortho Guest

    to eagle

    well i did consider the possibility to infection and thats why i ordered stool microscopy and culture and stools were not bulky and the diarrhoea was new onset with no previous history of bloating or smelly stools , thus unlikely but yes a great possibility. and yes i cleared all the stations.
  9. surgeonortho

    surgeonortho Guest

    case scenerio 3

    case 3: 23 year old female , 20 weeks pregnant, has been overseas with no investigations done in the past. the current uterine size is 30cm, rest of the general physical examination normal. talk to mother and manage.

    well guys the basic mistake which we all do in this case is that we assume that its polyhydroamnios and formulate a plan according to that and thus we are given a unsatisfactory mary, which doesnt mean a fail, but increase the chances of fail if we commit further mistakes.

    now whenever dealing with a aussie pregnant female always remember following things:
    always ask blood group.
    always ask about immunization.
    always ask weather the pregnancy was planned or unplanned.
    always ask weather she had any antenatal checkup and if not then organize blood group, CBE, rubella antibodies level, VDRL, gonorrhoea serology, HIV and if Rh negative then get a coomb's indirect and urine microscopy and culture.
    always ask about previous pregnancies and outcomes.

    now this female is 20 weeks pregnant, not been investigated and has a uterine size of 30cm, thus she is large for gestational age and not polyhydroamnios.

    i told the mother that your uterine size is greater than expected for this gestational age and most common case for this is wrong dates. ( with this statement the examiner was overtly happy as if became so emotional that she was about to kiss me and say bless you my child "bravo" haha).

    now i told that but we have to rule out more sinister causes which can give you the increased uterine size :
    polyhydroamnios secondary to neural tube defects, GI abnormalities, infection.
    Blood group mismatch giving hydrops fetalis ( unlikely as mother is O positive and its her first pregnancy)
    twin pregnancy
    diabetes
    uterine fibroids

    first thing is that since you havent had any investigations done i would like to do all the antenatal investigations .
    secondly i need to organize a ultrasound to rule out twins, hydrops, fibroids.
    will do a glucose challange test to check for deranged BSL.

    will review in few days time , as soon as the blood results and ultrasound are back and if required refer you to obstetrician.

    the examiner was happy and so was patient.
  10. guest 111

    guest 111 Guest

  11. triclops5

    triclops5 Guest

    great work!! and congrats

    hey doc u r doin a greast work posting ur experiences and this will help us in a big way i am sure!! thanks.
    I have a few queries:
    1. do u think the clinical exami book by tally and o connor is worth a buy for this xam?
    2. and i bet u r a rmo or a registrar now... I am to begin rmo ship soon... do you think the book called ON CALL by brown,celenza,cadogan is worth a buy bfore the rmo ship??
    thanks. keep the good work goin.
  12. surgeonortho

    surgeonortho Guest

    hi triclops

    hello there,
    well any clinical manual will do but go to any library with ur laptop and issue tally o'connor and copy the dvd there and then. thats the most important thing in that book.
    and rest of the books you can download books from anywhere
  13. JAMES BOND

    JAMES BOND Guest

    Many thanks for your recalls, much appreciated your help.

    You make this website alive as I have not seen such a nice recall for long time.
  14. surgeonortho

    surgeonortho Guest

    case scenerio 3

    case 3: 62 year old lady, presented to you (as a GP) with 6 weeks history of profuse brownish yellow vaginal discharge. take relevant history, ask for examination findings and advise the patient.

    well this was a case which is typical of vaginitis (most likely atrophic) but the critical error here is that you gotta rule out malignancy and if you dont you will receive a fail mark for sure.

    history: 62 year old lady, menupause 10 years back, presented to GP with 6 weeks history of profuse vaginal discharge , brownish yellow.
    no dysparunia, no HRT received, nil post-coital or post-menupausal bleeding.
    nil possibility of foriegn body, has one sexual partner and he doesnt have any symptoms.
    nil history of malignancy.
    PMHx unremarkable.
    Pap smear done 1 year back which was normal, has mammography every 2 years.

    Examination: general physical examination unremarkable.
    PV examination: no mass, no cervical motion or adnexal tenderness.
    PS examination: atrophic vagina with yellow brownish discharge. no other abnormality detected.

    explanation to the patient: atrophic vaginitis secondary to lack of estrogen, reduces the population of friendly bacteria and makes the unfriendly bacteria grow.
    treatment with oestrogen cream but HRT may be given in the form of oral tablets but increases the chances of endometrial cancer.
    choice of antibiotic would depend on the bug : will take sample for smear and put under micrscope if gardenella or chlamydia metrogyl/erythromycin and if candida then fluconazole.

    But to be on the safe side will organize a hysteroscopy to rule out any malignancy.
    then asked the patient has she got any question and she said no.

    i said i shall reveiw her once i got all the results.

    I hope this case discussion is up to the expectations of you guys.
  15. Guest

    Guest Guest

    thanks for the recall
  16. Guest

    Guest Guest

    dear doc:
    thank you for this million times.
    u did very very well. deserve to pass.

    some issues for disscusisng:

    Case 2: actually, you mentioned Rotavirus, but not diagnosis. and said Rotavirus vaccine is not useful, Right??? confused me??? Also, do we need to rule out the intussusception, malrotation, how did he get this disease(from siblings)? only 6 months, breastfed or bottlefed?? baby's Temperature??

    Case 1&2: two baby's are both 6months?? sure??

    case 3: 62 old lady one: could we ask STD questions? (trichomonas, chylamdia)? do we need to rule out uterus prolapse, incontinenece? and diabetes? UTI?
  17. aussilar

    aussilar Guest

    such smart guy and well prepared..

    thanks alot for the recalls...

    waiting for more....

    and for aussie pregnant women, why do they have to do STD screening

    tests? they are all too openminded? unbelievable !!!!
  18. surgeonortho

    surgeonortho Guest

    well my dear friend the more you get confused the more you are likely to fail. if they had to give u intussuception they would had probably given red currant jelly stool or mucus.
    secondly , in australia we normally dont have rotavirus vaccine in routine immunization.
    thirdly, i see hostility in your language.
    my dear friend in this examination only thing which you can avoid is being over confident.
  19. lone guest

    lone guest Guest

    rest

    still waitng for d rest in ur discussion,
    u r a good man.
  20. aussilar

    aussilar Guest

    Oral Rotavirus vaccine is free in Australia, and as immunization routine schedule...

    check rch, get answer...

    thank for sharing.
  21. Guest

    Guest Guest

    congrats
    thanks a lot for ur good feedback waiting for mondays's one funny to tell you that i am working in a hospital at this moment and didn't find time to study :shock: . just started on last week of march finished clinical handbook just once have to study again. :( going to sit in 16 th MAY 2009

    will you pl guide me how should i study from now on throughly have a wk holiday in middle of this month.

    ur feedback give me an impression that u have very good idea abt exam.pl reply.

    anyways congrats again
  22. Guest

    Guest Guest

    Rotavirus vaccine is given free in Australia in 2 months and 4 months for children born on/after 1 May 2007, according to NSW Immunisation Schedule.
  23. Guest

    Guest Guest

    Hi surgeonortho

    Thank you very much for sharing your wonderful experience

    I whole heartedly appreciate your efforts for keeping this forum alive.

    Beleive me, I really liked the way you have posted all recals, case disscussions and suggestions aswell.

    I humbly request you to continue posting such discussions from your experience of exam.

    awaiting for your kind response


    Thanks again
    Regards

    Cheers mate!!!
  24. surgeonortho

    surgeonortho Guest

    i am back

    guys i am back from my vacation so i shall continue posting the clinical scenarios.
    kind regards.
  25. guest 09

    guest 09 Guest

    Good on you and thank you very much.
  26. Thank You

    Hello surgeonortho,

    I am one :D of your many avid readers and I just wanted to thank you for sharing your experience with all of us. Although I already know that they will not repeat cases on the exams, your experience guides and instills proper clinical thinking in us. Thanks again!
  27. Guest

    Guest Guest

    Dear All,

    Even after passing all this,the chance to get a residency job is so so so hard.Imagine how will it be for a specialist program 100000 times more difficult to get if impossible.
  28. Dr Kothari

    Dr Kothari Guest

    Many many thanks

    Hi there,
    well I am just like other IMGs trying to get through this PART 2 exam. You are making wonderful amount of contribution to this website. Enthusiastic Doctors putting in so much efforts tells us that we are so united and ready to work for each other.

    Thanks a million.

    God bless you.
  29. case1

    pale + diarrhea +overseas = have you considered HUS in your differential ..it is more likely than cystic fibrosis and doing sweat test!
    thanks for your post
  30. case one

    i am talking about the first scenario
  31. DRmeme

    DRmeme Guest

    amc clinical

    Thanks to surgeonortho. It is good to see someone who gives back even after passing. Thanks alot
  32. Guest_100

    Guest_100 Guest

    Hi, no more cases? I was looking forward to more scenarious.
    Thanks
  33. bibs

    bibs Guest

    Thanks doc for the detailed recall, and the points. hope to get the rest of them soon. Just a question.. u seem to have been really well prepared.. how long did u prepare?. I got a lil more than a month, started about 2 wks back. Im still not sure i wnat to go ahead with this, got 5 more days to withdraw, and i dont have work experience in oz. undecided!!! any advices??

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