AMC Clinical Examination Melbourne - 27 Oct 07

Discussion in 'AMC Clinical Exam' started by Amanish, Nov 1, 2007.

  1. Amanish

    Amanish Guest

    Melbourne clinical exam 27 Oct 2007

    1. Emergent post coital pill
    2. post natal depression
    3. recurrent candidiasis
    4. Down Syndrome
    5. foreign body (sharp pin) swallowed by 4 year old boy
    6. 11year old has fracture of lateral epicondyle
    7. stroke
    8. generalized weakness
    9. CT show kidney problem
    10. daughter can’t speak after mother diagnosis with cancer
    11. breath holding attack
    12. peptic ulcer
    13. chest pain
    14. seminoma
    15. ?
    16. ?

    some one can add more please
  2. samora

    samora Guest

    thank you

    thank you very much dr. could you please add more details
  3. AH

    AH Guest

    Query

    How can I attach a file to post my feedback from MS word?
  4. samora

    samora Guest

    dear dr. you can copy and paste it or you can upload it and copy and put the link. just go to "www.2shared.com" and then upload your file and copy the link. or You can scan the feed back and again copy and past it here. the final one is to write it yourself!!! :lol:
    good luck.
  5. Guest

    Guest Guest

    TIA
    Stroke ( lateral medullary syndrome)
  6. samora

    samora Guest

    thanks a lot

    thanks alot mate. good luck
  7. AH

    AH Guest

    Mel 27 Oct feedback

    AMC CLINICAL EXAMINATION
    Melbourne 27 October 2007

    (The diagnosis within brackets is AMC diagnosis from the feedback)


    Paediatrics
    1. (Breath holding attack): You are working in ED. An anxious parent brought his 2 yo child Justin, who suddenly became unconscious an hour ago. The child looks normal now and resists examination.
    Task: Take relevant history (no examination required)
    Talk to parent about further management
    The anxious looking young father describes that his son was in a car, he banged to the car door, then cried, trembled his arms, stopped breathing and turned blue, wasn’t responding. The whole thing lasted for about a minute or so. No past or family history of epilepsy. The boy looks ok now, but sore in his fingers.
    (I missed the diagnosis because of the fast, anxious accent of the role-player, and I went along the pathway of epilepsy – so I failed this station).

    2. (Ingested foreign body): You are working in ED. Mum brought her 4 yo son who has swallowed a drawing pin.
    Task: Take a relevant history
    Ask examiner any investigation you want
    Talk to mother about management
    Mum says that her son swallowed a drawing pin (umbrella shaped board pin) an hour ago while playing with his elder sister, who is 7. Mum has brought the pack of pin to show to doctor. The boy has been behaving normally, no vomiting, choking or breathing difficulty happened. I asked the examiner for abdo X-ray, he pulled it out from the drawer which clearly shows the pin passed the stomach. I didn’t know the exact answer but told mum that it’s good the pin has already passed the stomach in an hour. So it’s quite likely that it will pass thru the gut embedded in faeces without affecting him. We can do X-ray daily to see the progress. It would be reassuring if the pin passes the narrowest part of the gut – the ileocaecal junction (drew picture to explain mum). Also told her that this is my understanding, but I am calling the surgical doctor who is the right person to assess him and explain properly to mum. If he thinks it’s risky to leave a sharp in the gut, he will probably take it out by an endoscope. I asked mum if she has any question - she said no. I then looked at the examiner and said - I finished. He smiled and said, “It’s a short station, isn’t it?â€
    (I said yeh, and by that I knew I passed this station).

    3. (Down syndrome): You are working as GP in a rural hospital. A 23 yo lady has delivered a term baby today. You have examined the baby and found features of Down’s syndrome (photo outside room: characteristic facies, single palmar crease).
    Task: Talk to mother
    I congratulated mum and said the baby looks very pretty. Also asked if she has a name for the baby. Then asked for history. This was her first pregnancy, no pre-existing illness, and normal antenatal check up and tests. No problem was anticipated. Normal delivery, baby is fine, sucking at breast. Then I told her that I have examined the baby, looks otherwise healthy but sorry to say that some of the external features suggest he might have a condition called ‘Down’s syndrome’ – does she know about it? She said no. Her partner was not here. So I explained that this is a genetic or chromosomal disorder that affects about 1 in 700 of all pregnancies. This is not her or her partner’s fault (she asked how it happened). I drew picture and said that normal cell has 23 pair of chromosomes, 23 from mum and 23 from dad. Most of the time in Down syndrome, what happens is that during cell division for growth in the womb, the 21st pair has an extra chromosome by a natural error/anomaly when the features develop. I explained the features to mum. Reassured her that he doesn’t have obvious heart problem or low tone (got the finding from examiner). He is sucking well which is good. The initial problems are poor feeding due to low tone, and later may be prone to respiratory infection. In future they would have lower than normal IQ, so will be lagging behind in education/learning and may require special schooling. But they are usually very social, love music and have very pleasant personality. I will call the Paediatrician to have a more detailed assessment and organize some tests like karyotype, echo, TFTs etc. I said to mum that although the features are quite suggestive but only karyotype or chromosome study can confirm the diagnosis. I mentioned that there are lot of support groups and resources in the coming days which I would provide her with and continue to liaise/coordinate with the multidisciplinary team. Said I will explain to her partner when he comes in and meanwhile if she has any concern any time re feeding or anything else, she can call me. Also, in future whenever she becomes pregnant there are tests to predict the risk and confirm the diagnosis of Down syndrome early and there are options of termination of pregnancy. Finally I asked mum if she has any more question - she said no.
    (Both mum and the examiner looked happy, I probably talked more than expected)

    O & G
    4. (Incomplete abortion): You are working as a GP. A 25 yo lady has come to you with 8 wk H/o amenorrhoea and PV bleeding.
    Task: Take relevant history
    Ask examiner any examination finding you want
    Talk to patient
    I greeted the patient, asked quickly how severe was the bleeding. She said started yesterday, like a period, small clots passed, feeling weak. Pregnancy test positive. I asked examiner for vitals – P100, BP 90/50, T37. On speculum exam – os open, clot lying in the os. I said I would remove the clot now with sponge-holding forceps. Started IV fluid to combat shock and call ambulance. Then I explained to mum (partner was not here). Sorry to say that there has been a miscarriage which is incomplete, needs to be evacuated completely in hospital, otherwise risk of bleeding and death, also requires IV fluid. I took previous history at that time. First pregnancy, planned, no illness or medication. Well before this event. Stable relationship, good support. Didn’t take HPV vaccine (Gardasil). I said I will inform the ED and talk to O & G Registrar and keep in touch with them to know how she was going. She asked why it happened. I said it’s hard say definitely, but most of the time early miscarriage like this is due to some major chromosomal abnormalities, and it is the nature’s way of handling it – aborting anomalous/malformed baby. Also mentioned that with subsequent pregnancies, she needs to be in touch regularly from the beginning. I asked patient if she has any question - she said no. I looked at the examiner - finished early.
    (I completely forgot to ask about blood group, which should have been a critical error, and was surprised to see that I passed this station. The examiner looked & sounded like a Serbian/Bosnian lady, was smiling all the time. Very kind!)

    5. (Recurrent monilial vaginitis): You are working as GP. A 25 yo lady has come to you with vaginal discharge and itchiness. This is the 3rd presentation in 3 months with similar problem. Last time you diagnosed her as vaginal moniliasis.
    Task: Take focused history
    Ask examiner any examination finding and investigation you want
    Talk to patient
    The lady was worried because the medications aren’t curing her, last time she was prescribed a cream. She doesn’t have Sx of UTI or diabetes. Single, stable partner. On OCP, normal periods. Hasn’t taken HPV vaccine (she looked at examiner for the answer). No ongoing medical condition. Non-smoker, minimal alcohol, no illicit drug. O/E – slightly red introitus with characteristic candidial discharge. I told the examiner that I would check the blood glucose level and the LFTs before I start the Rx. Told patient that this the same monilial infection that she had before but is occurring repeatedly, either because of resistance or some unexplained reason. For this she has to continue oral medication for a prolonged period like 6 months or so. I gave the script to her. She asked if she is going to be cured. I said hopefully she is, with the oral long term medication. Explained the side effects of medication and the need for doing blood tests. Also said I would see her in 6-8 weeks time for review, or earlier if any concern. I asked patient if she has any question - she said no.

    6. (Ruptured condom): A 20 yo woman has come to your general practice. She had an unprotected sex (condom ruptured) last night and wants contraception.
    Task: Talk to her (no need for physical examination)
    The young lady told that she is a student, had an unprotected sex with a new partner whom she knows recently. She has regular periods, no medical condition, and uses condom as contraception. Has multiple sexual relationship, hasn’t taken HPV vaccine. Non-smoker, casual alcohol, no illicit drug. I explained to her about STD risks associated with casual sex and failure rate of condom. I offered her another session to discuss the options of contraception (took brief history re contraindications of OCP). Mentioned that OCP will not protect against STD, so use of condom is important. Advised for partner to follow the instruction for using condom. Gave post-coital pill, instructions for use and mentioned the success rate. Asked her to come back in a week if misses next period. Offered STD screen if she thinks the current partner is not reliable. Examiner asked if I would give prophylactic antibiotic. I said no, unless she has positive tests or symptoms. Finally I asked patient if she has any other question - she said no.

    Psychiatry
    7. (Postnatal depression, moderate): GP setting. A young lady comes to you few weeks after delivery- not feeling well.
    Task: Talk to mother
    Typical case, feeling tired and helpless, sometimes irritated. No hallucination, delusion, suicidal ideation. Baby is breastfeeding, gaining weight, 2nd baby. No other medical condition, not on medication. Older child goes to school, supportive husband. No other family-friend /relative to help. Explained about PND, outcome, medication, respite care, supports. Gave script and asked to come with partner. She said she feels very tired and off. Then I offered hospitalization in mother-baby unit, explained what are the advantages and what is going to be done in the hospital. She agreed and became happy.

    8. (Psychogenic dysphonia): A young girl, who is a strict catholic, conducts the family prayer for her mother. Mother has a metastatic cancer. The girl has suddenly lost her voice when she heard her mother screamed in pain from another room.
    Task: Take further history
    Do appropriate examination (you will be provided with necessary equipment)
    Manage the case
    Old scenario, the girl was answering by nodding the head, or by writing on a paper. I sympathized for her mother and hoped for the best. Then took a brief history. No past or ongoing medical condition, especially of the throat, mouth or nervous system. No weakness or impaired sensation in any part of the body. Not on any medication. It didn’t happened to her before. No other stress apart from mum’s illness. Studying in Uni with good result. Examined the throat with tongue depressor (was on the table), checked movement of palate, uvula. Then explained to patient that sometimes emotional stress can lead to physical symptom without having any abnormality/disease of the part involved. She will not require any medication, needs relaxation – her mother is still with them as before. Before she gets her voice back, someone else in the family can conduct the prayer for her. She asked by writing on paper how long it would take for her to become normal again. I didn’t have any exact timeframe, but said hopefully few days and suggested some relaxation tips. Also told that I would review her in 2-3 days, if not improved would refer to psychologist for psychotherapy. I asked patient if she has any other question - she said no.

    Medicine/Surgery
    9. (Fever of undetermined cause): GP setting. A middle aged woman has been feeling tired for 2 weeks.
    Task: Take relevant history
    Ask examiner for physical findings you want
    Discuss possibilities with the examiner
    41 year old executive, previously well, has been feeling unwell and tired for last 2 weeks. No fever recorded, but sometimes feel feverish, no cough or respiratory symptom, no symptoms of UTI, hypothyroidism, diabetes, depression or Addison’s disease. No family H/O haemochromatosis. Appetite slightly reduced, no loss of weight. Normal bowel movement. No H/O recent travel. Supportive family, no stress at work. Normal periods, sexually active, on OCP, no other medication. I didn’t find any clue until this point. Asked examiner for examination finding- pale but not unwell looking, normal pulse, RR & BP, T37.6, no lymph nodes, thyroid not palpable, ENT normal. Liver/spleen not palpable, lungs clear, dual heart sounds, systolic murmur in R 2nd ICS and diastolic murmur in L 2nd ICS. I was puzzled matching the two murmurs. I couldn’t fit into one diagnosis, but I asked for character of pulse (?slow rising) & signs of infective endocarditis – all negative. (Also asked patient at this point if she had H/O rheumatic fever- said no). I told the examiner that I would do some investigations, but he asked what are the DDs. I said aortic stenosis plus pulmonary regurgitation, so infective endocarditis possible (I felt myself stupid because I couldn’t come a single diagnosis- thought am I missing something?), viral infection (but then how to explain murmurs- now while typing this feedback I think viral myocarditis is a possibility which can explain everything). The examiner, a young Indian or subcontinental who appeared to be a bit harsh asked which was my first diagnosis – I said infective endocarditis, then viral infection. I also added that I would admit her for investigations and observation (although management was not the task).
    (From the appearance of the examiner and the way of cross questions, I thought I was going to fail this station, but I passed- don’t know why and don’t know the diagnosis yet).

    10. (Incidental congenital renal anomaly): ED setting. A 56 yo lady comes for investigation results; she was seen 2 days ago for atypical ureteric colic. Plain x-ray didn’t show any stone. A CT scan (picture outside room) was done because of microscopic haematuria. Radiologist is unavailable to report the film, which is sent to you.
    Task: Read the CT scan to examiner
    Tell the result to patient (no history or examination)
    Outline further management
    (I failed this station, because I couldn’t figure out the findings [are we supposed to interpret a renal CT scan?]. I said it might be an ectopic kidney or a renal tumour, referred to urologist. Actually this was a horse-shoe kidney).

    11. (Recurrent lower limb weakness in a diabetic): GP setting. A middle aged man with type1 diabetes and hyperlipidaemia comes with recurrent weakness of leg on one side.
    Task: Take relevant history
    Ask examiner for physical findings you want
    Talk to patient
    40 yo man having type 1 diabetes for 12 years, well controlled on insulin (I asked for the diabetic book), has H/O recurrent weakness of one leg over past few months. Persists few hours and then goes off by itself. In between he remains well. No other symptoms of stroke like hemiparesis, dysarthria, and loss of consciousness. No visual disturbances. No other medical condition, on insulin only. His lipid levels are within normal limits now with dietary manipulation. No eye, renal or neuro complications of diabetes. Examination findings are all normal now (I included carotid auscultation, funduscopy and neuro exam of limbs). I explained this was a TIA, which is a mini stroke (drew picture to explain vascular narrowing) and can lead to a complete stroke. So needs hospitalization for investigation and observation. Will call the medical Registrar and arrange bed.

    12. (Chest pain and faintness): GP setting. A 42 yo man presents with central chest pain for one week.
    Task: Take history
    Ask examiner for physical findings you want
    Talk to patient
    Before entering into the room, my DD were AMI, pericarditis, PE, pneumothorax, peptic ulcer, pancreatitis etc. The man said he is ok to tell the history without analgesia, so I went ahead (didn’t ask examiner about vital signs). He has pain in upper chest centrally for last 1 week, radiating towards neck, not to upper limbs. It was dull, started gradually and then increasing over past few days. It’s not related to time of the day, food intake or his position. No vomiting or fever. He doesn’t have any breathing difficulty, but says feels tired. Hasn’t taken any medication for this pain. Didn’t have similar pain in the past, but has reflux for last few years for which he takes Ranitidine on and off- it helps to some extent. Normal appetite, no loss of weight. No stress at work or home. Non-smoker, casual alcohol, no illicit drug. I couldn’t come to a conclusion from history, asked about urinary symptoms- no, bowel- black for last few days. Asked patient how he was feeling- said had fainting on and off for last 24 hours. Immediately asked examiner about exam findings- pale looking, P100, BP 90/55, T37, RR18, no oedema or jaundice, no hepatosplenomegaly, no signs of chronic liver disease, lungs clear, no murmur. I was puzzled. Said it’s a bleeding from upper gut, stomach or above- probably due to bleeding peptic ulcer. Patient will need immediate hospitalization for blood transfusion, IV fluid, investigation and further treatment. I will contact the hospital, call an ambulance and open an IV line to start fluid before transfer.
    (I failed this station, as expected. I don’t know yet what exactly it was).

    13. (Duodenal ulcer): A 43 yo man, who is a busy courier had an upper g.i. endoscopy done for abdominal pain. Test for H. pylori was positive. The gastroenterologist has sent the endoscopy picture (photo outside room) to you which shows a duodenal ulcer.
    Task: Take relevant history
    Explain the condition to patient & manage
    The diagnosis was given, so this was a communication station. I took brief history re the symptoms, covering the risk factors for peptic ulcer, complications and treatment received in the past. Outlined the treatment plan and things to avoid. Gave pamphlet and follow up plan. The examiner asked me the drugs of triple therapy including the dosage and duration.

    14. (Recent orchidectomy for a testicular neoplasm): A 22 yo man had his R testicular lump (picture of the lump attached with portion of spermatic cord outside room) removed by surgeon 4 weeks ago. The patient has moved to your state after the operation. The surgeon didn’t get time to explain the histology and follow up plan to him and he has sent the report to you, which revealed a seminoma.
    Task: Explain the management and follow up to the patient
    Answer his questions (no history taking or examination)
    I asked the young man if he knew the diagnosis/histopath result. He said yes the surgeon has told him that he had cancer of testis but it was removed. I said surgical removal is part the treatment of testicular tumour. He had seminoma on histopath and the good news is that seminomas are extremely radiosensitive and the cure rate is >95%. I explained that he would require radiotherapy which is like an X-ray beam given to the testis area. This is to kill any remaining cancer cells in the area. Mentioned the side effects of radiotherapy. Advised preserving sperm in sperm bank for future fertility in case it is affected. Examiner asked when to start radiotherapy- I said now. The patient asked one of his friends had testicular tumour removed by scrotal incision, but in his case it was it was groin incision, why? I asked if he had undescended testis on that side- said no. I said this is to prevent intraoperative spread of cancer cells. Referred to radiotherapist and arranged follow up. Emphasized regular self-examination for early detection of relapse. I finished the station before the bell rang.

    15. (Acute vertigo): You are working in ED. A 50 yo man is brought in by his wife with 1 day H/O sudden onset vertigo, numbness of one side of face, drooping of one eyelid and weakness of one side of the body. He has unremarkable past history. His vertigo is much settled now, but his wife insists hospital admission.
    Task: Take relevant history
    Ask examiner for physical findings
    Answer examiner’s questions
    Before entering into the room I was a bit confused because I didn’t find any scenario from the recalls having lateral medullary syndrome and hemiparesis at the same time, but I read topic from Snell. Anyway, the story was that he suddenly developed vertigo (tilted to R as well) last night along with ptosis of R eye, numbness of R side of face and also weakness of the L side of the body. Previously well, F/H of stroke. Non-smoker, reasonable alcohol use, no illicit drug. No difficulty in speech or swallowing, no nasal regurgitation of fluid. Vertigo much improved now, still can’t walk because of hemi-weakness. When asked examiner gave long list of findings from her paper- Conscious, GCS15, vitals normal, no dysarthria. Left side- ptosis, impaired pain & touch on face, constricted pupils, hoarse voice. R side- spastic paresis of upper & lower limbs, brisk tendon jerks, impaired pain, temp and proprioception (position, vibration). No ataxia now. Examiner asked where the lesion is. I took the opportunity to explain:- on R side Horner’s syndrome, trigeminal, vestibular & vagus nerve involvement, along with contralateral pain and temp sensation lost – so it’s R lateral medullary syndrome (posterior inferior cerebellar or vertebral artery occlusion). On L side contralateral pyramidal tract (spastic paresis) and medial lemniscus involvement (proprioception) – so it’s R medial medullary syndrome (anterior spinal artery occlusion). (I forgot to ask about ipsilateral hypoglossal nerve involvement). That means lateral and medial medullary syndrome of R side. This is a brainstem stroke and patient will require hospitalization. The examiner looked very happy, nodding her head while I was giving the logical explanation.
    (I don’t know if lateral and medial medullary syndrome together was given in previous exams, but the lesion is best explained in Snell’s Neuroanatomy Page195).

    16. (Suprachondylar fracture humerus): You are working in ED. An 11 yo boy has had a fall and injury to R arm. X-ray is done (picture outside room).
    Task: Explain the X-ray to mother
    Outline the management (no need for physical examination)
    Q from mother: Is it going to be operated? How long will he have to take leave from school?
    Q from examiner: What are the associated injuries? Which one is more important? Which nerve is particularly affected?

    This was a typical X-ray of suprachondylar fracture. I asked about analgesia, she said yes. I asked the nurse for that. Then I explained the x-ray to mum, told her that this will be fixed be orthopaedic doctor under regional nerve block (called Bier’s block), then a plaster will be put on the arm. She has to bring her son for recheck after 24 hr. Meanwhile, signs of complications should be looked for- mainly increased pain/swelling, colour change of fingers- when she needs to bring her son back immediately. The plaster will be there for 4-6 weeks. Mum asked if it’s going to be operated- I said with nerve block the area will be numbed, then will be fixed without operation). Mum asked about leave from school (I forgot to mention). I told few days (mistake!). Then she asked what about writing? I said oh it’s on R arm, so has to be the whole period. Then examiner asked about associated injuries. I said vascular and nerve injuries. He asked which one is more serious? I said brachial artery. He asked which nerve? I said radial. He asked any other nerve? I said no. Finished my station.

    (I failed this station too, probably because I didn’t arrange for theatre immediately, didn’t mention about internal fixation [mum wanted to prompt], wasn’t detail in explaining the management to mum [including leave] and hesitant in answering examiner’s questions, probably wrong as well)



    (As you see, I succeeded very luckily by the Grace of Almighty, as I failed stations 1, 8, 11, 16. This exam is a lottery – one may fail with very good preparation or one can pass with very marginal preparation! It’s hard to perform well if you can’t figure out what to do before you enter the room. Good Luck for the lottery!)
  8. Guest

    Guest Guest

    Thank u AH for ur contribution....in station 11 the candidate failed 'caz he didn't mentioned or asked for the ECG results...probably that was the reason he failed(critical error made by him)....abt the Dx....iam not sure....any suggestions
  9. Guestz

    Guestz Guest

    great performance

    but u cant pass a chest pain station without performing an ECG
    I think thats why u couldnt pass it
  10. me

    me Guest

    THNAK YOU AH
  11. Guest

    Guest Guest

    Hi
    Thx for very nice and detailed comments. That CVA is called Brown Sequard sundrome.
  12. Guest

    Guest Guest

    i dont think so... havent heard of brown sequard presenting with horners or the cranial abnormalities... his diagnsois is perfect with an appropriate explanation..!!
  13. Guest

    Guest Guest

    Hey! can someone tell me about the details of bridging course held in Monash University Melbourne......about the avilable dates and fees

    Thanks
  14. sabrin

    sabrin Guest

    hi,
    i have just passed the AMC part 1 exam and starting to prepare for the clinincal exam.
    thanx a lot for such a detailed discussion about the exam...
  15. Kothari

    Kothari Guest

    Thanks

    Hi there thank you very much for the wonderful conversation. I think if someone old comes with chest pain, I would think of it as MI and get markers 8 hourly too.

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