BRISBANE -13th October 2007 1. PVD Took a further history, asked examiner examination findings and the findings were that the Pt. was on betaloc , smoker and had typical pain for PVD. He had reduced peripheral pulses and on asking invest.(FBC, EUC, LFT, TFT, Lipids, Doppler -carotids and leg, ECHO, BSL, ECG ) He had an ABPI of 0.6 and elevated lipids. I talked about the importance of quitting smoking , exercise- till pain starts so that collaterals develop, changing his medications to another antihypertensive because b-blockers can cause peripheral vasoconstriction, diet modification ,low dose aspirin and/or statins and review in 3 months but if things donâ€™t go well will refer the Pt to vascular surgeon for further management. The only: pt asked was that â€˜Do I need an operationâ€ I said that not at the moment but if you donâ€™t quit smoking things might go out of our hands and you will need an oper. 2. GOUT Pt had typical pain in the toe, was a truck driver and a beer lover and BMI 24.No hx was required so I told him the dx and the mechanisms that the kidneys are not coping with the excess uric acid (UA) in the body, it can also get deposited under the skin, in the urinary tract and form stones. So I gave him indomethacin and diet advice and then 4 weeks later allopurinol. Pt asked why he had joint Pain so I told him that the UA was irritating the lining of the joint and an inflammatory response results in pain. He then asked if it can happen again â€“I said yes but if the UA levels are kept under control it might not occur again. 3. SOMATISATION DISORDER Female in her 30â€™s had a long list of complaints this time was complaining of neck pain, no cause for anything could be found and the test results were Normal ,So she was sent to the psychiatrist who Dx her with functional neck pain and Somatisation disorder and she now came to you for advice. I explained to her that the specialist could not find any cause of her complaints which doesnâ€™t mean to suggest that she hasnâ€™t got the pain but we might have to look at other things which may be causing her problems. Asked her to look around herself and try to see if she could see any underlying problems in her life, relationships at home, work. Explore new activities like yoga, tai chi, meditation, socialise with people who have had similar problems in the past and how they overcame those problems. Took a brief Hx to rule out depression and suicidality, judgement and insight. 4. HIV COUNSELLING Man after a recent trip to Thailand had unprotected sex. Task was to take a sexual hx for 2 min. and then manage the Pt. I asked about his sexual hx there and before going there ,with whom he had sex with (male or female) and how many times and whether it was anal , oral or vaginal , IV drug use ,tattoos and body piercing, stable relationship ? Did he have sex with anyone since coming back. Talked about the differences between HIV and AIDS and implications of a positive test (reporting, contact tracing, duty to tell health care workers about your HIV status) and also talked about the window period â€“if test negative a repeat is necessary after 3 months. Pt asked if the results could be told over the phone- a stern NO because it is illegal. Then talked about safe sexual practices, Pt said -even here in Australia I said yes. 5. ANKLE SPRAIN Task was ankle exam. Asked pt. how she got the injury â€“the exact mechanism and whether she was able to walk straight after the injury. Then inspection, palpation, movement and walking. Told her about the support structures around the ankle (ATFL, PTFL, CFL, DELTOID Lig.)-the lateral ligaments had been stretched because she had pain on the lateral side on the talar tilt test, was able to bear wt. I told examiner about the Ottawa ankle rules for X-ray and advised the Pt Rest, ice, compression bandage and elevation, she could use crutches for a few days and gave her analgesics and then she could return to sport and/or physiotherapy for strengthening exercises. 6. ACUTE DELIRIUM Pt was agitated and angry at nursing staff after knee replacement, an initial physical examination had been done and the findings including some blood results were given, task was to tell your registrar those findings and how we intend to manage the patient. Resp. and CVS exam was normal Abd. Exam not quite so possible because the pt uncooperative Pt was disoriented and had been drinking 5-6 glasses of beer/day according to relatives On FBC â€“ macrocytosis, Raised GGT, raised LFT So I said I would do further invest. Like EUC, TFT, Blood and Urine cultures, BSL, Lipids, ABG, SaO, CXR, ECG, Cardiac enzymes. I told the examiner the causes of post-op delirium (sepsis, pneumonia, drug and alcohol withdrawal, cannula site infection, resp. or CVS failure â€¦) but said it looks like alcohol withdrawal because of macrocytosis, raised GGT and LFT. The examiner asked how I was going to control the patientâ€™s behaviour â€“I said haloperidol, he asked doses â€“I said have to check the doses but will give it IV. 7.TIA EXAMINATION (DO CVS, NEUROLOGICAL EXAM. UPPER AND LOWER LIMB AND CRANIAL NERVES ) Examiner did not ask me any qns. He just asked me to skip a few things in between by saying â€œNEXT-NEXTâ€ 8. SLEEP DEPRIVATION IN NIGHT SHIFT WORKER ( INJURES HAND WHILE WORKING) Young Pt who was working at a factory as a night shift worker had sustained a cut on his hand and the nurse who was doing the dressing told you that he apparently fell asleep while working. Task was to manage the case. I asked him the details of the event, what sort of machinery he works with, whether had the same problem in the past ,any h/o epilepsy, heart problems or other health issues , medications , ruled out depression and suicidality, married or not, stress at home /work, financial issues, appetite, children â€“he had two , asked about support in the family, who looks after children during the day, how much he sleeps during the day â€“he said 3-4 hours, asked why so or whether because of children or difficultly getting asleep, any snoring or poor sleep like easy arousal Explained the seriousness of the situation that he could have sustained serious injuries and emphasised the risk of a good sleep and/or change of shift,might consider sleep studies and also counselled about how to get a good sleepâ€¦(literature, dim light , quietness, meditation , tai chi , yoga ) 9. CHEST PAIN IN YOUNG MAN ( PLEURITIC CHEST PAIN) The pt had the worst pain ever , 10/10 hence offered morphine, LHS of chest, first time, no cough or SOB, no h/o asthma or other lung problems, no h/o CVS disease , no nausea/vomiting or sweating, no h/o indigestion or distaste in the mouth, not related to food, no f/h of clotting problems, never smoked, pain changes with change in position of body and with breathing , no recent throat infection , no fever , no trauma no swelling or redness in the calf or recent operation/immobilisation , no blood with cough or cough itself All physical exams (CVS and Resp.) and Investigations were normal (FBC, EUC, ABG, SaO, CXR, ECG, Cardiac enzymes, ECHO, V/Q Scan/Pulmonary CT Angiogram) Dx as pleuritic chest pain and gave pain killers 10. ABNORMAL STRESS TEST A man in his 50â€™s comes to you after a stress test showing ST-T depression 1-2 mm infero-lateral leads.The pt was a smoker. Task was to Mx the Pt Bloods show high lipids, all others normal. I told the pt that the exercise results have shown some changes in the ECG which may suggest some problems with the blood supply to the heart due to blockages in the arteries which supply them the blood- called coronary arteries. The problem happens due to a number of risk factors. These risk factors could be modifiable (eg. smoking, cholesterol, exercise, alcohol, diet, HT, Body wt., good DM control) or non-modifiable (family history). Itâ€™s vital that you immediately think about smoking cessation, limit your alcohol intake and watch what you eat. I am going to refer you to a cardiologist who might do some further tests like stress echo and/or angiogram where we pass a catheter from the groin area and to the heart and have a look at the arteries objectively by taking serial x-rays after passing a sp. Dye into the arteries. I do not want you to go on any long trip or do any vigorous exercise before you see a cardiologist and keep your spray with you and use it prn .You can take this reading material home for some information as well. The only Ques the pt asked was that can it have an affect on my sex life- I asked him if he had any sexual difficulties at the moment, he said no so I said He was right that it could cause sexual dysfunction but if that happens I am here to help you and we will sort it out. He also asked about driving- I said there are restrictions on driving but especially for heavy vehicle drivers, you should be all right to drive but do not go for long distance driving till you see the cardiologist. 11. INTUSSEPTION A young child I think 4 months has been vomiting, crying, drying his legs and slight has had a slight blood with the stools. On palpation there is a swelling in the RUG. He is refusing to eat and has not wetted his nappy. Task: Take a further focussed history and manage the case I asked the details of the vomit -since when, how many times, colour, amount, blood .Asks briefly about pregnancy, delivery, general health, vaccinations, fever, rash, anyone else in the family sick, on any regular medications Told her that the child has got a condition called Intusseption-It is the telescoping of one part of the intestines into the other ,the blood supply to the intestines is disrupted and this causes intestinal obstruction and pain which if not treated immediately can cause death of the cells of the intestines. So I am going to refer the child immediately to the hospital to be seen by a surgeon who might do a test called air/barium enema. A small tube will be passed through the backside of the child and a white liquid and/or air will be passed through it to look at the intestines objectively and also relieve the child of the problem i.e. remove the telescoping. If however it is not successful he might need surgery. Do not give him anything to eat and he will be given some fluids and antibiotics through the vein in the hospital .The mother or examiner did not ask any ques. 12. FEVER IN CHILD A few months old child had fever 39.5 C; a photo of the child was given inside the room. Task: Exam and management. I asked the examiner the child's gen. appearance and vitals - BP 70/40, HR 140 ,RR 27 and looks sick , any rash on the childâ€™s body as i could not see very clearly from the picture-none, ENT exam. and incl. discharge from the ears-none ,does the child look dehydrated ( decreased cap. return, depressed fontanelle, low BP, decreased skin turgor ,dry membranes) examiner said yes, CVS exam-normal Resp. exam.-Normal Abd. exam.-normal. I told the mother that the child has high fever and we need to admit him immediately to the hospital where we will have to give him some fluids through the veins and do some further tests like blood cultures to see if there are any germs in the blood, urine cultures to see if any there are any germs in the urine and probably a lumbar puncture where we take some fluid from the space around the spine to see if there are any germs there. the mother asked if there was something she could have done to prevent it - I said small children have low immunity and can have fevers. I briefly asked about the vaccinations and told her not to worry -they are in expert hands. The examiner asked what amount of fluid would i give-I said 10-20 ml/kg (although I was not sure) ,he also asked what antibiotics I would give-I said cefotaxime as it could be an evolving meningitis case. 13. VACCINATION ADVICE A young female has some queries regarding vaccination for her few months old girl. A standard vaccination schedule will be provided to you on request. The mother asked what vaccinations should I give to my child -I said children are vaccinated in Australia according to a standard vaccination schedule. How do them work-When a germ enters our body, our body produces special proteins called antibodies against the germ to kill them. Vaccination works in the same way but with a less amount and weakened germs so that our body produces the antibodies against germs and when the child goes into the society his body will be ready to combat those germs. What about homeopathy-I would only recommend vaccinations according to the standard Australian schedule. What are the side effects-side effects usually very mild like redness/soreness of the injection site, mild fever, feeling unwell, more serious side effect are very rare. What are the contraindications-A child with high fever >38.5, child with an immunodeficiency or who is on chemo or radiotherapy/steroids, child who lives with someone with immunodeficiency, severe life threatening allergic reaction previously, evolving neurological illness. Should I give my child the new vaccine for cervical cancer-That is given after 18 years of age? 14. MENORRHAGIA A 38 year old lady has heavy bleeding, she has 2 children and both she and her husband do not want any more children, she is not on the OCP. Take a further history and manage her. I asked about her periods-bleeding for 8-10 days/month, changes 6-7 pads/day, all been happening since the last 3 months, periods are painful, regular, passes clots, She said she could not be pregnant but hasnâ€™t done a pregnancy test ,no IMB or PCB, no H/O STDâ€™s, vaginal discharge or loss of weight, feels tired, last pap smear 6 months ago, otherwise healthy ,non smoker ,non drinker ,not on any regular medications, previous pregnancies uneventful, no hospitalisations/operations On exam she looked pale, vitals â€“normal, Abd â€“uterus looked enlarged and bulky, no adnexal tenderness, speculum exam-no cervical lesion or bleeding, CVS & Resp.-normal I said to her that we have to do some tests like FBC, EUC, LFT, TFT, and USG-pelvis but it looks like that you have got a condition called fibroids-benign growth in the uterus which is causing all these symptoms. I will refer you to a gynaecologist for further management, I will give you Fe tablets too. Examiner asked what will the Gyn. Do â€“she might consider managing you on medications, or conservative surgery where we remove the enlarged part of uterus and leave the rest because you might consider pregnancy in the future. 15. PROM AND CERVICAL STITCH A 36 weeks pregnant lady comes with ruptured membranes She also has a cervical stitch after a loop excision. Task: Take further history, manage the patient I asked her if the waters were still trickling-she said yes, trauma-no, related to intercourse-no, Abd. pain - no, pregnancy till now -uneventful,12 &18 week USG-normal (baby, placenta and waters),all Antenatal checkups normal, No heart disease, HT, lung disease, diabetes, liver , kidney problems. Baby kicking well, no blood P/V, not on regular medications, Blood gp O +ve. On exam, Vitals-normal,Abd.- F/H 37 weeks , FHR-145, fetal lie-longitudinal, presentation-cephalic, .Careful sterile speculum-Cervical lesion-no, bleeding-no, cord prolapse-no, CVS and Resp.exam. Normal, told her that her bag of waters had ruptured and we would do a CTG and an USG to make sure everything was fine with the baby. We would also take swabs from the vagina to exclude infection. She could be allowed to go home as we would prefer to prolong the pregnancy and present immediately if she gets fever or the contractions start or if she feels the baby's not moving well. I also said that we would start her on prophylactic antibiotics. She asked-would they remove the stitch or am I going to have a CS,I told her the stitch would be removed in the hospital once her contractions start and she would have a NVD unless something doesn't go well or if the baby doesn't feel good in which case a CS would be done. 16. PREGNANCY AND PNEUMONIA A young lady 25 years old is pregnant 20 weeks,she comes to your GP practice with fever 38 C ,wheezing,she had these episodes in the past as well and was treated with antibiotics and bronchodilators.Task: take further relevant history and manage the case. I asked her since how many days she had been like this-2 days,cough-mild not productive,sore throat -no,how was the pregnancy till now-uneventful,other health problems-no,no regular medications,all blood tests and urine tests -normal ,USG-normal,baby kicking well-yes.On exam she had bilateral wheeze and some crepitations in the right lower lobe,CVS and Abd exam-unremarkable.I told her that she had a chest infection and I would do some blood tests and give her antibiotics.She should take plenty or rest,keep fluid intake up and have a well balanced and light diet.I further asked if she was allergic to antibiotics she said yes-amoxycillin and cephalosporins give me a rash hence I said I will give you another class of antibiotics-examiner asked which one-macrolides and see you in a couple of days.She said can I take the same antibiotics as before -I asked which one she said doxycycline-NO because it can cause problems with the development of the baby. Guys I have passed the exam but havnâ€™t got the detailed results yet.Good luck to all !!!!!!