Clinical exam (Adelaide 31st of March, 2007) 1. Secondary amonorrhoea Stem: GP setting. 16y girl, dancer, havenâ€™t had period for last 2 years. Before was perfectly healthy. Ix done: LH normal, FSH normal, oestrogen slightly low. Task: Take relevant Hx Mx Hx: - Her diet ok. No skipped meal. Eat with her family. - No induced vomiting. No laxative using. - Exercise at least 2 hours every day since took dancing - Concerned about her body image. - No N/V/D - No weight gain - No vaginal discharge, vaginal bleeding - Not sexually active, not on OCP - No headache, visual disturbance - Not under stress, relationship with family and friends ok - No smoking, no alcohol, no iliciac drugs - No FHx of PCOS O/E: BMI 16.5, otherwise normal My Dx: Anorexia nervosa (other candidate says should be due to over exercise because her diet is ok) My Mx: refer to psychiatrist, dietician Qs from role player: can I have child in future? Qs from examinor: Any complication of amenorrhoea for 2 years? 2. Neck lump Stem: GP setting. Middle age man found a lump on his neck for several weeks. Not painful. There is a picture provided shows L supraclavical lump. Task: Hx, Ex, Mx Hx: - Lump noticed for several weeks, not painful, no discharge. - No change in size, color - No flu like symptoms, no infection - No N/V/D, no jaundice, no bowel habit change - Weight loss 6kg over last 2 months - Feeling tired - Smoking 20/day for long time - â€œSmokerâ€™s coughâ€ in the morning for long time. No sputum. No chest pain, no SOB - No FHx of cancer O/E: - Lump 2cm x 2cm, firm, not tender, not attached to skin or muscle - No other lymph nodes palpable - Chest clear - CNS normal - Abdo normal, PR normal - No groin lymph nodes My Mx: - refer for FNA - Advice about stopping smoking Qs from role player: Could it be cancer? What is FNA? 3. Pneumonia Stem: ED setting. Young male, SOB for 2 days. Task: Hx, ask for Ix result, and Mx Patient was lying on bed, pretending to be SOB. I offered him oxygen first, and asked examinor whether vitals are ok. Hx: - SOB for 2 days, gradually onset - R lower chest pain when taking deep breathing - Cough & yellowish sputum for last couple of days - No history of injury - No palpitation - No calf pain - No smoking - Previous healthy O/E: - Vitals normal - Trachea in middle - R lung base crackles, bronchial breathing sound, also dullness on percussion I asked for CXR, and examinor gave me CXR straightway after I mentioned it. It shows R lower lobe consolidation. Not sure about middle lobe. Mx: Abs. Role player asked which Abs. I said if you donâ€™t have allergy, penicillin. He said he is allergic to penicillin, then which Abs. I said erythemycin, but now I think itâ€™s wrong should be cefataxime. Qs from role player: Do I need to stay in hospital? How long do I need to take Abs? 4. Osteoprosis Stem: GP setting. Post-menopausal lady, had a fracture (L4 compression). You did bone scan and T score is < -3. Today she comes for the result. Task: Take relevant Hx Mx Hx: - Post-menopausal for 10 years, no hot flush, no night sweats. Didnâ€™t take HRT - 5 cups of coffee/day - No smoking, no alcohol - Donâ€™t like exercise - Not much outdoor activities - Donâ€™t like milk, cheese - Not on Meds - No FHx of bone condition Mx: - Advice about reduce coffee intake, increase exercise, increase sunlight exposure, increase milk product intake - VitD - Calcium - Biphosphnate (also talked about how to take it, and SE) - Raloxifene - HRT not suitable for her since post-menopausal for 10 years - Also I mentioned briefly about prevention measures for falls. Qs from role player: What is osteoprosis? Could it be something else? 5. Bee sting (anaphylatic shock) Stem: ED setting. A child had bee sting, now lip swollen, SOB, tachycardia, BP 60/40. Task: Give the nurse instructions about your management step by step. Answer the motherâ€™s Qs (In this station, 2 role players. One nurse, one the childâ€™s mother) After examinor checked my ID, the nurse rushed to me, and siad: â€œdoctor, quick, please have a look at Joshaâ€. There is a pile of clothes on the bed pretending to be the child Josha. I asked the nurse to check DRABC first. She said ABC ok, but child not responding well. I said ok then code blue. She was happy to hear that, I think. Then I said give O2, nebulized Ventolin, and adrenalin. She wants to know exactly the dose and route. I said 1:1000 0.01mg per kg intramuscularly. Then I asked her to check vitals again. BP is still 60/40. I said give steroid and get antihistamine ready for use. But she said BP still low. I was very hesitant at that moment, because I didnâ€™t know whether I should give adrenaline again. But I did give another shot of adrenaline (pls check it out, I am not sure), and then the nurse said BP was improving. Then the mother came to me, and she was very anxious. I reassured her, and explained the condition to her. I mentioned Epipen in the future, and bracelet, and allergy test. Also I recommended first-aid course. Qs from nurse: The child is stable now, can he go home? ---NO 6. Perforation of peptic ulcer Stem: ED setting. Middle age lady, abdo pain for 3 hours. She had back pain last week, and other doctor prescribed her NSAID. Task: Perform abdo examination Ix Mx Patient was lying on bed, and she appeared to be in distress. I started by asking for vitals, and offered patient pain killer. Then I took permission from her to exam. As soon as I put my hand on her abdo, she screamed. I turned to examinor, and said since patient canâ€™t tolerant exam, I would like to do Ix. Examinor asked me what else you could do without hurting patient. Then I realized I havenâ€™t done auscultation yet. Bowel sound was absent. I mentioned all the blood tests, CXR, AXR. Examinor asked which CXR, I said erect CXR. He handed over a CXR, and it showed air under diaphram. Examinor wanted me to point out where the air is. Mx: - Call surgical registra - blood for baseline, cross-match - IV line - Nil by mouth - Nasogastric tube - Morphin 7. AMI Stem: ED setting. Middle age male, compressing L chest pain for couple of hours, sweaty, distressed. There is ECG outside door, shows V4, V5, V6 ST segment elevation. Task: Relevant Hx Mx (From the stem, I knew it was a MI case. But when I looked at ECG, I straightway looked at II, III, AVF, and there was no ST elevation. I was very very panicky since I saw nothing on II III AVF. I got totally lost. Bell rang and I had to go into the room) Since I didnâ€™t get anything from ECG, I was really on the wrong track. I told patient his chest pain could be several possibilities. After I said that I could obviously sense that examinor and role player both very unhappy. Role player asked me what could be. I said could be AMI, could be electrolyte imbalance (I thought T wave a bit peaked), could beâ€¦ Examinor stopped me, and said: â€œSo you think it could be not AMI?â€ Then I realized I made a big mistake. I said well according to symptoms and ECG, I still consider AMI first. Then I mentioned everything about AMI: O2, GTN, aspirin (I asked about peptic ulcer), morphin, cardiac enzyme, call cardiologist. Examinor gave me prescription paper, and I need to write down all the meds I mentioned, the dose, route. Then examinor asked what cardiologist would do. I said PTCA. He said no facilities here, and it takes 4 hours to transfer. I said ok then would be thrombolytic therapy. Which thrombolytic medication? Bell rang. Finallyâ€¦â€¦. 8. DVT Stem: GP setting. Young lady, has been diagnosed DVT by dopplar U/S. The clot is extended to somewhere (I got the impression itâ€™s a big clot). She didnâ€™t have long trip. No operation recently. This is the 1st time she have DVT. No FHx of DVT. She is on OCP. Task: Explain the condition to patient Mx No furthur Hx taking needed I expalined the condition, and mentioned about hospitalization, heparin, wafarin. And all the stuff about wafarin (INR monitoring, inform doctors, inform dentists, interaction with other medications, food, avoid heavy sports, report immediately if any bleeding). Then I mentioned thrombophilia screening test. Advice stop OCP. I asked whether she is smoker, and she said no. I said thatâ€™s good, donâ€™t start. Patient smiled. Qs from role player: Whatâ€™s this thrombophilia test for? How long do I need to take wafarin? 9. Conversion disorder Stem: GP setting. Young male, cough on and off for last 6 months. No chest pain, no sputum. Seen by lots of specialist, and did lots of Ix including bronchoscopy all normal. Heâ€™s recently seperated from his wife, and his dad died of lung cancer 2 years ago. Task: Take relevant Psych Hx Expalin Dx and Mx. Hx: - No signs of depression: appetite ok, sleep ok, energy level ok - No suicital thought - No hallucination - No delution - Lots of worries in his life: wife left him, dad died of lung cancer 2 years ago Mx: - I explained there is no organic cause found for his cough. Most likely itâ€™s psychological cause. - I explained the relation between mind and body - Refer to psychiatrist - Advice about relaxation program - Donâ€™t bottle things up. Try to talk to someone, your family ot friends - Asked whether there is any social problems. Advice that social worker could be invovled. 10. Fetal movement reduced Stem: Countryside GP setting. 38 weeks pregant lady, primi. For the past 5 hours she feels that her babyâ€™s movement reduced. She is very concerned. Task: Hx, Ex, Mx Hx: - Baby still moving, but for past 5 hours she feels baby move less than usual. - All antenatal normal, single baby, U/S at 18w normal - No headache, no visual disturbance - No abdo pain - No contraction - No vaginal bleeding, no vaginal discharge, no gush of fluid - No injury O/E: - Vitals normal - Fundal height normal, uterus not tender, no contraction - Fetal HR 140/min, cephalic presentation, head not engaged - Speculum: Os closed, no bleeding Mx: - Reassured her that everything seems normal at this stage - Refer to hospital for CTG and U/S - U/S for biphysical profile - Qs from role player: If all the tests normal, can I go home? 11. PID Stem: ED setting. Young lady, RIF pain for 1 day. Task: Hx, Ex, Ix, Mx Hx: - Pain started since yesterday, constant dull pain, 6/10, localized in RIF. - Bowel ok, no N/V/D, no blood - Urine ok, no blood - Period normal. LMP 3 weeks ago. - Sexually active, on OCP, just have a new partner recently - Yellowish vaginal discharge - Feverish - Never pregnant before, no Hx of STD - PAP done normal O/E: - T 37.8? - RIF tenderness localized, no rebound, no rigidity, no mass - McBurney sign (-) - Speculum: Os closed, no bleeding - Bimanual: RIF tenderness, no mass, cervical excitation (+) Ix: FBE, U&E, LFT, lipase, abdo U/S, pregnancy test, vaginal swap Qs from examinor: Whatâ€™s DD? Qs from role player: Can I have child in future? 12. DM lower limb examination Stem: GP setting. Middle age lady, DM for long time. Comes for check up. Task: Exam her lower limb for any possible complications Tell examinor what youâ€™re examing Tell examinor your findings Inspection: No color change, no swelling, no hair loss, no scar, no ulcer, no fungal infection Palpation: - Temperature - Pulses (dorsalis pedis, posterior tibial, popliteal, femoral) Luckily I easily found the pulses. When I was about to do popliteal A, the examinor stopped me, and said since you have already found dorsalis pedis and posterior tibial, do you still need to check popliteal. I thought for a second, then said no need. Sensation: - pinprick - cotton wool - vibration - proprioception Reflexes Then I mentioned I would do tone and power, but examinor said thatâ€™s fine you donâ€™t need to do that. Examination findings: sensation loss below ankle level Qs from examinor: What Ix you would do? â€“ HbA1C, BSL How often do you check HbA1C? â€“ every 3 months 13. Prolonged QT Stem: GP setting. Lady SCH for long time. She is on typical antipsychotic meds at the moment. She had episodes of blurred vision before. Cardiologist just did ECG which showed QT prolonged. Task: Explain the result to patient Your management plan SE of typical and atypical antipsychotice meds - I expalined ECG change most likely due to SE of meds she is taking. - I would refer her to psychiatrist, who would probably change her meds to atypical antipsychotic meds. There would be overlapping period. Examinor asked me what is overlapping period. - I asked who is taking care of her meds, she said her mum does. I said then your mother should go to the psychiatrist with you. She would be invovled in decision making as well. - I expalined SE of both typical and atypical antipsychotic drugs 14. 4-month baby having fever and lethergy Stem: GP setting. 4-month old baby T38.2, since this morning lethergic, and not feeding well. Mum thinks baby is not responding well to her. No rash. Task: Relevant Hx, Mx I went into the room, and said to examinor since baby not responding well, I would call ambulance first. Examinor said stick to your task Hx: - Baby not feeding well since this morning - Only 1 wet nappy since morning - No vomiting - No rash - Urine not smelly - 1st time having this problem - Immunization NOT up to date, only one vaccine at birth. - Development normal - Nobody else at home having similar problem After I finished Hx, examinor said to me now you can call ambulance Qs from role player: Whatâ€™s wrong with my baby? â€“ I donâ€™t know. But he needs to go to hospital because he has signs of dehydration. It could be meningitis, it could be UTI or something else. Qs from role player: What doctors would do in hospital? â€“ They might do septic workup: FBE, blood culture, urine culture, CXR, also maybe LP. Qs from role player: How would they do LP? Can you just give me some medication so we can go home? I have another 2 years old daughter at home. What should I do? I also mentioned if it is meningoccal meningitis, need report, and all family members need treatment as well. 15. IDA Stem: GP setting. Post-menopausal lady, having SOB and palpitation. You did FBE which showed Hb 9.6, and MCV low. Task: Hx, Ix, Mx Hx: - Diet normal, not vegeterian - No N/V/D. No abdo pain, no heartburn - No bowel habit change, no blood on stool - Urine normal - Period stopped few years ago, no vaginal bleeding. PAP done regularly and normal - No weight loss, no loss of appetite - No smoking, alcohol - No FHx of cancer Ix: I mentioned about iron study, and examinor handed over the result. It showed iron decreased I explained to patient what is IDA Qs from role player: Why do I have IDA? â€“ Could be intake decreased, but unlikely in her case since her diet ok. Clould be blood loss from her bowel but not visible to naked eyes. So I would refer her for gastroscopy and colonoscopy. Also I gave her iron tablets. Qs: whatâ€™s SE of iron tablet? 16. Knee pain Stem: GP setting. 12-year old boy has R knee pain for past 3 months. He likes playing football. The pain worse after playing football. Heâ€™s a bit overweight, but otherwise healthy. On examination, there is a lump on tibial tubercle. It is painful when he stretches his right knee. X-ray showed a bone spur (on the tubercle site) Task: Relevant Hx from the mother Explain Dx and Mx I had totally no idea about this case. Some candidates said itâ€™s Osgood-Schlatter syndrome . Questions from the mother: Is it cancer? Why itâ€™s only on one leg? Could he still walk? Could he still go to school? All the best!!!