Melbourne retest june 2007

Discussion in 'AMC Clinical Exam' started by red rose 79, Jun 7, 2007.

  1. red rose 79

    red rose 79 Guest

    Melbourne Retest June 2007 Paper compiled by Malik

    1. A young man,who is a painter is admitted in hospital with acute asthma attack.He was admitted in ICU. It was the worst attack he ever had. He is shifted to the ward.He is on oral steroid.He wants to go home.O/E few rhonchi.PEFR is 450 ml.
    Your tasks
    1.Discuss with him severity of attack which he had
    2.Tell him which medications you are going to start him now
    3.Future management of asthma

    It was my first station.So I went inside.I asked him if he knows anything about asthma….he said not really
    So I told him whats asthma,s/s.I told him it will be a multidisciplinary approach.I will book his appointment at asthma clinic and he will be seen by asthma nurse which will educate him about use of spacer,respiratory physician will be involved.GP will be involved in care.
    I told him that he had a bad attack and its important for him to be compliant with medications from now onwards. we need to start him regular pulmicort one puff bd and ventolin puffs whenever needed.Told him about asthma action plan briefly if there are no s/s at night and morning continue as I told you …if there are s/s double dose of pulmicort and take ventolin 3 times daily regularly.I told him about warning signs ..if u r unable to speak or ventolin is not helping go to ED then.
    When I was stuck I asked do u have any concerns
    Questions asked
    I don’t like taking puffer is it imp? Yes its imp…otherwise you can have fatal attack ..asthma educator will tell u correct use of spacer
    Do I need any further investigations/? Well when you will go to asthma clinic they will do spirometry on u
    Do I need to see specialist?yes at asthma clinic u will be seen by respiratory doctor
    What are side effects of medications?They cause dryness in mouth so always gargle your mouth after pulmicort.
    At end Something struck to me he is painer so I told him well do u u know your asthma triggering factors..it can be your paints..there r different types of paints available so you need to work with those which don’t trigger your asthma..i will ask occupational therapist to see u …bell rang

    2.Young woman gave birth to baby 10 weeks ago,has 24 months old another child came to see u as she has no energy
    Tasks:
    Take relevant history
    Management

    I went inside greeted pt…congratulated her on having baby…asked her for how long have u been feeling like this…said ever since he was born I ruled out all depression s/s..low mood,disurbed sleep used to wake up in middle of night,tired,has suicidal tendency AT 4 OO am wants to harm herself by taking pills ..i asked do u have any pills ..said panadol tablets…no ideas of infanticide..no hallucinations/delusions good insight ..
    other history planned pregnancy,husband supportive..i told her you are having Postnatal Depression..i want u to go to hospital immediately in ambulance
    Do you have any concerns
    Do u think it can be anything else/? It can be problem of thyroid or low haemoglobin at hospital they will do all blood tersts
    Will medications will affect my baby? ..oh r u breastfeeding..well specialist will give u tablets in small dose and they will be safe for baby
    I don’t have anymore questions..examiner u can go out and wait.

    3.You are seeing middle aged man who smokes 15 cigrettes /day.He has some problem in throat
    Tasks
    Relevant history
    Examination findings investigations
    Manage

    I went inside greeted examiner and pt..there were 2 examiners so I knew I had to be careful in this station
    Hx. He had feeling of lump in throat. For 2 months .no h/o dysphagia to solids /liquids ,no sore throat ,no stucking of food while eating,no ulcer/heartburn..no regurgitation of food.
    No features of malignancy ,weight loss,low appetite night sweats/thyroid
    Asked about stress said not really No problems in sleeping .Had been smoker for years..i was stuck here ..there was no clue.
    Examination ; All normal no enlarged lymph nodes..
    Management I told him I am little bit concerned due to your smoking so I will refer u to specialist who will do investigations..if they are all normal them then I will send you to another specialist.
    Examiner whispered in my ear who will be another specialst I said psychiatrist for Globus Hystericus but we have to exclude organic causes first

    Examiner nodded so what will u do said..FBE,EUC,LFTS,TSH, BRONCHOSCOPY,CXR HEAD and neck…he asked what else…I don’t know what to say…I said Endoscopy he smiled which endoscopy…I said upper GI ..So u want to look into stomach as well okay what else ..bell rang
    After exam another candidate said indirect laryngoscopy…for which u have to refer to ENT
    I spoke to one of my senior colleages who has attended a lot bridging courses as well he said in if you have done BRONCHOSCOPY that’s fine…it will see larynx as well..in this case Critical error is if u send him home with Globus hystericus..He is smoker so u havre to exclude major causes .thats is definition of globus hystericus as well in the absence of organic causes


    4.You are seeing lady in ED she c/o off and on pain over few days,her bowel habits were normal but now she has constipation and had not passed flatus.Long stem

    Tasks
    Perform relevant examination
    Discuss d/d and investigations
    Management

    • I went inside greeted pt asked if she needs pain refief and she said yes I do..i said okay I will let nurse know about it.Did abdominal examination ..tally o connor one…O/E abomen was generalized tender ..percussion note tender I asked about PR Said B/L Tender with bogginess!!!Auscultation no bowel sounds
    • I told her it can be anything we need to do further tests FBE,EUC,LFTS,TSH,INR CXR erect,AXR ,pregenancy test she said I had periods 3 weeks ago
    Pt asked what it can be ; Well it can be intestinal obstruction,ischemia,gall bladder ,pancreas,appendix..it can be any hole in gut..perotonitis..DUE TO B/L TENDERNESS ON PR …said it can be abscess..she looked at examiner and said..where do you think is abscess..i said its huge tummy it can be anywhere so we have to do further tests
    What will u do now..well u cant eat and drink…pass N/G,iv lines ..IV fluids, and ask surgical reg to come and see you..
    No further questions..u can wait outside.

    5.A young man comes to GP clinic c/o tremors in hand drinks 4-5 cans of beer
    Task
    Relevant history
    Examination …investigations
    Management

    History:I asked about tremors ..said for few months…I asked about thyroid problems..nil..anxiety..no s/s ,TIA s/s any weakness in body said no Pt said whenever I hold newspaper I had them..when I drink ..i hold glass of drink tremors start and drink spill on me..any thing brings them on ..i am scared to hold glass of drink because I think they will initiate tremors and drink will spill….I Cant Understand What He wanted to convey by saying this 2 times
    Said that I am scared I wont have Parkinsonism
    No other problem besides drinking no h/o DM,HTN,High cholesterol

    Examination :power equal in all 4 limbs,no carotid bruit ,pulses equal,no rigidity
    No bradykinesia,no gait problem No tremors at rest

    Management ; I told him u r having Benign Essential tremors..you are not having Parkinsonism.Said I will refer you to general Physician he will strart you on propanalol ..do u have asthma..he said no okay.I think I mentioned u need to be careful with drinking as it increases risk factors for heart problem

    Another candidate said I mentioned alcohol withdrawal and LFTS and examiner said good .I did not mention them..plz do check

    6. female 35 yrs old has breast pain which is cyclical..her mother had breast cancer at age of 68..She is concerned about cancer.Not on OCP..NEVER HAD MAMMOGRAM
    O/E no lump palpable..b/l tendernress with lobularity
    Tasks
    Talk to pt tell her your diagnosis
    Management

    I told her you are having Cyclical Mastaslgia…it is due to hormonal imbalance.It is not cancer..regarding treatment before strart of periods wear comfortablr bra,do relaxation exerxises…have evening primose oil..i will give you mefenamic acid for pain control.
    You are 35 yrs old and u are very concerned about breast cancer so I will organize for you USG and mammogram.I will also refer u to breast screen Victoria.They will contact you regarding further investigations.
    Pt asked will I have these s/s after menopause as well…I told her it depends on stages of menopause in early stages of menopause u may still have them
    Its not cancer…no its not cancer
    Examiner said how can u be so confident that its not cancer I said that’s why i want to do USG and mammogram ….the pt will be satisfied and as GP I will be on safe side. He nodded his head and you can wait outside
    After examination another candidate said according to breast cancer guidelines u have to do both USG and mammogram

    7. 3 yrs old child had viral infection recently now came to you as GP have bruises and petechiae on body…had nose bleed the other day..otherwise playful
    Task
    Ask examiner examination findings and investigation results
    Management

    There were 2 examiners….
    Examination findings
    Alert,no problem of breathing,not cyanosed,not dehydrated,ear nose throat normal,no neck stiffness,chest cvs normal,GIT normal..bruises ..
    Investigations he gave me FBE Report on that Hb was normal,WCC normal,Plalelets low..i asked about PT APTT ,Bleeding time he said this is the only investigation available…
    talk to pt
    Told pt your child is havibg Idiopathic Thrombocytopenic Purpura.It happens after viral infection..at the moment it is serious condition but has very good outcome if u get early intervention.Said to her I need to send your child immediately to hospital.Because his platelets are low he can have bleed into head even with minor injury ..at hospital they will do blood tests..consultant will see your child..will give him steroid,immunoglobulin and if needed platelet infusion.
    Pt asked is it serious..said at the moment it is but has good outcome
    When do u want me to go..right now straightaway in the ambulance
    Pt said I don’t have anymore questions…Examiner asked wait outside

    8.A young lady comes with P/V Bleed and abdo pain.She had spontaneous abortion at 8 weeks before.She is planning preganancy
    Task
    HX
    Exam and inv
    Mx and future pregnancy advice

    At this station there were 2 examiners…incuding Dr Pepperrell …who is in AMC film as well.At that station I was bit confused didnt know why

    I asked is pt is stable ..pulse examiner said 60/min,BP 80/5O,temp not done,RR not done.I said 80/50 is criterion for code blue so I will call code blue.
    In the meanwhile I will stabilize the pt ,Foot end above,o2,IV line,draw bloods for FBE,EUC,LFTS,INR,CROSSMATCH AND Blood group.,urine pregnancy test I asked whats urine preganancy test she said its not available
    I said to examiner I will examine pt first then I will take history
    Examination findings.alert chest CVS normal,GIT some tenderness,P/V os open with Product of conception inside.I said I will remove product of conception.I asked any adenexal tenderness she said no.
    Then on hx she said I am planning pregnancy,feels tired and does not know her blood group I told her u are most likely having abortion…it can be ectopic..it can be abortion we need to do USG to find out more
    I said to examiner I will do Fetomaternal haemmorage test ..if in case she needs anti D and I will call O& G REG
    I told pt in your next pregnancy u need to have USG before 8 weeks.
    I asked about previous abortion if she had any d & c,if she received any anti D to all questions she said I don’t know.
    Pt asked why I am having abortions..i said for healthy pregnancy u need healthy baby,healthy uterus and healthy hormones..i will book your appointment at consultant clinic…they will do further tests
    Bell rang
    After exam one candidate said in this case critical error is if u dinr=t remove product of conception asit is cervical shock..secondly u have to give anti D because she has O-VE Blood…

    Its very stressful and unpredictable exam….
    Listen to pt questions and answer them wisely ..they deal with critical errors
    Do recalls and study recall topics as follows
    Medicine & Surgery common clinical cases in medicine and surgery by Peter Devitt
    O & G and paeds Guidelines of Royal women and children hospital Melbourne available online
    Psychiatry core clinical cases in PSYCHISTRY by Tom Clark
    And of course John Murtagh
  2. Guest

    Guest Guest

    Thank you but it has been posted before!!

Share This Page