SYDNEY 25 AUGUST, 2007

Discussion in 'AMC Clinical Exam' started by DRSUNEETKOHLI, Aug 26, 2007.

  1. TOPICS WERE:

    1) ALCOHOL COUNSELLING
    2) ACUTE MI
    3) BARTHOLIN'S ABSCESS
    4) SIDS COUNSELLING
    5) URETERIC STONE
    6) HEPATITIS
    7) INFLAMMATORY BOWEL DISEASE
    8) CROUP
    9) UTI IN 18 YEAR OLD FEMALE
    10) PSYCHOSIS IN 18 YEAR OLD GUY (DRUG INDUCED). TALK TO MOTHER. CONSENT NOT GIVEN FOR DIVULGING THE INFORMATION ABOUT DRUG ADDICITION BY THE SON
    11) HYPERTHYROIDISM
    12) CARDIAC MURMUR (DO CARDIOVASCULAR EXAMINATION)
    13) RECURENT ABDOMINAL PAIN IN 8 YEAR OLD
    14) ANTE-NATAL CARE IN A FEMALE WITH PREVIOUS THREE RECURENT ABORTIONS
    15) CASE OF TRAUMA IN 21 YEAR OLD - TAKE CONSENT FROM THE PATIENT FROM AMPUTATION
    16) DVT
  2. Guest

    Guest Guest

    thanks

    Thanks a lot mate
  3. Guest

    Guest Guest

    would you plz give more details about the senarios

    Thank you
  4. aaljobair

    aaljobair Guest

    more details

    Would U PLZ give a bit details of senarios -- which must help us .

    Thanx .
  5. dear friends,

    at the moment , got too many butterflies in my stomach while waiting for the result. let the result be out, i will definitely put in the details of all the stations and also the details why i flunked in a few stations (which i know i have did).
    just give me a couple of days.
    regards
  6. serendipity

    serendipity Guest

    Dear DRSUNEETKOHLI,


    PL. LET US HEAR A GOOD NEWS FROM UR SIDE ,ABOUT AMC

    CLINICALS , HELD ON 25.8.07. WITH ALL THE BEST, SERENDIPITY.
  7. dear friends,

    by the grace of god and the best wishes of family and friends, i have passed.

    thanks for your best wishes.

    let us discuss the stations one by one. it is possible to do so, and if you are willing to do so i will respond to all the queries and we can have a good discussion .

    (1) ALCOHOL COUNSELLING

    this was the first station

    facts given were:

    A 45 year olod male presents to the general practice. He admits to drinking five stubbies per day. Has had 2 minor accidents in the last few months. Having problems with money, work and personal relations. Has got the problem of impotence. Blood pressure recorded was 180/100.
    Bloods that were ordered showed macrocytosis and elevated GGT (other LFT’s were normal)

    Task:
    Explain the results to the patient
    Counsel him regarding the effects of alcohol
    Advise him about anything else

    now how would you go about it??
    give me the suggestions and we can discuss the station
    it will help us a lot, i can assure you that
  8. (2) second station was ACUTE MI

    a male patient has presented with 1 hour of crushing central chest pain. ECG showed ST segment elevation in V1 - V4 (anteroseptal MI)

    Task:
    Explain to the patient what is the diagnosis
    tell him what you are going to do.
    Fill the drug chart with the drugs that you are going to give.

    any views.................
  9. Guest

    Guest Guest

    Hey Suneet,
    Congrats buddy on clearing the exams. now to the first question, the alcohol counselling station.
    the results explaination shouldnt be too difficult, about how alcohol is affecting the liver and his B12 status and also his personal life. I'm wondering bout the elevated BP, does it have any relation with the alcohol, or just an incidental finding? correct me if i'm wrong.
    Counselling protocol, just follow what murtagh's mentioned, talk to him about the illefects, educate him about the benefits of giving up alcohol, therapy should be patient centred, ask and find out whats driving him to drink, and try and solve that issue> set goals and set targets. advise about AA, joining a group, advise that you'll be there for him when he wants help. ask him to come back for regular counselling sessions. Dont forget to inform him about the effects of withdrawal and how to counter them. I'm not sure if you should mention disulfiram, but if i do have time, i'd just add in a line talking about it, but ofcourse its a last line option. Mention should be made about social support for the person and whose there at home to help him out during this recovery process. I guess thats about it... cant think of anything else. if i missed something, feel free to add.....
  10. Guest

    Guest Guest

    Acute MI station

    Now to the second station, AMI, before i start off Suneet, i was wondering if the question specifically mentioned if you were an intern or a GP. Management would differ slightly accordingly, being an intern, you would need to call talk about informing the senior plus the consultant. and if you are a gp, mention about calling an ambulance, and calling the ER at the local hospital. explaining the diagnosis - start off with a matter of fact approach, but empathy must be shown by the you. Tell him plainly that he's having a heart attack, try and give a one line defintion as to what a h eart attack is. ask him if he's understoof it. inform him that its an emergency and we need to clear the clot asap. it starts off with giving tablets to thin the blood and to remove the clot. that he most probably would be transerred to a CCU or Intensive Care. the choice of lysing or placing a stent would be upto the consultant to decide upon. Advise him that this is not a good situation to be in, anything can happen, ask about calling relatives and family..stuff like that.
    NOw filling out the drug chart, i was wondering if they give you a chart, or a plain piece of paper, and you just have to write down the list of drugs and/or their doses?
    Drugs to be included include Asprin, Clopidogrel, Glycoprotein IIb/IIIa inhibitor and anti thrombin agents. You must say that since your just an intern(if thats the situation) that you'll have to confirm it with the consultant or senior on call.
    And ofcourse, the choice of lysing agent. Since the patient comes just within 1 hour of onset of pain, he comes into the category where PCI is an option where facilities are available, thats why i feel that getting a consultants opnion must be stressed.
    Righteo..cant think of anything else, just the drug chart query. if you could answer that it would be wonderful
    Cheers
  11. XYZ1

    XYZ1 Guest

    the other staions

    Now Suneet, it would really wonderful,Mate, if you could post the other stations and we disucss them. How were the examiners in general? friendly? were there any consitpated examiners in that lot??
  12. Guest

    Guest Guest

    congrate Sunnet for clear the clinical and also many many thanx for recall. Could you pl. post your ans. At second station, which setting that is gp or emergency, will we talk? I can't understand the filling out the drug chart. It will helpful if you post your opinion.
  13. dear georgerv

    you have done a good job there.
    i nearly did the same here.

    but what we missed is:

    (1) why and when did he start taking alcohol
    (2) any other substance abuse
    (3) is he depressed
    and most important
    (4) how is he coping with depression

    when it comes to counselling, do not think that you cannot ask any other questionns, especially a simportant as these ones.
    especially, always remember that depression, substance abuse and anxiety are interrelated... so try to find about the other things.
    and impotence is very important.

    studies have shown excess alcohol to be linked to hypertension and strokes. so that is surely an issue which needs to be addressed. just mention that in one line.

    rest all the issues you have dealt fine.
    i am a lousy typist, so excuse any mistakes on my part.
  14. Guest

    Guest Guest

    regarding 1st station

    I do think i added a part about asking as to why he started drinking alcohol, and i meant to cover depression. i just didnt put it up. he he. but i did forget about taking other recreational drugs. Thanks a lot for reminding me about that.

    regarding the AMI, i forgot to mention morphine and NTG either spray or tab. i had typed the reply late last night and maybe thats why it didnt strike me, its standard and i completely forgot. well atleast now i'll remember for sure:)

    waiting for the other stations Suneet. hope to hear from you soon.

    Cheers
  15. In regards to the first station :
    Very important to ask how is he coping with the impotence - it can lead too secondary depression and hence alcohol abuse
  16. In regards to the second station of ACUTE MI

    The candidate is at a hospital as an medical officer.

    How I went about it is:

    Explain to the patient the diagnosis – heart attack – meaning that one of the blood vessels supplying the heart itself is blocked & what needs to be done is to open that blood vessel. The means that can be used are either PCI or thrombolysis. Now sitting in a remote hospital, you have to do thrombolysis and then later shift the patient to the centre where PCI can be done.

    (1) oxygen - do not forget it
    (2) agents for pain relief
    GTN spray / tablet / infusion, and/or
    Morphine + metoclopramide; and /or
    Beta blocker (IV or oral) if the blood pressure permits (in the given case blood pressure and the heart rate were satisfactory)
    (3) aspirin + Clopidogrel
    (4) heparin infusion or subcutaneous enoxaparin
    (5) thrombolysis
    (6) ace inhibitor – may be started immediately or on the next day
    So the first five things are a must.

    DO NOT FORGET TO TAKE CONSENT ABOUT THE THROMBOLYSIS.
    DO NOT FORGET TO ASK ABOUT CONTRAINDICATIONS TO THROMBOLYSIS.

    And as regards to the drug chart, it was a proper drug chart used in the Australian hospitals. So better get acquainted with it.
    If someone can scan it and put it on the website of aippg somehow, it will help a lot of people. I do not how how to put it on the website, otherwise I would have done it.
  17. BARTHOLIN’S ABSCESS

    A 22 year lady comes to you in your general practice.
    Picture of Bartholin’s abscess given to you

    Task:
    · Take focused history
    · Advise the patient of the management
    · Answer any other questions that the patient may have

    History was that of severe pain (the role player was sitting uncomfortably on the chair) for three days in the vulval region, fever with chills.
    No history of dysuria, frequency, discharge per vaginum.
    Steady with the partner for years
    Taking OCP’s
    Never used IUCD
    No past medical illness

    The diagnosis was straightforward

    Advised the patient of the management: that it was an abscess and would need to be drained. Because I cannot do it, I would call the gynaecology registrar in the hospital and fix up and urgent appointment with him/her. The patient needs to got the hospital immediately. BUT before she goes, I would give her a shot of broad spectrum antibiotic and adequate analgesia.

    The patient asked me what would be done at the hospital – I told her that the abscess would be drained under adequate analgesia , the pus would be drained & swab for culture / sensitivity would be taken and antibiotics and analgesia would be given to her.
    She further asked me whether she would need to stay in the hospital – I did not know exactly – but I replied that it would depend on the recovery she makes and the discretion of the treating regisrar.
    Also I told her the nature of the illness – bartholin’s abscess and the treatment called marsupilisation (correct me if I am wrong).

    I was not prepared with this station and my gynaecology and obstetrics is horrendous. So I am not sure how I did in this station.

    Now this station can be approached in a different manner
    The GP may do the procedure himself/herself – but if you do not know how to do it, better to say I would need help. No need for heroics. It is a test to mainly see whether you are a safe doctor or not…
  18. SIDS COUNSELLING

    A 29 year old lady who is 6 months pregnant comes to you asking about SIDS. A neighbour of hers has lost 6 month old child due to SIDS.
    Task:
    Counsel the patient
    Answer her questions

    Seems to be a pretty straightforward question

    I started off by asking her what did she know about SIDS. She did not know much.
    So I told her the technical definition (which can be skipped) in layman’s language.
    Then I told her why it is so important – because it causes the maximum no. of deaths in under 6 months of age children. So I told her that I can discuss with her the results of various studies and simultaneously what the recommendations to prevent SIDS are, to which she said yes.
    So I told her point by point what studies found – and correspondingly what should and should not be done.

    SIDS is excellently given in the Royal college handbook of paediatrics. Just 2 pages and it covers it ina beautiful manner.
    If someone can tell me how to do it, I can scan the pages and put it on the website.

    But the thing was that this station was tackled in different way by many candidates and also the role player could ask about many other things.
    For example - she and her husband were still smoking, so one of the candidates was asked to give a bit of lecture about smoking as well.
    I gave a detailed explanation on SIDS. She asked me any relationship with the breast milk – and I told her that no independent factor has been found to reduce SIDS. So she asked me that she shall not breast feed her baby – and I had to counsel her on the benefits of breast feeding. By the time 8 minutes were nearly over – we reached the topic of smoking – and she told me that she and her husband were still smoking to which I replied that she / they would be better off quitting without any delay.
  19. btl

    btl Guest

    approach to difficult ques

    Dear Drsuneetkholi
    Thank you so much for your effort to explain the cases. Will you please give us the scenario of question 10 ; "psychosis in 18 year old guy.....". Will you also tell us how did you approach that case? That case Sounds like a difficult one.
  20. Guest

    Guest Guest

    2nd station

    Is it STEMI or NSTEMI?

    STEMI is associated with 'red thrombus' and NSTEMI is associated with 'white thrombus'. Treatment for STEMI includes aspirin and either emergency angioplasty or fibrinolytic therapy and NSTEMI is emergency antiplatelet and antithrombotic therapy followed by angiography.
  21. Guest

    Guest Guest

    About SIDS, according to Murtagh:
    P942- Risk factor is passive smoking ( before and after birth) and preventive advice are ensure breastfeed, ensure the baby should not expose to cigarette smoking.
  22. Congradulations DRSUNEETKOHLI
    And thank you for sharing your information with us
    If you have tiem can you post the other stations please

    thanks

    Saba
  23. Guest

    Guest Guest

    Thanks Suneet

    Thanks Mate, concerning the other cases you put up. My knowledge in OBG isnt worth mentioning. But you did go rather well with it. I was wondering if you mentioned a course of antibiotics to be added to the case as well.


    The prescription part for the AMI, did you have to write the dose as well, do you think that was important, i know the dose for most of the drugs, except the anti thrombin drugs and the lysis.
    For that case, i would have told the patient that the decision for lysis or PCI would be upto the consultant. ( I cant believe i forget to mention O2 all the time when it comes to handling SMI or cadiac cases, I know it should be done, but I always forget mentioning it)

    There's nothing much I can add about SIDS as well, you covered that pretty adequately.

    Waiting to hear about the other cases.
    Cheers
  24. Dear friends,

    The drug chart needed the doses of the drugs. Hence it will not be a bad idea to remember the doses of a few drugs.
  25. Station 10 :pSYCHOSIS IN 18 YEAR OLD GUY (DRUG INDUCED). TALK TO MOTHER. CONSENT NOT GIVEN FOR DIVULGING THE INFORMATION ABOUT DRUG ADDICITION BY THE SON

    The station included a 18 year old boy who has seen you in the general practice with severe psychotic features. He has agreed to taking drugs and has also consented to see the psychiatrist in the hospital.
    You are to talk to the mother about his condition. He has specifically told you not to tell his family about the drugs.
    Task:
    · Talk to the mother
    · Take information from her what she wants to give
    · Ask her what you want to ask
    · Answer her queries

    This was a station mainly about
    · Patient safety
    · Ethics

    The mother gave a detailed history about her son without me asking her any questions.
    I only asked her the family history (which was positive for schizophrenia)

    I told her the meaning of psychosis.
    She asked me the reason for her son being psychotic and repeatedly asked me about drug intake.
    I politely told her the causes of psychosis and told her that I do not know the exact cause, and that he needs to see the psychologist.

    She said that she would take him there in a few days, to which I replied that needs to be seen immediately.

    She said that she can drive her son to the hospital or walk with him to the hospital, to which I replied that we should call the ambulance, as the paramedics in the ambulance are well trained for any emergency (and that her son being severely psychotic was a medical emergency).

    The point in this station was not to divulge the information regarding drug intake at any cost , and not to let the patient go home. He should go to the hospital.
  26. Guest

    Guest Guest

    thank you very much. when you post your rest of the problem? we are waiting for that.
  27. dear friends,

    thanks for all your support.

    i am posting the rest of the stations here. they are not discussed as much in detail as you want the information of the stations pretty quickly in view of the coming exams. if however someone wants to discuss any of the stations, they are welcome to leave their comments and i can answer the queries.

    someone had asked me whether there were any constipated examiners.
    do not worry about that. all examiners especially the australian (or caucasian) ones are good to you. if you know the station it is easy. if not, then examiners do look constipated..

    all the best. work hard. it pays off............

    5) URETERIC STONE
    a 45 year old lady presents with pain in abdomen.
    Task:
    · Take history
    · Explain to the patient the diagnosis (or possibilities)
    · Discuss the diagnostic and management options


    6) HEPATITIS
    a 45 year old nurse presents thinking she has got hepatitis.
    Task:
    · Take history
    · Ask examiner for findings on physical examination
    · Discuss the possibilities
    · Discuss the investigations which you are going to order with the patient


    7) INFLAMMATORY BOWEL DISEASE

    a 25 year old male patient presents with diarrhoea and blood in the stools.
    Task:
    · Take history
    · Ask the examiner for findings on physical examination
    · Discuss the possible diagnosis and the investigations that you are going to order with the patient


    8)CROUP
    This was a relatively straightforward case.
    Priority was to see:
    (1) management
    (2) patient safety

    the case was of a three year old boy who has presented to the general practice with cough and being unwell. There is stridor present.
    Task:
    · Ask history and then ask for examination findings
    · Discuss the management with the father
    · Answer any questions

    The history was straightforward. The child had viral flu like illness developing 1 day back and then deteriorated overnight with cough and difficulty in breathing. Appetite had been normal up till the illness and had not deteriorated markedly and child was wetting nappies normally. No exposure to any person with flu recently. Mild fever was present.
    Immunization status: fully vaccinated
    No family history of asthma

    Examination findings (I had to ask everything from the examiner):
    Child appeared unwell
    Croupy cough
    Stridor present
    Chest recessions present
    SaO2 not available
    Chest: no specific findings
    Rest systems examination: Normal

    I explained the diagnosis of croup to the father (he was role player who was acting ignorant). I drew a picture of the resp. tree and told him that there was inflammation of the larynx (voice box), trachea (air or wind pipe) and the bronchi.
    He repeatedly asked me if antibiotics could have helped the child if the child was seen the day before, or was it his fault that he had not brought the child in yesterday when the illness started. I had to tell him that AB’s would not have made any difference and the illness is very unpredictable and no one can predict the onset of croup.

    Management was explained to the father:
    O2
    Adrenaline nebulizer
    Steroids (oral prednisolone or IM dexa)

    Now the safety factor:
    Child is having moderate to severe croup (stridor, chest recessions, unwell), hence the need for continuing observation. I told the father that the child would need to be observed in a hospital for the next few hours; and depending upon the course of events over the next few hours, further management can be decided. So I would call the ambulance and have the child shifted to the hospital for observation (after the adrenaline neb and the steroids have been given in the practice). DO NOT SEND THE CHILD BACK HOME.


    9) UTI IN 18 YEAR OLD FEMALE
    an 18 year old female comes to your general practice with 2 days symptoms of dysuria and frequency.
    Task:
    Take history
    Ask the examiner for physical examination findings
    Discuss the diagnosis with the patient, any additional investigations that you are going to do and the management


    11) HYPERTHYROIDISM
    a 45 year old female presents with the complaint of feeling nervy and jumpy
    Task:
    · Take history
    · Ask the examiner for examination findings
    · Discuss with the patient the diagnosis and the investigations that you are going to order

    12) CARDIAC MURMUR (DO CARDIOVASCULAR EXAMINATION)
    task:
    do a CVS examination of the patient (Talley O’ Conner)


    13) RECURENT ABDOMINAL PAIN IN 8 YEAR OLD
    a father has come to you with his 8 year old child (son) who has the chief complaint of recurrent pain in his abdomen.
    Task:
    · Take history
    · Ask the examiner for the findings
    · Tell the father the diagnosis and order any investigations that you want

    14) ANTE-NATAL CARE IN A FEMALE WITH PREVIOUS THREE RECURENT ABORTIONS
    a 28 year old woman presents in your general practice with 3 previous first trimester abortions.
    Task:
    · Take history
    · Ask the examiner for physical examination findings
    · Tell the examiner what investigations you are going to do and the examiner would tell you the results of the investigations
    · Tell the patient your plan for management

    15) CASE OF TRAUMA IN 21 YEAR OLD - TAKE CONSENT FROM THE PATIENT FROM AMPUTATION
    a 21 year old comes to you with motor vehicle accident. The surgical registrar has seen him and does not think that the limb can be salvaged. He has asked you to take the consent for amputation of the limb, even though the surgeon is the person who has to officially take the consent.
    Task:
    · Take consent for amputation of the limb


    16) DVT
    A 21 year old female presents with acute swelling of left calf after a long air flight. Doppler venous scan of the leg shows thrombosis in the popliteal vein.
    Task:
    · Take history (focused)
    · Discuss with the patient the management plan
  28. samora2

    samora2 Guest

    thank you

    thanks all

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