Sydney Nov 7 2009 Clinical Recall - Detailed recall

Discussion in 'AMC Clinical Exam' started by Ventose., Mar 20, 2010.

  1. Ventose.

    Ventose. Guest

    This one is a detailed recall of my test, I promised to post it earlier but did not get to recall the whole lot. Now that I have done it here it is. Hope you find it useful.

    AMC CLINICAL – NOV 7, 2009 SYDNEY


    1.8 Week old child complain of crying
    Task – Take detailed history for 6 minutes
    Advise mother about management
    Young mother first born. Complaining that child is crying a lot. More during the night. Feeding alright. Some amount of vomitting after feeds. No fevers. Growth and development satisfactory. No
    concerns during pregnancy and post pregnancy till birth.
    I asked all the history related to the baby.
    Physical examnination: all normal. No abnormalities. No signs of injuries.
    I had almost exhausted all my history. The role player was a young girl however she did not give me any hits. The examiner was also just a passive spectator.
    Suddenly I realised that I had forgotten to ask about the mother. I asked her – how she was coping. She said she was doing alright. However she feels that the baby is not feeding well.So she is feeding the baby several times of the day. She even got up and fed the baby. She had no signs of depression.
    I wanted to ask more. However ran out of time.
    Other history – supportive family, no depression, no h/o mental illness, no suicidal ideation.

    I failed this case. I should have explored the mother's angle as well.
    People who treated this case as Post natal depression/blues/maladjustment failed either.

    Mother was coping well. However being the first born mother was overtly anxious.

    AMC – Irritable baby – History (Paediatrics)

    Essentially normal baby with maternal anxiety.
    Essentially a paediatric case but have to r/o psychiatric aspect too.

    From other candidates who passed -
    Key issues are her husband just left her after birth, and her breastmilk not enough.
    Solutions are: if not support (only her mother), social worker support, and community nurse coming home to teach techniques of breastfeeding.
    Show your empathy and supportive attitude, baby is fine, nothing wrong



    2.24 Year old female complains of vaginal bleeding. 8 weeks amenorrhoea.
    Task – take history, Physical examination, investigation, management.
    Same case as in recalls.
    8 weeks amenorrhoea. Bleeding post amenorrhoea. Small amount. Asked if any clots, patient was not sure. Symptoms of pregnancy positive. Not trying to get pregnant. Not on OCPs or contraception either. No pain or cramping sensation. No sex or trauma involved. No signs of haemodynamic compromise. Blood group A +ve.
    Periods normally irregular once in 2 months or more. No breast tenderness or other signs of pregnancy – morning sickness etc.
    Urine Beta HCG positive. 10,000 units or something like that. Can't remember.
    Physical examination: When I asked how the patient was – haemodynamic compromise: examiner said the patient is the way she is sitting in front of you.
    P/A: soft non tender.
    P/V no active bleeding. Cervix closed. I forgot to ask about adnexal tenderness. (might have been tender in the right).
    Other examination unremarkable. No breast tenderness.
    I said the urine Beta HCG is positive. So it means that she could be pregnant. I will do some blood tests – Serum Beta HCG and arrange for an ultra sound. If the ultrasound confirms pregnancy then it is pregnancy and she will be treated as pregnancy. I she is pregnant then we will have to do all other tests that are done as a part of the antenatal work up.
    The role player asked me about ultrasound. What will I be looking for in ultrasound. I said it will be
    abdominal and transvaginal. Was not sure what she wanted.
    For some other candidates – the examiner gave Ultrasound finding saying a cyst in ovary.
    Anyway, I said it could be threatened haemorrhage but we will have to wait for the investigations.
    However I failed this case.
    I think I did not rule out and say ectopic pregnancy as one of the causes PV bleed which is important.
    AMC Diagnosis – PV bleed.

    3. 50 year old man with red painful leg. Picture provided.
    Task- take history, explain your management to the patient.
    50 year old man. Developed red patch on the right leg and he feels it is hot. No history of wound, injury or trauma. Not a diabetic, but has not had a blood test in a while. Feels feverish. This started 3 days ago. No complaint of any bleeding, discharge or itching from the spot. No swelling, numbness or pain in the calves. No history of DVT. No similar complains in the past. There is family history of diabetes. No other complains.
    On examination – a picture was provided with a red patch on the right leg on the anterior and medial aspects. The margins were clear. It was clearly a case of cellutitis.
    The examiner told that there is local rise in temperature. Rest of the findings as in the picture.
    No calf tenderness. Pulses palpable.
    He told me to the condition and management to the patient.
    I said that it is most likely to be cellulitis. However we have to rule out DVT. He would benefit from hospital admission for investigation and IV antibiotics. It is most likely to be caused by Staphylococcus. I asked him if he was allergic to anything. He said no. I said I will take bloods – FBC, CRP, ESR, Blood culture and also do Blood sugar, lipids and EUC. To rule out diabetes and since he had not had a check up. USG to r/o DVT. Also would start him on IV Flucloxacillin. He would need it for a 3-4 days and depending upon the inflammatory markers and clinical condition he can be shifted to oral antibiotics to complete the course of a minimum of 2 weeks.
    He was doubtful about getting admitted. But I said that it would be better for him to get admitted for IV antibiotics. I asked him if he had any family. He said he lived alone. I told him that he would benefit from at least 1-2 days of hospital stay. If he wants after the investigations are complete we can send him home on IV antibiotics under community nursing. But it would be ideal for him to get admitted. And that I would need to review him again with all he blood results and to check the progress. He was happy with management and was ready to get admitted. He said – 'Give me some time to pack my bags'.
    Diagnosis – Cellulitis Lower Limb

    4. 26 year old woman complains of hardness of hearing after delivery of her baby.
    Task – take brief history for 1 minute, physical examination, management.
    Finds difficult to hear since delivery. It is in both ears. Finds that she has to turn the TV vol up to hear better. Asked whether she heard better in noisy surroundings, she said no. No history of trauma, ear infections or use of medications like gentamicin. Family history of similar problems is positive – sister has similar problems
    Examination – there were 4 tuning forks that we had to choose from. I chose the 256 hz one.
    Performed Rinne's test – air conduction lesser than bone conduction. Not able to hear the tuning fork when placed near the near canal but can hear when placed on mastoid.
    Weber's test – Equal in both ears.
    Otoscopy – not done but asked to look for wax and tympanic membrane. The examiner said Okay.
    ( note – when you try to activate the tuning fork, it is better to strike it on the heel of your shoe and test it by placing against your ear, striking it against your palm or elbow may not work and it might be painful)
    Explained to the patient that she had conduction deafness most probably – otosceloris. Explained it by drawing a diagram.
    Told her the need to confirm diagnosis by doing a audiogram and ENT specialist consultation who might decide to do a surgery – prosthesis with vein graft.
    She asked whether this problem will get better with itself or by medications – No.
    Will her children get it – autosomal dominant, so a genetic pattern to it is seen.

    Diagnosis: Otosceloris/ Hearing Loss

    5. Mother comes to you complaining that her 18 month old child is not talking well.
    Task – take further history, physical examnination, management plan to the mother.
    18 month old child not talking. Mother anxious. Child just muttering a few unintelligible phrases. Growth and development normal till now. No infections. No ear infections, no history of trauma or accidents. No ear injury.
    Antenatal history – No use of any drugs or any illness in the mother. Asked about rubella and gentamicin
    Post natal – premature baby. Requiring phototherapy. Had jaundice.
    One sibling. Normal. Not problems. I was not sure about the normal milestones. So I asked the mother about the first child. She said the first child started talking at 12 months of age and she said that this child has not yet started talking.
    No family history of deafness or any speech disorders.
    Mother was concerned about Autism.
    Physical examination: Normal healthy looking baby.
    Growth chart given when asked. Normal.
    Ear – dull tympanic membrane. No wax.
    Nose and throat – NAD
    Other systems – normal.
    Management- told the mother that the child's speech is delayed possibly because there is some problem with the child. This could be because of the hearing defect. I will have to arrange the baby to have a formal audiogram and also referral to a ENT specialist.
    Mother wanted to know that could jaundice after birth have caused it. I said yes.
    Could it be autism? I said at this stage it looks like the baby has some hearing problems that has delayed speech.
    She wanted to know if it could be cured. I said we have to wait for the investigations and the opinion of the specialist. He will be able to advice about further management.
    Diagnosis: Hearing Loss or Autism.

    6. 30 year old man went to donate blood. BP was found to be elevated BP 170/100.
    Three consistent readings were elevated. Patient smokes ten cigarettes a day and moderate drinker of alcohol. Not on any medication. Family history of heart disease and hypertension.
    (long stem – cannot recollect the entire stem, details of family, social and occupational history were given).
    Task – perform focussed physical examination
    Explain further management to the patient.
    I was not at all organised. However the examiner was very helpful and was observing my every step.
    I gave a commentary as I went along as best as I could.
    I performed general examination – looking for BMI. Pulse rate. BP in all four limbs.
    Checked the CVS
    Endocrine – Thyroid and cushings.
    Eyes – fundoscopy.
    Urine dipstick – looking for glucose, protiens.
    ECG

    Finally after I had finished examination, the examiner asked me to advise the patient. I said we have to do some investigations – EUC, Blood glucose, Lipid profile, TFTs, serum cortisol level etc.
    If no cause is found then it meant that it is essential hypertension. The patient wanted to know if we will start medications. I said we will try to control it with diet and exercise. And if that fails then we may have to consider medication. But that will be later.
    I was not at all satisfied with the way I went. I was not organised but I guess I covered everything. The examiner was a nice person and tried to help me and put me back on the track when I started doing some unecessary examinations.
    I passed this case.
    Diagnosis - Hypertension

    7. 50 year old female complains of dizziness and dysphasia. Weakness in the right upper and lower limbs. Symptoms have resolved while waiting in the GP clinic.
    Task – Perform focussed physical examination.
    At the end of 6 minutes the examiner will stop you. Explain your diagnostic impression and management plan to the patient.
    Same case as in the AMC hand book. Did P/E as per the handbook.
    However forgot to do co-ordination tests and gait and balance.
    All findings were normal. No bruit in carotid arteries and no sensory loss or weakness. Cranial n. 5,6, 7, 8. 9. 10 normal. No e/o horners sydnrome.
    At the end of 6 minutes the examiner stopped me and asked what was my management. I told her that she had what we call a 'TIA'. A mini stroke. The symptoms have resolved. But she needs to get admitted to Hospital for investigation. We will do a CT scan of the brain and also blood tests – FBC, Euc, Blood sugars, Lipids. Carotid dopplers. And we will also start her on Aspirin and a statin. Also the neurologist will come and review her. Further management would be on the basis of the investigation findings.
    Diagnosis – Dysphasia and upper limb weakness.
    Essentially TIA.

    8. 24 year old female patient calls you at 4 a.m in the hospital ward complaining of abdomen pain. She has been seen by your registrar regarding this and no cause was found. She is insisting that her pain can get relieved by only morphine and she is insisting that she be given it for her pain.
    Task – Talk to the patient – history and further management
    It was a young Chinese girl. I started by introducing myself and asked her what was wrong and what woke her up at 4 a.m? She told me that she has severe pain in her tummy. When asked about the PQRST of the pain she said it is generally all over and it is pretty bad. She has had it for 2 years now. She takes morphine and it settles. She said that each time she has such a pain, she goes to the medical centre and the doctor gives her script of morphine and then she is alright. I asked her whether she was investigated for this pain. She said that she had all tests including colonoscopy and they were all normal. I asked her whether she has the reports. She said yes. Her bowel function was normal. She had no regular GP.
    Physical examination done by Registrar was normal.
    I told her that the senior doctor has examined her and he feels that there is no obvious cause for this pain. I told her that her body had become dependant on morphine and so she was experiencing this sort of pain. She got angry and asked me – Am I a junkie? I said no. Her pain is genuine and we need to solve it and sort it out. I further asked her about any addiction. None at all. Her family – she had a daughter but she does not live with her. She lives with her grandmother. She is single and is on a pension. I told her I emphatise with her condition and that her problem is genuine. I will organise for her to get investigated to find the cause of the pain. At the same time we need to address the issue of morphine. I said that there is a group of specialists who will deal with this. I avoided mentioning Drug and Alcohol. I said they will devise a plan for you to bring you off the dependance of morphine. She asked me that is for later, what about the pain for now. I said that I will not give her morphine. However there are other non opiate analgesics that will help with the pain. I said we will try NSAIDS and I will give her an injection of Ketorolac ( toradol ). This may give her some relief. I will review her some time later to see how she is going. I further said that her pain is genuine and we will try to help her in every way possible. I asked her how does that sound. She said that is fair enough and is willing to give it a try.
    AMC Diagnosis – Chronic Pain.
    I dealt this case as Chronic pain with opiate dependance.

    9. 60 year old female has come to you about a lump in the right breast.
    Picture provided. Right breast higher than the left. Nipple inverted. No signs of lyphoedema in the picture
    Task – History, Ask for Physical examination findings, Talk about your management plan.

    There was a picture of the the breast outside the room. The right breast higher than the left. The nipple was inverted and there seemed to be some amount of lyphoedema changes but not clear. I asked history. Important points was that this had started slowly. Never had a mammogrom or breast check up. Family history positive. Said she had been getting increasingly short of breath. The patient was very afraid and kept on asking me from time to time whether it was serious. She also said that there is family history of heart disease.
    I asked further examination findings. The examiner asked me to say what I saw in the picture.
    No axillary lymphadenopathy. I asked about the other finding. The examiner said you tell that patient what you will do. I said that I will do a thorough physical examination. Starting with the breasts. Since she was short of breath. I will check her CVS and Respiratory system. Looking for signs of any heart failure pedal oedema etc.
    She was very afraid and said that she is all alone, no family. She asked me if anything could be wrong with her heart.
    I said that I can understand her worries. I am there for her for support.
    I will arrange investigations like ultrasound, mammogram and then biopsy. If the biopsy it positive for breast cancer then we will have to do a CT scan for further staging. I said that I will be referring her to a specialist for further assessment. She asked me whether it was breast cancer. I said possibly but we have to wait for the investigation results. Till that time I cannot say anything in definite. She said that she was afraid. I said I will arrange support for her and I will be there with her all through this difficult period of her life.
    The examiner and role player were happy. He said Shukriya ( thank you in Hindi ) as I was leaving the room.
    AMC – Advanced breast cancer.

    10. 23 year old female come to you with pain abdomen lower abdomen radiating to the groin. Pain is subsided now. A CT was done.
    Task – Interpret the CT scan. Talk to the patient about your diagnostic impression and management plan.

    Same case as in the recalls. The CT scan showed a horse shoe shaped kidney.
    The examiner wanted me to explain the CT scan. Which I did.
    The role player asked me if it could be cancer. I said not likely.
    I said that the pain could have been because of a stone that you would have passed.
    However we will do some tests like EUC, TFTs and CMP.
    The patient should be aware and the abnormally positioned kidney. She should be careful especilally with contact sports. The examiner asked what sort of contact sports. I said – kick boxing. They both started laughing. The examiner asked me so what if I have a million dollars. Can I give it to her. I said by all means. She will be very lucky. There was still some time. So we made some small talk and when the bell rang I went out. Everyone seemed to be in a good mood in this station.
    Diagnosis – Congenital renal abnormality

    11. 45 year old female complaining of pain abdomen. Presented in ED.
    Task – take further history. Physical examination findings, talk about management plan.
    Same case as in previous recalls.
    Right upper quadrant pain. With some nausea and vomitting. Now settled. No radiation. Constant. No aggravating or relieving symptoms. No such pain in the past. No history of gall stones till now. No ulcers. No history of heart disease.
    Pain still there, about 6/10. Started suddenly. Did not eat a heavy meal. No chest pain. No SOB.
    Physical examination: Pain right upper quardrant. Tender. No rigidity, no gaurding.
    ECG – Normal.
    I said that it looks like acute cholecystitis. We will have to get the surgeons to come and see her. We will keep her nil by mouth. Put a canula and take baseline bloods and start her on fluids.
    Arrange for a ultrasound abdomen.
    The surgeon may decide to do a surgery to take the gall bladder out. It may be most probably by lapsoscopy. It depends upon the surgeons assessment.
    I asked if any concerns. She said no.
    AMC Diagnosis – Upper Abd pain and rigors.

    12. A 20 year old patient has been brought to your GP practice by his parents. He says that he has a specific information for the US president.
    Task – Take history, Present your diagnostic impression and finding(mental state
    examination) to the examiner with DD.
    20 year old boy brought to GP practice by the parents. He was very agitated. He had been to a music festival yesterday and it suddenly dawned on him that he has this mission to save the US president. Continuously talking. Saying that he had some important information for the american president and he had to go.
    He was answering questions but was really agitated. No insight and judgement. No suicidal intent or ideation.
    When I asked about drug usage he was not clear and became annoyed.
    I told the examiner – 20 year old boy agitated. Dishivelled and untidy to look at. Continuously talking. Unable to obtain full history. No insight or judgement.
    DD – Acute psychosis secondary to most possibly drug usage.
    Mania, Bipolar illness, Pre existing mental illness – schizophreniform disorder.
    AMC Diagnosis – Elevated Mood assessment


    13. 10 year old boy presented to GP practice with headache.
    Task – take further history from the father, physical examination findings (only those
    specific investigation finding that you ask for will be givne) , explain management plan
    to the father.
    Headache since the past few weeks. Mostly in the mornings. With vomitting. No fever, no visual disturbances. No aura. Growth and development normal. No other medical illnesses. No history of trauma or head injury. Family history of migraine positive.
    Physical examination: Healthy looking child alert oriented. Obs stable. Afebrile.
    I asked for Fundoscopy: Given a picture of the fundus – it did not look normal. ? Papilloedema.
    ENT – Normal.
    CVS – Normal.
    No rash neck rigidity.
    Management: I told the father the the fundus did not look normal. It looked like papilloedema. But I will get it confirmed by the senior doctor here.
    The examiner asked me if I was sure about this. I said that I am a junior but this does not look normal so I will get the findings confirmed.
    The examiner asked me to tell the father the plan – I said that the fundus looks abnormal. If my senior confirms that it is papilloedema. Then it might be because of raised intracranial hypertension. We need to take a CT scan. And further referral to a neurologist. It could be serious.

    The examiner asked me what if normal. I said if the fundus is normal then it could be migraine and we need to keep a watch on the headache. I will also give some pain relief since paracetamol was not helping, I will give something stronger like nurofen or paracetamol with codiene (painstop syrup). We also need to study the pattern of the headache.
    However I said that we need to rule out the serious cause by taking CT scan.
    I asked the father how does this plan sound. He said, that seems reasonable.
    The examiner was alright.
    I was worried because I wasn't sure about the papilloedema, but I passed the case.
    I guess, it was because I did say that I will rule out papilloedema, intracranial hypertension and do a CT scan. Thus keeping the patient safe.
    AMC Diagnosis – Child headache raised ICP

    14. 24 year old woman has presented to your GP practice with 12 month amenorrhoea.
    Task – take further history
    physical examination findings
    Management
    History of 12 months of amernorrhoea. Periods have been normal prior to that. Complaint of some pain in the tummy. Dull pain. I asked if there is any pattern to it. She said it comes every month. I asked whether it was approx at the same time as when she got her periods previously. She said yes. Also some amount of slight brownish discharge. No complain of excessive hot or cold. Not on any medications. No breast tenderness.
    No history of pregnancies in the past. History of D and C more than a year ago. Feels that the period have stopped after that.

    Physical examination: P/A – slight tenderness lower abdomen.
    PV – NAD
    Urine dipstick – Beta HCG negative.
    Other examination unremarkable.
    I said that most possibly the periods have stopped because she might have developed adhesions post D and C which is called Asherman's syndrome. However we need to confirm the diagnosis by doing a ultrasound of the uterus. If the diagnosis is confirmed the we need to refer her to a gynaecologist who will do a hysteroscopy for further management.
    AMC Diagnosis – Secondary Amenorrhoea

    15. 35 year old woman comes to your GP practice complaining of tiredness.
    Your colleague ordered some blood tests. The reports are here.
    FBC – HB (decreased), MCV (decreased) and blood film report provided. No other
    reports are available. She has come to you today to discuss the blood reports.
    Task - take further detailed history for 6 minutes.
    Explain management plan to the patient.
    Same case as in previous recalls – Fe deficiency anaemia.
    I ruled out hypothyroidism, any bleeding – from the gut and excessive periods, diet and cancers.weight loss. Diabetes and dementia.
    I said that we need to do some investigations FBC, EUC, TFTs and stool examination (faecal occult blood test).
    Also we need to find out the source of bleeding for which we need to do a colonoscopy and upper GI endoscopy.
    I will also give her dietary Fe supplements.
    I will be reviewing her regularly with all the the results.
    AMC Diagnosis - Anaemia

    16. Patient comes to your GP practice with 41 week pregnancy primi. Pregnancy has been uneventful till now. 34 week scan normal. All antenatal blood tests normal. No DM/HTN.
    GBS swab was done at 34 weeks which was normal. (long stem)
    Task – take further history
    Physical examination findings
    Explain your diagnosis and further management plan to the patient.
    Same case as previous recalls.
    Post dates pregancies. 41 weeks. Dates confirmed. Pregnancy normal till now. Ultrasound 34 week normal. No big baby or CPD. No fibroids. No malpresentation. Baby kicking.
    P/E – Normal lie presentation. Fetal heart sounds normals. No signs of poly hydramnios or oligo hydramnios.
    CTG – reactive.
    Management: I said that it is already 41 weeks. We will have to deliver the baby because it is post dates. We will have to admit the mother in hospital. Arrange for a USG to r/o big baby, placental abnormalities or CPD. If everything is normal the delivery will be induced using prostaglandits to ripe the cervix. I asked her whether she had bronchial asthma or any other medical problems – nil. There is no point in prolonging the delivery. We will keep a watch of meconium staining of liquor in which case we will have to suction the nose and mouth and oropharynx and visualise the vocal cords.
    If everything is well then the delivery will go uneventfully and everything will be fine.
    The mother agreed to get admitted to the hospital.
    AMC Diagnosis – Post date pregnancy.

    I passed in 14 out of the 16 stations. I failed Irritable baby and PV bleed cases.

    Good luck to everyone. You need to be very thorough with all the recalls. This is not an easy exam. The cases are mostly repeated but we need to be very thorough. We have to have all the facts on the tips of our fingers. So that we can recall them inside the room during the 8 minutes. Only repeated study and role play will help. We need to constantly go through the cases in our mind.
    Thanks for all the previous AMC candidates who have recalled their papers. We all should help each other. And do recall all your papers and pass them around.
    Thank you and Good luck!
  2. freesky

    freesky Guest

    You did a great job!

    Thank you very much. Thank you for your detailed recall and generosity.
  3. Guest

    Guest Guest

    Thanks !!
    May the God / Religion U believe in make UR future pathway smoother !!
  4. Thank you very much for the help.

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