Clinical recall 17 May 2008 Melbourne1. SIDS (see AMC Handbook of Clinical Assessment) Scenario and Qs asked by the role player were exactly the same as the publication. AMC Feedback: Sudden Infant Death Syndrome 2. A 2 year old child with cough of 4 days and now worse at night. Recent URI in the family. Fully immunised, previously well. There is a 6-week old sibling at home apart from his parents. On PE: The child is well, alert, active, and afebrile, not in any form of distress. When you checked the throat and touched the palate, the child started coughing with an inspiratory stidor. No need to take history. Tasks: • Explain your possible Diagnosis • Advice on plan of management I started by saying that there are several possibilities. One is that it can be a viral cough, an allergic cough (because the cough is primarily nocturnal) or a para-pertussoid cough which is a cough similar to pertussis but the organisms causing it are not necessarily pertussis (i.e., Bordatella parapertussis, Mycoplasma, Chlamydia). But I could sense that the role player was not happy with my answer. So I said, at the bottom of my list is pertussis. Then the role player suddenly became interested in my diagnosis. I continued to say that immunisation does not afford a 100 percent protection that is why there is a need for booster doses later on in life. If he gets infected with pertussis despite immunisations, it would be a modified symptom and not the typical text book presentation of pertussis. I would need to get some swabs from the nasopharynx to confirm the diagnosis. If this is Pertussis these are the following things that need to be addressed. • A reportable case. • He would need to have some erythromycin which is the drug of choice (or any of the macrolides – clarithromycin, roxithromycin). At this point the examiner asked me to whom will I give the erythromycin to. First, I said to the patient, to reduce his infectivity but that this would not necessarily alter the clinical course. Secondly, all household contacts need to have prophylaxis treatment. I am particularly concerned with the 6-week old baby since he would not have any protection because of the lack of transfer of maternal antibodies. Thus this 6-week old should receive prophylaxis Rx and should be immunised with DTPa which can be safely given as early as 6 weeks. This immunisation however, does not give immediate protection. I would need to follow up the 6-week old closely. With the 2 year old, it should not be a big problem on him having had 3 initial doses of DTPa and therefore his clinical course will be modified and not as severe as when he is not immunised. Q (question) from the role player. Where could he have gotten this? I said from someone who harbours the organism in the nasopharynx. I wasn’t able to clarify that the parents can have waning immunity and could have harboured this in their throats/nasopharynx. Also, I forgot to ask if the child is in childcare. If he manner of delivery and any previous issues like diabetes. baby kicking. Labour pains. VS then went straight to the obstetric examination.5kg to 4. PROM +/.ok. . bleeding. Gen appearance. these are the options: • Admission to hospital. You find out that she has a transverse lie. Then I asked pre-eclampsia Qs (questions). fundic height. I first asked current pregnancy issues. The patient should also be exempted from childcare temporarily until at least 5 days of erythromycin/clarithromycin Rx.N. the child carers’ nasopharynx should be checked if they carry the organism (potential source of infection) and should be treated and excluded from child care as well. Tasks: • Take further relevant history from the patient • Ask examination findings from the examiner • Tell the patient about your management plan. placenta praevia etc – role player said baby was normal and that she does not know any information on the placenta. and presentation. AMC Feedback: Pertussis 3. Dipstick urine. with an ultrasound. general health . immediate delivery just in case a cord entanglement.cord prolapse happens.can’t recall. we can also gauge the amount of amniotic fluid because too much amniotic fluid can also cause the baby to move around easily. She said she had 3 babies. • Second. I then asked any issues during this pregnancy. praevia and polyhydramnios from the ultrasound. A multigravid is now in your clinic and is 38 weeks pregnant. After making sure that there is no placenta praevia.is. I asked about their birth weights (3. placenta praevia can prevent a baby from positioning itself normally thus I would like to rule this out by doing an ultrasound (and a CTG to check on baby). water leaks etc. I said it is unlikely that you have an Rh-ve blood group but we can check that later. • The first one is a small pelvis and this causes cephalopelvic disproportion CPD – this is unlikely in her case as she has had 3 previous pregnancies with relatively large babies who were all vaginally delivered thus her pelvic passages have been tested for adequacy.e. 18 week scan – any abnormalities. I examined the patient.. contractions. having ruled out pl. • Lastly. I asked her blood group and she said she does not know. Because we are quite far from the hospital and also because she is already at term (38 weeks). the most probable cause of her transverse lie is the previous 3 pregnancies she had with relatively large babies causing her uterus and abdominal wall muscles to be stretched more than usual thus allowing more room for the baby to move around easily. we can attempt to gently externally rotate the baby with a double setup – meaning.2kg if I remember right). • Third. I explained that she has a transverse lie and there are several reasons for this. I asked her if she had injections (anti-D) . Then I asked about her previous pregnancies. Lives 80km from the hospital. There is the potential for the baby to return to its original transverse lie position again. ready for any potential complications i. FHT. Abdomen showed compatible FH with age of gestation. AMC Feedback: Transverse Lie 4. although CTG ‘s interpretation may not by accurate since baby is still premature o A fibronectin test may be done but I did not emphasize much on this. blood group. There was none. normal FHT. o Bed rest when in hospital. I finished this station early. You are working in a country hospital which is 300 km from the nearest neonatal intensive care unit. She asked me if I had any obstetrics training. I said none. She said no.whether there were any abnormalities and whether the placenta was low or not. ideally in a neonatal intensive care unit. I continued to ask about regularity (every 5 minutes) and duration (around 2 minutes) and figured out it was the start of labour pains. She has abdominal pain for 3 hours. o While awaiting transfer. I talked on the following issues: • That she is in active labour and since the baby is just 26 weeks old she needs to be admitted in a hospital which is capable of handling a baby of this age. she needs to have a drip in with a first dose of steroids to be given for the baby’s lung maturity. PE • Manage the case While reading the stem outside the room.• Schedule for a caesarean section because it would not be feasible for a vaginal delivery on a transverse lie. VS were normal. Your next patient is a 26/40prim. o She needs to have an ultrasound to rule out abruptio and chorioamnionitis (both contraindications for tocolytics) and CTG. longitudinal lie. correct date. She said as far as she knows they were normal. I started by asking the character and severity of the pain. Speculum showed the cervix to be 3cm dilated. o We hope we can delay (until at least the second dose of steroids) or stop progression of labour by giving her tocolytics. Task: • History. The examiner was very happy and said that was an excellent discussion. On PE. • I will arrange that she be transferred immediately and if possible by air ambulance while stabilising her. 18 week ultrasound . AMC Feedback: Premature labour . I said calcium channel blockers. Examiner asked me what tocolytic do I intend to give. I just mentioned it in passing. I asked about issues during pregnancy. it was spontaneous. I was already thinking of at least 2 differentials: abruptio placenta or premature labour. She described it at intermittent contractions. intact bag of water. Then I asked her if she had leaking bag of water or vaginal bleeding. I asked about trauma and possible reasons for the premature labour. Task: • Take a history • Examine the patient • Advise on plan of management I started by asking her details of her vaginal discharge – smell (foul). N. Pneumonia. As I recalled this station post exam. Also. has always been normal. General health including diabetes. relation to menstruation (no). dysuria (none). Pericarditis. I told him I will have to rule out Trichomonas. LMP 3 weeks ago. Gardnerella and will also test for Candida. She said she is with a steady partner for the past couple of years or so (no sure of the duration) and has had 2 previous relationships. Not on any medications and no allergy to medications. she should continue on practicing safe sex. A young female with recurrent greenish vaginal discharge. I also asked the patient’s permission to test her for STI – including high vaginal swabs for Chlamydia and Gonorrhoea and to complete my STI screen. I asked if it was alright to be asking some sensitive and personal Qs. Cervical ectropion. pain (none). monthly. I had the following differentials in my mind: Pneumothorax. I asked if she is sexually active. – general appearance normal. She said no. Then I said I’d like to focus my examination on the gynaecological aspect. Never been pregnant. I passed this station though. If positive for Gardnerella or Trichomonas she would need to be treated with metronidazole. I curiously asked the patient if there was any swab/culture taken before when she was treated by my colleague. Asthma . A 35 year old female with sudden onset of difficulty of breathing. Paps smear 2 years ago N. Examiner asked me what I was thinking. that is the best thing I’ve heard today! Any masses and tenderness in the abdomen – none.E. I feared that I might have done a critical error by totally ignoring the cervical ectropion which was seen on speculum examination. some blood tests. No previous STI. Periods regular. AMC Feedback: Green vaginal discharge 6. Your colleague treated her with antifungals and doxycycline but discharge is recurrent. fever (none). Will need to follow her up for progress. Before I went to management. I explained that I know that she and her partner are exclusive to each other and they use condoms but I need to check this (STI) still. Contraception – condoms. Then I said that I will have to do swabs.5.N. P. Tasks: • Take a history • Examination • Management plan When I was reading the stem outside the room. Then depending on the results I will have to treat her. Speculum examination – greenish yellow vaginal discharge which is foul smelling. I will need to also do a Paps smear on her too since the last one was 2 years ago. Pulmonary embolism. Even then I still asked for no cervical excitation? Or adnexal tenderness? The examiner answered with a firm “Nomal”. The examiner brightened up and said. PV examination was normal. VS especially temperature . (Long stem) . I asked her what she did in the plane – she said she slept most of the flight time. thrombophilic markers both for hereditary – protein C. I said. no liver disease before.don’t you think that this is too invasive as an initial investigation? Oh yes. I said that she needs to have immediate hospital admission as I am highly considering pulmonary embolism. She said she just arrived from New York 5 days ago (or less than a week ago). he asked – I said PT/INR. Then heparin will be ceased once warfarin kicks in. Dear Doctor Would you please see this patient? His liver function has been abnormal for 2 years. No leg swelling. The examiner asked what else? I said an ECG too. further down my list were: AMI and Dissecting aneurysm. Physical examination: I think the only abnormality is the slight increase in respiratory rate. S. I asked her if this was the first time this happened – Yes. family history) – none. I got excited so I immediately said she needs CTPA (CT pulmonary angiography). He feels tiredness. He got small calculi in his gall bladder. If she was coughing – yes. Is this progressive – No. Cardiopulmonary exam – N. sputum and colour –yes. He had haematemesis due to oesophageal varices. viral serology normal doesn’t drink alcohol. AMC Feedback: Shortness of breath 7. I started by asking the patient. brown (Aha! I have narrowed my differentials to either pulmonary embolism or pneumonia). The examiner was sitting very close to me and seemed very pleased. She will also need to have a V/Q scan. Though this is the gold standard of diagnosis. Finished early. A 60yrs old male patient. Then I asked medications (OCP and other DVT risk factors –recent surgery. He asked what will happen in hospital. tell me about it? She said. How long will she be treated? I said 6 months. I will have to request the following: FBE. No heart racing. No chest pain. No fever. yesterday in the office (clerical job) she suddenly felt this shortness of breath. I then asked recent long travelling. referred by his previous GP to see you – new to the area. pancreas was normal. he remarked.(because of the relatively young age of the patient). you can have Q3T3S1 but you may also have a normal ECG if PE is not severe. Examiner commented . How will she be treated? I said she will need to be started on heparin. coagulation profile (what do you mean. I was also planning to pin down the diagnosis in the first 5 Qs I will throw to the role player. What can you expect in the ECG? In severe PE. smoking. Factor V Leiden. That was what I was waiting for. aPTT). He had a pacemaker inserted a few years ago. no calf tenderness (I couldn’t recall if there was). either with the standard heparin or LMWH plus an overlap with warfarin because it takes time for warfarin to take effect (around 4-5 days for INR to be at least 2-3). homocysteine and acquired – lupus anticoagulant and antiphospholipids. General health – good. liver. And of course continued specialist referral for the heart and long-term follow up should be advantageous for his health. As soon as I said this the examiner handed me the result.Task: • Ask the examiner about Ix result • Explain the patient to the result. There are other parts in the stem regarding history but I could not recall them. I will also have to test him for other organ dysfunction such as diabetes from pancreatic involvement. it is recommended to have their future partners tested because of the possibility of having affected children. What will happen to his kids. Homozygous for C282Y (+). What about his siblings. renal function etc. Transferin saturation increased. It is an inherited disorder. they have to be tested for iron studies and the HFE gene. the frequency drops down to every 3-4 months. pancreas. he asked. I don’t think you have to take any more history from the patient apart from clarifying Qs. It is a condition with a disturbance in iron metabolism such that excess iron accumulates and deposits in organs such as the liver. I said that since you came from one set of parents. If your wife does not carry the gene. AMC Feedback: Abnormal Liver Function Tests 8. he asked. I said. some hormones from pituitary deposits. then the worst case scenario is that your children will have inherited one HFE gene and that should not be a problem to them. which means he has received one recessive gene each from his parents. gallbladder and maybe some other organs too which we will need to investigate. I’d like to do some tests to rule out a condition which we call haemochromatosis. . However. The examiner handed me a second laminated paper. we have to test your wife first. heart. Then I went on to say that your iron stores are very high which supports what I was initially thinking thus I would need to do some genetic testing for the gene. I said that depends on the degree of organ involvement. H63D (-) I asked him if he knows anything about haemochromatosis. He will need to have regular follow up. I briefly explained that you have to have a pair of the recessive gene to have haemochromatosis and that one gene inheritance is considered a “carrier” of the abnormal gene and should not cause any clinical significance to that person. Ferritin increased (1500). The treatment is aimed to bring down the iron load by doing phlebotomies around 500 ml every week for 1-2 years (read JMurtagh) then if levels are acceptable. Will I live to be 70? Well. pituitary and in fact can deposit in any organ causing its dysfunction. Perhaps a referral to a liver specialist will be necessary in the future for the possibility of a liver biopsy. Her father had colon carcinoma at 58 years old. That it is a good thing that we detected it now and that we can do something about it. I started by saying that he has multiple organ involvement namely the heart. A 48 year old lady came in for her biopsy results which showed adenocarcinoma of the colon. I will have to do some iron studies. stage I. the 5 year survival rate is >90-95%. Does she need colostomy like her father? I said. her friends and what her hobbies were. Then I said that they will need to have surveillance colostomies done when they reach their 40s or alternatively a bit sooner since some authorities recommend it to be done 10 years earlier from when a first degree relative was diagnosed to have the carcinoma (in her case around 38 years old for her children) . i. III. First of all I asked her if she came for the results of her biopsy and she said yes. I explained to her that the earlier we treat the better. II. On a piece of paper.bowel wall. she may need it but it may just be temporary especially if it is in its early stage. she can’t sleep.liver mets and other organs) and their respective prognosis (Dukes Staging in AMC book p94). I finished early.e. She said that she has a double job and shifts from one work to the other in a day. That she had to leave home and she is now renting out a unit with some friends with whom she shares the bills. What about her siblings.maybe it was the “nerves”). The examiner was very quiet. For the meantime their diet should be rich in fibre. How are things at home? She mentioned that the family is dysfunctional. .Task • • • s Explain the results of the biopsy to the patient Advise on management Answer the patients Qs. I told her that I have some disturbing news. A young female came to your GP to ask for antidepressants again. She asked if surgery is the only treatment. H – Home environment. I asked her if she would want someone to be with her before I explain the condition and if she would want me to go further. A middle aged woman was in the room waiting. She said she feels down. The biopsy results showed that she has carcinoma of the colon (at this point I tried to look at the stem to see which part of the colon but I don’t understand why I couldn’t see the part that is involved. That. IV. I drew the different stages 1-4 and the degree of involvement (I-mucosa. What will happen to her kids? I asked how old were they (I think they were in their teens). Economics (work and finances)..bowel wall and LNs. She said she does not socialise much as work keeps her busy. I asked about her social life. I said yes and the use of adjuvant chemotherapy +/. AMC Feedback: Carcinoma of the rectum 9. I screened for “HEADS”. She was previously treated with antidepressants before.XRT in selected cases improves overall survival. Tasks: • History • Management I started by asking why she thinks she needs antidepressants. A – Activities. E – Education. I said that your siblings need to be investigated with faecal occult blood in the stools and colonoscopies. Several issues happening (could not remember exactly what). if treated early.unless they have symptoms. most days a week. D – Depression. I asked about coping mechanisms. Last time you did MMSE and it was 25/30 (page with report was provided on the wall. S – Sexual activities. • I will follow things up with her to see how she is going. if there was anything that keeps her awake. I asked about delusions. Drugs.drugs. cigarette – none. • That the cornerstone of management is in her lifestyle change. Suicide risks. AMC Feedback: Coma 11. • Cognitive behaviour therapy and meditation techniques can certainly help. hallucinations. His children also report that his behaviour has changed recently. Tasks: • Take further history • Do at least one test to assess his cognitive function. I asked about eating. Her general health has been good. 2 weeks only to prevent dependency) just to break the cycle of anxiety and lack of sleep. low score in attention. • That she needs to socialise and find ways to relax and go out with friends and family. etc. Then I explained to her that giving an antidepressant is not the only solution to her problems. I could no longer remember the reason why an antidepressant was previously prescribed on her – but I know she did not have any major depressive symptoms previously including suicidal thoughts. AMC Feedback: Anxiety and Depression 10. no need to repeat MMSE (assume it was accurate) .Middle age man has come to your clinic. That she needs to cut down on her working hours because she is overworked and tired and unable to get enough sleep. I asked her if she is sexually active – No. alcohol. Assessment of a Comatose patient (AMC Handbook of Clinical Assessment) There were 3 people in the room. • If her finance is an issue. I asked about risk factor of harming herself and others – none. – None. I will be happy to arrange for that. as he changed the lanes while driving without obvious reason and almost caused MVA. • I briefly mentioned sleep hygiene (read JMUrtagh). the examiner and an observer. I asked her about sleep – what was bothering her. She said it is unaffected. Then just to complete the psychiatric assessment.. A patient lying comatose on the bed.e. recall sections). Should she wish to have a family counselling session with me. we may have to tap on community resources to help her out temporarily while she overcomes this situation. his wife is worried about his strange behaviour recently. She said she just cannot sleep and wakes up unrefreshed. there is no harm in trying a short-term sleeping tablet (i. • Antidepressants have certainly a role but only when all means mentioned before have been exhausted. • If she still has a problem coping. medications were all non contributory. tumours etc. work. home and work situations. I started by asking the patient the reason why his wife and children are concerned with him.. Thus I asked the patient and he could do this. activities/exercise. mood. Then the examiner interrupted and asked me for the diagnosis.. hard drinks. don’t worry about that. First I commended the patient for coming to see me to talk about his alcohol consumption. I asked about home situation. The role player was unable to do the interpretation of the saying “a stitch in time saves nine” and also found it difficult to do the motor sequencing test of the “fist-edgepalm”. how much. he does not know why and that he thinks they. how often – I gathered that it was way too much in excess of the recommended.Yes. I said he probably has frontal lobe dementia. wine and beer.A man who sees you about his alcohol consumption. Tasks: • History • Talk to the patient regarding issues with his alcohol consumption • Investigations and plan of management There were again 3 people including an observer. AMC Feedback: Frontal Dementia 12. I asked him general Qs on dementia like does he think he is forgetful and has he ever found difficulty in his way home. An elderly man around 60 was in the room. He said. I also asked about past medical history and general health. Read page 443 of the AMC handbook under the title “MMSE may be supplemented by specifically testing frontal lobe functioning via.nothing significant. He denies any change in his behaviour. I asked the examiner if there was time to do words beginning with F’s in one minute. Also he drinks different kinds of liquor. does he drink because he is in a lot of stress? –mood and suicide risks . The examiner answered that I have plenty of time. but he said.None • Did he get in trouble with the law because of his drink driving – yes. alcohol. you finished your task and can wait outside. Does he know where he is at the moment?Orientation Qs. Smoking.• Discuss your diagnosis with the examiner. • C-A-G-E Qs • “HEADS” check (as in the case above) i.. He asked me the basis for this. worry too much and that there is nothing wrong with him. especially his wife. and activities .any relationship issues? .” I did exactly what was on this outline. driving offence . I said that he has borderline MMSE 25/30 and that he is unable to do the tests I’ve done on him which can only mean that he has some form of frontal lobe deficits. I asked the following: • Alcohol consumption – what kind.. Then I moved forward to do my second task. He tried hard but kept repeating words he already used. I was about to explain the possible causes of frontal lobe problems such as vascular deficits/infarcts.e. mood. Melanoma is the third commonest skin malignancy in Australia and is related to prolonged sun exposure. LFT’s. Q from the patient: What advise do I need now as an immediate plan? I was thinking of what he meant and I was about to address the issue of drink driving but the bell rang. cholesterol and ECG • I can arrange counselling for him or if he wants I can arrange for further consultation with him and his wife for counselling and support should he decide to withdraw. The usual cut-off depth is 0. smoking and recreational drugs Motivation to stop – he said he is not sure yet but just came to ask. • I can arrange for him to have some blood tests like – FBE with red cell indices. No lymph node enlargement. Since there are different liquors he takes. However. I advised on the following • That his alcohol consumption is beyond the harmful effect of 4 standard drinks/day with 1-2 days free/week. The patient. the tumour excision did not indicate clear borders.diminished General health – weight. A picture was outside the wall. BSL. I will give him a reading material on the equivalent of one standard drink of the different liquors he takes. social and psychological aspects of his life.4mm. B12 and folate levels.A biopsy report of a melanoma with depth of involvement of 0. HPN.• • • Libido . diabetes. I told the patient the disturbing news of the biopsy result. I have to check this margin as I remember them to be so in squamous and basal cell carcinoma but wasn’t sure if this applied to melanoma (further readings post exam – 1cm clear margins). I said that the good news is that there is no LN involvement and that the depth is 0. Tasks: • You are to explain the biopsy result to the patient. it is still up to him to decide on what to do with his alcohol consumption and that we are here to help him out. cholesterol.75mm which could affect prognosis. No history and examination required. • That alcohol can have harmful effects on his physical. One standard drink is equivalent to 10g alcohol. • In the end. ideally I said 3-4mm of clear margins. . a school teacher had this mole for many years and noted it recently to be itchy thus a biopsy was done. • Advise on management.4 mm thickness with tumour extending to the lateral margins (couldn’t recall which site of the body). • It would be nice to mention alcoholics anonymous which I forgot to do. AMC Feedback: Excess alcohol consumption 13. I advised on the following: • Re-excising the tumour with clear margins of normal tissue – referral to a surgeon (or dermatologist) to do this. long sleeved top and use sun protection lotion.methotrexate. RF to monitor her disease progression as well. It is an inflammatory condition eroding cartilage. Wear wide brim hat. There was a very nice middle-aged role player who smiled and nodded her head when I said the answers she wanted to hear. But she was still hesitant. The role player said she does not like the use of steroids because of the ill effects on her mother. sulfasaline etc. ESR and RF. diabetes. Her mother has rheumatoid arthritis. I will definitely follow you up closely with your steroid use. the complications of steroid use are well recognized such as. I still would want to have some scans (CT) to make sure that no other LNs are involved in other sites. You suspected that it's rheumatoid arthritis. AMC Feedback: Melanoma 14. swelling and stiffness in both hands recently.4mm and no LN involvement is seen. the prognosis is excellent if the depth is just 0. He would need to be followed up on a regular basis for progress report and also to regularly check the skin for suspicious lesions. in RA.A 50 years old lady. Avoid prolonged sun exposure. with pain. It has an autoimmune component as well as genetic predisposition. However. You prescribed ibuprofen and run some blood tests for ANA. Referral to an oncologist for possible chemotherapy if LN involvement is seen. I said yes. we can use DMARDs in the early phases of treatment. Inflixamab. He should also regularly inspect his skin himself and report early for any skin change. However. • I explained that she has RA and that this is a chronic condition with flares and quiescent phases. Then we can also try Aspirin plus Panadeine (Panadol Codeine) combination. LFTs and CRP ESR. This was my very first station. The results showed that she has early rheumatoid arthritis. mood changes and long term effects of osteoporosis.• • • • Although LN involvement was not seen. starting from simple analgesics to stronger ones. I enumerated the DMARDS . • Counsel the patient and answer her questions . a violinist in an orchestra. There is also the possibility of using steroids. Therefore I said if you feel too strongly against it then we can use NSAIDS such as Ibuprofen. With modern day medicine and new drugs which we call DMARDs we can markedly delay and hopefully prevent further progression of the disease. • • Examiner asked about the side effects of DMARDS. . cyclosporine. to counteract the effect of cytokine (thought to be a mediator in RA) can also be used. myopathy (proximal muscle weakness). azathioprine. Task: • Explain the diagnosis to the patient. Early referral to physiotherapist and rheumatologist is the key to prevent further disease progression. gastric irritation. which is the “cushion” at the end of the bones in the joints. Although we usually recommend a step-up approach in pain management. She said “but I’ve been using this already with not much relief”. the use of steroids is limited only to flares and are of short courses usually. etc. I said bone marrow suppression and liver dysfunction that is why she needs to have regular check of her FBE. I was also comparing it to the right side which seemed to be unaffected. etc. I said conservatively. weakness – yes. A sibling had a recent bout of gastroenteritis. forearm and hands. Bell rang. Examiner was hurrying me up to proceed to examine the patient. Tasks: • History no more than 2 minutes • Do your examination and investigation • Dx There was a middle aged woman with a hospital gown seated already for my examination. extension. biceps. Then I moved to the back of the patient and talked about looking for any deformities swelling. we can talk about HRT on another consult to weigh the risks and advantages of using this and we can also talk about the use of bisphosphonates and dietary advice on calcium or supplements.A previously well 5 months old brought to you by the father because of sudden onset of intermittent screaming with few episodes of vomiting. She would need to have baseline bone scans (bone densitometry was what I was actually thinking but I said bone scans). abduction. Examine the patient as is. I said osteoporosis. AMC Feedback: Rheumatoid arthritis 15. swelling. Middle aged woman complaints of pain on the right arm. Any neck pains. flexion. The examiner kept on hurrying me up to examine the hands. There was obvious weakness of all movements of the right side. AMC Feedback: Prolapsed cervical disc with radiculopathy.none. There was limitation in all the movements. The examiner said I finished my task and that I can step outside. Numbness. forearm and hands. triceps. There was tenderness around the C6C7 area.no. Then I asked for the patient to do neck movements extension.non contributory. there was none. she said yes. 16. I will refer for physiotherapy. I said since I was considering cervical spondylosis I would request for an MRI. Any pins and needles? Not exactly. I asked her to tell me about the pain and she indicated pain in the arm. General health. The examiner said you don’t have to expose anything. Any trauma. Then I went to palpate the spinous process from the base of the occiput down the cervical spine. Then I checked for paravertebral tenderness. He handed me an MRI picture of the cervical spine which showed a prolapsed disc. Then I proceeded to do shoulder examination testing for powers (against resistance) of abduction and adduction. rotation to the right and left. I did not get to examine the sensory and reflexes as the examiner cut me short and asked what investigations I would request. and adduction. Any history of rheumatoid arthritis. However. muscle atrophy. Tasks: .Examiner asked what potential risks would the use of steroids do to this patient given her age – 50. I was quickly asked how I would manage the patient. I started by saying ideally I will have to expose the shoulders to check for asymmetry. wrist flexion. lateral flexion. extension. I had limited testing for finger flexion. urine tests etc. Past medical history was uneventful. vomiting. So I asked Qs pertaining to this such as: how is the infant in between episodes. Examiner asked me my differentials: I said volvulus. blood tests for FBE and electrolytes. PE: nothing contributory. There were 4 modified cases from the recalls. I would have gotten an obvious diagnosis of incarcerated/strangulated hernia if only I had checked the groin area. You will never know what cases will come out in the exams. Relax the day before and do not read anymore while waiting for your turn whilst in quarantine (especially for the group in the afternoon). There were 2 new cases to me which I have not encountered in my recalls at all. small gut obstruction. possibly either gas or contrast enemawhich can be both diagnostic and therapeutic . In hindsight. Just when you think you have a good grasp of the commonly repeated cases. I should have also asked for the groin examination. This particular exam had a lot of unfamiliar cases and only 2 cases came out from the book published. colour and character of stools. Think of a few differentials and keep on talking while ruling out the others and ruling in the most probable diagnosis. AMC Feedback: Incarcerated Hernia (the only station I failed) Comments: This candidate has reviewed almost 350 cases (including the 150 cases from the AMC publication). UTI. I discussed about going to theatre if the enema measures fail to reduce the intussuception.none. abdominal xrays. If you know them you would at least be able to talk about it and not be caught by total unawareness. PE Advise diagnosis and plan of management My first thought was intussuception because of the typical clinical picture. I couldn’t help but develop doubts in my diagnosis and my approach because they were modified in such a way that I have to think further and not fully rely on the diagnosis given in the recalls. A few of the cases were not exactly how we expected it to come out as in the previous recalls. I advised on nil by mouth and what they will do in the hospital such as IV fluid. Some exams will have very familiar repeated cases thus probably contributing to the relatively higher passing rates. early surgical referral. meningitis. it was still surprising to see unfamiliar cases. . It just adds more pressure to an already stressed out brain. any obvious straining when he wees . I advised on the possibility of intussuception (explained what it is) and that the baby needs to be admitted to hospital because of the suspected diagnosis. The exam in really “nerve-wrecking”. Rectal exam was normal. He was noted to be pale in between episodes. Try to know the cases by heart in all their aspects because they can appear in different “shapes and sizes”. It is possible that this was completely unexpected by some candidates and could have affected the low passing rate (35%). I also asked for fever.• • • History. All the best in your endeavours. Wenzel’s (Couldn’t thank you enough Dr Wenzel) class has a very good simulation of what happens in the exams. It is freely given by a kind hearted person who wants to help us IMGs (a rare precious opportunity). Get the most out of this class. Be observant to the role plays during the class because you will learn something from them even if the candidate performed badly or excellently. We happen to be just ahead of you in passing the clinical exams but soon enough you will also be in the same situation and we will be criss-crossing our paths again in the future. It is also a good way to establish networkings with people who are in the same situation as you are.Dr. You will pickup very precious “survival tips” which you can apply in your preparation for the exams and during the exam day itself. Listen carefully to the testimonies of those who passed. Cheers All. Hope this recall helps! .