7/28/2019 20081122 Melb Retest

1/6

22th November 2008 Melb retest

1. Diabetes foot examination

2. Abdominal examination

3. Painless haematuria

4. Chronic diarrhoea in 9mth old child5. PV bleeding after 8 weeks amenorrhoea

6. Adrenal tumour

7. Pethidine request

8. SOB pneumonia

1.

This middle age woman has long standing DM. The BSL control is poor through out

the life.

Task:

1. Examine her LL in view of finding complications of longstandinguncontrolled DM

2. Explain your findings and reasons while examining the LL to the examiner

Examination:

I started by saying longstanding DM would have Macro and microvascular

complication and this is what I am going to look for and elicit during the examination.

Stood up the patient for inspection

Quadricep wasting

Pigmentation

Charcots joins (loss of proprioception)

VV

Healed ulcer scars or ulcers

While standing Rombergs test for proprioception

Palpation:

Temperature

CRFT < 2

Nail and nail fold hygiene

Ulcers between toes and on the sole of the foot

All the pulses of the lower limbs

Sensation:

Looking for stocking type sensory loss using the mono filament. She had stockingtype sensory loss.

The filament was on the back of the knee hammer so I check the reflexes at the same

time which was normal.

Vibration both 128 and 256 tuning forks were there. Use the 128 one no sensation

until tibia.

Bell rang!!!!!!! Want get time to do everything therefore my advice select what you

want to do or what you think is most important in this station and do it first and then

go for the rest.

AMC feedbackDiabetes complications

7/28/2019 20081122 Melb Retest

2/6

2

AMC case 70 Q352 A377

Abdominal examination

3A 60 y.o man, who is c/o hematuria for 3 weeks, came to GP clinic. He

has past Hx of renal colic.

Task: take relevant Hx for 4 min, ask exam findings, arrange Ix, Dx,

DDx, Mx

Hx: Mr. X, I understand you have trouble with your waterworks. Could

you tell more about it?

Do you pass water more frequently? How often do you pass water? Do

you pass water at night? Do you have any sense of incomplete emptying?

Do you still have strong stream?Is there any dripping at the end of urination? Do you pass small amount

of urine more frequently?

Do you have any burning pain when you pass water? Can you hold your

urine or you have to rush?

Have you noticed that any blood in urine? Is it at the start, middle or end

of the urination? Did you have any injury in your private parts or groin or

hip? Do you have any bleeding from the other parts of your body?

Did you ever experience pain in your loin or tummy before?

Did you travel overseas recently? Did you eat large amount of beetrootrecently? Have you ever diagnosed with STD before?

Is there any Hx of bleeding disorders? Is there any family Hx of bleeding

disorders? Is there any Hx of strong sports or jogging?

Have you ever had kidney problems or stones before? Have you ever

diagnosed with UTI before?

Are you on any medication like blood thinning pills? Do you have any

pain in your other parts of your body? How is your appetite? Have you

lost weight recently? Do you have any family Hx of cancer? Have you

ever diagnosed with cancer before?

Smoking? Alcohol? Recreational drugs?

Exam: GA, vital signs, BMI, rash, pallorness, all LNs in the body, chest,

heart, abdomen, any loin pain, tenderness, mass? PR.

There is palpable bladder, on percussion- 3 cm dullness.

Urine dipstick.

Ix: FBE, coagulation profile, PSA (before PR), U&E, Urine M/C/S, U/S,

referral to urologist for cystography.

They may decide to do prostate biopsy.

7/28/2019 20081122 Melb Retest

3/6

Dx: Bladder Ca

DDx: Urinary calculi, stone, infection, trauma, BPH, kidney disease,

bleeding disorder, discoloration due to foods (beetroot).

412 months old baby brought in to your GP practice by his mom. He has been suffering

for ongoing diarrhoea for the last 6 weeks; he was investigated by other doctor who is

now overseas. Stoll microscopy showed no parasites or bacterial growth. Initially was

10kg now is 9.2kg. Still complaining of offensive diarrhoea and excoraited buttocks.

Otherwise he is well.

Take focused history from the mother.

Explain the Dx, and manage appropriately.

Coeliac disease

5A married woman mid 20's comes to you (GP) with 8 weeks of amenorrhoea and

sudden onset of bleeding. Has H/O miscarriage 1 year ago.Task : Take history and discuss with patient..(allowed to ask examiner for

investigations) diagnosis and management

spontaneous abortion

6

A middle aged woman, who is c/o abdominal pain with headache, came

to GP clinic. You arranged U/S; a photo was given on the door andshowed 5 cm mass on adrenal gland. Today she came for the result.

Task: explain the result, Hx, ask exam findings, Dx, Mx

2006 nov melb

Dx: Phaechromocytoma

Read CT Scan by yourself

Hx: Mrs. X, before I explain the result, Id like to ask some Qs.

Could you describe me your tummy pain? Is it constant or does it come

end go?Where is the pain exactly? How severe is the pain, 0-10?

Are there any relieving or precipitating factors? Have you had this for the

first time? How long does the pain last?

Are there any accompanying symptoms such as nausea, vomiting,

sweating, tremors or headache? Do you have any chest pain or

palpitations? What about your bowel motions?

What about your waterworks? Have you lost any weight or gained

weight?

Have you ever diagnosed with cancer before?

7/28/2019 20081122 Melb Retest

4/6

Do you have any striates on your tummy? Do you have any abnormal hair

or sopts in your skin? Have you ever diagnosed with HBP before? Do

you have any muscle weakness? Is your urination in big amount? (Cons

disease, poliuria)

Are there any changes in your periods? Is there any family Hx of canceror tumor especially in the kidney like phaechromocytoma?

Do you have any problem with your thyroid gland?

Exam:

GA, vital signs. BP sitting/standing, regularity of pulse, BMI,

distribution of fat, buffalo hump, striate, hirsutism,

all LNs in the body, thyroid, chest, heart, abdomen, any mass?,

lower limb edema.

Urine dipstick for sugar.

Ix;

24 hour urine collection for creatinine,

total adrenaline, noradrenaline, VMA and metanephrine,

plasma metanephrine,

serum parathyroid hormone to rule out hyperparathyroidism as a

part of MEN, serum calcitonin level, chromosomal screening for

mutations,

consultation of ophthalmologist for retinal angioma, MRI to exclude cerebellar hemangioblastoma (Von Hippel

Lindau).

Plasma ACTH and dexametasone suppression test (Cushing).

Serum rennin and ALD (Cons disease).

If CT and MRI dont show paeochromocytoma,

MIBG (metaiodobenzoilguanidine) test for confirmation.

Metanephrine is not affected by stress, motion or anxiety.

Plasma catecolamines or metanephrine must be measured both standing

and sitting.

In normal patient, there wont be a change.

If there is phaechromocytoma, CAs will increase but metanephrine

will not change.

Surgery is the treatment of choice.

Preoperative cautions are mandatory to prevent hypertensive crisis during

operation.

7/28/2019 20081122 Melb Retest

5/6

Start alpha blocker (phenoxibenzamynie) 7-10 days before

operation.

After alpha blockage, start beta adrenergic selective blockage.

Volume expansion with N/S.

Give last alpha blocker in the morning before operation.

AMC feed back: Adrenal tumour

7

A lady comes to A & D Department asking pethidine for pain relief of hisabdomen pain. You are surgical registrar and you found no any surgicalconditions. O/E, nothing was wrong.

Task: Talk to the pt and give the immediate Mx

On Hx, pt said she is on pethidine for 5 yrs on/off. Only pethidine help herrelieve the pain.

You try panadal, but pt said it didnt help himDuring this station: pt kept asking: What can you do now? What can you giveto me?

8

Stem: ED setting. Young male, SOB for 2 days.Task: Hx, ask for Ix result, and Mx

Patient was lying on bed, pretending to be SOB. I offered him oxygen first, and asked

examinor whether vitals are ok.

Hx: - SOB for 2 days, gradually onset

- R lower chest pain when taking deep breathing

- Cough & yellowish sputum for last couple of days

- No history of injury

- No palpitation

-No calf pain

- No smoking

- Previous healthy

O/E: - Vitals normal

- Trachea in middle

- R lung base crackles, bronchial breathing sound, also dullness on

percussion

I asked for CXR, and examinor gave me CXR straightway after I mentioned it. It

shows R lower lobe consolidation. Not sure about middle lobe.

Mx: Abs. Role player asked which Abs. I said if you dont have allergy, penicillin. He

said he is allergic to penicillin, then which Abs. I said erythromycin, but now I think

its wrong should be cefataxime.Qs from role player: Do I need to stay in hospital?

7/28/2019 20081122 Melb Retest

6/6

How long do I need to take Abs?