Recall Brisbane February 2008

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AMC CLINICAL EXAM RECALL BRISBANE FEBRUARY 2008

AMC CLINICAL EXAM RECALL

BRISBANE FEBRUARY 2008

1. A 17 year-old girl with a known peanut allergy has had moderate episode yesterday.

TASK; advise her of the management.This is a common station. Advise for the potential dangers of the peanut allergy, possibly

associated allergies to other nuts, Epipen carrying instructions with explanation of

contents and their use. Bracelet, referral to allergologist, advice for meticulous checking

of any food for descriptive labels of traces of nuts, leaflet. The chance for the allergy to

burn out over the years is small.

No questions from the role-player or the examiner.

Peanut Induced Anaphylaxis

2. A young man with nausea, vomiting, and abdominal pain which started out as central

but which moved to the right iliac fossa. There is guarding in the right iliac fossa onpalpation.

TASK; explain the possible likely diagnosis, give differential diagnoses. Management.

The patient was told that the likely diagnosis is appendicitis. I explained additional

examination/tests I would do to prove this, namely Rovsing, Psoas, obturator symptom.

The differential diagnoses I mentioned were renal colic, mesenteric adenitis, Crohns

disease. After that the conversation was about the forthcoming operation, why it was

needed, possible complications, and the regime for care after the operation. This refers to

case no. 140 in the Australian Medical Council Handbook of Clinical Assessment.

Initial Management Of Acute Appendicitis

3. Case no 113 in the Australian Medical Council Handbook of Clinical Assessment.

Sepsis (Paediatrics)

4. Case no. 79 in the Australian Medical Council Handbook of Clinical Assessment.

Here I nearly missed assessing the blood group for rhesus negative. The examiner

prompted me, asking whether I had anything else to add, and I remembered and was

saved.Threatened abortion (O&G)

5. A young woman unsuccessfully trying to conceive has been seen by your colleague

yesterday and now is in your consulting room with the investigation results, which are

borderline anaemia, thyroid function normal, follicle-stimulating hormone low, and

normal electrolytes. Her body mass index is 14.4; BP normal, without postural drop.

TASK; history, explanation of results, and management.

History- no problems at home, work or socially. She has been this skinny since her teensand claims to feel very comfortable. Not tired, has enough energy. Has had no periods

for several years. I missed asking about illicit drug use and hyperthyroidism symptoms.

I explained to her the connection between low BMI and failure to conceive, and the

hypothalamus, pituitary and ovary interrelationships. I explained osteoporosis following

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anovulation, and referred her for a bone density test. She was keen to start to eat so as to

conceive, and so was sent to a dietician, and to the community mental health service.

The examiner said nothing, but looked extremely grim.

Anorexia Nervosa, Diagnosis

6. A woman with a previous caesarian section, who is now at 28 wks gestation, has been

having vaginal bleeding, and has come to the emergency dept. She is rhesus positive.

TASK; focused history, examination findings from the examiner, management.

In the history I find that she has had an uncomplicated pregnancy till this moment. She

does not abuse drugs and has undergone no recent trauma except possibly that she has

had sex the previous night. Her morphology scan at 18 weeks showed the placenta to be

in a low position. Presently, she is feeling well. She does not feel dizzy when she stands

up..

On examination, she is haemodynamically stable, with BP 120/80 and HR 70 or so. Theabdomen is not tender. She is not in pain. The foetal HR was 140BPM.

I explained that this is probably a case of placenta praevia, and that I would urgently call

the obstetrics registrar for an ultrasound examination and CTG to discover the reason for

the bleeding, and to make sure of the babys well-being. I admitted her because the

bleeding may resume. I will NOT examine her vaginally (this would have been a critical

error; because it may cause bleeding).

The role-player asked me about the mode of delivery. I answered, If the case is placenta

praevia, delivery will only be via caesarian section.

The young Indian examiner was hostile from the beginning, making angry exclamations

when I mentioned wanting to check the vital signs in the first instance, and after that,

continued to look angrily at me for whole duration of the station. Perhaps somebody had

angered him before I arrived. In any case I will be surprised if I fail such an easy station.

Well, it happened that I did in fact fail this station.

It was because she looked so well and her vital signs were so stable that I didnt order a

blood cross-match for a possible transfusion while waiting for the obstetrician to arrive,

and this might have been the critical error.

Vaginal Bleeding At 26 Weeks Gestation (O&G) (Failed)

7. A 2 year-old child with limping and pain in one leg.

TASK; history, examination results from examiner, differential diagnoses, diagnosis,

management.

History; the pain began last night. There is no history of trauma, of easy bruising. The

childs delivery and developmental history to this moment have been normal. The father

has not noticed the child to be hot. He had a respiratory tract infection, possibly flu,

some ten days ago.

The examination findings from the examiner were; general appearance; normal, restrictedand painful internal rotation and abduction in the hip. The child is not febrile.

I explained that this is probably a case of irritable hip, with this typical history of flu 10

days ago, and restricted hip movement. The differential diagnoses are avascular necrosis

(Pertes Disease), septic arthritis, and perhaps, though unlikely, developmental dysplasia

of the hip.

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I would order C-reactive protein, erythrocyte sedimentation rate and full blood count and

X-ray of the hip, and I would refer the patient to the orthopaediatrician. Meanwhile, the

child will need at least a weeks rest.

30 seconds before the bell, the father turned to me and asked provocatively, Are you

sure that the problem is in the hip? I felt somewhat panicked, and asked the examiner

for the examination findings in the groin, knee and ankle. With a guarded smile, the

examiner answered, Normal. Then I replied that yes, I was certain that the problem

was in the hip.

Transient Synovitis Of Hip Irritable Hip (Paediatrics)


A man wants to discuss his wifes condition.

Patient confidentiality

9. Full page of text impossible to read in 2 minutes, describing investigation done on a manwith abnormal liver function test. He has a pacemaker fitted.

TASK; history, investigations from the examiner, management.

When I entered, I asked for permission to read for a little longer, and after 30 seconds

started to take the history. The patient had never used any drugs that could damage the

liver, or any alcohol. On questioning about his ancestry, he kept replying Australian!

He reported no skin-colour change. Hepatitis serology tests were negative, as was

monospot test. On the list of investigations given, there were normal Alkaline

Phosphotase (no cholestasis), but increased Alanine Aminotransferase (hepatocellular

damage). I asked for a serum iron study, and the examiner supplied an additional listwith significantly increased ferritin and transferrin saturation. After that, it was easy.

This refers to case no. 69 in the Australian Medical Council Handbook of Clinical

Assessment.

The management; once weekly venesection 500ml for at least 2 years, then every 2 to 3

months. screen 1st degree relatives for haemochromatosis.

Abnormal Liver Function Tests


A pregnant woman of 28 weeks gestation, with a positive Glucose Challenge Test result.

The scenario given was nearly the same as the above-mentioned Handbook case, with

just the one difference that the blood-sugar levels after 2 hours were not so high, but

rather were only 8-point-something.

After I began to take the history, the examiner stopped me to tell me that he was unable

to hear me. So I made my first mistake; instead of raising my voice, I moved my chair

closer to his. This violated his personal space and ruined his preferred arrangement of the

room. And then, after a time, asking about investigations, I said urinalysis, and he said

something like what?. I mistakenly thought that he had not heard me and repeated

URINALYSIS!, loudly. He looked insulted, and answered me with quiet venom

What.For.?. of course this was a test for protein, but the damage had been done.After that, I covered the case according to the book, except for neglecting to ask for foetal

lie and presenting part, and I didnt advise the mother to test her blood-sugar levels 4

times daily, which was a critical error. (I thought this was needlessly cruel, given that the

glucose levels were not so excessive).

Abnormal glucose challenge test (O&G) (Failed)

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11. A 3 year-old child has had a problem breathing through his/her nose (mostly mouth-

breathes), night-snoring, and frequent upper-respiratory tract infections.

TASK; history, examination, investigations from examiner, diagnosis, management.

This has been happening for the last several months. There are no sleep apnoea episodes.

Otherwise the childs development has been normal, has had all the proper vaccinations

and is thriving. The childs father suffers from allergies.. The mother hasnt noticed any

hearing problem in the child. The child does not take any medications.

On examination, there were difficulties with nose-breathing, with bilateral nasal secretion

(not malodorous) and constriction. Otherwise the throat was given to be normal (via

pharyngoscopy), as were the chest (via auscultation), and the ears (otoscopy).

The examiner was surprised by my attempts to view enlarged adenoids through the nose

or via the indirect epipharyngeal route; it seems that this is not done in this country.

Following my past experience, I explained to the mother what I thought was the likeliest

diagnosis, of adenoiditis, and that I would like to refer the patient to an ENT specialist for

eventual surgery.

I perceived that neither the role-player nor the examiner were satisfied with what I had

said. The role-player started to ask me about other possible management, and especially

about anti-biotics, and in an attempt to salvage some success I answered that we could

use an intranasal saline rinse, and then eventually antibiotics. But I forgot to ask for

about pharyngeal post-nasal drip, or for a nasopharyngeal swab, or about enlarged

cervical lymph nodes.

I felt that something had gone wrong. I mentioned that an allergy could be playing a rolehere, given the family history, and offered to arrange a skin-prick test. At this point, 20

seconds before the end of the station, the answer given by the examiner was not

available.I think it was a mistake to send the child for prospective surgery without trying

less invasive treatments first. I wonder whether perhaps they wanted me to speak mostly

about perennial rhinitis, and about strategies for dust-mite reduction etc. I forgot to

advise against smoking in the house as well.

See p 243 in the Royal Childrens Hospital Paediatric Handbook

Rhinitis (Paediatrics) (Failed)


A woman with chronic schizophrenia recently started a new medication, and gained 15

kg in 3 months. The role player was extremely convincing, and appeared to be authentic.

I asked her PASS questions (Psychosis, Anhedonia, Substance Abuse, Suicide). She had

no extrapyramidal side-effect symptoms, nor anticholinesterase symptoms. She had no

decreased tolerance to cold. The name of the drug she has started 3 months ago was

unknown to me (probably deliberately), and so I asked is this Olanzapine?. Examiner;

Yes. I ordered a blood sugar test, thyroid function test, a lipid profile. I forgot to ask

for a serum prolactin test.

My management was to explain this common side-effect of the drug to the patient, and togive her the option to start diet and exercise (referral to dietician), or to consider a change

of medication, urging her though, to take into consideration the probable side-effects of

any eventual new drug. I told her that a change of medication could be carried out only

by a psychiatrist, with gradually withdrawal from the old and introduction of the new.

The examiner seemed want to hear something else about my management. at almost the

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last possible moment, he said, The psychiatrist could see her not earlier than in a weeks

time. Shes taking 20 mg of Olanzapine!. I thought for 5 seconds and said, I cantchange her treatment myself (20 mg of Olanzapine, it turns out, is a normal dose, so this

seems to have been a case of the examiner attempting to provoke me into making an

error). But still I am not sure whether or not a GP is empowered to prescribe or change

antipsychotics. Please check this.

Weight Gain Side Effect Of Antipsychotic Drug

13. Case 59 in the Australian Medical Council Handbook of Clinical Assessment.

The examiner was the lovely Dr Marshal, from the AMC examination video. You dont

have to memorise the signs and tests for brain-death; the list is inside the room. The role-

player only wants you to explain the logic of the tests.

Diagnosis Of Brain Death

14. A 50-something-year-old man with a history of 2 weeks of headache.

TASK; take history, a real focused examination, diagnosis, management.

I questioned the patient about the nature of his pain; severity, duration, constancy,

nausea, vomiting, blurred or double vision, history of similar symptoms, and about any

history of drug abuse or trauma. I asked whether there had been any recent fever.

In the examination, I checked for neck stiffness, facial and pupillary asymmetry, and

visual abnormalities. The pain was definitely in the temporal area, but pulsation of the

temporal artery was present. I mentioned ophthalmoscopy and the examiner asked what I

was checking for.

For the management of temporal arteritis, see case no. 93 in the Australian MedicalCouncil Handbook of Clinical Assessment.

Headache

15. A middle-aged woman has had a black-out yesterday.

TASK; history, examination findings from examiner, differential diagnoses, diagnosis,

management.

The patient has a history of good health, but yesterday, while playing tennis, she had

fallen suddenly unconscious. She had no visual disturbances prior to the episode and was

not disoriented after it. She does not use drugs and her BP is usually normal. She

doesnt feel any numbness in her limbs and has no headache (I thought I knew what this

case would turn out to be, but tried to hide this fact from the examiner, and so I didnt

even ask about cardiovascular symptoms at this point).

After I offered to examine her, the examiner pointedly asked me, Do you want to finish

your history?. I asked about shortness of breath during exertion, palpitations,

orthopnoea, swelling of the ankles.

The examination revealed a normal cranial nerve, no carotid bruit, and no displaced apexbeat. There was no thrill, but there was a grade 3 systolic murmur over the aortic valve

propagating to the carotid artery. I asked about the Valsalva manoeuvre to exclude

hypertrophic obstructive cardiomyopathy.

I diagnosed aortic stenosis.

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The examiner asked me about differential diagnoses for syncope, and I mentioned

Transient ischaemic attack, hypoglycaemia, epilepsy, orthostatic hypotension, vasovagal

syncope, and hypotension-causing medications. I forgot to mention arrhythmia.

In the end, the examiner told me, You forgot, taking your history, something connected

with aortic stenosis. What did I miss?? The answer came to mind after the exam;

ANGINA. But I would not have expected to fail for this kind of omission.

This refers to case no. 36 in the Australian Medical Council Handbook of Clinical

Assessment.

Syncope (Failed)

16. A middle-aged man is concerned about the possibility of his contracting prostate cancer.

TASK; assess the risk of prostate cancer for this particular patient. Inform him about the

prostatic screening strategy in Australia.

Upon my entering the room, the examiner asked me whether I had understood the test,

and although I answered in the affirmative, he stood beside me and read to me the entire

stem. Probably he was upset with the levels of comprehension of previous candidates.

The role-players father had had prostate cancer of >70 years of age onset. The role-

player had not had any radioscopy and neither had he worked with toxins. I asked him

carefully about bladder-outlet obstruction and haematuria, neither of which he had, but I

neglected to ask about back-pain. The examiner wanted to hear specifically the triad of

screening tests;

i/ Digital Rectal Examination

ii/ prostatic-Specific Antigeniii/ Abdominal Ultrasonography

The required content is on pages 77 and 1102 in the latest edition of Murtagh.

Most decisive in this case was that at the end of the station, the role-player asked me to

describe the advantages and disadvantages of prostate cancer screening.

My comments were that the benefits are as for any screening; to discover problems early.

The disadvantage is inaccuracy; there are a lot of false negatives and false positives. And

the patient is subjected to high levels of anxiety that can not necessarily be relieved by

favourable results, and may be needlessly stressed by an unfavourable one.

Carcinoma of the prostate

CONCLUSION

More than half of the stations were from the Australian Medical Council

Handbook of Clinical Assessment.

The strong tendency in past exams for examiners to behave as observers remains

stable.

These particular examiners -and I have heard this about the Brisbane examiners-

do not appear to feel obliged to provide any positive feedback after you finish.Most of them maintain stony faces, and this could seem very discouraging,

especially if they have met you at the beginning of the station smilingly.

There were two relatively young examiners, and they both failed me for to my

mind- insufficient reason (see the vaginal bleeding and syncope cases).

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Recall Brisbane February 2008