Recall May 17 2008 Melbourne

7/28/2019 Recall May 17 2008 Melbourne

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Clinical recall 17 May 2008 Melbourne

1. 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. RecentURI in the family. Fully immunised, previously well. There is a 6-week oldsibling 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 thethroat and touched the palate, the child started coughing with aninspiratory 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 aviral cough, an allergic cough (because the cough is primarily nocturnal) or apara-pertussoid cough which is a cough similar to pertussis but the organismscausing it are not necessarily pertussis (i.e., Bordatella parapertussis,Mycoplasma, Chlamydia). But I could sense that the role player was not happywith my answer. So I said, at the bottom of my list is pertussis. Then the roleplayer 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 infectedwith pertussis despite immunisations, it would be a modified symptom and notthe typical text book presentation of pertussis. I would need to get some swabsfrom the nasopharynx to confirm the diagnosis. If this is Pertussis these are thefollowing 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 theexaminer asked me to whom will I give the erythromycin to. First, I said tothe patient, to reduce his infectivity but that this would not necessarilyalter the clinical course. Secondly, all household contacts need to haveprophylaxis treatment. I am particularly concerned with the 6-week oldbaby since he would not have any protection because of the lack oftransfer of maternal antibodies. Thus this 6-week old should receiveprophylaxis Rx and should be immunised with DTPa which can be safelygiven as early as 6 weeks. This immunisation however, does not giveimmediate 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 3initial doses of DTPa and therefore his clinical course will be modified andnot as severe as when he is not immunised.

Q (question) from the role player. Where could he have gotten this? I said fromsomeone who harbours the organism in the nasopharynx. I wasnt able to clarify

that the parents can have waning immunity and could have harboured this intheir throats/nasopharynx. Also, I forgot to ask if the child is in childcare. If he


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is, the child carers nasopharynx should be checked if they carry the organism(potential source of infection) and should be treated and excluded from childcare as well. The patient should also be exempted from childcare temporarilyuntil at least 5 days of erythromycin/clarithromycin Rx.

AMC Feedback: Pertussis

3. A multigravid is now in your clinic and is 38 weeks pregnant. Lives 80kmfrom the hospital. You find out that she has a transverse lie.

Tasks:

Take further relevant history from the patient

Ask examination findings from the examiner

Tell the patient about your management plan.

I first asked current pregnancy issues. Labour pains, contractions, baby kicking,bleeding, water leaks etc. Then I asked pre-eclampsia Qs (questions). I thenasked any issues during this pregnancy; 18 week scan any abnormalities,

placenta praevia etc role player said baby was normal and that she does notknow any information on the placenta. Then I asked about her previouspregnancies. She said she had 3 babies. I asked about their birth weights (3.5kgto 4.2kg if I remember right), manner of delivery and any previous issues likediabetes; general health - ok. I asked her blood group and she said she does notknow. I asked her if she had injections (anti-D) - cant recall. I said it is unlikelythat you have an Rh-ve blood group but we can check that later.

I examined the patient. Gen appearance, VS then went straight to the obstetricexamination, fundic height, FHT, and presentation. Dipstick urine- N.

I explained that she has a transverse lie and there are several reasons for this. 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 pregnancieswith relatively large babies who were all vaginally delivered thus herpelvic passages have been tested for adequacy.

Second, placenta praevia can prevent a baby from positioning itself

normally thus I would like to rule this out by doing an ultrasound (and aCTG to check on baby).

Third, with an ultrasound, we can also gauge the amount of amniotic fluid

because too much amniotic fluid can also cause the baby to move aroundeasily.

Lastly, having ruled out pl. praevia and polyhydramnios from the

ultrasound, the most probable cause of her transverse lie is the previous 3pregnancies she had with relatively large babies causing her uterus andabdominal wall muscles to be stretched more than usual thus allowingmore room for the baby to move around easily.

Because we are quite far from the hospital and also because she is already atterm (38 weeks), these are the options:

Admission to hospital. After making sure that there is no placenta praevia,we can attempt to gently externally rotate the baby with a double setup meaning, ready for any potential complications i.e., immediate delivery

just in case a cord entanglement, PROM +/- cord prolapse happens. There

is the potential for the baby to return to its original transverse lie positionagain.


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Schedule for a caesarean section because it would not be feasible for a

vaginal delivery on a transverse lie.

The examiner was very happy and said that was an excellent discussion. Sheasked me if I had any obstetrics training. I said none.

AMC Feedback: Transverse Lie

4. You are working in a country hospital which is 300 km from the nearestneonatal intensive care unit. Your next patient is a 26/40prim. She hasabdominal pain for 3 hours.

Task:

History, PE

Manage the case

While reading the stem outside the room, I was already thinking of at least 2differentials: abruptio placenta or premature labour. I started by asking the

character and severity of the pain. She described it at intermittent contractions.I continued to ask about regularity (every 5 minutes) and duration (around 2minutes) and figured out it was the start of labour pains. Then I asked her if shehad leaking bag of water or vaginal bleeding. She said no. I asked about traumaand possible reasons for the premature labour. There was none, it wasspontaneous. I asked about issues during pregnancy, correct date, blood group,18 week ultrasound - whether there were any abnormalities and whether theplacenta was low or not. She said as far as she knows they were normal. OnPE, VS were normal. Abdomen showed compatible FH with age of gestation,normal FHT, longitudinal lie. Speculum showed the cervix to be 3cm dilated,intact bag of water.

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 ofthis age, ideally in a neonatal intensive care unit.

I will arrange that she be transferred immediately and if possible by air

ambulance while stabilising her.o While awaiting transfer, she needs to have a drip in with a first dose

of steroids to be given for the babys lung maturity.o She needs to have an ultrasound to rule out abruptio and

chorioamnionitis (both contraindications for tocolytics) and CTG,although CTG s interpretation may not by accurate since baby isstill premature

o A fibronectin test may be done but I did not emphasize much on

this. I just mentioned it in passing.o We hope we can delay (until at least the second dose of steroids) or

stop progression of labour by giving her tocolytics. Examiner askedme what tocolytic do I intend to give. I said calcium channelblockers.

o Bed rest when in hospital.

I finished this station early.

AMC Feedback: Premature labour


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5. A young female with recurrent greenish vaginal discharge. Your colleaguetreated her with antifungals and doxycycline but discharge is recurrent.

Task:

Take a history

Examine the patient

Advise on plan of management

I started by asking her details of her vaginal discharge smell (foul); pain (none);relation to menstruation (no); fever (none); dysuria (none). I asked if it wasalright to be asking some sensitive and personal Qs. I asked if she is sexuallyactive. 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. Contraception condoms. No previous STI. Paps smear 2 years ago N, has always been normal.Never been pregnant. Periods regular, monthly. LMP 3 weeks ago. Generalhealth including diabetes, N. Not on any medications and no allergy tomedications.

P.E. general appearance normal. VS especially temperature - N. Then I said Idlike to focus my examination on the gynaecological aspect. The examinerbrightened up and said, that is the best thing Ive heard today! Any masses andtenderness in the abdomen none. Speculum examination greenish yellowvaginal discharge which is foul smelling. Cervical ectropion. PV examinationwas normal. Even then I still asked for no cervical excitation? Or adnexaltenderness? The examiner answered with a firm Nomal.

Before I went to management, I curiously asked the patient if there was anyswab/culture taken before when she was treated by my colleague. She said no.

Then I said that I will have to do swabs. Examiner asked me what I was thinking.

I told him I will have to rule out Trichomonas, Gardnerella and will also test forCandida. I also asked the patients permission to test her for STI including highvaginal swabs for Chlamydia and Gonorrhoea and to complete my STI screen,some blood tests. I explained that I know that she and her partner are exclusiveto each other and they use condoms but I need to check this (STI) still.

Then depending on the results I will have to treat her. If positive for Gardnerellaor Trichomonas she would need to be treated with metronidazole. I will need toalso do a Paps smear on her too since the last one was 2 years ago. Will need tofollow her up for progress. Also, she should continue on practicing safe sex.

As I recalled this station post exam, I feared that I might have done a critical

error by totally ignoring the cervical ectropion which was seen on speculumexamination. I passed this station though.

AMC Feedback: Green vaginal discharge

6. A 35 year old female with sudden onset of difficulty of breathing.Tasks:

Take a history

Examination

Management plan

When I was reading the stem outside the room, I had the following differentials inmy mind: Pneumothorax, Pneumonia, Pulmonary embolism, Pericarditis, Asthma


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(because of the relatively young age of the patient); further down my list were:AMI and Dissecting aneurysm. I was also planning to pin down the diagnosis inthe first 5 Qs I will throw to the role player.

I started by asking the patient, tell me about it? She said, yesterday in the office(clerical job) she suddenly felt this shortness of breath. I asked her if this wasthe first time this happened Yes. Is this progressive No. If she was coughing yes; sputum and colour yes, brown (Aha! I have narrowed my differentials toeither pulmonary embolism or pneumonia). No fever, No chest pain, No heartracing. I then asked recent long travelling. She said she just arrived from New

York 5 days ago (or less than a week ago). I asked her what she did in the plane she said she slept most of the flight time.

Then I asked medications (OCP and other DVT risk factors recent surgery,smoking, family history) none. General health good.

Physical examination: I think the only abnormality is the slight increase in

respiratory rate. Cardiopulmonary exam N. No leg swelling, no calf tenderness(I couldnt recall if there was).

I said that she needs to have immediate hospital admission as I am highlyconsidering pulmonary embolism. The examiner was sitting very close to meand seemed very pleased. He asked what will happen in hospital. I got excitedso I immediately said she needs CTPA (CT pulmonary angiography). Examinercommented - dont you think that this is too invasive as an initial investigation?Oh yes, I said. Though this is the gold standard of diagnosis, I will have torequest the following: FBE, coagulation profile (what do you mean, he asked Isaid PT/INR, aPTT), thrombophilic markers both for hereditary protein C, S,Factor V Leiden, homocysteine and acquired lupus anticoagulant and

antiphospholipids. She will also need to have a V/Q scan. The examiner askedwhat else? I said an ECG too. That was what I was waiting for, he remarked.What can you expect in the ECG? In severe PE, you can have Q3T3S1 but youmay also have a normal ECG if PE is not severe.

How will she be treated? I said she will need to be started on heparin, either withthe standard heparin or LMWH plus an overlap with warfarin because it takestime for warfarin to take effect (around 4-5 days for INR to be at least 2-3). Thenheparin will be ceased once warfarin kicks in. How long will she be treated? Isaid 6 months.

Finished early.

AMC Feedback: Shortness of breath

7. A 60yrs old male patient, referred by his previous GP to see you new tothe area.

Dear DoctorWould you please see this patient? His liver function has been abnormalfor 2 years. He feels tiredness, no liver disease before; viral serologynormal doesnt drink alcohol. He had a pacemaker inserted a few years

ago. He had haematemesis due to oesophageal varices. He got smallcalculi in his gall bladder, pancreas was normal. (Long stem)


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Task:

Ask the examiner about Ix result

Explain the patient to the result.

I started by saying that he has multiple organ involvement namely the heart,

liver, gallbladder and maybe some other organs too which we will need toinvestigate. Id like to do some tests to rule out a condition which we callhaemochromatosis. I will have to do some iron studies. As soon as I said thisthe examiner handed me the result. Ferritin increased (1500), Transferinsaturation increased. Then I went on to say that your iron stores are very highwhich supports what I was initially thinking thus I would need to do some genetictesting for the gene. The examiner handed me a second laminated paper.Homozygous for C282Y (+), H63D (-)

I asked him if he knows anything about haemochromatosis. It is a condition witha disturbance in iron metabolism such that excess iron accumulates and depositsin organs such as the liver, heart, pancreas, pituitary and in fact can deposit in

any organ causing its dysfunction. It is an inherited disorder, which means hehas received one recessive gene each from his parents. I briefly explained thatyou have to have a pair of the recessive gene to have haemochromatosis andthat one gene inheritance is considered a carrier of the abnormal gene andshould not cause any clinical significance to that person.

The treatment is aimed to bring down the iron load by doing phlebotomiesaround 500 ml every week for 1-2 years (read JMurtagh) then if levels areacceptable, the frequency drops down to every 3-4 months.

I will also have to test him for other organ dysfunction such as diabetes from

pancreatic involvement; some hormones from pituitary deposits; renal functionetc. He will need to have regular follow up.

What will happen to his kids, he asked. I said, we have to test your wife first. Ifyour wife does not carry the gene, then the worst case scenario is that yourchildren will have inherited one HFE gene and that should not be a problem tothem. However, it is recommended to have their future partners tested becauseof the possibility of having affected children.

What about his siblings, he asked. I said that since you came from one set ofparents, they have to be tested for iron studies and the HFE gene.

Will I live to be 70? Well, I said that depends on the degree of organinvolvement. That it is a good thing that we detected it now and that we can dosomething about it. Perhaps a referral to a liver specialist will be necessary inthe future for the possibility of a liver biopsy. And of course continued specialistreferral for the heart and long-term follow up should be advantageous for hishealth.

AMC Feedback: Abnormal Liver Function Tests

8. A 48 year old lady came in for her biopsy results which showedadenocarcinoma of the colon. Her father had colon carcinoma at 58 yearsold. There are other parts in the stem regarding history but I could notrecall them. I dont think you have to take any more history from thepatient apart from clarifying Qs.


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Task s

Explain the results of the biopsy to the patient

Advise on management

Answer the patients Qs.

A middle aged woman was in the room waiting. First of all I asked her if shecame for the results of her biopsy and she said yes. I told her that I have somedisturbing news. 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 dontunderstand why I couldnt see the part that is involved- maybe it was thenerves). I asked her if she would want someone to be with her before I explainthe condition and if she would want me to go further. I explained to her that theearlier we treat the better. On a piece of paper, I drew the different stages 1-4and the degree of involvement (I-mucosa, II- bowel wall, III- bowel wall and LNs,IV- liver mets and other organs) and their respective prognosis (Dukes Staging inAMC book p94). That, if treated early, i.e., stage I, the 5 year survival rate is>90-95%. She asked if surgery is the only treatment. I said yes and the use of

adjuvant chemotherapy +/- XRT in selected cases improves overall survival.

Does she need colostomy like her father? I said, she may need it but it may justbe temporary especially if it is in its early stage.

What will happen to her kids? I asked how old were they (I think they were intheir teens). Then I said that they will need to have surveillance colostomiesdone when they reach their 40s or alternatively a bit sooner since someauthorities recommend it to be done 10 years earlier from when a first degreerelative was diagnosed to have the carcinoma (in her case around 38 years oldfor her children) - unless they have symptoms. For the meantime their diet

should be rich in fibre.

What about her siblings. I said that your siblings need to be investigated withfaecal occult blood in the stools and colonoscopies.

I finished early. The examiner was very quiet.

AMC Feedback: Carcinoma of the rectum

9. A young female came to your GP to ask for antidepressants again. Shewas previously treated with antidepressants before.

Tasks:

History Management

I started by asking why she thinks she needs antidepressants. She said she feelsdown, she cant sleep. I screened for HEADS.H Home environment. How are things at home? She mentioned that the familyis dysfunctional. Several issues happening (could not remember exactly what).

That she had to leave home and she is now renting out a unit with some friendswith whom she shares the bills.E Education, Economics (work and finances). She said that she has a double

job and shifts from one work to the other in a day, most days a week.

A Activities. I asked about her social life, her friends and what her hobbieswere. She said she does not socialise much as work keeps her busy.


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D Depression, Drugs. I asked her about sleep what was bothering her; ifthere was anything that keeps her awake. She said she just cannot sleep andwakes up unrefreshed. I asked about eating. She said it is unaffected. I askedabout coping mechanisms- drugs, alcohol, cigarette none.S Sexual activities, Suicide risks. I asked her if she is sexually active No. Iasked about risk factor of harming herself and others none.

Then just to complete the psychiatric assessment, I asked about delusions,hallucinations, etc. None. Her general health has been good. I could no longerremember the reason why an antidepressant was previously prescribed on her but I know she did not have any major depressive symptoms previously includingsuicidal thoughts.

Then I explained to her that giving an antidepressant is not the only solution toher problems.

That the cornerstone of management is in her lifestyle change. That she

needs to cut down on her working hours because she is overworked and

tired and unable to get enough sleep. That she needs to socialise and find ways to relax and go out with friends

and family. Should she wish to have a family counselling session with me,I will be happy to arrange for that.

I briefly mentioned sleep hygiene (read JMUrtagh).

If her finance is an issue, we may have to tap on community resources to

help her out temporarily while she overcomes this situation.

If she still has a problem coping, there is no harm in trying a short-term

sleeping tablet (i.e., 2 weeks only to prevent dependency) just to breakthe cycle of anxiety and lack of sleep.

Cognitive behaviour therapy and meditation techniques can certainly help.

Antidepressants have certainly a role but only when all means mentionedbefore have been exhausted.

I will follow things up with her to see how she is going.

AMC Feedback: Anxiety and Depression

10. Assessment of a Comatose patient (AMC Handbook of ClinicalAssessment)

There were 3 people in the room. A patient lying comatose on the bed, the

examiner and an observer.

AMC Feedback: Coma

11.Middle age man has come to your clinic; his wife is worried about hisstrange behaviour recently, as he changed the lanes while driving withoutobvious reason and almost caused MVA. His children also report that hisbehaviour has changed recently. Last time you did MMSE and it was 25/30(page with report was provided on the wall, low score in attention, recallsections).

Tasks:

Take further history

Do at least one test to assess his cognitive function, no need to repeatMMSE (assume it was accurate)


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Discuss your diagnosis with the examiner.

An elderly man around 60 was in the room. I started by asking the patient thereason why his wife and children are concerned with him. He said, he does notknow why and that he thinks they, especially his wife, worry too much and that

there is nothing wrong with him. He denies any change in his behaviour. I askedhim general Qs on dementia like does he think he is forgetful and has he everfound difficulty in his way home. Does he know where he is at the moment?-Orientation Qs.

I asked about home situation, work, mood, and activities - nothing significant. Ialso asked about past medical history and general health. Smoking, alcohol,medications were all non contributory.

Then I moved forward to do my second task. Read page 443 of the AMChandbook under the title MMSE may be supplemented by specifically testingfrontal lobe functioning via.... I did exactly what was on this outline. The role

player was unable to do the interpretation of the saying a stitch in time savesnine and also found it difficult to do the motor sequencing test of the fist-edge-palm. I asked the examiner if there was time to do words beginning with Fs inone minute. The examiner answered that I have plenty of time. Thus I asked thepatient and he could do this. He tried hard but kept repeating words he alreadyused.

Then the examiner interrupted and asked me for the diagnosis. I said heprobably has frontal lobe dementia. He asked me the basis for this. I said thathe has borderline MMSE 25/30 and that he is unable to do the tests Ive done onhim which can only mean that he has some form of frontal lobe deficits. I wasabout to explain the possible causes of frontal lobe problems such as vasculardeficits/infarcts, tumours etc, but he said, dont worry about that, you finishedyour task and can wait outside.

AMC Feedback: Frontal Dementia

12.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. First I commended thepatient for coming to see me to talk about his alcohol consumption.

I asked the following:

Alcohol consumption what kind, how much, how often I gathered that it

was way too much in excess of the recommended. Also he drinksdifferent kinds of liquor, hard drinks, wine and beer.

C-A-G-E Qs

HEADS check (as in the case above) i.e., home and work situations- any

relationship issues? - Yes; activities/exercise, mood; does he drink becausehe is in a lot of stress? mood and suicide risks - None

Did he get in trouble with the law because of his drink driving yes,driving offence


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Libido - diminished

General health weight, diabetes, cholesterol, HPN, smoking and

recreational drugs

Motivation to stop he said he is not sure yet but just came to ask.

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. One standard drink is equivalent to10g alcohol. Since there are different liquors he takes, I will give him areading material on the equivalent of one standard drink of the differentliquors he takes.

That alcohol can have harmful effects on his physical, social and

psychological aspects of his life.

I can arrange for him to have some blood tests like FBE with red cell

indices, B12 and folate levels, LFTs, BSL, 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 hedecide to withdraw.

In the end, 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.

It would be nice to mention alcoholics anonymous which I forgot to do.

Q from the patient: What advise do I need now as an immediate plan? I wasthinking of what he meant and I was about to address the issue of drink drivingbut the bell rang.

AMC Feedback: Excess alcohol consumption

13.A biopsy report of a melanoma with depth of involvement of 0.4 mmthickness with tumour extending to the lateral margins (couldnt recallwhich site of the body). No lymph node enlargement. A picture wasoutside the wall. The patient, a school teacher had this mole for manyyears and noted it recently to be itchy thus a biopsy was done. No historyand examination required.

Tasks:

You are to explain the biopsy result to the patient.

Advise on management.

I told the patient the disturbing news of the biopsy result. Melanoma is the third

commonest skin malignancy in Australia and is related to prolonged sunexposure.

I said that the good news is that there is no LN involvement and that the depth is0.4mm. The usual cut-off depth is 0.75mm which could affect prognosis.However, the tumour excision did not indicate clear borders; ideally I said 3-4mmof clear margins. I have to check this margin as I remember them to be so insquamous and basal cell carcinoma but wasnt sure if this applied to melanoma(further readings post exam 1cm clear margins).

I advised on the following:

Re-excising the tumour with clear margins of normal tissue referral to asurgeon (or dermatologist) to do this.


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Although LN involvement was not seen, I still would want to have some

scans (CT) to make sure that no other LNs are involved in other sites.

Referral to an oncologist for possible chemotherapy if LN involvement is

seen. However, the prognosis is excellent if the depth is just 0.4mm andno LN involvement is seen.

He would need to be followed up on a regular basis for progress report andalso to regularly check the skin for suspicious lesions. He should alsoregularly inspect his skin himself and report early for any skin change.

Avoid prolonged sun exposure. Wear wide brim hat, long sleeved top anduse sun protection lotion.

AMC Feedback: Melanoma

14.A 50 years old lady, a violinist in an orchestra, with pain, swelling andstiffness in both hands recently. Her mother has rheumatoid arthritis. Yoususpected that it's rheumatoid arthritis. You prescribed ibuprofen and runsome blood tests for ANA, ESR and RF. The results showed that she hasearly rheumatoid arthritis.

Task:

Explain the diagnosis to the patient,

Counsel the patient and answer her questions.

This was my very first station. There was a very nice middle-aged role playerwho smiled and nodded her head when I said the answers she wanted to hear.

I explained that she has RA and that this is a chronic condition with flares

and quiescent phases. It is an inflammatory condition eroding cartilage,which is the cushion at the end of the bones in the joints. It has an

autoimmune component as well as genetic predisposition. With modernday medicine and new drugs which we call DMARDs we can markedlydelay and hopefully prevent further progression of the disease. Althoughwe usually recommend a step-up approach in pain management, startingfrom simple analgesics to stronger ones, in RA, we can use DMARDs in theearly phases of treatment. I enumerated the DMARDS - methotrexate,cyclosporine, azathioprine, sulfasaline etc. Inflixamab, to counteract theeffect of cytokine (thought to be a mediator in RA) can also be used.

Early referral to physiotherapist and rheumatologist is the key to prevent

further disease progression.

There is also the possibility of using steroids. The role player said she

does not like the use of steroids because of the ill effects on her mother. Isaid yes, the complications of steroid use are well recognized such as,gastric irritation, myopathy (proximal muscle weakness), mood changesand long term effects of osteoporosis, diabetes, etc. However, the use ofsteroids is limited only to flares and are of short courses usually. I willdefinitely follow you up closely with your steroid use. But she was stillhesitant. Therefore I said if you feel too strongly against it then we canuse NSAIDS such as Ibuprofen. She said but Ive been using this alreadywith not much relief. Then we can also try Aspirin plus Panadeine(Panadol Codeine) combination.

Examiner asked about the side effects of DMARDS. I said bone marrow

suppression and liver dysfunction that is why she needs to have regular check ofher FBE, LFTs and CRP ESR, RF to monitor her disease progression as well.


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Examiner asked what potential risks would the use of steroids do to this patientgiven her age 50. I said osteoporosis. However, we can talk about HRT onanother consult to weigh the risks and advantages of using this and we can alsotalk about the use of bisphosphonates and dietary advice on calcium orsupplements. She would need to have baseline bone scans (bone densitometrywas what I was actually thinking but I said bone scans).

The examiner said I finished my task and that I can step outside.

AMC Feedback: Rheumatoid arthritis

15. Middle aged woman complaints of pain on the right arm, forearm andhands.

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 myexamination. I asked her to tell me about the pain and she indicated pain in thearm, forearm and hands. Any pins and needles? Not exactly. Numbness,weakness yes. Any neck pains, she said yes. Any trauma- no. Any history ofrheumatoid arthritis- none. General health- non contributory.

Examiner was hurrying me up to proceed to examine the patient. I started bysaying ideally I will have to expose the shoulders to check for asymmetry,muscle atrophy, swelling. The examiner said you dont have to expose anything.

Examine the patient as is. Then I moved to the back of the patient and talkedabout looking for any deformities swelling, etc. Then I went to palpate thespinous process from the base of the occiput down the cervical spine. There wastenderness around the C6C7 area. Then I checked for paravertebral tenderness,there was none. Then I asked for the patient to do neck movements extension,flexion, lateral flexion, rotation to the right and left. There was limitation in allthe movements. Then I proceeded to do shoulder examination testing forpowers (against resistance) of abduction and adduction, biceps, triceps, wristflexion, extension. The examiner kept on hurrying me up to examine the hands.I had limited testing for finger flexion, extension, abduction, and adduction. Iwas also comparing it to the right side which seemed to be unaffected. Therewas obvious weakness of all movements of the right side. I did not get to

examine the sensory and reflexes as the examiner cut me short and asked whatinvestigations I would request. I said since I was considering cervical spondylosisI would request for an MRI. He handed me an MRI picture of the cervical spinewhich showed a prolapsed disc.

I was quickly asked how I would manage the patient. I said conservatively. I willrefer for physiotherapy. Bell rang.

AMC Feedback: Prolapsed cervical disc with radiculopathy.

16.A previously well 5 months old brought to you by the father because ofsudden onset of intermittent screaming with few episodes of vomiting. Asibling had a recent bout of gastroenteritis.

Tasks:


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History.

PE

Advise diagnosis and plan of management

My first thought was intussuception because of the typical clinical picture. So I

asked Qs pertaining to this such as: how is the infant in between episodes; colourand character of stools; vomiting. He was noted to be pale in between episodes.I also asked for fever; any obvious straining when he wees - none. Past medicalhistory was uneventful. PE: nothing contributory. Rectal exam was normal. Inhindsight, I should have also asked for the groin examination.

I advised on the possibility of intussuception (explained what it is) and that thebaby needs to be admitted to hospital because of the suspected diagnosis. Iadvised on nil by mouth and what they will do in the hospital such as IV fluid,early surgical referral; abdominal xrays, possibly either gas or contrast enema-which can be both diagnostic and therapeutic ; blood tests for FBE andelectrolytes; urine tests etc. I discussed about going to theatre if the enema

measures fail to reduce the intussuception.

Examiner asked me my differentials: I said volvulus, small gut obstruction, UTI,meningitis. I would have gotten an obvious diagnosis ofincarcerated/strangulated hernia if only I had checked the groin area.

AMC Feedback: Incarcerated Hernia (the only station I failed)

Comments:

This candidate has reviewed almost 350 cases (including the 150 cases from theAMC publication). Just when you think you have a good grasp of the commonlyrepeated cases, it was still surprising to see unfamiliar cases. There were 2 newcases to me which I have not encountered in my recalls at all. There were 4modified cases from the recalls. I couldnt help but develop doubts in mydiagnosis and my approach because they were modified in such a way that Ihave to think further and not fully rely on the diagnosis given in the recalls.

Think of a few differentials and keep on talking while ruling out the others andruling in the most probable diagnosis.

You will never know what cases will come out in the exams. Some exams willhave very familiar repeated cases thus probably contributing to the relatively

higher passing rates. This particular exam had a lot of unfamiliar cases and only2 cases came out from the book published. A few of the cases were not exactlyhow we expected it to come out as in the previous recalls. It is possible that thiswas completely unexpected by some candidates and could have affected the lowpassing rate (35%).

Try to know the cases by heart in all their aspects because they can appear indifferent shapes and sizes. If you know them you would at least be able totalk about it and not be caught by total unawareness.

The exam in really nerve-wrecking. Relax the day before and do not readanymore while waiting for your turn whilst in quarantine (especially for the groupin the afternoon). It just adds more pressure to an already stressed out brain.


14/14

Dr. Wenzels (Couldnt thank you enough Dr Wenzel) class has a very goodsimulation of what happens in the exams. Be observant to the role plays duringthe class because you will learn something from them even if the candidateperformed badly or excellently. Listen carefully to the testimonies of those whopassed. You will pickup very precious survival tips which you can apply in yourpreparation for the exams and during the exam day itself. Get the most out ofthis class. It is freely given by a kind hearted person who wants to help us IMGs(a rare precious opportunity). It is also a good way to establish networkings withpeople who are in the same situation as you are.

All the best in your endeavours. We happen to be just ahead of you in passingthe clinical exams but soon enough you will also be in the same situation andwe will be criss-crossing our paths again in the future.

Cheers All. Hope this recall helps!

Documents

Recall May 17 2008 Melbourne