Amc Clinical Recalls - 2004

Adelaide May 2004 1. Schizophrenia:

60 year old lady which wants a letter to move from her house. It seems to be Organic cause, paranoid schizophrenia. DDx includes delusional disorder, depression, OCD. 60 years old: should R/O any organic cause at this age with CT scan and U/A.

2. Acute Urinary Retention:

Middle aged lady unable to pass urine for 16 hours. First after palpating the bladder insert the catheter then take history (present, past and medications, alcohol), exam (abdominal and vaginal and PR), send urine for MSU, FBE and U&E, Abdominal X-ray, U/S. If there was a mass then CT with contrast. Remember herpes and fecal impaction as potential causes.

3. Coma: Young female brought by flat mates which has neck stiffness. 4. Lethargic baby: Lethargic 4 month old baby with high fever and no rash. Remember the complications of bacterial meningitis. Septic work up.

5. Diabetes Mellitus:

60 year old man with urinary symptoms and no history of diabetes. Very anxious regarding prostate cancer. A very tricky case to see whether you are looking for everything or you are single-minded. DDx: DM, prostate, CHF. Remember to look for edema. Admit the patient

6. Anorexia Nervosa:

The girl which is dehydrated and has postural BP drop. Remember admission and ECG.

7. Hypertension:

The 25 year old lady which is on OCP for 3 years and has had UTI in childhood.

8. Premature Rupture of Membranes:

sterile speculum examination. No digital exam. Ultrasound examination showing markedly reduced liquor volume in the presence of normal fetal kidneys and the absence of IUGR is highly suggestive of ROM. If the diagnosis is in doubt, the patient may be admitted for pad checks. Vaginal and ano-rectal swabs for GBS, microscopy and culture. CTG, FBE. A cervical suture, if present, should be removed immediately and submitted for culture. All women with PROM < 34 weeks gestation should be administered betamethasone injection 11.4mg IM Daily - 2 doses. Where there is no evidence of infection, the gestation is < 34 weeks and corticosteroids have not been completed, if contractions are occurring Tocolysis in order to complete the corticosteroids is reasonable. If the woman is GBS positive then induction should be considered from 32 weeks, otherwise induction should be considered from 36th week. Temperature and pulse control. FBE weekly, CTG twice a week, U/S fortnightly. All women should be observed in hospital for 72 hours. If they remain well and are not in labour, they can then be discharged for outpatient management. The woman would be instructed to take her temperature t.d.s., observe PV Loss and be aware of fetal movements- returning if there are reduced fetal movements felt. They should be seen once each week. Remember cord prolapse. Prophylactic antibiotics improve the outcome in PROM. The drug of choice is erythromycin 250 mg orally qid. (In those with no sign of infection). Intrapartum GBS prophylaxis: Benzyl penicillin 1.2 gr IV then 600 mg qid until delivery. If allergic: clindamycin 600 mg tds.

9. Back Pain (Sciatica): is examination.

Young man after lifting a heavy object. Task

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Cervical Cancer:

43 year old lady with bleeding (post coital) not related to periods. Remember multiparty, sex at early age, early pregnancy, multiple partners and smoking. Treatments of cancer include Radical hysterectomy, radiation and chemotherapy. Notes: all of these patients (intermenstrual or postcoital bleeding especially over 35) should be referred even with normal pap results. In postcoital bleeding ask about IUCD and OCP as well as looking for cervical ectropion. Change the OCP to a higher dose.

Chronic cough:

18 month old child with chronic cough at night for 10 month. Growing well, no wheeze, no allergies and no passive smoking. Remember normal approach. Remember postnasal drip, Reflux, FB, drugs and CF. Investigations: CXR, PH monitoring and manometry and a trial of bronchodilator. If normal reassurance and follow up or referral. Some candidates claim it was Asthma.

Knee exam: Medial meniscus injury. Remember arthroscopy Swollen ankles: 60 year old lady who travels a lot. Swelling goes away in the morning and worse at the end of the day. Mild SOB. If investigations for heart (Echocardiogram), kidney (U&E) and liver (LFT) were normal then “Idiopathic edema”. Ask about tension, depression and headache. May also involve face and hands. Management is with supportive stocking and salt restriction. Diuretic make it worse but a trial of sprinolacton is recommended.

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Spontaneous pneumothorax:

Remember to advice against flight and diving for 3 month and smoking and high altitudes. The recurrence rate for both primary and secondary spontaneous pneumothorax is about 40%. Repeated cases might need pleurodesis with sclerosant injection.

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Be careful to differentiate from Kawasaki. Benzyl penicillin for 10 days. Complications: Rheumatic fever, glomerulonephritis, otitis media. Some candidates claim it was meningitis, so make sure it’s not a purpuric rash. Scarlet fever rash is blanching and sandpaper in quality.

16.

Remember the pulse (irregular). Remember that revascularization cab be tried but the results are poor. Operation involves resection of the dead gut. Survival < 30%

Scarlet Fever:

Acute Abdomen (Mesenteric Infarction):

Melbourne Feb 2004

1. CVS exam: The 60 year old man which wants to travel overseas. 2. Abdominal Pain: 30 year old female with vomiting, fever and upper abdominal pain. Task is examination, investigation and management.

3. Bronchiolitis:

4 month old child with fever, wheeze, low sats (91%) and less wet nappies. RR=61

4. Newborn Jaundice:

30 hours old newborn with Jaundice. Billirubin is 240. Task is history, relevant physical exam and investigations and management. Notes: Is it conjugated or unconjugated? If conjugated needs urgent referral. (Atresia, cyst or neonatal hepatitis). Physiological jaundice is a diagnosis of exclusion. Reaches a maximum in day 3-5 and then starts to decrease. Remember that Billirubin >285 needs phototherapy and >360 needs exchange. You should exclude sepsis, ABO incompatibilities, IUGR, G6PD deficiency, hypothyroidism and medication effects. Check for: Onset before 24 hours of age, pallor, unwell baby, pale stools/dark urine, hepatosplenomegaly, abdominal distension, poor feeding/vomiting. If not present then most probably is physiologic and just review. If present then the minimum investigation is: FBE, Film, and Coomb’s test, SPA urine for culture and Billirubin and reducing substances.

5. Breast lump with cyclical pain:

42 year old lady which her mom had breast cancer. Task is history, exam and management. Remember to ask about OCP and change it to an OCP with lower progesterone like triphasil.

6. Atrophic Vaginitis:

A 65 year old lady with greenish discharge. Task is history, exam and investigations from examiner. Then explain to the patient and manage. Note: Investigations should include: PH, whiff test and wet film. In wet film looking for clue cells, spores, trichomonas and leucocytes. Also remember to check the urine. Then explain that due to the female hormone her vagina has got dry and this make it prone to infection and the treatment is replacement of this hormone by HRT or vaginal cream. Also treat the infection.

7. Intermittent claudication:

66 year old with right leg cramp while walking. Task is history, exam, investigation and management.

8. Diabetic Neuropathy:

43 year old lady with right leg weakness. Task is history (6 minutes), diagnosis and management. Ask about numbness, tingling and pain anywhere, Wasting of muscles, nausea and vomiting, indigestion, dizziness or faints due to postural drop, urinary problems, vaginal dryness (dyspareunia)or erectile dysfunction in males,

weakness, weight loss and visual problems like diplopia. Remember comprehensive foot exam. Referral for NCV and EMG. In management stress on foot care and podiatry and physiotherapist for weakness and tight sugar control. (And possibly endocrinologist referral). Explain to the patient: People with diabetes can, over time, have damage to nerves throughout the body. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in every organ system, including the digestive tract, heart, and sex organs. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk.

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9. Enuresis Gestational Diabetes:

All women (others than those at special risk see below) have a 75 g non-fasting glucose challenge test (GCT) performed at 26 weeks. If the 1-hour plasma glucose is ≥ 8.0, they will be recalled to have an oral glucose tolerance test. The glucose tolerance test is performed after a 10-12 hour fast. The fasting plasma glucose is measured, and then 75 g glucose solution is drunk in not more than 5 minutes, and the 2-hour plasma glucose measured. Patients may not smoke, eat nor drink anything other than water during t he test, and should not perform any exercise. Gestational diabetes (GDM) is defined by either a fasting plasma glucose value ≥ 5.5 and/or a 2-hour value ≥ 8.0. All women with GDM are seen initially by the diabetes nurse educator and dietician and obstetrician in diabetic clinic. Investigations: HbA1c, U&E, BSL. Ultrasound examination at 30 and 36 weeks for growth. All women with GDM will perform home blood glucose monitoring, initially 4 times each day before breakfast and 2 hours after each meal. The target levels are ≤ 5.0 fasting and < 6.7 mmol/L 2 hours after meals. Initially all women are treated with dietary and exercise advice. If this fails to achieve the targets, they should be reviewed by the dietician. If the targets are still not met, insulin therapy should be commenced. More frequent visits. Method of delivery depends on estimated fetal weight. Women with GDM should have an appointment made for a postpartum GTT prior to postnatal discharge.

Preeclampsia:

30 year old primi 32 weeks pregnant. BP is 170/110 and urine protein is increased. Task is focused history, investigations and management. Ask about visual disturbances, headache, abdominal pain (RUQ), weight gain, puffiness, antenatal visits, history of high BP, any medical problem, twins, DM, family history. Exam the reflexes, clonus, edema, fundoscopy, abdominal. Investigations: FBE, U&E, LFT, urine protein. She Needs admission with BP control. (Hydralazine 5-10 mg bolus then 5 mg hourly). Needs steroids. Complications are abruption, eclampsia, IUGR, bleeding due to platelets, HELLP. If any Neurologic sign then prophylactic MgSo4 should be started. (hyperreflexia, clonus, severe headache or visual disturbances)

Visual Problem:

25 year old lady having difficulty reading notice board. Same problem in father and brother. Relevant exam and management. Most probably keratoconus. NOTES: Keratoconus is a thinning of the central zone of the cornea, the front surface of the eye. As a result of this thinning, the normally round shape of the cornea is distorted and a cone-like bulge develops, resulting in significant visual impairment. 8% of patients have affected relatives. Keratoconus is estimated to occur in 1 out of every 2000 persons in the general population. Keratoconus generally affects both eyes. Keratoconus has been associated with conditions such as hay fever, asthma and eczema. In the early stages of the condition, spectacles are usually successful in correcting the myopia and astigmatism associated with the keratoconus. As the condition advances, the cornea becomes highly irregular and vision is no longer adequately corrected with spectacles. Rigid contact lenses are then required to provide optimal visual acuity. In about 15% of cases, the keratoconus progresses to the stage where corneal transplantation is required.

Wrist injury exam

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Postnatal depression Osteoporosis Renal Colic Sydney March 2004

1. Twin Pregnancy: complications

malpresentation),

Diet, Iron and folate, Dietician referral, maternal

(polyhydramnios, preeclampsia, anemia, PPH, APH, Cord prolapse,

fetal complications

(IUGR, malformations),

High risk antenatal care

2. HIV test and counseling: Don’t forget testing for other STD’s 3. Spontaneous pneumothorax: Primary—no prior lung disease. Secondary—complicating preexisting lung disease (Asthma, Cystic fibrosis, COPD, TB, menstrual pneumothorax), Remember 30%, simple aspiration or catheter

4. Shoulder exam after dislocation:

Remember musculocutaneous and radial nerves as well, warn against abduction and external rotation

5. Incomplete abortion and cervical shock:

It’s a vagal stimulation due to cervical pressure and uterine stimulation hence a drop in BP and pulse. Investigations for recurrent abortion: karyotyping of parents and fetal products, U/S, Antiphospholipid and lupus antibodies

6. Conversion disorder and lower limb exam:

Remember to consider this diagnosis only after proper physical exam and investigations

7. Cranial nerve II and VIII exam 8. Endometriosis 9. Hypothyroidism: Remember decreased ankle jerk reflex, chronic anemia, Bradycardia, dry skin, edema

10.GI malignancy:

55 year old lady with 6 month pain in LLQ. Just remember normal history which includes: present illness, past history, medications and family history. Remember to ask about weight loss, bowel actions. Remember first degree relative screening.

11.UTI follow up in a child: Remember repeat MSU and VCUG 12.Acute psychosis management 13.Croup 14.DVT: remember heparin dose (treatment: 5000 U bolus IV and 25000 U infusions over 24 hour. Prophylaxis: 5000 sc 12 hourly)

15.RA hand exam 16.Cardiac murmur in a child

Brisbane October 2004

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Pyloric Stenosis:

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Breast Lump:

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Delirium and MSE: The patient which got crazy after burn. Weight loss: 100 Kg man complaining of tiredness, lethargy and 2 Kg

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3 weeks old child with vomiting. First important question is asking about color. If Green color then urgent surgical referral. If non-bile stained then consider pyloric stenosis, GORD, infection (UTI, meningitis). Projectile vomiting can be present in GORD as well as pyloric stenosis. In PS look for peristalsis during test feeding from Left to Right. Treatment is longitudinal pyloromyotomy. 24 years old with lump and tenderness in right breast. There is a palpable auxiliary lymph node. On OCP. Fibroadenomas are more common in younger women and may become tender in the days before a period or grow bigger during pregnancy. Women have a choice about whether to have their fibroadenoma removed, but if it is monitored and continues to enlarge, it should be removed. Most often, younger women or those with smaller fibroadenomas will not have them taken out. The operation to remove a fibroadenoma is relatively simple. A general anesthetic is usually required. Remember U/S and FNA.

weight loss. NOTE: Remember stress and anxiety, malignancy, DM, Thyrotoxicosis, chronic infection, depression and medications. He had DM.

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Weight loss:

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Home delivery counseling:

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Trauma and difficulty breathing:

45 year old female with 7 Kg loss over 2 month. All the investigations are normal. Talk to the patient. NOTES: consider stress and depression. A 21 year old 17 weeks pregnant doesn’t like hospital and wants a home delivery. Talk to her. A guy in emergency after

car crash. There is a CXR. Maybe haemothorax.

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Vaginal Bleeding:

26 years old with bleeding after 8 weeks amenorrhea. BMI is 30. Remember abortion, PCOS and thyroid disorders. (when they provide BMI, it means something) NOTES: approach is taking history of everything with these 3 diagnoses in mind. Investigation with BHCG and U/S and TFT. If it should multiple small cysts then bingo. Some points

about PCOS: remember risks of DM, hyperlipidemia, hyperinsulinemia and hypertension. Also increased risk of ovarian and endometrial cancer. Investigations include: LH/FSH ratio (>2), serum testosterone and endometrial biopsy. Screening for all women with PCOD include: smoking history, BP, Glucose (tolerance test), lipids. Management is weight reduction (dietitian referral) and exercise and PCOS support group. Treating the risk factors if present. Treatment of insulin resistance with metformin or rosiglitazone. Hirsutism with cyproterone or spirinolactone. OCP can decrease the chance of malignancy of unopposed estrogen and helps with irregular bleeding. Ovulation induction by clomiphene. Assisted induction and at the end ovarian diathermy. (making punctures on the ovary with a hot needle)

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Globus Sensation:

23 year old girl feels something in the throat. Her friend died a few month ago of throat cancer. Talk to her. Notes: take a complete history of dysphagia; ask whether she gets relief after swallowing. Weight loss, pain and family history. O/E look generally at skin and hands, inside the mouth for any lump and uvula deviation, tongue deviation, any neck lymph node, thyroid nodule (any symptom of thyroid activity) and esophageal obstruction test. (With a glass of water and listening for murmur in tummy which 7 seconds is normal). Investigate anemia and TFT. If everything normal then reassurance and education and support. Don’t forget leaflet and websites.

UTI follow up LLQ abdominal pain: Diverticulosis RA hand exam HIV counseling: The guy which has come back from Thailand Spontaneous pneumothorax ? ?

Melbourne November 2004

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Primary Amenorrhea: A 15 year old girl with normal secondary sex features.

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Post date pregnancy:

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Thalassemia minor counseling:

41 weeks pregnant lady comes for routine antenatal check. Notes: usually after 41st week induction should be tried because of increased risks both for mother and fetus. The baby gets bigger and there is risk of Meconium passage and intrapartum complications. Remember to refer to Day Assessment Unit for frequent CTG and U/S and remember the Kicking chart. Induction can be tried by Misoprostol or Oxytocin. Young lady who is minor is married with a minor guy. Answer the questions about what is minor and major. What does the child need if it’s major? And prenatal diagnosis with CVS and amniocentesis. Notes: Thalassemias is a genetic (inherited) blood disorder that has one feature, the defective production of hemoglobin, the protein that enables red blood cells to carry oxygen. The individual with thalassemia minor has only one copy of the beta thalassemia gene (together with one perfectly normal beta-chain gene). The child born with thalassemia major has two genes for beta thalassemia and no normal beta-chain gene. Thalassemia major patients rarely live beyond puberty.

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Chest pain:

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Abruptio placenta:

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Croup:

45 year old man complaining of chest pain on exertion. Notes: with lifestyle changes remember to start Aspirin. 32 weeks pregnant with spotting. U/S not available and CTG doesn’t detect fetal heart rate. Notes: Candidate has not asked whether the mom is in shock or not. Anyway it’s a still birth. DDx asked by examiner: concealed abruption, cord knot, preeclampsia, infections. 7 month old child with barking cough and high temp. Remember admission. Question by mum: what is croup: Croup is a viral infection of the throat

(upper airway). The virus causes swelling of the voice box (larynx) and windpipe (trachea). This swelling makes the airway narrower, so it is harder to breathe.

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Chronic diarrhea:

3 years old child with foul smelling diarrhea for 3 weeks which is hard to flush down the toilet. Has lost a bit of weight. Task is

talk to mum, provisional diagnosis and DDx. NOTES: candidate has diagnosed giardia, but the point is talking about giardia and celiac both. Stool should be checked for cysts and ELIZA or nasogastric aspirate for finding trophosoites. At the same time Antiendomysial Ab and if needed duodenal biopsy. So be careful.

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First time Epilepsy:

7 year old child has had a tonic-clonic fit for 1 minute at school with incontinence. Now he is fine. Talk to dad and manage. First ask about any previous disease like diabetes. He Needs admission for investigation like CT scan and EEG. Whether to start treatment is depending on the investigation results and neurologist choice. 60 % of children have a self-limiting condition which will settle after withdrawal of medication. Remember usual advices.

9. OA hand exam Acute abdomen:

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55 year old man who has been taking diclofenac for 2 month. Has got a sudden pain for 2 hours. DDx: perforated ulcer, MI, cholecystitis, gastritis, AAA.

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18 year old girl complaining of difficulty reading. Task is eye exam. Father and brother wear glasses. Snellen chart. Remember pinhole test and fundoscopy and tonometry. Referral to optometrist.

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Impaired vision:

Lung cancer and hoarsness:

55 year old guy, smoker who is complaining of tiredness and hoarsness. Task is everything. DDx is lung cancer, thyroid cancer, laryngeal carcinoma, esophageal carcinoma, bulbar palsy. O/E he has had decreased air entry and dullness in left side.

Benzodiazepine dependency:

The patient who wants oxazepam for sleeping problems. She has been to your practice for 2nd time. Candidate says that she has had suicidal ideas. So find out the real cause of her problem. Maybe depression and then she needs admission and it has not been a case of benzodiazepine dependency. Somatization needs 2 GI symptoms, one sexual, one neural and something else. They must be referred to psychiatrist. Treatment is CBT and psychotherapy.

Colle’s Fracture:

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reduction is under anesthesia by flexion, ulnar deviation, pronation and traction. Complications: ruptured extensor policis longus, stiffness of elbow and MCP, regional pain syndrome. Remember simple percutaneous pin insertion for severe deformity.

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Old lady has lost 6 Kg in 3 month. Task is history for 6 min and investigation. Remember stress and depression, malignancy, DM, thyroid and chronic infection. Notes: remember FBE, U&E, BSL, TFT, ESR, CXR and stool occult blood. Remember a full search for a possible source of cancer. (ask about mammogram, pap smear, bowel, urinary, respiratory symptoms)

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Weight loss:

Somatization:

Ask about family history.

A young guy with several symptoms for some years.

Sydney May 2004 1. Hip examination:

Past history of posterior dislocation, now complaining of stiffness and little pain. Look (wasting, swelling, redness, limping and abnormal rotation of the legs), Feel (the greater trochanters should be at the same level otherwise the higher side is abnormal), Move (flexion and Thomas’s test (fixed flexion deformity in OA), rotation, abduction and adduction, extension, trendelenberg test and trendelenberg gait, true leg length which shorter side has problem and apparent leg length which shows tilting at pelvis if abnormal) Note: in OA internal rotation, abduction and extension are restricted. (IR extension AB). Sciatic nerve checked by foot dorsiflexion. Management: pain killer, physiotherapy, hydrotherapy, total hip replacement with cementless material, femoral osteotomy for young people

2. Meconium stained fluid in labour: as Melbourne April 2006 3. Acute Otitis media in a child: Remember follow-up for glue ear (blowing exercise on the back of the hand and closed nose is helpful) and audiometry if necessary. TM will heal up.

4. Acute Psychosis:

Mom wants to know about his son who has been admitted. Mom asked about schizophrenia: it’s a medical condition which affects the normal functioning of the brain and interferes with the person’s ability to think, feel and act. Causes are a combination of hereditary and other factors. Sometimes it has trigger factors like illness, surgery, stress and drugs. Management: medication and community support (information, accommodation, and help to find job, psychosocial rehabilitation and mutual support groups).

Prognosis: some recover completely and some have chronic disease through out the life which needs supervision. Investigations during maintenance: BP, BSL, prolactin level, cholesterol and TG, TFT, U&E, LFT, FBE, ECG. First at 3 month then 6 monthly. Always remember leaflet

5. Female Urinary Incontinence:

Differentiate between stress, urge (with no residual volume) and voiding dysfunction with bladder atony

(large residual volume). History, PMH, medications and exam (any abdominal mass and vaginal exam). R/O UTI. Urodynamic studies, U/S and residual volume. Stress: pelvic floor exercises, weight control, HRT and vaginal creams and physiotherapy for cough plus continence nurse. If studies showed GSI then may need surgery due to sphincter weakness. If urge or voiding dysfunction then look for Gynecologic and Neurologic causes with referral. Use anticholinergics if exercises didn’t help or was severe. Remember the chart and leaflet

6. SIDS:

say I’m sorry and ask how parents are coping. Remember grief counselor, SIDS support group and leaflet.

7. Diabetes type I counseling: always,

Remember to carry sweets

leaflet

8. CTS:

Tell her as far as you are not overusing your hands u can do everything

9. Cyclical mastalgia/Lump (Fibroadenosis):

Ask what kind of OCP she is taking. Changing to triphasil to reduce progesterone is beneficial. First degree relative with cancer increases the chance 3 fold. Advice about regular self exam with leaflet and education (remember national breast cancer website). Mx: Analgesia, good bra, well-balanced diet, weight reduction, no caffeine, exercise, then mefenamic acid, vitamin B1 and B6, evening primrose oil (EPO), follow up then Danazol

10.Oligohydramnios:

34 week pregnant and everything else is normal. Task: history, exam, investigation and management. U/S has shown decreased liquor. She needs referral to hospital for full checkup of baby. She needs more frequent monitoring, If fetal distress then delivery. Volume<500 is Oligohydramnios. Associated with: prolonged pregnancy, PROM, fetal urinary tract malformation. Increased chance of preterm birth. Late onset oligo has a good prognosis, but early onset is nasty. Oligohydramnios detected before 36 weeks in the presence of normal fetal anatomy and growth may be managed expectantly. Cord compression during labor is common.

11.Renal Stone: Remember X-ray, CT-KUB, U&E, Follow up and leaflet 12.Peripheral Vascular Disease: 50 year old man on metoprolol for HTN. Remember Doppler U/S and ankle brachial index. Talk about lifestyle (smoking, drinking, fatty food, weight, exercise, too much coffee)

13.Migraine 14.Chronic diarrhea: having steatorrhea. 15.COPD: Remember pnumococcal (every 4 years) and influenza (yearly) vaccination. Remember physio for chronic cough.

16.Depression:

45 year old female complaining of tiredness and constipation.

Melbourne April 2004 1. Supracondylar Fracture:

Remember radial artery, collar and cuff for 6 weeks after reduction and NO need for plaster. Elbow stiffness will resolve without therapy.

2. Alcohol counseling and Child abuse claim: Remember standard drinking and Gatehouse.

3. Cirrhosis examination: A patient with esophageal varices. 4. Post Strep Glomerulonephritis: A child with dark urine and puffy eyes. RBC + in urine and BP 140/95. 15% with throat infection (GABHS) and 25% with impetigo. Invariably resolves, but should be treated in hospital with special care. Investigation: ASO, reduced C3, and U&E and increased AntiDNase. Management: admission, bed rest, fluid restriction, penicillin (if swab positive), low protein diet, antihypertensive and diuretics. The family members should be screened for GABHS and careers treated. Proteinuria may remain for 6-12 month and hematuria may remain for years. Follow up and

leaflet.

5. Hypertension: The 25 year old on OCP. 6. Polyhydramnios: 26 year old 32 week pregnant. Fundal height is

more than gestational age. 50% fetal abnormality, 20% maternal (diabetes and twins) and 30% no cause found. Ask about breathlessness and edema. Predisposes to preterm labour, cord prolapse, abruption as membranes break, PPH and malpresentation. During labour Check early for cord prolapse. After labour pass a nasogastric tube in the baby to make sure esophagus is patent. Acute hydramnios tends to develop earlier in pregnancy than does the chronic

form—often as early as 16 to 20 weeks—and it may rapidly expand the hypertonic uterus to enormous size. Minor degrees of hydramnios rarely require treatment. Even moderate degrees with some discomfort usually can be managed without intervention until labor ensues or until the membranes rupture spontaneously. If dyspnea or abdominal pain is present, or if ambulation is difficult, hospitalization becomes necessary. Bed rest, diuretics, and water and salt restriction are ineffective. Recently, indomethacin therapy has been used for symptomatic hydramnios. Remember Amniocentesis

7. Manic attack:

22 year old student with decreased sleep and delusions. Task is MSE and DDx and management. Notes: Elevated mood, accelerated speech, agitation, racing thoughts and flight of ideas, increased activity and reduced sleep. Sometimes paranoid with grandiosity, overspending, impaired judgment, increased sex, poor insight variable psychotic features like delusions, paranoia and hallucinations. Episode may be precipitated by stress. Admission is necessary. Lithium (level 0.6-0.8), valproate and carbamazepine. Lithium side effects: tremor, GI upset, muscle weakness and weight gain. DDx: manic attack, schizophrenia, delusional disorder, drug abuse. Remember psychotherapy and psychosocial supports.

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8. Diabetes and lower limb exam 9. iron deficiency in a child Pancytopenia in childhood Acute Abdominal pain: 26 year old female with 6 hour RLQ pain.

Task is history, exam, Investigation and DDx. (appendicitis, ovarian cyst, mesenteric adenitis, mitelschmertz, renal colic, pyelonephritis)

Primary Amenorrhea:

18 years old with no menses. Secondary sexual characteristics are normal. Mom had menarche at 17. Notes: first look for pubic hair growth. If normal it excludes androgen insensitivity syndrome. (Also high testosterone levels). Then look for secondary characteristics like breast development. If normal then it means that ovaries are functional and we can rule out Turner syndrome. Low body weight, stress, intense exercise (such as experienced by gymnasts or ballet dancers) or obesity associated with PCOD may be involved in primary amenorrhea. So ask about weight and anorexia. Look for any outflow malformation like agenesis of uterus, vagina or septum. Ask whether she has cyclical lower abdominal pain which reveals a septum blocking the blood outflow. Tests: testosterone, FSH, U/S. If FSH is increased then karyotyping is necessary. Remember to ask about mother and sisters menarche. It can be familial and in that case she should use a contraceptive method despite amenorrhea.

Otosclerosis: In pregnancy. Shortness of Breath: A 65 year old man with SOB. No chest pain. Cough in the morning with sputum. Heavy smoker for 25 years. Task is history, investigation and management. Remember to ask about blood in sputum and weight loss. X-ray has shown pleural effusion. DDx: Infection, malignancy, RA, Lupus. Investigation: CT scan, pleural tap, bronchoscopy. Transudate from increased venous pressure like volume overload or CHF or decreased oncotic pressure like live or kidney failure. Exudate from inflammation or malignancy.

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SCC:

A patient who you have excised an ulcer from his forehead and now is coming for path report which shows SCC which has extended to margin of the sample. Talk to the patient and tell him the management.

Diverticulosis:

57 year old male with constipation and abdominal pain (LLQ) which has gone for U/S and the report is Diverticulosis. Colonoscopy has been normal. His father died of colon cancer at 65. Task is management and F/U. Notes: complications are: abscess, perforation, peritonitis, obstruction and fistula. WCC and CRP to determine inflammation. Usually responds to high-fiber diet. Advice to patient: the gradual introduction of fiber with plenty of water will improve most of the symptoms and prevent the complications. 1. Cereals, muesli and porridge 2. Wholemeal and multigrain bread 3. Fresh fruits and vegetables. Bran can be added to cereal. At first might be uncomfortable but soon gut will settle.

Some 2004 cases 1. Hypertension:

A 19 year old girl has had 2 borderline BP readings in the pas and family history of high BP. All the investigations have been normal. Now she is worried and has come to you for advices. The candidate has diagnosed anxiety (!!!) as the cause and has failed the station. Remember to ask about OCP in every female patient in every station.

2. Hodgkin Lymphoma:

a young lady with cervical lymph node has done biopsy and has had Hodgkin lymphoma. Now has come to you to ask about disease, treatment, duration and complications of chemotherapy and radiotherapy. Notes: Lay Explanation: The lymphatic system is one of the body's natural defenses against infection. It is a complex system made up of lymph organs, such as bone marrow, tonsils, the thymus and the spleen, and lymph nodes connected by a network of tiny lymphatic vessels. Hodgkin lymphoma is a cancer of the lymphatic system. Many people with Hodgkin lymphoma can be cured, even when the disease has spread to different areas of the body. Complications: Some chemotherapy drugs can cause permanent infertility although newer treatments carry less risk of this. Treatment with chemotherapy and radiotherapy can lead to a slightly increased risk of developing another cancer later in life. However, modern treatments and approaches to treating Hodgkin lymphoma are designed to limit these risks as much as possible. Mediastinal radiotherapy can cause coronary atherosclerosis. Cure will be achieved in >75% of cases.

3. GBS infection in pregnancy: asking about prevention in her baby.

Pregnant lady who has GBS

4. Autologus transfusion:

A lady who is preparing for hip replacement and is asking about risks and benefits of autologus transfusion. Examiner has asked about the amount, storage time limit, how often and contraindications. Notes: Benefits are obvious. Disadvantages: Possible anemia and hypovolemia, Need for surgery to be scheduled 3-5 weeks in advance, any normal reaction due to venipuncture. Contraindications: Anemia, coronary artery disease, recent MI or unstable angina, active bacterial infection

5. Chronic cough:

A young lady who has come back from Malaysia. Antibiotics have not responded.

6. Transfusion Refusal:

A pregnant lady with severe placenta previa who is refusing blood transfusion.

7. Pregnancy in an epileptic woman:

She should be told about risks of AEDs (anti epileptic drugs) on fetus and if not taking them then increased risk of having seizure and death risk for herself and fetus. If she has been seizure free for 2-3 years then neurologist might think of stopping the medication. Otherwise medication should be continued with the lowest dose possible. Blood Levels should be checked during pregnancy (usually they decrease). Folic acid 5mg daily and vit K (10mg daily during the last month of pregnancy) should be started. Tell her about cleft lip, palate and NTD. Most of the epileptic women will have normal babies with good control. Breast feeding is allowed with AEDs because baby has got used to them. Alcohol and smoking must be stopped. Pethidine is not recommended for pain relief during labour.

Sydney May 2004 Resit 1. IV Cannula Insertion 2. GORD: Middle aged guy with reflux. Explain the results of endoscopy and give him advices about lifestyle changes.

3.

ITP:

4.

Nausea in pregnancy:

a child with nose bleeds and bruises after a cold. Platelet is 15. Remember avoidance of IM immunization. 38 year old woman who is 8 weeks pregnant has had severe nausea and vomiting a week ago. Today she has ++ ketone in urine exam. Task is history, investigations and management. Notes: consider molar pregnancy with high BHCG. Uterus is not firm in molar pregnancy and she might have hyperthyroidism symptoms because HCG resembles TSH. Outlook is excellent with abortion and if needed chemotherapy. Remember the CXR if molar pregnancy. She needs admission with a full work up. U/S in molar pregnancy is like a “snowstorm”. Remember to tell her about increased risk in next pregnancy and also increased risk of Down syndrome (1:200) at her age. A molar pregnancy is the result of a genetic error during the fertilization process that in turn causes the growth of abnormal tissue (which is not an embryo) within the uterus

5.

Otosclerosis:

Lay terms: It describes a condition of abnormal growth in the tiny bones of the middle ear, which leads to a fixation of the stapes bone. The stapes bone must move freely for the ear to work properly and hear well. Remember hearing aid and stapidectomy

6.

Bereavement:

7.

DKA:

In a university girl who has lost her father and can’t sleep and concentrate for exam. Remember the 3 stages of bereavement. Remember the medical certificate. Advice she about religious ceremonies, help from friends and mum, relaxation techniques and short course sleeping tablets. Remember Risk assessment. An 18 year old girl who is feeling tired and cannot work properly in

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the farm In a country setting with limited resources. Remember 10 unit IM insulin and N/S and air ambulance. If they asked about infusion tell them that you will check with endocrinologist at the base hospital. It’s usually 6 U/hour. Saline rate is 1 L in first hour then 500 ml per hour for the next 2-3 hours.

8.

Postoperative Dehydration:

Fluid therapy

Melbourne August 2004 1. Otosclerosis: The woman, during pregnancy. 2. Infertility: A couple which wife is normal and man’s semen analysis is: count=2 million, mobility<20%. Task is history and management. History should include: sexual function (potency), previous testicular problems or STI or mumps, medical problems, any genitourethral surgery, occupation (heat, chemicals), drugs and alcohol. In women you should also ask about all menstrual history and previous problems and surgeries, eating disorders and obesity. Remember to ask about adequacy and timing of intercourse. After history, exam should include checking the secondary sexual characteristics in both. In men remember varicocele and in women the vaginal exam. The fist workup includes: body temperature chart and serum progesterone in day 21 and vaginal U/S and rubella status in women, semen analysis in men. If semen analysis is abnormal then check the FSH level and antisperm antibodies and refer. If FSH is 2.5 times normal then it’s an irreversible

testicular failure. (Endocrinologist) remember the IntraCytoplasmic Sperm Injection (ICSI).

3. Meningococcemia: 12 month old child. 4. Chronic diarrhea: Young man with 3 month diarrhea. Task is history, clinical finding and management plan. Chronic diarrhea workup. Ask about blood or mucus in stool and diarrhea at night. If present then it’s not functional. Ask about stress factors. Abdominal pain and whether it gets better after bowel motion. Ask whether he has problem flushing his motions down the toilet (steatorrhea). Ask about any joint pain, eye problem, mouth ulcer or skin rash. Ask about travel history, drugs and alcohol and never forget sexual history and HIV. (Gay bowel syndrome: This term refers to a collection of sexually transmitted enteric infections in HIV infected homosexuals.) Remember the family history. Exam: Check for any systemic sign of IBD and clammy and shaky hands of thyroid dysfunction. Look for mass in abdomen and also splenomegaly. Look for any sign of Addison’s disease (hyper pigmentation and postural drop). Investigations: first stool exam (remember giardia and C. difficile). Then FBE, U&E, ESR, HIV, antiendomysial ab and TFT. Sigmoid and colonoscopy (and Proctoscopy) with biopsy.

5. Post Partum Bleeding:

In a country setting and you have tried syntometrin with no response. Placenta has been complete. Task is relevant history, examination and management. Notes: Remember 4 T’s: 1. Tissue: retained tissue, invasive placenta 2.Trauma: laceration, uterine rupture or inversion 3. Tone: uterine atony 4. Thrombin: coagulopathies. Check for these T’s. You can start syntocinon infusion (40 U in 1 L N/S over 10 hours). If no response then you can try Misoprostol 800 microgram PR. you can give ergometrine till 1000 microgram/day, but check BP. If there is laceration press it. Check clotting by bedside clotting test for 7 minutes. If abnormal start FFP. If bleeding continued then laparotomy. Uterine inversion: unable to feel uterine fundus: should be replaced immediately with pain relief like pethidine. DO not forget uterine massage in atony.

6. Ischemic heart Disease:

56 year old man who has done the stress test and has shown ischemia. Smoker and fat. Discuss and manage.

7. Alzheimer’s disease:

Daughter of a guy with the disease comes to you for discussion. She is the only child.

8. Jaundice:

a nurse which is lethargic and thinks she has hepatitis. She has dark urine and brown stool. O/E hepatomegaly and tender, jaundice. Has been taking augmentin for 6 days. Task is: history, exam, possible diagnosis and DDx. Jaundice murtagh

10. 11.

9. Vasectomy: Task: explain and answer questions SIDS Vaginal birth after cesarean: Success rates for VBAC range

from 60-80%. The benefits of a trial of labor outweigh the risks. In the absence of contraindications, a woman with one previous cesarean delivery with a lower transverse uterine incision is a candidate for VBAC and should be counseled and encouraged to undergo a trial of labor. Contraindications: A previous classical uterine incision, Epidural anesthesia is not a contraindication for VBAC, Oxytocin use for induction or augmentation of labor is not contraindicated, not recommended for

12. 13. 14. 15.

16.

patients with multiple gestations, for patients with breech presentation, or for the use of prostaglandin gel. VBAC support meetings. Anaesthetist and theatre to be notified of any patient for planned VBAC in Delivery Suites and in labour. Length should not exceed 2 hours: 1 hour to allow for Passive descent, but no more than 1 hour of Active pushing.

Allergic reaction counselling: egg allergy in a child. lower limb exam Diabetes DVT: The guy which is on metoprolol Eating disorder: A young girl sent to you by her dentist, concerned

about dental caries due to eating disorder. Task is history and Advice. Remember to ask about laxative or diuretic use. Ask about family relationships. In bulimia periods are irregular and amenorrhea is rare. Management: referral to psychiatrist and psychologist for behavioural therapy and intensive psychotherapy and family therapy, Supportive care by doctors and allied health staff, try to address the underlying psychological or family problems, SSRI beneficial for those with depression. DO ASSESS THE RISK

Thyroid cancer:

A young girl with thyroid nodule and FNA which shows papillary carcinoma. Task is explanation and management. Notes: papillary is important not to miss because of high cure rate. 60% of thyroid cancers. Involves total thyroidectomy, ablative I131, Thyroxin replacement and follow up with thyroglobulin measurement and thallium scanning. Prognosis is good if young and female. Follicular cancer: 25% of cases. Spreads early via blood. Treatment is total thyroidectomy and Iodine ablation. Thyroidectomy: A major operation under GA. Before operation check Ca level and vocal cords by laryngoscope. Complications: 1. Early: haemorrhage, recurrent laryngeal nerve damage (temporary or permanent depending on the severity of the damage), removal of parathyroid glands and resulting hypocalcemia and tetany, thyroid storm (treat by Inderal and antithyroid drugs) 2. Late: Hypothyroidism

Sydney August 2004 1. Jaundice:

A newborn having jaundice from 3rd day to 2nd week. He is breastfeeding. Task is history and management. NOTES: child had conjugated Billirubin and pale stools. He should be admitted under gastroenterology for investigation. LFT, Viral serology, U/S, HIDA scan.

2. Stuttering: 4 year old child after attending the kindergarten. 3. Placenta Previa: 28 weeks pregnant lady who had bleeding for 2

hours and now settled. You are an HMO in hospital. 18th week U/S had shown a low lying placenta. Task is history and management. NOTES: she needs admission, ask about pain, amount of blood and color, whether it was the first time, any previous medical condition, ask about previous U/S and antenatal clinics, twin. O/E VITAL SIGNS, gentle abdominal palpation for uterine check (usually not tender in previa), FHR, NO VAGINAL EXAM, just check whether there is ongoing bleeding. If vital signs are normal then arrange U/S. Blood for FBE, Group & Crossmatch, coagulation profile, feto-maternal haemorrhage test. Above 24 weeks consider steroid injection. CTG to check the fetus. Anti

D if Rh negative. Maternal monitoring, bed rest and obstetrician review. For previa should book theatre for elective C/S and for abruption if fetal distress then induction of labour.

4. Addison’s disease:

45 year old guy complaining of pigmentation. History, exam and management. NOTES: history: is it general or local? Tell me more. Is it itchy? Have you used cosmetics? Fever, cough or N/V? Appetite? Weight loss? General feeling? Sleep? Easy bruising? Water and bowel work? THEN: any past history? Medications? FH of high iron in the blood? THEN: O/E vitals and orthostatic drop. Look for hyperpigmentation of palmar creases and mouth. Investigations: FBE, U&E, Iron panel, BSL, U/A, high ACTH and low cortisol. Confirmation is by Synachtin test: 250 microgram tetracosactide injected IM; if cortisol was increased then it’s not Addison. Hydrocortisone is the treatment. Remember bracelet for crisis.

5. OCP counseling 6. Cholangitis 7. HIV test counseling 8. CN II and VIII exam 9. Minimental Exam: In an old guy who has brought in by wife 10. 11. 12. 13. 14. 15. 16.

complaining of forgetfulness and increased alcohol intake. NOTES: Alcohol impairs the ability to form new memories. It interferes with the transfer of information from short-term to long-term memory.

Postnatal depression: Do not forget RISK ASSESSMENT Clavicle fracture Anaphylaxis Decreased fetal movements CTS: 35 year old teacher complaining of weakness and decreased

sensation in the right arm. Remember that in CTS the pain might radiate to arm.

Thyroid nodule management:

U/S and FNA and if needed radioisotope scan.

The first test is TSH. Then