Melbourne 25th Oct 2008

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Breech presentation in labour Vulval itch urinary retention HSP Giardia Osteomyelitis Somatoform D/O Acute psychosis Gall stone Ca prostate Lacerated wrist Herpes zoster with CLL Infective endocarditis DVT arm Angina Otoscelosis

O&G
Full term pregnant lady, 2nd pregnancy, regular antenatal check up. Physical examination shows breech presentation with 38 cm fundal height. FHR:140/min Task: Further history taking Management 1. In history: No signs of labor, No HT, DM, PE, 18 weeks ultrasound NAD Fetal movement normal First pregnancy: NVD at 41/40, baby BW 4.4kg. even role player was not sure about the gestational week ??? blood group-----not sure Management: According to RWH guideline (www.rwh.org.au) Explanation the difference between breech and cephalic presentation Role player preferred vaginal delivery Order US to confirm the type of breech presentation and to rule out fibroid or placenta praevia which can cause breech. Risk of vaginal delivery (fracture, hypoxia, ICH, probable C-section) is higher compare with C/S Continue CTG monitor during labor if choose vaginal delivery. Might offer the option of ECV if no contraindication, but depends on the consultant. Need to R/O cord prolapse when water breaks. Comments: similar as AMC Case 78. Surprisingly. Feedback is in labour, maybe the role player was not well prepared.

AMC feedback: Breech presentation in labour

2. 60 y. o lady presents with vulvae itchiness to GP clinic. Task: Take relevant history In physical examination, ask examiner for picture then explain to examiner Diagnosis and management In history: 2 years duration Very itchy, seen by many doctors and was provided HRT cream but no improvement. No vaginal bleeding or discharge, currently sexual active. Deny history or symptoms of DM, no allergy, no excessive soap use for local area, no previous Candida infection. . LMP 10 years ago, no menopausal symptoms Last Pap smear 3 years ago No UTI symptoms. No PMH or FH of any kinds of cancer In the picture provided by examiner, multiple redness of vulva, whitish thickened area around labia majora. Examiner asked the diagnosis---- Lichen Sclerosis is most likely, but need refer to specialist to rule out SCC (biopsy)---- examiner said, biopsy is negative for SCC. Management: Investigation: urine dipstick ( to rule out DM), Pap smear Topical steroid cream for 6/12 Regular follow up due to the low risk of malignant tendency. AMC feedback: Vulval itch

3.

24 y. o. lady in GP clinic, complaining of not passing urine for 16 hours and pain in vulvae area. Task: Further history, P/E and Management. In history: sexually active, new partner 2-3 days ago with unprotected sex First onset, no bleeding or discharge. No abdominal pain but discomfort. LMP 3 weeks ago No previous UTI, no current UTI symptoms No systematic unwell. Deny injury, not on any medication. Deny previous pelvic ultrasound. (to rule out uterus fibroid) PAP smear up to date In P/E: GA and V/S are normal Supra pubic dullness on percussion, rash and blisters on genital area.

Too tender to insert speculum Management: Transfer to hospital immediately for Supra Pubic Catheterization (explain the procedure) Offer pain management and Acyclovir for HSV Try pass urine under water Need to arrange Urine test to rule out UTI and STI screen test. Safe sex education Questions from role player: Can it happen again? AMC feedback: urinary retention

Paediatric
4. Picture provided (different from AMCQ book), 5 year old boy presented with intermitted tummy pain and limping, refused to walk. URTI 10 days ago. Task: History Ask P/E from examiner Order investigation, Diagnosis and Management. In history: First onset, one day duration. Limping, refuse to walk. Joint pain. No urine color change, Systemic well, afebrile P/E: BP 90/70 non-blenching purpuretic rash, distribute in buttocks and back of the legs. Investigation: FBE----examiner provided the result which is normal Urine Dipstick---RBC ++, protein +, the rest NAD U+E: not available Diagnosis: HSP Management: Admit to hospital Paracetamol for pain Steroid may be used to reduce the duration of abdominal pain. Monitor BP, renal function and urine. Follow up: 1 year for the above after discharge. Good prognosis AMC feedback: HSP 5. A 3 year old child presented with diarrhoea for 3 weeks. 2 other children at home. Task: history, P/E, Diagnosis and Management In history: watery diarrhoea, 3-4times/d, not explosive (not sure about smelly), no blood or mucus No tummy pain, no nausea or vomiting. Urine normal Child careyes Other 2 children and parents--- no diarrhoea, No traveling history, afebrile

No undigested food in the stool No pale stool, not difficult to flush, no buttocks atrophy Growth and development are normal. No milk intake during this period, not on medication P/E: active boy, 50th percentile weight and height, others NAD Diagnosis: suspect Giardiasis, DD: Coeliac disease, toddlers diarrhoea, diarrhoea caused by other viral or bacteria, lactose intolerance. Investigation: stool analysis m/c/s Can be confirmed by small bowel aspiration but not necessary at this stage. Management: Metronidazole 2g daily for 3/7 hygiene Follow up if not responsive AMC feedback: Giardia lamblia infection 6. 5 y. o boy presented with fever and limping to ED. Task: relevant history, ask P/E, Diagnosis and Management In history: No recently infection, Trauma: maybe First onset, one day history. Eating and drinking ok. Growth and development is normal. Immunization up to date. P/E: T 39.5, generally unwell Right tibia tubercle tenderness, no knee joint swelling. No localized redness. Refused to move the lower limb. Hip and ankle joint NAD. No LN enlargement in groin. Left side NAD Diagnosis: Osteomylitis Management: Admit to hospital Arrange FBE, Blood culture, knee X-ray, Bone scan IV antibiotics (flucloxacillin) then oral, 4-6 weeks totally Pain relief, elevation and immobilization the limb. AMC feedback: probable osteromyelitis

Psychiatry
7. (long stem) A 35 year old woman presented with cough for 6 months, dry cough, no other unwell. Investigations including CXR, CT, bronchoscopy etc are all normal. Task: Take psychiatric history for 4 minutes Diagnosis and Management In history: husband and 2 children left her 6 months ago Depression Questions--- negative

Suicidal idea--- no Anxiety: worried about her kids No hallucination or delusion Deny drug, no smoking, Alcohol on weekends His Father diagnosed with lung Ca 2 years ago. 4 mins bell rang before I finish the history. Management: Psychogenic cough Explain not organic, relationship between mind and body Refer for CBT Lifestyle modification, relaxation technique Social worker, contact husband and kids AMC feedback: Somatoform disorder 8. A 20 year old uni student failed the final exam, took illicit drugs, and had some behavior change recently, with hallucination and delusion. Grandma has the history of schizophrenia. He was diagnosed with acute psychosis. Patient gave consent to talk to his mom about his condition, but not the drugs. Task: talk to the mom. Counselling: Explain the condition Explore the possible reason Hospital admission and further investigation to exclude medical cause Psychiatrist review and put on medication Regular follow up Prognosis is good Questions from mom: Is it very necessary to be admitted? Can I just take him back home for a few days rest? Does he use any drugs? AMC feedback: First episode psychosis- parent

Medicine and Surgery

9. GP setting, 45 years old woman complained of bloating for 6/52. Previously you have done the physical examination which was normal. You arranged an US (photo provided) which reports three stones in the gallbladder, the CBD was not dilated and the gallbladder wall was not thickened. Task: Explain the US result to the patient Management Explain US by drawing a picture Diagnosis: Incidental gall stones Reassurance. Common condition, asymptomatic in most cases, bloating is non-specific. Option1. Observe: might have some complication (cholangitis, cholecystitis or Pancreatitis), if

high fever, jaundice or severe tummy pain, need to go to hospital. Option 2 Refer for surgery: depends on surgeon Complication of operation: bile leaking, abscess, bleeding, biliary colic post operation. Question from examiner: any medication for bloating? Which option do you suggest? AMC feedback: Incidental gall stones JMGP 629 JMPE 247 10. 68 year old man presented with urinary problems and investigation has been done which showed: Urine dipsticks: Nitrate and leucocytes. PSA: 6 (normal range was provided) Prostate biopsy: Prostate Ca (T2), Bone scan: NAD, CT chest and abdomen: no metastasis was found. Task: Explain the investigation result and management. Role player said I know I have prostate Ca. -----Not a breaking bad news case! Explain diagnosis of UTI and management Explain prostate Ca: T2 means not beyond prostate gland, and currently no sign of cancer spreading. It is a early stage. Options for management: 1. Conservative, observation--- not recommended due to symptomatic. 2. Radical prostatectomy 3. Radiotherapy: 4. Brachytherapy: 5. Hormone manipulation: for metastasis or locally advanced disease bilateral orchidectomy daily antiandrogenic tablet Side effect of the above management eg: impotence and incontinence Questions from patient: please tell me doctor, which is the best option for me? AMC feedback: Prostate Cancer /Diagnosis 11. Wrist cut of ulnar side, perform the physical examination. Finding from P/E: Vascular: normal capillary refill and pulse Nerve: ulnar injured (sensory loss of ulnar side with positive Froments sign), radial and medial nerve intact. Tendon: 4th and 5th flexor digitorum superficialis and profundus are both injured. Examiner send me out before I mention the management. AMC feedback: Lacerated wrist 12. (Photo was provided: unilateral rash alone the left rib cage, typical shingles) 60 year old lady presented to GP clinic with painful rash. She also complained of fatigue and weight loss for 6/52. Task: Take history for 5 min. Ask examination findings Diagnosis and Management

In history: focus on the cause of the shingles---looking for malignancy! First episode, previous chicken pox( role player was not sure) Weight loss 3-4 kg in 3-4 months, with fever and night sweat. GI system: no n/v/d, no color change of stool and urine, slightly epigastric discomfort. No abdominal pain. Respiratory: no cough, SOB Breast and PAP: NAD, no PV bleeding No smoking, alcohol or FH of malignancy P/E: T 38.0 Bilateral axillary and groin area LN enlargement No mass was found in abdomen. Respiratory NAD PV and PR NAD Suspected diagnose: Lymphoma /leukaemia Shingles Explain the relationship between the above two conditions. Immediately refer to specialist for LN biopsy and FBE, ESR and CRP then manage accordingly. Shingles management: systematic acyclovir (to prevent post hepatic neuralgia), paracetamol and local cream for pain. AMC feedback: Herpes zoster with chronic lymphatic leukaemia 13. A baker complained of tiredness for 1-2 months. Task: History Ask P/E finding Investigation and Management In history: no depression Weight loss 1-2 kg Fevernot noticed, no recent URTI Recent dental procedure Heart racing Deny PMH of heart disease, no previous IVDU. Examiner stopped me when I asked patient the other possible causes of tiredness such as DM and Hypothyroidism. P/E: T 37.8 No Osler node or petechiae Fundoscopy: NAD Hear rate and rhythm: 80 regular, systolic and diastolic murmur Splenomegaly Investigation: FBE, ESR,Blood culture(three sets at different times), ECG, Echo heart Management: Admit to hospital

Prolonged IV antibiotics AMC feedback: Fever of undetermined cause 14. 24 man cleric complained of right arm swelling. Task: History Ask P/E finding Investigation, Diagnosis and Management In history: First episode for 2 days, sudden onset. Swelling and pain of the right whole arm and hand No cough, SOB or chest pain. No trauma Playing basketball for 4 years. No medication, Forget to ask recently traveling and operation. No PMH of DVT, no FH of DVT P/E: G/A and V/S NAD Right whole arm swelling, tender with pitting oedema, no LN enlargement. Normal ROM Investigation: US of arm for DVT, if confirmed then admit and further investigation (thrombophilia screen, coagulation, ECG and V/Q scan). Management: warfarin and heparin, monitor INR. Also mentioned warfarin S/E and drug interaction. AMC feedback: Painful swollen right arm 15.Your patient that you know well, last time had a bit discomfort in his chest, you gave him GTN last time and it resolved so you arranged stress test. During the test, he had chest pain and also his ECG showed ST depression in antero-lateral leads. Angina was diagnosed. The cardiovascular risk factors were given in the second page: smokes for many years, has tried to cut down to 3-4 cigarettes/day, drinks occasionally, BMI 31, BP 145/90 cholesterol 6, no Hx of diabetes. No family history of heart problems. Task: tell the patients the result and your management short and long term Explain the angina, not heart attack Arrange further investigation: BSL, angiogram Life style modification: stop smoking, reduce weight, regular exercises, healthy diet, stress management. Medication: GTN, Aspirin, B-blocker, Statin Action Plan: ED by ambulance if chest pain more than 10 mins or not relieved by GTN. AMC feedback: Angina pectoris 16. GP setting, hearing loss noticed during pregnancy. AMC book case 54.

Tuning fork was hided. AMC feedback: hearing loss Finally, I found ONE case exactly from AMC book. Please note, currently AMC introduce new cases from the book, such as case 12. So we have to be well prepared and understand the knowledge rather than just remember the scenario. Thanks God, I passed all 16 stations. Special thanks to Dr. Wenzel and his Thursday evening classes and Mr. Alan and his VMPF short course. Good luck to every AMC candidate.