1: Snake bite

2: Immunization Advice
3: Falling off a horse
4: Primary Survey of a Trauma Patient
5: Facial Trauma Exam
6: Travel Advice
7: Warfarin Counseling:
8: Anti-coagulant Therapy
9:Sciatica
10: Weight loss- Good Case !!!
11: Insomnia in a Night Shift Worker

ADMIT!! - Once admission, Monitor Vitals 24 hrs. Open IV line and give
fluids (NS)

1:
You are HMO in country side hospital and a 32 years old woman comes in with complaint of

Now take History:

When did it happen?

What were you doing?

Hx:

being bitten by a snake on the right leg just below the ankle about half an hour ago.
o Tasks:

Provide first-aid

Did you see the snake? What color? (Type of Snake)

Relevant investigation and management

Neurotoxic symptoms:

Any headache? Blurred vision? Shortness of breath? Difficulty

**** In exam, DO NOT MOVE THE ROLE PLAYER EVEN IF THE PLAYER IS SITTING. DO IT

in swallowing? Dizzy? Sleepy eyes (ptosis)? Heart racing?

AS HE IS SITTING.

Weakness? Loss of consciousness

50% of snake bite mortality is from BROWN SNAKE.

Hematotoxin symptoms:

Bruises and marks after bites? Bleedings nose or/and gum?

START

Danger Response Airway Breathing Circulation Disability, Is my patient stable?

Passing water (urination) after bites, any changes in color and

First aid (Immediate Management)

blood

No suction, no washing, no incising, no excising

1st day:

PMHx:

Kidney problems and

Bleeding disorder before bite

Immobilize the limb with splint

Apply bandage from toes to upwards (exert compression to suppress lymphatic

Medication history steroid, aspirin, warfarin

spread

Allergic history NIL

Bite site location, oozing of blood, skin changes, redness,

o Ex:

Take swab from bite wound

Bandage over the wound leaving tip of toe or hand.

Immediately mark the bite wound over the bandage

Bandage should be in appropriate tightness (Must be able to insert 2 fingers)

Use splint if available (Not as necessary as IMMOBILIZATION)

Ptosis

Ask the patient to drink as much fluid as possible

PERLA (Pupils Equal and Reactive to Light and

ulceration

Complete neurological examination:

Accommodation)

Tongue protrusion

o FBE, U and E along with calcium level

Dysphagia

o Creatinine kinase (Rhabdomyolysis)

Tendon reflexes

o ECG (Electrical Problems)

Check local lymph nodes for LAD

o Coagulation profile (Haematotoxin)

Skin for bruises

o Blood for grouping and matching

Urine dipstick and BSL (save the first part of urine to save later

o ABG : (Acidosis)

on)

o Urine sample and freeze for later use

o Snake Venom Detection Kit

Brown: neurotoxic + vasculotoxic

Tiger: neurotoxic + vasculotoxic + rhabdomyolysis

Black: neurotoxic + vasculotoxic + rhabdomyolysis

Death Adder Snake: neurotoxic

Taipan: neurotoxic + vasculotoxic + rhabdomyolysis

o Myoglobulin

o Do not routinely give polyvalent-antivenom as there is high chance of

serum sickness especially if the type of snake is known
o Give SubCut adrenaline 5 minutes before ASV (anti snake venom) below

Mx:

0.25 mg for adult

0.05 for kids

If No signs and symptoms and snake venom kit (-) - repeat in 3

o IV ASV diluted in 1:10 Hartmanns solution

hours with URINE (save first urine)

o Infusion over 30 minutes

(if -) >> Repeat in 3 hours time >>

o Emergency kit in hand with adrenaline, antihistamine, steroid and O2 kit

(if still -) send home

o Infusion given >> check urine 3 hours afterwards

(if +) antivenom

o If still (+), another infusion

(if +) >> antivenom

o Give antivenom, until all the venom is neutralized

o No signs and symptoms but Snake venom kit (+) - Give Antivenom

o PO prednisolone 50 mg daily for next 5 days to prevent the risk of serum

o Signs and symptoms (+) but snake venom kit (-)

N/V, palpitation, anxiety, sweating and tummy pain

>> repeat test in 3 hours time if (+) >> give antivenom,

sickness. Once the patient snake venom test kit become negative, monitor
24 hours for the delayed anaphylaxis.
o Neostigmine for muscle paralysis if antivenom not available

o If Neourological or vascular signs:

Protocol for antivenom

Investigation:

Give antivenom >> repeat 3 hours time with urine

o FFP for coagulation defects

Complications of snake bite:

o DIC

o Renal failure
o Muscle paralysis (respiratory distress)
o Multiorgan failure

Constitutional symptoms like Fever? Headache? N/V? Any numbness/tingling in

the affected area? Any spasm or stiffness of muscles? Spasm of muscles of the

2:

face (risus sardonicus) or difficulty opening of the mouth (trismus)? Stiffness or

You are an HMO in ED seeing a 72-year-old male who stepped over a rusty nail yesterday. The patient

arching of the back (opisthotonos)? Any problem with your breathing? Any

recently migrated from Turkey to Australia. He has a history of COPD. There is a wound on the left foot

problems with swallowing?

o

that is clean and dressed.

When were you diagnosed with COPD? Before coming to austrlia i had a CXf
and was diagnosed with COPD. Do you feel SOB now? Any medications for

Task

Further history

that? Do you have any past history of serious medical or surgical conditions?

Management

Any FHx of COPD or other condition such as MI, DM, HTN, stroke? SAMA?

RCH tetanus guideline:

(heavy smoker but stopped 3 years ago)

Management
o

The condition I am concerned about is tetanus which can appear one day to
several months. It is a condition that results when clostridium tetani enter the
body through puncture wounds as in your case. These bugs multiply in the body
and produce a very powerful toxin called Tetanospasmin that can cause
uncontrollable spasm of the muscles. For this reason, I need to give you

1 dose now, in 6 weeks and 6 months of aDT (adult Diptheria and Tetatnus); Ig

immunization with aDT and Immunolobulin one injection IM on each arm. The

For big wounds: local disinfection, surgical debridement and antibiotics (penicillin or metronidazole) -

aDT will be given again in 6 weeks and 6 mos. The Ig is effective from the time it

prevent gas gangrene

is given.

History
o

Can you tell me more about it? (I was trying to help my son in the farm and

exposure. Do regular exercise to control you weight. Prophylaxis with annual

stepped on a rusty nail accidentally.) Did it penetrate the skin? (Yes.) Were you

influenza vaccine and 5-yearly pneumococcal vaccine. In case of exacerbation

wearing shoes at that time? Did you take it out by yourself? (Yes and my son

early treatment with amoxicillin. Possible referral for pulmonary rehabilitation.

cleaned it and dressed it.) Did you have bleeding from the wound? Only a small

Drugs which can be given are bronchodilators like ventolin, and LABA, inhaled

amount. Did you take any medication? Any swelling or redness after that? Do

steroids, etc. Home oxygen if required at later stages and CXR annually for

you have any pain in your foot now? Is it for the first time? (Yes.) Have you ever

screening of lung cancer.

been immunized against tetanus? If yes, when did you last have your booster
dose?

For your COPD, please avoid smoking especially passive smoking and dust

TIME OF
VACCINATION

WOUND

TT

HTIG
(tetanus
immunoglobin)

All

5-10 years

Clean
Others

>10 years
Uncertain or
less than 3
doses

All
Clean
Others

+
+
+

3 or more TT
<5 years

Disability: Would you kindly check her GCS: opens eye to pain, no verbal
response, withdraws to pain; If GCS<8 intubate.

3:
o

check her pupillary response (equal to light but sluggish)?

You are an on-call medical visiting officer. A Nurse from a town hospital which is 30km away is on the
phone who wants o talk to you about a 10-year-old girl who had fallen from a horse.

Do you know how to intubate? Does anyone know how to intubate? Can you

Exposure: Avoid hyporthermia

Task

Head and neck: Can you check her from head to toe for any other

Talk to the nurse on the phone

obvious injuries or sites of bleeding (swelling on the right temporal

Give appropriate advise for management

area)? Swelling on the head? Any laceration? Any discoloration on the

Ascertain Haemodynamic Stability first: DRSABCD

mastoid process or eyes? Any leakage of fluid from nose, or ear?

Is she safe to approach? (D)

What about her response? R Is she responsive/conscious? (unconscious and

Tracheal deviation? Paradoxical movements of the chest?

not responsive)
o

you? Can you ask the ambulance to standby?

Pelvis: injury, swelling or fracture, Any blood at the urethral meatus?

Airway: Can you check the airway? Check vomitus, bleeding, secretions, broken

Periphery: deformity, swelling, injury, fracture

I will arrange urgent transfer via air ambulance to a tertiary hospital (RCH)

Cervical collar?

because she needs an urgent CT scan. Please monitor the child especially her

Breathing: Is she breathing spontaneously? Are the chest movements equal?

vital signs, GCS and ABC and can you insert an indwelling catheter please. Can

Can you check the chest and tell me if the airway is clear? RR? Oxygen

you check her blood sugar level as well?

saturation? Can you give high-flow oxygen via face mask and attach it to a
pulse oximeter?
o

Abdomen: Bruise, distention, tenderness? Any blood at the urethral

meatus?

Can you call for help? (S- Send for help) Is there anybody else who can help

tooth, dentures? Can you pass a nasopharyngeal airway or Guedeal airway?

Chest: Rib tenderness or contusion or any obvious rib fractures?

Examiner questions:

What else can you do? Elevate the head of the bed around 20-

Circulation: I would like to know her pulse (60) and BP (145/85) Cushing

30 degrees (should not be in shock or compromise to spine).

reflex causes arterioles to constrict leading to ischemia increasing BP and

Mannitol (0.5-1g/kg)/anticonvulsants/steroids; She needs

activation of baroreceptors causing bradycardia. What about her peripheries? Is

urgent neurosurgical assessment and they might need to

it warm, cold or clammy? Can you pass an IV line with 2 wide-bore needles and

undergo surgery; Tetanus

take blood? (FBE, blood group and crossmatching, U&E, BSL, ABG, coagulation
profile)

Can you check the patients spine? It is not possible to check it

now because we need at least 3 people to check the spine
using the log roll technique.

Secondary survey: History (AMPLE allergy, medications,

past history, last meal, event/incident) and Physical
Examination, monitoring

Breathing: Look, listen and feel for breathing; get pulse oxymeter and give
oxygen; is the chest moving? Look for bulging or deformity and look for tracheal

4:

deviation. I need to listen for the chest sounds; (right side of the chest is not
Variant 1:

moving; (+) chest lag; breath sounds are absent). I am considering tension

A 25-years-old man was brought to the ED where you are working as HMO who had been involved in a

pneumothorax. I need to remove air by inserting a cannula on the 2nd ICS MCL

MVA. He has lost consciousness for 5 minutes.

then attach to underwater seal and drain

o

Circulation: feel for carotid pulse; ask for pulse and blood pressure; insert two

Variant 2:

large bore cannula and start patient on NSS or PLR (for fluids and take blood for

A 22-year-old male came to you at the ED because of fall from a horse.

investigations)

Task

Disability (neurological): GCS; for rapid assessment: ask patient to stick tongue

Perform primary survey

out, wiggle toes, ask to make a fist; look for PEARL and fundoscopy findings;

Immediate investigation

AVPU (alert, verbal response, pain, unresponsive)

Management

pelvic and check for any swelling and tenderness; put hands on the sides of the

Primary Survey: DR ABCDE

o

pelvis/back to check for any blood on the fingers

Danger: Wash hands!! Is my patient safe to approach? (check for glass, needle
o

or anything that may injure doctor or patient); on looking around there is no

Tension pneumothorax: presents with SOB; chest lag with bulging of the chest

obvious danger

and neck veins bulging out; tracheal deviation; increased JVP; decreased breath

Response: (goggles, gloves, gown); take care of neck injury!! Put a collar to keep

sounds and hyper-resonant chest

neck stable as much as possible Must put neck collar with examiners

Exposure: (don't move patient) expose areas such as chest, abdomen, and

Investigations

help!!!!! ; stand behind patient, hold neck (in line stabilization) while saying

FBE, BT and crossmatching

Nathan, my name is _____ one of the doctors taking care of you, can you hear

U/E/C

me? Do you have any pain anywhere? (i have pain on my chest); I will give you a

BSL

painkiller!!); ask for help!!

ABG if necessary

Airway: Can you open your mouth for me? Check for any injury, vomitus, blood,

CXR, cervical spine xray, AXR, pelvic xray

loss of teeth, dentures, etc. Suction if necessary; pick up foreign objects if

cranial CT scan

necessary with forceps (don't use hands)! Ask examiner to hold the head until

Refer to surgical registrar for secondary survey (full history and management)

you put the collar.

If unconscious patient - do modified jaw thrust and insert Guedel

may be appropriate: observation and reassessment when the

oropharyngeal airway (An oropharyngeal airway (also known as an oral

patient is able to fully participate in clinical assessment.

airway, OPA or Guedel pattern airway) is a medical device called an

airway adjunct used to maintain a patent (open) airway. It does this by
preventing the tongue from covering the epiglottis, which could prevent
the person from breathing. When a person becomes unconscious, the
muscles in their jaw relax and allow the tongue to obstruct the airway);
put cervical mask; give oxygen via bag-mask ventilation

Contraindication to oropharyngeal airway: basal skull fracture

One case: start with GCS and then primary survey Another case: left
pupil dilated -- neurologic cause
Another question: patient with cervical collar; how would you check
midline tenderness? (remove collar and palpate at the back cervical
spine) --- Nexus criteria (if negative then may remove collar)

RACGP Nexus Criteria:

midline cervical tenderness

altered mental status - orientation

focal neurologic deficit (weakness or paresthesia, numbness in

any limb)

evidence of drug or alcohol intoxication, and

presence of other injury considered painful enough to distract

from neck pain.

If none of these criteria is present, the patient is considered to

be at low risk of cervical spine injury and does not require
cervical spine imaging. If any one of the criteria is present,
cervical spine imaging is recommended to exclude injury. In
the case of intoxication, however, the 'wait and see approach'

Inspection (Look): there is a bruise on the left side of the cheek; no obvious
asymmetry or swelling is noted; no obvious fractures.

5:
o

A young female came to ED where you are working as an HMO after she had a MVA. She was sitting in

orbital floor fracture) or any swelling or redness;

the passenger seat and had her seatbelt on. She had an injury on her face (small bruise on left
cheek/maxilla)

Task
o

A. Focused history

B. Relevant examination (comment on what you are doing)

C. Further management

I would like to start with DRABC. Is my patient hemodynamically stable?

Would you like painkillers? I understand from my notes that you had an accident.

On the nose there is no obvious fracture; no obvious drainage of fluid.

Ask patient to open the mouth and look for any loss of tooth or injury.

On the ears look for any injury, bleeding, or fluid. There is no battle sign
(discoloration of mastoid due to basal skull fracture)

History:
o

On the neck and head, there is no obvious swellings, bumps, deformities

Feel: feel surrounding area for fracture or tenderness; feel head for any injury or
swelling; feel cervical spine and paraspinal muslces to look for tenderness;

Cranial Nerves: take torch to look for pupillary light reflex; do EOM extra ocular

I am sorry for that. Would you like to tell me more about it? (happened an hour

muscles (diplopia); ask for funduscopy and visual acuity; take pin to check for

ago, car was on signal and another car hit from behind and her face hit the

sensation; clench teeth; corneal reflex; close eyes and do not let patient open

dashboard during collision) Do you know the speed of the car coming from

them; open teeth and smile for me;

o

behind? You have an injury on the face do you want any painkillers?
o

Any numbness on the face?

Did you injure your head? Any other part of the body? Do you have any
headache? Did you lose consciousness? Any N/V? Blurred vision? Any leakage

Move: do ROM check range of motion of neck;

Management
o

Keep patient for few hours in ED for observation (delayed traumatic subdural and
intracranial hemorrhage can occur even with relatively mild injuries)

of fluid or blood in the ear or nose? Any feeling of dizziness or drowsiness? Do

In the eyes there is no raccoon eyes (purplish discoloration around the eyes:

you have any pain on the neck? Any problem moving your neck?

No CT scan needed; do only if warning signs are present ;

How did you come out of the car? How did you come to the hospital?

Discharge with red flags: headache, neck pain, fluid from the nose and ears,

When did it happen? How is your friend?

Any medications or previous injuries? If driving, were by any chance under the

How far do you live away from the hospital

influence of alcohol or drugs? SADMA?

Ice packs to reduce swelling

Examination (presence of torch, pin, and cotton)

o

Ask for consent

bleeding, drowsiness/LOC, N/V, blurring of vision (especially in first 24-48 hours)

Check plans (how long,

6:

where you want to go and

A 40-year-old couple came in to your GP clinic for travel advice. They lived in Australia for the last 30

what you are planning to do),

years and never traveled outside. Before going to UK, they will stopover at Thailand for 2 weeks.

Current medical conditions (recent operation, previous DVT)

Task

FHx of clots, allergies, heart conditions, motion sickness, immunization status,

medications, medical private cover for travel, smoking, alcohol use, illicit drug

Give travel advice

use,
Hepatitis:

Hepatitis A and typhoid mandatory

Hepatitis B (optional) tattoo

Flu UK

ASK when they are planning to leave??

Have they already bought their ticket?

All travelers to Asia and Europe should be uptodate with their immunization. For asia,
hepatitis A and typhoid can be given one single shot together. Hepatitis A can cover

Japanese encephalitis

you for a lifetime if you have another 2 shots (6 and 12 months). Typhoid will give you

Rabies

cover for 3 years only. If you need to travel again to destinations where typhoid is

Cholera

endemic, you need to have another shot.

Meningitis (Africa and Meccah)

DPT should be uptodate if there are chances of going to polio areas.

Malaria prophylaxis

Hepatitis B is optional if youre having an operation, tattoo or if there is risk of any contact

with blood.

Short stay: doxycycline 100mg 1 tab OD 1 week before travel, during,

and1-2 weeks after return

Please pack a medical kit (antibiotics, paracetamol, metoclopramide, loperamide, alcohol,

bandage, etc). Ensure that you have all medications that you might need to use. Check

Ricky aged 32 years visits your GP clinic. He is traveling to SEA in the next couple of weeks and

that these medications should be legal in your country of destination. I am happy to give

requests for shots as suggested by his mates. Ricky is otherwise healthy and fit. He is not on any

you a summary of your medications.

regular medications.

Pack first-aid items. Take some medications like sunscreen, anthistamine and motion
sickness tablets.

Task
o

How will you manage his request

Make sure you have medical insurance with premiums for travel.

Travel Advice

I will give report summary of immunization.

Congratulations on having your first trip.

History should include:

The night before you travel, sleep well. Quit smoking before travel. On travelling, drink

weeks (SE: photosensitivity and gastric upset) OR Mefloquine 250 mg 1 SD

rich/heavy food. Avoid caffeine and alcohol.

weekly 2 weeks before, during and 4 weeks after coming back

Wear loose non-restrictive clothing to avoid clots. Dont sit with your legs crossed. Move

Take only short naps.

Try to eat and sleep at the destination areas timing.

On arrival, avoid critical tasks and if needed to sleep, take short naps 40 minutes long
maximum.
While you are away, eat and drink safely. Wash your hands with soap and water before
eating. Select food that has been freshly and thoroughly cooked. Avoid uncooked food
especially eggs and street vendors. Avoid ice creams and boil/milk and water if not
bottled. Avoid brushing your teeth with unsafe water.

Act safely. Wash your hands. Avoid skin piercing and tattooing. I would advice you to
practice safe sex. Avoid insect bites. Apply repellants if needed. It is preferable to choose
an airconditioned hotel.

Safe Sex and Safe limits of Alcohol

Accidents (wear helmets, protect yourself)

Water/Sports injuries; avoid swimming in fresh water, lakes

Upon return if youre exposed to animal bites or feel ill or risk of mosquito bite or sexual
contact, come back to me for review (up to 6 weeks).

Doxycycline 100 mg OD 2 days before, OD during travel everyday then up to 4

plenty of water at the airplane and non-alcoholic drinks. Dont overeat and avoid

around when relevant. Exercise calf muscles when seated.

Malaria prophylaxis:
o

Use mosquito repellent, use light long-sleeve clothings, avoid going out after
dusk; use nets impregnated with permethrin or deltamethrin; avoid using
perfumes, cologne, or after-shave

Do not take anything from anyone (drug trafficking)

keep it between 2-3. If it is high, there is a high chance of bleeding, but if it is low,
there is chance of clot formation.

7:
o

INR will be monitored as follows:

You are an HMO and a 40-years-old patient came to the ED was diagnosed with pulmonary embolism.

Everyday 1st week

He is started on warfarin by the specialist.

2 times/week- next 2 weeks

Weekly 4 weeks

Task
o

Talk to the patient about warfarin treatment

Answer question

I am sorry to hear that you have pulmonary embolism, and I have come to know

INR results. Carry this diary with you all the time. Remember to take the

that you have been started on warfarin for treatment.

tablets strictly as directed and the blood tests. Always mention that you

Before I start to discuss about it, I would like to ask a few more questions.

take warfarin to any doctor, dentist or chemist. If you forget to take a

Bleeding disorders? Family history of bleeding disorders? Renal function? Any

dose, and remember in 2-3 hours, you can still take it but if longer than

medications (ASA)? Previous stroke or hemorrhage (ICH)? Recent surgeries?

this, then skip the dose and carry on with the usual dose

Liver disease? Alcohol (binge drinking)? Do you have history of uncontrolled high

(Do not take a double dose to compensate for a missed dose!!!). Note

blood pressure?

the date of the missed dose and inform the doctor about it. Do not take

In Females: LMP, OCP/HR, menstrual cycles (heavy periods), Pregnant by any

any medications unless prescribed by your doctor because warfarin can

chance, want to be pregnant ?

interact with them. These include medications including OTC such as

for common cold. Stop aspirin and NSAIDs. Drink to safe levels and

Counseling
o

Take the dose at the same time each day, preferably in the evening and
INR measured in the morning. Note in a diary the drug dosages and

History:
o

Monthly

Now I would like to talk about warfarin, what it is, how it works, how it needs to

avoid binge drinking interact- enzyme inhibitor and also risk of

be taken, and some of the red flags associated with its use and how to prevent

fall/injuries after drinking. Keep a well balanced and healthy diet, but

them.

avoid eating foods containing vitamin K like green leafy vegetables.

It is an anticoagulant medication used for the treatment and prevention of further

Management of Overdose

clot formation by thinning the blood. It is taken for 3-6 months but if you are

Urgent measurement of INR:

thrombophilia positive it needs to be taken lifelong.

>3 but <5 + bleeding: stop warfarin for 1-2 days then restart

The dose of warfarin is adjusted according to the values of a blood test called

>5 not acceptable: oral vitamin K (1-2 mg)

INR. It measures the time that your blood takes to clot and in your case, we will

Prolonged bleeding or bleeding in cavities: urgent hospital admission;

stop warfarin, IV Vitamin K, FFP, Prothrombin Complex Concentrate

Red flags: Immediately report to hospital if you have unexpected bleeding from minor
cuts, unusual nose bleeds and bleeding from gums, Bruises, bleeding at any time
especially from backpassages or change of color of stool/urine, purple toe syndrome (1st
3-8 weeks of treatment), heavy menstrual bleeding.

8:

Abdomen: hematoma or tenderness,

Management

STOP medications

Your next patient in your GP is a 60-year-old woman on warfarin for her AF. She missed her last

SEND to hospital

appointment 2 weeks ago because she was having a cruise trip. Today, she is in your office for her

<5 but with signs of internal bleeding

routine INR check. You ordered INR and came back as 4.5

>5 send to hospital!

Check INR daily!

Retroperitoneal Hemorrhage (Acute Exacerbation of Sciatica)

Task
o

History (took tablets for seasick; vomiting, not eating and drinking much).

Physical examination (extensive bruising over the legs and arms; vitals normal;
no carotid bruit; BMI, chest and heart are unremarkable; abdomen: soft, nontender)

Management

History
o

How was your trip? I understand that you came for your routine INR. Before
anything else, can I ask for a few more questions? Have you been taking your
medications regularly while you were on the trip? Did you skip or take double
doses? Did you take any other drugs while on the trip? What kind of food were
you eating? Have you been drinking when you were on the trip? What happened
when you got sick? What medications were given to you? How many times did
you take it?

Do you have any chest pain? Racing of your heartbeat? Did you have any
bleeding such as in the nose, gums, urine or backpassages? Do you have any
headache or abdominal pain?

Physical examination

General appearance and BMI

Vital signs

Chest and heart: carotid bruit, rate and rhythm of heart

o
9:

Mrs. Smith is an 83-year-old with back pain down to her left leg.

Task
o

Hx:

(had sciatica for 20 years?, bowel and bladder are okay, sharp pain,
radiating to back of the leg, noted dizziness; had abdominal pain before;
MRI before and had disc prolapse; feels sick but does not vomit;
feverish and no joint pain; but has arthritis; medications include digoxin,
panadol ostio, BP medication (atacan), warfarin for chronic AF)

PEx:
(looks pale, weak, very sick-looking, 128/44, HR 93 irregular, RR: 20,

oxygen saturation 100, T: normal; bibasal crepitations, JVP normal;

abdomen soft, mild diffuse tenderness, without organomegaly; normal
bowel sounds; PR: normal and no tenderness; no motor or sensory
defects, reflexes normal, mild pain with left hip flexion and IR; SLR
positive bilateral up to 30 degrees)
o

DDx:

Inx:

(Hgb 5.2, MCV 65,WBC 6.2, Plt normal, reticulocyte count not done;
ECG sinus rhythm, U&E pending, LFTs AST 714, ALT276, ALP normal,
PT w/ INR 7, total protein and albumin 3.1, CT scan of abdomen

Mx:

Causes of sciatica
o

Prolapse of disc compressing nerve root

Narrow exit or foramina

Bleeding especially if on warfarin

Inflammatory/infection: Tuberculosis, Infective Endocarditis, HIV, abscess,

hepatitis, chronic fungal or bacterial disease, atypical pneumonia

10:
Variant 1:

GI: Malabsorption, Coeliac disease, IBD

Your next patient is a 45-year-old female presenting with 7kg weight loss over the last 6 months. (2006

Cancers: lymphoma, stomach, pancreas, colon, Lung, prostate, renal

September Adelaide)

Severe heart, lung, or kidney disease leading to cachexia

Psychiatric disorders: depression, eating disorder

Can you tell me more about it?

When did you notice the weight loss? Any time when it was more?

Any observed trigger factor? Have you changed your diet at any time? Do you

Variant 2:
A middle aged woman comes to your clinic complaining of weight loss.

Task
o

Take history

(clothes getting loose, eat everything, no dietary restriction, periods

have a healthy diet? How is your appetite? Any changes? Fever? Night sweats?

regular, no hut flushes, not heavy period, lasts for 6 days, uses barrier

Cough?

contraception, stable relationship, no intermenstrual bleeding, no

Hx:

diabetes or hypertension, been hospitalized 12 for appendectomy, has

enjoy the things that you used to? How is your sleep? Do you think life is worth

2 kids, feels tired, +smoker)

living? Any problem with memory? Any recent dental procedure? Do you have
any weather preference? Do you feel tremors or more irritable? Dysphagia? Do

Examination

Recent travel abroad? Hows your mood? Any recent stresses? Do you still

(looks fine, alert, BMI 23.5, normal VS with no postural drop, chest

you eat more than you used to and still lose weight? Do you excessively drink

normal, bilateral equal air entry with no additional sounds or wheeze,

water? Any associated abdominal pain? Blood in stools? Change in bowel

chest is clear on PE, dual heart sounds with no enlargement or pleural

habits? Lumps or bumps in the body? Any known long-standing chronic medical

rub, no masses, no stigmata of neurofibrotamosis, abdomenpelvic

condition like kidney or liver disease? Do you pass more urine than usual? Any

examination normal,

difficulty passing or flushing of stools? Any particular food causing problems?

Investigation

Diagnosis and management

LMP? Any irregular/painful periods or abnormal bleeding?

o

Any FHx of cancers? Any previous diagnosis of cancer? Any recent investigation
of concern? Any recent blood transfusion or contact with someone who was

diagnosed with infections or exposure to any contact who have similar

DDx:
o

Endocrine: Hyperthyroidism, DM, adrenal insufficiency, Addison disease,

hemochromatosis

symptoms? Stable relationship? Have you or your partner ever been

diagnosed with STI? History of unprotected intercourse in the past? Pap

smear? Mammogram? Alcohol or drug usage? Smoking? Medication?
o

Do you have enough social support?

Physical examination

General appearance: pallor, dehydration, jaundice, abnormal moles,

skin changes/pigmentation, clubbing

All vital signs and BMI

Scalp (skin lesions)

Lymphadenopathy

ENT and thyroid especially ulcers and mass

Breast

Chest: fluid, additional sounds, signs of atypical pneumonia

Lungs: heart sounds and murmurs

Abdomen: organomegaly or masses

DRE

Pelvic examination

Extremities: Legs

Urine dipstick and BSL

FBE and blood film (anemia and infection), ESR/CRP, U&E, LFTs,

Inx:

RFTs, serum B-12 and folate, iron studies, TFTs, FBS, HbA1c, Blood
culture, CXR, CT scan of chest, ECG-12 leads, FOBT (>50), urine MCS

Others: endoscopy/colonoscopy, USD/CT scan of abdomen

Reduce excessive alcohol intake

Avoid illicit drugs

Avoid tobacco especially after dinner

Your next patient in GP Practice is a 25-year-old male who had a hand injury at work. The nurse in the

Avoid having pets and highly illuminated digital clocks in the bedroom

rural hospital noticed that he had some issues and was worried about him so they sent him to you.

Have Light snack or warm milk

Warm bath before bed

11:

Task
o

History (nurse wasnt happy with sleeping; do night-shifts; cannot sleep well in

the morning because of noisy children; sleeps 3-4 hours a day; no changes in

History
I understand from the notes that you had a cut on the wrist. Any pain or bleeding

weight; appetite is good; mood is okay; does not smoke but drinks alcohol;

at the moment? Any problem in the movement of your fingers or tingling of the

general health is good; BMI within normal; play with kids then goes to sleep;

hand? Can you tell me how it happened? Is it the first time (Got injured 3 months

does not wake up in between; cannot sleep more than 3 or 4 hours)

back also)? When did it happen? Are you happy with your work (Yes)? Do you

Diagnosis and management

often work at night or in the morning also? How many days a week (5)? What
are the timings (12-6am)? How many hours do you sleep at the daytime (3-4

Sleep hygiene Read Insomnia from JM Page 783

o

Encourage regular timings

hours)? Do you get a comfortable sleep in the morning? Any problems falling

Avoid lying on the bed for a long time worrying about getting to sleep

asleep (No)? Do you snore? Are you able to concentrate at work? Have you ever

Avoid oversleeping

slept or feel drowsy while at work (Yes)? Do you drive? Have you ever slept

Avoid frequent naps

while driving (Yes. It happened once)? Have you ever had problems with the

Encourage regular exercise 30 minutes before bedtime

law?

Avoid bright light exposure in the room

Avoid heavy meals or vigorous physical activity within 3 hours of bedtime

your problem to your employer? Hows your mood? Any change in your appetite

Encourage a quiet dark room for sleeping. Remove TV, radio, laptop, and mobile

and weight? Are you able to cope with normal day-to-day activities? SADMA?

phones.

How are things at home and at work (stressed at work)? Have you talked about

Hows your general health?

Counseling

Use a suitable mattress and pillow for comfort and support

Bed should exclusively be used for 2 things: sex and sleep

Dont like on the bed thinking about stressful situations

night-shift at work. I am concerned about it because you have injured yourself at

Allocate time earlier in the evening to go through the worrying issues

work and you have risked your life by dozing off while driving and while at work. I

Avoid caffeine before bedtime

will refer you for sleep study which we call polysomnography.

You have a sleep problem called insomnia and that is probably because of your

I will write a letter to your employer to decrease the number of hours at night and
advise you not to drive when youre sleepy and tired. At this stage, for your sleep
problems, I would like to advise you about the sleep hygiene. Practice it for a
week and well see how it goes. If it doesnt work, I will start you with short-term
sleeping pills. Should be limited to less than 2 weeks.

Benzodiazepines: alprazolam, oxazepam

Non-benzodiazepines: zolpidem 5-10mg at HS or zolpiclone 3.75-7.5mg at HS

(no hangover)

If you want, I can organize a social worker to handle your kids in the morning.

Referral to sleep clinic and Workplace safety

Review. Reading material.

Give medical certificate