Case Scenario (1)

77 year old woman brought by her daughter came to see you with the complaints of
progressive confusion over 2 weeks.
How would you approach?
I started the case by asking general condition of my patient and haemodynamically stable or
not
and also it is reliable to ask the history from the patient. If not, I would like to ask the
daughter
who is living together with her mum. I ask my history taking and physical examination
according
to my differential diagnosis of confusion. After that I explained the patient and her daughter
about the possible diagnosis and management plan.

Case Scenario (2)

7 year old boy with asthma brought by mum. The child has a ventolin 2 puffs. Parents
divorced and Dad didn’t admit that the child has asthma. The child is living with his dad 3
days per week.
How would you manage?
I assessed the respiratory distress first and how far the clinic and hospital and also
ambulance
service. I managed the child with nelbulized salbutamol and O2. After that I asked the child is
my regular patient or new one. As he is my regular patient, I reviewed his record. The child
had
the recent viral infection.
Also talk about asthma action plan and give the copies to all the carers of the child including
school. I would like to check the technique of inhaler and advise giving inhaler by using
spacer. I
would like to liaise with asthma educator although I didn’t know how, so I will ask my
supervisor about the process. In addition, I would like to discuss with dad who resisted on
asthma medication.

Case Scenario (3)

50 year old man came to the clinic for flu needle. The practice nurse told you that he
complaint of lack of energy and mild hypertention. The previous GP did FBS and FBE. His
FBS is 11.1 mmol/L and FBE – normal. However, the GP hasn’t done any action yet.
Do you see the patient now?
I asked the panel the previous GP is at the clinic or not. They replied the GP was on holiday
for a
week. So, as the patient has the symptom and FBS 11.1, I would like to see the patient now.
Do you tell that patient has DM?
Yes, I must tell that he has DM2 because he has the symptom and FBS 11.1
How would you manage?
I told them that start from history, physical examinations to detect any complications of DM.
Investigations I would like to do and why I want to do.
As a management, start from life style modification SNAP ( Smoking, Nutrition, Alcohol,
Physical activity), refer to dietician, regular follow up and if blood glucose is not well
controlled, start metformin. Depending on the investigation results, if there are
complications of
organ involvement, referred to the endocrinologist, podiatric, ophthalmologist, renal
physician,
diabetic educator, community nurse as a team care approach.

Case Scenario (4)

20 year old female came to see you with the complaint of sore in vagina for 2 days.
What are your D.Dx?
How would you approach?
I asked any blisters or ulcers in vagina. My D.DX are HSV, infected Bartholin’s cyst, Chancre.
Investigation viral culture for the HSV and STD screening
Treatment the onset is 2 days, I will give acyclovir 200mg qid for 5 days
Pain killer systemic and local
Safe Sex

1 16 year girl comes to your General Practice with history of missed period for 2
months. Her parents are well known to you. She is in a stable relationship with his boy
friend of 17 years. Discuss your approach to the patient.

My patient being a teenager I would like to take a detailed history in an empathetic

and supportive manner; explore the menstrual history and if she had regular menses
prior and not using any contraceptives my first priority would be to rule out a
pregnancy.
Before discussing any further one of the interviewer told me she is pregnant and how
would you approach the problem? My answer: I would like to assess her maturity as
she is a minor and would like to know from her about her wish to involve her parents
or in discussion of future management of the problem. I told them she being in stable
relationship I presume that she is mature enough and aware of the problem and the
consequence of her pregnancy.

I didn’t ask anything about the pregnancy symptoms at this stage. Further
management depends on her wish to keep the baby or not. If she choose to keep the
baby I would proceed with offering antenatal care including necessary investigations
(I have neither enlisted them nor did they ask), folic acid tablets and referral to
midwife. If her wish is not to keep the baby I have to counsel her about the options
available for termination and would refer her to concerned specialist who would
provide the necessary services, including counselling.

One of the panel members asked me “would you advice termination”?

I reiterated my position that I am not an advocate of termination and I have had the
experience of providing counselling to couples to make appropriate decision and
 later they came to me with their baby saying to me that “ this is your baby.” However
in Australian settings I am supposed to provide the information so that they can make
an informed decision.

Next question was what else you would do? I told about screening for STI and offered
Pap smear. When will you do Pap smear? - 2 yrs after the first sexual contact or 18 yrs
whichever is late.
Chair of the panel asked me suppose the partner is a 35 yrs old man, what would be
your advice? My answer: I have to report to the authority as it amounts to child abuse.
The panel members discussed among themselves and concluded the scenario.

2 74 yr old man comes to your clinic requesting a repeat prescription for drugs. He
hands over to you a bag containing a lot of medicines. ( They gave to me a plastic bag
with a lot of medicines)The medicines were Metformine, Verapamil, Atenolol,
Furosemide, combination of Hydrochloro thiazide and amiloride, Digoxine, Aspirin, an
ACEI and Prochlorperazine. How would you respond to his request?

I checked the medicines first. I have explained to the panel that he is on multiple
medications (polypharmacy) which means that he is having multiple medical
problems and co morbidities. Considering his age there may be compliance problem
as well. I have to take into account the possible drug interactions and the resulting
problems.
If I am consulting him for the first time I would like to get the medical reports from
the previous GP. (I had in my mind that any sensible GP cannot give him a repeat
script without knowing the medical conditions he is suffering from)They didn’t say a
word. I have enlisted possible medical conditions in him considering the medicines
he is taking; Diabetes (Metformine),Cardiac or renal failure, arrhythmia,
hypertension, possible coronary artery disease and a possibility of some ear problems
like Menier’s disease affecting the balance.

I discussed the possibilities of side effects and drug interactions. Metformine and beta
blocker and diuretic in diabetics, multiple diuretics causing electrolyte imbalance, the
possibility of intravascular volume depletion leading to hypotension and fall,
hyponatreamia and its complications and possible effect like arrhythmia due to
change in potassium levels. Beta blockers can mask the effect of hypoglycemia in
Diabetics. Possibility of brady arrhythmias when digoxin, atenolol, verapamil are
combined.

They asked me will you give him a repeat prescription?

I told them that I have to reassess the patient with a thorough history about the
current and past medical problems and treatment, family history, social history, drug
allergies and physical examination including an assessment of cognition to R/O
dementia which can affect his ability to adhere to the treatment and organize
investigations before I prescribe the medications.
 Then they asked me what investigations you would do? I have enlisted FBC, BSL,
HbA1c, U&E, Urine micro albumin, lipids, LFT, drug level of Digoxine, ECG and
organize an Echocardiogram to assess the heart for effects of hypertension, LV
ejection fraction, regional wall motion abnormalities, valvular heart disease etc and
then titrate the dose of medicine accordingly. He may even require a specialist review.

I believe I should have organized a home medication review by pharmacist, suggested

Webster pack for improving compliance and home visit by community nurse.

3 A 56 yr old man comes to you. He is sweating and pale. He developed chest pain
while playing Golf. What would be your approach to this patient? Physical findings
revealed on request were BP 146/86, Pulse 76/mt, BMI 32. An ECG was provided on
request.

My opening sentence: because of the excertional chest pain I would consider acute
coronary syndrome as the first possibility. I told them if the patient is stable (ABC
approach) I will quickly take an ECG. Even before I asked about any history of the
nature of chest pain or associated features they told me the above vitals and findings
and handed over the ECG to me. I have asked them about basal creps and heart
sounds and murmurs. I read the ECG which was definitely suggestive of inferior AMI
in sinus rhythm. I suggested he needs admission to hospital and will tell one of the
staff to organize ambulance while the necessary treatment is provided to the patient
which I mentioned in the order- comfortable position, oxygen, GTN spray, aspirin,
clopidogrel and IV morphine if he is still in pain. Once the patient is pain free I will
enquire about the risk factors for the cardiovascular disease.

They told me ambulance will take half an hour to come what will you do?
I suggested: I will arrange one to one monitoring by a nurse, put IV line and send
sample of blood for enzyme studies and reassure the patient and provide support and
will draft the referral letter. I forgot that I should have talked to the consultant in the
emergency. I told them that I am not sure whether GP is allowed to thrombolise the
patient in Australia. If they suggested then I would have asked about the
contraindications to thrombolytic therapy as he requires thrombolysis if there is
significant delay in access to hospital with PCI facility.

He has come back to you from hospital after the treatment. What will you do next?
Being his GP I am responsible for his ongoing care. I will find out the details of follow
up plan instructed from the hospital. He needs to be enrolled in a cardiac
rehabilitation programme. I mentioned about life style modification- SNAP. Then they
asked me will you advise him to continue playing Golf now. I have told them that is
not the suitable exercise for a Post AMI patient and instead suggested walking (BMI
was 32). I suggested about the need for control of lipid levels and the need to enquire
about post infarction angina, compliance about the medication and organizing follow
up appointment with cardiologist for the stress test after 6 weeks and
 echocardiography to assess the cardiac function including left ventricular ejection
fraction. The interview panel was happy.

4 A 3 yr old girl Riya is brought to you by her mother Belinda with breathing difficulty at
night. You have made a diagnosis of croup. Your task is to discuss the diagnosis with
the mother. Then discuss the treatment options with her. Clarify her queries and
misconcepts regarding immunization.

It was the only role playing station. Being a simple station and straight forward case, I
didn’t have any problem explaining about croup, management options and answering
the questions. One of the panel members was acting as the role player. She had some
reservations about using steroid for croup and I have explained in the line that use of
short course of steroid in croup is safe. I had to educate her about when she should
be concerned about and go to emergency, as safety netting ( basically what to do in
emergency or when the mother has concerns about the child – a clear follow up plan )
is important in paediatric patients. They didn’t ask for any clarifications about
immunization and the child was up to date with her immunization. The panel always
consulted each other before concluding each scenario.

5 A 20 yr old girl comes to you saying she doesn’t want to give the university exam and
she is breaking down in your office and she is crying. Her brother committed suicide 6
mo back. Discuss how would you manage the situation?

I would listen to her with empathy and explore what caused her to have the current
presentation. Given the history of emotional upset, desire to avoid the upcoming
university examination, in the back ground of a significant past history of the tragic
loss of her brother to self harm, I would consider a situational crisis, grief reaction,
depression or post traumatic stress disorder.

I would encourage her to tell her story and enquire what is troubling her. Do a formal
psychiatric assessment keeping in mind, the above possible differential diagnosis.

Any stressors (family, financial, educational, relationship or other issues)?

Try to rule out depression asking the symptoms of hopelessness, worthlessness,
joylessness, any biological symptoms of depression, mood, affect, any abnormal
perceptions, insight, judgment, suicidal risk etc or is it a prolonged grief reaction
following the death of the brother? Explore more into the circumstances of the death,
was there any violent method used by her brother in taking his own life? Did she
witness the death (more prone for PTSD), the support she and the family received
following the suicide of her brother, is she taking any drugs, (including recreational),
and alcohol?
When I suggested these, one of the GP revealed that she is not suicidal at the
moment, what would you do? (I couldn’t ask any other details)
 Suggested supportive psychotherapy and organize referral to psychologist for
psychotherapy.
One of the Panel members asked me you told depression and PTSD; and what would
you do further? I told them that I would prescribe an antidepressant to her and SSRI
would be my first choice. Will you advise her to take the exam now? I suggested that
my advice would be to defer the exam until she is able focus well on her studies and it
is wise to avoid another stress at this time. (I kept on thinking whether I have missed
out on something).

After the scenarios were discussed the panel asked me, do you have any questions to
ask, of course not about the outcome of the interview.
I didn’t ask any academic questions. Then they asked me do you think that you need
to know more about any areas? I told them that I haven’t been familiar with using
brush for taking Pap smear, not dealt with many cases of drug addiction apart from
alcohol and not seen many cases of skin cancer (they included
upskilling in women health, dermatology and psychiatry in the report to the medical
board and I was recommended for level 3 supervision).
I thanked the panel and told them that I was comfortable with the interview and the
non threatening environment. Then they told that, they were more nervous than me
and we all laughed.

1. A 4 YEAR OLD WITH COUGH. No Hx of diseases.

How ll the history and examination be done.

Hx; Cough Hx-duration,nature and xteristics, dry or productive, smoking at home by parents,
etc

associations-fever, post tussive vomiting

systemic review.
past medical Hx
Drug Hx
Family Hx- Examination;general examination-undress,physique,etc
then chest and CVS examination-inspection,palpation,percussion and auscultation
ENT examination
Further information-Pxt in respiratory distress using accessory muscles
mgt-try to determine the diagnosis while waiting for the ambulance IF ASTHMA DIAGNOSED
oxygen, 6 puffs SABA via small spacer/facemask, Secure IV ACCESS
Delay in ambulance-FURTHER MGT-SYSTEMIC STEROIDS, kiv AMINOPHYLLINE IF cvs CAN BE
MONITORED.

2.A home call from a man complaining of rash in the leg that is itchy,discharging,
anteromedial to lateral maleolar. How ll i determine the cause and manage.
Hx- duration,nature of discharge,contact with similar rash, rash in any other part of the
body,Hx of varicose veins, vascular claudication, diabetes.
Examination-general examination
Rash-site,nature of discharge,pulses distal to site.
If discharge is profuse-swab for mcs and scrapings for fungal flourescence
mgt-dressing, give antipruritic, if infection is suspected antibiotics may be required.
Further information given that patient had bedbugs on the bed and Dr had told him to prick
his hand everyday for tests which he has refused to do as reported by the wife-what will I do?
would want to know the reason for the finger prick tests and if for purposes of blood glucose
monitoring-
counsell patient and diabetic education on self care and mgt- patient still refuse the finger
pricking-may use urine dipstick tests though unreliable-
Further information;Urine tests said to be ketone+++
mgt; Referal to hospital for further assessment and investigations

3.A 13 year old boy with 6 hours Hx of headache. was given one tab of paracetamol only by
parents
How will i assess this patient.
Hx; site, nature-throbbing or diffuse,associations like aura,fever,neck pains, ear discharge,
tooth ache etc
systemic review-any neurological signs or signs of meningism etc
Past medical Hx, Family Hx of migraine, drug Hx
Differentials; migraine,tension headache,intracranial neoplastic lesion,meningitis,ENT
Further information-patient had dry oral mucosa and had played a video game(ve forgotten
the name of the game) throughout the night with blood shot eyes and photophobia-
Admitted i do not know the video game and the effect it may have.

4. A 52 year old woman with complaints of a flu. Had malaria in the past and feared she may
be having malaria again. Had rigors but ve subsided.
How will I assess and manage the patient since she is concerned about returning to work the
nextday after a break/leave.
Hx; duration of symptoms, nasal discharge, headache,cough,allergy, chest pains, nature and
periodicity of fever,travel overseas etc
systemic review
Drug, past medical Hx and family Hx
Recommend investigations in the hospital; blood film,FBE,
Differentials;
influenza,pneomonia,Ross river fever, Dengue fever.
If its influenza how will i manage
Mgt- reassurance
paracetamol
antihistamines-chlorpheniramine
 Adequate rest/nutrition/fluids
follow up for sequelae-depression

Case 1
30 year old woman with 30 week pregnancy comes to the GP clinic with main complaint of
lower abdominal pain.

Info after history taking and physical exam:

Intermittent, low rate, central abdominal pain with contraction of the uterus during
palpation. Vaginal exam: 3 cm cervix dilation, bulging membrane.

Diagnosis:
Premature labour

Management:
Ca-channel blockers (Nifedipine), Magnesium sulphate, steroids (for surfactant production).

Case 2
3 year old child with known anaphylaxis for peanuts has eaten chocolate bar containing
peanuts. He was brought to GP clinic by his mother immediately after
consumption.

Two scenarios:
1. Child is breathing normally. What should you do?
2. Child has anaphylactic reaction immediately after arrival to the clinic. Your
response?

In both cases you are alone with a nurse and emergency kit only. Ambulance has stuck in the
traffic jam. No help, no intubation skills.

Management:
Epinephrine, prednisolone, chlorphenamine, Basic Life Support Protocol

How much epinephrine? What the EpiPen is? Venous/intraosseous access?

Case 3
45 year old salesman was brought to ED with chest pain.

Two scenarios:
1. Stable upon arrival
2. Unstable and unconscious upon arrival

After focused history – look like Acute Myocardial Infarction, consider ECG.

ECG tracing is given – Anterior-lateral AMI

Management of AMI in ED settings, including indications/contraindications to thrombolysis

and what drug is the first choice (TPA).

Case 4
25 year old man presents to GP clinic with jaundice after trip to India and Thailand.

After taking comprehensive sexual and social history – hepatitis A.

Investigations?

Do you need to hospitalize him? He disagrees with hospitalization, what would be your
response? Is it notifiable disease? What about his close contacts? What is hepatitis A? What
is the difference between hepatitis A and B?