Perth 2008 Oct

Station 1 Examination of shoulder 25 yr male presented with shoulder pain. He had played rugby yesterday. Picture was given, R shoulder, not symmetry, mild swelling and appearance normal. Task: Take focused hx Examine the shoulder What is DDx Discuss the management Answer pts Qs This was my 1st station. Hx: how the injury happened? Any other joint pain? Any previous trauma? Any neck pain? Any radiation to arm/neck? (He was physically fit, no head trauma, fall on the ground, no LOC) Ex: Inspection: asymmetry in R center shoulder, no other bony deformity, no scars, mild swelling. Palpation: Tenderness over the R acromioclavicular & lateral side of shoulder. Movement: Active: All the movements are normal except abduction up to 90 and cant raise the arm above 90. DDx: rotator cuff injury, anterior dislocation, AC # Ix: ask for X-ray (no #, shoulder joint mildly displaced), shoulder U/S (there is a gap between AC and clavicle) Pt concerns: Whether I can play rugby this week? I am in Answer: No contact sports for 4 wks. if symptoms persists, I will refer to orthopedic surgeon. BELL RANG Critical error: not give approach to examine the pt.

Station 2 Recurrent abdominal pain 8 yr child, Tim, brought in by father as he has tummy pain. Task: Detailed hx Appropriate examination from examiner Discuss the management Hx: abd pain 3 wks, no radiation, no fever, no nausea, mild pain in all over the abdomen. He was active at home. Earlier similar episode in 3 months ago. Water works well, bowel movements normal, no constipation. Social hx: performance decreased, has problem with teacher, no school bullying. Happy family. No medication, NKA. Development normal. No surgical hx. Ex: afebrile, not pale, VS (pulse 85, BP 90/60, Temp 37, SaO2 98%, RR 14) Abd ex NAD, no tenderness, no organomegaly, no lymph nodes, no ascites, BS normal. CVS/RS normal. Mx: run office test. Probably dysfunctional due to emotional events at school. Talk about meeting with school teacher to investigate the problem. Recognize the problem is not caused

by appendicitis. Talk about warning signs (high fever, severe vomiting/dehydration, must come back or to ED). Arrange follow-up. Critical Error: Do not try to exclude organic causes, admit to hospital.

Station 3 Invasive ductal carcinoma of breast break bad news 22yr lady found a lump 2 months ago. It was painless lump. Her aunt has Ca breast at age 50. U/S was done and it was revealed as solid cyst. Later FNAC was done, showing invasive ductal carcinoma. Her BMI 28 and a smoker, on OCP. Today she came to follow-up. *There is no lymph nodes enlargement in axillary area or other areas. Task: Explain the result to patient What is the next investigation you will order? What are the options in regarding management? Answer the pts Qs (is mother to be screened? Fert ility? About OCP. If having a girl, will she get cancer?) The role player was very difficult to deal with. 1st, giving schedulebreaking bad news, explain it is cancer cells (I am afraid to say that I have a bad news, but there is no enlarging lymph nodes, which is good. So probably it may be in early stage. When she was shock, again showing empathy. I understand this is a distressful time) Talk about next investigation: referring to breast surgeon to do core biopsy, which is confirmation and for staging. Stage 1, 2have good prognosis, if proper treating. If spreading, stage 3 (lymph nodes) and stage 4 (distal) Do sentinel lymph node biopsyput a dye into main lymph glands and do X-ray can visualize if cancer cells spread in the ducts. These lymph nodes can be removed. No need to remove the whole axillary lymph nodes, which can prevent swelling of forearm in future. CT chestto analyze any spread to other organs, bone scan to determine any bone metastasis.. Explain options: lobectomy (only remove the quadrant containing lump and give followup), mastectomy (remove the whole breast) with late reconstructive surgery; talk about complications of anesthestia, surgery. Reassure early treatment will have better outcomes. If there is any spread, radiotherapy. In your case, this is unlikely. Talk about strong FMHx as her aunt has cancer. Talk about gene studies, BRCA1/2. Screen her mother and future her children. Risk factors: quit smoking, early menarche, sex hx (multiple partners), alcohol, hx of cancer. She asked about fertility. (since its early stage, only surgery. So oocytes wont be affected.) if she needs radiotherapy, then oocytes has to be stored for later use. Perform self breast examination, annual breast exam by doctors. Annual U/S of breasts until 35, then mammogram. STOPPING OCP and use other contraception because OCP can increase breast cancer. Other issues: she is sex active, so Pap smear. I talked about HPV vaccine to prevent cervical cancer. Critical Error: Be judgmental, no empathy; Do not perform core biopsy; Do not stop OCP.

Station 4

Pyelonephritis 40yr lady has come to GP as she was feeling unwell and flu-like symptoms. Task: Take full hx Appropriate examination Appropriate investigation What is working Dx/DDx Discus management and counselling concerns Hx: Do you feel hot/fever? (yes, 2-3 days ago) Is there any chills & rigors? (yes, fever is with chills and rigors) Is there night sweats? (No, but she sweated profusely during the day.) She was from QLD but she didnt travel anywhere or swim. Any abd pain? (No) How is water works, any burning sensation, any difficulty? (No) Any a/n/v? Did you have any backache? (She has felt backache for the last 2 days, with all joint and muscles aching.) Any medical conditions/medications? (No) Pap smear. Ex: She looks ill and sitting in the couch. VS (T39, pulse 110, BP140/90, SaO2 98%, RR 18), abd NAD, no tenderness/organomegaly/lymph nodes. No cervical lymph nodes. Other system normal. Urine dipstick: leucocytes++++, nitrates++, RBC++, no casts. Provisional Dx is pyelonephritis. No other investigations available. DDx: UTI, cystitis, any sepsis, Ross River fever/Dengue. Mx: I will admit the pt. (Pyelonephritiswhat is it: this will affect the kidney and renal failure if not treated) Further ix: FBE, CRP/ESR, blood culture, C3; MSU, U&E, U/S of kidneyany obstructions/hydronephrosis/stones, CXR. Start IV saline/ABOs (cefotaxime, metronidazole, gentamicin) When the blood culture result comes back, change the ABOs. Discuss with medical registrar. She has stayed in hospital 4-5 days. As she was sex active and unprotected sex, I will do STI screen incl. HIV. I finished this station on time. Critical Error: Fail to ask urine dipstick result, fail to admit.

Station 5 Testicular torsion Picture given: R testis was red, swollen. The other side was normal. 12yr boy came with mother with severe testicular pain. Task: Interpret the picture Appropriate examination Dx Explain your management and answer pts Qs Hx: What happen? (Tim went to play basketball and complained severe testicular pain 4hrs ago.) Any trauma? (No) Any abd pain? (No) Any fever? (No) Rate the pain. (9/10) Any a/n/v? Ex: GA (Tim in severe pain) VS NAD. Ask for abd signs (NAD). I told the examiner my Dx is testicle torsion. (examiner: talk to the pt). What is testicular torsion? Because the spermatoid cord got twisted. When it twisted, the blood supply also was cut down and if the testis not untwisted then there is a high chance of testis damage. It must be done within 6hrs. Then I explained about the operation and complications. The surgeon will untwist and fix the testis and the other one, which is called

orchiopexy. This will prevent future torsion of the left side. I will put IV cannula. I have to do the consent form (it was there!). Mother concerns: Will he lose the testis? (If the operation is not done within 6hrs, it is highly chance to lose it. Now you came in time. The operation will be done by experienced hands.) Whether or not my son will be fertile or any problem in sex function? (There wont be any problem in sex function and fertility wont be affected.) Can he play basketball again? (Once the both testes are fixed, in future there wont be any problem.) Critical Error: Fail to Dx testicular torsion, Fail to arrange emergency operation.

Station 6 Asthma (atypical presentation, infective episode) 3 yr child with high fever (38.5), and running nose for 2 days with dry cough. She had mild SOB. On exam: SaO2 96%, RR 28, no accessory muscle use, no retraction. On auscultation, wheezes over lung base. Task: Take relevant hx, no exam Dx Management, answer pts concerns (role player would mislead the candidates) Hx: When did cough start? (one day ago, cough more at night, child get up at 2am, found SOB) Any vomiting after the cough? (No) Is it barking cough? Any noising breathing? Any FMHx? (father and elder child, aunt are asthmatic) Any hx of hay fever, eczema? (Yes, aunt suffers from hay fever. She has similar symptoms) Anyone smoking at home? (partner smokes) Did she have similar episodes? (She had mild attacks which dx as bronchiolitis) Immu/birth hx are normal. Any pet at home? (No) Any carpet at home but not vacuumed for 3 months? (No) Dx: My dx is asthma. Mx: my mx is for the episodic asthma. Admit to the hospital. I explained what is asthma. (narrowing of windpipe, inflammatory, mucous secretion) What are the medication can be used? (Ventolin 4-6 puffs, repeated in 5 minutes if not relieved) Educated the pt about trigger factors and prevention in future. No pet at home, no smoking inside house. Vacuum the house every week. Early tx when URTI. Find out allergy to food. Weather condition could be aggravated it. Educate the spacer usage. (in exam, they hid the spacer!) I talked about Action Plan (4*4*4) Critical Error: fail to ask FMHx of asthma and hay fever, eczema; fail to give instruction about spacer usage; fail to give Action Plan.

Station 7 Salmonella 4yr child has chronic diarrhea, 4-5times/day for 4wks. Baby is excessive crying. Already admitted, treated with dehydration. IV fluid given, child became normal and discharged. During period, vomited also. Childs parents run a sandwich shop. 2 stool cult ures were done, it was salmonella infection. Father came to GP for followup. Task: Explain the result to father Talk to examiner about the types of major species

Discuss further mx and answer pts concerns. I explained the result: it is a gram ve bacteria infection. I inquired about general health of baby. This species can stay in body for a long time, even 6-12 months, or in gallbladder. The bacteria can invade the mucous membrane. Examiner: what are the types of toxins it produces? A: secretive enterotoxin, which alters cell wall and water balance; adhere to mucous membrane and pt becomes carrier. Enterotoxin, cytotoxin, invasive, which cause all the symptoms and signs Examiner: what are the major species? A: typhi and paratyphi. Paratyphi is more severe and chronic. And there are some minor species. I will screen the family members, fecal ABST, at least 3 samples in 2 months interval. The couple and employees of the shop, who handle the food, can be carriers to transfer disease by oral-fecal route. It is my obligation to inform the DHS and the inspectors will come to the shop to take samples. It is a notifiable disease. Pt is concerned about the business. (I discuss about my duty. He can employ other health people until all the family members and present employees are free of infections. I will followup with stool cultures. If any symptoms, diarrhea/vomiting, develops, ABO can be used, but it is still controversial issue. I will discuss with physicians.) Examiner: what kind of ABOs can be used? A: ceftriaxone, cotrimoxazole, azithromycin, and sometimes ciprofloxacin. In severe dehydrated or blood mucous stage, these ABOs can be used. In chronic stage, it may cause resistance and increase more organism. So do not use in this stage. I talked about general measures: child cannot go to shop, the persons cannot handle food till carrier state is cleared, washing hands before cooking and after toilet, eat well-cooked food, clean the house/bed sheet/linen, discard unsold food in the shop. I talked about Centerlink if he cannot employ others to run the shop. Critical Error: fail to screen family members and employees, fail to notify the DHS.

Station 8 OCP counselling (any female cases, remember 5P: period, pill, pregnancy, Pap, partner) 22yr female, uni student, not sex active now, wants to have sex with 2 male partners. Her friend told her that OCP will reduce STIs. She wants to discuss with you. Task: counselling the pt I will speak 2 major issues: OCP usage and STIs prevention. I asked about focus period hx, stable relationship (stable with one, and unstable with other one). Absolute contraindications (migraine, breast cancer, ovarian cancer, liver diseases, vaginal bleeding, DVT) and relative contraindications (smoking, alcohol, IVDA, HTN, DM). Any painful periods? Any previous travel associated problems? Any FMHx of bleeding disorders? I turned to examiner, I want to know some exam, GAVS, BMI, BP, breast/abd exam (all normal). I explained OCP to pt. there are 2 types of pills, 28 days and 21 days. Take the 1st pill at the 1st of period. Must take pill at the correct time. Must not forget to take pills. Once you have

taken 7 active pills, you would be safe for pregnancy with pearl index 1%. There is still a very small risk to get pregnancy. Talk about types of OCPs, monophase (fixed dose of E & P), diphase (two step progestin dose with constant estrogen), triphase (3 step progestin with 2 step of estrogen). But in your case, I recommend monophase pills because triphase will cause breakthrough bleeding. Examiner: what are the contraindications of OCPs? A: Absolute contraindications (migraine, breast cancer, ovarian cancer, liver diseases, vaginal bleeding, DVT) and relative contraindications (smoking with age>35yrs, alcohol, IVDA, HTN, DM). Then I explained the 7 day rule: if you missed one dose, immediate take the forgotten pill and take the regular one. If it is more than 24hrs, take the forgotten and regular pills, use condom as alternative methods. If you forget last end of the pills, take a pill from the new pack and that day pill, and use condom for 7 days. I talked about mechanism of OCPs: 2 types of hormones, E & P, interfere the ovulation. I talked side effects of OCPs (breast tenderness, breakthrough bleeding, a/n/v, HTN, weight gain). I will follow up for 3 months. Usu. these side effects will disappear in that period. If there is HTN, I will stop OCPs. I will measure your weight and other symptoms. When you diarrhea or vomiting, take another pill or go to doc. When you take any ABOs, tell the doc you are on OCP. I talked about benefits of OCPs: bleeding will decrease, painful periods will decrease, benign breast cyst decrease, and ovarian cancer. Examiner: continous OCP will cause breast cancer? A: usu OCPs over 40yrs will slightly increase chance. The increase will be localized disease and may due to progressing disease. But this is not this pts case. There is also slightly increased chance of cervical cancer. I will do regular Pap smear. Then I talked about Pap smear in future and HPV vaccine to this pt. I will start 1st today and continue for 2nd dose at 2nd month, 3rddose at 6 month. It is free program for women from 13 to 26yrs. I advise about this injection will decrease chance of HPV infection and cervical cancer. This vaccine is well tested and safe. (pt asked: I am allergic to eggs, does it affect me? I answered: this vaccine does not produce from egg substance, so its safe for you.) In future, I will do Pap, which is screening test. OCPs will NOT prevent STIs. Condoms must be used to prevent STIs. Pt asked: is that alright that I have 2 sex partners? I answered: it is your personal option to have multiple partner, but condoms should be used. I will give pamphlets and arrange followup to discuss issues if she doesnt understand. I also give other sheets about other contraceptive methods. Examiner: the pills will give rise to thromboembolic diseases? Bell Rang A: OCPs will increase chance of VTE by 3 times compared with non-OCP users. Critical Error: fail to ask BP and other contraindications of OCPs; fail to explain OCPs cannot prevent STIs.

Station 9 Stress incontinence with tiredness 54 yrs woman complains of incontinence for 6 months. Her BMI 31. She feels awful and tired, also depressed. Her hemoglobin is 70g/L. Task: Take detailed hx Appropriate ex Appropriate ix

Dx and Mx Counselling concerns Hx: Is the incontinence increased? Any burning sensation? (No) Any difficult urination? Any increased frequency at night? Any leaking during laughing or coughing or straining? (Yes) Has you leaked before get the toilet or car ( exclude urge incontinence)? (No) Any previous episodes? Any fever? Any abd pain? Any vaginal discharge? Any vaginal bleeding? I asked about detailed period hx, Pap smear. Do you feel anything coming down (exclude prolapse)? How is your bowel movement? Any loss of weight? I will ask some sensitive Qs. Sex active? (she has casual sex, no stable relationship. But she used condoms but sometimes unprotected) Any caffeine taken? (4-5/day) How is your delivery hx? (3 children. 1st delivered by forceps, 2nd normal vaginal, 3rdprolonged labor) She had appendix removed 10yrs ago, cervical polyp removed 2yrs ago. Smoking 10-15/day for 20yrs, drinking occasionally. I quickly asked about chest pain, SOB, dyspnea. I asked about depression Qs. ( she is worrying about leaking during working) Ex: GAVS (all normal except BMI 31). Abd ex: NAD. Vaginal ex: inspection ve, speculum: no prolapse, no vesicocele/rectocele, no discharge, bimanual: no mass/tenderness. I said, it seems normal, I want to do some ix. Ix: urine dipstick, urine culture, U&E, swab for high vaginal/ cervix; urodynamic study to identify the type of incontinence. In the mean time, bladder scan, U/S to exclude other causes. I will arrange iron study to find causes of anemia. Counselling: I will discuss about 3 issues: incontinence, anemia, weight. This incontinence is most likely due to stress incontinence because difficult labor hx. The pelvic muscles might be relax or torn at that time. Because of lack of support, you have this problem plus overweight may contribute to this issue. The mx: lifestyle modification. This incl. healthy diet and exercise. 30 minute walking for 5 days per wk. decrease weight. I will teach you the pelvic floor exercise to strengthen the muscles. (Patient Education book has detailed description). I will refer you to urologist to discuss in further details. I will refer you to dietitian for health diet as well. Reduce caffeine. Quit smoking since it may increase coughing and worsen incontinence. The tiredness may be due to anemia. I will give iron tablets and iron-fortified foods but I will arrange further ix for anemia in next counselling. If there is any SOB, chest pain, dizziness, please come back to me or ED. Pt asked for surgical options. I will refer you to gynecologist. He will provide options. One is strengthening muscles and bladder. Now new measures are available. It will use for urge and mixed type. Once we do all the ix with the results, refer to specialist and do exercises. Critical Error: fail to do urine culture, fail to talk lifestyle modifications.

Station 10 Preterm delivery 28wk pregnancy woman (30yrs) living 300km away from 3 rd hospital. She complains of contractions and abd pain. She comes to GP. Task: Take relevant hx Appropriate ex & ix Discuss management and answer concerns

Hx: I greeted the pt. Can you describe the contraction? How frequent? How long it lasts? (very strong, every 10-12 minutes, lasting for 2 minutes.) Whether any other pains? Did you have gush of fluid from vagina? Did you have vaginal bleeding? How is the antenatal checkup? 18wk U/S? Did you feel baby kicking? What is your blood group? Is your 1st pregnancy? FMHx of bleeding disorders? Fever/a/n/v? Did you have any other concerns? (my husband in interstate, I went to a pub and had a casual sex 3 days ago) I will ask you sensitive Qs. Did you have any IV drugs, cocaine? Do you have any trauma? Do you smoke/drink? Is this planned pregnancy? Any hx of preterm labor? Any surgical procedures? When was Pap? Ex: GAVS (all normal). CVS/RS ve. Abd ex: fundal height 28cm, cephalic presentation, engaged, single fetus. FHR 140. vaginal: inspection (no discharge), speculum (cervix 3cm, no fluid pool), bimanual: consistent soft, length 5cm, station -1, no tenderness. Fibronectin test ve, nitrazine ve. I asked what kind of instruments available. (only CTG) Mx: I am going to talk what is preterm labor, tocolytic therapy, stabilize and transfer to 3rd hospital, swab to exclude STIs and infections, and answer concerns. I want to admit you to local hospital. I will monitor baby by CTG. CTG indicated good heart rate, no acceleration/deceleration, any aphylaxis. I will stop the contraction by tocolytic for 48hrs to buy time to give steroids. (examiner: what steroids? A: betamethasone or dexamethasone, give 2 doses in 12 hours apart. This will reduce RDS, IVH, NEC) I will give nifedipine 10mg up to 40mg. I will discuss with 3rd hospital about the medication and mx and talk with NETS about transferring to there. Continuous CTG monitoring and midwife checks all the contraction and VS. I can assure you negative fibronectin means no delivery within one week. I will do analysis and sensitive. FBE, swab for gonorrhea/chlamydia/GBS. If you deliver within 2 days, NICU is necessary for the baby. In 3rd hospital, they will keep you there and monitor baby with CTG, U/S to see fetal tone/movement/HR/weight/presentation/placental position/AFI. Sometimes contraction will stop and keep you until baby mature. They will arrange serial U/S to see baby growth. As you live 300km away, youd better stay in 3rd hospital. Did you have any relatives in the city? (my sister lives close to 3rd hospital and she is a nurse) The obstetrician will discuss this later. If no contraction and everything is fine, they will discuss with you. I will send blood sample to 3rd hospital. If anything +ve, infection should be treated. (pt: will you tell this casual sex to my partner? A: No, everything is confidential. But chlamydia is +ve, it is my duty to inform DHS since it is notifiable disease. I suggest you tell your partner, but it is your choice.) If GBS +ve, penicillin will be given during the labor to prevent neonatal sepsis. If you deliver within 1wk, there are facilities available for you. I will talk with your partner about the preterm labor and arrange social worker to look after your elder child who is 5yrs. Examiner: could you summarize the risk factors of preterm labor? A: previous hx of PPROM, multiple pregnancy, hydramnios, hx of previous preterm labor, uterine anomaly, hx of cervical conization, cocaine abuse, abd trauma, pyelonephritis, any surgery during pregnancy. Examiner: why cant use beta-agonist? A: It can be used but has some side effects such as tachycardia, hyperglycemia, hypokalemia, widened pulse pressure. Examiner: if the pt having dyspnea during tocolysis, what is the cause? A: if dyspnea occurs, this is likely to be pulmonary edema. Examiner: did you know about weekly injection of 17-alpha-hydroprogestone caproate. BELL RANG... A: recent evidence shows that weekly injection of this from 20-36wks may prevent preterm labor in women who has previous preterm labor.

NOTES: workup for preterm labor: hx of assessing risk factors, physical ex, speculum ex to assess ROM; serial digital vaginal ex, FBE, urine drug screen for cocaine, urine culture/sensitivity, cervical test for gonorrhea/chlamydia, vaginal swab for GBS, U/S for fetal weight/growth/AFI, fibronectin/nitrazine tests. Critical Error: fail to give steroids, fail to transfer to 3rd hospital, fail to discuss sex hx.

Station 11 Hand exam 45yr man comes to GP. He has pain in the R hand. (this is a real pt) Task: Take focused hx Ex the hand Dx and discuss the mx I told the examiner, I will find whether it is RA (acute or chronic) or other causes (OA, CTS, deQuervain tenosynovitis) I greeted the pt. Before exam you, I will ask some Qs. During ex, if there is any pain, pls tell me to stop it. R u alrt? Did you have trauma? When did it start? (2wks ago) Is the pain in the morning with stiffness? (yes) Any other joint? (No, only this) Any FMHx of RA? (yes, my aunt has RA) Are you taken any medications or any medical problems? Whats your job? (gardener) Any factors worsen the pain? (activity will worsen the pain, but rest will relieve the pain) Ex: I took the pillow ( it was hidden somewhere) to the pt. Ask pt put hands on the pillow. Inspection: both hands (scar, swelling, bony deformity, only z-deformity in R thumb). Palpation (start from wrist, then hands. On R side, there is radial side tenderness. Palpate CMC, PIP, DIP on both hands, snuffle box. All ve. Check for subluxation, fluid effusion, crepitus, palmar surface for wasting/Oslers nodes. All ve) Function tests (opponent pollicis, giving the key, button/unbutton, write down names, comb hair, grip strength.) Movement: active (full range of movements, special tests for nerves [pen-touch for median, Formans test for ulnar, extension for radial, Phalen test for CTS], passive for strength and for FDS/FDP.), neurologic test (sensory). Finally, Finkelstein test to exclude DeQuervain tenosynovitis. My working Dx is acute RA. DDx: CTS, OA, and DeQuervain tenosynovitis and scaphoid #. Mx: Start from simple analgesia or NSAIDs if no heart burn. Exercise and refer physio. I will refer you to rheumatologist. Further test: FBE, ESR, RF, ANA and anti-CCP (cyclic citrullinated polypeptide). Critical Error: fail to perform hand exam, inappropriate exam way, or function tests.

Station 12 SVT 50yr man in ED with palpitation and dizziness. Smokes 20/day, drinks occasionally. Has stress work in the bank. Task: Take relevant hx Summarize to examiner Ask for appropriate ex/ix Discuss management and answer concerns

This is book case. I am concerned about cardiac causes, which is emergency. Is my pt stable? (yes) Now I will take the hx? Can you describe palpitation? When got it? How long it lasts? Is it increased or decreased? Any chest pain or SOB? (no. I got this 3 times per day for last 2 days. Last one lasts for 15minutes. It is like tumbling.) Any sweating? When did the dizziness happen? (before the palpitation) Spinning? (yes) Did you have blurred vision or double vision? (no) Hearing loss? (no) Did you take any medication or medical conditions? (10yr dx of HTN, but not took any medication or follow-up) Any shaking or tremor of hands? Bowel movement, constipation/diarrhea? Any palpitation when climbing the stairs? (yes) Did you get any dizziness when you get up? (no) Any excessive coffee? (4-5 per day) Summarization: 50 yr man presented with dizziness for 2 wks, and palpitation 3 episodes within 12hrs. intensity and duration of palpitation increased. It associates with vertigo, not chest pain/SOB/vision, hearing problems. He was dx HTN but not proper tx or followup. No hyperthyroidism symptoms or signs. NKA, unremarkable FMHx/PMHx. He is a heavy smoker and stress worker. Now I want to ex him. Ex: GA (anxious, otherwise normal). VS (BP 180/100mmHg sitting, standing not available; pulse 180, regular; others normal). Neck ex: no JVP, no bruits. CVS (apex not displaced, no thrills or murmurs.) No eye signs, no hand tremors. Ix: ECG (examiner gave it with only 4 leads available, I, III, aVL, V4). I measured the rate 1st and it is about 300/1.5=180/min. QRS is narrowed. P wave is seen, no PR prolonged, no ST elevation/depression. Left axis deviation. Normal T wave. My working Dx is SVT. DDx: AF, atrial flutter, hypothyroidism or MVP. BPPV is unlikely. I will refer this pt to cardiologist immediately to do echo to see heart chambers. TOE/TEE is best. 1st, rate has to be controlled. Cardiologist will start verapamil or diltiazem. Put on monitor. Control BP with medication. Further ix: caridac enzymes, U&E, FBE. CXR to see any enlargement, Holter monitor. Tx the underlying causes. Quit smoking and other lifestyle modifications. Critical Error: fail to dx SVT, fail to interpret ECG.

Station 13 New case: cellulitis + necrotizing fasciitis. Picture is given: redness in L leg and some black spots and redness rash, swelling ++. T 39. Task: focus hx, no further ex What is dx? Discuss mx and answer concerns. The pt was in couch. Pt said it was very painful. I gave him painkiller. When it happened? (3 days ago) When the rash appeared? (1 day ago) Any other joint pain? (No, just in the calf) Any a/n/v? (no, but feeling hot) Any chest pain or SOB (exclude PE)? (no) Any travel hx? (no) Any previous rash like this? (no) Any trauma? (no) Any medication or medical problems? (no) Smoking? (15/day) My working dx is cellulitis. Examiner asked for interpreting the picture. Mx: I will admit the pt. they will put IV fluid and 1L NS. Take blood test for FBE, BSL, ESR, blood culture, D-Dimer; CXR/ECG. I will mark the swelling to see any progressing. Raise the leg, using the tape (it was in the couch!!!) to measure the circumference. IV ABOs

(ceftriaxone, metronidazole, gentamicin). We will chang ABOs according to culture results. I will discuss with specialists. I will arrange Doppler to exclude DVT. Pt: is alrt I go back home? A: no, it is a serious disease and must be treated immediately. I will give you medical certificate and talk with your employer. (so he agreed to be admitted) Examiner: what are the complications? A: septicemia, necrotizing fasciitis, if it were the latter, fasciotomy needed to be done. Examiner: how could you know pt is improved? A: I marked the swelling, and measure that serially. Critical Error: fail to admit, fail to start IV ABOs, fail to do doppler U/S.

Station 14 DM 50yr woman to GP with increased urine at night for last 2-3 wks. She has weight loss about 2kg and her pants getting loose. She heard from radio about urge incontinence. She thinks it is due to urge incontinence. She smokes 5/day, used to smoke 30/day from 16yrs. She drinks 2 glass of wine per day. She wonders to know what is her recent problem. Task: No further hx or ex Ask appropriate ix from examiner Counselling the pt and answer her Qs When I got into the room, I straightaway asked for urine dipstick. (glucose ++) I asked random blood sugar. (16mmol/L) I asked for FPG. (9mmol/L). Then I asked U&E, urine microalbumin, creatinine/albumin ratio, HbA1C, FEB. (all pending) Counselling: I started to talk about DM. She was shocked and thought it was incontinence. Do you have any idea about DM? (No) Then I said: this counselling I will talk about what is DM, and its symptoms; and further ix, what is its complications (microvascular, macrovascular), explain the multidisciplinary team and care plan with lifestyle modifications and other measures, and emergency action plan. Then I said: it is a broad subject. There is an organ in our body called pancrease, which secret insulin to lower blood sugar. When there is a defect, glucose metabolites will damage heart, kidney, nerves, eyes, etc. Sometimes, the symptoms can come late even DM happened earlier. Because of this, I will check your eyes, kidney, and heart to see any changes. So I will refer you to eye doc, and arrange further tests for kidney and heart. It is a multidisciplinary approach, which incl. me, endocrinologist, DM educator, dietitian, podiatrist, and ophthalmologist. 1st of all, I want to you maintain a diary of your BSL half hour before each meal and 2hr after. From it, I can see how the BSL fluctuates. I am sorry to say that DM cannot be cured but can be well controlled by good lifestyle, which incl. healthy diet, low carbohydrate food. The dietitian will give you more details. I will also give you some pamphlets about DM. 2nd is exercise. Walking at least 30min for 5 days per wk will increase insulin sensitivity and keep you fit. And DM educator will teach you how to monitor the BSL and maintain the diary. I have to concern your smoking problem. Youd better quit smoking. I will talk about the drinking limit. So I will arrange further meetings with you. I would see you weekly to monitor the process. I will do 6 monthly checkup for HbA1C, annual test for eye doc/foot doc. If there is any complications, I will refer you to specialist. If you could control BSL within normal limits, the chance of complications will be reduced. As your BMI is high, I will monitor your weight

to achieve ideal. Your BP needs to be controlled under 130/80. If DM cannot be controlled by lifestyle modification, I will refer you to endocrinologist to start medications, such as metformin. I am going to talk about hyperglycemia/hypoglycemia symptoms. When you fell dizziness, jitteriness, it means hypoglycemia. You have to have some sweet in pocket and take it immediately. I will give you the Action Plan and put bracelet on wrist. When you travel interstate or abroad, I will give you further instructions. There is DM supporting group. I can give you info about them. But I should say, even with good control of BSL, you may still have some complications like eye problems. Poorly controlled would be even worse or come earlier. You will be put into the DM management plan to prevent further complications. Pt: Will I be put into insulin? A: Lots of people can be controlled by lifestyle modification and oral medications. Sometimes at late stage, if DM not well-controlled, insulin can be used. Critical Error: fail to dx DM, fail to mention complications and lifestyle modifications.

Station 15 Weight gain with Olanzapine 40yr woman dx with chronic schizophrenia. Recently she gains weight. Her BMI is 31. She lives with mother. Her mother concerns she is overweight. She has no psychotic symptoms or other side effects of medication. She smokes 15/day. Task: Take detailed mental state examination for 7 minutes. Examiner will interrupt you by asking you Qs about mx. I came in and told the pt, all info are confidential, I would ask you some sensitive Qs. Is this alrt? I understand you have weight problem recently, can you tell me more? (last 3 months, medication changed. After that, my weight increased.) What is the medication you are on? (olanzapine) Dose? (25mg) Before that, what medication you were using? (Stelazine) Why psychiatrist changed? (tremor and difficult to walk for last 6 months.) How is your mood now? (good) Have you ever felt depressed? (no) Have you ever thought to end your life or harm yourself? (no) How is your sleep? (6-8hr per day, no early waking) How is your appetite? (increased, I am eating lots of chocolate and junk food apart from normal food) Are you taking medication as the indication? (my mother gives me daily) Do you have experience about unusual voices/sensation/visual things? (No) Do you think someone control you or spy on you? (no) Do you think someone taking your thoughts out of your mind? (no) Do you think the TV or radio talking on you? (No) Do you think you need medical help? (yes) Are you able to concentrate? (yes, I can cope with my activity.) Do you have any hobbies? (I like reading.) Can you tell me what date is today? Where are we? Whats your birthday? Supposed you are in the cinema, there is a fire. What will you do? (runaway) Mary, I can assure you that it is side effect of olanzapine, which is atypical antipsychotic. Although it has less side effects compared with typical antipsychotic, such as Stelazine, unfortunately in some people, appetite increases and causes weight gain. But it is a good medication to control symptoms of psychosis. You can live a normal life with it. Anyway, I worry about the tremendous weight gain. So I will give you two options. One is lifestyle modification. Do you do exercise? (rarely) I explained exercise is a good option. Walking 30min for 5 days at least. Then I talked about healthy food, no junk food or chocolate. I will refer you to dietitian. He will teach you how much calories you could take per day. I will

arrange another meeting with you about quitting smoking. I will give you pamphlets about low glycemic food. Today, I will do further ix: FBE, BSL, lipids, U&E, and HbA1C. Second option: since I concern about your weight, I will refer you to community psychiatrist to discuss this medication. He might decide to reduce olanzapine or introduce another medication, like risperidone. To do this, he will admit you. When reducing the dose, there could be some withdrawal symptoms. Well watch for it. If introducing new drug, olanzapine will be gradually decreased and new drug will be gradually increased. So the whole process will take at least 2 wks. I will followup. If you have any concerns or problems, pls contact me. (examiner didnt ask any Qs. I finished early.) Critical Error: fail to take detailed hx, fail to talk about cross-over.

Station 16 Insomnia (shift worker) 25yr man who had a cut injury in wrist by machine had sutured and bandaged. The medical team nurse in rural hospital noticed he had some problem. He worried about it and sent him to you, the GP, to assess mental state. Task: Ask further hx, no ex Answer pts concerns Discuss the mx. If you want to refer, you should state why and who. I went into the room. The pt looked worrying. So I started. How are you feeling now? (yes, I am alrt) My medical team is worrying about you. I want to ask a few more Qs. What is your job? (mechanic in a bakery shop) How the injury happened? (while I was preparing, I slept on the machine wheel. Then my wrist was cut.) Are you doing night shift? (Yes, I do long night shifts. About 14hrs for 6 days.) How many hours you sleep? (I cannot sleep well because my house is close to the road, which is noisy. I try to put curtains to mimic night.) Are you able to concentrate on your jobs? (no, my concentration is decreased for last 2 months.) How is your appetite? (good) How do you go to work? (by car) Have you ever slept on wheel while driving? (yes, one month ago I had an accident and had whiplash injury. And there is still pain.) Do you have pain when reversing the car? (yes, I went to physio for this) How is your home situation? (I live with my wife who is supportive. I have 2 children.) Do you involve in any social activities? (no, I dont have time to do anything.) Have you had any PMHx of depression? Any FMHx of depression? Have you ever thought living is worthless? I want to ask sensitive Qs. How is your sexual life? (good) Do you smoke? (I smoke 10/day.) Do you drink alcohol? (2 glasses at weekends to get sleep, sometimes more.) Do you have any medical problems? (no) Are you on any medications? (one doc gave me benzodiazepine for sleeping, but it didnt help.) Any allergy? (no) Have you ever had trouble with law? (twice, caught by police because of alcohol limit and slept on wheel.) Have you ever talked with your employer about it? ( I tried but he didnt listen.) Are you happy with the job? (I liked it before. But now I cant concentrate on it because of night shift.) Are you able to cope with normal activity? (no, my wife does these as I have to sleep.) James, I believe you have a medical problem, insomnia, or sleep problem, because of night shift work. I concern about this problem as you have trouble with laws and were injured. Now, on mx, I am going to talk on what is insomnia, how you can improve by sleep hygiene, lifestyle modifications, and medication. If all failed, I will refer you to sleep study clinic in 3rd hospital. They will perform further study, polysomnography, to assess any organic causes.

I will arrange basic ix: FBE, TFT, U&E. I will talk with your employer to reduce your working hours and shifts to improve your sleep. Then I talked about sleep hygiene. Dont take coffee/smoke/drink alcohol before go to bed. Take normal meal 2 hours before sleep. You can read books to relax yourself before sleeping. Dont think too much about work. Sometimes yoga will help you. Exercise daily to keep your mind fresh. Eat healthy food. Having a warm shower. Sometime short-term benzodiazepine could help. But prolonged usage would lead to dependence. (pt agreed with it.) Dont drive when doing long shift. Ask your wife or take taxi. I will followup you. If not improving, I will send to sleep clinic with specialist. Critical Error: fail to take detailed hx.

My comments: 1. It is a difficult exam. To pass it, group studying is very important. You must find at least 3 people to mimic the real exam (one as candidate, one as role player, and one as examiner.) 2. During preparation, you must speak English since language skills are very important to pass the exam. 3. Please take Dr Wenzels class regularly for at least 6 months. It is a very useful to watch even though you are scared to go to the front be nch. Youd better do at least 5 cases with him. 4. The best course is VMPF long course, which could prepare you well not only in exam skills but in language skills. You could be a good doc after this course. 5. If you can afford, pls attend the VMPF trial exam as well. It is very practical and helpful. 6. AMC clinical book should be finished at least 3 times before the exam since it is the Bible. Other books are useful incl. Patient Education (5 th Edition), General Practice (4th Edition) at least once. Some useful OSCE books: Clinical Cases in Obs & Gyn (2 times), Clinical Problems in Medicine and Surgery (at least once), Core Clinical Cases in pediatrics, Talley & OConnor. 7. I want to thank VMPF staffs, and my study partners, Drs Romani and Kalyani and others who help me, Dr Suanda, Dr Latif and Dr Berenda. tthwewin is not available to chat Reply Forward