2

ND
MARCH 2013, SYDNEY,

Station 17:
A 26 year old male had an accident and brought to the Emergency Department with chest
pain and shortness of breath. His friend was driving the car and he has no significant
injuries. After arriving here, he was managed accordingly. His pulse, BP, respiratory rate all
were given as normal. He had done the baseline investigations and imaging. Blood tests
seem to be normal and the CT scan was given outside. You are working as a HMO. You are
about to see the patient now.
Tasks:
Interpret the CT scan to the patient
Explain management

Thinking time:
The CT scan was a clear cut case of Haemo-pneumothorax .Similar picture is given in
Handbook of Clinical Assessment page336. I got to explain the CT scan showing lungs, the
fluid and air and tell the patient about Intercostal tube drainage/ Chest tube drainage-the
procedure and complications in details.
The exam:
When I entered the room a very nice Aussie Examiner shook hands with me and introduced
the patient to me. The role player was breathing very fast holding the oxygen mask.
I told my examiner I understand hes haemodynamically stable. He told me, you dont have
to worry about it, we managed him initially and now the patient wants to know about the CT
scan report and management. So stick to your task. (!)(Somebody must have forgotten the
task, but not me!) I told him, yes I know!
Then I came by the side of the patient-
Me: Hey Mathew, are you feeling better now? Do you still have pain? I can offer you some
pain-killer if you want.
Pt: I am fine at this moment but worried about what is going on.
Me: I will tell you in a moment. By the way have you spoken with your friend?
Pt: Yes, I am glad that hes doing fine.
Me: Its going to be alright. Ok? Were here for you and well take every possible steps to
treat you, as quickly as we can .( I slightly pat the shoulder of my patient and knew that hes
on my side even before doing anything!)
CT scan:
Heres your CT scan, these are your lungs. I pointed out the black and white portion of it to
indicate air and fluid. Technically we call this Haemopneumothorax - blood and air in chest
cavity. As a result of the accident you got hurt in the chest cage which injured your lungs;
fluid most likely blood and air is entrapped in between your rt lung and its covering and
compressing the lung. This is the reason you are having pain and SOB.
Management:
So what we will do is to remove the entrapped air and blood through a procedure with safety
precaution, we call this- Chest tube drainage- we need to put a tube in your chest if you
agree because this is pretty big.
After cleaning the skin with disinfectant local anaesthesia will be given to numb the area.
Then small cut would be made with scalpel and open the tissues with forceps. After that
Chest tube would be introduced and fixed with a suture in the chest wall and connected with
the drainage system.
Like other procedures it carries some risks-
Pain- painkiller would be given to ease the pain.
Bleeding- expert doctor will do it with special techniques to prevent damage to vital
structures.
Infection- we will use sterile technique and even though it occurs well manage it with
appropriate antibiotics.
But these are rare, so you dont have to worry about that part.
Do you have any questions?
Pt: no, I understand.
Me: Dont worry too much, were going to take care of you. Then examiner asked me
questions.
Ex: What are the structures those may be injured in the procedure?
Me: The vital structures passing underneath the ribs.
Ex: In which area will you introduce the tube?
Me: Oh yes, usually on the 5th intercostal space in the mid-axillary line.
Ex: Show me the area. ( I showed; Thank God, I used to work under the supervision of a
chest physician!)
And I will make sure the position is right by doing scan or X-ray after the procedure!
Ex: Ok. The bell rang.
Itd be ok I said to the patient ( actually I was telling this aloud to counsel myself!).
When I stepped outside I quickly realised- I didnt mention the word injury to the
neurovascular bundle, I thought I did; I just told the vital structures!! And I did not take the
consent from the patient, I told if you agree only!!!
God, am I going to fail this station?
AMC FEEDBACK : INJURY TO CHEST

Station 17:
A young man met with an accident and was brought by an ambulance vital signs were given
normal. CTscan was done and is shown below(pic from AMC BOOK from pneumothorax
case
explaination) .Now patient has SOB and shallow breathing.
TASKS : Explain CTscan to thepatient
Management
Explain the procedure and take consent
There was an observer in this station and role player was wearing gown and was lying on
the table
with oxygen mask
Explained the CT scan with hemopneumothorax
Examiner : was their anything else
Me : rib fracture
explained the complete procedure of chest tube insertion starting from position of the patient
to
confirmation of position of tube .
Examiner asked me to show the site of insertion on the patient.
I asked the roleplayer to expose that area and showed exact site
Examiner : what are the complications?
Me : explained the complications but reassured that it is done by the experienced hands
Examiner interrupted and said you are the one who is doing the procedure and laughed.
Me: It is done under supervision and we will take necessary precautions to minimise the
risks
Examiner:Would you like to do any investigations?
Me: Yes , I would like to do FBE, ABG , Echo ( pericardial effusion) ,abd USG to see injuries
to
abdominal organs
Bell rang!!!
AMC FEEDBACK : INJURY TO CHEST

Station 19:
Psych station: Weight gain due to side effect of anti psychiatric drug( Olanzapine) in a
schizophrenic patient
same recall
RP: Is there any pill to decrease weight?
AMC FEEDBACK: Weight gain side effect anti psychiatric drug

Station 19:
A 38 year old lady is a known case of Schizophrenia. Her consultant gave her Olanzapine
(Zyprexa) for her illness couple of months ago. Now she is complaining of weight gain of
around 10 kg. She is very disappointed. Now she is in your GP clinic.
Tasks:
Take appropriate history.
Manage the patient.
Thinking time:
This is the side effect of antipsychotic medication. I need take psychiatric history. I need to
maintain confidentiality and make sure she is happy !
The station:
When I entered the room, the examiner introduced my patient. I found an overweight lady
with uncombed hair is looking at me suspiciously, mimicking a psych pt.
HOPC:
I introduce myself and started with confidentiality.
Hello Sandra, I understand you are on medication for Schizophrenia. I can see you put on
weight recently. Can you tell me a bit more about it?
Pt: I gained 10 kg in last 6 months. I am really worried.
Me: Are you taking the prescribed dose regularly? Did you change the dose?
Pt: I am following the prescription strictly.
Me: Thats good! Except for weight gain do you have any other side effects?
Pt: Like what?
Me: Dry mouth, blurred vision, constipation, abnormal movements in body and face, etc?
Pt: no.
Me: Good. Describe your daily diet and exercise.
She described her diet with lots of meats in it, less vegetables, more junk foods and she
never gets time to do any exercises. Her appetite is very good.
Me: Describe your mood & sleep?
Pt: Its pretty normal.
Me: Do you hear or see things when you are alone in a room?
Pt: No, I used to have those, but now its quite normal.
Me: Do you think TV/ radio is talking to you or somebody is putting thoughts in you or
stealing thoughts from you?
Pt: Not at all.
Me: Beautiful. So you think life is worth-living, dont you?
Pt: Yes! Of course!
Me: Nice!
Then I asked about if she has any other physical problems!
SADMA
HEADS
Social history
Occupation
Past medical and Psych history
Family history
Menstrual history
Management:
I understand Olanzapine is helping you for treating your symptoms of Schizophrenia. But as
you know every medication has some side effects. However, in your case it is weight gain.
What I want you to do is to modify your lifestyle a bit!
Healthy diet: more protein, more vegetables, less sugar would help. Avoid red meats and
fatty food and drinks. Try not to take junk foods. Drink a lot of water.
Exercise: If you dont get time to go to the gym, at least you need to walk briskly 20 to 30
mins 5 days a week.
You need to take less calories and exercise more to maintain your weight. Try this for 3
months.
Meanwhile you take your medication regularly without changing any doses.
Pt: What else can you do?
Me: In between, I will contact with your Psychiatrist, if she decides to change the medicine,
you may need to be admitted in the hospital for cross-over period! I drew the picture of
cross-over period and then explained - well decrease the dose of current medicine and
increase the dose of new medicine and then stop the previous medicine.
I will follow you up regularly. (I didnt mention- I have to check your BP, BSL, Lipid profile,
ECG, etc. Is this a critical error?)
Pt: Can you do anything else in the mean time? Please.
Me: Well, I can give you some appetite suppressants, but as you know those are not very
good drugs, and some have serious side effects!
Pt: Ok, thanks. But what else?( At last she seemed a bit happy! I am so confused. Was that
right? I dont know what else she wants!)
Bell rang!
Extra notes:
Olanzapine:
Dose: 5-20mg
Side effects: Weight gain, sedation, dizziness, restlessness, increased appetite, increased
triglycerides, increase chance of diabetes, anticholinergic side effects- dry mouth, blurred
vision, constipation, etc.
Olanzapine causes lipid derangements. Ask about last lipid level.
Ask about thyroid, DM, Liver, Kidney and Heart disease specifically!!
AMC FEEDBACK: Weight gain side effect anti psychiatric drug

Station 20:
A 27 year old lady presented in your GP clinic because she noticed a lump in her vulva
which is really painful. She has severe discomfort during sitting and walking;
Tasks:
Take focused history
Physical examination from examiner
Diagnosis
Management
Thinking time:
From the stem I understand this is a case of Bartholin cyst. I have to exclude if there is any
discharge or abscess there. But the D/D may be- Genital warts, Vulval tumour, etc.
The exam:
My examiner introduced my patient to me. She was sitting with half buttock on the chair,
showing severe discomfort.
HOPC:
Hey Jenny, You have a lump in your private area. When did you notice that? By the way, if it
is too much pain I can give you Panadol if you want.
Pt: Thanks so much. I had it already. It started 3 wks ago. This is the first time I have this
sort of problem. Its awful.
Me: Is it increasing in size? Pt: I think so.
Me: Any discharge? Pt: no.
Me: How painful is it? Pt: severe 9/10. I cant sit or walk!
Me: I can see.
Me: Is the pain radiating to anywhere? Pt: No.
Me: Anything increases or decreases the discomfort? Pt: nothing.
Me: Did you notice any lumps and bumps in the body? (Ca) Pt: no.
Me: Any rash or vesicle in the private part? (Herpes) Pt: no.
Me: Any fever? Pt: no, but increased temp in vulva (Only abscess which doesnt cause
fever.)
Me: What about water works and bowel habits? Pt: Ok.
Me: Any tummy pain? (PID) Pt: No.
Me: Tell me about your menstruation? Pt: Perfect. Last one was 1 week back.
Me: I will ask some personal questions if you dont mind. Pt: Ok.
Me: Are you sexually active? Pt: Yes, I have a stable partner.
Me: Does he have similar problem? Pt: Not at all.
Me: Do you feel pain during sex? Pt: Yes.
Me: What sort of contraception do you use, if any? Pt: Condom.
Me: Has your partner or you ever diagnosed with STIs? Pt: No.
Me: Do you do Paps regularly? Pt: Always, normal.
Me: Any significant medical and surgical conditions in the past? Pt: no.
SADMA
Physical Exam:
General appearance- As you see-irritable.
Vitals- N
LNs- no
CVS, Respiratory, Abdomen-N
As my patient is in severe pain, I am not doing Speculum or Bimanual exam, I only check the
lump-
Inspection- He gave me a picture showing left sided Bartholin cyst. No discharge, red in
colour. It was not the same picture that I was given, but it seemed the most educational
picture to me.

Palpation- Temp raised in labia majora, tender, soft ( ok, so I can call it abscess now- hot
and soft.)
I will do Urine dipstick test.
Diagnosis:
From the history and physical exam Ive got a suspicion that youve a condition known as
Bartholin abscess. I drew a picture. This is labia majora of your vulva, there are 2 glands on
each sides that opens in the vagina, and helps lubricating the area during sexual excitation.
But sometimes accidentally those get obstructed like other glands, and collect secretion
inside (cyst- not painful, hard). And then the bugs get a good environment to infect and then
it becomes an abscess ( soft, painful) within 2-3 days producing discomfort and pain. Its
usually bacteria. ( E.coli, Sterptococcus, Staphylococcus)
Pt: Is this a STI? Me: Its unlikely, but I will investigate that as well. But I need your consent
to carry out this. Pt: sure.
Management:
Sitz bathe- ( Both cyst and abscess) Special bathe with warm water several times a day
which relieves pain.
Abscess drainage- surgical procedure in the hospital.
Marsupialization- Cutting the abscess in the centre, leaving a permanent opening to drain
the pus and put suture in the outer sides, to prevent recurrence. Sometimes the entire gland
is removed rarely.
Antibiotics after drainage ( Penicillin+Metronidazole) according to C/S.( Gonorrhoea-
Ceftriaxone; Clamydiae -Azithromycin;)
The prognosis is excellent. Only 10% chance of recurrence after the procedure.
I will give you pain killer and local lignocaine gel.
I will urgently refer you to Gynaecologist.
Pt: How can I prevent it later on?
Me: Good question. Always practice safe sex (condom, washing genital area after sex). Pt: I
know.
Me: Maintain good personal hygiene, wear cotton underwear.
I will follow you up regularly. I will give you reading materials which would be helpful. Do you
have any questions?
Pt: Not at all. You have explained everything so clearly! The bell rang!!!
Note: Vaginal discharge may be present if the infection is due to STI specially Gonorrhoea.

AMC FEEDBACK : BARTHOLIN'S ABCESS

Station 20:
A middle aged female came with c/o painful lump down below
TASKS: history , examination, investigations and management
Pain q ns offered pain killer
A painful lump down below which is there always..
slight fever, no discharge
Periods nothing significant
partner :in a stable relationship , not diagnosed with PID before
Pills : not on any
pap smear : normal
Examination : examiner gave me a pic showing bartholin abcess
I did not want to perform p/s or p/v because she is in severe pain.
LAD -ve
explained what it is with the help of a diagram , its causes and its complications
I mmediately referred to specialist for marsupialisation
After drainage , need to send the secretions for culture and microscopy
Offered STI screening
Suggested antibiotics
Pain killers
RP: will it recur?
Yes there is a chance of recurrence but to decrease it we are doing this spl procedure called
marsupialisation . But after that u need to maintain personal hygiene..blah blah..
AMC FEEDBACK : BARTHOLIN'S ABCESS

Station 1:
A 35 year old man came to Emergency Department with chest pain.
Tasks: History, P/E, Inv., D/D.
Thinking time: D/D: AMI, Angina, Pericarditis, Endocarditis, Pul. Embolism, Pneumothorax,
Pleural effusion, Pneumonia, Psychogenic pain, Traumatic injury, GORD! Its gonna be
huge!
HOPC:
I asked my examiner if my patient is haemodynamically stable! He replied- yes. And then
introduced me to the patient.
Hey David, I understand you have pain in the chest. Do you want any painkiller now?
Pt: No, thanks for asking, but I am ok now.
Me: Ok, is it the first time? Pt: Yes.
Me: When did it start? Pt: Couple of hours ago.
Me: Where exactly it is? Pt: He showed his centre of the chest.
Me: Is it sharp, dull, crushing or what? Pt: I dont know- discomfort and intense pain. (If it
was AMI hed obviously know!)
Me: Can you tell me the intensity of it? Pt: 6-7.
Me: Any shortness of breath with it? Pt: a little bit.(!)
Me: Pain is constant or on and off? Pt: Not always constant!
Me: What makes it better or worse? Pt: Nothing.
Me: Any fever? Pt: I dont know.
Me: Well, Ill check that for you. Any cough? Pt: I little bit, no phlegm though.( I think thats
what he said!)
Me: Any sore throat? Pt: no.
Me: Any heart racing? Pt: no.
Me: Did you hurt yourself on the chest? Pt: no.
Me: Any leg pain? Pt: no.
Me: Have you ever diagnosed with DVT? Pt: no.
Me: Have you travelled recently? Pt: Yes, in England. (Only positive response)
Me: Any heart burn? Pt: no.
Me: Past significant illness- medical, surgical, psychiatric? Pt: nothing.
SADMA
Physical exam:
G/A: Anxious
Vitals: Pulse, BP, T, RR, O2 Sat- N
CVS-N
Respiratory-N
Abdomen-N
Limbs-N
Investigations:
FBE, ESR, CRP
Cardiac Enzyme-N
ECG- N
CXR- N
CTPA- N
VQ scan- Ex: Are you going to do that if CTPA is negative? Me: Not really. Ex: Right. Now
you can proceed on D/D. Me: Ok, thanks.
D/D:
MI- unlikely, no characteristic pain, no ECG findings
Angina-unlikely
Pericarditis- not characteristic pain
Pneumonia- may be
PE- there is a +ve history of travel
Chest trauma- no history
Pneumothorax- unlikely
Ex: What else?
Me: If nothing is positive, I will exclude Psychogenic causes(Oops! Its not Station 7 or 19!
But if it was my real patient Id consider it, dont I? I dont know what he thought! Was that a
stupid response? May be not!)
Ex: Ok, Good luck! Me: Thanks! Thanks- both of you!! The bell rang!!
AMC FEEDBACK: PLEURITIC PAIN WITH SIGNS OF INFECTION !!!

Station 1:
A 35 yr old man is in the emergency department with history of chest pain for the past 1 hour
TASKS: History , Examination , investigations and diagnosis
Is my patient hemodynamically stable?yes
started with reassurance
Sudden pain in the left lower chest(site of pleura), severity 8-9 ,offered painkiller and oxygen
no radiation ,no aggravating and relieving factors,not related with food
Associated with SOB
No h/o FEVER, COUGH
No h/o Trauma to the chest
travelled recently to UK (slept in the plane)
Past history: h/o fracture of neck of femur , undergone surgery an d was immobilised for few
wks
Had DVT and was on warfarin for 6 months.
Have not taken prophylaxis before leaving to UK
No CV risk factors
SADMA ( I did not remember)
Examination: GA: restless ,VS: NORMAL, BMI :NORMAL
Respiratory examination -normal
CVS -normal
Investigations :FBE, ESR, CRP, chest X ray, coagulation profile,ECG, Cardiac
enzymes,CTPA or
V/Qscan ,thrombophilia screening
Diagnosis : Pulmonary embolism b'cos sudden onset of chest pain and SOB, pleuritic in
nature ,
travel and past history of DVT.
DD's -Pnemothorax, pleurisy or pneumonia,angina , aortic dissection
AMC FEEDBACK: PLEURITIC PAIN WITH SIGNS OF INFECTION !!!

Station 2:
A boy was admitted in the hospital with fever, abdominal pain ,diarrhoea with blood after a
holiday
with his family in a caravan park where they ate from a food court. He was treated and now
he is
fine and ready to be discharged. You have seen two other children ( not related to the family)
with
same complaints. Stool microscopy and culture was done which revealed salmonella
TASKS: history , counselling
I was surprised by seeing history (what to ask and what is the purpose of asking)
anyhow I spent some time on history on presenting complaints, his past medical history and
contact
history. Nobody else in the family has similar symptoms
Counselling: explained about salmonella ,source of salmonella, mode of transmission ,
carrier state
management: The child is ready to be discharged but need to be followed up by stool
cultures until
3 consecutive negative samples.
Inform the child care or school.
Maintain personal hygiene...
stool examination for whole family, and workers of that food court
reporting to DHS
RP: Do we need any antibiotics?
Unfortunately ,there is no role for antibiotics in this condition .They will only worsen the
condition
Reassurance, Reading materials... This is the only one station where roleplayer indicated
me that I did well..
I finished this station a bit early
AMC FEEDBACK: SALMONELLA COUNSELLING

Station 2:
. You are an intern in a district hospital. You are about to see a 2 year old boy who was
admitted to the hospital and diagnosed with Salmonellosis. He was in a camp with his
parents. There were other 2 children in the hospital who were in the same camp. His father
is here to talk to you.
Tasks:
Take a focused history
Talk to the father about management
Thinking time:
I have to notify the DHS which is a critical error. Advise him about hygiene and follow up the
pt.
The exam:
There was an observer in this station. My examiner introduced my pt to me. I was very
surprised to see that the role-player was reading from his notes. I could not properly
understand his accent!! Even he couldnt understand me!! I had to repeat my words!! I was
really angry!!!
HOPC:
Me: Hello Mark, whats your sons name? RP: Charlie!
Me: I understand Charlie has Salmonella infection which presents with diarrhoea. Hows he
now?
RP: He still has diarrhoea 2-3 times but better now.
Me: Any fever? RP: No.
Me: Does he complain about tummy? RP: slight pain sometimes.
Me: Does he have any other siblings? RP: Yes, his elder sister is ok.
Me: Is he growing well? RP: Yes.
Me: What about immunization? RP: Updated.
Me: What about water works? RP: Good.
Me: Past significant illness? RP: No.
Me: Does he go to child-care? RP: Yes.
Me: What do you do for living? RP: We have a food-shop.
Management:
Mark, as you know Charlie has Salmonellosis, which is a kind of gastroenteritis, caused by a
bug, Salmonella. Its a common infection in children and young adults. The severity depends
upon number of bugs and health in general.The s/s are- diarrhoea, nausea, vomiting, fever,
dehydration, tummy pain, etc.
RP: How did he get the infection?
Me: The bugs get entry by eating uncooked or undercooked food- meat, row eggs etc. The
steps to prevent this infection are-
Cook properly. Store raw foods and left-overs in the fridge.
Dont use cracked eggs.
Clean tools, as for eg- kitchen board, utensils, before and after cooking.
Wash hands with soap after using toilet.
Do you have pets? RP: A cat.
Me: Human and pets can carry the bug and sometimes remain asymptomatic for long time.
Wash your hands after dealing with pets.
It is a notifiable disease. I will notify DHS regarding the infection. They are going to come
and take samples from all family members (including pet I guess). The reason is to protect
your family and others. As you have a food shop, its really dangerous, the infection can
spread to others.
They will culture stool for all family members to see if you are the carriers of the bugs.
RP: What are you going to do to treat by son?
Me: We will treat symptomatically- Healthy diet, plenty of water, proper hygiene. I will follow
him up with stool culture every 1-2 weeks and wait for 3 consecutive ve cultures to declare
him bug-free. We will also culture blood. He may carry this for weeks, in rare cases couple of
months to a year.
RP: Will you give antibiotics? Me: Yes, according to culture report! ( Damn!!! How did I make
this mistake? The correct answer is no! It will prolong the symptomatic period of excretion
of Salmonella, it can mask s/s too. If he does not have any s/s which doesnt mean hes free
of bugs!
Antibiotics are only given in- Immunocompromised pts, malnourished pts, less than 3
months of age and cancer patients.
RP: Will DHS close my shop? I dont have any complaints from my customers.
Me: Not exactly. Theyll come over and take samples and analyse them and then they will
decide.
RP: When can he go to child-care?
Me: Not now; when his s/s resolves completely.
(Every time you develop Gastroenteritis, doctor will ask you for a stool sample for testing- if it
is Salmonellosis they will treat you accordingly and report DHS. I did not mention this.)
AMC FEEDBACK: SALMONELLA COUNSELLING




Station 4:
A 38 year old Businessman had seen a TV programme on Excessive alcohol consumption.
He is consulting you as he is concerned about his drinking after watching that show.
Task: Counsel the patient.
Thinking time:
I need to explore his compulsion of drinking, attempt to quit, alcohol taking priority or not,
tolerance, S/S, any complications, social and legal problems, CAGE questions, etc. Here
counsel means everything!!
The exam:
HOPC:
Me: Hello Carl, I really appreciate your effort for coming over here and talk about a potential
problem-Excess alcohol consumption! (I didnt mention your drinking habit!!). Thanks for
your initiative, this is really thoughtful! But before going to any discussion I need to ask some
private questions which will help me to assess overall situation. Pt: Go ahead.
Me: When did you start drinking? Pt: At 17-18 yrs.
Me: How much do you drink? Pt: 2-3 SD drinks every day.
Me: What type of alcohol do you drink? Pt: All sort of drinks, specially beer, red wine, etc.
Me: Do you prefer to drink at home or at pub? Me: At pub with friends.
Me: Do you drink more in the weekends? Me: Yes.
Me: Are you aware of low risk drinking habit (safe level)? Pt: No.
Me: Well, its 1-2 SD 5d/wk. Do you drink heavily without appearing drunk? Pt: Yes.
Me: Do you like to go to the pub after work? Pt: Yes.
Me: How long can you go without alcohol? Pt: I cant stand for so long.
Me: Do you any S/S like shakiness, dizziness, nausea, vomiting, sweating, agitation, etc?
(Delirium Tremens)
Pt: Sometimes. Me: How is your sleep and appetite? Pt: Sleep and appetite decreased I
guess. I wake up early in the morning sometimes.
Me: Do you feel depressed or anxious? Pt: I feel depressed sometimes.
SADMA (Illicit drugs)
CAGE Qs:
Me: Did you try to cut down the drinking? Pt: never tried.
Me: Is criticism annoys you? Pt: not really.
Me: Do you feel guilty about it? Pt: Sometimes.
Me: Do you use alcohol as an eye-opener in the morning? Pt: sometimes.
Social history:
Me: Do you have any problem at your family? How many children do you have? Pt: I have a
happy family with 2 children.
Me: Any problem at work? Pt: No. But I cannot concentrate at work sometimes.
Me: Any legal issues like drink-driving? Pt: no. Me: Good.
Me: Past history- DM, HTN, High cholesterol, Gout, etc? Pt: no.
Me: Do you think alcohol has impact on your sexual life? Pt: I have less energy.
Management:
Carl, I think alcohol has a major impact on your life. Youve less energy, lack of sleep, less
appetite, depressed mood, loss of concentration. Alcohol does some bodily harm- HTN, DM,
high cholesterol, Stroke, Heart disease, Liver disease if consumed too much. I will do couple
of investigations- FBE, BSL, Lipid profile, LFT, U&E, RFT and see how it goes.
All the S/S will improve and youll have better sleep, increased appetite, more concentration
and energy if you cut down the alcohol a bit and follow the safe or low risk level of drinking.
As it has got impact on target organs, if you follow this your chance of getting serious
medical illnesses will be reduced too!
Pt: How can I cut down?
Me: Drink with food, have a glass of water in between drinks to quench thirst, switch to low
alcohol beers, avoid going to pub after work.
Avoid going to pub with heavy drinker, if under pressure tell my doctor told me to cut down.
Exercise more and plan other recreational activities instead of drinking.
Set a good example to your children and spend more time with your family.
Lots of helps out there Carl. We will make a plan together-
Support groups- ie-Alcohol anonymous: with them you can share your thoughts and get
supports.
Enrol yourself with programmes aiming to decrease alcohol.
Counselling sessions with psychologists will be advised.
Regular follow up with me to see progress and I will help you to control S/S during this
period.
Family meeting- to give you support if needed.
Ill give you some reading materials regarding this.
Eat regularly, do more exercises, get relaxed, maintain sleep hygiene- warm bath, no TV in
bedroom, etc. Dont drive under influence of alcohol, avoid it in empty stomach, dont use it
to quench thirst or as a stress-reliever. Keeping a diary is a good idea.
Pt: I dont know if I can do this! Me: You can give it a go. I will help you all the way through it.
Additionally there are some rehabilitation programs as well. I hope you will be alright.
The pt didnt seem happy at all, felt like he is very angry at me!!
Critical error: Judgemental attitude or blaming pt.
Book case: Condition-019 (P-66,121)
AMC FEEDBACK- EXCESS ALCOHOL CONSUMPTION

Station 4:
A middle aged man became concerned,after watching a TV show about harmful
consequences of
alcohol and came to ur GP clinic to know more about effects of alcohol.
TASK- Take history
Order necessary investigations if any
counsel him regarding the effects of alcohol
After introduction,
I took history on pattern of drinking ,tolerance, withdrawal,effects on his family and relations,
and
physical effects..
I didnt remember the exact amount but he drinks HEAVILY and more on parties and
weekend but
not a binge drinker.
C +
A -
G -
E -
Never experienced withdrawal effects.
No problem with law
sometimes arguments with his wife regarding his habit
no physical effects
mood Questions ( I asked this because RP was not maintaining eye contact )
Motivation.... he replied not motivated at all... will think to cut down if the complications
sounds
dreadly
Counselling-
I explained his dependency on alcohol
need to order some investigations- FBE (Peripheral smear ),LFT, serum folic acid and vit
B12 ,
Lipid profile, BSL( I forgot to order serum lipase and ECG )
I explained short term effects -sleeplessness, impaired judgement,lack of guilt, problem with
law, impaired memory, decreased work performance ( RP replied he has not faced any
problem at
work till now)
Long term effects Diabetes , HTN ,malabsorption, vit B12 and thiamine deficiency, effect
on
heart, brain and liver. Hence I need to order some investigations
Effects on sexual and social life
Bell rang...
The role player has a typical Aussy accent and he was not looking at me while talking.It was
difficult to understand what he was saying. So I said, Look John , Iam still getting used to
the
accent .So ,please dont mind if I ask u to repeat anything
At times, I doubted whether Iam in the right direction or not !!!
I was not happy with my performance
AMC FEEDBACK- EXCESS ALCOHOL CONSUMPTION

Station 5:
A 28 week primigravida came to your GP clinic for the first time. Her BMI is 40. and BSL is
14.3
mmol.Her pregnancy was uneventful so far.
TASK- Counsel her regarding management
Address her concerns
My thoughtsshe
is obese and probably gestational diabetes (need to confirm)
should explain GD ,causes , management( pregnancy , labour and post partum)
After I enter the room , examiner checked my ID and introduced to the roleplayer...
Hello Linda, I am Dr.... ,your GP
first of all let me congratulate you on your pregnancy...
How is your pregnancy so far? Good
As you know I checked your BSL .Your BSL is 14.3 and normal should be <7.
Have you ever diagnosed with Diabetes before ? No
Have u undergone sweet drink test ? no
I suspect that you have a condition called Gestational diabetes.
Do you have any idea regarding GD? I know diabetes but not GD
I explained GD , causes ( and risk factors ), and complications .
Complications of obesityREASSURED HER.. I understand that after listening this you are
quite worried but you are not
alone .Now onwards you are looked after by a multidisciplinary team that includes me as a
GP,
obstetrician, diabetic physician and diabetic educator in high risk pregnancy clinic.
Your blood sugar level is closely monitored because the level of blood sugar is directly
proportional to the congenital anamolies. Your BSL should be under control in order to
prevent
congenital anamolies of the baby
( the role player was happy with this sentence...
First ,I need to confirm GD by OGTT
Check the wellbeing of the baby by USG
will refer to high risk pregnancy clinic
more frequent ante natal visits
Explained life style management.. diet ,regular monitoring, if required we might put you on
insulin
RP- Is my condition managed by life style management alone?
Because of the obesity there are high chances that you might need insulin now, along
with lifestyle
modification. But specialist is going to decide .
Regarding you labour, it is done electively around 38 -39 wks in controlled environment by
the
specialist
RP-Is it possible to have a normal vaginal delivery?
Yes ,it is possible . But depends on the growth of the baby .Ceaserian section would be the
best
option in your case considering your weight as well. However, it depends on your wish and
specialist opinion.
After labour ,your BSL may come to normal but we need to repeat the test after 6 wks of
delivery
and 5 yrly thereafter because you are at high risk of developing diabetes in the future.
Then the bell rang.....
AMC FEEDBACK- GESTATIONAL DIABETES

Station 5:
A 26 year old lad presented in your GP clinic with 28 wks pregnancy. She has seen by one
of your colleague 2 wks ago, who sent some investigations. All the results appears to be
normal except for BSL- 21mmol/l. Her BMI is 41.
Tasks:
Take further relevant history.
Counsel her.
Thinking time:
It is a combination of Pg+Obesity+GDM. Apart from history I have to talk about treatment
plan, risks in mother and baby and mode of delivery, follow up, etc.
HOPC:
Hey Jenny, I am X, I know my colleague takes care of you and he sent some investigations.
Today I will discuss about the results. Before I go to the discussion, may I know is that a
planned pregnancy?
Pt: Yes, I was trying this for so long!
Me: Wow, great, Congratulations! How are you doing at this moment?
Pt: Pretty good. Me: Is that your 1st pregnancy?
Pt: Yes. Me: Any miscarriages? Pt: no.
Me: Good. Do you have any problems like increased thirst, increased urination, skin
infections? Pt: Yes, I thought it might be due to pg.
Me: Have you ever diagnosed with DM? Pt: No.
Me: Have you done all the ANC regularly? Pt: Yes, I dont have any problems.
Me: Nice. So you dont have headaches, visual problems, swelling of legs. Pt: no.
Me: How is your BP throughout pregnancy? Pt: Quite normal.
Me: Thats good. You dont have any bleeding, discharge, tummy pain; just to double check!
Pt: no.
Me: What do you think about your weight? Pt: I know its high! All my life I have struggling for
this! Me: I will help you with this matter.
Me: Do you have excessive hair growth, acne, etc? (PCOS) Pt: no.
Me: Have you ever had your lipid checked? Pt: no.
Me: Do you know your blood group? Pt: O positive.
Me: And USG? Pt: Everything is normal, single pregnancy.
Me: What about your period before? Pt: Absolutely Ok.
Me: You and your partner have never diagnosed with STIs? Pt: no.
Me: Have you done paps smear regularly? Pt: yes.
SADMA
Past medical, surgical, gynaecological problems- NAD.
F/H/O Obesity, DM, big babies, any other pregnancy complications ? Pt: not that I am aware
of.
Counselling:
I have got your results in my hand and the good thing is everything is normal apart from the
sweet drink test which appears to be increased and it is pretty high (I think it was FBS; If it is
more than 5.5 and more than 8 post prandial, its GDM. If more than 11, its obvious DM; Pt
had 21!!). We call it Gestational Diabetes which means DM in pg. It is a common condition in
pregnancy because placenta produces some hormones that oppose the action of insulin
which leads to high sugar level in blood. But sometimes it persists even after delivery. And
who is over-weight has more chance to become diabetic in future. So, I am worried a bit
about your high BMI-41, if more than 30 we call it Obesity, more than 35 is a severe form ( I
didnt mention morbid which may scare the pt. More than 25 is overwt.N-18-25), I am afraid!
It is really good that you are on regular ANC. But increased wt may affect your pregnancy.
You are at a high risk of: GDM(your case), Pg induce HTN, Sleep problems, Depression.
In Baby: Big babies(usually), Hypoglycemia, IUGR in some cases( PIH-IUGR), More fluid in
the baby sac (polyhydramnios)
In labour: Non-progression in labour, early labour following babys breathing problem(sp less
than 34 wks),difficulty in providing pain relief(BMI more, less effect.), big babies(Shoulder
dystocia), difficulty monitoring FHR, chance of having C/S.
After delivery: Infection, clotting problems.
In general: IHD, HTN, DM( youve it already), High cholesterol, Heart attack, Brain attack,
etc.
Obese people may have menstrual problems, fertility problems(may be it was your case).
Pt: Will my baby be Ok? Me: Jenny, dont be scared. We will monitor you more frequently to
prevent all those complications during pg and after labour. We will arrange multidisciplinary
team for you- GP, dietician, Obstetrician, Nurses, Diabetic educator, Diabetic specialist, and
other health professional will be involved in here. You need to buy a glucometer to check
BSL 3-4 times a day( Critical error may be). Your target BSL-5-7mmol 2 hrs after meal. If
you cant maintain this you will put you on Insulin. I will refer you to high risk pregnancy clinic
to avoid undesirable problems. I will arrange frequent monitoring-
USG- at 32 wks and then wkly
CTG-at 32 wks and then twice wkly (specially if polyhydramnios)
Obstetrician possibly advice you to have a C/S at 38 completed wks. The goal is to avoid
preterm delivery. After delivery we will need to continue checking BSL. It very important to
control body weight-
During Pg- Avoid too much carbohydrate, fat, chocolates. Eat more vegetables, fish
and water. Try walk 20-30 min at least 5 days a wk. Yoga is also good.
After delivery- I will put you on medication (ie- Lipase inhibitor-Xenical, Methyl
cellulose, acts on satiety centre-SSRIs, Amphetamine. I didnt mention the names.) to
lose wt and continue healthy life-style.
Last resort- If everything fails, we can do some procedures, as for example- Gastric banding(
criteria: morbid obesity, last resort, affects quality of life, DM/HTN, Age-16-47yrs; But life-
long special diet and exercise should be maintained). But every surgery carries some risks
as you know. Do you have any questions?
Pt: No, it was so nice of you that you informed me everything. Its so nice of you.
Me: Its my pleasure!
AMC FEEDBACK- GESTATIONAL DIABETES

Station 7:
A 24 (not sure ) year old man came with complaints of shortness of breath which previously
responded well to ventolin puffer but not recently. He met with an accident where he was in
a
helpless situation for a while .Later ambulance crew has arrived and extracted him from the
car and
was taken to hospital where he was undergone necessary investigations which were all
normal. His
vital signs and physical examination were given normal
TASK Take history
Explain the diagnosis to the patient
explain the management
After I enter the room ,there was a female examiner and a very young roleplayer
I introduced myself and assured confidentiality...
I asked detailed history about shortness of breath ,its onset progression ,diurnal variation
,associated
symptoms, aggravating and relieving factors
His SOB started 3 months ago (after the accident).He suddenly wake up in the night with
sweating and SOB and could not sleep then after.
I specifically asked whether he wake up because of SOB or he has any nightmares after
which he
has SOB and sweating? He replied ..yes ,He has nightmares then SOB
He is at times irritable, angry and is suffering from sleeplessness. He experiences
nightmares ,
flashbacks and avoids driving a car and even travelling in it (classical features of PTSD) .
They all
started after accident.
I took complete psych history, past history
social history: supportive family (didn't take SADMA cos time for that task was over)
Management- explained PTSD in detail and its symptoms
referred to specialist for assessment ad confirmation of diagnosis
referred to psychologist for CBT
Sleep hygiene
AMC FEEDBACK : PTSD

Station 7:
A 22 year old man presented with shortness of breath in your GP clinic. He has symptoms
for the last 6 months. He has taken some over the counter drugs by himself before which did
not improve his condition. CXR, spirometry and some other tests were done and all came
out as normal (It was a very big stem and all the investigations were given). He doesnt have
any significant illness before; except for an accident 6 months ago when he had fractured his
femur and ribs. He was hospitalized for couple of days and took appropriate treatment.
Tasks:
Take further focused history.
Talk to the patient about diagnosis.
Management is not required.
Thinking time:
This is the station where my mind didnt work properly. I could not get enough time to think
about anything!
HOPC:
Hello David, I understand you have SOB, could you please tell me a bit more about that?
Pt: I am having this for last 6 months.
Me: How often do you get that? Pt: Every now and then.
Me: Anything makes it better or worse? Pt: no.
Me: Do you have any chest pain with that? Pt: sometimes.
Me: Does it make you awake at night? Pt: no.( I thought he doesnt have any sleep
problem!!!)
Me: Do you feel your heart is racing? Pt:
Me: Do you have fever, cough and any other S/S? Pt: no.(He didnt mention- night terror,
anxiety, flash backs, fear! Usually pt tells you if there was any other S/S!! I could have come
back to the earth, if he was a bit helpful! He was an expressionless very uncooperative pt.
So do not depend on them all the time. Of course I admit my fault, but I was a bit confused
and puzzled when he didnt seem cooperative at all! May be he was asked to do that!!!)
Me: Do you have leg pain?(PE) Pt: no.
Me: Do you have any past history serious illness? Pt:no.
Me: Do you feel depressed? Pt: no.
SADMA(very imp)
( I didnt ask anything else! I totally forgot it was Station 7!!! Could not even remember that
after the exam!! Friends, it may happen!!! It was a clear-cut case of PTSD! One of my
favourite topic! I knew it by heart!! But my mind didnt click it at the right time!! Couldnt think
what to ask next! Now, I am writing what I have missed. I am trying to write a complete note
so you dont have to check anything else!! I am writing the remaining portion I should have
asked.)
Confidentiality
[HEADS(Home situation, Economic,Employment, Alcohol, Activity, Drugs,
Depression,Smoking,Social history, Sleep, Sex, Suicidal ideas)
ASEPTIC(Appearance-dress,posture; Speech; Emotion: anxious/depressed; Perception-
Hallucination; Thought-broadcast, insertion, reference, delusion; Insight; Cognition-briefly
MMSE)
(Remember those mnemonics and apply those when necessary)]
I know you had a car accident. I am so sorry to hear that. I know it is distressing but can you
tell me a bit more about it. Were you driving?
Was anybody with you at that time?
Have you been travelling with bad memories or any sudden images of the event? (flash
backs)
Tell me about your sleep pattern?(early awakening-depressed, anxiety- cant go to sleep,
both can happen here.) Do you have any nightmare/night terror/broken sleeps?
What about your appetite? ( may be decreased, or normal)
Do you drive now?
Do you feel anxious?
Do you feel depressed? Do you enjoy things you used to? (If not-depressed)
Are you in a relationship? Do you still have the same sexual drive like before?(if not-
depressed)
Do you think about harming yourself or others?
Do you think life is worth living? (Suicidal idea)
Do you hear or see things when nobody is around you?
Do you think somebody is stealing your thought or putting that in your mind or anybody is
trying to harm you? Do you think TV or radio talking about you?(Thought process and
delusion)
I dont think judgement Qs are applicable here.
I understand you are aware of your problem and seeking help for that.(Insight)
Diagnosis:
As I was not exactly sure about the diagnosis, I have given D/D and told him I will do some
more investigations and treat him accordingly. But I was supposed say like this-
Your situation is called Post traumatic stress disorder, which is a type of anxiety disorder.
The terrible accident had a great impact on your mind and due to that trauma you are having
stress and presenting with the bodily response as breathing problem. Deep in your mind you
are terrified and your body reacts for this reason, because body and mind walks hand-in-
hand! (I dont want to draw the old model of body and mind circle!! Examiners may be sick of
it! I dont know!! But its your choice!) Sometimes it takes a while to get rid of it!
I will refer you to Psychiatrist to seek further advice.
Extra notes:
Management:
Cognitive behavioural therapy may be applied which is a special technique to deal with the
stress(Psychologist)(Trauma focused psychotherapy- put on difficult situation and train them
how to decrease response).
If it doesnt work some medications can be given (SSRIs).
Sleep problem- Sleep hygiene (no TV,warm bath, warm milk, comfortable bed and
temp); Short term sleeping pills(BDZ).
Relaxation- Exercise, yoga.
I will follow you up with regular follow up. Next one is in a wk.
Support groups.
Reading materials.
AMC FEEDBACK : PTSD (PASSED)
AMC FEEDBACK : PTSD

Station 8:
A middle aged lady presented in your GP clinic with funny sensation in her hand specially at
night, which is relieved by shaking hands.
Tasks:
Do focused physical examination.
Advise her about management.
Thinking time:
I think this is a case of Carpal tunnel syndrome.
Physical examination:
I examiner seemed very nice. He welcomed me nicely and told me to give him my hands
and expressed some antiseptic gels there. I rubbed my hands and started my exam after
introducing myself and taking permission from her. I told her that I will ask couple questions
while examining her. Well Jane, which side is of your hand is affected? Right hand.
Could you please tell me where exactly is your discomfort? - She showed me her thumb,
middle and index fingers, pulp of fingers more affected(typical location of median nerve)
(part of ring fingers can be affected as well, but not the little finger).
What do you mean by funny feeling? - Its like pins and needles with tingling and numbness,
pain as well.
I know what relieves your pain but do you know what aggravates it? - hot water, excessive
use of the hand like gardening.
Does it hampers your sleep?-Yes.
Are you taking any medications? -Yes, Neurofen.(OCP, Pregnancy aggravates pain)
Do you have joint problems, arthritis or other serious medical conditions?-No.
What is your occupation?-School teacher (Repeatative movements)
Inspection: I compared with left side all the time.
Theres no feature of RA, no nodes, no joint deformities, skin appears to be normal, no
thenar muscle wasting.
Palpation:
Is that sore I asked while palpating the entire hand.
I checked all the movements of hands, specially fingers and thumb
I checked pulse(vascular component).
Now I want to check Nervous component of the hand- sensory and motor.
Sensory- With cotton wool first and then with neurotips (glucometer lancets were supplied
there!!). My examiner asked me what else are you going to do here? I didnt know what to
do. I thought he was asking about sensory part. I replied Upper limb sensory function. He
told me to show that. I followed the dermatome of the upper limb. The patient showed
sensory neurological deficit of median nerve distribution in the hand. I dont know was that
the thing he wanted to know from me?
Motor- Pen touch in the thumb for median nerve; Paper test- you dont have to do that. You
can proceed now, examiner said.
Special tests:
Tinel test- Hold the wrist in flexed position and tap the median nerve lateral to the palmaris
longus and flexor digitorum superficialis). Tingling in the tunnel area in median nerve
distribution shows positive test.
Phanel test- Hold the hands in the reversed prayer position for 60 sec- +ve if tingling
sensation and numbness)
Management:
Jane, from the physical examination it turns out youve a condition known as Carpal tunnel
syndrome. It is a painful disorder of hand caused by pressure on a nerve called Median
nerve which passes through a tunnel at wrist. The tunnel is formed by a tough membrane
(Flexor retinaculum) that makes a roof to a natural arch of wrist bones. The purpose is to
keep tendons, vessels and nerves in place. If it thickens it creates pressure over these
structures specially nerves.
So stop the precipitating factors ie- warm washing, repeated movement of hands.
Sometimes it improves without any medications.
Stop NSAIDs (causes fluid retention and put pressure over the tunnel).
Splint at night may help.
Fluid tablets can be given.
Local Cortisone injection may be tried. (USG guided)
Surgery- Last resort. It is a small procedure which relieves pressure on the nerve by cutting
through the tough membrane and creating space for the nerve. Risk of injury to nerve is
small and relieves discomfort immediately. Do you understand what I have explained?
Pt: Yes, I did. Well explained. The bell rang.
I thanked both my patient and my examiner.
AMC FEEDBACK :CARPAL TUNNEL SYNDROME

Station 8:
A middle aged women is in ur GP clinic with c/o tingling and numbness in the right hand
TASK: Perform relevant physical examination in no more than 5 mins
explain diagnosis to the patient
explain management
There was an observer in this station ,female examiner ( Asian looks like Indian) and middle
aged
Aussy roleplayer
Consent
Wash my hands ( examiner said that's ok no need to really wash )
asked for a pillow( The pillow was on the examination table, seemed that nobody used it
before
.when I asked for pillow ,examiner surprised !!!)
Exposure till elbow
Inspection- from nails to elbow ( no + ve findings)
Palpation from elbow to DIP
Movements- elbow , wrist , finger and THUMB movements( thumb limited, rest all are
normal)
Neurological examination- sensory ( absent in median nerve distribution)
motor( abnormal pen touch test)
FINISHED FIVE MINUTES ...SO QUICKLY( I told examiner that I need to do special tests
.Then
she asked me to first complete the other tasks )
I explained CTS, cause and risk factors
management- I asked whether there is any pain ( no pain)
Investigations- Nerve conduction studies
Referred to specialist but explained about splinting, steroid injections, most probably need
surgery
as the function of the nerve is affected.
I finished all the tasks then I did special tests phalen and tinel tests ( both are +ve)and
completedthe examination.
Thanked the patient
Bell rang!!!
AMC FEEDBACK :CARPAL TUNNEL SYNDROME(PASSED)

Station 9:
A young 18 yr old girl presented in your surgery with c/o breast lump
TASKS : history , examination and management
A small lump in the right breast which she noticed a week ago. She is a bit worried because
heer
mother had undergone surgery for breast cancer
No pain
No h/o suggestive of malignant features
No h/o of discharge or breast or areola or nipple changes
no h/o loss of wt or appetite
Other history not significant
Examination :
A 3cm lump present in the outer and upper quadrant of the breast ,not tender , no signs of
inflammation, firm in consistency , which is not fixed to the skin or chest wall, no nipple or
areola
changes , no LAD
Other breast normal
Management: Explained that it is a benign breast disease and explained why I think so
mentioned about triple examination and ordered USG and FNAB to confirm. Surgery is not
required now , unless there is a cosmetic problem but keep an eye on it.
Reassured again that it is not malignant and is not associated with a risk of cancer in the
future.
Because she has a family history , I explained about regular monthly self breast
examination,
yearly Physical examination by GP, and 2 yrly mammography after 35 yrs
Asked whether she has any sisters? no
Do you have any concerns?no
closure 4 R's
Finished early . I waited inside .
Examiner said This is your last station . Is this your first time to appear for the exam ?
Yes
He said I hope this is the last time
AMC FEEDBACK: FIBROADENOMA

Station 9:
A 24 year old female came to your GP clinic because she had noticed a lump on her right
breast. She is otherwise normal.
Tasks:
History
Physical exam
Management
Thinking time:
According to the age I think that should be Fibroadenoma. But I need to exclude malignancy,
advise triple test, reassure properly, ask about family history, genetic testing if required.
Similar book case: condition 060, P-315,329.
The exam:
Hi Linda, I understand youve noticed a lump in your right breast. Can you tell me a bit more
about it?
Pt: I noticed it 3-4 days ago. I am a bit worried. My mother had a breast cancer which was
removed last year.
Me: I can see you are anxious. Is this the first time youve noticed that? Pt: Yes.
Me: Do you have pain? Pt: No.
Me: Any fever? Pt: No.
Me: Did you notice lumps and bumps in the body? Pt: No.
Me: Any recent weight loss? Pt: no.
Me: When was your last menstruation? Pt: 7 days ago.
Me: Are those regular? Pt: Yes. Every 4 wks, lasts for 3-4 days and bleeding is average.
Me: Are you on a relationship? Pt: I have a stable partner.
Me: What sort of contraception do you use? Pt: OCP.
Me: Do you do Paps regularly? Pt: normal.
Me: Have you ever been pregnant? Pt: no.
Me: Do you have past history of any serious illness? Pt: no.
Me: Do you have any siblings? Pt: I have a sister.
SADMA
Physical Exam:
G/A: As you see
Vitals: N
LNs: Not palbable
Breast Exam:
Inspection: N
Palpation: Non tender, small palpable, homogenous lump.
Other systems: N
Management:
Linda, from the history and examination I have got a suspicion that according to your age
you may have Fibroadenoma which is a benign tumour of the breast; but I would obviously
exclude any nasty growth. I appreciate that you are aware of this. As you have a family
history of breast Ca, you are at slightly high in risk than average population. You have a
sister and I suggest she should be checked for this as well. We would do couple of
investigations to exclude other possibilities. But you dont have to worry because I am here
to help you at any situation. Fibroadenoma is a common condition which doesnt need any
excision and it is not cancer, doesnt become cancers. But we will take several pieces of
biopsy. We will do USG as well. Triple test check- clinical exam, Imaging and pathology- the
best way to diagnose those lumps.
Pt: Are you sure its not a cancer?
Me: I cannot tell you 100% unless I do those investigations.
Pt: My mother has it, so I am so scared.
Me: Dont be scared. I will help you and if you are still concerned I can get a second opinion
from the specialist after performing the investigations. And we will assure you by regular
follow up with clinical and imaging reviews.
Pt: I will follow whatever you say! But I am really worried. Does it need any operation?
Me: According to biopsy(FNAC, Core biopsy-better, tissue diagnosis) if it turns out as
benign, there is no need to take it out. But if you are anxious about it, you and your surgeon
may discuss about it and take the final decision. So, if you are still concerned I can refer you
to the Breast surgeon for further decisions. I am here for you all the time you need. I will give
you some reading materials. You can ask me any questions.
Pt: No, I am fine.
Me: I hope your mother is doing fine. How is she? Pt: She is good. Thanks for asking.
The bell rang!
AMC FEEDBACK: FIBROADENOMA


Station 10:
A 28 yr old female presented with severe pain during menses
TASKS: history not more than 4 mins
examination
Management
DD's- Endometriosis , fibroid, PID
History: severe lower abdominal pain of severity8-9 , starts on the day 1 of menses and
persists
through out periods, with no aggravating factors abd a bit relieved by pain killers
Periods: LMP 3 wks ago, 28 day cycle and 4-5 days of bleeding, changes pad twice a day
,previously not associated with pain but now does
Partner: in a stable relationship for a long time, never diagnosed with PID , pain during
intercourse
pills:on OCP
Pregnancy: never pregnant before and not planning for next 2 yrs
papsmear : regular and was normal 1 yr ago
Past history and family history was insignificant
Examination:
General appearance -normal
VS -normal
no pallor
BMI -normal
Abdomen normal
Pelvic examination : Inspection : normal
P/S: no abnormality
B/E: normal sized retroverted uterus
nodularity in POD
adnexal tenderness present
Urine dipstick and BSL normal
Management:
explained Endometriosis with the help of a diagram ,pathology and complications
ordered USG not that useful ,definite diagnosis is made by laparoscopy which is therapeutic
as well
Treatment, both medical( danazol) and surgical( laparoscopic breaking of adhesions )best
option
Any concerns? No
I finished early but waited inside...
AMC FEEDBACK: SEVERE ENDOMETRIOSIS


Station 10:
A 26 year old lady presented in your GP clinic with the history of severe pain during
menstruation.
Tasks:
History
Physical exam
Diagnosis
Management
Thinking time:
D/D: Endometriosis, Uterine fibroid, PID,etc.
The exam:
When I entered the room, my examiner introduced me with my patient- Ashley.
History: Hello Ashley, Welcome to my GP clinic. I know you are concerned about the pain
you are suffering during menstruation. Could you please tell me a bit more about it? By the
way are you having pain now? Do you need any pain killer at this moment?
Pt: Thanks for asking. That would be nice. Me: I will give you that in a moment.
Pt: Thanks.
Pain Ques:
Location: Lower tummy
Onset: Starts 1-2 days before the menstruation
Time: Continues throughout menstruation; Type: Dull in nature.
Radiation: Back and thigh
Aggravating factor: nothing
Relieving factor: Pain killers sometimes
Duration: Chronic for last couple of yrs
Intensity: 4-5/10
Offset: Stops when bleeding stops.
5ps + Blood group:
Period: LMP- 3 days back, Average 5-7 days, Excessive pain, bleeding average- more, 3-5
pads, fully soaked, no clots
Pill- OCP
Pregnancy- not pg, no children
Partner- stable
Paps- Normal, regularly checked.
Blood group- O +ve.
Associated Ques:
Do you have anorexia, nausea, vomiting?-no.
Consent:
Do you have painful intercourse?-Yes
Do you or your partner was ever diagnosed with STI?- No.
Did you ever used IUCDs?-No.
Past Medical, Surgical, Gynaecological history- No
SADMA
Physical examination:
G/A: As you see
Vitals: N
Abdomen: No visible or palpable mass, slight tenderness.
Pelvic exam(with consent):
Inspection:
Bleeding: amount- small amount, colour- bright red, no clots
Discharge; No (Not PID or infection)
Laceration, trauma, ulcer, rash, mass- no
Per speculum exam:
Vagina
Cervix- healthy.
Bimanual exam:
Uterus- size, shape, position, consistency-N
Cervix- motion tenderness-ve( not PID, ectopic pg)
Adnexa- FT, ovary-N;
Pouch of Douglus: No collection( Not PID or infection)
Only Uterosacral ligament nodule and tenderness( Suggestive of endometriosis)
Diagnosis:
Ashley, from the history and physical examination, most likely youve got a condition known
as Endometriosis.( Draw a picture). This is a condition in which retrograde menstruation or
back-flow menstruation occurs. Here the lining of womb is deposited in unusual location.
(Show the locations). So backing up menstruation may occur in Fallopian tube, ovary and
uterosacral ligaments, etc. Weve found a lump in this ligament in your case which is a +ve
evidence of it. When the womb is menstruating all the other womb tissues in the unusual
locations are also menstruating and small bleeding along with pain occurs.
I will refer you to Gynaecologist. She will do some investigations called Laparoscopy- a
small camera like instrument is introduced in tummy through the key hole under anaesthesia
to confirm the diagnosis. USG is also help to detect other conditions.
Management:
Medical treatment:
Analgesic-pain.
OCP(shes using), GnRH agonist, Progestogens, Danazol( Rx of choice, but serious side
effects ie- hirsutism, acne, deepening of voice, weight gain, fluid retention, liver disease in
long term; so used for less than 6 months. )
Surgery: More helpful.
Laparoscopic LASER surgery.( Burnt match stick appearance due to old blood collection).
Pregnancy is helpful (pseudomenopause state) because there no periods at that time.
I will give you reading materials.
Arrange some support groups, family meetings if needed. I will help you anytime you need
assistance. The bell rang.
(Infertility- Refer to infertility clinic- IVF, ICSI)
AMC FEEDBACK: SEVERE ENDOMETRIOSIS
Station 11:
A 4-5 yr old boy was brought to your GP clinic by his mom with c/o runny nose
TASK: HISTORY
Examination
Management
History- runny nose since 6months, continuous , white coloured discharge,no blood ,not foul
smelling,no seasonal variation
NO fever, SOB, headache, cough, ear infections or discharge, change in voice
Past history of eczema,but otherwise healthy
family h/o asthma and hay fever
BIND normal
home environment- cleans house and carpets twice a week, dad is a smoker but smokes
mostly outside, no pets
Examination examiner gave me a sheet of physical findings which were normal
Management- explained about Allergic rhinitis ,causes and risk factors
educated about smoking , keeping the child away from risk factors
referred to allergologist to find out the triggers
prescribed nasal decongestants
MOM: Could it be anything else, Doc?
ME: Yes, it could be Asthma but does he has any limitation of physical activity?
MOM: No
ME: Its highly unlikely 'cos no SOB ,no limitation of physical activity and concerns regarding
growth
Lets try this management first , if not improved then will refer to the paediatrician. Is that
alright?
Yes,doc ...sounds good
AMC FEEDBACK : RHINITIS

Station 11:
A 3 year old child has continuous watery discharge from his nose. He has history of
repeated URTI. He is with his mother who seeks advice in your GP clinic.
Tasks:
History
Diagnosis
Management
Thinking time:
D/D:
Allergic rhinitis, FB, Asthma.
The exam:
Hi Sally, I understand your baby boy William has discharge from the nose. Could you please
tell me a bit more about it.
RP: My baby cant breathe properly from his nose.
Me: How long does he have this problem? RP: couple of weeks.
Me: He is suffering from URTIs, is this related to any specific season?
RP: In winter it gets worse.
Me: Has he got any medication? RP: P/C, antibiotics before.
Me: Does he have fever? RP: Not really.
Me: Does he have sneezing, coughing? RP: He sneezes a lot, coughs and sometimes noisy
breathing.
Me: Any phlegm production? RP: No.
Me: Did he complain of itching? RP: Yes, he had eczema before,always complains of itching
in the eyes & nose. For the skin disease we saw a Specialist 6 months back.
Me: Does he complain of blockage and watery nose on both sides? RP: Yes.
Me: What makes it better or worse? RP: Cold weather and dust make it worse.
Me: Do you have pets at home? RP: No pets, no carpets. I am aware about asthma.
Me: Anyone smokes at home? RP: No.
Me: Any family history of any serious illness including Asthma, eczema? RP: Yes, his father
had childhood asthma.
Me: Does he have any hearing problems? RP: No.
Me: Any illness during Pg with this child? RP: No.
Me: Are you happy with growth and development? RP: Yes.
Me: Immunization updated? RP: Yes.
Me: Is he on any medication at this moment? RP: No.
Diagnosis:
From history I think William has Allergic Rhinitis. Here, the inner membrane of the nose is
very sensitive to some allergens ie- dust, carpet, pet, etc. So when he is exposed with the
specific situation, his nose gets irritated and presents with itching, blockage and runny nose.
This is a very common type of allergy, often runs in families.
Management:
I would like to refer him to the Paediatrist who will run couple of investigations- Skin prick
test for allergy, RAST etc, to confirm the diagnosis. He may put him on nasal spray-
Beclomethasone to relieve the symptoms.
The best way is to avoid the specific allergen.
Vacuum house every day. Avoid pets. Avoid using carpets.
I will give you some reading materials. Be aware if he suffers from breathing difficulty or
hearing problems, contact me ASAP. I will follow him up regularly.
You can contact me any time. The bell rang.
AMC FEEDBACK : RHINITIS(PASSED)


Station 13:
A 78 yr old women came with complaints of ( ahh could not remember)an Xray was done
and
given below
TASKS: explain the result , address her concerns
There was contrast Xray showing an obstruction in the colon
I explained the result . I thought it was a breaking bad news and did the same thing. But
there was
no reaction in the role player and she was busy in looking at her questions she has to ask...
The obstruction could be a benign or any nasty growth .
Could it be anything else?
What you are going to do now?
First need to perform investigations like colonoscopy
Before I explain the procedure
RP: before this procedure they will give some drink ..Is that right?
I was not sure about that but they will give some drink to empty your bowel to have a clear
view of
the bowel
Does it has any side effect?
I do not know(later on I came to know that it is colonlytely and it has side effect of postural
hypotension, vomiting ,bad taste but plz check)
Before I tell that she needs surgery...she asked will I have a stoma? Then we both laughed
I explained that she needs to have a surgery after assessment by the specialist , if it turns
out to be a
cancer
The surgery includes two steps ,first resection of that part of the bowel, followed by
reanastamosis
If you are fit enough and no complications during surgery , u might not need a stoma.
But if you are not fit for surgery or any complications during surgery, then you may need
stoma,
because it is a long procedure. But let me reassure that stoma if required will be
temporary.Once
you recovered we may plan for another surgery to reanastamose it.
Bell rang!!!
AMC FEEDBACK:CARCINOMA COLON

Station 13:
A 68 yrs old woman had tummy pain which was treated with analgesia and codeine. Now
she complains of constipation which she was treated with some medications but did not
seem improving. She was given Ba meal X-ray which is shown here.(similar picture is given
here). You are in a GP clinic.

Task:
Counsel the patient.
Thinking time:
I took a look at the picture. It was an old poor film of X-ray abdomen with stricture and apple
core appearance. So the diagnosis is Colon Cancer. I have to counsel and reassure the
patient and tell her about the possibilities.
The exam:
My examiner introduced me to the patient.
Me: Hello Chloe, I understand you have undergone Ba-meal X-ray and the film is in my
hand. But before going to the discussion may I ask you some questions.
Pt: Yes, of course.
Me: Do you have pain at this moment? Pt: no.
Me: Did you notice blood in the stool? Pt: sometimes.
Me: Do you have fever? Pt: Not that I am aware of.
Me: Do you suffer from nausea, vomiting? Pt: a bit nauseated.
Me: Any weight loss? Pt: I think so, couple of killos.
Me: Do you have any family history of Bowel problems? Pt: I am not sure.
Right.Chloe, here is your X-ray Abdomen. This is your bowel loops. Did you see there is a
narrowing on the left side? It has got Apple core appearance- which means it looks the
similar like when youve eaten most portion of the apple and a small part is remaining in the
centre- this is consistent with some change in the inner layer of the bowel, a suspicious
nasty growth, I am afraid! Are you ok?
Pt- I am fine, go ahead.
Me: But I am not sure yet! I need to refer you urgently to the surgeon. He will take some
biopsy samples and send those for histopathology to exclude other possibilities like benign
lesions, other pathologies,etc. If it turns out as a nasty growth, we will treat you immediately
with multidisciplinary team approach where lots of health professionals are involved- Me,
Surgeon, Cancer specialist, Psychologist, palliative care specialist, Occupational therapist,
Social workers, Physiotherapist, Nurses,etc.
Pt: Do you need to have a bag outside like I have seen before?
Me: You are knowledgeable. Yes, you may need colostomy bag. But most likely it would be
a temporary method. At that time stoma nurses will help to manage the situation. And there
is a special care, we call it palliative care- here severe ill patients are getting the highest
possible care and pain management. Our aim is to provide the best quality of life.
We will monitor you regularly with frequent follow up and investigations (CEA, USG, CT
scan, X-ray, Bone scan).
I will advise you to maintain healthy diet, exercise regularly, be positive.
I can arrange family meeting for you. Now we will wait for the result to come and treat you
accordingly.
There are also some support groups available. I will give you some reading materials so that
you can read those thoroughly at home.
You can visit me anytime if you like. Do you have any question?
Pt: No doctor, youve covered everything I need to know.
Me: Ok, great.
Then I looked at the examiner and was surprised to see that he was sleeping! My patient
repeated that I had covered everything it was so nice talking to me! Such a nice approach.
She wanted me to get rid of my examiner! But I didnt go away. I just repeated the
management plan and checked if she understood everything. Who knows may be he was
not sleeping; I didnt hear any snoring!!
The bell rang! My examiner got up from sleep. I thanked both and then left the room and
smiled!!
AMC FEEDBACK:CARCINOMA COLON

Station 14:
A 72 year old lady had frequent falls. She is living alone.
Tasks:
Take history.
Present the case to the examiner.
Discuss management.
Thinking time:
D/D:
Neurological: TIA/Stroke, Seizure/Epilepsy, Parkinsonism; SDH, EDH, etc.
CVS: Valvular heart disease, Aortic stenosis(during exercise), HOCM, Vasovagal shock,
Postural hypotension, MI;
Metabolic: DM (hypo,hyper);
Musculoskeletal: Osteoarthritis;
Environmental: Light, Stairs;
Eye: Cataract;
ENT: Menieres disease, Vestibulocochlear disease
Psychotic: Dementia, Delirium;
Alcohol
Medication: Polypharmacy specially( BDZ, Diuretics, Alpha blocker, TCA- may cause falls)
I would be huge!!!
The exam:
My patient Avril seemed cooperative. I decided to follow the chart:
Before the fall:
For Arrythmia/CVS causes: Syncope + Angina on exertion+ SOB = Aortic stenosis
Any palpitation?-No
Chest pain?-No (Angina/MI)
Sweating?-No (,,)
Dizziness?-No
Light headed?-Yes (Syncope)
Are you doing heavy work?-No
During the fall:
Did you lose consciousness?-No
Did you soil yourself?-No(Epilepsy)
Were you shaking?-No(,,)
After the fall:
Headache?-Stroke/TIA
Weakness?(,,)
Numbness, tingling?(,,)
Trauma or pain anywhere?-Not any serious injury;(Epilepsy-Tongue-bite)
General Ques:
For how many times did you fall?- 3 times, first time while gardening, other two- while
walking inside the house.
How long did those last?-Couple of minutes I guess.
Did anyone witnessed the scene?-No, I am Iiving alone.
I see. Did you fall at carpet or floor? Did you hurt yourself? If it hurts I can give you Panadol.
-Thanks doc, I fell on the carpet; Did not injure myself seriously. I took a Panadol already.
Good. Did you recover immediately after fall?- Yes, within couple of minutes;(Vasovagal
recovers immediately)
Did you get up and seek help by yourself?- Yes.
Do you have trouble in vision?- I had cataract which was removed last year.
Do you trouble in hearing?- I dont think so.
Did you diagnose with serious illness in the past? Yes, I have DM, HTN, Previous MI,
Stroke, etc (Dont remember clearly)
Do you get medical attention and specialist visits regularly?- Yes, I try to follow, but
sometimes not.
Are you taking any medications at this moment? Yes, Fluid tablets(diuretics),
Antihypertensive (Alpha blocker), and some other medication I dont remember.
Ok, I will check that later and talk to the specialist about your medication.
What about your bowel and bladder?-Ok.
Social History: Living alone, no help, uses walking aids for hip pain, has steps and stairs at
home, carpets are old, on pension.
SADMA: Drinks 2-3 SD every day, more in the weekends, smokes sometimes, No illicit
drugs usage, no allergy.


Case Presentation & Management:
Avril, a 72 year old lady had recurrent falls, first one while she was gardening and others
while walking inside the house. The fall lasted for couple of minutes. She was lightheaded
before the fall, didnt lose consciousness and didnt soil herself and after that she didnt
complain of residual weakness. She is a pensioner, who lives alone in house. She has
couple of medical conditions-DM, HTN, previous stroke, MI for which she is taking a group of
medication includes- Diuretics, anti-hypertensive and some other medicines. Polypharmacy
is a potential cause here. She is drinking 2-3 SD daily and more in the weekends, smokes
occasionally as well, which might contributed to the situation here.
Ex: Right, can you tell me what might be the causes of the falls?
Me: Yes; I told him all the causes I thought in 2 minutes. It might be due to TIA/Stroke- she
has previous history of it, Hypoglycemia- he has DM, vasovagal shock, Eye problem- she
had cataract, subdural haemorrhage- old age, alcoholic, Drug polypharmacy, Osteoarthritis-
she has hip pain, she has stairs and carpets- we need check if they are faulty, Delirium,ect.
Ex: Good. How do you manage this case?
Me: I will try to explore what might be the cause. I will do some investigations- FBE, BSL,
Lipid profile, ECG, LFT, U & E, CT head, Urine dipstick( Urinary tract infection).
I will refer her to Fall Clinic.
We will work as a multidisciplinary team involves-
Me- regular follow up
Physician- assess her for further management
Physiotherapist- If she needs any strengthening exercises
Occupational therapist- provide walking aids, fix light, carpets, stairs.
Geriatrician- to give age specific management if required.
Ex: Very good. Thank you so much doctor. The bell rang.
I thanked both and then left the room.
AMC feedback: MECHANICAL FALLS

Station 14:
MECHANICAL FALLS


Station 15(AMC BOOK CASE)
Palpitations and dizziness in a hypertensive patient
ECG shows atrial flutter with 2:1 block
AMC FEEDBACK : PALPITATION AND DIZZINESS

Station 15:
You are working in a hospital Emergency Dept as a HMO. You are asked to see a 50 year
old lady complaining of palpitation and dizziness. She has not seen a doctor for past 10 yrs.
(Book case 066- 349, 363)
Tasks:
History
Present the case to the examiner
Management
Thinking time:
D/D: Atrial flutter, Atrial fibrillation, Aortic stenosis, SVT, WPW syndrome.
The exam:
My examiner introduced me with my patient- Lauren. Me: Is my patient haemodynamically
stable? Ex: Yes.
HOPC:
Hi Lauren, how are you feeling now?
Pt: Not so good.
Me: Can you tell me what do you mean by palpitation?
Pt: My heart is beating too fast.
Me: How fast it is? Can you please tap it on the table?- She tapped a very fast regular
sound.
Me: How many attacks did you have? Pt: 4 times in last 3 days;
Me: How long did those last? Pt: About 1-2 hrs.
Me: What were you doing at that time? Pt: 2- during driving, 2- after meal.
Me: Anything makes it disappear? Pt: no.
Me: Does it start suddenly and stop suddenly? Pt: Yes.
Me: What do you mean by dizziness? Pt: I feel light headed as if I am going to faint out.
Me: Do you have dizziness and palpitation at the same time? Pt: Yes.
Me: Any other associated symptoms? Pt: Like what?
Me: Chest pain? Pt: No;
Me: Sweating? Pt; Yes( All arrhythmia may cause that)
Me: Did you have shortness of breath? Pt: Mild;
Me: Any nausea, vomiting? Pt: no.
Thyroid: (AF)
Me: Do you have any weather preference? Pt: no.
Me: Bowel problem? Pt: no.
Me: Weight gain? Pt: no. But I am overweight.
Me: What about diet and exercise? Pt: I am having take-away foods and I dont have time to
exercise.
Me: I will talk about it later. Did you have nervouseness, tremor? Pt: no.
SADMAC: Smoker- 20sticks/d, Alcohol- 6 SD/d, No drugs, Coffee- 6 cups/d.
Stress:
Me: What do you do for living? Pt: A company Manager.
H/O DM, HTN, High cholesterol.( ask about anemia, cardiac problems), not taking
medication.
F/H/O- Heart disease.(ask about HOCM)
Summary to the examiner:
Lauren, a 50 year old company manager has chief complains of 4
th
attack of palpitation and
dizziness; Ist 2 was during driving and the remaining are after meal. The episode lasted for
1-2 hours on an average. He also had SOB but there were no sweating, chest pain or
nausea-vomiting. She has a stressful job. She has a history of HTN, DM, High cholesterol.
She drinks heavily 6SD/d, Smokes 20/d, takes too much coffee- 6 cups/d. She is overweight
and leading a sedentary life-style. To conclude she has a increased risk of CVS problems.
Management:
I will do some investigations- FBE, BSL, Lipid profile, RFT, LFT, C-X-R, ECG And
Echocardiography if needed. I will take opinion from Cardiology registrar. Ex: Ok, your
ECgreport is available. (She took so much time to give me the ECG.It is not exactly the
same ECG I was given. . ItTth I)

She gave me a pretty awful ECG I guess 30 sec before the finishing time. It has poor quality,
may be 10 yrs old. Thats not a problem. The problem was the sequence of the ECG, tracing
was not sequential.
I tried to see the rhythm strip which was not very clear.
I knew it was Atrial flutterbut it didnt look like that. May be SVT! Time pressure!!!!(Pic-
Clinical Book- Page-366).
I ran out of time. The bell rang!! I mentioned the diagnosis but in reply she opened the door!!!
What I missed:
The diagnosis is Atrial flutter.
I will put her on cardiac monitor.
O2 by mask.
Call registrar and take specialist opinion.
Medical Rx:
Rhythm control Rate control
Amiodarone Beta blocker, Ca blocker, Digoxin
If unstable: Cardioversion ( If transoesophageal echo shows no clots)
Aspirin
Anticoagulant(if chronic; Heparin-Warfarin)
Regular follow up.
Atrial Flutter:
Rate- 150-250/min
ECG- regular very fast rate, absent P, A-V block can be associated which looks like irregular
rates, but dont be confused with atrial fibrillation. Check the ECG of SVT as well.
AMC FEEDBACK : PALPITATION AND DIZZINESS


Station 16:
A 6 year old girl presented with severe headache for last couple of weeks in your GP clinic.
Her mother wants to talk to you.
Tasks:
History
Physical examination
Management
Thinking time:
D/D: Tension headache, Migraine, Brain tumour(^ICP), Meningitis, Encephalitis, Vision
problem, Sinusitis, HTN, Bullying.
The exam:
A nice examiner with smiling face introduced me with my patient.
Me: Hi Eva, Can you tell a bit more about Samantha? RP: She is complaining of headache
for couple of wks now, which is increasing in intensity.
Me: Where exactly is the pain? RP: She shows in front of the forehead;(Tension Headache)
Me: Does it radiate all over the head? RP: She didnt mention that. But she said both sides
are affected.( Not Migraine)
Me: Sudden or gradual? RP: Gradual.
Me: Does she lie down that time? RP: Yes, she seems very sick.
Me: How frequently does she get the headache? RP: For most of the days of the week and
lasts for a few hrs.
Me: When the headache starts? RP: In the morning.(Tumour)
Me: What is the intensity of the headache? RP: 7-8.
Me: What makes it worse? RP: Coughing, sneezing( ^ICP)
Me: What makes it better? RP: if she vomits( ^ICP, Migraine)
Me: Does she wake up at night? RP: Sometimes.
Me: Does she take any medicine for that? RP: P/C.
Me: Does she complain of drowsiness or dizziness? RP: not really.
Me: Did she lose consciousness? RP: No.
Me: Any problems with vision? RP: no.
Me: Any weakness of arms or legs? RP: No. ( Brain lesion).
Me: Does she complains headache in the weekends? RP: Yes( Not Psychological then)
Me: Does it affect school performance? RP: Yes, she is missing classes.
Me: Did she complain of any bullying or any problem in the school? RP: no.
Me: Any recent fever, URTIs? RP: No( Meningitis, sinusitis)
Me: Any nasal discharge? RP: No(Cluster headache)
Me: Neck pain or stiffness? RP: No.( Brain infection)
Me: Is that associated with any food or bright light? RP: No (Migraine)
Me: Any stress at home or any family issues? RP: No.(Tension headache)
Me: Are you happy with her growth and development? Rp: Yes.
Me: Did you check BP anytime? RP: No.
Me: No problem, I will do that for you. What about immunization? RP: Updated.
Me: Water works and bowel habit? RP: Normal.
Me: Any significant illness in the past? RP: Not at all.
Me: F/H/O any significant illness? RP: No.
Physical examination:
G/A: Anxious
Vitals: P-70/min, BP-140/90mmHg, T- N,
System review:
Eye: Reactive pupil
I will do Ophthalmoscopy.
ENT-N
Neck stiffness- No
Neurological and other systems are normal
Ex: You wanted to do ophthalmoscopy; So here is the picture you are looking at.
He handed me a laminated photograph. The picture was not as clear-cut as I have given
here.

I watched that for couple of seconds- it is confusing and hazy! It did not seem to be an
obvious increased in pressure but a slight increase! I am confused! But what else it could
be? I looked at it again. No its not normal, It shows some increase in ICP!
Management to the RP:
Eva, from the history and P/E I have found that there is increased pressure in the brain; this
can be due to a nasty growth in the brain- brain tumour.
RP: Oh my god, what are you talking about? Are you sure this is tumour?
Me; I didnt mean to scare you. But I am not confirmed yet! She needs to be evaluated
further ASAP. I will admit her to the hospital. Paediatric specialist will assess her and send
some Investigations including some baseline investigations and CT scan/ MRI of the brain to
see if there is any growth. If it is confirmed then she may need surgery. But the surgeon will
discuss with you and take the final decision.
We will assess her with regular follow up.
There are support groups available.
I will be there to take care of her any time. Do you need me to call her father or anyone? RP:
No I am fine.
Me: I know it is hard but there are excellent treatments here in Australia. So dont get upset.
Lets see what we can do for you!!
The bell rang!
Ex: Wish you luck doctor. You are nearly there! I thanked both and shook hands with them.
Oh my God! My exam is finished!!!
Feedback: Child headache- Raised ICP( Passed) (Reaction- I was a bit confused when I
looked at the Ophthalmoscopy picture because it was hazy. But if it is not normal, then there
is some pathology! Always correlate with the history as well. RP and examiner- both of them
were nice.)
AMC FEEDBACK: RAISED ICP

Station 16:
A 4-5 YR old child was brought to your GP clinic by her mom with c/o headache
TASKS: history , examination and management
my thoughts.. need to rule out meningitis ,head trauma , raised ICP , tension headache and
migraine
After introduction, asked severity of the pain and offered pain killer
History: diffuse headache from the last 6 months with insidious onset gradually progressing
and
now becoming more severe enough that she need to take leave from school more often.
associated with vomitings, not forceful, present all through the day but more in the mornings
not noticed any aggravating factors, previously relieved by PCM but not now
no h/o fever , neck stiffness or rash
no h/o head trauma
no h/o weakness in the limbs , fits , vision or speech problem or abnormality of gait
Past history and BIND were normal
Has family h/o migraine
Happy family and enjoys the school. previously good performance at school but not now
no h/o bullying
Examination: generalappearance -dull
vital signs PR- 90/min ,BP -140/90, rest all normal
Growth charts normal
Neurological examination- gait
cranial nerves - Optic nerve including complete eye examination and fundoscopy(
papilloedema)
other cranial nerves are normal
ITPRC- normal
no neck stiffness
rest of the examination- normal
Management- I explained that it is raised ICP which could be because of some nasty growth
( in
soft and low voice)
she asked nasty growth means...
I said Iam afraid that it could be a tumour in the brain but we need to confirm
referred to the paediatrician for assessment and confirmation by CT scan, preferably MRI
and
further management.
What is the prognosis?
It depends on the type of the tumour . Most common are astrocytoma and medulloblastoma.
Specialist would be able to say the prognosis which depends on the type, location and grade
of the
tumour.
REASSURANCE
After confirming the diagnosis , your child might require Surgery.
Immediate referral to the specialist..
reading material
AMC FEEDBACK: RAISED ICP (PASSED)


Conclusion:
First of all, I would like to thank God from the bottom of my heart because He made this
happen. I know I got blessings from my parents. I would like to thank my siblings as well for
continuous support.
There is a man behind every success of a woman!!(I reversed the saying!). My husband did
an extra-ordinary job during last 3 months of my exam!!! He did everything so that I didnt
have to worry about anything! I am so blessed to have him because he is the most caring
person I have ever seen!!!
And of course, I would like to thank Dr. Johannes Wenzel for his legendary work for IMGs. I
wish him all the best.
Thanks to all my friends and reading partners for your support.
The names I have used here are imaginary. Because it is not possible to remember the
names!
I studied 12 hours per day for last 3 months of the exam. I listened to Enigma and relaxing
music every day to keep myself tension-free. I was very relaxed the previous day of my
exam, because I managed to revise everything at least 3 times. I was meditating in the
waiting area outside the exam stations and completed the exam without any anxiety for the
first time of my life! I tried to write the recalls flawless, so that you dont have to worry about
searching anything! But it was not that easy! It took me ages to finish!! I hope it would help
you. I thank all my ancestors who wrote recalls previously. I also encourage others to do the
same!!!
If I can do it you can do it too!!!!!
Wish you all the best. Keep me on your prayers. Take care.


I would like to thank Dr Wenzel, Dr Majid , Dr Awad, Dr Ehab, Dr Rahul , Dr Mehreen , Dr
Shipra, Dr Abdul and my study partners.
GOOD LUCK TO ALL