AMC Clinical Examination (Adelaide 23-09-2006)

(Note: I did this recall paper with help from two other study mates who sat the same
examination. There are total of 20 stations including 4 rest stations. I started from the 5 th
station and the paper is therefore recalled accordingly. I have tried to write in detail to give
you some clues as to how the examination is run. Please study it privately and don’t
distribute it widely.)

1. Posterior Position – In Labour at Term (O & G) (AMC feedback)

(Long stem)
A 25 yr primigravida woman, who has had good antenatal care, has started spontaneous
labour for 4 hrs at home. Now she comes to A & E department. Midwife calls you regarding
analgesia to relieve her pain and further management.

Your task is to:

(1) Take a focused history.
(2) Ask physical examination findings from the examiner, and
(3) Answer pt’s questions on pain relief and further mx plan.

Hx elicited from role player

-Pain (labour) starts 4 hrs ago, every 10 minutes feels a contraction.
-Baby movement is ok.
-No vaginal discharge/no gush/no bleeding
-No dizzy/headache/No urinary problem
-Good antenatal care, everything is normal during pregnancy.
-No any medical and Family Hx of hypertension and DM.
-Pap smear done 1 yr ago, normal. LMP about 40 weeks ago.
-No STD Hx.
-Don’t know blood group.
-No smoking/alcohol
-No any medications
-No known allergy

O/E
-GA: well
-V’signs: normal
-Abdo Exam: fundus height 40 cm, fetal heart sound normal, CTG normal
-Vaginal exam: cervix dilated 4 cm, cephalic presentation, ROP position (not sure should ask
Bishop score?).
-Other systems review normal

Management
I explained to her that so far everything is normal except ROP position, as most are ROA
position. I told pt as it is at early labour, there is a high chance baby can be spontaneously
rotated to ROA position, and if so can have normal vaginal delivery.

Regarding pain Mx, I said can give pethidine injection to relieve pain as it relieve pain
quickly and does not affect labour. I also told pt there is also another option of epidural, but
pt didn’t say anything.

Regarding labour Mx, I told pt we want to continue to observe for another 4 hrs. We will
close monitor mother’s vital signs and CTG to monitor baby’s wellbeing. If everything is

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going well, can go for normal delivery. If something happened during the next few hrs, like
any fetal distress and prolonged labour or eclampsia, etc. I will talk to my consultant, and
possibly will have C/S.

I asked pt do you have any questions to me? The role-play medical student looks at examiner
and then said no. I finish this task early and no questions from examiner.

2. Visual Disturbance
A 65 y.o. man comes to your GP clinic complaining of 3 episodes of blurred vision over the
last couple of weeks. He is currently on three medications for controlling his hypertension
and ischemic heart problem, ie, enalapril, atorvastin and aspirin.

Your task is to:

(1) Take a focused history for 4 minutes.
(2) Ask physical examination findings from the examiner.
(3) Explain to the patient the most likely cause of his condition and order necessary
investigations you would like to perform (results not given), and
(4) Provide your management plan to the patient.
(5)
(Note: role player looks like a real patient of similar age and told me the presenting complaint
straight away when asked open question.)

Key Hx:
-Sudden loss of vision of right eye for three episodes over the last 2 weeks, like a curtain
comes down.
-Each episode last for only a few minutes and back to normal completely.
-No eye pain,
-No dizzy, no headache, no fever.
-No weakness and numbness of arms and legs.
No other associated features.
Past Hx:
Hypertension for 15 yrs, and ischaemic heart problem for last few yrs. Pt is on three
medications as mentioned above. No other medications and no any other history.
Fhx: Forgot what pt told me.
Smoking: for many yrs, about 20 a day but stopped when had heart problem.
Alcohol: social.
No known allergy

O/E
-Completely normal except BP. I remember it is 160/90 mmhg. Forgot to ask carotid bruit
and fundoscopy.

Ix (examiner just ask what ix you want to do, no results given)

-FBE, U/E, Glucose, lipid profile, LFTS,
-CXR, ECG
-Echo
-Carotid Doppler U/S
-CT brain

Explanation:
Most likely TIA due to small clot blocking the brain vessels.

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Mx
Admit to hospital for further Ix and Tx.
Continue the current medications.

3. Elevated Mood - Psychotic

(long stem)
A university male student comes to your GP clinic sent by his university supervisor because of
some unusual behaviour problem which the teacher thought. He has written a thesis of
“Elixil of life” rather the thesis of “Using a mathematic formula to predict weather change”
as his supervisor assigned.

Your task is to:

(1) Take a focused history.
(2) Tell examiner the most likely diagnosis and differential diagnosis, and
(3) Explain to the examiner what are the risks of this patient.

Hx elicited from role player:

I can’t remember exactly what the pt told me at the beginning as I didn’t understand the word
of “Elixil” (I should ask examiner but I am afraid to ask).
-Basically he said he is too good and believe he made a great idea for his thesis. He
told me other classmates are not good enough compare to him. When asked how
about his school performance and what the teachers comment on his work, he refused
to answer me and jumped to other things.
-Doesn’t sleep too much.
-Full of energy.
-No hallucination like hearing voices.
-No delusional disorder.
-No any depressive symptoms.
-No suicide risk.
-No harmful to other people.
-No any medical and psych Hx.
-No smoking.
-Drink alcohol at club each night 2-3 beers as I remember.
-No medication and any drugs use.
During the history taken, patient is restless and keeping asking me “Are you a doctor? Yes?”.
He talks too much with flight of ideas.

Examiner ask me Dx and Ddx:

Mania/Ddx: psychosis, SCZ, bipolar disorder, drug related.

Qs from examiner
What are the risks of this patient? Depression and suicidal risk. What else? I don’t know.

Pt now wants to go home, do you want him to go home? I said pt is no suicidal risk and I
want to refer the pt to the psychiatrist.

Examiner asked me again, patient wants to go home, do you want him to go home now? Yes
or no? I didn’t answer his question immediately, but finally I said pt doesn’t fulfil the 5
criteria of mental health act for involuntary admission and pt can go home, but I told
examiner again I want refer the pt to psychiatrist. Then bell rang.

(I felt bad for this station. After examination, everyone said pt needs to admit to hospital.)

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(I failed this station. I think I made a critical error not to admit pt to hospital. So being a
safer doctor.)

4. Weight Loss
A 45 y.o. woman comes to your GP Clinic presented with 5 kgs of weight loss recently (stem
exactly like this).

Your task is to:

(1) Take a focused history.
(2) Examiner will tell you the physical examination findings after Hx taken, and
(3) Order necessary investigations in which you think the most likely the causes of her
weight loss.

(note: In the stem it is a 45 y.o woman, but when enter into the room, pt looks like a 65 y.o
lady)

Hx elicited from Pt:

-She lost 7 kgs over the last 6 months (After I introduced myself and said to her I
understand that you have lost 5 kgs, the lady corrected me and said: no doctor I lost 7
kgs and then stoped talking and expected me to say over what a period!)
-Appetite ok. Diet ok, eat normal diet as usual. Well-balanced diet on further enquiry.
-No Anaemic symptoms: No dizzy/headache. No SOB
-No any GI features: no constipation/no chronic diarrhoea/No GI bleeding/No abdo
pain.
-No heart problems.
-No thyroid problem/No intolerance to hot or cold weather.
-Periods are regular, no vaginal discharge/bleeding.
-No depression etc.
-No past Medical Hx.
-No any Hfx.
-No smoking/alcohol.
-No medication.

Completely normal Hx

After Hx taken, examiner told me completely normal physical examinations.

I explained to pt that from Hx taken and physical examinations, there are no any suggestions
of abnormalities, and I don’t know what are the causes. I told pt I need to do further
investigations.

Investigations
-FBE, U/E, urinalysis, glucose, cholesterol, ESR/CRP, LFTs, TFTs, etc.
-CXR, ECG (I said to examiner I consider to order these two tests but not sure as pt is clear of
any symptoms, then examiner answered: you are a doctor, are you going to do it or not? I
said yes, then examiner said: good)
-Blood film (forgot to ask)
-FOBT, colonoscopy.
Q from examiner: If FOBT is (-) ve, are you going to do colonoscopy? Yes.

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No Qs from pt and bell rang soon.

5. Sudden Shortness of Breath

A 25 yr man comes to the A & E department, presenting with acute shortness of breath over
the last 6 hrs. Physical examinations are completely normal. (stem exactly like this).

Your task is to:

(1) Take a relevant history with no more than 3 minutes.
(2) Perform necessary investigations as you think.
(3) Explain to Pt the diagnosis and Mx, and
(4) Answer pt’s questions.

Hx elicited from Pt:

-Acute onset of SOB 6 hrs ago.
-No chest pain. Pt said: uncomfortable on the upper right chest.
-No chest trauma/no injury. Occurred when play with friends.
-No fever/no any infection.
-No leg swollen/no recent overseas travelling (pt asked: do you mean DVT, doctor?)
-No any other medical Hx/No marfan syndrome/No asthma hx.
-No any Fhx.
-No smoking/social alcohol drinker.
-No any allergy.
(I forgot to ask if this happened in 1st time)

When asked physical examination, examiner said completely normal.

Investigations
When I said CXR, examiner give me the CXR film immediately and ask me to read it and talk
to pt. CXR clearly shows a small very darker area (black) on the right upper zone of chest.

Explanation
-Spontaneous pneumothorax. Leakage air in the pleural space either from lung or
chest wall.
-As the area is small and pt is no chest pain, Mx is conservative, no need chest
drainage.

Qs from Pt:
-Why I got this?
-Can I go home or stay in hospital?
-Will it happen again in future?
-What I need to do to prevent it in future?

No any Qs from examiner.

(I also failed this station. I think I made a critical error here, asking pt to go home rather
than staying in hospital observing for at least 24 hrs, as another candidate passed this
station. Again, being a safer doctor.)

6. Pubertal Menorrhagia (O & G)

A 12 y.o girl has first time heavy vaginal bleeding for 10 days. Mother comes to your GP
clinic seeking advice.

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Your task is to:
(1) Take a focused Hx from mother (only mother is in the room, no daughter).
(2) Ask physical examination findings from the examiner.
(3) Explain to mother the condition of her daughter and order further investigations, and
(4) Provide your management plan to the mother and answer mother’s questions.

(Note: When I read the stem in the 2 minutes time, I thought this is the easiest case so far.
However, when I went into the room, things are different. The examiner is tough and the
role-player, a middle thirty age of mother, is very unhelpful in answering my questions. I
made a few mistakes and forgot to ask several Hx and Mx in this station as they made me
very uncomfortable.

When I in the rest station, the lady also comes out to the reception area to have a break, but is
totally different person. She is happy with smiling face and talks to her colleagues nicely. So
I guess she might pretend to play as a difficulty role-player. Becareful in your examination if
you meet such difficulty role-player.)

Hx elicited from Mother:

-1st time bleeding for 10 days.
-Bleeding is heavy with clots (I forgot how much she told me). Wears 2 pads at a time
(examiner told me this). No tummy pain.
-No bleeding elsewhere, nor nose, no bruising, no rash.
-No any symptoms of hypothyroidism.
-Pubertal development: forgot to ask.
-Forgot to ask any symptoms related to anaemia, like dizzy, faint, SOB on exertion.
-No any medical hx, no any medications
-No Fhx of bleeding disorders.
-A 16 yrs old sister. Periods normal and regular since onset.

O/E
-GA: forgot what examiner said.
-V’signs: BP 100/60, pulse 100 (not sure exactly).
-No rash, no bruising.
-Abdo normal, other systems review normal.
-PV exam: wears 2 pads, can not to be done.
When I mentioned vaginal examination, I immediately realized I was wrong. I told examiner
I just want to have a look. Examiner said what do you want to look? I said I just want to
have a look at outside to see if there is bleeding (forgot to ask pubic hair). Examiner said, she
is wearing 2 pads now. Then he asked me: Do you want to go inside to have a look? No I
said. Critical error here: don’t do vaginal exam.

Investigations
When asked Ix, examiner didn’t tell me the results, just ask me what Ix you want to
do.

I said FBE, coagulation profile. Examiner asked what else? Hormonal profile.
Examiner asked what hormones? FSH, LH, E. Then examiner asked: Why do you
want to test these hormones? No reply and I know I made a mistake here.

What else you want to do? Pregnancy test (I almost asked sexual Hx from mother but I
didn’t do it).

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Advice to mother (examiner asked me to talk to mother re Mx)
I told mother the girl got a condition called pubertal menorrhagia. I explained to her
this is a common condition and due to the first period because of hormonal imbalance.
I reassured her that there is no secondary cause of her bleeding.

Mother asked me to explain what is hormonal imbalance? I explained to her it is

anovulation problem but she seems to be not understandable.

I also explained to mother that her daughter’s period will be regular after a few cycles
in the next couple of months.

Mx:
I only told mother that I can give her daughter the progesterone pills to stop bleeding.
But didn’t tell mother other Mx options, like admit to hospital, treat anaemia and long
term OCP pills, etc.

Qs from mother:
Does she need an operation? Does she need D + C?

7. Supracondylar Fracture Humerus

A 11 y.o. girl is brought to the hospital A & E department by her mother. Mother told you
that the girl was falling down on the right arm and now has painful elbow. You have ordered
x-ray and the film has backed to you now (x-ray film is attached on outside the room).

Your task is to:

(1) Read x-ray film and explain to the mother your diagnosis.
(2) Tell mother how you are going to manage her child.
(3) Answer mother’s questions, and
(4) Answer examiner’s questions

The x-ray is not so clear and is not the picture of the typical supracondylar fx as shown in
AMC Anthology book on page 197. My understanding is that the x-ray shows that there is an
impaction of fracture near the supracondylar humeral end, but is obviously no any
displacement. So I guess it is a supracondylar fx.

I explained to mother that her child has a fracture called supracondylar fx, which is the distal
part of the upper arm. I told mother my management plan are as follows:
-Refer to orthopaedic surgeon immediately.
-The surgeon will do internal fixation first and then put backslab (V-shape plaster).
-The girl need to back to hospital in 24 hrs for checking any vascular and neurological
complications, ie, pulses, skin colour and sensation of skin.
-Then the girl need to back to hospital in 2 weeks time for further check-up, and again in
another 4-6 weeks.

Qs from mother:
When my daughter can go back to school?
1-2 weeks if no pain, I answered.

Can my daughter write?

I didn’t answer her question immediately. I looked at the film again and the film is
marked on right arm. Mother noticed this and told me her daughter is writing using

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 her right hand. I told mother could ask her daughter to write on her left hand. Mother
seems to be unhappy for my answer and said this will be very uncomfortable for her
daughter. Then I said possibly after one week if there is no pain she might ask her
daughter to write, but don’t use the arm too much.

Qs from examiner:
What are the complications of this type fracture?
I answered brachial artery at risk and nerve injury as well. Examiner looks unhappy
for my answer. Which nerve is likely to be damaged? Medium nerve. What else the
other complication? I was thinking for a while, then suddenly the “Volkmann’s
ischemic contracture” go into my mind. When examiner heard of this, he said Ok, you
have finished your task and you can go to your next station.

(Note: I finished this station quite earlier, and I can’t remember whether in this station or in
Dr. Marshall’s station, the examiner told me you finish your task early, but that not mean you
failed the station. What a great examiner!).

8. Urinary Difficulties in a Male

A 65 y.o man comes to your GP clinic complaining of urinary problem (stem is exactly like
this, no more words)

Your task is to:

(1) Take a focused hx of 4 minutes.
(2) Ask physical examination findings from the examiner.
(3) Explain to the pt the likely cause of his condition and tell pt what investigations you
are going to do, and
(4) Outline your management plan.

Hx elicited from Pt (A real old gental man and is very helpful to give you the hx)
-He went to toilet 3-4 times at night over the last 3 mths.
-Voiding is difficulty: hesitancy/weak stream/terminal dribbling. When asked, pt told: take a
long time to start, when start not strong enough and dribbling after voiding.
-No stress/urge incontinence and dysuria.
-No pain includes abdo pain and loin pain.
-no bone/back pain
-No blood in the urine.
-no wt loss
-Appetite ok/bowel motion ok.
-no any symptoms suggested DM.
-No respiratory/liver symptoms (metastasis, forgot to ask)
Past Hx:-nil, no DM, renal problems before.
FHX:-Nil
Social Hx-forgot to ask
No Smoking/Social drinker
Medication-Nil
Allergy -Nil

Exam:
GA: Well
V’signs: normal
Abdominal: normal

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PR: enlarged prostate (when ask PR, examiner asked: What are you looking for?)
Other systems review unremarkable.

Explanation, Investigations and management

(When finished O/E, I turned back to pt and explain to pt most likely due to prostate problem,
and try to draw a picture. But when I look at the table, no paper and no pen supplied)

The I back to examiner and said I want to order further Ix, examiner told me talk to pt about
what tests you are going to do.

-FBE/U + E
-Urine Dipstick
-PSA:
-U/S
-Prostatic needle biopsy:
I explained to the pt the importance of PSA and what further Ix need to be done based on PSA
measurement.

Then I told pt about treatment: life style changes, medication, -blocker and refer for
urologist for relieve the obstruction by surgery.

Qs from Patient:
-What is PSA?
-If PSA is normal, what are you going to do for me?

No Qs from examiner.

Critical errors:
-Not asking BOO/Hameturia/metastatic spread symptoms- bone pain
-not doing PR: enlarged prostate
-Not doing PSA.

9. Neonatal Gut Obstruction (Paediatrics)

(long stem)
A young woman had a normal vaginal delivery with 1 day old baby was discharged to home.
The baby start to have greenish watery vomiting in the 1 st 24 hrs after birth. Baby has no
meconium. Mother has another 4 y.o. child at home but mother seems to be not caring the
baby as she stop breastfeeding at 4 months.

There is also a plain abdo x-ray film attached at outside the door (can’t remember this is GP
setting or at A & E department).

Your task is to:

(1) Read x-ray and tell mother the condition of the baby as shown in the x-ray.
(2) Answer mother’s questions

(Note: the role player is a young medical student but seems to be careless of her baby)

When I went into the room, I read the x-ray film again and can only recognized it is intestinal
obstruction (the film is very similar to AMC Anthology book P46, small bowel obstruction).

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I showed my empathy to the mother. I told mother the x-ray showed intestine obstruction
(bowel obstruction I repeat once) b/c the bowels are rotated (twisted) together The baby’s
vomiting feature also suggest this. I said to mother I am very concerned about the baby and
this is a medical emergency and I want to admit the baby to hospital immediately.

Followings are the conversations between the mother and me:

Doctor, is this a serious condition?

Yes. This is a medical emergency and baby to go to hospital.

Can I go to hospital with my baby?

Yes, you have to go. You can also ask your husband to go with you.
My husband is at interstate travelling. I can call your husband if you wish. Mother said no
need.

I told mother I understand you have another baby at home, I can organize a local community
nurse or social workers to look after her 4 yr old child. Mother said her mother is looking
after her child at home.

After this mother keep asked me: Doctor, is this serious condition? Do I need to go hospital
with my baby? I didn’t understand what she wants me to say. After my examination I
realized I should explained to her the serious outcome if left untreated.

In the hospital, what the doctors are going to do for my baby?

Further Ix, operation, untwisted the bowel.

My baby is too small, how they can do operation?

They are very experienced doctors specialising in this condition. They should have no
problem to fix the condition.

Can I feed my baby now?

No, you cannot feed the baby b/c of intestine rotation.

If I cannot feed my baby, what should do for my baby?

IV drips fluid.

After operation, can I feed my baby?

Is any problem for my baby in the future?
Is the baby growing ok in the future?
My milk is leaking now doctor, what can I do for it?

No Qs from examiner.

10. Grief Counselling (Psychiatry)

(long stem)
A middle-aged woman comes to your GP Clinic for regular check-up of her hypertension.
She is usually fine and no emotional responses. However, over the last week she suddenly
developed emotional tearful and is often crying. Her husband died of heart attack 12 months
ago.

Your task is to:

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 (1) Take a focused history for 5 minutes on psychiatric aspect related to her emotional
tearful.
(2) Tell examiner the most likely diagnosis.
(3) Explain the condition to the patient plus Mx, and
(4) Tell examiner what condition is associated with patient’s emotional crying.

(This station is an example, which I believe is somehow AMC want to test how smart you are and how you can
digest the task in a way of logical thinking. When I read the stem in 2 minutes time, I don’t feeling it is grief as
12 mths already, and also I don’t have the feeling of depression as the task is to deal with her suddenly emotional
response. However, I didn’t realize her emotional tearful and crying are due to one year anniversary of her
husband’s dying. A very good case!)

Hx elicited from patient:

(role play patient is a middle aged lady, she did an excellent job)
After introducing myself, I start with an open question: Mary, I am sorry to hear that you lost
your husband. I understand your feeling (actually I didn’t understand), can you tell me more
about why you are crying?

After my question, the lady start to crying. After a while, she told me she start crying since
one week ago because she missed her husband very much but she didn’t give me the clue of
“one year anniversary”.

Questions about grief:

She told me her daughter looks after her and she is often going out with family members and
friends. But I didn’t ask the relationship between her and her husband. I asked her husband’s
name, and she told me “Michael”.
Do you feel guilty? No
Do you feel angry if someone reminds you of Michael? No
Do you still keep Michael’s room and things as if he is still alive? Yes.

Questions about depression:

She told me her sleeping is not so good and sometimes she woke up early in the morning.
Apart from this, she has no any depressive symptoms. Her mood is not going down. She still
has her usually interest and her concentration is not affected.

There is no any hallucination such as hearing voices.

There is no suicide risk as she denied life is not to worth living. She doesn’t want to harm
herself.

No other medical and psychiatric Hx apart from hypertention.

Family support: forgot to ask.
No smoking/no alcohol.
No drug use/no other medications.

After Hx taken, examiner asked me the likely diagnosis: I said most likely to be grief not
depression. Then examiner asked me to explain to patient.

I explained to patient that she is still in grief and give her some advice like family support,
psychological therapy etc., and refer to psychiatrist.

Qs from examiner:

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What condition is associated with this lady’s emotional crying?
I told examiner not due to any medical and depression causes. Examiner looks unhappy for
my answer, and then bell rang.

(I failed this station.)

11. Eye problems in an Aboriginal Community

(long stem)
A nurse who is working in Northern Territory comes to your clinic, complaining of eye
problem (other candidates said nurse is no eye problem). She told you she is working with
local aboriginal community. She also bring along 4 photos which she took from four each
individual persons.

(Note: photos are on both outside and inside the room, one is sand appearance of red swollen
upper eyelid, another three look like cloudy eye, ulceration and scarring).

Your task is to:

(1) Tell the nurse the diagnosis based on the photos provided and explain to her the
causes.
(2) Tell patient how you are going to treat her condition.
(3) Advice patient how to prevent this condition in future.

Dr Marshall (I am pretty sure most of us know him from AMC video) is my examiner of this
station. He is very nice to you and talk to you very gently. When I went into the room. He
introduced himself and asked me: Are you Dr. ___. Can I look at your ID to make sure you
are the right Doctor? Then he said: Do you understand your task? Here is another information
sheet, If you like, you can read it again.

The nurse (a very shy Chinese Medical student role-player) is sitting on the chair holding the
4 photos. I look at the photos again and explained to her the condition we called Trachoma,
an eye infection caused by bacteria. I told her that I can only recognized two photos (one with
sand red eyelid, another one is very cloudy cornea).

I explained to her this is very common in aboriginal community due to poor environmental
and personal hygiene. She asked me again what the cause of the infection. I answered her it
is due to bacterial trachomatis (forgot to mention Chlamydia). If untreated, it can lead to
blindness.

I explained to her there is effective treatment of this condition. I only can say one antibiotic
of Doxycycline to treat for 7-10 days (Note: The standard Tx is Azithromycin 1g orally
weekly for 3 weeks to treat trachoma in indigenous communities).

Prevention
Use SAFE strategy for the control of trachoma (I only mentioned 3, forgot to refer to
surgeon for surgical correction of trichiasis)
S: surgical correction of trichiasis
A: Antibiotic treatment of trachoma
F: Facial cleanliness to prevent the spread of disease
E: Environmental changes to improve personal and community hygiene.

No further Qs from both patient and examiner and I finished early of this station.

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12. Painful Heels
A middle age woman, who is a bush walker, presents to your GP clinic with a 2-month history
of painful heel on both feet. There is no history of trauma and injury to the feet. Otherwise
she is healthy. You have ordered an x-ray and the film has backed to you.

Your task is to:

(1) Perform physical examination of her feet.
(2) Read ankle x-ray and tell patient what is the most likely diagnosis.
(3) Outline a management plan for the patient.

When I went into the room, the lady (looks real patient aged around 50 yrs old) is siting on
the couch with two legs fully exposed.

First I asked the lady, can you tell me where is the pain? The lady answered me said: Doctor,
when you do your examination I will tell you where is the pain?

Then I start to do the examination by inspection first and I told examiner there is no scar,
swelling, deformity. Examiner (a nice Indian doctor) stoped me and told me: “You don’t
need to tell me what you are going to do, just tell me your physical examination findings
when you finish your task.”

I did the ankle and feet examination followed by John Murtagh’s GP book on page 754. There
are no any other abnormalities except tenderness when you palpate the plantar fascia region
(under the heel). When I press this region, the lady told me: “give me more pressure here and
then she said pain is here doctor.”

13. Iron Deficiency Anaemia (Paediatrics)

A 18 month old boy, Anthony, is brought to your clinic by his father. Child had a cold a few
days ago, but now father is worried about him as he noticed child looks very pale.

You have performed some blood tests and results have backed to you (are attached on the
side of information sheet, Hb not given, but both ferritin and Fe are very low).

Your task is to:

(1) Explain to father what the test results mean.
(2) Take a focused hx from the father.
(3) Explain to the father the likely causes, and
(4) Answer father’s questions and give your Mx plan.

Hx elicited from father

-Cold a few days ago but now settled and father said that is not a problem.
-When enquire diet and feeding hx, father said breastfeeding until 9mths, then start
bottle feeding 6-7 bottles per day till now (I remember father said 2 Ls per day). Baby
doesn’t eat solid food, no meat introduced.
-No bruising, no bleeding elsewhere.
-Term born baby, no problem during pregnancy and delivery.
-Growth ok, no other milestones.
-No any other medical hx and no medications.
-Immunisation up-to-date.
-No Fhx, western Caucasian background of parent. (Examiner asks why you ask
parent’s ethnic background: thalassemia, then examiner said very good).

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Forgot to ask physical examination findings from examiner but this is not on task (not sure
this is a critical error).

Explanation
-Iron deficiency anemia due to cows milk
-Too low Fe in cows milk. Drinking habit of too muck milk.
-Needs to introduce solid food like meats, chesses, eggs, etc. Stoping bottle feeding and
decreasing milk drink.

Management
Change diet, refer to dietician and start fergon (tutor’s note: children with low iron have a
poor appetite and this improves with iron).

Qs from father
-Why cows milk cause anaemia of my child?
-What are the side effects of iron supplement?

Qs from examiner?
-Do you want to give the child iron supplement now? Yes or no?
(I made a stupid mistake here as I said to father child can has iron supplement, but I
answered to examiner no need).

14. Breath Holding Episodes (Paediatrics)

A 18 month old boy is brought to your GP clinic by his mother as his parents are worried
about the child so much. Parent have noticed that over the past few weeks child had several
episodes of sudden attacks of loss of consciousness, which is preceded by the child crying
angrily for a few minutes and then turning blue. Physical examination is completely normal
when you examine the child.

Your task is to:

(1) Take a focused history from the mother.
(2) Tell mother your diagnosis and explain the condition to the anxious mother.
(3) Answer mother’s questions.

Hx elicited from mother:

(When I went into the room, mother looks very anxious and stoped my introduction
saying: Doctor, I am very worried about my child.)
I started with an open question with sympathy: I understand you are very worried
about your child, can you tell me a bit more detail what happened with your child?
Then mother told me the story in full detail.

-Mother said the child first got very upset, then start crying, then loss of
consciousness, then turning blue, and then falling down on the ground.
-No fit (but mother told me child shaking his hands), no fever, no tongue-biting.
Completely back to normal after a few minutes (No post-ictal abnormalities).
-Term born baby, no problem during pregnancy and delivery.
-Growing is ok.
-Immunization up-to-date.
-No any medical Hx includes type I DM.
-No any FHx

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I explained to mother that child got a condition called Breath-holding attack, not an epilepsy.
I reassured mother that there is no need to worry about the child as it is no any harmful to
baby.

Qs from mother:
-What is breath-holding attack?
-Is it harmful to my baby? Mother asked this questions for several times.
-How can I prevent the child against these attacks in future? The best way of preventing these
attacks is to avoid the child being provoked, but I explained this very poorly to the mother (I
know how to say it, but I just couldn’t speak out. That’s the reason why we need practice
more and more).

15. Abdominal Pain (Lower) (O&G)

A 25 y.o woman comes to the A & E department complaining of acute abdominal pain on the
right lower abdomen.

Your task is to:

(1) Take a focused history.
(2) Ask physical examination findings from examiner.
(3) Order necessary investigations and tell examiner the most likely diagnosis and
differential diagnosis, and
(4) Answer patient’s questions regarding management.

When I went into the room, the role-paly medical student is lying on the bed and told me:
Doctor, I am pain, pain, pain…… Then I said, do you want pain killer right now to relieve
your pain before I take Hx. She looks at examiner and then said: No, Doctor, I can stay for a
while and you can take history now.

Hx elicited from role-player:

-Pain in the RIF region, start 2 days ago which I remember. Pain is not severe, but is
constant. Patient said pain is always there, no radiation. Pain is not initially starting
from central tummy then shift to RIF. Changing position or movement does not make
pain better or worse.

Not feeling feverish. Bowel motion ok, no blood. Urinary is ok.

-Pt is sexual active but only one partner. LMP 3 weeks ago. Can’t remember age of 1 st
period. But periods are regular and on OCP, so I didn’t ask if any pregnancy (another
candidate said pt stoped OCP 3 weeks ago and try to be pregnancy).
-No vaginal bleeding/discharge.
-Pt don’t know blood group.
-Pap smear done 1 yr ago and normal.
-No sex transmitted disease hx.
-No any medical Hx, nor significant Fhx.
-No smoking/alcohol.
-Not on any medications nor drugs.
-No known allergy.

O/E
-GA: pain, otherwise well.
-V’signs: normal. Another candidate said T:37.5 degree.
-Abdo: tenderness at RIF. No mass, no rebound tenderness, McBurney’s sign (-) ve.
-Vaginal examination: I forgot what examiner told me, but remember nothing abnormal.

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-Other systems review normal.

Investigations
I was surprised this station as examiner didn’t tell me the results when I asked Ix.
-FBE/urine analysis
-Pregnancy test, serum beta-HCG
-U/S

Qs from examiner:
What are the most likely Dx and DDx.
I said most likely ovary cyst torsion. DDx: appendicitis and torsion of ovary cyst but forgot to
mention ectopic pregnancy (that is why when you are under pressure, how easy you can make
a mistake.)

I explained to pt the most likely Dx is ovary cyst ruptured or torsion.

Qs from Patient:
-Do I need operation?
I said it is depended on the size of cyst and whether it is ruptured or not, and the blood
supplied to the ovary.
-Doctor, can you tell me what is the size of cyst I need to have an operation, and what is the
size I don’t need to have an operation?
-Does it affect my infertility?

16. Breast Lump Counselling

A 25-year-old woman presents with a lump in her left breast. She looks anxious and there is
pain with the lump, in particularly associated with her cycle. There is a family history of
breast cancer. Her mother was diagnosed as breast cancer at age of 50 years. You have
performed fine needle biopsy (FNA) and the result of pathology of the lump tissue has backed
to you. Pathologic results (attached on outside the wall) show that the lump is benign feature
and there is no evidence of malignancy.

Your task is to:

(1) Explain to the anxious patient the pathology report, and
(2) Answer patient’s questions.

I didn’t realize this is my last station as I thought I have one more station after this. When I
went in to the room, the examiner made a joke to me said: This is our last station, we can go
out together to have a nice lunch. At that time, I was wondering why he told me this?

The lady is a beautiful young Indian medical student and doesn’t look anxious.

I explained to her that the result has backed to me. I told her that It is a benign lump, not a
cancer. Patient is very happy and said to me: this is a good news to me.

As this is a counselling case, I didn’t talk too much. So I ask patient: do you have any
questions to me?

1st patient told me that her lump was a cyst and fully aspirated when performed FNA, so there
is no lump now. I asked her do you have any pain? She said no. (When I read the stem, it is
not mentioned et al whether the lump is cyst or fibroadenoma, so I was thinking 1 st to refer
her to see surgeon, but she gave me the clue here lump is cyst and aspirated already).

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Followings are the conversations:
Doctor, can you tell me how long you are going to follow me?
I was thinking for a while and then said every 1-2 yrs (I don’t know this, but I know
mammogram is done every 2 yrs).

Doctor, what are you going to do for me when I come back in 2 yrs?
U/S to see if any lump comes back. Then I told her not to do mammogram as she is too
young, and usually done after 40 yrs old.

Doctor, during the next 2 yrs, what can I do?

Self-breast examination.

Doctor, can you tell me how can I do this?

I told and show her how to do it and when to do it (but forgot to say after period).

Doctor, where I need to stop feeling it? Do I need to stop palpation just the outside margian
of my breast or anywhere else?
I know what she means and told her to do the axillary glands as well (she looks
happy).

Doctor, What else I need to do now?

I realize I need to take a brief history now.
She told me she is on OCP pills for 6 yrs. She didn’t ask me whether to stop it or not,
but I told her there is not strong evidence increasing risk of breast cancer with OCP
pills and suggest her to continue the pills (I am not sure I made a critical error here as
OCP is usually an CI for breast lump.)
How about pap smear? I asked. She said it was done 2 yrs ago and normal, then I said
you need to repeat it now and I can do it for her.

Doctor, my mother had breast cancer at age of 50 yrs old, do you think I will get it as well?
I explained to her that there is family Hx of breast cancer, and there is an increasing
risk of breast cancer if mother got it.

Doctor, I have another sister, she is 28 yrs old, does she need a test?
You can ask your sister to come for a U/S scan if she is concerned.

Do you have any more questions to me? No, thanks Doctor.

I finished this station early. When I went out, I realized that I have finished all stations
because the next station is number 5, which is the 1st station I started.

(I also failed this station. I am not sure why I failed it but I think one critical error I made is
not advising pt to stop OCP pills and changing into another method. Again, being a safer
doctor.)

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Note: My experiences of examination in Adelaide.
(1) Work very hard and be preparing for at least 6 months before examination.
(2) Don’t work too hard for the last week before your examination. Having a good sleep
the night before your examination. You need a very good energy and very clear brain
during the examination, otherwise you will be very difficulty in concentrating on your
exam.
(3) The first 2 stations is the key to success as you are very nervous and easy to make
mistakes.
(4) Don’t to be careless for last 2 stations. Remember we need to pass 12 stations. A one
careless station can be fatal.
(5) Most of the cases, the stems are short and you have practiced those many times. Scan
the stem in 10 seconds, get the idea of that station, read it again within half minute,
pick up the most important words in the stem. If the stem is short, then every word is
a meaning. Understand your task very clearly.
(6) Always introduce you to patient and shake hands if you can. When finishing your
task, remember to say “all the best to patient” and “thank you” to the examiner.
(7) Always start with an open question. Usually the patient will tell you the story straight
away.
(8) Most of the examiners and the role-paly patients want to pass you. If you are facing
difficulty examiners and role-player, don’t to be panic and to try to calm down.
Remember always respect both examiner and role-play patients no matter how they
treat you.
(9) Follow the station direction carefully as sometimes it is easy to miss a station or go to
a wrong station.

*Most importantly, I believe AMC is wishing our overseas trained doctors to achieve the
goal: Being a safer and good doctor in Australian community.

Acknowledgment: I did the VMPF 20-week long clinical bridging course. The advantage of
this course is that VMPF is not only aiming at helping you passing the examinations, but also
teaching you the ways how you can practice in Australian medical system in future. During
the course, we had a lot of time and chance to access to the live patients in the wards and
talked to the hospital registrars and consultants. I thank very much for Drs Newell and
Hillman, the two major well-respected medical tutors and Helen and Paul, the two excellent
professional role-paly patients and our English tutors. I also thank very much for my two
study groups. God blessing everyone if you are harder worker.

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