AMC Clinical 16/02/2013

Case 1 (Medicine)
A woman came to GP with complaint of something wrong with her nerves.
Task: History, PE , Explain Diagnosis and Investigations.
DD- Hyperthyroid, Panic attack, Phaeochromocytoma
History
What do you mean it? My hands are shaking.
Does it happen during rest or during activities?
Other part of body is shaking too? No
Any weather preference ? ( hot intolerance)
Any weight gain or loss ? ( weight loss for no reason even though with good appetite)
Any hair changes? ( yes)
Any heart racing? (yes)
Any loose stool ? ( yes)
How is your period ? ( irregular)
Any episode of panic attack like nausea, sweating, and tummy pain? ( no)
PMH- NAD
Family history of thyroid or adrenal gland problem? No
SADMA
PE
GA- BMI
VS- BP- normal, PR- irregular, RR, T- normal
Eye signs Nil
Thyroid- enlarged , bruit +, no retrosternal goiter , Pemberton sign ve
Heart- 1+2+ systolic murmur
Lungs- nad
Abdo- nad
CNS- nad
Peripheral myopathy +
Explain
You have a condition called hyperthyroidism .Thyroid is the important gland sitting in front of our
neck which produces important hormone for our body. In your case, there is increase level of thyroid
hormone because of hyperactive thyroid. The symptoms are the same as you have.
To confirm my Dx, want to do blood tests- FBE, U&E, LFT, CRP, ESR, TFT, B12 and folate, ECG, and
CXR. I dont want to do Urine VMA because I am positive that it is mainly thyroid problem.
You will be managed by multidisplinary team with the involvement of endocrinologist, cardiologist,
and GP.
AMC: Nervousness

Case 1 (Medicine)
40-45 years old women consult you in GP setting as she need some help to overcome her nerves.
Tasks
Take a focused history
Ask examination findings from the examiner
Tell the patient about your diagnosis and the investigations you want to do
I introduced myself to the patient and asked her to tell me more about her nerves she started
leaning towards me really anxiously which made me take my chair slightly backward. Then she told
me that she always on the edge and tries to overcome her nerves by taking her husbands diazepam.
She mentioned about her kids/teenage making her really on to the edge but when I ask about them
further she told problem is with me doctor not with my kids. I asked her are you really anxious?
She said yes but there is nothing else to say it is psych case (case 1 cannot be psych anyway). Then I
tried to take a system review. Do you have any hot/cold preference? RP said, now that you asked
doctor I feel hot always. That was a good hint for me then I asked do you have shakes/tremors? RP:
Yes. Bowels: diarrhoea Periods? Scanty
Then I went to examination general, vitals and Head to toe (Tally OConner type)
Pulse: irregularly irregular
No eye signs
Thyroid enlarged with a bruit / moves with swallowing
CVS: Systolic murmur over whole precordium
Examiner wanted inspection, palpation and auscultation in that order ( he was not happy when I
mentioned quick CVS exam.
Talk to the patient: I told RP after History and examination that suspect that she has an overactive
thyroid gland. Started drawing a picture with hypothalamic pituitary thyroid axis (TRH, TSH and
T3/T4) and how it altered in her situation.
Examiner reminded me you have few seconds tell her the investigations you wanted to do
I told TSH, T3, T4 and the bell rang
Diagnosis:? Hyperthyroidism (thyrotoxicosis)
AMC: Nervousness

2.Case 2 (O& G)

Young woman came to GP for pap smear result which showed HSIL and HPV +. Task- explain the
result, take history, and management plan
I started with History
I understand that you came her to know for result of pap smear we did previous day. Before
explaining to yo , can I ask a few questions? Some questions might be personal, is it okay for you?
5P
Period LMP- 2 weeks ago, regular
Partner- unstable before, not practised safe sex. But now on stable relationship for 2 months. Never
diagnosed with STD.
Pills- ? OCP not sure
Pregnancy- never pregnant before but plan to get within a year
Pap- previous pap smear results were normal
Now no other symptoms (bleeding after intercourse)
Explain
Well, the pap smear showed there is cellular changes which is quite different from normal. It is good
that we found out that changes early to prevent the change to cancer.
Now, I will refer you to the specialist for Colposcopy and Biopsy which is actually to visualize the
cervix and take tissue pieces. Then, the specialist will decide the treatment options which include
cryotherapy, Laser excision and others ( honestly I dont know much about the options to discuss) .
Then regular follow up with gynaecologist and GP for pap smear is important.
Another thing is HPV is detected which is acquired via sexual transmission. There are many subtypes
of HPV of which certain types can be associated with cervical cancer.
RP asked : does her partner cheat on her? I replied her that it can be positive even on stable
relationship and examiner doesnt look happy for my reply
So, with your consent, other STD screening should be done such as HIV, Syphillis, HBV, Clamydia and
gono.
We dont need to treat HPV , it can recover spontaneously.
But , practise sex safe.
RP asked me about Gadasil Vaccination. I said good question and I can give you that vaccination
which can prevent other types of HPV . Safe sex is paramount important.
AMC: HSIL with HPV on Smear

2.Case 2 (O& G)
20-25 years old women who consults you at a general practice. One of your fellow GPs has
requested a PAP smear report for her. The report comes as HIGH GRADE INTRAEPITHELIAL
NEOPLACIA.
Tasks:
Inform the patient about the PAP smear report
Ask any history you require
Tell the patient about your management plan
Answer any questions patient might have
I told her that your PAP report has arrived but I need to ask few questions before I describe the
report. When was the previous one? Was it normal? Yes
Tell me about your periods, pregnancies and partners. She has had multiple partners. But sexually
active with current partner for last 2 years. Not using any condoms. No previous pregnancies. Not on
pills. I forgot to ask about any history of STDs.
Then I describe the PAP smear report to her. First of all this is not cancer. I drew a picture of uterus
and cervix and described that the epithelium has changes in the cervix area. It is due to the HPV virus
and there are 4 subtypes two of them cause changes that can later develop in to Cancer. But her
condition can sometimes resolve spontaneously and only sometimes can develop into cancer.
I told I am going to repeat PAP in 6 months and if positive do another PAP in another 6 months ( I
mixed it up with LGIEN) if become normal go back to usual every 2 year PAP tests. Later I corrected it
by saying that I will refer you to gynaecologist for a colposcopy and biopsy (I said cone biopsy).
RP asked was it my boyfriend who gave this to me. I told it is hard to tell since you had multiple
partners. Virus takes long time to make changes in epithelium (she asked the same question three
times may be she wanted me to investigate for other STDs which I forgot.
I wanted to get pregnant and will this affect pregnancy plans? I told most probably not
Gynaecologist will monitor you and advice on pregnancy
RP:What Can be done to prevent spread of virus? I told you can use condoms but if you want to get
pregnant you need to avoid using condoms
AMC: HSIL with HPV on Smear

3.Case 3 (Surgery)
25 year old male came to ED after MVA. Primary survey was already done. Vital signs BP- 120/70 (
not sure but within normal range) , PR- 110/120 , others insignificant. Xray of lower leg which
showed both tibia and fibular fracture ( unstable ) and also photo of lower leg showed abrasion and
swollen.
Task- Examine the leg to detect the complications, Tell the diagnosis and initial management plan
It was my first station and so time for shaking is longer than that I anticipated
Once I entered the room, I just started with primary survey ( Cervical collar + DR ABC )
As patient is in pain, offer him some pain killers.
PE (My voice was trembling and hands were shaking )
Inspection- looking at the photo and mention that there is swelling over the left leg, no obvious
deformity, no active bleeding, no muscle wasting
Palpation- tenderness over the left leg, check the capillary refill and dorsalis pedis, and post tibial
artery. ( Examiner came and checked it )
Others the patient was too painful to do movement.
I do not know what to do after that. What an awkward situation!!!
So, I go to the management
Explain the patient that both of the long bones of your calf ( tibia and fibula) broken and it needs to
be fixed by ortho specialist.
Now, I will contact to ortho reg.
Do blood tests including FBE , blood group and hold.
NBM, IVF, IV antibiotic, Tetanus toxoid, I V analgesia
Ortho team will assess you and admit you under their team.
You will undergo operation what we called open reduction and internal fixation. Aim is to make the
normal alignment and to stabilize the bones with pin. Then , they will apply back cast.
Role player asked me which tests you want to do? I thought he might ask me some part of physical
examination. Then examiner asked that which investigations you want to order apart from blood
tests? I answered Xray ( chest, neck, and pelvis ) and ( AP, Lateral and special view for the left leg ).
Then the bell rang.
My heart sank after this case and I didnt perform well. Fortunately, my next station was rest station
and so time to calm down and remind myself that 4 stations can be failed and move on !!!
AMC: Fractured tibia and fibula

3.Case 3 (Surgery)

Case note given (almost a page) outside the door about a young man who had a road traffic accident
(trauma) in a rural? dirty road. The wound in the left leg is given as a picture outside wall. His BP/PR
and other vitals are included in the case note (normal)
(Inside the room the role player lying on the bed with a mid-leg area bandaged, there is an X-ray leg
showing complex fracture involving both tibia and fibula in the middle)
Tasks:
Perform relevant examination
Advise the patient about your management
AMC: Fractured tibia and fibula



4.Case 7 (Psychiatry):
Daughter of a father who was recently diagnosed by the consultant after your referral two weeks
ago.as having mild dementia comes to you/GP. She is busy lawyer who do not have much time to
look after her father but she is very concerned about his recent deterioration of function. You have
not seen her father since you referred him to neurologist/specialist for assessment for dementia.
She herself, her father and her mother who passed away recently (9 months ago) all are your
patients. You are aware that she is not getting on very well with her father. She has got the fathers
consent to talk about his illness.
Tasks
Talk to the daughter about her concerns
Advise her about your management plan.
AMC: Alzheimer type dementia

4.Case 7 (Psychiatry):
70 year old man had CT brain and showed brain atrophy and so diagnosed with Alzheimer Dementia.
All the blood tests for dementia are within normal. Now, daughter who has the consent to get about
her father condition came to your GP and discussed with you. Task : Listen to patients concern ,
answer her questions and tell the management plan.

Firstly, greet and double check about the consent .
Then, explain her about her fathers diagnosis with sympathy.
RP asked : I think my father is depressed and can you give him Antidepressants straightaway? I
explained her that people with dementia can get easily depressed and he better needs to be
reviewed by experienced psychiatrist for anti depressant.
RP asked: Which anti depressant ? It can be SSRI
RP : what is the dose? He will start with low dose , probably 25-50 mg .
RP: Side effects? Nausea, vomiting and tummy upset but all are quite manageable. For
antidepressant, it will take 3-4 weeks to get the effect and so we will review him later.
RP: I heard some medications for Dementia , so please write some meds for me and I will go and
grab from Pharmacy !
Ans: I was a bit confused at that time and told her that I will check in MIMS. Out of sudden, I got the
idea. Well, it will be the best for him to be assessed by Age care assessment team who will take
proper history and do physical examination. Then , experts from that team will decide the treatment
for that. By the way, the study shows that the medications for Dementia cant not prevent it but can
slow down the progress. Role player looks happy.
RP: He is living alone right now. She is living in interstate and has difficult to look after him properly.
Ans: I do understand that it is difficult situation for you to come across. Firstly, ACAT team will assess
your father and then if they think he cant manage at home, he will be referred to Nursing home with
enough facilities and care. Or if they think he can manage at home, we will go with multidisplinary
team with the involvement of Geriatric physician, social workers, physiotherapists, meal on wheels,
trained nurse, psychiatrist, psychologist and so many support groups. In that way, it can reduce the
burden on you.
She run out of questions and then I start to vomit all the things I know about Dementia. Let me give
you some advice for your father. Please lock unnecessary doors at home and remove lock of
bathroom and toilet. Let him recall the past event to enhance his confidence and you can keep diary
for him in which put the important contact numbers for him.
I will regularly follow him up. Does he have any other sons or daughters? If you want, I can arrange
family meeting and so that they can visit him more frequently and provide emotional support. Then
the bell rang.
Actually, it was station 7 and I even didnt notice it is psych station. I just thought it is just the recall
case of Dementia. Once I arrived station 8, rest station, I just found out that the previous station was
Psych.
AMC: Alzheimer type dementia

5.Case 19 Psychiatry
30 years old male. Presented to ED with a cut injury to his wrist. He is a factory worker doing night
shifts these days. Triage nurse has put a dressing to the wound and got him to see you to discuss his
problems.
Advise him regarding his condition
Answer the questions that the patient might have
? Work shift insomnia (previous recall)
AMC: Insomnia

5.Case 19 Psychiatry
A 25 year-old male had a wrist cut injury by machine at work. The nurse in the rural hospital noticed
that he had some problems. Shes worried about it and send him to you. He passed recent medical
check up for scuba diving.Task relevant history, explain diagnosis and management, answer
questions.
Confedentiality
Why did it happen? He gets sleepy
Is it the first time? Yes
Are you doing night shifts? Yes
How many hours do you need to work for a night?
Can you sleep well after coming back from work? No, I have to look after my kids. And also has
dreams so doesnt get good sleep.
Depression + risk factors assessment
each question for mania, schiz, GAD, PTSD.
Past history of mental illness, medical conditions
SADMA - has 2 kids and wife is working too. Otherwise, a lovely family.
You have injury to your wrist because of lack of sleep. I get thought block to speak Insomnia It is
risk to get self harm at work, accidents, concentration ability and physical appearance.
I forget to mention that we dont need to do medical check up as you had recently. I should have
though.
I will contact to your employer and negotiate with him to change to your roster. I will contact to
social workers to look after your kids. Besides, arrange family meeting so that they will understand
your situation and give support for you. Explain about sleep hygienes. Follow you up regularly.
AMC: Insomnia

6.Case (Monash RP)/Surgery
65 year old man came to ED for abdominal pain with fever. Task- history, PE, Inv and mgt.
DD- diverticulitis, mesenteric ischaemia, appendicitis and others
Haemodynamically stable or not?
Do you need pain killer? Yes . So, will ask the nurse to give you morphine and maxalon.
History
LOTRADIO
Pain near the umbilicus, intermittent but now constant and severe, 8 out of 10, radiated to the
back? , started yesterday or a few days ago
Associated symptoms- just high temperature
Normal bowl and urinary symptoms
History of Cholecystectomy + (cant remember when )
PMH- nil heart problems and generally healthy
SADMA- not significant
I move on PE after 3mins though I dont know what is wrong with him
PE
GA- looks ill
VS- T- 39 , BP and PR normal, RR normal
Sign of dehydration nil
Heart and lungs- NAD
Abdo- superficial tenderness + , Liver 2 cm enlarged
PR- normal
Then , suddently asked for Jaundice examiner said YESSS
Inv
Office tests- urine FWT, BSL
Blood tests- FBE, U&E, LFT, CRP, ESR, Blood culture, Lipase and amylase, ECG, USG abdo , CT abdo,
ERCP, MRCP ( actually I didnt plan to say a wide range of investigations, but examiner keeps asking
me whatelse until ERCP and MRCP.
Question from examiner: what is the diagnosis ? His clinical picture shows Cholangiohepatitis , other
things can be such as.He stopped me and asked me explain to patient.
The condition you have is called cholangiohepatitis. Draw the diagram and explain that the bile duct
and liver gets infection and inflamed.
Plan is
Contact to surg reg
From now on, NBM, IVF, IV analgesia, IV antibiotics
Admit under surgical team after being reviewed by surg reg. They will do the tests that I mentioned
previously.
Reassure that he is under safe hand.
Then the bell rang.
I didnt perform well in that case esp for PE part, I should have asked Jaundice first and then the
stupid thing is I asked for Murphy sign in the clinical setting of previous cholecystectomy
AMC: Jaundice


6.Case (Monash RP)/Surgery
Middle aged women complains of abdominal pain and fever (only a short description outside the
room)
Tasks
Take additional history you require
Ask examination findings from the examiner
Tell the patient your diagnosis and management
Diagnosis? Cholangitis (patient said she had a cholecystectomy before)
AMC: Jaundice


7.Case (paediatrics)-10
Step-Mother of 9 years old complains that he has strange behaviour at school
Tasks
Talk to the mother and ask more information you need
Tell her about your diagnosis and management
Diganosis? Absence seizures? ( I told he has some kind of fit cant remember I mentioned the word
abscence)
AMC: Epilepsy-absence/petit mal

7.Case (paediatrics)-10
GP setting, mother is concerned for 9 year old boy who is daydreaming most of the day time. Task-
History, PE and Management.
DD- Absence seizure, Epilepsy, Hearing & Vision problem, Autism, ADHD, and Social issues.
History
For how long have you noticed this problem?
Did it happen both at home and school?
Daydreaming means stoping doing things, staring for a while and then continue doing as if nothing
happens ? Yes
How long does it last? ( a few secs)
Any abnormal movement ? any LOC? Any head injury?
Any concern about hearing and vision?
Does he play with a particular toy?
Can he concentrate well?
*active/ lethargic, eating well, sleeping well, wee and poo Normal Family history of Epilepsy?
BINDS- Social any problems at home? Performance at school? ( grade is not as good as before) ,
relationship with family members and friends?
PE
GA- normal, Growth Chart- within normal limit
VS- stable
No dysmorphic features,
All the systems including CNS- NAD
Plan
From History and PE, I suspect your child is having a condition called absence seizure which is
common in this age group mainly because of disturbance of electrical impulse in the brain. The
symptoms are the same as what you told me. To confirm my diagnosis and exclude other possible
causes, will refer you to Paediatrician for EEG and order basic blood tests.
Now, also refer the child to specialist for hearing and vision check ( role player is happy with that
sentence )
If absence seizure is confirmed, Paediatrician will give him Ethosuxemide .
I also want to contact school teachers and let them know about your child condition so that they
can take part in his management plan.
5 R
Let me reassure you that it wouldnt have effect on his intellectual , growth and developement.
Referal done
Red flags- if he has abnormal movement, LOC or if you are concerned, come to see me anytime.
I will give you reading materials.
I will follow him up regularly.
Questions from RP-
1.EEG is dangerous procedure? No, it is Non-invasive just like ECG, some electrodes will be put on his
head and the electrical impulse will be recorded on machine.
2. When can Ethoxesumide be stopped?
Depends on EEG result, his symptoms free period and decision of Paediatrician.
I finished this case a bit earlier.
Role player is so helpful and she told me everything including differentials once I ask one question.
AMC: Epilepsy-absence/petit mal



7.Case (paediatrics)-10
GP in rural area, father of 4year old boy came to you because his son refuses to walk and cries a lot.
Task- History, PE , DD and Mgt.

DD- Septic arthritis, OM, Injury ( for acute)
Transient synovitis, SCFE, Osgood ( for chronic )
History
When did he refuse to walk? ( yesterday) , so I go to acute DD
Previously, can he walk properly?
Which side do you think is wrong? ( Lt)
Any temperature? ( high )
Any swollen joint? ( Yea sort of )
Any specific painful point? ( Yes around knee )
Any chance he can get injury? ( No)
Any recent infection in somewhere? ( secondary inf) No
*Lethargic, cant eat well and sleep well, normal wee and poo
Anyone at home sick?
Medications and Allergy
Any concern about his growth and development?
PE
GA- lethargic
Sign of dehydration, growth Chart Normal
VS- T- 39, others not significant
Nil neck stiffness,ENT, Lymph node, Heart + Lungs+ Abdo including hernia orifices- NAD
Gait
Focus on Leg- compared both legs , any sign of inflammation + , any tibial tuberosity tenderness, any
tenderness over joint movements
+
Plan
From history and PE, your son is having OM which is infection of bone or Septic arthritis , infection of
joint. I cant say it definitely without any investigations.
If paediatrician and enough facilities are available in rural hospital , I will refer him to there.
Otherwise, I need to refer him to tertiary hospital via Ambulance.
In hospital, blood tests FBE, CRP, ESR, blood culture, Xray of the joint, USG of the joint, Bone scan
to confirm OM and aspiration of fluid from joint and send it to pathology.
For treatment, IV antibiotic for 7-10 days followed by oral antibiotic for 3 weeks. Paracetamol to
relieve his pain and temperature.
Father is anxious so reassure him that he come in good time and with the effective treatment, he
will recover completely.
Review the boy in the clinic when he is discharged from the hospital.
Ask father that does he need any social worker? No , Thanks
Do you want me to contact to your wife? No, thanks he will ring to her right now.
Finish early as it is recall.
AMC: Septic arthritis

7.Case (paediatrics)-10
You a GP in a small country town and the only doctor who is also oncall for an ED of a small country
hospital. 18 months old girl brought to you by her father. The girl is refusing to walk since yesterday
Tasks
Take relevant history
Ask examination findings from the examiner
Talk to the father about diagnosis and management plan
Dignosis? Septic arthritis
AMC: Septic arthritis


9.Case (Paediatrics)
2 years old child having a left sided neck lump and fever. Mother brought the child to you a GP
Tasks
Take history
Ask examination findings from the examiner
Diagnosis and management plan to the mother
Dignosis ? lymphadenopathy
AMC: infective lyphadenitis

9.Case (Paediatrics)
ED setting, 3 year old baby girl , brought by mom as she noticed painful swelling in her neck. Task-
History, PE, and Mgt.

DD- Lymphadenitis, Lymphoma

History
When did you notice it? ( yesterday)
Is it getting bigger or the same? ( may be bigger and painful)
Does she have temperature? ( yea she looks hot)
Did she have any recent infection ? ( she had kind of sore throat 3-4 days ago which seems to be
improving )
Any running nose, noisy breathing, SoB?
Any lumps or bumps on other part of body? ( No)
How is her weight and appetite? ( normal)
*lethargic, drowsy, not feed well, cant sleep well, wet nappies reduced, poo normal*
Any one at home sick?
Medications, and allergy?
BINDS
PE
GA- looks drowsy, unwell
T- 38.6, others not significant
Neck stiffness- nil
Sign of dehydration- Nil
Nil signs of respiratory distress
ENT- Tympanic membrane bulging, Throat- red and inflamed
One cervical lymph node- 3 cm, tender, inflamed at posterior triangle
Nil other LN Enlargement
Chest, Heart- NAD
Abdo NAD
Nil Rash

Plan
From history and PE, she is having a condition called lymphadenitis which is inflammation of lymph
node due to recent infection she has . It might be caused by bugs or virus. But in her case, I suspect
that it can be bugs because of her clinical symptoms.
Now, contact to Paed Reg and the girl will need admission as she is drowsy. In hospital, blood tests
including FBE, CRP, ESR, blood culture, throat swab, CXR will be done. Antibiotics might be given to
her. Reassure her that the girl will recover completely after proper treatment. When discharge from
hospital, GP will follow her up.
Social workers can help you if you need it.
But role player kept asking me that which tests will be done in the hospital ? I have no idea apart
from the above investigations. Does she want me to say Biopsy ??? ( might be my wild idea) . I am
not happy with my performance though.
AMC: infective lyphadenitis

10.Case (Surgery)
46 years old women presented to you earlier in your GP practice with a lump on upper out quadrant
of her left breast. You organised an ultrasound scan which suggested a suspicious lesion and the
biopsy done by the breast surgeon report came as invasive ductal carcinoma.
Patient is here today to get her biopsy report. Talk to the patient about her report and advise her on
further management plan.
Diagnosis: Breast cancer breaking bad news
AMC: Breast Cancer

10.Case (Surgery)
GP setting, over 50 year old lady came for FNAB result which showed carcinoma of right breast but
no spread. Hormonal receptors positive. Task: explain the report, management plan and answer the
patients questions.
Breaking bad news.
Reassure that there is no spread.
Management Plan
MDP approach with the involvement of surgeon, oncologist, and GP.
Refer to Specialist who will do investigations to know the spread such as CT chest, abdomen, neck
and other blood test to know the general health .
Options
Surgery ( total or partial mastectomy ) with complications and benefits+ lymph node biopsy
RT with complications
CT if spread+ with complications of CT
Tamoxifen but I didnt mention the name just said that medication as hormonal receptor is +

After treatment, regular follow up with Specialist , and me by doing blood tests and imaging scans.
Important to do self breast exam including armpit with detail methods.
Any lump or any changes , come and see me anytime.
Will follow you up regularly.
Do you have any daughters? Yes 2 daughter both are within 20s. So, they have slight increase risk of
having breast cancer. Self breast exam after period. I will see them every year . Once they are over
35 years of age, will do mammogram for them.
Reading materials.
Reassure again.
AMC: Breast Cancer


11.Case (O & G)
65 years old lady presented with bleeding PV after 10 years of Amenorrhoea. Reached menopause
at the age of 55 years.
Tasks:
Take relevant history
Ask examination findings from the examiner
Talk to the patient about your diagnosis and your management.
Diagnosis: Post-menopausal bleeding (endometrial cancer/atrophic vaginitis)
AMC: Post-Menopausal Bleeding

11.Case (O & G)
GP setting, over 50 year old woman came to you as she had vaginal bleeding for 2 days. Pap Smear
was done 2 years ago. Task- History, PE and Mgt.

DD- Ca endometrium, Ca cervix, Atrophic Vaginitis, Polyp, Bleeding disorder
History
As you have bleeding from down below for 2 days, how many pads do you need to change ? ( not
even one in a day , which is more like spotting)
What is the color of the blood? ( bright red)
How is your weight and appetite? ( Normal)
Any lumps or bumps over your body? ( No)
Any bleeding after intercourse? ( I havent been sexually active for a long time )
Do you have any hot flushes, dry vagina? (Vagina might be dry )
Any bleeding from other part of body? ( No)
Do you feel dizzy , heart racing ? ( No)
5 P
Period LMP 5 year ago.
Partner- stable, nil STD before
Pregnancy- have 2 children
Pills / Hormonal treatment- Nil
Pap smear- 2 years ago and normal
Mammogram- a year ago and normal
SADMA

PE
GA- BMI- within normal range
VS- stable , no postural drop
Heart+ lungs- Normal
Abdo- NAD
Vaginal inspection with patients consent- bleeding +, sign of atrophic changes +
Speculum exam- there is active bleeding but not heavy
Bimanual exam- uterine size normal, no cervical motion tenderness
Urine FWT and BSL
Plan
From history and PE, I suspect that you have a condition called atrophic vaginitis due to lack of
female hormone. So, the vaginal wall becomes dry and tends to bleed. But, it is important to rule out
other possible causes such as nasty lesion of the womb, cervix ( neck of the womb) or polyp in the
womb by doing some investigations and imaging scan.
Basic blood tests such as FBE, U&E, LFT, CRP,Hormonal Assay, Blood G&H, USG ( abdo and pelvis).
Now I will refer you to the gynaecologist for hysteroscopy to see any growth or any abnormality in
your womb and if there is any lesion, biopsy will be taken. Now, I will do Pap Smear as it was done in
2 years ago and time to do it again.
Once everything is ruled out and atrophic vaginitis is confirmed, we can give you vaginal cream. To
sit on the safe side, we better undergo the above mentioned investigations.
I will follow you up regularly.
Any concern or questions? Happy with my plan?
AMC: Post-Menopausal Bleeding

12.Case (O& G)
1.A young woman who might be pregnant had recent contact with rubella child and came to your GP
for about it. Task History, PE and Mgt.
Points- to confirm pregnant, to detect Rubella infection, and options for her.
History
RP: As soon as I greet the role player and she told me like that.This morning, she had contact with a
rubella child who was diagnosed by GP. So , she is sure that the child had rubella. As the same time,
she has not had her period for about 8-9 weeks and had symptoms of breast tenderness, nausea and
vomiting esp in the early morning. What a good role player !
Now, do you have temperature, rash, and joint pain? No
Have you had rubella before ? ( cant remember)
Have you had rubella vaccination (dont know)
Her LMP was 8-9 weeks ago, period was irregular
Her pregnancy was the first time and not confirmed yet. She is planning to get pregnant.
Other Ps- not significant
SADMA
PE
GA- well
VS- all are within normal limit
Heart+ lungs- NAD
Abdo- NAD
Rash- Nil
Vaginal Inspection with consent- Nil bleeding, nil discharge
Urine FWT
Urine BhCG is positive
Plan
Congratulations, you get pregnant. Well, we need to do blood tests to detect Ig G and IgM for
rubella infection.
If IgG is positive , it means you have immunity for infection which is good and we dont need to do
anything.
If IgG is negative and IgM is negative too, you need to avoid contact with rubella child. But we need
to check IgM after a few weeks as you had contact with rubella child in this morning.
If IgM is positive , I am sorry that there is high risk of having baby with cataract, nerve deafness and
other congenital abnormalities. In that case, we need to consider to terminate your pregnancy and
will refer you to OG specialist. Show sympathy for these sentences.
But hope for the best. I want to arrange antenatal blood tests for you and you can start taking folic
acid.
I will see you after a few days when the blood results are available.
AMC: Potential Rubella Infection (O & G)

12.Case (O& G)
A young woman in early pregnancy claims that she has exposed to a child with Rubella infection.
Tasks:
Take history
Advise her about your management
Diagnosis: Rubella in early pregnancy
AMC: Potential Rubella Infection (O & G)

13.Case (Medicine)
A Middle aged woman complains of abdominal pain and headache. She thinks that she got flu.
Tasks:
Take history
Ask examination findings from the examiner
Order relevant investigations
(You do not have to talk about your treatment)
Diagnosis: Acute Pyelonephritis
AMC: Fever with Chills

13.Case (Medicine)
Middle age woman to GP for flu like symptoms and feeling unwell.
Task History, PE, Mgt.
DD- Infection( viral or bacterial) including IE, ross river fever, Lymphoma, Malignancy
History
What do you mean flu like symptoms ? Any temperature? Yes
Did you measure it? No
Constant or up and down ? may be constant
Any headache, neck pain ?
Any sore throat, cough?
Any chest pain, SOB, palpitation , any dental or surgical procedure?
Any tummy pain, back pain, vomiting, nausea, diarrhoea?
*Left sided back pain + , and vomited once
Any frequent urination and burning sensation while passing urine? No
Any rash , joint pain ?
Travel to anywhere? No
How is weight and appetite, any lumps or bumps?
PMH- generally healthy
Medications- Nil
Allergy- NKDA
SAD insignificant
PE
GA- looks ill
VS- febrile, Others- stable
No sign of respiratory distress
No neck stiffness and rash
ENT- Nil
Heart + lungs- NAD
Abdo- renal angle tenderness+
PR- NAD
PV- nil bleeding nor discharge
Office tests Urine FWT nitrates+++, leuk +++
BSL- not done yet
Mgt
From history and PE, I think you have a condition called Pyelonephritis which is the infection of
kidney caused by bugs mainly from the back passage. So I need to refer you to the hospital in which
you will be seen by Physician and admitted under them. Will need to do a list of tests such as FBE,
U&E, LFT, CRP, ESR, blood culture, Urine MCS, USG, CT KUB.
For treatment, will be given IV antibiotics for a few days then followed by Oral antibiotics for a few
weeks. Antibiotic will be changed according to culture result.
Analgesia to relieve symptoms.
IVF or have ample amount of fluid.
Will get better with those treatment.
Will be discharged from hospital once your condition improves and IV antibiotics are ceased.
I will follow you up after being discharged from the hospital and will check Urine again 3 weeks after
treatment to make sure that bugs are totally clear.
AMC: Fever with Chills

14 Case: (Medicine)
Middle age women with a five years history of shoulder pain came to you recently with feeling weak.
You did the blood test for that and you have got the results
Hb 8.2% (normal 12-16)
MCV 68 (normal range 76-106 fl)
MCHC also low
Blood film shows hypochromic microcytic red cells
Serum Iron and ferritin also low
Tasks
Explain the results
Take relevant history
Advice about further management
Diagnosis: Fe deficiency anaemia
AMC: Iron-deficiency anaemia

14 Case: (Medicine)
Hypochromic microcytic anaemia , IDA for further management ( Book Case)
AMC: Iron-deficiency anaemia



15.Case (Surgery)
Middle aged woman complains of Pins and Needles sensation in the right hand for few days.
Tasks
Take History
Do relevant examination
Discuss diagnosis and management with the patient
Diagnosis: Carpel Tunnel Syndrome
AMC: Carpal Tunnel Syndrome

15.Case (Surgery)
Carpal Tunnel Syndrome ( Book case but no history )
AMC: Carpal Tunnel Syndrome

16.Case (Medicine)
COPD with Emphysema ( exactly the same as book case)
AMC: COPD


16.Case (Medicine)
55 years old male patient smoker for 30 years stopped 2 years ago. Came to you GP last week you
organise lung function tests. Results given (AMC book case)
Tasks:
Explain the results to the patient
Diagnosis and management to the patient
Answer any questions patient might have
Diagnosis: COPD
AMC: COPD