6

th
April 2013

Station 9
35 y male came to your GP practice with tiredness and fever for several weeks. He is HIV
positive.
Task: Take further history
Management
History:
Current symptoms: tiredness + fever; dry cough; no chest pain, SOB or rashes
System review: no problems with waterworks or bowel movements; reduced appetite; no
weight changes
HIV follow-up: stopped seeing doctor and ceased medication himself six months ago
Sexual history: have a male partner practising all modes of sexual activities (e.g. oral and
anal); use condoms; partner knows about HIV history, no other STDs
SAMAD unremarkable
Management:
Sending patient to hospital to have investigations (e.g. FBC, urine & blood MCS, NGA,
Chest X-ray, viral load, CD4 count)
Dx: atypical pneumonia
DDx: other infections
AMC Feedback: Fever in an immune-compromised patient
Status: PASS

Station 9

25 year-old man who is HIV positive came to see you as he is having some hot and cold
feeling
over a few days.
Task
Take History
Ask physical examination findings from examiner
Management plan.
History.. He is homosexual,diagnosed with HIV over 5 years, not compliance with ART,
misses last
HIV clinic appointment, not know his CD4 status. Having fever with chill and rigor, no
urinary
symptoms, no abdominal pain, dry coughing with SOB on exertion (+) over a week, no
rash.No
other positive finding, aware of safe sex, his partner is fine, allergic to penicillin. No TB
contact, no
recent travelling.
Physical examination: Temperature is over 39'C with 94% SaO2, All other examinations are
normal. No renal angle tenderness, no abnormal breath sound, urine dipstick normal.
Management: I told him that he is most possibly suffering from infection in the lungs which
we
called pneumocystic pneumonia (PCP). For that I will admit you to the hospital. There some
blood
tests (FBE, U&E, ), CXR will be done. To confirm the diagnosis we can take the secretion
from
your pharynx and do PCR. For the infection, we will put you on Cotrimazole which is
antibiotic
orally. If the infection is not responsive, we will change to IV antibiotic.
The most important thing is to take ART as this infection took place as you did not take
antiviral
therapy. Then explain difference between HIV and AIDS and how important the compliance
with
medications is.
He asked me what are the other possible causes. I said there are couples of things like TB,
other
chest infections like Avian Intracellularlae complex.... Bell Rung.
Feedback: Fever in an immuno-compromised patient
Status: PASS

Station 9
A 30 yo male complained of on and off fever. He is HIV positive
Tasks:
Focused history
Findings from examiner
Diagnosis
Management
2 minutes thinking time: rule out all infection from head to toe, most likely atypical
pneumonia. CD4, antiretroviral
Me: Hi Mr X, my name is Z one of the GPs here, nice to meet you. I understand you had
fever on and off for a few weeks. Could you tell me more about it.
RP: I just havent felt well and I have fever on and off.
Me: Any chills? Have you taken any medication for it?
RP: Yes sometimes, only paracetamol
Me: Did you travel recently?
RP: No
Me: Do you have any headaches? Neck Stiffness? Rashes?
RP: No
Me: Did you suffer from any upper respiratory tract infection? Cough or cold?
RP: I have some cough
Me: Is it productive or dry cough
RP: Dry cough
Me: Any chest pain or shortness of breath?
RP: No
Me: Any tummy pain?
RP: No
Me: Any lumps or bumps? Night sweats? Change in body weight?
RP: No
Me: Any changes to your waterwork or bowel motion
RP: No
Me: Could I please do the physical examination: general appearance, vital signs, ENT,
cervical lymphadenopathy, neck stiffness, skin rash, chest, heart, abdomen, pelvic.
E: All normal
Me: Mr X from history and physical examination you are having fever due to an infection in
your body. However, the source of infection is still unknown at the moment. Your physical
examination did not reveal any abnormalities. However, I am it is highly likely that you
might have atypical pneumonia, which is an infection in the lungs. This is because you have
the fever and dry cough. We need to confirm by performing CXR. I would like to perform
some investigations: FBE, ESR, CRP, renal function test, liver function test, thyroid function
test, CD4 count, blood culture, urine MCS, CXR. You will be admitted into the hospital and
iv fluid will be given. I will consult the infectious disease specialist who may start you on
antibiotics and also antiretroviral therapy.
RP: I took antiretroviral therapy before but stopped taking a few months ago.
Me: So we will check your CD4 count and most likely you have to start the antiretroviral
therapy again
AMC Feedback: Fever in immune-compromised patient
Status: Failed

Station 10
Book case Condition 76 APSGN
History.. the child has got skin rash on his cheek 2 weeks ago, it improve by itself without
any
medications.
Feedback: Haematuria in a child
Status: PASS

Station 10
6 y old came with mother to your GP clinic because of dark urine.
Task: History taking
Ask for PE
Management
History:
Current symptoms: dark urine + reduced urine output; no complaint of burning sensation; no
oedema
Other symptoms: no fever, cough, sore throat, or joint pain
System review: Had impetigo 2 weeks ago, self medication with topical lotion with good
effect; no pain anywhere; normal bowel motions; BIND normal, one sister at home who had
impetigo as well and was treated the same way
Social history: parents coping well
PE:
Normal looking child with no rashes or sores. Normal growth chart. BP 116/90 (the examiner
gave something wrong at first then corrected by the role player), otherwise normal.
Remaining physical examination is unremarkable.
Urine dipstick: RBCs+, WBCs+, protein+, no signs of infection (specifically said by
examiner)
Management:
Send patient to hospital for further investigations (e.g. anti-streptolysin-0-titre and ESR) and
treatment (e.g. antibiotics and general supportive therapy); Monitor BP and urine output, use
antihypertensive medication if BP high and diuretics if swelling and hypertension; Dietary
salt and fluid restriction may be necessary.

Ask about another childs condition. Ask mum bring another child to see doctor if similar
condition happens.

AMC Feedback: Haematuria in a child (Paediatrics)

Status: PASS


Station 10
A father brought his child to the GP because of darkening of urine.
Tasks:
Focused history
Physical examination
Diagnosis and management
Me: Hi Mr X, my name is Z one of the GPs here. I understand your daughter has darkening
of her urine. Can you tell me more about it.
RP: I noticed that since 2-3 days ago her urine is darkening in colour, almost like coke.
Me: Is this the first time?
RP: Yes
Me: Any trauma to the tummy or private area?
RP: No
Me: Any bleeding from anywhere in the body? Nose bleed, gum bleeding, bleeding from the
back passage?
RP: No
Me: Does your child cry when passing urine?
RP: No
Me: Any change to the smell of her urine
RP: No smell
Me: Any decrease in volume of urine or the number of time she goes to the toilet?
RP: No
Me: Any swelling of her face, around the eyes, hands or legs?
RP: Yes, some swelling on the face and legs
Me: Any fever?
RP: No
Me: Any recent upper respiratory infection?
RP: No
Me: Any skin rash?
RP: She had some skin rash around her mouth a few weeks ago.
Me: Did you visit the doctor to receive any treatment
RP: No, it cleared up on its own
Me: Any past history of medical or surgical conditions that I should be aware of?
RP: No
Me: Any family history of kidney problems, heart problems, bleeding problems?
RP: No
Me: Asked BINDS
RP: Normal
Me: Any allergy to medication
RP: No
Me: Could I please ask for physical examination findings. Could I get the general appearance
of the child? Are there any signs of dehydration, oedema, skin rash?
E: Child is not dehydrated, there is swelling on the face and extremities. No skin rash.
Me: Vital signs please, BP sitting and standing, pulse, temperature, respiratory and oxygen
saturation
E: BP 140/90, the rest are normal.
Me: I would like to examine the ear, nose and throat for any signs of inflammation
E: Normal
Me: Any cervical lymphadenopathy?
E: Normal
Me: Examine the chest and heart
E: Normal
Me: Abdomen for any distension, organomegaly, tenderness
E: Normal
Me: Urine dipstick, blood sugar level
E: Positive for protein and blood
Me: Mr X, from history and physical examination, your child is mostly likely having a
condition called post streptococcal glomerulonephritis. Have you ever heard about it? This
condition is most likely caused by the skin rash that she had a few weeks ago. The bugs on
the skin called streptococcus may have entered her blood stream. Her body produces
antibodies towards the bug, forming a complex. These substances are then deposited in the
kidney, causing damage of her kidneys. Therefore, some of the protein and red blood cells are
leaking from her kidney, causing the changes in her urine colour. I would like to admit your
child to the hospital immediately where she will be seen by the nephrologist. Further
investigations will be performed to confirm the diagnosis: FBE, Urea and electrolyte, C3, C4,
Albumin, ASTO, DNAse B, cholesterol level, abdominal usg. In the hospital, your child will
be given intravenous fluids, antibiotics, and medication to decrease her blood pressure and
reduce fluid from her body. Her vital signs, body weight and fluid balance will be monitored
closely. She will be placed on a special diet with low salt and low protein. In the future, your
child has to come back to monitor her blood pressure and kidney functions.
AMC Feedback: Haematuria in a child ( Paediatrics)
Status: PASS

Station 11

55 y female came with itchiness around private area. Picture provided.

Task: History taking
Explain the picture to examiner
Management

History:

Current symptoms: itchiness last for several weeks + first time; no abdo pain, discharge or
bleeding

5Ps: not sexually active; no previous STD; recent onset menopause with previous regular
periods; no OCP or HRT; (cannot remember how many children)

System review: normal waterworks & bowel movements; good appetite; no weight loss

No history of any chronic medical problems or surgical/gynaecological procedures; no family
history; SAMAD unremarkable

Explain to examiner about the picture

Management:

Told patient the most likely diagnosis is Lichen Sclerosus. Explained what is Lichen
Sclerosus inflammatory change of unknown causes, could be autoimmue. Lichen sclerosus
should be treated aggressively to avoid scarring which is irreversible once happens.
Treatment is daily topical corticosteroid cream application; regular follow-up review to
monitor the side effects caused by steroids and cancer.

AMC Feedback: Vulval itch

Status: PASS

Station 11

A 68 YO female came to your GP clinic complaining of rash with severe itchiness down
below
for the past 2 years. You will be shown a photo by the examiner.
Tasks: Take history,Describe the rash in the photo to your examiner. Proceed
accordingly(Management).
History---- She has been suffering this condition for 2 years. She has tried Oestrogen cream
but
it did not help. No feature of history, no menopausal features, no dyspareunia. Pap smear
recently
done and it was normal. She has 3 kids.
Physical Exam...Scaly lesions on labia majora..., no sings of infection, atrophic features(+)
Other system examinations are normal.
Explanation....It is a kind of dermatitis quite common in your age. It is known as lichen
sclerosis.
I will give you hydrocortisone cream which will be very helpful, and for the itchiness, I can
give
you antihistamine. But we do have very important issue to be addressed. That is you need to
be
reviewed by a gynaecologist, to take a small piece of t/s from it to rule out cancer because
sometime
it could be a precursor lesion of Ca Vulva. I do not mean that you will have cancer but we
just make
sure that it is not cancer. R u happy with this? .
AMC Feedback : Vulva Itch

Status: PASS


Station 11

60 years old female came to GP because of itchiness in her vulva for 2 years
Tasks:
History
Picture will be given by examiner
Management
2 minutes thinking time: lichen sclerosis, vulval cancer, dermatitis
Me: Good morning Mrs X, my name is Z, one of the GPs here. I understand you have some
itching in your private area, could you tell me more about it.
RP: Doctor, I have had this itching for a long time and its getting worse
Me: Did you apply any lotion or perfume to the area?
RP: No
Me: Any bleeding?
RP: Sometimes it bleeds if I scratch it, sometimes a bit of skin comes off
Me: Any pus or fluid coming out? Any smell?
RP: No
Me: Any lumps and bumps? Any change in body weight? Any night sweat?
RP: No
Me: Any other skin lesions on your body? Ulcers?
RP: No
Me: Any past history of diabetes, medical or surgical condition?
RP: No
Me: Are you still sexually active? Any problems during intercourse?
RP: Yes, no
Me: May I know when was your last menstrual period? Did you take any HRT? Any bleeding
after that?
RP: Many years ago, had hot flushes and was given HRT for a while. No bleeding
Me: Are you regular with your pap smear? When was the last one and what was the result?
RP: Yes, normal.
Me: SADMA
RP: not significant
Me: Any family history of any cancers?
RP: No
Me: Could I please examine the patient. The examiner gave the picture of lichen sclerosis.
Mrs X, from the history and physical examination, I think you are having a condition called
lichen sclerosis. I pointed to the picture. These whitish areas are thickened and its the itchy
area. And there are some bleeding and scratch marks here due to the scratching. Mrs X, I
would like to confirm the diagnosis and rule out nasty growths in the vulva by performing a
biopsy of these whitish areas. I would also perform blood sugar level to exclude diabetes.
RP: What is causing this doctor?
Me: The cause of lichen sclerosis is unknown. It could be due to an autoimmune condition, in
which your own bodys immune system starts attacking your own body parts. It could also be
genetic, which means its passed down in your family. I would prescribe you some steroid
cream that you have to use for quite a long period of time. Its applied twice a day for a
month, then once a day for a month, then twice weekly for a few months and later tapered
down slowly. Please use loose cotton underwear and try to avoid scratching the area. Please
also maintain good hygiene by wiping / washing from front to back. I will give you some
reading material. Please come back for a review in a week time to monitor your progress. If
the condition gets worse or there is a lot of bleeding please come back and I will refer you to
the specialist.
AMC Feedback: Vulval itch
Status: PASS

Station 12

A 56 years old lady who fell on her outstretched right arm and is experiencing pain. AP and
lateral x rays were performed. ED setting.
Tasks:
Explain X ray to patient
Management
Me: Hi Mrs X, my name is Z one of the intern here. Are you currently in pain? Would you
like me to arrange some painkiller for you?
RP: They have already given me painkiller doctor.
Me: I used the X- ray to explain to her. Mrs X I have the results of your x ray here with me. It
appears that you have fractured your arm. As you can see here, there is a discontinuity in the
contour of your bone. This means that there is a facture in the radial bone of your right arm
and its known as a colles fracture. Have you ever heard about it? I will consult the
orthopaedic specialist for management. Most likely, a regional / local anaesthetic block will
be performed to numb the lower part of your right arm. And manipulation will be done by
performing traction of your hand, this is done by slight pulling of your hand. Later your right
arm will be placed in a cast. (While I explained, I demonstrated using my own hand. I
showed the final position of the hand in a cast using my own hand. I did this because the task
was explain to the patient and thought this was the most effective way for the patient to
understand.) The cast will begin from below the elbow till the base of the fingers and it will
not include the thumb. (Full ulnar deviation, slight flexion and full pronation not including
the thumb). Your arm will be placed in a sling too to support your arm. You can remove the
sling at night and place the arm on top of a pillow to prevent any swelling. Please come back
for a review in 24 hours to check on your arm. If at any time you have lost of sensation of
your fingers or tingling sensation, excessive swelling, blue discolouration of your fingers
please come back to the ED. You will be given painkillers as well. I will give you some
reading materials. Do you have any questions for me?
E: When is the patient supposed to come back?
Me: in 24 hours. Then the examiner went back to sleep.
AMC Feedback: Colles fracture of the wrist
Status: PASS

Station 12

A 60 y female came to ED because of the painful right wrist. Patient had a fall at home and
she tried to protect herself by putting her right arm and hand out, softening the fall. X-ray of
wrist has been taken and showed fracture.

Task: Explain the X-ray to patient
Talking about the management

Firstly, I expressed my sympathy to my patient and asked about pain and any need of
painrelief. Then I explained the X-ray to my patient. (There is a picture of X-ray provided,
very straightforward.)

Management:

Reassure the patient this type of fracture has good prognosis with appropriate treatment.
Reduction under general anaesthesia. The hand is going to be hold in a specific position, then
a cast will be put on from knuckles to below the elbow. The arm is immobilized in a sling but
the patient is encouraged to move her fingers and shoulder regularly as well as later the elbow
to avoid stiffness in the long run. Emphasised that she needs to come back immediately if
there are any signs of increasing pain or swelling, tightness, cold fingers or colour change etc.
Otherwise come back 24 hours later to check the cast make sure not too tight.
Referral to fracture clinic and review in one week.
The plaster can be removed after 5-6 weeks and if the fracture is clinically stable and not
tender the patient can start to mobilize. The patient can be referred to see physio afterwards.

Role player asked: How can you make sure the bone heals?
I answered: I can arrange another X-ray to confirm it. But usually its not necessary.

Examiner: If patient doesnt like needles, how would you give the anaesthesia?
I answered: I could give local anaesthesia spay.

Still have time. I mentioned that this type of fracture at this age usually indicate patient could
have osteoporosis. The patient needs to see local doctor for further assessment like bone
density scan and needs advice about diet, exercise and fall prevention. Role player asked me
to tell her a bit about diet.

AMC feedback: Colles fracture of the wrist

Status: PASS

Station 12
68 year-old lady fell on her right outstretched hand and got the pain and swelling on her right
wrist. She visited you in ED and X rays has been done. ( X rays picture was given)
Task
(a) Explain the finding of X rays to the patient.
(b) Discuss your follow up and management plan with patient.
Fracture on the distal end of right radius and angulation with posterior displacement and
impaction and this is also called colle's fracture. Examiner asked me what else I see in the X
rays. I
did not see anything else and carpal bones are intact. So I said I dont see anything else and I
could
not see carpal bones clearly. It is probably due to poor quality of photo. (After exam I
imagine if
there might be osteoprotic feature in that)
Then I told her that I am going to discuss with orthopaedic registrar. He might come and
assess
you then will do reduction under anaesthesia (Short GA) and put the plaster on. Examiner
asked
how far POP goes.I said from metacarpophalgeal joint to below elbow in semi prone position
and
arm sling.
Then I said we will do recheck X rays and she have to be followed up by a GP or me in 24hrs.
But
if she experience pain, colour changes, numbness..... , come back here. We need to remove
the
plaster... Then I mention physiotherapy..... and she will stay with that for 4 to 6 weeks
depending on
her condition. If it is not healed until that time, she might be staying with that up to 8 weeks
or
longer.
I also mention about osteoprosis(Thinning of the bones) and ask her when she got to
menopause
and if she got HRT. She said no. Then I said there might be osteprosis and she might get
DEXA
scan done. If she has Osteoprosis, she may get bisphosphonate and encourage her to eat more
calcium, Vit D, do more exercise, sun exposure....
AMC Feedback: Colles fracture of the wrist
Status: PASS

Station 13
Rest station

Station 14

Comatose patient, book case. Please read the case.
Tasks:
Check GCS
Differential diagnosis
Investigations
GCS: I applied pressure on the patients fingernail. The patient opened her eyes, said shit and
brushed my hand away with the left hand. Count according to the GCS chart given
The only positive finding: Neck Stiffness
The examiner asked me what physical examination to perform for a patient who is in a deep
coma. I didnt know and he kindly volunteered the answer. He told me to check tone for
rigidity and I did that for the upper extremities and he said thats fine.
AMC Feedback: Coma
Status: PASS

Station 14
Book Case Condition 44... Assessment of a comatose patient
Positive findings GCS 8 to 9, neck stiffness, increase tone and knee reflex on right lower
limb.
AMC Feedback: Coma
Status: PASS

Station 14

Coma --same as handbook

AMC feedback: Coma

Status: PASS

Station 15
Middle aged female complaining of tiredness. She is on long term dialysis. A very long stem.
ECG was given (hyperkalemia). She was on a long list of medication
Tasks:
Explain ECG to patient
History
Ask for investigation findings and management
Me: I would like to ask if my patient is hemodynamically stable
E: Yes, you may proceed
Me: Good morning Mrs X, my name is Z one of the doctors here. I have your ECG results
with me, before explaining may I ask you some questions. When was your last hemodialysis?
RP: 3 days ago
Me: Did you take your medications on time? Any chance you may have taken extra doses or
forgotten? Taken other over the counter medications on your own?
RP: yes, no, no
Me: Did you have a recent upper respiratory infection? Fever? Chest pain? SOB?
RP: No
Me: Any swelling on any part of your body?
RP: No
Me: Any changes or decrease in the volume of your urine?
RP: Yes, decreased
Me: Any nausea or vomiting?
RP: I feel nauseated but no vomiting
Me: Do you feel more sleepy or changes in consciousness?
RP: No
Me: Any weather preference? Tremors?
RP: No
Me: Could I ask for some investigations: urea and electrolyte, creatinine, glomerular filtration
rate, FBE
E: hyperkalemia - 7, elevated urea and creatinine, others not provided
Me: Mrs X, your ECG result shows some changes that indicates hyperkalemia. It can be seen
by the tall T waves (I pointed on the ECG and showed the patient). This is further confirmed
by the blood results as well. Hyperkalemia means that potassium or a certain minerals in your
blood that are usually removed from the body or balanced by the kidneys are retained in the
body. This is because your kidneys are not functioning as it should be. Your renal function
tests also show some abnormality. Your tiredness is mostly due to the hyperkalemia and you
might be having an acute on chronic exacerbation of renal failure or worsening of your
chronic renal failure condition. This is a medical emergency therefore we need to admit you
into the hospital. I will consult the nephrologist for confirmation of diagnosis and
management. (I actually forgot to say calcium gluconas!!!!) Most probably you will have to
undergo an immediate hemodialysis because the potassium level is too high. In the mean time
you will be given insulin with glucose infusion and sodium bicarbonate to decrease the
potassium level in your blood. IV lines will be inserted. Your fluid intake and output will be
monitored closely together with your body weight. The specialist will review the medication
that you are taking and may decide to change them.
AMC Feedback: Hyperkalaemia in ESRD
Status: PASS

Station 15
You are HMO in ED of a rural hospital. A 50 year old lady who is on dialysis came and
visited
you for the complaint of palpitation. Heart rate is 75. The picture of ECG has been shown
(Ventricular Tachycardia). (Long stem)
Your Tasks,
(1)Describe ECG finding to examiner.
(2)Take focused history not more than 3 mins.
(3)Ask investigation from examiner.
(4)Explain your management plan to the patient.
Examiner is Prof John Mutagh. I asked him if my patient was thermodynamically stable or
not.
He said her vitals were given in the stem. (Actually only HR was mentioned which is 75) and
asked
me to proceed...
I said wide complex QRS complex with regular heart beat. It is Ventricular tachycardia.
History... getting dialysis once 3 days. Her due is tomorrow. She is not feeling well and
palpitated
since yesterday. No fainting, no dizziness, no chest pain,...., no fever.... Getting dialysis over
3
years.... taking meds... (a list of medications was shown by the patient)
When I asked FBE ( normocytic normochromic anaemia), BSL normal , U&E ( K+ 7.2, low
Na,
high creatine and urea ) Mg and Ca not done yet...
Then I told the patient that her potassium level is very night now and it is affecting her heart.
So
her heart is beating abnormally and it is known as VT. It is a serious condition and it can lead
to a
crisis. So you will be under our observation and put on cardia mornitor. To protect your heart,
we
will give you IV calcium glucoronate. To lower K+ level, we will give you Insulin and
glucose, Neb
Ventolin and resin to decrease K+ absorption from your bowel.
The most important thing we need to do is urgent dialysis. We will refer you to nearest
hospital
which has dialysis facilities. She asked me if she can go and drive there. I said no and we will
arrange ambulance urgently to transfer her to do dialysis. .
AMC Feedback: Hyperkalaemia in ESRD
Status:PASS

Station 15

70 y female with known history of chronic renal failure came with malaise and tiredness. You
are HMO emergency in a rural hospital. There is an ECG provided.

Task: Explain ECG to the patient
History taking
Ask for PE and Ix
Mx

ECG: peak T wave, prolonged PR intervals

Patient was on several medications (a list of meds). IxK: 7 mmols/l, creatinine and urea
slightly high

Told patient the diagnosis is hyperkalemia which means the potassium, one of the electrolytes
in blood, lever is high. Asked patient to stop all the medication herself and will admit her and
give her IV fluids, calcium (to protect heart), glucose and insulin (to reduce the K level);
monitor her condition and recheck K, if cannot be treated well need to transfer patient to
tertiary hospital coz dont have dialysis facility here.

AMC feedback: Hyperkalaemia in ESRD

Status: PASS

Station 16
You are in GP and a 5 year-old boy who recently complain of having frequent urination and
bed
wetting. He is well dehydrated and no other special complaints. Urine dipstick showed
5+glucose,
and 2+Ketone. BSL 23 mmol/dl.
Tasks
Explain the condition of the child to the father.
Answer his father's question.
Explain about your management plan for him.
Explanation... No special history, no fever, no vomitting, child is well. I explained that your
son
has a condition called Diabetes and asked him how much he knew about DM. He said no.
Then I
told him that in our body, pancreas secret a hormone called insulin to keep blood sugar level
normal
in the blood. In your son case, insulin is not secreted enough to control blood sugar level
that's why
his BSL is very high and the cells cannot use sugar. So the cells used other things like fat and
ketone
is excreted as a by product. As a result, we have found glucose and ketones in his urine. That
ketone
can damage his body organ. Father asked me what is the reason. I said we don't know
definitely yet
and probably his body produce a chemical called antibody to attack the cells in pancreas
which
produce insulin.
Regarding Management, I will refer him to hospital, we need admission. He will be treated
by
paediatricians and they will take the blood for FBE, U&E, BSL,.... Now he might have
electrolyte
imbalance that need to be urgently corrected by giving him IV fluid. The most important
thing is to
lower his glucose level, we will give him IV insulin. Once condition is settled down we will
give
him SC insulin. Sometime he might also have infections in his body with this condition. So
we
might need to take blood or urine culture.... and treat it.
For long term, he will need insulin life long to control his sugar, normally two time a day by
giving
SC. When he is discharge the doctors from hospital will teach you how to give insulin SC. To
monitor his sugar level he might need to do BSL testing 3 to 4 times a day. Be also aware of
hypoglycaemia then the bell rung.
AMC Feedback: Newly diagnosed child diabetes mellitus
Status: PASS

Station 16
5 years old boy admitted into the hospital because of tiredness, vomiting and feeling unwell.
BSL is very high and urine ketones ++. Modified book case.
Tasks
Talk to father
Immediate and long term management
2 minutes thinking time: Explain about DKA and management, explain about DM just like in
book
Me: Good morning Mr x, my name is Z one of the doctors here. I am here to explain about
your sons condition. Let me assure you that his condition is stable now and we are taking
good care of him. Your son is suffering from one of the complications of diabetes called
diabetic ketoacidosis. Have you ever heard about this?
RP: I have heard about diabetes but not the other one you mentioned.
Me: Mr X, the balance of glucose in our body is controlled by a hormone called insulin,
which is produced by a gland called the pancreas. This gland is located below the stomach.
There are 2 types of diabetes. In type 1 there is a lack of production of insulin, in type 2 the
insulin is produced but it is not enough. Your son is suffering from type 1 diabetes and
because of this he will need lifelong replacement of insulin. At the moment, to manage
diabetic ketoacidosis, IV lines will be inserted and IV fluids given. This is done to replace the
fluid lost by the body. After replacing the fluid, insulin will be given to manage the condition.
This will be done in consultation with the endocrinologist.
RP: So who is going to give him the insulin?
Me: Mr X, I will refer you to the diabetic educator, who will teach you and your partner to
administer the insulin injections for your child
RP: I dont think I can do that
Me: Mr X, I understand that it may be difficult for you and your partner in the beginning. Let
me assure that there is a lot of support for you. The diabetic educator and nurses may do
home visits to teach you how to do it so that you can gain more confidence. In addition, you
will have to check your sons BSL at least 3-4 times a day. This is done using the glucometer,
which needs a small prick of the finger to measure the sugar level. The educator will teach
you how to do it. Please maintain a book to record all his BSL readings and insulin regimen. I
will also provide you with 3 copies of the hypoglycaemia action plan that you have to carry
everywhere you go and give copies to his school or child care. If at any time your sons BSL
is low, he is not feeling well, nauseous, vomiting, shaking please give him 6 jelly beans. If his
condition does not improve please give him a full meal. If he still does not improve or loses
consciousness please give him a shot of the glucagon injection.
RP: What about his future and sports?
Me: Mr X, the aim is to provide your son with a life that is as normal as possible. We
encourage for him to take active participation in sports and school activities. However, with
sports it is best to stay away from dangerous sports such as rock climbing, diving. If he wants
to swim, it has to be monitored. And his insulin regimen may need to be modified. We also
encourage him to join in school camps or sleepover. You can volunteer to help in the school
camp or usually there is a trained teacher or nurse who attends the camp as well. Let me
assure you that your sons condition is manageable and there will be a lot of support. I will
give you reading material and provide you contact of support groups.
AMC Feedback: Newly diagnosed child diabetes mellitus
Status: PASS


Station 16

6 y boy brought to hospital by his father because of thirsty, tiredness and frequent urination.
Urine dipstick showed sugar++, ketone++.

Task: Explain the diagnosis of diabetes to parent
Answer parents questions

This seems to be a very easy station, but I feel a bit hard to me as I didnt know whether I
should say its only type 1 diabetes or ketoacidosis. I explained what are type 1 diabetes and
ketoacidosis . The role player kept asking me whether it is ketoacidosis or not. I asked
examiner is there any other test results available like ABGs. The Examiner said no. So I
mentioned it is hard for me to say it is or not at this stage because I dont have enough
evidence. Ketone in the urine dipstick could indicate ketoacidosis but also could be the sign
of dehydration. I will arrange further blood test to rule in or out. However, usually type 1
diabetic patient usually present to hospital with ketoacidosis. The role player asked me
questions similar to the book case (e.g. sleepover and exercises)

AMC feedback: Newly diagnosed child diabetes mellitus

Status: FAIL

I dont know why I failed, but I noticed that the role player was not happy at that time.


Station 17

40 y female came with upper abdo pain.

Task: History
Ask PE
Dx and DDx
Ix

History:

Current History: Upper middle tummy pain; severity 5-6/10, dont need any pain relief; pain
doesnt travel anywhere; no fever, SOB, vomiting or diarrhea

System review: normal waterworks and bowel motions; good appetite; no weight loss

Past History: had gall stone before but this times pain is different; had back pain several
weeks ago treated with Nurofen for two weeks

SAMAD unremarkable

PE:

Unremarkable

Dx: Peptic ulcer

DDx: Gall bladder stone, pancreatitis, AMI, Pneumonia

Ix: FBC, U&E, ESR, CRP, Amylase. Lipase, chest/ abdo X ray, abdo U/S, endoscope

Questions:

Role player: What is Endoscope?

I answered: The one you are gonna have is called gastroscope. Its a flexible tube with
camera on the top of it. The specialist is going to do it for you. The tube is going to be
inserted from your mouth to have a look at your stomach. Peptic ulcer can be confirmed by
doing it. If see anything suspicious, we are going to do biopsy, which means taking a small
pieces of tissue out and send for lab exam to rule in or out the cancer.

AMC feedback: Gallstones or Peptic Ulcer

Status: PASS

Station 17
A middle aged female came with upper abdominal pain. She presented to the ED a few weeks
ago with similar pain. USG was performed and gallstone was detected. Her symptoms
subsided. Today, the pain returned and she is back in the ED.
Tasks:
Take further focused history
Explain differential diagnosis and possible diagnosis to patient
Order investigations
Management
2 min thinking time: differentials of upper abdominal pain gallstone, choledocholithiasis,
peptic ulcer, basal pneumonia, cardiac problems, cholangiocarcinoma, pancreatic cancer
Me: Hi Mrs X, I understand you are having upper abdominal pain, could you tell me more
about it please.
RP: I have been experiencing this pain for a couple of weeks
Me: Could you kindly point out the exact location of the pain
RP: points to epigastric region
Me: does the pain run to any other location?
RP: no, its just in the area she pointed to
Me: could you describe the type of pain, is it sharp, constricting, burning?
RP: its like a burning sensation
Me: from the scale of 0 to 10, 0 being no pain and 10 the worse pain, how would you grade
the pain? Would you like me to arrange some painkiller?
RP: 4/10, no thank you I am fine.
Me: is the pain associated with nausea, vomiting, fever, chest pain, yellow discolouration of
the skin? (These questions were asked separately)
RP: no
Me: any changes to your waterworks or bowel motion?
RP: no
Me: any loss of body weight? Lumps or bumps? Night sweats?
RP: no
Me: any past history of medical or surgical conditions that I should be aware of?
RP: no
Me: Do you smoke? Drink alcohol? Ever tried illicit drugs before?
RP: I smoke 10 cigarettes a day for 10 years.
Me: If it is ok with you, I would like to arrange another consultation to discuss about your
smoking. Is that ok?
RP: yes doctor
Me: Are you currently on any medication or pills? Any allergies to medication?
RP: I am taking ibuprofen for the back pain that I have, I started taking them about a week
ago. No allergies
Me: Mrs x, from history I have a few possible diagnosis in my mind. However, the most
likely is a peptic ulcer due to the intake of ibuprofen. Other possible diagnoses are gallstones,
stones in the bile ducts, very less likely would be nasty growths. In order to confirm the
diagnosis I have to arrange some investigations for you. I would like to order abdominal
ultrasound, urea breath test to detect H. pylori infection. Peptic ulcer maybe caused by an
infection by H.pylori. If the test is negative for the bug, you will be started on a 4 weeks
course of proton pump inhibitor. This medication is to decrease the secretion of acid in your
tummy. If H.pylori is positive, you will be started on triple therapy which consist of 2
antibiotics and the ppi. In the mean time, please stop taking ibuprofen, you can take panadol
for your back pain. If the medication does not help your symptoms, I will refer you to the
gastroenterologist, who will perform an upper gastrointestinal endoscopy. That is inserting a
scope / camera from your mouth to see the inner side of your tummy. If there are ulcers,
biopsy which is taking a small tissue will be done for further investigations. I will give you
some reading material. Please come back for a review in about 2 weeks. If at any time the
pain worsens, you experience bloody vomit, changes in your stool colour please come back to
the ED as soon as possible. Thank you.
AMC Feedback: Gallstones or Peptic Ulcer
Status: PASS

Station 17
A 45 year old patient visited your GP clinic complaining of upper abdominal pain. He was
recently discharged from ED where he was treated for abdominal pain and USS showed gall
stones.
Now he is suffering from increasing abdominal pain.
Task.
History
Physical Examination
Management
History... pain is 4-5/10, in epigastrium, radiate to back, no nausea and vomiting, no fever, no
jaundice, no urinary problem, no change in colour of urine and stool, no itchiness, no wt loss,
no
appetite change, .. smoking about 15 cigarettes for 20 years, taking Ibuprofen for back
pain ..
PE . All finding are normal
Management... I said it is probably due to PUD(Gastritis or ulcer in the stomach) although he
has
got gall stone. The reason is he is taking Ibuprofen which has irritation effect on stomach.
Smoking
is also associated with this condition.
For this, I will give you a prescription of PPI and Mylenta The most important he should
do it to
stop taking Ibuprofen. I also encourage you to consider to quite smoking and I am here to
help you
for that we can discuss later about that. I will also organise some Investigations to rule out
some
other causes. We will do FBE, LFT, U&E and USS abdomen to rule out gall bladder
causes,
ECG to rule out heart attack and OGS scope and H pylori test to confirm the diagnosis.
Depending
on the result he might need to take antibiotics. ...
AMC Feedback: Gallstones or Peptic Ulcer
Status: PASS

Station 18
Rest station

Station 19
A long task about a PHD student who was asked by his professor to see you because he was
concerned. The student recently changed his thesis from physics quantum theory to one about
orgasm.
Tasks:
Take a psychiatric history
Explain possible cause of his condition
2 min thinking time: mania case, ask about risky behaviours and SAD MA. DD: drug induced
psychosis, bipolar disorder
Me: Hi X, nice to meet you. Thank you for coming to see me. I understand that you changed
your thesis recently, could you tell me more about it.
RP: Throughout the 8 min the rp was very excited, speaking really fast, and standing up at
times and looking at his hp saying that he has to leave soon. He spoke for quite a bit about
his new thesis.
Me: Could you tell me hows your mood?
RP: I feel great doctor, full of energy.
Me: any time when your mood is low?
RP: no doctor, I am feeling great
Me: how about your sleep? How many hours do you usually sleep?
RP: I dont really have to sleep much, I am so full of energy
Me: how about your appetite?
RP: my appetite is good
Me: Any change to your body weight?
RP: no doctor
Me: Do you think that life is still worth living?
RP: of course doctor, life is great!
Me: Have you ever thought about harming yourself or others?
RP: no doctor
Me: have you ever seen / heard / felt things that others cant? Any strange experiences? Do
you have special powers? Do you think someone wants to harm you? Have you ever had
thoughts inserted or taken out of your head? Do you think the radio / tv is talking about you
RP: no
Me: X, Im going to ask some sensitive questions, is that ok? I would like to assure you that
everything we talk about will remain confidential between you and I unless I think that you
are in danger, others are in danger because of you or I have to give a statement in court.
RP: yes, sure
Me: Do you smoke? Drink alcohol? Tried illicit drugs?
RP: I dont smoke. I drink about half a bottle of wine every day. I dont do drugs.
Me: are you sexually active? Do you practice safe sex with the use of condoms?
RP: yes doctor, I go out every night and sleep with different girls. Its for my thesis doctor, its
really exciting. I dont use condom.
Me: Do you spend a lot of money? Do you gamble?
RP: yes, I spend a lot of money. But thats all for research. I dont gamble.
Me: have you ever been involved in a MVA or gotten into trouble with the authorities?
RP: no
Me: Do you have a past history of psychiatric condition? Have you ever seen the psychiatrist
before? Any family history of psychiatric condition?
RP: no
Me: X, from the history I think you are having a condition called mania, have you ever heard
about it? Mania is a condition in which your mood is really high, you are full of energy and
requires very little sleep. I am concerned about you because of some behaviours that are risky
to you and others. You are currently drinking more than the safe limit, having unprotected
sex which exposes you to potential STI, you are also spending a lot of money on your
research. I would like to refer you to a psychiatrist for confirmation of my diagnosis and
management. You most probably have to be admitted into the hospital and given some mood
stabilizer for your condition. In the hospital, investigations will be done to confirm the
diagnosis and to rule out other causes such as drug psychosis and bipolar disorder. Your
condition could be because you are under a lot of stress, drug induced or due to an underlying
organic condition. Would you like me to contact any family members or friends? In the future
please limit your alcohol intake to the safe limit and have safe sex with the use of condom.
AMC Feedback: Acute Mania
Status: PASS


Station 19

28 y male PHD student changed his research project to Orgasm.

Task: History taking
Tell the patient your diagnosis and reasons behind it
Mx

History:

Patient volunteered that several weeks ago he realized his interest is to study in the topic of
Orgasm. He claimed that he went to Pubs to find young girls to have unprotected causal sexes
for study purpose. He doesnt need sleep and feel great. He spent a lot more than he could
afford. No suicidal or homicidal ideations. No delusions or hallucinations. No insight.
Cognition and judgment are intact. Lives with wife and feels wife couldnt understand his
research regarding Orgasm. No past or family history of mental problems. Not using
cigarette, alcohol or recreational drugs.

Mx:

I mentioned to patient I was going to admit him to the hospital. If he doesnt agree, I am
going to involuntarily admit him because he has mania and has no insight. With appropriate
treatment, it can be controlled. Now I need to arrange ambulance and send him to the
psychiatric ward and the psychiatrist is going to further assess him and take good care of him.

AMC Feedback: Acute mania

Status: PASS

Station 19
27 years old PhD mathematics student changed her thesis title from 'formula.... ' to '
organism.....'. Her supervisor sent her to be assessed..... ( long stem) She does not have past
psychiatric illnesses.
Task...
Take the history and assess her mental status.
Explain her about her illness and the risks.
Once I came in and greeted her, she kept talking non stop that she is special and doing
research
about organism .... She is not sleeping very well, have full of energy, no suicidal/homicidal
ideation, used to be in stable relationship with her husband, have many partners now due to
her
thesis title,no features suggestive of STI, spent a lot of money, her mother has got shock
therapy for
psychiatric illness few years ago, no drug uses recently, no alcohol, no accidents, judgement
is fine,
well orientated, .... ( Typical history for mania)
I told the examiner that I will ask CAT team to assess her for hospitalisation. She said
management
is not your task.
I told the pt that her mood is quite elevated and this condition is called acute mania. It could
be
due to other conditions like drug uses although you did not say that so. Other differential
diagnosis
are drug overuses, acute psychosis, bipolar disorder ( I explain them in lay man term ).
Then she asked me what are the harms. I said killing or harming others, STD/STI, accidents ,
financial crisis, drug and alcohol issues....
AMC Feedback: Acute Mania
Status: PASS

Station 20

22 y primigravida with gestational age 20 weeks came to your GP clinic to consult about the
mode of delivery. She was told that vaginal delivery could cause weakness of pelvic floor
muscle and she wants to have a CS.

Task: Explain the advantages and disadvantages of CS and vaginal birth.

Firstly, I asked her what she knows about two modes of delivery and any other reasons make
her want to have a CS.

Then I explained what CS is and what kind of advantages (1. Controlled time of delivery;
2.no birth trauma down below; 3.less possibilities of pelvic floor problems; 4.no labour pain)
and disadvantages (1.its a surgery carrying risks like all the other surgeries; 2. Scar in uterus
could cause rupture or ectopic pregnancy<very rare, pregnancy happens on the scar> next
time; 3. Increased chances of future gynaecological problems) could carry.

Then I explain what could involve in vaginal delivery and advantages (1.natural way; 2.good
to the baby, reduce the chance of developing wet lungs; 3.shorter stay in hospital) and
disadvantages (1. Possible birth trauma to adult and baby; 2.labour pain; 3. Pelvic floor
weakness)

I also explained vaginal birth could contribute to pelvic floor weakness but women can have
perfect pelvic floor muscle after virginal birth if they had appropriate pelvic floor muscle
exercises with physiotherapist. On the other side, women didnt have vaginal delivery could
have pelvic floor weakness.

No questions from role player or examiner.

AMC Feedback: Request for elective caesarean section
Status: PASS

Station 20
24year-old primigravida comes to you to discuss about her delivery at 20 weeks of pregnancy.
Her
friend has delivered a baby by LSCS. She also heard that having LSCS preserve her pelvic
muscles,
and her vaginal wall weakness.
Your Tasks..
Take the history.( All investigation has been done and all normal) for 3 minutes ( Physical
examination is not needed to be done)
Counsel about LSCS Vs normal delivery.
History... Primigravida , planned pregnancy, took OCP before, PAP smear recently done and
normal. No complications so far during pregnancy, feel baby movement normally, Blood
group O+,
No bleeding d/o, no previous surgery, No drug allergy
Counselling... We don't normally recommend LSCS without definite indications as it has may
risk.
It is an operation during which a small incision is made on your tummy wall and cut the
uterus to
take out the baby. It is done under anaesthesia and she wont know or feel it. But there are
some risks
eg, risk of GA/LA like low BP and shock, allergic reaction, bleeding, injury to near by organ
in
tummy, infection, longer hospital stay, increase risk of PE, baby has a risk of transient apnoea
attack
as secretions form the lungs not squeezed out. The benefit is can preserve pelvic muscle
Regarding Vaginal delivery, low risk of bleeding and infections, short hospital stay, Now we
also
offer total pain relief during normal delivery (Epidural )
I will give you some reading materials to know it better...
Then role player asked me anything else...
I told her that LSCS limit the number of deliveries ( U can have only 3 children)... Bell rung.
I missed to tell her that complications(Uterine rupture) during the future pregnancies.
AMC Feedback: Request for elective Caesarean Section
Status: PASS

Station 20
30 weeks gestational age primigravida came to seek advise regarding low segment transverse
caesarian section because she read that normal vaginal delivery can cause pelvic damage.
Tasks:
Talk to patient
Discuss risks and benefits of having normal delivery vs c section
2 minutes thinking time: unfamiliar topic, history regarding current pregnancy, any
contraindications to normal vaginal delivery placenta previa, fibroid, cervical problems.
Me: Hi Mrs X, nice to meet you. I understand you are here to discuss about methods of
delivery. Do you have any specific concern that you would like me to address?
RP: Doctor, I read that normal vaginal delivery can cause pelvic damage, so I am considering
CS.
Me: ok, before I discuss your options can I ask you some questions?
RP: yes
Me: Is this a planned pregnancy?
RP: yes
Me: Hows your pregnancy going? Do you have any complaints such as bleeding or
discharge from down below? Tummy pain? Headache? Blurring of vision? (questions asked
individually)
Rp: all normal
Me: congratulations, have you gone for routine antenatal care? How are the results of your
first antenatal screening tests, 18 weeks ultrasound, 28 weeks sweet drink test? (questions
asked individually)
RP: All tests were normal
Me: Before when you had your periods, were they regular? Any tummy pain? Excessive
bleeding? (questions asked individually)
RP: Regular, no, no
Me: Do you know your blood group? (I cant remember her answer. If RH -, need to check
indirect coombs and give anti D)
Me: Are you regular with your pap smear? When was the last one and what was the result?
RP: yes, normal
Me: Before you were pregnant, did you use any form of contraception?
Me: are you in a stable relationship? Have you or your partner been diagnosed with a
sexually transmitted infection?
RP: yes, no
Me: Have you undergone any gynecological procedures or procedures to your tummy?
RP: no
Me: Any past history of medical or surgical problems?
RP: no
Me: SADMA
Me: Mrs X, I think your pregnancy is going really well. Usually we recommend women to
deliver via normal vaginal delivery as it is the most natural method of delivery. And in
majority of women without any complications, vaginal deliver can be achieved successfully.
Regarding your concerns about pelvic floor damage, it is true that during labour, some of the
muscles in the pelvic are stretched in order to allow the baby to be delivered. However, this
varies in different individuals. It depends on the size of the baby, the size of the pelvis and
other factors. Problems that might arise due to this may be prevented by performing pelvic
floor exercises. I can give you some reading material and refer you to a physiotherapist who
can teach you more about these exercises. With vaginal delivery, usually the recovery time is
faster. Women are usually mobile the day after delivery. Usually CS is done if there are
indications. This may be done if the baby is too big to go through the passageway or pelvic.
Or if something is blocking the passageway, such as cases where there is placenta previa
where the placenta is blocking the passage, or if there is a large fibroids or growth in the
womb that blocks the passage. CS may also be done if labour is not progressing well and if
the baby is in stress. CS is more invasive as a cut has to be made in the tummy and anesthesia
is required. Complications such as bleeding, infection and anesthesia complications may
occur. Recovery time may be slightly longer. Please consider what I have said, at the end of
the day the decision is yours. If you like, I could arrange a consultation with the obstetrician
at 34 weeks to discuss the methods of delivery and you and the specialist can decide together
the best method. I will give you some reading material and please come again for the next
antenatal visit. Thank you.
AMC Feedback: Request for elective caesarean section
Status: PASS

Station 1
53 year-old lady comes to your GP clinic complaining of SOB over a period of time.........
Task
Take history not more than 5 mins
Ask Physical examination findings from examiner.
Discuss your management plan with the patient.
History... SOB over 6 months, getting worse, SOB on exertion but can do daily activities, no
orthopnoea, no paroxysmal nocturnal dyspnoea, no oedema, but dry coughing (+), no weight
loss,
no fever, no appetite change, no chest pain .. She has been smoking over 30 years, 35
cigarettes
per day, social drinker, no other positive history .
Examination: Examiner give me a card containing the findings... decrease breath sound and
vocal
resonance on right lower side of the chest with dullness on that area. CVS examination is
normal.
Management: You are probably suffering from a condition known as pleural effusion. I will
explain
a bit more about that. Normally there are two layer covering the lungs. In your case there is a
fluid
collection between these two layers and it is known as pleural effusion which compress on
your
lung that's why you could not breath properly. To confirm this, we need to do CXR. Another
possible cause is infection in your lung.
We have one more important issue to be addressed. That is the underlying cause. Pleural
effusion
happens secondary to underlying cause which we need to be discovered. In your case we
need to
rule out malignancy(Cancer in the lung). So I am going to organise some investigations like
FBE,
U&E, .. CT scan and probably bronchoscopy. I will also admit you to take the fluid out
from the
pleural cavity. We can also do some test like plural fluid analysis.
She asked me she is having lung cancer. I said I dont say so but there is a possibility because
of her
long term smoking history.
AMC Feedback: Shortness of Breath
Status: PASS

Station 1
60 y male came with SOB to your GP clinic.
Task: History
Ask PE
Mx
History:
Current History: SOB happens when climbing stairs; no problem during the night; no
oedema; no fever, cough or chest pain
System review: reduced appetite & weight loss; normal waterworks and bowel movements;
no pain or bumps or lumps anywhere
No past history of lung or heart problems
SAMAD: heavy smoking for long time
PE:
Chest: dullness & reduced air entry of right lower lobe of lungs
Mx:
Told patient the most likely Dx is pleural effusion could be caused by cancer or infection
which need further Ix (e.g. Chest X ray, bronchoscope) to confirm. Draw a picture to explain.
Also mentioned DDx like pneumonia, heart failure, COPD which are all unlikely.
AMC feedback: Shortness of breath

Status: PASS

Station 3
Essential tremor the same as book case
AMC feedback: Tremor
Status: PASS

Station 3
40 years old male came to GP clinic complaining of having the shakes
Task
History
Physical examination
Diagnosis
Management
2 minutes thinking time: Benign essential tremor, Differential diagnosis: alcohol induced,
hyperthyroidism, Parkinson disease. Explore use of alcohol due to the tremors, effects on
health if any.
Me: Good morning Mr X, my name is Y one of the GPs here, nice to meet you. I understand
you have the shakes, could you tell me more about it.
RP: I have had the shakes since my twenties and its getting worse.
Me: Does it affect both hands? Is it worse in any side?
RP: Yes, worse in right
Me: When does the shake usually occur? When resting or reaching out for objects or during
activities?
RP: When reaching out and doing certain activities
Me: How is this affecting your life? Any difficulties performing day to day activities?
RP: Its difficult to read the newspaper
Me: Any head shaking, mouth twitching or shakes in your voice?
RP: No
Me: Do you have any weather preference? Changes to bowel habit? Changes to body weight?
(Hyperthyroid)
RP: No
Me: Is it difficult for you to get up from the chair and walk? Do you notice that you are
walking at a slower speed now? (Parkinson)
RP: No
Me: Do you have any past history of medical or surgical condition?
RP: No
Me: Any family history of anyone with the same complaint?
RP: My dad also had the shakes and my cousin had Parkinson disease
Me: SAD MA
RP: Does not smoke, drink 1-2 bottle of beer a day
Me: Have you noticed that alcohol helps the shakes? Have you increased your intake of
alcohol?
RP: yes, no
Me: I would like to perform physical examination on you. Examiner gave a piece of paper
with the findings.
PE: Coarse tremor on movement, all others normal.
Me: Mr X, from history and PE most likely you have a condition called benign essential
tremor have you ever heard about it?
RP: well from what I understand its benign so its not malignant, tremor means shake, but I
dont quite understand it.
Me: Your condition is also known as benign familial tremors.
RP: so its familial?
Me: unfortunately yes, this condition is inherited or passed down. You mentioned that your
father had the shakes too. Usually this condition may begin in the early 20s and unfortunately
it worsens with age. Let me reassure you that your condition is not Parkinson disease. In
Parkinson, tremors usually occur at rest and there will be other signs found in PE, which is
not present in your case. I would like to perform some investigations to confirm the diagnosis
and to exclude other causes. I would like to perform the thyroid function tests because
problems with your thyroid may also cause shakes. FBE and liver function tests to see the
effect of alcohol on your body. First of all I would like to advise you to drink within the safe
level, which is 2 SD a day for males. I will prescribe you medication called beta blocker to
help your shakes. I will give you some reading material regarding your condition. Please
come back for a review to go over the results and to monitor any improvement in your
condition. Thank you.
AMC Feedback: Tremor
Status: PASS

Station 3
Book case Condition 33... Benign Essential Tremor with heavy alcohol drinking
Feedback: Tremor
Status: PASS

Station 2
An 18 month old child was brought to the ED because of an asthma attack. The patient is ok
now and was given the puffer, spacer and face mask. Mom has come to the GP to ask about
the use of puffer and spacer and further advice.
Tasks:
Assess severity
Assess technique
Asthma management
2 minutes thinking time: severity of asthma attack, asthma pattern, ask mom to show
technique and show her how to do it, future management
Me: Hi Mrs X, my name is Z one of the GPs here. I understand your daughter has an asthma
attack recently, could you tell me more about this.
RP: My daughter had difficulty breathing and we brought her to the hospital. She was
diagnosed with asthma and they told us to use this puffer, spacer and mask. 6 puffs if she has
another attack
Me: Was that the first time she had difficulty breathing?
RP: No, she had difficulty breathing before in the past, but not as bad as the last attack. We
just found out she had asthma.
Me: Did she have an upper respiratory infection before the shortness of breath?
RP: yes she had cold and a slight fever, I gave her panadol
Me: before going to the hospital did you notice that it was difficult for her to breathe? Did
you see vigorous movements of the muscled of her neck and chest? Did she turn blue?
Difficulty speaking? Drowsy?
RP: Just difficulty breathing, I didnt notice about her muscles, she didnt turn blue, could
still speak, not drowsy?
Me: Did you have to stay overnight in the hospital? What treatment was given?
RP: no we only stayed a few hours, they gave the puffer.
Me: Does your daughter have eczema?
RP: yes she has this skin condition in the fold of her arms
Me: Is there a family history of asthma, hay fever, rhinitis allergy?
RP: there is a family history of asthma, I think its the dad
Me: Could you please show me how you give your daughter her medication
RP: Sorry doctor, I forgot the face mask but usually this is how I do it The RP pressed the
puffer 6 times at one go. Thats how I give it to my daughter and her condition improves.
Me: Ok Mrs X, the way you are doing it is incorrect. When you are giving the medication,
please ask your daughter to sit up straight so that it will be easier. Make sure that the face
mask covers her mouth and nose. Make sure that there is a good seal so that no air will
escape. Check the expiry date, remove the cap and shake the puffer. Insert the puffer to one
side of the spacer and press the puffer once and allow your daughter to breathe in and out 4
times in a minute. Then please repeat about 6 times. Please clean the spacer by rinsing in
warm soapy water and air dry it at least once a month. Please always bring 2 puffers
wherever you go in case one is finished. Or you can put the canister in a bowl of water, if it
sinks it still has medication in it. When your daughter is well she will have symptoms less
than 3x times a week. When there is symptoms, please give her the medication as I have
shown you. If her symptoms occur more often, please double the dose and I will have to
prescribe another medication for her. The other medication is a preventer, which contains
corticosteroid. If her condition is severe and doesnt resolve with her puffer, please call 000
and continue the medication. Asthma is usually triggered by an upper respiratory infection, so
if she has one please come to the gp. Please keep your child away from smoke and dust.
Please try to vacuum your house at least once a week or as often as possible. Do you have
any pets? No. I will give you reading material and 3 copies of asthma action plan for you to
give to the childcare and to bring wherever you go. Then the examiner hurried to give me the
asthma action plan, she was hiding it in her hands and I think I just made a serious error. I
was explaining the components of asthma action plan earlier but didnt ask for it, or didnt
specify that I was doing it. I hurried to explain the plan but only managed to reach the yellow
section / when she is not well. The bell rang and I think I failed this station.
AMC Feedback: Explain, demonstrate and check use of bronchodilator MDI metered dose
inhaler and spacer
Status: PASS

Station 2
GP setting, 18months old baby was discharged from ED yesterday with the diagnosis of
asthma
with ventolin inhaler. Mother does not know how to use ventolin inhaler and spacer. (Long
stems)
Your Task .
Take the history for severity assessment of his asthma not more than 3 mins
Assess the technique how mother give ventolin to him
Advice how to use spacer and ventolin to mother.
History.... infrequent intermittent attack, 3 times of attack within 6months, few day and night
symptoms, never used ventolin before, not know trigger, can play actively without having
SOB,
father has got asthma when he was young but now grew out of it, no smoker at home, good
ventalation, no concern about growth and development, immunization up to date... (Ventolin
puffer
and Spacer are on the table but no mask on spacer)
Assessment... she press ventolin 3 times straight into puffer and she said she dont know how
to use
it.
I said the way she did is not correct. To use spacer and puffer effectively, she should make
correct
choice of mask that has to cover the child's nose and mouth not too big or small. Shake
ventolin
puffer before using it. If it finishes, you cannot hear the shake or nothing would be released
when
you press puffer. To use it after shaking puffer, attach to the spacer,put the mask on his face
then
press puffer one time and let him to take 4 breaths then give him another dose...
Then she asked me how she can take care of spacer. I said just wash spacer 2 to 3 monthly,
dont
wipe or brush then let it air dry. Then I explained her to give puffer whenever the child has
dry
cough, wheezing or SOB.
Then Examiner asked me to tell her about the summary of my history and what to do. I told
her that
her child has got asthma attack intermittently and infrequently. Then I explained her asthma
action
plan what to do when he is well, when he is unwell and during the attack.
Well means intermittently and infrequently, use ventolin prn.
Unwell means frequent day and night asthmatic attack, 3 time of ventoline use during a
week,....
He might need to use preventer at that time and ask her to come back to me... During
asthmatic attack, use ventolin 4x4x4 if not relief, dial 000.
I said I will give copies of action plan to her...
Then I was bout to talk asthma triggers , then the bell rung..
AMC Feedback:Explain, demonstrate and check use of Bronchodilator MDI and spacer
Status: PASS

Station 2
1.5 y girl had an asthma attack one week ago and was discharged with Ventolin puffer, spacer
and mask. Father came to your GP clinic wanted to know how to use puffer and spacer.
Task: History taking no more than 3 min
Explain how to use puffer and spacer
History:
The girl had an asthma attack one week ago and was discharged from hospital. No asthma
before. BINDS unremarkable. No past history of any other medical problems. Father and
Mother have asthma. No one smokes at home. No pets at home.
Mx:
Asked Father to demonstrate how he uses puffer and spacer. He did everything correct except
he put all the 4 puffs at one time. I told him give one puff at one time and also asked him
about Asthma Action Plan. He said he had no idea about Asthma Action Plan. Then examiner
threw an Asthma Action Plan to me. I didnt finish explaining before the bell rang.
AMC feedback: Explain, demonstrate and check use of Bronchodilator MDI metered dose
inhaler and spacer
Status: PASS

Station 4
Long stem. About an old patient who had surgery for sigmoid cancer, which was found to be
inoperable during the surgery due to widespread metastasis. The surgeons performed a
colostomy. Youre an intern and you are to tell the patient about the surgery. The daughter is
here to speak to you as she doesnt want her father to be told about his condition. The
daughter has permission to speak about the fathers condition. The daughter is a nurse. The
patient lives on his own.
Tasks:
Speak to daughter
Answer her questions and concerns regarding her fathers condition
2 minutes thinking time: Break bad news, patient has right to know, discuss palliative care
and future management
Me: Good morning Mrs X, my name is Z one of the interns here. I understand you are here to
discuss your fathers condition. Are you here alone, would you like to call a family member
to be present? I am afraid I dont have good news regarding the surgery. During the surgery it
was found that his cancer has spread quite extensively and it is no longer operable.
RP: started crying and I kept quiet, and offered her tissue.
Me: Are you ok to continue Mrs X? or would you like me to continue another day?
RP: Its ok, I just dont want my dad to know about his condition. He doesnt deal well with
bad news. Before when mom was ill, he didnt take it well and he was really depressed. Can
we just not tell him about his condition.
Me: Mrs X, unfortunately I am unable to keep your dads condition from him. Every patient
has the right to know regarding his own condition.
RP: Throughout the consultation, the daughter kept insisting not to tell her dad, or at least not
now. She wanted to tell the dad on her own at a later time, when she feels that her dad is
ready.
Me: Mrs X, every patient has the right to know about his own condition. Let me reassure you
that there will be a lot of support for your dad, to deal with his reactions towards the news.
What I can do is when I speak to him, I will ask him first how much he knows regarding his
own condition and the surgery. I will try to find out if he knows anything regarding his
surgery. I will also ask him if he would like to be informed of any news that is not good
regarding his own condition. If your father chooses not to know about his condition then we
will not tell him about it. But, if he would like to know, he will be told regarding his
condition. It is better for us to tell him regarding his condition as soon as possible as there is
much to be done for his future management and there are many decisions he has to make
regarding his condition. His care would be done by a multidisciplinary team known as the
palliative care team. The team consists of the oncologist, pain specialist, stoma care nurses,
social worker, psychiatrist, psychologist and the GP. The team aims to provide the best
quality of life for your father and to meet his physical, emotional and psychological needs.
His pain will be managed by the pain specialist as there might be some pain due to his
condition in the future. The aged care assessment team would also assess your fathers living
condition to see if he is suitable to live on his own. There are other living options as well such
as nursing homes, inpatient palliative, or even with you Mrs X if you choose to. If you would
like him to stay with you, there is respite care to help you in his care when you are tired, so
that you may get a break too. With your dads consent, I could also arrange a family meeting
to discuss his condition together. Let me reassure you that there is a lot of support for your
dad and you as well.
AMC Feedback: Colon cancer counselling :
Status: PASS

Station 4
87 year old man diagnosed with Ca colon and did surgery today. The cancer is spreading to
the
whole abdomen and liver. You are HMO in surgery ward. His daughter is a nurse who does
not
want to her father know about his condition.....Consent has been give to discuss the issue with
his
daughter. ( long stem)
Task
Talk to the patient daughter
The role player keeps talking that she is very worried about her father condition. She does not
want
to know her father his condition. Her father used to be a strong and independent man. 6
months ago
her mother died and he is a bit depressed. She thought he could handle this situation.She
wants me
to hold the disclosure to her father until pathology result comes out. I said so sorry to hear his
father
story. We will assess his response... If he is well orientated and wants to know about his
condition I
will have to disclose the operative findings. Every patient has a right to know their own
condition
and involve in the decision of further management plan. I will also arrange family meeting if
he
allows to do so.
Then she asked me to hold the disclosure for 24 hrs as he just got surgery today and this bad
news would be impact on him.... I said I can see how much this situation is hard for her and
her family. I
also told her that her father is very luck to have such a very caring and loving daughter like
you. I
also appreciated her concern and cheered her up. I also tried to talk other management plan
like
palliative care. She said she is a plliative care nurse and she knows every kind of support and
services. :(
But I told her that I will assess him soon and if he fully recovers from GA, well orientated
and asks
me about the operation I have to disclose him. I also told her that before disclosure I will ask
the
permission from him to get her around us like family meeting.
She said she dose not agree and want me to hold just for 24 hrs...
I failed to convince her and I keeps talking about patient right and desire....
Finally she said I am not happy with you and then Bell rung.... :(
AMC Feedback: Colon Cancer counselling
Status: FAIL (as I expected)

Station 4
87 y male had bowel surgery and confirmed advanced bowel cancer. His daughter, a RN,
came with written consent to disclose his fathers condition.
Task: Consult the daughter
I expressed my sympathy first and then ask what I can do for the daughter. She asked me not
to tell her father about the bad news. I asked why she didnt want me to tell his father. She
said that she didnt think her father is ready for that. I told her that as her fathers doctor I
have to let her father to make the call himself. I will break the bad news in a sensitive way.
Let her father know its not going to be good news and if he is not ready for it we can wait. If
he is ready to listen to it, I will ask whether he would like anyone to accompany him to listen
together and you as his daughter could be there if he wishes. I am going to deliver the news in
the way that he requires, either briefly or in details. For his advanced colon cancer, we can
provide palliative care which involves multidisciplinary team will take a good care of his
father.
The role player seemed to become relived at last.
AMC: feedback: Colon cancer counselling
Status: FAIL
To be honest, I dont know what went wrong. I thought I did well and definitely could pass
this one. The role player seemed to be relived and happy at last. Please check the other recalls
for this station.

Station 5
Rest station


Station 6
Long stem. A 25 yo female just delivered her baby, baby is healthy. Labour was not
prolonged, instrumental delivery was not needed and a dose of ergometrin was already given.
An episiotomy was not performed. While delivering the placenta, controlled traction was
performed and the cord snapped. The patient experienced bleeding of about 1L.
Tasks:
Ask examiner for physical findings
Talk to patient
Manage the case
2 minutes thinking time: PPH, have to remove placenta immediately, probably needs
emergency sx, stabilize vitals
Me: Could I please know the patients vital signs BP sitting and standing, pulse, respiratory
rate, temperature and oxygen saturation.
E: BP is 90/60 lying, no other BP provided, slightly tachycardic, others normal, SO2 not
provided
Me: I would like to attach the patient to 2 large bore IV lines and run NS infusion
E: You can speak to the patient about that later, any more PE?
Me: I would like to do a focused examination on the abdomen and pelvic. Could I palpate the
uterus to know the consistency, size and location.
E: Uterus is soft and lax, (I forgot the height of the uterus, its above the symphysis)
Me: I would like to inspect the pelvic for any bleeding, laceration and to see if the placenta is
visible. (I forgot to do fundal massage, and didnt give ergometrin as it was already given. I
was thinking that its probably not due to the laceration since bleeding already stopped, baby
was within normal weight, and she didnt have prolong labour)
E: active bleeding, and cord is visible, placenta still within the uterus
Me: May I know what is the patients blood group?
E: O negative
Me: thank you, I will speak to the patient now. Hi Mrs X, my name is Z, one of the HMO
here. Mrs X, you are currently having a condition called postpartum haemorrhage. This is
bleeding that occurs after delivery. There are many reasons as to why this may occur such as
a long labour, instrumental delivery, bleeding problems, tear in the vaginal passage. In your
case, mostly its because the placenta is still inside the womb and this is preventing the womb
from contracting well. That is why you are bleeding. I would like to arrange for 2 IV lines to
be inserted and to start giving you fluid. I would also take some blood samples for
investigation. Such as FBE, coagulation profile, blood group and cross matching, indirect
coombs test, kleihauer test, renal function test and liver function test. I would also consult
the obstetrician regarding your condition. Most likely, you will need to go for immediate
surgery to remove the placenta. You will be placed under general anaesthesia. If after
removal of the placenta, you are still bleeding, the obstetrician may inject a medication into
your womb muscles to help it to contract better. If the bleeding still continues, the
obstetrician may perform ligation of the uterine artery. That is using procedures to prevent
blood flow to the womb in one of the major vessels that supply the womb. If the bleeding still
continues, the last resort would be to perform hysterectomy, which is the removal of your
womb. Mrs X, because your blood group is O-, we need to run some tests and give you anti D
injection to prevent isoimmunisation. Isoimmunisation is when you develop antibodies to
your babies blood and in future pregnancies these antibodies may cross the placenta to harm
the baby. Let me reassure you that you are in the best hands, the specialist will do their best
to manage your condition.
AMC Feedback: Primary postpartum haemorrhage
Status: PASS


Station 6
A woman just delivered baby and the cord was snapped in the uterus. You are HMO and need
to solve it.
Task: Ask PE from examiner
Mx
It should be an easy one but I felt so frustrated during and after this station. I started from
asking the PE. I made a mistake by asking the abdo and pelvic exam results first. The
examiner shouted at me and asked me to read the task again. I then ask vital signs (forgot
about GA at all). When I asked is there any signs of laceration, the examiner yelled at me
again the patient lost 1L blood do you think you can see anything?! When I asked is there
any clots in the blood, he shouted again 1L blood! 1L blood! and asked me to read the task
again. I was shocked and thought I definitely would fail this one. I wanted to leave the room
but I told myself I should at least talk to my patient before leaving. Then I asked this
examiner can I talk to my patient. Then I talked to my patient, a very very nice lady but she
was not the examinerI mentioned everything I know from handbook. Then the bell rang I
left the room and didnt dare to look at that examiner again. I was pretty sure I would fail but
I passed. I am confused.
AMC feedback: Primary postpartum haemorrhage
Status: PASS

Station 6
This 25 year-old primigravida hd a normal vaginal delivery by midwife 20 mins ago in a
country district hospital in which you are a HMO and currently on call for Obestetric untit.
The Pregnancy has been perfectly normal. The estimated blood loss at delivery was only
250 ml. However 1500 ml of bright blood has been passed in last 15 mins and the cord is
snapped in the vagina. The midwife just phone you to advise you of these facts and ask you
to come and help with the patient's care. She has got IM Oxytoxin 10 U soon after the
delivery.
Your Tasks
Explain the patient about the condition.
Ask the examiner about the examination findings and your management.
Pt is alert and conscious but having low BP and rapid Pulses. So I mentioned that I will
resuscitate
her by giving fluid and probably blood after doing the blood tests (FBC, Coagulation profile,
Grouping and matching).
Then I asked the examination findings focusing on abdomen and vaginal examination( Uterus
is
flabby- 2 to 3 cm above the umbilicus and cannot inspect vagina due to the cord). Other
examinations were normal.
I explained the pt that she has got a condition called retained placenta that most probably due
to the
poor contraction of the uterus. The other reason is the fact that the placenta is adhered very
deeply
to the uterus. Then I also told her that her BP was low due to excessive blood loss for that she
might
need blood transfusion although we gave her plenty of fluid.
Then I told her that we will give her Oxytocin infusion to make her uterus contract better and
normally placenta should be delivered within 15 to 30 mins after the baby's delivery.
Examiner
asked me that how I would do to make uterine contraction better. I answered that we can try
Oxytocin infusion, then IM ergort or PV prostagladin. Then I continued to explain the pt that
we
might probably need to take the placenta out manually. She asked me if I will be doing the
procedure on my own. Then I remember immediately and told her I will call obstetric
registrar to do that as I am just HMO. ( how nice she is)
At that time examiner ask me whether the procedure will be done in labour room. Then I
answer
that we will send her in OT and manual removal will be done under short GA by the obstetric
registrar.
Then examiner asked me if bleeding is not controlled even after placenta delivery, what I will
do.
I said that I will find out the cause of bleeding eg tear in vagina, inspection of placenta for
completeness to rule out RPOC. Then he told me you don't find any reason, what I will do. I
said
we might probably think of the other reason like DIC and I ask him again the bleeding is
clotted or
not.
Then I said we might think of doing laparotomy, then doing uterine artery or internal iliac
artery
ligation or hysterectomy if indicated. Then the observer asked me what I will do if pt has DIC.
I
said I will give her fresh blood or FFP. The bell rung.
( I missed to pass urethral catheter )
AMC Feedback: Primary Postpartum Haemorrhage
Status: PASS

Station 7
40 year-old patient who has been drinking..... .You have seen him last week and increased
BMI
and BP 170/95mmg and others normal. You arranged some investigations
FBE.. decrease MCV
BSL... Normal
LFT.. increase GGT
One more left which is normal.
Task..
Explain the results to the patient.
Ask the examination findings from examiner
Discuss management plan with the patient. (No history taking required)
Explanation.... The test results are not very bad. Because of chronic alcohol drinking. The
liver is
affecting a bit showing increasing one enzymes from the liver, size of RBC is increase.
Examination.... All normal expect BP 170/95mmHg.
Management... I have examined you and everything is normal expect high BP. I have noticed
that
you have been alcohol a bit too much. Then I asked him CAGE questions. According to that
he is
not alcohol dependent. So I told him that drinking alcohol is one of the contributing factors
for high
BP. I also mentioned that to reduced alcohol to the safe level and explain what the safe level
is.
Then he asked me what is one standard drink of alcohol. I said it depends on types eg, one
bottle 325 ml of beer is one standard drink of alcohol. I also said life style changes ( reduce
alcohol,
exercise, diet etc).I told him that he should do those things first for a few weeks unless his BP
is not
well controlled with those measure, we would consider to put him on medications for HTN.
He also asked me if he could take medication without reducing alcohol drinking. I said
without
that measure, we wont be able to control BP. I also mentioned other effects of alcohol like
social,
accidents and other health issues.
AMC Feedback: Alcohol use and sequelae
Status: PASS

Station 7
60 y male came to your GP clinic to know the results of LFT and FBE. He has history of
heavy drinking 5-6 standard drinks every day.
Task: explain the results and consult the patient
I explain the results to my patient and asked the CAGE questions. I told my patient about the
safe drinking level and asked him to think about quitting.
Questions:
Role player: Can I just quit drinking by myself?
I answered: I am afraid that you will need special help to your alcohol cessation. I can
provide the further information about alcohol and drugs clinic once you make the decision
you can contact them yourself and they will take care of you through the process of quitting.
AMC feedback: Alcohol use & sequelae
Status: PASS

Station 7
A long stem about a middle aged man who drinks alcohol. BP elevated. He visited you a
week ago and had some blood tests done. He is back for the results. MCV increased, GGT
increased
Tasks:
Explain results to patient
Ask for physical findings
Advise patients
2 minutes thinking time: alcohol counselling, CAGE, FLAGS
Me: Hi Mr X, my name is Z, I am one of the GPs here. I understand you are back for your
results, is it ok for me to ask you some questions?
RP: Yes
Me: Do you have any complaints?
RP: No, Im quite healthy
Me: Do you experience any heartburn? Nausea? Vomiting? Bloody vomit? Changes in the
colour of your stool? Tummy pain? Headaches? Changes in your vision? (Questions asked
separately)
RP: No
Me: CAGE question
RP: Negative to the questions
Me: Have you gotten into trouble with the authority before?
RP: Yes, I think he had a drink driving charge
Me: Do you smoke? Have you ever used illicit drugs before?
RP: No
Me: do you have past history of medical or surgical condition?
RP: no
Me: Could I please perform the physical examination
E: All as written in the stem except that liver is palpable 1-2cm below ribs.
Me: Mr X the results showed that all is well except for the increase in your liver enzymes
GGT and there are changes to the size of your red blood cell. On top of that you have
elevated BP and your liver is enlarged as well. These changes may be attributed to your
alcohol intake. Your alcohol intake is slightly excessive and is above the safe limit of intake
for males. I think it might be best for you to quit drinking. What do you think?
RP: He got really upset and his tone of voice increased. Excessive? Quit drinking? Thats not
possible. (I think I said the wrong thing, should have said try to cut down or even quit. I think
I got into trouble because of my choice of words.)
Me: Mr X, you are currently consuming more alcohol than the safe limit. The safe limit is 2
SD a day for males. How about cutting down on your alcohol intake?
RP: Ok, I can try to cut down, but not quit! He was upset throughout the whole consultation.
what is a SD?
Me: 1SD is 10g of alcohol and the content of alcohol depends on the kind of beverage you
are having. You have to read the alcohol content level from the bottle.
RP: I drink beer
Me: ok, you have to see the alcohol content from the beer bottle and try to drink only 2SD a
day. By cutting down it will be beneficial for your health as the alcohol has already had some
effect on your body.
RP: Are you sure its because of the alcohol?
Me: I am fairly certain as the changes in your results are often seen in people who consume
too much alcohol. I would like to provide you some strategies to help cut down. It is best to
inform your family members as their support is very important. Please drink water first to
quench your thirst before drinking. Try to eat before drinking and avoid places where you
tend to drink. It is also best to have some lifestyle modification such as eating a healthy diet
and exercising 30 minutes a day for most days of the week. I could also refer you to alcohol
anonymous or support groups to help you during this process.
RP: yes doctor, I think thats my problem, last time I didnt eat before drinking. Bell rang
AMC Feedback: Alcohol use and sequale
Status: PASS

Station 8
Rest station

I passed 14/16 stations! I spent four months on serious study with my study partners. I used
Dr. Wenzels case notes, recalls and handbook. I attended TEEMWORK trial exam and I
passed 11/16 two weeks before my real one. I have to say TEEMWORK course is very
helpful which made me realised what I can improve although only two weeks left.
Tips:
Role playing Dr. Wenzels case notes
Attend at least one trial exam
Stop reading one day before exam & dont discuss in the waiting room

THANK YOU!!! Jesus and Dr. Wenzel, without YOU I could not make it and also BIG
thanks to my study partners. Good luck everyone!


I passed 15 out of 16 stations and failed ........station.
Thank Dr Wenzel for his great effort and time to IMGs and Dr Majid who gave us
invaluable
lectures. I am very luck to have those great teachers.
I also pay my gratitude to my friends from VMPF groups especially Eliza Yu, Lynn
who always
gives me good suggestions and did role play.
My suggestion is to do role play as much as you can. If you do so, practice at least 4
stations
straight, not one by one. It will give you good stamina. I did not feel tired or confused
in the exam.
I feel very comfortable throughout the exam. Dont memorise the notes and recalls.
Understanding
the concepts, dealing the role players in a good manner confidently and good
communication are
important.
Good Luck for all....