Clinical Station in Sydney May 20

[MedMRI]

1. 45 yrs old F with R knee pain xrays showed early degenerative changes,BMI 45, waist circumferance 110 cm. councelling and management.

2. 25 yrs old primi 20 week gestations. council her regarding pain relief during labour.

3. 60 yrs old lady C/O giddiness, inability to walk, loss of sensation over L side of face and numbness over R side of body. diagnosis and management. TIA in vertibrobasiler distribution.

4. 25 yrs old M comes to u for script of oxazepam. u prescribed him 25 mg serepax 30 tabs last week. diagnosis and management.
   benzo dependency.

5. 50 yrs old comes to u in emergency with r leg pain. history examination diagnosis. PVD
   6.25 yrs old F numbness aqnd tingling R hand wakes up in the night because of this. examination, diagnosis and management. carpal tunnel syndrome. examiner asked for causes.

6. 5 months old child with screaming . intussception

7. nocturnal enuresis.

8. 25 yrs old F on ocp started 6 weeks ago C/O irregular bleeding since 4 weeks council and manage. breakthrough bleeding increase the dose of oestrogen contents. pt. asked me do i have cancer will i become pregnant.

9. 25 yrs old 20 weeks gestation . past h/o asthma now C/O cough producing yellow colour sputum unwell. diagnosis and management.
   examiner asked me which antibiotics u will give. basically pnumonia and asthma in pregnancy.

10. 50 yrs old with chest pain radiating to back, shoulder train driver had flu few days ago. history diagnosis management. pericarditis

11. febrile convulsion

12. 20 yrs old with severe headach. history examination D/D management. could be meningitis, subarachnoid haemorrhage, migraine.

13. harmful alcohol drinking councelling examination of pt.

14. lymph node biopsy from neck showed squamous cell carcinoma examine and investigate the pt. for primary.

15. 20 yrs old man 20 % burn dressed few hours ago. now agitated., pulled out canula, diagnosis do mental state examination and management.

16. 50 yr old man having Rt calf pain when walking, releived by rest. It is getting worse now. Task is to take history,ask PE, and I/Vs from the examiner, and to explain the Diagnosis and how you will mangae him.
    The pt gave the history that is typical for PVD, intermittent claudication.(If they want you to get the Dx of a particular d/s, they give the h/o typical of that d/s so that you won’t be misled.)

P/E was “Vitals are normal”. Then you have to ask specific Qs like " What are the findings of ht and lungs exam, periphral pulses, etc". I was told the patent’s left leg pulses are normal. In his problem leg, i.e rt leg, femoral pulse is weak, and there are no popliteal and dorsalis pedis.
So, I explained the pt what is wrong with him, and told him to stop smoking, what I/Vs were to be done on him.

2. 36 wk pregnant lady, asking information for pain during labour.
   This is pure councelling station, so I told her “there are several options that she can choose”. I told her about N20, cutaneous electrical stimulation, and I/M morphine or pethidine injection, and epidural and spinal anaesthesia. She asked the complications of these various methods, and what would be the best option in case she needed CS.

3.20 wk pregant lady with cough, and wheezing. Scenario doesn’t tell you exactly that she has the history of asthma. She has previous episodes of cough and wheeze for about 2 /3 episodes every year in the past 3 or 4 years. Those attacks were all releived by Antibiotics and bronchodilator.
The task is to take history, ask P/E and I/V from examiner and mgt.

She told me “she has been couging for 2 or 3 days, production of phlegm, and feeling hot. There is absolutely nothing’s worng with her pregnancy. Since her previous attacks were releived by Antibiotics, she wants to take the same ABs”.
P/E. pulse rate is 120/minutes, T is high, and BP-normal. RR is within normal. There are wheezing all over the lungs, and RT lower zone is having crackels. Cx’ray not done… I/V- white cells are elevated.
So, I told her “she is having infection in her rt lung± asthma, and she needs AB”. She repeated the Qs if she can take the same AB ( in the exam, if the role players repeatedly ask you the same Q, beware that you follow their lead, and anser their Q). So, this time, I asked " what AB did you take last time?", and she replied " Doxycycline". So I told she couldn’t take it cos she is pregnant now, and I will give her Amoxycillin. She asked " is it a kind of penicillin?" . I said " yes, why? R U allergic to penicillin?", she said " Yes". So I changed to Erythromycin.

In this sceanrio, the key point is that whether the candidate is aware that Doxy is not choice of drug for pregnancy. For me to reach that answer, it took the whole 8 minutes. Cos first I didn’t follow the lead of the role player and whenever she raised that Q of " Can I take the same AB I took last time?" in the middle of history taking , I told her " please let me finish the histroy, let me decide what is wrong with you first". After P/E, and I/Vs , I dignosed her as having lower respiratory tract infection,most likely pneumonia, and arranged her to be admitted, to organize the blood test, blood culture, and to start oral AB in the hospital.
Actually, it was not the anser they want, so the examiner told me " the pt is not coming to the hospital, and what you will do?".

4. A young lady getting married soon started OC pills 6 weeks ago. She has been having intermenstural bleeding for 4 weeks now. This station is also councelling. When I asked her, she said " bleeding is just spotting, and there are no other problems. Her period is ok, and about 12 days after her period, that bleeding has started". She is concerned that she will be pregnant and hav cancer. I assured her that it is the side effect of OC pills, and if she takes the tablets regularly, she can’t be pregnant. For worries for CA, she should go for Pap smear., but don’t think bleeding is from CA. She told me " my mum told me currette can help my bleeding, will I need it?"

I advised her to wait for another 4 or 6 weeks cos it can settle in 3 months time, and if not, she has to increase the dose of OC pills or change another brand.

5. Enuresis… This is very simple… just to rule out UTI, assure the mother there is no underlying d/s, and to try alarm system… and give advice like no to restrict fluid at night time, awake the boy from sleep etc…

6. 17 month old boy having convulsion, T was high. Admitted in the hosptial. This is the 2 second day of his admission, and his T is 38, and he is having red throat. But no more convulsion, and eating nicely.
   Task is history, I/Vs, and councelling the father.

7. 5 month old boy, crying for 6 hours, intermittently screaming and went plae. P/E shows that there is a mass in the right side of his abdomen, stool is normal.
   Task is expalin mother what is worng with the baby and tell her your management.

So, I told her the baby is having serious problem, acute abdomen, that his intestine got twisted inside (the word " invaginate" didn’t come to my mind, too bad), so they got ischamia. Hav to transfer the baby to larger hospital, to be seen by specialist surgeon, and he will probably need operation. Besides, baby can’t be fed, he will get I/V fluid for his nutrition and will need blood test and USG to confirm Dx.
Mother asked me her baby will be operated, there are other methods for the problme. Becos I didn’t metion about Ba enema… ( I totally forgot about it, and I told her the surgeon may try warm normal saline put thru his back passage, but I am not sure what they will do to her son).

8.25 yr old man taking oxazepam 30 mg a day for 4 yrs. His last prescription was about 1 week ago, given 25 tabs. He finished them all in 1 week, and now asking for the tabs again.
Task is hostory and mgt the pt.
I asked him why he has been taking for tht tab for long, and he said he got poor concentration, palpitations, and restless if he didn’t take it. I also asked him whether he was having any drepressive symptons, and psychotic symptons, and he denied. He was not also suicidal. He kept on asking whether I would write him the prescription again. I told him that “he is now addicted to oxazepam, so he needs to be seen by psychiatrist, and I can’t prescribe him any med right now”, but he can’t stop that med immediately cos it is dangerous for him. He needs to wean off that tab slowly, and the best is to be done under the surpervision of Psychiatrist, and may be as an inpatient".

9. A young man got 20% partial thickness burn on both forearms, has been in hospital for 36 hrs. Last night, he was restless, unable to sleep whole night, and said hearing things. He is on morphine infusion 1 mg/hr.

Task history, mental state examination, and tell the examiner how you will manage the pt.

When I saw the pt, he was lying on bed, moaning. He was cooperative, and answered all the Qs nicely. He told me he couldn’t sleep becos he is having bad dreams about the fire, and he wounds are so painful.He said he didn’t know that how long he has been in the hospital. He dendied using any illicit durgs, and having any mental illness before. He also denided seeing things. So, I ruled out withdrawl of drugs, or acute psychosis. His problem is “Pain” , and acute stress condition. I know my provisional Dx is a good one, but I can’t think of anything else. (I was thinking to myself that I wanted to increase the dose of morphine, but I am not sure of safe dose of morphone. I wanted to give him Diazepam, but I didn’t tell the examiner about this.) I told the examiner that I would give him painkiller, like Voltran supository. Examiner said “what you will go about his restlessness?”. That time, bell rang.

I feel that I should talk about what I thought, and tell him I want to increase the dose of morphine, but hav to check with the book, and sedate him…

10. A 50 yr old lady got sever dizziness while eating in the morning.
    vomitted 1 time. Now she is feeling fine unless she moves herslef alot, but having numbness of left face and Rt side of the body.
    She has hypertension and hypercholestrolaemia and on medication.

P/E vitals, BP 160/90, others are normal. cranial nerves examiantion is absolutely normal. limbs power 5/5. Ht, and lungs are normal. neck- no burit. ears are normal, no tinnitus, hearing loss, tympanic memb normal.
On that point, I was absolutely lost. I don’t know what is worng with her.
The examiner asked me " your physical examination is complete? Do you want to examine any place?". I don’t know what to do… ( I think, I missed to do cervical spines examination).
I told the examiner tht this lady has to be admitted for thorough I/Vs.
But I still can’t think of what is worng with her. I have to wait for feedback.

11. Middle age train driver having pain in the left side of the chest and back for 6 hours.
    Task is history, P/E, I/Vs, and mgt.

The pt gave history of pain which was not so severe, not associated with exertion. Pain is brought about by only coughing and deep breathing. He also got mild fever and running nose a few days before. He denided having H/T, DM, smoking.
P/E vitals and all findings were normal except a noise at he apex area.
I aske " it sounds like rub", and examiner siad “yes”. I have to give differentials and I/Vs and mgt.

12.A young man having sever headache for 1 day. pain getting worse, vomitted twice. Task focus history, ask P/E from examiner, and expalin the Dx to the patient, and mgt.

Pain whole head, rate 10/10. He has migraine, but thinks that this pain is different from migrain. no lacrimation, no rhinorrhoea. So I asked the examiner P/E… Vitals… are normal excpet he is having fever. neck is stiff midly, no rash on the body, no other abn. I told the pt that he is having inflammation of the brain, needs admission. Examiner asked me what I will do. I said blood test, culture, CT brain to r/o increased ICP, and if not, Lumbar puncutre.

13. 50 yr old lady, very obese,BMI 45, Abd circumfrence is 110 cm, having Rt knee pain.
    Task is to ask history concerning with her obesity, explain co-morbidity associated with obesity, outline her how to reduce weight. Although she is having Rt knee pain, main task is councelling for obesity.

14. A photograph showing the neck with enlarged lymph node on the left.Lynph noed was already biopsied, and showed that secondary squamous cell metastasis. The pt is a smoker, 20 cigarettes per day for 20 yrs.
    Task is to do “FOCUS P/E looking for the primary site” and to do I/V.

First thing that got into my mind is to do P/E of the respiratoy. I have to tell the examiner the reason of my P/E. For example, if i look at his fingers, I have to tell him that I m chekcing for finger clubbing, or wrist pain cos pt with lung cancer can have HOPA.
The main point here is whether you think what are the possible causes of Squamous cells metastatsis, and examine mouth, and face to r/o skin cancer.
Please don’t forget to examine the mouth if you see patient with lymph nodes in the neck.

15. A business man watched the TV program of dangerous effects of alcohol, and worried for himslef and came for councelling.
    Task is to take histroy to decide whether he is abusing alcohol, having withdrawl symptons. To do Focus examination of the system that alcohol has it toxic effects, and councelling him for alcohol drinking.

So, I decided to examine whether pt has liver toxicity symptons.
And councelled him according to Patient education by J Murtagh.

16. A young lady with tingling and numbness of the Rt hand.
    Task is to do P/E, and tell the Dx and mgt.

These are my experiences and I am not sure what I have done are correct.

When you take the exam, you will be allocated to one of these 20 stations. So, some hav to start with rest station, and sit for 10 minutes outside before taking clinical station. You will be told to stand with your back outside the room, and turn around and start to read the Q only when the bell rings. After 2 minutes, the bell rings again, and then you have to enter the exam room. If you finish a station earlier than 8 minutes, you can go out and stand infront of the next station, but can read the Qs only when the bell rings.