Perth Oct'07 AMC part 2 with comprehensive explanations

AUSTRALIA AMC CLINICAL EXAM
#1

I have heard that Perth is not a good center. The questions were easy but we had some difficult examiners who had Parkinsonism/ face. 50% were not helpful and 25% helpful and 25% neutral. They asked some questions that were tough and the role players were ok.

I have tried to explain the stations comprehensively to the best of my ability.

The stations were as follows

Paeds

  1. Sexual abuse.
    Mother separated from husband 5 months ago with lots of animosity. Child goes there alternate weekends. Today says that she wont go. Mother moved with new boy friend 3 weeks ago.
    Examination findings given
    No rashes or bruises
    Red vulva

Counsel mother and further management.

  1. Growth is less according to mother. 2 and half year old boy or 4 yrs. Mother says that he is not eating properly. 2 sibblings 10 and 12 no problems. Mother concerened about eating habits.

Examination findings given
Ht and wt given
Take Hx and manage

In this station you are expected to take a full Hx. All are normal and the child has good development with Immu up to date.
You have to specifically ask for percentile charts, otherwise it wont be given to you. Both ht and wt are normal. I reassured mother with emphasis on diet.

  1. Swelling in neck of a 3 yr old. Mother concerened as her sister/ friend’s daughter has lymphoma. No Examination findings.

I took Hx. No abnormality. Development well. O/E swelling not fixed, non tender. Reassured mother. Offered USG. Pt specifically asked if FNAC can be done. I told her Excision Bx is best for Lymphoma. Overall mother needs re assurance. Others did not get that particular Q from role player. I was the only one who was asked by role player about FNAC.

OBG

  1. Sterilisation: 32 yrs old married with husband. 3 children. Straight forward.
  2. 65 yr old with post menopausal bleed.

Menopause at 50 yrs. Had a bleeding episode lasting 1 day last week.
Pt gives Hx of using HRT and also c/o pruritis vulvae.
Examination findings: Obese.

I told she has 2 risk factors for Endometrial CA. would like to rule out.
I explained diff diagnosis for pruritis vulvae. Time ran out.

  1. Anaemia in Preg. Hb 90. Iorn studies not available.

I mentioned Hb electrophoresis not required as it is only indicated if MCV less than 80.
Otherwise straight forward.

Psych

  1. 21 yr old pt with psychosis. You have admitted him. Pt accepts using drugs but has not given consent to discuss with others. (Repeated)

Explain condition to father. Father asks is his son has used drugs.!!! They always want to trap us!!. I told father that he has used drugs. There is no Pt confidentiality here as pt cannot take an informed decision. This was told by a white psych reg in my hospital. But looks like its wrong. For AMC purpose you should not tell parent.

  1. Anorexia nervosa

Med and Surgery

  1. Acute MI/ arrest

Pt is in agony giving a Hx of 1 hr central CP radiating to jaw and left arm. After Hx when asked for ECG pt collapses. Examiner asks what to do. I said pulse, then I was thinking for a while and said correct reversible factors, she still asked what else. Then it struck me I said monitor. She showed an ECG of VF and asked me treatment. DC shock. Then pt is awake. ECH shows MI. ST elevation in V2 to V5. Then I explained mamagement. A bit tricky with the sudden VF ECG thrust upon you!!

  1. Young girl with swelling to right arm.

I asked about injury, insect bite, cellulits and Questions about prev mastectomy and axillary dissection. All –ve. Also asked Questions about DVT. Pt gives Hx of playing basket ball and said she was using the arm to paint the house 2 days ago.

Examination findings (if specifically asked): swelling in whole of arm. No pain. No cellulites or raised temp. All pulses palpable.

I asked for imaging. Not available. I said USG of lymphatic system and rule out DVT. Examiner was not entirely pleased. I checked in internet that vigorous use of arm can cause self induced DVT. This particular examiner was a GP I think. When asked for bit further investigations he was blank. He didn’t know much. I guess he was probably coached to elicit only diagnosis. If we thought of something else he was not aware of other differentials. If possible check this link

I wanted to rule out DVT and lymphedema.

  1. Visual acuity. Pt 17 yrs old and c/o blurry vision. VA was 6/24 both eyes and 6/16 with pin hole. Examiner said no need 3,4 and 6 cranial nerves.
    Looked like myopia. I said he needed concave lens. Did not have tome to refer to Ophthalmologist. Moreover the fundoscopy was not working and I had to waste 30-40 secs before examiner came to my rescue !!! Very bad examiner who thought its my mistake the fundoscopy didn’t work!!!. Keeping a faulty instrument……

  2. 55 yr old lady smoker with SOB.
    Hx I ruled out Pneumonia, CA bronchus. Asked for asthma and COPD. Asked a few questions to rule out PE.
    Examination findings decreased breath sounds to right base.
    I asked for inv. Nothing. CXR not done. Examiner asked to counsel me regarding management.
    This is really unfair, as we don’t discuss treatment options with pt before diagnosis. Examiner told me to manage her with the likely cause. I was thinking in terms of emphysema and counseled her to stop smoking and other things. I completely forgot about the decreased breath sounds to right base.
    The problem is if CXR had been given we can proceed towards diagnosis. To counsel for something only based on clinical findings might throw you off track. That’s what happened to me !!! I told in diff diagnosis about pneumonia, PE, CA, COPD and failure but ended up explaining emphysema when maybe I should have explained CA or even pleural effusion.

  3. 50 yr old lady with 4 yr Hx of constipation. UGI and colonoscopy done 1 month ago are normal. FOB normal. Manage.
    Looks like normal constipation. I wanted to rule out Hypothyroid. Explained about diet and Exercise and Coloxyl. Strange station.

  4. Hip pain. Repeated. 50 yr old brick layer with chronic back pain. Now presents with pain in ant thigh and groin.

The role player gave Hx like intermittent claudication. By the time I ruled out malignancy and claudication, time almost ran out. In the remaining time I asked for exam. He had heberden node. I did not have time to explain management although I diagnosed OA. This particular examiner was very slow in giving the exam findings and the role player always kept looking at his script to answer. Obviously he was not prepared rather not coached/taught or handle to answering questions towards malignancy and intermittent claudication. These people expect us to diagnose OA of hip just with a Hx of hip pain and thigh pain !!!
Very poor examiner and role player.
Even though I have seen this Q in past papers and knew the diagnosis the role player took me in a different direction. Lots of wasted time.

  1. Renal colic in 20 yr ols lady. Finally a straight forward station with straight forward answers from role player. But the way the pt was wincing in abdominal examination it was hard to believe it was renal colic. She was very tender in LIF abd and I also included Diverticulitis and Ectopic in diff diagnosis. U/A blood +++. No leuc or nitrites. Beta HCG not available. LMP 2 wks ago. The examiner made it up. I think he was not expecting ectopic in differential. This examiner was good and he told me that the diagnosis was indeed renal colic.

  2. Autologus blood transfusion.

50 yr ols lady is undergoing THR . Wants to know about options of donating her self blood. In counseling pt asked me how much units she should donate before hand and what will happen to the blood if she does not require them. Also she asked me what happens if she requires more blood that she has already saved for herself. What is the life of stored blood.

These questions look straightforward. But when you are suddenly asked something unexpected you are unprepared.

The questions when you read might look very easy. The OA hip station both examiner and role player were bad. In the swelling of arm station the examiner was pathetic. If by chance you get these as your initial stations you moral would be affected and will subsequently affect the rest of the exam. The main problem was most of the stations had normal variants. Its easy to detect disease, but difficult to call something normal.
Looks easy but the exam room can do a lot of tricks.