Adelaide April2008

7/28/2019 Adelaide April2008

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Adelaide 5th of April 2008

Obstetrics and Gynaecology

Case 1

25y.o. Rh-ve woman Gravida 1 Para 1, 30 wks. of gestation came to EDcomplaining of vaginal bleeding and a little pain in her lower abdomen.Routine antenatal tests were normal, US at 18 wks. was normal.

Task: Focused history, physical examination, management.

The patient was hemodynamically stable. She developed bleeding in themorning and used 2 pads until was seen by me. The color of the blood was notbright. At the time of examination these bleeding nearly stopped and womandid not have any pain. She did not have any other complains and felt her baby

kicking. Lady did not have any trauma, did not have intercourse, did notoverstrain herself physically.

On PE: the patient was not in distress,VS"s were normal,abdomen was not tender,fundal height was 30 cm,cephalic presentation,FHR was 140,PV- cervix was closed, spotting,uterus was not tender.

Provisional diagnosis: Mild placenta abruption (


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Case 2

28 y.o. lady has past medical history of 2 miscarriages at 8 and 10 wks of

gestation. She came to your GP setting last week and you ordered someinvestigations.

Task: Explain results of investigations and further management. Informationabout investigations will be provided on request.

Diagnosis: Recurrent miscarrier (1 trimester).

Investigations: 1 PV examination to exclude uterine myomata and cervical

incompetence

2 US examination to exclude uterine malformations

( submucosal myomata, uterine septa), cervical incompetence.

3 STD and TORCH infections screening.

4 TFT to exclude poorly controlled thyroid diseases.

5 Hormonal profile to exclude PCOS.

6 Genetic consultation to exclude chromosomal abnormalities

7 Test for human leucocyte antigen ( HLA ).

8 Lupus Anticoagulation test.

9 Anticardiolipin antibody test.

10 BSL to exclude poorly controlled DM.

11 Rubella status.

All tests were normal. The cause of miscarriage was unknown.

Management: Monitoring in high risk clinic ( needs referral).Stop smoking.Avoid sex intercourse until 12 wks of gestation.Do not travel.Do not overstrain yourself physically.Acupuncture.Every miscarriage increases the risk of further miscarriage by

5%(20%,25%).

AMC feedback: Recurrent miscarriage.


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My status: Passed.

Case 3

A parent requesting sterilisation of her intellectually disabled daughter.

Condition 122- p 637 AMC handbook of clinical assessment.

AMC feedback: Contraception request.My status: Passed.

Paediatrics

Case 1

You work in ED. Your next patient is a 3 y.o. girl, who has been brought in byher dad, because she complained about a painful right leg. Girl was fine lastnight but when she woke up this morning she complained about pains in her

R. hip and difficulties to walk.Task: Focused history, physical examination, investigations, management.

Girl has always been well, active. No childhood diseases, no operations, notrauma. Normal pregnancy, normal delivery, normal development,

immunisations up to date. 2 weeks ago she had a flu like infection with cough,sore throat and fever but got over very quickly without any medications.

On PE: The patient appeared well, not flushed, not in obvious pains. VS"s

normal.Her physical examination was unremarkable except for her R.lower limb.Inspection of her R. lower limb was normal, but there was markedpainful limitation of active and passive movement in her R. hip

mainly on rotation and abduction.Girl had marked limp and did not want to walk.

Investigations:1 FBC , blood culture2 US of the hip3 X-ray of the hip

X-ray was normal; US showed synovial effusion.( on request)

Diagnosis: Transient synovitis/ Irritable hip.

Management:Admission.


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Observation.Bed rest.Analgesics.Mobilisation.

The more the child can rest, the quicker the recovery ( usually settles within afew days). Patients may have a relapse if they increase their activity tooquickly.

AMC feedback: Transient Synovitis of Hip- Irritable Hip.My status: Passed.

Case 2

You work in GP setting. Your next patient is 12 mths old girl, who has beenbrought in by her mother because she had been unwell with fevers for the

past 48 hours. She had vomited twice, but has had no diarrhoea. Dipstick ofurine ( urine bag specimen) showed protein, nitrites, leucocytes.

Task: diagnosis, management.

Explanation: Your child most probably developed condition which is calledUTI. A UTI is an infection in the urine. It may affect the bladderand sometimes the kidneys. UTI is quite common, particularly inyoung children who are still in nappies. It is usually caused by

germs from the poo, which are on the skin, get into the urethra (the tube from which urine passes out of the bladder). This canhappen to any baby and is not due to poor washing or changing.

Management: Hospitalization.Consultation of pediatrician.Microscopy and culture of urine specimen( supra-pubicaspiration or catheterisation).US ( to exclude urinary tract obstruction).Antibiotics:If oral medication is appropriate Trimethoprim 4 mg/kg BD or

Cephalexin 15mg/kg TDS2 If severe vomiting- Gentamicin 7,5 mg/kg IV daily andPenicillin 50 mg/kg IV 6 hourly.For 1 week!Check antibiotic sensitivity and adjust therapy in 24-48 hours.If recurrent UTI- US and MCU, prolonged antibiotico-therapy.

Micturating Cysto-Urethrogram( MCU) explanation:

This test involves putting catheter into the bladder through the urethra. Dyeis injected through the catheter and X-ray pictures are taken. The test is done

mainly to look for a condition known as urinary reflux ( VUR).Draw a picture and explain VUR.


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AMC feedback: UTI.My status: Passed.

Case 3

30 y.o. woman who has 2 y.o. son with Down Sd. came to your GP settinginquiring about further pregnancy.

Task: Counsel the patient.

Counseling: Incidence of Down Sd.- 1,4 per 1000 live births.Risk increases with maternal age.30y.o.- 1:350; 35y.o.-1:250; 37y.o.-1:200; 40y.o.-1:100.Risk of 2-d child with Down Sd. is 1:100.

Risk of Down Sd. in normal population is 1:600-700.

Screening tests: 1 US for measurement of nuchal translucency bw 11-13 wks.2 Maternal serum test for B-hCG and PAPP-A bw 10-13 wks.3 Maternal serum ( quadruple ) test: AFP+B

hCG+oestriol+inhibin A bw 14- 18 wks, can detect 85-90%.4 CVS bw 9-12 wks ( if risk>1/200-250), can detect 100%.

5 Amniocentesis bw 15-18wks, can detect 100%, fetal loss

0,5-1%.Performance of CVS and Amniocentesis: Obstetrician will put a needlethrough your abdomen and womb under US to get sells of the baby fromchorion or from the fluid around him/her and then analyse. By this procedure,woman can know the conclusive result whether the baby has Down Sd or not.

AMC feedback: Down Sd.My status: Passed.

Psychiatry.

Case 1

You work in hospital.17 y.o. girl and her family are suffering at the bedside of their mother who isin the terminal phase of liver disease. Girl was not able to speak any moreafter she heard her mother screaming in pain a while ago.

Task: Focused history, physical examination, diagnosis, management.


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History: Q- Can you answer my Q-s by indicating with your head "yes" and"no"?A- " Yes"Q- Did it happen to you before?A-"No"Q- Do you have any other complains?A-"No"Q- Have you had any infections recently?A-"no"Q- Do you feel any discomfort or any lump in your throat?A-"No"Q- Can you cough?A-"Yes", she did.Q- Any problems with your health? Are you on any medications ?

Any operations before?

A-"No"Q- Smoking, alcohol, recreational drugs?A-"No"

On PE: GA- normal.VS"s- normal.Inspection of neck and LN- normal.Throat on examination with pocket torch and with spatula- normal(instruments were provided).

Diagnosis: Conversion disorder.

Explanation: There is strong link bw our brain and our body. Because you

worry about your mum very much, your body reacts to this bymaking you unable to speak. This condition will disappear by itselfwith time.

Management: Consultation of Psychiatrist in hospital.

Referral to psychologist for CBT.Referral for counseling.

AMC feedback: Psychogenic dysphonia.My status: Passed.

Case 2

You work in ED. 30 y.o. man who was previously diagnosed withschizophrenia had a relapse 2 days ago . His GP prescribed Resperidone . Hetook 2 tab yesterday morning, 2 tab yesterday evening and 2 tab today in the

morning. After this he started to feel dizzy , drowsy and to have headache.



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The patient has had no nausea, vomiting, gastric discomfort, blurred vision,agitation, anxiety. But he had difficulties with sleep lust night. He does notremember what medication he took before for his condition. His healthgenerally- OK. No smoking, no alcohol, no recreational drugs. Married, has 2children, works as a seller.

On PE: GA- looked confusedP=110, RR=18, BP(lying)= 120/85, BP(sitting)= 100/70 (posturalhypotension).

Otherwise PE was unremarkable.

Management: Hospitalisation.Stop taking Resperidone.O2.

Monitoring.Chek blood drug level,ABG, BSL.Consultation of psychiatrist.

Q. from examiner: What psychiatrist will do?A. Psychiatrist may decrease dose of Resperidone or may change thismedication for Olanzapine or Clozapine.AMC feedback: Side effects of anti-psychotic medication.My status: Passed.

Medicine and Surgery.

Case 1

25 y.o. driver came to your GP setting for some advice regarding his epilepsy.The patient was sent to you by specialist who already prescribedCarbamazepin. He had several febrile convulsions in his childhood and 1epileptic seizure 2 wks ago. EEG confirmed diagnosis.

Task: Explain condition, advice accordingly.

Explanation: Epilepsy is the recurrent tendency to spontaneous, disorderedelectrical discharge in your brain manifestating as a seizures inyour body.Draw a picture from " Patient education".You are more prone to develop this condition, because of yourpast medical history of febrile convulsions, then other people.

Patient education: 1 Take Carbamazepin tab. regularly.

2 It is not possible to drive (seek help in Centrelink to

change work ). Restrictions range for drivingfrom 1 mths to 2 yrs, depending on the seizures.


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3 Avoid swimming alone.4 Avoid physical exhaustion, stress, lack of sleep.5 It is better to stop consumption of alcohol, because

it can interact with medicine or to cutdown (patient drinks 1-2 stub of beer 3-4 daysper week).

6 Regular checkups- to watch for any side effects ofthe medicine and to have blood test to check thelevel of drug in the blood.

7 Wear a special bracelet to worn about yourcondition.

Q. from the patient: Should I take this medicine for whole my life?A.- Once complete control has been established for several years, themedication can be gradually withdrawn and stopped.

AMC feedback: Epilepsy - idiopathic.My status: Passed.

Case 2

26 y.o. woman came to your GP setting. She had high BP checked in 3occasions ( 135/85; 140/90; 145/90 ). She was not overweight and did not have

family history of hypertension.

Task: Focused history, management.

The patient started to have BP-problems 6 mths ago. She does not have anycomplains. Her high BP was found during regular checkup. Her healthgenerally is OK. Woman is on OCP " Microginon-30" for 3 yrs. She did not

have any side effect of OCP before. Woman is not on any medications. The

patient smokes 15 cigarettes per day and consume alcohol very rare; does notexercise, has normal diet, does not use recreational drugs. Her job is notstressful. She is in stable relationships with her partner and planning tobecome pregnant next 6 mths.

Management: Stop OCP and use condom until ready to be pregnant.

Quit smoking ( give her "QUIT KIT" and organise next

appointment to discuss this problem).

Life stile modifications ( exercising, reducing salt in diet ).

Urine tests: Urinalysis for protein and glucose, microscopy,


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urine culture.

Biochemical tests: potassium, sodium, creatinine, urea,

glucose, uric acid, cholesterol ( total, HDL, LDL).

ECG.

Renal US.

Consider referral to physician.

Followup in 1 week and 3 mths time.

AMC feedback: Hypertension.

My status: Passed.

Case 3

You work in GP clinic. Your next patient is 25 y.o. man with chronic diarrhoeafor more than 6 mths.


2 weeks ago the patients condition got worse -he noticed some fresh bloodon his stool and on the paper, no mucus, no fat. There is no abdominal pain or

pain on defaecation, no nausea, no vomiting. Now he needs to go to toilet 3-4times per day ( before- only 2 times per day), sometimes he wakes up at nighttime because of urge. Man lost 5-6 kg over 6 mths. He did not travel overseas,did not change his diet; his family history is unremarkable. The patient doesnot smoke, drinks 2-3 stub of beer per week; does not have any stress at hiswork place and home. He is not on any medication. There is no joints pain, noproblems with eyes.

On PE: The patient looks pale, no jaundice. BMI= 20. VS"s- normal. PE isunremarkable except PR- fresh blood on the gloved finger.

Management: Stool microscopy and culture.

Sigmocolonoscopy.

Upper GIT endoscopy.

Feacal fat.

FBE, ESR, CRP.

TFT.

Total serum Ig A.


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Ig A antigliadin antibodies.Endomysial antibodies.Tissue transglutaminase antibodies.Consider referral to surgeon, physician, dietician.

Differential diagnosis: Inflammatory bowel diseases, haemorrhoids, fissure in

ano, cancer, diverticular disease, polyps, Meckel's

diverticulum,coeliac disease, chronic pancreatitis/

cystic fibrosis, hypothyroidism, irritable bowel Sd.

AMC feedback: Diarrhoea ( recurrent ).My status: Passed.

Case 4.

68 y.o. man came to your GP clinic, complaining of pain in his R. calf onwalking , relived by rest. It is getting worse now. He smokes 15-20 cigarettesper day, drinks 2-3 stub of beer per day, has 2-3 days free of alcohol. Thepatient is on diuretics for his hypertension. His BMI- normal.

Task: Physical examination, diagnosis, management.

It was real patient.PE: GA- normal.

VS"s: P=90, BP=140/ 85.After that I examined lower limbs for peripheral vascular disease: 1Claudication on walking; 2 On inspection: no atrophic changes of skin, nocolor changes of calfs and feet, no ulcers, no swellings, no deformities, novisible veins, no muscle wasting, but there is absence of hairs; 3 Onpalpation: temperature- normal, no tenderness, capillary refill=5'', all pulses

are present( femoral, popliteal, posterior tibial, dorsalis pedis ), no sensorychanges, reflexes are normal (information provided by examiner ) ;4Performance of Buerger"s test- positive ( examiner words ); 5 ABI=0,25.

Provisional diagosis: Chronic lower limb ischemia .

Management: Control of high BP.

Stop smoking, start exercising.

Check BSL, lipid- profile.

FBE ( exclude polycythemia and thrombocytosis ).


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Dopler US.

Angiography.

Referral to vascular surgeon.

Aspirin 150 mg per day ( examiner said that I can"t

prescribe it now).

Q. from examiner: What is the differential diagnosis of calf pain?A. : DVT, Acute lower limb ischaemia, trauma, muscle pain due to diuretics,

DM changes, varicose veins. (Examiner wanted to hear smth. else ).

Q. from examiner: What could be the causes of patient condition?A.: Atherosclerosis, embolisation.Q. from examiner: What surgeon will do?A.: Bypass graft or enderterectomy.DO NOT FORGET TO WASH YOUR HANDS AFTER PATIENT!!!

AMC feedback: Leg cramps on exercise.My status: Passed.

Case 5

You work in GP clinic. Your next patient is 38 y.o. woman with chest pain andcoughing who had cholecystectomy 5-6 weeks ago. You saw her yesterdayand ordered CXR. On PE: pale, in distress, SOB; VS"s: T=37,7; BP= 135/85; RR-25-26; P= 94; Lung percussion and auscultation: dullness,reduced breath sounds and vocal resonance over R. lower lobe, pleuralfriction rub.

Task: Explain results of CXR (CXR will be provided by examiner ),management. You can ask some relevant Q-s.

On AP view of CXR I could see small amount of fluid on the R. side of the

chest, but on the Lat. view I saw consolidation as well ( I was not sure aboutconsolidation, so I did not tell about it, but after had regrets about this ). Iexplained to patient that she had a collection of fluid in the pleural space anddraw a picture for her.

Short history: Woman now is in pain= 7-8 ( from 0 to 10 ), Panadol does notwork, cough is getting worse; she feels high temperature ; after operation shewas all right, but about 1 week ago developed SOB , cough, weakness; sheused to be a severe smoker 2-3 y. ago; generally her health is OK.

Management: Hospitalisation.

O2


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Pain relive.

FBE, culture; ABG.

Diagnostic aspirate of effusion .

Ventilation/ perfusion lung scan ( to exclude PE ).

CT scan ( to exclude Ca ).

ECG.

Consultation of physician.

Antibioticotherapy.

IV fluid

Q. from patient: Could it be a Ca of lungs?A.: Yes.Q. from examiner: What you can see on XR?A.: Pleural effusion on the R. side. ( consolidation ? ).Q. from examiner: What is you differential diagnosis?

A.: PE, Pneumonia, Ca, pneumothorax, pericarditis.

AMC feedback: Pleurisy with effusion.My status: Passed.

Case 6

You work in GP clinic. Your next patient is 56 y.o. old women complaining ofbloating and abdominal pain. You saw her yesterday and ordered ultrasoundof abdomen (US was given with stem). US revealed 3 stones in gall bladder.

Task: explain result of US, management.

From description of US I explained to the patient that she had mildinflammation of gall bladder caused by gall stones. I asked if she was on anymedication. She was taking Mylanta for bloating and Panadol for pain but itdid not work. She did not have nausea or vomiting and any other complaints. Idraw a picture of gall bladder with stones in common bile duct and explainedsuch possible complications like billiary colic obstruction; cholangitis andadded infection.

Management: Refferal to surgeon

Pain relieve (Panadine, Pethidine)

Arranging of operation during upcoming week (explain


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preoperative preparation, laparoscopic operation techniques

and postoperative complications).

AMC feedback: Incidental gall stones.My status: Passed.

Case 7

Condition 124, p 639 AMC handbook of clinical assessment.End of life request from terminally ill patient.

AMC Feedback: end of life request.My status: Passed.

Case 8

Condition 137, p 675 AMC handbook of clinical assessment.Review of cytology after aspiration of breast lesion.AMC Feedback: Breast lump.My status: Passed.

Documents

Adelaide April2008