Sydney 2008 March

7/28/2019 Sydney 2008 March

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Sydney 2008 March Breaking bad news

60 yrs old her In greece came for check up and you

examined her, on examination you found that her heart s enlarged and you did an X - ray and on X- ray

heart seems normal but Sver is found to be enlarged so you ordered CTscan, reasufis have come

today and margarate has come to talk to you about the results.

Task talk to the patient and interpret CTscanAfter greeting 1 started talking to her that we havegct the result of your CT scan today Then ishowed her that them are some suspicious tescsws in her CT Iwer we called andgradually told her that ft could be something nasJy that might have come here from somewhereelse like bowel pancreas, fiver Itself, then patient asked me what are you going to do now.and itofd her that we are going to do the Biopsy which ts to take a smait pteee of tfesuse from here andanalyse it in the lab to find ut from where it has came and accordingly we will plan for the treatmentThen the patient asked me that she is going to Greece in 2 weeks time. I advised her that i wilt

check with the radiologists t do biopsy early and also do some blood test like Tumor markers asearly as possible and its better if she wail for the diagnosis to be' confirmed first and {hen you canplan for your trip easilyExaminer asked me what are the test you are going to do before fiver biopsy and what are thetumor markers you are going to do?

Acute psycosis

25yrs old university student came to your general practice because of wrist cut injury which he does

not know how he got that, Nurse has done the bandage and during history you found out thathe is

also taking some sort of drugs, he has some work problems and hallucinations and delusions . He is

paranoid also. He has no insight as well He is not suicidal and is living with his classmate in a

shared room. No other medical problem as such. After bandaging you need to talk to him about

management. No more histroy or examination .

Talk to him about managementI just talked to him about my diagnosis is acute psycosis and why i am thinking so . I told him aboutsome reasons of acte psycosis and what i am going to do .\ told him as well as examiner aboutmanagement which is to do invalunfry admission and which is by activating the mental health actNSW. In hospital some blood test will be done to check which drugs he is taking and also psycitristwiil also do assesment and accordingly further managment will be done.

Secondary PPH

A 25 year old mother complain ofdizziness after second delivery.

task take history .examination finding from examiner and manage


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in histroy patient whole pregnancy was alright .delivery was alright .baby was fine, episiotomywound was ok. After delivery bleeding gradually decreased but for one day it started again notassociated with pain or cramps or fever. She didnt pass any clot, not on any medication orbleeding problem . She was breast feeding . good family support, no history of trauma. Thiswas second -delivery.. First delivery was ok. Delivery was in hospital.Examination findings were all ok except uterus was 2 cm below the umblicus, non tender, firm .no adenexal tenderness.

I explained to her about the diagnosis and told her the reasons as well .

Then Ijust said that in your case your womb is still big so i need to send you to hospital to findout why is it big . over there USG will be done and ergometrine will be given and if necessaryD&C will be done .Obstrafician will look her as well, and btood test will be done.

CVS examination

/ Respiratory examination

25 yr old man complaining of dry cough for 6 weeks started after chest infection. Father has

history of hay fever, patient himself has no known allergies.

Task Do respiratory examination in 4 min Ask forinvestigation finding Tell your diagnosis

1 performed respiratory system examination from tally book then examiner asked me myfindings which i told are normal, then she asked me about investigation and i asked aboutspirometry which showed 15% improvment in FEV1 after the bronchodilater. and i told aboutthe diagnosis as Asthma .


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A 12 month old child has come to you with histroy of refusal to walk for one day. Father has

come to talk to you

Tsf&k take histroy ,ask examination finding, manage

In histroy child has been sick for about one day with fever and refusal to walk as well asfeeding tess than usual. mother recorded her temperature which was 38,5 F No vomiting, norash, no injury, no history of contact with any other person having infection, not drowsy, 2weeks before history of URTl .two other kids at home who are healthy and fine, no history ofany allergies. Al! pregnany details were ok,, healthy child so far except for this problem today.Immunization up to dateExamintion child is irritable, feverish 39F knee is swollen red warm restricted ail movements,no rash no neck stifness .throat is ok

managment I totd to the father that his child is sick and we need to admit him in hospital, hemight have got infection of knee joint of he might have got infection of bone we call

osteomylitis. It is very important to start him on antibiotics and do some blood test like FBCand culture, ESR, CRP and bone scan and if necessary specialist might do joint fluidaspiration and culture as weil to make sure.Father ask about how much he has to stay in hospital and how long will be the antibiotics will begiven to him, what are the complications involved-

Pyloric stenosis


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5 wks old baby presented with history of vomiting .

Task take history examination finding from examiner and manage

On history child has two weeks of vomiting and vomitus contains only breast milk, notgreenish, no blood and comes immediately after feed, child is now passing less urine and lessbowel action as weli. No fever, not drowsy but irritable child . mother takes care of the childherself and he deosnt go to daycare. there is another child with history of gasteroentritis2weeks before. Pregnancy details are fine .immunization is uptodate.Examination finding child is irritable ,no depressed fontenelle no sign of dehydration, no rash ,vitals normanl. abdominal examination is not possible because child is crying .then i asked thati want to observe how the child vomits after feed and examiner ask that vomitus is forcefuland child cries after thatManagement I told the mother that child might have got a problem we called pyloric stenosisand drawed diagram for that. Told her that child needs to be admited and assesed bypeadratrician , in hospital child will be necked .electrolytes will be balanced then once stablewill be operated we called pyloromyotomy. Case is from AMC books and all questions askedwere from book.

Child Abuse

1 yr old child came with histroy of roll over injury and brusies on face and is irritabe and crying

for one day.Parents are uni students 23 & 24 old , height and weight of child dropped from

50th to 30th . You have assesed child and talk to parents about management.

Task take further history and manage


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SO i asked about pregnany details which was unplanned but otherwise without any significantproblem, birth weight was 3.5kg .child was breast fed up till 2 months then bottle fed-immunization s up to date . no problem before, parents were uni students . no financialsupport, no social support, both parents smoke, drinks vodka, marruagna smoke. I just toldmother that as your child has rolled over injury so I am concerned about health of your babyand we need to admit him and do CT scan as we need to rule about head injury, motherbecame furious and said to me are you saying that dont take care of my child .then I told herthat I am not commenting on your parenting I am just telling you how we need to take care ofyour child and he needs assesment from peadiatrician. Then she said that his father will bevery angry when he came to know this all and i wont take her to hospital. then I just said that ineed to inform to DOCS and send your child to hospital and bell rang.

/ BPH(AMC)58 yr old man came with history of urinanry problems .

Task take history and examination finding from examiner

do investigations and tell your diagnosis and management


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Gout fromAMC

talk to patient about gout and manage

Aute Inferior Myocardial Infarction f rom AMC

Take relevant history do investigation and tell your diagnosisJ L e h U , c ^ - J ^ 4 f t t e w

Irritable bowel syndrometake a psychosocial histroy and manage

Patient was flight attendant , anxious personality, all investigation done and specialist told her thatshe has got irritable bowel syndrome and she has come to talk to you about diagnosis .she hassome family problems as well as problem with his boy friend and work problems as well. so Iexplained about irritable bowel syndrome and managment as well as psycosocial managment

Ectopic pregnancy

4 weeks before patient was diagnosed with ectopic pregnancy and laproscopic removal was done on

left side , right side is ok. BHCG is 15000 at that time.

tatee a relevent histroy and answer her questions

In history this was patient first pregnancy and before that she was on OCR and single partner for10^fs. Menstural details were ok . past history of some sort of infection was ther but noinvestigations were done for that, no history of pelvic surgery.no family history of endometriosis orafiy^thing else.pap smear was normal.So rdraw a diagrm and explained about ectpoic pregnancy and told her that it could be infection3o i will do BHCG and Vaginal swab and check it out. told her about that other tube is fine andtesSthy so she can get pregnantagain but chances of ectopic pregnancy are increased .she askedme about how she can know about ectopic pregnancy and i told her as yout periods are regular sotf-u misses even one day check it out or come to me and i will check for you . some time there are*yfnptoms and some time not but when you think u miss your period come .then she asked abouthat are the other ways of treating ectopic prgnancy.

Testicular swelling

25 yr old man came to you to know about the USG results done last time because his left

testicle side seems to be more prominent than other .USG results shows some homogeneous

echogenic foci


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TeW the patient about the results and talk to him

i told about the USG finding and told him about suspicion of cancer which could be seminoma orteratoma but seminoma is more cmmon and told him about futur managment. I told him that i amgoing to send him to surgen for surgery and told him about it will be done, he need to do selftesticular examination and come for regular follow ups as well. after staging further managmentwill be palnned which could be radiotherapy .patient asked me about prognosis and further followup . asked about his fertility which i told will not be effected much and during therapy we will store thesperms .examiner asked me about whether we will do FNAC or not and why, I told we will not do itbecause of pread of cancer to other lymphatics.

Tiredness and Fatigue

42 yr old baker presented with 2 months history of fatigue and tirdness .take history in detail take examination finding from examiner tell your diagnosis and

investigations you want to do no managment

I took a detailed history to rule out other causes of tiredness . patient said no to every questionexcept that past history was positive for dental extraction 3 months beforeexamination finding were only positive for pan systolic murmur and splenomegaly

I told examiner that my diagnosis is Infective endocarditis and told about investigations I want todo which were FBC and Culture ,ESR,CRP,ECG,Urine complete and cultre.Echo


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Dysfuntibnal uterine bleeding

12 yr old girl came with bleeding history for about 10 days . ist period .

take history examination finding from examiner and manage

ON history it was first period and she has been bleeding for about 10 days .quiet heavy, nopassage of Clots, no pain , no fever, no discharge, no family history of bleeding disorder, nomedical or surgical problem, no thyroid problem, no medication usage, not sexually active, motherstarted having periods in same age and sister too but none have got this kind of problem . I askedexaminer about examination finding and every thing was ok . BP 100/60 pulse 100 /min tempnormal no abdominal findings pregnancy test negativeI told mum about Dysfunctional uterine bleeding and also other causes as well, so we need toadmit her in hospital start some I/V estrogen then progesterone tablets 14 days . side effects ofmedications as well. obstretitian will check here and might put her OCR for 6 months .MUM askedme about any other medication beside OCP the i told her that yeas we do have mefenemic acidand trenxemic acid but they are not as effective as ocp in regulating the hormonal axis . then sheagreed . I told about list of investigations that we need to do in hospital.

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Sydney 2008 March