Adelaide May 2004

1. Schizophrenia:60 year old lady which wants a letter to move fromher house. It seems to be Organic cause, paranoid schizophrenia. DDx includes delusional disorder, depression, OCD. 60 years old: should R/O anyorganic cause at this age with CT scan and U/A.

2. Acute Urinary Retention:Middle aged lady unable to pass urine

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for 16 hours. First after palpating the bladder insert the catheter then take

history (present, past and medications, alcohol), exam (abdominal and

vaginal and PR), send urine for MSU, FBE and U&E, Abdominal X-ray, U/S. If

there was a mass then CT with contrast. Remember herpes and fecal

impaction as potential causes.

3. Coma:Young female brought by flat mates which has neck stiffness.

4. Lethargic baby:Lethargic 4 month old baby with high fever and norash. Remember the complications of bacterial meningitis. Septic work up

5. Diabetes Mellitus:60 year old man with urinary symptoms and no

history of diabetes. Very anxious regarding prostate cancer. A very tricky

case to see whether you are looking for everything or you are single-minded.

DDx: DM, prostate, CHF. Remember to look for edema. Admit the patient

6. Anorexia Nervosa:The girl which is dehydrated and has posturalBP drop. Remember admission and ECG.

7. Hypertension:The 25 year old lady which is on OCP for 3 years andhas had UTI in childhood.

8. Premature Rupture of Membranes:sterile speculum

If the woman is GBS positive then induction should beconsidered from 32 weeks, otherwise induction should be

considered from36th week.Temperature and pulse control. FBE weekly, CTG twice a week, U/S fortnightly. All womenshould be observed in hospital for 72 hours. If they remain well and are not in labour, they can

Prophylactic antibioticserythromycin 250 mg orally qid. (In those with no sign of infection). Intrapartum GBSprophylaxis: Benzyl penicillin 1.2 gr IV then 600 mg qid until delivery. If allergic: clindamycin600 mg tds.

9. Back Pain (Sciatica):Young man after lifting a heavy object. Taskis examination.

10. Cervical Cancer:43 year old lady with bleeding (post coital) not

related to periods. Remember multiparty, sex at early age, early pregnancy, multiplepartners and smoking.

Treatments of cancer include Radical hysterectomy, radiationand chemotherapy. Notes: all of these patients

(intermenstrual or postcoital bleedingespecially over 35) should be referred even with normal pap results. In

postcoitalbleeding ask about IUCD and OCP as well as looking for cervical ectropion. Changethe OCP to a

higher dose.

11. Chronic cough:18 month old child with chronic cough at night for 10

month. Growing well, no wheeze, no allergies and no passive smoking. Remember

normal approach. Remember postnasal drip, Reflux, FB, drugs and CF.

Investigations: CXR, PH monitoring and manometry and a trial of bronchodilator. If

normal reassurance and follow up or referral. Some candidates claim it wasA st hma.

12. Knee exam: Medial meniscus injury. Remember arthroscopy

13. Swollen ankles:60 year old lady who travels a lot. Swelling goes

away in the morning and worse at the end of the day. Mild SOB. If investigations for

heart (Echocardiogram), kidney (U&E) and liver (LFT) were normal then

“Idiopathic edema”. Ask about tension, depression and headache. May also

involve face and hands. Management is with supportive stocking and salt restriction.

Diuretic make it worse but a trial of sprinolacton is recommended.

14. Spontaneous pneumothorax:Remember to advice against

flight and diving for 3 month and smoking and high altitudes. The recurrence rate for

both primary and secondary spontaneous pneumothorax is about40 % . Repeated

cases might need pleurodesis with sclerosant injection.

15. Scarlet Fever:Be careful to differentiate from Kawasaki. Benzyl

penicillin for 10 days. Complications: Rheumatic fever, glomerulonephritis, otitismedia. Some candidates claim it

was meningitis, so make sure it’s not a purpuricrash. Scarlet fever rash is blanching and sandpaper in quality.

16. Acute Abdomen (Mesenteric Infarction):Re me mbe rthe pulse (irregular). Remember that revascularization cab be tried but the results are poor. Operation involves resection of the dead gut. Survival < 30%

Melbourne Feb 2004 1. CVS exam:The 60 year old man which wants to travel overseas.

2. Abdominal Pain:30 year old female with vomiting, fever and upper

abdominal pain. Task is examination, investigation and management.

3. Bronchiolitis:4 month old child with fever, wheeze, low sats (91%)and less wet nappies. RR=61

4. Newborn Jaundice:30 hours old newborn with Jaundice. Billirubin

conjugated or unconjugated>360 needs exchange. You should exclude sepsis, ABO

incompatibilities,

5. Breast lump with cyclical pain:42 year old lady which her

6. Atrophic Vaginitis:A 65 year old lady with greenish discharge.Task is history, exam and investigations from examiner. Then explain to the patient and manage. Note: Investigations should include:PH, whiff test and wet film. In wet film looking for clue cells, spores, trichomonas and

7. Intermittent claudication:66 year old with right leg crampwhile walking. Task is history, exam, investigation and management.

8. Diabetic Neuropathy:43 year old lady with right leg weakness.

9. Enuresis

10. Gestational Diabetes:All women (others than those at special risk seebelow) have a 75 g non-fasting glucose challenge test (GCT) performed at 26 weeks. If the 1-hour plasma glucose is ≥ 8.0, they will be recalled to have an oral glucose tolerance test. Theg luc os etolerance test is performed after a 10-12 hour fast. The fasting plasma glucose is measured, and then

Gestational diabetes (GDM) is defined by either a fasting plasma glucose value≥ 5.5 and/or a 2-hour

value ≥ 8.0. All women with GDM are seen initially by the diabetes nurse

The target levelsare ≤ 5.0 fasting and < 6.7 mmol/L 2 hours after meals. Initially all women are

treated with dietary and

11. Preeclampsia:30 year old primi 32 weeks pregnant. BP is 170/110

12. Visual Problem: 25 year old lady having difficulty reading noticeboard. Same problem in father and brother. Relevant exam and management. Most probably keratoconus. NOTES: Keratoconus is a thinning of the central zone of thecornea, the front surface of the eye.As a result of this thinning, the normally round

8% of patients have affected relatives.

13.Wrist injury exam 14. Postnatal depression 15. Osteoporosis 16. Renal Colic

Sydney March 2004 1. Twin Pregnancy:Diet, Iron and folate, Dietician referral, maternalcomplications(polyhydramnios, preeclampsia, anemia, PPH, APH, Cord prolapse,

malpresentation), fetal complications (IUGR, malformations), High risk antenatal care

2. HIV test and counseling:Don’t forget testing for other STD’s

3. Spontaneous pneumothorax:Primary—no prior lung disease.Secondary—complicating preexisting lung disease (Asthma, Cystic fibrosis, COPD,

TB, menstrual pneumothorax), Remember 30%, simple aspiration or catheter

4. Shoulder exam after dislocation:Re me mbe rmusculocutaneous and radial nerves as well, warn against abduction and external rotation

5. Incomplete abortion and cervical shock:It’s a vagalstimulation due to cervical pressure and uterine stimulation hence a drop inBP and pulse. Investigations for recurrent abortion: karyotyping of parentsand fetal products, U/S, Antiphospholipid and lupus antibodies

6. Conversion disorder and lower limb exam: Remember to consider this diagnosis only after proper physical exam and investigations

7. Cranial nerve II and VIII exam8. Endometriosis9. Hypothyroidism:Remember decreased ankle jerk reflex, chronicanemia, Bradycardia, dry skin, edema

10.GI malignancy:55 year old lady with 6 month pain in LLQ. Just

remember normal history which includes: present illness, past history,

medications and family history. Remember to ask about weight loss, bowel

actions. Remember first degree relative screening.

11.UTI follow up in a child:Remember repeat MSU and VCUG

12.Acute psychosis management13.Croup14.DVT:remember heparin dose (treatment: 5000 U bolus IV and 25000 Uinfusions over 24 hour. Prophylaxis: 5000 sc 12 hourly)

15.RA hand exam 16.Cardiac murmur in a child

Brisbane October 2004 1.Pyloric Stenosis:3 weeks old child with vomiting. First important

question is asking about color. If Green color then urgent surgical referral. If

non-bile stained then consider pyloric stenosis, GORD, infection (UTI,

meningitis). Projectile vomiting can be present in GORD as well as pyloric

stenosis. In PS look for peristalsis during test feeding from Left to Right.

Treatment is longitudinal pyloromyotomy.

2.Breast Lump:24 years old with lump and tenderness in right breast.

There is a palpable auxiliary lymph node. On OCP. Fibroadenomas are more

common in younger women and may become tender in the days before a

period or grow bigger during pregnancy. Women have a choice about whether

to have their fibroadenoma removed, but if it is monitored and continues to

enlarge, it should be removed. Most often, younger women or those with

smaller fibroadenomas will not have them taken out. The operation to remove

a fibroadenoma is relatively simple. A general anesthetic is usually required.

Remember U/S and FNA.

3.Delirium and MSE:The patient which got crazy after burn.

4.Weight loss:100 Kg man complaining of tiredness, lethargy and 2 Kgweight loss. NOTE: Remember stress and anxiety, malignancy, DM, Thyrotoxicosis, chronic infection, depression and medications. He had DM.

5.Weight loss:45 year old female with 7 Kg loss over 2 month. All theinvestigations are normal. Talk to the patient. NOTES: consider stress and depression.

6.Home delivery counseling:A 21 year old 17 weeks pregnantdoesn’t like hospital and wants a home delivery. Talk to her.

7.Trauma and difficulty breathing:A guy in emergency aftercar crash. There is a CXR. Maybe haemothorax.

8.Vaginal Bleeding:26 years old with bleeding after 8 weeks

amenorrhea. BMI is 30. Remember abortion, PCOS and thyroid disorders.

(when they provide BMI, it means something) NOTES: approach is taking

history of everything with these 3 diagnoses in mind. Investigation with BHCG

and U/S and TFT. If it should multiple small cysts then bingo. Some points

about PCOS: remember risks of DM, hyperlipidemia, hyperinsulinemia and

hypertension. Also increased risk of ovarian and endometrial cancer.

Investigations include: LH/FSH ratio (>2), serum testosterone and

endometrial biopsy. Screening for all women with PCOD include: smoking

history, BP, Glucose (tolerance test), lipids. Management is weight reduction(dietitian referral) and exerciseand PCOS support group. Treating the risk

factors if present. Treatment of insulin resistance with metformin or

rosiglitazone. Hirsutism with cyproterone or spirinolactone.OCP can decrease

the chance of malignancy of unopposed estrogen and helps with irregular

bleeding. Ovulation induction by clomiphene. Assisted induction and at the

end ovarian diathermy. (making punctures on the ovary with a hot needle)

9.Globus Sensation:23 year old girl feels something in the throat.

Her friend died a few month ago of throat cancer. Talk to her. Notes: take acomplete history of dysphagia; ask

whether she gets relief after swallowing.Weight loss, pain and family history. O/E look generally at skin and

hands,inside the mouth for any lump and uvula deviation, tongue deviation, anyneck lymph node, thyroid nodule

(any symptom of thyroid activity) andesophageal obstruction test. (With a glass of water and listening for murmurin tummy which 7 seconds is normal). Investigate anemia and TFT. If everything normal then reassurance and education and support. Don’t forget leaflet and websites.

10. UTI follow up 11. LLQ abdominal pain:Dive r ticulo sis

12. RA hand exam 13. HIV counseling:The guy which has come back from Thailand

14. Spontaneous pneumothorax

Melbourne November 2004 1.Primary Amenorrhea: A 15 year old girl with normal secondarysex features.

2.Post date pregnancy:41 weeks pregnant lady comes for routine

antenatal check. Notes: usually after 41st week induction should be tried

because of increased risks both for mother and fetus. The baby gets bigger

and there is risk of Meconium passage and intrapartum complications.

Remember to refer to Day Assessment Unit for frequent CTG and U/S and

remember the Kicking chart. Induction can be tried by Misoprostol or

Oxytocin.

3.Thalassemia minor counseling:Young lady who is minor is

married with a minor guy. Answer the questions about what is minor and

major. What does the child need if it’s major? And prenatal diagnosis with

CVS and amniocentesis. Notes: Thalassemias is a genetic (inherited) blood disorder that

has one feature, the defective production of hemoglobin, the protein that enables red blood cells

to carry oxygen. The individual with thalassemia minor has only one copy of the beta thalassemia

gene (together with one perfectly normal beta-chain gene). The child born with thalassemia

major has two genes for beta thalassemia and no normal beta-chain gene. Thalassemia major

patients rarely live beyond puberty.

4.Chest pain:45 year old man complaining of chest pain on exertion.Notes: with lifestyle changes remember to startAspir in.

5.Abruptio placenta:32 weeks pregnant with spotting. U/S not

available and CTG doesn’t detect fetal heart rate. Notes: Candidate has not

asked whether the mom is insho ck or not . Anyway it’s a still birth. DDx

asked by examiner: concealed abruption, cord knot, preeclampsia, infections.

6.Croup:7 month old child with barking cough and high temp. Rememberadmission. Question by mum: what is croup: Croup is a viral infection of the throat(upper airway). The virus causes swelling of the voice box (larynx) and windpipe (trachea). This swelling makes the airway narrower, so it is harder to breathe.

7.Chronic diarrhea:3 years old child with foul smelling diarrhea for 3weeks which is hard to flush down the toilet. Has lost a bit of weight. Task is

talk to mum, provisional diagnosis and DDx. NOTES: candidate has diagnosedgiardia, but the point is talking

about giardia and celiac both. Stool should bechecked for cysts and ELIZA or nasogastric aspirate for finding

trophosoites.At the same time Antiendomysial Ab and if needed duodenal biopsy. So becareful.

8.First time Epilepsy:7 year old child has had a tonic-clonic fit for 1

minute at school with incontinence. Now he is fine. Talk to dad and manage.

First ask about any previous disease like diabetes. He Needs admission for

investigation like CT scan and EEG. Whether to start treatment is depending

on the investigation results and neurologist choice. 60 % of children have a

self-limiting condition which will settle after withdrawal of medication.

Remember usual advices.

9. OA hand exam 10.

Acute abdomen:55 year old man who has been taking diclofenacfor 2 month. Has got a sudden pain for 2 hours. DDx: perforated ulcer, MI, cholecystitis, gastritis, AAA. 11.

Impaired vision:18 year old girl complaining of difficulty reading.Task is eye exam. Father and brother wear glasses. Snellen chart. Remember pinhole test and fundoscopy and tonometry. Referral to optometrist. 12.

Lung cancer and hoarsness:55 year old guy, smoker who is

complaining of tiredness and hoarsness. Task is everything. DDx is lung cancer,

thyroid cancer, laryngeal carcinoma, esophageal carcinoma, bulbar palsy. O/E he has

had decreased air entry and dullness in left side.13.

Benzodiazepine dependency:The patient who wants

oxazepam for sleeping problems. She has been to your practice for 2nd time.

Candidate says that she has had suicidal ideas. So find out the real cause of her

problem. Maybe depression and then she needs admission and it has not been a case

of benzodiazepine dependency. Somatization needs 2 GI symptoms, one sexual, one

neural and something else. They must be referred to psychiatrist. Treatment is CBT

and psychotherapy.14.

Colle’s Fracture:reduction is under anesthesia by flexion, ulnardeviation, pronation and traction. Complications: ruptured extensor policis longus, stiffness of elbow and MCP, regional pain syndrome. Remember simplepe r cutane o uspin insertion for severe deformity.15.

Weight loss:Old lady has lost 6 Kg in 3 month. Task is history for 6

min and investigation. Remember stress and depression, malignancy, DM, thyroidand chronic infection. Notes:

remember FBE, U&E, BSL, TFT, ESR, CXR and stooloccult blood. Remember a full search for a possible source

of cancer. (ask aboutmammogram, pap smear, bowel, urinary, respiratory symptoms)16.

Somatization:A young guy with several symptoms for some years.Ask about family history.

Sydney May 2004 1. Hip examination:Past history of posterior dislocation, now

complaining of stiffness and little pain.Lo o k (wasting, swelling, redness,

limping and abnormal rotation of the legs),Fe e l (the greater trochanters

should be at the same level otherwise the higher side is abnormal),Mo ve

(flexion and Thomas’s test (fixed flexion deformity in OA), rotation, abduction

and adduction, extension, trendelenberg test and trendelenberg gait, true leglength which shorter side has problem and apparent leg length which shows

tilting at pelvis if abnormal) Note: in OA internal rotation, abduction and

extension are restricted. (IR extension AB). Sciatic nerve checked by foot

dorsiflexion. Management: pain killer, physiotherapy, hydrotherapy, total hip

replacement with cementless material, femoral osteotomy for young people

2. Meconium stained fluid in labour:as Melbourne April 2006

3. Acute Otitis media in a child:Remember follow-up for glue ear(blowing exercise on the back of the hand and closed nose is helpful) and audiometry if necessary. TM will heal up.

4. Acute Psychosis:Mom wants to know about his son who has been

admitted. Mom asked aboutschiz o phr e nia: it’s a medical condition which

affects the normal functioning of the brain and interferes with the person’s

ability to think, feel and act. Causes are a combination of hereditary and

other factors. Sometimes it has trigger factors like illness, surgery, stress and

drugs. Management: medication and community support(in fo rmat ion ,accommodation, and help to find job, psychosocial rehabilitation and mutual support groups).

Prognosis: some recover completely and some have chronic disease throughout the life which needs

supervision. Investigations during maintenance: BP,BSL, prolactin level, cholesterol and TG, TFT, U&E, LFT,

FBE, ECG. First at 3month then 6 monthly. Always rememberleaflet

5. Female Urinary Incontinence:Differentiate between stress,urge (with no residual volume) and voiding dysfunction with bladder atony

continence nurse.leaflet6. SIDS:say I’m sorry and ask how parents are coping. Remember griefcounselor, SIDS support group andleaflet.

7. Diabetes type I counseling:Remember to carry sweetsalways,leaflet

8. CTS:Tell her as far as you are not overusing your hands u can doeverything

9. Cyclical mastalgia/Lump (Fibroadenosis):Ask what

breast cancer website). Mx: Analgesia, good bra, well-balanced diet, weightreduction, no caffeine, exercise, then mefenamic acid, vitamin B1 and B6, evening primrose oil (EPO), follow up then Danazol

10.Oligohydramnios:34 week pregnant and everything else is normal. Task:

.11.Renal Stone:Remember X-ray, CT-KUB, U&E, Follow up andleaflet

12.Peripheral Vascular Disease:50 year old man on metoprolol forHTN. Remember Doppler U/S and ankle brachial index. Talk about lifestyle (smoking, drinking, fatty food, weight, exercise, too much coffee)

having steatorrhea.Remember pnumococcal (every 4 years) and influenza (yearly)vaccination.

Remember physio for chronic cough.

16.Depression:45 year old female complaining of tiredness and constipation.

Melbourne April 2004 1. Supracondylar Fracture:Remember radial artery, collar andcuff for 6 weeks after reduction and NO need for plaster. Elbow stiffness will resolve without therapy.

2. Alcohol counseling and Child abuse claim: Remember standard drinking and Gatehouse.

3. Cirrhosis examination:A patient with esophageal varices.

4. Post Strep Glomerulonephritis:A child with dark urine and

The familymembers should be screened for GABHS and careers treated. Proteinuria mayremain for 6-12 month and hematuria may remain for years. Follow up and leaflet.

5. Hypertension:The 25 year old on OCP.

6. Polyhydramnios:26 year old 32 week pregnant. Fundal height is

7. Manic attack:22 year old student with decreased sleep and

8. Diabetes and lower limb exam 9. iron deficiency in a child 10. Pancytopenia in childhood 11. Acute Abdominal pain:26 year old female with 6 hour RLQ pain.Task is history, exam, Investigation and DDx. (appendicitis, ovarian cyst, mesenteric adenitis, mitelschmertz, renal colic, pyelonephritis)

12. Primary Amenorrhea:18 years old with no menses. Secondarysexual characteristics are normal. Mom had menarche at 17. Notes: first look for pubic hair growth. If normal it excludes androgen insensitivity syndrome. (Also high

malformation like agenesis of uterus, vagina or septum. Ask whether she has cyclical lower abdominal pain which reveals a septum blocking the blood outflow. Tests:

13. Otosclerosis:In pregnancy.

14. Shortness of Breath:A 65 year old man with SOB. No chest pain.Cough in the morning with sputum. Heavy smoker for 25 years. Task is history, investigation and management. Remember to ask about blood in sputum andwe ight

loss. X-ray has shown pleural effusion. DDx: Infection, malignancy, RA, Lupus.

15. SCC:A patient who you have excised an ulcer from his forehead and now

is coming for path report which shows SCC which has extended to margin of the sample. Talk to the patient and tell him the management.

16. Diverticulosis:57 year old male with constipation and abdominal pain

CRP to determine inflammation. Usually responds to high-fiber diet. Advice to

Some 2004 cases 1. Hypertension:A 19 year old girl has had 2 borderline BP readings in

Remember to ask aboutOCP in every female patient in every station.

2. Hodgkin Lymphoma:a young lady with cervical lymph node has

lymphatic system. Many people with Hodgkin lymphoma can be cured, even when the

3. GBS infection in pregnancy:Pregnant lady who has GBSasking about prevention in her baby.

4. Autologus transfusion:A lady who is preparing for hip

5. Chronic cough:A young lady who has come back from Malaysia.Antibiotics have not responded.

6. Transfusion Refusal:A pregnant lady with severe placenta previawho is refusing blood transfusion.

7. Pregnancy in an epileptic woman:She should be told

Sydney May 2004 Resit 1. IV Cannula Insertion 2.GORD: Middle aged guy with reflux. Explain the results of endoscopy andgive him advices about lifestyle changes.

3.ITP:a child with nose bleeds and bruises after a cold. Platelet is 15.Remember avoidance of IM immunization.

4.Nausea in pregnancy: 38 year old woman who is 8 weeks

CXR

5.Otosclerosis:Lay terms: It describes a condition of abnormal growth in the tiny

bones of the middle ear, which leads to a fixation of the stapes bone. The stapes bone must move freely for the ear to work properly and hear well. Remember hearing aid andstapidectomy

6.Bereavement:In a university girl who has lost her father and can’t

7.DKA:An 18 year old girl who is feeling tired and cannot work properly in

.8.Postoperative Dehydration:Fluid therapy

Melbourne August 2004 1. Otosclerosis:The woman, during pregnancy.

2. Infertility:A couple which wife is normal and man’s semen analysis is:

testicular failure. (Endocrinologist) remember the

IntraCytoplasmic Sperm

Injection (ICSI).

3. Meningococcemia:12 month old child.

4. Chronic diarrhea:Young man with 3 month diarrhea. Task is

5. Post Partum Bleeding:In a country setting and you have tried

12346. Ischemic heart Disease:56 year old man who has done thestress test and has shown ischemia. Smoker and fat. Discuss and manage.

7. Alzheimer’s disease:Daughter of a guy with the disease comes toyou for discussion. She is the only child.

8. Jaundice:a nurse which is lethargic and thinks she has hepatitis. She

9. Vasectomy:Task: explain and answer questions

10. SIDS 11. Vaginal birth after cesarean:Success rates for VBAC range

incision, Epidural anesthesia is not a contraindication for VBAC,O xyto cin use forinduction or augmentation of labor is not contraindicated, not recommended for

12. Allergic reaction counselling:egg allergy in a child.

13. lower limb exam Diabetes 14. DVT:The guy which is on metoprolol

15. Eating disorder:A young girl sent to you by her dentist, concerned

16. Thyroid cancer:A young girl with thyroid nodule and FNA which

Sydney August 2004 1. Jaundice:A newborn having jaundice from 3rd day to 2nd week. He is

2. Stuttering:4 year old child after attending the kindergarten.

3. Placenta Previa:28 weeks pregnant lady who had bleeding for 2

FB E Group & Crossmatch coagulation profile feto-maternal haemorrhagetest. Above 24 weeks

consider steroid injection. CTG to check the fetus. Anti

4. Addison’s disease:45 year old guy complaining of pigmentation.

In an old guy who has brought in by wife

10.Postnatal depression:Do not forget RISK ASSESSMENT

11. Clavicle fracture 12. Anaphylaxis 13. Decreased fetal movements 14. CTS:35 year old teacher complaining of weakness and decreasedsensation in the right arm. Remember that in CTS the pain might radiate to arm.

15. Thyroid nodule management:The first test is TSH. ThenU/S and FNA and if needed radioisotope scan.