Recall 72 – 17.3.12 - 17 March 2012_Adelaide
Obstetrics & Gynaecology
1. Rural GP clinic, local hospital 50 km, Metropolitan hospital 200 km, P0+0,
30 w, c/o leaking clear water for few hours, no contractions, no fever,
regular ANC, P/A: soft, not tender, cephalic, 30 cm fundal height, FHS
normal. speculum examination: liquor ++, no bleeding or discharge, os
admit 1 f, no cord prolapse, take hvs. Refer to tertiary hospital, give steroid
(Dexamethasone 12.4mg im) 2 injections 12 hours apart; I haven’t give
antibiotics as it is not prolonged time, less than 12 hrs but prophylactic
antibiotics should be ok. Fibronectin/Nitrazin test for liquor amnii and urine
Causes: trauma, abnormal presentation, polyhydramnios, incompetent cervix,
AMC feedback: Premature rupture of the membranes
2. A young lady presented with a painful swelling at left labia, can’t sit, you
are provided with a picture, red, painful and tender swelling plus temp, ask
5 ps, no urinary symptoms, no sti, painful speculum examination, need to
give her analgesics and antibiotics and then refer
her to a gynaecologist or ED for marsupialisation under general anaesthesia,
Infected Bartholin Cyst
AMC feedback: Bartholin’s abscess
3. 45- y-old female, P3+0, Last delivery 10y, not on contraception, she has
heavy period plus clots, changed 40 pads, seen by a gynaecologist recently,
hysteroscopy and endometrial sampling normal, no bleeding from other
sites, no family history of bleeding disorder, not on any medication o/e:
haemodynamically stable, obese, mild pallor, no postural hypotension, no
hot or cold preferences , chest, heart and abdomen NAD, speculum and pv:
bleeding ++ and clots, ut bulky. Ix: U/S, FBC, clotting profile, ECG, TFT,
Management: Norethisterone NE 5mg/2h till bleeding stop, then 5mg tds
for 2 weeks, Aminocaproic acid or Tranexamic acid, NSAIDs (Mefamenic
acid), OCP( oestrogen 50 micg), MDPA, Danazol, IUCD (Mirena).
If medical treatment failed refered to the gynaecologist again, surgical
treatment option: Endometrial ablation or hysterectomy, the pt refused
AMC feedback: Menorrhagia
4. A father concerned about his son 6-y-old, who fell while was riding a
bicycle last night, today complained of sever lower abdominal pain &
vomiting since 3 hours. Distressed child, no signs of dehydration, abdomen
tender R lower abdomen, no guarding, rebound, rigidity, no masses,
hernial orifices normal, R testicle raised up, no swelling or redness. It is an
urgent condition and need to be referred to a tertiary hospital, for surgical
exploration to restore blood supply, it is possible to loose the testicle if there
is any delay. Torsion R Testicle, AMC feedback: Torsion of Testis
5. 6-y-old boy, the second of three children, his mum P3+0 complained of his
disruptive behaviour, rude and aggression, low marks at school, teacher has
similar observations, the child is difficult to settle in the class with lack of
concentration, mum is very tired, the father is a busy truck driver interstate,
the child never seen by a doctor for this problem even it is going on since
his birth, BIND questions all normal, growth chart for height and weight
all are normal, milestones without any delay.
Need to refer to the paediatric psychologist, eye and hearing check, social worker for the mother help
(mum is not depressed), family and school meeting and review. The most
likely diagnosis is Behavioural Changes, ADHD
AMC feedback: Oppositional Defiant Disorder (New Case), Failed:
6. A lady, 30-y-old, P1+0, a previous Down’s syndrome, she is willing to
conceive again and she wants to know her chance to have a normal child,
and wether there are any screening and confirmatory tests, her husband is
very concerned of having another Down baby. She hadn’t had folic acid in
the previous pregnancy. I explained that the risk of recurrence is 1%, needs
to report early if she decide to conceive and to start folic acid 5mg 3 months
before conception and 3 months after. The screening involves:
Confirmatory Tests include:
• CVS (10-12 w), result available in 48hrs, incidence of miscarriage
Amniocentesis (14-16 w), result take 2 weeks, incidence of
miscarriage is 1: 200 You need to talk to the husband as well in the
next visit, explore how they cope with their child, and give pamphlets.
AMC feedback: Down Syndrome – Genetic Counselling
Trimester (11-13 w): Nuchall translucency US, free B-hcg and
Trimester (14-16w): US, AFP, B-hcg, Inhibin, unconjugated
is 1:100, it is quicker and earlier
7. A university student wants to see the Prime Minister urgently to talk to
him about the terrorist attack, he has no time to waste, and he is in a hurry
and has no time to answer your question, elevated mood, flight of ideas, not
hostile. (Do HEADSSS, MSE, MMSE, Psychotic features), need admission
voluntary/involuntary, give a summary to the examiner and DD: (Schizophrenia,
AMC feedback: Hypomania/Mania
8. A lady,45-y-old, a known case of chronic schizophrenia, on Olanzapine,
gained weight 12 kg in 3 months. She is not on any medication and has no serious
illness, lives on her own, doesn’t cook, High BMI. You need to do MSE and
MMSE and psychotic questions, need to be referred to the psychiatrist to change
her medication possibly to Resperidone with cross over period of 2 weeks in the
hospital or at the community with the GP supervision and someone to live with
the patient, reduce Olanzapine
gradually and increase the Resperidone gradually, Ix: drug level ½ live, Lipid
profile, blood sugar, FBC.Advice life style modification as well
Anti-psychotic medication side effect (Olanzapine SE)
AMC feedback: Weight gain side effect anti-psychotic drug
Medicine & Surgery:
9. A 50-y-old woman, hypertensive on Enlarpil and hydrochlorothiazide, BP
150/90 no proteinuria BMI 30 Positive family history of stroke, eat junk
food, sedentary life, Urine dipstick showed ++++ sugar last visit, Today
came to discuss with you the blood sugar result, she is a symptomatic, RBS
15 mmol/l, task: to counsel her.
It is Type 2 DM, assess her CVS risk factors, and order some investigations:
GTT even the picture is clear. FBC, Urea & Electrolyte, lipid profile, HBA1C,
TFT, ECG, urine M & C/S, 24 hr for protein. Stop the hydrochlorothiazide as
it contributing to her hyperglycaemia.
Advice lifestyle modification, Exercise, healthy diet, Metformine and refer her
to Endocrinologist to assess as she might need insulin as well.
Refer to Dietician, Ophthalmologist and podiatrict annually, HB A1C every 3
months. Educate her about using glucometer before and after meal several
time a day, educate her about hyper and hypoglycaemia, to learn about
glycemic index when go to the supermarket. Type II DM.
AMC feedback: Type II diabetes mellitus
10. 45-Y-old, healthy man, overnight swelling L leg 2/3 (Picture provided),
was doing gardening last night denies any bites or injury, not diabetic,
no h/o PVD, no trauma, no rhumatological joint pain, no sign of DVT,
no serious illness, SAD ok. No allergy. Management: Start IV antibiotics
(Fluxocloxacillin ), referred to the hospital. Cellulitis of L leg
AMC feedback: Cellulitis of left leg
11. Middle aged man presented with L shoulder skin lesion confirmed
Melanoma, grade II (tumour cells extend into the superficial papillary
dermis), histopathology report (previously excised with 4mm margin)
provided, the bad news it is skin cancer, the good news it is localised not
spread, no metastases to liver or LNs, futher excision is required 1-3 cm by
cosmotic surgeon, prognosis 85% 5 years survival rate.
Preventive measures: slip, slap, slop (sunscreen, hat, avoid sun exposure at
Review 6 monthly and annual chest x-ray
The examiner asked about the types of melanoma (nodular(most dangerous due to vertical growth phase),
superficial spreading melanoma(commonest), Lentigo maligna(in elderly); Acral lentiginous - inc subungal). Melanoma
AMC feedback: Melanoma
12. 45-y-old, c/o R leg pain after 100m walk, no rest pain, not on any
medication, no AF, Task: physical examination + Management.
Smoker, need to stop (Quit), high BMI (modified life style)
Positive findings: no trophic changes, no ulceration, no swellings, sensations
intact for light touch and pin prick for. Absence of peripheral pulses R LL:
DP, PT, Popliteal artery and weak pulse of femoral, Normal Left LL pulses.
ABI=0.6 R leg, (occlusion above inguinal ligament) Put him on aspirin and do
general investigations (FBC, random BS, lipid profile, ECG, Doppler US and
refer him to vascular surgeon for angiography and angioplasty (Stent) / bypass
graft. PVD/Intermittent Claudication
AMC feedback: Intermittent claudication
13. AMC book case, undisplaced fracture R clavicle, Read the provided X-ray
and explains to the patient, perform shoulder examination and show how to
apply the sling (8 shaped or St Johns). Check the pulse and the sensation,
The x-ray is the same of the AMC book, the attached x-ray pic is displaced #
AMC feedback: Fracture clavicle
14. A lady, 40-y-old, intermittent fever for 4 months, night sweating, tiredness,
history of travel to Bali with her husband, no mosquito bite, no rash, no
lumps or bumps, 5ps all ok, no cardiovascular or respiratory symptoms or
signs, bowel and water works are ok. Not pallor or jaundiced.
The vital signs all Normal with low grade fever, the focused examination is the
gastrointestinal: the spleen enlarged 2 F, scratching abdominal mark, the DD:
Malaria, Lymphoma, Infectious mononucleosis. Ix: FBC, ESR & CRP, Blood
C/S, blood film for malaria, LFT, RFT, Urine and stool. Pyrexia of unknown
Origin, AMC feedback: Intermittent fever, Failed: the most likely
Diagnosis is lymphoma and not malaria?
15. A young man was found unconscious by his friends in their apartment,
brought to the hospital and you are the HMO, Task: Do GCS, examination,
DD and Managemet.
It is a real patient and not a manikin, Do DRABCDE/primary survey and
secondary survey, the patient is not responding to the verbal or painful stimuli,
the initial score is 3, looking at the eyes: pin point pupils (eye drops may be
used), put endotracheal tube connected to oxygen, IV Canula, take blood for
BS, UE, LVT, FBC, CRP & ESR, blood for alcohol and drugs for medico
legal, ABG, CT brain.
DD: drug overdose (opioid), Head injury, Hypoglycaemia, Meningitis
Coma (drug overdose)
AMC feedback: Coma, Failed: disorganised?
16.You are HMO called to see this 45-Y-OLD man, presented with sever
indigestion, sweating for few hours. Task: H/O, Examination, Ix,
Management, summary to the examiner (Registrar/Consultant).
Pt is distressed pain 9/10 radiated to the jaw, give morphine, oxygen then
proceed with history: no haematemesis or melaena, no GORD or anaemia,
smoker, Casual drinker, second episode of pain, no h/o serious illness, family
O/E: V/S N, no raised JVP no carotid bruit, no heart murmur, no gallop, pulse
regular 96/m, Chest is clear Abdomen NAD, LL no oedema.
Ix: FBC, CRP, ESR, TROPONIN, U&E, BS, ECG, chest XR
Continuing ECG monitoring, the ECG: sinus rhythm, raised ST segment in
lead II, III, aVF & chest lead v1 v2, Summarise the case and admit the patient
to the cardiac unit, Acute Chest Pain, Inferio-Lateral Myocardial
Infarction, AMC feedback: Acute myocardial infarction
I would like to thank Dr. Wenzel (Monash) for his tireless effort to support
the IMGs, Dr. Laurie Simpson (RACGP), Dr Sharmila and Dr Sriram
(RMH),Gillian Fawcett and Dr Sean (Western Health), Belinda Bull (North
West Health) and my Austin Study Group.
I hope that you find this summary is a useful guide in your preparation for
the examination , that’s what I have remembered, please check with the other
candidates of the same exam and read the main topics from the texts and from
Dr. Wenzel’s scenarios.
I have stressed only on the positive findings regardless any details.
Most scenarios have 4 tasks (h/o, examination findings from the examiner,
Two physical examination in this exam: (# clavicle & applying sling. Coma
Always remember to check that your patient understands you by using lay
language, Review and provide pamphlets.
Don’t forget to wash your hand before and after examination of your patient,
taking his consent beforehand, if you examining a woman ask for the chaperon
to attend for vaginal examination.
Consider issues of Ethics and confidentiality
All images were downloaded from the website and some are close to what was
in the exam (Webmaster's note: Sorry I had to omit the photos due to copyright risks; but your recall is the most beautifully illustrated of all I have seen!)
Over all Pass: 13/16.