CLINICAL EXAM 23 JUNE 2012 (MELBOURNE)
Please note I do not have the feedback as yet.
OTC = over the counter
MC&S = microscopy, culture and sensitivity
ICP = intra-cranial pressure
DD = differential diagnosis
DRE = digital rectal exam
ICD = intercostals drain
1) MANIA: a young lady was constantly walking about in this station and was very unco-operative.
She kept saying she needed to see the president. Of note she did NOT have any hallucinations.
However, she had delusions, with elevated mood, perseveration, flight of ideas and no insight/
judgment. Not suicidal. Not on any medication (OTC or otherwise). Substance use/abuse could
not be ascertained. DD = Mania, BMD II, substance abuse/abuse. Of note the examiner did not
like that I mentioned possibly psychosis due to Schizophrenia as there was no hallucinations.
2) IBS: same story, all the investigations are normal. The patient still not happy. She needed more
reassurance and could not understand how the symptoms could be due to stress of the mind.
She was also not very co-operative, had a lot of problems in different aspects of her life (two
jobs, no friends, problems with boyfriend and family). She did not abuse alcohol or substances.
But through reassurance and simple explanation she finally gave in and said she would try to
decrease her stress.
1) DIARRHOEA, ROTAVIRUS: 19 month old baby with diarrhea for a week, no sign of dehydration.
Has not had any vaccination either. Admit child for observation, to continue breast feeding.
Monitor vitals and for signs of dehydration. To address the issue of immunization with the mom.
Also to send the stool for MC&S, ova and parasites.
2) TENSION HEADACHE: a 9 year old girl with an intermittent headache with no associated early
morning vomiting or any other signs of raised ICP. Also to rule out migraine (there was no family
history of migraine and no nausea or visual disturbances). Mother concerned it might be tumour
in the brain. Need to reassure. The child was bullied at school hence the headaches. To get the
teachers and family involved and to provide support for the child.
3) CONJUGATED HYPERBILIRUBINAEMIA, OBSTRUCTIVE JAUNDICE: 2 weeks of with onset of yellow
skin, noticed on day three. Of note, it was associated with dark urine and pale stool. The baby
was otherwise well in all aspects. The role player was really mean, seemed dis-interested and
tried to confuse me actually. DD = biliary atresia, choledochal cyst, cholelithiasis, bile mucus
plug, bile duct stenosis. Always explain what it could be with a diagram. Role player asked if
mom can continue to breast feed and could it be due to her breast milk. The answer is yes and
no respectively. Plan is to admit, do imaging such as ultrasound/DEXA scan. Bloods for possible
infectious causes like hepatitis, CMV, HSV, EBC, coxsackie, syphilis, Toxo etc.
1) RESP EXAM, ASTHMA: young male, with a history of hay fever but he does not smoke. Task is to
do the examination, followed by investigations. Of note spirometry will only be provided once
asked for, which showed > 15% improvement in FEV1 post bronchodilator hence Asthma. To
advise and explain what asthma is and how to use the pumps. Avoid trigger factors etc. etc.
2) LOWER BACK & LOWER LIMB EXAM: young girl with lower back pain eversince lifting something
heavy. LOOK, FEEL, MOVE. Gait, pain in right leg. Trendelenberg test negative. Could not
perform slump test as patient was in pain. There was limited movement in all directions of
the lower back as well as tenderness over the spinous processes of L4/L5 region. Once patient
is lying on her back, straight leg raising test was positive. Also to perform neurological exam.
Pulses intact but loss of ankle reflex and loss of sensation in the L5/S1 distribution. Of note, the
hammer and cotton wool was somewhat hidden. Ended with explaining to patient what she has,
refer for physio and to educate on proper/hygienic method of lifting heavy objects in the future.
3) HAEMATURIA: elderly male with dribbling, poor stream, urgency and frequency. He also had a
past history of renal calculi in the past and was on Aspirin. However, no weight loss or appetite.
On examination, only enlarged prostate on DRE, everything else was normal. DD = recurrence
of renal calculi, renal ca, bladder ca, medication related, BPH, UTI, bilharzia. Investigations
= urine for MC&S, urine dipsticks, PSA, renal U/S. They just wanted a differential, not even
4) CHRONIC DIARRHOEA: middle aged male with about 3 months history of diarrhea, weight
loss and speck of blood noticed to be on the stool only on one occasion. Nothing of note on
examination. DD = IBS, IBD, celiac disease, infective cause, hyperthyroidism, must rule out
malignancy (Left sided Colon Ca). Here again, they wanted mainly differentials. Investigations
should reflect your differentials.
5) TRAVEL ADVICE: young male going to South East Asia. Has had previous boosters in the past last
year when he went to Bali. Advised as per Murtagh, pre- trip, during the flight and post flight.
Such as malaria prophylaxis, to use condoms when engaging in sexual activities, to avoid raw
food and ice, walk around on the plane, decrease alcohol and coffee intake on flight, to rest
once landed and not to make hasty decisions after a long flight etc. etc. and to return to GP after
the trip for review.
6) DELIRIUM DUE TO UTI: 86 year old female with urinary incontinence, mild fever and confusion
for the past three days. Also on history has had a previous history of stroke a couple of years
back, currently no residual weakness. Past medical history is hypertension. Of note, she was
on lots of medications (2 ACEI’s, statin, ASA) Explain to the patient the cause for the confusion,
which would be delirium and what could be causing it (a possible UTI), always look for other
sources of infection such as pneumonia to which the role player said her mother is not coughing
though. Role player asked if the confusion could be due to the stroke she had years ago? I said
unlikely. I also mentioned the medication needs to be reviewed as she was on two ACEI’s.
7) ACUTE LOWER ABDOMINAL PAIN: young female with pain in the suprapubic area, that was 8/
10, non-radiating. Associated vaginal discharge. Asked the 5 P’s. She is sexually active, does
not use condoms, currently in a new relationship. No dysuria and LMP was two weeks ago, was
always regular. Physical examination was unremarkable, no rebound or tenderness, no masses
or organomegaly. Speculum and per vaginal was positive for a discharge yellow green, os closed.
DD = must rule out ectopic pregnancy, PID (tubo-ovarian complex rupture), UTI, appendicitis.
Investigations = high and low vaginal swabs for MC&S, urine – preg test, PCR Chlamydia, STI
screening (including HIV), to give sydromic management for STI and of note to treat the partner
as well and advise patient to wear condoms until the course of antibiotics is complete and get
PAP smear done.
8) PLEURAL EFFUSION: post – op chest pain (think they said 6 weeks post-op for a perforated
diverticulitis), intermittent, non-pleuritic in nature, nothing made it better or worse. There
was associated fever. Physical examination revealed dullness to percussion on the right lower
zone with decreased air entry on the right. The examiner showed Chest XRAY upon request
which showed a right sided pleural effusion. DD = right lower lobe pneumonia or a sub-hepatic
abscess. Plan was to admit, possible CT chest to ascertain the cause and if pleural effusion to do
a pleural tap and send for MC&S, if patient becomes symptomatic may need to perform an ICD.
9) HIRSUTISM: this was not a good station for me. I thought the examiner was rude. The stem was
a middle aged woman who has been trying to get pregnant for a year now and was having about
3 months of amenorrhoea. There was also a picture of an obese female with facial hair. DD =
PCOS, Cushing’s disease, exogenous corticosteroid and last but definitely not least prolactinoma.
Physical examination was all normal. BMI normal (even though picture was an obese lady, so
don’t get confused like I did). Investigations = testosterone, FSH, LH, androgens, PRL, U/S pelvis
to look for cystic ovaries and CT brain. Management would depend on the size of the tumour.
1) EPILEPSY AND PREGNANCY: to explain the effects of epilepsy on pregnancy and vice versa.
The case was the same as the book. Carbamazepine as the drug of choice as patient was on
Epilim and to commence high dose (5mg) of folic acid early preferably three months prior to
conception (all this already in the book).
2) FIBROADNOMA: also same as book case. There was however, a picture – an ultrasound of the
2x1cm mass, it was homogenous and examiner asked me to describe to him and the patient
what it was. All he wanted to hear was the diagnosis of a breast mouse/fibroadenoma. Patient
was concerned it might be cancer just like in the book.
Hope this helps. I just wrote it now. Its difficult to comment in more detail without the feedback. All the
VMPF trial exam topics were as follows:
1) ALL (acute lymphoblastic leukaemia)
2) ACUTE MYOCARDIAL INFARCT
3) THYROIDECTOMY – counsel complications
4) STI (sexually transmitted infection)
5) ANOREXIA NERVOSA
6) SHOULDER EXAM – OA/frozen shoulder
7) PPROM (prelabour preterm rupture of membrane)
8) BPH/CANCER OF PROSTATE
9) RECURRENT FALL
10) VENOUS ULCER
11) DECREASED WEIGHT (PAEDS)
12) ADVANCED MATERNAL AGE
13) RESPIRATORY EXAM
15) PYLORIC STENOSIS
16) CHAMPIX – do NOT give patient with psychiatric illness Champix. Of note, there was a MIMS
provided on the table so don’t be afraid to use the book. Even though psychiatric illness is not a
contraindication according to MIMs , they failed me as I gave my patient who had bipolar illness,
which was under control for many years.