AMC 2012 June 23 Melbourne PM
(Cases were written before I received AMC feedback, I failed 2 stations
which I highlighted.)
1. (AMC feedback: Probable PID in young woman (O&G) )24yo female with lower
abdo pain. Hx, ask Ex result from examiner, Ix, DDx.
Hx: lower central abdo pain 7/10, constant, no radiation, not a/w N+V+D, no urinary Sx,
BA today, LMP 3/52 ago. No PHx of PID/STI or ovarian cyst, New partner 6 weeks ago.
Ex: T? (I think afebrile), both RIF and LIF tenderness with rebound, PV discharge from
OS but no blood.
Ix: bHCG, FBE, UEC, ESR, CRP, pelvic US, (I cant remember whether did I mention
STD screening) .
(bell ring when I was talking about Ix. Examiner said 'Oh! that is awfully fast, but you are
alright, just go!"
2. (AMC feedback: Acute Brain Syndrome) 85yo female acute confusion, bought in by
daughter to ED.
Hx: lives with daughter, normally well and independent, occasionally SOB after walking
only. Now confused and became incontinent. Denies recent illness. But urine smells!
When I asked for meds, daughter flipped a card table, 'this is the list'', on it got a ACEI,
Aspirin, a statin, and something nocte I dont recognise, probabely sleeping tablets, Vit D,
only 5, 6 of them.
Ex: there is no Ex in task, and Ex said pt is next door. Urine dipstick showed leuk, nitrate
Ix: FBE, UEC, ESR, CRP, Urine MCS, I said I would like to Ex pt for neuro Sx, if +ve,
CTB, DDx, most likely UTI, others like polypharmacy but unlikely according to meds
Mx: Admit, start ABx, then change if needed when culture result is back, review by allied
Q: how long she needs to stay in hospital for? I said depends on what we find and how
she responds to treatment, most likely just few days, then the bell rang.
3. (AMC feedback: Neonatal conjugated hyperbilirubinemia (Peadiatrics) ) 2wk
old baby jaundice since 3rd day after birth. normal pregnancy, delivery, breast feeding,
putting on weight, eating alright, active, both mother and baby's blood groups are O-ve.
bloods showed : bilirubin 220, unconjugated 160 (my mind went blank when i read this
so didnt even think what does unconjugated bilirubin means). Hx, Explain Ix result, Dx
and Mx. (warning! failed station)
(I got the celebrity syndrome when I opened the door, Dr. J. Murtagh came to greet me, I
was shocked and said " glad to finally meet you'', he is soo nice, but I was extra nervous
in this station!)
Hx: prengnacy, delivery all, normal, baby is putting on weight, except jaundice, that
hasn't change (worse or better), but has dark urine and grey stool! no fever.
I said blood result showed bilirubin is high but not alarming high, but we need to keep
an eye on it, if it becomes higher we need to start phototherapy, needs admission. likely
to cause by breast milk. So should I ask my wife to stop breast feeding? No, continue
plz, not necessary, and breast feeding jaundice normally won't get much worse. but need
to exclude other possibility like biliary atresia, which is narrowing and blockage of the
biliary duct, need to do US and if confirmed need surgery. I keep trying to reassure the
father, but he didn't show any signs of relieve at all, so I was panicking, and when I
mention surgery he said baby is soo small! I thought i was on the wrong track!
4. (AMC feedback: Back & leg pain (acute)) 25yo works in supermarket got acute
lower back pain when lifting heavy object. Ex, Summary of Ex to examiner, Dx, Mx.
Ex: inspection, walk, squat, ROM, pretty much limited to every direction. here I knew i
forgot something but couldnt remember then went on to ask pt to lie down, so tone, light
touch (examiner said only light touch needed no need to do pin prick), I found loss of
sensation in R) S1 region, then I did reflex(tendon hammer available), all normal, but I
forgot to do power!!!(altho I did the screening test), Then here i remember the walking on
heel and toe so asked pt to get up and do those. Pt had problem walking on heel but ok to
walk on toe! so L5??? I was confused..so I said likely disc prolapse of L5/S1 region.
Mx: Rest, will provide certificate, analgesics, and next time when lifting heavy object, (I
showed how to do it correctly).
5. (AMC feedback: Persistent effusion with several possible diagnoses) 60yo had
sigmoid abccess drained 6wks ago, had course of antibiotics, but recovered slowly. now
presented with pleuritic CP, no cough, no sputum, no haemoptysis, no fever, had XR
done. Explain the XR to patient, Explain Dx and Ix.
Inside room Pt gave me 2 pic of XR, AP and lateral of CXR, showed just a little bit of
opacity in the right lower lobe region.
Please refer to Dr. Wenzel's case. "pleural effusion, persistent"
6. (AMC feedback:Persistent Cough )24yo, non smoker, PHx of hayfever, had an
episode of URTI, resolved after ABx but cough presists, Do Respiraty Ex, and order Ix,
and explain Ix findings to pt.
RP is an asian guy, sitting on a chair wearing pt's gown. He is completely emotionless,
even worse than the examiner!
Resp Ex, I only finished back, then examiner asked me to stop and order Ix before I get
to the front, i said I need peak flow meter, she said ' what else is equivalant to peak flow
meter? '' Spirometry!
Yeah, then she handed me this paper with 2 diagram and a big table with lots and lots
of numbers on it, I was soo nervous, numbers flow in front of my eyes but I couldn't
retain any information, all I got is FEV1 pre and post bronchodilator, improved 16%, so
I explain that to pt. and said most likely you've got asthma, which is narrowing of small
wind pipe due to spasm and inflammation. Can see from here, Total lung capacity is
normal, But you have good response after bronchodialator.
7. (AMC feedback: Viral gastroenteritis (Peadiatrics) )6month old baby 12 hours of
V+D, bought in to GP clinic by mother.
Hx: no sick contact but, baby not immunized! pregnancy, delivery all normal, growth
normal, still active, no drawing up legs, no fever, still tolerating food, no reduced nappy,
also got 3yo and 5yo silblings at home who also haven't been immunized.
Ex: no signs of dehydration, active, pulse is 140 but baby is crying, afebrile, other vitals
Dx: Gastroenteritis, likely viral and most common rotavirus
Mx: (others said that 6month old we have to admit), but I said giving that no signs of
dehydration and mother said still eating and drinking well, no decreased nappy, and no
difficulty to look after kids at home, I said I would keep them in GP clinic for a few
hours for trial of feed, if tolerating, then can be managed at home, hand hygeine!! and
gastrolyte, continue feeding, if not tolerating food, reduced nappy or become sick or
concerned in any way, bring back to GP or ED. Also advised mother regarding Rotavirus
vaccine, giving at 2, 4, 6month, should be given to all 3 children, of coz this baby just
wait till he gets better.
8. (AMC feedback: Hirsutism (possible ovarian/adrenal tumour) (O&G) )22yo
female, excessive hair growth on chin and face, send it by beauty therapist. Pic outside
showing chin and neck of a fat person, eyes covered, so can't even tell male or female.
(so I was thinking, hmm must be PCOS!)
Hx: RP is a very think and very manly female, when asked about periods she said used
to be regular, then on OCP, then stopped OCP then now period stopped completely for
6month. so I thought hmm must be PCOS, also said she is married and trying to become
pregnant. So I thought must be PCOS so I didnt ask much go straight to Ex:
Ex: 1st I asked BMI, was expecting 29, 30, but examiner said 22!, I was shocked, ask for
moon face, No!, wide back, No! breast normal.
Ix: FSH, LH, testosterone, GnRH, pelvic US, CT abdo, CTB.
9. (AMC feedback: Mild Adjustment Disorder and Irritable Bowel Syndrome )Mid
age female has chronic abdo pain, fully investigated and no pathology found, Dx irritable
bowel syndrome 2 weeks ago. Take psycho Hx and make Dx and Mx.
Hx: She is frustrated that after all these investigation noone knows what is wrong with
her. Because this is psych station so ask HEADSS questions. Turns out her relationship
with husband is not good, she suspects husband having an affair, her relationship with
boss is also not good, which she feels quite stressful. I didn't do well in this station,
and Dx Anxiety + somatiform disorder. Mx: Counselling, CBT, and family meeting +
meds, .but I found Dr. Wenzel's case which is similar, Dx: Major Depression + somatic
10. (AMC feedback: Haematuria ) 65yo male with haematuria and BOO symptoms.
Hx, Ex, Ix.
Hx: Has all Sx of BOO, weaker urine stream, hesitation to start, dribbling at the end, wet
shoes, but now also has frank blood in urine, Denies weight loss, lumps and bumps in
body, On aspirin only , no other anticoagulants.
Ex: No abdo signs, PR - enlarged prostate, smooth and mid groove palpable ( no
Ix: FBE, UEC, PSA, Refer to Urologist for cystoscopy, if suspicious lesion found,
biopsy, if major bleeding site found, can do local haemostasis.
Explain to pt painless haematuria in his age group, we need to exclude Bladder Ca (TCC)
first. Cystoscopy has to be done after it stops bleeding, now need to look out for urinary
retention, because blood clots can block urethra completely. No need to stop aspirin at
this stage risk of CVA, unless major bleeding. If urinary retention, needs to have IDC
insertion +/- Continue bladder wash out. Cystoscopy + Biopsy can confirm Dx.
11. (AMC feedback: Breast Lump)20+ female, found to have a small lump in
breast, outer, upper quardrant, US showed a 1.5x 1cm, well defined lump.No any
malignant signs (nipple retraction/discharge/skin changes etc) counselling. No Hx
required. (warning! failed station!)
I said this is most likely fibroadenoma, which is a very very common benign breast
disease. If want to confirm diagnosis, we could do FNAC, which is using a needle
to take multiple samples from the lump and check the sample under microscopy , if
inconclusive, can try core biospy, but these are not necessary, because from the features
of this lump it is almost certain it is benign, but I can organize those Ix if you are really
worried.(Examiner stopped me here and ask 'so you wouldn't order FNAC is that right?'
I hesitated a little thought he wanted to remind me something, but still said "No, because
it is almost certain a benign lump, but if pt is really concerned I would organize further
Ix", The Examiner node and then turn away start looking at the marking form and seems
uninterested in what I'm going to say afterwards! I panicked a little and thought I failed
already!) this benign lump does not need surgical removal, but if you are really worried
I can refer you to a surgeon to get it removed. RP asked : Would the surgery affect the
appearance of my breast? Reply: It is a very small lump, you will have a small scar
from the surgery, but wont affect your breast other than that. Then I talked about self
breast examination, given that 1 in 14 of women develop breast Ca. Even for pt who
had mastectomy can have breast reconstruction surgery to restore the appearance of
her breasts. (here examiner suddenly became interested and start listen to me, got me
confused if I'm on the right track or not.)
12. (AMC feedback: Overseas travel risks I )24yo male planning to travel overseas,
come to GP clinic for advice.
I asked few questions to establish his plan: single young male, plan to travel with few
mates to ???? place for holiday I asked again where? Examiner said somewhere south
east asia. Plan to enjoy the beach, go to bar, drink some beer. Trip is around 4 weeks
away. No PHx of DVT/PE no other medical problem. Has had all vaccination last year
including Hep B.
I talked about food safety issue: drink bottled/boiled water, eat well cooked food, avoid
street vendor food/raw food/dairy product. Hand hygiene,
If bush walking, wear long sleeves, long pants, use masquito repellent/net, Also will give
some antibiotics for him to take.
Avoid sexual contact, safe sex, if has risky sexual contact, see doctor and screening/treat
(plenty of time left! so ) I asked how long is the flight, he said 7 hours!! - advised pt to
drink plenty of water, regular exercise, foot pump exercise, avoid alcohol on the plane.
(Still had time left so ) I will prepare a travel kit for you with bandage, some ABx,
antiseptic, simple analgesics, and condom in it.
Any questions? No. (pretty much the only station I left room early!)
13. (AMC feedback: Headache - tension (peadiatrics))9yo girl has chronic headache,
brought in by mother to GP clinic. Hx, Mx.
I asked features about the headache. But mother doesn't know much details. So I tell
examiner that I should interview the girl as well. No PHx or FHx of migraine. Normally
worse in the morning but can happen at any time. Not a/w N+V.Otherwise well. Then
asked the HEADSS question, mother said some girls at school have been rough to the
So I said it is likely to be tension headache. Reassure and treat with simple measures,
such as relaxation technique and simple analgesics. But also the possibility the girl has
been bullied at school which can cause problem. Offer to meet with teacher and parents
together to follow up this.
14.(AMC feedback: Chronic diarrhoea) Mid age female with chronic diarrhoea for
months, has had colonoscopy done which was normal. Hx. Ix. Mx.
I asked about diarrhoea, not hard to flush, no blood/mucus, not a/w certain food. no abdo
pain/weight loss. No other medical problem. No FHx of bowel problem. No recent travel
So I said could be something wrong in the small bowel as colonoscopy is normal.
Would like to do Stool MCS, also look for parasites, coeliac disease screening test : IgA
Antigliadin AB,IgA Anti endomysial AB,IgA transglutaminase AB
Examiner asked about coeliac disease, So I explained to patient because your bowel is
unable to process gluten which is common in food, damaged the lining of small bowel,
causing diarrhoea, (bell rang!) I quickly said needs small bowel biopsy before I went out.
(I spend too much time on Hx taking).
15. (AMC feedback: Pre-pregnancy counselling - epilepsy (O&G) )24yo female with
epilepsy is planning to have a baby.
Hx: She hasn't had a fit for many years. Still taking sodium volproate, follow up with her
neurologist. On Microgynon 30. Otherwise well.
Mx: Usual pre pregnancy investigations. Refer her back to neurologist to review
meds, neurologist may consider to change sodium volproate to other meds that is safer
for pregnancy eg. Carbamazepine. She asked : so should I stop taking meds while
I'm pregnant. I said NOOOO!, the risk of her having a fit while pregnant is far more
dangerous than the slight increase risk of malformation of baby. Then she asked what
kind of malformation? (My mind suddenly went blank for a few sec) said I'm not sure,
I can look it up :P. Then I talked about referring her to high risk pregnancy clinic to be
looked after by multidiciplinary team including neurologist, midwife, GP, etc etc. she
needs more frequent follow up and US, also needs to take higher dose of folic acid 5mg
daily as risk of neuro tube defect in baby (then I suddenly realise this is what she was
asking!), asked about her home situation, live at home with husband, but mother can
help, not far from hospital. Advise her to have a system to call for help if she needs. She
asked about if meds are safe for her to breast feed, I said yes the concentration of her
meds is very very low in breast milk, safe for baby, and breast milk has lots of benefit etc
etc, when breast feeding, better to sit on a mat on the floor in case of a fit and injury the
baby. Bath baby in shallow water or better have someone to help in case of accidentally
drowning the baby if she has a fit. She asked about contraception after delivery, I said if
fully breast feed baby, no need for 1st 6months, but after that if still wants to use OCP,
better change to Microgynon 50, as meds increases liver enzyme activity, also has other
options such as IUD or implant etc. Both roleplayer and examiner looked happy, no
16.(AMC feedback: Hypomania/mania ) young uni student brought in by concerned
parents as she insists on flying to US to meet the president. Hx, Summarise mental state
examination to examiner.Dx. Mx.
As soon as examiner and roleplayer finish introducing themselves, Roleplayer started
pacing in the room. To most of my questions she appeared not interested and annoyed
as she is in a hurry to get on the plane, said I'm wasting of her time, I don't understand
how important this is. At one stage she said something completely random and doesn't
make sense. A lot of the questions were not answered directly. so MSE is based a lot on
observation of her behaviour. After I finish all questions, examiner stopped the roleplayer
and asked me to report MSE.
Hx: she found out about a terrorist plot at a music concert, and is planning to tell the
president. She refuses to reveal what exactly it is about to me. She did not respond
directly to me regarding illicit drug use.
Report MSE: Young female casually dressed, non cooperative, reasonable eye contact.
Speech: normal tone, volume, rhythm. Mood is ok to elevated. Affect liable. Flight of
ideas. Denies hallucination. Has gradiose ideation and delusion of having information
regarding a terrorist attack. Cognition and judgment seems intact, Completely
insightless. Denies sleep disturbance.
Dx: Acute psychosis ? drug induced ? schizophrenia
Mx: Involuntary admission to psych ward. Urine drug screening. Bloods FBE, UEC,