2012 March 31 Recall (afternoon, blue group) Brisbane
Hi guys First of all I apologize for writing this recal very late. Due to some
personal reasons I was not able to do so. I am sure you have other informative
recalls for the same March 2012 exam. Let me try to give you some rough
idea about the how the exam looked like from my perspective. Please dont
prepare from my recall. Just give a read and if it helps in even giving some
confidence I will be glad.
Most of the stems are big. I understand that exact reproduction is impossible.
When I see the stem I ask myself some basic questions like 1. where am I?
(hospital/ Gp) 2. whom am I seeing? ( men/women/ age) 3. Is it emergency? 4.
What am I supposed to do now? ( tasks). These can get you through any big
stem in a minute.
• A 28 yr old lady in her 26 week pregnancy (primigravida) comes with a complaint of
painful contractions comes to a rural hospital which is 300 km away from the tertiary
hospital where the neonatal intensive care facilities are available. Her antenatal visits
are unremarkable and her blood group is Rh positive.
1.Take a focused History
2. Examination findings from examiner
Very straight forward and repeated case. No new questions from RP or examiner. Try to
memorize even the questions asked by examiners from other recalls. Hard to believe,but fact
is the same questions are asked by examiners. Dont waste time in bigger books,try simple
wiki for answers in one or two lines.
First, I asked the examiner whether the patient is haemodynamically stable or not(Yes)
After introduction, the apparently anxious RP asked me, “ Doctor, Am I in labour?’’.
HOPI: when did the pain start? Where? Character of pain? How severe it is? Duration and
interval (regular contractions last for about 1 min and every 3 minutes).
Water leakage? bleeding from down below? No
Do you feel hot to touch? No
System Review: Waterwork and bowel? fine
Any accident or sexual activity immediately before that? No
Are you on any medication? Allergy? No
Past History: NAD
Family history: NAD
Examination: Patient is in pain and anxious
Abdo: fundal height 26 week, longitudinal lie, head presentation, FHS 140 strong and regular
PE: 3 cm dilated, no cord presentation, membrane intact
I said after our talk and examination, it is mostly premature labour which means early labour.
Normally the labour occurs between 38 to 40 weeks in most cases. Unfortunately, in your
case, it is earlier. I will give you steroid injection for baby’s lungs maturity and tocolytics
which inhibits the contractions. I am going to do some investigations like swab for infection
and to confirm the labour. It is important to send you to the hospital where the facilities for
the newborn baby are available. You will need USG scan and continuous CTG monitoring
which means to watch the baby’s heart activities. Specialists will take care of you and your
baby. Please try not to worry too much.
RP: Will my baby be alright?
As the baby is quite young, the intensive care will be needed. We will try to delay the
labour to be able to give two steroid injections. You will be fine with special care. Finally
I remember to smile at RP who also smiled at me. The bell rang and I said thank you very
much to both RP and Examiner and ran to next station.
1.name some tocolytics and doses?
2.causes of preterm labour?
AMC feedback: premature labour (O&G) passed
• A 25 year old lady who delivered a full term baby 6 weeks ago comes to GP. The
delivery was normal vaginal, no episiotomy was done. No complication.
• Take history
• Ask examiner the examination findings
• Manage the case.
• I had No idea what the case is. Thought it is a post partum blue/ Psychosis/
Depression . But the role player was very happy and gave no information whatsoever.
I came out of the station in 4 mins. Didnt even give a try. Please dont do that. Try to
stick to some basic history and you can do the case.
AMC feedback: post partum check up (O&G) failed
3.A 58 year old lady comes to GP with a complaint of something protruding from down
below and rash around private area for several months.
Tasks: Take relevant history
Ask for physical examination findings
Role player was a lady around 50's . Looked like a real patient. Not sure. Often I spoke too
fast and she couldnt understand. Guys please speak clear and slow and that will be very
helpful in the exam.
HOPI: She noticed some discomfort and a mass protruding from down below. No discharge.
No bleeding. Rash- itchy, around the private area and groin, no weight loss, no loss of
appetite, no lump or bump. No fever.
System review: do you leak urine while coughing or straining? yes. Do you have a strong
urge to void or leak on the way to toilet? No. Any burning sensation during passage of water?
no. No vaginal discharge, no bleeding. Bowels are normal. No skin rash or joint pain. No
thirst or frequent urination.
Past history: have you ever checked your sugar level? Never, no other diseases like
connective tissue disease.
Family history: unremarkable
5P- menopause 5 years ago, no hRT, married with 2 children, big babies (NVD), I did not ask
the history of gestational diabetes but one candidate said it is positive.
Pap smears were normal.
Social history: Smoking- I can’t remember what she replied. No medication. How does it
affect your life?
Examination- BMI 29, Lungs- clear, abdo- no fluid or mass.
Pelvic examination with the consent of the patient- Cervix can be seen at the Vg orifice,
cervix looks healthy, no discharge, small cystocele, I asked the cough impulse +
Rash around the private area and groin is seen
I would like to do office tests- urine dipstick-urine sugar positive, BSL 11.3 mmol/l
Explanation: According to the history and physical examination, I think u most likely it is
a condition called utero vaginal prolapse. Let me draw a picture. In female body, womb
called uterus and the bladder in the tummy. There are groups of muscles and ligaments that
support that maintain the womb in the normal position. In your case, it decent from it’s
normal position because of weakness of the support. It could be related to big babies, low
estrogen level after cessation of periods, and high body weight. For that, I’d like to refer
you to specialist gynaecologist who can do repair surgery or removal of womb depending
on the situation. If you want to keep the womb, we can do repair surgery. RP: no I have a
complete family. I also talked about general measure such as pelvic floor muscle exercises by
physiotherapy, reducing weight with diet and exercises, avoidance of coughing or straining.
We also found out high blood sugar level and could be diabetes. You may need OGTT to
confirm it. I will refer you to physician. The rash could be a condition called candidiasis,
which is a kind of fungal infection and it is likely to be related to high sugar level in your
I will give u reading materials and I will follow you up regularly. RP looked happy.
AMC feedback: Prolapse (O&G) passed
• A father of 5 yr old boy comes to GP because the boy is suffering from frequent
urination both day and night. His mother has history of celiac disease but no family
history of diabetes mellitus. IVx shows Urine sugar ++++, ketone+++. His blood
sugar level is ?15 mmol/L.
• Discuss the diagnosis with the father
• Explain the immediate and long term management
• Answer the questions from father
First, I asked the examiner whether the patient is stable or not. Yes
After introduction, I told the RP ( a young man who had no interest in the exam, when I told
him about his son's condition,he showed no emotion whatsoever) that mostly it is diabetes
ketoacidosis which means very high sugar level. There are two types of DM, type 1 and 2.
In your boy’s case it is type one. I drew a picture where the pancreas gland is located and
the insulin hormone control the blood sugar level by shifting glucose into the tissue. In your
boy’s case, the insulin producing cells are destroyed most probably due to immune reaction
in which our defense mechanism is fighting against our own cells. In your son’s case it is the
insulin producing cells.Told somethng about ketones as well.The RP was totaly dull. So I just
told him that ' may be this is not the right time to load you with too many information,I can
clearly explain you whenever you want me to'
Then I moved to immediate management. I said it is necessary to be admitted and asked
RP whether it is alright for him. He said if it is required, he will accept that. I said it is
important and I will arrange for the ambulance. At hospital, he will receive intravenous fluid
replacement , insulin infusion and potassium replacement. Some electrolyte disturbance will
be corrected. Then I moved to long term management. I said the boy will need medi-alert
bracelet so that when he is suffering from serious complications like hyper or hypo attacks
which mean very high or very low sugar level, he can have help immediately. Then he will
need regular insulin injections at least two times a day and monitoring four times a day. The
diabetic educator nurse will show you how to do injections which is subcutaneously. He will
need finger prick for measuring sugar. Then I talked whatever I could about the Diabetes as
given in the book to the emotionless father . I covered about sports,camping.
AMC feedback: newly diagnosed child diabetes mellitus passed
• 11month old boy admitted to hospital yesterday for convulsion. He got sore throat and
fever two days ago.
Examination results show Temperature 39, alert.
Investigations are given.
CRP-10, FBC- mild lymphocytosis, BSL-normal, U&E- normal
Lumber puncture has not done yet.
This is the exact book case. But the difference is just it is given in a different way. The
investigation results are given outside. Even the diagnosis is given. The task is to talk to
mother about the diagnosis and treatment. The chart shows lumbar puncture not done and
waiting for few other results. Dont get distracted by that.
I dealt like the same book case.The examiner was a kind lady. After my disaster with
first case , this is my second case. The role player was very co operative and that changed
everything. I felt confident and I kept smiling assuring her about the febrile convulsion. Just
repeated the things given in book. I did ask her about sore throat and she said the baby is ok
now. I also mentioned that few other investigations are pending but still I was assuring her
that everything should be fine.
AMC feedback: febrile infant (paediatrics) passed
• A mother of 4 month old baby comes to GP as the baby has been lethargic and not
feeding well for one day.
Task: take a focused history
My first station. After waiting for two hours, all I wanted was to take the flight back
home. So I was panicking,read the stem,but I did not do what is supposed to be
done in the reading time. So I just stood there like a pillar without thinking about the
There was a young lady with a doll and an examiner. I went in, introduced myself and
started the history. The lady was not so co operative. Sometimes she gave me some
smiles which said ''hey im not the real mother''.
When did it start? This morning.
The baby is hot to touch and not feeding well.
Reduced number of nappies? Yes.
Loose stools? Yes. 3 times since morning. watery in consistency. Non foul smelling.
noisy breathing? no
Blue book / red book ?( I dont remember what book it is? ) She had no idea what it is.
Examiner not happy to help.
Social history: Mum is single mother with little support, she also has one daughter of 5 year
old and she has to take care of both of her children. She lives with her sister’s family. I ask
mum, are u coping well with taking care of your children? How is your mood? She looked
tired. I said I will talk about social support group and maternal and child health later.
Exam-percentiles normal, temperature- 39, lethargic and pale in general appearance. Not
in distress, No signs of dehydration like sucken anterior fontanelle, dry mucous membrane,
reduced skin turgor, capillary refill, No rash.
Respiratory and CVS examination normal. No liver enlargement.
I missed the station by miles. Not listening to examiner and role player. As Dr.Wenzel says
your antennas should go up when u see a child with lethargy,not feeding. Well mine was
burried deep. I focussed more on Rash and when the role player said loose stools somehow
sepsis went out of my mind. Instead of advising the mother about possible sepsis,I talked
about viral diarrhoea.I talked about admission. When I left the station she asked Any
AMC feedback: febrile infant (Paediatrics ) failed..
A middle aged guy comes for follow up investigation results. he has been having chest pain,
muscle aches and pain and sleep disturbance for several months. he drinks 6 cups of coffee
per day. he also smokes 20 cig a day. he is perfectionist and have stress at work.
All investigation results normal.FBE, ESR, CRP, ECG, CXR, TFT, LFT, U&E all normal
he is diagnosed with generalized anxiety disorder.
• explain about the investigation results and why they are ordered.
• Discuss about the diagnosis and management.
After introduction, I explained about each investigation. ECG was done to exclude heart
conditions, TFT to exclude high thyroid hormone level we call it hyperthyroidism, cancer,
liver and kidney diseases are also excluded. All the results are normal. That’s great for him.
Then I said the most likely condition is GAD.
I explained GAD, mind and body circles. RP asked me what it means? How are they related?
The body responds to the unconscious conflicts in the form of physical symptoms like
headache, chest pain. Because of some hormonal changes during stress these symptoms
appear. RP looked happy.
I explored a little bit about his home and work situation. he has no problem at home. I said
it is important to treat this problem as it can lead to heart disease and high blood pressure in
long run. So I’d like to give you some helpful tips. I do recommend that you stop smoking
as it can lead to various conditions like heart disease, lung disease and many other hazards.
I also like you to reduce the coffee intake that can cause increased heart rate. They are not
a good answer to reduce stress. There are some useful measures like relaxation techniques
(yoga, meditation, exercises). For sleep disturbances, you can try sleep hygiene methods.
RP asked me what sleep hygiene is? It means to have an optimal condition to get to sleep.
For example good ventilation, optimal temperature, clean bed, quiet room. You can have a
warm bathe, a glass of milk before bed time. Don’t think about the work and don’t use bed
for watching TV, reading.
I will give you medical certificate to have some days off and have holidays. Sharing of
responsibilities is also another option. Rp looked happy and said ‘If these measures don’t
help, what will you do?’
Refer to psychologist- for CBT which is a counseling section. The psychologist will talk to
you and helps you to find out unconscious conflict in your mind and then replace the negative
behavior with positive one. I will follow you up regularly. If you notice any change in your
symptoms please come back to me. I will give you some medications for your symptoms.
For sleep disturbance, we will try sleep hygiene first. If it doesn’t help, I can prescribe
some sleeping pills. They are just for short term not more than 2 weeks because they can be
AMC feedback: generalized anxiety disorder passed
Q- Husband of 25 year old lady who had her first baby 2 weeks ago come and visit in
ED complaining about his wife change in behavior. The patient isn’t concerned about her
problem but her husband is so worried about her behavior. The husband got consent to talk
about his wife. Delivery is normal vaginal delivery. She doesn’t want to come and see doc, so
husband come and talk with doc and she is waiting in waiting area with the baby and nurse
• Take history
• Discuss about the immediate management and further management with the husband
HOPI: I started with Congratulations for the first baby boy. The RP looked upset about it and
said he can’t be happy because he is too tired to prepare bottle milk for the baby and take
care of him. His wife doesn’t do anything. Behaving oddly, and husband dare not to leave
the baby alone with her. She is also not taking care of the baby, not feeding,not caring. ( Role
player was a miiddle aged man and a good actor,almost like a real patient)
I asked with whom they live- only 3. Then I asked depression questions. How is her mood-
Very low/ elevated? Average. How is her sleep? She doesn’t sleep much- doing these and
those. Do you think her memory and concentration are deteriorated? Yes, she doesn’t pay
attention to something.How is her appetite? She doesn’t eat well. Do you think she has any
idea to harm herself or the baby? Yes, she thinks the baby and me are evils. Do you think she
is weak and has no energy? No. Do you think she feels guilty? No.
I moved to psychotic features. Do you think she is seeing things that nobody can see? Not
sure. Do you think she is hearing voices or talking herself when no one is around? Not sure.
Does she have any abnormal thought? Yes, she believes the baby and me are devils.
Then I went for the anxiety questions. Do you think she is an anxious person? Is the any
ritual that she needs to do daily? No.
Aggravating factors: Any significant event or accident before?
Past history: was she generally healthy? Any mental illness before? No
Family history: is there any one with mental illness in her family? No
Then the examiner told me to move to other tasks.
I found some psychotic features from history. I am not sure what it is but she needs to get
admitted to the hospital for psychiatric assessment and urgent treatment.
RP: What will you do now? I said I am going to talk to her and try to discuss about
admission. If she refuses my advice, I will admit her involuntarily because it is a psychiatric
emergency. I will call the crisis assessment team and likely to go for ECT and medication.
There is a risk to herself and other people as she has psychotic symptoms. As she thinks you
and your baby are evils, we call it illusion. I will also help you to get support from maternal
and child health care and social workers. We will try to arrange maternal and child unit care.
Do you have any other concern? RP said I just want the situation to be well managed.
Please try not to worry too much we will manage the situation appropriately.
The bell rang.
AMC feedback: postpartum psychosis passed
Medicine and Surgery
• A middle age woman comes to Hospital with sore throat for 2 or 3 days.
• Take history
• Examination findings from examiner
• Discuss diagnosis and management
The stem was big. It said you are HMO in a busy hopital. You are busy with a case doing
something. Nurse comes and tells you that there is a lady who wants abtibiotics. Then i knew
the case and as Dr.Wenzel says I bet my money on the right horse. After introduction, I
HOPI: sore throat: when did it start? How severe it is?
Is it the first time? No last year it happened, took antibiotics. RP said she wants antibiotics. I
told her before I give any antibiotic I would like to ask her some more questions.
Then associated symptoms fever? no, coughing ? no, sneezing ? present, flulike symptoms?
present , ear ache? ear discharge? no, pain on swallowing? no, hoarseness of voice? no,
weight loss? no, loss of appetite? no, lumps or bumps on the body esply at neck (no).
System review: headache, shortness of breath, rashes on the body, joint pain and swellings,
abnormal discharge, waterworks, bowels, chest pain, heart racing.
Past history: NAD
Family history: NAD
Social history: smoking (no), Alcohol, IV drugs (No), sexual (protective sex), recent travel
Examination: general appearance: fine, no pallor, not short of breath, no stroidor
ENT: nose: some nasal discharge, ear: normal, throat: red no discharge, tonsils: normal
Neck: no neck glands palpable
Lungs: clear and examiner told me the whole body examination was unremarkable.
I explained RP that Ms…., I can’t find any serious problem and it is most likely viral
infection. I will take throat swab to exclude the bacterial infection. You don’t need antibiotic
right now because it doesn’t look like bacterial infection. RP said I want antibiotic because
last time it became better. I said we are afraid of antibiotic resistance and don’t usually
recommend in viral infection. I will give you pain killers for sore throat. You can try asprin
powder gurgles or salt water gurgles. Please take soft gentle food during the painful period.
I will see you after 2days. If you have any high fever, shortness of breath, severe sore throat,
neck glands and pain on swallowing please come to me immediately. I smiled at RP and
reassured that she will be fine. I asked RP any concern(no).
AMC feedback: sore throat passed
• A middle age woman with intermittent hoarseness of voice
• Ask examination findings
• Discuss the diagnosis and management
HOPI: when did it start? A few days. Is it the first time? (no, first time was a few weeks ago)
Is it associated with fever? No. Any weight loss recently? No. Any lump or bumps all over
the body? No. Night sweat? No.
System review: Do you notice pain on swallowing? Choking or ear ache? Ear discharge?
Sneezing? Shortness of breath? Noisy breathing? Change in Weather preferences? Neck
gland enlargement? Rash on skin? Chest pain? Heart racing? Bowels and waterwork? All
Past History: NAD
Family History: NAD
Socai History: Can I know your occupation? Teacher. Do you need to use your voice a lot?
Yes. Is there any chance that you expose to chemicals like or radiations? No.
Can I ask you some sensitive questions?
Do you smoke? Yes, a pack per day.
Do you drink alcohol? Socially.
How about recreational drugs? No. Are you sexually active? Yes. Do you practice safe sex?
General Appearance: no cachectic feature. BMI normal. No pallor or Jaundice or rash
Vitals: stable, no wheezing or stroidor
ENT: No abnormal finding. Laryngoscopy= not possible.
I asked for Horner’s syndrome signs: ptosis, meiosis, enopthalmosis, anhydrosis(none)
Cranial nerves: normal
Neck: thyroid gland enlargement-no, neck glands-no, trachea-mid line
Head and neck skin lesions-no
Respiration system: air entry is reduced on Rt side, percussion notes-dull on Rt lower zone. I
asked about vocal fremitus and resonance- not available
Explanation: Ms…., from our talk and examination, there could be solid or fluid in the
Rt side of chest. I drew a picture and explained pleural membranes and lungs. It could be
associated with hoarseness of voice. So I’d like to do some investigations. I will do CXR, and
CTscan of Head and Neck and Chest. Some basic blood tests like FBE, ESR, kidney function
test and liver function test will be done.
RP: what do you think, doctor? I am concerned that it could be a nasty lesion in lungs but I
am not 100% sure. We need to exclude the serious conditions first. It could be due to overuse
of voice or simple infection. But it is important to find out the serious condition early so that
we can manage appropriately. I will see you after the results come back.
RP: Can you give me antibiotic and send me home? No, I need to exclude the life threatening
The bell rang.
AMC feedback: Hoarseness passed
• A 56 year old woman comes to GP with lethargy.
• Take history
• Ask examination findings
• Discuss about diagnosis and investigations
After introduction, I started with
HOPI: RP said she felt tired and lethargic for a few months. ( same as book- her daughter
thinks she became very slow).
How severe it is? Can you do routine daily activities?
Is it associated with weight changes? She gained weight.
Any changes in Weather preference? afraid of cold weather.
Loss of appetite? No
Any lump at the neck? No
Any skin color changes? No
Voice changes? I can’t remember what she said.
Did you notice any fever? No
How is your mood? Felt lazy, sleepy
Do you think life is not worth living? No
How is everything at home? Ok
System review: constipated, no chest pain, no heart racing, no shortness of breath, no
frequent urination, no thirst, not pale, no skin rash and no muscle or joint ache and pain.
Past history: not significant
Family history: not remarkable
Social history: no smoking, no alcohol drinking, not on any medication, no recent travelling
Examination: puffiness on face and expressionless face, looked tired, no pallor, no jaundice
Vitals: PR 56/min, regular
Neck: no thyroid enlargement, no neck glands
Ht, lungs, abdo: normal
Nervous system: delayed relaxation of ankle jerks
Urine dipstick test: normal
Explanation: Ms…, from our talk and examination, it is most likely Hypothyroidism. Have
you ever heard about that? Let me draw a picture, in our neck there is a gland called thyroid
gland. It produces thyroid hormone which is important for bone growth, metabolism control.
It is one of the stress hormones. In your case, the thyroid gland cannot produce enough
thyroid hormone. To confirm this, I’d like to do TFT first. If required, we may do thyroid
scan, USG neck.
RP asked why she has no goiter. It could be due to immune mechanism in which our body
defense mechanism is fighting against our own cells. Sometimes the cause is unknown.
RP asked what treatment she needs. I said Thyroid hormone replacement.
RP: in what form? Tablets, starting from low dose
RP: How long should I need to take it? Unfortunately, lifelong treatment will be required.
The bell rang.
AMC feedback: lethargy passed
4.A middle aged woman comes to GP with discomfort at SPA and burning sensation during
passage of urine.
• Take history
• Ask physical examination
• Discuss about the diagnosis and management with patient
• The examiner will ask you to do one task
HOPI: she has been suffering the burning sensations for 2 days. Urine color is normal, no
blood or sentiment. No fever or chills. No loin pain. No incontinence.
System review: no vaginal discharge, normal bowel functions.
Past history: similar episode few months ago.
I asked 5Ps, periods- 4 to 6 weeks cycles, regular, not heavy or painful, LMP-6 weeks ago.
She is using condoms(pills). Pregnancy- is there any chance that you can get pregnant?
Not sure. Do you have any morning sickness and breast tenderness? No. I said I will do
pregnancy test for you today. (I said that before I forget)
Pap smears- normal. Partner- fine, no similar symptoms or discharge.
SAD: none, not on any medication.
Examination: general appearance: fine, BMI- normal
Vitals: temperature-normal, others- stable
Abdominal: soft, no bladder distension
Urine dipstick test: nitrites and leukocyte esterase ++++
Pregnancy test: not available
Explanation: from history and examination, most likely it is urinary tract infection. Let me
draw the urinary tract. Then I explained two kidneys, ureters, bladder, urethra. In your case,
the infection causes swelling of the lining of urine pipe and bladder. This leads to burning
sensation. To confirm the type of the bugs, I will send the urine for culture and sensitivity.
You will need to take antibiotics for at least 3 days.
The examiner gave me a prescription paper. I filled the form accordingly, pt’s name- I wrote
completely Mrs….., pt’s age, pt’s address- she gave full address up to post code.I said I will
choose safe one as I am not sure whether she is pregnant or not. Then I wrote Cephalexin
500mg tds . I signed it, wrote the date.
I said I would like to see you after 2days. I will check the pregnancy test. Meanwhile if
you notice any high fever, chills, loin pain, vomiting, blood in urine, please come back
The bell rang. I said thank you. The examiner took the prescription paper from RP.
AMC feedback: urinary tract infection passed
5.A 56 year old man comes to GP with indigestion and chest discomfort.
• Take history
• examiner will give you some findings.you dont have to ask for.
• Discuss the diagnosis and management with patient
I asked the examiner whether the patient is haemodynamically stable.
This is one another case,very simple yet I failed . Role player was very smart in
giving the answers.
HOPI: he started to notice the indigestion for a few months.Usually Comes when walking
uphill. Sometimes feels nauseaus. Retrosternal? Not sure,more like epigastric. Radiation?
No.( He keeps talking,to be focussed is one of the catch here, I did not care to listen about
what he said,he kept talking abut dogs,job blah blah blah)...
System review: no shortness of breath, no heart racing, no headache, no weight loss or loss
of appetite, no skin color changes, bowels and urine are normal, no reflux history, no calf
Past history; NAD
Family history: nil
Social history: he used to smoke but stopped a year ago. He is not on any medication.
Then examiner gave me a sheet which said all CVS is normal includng ECG. ( I totally got
lost here, I changed my mind to GIT)
I drew GIT picture. Told everything about reflux,acid,Ulcer. Didnot talk a word about CVS.
AMC feedback: Angina Pectoris FAILED.
6.A 48 year old farmer with bleeding per rectum had underwent sigmoidoscopy. The biopsy
result shows adenocarnoma of sigmoid colon. he is here for the result.
• Explain the result to patient
• Discuss the immediate management, preoperative preparation and operation
• Further management
• Answer the patient’s questions.
The stem was very long. All I can grasp is you are intern in surgery ward,patient has
After introduction, I started how are you today? Are you alone? Would you like to have any
family member to discuss about the result? No
.., I am really sorry to tell you that the result shows adenocarcinoma of sigmoid colon, which
means the cancer of large bowel. How are you feeling? Are you alright? Wait for a while.
RP . Oh My God, I cant believe.
Dont worry you are in safe hands. We will do staging investigations to make sure that there
is no spread in other parts. We will do CT scan of tummy, chest, head and neck and bone
scan if required. the surgeon will see you for further assessment and management. After the
stage is confirmed, I think you are in early stage, the surgeon will discuss about the operation.
We will try to aim for a cure for you as much as we can. (then I talked about the preop
preparation as it is required in tasks) RP asked what will be done before operation.
I said you will be seen by the anesthetist whether you are fit for operation or not. You
will need some blood tests to exclude bleeding or clotting problems, liver function and
kidney function test. Then you will be admitted to hospital. One day before operation, you
will have to avoid solid food and take fluid or oral rehydration fluid and bowel wash with
enema or saline wash to clean the bowel. It is to reduce the complications during operations
like infection and bleeding. Then I talked about operation, drew a picture and explained
the resection and anastomosis. Then, colostomy may or may not be needed depending on
whether the procedure is associated with complications or not. If it is done, it will most likely
be temporary. RP asked me how long? 3 months. Stoma care will be educated by stoma
RP asked how long he needs to stay in hospital. I said when your bowels return normal, you
can eat well, no fever or other complications, you can go home. Usually it take at least a
week. (Some candidates talked about laproscopy and open operations, I forgot about it)
RP asked after that, what will be done for further management. I said we will monitor with
tumour maker CEA. How frequently? 3 to 6 monthly. And colonoscopy 6 to 12 monthly.
RP asked why he got this cancer? The exact cause is unknown, but there are some risk factor
like family history.( RP interrupted my father had bowel cancer. I asked him at what age-
58yr. I asked if there is any other family member or relative who had bowel or other cancers.
Now there are two people in your family who got bowel cancer, we need to screen your
siblings. I will arrange colonoscopy for them. (10 yrs earlier than the age at which diagnosis
Do you have any other concern? No
AMC feedback: carcinoma of the rectum passed
• A middle aged woman with calf muscle pain comes back for the investigation results.
She is taking HRT. Family history shows 3 people with clotting problem.
• ask the examiner for the investigation results
• explain the diagnosis to patient
• discuss immediate management and further management
Dr.Wenzel was examiner. I asked the examiner Doppler USG result- there is a blood clot
extending from thigh to knee. Then I asked about Thrombophilia screening and examiner said
will be ordered.
Explanation: Ms…, according to the result, we found that there is a blood clot in your leg.
I drew a picture about artery and vein. I explained DVT. So you need to be admitted and
take appropriate treatment. In hospital, the specialist will take care of you. Before the blood
thinner is given, they will do base line INR which means PT that measure the clotting of the
blood. And you will need thrombolic screeninig as there is a family history. Sometimes the
clotting problem can run in family. You will receive heparin injections and warfarin tablets.
These are blood thinner. There will be monitoring with INR daily until the target level is
achieved. We will aim to maintain the INR about 2 to 3 which means your blood will be 2 to
3 times thinner that average person so that I will not clot. After the target level is achieved,
the heparin injection will be stopped and warfarin will be continued for at least 6 months.
If the thrombophilic screening is positive, you will need lifelong warfarin. You can use
stocking, take more fluid and move around.
RP asked me side effects of these drugs. I said bleeding is the most common SE. she will
need regular monitoring and tell the doctors that she is taking warfarin. There are drug
some interactions as well. If she has vomiting or diarrhea, please see the GP as the action of
warfarin can be changed.
RP said I am planning to travel by air, what should I do? I said you will need preventive
heparin injections, and talked about the general measures.
I also said you are taking HRT, you will need to stop it. I will refer you to the specialist
gynaecologist for other alternates.
AMC feedback: DVT passed.
8.A 60 year old man came to ED with transient visual loss.
• Do physical examination
• Discuss about the diagnosis and management
After introduction, I explained I would like to examine your heart and vessels, then I will
do nervous system examination. I washed my hands. Then start cranial nerves(. Role player
got upset when I said the names of cranial nerves. She asked what is it? I thought it is a bad
idea to spend time in explaining what cranial nerves are? So please dont use jargons,you are
wasting time) Do you have any problem with smell sensation. No. I did visual acuity. I then
did light reflexes and accommodation reflex. I said I will do fundoscopy with dim light. I did
not show how we use the fundoscopy. I did eye movement. All normal. Examiner was so nice
she asked me what will you examine next. I said I will do upper and lower limb neurological
examination. Then I will do cardiovascular system examination. Vitals first, then carotid
bruit. Heart sounds.
Examiner told me to explain the patient. Mr…. , after examination, I can’t find any
abnormality but we need to do some more investigations. We call it ministroke. I explained
about the carotid artery athrosclerosis and heart palpitations. You need to be admitted and
have a complete check up. We will do blood tests FBE, ESR, BSL, Lipid profile, LFT, KFT
and carotid Doppler which means we will scan with USG probe on the neck, ECG, CXR,
echocardiogram and CT brain.
The bell rang. I said thank you to both of them.
AMC feedback: transient visual loss due to thromboembolism passed
Finally I passed. To be frank, I did not expect a pass. That is because not that I dont know
the case. I knew the case, still because of not following the basic rules of this exam I lost the
cases. According to my experience these are the things you got to follow in exam
1. always think of differentials when you are in 2 minutes reading time ,though you know the
2. be clear and slow
3. listen carefuly to examiner and role player
4 .confidence and clear mind alone can be enough to pass many stations.,stress handling is
very mandatory in this exam. Doing 16 stations one after another is not a game.
5. Deep knowledge is not needed. But should know what is what. This exam is neither
tough nor easy( I know this is a boring statement, people told me 1000 times). It is about
what exactly the Australian system wants you to think when you see a patient. For example
someone with tiredness what are causes you think about? Causes could be many. But what
AMC wants you to think for tiredness is very important.So instead of wasting time on
some big books try to see what are the cases in the AMC list so that you know these are
the diagnosis you need to have in mind when you see a patient with tiredness and then start
preparing accordingly. If you prepare without knowing what are the cases in AMC you are
simply beating around the bush.
I like to thank Dr.Wenzel, Alan, my study partners who inspired me with their dedication and
commitment especially Anitha,Nikki,Sharmila,Satheesh,yan,padma,bargavi who kept me
telling that I will pass for sure( I am not sure if they really believed so!!!)....
Best of Luck for all candidates!