26th July 2008 Brisbane

1. SOB 2. Bulimia Nervosa 3. Torsion of the testis 4. IDA AMC Case 111 5. Urinary incontinence AMC case 128 6. Pre pregnancy counselling in IDDM AMC case 14 7. Abdominal pain ( acute) AMC case 140 8. Chest pain ( AMI) AMC case 65 9. Urinary retention 10.UTI in child 11.Weakness in the rt arm and leg 12. Alzheimer 13. Request for breast reduction 14. Breath holding attack 15. Adrenal tumour 16. Epilepsy Case 1 50 yr old man comes to your GP complaint of SOB Task : History Exam finding from examiner D/Dx and Manage the patient I asked about duration ( 2 months, getting worst, more on exertion) no pain, productive cough with greenish sputum, no fever, no palpitations, no medication, no travel history, smoke 25/ day, Alcohol occasionally. O/E : no anaemia, normal vital signs, no trachea deviation. There was dullness on Rt. Lower lobe. Dx is Pleural Effusion, might be due to lung cancer, pneumonia, CCF, TB. Ive sent the patient to hospital to have more investigation. I said that I suspect the lung cancer, considering his long time smoking history. In hospital, they will do FBE, ESR, CXR, CT of the chest, aspiration of the fluid and send for analysis, bronchopy and biopsy. AMC feedback : shortness of the breath Case 2 passed

18 yrs old girl with IDDM treated in hospital because of DKA. She is going to be discharged from the hospital. You are HMO. In history she has normal weight, binge eating, make herself vomiting, using laxatives. Task : take further history Management She said she doesnt want to go to GP, she doesnt trust him. I asked HEADSS questions, she lives with her parents, normal relationship, working ( I dont remember where), no smoking, no alcohol, no drugs. She feels that she is fat and everyone wants to lose weight now, she doesnt think that is abnormal. I said that she shouldnt skip meals because she is Diabetic, it might be dangerous. I asked would you like to worry less about your body weight? She said Yes. Ill refer you to Psychiatrist and Psychologist. Q from roleplayer : what is the difference between them? AMC feedback : Bulimia Nervosa failed

Another candidate : as soon as I greet her she said : pls do not tell my GP about this, otherwise he must be very angry with me. I answered the conversation between you and me today will not be out of this room. I explained she got Bulimia nervosa, which was a kind of eating disorder. People with this condition had overvalued idea about eating and body image. It is very common in young people, as some people use this way to cope stress in their life. I also took a little bit history. She was a hair dresser, doing well with her colleagues and her parents. She has no suicidal idea and had not used any drugs. I convinced her that what she has done was harmful to her health, esp skipping meals and Insulin potentially might endanger her life. Her eating habit also affect her heart, skin, bone, period, blood system, stomach, teeth and food pipe. Then I mention the family meeting, dietician and psychiatrist involvement. Specifically, CBT or sometimes some medication might be needed. CBT would help her to correct the overvalue idea about eating habit and body image. Then role player asked : what is the difference between a psychologist and psychiatrist? I answered both of them do the talking therapy, which is CBT but psychiatrist can also prescribe the medications. At last, I mention the follow up and written information. Case 3 8 years old boy complaining of pain in right groin area, vomited twice, previously healthy. He was riding his bike before the pain started 3 houirs ago. Task : take history

Ask examination finding Talk to worry mother about management. In history, Pregnancy, delivery, growth and development are normal. Immunisation up to date. No disease, not on any medications. From examiner : Looks in pain, groin area no swelling, no scrotal mass, very tender. He doesnt allow to touch. The right testis in high position, horizontal lie. Abdomen is not tender. I explain the mother about torsion of the testis. I said the boy needs urgent admission, surgeon will rotate back, and fix to the scrotum. If another testis is in horizontal position, he will fix it as well. Q from mother, Will he be infertile? Probably not, because there are only 3 hours passed since the pain has started. I said US can be done to assess the viability of the testis. What is the chance of recurrence? If surgeon will fix it, very low. AMC feedback: Torsion of the testis passed Case 4 Case 111 IDA from AMC book, but all investigations were provided in question stem including iron studies. It means that you know already that it is IDA. Hb was 84 g/L (different than in the book.) Task : Explain to the patient Management After I said everything according to the book, the patient prompted me to admit him and I admitted. AMC feedback : Anaemia passed AMC

Case 5 Case 128 from AMC book, but the lady has stress incontinence only. Task is the same. AMC feedback : Urinary incontinence/ stress incontinence passed

Case 6

Case 14 from AMC book. AMC feedback : Pre pregnancy counselling Diabetic passed

Case 7 Case 140 from AMC book, but apart from given task from the book, discuss differentials. Id said ectopic pregnancy, Ovarian cyst torsion or rupture, midcycle pain, PID. AMC feedback : Abdominal pain ( acute) passed AMC Q 678 A 728

Case 8 Case 65 from AMC book, but ECG was provided on the door. You are in country hospital. ( Anterior AMI) Task : Explain to the patient about his condition Institute management Write down the medications in the medication sheet provided. I said about thrombolysis and transfer the patient to bigger hospital. AMC feedback : Chest pain Case 9 24 years old woman with retention of urine and pain in the vulva in GP Task : Take history Ask examination finding Management When I enter the room, I saked the womam Can you pass the urine yourself? No. I said that I want to perform SPA or pass the catheter, because patient has discomfort. After the I passed the catheter she feels much better. Then I started taking history. First attack, no fever, has some discharge from the vagina ( white colour) regular period, LMP 3 weeks ago, no bleeding in between period, PAP regular, no STIs in the past, has a passed AMC Q 348 A 356

partner for couple of months, had 3 partners in the past, no chronic medical conditions, no medication and not practising safe sex. O/E GA normal, PV inspection swollen vulva, vesicles all over it,. Im not going do speculum and VE because of the pain. The rest of exam was normal. Id like to see you again after pain settle. Now Ill take the swabs for STIs ( explained). Now treatment is Acyclovir tab for 5-7 days, and lignocaine gel locally. It will help considering it is a first attack. Also Ill do pregnancy test. Advised not to have unprotected sex during acute attack. Invite her partner for check up. This is a case about Herpes infection. AMC feedback : Urinary retention passed

Case 10 18 months old child come with father, irritable, T` 37.4`C, urine in bag specimen Leukocytes, no nitrites, no RBC Task : talk to the father Management I started to treat him as he has UTI, but role player asked me Could it be anything else? I said yes, it might be simple viral infection. Ill do SPA in my office and if nothing is found, Ill send him home, no antibiotics are required. AMC feedback : febrile toddler with pyuria failed

Another candidate : Me - How is your daughter now? How is her eating and drinking? How many have you changed so far? How about temperature now? Any rash on the body? Father T 37.4, She is all right, Tell me what is the problem. Me We got your daughters bag urine test back, There are some abnormal findings. It may indicate the infection involving the his water passing system. ( Drew the picture) But there is also the possibility of contamination by outside. As you know, there are lots of bug around that area. Because we do not want to miss the possibility of infection for your daughters best interest, Ill refer her to hospital. Medical staffs will take the clean urine out directly from the bladder. ( I point out in the picture)

This is called suprapubic aspiration. It is a bit sore for your child, but very quick and you can accompany her. The sample will be sent to the lab for the culture and and other test for purpose of medication. Father Will my child need admission? Me It depends. As I have mentioned, SPA urine is , it means bag urine is false + and contamination. Then your daughter will go home. But if SPA urine is + specialis will decide what to do at that time. If that is the case, most probably your child will be put on antibiotics for few days. The specialist may consider the further investigation for the child after recovery, like US and micturition cystourethrogram. ( I drew the picture to explain how MCU done) passed

Case 11 60 years old man come to your GP with weakness in Rt arm and leg Task : History, examination findings and management I started to ask the all questions for TIA. No vomiting, no blurred vision, no weakness in the face, doesnt smoke, alcohol occasionally. He is on Wafarin because of palpitation. No other medications. After examiner prompted me. I asked about trauma. ( They both look happy after this question) He fell 2 weeks ago and bumped his head. O/E reduced power in rt arm and leg, BP normal, Pulse 90, irregular, no carotid bruits, opthalmoscopy is normal. I said admission, coagulation profile, CT head, it might be subdual haematoma after his fall. S- of Meningism Neck stiffness, Pupil-3rd nerve palsy, Kernig sign AMC feedback : weakness in the rt arm and leg passed Case 12 Woman came to GP to discuss about the condition her father. 65 years old father was recently diagnosed with Alzheimer type of dementia by Neurologist. The consent obtained. Task : Listen to the daughter Explained the condition

Discuss treatment and management options Answer Qs Daughter : I do not want to look after my father as you know Im very busy at work and I dont have a good relationship with him. Me : Okay, I understand that it must be very stressful at this. We have a Age Care Assessment Team, It includes a lot of people who are going to look after your father. We need to assess him what level of support he needs, whether he is going to nursing home, respite care, residential care or private hospitals. Geriatrician ( the specialist ) will assess your fathers health and medications. My role as a GP is to follow up him regularly. Occupational therapist will assess oyur father safety issue, the light at night, rails at home,step in the yard and other modifications at home. Social workers are also involved. If he cant cook, arrange for meal on wheel. If he cant do house work, arrange the people to help. Pls dont worry, well look after your father as a team. Daughter : Can my father have depression? Me : Its possible. For the people with dementia, they may have depression. Sometime, we called depression pseudo dementia. But please dont worry, I need to assess him, to do MMSE on him. After assessment, if it is a case, we can give some medication. It is too early to say at the moment. Daughter : Will inherit the dementia from my father? Me : Its difficult to say, there is a rare type which can run in the family. But normally, it happens at young age. Regarding this issue, specialist will explain more to you. AMC feedback : Dementia of Alzheimer type Case 13 35 years old woman comes to GP with request to reduce her breast. When you ask her why, she started to cry. Task : History and management She thinks if she removed her breasts her life will be happier. Her husband left her 6 months ago, since then she lives alone. I asked depression QQS, No suicidal or homicidal thoughts, Appetite is normal, sleep is disturbed, wake up early. I said that I suspect depression, will talk to psychiatrist, may be tablets will be needed. No admission, But referral to psychiatrist.

I considered body dysmorphic disorder as differential diagnosis. P : I want my husband back. C : Did you ask him directly why he left? P : no C Ill try to organised meeting with him, may be we can solve the problem. AMC feedback : A request for bilateral breast reduction Case 14 2 years old child fell, become unconscious for few seconds. Father is worry. Task : History Talk to the father and answer his Qs. In history, growth and development are normal. Immunization up to date. First time happened, before the event he injured his finger in car door. His niece has epilepsy. Typical case about breath holding attack. Q? prognosis : good, should grow out of it be age 5-6. Q? Is it epilepsy : no, doesnt look like. If it happened more than twice per week bring him back to me, Ill check his FBE to exclude anaemia. If he become very drowsy after attack, sleep long time after it, wet himself, convulsion more than 5 min or unusual behaviour, come back to me or go to hospital. AMC feedback : Breath holding attack Case 1522 54 years old woman comes to GP complaining of epigastric pain. CT abd has been done. 5 cm Suprarenal mass found. Task : Explain the result of T scan Ask history and examination finding Management In history, she has abdominal pain and palpitation, no hot or cold preference. No chronic medical condition, not on any medication. O/E GA normal, no hirsutism, no obesity, no signs of cushing, no lump in the neck. BP 160/90, P 90, T normal. I suspect Pheochromocytoma, will send to the surgeon for the operation. Theyll give you some medications to control your BP before operation. AMC feed back : Adrenal tumour passed passed passed

Case 16 25 years old lady has been diagnosis with epilepsy, prescribed Carbemazepine. She is a courier. Used condom for contraception. Task : Explain the condition Counsel the patient This is counselling station. Take your medication regularly, dont drink much alcohol, dont swim alone. Wear bracelet. Bring your partner to me, Ill explain how to help you if seizure occurs. Q? - Is it curable? No just control the system with medication. - How long Im not allowed to drive? From 1 month to a year depend on your condition. Go to Centrelink they will pay you to study another profession or ask your boss to offer you another job. - Is this medication safe during pregnancy? We may reduced the risk to minimum, providing you take 5 mg Folic acid 3 month before and until 12 weeks of pregnancy. - Should I take it for life? No, if you are free of fit for 2 years, your neurologist will review and may stop the medication. AMC feedback : Epilepsy ( Idiopathic) passed