Wednesday Clinical tutorial 5/11/2008 by Dr Matthew CAI 12 cases, Not to be published .

Most of these cases may will be repeated in coming AMC real exam. They are highly valuable cases. Wednesday Clinical tutorial 29/10/2008 by Dr Matthew CAI Case 1 Mr James Brown, 63 years, Retired teacher saw you 1 week ago complaining of dyspnoea on exertion, and you noted pallor. Hb 103, iron deficiency. No obvious source of blood loss. Barium enema ordered, looking for occult GIT blood loss. Several sigmoid diverticulae present. Intraluminal mass in ascending colon, with neoplastic appearance Mr Brown has come for the result of his Barium Enema. Task : Manage this patient and answer her questions Case 2 Mr Lees mother is a patient of yours in the local Nursing Home. She has a 5 year history of Alzheimers Disease, is now bed fast, severely demented, doubly incontinent, with several large pressure areas which will not heal. You recently commenced her on Morphine for relief of pain prior to dressing changes. He is a strong opponent of euthanasia, and is concerned that, although his sister gave consent, that you are giving her Morphine to hasten her death. Task : Manage this patient and answer her questions Case 3 Tracy Smith aged 6 months Daughter of Peter, a young man who has been a patient of yours for many years. Peter has custody of his daughter, and lives with his parents, who are also your patients. Peter has brought Tracey to see you urgently, because he just found her lying on the floor, beside her bouncer, not breathing. Tracey was recently in hospital with presumed apnoea, and has been using an apnoea alarm. Tracey is pale, unresponsive, and breathing quietly. She has a large haematoma on the side of her face, with no Abrasion Task : Manage this patient and answer her questions

Case 4

Mr Peter James 33 yrs old unemployed, Peter has been a patient since childhood. He has a history of intravenous drug use, but is now on Methadone maintenance. His new girlfriend, Eva, also has a history of Heroin use, and has been on Methadone before. She has been injecting Heroin again for several months, and has just discovered she is 14 weeks pregnant. Peter wants her to commence Methadone as soon as possible, and Eva is apparently in agreement with this. Peter has come to speak to you to see if you can help. Task : Manage this patient and answer her questions

Case 5

A 25 year old lady comes to see you as a GP , she is 6 weeks pregnant, but she is a university student in her final year, she has no plan to raise up a child, and she is asking about how to do abortion Task : Manage this patient and answer her questions

Case 6 A 57 year old man comes to see you as a GP , she has CT coronary scan done and now return to ask you some questions Task : Manage this patient and answer her questions Case 7 A 25 year old lady comes to see you as a GP , she is 6 weeks pregnant, and she is a university student in her final year, she has a swelling lump in her neck. Task : 1 Examination 2 Manage this patient and answer her questions Wednesday Clinical tutorial 22/10/2008 by Dr Matthew CAI Case 1

This is 65 year old man comes to see you with Tremor, please perform a Parkinson disease examaination Case2 This is a 78 year old man with eye pain , please do a eye's examination Case 3 This is a 23 year old man with elbow pain, please take history and perform an elbow examination Case 4 This is 65 year old man with right leg pain, do an examination Case 5 This is 25 year old man have a MVA, now neck pain, please do neck examination Case 6 Shoulder examination case 7 hand examination Case 8 Thyroid examination Case 9 Neurology and CN Case 10 Back and hip examination Case 11 22 years' old young man came with dizziness to you. His left eye is funny and he is feeling clumsy on one side of his body. he also had problems with speaking and drinnking water. your task is to take a focused brief hisotry and diagnose the case and answer the examiners questions

duration: one and a half year family history: hypertension Examiner show MRI DDx: multiple sclerosis? migraine? Case 12 nine years old girl diagnosed with insulin IDD six months back. Family relocated in the country side. you are GP. father is worried about management, because in the city they had all facilities. taks: manage IDD in country side and answer the dad's quesiton what are the difference between IDDD management in country side and in city? case13 5 year old girl is brought by her mother. she is having rashes over vulval region. mother is saying that she went to see her divoiced husband and when she returned she is having these rashes. she is avoiding her father. mother is living with her boyfriend. you do the examination, there is rash present. manage the case, no history taking. it is obviously child abuse, how we can approach it in more professional way? Wednesday Clinical tutorial 15/10/2008 by Dr Matthew CAI

case 1 A 74 year old male is referred to the ED by his cardiologist. The patient is post MI 3 years ago and has been chest pain free on clopidogrel 75 mg daily post stenting a year ago. Despite a regime of atenolol 100 mg and lisinopril 80 mg, BPs are consistently 150s/80s. Cardiac echo is normal and LDL is 68 on Vytorin 10/40 mg. He is fatigued and complaining of moderate headache the past week. He has been taking ibuprofen 200 mg 2-3 x/day and has 5/10 scale headache now. His mother had hypertension You are the RMO and starting interview him and noticed that something is not right while you are taking history Task: 1) Take the relevant history. 2) Do a physical examination 3) Tell the examiner what investigations you want to do.

4) Give your Differential. What is the underlying etiology? 5) Management plan Case 2 GP setting. The mother of a 3yo child comes to see you because her daughter has had a fit for 2 minutes. Physical examination findings are normal. o Tasks: 1. Further history 2. Tell the mother about the condition 3. Further Management Case 3 The mother of a 3yo girl comes to see you because the staff at the childcare centre complained that the child has strange behaviour. o Tasks: 1. focus hx 2. tell the mother about the condition 3. further Mx Case 4 A woman with 10wks pregnant comes to see you because her 5yo niece had rashes on the back (picture provided: blisters). She has 2 children, aged 9mths and 6yo. o Task: 1. provide Dx from a given picture 2. advise mother about pregnancy and Mx about two children. Case 5 A woman of 40 year old woman complains about chest pain for about 3 months. All investigations including ECG and blood tests are normal. While you were talking to her and told her it is not a heart problem, she suddenly begins to cry. She also insists that she know its a heart problem. She is currently working and looking after her sister who has just had surgery. Task: Take the relevant history. Do a physical examination Tell the examiner what investigations you want to do. Give your Differential. What is the underlying etiology? Management plan

Case 6 A 23 year old university student claims that she has important information to report to the United States president. He hasnt slept for a few nights and his performance is not good now. Tasks: 1. Mental state examination 2. Summarise your findings to the examiner and 3. Discuss differential Dx with the examiner.

Case 7 Short case You are Smiths family doctor, You referred Mr. Smith who is a 40 year old CEO in a large company to hospital for vasectomy two days ago. He was doing well until yesterday developed a high fever and rigor. He was unable to attend your surgery because he was too sick. Instead, his wife came to see you. There was some wound discharge according to his wife. Mrs. Smith is requesting some antibiotics for a quick fix. You are not happy to do so without seeing the patient. The wife was angry and questioned how the operation was performed, why he got infected, why did you send him to the small hospital? The consultation became very difficult to continue. Your task is to explain to his wife about your opinion and answer his wife questions. Wednesday Clinical tutorial by Dr Sanjiv Shed 17/09/2008 and 8/10/2008 Wednesday Clinical tutorial by Dr Bryony Stanton 24/09/2008 and 1/10/2008 Dr Sanjiv Shed is AMC clinical examiner, you may see him while you are doing your real clinical exam . Cases will be distributed in classroom Wednesday Clinical tutorial by Dr Matthew CAI yet to decided case 1 A 74 year old male is referred to the ED by his cardiologist. The patient is post MI 3 years ago and has been chest pain free on clopidogrel 75 mg daily post stenting a year ago. Despite a regime of atenolol 100 mg and lisinopril 80 mg, BPs are consistently 150s/80s. Cardiac echo is normal and LDL is 68 on Vytorin 10/40 mg. He is fatigued and complaining of moderate headache the past week. He has been taking ibuprofen 200 mg 2-3 x/day and has 5/10 scale headache now. His mother had hypertension You are the RMO and starting interview him and noticed that something is not right while you are taking history Task:

1) Take the relevant history. 2) Do a physical examination 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Case 2 GP setting. The mother of a 3yo child comes to see you because her daughter has had a fit for 2 minutes. Physical examination findings are normal. o Tasks: 1. Further history 2. Tell the mother about the condition 3. Further Management Case 3 The mother of a 3yo girl comes to see you because the staff at the childcare centre complained that the child has strange behaviour. o Tasks: 1. focus hx 2. tell the mother about the condition 3. further Mx Case 4 A woman with 10wks pregnant comes to see you because her 5yo niece had rashes on the back (picture provided: blisters). She has 2 children, aged 9mths and 6yo. o Task: 1. provide Dx from a given picture 2. advise mother about pregnancy and Mx about two children. Case 5 A woman of 40 year old woman complains about chest pain for about 3 months. All investigations including ECG and blood tests are normal. While you were talking to her and told her it is not a heart problem, she suddenly begins to cry. She also insists that she know its a heart problem. She is currently working and looking after her sister who has just had surgery. Task: Take the relevant history. Do a physical examination Tell the examiner what investigations you want to do.

Give your Differential. What is the underlying etiology? Management plan Case 6 A 23 year old university student claims that she has important information to report to the United States president. He hasnt slept for a few nights and his performance is not good now. Tasks: 1. Mental state examination 2. Summarise your findings to the examiner and 3. Discuss differential Dx with the examiner.

Case 7 Short case You are Smiths family doctor, You referred Mr. Smith who is a 40 year old CEO in a large company to hospital for vasectomy two days ago. He was doing well until yesterday developed a high fever and rigor. He was unable to attend your surgery because he was too sick. Instead, his wife came to see you. There was some wound discharge according to his wife. Mrs. Smith is requesting some antibiotics for a quick fix. You are not happy to do so without seeing the patient. The wife was angry and questioned how the operation was performed, why he got infected, why did you send him to the small hospital? The consultation became very difficult to continue. Your task is to explain to his wife about your opinion and answer his wife questions. Wednesday Clinical tutorial by Dr Sanjiv Shed 10/09/2008 No cases provided Wednesday Clinical tutorial by Dr Matthew CAI 03/09/2008 We will do the most recent cases: Sydney 2008 08 29 and Melbourne 2008 08 09

Case 1 (2008 08 29 Sydney) Last Friday You are an Emergency Intern working a late shift. You review an obese 11 year old child who presents to emergency complaining of pain in his right knee. His mother denies any other major problems. Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do.

4) Give your Differential. What is the underlying etiology? 5) Management plan

Case 2 (2008 08 09 Melbourne) Your next patient in your GP surgery is a 25yo man, who has been seen by one of the other GPs in the surgery two wks ago when he presented with a small nodule in the right side of his neck. Your colleague took a history and examined the patient and came to the conclusion that it was most likely a lump in the thyroid gland and arranged U/S, isotope scan and a fine needle aspirate for cytology. He came today for the test results. The U/S revealed a single, solid nodule of about 1.5x2cm with changes consistent with a papillary carcinoma in the right lower part of the thyroid gland. The iodine 131 radioisotope scanning demonstrates a cold nodule in the same area. The FNA confirms a papillary carcinoma.

Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management Case 3 (2008 08 09 Melbourne) O&G: Your are a resident in a country hospital. A woman in the labour ward has just had a fit one hour after the delivery of her baby. The seizure was controlled and now the mother is asleep. The husband is with her and wants an explanation. Task:

1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Summarise your history and findings and provisional diagnosis, Give your Differential. What is the underlying etiology? 5) Explain management plan to husband Case 4 (2008 08 09 Melbourne) A 29 years old lady comes to see you for routine prenatal clinic, she is 34 weeks pregnant and progress well previously, she was G1P0 and very anxious about this pregnancy as her sister had still born at 35 weeks pregnant. She found her tummy was not growing any more.

Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Summarise your history and findings and provisional diagnosis, Give your Differential. What is the underlying etiology? 5) Management plan

Case 5 (2008 08 09 Melbourne) A 22 years old lady comes to see you for advise , she is university student and her period was stop 12 months ago. She lives with her boyfriend in Sydney, She is not using any form of contraception. She smokes 20 cigarettes a day, and drink alcohol 3 glasses a day. She was depressive as her boyfriend saw her as an ugly fatty woman . She is trying hard to lose weight. Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Case 6 ( 2008 08 29 Sydney )

A 25-year-old, G3P1 with D&C x 2 woman presented with a positive pregnancy test and vaginal bleeding. She complained that she was badly vomiting every day for past three months, Otherwise she was well. She has no history of DM, previous two pregnancies were miscarried. She come to see you as a GP for prenatal check up and advise to stop her vomiting Task: 1) Take the relevant histor 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Wednesday Clinical tutorial by Dr Matthew CAI 27/08/2008 9 August 2008 AMC Melbourne Clinical Exam

Case 1 A 45-year-old woman suffers severe complications during treatment for right pleural effusion. She has history of right breast cancer, followed by sentinel nodes surgery. She has received chemotherapy after the surgery. A change in her right hand is noticed; it is blistered, extremely swollen, and tense. The distal hand and fingers are darkly discolored and cool, and the radial and ulnar pulses are not palpable. The fingers are all in a slightly flexed position, and the nail beds are blackened. Picture will be provided.

Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Case 2 A 50 year old man complains of blurred vision. He has past history of by-pass surgery 2ys ago, hypertension and DM. He is taking medication of Metformin, enalapril, simvastatin, aspirin 100mg. Now he came to see you as a GP to check his eyes Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Case 3 Mr Smith is age 47 year old an accountant who is also an active member at his local church , In his capacity, he has taken a hard line on homosexuality, which he believes is a sinful perversion . He has a good relationship with his son Matthew, 18 year old university student, Mr. Smith found Matthew shows no interest in girls and has several male friends. Mr Smith accidently found Matthew was kissing his male friend in his bedroom. Mr Smith was so upset and has not yet talked with his wife. Now he is seeking your advise Task Interview Mr. Smith and advise him appropriate Case 4 A 65 year old woman presents with a swollen sore right lower leg for 2 days (picture provided).She complained severe pain of her right leg and felling general unwell. She

has no Shortness of breath . Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. What is the underlying etiology? 5) Management plan Case 5 Cardiovascular system examination. 65yo man who is travelling overseas soon, presents to GP for a pre-travel check up. o Tasks: 1. perform physical examination 2. provide running commentary 3. no need for abdominal and lower limb examination o Qs from the examiner: 1. Is the murmur systolic or diastolic? 2. whats the Dx? Case 6 A 25yo man, who is a truck driver, presents to your GP clinic with ear pain for 3 days. No discharge. 3 episodes in the past with yellow discharge. Picture provided. (redness in tympanic membrane and some crystal substances deposits on the lower part of the ear drum)An otoscope and a turning fork are on the table. Tasks: hx, perform physical examination, Dx, Mx. Case 7 A 68 year old man presented to your surgery after episode of right upper quadrant abdominal pain , which has resolved after 4 hours. Clinical exam revealed blood pressure 160/100, others were unremarkable Tasks: 1. Explain CT to the patient 2. explain the condition 3. further Ix 4. answer patients questions. Case 7 A 25yo man who is a computer worker presents with diarrhoea of 3 weeks duration. This is the 4th episode in the past 3ys. In the past, he was treated with antibiotics but has had no improvement. o Task: 1. take further hx 2. ask examination findings from the examiner 3. further Ix and Mx Case 8

A 25yo man presents to your GP practice with back pain after lifting heavy box at work. On examination, no neurological findings were present. The only positive sign is tenderness in the paravertebral area. o Task: 1. explain condition to the patient (see patient education p118; Backache) 2. advise on further Mx 3. write a prescription for the patient 4. To write a medication on an outside script Wednesday Clinical tutorial by Dr Matthew CAI 20/08/2008

This week we are focus on difficult consultation, you will see all the cases below are very difficult patients, you may find hard to continue, let us show you the way to do it. Case 1 Barbara Smith is 38 year olds house wife, she married to Robert who is a lawyer, She comes to see you as a Gp for skin bruising and depression . She has been married for five years with two children, she is non smoker and drink alcohol occasionally. She is taking OC pill , otherwise , she is healthy Task Interview this lady and manage her appropriate Case 2 George Smith is 38 year olds man ,he comes to see you because of chest wall pain, he played baseball three dyas ago and missed a catch the ball hitting to his right chest wall. He went to ED , but was discharged after a normal chest xray, He is wondering if you can offer him better medications to stop the pain. He married to Julianne Robert with two children . he is non smoker and drink alcohol occasionally. He is not taking any regular medications. During the exam, he is well, blood pressure was 150/95 mmHg, George told you that this is normal for him, as he has same three years ago. There was bruising marks on chest wall, otherwise were all normal Task: Interview this patient and manage him appropriate

Case 3

Helen Smith is 40 year olds lady ,she comes to see you with her 7 years old daughter Tara because of her daughter leg laceration wound., she played baseball three hours ago and missed a catch the ball landing on a dirty sharp metal , cutting to her right leg. You are about to dress her leg. She married to Robert with four children who all not immunized , She does not believe vaccination. She believes all children should develop their own immunity naturally . Tara is just recovering from measles. Task: Interview this patient and advise her appropriate Case 4 Lisa Smith is 38 year olds house wife, she married to Robert who is a labour, She comes to see you as a Gp for advise her pregnancy . She has been with Robert for five years with no children, she is non smoker and drink alcohol occasionally. She is using condom for contraception, otherwise , she is healthy Robert has very difficult school when he was labeled dyslexic, He has very limited skill of writing and reading, when Lisa told him about 11 weeks pregnant , he was very upset and said No kid of mine is going through what I went through He decided Lisa should have a termination Task Interview this lady and manage her appropriate

Case 5 Dr Martin Smith is a hospital physician in a large local Hospital, Three months ago , he went to a Multi-disciplinary international conference In Vienna , Dr Smith was traveling alone, During the conference, he met a doctor from Thailand who is very lost and lonely. After the meeting, Dr Smith went out with her and has unprotected sex . Now Dr Smith returned home and increasingly worry about HIV and felt quilt to his wife, He felt sick inside and see you as a GP for HIV test. Task: Interview him and advise him appropriated

Case 6 Mr Smith is age 47 year old an accountant who is also an active member at his local

church , In his capacity, he has taken a hard line on homosexuality, which he believes is a sinful perversion . He has a good relationship with his son Matthew, 18 year old university student, Mr. Smith found Matthew shows no interest in girls and has several male friends. Mr Smith accidently found Matthew was kissing his male friend in his bedroom. Mr Smith was so upset and has not yet talked with his wife. Now he is seeking your advise Task Interview Mr Smith and advise him appropriate

Wednesday Clinical tutorial by Dr Matthew CAI 13/08/2008 Case1 Eric O'Malley is a 51 year old man who came to emergency because of chest pain and palpitation. He is a bank manager and work very hard every day. He lives in Sydney with two children.

Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. 5) Management plan

Case 2 Sandra Anderson is 81 year old woman who was brought to emergency by ambulance semiconscious, hypotensive and bradycardia. Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. 5) Management plan Case 3 Andrew McDonald is 60 year old man who has a cardiac arrest while the ambulance is rolling into the emergency. He is quickly brought into the resuscitation room. In the next eight minutes run code blue and manage him.

Task: 1) manage this patient according , you can also do the following tasks 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential.

Case 4 Tim Brown is a 39 year old male who came to emergency because of sharp chest pain. He feels unwell and trouble breathing Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. 5) Management plan Case 5 A lady 44years age came to your G P surgery with complain of fatigue for three months , she devoice her husband one year ago, and felt very depressed since. She also had poor appetite and only eat once a day , she lost 5 kg in past six months due to poor dietary as patient stated .

Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do. 4) Give your Differential. 5) Management plan

Case 6 John Smith is a 54 year old brick layer , he presented to you with a problem of polyuria, please interview him Task: 1) Take the relevant history. 2) Ask the examination finding from examiner only given what you ask 3) Tell the examiner what investigations you want to do.

4) Give your Differential. 5) Management plan

Wednesday Clinical tutorial by Dr Matthew CAI 06/08/2008 Clinical Examination recall Brisbane 26 July 2008

Station 1 Case: Confusion, Agitation, and Delusions A 35-year-old woman was admitted to the psychiatry service 5 days after the birth of her first child because of confusion, agitation, and delusions. A diagnosis of bipolar disorder had been made 2 years earlier, which was treated with lithium and citalopram. Task: 1. Take relevant History from the patient 2. Ask the examination findings from the examiner 3. Advise appropriate investigations 4. Talk to her about your management plan . 5 She wants to breast-feed her infant. What medications would be safe and effective for her to use? Station 2 24 year old woman comes with retention of urine and pain in vulva. You are her GP. She was previous healthy, and she wants a work certificate Task: 1. Take relevant History from the patient 2. Ask the examination findings from the examiner 3. Advise appropriate investigations 4. Talk to her about your management plan . Station 3 A 45 year old lady comes to your GP clinic to discuss about the condition of her father. Her father 65 years old has been diagnosed with Alzheimer type of dementia by neurologist recently. The consent regarding giving the information about her father is obtained. Task: listen to the daughter, explain the condition, discuss treatment and management options and answer her questions

Station 4 25 year old lady has been diagnosed with epilepsy and prescribed with Carbamasepine. She wants the repeated scripts and general advise

Task: Take a brief history then explain the condition and counselling the patient

Station 5 A 57 year old lady , Annette Kohler, presented to you in ED. The patient is looking unwell, and is experiencing some chest pain and SOB, but she is stable. Tasks: 1. Take relevant History from the patient 2. Ask the examination findings from the examiner 3. Advise appropriate investigations 4. Talk to her about your management plan . Station 6 You are RMO in ED to see this 65 year old man with acute chest pain please see this patient Tasks: 1. Take relevant History from the patient 2. Ask the examination findings from the examiner 3. Advise appropriate investigations 4. Talk to her about your management plan . 5. write down your medications in the provided medications sheet Wednesday Clinical tutorial by Dr Matthew CAI 30/07/2008 Station1 This is a practical station , equipments provided for your performance . A 75 years old man presented with right big toe ulceration 2 months after suffering a fall that injury his big toe . Later, he developed progressive symptoms of right lower limb claudication, making it impossible to perform activities of daily living independently . You are the RMO in a busy ED , your registrar is asking to do Ankle Brachial Pressure Index in five minutes and explain him the findings Station 2. A 45 year old female patient presented to your GP practice with mild abdominal pain last week and you ordered an abdominal ultrasound. Today the patient is back for review. U/S was shown on the door. This patient looks very anxious and very keen to do more tests for a definite diagnosis. Task: Explain the result to the patient, Relevant history taking, ask physical examination findings from the examiner

Probable diagnosis Manage the case (order relevant investigations if needed).

Station 3. You are the father of Peter Smith, 6 year old boy who comes to see you in General Practice because the school teacher concerning that your son is over-active and not listening to her advice and instructions (disruptive behavior).

Task: Take relevant history from the father and Give advice Dx Management. Station 4. Anne Smith is 4 month old baby brought in by father to the ED with shortness of breath, and cough for 2-3 days. The baby had a cold earlier. Task: take relevant history from the father Get PE findings from examiner Advice your Dx Mx the case

Station 5 A 72 years old gentleman had a knee replacement operation two days ago and he recovered well. Today the patient became agitated and confused. The nurse informed the registrar on call and was told to give the patient Olanzepine. You are an intern and were asked to review the patient. Examination findings: The pt confused. T38.2 C and bibasal lung crackles. Task: Take history from the wife Tell your DDx to the wife and how you are going to manage the patient.

Station 6 A 41 week primigravida come to your general practice concerning about her pregnancy. She is very active and wants to clarify some questions. Task:

Take relevant history. Get relevant PE findings from examiner Management plan and answer her questions. Station 7 A 40 years old lady, a violinist in orchestra, complaints of pain, swelling and stiffness in both hands recently. Her mother has rheumatoid arthritis. You suspect that she may have rheumatoid arthritis. You prescribe ibuprofen and run some blood tests for ESR, ANA and RF Antibodies. The results shows that she has early rheumatoid arthritis. Today she comes to you (a GP) for the result. She said that she has pain in the wrist as also. Task: Explain the diagnosis to the patient, Counsel the patient and answer her questions.

Station 8 A 25 years old lady who is 10 weeks pregnant (G3P2) comes to your general practice She stated that her niece, Mandy, has got a skin lesion for which she took a picture. Shes worried and comes for advice. She is previous healthy and seeing another GP, she is now want you to be her GP because she just moved to your area. Task: Advice the diagnosis and manage the case.

Wednesday Clinical tutorial by Dr Matthew CAI 23/07/2008 Station 1: This is a practical station of Spirometry: John Smith, 65 year old, was a bus driver employed by the Melbourne Transit Authority. Over his 35 years of employment he had been exposed to his passengers tobacco smoke, and that of his co-workers in the tea room and at shift breaks. He was diagnosed with small cell carcinoma of the lung, a type of lung cancer that has an above average strength of association with smokingboth active and passive. Towards the end of 1987 Mr Smith developed a severe cough that was aggravated by diesel bus fumes, and on the basis of this cough was declared unfit for work by his doctor in January, 1988. A claim for workers compensation was lodged. Now he is coming to your GP room for further investigations.

Tasks: 1 performs a spirometry on this 65 year old man. 2 explained the results given by a examiner Station 2 A 21 year old student has a heart murmur coming and going, he comes to your GP for diagnosis. He has no cardiac symptoms, There was no SOB. There was no family history of heart diseases. Tasks: 1. do a cardiovascular examination. 2. Present what you have found to your examiner. 3. Present your diagnosis to your examiner and answer examiner. Station 3 A 22 year student presents with poor sleeping, It was end of year exam in university. He was worried about the exam. Recently, his father passed away unexpectedly due to heart attack. Task: 1 Please take a history, 2 Counsel this patient, 3 Make a management plan

Station 4 A 6 year old Chinese girl presented with intermittent peri-umbilical abdominal pain associated with non-bilious emesis for 4 days. She had mucosal pigmentation on her lips. Her mother brought this girl to see you for management Task: 1 Please take a history, 2 Examination and investigations, 3 Make a management plan Station 5 . A 20 year old man presented with swelling in the neck. Your colleague has seen this patient and PE showed a goitre in the neck Other PE was unremarkable. He ordered ultrasound which showed multinodular goitre of thyroid.

TFT showed FT4 10 (10-24), TSH 0.6 (0.4-1.5). Now this patient return for blood tests result and your colleague is in holiday, you are about to see the patient. Task: 1 take a focal history No further physical examination is required 2 Explain to this patient about the diagnosis, treatment and complications of treatment.

Station 6 A 74 year old lady presented with left lower leg pain, she has been smoking for 50 years and was a waitress. She complained that left leg pain for three months, she felt difficult to do shopping. She was previously seen by other GP. But she moved to your area recently and would like you to take care of her

Task: 1 Please take a history, 2 Examination and investigations, 3 Make a management plan Clinical tutorial groups Wednesday 09/07/ 2008: By Dr Bryony Van Santen Case 1 Young man came for results of US scan, in the stem it was stated that the scan results showed a lump most probably malignant. Task: talk to the patient, further management Case 2 In the stem a description of a toe with gout was given, but "gout" was not named. Patient was taking antihypertensives (hydrochlorothiazide). Task was to tell the patient the diagnosis and to explain about the disease and tell further management Case 3 In the stem was a story of a woman who went to the doctor for something she thought was insignificant. The doctor was unsure what the problm was, and had a CT scan done. The scan was given (one slice

of liver with multiple hyperdense spots in it). Task talk to the patient Case 4 Stem stated a G2P1, 10 days postpartum, came to see the doctor because she had started bleeding again after het delivery. Task Take a focused history, ask examination findings from examiner, state which investigations you would like and manage the case. Case 5 - 3 month old baby crying for 2 days, has 2 bruises on it's face. Parents are uni students, in their early 20's. Manage the case. Case 6 - 12 year old girl presented with heavy period. Role player was there as girls mother. Take a focused history, ask exam findings from the examiner and manage.

Case 7 - cardiac examination. This was a physical exam station. Task do the cardiac exam, you do not need to exam the abdomen or the legs. Patient was a real patient. A woman with 2 valve replacements and a pacemaker. Case 8 - respiratry examination. This was a physical exam station with a healthy role player. Task do a physical exam and give a running commentary to the examine. Ask results of investigations from examiner and explain these to the patient. Briefly discuss anagement to the patient. I was given spirometry findings consistent with asthma. Case 9 55 year old woman, who worked as a baker, fatigued with pain in het body for 2 weeks. Take a history, ask examination findings from the examiner, tell which investigtions you would do (the results will not be available now) and tel your diagnosis. on exam (given when asked for) murmers heard, patient said she had had dental work done (a few seconds before the bell rang) Case 10 The patient was an old role player. Take a focused history, ask

examination findings from examiner, investiations and manage. Typical story of BPH by the patient. Examiner was very nice and asked leading questions and helped a bit along the way Case 11 - Leg pain in a 12 month old baby. Take a focused history, ask examination findings, tell which investigtions you would like to do, give differential diagnosis and manage the case. The "mother" was there. On asking the child had a fever, didn't want to use the leg and wasn't as mobile as before. On exam the child looked unwell and in pain. Case of septic arthritis Case12 GP setting, very long stem, patient was known with psycosis, with one sentence in bold letters "patient is psycotic and hallucinating". The "patient" had cut her wrist in an "accident". She was continuously talking and saying she needed to go home and needed sleeping tablets. She would not let you speak. She had absolutly no insight in her problem. She said she didn't have to stay if she didn't want to, you had no right to keep her etc etc. She said the same thing over and over for 5 minutes. Then a bell rang and the examiner asked what you would do and how you would go about it. Then asked what you would do if the abulance was 2 hours away and the police unavailable. Then asked how long a schedule is valid for. Case 13 Long stem with a young woman who had been to see many doctors and noone had told her what the problem was. She had had abdominal pain for years and no diagnosis. She had just been to see a gastroenterologist and he told her she had IBS. The patiet comes to you angry as the other doctor hadn't explained what the problem was and told her it was in her head. Task is to talk to the patient and explain about the link between mind and body. Management is not necessary Case 15 - Patient coming for information after she had had an ectopic pregnancy. She had had a salpingectomy and wanted some information about what would happen in further pregnancies, if she could get pregnant again, if she had a higher risk of ectopic, why her tube was taken, if there were other methods of dealing with ectopic, why she had an ectopic. Clinical tutorial groups Wednesday 09/07/ 2008: By Dr Matthew Cai

Station 1 Case 2 You are the resident in ED and asked to see a 42 year old man with severe abdomen pain , he has long history of hepatitis B and drink 5 bears a day, you confirmed a HCC occupied whole liver after a CT scan biopsy, he is non operatable . You are asked to counsel, and tell about the diagnosis and investigations results (repeat from Adelaide)

Station 2 Case details A 24 month old boy was BIBA to the emergency department with a seizure associated with fever. He was unwell for last 2 days with ear infection. There was no rashes . He was vomiting once. He has been in good health except for a high fever that developed two days ago to about 39.9 degrees. His mother gave him a small dose of Panadol but no other medications. About 20 minutes ago the mother noticed he was shaking of the arms and legs and his eyes had a blank stare. He was not responding to mother when this happen. This went on for what seemed like 5 minutes. He has no tongue bite. He has been ill with a slight cough and mild nasal congestion. Just prior to the seizure, he was playing with some toys.

Station 3 A 62 year old lady had a fall two days ago, now she complained the left wrist pain.

Tasks: Please explain treatment option, consent patient if needed Station 4 A 10 year old male presents with decreased appetite and intermittent tactile fever for the last five days. He complains of pain in his right leg and he has been having an increasingly difficult time walking over the last 2 days. He has a history of falling seven days ago. His mother denies reports of recent weight loss, cough, or dysuria. He has no previous medical problems. Station 5 45 years old taxi driver comes to your GP set up with complaining of pain redness, swelling in the right big toe on the first metatarsophalangeal join. This is the second time he is having such an attack. He is moderately obese and non-smoker but drinks about 4-5 standard beer per day. He has been on anti hypertensive therapy (diuretic) for the last few years. His general health has been fine otherwise.

Task: Ask for relevant history from the patient and ask investigation from examiner; explain your diagnosis and further management to the patient. Station 6 A 65 year old patient with known comes with left iliac fossa pain and discomfort. Task: Take further history and answer patients questions. Clinical tutorial groups Wednesday 02/07/ 2008: By Dr Matthew Cai Station 1 A 21 year old male university student who is studying engineering full time presented to your GP clinical for depression counselling. He feels down all time, sometime wake up in the middle of night and crying. He lives with parents in inner suburbs of Sydney, one older sister aged 23 and two younger brothers aged 17, 14. Task: 1 Take further history 2 Managing and counselling this Station 2 A 65-year-old man presents to the emergency department complaining of difficulty breathing. He describes worsening dyspnea on exertion, which is often associated with chest tightness, wheezing, and coughing. You are the RMO in ED and about to see him Tasks : 1. Take history from the patient; 2. Ask examination and investigation result from the examiner. 3. Give your D/D and diagnosis, explaining your management plan Station 3 Shoulder examination 36-year-old man with right shoulder pain for 6 months months, he complained that the pain was persistent but not travels down to his right thumb and index finger. He is taking panacetamol with poor effect. He is a non smoker, lives with his wife and two children Task: Please exam this mans shoulders

Tasks : 1. Take history from the patient; 2. Ask examination and investigation result from the examiner. 3. Give your D/D and diagnosis, explaining your management plan Station 4 There is a 50 ys old lady who is planning to go to Europe in a month time. She is here for preliminary assessment. 2 years ago she was found to have a murmur. She did not follow up on that. You are the GP and about to see her Task: 1. examine the patient 2. give your diagnosis 3. management Satation 5 A 7 year old previously healthy female presents to her primary care physician with a 12 day history of persistent thick nasal discharge, nasal congestion, cough, and intermittent low grade fever. Tasks : 1. Take history from the patient; 2. Ask examination and investigation result from the examiner. 3. Give your D/D and diagnosis, explaining your management plan

Station 6 CT scan films reading , There are some real CT scan to be reported by you .

Clinical tutorial groups Wednesday 24/06/ 2008: By Dr Matthew Cai Station 1 A 32-year-old man of Thai descent presents to the emergency department (ED) after experiencing a syncopal event at home one hours ago. His wife, who has accompanied him to the ED, witnessed the event. She states that they had been talking in the kitchen when her husband complained of feeling dizzy. He then became nauseous and slumped over onto the table; before she could get up and help him, he fell out of his chair and hit his head on the floor. After some time lying on the floor, he regained consciousness. His wife did not notice any seizurelike activity (including

no jerky body movements, tongue biting, or incontinence) in her husband when he was unconscious. When he regained consciousness, he was immediately fully awake, alert, and conversant; there was no period of confusion or garbled speech. The patient reports that he has had several such episodes in the past several years, but he has never sought medical evaluation for them. At the time of presentation, the patient has no specific complaints other than a bruise on his forehead and mild embarrassment Tasks : 1. Take history from the patient; 2. Ask examination and investigation result from the examiner. 3. Give your D/D and diagnosis, explaining your management plan This station is to train you to read a huge written history of the case, you nee to read fast , then testing your skill on Syncopy 2. A 2 year old child with cough of 4 days and now worse at night. Recent URI in the family. Fully immunised, previously well. There is a 6-week old sibling at home apart from his parents. On PE: The child is well, alert, active, and afebrile, not in any form of distress. When you checked the throat and touched the palate, the child started coughing with an inspiratory stidor. No need to take history.

Tasks : 1. Give your D/D and diagnosis, explaining your management plan 3 A multigravid is now in your clinic and is 38 weeks pregnant. Lives 80km from the hospital. You find out that she has a transverse lie. Tasks: Take further relevant history from the patient Ask examination findings from the examiner Tell the patient about your management plan. 4. You are working in a country hospital which is 300 km from the nearest neonatal intensive care unit. Your next patient is a 26/40prim. She has abdominal pain for 3 hours. Task: History, PE Manage the case

5 . A young female came to your GP to ask for antidepressants again. She was previously treated with antidepressants before.

Tasks: History Management 6 You are the only doctor in a private hospital ED, there is a 60 year old lady brought in by ambulance, She has no responding to you. Task: Managing this case as much as you can, including history, PE, investigations and Treatment.

Wednesday Clinical tutorial by Dr Matthew CAI 23/07/2008 Station 1: This is a practical station of Spirometry: John Smith, 65 year old, was a bus driver employed by the Melbourne Transit Authority. Over his 35 years of employment he had been exposed to his passengers' tobacco smoke, and that of his co-workers in the tea room and at shift breaks. He was diagnosed with small cell carcinoma of the lung, a type of lung cancer that has an above average strength of association with smokingboth active and passive. Towards the end of 1987 Mr Smith developed a severe cough that was aggravated by diesel bus fumes, and on the basis of this cough was declared unfit for work by his doctor in January, 1988. A claim for workers compensation was lodged. Now he is coming to your GP room for further investigations. Tasks: 1 performs a spirometry on this 65 year old man. 2 explained the results given by a examiner Station 2 A 21 year old student has a heart murmur coming and going, he comes to your GP for diagnosis. He has no cardiac symptoms, There was no SOB. There was no family history of heart diseases. Tasks: 1. do a cardiovascular examination. 2. Present what you have found to your examiner.

3. Present your diagnosis to your examiner and answer examiner. Station 3 A 22 year student presents with poor sleeping, It was end of year exam in university. He was worried about the exam. Recently, his father passed away unexpectedly due to heart attack. Task: 1 Please take a history, 2 Counsel this patient, 3 Make a management plan

Station 4 A 6 year old Chinese girl presented with intermittent peri-umbilical abdominal pain associated with non-bilious emesis for 4 days. She had mucosal pigmentation on her lips. Her mother brought this girl to see you for management Task: 1 Please take a history, 2 Examination and investigations, 3 Make a management plan Station 5 . A 20 year old man presented with swelling in the neck. Your colleague has seen this patient and PE showed a goitre in the neck Other PE was unremarkable. He ordered ultrasound which showed multinodular goitre of thyroid. TFT showed FT4 10 (10-24), TSH 0.6 (0.4-1.5). Now this patient return for blood tests result and your colleague is in holiday, you are about to see the patient. Task: 1 take a focal history No further physical examination is required 2 Explain to this patient about the diagnosis, treatment and complications of treatment.

Station 6

A 74 year old lady presented with left lower leg pain, she has been smoking for 50 years and was a waitress. She complained that left leg pain for three months, she felt difficult to do shopping. She was previously seen by other GP. But she moved to your area recently and would like you to take care of her

Task: 1 Please take a history, 2 Examination and investigations, 3 Make a management plan