Adelaide May 2004

1. Schizophrenia: 60 year old lady which wants a letter to move from

her house. It seems to be Organic cause, paranoid schizophrenia. DDx
includes delusional disorder, depression, OCD. 60 years old: should R/O any
organic cause at this age with CT scan and U/A.
2. Acute Urinary Retention: Middle aged lady unable to pass urine
for 16 hours. First after palpating the bladder insert the catheter then take
history (present, past and medications, alcohol), exam (abdominal and
vaginal and PR), send urine for MSU, FBE and U&E, Abdominal X-ray, U/S. If
there was a mass then CT with contrast. Remember herpes and fecal
impaction as potential causes.
3. Coma: Young female brought by flat mates which has neck stiffness.
4. Lethargic baby: Lethargic 4 month old baby with high fever and no
rash.
Remember the complications of bacterial meningitis. Septic work up.
5. Diabetes Mellitus: 60 year old man with urinary symptoms and no
history of diabetes. Very anxious regarding prostate cancer. A very tricky
case to see whether you are looking for everything or you are single-minded.
DDx: DM, prostate, CHF. Remember to look for edema. Admit the patient
6. Anorexia Nervosa: The girl which is dehydrated and has postural
BP drop. Remember admission and ECG.
7. Hypertension: The 25 year old lady which is on OCP for 3 years and
has had UTI in childhood.
8. Premature Rupture of Membranes: sterile speculum
examination. No digital exam. Ultrasound examination showing markedly reduced liquor
volume in the presence of normal fetal kidneys and the absence of IUGR is highly suggestive
of ROM. If the diagnosis is in doubt, the patient may be admitted for pad checks. Vaginal and
ano-rectal swabs for GBS, microscopy and culture. CTG, FBE. A cervical suture, if present,
should be removed immediately and submitted for culture. All women with PROM < 34 weeks
gestation should be administered betamethasone injection 11.4mg IM Daily - 2 doses. Where
there is no evidence of infection, the gestation is < 34 weeks and corticosteroids have not
been completed, if contractions are occurring Tocolysis in order to complete the
corticosteroids is reasonable. If the woman is GBS positive then induction should be
considered from 32 weeks, otherwise induction should be considered from 36th week.
Temperature and pulse control. FBE weekly, CTG twice a week, U/S fortnightly. All women
should be observed in hospital for 72 hours. If they remain well and are not in labour, they can
then be discharged for outpatient management. The woman would be instructed to take her
temperature t.d.s., observe PV Loss and be aware of fetal movements- returning if there are
reduced fetal movements felt. They should be seen once each week. Remember cord
prolapse. Prophylactic antibiotics improve the outcome in PROM. The drug of choice is
erythromycin 250 mg orally qid. (In those with no sign of infection). Intrapartum GBS
prophylaxis: Benzyl penicillin 1.2 gr IV then 600 mg qid until delivery. If allergic: clindamycin
600 mg tds.
9. Back Pain (Sciatica): Young man after lifting a heavy object. Task
is examination.
10. Cervical Cancer: 43 year old lady with bleeding (post coital) not
related to periods. Remember multiparty, sex at early age, early pregnancy, multiple
partners and smoking. Treatments of cancer include Radical hysterectomy, radiation
and chemotherapy. Notes: all of these patients (intermenstrual or postcoital bleeding
especially over 35) should be referred even with normal pap results. In postcoital
bleeding ask about IUCD and OCP as well as looking for cervical ectropion. Change
the OCP to a higher dose.
11. Chronic cough: 18 month old child with chronic cough at night for 10
month. Growing well, no wheeze, no allergies and no passive smoking. Remember
normal approach. Remember postnasal drip, Reflux, FB, drugs and CF.
Investigations: CXR, PH monitoring and manometry and a trial of bronchodilator. If
normal reassurance and follow up or referral. Some candidates claim it was Asthma.
12. Knee exam: Medial meniscus injury. Remember arthroscopy
13. Swollen ankles: 60 year old lady who travels a lot. Swelling goes
away in the morning and worse at the end of the day. Mild SOB. If investigations for
heart (Echocardiogram), kidney (U&E) and liver (LFT) were normal then
“Idiopathic edema”. Ask about tension, depression and headache. May also
involve face and hands. Management is with supportive stocking and salt restriction.
Diuretic make it worse but a trial of sprinolacton is recommended.
14. Spontaneous pneumothorax: Remember to advice against
flight and diving for 3 month and smoking and high altitudes. The recurrence rate for
both primary and secondary spontaneous pneumothorax is about 40%. Repeated
cases might need pleurodesis with sclerosant injection.
15. Scarlet Fever: Be careful to differentiate from Kawasaki. Benzyl
penicillin for 10 days. Complications: Rheumatic fever, glomerulonephritis, otitis
media. Some candidates claim it was meningitis, so make sure it’s not a purpuric
rash. Scarlet fever rash is blanching and sandpaper in quality.
16. Acute Abdomen (Mesenteric Infarction): Remember
the pulse (irregular). Remember that revascularization cab be tried but the results
are poor. Operation involves resection of the dead gut. Survival < 30%
 Melbourne Feb 2004

1. CVS exam: The 60 year old man which wants to travel overseas.
2. Abdominal Pain: 30 year old female with vomiting, fever and upper
abdominal pain. Task is examination, investigation and management.
3. Bronchiolitis: 4 month old child with fever, wheeze, low sats (91%)
and less wet nappies. RR=61
4. Newborn Jaundice: 30 hours old newborn with Jaundice. Billirubin
is 240. Task is history, relevant physical exam and investigations and
management. Notes: Is it conjugated or unconjugated? If conjugated
needs urgent referral. (Atresia, cyst or neonatal hepatitis). Physiological
jaundice is a diagnosis of exclusion. Reaches a maximum in day 3-5 and then
starts to decrease. Remember that Billirubin >285 needs phototherapy and
>360 needs exchange. You should exclude sepsis, ABO incompatibilities,
IUGR, G6PD deficiency, hypothyroidism and medication effects. Check for:
Onset before 24 hours of age, pallor, unwell baby, pale stools/dark urine,
hepatosplenomegaly, abdominal distension, poor feeding/vomiting. If not
present then most probably is physiologic and just review. If present then the
minimum investigation is: FBE, Film, and Coomb’s test, SPA urine for culture
and Billirubin and reducing substances.
5. Breast lump with cyclical pain: 42 year old lady which her
mom had breast cancer. Task is history, exam and management. Remember
to ask about OCP and change it to an OCP with lower progesterone like
triphasil.
6. Atrophic Vaginitis: A 65 year old lady with greenish discharge.
Task is history, exam and investigations from examiner. Then explain to the
patient and manage. Note: Investigations should include: PH, whiff test and
wet film. In wet film looking for clue cells, spores, trichomonas and
leucocytes. Also remember to check the urine. Then explain that due to the
female hormone her vagina has got dry and this make it prone to infection
and the treatment is replacement of this hormone by HRT or vaginal cream.
Also treat the infection.
7. Intermittent claudication: 66 year old with right leg cramp
while walking. Task is history, exam, investigation and management.
8. Diabetic Neuropathy: 43 year old lady with right leg weakness.
Task is history (6 minutes), diagnosis and management. Ask about
numbness, tingling and pain anywhere, Wasting of muscles, nausea and
vomiting, indigestion, dizziness or faints due to postural drop, urinary
problems, vaginal dryness (dyspareunia)or erectile dysfunction in males,
 weakness, weight loss and visual problems like diplopia. Remember
comprehensive foot exam. Referral for NCV and EMG. In management stress
on foot care and podiatry and physiotherapist for weakness and tight sugar
control. (And possibly endocrinologist referral). Explain to the patient: People
with diabetes can, over time, have damage to nerves throughout the body. Neuropathies lead to
numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may
also occur in every organ system, including the digestive tract, heart, and sex organs. People
with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the
greater the risk.

9. Enuresis
10. Gestational Diabetes: All women (others than those at special risk see
below) have a 75 g non-fasting glucose challenge test (GCT) performed at 26 weeks. If the 1-hour
plasma glucose is ≥ 8.0, they will be recalled to have an oral glucose tolerance test. The glucose
tolerance test is performed after a 10-12 hour fast. The fasting plasma glucose is measured, and then
75 g glucose solution is drunk in not more than 5 minutes, and the 2-hour plasma glucose measured.
Patients may not smoke, eat nor drink anything other than water during t he test, and should not
perform any exercise. Gestational diabetes (GDM) is defined by either a fasting plasma glucose value
≥ 5.5 and/or a 2-hour value ≥ 8.0. All women with GDM are seen initially by the diabetes nurse
educator and dietician and obstetrician in diabetic clinic. Investigations: HbA1c, U&E, BSL. Ultrasound
examination at 30 and 36 weeks for growth. All women with GDM will perform home blood glucose
monitoring, initially 4 times each day before breakfast and 2 hours after each meal. The target levels
are ≤ 5.0 fasting and < 6.7 mmol/L 2 hours after meals. Initially all women are treated with dietary and
exercise advice. If this fails to achieve the targets, they should be reviewed by the dietician. If the
targets are still not met, insulin therapy should be commenced. More frequent visits. Method of
delivery depends on estimated fetal weight. Women with GDM should have an appointment made for
a postpartum GTT prior to postnatal discharge.
11. Preeclampsia: 30 year old primi 32 weeks pregnant. BP is 170/110
and urine protein is increased. Task is focused history, investigations and
management. Ask about visual disturbances, headache, abdominal pain (RUQ),
weight gain, puffiness, antenatal visits, history of high BP, any medical problem,
twins, DM, family history. Exam the reflexes, clonus, edema, fundoscopy, abdominal.
Investigations: FBE, U&E, LFT, urine protein. She Needs admission with BP control.
(Hydralazine 5-10 mg bolus then 5 mg hourly). Needs steroids. Complications are
abruption, eclampsia, IUGR, bleeding due to platelets, HELLP. If any Neurologic sign
then prophylactic MgSo4 should be started. (hyperreflexia, clonus, severe headache
or visual disturbances)
12. Visual Problem: 25 year old lady having difficulty reading notice
board. Same problem in father and brother. Relevant exam and management. Most
probably keratoconus. NOTES: Keratoconus is a thinning of the central zone of the
cornea, the front surface of the eye. As a result of this thinning, the normally round
shape of the cornea is distorted and a cone-like bulge develops, resulting in
significant visual impairment. 8% of patients have affected relatives. Keratoconus is
estimated to occur in 1 out of every 2000 persons in the general population.
Keratoconus generally affects both eyes. Keratoconus has been associated with
conditions such as hay fever, asthma and eczema. In the early stages of the
condition, spectacles are usually successful in correcting the myopia and astigmatism
associated with the keratoconus. As the condition advances, the cornea becomes
highly irregular and vision is no longer adequately corrected with spectacles. Rigid
contact lenses are then required to provide optimal visual acuity. In about 15% of
cases, the keratoconus progresses to the stage where corneal transplantation is
required.
13. Wrist injury exam
14. Postnatal depression
15. Osteoporosis
16. Renal Colic

Sydney March 2004

1. Twin Pregnancy: Diet, Iron and folate, Dietician referral, maternal

complications (polyhydramnios, preeclampsia, anemia, PPH, APH, Cord prolapse,
malpresentation), fetal complications (IUGR, malformations), High risk antenatal care
2. HIV test and counseling: Don’t forget testing for other STD’s
3. Spontaneous pneumothorax: Primary—no prior lung disease.
Secondary—complicating preexisting lung disease (Asthma, Cystic fibrosis, COPD,
TB, menstrual pneumothorax), Remember 30%, simple aspiration or catheter

4. Shoulder exam after dislocation: Remember

musculocutaneous and radial nerves as well, warn against abduction and
external rotation
5. Incomplete abortion and cervical shock: It’s a vagal
stimulation due to cervical pressure and uterine stimulation hence a drop in
BP and pulse. Investigations for recurrent abortion: karyotyping of parents
and fetal products, U/S, Antiphospholipid and lupus antibodies
6. Conversion disorder and lower limb exam:
Remember to consider this diagnosis only after proper physical exam and
investigations
7. Cranial nerve II and VIII exam
8. Endometriosis
9. Hypothyroidism: Remember decreased ankle jerk reflex, chronic
anemia, Bradycardia, dry skin, edema
10.GI malignancy: 55 year old lady with 6 month pain in LLQ. Just
remember normal history which includes: present illness, past history,
medications and family history. Remember to ask about weight loss, bowel
actions. Remember first degree relative screening.
11.UTI follow up in a child: Remember repeat MSU and VCUG
12.Acute psychosis management
13.Croup
14.DVT: remember heparin dose (treatment: 5000 U bolus IV and 25000 U
infusions over 24 hour. Prophylaxis: 5000 sc 12 hourly)
15.RA hand exam
16.Cardiac murmur in a child

Brisbane October 2004

1. Pyloric Stenosis: 3 weeks old child with vomiting. First important

question is asking about color. If Green color then urgent surgical referral. If
non-bile stained then consider pyloric stenosis, GORD, infection (UTI,
meningitis). Projectile vomiting can be present in GORD as well as pyloric
stenosis. In PS look for peristalsis during test feeding from Left to Right.
Treatment is longitudinal pyloromyotomy.
2. Breast Lump: 24 years old with lump and tenderness in right breast.
There is a palpable auxiliary lymph node. On OCP. Fibroadenomas are more
common in younger women and may become tender in the days before a
period or grow bigger during pregnancy. Women have a choice about whether
to have their fibroadenoma removed, but if it is monitored and continues to
enlarge, it should be removed. Most often, younger women or those with
smaller fibroadenomas will not have them taken out. The operation to remove
a fibroadenoma is relatively simple. A general anesthetic is usually required.
Remember U/S and FNA.
3. Delirium and MSE: The patient which got crazy after burn.
4. Weight loss: 100 Kg man complaining of tiredness, lethargy and 2 Kg
weight loss. NOTE: Remember stress and anxiety, malignancy, DM,
Thyrotoxicosis, chronic infection, depression and medications. He had DM.
5. Weight loss: 45 year old female with 7 Kg loss over 2 month. All the
investigations are normal. Talk to the patient. NOTES: consider stress and
depression.
6. Home delivery counseling: A 21 year old 17 weeks pregnant
doesn’t like hospital and wants a home delivery. Talk to her.
7. Trauma and difficulty breathing: A guy in emergency after
car crash. There is a CXR. Maybe haemothorax.
8. Vaginal Bleeding: 26 years old with bleeding after 8 weeks
amenorrhea. BMI is 30. Remember abortion, PCOS and thyroid disorders.
(when they provide BMI, it means something) NOTES: approach is taking
history of everything with these 3 diagnoses in mind. Investigation with BHCG
and U/S and TFT. If it should multiple small cysts then bingo. Some points
 about PCOS: remember risks of DM, hyperlipidemia, hyperinsulinemia and
hypertension. Also increased risk of ovarian and endometrial cancer.
Investigations include: LH/FSH ratio (>2), serum testosterone and
endometrial biopsy. Screening for all women with PCOD include: smoking
history, BP, Glucose (tolerance test), lipids. Management is weight reduction
(dietitian referral) and exercise and PCOS support group. Treating the risk
factors if present. Treatment of insulin resistance with metformin or
rosiglitazone. Hirsutism with cyproterone or spirinolactone. OCP can decrease
the chance of malignancy of unopposed estrogen and helps with irregular
bleeding. Ovulation induction by clomiphene. Assisted induction and at the
end ovarian diathermy. (making punctures on the ovary with a hot needle)
9. Globus Sensation: 23 year old girl feels something in the throat.
Her friend died a few month ago of throat cancer. Talk to her. Notes: take a
complete history of dysphagia; ask whether she gets relief after swallowing.
Weight loss, pain and family history. O/E look generally at skin and hands,
inside the mouth for any lump and uvula deviation, tongue deviation, any
neck lymph node, thyroid nodule (any symptom of thyroid activity) and
esophageal obstruction test. (With a glass of water and listening for murmur
in tummy which 7 seconds is normal). Investigate anemia and TFT. If
everything normal then reassurance and education and support. Don’t forget
leaflet and websites.
10. UTI follow up
11. LLQ abdominal pain: Diverticulosis
12. RA hand exam
13. HIV counseling: The guy which has come back from Thailand
14. Spontaneous pneumothorax
15. ?
16. ?
 Melbourne November 2004

1. Primary Amenorrhea: A 15 year old girl with normal secondary

sex features.
2. Post date pregnancy: 41 weeks pregnant lady comes for routine
antenatal check. Notes: usually after 41st week induction should be tried
because of increased risks both for mother and fetus. The baby gets bigger
and there is risk of Meconium passage and intrapartum complications.
Remember to refer to Day Assessment Unit for frequent CTG and U/S and
remember the Kicking chart. Induction can be tried by Misoprostol or
Oxytocin.
3. Thalassemia minor counseling: Young lady who is minor is
married with a minor guy. Answer the questions about what is minor and
major. What does the child need if it’s major? And prenatal diagnosis with
CVS and amniocentesis. Notes: Thalassemias is a genetic (inherited) blood disorder that
has one feature, the defective production of hemoglobin, the protein that enables red blood cells
to carry oxygen. The individual with thalassemia minor has only one copy of the beta thalassemia
gene (together with one perfectly normal beta-chain gene). The child born with thalassemia
major has two genes for beta thalassemia and no normal beta-chain gene. Thalassemia major
patients rarely live beyond puberty.

4. Chest pain: 45 year old man complaining of chest pain on exertion.

Notes: with lifestyle changes remember to start Aspirin.
5. Abruptio placenta: 32 weeks pregnant with spotting. U/S not
available and CTG doesn’t detect fetal heart rate. Notes: Candidate has not
asked whether the mom is in shock or not. Anyway it’s a still birth. DDx
asked by examiner: concealed abruption, cord knot, preeclampsia, infections.
6. Croup: 7 month old child with barking cough and high temp. Remember
admission. Question by mum: what is croup: Croup is a viral infection of the throat
(upper airway). The virus causes swelling of the voice box (larynx) and windpipe (trachea). This
swelling makes the airway narrower, so it is harder to breathe.

7. Chronic diarrhea: 3 years old child with foul smelling diarrhea for 3
weeks which is hard to flush down the toilet. Has lost a bit of weight. Task is
 talk to mum, provisional diagnosis and DDx. NOTES: candidate has diagnosed
giardia, but the point is talking about giardia and celiac both. Stool should be
checked for cysts and ELIZA or nasogastric aspirate for finding trophosoites.
At the same time Antiendomysial Ab and if needed duodenal biopsy. So be
careful.
8. First time Epilepsy: 7 year old child has had a tonic-clonic fit for 1
minute at school with incontinence. Now he is fine. Talk to dad and manage.
First ask about any previous disease like diabetes. He Needs admission for
investigation like CT scan and EEG. Whether to start treatment is depending
on the investigation results and neurologist choice. 60 % of children have a
self-limiting condition which will settle after withdrawal of medication.
Remember usual advices.
9. OA hand exam
10. Acute abdomen: 55 year old man who has been taking diclofenac
for 2 month. Has got a sudden pain for 2 hours. DDx: perforated ulcer, MI,
cholecystitis, gastritis, AAA.
11. Impaired vision: 18 year old girl complaining of difficulty reading.
Task is eye exam. Father and brother wear glasses. Snellen chart. Remember
pinhole test and fundoscopy and tonometry. Referral to optometrist.
12. Lung cancer and hoarsness: 55 year old guy, smoker who is
complaining of tiredness and hoarsness. Task is everything. DDx is lung cancer,
thyroid cancer, laryngeal carcinoma, esophageal carcinoma, bulbar palsy. O/E he has
had decreased air entry and dullness in left side.
13. Benzodiazepine dependency: The patient who wants
oxazepam for sleeping problems. She has been to your practice for 2nd time.
Candidate says that she has had suicidal ideas. So find out the real cause of her
problem. Maybe depression and then she needs admission and it has not been a case
of benzodiazepine dependency. Somatization needs 2 GI symptoms, one sexual, one
neural and something else. They must be referred to psychiatrist. Treatment is CBT
and psychotherapy.
14. Colle’s Fracture: reduction is under anesthesia by flexion, ulnar
deviation, pronation and traction. Complications: ruptured extensor policis longus,
stiffness of elbow and MCP, regional pain syndrome. Remember simple percutaneous
pin insertion for severe deformity.
15. Weight loss: Old lady has lost 6 Kg in 3 month. Task is history for 6
min and investigation. Remember stress and depression, malignancy, DM, thyroid
and chronic infection. Notes: remember FBE, U&E, BSL, TFT, ESR, CXR and stool
occult blood. Remember a full search for a possible source of cancer. (ask about
mammogram, pap smear, bowel, urinary, respiratory symptoms)
16. Somatization: A young guy with several symptoms for some years.
Ask about family history.
 Sydney May 2004

1. Hip examination: Past history of posterior dislocation, now

complaining of stiffness and little pain. Look (wasting, swelling, redness,
limping and abnormal rotation of the legs), Feel (the greater trochanters
should be at the same level otherwise the higher side is abnormal), Move
(flexion and Thomas’s test (fixed flexion deformity in OA), rotation, abduction
and adduction, extension, trendelenberg test and trendelenberg gait, true leg
length which shorter side has problem and apparent leg length which shows
tilting at pelvis if abnormal) Note: in OA internal rotation, abduction and
extension are restricted. (IR extension AB). Sciatic nerve checked by foot
dorsiflexion. Management: pain killer, physiotherapy, hydrotherapy, total hip
replacement with cementless material, femoral osteotomy for young people
2. Meconium stained fluid in labour: as Melbourne April 2006
3. Acute Otitis media in a child: Remember follow-up for glue ear
(blowing exercise on the back of the hand and closed nose is helpful) and audiometry
if necessary. TM will heal up.
4. Acute Psychosis: Mom wants to know about his son who has been
admitted. Mom asked about schizophrenia: it’s a medical condition which
affects the normal functioning of the brain and interferes with the person’s
ability to think, feel and act. Causes are a combination of hereditary and
other factors. Sometimes it has trigger factors like illness, surgery, stress and
drugs. Management: medication and community support (information,
accommodation, and help to find job, psychosocial rehabilitation and mutual support groups).
Prognosis: some recover completely and some have chronic disease through
out the life which needs supervision. Investigations during maintenance: BP,
BSL, prolactin level, cholesterol and TG, TFT, U&E, LFT, FBE, ECG. First at 3
month then 6 monthly. Always remember leaflet
5. Female Urinary Incontinence: Differentiate between stress,
urge (with no residual volume) and voiding dysfunction with bladder atony
 (large residual volume). History, PMH, medications and exam (any abdominal
mass and vaginal exam). R/O UTI. Urodynamic studies, U/S and residual
volume. Stress: pelvic floor exercises, weight control, HRT and vaginal
creams and physiotherapy for cough plus continence nurse. If studies showed
GSI then may need surgery due to sphincter weakness. If urge or voiding
dysfunction then look for Gynecologic and Neurologic causes with referral.
Use anticholinergics if exercises didn’t help or was severe. Remember the
chart and leaflet
6. SIDS: say I’m sorry and ask how parents are coping. Remember grief
counselor, SIDS support group and leaflet.
7. Diabetes type I counseling: Remember to carry sweets
always, leaflet
8. CTS: Tell her as far as you are not overusing your hands u can do
everything
9. Cyclical mastalgia/Lump (Fibroadenosis): Ask what
kind of OCP she is taking. Changing to triphasil to reduce progesterone is
beneficial. First degree relative with cancer increases the chance 3 fold.
Advice about regular self exam with leaflet and education (remember national
breast cancer website). Mx: Analgesia, good bra, well-balanced diet, weight
reduction, no caffeine, exercise, then mefenamic acid, vitamin B1 and B6,
evening primrose oil (EPO), follow up then Danazol
10.Oligohydramnios: 34 week pregnant and everything else is normal. Task:
history, exam, investigation and management. U/S has shown decreased liquor. She
needs referral to hospital for full checkup of baby. She needs more frequent
monitoring, If fetal distress then delivery. Volume<500 is Oligohydramnios.
Associated with: prolonged pregnancy, PROM, fetal urinary tract malformation.
Increased chance of preterm birth. Late onset oligo has a good prognosis, but early
onset is nasty. Oligohydramnios detected before 36 weeks in the presence of normal
fetal anatomy and growth may be managed expectantly. Cord compression during
labor is common.
11.Renal Stone: Remember X-ray, CT-KUB, U&E, Follow up and leaflet
12.Peripheral Vascular Disease: 50 year old man on metoprolol for
HTN. Remember Doppler U/S and ankle brachial index. Talk about lifestyle (smoking,
drinking, fatty food, weight, exercise, too much coffee)
13.Migraine
14.Chronic diarrhea: having steatorrhea.
15.COPD: Remember pnumococcal (every 4 years) and influenza (yearly)
vaccination. Remember physio for chronic cough.
16.Depression: 45 year old female complaining of tiredness and constipation.
 Melbourne April 2004

1. Supracondylar Fracture: Remember radial artery, collar and

cuff for 6 weeks after reduction and NO need for plaster. Elbow stiffness will
resolve without therapy.
2. Alcohol counseling and Child abuse claim:
Remember standard drinking and Gatehouse.
3. Cirrhosis examination: A patient with esophageal varices.
4. Post Strep Glomerulonephritis: A child with dark urine and
puffy eyes. RBC + in urine and BP 140/95. 15% with throat infection (GABHS)
and 25% with impetigo. Invariably resolves, but should be treated in hospital
with special care. Investigation: ASO, reduced C3, and U&E and increased
AntiDNase. Management: admission, bed rest, fluid restriction, penicillin (if
swab positive), low protein diet, antihypertensive and diuretics. The family
members should be screened for GABHS and careers treated. Proteinuria may
remain for 6-12 month and hematuria may remain for years. Follow up and
leaflet.
5. Hypertension: The 25 year old on OCP.
6. Polyhydramnios: 26 year old 32 week pregnant. Fundal height is
more than gestational age. 50% fetal abnormality, 20% maternal (diabetes
and twins) and 30% no cause found. Ask about breathlessness and edema.
Predisposes to preterm labour, cord prolapse, abruption as membranes break,
PPH and malpresentation. During labour Check early for cord prolapse. After
labour pass a nasogastric tube in the baby to make sure esophagus is patent.
Acute hydramnios tends to develop earlier in pregnancy than does the chronic
 form—often as early as 16 to 20 weeks—and it may rapidly expand the
hypertonic uterus to enormous size. Minor degrees of hydramnios rarely
require treatment. Even moderate degrees with some discomfort usually can
be managed without intervention until labor ensues or until the membranes
rupture spontaneously. If dyspnea or abdominal pain is present, or if
ambulation is difficult, hospitalization becomes necessary. Bed rest, diuretics,
and water and salt restriction are ineffective. Recently, indomethacin therapy
has been used for symptomatic hydramnios. Remember Amniocentesis
7. Manic attack: 22 year old student with decreased sleep and
delusions. Task is MSE and DDx and management. Notes:
Elevated mood, accelerated speech, agitation, racing thoughts and flight of
ideas, increased activity and reduced sleep. Sometimes paranoid with
grandiosity, overspending, impaired judgment, increased sex, poor insight
variable psychotic features like delusions, paranoia and hallucinations.
Episode may be precipitated by stress. Admission is necessary. Lithium (level
0.6-0.8), valproate and carbamazepine. Lithium side effects: tremor, GI
upset, muscle weakness and weight gain. DDx: manic attack, schizophrenia,
delusional disorder, drug abuse. Remember psychotherapy and psychosocial
supports.
8. Diabetes and lower limb exam
9. iron deficiency in a child
10. Pancytopenia in childhood
11. Acute Abdominal pain: 26 year old female with 6 hour RLQ pain.
Task is history, exam, Investigation and DDx. (appendicitis, ovarian cyst, mesenteric
adenitis, mitelschmertz, renal colic, pyelonephritis)
12. Primary Amenorrhea: 18 years old with no menses. Secondary
sexual characteristics are normal. Mom had menarche at 17. Notes: first look for
pubic hair growth. If normal it excludes androgen insensitivity syndrome. (Also high
testosterone levels). Then look for secondary characteristics like breast development.
If normal then it means that ovaries are functional and we can rule out Turner
syndrome. Low body weight, stress, intense exercise (such as experienced by
gymnasts or ballet dancers) or obesity associated with PCOD may be involved in
primary amenorrhea. So ask about weight and anorexia. Look for any outflow
malformation like agenesis of uterus, vagina or septum. Ask whether she has cyclical
lower abdominal pain which reveals a septum blocking the blood outflow. Tests:
testosterone, FSH, U/S. If FSH is increased then karyotyping is necessary.
Remember to ask about mother and sisters menarche. It can be familial and in that
case she should use a contraceptive method despite amenorrhea.
13. Otosclerosis: In pregnancy.
14. Shortness of Breath: A 65 year old man with SOB. No chest pain.
Cough in the morning with sputum. Heavy smoker for 25 years. Task is history,
investigation and management. Remember to ask about blood in sputum and weight
loss. X-ray has shown pleural effusion. DDx: Infection, malignancy, RA, Lupus.
Investigation: CT scan, pleural tap, bronchoscopy. Transudate from increased venous
pressure like volume overload or CHF or decreased oncotic pressure like live or
kidney failure. Exudate from inflammation or malignancy.
15. SCC: A patient who you have excised an ulcer from his forehead and now
is coming for path report which shows SCC which has extended to margin of the
sample. Talk to the patient and tell him the management.
16. Diverticulosis: 57 year old male with constipation and abdominal pain
(LLQ) which has gone for U/S and the report is Diverticulosis. Colonoscopy has been
normal. His father died of colon cancer at 65. Task is management and F/U. Notes:
complications are: abscess, perforation, peritonitis, obstruction and fistula. WCC and
CRP to determine inflammation. Usually responds to high-fiber diet. Advice to
patient: the gradual introduction of fiber with plenty of water will improve most of
the symptoms and prevent the complications. 1. Cereals, muesli and porridge 2.
Wholemeal and multigrain bread 3. Fresh fruits and vegetables. Bran can be added
to cereal. At first might be uncomfortable but soon gut will settle.

Some 2004 cases

1. Hypertension: A 19 year old girl has had 2 borderline BP readings in

the pas and family history of high BP. All the investigations have been
normal. Now she is worried and has come to you for advices. The candidate
has diagnosed anxiety (!!!) as the cause and has failed the station.
Remember to ask about OCP in every female patient in every station.
2. Hodgkin Lymphoma: a young lady with cervical lymph node has
done biopsy and has had Hodgkin lymphoma. Now has come to you to ask
about disease, treatment, duration and complications of chemotherapy and
radiotherapy. Notes: Lay Explanation: The lymphatic system is one of the body's
natural defenses against infection. It is a complex system made up of lymph organs,
such as bone marrow, tonsils, the thymus and the spleen, and lymph nodes connected
by a network of tiny lymphatic vessels. Hodgkin lymphoma is a cancer of the
lymphatic system. Many people with Hodgkin lymphoma can be cured, even when the
disease has spread to different areas of the body. Complications: Some chemotherapy
drugs can cause permanent infertility although newer treatments carry less risk of
this. Treatment with chemotherapy and radiotherapy can lead to a slightly increased
risk of developing another cancer later in life. However, modern treatments and
approaches to treating Hodgkin lymphoma are designed to limit these risks as much
as possible. Mediastinal radiotherapy can cause coronary atherosclerosis. Cure will be
achieved in >75% of cases.
3. GBS infection in pregnancy: Pregnant lady who has GBS
asking about prevention in her baby.
4. Autologus transfusion: A lady who is preparing for hip
replacement and is asking about risks and benefits of autologus transfusion.
Examiner has asked about the amount, storage time limit, how often and
contraindications. Notes: Benefits are obvious. Disadvantages: Possible
anemia and hypovolemia, Need for surgery to be scheduled 3-5 weeks in
advance, any normal reaction due to venipuncture. Contraindications:
Anemia, coronary artery disease, recent MI or unstable angina, active
bacterial infection
5. Chronic cough: A young lady who has come back from Malaysia.
Antibiotics have not responded.
6. Transfusion Refusal: A pregnant lady with severe placenta previa
who is refusing blood transfusion.
7. Pregnancy in an epileptic woman: She should be told
about risks of AEDs (anti epileptic drugs) on fetus and if not taking them then
increased risk of having seizure and death risk for herself and fetus. If she
has been seizure free for 2-3 years then neurologist might think of stopping
the medication. Otherwise medication should be continued with the lowest
dose possible. Blood Levels should be checked during pregnancy (usually they
decrease). Folic acid 5mg daily and vit K (10mg daily during the last month of
pregnancy) should be started. Tell her about cleft lip, palate and NTD. Most of
the epileptic women will have normal babies with good control. Breast feeding
is allowed with AEDs because baby has got used to them. Alcohol and
smoking must be stopped. Pethidine is not recommended for pain relief
during labour.

Sydney May 2004 Resit

1. IV Cannula Insertion
2. GORD: Middle aged guy with reflux. Explain the results of endoscopy and
give him advices about lifestyle changes.
3. ITP: a child with nose bleeds and bruises after a cold. Platelet is 15.
Remember avoidance of IM immunization.
4. Nausea in pregnancy: 38 year old woman who is 8 weeks
pregnant has had severe nausea and vomiting a week ago. Today she has ++
ketone in urine exam. Task is history, investigations and management. Notes:
consider molar pregnancy with high BHCG. Uterus is not firm in molar
pregnancy and she might have hyperthyroidism symptoms because HCG
resembles TSH. Outlook is excellent with abortion and if needed
chemotherapy. Remember the CXR if molar pregnancy. She needs admission
with a full work up. U/S in molar pregnancy is like a “snowstorm”. Remember
to tell her about increased risk in next pregnancy and also increased risk of
Down syndrome (1:200) at her age. A molar pregnancy is the result of a
genetic error during the fertilization process that in turn causes the growth of
abnormal tissue (which is not an embryo) within the uterus
5. Otosclerosis: Lay terms: It describes a condition of abnormal growth in the tiny
bones of the middle ear, which leads to a fixation of the stapes bone. The stapes bone must
move freely for the ear to work properly and hear well. Remember hearing aid and
stapidectomy
6. Bereavement: In a university girl who has lost her father and can’t
sleep and concentrate for exam. Remember the 3 stages of bereavement.
Remember the medical certificate. Advice she about religious ceremonies,
help from friends and mum, relaxation techniques and short course sleeping
tablets. Remember Risk assessment.
7. DKA: An 18 year old girl who is feeling tired and cannot work properly in
.
the farm In a country setting with limited resources. Remember 10 unit IM
insulin and N/S and air ambulance. If they asked about infusion tell them that
you will check with endocrinologist at the base hospital. It’s usually 6 U/hour.
Saline rate is 1 L in first hour then 500 ml per hour for the next 2-3 hours.
8. Postoperative Dehydration: Fluid therapy

Melbourne August 2004

1. Otosclerosis: The woman, during pregnancy.

2. Infertility: A couple which wife is normal and man’s semen analysis is:
count=2 million, mobility<20%. Task is history and management. History
should include: sexual function (potency), previous testicular problems or STI
or mumps, medical problems, any genitourethral surgery, occupation (heat,
chemicals), drugs and alcohol. In women you should also ask about all
menstrual history and previous problems and surgeries, eating disorders and
obesity. Remember to ask about adequacy and timing of intercourse. After
history, exam should include checking the secondary sexual characteristics in
both. In men remember varicocele and in women the vaginal exam. The fist
workup includes: body temperature chart and serum progesterone in day 21
and vaginal U/S and rubella status in women, semen analysis in men. If
semen analysis is abnormal then check the FSH level and antisperm
antibodies and refer. If FSH is 2.5 times normal then it’s an irreversible
 testicular failure. (Endocrinologist) remember the IntraCytoplasmic Sperm
Injection (ICSI).
3. Meningococcemia: 12 month old child.
4. Chronic diarrhea: Young man with 3 month diarrhea. Task is
history, clinical finding and management plan. Chronic diarrhea workup. Ask
about blood or mucus in stool and diarrhea at night. If present then it’s not
functional. Ask about stress factors. Abdominal pain and whether it gets
better after bowel motion. Ask whether he has problem flushing his motions
down the toilet (steatorrhea). Ask about any joint pain, eye problem, mouth
ulcer or skin rash. Ask about travel history, drugs and alcohol and never
forget sexual history and HIV. (Gay bowel syndrome: This term refers to a
collection of sexually transmitted enteric infections in HIV infected
homosexuals.) Remember the family history. Exam: Check for any systemic
sign of IBD and clammy and shaky hands of thyroid dysfunction. Look for
mass in abdomen and also splenomegaly. Look for any sign of Addison’s
disease (hyper pigmentation and postural drop). Investigations: first stool
exam (remember giardia and C. difficile). Then FBE, U&E, ESR, HIV,
antiendomysial ab and TFT. Sigmoid and colonoscopy (and Proctoscopy) with
biopsy.
5. Post Partum Bleeding: In a country setting and you have tried
syntometrin with no response. Placenta has been complete. Task is relevant
history, examination and management. Notes: Remember 4 T’s: 1. Tissue:
retained tissue, invasive placenta 2.Trauma: laceration, uterine rupture or
inversion 3. Tone: uterine atony 4. Thrombin: coagulopathies. Check for
these T’s. You can start syntocinon infusion (40 U in 1 L N/S over 10 hours).
If no response then you can try Misoprostol 800 microgram PR. you can give
ergometrine till 1000 microgram/day, but check BP. If there is laceration
press it. Check clotting by bedside clotting test for 7 minutes. If abnormal
start FFP. If bleeding continued then laparotomy. Uterine inversion: unable to
feel uterine fundus: should be replaced immediately with pain relief like
pethidine. DO not forget uterine massage in atony.
6. Ischemic heart Disease: 56 year old man who has done the
stress test and has shown ischemia. Smoker and fat. Discuss and manage.
7. Alzheimer’s disease: Daughter of a guy with the disease comes to
you for discussion. She is the only child.
8. Jaundice: a nurse which is lethargic and thinks she has hepatitis. She
has dark urine and brown stool. O/E hepatomegaly and tender, jaundice. Has
been taking augmentin for 6 days. Task is: history, exam, possible diagnosis
and DDx. Jaundice murtagh
9. Vasectomy: Task: explain and answer questions
10. SIDS
11. Vaginal birth after cesarean: Success rates for VBAC range
from 60-80%. The benefits of a trial of labor outweigh the risks. In the absence of
contraindications, a woman with one previous cesarean delivery with a lower
transverse uterine incision is a candidate for VBAC and should be counseled and
encouraged to undergo a trial of labor. Contraindications: A previous classical uterine
incision, Epidural anesthesia is not a contraindication for VBAC, Oxytocin use for
induction or augmentation of labor is not contraindicated, not recommended for
 patients with multiple gestations, for patients with breech presentation, or for the
use of prostaglandin gel. VBAC support meetings. Anaesthetist and theatre to be
notified of any patient for planned VBAC in Delivery Suites and in labour. Length
should not exceed 2 hours: 1 hour to allow for Passive descent, but no more than 1
hour of Active pushing.
12. Allergic reaction counselling: egg allergy in a child.
13. lower limb exam Diabetes
14. DVT: The guy which is on metoprolol
15. Eating disorder: A young girl sent to you by her dentist, concerned
about dental caries due to eating disorder. Task is history and Advice. Remember to
ask about laxative or diuretic use. Ask about family relationships. In bulimia periods
are irregular and amenorrhea is rare. Management: referral to psychiatrist and
psychologist for behavioural therapy and intensive psychotherapy and family
therapy, Supportive care by doctors and allied health staff, try to address the
underlying psychological or family problems, SSRI beneficial for those with
depression. DO ASSESS THE RISK
16. Thyroid cancer: A young girl with thyroid nodule and FNA which
shows papillary carcinoma. Task is explanation and management. Notes: papillary is
important not to miss because of high cure rate. 60% of thyroid cancers. Involves
total thyroidectomy, ablative I131, Thyroxin replacement and follow up with
thyroglobulin measurement and thallium scanning. Prognosis is good if young and
female. Follicular cancer: 25% of cases. Spreads early via blood. Treatment is total
thyroidectomy and Iodine ablation. Thyroidectomy: A major operation under GA.
Before operation check Ca level and vocal cords by laryngoscope. Complications: 1.
Early: haemorrhage, recurrent laryngeal nerve damage (temporary or permanent
depending on the severity of the damage), removal of parathyroid glands and
resulting hypocalcemia and tetany, thyroid storm (treat by Inderal and antithyroid
drugs) 2. Late: Hypothyroidism

Sydney August 2004

1. Jaundice: A newborn having jaundice from 3rd day to 2nd week. He is

breastfeeding. Task is history and management. NOTES: child had conjugated
Billirubin and pale stools. He should be admitted under gastroenterology for
investigation. LFT, Viral serology, U/S, HIDA scan.
2. Stuttering: 4 year old child after attending the kindergarten.
3. Placenta Previa: 28 weeks pregnant lady who had bleeding for 2
hours and now settled. You are an HMO in hospital. 18th week U/S had shown
a low lying placenta. Task is history and management. NOTES: she needs
admission, ask about pain, amount of blood and color, whether it was the first
time, any previous medical condition, ask about previous U/S and antenatal
clinics, twin. O/E VITAL SIGNS, gentle abdominal palpation for uterine check
(usually not tender in previa), FHR, NO VAGINAL EXAM, just check whether
there is ongoing bleeding. If vital signs are normal then arrange U/S. Blood
for FBE, Group & Crossmatch, coagulation profile, feto-maternal haemorrhage
test. Above 24 weeks consider steroid injection. CTG to check the fetus. Anti
 D if Rh negative. Maternal monitoring, bed rest and obstetrician review. For
previa should book theatre for elective C/S and for abruption if fetal distress
then induction of labour.
4. Addison’s disease: 45 year old guy complaining of pigmentation.
History, exam and management. NOTES: history: is it general or local? Tell
me more. Is it itchy? Have you used cosmetics? Fever, cough or N/V?
Appetite? Weight loss? General feeling? Sleep? Easy bruising? Water and
bowel work? THEN: any past history? Medications? FH of high iron in the
blood? THEN: O/E vitals and orthostatic drop. Look for hyperpigmentation of
palmar creases and mouth. Investigations: FBE, U&E, Iron panel, BSL, U/A,
high ACTH and low cortisol. Confirmation is by Synachtin test: 250 microgram
tetracosactide injected IM; if cortisol was increased then it’s not Addison.
Hydrocortisone is the treatment. Remember bracelet for crisis.
5. OCP counseling
6. Cholangitis
7. HIV test counseling
8. CN II and VIII exam
9. Minimental Exam: In an old guy who has brought in by wife
complaining of forgetfulness and increased alcohol intake. NOTES: Alcohol
impairs the ability to form new memories. It interferes with the transfer of
information from short-term to long-term memory.
10. Postnatal depression: Do not forget RISK ASSESSMENT
11. Clavicle fracture
12. Anaphylaxis
13. Decreased fetal movements
14. CTS: 35 year old teacher complaining of weakness and decreased
sensation in the right arm. Remember that in CTS the pain might radiate to arm.
15. Thyroid nodule management: The first test is TSH. Then
U/S and FNA and if needed radioisotope scan.
16.