20/7/2018

P.K.Yin

I passed 13/14
I failed one station ankle pain PE

Feeding problem Pass Global Score 4

key step 1234 all yes ,
approach to patient 4
Dx/D/Dx 3
Management plan 4

ED , 4 D old brought by mom , as community nurse is concerned the child is not feeding well
History , PEFE card , DX with reason , Mx

Hello rose , i am dr yin , one of the intern doctor from this ED , Yes doctor , I am concerned my baby's feeding .

would you like to tell me more about it yes i am breastfeeding the baby , but however she look hungry all the

time after i stop feeding , how often do you give feeding .... 3-4 hrs, how long in each time 15 mins, do you have

enough milk supply ... i am not sure doctor , this is my first baby , thats why i dont know much.... No problem ,

rose , i will check out it for you. do you have any soreness, redness or nipple sores ... no , can the baby suck well...

yes i think so doctor , does the community nurse check out your milk supply? what did she say? yes she just

asked me to go to hospital , apart from feeding concern , does the baby has fever / rash/ lumps bumps in the

body no , yellow discolouration of skin Yes , when did you start to notice it .. i am not sure , no ENT

discharge ,no cough ,no fast breathing , no tummy distension, navel fine , well baby questions ..... is the baby alert

and active ... yes he is active , any poo problem , what colour is it .... dark green , small amount , any smell when

she pee ... no , what colour , yellow , do you think wet nappy numbers reduced ... dont know doctor , its my first

experience , last time i changed was 2 hrs ago, BINDS-where did you deliver the baby , at hospital , how.. NVD ,

any problem at that time ... the baby was fine but i got bleeding after delivery , was taken to do the procedure to

stop bleeding , baby got initial immunization, no sickness during pregnancy , regular AN care , no family history

of liver infection or jaundice , social . from a happy family , no scoical problem

PEFE card - was a long reading

baby is active and vigorous , vital all normal , no pallor , mild jaundice , baby sucking her fist , dry lip+ ,
Body wt 13% reduced compared with birth weight , exact birth wt and current body wt was given
Anterior fontanelle is normal
CRT is <2 sec , other examination normal ….
no urine dipstick is given

Rose , based on my examination finding and your story, i realized that baby looks hungry even tho you feed her,
she is sucking her fist while i examined her , her lips are dry and she lose body wt compared with her birth wt ,
she has only small amount of dark green stool , these findings make me suspect that the baby has inadequate
feeding. ( pt nod) , when the baby has inadequate feeding, the baby can lead to dehydration ( loss of fluid from
the body) , that can cause inadequate excretion of yellow pigment from the body , that inturn can cause yellow
skin and eye ( what we call breast feeding jaundice) .

Rose , there are a few reasons that can cause inadequate feeding
 mother cause , when the mother have insufficient milk supply , esp mothers in their first experience of
having baby, it is quite common to have it.
 baby cause , if the baby has infection in the body , sucking problem , food pipe problem or blocking in the
bowel ( however , i dont see any features suggesting for infection and other cause and baby is active

Management
i will send the child to hospital ( the pt said why do you send me to hospital)
i look at the stem again, remembered that we are in Ed , so i will call my senior doctor to come and review the
baby . i will also call latational educator to help you with breast feeding and to check whether you have adequate
milk supply or not , we will use the pump ( i forgot the name sucker ) to assist with your breast feeding , if the
breast feeding is still not adequate , We will also do the blood test to find out the cause of inadequate feeding . we
may need to give the baby formula feeding , baby needs close checking , so if the feeding then ok , i want to
review the baby every 2 days .

PS , in this station , my approach is , i focus on feeding , not on jaundice , and i was also confused whether
to admit or not , but i chose not to , i got the history of PPH , but i didnt explain about Sheehan syndrome
because it didnt come into my mind at that time , yes i believe this made me to get 3 in D/Dx , and my choice of
not admitting the baby was right to get passed marks in management

Testicular Torsion

 Groin pain Pass , global score 6

 Key step 1, 2, 4 Yes , Yes , Yes

 Key step 3 No

 history 5

 choice and technique of examiantion , organisation and sequence 5

 Accuracy of examination 5

 Dx/DDx 6

11 yr old presented with scrotum pain ,

History , PEFE , dx with reason

Father asked what's wrong with his child and showing that he is very worried.
i calmed him down and tell him i will give pain killer and started the history
scrotum pain ... started 4 hrs ago , was the first time , on the right side of scrotum , no radiation , was crying a
lot because of severe pain , no relieving factor , he was playing soccer 4 hrs ago, he said no hit or fall or injury to
scrotum at that time
when asked about vomiting has vomited one time , the food that he ate, no greensih colour ,
has noticed redness and swelling on right side of scrotum as well
no problem with his pee and poo
no swelling at groin area or no tummy distension
has no fever
other history unremarkable
PEFE
child is crying and painful distress, Vital Stable
no pallor , no jaundice , no sign of dehydration
abdominal examination I no distension , no scar no bruise
P non tender
A normal
Hernia orifices intact
genital examination with the father consent
examiner give me the picture and tell me to ask for other findings
Sample picture

i described it to examiner and started to ask

palpation -
started with normal left side
on right side , any tenderness on testes?.... very tender
how is the testes position ...horizontal or longitudinal?.... horizontal
any high riding ? ... yes
how about prehn test..... examiner asked what is prehn test?
i described .... does the pain relieve on elevation of scrotum .... no
can get above the swelling? yes
no discharge from penis ,
any inguinal lymhadenopathy ... no
any sign of trauma ... no
urine dipstick and BSL not available

Explanation
John, based on the story you gave it to me and examination findings , most likely david has a condition called
testicular torsion. Have you ever heard of it before ? No . i explained by drawing , This is scrotum which is a sac
that holds the testes . the testes is connected with the cord like structure which contains blood vessel that supply
O2 to the testes . in case of testicular torsion, the testes is twisted along its stalk , cutting off its own blood
supply , the exact cause of twisting is not known but sometimes it may be preceded by minor trauma . as you
mention he was playing soccer before this happened. This is surgical emergency , because if we dont fix this
immediately , the testis is no longer getting the blood and can die ...... but John ,i really do appreciate you
brought him in time. try not to worry , david is in safe hands , i will call surgeon to review and fix with surgery ,
we need to untwist it ( Mx was not a task )
so i also continue some D/Dx ....as time left
i also think about direct major trauma to testes but no history like that, or infection of testes it is unlikely ,
infection of testes is rare in his age and usu not sudden onset like this
i also think about hernia that is stucked in the groin but PE not suggesting for it .
i also think about blockage of bowel , urine infection , but they are very unlikely , tummy examination is fine.

Abdominal Pain
Pass global score 4
key step 1, step 2 Yes
key step 3 No
approach to patient /relative 5
choice and technique of examiantion , organisation and sequence 5
Dx/DDx 3
choice of investigation 4

10 yr old boy with pain in abdomen for 3 days , getting worse , your colleages check vital sign and urine
dipstick ( ketones +++) no WBC , no RBC, BSL normal
History
PEFE
Dx
Further investigations
History to mother after pain killer offer
pain in whole abdomen , getting worse over 3 days , very severe,
vomiting from last evening, multiple times, whatever he ate , no greenish color, no blood ,
can't tolerate any food since then
no change in pee and poo
History of injury with bicycle crash few days back to his upper tummy, was minor pain at that time , thats why
she didnt consult to doctor immediately ,
no fever
no other past medical or surgical history
PEFE
painful distress, dehydrated, look pale , bruise in epigastrium , tenderness + , no RT , no guarding or rigidity ,
murphy sign - negative
no liver dullness obliteration , no organomegaly , Bowel sound is minimal
hernia orifices intact , genitals normal,
other examination unremarkable
urine dipstick already given in the stem .. so dont need to ask again.
Explanation
Rose , i did examination , based on the findings , i found the bruise over the upper tummy , where he has the
most pain. there i strongly suspect that at the time he got accident , he might have injured to organ inside the
tummy. there are some organs around there..... i draw the pic ( solid organs like liver on the right, spleen on the
left, and pancreas in the middle and back) , ( hollow organs like stomach , duodenum small intestine ) ..... these
organs may get bruised or injured , or the bowel might have perforate but perforation is less likely based on the
PE findings .... so we need to run some investigations to find out the exact problem here
i will call senior specialist for further assessment
we will run some base line testing , full blood examination , inflamatory marker, liver func test , kidney function
test , ( i forgot pancreatic enz) ... CXR to rule of perforation of bowel...
We will also need to do CT scan , special imaging to tummy to check these organs as well
and reasure her

PS , i didnt tell most likely pancreatitis , i guess that put me to get D/Dx to be 3
i forgot to tell the examiner about resuscitation , may be that is one key step
Transient tenosynovitis

Gait disturbance pass , Global score 4

key step 1, 2, 3 Yes
key step 4 No
history 4
choice and techique of examiantion, organisation and sequence 4
Dx/DDx 5
choice of investigation 4
patient counselling /education 3

2 yr old baby , wake up this morning unable to walk ,

History , PEFE , Dx and DDx and Mx
history to mother
unable to walk since this morning , first time it happen like that , complained of pain around the knee , no
radiation ,
no redness , no swelling , no fever but recently flu like symptoms + one week ago , no treament at that time , no
history of trauma or fall or twisting leg , no previous joint pain problem , no pain or swelling in other joint areas ,
no rashes or spot on the skin, no bleeding problem
well baby questions are normal
BINDs .... NAD
past history ... NAD
family history ... NAD
Social history ... NAD , no one smoking around baby

PEFE - GA fine, no dehydration , no pallor , vital sign normal but temperature is 37.4, growth chart normal ,
lower limb examination .... I comparing both lower limbs , no redness , no swelling , no deformity , no bruise ,
on palpation ... no local rise of temperature , tenderness.... asked specifically where to examine , i said as the child
complained of pain in knee, i will started knee and then hip and ankles and along thigh and shin ----no
tenderness
movement .... knee movement ( flexion and extension ) normal
hip movement (reduced abduction external rotation and internal rotation) ( examiner asked
detailed where to examine and what movement to examine in each joint ) ,
no other abnormal findings

Explanation
Lilia , there are a few things that can make a child unable to walk. based on your story and examination
findings , most likely john have a condition called transient tenosynovitis at his right hip , it is inflammation of
covering of hip joint , even tho he complained of pain in his right knee , the problem is in his hip as hip and knee
has the same nerve supply , the pain may sometimes show up at knee but there is no problem in his knee . this
condition is strongly associated with flu or viral infection he has a wk ago, the viral infection can also affect on
joints .but this is not serious , we can do effective mx for it ...
There are other possible dx i have ruled out like
septic arthritis which is bacterial infection of joint( serious one ) but he doesnt have high fever suggesting for it ,
trauma or fracture of thigh bone , but less likely , no trauma history
bleeding disorder that can affect the joint like hemophilia or immune related problem like henoch scholen purpura
but less likely
perthes disease , which is a condition due to lack of blood supply to head of thigh bone that definitely need to be
ruled out

Mx
i will run investigation like
full blood examiantion and inflamatory markers, to rule of bacterial infection of joints
USG to hip joint to check any fluid collection in joint space
X ray to hip , to differentiate with perthes disease or fracture

for treatement , mainly is supportive care , i will give effective pain killer , let him rest , dont let him wt bearing
during this period ,the inflammation should have resolved in 7-10 days time . can put ice packing on the hip
joint to reduce swelling and pain . I will review him when the results are back as well . Red flags , if the child has
high fever , generally sick , pain get worse , immediately see me or bring him to ED , or otherwise , i will review
in 2 wks to check with another x ray again to rule out perthes .

Body dismorphic disorder

Surgical consultation Pass Global Score -4

key step 1,2, 3 yes yes yes
approach to pt 4
History 4
Dx and D/Dx 4
patient counselling /education 4

Female patient , coming for breast reduction surgery referral ,

History ,
explain the reason that motivates her request ,
further mx plan

(((patient is crying from the start , she is lean and thin lady , sitting on the chair , with very low neckline
blouse ))))
I gave her tissues , jenny i can see you are very sad . would you like to tell me what is it about , so that i can help
you . Dr my breasts are so uncomfortable and big , yes jenny , i will certainly try my best to help you , i tell
confidential before asking further question ........would you tell me since when you are having this problem ( few
months now ) do you have any lump , rednesss, discharge from the nipples ...... no , so you just concern only for
the breast size , does any one comment about it .. no , do you check yourself in the mirror often .... i just check it
regularly, do you do anything to hide it .... no , do you concern about other body parts .... no , does it affect your
daily activity ......she started to cry more ........and telling i have so many problem , i broke up with my husband
few months back ....i gave another tissues, i can see it must be very distressing to you .... so who are you living
with now , i live alone , any family ... i lost my father 6month back ... sorry to hear that , Jenny , were you very
close to your father .... she said , yes since my mom passed away at my age of 13, he was the only family
member ...... pt work at a company , no financial problem ,
Depression question low mood, not sleep well , wake up early morning , eat normal , she thinks she is gaining wt
( at that point , i asked her do you have any excessive concern about body wt , are you afraid of gaining wt .....
no) , do you enjoy doing fun activities when you are free .... yes i go out with my fris and i feel good when i go out
with them ..... no sucidal and homicidal ideation , do you feel guilty of something you have done before ... no ,
she denies halluniation question ,
PTSD ... no nightmares , vivid dreams , flashback memories ,
GAD .. are you easily anxious person ... no , SADMA .... alcohol drinking (+) , no past or family history of mental
illness,
Explanation
Jenny , i can see you have been thr a very tough time . Things are very difficult to you . you lost your father and
relationship problem as well , and have a lot of stress, and you are not coping well . I think your problem is more
than breast reduction surgery request , Many ppl on the world concern about their body image , it is natural but
when it become excessive , like in your case , it can make you so much distressed . i think you are having
condition called BDD , which is anxiety disorder , the stress you are having push you to have this excessive
concern about the breast size, and i think depression as well , as you have low mood , early morning awakening ,
so i would like to refer you to specialist , psychiatrist who will do further assessment on you. and the psychologist ,
who will do talk therapy who will help you to change negative thoughts to positive thoughts
i personally think your breast size are normal , you dont need breast reduction surgery , cos surgery can have
many risk ( infection , bleeding , anaesthesia ), we dont want to put you at risk unless it is necessary , even
though you do the surgery , if we dont fix the actual problem , things can come back again and you may not be
satisfied with the result either
At that point she said , my breasts are too uncomfortable , i said , i utd , how about we try the talk therapy
first , i believe it will be very helpful to you . but after that , if you still think that , you need breast reduction
surgery, i will refer you to plastic surgeon for second opinion . How does that sound to you ... she nod ...
i will do regular follow up , but if you feel very low , have harmful thoughts towards your self .... pls come back to
see immediately
i will arrange family meeting ( she started to cry again ... i know i said wrong , she has no family ) i gave her
tissues ,said i mean will do meeting with your fris if you agreed so that they can give you support ......

This station is a lot of talking and reassurance station , I involuntarily gave her tissues 3 times whenever she
accelerated to cry :D bec i dont know what to do any thing else

Heroin

Substance use pass , global score 5

key step 1,2,3,4 all yes
approach to patient 5
history 4
Dx/DDx 5

Patient who is your occasional patient , has 2 children , husband find out she is using heroin , now very distressed
cos husband said if she not stopping , will leave her and take her children away from her , debt on credit card
and from family and friends as well
History for 6 mins
Tell examiner the diagnosis with reason

Jasmmine, i utd that you would like to stop heorin using , i really appreciate that you have come to see me

today , i am sure that you made the right decision . Before that would you mind if i ask you a few question ,
Every thing we discuss here is confidential , i will not disclose any formation unless it is dangerous to you and

other people ,

since when you use the heroin , i used it since my 20 , but i stopped using it , but lately i restarted using it 5

years ago , is there any reason why u started to use it again , my fris use it , so i just happened to use it , where

do you get it from my fris .. where do you usu use it .. sometimes alone at home , sometimes at fris place , in

what method do you prefer using it ... injection , she does not share needles

have you been increasing the dose of using lately ... no but i dont use very often before but now i use all week

days .. only in the weekend , i dont use as i have to work as online marketing ... How long can you go without

using it ... she does not give specific answer, do you have any symptoms if you dont use ... feel anxious and

somtimes , craving for it ... do you feel relieve when you use it again Yes

how is your motivation level to stop using it on the scale from 1 to 10 , its 10 , great i appreciate that , do you

use any other drugs no , other SADMA is negative ,

how is your general health , good , any fever ,wt loss , lumps and bumps , yellow discolouration of skin , Running

nose , watery eye ,yawing , drownsiness.... no how is your mood , good appeptie , sleep ..... normal ... psychosis

do you hear or see thing that other ppl can not see or hear no have you ever been troubled with law and crime

or accident ... no ... would you tell me more about family life .... live with husband and two children , by any

chance , when your husband find out that you have been using it, does he do anything violent to you ... no , he's

good to me , how about when you are on drugs , any violence to yr children ... no , financial problem + , feeling

stressed about that ,

I started to counsel some , rehabilatation center, medication for withdrawal sym, family meeting , centerlink ,to

stay away from ppl who use drug.......... after some times , examiner stopped me , you are not supposed to tell

anything to pt ......

I looked at the question , i turned to examiner , and said

based on the story , my dx is my patient has heroin addiction , the reason is she has tolerance ( even tho she is

not increasing the dose of heroin , she has been increasing the frequency of using ) , and dependent on heroin ( as

she has withdrawal symp if she does not use it ), her motivation level is very high to stop heroin , she does not

share the needle so she does not increase the risk of getting HIV , Hep B and C ,

she does not have any symp of depression or psychosis or overdose, but she has family problem and financial issue

that make her stress a lot

in this station , i left long time .....

Papillary thyroid cancer counselling

Neck lump Pass Global score 7
key step 1,2,3,4 Yes
approach to pt 7
interpretation of investigation 7
Management plan 7
patient counselling 6

27 yr old man with history neck swelling , USS solid mass at left lower lobe at (RT or left side, i dont remember )
of thyroid gland ,
no LN enlargement both on examination and USS finding .
FNAC neuclear atypia , papillary thyroid CA ( alittle bit details was given in the stem about the swelling)
Explain the investigation to patient ,
counsel the mx plan ,
explain the risk of possible treatment you suggested.

the patient said to me he has come for the result soon after my introduction , yes bryan , i have the result with
me now . how are you doing these days ... i am fine , any pain at biopsy site ... no , do you come alone today ...
yes.... , may i know what is your expectation about the result .... i hope its fine.... bryan , now i am going to
explain about the result , as you have swelling in your neck , we did the examination and usg to your neck , found
out that it is originated from thyroid gland . the biopsy was done to that swelling . I am afraid to tell you the
result comes back as cancer in the thyroid gland .
i waited for his expression ....... seriously .... no expression .....
how are you feeling on hearing this result ? you can tell me whats going thr in your mind?
are you worried ...... yes i am worried, i can't see any worried face , even smiling from one angle of his lip.( not a
good actor)
I just continued , Bryan , i do utd that this comes as a shock to you . but we can do a lot of things . you dont
have to go thr this alone , if this is in early stage and if we start treatment as early as possible you will have
higher chance to be cure .
( i can see the examiner moved the position from my back to the place where i can see her clearly)

Let me explain detail , is that okay with you , or do you want to make another appointment
in our neck there is butterfly shaped gland,we called thyroid gland that produces thyroid hormones which is very
important for the metabolism of each and every cell in our body . Now the cancer is in the thyoid gland , i
explained with pic , the type of cancer is papillary thyroid cancer which is most common type of cancer in
thyroid . the good thing is , it is slow growing tumour . and it spread usu thr the lympatic channel , but i cannot
see any gland or lymph node enlargement in your neck , thats the good point , most likely your cancer is in the
early stage

we will help you with MDT , i will first refer you to ENT specialist and cancer specialist who will do further
assessemnt for staging , like CT scan to your body to make sure its not spread .the main part of treatment is
surgery , before the surgery , we will need blood test to make sure you are fit for surgery , checking thyroid
hormone level in your blood as baseline . the surgeon may need to remove the whole thyroid gland to treat for it .
so after the surgery , there will no longer thyroid hormone in your body , so you may need to take hormone
replacement throughout your life . the surgeon may consider giving you radioiodine therapy which is medicine
that has radio- iodine that you can take by mouth to make sure the possible remaining cancer cells are killed .
but the specialist will decide for it for mx . i'm just mentioning the possible options . after treatment , regular
frequent follow up is required with blood tests .

Bryan, we are here to help you . you are not alone . do you have family member , would you like to bring them in
next appointment , so that they can utd your condition and can give support . when you go home if you have any
concern , you can contact me anytime . if you feel stressed about this conditon , i can refer you to psychologist as
well . there are alot of support gp available for you.
my last task is to explain complication , well i actually dont want to tell too much risk of treatment in BBN
station but it was a task , so i have to
bryan , every treatment is not without the complication , i want to tell you about them but dont be scared , we
can do many things to prevent it .
infection , injury , bleeding , anesthesia side effect , injury to nerve the supply the voice box , leading to HOV ,
low thyroid hormone level , soemtimes injury to nearby gland what we called parathyroid gland that maintains
the normal calcium level in body can lead to low calcium level
but the surgeon is well experienced so we will do many thing s to make cx as less as possible

Ps, even though the patient is not a good actor , be yourself a good actress/actor :D , showing a lot of sympathy
is key in BBN

Pericarditis ( unscored )
52 yr old , chest pain that radiate to back , shoulder , and neck
History
PEFE
Investigation from examiner and interpret to examiner
Dx and DDx to patient

There was a man sitting on the bed , i introduce and offer pain killer , ask whether hemodynamically stable or
not ..... examiner stick to your task
i start history ,

pain question ... pain in center of chest , radiating to back , neck and left arm , started this morning , severity ,
worsened by breathing and coughing , reliving factor ( do you feel relieved when you lean forward ... said not
sure ) , How about lying flat , does it get worse ? said not sure

patient offered information by himself ... he got the cold 2 wks back ,
no fever , cough and cold currently
no SOB , no wheezing
no sweating , no nausea , no vomiting , no dizziness ,

no trauma to chest
no rash on the chest
no recent travel , no recent surgery , no prolong immobilization, no leg pain or swelling

PMH - nil
PSH - nil
Family history - Nil
occupation- executive officer
SADMA not positive

I returened to examiner for PEFE ,

GA , no pallor , no Jaundice , Vital sign HR increase( round about 100) , temp 37.4 , RR and BP
normal , BMI i dont remember ,
REsp normal
CVS normal first and second sound
any added sound .... nosiy sound present
is it pericardial rub.... yes rubbing in nature
any murmur ..... no
no features of heart failure ( BBC JVP, Oedema),

ECG interpretation
this is ECG of mr who presented with chest pain , done on today ,
Rate is /min
regular rhythm
P wave and QRS complex are normal
but there is wide spread concave ST elevation and slight PR depression in all leads apart from aVR and V1 which
has ST depresstion
( pointing out the findings to the examiner in ECG paper )

Examiner asked me to explain Dx to patient

John , based on the PE findings and your history , your chest pain is most likely due to a condition called
pericarditis , have you ever heard of it before . it is the inflammation of covering of your heart , normally our
heart is covered by a covering called pericardium . as you recently had the flu , sometimes viral infection can
affect on the heart and and causes pericarditis..... the covering of heart can rub against the heart at the time
when you cough or deep breath , thats why you have more pain at those times.
other important thing we need to rule out is , heart attack , but based on findings and ECG , its less likely but we
need to repeat the Ecg and blood test to check for heart enzymes to be sure
when you have chest pain ,
we need to think of heart problem , which i have mentioned
lungs problem, like infection ( pneumonia ) , blood clot blocking in blood vessel of lungs (PE) , pneumothorax ( air
leakage from the lungs )
musculoskeleton problem , like inflammation of ribs called costochodritis
skin problem like herpes rash
food pipe problem like acid reflux
but they are very less likely.

Infective endocarditis

Tiredness pass , global score 5

key step 1,2,3,4 yes
key step 5 No
approach to patient 4
history 4
choice and technique of examiantion, organisation and sequence 6
Dx /DDx 4

47 yr old , tiredness, LOA , but no LOW , fever and sweats , body aches + , history of heart mumur 5 years ago ,
generallly healthy ,
History
PEFE
Dx with reasons
introduce
Jenny , i do utd you are very tired and having fever and night sweat as well , would you mind if i ask you more
tiredness... duration 3-4 wks
it is persistent or off and on , persistent
any particular time of day the whole day
fever ... same duration
didnt measure the temp
no chills
Night sweat
body aches +
LOA + but no LOW
no lumps and bumps in body
no anemia symptoms ( no pallor , no palpitation , no dizziness
no skin colour changes
no thyroid symp
no DM symp
Source of infection -no headache, cough and cold , chest pain , SOB , vomiting , abdominal pain, pee and poo
prolem
when i asked about period ... she said she does not have period as she is on mirena
no discharge from down below ,
partner ... safe sex, no STI before
pap smear .. was normal
SADMA negative
Past history heart murmur
have you done any invx before no
did the previous doctor tell you exact dx no
did the doctor tell you to take antibiotics when you do any surgery or procedure ... no
have you ever recently done any dental procedure ... yes , root cannal 4 wks back
no antibiotics taken at that time
no family history of heart disease

PEFE
GA , no pallor , no jaundice , fever 38 , PR regular , RR , BP
BMI , no lymphadenopathy
no thyoid gland enlargement
CVS 1st and 2nd sound normal
PSM that radiates to axilla ,
no raise JVP , no BBC , no oedema
REsp normal
said i will check periphery for sign of infective endocarditis
spinter haemorrhage ... examiner gave me the nail pic
he asked me to point out where
i asked osler node and janesway lesion roths spot , negative
Abdominal examination i check splenomegaly 2 cm below left costal margin
no other mass , no tenderness
no pedal oedema

urine dipstick , BSL and ECG not available

Explanation
Jenny , according to your story and PE findings , most likely cause of your symptoms is a condition of infective
endocarditis . let me explain , Drawing , in our heart , there are 4 chambers , 2 upper chambers and 2 lower
chambers , which are separated by valves ( which are door like structures ) , most likely you have got problem in
your valves that produces abnormal heart sound called murmur and when you have this , it is prone to get
infection easily . in your story , you recently had the root canal treatment , most possibly , the bugs in your oral
cavity got a chance to go into the blood stream and reach to the heart valve and can cause the infection
There are other possible causes that can lead to your symptoms , for example
infection anywhereelse in your body ( lung , urine ) but less likely
nasty growth in body like lymphoma but i didnt find any glands enlargement on examination
thyroid and Dm, anemia problem can also cause tiredness but your symps does not fit into those
i will liase with heart specialist to do echo to your heart and blood test to confirm this diagnosis

I think i should have done some pelvic examiantion as well , as she has IUCD to check for any sign of infection of
it , if present, it can be the source of infective endocarditis as well

Weight loss pass Global score 6

approach to patient 5
history 5
interpretation of investigation 7
Dx/DDx 7

72 yr old lady , history of living in nursing home , present with SOB and LOW and cough with blood streak ,
Your colleages did examiantion …. Crepitaion in lung ( not mentioned site in stem)
Spo2 92% , other vital normal
X ray given in stem ( left upper lobe opacity )
History , Explain the x ray to patient , DDx based on the x ray findings
patient was on the bed , with nasal canula , pretending getting oxygen. i asked examiner to check vital sign , said
the same as the stem .....
told the pt if anytime she is not comfortable during consultation , please let me know
history taking .... SOB for a few months now worsening over 3 wks , worse with activity ,walking distance also
reduced , no PND , no orthopnoea , no leg swelling , no chest pain , no palpitation , cough for few months
now , productive of yellow sputum lately blood streaks in sputum , no wheezing , wt loss + , apeptitie loss + , no
lumps and bumps in the body , no one comment that you look pale , no blood loss , no change in voice , no
weakness or tingling and numbnesss of finger , no history of travelling to oversea , no contact with ppl who are
coughing , no blood clot problem in the past or family history ,
SADMA used to be heavy smoker , stopped 5 yrs ago , i appreciated, no alcohol drinking , no Recreational drugs,
not on any medication , Past medical history - no HTN , no DM , no ht disease , PSH - nil
occupation . used to work as Retail for many years

I explain the x ray to pt , lets look at the xray , the white shadow in the middle is your heart , the black area on
each side of your heart is your right and left lungs , these are your ribs ,
on comparing right and left lung , we can see white rounded shadow in left top part of lung , this is abnormal
findings , most likely the cause of your symptoms , other wise your heart size is normal , your lungs are increase
in size ,( might be related to smoking you had before ) but i dont see any abnormality in other parts of your lungs

( examiner came behind me while i am explaining the x ray )

there are few reasons the can cause this ....

like infection bacterial infection in the lung but less likely as you dont have any fever
Tuberculosis infection which is possible cause we need to rule out , however it is rare in australia ,
you dont have travelling history and contact history , but as you are living in nursing home , we need to consider
it as well.
i am afraid , i am concerned it might be the nasty growth in lung ( patient asked what is it ) , it means
cancer in the lungs , patient pretend to worry, but it is my working diagnosis , we are going to help you , you
dont have to go thr this alone ,
other possible causes are B9 growth in lung but very less likely ( pt asked what is B9) i said the growth that is
not cancerous , it could be pus collection in the lungs we called abscess , but usually it wd be in lower part of
lungs , so it less likely. , i think about blood clot blocking in blood vessel of lung but your symptoms are not acute
onset , it is unlikely.
i also think about COPD , which is inflammation and narrowing of airways strongly associated with smoking ,
it may coexist but its not the main cause of your symptoms
other cause of SOB like heart condition , anemia are less likely , but i can do further testing to rule them out

Time left .... so i talk further testing like CT scan , admit and review with specialist( even tho its not asked) ,
biopsy
Chondromalacia patella

Knee pain pass global score 5

key step 1 , 2 Yes
key step 3 No
approach to patient 4
history 5
Dx/D/Dx 5
management plan 5

22 yr old , Female patient with knee pain , interfere with her sports
History , PEFE card , Dx and DDx , and Mx
Positive finding - history hockey player , pain on going upstair and downstair , pain 6 months ,PEFE card -

pain killer offer

pain questions , pain on the right knee for few months ....said at my knee cap pointing towards it , severity .../10 ,
worse with going upstair and downstairs , never consulted to doctor before ..., history of hockey playing , .... hours
a day , i asked any increase in training .. she said no , but routinely she has to play a lot , she has got 3 games in
every week , no redness , no swelling , no fever , no history injury or fall , no twisting , no change in foot wear
recently , no joint pain in other areas , no preexisting joint problem , no family history of bone and joint disease ,
no rashes in body , SADMA NAD
concern .. conerned that she can't play sports well

PEFE card
long findings
Right knee pain on pressure on patella , meniscus and ligament normal , normal range of movement ,
( yes , they didnt mention any name of special test)
Left knee .... they wrote findings ... all normal

Explain Dx and D/Dx

jenny , based on the examination finding , most likely cause of your knee pain is due to a condition called
condromalacia patella , have you ever heard of it before ,( drawing ) it is the inflammation of undersurface of
knee cap , as you are very active and play sports , sometimes it may lead to repeated stress and strain , the
undersurface of knee cap rub against the thigh bone repeatedly leading to inflammation . thats why you have the
pain esp when i press over the knee cap .
I also think about tendon , meniscus and ligament injury which are the supporting strutures of your knee , but
they are less likely , because their examiantion finding were normal , i think about fracture , but unlikely .
as you dont have preexisting joint disease before and there is no limmitation of range of movement , the arthritis
is less likely , infection of joint is far away from my dx as you dont have fever

Management
Jenny , i know its discomfort but it is not serious condition , we can help you
i will prescribe you effective pain killer , you take it after your meal to prevent stomach burn.
you can apply ice packing when you have the pain ,
you will need to rest during this painful period , i will give you certificate . ( patient said she wants to play sport )
i said jenny i am sorry , during this inflammation , i wd advise you to rest , not involving in sport as this may
cause further damage to your knee joint , however i wd refer you for physiotherapist who can help you to do
effective exercise so that you will have quick recovery and can return back to your normal sport activities as usual
gradually .
i tell red flags ....fever , persistent pain , redness and swelling

Post menopausal vaginal discharge

Pass , Global score 4
key step 1, 3, 4 Yes
key step 2 No
approach to pt 4
history 4
choice and technique of examiantion , organisation and sequence 5
Dx/Dx 5
Mx plan 4

62 yr old femal , persistent vaginal discharge ,

History , PEFE , DX , Mx plan
history
discharge .. yellowish or brownish vaginal discharge for 3 wks , no foul smelling , no blood , no need to use pap,
not itchy , just irritation , especially when she passed urine , no rash in her down below , no swelling from her
down below, no urinary symptoms , no abdominal pain , no fever , no LOW , no LOA , no lumps and bumps in
the body ,

period last time at age of 52 , no menopausal symp , not on HRT , has 3 children , normal vaginal delivery , pap
smear 18 mths ago , ( result were good) , mamogram done , good , husband died? , not sexually active , no
PMH or PSH , no family history of gynaecology cancer , SADMA not relevant

PEFE
BMI as you see , normal
vital sign BP 140/90, PR 80 min , RR 20 min , temp normal
no pallor , no jaundice
CVS normal
REsp normal
abdomen normal
pelvic inspection - no discharge , no mass , coughing ... no urine leakage , no prolapse
SS atrophic changes + , os normal
BME normal
urine dipstick , BSL not available

Explanation
Julia , based on the examination finding and history taking , most likely the cause of vaginal discharge is due to a
condition called atrophic vaginitis , ,which is very common in women after menopause , causing thining and
dryness of vagina due to lack of female hormone after menopause .that can lead to irritation easily and discharge
as well. this is not serious condition . however , whenever a women in her post menopause has discharge we
should also consider and rule out other condition , like nasty conditon of neck of womb ( CA cervix ) nasty
condition of womb ( CA endometrium ) , even tho it is less likely , infection of womb is unlikely as you are not
sexually active ,
so i would like to refer you to specialist , who will do further assessment , take swab for discharge , doing usg to
your belly to check thickness of the womb and pap smear , if anything suspicious , biopsy ,
i will prescribe lubricant and oestrogen cream to apply in your down below to relieve the condition , and will
review you regularly .
as your blood pressure is a bit high side , i will make another appointment to recheck your BP as well

6 wks post partum

Health review Pass , global score 5

key step 1,2,3,4 all yes
history 6 ,
chocie and technique of examination , organisation and sequence 6
patient counselling/education 4

Women come for 6 wk post partum check up , child was examined by your colleagues yesterday , normal , didn’t
bring the child today , on the stem , pregnancy and delivery was uneventful nor episiotomy or laceration at
delivery , normal vaginal delivery
History , PEFE , counsel

hello , Karen , i do utd you have come for 6 wks post partum check up , how are you doing these days ... i am
fine , how is your motherhood .... totally fine , do you get enough support ... yes ... how your mood ... great ...
she said she didnt bring the child today who has been already checked out and normal.....

any specific concern ... no

i asked systemic question ... no fever , no cough , no sOB , no chest pain , no abdominal pain , appetite good, no
pee and poo problem , no discharge or bleeding from down below
breast feeding the baby ... fine , no soreness , baby suck well , give the exclusive breast feeding 4 hrly

so i said i would like to ask private and sensitive quesiton

5 P .... have you restarted sexaul activity ... said yes doctor , its embarassing , i restarted 4 days ago ,
any problem ... pain on sexual interourse , but no contact bleeding , no discharge
have not returned any period
pill ... have you ever use contraception pill before .. yes i use microgynon 30 ,
will you be interested in talking about contraception again...... ... yes i am interested doctor , but i
dont like minipills .......
pap smear ... i did it 5 yrs back ... havent done one since then
do you have any plan to get pregnany in near future .... i dont have plan yet but if i get it , i dont mind

SADMA NAD
no PMH or PSH

PEFE
GA , VS , CVS , RESP , BREAST .. all normal
abdomen normal
pelvic examiantion .... atrophic changes , no dischagre

Explanation
Karen , i did examination on you , you are generally healthy , only finding is there is some dryness and thining
of your down below . what we called atrophic changes . it is quite common after the delivery because as you are
breast feeding , sometimes it cause reduced female hormone in the body leading to dryness. but its not serious ,
it will resolve with time . i will prescribe soothing cream and if oestrogen cream to apply, if not relieved , will
refer you to specialist .
as your pap smear is already due , i will arrange one for you
now in terms of contraception , microgynon is not suitable for your breast feeding , as it can suppess breast
feeding
there are other options like depo injection to your buttock every 12 wks , its effective , but there are some side
effect , risk of delayed returning to fertility after stopping it , risk of wt gain , acne
another one is IUCD , it last long 5 years , very effective , no delay in returning to fertility when you stop it, but
the side effects are increase risk of infection , ectopic pregnancy
another option is implant , that can last 3 yrs , which is very effective as well , but it needs minor procedure
done by specialist to put under the skin of your arms
i am going to give you reading materials so you can think about each options

bell rang
i didnt have time to talk about non hormonal method

New case ( unscored)

27 years old Generalized abdominal pain
History , PEFE , diagnosis with reason
I was thinking surgery or medicine or OG ( like PID , ectopic)
But on entering pt is sitting on the chair , look tummy distension I thought that may be she is fat or intestinal
obstrution or bowel distension :D , I just took most of history time to ask about surgery and medicine cause ,
when I asked about LMP is 6 months ago , immediately turned to obstetric question quickly… regular follow up ,
blood test normal , blood gp o pos , Folic acid + , USG normal , feeling baby kicking , no headache , no vision
disturbance , no bleeding , no water leakage, no leg swelling
PEFE need to ask all before giving me card ( long findings card)
vital sign is normal , BP 120/70
SFH is 26 cm
no uterine tenderness ( sure)
as I remember there is no abdominal sign ( I don’t remember contraction is given in the card )
cervix is 3 cm dilated ….. ( as I remember ,not sure , no discharge or bleeding )
Tell about preterm labour , so that i need to transfer you immediately to hospital
Pt started to cry , no time for D/Dx ( was not asked though ) , I am also shocked cos nothing about pregnant
was given in stem

PE
cubital tunnel syndrome

hand problems
pass , global score 4
key step 1 No
key step 2,3,4,5 all yes
approach to pt 4
choice and technique of examiantion, organisation and sequence 3
accuracy of examination 4
Dx/DDx 4

factory worker , presented with T and numbness sensation of right hand ,

PE and Dx and D/Dx

i did upper limb neurological examiantion

sensation was reduced in right little finger , motor and reflexes are normal
palen test and tinel test for median nerve was negative

i did tapping behind medial epicondyle , but patient didnt give me T and numbness , i am pretty sure i am
tapping the right place , so i tap again and again , still he didnt give me finding , i was really confused , i
asked whether he has neck pain ... he said no,

finally , i was just holding and rolling the skin behind the medial epicondyle before tapping, suddenly patient gave
me the positve result ,
so i guess , they want us to palpate the groove behind the epicondyle before tapping ,
I didnt have much time to do tooth prick sensation test , so i skipped it
these made me get 3 in choice and technique of examiantion

Archilles tendonitis
I failed this with accuracy of examination 3 , GBS 3
i got thompson test positive as the patient has no planter flexion on affected side , so i mentioned what i see ,
but other got negative in that test