Hi,

everyone!

In the best “better-late-than-ever” style, here go the results and comments of the
Clinical Exam that I took on Dec 11th, 2018.

I passed 11 stations out of 14 but by the end of the exam I was pretty sure I had failed or
luckily would have a retest. This was my second time sitting this exam but at the first,
on Nov 2017, I was not prepared at all.

I was incredibly calm and confident at this time but I knew I had some weakness to
overcome. Notably I had issues with the PE and Psychiatry. I failed two PE (eye and
shoulder) but surprisingly I passed the Psych cases.

I suggest that you rehearse a lot PE because it is quite hard to give running
commentaries to the examiner. On PE stations you’ll have to interact with the examiner
and they will be paying very close attention to everything you do and mention. And they
are not very friendly.

Use your resting stations! Have water, go to the toilet, stretch yourself and keep in mind
things you shouldn’t skip like asking about HPV screening, vaccines, travel history,
family history, home situation, BMI, vital signs, office test, referral, red flags… all these
things that suddenly go blank during the exam. I was repeating these like a mantra!

Show that you are confident and in control. DON’T SHOW HESITATION! Listen to the
patient. They are very well trained and when they realize you know what you are doing
and not fishing information, they will open up to you and give what you are looking for.
For example, in the case of the fundal height not compatible with date, when I asked the
patient about her husband she was very emphatic in saying that he was a very big and
bulky man and that her sister had very big babies. She was almost implying that I was
on the right track. So, I ruled out other causes of macrosomia and ended up telling her
that it was a genetic cause. She seemed very happy in the end.

So, here go the stations. I will try to write as much as I can remember because at the end
of the exam everything goes blurry in your mind.

I hope you find the explanation helpful!

Station 1 (Chest Pain) Global Score 6 Pass

47-year-old man comes to the ED complaining of chest pain and feeling dizzy. He had
had chest pain before but it is getting worse. He passed some dark stools and had been
on Ibuprofen for knee pain for the last 3 months. Tasks: Hx, PEFE, Dx and DDX.

When I read this case outside, the first thing that caught my attention was: NO Mx! What
do I do now?
I came in the room, greeted the examiner and the patient. Asked about vital signs (I
don’t remember them now) and said the examiner that due to the dizziness I would like
to lay patient down on the resuscitation cubicle, start IV fluids, attach him to monitors
and give him morphine. Examiner told me to proceed.

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I asked the patient how he was feeling and if he was ok to proceed.
Than I started asking about the chest pain. He told me it was a strong pain in the chest,
traveling to the neck and arm. He had had that before during exercises and pain would
go away at rest. But that time the pain was not going away and it was more intense (
8/10).
Than I asked about the stools. He told me it was very dark and no red blood. First time it
happened to him. Very mild epigastric pain.
I asked questions to rule out other causes: cough? Fever? Weight loss? Recent flu-like
symptoms? Relation of pain to meals? GORD? Rash? Lumps? SADMA? FH? Previous
diseases?
On PEFE I asked about the vitals again. There was postural drop and tachycardia.
Positives: pallor, sweating, CRT more than 2sec. RS normal. CVS S1, S2 no murmurs.
Abdomen: mild epigastric tenderness on palpation, abdominal sounds normal. Gained
consent and asked for DRE. Examiner said: “ No hemorrhoids, dark stools with blood on
the glove. Positive test for blood”. I asked about office tests and ECG (not done). I
thanked him and went back to the patient (always calling him by his name).
I explained to him: “ John, most likely you have a bleeding ulcer due to the medication
you were taking for the knee pain. This ulcer most likely is in your stomach or
duodenum (I draw it!). The bleeding is causing your dizziness because of anemia and
low blood pressure.
But my biggest concern at the moment is your chest pain. Most likely you had a stable
angina that is when you don’t have enough oxygen coming to the muscles of your heart.
Anemia makes angina worse and can lead to an AMI. That’s why your pain is not getting
better now when you rest.
I started saying that we would have to admit him and run some investigations and that
he might need blood transfusion. Than I remembered it wasn’t my task.
I continued explaining my DDx for chest pain: pericarditis but no recent flu, pneumonia
but no cough and fever, pleural effusion but no dullness on chest percussion, GORD but
no relation to meals, gastritis but the pain stopped with exercises, Zoster but no
vesicles. Than I gave quick DDX for the anal bleeding: diverticulitis, hemorrhoids, anal
fissures, colitis, polyps and tumors.
Bell rang. Both patient and examiner looked happy.

Key step 1: no. Approach to patient/relative: 7
Key step 2:yes. Choice & Technique of exam, organization and sequence: 5
Key step 3:yes. Diagnosis/ Differential diagnoses: 6
Key step 4: yes. Management plan: 5
Key step 5:yes

Station 2 (Shortness of Breath) Global Score 4 Pass

22-year-old woman comes to ED complaining of SOB. O2 Sat: 90%. Other vitals: normal.
Task: Take further history, explain Dx and DDx.


I came in the room, greeted the examiner and the patient. I confirmed the vital signs and
said that I would like to lay patient down in 45º, start on oxygen through catheter and
oximeter. (Although patient was already lying in bed on 45º and with a catheter on her
nose).

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I approached the patient, introduced myself and asked if she was comfortable at the
moment and if she would answer some questions. Than I told her if she’d feel any
discomfort or SOB, I would stop. She said she was fine to continue.
I started asking about the SOB:
First time? Yes. Sudden or gradual? Gradual. Any position that makes it better or worse?
No. Any pain? Yes when breathing in (I don’t remember in which side!) . Any fever?
Yes. Any recent URTI? Yes. A Week ago. Any phlegm? Yes. Greenish, no blood. Any
weight loss? No. Any recent travel? No. Any pain or edema in the legs? No. Any trauma?
No Any funny racing of the heart? No.
Asked consent and asked about sexual life. OCP? No STDs? No. Regular periods? yes. Any
heavy bleeding? No. Any bleeding from some where else? No
SADMA HO- unremarkable
Diet: normal
Vaccination? Up to date.
Previous history? No asthma, no bronchitis, no cystic fibrosis, no anemia.
Occupation: nothing positive
Home situation: unremarkable.

Than I explained: “ According to your history, most likely you have an infection on your
lung. We call it pneumonia. When a bug comes into your lung, it causes an inflammation.
That’s why you have fever, sputum when you cough and SOB due to liquid in your lungs.
It can be caused by several kinds of bugs like virus, bacteria or fungus. It is a common
condition with a very good prognosis. Don’t worry!
Are following me? (she said yes)
Other causes for your SOB could be:
Pulmonary embolism but you have no history of recent travel, use of OCP, pain in your
legs or sudden onset of SOB;
Pneumothorax but you had no trauma and the onset was not sudden;
Pleural effusion (I gave no explanation);
Anemia but your diet is normal, you had no bleeding and no family history;
Tuberculosis but you have no history of travelling to areas of risk and no weight loss;
Asthma but you have no previous or family history and usually it doesn’t come with
fever and sputum; and
Cancer but you had no weight loss.”
I forgot to mention heart conditions like Heart failure, MI, angina.
I thanked both and left the room.

Key step 1:yes Approach to patient/relative: 4
Key step 2:yes. Choice & Technique of exam, organization and sequence: 4
Key step 3:no. Diagnosis/ Differential diagnoses: 4
Key step 4:yes. History: 4
Key step 5:yes



Station 3 Resting Station

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Station 4 (Breathing difficulty) Global Score 4 Pass

The father of a twelve-year-old child has come to you because he has recently been
discharged from the hospital after an asthma attack. It was his second hospitalization in
two years.
Take Hx, explain how to use MDI and management plan.
I came in the room and greeted both examiner and the father.
I introduced myself and started asking about the child. How he was at the moment, if he
had any SOB, any complaint, any fever, any problem coping with school, any problem
during exercising… Everything was fine.
Than, I asked detail about the asthma episode: when it started, how severe it was, what
was the child doing when it started, if he had used any puff before going to hospital ( He
said no), anything that might have triggered it like insect bite or any food (he said he
didn’t know) and any relation with any season.
I asked about the child development (normal), vaccination, nutrition (normal, no
allergies). Any problem at school? No. Any SOB when playing sports? No. Any
medication? No. Any other condition? No.
I asked about home situation: anyone smoking at home? He said that he smokes. ( I
offered him to book another appointment so that we could talk about quit smoking if he
was interested in it.) Any pet? No. Any carpets and curtains? Yes. Enough support? Any
financial issues?
Than I explained how to assemble the MDI and how to use it. I asked him to do it
himself. I explained how to clean it.
I explained how to recognize if the puff bottle was full or empty, suggested to always
keep an extra one at home and school. Told him that I would be pleased to give
explanation to any carer or any one from school.
Than I explained the 12X12X12 plan and when to call 000.
Told him about using the puff before exercises.
I told him that he should never smoke inside their home and explained that carpets and
curtains should be vacuumed.
I told him about support groups and the red flags.
In the end I told him I would have everything written down and would give him some
reading material.
( Action Plan Chart was not available).


Key step 1:yes Approach to patient/relative: 4
Key step 2:yes. History: 4
Key step 3:no. Familiarity with test equipment: 4
Management: 4


Station 5 (Vaginal bleeding) Global Score 4 Pass

58-year-old woman comes to GP Clinic for the results of her ultrasound. It shows a 7mm
endometrium.
Tasks: History, explain the results and DDx. (Relevant PE will be given on a chart)

I came in the room and greeted both the examiner and the patient.

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I introduced myself and noticed patient was distressed. She said she wanted to know
the results.
I told her I would be pleased to explain her the results but I would need to make some
questions first. She agreed.
I asked her to tell me more about her bleeding. When it started? Last month. How long
did it last? 5 days. How many pads? A couple. Fully soaked? No. Any clot? No. Any
abdominal pain? No. Any fever? No. When was your last period? 5 years ago. Did you
have hot flushes back than? Yes. Were you on HRT? No. Any symptoms now? No.
I told her I would have to ask some sensitive questions. She nodded. I asked if she was
sexually active? Yes. Any bleeding during or after intercourse? No. Any pain during
intercourse? No. Any STD? No.
Any weight loss? On the contrary, doctor, I have been putting on weight. (that caught my
attention).
Any lumps or bumps anywhere in the body? No.
I asked about her HPV screen she said she had done last year and was normal.
I asked about mammogram and she said the last one was three years ago. I told her I
would arrange one for her.
Smoke? No. Any medication? No. Any Blood thinners? No. Any drug? No. Diet? Normal
and rich in calcium.
Home situation was unremarkable.
Family history: unremarkable
Previous conditions: none.

I asked for the PE chart. Everything was normal but BMI was 30.
I showed her the ultrasound result and explained it to her. I draw the uterus and
showed her what the endometrium was. I told her that normally it is 5mm but hers was
7mm and that was the cause of bleeding. I named the condition: endometrial
hyperplasia.
I explained that when menopause occurs, the ovaries stop producing hormones like
estrogen and progesterone. But her body was producing estrogen because she was
overweight.
She looked at me and said with half a smile: “ you don’t need to be this direct, doctor!”
I said: “ I am sorry, let me rephrase it. As you told me earlier, you have been putting
weight and your BMI is 30. That’s the main reason why your body is producing
estrogen. It acts on the endometrium making it thicker as you don’t have progesterone
to oppose its action.”
“Other causes of postmenopausal bleeding could be: atrophic vaginitis but it is unlikely
because there was no atrophy on the specular exam and you have no bleeding and no
pain during sexual intercourse; coagulation problems but you have no family history
and you are not using any blood thinner; polyps but it did not show on your ultrasound;
cancer but you have no weight loss, no family history and no lumps or bumps in your
body.”
Patient seemed happy in the end.

Key step 1:yes. Approach to patient/relative: 5
Key step 2:yes. History: 5
Key step 3:yes. Interpretation of investigation. 4
Key step 4:yes.

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Station 6 (Shoulder injury) Global score 3 Fail

A male patient had a bicycle accident and fell over his shoulder.
Explain the X-ray to the patient, perform PE and management.

I totally ruined this case.
And the examiner was not very friendly.
First I washed my hands.
The approach to the patient wasn’t bad.
I started explaining the X-ray. But that was when I had my first doubt. The clavicle
fracture had many fragments and it seemed dislocated from the shoulder. All the cases I
had seen before were of aligned fracture. So, I wasn’t sure if the Mx would be only
immobilization and painkiller.
I told the patient what I would perform and gained consent. I started telling him that I
would not move his arm due to the fracture.
Than I started the PE: on inspection I mentioned the bruise (there was a make up over
the collarbone) and that skin was intact. Than I felt the temperature on the hands, the
pulse and the CRT. When I told that I would gently touch the clavicle the examiner
shouted: “Don’t touch the fracture!” and seemed angry. I was so nervous that I checked
for the hands movements and totally forgot to check sensation.
Than I assembled the arm sling asking patient if he was comfortable.
I explained him that for most clavicle fractures a sling, painkiller and physiotherapy
would be enough. But in his case I would ask for the opinion of an Orthopedist because
his fracture seemed unstable and he would decide if a surgery would be necessary.
The bell rang and I was glad I left.

Key step 1:yes. Choice & Technique of exam, organization and sequence: 4
Key step 2:yes. Diagnosis/Differential diagnoses: 4
Key step 3:yes. Management Plan: 2
Key step 4:no. Performance of procedure: 4


Station 7 (Sore throat) Global score 4 Pass

The mother of a twelve-year old boy comes to your GP because her son developed sore
throat for the last 2 days. She seems very worried.
Tasks; History(2min), PEFE, dx and ddx

This was a rather difficult case because of the many tasks. When outside I kept in mind
the ddx but mostly Quinsy because it is an emergency. Also, I knew I would have to
establish if it was a recurrent infection otherwise I would have to refer for
tonsillectomy.
I came in the room, greeted the examiner and the mom.
I introduced myself. She was very stressed but cooperative.
I was fast on my questions: When did it start? 2 days ago. First time? Yes. Anyone else at
home with same symptoms? No. Fever? Yes 39ºC. Weight loss? No. Able to eat? Yes but
very painful. Running nose? No. Cough? No . Recent travel? No. Any difficulty breathing?
Any noise when breathing? No. Able to sleep? Yes.
Vaccination: up to date

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Normal development
SADMA
Home situation? (first bell rang)
PEFE: general appearance: child seemed well.
Enlarged tonsils, inflamed with exudate. No uvula deviation. Palpable cervical lymph
nodes. No hepatosplenomegaly. No neck stiffness. Office test: normal
I started explaining the mother: “ According to the history and PE, Paul has an infection
on his tonsils. That’s what we call tonsillitis. The tonsils are organs in our throat
responsible for protecting us from infections. Different bugs can cause this infection. In
your son case, most likely, it is a bacteria because of the high fever and the white
plaques. Don’t worry! It is a very common condition and it has a good prognosis.
Other causes for this condition would be Quinsy, but he has no uvula deviation; dental
abscess but his teeth are in good condition; EBV but he has no hepatosplenomegaly;
meningitis but he has no neck stiffness. (I forgot scarlet fever!)
We will start him on antibiotics (Amoxicillin and clavulanic acid), antipyretic and
lozenges. We’ll take blood samples for investigation and oral swab for microscopy and
sensitivity.
Red flags: difficult breathing and stridor. Must take immediately to ED.
On the weeks following the infection, must observe any change in urine quantity or
color, facial edema, swallowing of the legs, SOB and joint pain because it might affect the
kidneys or develop rheumatic fever.
I want to review him when he finishes the antibiotics.
Reading materials.

The mother was still not happy.

Key step 1:yes. Approach to patient/relative: 5
Key step 2:yes. History: 4
Key step 3:no. Choice & Technique of exam, organization and sequence: 3
Key step 4:yes. Diagnosis/Differential diagnoses: 5
Management plan: 4


Station 8 Rest station


Station 9 (Knee pain) Global score 5 Pass

17-year old male complaining of knee pain. The pain is on and off but it has been
getting worse because he has been training harder for a soccer championship. It is
worse when he runs or jumps.
Task: Perform PE and explain DDX.

I had the same case on my first exam attempt in nov 2017.

I got in the room and greeted the examiner and the patient. He was sit on the chair by
the table wearing shorts.
I introduced myself and explained him what I was going to do: “ My task here today is to
perform a PE on you. It will involve me taking a look, touching your legs and perform

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some special tests. I will be very gentle. If you feel any discomfort let me know and I will
stop. Is that ok for you?” Patient consented.
“ I will be giving running commentaries to the examiner. If you feel like asking
something, feel free to interrupt me.”
I washed my hands and asked patient to stand up, and offered help. I asked if he was in
pain at the moment and he denied.
Appearance: no mobility aid. Standing upright.
I commented: “ I see no scars, swelling, erythema and asymmetry. No genu valgus, no
genu varus and no quadriceps wasting.
I moved posteriorly and commented: no scars, no asymmetry and no Baker’s cyst.
Than moved laterally and commented: no genu recarvatum.
I asked patient to walk towards the bed and commented on the gait: normal heel strike,
not antalgic, no limping.
I asked patient to lay down in bed and offered him help.
I felt for temperature and pulse.
Using both hands and one knee at a time, I palpated the quadriceps, suprapatellar pouch
looking for effusion, tested for patellar fluctuation, did the bulge test. I palpated the
head of the fibula and the tibial tubercle (patient complained of pain). I did the Clark
test and patellar apprehension test.
Than I checked the active movements: flexion, extension, internal rotation and external
rotation.
I performed the anterior drawer test (cruciate ligament testing), the LCL and MCL
testing. I asked the patient to lay on his tummy and performed the grinder
test(meniscus exam).
I thanked the patient and washed my hands again.
I explained the patient: “Most likely like you have a condition called Osgood Schlatter
Disease. It is not uncommon and it is not a serious condition. It happens because in
your age bones grow faster than tendons making tendons to pull out the tuberosity.
That’s why you have pain when I palpate this area.
It could be due to other reasons like patelo-femoral syndrome, osteomyelitis, septic
arthritis, fracture and meniscal injuries.” (for each of them I gave reasons why I thought
it wasn’t that).
The bell rang patient seemed convinced and the examiner had a poker face.


Key step 1:yes. Approach to patient/relative: 5
Key step 2:yes. Choice & Technique of exam, organization and sequence: 5
Key step 3:yes. Diagnosis/ Differential diagnoses: 4
Key step 4:yes. Accuracy of Examination: 5
Key step 5:yes


Station 10 ( Visual problem) Global score 2 FAIL

57-year-old man with complaints of double vision. He has hypertension and diabetes
and he is on medication.
Task: PE and DX.

This station was another tragedy.

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The examiner was not nice at all and neither was the patient.
My performance was mediocre.
The only thing that I can tell is that patient had decreased visual acuity on one side ( I
don’t remember which) and diplopia when looking upwards to the left.
The fundoscopy showed AV nicking. I am not sure if there was papilledema (I thought
no).
I don’t think I can help much with this case.

Key step 1:yes. Approach to patient/relative: 4
Key step 2:yes. Choice & Technique of exam, organization and sequence: 3
Key step 3:yes. Familiarity with test equipment 4
Key step 4:yes. Accuracy of Examination: 2
Key step 5:no. Diagnosis/ Differential diagnoses. 2

Station 11 Pilot Case (Assessed, not scored)

A woman comes for her 6-week postpartum check. She has no complaints.
Tasks: Hx, PEFE, Dx and Mx.

I came in the room and greeted the examiner and the patient.
I introduced myself and congratulated the mom for the baby. I asked how he was, if he
was thriving, how she was coping with it, if she had enough support.
Than I went to more specific questions:
How was the delivery? Vaginal
Was it at home or at the hospital? At home
Was it necessary to have a cut down below? Yes. Is it healing well? Yes
Did the baby have any complication? No. Did he need CPR or go to ICU? No.
Did you have any bleeding? No.
Were you both discharged together from hospital? Yes
Do you have any fever? No.
Did you have gestational diabetes? No
Are you breast feeding? Yes Any breast tenderness? No Any bleeding? No Any nipple
fissure? No
Any vaginal discharge? No, only on the first week after delivery.
Are you back to your sexual life? Yes. Are you on any kind of contraception? Condom
Any pain during sexual intercourse? Yes, doctor. And it is very dry. But it is ok if I use
lubricants. Any bleeding? No.
Any edema of the legs? No
SADMA
Last HPV screening? (I don’t remember the answer exactly but I think she was due for a
screening.)
( I skipped family history)

I excused and asked PEFE:
Everything was normal except for vaginal atrophy on speculum exam.
Urine dipstick and BSL were normal.
I thanked the examiner and returned to the patient:
“ Mary, according to your Hx and PE, you have a condition called atrophic vaginitis. It is
a common condition and it is not serious. It happens because the hormone that is

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responsible for the milk production acts lowering the production of estrogen by the
ovary. This comes to normal in a few weeks. Meanwhile you can continue with the
lubricants. If it doesn’t get any better we can start you on estrogen vaginal cream.
As you are back to your sexual life, we should discuss the contraceptive options because
you can only have pills or other devices with progesterone…”
The bell rang.
I thanked both as I left.




Station 12 (Abdominal pain) Global score 4 PASS (my last station)

A female patient comes to you complaining of abdominal pain. She had been seen by a
gastro specialist that made all possible investigations, including Celiac Disease tests, and
found everything was normal. He said it was a mild IBS.
Task: take a psychosocial history, explain causes and diagnosis.

I came in the room and greeted the examiner and the patient. The examiner was very
nice.
I introduced myself. Patient was obviously very angry and agitated.
I assured confidentiality.
I started with an open question: “ Could you tell me what is happening to you?”
She answered: “ Doctor, I have this pain in my tummy and diarrhea. I have been to many
doctors and they all say I have no disease and that it is all in my head!”
Than I asked about her mood, suicidal ideation, thoughts of harming someone else and
hallucinations. All normal.
I asked if anything happened that started her with those symptoms. She denied.
SADMA unremarkable
I asked about her sleep and she said she had problem sleeping.
I asked about any stress in her job and she said: “ I hate my job. Everyone is awful there.
I am trying to change jobs but, you know doctor, no one wants to hire a person with this
problems. I am fed up with this job interviews.”
I asked about her home situation and she said: “ I think my husband is cheating on me.” I
asked what made her believe that and if she had any proof that and she said: “ No,
doctor. But who wants someone always sick like me.”
I asked if she usually anticipate problems and she said yes.
I started to explain her: “ Look, the fact that your problem is in your head doesn’t mean
that the problem is not real.” I noticed that I caught her attention and she sais: “ Doctor,
I am tired of listening to this mind-body axis explanation.” (I froze for a second because
that was what I was about to say.) Than I said: “ Well, you know, people reacts in
different ways when they are stressed. Some people have headache, some people sweat
too much, some people feel the heart racing… In your case you have tummy pain and
diarrhea and because you have diarrhea you get stressed. You are going round in this
cycle and we have to break it. “ (She smiled)
Than I told her that she also might have anxiety disorder.
Bell rang.
Both examiner and patient were smiling.

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Key step 1:no. Approach to patient/relative: 5
Key step 2:yes. History: 4
Key step 3:yes. Patient Counseling/education. 4
Key step 4:no. Diagnosis/Differential diagnoses: 3


Station 13 Resting Station (That was my first station)


Station 14 (Jaundice) Global score 5 PASS

67-year-old woman comes to GP complaining of abdominal pain and fever for two days.
Task: take history, PEFE, DDx, Mx.

I greeted both patient and examiner.
I introduced myself and started with an open question: ‘Can you tell me more about
your tummy pain?” She said it started two days ago on RUQ.
(I was rushing with the questions because of time mx!)
Intensity? Moderate
First time? No
Anything makes it better or worse? no
Does it travel any where? No
Any relation with food? No
(I was getting frustrated because I had cholecystitis in my mind)
Any nausea or vomiting? No
Fever? Yes Did you measure it? 38
Any change in skin color? “ I think I’m yellow”
Any change in urine color? Yes, it’s dark.
What about stools? It’s pale.
Any weight loss? No
Any recent travel? No
Any blood transfusion? No
Alcohol? No
Sorry, for asking but are you sexually active? No.
Have you ever used any kind of street drugs? No
Do you smoke? No
Are you using or have recently used any medication? No
Have you done any recent surgery? YES, doctor, I had my gallbladder removed 6 months
ago because of stones.
(I was relieved!)
I excused and turned to the examiner for PEFE: VS (only fever) jaundice, tenderness on
URQ, Murphy sign negative, bowel sounds normal. Office test: urobilinogen +++
I thanked the examiner and went back to patient.

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“ Look, according to your history and PE, you have stones forming inside your liver(I
draw it!). As you had your gallbladder removed, we call it Postcholecystectomy
syndrome. It is a common condition. The bile produced by your liver is not draining to
your intestine. That’s why you are yellow, urine is dark and stools are pale.
But I am concerned because you have pain, fever and jaundice. This might indicate
inflammation in the tubes inside your liver. That’s called cholangitis.
I will have to admit you. I will contact the hospital and talk to the gastroenterologist. I
will take blood samples for investigation like FBC, UEC, liver function9 AST, ALT,
bilirubin, phosphatase, gama-GT)) , amylase, RFT, blood type, serology for hepatitis A,B
and C, cardiac enzymes.
ECG
Image investigation might be necessary like abdominal X-ray, US and CT scan.
A procedure called ERCP might be considered. A flexible camera is introduced through
your mouth till your stomach under anesthesia. The specialist can than introduce tools
to remove the stones and drain the bile.
In some cases an open surgery is needed.
You will be started on IV fluids, antibiotics and painkillers. (I forgot antipyretics)
Don’t you worry I assure you will be on very safe hands.”
“ Other causes for your condition could be hepatitis, head of the pancreas tumor,
cholangiocarcinoma and strictures.”
The bell rang.
Everyone seemed happy.

Key step 1:yes. Choice of investigation: 5
Key step 2:yes. History: 5
Key step 3:yes. Choice & Technique of exam, organization and sequence: 5
Diagnosis/Differential diagnoses: 5


Station 15 ( Leg and buttock discomfort) Global score 4 PASS

57-year-old man comes to your GP clinic with complaints of pain in the calf. He is a
known case of diabetes, hyperlipidemia and smoker. His blood tests show high glucose
and high lipids.
Tasks: History, PEFE, Dx and implications to the patient.

When I was outside I was puzzled about this “implications to the patient” task because it
made me think I would have to look for something else.
I entered the room and greeted both examiner and patient.
The examiner was very nice.
I introduced myself and started with open question: “Can you tell me more about your
calf pain?”
He just told me that it was a calf pain when he walked.
I kept asking:
What kind of pain? A cramp.
When did it start? For the last 2 months
Is it on and off or continuous? On and off.
Is it progressive? Yes
What makes it worse? When I walk or climb stairs.

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What makes it better? When I stop and rest.
Does it happen during the night? Yes. I have to wake up and hang my leg on the bedside.
Any chest pain? No
Any SOB? No
Any abdominal pain? No
Any recent travel? No
Any fever? Yes (I got alarmed!)
Any change in urine color? No
Any trauma? No
Any back pain? No
Any recent surgery? No
Smoke? Yes. (I offered further counseling if he wanted to quit it)
Allergy? No
Drugs? No
Alcohol? No
Medication? Only for diabetes and hyperlipidemia. No blood thinners.
Home situation? Good support
I forgot to ask family history.
I excused and started taking history from examiner:
General appearance: “ As you see”
Vital signs all normal.
PICCLED (clubbing)
BMI: 28
ENT: normal
RS: Normal
CVS: S1 S2 no added sound.
Abdomen: all normal. Pulsing mass? No. Any bruit? No. Femoral pulse? Absent on the
right side (I told her: I assume popliteal and dorsalis pedis are also absent. She
confirmed)
Leg exam: Pallor? Yes. Shinny skin? Yes. Loss of hair? Yes. Temperature? Cold. CRF?
More than 3 seconds. Cyanosis? Yes
I said: I would like to do the Buerger test. She said it was positive on the right side.
(By this time I was sure about PVD but I was still thinking about the fever).
I asked: Any ulcer? Yes. Any sign of infection? Yes. Redness, presence of pus and
offensive odor.
Office test: presence of glucose.
I asked about Doppler: Not available.
I thanked her and went back to patient.
“ John, according to your history and PE, you have an obstruction in the arteries that
take blood to your leg(I Draw it.). It is what we call PVD. Certain conditions rises the
risk of PVD like hyperlipidemia, diabetes, high BMI and smoking. It is a common
condition but if untreated the prognoses is not good.
I am very concerned about the ulcer in your leg because it is infected.
Are you following me? Yes.
I wouldn’t like to tell you this, John, but if infection doesn’t get any better and treatment
doesn’t improve the blood flow to your leg, I am afraid an amputation might be needed.
(3sec pause). Are you with me? Do you want me to continue?
You need to be admitted and we will do whatever possible to save your foot and leg.
Bell rang, I thanked them and left.

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Examiner seemed happy.


Key step 1:yes. Approach to patient/relative: 4
Key step 2: no. Choice & Technique of exam, organization and sequence: 5
Key step 3:yes. History. 4
Key step 4:yes. Diagnosis/ Differential diagnoses. 5


Station 16 Pilot Case (assessed, not scored)

56-year-old female patient comes to your GP for the results of her tests. She is on
thyroid hormone replacement therapy with Levothyroxine.
Task: take history ,ask Ix from examiner and explain to the patient, Dx and DDX.
Ix: TFT all normal. Ca=9,2. PTH was high.

I came in the room and greeted the examiner and the patient.
I introduced myself.
I started with an open question: How are you today? I am fine, doctor. Do you have any
complaints? No.
Than I started making thyroid questions: any preferable weather? Any weight loss or
gain? Any change on bowel habits? Any tremor? Any funny racing of the heart? All
negative.
Did you have any of this symptoms before starting on the Levothyroxine? She said no.
Why are you taking this medication? Because the doctor said my hormones were low.
I asked about water works, edema, kidney stones… normal.
Last period? Were they regular before? Yes. Any menopausal symptoms back than? Yes.
Were you on HRT? No. Do you take calcium for the bones? I used to doctor. I started 10
years ago when exam showed low bone density. But I stopped a few years ago because
calcium was on the high side.
SADMA
Family history
Home situation.


After history had not been positive for anything, I explained the patient what
parathyroid are , I drew a picture, explained the action of the hormones and told her
that post menopausal women are at higher risk. I could not come with many DDx , so I
told her it could be an adenoma, hyperplasia and kidney failure. Later I read at Murtagh
that the use of Levothyroxine is a cause of Hyperparathyroidism.
Than I explained some complications and told her I would refer her to the
Endocrinologist.

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Station 17 ( Behavioral Change) Global score 4 PASS

22-year-old man brought him by his father for behavioral change. He was previously
diagnosed with schizoaffective disorder but has poor compliance with medication.
Task: Do MSE (6min) and present it to the examiner.

This station was my biggest deception but also my biggest surprise.
I had an MSE on my first exam. It was a 4-min movie in a patient with mania. I failed the
case.
So I studied MSE like crazy until I knew it by heart.
Good thing I did not need to give diagnosis.

I came in the room and greeted the examiner. She was very nice.
I greeted the patient, introduced myself and assured confidentiality.
I took the paper sheet on the table and wrote the acronym ASEPTTICJ 3R.
It was very difficult to understand the patient.
But I kept taking quick notes in front of each item.
I did pretty well.
But when it came to presenting to the examiner, I was too slow and the bell rang before
I could finish it.
I was very disappointed thinking I would fail this station.
What was my surprise when I saw that I passed it!

Key step 1:yes. Approach to patient/relative: 5
Key step 2:yes. Choice & Technique of exam, organization and sequence: 4
Key step 3:yes. Accuracy of Examination: 4
Key step 4:no.


Station 18 Rest Station


Station 19 (Breast pain) Global score 3 FAIL

27-year-old-lady comes to the GP clinic complaining of pain in both breasts.
Task: History, PEFE, Dx, DDx, MX

I don’t remember much of this case but I think PEFE was in a card and there was a
ultrasound.
My performance was really bad.
Patient said that pain was worse before the periods and relived after it. She also had a
lump on her right breast. Her mother was in treatment for breast cancer.
Lumps had benign features (rubbery, mobile, not fixed, not hard, no skin changes).
I explained her the reason for her pain but I could not come to the words “ cyclic
mastalgia”. I went blank!
Sorry, I can’t help much with this case.

Key step 1:yes. Approach to patient/relative: 3
Key step 2:yes. History: 4

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Key step 3: no. Management plan 3
Key step 4:no. Diagnosis/Differential diagnoses: 3




Station 20 ( Antenatal care) Global Score: 4 PASS

27-year-old female, 34w pregnant. She missed her last antenatal check. All her blood
tests and US were normal. Fundal height is 37cm.
Task: History, PEFE, Dx, DDx and Mx.

I came in the room and greeted the examiner and the patient.
I introduced myself and started by congratulating the patient for her pregnancy.
Than I started to slowly get into the questions:
How are you feeling right now? Any concerns?
Are you feeling any pain? Any vaginal discharge?
Is it your first pregnancy? Yes.
Was it planned? Yes.
When was your last period? Was it regular before? Yes. Any heavy bleeding? When and
how did you confirm your pregnancy?
Did you have early symptoms of pregnancy like morning nausea and breast tenderness?
Yes. What about now? No.
Were you on folic acid? Yes.
Did you make morphologic scan at around 20 weeks? Yes. Any concerns? No, it was
normal. Was it only one baby? Yes
Did you do the sugar test at 28 weeks? Yes. It was normal
Are you feeling the baby kicking? Yes
Any blurry vision? No. Headache? No. Tummy pain? No.
SADMA- unremarkable
When was your last HPV screen? (I don’t remember the answer!)
Do you have good support at home? Yes.
Is your partner the father of the baby? Yes. Is he a big man? Yes, doctor, he is a very big
and bulky man.
Did anyone else in your family have big babies? Yes. My sister had three kids and they
were all very big. Was she diabetic? No.
Did you have any infection? No.
Are you coping well with the pregnancy? Yes

I excused her and asked the examiner for the PE:

I started with GA: “as you see”
Vital signs: normal
PICCLED
ENT: normal
RS: normal
CVS: normal

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Abdomen: Soft, not tender. Fundal height: 37. Presentation and lying? Longitudinal and
cephalic. Fetal HR? 150. (I was a little confused at this part and the examiner did not
seem happy)
‘With the consent of the patient and the presence of a chaperon I would like to perform
the pelvic examination. “ Examiner asked: “what do you want to know?”
On inspection: Any discharge? No. Any bleeding? No. Any rash or vesicles? No.
Sterile speculum examination: Any discharge? No. Any bleeding? No. Is os open or
closed? Closed
Than I said that I was not going to perform the bimanual examination.
Asked for office test: Urine dipstick and BSL. (I don’t remember if it was normal or
unavailable)

I thanked the examiner and went back to the patient: “ According to your history and
PE, most likely the cause of fundal height not compatible with the gestational date is
because you have a big baby. That’s what we call macrosomia. The reason is probably
genetic because your husband is a big man and you have family history of big babies.
This is a very common cause.
Other causes could be wrong date, but you confirmed the pregnancy early right after
missing your period; big baby due to diabetes but your glucose levels are normal so far;
multiple pregnancy but the US shows only one baby, fibroids but you had no problems
with your periods before pregnancy and it is not shown on US; and polihydramnios.
You are due to a new US at 34 weeks, which I will arrange now.
On 36 weeks we will do the bug test and I will see you weekly.
When you go into labor, the obstetrician will follow you up. If they think baby is too big
for vaginal delivery, a C-section might be performed”
Bell rang and I had no time for red flags and reading material.


Key step 1:yes. Choice of investigation: 4
Key step 2:no. History: 5
Key step 3:yes. Choice & Technique of exam, organization and sequence: 3
Key step 4:yes. Diagnosis/Differential diagnoses: 5
Key step 5:yes.

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