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Adelaide 13th September 2008

1. Asthma paed

2. Pancytopenia

3. Febrile convulsion4. Pelvic mass

5. Eclampsia

6. Gestational diabetes

7. Paranoid schizophrenia

8. Anxiety/ depression

9. Haemochromatosis

10. Polymyelgia Rheumatica

11. Diabetes leg examination12. Hypertension - physical examination

13. Leg cramp

14. Lymphoedema

15. Primary survey of trauma patient

16. Osteoporosis

Paediatrics:

Case 1nsionYoure seeing 3 year old Sarah one week after a hospital admission with an episode ofasthma. This is her third episode in past two years. She has been prescribed terbutalin

syrup (bracanyl) from the hospital.

On examination her height and weight is in 50 th percentile and can hear wheezing in herlungs.

Task:z1. Take relevant history

2. Explain the condition and your management to her mother

In the history:

No eczema or allerigies

Wakes up about 3 nights per week with coughUses terbutalin syrup once a week for exacerbations

Gets cough if she plays too hard

Mother is a smoker no petsHas an elder brother who has Asthma

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I took too much time in taking history therefore ran out of time to tell my management.

I summarised it saying need to identify what make her asthma worse and avoid themincluding mothers smoking and use of relievers and preventers.

I failed this station and later found out that when you talk about spacer device they will

provide you with one, which you have to explain to the mother.

AMC feedbackAsthma

Case 2

7 years old Taylers mother is in your practice to know about her sons recent blood

results. You have ordered following investigations when you last saw him with multiplebruises and mild fever.

FBE

Hb 65g/L

WCC 0.6Neutrophils 0.4

Lymphocytes 0.2Platlets 25

Blood film Normocytic Normochromic anaemia. No abnormal cells seen

His father is working overseasTask

1. Explain the results to the mother

2. Tell the probable diagnosis3. Explain you management to the mother

Explain to the mother that I have bad news to tell and ask whether she needs someone

with her. She was happy to go on and I explained the results and told this looks like

pancytopaenia and what it meant.

Told her son needed immediate hospital admission for specialized care for this problemand it would be prudent to ask your husband to come back because you will need a

companion to help you and your child through this difficult period.

In hospital he will be managed by a haematologist. He might need blood and platelettransfusions if required. He will be given antibiotics to protect him from infection and

may isolate him from rest of the wards to protect him from catching any infections.

He would under go a bone marrow biopsy which would be performed under anaesthesiato determine the cause of this condition. Possible reason were indopathic, viral, drug

related or may be leukaemia (but unlikely because the peripheral blood film doesnt

show any abnormal cells)Depending on the cause he can be treated with bone marrow transplant, immunoglobulin

or steroids.

Is this a condition is severe?

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Yes it is thats why I am organizing prompt admission to hospital

What can cause this condition?

Viruses, drugs, idiopathic (I couldnt remember much)The bell rang!!!!!!!!!!

AMC feedbackPancytopaenia

Case 3

4 years old Sam was brought to the ED by his father after suffering from a fit like

episode with a fever. Now the child is ok. You have examined the child and diagnosed

uncomplicated febrile convulsion due to a viral infection.

Task

1. Take relevant history

2. Explain the condition to the father

3. Tell your management to him

I greeted the medical student (Tom) and said I have good news and nothing to be

alarmed at this moment. Sam is doing fine and what you have witnessed is a febrile

convulsion. This is convulsion or fit due to abnormal firing of brain cell in response to

the temperature changes in Sams body. This occurs because Sams brain is stilldeveloping and is more sensitive to the changers compared to a mature persons brain.

This does not mean he has any problems with his brain at the moment. I stressed this is

not epilepsy and the chances of Sam getting epilepsy is only slightly higher than thenormal population so nothing to be concerned at the moment.

Explained what parents can do at home to prevent it from happening, like paracetamoland tepid sponging if they feel he is going to get a febrile illness. If he gets anotherfebrile convulsion which is more likely to keep him in a safe place, not to put stuff into

the mouth, watch out for abnormal signs such as one side of the body moving or prolong

fit or any hint of suspicion by the parents, then bring the child to the hospital.

Pamphlets to read

My wife is pregnant and will that child have this problem as well?

Yes high possibility due to 1st degree relativeOne of my friends who have epilepsy is taking a drug called Sodium Valproate, does my

child need any medication?

No, your friend has epilepsy whereas your son has febrile convulsion. Therefore, at themoment no treatment is needed.

AMC feedbackFebrile Convulsion (this in the AMC DVD)

Obstetric and Gynaecology

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Case 4

24 year old female had a pap smear done by one of yourcolleague 2 years ago. She hascome back to repeat the test. While you are examining her you have found an abdominal

mass extending 2cm above the umbilicus.

Task:

1. Take relevant history

2. Ask for examination findings( he will only tell you what you ask)3. Probable diagnosis and management

Regular periods

Normal menstruation no heavy bleeding/pain/ dischargeLMP 3 weeks ago

Uses Condoms for contraception

Stable partner no history of STIs or dyspariunia/dysmenorrhea

Have gained about 2 kg during past few monthsNo other medical or family history of concern

Examination

Avergae built.

Vitals normal

Abdomen mass extending from pelvis 2 cm above umbilicus, uniform and regular.Cervix normal mass continuous with uterus no adenexial masses

My probable diagnosis is fibromyomata (fibroid).

Explanation:Benign condition commonly seen in reproductive age women. It is not a cancer. Toconfirm the diagnosis need to do an USS.

Ill refer you to gynaecolist, who will do the USS and suggest management options.

Depending on the position of the fibroid he will offer either surgery or watch and wait

approach.

Questions:

Can I get pregnant?Depending on the position of the fibroid you may have trouble getting conceived, if you

get pregnant this might course you to have miscarriage or if you go till term may course

problems with delivery of the baby and during the pregnancy it can cause problems liketorsion or red degeneration which might lead to premature delivery or urgent surgery.

Can it be anything else?With your history and examination this is the most probable cause.

I did not offer pregnancy test as it is unlikely.

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AMC feedbackMass found in lower abdomen

Case 5

A 26 year old primigravida at 36 weeks presents to the emergency department with

excruciating headache. Youre the attending HMO.

Task:

1. Take relevant history

2. Request relevant examination findings from the examiner (you will only be givenwhat you ask for)

3. Explain your management

History to differentiate SAH or Pre-eclamticSevere pain 9/10

Generalized

Gradual onset

No visual disturbancesNotices increase ankle swelling during past 2 weeks.

Previously normotensiveAnte natal period uneventfull, all investigations and scans normal

Baby is kicking fine.

No vaginal discharge

Examination:

BP 170/110

Ankle oedemaExaggerated KJ/AJ + clonus

SFH = POA = 36wksCephalic head entering pelvisFSH +

Urine ward test protein 4+

Management:I told this is an emergency; she is having pre-eclampsia and can going to eclamtic fits

any time.

Examiner told shes now started to have a fit manage.

Left lateral

Call for helpOxygen via face mask

IV diazepam

IV MgSO4IV hydralazin to bring the BP slowly down

Inform obstetric team as she will need emergency delivery

Examiner said you have finished the station so go out side and wait..

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AMC feedbackEclampsia

Case 6

A 24 year old primigravida visited you last week at POA of 26 weeks for GCT, Hb, and

Indirect Coombs test. Now at 27 weeks shes coming to receive her results to yourpractice.

GCT: elevated (cant remember the values)

Hb: NormalIDC: Negative

Task:

1. Explain the results2. Take relevant history

3. Explain the management

Explanation, you may have GDM but need to do GTT to confirm it.Examiner hands you the GTT. Fasting and 2 hour glucose levels elevated.

Youre having GDMHistory

Strong FH of DM

Average built

No diabetic symptoms like polyuria/polydipsia/nocturiaHealthy diet

All antenatal investigation, check ups and scans normal so far.

Plan:

First well try diet to achieve glycaemic control. Youll have to monitor blood sugar 3 4 times a day using a glucometer at home. I will refer to a dietician for assistance.After 3 weeks if you cant achieve good control with diet have to consider insulin for the

rest of the pregnancy as the diabetes going to get worse as the pregnancy progresses,

which is a good indicator of placental well being.

You will be seen by an endocrinologist and obstetrician.Your rest of the antenatal follow ups will be done in a special clinic.

Youll have more frequent clinic visits and more USS to check the babys progress.

You do not need to worry as this is not an uncommon thing, lot of women with diabetesdeliver healthy babies.

Reading material, referral letter to dietician/endocrinologist/obstetrician

AMC feedbackPositive GCT (AMC book case)

PsychiatryCase 7

A 30 year old Maria has come to your practice requesting for a letter to Department of

Housing Authority to find her new accommodation.

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You have seen 30 year old lady several times during the past few weeks because of

extensive contact dermatitis due to cleaning agents. She had nervous breakdown 4 years

ago after separating from her husband. She has stopped her medication 3 years ago.She in your practice today to get a letter to Housing Authority for change of

accommodation as she has been troubled by the neighbours.

Task:

1. Take psychosocial history of this woman. (including the mental state

examination)2. Present your finds of MSE to examiner

3. Give your DDs

History + Mental State:

Well dressed

Appears well groomed

Normal moodSpeech is normal

Perception:Delusion of reference: She was watching a program on TV where she believes they

discussed about her.

Delusion of persecution: She believes her former husband is causing all the current

problems she is facing with her neighboursHallucinations: Second person: she hears voices talk about her next door. (She knows

there is nobody living next door)

She strongly believe the neighbours throw things into her house which she needs tocontinuously clean (this is causing her the dermatitis)

No insightGood judgment and no suicidal ideas or plans

She has stopped medication herself previously because she thought she was feeling well.

She lives by herself.

DD: Acute psychotic attack

Schizophrenia

Drug withdrawalBrain tumour

Examiner: What are you going to do about her?Need urgent assessment done on her and seen by a psychiatrist.

She needs admission and if she refuses has to consider involuntary admission because

she has paranoid ideations, loss of insight, live by herself and previously also stopmedication on her own.

AMC feedbackParanoid Schizophrenia

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Case 08

A young female who has been a patient of your clinic due to her long term bowel

problems is here after her colonoscopy and gastroscopy.Gastroenterologist has confirmed it was irritable bowel disease but failed to explain what

it was and re-referred her back to you for further management.

She has been suffering with these symptoms for 4 years.

Tasks:

1. Take psychosocial history2. Explain the condition and answer her concerns

3. Arrange further management

I knew what was happening in this station even before I went in as I could hear thisyoung girl shouting at the candidates from my rest station. What ever you tried to talk

she would brat down on your neck and blaming you for all the misery this has caused her

due to your inability to diagnose her condition for 4 years.

She is angry because the gastroenterologist has told her that IBD is due to stress andassociated with brain/mind.

By the time I finish the station my ears were ringing and I just sat there hopelesslybecause I didnt had any idea what I should do or say.

I tried asking HEADS questions and this is what I found or hear while in the rest station

She is 24 and works as an airhostess

Have problems at home with boy-friend and also at workShe is stressed to the max

Smokes and drinks but no increase in recent times

Not on any other drugs

So still no idea how to get around it but I passed this station and in a friendly chat withan examiner said the expectation may have been for the candidates to sit there and listento her and not get offended.

AMC feedbackMixed anxiety/depression Atypical abdominal pain

General MedicineCase 9

A 55 year old retired manual labourer has been referred to you by your colleague foryour opinion regarding abnormal liver function tests.

This is the famous recall with a referral letter from GP

Pt has pace maker for bradycardiaSerology negative

Never done drugs or alcohol

Continuously elevated liver function for 2 yearsResults of GGT/ALT were given.

Task:

1. Explain the results

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2. Request further investigations

3. Give the diagnosis and explain the management

Investigations:

Serum iron studies- Iron level, Ferritin, Trans ferrin saturation elevated

HFE gene study - Homozygous for C282Y geneRBS - Normal

Diagnosis Haemochromatosis

Explain that this can be controlled but cant be cured

Regular venesection

Specialist care by gastroenterologistWatch out for diabetes

Can cause cirrhosis if not managed properly which if happens will increase your chances

of having a liver cancer

Questions:

What about my son, does he need a test?No need if he is below 40 as we cant prevent him from getting this if he carries the

gene. Also symptoms only manifest in late 40s and above.

But advice the son about the risk if the disease and beware of it.

Good news is people can have normal life expectancy with good management of thecondition with minimal complications

AMC feedbackAbnormal liver function tests

JMPE 5

th

250

Case 10

A 60 year old retired accountant is in your practice because of gradually worsening

aches and pains in his body.

Task:

1. Take focaused history

2. Ask for relevant physical examination findings from the examiner3. Request relevant investigations

4. Give the diagnosis and management plan

History:

Pains started in back of the shoulders not in the shoulder joint.

Worse in the morning, then gets better and again worse in the evening.Gradually getting worse for couple of weeks

Now the pain is in his hips and upper thigh as well.

Never had similar pains.

No arthritis or joint problems in the past.

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Not on any medication.

Hasnt lost any weight.

No headaches, visual problems or mastication problemsNo family history of similar condition or malignancy

Non alcoholic and non smoker

No other medical or surgical problems (including gastritis, osteoporosis)

Examination:

Normal BMI, Healthy lookingVitals normal

Pain on shoulder girdle not on the joint. Similar on hip as well

CVS and RS normal.

Abdomen no masses, PR prostate normal.No point tenderness over spine

Investigation:

ESR, CRP, FBEGastroscopy and colonoscopy

Diagnosis: Polymyalgia Rhuematica

Management:

Oral Prednisolne + Osteoporosis prophylaxisRhuematology referral

Educate about warning signs of temporal arteritis.

Acute pain relief with paracetamol and NSIADsAMC feedbackAches and pains

AMC case 68 Q351 A371

Case 11

This middle age woman has long standing DM. The BSL control is poor through out the

life.

Task:

1. Examine her LL in view of finding complications of longstanding uncontrolled

DM2. Explain your findings and reasons while examining the LL to the examiner

Examination:I started by saying longstanding DM would have Macro and microvascular complication

and this is what I am going to look for and elicit during the examination.

Stood up the patient for inspectionQuadricep wasting

Pigmentation

Charcots joins (loss of proprioception)

VV

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Healed ulcer scars or ulcers

While standing Rombergs test for proprioception

Palpation:Temperature

CRFT < 2

Nail and nail fold hygieneUlcers between toes and on the sole of the foot

All the pulses of the lower limbs

Sensation:Looking for stocking type sensory loss using the mono filament. She had stocking type

sensory loss.

The filament was on the back of the knee hammer so I check the reflexes at the same

time which was normal.Vibration both 128 and 256 tuning forks were there. Use the 128 one no sensation until

tibia.

Bell rang!!!!!!! Want get time to do everything therefore my advice select what you wantto do or what you think is most important in this station and do it first and then go for the

rest.

AMC feedbackDiabetes complications

Case 12

A 30 year old gentle man has found to be having a blood pressure of 170/100 during a

routine medical check up. This was repeated three times during the past few weeks and

still high.Family history: Mother died of a stroke at 50 years and father had a myocardial infarct at

45 years.

Task:

1. Do relevant physical examination. (explain what your looking for the examiner

as you go)

2. Explain your further management to the patient

Examination:

I started by saying the examiner that I am looking for cause for secondary hypertensionin the young man with strong family history of cardiovascular disease.

Role player was a medical student.

General appearance looking for Cushin or acromegalyStarted by feeling for pulse (rate, rhythm, character and volume)

Any R R delays or R F delays indicating Co-arctation of Aorta

BP when requested I was asked to measure it using a wall mounted BP apparatus. Once Idid it the examiner was impatient and was rushing me through rest of the examination.

When I came to abdomen he asked what I want look for I said kidneys. He ask me to

show him how I would look for them, therefore I explain I would ballot for them to feel

whether they are enlarged (polycyctic), forgot to listen for brui in the tummy.

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Then told me to tell what further investigation I would do to the patient.

Told him you may be having secondary hypertension and I need to find the cause if I amto bring down your BP. First would like to do and USS of you abdomen to look for you

kidneys and the renal arteries.

The bell rang!!!!!!!!!!!!

After the exam I found out everybody was asked to check the BP and some struggled to

do so, therefore my advice is learn it as I believe this station was to check yourexamination technique nothing else.

AMC feedbackHypertension

Case 13

A 50 year gentlemen is in your practice because of his worsening leg pains. He gets it on

his calves when walking. Recently the distance he could walk without getting the leg

pain has significantly shortened. He used to a around of golf very week which he isunable to do now.

He smokes 30 cigarettes per dayOn an ACE inhibiter for his hypertension

Task:

1. Do relevant examination of the limbs. (Youre not required to examine the hear)2. Explain the reasons for the findings

This was a real patient. He had a surgical scar from a bypass surgery on his left leg.As usual I proceeded to inspect the lower limbs muttering the mantra of pigmentation,

scars, colour, hair when the examiner interrupted and said go ahead palpate and tell mewhat you find.Palpation I couldnt feel any of the lower limb pulses in either legs. I said I want to do

Bergers test and ABPI. He asked me to show him how to do the Bergers test which I

did. Then he told the ABPI in Left is 0.25 and Right 0.9.

Questions:What do you think he is having?

Peripheral Vascular disease

Where do you think the problem is according to history?Superficial femoral

Good, Now show me where the superficial femoral artery runs?

Which I was not sure and I showed him the lateral aspect of the thigh. He told me its inthe medial side of the thigh.

You didnt felt any pulses up to femoral artery, therefore where do you think the

obstruction is?Either in external iliac or common iliac artery

Since you couldnt feel both where do you think the problem is?

Abdominal Aorta

Good, what can be the cause?

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Aneurysm

Very good, How would you know youre right, show me how you would look for an

AAA?I showed him how to look for an expansible pulsation

Excelent, What is your management of this patient?

Need urgent vascular surgical referralYour vascular surgeon is not available for months advice the patient regarding the

management till then?

Need to stop smoking; I can help if youre willingDo moderate exercise as you can tolerate. This would improve the blood supply to the

leg

Cardiology opinion on management of hypertension and ACE Inhibitor (I was not sure

whether to stop or not)

The bell rang!!!!

AMC feedbackLeg cramps on exercise

Case 14

Mrs A is 48 years and was diagnosed with breast cancer three years ago and had

mastectomy done o her left side. Since then she had radiotherapy and chemotherapy.

Now she has come with increasing swelling of her left hand. You have notice some

telengetaciae in her left axial and chest.

Task:

1. Tell her you diagnosis and explain it2. Talk about the management

No further history taking is required

Explanation:

With the information I have gather it looks like this may be either lymphoedema or

DVT.

Tell me how rapidly did the swelling got worse?Over few weeks

Does it hurt?

No(There was a picture as well which shows a lymphoedema arm)

I need to rule out DVT and for which I need to do a Doppler and CT scan. This condition

is similar to what we get in lower limbs and you are more at risk to get it in your armbecause of the surgery and complications due to radiotherapy.

If the tests are negative and most likely with the information you may be having

lymphoedema.This a complication of removal of lymph nodes from your arm pit during your

mastectomy.

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Other than arteries and veins there is a third vessel system which we call lymphatics

which drains fluid from tissue. Because of the surgery and the radiotherapy the drainage

of lymph is obstructed causing it to accumulate in you arm. This is lymphoedema.Good news is that we can control it and treat it but not necessary cure it.

There is specific clinic for this in the breast clinic, where you have specially trained

physiotherapist to do special physic to your arm so the fluid can be drained out into thebody.

You need to where compression bandages at all times due to the risk of DVT

Dont let the arm get sun burnt or injured during house hold choresDont allow to check BP, draw blood or put cannulas in this hand.

If it is severe there is micro surgery which can correct the lymph drainage.

Here are some reading materials about this condition.

Any questions you would like ask?

Role player

Is this a cancer?

Most likely not but it is one of the possibilities that we have to exclude.

AMC feedbacklymphoedema/upper limb

Case 15

A 25 year old man was herding the sheep on a motor bike when he accidentally hit log

and fell down and hit his head. He has lost consciousness for 5 minutes. He was broughtto the emergency department by his friend who was riding with him. You are the

attending HMO.

Task:

1. Perform primary survey2. Request immediate investigations3. Suggest immediate managements needed

When I went in I was shown all the equipment I should be utilizing during the

management.There was cervical collar, Hudson mask, tubing..

There was a medical student lying in the bed covered with a bed sheet

I started by say I would follow DR ABC and check the air way (I forgot to check forresponse at this point)

I said before doing anything I would like to stablize the cervical spine using the cervical

collar.Examiner: Good show me how you would do it?

I need someone to keep the head and neck in-line till is pass the collar under the neck.

Examiner: Show me how you would place the collar?I showed how to do it

Then air way, it was clear

Breathing, I looked, listened and felt breathing.

Examiner: Left chest is not moving with breathing. What are you going to do?

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I need to exclude tension pnuemothorax as it is life threatening

Examiner: How would you do that?

Listen to lung for breath sounds and check whether patient is deteriorating.Examine: Ok Listen for BS?

I listen for the sounds using the steth

Examiner: How do you know patient is deteriorating?Decrease in SaO2 and by asking the patient.

Examiner: SaO2 94% in room air and you can ask the patient for the deterioration.

I asked whether the there is any pain which was and arranged pain killers. Askedwhether his is progressively feeling difficult to breath, he said no I am alright.

Examiner: What next?

Cardiovascular

Examiner: Anything else before that?Ohhh I am so sorry I need to put oxygen via mask

Examiner: Ok assume you have done that and go on to the cardiovascular

Need to feel for carotid pulse for volume and rate and BP

Examiner: Pulse 110 and BP 100/60Patient is haemodynamicaly unstable.

Need two wide bore cannulas in both hands and start fluid resuscitation. Same timewould like to connect him to the monitoring and arrange base line blood investigations.

Examiner: What other investigations do you need?

Cervical, chest and pelvic x-rays and CT brain

I was told I have finished the station early so go out side and wait.

I thought I have failed this as you must have noticed I have done things wrongly but for

my amassment I have passed this station.

AMC feedbackPrimary survey of trauma patient

Case 16

A 68 year old menopaused lady was investigated for a back pain and found to have a

fractured thorasic vertebra. She has under gone a DXA scan which revealed T -3 score.

Her FBC ESR and UFR are normal. She has come to gather her results today from hergeneral practitioner.

Task:1. Take focused history

2. Tell the diagnosis and management

History:

Got the fracture while trying to get off the bed.

This is the first time.Menopaused for 18 years

Never took HRT

No PV bleeding/ wt lost/ bowel habit change/ bone pains

Dont like diary products

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Not much out door activity

Family history of osteoporosis in her mother at 80

No medical or surgical co-morbidities.Not on any medications, alcohol and smoking

Most likely osteoporosis, which is thinning or sponging of the bone due to lost of female

hormones in your body following menopause.

Management:

Talked aboutPhysiotherapy to improve bone thickness and muscle strength. This helps to prevent

fractures and falls

Dietician for dietary advice regarding fortified foods with vit D and Ca

Increase out door activities which would expose you to sun light. Help to produce Vit Din the body

Keep up the good habits

Medical management would include drugs like bisphosphonate, Ca and Vit D

supplementation, Strontium and raloxifenExplained what each drug does.

Said here are some pamphlets to read. Do you have any questions?

Can this be cured?

I am I having a cancer?

No can not be cured but can be control to the limit where youll be able to lead a normal

life with reduce risk of fractures

Didnt get to answer the second question as the bell rang.

This station I failed.. Presumably due to the fact I didnt alleviate her worries about acancer.

AMC FeedbackOsteoporosis

Thank god finally the nightmare was over and can look forward to building my medical

career in Australia now.I have thank my study partner for all the help and also all the other friend who supported

me and encourage me during these few months.

Looking back, my advice to everybody who is sitting the exam is to improve thecommunication skills because this is more about how you would communicate you

medical knowledge to a lay person. Therefore keep doing the role plays.

Good Luck!!!!!!!and mind my spelling and grammar mistakes