AMC Clinical exam preparation

amc clinical exam

Father of 13 year old girl, worried for his daughter regarding her eating habits.
BMI-18, all other examinations normal. No signs of Anorexia on examination at all. ( Such as lanugo hair, dental caries,…)

Task- Ask history and address his concerns.Me- How can I help you today?
RP- I am too worried for my daughter doctor. She is not eating much.

Me- Can you tell me more about it ?
RP- Yes, she is very picky with food. It has been about 6 months. She eats meals 3 times a day regularly but she just chooses vegetables , she doesn’t like meats and sweets a lot cos she believes eating veges is healthy.

Me-Do you think she loses her weight?
RP- Umm, yes, she is thin.

Me- Do you know her body weight?
RP- No but she is thin.

Me- How does she assume her body weight then?
RP- She thinks that she needs to reduce her weight to keep herself healthier.

Me- So, do you really think she is thin as compared with other girls of same age?
RP- Yes

Me- Do you know BMI?
RP- No

Me- Ok, let’s talk more about her eating habits then. Do you see foods being hidden in the room ? Are you aware that she is trying to induce vomiting after eating ? Are you aware she is taking tablets for waterwork and bowels ? Are you aware is she taking any hormones to reduce her weight?
RP- No to all questions

Me- Did you ever see episodes of irresistible eating with her?
RP-No

Me- What about exercises ?
RP- Oh yes, she likes ballet, and she participates in school sports and she is very active.

Me- How much time does she spend doing exercises each day ?
RP- She participates in all those school activities and she spends not much time at home doing exercises. ( He can’t tell the estimated hours)

Me- How is her school performance? Any comments from teacher regarding her eating habits ? What about relationship with friends? Is she happy at school?
RP- She is brilliant student at school. Every teacher and friends love her.

Me- How is everything at home ? Any siblings? Relationship with siblings?
RP- Has one sister. Everything good and stable at home. No family or financial problems.

Me- Do you mind if I ask you some sensitive questions ?
RP- Go ahead

Me- Has she started her period yet ?
RP- No

Me- Has she developed breast, pubic hair , axillary hair? Growth spurt ?
RP- Yes all seem normal like other girl at home.

Me-Are you aware is she in a relationship ?
RP-No

Me- Any other medical problems , regular medications , family history of eating problems or depression?
RP-No


Me- Well , X, I really appreciate your concern. But to explore more , I have to talk with your daughter in person.
RP- Of course doctor. But I want to know what do you think about her eating ?

Me- Yes, I am suspicious that she has a problem with eating. Her BMI ( have to explain BMI) is in the lower limit of normal.
Have you ever heard about Anorexia nervosa ?
RP- No

Me- It is a problem with eating originating from abnormal belief about self body image. This is not an uncommon problem in teenage group. But good thing is , it can be managed very effectively with a multidisplinary approach. And you have made a very good decision of coming to see me quite at an early stage. Cos if it is left unattended, it can have effect on her nutrition, heart, fluid and electrolyte balance in the body, menstruation, to summarise , it can danger all body systems.

So, basically, after assessing her and confirming that she got a problem with eating, I will refer her to a psychologist for counselling, dietician and if needed I will refer her to Paediatric Specilaist.
However at this stage, I believe I can manage her in my GP setting with the help of psychologist and dietician without hospital admission.

RP- I am very concerned Dr. What shall I do in the meantime ?
Me- I will give you appointment either this evening or tomorrow.

RP- What is CBT?
Me- Our body and mind are always connected. CBT is a counselling which makes people realise that the abnormal behaviour is rooted from the abnormal thinking and beliefs. After that realisation, psychologist will teach her how to change that abnormal thinking and behaviour.

I will regularly follow you up as well.
Do you have any other concerns?
RP- No, thank you doctor . ( Bell rang)

Feedback- Always consult in a reassuring manner to a worrying parent. No comment like “ Admission to the hospital is mandatory “.. Cos in this station, the father acts as a very worrying father and I had to control my conversation all the time with reassurance.