adelaide 13th september 2008
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Adelaide 13th September 2008
Paediatrics:Case 1
Youre seeing 3 year old Sarah one week after a hospital admission with an episode of
asthma. This is her third episode in past two years. She has been prescribed terbutalinsyrup (bracanyl) from the hospital.
On examination her height and weight is in 50 th percentile and can hear wheezing in her
lungs.
Task:
1. Take relevant history2. Explain the condition and your management to her mother
In the history:
No eczema or allerigiesWakes up about 3 nights per week with cough
Uses terbutalin syrup once a week for exacerbationsGets cough if she plays too hard
Mother is a smoker no pets
Has an elder brother who has Asthma
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 0.2
Platlets 25
Blood film Normocytic Normochromic anaemia. No abnormal cells seen
His father is working overseasTask
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1. Explain the results to the mother
2. Tell the probable diagnosis
3. Explain you management to the mother
Explain to the mother that I have bad news to tell and ask whether she needs someonewith 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 platelet
transfusions if required. He will be given antibiotics to protect him from infection andmay 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 anaesthesia
to determine the cause of this condition. Possible reason were indopathic, viral, drug
related or may be leukaemia (but unlikely because the peripheral blood film doesntshow any abnormal cells)
Depending on the cause he can be treated with bone marrow transplant, immunoglobulinor steroids.
Is this a condition is severe?
Yes it is thats why I am organizing prompt admission to hospitalWhat 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 diagnoseduncomplicated febrile convulsion due to a viral infection.
Task1. 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 bealarmed 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 still
developing and is more sensitive to the changers compared to a mature persons brain.
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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 the
normal population so nothing to be concerned at the moment.Explained what parents can do at home to prevent it from happening, like paracetamol
and tepid sponging if they feel he is going to get a febrile illness. If he gets another
febrile convulsion which is more likely to keep him in a safe place, not to put stuff intothe 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 relative
One of my friends who have epilepsy is taking a drug called Sodium Valproate, does mychild need any medication?
No, your friend has epilepsy whereas your son has febrile convulsion. Therefore, at the
moment no treatment is needed.
AMC feedbackFebrile Convulsion (this in the AMC DVD)
Obstetric and Gynaecology
Case 4
24 year old female had a pap smear done by one of yourcolleague 2 years ago. She has
come back to repeat the test. While you are examining her you have found an abdominalmass 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/ discharge
LMP 3 weeks agoUses 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
ExaminationAvergae built.
Vitals normal
Abdomen mass extending from pelvis 2 cm above umbilicus, uniform and regular.
Cervix normal mass continuous with uterus no adenexial masses
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My probable diagnosis is fibromyomata (fibroid).Explanation:
Benign condition commonly seen in reproductive age women. It is not a cancer. To
confirm 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 youget 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 like
torsion 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.
AMC feedbackMass found in lower abdomen
Case 5
A 26 year old primigravida at 36 weeks presents to the emergency department withexcruciating headache. Youre the attending HMO.
Task:1. Take relevant history
2. Request relevant examination findings from the examiner (you will only be given
what you ask for)
3. Explain your management
History to differentiate SAH or Pre-eclamtic
Severe pain 9/10Generalized
Gradual onset
No visual disturbancesNotices increase ankle swelling during past 2 weeks.
Previously normatensive
Ante natal period uneventfull, all investigations and scans normalBaby is kicking fine.
No vaginal discharge
Examination:
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BP 170/110
Ankle oedema
Exaggerated KJ/AJ + clonusSFH = POA = 36wks
Cephalic head entering pelvis
FSH +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 help
Oxygen via face mask
IV diacepamIV MgSO4
IV hydralazin to bring the BP slowly downInform obstetric team as she will need emergency delivery
Examiner said you have finished the station so go out side and wait..
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: Normal
IDC: Negative
Task:
1. Explain the results
2. Take relevant history3. 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 GDM
HistoryStrong FH of DM
Average built
No diabetic symptoms like polyuria/polydipsia/nocturia
Healthy diet
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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 therest 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 diabetes
deliver 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.
You have seen 30 year old lady several times during the past few weeks because ofextensive 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 dressedAppears well groomed
Normal mood
Speech is normalPerception:
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 neighbours
Hallucinations: Second person: she hears voices talk about her next door. (She knows
there is nobody living next door)
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She strongly believe the neighbours throw things into her house which she needs to
continuously clean (this is causing her the dermatitis)
No insightGood judgment and no suicidal ideas or plans
She has stopped medication on her on previously because she thought she was feelingwell.
She lives by herself.
DD: Acute psychotic attack
Schizophrenia
Drug withdrawal
Brain 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 becauseshe has paranoid ideations, loss of insight, live by herself and previously also stop
medication on her own.
AMC feedbackParanoid Schizophrenia
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 whatit 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 history
2. 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 this
young gal shouting at the candidates from my rest station. What ever you tried to talk shewould 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 hopelessly
because 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 work
She is stressed to the max
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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 with
an examiner said the expectation may have been for the candidates to sit there and listen
to 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 for
your opinion regarding abnormal liver function tests.This is the famous recall with a referral letter from GP
Pt has pace maker for bradycardia
Serology negative
Never done drugs or alcoholContinuously elevated liver function for 2 years
Results of GGT normal/ALT increased were given.
Task:
1. Explain the results2. 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 gene,H63D gene,RBS - Normal
Diagnosis Haemochromatosis
Explain that this can be controlled but cant be cured
Regular venesection
Specialist care by gastroenterologist
Watch out for diabetesCan 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 thegene. 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 the
condition with minimal complications
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AMC feedbackAbnormal liver function tests
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 history2. Ask for relevant physical examination findings from the examiner
3. 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 weeksNow the pain is in his hips and upper thigh as well.
Never had similar pains.No arthritis or joint problems in the past.
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, FBE
Gastroscopy and colonoscopy
Diagnosis: Polymyalgia Rhuematica
Management:Oral Prednisolne + Osteoporosis prophylaxis
Rhuematology referral
Educate about warning signs of temporal arteritis.
Acute pain relief with paracetamol and NSIADs
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AMC feedbackAches and pains
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 complicationand this is what I am going to look for and elicit during the examination.
Stood up the patient for inspection
Quadricep wasting
PigmentationCharcots joins (loss of proprioception)
VVHealed ulcer scars or ulcers
While standing Rombergs test for proprioception
Palpation:
TemperatureCRFT < 2
Nail and nail fold hygiene
Ulcers between toes and on the sole of the footAll the pulses of the lower limbs
Sensation:Looking for stocking type sensory loss using the mono filament. She had stocking typesensory 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 untiltibia.
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.
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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 hypertension
in 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 I
did 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 feelwhether they are enlarged (polycyctic), forgot to listen for brui in the tummy.
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 todo 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 legpain has significantly shortened. He used to a around of golf very week which he is
unable 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.
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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 me
what 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 diseaseWhere 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 arterySince you couldnt feel both where do you think the problem is?
Abdominal AortaGood, what can be the cause?
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 14Mrs 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 sometelengetaciae in her left axial and chest.
Task:
1. Tell her you diagnosis and explain it
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2. 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 yourmastectomy.
Other than arteries and veins there is a third vessel system which we call lymphaticswhich 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 trainedphysiotherapist to do special physic to your arm so the fluid can be drained out into the
body.
You need to where compression bandages at all times due to the risk of DVTDont let the arm get sun burnt or injured during house hold chores
Dont 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 playerIs this a cancer?
Most likely not but it is one of the possibilities that we have to exclude.
AMC feedbacklymphoedema/upper limb
Case 15A 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 brought
to the emergency department by his friend who was riding with him. You are theattending HMO.
Task:
1. Perform primary survey
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2. Request immediate investigations
3. 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 for
response 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?
I need to exclude tension pnuemothorax as it is life threateningExaminer: 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 stethExaminer: 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. Asked
whether 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 cardiovascularNeed to feel for carotid pulse for volume and rate and BP
Examiner: Pulse 110 and BP 100/60
Patient is haemodynamicaly unstable.Need two wide bore cannulas in both hands and start fluid resuscitation. Same time
would 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
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Case 16
A 68 year old menopaused lady was investigated for a back pain and found to have afractured 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 her
general practitioner.
Task:
1. Take focused history2. 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 painsDont like diary products
Not much out door activityFamily 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 femalehormones in your body following menopause.
Management:Talked about
Physiotherapy to improve bone thickness and muscle strength. This helps to preventfractures and fallsDietician 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 D
in the body
Keep up the good habitsMedical management would include drugs like bisphosphonate, Ca and Vit D
supplementation, Strontium and raloxifen
Explained 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 normallife with reduce risk of fractures
Didnt get to answer the second question as the bell rang.
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This station I failed.. Presumably due to the fact I didnt alleviate her worries about a
cancer.
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 supportedme and encourage me during these few months.
Looking back, my advice to everybody who is sitting the exam is to improve the
communication 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