Case studies 3

Discussion in 'USMLE STEP 2 CS' started by doc179, Jul 14, 2006.

  1. doc179

    doc179 Guest

    Case studies 3





    0 minute stations

    1.1.1. First year university student, 9 weeks pregnant, considering abortion. Take a history and counsel.
    Findings: tearful, guilty, sleep disturbance, has not engaged social supports.

    1.1.2. 20 yr old female wants an oral contraceptive. Take a history and counsel.

    1.1.3. 16 yr old boy with epilepsy documented by neurologist, comes to you because he does not want to see his parent’s family doctor. Wants a driver’s licence. Take a history and counsel.

    1.1.4. 48 yr old woman complains of “diseased stomachâ€, has had negative investigations by several other doctors. Take a history and perform a mental status examination.
    Q: without looking at this patient again, describe her appearance. What is your diagnosis?

    1.1.5. 60 yr old woman with acute confusion. Perform a focussed physical exam excluding mental status.

    1.1.6. A young man is brought to the ER department with an epigastric stab wound sustained in a bar fight. There is a nurse in the room. Manage.

    5 minute couplets

    1.2.1. 30 yr old woman with 6 weeks of epistaxis, petechiae and easy bruising. Perform a focussed physical exam.
    Findings: petechiae, bruises.
    Q: The patient has a normal CBC except for platelets 20 (normal 130-400). What is the most
    likely diagnosis? What four areas on history would help confirm this diagnosis? What four
    investigations would you order?

    1.2.2. 62 yr old man presents to the ER department with 12 hr suprapubic discomfort and inability to urinate. Catheterization yields 1200 cc urine. Take a history.
    Q: What is the most likely cause of this man’s problem? Give three other possible diagnoses.
    What four investigations would you order?

    1.2.3. 6 mo old child who just had a seizure. Take a history from the mother in the ER department.
    Findings: Short seizure with T 39.5C. Never had seizures in the past. Developmentally normal.
    Q: What is the most likely diagnosis? What would you tell the mother about any possible
    recurrence? What advice do you give if the child has another seizure?

    1.2.4. 68 yr old man with difficulty swallowing. Take a history.
    Findings: Throws up after eating. Can swallow liquids only. Weight loss and fatigue. Smoker.
    Q: X-ray of barium swallow showing narrowing of contrast at T 5-6: Describe the “abnormalityâ€.
    What is the likely diagnosis? What investigation would confirm the diagnosis? What further
    investigations would you order?

    1.2.5. 23 yr old with BP 160/100 in both arms. Perform a focussed physical exam.
    Q: Give four possible diagnoses. What four investigations would you order? If these
    investigations were negative, give two steps in your initial management plan.

    1.2.6. 21 year old female with bloody diarrhea. Take a history.
    Findings: Abdominal cramping. Six watery stools in the past 4 hrs containing maroon-coloured
    blood. Feels dizzy and weak. No previous history of diarrhea, previously well.
    Q: What two findings on history indicate the seriousness of the problem? Give 3 possible
    diagnoses? Give 4 investigations appropriate to this situation.


    Answers Questions

    1.1.1. History: combine a pregnancy history with a social history and a screen for depression. (Note that every history should include name, age, occupation, past medical history, family history, medications, drugs, and review of systems).

    Pregnancy: GTPAL (# of gestations, term pregnancies, premature births, abortions, live
    children). History of problems, if any, with previous pregnancies. Current pregnancy: establish
    gestational age by last menstrual period (LMP). If periods are regular, the gestational age is the
    number of weeks from the LMP less 2 weeks. Ask about use of alcohol, smoking, drugs,
    maternal illnesses during the pregnancy (particularly diabetes, rubella, toxoplasmosis, herpes,
    CMV, thyroid dysfunction, hypertension, hypercoagulation). Use of birth control, if any. Past
    medical history, family history of pregnancy-related problems, medications.

    Social: Status of any relationships at present including the relationship with the child’s father.
    Social supports (family, friends, boyfriend). Do they know? Are they helping?
    Employment/financial/educational status of the patient. Does she feel prepared to raise a child?

    Psychiatric: How does the patient feel about this decision? How is she coping? Cover
    mnemonic for major depression (SIGECAPS: sleep, interest, guilt, energy, concentration,
    appetite, psychomotor, suicide) Positive diagnosis of major depression requires five of these
    over a 2 week period, one of the five must be a loss of interest or depressed mood.

    Counselling: Base advice on problems identified on the obtained history. (Note that it is always
    advisable while counselling to make empathetic statements...â€This must be hard for you.†For
    general principles of counselling, see 2.1.6.)

    Health While Pregnant: Recommend abstinence from harmful agents (alcohol, smoking) while
    pregnant, and use of medications only after consulting with a physician, treatment for pregnancy-
    related illnesses as above, and healthy eating habits.

    Social Supports: Discuss the importance of engaging social supports and consider a visit with
    both the patient and the partner or other supporting person.

    Abortion: Provide information on local abortion services. Make the patient aware that the
    gestational age limit after which many practitioners will not perform an elective abortion in
    Canada is 20 weeks, but that this is a late limit and her decision should be made sooner. Inform
    the patient that further advice is available from private gynecologists who perform abortions and
    counsellors at elective abortion centres. Offer to refer the patient is she wishes.

    Depression Management: Normalize the patient’s depressed mood in view of her
    circumstances. If there is evidence of major clinical depression, arrange close follow-up to
    monitor for suicidal ideation, refer to psychiatry. DO not prescribe medications at this time
    (because of the pregnancy).

    1.1.2. History: Name, age, occupation/school level. Why does patient want an OCP? Has she been on it before? If so, why was it stopped? How long has the patient been sexually active? How many partners? Current contraception use? Is there a possibility that the patient could be pregnant? Obtain the date of last menstrual period.

    Pregnancy History: GTPAL, history of any problems with previous pregnancies.

    Gynecological History: Ask about sexually transmitted disease, migraine, fibroids, diabetes,
    thromboembolic disease, heart problems, cancer, liver disease, date of last PAP smear. When
    did the patient start menstruating? Menstrual history: regularity and duration of periods,
    heaviness of flow (# of pads required), cramping, associated discomfort, bloating, mood swings.
    Medications, drugs, alcohol, smoking, past medical history (esp breast Ca), family history, review
    of systems.

    Counselling: Contraindications to OCP: active thromboembolic disease (includes coronary and carotid disease, symptomatic mitral valve prolapse, active DVP), proliferative retinopathy, history of breast Ca or other estrogen dependent tumours (liver, reproductive tract), impaired liver function, pregnancy.

    Relative Contraindications to OCP: smoker >35 yrs old, diabetes, migraines, fibroids.

    Mechanism of Action of OCP: Standard preparations contain estrogen and progesterone,
    prevents ovulation by interfering with feedback of hormone signalling.

    Available preparations: 21 day vs 28 day tablets. Other preparations: depo injections q 3 months,
    implants q 5 yrs. Longer term preparations offer lower cost over the duration of action (but
    greater one-time cost) and greater convenience.

    Benefits of all hormonal contraceptives: virtually no chance of pregnancy when taken as
    directed, reduces risk of reproductive tract cancers, improves regularity of menses, often
    reduces menstrual discomfort, flow, and other symptoms. Often clears acne.

    Risks of hormonal contraceptives: Slight weight gain is usual (5 lbs), increases risk of DVT
    especially in combination with smoking. May stimulate estrogen-receptor positive breast cancers
    but does not appear to cause them. May have to try two or three different preparations to arrive
    at the best one for the patient. Also note that hormonal contraceptives do not provide any
    protection against STDs, unlike barrier methods. Start on 1st day of next period. Place package
    in an obvious location to help you remember. Take at the same time each day. Use additional
    contraception for the first two months, as OCP contraception is not reliable until then. If you miss
    a day, take two pills the next. If you miss two days, take two pills for the next two days and use
    an alternative method until the next period. Give prescription for OCP of choice. Arrange follow
    up.

    1.1.3. History of Seizure Disorder: Describe seizures, frequency, duration, what body parts affected and in what order, premonitory signs, post ictal state (decreased LOC, headache, sensory phenomena), degree of control achieved with medications, at what dose and for how long? Corroboration from family if possible. Was a CT scan done when seizures were first diagnosed? Number and description of recent seizures. Are they different from previous seizures? Is the patient having any new symptoms such as headache, morning vomiting, new neurological deficits? Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias, peripheral neuropathy, gingival hypertrophy (phenytoin).

    Compliance: Is the patient taking meds? Why not? Problems at school or home? Medications,
    drugs and alcohol, smoking, allergies, past medical history, family history, review of systems.

    Counselling: Discuss importance of compliance with medication and avoiding dangerous
    activities such as driving until good control is achieved. Inform the patient that the Ministry of
    Transportation requires a full year seizure-free before they will grant or renew a driver’s licence
    to people with epilepsy. Inform patient that you will be notifying the MOT and that you are
    required by law to do so.

    If alcohol is an issue, inform the patient that chronic alcohol intake may decrease blood levels of
    anti-epileptics and acute alcohol intake can precipitate seizures by lowering the seizure
    threshold. It is generally recommended that the patient not drink at all. Fatigue and concurrent

    illness can also lower the seizure threshold. The patient should consult a physician before taking
    any other medications as they may also lower the seizure threshold.

    If the patient is having stress management or anxiety issues, he may require further counselling.
    Outline a treatment plan consisting of EEG, CT head, metabolic screen, medications (if not done
    already), and follow up appointments. Get the parents involved if possible. Arrange regular follow
    up to monitor progress and serum anti-epileptic levels.

    1.1.4 History for depression: Change in sleep pattern, anhedonia (inability to enjoy previously enjoyable activities), guilt, hopelessness, fatigue, mood, concentration, memory, appetite and weight gain or loss, irritability, psychomotor retardation/agitation, anxiety, diurnal variation in mood and activity with nadir in the early morning, suicidal ideation.

    Suicidal ideation: Does patient intend to harm self, reason for suicidal thoughts, current plan,
    lethality of plan, access to lethal means, has patient given away prized possessions or written
    final notes to loved ones, previous attempts.

    Diagnosis of major depression vs dysthymia: Mnemonic for major depression SIGECAPS,
    positive diagnosis of major depression requires five of these over a 2 week period. One of the 5
    must be either loss of interest or depressed mood. A diagnosis of dysthymia requires depressed
    mood for most of the day, more days than not, for at least 2 yrs. A diagnosis of depression
    cannot be made in the face of bereavement within the past two months or drug or alcohol abuse.

    Differential for Depression: Check for bipolar mood disorder, schizophrenia, psychotic
    depression and obsessive-compulsive disorder. Ask about manic episodes, paranoia,
    hallucinations (especially voices), obsessive thoughts, previous psychiatric problems, family
    history of psychiatric disorders, substance abuse, relationship problems, problems at work.

    Medical Causes of Depression: Ask about hypothyroidism, adrenal dysfunction,
    hypercalcemia, mononucleosis. Consider chronic fatigue syndrome. Drug use, smoking,
    allergies, past medical history including psychiatric history and history of abuse, family history,
    review of systems.

    Mental Status: Appearance, attitude (?cooperative), mood/affect (flat, sad, happy, mad), motor,
    speech (rate, rhythm, volume, quantity, articulation), thought content (delusions, illusions,
    hallucinations), thought process (coherent, flight of ideas, logical), insight, intellect.

    Mini Mental Status Score: Orientation to time (5 pts - year, season, month, day, place),
    Orientation to place (5 pts - country, city, building, floor), recall of 3 objects (3 pts), concentration
    (5 pts - serial 7s or spell WORLD backwards), name 3 objects (3 pts), repeat “No ifs ands or
    buts†(1 pt), 3-step command (3 pts), written command “close your eyes†(1 pt), copy interlocking
    pentagrams (1 pt), write a sentence (1 pt). Total = 30

    Patient’s appearance: untidy and dirty

    Diagnosis: Major depression

    1.1.5. Neurologic Exam: What follows is a practical, regionally organized neurologic exam which can be completed in less than 8 minutes. It begins with the patient sitting, then standing, then lying down. Note that every physical exam should include vitals, although examiner will ask to move on.
    Patient Sitting (shoes and socks removed) - GCS only if patient poorly responsive (See 3.1.1).
    Examiner will remind you to omit the MMSE. Cranial nerves. Extra-ocular movements (patient
    follows your finger or the handle of a reflex hammer in an “H†pattern, check for diplopia in the
    centre and at the extremities of the visual fields. Pupillary light reflex and accommodation,
    corneal reflex. Fundi, checking for papilloedema using ophthalmoscope. Facial sensation to light
    tough in the ophthalmic, maxillary, and mandibular divisions of the trigeminal nerve.
    Facial muscle power - raise eyebrows, squint eyes closed, show teeth, protrude tongue, observe
    palatal movement on saying “Ahâ€. Gag reflex, observe symmetric movement of the palate.
    Gross hearing: rub thumb and finger together while approaching the patient’s ear, note when
    they can hear the sound. Sternocleidomastoid power and trapezius power. Pronator drift - arms
    straight out in front of patient with palms up, eyes closed, and look for the curling of fingers from
    the ulnar side, pronation and downward movement of the affected side. Hoffman’s reflex - with
    the patient’s relaxed hand in a palm-down position, squeeze and flick the nail of the index finger
    between your thumb and long finger. Thumb flexion indicates a positive test and denotes upper
    motor neuron lesion (similar to Babinski’s reflex).Palmomental reflex - scratch palm and twitch of
    ipsilateral mentalis/orbicularis oris. Cerebellar tests: finger-nose, rapid alternating movements
    (dysdiadocokinesis), heel-shin.
    Body power: Deltoids, triceps, wrist extension and flexion, finger abduction and adduction, psoas
    (hip flexion of each knee off the bed against resistance), quadriceps, hamstrings, ankle
    dorsiflexion (test plantar flexion while standing).
    Body sensation: light tough, pin prick, cold temperature (use a metal K-basin or tuning fork) are
    tested on the distal upper limbs (forearms and hands) and lower limbs (foreleg and feet).
    Vibration sensation is tested using a C-120 Hz tuning fork on the joint capsules of the most distal
    joints at which the vibration can be felt.
    Reflexes: biceps, triceps, brachioradialis, knee, ankle, Babinski
    Patient Standing: Gait - observe for wide-base, Parkinson’s shuffle, consistent lateralizing falls.
    Balance - tight-rope walk, stand with arms crossed and feet in line. Rhomberg (feet together,
    eyes closed).
    Plantarflexion power: Hold patient’s hands for balance, ask patient to stand on one foot, then
    raise themselves up on their toes.
    Patient Lying: Tone - passive rapid alternating forearm rotation, passive rapid elbow
    flexion/extension with one thumb on the biceps tendon to feel for cogwheeling. Rapid lifting of
    the relaxed leg from behind the knee - heel remains on the bed in the normal tone.

    1.1.6. Manage according to ATLS protocol (see 3.1.1)

    1.2.1. Hematologic Exam: Patient disrobed to underwear, draped below the waist.
    Patient Sitting: Inspect the patient generally for petechiae, abnormal skin tone, hair falling out,
    inspect the finger and toe nails for dystrophy, flame hemorrhages, leukonychia. Inspect the palm
    for erythema and Dupuytren’s contractures. Look in the nose and mouth for bleeding, petechiae,
    masses. Palpate the anterior and posterior triangles of the neck, the supra and infra clavicular
    areas, and the axillae for lymph nodes. Palpate the thyroid while standing behind the patient, ask
    her to swallow.
    Chest - from behind the patient, inspect the skin. Percuss the lung fields for effusions and
    consolidations, auscultate the lung fields. Percuss and auscultate the anterior lung fields (for a
    complete chest exam 2.2.2). Listen over the aortic, pulmonary, tricuspid and mitral areas (for
    complete cardiac exam see 2.1.1).
    Patient Lying: Compress the sternum and ribcage for pain (seen in multiple myeloma). Inspect
    the abdomen. Auscultate for bowel sounds. Palpate for enlargement of the spleen and liver.
    Percuss the liver. Palpate the groin for lymph nodes. Note: avoid rectal exam as this trauma may
    cause bleeding.
    Most likely diagnosis: Idiopathic thrombocytopenic purpura (ITP). Also called immunologic
    thrombocytopenic purpura.
    Four findings on history which would help confirm the diagnosis: 1. Remitting-relapsing
    course, 2. Mild fevers, 3. Splenic discomfort due to mild enlargement, 4. Bleeding after low
    doses of NSAID.
    Four investigations: Blood smear, INR/PTT (for hemophilia), serum urea/creatinine (for
    hemolytic-uremic syndrome), serum platelet-associated IgG (for ITP).

    1.2.2. History: name, age, occupation. History of suprapubic pain and inability to urinate. History of pain on urination, frank blood in the urine, colour of urine, difficulty initiating or maintaining stream, fever, renal pain, groin pain. Previous renal colic/diagnosed prostate hypertrophy, prostate cancer, prostatism, nephrolithiasis? Malignant symptoms: night sweats, weight loss, fatigue. Medications, drugs/alcohol, smoking, past medical history, past surgical history, history of pelvic radiation, TURP, family history, review of systems.
    Most likely diagnosis: Benign prostatic hyperplasia.
    Other possible diagnosis: UTI, prostatitis, prostate cancer
    Four Investigations: urea/creatinine, urinalysis, PSA, renal ultrasound.

    1.2.3. History: Describe seizure, duration, what body parts affected and in what order, premonitory signs, post ictal state (decrease in LOC, headache, sensory phenomena). Previous seizure? Ask about preceding trauma or illness, the child’s temperature at the time of the seizure. History of problems during the pregnancy and birth (See 2.2.3). Developmental history (see 3.1.4). Child’s medical history, surgical history, medications, allergies.
    Most likely diagnosis: Febrile seizure
    Prognosis: After a single seizure, 65% will never have another seizure, 30% will have further
    febrile seizures, 3% will go on to have seizures without fever, and 2% will develop lifelong
    epilepsy.
    Treatment of recurrence: Control fever with anti-pyretics (tylenol) and use sublingual Ativan
    1 mg or rectal diazepam 5-10 mg if a seizure occurs at home. Turn patient onto her side, do not
    force objects or fingers into mouth. Bring to ER if seizure does not stop within 10 minutes.
    Seizures do not cause mental impairment unless they are prolonged (>30 min), although
    seizures can be a symptom of brain damage. Patient should be investigated with CT head and
    EEG. Prophylactic anticonvulsant therapy is a consideration with repeated seizures.

    1.2.4. History: Onset, chronology, description of problem, aggravating and relieving factors. Is the problem worse with solids (suggests mechanical obstruction) or liquids (suggests neurological dysfunction, often can’t swallow either solids or liquids). Is there a sensation of a lump in the throat? (Globus hystericus = transitory sensation of a lump in the throat related to anxiety). Ask about peptic ulcer, reflux, hiatus hernia, weight loss, night sweats, fatigue, hematemesis, black stools, pain. Medications, drugs/alcohol, allergies, smoking, past medical history, family history, review of systems.
    Description of Barium Swallow Findings: (String sign) Graded narrowing of intra-esophageal
    contrast to 2 mm thickness extending from T5 to T6 level.
    Most likely diagnosis: Esophageal cancer
    Investigation to confirm diagnosis: Endoscopy with biopsy
    Further Investigations: CT chest (for mediastinal and lymph node involvement), chest x-ray,
    liver function tests, abdominal u/s for mets.



    1.2.5. Physical Exam for Hypertension: Combines exams for atherosclerosis, coarctation, hyperthyroidism, and Cushings. Patient should be disrobed to underwear, and draped below the waist.

    Patient Sitting: Take vitals (need BP in all 4 limbs - do legs when lying down). Inspect
    for cyanosis, arcus senilis in the eyes (sign of high cholesterol), bulging veins in the upper
    chest (SVC syndrome), supraclavicular fat pad, buffalo hump, moon face, truncal obesity,
    striae, nicotine stains on fingers, clubbing, flame hemorrhages on nails, obesity, high work
    of breathing, intercostal indrawing, symmetric chest movement, visible apex beat.

    Fundoscopy for retinopathy of hypertension: (in order of increasing severity of
    damage) constriction and sclerosis of retinal arterioles, hemorrhages, exudates,
    papilloedema
    Thyroid exam: Inspect patient for proptosis, “thyroid state†(upper lids do not overlap
    the irises). Have patient follow your finger up and down to check for lid lag and globe lag.
    Is skin thin, dry, and flaky or diaphoretic? Palpate thyroid standing behind the patient and
    ask them to swallow. Inspect nails for leukonychia and hands for tremor (can place a piece
    of paper on the hand held horizontal to detect fine tremor). Check biceps reflexes with
    thumb held over tendon, feel for slow phase reflex of hypothyroidism. Hyperthyroid nails:
    “Plummer’s nails†- soft with onycholysis.

    Palpate the apex, note whether it is laterally displaced (lateral to the mid-clavicular line)
    and feel for thrill or heave, feel radial pulses in the arms simultaneously, note any delay.

    Percuss the lung fields anteriorly and posteriorly.

    Auscultate the lung fields anteriorly and posteriorly, listen to the heart in the mitral (apex,
    5th interspace, mid-clavicular line), tricuspid (right sternal border, 5th interspace), pulmonic
    (left sternal border, 2nd interspace) and aortic (right sternal border, 2nd interspace) areas as
    well as over the right clavicle, and both carotids. Listen for rub. To bring out an aortic
    murmur (typically aortic regurgitation) and coarctation bruits, ask patient to lean forward,
    exhale and stop breathing while you listen over the aortic and pulmonic areas.

    Patient Lying: Auscultate for bruits over the renal arteries. Observe for pulsations due to
    AAA, palpate abdomen for hepatomegaly. Palpate femoral pulses, and auscultate for
    femoral bruits, palpate the popliteal pulses, inspect the legs and feet for venous stasis or
    arterial insufficiency ulcers, palpate the dorsalis pedis and tibialis posterior pedal pulses.
    Feel the ankle for pitting edema.

    Tibial BP: BP cuff placed around calf, auscultate the tibialis posterior pulse posterior to
    the medial malleolus.

    JVP: Raise the head of the bed 30 degrees and inspect the neck. A jugular venous
    pulsation higher than 4 cm ASA is abnormal. Check the hepatojugular reflux (compress
    the liver, the JVP should either not rise or remain elevated only transiently).

    Four possible diagnoses: Essential hypertension, Renal artery insufficiency, Drub-induced
    (thyroid hormone and OCP), Coarctation of the aorta.

    1.2.6. History: Name, age, occupation. Onset, duration, frequency of diarrhea. Appearance of stools: how well formed, is blood on or mixed with stools, is blood bright red or dark brown-black. Pain with bowel movements, abdominal pain or cramps with location, radiation, precipitating factors and alleviating factors, quality, severity, timing with respect to defecation, gas, bloating, heart burn, peptic ulcer, reflux, hiatus hernia.

    Extra-intestinal manifestations of inflammatory bowel disease: ask about iritis, arthritis,
    mouth ulcers, anal ulcers, skin lesions, kidney stones.

    Infectious diarrhea: Inquire about fever, nausea, vomiting, weight loss, fatigue, recent
    travel, consumption of unusual foods or foods which may have been contaminated. Recent
    exposure to antibiotics. Family members sick at home, pelvic pain, vaginal bleeding,
    vaginal discharge. Past medical history, medications (esp. NSAIDS), family history of
    Crohn’s, ulcerative colitis, familial polyposis, review of systems.

    Two findings which indicate the seriousness of the problem: Patient feels dizzy and
    weak


    Three possible diagnoses: 1. Gastroenteritis, 2 Bleeding peptic ulcer, 3. Inflammatory
    bowel disease.

    Four investigations: CBC with differential, Stool for ova and parasites, and culture,
    C. Difficile toxin, endoscopy (from above first). Type and crossfor 4 units of PRBCs.


    1996 Questions

    10 minute stations

    2.1.1. Middle-aged woman with systolic ejection murmur radiating into carotids. Perform physical exam.

    2.1.2. 50 yr old man with left-sided chest pain. Manage (means history, physical, investigations and treatment). Findings: bruises on chest wall, normal chest x-ray, and ECG.

    2.1.3. Young man with recent onset back pain and limp. Take history and physical.

    2.1.4. 25 yr old man wishes to refill a prescription of Fiorinal for tension headache. Manage.

    2.1.5. Elderly woman in hospital pot-op day 5 of total hip replacement. Acute chest pain, tachycardia, shortness of breath. Manage.

    2.1.6. Young mother with 6 wk old baby, has recently immigrated from Ghana. Poor English skills. Concerned about whether she should have her baby immunized. Counsel.

    2.1.7. 40 yr old woman, appears sad, requests sleeping pills. Manage.

    2.1.8. 60 yr old woman with multiple pains. Investigated by several other doctors, all lab tests normal. Manage.

    2.1.9. A young man presents to the Emergency Department having twisted his ankle. Manage.

    2.1.10. 16 yr old known epileptic on Dilantin, is having 3 seizures per month and requests better
    medication. Manage. Findings: not taking meds, experiencing stress.

    5 minute couplets

    2.2.1. 50 yr old woman with headache and normal vitals. Take a history.
    Q: Describe appropriate investigations and treatment for temporal arteritis.

    2.2.2. HIV positive man. 1 week of shortness of breath, cough, fatigue. Perform a physical exam.
    Q: Give a differential diagnosis for a CXR showing a fine reticular pattern in the left lower
    lobe. Manage

    2.2.3. A 2 day old infant has serum bilirubin 220 (ref. Max 200). Take a history from the mother.
    Q: What are the possible causes for this abnormality? Give investigations and treatment.

    2.2.4. A 50 yr old man is denied life insurance because of abnormal liver function tests. AST>ALT very elevated. AP slightly elevated, bilirubin normal. Take a hostory.
    Q: Give a differential diagnosis. What investigations would you order?

    2.2.5. 19 yr old female with a vaginal discharge. Take a history.
    Q: Give three possible diagnosis. What investigations would differentiate these?

    2.2.6. 60 yr old man with microscopic hematuria on routine analysis. Take a history.
    Q: Give a differential diagnosis. What investigations would be helpful?

    2.2.7. 25 yr old male with a history of dyspepsia and binge drinking has abdominal pain. Perform a focussed physical exam.
    Q: What radiological investigations would you order and why?

    2.2.8. 70 yr old male with neck pain and left arm weakness. Perform a focussed physical exam.
    Findings: Decreased sensation over left index and middle finger, mild wrist extensor and
    triceps weakness.
    Q: Describe a cervical spine film of the patient’s neck (shows narrowing of C6-C7 disc
    space). Diagnosis and treatment.

    2.2.9. A 30 yr old patient with type I diabetes presents to the ER with abdominal pain and vomiting. Take a history.
    Labs: Glucose 25, K 6.0, pH 7.22, bicarb 14. What is your diagnosis and management?

    2.2.10. A mother with her 6 wk old who has been vomiting for 3 days. Take a history.
    Q: Investigations show a palpable mass in the right epigastrium, metabolic hypochloremic
    alkalosis, and a positive esophageal string sign on barium swallow. What is the diagnosis?
    Give a a differential diagnosis for vomiting in an infant.

    Answers to 1996 Questions

    2.1.1. The physical exam for a patient with a heart murmur is a cardiopulmonary exam:

    Patient sitting: Take vitals.

    Inspect for cyanosis, arcus senilis in the eyes (sign of high cholesterol), bulging veins in
    the upper chest (SVC syndrome), nicotine stains on fingers, clubbing, flame hemorrhages
    on nails, obesity, work of breathing, intercostal indrawing, symmetric chest movement,
    visible apex beat.

    Palpate the apex, note whether it if laterally displaced (lateral to the mid-clavicular line)
    and feet for thrill or heave, feel radial pulses bilaterally.

    Percuss the lung fields anteriorly and posteriorly.

    Auscultate the lung fields anteriorly and posteriorly, listen to the heart in the mitral (apex,
    5th interspace, mid-clavicular line), tricuspid (right sternal border, 5th interspace), pulmonic
    (left sternal border, 2nd interspace) and aortic (right sternal border, 2nd interspace) areas as
    well as over the right clavicle, and both carotids. Listen for rub. To bring out an aortic
    murmur (typically aortic regurgitation, ask patient to lean forward, exhale and stop
    breathing while you listen over the aortic area. To bring out a mitral murmur, ask patient
    to lie supine and roll partly onto the left side while you listen over the apex. In general,
    murmurs are accentuated by increasing the dynamicity of the heart with mild exercise,
    such as asking the patient to lie down and get up again.

    Innocent murmurs are <3/6 in intensity, peak early in systole, stop long before S2, are
    heard best at the base of the heart (aortic and pulmonic areas), are not associated with
    clicks or heaves, and ECG and CXR are normal.

    Patient lying supine: Auscultate for bruits over the renal arteries in the abdomen.
    Observe for pulsations due to AAA, palpate abdomen, femoral pulses, and auscultate for
    femoral bruits, palpate the popliteal pulses, inspect the legs and feet for venous stasis or
    arterial insufficiency ulcers, palpate the dorsalis pedis and tibialis posterior pedal pulses.
    Feel the ankles for pitting edema.

    JVP: Raise the head of the bed 30 degrees and inspect the neck. A jugular venous
    pulsation higher than 4 cm ASA is abnormal and a sign of CHF or fluid overload. Check
    the hepatojugular reflux (compress the liver, the JVP should either not rise or remain
    elevated only transiently).

    2.1.2. History for chest pain: Describe the pain, location, radiation, quality, time of onset, duration, intensity, circumstances under which it occurs, aggravating and relieving factors, associated symptoms such as nausea, SOB, dizziness, diaphoresis, dependent edema, leg pain. Respiratory symptoms: cough, sputum, fever, hemoptysis, GI symptoms, heartburn, dysphagia. Previous episodes, chronology of these. History of trauma, asthma, bronchitis, COPD, pneumothorax, recent viral illness and previous chicken pox (herpes zoster can cause chest pain), gastritis, peptic ulcer, reflux. Risk factors for heart and lung disease: smoking, hypertension, hyperlipidemia. PMH especially diabetes, heart disease including pericarditis, lung disease, GI problems, surgical history, and family history. Medications, drug use, smoking, allergies, ROS.

    Physical exam: cardiopulmonary exam as in 2.1.1. with the addition of inspection and
    palpation of the chest wall for traumatic or MSK pain source.

    Investigations: CXR, ECG.

    Treatment: Given a normal CXR and ECG with a chest wall bruise as evidence of
    trauma, send patient home, recommend non-prescription pain medication and advise that
    the pain should subside gradually. Since the patient is at risk because of his age group and
    male gender, explain the symptoms of MI and advise to return immediately if these occur.

    2.1.3. A differential for low back pain is:
    1. Mechanical (muscle strain/spasm or facet joint pain)
    2. Intervertebral disk bulging, herniation or rupture
    3. Spinal stenosis (narrowing) which can be caused by osteophytes, congenital narrow
    canal, spondylolisthesis (forward or backward slipping of one vertebra on another), or
    malignant tumour (eg. In a young person), lymphoma
    4. Discitis/osteomyelitis
    5. Pyelonephritis
    6. Ankylosing spondylitis
    7. Vertebral compression fracture
    8. Malignancy
    9. Malingering

    Because discogenic and stenotic radiculopathy which have not improved over at least
    4 wks may be treated surgically, the priority of a history and physical for back pain is to
    differentiate radiculopathy from other causes and to identify the nerve root.

    The most common disk herniation is a posterolateral L4-5, which compresses the L5 root.
    The herniation will also compress the L4 root if the herniation is far lateral, and the S1
    root if it is more medial (central). The second most common herniation is a posterolateral
    L5-S1, which compresses the S1 root. In the thoracic and lumber spine, the nerve roots
    exit below the pedicles of the vertebra of the same number, while in the neck the nerve
    root exits above the pedicle of the vertebra of the same number. L5 compression produces
    lateral calf pain, numbness of the medial dorsum of the foot (including web of great toe),
    and ankle dorsiflexion weakness. S1 compression produces posterior calf pain, lateral foot
    numbness and ankle plantarflexion weakness (with decreased ankle jerk).

    History: Describe the pain, location, radiation (L5 radiculopathy causes radiation from
    buttock to lateral calf, S1 radiates posteriorly down leg to heel), quality, duration,
    frequency, intensity, circumstances under which it occurs, aggravating and relieving
    factors. Onset and chronology, previous episodes. Previous investigations and treatment.

    Pain worse lying down and bilateral leg weakness suggests spinal stenosis or ankylosing
    spondylitis. Spinal stenosis is characterized by worsening of symptoms with standing and
    walking, with relief on bending and sitting (a typical history of leaning on and bending
    over the shopping cart for relief of pain while shopping suggestive of spinal
    stenosis).Ankylosing spondylitis is characterized by morning stiffness relieved by activity.
    Pain worse in back than in buttock or leg suggests mechanical back pain. Pain worse in
    buttock or leg than in back suggests radiculopathy.

    Has the patient had a fever, weight loss, night sweats (signs of cancer), urinary tract
    infection (sign of urinary retention), joint pain, uveitis (sign of ankylosing spondylitis)?
    Ask about effect on activities of daily living, functional limitations. Associated numbness,
    weakness.

    Are the symptoms improving or worsening? What are the patient’s conclusions about the
    pain and expectations of the physician?

    Medications, drugs and alcohol, smoking, PMH, family history, ROS.

    Cauda equina syndrome: Inquiry into bowel, bladder, and sexual function to reveal this
    rare syndrome is obligatory and a source of frequent false alarms. Because these functions
    may not recover once lost, cauda equina syndrome due to surgically treatable lesion is a
    surgical priority if the time course is subacute and an emergency if the loss of function is
    acute. The syndrome consists of saddle anesthesia (peroneal numbness), lax anus,
    impotence, urinary retention, and bowel incontinence. Note that this combination of signs
    is due to preservation of sympathetic tone with loss of parasympathetic tone. Sympathetic
    tone is preserved because it is carried extra-spinally, while parasympathetic signals are
    carried via the inferior spine and nerve roots. Note that bowel contraction and penile
    erection are parasympathetically driven.

    Physical: Standing: Assess gait, posture, range of motion including rotation, lateral and
    forward flexion, extension (pain worse on forward flexion and relief on extension suggest
    discogenic pain, pain worse on extension suggests facet joint pain). For ankylosing
    spondylitis: Wright-Schober test positive when distance between the lumbosacral junction
    and a point 10 cm above identified by palpation on the erect spine, distract by less than
    5 cm on full forward flexion of the spine. Lateral flexion is impaired when the hand moves
    downward by less than 3 cm on the ipsilateral thigh. Look for scoliosis on standing
    (shoulder heights equal?) And forward flexion, check for rib hump. Inspect back for spina
    bifida. Palpate for tender areas esp. sacroiliac joints. Compress pelvis to elicit pain of
    sacroiliitis (Hallmark of ankylosing spondylitis). Muscle tone, percuss costo-vertebral
    angles for renal pain. Have patient walk on toes, heels. Ask patient to stand on one foot at
    a time and push up into tiptoe for ankle plantarflexor strength (S1).

    Sitting: Knee jerks (L4) with quadriceps exposed, watch contraction. Ankle jerks (S1),
    rapidly dorsiflex each foot to test for clonus. Babinski. Compare calf girths for wasting by
    measuring calf circumference 10 cm below tibial tuberosity. Test power of quadriceps,
    hamstrings, psoas (raise knee up against resistance), ankle dorsiflexors. Ask patient to
    straighten both legs and compare this position to the degree of forward flexion the patient
    was able to achieve on standing range of motion. Suspicion of malingering is raised if the
    patient claims to be unable to bend from a standing position but is able to extend the knees
    from a sitting position.

    Supine: Feel for lymph nodes at neck, clavicle, axillae, groin. Test hip extensors (patient
    presses leg into bed while you try to raise it). Sensation at both legs: light touch and
    pinprick - compare medial dorsum of foot (L5) with lateral foot (S1) and lateral calf (L5)
    with posterior calf (S1). Vibration and position sense in big toes. Straight leg raise: Raise
    patient’s head off bed as far as patient will allow, note angle, note whether this reproduced
    the patient’s ipsilateral or contralateral radicular pain. Bowstring test: Flex hip to 90
    degrees, extend knee to the point of pain and press on the hamstring tendon which is
    medial. Note reproduction of pain. Peripheral vascular exam: Inspect for venous stasis or
    arterial insufficiency ulcers, check femoral pulses and auscultate for femoral bruits, feel
    popliteal, dorsalis pedis, and tibialis posterior pulses.

    2.1.4. History: Description of headache pain, location, quality, intensity, duration, onset including time of day (morning headache associated with raised intracranial pressure), previous episodes, aggravating factors, relieving factors (eg. Coughing and bending worsen headache in raised ICP, and chocolate, cheeses can trigger migraines), associated symptoms (aura, nausea, vomiting, photophobia, phonophobia, nuchal rigidity, weakness, numbness, visual disturbances), medical history, medication history, current meds, allergies, family history, substance abuse inquiry, smoking, mood, stress, anxiety. ROS.

    Given a benign history with no suspicion of raised ICP or focal deficits, and a description
    of headache consistent with the common tension headache, a full neurological examination
    is not indicated. Suggest to the examiner that you would perform a brief neurological
    screening exam. You will be told to move on.

    Treatment: Explain that Fiorinal is a combination preparation of barbiturate and ASA
    which is properly used only for the relief of occasional tension headaches. It is habit-
    forming, can precipitate a withdrawal syndrome including agitation, delirium and seizures,
    and has additive sedative effects with other CNS depressants. The fact that this patient has
    consumed an entire prescription in 4 days suggests overuse due to dependeance. He may
    also have analgesic headache syndrome in which inappropriately used analgesics actually
    cause headaches. Suggest a drug holiday with weaning from caffeine and alcohol, proper
    sleep hygiene, diet, exercise and stress management. Chronic headache may also be a
    symptom of depression or anxiety, arrange follow up to evaluate for these if the patient
    does not improve.


    2.1.5. Life-threatening causes of acute chest pain: MI, PE, pneumothorax and tension pneumothorax, aortic dissection. Other causes: angina, gastritis, reflux, peptic ulcer, pericarditis, herpes zoster, MSK.

    Rapid cardiopulmonary history including any history of high blood pressure, heart
    problems, smoking, COPD.

    Physical: As in 2.1.1. plus additional attention to calf size, tenderness, redness and
    pleuritic chest pain.

    Homan’s Sign: Pain in the calf on dorsiflexion of the foot - indicates thrombophlebitis.
    Check that trachea is midline. Inspect surgical wound. Is the patient on DVT prophylaxis
    or anti-coagulation?

    Treatment: Raise head of bed. Give oxygen 6L/min by mask. Monitor oxygen saturation
    (order stat CBC, lytes, glucose, INR/PTT, CK-MB, ABG, CXR, ECG). Give chewable
    ASA 160-325 mg immediately. Secure IV access, bolus IV lasix 40 mg push if fluid
    overload is suspected, and ventolin if wheezes are heard, give sublingual nitro spray or
    0.3 mg sublingual nitroglycerin if blood pressure is adequate and 1 mg morphine IV.

    Repeat nitroglycerin q 5 min X 3. May require additional morphine and nitroglycerin.
    Repeat CK-MB q 8hr X 3.

    ECG: If ECG shows significant ST elevation (more than 1mm in two anatomically
    consecutive leads), or a new left bundle branch block, then the patient is having an MI.
    Order stat cardiology consult for possible lytic therapy or cardiac catheterization. If less
    severe signs of ischemia are present (flipped T waves, ST depression), follow with repeat
    ECGs until resolved.

    S1Q3T3: This classic pattern (wide S-wave in lead 1, Q-waves in lead III, T wave
    inversion in lead III) with right axis deviation and RBBB are signs of right heart strain
    seen in massive PE.

    A-a gradient: An elevated A-a (alveolar pO2-arterial pO2) gradient is a sign of pulmonary
    embolus but also occurs in any condition in which there is a ventilation-perfusion
    mismatch (eg. Pneumonia, PE, COPD). It is determined from the ABG:
    A-a = 713(FiO2) - 1.25(PaCO2)-PaO2 (normal 12 in child, 20 in 70 yr old)

    Note that the inspired oxygen fraction (FiO2) is not known unless the patient is on room
    air, a ventimask, or mechanically ventilated. This is because the patient breathes in more
    by an unknown amount than the output of nasal prongs or ordinary mask. Roughly,
    however, 2L/min gives 26% FiO2, 3L=30%, 4L=35%, and 6L=40%. 40% is considered
    the maximum inspired oxygen obtainable without a high flow mask such as a ventimask.

    ABG normal values: pH 7.35-7.45, pO2 80-100 mmHg, bicarb 24, pCO2 40

    Indications for intubation: An ABG showing poor pO2 (in the 60s or if less than 80 on
    high inspired oxygen concentrations), elevated pCO2 (greater than 80), acidemia, or
    GCS<8 (not able to protect airway) may indicate need for intubation if these are not
    quickly correctable. Consult ICU.

    CXR sign of PE: wedge-shaped infiltrate (Hampton’s hump) or oligemic area, unilateral
    effusion, raised hemidiaphragm. A normal CXR is also consistent, and usual, with PE.

    Specific Investigations for PE: CT Chest (can only see PE which is large enough to be
    clinically significant), V/Q scan (conclusive when it shows high or low probability), and
    serial (q 2 days) leg dopplers for presence of DVT above the knee.

    Treatment/: If suspicion of PE is high, anticoagulate before waiting for tests with heparin
    7500 units IV bolus, then infuse at 1200 units/hr, Measure PTT q 6hr, adjust dose for PTT
    70-90 sec. If a diagnosis of PE is made, warfarinize, continue anti-coagulation for
    3 months.

    2.1.6. General principles of counselling are to be aware of communication barriers such as language difficulties, to understand the patient’s objectives, fears, preconceptions to deal with these in an empathetic non-judgmental way and to normalize them, to transmit information in a way that is consistent with the patient’s expectations and understandable to them, and to invite further questions and feedback.

    Ask if the patient would prefer someone perhaps a family member to translate. Ask about
    the patient’s concerns, what does she want to know and why? Explain that vaccines
    protect children from diphtheria, tetanus, pertussis, polio (DPTP) mumps, rubella, measles
    (MMR), influenza (Hib) and hepatitis (HepB). All of which were once common and
    caused serious, sometimes fatal illness in Canada, and all of which are now hardly ever
    seen because of vaccines. Explain that because the vaccines stimulate the immune system,
    some children have a temporary sore arm at the site of injection, malaise, mild fever, or
    rash. It is very rare to have a more serious reaction (seizures, encephalopathy have been
    reported). Standard modern vaccines are not known to cause disease or to have long term
    deleterious effects. Compare these risks with the risk of not being vaccinated. Explain the
    recommended immunization schedule (below) and give the patient some information
    pamphlets, invite further questions and ask her to return in two weeks for the child’s first
    immunization.

    Contraindications to vaccination: Previous serious reaction to vaccine. Special
    contraindications to MMR, which is a live attenuated vaccine suspended in egg white
    protein and preserved with neomycin: allergy to egg or neomycin, pregnancy, and
    immunocompromised state. Special contraindications to the pertussis component of DPTP
    (which is thought to be the component responsible for seizures and encephalopathic
    vaccination reactions when they occur) = progressive neurologic epilepsy.


    Recommended Immunization Schedule:
    2 months DPTP, Hib
    4 months DPTP, Hib
    6 months DPTP, Hib
    1 yr. MMR
    18 months DPTP, Hib
    4-6 yr MMR DPTP
    12-13 yr Hep B
    14-16 yr TdP (certificate of immunization for high school)
    q 10 yr Td

    2.1.7 Sleep History: Usual requirements, chronology of sleep problems, stressors, sleep hygiene (when, where, regularity, shifts at work, late exercise, meals, alcohol, caffeine, prescription and non-prescription remedies, drugs and medications), sleep latency (time to fall asleep), nocturnal awakening, early morning wakening, daytime somnolence, somnolence while driving, working or during conversation.

    Depression screen: Change in sleep pattern, anhedonia, guilt, hopelessness, fatigue, mood,
    concentration, memory, appetite, weight gain or loss, irritability, psychomotor
    retardation/agitation, anxiety, diurnal variation in mood and activity in the morning,
    suicidal ideation. Must fully explore suicidal ideation: does patient intend to harm self,
    reason for suicidal thoughts, current plan, lethality of plan, access to lethal means, has
    patient given away prized possessions or written final notes to loved ones, previous
    attempts.

    Diagnosis of major depression vs dysthymia: Mnemonic for major depression SIGECAPS.
    A diagnosis of dysthymia requires depressed mood for most of the day, more days than
    not, for at least 2 yrs. A diagnosis of depression cannot be made in the face of
    bereavement within the past 2 months or drug or alcohol abuse.

    Differential: Check for bipolar mood disorder, schizophrenia, psychotic depression and
    obsessive compulsive disorder. Ask about manic episodes, paranoia, hallucinations (esp
    voices), delusions, illusions, obsessive thoughts, previous psychiatric problems, family
    history of psychiatric disorders, substance abuse, relationship problems, problems at work.

    Mental Status: Appearance, attitude (?co-operative), mood/affect (flat, sad, happy, mad), motor,
    speech (rate, rhythm, volume, quantity, articulation), thought content (delusions, illusions,
    hallucinations), thought process (coherent, flight of ideas, logical), insight, intellect.

    Mini Mental Status Score: Orientation to time (5 pts - year, season, month, day, place),
    Orientation to place (5 pts - country, city, building, floor), recall of 3 objects (3 pts), concentration
    (5 pts - serial 7s or spell WORLD backwards), name 3 objects (3 pts), repeat “No ifs ands or
    buts†(1 pt), 3-step command (3 pts), written command “close your eyes†(1 pt), copy interlocking
    pentagrams (1 pt), write a sentence (1 pt). Total = 30

    Medical causes of depression: Hypothyroidism, adrenal dysfunction, hypercalcemia,
    mononucleosis. Consider chronic fatigue syndrome, drug use, smoking, allergies, PMH including
    psychiatric history and history of abuse, family history, review of systems

    Proper sleep hygiene: Regular bed and wake times, avoid daytime naps, regular exercise but not
    late in the evening, do not use the bed for reading, Tv, paperwork, etc, avoid caffeine, alcohol,
    smoking

    Treatment of Major Depression: Pharmacotherapy, psychotherapy, family therapy. Start Prozac
    (fluoxetine) 20 mg q am, may increase to 40 mg q am after 1 week. Takes 2-4 wks to work.
    Explain side effects of sleep disturbance, anorgasmia, nausea (see SSRI summary below).

    SSRI Start at (mg) OD Therapeutic (mg (OD)

    Fluoxetine (Prozac) 20 20-80
    generally energizing

    Fluvoxamine (Luvox) 50 150-300
    more sedating

    Sertroline (Zoloft) 50 50-150
    used in elderly

    Paroxetine (Paxil) 10-20 20-60
    used in mixed anxiety-depression


    2.1.8. History of multiple pains: Should address the differential for multiple pains.

    Depression with somatization: Major depression presents with a somatic complaint, commonly
    headache, stomach pains, sleep disturbance, eating disturbance, or bowel habit changes. This is
    a frequent presentation of depression in the elderly. Tx as in depression (2.1.7)

    Somatization Disorder: Multiple non-intentional complaints in multiple organ systems beginning
    before age 30 that occur over several years, with treatment sought and significant impairment in
    functioning. Diagnostic criteria: 4 pain symptoms at 4 different sites, 2 GI symptoms other than
    pain, one reproductive or sexual symptom other than pain, one pseudo-neurological symptom
    (temporary blindness). Tx: counselling, psychotherapy, close follow-up, reassurance.

    Conversion Disorder: Psychic perturbation presents as one or two neurological complaints.
    Tx: anxiolytics (eg. Lorazepam 1 mg po q 6hr, relaxation therapy, counselling, close follow-up.

    Pain Disorder: eg. Chronic post-traumatic or post-surgical pain. Pain not fully accounted for by
    current tissue injury, exacerbated by psychic factors and associated with functional impairment.
    Tx: amitryptyline 25-75 mg po qhs.

    Hypochondriasis: Exaggeration or misinterpretation of normal sensory phenomena to the point
    of functional disability. Associated with obsessive fear of serious illness and doctor shopping.
    Tx: counselling, reassurance, close follow-up.

    Fibromyalgia: Also called fibrositis and fibromyositis. 80-90% of cases occur in middle-aged
    women, may afflict 5% of adult women. Associated with absent or decreased non-REM stage 4
    sleep, patients wake from sleep feeling unrefreshed. Constant, aching, axial pain with bilateral
    tender points (not trigger points, at which referred pain is triggered due to myofascial pain from
    overuse, eg tennis elbow). The disorder follows a waxing and waning course ultimately without
    progression or resolution, and may become disabling. Characteristic reproducible tender points
    are located bilaterally at lateral border of sternum, sternocleidomastoid, posterior neck,
    trapezius, rhomboids, over sacroiliac joints, lateral thigh, posterior and medial knee. Patient
    should have eleven of the above eighteen tender points for a diagnosis.
    Tx: amitryptyline 25 - 75 mg po qhs.

    Chronic Fatigue Syndrome: Similar to fibromyalgia but fatigue is the dominant feature and
    pain and tender points may be less prominent or absent.
    Tx: amitryptyline 25-75 mg po qhs.

    Factitious Disorder or Malingering: Factitious disorder involves misrepresentation of history
    and symptoms for the purpose of assuming the sick role with its inherent secondary gains
    (attention and sympathy, justification for inadequacies). Munchausen’s syndrome is a type of
    factitious disorder in which physical findings are faked by contamination of lab tests or ingestion
    of inappropriate medications or substances. Typically, the patient is a medical paraprofessional
    motivated by hostility toward the medical establishment eg. Nurse takes coumadin to fake
    hemophilia. Malingering is distinguished from factitious disorder by a motivation for secondary
    gain other than the sick role, such as insurance benefits.
    Tx: Counselling.

    History: Pain description, location, duration, chronology, aggravating and relieving factors, are
    pains linked to one another?

    Somatoform disorders screen: How has your health been for most of your life? How have your
    pains affected your job, social life, relationships, and your life generally? Are you often unwell,
    how often do you visit the doctor? Do you worry that you have a serious illness? If a doctor tells
    you that there is nothing medically wrong, how does that make you feel? Do you believe him or
    her?

    Associated symptoms: Review of systems, medications, allergies, smoking, alcohol, drug use,
    family history. Depression history as in 2.1.7.

    Diagnosis and treatment: For non-specific pains with depressive symptoms, the patient most
    likely has depression with somatization. Treat for depression as 2.1.7.


    2.1.9. History of ankle strain: History of a plausible mechanism of injury involving significant inversion or eversion of the foot with pain and swelling. Time of injury, onset of pain and swelling (may be delayed), noises heard at time of injury. Previous ankle or other injuries. Ability to walk post injury (often preserved if ligaments are not ruptured). Past medical history, medications, allergies, family history).

    Physical exam: Inspect for gross deformity, erythema, swelling bruising. Check distal
    circulation, sensation, active and passive range of motion, palpate for tenderness at joints.
    Examine the joints above and below the affected joint. Identify sites of maximal tenderness.

    Talar drawer sign: Stabilize the tibia and pull forward on the heel, talar drawer sign is anterior
    movement of the talus. Greater than 3 mm anterior movement may be significant, 1 cm is
    significant and indicates anterior talofibular ligament rupture.

    Talar tilt: Stabilize the tibia, grasp the talus and tilt in eversion and inversion. Movement beyond
    the normal range (compare with the opposite side) is a positive talar tilt and indicates lateral
    (calcaneofibular) ligament rupture if the tilt occurs in inversion or medial (deltoid) ligament if the
    tilt occurs in eversion.

    Ottawa Ankle Rules: For taking ankle series x-rays (includes lateral and AP ankle with mortis
    view). X-ray if there is pain over the navicular or base of the 5th metatarsal or tenderness on
    palpation of the posterior medial or lateral malleolus or if the patient is unable to weight bear. For
    foot series (AP and lateral foot): X-ray if there is dorsal foot pain plus tenderness at base of 5th
    metacarpal. Calcaneal views if there is pain on palpation of heel. Pain in the ankle on squeezing
    the calf is a sign of ankle fracture.

    Treatment for ankle sprain: Rest, use crutches, avoid weight bearing. Ice for 20 min QID for
    2-3 days. Compression with tensor bandage or tape. Elevate. Rehabilitation: start active range of
    motion exercises 2 days post injury, may weight bear after pain and swelling have subsided. Full
    ligament healing may take 6 weeks in severe injury or more if re-injury occurs. Complete
    ligament rupture with joint instability (positive talar drawer sign or talar tilt) should be evaluated
    by Orthopedics.


    2.1.10. History of seizure disorder: Describe seizures, frequency, duration, what body parts affected
    and in what order, premonitory signs, post-ictal state (decrease in level of consciousness,
    headache, sensory phenomena), degree of control achieved with Dilantin at what dose and for
    how long. Age of first seizure. Corroboration from family if possible.

    Side effects of Dilantin (phenytoin): Drowsiness, poor concentration, poor performance in school,
    acne, nystagmus, dysarthria, ataxias, peripheral neuropathy, hypertrichosis (excessive
    hairiness), gingival hypertrophy.

    Number and description of recent seizures, are they different from previous seizures? Is the
    patient having any new symptoms such as headache, morning vomiting, new neurological
    deficits? If the drug has worked in the past, why does the patient believe it is no longer effective?

    Compliance: Is the patient taking meds? Why not? Problems at school or home? Ask about
    relationship problems. Depression screen as in 2.1.7. Social supports, medications, drugs and
    alcohol, smoking, allergies, PMH, family history, ROS.

    Physical Exam: Neurologic exam including mini-mental, cranial nerves, bulk, tone, power,
    sensation, cerebellar exam, deep tendon reflexes.

    Send blood for serum Dilantin level.

    Treatment: Discuss importance of compliance. If alcohol is an issue, inform the patient that
    chronic alcohol intake may decrease blood levels of phenytoin (via increased liver metabolism)
    and acute alcohol can precipitate seizure. The same is also true of sedatives, cocaine,
    amphetamines, and insulin. Fatigue and other illnesses can also lower seizure threshold, in
    addition to various other medications. If patient is having stress management, anxiety issues, he
    may require further counselling. If Dilantin levels are therapeutic but the patient is having severe
    side effects or poor seizure control, a second drug may be added (usually carbamazepine or
    valproic acid).

    Discuss avoidance of dangerous activities including driving. MOT regulations require 1 year
    seizure free before they will grant a driver’s license in Canada. Inform the MOT of the patient’s
    seizure disorder if you have not already done so.

    Discuss what to do in the event of a seizure. Counsel parents if possible. Bystanders are not to
    insert objects into the patient’s mouth, Turn patient on his side while seizing. Call ambulance or
    take to ER if seizure doesn’t stop in 10 min. Arrange regular follow-up to monitor progress and
    serum Dilantin levels.

    2.2.1. Headache history as in 2.1.4. A history of unilateral lancinating pain with swelling and tenderness in the temporal area should prompt inquiry after symptoms of polymyalgia rheumatica (PR), which is related to temporal arteritis and may be a more systemic variant of the same underlying disease. Symptoms of both PR and temporal arteritis include low grade fever, malaise, anorexia, weight loss, bilateral proximal muscle weakness, aching and pain as well as joint inflammation. Jaw claudication, stroke and blindness may occur due to vasculitic occlusion of arterial supply. Ask about visual changes.

    Investigations for temporal arteritis: CBC (mild anemia with increased WBC), ESR
    (>50 mm/hr, normal 30), C-reactive protein, liver enzymes, temporal artery biopsy, may add
    temporal artery angiogram to guide biopsy.

    Treatment: In the absence of visual symptoms, without waiting for biopsy, start high dose oral
    prednisone, 60 mg OD until symptoms subside and ESR normal, then 40 mg OD for 4-6 weeks,
    then taper to 5-10 mg OD for 2 yrs. (Relapses occur in 50% if treatment is terminated before
    2 yrs). Treatment does not alter biopsy results if the sample is taken within 2 weeks. Monitor
    ESR regularly.

    If visual symptoms are present, or develop during treatment, the patient is admitted and given IV
    prednisone 1 g q 12 hr for 5 days.

    2.2.2. A physical exam for query pneumonia consists of the cardiopulmonary exam as in 2.1.1. with additional attention to the chest and pharynx and signs of HIV infection.

    Examination for lobar consolidation: In general, pulmonary effusion decreases transmission
    of breath and vocal sounds to the chest wall, while consolidation (seen in pneumonia) increases
    it. Four maneuvers bring out the effect of increased transmission: tactile fremitus is increased
    transmission of palpable fremitus to the chest wall while the patient repeats “ninety-nineâ€.
    Bronchophony is enhanced transmission of spoken words such as “ninety-nineâ€, egophony is a
    change from an “ee†to an “ay†sound over the affected area while the patient sustains an “eeeeâ€
    sound, and whispered petroliloquy is a marked increase in audibility through the chest wall over
    the affected area while the patient whispers “ninety-nineâ€.

    Signs of consolidation: Increased tactile fremitus, percussion dullness, crackles, bronchial
    breath sounds, increased voice transmission (bronchophony, egophony, whispered petroliloquy).

    Signs of HIV infection (and possible impending AIDS): Check entire skin surface for Kaposi’s
    sarcoma, examine pharynx for thrush or hairy leukoplakia (EBV-related epithelial proliferation
    causing raised plaques on the sides of the tongue), palpate neck, clavicle, axillae, and groin for
    lymph nodes enlarged by non-Hodgkin’s lymphoma. Examine abdomen for hepatic or splenic
    enlargement.

    Differential diagnosis of unilateral lobar reticular pattern on CXR: pneumocystis carinii
    pneumonia (PCP), cytomegalovirus (CMV), tuberculosis, Cryptococcus neoformans,
    Hemophilus, Streptococcus, mycoplasma, chlamydia. The classic CXR of PCP, an AIDS-
    defining illness, is bilateral hilar infiltrates but X-ray findings are variable and may be alveolar or
    interstitial.

    Investigations: O2 sat/ABG, CBC with differential and CD4 count, LDH (elevated in 95% of PCP
    pneumonias and not in other pneumonias), blood cultures, sputum for cytology, gram stain,
    culture and TB stain if sputum available (cough usually non-productive and induced sputum may
    fail), bronchoscopy with cytology, gram stain and culture of bronchial washings and brushings
    (may see bronchial Kaposi’s).

    Treatment: DS Septra 2 tabs QID x 14 days outpatient with 1 tab OD or BID 3/week continued
    as prophylaxis. More specific therapy with results of diagnostic tests. In severe illness, admit to
    hospital, give IV septra at same dose and prednisone 40 mg BID x 5 days, then 20 mg OD for
    prophylaxis.

    Patient should be referred to an AIDS specialist for antiviral and possible experimental therapies.
    Counselling and referral to support organization. Follow-up appointment.

    2.2.3. Mother’s obstetrical history: GTPAL (gestations, term pregnancies, premature births, abortions, live children), history of previous pregnancies including neonatal jaundice, maternal medical history esp. liver disease, illness during pregnancy esp. diabetes (large birth weight, pre-eclampsia), rubella (teratogenic), toxoplasmosis (from cats, infects fetal brain), herpes (infects fetus, frequently fatal), CMV (damages fetal liver), teratogenic medications taken during pregnancy, drug and alcohol use, maternal blood type, complications of present pregnancy including gestational hypertension or diabetes, hyper/hypothyroid, hypercoagulation. Family history of neonatal jaundice, liver problems.

    Newborn history: Gestational age at birth, caesarean induction, rupture of membranes -
    artificial or prolonged, fetal distress, forceps or vacuum delivery, meconium, APGARs, was
    resuscitation required, initial bloodwork, breast fee
  2. trevor

    trevor Guest

    doc179,
    do you have the rest of the answers to the 1996 questions? the answers were very helpful but the last answer was on 2.2.3. 2yo infant. it would be nice if you also have the answers from 2.2.4. 50 yo man w/ abno lfts to 2.2.10. thanks.

Share This Page