1992-1997 and 2004 questions and answers

8/15/2019 1992-1997 and 2004 Questions and Answers

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The Resident’s Guide to the LMCC II

3rd Edition

The Licentiate of the Medical Council of Canada Exam, part II, also known as the MCCQE II, was the traditional means of

qualifyin for a eneral license to practice medicine in Canada! "ow that #oth the internship year and the eneral license are

no loner a$aila#le, many residents $iew the exam as a stressful and expensi$e exercise in futility! %hile the process isstressful and expensi$e, it need not #e futile! &reparation for the exam can #e an enlihtenin re$iew! 'cenarios tend to repeat

o$er the years, the pass rate is reater than ()* on the first attempt, and there is an option to rewrite, so don+t panic!

The exam is an 'CE -#ser$ed 'cenario Clinical Exam. in which the candidate proresses throuh a series of stations! /ourstartin point is determined alpha#etically! 0t each station there is a physician examiner and either a real person posin as a

patient or a telephone o$er which you must speak to a patient or another physician requestin assistance!

The most recent sessions -since 1((2. contain six short cases known as )minute couplets, in which the candidate is allotted )minutes to assess a patient and ) minutes to write short answers to questions related to the case! There was also a series of six

loner cases in which the candidates were presented with a more in$ol$ed clinical pro#lem, such as a resuscitation or

psychosocial counselin session, lastin 14 minutes each! The physician examiner may ask one or two questions in the last

minute of a 14minute station! There is one minute #etween stations durin which you can look at a #rief description of the patient and consider your approach! ccasionally 5pilot6 questions will #e included in the exam, which will not count towards

the final mark #ut are used to test new questions! /ou will not know which questions are 5pilot6 questions!

The content of the exam is eneral medicine! This means family practice 7 emerency medicine! The followin topics appearconsistently8

Pediatrics 9 diarrhea, de$elopment, neonatal :aundice, asthmaObs/Gyn 9 amenorrhea, $ainal #lood, a#dominal pain, &I;, C&, electi$e a#ortion counselinSuturing 9 choice of suture, tetanus $accineChest Pain 9 read CResuscitation 9 fluid resuscitation after #lood loss, 0?C@sOverdose 9 0'0, TC0Needle stic 9 0I@', hepatitis, $accinationsPsychiatry 9 depression, mania, schiAophreniaNeurosurgery 9 #ack and neck radiculopathies, carpal tunnel

-"ote that e$ery history should include name, ae, occupation, past medical history, family history, medications, drusBalcohol,

re$iew of systems.

!""#

!$ %irst year university student& " 'ees (regnant& considering abortion$ Tae a history and counsel$ %indings) tear*ul&

guilty& slee( disturbance& has not engaged social su((orts$

+istory8 com#ine a prenancy history with a social history and a screen for depression!

Pregnancy8 &atient I@ -name, ae, occupation.! >T&0L -num#er of estations, term prenancies, premature #irths, a#ortions,

li$e children., history of pro#lems, if any, with pre$ious prenancies! Current prenancy, esta#lish estational ae ->0. #y lastmenstrual period -LM&. if reular periods and sure dates -if unsure a datin ultrasound would #e needed.! The >0 is the

num#er of weeks from the first day of the LM&! The E@C is first day of LM& 2 days 9 3 months! 0sk a#out use of alcohol,smokin, drus, domestic $iolence -)4* #eins in prenancy., maternal illnesses durin the prenancy -particularly dia#etes,

ru#ella, toxoplasmosis, herpes, CMD, thyroid dysfunction, ;T", hypercoaulation.! se of #irth control, if any! &ast medical

history, family history of prenancy related pro#lems, medications!

Social8 'tatus of any relationships at present includin relationship with the child+s father! 'ocial supports -family, friends,

#oyfriend., do they knowF 0re they helpinF EmploymentBfinancialBeducational status of the patient, does the patient feel

prepared to raise a childF

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decreased, decreases 2ctopic prenancy rates and of course8 $irtually no chance of prenancy when taken as directed -(K

((!)*.!

Riss o* hor.onal contrace(tives8 sliht weiht ain is usual -) l#s., increases risk of @DT especially in com#ination with

smokin, may stimulate estroenreceptor positi$e #reast cancers, #ut does not appear to cause them, may ha$e to try two or

three different preparations to arri$e at the one for the patient! 0lso note that hormonal contracepti$es do not pro$ide as much

protection aainst sexually transmitted diseases, compared to #arrier methods!

-irections8 'tart C& on the first day of the next menstrual period! &lace packae in an o#$ious location to help you toremem#er! Take at the same approximate time each day! se additional contraception for the first two months, as C&

contraception is not relia#le until then! If you miss a day, take two pills the next! If you miss two days, take two pills for thenext two days and use an alternati$e method until the next period! >i$e prescription for C& of choiceGany family mem#ers

-sistersBmother. on C&F %hat works for themF 0rrane follow up!

3$ !4 year old boy 'ith e(ile(sy docu.ented by neurologist& co.es to you because he does not 'ant to see his (arent’s

*a.ily doctor$ 5ants a driver’s license$ Tae a history and counsel$

+istory o* sei6ure disorder8 &atient I@! 0e of onset -primary eneraliAed rarely #ein 3 or J H4 years old.! &recipitants8

'leep depri$ation, drus, Et;, TD screen, stro#e, emotional upset! @escri#e seiAures -Nacksonian marchF 'ali$ation,cyanosis, tonue #itin, incontinence, automatisms, motor $s! $isualBustatoryBolfactory., frequency, duration, what #ody parts

affected and in what order -motor 9 frontal lo#e, $isualBolfactoryBustatory hallucinations O temporal lo#e., promontory sins

-presence of aura8 implies focal attack., postictal state -decrease in le$el of consciousness, headache, sensory phenomena,

tonue soreness, lim# pains, Todd+s paralysis hemipleia., deree of control achie$ed with medications, at what dose and forhow lon, corro#oration from family if possi#le! %as a CT scan done when seiAures were first dianosedF "um#er and

description of recent seiAures, are they different from pre$ious seiAuresF Is the patient ha$in any new symptoms such as

headache, mornin $omitin, new neuroloical deficits! If the dru worked in the past why does the patient #elie$e it isn+t

workin nowF 'ide effects of antiepileptics8 drowsiness, poor concentration, poor performance in school, ataxias, peripheralneuropathy, acne, nystamus, dysarthria, hypertrichosis -excessi$e hairiness., ini$al hypertrophy -phenytoin.! Medications,

drus and alcohol, smokin, alleries, past medical history, family history, re$iew of systems!

Co.(liance8 Is the patient takin medsF %hy notF &ro#lems at school or homeF 0sk a#out relationship pro#lems! @epressionscreen as in P1( a#o$e! 'ocial supports!

Physical e7a.8 neuroloic exam includin mini mental, cranial ner$es, #ulk, tone, power, sensation, cere#ellar exam, deep

tendon reflexes!

Treat.ent8 @iscuss importance of compliance with medication and a$oidin danerous acti$ities such as dri$in until ood

control is achie$ed! Ministry of Transportation reulations require 1 year seiAure free #efore they will rant a dri$er+s license

in Canada! Inform the MT of the patient+s seiAure disorder if you ha$e not already done so and inform the patient that this isrequired #y law! If alcohol is an issue, inform the patient that chronic alcohol intake may decrease #lood le$els of antiepileptics

-$ia increased li$er meta#olism., and excess alcohol intake can precipitate seiAures #y lowerin the seiAure threshold there#y

precipitatin a seiAure! It is enerally recommended that the patient not drink at all! atiue and concomitant illness can also

lower seiAure threshold! The patient should consult a physician #efore takin other medications, as they may also lower theseiAure threshold! The same is also true of sedati$es, cocaine, amphetamines and insulin! atiue and other illnesses can also

lower seiAure threshold, in addition to $arious other medications! If patient is ha$in stress manaement, anxiety issues, he

may require further counselin! utline a treatment plan consistin of8 EE>, CT head, meta#olic screen, medications -if not

done already., and follow up appointments! >et the parents in$ol$ed if possi#le!

'end #lood for serum @ilantin -phenytoin. le$els if patient is on this already! If @ilantin le$els are therapeutic, #ut the patient isha$in se$ere side effects or poor seiAure control, a second dru may #e added -usually car#amaAepine or $alproic acid.!

@iscuss what to do in the e$ent of seiAure, counsel parents if possi#le! ?ystanders are not to insert o#:ects into the patient+s

mouth! Turn patient on his side while seiAin! Call am#ulance or take to Emerency if seiAure doesn+t stop in ) minutes!

0rrane reular follow up to monitor proress and serum @ilantin le$els!

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Indications and i.(ortant side8e**ects o* .a9or antie(ile(tic drugs

-rug Indication -ose8related Idiosyncratic

Carba.a6e(ine

:Tegretol;

&artial or eneraliAed

tonicclonic seiAures

@iplopia, diAAiness, headache, nausea,

drowsiness, neutropenia, hyponatremia

Mor#illiform rash, aranulocytosis,

aplastic anemia, hepatotoxic effects,'te$ensNohnson, teratoenicity

Phenytoin

:-ilantin;

&artial or eneraliAedtonicclonic seiAures,

status epilepticus

"ystamus, ataxia, nausea, $omitin,ini$al hyperplasia, depression,

drowsiness, paradoxical increase in

seiAures, mealo#lastic anemia

0cne, coarse facies, hirsutism, #looddyscrasias, Lupuslike syndrome,

rash, 'te$ensNohnson, @upuytren+s,

hepatotoxic effects, teratoenicityMC or su#stance a#use!

Manic e(isode8 Expansi$e, ele$ated or irrita#le mood x 1 week with 3 of followin8 >'T&0I@ 9 randiosity -or inflated selfesteem., sleep -less need for., talkati$e, pleasura#le acti$ities -with painful consequences., acti$ity increased -oal directed or

psychomotor., ideas -fliht of., distracti#ility! "ot mixed episode! 'e$ere enouh to cause psychotic featuresBimpaired

socialBoccupational functionin! "ot su#stance a#use or >MC!

-i**erential *or de(ression8 Check for #ipolar mood disorder -manicdepressi$e., schiAophrenia, psychotic depression and

o#sessi$ecompulsi$e disorder! 0sk a#out manic episodes, paranoia, hallucinations -esp! $oices., o#sessi$e thouhts, pre$ious

psychiatric pro#lems, family history of psychiatric disorders, su#stance a#use, relationship pro#lems, pro#lems at work-#asically a mental status exam.!

Medical causes o* de(ression8 ask a#out hypothyroidism, adrenal dysfunction, hypercalcemia, mononucleosis! Consider

chronic fatiue syndrome! @ru use, smokin, alleries, past medical history includin psychiatric history and history of

a#use! amily history, re$iew of systems!

Mental status8 appearance, #eha$ior -dress, roomin, posture, ait, apparent ae, physical health, #ody ha#itus, expressions,

attitude cooperati$eF, psychomotor acti$ity, attention, eye contact., speech -rate, rhythmBfluency, $olume, tone, quantity,

spontaneity, articulation., mood -su#:ecti$e emotional state in patient+s own words., affect -Quality 9 euthymic, depressed,ele$ated, anxious =ane 9 full, restricted 'ta#ility 9 fixed, la#ile 0ppropriateness Intensity flat, #lunted., suicidal ideation

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#ackwards., lanuae tests8 comprehension -3 pts, three point command., readin -1 pt, 5close your eyes6., writin -1 pt,

complete sentence., repetition -1 pt, 5no ifs, ands or #uts6., namin -H pts, watch, pen., spatial a#ility -1 pt, intersectin

pentaons.

Cranial nerves 9 C" III, ID, DI8 Extraocular mo$ements -patient follows your finer or the handle of a reflex hammer in an

;pattern, check for diplopia in the center and at the extremes of the $isual fields! C" II8 Disual fields #y confrontation 9 -one

eye at a time. patient holds own hand o$er one eye and counts finers flashed in left and riht fields simultaneously -upper andlower. or identifies the wilin finer as it enters each quadrant on confrontation if too confused to count! ?y acuity8 'nellen

card! undi 9 check for papilledema usin ophthalmoscope! C" II, III, D1 7 DII8 &upillary liht reflex and accommodation,corneal reflex! C" D8 acial sensation to liht touch in the ophthalmic, maxillary and mandi#ular di$isions of the trieminal

ner$e! Trieminal motor8 clench teeth, lateral :aw mo$ement! C" DII, ross hearin 9 ru# thum# and index lihtly while

approachin the patient+s ear, note when they #ein to hear the sound! C" C'.8


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Glasgo' Co.a Scale

2ye O(ening -E. C' of K or less is considered an indication for intu#ation #ecause of the risk of poor protection of the airway from aspiration!

Pri.ary orders8 oxyen, monitorin -EC>, H sat, automatic ?& cuff or arterial line., ID access8 need two lare#ore -1

aue, 1R if possi#le 9 femoral $ein cortice with H lumens., run wide open with normal saline for acutely low ?&, may need to #e more restrained if pulmonary edema is a pro#lem! Coma cocktail if dianosis not known already8 thiamine 144 m ID,

narcan 1 m ID, flumaAenil 4!1 m ID -1 amp @)4% is no loner included in this cocktail #ecause of deleterious effects of hih

serum lucose on the in:ured #rain.! Initial in$estiations8 C?C, lytes, urea, creatinine, 0?>, lucose, ioniAed Ca, CM?,

troponin, I"=B&TT, EC>, porta#le C


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&atient sittin

Inspect the patient enerally for petechiae, a#normal skin tone, hair fallin out! Inspect the finer and toe nails for dystrophy,flame hemorrhaes, leukonychia, inspected the palm for erythema and @upuytren+s contracture! Look in the nose and mouth

for #leedin, petechiae, masses! &alpate the anterior and posterior trianles of the neck, the supra and infra cla$icular areas,

and the axillae for lymph nodes! &alpate the thyroid while standin #ehind the patient, ask her to swallow! Chest 9 from

#ehind the patient, inspect the skin! &ercuss the lun fields for effusions and consolidations, auscultate the lun fields! &ercussand auscultate the anterior lun fields! Listen o$er the aortic -riht upper sternal #order Hnd IC' 9 systolic O stenosis, diastolic

O reuritation, continuous O ?T shunt, riht or left., pulmonary -left upper sternal #order H

nd

IC' 9 systolic O 0'@, pulmonaryflow, continuous O ductus, L?T shunt., tricuspid -left lower sternal #order ) th IC' 9 systolic O reuritation !!! 'till+s murmur,

diastolic O stenosis. and mitral -apex )th IC' and midcla$icular line 9 systolic O prolapse, reuritation diastolic O stenosis.areas!

&atient lyin supine

Compress the sternum and ri#cae for pain -seen in multiple myeloma.! Inspect the a#domen! 0uscultate for #owel sounds!

&alpate for enlarement of the spleen and li$er! &ercuss the li$er! &alpate the roin for lymph nodes! "ote8 a$oid rectal exam

as this trauma may cause #leedin!

Most liely diagnosis8 idiopathic throm#ocytopenic purpura -IT&., also called immunoloic throm#ocytopenic purpura or

%edhof+s disease!

%our *indings on history 'hich 'ould hel( to con*ir. the diagnosis8 1! =emittinrelapsin course, H! Mild fe$ers, 3!'plenic discomfort due to mild enlarement, R! ?leedin after low doses of "'0I@!

%our investigations8 ?lood smear, I"=B&TT -for hemophilia., serum ureaBcreatinine -for hemolyticuremic syndrome., serum

plateletassociated I> -for IT&.!

?$ 4 year old .an (resents to the 2.ergency -e(art.ent 'ith ! hours su(ra(ubic disco.*ort and inability to

urinate$ Catheteri6ation yields !00 cc urine$ Tae a history$ B) 5hat is the .ost liely cause o* this .an’s (roble.

Give three other (ossible diagnoses$ 5hat *our investigations 'ould you order

+istory8 name, ae, occupation! ;istory of suprapu#ic pain and ina#ility to urinate! ;istory of pain on urination, frank #lood

in the urine, color of urine, difficulty initiatin or maintainin urinary stream, fe$er, renal pain, roin pain! &re$ious renal colicB

dianosed prostate hypertrophy, prostate cancer, prostatism, nephrolithiasis, TIsF Malinant symptoms8 niht sweats, weiht

loss, fatiue! Medications, drusBalcohol, smokin, past medical history, past surical history, history of pel$ic radiation,T=&, family history, re$iew of systems!

Most liely diagnosis8 #enin prostatic hyperplasia!

Other (ossible diagnoses8 TI, prostatitis, prostate cancer!

our in$estiations8 ureaBcreatinine, urinalysis, prostate specific antien -&'0., renal ultrasound!

Treat.ent8 watchful waitin -)4* resol$e spontaneously., medical -alphaadreneric antaonists 9 TeraAosin, doxaAosin,

tamsulosin )alphareductase inhi#itors 9 finasteride., surery -T=& $s! open prostatectomy., minimally in$asi$e -stents,

microwa$e therapy, laser a#lation, cryotherapy, ;I, T"0.!

"$ 4 .onth old child 'ho 9ust had a sei6ure$ Tae a history *ro. the .other in the 2.ergency -e(art.ent$ %indings)

short sei6ure 'ith T 3"$D C$ Never had sei6ures in the (ast$ -evelo(.entally nor.al$ B) 5hat is the .ost lielydiagnosis 5hat 'ould you tell the .other about any (ossible recurrence 5hat advice do you give i* the child has

another sei6ure

+istory8 "ame, ae! @escri#e seiAure duration, what #ody parts affected and in what order, premonitory sins, postictal state

-decrease in le$el of consciousness, headache, sensory phenomena.! &re$ious seiAureF 0sk a#out precedin trauma or illness

or medications taken, the child+s temperature at the time of the seiAure! Meninitis sins, neuroloical! ;istory of pro#lemsdurin the prenancy and #irth! @e$elopmental history! Child+s medical history, surical history, medications, alleries!

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Selected -evelo(.ental Milestones

S(eech months

1H months

HR months

H3 years

initiates sounds, eye contact

H words #eyond mama and dada

H3 word phrases

short sentences

Gross .otor months

( months

1H months

1) months

roll o$er

stand

cruise

walk %ine .otor 1H months

HR months pincer raspturns paes in a #ook

Social months

( monthsH years

) years

straner anxiety

separation anxietysays 5no6

prints name

Most liely diagnosis8 fe#rile seiAure -fe#rile seiAures usually months to years, associated with initial rapid rise in

temperature, no neuroloic a#normalitiesBe$idence of C"' infectionBinflammation #efore or after, no history of nonfe#rile

seiAures, most common eneraliAed tonicclonic, 1) minutes duration, no recurrence in HR hours, atypical may show focaloriinBJ 1) minutesBJ 1BHR hoursBtransient neuroloic defect.!

Prognosis8 after a sinle fe#rile seiAure )* will ne$er ha$e another seiAure! 34* will ha$e further fe#rile seiAures, 3* willo on to ha$e seiAures without fe$er and H* will de$elop lifelon epilepsy!

Manage.ent8 find source of fe$er, Tylenol -antipyretics., L& to rule out meninitis if sins of meninitis, counselin and

reassurance to patient and parents if fe#rile seiAures!

Treat.ent o* recurrence8 control fe$er with antipyretics -Tylenol., tepid #ath, fluids for comfort only and use 0ti$an

-loraAepam. 1 m 'LB& -or diaAepam )14 m &=. if a seiAure occurs at home! Turn patient onto hisBher side, do not force

o#:ects or finers into mouth! ?rin to E= if seiAure does not stop within fifteen minutes! 'eiAures do not cause mental

impairment unless they are proloned -J 34 min., althouh seiAures can #e a symptom of #rain damae! &atient should #ein$estiated with CT head and EE>! &rophylactic anticon$ulsant therapy is a consideration with repeated seiAures!

!0$ 4? year old .an 'ith di**iculty s'allo'ing$ Tae a history$ %indings) thro's u( a*ter eating$ Can s'allo' liEuids

only$ 5eight loss and *atigue$ S.oer$ B) F8ray o* bariu. s'allo' sho'ing narro'ing o* contrast at TD84) describe

the abnor.ality$ 5hat is the liely diagnosis 5hat investigation 'ould con*ir. the diagnosis 5hat *urther

investigations 'ould you order

+istory8 -@ysphaia O difficulty swallowin. onset, chronoloy, description of pro#lem, ara$atin and relie$in factors! Isthe difficulty transferrin food from mouth to esophaus suestin oropharyneal dysphaia with food ettin stuck

immediately after swallowin often with nasal reuritationF %ith esophaeal dysphaia food seems to #e stuck further down!

Is the pro#lem worse with solids -suests mechanical o#struction., or liquids -suests neuromuscular dysfunction, often can+t

swallow either solids or liquids.! Is there a sensation of a lump in the throatF -lo#us hystericus O transitory sensation of alump in the throat related to anxiety.! &roression from solid swallowin difficulty to difficulty swallowin #oth solids and

liquids suests proressi$e o#struction such as from a worsenin stricture or rowin tumor! The com#ination of intermittent

o#struction and chest pain suests esophaeal spasm! 0sk a#out peptic ulcer, reflux, hiatus hernia, weiht loss, niht sweats,

fatiue, hematemesis, #lack stools, pain! Medications, drusBalcohol, alleries, smokin, past medical history, family history,re$iew of systems!

Oro(haryngeal8 "euroloical → cortical → pseudo#ul#ar palsy -M" lesion. due to #ilateral stroke #ul#ar → ischemia

-stroke. syrino#ul#ia tumor -LM". peripheral → polio 0L'! Muscular → M@ cricopharyneal incoordination -failure of

E' to relax with swallowin., sometimes seen with >E=@ Senker+s di$erticulum!

2so(hageal8 solid food only → mechanical o#struction → intermittent O lower esophaeal rinBwe# proressi$e → heart#urn

O peptic ulcer ae J )4 O carcinoma! 'olid or liquid food→ neuromuscular disorder → intermittent O diffuse esophaeal

spasm proressi$e → reflux O scleroderma respiratory symptoms O achalasia!

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, T';, renal B'!

Initial Manage.ent8 1! 'mokin cessation! H! 0lcohol restriction to low risk drinkin uidelines! 3! 'alt restriction -max! (4

134 mmol 9 32 per day.! R! 'aturated fat intake reduction! )! %eiht reduction if ?MI J H) -at least R!) k.! ! =eular

aero#ic exercise -)44 min, 3Rx per week.!

!$ ! year old *e.ale 'ith bloody diarrhea$ Tae a history$ %indings) ,bdo.inal cra.(ing$ Si7 'atery stools in the

(ast *our hours containing .aroon colored blood$ %eels di66y and 'ea$ No (revious history o* diarrhea (reviously

'ell$ B) 5hat t'o *indings on history indicate the seriousness o* the (roble. Give three (ossible diagnoses$ Give *our

investigations a((ro(riate to this situation$

+istory8 name, ae, occupation! nset, duration, frequency, of diarrhea! 0ppearance of stools8 how well formed, is #lood on

-analBrectal laceration. or admixed with stools, is #lood #riht red -lower tract #leed. or dark #rown#lack -upper tract #leed,

e!! stomach.! &ain with #owel mo$ements, a#dominal pain or cramps with location, radiation, precipitatin factors andalle$iatin factors, quality, se$erity, timin with respect to defecation, as #loatin! ;eart #urn, peptic ulcer, reflux, hiatus

hernia! Extraintestinal manifestations of inflammatory #owel disease8 ask a#out iritis, arthritis, mouth ulcers, anal ulcers, skin

lesions, kidney stones! Infectious diarrhea8 inquire a#out fe$er, nausea, $omitin, weiht loss, fatiue! =ecent tra$el,

consumption of unusual foods or foods which may ha$e #een contaminated! =ecent exposure to anti#iotics! amily mem#erssick at home! &el$ic pain, $ainal dischare, $ainal #leedin! &ast medical history, medications -especially "'0I@s,

laxati$es, anti#iotics., family history of Crohn+s, ulcerati$e colitis, familial polyposis, re$iew of systems!

T'o *indings 'hich indicate the seriousness o* the (roble.8 patient feels diAAy and weak!

Three (ossible diagnoses8 astroenteritis, #leedin peptic ulcer, inflammatory #owel disease!

%our investigations8 C?C with differential, stool for o$a 7 parasites with culture 7 sensiti$ities, Clostridium difficile toxin!Endoscopy -#ut a#o$e first.! Type and cross for R units &=?Cs!

!""4

!3$ Middle aged 'o.an 'ith systolic e9ection .ur.ur radiating into the carotids$ Per*or. (hysical e7a.$

The physical exam for a patient with a heart murmur is a cardiopulmonary exam!

&atient in sittin position8 take $itals

Inspect for surical scars, trauma, #ony a#normalities, cyanosis, arcus senilis in the eyes -sin of hih cholesterol., #ulin

$eins in the upper chest -'DC syndrome., nicotine stains on finers, clu##in, flame hemorrhae on nails, o#esity, work of #reathin, intercostal indrawin, symmetric chest mo$ement, $isi#le apex #eat!

&alpate the apex, note whether it is laterally displaced -lateral to the midcla$icular line. and feel for thrill or hea$e, feel radial pluses #ilaterally!

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&ercuss the lun fields anteriorly and posteriorly!

0uscultate the lun fields anteriorly and posteriorly, always e$aluate heart sounds #efore murmur! irst listen for '1 and 'H,then look for '3 and 'R and any other unusual heart sounds! Listen o$er the aortic -riht upper sternal #order H

nd IC' 9 systolic

O stenosis, diastolic O reuritation, continuous O ?T shunt, riht or left., (ul.onary -left upper sternal #order Hnd IC' 9

systolic O 0'@, pulmonary flow, continuous O ductus, L?T shunt., tricus(id -left lower sternal #order )th IC' 9 systolic O

reuritation !!! 'till+s murmur, diastolic O stenosis. and .itral -apex )th IC' and midcla$icular line 9 systolic O prolapse,reuritation diastolic O stenosis. areas as well as o$er the riht cla$icle, and #oth carotids! Listen for ru#! To #rin out an

aortic murmur -typically aortic reuritation., ask patient to lean forward, exhale and stop #reathin while you listen o$er theaortic area! To #rin out a mitral murmur, ask patient to lie supine and roll partly onto the left side while you listen o$er the

apex! In eneral, murmurs are accentuated #y increasin the dynamicity of the heart with mild exercise, such as askin the patient to walk up a fliht of stairs!

Murmurs are descri#ed in terms of where they are heard loudest, where the sound radiates, whether it occurs in systole or

diastole, the pitch -e!! hih, low., quality -e!! harsh, #lowin, musical., contour -e!! crescendo, decrescendo or plateau. andits loudness raded out of six -e!! IIBDI.! The murmur of aortic stenosis is loudest o$er the aortic area, radiates to the cla$icle

or carotids, occurs in systole, has medium or hih pitch, is harsh and crescendodecrescendo! 0 mitral reuritation murmur #y

contrast, is loudest o$er the apex, also occurs in systole, radiates to the axilla, is medium to hih in pitch, #lowin and plateau!

Innocent murmurs are 3B in intensity, peak early in systole, stop lon #efore 'H, are heard #est at the #ase of the heart -aortic

and pulmonary areas., are not associated with clicks or hea$es, and EC> and CI M'B"euro &sycholoic

&neumonia wB pleuritis

&neumothorax

&E

&ulmonary hypertension

Esophaeal reflux

lcer

0rthritis

Chondritis

=i# fractures

;erpes Soster

0nxiety

&anic

+istory *or chest (ain8 descri#e the pain, location, radiation, quality, time of onset, duration, intensity, circumstances under

which it occurs, ara$atin and relie$in factors, associated symptoms such as nausea, shortness of #reath, diAAiness,

diaphoresis, dependent edema! Le pain! =espiratory symptoms8 couh, sputum, fe$er, hemoptysis! >I symptoms8 heart#urn,dysphaia! &re$ious episodes, chronoloy of these! ;istory of trauma, asthma, #ronchitis, C&@, pneumothorax, recent $iral

illness and pre$ious chicken pox -;erpes Soster can cause chest pain., astritis, peptic ulcer, reflux! =isk factors for heart and

lun disease8 smokin, hypertension, hyperlipidemia! &ast medical history, especially dia#etes, heart disease includin pericarditis, lun disease, >I pro#lems, surical history, and family history! Medications, dru use, smokin, alleries, re$iew

of systems!

Physical e7a.8 Cardiopulmonary exam as in question P13!

Investigations8 C!

1H


13/56

Treat.ent8 i$en a normal C with a chest wall #ruise as e$idence of trauma send patient home, recommend non

prescription pain medication -Tylenol andBor i#uprofen. and ad$ise that the pain should su#side radually! 'ince the patient is

at risk #ecause of his ae roup and male ender, explain the symptoms of myocardial infarct -MI. and ad$ise to returnimmediately if these occur!

!D$ Houng .an 'ith recent onset bac (ain and li.($ Tae history and (hysical$

, di**erential *or lo' bac (ain is8

1! @eenerati$e -(4* of all #ack pain.Mechanical -deenerati$e, facet :oint pain, muscle strainBspasm.

'pinal stenosis -conenital, osteophyte, central disc.&eripheral ner$e compression -disc herniation or rupture.

H! Cauda Equina syndrome

3! "eoplastic8 primary or metastatic

R! Trauma8 fracture -compression, distraction, translation, rotation.)! 'pondyloarthropathies8 e!! ankylosin spondylitis

! @iscitisBosteomyelitis

2! =eferred8 aorta -a#dominal aortic aneurysm., renal -pyelonephritis., ureter -nephrolithiasis., pancreas -pancreatitis.

K! Malinerin

?ecause discoenic and stenotic radiculopathy which ha$e not impro$ed o$er at least R weeks may #e treata#le surically, the

priority of a history and physical for #ack pain is to differentiate radiculopathy from other causes and to identify the ner$e root!

The most common disk herniation is a posterolateral LR), which compresses the L) root! The herniation will also compress

the LR root if the herniation is far lateral and the '1 root if it is more medial -central.! The second most common herniation is a

posterolateral L)'1, which compresses the '1 root! In the thoracic and lum#ar spine, the ner$e roots exit #elow the pedicles

of the $erte#ra of the same num#er, while in the neck the ner$e root exits a#o$e the pedicle of the $erte#ra of the same num#er!L) compression produces radiation from #uttock to lateral calf, lateral calf pain, num#ness of the medial dorsum of foot

-includin we# of reat toe., and ankle dorsiflexion weakness, '1 compression produces radiation posteriorly down le to heel,

posterior calf pain, lateral foot num#ness and ankle plantar flexion weakness -with decreased ankle :erk.!

+istory8 =ed flas -?0C&0I". → ?8 #owel or #ladder dysfunction 08 anesthesia -saddle. C8 constitutional

symptomsBmalinancy 8 chronic disease &8 paresthesias 08 ae J )4 I8 ID dru user "8 neuromotor deficits!

@escri#e the pain, location, radiation -L) radiculopathy causes radiation from #uttock to lateral calf, '1 radiates posteriorly

down le to heel., quality, duration, frequency, intensity, circumstances under which it occurs, ara$atin and relie$infactors! nset and chronoloy, pre$ious episodes! &re$ious in$estiations, treatment!

&ain worse lyin down and #ilateral le weakness suests spinal stenosis or ankylosin spondylitis! 'pinal stenosis is

characteriAed #y worsenin of symptoms with standin and walkin, with relief on #endin and settin -a typical history of

leanin on and #endin o$er the shoppin cart for relief of pain while shoppin is suesti$e of spinal stenosis.! 0nkylosin

spondylitis is characteriAed #y mornin stiffness relie$ed #y acti$ity! &ain worse in #ack than in #uttock or le suestsmechanical #ack pain! &ain worse in #uttock or le than in #ack suests radiculopathy! &redominatin symptoms of stiffness

are suesti$e of ankylosin spondylitis! ?ack pain is recurrin and tends to #e nocturnal! Mornin stiffness impro$es o$er

the day! May #e associated with weiht loss, fe$er, fatiue, anemia! ocus on :oint symptoms -typically lare :oints., u$eitis

-occurs in one third of cases., and family history!

;as the patient had a fe$er, weiht loss, niht sweats -sins of cancer., urinary tract infection -sin of urinary retention., :oint

pain, u$eitis -inflammation of the u$eal tract8 iris, ciliary #ody, and choroids→ sin of ankylosin spondylitis.F 0sk a#outeffect on acti$ities of daily li$in, functional limitations! 0ssociated num#ness, weakness! 0re the symptoms impro$in orworseninF %hat are the patient+s conclusions a#out the pain and expectations of the physicianF Medications, drus and

alcohol, smokin, past medical history, family history, re$iew of systems!

Cauda eEuina syndro.e8 Inquiry into #owel, #ladder, and sexual function to re$eal this rare syndrome is o#liatory and asource of frequent false alarms! ?ecause these functions may not reco$er once lost, cauda equina syndrome due to a surically

treata#le lesion is a surical priority if the time course is su#acute and an emerency if the loss of function is acute! The

syndrome consists of saddle anesthesia -perineal num#ness., lax anus, impotence, urinary retention and #owel incontinence!

"ote that this com#ination of sins is due to preser$ation of sympathetic tone with loss of parasympathetic tone! 'ympathetic

13


14/56

tone is preser$ed #ecause it is carried extraspinally, while parasympathetic sinals are carried $ia the inferior spine and ner$e

roots! "ote that #owel contraction and penile erection are parasympathetically dri$en!

Physical e7a.8

'tandin

0ssess ait, posture, rane of motion includin rotation, lateral and forward flexion, extension -pain worse on forward flexion

and relief on extension suest discoenic pain, pain worse on extension suests facet :oint pain.! or ankylosin spondylitis8%riht'cho#er test positi$e when distance #etween the lum#rosacral :unction and a point 14 cm a#o$e -identified #y

palpation on the erect spine., distract #y less than ) cm on full forward flexion of the spine! Modified 'cho#er -i!e! detection of decreased forward flexion of lum#ar spine.! Lateral flexion is impaired when the hand mo$es downward #y less than 3 cm on

the ipsilateral thih! Look for scoliosis on standin -shoulder heihts equalF. and forward flexion check for ri# hump! Inspect

#ack for spina #ifida! &alpate for tender areas especially sacroiliac :oints, compress pel$is to elicit pain of sacroiliitis -hallmark

of ankylosin spondylitis.! Muscle tone, percuss costo$erte#ral anles for renal pain! ;a$e patient walk on toes, heels! 0sk patient to stand on one foot at a time and push up into tiptoe for ankle plantar flexor strenth -'1.!

'ittin

nee :erks -LR. with quadriceps exposed, watch contraction! 0nkle :erks -'1., rapidly dorsiflex each foot to test for clonus!

?a#inski! Compare calf irths for wastin #y measurin calf circumference 14 cm #elow ti#ial tu#erosity! Test power of

quadriceps, hamstrins, psoas -raise knee up aainst resistance., ankle dorsiflexors! 0sk patient to straihten #oth les and

compare this position to the deree of forward flexion the patient was a#le to achie$e on standin rane of motion! 'uspicionof malinerin is raised if the patient claims to #e una#le to #end from a standin position #ut is a#le to extend the knees from

a sittin position!

'upine

eel for lymph nodes at neck, cla$icle, axillae, roin! Test hip extensors -patient presses le into #ed while you try to raise it.!

'ensation in #oth les8 liht touch, pin prick 9 compare medial dorsum of foot -L). with lateral foot -'1. and lateral calf -L).

with posterior calf -'1.! Di#ration and position sense in #i toes! 'traiht le raise8 raise patient+s heel on #ed as far as patientwill allow, note anle, note whether this reproduced the patient+s ipsilateral or contralateral radicular pain! ?owstrin test8 flex

hip to (4 derees, extend knee to the point of pain and press on the hamstrin tendon, which is medial, note reproduction of

pain! &eripheral $ascular exam8 inspect for $enous stasis or arterial insufficiency ulcers, check femoral pulses and auscultate

for femoral #ruits, feel popliteal, dorsalis pedis and ti#ialis posterior pulses!

!4$ D year old .an 'ishes to re*ill a (rescri(tion o* %iorinal *or tension headache$ Manage$

+istory8 description of headache pain, location -onesided $s! #ilateralBocciput$ertex→ @o you feel pain on one or #oth

sidesF If onesided, is it always the same sideF If present on #oth sides, did the pain start on one sideF Is it usually maximal on

one sideF., quality -pulsatile $s! nonthro##in→ %hat kind of pain is it 9 tihtenin, pressin, thro##in, poundin, pulsatin,

#urnin, etcF @o different types of pain occur at different times in any one attackF If so, what typesF., intensity, duration -atleast 2H hours in miraine, if not treated., onset includin time of day -mornin headache associated with raised intracranial

pressure., pre$ious episodes, ara$atinBrelie$in factors -e!! couhin and strainin worsen headache in raised IC& and

chocolate or cheese can trier miraines., associated symptoms -aura, nausea, $omitin, photopho#ia 9 liht, phonopho#ia 9

sound, osmopho#ia 9 odors, nuchal riidity, weakness, num#ness, $isual distur#ances., medical history, medication history-when was this prescri#ed, do you ha$e the empty #ottle, has it #een prescri#ed #eforeF., current meds, alleries, family

history, su#stance a#use inquiry, smokin, alleries, mood, stress, anxiety inquiry! =e$iew of systems!

Red *lags *or headaches8 must rule out headaches resultin from meninitis, trauma -su#arachnoid hemorrhae, epiduralhemorrhae., tumor, temporal arteritis! ;istory8 new onset, headache worse at niht, headache wakes patient at niht, fe$er,

neck stiffness, seiAures, trauma, chanes in LCB#eha$ior, $omitin, se$ere, $ery younBold patients! &hysical exam8 fundi

a#normal, erniB?rudAinski sins -meninitis., focal neuroloical findins!

>i$en #enin history with no suspicion of raised IC& or focal deficits and a description of headache consistent with the

common tension headache, a full neuroloical examination is not indicated! 'uest to the examiner that you would perform a

#rief neuroloical screenin exam! /ou will #e told to mo$e on!

1R


15/56

Treat.ent8 Explain that iorinal is a com#ination preparation of #ar#iturate -#utal#ital., caffeine and 0'0 which is properly

used only for the relief of occasional tension headaches! It is ha#itformin, can precipitate a withdrawal syndrome includin

aitation, delirium and seiAures and has additi$e sedati$e effects with other C"' depressants! The fact that this patient hasconsumed an entire prescription in four days suests o$eruse due to dependence! ;e may also ha$e analesic headache

syndrome in which inappropriately used analesics actually cause headaches! 'uest a dru holiday with weanin from

caffeine and alcohol, proper sleep hyiene, diet, exercise and stress manaement! Chronic headache may also #e a symptom of

depression or anxiety, arrane follow up to e$aluate for these if the patient does not impro$e!

!#$ 2lderly 'o.an in hos(ital (ost8o( day D o* total hi( re(lace.ent$ ,cute chest (ain& tachycardia& tachy(nea&shortness o* breath$ Manage$

5orry about8 Lifethreatenin causes of acute chest pain8 MI, &E, pneumothorax and tension pneumothorax, aortic dissection!

ther causes anina, astritis, reflux, peptic ulcer, pericarditis, herpes Aoster, musculoskeletal!

-i**erential -iagnosis *or Chest Pain

Cardiac Non8Cardiac

0nina

MI

&ericarditisMyocarditis

@issectin aorta

&ulmonary >I M'B"euro &sycholoic

&neumonia wB pleuritis&neumothorax

&E

&ulmonary hypertension

Esophaeal refluxlcer

0rthritisChondritis

=i# fractures

;erpes Soster

0nxiety&anic

+istory8 =apid cardiopulmonary history includin any history of hih #lood pressure, heart pro#lems, smokin, C&@!

Physical e7a.8 Is a cardiopulmonary exam as in question P13 a#o$e with additional attention to risk factors for postopcomplications -i!e! inacti$ityBdecreased mo#ility resultin in @DTB&E.!

+o.an’s sign8 pain in the calf on dorsiflexion of the foot 9 indicates throm#ophle#itis! Check that trachea is midline! Inspect

surical wound! Is the patient on @DT prophylaxis or anticoaulationF

Treat.ent8 =aise head of #ed! >i$e oxyen LBmin #y mask! Monitor oxyen saturation! rder stat C?C, lytes, lucose,

I"=B&TT, serial CM? and Troponin, 0?>, C! >i$e chewa#le 0'0 143H) m immediately! 'ecure ID access,

#olus ID lasix R4 m, push if fluid o$erload is suspected, and $entolin if wheeAes are heard, i$e su#linual nitro spray or 4!3m su#linual nitro if #lood pressure is adequate and 1 m morphine ID! =epeat nitro q)min x 3! May require additional

morphine and nitro! =epeat CM? and Troponin qKh x 3!

2CG8 if EC> shows sinificant 'T ele$ation -more than one millimeter in two anatomically consecuti$e leads., or a new left #undle #ranch #lock, then the patient is ha$in an MI! rder stat Cardioloy consult for possi#le lytic therapy or cardiac

catheteriAation! If less se$ere sins of ischemia are present -flipped T wa$es, 'T depression., follow with repeat EC>s until

resol$ed!

S!B3T38 This classic pattern -wide 'wa$e in lead I, Qwa$es in lead III, T wa$e in$ersion in lead III. with riht axis de$iation

and =??? are sins of riht heart strain seen in massi$e &E!

,8a gradient8 0n ele$ated 0a -0l$eolar pHarterial pH. radient is a sin of pulmonary em#olus #ut also occurs in anycondition in which there is a $entilationperfusion mismatch -e!! pneumonia, pulmonary edema, C&@.! It is determined

from the 0?>8

0a O 213 -iH. 9 1!H) -&aCH. 9 &aHUnormal8 1H in child → H4 in 24 year oldV

"ote that the inspired oxyen fraction -iH. is not known unless the patient is on room air, a $entimask or mechanically$entilated! This is #ecause the patient #reathes in a proportion of room air which mixes with the oxyen deli$ered #y face

mask or nasal prons there#y dilutin it #y an unknown amount! =ouhly, howe$er, HLBmin i$es H* iH, 3LO34*,

RLO3)*, and LOR4*! R4* is considered the maximum inspired oxyen o#taina#le without a hih flow mask such as a

$entimask!

,1G nor.al values8 p; 2!3)2!R), pH K4144 mm;, #icar#onate HR, pCH R4

1)


16/56

Indications *or intubation8 0n 0?> showin poor pH -in the 4s, or if less then K4 on hih inspired H concentrations.,

ele$ated pCH -reater than K4., acidemia, or >C' K -not a#le to protect airway. may indicate need for intu#ation if these are

not quickly correcta#le! Consult IC!

CFR signs o* P28 wedeshaped infiltrate -;ampton+s hump. or oliemic area, unilateral effusion, raised hemidiaphram! 0

normal C0 year old 'o.an& a((ears sad& reEuests slee(ing (ills$ Manage$

+istory8 "ame, ae, occupation! 'ocial situation! 'tressful life e$ents! @epression commonly presents with sleep distur#ance

therefore screen and treat for depression as in question PR a#o$e! This should #e in addition to a sleep history! Medications,

alleries, drusBsmokinBalcohol, past medicalBsurical history, family history, re$iew of systems!

1


17/56

Slee( history8 usual requirements, chronoloy of sleep pro#lems, stressor, sleep hyiene -when, where, reularity, shifts at

work, quiet, late, exercise, meals, alcohol, caffeine, prescription and nonprescription remedies, drus and medications., sleeplatency -time to fall asleep., nocturnal awakenin, early mornin wakenin, daytime somnolence, somnolence while dri$in,

workin or durin con$ersation!

Pro(er slee( hygiene8 reular #ed and wake times, a$oid daytime naps, reular exercise #ut not late in the e$enin, do not usethe #ed for readin, TD, paperwork, etc!, a$oid caffeine, alcohol, smokin!

0$ 40 year old 'o.an 'ith .ulti(le (ains investigated by several other doctors& all lab tests nor.al$ Manage$

+istory o* .ulti(le (ains8 should address the differential for multiple pains!

-i**erential *or .ulti(le (ains)

-e(ression 'ith so.ati6ation8 ma:or depression presents with a somatic complaint commonly headache, stomach pains,sleep distur#ance, eatin distur#ance, or #owel ha#it chanes! This is a frequent presentation of depression in the elderly!

Treat as in depression -see P1( a#o$e.!

So.ati6ation disorder8 multiple nonintentional complaints in multiple oran systems #einnin #efore ae 34 that occur o$er se$eral years, with treatment souht and sinificant impairment in functionin! @ianostic criteria8 at least K physical

symptoms that ha$e no oranic patholoy8 R pain symptoms at R different sites, H >I symptoms other than pain, 1 reproducti$e

or sexual symptom other than pain, 1 pseudoneuroloical symptom -e!! temporary #lindness.! Complications8 anxiety,

depression, unnecessary medications or surery! ften a misdianosis for an insidious illness so rule out all oranic illnesses-e!! M'.! Treatment8 counselin, psychotherapy, close followup, reassurance!

Conversion disorder8 psychic pertur#ation presents as one or two neuroloical complaints affectin $oluntary motor or

sensory function! &sycholoical factors thouht to #e etioloically related to the symptom as the initiation of symptoms is preceded #y conflicts or other stressors! 5 La belle indifference6 9 patient+s inappropriately ca$alier attitude towards a serious

symptom! Treatment8 anxiolytics -e!! loraAepam 1 m & qh., relaxation therapy, counselin, close followup!

Pain disorder8 e!! chronic posttraumatic or postsurical pain! &ain not fully accounted for #y current tissue in:ury,exacer#ated #y psychic factors and associated with functional impairment! Treatment8 amitriptyline H)2) m & q;'!

+y(ochondriasis8 exaeration or misinterpretation of normal sensory phenomena to the point of functional disa#ility!

E$idence does not support a physical disorder! 0ssociated with o#sessi$e fear of serious illness and doctor shoppin despite

reassurance! ?elief is not delusional as person acknowledes unrealistic interpretation! Treatment8 counselin, reassurance,close followup!

%ibro.yalgia8 also called fi#rositis and fi#romyositis! K4(4* of cases occur in middleaed females, may afflict )* of adultwomen, typically cardio$ascularly unfit, depressed, pre$iously normal life -onset often after car accident.! 0ssociated with

a#sent or decreased non=EM stae R sleep, patients wake from sleep feelin unrefreshed! Constant, achin, axial pain with

#ilateral tender points -not trier points, at which referred pain is triered due to myofaschial pain from o$eruse, e!! tennis

el#ow.! The disorder follows a waxin and wanin course ultimately without proression or resolution, and may #ecomedisa#lin! Characteristic reproduci#le tender points are located #ilaterally at lateral #order of sternum, sternocleidomastoid,

posterior neck, trapeAius, rhom#oids, o$er sacroiliac :oints, lateral thih, posterior and medial knee! &atient should ha$e ele$en

of the a#o$e eihteen tender points for a dianosis! Treatment8 amitriptyline H)2) m & q;'!

Chronic *atigue syndro.e8 similar to fi#romyalia #ut fatiue is the dominant feature and pain and tender points may #e less

prominent or a#sent! Treatment8 amitriptyline H)2) m & q;'!

%actitious disorder or .alingering8 actitious disorder in$ol$es misrepresentation of history and symptoms for the purposeof assumin the sick role with its inherent secondary ains -attention and sympathy, :ustification for inadequacies.!

Munchausen+s syndrome is the type of factitious disorder in which physical findins are faked #y contamination of la# tests or

inestion of inappropriate medication or su#stances! Typically the patient is a medical paraprofessional moti$ated #y hostility

toward the medical esta#lishment, e!! nurse takes coumadin to fake hemophilia! Malinerin is distinuished from factitiousdisorder #y a moti$ation for secondary ain other than the sick role, such as insurance #enefits! Treatment8 counselin!

+istory8 &ain description, location, duration, chronoloy, ara$atin and relie$in factors, are pains linked to one anotherF

12


18/56

So.ato*or. disorders screen8 ;ow has your health #een for most of your lifeF ;ow ha$e your pains affected your :o#,

social life, relationships, and your life enerallyF 0re you often unwell, how often do you $isit the doctorF @o you worry that

you ha$e a serious illnessF If a doctor tells you that there is nothin wron, how does that make you feelF @o you #elie$e himor herF

,ssociated sy.(to.s8 re$iew of systems, medications, alleries, smokin, alcohol, dru use, family history, depression

history as in PR a#o$e!

-iagnosis and treat.ent8 or nonspecific pains with depressi$e symptoms the patient most likely has depression withsomatiAation! Treat for depression as in PR!

!$ , young .an (resents to the 2.ergency -e(art.ent having t'isted his anle$ Manage$

+istory *or anle s(rain8 history of a plausi#le mechanism of in:ury in$ol$in sinificant in$ersion or e$ersion of the foot

with pain and swellin! Time of in:ury, onset of pain and swellin -may #e delayed., noises heard at time of in:ury! &re$iousankle or other in:uries! 0#ility to walk post in:ury -often preser$ed if liaments are not ruptured.! &ast medical history,

medications, alleries, family history!

Physical e7a.8 inspect for ross deformity, erythema, swellin, #ruisin! Check distal circulation, sensation, acti$e and passi$e rane of motion, palpate for tenderness at :oints! Examine the :oints a#o$e and #elow the affected :oint! Identify sites

of maximal tenderness! &oint tenderness o$er the area anterior -anterior talofi#ular liament., inferior -calcaneofi#ular

liament., or posterior -posterior talofi#ular liament. to the lateral malleolus are sins of lateral liamentous in:ury!

Tenderness o$er the area medial and inferior to the medial malleolus indicates deltoid -medial. liament in:ury!

Talar dra'er sign8 'ta#iliAe the ti#ia and pull forward on the heel, talar drawer sin is anterior mo$ement of the talus! >reater

than 3 mm anterior mo$ement may #e sinificant! 1 cm is sinificant and indicates anterior talofi#ular liament rupture!

Talar tilt8 'ta#iliAe the ti#ia, rasp the talus and tilt in in$ersion and e$ersion! Mo$ement #eyond the normal rane compared

with the opposite side is a positi$e talar tilt and indicates lateral calcaneofi#ular liament rupture if the tilt occurs in in$ersion

or medial -deltoid. liament rupture if the tilt occurs in e$ersion!

SEuee6e test8 &ain in the ankle on squeeAin the calf is a sin of ankle fracture!

Otta'a ,nle Rules8 for takin ankle series xrays -includes lateral and 0& ankle with mortis $iew.!


19/56

pressure., pre$ious episodes, ara$atinBrelie$in factors -e!! couhin and strainin worsen headache in raised IC& and

chocolate or cheese can trier miraines., associated symptoms -aura, nausea, $omitin, photopho#ia 9 liht, phonopho#ia 9

sound, osmopho#ia 9 odors, nuchal riidity, weakness, num#ness, $isual distur#ances.! 0 history of unilateral lancinatin painwith swellin and tenderness in the temporal area should prompt inquiry after symptoms of polymyalica rheumatica -&= 9

pain and stiffness in muscles of neck, shoulders, upper arms, hips, lower #ack and thihs → no weakness or atrophy →

increased E'=, anemia, normal C → responds to steroids immediately., which is related to temporal -iant cell. arteritis and

may #e a more systemic $ariant of the same underlyin disease! 'ymptoms of #oth &= and temporal arteritis include low radefe$er, malaise, anorexia, weiht loss, #ilateral proximal muscle weakness, achin and pain, as well as :oint inflammation! Naw

claudication, stroke and #lindness may occur due to $asculitic occlusion of arterial supply! 0sk a#out $isual chanes! Medicalhistory, medication history -when was this prescri#ed, do you ha$e the empty #ottle, has it #een prescri#ed #eforeF., current

medications, alleries, family history, su#stance a#use inquiry, smokin, alleries, mood, stress, anxiety inquiry! =e$iew ofsystems!

Investigations *or te.(oral arteritis8 C?C -mild anemia with increased %?C., E'= -reater than )4 mmBh, Unormal 34V., C

reacti$e proteins, li$er enAymes, temporal artery #iopsy, may add temporal artery anioram to uide #iopsy!

Treat.ent8 -in the a#sence of $isual symptoms. without waitin for #iopsy, start hih dose oral prednisone 4 m & @ until

symptoms su#side and E'= normal, then R4 m & @ for R weeks, then taper to )14 m & @ for H years -relapses

occur in )4* if treatment is terminated #efore H years.! Treatment does not alter #iopsy results if the sample is taken within Hweeks! Monitor E'= reularly! If $isual symptoms are present, or de$elop durin treatment, the patient is admitted and i$en

prednisolone 1444 m ID q1Hh for ) days!

>$ +I< (ositive .an$ ! 'ee o* shortness o* breath& cough& *atigue$ Per*or. a (hysical e7a.$ B) Give a di**erential

diagnosis *or a CFR sho'ing a *ine reticular (attern in the le*t lo'er lobe$ Manage$

Physical e7a.8 0 physical exam for query pneumonia consists of the cardiopulmonary exam as in question P 13 with

additional attention to the particular sins and symptoms of ;ID infection!

27a.ination *or lobar consolidation8 In eneral, pulmonary effusion decreases transmission of #reath and $ocal sounds to

the chest wall, while consolidation -seen in pneumonia. increases it! our maneu$ers #rin out the effect of increasedtransmission8 tactile *re.itus is increased transmission of palpa#le fremitus to the chest wall while the patient repeats

5ninetynine6, broncho(hony is enhanced transmission of spoken words such as 5ninetynine6, ego(hony is a chane from an

5ee6 to an 5ay6 sound o$er the affected area while the patient sustains an 5ee6 sound, and 'his(ered (ectoriloEuy is a marked

increase in audi#ility throuh the chest wall o$er the affected area while the patient whispers the words 5ninetynine6 or 5onetwothree6!

Signs o* consolidation8 increased tactile fremitus, percussion dullness, crackles, #ronchial #reath sounds, increased $oice

transmission -#ronchophony, eophony, whispered pectoriloquy.!

Signs o* +I< In*ection8 -and possi#le impendin 0I@'. check entire skin surface for aposi+s sarcoma, examine pharynx for

thrush or oral hairy leukoplakia -Epstein?arr $irusrelated epithelial proliferation causin raised white plaques on the sides of

the tonue., palpate neck, cla$icle, axillae, and roin for lymph nodes enlared #y non;odkin+s lymphoma! Examinea#domen for hepatic or splenic enlarement!

-i**erential diagnosis of unilateral lo#ar reticular pattern on C


20/56

D$ , day old in*ant has seru. bilirubin 0 .ol/L :re*$ Ma7 00 .ol/L;$ Tae a history *ro. the .other$ B) 5hat

are the (ossible causes *or this abnor.ality Give investigations and treat.ent$

)4* of term infants de$elop $isi#le :aundice -J K)1H4 WmolBL or ) mBdL.

Mother’s obstetrics history8 >T&0L -num#er of estations, term prenancies, premature #irths, a#ortions, li$e children.,

history of pre$ious prenancies includin neonatal :aundice, maternal medical history esp! li$er disease, illness durin prenancy esp! dia#etes -lare #irth weiht, preeclampsia., ru#ella -teratoenic., toxoplasmosis -from cats, infects fetal #rain.,

herpes -infects fetus, frequently fatal., CMD -damaes fetal li$er., teratoenic medications taken durin prenancy, dru andalcohol use, maternal #lood type, complications of present prenancy includin estational hypertension or dia#etes,

hyperBhypothyroid, hypercoaulation! amily history of neonatal :aundice, li$er pro#lems!

Ne'born history8 estational ae at #irth, caesarean, induction, rupture of mem#ranes artificial or proloned, fetal distress,

forceps or $acuum deli$ery, meconium, 0&>0=s, was resuscitation requiredF Initial #lood work, #reast feedinF ;ow often

and how well, color of 1st stool, color of urine, $omitin, neonate muscle tone, #eha$iors, fe$er, irrita#ility, lethary!

Causes o* neonatal 9aundice8 uncon:uated O physioloic neonatal :aundice = patholoic8 hemolytic → 0?=h

incompati#ility, neonatal sepsis, splenomealy, hereditary spherocytosis, >&@ etc! nonhemolytic → #reast milk :aundice,

#reakdown of cephalohematoma, polycythemia, sepsis, >il#erts, Criler"a::ar, hypothyroidism! Con:uated8 >I o#structionin fetus -increases enterohepatic circulation., #ile duct o#struction, druinduced and multiple other less common causes!

Investigations8 se #lood o#tained #y $enipuncture, not heal prick, as sludin of heel prick #lood in skin capillaries distortscell counts and concentrations! Measure direct -con:uated. and indirect -uncon:uated. #iliru#in, neonatal and maternal #loodtypes, Coom#+s test -see #elow., #lood smear, C?C with reticulocyte count! 'eptic workup, urinalysis, #lood cultures, C


21/56

+istory8 "ame, ae, occupation! ;istory of :aundice, hepatitis, forein tra$el, #lood transfusions, recreational ID dru use!

@ark urine, pale stool, a#dominal pain, fe$erBchills, decreased appetite, weiht loss, niht sweats, nausea and $omitin, pruritis, easy #ruisin, ynecomastia, hemorrhoids -from portal hypertension., alcohol use 7 C0>E questionnaire -see #elow.!

'exual history8 num#er of past and present partners, enders of same, sexually transmitted disease! Medications, dru use,

smokin, alleries, past medical history, family history, re$iew of systems!

C,G2 Euestionnaire8 Control 9 ha$e you tried to cut down on your alcoholF 0ner 9 ha$e you e$er felt anry when someone

suested you decrease your alcohol intakeF >uilty 9 ha$e you e$er felt uilty a#out your drinkinF Eye opener 9 do yousometimes ha$e a drink to et started in the morninF

Liver 2n6y.es8 ↑ 0'T 7 0LT are sensiti$e #ut nonspecific markers of hepatocellular damae → hepatitis -inflammation.

$ascular in:ury -ischemia.! 0'T J 0LT O alcoholic li$er disease 0LT J 0'T O $iral hepatitis! ↑ 0L& 7 ↑ >>T are markers

of cholestatic disease → intrinsic -toxic, infectious, inflammatory., systemic -sepsis, prenancy., infiltrati$e -tumor, fat,

lymphoma., mass lesions -stone, tumor, a#scess.! 0'TB0LT J H -0'T usually 344. → alcoholic li$er! 'erum transaminases

J 1444 due to 1. $iral hepatitis, H. drus, 3. passae of common #ile duct stone, R. hepatic ischemia!

-i**erential8 alcoholic li$er disease, $iral hepatitis, li$er malinancy -metastatic or primary.!

Investigations8 Diral seroloy -;ep 0, ?, C anti#ody and ? antien 9 presence of ? antien for J months indicates chronic

carrier state., >>T, 0'T, 0LT, 0lk&hos, L@;, #iliru#in, I"=B&TT, al#umin, lucose -cirrhosis., serum ceruloplasmin, serum

copper -%ilson+s disease., serum ferritin, total iron #indin capacity -TI?C, for hemochromatosis., 0"0, antismooth muscleanti#ody -autoimmune hepatitis, also called chronic acti$e hepatitis., a#dominal ultrasound, li$er #iopsy!

#$ !" year old *e.ale 'ith vaginal discharge$ Tae a history$ B) Give three (ossible diagnoses& 'hat investigations

'ould be hel(*ul

+istory8 "ame, ae, occupation, description of dischare, onset, chronoloy, pre$ious episodes, $olume, color, consistency,

odor, timin -related to mensesF.! 0ssociated symptoms8 pain includin a#dominal, #urnin, fe$er, itch, dyspareunia, dysuria,

urency, frequency, ara$atin and relie$in factors! 'exual history8 num#er of past and present partners, ender, type ofcontraception -condoms., possi#ility of prenancy, past history of sexually transmitted disease! #stetricsBynecoloy history8

->T&0L. prenancies, a#ortionsBmiscarriaes, #irths, pap smears -normalF., menstrual pattern! Medications -especially

anti#iotics., oral contracepti$es, other dru use, alleries! &ast medical history includin dia#etes! amily history, re$iew of

systems!

Causes o* discharge8 &hysioloical8 normal midcycle dischare, increased estroen states! Infectious8 candidiasis, #acterial

$ainosis ->ardnerella $ainalis., trichomonas infection, chlamydia, onorrhea -"TE8 onorrhea and chlamydia can cause

cer$icitis, &I@ and urethritis, #ut do not cause $ainitis 9 #ut Toronto "otes includes them in the differential for $ainaldischare., #artholinitis or ?artholin a#scess, &I@! "eoplastic8 $ainal intraepithelial neoplasia -D0I"., $ainal squamous cell

carcinoma, in$asi$e cer$ical carcinoma, fallopian tu#e carcinoma! ther8 allericBirritati$e $ainitis, forein #ody, atrophic

$ainitis, entero$ainal fistulae!

Investigations8 speculum exam, swa# and culture, saline slide microscopy and ; whiff test -add ; to $ainal secretions

on a slide.! These i$e results as follows8

Candidiasis8 inflamed appearance, lumpy white dischare, spores and pseudohyphae seen under microscope! Treatment8miconaAole $ainal suppository!

1acterial vaginosis8 noninflamed, thin ray secretions, clue cells under microscope -epithelial cells with o#scured #ordersdue to adherence of #acteria., fishy odor on ; test! Treatment8 metronidaAole )44m & ?I@ x 2 days -in prenancy use0moxicillin )44m TI@ x 2 days.!

Tricho.onas8 inflammations, frothy yellowrayreen dischare, motile trichomonads seen under microscope! Treatment8

metronidaAole H x 1 or )44m & ?I@ x 2 days -in prenancy use ClotrimaAole $ainal suppositories.!

?$ 40 year old .an 'ith .icrosco(ic he.aturia on routine urinalysis$ Tae a history$ B) Give a di**erential diagnosis&

'hat investigations 'ould be hel(*ul

H1


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23/56

muscles -frown, raise eye#rows, show teeth, protrude tonue., facial sensation, a, ;orner+s triad -ptosis, anhidrosis, miosis

on side of sympathetic palsyF., sternocleidomastoid and trapeAius power! Cere#ellar testin8 finernose, heelshin,

dysdiadocokinesis, ait, =hom#er, &ronator drift!

Nec 8 inspect for lesions, asymmetry, muscle wastin, especially sternocleidomastoids, palpate for nodes, masses, palpate

dorsal $erte#ral spines, rane of motion!

Shoulders& ar.s& hands8 inspect for symmetry, wastin, fasciculations, skin lesions! &ower8 Test deltoids -C)., #iceps -C.,

triceps and wrist extension -C2., hand intrinsics -CK.! "ote that each muscle roup actually has mixed ner$e root inner$ation,i!e! deltoids and #iceps -C),., triceps -C,2,K., wrist extension -C,2., hand intrinsics -CK,T1.! 'ympathetic outflow occurs at

CK, T1! 'ensation8 check pinprick, $i#ration, liht touch o$er the shoulder -C)., thum# -C., index and middle finer -C2.,rin and little finer -CK.! @eep tendon reflexes at #iceps, triceps, #rachioradialis, ;offman+s sin -the ?a#inski of the upper

lim#8 flick relaxed index finer dorsally, thum# a#ducts for positi$e test.! ToneBriidity8 check for increased tone #y rapid

supination and rapid extension of el#ow!

Lateral Cervical -isc Syndro.e

C>8D CD84 C48# C#8T!

Root involved

Motor

Re*le7

Sensory

C)

@eltoid'upraspinatus

?iceps

'upinator

'houlder

C

?iceps

?iceps

Thum#

C2

Triceps

Triceps

Middle finer

CK

@iital flexorsIntrinsics

iner :erk

=in finer Little finer

Peri(heral nerves8 Check two point discrimination at each finertip! To determine peripheral ner$e damae8 Median ner$eterritory is the palmar surface of the thum#, and the palmar surface and dorsal tips of the index, middle and thenar side of the

rin finers! 'ensation to the ulnar side of the hand is the ulnar ner$e, and the dorsal surface of the thenar side of the hand is

radial ner$e inner$ated! The median ner$e also inner$ates most muscles of the thenar eminence, and the 1st and Hnd lum#ricals!

The thum# is weak in a#duction at (4 derees to the plane of the hand in median ner$e dysfunction! Tinel+s sin8 tappin the palmar surface of the wrist elicits shootin paresthesia in median distri#ution! &halen+s sin8 maximally flexin #oth wrists #y

pushin the dorsi of the hands toether elicits median ner$e distri#ution num#ness or paresthesias after 344 seconds!

C8s(ine F8rays8 Lateral8 an adequate lateral shows the top of the T1 $erte#ra8 look for alinment of the anterior and posteriormarins of $erte#ral #odies as well as spinous processes! 'pinous processes may ha$e a#normal separation in in:ury! The

maximal normal distance #etween the posterior aspect of the anterior arch of C1 and the dens is 3mm in adults and )mm inchildren! Look for reularity of disk space heiht, as in the disk space -suests deeneration., osteophytes, pre$erte#ral

swellin reater than one third of the $erte#ral #ody width -2 mm from C1R, HHmm from C)2.! ;anman+s fracture8 coronal plane fracture throuh the #ase of #oth pedicles of CH, caused #y hyperextension in:ury, separates the posterior elements of CH

from its #ody! 0&8 check alinment of processes and $erte#ral #odies, distance #etween spinous processes should #e reular,

pedicles should #e seen in cross section -erosion of a pedicle can cause the 5winkin owl sin6 where the pedicles are the eyes

and the spinous process, the #eak.! dontoid $iew8 trace #one cortex around the outline of the dens, misalinment of thisoutline indicates odontoid fracture, articular spaces of atlantoaxial :oints on either side of the dens should #e equal! "ote8

odontoid fracture type I 9 tip, type II 9 #ase, type III 9 throuh #ody of CH!

-iagnosis8 0 narrowed C,2 disk space suests disk deeneration at that le$el! C,2 disk herniation would impine on the C2ner$e root -cer$ical roots exit a#o$e the $erte#ra of the same num#er. which is consistent with clinical C,2 ner$e root

dysfunction on sensory and motor exam!

Treat.ent8 most patients respond to conser$ati$e therapy8 soft collar, "'0I@, acetaminophen! If symptoms persist for twoweeks or neuroloic symptoms proress, refer to "eurosurery for myeloram, CT neck and possi#le CT myeloram, M=I, or

EM>, ner$e conduction studies! May require decompressi$e laminectomy or anterior discectomy with #one raft fusion!

3!$ , 30 year old (atient 'ith ty(e I diabetes (resents to the e.ergency de(art.ent 'ith abdo.inal (ain and vo.iting$

Tae a history$ B) Labs) Glucose D& K 4$0& (+ #$& 1icarb !>$ 5hat is your diagnosis and .anage.ent

+istory *or abdo.inal (ain and vo.iting8 quality of the pain, location, onset, chronoloy, radiation, associated symptoms,

ara$atin and relie$in factors! "um#er of episodes of $omitin, description of $omit, presence of #lood and #ile!0ssociated prodromal illness, fe$er, malaise, sore throat, couh, urinary symptoms, diarrhea! oods eaten, other people sickF

H3


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&re$ious similar episodeF &olydipsia, polyuria, lethary, anorexia, hyper$entilationF ther precipitants of @0, recent

surery, recent trauma, prenancy, MI, noncompliance or wron insulin dose, infection!

-iabetes history8 time since dianosis, medications, #lood suar monitor at homeF @ia#etic control, polyuria, polydipsia, diet,

exercise, drus, alcohol, smokin, complications of dia#etes -retinopathy, neuropathy, nephropathy, infections.! %ho follows

patient+s @MF ;as patient taken insulin since feelin unwell, last insulin doseF &ast medical history, current medications,

alleries, family history, re$iew of systems!

-iagnosis8 dia#etic ketoacidosis!

Manage.ent8 oley, ID, lytes, lucose, 0?>, serum ketones! 'eptic workup8 C?C, C if is critically ele$ated! 1 L "' per hour x H3 hours or until tachycardia and ?& normaliAe, then )44 ccBhr x H hours, then H)4

ccBh x ) hours! Insulin drip at H Bhr! Check lucose and lytes qHh! %hen lucose drops to 1), switch fluids to maintenanceHB3

1B3 @)%B"' H4 mEq ClBL -R8H81 rule.! ?ein diet and reular insulin reimen! If the @0 was the result of non

compliance close followup and education such as diet and dia#etes manaement counselin with a dietitian are required!

3$ , .other 'ith her 4 'ee old 'ho has been vo.iting *or three days$ Tae a history$ B) Investigations sho' a

(al(able .ass in the right e(igastriu.& .etabolic hy(ochlore.ic alalosis$ 5hat is the diagnosis Give a di**erential

diagnosis *or vo.iting in an in*ant$

+istory o* in*ant vo.iting8 ae of onset, duration, se$erity, chronoloy, association with feedin or #ody position, description

of force, $olume, color, composition -#ilious, fecal, #lood, reuritant., ettin worse or #etter, is child still hunry afterward,

or does he settle! Couhin or ain with feeds -tracheoesophaeal fistula.! 0ssociated diarrhea, constipation, fe$er, weihtloss, a#dominal distention, urination! 0re other children sickF ;as child #een in contact with an infected person!

Mother’s obstetrics history and ne'born history8 as in question PH) a#o$e

-evelo(.ent history8 ae and weiht normorams, feedin history8 quantity, frequency, #reast $s! #ottle -which formula.,

colic, feedin difficulties! &ast medical history, medications, family history!

-iagnosis8 pyloric stenosis!

-i**erential diagnosis *or in*ant vo.iting8 "ew#orn8 conenital malformation -pyloric stenosis, tracheoesophaeal fistula,

duodenal atresia, malrotation of the intestine.! &ost new#orn period8 astroenteritis, peritonitis, appendicitis, hepatitis, ulcers,

pancreatitis, o$erfeedin, reflux, food allery, milk protein intolerance, systemic infection!

!""D

33$ #" year old *e.ale colla(ses in the .all$ Patient is dro'sy& unres(onsive to verbal sti.uli$ Manage$ %indings) +R

>0& 1P ?0/>0& 2CG co.(lete heart bloc$

Rescusitation8 0TL'B0CL' format as in question P a#o$e!

Manage.ent o* co.(lete heart bloc 8 -& wa$es seen on EC> not related to Q=' complexes.! Transcutaneous pacin

-atropine 1 m ID may #e tried #ut is rarely effecti$e.! &atient will require sedation -midaAolam H m ID. and analesia

-morphine H m ID. #efore startin external pacin! %ill require placement of a trans$enous pacer until a permanent pacer can #e placed! Consult CardioloyBCCBIC!

Causes o* ,< conduction abnor.alities8 calcification of the conductin system -Le$+s and Lenere+s disease., inferior MI,coronary spasm, diitalis o$erdose, tricyclic antidepressant o$erdose, X#lockers, calcium channel #lockers, $iral rheumaticfe$er, Lyme disease, sarcoid, amyloid, hemochromatosis, cardiac tumor, conenital!

3>$ D year old .ale 'ith tricyclic antide(ressant overdose$ Manage$

Resuscitation8 0TL'B0CL' as in question P a#o$e 9 0?C@, orders, secondary sur$ey, second orders!

+istory -from patient and familyBfriends.8 ask for the empty pill #ottles to confirm the dru -this may #e a pass criterion., how

many pills, when taken, concurrent inestions of alcohol or other drus! %here was the patient foundF %as there a period ofunconsciousness, how lon did this lastF ther symptoms -$isual #lurrin, seiAure.! @id the patient i$e any warnin of the

HR


25/56

attempt -note, phone calls, i$in away possessions., was there a precedin depression or strane #eha$ior, pro#lems at work

or with a relationship! &re$ious attemptsF Medications, drus, alcoholism, smokin, alleries, past medical and psychiatric

history, family history, re$iew of systems!

Investigations8 C?C, lytes, urea, creatinine, lucose, I"=B&TT, 0?>, C, serum osmolality, 0L&, 0'T, 0LT, total #ili, >>T,

Toxicoloy 'creen -0'0, acetaminophen, TC0 le$el, #ar#iturates, #enAodiaAepines, Et;., EC>! Castric la$ae -rare. if less than 1 hour since inestion! 0cti$ated charcoal 14 B dru inested or 1 Bk #odyweiht ">! ;ydrate with normal saline to promote diuresis for excretion of TC0 and possi#le myolo#inuria -occurs due to

muscle #reakdown followin proloned coma lyin on a hard surface.! 0lkaliniAe with 1 amp #icar# ID -or 1H mEqBk. andhyper$entilation if the patient is intu#ated! ollow 0?>s or $enous ases, aim for p; 2!R)2!))! =emainin treatment is

symptomatic8 treat seiAures with loraAepam H m ID, treat cardiac dysrhythmias, hypotension, aitation and coma as they arise!

Consult IC for HR hours minimum monitorin! Q=' J 4!1s indicates increased risk of seiAures and dysrhythmias! &sychiatric

consult after patient is medically cleared!

TC, To7icity)

Therapeutic le$els are HR mBk! Lifethreatenin symptoms usually occur at le$els J 14 mBk!,nticholinergic e**ects8 hyperthermia, tachycardia, mydriasis -dilated pupils., decreased sweatin and secretions, $asodilation,constipation, urinary retention, ileus! C"' effects are eneraliAed seiAures, myoclonus, ataxia, hyperreflexia, confusion,

aitation, hallucinations, acute psychosis, decreased le$el of consciousness, respiratory depression -mnemonic8 ;ot as a hare,

#lind as a #at, dry as a #one, red as a #eet, mad as a hatter, the #owel and #ladder lose their tone and the heart oes on alone.!Buinidine e**ects8 conduction delay -prolonation of Q=', &=, QT, T wa$e flattenin., heart #lock, #radycardia, asystole,$entricular dysrhythmias and resultant hypotension!

3D$ !4 year old *e.ale in hos(ital *or ,S, overdose$ Medically cleared$ Tae a history$

+istory8 patient name, ae, occupation! Circumstances surroundin the attempted suicide! &recedin conflicts at work or with

family or in a relationship! =ecent loss of employment or lo$ed one! %arnin sins8 suicide note, i$in away priAed

possessions! @escri#e the attempt, how many pills taken, what kinds, concurrent alcohol or dru use! @id the patient really

want to die or was the attempt a cry for helpF >aue the lethality of the attempt in terms of the means used and the chances ofdisco$ery! &re$ious attempts, descri#e these! Is patient now acti$ely suicidal or remorseful! If the patient acti$ely suicidal,

what is the current planF Medications, druBalcohol use, alleries, past medical history, family history -esp! psychiatric., social

supports8 re$iew of systems!

Psychiatry) ;istory for depressionBmania, mental status exam, multiaxial dianosis as in question PR a#o$e!

34$ %ather 'ith 3 year old child 'ho is not s(eaing$ Tae a history$ %indings) not s(eaing 'ell& recurrent ear

in*ections& (oor hearing$ Mae a diagnosis$

+istory8 of not speakin should determine whether the pro#lem is primary -ne$er spoke. or secondary -stopped speakin.!

'econdary causes of mutism are psycholoical upset -due to family discord, etc!. and rare inherited neurodeenerati$e

conditions! &rimary mutism may #e part of a lo#al de$elopmental delay or related to hearin pro#lems which are eitherconenital -inherited, intrauterine infections., ototoxic drus -e!! streptomycin. or trauma!

Pregnancy and birth history8 >T&0L -num#er of estations, term prenancies, premature #irths, a#ortions, li$e children.,

history of pre$ious prenancies includin neonatal :aundice, maternal medical history, illness durin prenancy, ru#ella-teratoenic., toxoplasmosis -from cats, infects fetal #rain., herpes -infects fetus, frequently fatal., CMD -damaes fetal li$er.,

teratoenic medications taken durin prenancy, dru and alcohol use, family history of deafness or late speakin! "ew#ornhistory8 estational ae at #irth, caesarean, induction, rupture of mem#ranes artificial or proloned, fetal distress, forceps or

$acuum deli$ery, meconium, 0&>0=s, was resuscitation requiredF Initial #lood work, #reast feedinF ;ow often and howwell, color of 1st stool, color of urine, $omitin, neonate muscle tone, #eha$iors, fe$er, irrita#ility, lethary!

-evelo(.ental history :*ro. (arent;8 'ee question P(! >rowth8 expected heiht and weiht for aeF 'peech, has child e$er

spoken words or phrases, are these used appropriately, has the child made sounds, chronoloy and description of these! ;owdoes the child communicate if not throuh speechF >ross Motor8 when did the child start walkin, runnin! ine motor8 when

did you notice pincer rasp, turnin paes in a #ook! 'ocial #eha$ior!

H)


26/56

+earing8 does the child wake up in response to soundsF 'tartle to loud soundsF Come when calledF nderstand spoken

instructionsF ;istory of ear infections, wax pro#lems! 0sk a#out swimmin! &ast medical history, medications, alleries,

family history, re$iew of systems!

-iagnosis8 i$en recurrent otitis media with poor hearin the most likely dianosis is retarded speech de$elopment due to poor

hearin! =efer to E"T for hearin tests, possi#le tu#es -tympanic drainae.!

3#$ >0 year old *e.ale 'ith *atigue$ Tae a history$ %indings) cold intolerance& 'eight gain$ Mae a diagnosis$

%atigue history8 onset, chronoloy, past episodes, functional limitations, associated with exertionF =ecent $iral illness

-mononucleosis., cold intolerance, weiht ain, dry skin, #rittle hair, hoarseness -hypothyroidism., associated muscle aches-fi#romyalia., chest pain -anina., shortness of #reath -conesti$e heart failure.! Slee( history8 usual requirements,

chronoloy of sleep pro#lems, stressor, sleep hyiene -when, where, reularity, shifts at work, quiet, late, exercise, meals,

alcohol, caffeine, prescription and nonprescription remedies, drus and medications., sleep latency -time to fall asleep.,

nocturnal awakenin, early mornin wakenin, daytime somnolence, somnolence while dri$in, workin or durincon$ersation! -e(ression screener8 as in question PR a#o$e! Must fully explore suicidal ideation8 does patient intend to harm

self, reason for suicidal thouhts, current plan, lethality of plan, access to lethal means, has patient i$en away priAe

possessions or written final notes to lo$ed ones, pre$ious attempts! Medications -especially TC0s, sedati$es,

antihypertensi$es., alleries, druBalcohol use, smokin, past medical history, family history, re$iew of systems!

-i**erential -iagnosis8 Chronic fatiue, C;, ischemia, thyroid disease, sleep distur#ance, depression!

-iagnosis8 most likely hypothyroidism i$en cold intolerance and weiht ain!

3?$ 3D year old .ale 'ith bac (ain and sti**ness$ Tae history and (er*or. a *ocused (hysical e7a.$ %indings) !0c.

se(aration bet'een lu.bar s(ines 'hile erect increases by less than D c. 'hen bac is *le7ed *or'ard :(ositive 5right8

Schober test;& lateral *le7ion i.(aired$ B) Give the diagnosis and t'o associated conditions$

+istory and Physical8 see question P1)!

-iagnosis8 #ased on typical history of #ack pain, lum#ar spine


27/56

quickly to satisfy partner, cannot achie$e orasm or orasm without e:aculation, retrorade e:aculation! Circumstances under

which impotence occurs8 only with certain partners, only at certain times or locations, what percentae of the timeF Is

impotence related to lack of sexual desireF &resence and firmness of mornin or nocturnal erections! @oes the patient sustainerections in mastur#ationF 0ssociated pro#lems8 anxiety attacks, anhedoniaBdepression, perineal or peripheral num#ness, poor

peripheral circulation! Exercise, medications, contracepti$e use, druBalcohol use, smokin, cholesterol, alleries, past medical

history, family history, re$iew of systems!

Counseling8 @iscuss causes of impotence in terms of oranic $s! inoranic etioloy and that it tends to cause reat anxiety

-normaliAe patient+s feelins.! Erectile dysfunction can often #e impro$ed with lifestyle chanes8 exercise, weiht loss,impro$ed diet, decreased alcohol intake, smokin cessation, stress manaement, sleep hyiene, #etter dia#etic control, and

:oint counselin with partner to decrease anxiety! Impro$ement of patient+s relationship with partner8 address sexual #oredom!=e$iew medications8 suest chanes! Explain that many oranic causes of impotence are unfortunately not re$ersi#le!

@escri#e therapeutic options8 counselin with partner on alternati$e means of sexual ratification, testosterone preparations or

#romocryptine -for prolactinoma. if patient is shown to ha$e hormonal distur#ance on #lood work -measure testosterone and

onadotropins., sildenafil -$iara., yohim#ine and traAodone preparations for impotence -poorly effecti$e and expensi$e., penile selfin:ection with phentolamine, papa$arine 7 &>E1 or &>E1 alone -34 aue needle, last 344 min!, quite popular.,

$acuumru##er rin de$ice, penile prostheses! 0rrane follow up with #oth partners!

>!$ Houng 'o.an 'ith tunnel vision$ Negative investigations by a neurologist and o(hthal.ologist$ Tae a history$

%indings) concerned that her husband is having an e7tra.arital a**air$ Counsel$

+istory8 @escription of $isual pro#lem, functional limitations, onset duration, chronoloy, ara$atinBrelie$in factors,

associated headache, eye pain, nausea, anxiety, palpitations, tremor! &re$ious episodes of eye pro#lems or other unusual phenomena -#lindness, paralysis, num#ness, a#dominal pain.! %hat doctors has patient seen, what did they sayF &ro#lems at

work, home, with relationships! %ho can the patient o to for support in her lifeF &sychiatric pro#lems in the pastF @epression

screener and sleep history as in questions P3 and P1(! Medications, dru and alcohol use, alleries, past medical history, family

history, re$iew of systems!

Conversion disorder8 psychic pertur#ation presents as one or two neuroloical complaints affectin $oluntary motor or

sensory function! &sycholoical factors thouht to #e etioloically related to the symptom as the initiation of symptoms is

preceded #y conflicts or other stressors! 5 La belle indifference6 9 patient+s inappropriately ca$alier attitude towards a serioussymptom! Treatment8 anxiolytics -e!! loraAepam 1 m & qh., relaxation therapy, counselin, close followup!

Counseling8 "ormaliAe this pro#lem and $alidate the patient+s feelins8 the fact that se$eral specialists ha$e said there is

nothin wron with the patient+s $ision does not mean that there is not a su#tle medical pro#lem which may #ecome apparent

later! or this reason it is important to stick with one doctor who knows the patient well and can coordinate further referrals ifnecessary! Many people who are faced with the possi#ility of marital infidelity automatically acti$ate a defense mechanism

which i$es them time to ad:ust, and which is not under conscious control8 'uch a reaction also helps the patient to enlist

needed support from others! This is a normal reaction for these people! These symptoms can $ary widely from paralysis, tonum#ness, to pains, to ina#ility to speak, and $isual pro#lems includin #lindness and tunnel $ision! utline a plan for

manaement8 address possi#le sources of anxiety and stress8 a frank discussion with the patient+s hus#and a#out fidelity is

required and may #e done pri$ately or if #oth partners are willin, in consultation with you or a marital therapist! The patient

should try to consolidate a support network8 parents, friends, etc! Consider depression, sleep or anxiety medications asappropriate! 0rrane follow up with #oth partners!

>$ 30 year old .ale *ro. another city$ 5ants %iorinal (rescri(tion *or chronic headaches rene'ed$ Manage$

'ee question P1!

>3$ 3 year old *e.ale 'ith > hour abdo.inal (ain$ Per*or. *ocused (hysical e7a.$ %indings) (eritoneal signs& (oint

tenderness at Mc1urney’s (oint$ B) Give a di**erential diagnosis& order investigations$ 5hat *urther history 'ould

hel( con*ir. diagnosis

Physical e7a. *or abdo.inal (ain8 see question PH(!

Rectal8 rectal shelf, check for ross or occult #lood! 0lso include a pel$ic manual and speculum exam! -won+t #e asked to

perform this at the LMCC II.! Check for pain with cer$ical motion -seen in &I@., pain on palpation of o$aries, mass, cer$ical

dischare! Take swa#s -see in$estiations.!

H2


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-i**erential diagnosis8 appendicitis, o$arian cyst, rupture or o$arian torsion, mittelschmerA, ectopic prenancy -life

threatenin., hepatitis, cholecystitis, astroenteritis, peptic ulcer, pel$ic inflammatory disease -&I@., urinary tract infection

-TI., pyelonephritis, kidney stone, inflammatory #owel disease, intestinal o#struction due to $ol$ulus or I?@!

Investigations8 0?< 3 $iews, a#dominalpel$ic ultrasound, C?C, lytes, urea, creatinine, I"=B&TT, lucose, XhC>! rinalysis!

'tool for occult #lood! Cer$ical swa#s for culture and pap smear! If = is imminent order type and cross for H units, C>$ 4 year old *e.ale 'ith le*t lo'er Euadrant (ain$ Per*or. (hysical e7a.$ %indings) lo' grade *ever& so.e

abdo.inal distention& LLB tenderness 'ithout rigidity& (oorly de*ined le*t lo'er Euadrant .ass$ B) ,bdo.inal series

sho's .ulti(le air/*luid levels$ -escribe$ Give di**erential diagnosis 'ith .ost liely diagnosis$ Order *urther

investigations$

Physical e7a. *or abdo.inal (ain8 see question PH( and PR3!

-i**erential diagnosis8 di$erticulitis, di$erticular a#scess, constipation with o#struction, >I malinancy with perforation,

allstone ileus, o#struction due to $ol$ulus -usually =LQ pain., Crohn+s, mesenteric ischemia or infarct, o$arian tumor, &I@,uterine perforation!

Most liely diagnosis8 di$erticulitis!

Investigations8 a#dominalpel$ic CT -ultrasound if CT una$aila#le., stool for occult #lood,

1992-1997 and 2004 questions and answers

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