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5th Med Final Exam Hints

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Medicine:

Short Cases:

Categories:

- Cardiovascular
- Respiratory
- Neuro
- MSK – connective tissue
- Endocrine

CVS:

Likely case: Murmur

- Dx: Mitral regurgitation or aortic stenosis (B. Creeden prefers A.S)
- Possible valve replacement (always a left sided valve)
- Will be asked to auscultate pt’s praecordium
o Hint: Quickly check for saphenous scars – sternotomy scar likely for
valve replacement if scar not visible.
o Ensure to feel for/find apex beat – shows where heart is!
o See excess bruising while auscultating – valve replacement (warfarin
levels = 3-4)
o Can’t hurt to take pulse while auscultating

Respiratory:

Likely case: Crackles:

- Dx: Fibrosis.
o Will be soft/subtle but audible
o Ask pt to cough. If cleared by coughing, NOT fibrosis
o Unlikely to hear apical, likely bibasal or unibasal – fibrosing alveolitis
o Hint: keep eyes open while auscultating to perform inspection for signs
pointing to fibrosis eg: scleroderma, rheumatoid disease, clubbing

Neuro:

Hint: May be asked to look at patient and spot diagnose appropriate test you would
perform.

Likely case: CN Palsy:

- Usually involves
o ocular muscles
o facial nerve palsy
o fields of view (rare)

temp. Test vibration. swollen). Balding . Psoriasis can mimic RA so check the nails and extensor surfaces carefully.Likely Case: Diabetic Foot: . . job of short case is to determine whether active or not (red. Hint: Observe as much as possible without touching as patient may be in real pain. Not so much if in bed. Probably pt with a very mild stroke exhibiting mild hemiparesis Muskuloskeletal/Connective Tissue Disease: Likely Case: Rash . . psoriasis is a stable rash. . hot. COGWHEEL RIGIDITY . Glabellar tap: Parkinson’s patient will continue to blink. Not specific test for Parkinson’s Likely Case: Stroke: . Psoriasis pits nails and affects extensor surfaces. Likely Case: Parkinson’s: If patient is sitting in a chair with shoes on. Tone o Expect hypertonia o Do bilaterally as Parkinson’s can present unilaterally o Reinforce maneuver makes tone become jerky . Probably no ulcer . Possible case: Discoid Possible Case: Myotonic Dystrophy . Brisk reflexes . Examination: GET PATIENT TO WALK TO ILLUSTRATE BRADYKINESIA. Not very suitable for short case (has happened) but better for long case as patient pedal hygiene and student hand washing separate issues. Ethically difficult to maintain a good clinical rash of cellulitis! . sensation. SHUFFLING GAIT. tender. Ptosis (eyelid infringes on pupil) . Be prepared to introduce self WITHOUT shaking hand. they are likely prepared to be asked to walk. If told patient has RA (Dr. Phelen often does this). Permanently corrugated forehead Likely Case: Rheumatoid Arthritis: . High probability of being psoriasis. proprioception . Listen to the question being posed!!! .

Ask: Difficulty with swallowing? o Implies esophageal involvement – poorer prognosis Endocrine Acromegaly Thyroid (Graves’) – especially in SIVUH . . examiner will want to know 1 to 3 things: o Is thyroid involved? o What is thyroid status? o Are eye signs present? .Examination: o Pt to stick out tongue while looking at neck to r/o thyroglossal cyst o Diaphoresis . always looking at pt for signs of tenderness: o Temp first o 4 point (index finger and thumb of both hands) over all joints. . Also has X present. Ask pt to place hands on pillow. .If it is a thyroid exam. psoriatic arthritis) which is/is not currently active. Functionality Testing: use discrimination based on pt. Palpation. involved in psoriatic arthritis (psoriatic arthropathy). Ask patient to put backs of hands to opposite cheeks to check extensor surfaces for tophi. Sometimes only distinguishing feature o 6 point examination for wrists (tenderness and subluxation). Give summary: Condition involves X joints. which are warm and tender to touch. observe joints.. mouth. eyes o Sclerodactyly o Examine: Hands: CReST o C = calcinosis o Re = Reynaud’s (do not elicit as is painful condition! It’s there or it isn’t) o S = Sclerodactyly o T = Telangiectasia – usually in mouth though rarely found on chest . especially DIP and nails (tenderness and subluxation) o Hint: DIPs spared in RA.Next step is to determine status (active or not): .A.Establish suspicion of Grave’s with examiner via observation of goiter? Ex- opthalmos? . Hint: brush hair back to check backs of ears for tophi! . Based on these findings this would be X (R. Likely case: Scleroderma: . current state o Write with pen? o Unbutton shirt –small buttons different level than large buttons o Pick up cup o Pass cup between hands o Cup with straw – probably can’t pick it up so ask to push it side to side. Observe: o Pinching of skin around nose.

begin with hands and arms. Impaired renal function in the presence of these volumes of contrast can result in contrast nephropathy. craggy edge . expect hard.Renal function. likely topic: EVAR Question 1: What do you need to ensure is present for EVAR? . Hint: o Tender hepatomegaly: acute scenario o Non-tender hepatomegaly: chronic scenario Vascular: If FULTON is the examiner. OBSTETRICS: Likely patients: . EVAR utilizes high doses of contrast medium which is cleared by the kidney. Palmar erythema and spider naevi – indicate chronic disease o Unlikely to palpate liver edge o If liver palpable. Small for dates (LMP very important here – dating accuracy) .Strong femoral pulses bilaterally because that is the method of access. eye angle should normally be 30-40 o? (Use hand to be dramatic about it)  Look from above to see if protruding?  Test lid lag Surgery Gastrointestinal: Likely case: Abdominal pain: If patient is jaundiced and asked to examine abdomen. hung in hypo o Eye signs:  Look for white of cornea between upper rim of pupil and eye lid  Look from side. o Pulse – will be tachy at rest o HPO of wrist o Acropatchy of fingertips o Establish fine tremor – place piece of paper on outstretched hands o Pre-tibial myxoedema – indicates hyperthyroid states o Reflexes – hyper in hyper. . Question 2: What else do you need to know prior to EVAR? .

If sensitive. She is sure of her dates iv. Do in this order to keep examiners listening and you talking as little about obstetrics as possible!: 1. HTN (social hx: would BP be lower if home with family?) After ½ hour examiners will appear: Have patient sitting on 2 pillows for presentation Ten steps to 1H. On OCP? Bleed may have occurred as chemical withdrawal bleed from pill otherwise: b. Daughter in ballet? ii.” c. Diabetes . Past medical and past surgical history 4. . Diabetes? ii.) 2. Introduce patient to examiners a. Twins – in for a rest . I’d like you to meet Mary Murphy from Glasheen Rd. Know children’s names and ages b. “I would like to discuss afterwards. What does the family do? i. Congenital Abnormalities iv. Know heaviest weight at birth c. Has had a scan in early pregnancy which concurred with her dates 6. HTN? iii. Confirm facts with patient: “isn’t that right Mrs. Not on pill ii. Her cycle is X days of which she bleeds X days iii. (eg: Examiner X and Examiner Y. Rheumatic Fever v. Domestic situation i. Always include a comment on these 5 (stating relevant negatives buys time): i. Reason for Admission: a. Social History – make it about the family! a. Who minds the kids/siblings in her absence? b. Son playing hurling or football? . Phrase along these lines: i. Menstrual History a. Eg: Mary Murphy is in for PPH following birth 2 weeks ago 3. Past Obstetric History (KISS philosophy if normal) a. Multiple Pregnancies 7. Murphy?” 5. Family History a.

Do not pull covers down from patient’s waist. CVS/Resp systems first: i. Booked on… ii. rip up the end of the bed to look at the feet for: 1. side. If can’t find it again. Caution of pitfall: 1. This is a bit of a distraction to both you and examiner. In summary and Management . 9. All pregnant women have it! c. oedema (and medial tibia) 2. Engaged/not engaged? ii. Smoke/drink/etc… 8. fetus moved (which they should do all the time). Scan on… agreed with dates iii. This gives a sense that you’ve got to know the patient a bit beyond her current situation d. Time to ‘guild the lily’: Ask the examiner a question about the patient they likely won’t know but is relevant to pt iii. Not a slick move! 10. Cephalic presentation? 2. NB: mention haematinic murmur of pregnancy/reproduction if pregnant. iii. Events of Pregnancy – do this late in the presentation so you don’t say something that has you talking the entire time about technical obstetrics and forget about the patient! a. Auscultation: Can say you heard heart over the back on the L. Normal until rash: what is rubella status? c. Eg: normal until flank pains. iv. Ask for result of msu query infection? ii. Look at feet/ankles. (Did you happen to see the results of…?) i. varicose veins. No matter how neatly the bed is made up by the nurses. Describe hx of pregnancy i. Had normal pregnancy until… b. snaps them back from a day dream. Make certain of presentation otherwise say unsure. Of Abdomen: IPPA approach: i. Mrs Murphy looks well/fatigued/pale/content/bored… b. and shows you were thinking beyond getting and presenting a good history. On Examination: a. iii. Normal until blood pv: what was blood group? Hb? iii. Honesty makes fewer mistakes than guesses.