Final Exam practice case vignettes

Station 1:
Do an MSK hip exam

Q1: Interpret this xray of the patient’s hip, provide your pertinent findings and a provisional
diagnosis.
Right hip joint space narrowing (bone on bone), subchondral sclerosis, subchondral cysts,
Q2: what sort of findings would you get on a physical exam?
Anterior hip pain radiating down front of leg, reduced flexion, reduced extension, reduced
internal rotation, Thomas test positive, straight leg negative,

Q3: What would be the indications for surgery in this patient?

Hip OA is an elective surgery (there is no rush). Indications for hip replacement are
symptoms of OA that impair ADL, radiographic signs of OA, and preferably age >50yo.

MSK Hip Exam outline

 Introduction:
o Expose from legs to underwear.
 o lying at 45° after functional exam is completed.
o Ask which knee, if any, is affected/painful.
o Do uninjured knee first

MSK exam structure: Look --> Feel --> Move --> Special tests
 Look
o Gait
 Trendelenburg, Antalgic, or limp due to hip shortening/rotation.
o Trendelenberg special test - have the patient standing hip width apart, they
can support themselves slightly facing a wall, then lift one knee (normally the
side lifting the knee rises slightly, but sagging or compensation by leaning the
other direction = positive test)
o SWIFT AS
 Skin changes - erythema, swelling, scars
 Wasting of the muscle bulk around the hip
 ASymmetry of the pelvis (look at ASIS, PSIS, and gluteal folds for
symmetry), and lumbar lordosis
o Patient resting on bed - also comment on obvious rotation or shortening of
leg.
 Feel
o Palpate all areas of the hip looking for PERC - pain, effusion
(swelling)/deformity, ROM, crepitus --> the last 2 are done on movement.
o Areas: femoral head (infero-medial to mid-inguinal point) --> greater
trochanters (bony prominence on lateral hip) --> lesser trochanter (posterior,
midway on gluteal fold, or just lateral to ischial tuberosity) --> ischial
tuberosity (right near the cold end)
 Move
o Full range of active movement: hip flexion, hip flexion with knee flexed,
external/internal rotation (with knee flexed), abduction/adduction (with knee
extended), hip extension (with patient prone). Assess for Pain, ROM.
o Check passive range only if active movements are restricted.
 Special tests
o Thomas test first check for excessive lumbar lordosis with pt lying supine
(shouldn't be able to put hand under their lower back), then get them to
bring one knee up and hug it (the test is positive if the opposite knee comes
off the bed and the patient feels a stretch in that opposite hip).
o Apparent and True leg length comparison - measure from umbilicus to
medial malleolus (apparent) and from ASIS to medial malleolus (true), and
compare the lengths of both legs (iff apparent leg length is different, then leg
shortening on one side is more due to pelvis tilt rather than short leg on one
side)
o Can also do straight leg raise to differentiate pain from sciatica which can
sometimes cause conflicting pain localisation.

Marks:
 Austin
 Yan
Station 2
Do a GIT exam

Q1: The patient is a 22yof with RIF pain that gradually increased over the period of 6 hours.
She is sexually active and had her last period 2 weeks ago. Findings are: good colour, normal
vital signs, afebrile, looking distressed, RIF tenderness on palpation, percussion tenderness,
increased bowel sounds, psoas sign positive
What are your differentials?
Appendicitis, ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, renal colic,
gastroenteritis, bowel obstruction (intussusception), Crohn’s disease, PID.

Q2: Interpret this ultrasound of the RIF region in this patient and give a possible diagnosis.
The first one shows a target sign which is iconic of the inflamed lumen in appendicitis.
The second one shows a blind ended tube like structure which is likely the appendix given the
region. There are hyperechoic changes of the viscus wall indicating inflammation and
hypoechoic changes of the lumen indicating oedema and fluid collection.
GIT exam outline:
 Introduction:
o Exposure, usually from waist up, or if not possible, comment that you would
expose abdomen between nipples and pubis for abdo inspection; offer gown;
offer chaperone
o First part of exam completed while sitting on edge of bed, and then flat on
bed for abdo inspection.

 General inspection: Mental status, cachexia, muscle wastage, colour, bruising,

vomitus bags
o A - alert/not alert, confusion (hepatic encephalopathy)
o B - breathing: SOB, accessory muscle use
o C - colour + contour (shape): jaundice, pallor, peripheral cyanosis, bruising,
muscle wastage, cachexia.
o D - distress: Well/unwell
o E - extras: stool/urine samples, colostomy bag, NG tube.
 Vitals
o HR, BP, temp, BSL, SpO2.
 Nails
o clubbing
 causes of bilateral clubbing - pulmonary disease (e.g. CF, fibrosis,
tumour), maliganancy, CHF, IBD, coeliac, infective endocarditis.
o capillary refill
o leukonychia
 partial whitening: traum to nail root/bed, chemo, heavy metal
poisoning
 complete whitening: systemic GIT and endocrinological conditions
such as cirrhosis, CKD, iron/zinc deficiency.
o koilonychia iron deficiency anaemia, connective tissue disease.
 Hands
o Arthropathy
o Palmar erythema
 Increased perfusion of palms, mostly due to hyper-oestrogenic states
in conditions such as: chronic liver failure, autoimmune (e.g. RA),
hyperthyroidism, neoplasm.
o Dupuytren's contracture
 alcoholism, smoking, and also higher in people with manual labour.
o Palmar crease palor
 Wrist
o Hepatic flap - liver disease
 Arms
o muscle wasting
o scratch marks - from pruritus due to jaundice.
o spider naevi (only present in SVC distribution) / bruising liver cirrhosis
(alcoholism), hyper-oestrogenic state, thryotoxicosis
 Face
o Parotid gland enlargement
 Eyes
o Conjunctival pallor
o Scleral icterus
o Kayser-Fleischer rings
 brown rings around cornea due to copper deposits form Wilson's
disease (can't get rid of copper) or chronic liver disease.
o Iritis
o Xanthelasma
 Mouth
o Angular stomatitis
 lesions/rash in corners of mouth - candidiasis/bacetiral infection,
Vitamin Bs deficiency
o Telangiectasis
 blanching red blots on face (sometimes similar to spider naevi): liver
cirrhosis, SLE, hereditary haemorrhagic telangiectasis (genetic
conditions of increased AV malformations leading to bleeds from GIT
and skin).
o Candidiasis of tongue
o Glossitis
o Leukoplakia smoking, spirits, sepsis or syphilis
o Dentition, tooth decay, dentures, gingivitis (just indicates how well they can
eat)
o Ulceration of mouth mucosa
o Fetor hepaticus oral hygiene, ketosis, uraemia, alcohol
 Cervical / Axillary lymph nodes and Parotid enlargement (mention it, but the
examiner will probably tell you to move on or that they are normal)
 Chest
o Gynaecomastia
o Patchy hair loss
o Spider naevi /bruising
 Abdomen
o Inspection
 Scars
 masses (pulsatile or non-pulsatile)
 distension
 caput medusa or other prominent veins
 striae
 spider naevi / bruising
o Palpation+Percussion
 Ask about pain
 Light palpate (start on opposite of painful site, if any)
 Deep palpate
 Rebound tenderness vs Percussive tenderness
 If the patient has a lot of pain you can percuss over painful
areas, which if painful suggests peritonitis, which avoids
having to cause more pain by doing rebound tenderness or
deep palpation.
  Note any tenderness, guarding, masses
 Palpate and percuss Liver (normal size 13cm)
 Palpate and percuss Spleen (normally not palpable or percussible)
 Ballot Kidneys
 Palpate Aorta (should be <5cm and not expansive with pulsation)
 Percuss for shifting dullness
 Special tests and signs
 Murphy’s sign - pain on inspiration below right costal margin,
suggesting cholecystitis
 McBurney point tenderness - tenderness distal two thirds
between umbilicus and ASIS, suggestive of appendicitis.
 Rovsing sign - RLQ tenderness on palpation of LLQ, suggestive
of appendicitis.
 Psoas sign - pain when patient flexes right hip from straight
position, against resistance of the examiner - suggest pain
from irritation by psoas movement against the inflamed
retrocecal appendic.
 Cullen’s sign - periumbilical ecchymosis from acute
pancreatitis bleed.
 Grey Turner sign - flank ecchymosis from acute pancreatitis
retroperitoneal bleed.
o Auscultation
 Over aorta (just above umbilicus), hepatic vein (just above umbilicus),
liver (Murphy's point), renal vessels (left and right just above
umbilicus).
 Note any bruits (high pitch - "use bell for bruits"), hums (low
pitch), rubs (creaking/grating with breathing)
 Bowel sounds for 30 seconds

 Extra tests if appropriate:

o Peripheral oedema
o Ecchymosis or bruising of legs
o Inguinal lymph nodes
o femoral and inguinal hernias
o DRE
o Urinalysis
o Temperature chart
source: OSCE marking rubric + Talley summary + CCS guide

Marks:
 Yan
 Austin
 Dave