LMCC II Compilation Most Recent

8/15/2019 LMCC II Compilation Most Recent

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The Resident’s Guide to the LMCC II

5th Edition – 2007-2008

The Licentiate of the Medical Council of Canada Exam, part II, alo !no"n a the MCC#E II, "a the traditional mean of $ualif%in& for

&eneral licene to practice medicine in Canada' (o" that )oth the internhip %ear and the &eneral licene are no lon&er a*aila)le, man%reident *ie" the exam a a treful and expeni*e exercie in futilit%' +hile the proce i treful and expeni*e, it need not )e futile'

reparation for the exam can )e an enli&htenin& re*ie"' cenario tend to repeat o*er the %ear, the pa rate i &reater than .5/ on the fi

attempt, and there i an option to re"rite, o dont panic'

The exam i an 1CE 1)er*ed cenario Clinical Exam3 in "hich the candidate pro&ree throu&h a erie of tation' 4our tartin& po

i determined alpha)eticall%' t each tation there i a ph%ician examiner and either a real peron poin& a a patient or a telephone o*er"hich %ou mut pea! to a patient or another ph%ician re$uetin& aitance'

The mot recent eion ince 6..73 contain ix hort cae !no"n a 5-minute couplet, in "hich the candidate i allotted 5 minute to

ae a patient and 5 minute to "rite hort an"er to $uetion related to the cae' There "a alo a erie of ix lon&er cae in "hich t

candidate "ere preented "ith a more in*ol*ed clinical pro)lem, uch a a reucitation or p%choocial counelin& eion, latin& 60

minute each' The ph%ician examiner ma% a! one or t"o $uetion in the lat minute of a 60-minute tation' There i one minute )et"tation durin& "hich %ou can loo! at a )rief decription of the patient and conider %our approach' 1ccaionall% pilot $uetion "ill )e

included in the exam, "hich "ill not count to"ard the final mar! )ut are ued to tet ne" $uetion' 4ou "ill not !no" "hich $uetion

pilot $uetion'

The content of the exam i &eneral medicine' Thi mean famil% practice 9 emer&enc% medicine' The follo"in& topic appear conitentl

Pediatrics – diarrhea, de*elopment, neonatal ;aundice, athmaObs/Gyn – amenorrhea, *a&inal )lood, a)dominal pain, I, EC?Resuscitation – fluid reucitation after )lood lo, @CAOverdose – , TCNeedle stic – IA, hepatiti, *accinationPsychiatry – depreion, mania, chiBophreniaNeurosurgery – )ac! and nec! radiculopathie, carpal tunnel

(ote that e*er% hitor% hould include name, a&e, occupation, pat medical hitor%, famil% hitor%, medication, dru&alcohol, re*ie" of

%tem3

t each E tation, there i a heet litin& poi)le in*eti&ation e'&' electrol%te include (a, Cl, D, etc' Li*er enB%me includeT, LT, L, LA'

The corin& ha the mean a 500, "ith a tandard de*iation of 600' 1n thi exam %ou needed to core F7G, and pa . tation in ord

to pa the exam' nd %ou ha*e to demontrate ethical )eha*iour and !ill appropriate for a ph%ician


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LMCC General Revie!"istory

#ey $uestions%

&dult%

6' LocationH e*erit%H Timin&H &&re*atin&>elie*in& factorH ociated %mptom

2' +h% i that a "orr% to %ou

F' +hat cant %ou do no" that %ou can do )efore e*ie" of %tem

Child%

6' renatal

2' (atal – methodH complication

F' renatal – ?>H onet of repirationH )irth"ei&htG' Jeedin&


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2' enarche! enopause

F' Periods: re&ularit%, duration, onet, amount, prementrual %mptom

mood, "ei&ht, matod%nia, headache3 mentrual dicomfort5' Amenorrhea: ro pre&nanc% fre$uenc%, (, fati&ue3

G' Abdominal or pelvic procedures

5' "nfections! Vaginal discharge! #ores or $umps! PruritusK' Partners: num)erH multipleH hi&h-ri!, ame-ex

7' %ontraceptive H&

8' PAP smear

.' enopausal symptoms: hot fluhe, d%pareunia, incontinence, depreionA' Muculo!eletal:

6' Joints: pain, "ellin&, redne, heat, tiffne, location, %mmetrical,mi&ration, limitation of motion

2' Activitie: ALH clim)in& tairH ittin&H tandin& up from chairH pinchH"ritin&

F''enerali(ed symptoms: fe*er, anorexia, "ei&ht lo

G' )ashes* Nails* %on+unctivitis* '"* ,rethritis* Preceding sore throat

E' (er*ou 6' Wea-ness: onet, pro&reion, location, dital *' proximal e&' trippin& for

dital le& "ea!ne3

2' #ei(ure disorders! Head in+uries

Aifferential Lo" @ac! ainLe& ain

6' %ommon $ow Bac- Pain

-pain relie*ed )% ret, a&&ra*ated )% mo*in&, liftin& or t"itin& motion-lum)oacral area to poterior thi&h )ut not )elo" !nee

2' #ciatica

-hootin& pain to )elo" !nee in dermatomal ditri)ution L5, 63

-paretheia and poi)le local "ea!ne

-pain on trai&ht le& raiin&, decreaed reflexe ep' an!le ;er!F' $umbar stenosis

-"ore "ith "al!in& and impro*e "ith flexion of pine

G' Nocturnal Bac- Pain - ro mali&nanc%

5' )eferred Pain - e&' pancrea, aortic aneur%m, peptic ulcer K' Vascular

-C


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C' >epirator%

a3 lo"er )order: anterior Kth3 and poterior 60th3 at inpiration)3 chec! for c%anoi and clu))in&

c3 tactile fremitu - decreaed "ith pleural effuion 9 pneumothoraxH increaed "ith

pneumoniad3 normal diaphra&matic excurion O 5-K cm

e3 )ronchial )reath ound - loud and lon& expirator% phae "ith hi&h pitch

f3 e&ophon%, "hipered pectorili$u% O conolidation

A' Cardio*acular

a3 - ax*% atrial contraction-relaxation-fillin&-empt%in&3H G cm -a "a*e increae "ith tricupid tenoi and diappear " a'fi)'

)3 F *entricular &allop3 - *entricular o*erloadin& heart failure3H G atrial &allop3 -increaed *entricular tiffne e&' h%perteni*e cardiom%opath%3

c3 plittin& ph%iolo&ical increae "ith inpirationH paradoxical plit in L@@ and

"idened plit in pulmonic tenoi

d3 @ -in )oth arm differential hould not )e P60 mm3H chec! for poturalh%potenion %tolic drop P 203

-cuff: len&th e$ual to 80/ and "idth e$ual to G0/ of lim) circumference

-pulu paradoxu - drop of P60 in %tolic indicate tamponade, contricti*e

pericarditi or o)tructi*e air"a% dieaee3 pical impule - increae duration " h%pertenionH diplacement "ith enlar&ement

f3 Murmur:

i3 it up and lean for"ard to aucultate aortic murmurH innocent murmuruuall% diappear on ittin& or leanin&ii3 ?rade 5 - teth partl% off chetH K - entirel% off chet

iii3 an%tolic murmur - re&ur&' acro *al*e

i*3 Earl% diatolic - re&ur&' acro emiluminar or aortic

*3 Mid%tolic - aortic tenoi 9 innocent murmur*i3 re%tolic 9 middiatolic - *al*e tenoi

*ii3 Continou - A

*iii3 Increaed tro!e *olume e&' $uattin&, no aal*a3 increae intenit% of

aortic tenoi )ut decreae h%pertrophic cardiom%opath%&3 ulu alternan - LJH Lar&e )oundin& pule - aortic re&ur&'

E' )domen

a3 Chec! in&uinal and femoral area)3 Liten for )ruit aorta, iliac, renal, femoral3

c3 Chec! upper and lo"er )order of li*er normal pan - K-7 cm3

d3 pleen in Trau)eQ pace hould remain t%mpanic e*en on inpiration3

e3 Mention A>Ef3 Didne%, orta normal "idth no more than F cm3

&3 oa i&n - raie thi&h a&aint handH 1)turator i&n - internal rotation of hip

h3 Intra)dominal ma o)cured )% contraction * ma in "all

J' ?enital

a3 retro*erted * retroflexed uteru

)3 thelarche: 8-6F %r menarche: 60-6K %r

?' re&nanc%

a3 fundu at: pu)ic %mph%i 62 "3, um)ilicu 20 "3)3 oftenin& of ithmu


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-normall%, *ein fill from )elo" F5 ec3

-releae compreion normall%, no additional fillin&3

h3 llenQ teti3 Mar!ed pallor on ele*ation u&&et arterial inufficienc% "ith unuual ru)or on

depenenc%H c%anoi on dependenc% u&&et *enou inuffienc%

I' Mu!ulo!eletal

'eneral approach

Inpection - "ellin&, redne of ;tH deformitieH urrroundin& tiue e&'

atroph%3alpation - )on% landmar!H heatH tenderneH crepituH Can&e of Motiontren&th

a3 Hands 0 Wrist i3 ma!e a fit

ii3 flex 9 extend, ulnar 9 radial de*iation

iii3


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m3 @a)in!iQ repone a)normal3 - doriflexion of )i& toe

n3 Clonu- harpl% doriflex foot and maintainH aterixi hepatic encephalopath%3

o3 @rudBin!iQ - flex nec! caue flexion of hip 9 !neeH Derni&Q - )ilateral pain on!nee extenion

p3 LM( - ipilateral upperlo"er face paral%iH M( - contralateral lo"er face

$3 nconciou atient

-@C and ta)iliBe C-pine

-pupil li&ht rxn often intact in meta)olic3

-ocular mo*ement &aBe preference to"ard tructural leion and a"a% fromirritati*e leion3

-oculocephalic lo u&&et )raintem dama&e3-oculo*eti)ular to"ard cold timulu if intact )raintem3

-chec! for unuual odor, loo! for needle mar! or head trauma, !in color


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October 00A40 )inute stations%

63 Mom of a 2 %ear old come in )ecaue of concern of child diet' +onderin& if the child i &ettin& too much u&ar' ?r"oth chart &i*

and child i at 50/ irritated, com)ati*e, dioriented'

The dau&hter ha a lit of her mother med and %ou are to &i*e ad*ice re&ardin& her med'

4ou find he i on:

traBadone

ti*an

F = o*er the pat month "ith chet pain, 1@, uffocatin& feelin&, anxiet%, and feelin& a thou&h he i lo

hi mind' ll exam ha*e )een and are normal' 4ou ha*e !no"n him for 68%ear a hi famil% ? and he ha al"a% )een health%, acti*e

into port''

Ta!e a hitor% and counel'

4ou are a!ed for a dia&noi'

83 hu)and and "ife come into E>, )ecaue the% &ot into an ar&ument and he puhed herVhe fell and lacerated her forehead' he i n

)ein& utured up )% another ph%ician and %ou are ent in to tal! to the hu)and'


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23 F0 %ear old female "ith pain to poterior nec! radiatin& do"n arm' Ao a focued ph%ical'

+ritten: 60 interpret a lateral c-pine x ra% 23 dia&noi F3 recommendation of treatment'

F3 50 %ear old male "ho drin! G-K )eer da%, ha *omited )lood 6x K month a&o and a&ain lat "ee!' A1 a focued ph%ical exam'

find all the ti&mata of li*er dieae3

+ritten: 63 +hat are hi ri! factor for hi pro)lem 23 ho" "ill %ou treat him

G3 F %ear old had a firt time eiBure and i no" in E>' 4ou are tal!in& to MomV'ta!e a focued hitor% %ou find child ha had a fe)

illne3'

+ritten 63 "hat i the chance thi "ill happen a&ain in the future 23 "hat tet "ould %ou order on the thi child F3 "hat i the li!dia&noi

53 5K %ear old male had 60 min of chet pain 6 "ee! a&o'


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October 00E

6' F0 %ear old man "ith T%pe 6 dia)ete for 20 %ear preent "ith a)dominal pain, nauea and *omitin&' Ta!e a hitor%'


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G' 1C – counel a %oun& "oman on )irth control option' ?et hx to ro contraindication'

5' )reat feedin& - hx 9 counel

232 )inute stations%

6' T2AM - hx

2' !id " !nee pain - exam

F' nephrotic %ndrome - hx

G' a)do pain - exam, =-ra% that %ou need to interpret'

5' phone ad*ice re: trauma – there "ill )e a nure on the phone a!in& %ou for tep )% tep mana&ement of a patient that ha


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May 00E

6' male lo of interet in pleaura)le acti*itie lo" mood lo" ener&% decr conc for G %r )ut till functionin&VVd%th%mia *depreion treatment

2' panic epiode counelin& >= patient phoned after a "ee! and cancelled next appointment "hat to do +ant a cop% of hi char

u &i*e

F' 60 month child "ith foter parent ha*in& non pecific diarrhea V' @iolo&ical mother phone "ant to a! a)out hi health "hat"ould %ou tell her

G' F %r child "ith intermittent fe*er F8'5 for 2 "ee! and reddih rah on tomach and chet for 6 da% diffential Ax F tet to do

5' 26 female for counelin& earl% exual acti*it% and mo!er

K' G6 female infertilit% menorrha&ia d%menorrhea *a&inal )leedin& counelin&7' E> tation chet pain 2 hour reponded partiall% to nitro firt EC? no chan&eXunta)le an&ina econd EC? inf MI

8' Crohn dieae repeated *x a)dominal pain =-ra% multiple fluid le*el Mx

.' C


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October 00<40 )inute stations HA5

6' 6K %'o' female i a!ed )% her mother to come and ee %ou )ecaue of a ix month hitor% of *omitin&'

a' Tae a relevant history8

i' he hand %ou piece of paper at )e&innin& of tation: 57, 6F5l)3i' Thin! he i fat, normal @MI, elf-induced *omitin&

ii' cademic difficultie

iii' Jre$uent ar&ument )et"een parent

i*' Exercie 6'5 hourda%, a)ue laxati*e )' . min mar! - ?hat is your diagnosis=

2' 25 %'o' female "ith a hitor% of AM i )rou&ht in )% her emplo%er un"ell and confued' and ( in the am, and he ha nohad )rea!fat'

*' +hat I olution do %ou "ant no"

*i' Turn out her pre*iou epiode "a ;ut li!e the current one'

F' K0 %'o' male 1A F for colon cancer' reent "ith udden onet left ided harp chet pain' and >> ele*ated' @ ta)le'a8 Per7or) a *hysical e(a)8 '(*lain your e(a)ination and describe your *ositive/negative 7indings8

i' @C

ii' atient i in o)*iou repirator% ditre, clutchin& L ideiii' Left calf mar!edl% tender, poiti*e 'iii' iual hallucination

i*' (o medication or alcohol hitor%

)' MME 20, eein& pider on ceilin&, clearl% poor ini&ht'

c' Examiner a% to fore&o a delirium


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i' +hat i %our dia&noi I it eriou

ii' 20, F7'8C3, and %ou initiall% mana&e a a

poi)le ?I )leedperforated *icou' 4ou find out he ha had pancreatiti )efore and i a hea*% drin!er' t the end of the tation hi

&irlfriend call and "ant to !no" ho" he i' *iit, )ecaue the% didnt offer thi freel%, )ut he had )een to

recentl% "ith "hat ounded to )e AD' ?irl i "antin& to &et more in*ol*ed in her o"n mana&ement, and )oth &irl and Mom interet

in more dia)ete education'

2 3 2 )inute stations H


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6' 1ption included referral, admiion to *ariou poi)le er*ice, admiion "ith conultation, out-

patient follo"-up'

2' 6G %'o' )o% athletic male preent "ith anterior ri&ht !nee pain that i reproduci)le durin& ph%ical acti*itie'

a' Per7or) a 7ocused *hysical e(a)ination8 8 '(*lain your e(a)ination and describe your *ositive/negative 7indin

> ti)ial plateau pain on exam' )' +ritten #uetion:

i' ?hat is your diagnosis=

"ritten3ii8 List investigations that you !ould order state noneJ i7 none needed

"ritten3

iii' "o! do you )anage this *atient="ritten3

i*' The 7ather ass you !hat is the *atient’s *rognosis=

"ritten3

F' F5 %'o' female preent "ith a 7 month hitor% of amenorrheaa8 Tae a 7ocused history8


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8' F month old infant "ith *omitin&' (on-)iliou, non-pro;ectile' ound li!e ?E>A' 4ou find out that he chan&ed from )reat mil! to

Enfelac "ith iron 6 month a&o' Mom a )it treed )ecaue hu)and lot hi ;o) recentl%' Ta!e a hitor%'E: Interpret the &ro"th chart &i*en ho" normal len&th and


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S*ring 00<40 )inute stations

6' Middle a&ed male come in "ith "ife after ha*in& 2 eiBure latin& 2min each' @oth "ere tonic clonic, &eneraliBed' e and

mana&e' +ife there, no nure'

a' Temp ele*ated' >et of *ital normal' ?C Z60 )' Important hx: alcohol a)ue, )ut none in the lat 2 da%' ed to ta!e ati*an prn'

c' e and mana&e includin& tet and treatment3 for alcohol "ithdra"al eiBure and decreaed L1C'

d' t the end, %ou ha*e to tell the "ife 2 tet or treatment %ou "ould do initiall% for the patient'

2' @C: 2.%o female had a pre*iou C ection lo" tran*ere inciion3 emer&entl% for a true !not in the cord' Meconium tainin

o)er*ed' 1ther"ie, pre&nanc% "a normal' (o" 60"! pre&nant'a' (o" "antin& %ou to enure that he "ill ha*e a *a&inal )irth'

)' +ant to !no" "h% he didnt ha*e a *a& )irth lat time JIJE3c' Aicu reaon for not ha*in& a @C and reaon for a C ection and explain that he ma% or ma% not )e a)le to ha*e

*a& )irth thi time'

d' +ant a cop% of her dichar&e ummar% from lat time

e' ! "h% her friend aid that once a C, al"a% a Cf' ! if it afe for her to ha*e her deli*er% at home

F' Infertilit%: F0%o female come in "ith concern a)out infertilit%' I, ad;ut leepin& ha)it, ocial upport for financial ituation'

232 )inute stations

6' G5%o male "ith hemopt%i' (e" patient to %ou' Jocued hitor%'a' mo!er

)' @ x all poiti*e'

c' #uetion:

i' Interpret C=>: ca*itar% leion in >L


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ii' Li!el% Ax name 23: T@' Lun& C

iii' Initial mana&ement:

6' putum c%tolo&%2' cid fat

F' CT

2' a&inal dichar&e x 6"! in %oun& female

a' 1ne epiode of IA not *er% "illin& to &i*e info' 1nl% come up "hen %ou a! a)out ur&erie'3

)' Jih%, foul mellin&' (o a)do painother %mptom of IA'

c' exuall% acti*e ha had 20 partner3' 1nl% on 1C' artner ha no %mptom' ap 2%r a&o normal' mo!in&'d' #uetion:

i' Micro)ial caue: name F6' ?ardnerella *a&inali

2' TrichomoniaiF' (' &onorrhea

ii' In*eti&ation

6' CS of dichar&e

2' D1< +hiff3 tetiii' 2 caue that "ould "arrant informin& pu)lic health

6' ?onorrhea

2' Chlam%dia

F' (ote: the% a! for MIC>1@IL caue3

F' Mother comin& in concerned a)out 2%o on "ho ha )een ha*in& cou&h x 6mo and no relief "ith moxil from other dr'

a' : free air under diaphra&m

iii' Li!el% caue: perforated peptic ulcer

i*' 2 mot important intial apect of mana&ement in next K0 min3:6' ?en ur& conult

2' i* I pantoloc3

5' Middle a&ed male come in an&r% )ecaue he ha )een denied inurance due to ele*ated LJT LTPT, increaed l! ho,normal )ili3'


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K' Middle a&ed female comin& in )ecaue of ea% )ruiin& and epitaxi' Ex'

a' Li&ht "ere off' Turn them onUUU )' Ma!e-up on: petechiae and )ruiin& and epitaxi

c' Ex: !in, l%mph node, li*er, pleen, percu chet

d' #uetion:i' Li!el% caue: IT

ii' oint on hitor% that lead to Ax hx of flu, fe*er, "t lo on the lit'

iii' Initial treatment ha failed' +hat do %ou do no"

6' )one marro"2' coa& profile "a done )efore3)lood mear

7' K2 % o "oman "ith acute onet thoracic )ac! pain' Ta!e and "

pro)a)l% on teroid at ome point' lo, famil% hx of earl% hip [ in mother' E: lit G ri! factor for oteoporoi in thi "omacute pain mana&ement, mana&ement of oteoporoi F tep "ith doe of med3'


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October 00240 )inute stations

K6%o female C1 >adiation lea!in& to her houe x60 %r !eepin& a metal rin& to protect her3' Jocued , no defi)rillatio

#uetion: "hat "ould %ou do if he "ent into fi) and arret

2. %o female 60 "ee! pre&nant come in to dicu current pre&nanc% and poi)ilit% of @C 4ou are &i*en a cop% of the

dichar&e ummar% from the lat deli*er% – ectioned for decal and meconiumfetal ditre' True not in cord' Ta!e a focued hitor% ancounel' he alo "ant to do a home )irth'

Joter mother )rin& in her 60 mo foter child to dicu 8 "! , ED?, echocardio&ram and T< normal' Ta!e a focued hitor%'

# at . minute: ro*iional dia&noi

.3 4oun& "oman, recent immi&rant, poor po!en En&lih and cant read En&lih "ant >x refill' none re$uired3603 20 omethin& pre&nant "oman at F7 "ee!, firt pre&nanc%' , @ 6K0.0, 620, >> 20, .K/ >' Mana&e

(ure in room' (o" ta)le, tal!in&' (o 1@ no", mild chet pain'


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?ait i funn%, a if "al!in& on &la' (ormal motor exam' enor% exam ho" lo of oft touch and pin pric! )ilaterall% in )oth

le&, in toc!in& ditri)ution' lo no *i)ration and proproception in feet' Lo of doral deep tendon reflexe, normal !nee ;er!

# at . minute: "hat i the dia&noi +hat i %our mana&ement plan673 78 %o female on man% medication' >ecentl% een for pneumonia and &i*en Er%throm%cin' omitin& and anorexic' Jor rechec

"ith C=>' Aau&hter tate more confued latel%' reent lit of medication' 2-F )enBo, )x, heart medication' Mana&e me

Aecri)e C=> no con*incin& pneumonia3

ol%pharmac% er%throm%cin, i)uprofen for 1, cimetidine, di&oxin, theoph%llin for C1A, furoemide, ati*an for anxiet% after

hu)and died 8 month a&o, triaBolam for inonia3

I aid "e hould &i*e mother fluid, ta)iliBe her in E>, do ome )lood "ot! includin& theophilline le*el, and "itch her onto

inhaled teroid intead, "ean off the )enBo'

683 58 %ear old &u% "ith erectile d%function' Counel and mana&e'3, cut do"n ET1 cardiome&al%, no pleural effuion , no Derle% @, no fluid in fiure323 dia&noi C doc %ou3

E 63 Mana&ement in E> in 5 line 23 nother i)lin& had ame incidence in F %r a&o, "hat do %ou do C3

F3 +hat do %ou tell the mother

F)3 Telephone in the room' Aitrau&ht mother "ant to tal! to E> doc' F %ear old ha in&eted ome drain fluid'Mother i at home "ith on' ?rand mother preent' 60 minute )efore, !id found to ha*e in&eted ome drain fluid from the cloe

un!no"n amount' 1ri&inal )ottle not preent' The% tried to induce *omitin& )% &i*in& mil! and mutard po"der to !id, )ut no lu

Did retle and cr%in& no"'

E 63 J1> thin& on Ex "hen the !id &et to E> ital, orophra%n&eal exam, repirator% exam and mental tatu3

23 rinciple of Mx in E> I aid @C, @+ includin& @?, omolalit%, chec!in& )ottlea&ent in&eted, poion controF0%o male "ith M and femurti) [ fixed FK hr a&o' (o" co 1@, fe*er' Ao E had rahe on the chet3 fat em)olim3

E 63 C=> &i*en Aia&noi

23 +hat F in*eti&ation "ould %ou orderK5 %o female "ith )lood% nipple dichar&e' Jocued 2'K'

E 63 Li!el% dia&noi

23 F initial in*eti&ation


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May 002232 )inute stations

63 Male G8 %r Le& cramp


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October 00640 )inute stations%

63 G8 %o "ith fe*er for the pat F "ee!' Jocued if %ou a! for it3, interpret'

F3 62 %o dia)etic, ;ut mo*ed to to"n' Ta!e a hitor% of dia)ete control, counel

G3 2 "! old infant, )reatfed' @+ F'K!&, no" F'.!&' Mother "orried not )reatfeedin& ri&ht and not &ainin& enou&h "ei&ht' otator cuff tear323 Mana&ement (IA, ph%io3

F3 +hat direction do %ou &i*e him if he "anted to appl% for +I@ +ill %ou &i*e +I@ info a)out pt if the% a! for it

G3 F2 %o "ith F meaurement of hi&h )lood preure' @ 6K0600 )oth arm' Ao a Ex dont need to do @3E: 63 Mot li!el% caue of the h%pertenion in him pic! F3

23 +hat in*eti&ation %ou "ould do pic! 53

F3 +hat do %ou ad*ie him pic! F3

53 K "ee! old contantl% cr%in&, mother in to ee %ou' Jocued


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May 00640 )inute stations

6' F0 %o male preent "ith fall' "ith inferior T ele*ation' Treat medicall%, conider T(D$uestion: if man "ant to lea*e M after treatment, )efore een )% cardiolo&%3, "hat do %ou do &cute )anage)ent8 MEDICIN

F' K5 %o female "ith rectal C doe not "ant 1>' Counel her' Turn out her friend died "ith the ame 1>' 1ffer otom% nure to comin, tal! a)out fear etc' "( only Hcounselling /CL'O5 SURGERY

G' F5 %o female 8 "! pre&nant "orried a)out ri! of &enetic defect' Counel' he a! if her hu)and didnt "ant a)ortion )ut he did

the tet "ere a)normal, "ho "hould ha*e the le&al ri&ht "( only Hcounselling / CL'O5 OBS/GYN

5' 5K %o male "ith hemopt%i' 1n coumadin for fi)' Chronic hemopt%i, no" "ore' Ex-mo!er' (o C, no AT ri!' "ith dilated @ loop and air-fluid le*el' Interpret =>

2' +hat i Ax @13F' J' eptic hip' "( and P(' MEDICIN

E: 6' +hat i the dia&noi in&le in*eti&ation

2'


26/118


27/118

October 00:40 )inute stations

6' K0 %o female four da% pot-op uncomplicated h%terectom% for fi)roid' (o" confued, "ith *iual and auditor% hallucination' +to lea*e hopital' >ecei*in& T%lenol [F for pain control until FK hour priorH ti*an 6 m& $h for inomniaanxiet%'Co)*lete "( 7ocused MS'8 &ssess 7or ca*acity to consent 7or treat)ent / investigation / discharge8

- iual hallucination onl% – tran&er dancin& "ith li&htH no uicidal homicidal thou&ht

- (o fe*er, chill' (o aller&% to TF or ti*an- re*iou hitor% of hepatiti'

- MME difficultH pt !eep refuin&H need to )e peritentH MME core N 2G

4 at 5 minutes: I thi patient competent If he choe to &o home ri&ht no", "hat "ould %ou do

"istory: onet of hallucination, duration, decription' ociated fe*er, a&itation, "eatin&, tremor, decreaed le*el of concioune,eiBure Miperception and illuion, impaired attention pan, diorientation, impaired le*el of concioune, deluional thin!in&, affect

%mptom mood – ad3' Jluctuatin& coure n% pro)lem "ith ur&ical reco*er%, "ound healin&, mo)iliBation mount of alcohol

conumed at home' , li*errenal tet, urinal%i, EC?' indicated )% hitor%: T

CT head, toxicolo&% creen, >AL, L, LE preparation, @62 and folic acid le*el, EE?'

Mana&ement% Treat underlying cause HGMC etc858 Sto* all non.essential )edications8 Maintain nutrition hydration electrolytebalance and )onitor vitals8 Psychosocial K Buiet/!ell lit environ)ent roo) close to observation 7a)ily )e)ber 7or

reassurance8 Phar)acological K halo*eridol .2 )g IM lorae*a) 4 )g SL *hysical restraints i7 *atient violent8

2' 2F %o "oman' Jriend concerned re: "ei&ht lo, difficultie concentratin& at "or!' +orried a)out loin& her ;o)' Jather died 65 mon

a&o, and famil% no" relie on her alar%' ocused history'

- +or! a receptionit, not "ant to chan&e ;o)H made error at "or!, late for "or!

- @ro!e up "ith her )o%friend G month prior' nni*erar% of her father death four "ee! prior - oiti*e depreion creenin& F mo' hx3, no uicidal homicidal ideation

- (e&ati*e for mania creenin&, ne&ati*e anxiet% creen

- (o report of a)ue from home li*e "ith mom, a fe" i)lin&3' (o u)tance ue, mo!in&, Et1<

F' F0 %oman "ith 5 hr of acute epi&atric pain, nauea, *omitin&' +orenin&' ital pro*ided: @ .0K0, 620, >>28, F7'8C' Manage'

- )% am)ulance' Aau&hter preent' @ 80G0, G0,TF7'2C' Manage patient "ith nure' 6 7reat as A%$# station 6

History

- atient complained of hortne of )reath, heart poundin&, diBBine ;ut )efore faintin&

-


28/118

- elati*e contraindication: pre&nanc%' Auration of treatment: G-62 "ee! uuall% ade$uate'

yban Hbu*ro*ion5 → appro*ed in Canada in u&ut 6..8 → act on dopaminer&ic re"ard3 and noradrener&ic "ithdra"al3 path"a%'

Contraindication: eiBure diorder, alcoholim, eatin& diorder, recent M1I ue, current pre&nanc%H caution if uin& >I reduction of

eiBure threhold3' Aoe *arie "ith amount the patient mo!e' atient continue to mo!e for firt "ee! of treatment and then complete

top therapeutic le*el reached in one "ee!3' >ecommend a)tinence from alcohol due to ri! of toxic le*el "ith li*er d%function' i

effect: headache, inomnia, dr% mouth, "ei&ht &ain'

8' F0 %o man "ith a K mth


29/118


30/118

- 1ne older iter K %o3, no


31/118


6' 6K %o female "ith preumed o*erdoe' 6 pre*iou attempt, no med' &ssess 7or sa7ety/suicide ris and ability to discharge 7ro

e)ergency' Too! 65 , didnt intend to !ill herelf' eturn to E> in Fd, till fe)rile, leu!oc%toi' Interpret C=> >ML infiltrate3

23 +hat i the dia&noi C3

F3 +hat i the mot li!el% patho&en #. pneumoniae3G3 Lit F mana&ement tep

2' G0-ih %o female "ith hootin& le& pain "hen he flexe her nec!' lo fleetin& *iual %mptom and urinar% retention' lternati*e

"ith acute urinar% retention' Jole%: 6200cc clear urine' "( only8 oor tream, "ei&ht lo, lo" )ac! painE: 63 Mot li!el% dia&noi

23 G other poi)le AAx

F3 F in*eti&ation

G3 h%ical examination ho" an enlar&ed protate' (ext tep in mana&ement


32/118

53 Aau&hter doe not "ant him told if he ha cancer' mana&ement 23 In*eti&ation F3 d*ice re: pre*ention


33/118


63 G0 %o male, perium)ilical a)do pain x2G hr, fe)rile' ocused "(' L@M 2Ghr a&o, *iual chan&e' (o afi)other

23 F thin& %ou "ould monitor pecificall% a the% pertain to poionin& or omethin& li!e that3'

F3 Jind out imilar incident prior "ith !idQ i)lin&' +ho do %ou call +hat i %our reponi)ilit% +hat to tell mom

40 )inute stations

63 70 %o "oman fell do"n at hoppin& mall' t in E'>', *ital &i*en' (ure in room "ith %ou' &ssess and )anage patient

Ao ?C 83, med Ai&oxin, pironolactone3, ad*anced directi*eEC?: Frd de&ree heart )loc!' @ 70 %tolic, G0' 70 after 0'5m tropine' (o pro)lem "ith fluid )olu

4 at 5 minutes ?i*en ad*anced directi*e of A(>, ho" "ould %ou further mana&e thi pt If he &oe into J, "hat "ould %ou do

Ma!e ure %ou tell them that %ou "ould &i*e upporti*e meaure i'e' pain control and that %ou "ould "rite a A(> orde

23 F5 %o female come to %our office "ith complaint of lethar&% and decreaed interet in acti*itie' ocused "( and counsel8

4oun& children at home, no Mx, no I'


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35/118


6' F2 %ear old mother preent to %our office )ecaue her G %ear old on ha had an aller&ic reaction to peanut' L# pain x6 "!' erform a ph%ical exam' Jindin& include ditended a)domen and tenderne at Mc@urne%#: The patient ha a hitor% of Crohn and preent "ith the follo"in& a)dominal x-ra% ho" mall )o"el o)truction3, "hat i

the dia&noiMother "ant to &o on a campin& trip "ith her .%o on "ho uffer from primar% enurei'


36/118

October 4111

40 )inute stations

6' Man in 20Q fell off ladder 6G feet' @ruied o*er left anterior ri)' 1n ta)le in c-collar' C, rep normal' !in& for pain relief' Mana&e

2' +oman in K0Q dichar&ed G da% a&o from hopital "ith E' +a on 5 m& of coumadin 1A, dichar&ed "ith I(> of 2'0' I(> toda% 6'0

Counel and mana&e'

F' 60 %ear old child "ith fre$uent >I, in toda% "ith one' h%ical exam and addre parent concern'

G' Jemale KF %ear old G da% pot ?I ur&er% "ith 65 minute of 1@' h%ical exam'

5' 6K %ear old female in office )ecaue her mother i concerned a)out her *omitin&'


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411A232 )inute stations

6' Ta!e hx' Jrom man "ith acute urinar% retention'

ep: mot li!el% dx, ddx, in*eti&ation

2' Ta!e hx' Jrom mom of child "ith fe)rile eiBure

pep: dx, tell mom ri! of recurrence, tell mom ho" to mana&e a future eiBure

F' Ta!e hx' Jrom man "ith d%pha&ia pep: ho"n )arium "allo", decri)e xra% findin&, &i*e dx, &i*e "or!up

G' Examine %oun& man "ith acute hip pain

pep: ddx, !e% hx point, in*eti&ation

5' Examine %oun& "oman "ith purpura and epitaxi

pep: hx, dx, in*eti&ation

K' Examine 20 %'o female "ith h%pertenion

pep: ddx, in*eti&ation, "hat to do if %our in*eti&ation are normal

7' Ta!e hitor% from mother of child "ith chronic cou&h unreponi*e to a)x

pep:ddx, !e% hx' Element, in*eti&ation

8' Examine %oun& "oman "ith ll$ pain pep: ddx, !e% hx' Element, in*eti&ation

.' Ta!e hx' Jrom "oman "ith menorrha&ia

pep: ddx, !e% hx element, in*eti&ation

60' Examine man "ith calf claudication

pep: interpret e!&, ri! factor, in*eti&ation

66' Ta!e hitor% from man "ith o) and putum

pep: er rx, in*eti&ation, ad*ice re: pre*ention

40 )inute stations

6' Counel %oun& "oman "ith un"anted pre&nanc% motl% re: a)ortion3

2'


38/118


39/118

Mechanis) o7 action o7 OCP: tandard preparation contain etro&en and pro&eterone or ;ut pro&eterone, pre*ent o*ulation )%

interferin& "ith feed)ac! of hormone i&nalin&, atrophic endometrium, chan&e in cer*ical mucou mucou plu&Vthou&ht to )e due topro&eterone component3'

&vailable *re*arations: 26 da% *' 28 da% ta)let 7 place)o da%3' 1ther preparation: Aepo in;ection $Fm Aepo-ro*era –medrox%pro&eterone, retoration of fertilit% ma% ta!e up to 6-2 %ear, irre&ular mentrual )leedin&3, implant $5% (orplant –

le*onor&etrel, ix capule inerted u)dermall% in arm, irre&ular mentrual )leedin&3' Lon&er term preparation offer lo"er cot o*er th

duration of action )ut &reater one-time cot3 and &reater con*enience'

9ene7its o7 all the hor)onal contrace*tives: @CAE: &nemia reduced, often clear &cneH 9eni&n )reat dieae and c%t decreaedH

Cancer o*arian decreaed3, C%cle re&ulated, Increaed Cer*ical mucou "hich reduce TAH ;%menorrhea decreaed, decreae 'ctopre&nanc% rate and of coure: *irtuall% no chance of pre&nanc% "hen ta!en a directed .8-..'5/3'

Riss o7 hor)onal contrace*tives: li&ht "ei&ht &ain i uual 5 l)3, increae ri! of AT epeciall% in com)ination "ith mo!in&, ma

timulate etro&en-receptor poiti*e )reat cancer, )ut doe not appear to caue them, ma% ha*e to tr% t"o or three different preparation

arri*e at the one for the patient' lo note that hormonal contracepti*e do not pro*ide a much protection a&aint exuall% tranmitted

dieae, compared to )arrier method'

;irections: tart 1C on the firt da% of the next mentrual period' lace pac!a&e in an o)*iou location to help %ou to remem)er' Ta!e

the ame approximate time each da%' e additional contraception for the firt t"o month, a 1C contraception i not relia)le until then

%ou mi a da%, ta!e t"o pill the next' If %ou mi t"o da%, ta!e t"o pill for the next t"o da% and ue an alternati*e method until the nperiod' ?i*e precription for 1C of choiceVan% famil% mem)er itermother3 on 1C +hat "or! for them rran&e follo" up'

:8 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 7a)ily docto?ants a driver’s license8 Tae a history and counsel8

"istory o7 seiure disorder: atient IA' &e of onet primar% &eneraliBed rarel% )e&in N F or P 20 %ear old3' recipitant: leep

depri*ation, dru&, Et1


40/118

Aicu "hat to do in the e*ent of eiBure, counel parent if poi)le' @%tander are not to inert o);ect into the patient mouth' Turn

patient on hi ide "hile eiBin&' Call am)ulance or ta!e to Emer&enc% if eiBure doent top in 5 minute'

rran&e re&ular follo" up to monitor pro&re and erum Ailantin le*el'

Indications and important side-efects o major antiepileptic drugs;rug Indication ;ose.related Idiosyncratic

Carba)ae*ine

HTegretol5

artial or &eneraliBed

tonic-clonic eiBure

Aiplopia, diBBine, headache, nauea,

dro"ine, neutropenia, h%ponatremia

Mor)illiform rah, a&ranuloc%toi,

aplatic anemia, hepatotoxic effect,

te*en-ohnon, terato&enicit%Phenytoin

H;ilantin5

artial or &eneraliBed

tonic-clonic eiBure,

tatu epilepticu

(%ta&mu, ataxia, nauea, *omitin&,

&in&i*al h%perplaia, depreion,

dro"ine, paradoxical increae ineiBure, me&alo)latic anemia

cne, coare facie, hirutim, )lood

d%craia, Lupu-li!e %ndrome,

rah, te*en-ohnon, Aupu%tren,hepatotoxic effect, terato&enicit%

Dal*roate

H'*ival

;a*aene5

ll &eneraliBed

eiBure or partial

eiBure

Tremor, "ei&ht &ain, d%pepia,

nauea, *omitin&, alopecia, peripheral

edema

cute pancreatiti, hepatotoxic

effect, throm)oc%topenia,

encephalopath%, terato&enicit%'thosu(i)ide

Harontin5

)ence eiBure (auea, anorexia, *omitin&, a&itation,

dro"ine, headache, lethar&%

>ah, er%thema multiforme, te*en-

ohnon, Lupu-li!e %ndrome,

a&ranuloc%toi, aplatic anemia

68 6A year old !o)an co)*lains o7 diseased sto)ach8J "as had negative investigations by several other doctors8 Tae a history

*er7or) a )ental status e(a)ination8 $% ?ithout looing at the *atient again describe her a**earance8 ?hat is your diagnosis=

"istory 7or de*ression: IA name, a&e, emplo%ment tatu, marital tatu, li*in& arran&ement3, chief complaint,


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clinical impreion of uicide ri! and pro)a)ilit% of attempt3, thou&ht proce coherent, fli&ht of idea, tan&entialit%, circumtantialit%,

thou&ht )loc!in&, neolo&im, clan&in&, pere*eration, "ord alad, echolalia3, thou&ht content deluion – )iBarre *' non-)iBarre,

o)eion, preoccupation, pho)ia, recurrent theme3, perceptual ditur)ance illuion, hallucination, deperonaliBation, derealiBationini&ht, co&nition, ;ud&ment'

Multia(ial Su))ary:xi I – clinical diorder – AM IH differential dia&noi

xi II – peronalit% diorder – AM IH mental retardation

xi III – ?MC a the% pertain to xi I and other xe3

xi I – p%choocial and en*ironmental pro)lemxi – &lo)al aement of functionin& ?J3 – 0-600

Mini.Mental Status: orientation to timeplace 5 pt, %ear, eaon, month, da%, da% of "ee!H 5 pt, countr%, pro*ince, cit%, hopital, floor3

memor% F pt, honet%, tulip, )lac!H F pt, dela%ed recall3, attentionconcentration 5 pt, erial 7, +1>LA )ac!"ard3, lan&ua&e tetcomprehenion F pt, three point command3, readin& 6 pt, cloe %our e%e3, "ritin& 6 pt, complete entence3, repetition 6 pt, no if,

and or )ut3, namin& 2 pt, "atch, pen3, patial a)ilit% 6 pt, interectin& penta&on3

Patient’s a**earance: lo*enl%

;iagnosis: ma;or depreion

Treat)ent o7 )aFor de*ression: pharmacotherap%, p%chotherap%, famil% therap%' tart fluoxetine proBac3 20 m& $M, ma% increae t

m& $M after 6 "ee!' Ta!e 2-G "ee! to "or!' Explain ide effect of leep ditur)ance, anor&amia, nauea ue >I ummar% )elo"

&d)it: "hen patient i acti*el% uicidal, i'e' plan are pecific, patient ha &i*en a"a% poeion, "ritten final note to lo*ed one' Jor

uicidal ideation "ithout current intent, dichar&e onl% "ith "ritten contract "ith the patient to inform %ou immediatel% if the% feel li!el%

ma!e an attempt' ?i*e num)er to call and arran&e re&ular follo" up )efore patient lea*e the office'

SSRI antide*ressant su))ary

Start at% H)g O;5 Thera*eutic% H)g O;5

Jluoxetine roBac3 – &enerall% ener&iBin& 20 20-80

Jlu*oxamine Lu*ox3 – more edatin& 50 650-F00

ertroline Woloft3 – ued in the elderl% 50 50-650aroxetine axil3 – ued in mixed anxiet%depre 60-20 20-K0

28


42/118

Cranial nerves – C( III, I, I: Extra-ocular mo*ement patient follo" %our fin&er or the handle of a reflex hammer in an hom)er& feet to&ether, e%e cloed3' lantar flexion po"er – hold patient hand for )alance, a! patient to ta

on one foot, then raie themel*e up on the toe'

"atient lying supine

Tone – pai*e rapid alternatin& forearm rotation, pai*e rapid el)o" flexionextenion "ith one thum) on the )icep tendon to feel for co

"heelin&' >apid liftin& of the relaxed le& from )ehind the !nee – heel remain on the )ed in normal tone'


43/118

Glasgow Coma Scale

Eye OpeningE3

VerbalResponse

3

est !otorResponse

M3

pontaneouTo peech

To ain

ne*er

GF

2

6

1riented and con*ereConfued con*eration

Inappropriate "ord

Incompreheni)le ound

(one

5G

F

2

6

1)e% commandLocaliBe pain

+ithdra"al to pain

)normal flexion decorticate3

)normal extenion decere)rate3

(il

K5

G

F

2

6

Note: tandard painful timulu i ru))in& the !nuc!le on the ternum' Jor "ithdra"al, appl% preure on the )ae of the nail )ed "ith a p

Aecorticate poture i arm flexion "ith le& extenion on the ame ide of the )od%, ma% )e unilateral or )ilateral' Indicate a leion a)o*e

)raintem' Aecere)rate poture i arm and ipilateral le& extenion, ma% )e unilateral or )ilateral, indicate )raintem in*ol*ement' ?C

of 8 or le i conidered an indication for intu)ation )ecaue of the ri! of poor protection of the air"a% from apiration'

Pri)ary orders: ox%&en, monitorin& EC?, 12 at, automatic @ cuff or arterial line3, I acce: need t"o lar&e-)ore 6K &au&e, 6G if

poi)le – femoral *ein cortice "ith 2 lumen3, run "ide open "ith normal aline for acutel% lo" @, ma% need to )e more retrained if

pulmonar% edema i a pro)lem' Coma coc!tail if dia&noi not !no"n alread%: thiamine 600 m& I, narcan 6 m& I, flumaBenil 0'6 m& I

amp A50+ i no lon&er included in thi coc!tail )ecaue of deleteriou effect of hi&h erum &lucoe on the in;ured )rain3' Initial

in*eti&ation: C@C, l%te, urea, creatinine, @?, &lucoe, ioniBed Ca, CD-M@, troponin, I(>TT, EC?, porta)le C=>, cro-ta)le later

C-pine and hard collar if there i head in;ur% or an% i&nificant trauma'

Secondary survey:


44/118

"e)atologic e(a): patient diro)ed to under"ear, draped )elo" the "ait'

"atient sitting

Inpect the patient &enerall% for petechiae, a)normal !in tone, hair fallin& out' Inpect the fin&er and toe nail for d%troph%, flame

hemorrha&e, leu!on%chia, inpected the palm for er%thema and Aupu%tren contracture' Loo! in the noe and mouth for )leedin&,

petechiae, mae' alpate the anterior and poterior trian&le of the nec!, the upra and infra cla*icular area, and the axillae for l%mphnode' alpate the th%roid "hile tandin& )ehind the patient, a! her to "allo"' Chet – from )ehind the patient, inpect the !in' ercu

the lun& field for effuion and conolidation, aucultate the lun& field' ercu and aucultate the anterior lun& field' Liten o*er theaortic ri&ht upper ternal )order 2nd IC – %tolic O tenoi, diatolic O re&ur&itation, continuou O @T hunt, ri&ht or left3, pulmonar% l

upper ternal )order 2nd IC – %tolic O A, pulmonar% flo", continuou O ductu, L@T hunt3, tricupid left lo"er ternal )order 5 th IC%tolic O re&ur&itation ''' till murmur, diatolic O tenoi3 and mitral apex 5 th IC and midcla*icular line – %tolic O prolape,

re&ur&itationH diatolic O tenoi3 area'

"atient lying supine

Compre the ternum and ri)ca&e for pain een in multiple m%eloma3' Inpect the a)domen' ucultate for )o"el ound' alpate for

enlar&ement of the pleen and li*er' ercu the li*er' alpate the &roin for l%mph node' (ote: a*oid rectal exam a thi trauma ma% cau

)leedin&'

Most liely diagnosis: idiopathic throm)oc%topenic purpura IT3, alo called immunolo&ic throm)oc%topenic purpura or +edhof diea

our 7indings on history !hich !ould hel* to con7ir) the diagnosis: 6' >emittin&-relapin& coure, 2' Mild fe*er, F' plenic dicomfo

due to mild enlar&ement, G' @leedin& after lo" doe of (IA'

our investigations: @lood mear, I(>TT for hemophilia3, erum ureacreatinine for hemol%tic-uremic %ndrome3, erum platelet-

aociated I&? for IT3'

A8


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46/118

;escri*tion o7 9ariu) s!allo! 7indings: trin& i&n, &raded narro"in& of intra-eopha&eal diameter extendin& from T5 to T8 le*el'

Most liely diagnosis: eopha&eal cancer'

Investigation to con7ir) diagnosis: endocop% "ith )iop%'

urther investigations: CT chet for mediatinal and l%mph node in*ol*ement3, chet =-ra%, li*er function tet, a)dominal ultraound

met3'

448 : year old !ith 9P 4


47/118

Claification of @

A@: N .0 normal3, .0-60G mild e&ular aero)ic exercie 50-K0 min, F

per "ee!3'

48 4 year old 7e)ale !ith bloody diarrhea8 Tae a history8 indings% &bdo)inal cra)*ing8 Si( !atery stools in the *ast 7our h

containing )aroon colored blood8 eels diy and !ea8 No *revious history o7 diarrhea *reviously !ell8 $% ?hat t!o 7indings

history indicate the seriousness o7 the *roble)= Give three *ossible diagnoses8 Give 7our investigations a**ro*riate to this situati

"istory: name, a&e, occupation' 1net, duration, fre$uenc%, of diarrhea' ppearance of tool: ho" "ell formed, i )lood on analrecta

laceration3 or admixed "ith tool, i )lood )ri&ht red lo"er tract )leed3 or dar! )ro"n-)lac! upper tract )leed, e'&' tomach3' ain "ith

)o"el mo*ement, a)dominal pain or cramp "ith location, radiation, precipitatin& factor and alle*iatin& factor, $ualit%, e*erit%, timin&

"ith repect to defecation, &a )loatin&' @C'


48/118

411<

4:8 Middle aged !o)an !ith systolic eFection )ur)ur radiating into the carotids8 Per7or) *hysical e(a)8

The ph%ical exam for a patient "ith a heart murmur i a cardiopulmonar% exam'

atient in ittin& poition: ta!e *ital

Inpect for ur&ical car, trauma, )on% a)normalitie, c%anoi, arcu enili in the e%e i&n of hi&h choleterol3, )ul&in& *ein in the up

chet C %ndrome3, nicotine tain on fin&er, clu))in&, flame hemorrha&e on nail, o)eit%, "or! of )reathin&, intercotal indra"in&,

%mmetric chet mo*ement, *ii)le apex )eat'

alpate the apex, note "hether it i laterall% diplaced lateral to the mid-cla*icular line3 and feel for thrill or hea*e, feel radial plue

)ilaterall%'

ercu the lun& field anteriorl% and poteriorl%'

ucultate the lun& field anteriorl% and poteriorl%, al"a% e*aluate heart ound )efore murmur' Jirt liten for 6 and 2, then loo! for

and G and an% other unuual heart ound' Liten o*er the aortic ri&ht upper ternal )order 2nd IC – %tolic O tenoi, diatolic O

re&ur&itation, continuou O @T hunt, ri&ht or left3, *ul)onary left upper ternal )order 2nd IC – %tolic O A, pulmonar% flo",

continuou O ductu, L@T hunt3, tricus*id left lo"er ternal )order 5th IC – %tolic O re&ur&itation ''' till murmur, diatolic O teno

and )itral apex 5th IC and midcla*icular line – %tolic O prolape, re&ur&itationH diatolic O tenoi3 area a "ell a o*er the ri&ht

cla*icle, and )oth carotid' Liten for ru)' To )rin& out an aortic murmur t%picall% aortic re&ur&itation3, a! patient to lean for"ard, exha

and top )reathin& "hile %ou liten o*er the aortic area' To )rin& out a mitral murmur, a! patient to lie upine and roll partl% onto the left

ide "hile %ou liten o*er the apex' In &eneral, murmur are accentuated )% increain& the d%namicit% of the heart "ith mild exercie, uc

a a!in& the patient to "al! up a fli&ht of tair'

Murmur are decri)ed in term of "here the% are heard loudet, "here the ound radiate, "hether it occur in %tole or diatole, the pitc

e'&' hi&h, lo"3, $ualit% e'&' harh, )lo"in&, muical3, contour e'&' crecendo, decrecendo or plateau3 and it loudne &raded out of ix

e'&' III3' The murmur of aortic tenoi i loudet o*er the aortic area, radiate to the cla*icle or carotid, occur in %tole, ha medium

hi&h pitch, i harh and crecendo-decrecendo' mitral re&ur&itation murmur )% contrat, i loudet o*er the apex, alo occur in %tole

radiate to the axilla, i medium to hi&h in pitch, )lo"in& and plateau'

Innocent murmur are NFK in intenit%, pea! earl% in %tole, top lon& )efore 2, are heard )et at the )ae of the heart aortic and

pulmonar% area3, are not aociated "ith clic! or hea*e, and EC? and C=> are normal'

atient l%in& upine

ucultate for )ruit o*er the renal on the a)domen' 1)er*e for pulation due to a)dominal aortic aneur%m, palpate a)domen, femora

pule, and aucultate for femoral )ruit, palpate the popliteal pule, inpect the le& and feet for *enou tai or arterial inufficienc%

ulcer, palpate the dorali pedi and ti)iali poterior pedal pule' Jeel the an!le for pittin& edema'

DP: >aie the head of the )ed F0 de&ree and inpect the nec!' ;u&ular *enou pulation hi&her than G-5 cm a)o*e the ternal notch

approximatel% the le*el of the ri&ht atrium3 i a)normal' If no i *ii)le then %ou ma% ha*e to raie or lo"er the )ed for hi&h or lo"

repecti*el%' Chec! the hepato;u&ular reflux upine, mouth open, )reathin& normall% → compre the li*er, the ;u&ular *enou pul

hould either not rie or remain ele*ated onl% tranientl%, a utained ele*ation P 6 cm in the i patholo&ical3' Thi i ued to ae hi

;u&ular *enou preure and > function'

468 20 year old )an !ith le7t.sided chest *ain8 Manage H)eans history *hysical investigations and treat)ent58 indings% bruise o

chest !all nor)al C-R and 'CG8

;i77erential ;iagnosis 7or Chest Pain

Cardiac Non.Cardiac

ulmonar% ?I MD(euro %cholo&ic


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n&ina

MI

ericarditi

M%ocarditi

Aiectin& aorta

neumonia " pleuriti

neumothorax

E

ulmonar% h%pertenion

Eopha&eal reflux

lcer

rthriti

Chondriti

>i) fracture

epirator% %mptom: cou&h, putum, fe*er, hemopt%i' ?I %mptom: heart)urn, d%pha&ia' re*iou epiode, chronolo&% of

thee' and EC? "ith a chet "all )ruie a e*idence of trauma end patient home, recommend non-precription

pain medication T%lenol andor i)uprofen3 and ad*ie that the pain hould u)ide &raduall%' ince the patient i at ri! )ecaue of hi a&

&roup and male &ender, explain the %mptom of m%ocardial infarct MI3 and ad*ie to return immediatel% if thee occur'

428 ,oung )an !ith recent onset bac *ain and li)*8 Tae history and *hysical8

& di77erential 7or lo! bac *ain is:

6' Ae&enerati*e .0/ of all )ac! pain3

Mechanical de&enerati*e, facet ;oint pain, mucle trainpam3

pinal tenoi con&enital, oteoph%te, central dic3

eripheral ner*e compreion dic herniation or rupture3

2' Cauda E$uina %ndrome

F' (eoplatic: primar% or metatatic

G' Trauma: fracture compreion, ditraction, tranlation, rotation35' pond%loarthropathie: e'&' an!%loin& pond%liti

K' Aicitioteom%eliti

7' >eferred: aorta a)dominal aortic aneur%m3, renal p%elonephriti3, ureter nephrolithiai3, pancrea pancreatiti3

8' Malin&erin&

@ecaue dico&enic and tenotic radiculopath% "hich ha*e not impro*ed o*er at leat G "ee! ma% )e treata)le ur&icall%, the priorit% of a

hitor% and ph%ical for )ac! pain i to differentiate radiculopath% from other caue and to identif% the ner*e root'

The mot common di! herniation i a poterolateral LG-5, "hich compree the L5 root' The herniation "ill alo compre the LG root if

herniation i far lateral and the 6 root if it i more medial central3' The econd mot common herniation i a poterolateral L5-6, "hich

compree the 6 root' In the thoracic and lum)ar pine, the ner*e root exit )elo" the pedicle of the *erte)ra of the ame num)er, "hil

the nec! the ner*e root exit a)o*e the pedicle of the *erte)ra of the ame num)er' L5 compreion produce radiation from )uttoc! to lat

calf, lateral calf pain, num)ne of the medial dorum of foot includin& "e) of &reat toe3, and an!le doriflexion "ea!ne, 6 comprei

produce radiation poteriorl% do"n le& to heel, poterior calf pain, lateral foot num)ne and an!le plantar flexion "ea!ne "ith decre

an!le ;er!3'

"istory: >ed fla& @CDI(3 → @: )o"el or )ladder d%functionH : anetheia addle3H C: contitutional %mptommali&nanc%H D:

chronic dieaeH : paretheiaH : a&e P 50H I: I dru& uerH (: neuromotor deficit'

Aecri)e the pain, location, radiation L5 radiculopath% caue radiation from )uttoc! to lateral calf, 6 radiate poteriorl% do"n le& to he

$ualit%, duration, fre$uenc%, intenit%, circumtance under "hich it occur, a&&ra*atin& and relie*in& factor' 1net and chronolo&%,

pre*iou epiode' re*iou in*eti&ation, treatment'


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ain "ore l%in& do"n and )ilateral le& "ea!ne u&&et pinal tenoi or an!%loin& pond%liti' pinal tenoi i characteriBed )%

"orenin& of %mptom "ith tandin& and "al!in&, "ith relief on )endin& and ettin& a t%pical hitor% of leanin& on and )endin& o*er th

hoppin& cart for relief of pain "hile hoppin& i u&&eti*e of pinal tenoi3' n!%loin& pond%liti i characteriBed )% mornin& tiffn

relie*ed )% acti*it%' ain "ore in )ac! than in )uttoc! or le& u&&et mechanical )ac! pain' ain "ore in )uttoc! or le& than in )ac!

u&&et radiculopath%' redominatin& %mptom of tiffne are u&&eti*e of an!%loin& pond%liti' @ac! pain i recurrin& and tend t

)e nocturnal' Mornin& tiffne impro*e o*er the da%' Ma% )e aociated "ith "ei&ht lo, fe*er, fati&ue, anemia' Jocu on ;oint %mpto

t%picall% lar&e ;oint3, u*eiti occur in one third of cae3, and famil% hitor%'


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except health% i

adminitered C "hile the other are IM' )onths AT,


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"y*ochondriasis: exa&&eration or miinterpretation of normal enor% phenomena to the point of functional dia)ilit%' E*idence doe not

upport a ph%ical diorder' ociated "ith o)ei*e fear of eriou illne and doctor hoppin& depite reaurance' @elief i not

deluional a peron ac!no"led&e unrealitic interpretation' Treatment: counelin&, reaurance, cloe follo"-up'

ibro)yalgia: alo called fi)roiti and fi)rom%oiti' 80-.0/ of cae occur in middle-a&ed female, ma% afflict 5/ of adult "omen,

t%picall% cardio*acularl% unfit, depreed, pre*ioul% normal life onet often after car accident3' ociated "ith a)ent or decreaed non

>EM ta&e G leep, patient "a!e from leep feelin& unrefrehed' Contant, achin&, axial pain "ith )ilateral tender point not tri&&er poi

at "hich referred pain i tri&&ered due to m%ofachial pain from o*erue, e'&' tenni el)o"3' The diorder follo" a "axin& and "anin&

coure ultimatel% "ithout pro&reion or reolution, and ma% )ecome dia)lin&' Characteritic reproduci)le tender point are located)ilaterall% at lateral )order of ternum, ternocleidomatoid, poterior nec!, trapeBiu, rhom)oid, o*er acroiliac ;oint, lateral thi&h,

poterior and medial !nee' atient hould ha*e ele*en of the a)o*e ei&hteen tender point for a dia&noi' Treatment: amitript%line 25-75

1 $


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'(a)ination 7or lobar consolidation: In &eneral, pulmonar% effuion decreae tranmiion of )reath and *ocal ound to the chet "al

"hile conolidation een in pneumonia3 increae it' Jour maneu*er )rin& out the effect of increaed tranmiion: tactile 7re)itus i

increaed tranmiion of palpa)le fremitu to the chet "all "hile the patient repeat ninet%-nine, broncho*hony i enhanced

tranmiion of po!en "ord uch a ninet%-nine, ego*hony i a chan&e from an ee to an a% ound o*er the affected area "hile the

patient utain an ee ound, and !his*ered *ectoriloBuy i a mar!ed increae in audi)ilit% throu&h the chet "all o*er the affected are

"hile the patient "hiper the "ord ninet%-nine or one-t"o-three'

Signs o7 consolidation: increaed tactile fremitu, percuion dullne, crac!le, )ronchial )reath ound, increaed *oice tranmiion

)ronchophon%, e&ophon%, "hipered pectorilo$u%3'

Signs o7 "ID In7ection: and poi)le impendin& IA3 chec! entire !in urface for Dapoi arcoma, examine phar%nx for thruh or or

hair% leu!opla!ia Eptein-@arr *iru-related epithelial proliferation cauin& raied "hite pla$ue on the ide of the ton&ue3, palpate nec!

cla*icle, axillae, and &roin for l%mph node enlar&ed )% non-

C, an IA-definin& illne, i )ilateral hilar infiltrate, )ut =-ra% findin& are *aria)le and ma% )e al*eolar or intertitial'

Investigations: 12 at@?, C@C "ith differential and CAG count, LA< ele*ated in .5/ of C pneumonia and not in other

pneumonia3, )lood culture, putum for c%tolo&%&ram taincultureT@ tain if putum a*aila)le cou&h uuall% non-producti*e and indu

putum ma% fail3, )ronchocop% "ith c%tolo&%, &ram tain and culture of )ronchial "ahin& and )ruhin& ma% ee )ronchial Dapoi3'

Treat)ent: eptra A 2 ta) $8h x 6G da% outpatient "ith 6 ta) 1A or @IA F"ee! continued a proph%laxi' More pecific therap% "it

reult of dia&notic tet' In e*ere illne, admit to hopital, &i*e I eptra at ame doe and rednione G0 m& @IA x 5 da%, then 1A x

da%, then 20 m& 1A for proph%laxi' atient hould )e referred to an IA pecialit for anti*iral and poi)le experimental therapie'

Counelin& and referral to upport or&aniBation' Jollo" up appointment'

28 & day old in7ant has seru) bilirubin 0 )ol/L Hre78 Ma( 00 )ol/L58 Tae a history 7ro) the )other8 $% ?hat are the

*ossible causes 7or this abnor)ality= Give investigations and treat)ent8

50/ of term infant de*elop *ii)le ;aundice P 85-620 _molL or 5-K m&dL3

Mother’s obstetrics history: ?TL num)er of &etation, term pre&nancie, premature )irth, a)ortion, li*e children3, hitor% of pre*i

pre&nancie includin& neonatal ;aundice, maternal medical hitor% ep' li*er dieae, illne durin& pre&nanc% ep' dia)ete lar&e )irth

"ei&ht, pre-eclampia3, ru)ella terato&enic3, toxoplamoi from cat, infect fetal )rain3, herpe infect fetu, fre$uentl% fatal3, CM

dama&e fetal li*er3, terato&enic medication ta!en durin& pre&nanc%, dru& and alcohol ue, maternal )lood t%pe, complication of preen

pre&nanc% includin& &etational h%pertenion or dia)ete, h%perh%poth%roid, h%percoa&ulation' Jamil% hitor% of neonatal ;aundice, li*e

pro)lem'

Ne!born history: &etational a&e at )irth, caearean, induction, rupture of mem)rane artificial or prolon&ed, fetal ditre, forcep or

*acuum deli*er%, meconium, ?>, "a reucitation re$uired Initial )lood "or!, )reat feedin&


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E8 41 year old 7e)ale !ith vaginal discharge8 Tae a history8 $% Give three *ossible diagnoses !hat investigations !ould be

hel*7ul=

"istory: (ame, a&e, occupation, decription of dichar&e, onet, chronolo&%, pre*iou epiode, *olume, color, conitenc%, odor, timin&

related to mene3' ociated %mptom: pain includin& a)dominal, )urnin&, fe*er, itch, d%pareunia, d%uria, ur&enc%, fre$uenc%,

a&&ra*atin& and relie*in& factor' exual hitor%: num)er of pat and preent partner, &ender, t%pe of contraception condom3, poi)ili

of pre&nanc%, pat hitor% of exuall% tranmitted dieae' 1)tetric&%necolo&% hitor%: ?TL3 pre&nancie, a)ortionmicarria&e,

)irth, pap mear normal3, mentrual pattern' Medication epeciall% anti)iotic3, oral contracepti*e, other dru& ue, aller&ie' at

medical hitor% includin& dia)ete' Jamil% hitor%, re*ie" of %tem'

Causes o7 discharge: h%iolo&ical: normal midc%cle dichar&e, increaed etro&en tate' Infectiou: candidiai, )acterial *a&inoi

?ardnerella *a&inali3, trichomona infection, chlam%dia, &onorrhea (1TE: &onorrhea and chlam%dia can caue cer*iciti, IA and

urethriti, )ut do not caue *a&initi – )ut Toronto (ote include them in the differential for *a&inal dichar&e3, )artholiniti or @artholin

a)ce, IA' (eoplatic: *a&inal intraepithelial neoplaia I(3, *a&inal $uamou cell carcinoma, in*ai*e cer*ical carcinoma, fallopi

tu)e carcinoma' 1ther: aller&icirritati*e *a&initi, forei&n )od%, atrophic *a&initi, entero*a&inal fitulae'

Investigations: peculum exam, "a) and culture, aline lide microcop% and D1< "hiff tet add D1< to *a&inal ecretion on a lide3

Thee &i*e reult a follo":

Candidiasis: inflamed appearance, lump% "hite dichar&e, pore and peudoh%phae een under microcope' Treatment: miconaBole *a&i

uppoitor%'

9acterial vaginosis: non-inflamed, thin &ra% ecretion, clue cell under microcope epithelial cell "ith o)cured )order due to adheren

of )acteria3, fih% odor on D1< tet' Treatment: metronidaBole 500m& 1 @IA x 7 da% in pre&nanc% ue moxicillin 500m& TIA x 7

da%3'

Tricho)onas: inflammation, froth% %ello"-&ra%-&reen dichar&e, motile trichomonad een under microcope' Treatment: metronidaBol

& x 6 or 500m& 1 @IA x 7 da% in pre&nanc% ue ClotrimaBole *a&inal uppoitorie3'

A8


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18 2 year old )ale !ith a history o7 dys*e*sia and binge drining has abdo)inal *ain8 Per7or) a 7ocused *hysical e(a)8 $% ?

radiological investigations !ould you order and !hy=

Physical e(a) 7or abdo)inal *ain: *ital, poture unmo*in& in fetal poition u&&et peritoniti "hile "rithin& u&&et renal colic3,

;aundice, nutritional tatu, )uccal mucoa, teeth, )reath hepatic fetor3, parotid h%pertroph%, &loiti, inpect chet for telan&ectaia,

&%necomatia, lo of axillar% hair' o*in& i&n: palpation of the LL# produce >L# pain' oa i&n: pain on

pai*e or acti*e flexion at the hip, indicate peritoneal irritation o*er the poa or poa a)ce' 1)turator i&n: pain on internal or exter

rotation of the hip, indicate )o"el herniation into the o)turator canal' e for acite' ! patient to roll onto ide and pound

coto*erte)ral an&le li&htl% "ith fit, C an&le tenderne indicate !idne% pain due to p%elonephriti or nephrolithiai' alpate &roin f

hernia'

Rectal: palpate protate, rectal helf, chec! for &ro or occult )lood'

Radiological Investigations: &bdo)inal : vie!s: upine, upri&ht, left lateral decu)itu' Ailated )o"el "ith multiple airfluid le*el

indicate ileu' Ailated proximal )o"el "ith collaped dital )o"el indicate o)truction' Chec! for &atric ditenion' mall )o"el ha

circular plica: line &o all the "a% acro' Lar&e )o"el ha interrupted hautra: line &o half"a% acro' Chec! for calcified !idne% tone,

fecolith and appendiceal airfluid le*el' Can ee &alltone and a)dominal aortic aneur%m if calcified' &bdo)inal ultrasound: &alltone

cholec%titi, pancreatiti, appendiciti, h%dronephropath%, !idne% tone, a)dominal aneur%m' C-R : chec! for free air under the diaphr

in an upri&ht film'

:08 E0 year old )ale !ith nec *ain and le7t ar) !eaness8 Per7or) 7ocused *hysical e(a)8 indings% decreased sensation over

inde( and )iddle 7inger )ild !rist e(tensor and trice*s !eaness8 $% ;escribe a cervical s*ine 7il) o7 the *atient’s nec Hsho!s

narro!ing o7 Chom)er&, ronator drift'

Nec : inpect for leion, a%mmetr%, mucle "atin&, epeciall% ternocleidomatoid, palpate for node, mae, palpate doral *erte)ral

pine, ran&e of motion'

Shoulders ar)s hands: inpect for %mmetr%, "atin&, faciculation, !in leion' o"er: Tet deltoid C53, )icep CK3, tricep and

"rit extenion C73, hand intrinic C83' (ote that each mucle &roup actuall% ha mixed ner*e root inner*ation, i'e' deltoid and )icep

C5,K3, tricep CK,7,83, "rit extenion CK,73, hand intrinic C8,T63' %mpathetic outflo" occur at C8, T6' enation: chec! pinpric!

*i)ration, li&ht touch o*er the houlder C53, thum) CK3, index and middle fin&er C73, rin& and little fin&er C83' Aeep tendon reflexe a)icep, tricep, )rachioradiali,


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Lateral Cervical ;isc Syndro)e

C6.2 C2.< Cin& fin&er

Little fin&er

Peri*heral nerves: Chec! t"o point dicrimination at each fin&ertip' To determine peripheral ner*e dama&e: Median ner*e territor% i the

palmar urface of the thum), and the palmar urface and doral tip of the index, middle and thenar ide of the rin& fin&er' enation to t

ulnar ide of the hand i the ulnar ner*e, and the doral urface of the thenar ide of the hand i radial ner*e inner*ated' The median ner*e

alo inner*ate mot mucle of the thenar eminence, and the 6t and 2nd lum)rical' The thum) i "ea! in a)duction at .0 de&ree to the

plane of the hand in median ner*e d%function' Tinel i&n: tappin& the palmar urface of the "rit elicit hootin& paretheia in median

ditri)ution' halen i&n: maximall% flexin& )oth "rit )% puhin& the dori of the hand to&ether elicit median ner*e ditri)ution

num)ne or paretheia after F0-K0 econd'

C.s*ine -.rays: Lateral: an ade$uate lateral ho" the top of the T6 *erte)ra: loo! for ali&nment of the anterior and poterior mar&in of

*erte)ral )odie a "ell a pinou procee' pinou procee ma% ha*e a)normal eparation in in;ur%' The maximal normal ditance

)et"een the poterior apect of the anterior arch of C6 and the den i Fmm in adult and 5mm in children' Loo! for re&ularit% of di! pa

hei&ht, &a in the di! pace u&&et de&eneration3, oteoph%te, pre-*erte)ral "ellin& &reater than one third of the *erte)ral )od% "idth

mm from C6-G, 22mm from C5-73'


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Manage)ent: Jole%, I, l%te, &lucoe, @?, erum !etone' eptic "or!-up: C@C, C=>, )lood culture, urinal%i, EC? if D i critical

ele*ated' 6 L ( per hour x 2-F hour or until tach%cardia and @ normaliBe, then 500 cchr x 2 hour, then 250 cch x 5 hour' Inulin dr

at 2 hr' Chec! &lucoe and l%te $2h' +hen &lucoe drop to 65, "itch fluid to maintenance 2F-6F A5+( S 20 mE$ DClL G:2:6

rule3' @e&in diet and re&ular inulin re&imen' If the AD "a the reult of non-compliance cloe follo"-up and education uch a diet an

dia)ete mana&ement counelin& "ith a dietitian are re$uired'

:8 & )other !ith her < !ee old !ho has been vo)iting 7or three days8 Tae a history8 $% Investigations sho! a *al*able )ass in

the right e*igastriu) )etabolic hy*ochlore)ic alalosis8 ?hat is the diagnosis= Give a di77erential diagnosis 7or vo)iting in an

in7ant8

"istory o7 in7ant vo)iting: a&e of onet, duration, e*erit%, chronolo&%, aociation "ith feedin& or )od% poition, decription of force,

*olume, color, compoition )iliou, fecal, )lood, re&ur&itant3, &ettin& "ore or )etter, i child till hun&r% after"ard, or doe he ettle'

Cou&hin& or &a&&in& "ith feed tracheoeopha&eal fitula3' ociated diarrhea, contipation, fe*er, "ei&ht lo, a)dominal ditention,

urination' re other children ic!


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Psychiatry% , "a reucitation re$uired

Initial )lood "or!, )reat feedin& ecent *iral illne mononucleoi3, c

intolerance, "ei&ht &ain, dr% !in, )rittle hair, hoarene h%poth%roidim3, aociated mucle ache fi)rom%al&ia3, chet pain an&ina3,

hortne of )reath con&eti*e heart failure3' Slee* history: uual re$uirement, chronolo&% of leep pro)lem, treor, leep h%&iene

"hen, "here, re&ularit%, hift at "or!, $uiet, late, exercie, meal, alcohol, caffeine, precription and non-precription remedie, dru& an

medication3, leep latenc% time to fall aleep3, nocturnal a"a!enin&, earl% mornin& "a!enin&, da%time omnolence, omnolence "hile

dri*in&, "or!in& or durin& con*eration' ;e*ression screener: a in $uetion [G a)o*e' Mut full% explore uicidal ideation: doe patient

intend to harm elf, reaon for uicidal thou&ht, current plan, lethalit% of plan, acce to lethal mean, ha patient &i*en a"a% priBe

poeion or "ritten final note to lo*ed one, pre*iou attempt' Medication epeciall% TC, edati*e, antih%perteni*e3, aller&ie,

dru&alcohol ue, mo!in&, pat medical hitor%, famil% hitor%, re*ie" of %tem'

;i77erential ;iagnosis: Chronic fati&ue, C and


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treor' $a belle indifference – patient inappropriatel% ca*alier attitude to"ard a eriou %mptom' Treatment: anxiol%tic e'&'

loraBepam 6 m& 1 $Kh3, relaxation therap%, counelin&, cloe follo"-up'

Counseling: (ormaliBe thi pro)lem and *alidate the patient feelin&: the fact that e*eral pecialit ha*e aid there i nothin& "ron& "

the patient *iion doe not mean that there i not a u)tle medical pro)lem "hich ma% )ecome apparent later' Jor thi reaon it i import

to tic! "ith one doctor "ho !no" the patient "ell and can coordinate further referral if necear%' Man% people "ho are faced "ith the

poi)ilit% of marital infidelit% automaticall% acti*ate a defene mechanim "hich &i*e them time to ad;ut, and "hich i not under

conciou control: uch a reaction alo help the patient to enlit needed upport from other' Thi i a normal reaction for thee people'

Thee %mptom can *ar% "idel% from paral%i, to num)ne, to pain, to ina)ilit% to pea!, and *iual pro)lem includin& )lindne and

tunnel *iion' 1utline a plan for mana&ement: addre poi)le ource of anxiet% and tre: a fran! dicuion "ith the patient hu)ana)out fidelit% i re$uired and ma% )e done pri*atel% or if )oth partner are "illin&, in conultation "ith %ou or a marital therapit' The pat

hould tr% to conolidate a upport net"or!: parent, friend, etc' Conider depreion, leep or anxiet% medication a appropriate' rran

follo" up "ith )oth partner'

68 :0 year old )ale 7ro) another city8 ?ants iorinal *rescri*tion 7or chronic headaches rene!ed8 Manage8

ee $uetion [6K'

6:8 : year old 7e)ale !ith 6 hour abdo)inal *ain8 Per7or) 7ocused *hysical e(a)8 indings% *eritoneal signs *oint tenderness

Mc9urney’s *oint8 $% Give a di77erential diagnosis order investigations8 ?hat 7urther history !ould hel* con7ir) diagnosis=

Physical e(a) 7or abdo)inal *ain: ee $uetion [2.'

Rectal: rectal helf, chec! for &ro or occult )lood' lo include a pel*ic manual and peculum exam' "ont )e a!ed to perform thi at

LMCC II3' Chec! for pain "ith cer*ical motion een in IA3, pain on palpation of o*arie, ma, cer*ical dichar&e' Ta!e "a) ee

in*eti&ation3'

;i77erential diagnosis: appendiciti, o*arian c%t, rupture or o*arian torion, mittelchmerB, ectopic pre&nanc% life-threatenin&3, hepatiti

cholec%titi, &atroenteriti, peptic ulcer, pel*ic inflammator% dieae IA3, urinar% tract infection TI3, p%elonephriti, !idne% tone,

inflammator% )o"el dieae, intetinal o)truction due to *ol*ulu or I@A'

Investigations: @= F *ie", a)dominal-pel*ic ultraound, C@C, l%te, urea, creatinine, I(>TT, &lucoe, `hC?' rinal%i' tool foroccult )lood' Cer*ical "a) for culture and pap mear' If 1> i imminent order t%pe and cro for 2 unit, C=>'

"el*7ul 7urther history: a hitor% of &radual onet *a&ue perium)ilical or LL# pain mi&ratin& to a harper, more localiBed pain in the >L

o*er e*eral hour aociated "ith anorexia, nauea, and controlled )% till fetal poture u&&et appendiciti'

668


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Physical e(a) 7or abdo)inal *ain: ee $uetion [2. and [GF'

;i77erential diagnosis: uterine perforation )% IA, pel*ic inflammator% dieae IA more common "ith IA3, o*arian c%t "ith torion

rupture, tu)o-o*arian a)ce, ectopic pre&nanc% alo more common "ith IA3, &atroenteriti, inflammator% )o"el dieae, intetinal

o)truction due to *ol*ulu or I@A, appendiciti'

Investigations: @= F *ie", a)dominal-pel*ic ultraound, C@C, l%te, urea, creatinine, I(>TT, &lucoe, `hC?' rinal%i' tool for

occult )lood' Cer*ical "a) for culture and pap mear' If 1> i imminent order t%pe and cro for 2 unit' C=>'

6i! for mother: end or&an d%function

!idne%, li*er3, cere)ral hemorrha&e 50/ of death3, left *entricular failurepulmonar% edema, lo of pre&nanc% due to a)ruption often

"ith AIC3, eiBure, # tenderne, reflexe, C@C, l%te, creatinine, ur

uric acid, urinal%i "ith microcop%, 2G hour urine proteincreatinine clearance, LJT, I(>TT' Jetal , non-tre tet, )ioph%ical

profile ultraound "ith 5 criteria3, Aoppler flo"' @ed ret in left lateral decu)itu poition to reduce a)dominal *eel compreion3,

normal dietar% altprotein inta!e' (o ue of diureticantih%perteni*e'

ollo! u*: dail% @, dail% "ei&ht, dail% reflexe, fetal mo*ement count at home if patient li*e reaona)l% cloe to a hopital and can &e

tranportation fat3, fre$uent follo"-up *iit for )lood "or!, urinal%i and fetal monitorin&, )ed ret prefera)l% left ide3' Intruct patie

on "orenin& i&n: rapid "ei&ht &ain, li*er pain, *iual ditur)ance, peritent headache, dro"ine or eiBure'


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;elivery: earl% hopital admiion at FK "ee!3 for cloe monitorin& and adminitration of I M&1G G & o*er 20 minute, if i&n of C(

in*ol*ement are preent h%perreflexia, decreaed L1C, eiBure3' oi)le induction of earl% deli*er% or Cearean ection' Conider I

h%dralaBine firt line treatment3 5-60 m& I o*er 5 minute $65-F0min, econd line: la)etolol 20-50 m& I $60min, third line: nifedipine

20 m& 1 $20-K0min if deli*er% i not imminent or if deli*er% i imminent to decreae @ after coner*ati*e meaure tried diuretic and

alt or fluid retriction not ueful and ma% )e harmful3'

6E8 :0 year old !o)an !ith vaginal bleeding at :0 !ees gestation8 Tae a history8 $% Give a di77erential diagnosis8 Order

investigations8

"istory: patient IA name, a&e, occupation3, ?TL, "ee! of &etation' 1net of )leedin&, duration, etimate $uantit% num)er of padoa!ed3, color and conitenc% of )lood, aociated fe*er, chill, a)dominal dicomfort pain3, contraction, fetal mo*ement, li&htheadedn

lat exual intercoure ma% caue pottin& due to fria)le cer*ix3' ro)lem "ith pre*iou pre&nancie, pro)lem in thi pre&nanc%, medic

*iit to thi point, in*eti&ation done' ociated a)dominal trauma accident or a)ue3, dru& ue cocaine3, father and mother )lood t%

medication, alcohol, mo!in&, pat medical hitor%, famil% hitor%, re*ie" of %tem'

;i77erential diagnosis: placenta pre*ia placenta co*er internal o of cer*ix – the mot common caue of painle )leedin& in the third

trimeter3, )lood% ho" heddin& of cer*ical mucou plu&3, a)ruptio placenta eparation of placenta from uterine "all – uuall% painful3

*aa pre*ia fetal )leed due to root *eel of um)ilical cord o*erl%in& the cer*ical o – extremel% dan&erou to the fetu3' 1ther caue:

uterine rupture, coa&ulopath% AIC3, molar &etation, *a&inal tear, *a&inal infection, cer*ical pol%p, cer*iciti, cer*ical cancer, placenta

accreta, )leedin& from )ladder or )o"el' (1TE: no *a&inal exam until pre*ia ha )een ruled out )% 3'

Investigations: maternal *ital, C@C, I(>TT, fi)rino&en, t%pe and cro-match if )leedin& i e*ere, >h tatu ma% need >ho&am &am

&lo)ulin to pre*ent formation of anti)odie a&aint fetal )lood if mother i >h ne&ati*e and father i >h poiti*e3, fetal monitor, fetal

ultraound, maternal monitorin&, I acce, pel*ic peculum and manual exam "ith di&ital cer*ical exam do thee onl% after ultraound t

rule out placental pre*ia – can caue further )leedin& in pre*ia3, pt tet for fetal hemo&lo)in in *a&inal )lood, tet maternal )lood for

preence and amount of fetal hemo&lo)in determine amount of >ho&am re$uired to neutraliBe fetal )lood anti&enicit%3'

6A8 :4 year old 7e)ale !ith right hand nu)bness and !eaness8 Tae a history and *er7or) 7ocused *hysical e(a)8 $% ;i77erent

diagnosis investigations and treat)ent8

"istory: name, a&e occupation, amount of "or! done "ith hand, decription of %mptom, onet, duration, chronolo&%, time of da%,

a&&ra*atin& and relie*in& factor' re*iou epiode, in*eti&ation' ! a)out pain at ni&ht, difficult% turnin& a !e% or openin& ;ar i&nof "ea!ne3' Junctional limitation' ociated in;ur%, nec! pain, num)ne or "ea!ne in other area, *iual pro)lem, headache, nau

Medication, dru&alcohol ue, mo!in&, aller&ie, pat medical hitor% epeciall% AM, h%poth%roidim, rheumatoid arthriti, pre&nanc%3

ur&ical hitor%, famil% hitor%, re*ie" of %tem'

Physical e(a): ee $uetion [F0'

;i77erential diagnosis: carpal tunnel compreion of median ner*e, cer*ical radiculopath%, tro!eTI, dia)etic peripheral neuropath%,

)rachial plexu in;ur% or tumor'

Investigations: ner*e conduction tudie'

Treat)ent: modif% manual "or!, "rit plint often "orn at ni&ht3, (IA, local corticoteroid in;ection, control underl%in& %temic

contri)utor e'&' dia)ete, h%poth%roidim, arthriti3, ur&ical decompreion *ia flexor retinaculum releae (eurour&er% or latic ur&

conult3'

618 2: year old 7e)ale !ith incidental solitary lung nodule on C-R8 Tae a history8 indings% non.s)oer te(tile !orer no

sy)*to)s8 $% C-R sho!s ho)ogeneous round c) o*aci7ication in right u**er lobe8 Give a di77erential diagnosis and identi7y t

)ost liely diagnosis8 Order 7urther investigations8

"istory: name, a&e, occupation, li*in& condition, ho))ie, pet, ep' )ird, cat, tra*el hitor%, contact "ith haBardou u)tance e'&'

a)eto3' oiti*e T@ !in tet'


68/118

anorexia, ni&ht pain mo!in&' lcoholim' Lun& %mptom: cou&h, putum, hortne of )reathd%pnea, hemopt%i, "heeBe, orthopnea

(A, chet "all pain, Medication: dru&alcohol, aller&ie, pat medical hitor%, famil% hitor%, re*ie" of %tem'

;i77erential diagnosis: le than F cm i more li!el% to )e )eni&n )ut &reater than F cm i more li!el% mali&nant: neoplam G5/3 → prim

O 70/, )eni&n hamartoma, lipoma3 O 65/, metatatic O 60/H infection 5F/3 → T@, hitoplamoi, coccidiom%coiH other 2/3 →

&ranuloma car tiue from old pneumonia, T@ &ranuloma, hitoplamoi, ilicoi, arcoid3, *acular - malformation, infarct3,

con&enital c%t3, round pneumonia, round atelectai, loculated effuion' ercenta&e are for leion &reater than F cm'

Most liely diagnosis: &ranuloma'

Investigations: old C=> for comparion if leion i old and unchan&in&, inter*ention are le a&&rei*e, calcification i alo aociated

"ith )eni&n leion uch a old &ranuloma3, CT chet "ith CT &uided needle )iop%, putum for c%tolo&% and acid-fat tainin& T@3, T@

!in tet, )ronchocop% "ith )iop% and "ahin& if leion een, open )iop% or lo)ectom%'

&lgorith): olitar% nodule → pre*iou C=> → )eni&n or unchan&ed repeat in $F-Kmonth for 2 %ear if unchan&ed o)er*e, if chan&ed

an% time continueV3, mali&nant or chan&ed → CT thorax: cancer ta&e and treat3, calcification o)er*e3, no dia&noi → )ronchocop%

tranthoracic needle apiration → till no dia&noi reect for dia&noi3, inflammator% treat caue3, cancer ta&e and treat3'

208 Mother !ith < )onth old child !ho has diarrhea8 Tae a history8 inding% recently s!itched 7ro) breast )il to )il *o!der

7or)ula8 $% Give a di77erential diagnosis8 Reco))end treat)ent8

"istory: Aitin&uih )et"een acute diarrhea, chronic diarrhea "ith or "ithout failure to thri*e' (ame, a&e, a&e of onet and chronolo&% of

diarrhea, conitenc%, color, $uantit% and fre$uenc% of diarrhea, )lood in tool, concurrent illne, *omitin&, fe*er, anorexia, difficult%

)reathin&, laitude, dr% mouth, e%e, lo" urine output, illne affectin& other children in the famil% or adult' Jeed and feedin& hitor%

fruit ;uice3' ?ro"th pattern: "ei&ht lo >ecent immuniBation, tra*el, anti)iotic' Medication, pat medical hitor%, aller&ie, )irth hito

pre&nanc% pro)lem, maternal illne durin& pre&nanc%, famil% hitor%, re*ie" of %tem'

;i77erential diagnosis: infection )acteria: camp%lo)acter, almonellaH anti)iotic induced: c' diff colitiH paraitic: &iardiaH pot infectiou

econdar% lactae deficienc%3, intolerant of formula chan&e component of lactoe intolerance3, toddler diarrhea K month to FK month

reol*e pontaneoul% )% a&e 2-G %ear → lot of ;uice o*er"helm mall )o"el → diaccharide mala)orption3, o*erfeedin&, omotic

diarrhea due to hi&h omolalit% li$uid uch a ;uice, &atroenteriti' +ith "ei&ht lo conider mala)orption %ndrome: celiac dieae,

lactoe intolerance, mil! protein aller&%, c%tic fi)roi "ith chet infection3, I@A unuual at thi a&e3, enB%me deficiencie, li*er diea

)iliar% atreia, th%rotoxicoi'

Treat)ent: tr% non-mil! o% )aed3 formula' rran&e follo" up'

Note: Treatment for Toddler diarrhea → reaurance, elf-limitin&, G f → fi)er, normal fluid inta!e, F5-G0/ fat, dicoura&e exce frui

;uice'

248 20 year old )ale alcoholic8 Do)ited bright red blood 4 !ee ago8 Per7or) *hysical e(a)8 $% Give di77erential diagnosis8 ?h

is your treat)ent *lan=

Physical e(a): ee $uetion [2.'

;i77erential diagnosis: eopha&iti, &atriti, duodenal ulcer, peptic ulcer, Mallor%-+ei partial thic!ne3 tear, eopha&eal *arice, &atr

or eopha&eal cancer, lun& tumor, aorto-enteric fitula rare – can occur after pre*iou aortic ur&er%3'

Treat)ent *lan: place on omepraBole 20 m& 1 1A, patient to refrain from alcohol, dicontinue (IA, dra" )lood for I(>TT, T

LT, L, ??T, total )ili, C@C, l%te, urea, creatinine' C=> chec! for perforation → air under diaphra&m3, refer to &atroenterolo&% for

endocop%' Conider admiion if patient unrelia)le or tranportation i a pro)lem'

28 Tele*hone rings% hysterical )other says her child s!allo!ed a cleaning agent8 Manage over the *hone8 $% ?hat do you do a7t

hanging u* the *hone= ?hat investigations do you order in the 'R=


69/118

Over the *hone: Eta)lih calm, reaurance, o)tain caller name, phone num)er, addre' Child a&e, "ei&ht, medical pro)lem,

medication, aller&ie' Identif% a&ent in&eted, ha*e caller read haBard la)el if poi)le'


70/118

4116

2:8 aie head of )ed' ?i*e ox%&en K Lmin )% ma!' Monitor ox%&en aturation' 1rder tat C@C, l%te, &lucoe, I(>TT, er

CD-M@ and Troponin, @?, C=>, EC?' ?i*e che"a)le 6K0-F25 m& immediatel%' ecure I acce, )olu I laix G0 m&, puh if

fluid o*erload i upected, and *entolin if "heeBe are heard, &i*e u)lin&ual nitro pra% or 0'F m& L nitro if )lood preure i ade$uate

6 m& morphine I' >epeat nitro L $5min x F' Ma% re$uire additional morphine and nitro' >epeat CD-M@ and Troponin $8h x F'

;iagnosis: e*ere anterior "all ichemia e*ol*in& to infarct' >e$uired throm)ol%tic or cardiac catheteriBation' r&ent Cardiolo&% conu

a*aila)le'

268 A year old )ale arrives in the '; having 7allen


71/118

;i77erential% Caue of one "ee! of )iBarre )eha*ior: manic epiode )ipolar mood diorder3, depreion, dru&-induced teroid,

amphetamine, alcohol3, or&anic h%poth%roidim, frontal lo)e tumor, M, dementia3, chiBophrenia'

"istory:

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