5th Med Final Exam Hints:

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 pts 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 Cant 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)
Likely Case: Diabetic Foot:

- Test vibration, temp, sensation, proprioception

- Probably no ulcer
- Not very suitable for short case (has happened) but better for long case as
patient pedal hygiene and student hand washing separate issues.

Likely Case: Parkinsons:

If patient is sitting in a chair with shoes on, they are likely prepared to be asked to
walk. Not so much if in bed.

- Examination: GET PATIENT TO WALK TO ILLUSTRATE BRADYKINESIA,

SHUFFLING GAIT, COGWHEEL RIGIDITY
- Tone
o Expect hypertonia
o Do bilaterally as Parkinsons can present unilaterally
o Reinforce maneuver makes tone become jerky
- Brisk reflexes
- Glabellar tap: Parkinsons patient will continue to blink. Not specific test for
Parkinsons

Likely Case: Stroke:

- Probably pt with a very mild stroke exhibiting mild hemiparesis

Muskuloskeletal/Connective Tissue Disease:

Likely Case: Rash

- High probability of being psoriasis; psoriasis is a stable rash. Ethically

difficult to maintain a good clinical rash of cellulitis!
- Psoriasis pits nails and affects extensor surfaces.
- Psoriasis can mimic RA so check the nails and extensor surfaces carefully.

Possible case: Discoid

Possible Case: Myotonic Dystrophy

- Balding
- Ptosis (eyelid infringes on pupil)
- Permanently corrugated forehead

Likely Case: Rheumatoid Arthritis:

- If told patient has RA (Dr. Phelen often does this), job of short case is to
determine whether active or not (red, hot, tender, swollen). Listen to the
question being posed!!!
- Hint: Observe as much as possible without touching as patient may be in
real pain. Be prepared to introduce self WITHOUT shaking hand.
 - Ask pt to place hands on pillow, observe joints. Ask patient to put backs of
hands to opposite cheeks to check extensor surfaces for tophi.
- Hint: brush hair back to check backs of ears for tophi!
- Palpation, always looking at pt for signs of tenderness:
o Temp first
o 4 point (index finger and thumb of both hands) over all joints,
especially DIP and nails (tenderness and subluxation)
o Hint: DIPs spared in RA, involved in psoriatic arthritis (psoriatic
arthropathy). Sometimes only distinguishing feature
o 6 point examination for wrists (tenderness and subluxation).
- Functionality Testing: use discrimination based on pt. 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 cant pick it up so ask to push it side to side.

Give summary: Condition involves X joints, which are warm and tender to touch.
Also has X present. Based on these findings this would be X (R.A.; psoriatic
arthritis) which is/is not currently active.

Likely case: Scleroderma:

- Observe:
o Pinching of skin around nose, mouth, eyes
o Sclerodactyly
o Examine: Hands: CReST
o C = calcinosis
o Re = Reynauds (do not elicit as is painful condition! Its there or it
isnt)
o S = Sclerodactyly
o T = Telangiectasia usually in mouth though rarely found on chest
- Ask: Difficulty with swallowing?
o Implies esophageal involvement poorer prognosis

Endocrine
Acromegaly
Thyroid (Graves) especially in SIVUH
- If it is a thyroid exam, examiner will want to know 1 to 3 things:
o Is thyroid involved?
o What is thyroid status?
o Are eye signs present?
- Establish suspicion of Graves with examiner via observation of goiter? Ex-
opthalmos?
- Next step is to determine status (active or not):
- Examination:
o Pt to stick out tongue while looking at neck to r/o thyroglossal cyst
o Diaphoresis
 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, hung in hypo
o Eye signs:
Look for white of cornea between upper rim of pupil and eye lid
Look from side, 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, begin with hands and arms.

- Palmar erythema and spider naevi indicate chronic disease

o Unlikely to palpate liver edge
o If liver palpable, expect hard, craggy edge
- Hint:
o Tender hepatomegaly: acute scenario
o Non-tender hepatomegaly: chronic scenario

Vascular:

If FULTON is the examiner, likely topic: EVAR

Question 1: What do you need to ensure is present for EVAR? - Strong femoral
pulses bilaterally because that is the method of access.

Question 2: What else do you need to know prior to EVAR? - Renal function. EVAR
utilizes high doses of contrast medium which is cleared by the kidney. Impaired
renal function in the presence of these volumes of contrast can result in contrast
nephropathy.

OBSTETRICS:

Likely patients:

- Small for dates (LMP very important here dating accuracy)

 - Diabetes
- Twins in for a rest
- HTN (social hx: would BP be lower if home with family?)

After hour examiners will appear:

Have patient sitting on 2 pillows for presentation

Ten steps to 1H. Do in this order to keep examiners listening and you talking as
little about obstetrics as possible!:

1. Introduce patient to examiners

a. (eg: Examiner X and Examiner Y, Id like you to meet Mary Murphy
from Glasheen Rd.)

2. Reason for Admission:

a. Eg: Mary Murphy is in for PPH following birth 2 weeks ago

3. Past medical and past surgical history

4. Past Obstetric History (KISS philosophy if normal)

a. Know childrens names and ages
b. Know heaviest weight at birth
c. Confirm facts with patient: isnt that right Mrs. Murphy?
5. Menstrual History
a. On OCP? Bleed may have occurred as chemical withdrawal bleed from
pill otherwise:
b. Phrase along these lines:
i. Not on pill
ii. Her cycle is X days of which she bleeds X days
iii. She is sure of her dates
iv. Has had a scan in early pregnancy which concurred with her
dates

6. Family History
a. Always include a comment on these 5 (stating relevant negatives buys
time):
i. Diabetes?
ii. HTN?
iii. Congenital Abnormalities
iv. Rheumatic Fever
v. Multiple Pregnancies

7. Social History make it about the family!

a. Who minds the kids/siblings in her absence?
b. Domestic situation
i. If sensitive, I would like to discuss afterwards.
c. What does the family do?
i. Daughter in ballet?
ii. Son playing hurling or football?
 iii. This gives a sense that youve got to know the patient a bit
beyond her current situation
d. Smoke/drink/etc

8. Events of Pregnancy do this late in the presentation so you dont

say something that has you talking the entire time about technical
obstetrics and forget about the patient!
a. Describe hx of pregnancy
i. Booked on
ii. Scan on agreed with dates
iii. Had normal pregnancy until
b. Time to guild the lily: Ask the examiner a question about the patient
they likely wont know but is relevant to pt iii. (Did you happen to see
the results of?)
i. Eg: normal until flank pains. Ask for result of msu query
infection?
ii. Normal until blood pv: what was blood group? Hb?
iii. Normal until rash: what is rubella status?
c. This is a bit of a distraction to both you and examiner, snaps them
back from a day dream, and shows you were thinking beyond getting
and presenting a good history.

9. On Examination:
a. Mrs Murphy looks well/fatigued/pale/content/bored
b. CVS/Resp systems first:
i. NB: mention haematinic murmur of pregnancy/reproduction if
pregnant. All pregnant women have it!
c. Of Abdomen: IPPA approach:
i. Caution of pitfall:
1. Cephalic presentation?
2. Engaged/not engaged?
ii. Make certain of presentation otherwise say unsure. Honesty
makes fewer mistakes than guesses.
iii. Auscultation: Can say you heard heart over the back on the L.
side. If cant find it again, fetus moved (which they should do all
the time).
iv. Look at feet/ankles. No matter how neatly the bed is made up
by the nurses, rip up the end of the bed to look at the feet for:
1. oedema (and medial tibia)
2. varicose veins.
Do not pull covers down from patients waist. Not a slick move!

10. In summary and Management