Friday, February 10, 2012

~aku bukan parasit~ #004 Short case examination

May peace be upon us all

As promised, my supervisor's tips for the coming short case. *This may be incomplete and perhaps I mixed up some of my thoughts and understanding. Disclaimer: pleaese don't blame anyone is none of this is happening*

Firstly, you need to be able to know the diagnosis before you start examining. What? HOW? hehe. Not entirely true. What it really means is that you need to come up with your differentials based on the question alone. As the Dr says: typical cases. You then examine, get the signs, then it fits into a pattern-which confirms your thought and then you got your provisional and differentials:) In other words, it is the retrograde of your learning process. When we are learning, we get the signs, and then "oh, this must be this or that". Then we get to learn the etiology, pathophysiology, etc. honestly, I hardly do this. Seriously melalut? Let's move on. 

If you got hands examination, it is often scleroderma, RA, PsA. So if your question is "examine the hand", your differentials are at least these three. See? You have the differentials already. How to differentiate? You know better than me :) *A little bit on PsA: Look for pitting of the nails, sublingual hyperkeratotic, onycholysis, total nail dystrophy, psoriatic plaques(at the extensor surfaces[hand and legs], behind the ear, along the hairlines, periumbilicus).

Q: Examine the pulse. This is either AF or collapsing pulse. If this question, unlike CVS examination, palpate the pulse for 1 minute(you might miss slow AF if you palpate for only 15-30 secs). Your differentials: causes of collapsing pulse(5): AR/MR is common, A-V fistula, PDA, rupture of sinus valsalva. (other causes(including bounding pulse): APAMBATAF; aortic regurg; PDA; AV Fistula; MR; Beri-beri; Anemia; Thyrotoxicosis; Atherosclerotic aorta; Fever-bacterial endocarditis), causes of AF(refer the workshop :P)

Q: Inspect and proceed/ Look and proceed. The differentials: Cushingoid features[moon face], Parkinson[expressionless], thyroid[goitre or thyroid eye disease], *stroke[maybe unlikely for undergrad, the clue is Ryle's tube and reduced nasolabial fold]. It is going to be something obvious enough to be noted by undergraduates :D.

**if thyroid[if you notice goitre/neck lump], proceed to the neck first[due to time constraint]. After that only you proceed to the thyroid function status. Hands-fine tremor(kembangkan jari/spread the fingers), sweating, warm, AF; eye-lid lag, lid retraction, chemosis, ophthalmoplegia; reflex(don't forget!)- in hypothyroid=delayed relaxation --> ankle jerk!(don't know why) read this.;CVS and respiratory may have findings if patient is in failure but maybe not enough time for that.Note that presence of clubbing/thyroid eye ds/ pretibial myxedema is specific for Grave's ds. 

Skin: Psoriasis. Any other possibilities? Ulcer- unlikely bcoz they often in Surgery or Orthopaedics.

CVS: murmur-most common MR, VSD(can be in someone who is 40-50 years old), AR, TR(raised JVP but not tachypnoeic. Possible- AS, prosthetic valve(often have murmur as well- soft/ejection systolic murmur-this is normal, only if loud or diastolic murmur=the valve is failing). Uncommon: MS, ASD. CCF is even more uncommon because treated CCF does not have much finding and acute patient is not stable enough for exams. *just in case: CCF= raised JVP+tachypnoea


  1. Pleural effusion (stony though you may still unable to diff btwn stony and dull dullness+reduced/absent breath sound/vocal fremitus)
  2. Consolidation: (dullness+ increased vocal fremitus) - consolidation only have two possible causes - infection and malignancy. 
  3. Collapse: may present in patient who has had lobectomy/pneumonectomy[any lateral scar?]
  4. Generalised coarse creps: think of bronchiectasis
  5. Only generalised fine creps/scattered: fibrosis
**according to Dr, bronchiectasis and fibrosis are very easy to get because they are under regular follow-up, so can contact them any time. 
also, please give full diagnosis. Eg: AEBA/AECOPD secondary to pneumonia. 

-polycystic kidney ds(look for fistula[run your hand over the pt's arm]/nephrectomy scar[very lateral])
**ballotable kidney: bilateral-PCKD, unilateral-renal cell Ca/obstructive uropathy/PCKD with one kidney removed already.
**transplanted kidney: unlikely for undergrad. Just in case, there is J-shaped/curved scar at the inguinal region with mass underneath. 

Neuro: (upper limb/lower limb/cranial nerve[not common but possible; facial nerve{VII} or eye{III, IV, VI}])
-stroke: Ryle's tube, facial asymmetry
-if one sided lesion+aphasia/dyspasia: consider stroke
-if both lower limb: spinal cord lesion (LMNL)

**don't forget peripheral neuropathy

footnote: This list is not comprehensive. Let us all learn to become a good doctor rather than just passing the exam. May Allah grant His blessings to those who strive and leave the rest to Him.

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