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The Residents Guide to the LMCC II

3rd Edition
Revised by AMB.
The Licentiate of the Medical Council of Canada Exam, part II, also known as the MCCQE II, was the
traditional means of qualifying for a general license to practice medicine in Canada. Now that both the
internship year and the general license are no longer available, many residents view the exam as a
stressful and expensive exercise in futility. While the process is stressful and expensive, it need not be
futile. Preparation for the exam can be an enlightening review. Scenarios tend to repeat over the years,
the pass rate is greater than 95% on the first attempt, and there is an option to rewrite, so dont panic.
The exam is an OSCE (Observed Scenario Clinical Exam) in which the candidate progresses through a
series of stations. Your starting point is determined alphabetically. At each station there is a physician
examiner and either a real person posing as a patient or a telephone over which you must speak to a
patient or another physician requesting assistance.
The most recent sessions (since 1997) contain six short cases known as 5-minute couplets, in which the
candidate is allotted 5 minutes to assess a patient and 5 minutes to write short answers to questions related
to the case. There was also a series of six longer cases in which the candidates were presented with a
more involved clinical problem, such as a resuscitation or psychosocial counseling session, lasting 10
minutes each. The physician examiner may ask one or two questions in the last minute of a 10-minute
station. There is one minute between stations during which you can look at a brief description of the
patient and consider your approach. Occasionally pilot questions will be included in the exam, which
will not count towards the final mark but are used to test new questions. You will not know which
questions are pilot questions.
The content of the exam is general medicine. This means family practice & emergency medicine. The
following topics appear consistently:
Pediatrics diarrhea, development, neonatal jaundice, asthma
Obs/Gyn amenorrhea, vaginal blood, abdominal pain, PIH, OCP, elective abortion counseling.
Suturing choice of suture, tetanus vaccine
Chest Pain read CXR, ECG
Resuscitation fluid resuscitation after blood loss, ABCDs
Overdose ASA, TCA
Needle stick AIDS, hepatitis, vaccinations
Psychiatry depression, mania, schizophrenia
Neurosurgery back and neck radiculopathies, carpal tunnel
1

(Note that every history should include name, age, occupation, past medical history, family history,
medications, drugs/alcohol, and review of systems).

1997
1. First year university student, 9 weeks pregnant, is considering abortion. Take a history and
counsel. Findings: tearful, guilty, sleep disturbance, has not engaged social supports.
History: combine a pregnancy history with a social history and a screen for depression.
Pregnancy: Patient ID (name, age, occupation). GTPAL (number of gestations, term pregnancies,
premature births, abortions, live children), history of problems, if any, with previous pregnancies. Current
pregnancy, establish gestational age (GA) by last menstrual period (LMP) if regular periods and sure dates
(if unsure a dating ultrasound would be needed). The GA is the number of weeks from the first day of the
LMP. The EDC is first day of LMP + 7 days 3 months. Ask about use of alcohol, smoking, drugs,
domestic violence (50% begins in pregnancy), maternal illnesses during the pregnancy (particularly
diabetes, rubella, toxoplasmosis, herpes, CMV, thyroid dysfunction, HTN, hypercoagulation). Use of
birth control, if any. Past medical history, family history of pregnancy related problems, medications.
Social: Status of any relationships at present including relationship with the childs father. Social supports
(family, friends, and boyfriend), do they know? Are they helping? Employment/financial/educational
status of the patient, does the patient feel prepared to raise a child?
Psychiatric: How does the patient feel about this decision? How is she coping? Cover mnemonic for
major depression. MSIGECAPS: mood (depressed), sleep (increased or decreasedif decreased, often
early morning awakening), interest (decreased), guilt/worthlessness, energy (decreased or fatigued),
concentration/difficulty making decisions, appetite and/or weight increase or decrease, psychomotor
activity (increased or decreased), suicidal ideation positive diagnosis of major depression requires five
of these over a 2 week period, one of the five must be loss of interest or depressed mood. Symptoms do
not meet criteria for mixed episode, significant social/occupational impairment; exclude substance or
GMC, not bereavement.
Counseling: Make empathetic statements, e.g. This must be very hard for you.
Health while pregnant: recommend abstinence from harmful agents (alcohol, smoking, drugs) while
pregnant and use of medications only after consulting with a physician, treatment for pregnancy-related
illnesses as above, and healthy eating habits.
Social supports: Discuss the importance of engaging social supports, and consider a visit with both the
patient and her partner or other supporting person.
Abortion: Provide information on local abortion services. Make the patient aware that the gestational age
limit after which many practitioners will not perform an elective abortion in Canada is 20 weeks; but that
2

this is a late limit and her decision should be made sooner, before 16 weeks would be best. Inform the
patient that further advice is available from private gynecologists who perform abortions and counselors
at elective abortion centers. Offer to refer the patient if she wishes.
Depression management: Normalize the patients depressed mood in view of her circumstances. If there
is evidence of major clinical depression, arrange close follow up to monitor for suicidal ideation, refer to
psychiatry. Do not prescribe medications at this time (because of the pregnancy).

2. 20 year old female wants an oral contraceptive. Take a history and counsel.
History: Name, age occupation/school level. Why does patient want an OCP? Has she been on it before
or other forms of contraception? If so, why was it stopped? How long has the patient been sexually
active? How many partners? Current contraception used. Is there a possibility that the patient could be
pregnant? Obtain the date of last menstrual period.
Pregnancy history: GTPAL (number of gestations, term pregnancies, premature births, abortions, live
children), history of problems, if any, with previous pregnancies.
Gynecological history: Ask about sexually transmitted disease (STDs), PID, migraine, fibroids, diabetes,
thromboembolic disease, heart problems, cancer, and liver disease. Date of last Pap smear, history of
abnormal Pap smear and follow-up/treatment? When did the patient start menstruating? Menstrual
history: regularity and length of cycle and duration of periods, heaviness of flow (number of pads
required), cramping, associated discomfort/pain, bloating, mood swings (PMS). Medications, drugs,
alcohol, smoking, past medical history (especially breast cancer), family history, review of systems.
Counseling:
Contraindications to OCP: current pregnancy, undiagnosed vaginal bleeding, active
cardiovascular/thromboembolic diseases (includes coronary and carotid disease, symptomatic mitral valve
prolapse, cerebrovascular disease, moderate-severe HTN, active DVT), proliferative retinopathy, history
of breast cancer or other estrogen dependent tumors (liver, breast, uterus), impaired liver function
(obstructive jaundice in pregnancy), congenital hyperlipidemia, age > 35 and smoking, Wilsons disease.
Relative contraindications to OCP: smoker > 35 years old, diabetes, migraines, fibroids.
Mechanism of action of OCP: standard preparations contains estrogen and progesterone or just
progesterone, prevents ovulation by interfering with feedback of hormone signaling, atrophic
endometrium, change in cervical mucous (mucous plugthought to be due to progesterone component).
Available preparations: 21 day vs. 28 day tablets (7 placebo days). Other preparations: Depo injections
q3m (Depo-Provera medroxyprogesterone, restoration of fertility may take up to 1-2 years, irregular
menstrual bleeding), implants q5y (Norplant levonorgestrel, six capsules inserted subdermally in arm,
irregular menstrual bleeding). Longer term preparations offer lower cost over the duration of action (but
greater one-time cost) and greater convenience.
Benefits of all the hormonal contraceptives: ABCDEs: Anemia reduced, often clears Acne; Benign
breast disease and cysts decreased; Cancer (ovarian decreased), Cycles regulated, Increased Cervical
mucous which reduces STDs; Dysmenorrhea decreased, decreases Ectopic pregnancy rates and of course:
virtually no chance of pregnancy when taken as directed (98-99.5%).

Risks of hormonal contraceptives: slight weight gain is usual (5 lbs), increases risk of DVT especially
in combination with smoking, may stimulate estrogen-receptor positive breast cancers, but does not
appear to cause them, may have to try two or three different preparations to arrive at the one for the
patient. Also note that hormonal contraceptives do not provide as much protection against sexually
transmitted diseases, compared to barrier methods.
Directions: Start OCP on the first day of the next menstrual period. Place package in an obvious location
to help you to remember. Take at the same approximate time each day. Use additional contraception for
the first two months, as OCP contraception is not reliable until then. If you miss a day, take two pills the
next. If you miss two days, take two pills for the next two days and use an alternative method until the
next period. Give prescription for OCP of choiceany family members (sisters/mother) on OCP? What
works for them? Arrange follow up.
3. 16 year old boy with epilepsy documented by neurologist, comes to you because he does not want
to see his parents family doctor. Wants a drivers license. Take a history and counsel.
History of seizure disorder: Patient ID. Age of onset (primary generalized rarely begin < 3 or > 20 years
old). Precipitants: Sleep deprivation, drugs, EtOH, TV screen, strobe, emotional upset. Describe seizures
(Jacksonian march? Salivation, cyanosis, tongue biting, incontinence, automatisms, motor vs.
visual/gustatory/olfactory), frequency, duration, what body parts affected and in what order (motor
frontal lobe, visual/olfactory/gustatory hallucinations = temporal lobe), promontory signs (presence of
aura: implies focal attack), post-ictal state (decrease in level of consciousness, headache, sensory
phenomena, tongue soreness, limb pains, Todds paralysis - hemiplegia), degree of control achieved with
medications, at what dose and for how long, corroboration from family if possible. Was a CT scan done
when seizures were first diagnosed? Number and description of recent seizures, are they different from
previous seizures? Is the patient having any new symptoms such as headache, morning vomiting, new
neurological deficits? If the drug worked in the past why does the patient believe it isnt working now?
Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias,
peripheral neuropathy, acne, nystagmus, dysarthria, hypertrichosis (excessive hairiness), gingival
hypertrophy (phenytoin). Medications, drugs and alcohol, smoking, allergies, past medical history, family
history, review of systems.
Compliance: Is the patient taking meds? Why not? Problems at school or home? Ask about relationship
problems. Depression screen as in #19 above. Social supports.
Physical exam: neurologic exam including mini mental, cranial nerves, bulk, tone, power, sensation,
cerebellar exam, deep tendon reflexes.
Treatment:
Discuss importance of compliance with medication and avoiding dangerous activities such as driving until
good control is achieved.
Ministry of Transportation regulations require 1 year seizure free before they will grant a drivers license
in Canada. Inform the MOT of the patients seizure disorder if you have not already done so and inform
the patient that this is required by law.
If alcohol is an issue, inform the patient that chronic alcohol intake may decrease blood levels of
antiepileptics (via increased liver metabolism), and excess alcohol intake can precipitate seizures by
lowering the seizure threshold thereby precipitating a seizure. It is generally recommended that the patient
not drink at all. Fatigue and concomitant illness can also lower seizure threshold. The patient should
consult a physician before taking other medications, as they may also lower the seizure threshold. The
same is also true of sedatives, cocaine, amphetamines and insulin. Fatigue and other illnesses can also
4

lower seizure threshold, in addition to various other medications. If patient is having stress management,
anxiety issues, he may require further counseling. Outline a treatment plan consisting of: EEG, CT head,
metabolic screen, medications (if not done already), and follow up appointments. Get the parents
involved if possible.
Send blood for serum Dilantin (phenytoin) levels if patient is on this already. If Dilantin levels are
therapeutic, but the patient is having severe side effects or poor seizure control, a second drug may be
added (usually carbamazepine or valproic acid).
Discuss what to do in the event of seizure, counsel parents if possible. Bystanders are not to insert objects
into the patients mouth. Turn patient on his side while seizing. Call ambulance or take to Emergency if
seizure doesnt stop in 5 minutes.
Arrange regular follow up to monitor progress and serum Dilantin levels.
Indications and important side-effects of major antiepileptic drugs
Drug
Indication
Dose-related
Carbamazepine Partial
or Diplopia, dizziness, headache,
(Tegretol)
generalized
nausea,
drowsiness,
tonic-clonic
neutropenia, hyponatremia
seizures
Phenytoin
(Dilantin)

Partial
or
generalized
tonic-clonic
seizures, status
epilepticus

Nystagmus, ataxia, nausea,

vomiting, gingival hyperplasia,
depression,
drowsiness,
paradoxical
increase
in
seizures, megaloblastic anemia

Valproate
(Epival,
Dapakene)
Ethosuximide
(Zarontin)

All generalized
seizures or partial
seizures
Absence seizures

Tremor, weight gain, dyspepsia,

nausea, vomiting, alopecia,
peripheral edema
Nausea, anorexia, vomiting,
agitation,
drowsiness,
headache, lethargy

Idiosyncratic
Morbilliform
rash,
agranulocytosis,
aplastic
anemia, hepatotoxic effects,
Stevens-Johnson,
teratogenicity
Acne, coarse facies, hirsutism,
blood dyscrasias, Lupus-like
syndrome,
rash,
StevensJohnson,
Dupuytrens,
hepatotoxic
effects,
teratogenicity
Acute pancreatitis, hepatotoxic
effects,
thrombocytopenia,
encephalopathy, teratogenicity
Rash, erythema multiforme,
Stevens-Johnson, Lupus-like
syndrome,
agranulocytosis,
aplastic anemia

4. 48 year old woman complains of diseased stomach. Has had a negative investigation by several
other doctors. Take a history and perform a mental status examination. Q: Without looking at the
patient again, describe her appearance. What is your diagnosis?
History for depression: ID (name, age, employment status, marital status, living arrangements), chief
complaint, HPI: MSIGECAPS mood (depressed), anxiety, diurnal variation in mood and activity with
nadir in the early morning, irritability, change in sleep pattern (increased or decreased, if decreased
usually morning awakening), interest (decreased), anhedonia (inability to enjoy previously enjoyable
activities), guilt, hopelessness, worthlessness, energy (fatigue), concentration, memory, difficulty making
decisions, appetite and weight gain or loss, psychomotor retardation/agitation, suicidal ideation. Also

inquire about past psychiatric/medical/surgical history, allergies, meds, family history, personal history,
review of systems.
Suicidal ideation: does patient intend to harm self, reason for suicidal thoughts, current plan, lethality of
plan, access to lethal means, has patient given away prize possessions or written final notes to loved ones,
previous attempts.
Diagnosis of major depression: Mnemonic for major depression MSIGECAPS: mood, sleep, interest,
guilt, energy, concentration, appetite, psychomotor, suicide, positive diagnosis of major depression
requires five of these over a 2 week period. One of the five must be either loss of interest or depressed
mood. Cannot be a mixed episode and symptoms must cause social/occupational impairment. Cannot be
GMC or substance abuse or bereavement. (A diagnosis of depression cannot be made in the face of
bereavement within the past two months or drug or alcohol abuse.)
Dysthymia: A diagnosis of dysthymia requires depressed mood for most of the day, more days than not,
for at least two years. Presence while depressed of at least 2 of: poor appetite or overeating, insomnia or
hypersomnia, low energy/fatigue, low self esteem, poor concentration or difficulty making decisions,
hopelessness. Never without depressed mood for more than 2 months at a time, no MDE, manic, mixed
or hypomanic episodes in past, not GMC or substance abuse.
Manic episode: Expansive, elevated or irritable mood x 1 week with 3 of following: GSTPAID
grandiosity (or inflated self esteem), sleep (less need for), talkative, pleasurable activities (with painful
consequences), activity increased (goal directed or psychomotor), ideas (flight of), distractibility. Not
mixed episode. Severe enough to cause psychotic features/impaired social/occupational functioning. Not
substance abuse or GMC.
Differential for depression: Check for bipolar mood disorder (manic-depressive), schizophrenia,
psychotic depression and obsessive-compulsive disorder. Ask about manic episodes, paranoia,
hallucinations (esp. voices), obsessive thoughts, previous psychiatric problems, family history of
psychiatric disorders, substance abuse, and relationship problems, problems at work (basically a mental
status exam).
Medical causes of depression: ask about hypothyroidism, adrenal dysfunction, hypercalcemia,
mononucleosis. Consider chronic fatigue syndrome. Drug use, smoking, allergies, past medical history
including psychiatric history and history of abuse. Family history, review of systems.
Mental status: appearance, behavior (dress, grooming, posture, gait, apparent age, physical health, body
habitus, expressions, attitude - cooperative?, psychomotor activity, attention, eye contact), speech (rate,
rhythm/fluency, volume, tone, quantity, spontaneity, articulation), mood (subjective emotional state in
patients own words), affect (Quality euthymic, depressed, elevated, anxious; Range full, restricted;
Stability fixed, labile; Appropriateness; Intensity - flat, blunted), suicidal ideation (low, intermediate,
high poor correlation between clinical impression of suicide risk and probability of attempt), thought
process (coherent, flight of ideas, tangentiality, circumstantiality, thought blocking, neologisms, clanging,
perseveration, word salad, echolalia), thought content (delusions bizarre vs. non-bizarre, obsessions,
preoccupations, phobias, recurrent themes), perceptual disturbances (illusions, hallucinations,
depersonalization, derealization), insight, cognition, judgment.
Multiaxial Summary:
Axis I clinical disorders DSM IV; differential diagnosis
Axis II personality disorders DSM IV; mental retardation
6

Axis III GMC (as they pertain to Axis I and other Axes)
Axis IV psychosocial and environmental problems
Axis V global assessment of functioning (GAF) 0-100
Mini-Mental Status: orientation to time/place (5 pts, year, season, month, day, day of week; 5 pts,
country, province, city, hospital, floor), memory (3 pts, honesty, tulip, black; 3 pts, delayed recall),
attention/concentration (5 pts, serial 7s, WORLD backwards), language tests: comprehension (3 pts,
three point command), reading (1 pt, close your eyes), writing (1 pt, complete sentence), repetition (1
pt, no ifs, ands or buts), naming (2 pts, watch, pen), spatial ability (1 pt, intersecting pentagons)
Patients appearance: slovenly
Diagnosis: major depression
Treatment of major depression: pharmacotherapy, psychotherapy, family therapy. Start fluoxetine
(prozac) 20 mg qAM, may increase to 40 mg qAM after 1 week. Takes 2-4 weeks to work. Explain side
effects of sleep disturbance, anorgasmia, nausea (use SSRI summary below).
Admit: when patient is actively suicidal, i.e. plans are specific; patient has given away possessions,
written final notes to loved ones. For suicidal ideation without current intent, discharge only with written
contract with the patient to inform you immediately if they feel likely to make an attempt. Give number
to call and arrange regular follow up before patient leaves the office.
SSRI antidepressant summary
Start
OD)
Fluoxetine (Prozac) generally energizing
20
Fluvoxamine (Luvox) more sedating
50
Sertroline (Zoloft) used in the elderly
50
Paroxetine (Paxil) used in mixed 10-20
anxiety/depress

at:

(mg Therapeutic:
OD)
20-80
150-300
50-150
20-60

(mg

5. 60 year old woman with acute confusion. Perform a focused physical exam excluding mental
status.
Neurologic exam: what follows is a practical, regionally organized neurologic exam which can be
completed in less than eight minutes (with practice). It begins with the patient sitting, then standing, then
lying down. Note that every physical exam should include vitals, although in this case the examiner will
ask you to move on.
Patient sitting (shoes and socks removed):
GCS/MMSE only if patient poorly responsive. The examiner will remind you to omit the mini mental
status exam.

Glasgow Coma Scale

Eye
(E) Verbal Response
Openi
ng
Spontaneou 4
Oriented
and
s
3
converses
To speech
2
Confused
To Pain
1
conversation
never
Inappropriate words
Incomprehensible
sounds
None

(V
)

Best Motor Response

(M
)

5
4
3
2
1

Obeys commands
Localizes pain
Withdrawal to pain
Abnormal
flexion
(decorticate)
Abnormal
extension
(decerebrate)
Nil

6
5
4
3
2
1

Mini-Mental Status: orientation to time/place (5 pts, year, season, month, day, day of week; 5 pts,
country, province, city, hospital, floor), memory (3 pts, honesty, tulip, black; 3 pts, delayed recall),
attention/concentration (5 pts, serial 7s, WORLD backwards), language tests: comprehension (3 pts,
three point command), reading (1 pt, close your eyes), writing (1 pt, complete sentence), repetition (1
pt, no ifs, ands or buts), naming (2 pts, watch, pen), spatial ability (1 pt, intersecting pentagons)
Cranial nerves CN III, IV, VI: Extra-ocular movements (patient follows your finger or the handle of a
reflex hammer in an H-pattern, check for diplopia in the center and at the extremes of the visual fields.
CN II: Visual fields by confrontation (one eye at a time) patient holds own hand over one eye and
counts fingers flashed in left and right fields simultaneously (upper and lower) or identifies the wiggling
finger as it enters each quadrant on confrontation if too confused to count. By acuity: Snellen card. Fundi
check for papilledema using ophthalmoscope. CN II, III, V1 & VII: Pupillary light reflex and
accommodation, corneal reflex. CN V: Facial sensation to light touch in the ophthalmic, maxillary and
mandibular divisions of the trigeminal nerve. Trigeminal motor: clench teeth, lateral jaw movement. CN
VII, XII: Facial muscle power raise eyebrows, squint eyes closed, show teeth, protrude tongue, observe
palatal movement on saying Ah, puff cheeks, platysma. CN VII, IX, X: Gag reflex, observe symmetric
movement of palate, swallowing, taste. CN VIII: Gross hearing rub thumb and index lightly while
approaching the patients ear, note when they begin to hear the sound. CN XI: Sternocleidomastoid
power and trapezius power.
Body Pronator drift arm straight out in front of patient with palms up, eyes closed. Look for curling
of fingers from the ulnar side, pronation and downward movement of the affected side. Hoffmans reflex
with the patients relaxed hand in a palm-down position, squeeze and flick the nail of the index or long
fingers between your thumb and long finger. Thumb flexion indicates a positive test and denotes upper
motor neuron lesion (similar to Babinskis reflex). Cerebellar tests finger-nose rapid alternating
movements (dysdiadocokinesis), heal-shin. Body power deltoids, biceps, triceps, wrist extension and
flexion, finger abduction and adduction, psoas (hip flexion lift each knee off the bed against resistance),
quadriceps, hamstrings, ankle dorsiflexion (test plantar flexion while standing). Body sensation light
touch, pin prick, and cold temperature (use a meta K-basin or turning fork) are tested on the distal upper
limbs (forearms and hands) and lower limbs (foreleg and feet). Vibration sensation is tested using a C120 Hz tuning fork on the joint capsules of the most distal joints at which the vibration can be felt. Body
reflexes biceps jerk, brachioradialis, knee, ankle, Babinski.
Patient standing

Gait observe for wide-base, Parkinsonian festination/shuttle, consistent lateralizing falls. Balance
tight-rope walk, stand with arms crossed and feet in line, Rhomberg (feet together, eyes closed). Plantar
flexion power hold patients hands for balance, ask patient to stand on one foot, then raise themselves up
on the toes.
Patient lying supine
Tone passive rapid alternating forearm rotation, passive rapid elbow flexion/extension with one thumb
on the biceps tendon to feel for cog-wheeling. Rapid lifting of the relaxed leg from behind the knee
heel remains on the bed in normal tone.
6. A young man is brought to the Emergency department with an epigastric stab wound sustained in
a bar fight. There is a nurse in the room. Manage.
Unstable means either an acutely changing condition, vital signs dangerously beyond normal ranges (e.g.
low BP), or any life-threatening condition which is inadequately controlled. This patient is unstable due
to stab wound with unknown consequences which is an acutely changing and inadequately controlled
problem and therefore requires stabilization or resuscitation.
The ACLS and ATLS format is useful: i.e. primary survey, orders, secondary survey, orders. Note that the
simulated patient may have an impressive simulated injury. Do not allow this to distract you from the
primary survey.
Primary survey: (mnemonic ABCD)
Airway: check for patent airway (look in mouth), is airway threatened by blood? High chance of
aspiration due to poor level of consciousness, neck or face swelling. If airway is compromised,
immediately place an oral airway or intubate.
Breathing: is patient breathing, check O2 sat, may require immediate manual bag-valve mask followed by
intubation with positive pressure ventilation.
Circulation: BP, HR, rhythm on monitor, active high volume bleeding. Patient may require immediate
chest compressions, defibrillation or cardiac drugs if there is an unstable rhythm (Ventricular fibrillation,
unstable ventricular tachycardia, PEA, asystole, PST, or bradycardia).
Debilitation: refers to the Glasgow Coma Scale (GCS):

Glasgow Coma Scale

Eye
(E) Verbal Response
Openi
ng
Spontaneou 4
Oriented
and
s
3
converses
To speech
2
Confused
To Pain
1
conversation
never
Inappropriate words
Incomprehensible
sounds
None

(V
)

Best Motor Response

(M
)

5
4
3
2
1

Obeys commands
Localizes pain
Withdrawal to pain
Abnormal
flexion
(decorticate)
Abnormal
extension
(decerebrate)
Nil

6
5
4
3
2
1

Note: Standard painful stimulus is rubbing the knuckle on the sternum. For withdrawal, apply pressure
on the base of the nail bed with a pen. Decorticate posture is arm flexion with leg extension on the same
side of the body, may be unilateral or bilateral. Indicates a lesion above the brainstem. Decerebrate
posture is arm and ipsilateral leg extension, may be unilateral or bilateral, and indicates brainstem
involvement. A GCS of 8 or less is considered an indication for intubation because of the risk of poor
protection of the airway from aspiration.
Primary orders: oxygen, monitoring (ECG, O2 sat, automatic BP cuff or arterial line), IV access: need
two large-bore (16 gauge, 14 if possible femoral vein cortice with 2 lumens), run wide open with normal
saline for acutely low BP, may need to be more restrained if pulmonary edema is a problem. Coma
cocktail if diagnosis not known already: thiamine 100 mg IV, narcan 1 mg IV, flumazenil 0.1 mg IV (1
amp D50W is no longer included in this cocktail because of deleterious effects of high serum glucose on
the injured brain). Initial investigations: CBC, lytes, urea, creatinine, ABG, glucose, ionized Ca, CK-MB,
troponin, INR/PTT, ECG, portable CXR, cross-table lateral C-spine and hard collar if there is head injury
or any significant trauma.
Secondary survey: Head to toe physical exam. Vitals. Head and neck: inspect for lacerations and
contusions, pupillary response, dolls eyes (careful of neck, may not be able to turn head enough to do
this), corneal reflexes, palpate facial bones for stability, look in nose and ears for blood or CSF leaks,
hemotympanum. Check oral cavity, gag reflex, palpate dorsal cervical spines for pain and alignment, is
the trachea midline? Chest: breath sounds, heart sounds, radial pulses bilaterally. Abdomen: rigidity is an
indicator for immediate general surgery, auscultate for bowel sounds, palpate liver and spleen. Log roll
patient onto back, inspect. Rectal. Palpate for pelvic stability and intactness of long bones.
Secondary orders: foley, NG tube if patient may go to surgery or require charcoal. Specific interventions
based on findings. Further X-rays, CT head if cause of decreased level of consciousness unclear or if
there may have been a seizure.
Clearing C-spines: The principle of clearing C-spines is to rule out both bony fractures and ligamentous
injury, either of which can make the spine dangerously unstable. Most emergency physicians will clear
the cervical spine in the case of an alert patient who has no pain on palpation of the dorsal spinous
processes and a normal cross-table lateral C-spine X-ray. If the patient has neck pain, flexion/extension
plane films are done. These involve gently flexing, then extending the neck and taking views at each
extreme. The patient must be alert enough to warn the examiner of paresthesias in the hands or increased
neck pain on movement during this procedure, which may indicate compromise of the neural elements.
Flexion/extension views may be done under fluoroscopy if the patient is not alert.
10

History: if available: How did the patient obtain the wound, was there mechanism of action for other
injury, i.e. collapse/fall, preceding and subsequent events, did patient lose consciousness, duration of
unconsciousness, did the patient fall, injuries during fall, medications and drugs, smoking, allergies, past
medical history, family history, review of systems.
Management: For unstable blood pressure, blood loss is the most likely cause (CBC may be normal with
a large acute blood loss), type and cross for 4-6 units depending on estimated severity and hang blood as
soon as possible. Is the patients abdominal wound the first priority? Examine for head injury, other
injuries. Explore wound with a gloved finger on secondary survey, if wound is more than superficial,
consult general surgery and prepare patient for immediate surgical exploration in the OR. Obtain details
of the history from family or witnesses if possible.
7. 30 year old woman with six weeks of epistaxis, petechiae and easy bruising. Perform a focused
physical exam. Findings: petechiae, bruises. Q: The patient has a normal CBC except for platelets
20 (normal 130-400). What is the most likely diagnosis? What four areas on history would help to
confirm this diagnosis? What four investigations would you order?
Hematologic exam: patient disrobed to underwear, draped below the waist.
Patient sitting
Inspect the patient generally for petechiae, abnormal skin tone, hair falling out. Inspect the finger and toe
nails for dystrophy, flame hemorrhages, leukonychia, inspected the palm for erythema and Dupuytrens
contracture. Look in the nose and mouth for bleeding, petechiae, masses. Palpate the anterior and
posterior triangles of the neck, the supra and infra clavicular areas, and the axillae for lymph nodes.
Palpate the thyroid while standing behind the patient, ask her to swallow. Chest from behind the
patient, inspect the skin. Percuss the lung fields for effusions and consolidations, auscultate the lung
fields. Percuss and auscultate the anterior lung fields. Listen over the aortic (right upper sternal border
2nd ICS systolic = stenosis, diastolic = regurgitation, continuous = BT shunt, right or left), pulmonary
(left upper sternal border 2nd ICS systolic = ASD, pulmonary flow, continuous = ductus, LBT shunt),
tricuspid (left lower sternal border 5th ICS systolic = regurgitation ... Stills murmur, diastolic = stenosis)
and mitral (apex 5th ICS and midclavicular line systolic = prolapse, regurgitation; diastolic = stenosis)
areas.
Patient lying supine
Compress the sternum and ribcage for pain (seen in multiple myeloma). Inspect the abdomen. Auscultate
for bowel sounds. Palpate for enlargement of the spleen and liver. Percuss the liver. Palpate the groin for
lymph nodes. Note: avoid rectal exam as this trauma may cause bleeding.
Most likely diagnosis: idiopathic thrombocytopenic purpura (ITP), also called immunologic
thrombocytopenic purpura or Wedhofs disease.
Four findings on history which would help to confirm the diagnosis: 1. Remitting-relapsing course, 2.
Mild fevers, 3. Splenic discomfort due to mild enlargement, 4. Bleeding after low doses of NSAID.
Four investigations: Blood smear, INR/PTT (for hemophilia), serum urea/creatinine (for hemolyticuremic syndrome), serum platelet-associated IgG (for ITP).

11

8. 62 year old man presents to the Emergency Department with 12 hours suprapubic discomfort
and inability to urinate. Catheterization yields 1200 cc urine. Take a history. Q: What is the most
likely cause of this mans problem? Give three other possible diagnoses. What four investigations
would you order?
History: name, age, occupation. History of suprapubic pain and inability to urinate. History of pain on
urination, frank blood in the urine, color of urine, difficulty initiating or maintaining urinary stream, fever,
renal pain, groin pain. Previous renal colic/ diagnosed prostate hypertrophy, prostate cancer, prostatism,
nephrolithiasis, UTIs? Malignant symptoms: night sweats, weight loss, fatigue. Medications,
drugs/alcohol, smoking, past medical history, past surgical history, history of pelvic radiation, TURP,
family history, review of systems.
Most likely diagnosis: benign prostatic hyperplasia.
Other possible diagnoses: UTI, prostatitis, prostate cancer.
Four investigations: urea/creatinine, urinalysis, prostate specific antigen (PSA), renal ultrasound.
Treatment: watchful waiting (50% resolve spontaneously), medical (alpha-adrenergic antagonists
Terazosin, doxazosin, tamsulosin; 5-alpha-reductase inhibitors finasteride), surgery (TURP vs. open
prostatectomy), minimally invasive (stents, microwave therapy, laser ablation, cryotherapy, HIFU,
TUNA).
9. 6 month old child who just had a seizure. Take a history from the mother in the Emergency
Department.
Findings: short seizure with T 39.5 C. Never had seizures in the past.
Developmentally normal. Q: What is the most likely diagnosis? What would you tell the mother
about any possible recurrence? What advice do you give if the child has another seizure?
History: Name, age. Describe seizure duration, what body parts affected and in what order, premonitory
signs, post-ictal state (decrease in level of consciousness, headache, sensory phenomena). Previous
seizure? Ask about preceding trauma or illness or medications taken, the childs temperature at the time of
the seizure. Meningitis signs, neurological. History of problems during the pregnancy and birth.
Developmental history. Childs medical history, surgical history, medications, allergies.
Selected Developmental Milestones
Speech
6 months
initiates sounds, eye contact
12 months
2 words beyond mama and
24 months
dada
2-3 years
2-3 word phrases
short sentences
Gross
6 months
roll over
motor
9 months
stand
12 months
cruise
15 months
walk
Fine motor 12 months
pincer grasp
24 months
turns pages in a book
Social
6 months
stranger anxiety
9 months
separation anxiety
2 years
says no
5 years
prints name
12

Most likely diagnosis: febrile seizure (febrile seizures usually 6 months to 6 years, associated with initial
rapid rise in temperature, no neurologic abnormalities/evidence of CNS infection/inflammation before or
after, no history of non-febrile seizures, most common generalized tonic-clonic, < 15 minutes duration, no
recurrence in 24 hours, atypical may show focal origin/> 15 minutes/> 1/24 hours/transient neurologic
defect).
Prognosis: after a single febrile seizure 65% will never have another seizure. 30% will have further
febrile seizures, 3% will go on to have seizures without fever and 2% will develop lifelong epilepsy.
Management: find source of fever, Tylenol (antipyretics), LP to rule out meningitis if signs of meningitis,
counseling and reassurance to patient and parents if febrile seizures.
Treatment of recurrence: control fever with antipyretics (Tylenol), tepid bath, fluids for comfort only
and use Ativan (lorazepam) 1 mg SL/PO (or diazepam 5-10 mg PR) if a seizure occurs at home. Turn
patient onto his/her side, do not force objects or fingers into mouth. Bring to ER if seizure does not stop
within fifteen minutes. Seizures do not cause mental impairment unless they are prolonged (> 30 min),
although seizures can be a symptom of brain damage. Patient should be investigated with CT head and
EEG. Prophylactic anticonvulsant therapy is a consideration with repeated seizures.
10. 68 year old man with difficulty swallowing. Take a history. Findings: throws up after eating.
Can swallow liquids only. Weight loss and fatigue. Smoker. Q: X-ray of barium swallow showing
narrowing of contrast at T5-6: describe the abnormality. What is the likely diagnosis? What
investigation would confirm the diagnosis? What further investigations would you order?
History: (Dysphagia = difficulty swallowing) onset, chronology, description of problem, aggravating and
relieving factors. Is the difficulty transferring food from mouth to esophagus suggesting oropharyngeal
dysphagia with food getting stuck immediately after swallowing often with nasal regurgitation? With
esophageal dysphagia food seems to be stuck further down. Is the problem worse with solids (suggests
mechanical obstruction), or liquids (suggests neuromuscular dysfunction, often cant swallow either solids
or liquids). Is there a sensation of a lump in the throat? (globus hystericus = transitory sensation of a
lump in the throat related to anxiety). Progression from solid swallowing difficulty to difficulty
swallowing both solids and liquids suggests progressive obstruction such as from a worsening stricture or
growing tumor. The combination of intermittent obstruction and chest pain suggests esophageal spasm.
Ask about peptic ulcer, reflux, hiatus hernia, weight loss, night sweats, fatigue, hematemesis, black stools,
pain. Medications, drugs/alcohol, allergies, smoking, past medical history, family history, review of
systems.
Oropharyngeal: Neurological cortical pseudobulbar palsy (UMN lesion) due to bilateral stroke;
bulbar ischemia (stroke); syringobulbia; tumor (LMN); peripheral polio; ALS. Muscular MD;
cricopharyngeal incoordination (failure of UES to relax with swallowing), sometimes seen with GERD;
Zenkers diverticulum.
Esophageal: solid food only mechanical obstruction intermittent = lower esophageal ring/web;
progressive heartburn = peptic ulcer; age > 50 = carcinoma. Solid or liquid food neuromuscular
disorder intermittent = diffuse esophageal spasm; progressive reflux = scleroderma; respiratory
symptoms = achalasia.

13

Differential diagnosis: Mechanical obstruction: tumor, stricture (secondary to GERD, trauma etc.).
Neuromuscular obstruction: achalasia (cardiac sphincter does not relax), cranial nerve palsy, MS,
supranuclear palsy, stroke, motor neuron disease, myasthenia gravis, muscular dystrophy.
Description of Barium swallow findings: string sign, graded narrowing of intra-esophageal diameter
extending from T5 to T8 level.
Most likely diagnosis: esophageal cancer.
Investigation to confirm diagnosis: endoscopy with biopsy.
Further investigations: CT chest (for mediastinal and lymph node involvement), chest X-ray, liver
function tests, abdominal ultrasound (for mets).
11. 23 year old with BP 160/100 in both arms. Perform a focused physical exam. Q: Give four
possible diagnoses. What four investigations would you order? If these investigations were
negative, give 5 steps in your initial management plan.
Physical exam for hypertension: combines exams for atherosclerosis, coarctation, hyperthyroidism
and Cushings. Patient should be disrobed to underwear and draped below the waist.
Patient Sitting
Take vitals (need BP in all four limbs legs to be done when patient is lying down). Inspect for cyanosis,
arcus senilis in the eyes (sign of high cholesterol), bulging veins in the upper chest (SVC syndrome),
supraclavicular fat pad, buffalo hump, moon face, truncal obesity, striae, nicotine stains on fingers,
clubbing, flame hemorrhages on nails, obesity, high work of breathing, intercostal indrawing, symmetric
chest movement, visible apex beat.
Fundoscopy for retinopathy of hypertension: (in order of increasing severity of damage) constriction and
sclerosis of retinal arterioles, hemorrhages, exudates, papilledema.
Thyroid exam: Inspect patient for proptosis, thyroid stare (upper lids do not overlap the irises). Have
patient follow your finger up and down to check for lid lag and globe lag. Is skin thin dry and flaky or
diaphoretic. Palpate thyroid standing behind patient, ask patient to swallow. Inspect nails for leukonychia
and hands for tremor (can place a piece of paper on the hand held horizontal to detect fine tremor) and
clubbing/thickening of distal phalanges. Check biceps reflexes with thumb held over the tendon, feel for
slow return phase reflex of hypothyroidism.
Palpate the apex, note whether it is laterally displaced (lateral to the mid-clavicular line) and feel for thrill
or heave, feel radial pulses in the arms simultaneously, note any delay.
Percuss the lung fields anteriorly and posteriorly.
Auscultate the lung fields anteriorly and posteriorly, listen over the aortic (right upper sternal border 2 nd
interspace systolic = stenosis, diastolic = regurgitation, continuous = BT shunt, right or left),
pulmonary (left upper sternal border 2nd interspace systolic = ASD, pulmonary flow, continuous =
ductus, LBT shunt), tricuspid (left lower sternal border 5th interspace systolic = regurgitation ... Stills
murmur, diastolic = stenosis) and mitral (apex at 5th interspace and midclavicular line systolic =
14

prolapse, regurgitation; diastolic = stenosis) areas, as well as over the right clavicle, and both carotids.
Listen for rub. To bring out an aortic murmur (typically aortic regurgitation), and coarctation bruits, ask
patient to lean forward, exhale and stop breathing while you listen over the aortic and pulmonic areas.
Patient Lying Supine
Auscultate for bruits over the renals on the abdomen. Observe for pulsations due to abdominal aortic
aneurysm, palpate abdomen for hepatomegaly. Palpate femoral pulses, and auscultate for femoral bruits,
palpate the popliteal pulses, inspect the legs and feet for venous stasis or arterial insufficiency ulcers,
palpate the dorsalis pedis and tibialis posterior pedal pulses. Feel the ankles for pitting edema.
Tibial BP: BP cuff placed around calf, auscultate the tibialis posterior pulse posterior to medial malleolus
on right and left.
JVP: Raise the head of the bed 30 degrees and inspect the neck. A jugular venous pulsation higher than
4-5 cm above the sternal notch (approximately the level of the right atrium) is abnormal. If no JVP is
visible then you may have to raise or lower the bed for high or low JVPs respectively. Check the
hepatojugular reflux (supine, mouth open, breathing normally compress the liver, the jugular venous
pulse should either not rise or remain elevated only transiently, a sustained elevation > 1 cm in the JVP is
pathological). This is used to assess high jugular venous pressure and RV function.
Classification of BP
DBP: < 90 (normal), 90-104 (mild HTN), 105-114 (moderate HTN), > 115 (severe HTN)
SBP: < 140 (normal), 140-159 (borderline isolated systolic HTN), > 160 (isolated systolic HTN)
Four possible diagnoses: essential hypertension, renal HTN (renal artery insufficiency, renal
parenchymal disease), endocrine (thyroid hormone, OCP, primary hyperaldosteronism,
hyperparathyroidism, pheochromocytoma, Cushings) coarctation of the aorta, others (enzymatic defects,
neurological disorders, drug-induced (prolonged corticosteroid use), hypercalcemia, watch for labile
white-coat HTN).
Investigations: Repeat BP 3x over next 6 months, urinalysis, CBC, Cr, lytes, fasting serum glucose,
cholesterol panel, 12 lead ECG, TSH, renal U/S.
Initial Management: 1. Smoking cessation. 2. Alcohol restriction to low risk drinking guidelines. 3. Salt
restriction (max. 90-130 mmol 3-7 g per day). 4. Saturated fat intake reduction. 5. Weight reduction if
BMI > 25 (at least 4.5 kg). 6. Regular aerobic exercise (50-60 min, 3-4x per week).
12. 21 year old female with bloody diarrhea. Take a history. Findings: Abdominal cramping. Six
watery stools in the past four hours containing maroon colored blood. Feels dizzy and weak. No
previous history of diarrhea previously well. Q: What two findings on history indicate the
seriousness of the problem? Give three possible diagnoses. Give four investigations appropriate to
this situation.
History: name, age, occupation. Onset, duration, frequency, of diarrhea. Appearance of stools: how well
formed, is blood on (anal/rectal laceration) or admixed with stools, is blood bright red (lower tract bleed)
or dark brown-black (upper tract bleed, e.g. stomach). Pain with bowel movements, abdominal pain or
cramps with location, radiation, precipitating factors and alleviating factors, quality, severity, timing with
respect to defecation, gas bloating. Heart burn, peptic ulcer, reflux, hiatus hernia. Extra-intestinal
15

manifestations of inflammatory bowel disease: ask about iritis, arthritis, mouth ulcers, anal ulcers, skin
lesions, kidney stones. Infectious diarrhea: inquire about fever, nausea, vomiting, weight loss, fatigue.
Recent travel, consumption of unusual foods or foods which may have been contaminated. Recent
exposure to antibiotics. Family members sick at home. Pelvic pain, vaginal discharge, vaginal bleeding.
Past medical history, medications (especially NSAIDs, laxatives, antibiotics), family history of Crohns,
ulcerative colitis, familial polyposis, review of systems.
Two findings which indicate the seriousness of the problem: patient feels dizzy and weak.
Three possible diagnoses: gastroenteritis, bleeding peptic ulcer, inflammatory bowel disease.
Four investigations: CBC with differential, stool for ova & parasites with culture & sensitivities,
Clostridium difficile toxin. Endoscopy (but above first). Type and cross for 4 units PRBCs.
1996
13. Middle aged woman with systolic ejection murmur radiating into the carotids.
physical exam.

Perform

The physical exam for a patient with a heart murmur is a cardiopulmonary exam.
Patient in sitting position: take vitals
Inspect for surgical scars, trauma, bony abnormalities, cyanosis, arcus senilis in the eyes (sign of high
cholesterol), bulging veins in the upper chest (SVC syndrome), nicotine stains on fingers, clubbing, flame
hemorrhage on nails, obesity, work of breathing, intercostal indrawing, symmetric chest movement,
visible apex beat.
Palpate the apex, note whether it is laterally displaced (lateral to the mid-clavicular line) and feel for thrill
or heave, feel radial pluses bilaterally.
Percuss the lung fields anteriorly and posteriorly.
Auscultate the lung fields anteriorly and posteriorly, always evaluate heart sounds before murmur. First
listen for S1 and S2, then look for S3 and S4 and any other unusual heart sounds. Listen over the aortic
(right upper sternal border 2nd ICS systolic = stenosis, diastolic = regurgitation, continuous = BT shunt,
right or left), pulmonary (left upper sternal border 2nd ICS systolic = ASD, pulmonary flow, continuous
= ductus, LBT shunt), tricuspid (left lower sternal border 5th ICS systolic = regurgitation ... Stills
murmur, diastolic = stenosis) and mitral (apex 5th ICS and midclavicular line systolic = prolapse,
regurgitation; diastolic = stenosis) areas as well as over the right clavicle, and both carotids. Listen for
rub. To bring out an aortic murmur (typically aortic regurgitation), ask patient to lean forward, exhale and
stop breathing while you listen over the aortic area. To bring out a mitral murmur, ask patient to lie
supine and roll partly onto the left side while you listen over the apex. In general, murmurs are
accentuated by increasing the dynamicity of the heart with mild exercise, such as asking the patient to
walk up a flight of stairs.
Murmurs are described in terms of where they are heard loudest, where the sound radiates, whether it
occurs in systole or diastole, the pitch (e.g. high, low), quality (e.g. harsh, blowing, musical), contour (e.g.
crescendo, decrescendo or plateau) and its loudness graded out of six (e.g. II/VI). The murmur of aortic
stenosis is loudest over the aortic area, radiates to the clavicle or carotids, occurs in systole, has medium
16

or high pitch, is harsh and crescendo-decrescendo. A mitral regurgitation murmur by contrast, is loudest
over the apex, also occurs in systole, radiates to the axilla, is medium to high in pitch, blowing and
plateau.
Innocent murmurs are <3/6 in intensity, peak early in systole, stop long before S2, are heard best at the
base of the heart (aortic and pulmonary areas), are not associated with clicks or heaves, and ECG and
CXR are normal.
Patient lying supine
Auscultate for bruits over the renals on the abdomen. Observe for pulsations due to abdominal aortic
aneurysm, palpate abdomen, femoral pulses, and auscultate for femoral bruits, palpate the popliteal
pulses, inspect the legs and feet for venous stasis or arterial insufficiency ulcers, palpate the dorsalis pedis
and tibialis posterior pedal pulses. Feel the ankles for pitting edema.
JVP: Raise the head of the bed 30 degrees and inspect the neck. A jugular venous pulsation higher than
4-5 cm above the sternal notch (approximately the level of the right atrium) is abnormal. If no JVP is
visible then you may have to raise or lower the bed for high or low JVPs respectively. Check the
hepatojugular reflux (supine, mouth open, breathing normally compress the liver, the jugular venous
pulse should either not rise or remain elevated only transiently, a sustained elevation > 1 cm in the JVP is
pathological). This is used to assess high jugular venous pressure and RV function.

14. 50 year old man with left-sided chest pain. Manage (means history, physical, investigations and
treatment). Findings: bruise on chest wall, normal CXR and ECG.

Differential Diagnosis for Chest Pain

Cardiac
Non-Cardiac
Angina
Pulmonary
MI
Pneumonia
w/
Pericarditis
pleuritis
Myocarditis
Pneumothorax
Dissecting
PE
aorta
Pulmonary
hypertension

GI
Esophageal
reflux
Ulcer

MSK/Neuro
Arthritis
Chondritis
Rib
fractures
Herpes
Zoster

Psychologic
Anxiety
Panic

History for chest pain: describe the pain, location, radiation, quality, time of onset, duration, intensity,
circumstances under which it occurs, aggravating and relieving factors, associated symptoms such as
nausea, shortness of breath, dizziness, diaphoresis, dependent edema. Leg pain. Respiratory symptoms:
cough, sputum, fever, hemoptysis. GI symptoms: heartburn, dysphagia. Previous episodes, chronology
of these. History of trauma, asthma, bronchitis, COPD, pneumothorax, recent viral illness and previous
chicken pox (Herpes Zoster can cause chest pain), gastritis, peptic ulcer, reflux. Risk factors for heart and
lung disease: smoking, hypertension, hyperlipidemia. Past medical history, especially diabetes, heart
17

disease including pericarditis, lung disease, GI problems, surgical history, and family history.
Medications, drug use, smoking, allergies, review of systems.
Physical exam: Cardiopulmonary exam as in question #13.
Investigations: CXR, ECG.
Treatment: given a normal CXR and ECG with a chest wall bruise as evidence of trauma send patient
home, recommend non-prescription pain medication (Tylenol and/or ibuprofen) and advise that the pain
should subside gradually. Since the patient is at risk because of his age group and male gender, explain
the symptoms of myocardial infarct (MI) and advise to return immediately if these occur.
15. Young man with recent onset back pain and limp. Take history and physical.
A differential for low back pain is:
1. Degenerative (90% of all back pain)
Mechanical (degenerative, facet joint pain, muscle strain/spasm)
Spinal stenosis (congenital, osteophyte, central disc)
Peripheral nerve compression (disc herniation or rupture)
2. Cauda Equina syndrome
3. Neoplastic: primary or metastatic
4. Trauma: fracture (compression, distraction, translation, rotation)
5. Spondyloarthropathies: e.g. ankylosing spondylitis
6. Discitis/osteomyelitis
7. Referred: aorta (abdominal aortic aneurysm), renal (pyelonephritis), ureter (nephrolithiasis), pancreas
(pancreatitis)
8. Malingering
Because discogenic and stenotic radiculopathy which have not improved over at least 4 weeks may be
treatable surgically, the priority of a history and physical for back pain is to differentiate radiculopathy
from other causes and to identify the nerve root.
The most common disk herniation is a posterolateral L4-5, which compresses the L5 root. The herniation
will also compress the L4 root if the herniation is far lateral and the S1 root if it is more medial (central).
The second most common herniation is a posterolateral L5-S1, which compresses the S1 root. In the
thoracic and lumbar spine, the nerve roots exit below the pedicles of the vertebra of the same number,
while in the neck the nerve root exits above the pedicle of the vertebra of the same number. L5
compression produces radiation from buttock to lateral calf, lateral calf pain, numbness of the medial
dorsum of foot (including web of great toe), and ankle dorsiflexion weakness, S1 compression produces
radiation posteriorly down leg to heel, posterior calf pain, lateral foot numbness and ankle plantar flexion
weakness (with decreased ankle jerk).
History: Red flags (BACKPAIN) B: bowel or bladder dysfunction; A: anesthesia (saddle); C:
constitutional symptoms/malignancy; K: chronic disease; P: paresthesias; A: age > 50; I: IV drug user; N:
neuromotor deficits.
Describe the pain, location, radiation (L5 radiculopathy causes radiation from buttock to lateral calf, S1
radiates posteriorly down leg to heel), quality, duration, frequency, intensity, circumstances under which it

18

occurs, aggravating and relieving factors.

investigations, treatment.

Onset and chronology, previous episodes.

Previous

Pain worse lying down and bilateral leg weakness suggests spinal stenosis or ankylosing spondylitis.
Spinal stenosis is characterized by worsening of symptoms with standing and walking, with relief on
bending and setting (a typical history of leaning on and bending over the shopping cart for relief of pain
while shopping is suggestive of spinal stenosis).
Ankylosing spondylitis is characterized by morning stiffness relieved by activity.
Pain worse in back than in buttock or leg suggests mechanical back pain. Pain worse in buttock or
leg than in back suggests radiculopathy.
Predominating symptoms of stiffness are suggestive of ankylosing spondylitis.
recurring and tends to be nocturnal.

Back pain is

Morning stiffness improves over the day. May be associated with weight loss, fever, fatigue, anemia.
Focus on joint symptoms (typically large joints), uveitis (occurs in one third of cases), and family history.
Has the patient had a fever, weight loss, night sweats (signs of cancer), urinary tract infection (sign of
urinary retention), joint pain, uveitis (inflammation of the uveal tract: iris, ciliary body, and choroids
sign of ankylosing spondylitis)? Ask about effect on activities of daily living, functional limitations.
Associated numbness, weakness. Are the symptoms improving or worsening? What are the patients
conclusions about the pain and expectations of the physician? Medications, drugs and alcohol, smoking,
past medical history, family history, review of systems.

Cauda equina syndrome: Inquiry into bowel, bladder, and sexual function to reveal this rare syndrome is
obligatory and a source of frequent false alarms. Because these functions may not recover once lost,
cauda equina syndrome due to a surgically treatable lesion is a surgical priority if the time course is
subacute and an emergency if the loss of function is acute. The syndrome consists of saddle anesthesia
(perineal numbness), lax anus, impotence, urinary retention and bowel incontinence. Note that this
combination of signs is due to preservation of sympathetic tone with loss of parasympathetic tone.
Sympathetic tone is preserved because it is carried extra-spinally, while parasympathetic signals are
carried via the inferior spine and nerve roots. Note that bowel contraction and penile erection are
parasympathetically driven.
Physical exam:
Standing
Assess gait, posture, range of motion including rotation, lateral and forward flexion, extension (pain
worse on forward flexion and relief on extension suggest discogenic pain, pain worse on extension
suggests facet joint pain). For ankylosing spondylitis: Wright-Schober test positive when distance
between the lumbrosacral junction and a point 10 cm above (identified by palpation on the erect spine),
distract by less than 5 cm on full forward flexion of the spine. Modified Schober (i.e. detection of
decreased forward flexion of lumbar spine). Lateral flexion is impaired when the hand moves downward
by less than 3 cm on the ipsilateral thigh. Look for scoliosis on standing (shoulder heights equal?) and
forward flexion; check for rib hump. Inspect back for spina bifida. Palpate for tender areas especially
19

sacroiliac joints, compress pelvis to elicit pain of sacroiliitis (hallmark of ankylosing spondylitis). Muscle
tone, percuss costovertebral angles for renal pain. Have patient walk on toes, heels. Ask patient to stand
on one foot at a time and push up into tiptoe for ankle plantar flexor strength (S1).
Sitting
Knee jerks (L4) with quadriceps exposed, watch contraction. Ankle jerks (S1), rapidly dorsiflex each foot
to test for clonus. Babinski. Compare calf girths for wasting by measuring calf circumference 10 cm
below tibial tuberosity. Test power of quadriceps, hamstrings, psoas (raise knee up against resistance),
ankle dorsiflexors. Ask patient to straighten both legs and compare this position to the degree of forward
flexion the patient was able to achieve on standing range of motion. Suspicion of malingering is raised if
the patient claims to be unable to bend from a standing position but is able to extend the knees from a
sitting position.
Supine
Feel for lymph nodes at neck, clavicle, axillae, groin. Test hip extensors (patient presses leg into bed
while you try to raise it). Sensation in both legs: light touch, pin prick compare medial dorsum of foot
(L5) with lateral foot (S1) and lateral calf (L5) with posterior calf (S1). Vibration and position sense in
big toes. Straight leg raise: raise patients heel on bed as far as patient will allow, note angle, note
whether this reproduced the patients ipsilateral or contralateral radicular pain. Bowstring test: flex hip to
90 degrees, extend knee to the point of pain and press on the hamstring tendon, which is medial, note
reproduction of pain. Peripheral vascular exam: inspect for venous stasis or arterial insufficiency ulcers,
check femoral pulses and auscultate for femoral bruits, feel popliteal, dorsalis pedis and tibialis posterior
pulses.

16. 25 year old man wishes to refill a prescription of Fiorinal for tension headache. Manage.
History: description of headache pain, location (one-sided vs. bilateral/occiput-vertex Do you feel pain
on one or both sides? If one-sided, is it always the same side? If present on both sides, did the pain start
on one side? Is it usually maximal on one side?), quality (pulsatile vs. non-throbbing what kind of
pain is it tightening, pressing, throbbing, pounding, pulsating, burning, etc? Do different types of pain
occur at different times in any one attack? If so, what types?), intensity, duration (at least 72 hours in
migraine, if not treated), onset including time of day (morning headache associated with raised
intracranial pressure), previous episodes, aggravating/relieving factors (e.g. coughing and straining
worsen headache in raised ICP and chocolate or cheese can trigger migraines), associated symptoms
(aura, nausea, vomiting, photophobia light, phonophobia sound, osmophobia odors, nuchal rigidity,
weakness, numbness, visual disturbances), medical history, medication history (when was this prescribed,
do you have the empty bottle, has it been prescribed before?), current meds, allergies, family history,
substance abuse inquiry, smoking, allergies, mood, stress, anxiety inquiry. Review of systems.
Red flags for headaches: must rule out headaches resulting from meningitis, trauma (subarachnoid
hemorrhage, epidural hemorrhage), tumor, temporal arteritis. History: new onset, headache worse at
night, headache wakes patient at night, fever, neck stiffness, seizures, trauma, changes in LOC/behavior,
vomiting, severe, very young/old patients. Physical exam: fundi abnormal, Kernig/Brudzinski signs
(meningitis), focal neurological findings.

20

Given benign history with no suspicion of raised ICP or focal deficits and a description of headache
consistent with the common tension headache, a full neurological examination is not indicated. Suggest
to the examiner that you would perform a brief neurological screening exam. You will be told to move
on.
Treatment: Explain that Fiorinal is a combination preparation of barbiturate (butalbital), caffeine and
ASA which is properly used only for the relief of occasional tension headaches. It is habit-forming, can
precipitate a withdrawal syndrome including agitation, delirium and seizures and has additive sedative
effects with other CNS depressants. The fact that this patient has consumed an entire prescription in four
days suggests overuse due to dependence. He may also have analgesic headache syndrome in which
inappropriately used analgesics actually cause headaches. Suggest a drug holiday with weaning from
caffeine and alcohol, proper sleep hygiene, diet, exercise and stress management. Chronic headache may
also be a symptom of depression or anxiety, arrange follow up to evaluate for these if the patient does not
improve.
17. Elderly woman in hospital post-op day 5 of total hip replacement.
tachycardia, tachypnea, shortness of breath. Manage.

Acute chest pain,

Worry about: Life-threatening causes of acute chest pain: MI, PE, pneumothorax and tension
pneumothorax, aortic dissection. Other causes angina, gastritis, reflux, peptic ulcer, pericarditis, herpes
zoster, musculoskeletal.

Differential Diagnosis for Chest Pain

Cardiac
Non-Cardiac
Angina
Pulmonary
MI
Pneumonia
w/
Pericarditis
pleuritis
Myocarditis
Pneumothorax
Dissecting
PE
aorta
Pulmonary
hypertension

GI
Esophageal
reflux
Ulcer

MSK/Neuro
Arthritis
Chondritis
Rib
fractures
Herpes
Zoster

Psychologic
Anxiety
Panic

History: Rapid cardiopulmonary history including any history of high blood pressure, heart problems,
smoking, COPD.
Physical exam: Is a cardiopulmonary exam as in question #13 above with additional attention to risk
factors for post-op complications (i.e. inactivity/decreased mobility resulting in DVT/PE).
Homans sign: pain in the calf on dorsiflexion of the foot indicates thrombophlebitis. Check that
trachea is midline. Inspect surgical wound. Is the patient on DVT prophylaxis or anti-coagulation?

21

Treatment: Raise head of bed. Give oxygen 6 L/min by mask. Monitor oxygen saturation. Order stat
CBC, lytes, glucose, INR/PTT, serial CK-MB and Troponin, ABG, CXR, ECG. Give chewable ASA 160325 mg immediately. Secure IV access, bolus IV lasix 40 mg, push if fluid overload is suspected, and
ventolin if wheezes are heard, give sublingual nitro spray or 0.3 mg sublingual nitro if blood pressure is
adequate and 1 mg morphine IV. Repeat nitro q5min x 3. May require additional morphine and nitro.
Repeat CK-MB and Troponin q8h x 3.
ECG: if ECG shows significant ST elevation (more than one millimeter in two anatomically consecutive
leads), or a new left bundle branch block, then the patient is having an MI. Order stat Cardiology consult
for possible lytic therapy or cardiac catheterization. If less severe signs of ischemia are present (flipped T
waves, ST depression), follow with repeat ECGs until resolved.
S1Q3T3: This classic pattern (wide S-wave in lead I, Q-waves in lead III, T wave inversion in lead III)
with right axis deviation and RBBB are signs of right heart strain seen in massive PE.
A-a gradient: An elevated A-a (Alveolar pO2-arterial pO2) gradient is a sign of pulmonary embolus but
also occurs in any condition in which there is a ventilation-perfusion mismatch (e.g. pneumonia,
pulmonary edema, COPD). It is determined from the ABG:
A-a = 713 (FiO2) 1.25 (PaCO2) PaO2
[normal: 12 in child 20 in 70 year old]
Note that the inspired oxygen fraction (FiO2) is not known unless the patient is on room air, a ventimask
or mechanically ventilated. This is because the patient breathes in a proportion of room air which mixes
with the oxygen delivered by face mask or nasal prongs thereby diluting it by an unknown amount.
Roughly, however, 2L/min gives 26% FiO2, 3L=30%, 4L=35%, and 6L=40%. 40% is considered the
maximum inspired oxygen obtainable without a high flow mask such as a ventimask.
ABG normal values: pH 7.35-7.45, pO2 80-100 mmHg, bicarbonate 24, pCO2 40
Indications for intubation: An ABG showing poor pO2 (in the 60s, or if less then 80 on high inspired O2
concentrations), elevated pCO2 (greater than 80), acidemia, or GCS < 8 (not able to protect airway) may
indicate need for intubation if these are not quickly correctable. Consult ICU.
CXR signs of PE: wedge-shaped infiltrate (Hamptons hump) or oligemic area, unilateral effusion, raised
hemidiaphragm. A normal CXR is also consistent, and usual, with PE.
Specific investigations for PE: CT chest (can only see PE which is large enough to be clinically
significant), V/Q scan (conclusive when it shows high or low probability), and serial (q2d) leg Dopplers
for presence of DVT above the knee.
Treatment: if suspicion of PE is high, anticoagulate (before waiting for tests) with heparin 7500 U IV
bolus, then infuse at 1200 U/h. Measure PTT q6h, adjust dose for PTT 70-90s. If a diagnosis of PE is
made, coumadin (warfarin) should be started, continue anti-coagulation for 3 months.
18. Young mother with 6 week old baby has recently immigrated from Ghana. Poor English skills.
Concerned about whether she should have her baby immunized. Counsel.

22

Counseling: General principles of counseling are to be aware of communication barriers such as language
difficulties, to understand the patients objectives, fears, preconceptions, to deal with these in an
empathetic, non-judgmental way and to normalize them to transmit information in a way that is consistent
with the patients expectations and understandable to them, and to invite further questions and feedback.
History: Ask if the patient would prefer someone, perhaps a family member to translate. Ask about the
patients concerns, what does she want to know and why? Explain that vaccines protect children from
diphtheria, tetanus, pertussis, polio (DPTP), mumps, measles, rubella (MMR), influenza (Hib) and
hepatitis B (Hep B). All of which were once common and caused serious, sometimes fatal illness in
Canada, and all of which are now hardly ever seen because of vaccines. Explain that because the vaccines
stimulate the immune system, some children have a temporary sore arm (with induration and tenderness)
at the injection site, malaise, mild fever or rash. Allergic reactions to vaccines also occur including
urticaria, rhinitis, and anaphylaxis. It is very rare to have a more serious reaction (seizures,
encephalopathy have been reported). Standard modern vaccines are not known to cause disease or to
have long-term deleterious effects. Compare these risks with the risk of not getting vaccinated. Explain
the recommended immunization schedule (below), give the patient some information pamphlets, invite
further questions and ask her to return in two weeks for the childs first immunization.
Contraindications to vaccination: previous serious reaction to vaccine. Special contraindication to
MMR, which is a live attenuated vaccine suspended in egg white protein and preserved with neomycin:
allergy to egg or neomycin, pregnancy and immunocompromised state (except healthy HIV positive
children). Special contraindications to the pertussis component of DPTP (which is thought to be the
component responsible for seizures and encephalopathic vaccination reactions when they occur):
progressive neurologic disorder and epilepsy. Hib not to be given after age 5. TdP should not be given in
first trimester of pregnancy.

Recommended Immunization Schedule:

DPTP = diphtheria, tetanus, acellular pertussis and
inactivated polio, Hib = Hemophilus influenza type b,
MMR = measles, mumps, rubella, Hep B = hepatitis B,
TdP = tetanus, diphtheria toxoid and pertussis, Td =
tetanus and diphtheria toxoid, NB: MMR is administered
SC while the others are IM.
2 months
DPTP, Hib (given as Pentacel)
4 months
DPTP, Hib
6 months
DPTP, Hib
1 year
MMR
18 months
DPTP, Hib
4-6 years
MMR, DPTP
12-13 years Hep B (3 doses initial, 1 month, 6
months)
14-16 years TdP (certificate of immunizations for high
school)
q10yrs
Td
23

19. 40 year old woman appears sad, requests sleeping pills. Manage.
History: Name, age, occupation. Social situation. Stressful life events. Depression commonly presents
with sleep disturbance therefore screen and treat for depression as in question #4 above. This should be in
addition to a sleep history. Medications, allergies, drugs/smoking/alcohol, past medical/surgical history,
family history, review of systems.
Sleep history: usual requirements, chronology of sleep problems, stressor, sleep hygiene (when, where,
regularity, shifts at work, quiet, late, exercise, meals, alcohol, caffeine, prescription and non-prescription
remedies, drugs and medications), sleep latency (time to fall asleep), nocturnal awakening, early morning
wakening, daytime somnolence, somnolence while driving, working or during conversation.
Proper sleep hygiene: regular bed and wake times, avoid daytime naps, regular exercise but not late in
the evening, do not use the bed for reading, TV, paperwork, etc., and avoid caffeine, alcohol, and
smoking.
20. 60 year old woman with multiple pains investigated by several other doctors, all lab tests
normal. Manage.
History of multiple pains: should address the differential for multiple pains.
Differential for multiple pains:
Depression with somatization: major depression presents with a somatic complaint; commonly
headache, stomach pains, sleep disturbance, eating disturbance, or bowel habit changes. This is a frequent
presentation of depression in the elderly. Treat as in depression (see #19 above).
Somatization disorder: multiple non-intentional complaints in multiple organ systems beginning before
age 30 that occur over several years, with treatment sought and significant impairment in functioning.
Diagnostic criteria: at least 8 physical symptoms that have no organic pathology: 4 pain symptoms at 4
different sites, 2 GI symptoms other than pain, 1 reproductive or sexual symptom other than pain, 1
pseudo-neurological symptom (e.g. temporary blindness).
Complications: anxiety, depression,
unnecessary medications or surgery. Often a misdiagnosis for an insidious illness so rule out all organic
illnesses (e.g. MS). Treatment: counseling, psychotherapy, close follow-up, reassurance.
Conversion disorder: psychic perturbation presents as one or two neurological complaints affecting
voluntary motor or sensory function. Psychological factors thought to be etiologically related to the
symptom as the initiation of symptoms is preceded by conflicts or other stressors. La belle indifference
patients inappropriately cavalier attitude towards a serious symptom. Treatment: anxiolytics (e.g.
lorazepam 1 mg PO q6h), relaxation therapy, counseling, close follow-up.
Pain disorder: e.g. chronic post-traumatic or post-surgical pain. Pain not fully accounted for by current
tissue injury, exacerbated by psychic factors and associated with functional impairment. Treatment:
amitriptyline 25-75 mg PO qHS.
Hypochondriasis: exaggeration or misinterpretation of normal sensory phenomena to the point of
functional disability. Evidence does not support a physical disorder. Associated with obsessive fear of
serious illness and doctor shopping despite reassurance. Belief is not delusional as person acknowledges
unrealistic interpretation. Treatment: counseling, reassurance, close follow-up.
24

Fibromyalgia: also called fibrositis and fibromyositis. 80-90% of cases occur in middle-aged females,
may afflict 5% of adult women, typically cardiovascularly unfit, depressed, previously normal life (onset
often after car accident). Associated with absent or decreased non-REM stage 4 sleep, patients wake from
sleep feeling unrefreshed. Constant, aching, axial pain with bilateral tender points (not trigger points, at
which referred pain is triggered due to myofaschial pain from overuse, e.g. tennis elbow). The disorder
follows a waxing and waning course ultimately without progression or resolution, and may become
disabling. Characteristic reproducible tender points are located bilaterally at lateral border of sternum,
sternocleidomastoid, posterior neck, trapezius, rhomboids, over sacroiliac joints, lateral thigh, posterior
and medial knee. Patient should have eleven of the above eighteen tender points for a diagnosis.
Treatment: amitriptyline 25-75 mg PO qHS.
Chronic fatigue syndrome: similar to fibromyalgia but fatigue is the dominant feature and pain and
tender points may be less prominent or absent. Treatment: amitriptyline 25-75 mg PO qHS.
Factitious disorder or malingering: Factitious disorder involves misrepresentation of history and
symptoms for the purpose of assuming the sick role with its inherent secondary gains (attention and
sympathy, justification for inadequacies). Munchausens syndrome is the type of factitious disorder in
which physical findings are faked by contamination of lab tests or ingestion of inappropriate medication
or substances. Typically the patient is a medical paraprofessional motivated by hostility toward the
medical establishment, e.g. nurse takes coumadin to fake hemophilia. Malingering is distinguished from
factitious disorder by a motivation for secondary gain other than the sick role, such as insurance benefits.
Treatment: counseling.
History: Pain description, location, duration, chronology, aggravating and relieving factors, are pains
linked to one another?
Somatoform disorders screen: How has your health been for most of your life? How have your pains
affected your job, social life, relationships, and your life generally? Are you often unwell, how often do
you visit the doctor? Do you worry that you have a serious illness? If a doctor tells you that there is
nothing wrong, how does that make you feel? Do you believe him or her?
Associated symptoms: review of systems, medications, allergies, smoking, alcohol, drug use, family
history, depression history as in #4 above.
Diagnosis and treatment: For non-specific pains with depressive symptoms the patient most likely has
depression with somatization. Treat for depression as in #4.
21. A young man presents to the Emergency Department having twisted his ankle. Manage.
History for ankle sprain: history of a plausible mechanism of injury involving significant inversion or
eversion of the foot with pain and swelling. Time of injury, onset of pain and swelling (may be delayed),
noises heard at time of injury. Previous ankle or other injuries. Ability to walk post injury (often
preserved if ligaments are not ruptured). Past medical history, medications, allergies, family history.
Physical exam: inspect for gross deformity, erythema, swelling, bruising. Check distal circulation,
sensation, active and passive range of motion, palpate for tenderness at joints. Examine the joints above
and below the affected joint. Identify sites of maximal tenderness. Point tenderness over the area anterior
(anterior talofibular ligament), inferior (calcaneofibular ligament), or posterior (posterior talofibular

25

ligament) to the lateral malleolus are signs of lateral ligamentous injury. Tenderness over the area medial
and inferior to the medial malleolus indicates deltoid (medial) ligament injury.
Talar drawer sign: Stabilize the tibia and pull forward on the heel, talar drawer sign is anterior
movement of the talus. Greater than 3 mm anterior movement may be significant. 1 cm is significant and
indicates anterior talofibular ligament rupture.
Talar tilt: Stabilize the tibia, grasp the talus and tilt in inversion and eversion. Movement beyond the
normal range compared with the opposite side is a positive talar tilt and indicates lateral calcaneofibular
ligament rupture if the tilt occurs in inversion or medial (deltoid) ligament rupture if the tilt occurs in
eversion.
Squeeze test: Pain in the ankle on squeezing the calf is a sign of ankle fracture.
Ottawa Ankle Rules: for taking ankle series x-rays (includes lateral and AP ankle with mortis view). Xray if there is pain over the malleolar zone AND tenderness on palpation of the posterior medial or lateral
malleolus OR if the patient is unable to weight bear immediately and in ER. For foot series (AP and
lateral foot): X-ray if there is pain in midfoot zone AND bony tenderness over the navicular or base of 5 th
metatarsal OR unable to weight bear immediately and in ER. Calcaneal views if there is pain on palpation
of heel.
Treatment for ankle sprain: (remember RICE) Rest, use crutches, avoid weight bearing but early
mobilization. Ice for 20 minutes QID for 2-3 days. Consider NSAIDs: Ibuprofen 400-600 mg PO q6h if
no contraindications. Compression with tensor bandage or tape but not to the point of pain. Elevate.
Rehabilitation: start active range of motion exercises 2 days post injury, may weight bear after pain and
swelling have subsided. Full ligament healing may take 6 weeks in severe injury or more if re-injury
occurs. Complete ligament rupture with joint instability (positive talar drawer sign or talar tilt) should be
evaluated by Orthopedics.
22. 16 year old known epileptic on Dilantin is having 3 seizures per month and requests better
medication. Manage. Findings: not taking meds, experiencing stress.
See question #3 above.
23. 50 year old woman with headache and normal vitals. Take a history. Q: Describe appropriate
investigations and treatment for temporal arteritis.
History: description of headache pain, location (one-sided vs. bilateral/occiput-vertex Do you feel pain
on one or both sides? If one-sided, is it always the same side? If present on both sides, did the pain start
on one side? Is it usually maximal on one side?), quality (pulsatile vs. non-throbbing What kind of
pain is it tightening, pressing, throbbing, pounding, pulsating, burning, etc? Do different types of pain
occur at different times in any one attack? If so, what types?), intensity, duration (at least 72 hours in
migraine, if not treated), onset including time of day (morning headache associated with raised
intracranial pressure), previous episodes, aggravating/relieving factors (e.g. coughing and straining
worsen headache in raised ICP and chocolate or cheese can trigger migraines), associated symptoms
(aura, nausea, vomiting, photophobia light, phonophobia sound, osmophobia odors, nuchal rigidity,
weakness, numbness, visual disturbances). A history of unilateral lancinating pain with swelling and
tenderness in the temporal area should prompt inquiry after symptoms of polymyalgica rheumatica (PR
pain and stiffness in muscles of neck, shoulders, upper arms, hips, lower back and thighs no weakness
26

or atrophy increased ESR, anemia, normal CK responds to steroids immediately), which is related
to temporal (giant cell) arteritis and may be a more systemic variant of the same underlying disease.
Symptoms of both PR and temporal arteritis include low grade fever, malaise, anorexia, weight loss,
bilateral proximal muscle weakness, aching and pain, as well as joint inflammation. Jaw claudication,
stroke and blindness may occur due to vasculitic occlusion of arterial supply. Ask about visual changes.
Medical history, medication history (when was this prescribed, do you have the empty bottle, has it been
prescribed before?), current medications, allergies, family history, substance abuse inquiry, smoking,
allergies, mood, stress, anxiety inquiry. Review of systems.
Investigations for temporal arteritis: CBC (mild anemia with increased WBC), ESR (greater than 50
mm/h, [normal 30]), C-reactive proteins, liver enzymes, temporal artery biopsy, may add temporal artery
angiogram to guide biopsy.
Treatment: (in the absence of visual symptoms) without waiting for biopsy, start high dose oral
prednisone 60 mg PO OD until symptoms subside and ESR normal, then 40 mg PO OD for 4-6 weeks,
then taper to 5-10 mg PO OD for 2 years (relapses occur in 50% if treatment is terminated before 2 years).
Treatment does not alter biopsy results if the sample is taken within 2 weeks. Monitor ESR regularly. If
visual symptoms are present, or develop during treatment, the patient is admitted and given prednisolone
1000 mg IV q12h for 5 days.
24. HIV positive man. 1 week of shortness of breath, cough, fatigue. Perform a physical exam. Q:
Give a differential diagnosis for a CXR showing a fine reticular pattern in the left lower lobe.
Manage.
Physical exam: A physical exam for query pneumonia consists of the cardiopulmonary exam as in
question # 13 with additional attention to the particular signs and symptoms of HIV infection.
Examination for lobar consolidation: In general, pulmonary effusion decreases transmission of breath
and vocal sounds to the chest wall, while consolidation (seen in pneumonia) increases it. Four maneuvers
bring out the effect of increased transmission: tactile fremitus is increased transmission of palpable
fremitus to the chest wall while the patient repeats ninety-nine, bronchophony is enhanced
transmission of spoken words such as ninety-nine, egophony is a change from an ee to an ay sound
over the affected area while the patient sustains an ee sound, and whispered pectoriloquy is a marked
increase in audibility through the chest wall over the affected area while the patient whispers the words
ninety-nine or one-two-three.
Signs of consolidation: increased tactile fremitus, percussion dullness, crackles, bronchial breath sounds,
increased voice transmission (bronchophony, egophony, whispered pectoriloquy).
Signs of HIV Infection: (and possible impending AIDS) check entire skin surface for Kaposis sarcoma,
examine pharynx for thrush or oral hairy leukoplakia (Epstein-Barr virus-related epithelial proliferation
causing raised white plaques on the sides of the tongue), palpate neck, clavicle, axillae, and groin for
lymph nodes enlarged by non-Hodgkins lymphoma. Examine abdomen for hepatic or splenic
enlargement.
Differential diagnosis of unilateral lobar reticular pattern on CXR: pneumocystis carinii pneumonia
(PCP), Kaposis, lymphoma, cytomegalovirus (CMV), tuberculosis, Cryptococcus neoformans,
Hemophilus, Streptococcus, mycoplasma, chlamydia. The classic CXR of PCP, an AIDS-defining illness,
is bilateral hilar infiltrates, but X-ray findings are variable and may be alveolar or interstitial.
27

Investigations: O2 sats/ABG, CBC with differential and CD4 count, LDH (elevated in 95% of PCP
pneumonias and not in other pneumonias), blood cultures, sputum for cytology/gram stain/culture/TB
stain if sputum available (cough usually non-productive and induced sputum may fail), bronchoscopy
with cytology, gram stain and culture of bronchial washings and brushings (may see bronchial Kaposis).
Treatment: Septra DS 2 tabs q8h x 14 days outpatient with 1 tab OD or BID 3/week continued as
prophylaxis. More specific therapy with results of diagnostic tests. In severe illness, admit to hospital,
give IV Septra at same dose and Prednisone 40 mg BID x 5 days, then OD x 5 days, then 20 mg OD for
prophylaxis. Patient should be referred to an AIDS specialist for antiviral and possible experimental
therapies. Counseling and referral to support organizations. Follow up appointment.
25. A 2 day old infant has serum bilirubin 220 mol/L (ref. Max 200 mol/L). Take a history from
the mother. Q: What are the possible causes for this abnormality? Give investigations and
treatment.
50% of term infants develop visible jaundice (> 85-120 mol/L or 5-6 mg/dL)
Mothers obstetrics history: GTPAL (number of gestations, term pregnancies, premature births,
abortions, live children), history of previous pregnancies including neonatal jaundice, maternal medical
history esp. liver disease, illness during pregnancy esp. diabetes (large birth weight, pre-eclampsia),
rubella (teratogenic), toxoplasmosis (from cats, infects fetal brain), herpes (infects fetus, frequently fatal),
CMV (damages fetal liver), teratogenic medications taken during pregnancy, drug and alcohol use,
maternal blood type, complications of present pregnancy including gestational hypertension or diabetes,
hyper/hypothyroid, hypercoagulation. Family history of neonatal jaundice, liver problems.
Newborn history: gestational age at birth, caesarean, induction, rupture of membranes artificial or
prolonged, fetal distress, forceps or vacuum delivery, meconium, APGARs, was resuscitation required?
Initial blood work, breast feeding? How often and how well, color of 1 st stool, color of urine, vomiting,
neonate muscle tone, behaviors, fever, irritability, lethargy.
Causes of neonatal jaundice: unconjugated = physiologic neonatal jaundice OR pathologic: hemolytic
ABORh incompatibility, neonatal sepsis, splenomegaly, hereditary spherocytosis, G6PD etc.; nonhemolytic breast milk jaundice, breakdown of cephalohematoma, polycythemia, sepsis, Gilberts,
Crigler-Najjar, hypothyroidism. Conjugated: GI obstruction in fetus (increases enterohepatic circulation),
bile duct obstruction, drug-induced and multiple other less common causes.
Investigations: Use blood obtained by venipuncture, not heal prick, as sludging of heel prick blood in
skin capillaries distorts cell counts and concentrations. Measure direct (conjugated) and indirect
(unconjugated) bilirubin, neonatal and maternal blood types, Coombs test (see below), blood smear, CBC
with reticulocyte count. Septic work-up, urinalysis, blood cultures, CXR, AXR, CSF.
Coombs test: a two-part test. 1. Direct antiglobulin test: detects presence of anti-red cell autoimmune
antibodies attached to red cells. Patients red cells agglutinate when mixed with a solution containing
anti-human immunoglobulin antibodies, i.e. multiheaded anti-immunoglobulin antibodies bind to the
constant chains of antibodies on the red cell surface, sticking red cells together. 2. Indirect antiglobulin
test: detects presence of anti-red cell antibodies in patients serum. Patients serum incubated with red
cells of the same blood group, test is positive if agglutination occurs.

28

Treatment: The aim of treatment is to correct anemia and decrease hyperbilirubinemia. Severe
hyperbilirubinemia may lead to kernicterus (deposition of bilirubin in the brainstem and basal ganglia
leading to mental retardation, cerebral palsy, hearing loss and paralysis of upward gaze). Indications for
intervention: In general, serum total bilirubin level greater than 300 um/L is an indication for
phototherapy, while levels greater than 400 um/L call for exchange transfusion or plasmaphoresis.
Therapeutic modalities: In phototherapy photoisomers of bilirubin are produced which are more watersoluble and can be excreted without conjugation, while exchange transfusion replaces the babys blood
with donor blood. Plasmaphoresis is the replacement of blood plasma with donor plasma while retaining
the patients own red and white cells.
Specific treatment of jaundice depends on the cause:
Physiologic jaundice: occurs on day 2-3 in 50% of term infants (NEVER within 1 st day) and resolves by
day 7. It is more common in preterm infants where it occurs later, up to day 6, and lasts longer. Due to
transient limitation in bilirubin conjugation (i.e. the hyperbilirubinemia is unconjugated or indirect).
Usually requires no treatment.
ABORh incompatibility jaundice: Rh incompatibility (Rh negative mother with Rh positive fetus) tends
to be more severe than other incompatibilities (ABO incompatibility: e.g. O mother with A or B fetus) and
may cause hydrops fetalis (generalized edema, including pulmonary edema, with high output heart
failure). Treatment for all types is exchange transfusion or plasma electrophoresis.
Sepsis-related jaundice: treat underlying cause and use phototherapy.
Breast milk jaundice: occurs day 4-7 and peaks at 2nd to 3rd week, rare (1:200), long chain fatty acids in
breast milk competitively inhibit glucuronyl transferase activity. Treatment is to substitute formula for
breast milk for 2-4 days, then resume.
26. A 50 year old man is denied life insurance because of abnormal liver function tests. AST > ALT
very elevated, ALP slightly elevated, Bili normal. Take a history. Q: Give a differential diagnosis.
What investigations would you order?
History: Name, age, occupation. History of jaundice, hepatitis, foreign travel, blood transfusions,
recreational IV drug use. Dark urine, pale stool, abdominal pain, fever/chills, decreased appetite, weight
loss, night sweats, nausea and vomiting, pruritis, easy bruising, gynecomastia, hemorrhoids (from portal
hypertension), alcohol use & CAGE questionnaire (see below). Sexual history: number of past and
present partners, genders of same, sexually transmitted disease. Medications, drug use, smoking,
allergies, past medical history, family history, review of systems.
CAGE questionnaire: Control have you tried to cut down on your alcohol? Anger have you ever felt
angry when someone suggested you decrease your alcohol intake? Guilty have you ever felt guilty about
your drinking? Eye opener do you sometimes have a drink to get started in the morning?
Liver Enzymes: AST & ALT are sensitive but non-specific markers of hepatocellular damage
hepatitis (inflammation) vascular injury (ischemia).
AST > ALT = alcoholic liver disease; AST/ALT > 2 (AST usually < 300) alcoholic liver.
ALT > AST = viral hepatitis.

29

 ALP & GGT are markers of cholestatic disease intrinsic (toxic, infectious, inflammatory),
systemic (sepsis, pregnancy), infiltrative (tumor, fat, lymphoma), mass lesions (stone, tumor,
abscess).
Serum transaminases > 1000 due to 1) viral hepatitis, 2) drugs, 3) passage of common bile duct
stone, 4) hepatic ischemia.
Differential: alcoholic liver disease, viral hepatitis, liver malignancy (metastatic or primary).
Investigations: Viral serology (Hep A, B, C antibody and B antigen presence of B antigen for > 6
months indicates chronic carrier state), GGT, AST, ALT, AlkPhos, LDH, bilirubin, INR/PTT, albumin,
glucose (cirrhosis), serum ceruloplasmin, serum copper (Wilsons disease), serum ferritin, total iron
binding capacity (TIBC, for hemochromatosis), ANA, anti-smooth muscle antibody (autoimmune
hepatitis, also called chronic active hepatitis), abdominal ultrasound, liver biopsy.
27. 19 year old female with vaginal discharge. Take a history. Q: Give three possible diagnoses,
what investigations would be helpful?
History: Name, age, occupation, description of discharge, onset, chronology, previous episodes, volume,
color, consistency, odor, timing (related to menses?). Associated symptoms: pain including abdominal,
burning, fever, itch, dyspareunia, dysuria, urgency, frequency, aggravating and relieving factors. Sexual
history: number of past and present partners, gender, type of contraception (condoms), possibility of
pregnancy, past history of sexually transmitted disease. Obstetrics/gynecology history: (GTPAL)
pregnancies, abortions/miscarriages, births, pap smears (normal?), menstrual pattern. Medications
(especially antibiotics), oral contraceptives, other drug use, allergies. Past medical history including
diabetes. Family history, review of systems.
Causes of discharge: Physiological: normal midcycle discharge, increased estrogen states. Infectious:
candidiasis, bacterial vaginosis (Gardnerella vaginalis), trichomonas infection, chlamydia, gonorrhea
(NOTE: gonorrhea and chlamydia can cause cervicitis, PID and urethritis, but do not cause vaginitis but
Toronto Notes includes them in the differential for vaginal discharge), bartholinitis or Bartholin abscess,
PID. Neoplastic: vaginal intraepithelial neoplasia (VAIN), vaginal squamous cell carcinoma, invasive
cervical carcinoma, fallopian tube carcinoma. Other: allergic/irritative vaginitis, foreign body, atrophic
vaginitis, enterovaginal fistulae.
Investigations: speculum exam, swab and culture, saline slide microscopy and KOH whiff test (add KOH
to vaginal secretions on a slide). These give results as follows:
Candidiasis: inflamed appearance, lumpy white discharge, spores and pseudohyphae seen under
microscope. Treatment: miconazole vaginal suppository.
Bacterial vaginosis: non-inflamed, thin gray secretions, clue cells under microscope (epithelial cells with
obscured borders due to adherence of bacteria), fishy odor on KOH test. Treatment: metronidazole
500mg PO BID x 7 days (in pregnancy use Amoxicillin 500mg TID x 7 days).
Trichomonas: inflammations, frothy yellow-gray-green discharge, motile trichomonads seen under
microscope. Treatment: metronidazole 2 g x 1 or 500mg PO BID x 7 days (in pregnancy use
Clotrimazole vaginal suppositories).

30

28. 60 year old man with microscopic hematuria on routine urinalysis. Take a history. Q: Give a
differential diagnosis, what investigations would be helpful?
Etiology of Hematuria by Age Group
Age
Etiology (in order of decreasing
frequency)
0-20
Glomerulonephritis, UTI, congenital
anomalies
20-40
UTI, stones, bladder tumor
40-60
Male: bladder tumor, stones, UTI
Female: UTI, stones, bladder tumor
> 60
Male: BPH, bladder tumor, UTI
Female: bladder tumor, UTI
History: patient ID, suprapubic pain, pain on urination, frequency, urgency, frank blood in the urine
(globular clots from bladder or string shaped clots from ureters), color of urine, difficulty initiating or
maintaining urinary stream, renal pain, back pain, groin pain. Provoking factors (e.g. exercise, trauma).
History of recent UTI, STDs, TB exposure, pelvic irradiation, bleeding diathesis, smoking. Fever, chills,
nausea, fatigue. Previous renal colic/diagnosed nephrolithiasis? History of hypercalcemia, hypertension.
Malignant symptoms: night sweats, weight loss, fatigue.
Medications, drugs (NSAIDs,
anticoagulants)/alcohol, smoking, anticoagulants and salicilates, past medical history, past surgical
history, family history (polycystic kidney disease?), review of systems.
Differential diagnosis: BPH, transitional cell carcinoma of bladder, UTI, nephrolithiasis, hydronephrosis,
prostatitis, prostate cancer, renal cell carcinoma, glomerulonephritis, trauma (heart valve, muscle
injury/breakdown), essential hematuria (tends to occur in children). NOTE: microscopic hematuria is
normal in 10% of population.
Investigations: prostate specific antigen (PSA), CBC (to rule out anemia, leukocytosis), urine for
microscopy (casts, crystals, culture and sensitivity, cytology), abdominopelvic ultrasound, cystoscopy,
intravenous contrast urography, intravenous pyelogram (IVP).
29. 25 year old male with a history of dyspepsia and binge drinking has abdominal pain. Perform a
focused physical exam. Q: What radiological investigations would you order and why?
Physical exam for abdominal pain: vitals, posture (unmoving in fetal position suggests peritonitis while
writhing suggests renal colic), jaundice, nutritional status, buccal mucosa, teeth, breath (hepatic fetor),
parotid hypertrophy, glossitis, inspect chest for telangectasia, gynecomastia, loss of axillary hair. Hands:
palmar erythema, clubbing, Dupuytrens contracture, wasting of hand intrinsics.
Abdominal exam (supine): inspect for caput medusa, Cullens sign (umbilical bruising intraperitoneal
bleed), Gray-Turners sign (bruising of flank retroperitoneal bleed), pulsations, auscultate for bowel
sounds, renal bruits. Estimate size of liver and spleen by percussion. Palpate for liver edge, Murphys
sign (examiner presses on liver edge after patient has exhaled, patient catches breath on inspiration),
splenic enlargement (begin palpation at right lower quadrant to catch very large spleen and percuss at
Traubs space), hard stool in bowel. Note cough tenderness, rigidity, rebound, guarding, tenderness, pain
at McBurneys point (one third of the way along the line between the right anterior iliac crest and the
umbilicus). Rovsings sign: palpation of the LLQ produces RLQ pain. Psoas sign: pain on passive or
active flexion at the hip, indicates peritoneal irritation over the psoas or psoas abscess. Obturator sign:
31

pain on internal or external rotation of the hip, indicates bowel herniation into the obturator canal. Assess
for ascites. Ask patient to roll onto side and pound costovertebral angles lightly with fist, CV angle
tenderness indicates kidney pain due to pyelonephritis or nephrolithiasis. Palpate groins for hernias.
Rectal: palpate prostate, rectal shelf, check for gross or occult blood.
Radiological Investigations: Abdominal 3 views: supine, upright, left lateral decubitus. Dilated bowel
with multiple air/fluid levels indicates ileus. Dilated proximal bowel with collapsed distal bowel indicates
obstruction. Check for gastric distension. Small bowel has circular plica: lines go all the way across.
Large bowel has interrupted haustra: lines go halfway across. Check for calcified kidney stone, fecolith
and appendiceal air/fluid level. Can see gallstones and abdominal aortic aneurysm if calcified.
Abdominal ultrasound: gallstones, cholecystitis, pancreatitis, appendicitis, hydronephropathy, kidney
stones, abdominal aneurysm. CXR: check for free air under the diaphragm in an upright film.
30. 70 year old male with neck pain and left arm weakness. Perform focused physical exam.
Findings: decreased sensation over left index and middle finger, mild wrist extensor and triceps
weakness. Q: Describe a cervical spine film of the patients neck (shows narrowing of C6-7 disk
space). Diagnosis and treatment?
Physical exam for neck pain: guided by differential for the causes of neck pain: musculoskeletal,
discogenic, stenotic, malignant or brainstem infarct. Take vitals, cranial nerves: pupillary reflexes,
extra-ocular movements, visual fields, facial muscles (frown, raise eyebrows, show teeth, protrude
tongue), facial sensation, gag, Horners triad (ptosis, anhidrosis, miosis on side of sympathetic palsy?),
sternocleidomastoid and trapezius power. Cerebellar testing: finger-nose, heel-shin, dysdiadocokinesis,
gait, Rhomberg, Pronator drift.
Neck: inspect for lesions, asymmetry, muscle wasting, especially sternocleidomastoids, palpate for nodes,
masses, palpate dorsal vertebral spines, range of motion.
Shoulders, arms, and hands: inspect for symmetry, wasting, fasciculations, skin lesions. Power: Test
deltoids (C5), biceps (C6), triceps and wrist extension (C7), hand intrinsics (C8). Note that each muscle
group actually has mixed nerve root innervation, i.e. deltoids and biceps (C5,6), triceps (C6,7,8), wrist
extension (C6,7), hand intrinsics (C8,T1). Sympathetic outflow occurs at C8, T1. Sensation: check
pinprick, vibration, light touch over the shoulder (C5), thumb (C6), index and middle finger (C7), ring
and little finger (C8). Deep tendon reflexes at biceps, triceps, brachioradialis, Hoffmans sign (the
Babinski of the upper limb: flick relaxed index finger dorsally, thumb abducts for positive test).
Tone/rigidity: check for increased tone by rapid supination and rapid extension of elbow.
Lateral Cervical Disc Syndrome
C4-5
C5-6
Root
C5
C6
involved
Deltoid
Biceps
Motor
Supraspinatus
Biceps
Supinator
Biceps
Reflex
Shoulder
Thumb
Sensory

C6-7
C7
Triceps

C7-T1
C8
Digital flexors
Intrinsics

Triceps
Middle
finger

Finger jerk
Ring finger
Little finger

32

Peripheral nerves: Check two point discrimination at each fingertip. To determine peripheral nerve
damage: Median nerve territory is the palmar surface of the thumb, and the palmar surface and dorsal tips
of the index, middle and thenar side of the ring fingers. Sensation to the ulnar side of the hand is the ulnar
nerve, and the dorsal surface of the thenar side of the hand is radial nerve innervated. The median nerve
also innervates most muscles of the thenar eminence, and the 1 st and 2nd lumbricals. The thumb is weak in
abduction at 90 degrees to the plane of the hand in median nerve dysfunction. Tinels sign: tapping the
palmar surface of the wrist elicits shooting paresthesia in median distribution. Phalens sign: maximally
flexing both wrists by pushing the dorsi of the hands together elicits median nerve distribution numbness
or paresthesias after 30-60 seconds.
C-spine X-rays: Lateral: an adequate lateral shows the top of the T1 vertebra: look for alignment of the
anterior and posterior margins of vertebral bodies as well as spinous processes. Spinous processes may
have abnormal separation in injury. The maximal normal distance between the posterior aspect of the
anterior arch of C1 and the dens is 3mm in adults and 5mm in children. Look for regularity of disk space
height, gas in the disk space (suggests degeneration), osteophytes, pre-vertebral swelling greater than one
third of the vertebral body width (7 mm from C1-4, 22mm from C5-7). Hangmans fracture: coronal
plane fracture through the base of both pedicles of C2, caused by hyperextension injury, separates the
posterior elements of C2 from its body. AP: check alignment of processes and vertebral bodies, distance
between spinous processes should be regular, pedicles should be seen in cross section (erosion of a
pedicle can cause the winking owl sign where the pedicles are the eyes and the spinous process, the
beak). Odontoid view: trace bone cortex around the outline of the dens, misalignment of this outline
indicates odontoid fracture, articular spaces of atlantoaxial joints on either side of the dens should be
equal. Note: odontoid fracture type I tip, type II base, type III through body of C2.
Diagnosis: A narrowed C6,7 disk space suggests disk degeneration at that level. C6,7 disk herniation
would impinge on the C7 nerve root (cervical roots exit above the vertebra of the same number) which is
consistent with clinical C6,7 nerve root dysfunction on sensory and motor exam.
Treatment: most patients respond to conservative therapy: soft collar, NSAID, acetaminophen. If
symptoms persist for two weeks or neurologic symptoms progress, refer to Neurosurgery for myelogram,
CT neck and possible CT myelogram, MRI, or EMG, nerve conduction studies. May require
decompressive laminectomy or anterior discectomy with bone graft fusion.
31. A 30 year old patient with type I diabetes presents to the emergency department with abdominal
pain and vomiting. Take a history. Q: Labs: Glucose 25, K 6.0, pH 7.22, Bicarb 14. What is your
diagnosis and management?
History for abdominal pain and vomiting: quality of the pain, location, onset, chronology, radiation,
associated symptoms, aggravating and relieving factors. Number of episodes of vomiting, description of
vomit, presence of blood and bile. Associated prodromal illness, fever, malaise, sore throat, cough,
urinary symptoms, diarrhea. Foods eaten, other people sick? Previous similar episode? Polydipsia,
polyuria, lethargy, anorexia, hyperventilation? Other precipitants of DKA, recent surgery, recent trauma,
pregnancy, MI, non-compliance or wrong insulin dose, infection.
Diabetes history: time since diagnosis, medications, blood sugar monitor at home? Diabetic control,
polyuria, polydipsia, diet, exercise, drugs, alcohol, smoking, complications of diabetes (retinopathy,
neuropathy, nephropathy, infections). Who follows patients DM? Has patient taken insulin since feeling
unwell, last insulin dose? Past medical history, current medications, allergies, family history, review of
systems.

33

Diagnosis: diabetic ketoacidosis.

Management: Foley, IV, lytes, glucose, ABG, serum ketones. Septic work-up: CBC, CXR, blood
cultures, urinalysis, ECG if K is critically elevated. 1 L NS per hour x 2-3 hours or until tachycardia and
BP normalize, then 500 cc/hr x 2 hours, then 250 cc/h x 5 hours. Insulin drip at 2 U/hr. Check glucose
and lytes q2h. When glucose drops to 15, switch fluids to maintenance 2/3-1/3 D5W/NS + 20 mEq KCl/L
(4:2:1 rule). Begin diet and regular insulin regimen. If the DKA was the result of non-compliance close
follow-up and education such as diet and diabetes management counseling with a dietitian are required.
32. A mother with her 6 week old who has been vomiting for three days. Take a history. Q:
Investigations show a palpable mass in the right epigastrium, metabolic hypochloremic alkalosis.
What is the diagnosis? Give a differential diagnosis for vomiting in an infant.
History of infant vomiting: age of onset, duration, severity, chronology, association with feeding or body
position, description of force, volume, color, composition (bilious, fecal, blood, regurgitant), getting
worse or better, is child still hungry afterward, or does he settle. Coughing or gagging with feeds
(tracheoesophageal fistula). Associated diarrhea, constipation, fever, weight loss, abdominal distention,
urination. Are other children sick? Has child been in contact with an infected person.
Mothers obstetrics history and newborn history: as in question #25 above
Development history: age and weight normograms, feeding history: quantity, frequency, breast vs. bottle
(which formula), colic, feeding difficulties. Past medical history, medications, family history.
Diagnosis: pyloric stenosis.
Differential diagnosis for infant vomiting: Newborn: congenital malformation (pyloric stenosis,
tracheoesophageal fistula, duodenal atresia, malrotation of the intestine). Post newborn period:
gastroenteritis, peritonitis, appendicitis, hepatitis, ulcers, pancreatitis, overfeeding, reflux, food allergy,
milk protein intolerance, systemic infection.
1995
33. 79 year old female collapses in the mall. Patient is drowsy, unresponsive to verbal stimuli.
Manage. Findings: HR 40, BP 80/40, ECG complete heart block.
Rescusitation: ATLS/ACLS format as in question #6 above.
Management of complete heart block: (P waves seen on ECG not related to QRS complexes).
Transcutaneous pacing (atropine 1 mg IV may be tried but is rarely effective). Patient will require
sedation (midazolam 2 mg IV) and analgesia (morphine 2 mg IV) before starting external pacing. Will
require placement of a transvenous pacer until a permanent pacer can be placed.
Consult
Cardiology/CCU/ICU.
Causes of AV conduction abnormalities: calcification of the conducting system (Levs and Lenegres
disease), inferior MI, coronary spasm, digitalis overdose, tricyclic antidepressant overdose, -blockers,
calcium channel blockers, viral rheumatic fever, Lyme disease, sarcoid, amyloid, hemochromatosis,
cardiac tumor, congenital.
34. 25 year old male with tricyclic antidepressant overdose. Manage.
34

Resuscitation: ATLS/ACLS as in question #6 above ABCD, orders, secondary survey, second orders.
History (from patient and family/friends): ask for the empty pill bottles to confirm the drug (this may be a
pass criterion), how many pills, when taken, concurrent ingestions of alcohol or other drugs. Where was
the patient found? Was there a period of unconsciousness, how long did this last? Other symptoms (visual
blurring, seizure). Did the patient give any warning of the attempt (note, phone calls, giving away
possessions), was there a preceding depression or strange behavior, problems at work or with a
relationship. Previous attempts? Medications, drugs, alcoholism, smoking, allergies, past medical and
psychiatric history, family history, review of systems.
Investigations: CBC, lytes, urea, creatinine, glucose, INR/PTT, ABG, CK, serum osmolality, ALP, AST,
ALT, total bili, GGT, Toxicology Screen (ASA, acetaminophen, TCA level, barbiturates, benzodiazepines,
EtOH), ECG. CXR (for aspiration pneumonia).
Treatment: Gastric lavage (rare) if less than 1 hour since ingestion. Activated charcoal 10 g/g drug
ingested or 1 g/kg body weight NG. Hydrate with normal saline to promote diuresis for excretion of TCA
and possible myoglobinuria (occurs due to muscle breakdown following prolonged coma lying on a hard
surface). Alkalinize with 1 amp bicarb IV (or 1-2 mEq/kg) and hyperventilation if the patient is intubated.
Follow ABGs or venous gases, aim for pH 7.45-7.55. Remaining treatment is symptomatic: treat seizures
with lorazepam 2 mg IV, treat cardiac dysrhythmias, hypotension, agitation and coma as they arise.
Consult ICU for 24 hours minimum monitoring. QRS > 0.1s indicates increased risk of seizures and
dysrhythmias. Psychiatric consult after patient is medically cleared.
TCA Toxicity:
Therapeutic levels are 2-4 mg/kg. Life-threatening symptoms usually occur at levels > 10 mg/kg.
Anticholinergic effects: hyperthermia, tachycardia, mydriasis (dilated pupils), decreased sweating and
secretions, vasodilation, constipation, urinary retention, ileus. CNS effects are generalized seizures,
myoclonus, ataxia, hyperreflexia, confusion, agitation, hallucinations, acute psychosis, decreased level of
consciousness, respiratory depression (mnemonic: Hot as a hare, blind as a bat, dry as a bone, red as a
beet, mad as a hatter, the bowel and bladder lose their tone and the heart goes on alone).
Quinidine effects: conduction delay (prolongation of QRS, PR, QT, T wave flattening), heart block,
bradycardia, asystole, ventricular dysrhythmias and resultant hypotension.
35. 16 year old female in hospital for ASA overdose. Medically cleared. Take a history.
History: patient name, age, occupation. Circumstances surrounding the attempted suicide. Preceding
conflicts at work or with family or in a relationship. Recent loss of employment or loved one. Warning
signs: suicide note, giving away prized possessions. Describe the attempt, how many pills taken, what
kinds, concurrent alcohol or drug use. Did the patient really want to die or was the attempt a cry for help?
Gauge the lethality of the attempt in terms of the means used and the chances of discovery. Previous
attempts, describe these. Is patient now actively suicidal or remorseful. If the patient actively suicidal,
what is the current plan? Medications, drug/alcohol use, allergies, past medical history, family history
(esp. psychiatric), social supports: review of systems.
Psychiatry: History for depression/mania, mental status exam, multiaxial diagnosis as in question #4
above.
36. Father with 3 year old child who is not speaking. Take a history. Findings: not speaking well,
recurrent ear infections, poor hearing. Make a diagnosis.
35

History: of not speaking should determine whether the problem is primary (never spoke) or secondary
(stopped speaking). Secondary causes of mutism are psychological upset (due to family discord, etc.) and
rare inherited neurodegenerative conditions. Primary mutism may be part of a global developmental
delay or related to hearing problems which are either congenital (inherited, intrauterine infections),
ototoxic drugs (e.g. streptomycin) or trauma.
Pregnancy and birth history: GTPAL (number of gestations, term pregnancies, premature births,
abortions, live children), history of previous pregnancies including neonatal jaundice, maternal medical
history, illness during pregnancy, rubella (teratogenic), toxoplasmosis (from cats, infects fetal brain),
herpes (infects fetus, frequently fatal), CMV (damages fetal liver), teratogenic medications taken during
pregnancy, drug and alcohol use, family history of deafness or late speaking. Newborn history: gestational
age at birth, caesarean, induction, rupture of membranes artificial or prolonged, fetal distress, forceps or
vacuum delivery, meconium, APGARs, was resuscitation required? Initial blood work, breast feeding?
How often and how well, color of 1 st stool, color of urine, vomiting, neonate muscle tone, behaviors,
fever, irritability, lethargy.
Developmental history (from parent): See question #9. Growth: expected height and weight for age?
Speech, has child ever spoken words or phrases, are these used appropriately, has the child made sounds,
chronology and description of these. How does the child communicate if not through speech? Gross
Motor: when did the child start walking, running. Fine motor: when did you notice pincer grasp, turning
pages in a book. Social behavior.
Hearing: does the child wake up in response to sounds? Startle to loud sounds? Come when called?
Understand spoken instructions? History of ear infections, wax problems. Ask about swimming. Past
medical history, medications, allergies, family history, review of systems.
Diagnosis: given recurrent otitis media with poor hearing the most likely diagnosis is retarded speech
development due to poor hearing. Refer to ENT for hearing tests, possible tubes (tympanic drainage).
37. 40 year old female with fatigue. Take a history. Findings: cold intolerance, weight gain. Make a
diagnosis.
Fatigue history: onset, chronology, past episodes, functional limitations, associated with exertion?
Recent viral illness (mononucleosis), cold intolerance, weight gain, dry skin, brittle hair, hoarseness
(hypothyroidism), associated muscle aches (fibromyalgia), chest pain (angina), shortness of breath
(congestive heart failure). Sleep history: usual requirements, chronology of sleep problems, stressor,
sleep hygiene (when, where, regularity, shifts at work, quiet, late, exercise, meals, alcohol, caffeine,
prescription and non-prescription remedies, drugs and medications), sleep latency (time to fall asleep),
nocturnal awakening, early morning wakening, daytime somnolence, somnolence while driving, working
or during conversation. Depression screener: as in question #4 above. Must fully explore suicidal
ideation: does patient intend to harm self, reason for suicidal thoughts, current plan, lethality of plan,
access to lethal means, has patient given away prize possessions or written final notes to loved ones,
previous attempts. Medications (especially TCAs, sedatives, antihypertensives), allergies, drug/alcohol
use, smoking, past medical history, family history, review of systems.
Differential Diagnosis: Chronic fatigue, CHF, ischemia, thyroid disease, sleep disturbance, depression.
Diagnosis: most likely hypothyroidism given cold intolerance and weight gain.

36

38. 35 year old male with back pain and stiffness. Take history and perform a focused physical
exam. Findings: 10cm separation between lumbar spines while erect increases by less than 5 cm
when back is flexed forward (positive Wright-Schober test), lateral flexion impaired. Q: Give the
diagnosis and two associated conditions.
History and Physical: see question #15.
Diagnosis: based on typical history of back pain, lumbar spine X-rays showing fusion of the sacroiliac
joints or sacroiliitis and syndesmophytes (disk spaces undergoing fusion), elevated ESR and HLA-B27
tissue antigen positive this is probably ankylosing spondylitis.
Associated conditions: inflammatory arthritis, uveitis, psoriasis, IBD, amyloidosis, radiculopathy,
pericarditis, angina, conduction abnormalities.
Treatment: No cure. Regular therapeutic exercise to prevent deformity/disability (esp. swimming and
back extension exercises). To control pain and stiffness: indomethacin (100 mg PO OD), naproxen (250
mg PO BID-TID), etc. Surgery helpful in severe cases: e.g. total joint replacement.
39. 35 year old male with 1 year history of back and leg pain. Do a physical exam. Findings: right
foot dorsiflexion weakness with dorsal foot numbness. Make a diagnosis and identify the level of
lesion.
History and Physical exam: see question #15.
Diagnosis: L4,5 disk herniation with L5 radiculopathy.
40. 47 year old male with impotence. Wants a pill for this. Fears losing his girlfriend. Take a
history and counsel.
Background: The causes of erectile dysfunction are subdivided in to psychic and organic categories.
Current literature favors an approximately 1:1 ratio of organic to psychic etiology. The problem is rarely
primary (never had ability to sustain erection). The organic causes are: drugs (-blockers, thiazides, H 2
blockers, antidepressants, antipsychotics, Digoxin, clofibrate, sedatives, alcohol, heroin), hormonal
(diabetes, gonadal dysfunction, prolactin-secreting pituitary tumor, associated with loss of libido and
testicular atrophy), neurogenic (stoke, MS, spinal cord injury), iatrogenic (drugs, surgery, radiation),
vascular (peripheral vascular disease, DM, HTN). Impotence is grossly defined as inability to have
satisfactory intercourse due to erectile dysfunction in at least 25% of encounters.
History: Current partners. Problems in these relationships. Why is the patient seeking medical attention
for this now? Onset of erectile dysfunction and chronology. Description of the problem: no erection at
all, cannot sustain erection, ejaculate too quickly to satisfy partner, cannot achieve orgasm or orgasm
without ejaculation, retrograde ejaculation. Circumstances under which impotence occurs: only with
certain partners, only at certain times or locations, what percentage of the time? Is impotence related to
lack of sexual desire? Presence and firmness of morning or nocturnal erections. Does the patient sustain
erections in masturbation? Associated problems: anxiety attacks, anhedonia/depression, perineal or
peripheral numbness, poor peripheral circulation. Exercise, medications, contraceptive use, drug/alcohol
use, smoking, cholesterol, allergies, past medical history, family history, review of systems.
Counseling: Discuss causes of impotence in terms of organic vs. inorganic etiology and that it tends to
cause great anxiety (normalize patients feelings). Erectile dysfunction can often be improved with
37

lifestyle changes: exercise, weight loss, improved diet, decreased alcohol intake, smoking cessation, stress
management, sleep hygiene, better diabetic control, and joint counseling with partner to decrease anxiety.
Improvement of patients relationship with partner: address sexual boredom. Review medications:
suggest changes. Explain that many organic causes of impotence are unfortunately not reversible.
Describe therapeutic options: counseling with partner on alternative means of sexual gratification,
testosterone preparations or bromocryptine (for prolactinoma) if patient is shown to have hormonal
disturbance on blood work (measure testosterone and gonadotropins), sildenafil (viagra), yohimbine and
trazodone preparations for impotence (poorly effective and expensive), penile self-injection with
phentolamine, papavarine & PGE1 or PGE1 alone (30 gauge needle, last 30-60 min., quite popular),
vacuum-rubber ring device, penile prostheses. Arrange follow up with both partners.
41. Young woman with tunnel vision. Negative investigations by a neurologist and ophthalmologist.
Take a history. Findings: concerned that her husband is having an extramarital affair. Counsel.
History: Description of visual problem, functional limitations, onset duration, chronology,
aggravating/relieving factors, associated headache, eye pain, nausea, anxiety, palpitations, tremor.
Previous episodes of eye problems or other unusual phenomena (blindness, paralysis, numbness,
abdominal pain). What doctors has patient seen, what did they say? Problems at work, home, with
relationships. Who can the patient go to for support in her life? Psychiatric problems in the past?
Depression screener and sleep history as in questions #3 and #19. Medications, drug and alcohol use,
allergies, past medical history, family history, review of systems.
Conversion disorder: psychic perturbation presents as one or two neurological complaints affecting
voluntary motor or sensory function. Psychological factors thought to be etiologically related to the
symptom as the initiation of symptoms is preceded by conflicts or other stressors. La belle indifference
patients inappropriately cavalier attitude towards a serious symptom. Treatment: anxiolytics (e.g.
lorazepam 1 mg PO q6h), relaxation therapy, counseling, close follow-up.
Counseling: Normalize this problem and validate the patients feelings: the fact that several specialists
have said there is nothing wrong with the patients vision does not mean that there is not a subtle medical
problem which may become apparent later. For this reason it is important to stick with one doctor who
knows the patient well and can coordinate further referrals if necessary. Many people who are faced with
the possibility of marital infidelity automatically activate a defense mechanism which gives them time to
adjust, and which is not under conscious control: Such a reaction also helps the patient to enlist needed
support from others. This is a normal reaction for these people. These symptoms can vary widely from
paralysis, to numbness, to pains, to inability to speak, and visual problems including blindness and tunnel
vision. Outline a plan for management: address possible sources of anxiety and stress: a frank discussion
with the patients husband about fidelity is required and may be done privately or if both partners are
willing, in consultation with you or a marital therapist. The patient should try to consolidate a support
network: parents, friends, etc. Consider depression, sleep or anxiety medications as appropriate. Arrange
follow up with both partners.
42. 30 year old male from another city. Wants Fiorinal prescription for chronic headaches renewed.
Manage.
See question #16.
43. 23 year old female with 24 hour abdominal pain. Perform focused physical exam. Findings:
peritoneal signs, point tenderness at McBurneys point. Q: Give a differential diagnosis, order
investigations. What further history would help confirm diagnosis?
38

Physical exam for abdominal pain: see question #29.

Rectal: rectal shelf, check for gross or occult blood. Also include a pelvic manual and speculum exam.
(wont be asked to perform this at the LMCC II). Check for pain with cervical motion (seen in PID), pain
on palpation of ovaries, mass, cervical discharge. Take swabs (see investigations).
Differential diagnosis: appendicitis, ovarian cyst, rupture or ovarian torsion, mittelschmerz, ectopic
pregnancy (life-threatening), hepatitis, cholecystitis, gastroenteritis, peptic ulcer, pelvic inflammatory
disease (PID), urinary tract infection (UTI), pyelonephritis, kidney stone, inflammatory bowel disease,
intestinal obstruction due to volvulus or IBD.
Investigations: ABX 3 views, abdominal-pelvic ultrasound, CBC, lytes, urea, creatinine, INR/PTT,
glucose, hCG. Urinalysis. Stool for occult blood. Cervical swabs for culture and pap smear. If OR is
imminent order type and cross for 2 units, CXR.
Helpful further history: a history of gradual onset vague periumbilical or LLQ pain migrating to a
sharper, more localized pain in the RLQ over several hours associated with anorexia, nausea, and
controlled by still fetal posture suggests appendicitis.
44. 62 year old female with left lower quadrant pain. Perform physical exam. Findings: low grade
fever, some abdominal distention, LLQ tenderness without rigidity, poorly defined left lower
quadrant mass. Q: Abdominal series shows multiple air/fluid levels. Describe. Give differential
diagnosis with most likely diagnosis. Order further investigations.
Physical exam for abdominal pain: see question #29 and #43.
Differential diagnosis: diverticulitis, diverticular abscess, constipation with obstruction, GI malignancy
with perforation, gallstone ileus, obstruction due to volvulus (usually RLQ pain), Crohns, mesenteric
ischemia or infarct, ovarian tumor, PID, uterine perforation.
Most likely diagnosis: diverticulitis.
Investigations: abdominal-pelvic CT (ultrasound if CT unavailable), stool for occult blood, urinalysis,
cervical swabs and pap, CBC, lytes, urea, creatinine, INR/PTT, glucose, for possible preop: ECG, CXR,
type and cross 4 units.
45. 24 year old female with left lower quadrant abdominal pain who has an IUD. Perform physical
exam. Findings: signs of peritoneal irritation. Q: Give a differential diagnosis, order investigations.
Physical exam for abdominal pain: see question #29 and #43.
Differential diagnosis: uterine perforation by IUD, pelvic inflammatory disease (PID more common with
IUD), ovarian cyst with torsion or rupture, tubo-ovarian abscess, ectopic pregnancy (also more common
with IUD), gastroenteritis, inflammatory bowel disease, intestinal obstruction due to volvulus or IBD,
appendicitis.
Investigations: ABX 3 views, abdominal-pelvic ultrasound, CBC, lytes, urea, creatinine, INR/PTT,
glucose, hCG. Urinalysis. Stool for occult blood. Cervical swabs for culture and pap smear. If OR is
imminent order type and cross for 2 units. CXR.
39

46. 20 year old female at 36 weeks gestation with hypertension and proteinuria. Counsel patient on
etiology and risks to fetus and mother. Q: Outline a plan for management.
Background: Hypertension may be pregnancy induced or pre-existing hypertension can be worsened by
pregnancy. Pre-eclampsia is pregnancy-induced or worsened hypertension (systolic BP increased by 30
mmHg, and diastolic by 15mmHg over non-pregnant/T1 pressures) with renal impairment (proteinuria
> +1 on dipstick or > 300 mg/24 hour collection) and/or non-dependent edema (e.g. face, hands) onset >
20 weeks. Eclampsia is pre-eclampsia with CNS involvement, usually decreased level of consciousness
and seizures. Other end organs may be affected, particularly the liver and placenta. May progress to
death through multi-organ failure. Imbalance of thromboxane (vasoconstrictor) and prostaglandin
(vasodilator) causes arteriolar constriction capillary damage protein extravasation and hemorrhage.
Both pre-eclampsia and eclampsia fall under the new heading of pregnancy-induced hypertension (PIH).
Mild PIH: no CNS involvement or criteria for sever PIH.
Severe PIH: 2 of the following:
1. BP > 160/110
2. pulmonary edema or cyanosis
3. CHF
4. proteinuria/oliguria/ Cr
5. LFTs/RUQ or epigastric pain
6. visual disturbances/hyperreflexia/clonus/headache/convulsions
7. N&V
8. thrombocytopenia/microangiopathic hemolysis
9. IUGR
Eclampsia: grand mal seizures in woman with preeclampsia.
Counseling: You have pre-eclampsia. Define as above. Condition is common: 5% of pregnant
population, more common in first pregnancies. Cause seems to be imbalance of thromboxane
(vasoconstrictor) and prostaglandin (vasodilator) which causes arteriolar constriction capillary damage
protein extravasation and hemorrhage. Severity varies. Risks for mother: end organ dysfunction
(kidneys, liver), cerebral hemorrhage (50% of deaths), left ventricular failure/pulmonary edema, loss of
pregnancy due to abruption (often with DIC), seizures, HELLP syndrome, death. Risks for fetus:
malnutrition, hypoxia, incomplete maturation, which can result in low birth weight (IUGR), prematurity,
death. Overall treatment strategy is to slow progression of hypertension until the baby can be delivered.
Delivery is curative.
Management plan:
Initial exam and investigations: vitals, body weight, examine for edema, check for RUQ tenderness,
reflexes, CBC, lytes, creatinine, urea, uric acid, urinalysis with microscopy, 24 hour urine
protein/creatinine clearance, LFTs, INR/PTT. Fetal HR, non-stress test, biophysical profile (ultrasound
with 5 criteria), Doppler flows. Bed rest in left lateral decubitus position (to reduce abdominal vessel
compression), normal dietary salt/protein intake. No use of diuretics/antihypertensives.
Follow up: daily BP, daily weight, daily reflexes, fetal movement counts at home (if patient lives
reasonably close to a hospital and can get transportation fast), frequent follow-up visits for blood work,

40

urinalysis and fetal monitoring, bed rest (preferably left side). Instruct patient on worsening signs: rapid
weight gain, liver pain, visual disturbance, persistent headache, drowsiness or seizures.
Delivery: early hospital admission (at 36 weeks) for close monitoring and administration of IV MgSO 4 4
g over 20 minutes, if signs of CNS involvement are present (hyperreflexia, decreased LOC, seizure).
Possible induction of early delivery or Cesarean section. Consider IV hydralazine (first line treatment) 510 mg IV over 5 minutes q15-30min, second line: labetolol 20-50 mg IV q10min, third line: nifedipine
10-20 mg PO q20-60min if delivery is not imminent or if delivery is imminent to decrease BP after
conservative measures tried (diuretics and salt or fluid restriction not useful and may be harmful).
47. 30 year old woman with vaginal bleeding at 30 weeks gestation. Take a history. Q: Give a
differential diagnosis. Order investigations.
History: patient ID (name, age, occupation), GTPAL, weeks of gestation. Onset of bleeding, duration,
estimate quantity (number of pads soaked), color and consistency of blood, associated fever, chills,
abdominal discomfort (pain), contractions, fetal movement, lightheadedness, last sexual intercourse (may
cause spotting due to friable cervix). Problems with previous pregnancies, problems in this pregnancy,
medical visits to this point, investigations done. Associated abdominal trauma (accident or abuse), drug
use (cocaine), father and mothers blood type, medications, alcohol, smoking, past medical history, family
history, review of systems.
Differential diagnosis: placenta previa (placenta covers internal os of cervix the most common cause of
painless bleeding in the third trimester), bloody show (shedding of cervical mucous plug), abruptio
placenta (separation of placenta from uterine wall usually painful), vasa previa (fetal bleed due to root
vessels of umbilical cord overlying the cervical os extremely dangerous to the fetus). Other causes:
uterine rupture, coagulopathy (DIC), molar gestation, vaginal tear, vaginal infection, cervical polyp,
cervicitis, cervical cancer, placenta accreta, bleeding from bladder or bowel. (NOTE: no vaginal exam
until previa has been ruled out by U/S).
Investigations: maternal vitals, CBC, INR/PTT, fibrinogen, type and cross-match if bleeding is severe,
Rh status (may need Rhogam gamma globulin to prevent formation of antibodies against fetal blood if
mother is Rh negative and father is Rh positive), fetal monitor, fetal ultrasound, maternal monitoring, IV
access, pelvic speculum and manual exam with digital cervical exam (do these only after ultrasound to
rule out placental previa can cause further bleeding in previa), Apt test for fetal hemoglobin in vaginal
blood, test maternal blood for presence and amount of fetal hemoglobin (determines amount of Rhogam
required to neutralize fetal blood antigenicity).
48. 31 year old female with right hand numbness and weakness. Take a history and perform
focused physical exam. Q: Differential diagnosis, investigations and treatment.
History: name, age occupation, amount of work done with hands, description of symptoms, onset,
duration, chronology, time of day, aggravating and relieving factors. Previous episodes, investigations.
Ask about pain at night, difficulty turning a key or opening jars (signs of weakness). Functional
limitations. Associated injury, neck pain, numbness or weakness in other areas, visual problems,
headache, nausea. Medications, drug/alcohol use, smoking, allergies, past medical history (especially
DM, hypothyroidism, rheumatoid arthritis, pregnancy), surgical history, family history, review of systems.
Physical exam: see question #30.

41

Differential diagnosis: carpal tunnel compression of median nerve, cervical radiculopathy, stroke/TIA,
diabetic peripheral neuropathy, brachial plexus injury or tumor.
Investigations: nerve conduction studies.
Treatment: modify manual work, wrist splint (often worn at night), NSAIDs, local corticosteroid
injections, control underlying systemic contributors (e.g. diabetes, hypothyroidism, arthritis), surgical
decompression via flexor retinaculum release (Neurosurgery or Plastic surgery consult).
49. 53 year old female with incidental solitary lung nodule on CXR. Take a history. Findings: nonsmoker, textile worker, no symptoms. Q: CXR shows homogeneous round 2 cm opacification in
right upper lobe. Give a differential diagnosis and identify the most likely diagnosis. Order further
investigations.
History: name, age, occupation, living conditions, hobbies, pets, esp. birds, cats, travel history, contact
with hazardous substances (e.g. asbestos). Positive TB skin test. History of pneumonia, TB etc.
Malignant symptoms: weight loss, fatigue, change of bowel habits, anorexia, night pain Smoking.
Alcoholism. Lung symptoms: cough, sputum, shortness of breath/dyspnea, hemoptysis, wheeze,
orthopnea, PND, chest wall pain, Medications: drugs/alcohol, allergies, past medical history, family
history, review of systems.
Differential diagnosis: less than 3 cm is more likely to be benign but greater than 3 cm is more likely
malignant: neoplasm (45%) primary = 70%, benign (hamartoma, lipoma) = 15%, metastatic = 10%;
infection (53%) TB, histoplasmosis, coccidiomycosis; other (2%) granuloma (scar tissue from old
pneumonia, TB granuloma, histoplasmosis, silicosis, sarcoid), vascular (A-V malformation, infarct),
congenital (cyst), round pneumonia, round atelectasis, loculated effusion. Percentages are for lesion
greater than 3 cm.
Most likely diagnosis: granuloma.
Investigations: old CXR for comparison (if lesion is old and unchanging, interventions are less
aggressive, calcification is also associated with benign lesions such as old granulomas), CT chest with CT
guided needle biopsy, sputum for cytology and acid-fast staining (TB), TB skin test, bronchoscopy with
biopsy and washings if lesion seen, open biopsy or lobectomy.
Algorithm: solitary nodule previous CXR benign or unchanged (repeat in q3-6months for 2 years if
unchanged observe, if changed at any time continue), malignant or changed CT thorax: cancer (stage
and treat), calcification (observe), no diagnosis bronchoscopy or transthoracic needle aspiration still
no diagnosis (resect for diagnosis), inflammatory (treat cause), cancer (stage and treat).
50. Mother with 6 month old child who has diarrhea. Take a history. Finding: recently switched
from breast milk to milk powder formula. Q: Give a differential diagnosis. Recommend treatment.
History: Distinguish between acute diarrhea, chronic diarrhea with or without failure to thrive. Name,
age, age of onset and chronology of diarrhea, consistency, color, quantity and frequency of diarrhea, blood
in stool, concurrent illness, vomiting, fever, anorexia, difficulty breathing, lassitude, dry mouth, eyes, low
urine output, illness affecting other children in the family or adults. Feeds and feeding history (esp. fruit
juice). Growth pattern: weight loss? Recent immunization, travel, antibiotics. Medications, past medical

42

history, allergies, birth history, pregnancy problems, maternal illness during pregnancy, family history,
review of systems.
Differential diagnosis: infection (bacteria: campylobacter, salmonella; antibiotic induced: c. diff colitis;
parasitic: giardia; post infectious: secondary lactase deficiency), intolerant of formula change (component
of lactose intolerance), toddlers diarrhea (6 months to 36 months, resolves spontaneously by age 2-4
years lots of juice overwhelms small bowel disaccharide malabsorption), overfeeding, osmotic
diarrhea due to high osmolality liquids such as juice, gastroenteritis. With weight loss consider
malabsorption syndrome: celiac disease, lactose intolerance, milk protein allergy, cystic fibrosis (with
chest infections), IBD (unusual at this age), enzyme deficiencies, liver disease, biliary atresia,
thyrotoxicosis.
Treatment: try non-milk (soy based) formula. Arrange follow up.
Note: Treatment for Toddlers diarrhea reassurance, self-limiting, 4 fs fiber, normal fluid intake,
35-40% fat, discourage excess fruit juice.
51. 50 year old male alcoholic. Vomited bright red blood 1 week ago. Perform physical exam. Q:
Give differential diagnosis. What is your treatment plan?
Physical exam: see question #29.
Differential diagnosis: esophagitis, gastritis, duodenal ulcer, peptic ulcer, Mallory-Weiss (partial
thickness) tear, esophageal varices, gastric or esophageal cancer, lung tumor, aorto-enteric fistula (rare
can occur after previous aortic surgery).
Treatment plan: place on omeprazole 20 mg PO OD, patient to refrain from alcohol, discontinue
NSAIDs, draw blood for INR/PTT, AST, ALT, ALP, GGT, total bili, CBC, lytes, urea, creatinine. CXR
(check for perforation air under diaphragm), refer to gastroenterology for endoscopy. Consider
admission if patient unreliable or transportation is a problem.
52. Telephone rings: hysterical mother says her child swallowed a cleaning agent. Manage over the
phone. Q: What do you do after hanging up the phone? What investigations do you order in the
ER?
Over the phone: Establish calm, reassurance, obtain caller name, phone number, address. Childs age,
weight, medical problems, medications, allergies. Identify agent ingested, have caller read hazard label if
possible. How much was taken and when? What is childs present condition? Any other agents taken?
Have child drink 2-3 glasses of milk if alert (works for alkali or acid). Do not induce vomiting (exposes
esophagus and pharynx to the corrosive agent again). If amount ingested was very small, may not need to
come in, warn that child may vomit. If amount unknown or significant, child may come to ER
immediately. Mom may drive if calm, otherwise you will send an ambulance. Have child lie on his side
in case of vomiting.
After hanging up: send ambulance, call the poison center with the description of the agent and ask for
direction as to treatment etc.
Investigations: CBC, lytes, glucose, urea, creatinine, serum osmolality, serum ketones, ABG, CXR,
toxicology screen if ingested agent unknown.
43

1994
53. 60 year old male with 20 minutes chest pain. Diaphoretic, ECG shows 2 mm ST elevation in V1,
2, 3. Manage.
History and Physical: see question #13, #14 and #17.
Treatment: Raise head of bed. Give oxygen 6 L/min by mask. Monitor oxygen saturation. Order stat
CBC, lytes, glucose, INR/PTT, serial CK-MB and Troponin, ABG, CXR, ECG. Give chewable ASA 160325 mg immediately. Secure IV access, bolus IV lasix 40 mg, push if fluid overload is suspected, and
ventolin if wheezes are heard, give sublingual nitro spray or 0.3 mg SL nitro if blood pressure is adequate
and 1 mg morphine IV. Repeat nitro SL q5min x 3. May require additional morphine and nitro. Repeat
CK-MB and Troponin q8h x 3.
Diagnosis: severe anterior wall ischemia evolving to infarct.
catheterization. Urgent Cardiology consult if available.

Required thrombolytics or cardiac

54. 28 year old male arrives in the ED having fallen 6m from a scaffold. Assess.
Rescusitation: see question #6.
History: if available: Nature of fall, preceding (seizure, etc.) and subsequent events, has patient ever
experienced similar symptoms before, did patient lose consciousness, were there seizure-type phenomena,
injuries during fall, duration of unconsciousness, post-ictal drowsiness, medications and drugs,
alcohol/illicit drug involvement, smoking, allergies, past medical history, family history, review of
systems.
55. 22 month old female child brought to emergency by her mother with fractured left humerus.
Two previous fractures in past 3 months, bruises seen on forehead. Manage.
Warning signs of child abuse: explanation doesnt match injury, delay in seeking treatment, recent
family crisis, injuries of varied ages/recurrent/multiple injuries, distinctive marks, atypical pattern of
injury, unrealistic expectations of child behavior by caregivers.
Risk factors for child abuse: environmental (social isolation, poverty, domestic violence), caregiver
(substance abuse, jealousy between boyfriend and father, parents abused themselves,
personality/character disorder or mental illness, poor social and vocational skills/below average
intelligence), child factors (disability, difficult child i.e. temperament, premature).
History: how did the injury happen? Who was looking after the child when it happened? Who are the
childs care givers, and who lives in the house or comes in contact with the child. How did the child get
the bruises? What happened with the other fractures? Any other injuries in the past? Is the child accident
prone or difficult to handle? What is the childs personality: open vs. withdrawn. Are there other children
in the house? Have they had broken bones or other injuries? Was this child a planned pregnancy,
problems with pregnancy, birth history. Developmental milestones as in question #9. Where does the
child live (isolation), income level of parents, problems with the law, alcoholism, drug use, smoking by
caregivers or other adults in the home, what is the typical response of caregivers when the child cries or
misbehaves? Were the caregivers abused as children? Is there spousal abuse, sexual abuse or incest? Has

44

the Childrens Aid Society been involved with this child or other children? Interview relatives, friends.
Childs medical history, medications, allergies, review of systems.
Physical exam: observe childs behavior, constant watchfulness associated with child abuse. Inspect for
malnutrition, bruises, scars, burns, especially on the flexor surfaces. Inspect oral cavity, perineum, anus,
genitalia. Ophthalmoscopy for retinal hemorrhages (shaken baby syndrome). Evaluate for development,
neurological exam for possible brain injury.
Investigations: X-rays for old fractures, if records not available, CBC, lytes, urea, creatinine, INR/PTT,
albumin (malnutrition).
Treatment: admit for the childs safety and investigations, consult child psychiatrist and pediatric
orthopedic surgeon. Obligated to report suspicion of child abuse to Childrens Aid Society. Family
therapy, frequent follow up to monitor development.
56. 35 year old male. 1 week hyperactivity, histrionic, spending spree, bizarre behavior. Take a
history.
Differential: Causes of one week of bizarre behavior: manic episode (bipolar mood disorder), depression,
drug-induced (steroids, amphetamines, alcohol), organic (hypothyroidism, frontal lobe tumor, MS,
dementia), schizophrenia.
History: Description of symptoms: onset, duration, chronology, aggravating and relieving factors (drug
use). Is patient a danger to himself or others (suicidal or homicidal)? Does patient have alternating up and
down periods, how long do these last? How frequent? Are they cycling faster than before? Ask about
mood, sleep, interest, guilt, energy, concentration, appetite/weight, psychomotor, suicide/morbid ideation.
Paranoia, ideas of reference (thought broadcasting; special messages, mind reading), special powers,
magical thinking, secret identity, voices, visual or tactile hallucinations. Current life events, stress,
relationship problem, bereavement. Previous psychiatric problems, family history or psychiatric
disorders, substance abuse, relationship problems, problems at work. Work and relationship histories. Ask
about hypothyroidism, adrenal dysfunction, hypercalcemia, mononucleosis. Medications, drugs, alcohol,
smoking, allergies, past medical history including psychiatric history and history of abuse. Family history,
review of systems.
Manic episode: Expansive, elevated or irritable mood x 1 week with 3 of following: GSTPAID
grandiosity (or inflated self esteem), sleep (less need for), talkative, pleasurable activities (with painful
consequences), activity increased (goal directed or psychomotor), ideas (flight of), distractibility. Not
mixed episode. Severe enough to cause psychotic features/impaired social/occupational functioning. Not
substance abuse or GMC.
Diagnosis of major depression: see question #4.
Mental status: see question #4.
57. 22 year old male. Hears voices. Take a history.
History as in question #56 and #4 with special attention to the chronicity of symptoms, and work, school,
and relationship histories.
DSM IV Criteria for the diagnosis of schizophrenia:
45

A: 2 or more of the following characteristic symptoms occurring for a significant portion of a 1 month
period: delusions, hallucinations, disorganized speech, catatonic or grossly disorganized behavior,
negative symptoms (flat affect, alogia poverty of speech, avolition, anhedonia, apathy, affectional
impairment). Only 1 symptom if delusions are bizarre or hallucinations consist of a voice keeping
running commentary or 2 voices conversing.
B: Social or occupational dysfunction.
C: Continuous sign of some disturbance for at least 6 months including the month of more severe
disturbance in A.
D: Schizoaffective or mood disorder excluded.
E: Substance abuse or general medical disorder excluded.
F: If there is a history of autistic disorder or pervasive developmental disorder, then the diagnosis of
schizophrenia is made only if delusions or hallucinations are prominent for at least 1 month.
Note that schizophrenic symptoms < 1 month = brief psychotic disorder, < 6 months = schizophreniform
disorder, > 6 months = schizophrenia.
58. 16 year old male with three episodes of sudden loss of awareness lasting < 1 minute, wants
information on epilepsy. Counsel.
History: see question #3.
Counseling: Cause of seizures disturbed electrical activity in the brain, often with a tiny focus of
abnormal tissue from previous infection, trauma (including birth trauma) or inherited. About 2% of the
population have epilepsy. Your seizures appear to be absence or petit-mal, which start in young people.
One third of cases resolve spontaneously with age. Seizures do not damage the brain unless they are
prolonged (> 30 minutes) and absence seizures are not associated with decreased intelligence or learning
ability. Most people with this type of epilepsy are well controlled on medication and have no limitations
in their activities, careers or relationships.
Further counseling and treatment: see question #3.
59. Young man in the emergency department with a stab wound to the belly. Manage.
See question #6.
60. 18 year old female wants oral contraceptive. Manage.
See question #2.
61. 35 year old woman feels depressed. Manage.
See question #4.
62. 5 year old girl with pain on urination. Mother concerned about UTI and sexual abuse. Order
investigations and counsel.
Algorithm: Possible UTI Is immediate antimicrobial therapy indicated? (e.g. infant, toxic,
dehydrated) if yes (urine specimen for culture via SPA/catheter initiate Abx therapy [TMP/SMX or
cephalosporins i.e. cefixime, cefprozil]: consider hospital if toxic, vomiting and cannot take PO meds or if
46

< 6 months); if no (U/A on specimen bag U/A positive for LE, nitrites, WBC? no? unlikely
UTI if no symptoms yes? Obtain urine for culture SPA/catheter) is the culture positive?
no? (no UTI) yes? (7-14 days of Abx; prophylaxis [TMP/SMX or nitrofurantoin] until imaging
completed) clinical response in 48 hrs? no? (immediate urinary tract U/S) yes? (U/S as soon as
convenient) ultimately VCUG as soon as convenient.
Investigations: midstream clean catch voided urine specimen (or bag urine). May need to catheterize or
aspirate suprapubically (SPA) to obtain a good specimen. Urine dipstick. Microscopy, culture and
sensitivity most common pathogen is E. coli serotypes from bowel flora others include Klebsiella,
Proteus, enterococci, S. saprophyticus. If child appears systemically ill, take blood for cultures, CBC,
urea, creatinine, lytes. Renal ultrasound for major malformations and voiding cystourethrogram (VCUG)
should be done in all children 2 months to 2 years old with UTI. Radiological investigations may be
postponed until the second UTI in girls over 2 years old due to higher rate of benign UTI. Postpone the
VCUG 3-6 weeks to allow normalization of flow after UTI.
Counseling: Ask why the mother is concerned about sexual abuse. UTI alone is not a good indicator.
Explain that, in girls UTIs are common because of short urethra and proximity to anal area. Describe
front to back wiping after urination, and general hygiene. Give prescription for TMP/SMX (Septra) 2/10
mg/kg/d PO OD or Nitrofurantoin 2 mg/kg/d PO OD x 7-10 days if urine dip is positive for white cells
and patient not allergic. Arrange follow up in > 2 weeks for re-culture of urine. Explain need for
ultrasound and VCUG to rule out flow abnormalities which may threaten kidney function (this may be
postponed until second UTI in girls over the age of 2 due to increased incidence of benign UTI), arrange
these. Consider hospitalization for pyelonephritis, rehydration or child < 6 months old.

63. Elderly lady on Digoxin and Lasix with syncopal attacks. Take a history. Q: Give a differential
diagnosis. What investigations would you order?
History: onset, duration, chronology, description of events. Have the patients episodes been witnessed?
Does the patient lose consciousness, are there warning signs of post-ictal symptoms, can the patient
prevent an episode by sitting down or other means. If dizziness is a feature, is this light-headedness or
true vertigo (vertigo means that the patient senses actual movement of either the room or themselves).
What is the patient doing when these episodes occur? Are muscle jerks a feature? Associated fatigue,
weakness, nausea/vomiting, chest pain, shortness of breath, palpitations, focal neurological symptoms.
Past medical history (e.g. diabetes, heart disease), medications, drug use, alcohol, smoking, allergies,
family history, review of systems.
Differential diagnosis: Medication induced bradycardia (Digoxin), hypovolemia (Lasix). Cardiovascular
arrhythmia, valvular disease, subclavian steal. Metabolic: hypoglycemia. Central nervous system:
seizures (e.g. narcolepsy, tumor), stroke/TIA, cervical spondylosis, anxiety with hyperventilation, middle
ear (benign positional vertigo, acoustic neuroma, Menieres disease). Autonomic: vagal, orthostatic
hypotension. Infection in elderly can present in many ways: UTI etc.
Digoxin overdose: anorexia, nausea, vomiting, bradycardia, visual effects: yellow, green or white halo
around objects, decreased level of consciousness, abdominal pain and diarrhea. ECG shows junctional
tachycardia, PVCs, AV block, and sometimes PSVT.

47

Physical exam should include: vitals, orthostatic BP, check for signs of dehydration (thirst, mucous
membrane moistness, HR, urine output, skin turgor, BP), cardiopulmonary exam (see question #13),
neurologic exam (see question #5) and mini-mental status exam (see question #4).
Investigations: Digoxin level, CBC, lytes, urea, creatinine, INR/PTT, glucose, ECG, 24 hour Holter
monitor, echocardiogram, EEG, CT head, carotid Doppler.
64. 30 year old male, married with 2 children. Brought in by police for violent and dangerous
behavior. Take a history. Q: Would you admit this patient? What are the criteria for a Form 1?
History: Attempt to determine whether patient is sad (depressed), bad (antisocial, reaction to stressful or
frustrating events, poor anger management), or mad (mania, schizophrenia). Is the episode related to
drugs of abuse or organic (brain tumor, metabolic disturbance)? Cover history for depression (see
question #4), mania (see question #4) and schizophrenia (see question #57) with mental status exam (see
question #4) and mini mental (see question #4).
Criteria for admission: patient requires observation or medication in a controlled, safe setting for
diagnosis, patient appears to be a danger to himself or others, environment at home unsuitable for the
patient at this time, patient requires medical work up for organic causes, patient in need of detoxification.
Criteria for a Form 1: Forcible admission for assessment without right to appeal, maximum 72 hours,
can be administered by any licensed physician who has seen the patient within a week, both criteria must
be met:
1. Patient appears to be danger to himself/herself or others.
2. Patient appears to be currently suffering from a mental illness.

65. 65 year old male with dysphagia. Take a history. Q: Differential diagnosis and investigations.
History: see question #10.
Investigations: Barium swallow (liquid and with marshmallow for transfer), endoscopy with biopsy, CT
chest, esophageal manometry, 24 hour pH reflux study.
66. 65 year old male outpatient with shortness of breath, cough, sputum. Take a history and
perform a physical exam. Findings: Lobar consolidation with yellow-green sputum. Q: Given a
diagnosis of pneumonia, recommend treatment.
History: Name, age, occupation, travel history, pets.
Cough (acute, chronic, worse in any
position/season/night, anything relieve), sputum (what color, quantity, frequency, quality), hemoptysis
(quantity, frequency, quality e.g. blood tinged/clots), dyspnea (constant, duration, onset, frequency,
severity, exercise tolerance, triggers, alleviating), fever, chills, malaise, fatigue, increase in asthmatic
symptoms (wheeze, cough), preceding viral illness. Onset, chronology of symptoms, positional factors
(orthopnea), chest pain, ankle swelling. History of COPD? Medications, compliance with meds (observe
use of puffers), drugs of abuse (alcohol), smoking, allergies, past medical history, family history, review
of systems.
Physical Exam: Cardiopulmonary exam as in question #13 and #24.

48

Treatment: for diagnosis of community-acquired pneumonia, admit if patient is systemically ill (may
have septicemia), if the patient is debilitated or hypoxia is a feature (send blood cultures and give
oxygen). Start IV cefuroxime 750 mg IV q8h. Switch to a more specific oral antibiotic when culture
results become available. For outpatient therapy: Clavulin (amoxicillin + clavulanate) 500/125 mg PO
BID. Follow up in 1 week. Discontinue therapy after 3 afebrile days.
Note: this therapy does not cover atypicals. Practices vary according to the treatment population:
Antibiotic therapy for pneumonia
Presentation
Likely Organisms
Community acquired, no Streptococcus pneumonia (typical) or Mycoplasma pneumoniae &
COPD
chlamydia (atypical)
Community acquired with add Haemophilus influenza
COPD
Alcoholics & debilitated add Gram negatives, Legionella and anaerobes (in aspiration)
patients
Diabetics
or
hospital add Staphylococcus aureus and in very ill patients: Pseudomonas
acquired
aeruginosa
Therapies:
1. IV cefuroxime 750mg IV q8h covers: Strep, Staph (unless it is MRSA), gram negatives, anaerobes.
Change to more specific oral agent when organism known.
2. Clavulin (amoxicillin + clavulanate) 500/125mg PO BID. Covers Strep, Staph, gram negatives and
anaerobes.
3. Septra (trimethoprim + sulphamethoxizole) 2 tabs PO BID (or 1 DS tab BID) covers Strep, Staph and
gram negatives.
4. Erythromycin 500mg PO/IV QID covers Strep and atypicals.
5. Penicillin G 1-2 million units IV q4h effectively covers Streptococcus only. Oral version is penicillin
V 250-500mg PO q6h.
6. Piperacillin 3g IV q6h + Tobramycin 2mg/kg IV q8h is a standard therapy for Pseudomonas
aeruginosa. Piperacillin also covers Strep, gram negatives and anaerobes, while Tobramycin adds
further gram negative coverage with synergy.
7. Clindamycin 300mg IV q8h or PO q6h covers Strep, Staph and anaerobes.
8. Vancomycin 1g IV q12h or 125mg PO q6h for MRSA also covers Strep and anaerobes.
Sanford Guide: Rx influenced by local prevalences.
Presumed
viral Influenza,
parainfluenza,
pneumonia
in adenovirus, RSV, hantavirsu
adults: cought, no
sputum,
dyspnea/hypoxia,
interstitial
infiltrates

49

For influenza A or B:
zanamivir 10mg inhaled
BID x 5d or oseltamivir
75mg PO BID x 5d.
Start within 48 hours of
symptoms onset.

For influenza A:
rimantadine 100mg
PO
2x/d
or
amantadine 100mg
PO 2x/d.

Adults over age

18:
Community
acquired;
nonhospitalized.

Smokers: S. pneumo, H.
influenzae,
Moraxella
catarhalis.
Post-viral
bronchitis: S. pneumo,
rarely S. aureus. No comorbidity:
Mycoplasma,
Chlamydia
pneumoniae,
viral, rarely S. pneumo.
Alcoholic
stupor:
S.
pneumo,
anaerobes,
coliforms.
Epidemic:
Legionaires.
Birds:
Psittacosis.
Rabbits:
Tularemia.
Parturient
livestock or cats: Coxiella
burnetii.
Airway
obstruction: Anaerobes.

Azithro 0.5gm PO x1
then 0.25 gm/d or
clarithro 500mg PO BID
or clarithro ER 1gm PO
OD.
Rx duration varies: rx
until afebrile 3-5d.

FQ with enhanced
activity
vs.
S.
pneumo or O Ceph 2
or
AM/CL
875/125mg PO BID
or doxy 100mg PO
BID
or
telithro
800mg PO OD x710d.
In ICU: (P Ceph 3
IV + azithro 500mg
IV OD) or (FQ with
enchanced activity vs.
S. pneumo); add P
Ceph 3 for dual
coverage if suspect
Gm-neg enteric.

Adults over age

Non-ICU bed: [P Ceph
18:
Community
3 IV (erythro 15-20
acquired;
mg/kg/d q6h or azithro
hospitalized. (Note:
500mg IV OD)] or
severe S. pneumo
(cefuroxime + erythro)
in
postor (FQ with enhanced
splenectomy,
activity vs. S. pneumo)
myeloma,
lymphoma pts.)
O Ceph 2: cefdinir 300mg PO q12h, cefpodoxime proxetil 200mg PO q12h, cefprozil 500mg PO q12h,
cefuroxime axetil 250-500mg PO q12h.
P Ceph 3: cefotaxime 2gm q4-8h IV, ceftriaxone 1-2gm IV OD, ceftrizoxime not as active in vitro vs. S.
pneumo.

67. Young female with malaise, tender lymph nodes in the neck, left upper quadrant abdominal
pain. Perform a physical exam. Q: Give a differential diagnosis.
Physical exam: see question #29 and #43. Also: Palpate for lymph nodes in the neck, supra and infraclavicular, axillae, groin. Examine the oral cavity and pharynx. Check for rashes.
Differential diagnosis: neoplastic: lymphoma, leukemia. Viral infection: mononucleosis, HIV, EBV.
Bacterial: syphilis. Inflammatory autoimmune disease: sarcoidosis, lupus. Liver disease with portal
hypertension. Serum sickness, allergic reaction.
68. 65 year old man with ataxia, dizziness, macrocytic anemia. Take a history. Finding: poor diet.
Q: Give a differential diagnosis. What is the most likely diagnosis? What investigations would you
order?
History: onset, chronology, description of symptoms. Setting in which symptoms occur. Functional
limitations (driving, walking, stairs, reaching upward). Differentiate light-headedness from true vertigo
(room or self spinning). Peripheral numbness, psychiatric features: mild depression, irritability, paranoia
(seen in B12 deficiency). Weakness, eye symptoms, tremor. TIA or stoke phenomena: sudden neurologic
deficit (loss of vision, speech, motor or sensory changes). Check for heart problems, hypertension,
diabetes. CAGE alcoholism screen as below, history of syphilis, MS, hypothyroidism (decreases
secretion of intrinsic factor) use of chemotherapeutic agents (interfere with DNA synthesis). Diet, weight
loss or gain, chronic diarrhea (malabsorption), abdominal pain. Symptoms of hypothyroidism. Previous
gastric surgery. Signs of intracranial hypertension (hydrocephalus): morning nausea, vomiting, headache.
General signs of malignancy: anorexia, fatigue, night sweats. Past medical history, medications,
drugs/alcohol, smoking, allergies, family history, review of systems.

50

CAGE questionnaire: Control have you tried to cut down on your alcohol? Anger have you ever felt
angry when someone suggested you decrease your alcohol intake? Guilty have you ever felt guilty about
your drinking? Eye opener do you sometimes have a drink to get started in the morning?
Differential diagnosis: Anemia due to vitamin B12 deficiency: usually due to malabsorption (Crohns,
celiac disease etc.), lack of intrinsic factor pernicious anemia (auto-antibodies against gastric parietal
cells associated with thyroid and adrenal insufficiency), post gastrectomy, long term use of antacids,
pancreatic insufficiency or malnutrition (vegan diet). Severe hypothyroidism. Due to Folate (B6)
deficiency: Poor nutrition (alcoholism, poverty, infancy found in green leafy vegetables),
malabsorption, medication or drug-induced (alcohol, anticonvulsants, antifolates e.g. MTX, BCP),
increased need (pregnancy, prematurity, hemolysis, hemodialysis, psoriasis, exfoliative dermatitis).
Ataxia, dizziness: Wernickes encephalopathy, hepatic encephalopathy, inner ear problem (benign
positional vertigo, acoustic neuroma, Menieres), postural hypotension, brainstem stoke or TIA,
intracranial tumor.
Most likely diagnosis: Vitamin B12/folate deficiency secondary to poor diet.
Investigations: CBC and differential with blood smear, lytes, urea, creatinine, INR/PTT, GGT, AST, ALT,
ALP, serum folate, screen for serum B12, RBC folate, serum ferritin. Schillings test: measures absorption
of B12. Bone marrow Barium enema if suspect pernicious anemia (pernicious anemia is associated with
bowel cancers).
69. 42 year old man found unconscious in the street. Appears to have been struck in the head.
Perform physical exam. Findings: GCS 11, unilateral body weakness. Q: What is your
differential? Evaluate C-spine film. Describe your initial treatment and investigations.
Initial management: rescusitate as required using the ATLS/ACLS format (see question #6).
History: if available: Nature of collapse, preceding and subsequent events e.g. trauma, has patient ever
experienced similar symptoms before, did patient lose consciousness, were there seizure-type phenomena,
injuries during fall, duration of unconsciousness, post-ictal drowsiness, medications and drugs, smoking,
allergies, past medical history, family history, review of systems.
Differential diagnosis: concussion, subdural bleed, epidural bleed, brain contusion, seizure or post-ictal
weakness, brainstem or spinal cord injury.
Clearing C-spines: The principle of clearing C-spines is to rule out both bony fractures and ligamentous
injury, either of which can make the spine dangerously unstable. Most emergency physicians will clear
the cervical spine in the case of an alert patient who has no pain on palpation of the dorsal spinous
processes and a normal cross-table lateral C-spine X-ray. If the patient has neck pain, flexion/extension
plane films are done. These involve gently flexing, then extending the neck and taking views at each
extreme. The patient must be alert enough to warn the examiner of paresthesias in the hands or increased
neck pain on movement during this procedure, which may indicate compromise of the neural elements.
Flexion/extension views may be done under fluoroscopy if the patient is not alert.
Treatment: normalize vitals, oxygen saturation, ABGs, hydrate to maintain BP, give blood if necessary,
correct coagulopathy. Immobilize cervical spine. Consider intubation (careful of the neck). Control ICP,
load with dilantin 1g IV to prevent seizures, give 20% mannitol 50g IV, rapid sequence intubate with sux,
fentanyl, etomidate/propofol/ketamine, spray cords with lidocaine and hyperventilate to pCO2 35mmHg.
51

Consult Neurosurgery. CT head and neck. May need MRI for delineation of brainstem or spinal cord
injuries.
70. 4 year old boy with cough for 6 weeks. No improvement on antibiotics 3 weeks ago. Take a
history. Q: What is your differential diagnosis? Give the most likely diagnosis and describe a
treatment plan.
History: Name, age. Prodromal illness, fever, malaise, rhinorrhea, sore throat, shortness of breath,
wheeze. Is cough productive? Color of sputum, quantity. Any chest pain? Aggravating and relieving
factors. Onset of cough, chronology, time of day (night), worse with exposure to polluted air, cold air,
dust, smoke, exercise, in grassy areas, weedy areas, forests, certain rooms, in bed. Did symptoms
improve with Amoxicillin? Allergic symptoms: red eyes, itching, itch in back of throat. Family pets. Air
conditioning. Type of bedclothes and pillows (feather, synthetic, foam). Recent change in the childs
environment, different bedclothes, new room, change of season. Are there smokers in the house? Past
medical history, medications, allergies, family history (asthma, allergy, CF), review of systems.
Differential diagnosis: asthma, bronchitis, bronchiolitis (upper respiratory tract infection), chronic
sinusitis, rhinitis, TB, recurrent pneumonia, collapsed lung, cystic fibrosis.
Approach to cough:
1. Productive: bronchiectasis, bronchitis, abscess, bacterial pneumonia, TB
2. Nonproductive: viral infections, interstitial lung disease, anxiety, allergy
3. Wheezy: suggests bronchospasm, asthma, allergy
4. Nocturnal: asthma, CHF, postnasal drip, GERD, or aspiration
5. Barking: epiglottal disease (croup)
6. Positional: abscess, tumor
7. Differential diagnosis:
a. Airway irritants: inhaled smoke, dusts, fumes, aspiration (gastric contents, oral secretions,
foreign body), postnasal drip
b. Airway disease: URTI including postnasal drip and sinusitis, acute or chronic bronchitis,
bronchiectasis, neoplasm, external compression by node or mass lesion, asthma, COPD
c. Parenchymal disease: pneumonia, lung abscess, interstitial lung disease
d. CHF
e. Drug-induced
Investigations: CXR, CBC, lytes, INR/PTT, urea, creatinine, pulmonary function tests (> 4 years of age).
Most likely diagnosis: asthma.
Treatment: Acute: O2 to keep SpO2 > 92%. Fluids. 2-agonists: Salbutamol (Ventolin) 0.03 cc/kg in 3 cc
NS q20min via mask until improvement then q1hour as necessary. Ipratropium bromide (Atrovent) if
severe: 1 cc added to each of first 3 Ventolin masks. Steroids: prednisone 2 mg/kg in ER, then 1 mg/kg
PO OD x 4 days. Chronic: Sodium cromoglycate (Intal) 2 puffs QID. Add ventolin 2 puffs PRN if acute
breathlessness with wheeze is a feature. Modify the home environment to decrease contact with common
allergens: dust mites, pollen, pet hair (especially cats). Control dust with thorough and regular cleaning.
Boil bedclothes, plastic undercovers on mattress and pillows, remove rugs, install air conditioner.
Remove pets. No smoking in the house (second hand smoke is a cause of childhood asthma). Warn
parents of the symptoms of a severe asthma attack, status asthmaticus and when to come to the ER.
Discuss treatment strategy, a regular anti-immune medication (sodium cromoglycate or inhaled steroid)
with PRN bronchodilator.
52

71. A 60 year old woman with a history of atrial fibrillation and congestive heart failure returns to
the office for the results of her Digoxin level, which is subtherapeutic. Take a history and counsel.
Q: What are the effects of a Digoxin overdose?
History: Name, age, occupation. Ask about symptoms of atrial fibrillation: sudden fatigue, palpitations,
general weakness, light-headedness, CNS embolic phenomena (TIA, stroke). Symptoms of Digoxin
overdose which the patient may have had in the past: anorexia, nausea, vomiting, bradycardia, visual
effects: yellow, green or white halo around objects, decreased level of consciousness. Symptoms of
congestive heart failure: ankle edema, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea.
Cough, wheeze, hemoptysis. Is patient taking her Digoxin regularly, if not, why? Medications and
whether patient is taking these, drugs and alcohol, smoking, allergies, past medical history, family history,
review of systems.
Counseling: explain action of Digoxin: prevents fibrillation by slowing the heart rate while increasing its
force of contraction. Helps both atrial fibrillation and congestive heart failure. Must be taken regularly.
Discuss reasons why patient may not have been taking medication. Memory problem? Concern about the
side effects? Feels she no longer needs the medication? Emphasize the need to discuss these concerns
with you before altering medications. Discuss symptoms of overdose which the patient might watch for.
Consider alternative medication if side effects are a problem. Develop a follow-up plan to monitor
compliance and cardiovascular status. Arrange follow-up.
Effects of Digoxin overdose: anorexia, nausea, vomiting, bradycardia, visual effects: yellow, green or
white halo around objects, decreased level of consciousness.
72. 60 year old woman with hypercalcemia on an insurance physical. Take a history and perform a
physical exam. Finding: sister had a parathyroid adenoma. Q: Give a differential diagnosis for
hypercalcemia. What investigations would you order?
History: Symptoms of hypercalcemia: Bones, Stones, psychosis-based Moans, and abdominal Groans
fatigue, muscle weakness, arthralgias, renal colic due to nephrolithiasis, emotional lability (can progress
to psychosis and coma), bone pain, abdominal pain, nausea, vomiting, constipation, ileus, polyuria,
polydipsia, nocturia. Onset, duration of these. General malignancy symptoms: weight loss, night sweats,
fatigue. Orthostatic hypotension (Addisons). Heat intolerance, hyperactivity (hyperthyroid). Diet,
especially amount of milk and use of calcium supplements and antacids. Medications, drugs and alcohol,
smoking, allergies, past medical history (especially heart burn, reflux, gastritis, peptic ulcer), family
history (especially of multiple endocrine neoplasia MEN), review of systems.
Physical exam: Trousseaus sign (inflate BP cuff, leave on 1-2 minutes, distal arm goes into titanic
flexion, indicates hypercalcemia). Inspect for signs of Addisons: bronze skin tone, orthostatic
hypotension, or of Cushings: moon facies, striae, buffalo hump. Chest: palpate sternum and ribs for bone
pain, examine breasts for signs of malignancy: dimpling, mass. General cardiopulmonary exam.
Abdominal exam, palpate liver carefully for masses, percuss kidneys for pain. Rectal: test stool for occult
blood. Examine long bones for straightness and tenderness (Pagets disease of bone).
Differential diagnosis: parathyroid adenoma (hyperparathyroidism) due to solitary adenoma, hyperplasia,
carcinoma, inherited MEN (multiple endocrine neoplasia may also have pituitary adenoma causing
Addisons or Cushings), malignancy (myeloma, lung, breast, squamous in any site), high bone turnover
(Pagets disease of bone, hyperthyroidism, Vit A excess), vitamin D in pharmacologic doses, milk-alkali

53

syndrome (large ingestion of milk and alkali, usually for gastric hyperacidity), aluminum intoxication,
drugs (thiazides, lithium, CaCO3), familial hypocalciuric hypercalcemia.
Investigations: CBC, lytes (including Ca & Ca++, Mg, PO4), urea, creatinine, albumin, AST, ALT, ALP,
GGT, INR/PTT, serum cortisol, serum PTH, TSH, serum protein electrophoresis (for monoclonal
gammopathy of myeloma). Plane X-rays of tender or malformed bones, including skull (see salt and
pepper lesions). CT head, thyroid, adrenals.
1993
73. 50 year old woman states that the Russians are leaking radiation into her house. Take a history
with mental status exam.
History should focus on depression, mania and schizophrenia. Mental status exam. See questions #4 and
#57.
74. Obese patient wants help with weight loss. Counsel.
History: Name, age, occupation, weight history, note ups and downs if present, past attempts to lose
weight, successes, obstacles, goals. Dietary habits: frequency of meals, snacking, eating at night, foods
eaten, binge eating, guilt about food, hoarding, concealing eating from others. Estimate daily caloric
intake. Alcohol intake. Smoking, drug use. Exercise history. Overweight relatives? Diseases associated
with weight gain: hypothyroidism, DM type II, Cushings, major depression, anxiety disorder, some
medications (TCA, steroids, OCP). Problems associated with overweight: gout, sleep apnea,
cholecystitis, back pain, cardiovascular disease, hemorrhoids, lower limb joint pain and osteoarthritis.
Why is patient seeking medical help for this now? Crisis in patients life, stress, anxiety? Assess patients
self-image: does patient feel underweight, overweight or normal? Does patient feel that weight interferes
with health? With activities? Screen for eating disorders. Medications, drugs and alcohol, allergies, past
medical history, family history, review of systems (include sleep habits, apneic spells, OTC medications).
Physical exam: vitals, calculate BMI (body mass index) = weight (kg)/height 2 (m2). Ideal is 20-25 for a
male, but varies depending on frame. 25-30: overweight; 30-35: obese; > 40: morbidly obese. Use
standard height-weight tables for males and females to gauge percent overweight (>20% = obese). Direct
physical to pertinent positives from history. Inspect for Cushingoid features: moon facies, buffalo hump,
striae, visual field defects. Fat distribution: centripetal fat associated with greater heart disease and
diabetes risk. Fundoscopic exam for retinopathy. Cardiopulmonary exam, abdominal exam (not liver
size). Check for signs of hypothyroidism: hypothermia, goiter, dull facial expression, lid lag absent, lids
droop, periorbital swelling, hair is sparse, coarse and dry, skin is also coarse, dry scaly and thick. Patients
are forgetful, show change in personality which may progress to psychosis, deep tendon reflexes show
slow return phase (brisk contraction and slow relaxation), leukonychia (whitened nails), orange palms and
soles due to carotene deposition, bradycardia, pericardial effusion, pleural effusions, myxedema, nonpitting edema, carpal and tarsal tunnel nerve compression due to myxedema, causing paresthesias and
numbness in the hands and feet.
Counseling: Motivation: how would being at ideal body weight improve the patients life? Emphasize
health, lifestyle, self esteem, relationship benefits. Discuss nutrition-related problems: heart disease,
obesity, hypertension, osteoporosis, anemia, dental decay, cancer, gastrointestinal disorders, respiratory
compromise, high lipids, diabetes, sleep apnea, osteoarthritis. Discuss diets tried and why these failed.
Fad diets involve unusual or extreme eating patterns and are not designed to be maintained for a lifetime
therefore these should be discouraged. Weight loss agent Ponderal no longer available. SSRIs such as
54

Paxil may assist with weight loss, unfortunately, when the drug is discontinued, most people regain
weight. Explain that the brain has a satiety set point which can be reset over time with reduction in
caloric intake. Warn that the bodys ability to determine caloric content is very good, and will not be
fooled by so-called diet products. Recommend a balanced diet consisting of ordinary foods, with three
distinct meals per day of small size. No eating at night and be careful of snacks. Inform patient that he
will be hungry for at least the first two weeks of reduced intake. Suggest visualization techniques,
redirection of interests, and to think of hunger as a sign of positive progress on weight loss. Group
support can be beneficial too: Weight watchers, overeaters anonymous etc. behavior modification.
Dietary recommendations: reduce fat to 20% of caloric intake. Ideal caloric intake can be estimated at
8-10 Cal/lbs (ideal weight) for females and 10-12 Cal/lbs (ideal weight) in males. Emphasize that caloric
intake is more important for weight loss than food composition (i.e. excessive calories lead to weight gain
even if they are non-fat).
Exercise recommendations: sudden intense exercise in sedentary patient unwise. Exercise tends to
provide a good excuse for overeating and may be dangerous in an obese patient. Recommend mild daily
exercise such as 1 hour walking per day. More vigorous exercise can be initiated when weight is lost.
Arrange regular follow-up for body mass monitoring and counseling.
75. Alcoholic smoker with cough, sputum, shortness of breath. History and physical exam. Order
investigations.
See question #66.
76. 70 year old man with dysphagia. Manage.
See question #65.
77. 64 year old woman with resting tremor. Perform focused physical exam.
Hallmarks of Parkinsons disease: TRAP: Tremor (rest, pill-rolling, 4-7 Hz, can be suppressed by
voluntary movement), Rigidity (lead pipe and cog-wheeling), Akinesia/bradykinesia, Postural instability
(festinating gait, retropulsion, falls). Remember to explain to the examiner what signs of Parkinsons you
are looking for at each step in the exam. Other features include: mask-like face, lack of blinking,
blepharoclonus (fluttering of closed eyelids), dysphagia, drooling, hypophonia, micrographia, gait: start
hesitation, small shuffling steps, loss of arm swing, subcortical dementia (apathy, forgetful, poor ability to
use knowledge).
Physical exam: vitals, observe patient at rest: look for pill-rolling tremor in the upper limb which is
worst at rest, may also have head tremor (titubation), stooped posture, open-mouthed, mask-like face,
generally hypokinetic with decreased blinking and drooling. Mini mental status: dementia associated
with Parkinsons (50% of patients), may find poor short term memory, poor concentration, abstraction,
micrographia. Depression may also be a feature, screen for depression: MSIGECAPS. Cranial nerves,
body power, pronator drift, deep tendon reflexes and Babinski are normal in Parkinsons. Tone: bilateral
lead pipe (constant) rigidity with possible cog-wheeling due to tremor superimposed on passive motion.
Test elbow, forearm rotation and knee by applying rapid passive motion while feeling the muscle tendon.
Cerebellar testing: finger-nose and heel-shin tests show improvement of tremor with intention (i.e. a
resting tremor rather than an intention tremor), rapid alternating movements are poor bilaterally in
55

Parkinsons and Rhomberg is positive due to postural instability. The Parkinsonian gait is unsteady and
shuffling with small steps, decreased arm swinging, and a tendency to fall forward or backward. Patients
may try to increase forward speed to keep from falling (festination).
Mini-Mental Status: orientation to time/place (5 pts, year, season, month, day, day of week; 5 pts,
country, province, city, hospital, floor), memory (3 pts, honesty, tulip, black; 3 pts, delayed recall),
attention/concentration (5 pts, serial 7s, WORLD backwards), language tests: comprehension (3 pts,
three point command), reading (1 pt, close your eyes), writing (1 pt, complete sentence), repetition (1
pt, no ifs, ands or buts), naming (2 pts, watch, pen), spatial ability (1 pt, intersecting pentagons)
78. 12 year old female with fever, photophobia, neck stiffness. Manage.
History: name, age, onset of symptoms, duration, increasing or decreasing in severity, fever, nausea,
vomiting, photophobia, phonophobia, neck stiffness, headache, rash. Immunocompromised? (HIV,
asplenia, prematurity), parameningeal infection? (sinusitis, mastoiditis), environmental risk factors? (daycare centers, household contact, travel to endemic regions). Medications or other interventions tried?
History, severity, chronology of migraines. Premonitory visual disturbance? Recent neurosurgery, head
trauma, other illness? Contacts with meningitis at school or work. Medications, drugs/alcohol, allergies,
past medical history, family history, review of systems.
Physical exam: vitals, GCS, note general appearance of patient if patient is very ill, a resuscitation
approach (ATLS/ACLS) may be appropriate, orientation. Inspect for meningococcemial rash. Cranial
nerves: pupillary reflexes, note photophobia if present, extraocular muscle movement, check for double
vision, visual fields, facial sensation and movement, gross hearing, sternocleidomastoid and trapezius
power. Tone: passive rapid movement at elbows, rotation of forearms and flexion/extension of knees.
Pronator drift. Cerebellar testing: finger-nose, heel-shin, rapid alternating movements of forearms.
Power of deltoids, triceps, biceps, wrist extension and flexion, finger abduction and adduction, psoas,
quadriceps, hamstrings, ankle dorsiflexion and plantar flexion. Deep tendon reflexes at triceps, biceps,
brachioradialis, knee, ankle, Babinski. Light touch, pin prick over limbs and body, vibration sense at
joints. Signs of meningismus: Kernigs: pain in the neck on extension of the knee with the hip in 90
degrees of flexion. Brudzinskis: pain on passive flexion of the neck. Nuchal rigidity. Opisthotonos:
spasm in which head and heels are bent backward and body bowed forward.
Investigations: CBC, lytes, INR/PTT, urea, creatinine, glucose, blood cultures, ABG, CT head followed
by lumbar puncture if history and physical are suspicious for raised intracranial pressure (lumbar puncture
may, rarely, precipitate brain herniation in the presence of raised ICP).
Treatment: isolation, initiate IV antibiotics immediately (before CT and LP) if the clinical picture is
suspicious for meningitis. Cefotaxime 2 g IV q4h + ampicillin 50 mg/kg IV q6h. Consult ICU. Consider
intubation and intensive management of ICP. Monitor glucose, acid-base & volume status and manage as
needed. Steroids for Hib meningitis (give early). Anticonvulsants for seizures. Report to public health.
79. 17 year old female with chronic diarrhea. Take a history.
Background: Causes of chronic diarrhea in a 17 year old: Crohns, ulcerative colitis, irritable bowel,
malabsorption (Celiac disease, tropical sprue), lactose intolerance, intestinal infection (C. difficile,
giardia, amoebiasis), pancreatic dysfunction, unusual but may be laxative abuse.
History: onset of diarrhea, duration, consistency and color of stools, do they float? Is there blood or
mucous? Frequency of BMs/day, weight loss, appetite. Dietary history. Is diarrhea worse with milk
56

(lactose intolerance tends to produce explosive diarrhea after milk ingestion hereditary)? Laxative use.
Use of antibiotics in the past 6 weeks. Travel history. Fever, nausea, vomiting, infectious illnesses.
Associated abdominal pain, fatigue, uveitis, mouth or anal ulcers, ankylosing spondylitis, sacroiliitis,
renal problems (due to malabsorption), arthritis (these are associated with Crohns). Malnutrition
signs/symptoms: lassitude, weakness, hair falling out, skin rash, easy bruising, weight loss, anemia,
neurologic findings (carpal and tarsal nerve compression, confusion, emotional lability, loss of
corticospinal vibration and position sense), glossitis. Medications, drugs and alcohol, smoking (decreases
risk and symptoms of inflammatory bowel disease), past medical history (IBD, abdominal surgery),
family history, review of systems.
Classification of Chronic Diarrhea
Type
Characteristics
Inflammatory
Fever, hematochezia, abdominal pain; usually
Ulcerative colitis
weight loss with carcinoma
Crohns disease
Malignancy: lymphoma,
adenocarcinoma
Osmotic
Stool volume decreases with fasting
Ingestion
Increased stool osmotic gap:
Lactose intolerance
fecal [Na+] + [K+] < serum osmolality
Medications, laxatives
25 mmol/L
Maldigestion
and
Malabsorption
Weight loss, fecal fat > 7-10 g/24h stool collection
Pancreatic insufficiency
Anemia, hypoalbuminemia
Bile salt deficiency
Celiac Sprue
Whipples disease
Bowel resection
Secretory
Large volume (> 1 L/d); little change with fasting
Bacterial enterotoxins
Normal stool osmotic gap:
Secretagogues VIP, Secretory: fecal [Na+] + [K+] = serum osmolality
gastrin, carcinoid
Functional
IBS
80. Young mother with black eye, hit by her boyfriend. Manage.
Warning signs of domestic violence: obsessive need to control victim by controlling money, restrictions
on going out, not allowed to see certain people. The Spanish Inquisition where were you, who were
you with, what did you do? Social isolation. Threats. Verbal abuse aimed at decreasing self-esteem of
victim. Cycle of violence followed by remorse, then increased violence.
Risk factors for domestic violence: social isolation, poverty, substance abuse, partners parents had abuse
relationship, personality/character disorder or mental illness.
History: Describe violent episode, what triggered it? Were objects used as weapons? Injuries? Was the
boyfriend remorseful afterward? History of previous episodes of violence or loss of temper by boyfriend.
What is patients response? Has patient been in an abuse relationship before? Were the patients parents
in an abusive relationship? Is boyfriend controlling, does he restrict her activities, question her
57

excessively after she has been out, engage in verbal abuse or threats? Is the violence increasing in
severity? Are there children in the house? Who are the biological parents? Ask about violence to the
children, sexual abuse. Does the patient or her partner abuse alcohol or other drugs? Is money a
problem? Is the boyfriend willing to seek help?
Counsel: Explain that the boyfriend hitting the patient is a criminal assault and an example of domestic
violence. Domestic violence tends to increase over time unless the victim leaves, or the abuser and
couple seek therapy. Very often, women dont leave their abusive partner until they are seriously hurt or
before they are killed. Domestic violence between adult partners tends to be reflected in future behavior
of children who are exposed to it and there is a risk of violence to the children. Child abuse is a criminal
act and if suspected, is reportable to police by law. Spousal abuse is also a criminal act but is not
reportable by law. Recommend that the patient not return to the abuser if there is risk to her safety (e.g.
not the first assault, abuser not remorseful). If the patient does return, an exit plan should be developed to
ensure patient safety. Document all evidence of abuse (pictures, sketches) and related visits; quote patient
directly in chart.
Alternatively, the patient can contact the police to obtain a restraining order on the abuser. Develop a plan
with the patient to seek alternate living arrangements (womens abuse shelter), enlist the help of patients
support structure (friends, other family members), contact the police (patient should be informed that, if
contacted, the police will lay charges whether the patient wants to or not). Counsel patient on how to
enter into controlled, safe, contact with the abuser to discuss possible therapy for anger management and
controlling behaviors, with therapy as a couple for relationship problems. Social worker referral. Arrange
follow up.
81. Patient kicked by horse, now hypotensive in emergency department. Manage.
Rescusitation: The ACLS and ATLS format is useful: see question #6.
History: if available: Where was the patient kicked, when, was there mechanism of action for other
injury, i.e. collapse/fall, preceding and subsequent events, did patient lose consciousness, duration of
unconsciousness, did the patient fall, injuries during fall, medications and drugs, smoking, allergies, past
medical history, family history, review of systems.
Management: For unstable blood pressure, blood loss is the most likely cause (CBC may be normal with
a large acute blood loss), type and cross for 4-6 units depending on estimated severity and hang blood as
soon as possible. Is the patients abdominal wound the first priority? Examine for head injury, other
injuries. Check for abnormalities on abdominal exam suggestive of splenic rupture. With clear surgical
abdomen (rigidity, rebound, absence of bowel sounds), consult general surgery and prepare patient for
immediate OR. If less severe abdominal bleeding is suspected, consider CT abdomen or diagnostic
peritoneal lavage.
82. Suturing station. Suture laceration on a rubber forearm. Choose suture type. Is a tetanus
booster required?
Suturing station: past years have included a point for introducing yourself to the rubber forearm.
History: Name, age, occupation, mechanism of injury, environment in which injury occurred. How long
since the injury. Any distal loss of sensation, motor power? Other injuries. Past medical history,
medications, drug/alcohol use, smoking, allergies, review of systems.

58

Choice of suture: use non-absorbable monofilament such as 3-0 Prolene or Ethylon. Braided sutures can
harbor bacteria and absorbables cause more inflammatory reaction in the skin. Given a choice between 30 silk (a braided non-absorbable) and chromic gut (a braided absorbable), choose silk.
Technique: for small wound use interrupted sutures starting at the middle of the wound. Anesthetize with
lidocaine without epinephrine, cleanse and irrigate wound beforehand and drape, glove and observe sterile
technique.
Tetanus immunization status: Dose Td 0.5 mL IM. Usual schedule of immunizations for tetanus
(prepared as diphtheria-tetanus toxoid plus pertussis vaccine, i.e. DTP) is 2, 4, 6, 18 mo., 4-6 years, Td
(diphtheria-tetanus toxoid) at 14-16 years and repeat q10y.
Last tetanus immunization treatment
0-5 years ago none
5-10
years boost (Td)
ago
>10 years ago boost and give immunoglobulin
(passive)
uncertain
boost and give immunoglobulin
(passive)
Follow up: Warn of signs of wound infection. Remove sutures in 7 days (5 days on the face to minimize
scarring, the face heals faster and is less likely to become infected due to better blood supply).
Recommend Tylenol plain if pain is a problem.
83. Female, 7 weeks pregnant with lower abdominal pain and vaginal bleeding. Take a history.
Finding: previous spontaneous abortion at 6 weeks gestation. Q: Give a differential diagnosis,
which is most likely? What three findings on vaginal examination would confirm this diagnosis?
Definitions:
1. Threatened abortion = any uterine bleeding or cramping in the first 20 weeks of gestation.
2. Inevitable abortion = intolerable pain or bleeding x 1 week, cervix open. Life-threatening to the
mother.
3. Incomplete abortion = membranes ruptured, part of products of conception passed, cervix open.
4. Complete abortion = uterus empty, bleeding and complete sac and placenta passed, cervix open.
5. Missed abortion = fetal death and retention of products; presents as pregnancy not progressing, cervix
closed.
6. Habitual = 3 or more consecutive spontaneous abortions.
20-30% of pregnancies have uterine bleeding or cramping in the first 20 weeks. Half of these abort. Most
spontaneous abortions are associated with abnormal fetus.
History: patient ID (name, age, occupation), GTPAL, weeks of gestation. Onset of bleeding, duration,
estimate quantity (number of pads soaked), color and consistency of blood, associated fever, chills,
abdominal discomfort, light headedness. Problems with previous pregnancies, problems in this pregnancy,
medical visits to this point, investigations done. Associated abdominal trauma (accident or abuse), drug
use (cocaine), father and mothers blood type, medications, alcohol, smoking, past medical history
(diabetes, lupus), family history, review of systems.

59

Differential diagnosis: threatened abortion, incomplete abortion, non-uterine bleeding source trauma:
post-coital vs. lesion: cervical polyp, neoplasm etc. (vaginal, cervical, vulvar), abnormal pregnancy
(ectopic, molar), physiologic bleeding (due to placental development).
Most likely diagnosis: incomplete abortion. Three findings which would confirm this: ruptured
membranes, products of conception passed, cervix dilated (os open).
84. 60 year old male with hemoptysis and shortness of breath. Take a history. Findings: history of
CAD, HTN, hasnt been taking antihypertensives for six weeks. Q: describe CXR, (shows enlarged
heart, upper lobe vascular redistribution, Kerley B lines, bilateral interstitial infiltrates and
bilateral small effusions). Read ECG: shows Q waves and inverted T waves in V1-4. What is the
diagnosis?
History: name, age, occupation. Onset of symptoms, duration, time of day. Has patient had these before?
Smoking history. Prelude of fatigue, ankle edema, orthopnea, paroxysmal nocturnal dyspnea,
palpitations, chest pain/heaviness/tightness, pain in left arm or jaw/teeth. History of angina, other cardiac
problems. History of GI bleeds, reflux, varices, gastritis, peptic ulcer, COPD history, cough, sputum,
wheeze. History of immobilization, leg pain or swelling, previous DVT, PE. Medications has patient
been taking them? Drugs, alcohol, allergies, smoking, surgical history, family history, review of systems.
CXR: consistent with pulmonary edema and CHF.
Diagnosis: ECG: anterior wall myocardial infarct.
85. 2 year old child with 9 week history of cough, on Amoxicillin for 2 weeks. Take a history. Q:
Give a differential diagnosis. What investigations would you order?
See question #70.
86. Young female with secondary amenorrhea for 6 months. Take a history. Q: What investigations
would you order. Give a differential diagnosis. What is the most likely diagnosis, what results
would confirm this diagnosis?
History: age of menarche, regularity of previous menses, flow, duration, accompanying cramps, bloating,
psychic disturbance. Headache, visual field disturbance (for sellar tumor). Signs of virilization: increased
quantity and coarseness of body hair and facial hair, acne, increased sexual drive, increased muscle bulk.
Galactorrhea? Diet history: has patient lost/gained weight lately? Thyroid symptoms: energy levels,
emotional lability/depression, cold intolerance, or feels hot, jumpiness. Exercise history: is patient
engaging in vigorous exercise such as running? Sexual history: contraception, is pregnancy a possibility?
Medications, drugs and alcohol use, smoking, allergies, past medical history with surgical history, family
history, review of systems.
Approach: History and physical pregnancy test TSH and Prolactin (high/low
hypo/hyperthyroid; high, > 100, or symptoms of hyperprolactinemia CT to rule out tumor)
progesterone challenge (+ve withdrawal bleed anovulation; no withdrawal bleed end-organ
failure or outlet obstruction) FSH, LH (high ovarian failure; low hypothalamic dysfunction)
Investigations: hCG, TSH, serum LH, FSH, serum prolactin, serum testosterone, sex-hormone binding
globulin (SHBG), DHEA-S, progesterone trial for uterine bleeding (indicates functional endometrium).
60

Differential diagnosis: pregnancy, polycystic ovary syndrome (Stein-Leventhal syndrome), hypothalamic

dysfunction, excessive exercise, stress, weight loss, adrenal dysfunction (e.g. Cushings), thyroid
dysfunction, prolactinoma, hypopituitarism.
Most likely diagnosis: PCOS
Confirmed by: elevated LH, low or normal FSH with well estrogenized vaginal mucosa, increased serum
androgens, ovarian cysts seen on ultrasound.
87. Mother with low birth weight baby, just delivered. Take a history. Q: On physical exam of the
baby you find emaciation with wrinkled yellow skin and yellow tears. What is the problem? Give
three underlying causes for this. Give two potential problems which may arise in the next 48 hours.
Mothers obstetrics and newborn history: see question #25.
Causes of intra-uterine growth restriction (IUGR)
1. symmetric IUGR (normal head to body size), familial, maternal gestational infections (mnemonic
ToRCH), toxoplasmosis (carried in cat feces), rubella, cytomegalovirus (CMV), herpes
2. Asymmetric IUGR (small body): placental insufficiency due to maternal malnutrition, smoking,
drugs and alcohol, illness during pregnancy (e.g. Crohns), hypertension.
3. Jaundiced, emaciated baby: hyperbilirubinemia.
Three underlying causes: ABO or Rh
incompatibility, neonatal liver insufficiency (CMV) and sepsis (TORCH).
All causes of neonatal jaundice: Unconjugated = physiologic neonatal jaundice OR pathologic:
hemolytic ABORh incompatibility, neonatal sepsis, splenomegaly, hereditary spherocytosis, G6PD
etc.; non-hemolytic breast milk jaundice, breakdown of cephalohematoma, polycythemia, sepsis,
Gilberts, Crigler-Najjar, hypothyroidism. Conjugated: GI obstruction in fetus (increases enterohepatic
circulation), bile duct obstruction, drug-induced and multiple other less common causes.
Two potential problems arising in the next 48 hours: kernicterus (hyperbilirubinemic seizures and
brain damage: deposition of bilirubin in the brainstem and basal ganglia leading to mental retardation,
cerebral palsy, hearing loss and paralysis of upward gaze), hydrops fetalis (generalized edema, including
pulmonary, with high output heart failure).
88. A young man fell while inebriated and sustained a laceration to the right wrist. Perform a
focused physical exam. Findings: numbness on ulnar side of hand, Allens test shows no ulnar
artery refill, FDS impaired in little and ring finger. Q: What four structures were lacerated?
Management?
Physical Exam:
Vascular: capillary refill, is hand pink and warm? Allens test: compress ulnar and radial arteries at the
wrist, have patient open and close hand to remove blood, then release one side the hand should flush
pink due to blood supply from the side released. (Usually used to demonstrate function of ulnar artery).
Doppler probe.
Sensory: digital nerves: check two point discrimination on either side of each digit. Pin-prick sensation:
Median nerve territory is the palmar surface of the thumb, and the palmar surface and dorsal tips of the
index, middle and thenar side of the ring fingers. The ulnar side of the hand is ulnar nerve, and the dorsal
61

surface of the thenar side of the hand is radial nerve innervated. The median nerve also innervates most
muscles of the thenar eminence, and the 1st and 2nd lumbricals. The thumb is weak in abduction at 90
degrees to the plane of the hand in median nerve dysfunction. The ulnar portion of the palm is supplied
by the cutaneous branch of the ulnar nerve, while the thenar portion is supplied by the cutaneous branch
of the median nerve.
Neuromotor examination of the Hand
Median
Sensory
Redial aspect of index finger
pad
Motor
Flex DIP of index finger
Extrinsic
(FDP)
Motor
Intrinsic

Ulnar
Ulnar aspect of little finger
pad
Flex DIP of little finger
(FDP,
extensor
carpi
radialis)
Thumb to ceiling with palm Abduct index finger (first
up (abductor pollicis brevis) dorsal interosseous)

Radial
Dorsal webspace of
thumb
Extend wrist and thumb
(extensor
pollicis
longus)

Motor: (dont ask patient to apply force against resistance as this may rupture a partially severed tendon
test active ROM only). Median nerve: thumb abduction. Ulnar nerve: finger spread against resistance.
Radial nerve: wrist extension. FDS flexes the MCP and PIP joints of the fingers, while FDP (flexor
digitorum profundus) flexes the DIP. To test FDP function hold the MCP/PIP joints in extension and ask
patient to flex DIPs. Both the FDS and FDP can flex the entire finger, but the FDP tends to flex them all
at once, while the FDS can flex fingers in isolation. To test FDS: hold all fingers except the one you are
testing in extension and ask patient to flex the remaining finger.
Tendon Examination of the Hand
MCP
Extensor
Communis
tendons
Flexor tendons Intrinsics
(lumbricals)

PIP
Extensor digitalis (lateral
bands)
Flexor
digitorum
superficialis

DIP
Intrinsics
bands)
Flexor
profundus

(lateral
digitorum

Structures superficial to the flexor retinaculum (in order from ulnar to thenar): ulnar nerve, ulnar artery,
cutaneous branch of ulnar nerve, palmaris longus tendon, cutaneous branch of median nerve.
Structures immediately deep to flexor retinaculum (ulnar to thenar): 4 flexor digitorum superficialis
tendons (FDS), median nerve, palmaris longus tendon, cutaneous branch of median nerve.
Structures lacerated: given diminished ulnar territory sensation, Allens test shows no refill from ulnar
circulation, and FDS weakness in little finger and ring finger, the following structures were included in
the laceration: ulnar nerve, ulnar artery, flexor retinaculum, ulnar two divisions of FDS.
Treatment: Clean and explore wound under local anesthetic and sterile conditions. Consult plastic
surgery for microvascular repair. If at night, may suture skin closed and arrange for patient to be seen by
plastic surgeon the next day.
89. A young man sustains a head injury on falling from his bicycle. Patient has been
hemodynamically stabilized. Perform a focused neurological exam. Q: Lateral skull and lateral Cspine X-rays provided. Are they adequate? Are they normal? The patient has continuing
sanguinous discharge from his nose. What is the likely cause of this. Treatment?
62

Begin by assessing the level of consousness using the Glasgow Coma Scale:
Glasgow Coma Scale (GCS):
Glasgow Coma Scale
Eye
(E) Verbal Response
Opening
Spontaneou 4
Oriented
and
s
3
converses
To speech
2
Confused
To Pain
1
conversation
never
Inappropriate words
Incomprehensible
sounds
None

(V
)
5
4
3
2
1

Best Motor Response

(M
)
Obeys commands
6
Localizes pain
5
Withdrawal to pain
4
Abnormal
flexion 3
(decorticate)
2
Abnormal
extension 1
(decerebrate)
Nil

NB: Standard painful stimulus is rubbing the knuckle on the sternum. For withdrawal, apply pressure on
the base of the nail bed with a pen. Decorticate posture is arm flexion with leg extension on the same side
of the body, may be unilateral or bilateral. Indicates a lesion above the brainstem. Decerebrate posture is
arm and ipsilateral leg extension, may be unilateral or bilateral, indicates brainstem involvement. A GCS
of 8 or less is considered an indication for intubation because of the risk of poor protection of the airway
from aspiration.
Head and Neck: inspect for lacerations and contusions, cranial nerves: extra-ocular movements, visual
fields by confrontation, pupillary reactivity, dolls eyes (careful of neck, may not be able to turn head
enough to do this), and accommodation, corneal reflex and facial sensation, palpate facial bones for
stability, look in nose and ears for blood or CSF leaks, hemotympanum, facial muscle power, gross
hearing, sternocleidomastoid power and trapezius power. Check oral cavity, gag reflex, palpate dorsal
cervical spines for pain and alignment, is the trachea midline? Pronator drift, cerebellar tests: finger-nose,
heel shin, rapid alternating movements (dysdiadocokinesis). Body power, tone, sensation. Deep tendon
reflexes, Babinski. Log roll patient onto back, inspect, palpate spine.
If GCS is significantly less than 15: Head and Neck: inspect for lacerations and contusions, cranial
nerves: pupillary reactivity, dolls eyes (careful of neck, may not be able to turn head enough to do this),
corneal reflex, palpate facial bones for stability, look in nose and ears for blood or CSF leaks,
hemotympanum. Check oral cavity, gag reflex, palpate dorsal cervical spines for alignment, is the trachea
midline? Brainstem (breathing pattern). DRE for sphincter tone. Deep tendon reflexes, Babinski. Log
roll patient onto back, inspect, palpate spine.
Differential diagnosis: concussion, subdural bleed, epidural bleed, brain contusion, seizure or post-ictal
weakness, brainstem or spinal cord injury.
Clearing C-spines: The principle of clearing C-spines is to rule out both bony fractures and ligamentous
injury, either of which can make the spine dangerously unstable. Most emergency physicians will clear
the cervical spine in the case of an alert patient who has no pain on palpation of the dorsal spinous
processes and a normal cross-table lateral C-spine X-ray. If the patient has neck pain, flexion/extension
plane films are done. These involve gently flexing, then extending the neck and taking views at each
extreme. The patient must be alert enough to warn the examiner of paresthesias in the hands or increased
63

neck pain on movement during this procedure, which may indicate compromise of the neural elements.
Flexion/extension views may be done under fluoroscopy if the patient is not alert.
Treatment: Continuous sanguinous nasal discharge after head injury is likely a leak of CSF mixed with
blood. This represents a break of the meninges and can, rarely, lead to meningitis (< 5% of cases).
Prophylactic antibiotics not indicated as this selects for resistant organisms. If meningitis results, it is
usually due to less virulent organisms than in other settings. > 90% of leaks resolve spontaneously within
4 weeks. If leak does not subside spontaneously, a surgical repair may be necessary. Consult
neurosurgery. CT head and neck. May need MRI for delineation of brainstem or spinal cord injuries.
Key Points:
1. Never do lumbar puncture in head injury.
2. All patients with head injury have C-spine injury until proven otherwise.
3. Dont blame coma on alcohol: there may also be a hematoma.
4. Low BP after head injury means injury elsewhere.
5. Must clear c-spine both radiologically AND clinically.
90. Older man with 50 RBC/HPF on routine urinalysis. Take a focused history. Q: What is the
likely diagnosis? Give three other possible diagnoses. What two investigations would you order?
History: see question #28.
Likely diagnosis: benign prostatic hyperplasia.
Differential diagnosis: transitional cell carcinoma of bladder, UTI, nephrolithiasis, hydronephrosis,
prostatitis, prostate cancer, renal cell carcinoma, essential hematuria (tends to occur in children).
Two investigations: prostate specific antigen (PSA), cystoscopy, renal, bladder and prostate ultrasound,
intravenous pyelogram (IVP).
91. 20 year old female with hypertension. Perform a physical exam.
diagnosis. What investigations would you order?

Q: Give a differential

See question #11.

92. 67 year old male complains of bladder distension, inability to urinate and dribbling of urine
from the urethra. Take a history. Q: What investigations would you order?
History: patient ID. Onset of symptoms, chronology, previous episodes. Associated constipation,
perineal numbness, leg weakness, diabetic neuropathy. Is patient on a new medication? Suprapubic pain,
pain on urination, frank blood in the urine, color of urine, difficulty initiating or maintaining urinary
stream, renal pain, groin pain. Previous renal colic or diagnosis of nephrolithiasis? Known prostatic
hypertrophy or cancer? Diabetes? B12 deficiency? Recent surgery? History of hypercalcemia,
hypertension. Malignant symptoms: night sweats, weight loss, fatigue. Medications, drugs/alcohol,
smoking, past medical history, past surgical history, family history, review of systems.
Investigations: urinalysis, urine microscopy and culture with sensitivities, cystoscopy, PSA, renal and
pelvic ultrasound.
1992
64

93. 60 year old female feeling depressed. Complains of stomach pain. Perform focused mental
status exam.
Mental status: appearance, behavior (dress, grooming, posture, gait, apparent age, physical health, body
habitus, expressions, attitude - cooperative?, psychomotor activity, attention, eye contact), speech (rate,
rhythm/fluency, volume, tone, quantity, spontaneity, articulation), mood (subjective emotional state in
patients own words), affect (Quality euthymic, depressed, elevated, anxious; Range full, restricted;
Stability fixed, labile; Appropriateness; Intensity - flat, blunted), suicidal ideation (low, intermediate,
high poor correlation between clinical impression of suicide risk and probability of attempt), thought
process (coherent, flight of ideas, tangentiality, circumstantiality, thought blocking, neologisms, clanging,
perseveration, word salad, echolalia), thought content (delusions bizarre vs. non-bizarre, obsessions,
preoccupations, phobias, recurrent themes), perceptual disturbances (illusions, hallucinations,
depersonalization, derealization), insight, cognition, judgment.
94. 16 year old girl brought to the office by a classmate for weight loss over the past six months.
The classmate is worried about anorexia nervosa. Take a history and counsel.
History: amount of weight lost, time frame. How did the patient lose the weight? What is the patients
diet now? Still losing weight? How often does the patient weigh herself? Are you proud of this weight
loss? Do you think you need to lose more? Are you afraid of becoming fat? Do you admire women
who are smaller than you? Binge eating, post-prandial vomiting, laxative or diuretic abuse, excessive
exercise, diet pills. Wearing baggy clothes to conceal fatness, unable to look at self in a mirror or to be
touched by others. Ask about the home environment, is there a problem with expressing conflict openly?
Signs of malnutrition, amenorrhea (> 3 consecutive menstrual cycles missed), sallow skin, rash, easy
bruising, dry and sparse hair, lassitude, weakness, anemia, neurologic findings (carpal and tarsal nerve
compression, confusion, emotional lability, loss of corticospinal vibration and position sense), glossitis,
heart burn, teeth erosion, GI bleeding.
Counsel: Determine ideal body weight using standard height/weight charts (BMI = weight (kg)/height 2
(m2), ideal is about 20-25 for females). Show patient her position on the chart. Explain that anorexia
nervosa is a modern disease of highly motivated young women. These women exercise extreme control
over their bodies, often as a means of sublimating their inability to express conflict at home. Warn patient
that excessive weight loss has led to the deaths of many young women who were unable to correct their
anorexia. Explain that proper body weight is essential for health and mental function, including learning
and performing well at school/career. You understand that the patient may be proud of her weight loss.
Being underweight may show a great deal of self control and will power, but being at ideal weight shows
more. Invite patient to develop a healthy body image by not equating soft or fatty body areas with
overweight. Emphasize that attractiveness and good health depend on a good balance of fatty tissues as
well as lean. Contract with the patient to gain a certain number of pounds per week. Discuss how she
will do this.
Contract for specific weight gain goals (2 lbs/week). Involve dietician. Halt diuretics, laxatives, diet
pills. Close monitoring of weight, vitals, heart rhythm, potassium. Arrange follow up with patient and
her family to discuss family dynamics, expression of conflict in the home.
95. 2 year old child with history of fever and 1 seizure. Counsel parents.
See also question #9.

65

Most likely diagnosis: benign febrile seizure (febrile seizures usually occur 6 months to 6 years,
associated with initial rapid rise in temperature, no neurologic abnormalities/evidence of CNS
infection/inflammation before or after, no history of non-febrile seizures, most commonly generalized
tonic-clonic, < 15 minutes duration, no recurrence in 24 hours, atypical may show focal origin/> 15
minutes/> 1/24 hours/transient neurologic defect).
Counsel parents regarding febrile seizure: A typical febrile seizure is a brief generalized tonic-clonic
seizure related to high fever (at least 39 degrees Celsius) and occurring between the ages of 3 months and
7 years. The post-ictal stage is characterized by improvement in confusion, lethargy, limpness. The
greatest risk factor for febrile seizures is a history of febrile seizures in the parents. This is the most
common seizure in children (3-5% of children, M > F). Occur between the ages of 6 months and 6 years.
Thought to be due to initial rapid rise in temperature. These seizures may come about as a result of fever
from any cause, including post immunization. In the absence of an abnormal developmental history (CP,
developmental delay), and an otherwise well child, they are usually benign. Seizures do not cause mental
impairment unless they are prolonged (> 30 min) but can be a symptom of brain damage.
Prognosis after a single febrile seizure: 65% will never have another seizure, 30% will have further
febrile seizures, 3% will go on to have seizures without fever, and 2% will develop lifelong epilepsy (risk
factors for this are: developmental and/or neurological abnormalities of child prior to seizures, family
history of non-febrile seizures and an atypical initial seizure).
Treatment of recurrence: control fever with antipyretics (Tylenol), tepid bath, fluids for comfort only
and use Ativan (lorazepam) 1 mg SL/PO (or diazepam 5-10 mg PR) if a seizure occurs at home. Turn
patient onto his/her side, do not force objects or fingers into mouth. Bring to ER if seizure does not stop
within 10 minutes. Seizures do not cause mental impairment unless they are prolonged (> 30 min),
although seizures can be a symptom of brain damage. Patient should be investigated with CT head and
EEG. Prophylactic anticonvulsant therapy is a consideration with repeated seizures.

96. Operating room nurse sustained needle stick injury.

Counsel.

Worried about hepatitis and AIDS.

History: Name, age, occupation. Determine severity of exposure: hollow bore needle? Needle gauge?
Depth of penetration? Did needle contain blood from a patient? Was any blood injected? Is the HIV and
hepatitis status of the patient known? Is the nurse immunized against Hep B?
Patient known
have:
HIV
Hep B
Antigen Hep B
Antibody Hep C

to Odds
Transmission
0.3%
40%
10%
5%

of

Counsel: HIV has a high mortality rate within 5 years of testing positive, and is eventually fatal in most
cases, however patients with HIV have a much longer life expectancy than in the past due to improved
66

anti-retroviral therapy. Hepatitis B causes fulminant hepatic necrosis in 1% of those infected, which is
fatal in 60% of cases. 5% of those infected with Hep B remain in a chronic carrier state, which is
associated with a 25-40% risk of cirrhosis and 2-5% per year risk of hepatocellular cancer. There is a >
50% risk of chronic liver disease once infected with Hep C; the risks of cirrhosis and hepatocellular
cancer are similar to those for Hep B. The overall risk of transmission is as described above.
Recommend baseline testing for HIV, Hep B, and C in nurse and patient (require consent for HIV testing).
If the patient was recently infected, he/she may not become positive on antigenic testing for up to 3
months. Therefore nurse and patient should be retested. Recommend HIV prophylaxis (AZT + 3TC x 4
weeks and consult Infectious Disease specialist) for significant needle stick from a patient with known
HIV or who is at high risk (multiple partners, IV drug use, anal intercourse, recent immigrant from
endemic area). If the nurse is not effectively immunized (i.e. antibody titers tested) against Hepatitis B,
recommend immunization. If patient is found to be Hep B or C positive, give the nurse passive immunity
gamma globulin, Hep B gamma globulin (HBIG) within 7 days of exposure, has been proven to be
effective in preventing transmission.
97. Demonstrate and counsel a patient on breast self-examination and mammography screening.
Breast exam: Sitting: Inspect in four separate positions: 1) sitting with arms at her side, 2) sitting with
both arms raised above her head, 3) sitting with hands pushing on hips and elbows out, 4) patient leaning
forward: inspect for size and symmetry, visible masses/contour changes, skin retraction, erythema,
dimpling, nipple retraction/inversion/ulceration/size & shape, peau dorange around nipple and elsewhere.
Palpation of axillary, infraclavicular, supraclavicular nodes. Supine (with pillow under shoulder), each
breast examined separately, drape other breast, small circular motions covering an area of approximately 1
square inch divide into light, medium and deep palpation and perform in all four quadrants. Can denote
position of lumps by clock position with cm distance from nipple. Nipple squeeze to try to exude any
fluid from the nipple (ask patient to squeeze nipple herself). Watch for dimpling, bloody nipple discharge
and inflammation.
Mammography: Yearly mammography screening of proven benefit from age 50. Benefit as a screening
test equivocal from age 40 in the general population but is recommended if there is a positive family
history of breast cancer. Breast cancer in two first degree relatives (parents, siblings, children) is an
indicator for yearly mammography starting at 5-10 years before youngest family members presentation.
98. 60 year old male, difficulty walking. Perform a neurological exam.
See neurological exam in question #5.
99. 37 year old well G1P0 female, 9 weeks pregnant. Manage.
History: Patient ID: Planned pregnancy? Status of any relationships at present including relationship
with the childs father. Social supports (family, friends, boyfriend), do they know? Are they helping?
Employment/financial/educational status of the patient, does the patient feel prepared to raise a child?
Provisions for care of child when born? GTPAL (number of gestations, term pregnancies, premature
births, abortions, live children), history of problems, if any, with previous pregnancies. Current
pregnancy, establish gestational age (GA) by last menstrual period (LMP) if regular periods and sure dates
(if unsure a dating ultrasound would be needed). The GA is the number of weeks from the first day of the
LMP. The EDC is first day of LMP + 7 days 3 months. Smoking (prepared to quit?), alcohol (no
alcohol during pregnancy), illicit drugs, diet, exercise, medications (avoid during pregnancy: including
over the counter). Diabetes, family history of inherited disorders, heart disease, circulatory problems,
67

renal disease, hypertension. Menstrual history, regularity of cycles, how long has patient not used
contraception. Any morning sickness, vaginal bleeding? Past medical and surgical history, medications,
drugs/alcohol, smoking, allergies, family history, review of systems.
Psychiatric: Cover mnemonic for major depression. MSIGECAPS: mood (depressed), sleep (increased
or decreasedif decreased, often early morning awakening), interest (decreased), guilt/worthlessness,
energy (decreased or fatigued), concentration/difficulty making decisions, appetite and/or weight increase
or decrease, psychomotor activity (increased or decreased), suicidal ideation positive diagnosis of major
depression requires five of these over a 2 week period, one of the five must be loss of interest or
depressed mood. Symptoms do not meet criteria for mixed episode, significant social/occupational
impairment, exclude substance or GMC, not bereavement.
Physical: vitals, weight, height, palpation of neck and thyroid gland, fundoscopic exam, check lid lag,
reflexes, cardiopulmonary exam, breast exam, abdominal exam. Palpate uterus, measure symphysisumbilicus distance. Doppler for fetal heart (may not detect until 10 weeks). Vaginal bimanual and
speculum exam (cervix should be closed). Pap smear (if none in last 6 months, use speculum, not brush
in os), swab cervix for cultures (GC, chlamydia).
Investigations: CBC, lytes, INR/PTT, urea, creatinine, urinalysis, ECG. Blood group and type, Rh
antibodies, VDRL and HbsAg routine, rubella titer, HIV serology offered, serum folate, urine dip,
microscopy and culture, TB skin test in patients from an endemic area, genetic testing as indicated on
history or for sickle cell in blacks. Triple screen (MSS) MSAFP, hCG, uE3 Trisomy 18, Trisomy
21, NTD (at 16 weeks). Amniocentesis at 15-16 weeks for alpha-fetoprotein and acetyl cholinesterase.
Chorionic villus sampling (10-12 weeks) should be offered given the patients age. Fetal ultrasound.
Counseling: Discuss risk of Downs syndrome due to maternal age, value of fetal genetic testing.
Recommend daily pregnancy vitamin preparation, milk and healthy diet. Do not increase food intake
dramatically excessive weight gain not recommended, 2-3 lbs per month for a total of 25-30 lbs gain in
weight ideal. Do not diet during pregnancy. Continue normal activities and customary exercise. No
alcohol, no smoking, no medications of any kind unless discussed with MD. Control morning sickness
with small meals and bland foods. Lying on side decreases swelling and discomfort. Hemorrhoids,
backache, heartburn, increased vaginal discharge are common. Follow-up every 4 weeks until 32 weeks,
then increase to every 2 weeks. Call if any concerns or troubling symptoms, especially abdominal pain,
vaginal bleeding, persistent headache, illness or infection.
100. 60 year old female with bloody vaginal discharge. Take a history.
History: Name, age, occupation. Think about: blood dyscrasias, thyroid dysfunction, malignancy, PCOS,
endometriosis, PID, fibroids, unopposed estrogen, or polyps. Onset of bleeding, frequency, estimate
quantity (number of pads), color, consistency of discharge, associated pain, vaginal discomfort, cramping.
Previous episodes, history of fibroids, polyps, PID, PCOS. Post coital and rectal bleeding. Weight loss,
night sweats, fatigue. History of easy bruising/bleeding, inherited blood coagulation disorders. Age of
menarche, age of menopause, age of first sexual activity. Use of hormonal replacement therapy, which
preparation? History of fibroids, reproductive tract cancers, last Pap smear. Pregnancy history.
Medications, drugs/alcohol, smoking, past medical history, surgical history, family history, review of
systems.
101. 30 year old man with hematemesis and abdominal pain in the emergency department. BP
80/50, tachycardia. Manage.
68

Resuscitate as in question #6. Consult gastroenterology for immediate endoscopy.

102. Pregnant woman, 36 weeks gestation, has proteinuria and BP 150/85 (pre-gestational BP
110/65). Manage.
See question #46.
103. A mother is worried that her 1 year old looks pale. Take a history. Finding: breast fed for the
first 2 months, then 2% milk. Q: What is the most likely diagnosis? What investigations would you
order?
History: Name, age. Feeds and feeding history (esp. fruit juice, excess milk). Growth pattern: weight
loss? Diarrhea? (consistency, color, quantity and frequency), blood in stool, melena stools, concurrent
illness, vomiting, fever, anorexia, difficulty breathing, lassitude, dry mouth/eyes, low urine output, illness
affecting other children in the family or adults. Recent immunization, travel, antibiotics. Medications,
past medical history, allergies, birth history, pregnancy problems, maternal illness during pregnancy,
family history, review of systems.
Most likely diagnosis: Iron deficiency anemia (most common cause of childhood anemia). Typically in
bottle-fed infants (6-24 months) receiving large volumes of cows milk should add iron-fortified cereal
and iron rich foods starting at 6 months.
Investigations: CBC with peripheral smear, lytes, urea, creatinine, INR/PTT, serum ferritin, albumin.
104. Elderly man with creatinine 1000. Take a history. Q: Give a differential diagnosis. What
investigations would you order?
History: Patient ID. suprapubic pain, pain on urination, frequency, urgency, frank blood in the urine
(globular clots from bladder or string shaped clots from ureters), color of urine, difficulty initiating or
maintaining urinary stream, renal pain, groin pain. Provoking factors. Associated symptoms including
saddle anesthesia, loss of bowel control. History of recent UTI, STDs, TB exposure, pelvic irradiation,
bleeding diathesis, smoking. Fever, chills, nausea, fatigue.
Previous renal colic/diagnosed
nephrolithiasis? History of hypercalcemia, hypertension. Malignant symptoms: night sweats, weight
loss, fatigue. Medications, drugs (NSAIDs, anticoagulants)/alcohol, smoking, past medical history, past
surgical history, family history (polycystic kidney disease?), review of systems.
Differential diagnosis:
1. Pre-renal: Hypovolemia, poor cardiac output, renovascular disease, NSAID/ACEi use, liver failure.
2. Renal: Vascular malignant HTN, cholesterol emboli, HUS/TTP; Tubulo-interstial ATN
(ischemic/toxin endogenous/exogenous), AIN; Glomerular (< 5%). Causes: X-ray contrast,
myoglobinuria, acute glomerulonephritis, DIC, pyelonephritis, intrarenal precipitation in hypercalcemia,
myeloma.
3. Post-renal: Obstruction: upper (clot, tumor, stone, external compression), lower (BPH, clot, stone,
stricture, autonomic dysfunction).
Investigations: CBC, lytes, urea, creatinine, phosphate, ionized Ca++, magnesium, INR/PTT, AST, ALT,
ALP, GGT, prostate specific antigen, CK-MB, troponin, ABG. Urinalysis: microscopy, dip, culture and

69

sensitivity. Abdominal x-ray, abdominal pelvic ultrasound. Post-void catheterization. (Avoid IVP due to
dye).
105. 1 year old boy with 6 months diarrhea. Take a history. Q: Give a differential diagnosis.
See question #50.
106. 58 year old lady in hospital 4 days post-op hysterectomy for fibroids. Agitated, had tactile
hallucinations the previous night. Take a history. Finding: history of alcoholism. Q: What is the
most likely diagnosis?
History: onset of hallucinations, duration, description. Tactile hallucinations or bugs crawling on skin or
on ceiling suggest alcohol withdrawal. Associated fever, agitation, sweating, tremor, decreased level of
consciousness, seizure? Any problems with surgical recovery, wound healing, mobilization? Amount of
alcohol consumed at home. History of alcoholism, leg swelling, SOB, chest pain. Current state. Post-op
medications (morphine, Demerol) previous bad reactions to these or to antibiotics? Previous episode
like this one? Past medical history, medications, drug and alcohol use, smoking, allergy, family history,
review of systems.
Most likely diagnosis: alcohol withdrawal.
107. Young man with a swollen cervical lymph node. Perform a focused physical exam. Q: CXR
shows mediastinal widening with perihilar nodes. Describe. Give five features on history which
would be helpful for diagnosis.
Physical exam: vitals, jaundice, nutritional status, buccal mucosa, teeth, breath (hepatic fetor), parotid
hypertrophy, glossitis, inspect chest for telangectasia, gynecomastia, loss of axillary hair. Hands: palmar
erythema, clubbing, Dupuytrens contracture, wasting of hand intrinsics. Palpate for lymph nodes in the
neck, supra and infra-clavicular, axillae, groin. Examine the oral cavity and pharynx. Check for rashes.
Abdominal exam (supine): see question #29.
Differential diagnosis: lymphoma, leukemia, viral infection (mononucleosis, HIV, EBV), inflammatory
autoimmune disease (sarcoidosis, lupus), serum sickness (severe allergic reaction short of anaphylaxis),
TB, liver disease with portal hypertension.
Five features on history helpful for diagnosis: viral prodrome, family history of sarcoid, lymph nodes
painful, bone pain, pruritis, weight loss.
108. Female patient found to have a nodule on routine CXR. Perform a focused physical exam. Q:
Give a differential diagnosis. What investigations would you order?
Cardiopulmonary exam as in question #13 and #24. See also question #49.
Investigations: old CXR for comparison (if lesion is old and unchanging, interventions are less
aggressive, calcification is also associated with benign lesions such as old granulomas), CT chest with CT
guided needle biopsy, sputum for cytology and acid-fast staining (TB), TB skin test, bronchoscopy with
biopsy and washings if lesion seen, open biopsy or lobectomy.

70

Algorithm: solitary nodule previous CXR benign or unchanged (repeat in q3-6months for 2 years if
unchanged observe, if changed at any time continue), malignant or changed CT thorax: cancer (stage
and treat), calcification (observe), no diagnosis bronchoscopy or transthoracic needle aspiration still
no diagnosis (resect for diagnosis), inflammatory (treat cause), cancer (stage and treat).
109. 60 year old male slipped and fell 6 days ago. Comes to you because of hemoptysis. Perform a
focused physical exam. Finding: positive Homans sign. Q: What is the most likely diagnosis? Give
a plan form management.
Cardiopulmonary exam as in question #13, plus additional attention to calf size, tenderness, redness and
pleuritic chest pain.
Homans sign: pain in the calf on dorsiflexion of the foot indicates thrombophlebitis. Check that
trachea is midline. Is the patient on DVT prophylaxis or anti-coagulation?
Most likely diagnosis: pulmonary embolus.
Specific investigations for PE: CT chest (only shows clinically significant PE), V/Q scan (conclusive
when is shows high or low probability), pulmonary angiogram (gold standard but invasive), ECHO, and
serial (q2d) leg Dopplers for presence of DVT above the knee. Others: CXR (often normal, Hamptons
hump, Westermarks sign, rarely dilatation of proximal PA), ECG (sinus tachycardia, S 1Q3T3), ABG
(PaO2 usually decreased, PaCO2 decreased due to increase in overall minute ventilation, increased A-a
gradient), D-dimer. See also question #17.
Treatment: if suspicion of PE is high, anticoagulate before waiting for these tests with heparin 7500 U IV
bolus (80 U/kg), then infuse at 1200 U/hr (18 U/kg/h). Measure PTT q6h, adjust dose for PTT 70-90s
(2.5-3 times normal baseline). Start coumadin, to INR 2-3, continue coumadin for 3 months.
110. Telephone in room. Mother calls because her child has just ingested a caustic cleaner. Manage
over the phone. Q: What do you do after hanging up the telephone? Give a plan for management.
See question #52.
111. Telephone in the room. Physician in a peripheral center calls wishing to transfer an unstable
patient who has been in a motor vehicle accident. Manage over the phone. Q: CXR shows
opacification of the right lung. What is your diagnosis? Give the immediate management of this
problem.
Over the telephone: Physicians name, name of center, patients name. Injuries, investigations done,
vitals, lab values. GCS, is patient intubated? Peripheral physician must not transfer patient until he is
stabilized, i.e. good BP, good oxygen sats, bleeding controlled, blood products given as needed.
Estimated time of arrival? Physician accompanied?
CXR: likely hemothorax.
Treatment: Chest tube in ER, drain hematoma and connect to suction through a bubble chamber. Consult
thoracic surgery, prepare patient in case of immediate OR.

71

112. Young woman with bilateral migratory arthritis of recent onset. Take a history. Q: Give a
differential diagnosis. What investigations would you order?
Note: Migratory arthritis suggests gonococcal infection.
History: Patient ID. Onset of arthritic symptoms, durations, joints affected, chronology. Associated
fever, malaise, fatigue, rash, abdominal pain and cramps, vaginal discharge, pain with urination,
dyspareunia (painful intercourse). History of arthritis (rheumatoid, osteoarthritis), psoriasis, Lyme disease
(camping trips), Reiters syndrome, ankylosing spondylitis, sexually transmitted diseases including PID.
Sexual history: present partners, number of partners, fidelity of partner(s), use of condoms. Medications,
drugs/alcohol, smoking, allergies, past medical history, family history, review of systems.
Differential diagnosis: gonococcal arthritis, psoriatic arthritis, Lyme disease, Reiters syndrome,
ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, gout.
Investigations: CBC, ESR, lytes, urea, creatinine, INR/PTT, blood cultures. Cervical swab for culture and
sensitivity. Joint aspirate for microscopy and culture.
1999
113. 48 year old woman with multiple complaints. Has had negative investigations by several other
doctors. Take a history and perform a mental status examination. Q: Without looking at the patient
again, describe her appearance. What is your diagnosis?
114. 32 year old mother presents to your office because her 4 year old son has had an allergic
reaction to peanuts. He was brought to the emergency departement and treated yesterday. He is
now well. Counsel.
115. 30 year old female with lower abdominal pain for 1 week. Perform a physical exam. Findings
include distended abdomen and tenderness at McBurneys. Q: The patient has a history of Crohns
and presents with the following abdominal x-ray (shows small bowel obstruction), what is the
diagnosis?
116. A 2 day old infant with jaundice and a serum bilirubin of 220 mol/L (ref. Max 200 mol/L).
Take a history from the mother. Q: What are the possible causes for this abnormality? Give
investigations and counsel.
See Question #25.
117. 35 year old male outpatient with shortness of breath, cough, sputum. Take a history and
perform a physical exam. X-ray findings: PCP. Q: Recommend further investigations and
treatment.
118. 66 year old male with symptoms of claudication. Do a focused physical exam. Q: What 2
investigations would be most appropriate. What 5 risk factors on history would point to the
diagnosis.
119. Mother wants to go on a camping trip with her son who suffers from enuresis. Counsel.

72

120. Young female with secondary amenorrhea for 6 months. Take a history. Q: What
investigations would you order. Give a differential diagnosis. What is the most likely diagnosis,
what results would confirm this diagnosis? Counsel with regards to OCP.
See question #86.
121. Telephone in the room. Nurse in a peripheral center calls wishing to transfer a patient who has
had a febrile seizure. Manage over the phone. Counsel to get patient ready for transfer.
122. 25 year old male has had a scaffold fall on him. He presents with chest pain and would like
something for the pain. Normal respiratory exam and normal cardiac exam. Manage.
123. 30 year old G1P0 with pre-eclampsia. Counsel.
See question #46.
124. 40 year old male just passing through wants Tylenol #3 to hold him until next week.
Manage.
See question #16.
2004 - October
125. 39 year old woman who would like to quit smoking. Counsel.
History: Name, age, occupation. Smoking habits: amount, duration, frequency, time of day. Gain from
smoking (e.g. weight loss, decreased anxiety, social relationships). Personal concerns about smoking and
quitting, foreseen benefits from quitting, interest in quitting (a person will only quit if they are willing).
Previous attempts and results, medical situation: SOB, cough, asthma, COPD, HTN. Social situation:
other smokers in family/social network. Nicotine dependence: preoccupation or compulsion to use,
impairment or loss of control over use, continued use despite negative consequences, minimization or
denial of problems associated with use. Past medical history, allergies, medications, alcohol/drug use,
family history, review of systems.
Counseling: 2 important components that need to be addressed: 1) physical/chemical addiction:
symptoms of withdrawal (tremors/irritability) and 2) habitual/environmental factors: psychological,
social, and spiritual components. Advise patient of health risks: Smoking is the single most preventable
cause of death responsible for 80% of lung cancers, COPD, cardiovascular disease, also a factor in PUD,
low birth weight babies, premature aging, upper GI/respiratory cancers, respiratory infections, SIDS.
Ages 25-34 have highest prevalence of smoking, 15% of smokers smoke > 25 cigarettes/day. After
assessing smoking habits advise every smoker to quit at every visit assess stage of change (see table
below). Motivate smoker to attempt to quit: benefits include decreased respiratory infections, increased
exercise tolerance/energy, increased taste/smell, ask for a commitment to quit (set a date), assist the
smoker to quit (physician counseling).
Begin with self-help materials: remove ashtrays/lighters, increase high fiber snacks/gum, increase aerobic
exercise, self-reward, may also use nicotine patch/gum or attend smoking withdrawal programs. Reward
goals that are met: plan for new social relationships and activities to make it easier to make a serious
attempt to change behavior. Follow-up: set firm dates. Anticipate problems: weight gain, withdrawal
73

symptoms. Continue to monitor/support. Do not give up if failed. Most relapses occur in first year; most
people try > 5 times before quitting.
Stages of Change Model
Barriers
Motivational drift
Low social support

Maintenance

Processes
Reinforcement
management
Helping relationship
Reinforcement

Lack of perceived self- Action

efficacy

Attitudes and emotions

Lack of knowledge
Contemplation
Self evaluation

Denial/trivialization
Precontemplation Consciousness raising
Perceived invulnerability
Faulty conceptions
Treatment:
Nicotine patch continuous self-regulated amount of nicotine, decreases craving and/or withdrawal,
will not replace immediate effects of smoking, habit or pleasure. Indications: nicotine dependent, high
motivation to quit smoking. Contraindications: smoking while on patch, allergy, MI, CVA. Relative
contraindication: pregnancy. Duration of treatment: 4-12 weeks usually adequate.
Zyban (bupropion) approved in Canada in August 1998 acts on dopaminergic (reward) and
noradrenergic (withdrawal) pathways. Contraindications: seizure disorder, alcoholism, eating disorder,
recent MAOI use, current pregnancy; caution if using SSRI (reduction of seizure threshold). Dose varies
with amount the patient smokes. Patient continues to smoke for first week of treatment and then
completely stops (therapeutic levels reached in one week). Recommend abstinence from alcohol due to
risk of toxic levels with liver dysfunction. Side effects: headache, insomnia, dry mouth, weight gain.
126. 65 year old woman post hysterectomy having hallucinations at night for the last two nights.
Take a history. Q: Most likely diagnosis? If this woman wants to go home from hosptial and is
medically cleared is she competent to make that decision? Would you allow her to go home?
History: onset of hallucinations, duration, description. Associated fever, agitation, sweating, tremor,
decreased level of consciousness, seizure? Misperceptions and illusions, impaired attention span,
disorientation, impaired level of consciousness, delusional thinking, affective symptoms (mood sad).
Fluctuating course? Any problems with surgical recovery, wound healing, mobilization? Amount of
alcohol consumed at home. History of alcoholism, leg swelling, SOB, chest pain. Current state. Post-op
medications (morphine, Demerol) previous bad reactions to these or to antibiotics? Previous episode
like this one? Past medical history, medications, drug and alcohol use, smoking, allergy, family history,
review of systems.
Most likely diagnosis: delirium.
Differential Diagnosis: I WATCH DEATH: I = infectious (encephalitis, meningitis, UTI, pneumonia), W
withdrawal (alcohol, barbiturates, benzodiazepines), A acute metabolic disorder (lytes, hepatic/renal
failure), T trauma (head injury, postop), C CNS pathology (stroke, hemorrhage, tumor, seizure,
Parkinsons), H hypoxia (anemia, cardiac failure, pulmonary embolus), D deficiencies (vit. B12, folic
74

acid, thiamine), E endocrinopathies (thyroid, glucose, parathyroid, adrenal), A acute vascular (shock,
vasculitis, hypertensive encephalopathy), T - toxins, substance abuse, medication (alcohol, anesthetics,
anticholinergics, narcotics), H Heavy metals (arsenic, lead, mercury).
Investigations: CBC, lytes, calcium, phosphate, magnesium, glucose, ESR, liver/renal tests, urinalysis,
ECG. As indicated by history: TSH, CT head, toxicology screen, VRDL, LP, LE preparation, B12 and
folic acid levels, EEG.
Management: Treat underlying cause (GMC etc.). Stop all non-essential medications. Maintain
nutrition, hydration, electrolyte balance and monitor vitals. Psychosocial quiet/well lit environment,
room close to observation, family member for reassurance. Pharmacological haloperidol 2-5 mg IM,
lorazepam 1 mg SL, physical restraints if patient violent.
127. 30 year old man with abdominal pain in the emergency department. Findings: Diaphoretic. BP
80/50, tachycardia. Manage.
128. 32 year old mother presents to your office because her 4 year old son has had an allergic
reaction to peanuts. He was brought to the emergency departement and treated yesterday. He is
now well. Counsel.
129. 35 year old woman feels depressed. Findings: Recently lost her father. Take a focused history
including a mental status exam.
130. 35 year old male with back pain and stiffness. Take history and perform a focused physical
exam. Findings: 10 cm separation between lumbar spines while erect increases by less than 5 cm
when back is flexed forward (positive Wright-Schober test), lateral flexion impaired. Q: Give the
diagnosis and two associated conditions.
131. 79 year old female collapses in the mall. Patient is drowsy, unresponsive to verbal stimuli. She
is there with her grand-daughter. Findings: HR 40, BP 80/40, ECG complete heart block. Manage.
132. A young man sustains a head injury on falling from his bicycle. Patient has been
hemodynamically stabilized. Perform a focused neurological exam. Q: Lateral skull and lateral Cspine X-rays provided. Are they adequate? Are they normal? The patient has continuing
sanguinous discharge from his nose. What is the likely cause of this. Treatment?
133. 30 year old woman with vaginal bleeding at 30 weeks gestation. Take a history. Q: Give a
differential diagnosis. Order investigations.
134. 65 year old male outpatient with shortness of breath, cough, sputum. Take a history and
perform a physical exam. Findings: Lobar consolidation with yellow-green sputum. Q: Given a
diagnosis of pneumonia, recommend treatment.
135. Mother with 6 month old child with failure to thrive. Take a history. Q: Give a differential
diagnosis. Recommend treatment.
136. Abcess station. Perform an irrigation and drainage.
2004 - May
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137. 77 year old female admitted for resection of colon cancer which presented with painless
bleeding per rectum has decided to withdraw her consent for surgery. She has been seen by
psychiatry and deemed competent, you are covering for her family doctor, counsel.
138. 37 year old female 9 weeks pregnant is worried about genetic problems more frequent in
women becoming pregnant later in life and is asking about genetic testing. Counsel.
139. 30 year old male has had 1 week of worsening hip pain which has progressed to failure to
weight bear. Vitals: BP 130/80, P 85, T 39.5. Conduct a focused history and physical. Q: What is at
the top of your differential. What single investigation would help confirm your suspicion.
140. 45 year old female presents to your office with difficulty sleeping. Take a focused history. Q:
What is the likely diagnosis and what is the single most appropriate outpatient treatment.
141. Mother of 3 year old presents because her child seems to have delayed speech development
compared to an older brother. She is worried that her child may be retarded. Take a history and
counsel.
142. 56 year old male patient on Warfarin for atrial fibrillation presents to your office with 3 day
history of coughing up blood. Take a history and perform a focused physical examination. Q: This
patient is unhappy with his care and would like an original copy of his chart so he may go to
another physician. What do you do.
143. 25 year old male has fallen 40 feet (12 meters) off his parents roof while helping with repairs.
He presents with shortness of breath, tachypnea, and vitals as follows: BP 80/40 P 130 RR 20.
Manage.
144. 56 year old male presents to the ER with chest pain which seems to have resolved partially with
Nitro spray administered en route by EMS. He has a normal ECG (which may show some mild
changes in the inferior leads). Manage. Second ECG taken after another bout of chest pain shows
clear ST elevation in 3 consecutive inferior leads (II, III, aVF). Q: After receiving treatment but
before Cardiolgy has seen this patient he wants to discharge himself despite the risks of doing so.
What do you do?
145. Mother of 2 year old has brought her son back to see you when her sons cough has failed to
resolve after 4 weeks. He has received antibiotic treatment (Amoxicillin) and has been using a
cough suppressant without improvement. Findings: Cough is non productive but loose. History of
eczema-like rash in child and mother. Father smokes. Q: Single most appropriate diagnosis. What
information on history leads you to this conclusion.
146. 23 year old female with 24 hours of progressive abdominal pain. Do a focused physical exam.
Findings: Patient in fetal position. LLQ pain. Guarding, rebound. Q: Differential diagnosis. Long
term consequences of the most likely diagnosis.
147. 66 year old male with symptoms of claudication. Do a focused physical exam. Q: What 2
investigations would be most appropriate. What 5 risk factors on history would point to the
diagnosis.

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148. 21 year old male brought into the emergency department by a friend due to neck stiffness.
Take a focused history. Findings: Patient is on haldol. Q: What is the most likely cause of this
patients neck stiffness. Outline a management plan for this patient. The patient is treated and
discharged but 2 hours later his mother calls because he was out on the balcony trying to fly, what if
any are your professional responsibilities to this patient.
149. 33 year old male with elevated LFTs on routine blood work while applying for life insurance.
The patient is upset about these results and would like you to fix it. Labs: AST 110 ALT 170 ALP
100 Bili 26. Findings: patient is consuming approximately 20 alcoholic beverages per week. Father
died at 56 years old of cirrhosis. Q: Differential diagnosis (top three). Given the above labs what are
the top three likley causes of these elevated enzymes.
150. 71 year old female who has not had a family doctor for three years. Her daughter who is your
patient and has asked that you see her because her mother is worried about problems with her
memory and is worried about developing dementia. Findings: Previously got a shot once a month
and used to take thyroid pills but has not kept up with these since her family doctor moved. Q:
Most likely diagnosis. What are two likely causes of this diagnosis. What two tests would you order
to confirm your suspicions.
Other Cases:
151. 42 year old male post surgical receiving blood products, has a reaction. Manage.
History: Name, age, occupation. What is the reaction? Chills, fever, urticarial, rash, anaphylaxis, muscle
pain, back pain, N/V, chest pain, wheezing, dyspnea, tachypnea (ARDS), feeling of impending doom,
hemoglobinuria, renal failure DIC. When was the transfusion started and how long afterwards did the
reaction occur? Why is the patient receiving blood? Recent bleeding or surgery? Focused history of
current medical problems and treatments. How much has been received and was the blood checked. Stop
transfusion and re-check blood type in bag for obvious clerical errors (most common cause of transfusion
reactions is still clerical error).
There are multiple types of reactions and treatment varies according to the type of reaction. You must
determine the type of reaction by the time course and symptoms:

77

Acute complications of blood transfusions

Cause
Signs, symptoms
Febrile Non- Antibodies stimulated by Chills, fever
hemolytic
previous exposure against
transfusion
antigens
on
donor
reactions
lymphocytes, granulocytes,
platelets or to lymphokines
Allergic
Interaction between donor Itching, rash
(urticarial)
plasma proteins and recipient
reactions
IgE antibodies
Anaphylaxis
Acute
hemolytic
transfusion
reactions

Rare, usually IgA deficient

patients reacting against IgA
in donor plasma
Usually due to incorrect
patient/blood identification

hemolysis
due
to
complement activation

Citrate toxicity

Toxicity
secondary
hypocalcemia

Hyperkalemia

High levels of potassium in

stored
blood
due
to
hemolysis

Circulatory
overload

With prior CHF and in

elderly

Dilutional
coagulopathy

Seen
with
massive
transfusion, packed cells
contain no factor VIII or V or
platelets
Never give blood > 4 hours Chills, rigors, fever,
after a bag has been entered! hypotension,
shock,
DIC
(profound
symptoms with gram
negatives)

Bacterial
infections

to

Management
Stop transfusion
Acetaminophen
Steroids
Filtered blood
Washed blood
Antihistamines
Slow infusion
Steroids
Washed blood
Bronchospasm
IV epinephrine
Shock
IgA deficient blood
components in future
Muscle pain, back pain, Stop infusion
chest pain
Hydrate aggressively
Fever, N/V, wheezing
Dyspnea, tachypnea
Feeling of impending
doom
Hemoglobinemia, renal
failure
Hypocalcemia signs
Prevented by giving 10
mL of 10% calcium
gluconate for every 2
units of blood
Hyperkalemia signs
Kayexalate
Calcium gluconate
Insulin + glucose
Salbutamol
Signs of CHF
Minimize amount of
saline given with the
blood
Coagulopathy
Correct with FFP and
platelets
Broad spectrum Abx
Blood culture and
sensitivity
Resuscitation for shock

Delayed complications from transfusions include (days to weeks):

1. Viral infection: HIV < 1:500,000; HBV < 1:250,000; HCV: < 1:10,000.
2. Delayed hemolytic transfusion reaction 5-10 days weak alloantibodies anemia, fever,
history of recent transfusion, jaundice, positive direct Coombs test.

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3. Iron overload repeated transfusions over long periods of time secondary hemochromatosis
(dilated cardiomyopathy, cirrhosis, DM, hypothyroidism, delayed growth and puberty) use of
iron chelators after transfusion can reduce chance of overload.
4. Graft versus host disease transfused T-lymphocytes attack host 4-30 days later usually in
immunocompromised fever, diarrhea, liver function abnormalities, pancytopenia 90%
mortality prevention with gamma irradiation of blood components

79