Professional Documents
Culture Documents
Case 1 - For Candidate
Case 1 - For Candidate
UNSW Medical S
UNSW Medical S
Position/Exposure
Make sure that any jewellery or watches are removed.
Patient should be exposed beyond the elbows and forearms on a pillow.
Inspection
Look on the dorsal surface and then palmar surface for:
MCP positioning and alignment (knuckles)
Muscle wasting
o Easily seen at hypothenar and thenar eminences - can ask patient to turn hands
onto palmar side and extend fingers.
Swellings and deformities
Scars (e.g. carpal tunnel release on wrist)
Skin colour changes and nail abnormalities
Asymmetry testing:
Praying position - normal is ~90
Inverted pray position - normal is ~90
Look at the dorsum of the patients arms at the elbow
Fleshy nodules may be present in RA
Psoriatic lesions
Palpation and Movement
Wrist
Palpate bimanually
Flex and extend passively
Look for radial/ulnar deviation.
MCPs
Squeeze MCP joints from the side
Palpate each joint individually for tenderness etc
Assess passive movements of flexion and extension as you go
PIPs/DIPs
Palpate and move IP joints passively
Functional Assessment
Grip Strength - get patient to squeeze two of your fingers in each hand
Pincer Grip - thumb and index finger - try to force apart
Opposition Strength - thumb and little finger - try to force apart
Practical Test - undo a button/write with a pen
Viva Questions:
Can you tell me the normal range of movements of each hand and wrist joint?
o Wrists
Flexion/Extension - 75; Radial/Ulnar Deviation - 20
o MCPs
Flexion - 90; Extension - 30; Adduction/Abduction - 25
o PIPs - Flexion - 120; DIPs - Flexion - 90
Do you think Mrs. Felty's history is more consistent with rheumatoid arthritis or osteoarthritis? What clinical
features would you expect to find in the hands of someone with RA vs OA?
RA
OA
Soft, boggy swellings of the wrists, MCPs and
Hard, bony swelling of the PIPs, DIPs and 1st
PIPs, with sparing of DIPs
CMC
Boutonniere's and Swan Neck Deformity
Heberden's nodes (DIP)
Z deformity of the thumb
Bouchard's nodes (PIP)
MCP ulnar deviation and palmar subluxation
Osteophytes
UNSW Medical S
Psychosocial History
Smoking: nil
Alcohol: 1-2 glasses of wine 3 nights a
NOTE TO PATIENT: dont tell student about depression or
week and sometimes you have a bit
suicide attempt unless specifically asked about it.
more. If specifically asked what a bit
However please repeat how desperately you need this
more means, say 2 bottles of wine but
job.
thats only happened twice.
Been drinking since you started dating
Main Concern:
your girlfriend 4 years ago.
Youre out of money and your girlfriend is about to
Recreational Drugs: nil
leave you for a guy named Vu. You REALLY need
Occupation: Unemployed so you really
this job. Youve been depressed and have tried
need this job!
taking your life twice in the past by trying to drink
Home: Lives with girlfriend who is a plain
too much alcohol.
clothes model and looks down on you for
Keep emphasizing how desperately you need this
having no job
job.
Sexual History: nil - never had sex.
Presenting Complaint
Travel History: nil
You have no presenting complaint
Feels unsupported emotionally and
If asked Why have you come to see me?, explain
financially
that you need to get this checkout chick job at
Diet: normal
Coles, so you have to get a general check up done. Depression History (only say if specifically
If asked open question about whats wrong, just
asked)
say you feel fully healthy (e.g. Have you noticed
Only admit to feeling depressed, if
any changes to your health recently? Nope, I feel
specifically asked if youve been feeling
fine)
sad or depressed
Student should begin a systems review and start
For the last 4 years, youve been feeling
asking you associated symptoms. Deny all of them,
sad, feeling guilty, youve lost interest in
except trouble concentrating if specifically asked.
your hobbies and have trouble
Just say a little bit of trouble concentrating but
concentrating
youve had that for ages.
Suicide History (only say if specifically asked)
Past Medical History
You believe life isnt worth going on
Had the flu a week ago but you think youre all
with/world would be better off without
better now
you
No surgical history
Have thought about taking your own life
Only when specifically asked if youve been to
You would do it by drinking yourself to
hospital before, say you have twice for drinking a
death.
little bit too much.
You have access to a lot of wine at home
Medications and Allergies
Have tried taking your own life twice by
Nil prescription medications.
drinking yourself to death with alcohol
Taking multivitamins for general health.
and thats why youve been to hospital
Allergic to penicillin; causes generalized rash
twice
Family History
If asked how can they can help you, say:
Mum has Hypertension, Diabetes type 1 and
by passing you on this checkup
Hypercholesterolaemia.
UNSW Medical S
Neuro
o Headache or pain anywhere?
o Changes in vision or hearing?
o Changes in taste or smell?
o Weakness, numbness or clumsiness?
o Blackouts, fits, faints dizziness?
o Vomiting or drowsy or nausea?
o Memory or concentration?
o Bladder or bowel problems?
Cardiac
o Chest pain or discomfort?
o Pain in legs or anywhere else?
o Ever aware of your own heart
thumping?
o Cold sweats?
o Swelling in ankles?
o Trouble breathing?
Respiratory
o Trouble breathing?
o Wheeze or cough?
o Chest discomfort or any pain
elsewhere?
o Fever, chills, sore muscles or joints?
o Runny or blocked nose?
o Trouble speaking or swallowing?
Gastro
o Any weight loss or changes to eating
habits?
o Vomiting, fever, fatigue?
o Trouble swallowing or reflux?
o Pain or bloating?
o Changes to bowel habits?
o Changes to urinary habits?
o Discharges or itchiness from genitals?
Musculoskeletal
o Any swelling or pain?
o Any joint locking up or giving way
suddenly?
o Any trouble moving?
UNSW Medical S
Family History
Mum has Hypertension, Diabetes type 1 and
Hypercholesterolaemia.
Psychosocial History
Smoking: nil
Alcohol: 1-2 glasses of wine 3 nights a
UNSW Medical S
3. Name the muscles that form the Palatine Arches? What are they innervated by?
Answers
1. Occipital and post-auricular drain to superficial cervical then deep cervical. Everything else (i.e.
pre-auricular, submandibular and submental) drain directly into deep cervical. All the lymph
nodes eventually drain into the deep cervical lymph nodes.
These nodes then drain into the left and right jugular trunks. The right jugular trunk then joins
the thoracic duct. The thoracic duct then has the left subclavian trunk also join it; the left
bronchiomediastinal trunk sometimes also joins it.
The right jugular trunk then joins the right lymphatic duct. The right subclavian trunk also then
joins the right lymphatic duct; the right bronchiomediastinal may also join.
The right lymphatic duct and thoracic duct both empty in the junction of their respective
internal jugular vein and subclavian veins, forming the brachiocephalic vein. Left and right
brachiocephalic veins join to form the superior vena cava and empties into the right atrium.
UNSW Medical S
General Inspection
o Observe the:
Lips, buccal mucosa, gums, palate and teeth - note any signs of
inflammation such as erythema or swelling.
Inspect the tongue in mouth and then poked out and then touched to roof
of mouth (to inspect floor or tongue).
o Ask patient to say "Ahh" and inspect oropharynx and uvula.
Use a tongue depressor, if necessary, to obtain a better view of the pharynx.
It is important that the depressor does not cause the patient to gag.
o Inspect tonsils: size, shape, colour, discharge.
Palpation
o Full oral cavity examination should include palpation of the tongue for lumps
(wearing gloves) as well as palpation of the salivary glands and cervical lymph nodes.
The tonsils are part of the lymphatic system and should be examined when conducting
a systematic examination of the lymphatic system. The examination of the oral cavity
includes more than looking at the tonsils but the focus here is on examining the tonsils.
General Inspection
o Observe for:
Swelling
Asymmetry
Scars
o Ask about any tenderness present before proceeding with palpation.
UNSW Medical S
Post-auricular (mastoid)
on the mastoid insertion of the Sternocleidomastoid muscle and inferior to
the Auricularis posterior.
Post-auricular node
Occipital
Near the insertion of the trapezius to the skull
Resting on the insertion of the Semispinalis capitis (if you want to sound
like a precise pro)
Posterior Cervical triangle
Formed by clavicle, trapezius (ant.) and sternocleidomastoid (post.)
Palpate down to scalene node behind scalene insertion at clavicle.
Anterior Cervical triangle (deep & superficial Cervical Lymph nodes)
Formed by mandible, SCM (ant.) and the midline.
Palpation here is for both superficial and deep anterior cervical chain nodes
- deep nodes difficult to feel even when enlarged as they are deep to SCM,
closely located to and around the neurovascular bundles.
Supraclavicular fossae
Ask patient to shrug their shoulders and feel behind the clavicle.
UNSW Medical S
Presenting Complaint
Burning sensation when peeing - began 3
days ago.
Burning has become more and more painful
since then.
Since yesterday, you have also been
experiencing some pain "low down on my
bell" (suprapubic).
When prompted you have also been
experiencing:
o That you need to pull over in your
taxi while working to pee more
often (frequency).
o Been getting up a night more often
to pee, never used to.
o You don't get any warning, and just
suddenly feel like you need to go.
Awkward when you have a
customer in your taxi.
No fever, renal angle pain, or other urethral
discharge.
Travel History
Nil
Sexual history
Married and committed to monogamous
relationship. No engagement with sex
workers, IVDU etc. Confident that wife is
clean as a whistle too.
Don't use contraception or condoms - wife is
pregnant.
Family History
Brother with prostate cancer
Father died of IHD in his 50s
Mother died of ovarian cancer.
Your children and grandchildren are all alive
and well.
Psychosocial History
Live with wife in a small one-bedroom
apartment on third floor of a building.
Alcohol - 2 beers a day usually, sometimes a
few more on weekends (since 18 if pushed).
Smoked 5 cigarettes a day in youth (from 18
to 25 if pushed).
Nil recreational drugs.
Taxi driver - work 10 shifts a week, long
periods of time with no sleep and no break
(not even to go to the toilet, "simply gotta
tough it out").
No children, but wife is currently pregnant still in first trimester.
Main Concern
Your main concern is that your illness will
prevent you from working the long hours
you have been currently.
This concerns you because you are already
"on the ropes" financially and can't afford to
stop working.
UNSW Medical S
General Inspection
o Wasting (malignancy, alcoholic cirrhosis), pallor and jaundice (skin and scleral icterus HCC
damage or biliary obstruction causing hyperbilirubinaemia).
o Make an obvious attempt to look around the immediate environment for any salient
features (oxygen bottles, walkers etc).
o Other symptoms: leukonychia (hypoalbuminaemia), clubbing, palmar erythema, bruising,
scratch marks (pruritus), spider naevi, gynecomastia chronic liver disease.
o E.g. "On general inspection there does not appear to be any wasting, pallor..."
Inspection of Abdomen
o Look from above:
Localised Swelling (enlargement of abdominal or pelvic organ, hernia)
General Distension (fat, fluid (ascites), flatus (gaseous distension from bowel
obstruction), faeces, 'filthy' tumour)
Scars (laparascopic, nephrectomy, transplanted kidney or other).
Other: caput Medusae, striae.
o Look from abdominal level
Repeat from abdominal level and ask patient to take slow deep breaths through
their mouth and watch for asymmetrical movement indicating presence of a mass.
o E.g. "On closer inspection of the abdomen there does not appear to be..."
Begin in right lower quadrant/iliac fossa with hand parallel to right costal margin and
lateral to lateral margin of rectus abdominis.
Ask patient to breathe deeply and adjust hand during expiration to be ready during next
inspiration. (Not too much pressure or lifting movement from liver is missed).
Move up ~2cm if liver is not palpated and repeat until costal margin is reached.
If liver is palpated, move along edge to xiphisternum until no longer palpable.
UNSW Medical S
o
o
o
Percuss upper border beginning in 3rd IC space and percuss firmly down MCL.
Confirm sound change with patient respiration.
Measure liver span in MCL
A normal liver span is 8-12cm (>13cm is abnormal)
Left hand posterolaterally over left lower ribs and right hand beginning in below umbilicus
TO
in midline and orientated obliquely towards axilla.
Ask patient to breathe deeply and adjust hand during expiration to be ready during next
inspiration. Hand moves upwards and laterally towards left hand.
If spleen not palpated, patient rolls onto their right (towards examiner) and place left arm
across upper chest if required - palpate again under costal margin.
Spleen usually needs to be enlarged 1.5-2 times normal size to be palpated.
Percussion
Percussion for lower spleen pole in Traub's space (9th ICS anterior to anterior axillary line)
this should be resonant normally.
Palpation of Kidneys
o With patient still rolled over, place right hand in left renal angle (made by 12th rib and
lateral margin of vertebral column).
o Return patient to supine so they are resting on your right hand
o Left hand placed anteriorly lining up with right hand (below costal margin and lateral to
rectus abdominis).
o As patient inspires deeply, flex at MCP of posterior hand and push in with top hand.
o Repeat on other side with hands swapped.
General Percussion
o Performed to determine whether abdominal distension is due to gas or fluid (ascites). Ensure
the patient is lying flat.
o Percuss for flank dullness starting from midline and moving laterally to the left flank. Fingers
should be parallel to rectus abdominis.
o Dullness should not be detected until lateral abdominal wall.
o If detected before lateral abdominal wall test for shifting dullness.
Note where dullness was detected early and roll patient onto right side.
Wait 30 seconds
Percuss at original point of dullness which should be resonant to confirm shifting
dullness.
Percuss further laterally to confirm shifting dullness and percuss medially to
determine extent of shifting dullness.
UNSW Medical S
The absence of flank dullness is reliable sign for excluding ascites and hence not necessary to test for shifting
dullness if there is no flank dullness. In contrast, flank dullness alone is not reliable enough to conclude ascites
and therefore must test of shifting dullness.
Auscultation
o Warm the diaphragm of the stethoscope before auscultating.
o Listen for bowel sounds:
Due to peristalsis and can be heard anywhere in abdomen.
Place stethoscope diaphragm below umbilicus and listen for at least 30 seconds
before concluding that bowel sounds are absent.
Report as absent or present.
o Listen for arterial (aortic) bruits:
Stethoscope diaphragm in midline 1cm above umbilicus to listen to AA.
o Listen for renal bruits:
2.5cm lateral to site listened to for aortic bruit on either side.
Viva Questions
Given this man's history are there any other aspects of examination you would like
to perform?
o Urinalysis (then ask: what results will you be looking for? Leukocytes, nitrates,
red blood cells, etc.)
o Midstream urine (then what?) then send to lab for culture, staining and
microscopy
Can you describe the surface anatomy markings of the liver?
o Liver upper border - horizontal line across 5th ribs
o Liver lower border - oblique line from lowest point of right costal margin
across to the left 5th rib in the midclavicular line.
What is the normal liver span?
o 8-12 cm in the MCL (>13 is considered hepatomegaly)
Where do the kidneys normally lie?
o Located retroperionteally
o Lie in renal angle made from 12th rib and lateral margin of vertebral column
o Kidneys extend from T12 to L2 with the right kidney slightly lower than the
left kidney.