Examination Medicine: A Guide to Physician Training (70 page)

Discussion

First examiner

1. 
History of childhood infections and asthma: Was this typical of hypogammaglobulinaemia? Did she have time off school? Admissions to hospital? Inability to play sport, etc?

2. 
Dyspnoea – current causes: Obesity? Asthma? PE or something else? How to investigate?

3. 
Back pain – has this been nocturnal? Is its current treatment satisfactory? This is her main worry.

4. 
Obesity – is she serious about weight loss? What is her attitude to illness? Is there some secondary gain?

5. 
Asthma – she has pets at home that she is said to be allergic to. How severe is it? Is current Rx satisfactory?

6. 
Immobility – what might be done?

Second examiner

1. 
What risks would further surgery involve? How would you advise her anaesthetist?

2. 
Hypertension – is it well controlled? Is there a need to investigate and consider renal artery angioplasty? Discuss use of beta blocker.

COMMENTS

1. 
Problem of a patient enthusiastic about her illnesses.

2. 
Sometimes difficult to get to the point during history-taking, but of course a problem for examiners as well.

3. 
Any illness that begins in childhood requires questions about its effect on education – time off school, playing of sport, socialising with other children and effect on final level of education.

4. 
Discussion about treatment of problems that seem severe, e.g. immobility, but do not really seem to worry the patient.

5. 
Some more straightforward medical problems, e.g. hypertension, possible renal artery stenosis, use of beta blockers for an asthmatic.

This case has an interesting mix of significant medical, but also of social and perhaps psychiatric problems. A good candidate needs a sensible and realistic approach to these probably insoluble aspects of the case.

CASE 5

Mrs CE is a 73-year-old outpatient with chronic renal failure and on haemodialysis.

The aetiology of her chronic kidney disease was analgesic nephropathy; she used Vincent’s Powders at the rate of 36 a day for 25 years and stopped 30 years ago.

She has now been dialysing for 2 years. She has 5 hours 3 times a week. Her right arm fistula works well. She has had recurrent renal ‘stones’.

She doesn’t know her dry weight and is unsure about fluid, salt or dietary restrictions. She remembers having had some parathyroid problems while on tablets in 2009. Her calcium levels were too low and the tablets were stopped.

In 2007 her renal failure was precipitated after an episode of pancreatitis requiring ICU admission. She remembers severe abdominal pain, but little else of this illness. The pancreatitis has meant she is not suitable for peritoneal dialysis.

She passes no urine.

In 2004 she swallowed a fish bone and developed peritonitis and required emergency surgery.

In the past she drank 6–8 whiskies a day (more when friends visited) for 10 years. She is now a non-drinker.

She thinks her liver is normal now. There have been no problems with it or with exocrine pancreatic function.

Hypertension was diagnosed after this illness and is being treated with metoprolol 50 mg daily.

There is some exertional dyspnoea but no orthopnoea. Her back limits her more than shortness of breath. This has been present since she was assaulted by her first husband over many years.

She needs a knee replacement. She has had both her hips and the left knee replaced. Three lots of back surgery have been performed following her injuries. A new left knee replacement has been recommended after she fell on her knee a few months ago.

She has no history of ischaemic heart disease. She does not know if her cholesterol level is elevated. She smoked for 20 years until 10 years ago.

There is a history of gout many years ago.

Her medications include:

• 
analgesics for her back (she is not sure what these are at the moment)

• 
arensep monthly (doesn’t know current haemoglobin)

First marriage at 16. Very difficult life with first husband.

She cannot drive. Her husband brings her to dialysis 40 mins from home and does all the housework, shopping and cooking. He is very different from her first husband whom she divorced 29 years ago. She remarried 5 years ago. She has two children, one of whom lives locally.

Gall stones have been found and an ERCP recommended. Gall stones were not found at the time of her pancreatitis.

She is very happy in her second marriage. Her main concern about her health is her immobility and constant back pain.

Examination

1. 
BMI 24.

2. 
Working fistula.

2. 
Blood pressure 120/80 mmHg, pulse 70/min. 1/6 systolic ejection murmur.

4. 
Scars over cervical and lumbar spine.

5. 
Abdominal examination normal.

6. 
Peripheral pulses normal.

7. 
Reflexes normal.

8. 
Power limited by knee pain.

Discussion

First examiner

1. 
Discussion about details of illness that led to dialysis and analgesic nephropathy (now rare).

2. 
Dialysis problems: diet, calcium levels, drugs, cardiovascular protection.

3. 
Patient’s understanding of her illness.

4. 
Back pain management (one of her main concerns).

5. 
Is she a candidate for a transplant? Screening for transitional cell carcinoma.

Second examiner

6. 
Fitness for knee surgery.

7. 
Significance of murmur.

COMMENTS

1. 
This case involves the usual discussion about CKD and dialysis: cause of renal failure, choice of type of dialysis, patient’s understanding of illness – dry weight, diet, haemoglobin, etc.

2. 
Analgesic nephropathy is now a rare cause of CKD, but candidates need to know something about it – including risk of transitional cell carcinoma.

3. 
This woman had a very difficult life for many years with her first husband and now copes with her chronic illness cheerfully – some details about her domestic problems and their effect on her current state of mind are important.

4. 
Common further questions would involve asking about your management of her back pain and discussion of her suitability for knee surgery and transplant. These may not have clear-cut answers, but a sensible approach would be expected.

CASE 6

Mr AH is a 76-year-old retired stockbroker. He is an outpatient.

Problem list provided to the examiners

1. 
Type 2 diabetes.

2. 
Asthma.

3. 
Hypertension.

4. 
Muscle cramps secondary to statin use.

5. 
Carcinoma of the prostate.

6. 
Carcinoma of the colon.

7. 
Social aspects.

8. 
Knee replacements.

Mr AH was due to have CT scans of his chest abdomen and pelvis as follow-up of his two malignancies and felt anxious about the results of these tests.

Carcinoma of the prostate was diagnosed in 2006 after a screening PSA test. Radical prostatectomy and external radiotherapy was the management.

He had a period of urinary incontinence, which has now resolved.

There was minor radiation proctitis.

Carcinoma of the colon was diagnosed in 2009 after a positive screening faecal occult blood test – anterior resection but no colostomy.

Several adjacent lymph nodes were involved.

His postoperative course was complicated by a period of bowel obstruction and he required parenteral feeding for 10 days.

He had a course of chemotherapy including, he thought, 5 FU and a platinum-based drug. The main complications were nausea and painless peripheral neuropathy. The neuropathy has improved slightly if anything.

Follow-up colonoscopies and CT scans have been normal so far.

There have been no bowel symptoms apart from some intestinal hurry.

Type 2 diabetes was diagnosed in 2006. It has only ever been treated with diet. He has lost no weight since the diagnosis and is currently 100 kg (BMI 30). HbA1C recently was 6.1. He has had no identified complications of diabetes. He checks his BSL every few days.

He has had a recent episode of cough wheeze and fever.

He reports recurrent childhood asthma, but no problems with missing school and no admissions to hospital.

His chest symptoms occur almost every winter and are debilitating; he produces large volumes of discoloured sputum.

He has been given five courses of antibiotics this year.

He thinks one set of sputum cultures has been performed, but doesn’t know the result.

There have been no chest investigations for years.

Last year he had a nasal polyp removed.

Has frequent problems with a blocked nose and symptoms of sinusitis which usually precede his chest symptoms; sometimes he uses intranasal steroids.

He has often treated with a course of prednisone for 10 days by his local doctor for these illnesses.

He uses regular seretide 2 puffs mane and salbutamol as required.

He has been treated for hypertension for 6 years with candesartan/hydrochlorothiazide.

He has been told he has a heart murmur which needs review in a few years.

He associated the use of two different statins with muscle pains in the legs and has stopped them; he is unsure of his untreated cholesterol level.

He is moderately active; plays golf using a cart and walks 3 km 5 days a week. He is mostly limited by joint problems – two previous knee replacements and chronic back pain and two previous laminectomies, but also by dyspnoea and wheeze.

His wife, who is affected by dementia, has been admitted in the last few weeks to a nursing home which is half an hour’s drive away. He drives to visit her 6 days a week. He lives with his 48-year-old son who works but is mildly mentally retarded. He has three other children whom he sees often.

He smoked until 25 years and has a 25-packet-year history of smoking. He drinks 4 or 5 glasses of wine a day.

When asked what troubled him most he described his worry about his forthcoming screening tests and the limitations caused by his frequent respiratory symptoms.

Examination

1. 
Obesity.

2. 
Abdominal and back and knee scars.

3. 
BP 135/70 mmHg pulse 75/minute and regular.

4. 
There were occasional expiratory wheezes, his cough was dry.

5. 
He had signs of mild aortic regurgitation and stenosis.

6. 
Peripheral neuropathy in stocking distribution – hands unaffected. Reflexes absent distally and proprioception and vibration sense reduced.

Discussion

First examiner

1. 
Diagnosis of respiratory symptoms: asthma vs COPD. Possibility of bronchiectasis. What investigations are indicated, e.g. CXR, HRCT of the chest, sputum culture (possibility of unusual organisms, e.g. atypical mycobacteria, pseudomonas)? Investigation of sinusitis because this seemed to precipitate attacks. IgE for bronchopulmonary aspergillosis. Lifelong problem of recurrent infections – consider immunodeficiency and investigate. Consider aspirin sensitivity, however, he takes regular aspirin without difficulty.

2. 
Management of respiratory problems: once daily seretide – is this appropriate? Is intermittent steroid treatment appropriate? Management of sinusitis, e.g. regular inhaled nasal steroids. Should he have antibiotics or steroids at home for use at onset of symptoms? Would postural drainage, a flutter valve or physiotherapy be helpful for his productive cough?

3. 
Is candidate happy with the current management of follow-up of the two malignancies? What to do if PSA up again? Is it worth checking the CEA?