31st May 2008 Melbourne retest 1. 2. 3. 4. 5. 6. 7. 8.

Diabetes foot examination Neck gland SCC Premature rupture of membrane Postpartum psychosis Head banging Ca prostate Syncope Spontaeneous pneumothorax

1. Your next patient is a middle aged woman, Mrs. Baker, who has suffered from mature onset diabetes mellitus for 10 years which has been poorly controlled, recent HbA1c was 11, and it was decided to start her on insulin. Your task is: to examine her lower limbs and to discuss your findings with the examiner. What implements do you require for this examination: Cotton wool balls Neurology pin or microfilament Tuning fork (128 Hz, not 256 Hz which you use for hearing tests! Reflex hammer EXAMINATION: (LOOK, LISTEN, FEEL !!!!): Inspection: SKIN: hairless and atrophic because of small vessel disease and ischaemia. Ulcers: on toes or pressure areas! (combination of macro and micro vascular disease and peripheral neuropathy) Infection: superficial infections are common, e.g. boils, cellulitis and fungal infections (tinea pedis) (due to ischaemia and high tissue glucose providing ideal environment for bacterial growth). Pigmented scars / diabetic dermopathy, small rounded plaques with raised borders lying in a linear fashion over the shins. Necrobiosis lipoidica diabeticorum: rare, striking localized skin atrophy with lipid deposits over shins. Starting as flat red or yellow plaques which later ulcerate. Very hard to treat. Gangrene: advanced macro vascular problems (pulseless foot) or peripheral neuropathy problem (painless foot). It can also be due to micro vascular changes where pulses are still palpable! The tissue becomes necrotic with black skin either dry or moist! Injection sites: usually on thighs Charcots joint: due to loss of sensation (proprioception) the knee joint is exposed to frequent injuries which the patient does not even notice, leading to joint deformity.

Palpation: Injection sites: possibly atrophy or hypertrophy in the area of the thigh if patients have injected for years. Pulses! Temperature Capillary return Neurological Examination: Peripheral neuropathy: distal, symmetric loss of sensation (stocking paraesthesia) with numbness and tingling and reduced sensation of light touch, pain and vibration. Position sense reduced. Abnormal two point discrimination. Mononeuropathy: acute mononeuropathy most commonly affects the femoral or sciatic nerve following an occlusion of vessels supplying the nerve. Reflexes: reduced deep reflexes Diabetes foot examination

2.
Middle age man had lymph nod on side of neck, biopsy showed squamous cell epithelial carcinoma. He was smoker for 20 years. Examine the patient and tell the examiner what youre looking for. I had no idea about this case, all what I thought about is metastasis from skin (face) but you should think of buccal mucosa, tongue, adenoids, larynx, pharynx, oesophagus, lungs, (all respiratory system). And check other lymph nod as well. Horners syndrome : ptosis, miosis, anhydrosis Causes : Lateral medullary syndrome : nystagmus, 5th, 9th and 10th Cr n, pain and T`, Carotid aneurysm or bruit, Respiratory exam Ca of the apex of the lung : clubbing, neck L/N, weakness of finger abduct, Neck gland SCC 3.

A lady who is 35 (or 32) weeks pregnant came to hospital (probably countryside) and is c/o PROM few hours ago. She has an Hx of cervical cone biopsy for an abnormal Pap smear and the cervix was sutured. Task: Hx, exam, Mx Hx: Mrs. X, I know that youve passed water a few hours ago. Id like ask some Qs. How did it happen? When did it happen exactly? What is the color of the water? How many pads did you use? Are they flooded or not? Do you have any pain or contractions? Have you had any vaginal secretions before? Do you have any fever? What about your waterworks? Any frequency, urgency, burning sensation?

Do you still feel that the baby is kicking? Is this your first pregnancy? Do you have any dizziness, vomiting, flushing, or palpitations? What about previous antenatal check ups? 18 weeks U/S? Is it a single baby? Are there any detected problems such as DM, HBP, infections since youve become pregnant? When was the last Pap smear? What was the result of cone biopsy? How far do you live from the hospital? Who is supporting you in case of an emergency? Do you have any relatives living close to hospital? Are you on any medication? Smoking? Alcohol? Recreational drugs? Exam: GA, vital signs, chest, CVS, any abd tenderness, fundal height, presenting part, fetal heart rate, dont do digital vaginal exam. Speculum; pouring of fluid from post. vag. fornix. Id like to arrange nitrazine test to confirm PROM also fetal fibronectine and high vaginal swab. Cervix is favorable or not? Ferm test???????? Ix: FBE, urine MS, U/S (oligohydramnios, placental position, viability of the baby), blood group and hold, GBS swabs. Mrs. X, Id like to refer you to hospital for an admission. You need to be observed for any signs of fetal or maternal infection till delivery. If it is 32 weeks of gestation, aim to delay delivery because the baby needs steroids. If it is 35 weeks and more, take weekly high vaginal swabs, FBE, CTG should be considered. Start antibiotics like erythromycin 250 mg orally every 6 hours for 10 days. Give 2 corticosteroid injection by12 hours apart to reduce the risk of respiratory distress syndrome. If there are contractions, tocolytics can be given. Cervical suture will be removed only before delivery. If there is no sign of infection and the labor after 2-3 days, patient can ambulate or she can stay close to hospital. The obstetrician will decide this. Beware of the signs of infection (high fever, secretion). Abstain from sexual intercourse, try to have rest, if there is any fever or vaginal discharge, you should come straight away. Mrs. X, in most cases (80%) after PROM, the baby is delivered in 7-10 days. In 20 % of cases, the patient will not go to labor.

The main problem is high risk of infection and possibility of C/S is higher Prematur rupture of membrane 4.
A man comes to you (emergency department doctor) saying that his wife who recently gave birth has started to act strange..accuses baby of being evil (child of satan)..wants your help.. Post partum psychosis 5.

2 years old child fell, become unconscious for few seconds. Father is worry. Task : History Talk to the father and answer his Qs. In history, growth and development are normal. Immunization up to date. First time happened, before the event he injured his finger in car door. His niece has epilepsy. Typical case about breath holding attack. Q? prognosis : good, should grow out of it be age 5-6. Q? Is it epilepsy : no, doesnt look like. If it happened more than twice per week bring him back to me, Ill check his FBE to exclude anaemia. If he become very drowsy after attack, sleep long time after it, wet himself, convulsion more than 5 min or unusual behaviour, come back to me or go to hospital.
Head banging

6. Ca prostate in 80 years old man 7. Syncope AMC case 36, Q147 A173

8. Spontaeneous pneumothorax AMC case 62 Q317 A334