Examination Medicine: A Guide to Physician Training (69 page)

In 2007 he had left and then right hip replacements. He thinks the left was because of avascular necrosis and the right was because of osteoarthritis. He is not aware of having had any bone density assessments.

His recent admission was with dyspnoea and productive cough – antibiotics and steroids were used to treat this, but have now been stopped.

COPD was diagnosed but his spirometry measurements were not abnormal as far as he knows. He smoked until 5 years ago – 25 packet years altogether.

His cough is still productive. He can walk 200 m on the flat, he plays golf with a cart.

He is being treated with symbicort II bd and salbutamol 2 puffs prn.

Obstructive sleep apnoea (OSA) was diagnosed in 2007. He snores and has mild day-time sleepiness but never when driving. His sleep study was positive. He has been unable to tolerate a mask.

He has been overweight for many years and is currently 140 kg for 2 m of height. He has been unable to lose weight despite insight into his problem.

He has a long history of hypertension, which has been difficult to control since he developed kidney disease. His current treatment for this includes: diltiazem 180 daily, candesartan 16 daily, prazosin 5mg bd and hydralazine 50/mg bd.

He had angioedema with an ACEI and his ARB was initiated in hospital.

In 2010 he had symptomatic AF requiring two cardioversions. He takes amiodarone 200 bd for this and has had no symptomatic recurrences. He is anticoagulated with warfarin. His INR target is 2–3 and he is having weekly blood tests. His INR was 5.4 during admission when on antibiotics. He has had no bleeding problems.

He has peripheral oedema much worse with diltiazem 360 mg. He has never used support stockings, but takes frusemide 80 mg daily. An episode of cellulitis in the legs occurred 2 years ago and required treatment with IV antibiotics.

He still works and supports his family (sedentary job, good employer), but he is not sure for how much longer he will be able to continue. He feels his breathlessness is his worst problem.

Examination

The examination revealed:

1. 
Obesity.

2. 
BP 120/80 mmHg, Pulse 80 regular.

3. 
Not dyspnoeic at rest, loose cough.

4. 
Not clubbed.

5. 
Widespread polyphonic wheezes and coarse inspiratory crackles.

6. 
Reduced chest expansion.

7. 
Soft systolic ejection murmur, apex beat not palpable.

8. 
Peripheral oedema moderately severe and venous staining.

9. 
Transplant palpable in abdomen, left arm fistulae working.

Test results available to examiners:

1. 
CXR increased lung markings, thickened bronchial walls, overinflated chest.

2. 
ECG left bundle branch block, sinus rhythm.

3. 
Spirometry FEV1/VC 71% little reversibility.

4. 
Echo severe LV, dilated left atrium, systolic function preserved.

Discussion

First examiner

1. 
 

a. 
What does patient see as his main problem? Does COPD explain all the symptoms and signs?

b. 
What other possibilities, e.g. bronchiectasis, pneumocystis, bronchopulmonary aspergillosis?

c. 
How to investigate and manage?

2. 
 

a. 
Current renal function satisfactory or a problem?

b. 
What measures to investigate and treat? E.g. BP, chronic rejection, cyclosporin?

c. 
Surveillance of current anti-rejection Rx: full blood count, skin, blood levels, indications for kidney biopsy?

3. 
AF management, amiodarone toxicity and surveillance, warfarin management.

4. 
Peripheral oedema significance and management – calcium antagonists, venous problems, right heart failure – any signs of this?

Second examiner

1. 
Obstructive sleep apnoea management – what else to do?

2. 
Chronic illness, work, money, etc.

3. 
Obesity – what approach? (if time)

COMMENTS

A long case with a number of active problems.

1. 
Recent lung disease perhaps not explained by COPD.

2. 
Renal function possibly deteriorating despite patient’s claim of stable creatinine.

3. 
Opportunity to discuss management of surveillance of anti-rejection Rx.

4. 
Management of AF and warfarin and amiodarone.

5. 
Approach to peripheral oedema not always or even usually heart failure but possibility of right heart failure and pulmonary hypertension.

6. 
OSA and obesity.

The examiners would be keen for a differential diagnosis of his dyspnoea and lung disease. You would want to talk about transplant surveillance and management. There would be time for both.

CASE 3

Mr WP 64 is a wheat farmer who is currently in hospital 100 km away from his home and farm.

In 2008 he discovered a painless testicular mass. There were no sweats or fevers. He underwent a single orchidectomy. He was unable to remember a preceding biopsy. Lymphoma was diagnosed.

He was treated with 8 cycles of R-CHOP treatment delayed by drug side-effects (fever, oedema), but completed in 8 months and followed by maintenance rituximab.

In 2011 he relapsed. He developed back pain and left leg weakness. There were no bowel or bladder symptoms. He was admitted to hospital for 5 months and unable to walk. There was numbness of the left leg and a necrotic ulcer developed on the heel. There was little improvement in power while he was in hospital.

He then had an episode of diplopia and ptosis without associated headache.

An MRI of the brain was performed. He was unsure of the result. During the same admission he had an episode of chest pain and dyspnoea. A CTPA showed pulmonary embolism.

He was treated with intravenous and intrathecal methotrexate and anticoagulated with warfarin. An episode of pleuritic chest pain was diagnosed as pericarditis. He is not sure how this was treated.

He is currently awaiting autologous bone marrow transplant, having had stem cell harvesting.

He has lost 15 kg during this illness.

In the past he has had a CVA in 2007. This was treated with clopidogrel.

A transoesophageal echo showed a patent foramen ovale. He had a long history of hypertension and hyperlipidaemia. He was never a smoker.

His main worries about his health are about his prospects of recovery and return to his family and the farm, which is currently being managed with difficulty by his son.

Examination

1. 
Left foot drop with S1 and L5 loss of sensation.

2. 
Absent reflexes in the left leg.

3. 
Moderate weakness of knee extension and flexion mild weakness at hip.

4. 
Right leg normal power and reflexes.

5. 
Absent right testis.

6. 
Eye movements normal.

Investigations available to the examiners

1. 
Histology – Large B cell lymphoma.

2. 
MRI brain thickening of right 3rd nerve within the prepontine cistern.

3. 
MRI foot showed osteomyelitis.

4. 
CTPA showed a pulmonary embolus in the lateral segment of the right middle lobe.

5. 
MRI lumbar spine retroperitoneal lymphadenopathy on the left side of the pelvis and involvement from L4 to the sacral nerves extending to the cauda equina nerve roots.

Discussion

First examiner

1. 
Management of lymphoma and BM transplant:

a. 
a common transplant problem, immunosuppression surveillance

b. 
lymphoma staging – presentation with non-lymph node involvement, no B symptoms implications for prognosis

c. 
common side-effects of CHOP and rituximab

    
Appropriate tests (as above) and their interpretation.

2. 
Management of osteomyelitis.

3. 
Management of leg weakness – including rehabilitation.

4. 
Loss of independence and prognosis.

Second examiner

1. 
Anticoagulation – management of TIA and PFO, use of clopidogrel vs aspirin.

2. 
Ability to work, run farm, etc. How has he coped with 5 months in hospital, far from family?

COMMENTS

A complicated case involving:

1. 
Diagnosis of lymphoma – discussion about staging, etc.

2. 
Complications of treatment, first of drugs and then theoretically about complications of bone marrow transplant.

3. 
Disease recurrence with a variety of neurological problems and problems of immobility – necrotic ulcer, psychological.

4. 
Significant examination findings.

5. 
Need for anti-coagulation; opportunity to discuss warfarin management.

6. 
Investigation of possible cerebral ischaemic episode. Significance of PFO.

7. 
Patient’s concerns about his prognosis. Loss of income, separation from family, long period in hospital – all possible areas for discussion.

The examiners have plenty to choose from and are likely to want to discuss some problems in detail and to ensure the candidate has thought about the others by asking a few questions on each.

CASE 4

Mrs AP is a 72-year-old retired nurse who has come in for the exams.

She has a long history of hypertension, which has recently been difficult to control. A CT of the renal arteries showed ‘thickening’.

She smoked for 18 years until 10 years ago. She has had lower back pain for 10 years, not relieved following a laminectomy. Spinal canal stenosis was diagnosed 4 years ago.

She has had a gain in weight over the last 5 years from 88 to 107 kg. Her BMI is 40.

A thyroidectomy was performed in 2008 following a biopsy which showed atypical cells. The tumour, however, was benign.

She is breathless on mild exertion, but not at rest.

She had a right hip replacement in 2000.

In 2010 she had a left hip replacement. She became very dyspnoeic 5 weeks later, with investigations for a DVT. There were multiple pulmonary emboli, but no DVT was found. She was treated with enoxaparin and then warfarin for 10 months.

Currently she can walk 30 metres on the flat. She is limited by dyspnoea and knee pain.

She has been diagnosed with asthma and an allergy to cats and dogs. She has 3 cats at home.

She suffered from childhood chest infections and sinusitis but no ear infections. She coughs up little phlegm and has never had an admission to hospital with asthma or required steroid treatment.

In 1999 hypogammaglobulinaemia was diagnosed. She was given vaccinations for influenza, whooping cough, pneumonia (possibly pneumococcus and Haemophilus influenzae) and hepatitis.

She now receives monthly gammaglobulin injections. These were given IM for 5 years, then IV. She feels she is much improved and requires only one or two courses of antibiotics per year now.

She is currently taking atenolol 50 mg a day for hypertension and detected ventricular bigeminy (asymptomatic). She had had problems with previously prescribed ACE inhibitors and AR blockers, but can’t remember what they were.

She is unable to drive and only goes out with a frame. Her husband does the shopping and housework.

Her main concern about her health was her back pain. She was not especially worried about her immobility or her weight.

Examination

1. 
Obese.

2. 
BP 150/80 mmHg.

3. 
Able to walk with great difficulty, but not apparently concerned.

4. 
Chest clear.

5. 
FET normal −5s.