Emergency Medicine – Practice Questions
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Cardiology – Practice Questions
Anesthesia and Perioperative Medicine – Practice Questions
Nephrology
Case 3 – Amenorrhea
You are seeing Cindy Albrecht, a 19 year old female, for amenorrhea. Please take a focused history for her complaint.
History
- Distinguishes primary vs. secondary amenorrhea (patient has had previous menstrual periods)
- Age of menarche
- Onset of last menstrual period
- Amount and changes in flow in recent menstrual periods
- Length of menstrual period
- Menorrhagia
- Dysmenorrhea
- Current use of birth control pills or other oral hormones
- Presence of vaginal discharge/itching
- Morning sickness
- Abdominal pain/discomfort
- Recent dieting
- Recent fractures
- Excessive exercise
- Galactorrhea
- Symptoms of hyperthyroidism (sweating, palpitations, heat intolerance)
- Symptoms of hypothyroidism (feels slow, cold intolerance, constipation)
- Symptoms of hypoestrogen state (hot flashes, night sweats, vaginal dryness)
- Personal history of chronic disease
- Pregnancy history
- Current and past sexual history, including partners, method of intercourse, and contraception
- Smoking and alcohol history
- Family history of genetic abnormalities and infertility
Case 2 – Vaginal Discharge
You are seeing Stacey Holland, a 23 year old female, for vaginal discharge. Please take a focused history for her complaint.
History
- Onset and duration of vaginal discharge
- Appearance of discharge
- Association with menstruation
- Presence of blood
- Itching
- Dyspareunia
- Pain on defecation
- Fever
- Nausea/vomiting
- Perineal/vaginal sores
- Abdominal pain/discomfort
- Rash or other lesions
- Swollen joints
- Vision changes
- Dysuria
- Hematuria
- Increased frequency of urine
- Last menstrual period
- Menorrhagia
- Dysmenorrhea
- Regularity of menstruation
- Past abdominal surgery
- Pregnancy history
- Current and past sexual history, including partners, method of intercourse, and contraception
- Smoking and alcohol history
- Medications – especially oral contraceptive pill
- Allergies
- Personal history of sexually transmitted infections and related investigations/treatment
- Last Pap smear and result
Case 1 – Breast Mass
You are seeing Mrs. Thompson, a 56 year old woman, in your outpatient clinic today. She is worried about a left breast mass, and would like your reassurance that it isn’t cancer. Take a focused history of her complaint and perform a focused physical exam.
History
- Onset of awareness of mass
- Size of the mass and change in size
- How mass was identified
- Mastalgia
- Associated discharge, including pus and blood (none)
- Size/tenderness association with menstrual cycle
- Nipple changes
- Skin changes (on affected breast)
- Systemic symptoms – weight loss, low energy, anorexia
- Associated shortness of breath or chest pain
- Changes in personality – suggestive of brain metastases
- Bone pain – suggestive of bone metastases
- Inquires about date of menopause
- Pregnancy history
- Breastfeeding history
- History of chest radiation
- Age of menarche
- Alcohol history
- Smoking history (quantity in pack-years)
- Past and current use of hormone replacement and oral contraceptive pills
- Family history of breast, ovarian, or colon cancer
- Past history of breast masses
- Past mammography results
- Addresses patient’s concerns regarding the mass
Physical Examination
Inspection
- Drapes patient appropriately
- Inspects breast skin for discoloration, retraction, peau d’orange, or bruising
- Comments on presence of asymmetry
- Examines nipples, commenting on absence of discharge, irregularities, or retraction
- Examines areolas (no abnormalities)
Palpation
- Uses radial or strip method to palpate both breasts,
- Comments on texture, size, firmness, and mobility of any palpated masses
- Palpates axillary nodes bilaterally
- Palpates infraclavicular and supraclavicular nodes
Case 4 – Renal Colic
You are seeing Ms. Hamilton, a 64 year old man, for left sided back pain. She says it began three days ago and isn’t getting any better. Take a focused history of her complaint and perform a physical examination.
History
- Onset and duration of pain
- Progression of pain
- Location of pain (unilateral)
- Frequency of pain (intermittent)
- Quality of pain (sharp)
- Radiation (to abdomen and groin)
- Flank pain (yes)
- Changes in amount of urine
- Dysuria
- Urgency
- Hematura (some darkening)
- Post-void dribbling
- Fever (recently)
- Nausea/vomiting
- Diarrhea (none)
- Diaphoresis
- Current Medications
- Diet history (focusing on calcium and oxalate intake)
- Personal history of renal stones
- Personal history of urinary tract infections
- Family history of renal stones
- Past medical history
Physical Examination
Inspection/Vitals
- Comments on general appearance of patient (uncomfortable, diaphoretic)
- Measures heart rate (elevated) and states that temperature should also be measured
Renal Examination
- Palpates location of back in which pain is located
- Assesses for CVA percussion tenderness
- Attempts to palpates for kidneys with patient supine
- Auscultates for renal bruits bilaterally
Abdominal Examination
- Inspects abdomen for masses, scars
- Auscultates in all four quadrants of the abdomen
- Palpates all quadrants for tenderness, commenting on absence/presence of guarding
- Assesses for rebound tenderness in the left and right lower quadrants
- States that they would perform a digital rectal examination as part of the abdominal examination
Special Maneuvers
- Examines for signs of appendicitis: McBurney’s point tenderness, Rovsing’s sign, Psoas sign
Case 3 – Testicular Mass
You are seeing Bill Byrd, a 40 year old man in your outpatient clinic because he recently noticed a testicular mass. Perform a full genital examination.
Physical Examination
Scrotum
- Inspects scrotum for asymmetry and skin lesions
- Palpates testicles bilaterally
- Comments on masses: size, location, consistency, tenderness, irregular shape
- Palpates epididymis for tenderness, enlargement
Penis
- Inspects penis for erythema, swelling, deformity
- Palpates along penile shaft for irregularity
- Examines foreskin for signs of infection
- Exposes glans for inspection, and replaces the foreskin after completing the examination
- Examines meatus for discharge
Hernias
- Palpates inguinal region bilaterally for presence of hernias
- Assesses for hernias with patient standing up
- Asks patient to bear down during palpation of scrotum
Digital Rectal Examination
- States that a digital rectal examination would be performed as part of the genitourinary examination
Case 2 – Hematuria
You are seeing Mr. Ali, a 72 year old male, in your outpatient clinic today for ‘bloody urine.’ Take a focused history of his complaint.
History
- Onset and duration of hematuria
- Progression or worsening of hematuria
- Clarifies color of urine (bright red blood)
- Urinary frequency
- Pain on urination
- Urgency
- Nocturia
- Incomplete voiding
- Hesitancy
- Penile tip pain
- Flank Pain
- Abdominal discomfort/fullness
- Systemic Symptoms – weight loss, fever, night sweats
- Personal history of bleeding diathesis
- Personal history of renal stones
- Past history of renal disease
- Current medications
- Surgical history
- Smoking history (quantity in pack-years)
- Occupational history – especially exposure to exogenous toxins
- Concerns as to what is causing the hematuria
- Past history of urinary tract infections
- Family history of urogenital cancers