Author: Tim Milligan

Case 2 – Infant Diarrhea

Tim Milligan Pediatrics

You are seeing Mrs. Bosco, a 25 year old female who recently gave birth to a baby named Michael six weeks ago. Today, she presents to your office because she is concerned about the baby’s health. Take a focused history of Mrs. Bosco’s complaint.

History

  • Determines chief complaint is diarrhea
  • Volume of diarrhea (i.e. frequency of diaper change)
  • Appearance of diarrhea (appears brown, with no blood)
  • Associated nausea/vomiting
  • Lethargy
  • Child’s level of activity
  • Fever and peak temperature
  • Changes in urination, including odor
  • New rashes
  • Symptoms of URTI
  • Recent weight loss
  • Volume of oral intake
  • Infectious contacts
  • Past medical history (none)
  • Asks about developmental milestones appropriate for child’s age
  • Pregnancy history (normal)
  • Vaccinations to date
  • Allergies (none)
  • Current medications (none)
  • Inquires about mother’s stress, caregiver burden
  • Inquires about mother’s support for the care of the infant
  • Inquires about post-partum depression
  • Inquires about mother’s other concerns related to raising her infant

Case 2 – Sore Throat

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Tom, a 10 year old boy, in your outpatient clinic today for a sore throat. Take a focused history of his complaint and perform the relevant physical examination.

History

  • Onset of sore throat
  • Severity
  • Alleviating factors
  • Aggravating factors
  • Change in voice
  • Presence of fever
  • Odynophagia
  • Associated cough, sputum production
  • Shortness of breath
  • Neck tenderness and swelling
  • Otalgia
  • Recent upper respiratory illness
  • Personal history of throat infections
  • Infectious contacts
  • Allergies to medication
  • Vaccination history
  • Development history

Physical Examination

Oropharynx

  • Uses tongue depressor and light to examine oropharynx
  • Comments on the presence of erythema and exudates in oropharynx
  • Comments on other findings in the oropharynx e.g. enlarged tonsils, lesions, deviated uvula

Node Examination

  • Palpates the lymph nodes of the head and neck
  • Names the nodal regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient about tenderness during examination

Respiratory

  • Auscultates in all lung fields
  • Comments on findings

Case 5 – Dizziness

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Rodriguez, a 31 year old man, because he often feels dizzy. Take a focused history and perform the Dix-Hall Pike maneuver.

History

  • Clarifies symptoms are descriptive of vertigo (‘the room spinning around’)
  • Duration of dizziness
  • Frequency
  • Associated activity, especially head turning
  • Other precipitants
  • Aural fullness (none)
  • Decreased hearing from one ear
  • Tinnitus (none)
  • Otalgia (none)
  • Syncopal episodes
  • Chest pain or shortness of breath
  • Nausea or vomiting
  • Vision changes
  • Sensory deficits (none)
  • Motor deficits (none)
  • Trauma to either ear
  • Previous episodes of otitis media
  • Smoking and alcohol history
  • Effect on daily activities

Dix-Hallpike Maneuver

  • Explains procedure to patient, and what they might expect
  • Asks patient to lie down and tilts head back and towards one side
  • Repeats maneuver on opposite side
  • Comments that they are looking for geotropic nystagmus towards affected ear
  • Comments on reversal when leaning toward non-affected ear

Case 4 – Neck Mass

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mrs. Nguyen, a 52 year old woman, because she noticed a large swelling on her neck. Take a focused history and perform a focused head and neck examination.

History

  • Clarifies location of mass (patient thinks it’s on the her right side of her neck)
  • Onset of mass
  • Progression in size
  • Pain
  • Dysphagia
  • Odynophagia
  • Change in voice
  • Symptoms suggestive of hyperthyroidism
  • Symptoms suggestive of hypothyroidism
  • Systemic symptoms – weight loss, night sweats, anorexia
  • Infectious symptoms – nausea/vomiting, fever, diarrhea
  • Past medical history
  • Personal history of malignancy
  • Exposure to head and neck irradiation
  • Exposure to tobacco, smoking, alcohol, and betel nuts
  • Asks patient about ethnic origin (South East Asia)
  • Personal history of thyroid disease
  • Family history of thyroid disease
  • Family history of head and neck cancer

Physical Examination

Inspection

  • Comments on location of mass and any neck asymmetry
  • Comments on stigmata of hyperthyroidism in head and neck (exophthalmos, lid lag, etc.)
  • Comments on stigmata of hypothyroidism in head and neck (skin and hair changes)
  • Comments on size of thyroid and observes thyroid as patient swallows

Palpation

  • Comments on quality, size, and mobility of mass (mass is hard, irregular, and tethered)
  • Comments on size of mass (~2 cm in diameter)
  • Palpates all lymph node regions of the head and neck
  • Names the regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient if palpation is tender
  • Palpates both lobes of the thyroid; comments on size and nodularity
  • Auscultates thyroid and comments on absence of bruits

Case 3 – Hearing Difficulty

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Syed, a 73 year old man, in your outpatient clinic. He says that his family members have told him that they have a difficult time communicating with him because he has poor hearing. Take a focused history, and perform the pertinent physical examination maneuvers.

History

  • Inquires whether patient is aware of hearing loss (he agrees)
  • Onset of hearing difficulty
  • Settings in which difficulty is worst (noisy crowds)
  • Whether hearing difficulty is worse with specific frequency (patient unsure)
  • Otalgia
  • Exudation from ear, including pus and blood (none)
  • Phonophobia
  • Tinnitus
  • Vertigo
  • Associated neurologic deficits elsewhere in the body
  • Vision loss
  • Headache
  • Use of ear plugs
  • Trauma to the ear, including digital
  • Past history of cerumen
  • Use of any hearing aids
  • Past history of hearing difficulty
  • Past exposure to noise (including occupational history)

Physical Examination

Inspection

  • Comments on the gross appearance of both ears
  • Uses otoscope to examine the auditory canal, commenting on its appearance
  • Examines tympanic membrane and comments on its appearance

Special Tests

  • Performs the Rinne Test bilaterally
  • Performs the Weber Test
  • Interprets the results of these two tests
  • Performs whisper test bilaterally

Case 1 – Blurry Vision

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mrs. Woods, a 74 year old woman, in your ambulatory clinic today. She states that her vision has become blurry. Take a focused history of this complaint and perform the relevant physical examination.

History

  • Onset and duration of blurry vision
  • Progression of blurry vision
  • Foreign body sensation, or history of foreign body in affected eye
  • Awareness of a red eye (none)
  • Visual field defects
  • Change in acuity
  • Double vision
  • Eye pain
  • Pain with eye movement
  • Presence of flashes and floaters
  • Photophobia
  • Excessive or poor lacrimation
  • Association with any extra-ocular symptoms: rashes, arthritis, urethritis
  • Change in colour vision
  • Distinguish between blurred vision vs. metamorphopsia (distorted vision)
  • Use of corrective lenses
  • Exposure to environmental irritants
  • History of diabetes, hypertension, cardiac disease, and stroke (risk factors for CRVO, CRAO)
  • History of cataract removal
  • Past ocular disease, including trauma
  • Smoking and alcohol history
  • Medications and allergies
  • Family history of eye diseases, e.g. glaucoma, retinal detachment
  • Inquires if patient is driving since onset of vision changes
  • Effect on daily living

Physical Examination

Inspection

  • Comments on absence of ptosis
  • Comments on appearance of lid, eyelashes, lacrimal glands
  • Comments on appearance of conjunctiva and sclera

CN II

  • Asks patient about prescription for corrective lenses before beginning examination
  • Checks visual acuity using Snellen Chart at 14 inches or 20 feet
  • Assesses pupillary response to light
  • Assesses pupillary accommodation
  • Assesses for RAPD/Marcus Gunn pupils
  • Assesses visual fields by confrontation
  • Performs fundoscopy and comments on findings, specifically the disc-to-cup ratio
  • States that color vision testing should be performed
  • States that a slit lamp examination should be performed

CN III, IV, & VI

  • Comments on absence of nystagmus
  • Assesses all six cardinal movements of the extraocular muscles
  • Asks patients about diplopia in all directions of gaze

Case 5 – Worsening Tremor

Tim Milligan Neurology

You are seeing Ms. Wilmington, a 63 year old woman, in your outpatient clinic. She tells you that her old tremor is getting worse. Take a focused history of her complaint and perform a focused physical exam.

History

  • Onset of tremor
  • Onset of worsening of the tremor
  • Clarifies if tremor occurs during rest or activity (rest)
  • Difficulty performing specific tasks due to tremor (writing)
  • Change in gait – slowing, fewer steps, less arm swing
  • Stability of gait
  • Need for assistive devices for ambulation
  • Difficulty with fine motor skills
  • Posture changes
  • Difficulty initiating movement
  • Psychomotor retardation
  • Change in affect
  • Difficulty with short term memory
  • Change in voice
  • Effect on ADLs
  • Effect on IADLs
  • Personal history of a psychotic disorder
  • Family history of Parkinson’s and/or essential tremour
  • Current medications
  • Addresses patient’s concerns as to what is causing these symptoms
  • Inquires about symptoms of depression
  • Patient’s concerns about independence

Physical Examination

Vitals/Inspection

  • Measures orthostatic changes – comments on hypotension
  • Inspects for masked face (none)
  • Comments on stooped posture
  • Comments on presence of resting tremor
  • Comments on altered speech

Motor Examination

  • Tests tone in upper extremities – comments on presence of cogwheeling
  • Tests for essential tremor, likely not present
  • Tests for intent tremor, likely not present

Sensory Examination

  • Tests reflexes (normal)
  • Tests for primitive reflexes associated with Dementia – palmomental and glabellar
  • States that a sensory examination should be performed, though it would be normal

Gait Examination

  • Evaluates patient getting up from chair, comments on bradykinesia
  • Comments on shuffling gait
  • Comments on stability of gait
  • Comments on festinating gait and lack of arm swing
  • Performs retropulsion test (positive)

Case 4 – Headache

Tim Milligan Neurology

You are seeing Ms. Davis, a 32 year old woman, in your ambulatory clinic today. She states that she has had a worsening headache over the last week. Take a focused history of this complaint. Then, examine all cranial nerves except for I, II, & VIII.

History

  • Onset and duration of headache
  • Location of headache, unilateral vs. bilateral (entire head, bilateral)
  • Severity
  • Frequency
  • Radiation
  • Quality of headache (dull, diffuse)
  • Alleviating factors
  • Triggers for the headache/aggravating factors
  • Temporal association (headache not worse in mornings)
  • Association with nausea/vomiting
  • Vision changes before or during headache
  • New sensory symptoms: weakness, numbness, tingling in upper or lower extremities
  • Photophobia/phonophobia
  • Association with menstrual cycle
  • Systemic symptoms – weight loss, low energy, anorexia
  • Fever and neck stiffness
  • Personal history of head trauma
  • Personal history of migraines
  • Family history of migraines
  • Effect on daily activities
  • Use of oral contraceptive pills
  • Caffeine intake
  • Smoking and alcohol history

Physical Examination

CN III, IV, & VI

  • Assesses all six cardinal movements of the extra ocular muscles
  • Asks patients about diplopia in all directions of gaze
  • Comments on absence of nystagmus
  • Comments on absence of ptosis

CN V

  • Examines for light touch in all three nerve divisions (forehead, cheek, chin)
  • Palpates masseter and temporalis muscles and comments on bulk
  • Tests masseter muscle power by opposing jaw opening
  • Tests right and left pterygoids muscle power by opposing lateral jaw movement
  • States that the corneal reflex should be tested and explains the procedure

CN VII

  • Raise eyebrows
  • Tightly clench eyes (and tries to open them)
  • Puff cheeks (and tries to deflate them)
  • Show the lower teeth only
  • Comments on the presence/absence of facial asymmetry/droop

CN IX & X

  • Assesses palatal elevation
  • Assesses gag reflex with tongue depressor
  • Asks patient to swallow
  • Tests phonation
  • States that taste on the posterior 1/3 of the tongue should be tested, and describes how

CN XI

  • Assesses power of both sternoclediomastoid muscles
  • Assesses power of both trapezius muscles

CN XII

  • Examines the tongue for fasciculations
  • Asks patient to protrude tongue, examines for deviation
  • Assesses power of tongue in lateral plane

Case 3 – Seizure

Tim Milligan Neurology

You are seeing Oleg Markov, a 15 year old male, in your ambulatory clinic today. He states that he has recently experienced moments during the day where he loses awareness for minutes at a time but soon fully recovers. Take a focused history of this complaint.

History

  • Onset and duration of awareness deficit
  • Frequency
  • Factors which precipitate these episodes
  • Injury sustained as a result of the seizure
  • Post-ictal symptoms: confusion
  • Associated sensory deficits
  • Associated motor deficits
  • Associated cognitive deficits
  • Muscle spasms
  • Anatomical progression of motor involvement (e.g. Jacksonian March)
  • Symptoms suggesting aura
  • Associated incontinence
  • Tongue biting and salivation
  • Automatisms associated with these episodes
  • Personal history of head trauma
  • Congenital neurological disorder
  • Perinatal infection
  • Medications
  • Drug history
  • Personal history of seizure disorder
  • Family history of seizure disorders
  • Effect on daily activities

Case 2 – Ataxia

Tim Milligan Neurology

You are seeing Mrs. Salamanca, a 45 year old female, in your outpatient clinic. She’s been complaining of unsteadiness when she walks. Please perform a complete examination of her coordination.

Physical Examination

Gait

  • Asks patient to walk to assess gait
  • Assesses toe walking
  • Assesses heel walking
  • Assesses tandem gait
  • Comments on wide, ataxic gait with unequal steps

Balance

  • Performs Rhomberg Test

Motor examination

  • Gross: Performs heel to shin test
  • Gross: Performs finger to nose test
  • Fine: Alternating fingers to thumb
  • Fine: Alternating palm to hand
  • Assesses for intention tremor
  • Assesses for dysarthria
  • Assesses for nystagmus