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Family

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h/a
back pain/sciatica
hip pain
leg pain
sleep disturbance
fibro
smoking cessation
diabetes management
hypertension

Couplet station
1.

Leg Pain: history and causes

5) 70 yo f w h/ache. Take hx. o/e: jaw s/s and R visual changes. No


afib or other hix. No other findings on hx. WRITTEN: most likely dx. What are three
tests you would order to confirm? What is the major complication of this dx?
List you management in general terms.
10 min
6. TAKE HX FROM WOMAN WITH SLEEP DISTURBANCE
Q1- DX, Q2- MANAGEMENT
4. EXAMINE MAN WITH LOW BACK PAIN
Q1- DX (DISK PROLAPSE) Q2- WHAT LEVEL
7. Woman in ?50's c/o numerous aches and pains. History and management. Give diagnosis.
1.
2.

Man with headache: would like prescription for fiorinal


Back pain, radiating down leg: history and physical

LBP
7. 42 year old woman wants to quit smoking following an episode of acute bronchitis one month prior.
Take a relevant history and advise.
Findings: was quite ill with this bronchitis, father has had two strokes, her teenaged kids and talking about
wanting to smoke, her husband who smokes is also willing to quit. Has tried twice before cold turkey but
didnt work. Advise about behavioural techniques, meds (bupropion ask about seizures), the patch, the
gum, support groups. Offer to speak to husband and kids too.

Sciatica in a patient with L5-S1 nerve root involvement


Back pain history

- Eight most important questions:


1. Where is the pain worst? radiation?
2. Onset, duration?
3. Aggrevating/relieving factors
4. Previous attacks
5. Previous treatment
6. Surgery in past
7. Occupation
8. Limitations, ADL's
Ask about red flags :
- history of trauma, strenuous lifting
- tumor/infection : history of cancer, constitutional symptoms, IV drug abuse, recent bacterial infection,
immunosuppresion (disease or meds)
- sx of cauda equina : fecal incont, urinary retention, frequency, neuro deficit in lower extremities, saddle
anesthesia
R/O rheum causes so ask about Extraarticular features - uveitis, buttock pain, rash, heel pain, balonitis,
abdo apin, etc....
PEP - physical examination
1. Observation - back shape, curvature, posture, trendelenburg
2. Back Flex/Extend - rotation, point tenderness, ROM, Gait
3. L4,L5,S1 conduction tests - sensation, relexes, heel walk, toe walk, squat
4. Irritative tests - SLR, femstretch test (L2-L4)
5. Babinski
6. Saddle senation S3-S5
L3-4 (L4)

L4-5 (L5)

L5-S1 (S1)

Pain

femoral

sciatic

sciatic

Motor

knee extension

dorsiflexion

plantar flexion

reflex

knee jerk

medial hamstring

ankle jerk

sensory

medial leg

dorsal foot

lateral foot

31 yo man with 10 year history of IDDM presents with blood sugar book - history
History

look at blood glucose book


ask about symptoms of hypoglycemia - is he aware?
ask about meals and snacks - does he know about the Canada Food Guide
exercise routine and daily activities
monitoring his glucose
past medical history
family history
medications: especially new ones
allergies
social: smoking, alcohol

PEP
4 suggestions to correct blood sugar levels (pre-lunch hypoglycemia, late evening hyperglycemia)
Insulin
regular
NPH/lente
ultralente

Duration
short
intermediate
long

Onset
-1
2-4
4-5

Peak
1-3
8-10
-

Duration
5-7
18-24
25-36

reduce Humulin R at breakfast (pre-lunch hypoglycemia)


ensure mid morning snack (pre-lunch hypoglycemia)
increase Humulin R at dinner (late evening hyperglycemia)
increase Humulin NPH (late evening hyperglycemia)

Man with hip pain


Physical
Inspect: resting position of hip (do not tend to see swelling/redness because joint is deep)
Palpate: tenderness
trochanter: widest point when lying, highest point when on side
trochanteric bursa: just posterior to greater trochanter
ROM: active and passive
flexion
internal rotation: keep femur center line, and move foot outwards
external rotation: keep femur center line, and move foot inwards
abduction: hand on opposite iliac crest and abduct until opposite crest moves
adduction: across other leg to about 20 degrees
extension with patient on side
SI joint: one inch lateral to dimples of Venus - palpate for tenderness and load laterally
If time: knee exam

Positive Trendelenberg: when standing on one foot on weak side, contralateral side of pelvis drops
weak abductors, trochanteric fracture
painful hip due to OA, acetabular instability
fractured pelvic side wall
Gait: Trendelenberg gait occurs when leans over the side that is weak
PEP
xray
OA describe joint space narrowing, sclerosis, subchondral cysts, osteophytes

management of OA
conservative (weight loss, PT, OT, rest)
acetaminophen, NSAIDs for inflammation, intraarticular steroids;
surgical options
replace: arthroplasty
realign: osteotomy
ablate: arthrodesis

45 year old, three year history of HTN, first visit with you: physical
The search is, of course, for target organ damage. Do a full screening physical exam with emphasis on the
following:
Retina:
narrowing/irregularity of arterioles
AV nicking
flame-shaped or circular hemorrhages
cotton-wool exudates (localized axon swellings and swollen nerve fibres in avascular areas)
papilledema with blurring of the temporal edge of the optic disc
Heart:
looking for evidence of LVH, LV failure, or involvement of various arteries by atherosclerosis
so for the cardiovascular exam:
listen for carotid bruits, carotid pulse should have normal upstroke and volume (unless coarctation is
causing HTN)
check the JVP (>4cm is elevatednormal unless right heart failure also)
palpate the PMI to see whether it is displaced (normally in 5th intercostal space, midclavicular line), diffuse
(> size of a quarter) or sustained (>2/3 of systole)
palpate for heaves/thrills (LVH heave = sustained PMI)
auscultate: S4 = stiff LV wall (LVH), S3 = floppy LV wall (LV failure)
other signs heart failure: pulmonary crackles (LHF), liver congestion (RHF)
Arteries and Veins/ Peripheral Vascular Exam:
palpation of pulses (femoral, popliteal, posterior tibial, dorsalis pedis), note symmetry
listen for bruits: femorals, popliteals, renal (renal bruits = cause HTN, not really target organ damage)
examine abdominal aorta for aneurysm (complication of concomitant atherosclerosis)
Brain:
if time can do a neuro exam for evidence of residual neurological deficit from previous cerebral infarction
motor: bulk, tone (spastic vs. rigid), power, reflexes, Babinski
sensory: pain & temp, vibration
cerebellar
Evidence of secondary causes of HTN (not classically in this age group):
-Cushings: truncal obesity, hirsutism, acne, striae, moon fascies, etc.
-Primary hyperaldosteronism: muscular weakness, hypoactive deep tendon reflexes

60 year old female with headache


ID: age, sex, occupation
HPI:

OPPPQRST
Onset: sudden vs acute, activity at time of onset
Position: localized temporal (GA arteritis), occipital (meningitis, tension), bandlike (tension), periorbital
(cluster)
Provocation/alleviation: position, time of day, activity, stress, medication
Progression: of pain
Quality of head pain: throbbing (migraine, TA), squeezing (tension), explosive (SAH), expanding
intracranial lesion (mild headache)
Radiation: of pain around head, to eyes, neck, etc
Symptoms associated:
raised ICP: nausea, vomiting, visual changes, weakness/paralysis, paresthesias, seizures (ANY focal
neurological deficits are worrisome)
Meningitis: fevers, chills, hx of preceding infection (URTI, ear, dental), recent dental work, neck stiffness,
etc
Migraines: scintillating scotomata, transient hemianopias, hemimotor or hemisensory disturbances (auras),
photophobia, sonophobia, triggers
Temporal arteritis: jaw claudication, proximal muscle soreness (PMR), visual changes, fever, anorexia
Tension: other psychophysiologic disturbances (stressors, abdo pain, etc)
Cluster: ipsilateral lacrimation, conjunctival injection, rhinorrhea, facial flushing
Temporal Profile:
tension: get worse as day progresses
migraine: unpredictable although usual duration 6 - 36 hours
cluster: repetitively occur over weeks or months, often one or two attacks daily, typically nocturnal and last
a half hour to a few hours), peak in spring or fall
PMHx:
Medical: coagulopathies/bleeding tendencies, hypertension
Surgical:
Psychiatric:
Meds: anticoagulation, immunosuppression, birth control/exogenous estrogens
FHx: usually strong family history of migraines, not true for clusters
-also ask fhx brain tumours
SHx: social stressors, etc