Bckgrd history
Diabetes mellitus dx 2000
Osteoarthritis of bilateral ankles, knees, hip
Breast Ca dx 2000 treated by mastectomy
Bladder Ca dx 1998 treated by CBG
?IHD allegedly reported by dr, not personally known
PC
Admitted to hospital due to the need for amputation of all phalanges of (L) leg and 2 phalanges of (R) leg, as a consequence of diabetes. After surgery during hospital stay, was investigated to found to have metastatic Ca involving the bone, she isn’t sure which bone (as reported by pt).
Personal feedback
Presentation was generally out of range, here & there. alth i presented throughly in some parts, i missed out some vital parts, but lucky with prompting. I hope the examiners take into account the complexity of the case, but purely unlucky also the disorganisation of my present. (long case- 25%, short case (each)- 25%, consultant assessment- 25%)
Scenario
Qn- wts the presenting complaint? there must be an issue that requires the pt to be admitted, not just purely diabetes. did you ask why she was admitted?
(this is the vital part i’ve missed, mainly focusing on the Bone cancer. I back-up by saying diabetes was the primary reason she attribute her surgery to, definitely this is a very important part of history wch shud be asked but unfortunately i did not)
Qn- what do you think is the issue with her leg that needs to be amputated?
Can be due to diabetes.. an ulcer.. apart from diabetes? she might have an infection like cellulitis does cellulitis require amputation you think? no actually.. it can be treated with antibiotics. Im thinking of the sort of tissue infection wch can eat up your tissues- a necrotising-type. okay do you know the terminology for that one? (i knew i was going the right way but..) sorry i don’t know.
Qn- you said she’s got Bone Ca.why do you think where the source may be from.
A typical metastatic source of bone Ca would be the breast. Alth she had mastectomy, Ca wud have already lurked into the bloodstream & spreaded.
Qn- Can you tell us wt medications she’s on
(i missed this one)
Qn- She’s on thyroxine, do you know why she’s on this?
I actually asked her while reviewing the charts, but she denied any explanation given coz she has already got so many co-morbidities. why do you think she may be on? did she have any thyroidectomy scar on her neck? no, she did not have any scar, i’d examined her neck. the possibilities maybe a thyroid adenoma or diffuse hyperplasia of thyroid gland. besides thyroidectomy, what other reasons you think she wud be on it? i couldn’t think of any.
Qn- the pt may be confused abt her condition. given her real condition is a pathological abdominal lymphadenopathy, how would this affect your approach?
what! so she doesn’t have bone Ca! oh my god.. i did notice a lymphadenopathy in her right inguinal region but did not present coz my notes were all over! And i did not focus on doing the abdominal exam very well.
Ok.. i’d think of lymphoma coz it can affect the abdomen. i did examine the lymph nodes & found to have an enlarged lymph node. ok.. why did you not tell us that you’ve examined the lymph nodes? sorry, i forgot to tell.
In the end, its not so bad. it was a complex case, not clear-cut. i answered some qns relatively well. always kept on backing myself up. my other 2 short cases were:
Pt presenting with fever, jaundice, abdominal pain. generally, i elicited involuntary guarding (rigidity) all over the abdomen. giving generalised peritonitis as one of my reasons, but i basically ruled this one by saying anyone presenting with the triad should be ruled out for acute cholangitis until proven otherwise (i could see the examiner tick)
Examine this pt with tachycardia. apparently on examination, a huge clicking sound even on bedside. no murmur, but thrills over LSE. I gave the answer as a metallic valve replacement. which valve? Given its in the LSE, i’d think its pulmonic valve altgh its a less likely compared to mitral & aortic valves. so which one do you think it is? mitral valve. 50:50.
wish me luck,
keith
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