medicine osces

8/15/2019 Medicine OSCEs

1/22

Medicine

Couplet stations

3. TAKE HX. FROM MAN WITH DY!HA"IA

!E!# HOWN $ARI%M WA&&OW' DECRI$E XRAY FINDIN"' "I(E DX' "I(E

WORK%!

). EXAMINE YO%N" WOMAN WITH !%R!%RA AND E!ITAXI

!E!# HX' DX' IN(ETI"ATION

*. EXAMINE +, Y.O FEMA&E WITH HY!ERTENION

!E!# DDX' IN(ETI"ATION' WHAT TO DO IF YO%R IN(ETI"ATION ARE

NORMA&

-. EXAMINE MAN WITH CA&F C&A%DICATION!E!# INTER!RET EK"' RIK FACTOR' IN(ETI"ATION

). TAKE HITORY FROM MAN WITH O$ AND !%T%M!E!# ER RX' IN(ETI"ATION' AD(ICE RE# !RE(ENTION

. A. +* /ea0 old 1ale 0e2used li2e insu0ance ecause o2 ele4ated &FT5s. Focussed

6isto0/. $. Dd7' ot6e0 tests 8ould o0de0.

). HI( patient 8it6 inc0easin9 e7e0cise intole0ance and d/spnea' no8 d/spneic at 0est.!6/sical e7a1.

$# inte0p0et CXRa/' Dd7' R7

. HI( patient 8it6 O$# e7a1ine and CXR

+. C0o6n5s patient 8it6 R&: pain# e7a1ine and AXR

-. -,s 1an p0esents 8it6 ele4ated A T ;+,,< and A&T ;+,,< ;A&! ,' ili +*< on

sc0eenin9 at ti1e o2 insu0ance. Wants test 0epeated. + d0in=s on 8ee=end. CA"E

e>ui4ocal. Ne4e0 d0an= 1o0e. I( 6e0oin as teens. Is a ?anito0 at a 6ospital. Had pe0inatal ?aundice ut not6in9 since. !0e4iousl/ 6ealt6/. Ne4e0 t0ans2used. No FMH7.

History only. MEDICINE

!E!# . W6at is 6is dia9nosis ;acute 6epatitis<

+. W6at a0e t6e t60ee li=el/ etiolo9ies ;H$(' HC(' alco6ol<

3. W6at is /ou0 0epo0tin9 0esponsiilit/ at t6is ti1e ;none' ut i2 H$( o0

HC(' 1ust 0epo0t to pulic 6ealt6


2/22

< *, /o 1 ca1e to MD a 2e8 da/s a9o NFW. You0 o22ice pa0tne0 did a

C$C@ MC( +,' ane1ic' lo8 W$C' lo8 plts. Ta=e a 0ele4ant 67. OE# !e0ip6e0al

neu0opat6/' p0os 8al=in9 at ni96t. Tin9lin9. o1e 1ental s/1pto1s. No consitutional illnesses as 2a0 as I can 0e1e1e0. No ETOH. W0itten# 9i4e 1ost li=el/

d7' 9i4e + ot6e0 possiilities 2o0 t6e neu0opat6/ ;I said pe0ip6e0al neu0opat6/ +nda0/ to

l/1p6o1a' 9ast0ic' causin9 + de2icienc/' o0 DM


3/22

cou1adin 20o1 2a1il/ docto0' dose et8een ) and . No constitutional s/1pto1s. At

nine 1inutes# e7a1ine0 as=s /ou 86at /ou do 86en t6e ne7t da/ t6e patient calls sa/in9

6e is un6app/ 8it6 t6e ca0e /ou 6a4e 9i4en 6i1 and 8ants a cop/ o2 6is c6a0t.

CH$ Med3. G, /o lad/ collapses at 1all' &OC' 0ou96t to ER / a1ulance' 90anddau96te0 8it6

6e0 to ans8e0 >uestions. $! G,-,' HR -,. Mana9e.

Findings: patient complained of shortness of breath, heart pounding, dizziness justbefore fainting. Has history of hypertension, no other cardiac history. EKG shos third

degree heart bloc!. Granddaughter mentions that she"s on digo#in, but the nurse

ouldn"t gi$e me the le$el. %ou"re supposed to treat this as an acute coronary&'()S

station.

$ac= !ain Med

G. 3, /ea0 old 1an 8it6 a si7 1ont6 6isto0/ o2 8o0senin9 ac= pain associated 8it6

1o0nin9 sti22ness' i1p0o4e1ent o2 t6e sti22ness 8it6 e7e0cise. Do a 2ocused p6/sicale7a1.

Findings: limited mo$ement of the bac!. *efle#es, sensation, strength all normal.Straight leg test negati$e, no signs of cauda e+uina.

:uestions# 86at is t6e 1ost li=el/ dia9nosisB W6at ot6e0 dia9noses a0e possile

conside0in9 t6e 6isto0/ ;ot6e0 t6an ac= pain


4/22

D0u9 0eaction se0u1 sic=ness' p6en/toin

Mali9nanc/ solid tu1o0s 8it6 1ets e9. HN cance0 ;ce04ical


5/22

. Hepatic 0uit 6i96tu0ulent 2lo8 o4e0 li4e0 6epatocellula0 ca' alc 6epatitis

+. Hepatic 20iction 0u in2la11ation o2 li4e0

3. (enous Hu1 ;epi9ast0ic< so2t 6u11in9 noise 8it6 s/stolic and diastolic

co1ponents' indicates inc0eased collate0al ci0culation et8een po0tal and s/ste1ic

4enous s/ste1s' as in 6epatic ci006osis

PEP - Viruses that cause hepatitis and 2 ith fecal oral spread

Hep A'$'C'D'E' E$(' CM(

Hep A and E and t0ans1itted t60u 2ecalo0al sp0ead' ot6 o2 86ic6 do NOT cause

c60onic 6epatitis*+& ,ocused liver exam - alcoholic

• Hands

• Cluin9' leucon/c6ia ;pale nail<

• Dupu/t0en5s cont0actu0e' pal1a0 e0/t6e1a' spide0 ne4i' tattoos' 6epatic 2lap' pallo0' sc0atc6 1a0=s'9ene0aliJed pi91entation

• Eyes and face

• Icte0us' c/anosis' pa0otid enla09e1ent' 2eto0 6epaticus

• (hest

• pide0 ne4i' loss o2 a7illa0/ 6ai0' 9/neco1astia

• 'bdomen

• pleno1e9al/' ascites' 6epato1e9al/' caput 1edusae

• G

• Testicula0 at0op6/' loss o2 puic 6ai0

• )eg edema

(5 yo !emale ith hx o! oliuria # ie enal ,ailure

T6in= p0e0enal' 0enal and post0enal causes

History

a1ount o2 u0ine output

p0e0enal s/1pto1s o2 6e1o006a9e' 6ea0t2ailu0e' sepsis' in2ection' 4o1itin9' dia006ea'

2e4e0' c6ills' NAID' ACEIs

ie lood loss' 1elena stools' 6e1ate1esis' c6est pain' d/spnea' o0t6opnea' !ND'

palpitations' s/ncope' diJJiness' ado pain etc. 0enal 1edications causin9 0enal 2ailu0e 0adiocont0ast' 9enta1icin' c6e1ot7 a9ents'

a1ino9l/cosides' 0i2a1pin' ci1etidine' allopu0inol' t6iaJides' 2u0ose1ide

1ali9nant HTN ;HA' lu00/ 4ision


6/22

post0enal $!H' stones ;2lan= pain


7/22

lipid lo8e0in9 a9ents do 2astin9 lipid p0o2ile' i2 total c6ol ).) o0 &D& +.*

HM" CoA 0eductase in6iito0s

+. !6a01ocot6e0ap/

t60o1ol/sis i2 1eets indications and no cont0aindications

anticoa9ulation aspi0in' 6epa0incou1adin ;3 1ont6s<

eta loc=e0s 0educe 1o0talit/

ACEin6iito0s 0educe 1o0talit/' especiall/ 9ood i2 67 CHF

nit0ates s/1pto1atic cont0ol onl/

- /efine primary, secondary and tertiary pre$ention

!0i1a0/ !0e4ention p0e4entin9 disease e2o0e it occu0s' t6e0e/ 0educin9 t6e incidence

o2 disease ;e9 i11uniJation' dieta0/ 0eco11endations<

econda0/ !0e4ention ea0l/ detection o2 disease in an as/1pto1atic pe0iod e2o0e it p0o90esses and t6e t0eat1ent 86ic6 1a/ occu0 as a 0esult o2 sc0eenin9

Te0tia0/ p0e4ention atte1pts to 0educe co1plications / t0eat1ent and 0e6ailitation'

86ic6 a0e ca00ied out p0i1a0il/ / t6e e7stin9 6ealt6 ca0e s/ste1.

(% yo man to be exmained !or decreased lun volume in le!t hemithorax # !ocus

posterior chest

Physical Examination :

Inspection 0esp. dist0ess ;Bpa0ido7ical


8/22

c6est 8all

1o4e1ent

t0ac6ea

s6i2ted

pe0cussion 0eat6

sounds

ad4ent.

sounds

4oice

sounds

pneu1o dec0. o4e0

a22ected

side

cont0alat

s6i2t

6/pe0

0esonant

dec0.

asent

none'

possile

pleu0al 0u

none

atelectasis dec0. o4e0

a22ected

side

ipsilat s6i2t dull dec0. o0

asent

c0ac=les'

0onc6ial

0eat6

sounds

ao4e

le4el o2

atelect.

1a/ 6a4e

e9op6on/

ao4e

le4el o2

atelectasis

< 2liuria history - 3H,

• !0e0enal

• (olu1e depletion L inta=eB

• !oo0 ca0diac output ;CHF' ta1ponade' MI' !E<

• 7#BDOE' o0t6opnea' !ND' an=le ede1a

• !0ecipitants# MI' HTN' 4al4ula0 6ea0t disease' con9enital 6ea0t disease' pe0ica0dial disease'

ca0dio1/opat6/' !E' 2luid o4e0load' sodiu1 0etention' salt o4e0load' d/s06/t61ia' eta

loc=e0' 0enal disease' ane1ia' 2e4e0 and in2ection' p0e9nanc/' nonco1pliance 8it6 1eds o0

diet.

•

Ris=# CAD' HTN' ca0dio1/opat6/• 6oc=sepsis L 2e4e0' c6ills' 2ocus o2 in2ection

• Renal

• "lo1e0ula0 nep60itides

• Tuula0 inte0stitial L p/elo' 6/pe0calce1ia

• ATN L 0ecent su09e0/

• Nep60oto7ic a9ents L antiiotics' cont0ast d/e' anaest6etics' NAIDs' c6e1o

• (ascula0 p0ole1s L e1oli' 0enal 4essel t60o1osis

• !ost0enal

• Ost0uction L stones' tu1ou0' $!H' st0ictu0es' clots' 0et0ope0itoneal 1ass

•$ladde0 0uptu0e L t0au1a

+< 3hest pain - 34$ anina history

• !ain desc0iption

• E4e0 6ad an/ C! e2o0eB

• :ualit/# 6ea4/' u0nin9' ti96tness' stain9' p0essu0e

• !0ecipitatin9 A990a4atin9# 8al=in9 le4elup6ill >uanti2/' 2ood' cold


9/22

• Alle4iatin9# 0est' NT" ;in , 1in<

• Radiation# a01s' ?a8' epi9ast0iu1

• Onset

• ite

• Associated /1pto1s

• N' (' diap6o0esis' palpitations' d/spnea' o0t6opnea' !ND

• CAD Ris= 2acto0s

• 1o=in9' DM' HTN' 6/pe0lipide1ia' 2a1 67 ;2i0st de90ee 0elati4e L 1ale)) /o' 2e1ale*, /o<

• !MH

• Also' p0e4ious ca0diac disease

• Meds

3< espiratory exam - emphysema

• 0nspection

• Face L dist0ess' nasal 2la0in9' pu0sed lips

• C/anosis ;20enulu1lips' 2in9e0toesnose<

• !ostu0e ; usuall/ leanin9 28d' elo8s 0estin9 on =nees<

• Nec= L accesso0/ 1uscles

• C6est L A! dia.' de2o01ities' ind0a8in9' ass/1et0/

• Resp 0ate and patte0n

• Hands L cluin9 ;not seen in e1p6/se1a


10/22

• T0ac6ea cent0al

• I1pai0ed pe0cussion note

• $0onc6ial 0eat6 sounds

• c0ac=les

*6& Post#exam probe: $$x LLL crackles

• Con9esti4e 6ea0t 2ailu0e

• Ost0ucti4e lun9 disease

• Inte0stitial 2i0osis

• !neu1onia

• Atelectasis

• !ul1ona0/ e1olus

• $0onc6o9enic ca0cino1a

• $0onc6itis

• $0onc6iectasis

• Nonca0dio9enic pul1ona0/ ede1a

71P8

• Int0oduce /ou0sel2

• Al8a/s con2i01 a9e' occupation

• Allo8 patient to state t6ei0 c6ie2 co1plaint

• Al8a/s as= aout# p16' 1eds' alle09ies' s1o=in9' alco6ol' 2a1il/ 6isto0/

• Don5t 2o09et to d0ape

*'& History and physical o! 9oint - 4 24

• History

• A9e

• "ende0 ; 1ales 1ostl/ se0one9ati4e<

• !ain# 8o0se 8it6 0est P in2la11ato0/' ot6e0 pain >5s

• Mo0nin9 sti22ness# *, 1in P in2la11ato0/' 3,*, 1in P nonin2la11ato0/

• Dist0iution o2 ?oint in4ol4e1ent

• /11et0ical' as/11et0ical

• &a09es1all

• !e0ip6e0alcent0al ;spinal dist<

• %ppe0lo8e0 li1s

• Te1po0al p0o2ile o2 disease acti4it/ ;e9. OA slo8l/ and steadil/ p0o90essi4e' 4s. 9out' inte01ittent

e7ace0ations and 0e1issions<

• De90ee o2 disailit/# 2unctional capacit/ and AD&s

• T0eat1ent

• Fa1il/ 6isto0/# A' &E' RA

• !MH# DM' I$D' pso0iasis' "%"I in2ections' 0enal disease

• Meds# diu0etics' c/clospo0in' 6/d0alaJine' p0ocaina1ide' anticon4ulsants

• E7t0aa0ticula0 2eatu0es# ;too 1an/ to list Constitutional' s=in' 1ucous 1e10ane lesions'

u0et60itis' Ra/naud5s' con?uncti4itis' "I' pleu0ope0ica0dial pain' etc.


11/22


12/22

• %A: conservative (education, 7, *7), -"A#Ds for short term

and start on a DA%D with appropriate baseline tests8corticosteroids for acute flares or bridging to onset of DA%D

Woman with hand pain, swelling in fingers

• joint pain: location, onset/duration, swelling, function of joint, ADLs• characteristics: morning stiffness, worse after rest/activity

• course: have you ever had it before (chronic/subacute/acute)

• pattern of joint involvement: other joints

• etra articular features: s!in, eyes, bowel, !idney, lung involvement, urethritis,

cervicitis, "# joints, enthesitis

• constitutional symptoms

• seual history

• past medical history

• family history (arthritis, collagen vascular diseases)

• medications, allergies• social history: smo!ing, alcohol

PEP

• ray: periarticular osteopenia, erosions

• management of %A

• patient education, eercise, *7, 7

• symptomatic treatment: -"A#Ds, corticosteroids

(intraarticular/systemic)

• DA%Ds

• 9ydroychloro.uine (antimalarial): dose 33 mg/day

• si month trial• hyperpigmentation, myopathy, rash, diarrhea, retinal

toicity

• baseline phthalmologic eam . 1 months

• ethotreate (folic acid antagonist)

• starting dose ;


13/22

• rash, myelosuppression, ?#, heartburn, diiness,

headache

• 0 with differential and chemistry profile monthly

*& 0elena - history

• ee uppe0 "I leed

Woman with acute MI complains of chest pain9istory

• chest pain

• associated symptoms: nausea, vomiting, "0, diaphoresis

• previous history of chest pain

• cardiac ris! factors

• past medical history

• family medical history

• medications, allergies

• social: smo!ing, alcohol

*hysical Bam

• general appearance

• vitals

• chest eam

• cardiac eam

#nvestigations

• 0, lytes, 0C-, r, A"7, LD9, 0ili, *7, *77

• /$0 or 7roponin #, B?

#ndications for thrombolysis

• "7 elevation 4 &mm in two contiguous leads

• new bundle branch bloc!

• within &' hours post onset of pain8 the earlier the better 2 = hours

ontraindications for thrombolysis

• recent major surgery (within '$ wee!s)

• active internal bleeding or bleeding diathesis (not including menses)

• history of hemorrhagic stro!es or any recent stro!e

• mar!ed hypertension (0*4&>3) or diastolic 4&33

• !nown intracranial neoplasm, A@, or aneurysm

• *% 4&3 min of chest compressions within 1 wee!s

• pregnancy

#ndications for Angioplasty

• trend toward lower mortality, less reinfarction, fewer stro!es when compared

to thrombolysis


14/22

• as effective but not superior to thrombolysis plus A"A

• considered for those in which contraindications eist for thrombolysis

• emergent in all patients with shoc!

Respiratory physical exam

*hysical• ?eneral Appearance

• @itals: %%

• #nspect: cyanosis, accessory muscle use, A* diameter

• *alpate: tracheal deviation, respiratory ecursion

• *ercussion: diaphragmatic ecursion, lung areas

• Auscultate

• "pecial tests: tactile fremitus, whisper pectorilo.uy, egophony

PEP

• crac!les at bases: atelectasis, pneumonia, upper border of effusion,

pulmonary edema• pneumonia $ community ac.uired

• not severe, 2 =5 years: S. pneumoniae, Mycoplasma, Chlamydia

• treatment: macrolides, or tetracycline/doycycline

• not severe, 4 =5 years E/$ comorbid: Above + H. flu, Klebsiella, Staph,

Legionella

• treatment: etended gm negative coverage F cefuroime,

clarithromycin

• treat iv< until afebrile >$;' hours then switch to p


15/22

• @itals

• -" status: alert or decreasing L

• Abdomen: E RE"#$% for melena, 0 positive blood

• "igns of chronic liver disease

old woman with asymptomatic anemia & 'istory

dd of anemia:decreased %0 production$lac! of essential nutrient (0&', folate, iron)$marrow injury (radiation)$marrow inhibition (drug, immunologic agent)$marrow replacement (neoplasm, fibrosis)$hereditary defect$endocrine problem (hypothroid, hypopituitary, renal failure/low erythropoeitin)

$idiopathic (GrefractoryH)

%0 loss (bleeding)$acute$chronic with secondary iron deficiency

%0 destruction (hemolysis)intracorpuscular defect$abnormal 9b (")$defective globin synthesis (thalassemia)$defective heme synthesis (prophyria)

$defective enyme (?=*D)$membrane defect (hereditary spherocytosis)$*-9etracorpuscular defect$primary F autoimmune$secondary:physical agent (microangiopathy)chemical agent (drug)infection (malaria, septicemia)neoplasm (especially lymphoma)connective tissue disease (lupus)

splenomegalyimmuniation (newborn, transfusion)

9#"7%I

#D: age, se, occupation9*#: how was anemia pic!ed up (i


16/22

$r/o symptoms: fatigue, "0, chest pain, palpitations, has her family commentedon her being pale or jaundiced$loo! for cause:as! about diet: 0&' and iron (meats), folate (greens)alcohol inta!e

medications: antacids decrease Je absorptionsource of bleeding (melena, hematocheia, menorrhagia, hematuria)fevers, chills, nightsweats, weight losstravel (malaria$endemia areaK, # !now this one is a stretch for asymptomatic)past history of anemia: therapy employed, response to treatmentfamily history of anemia, jaundice, gallbladder disease, splenectomy

*9: any medical or surgical illnessessmo!ing, drug allergies

15 year old with abdo cramps and diarrhea for ' wee!s $ 9istory

#D:9*#:history of diarrhea:.uantify: volume, fre.uency (is it really diarrhea defn: increase in fluidity and/fre.uency).uality: colour, consistency, presence of melena, hematocheia (blood Fcathartic)associated symptoms: tenesmus, relief with defecation, urgency,

nausea/vomiting

history of cramps: **M%"7nset: sudden vs gradual*osition: where are the cramps*rovocating/alleviating factors: foods, (chocolate, peppermint, caffeine), alcohol,drugs, stress, activity, etc<Muality: what do the cramps feel li!e (true crampy pain vs sharp/dull, etc)%adiation of pain"ymptoms associated: fever, myalgias, weight loss, chills (and those above)7emporal profile: progression of symptoms with time

ris! factors for infectious: daycare wor!er/children at daycare, outbrea!s

mechanisms of diarrheaabnormal intestinal motilityincreased permeability causing fluid/electrolyte secretionimpaired intestinal absorptionintraluminal nonadsorbable osmotically active solutes


17/22

Btiology of Acute diarrhea:#nfectiousbacterial (salmonella, shigella, campylobacter, vibrio cholerae, enteropathogenicBcoli,


18/22

hemolytic anemia: macrocytes and microspherocytes with polychromasia (morepurple)sic!le cellaplastic anemia (marrow full of fat cellsKloo!s empty)hypersegmented *-s (4$5) as seen in megaloblastic anemia (folate/0&')

AL: blasts with big, multiple nucleoli, Auer rod in cytoplasm ALL: blasts with hardly any cytoplasm, big nucleiLL: lots of small, well$differentiated lymphocytes, smudge cellsinfectious mono: big lymphocytes with indented cytoplasmspherocytes: small, round %0Os with no central area of pallor myelofibrosis: tear$drop %0Os (poi!ilocytes)

ultiple myeloma: plasma cells, %ouleau9odg!ins: %eed "ternberg cell (owlOs eyes)

'5 yo male with rohnOs disease and abdo pain $ p$ma!e sure you prepare patient properly: lighting, adjust head of bed so patientlying flat

#nspection:Btra$abdominal:?eneral appearance:

anoreia, weight loss, severe wasting due to malabsorption9ead + nec!:mouth for ulcerseyes: uveitis, chorioretinitis, iridocyclitis"!in, especially over legs:rashes: erythema nodosm, erythema multiforme, pyoderma gangrenosumthrombophlebitis

Abdominal #nspectioncontour: flat, scaphoid (malnourished), protuberant (fat, fluid, feces, flatus, fetus,fatal growth/aneurysm), distended (lower P F pregnancy, fibroids, ovariantumour, upper P F gastric dilation, left lobe of liver)scars (past h surgery)visible peristalsis (bowel obstruction)visible pulsations (aneurysm, probably normal in thin person)hernia

Auscultationbowel sounds


19/22

$must listen for full 5min before saying absent$increased F early pyloric/intestinal obstruction, diarrhea$absent $ ileus, (also uremia, spinal cord injury)$can also listen for bruits (renal/iliac, liver in hepatic A/alcoholic hepatitis),venous hum or friction rubs over liver and spleen (rub only, meaning infarction)

*ercussion$as! about pain first$percuss lightly in all .uadrants$usually tympanic, identify air in stomach and bowel, and suprapublic dullness

*alpation$watch patientOs face, as! patient to point to area of ma tenderness$peritoneal inflammation: cough, suc! in abdomena) light palpation$areas of tenderness, guarding, masses

b) deep palpationA"": consistency, contour, sie, mobility, pulsation, tenderness

Liver percussion$start below umbilicus in midclavicular line and percuss upward to find lowerborder $start at nipple line and percuss down to find upper border Liver palpation$place hand well below lower border of liver dullness and press gently in and up$as! patient to ta!e deep breath$if palpable edge, find the medial and lateral edges

"pleen (see previous eam)idney (wonOt be part of rohnOs physical eam)

(5 yo 5yr hx of !ac)pain and morning stiffness - pxInspection$difference in height of shoulders, iliac crests, s!in creases$genus varum/valgus, popliteal swelling (0a!erOs cyst)$posture$spinal curvature: normal is cervical concavity, thoracic conveity and lumbarconcavity (in an!ylosing spondylitis get loss of normal lumbar lordosis andincreased thoracic !yphosis)$s!in abnormalities: psoriasis, scars$muscle bul!: buttoc!s, hamstrings, gastrocnemiusPalpation$do with patient prone


20/22

$spinous process with thumbs, fist percussion, muscle spasmRange of Motion$patient supine"-spine*$fleion $ chin to chest

$etension: loo! at ceiling$rotation: chin to shoulder $lateral bending: chee! to shoulder #-spine*$chest epansion measured at nipple line (7) should be 5 $ = cm%-spine +decreased mo!ility in an)ylosing spondylitis and $*$forward fleion: touch the floor with legs straight$stabilie pelvis for etension, rotation and lateral bending$lateral fleion: finger to fibula distance$rotation: to stabilie patient put one hand on iliac crest, other on oppositeshoulder

ait*$normal: hip abductors of weight bearing joint contract and raise opposite pelvis$7rendelenberg/waddling gait: pelvis drops on opposite side when weight isplaced on the affected side (dislocated hip, wea! abductors)$heel wal!ing (dorsifleion) and toe wal!ing (plantarfleion).upine$straight leg raising$chec! "# joint:fle hip and !nee against abdomen and hyperetend opposite !nee, loo!ing for"# pain on hyperetended sidesacral compressionProne$femoral stretch: bend !nee until fully fleed or pain in anterior thigh$hip etension%ateral /ecu!itus$sacral compression test ("# joint)$power: hip abductors, gluteus medius (L5)$rectal eam for sphincter tone, perianal sensation

$offer to also do a neurological eam for power, sensation and reflees and theywill refuse

Qchec! "# joint thoroughly since sounds li!e an!ylosing spondylitis scenario, alsochec! for etra$articular manifestations of an!/spon:

$anterior uveitus, (136), aortitis, aortic regurgitation, cauda e.uinasyndrome


21/22

01 yo with palpitations, irregular rhythm and fatigue - hx

9*#:$symptomatology: onset, provocation/alleviating factors, temporal profile, i


22/22

*revious surgery:$terminal ileal resection (no bile salt reabsorption)

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