Download Practice of Medicine-1

Practice of Medicine-1
Take Home Exam
April 18th – April 26th, 2004
Please fill in name and SSN where requested.
NAME______________________________
SSN________________
"PLEDGE: On my honor as a student I have neither given nor received aid
on this examination.
___________________________
___________
NAME: _________________________
INSTRUCTIONS FOR TAKE-HOME EXAM
1. This is an open book exam, but it should be your own work only. Do not
discuss the questions or your responses with anyone – fellow students,
friends, family, e-mail advisors, you name it. Answers will be based on
lecture notes, assigned readings, your two textbooks and material in the
course handbook and small group guides, as well as library research.
2. There are two cases on this exam. Each case is accompanied by one
question. Each question requires a brief essay answer.
3. This exam is worth 20 points toward your first semester grade. Each case
is worth 10 points.
4. Post questions regarding the exam to the Practice of Medicine discussion
group, located on the Practice of Medicine web page. This will be checked
several times daily, allowing all of your classmates to see responses to
questions about the exam. Beginning on Friday April 22nd, after 5:00 p.m.
and over the weekend, please send questions about Part 1 to
[email protected] and questions about Part 2 to [email protected]. We
will send your question and the answer to the entire class.
5. Please type your name at the top right-hand corner of each page, where
indicated.
6. You may respond directly beneath each question, or on separate pages.
Exams must be completed on a word processor. Hand-written exams will
not be graded. Please use a size 12 or larger font. Please limit responses
for each question to no more than one page in length.
7. Your take-home exam is due at 9AM, April 26th. It should be typed and emailed to Robin Stevens, [email protected]. E-mail the entire
exam, including the first page, to Robin Stevens as an attachment. The file
name for your exam must be exactly like this: first and last name_pom
2005 spring take home.doc. For example, John Gazewood_pom 2005
spring take home.doc. Fill out the front page (your typed name will be
accepted as a signature). And be sure your name is typed in the top right
hand corner of each page!
8. You will note that the exam is separated into “Part 1” and “Part 2.” Dr.
Bargmann and Dr. Gazewood will each grade one half of the exam.
Please be sure that your responses to Part 1 and Part 2 are on separate
pages, to allow for distribution of your answers to the appropriate person.
2
NAME: _________________________
Part 1 begins here
Part. 1
68 year old Harold Moore comes to you because of episodes of chest tightness
that have occurred for around two months. His tightness occurs mainly when he
carries bags or books up stairs and improves with rest. It has not occurred more
often over time.
He has had no fever, no edema, and no orthopnea or paroxysmal nocturnal
dyspnea.
Past Medical History:
Heart murmur
High cholesterol
Medications:
Cholesterol pill daily
Aspirin one tablet daily
Family history:
Father died at 38 in an automobile accident. Mother died of pneumonia at 88. No
known heart disease.
Social history:
He has never smoked and rarely has an alcoholic beverage. He is happily
married with two grown children. He is retired.
Physical Examination:
He is comfortable and in no distress. Blood pressure is 130/82, pulse 72 and
regular, respirations 16.
Neck: no thyroid enlargement, no jugular venous distension
Chest: clear to percussion and auscultation
Heart: Easily palpable PMI in fifth intercostal space at midclavicular line. No thrill,
lift or heave. Regular rate and rhythm. Loud systolic murmur easily heard at his
right sternal border, left lower sternal border and apex. Very brief sound, heard
only with the bell of the stethoscope at the apex, almost at the end of diastole.
Pulses: carotid 1-2+, a bit slow on the upstroke. Radial 2+ and equal.
Extremities: no cyanosis, clubbing or edema.
1. Explain his diastolic sound. What is it? What does it mean?
2. What are some possible causes for his heart murmur and chest tightness?
Give three possible diagnoses that could cause these findings, and explain what
aspects of history and physical exam make each more or less likely.
Say which one you think is most likely, and why.
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NAME: _________________________
Part 2 begins here
Part. 2
You are a third-year medical student caring for a 68 year/old African-American
woman who was admitted to the hospital one week ago for treatment of a
bacterial infection in an intravenous catheter used for dialysis. She is responding
to treatment, and the interventional radiologists were able, with great difficulty, to
replace the catheter. They will not be able to replace it again. The patient has
had end-stage renal disease and has been on dialysis for many years. Due to a
clotting disorder, she has had many different vascular grafts and catheters
placed for use in dialysis that have failed, and is not a candidate for
transplantation or peritoneal dialysis. All potential sites for dialysis have been
used, and the patient has this one remaining catheter – placed in the lumbar
artery and vein – for dialysis. The nephrologists, the interventional radiologists,
and the vascular surgeon who specializes in obtaining dialysis access all agree
that when this catheter stops functioning and cannot be replaced, which is
inevitable, the patient will no longer be able to receive dialysis and she will die.
The patient wants to remain a “full code” – to be resuscitated if her heart stops
beating or she stops breathing. She is reluctant to discuss end-of-life issues. Her
two sons and three daughters are very supportive and involved, are aware of the
precariousness of her situation, and want “everything done.” They also want her
to be a “full code.” They too are reluctant to discuss end-of-life issues, and
express to you that “everything is in the Lord’s hands.” Your resident is growing
frustrated with this family, and explains to you that “coding” – attempting to
resuscitate – this patient will be futile. Once she can no longer receive dialysis
she will die, and coding her will only serve to prolong her dying. Your resident
does not believe that he could, in good conscience, attempt to resuscitate her,
despite her and her family’s wishes – he thinks it would not be in her best
interest. Your resident believes you have a good relationship with this patient,
and wants you to talk to her and her family.
Before you talk with this patient and her family, you decide to spend some time
analyzing the situation and thinking about possible strategies that might help the
patient and the family.
Briefly describe the issues in this situation, other information that you need to
better understand the patient and her family, and potential strategies for working
through this situation with the family. (These strategies can include asking for
help from other “experts.”)
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