Part 1Name______

Practice of Medicine-1

Take Home Exam

November 12th – November 19th, 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.”

______

1

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.

  1. This exam is worth 20 points toward your first semester grade. Each case is worth 10 points.
  1. Over the weekend, please send questions about Part 1 to and questions about Part 2 to . We will send your question and the answer to the entire class. Beginning on Monday, Nov 15th, 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.
  1. Please type your name at the top right-hand corner of each page, where indicated.
  1. 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.
  1. Your take-home exam is due at 9AM, November 19th. It should be typed and e-mailed to Robin Stevens, . 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 2004 fall take home.doc. For example, John Gazewood_pom 2004 fall 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!

1

NAME______

  1. 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.

Part 1 begins here

Part. 1
Jack X is a 65 year old man with paranoid schizophrenia who has lived in a community residential facility for the mentally handicapped for eight years. He did well with medications, and five years ago he married Anne, a mildly mentally retarded woman in the same facility.

His schizophrenia has become resistant to medications, and for the past three months, he has increasingly refused to eat or drink because he is convinced that the water in the facility is poisoned. For almost two weeks, he would not eat or drink at all. When he became increasingly lethargic and then unarousable, the facility sent him to the hospital.

In the hospital, he has received intravenous (IV) fluids and has become alert again. Anne stays by his bedside night and day. With her encouragement, he is eating a bit and taking (sealed bottled only) water. But his kidney function has not improved at all. And he has been pulling out his IVs, saying that the IV fluid is poisoned, too.

Anne won’t let the doctor speak to Jack directly. She won’t tell Jack that his kidneys have failed and refuses to let the doctor tell him, saying that this will just upset him more. She says that he definitely doesn’t want dialysis and that God will heal his kidneys if He chooses to.

His doctor, a nephrologist, is convinced that Jack needs dialysis, and soon. He is fairly certain that Jack will need lifelong hemodialysis. Jack will need to be sedated to be dialyzed. If he is dialyzed, Medicare and Medicaid will pay for it in full.

The doctor calls you for an ethics consult. Identify the problem and the issues you’ll need to address. You need not come up with a “right answer.”

(Please be brief – limit your response to 1 ½ pages or less.)

Part 2 begins here

Part 2. A patient with shortness of breath.

Mr. Z is a 64 year-old man who has been healthy who comes into the office with a chief complaint of shortness of breath. Mr. Z began feeling short of breath several months ago, when he noticed that he felt winded after going up a flight of stairs. Since that time he has become progressively more short of breath. For example, he has to stop halfway up a flight of stairs now to catch his breath, and he has to sleep sitting up on several pillows. He has also developed a dry, nagging cough that won’t go away. He comes in today because he wants to find out why his breathing won’t get better, even after quitting smoking 1 month ago.

He also notes that he has not had as much energy the last few months, and has lost a few pounds. He has a chronic morning “smoker’s cough” that he has had for 5 or 6 years. He has had no fevers or chills.

He has no other medical problems, doesn’t see the doctor regularly. He takes an aspirin a day. He smoked a pack of cigarettes a day for 45 years until quitting 1 month ago. He has an occasional beer. His family history is remarkable for hypertension and diabetes.

He is married, works as a sales manager, and has two grown children. He enjoys gardening and golf.

Physical Exam

Vital signs: T 37°C, P 84; R 20; BP 134/72.

General: No acute distress, appears about stated age.

Head, eyes, ears, nose and throat: Normal

Neck: Normal

Heart exam: Normal

Chest exam: Increased AP diameter. Symmetric excursion. Resonant to percussion on right. On left, resonant to percussion upper lung, dull to percussion over lower half of left lung-field. On auscultation, Right lung has normal breath sounds with a few rhonchi and slight expiratory wheezing. Left upper-lung field has similar findings, but halfway down the left lung field there are crackles, and below this, in the lower half of the lung-field, breath sounds are not heard.

There is a decrease in tactile fremitus over the lower lung field on the left.

You notice no e to a change.

Abdomen: The abdominal exam is normal.

The remainder of the exam is normal.

Question

Develop a differential diagnosis for this patient. Provide three potential diagnoses, identify the one you think is the most likely diagnosis, and provide your reasoning. The reasoning would include which features of the patient’s history and physical findings “fit” or “don’t fit” with each potential diagnosis, and why you believe the most likely diagnosis best explains the patient’s illness. You will be graded on your reasoning, not on whether or not you achieve the correct diagnosis or differential. You may use additional resources other than course materials. Please provide a reference if you do use an outside resource. This should take you no more than 1 ½ to 2 pages.

1