Available in Packages: PRESENT Podiatry Board Review w/ Boards By The Numbers
This 2nd part of Dr. Schuberth's board preparation lectures focuses on the oral exam. In particular, he offers a mock oral exam presenting 3 practice questions with appropriate responses. These practice questions demonstrate how a candidate should organize their thought process to successfully complete the examination. Detailed step-by-step analysis of the "points to pass" for each practice question is provided along the way.
John Schuberth, DPM
Chief, Foot and Ankle Surgery
Kaiser Foundation Hospital
San Francisco, CA
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Jack Schuberth: Now, I’ll let you listen to a strategic plan for taking the examination. Let’s try to employ some of these concepts. Be ready to pause the presentation at any point so that you can organize your thoughts, again, the prevailing theme in this practice session. There are numerous philosophies on how this can best be accomplished but I’ve chosen a way that will integrate with the prior presentation, and hopefully, will get you accustomed to actually taking the examination. Perhaps the most effective way is to actually give you a practice examination. Most importantly, it will help you think through a specific question regardless of the subject matter. It really serves little purpose to try and predict what questions will actually appear on the examination. Furthermore, remember that the successful candidate will have a process that is organized, logical and succinct regardless of the topic. But no specific technique will substitute for a lack of understanding of the surgical fundamentals, a good knowledge base and a rational approach to the examination. During this two-part series, we’re going to try and cover all of the important subcategories of subject material. As you can gather from the ABPS website, there are actually seven areas that comprise the material for the examination. And they are biomechanical and acquired deformities, congenital and/or pediatric deformities, infections, metabolic conditions and/or emergency medical management, neoplastic conditions such as primary or metastatic tumors, traumatic conditions and lastly, surgical or traumatic complications. In Part I of the mock oral examination, we’re going to cover the first three topics. And then the second part of this practice endeavor, we’ll cover the last three. As you can see, the subject of metabolic conditions and emergency medicine will be omitted. I chose to eliminate this one because in my mind, there is little to say about emergency conditions other than read the book. In other words, remember the basics of resuscitation, save the life or limb and think horses not zebras when there is trouble. To capitulate, know how to recognize and treat anaphylactic shock, drug overdose, toxic drug reaction, such as an overdose of Xylocaine, pulmonary embolism and DVT, intraoperative MI, respiratory arrest and other entities that may cause to the demise of the patient. Now, remember that you only have to provide the cure that would be expected of you not that expected by a board-certified internist, allergist, or anesthesiologist. Yes, you may have to identify the V-tach on a rhythm strip, but diagnosing an inferior or lateral MI is well beyond the scope of this exam and presumably your own skills. The format that we will follow is rather simple. We’re going to present the case and then give you a proposed line of questioning, just as the examination does. What we’ll add is the expected responses, the thought process and rationale and were appropriate key statements that should be made by the candidate in order to elicit the information to get the question right. It is expected that you pause the presentation each time before you go on to the next slide or series so that you can actually organize your thoughts. Use the pause button liberally so that you get the most benefit from this part of the presentation. Although this is a controlled environment, the listener will sense a pattern, a pattern that will become the blueprint for successful navigation through the examination. Question one, a 35-year-old healthy female comes in to your office complaining of pain in the ball of the right foot for nine months’ duration. She was seen by another doctor, and given a cortisone shot which helped for about two days. The pain is aggravated by shoe gear and ambulation and relieved by rest and removing the shoe. Please discuss your evaluation, diagnosis and treatment plan for this patient. Okay. Now, you have some of the question in front of you and it’s time to refine the information given so that you can focus your thought process. Please pause and before you go on to the next slide, think about what you might want to ask this patient if she were sitting in your office. Think about those questions as you would ask to get the most information, again, remembering that this is a testing situation. You don’t have your patient information form in front of you as you would in your office.
The questions that I would ask, although not necessarily in this order are, “Mrs. Smith, you say that you’re healthy, does this mean that you're not taking any medications and you’re not being treated for anything by your regular MD?” Number two. “Can you be more specific as to the type and location of your pain? Is it burning, radiating, sharp, or a dull ache?” Number three. “Was there any history of injury or change in activity just before the onset of symptoms?” Number four. “What did the other doctor tell you your diagnosis was?” And lastly, “Do you have any allergies?” Okay. So now, why these five questions. Let’s take each one of them in isolation and show how each one helps to qualify the patient profile and provide you with useful information. The first one is simplistic but it compels the examiner to disclose to you the overall condition of the patient. He or she may dismiss this question by telling you, “Yes, doctor, the patient is healthy, please move on.” Or the examiner might tell you that the patient takes prednisone and her rheumatologist treats her for lupus. But the latter is unlikely because no one would consider someone with lupus healthy. Nevertheless, you now know that in this case healthy means healthy. The examiner is also highly unlikely to tell you that the patient takes legal thyroid if there is no bearing on that medication for the rest of the question. However, most doctors would consider patients healthy that take only thyroid supplements. Just to twist this scenario a bit more. Suppose that the examiner did say that the patient did take thyroid, you might then follow up with why. That scenario might evolve into idiopathic hypothyroidism which of course would have nothing to do with the foot problem or secondary to a thyroid tumor. In that case, you might quickly shift gears to consider the workup of a metastatic thyroid tumor. But naturally, the latter cause would not be consistent with the symptom complex presented here. So hopefully, you can see what that first question has the capacity to tell you that the patient is taking no medications and is not being treated for any condition. The second and third questions really start to get into the case at hand. We know that there is forefoot pain that is made worst with ambulation and shoe gear and this can send mixed messages to any doctor. Let’s get the refinement from the patient. Of course, already the differential should be in your head. Pause the presentation and think about the differential before you go on to the next slide based on the information that you have elicited or has been provided to you already. The differential diagnosis, in my mind, should include neuroma, capsulitis or a metatarsophalangeal joint disorder, stress fracture or any rheumatologic condition. The patient examiner says, “Doctor, the pain is located just under the ball over the middle two toes and is very deep and severe with each and every step I take. And no, doctor, there was no injury. The pain just came on gradually.” All of a sudden, the differential becomes narrow to the first two, a neuroma and a second, third metatarsophalangeal joint problem. Now, we can ask about prior treatment but don’t be fooled about prior treatment. As you know, the past diagnosis may be dead wrong just as in real life. Yet, the board process is such that distracters like this are only placed if there is a usual purpose to the flow of the question or they are attached to a point to pass. The patient responds, “The other doctor said something about a pinched nerve between my first and second metatarsals, so we injected it.” Now, this was a key response. It does two things or at least it should do two things. First, it should invoke a sense of suspicion that the diagnosis may be wrong. How many neuromas are present in the first intermetatarsal space? There is one more key, but I’m going to leave it alone for now and come back to it. The last question is easy. But remember if there is an allergy, think about the alternative medications for a given condition. For the purposes of this question, however, the patient reports no allergies. By now, you should have concluded that you’re dealing with a very healthy female with pain in the forefoot. It’s made worst by weightbearing. It’s time to examine the patient. Sometimes, you might be supplied a picture. But in this case, we’re not going to provide because I want you to get the hang of focusing on your examination based on the information that you have elicited or that has been provided to you.
You may want to ask, “Well, what does the foot look like?” Then the examiner will most likely direct you to be more specific, meaning that they want you to continue with a more detailed examination. Keeping in mind what are differential diagnoses of neuroma versus metatarsalgia, you might want to focus on the forefoot. Personally, I would begin at the second metatarsal and third metatarsophalangeal joints and ask if there were any areas of erythema, warmth or nodularity or tenderness to palpation. The examiner would respond by saying that there is indeed tenderness to palpation over the dorsal aspects of the second and third metatarsophalangeal joints as well as diffuse plane plantarly over the same area. Now the question arises, now what? You can go several different directions. One is to jump right to the neurologic examination. But I don’t recommend this approach because it distracts your thought process and in a sense jumps around. Rather, I would focus on the biochemical aspects of the examination. Think of those things as you would want to know from a biomechanical standpoint that can cause pain at the second and third metatarsophalangeal joints before you move in this presentation. Please pause and enlist those factors in your mind. These factors are hallux valgus, a hypermobile or insufficient first ray, hallux rigidus or equinus. What’s important here is that the candidate formulated a differential diagnosis based on what already is known. Note that there is absolutely no mention of a short first or a long second because these things cannot possibly be known at this time without seeing a radiograph. Examination should focus on those parameters that should be determined for each of these factors. To reiterate, they are hallux valgus, hallux rigidus, first ray insufficiency or hypermobility, second and third metatarsophalangeal joint instability via the so-called Lachman test and equinus. Here are the following positive responses that you will get back if you ask for this information. Often, a sheet of paper with all this information written out is placed in front of you so that you can refer to it easily. There is 75 degrees of dorsal flexion and 25 degrees of plantar flexion of the first metatarsophalangeal joint without pain or crepitus. The first ray range of motion has eight millimeters of dorsal excursion and two millimeters of plantar excursion. There is no evidence hallux valugus. The toe is aligned well when the transfer is planned. The second and third metatarsophalangeal joints do not appear to be well located and the proximal phalanges can easily be displaced superiorly with dorsal pressure. Ankle joint dorsiflexion shows minus 15 degrees with the knee fully extended in the subtalar joint neutral and a positive 10 degrees of dorsiflexion with the knee flexed in the subtalar joint neutral. Lastly, the hindfoot range of motion is otherwise normal, including a subtalar joint and the midtarsal joint. Excellent biomechanical profile but you’re not finished with the physical exam. Certainly, you’d like to ask about muscle testing and ask about the other foot. The examiner respond, at least in this case, the muscle testing is normal and so is the other foot. Now, you should decide what’s next. What would you do if this patient was sitting in your office? Pause the presentation and think about where you’d like to go from a physical exam standpoint to get enough information to treat this patient in this testing situation. Certainly, you’d like to ask about pulses and capillary refill and also any dermatologic conditions. In the context of this case, specifically, you’d like to know if there are any callosities on the ball of the foot and certainly any other dermatologic lesions. For this question, the examiner tells you that there are no derm lesions and the circulation is normal. The final physical exam component is the neurologic exam. This will help you cement the diagnosis. Of course, you want to do a detailed neuro exam, including a sensory, the parameters to the adjacent sides of the first and second toes, the second and third toes, the third and fourth toes as well as the rest of the dermatomes. The examiner responds, the neurologic examination is completely normal, and then ask you to go on.
Most likely, the examiner will ask you, “What diagnostic studies would you order for this patient?” Here the temptation is to order every test and see if they have it. But obviously, you want to start with plain radiographs. It’s always best to order more than you need as impractical as it is because if you don’t ask for it, you may not get it. The examiner is obligated to give you what you ask for each and every time. Once you have the radiographs, it’s usually time to interpret them. Radiographs that have been presented to you. The examiner will often prod you by saying, “Can you please interpret what you see?” Remember that you should read the x-rays first as a radiologist and then as a foot surgeon. Study them and formulate your radiology report before you proceed. Please pause the presentation. The candidate should disclose that this is an AP oblique and lateral of the right foot. One should comment on the bone density which appears appropriate for this patient’s age. Now look at the joint spaces of the other joints, then go on to discuss the pertinent and alignment issues. Obviously, there is a dislocation of the second and third metatarsophalangeal joints with the dorsal lateral displacement. Also note the cortical hypertrophy of the central metatarsals. As far as the first ray, there is clear elevation and perhaps a hallux valgus. But remember from the examination that the first metatarsophalangeal joint range of motion was not limited. So when you consider your diagnosis, take that into account. Certainly, one can comment upon the increased hallux abductus and intermetatarsal angles. Lastly, what about the length pattern of the metatarsals? Note that virtually all of these findings are pertinent to the management of this particular patient. Now that you have evaluated this patient, the examiner will likely say, “What is your diagnosis of this patient?” The candidate should now assimilate all of the information and portray it in a concise fashion. Please pause the presentation and formulate your diagnosis. The correct diagnosis is, central metatarsalgia or overload, subluxed or dislocated second and third metatarsophalangeal joints and elevated or hypermobile first ray, and lastly, gastrocnemius equinus. The examiner will then go on to ask you, “What are the surgical options for this patient?” Note that in this case, the examiner qualified that nonsurgical options were not desired, so you can go right in to the surgical treatment. Now that you supposedly know the diagnosis, you can start cutting. Keep in mind that you may have missed the diagnosis or a component thereof. But you can still do the operations. Although you’ve heard this before, remember that you are not penalized for missing prior portions of a question. If you do miss one, don’t dwell on it because you can be redeemed. This situation is called double jeopardy and it’s always avoided in the examination questions. A good example of this is that if you failed to mention the equinus. You would notify the gastrocnemius equinus was present on the datasheet. So the examiner is likely looking for an approach to the gastroc equinus and will remind you to address it if you happen to fail to mention it when you were reciting the diagnosis. Surgical treatment for this patient should consist of a gastrocnemius recession, a plantarflexory osteotomy or Lapidus procedure of the first ray, a flexor tendon transfer or plantar plate repair of the second and third metatarsophalangeal joints and a possible hammertoe correction of the second and third digits, meaning fusion or resection of the head. Any other operations may be indicated but are not part of the question in this particular situation. Now, in many cases, this will conclude the question and it will in this case. Let’s go over the points to pass. As you sit there, you really should have no idea what the points to pass were on this question really were. That’s the whole concept. The first point to pass for this question, was one where the candidate correctly formulated a differential diagnosis that included neuroma, capsulitis or metatarsophalangeal joint disorder, a stress fracture or rheumatologic condition.
The second point to pass, was that the candidate correctly interpreted the radiographs and included the following observations. The firs metatarsal was elevated on the sagittal plane. There are dislocated second and third metatarsophalangeal joints. And lastly, there is cortical hypertrophy of the central metatarsals. The next point to pass was that the candidate made the correct diagnosis that included sub second or third metatarsalgia or overload, dislocated second and third metatarsophalangeal joints and elevated or hypermobile first ray, and lastly, gastrocnemius equinus. The next point to pass is that the candidate formulated a logical surgical treatment plan that included gastrocnemius recession, plantarflexory osteotomy or Lapidus procedure of the first ray, flexor tendon transfer or plantar plate repair for the dislocated metatarsophalangeal joints, and lastly, possible hammertoe procedure, meaning the fusion or phalangeal head resection. Now that you’re done with this question, let’s provide a little analysis. Hopefully, you will have cultivated some skill during the first question. That should be put to use for the remainder of this exercise. This was an extremely straightforward question in which we allow tremendously way in the answers. However, this is not always the case. There’s a question dealt with fundamental information that every foot and ankle surgeon should have at the tip of their tongue. There really should be no excuses for missing this particular question. Although you may not think necessarily exactly the way that I did in this question, you should really be in the ballpark. Good luck on the second question. Question two, you are called to the nursery to examine a one-day-old male child. The pediatrician tells you that the feet are crooked. Please discuss your evaluation, diagnosis and treatment plan. Here’s a clinical photo of one foot of the child at birth. You can toggle back and forth between these two slides to study some of the question and the picture simultaneously. As suggested, here’s a dorsal and plantar view of the patient’s right foot. You can assume that the left foot looks exactly the same. For the purposes of this question, we’re going to deal only with the right foot and assume that the situation is bilateral. They just want to do when they are given a clinical photograph is to jump right to the examination. However, one should remember that this mentality will only get you into trouble. If you are tempted, most but not all of the examiners would stop you and say, “Isn’t there something you’d like to know before you examine the patient?” Well, obviously, the history of present illness and past medical history of the child is irrelevant. Yet, there are some key questions that one should ask the parents regarding most congenital deformities. Pause the presentation and think of those questions before you proceed to the next slide. Those questions are, is this your first child? Is there any family history of this or any other congenital deformities? How long was the gestation? And lastly, what were the Apgar scores? These questions are important for a variety of reasons but it gives the surgeon some idea of the child’s overall delivery and gives important historical information that should be passed on to the parents. For example, the first born of mothers typically is sustained in utero with less amniotic fluid, a condition known as oligohydramnios. This has been shown to increase the incidence of positional congenital deformities, simply because there is insufficient fluid in which the fetus can float. The second question plays as a genetic question in the perspective. Parents are quite curious as to the likelihood of passing this straight on to subsequent children or for that matter, the likelihood of the child itself passing it on. The length of gestation is important to qualify the child’s overall maturity. In other words, premature infants present a higher risk of anesthesia should any surgery be necessary. Lastly, one would like to know the Apgar scores at birth to again give some insight as to the health of the newborn baby. Once the candidate has indicated the questions that should be asked, the examiner would direct him or her to proceed with the examination. The candidate should now formulate a plan for examination and characterize the key components of that examination.
Pause the presentation and think about those issues that should be explored on the initial exam. The key components of the examination are reducibility of the abduction, the stability or congruency of the hips, the position of the hindfoot or heel, and lastly, muscle tone. Candidate is now asked to describe his or her examination technique to determine the rigidity of the deformity. Please pause the presentation and think about how you would do this if you were presented with this young patient in real life. The key components are, one thumb in the space between the cuboid and fifth metatarsal as seen here. The other hand grasps all the metatarsal heads in the hallux as seen in the photograph. The heel should be placed in neutral and a gentle abduction before should be applied against the stable fulcrum as seen in the photograph. Although this is difficult to translate in a testing situation, the point is that the candidate should be adept at describing clinical maneuvers to the examiner. Remember, in part one, we talked about putting yourself in your office or in this case, the hospital and just describing your experience. It isn’t really as hard as it seems and what’s in practice will become second nature. The examiner will then ask you, “What can you conclude from this photograph?” The candidate should respond that the deformity is reducible because of the forefoot can be abducted past the midline. The next part is how would you manage this patient? The newborn child with the reducible but clinically evident metatarsus adductus should be treated with serial casting. Well, this child was not treated and presents three years later by the parents. Well, the chief complaint that the child trips a lot over his own feet. Here is a clinical photograph of the child at that time. Proceed with your evaluation but before you do, pause and think about what you will do from a history and physical standpoint. The candidate should update the history specifically this should include the age when the child began to walk and any major illnesses or injuries. The examiner will then go on to ask, “How would you conduct your physical examination of this child?” Again, think about what really needs to be determined. The examination should be focused upon the foot and the neurological component specifically. You’d like to know the rigidity of the deformity, you’d like to do a gait examination, note whether there’s any pathologic reflexes, the overall muscle tone and lastly, the suppleness of the hindfoot. The candidate is then told, the deformity is not correctible with passive manipulation. How would you proceed from here? Here are some radiographs of the child at this time. Pause the presentation and study them before you move on. On these radiographs, the candidate should recognize resistant metatarsus adductus. They should note the talocalcaneal relationship. They should note the metatarsal basis around it instead of squared off as would be seen in an older child. They should note the hallux adductus. And lastly, the fact that the epiphysis are open. Although this latter point is rather obvious, it really must be mentioned as part of the radiological report. The candidate is then asked, “How would you treat this child surgically?” Pause the presentation and formulate a surgical treatment plan in your mind. The most appropriate surgical care for this particular child would be release of the tarsometatarsal joint ligaments. The candidate is then asked, “How would you stabilize the procedure?” The candidate should respond, K-wire fixation. The child’s parents refuse a surgical procedure and come back at age 11, all other aspects of the history are the same except that the child now has difficulty finding shoes. Here are the radiographs of the patient at this time. Again, pause the presentation and formulate a radiologic report.
Well, in this case, we're not going to ask you for your radiology report. Instead, we're going to go right into the surgical treatment. The candidate is asked, “How would you treat this patient surgically?” Pause the presentation and formulate a plan. The most appropriate way to address an 11-year-old with persistent metatarsus adductus is with pan metatarsal based or shaft osteotomies. The candidate is then asked, “How exactly would you do it?” We would like you to include as much detail as possible, almost as if you were dictating an operative report. The key components are working lateral to medial, oblique or transverse-based osteotomies. One can also choose to do a transverse-oriented osteotomy or the so-called leopard procedure. The osteotomy should be fixated with a screw or K-wire. And lastly, the osteotomy on the first metartarsal must be distal to the physis. That concludes the second question. Now, let’s go over the points to pass. The first point to pass would be that the candidate took an appropriate history on a newborn child to include the following components. Is this your first child? Is there any family history of this or any other congenital deformities? How long was the gestation? And lastly, what were the Apgar scores? Second point to pass was that the candidate recognize the integral components of a newborn child with metatarsus adductus. These include reducibility of the adduction, disability or congruency of the hips, the position of the hindfoot and an overall assessment of the muscle tone. The next point to pass was that the candidate knew the key components to the manipulation of metatarsus adductus. These include one thumb should be placed in a space between a cuboid and fifth metatarsal, the other hand on the metatarsal heads, the heel must be placed in neutral, and lastly, a gentle abductory force should be applied against the stable fulcrum. The next point to pass is rather simplistic. All the candidate needed to recognize in this newborn child was that the metatarsus adductus was indeed flexible. The next point to pass, assess the candidate’s ability to modify an examination appropriate for a three-year-old child that presents with metatarsus adductus. The candidate should have assessed the rigidity of the deformity, should have performed the gait examination, should have elicited the presence of pathologic reflexes, assess the overall muscle tone, and assess the suppleness of the hind or midfoot. This point to pass evaluated the candidate’s ability to interpret an AP radiograph on a three-year-old child. These components include the fact that the metatarsus adductus is still present, some comment on the hindfoot relationships, specifically the talocalcaneal angle, the fact that the metatarsal bases were rounded instead of squared off, the presence of hallux abductus, and the fact that the epiphysis was still open. The next point to pass assess the candidate’s ability to properly care for a three-year-old child with metatarsus adductus. All that needed to be related was that the surgeon would have performed tarsometatarsal joint ligament releases in this three-year-old child. The next point to pass assesses the candidate’s knowledge of dealing with an 11-year-old with metatarsus adductus. The appropriate answer was performing metatarsal osteotomies on all five metatarsals. The last point to pass in this particular question was that the candidate could identify these key features of a pan metatarsal based osteotomies. The key components include working lateral to medial, doing oblique or transverse-based osteotomies or the transverse-oriented osteotomies, the so-called leopard procedure, using screw or K-wire fixation, and the fact that the first metatarsal osteotomy must be performed distal to the growing physis. Well, as you can tell, that question was kind of a complete survey of the surgical management of metatarsus adductus. Again, don’t fret if you miss some of the points to pass.
The purpose of this exercise was to get you to think, and more importantly, organize your thoughts. Now, remember that I have not field tested these questions. In fact, each one of them merely represents the way that I approach this particular clinical problem. Now, that may or may not be the exact way that you would do it in real life, but I’ve tried hard to place you into an examination setting. For the last one of the series, try and organize your thoughts ahead of this slide so that hopefully, the flow will become easier. Try and push yourself in your own environment back home. Pretend that you’re in your hospital in your office where you’re quite likely to practice good medicine and common sense. This will help immensely when you actually sit down to take the examination in June. Okay, let’s move on to question three. A 40-year-old male presents to the emergency room with a painful foot. He states that he noticed the foot becoming a bit more red over the past few weeks but only during the last few days did he have enough pain to want presentation. Here are some clinical photographs of the patient’s foot. Please discuss your evaluation, diagnosis and treatment plan. So you should pause the presentation and study them carefully. As you studied those pictures, you should have organized your thoughts. From the looks of this photo, you can already tell that this question could go anywhere, but at least the catapult point will be consistent and predictable. You have taken care of this patient many times in your practice and/or your residency. Although the stakes are high in real life, a common sense approach will most likely prevail as it will in this test. Here, the focus on the question is really a bit different. What do you really want to know to take care of this patient? Well, the essential information that you want to know are the following. You’d like to know what medications this patient is taking. You’d like to know if the patient is diabetic, and if so, for how long. Lastly, are there any fever, chills, malaise, night sweats or other constitutional symptoms. Now, there might be other questions that you’d want to ask the patient, but most of the additional questions will not help you proceed with expediency. For the purposes of this question, the patient relates to you that he has been healthy all of his life and not taking any medications. The patient relates and he feels like he has the flu. Still in the emergency room, how will you proceed from there? Although it seems rather elemental, you must examine this patient carefully. What are the most significant components of a physical exam at this time? Just focus on the physical examination and pause the presentation if you highlight those things that you really like to know as you examine the patient. They include vital signs, pedal pulses, the presence of lymphadenopathy, and lastly, the presence or absence of palpable crepitus in the foot. Your preliminary examination is complete, the information comes back. The patient presents with a blood pressure of 100/70, a pulse rate of 95, respirations of 16, and oral temperature of 102.2 with palpable pedal pulses. You know that there is palpable crepitus in the forefoot and palpable inguinal lymph nodes. How would you proceed from there? Obviously, we need more clinical information to determine the veracity of the problem, such as labs and radiographs. In this instance, we’re going to give you the labs. The labs come back. Glucose is 432 milligrams per deciliter, a potassium of 3.1, a sodium of 134, a pH of arterial blood gas is 7.2, bicarb 13.8, a CBC shows 3400 WBCs with a left shift, a hematocrit of 41.2 and a hemoglobin of 13.7. Pause the presentation and look at these labs and commit them to memory. What is your working diagnosis at this time? Pause and think before I give you the answer. Well, this patient has a classic case of diabetic ketoacidosis. The internal medicine team has been summoned but asks you to initiate basic or medical treatment for DKA or diabetic ketoacidosis. What maneuvers are you going to take? Please pause the presentation and think about this before you answer.
The correct maneuvers are as follows. I want you to administer one liter of normal saline intravenously. One-half normal saline is acceptable but not optimal. You should give some intravenous insulin, some potassium chloride, 20 to 40 milliequivalents per liter of saline. You should express some concern for antibiotics. But if the candidate elects to wait until a definitive culture has been taken in the operating room, that is satisfactorily. The patient should also have some blood cultures drawn before the administration of intravenous antibiotics. The candidate is now told that the patient is stabilized and the medical team has arrived to further treat the patient. The radiographs that you ordered an hour ago have been returned and are presented to you. Here are the films. Pause the presentation and take some time to study them because you can expect that you’re going to be asked to interpret them. Now, in contra-distinction to the last patient or the last question in interpreting the radiographs, we’re not going to get as detailed. The two things that you should have noted in these radiographs are these. You should have noted the osteomyelitis and the proximal phalanx of the hallux. Secondly, you should have noted the obvious gas in the soft tissues, particularly over the fourth and fifth digits. That’s all that’s going to be required to interpret these radiographs for this particular question. As you have noted in many other instances, far more detail might be required. How would you proceed from here? Well obviously, this patient needs a transmetatarsal amputation. The candidate should take the patient to the operating room for this procedure. An additional component of this question is that the candidate should express the fact that this is an urgent clinical situation and must be done expediently. The candidate is then asked, “How would you do the transmetatarsal amputation in this patient?” Include all the pertinent technical considerations when performing the operation. These include a long plantar flap, a short dorsal flap, some concern for closing the wound and establishing the proper parabola. The plantar, medial and lateral bevels should be discussed in some fashion. The candidate is now told while performing the TMA, the infection extends slightly proximal to the plantar midshafts of the metatarsals, how would you deal with this situation? The candidate should respond that all of the necrotic tissue should be debrided and that one should worry about closure of the wound at a later day. This is a clinical photograph of the result of TMA about a week after. The white area represents the distal aspect of the first cuneiform. What are your options for closing this wound at this later date and what else should you be concerned about? Pause and think about this because this is an important component to the question. The options for closure include back treatment, a split thickness skin graft, a full thickness skin graft, graduated elastic tension, and lastly I want you to clearly be concerned about the loss of tibialis anterior tendon function because of the exposed first cuneiform. One should have surmised that insertion of the tendon would be compromised by doing a more proximal TMA and was expected. For this question, let’s go on to the points to pass. The first question is obvious and that is that the candidate asks the essential initial questions upon presentation of the patient. Here, we’re going to require you to get three of the three questions that we feel are essential in taking care of this patient. They are as follows. What medications this patient was taking. Was he diabetic? And lastly, the presence or absence of constitutional symptoms, including fever, chills or night sweats. Second point to pass was that the candidate elicited the critical physical examination findings to include vital signs, the presence of pulses, the presence of lymphadenopathy and the presence of palpable crepitus in the foot. Another point to pass was that the candidate established the diagnosis of diabetic ketoacidosis based on the initial presentation and the appropriate lab data. It’s a little bit more difficult.
Here, we expect the candidate to administer the appropriate initial medical management and are requiring only three of the five essential components. They include the administration of one liter of normal saline intravenously. We would accept the half normal saline, but it is not the most optimal treatment for this particular patient. The use of intravenous insulin, the use of intravenous potassium chloride, some concern for antibiotic should be provided. But if the candidate waited until a definitive culture was taken in the operating room, that was satisfactory. And lastly, the candidate should have drawn blood cultures before any antibiotic administration. As we mentioned, the radiographic interpretation for this point to pass is rather elemental. Here all but was expected was that the candidate noted the presence of osteomyelitis in the proximal phalanx, and the gas in the soft tissues. The next point to pass was simply that the candidate did an emergent transmetatarsal amputation. The next point to pass was that the candidate performed a TMA with satisfactory technique. These components include establishment of a long plantar flap and a short dorsal flap, concern for closing the wound and establishment of a parabola with the plantar, medial and lateral bevel as appropriate. This next point to pass determine the candidate’s ability to deal with the guillotine amputation. Options for skin closure include back treatment, a split thickness or full thickness skin graft, and lastly, graduated elastic tension. A separate component of this question was that the candidate dealt with the loss of tibialis anterior tendon function. There have been situations in the past where this would have been an absolute necessity to pass this point to pass. However, for the purposes of simplicity, we have bundled it into the options for skin closure. Most people would feel that dealing with the function or the loss of tibialis anterior would be far more critical than the choices for wound treatment. Let’s spend another minute or two discussing your experience of these first three questions. Undoubtedly, you are frustrated but you really shouldn’t be. Remember that the sole purpose of this practice exam is to get you to organize and perfect the thought process that is entirely logical. Even though the so-called right answers are based on some medical practice, they may not always be what you would do in a similar situation. Yet, remember that this test is designed to test competence of practice, not brand you as the so-called best surgeon. It is indeed artificial, so you’re supposed to capitalize on this opportunity to see how the examination flows, and you really shouldn’t dwell on the specific answers.