iHuman Dianne Steinberg: differentials and chest exam

Do the iHuman case before drafting anything, and record the examination findings as you go, because the third question asks for them specifically and they cannot be reconstructed afterwards from a summary. The first question asks for a list of appropriate differential diagnoses with reasoning, and the discipline is the same as in any differential: each candidate has to be tied to a finding that supports it and, ideally, to one that would argue against it. Build the list from the presenting complaint and the history the case gives you rather than from a textbook list of respiratory diagnoses, since the marks are for reasoning from this patient's data. Keep the list to a workable size — three to five well-argued candidates beats eight named ones, since the reasoning is what is marked rather than the breadth of the list, and a long list dilutes the argument for each.

The second question asks for the final diagnosis and the assessment findings that support it, which is a request for convergence: say which specific findings, taken together, made this diagnosis rather than the others on your list, and be explicit about the finding that excluded your nearest alternative. That is what a diagnostic argument looks like. The third question is the most technical and the most commonly under-answered, because it asks about all three examination modalities rather than auscultation alone. Auscultation covers breath sound character and intensity, and the presence, timing and location of crackles, wheeze, rhonchi or a rub, plus transmitted voice sounds where they are relevant. Palpation covers chest expansion symmetry, tactile fremitus, tenderness and tracheal position. Percussion covers resonance against dullness or hyperresonance, and diaphragmatic excursion. For each, say what was found in this patient and whether it was normal — and say what each finding would have indicated had it been abnormal.