U of A 2009 OSCE CEX

Contents

Basic Exam.. 2

Head and Neck. 4

Back Thorax, and Lungs. 7

Heart 9

Neurologic Exam.. 11

Headache. 13

Muscle Weakness. 15

Tremor 17

Low Back Pain. 19

Arm and Hand Pain. 21

Elbow.. 21

Wrist 22

Hand. 22

Shoulder Pain. 23

Chest Pain. 25

Chronic cough. 27

Dyspnea. 29

Edema. 31

Hemoptysis. 33

Palpitations. 35

 

 

Contents

 

August 12 and 14, 2008

General Appearance, Vital Signs, and Mental Status Exam

 

 

____ Wash hands before starting examination.

 

Casual Observations of General Appearance 

____ General appearance: manner of dress, grooming,  alertness, clarity of thought and articulation

____ State of nutrition: degree of health and vigor, obesity, frailty, impact of illness (acute or chronic)

____ Body habitus: physique, posture, proportions, asymmetry, strength, agility, fluidity of motion, balance, tremor

____ Speech: inflection, tone, volume, word choice

____ Psychological: mood, eye contact, facial expression, body position, signs of distress, attitude toward interview/examination

 

 

Vocabulary

·         central obesity

·         cachexia

·         hypomania

·         psychomotor slowing

·         tangentiality 

·         bradykinesia

·         Korotkoff sounds

·         systolic and diastolic pressure

·         pulse pressure

·         white coat hypertension

·         delirium

·         dementia

 

 

Vital Signs

____ Measure the blood pressure

Locate the brachial artery pulse.

Place cuff snugly with the marker above the artery

Inflate the cuff quickly to 30 mmHg above the systolic pressure as noted by the disappearance of Korotkoff sounds or by the disappearance of the brachial pulse.  

Deflate the bladder 3 mmHg per second

Record the pressure at which the pulse is first heard (or brachial pulse is first felt)

Record the disappearance as the diastolic pressure (or in children, the point of muffling)

____ Count respiratory rate for 30 seconds.

____ Palpate radial pulse and count for 15 seconds.

 

Key knowledge

Standards for blood pressure measurement:

·         BP should be taken after the patient has been sitting quietly with the back supported for five minutes in a warm, quite setting.

·         The arm is supported at the level of the heart.

·         No caffeine or smoking during the prior hour

·         No decongestants or eye drops for pupillary dilatation

·         The length of the bladder should be 80 percent of the circumference of the upper arm.

·         While taking the BP, Korotkoff sounds sometimes fade away just below the systolic pressure and then reappear at a lower pressure (an auscultatory gap).  This is why it is important to inflate the cuff at least 30 mmHg above the disappearance of the pulse.

·         Take at least two readings, separated by as much time as possible

·         For the diagnosis of hypertension, two or more readings at each of two or more office visits.

·         Check blood pressure in both arms; if pressures differ, use the higher arm

·         If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30

 

 

Mental Status Exam - The Mini-COG

(for appropriate patients)

____ Instruct the patient to listen carefully to and remember 3 unrelated words.  Have them repeat the words back to you.

____ Perform the clock-drawing test (CDT):

         Instruct the patient to draw the face of a clock.  Use either a blank sheet of paper or a sheet with a circle already drawn on the page.

         After the patient puts the numbers on the clock face, ask him / her to draw the hands of the clock to read a specific time, such as “Ten ‘till two.” These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distractor.

____ After the CDT, ask the patient to repeat the 3 previously presented words.

 

 

Key Knowledge

The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT). The Mini-Cog can be administered in about 3 minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations.

 

Scoring for the Mini Cog

Give 1 point for each recalled word after the CDT distractor. Score 1-3.

-       A score of 0 indicates positive screen for dementia.

-       A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

-       A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

-       A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

 

Documentation Skills - On paper, document your findings from the above exam.

____ Write a sentence that creates a snapshot description of the general appearance and characteristics of your patient.

____ Record the patient's vital signs including the units of measurement.

____ Record the results of the Mini-COG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contents

 

August 19 and 21, 2008

Head and Neck

 

Skin

____ Inspect face, hair, scalp, and palpate skull. 

 

Vocabulary

·         Pinna

·         Tympanic membrane

·         Ossicles

Key Knowledge

Normally, air conduction is better than bone conduction.  With conductive hearing loss, bone conduction is better.  With sensorineural deafness, both air and bone conduction are impaired to the same degree.

In the Weber test, normally sound is heard in the center.  With conductive hearing loss, the sound is heard best on the affected side.  With sensorineural hearing loss, the sound is heard best on the other (unaffected) side.

 

 

Vocabulary

·         Conjunctiva

·         Anterior and posterior chambers

·         Fundus

·         Optic disk

·         Fovea 

·         Cataract

·         Hemianopsia

 

Key knowledge

In older patients, cataracts can interfere with the visualization of the fundus.  Therefore a quick inspection of the anterior chamber and lens should precede fundoscopy.  Cataracts will appear as black opacities in the red reflex.

 

 

Ears

____ Inspection, gentle tug on pinna

____ Screen for hearing loss (occlude one ear canal and softly say a word into the other) (CN VIII). 

____ Rinne test to compare air and bone conduction.

____ Weber test to assess for lateralization.

____ Otoscopic examination of the auditory canals

 

 

Eyes

____ Inspect the eyelids, lacrimal duct, conjunctiva and cornea of each eye.

____ Measure visual acuity using a pocket Snellen card (CN II).

____ Observe direct and consensual pupillary responses (CN III).

____Test visual fields in each eye by confrontation.

Cover one eye with one hand.

Have the patient look at your nose.

Stretch your arms out, with your fingers in a V-for-Victory sign. Move your hands in to the periphery of your own vision.

Wiggle one set of fingers, and ask the patient if he/she sees anything move.

Change position of your hands to check both sides, as well as inferiorly and superiorly.

____ Perform an ophthalmoscopic exam

Adjust panoptic settings.  Use the small circle for illumination.  Focus on your hand held 15-20 inches away from the panoptic. 

Place patient in stable, comfortable position.

Dim room lights.  Have patient fix gaze on a distant point.

Start 2-3 feet from the patient looking through the iris at the red reflex, checking for opacities.

Move 15 degrees temporal to patient’s line of sight and advance, keeping red reflex in view, until the rubber cone is gently applied to the patient’s brow.  You should see the retinal vessels. 

Follow the vessels centrally to inspect the optic disk, then outward into each of the four quadrants. 

 

Nose / nasal passages

____ Inspection of the external nose

____ Palpation of the frontal and maxillary sinuses

____ Check for patency of both nasal passages

____ Examine nasal passages using a nasal illuminator

____ Transilluminate the maxillary sinuses

 

Vocabulary:

·         Nasal septum

·         Turbinates (nasal concha)

·         Paranasal sinuses

·         Mucosa 

Mouth

____ Inspect lips 

____ Using a tongue depressor, inspect teeth, gums, tongue, palate.

____ Inspect floor of mouth and base of tongue.

____ Observe elevation of the palate by asking patient to say “ah” (CN IX)

____ Inspect posterior pharynx.

____ Perform palpation of the base of the mouth.

 

Vocabulary:

·         Buccal mucosa

·         Anterior and posterior pillars

·         Uvula

·         Parotid duct (Stensen’s duct)

 

 

Neck

____ Inspection of the neck.   

____ Palpate lymph nodes: occipital, posterior auricular, posterior cervical, anterior cervical, preauricular, submandibular, submaxillary, submental

____ Supraclavicular nodes (while patient takes a deep breath)

____ Palpate thyroid gland from behind or side.  Note motion while patient is swallowing a sip of water.

____ Palpate carotid pulses.

____ Auscultate carotids.  Instruct patient to hold his/her breath as you listen (hold your breath at the same time so you will remember to tell patient to “stop breathing”........ “Breathe”).

 

 

Vocabulary

·         Adenopathy

·         Goiter

·         Carotid arteries

·         External jugular veins

 

 

 

Documentation Skills - On paper, document your findings from the above exam.

____ Skin

____ Ears

____ Eyes

____ Nose

____ Mouth

____ Neck

 

 

 

Reference:

Swartz MH, Textbook of Physical Diagnosis, Saunders (2006), pages 302-305.

 

 

Contents

 

August 26 and 28, 2008

Back, Thorax, and Lungs 

 

 

Skin

____ Examine the skin of the back and shoulders for lesions, sum damage, bruising.

 

Back

____ Inspect posture and spinal curvatures from the patient’s side and from the back.

____ Test flexion, extension, and rotation of neck.

____ Palpate cervical vertebrae, and assess for tenderness/spasm in the cervical musculature.

____ Gently perform fist percussion thoracic and lumbar vertebrae, assessing for tenderness. 

____ Palpate sacroiliac joints bilaterally for tenderness.

____ Test flexion by having patient bend at waist to touch toes.

____ While bending forward, check for scoliosis.

____ Have patient bend to each side from the waist.

____ Test spinal extension by having the patient bend backwards.

 

 

Vocabulary

·         Cervical

·         Thoracic

·         Lumbar

·         Sacral

·         Kyphosis

·         Lordosis

·         Scoliosis

 

Key knowledge

In older adults, problems of the spine are among the most common disabilities. 

 

 

Thorax

____ Observe and describe the general configuration of the chest.

____ With hands on the back, check for symmetry of thoracic excursion.

____ Palpate above the suprasternal notch for tracheal deviation.

 

Vocabulary

·         Sternum

·         Manubrium

·         Costochondral junctions

·         Costal margins

·         Tracheal, bronchial, bronchovesicular, and vesicular breath sounds

·         Crackles, wheezes, rhonchi  

·         accessory muscles respiration

 

Key knowledge

The surface landmarks of the chest help to locate the underlying organs.  Important landmarks include the angle of Louis, the second intercostal space, and the numbered interspaces below that.  Key references are the midclavicular line, the anterior axillary line, and the posterior axillary lines. 

 

Key knowledge

The breath sounds are generated by airflow in the larger, central airways, and conducted through the lung tissue to the chest wall.

 

 

 

 

 

 

 

Lungs

____ Describe the patient’s respiratory status.

____ Ask patient to cross arms to move scapulae and expose lung fields.

____ Percuss lung fields posteriorly, laterally, and anteriorly.

____ Instruct patient to breathe through open mouth.

____ Auscultate posterior, lateral and anterior lung fields and supraclavicular fossae, moving from side to side to check for symmetry.

____ Using the heel of the hand, check tactile fremitus, holding the hand against the posterior lung base while asking the patient to say, “One, two!”

 

Documentation skills - on paper, document your findings from the above exam.

____ Skin

____ Spine

____ Thorax

____ Lungs

 

 

Contents

 

September 2 and 4, 2008

Heart

Note: Measurement of vital signs has been covered in Session 1.  Auscultation of the carotid arteries has been covered in Session 2.  The aorta and femoral arteries will be examined in Session 5, and the pulses of the arms and legs in Session 6.  Although separated in this course, these parts of the cardiovascular exam are often performed together.  

With the patient sitting, leaning forward, listen with the diaphragm at the left sternal border.

____ Listening at Erb’s point (l the diagram below) focus on systole (for a mid-systolic click or late systolic murmur – of mitral valve prolapse). 

____ Then, a little bit lower (m on the diagram below) and with firm pressure focus on diastole (for a high-pitched decrescendo diastolic murmur – of aortic insufficiency).  

____ Also, listen for a friction rub.

Now with the patient supine, head elevated 30°, observe and examine the skin

____ Skin.  Examine the skin of the anterior chest for scars, nevi, rash, and spider angiomas.

Observe and examine the neck

____ Observe for jugular venous distension, and estimate the jugular venous pressure. You may need to move patient progressively more upright. 

____ Perform the abdomino-jugular test (hepato-jugular reflux).

____ Palpate the carotid arteries.

­­­­____ Note the pulse contour.

____ Observe the rhythm of the pulse.

Observe and examine the chest

____ Observe precordium for asymmetry, deformities, heaves, or apical motion.

____ Palpate for lifts or heaves with the heel of the hand pressing firmly over the lower left sternal border.

­­­­____ Palpate for the presence, location, and size of the apical impulse.

____ Percuss in the left 5th intercostal space for the transition from dullness to resonance (men only).

Listen with the diaphragm to the aortic area j

____ Focus on systole, listening for a systolic murmur.  If present, assess its shape, radiation, pitch and intensity.

Listen with the diaphragm to the pulmonic area k  

____ Focus on S1 (splitting?) and any sounds around it (ejection click?). 

____ Then focus on S2 (physiologic splitting?).

____ Then systole for murmurs.

____ Then diastole for murmurs. 

Listen with the diaphragm to the tricuspid area m

____ Focus on systole for murmurs and midsystolic clicks.

____ Focus on diastole listening for an opening snap following S2 (from ASD or Ebstein’s anomaly).  

Switch to the bell at the tricuspid area m

____ Use light pressure.  Focus on diastole for S3 or S4 gallops or a low pitched rumbling murmur.

Turn the patient on the left side (lateral decubitus)

____ Palpate for the apical impulse and note whether it is sustained, single or double (or even triple) in contour.

Listen with the diaphragm to the mitral area n

____ Focus on S1,

____ Then focus on S2,

____ Then systole for murmurs,

____ Then diastole for an opening snap following S2.

Switch to the bell at the mitral area n 

­­­­____ Focus on diastole listing for S3 or S4 gallops, and for a low pitched rumbling decrescendo murmur.

­­­­­­­­­­Documentation skills - on paper, document your findings from the above exam.

____ Jugular veins / abdomino-jugular test

____ Carotid arteries

____ Precordial palpation

____ Cardiac auscultation

Vocabulary

·         Aortic, pulmonic, mitral, and tricuspid valves.

·         holosystolic murmur

·         ejection type murmur

·         third and fourth heart sounds (gallop rhythm)

·         precordial lift

·         jugular venous distention

·         pericardial friction rub

 

Key knowledge

Cardiac rhythm is classically described as regular, regularly irregular, or irregularly irregular.  

Usually, blood flows quietly through cardiac chambers and vessels.  A heart “murmur” is caused by increased or turbulent flow across a roughened surface, through a small hole, a narrowing, or a damaged valve that is too tight (stenotic) or is leaking (regurgitant).

 

 

 

 

 

 

 

 

Key knowledge

The first heart sound (called S1) is generated by closure of the mitral and tricuspid valves, and has two components (M1 and T1).

If the aortic valve is stiff (or if there is severe hypertension) the aortic valve may create an “ejection click” which will closely follow S1.

The second heart sound (S2) is generated by closure of the aortic and pulmonic valves.  It also has two components (A2 and P2), that “split” into two closely separated sounds during inspiration and merge into a single sound during expiration?

 

 

 

 

 

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Reference: Richard J. McCarty, MD, Snap, Clickle, Plop, presentation notes, spring 2008.

 

Contents

 

September 23 and 25, 2008

Neurologic exam

 

Note: Mental status exam was covered in Session 1.  Hearing acuity, visual acuity, and elevation of the palate were checked in Session 2. 

 

Cranial Nerves: 

____ CN I: test sense of smell.  (Not usually done). Ask patient if there has been any change in smell or taste.

____ CN II: (Note: visual acuity checked in Session 2)

____ CN III, IV, VI (oculomotor): check extraocular motions in six positions of gaze and pupil reflex

____ CN V: Corneal reflex (not routine)

____ Sensation to light touch forehead, cheeks, jaw

____ Clench teeth while palpating masseters, temporalis

____ CN VII: wrinkle forehead; try to open eyelids closed tight; puff out cheeks; smile baring teeth

____ CN VIII: (Note: hearing acuity, Weber, and Rinne tests were checked during Session 2).

____ CN IX (also CN X):  On vocalizing “ah”, check for symmetric elevation of palate.

____ CN IX: the gag reflex not routinely checked

____ CN X: Tested with CN IX above.  Also, check quality of voice for dysphonia, dysarthria.  Ask about difficulty with swallowing.

____ CN XI: Patient’s turns head left and right against resistance. 

____ Shoulder shrug against resistance.

____ CN XII: observe tongue for fasciculation.  Have patient stick out tongue; check for deviation.

 

Neurologic Examination

Motor

____ Upper extremities: grip, biceps, triceps, deltoid.

____ Lower extremities; iliopsoas, quadriceps, hamstrings, foot dorsiflexion and plantar flexion.

____ With patient’s eyes closed, check for pronator drift of the outstretched arms.

____ Test for increased muscle tone in the arms. With the patient relaxed, move the elbow and wrist on each side, checking for resistance, stiffness, tremor, cogwheeling.

 

Cerebellar

____ Tap fingers repeatedly against the thumb, or clap hands alternating one hand front-and-back to test rapid alternating movements.

____ Have patient alternatively touch the tip of their nose, then your fingertip as you move your hand.

____ Have patient touch their heel to the knee of the opposite leg and slide it down the shin to the ankle.

____ Have the patient stand with feet together and then close the eyes (Romberg test).  Watch for 20 sec.

 

Sensory

____ Test light touch with monofilament on both feet

____ Test position sense on one digit on all four limbs

____ Test vibration sense on both ankles or toes

 

Reflexes               

____ Cradle the arm across your forearm and test the biceps, triceps, and brachioradialis reflexes.

____ With the patient’s legs dangling and hands clenched together, test the patellar reflex.

____ Gently dorsiflex the foot and test Achilles reflexes.

____ Stroke the sole of the foot in an arc to test the plantar response.

 

Documentation skills: on paper document your findings from the neurologic exam.

____ cranial nerves

____ motor

____ cerebellar findings

____ sensory

____ reflexes

 

 

Key Knowledge: The names and basic function of the 12 cranial nerves.   

 

·         I (olfactory): sense of smell

·         II (optic): visual image to brain

·         III (oculomotor): Innervates levator palpebrae, superior, medial, inferior rectus, inferior oblique, as well as the iris; collectively these perform most eye movements. 

·         IV (trochlear):  Innervates the superior oblique, which depresses and inward rotates the eye.

·         V (trigeminal) sensation from the face; motor to muscles of mastication

·         VI (abducens): Innervates the lateral rectus, which abducts the eye (away from nose).

·         VII (facial) motor to the muscles of facial expression and stapedius; taste from the anterior 2/3 of the tongue; secretomotor to the salivary glands (except parotid) and the lacrimal gland,

·         VIII (vestibulocochlear)  sound, rotation and gravity

·         IX (glossopharyngeal)  taste from the posterior 1/3 of the tongue; secretomotor to the parotid gland; motor to the stylopharyngeus

·         X (vagus) branchiomotor to most laryngeal and pharyngeal muscles; parasympathetic fibers to nearly all thoracic and abdominal viscera down to the splenic flexure; receives taste from the epiglottis; motor to muscles of voice and the soft palate.

·         XI (accessory) muscles of the neck; overlaps with functions of the vagus.

·         XII (hypoglossal) motor to the muscles of the tongue and other glossal muscles.

 

Vocabulary

·         Upper and lower motor neuron

·         Proprioception

·         Muscle tone

·         Clonus

·         Ataxia

 

 

 

 

 

 

 

Contents

 

HPI:

O = Onset: When did it begin                                                                             

P = Position, Pattern: one-sided, bend-like                                             

Q = Quality: sharp, dull, heavy, throbbing

R = Radiation (if pain)                                                                                       

S = Severity: 1-10                                                                                              

T = Timing: with what activities does it occur                                        

A = Aggravating/Alleviating: what makes it better/worse?         

      Have you tried any medication?                                                                  

D = Duration                                                                                                      

A = Associated Symptoms                                                                                 

a.    Migraine:

                                                              i.      Is there an aura?                                                                                 

                                                            ii.      Are there scotomata or sensory/motor symptoms?

                                                          iii.      Photophobia, phonophobia                                                                 

b.    Temporal Arteritis:

                                                              i.      Visual loss/eye pain/diploplia                                                 

                                                            ii.      Proximal muscle pain, jaw claudication                                              

c.       Brain tumor:

                                                              i.      Weakness/dysequilibrium/neurologic symptoms                    

                                                            ii.      Confusion or lethargy                                                             

                                                          iii.      New onset seizure                                                                               

                                                          iv.      New onset after age 50                                                                       

                                                            v.      Nocturnal awakenings due to pain                                          

                                                          vi.      Worse with valsalva                                                                

                                                        vii.      Nausea/vomiting                                                                                 

                                                      viii.      History of malignancy                                                            

d.      Meningitis:

                                                              i.      Fever                                                                                                  

                                                            ii.      Neck pain/stiffness                                                                             

e.       Subarachnoid hemorrhage:

                                                              i.      Family history of migraine headache or subarachnoid hemorrhage                                                                                        

                                                            ii.      Thunderclap headache/onset with exertion                             

f.       Cluster headache:

                                                              i.      Runny nose/nasal congestion; lacrimation                              

                                                            ii.      Headache around the eye                                           

Previous evaluation and treatment

           

Allergies:

 

 

 

Past Medical & Past Surgical History

 

Medications:

Use of headache medications:  NSAID, Acetaminophen, prescription pain medications or prescription migraine medications                                                                                                                

 

Social History:

 

 

High Risk Behaviors/Habits:

 

Family History:

Family history of migraine headaches?                                                                                   

 

Physical Examination:

1.      Vital signs (note or perform)                                                                           

2.      Cranial nerve exam

a.       CN II (visual acuity, visual fields, funduscopic exam)                                   

b.      CN III, IV, VI (extraocular movements, papillary light reflex [II/III])

c.       CN V (sensation of face, chewing movements)                                              

d.      CN VII (facial expression)                                                                              

e.       CN VIII (hearing)                                                                                           

f.       CN IX/X (symmetric elevation of soft palate)                                                

g.       CN XI (head, neck, shoulder movements)                                          

h.      CN XII (tongue movements)                                                               

3.      Palpate temporal arteries (particularly if age > 50)                                          

4.      Screening motor examination                                                                         

5.      Palpate neck and shoulder muscles                                                                 

6.      Screening sensory examination                                                                                   

7.      Reflexes                                                                                                                     

8.      Cerebellar examination                                                                                               

9.      Gait     

 

Contents

 

HPI:

1.     O = Onset: When did it begin?

2.     P = Position, Pattern: unilateral, bilateral? upper or lower extremities?

3.    Q = Quality: Diffuse or focal?

4.    R = Radiation (if pain) (N/A)

5.    S = Severity: 1-10. compare to other weaknesses.

6.    T = Timing: with what activities does it occur

7.    A = Aggravating/Alleviating

a.    Does your weakness get worse with exercise? (Myasthenia gravis)

8.    D = Duration

9.    A = Associated Symptoms

a.    Is it difficult to participate in all activities? (often due to functional weakness)

b.    Are there any pains that affect or contribute to your weakness (think of diseases that cause muscle or joint pain – arthritis)

c.    Do you have any numbness or tingling associated with your weakness? (MS, CVA, polyneuropathies)

d.    Can you see your muscles twitching? (ALS)

e.    Is the weakness confined to 1 side of body (stroke, TIA)

 

  1. Previous evaluation and treatment

 

Allergies:

 

Past Medical & Past Surgical History

Associated with mononeuritis, polyneuropathies, and ischemic stroke:

1.      Diabetes

Associated with ischemic stroke:

1.      Diabetes

2.      Hypertension

3.      Hypercholesterolemia

4.      History of cigarette smoking

 

 

Medications:

 

 

Social History:

 

 

High Risk Behaviors/Habits:

Do you use tobacco?

 

Family History:

a.     Any family history of stroke or neurologic disease?

b.    Any family history of hypertension?

 

Physical Examination:

1.      Inspection of the muscle

a.       Atrophy

b.      Enlargement

c.       Fasciculations

d.      Ptosis

2.      Palpation

a.       Muscle tenderness

b.      Increased tone or rigidity

3.      Motor exam (muscle strength testing) using scale of 0-5.

4.      Ascertain distribution of weakness

5.      Assessment of motor function (e.g., timed 50 foot walk)

  1. Deep tendon reflexes

 

 

Contents

 

HPI:

1.     O = Onset: did the tremor start gradually or abruptly?                                     

2.     P = Position, Pattern: which parts of the body are affected by the tremor?

3.    Q = Quality:

a.       Does the tremor occur at rest (Parkinson’s)                                        

b.      Does the tremor occur with action (Action tremor, essential tremor, cerebellar pathology, toxins)

c.       Does the tremor interfere with daily activities                                     

4.    R = Radiation (if pain)                                                                                     

5.    S = Severity (1-10)                                                                                                       

6.    T = Timing (with what activities does it occur)                                                 

7.    A = Aggravating/Alleviating: Does stress, anxiety or fatigue increase or decrease the tremor? (can occur with all tremor types)                                      

a.       Does alcohol decrease the tremor?

b.      Does alcohol improve the tremor (65-70% of patients with essential tremor report improvement with alcohol)?

8.    D = Duration                                                                                                                

9.    A = Associated Symptoms

a.       Gait disturbance or falls (Parkinson’s, or secondary to neuroleptic medication)

b.      Neurologic symptoms (muscle weakness, etc.)                                               

    1. Hyperthyroid symptoms (heat intolerance, weight loss, etc.)  
  1. Previous evaluation and treatment.                                                                 

 

 

Allergies:

 

Past Medical & Past Surgical History

 

Medications:

a.       Prescription drugs: (theophylline, albuterol, valproic acid, can

cause postural tremors)

 

Social History:

 

High Risk Behaviors/Habits:

1.      Alcohol Use                                                                                                              

a.       Alcohol, caffeine and nicotine, amphetamines (may have an adrenergic enhancing effect).

 

Family History: is there a family history of tremor?                                      

 

Physical Examination:

1.      Thyroid Exam                                                                                                                   

2.      Observation of the tremor

a.       At rest                                                                                                                   

b.      With action                                                                                                           

c.       With standing                                                                                                        

3. Observation of gait and stability                                                                             

4. Motor exam                                                                                                                        

a.       Check for increased muscle tone (rigidity)                                                           

b.      Check for slowed movements (bradykinesia)                                           

c.       Muscle strength                                                                                                     

5. Coordination testing                                                                                                            

a.       Finger tapping                                                                                                       

b.      Rapid alternating movements                                                                                

c.       Finger-to-nose testing                                                                                            

6. Mini-Cog                                                                                                                            

 

Contents

 

HPI:

Age of patient

š           O = Onset

š            P = Position, Pattern

š            Q= Quality

š            R= Radiation

š            S= Severity (1-10)

š            T= Timing (with what activities does it occur)

š            A= Aggravating/Alleviating (including medications)

š            D= Duration

š            A= Associated Symptoms

       a. Fevers/Chills

       b. Dysuria

       c. Abdominal pain

       d. Unintentional weight loss

       e. Weakness/numbness

      f.  Fecal or urinary (overflow) incontinence

       g. Gait disturbance

       h. Pain at rest

        i. Nocturnal symptoms

a.       Previous evaluation and treatment

 

Allergies:

 

 

Past Medical & Past Surgical History:

š        1.   History of malignancy

š        2.   Osteoporosis

š        3.   Recent intravenous catheter

š        4.   Immuocompromised state (chemotherapy, HIV, etc.)

 

 

 

Medications:

š        1.   Current or past steroid use

 

 

Social History:

 

 

High Risk Behaviors/Habits:

š        1.   Current or past IVDA

 

 

Family History:

 

 

Physical Examination:

š        1.  Vital signs

š        2.  Musculoskeletal

š        a.  Evaluation of movement and gait

š        b.  Inspection of spine and posture

š        c.  Palpation of spine and paraspinal muscles

š        d.  Straight leg raise test

š         3. Neurologic exam

š        a.  Quadriceps strength (knee extension) – L3

š        b.  Dorsiflexion of ankle and great toe and/or heel walk – L4/L5

š        c.  Ankle/foot plantarflexion or toe walk (S1)

š        d.  Light touch sensation

š      i.   Anterior/lateral thigh – L3

š     ii.   Medial ankle/foot – L4

š    iii.   Dorsum of foot – L5

š    iv.   Lateral plantar foot – S1

š        e.  Patellar reflex – L3/L4

š        f.  Achilles reflex – S1

 

Contents

 

HPI

 

            How the symptoms started (open-ended)                                                      

                      a. Mechanism of injury or trauma, if any

     O= When symptoms started and duration of pain                                                

     P=  Location of pain and radiation, if any                                                                       

     Q= Description/quality of pain                                                                            

     S= Severity of pain                                                                                                          

     T= Timing and frequency of the pain                                                                  

     A= Changes in pain since onset (worse, less, etc)            

                       a. Aggravating/alleviating factors (including medications)       

     A= Associated Symptoms

                   a. Tell how you use your arms (or hands) at work or at home               

                   b. Associated/alarm symptoms or history                                                          

                   c. If arm complaint – is it associated with chest pain or shortness of  

                         breath

                   d. Numbness, burning or tingling                                   

                   e. Neck complaints        

                   f.  Redness                                                                                             

                  g.  Swelling                                                                                                         

                  h. Previous symptoms or evaluation and treatment                                                                     

Allergies:

 

 

Past Medical & Past Surgical History:

 

 

Medications:

 

 

Social History:

 

 

High Risk Behavior/Habits:

 

 

Family History:

 

 

PHYSICAL - Did the student correctly perform the following physical exam skills (elbow, wrist OR hand):

Elbow

   1.  Palpate lateral and medial epicondyles                                                           

    2.   Palpate olecranon bursa and fossa                                                                  

    3.   Range of Motion:  Flexion                                                                              

    4.   Range of Motion:  Extension                                                                          

    5.   Range of Motion:  Supination                                                                         

    6.   Range of Motion:  Pronation                                                                           

 

Wrist

    1.   Palpate soft tissue and carpals                                                                        

    2.   Palpate ulnar styloid                                                                                       

    3.   Range of Motion:  Flexion                                                                              

    4.   Range of Motion:  Extension                                                                          

    5.   Range of Motion:  Ulnar – Radial                                                                   

    6.   Perform tests for Tinel’s Sign and Phalen’s Sign                                             

 

Hand

    1.   Palpate C-MC joint of the thumbs                                                                   

    2.   Palpate MCP joints of all digits                                                                       

    3.   Palpate IP joints of the thumbs                                                                       

    4.   Palpate PIP joints of all fingers                                                                       

    5.  Palpate DIP joints of all fingers                                                          

    6.   Palpate palmar fascia and tendons                                                                  

    7.   Range of Motion:  Making fist                                                                        

    8.   Range of Motion:  Making a claw by flexing

the PIP and DIP joints                                                                         

    9.   Range of Motion:  Extension                                                                          

   10.  Check grip strength                                                                                         

(optionally with a sphygmomanometer)

 

Contents

 

HPI

 

Patient’s Name:

Age:

Occupation:

 

   O = Onset

   P = Position, Pattern           

   Q = Quality            

   R = Radiation

   S = Severity (1-10)

   T = Timing (with what activities does it occur)

   A = Aggravating/Alleviating (including medications)

   D = Duration

   A = Associated symptoms?

         a. neck pain

         b. numbness/ tingling in arms.

 

 Allergies:

 

 

Past Medical & Past Surgical History:

  1. Previous shoulder injury

  2. Ongoing medical conditions

 

Medications:

 

 

Social History:

  1. Sports participation

 

Family History:

 

 

 

PHYSICAL EXAM – Did the student correctly perform the following physical exam skills?

   1.  Look; expose both shoulders and examine the skin, shape of the shoulders and       

          posture of the arms?

   2.  Feel; for tenderness of the AC joint, biceps tendon, and beneath the acromion 

          process?

 

  3.  Move the shoulder?

a.       Assess active ROM

b.      Then assess passive ROM

 

 

  4. Perform provocative testing

   a.  AC joint

   b. Subacromion space

   c. Supraspinatus

         d. Infraspinatus & teres minor

   e. Subscapularis

   f.  Biceps

         g. Glenohumeral joint

         h.  Cervical nerve root

Contents

 

HPI:

Age of patient

O = Onset

P = Position, Pattern, Location

Q = Quality (type of pain)

a. Pressure, aching, tearing, sharp, pleuritic, etc.

R = Radiation

a. Jaw, neck

b. Left and/or right arms

c.  Back

d. Epigastrum

S = Severity (1-10)

T = Timing (with what activities does it occur)

A = Aggravating

a. Exercise

      b. Stress

      c. Eating

      d. Laying down

 Alleviating

      e. Rest

      f. Nitroglycerin

      g. Sitting up/leaning forward

h. Antacids

D = Duration

A = Associated Symptoms

                   a. Nausea/vomiting

                   b. Diaphoresis

                   c. Syncope or pre-syncope

 d. Dyspnea

                   e. Hemoptysis

Previous evaluation and treatment

 

Allergies:

 

 

Past Medical & Past Surgical History

  1. Coronary Heart Disease
  2. Diabetes Mellitus
  3. Hypertension
  4. Dyslipidemia
  5. Peripheral arterial disease
  6. Chronic Kidney Disease

           

Medications:

  1. General

 

Social History:

 

High Risk Behaviors/Habits:

  1. Tobacco
  2. Cocaine

 

Family History:

  1. Premature CHD
  2. Venous thromboembolism

 

Physical Examination:

  1. General Appearance
  2. Vital signs and (if possible) Body Mass Index
    1. BP in both arms if aortic dissection is being considered
  3. Cardiovascular examination
    1. Inspection of chest wall (including skin for rashes)
    2. Palpation of chest wall (reproducibility of chest pain) and PMI
    3. Auscultation

                                                              i.      Sitting

                                                            ii.      Supine

                                                          iii.      Left lateral decubitus (S3, S4, mitral stenosis)

    1. Jugular venous pressure
  1. Pulmonary examination
    1. Auscultation: anterior, posterior, lateral
    2. Percussion: anterior, posterior, lateral
  2. Abdominal examination
    1. Auscultation
    2. Palpation, light and deep
    3. Palpation of the aorta
  3. Extremities
    1. Pulses

                                                              i.      Radial (note symmetry)

                                                            ii.      Posterior tibial, dorsalis pedis

    1. Assessment of edema

 

Contents

 

HPI:

Age of patient

1.   O = Onset

      2.   P = Position, Pattern

a.    Does the cough occur lying down?

3.    Q = Quality

a.    Dry vs. productive

4.    R = Radiation N/A

5.    S = Severity

6.    T = Timing (with what activities does it occur)

7.    A = Aggravating/Alleviating

8.    D = Duration

9.    A = Associated Symptoms

a.    Hemoptysis

b.    Shortness of breath

c.    Lower extremity edema

d.    Fever, chills

e.    Wheezing

f.Rhinitis/post-nasal drip/nasal congestion

g.    Recent upper respiratory tract infection

h.    Heartburn/GERD symptoms

10.  Previous evaluation and treatment

 

Allergies:

 

 

Past Medical & Past Surgical History:

  1. Hypertension
  2. Coronary heart disease/CHF
  3. Asthma/COPD
  4. Allergic rhinitis/seasonal allergies
  5. Previous pneumonia; if so, when
  6. GERD
  7. Sinusitis (recent, recurrent, chronic)

 

 

           

Medications:

  1. General
  2. Angiotensin-converting enzyme inhibitors
  3. Any medications added recently

 

Social History:

 

High Risk Behaviors/Habits:

  1. Tobacco

 

Family History:

 

Physical Examination:

1.   General appearance

  1. Vital signs
  2. HEENT examination
    1. Nasal passages for congestion, drainage
    2. Throat
    3. Ears (otoscope)
    4. Sinus palpation and transillumination (if appropriate)
  3. Neck/adenopathy
  4. Pulmonary examination
    1. Inspection (anterior-posterior diameter)
    2. Auscultation: anterior, posterior, lateral

                                                              i.      Forced expiration

    1. Percussion: anterior, posterior, lateral
  1. Abdominal examination
    1. Auscultation
    2. Palpation: light, deep

 

Contents

 

HPI:

Age of patient

1.   O = Onset

      2.   P = Position, Pattern

a.    Dyspnea at rest

b.    Dsypnea on exertion

c.    Orthopnea

d.    Paroxysmal nocturnal dyspnea

3.    Q = Quality

a.    Hard to take a deep breath, increased effort to breath, etc.

4.    R = Radiation N/A

5.    S = Severity

6.    T = Timing (with what activities does it occur)

7.    A = Aggravating

a.    Exertion

b.    Laying flat

c.    Anxiety

 Alleviating

d.    Rest

e.    Sitting up

8.    D = Duration, chronology

a.    Progression of symptoms (improving, stable, worsening)

9.    A = Associated Symptoms (as appropriate)

a.    Cough

b.    Hemoptysis

c.    Fever, chills

d.    Lower extremity edema

e.    Chest pain/pressure

f.Wheezing

g.    Anxiety

h.    Decreased urine output

10.  Previous evaluation and treatment

 

Allergies:

 

 

Past Medical & Past Surgical History:

  1. COPD/Asthma
  2. Coronary heart disease/congestive heart failure
  3. Valvular heart disease
  4. Venous Thromobembolism (DVT, PE)
  5. Collagen-Vascular disease
  6. Anemia
  7. Kidney disease
  8. Diabetes Mellitus

           

Medications:

  1. General
  2. Any medications started recently

 

Social History:

 

High Risk Behaviors/Habits:

  1. Tobacco use

 

Family History:

  1. Premature CHD
  2. Venous thromboembolism

 

Physical Examination:

  1. General appearance
    1. Able to speak full sentences
  2. Vital signs, including respiratory rate
  3. Pulmonary examination
    1. Inspection

                                                              i.      Use of respiratory accessory muscles, work of breathing

                                                            ii.      Check for increased anterior-posterior diameter

    1. Auscultation: anterior, posterior, lateral
    2. Percussion: anterior, posterior, lateral
    3. Expansion (symmetric)
  1. Cardiac examination
    1. Inspection
    2. Palpation of PMI
    3. Auscultation

                                                              i.      Sitting

                                                            ii.      Supine

                                                          iii.      Left lateral decubitus (S3, S4, mitral stenosis)

    1. Jugular venous pressure
  1. Extremities
    1. Assessment of lower extremity edema
    2. Assessment for clubbing
    3. Assessment for cyanosis

Contents

 

HPI:

Age of patient

1. O= Onset

2.    P = Position, Pattern, Location

a.    Unilateral vs. bilateral

b.    Peripheral vs. central or diffuse

3.    Q = Quality N/A

4.    R = Radiation N/A

5.    S = Severity

6.    T = Timing (with what activities does it occur)

a.    Intermittent vs. persistent

b.    All day vs. present in the evening, etc.

7.    A = Aggravating/Alleviating

8.    D = Duration

a.    Progression

9.    A = Associated Symptoms (in addition to those in other categories)

a.    General (occurs with multiple etiologies):

                                                              i.      Weight gain; if so, time frame

                                                            ii.      Shortness of breath/dyspnea on exertion

b.    Allergy and anaphylaxis

                                                              i.      Sensation of swelling in throat/lips

c.    Congestive heart failure

                                                              i.      Waking up at night short of breath (paroxysmal nocturnal dyspnea)

                                                            ii.      Sleeping with head raised up (orthopnea)

d.    Venous thromboembolism

                                                              i.      Unilateral leg edema/pain

                                                            ii.      Pleuritic chest pain

                                                          iii.      Hemoptysis

                                                          iv.      Recent immobility

e.    Cirrhosis

                                                              i.      Abdominal distension

                                                            ii.      Jaundice (skin/eyes)

10.   Previous evaluation and treatment

 

 

 

Allergies:

  1. Known allergies and any recent exposure to them

 

Past Medical & Past Surgical History

  1. Coronary Heart Disease and/or CHF
  2. Hypertension
  3. Valvular heart disease or Rheumatic Fever
  4. Kidney disease
  5. Diabetes Mellitus
  6. Liver disease, hepatitis B/C
  7. Venous thromboembolism (PE or DVT)
  8. Malignancy
  9. Recent surgery

           

Medications:

  1. General
  2. Calcium-channel blockers
  3. NSAIDs
  4. Angiotensin-coverting enzyme inhibitors or angiotensin receptor blockers (especially recently prescribed)

 

Social History:

  1. Diet: sodium intake (restaurants, processed foods)

 

High Risk Behaviors/Habits:

  1. Alcohol intake
  2. IVDA

 

Family History:

  1. Venous thromboembolism
  2. Premature CHD

 

Physical Examination:

1.   General appearance

2.   Vital signs

  1. Cardiac examination
    1. Inspection
    2. Palpation of PMI
    3. Auscultation

                                                              i.      Sitting

                                                            ii.      Supine

                                                          iii.      Left lateral decubitus (S3, S4, mitral stenosis)

                                                          iv.      Jugular venous pressure

  1. Pulmonary examination
    1. Auscultation: anterior, posterior, lateral
    2. Percussion: anterior, posterior, lateral
  2. Abdominal examination
    1. Inspection: caput medusa, distension
    2. Auscultation
    3. Palpation, light and deep

                                                              i.      Palpate liver edge using correct technique

                                                            ii.      Check for splenomegaly

    1. Percussion

                                                              i.      Liver span

                                                            ii.      Traube’s space

  1. Extremities
    1. Check for edema

                                                              i.      Check for pre-sacral edema

 

Contents

 

HPI:

Age of patient

1.    O = Onset

2.    P = Position, Pattern N/A

3.    Q = Quality/quantity

a.    Amount

b.    Color

c.    Presence of sputum

4.    R = Radiation N/A

5.    S = Severity (relates to amount, above)

6.    T = Timing/frequency

7.    A = Aggravating/Alleviating

8.    D = Duration

9.    A = Associated Symptoms

a.    Chest pain

b.    Cough: acute or chronic

c.    Shortness of breath

d.    Fevers, chills, night sweats

e.    Weight loss

f.Recent immobility

g.    Nose bleeds or bleeding elsewhere

h.    Sinus symptoms

i. Nausea, vomiting

j. Dyspepsia

10.   Previous evaluation and treatment

 

Allergies:

 

 

 

Past Medical & Past Surgical History

  1. Recent surgery
  2. Venous thromboembolism (PE or DVT)
  3. Malignancy
  4. Pulmonary disease/chronic cough
    1. Asthma or COPD
    2. Recurrent pneumonia
    3. TB, TB exposure, +PPD
  5. Sinusitis/allergic rhinitis
  6. Cardiac disease
    1. Valvular heart disease
    2. Congestive heart failure
  7. Thrombocytopenia or bleeding disorders
  8. Liver disease
  9. Peptic ulcer disease

10.  HIV

11.  Collagen-vascular disease

           

Medications:

  1. General
  2. Warfarin
  3. Aspirin, NSAIDs
  4. Oral contraceptives

 

Social History:

1.      Recent travel

a.       Duration of plane ride

b.      Travel to areas endemic for TB

2.      Blood transfusions (especially before 1985)

 

High Risk Behaviors/Habits:

  1. Tobacco
  2. Cocaine
  3. Intravenous drug use
  4. High risk sexual practices

 

Family History:

  1. Venous thromboembolism

 

Physical Examination:

  1. General appearance
  2. Vital signs including respiratory rate
  3. Skin: inspection for bruising
  4. HEENT examination
    1. Inspection of nares
    2. Inspection of oropharynx
  5. Pulmonary examination
    1. Inspection

                                                              i.      Work of breathing

                                                            ii.      (Respiratory rate if not taken with vitals)

    1. Auscultation: anterior, posterior, lateral
    2. Percussion: anterior, posterior, lateral
  1. Cardiovascular examination
    1. Inspection
    2. Auscultation

                                                              i.      Sitting

                                                            ii.      Supine

                                                          iii.      Left lateral decubitus (S3, S4, mitral stenosis)

    1. Jugular venous pressure
  1. Abdominal examination
    1. Inspection
    2. Auscultation
    3. Palpation, light and deep
  2. Extremities
    1. Assessment of edema

Contents

 

HPI:

Age of patient

O = Onset/Offset

a.  Gradual vs. abrupt

P = Position, Pattern

a.    Positional component

b.    Regular vs. irregular

c.    Tap out rhythm of the palpitations

Q = Quality

d.    Fluttering, racing, slow, pounding/flip-flopping, etc.

R = Radiation

e.    To neck

S = Severity

T = Timing (with what activities does it occur)

A = Aggravating/Alleviating

f.Are symtoms terminated by valsalva or rubbing neck?

D = Duration

A = Associated Symptoms

g.    Anxiety

h.    Alarm symptoms

                                                              i.      Syncope or pre-syncope

                                                            ii.      Chest pain

                                                          iii.      Shortness of breath

Previous evaluation and treatment

 

Allergies:

 

 

 

 

Past Medical & Past Surgical History

  1. Cardiac disease: Coronary heart disease, CHF, valvular heart disease
  2. Hypertension
  3. Thyroid disease
  4. Diabetes Mellitus
  5. Psychiatric illness

           

Medications:

  1. General
  2. Levothyroxine
  3. Beta-blockers recently stopped

 

Family History:

1.      Student provides summary to patient

 

Social History/ High Risk Behaviors/Habits:

  1. Nicotine
  2. Cocaine
  3. Amphetamines
  4. Caffeine intake

 

Physical Examination:

  1. General appearance
  2. Vital signs
  3. Neck: examination of the thyroid
  4. Cardiac examination
    1. Inspection
    2. Palpation of PMI
    3. Auscultation

                                                              i.      Sitting

                                                            ii.      Supine

                                                          iii.      Left lateral decubitis (S3, S4, mitral stenosis)

    1. Examination of Jugular veins

                                                              i.      Pattern

                                                            ii.      Estimate jugular venous pressure

  1. Pulmonary examination
    1. Auscultation, anterior and posterior
    2. Percussion, anterior and posterior
  2. Extremities
    1. Assessment of edema
    2. Pulses: posterior tibial, dorsalis pedis
    3. Student performed oral presentation to group