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USMLE Step 2 CS Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

S NOTES

 

By JH Terry

 

Copyright © JH Terry 2015

 

 

These notes are provided as a resource and helped me to pass the USMLE Step 2CS. I have obtained the notes from various resources and acknowledge them at the end. If you are a foreign medical graduate it is important to note that in US medicine they utilize simulated patients to practice from the beginning of medical school. I would encourage you to practice with one of these patients as they can provide you insight into these practices. Contact your local medical school to practice with them and obtain their critique. Remember to practice a lot before scheduling the exam. Also confidence is key – remember you are the doctor and must show your knowledge. By practicing this will aid you in being more confident. If you are nervous in exams try hypnosis. More than anything else do not give up.

 

EXAM FORMAT

*
p<{color:#000;background:transparent;}. 10 – 12 SPs

*
p<{color:#000;background:transparent;}. Each encounter only 15 min

*
p<{color:#000;background:transparent;}. When 5 min remaining warning announced

*
p<{color:#000;background:transparent;}. Consists of:

*
p<{color:#000;background:transparent;}. Doorway information and Meeting patient: 10 – 20 seconds

*
p<{color:#000;background:transparent;}. History taking: 7-8 minutes

*
p<{color:#000;background:transparent;}. Physical exam: 3-5 minutes

*
p<{color:#000;background:transparent;}. Discuss findings and plans, Answer any questions patient has: 2-3 minutes

*
p<{color:#000;background:transparent;}. Patient note: 10 min

*
p<{color:#000;background:transparent;}. Practice is the best way to improve your performance, efficiency and sense of timing

 

INTRODUCTION

*
p<{color:#000;background:transparent;}. Doorway Information

*
p<{color:#000;background:transparent;}. Write down pertinent doorway information (chief complaint, vital signs)

*
p<{color:#000;background:transparent;}. Write down a possible differential to determine history and examination to focus on

*
p<{color:#000;background:transparent;}. Memorize patient name

*
p<{color:#000;background:transparent;}. Knock on Door (wait for patient to say you can enter)

*
p<{color:#000;background:transparent;}. Introduce yourself to the patient (remember to say their name and yours, also that you are the doctor on call)

*
p<{color:#000;background:transparent;}. Shake hand except if they are in severe pain

*
p<{color:#000;background:transparent;}. Ask: how may I help you today?

 

HISTORY

*Must be organized and well-planned. Ask questions pertinent to chief complaint.

CHIEF COMPLAINT

Why the patient came in today. Can be in patient’s own words.

HISTORY OF PRESENT ILLNESS (HPI) OLDCARTS

table<>. <>. |<>.
p={color:#000;background:transparent;}. MNEMONIC |<>.
p={color:#000;background:transparent;}. DESCRIPTION |<>.
p={color:#000;background:transparent;}. EXAMPLES | <>. |<>.
p={color:#F00;background:transparent;}. O |<>.
p<{color:#000;background:transparent;}. Onset of symptoms?

Sudden pain – pneumothorax, Pulm Embolism, rib #

Slow, sharp pain – pneumonia, pleurisy

Ripping/tearing pain – aortic dissection

Heavy/tight/squeezing – acute coronary syndrome |<>.
p<{color:#000;background:transparent;}. “When did it begin?”

“What were you doing when it started?”

“Did it come on slowly? Suddenly?”

“When were you last completely well?” | <>. |<>.
p={color:#F00;background:transparent;}. L |<>.
p<{color:#000;background:transparent;}. Location of symptoms?

(Use paraphrasing to ensure you have correct location)

If no location but symptom (fatigue, fever, SOB) have patient begin talking about problem |<>.
p<{color:#000;background:transparent;}. “Where does it hurt?”

“On which side?”

“Could you point and show me where?”

“Please tell me about your symptoms.” (if no location) | <>. |<>.
p={color:#F00;background:transparent;}. D |<>.
p<{color:#000;background:transparent;}. Duration of symptoms? |<>.
p<{color:#000;background:transparent;}. “How long does the pain last?”

“Does the pain ever go away?”

“When was the last time you didn’t have pain?” | <>. |<>.
p={color:#F00;background:transparent;}. C |<>.
p<{color:#000;background:transparent;}. Character of symptoms? |<>.
p<{color:#000;background:transparent;}. “What does it feel like?” | <>. |<>.
p={color:#F00;background:transparent;}. A |<>.
p<{color:#000;background:transparent;}. Aggravating Symptoms?

IHD – exertion, walking up stairs, sexual intercourse

Asthma – physical exertion, exposure to cold air, dust, smoking, animals

Ulcer – eating food, taking NSAIDs

Meningitis – movement, jumping up & down

Migraine – exposure to sound/light

Muscle contraction headache – stress

Gallbladder – eating fatty foods

Pancreatitis/gastritis – alcohol ingestion

Polymyalgia rheumatica – gel phenomenon (stiff, sore joints after resting a few hours)

Musculoskeletal Pain – moving about

Alleviating Symptoms?

Angina Pectoris – rest

Pericarditis – sitting forward

Renal colic – moving about

Muscle contraction headache – massage

Migraine – dark, quiet room; caffeine ingestion

Ulcer/GERD – antacids, eating food

Gastric outlet obstruction – vomiting

Musculoskeletal pain – keeping still and not moving |<>.
p<{color:#000;background:transparent;}. “Does anything make it worse?”

“Does anything make it better?”

Can also ask on activities that directly make symptoms better or worse.

| <>. |<>. p={color:#F00;background:transparent;}. R |<>. p<{color:#000;background:transparent;}. Radiation of symptoms?

Groin/testicle – kidney stone

Right scapula tip – gallbladder

Top of shoulders – spleen injury

Lower abdomen – testicular torsion

Back – pancreatitis, posterior penetrating gastric ulcer, abdominal aortic aneurysm

Down Leg – sciatica

Radiating to ear – Pharyngitis pain

Arms/neck/back/jaw – ischemic chest pain |<>.
p<{color:#000;background:transparent;}. “Does the pain move anywhere?” | <>. |<>.
p={color:#F00;background:transparent;}. T |<>.
p<{color:#000;background:transparent;}. Timing/Frequency of symptoms? |<>.
p<{color:#000;background:transparent;}. “How often does it happen?”

“Is it getting better or worse?”

“Does the pain come and go?” | <>. |<>.
p={color:#F00;background:transparent;}. S |<>.
p<{color:#000;background:transparent;}. Severity of symptoms?

Pain – pain scale, subjective grading, General appearance can note objective view of pain

Symptom – ask how bad it is, any functional impairment (dementia, depression, Parkinson’s, other chronic conditions) or how affecting patient’s life |<>.
p<{color:#000;background:transparent;}. Pain: “On a scale from 1 to 10, with 10 being the worst pain, how would you rate your pain?”

Symptom:

“How is this weakness affecting your life?”

“How much has this been happening?”

“How many pads or tampons do you use a day?”

“How much sputum do you have?”

Functional Impairment (DEATH):

“Are you having any problems getting dressed?”

“Are you able to prepare your own food and eat it?”

“Are you having any falls?”

“Any problems getting off and on the toilet?”

“Are you able to bathe or shower by yourself?” | <>. |<>.
p={color:#F00;background:transparent;}. + |<>.
p<{color:#000;background:transparent;}. Associated Symptoms – symptoms that commonly occur in diagnoses you are considering, can ask good associated – symptom questions based on chief complaint and preceding history.

Close-ended questions until a positive response, then ask an open ended question.

|<>. p<{color:#000;background:transparent;}. If CC is MI, ask on palpitations, syncope, SOB, diaphoresis, nausea & vomiting

Cough – fever, sputum, SOB, chest pain, hemoptysis

Joint Pain – redness, swelling, heat, loss of function, rash, fever

Abdominal Pain – fever, anorexia, emesis, diarrhea, dysuria, jaundice, gas (bowel obstruction)

“Do you have any loss of appetite?”

“No.”

“Are you having any problems urinating?”

“Yes.”

“Tell me more about it.” |

 

 

PAST MEDICAL HISTORY PAMHUGSFOSS

*
p<{color:#000;background:transparent;}. At least 1 question on medications and allergies on all patients

*
p<{color:#000;background:transparent;}. Ask LMP for women post menarche

table<>. <>. |<>.
p={color:#000;background:transparent;}. MNEMONIC |<>.
p={color:#000;background:transparent;}. DESCRIPTION |<>.
p={color:#000;background:transparent;}. EXAMPLES | <>. |<>.
p={color:#F00;background:transparent;}. P |<>.
p<{color:#000;background:transparent;}. Previous episodes of chief complaint |<>.
p<{color:#000;background:transparent;}. “Have you ever had this before?” | <>. |<>.
p={color:#F00;background:transparent;}. A |<>.
p<{color:#000;background:transparent;}. Allergies/ Allergic reaction (rash, SOB, runny nose, watery eyes, bee sting, anaphylaxis)

*
p<{color:#000;background:transparent;}. Medications

*
p<{color:#000;background:transparent;}. Foods

*
p<{color:#000;background:transparent;}. Plants or animals

*
p<{color:#000;background:transparent;}. Environmental Sources

|<>. p<{color:#000;background:transparent;}. “Do you have any allergies?”

“Do you have any allergies to prescription meds?”

“How about any bad reaction to OTC pills?”

“Any bad reactions to food?”

“Do you have any allergies to animals or plants?”

“Anything else you can tell me about your allergies?” | <>. |<>.
p={color:#F00;background:transparent;}. M |<>.
p<{color:#000;background:transparent;}. Medications, including birth control, over the counter (OTC), herbals & vitamins (if unfamiliar with drug, ask what used for; diagnosis could be secondary to noncompliance so note when meds started or dosage increased and when side effects began)

Common Herbals & Uses: St. John’s Wort – depression, saw palmetto – BPH, Ginseng – stress/memory, cranberry – UTI, Echinacea – URI

Common Medications and their Side Effects

NSAIDS (aspirin, ibuprofen, naproxen) – GI bleeding, ulcer, allergic reaction, renal insufficiency

Diuretics (Lasix, furosemide, HCTZ, spironolactone, Bumex) – renal failure, hypotension, electrolyte disorder, syncope, gout (thiazides)

Digoxin – arrhythmias, headache, dizziness, fatigue, nausea/vomiting

Beta Blockers (atenolol, metoprolol, Toprol XL) – bradycardia, depression, ED, hypotension, wheezing

ACE inhibitors (Lisinopril, captopril, Avapro, enalapril) – renal failure, hyperkalemia, cough, angioedema

SSRIs (fluoxetine, Prozac, Paxil) – confusion, fever, anxiety, hyperreflexia, tremors, insomnia, tachycardia, HTN (serotonin syn.)

Statins (atorvastatin, simvastatin) – rhabdomyolysis (renal failure, muscle pain), liver failure (jaundice) |<>.
p<{color:#000;background:transparent;}. “Are you taking any medications?”

“Do you take prescription medications?”

“How about over-the-counter pills?”

“Do you take any vitamins or herbs?”

“What do you take that for?”

“Could you spell that for me please?”

“Are you taking your medication regularly?” | <>. |<>.
p={color:#F00;background:transparent;}. HITS |<>.
p<{color:#000;background:transparent;}. Hospitalizations – only one or two word description of why pt hospitalized as current case may be complication or progression of disease

Illness – Ask about specific diseases individually, make sure to wait for pt to say yes or no before asking next question

Trauma – If major will usually find out when asking about hospitalizations or surgeries

Surgery – all of the operations even outpatient, if see scar during examination ask about it, pay attention to what pt telling you |<>.
p<{color:#000;background:transparent;}. “Have you ever been hospitalized?”

“Have you ever stayed overnight in the hospital?”

“Have you ever had any major illness?”

“Have you ever had high blood sugar?”

“Have you ever had high blood pressure?”

“How about high cholesterol?”

“Have you ever had any major injuries?”

“Have you had any head injuries?”

“Have you ever had any operations?”

“Where did this scar come from?” | <>. |<>.
p={color:#F00;background:transparent;}. RUGS |<>.
p<{color:#000;background:transparent;}. Review of Systems

Urinary – if no go to another system, if yes go through urinary complaint questions

GI – weight gain (depression, eating disorders, hypothyroidism, Cushing’s, edema secondary to liver failure, heart failure or nephrotic syndrome); weight loss (depression, eating disorders, cancer, hyperthyroidism, amphetamine use, chronic diseases)

Sleep – hypersomnia (depression, hypothyroidism, sleep apnea, drugs); hyposomnia (depression, hyperthyroidism, mania, drug use) |<>.
p<{color:#000;background:transparent;}. Urinary:

“Do you have any problems urinating?”

“How often do you urinate?”

“How many times do you get up at night to urinate?”

“Do you have any burning urination?”

“Any blood?”

“Is the stream weak?”

“Do you ever have any accidents?”

GI:

“Has there been any recent change in your weight?”

“Are you on any special diet?”

Sleep:

“Has there been any change in how much you sleep?” | <>. |<>.
p={color:#F00;background:transparent;}. F |<>.
p<{color:#000;background:transparent;}. Family History

Only relevant if the diagnosis you are considering has a genetic or familial component, don’t ask if irrelevant, do transitional statement before going into family history. Offer condolences if death was less than a year ago or if patient’s facial expression suddenly becomes sullen.

|<>. p<{color:#000;background:transparent;}. “I want to ask you some questions on your family’s history.”

“Does anyone in your family have what you have?”

“Does anyone in your family have high blood sugar?”

“How about high blood pressure?”

“Does anyone in the family have any serious illness?” | <>. |<>.
p={color:#F00;background:transparent;}. O |<>.
p<{color:#000;background:transparent;}. Ob/Gyn

Ask about last menstrual period for all women past menarche

Get more detailed Ob/Gyn if complaints of abdominal pain, abnormal vaginal bleeding, dysuria, discharge, sometimes syncope (ectopic pregnancy)

GPA status: G – number of times pregnant, P – number of live births, A – number of miscarriages/abortions

Gyn – regularity, cramps/pain, flow, cycle length, age of menarche/menopause, spotting, vaginal discharge, last pap smear |<>.
p<{color:#000;background:transparent;}. G – “How many times have you been pregnant?”

P – “How many times have you given birth?”

A – “Have you had any miscarriages or abortions?”

“When was your last menstrual period?”

“Was it normal?”

“Do you have a period every month?”

“How long between periods?”

“Are you regular? How many days do you use pads or tampons?”

“On a heavy day, how many pads or tampons do you use?”

“When did you start having periods? When did you stop menstruating?”

“Any mood swings or irritability around your period? Anything else?” | <>. |<>.
p={color:#F00;background:transparent;}. S |<>.
p<{color:#000;background:transparent;}. Sexual History

Only needed if relevant to the case, especially if you think patient could have an STD. Sexual function could be compromised by diagnoses you are considering (ie angina precipitated by sexual intercourse, ED caused by depression/diabetes/ beta blockers). Practice over and over again until not embarrassed to ask.

|<>. p<{color:#000;background:transparent;}. “Are you sexually active?”

“Do you use contraception?”

“How many sexual partners have you had in the last six months?”

“Are your partners men, women or both?”

“Have you ever been tested for HIV?”

“Have you ever had a sexually transmitted disease?”

“Do you have any concerns about sexual function?” | <>. |<>.
p={color:#F00;background:transparent;}. S |<>.
p<{color:#000;background:transparent;}. Social History (WHETARD) – depending on case ask parts or all

Work Life – may give diagnosis (ie coal miner with SOB – pneumoconiosis)

Home Life – just need who they live with & stress at home

Exercise – only ask for general checkup, annual physical or periodic health exam, not for acute problems

Tobacco – pack years = # packs per day x number of years; if CC is smoking cessation note when started to smoke, what tried to do to stop in the past, methods of quitting have and have not been successful

Alcohol – can advise no alcohol if affect pt’s health (hepatitis with jaundice, pregnancy or trying to get pregnant); binge drinking is >5 drinks for men or > 4 drinks for women on one occasion (1 drink is 1 oz liquor, 4 oz wine, or 12 oz beer)

Recreational Drugs – find out specific names, route used (ingested, smoked, snorted, IV), when last used, if willing to quit, method of quitting used in the past

Diet (if not addressed in ROS)

Common names Recreational Drugs

Alcohol – booze, brews, brewskis

Amphetamines – speed, crank, crystal meth

Cannabis – hash, hashish, dope, pot, reefer, bud, ganja, weed, grass

Cocaine – blow, coke, toot, nose candy, crack

Benzodiazepines/barbiturates – downers

Heroin – horse, brown sugar, smack

PhencyclidinePCP, angel dust

Anabolic Steroids – ‘Roids |<>.
p<{color:#000;background:transparent;}. “Have you ever used tobacco products?”

“Do you drink alcohol?”

“How much alcohol do you drink?”

CAGE: (Ask if more than 2 drinks per day men or 1 drink per day women, any positive response suggests may be an alcohol problem, only ask if has not met criteria for binge drinking)

“Have you ever felt you should Cut down on your drinking?”

“Have people Annoyed you by criticizing your drinking?”

“Have you ever felt bad or Guilty about your drinking?”

“Have you had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener)”

“Do you use recreational drugs?”

“What do you use?”

“How do you take it?”

“When did you last use?”

“How much exercise do you get?”

“Do you work?”

“Are you having any stress from work?”

“Who do you live with?”

“Is there any stress at home?” |

*
p<{color:#000;background:transparent;}.

 

ROS

<>.
p={color:#000;background:transparent;}. Questions
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>/6.
<>.
<>.
<>.
<>.
<>.
<>/7.
<>.
<>.
<>.
<>.
<>.
<>.

 

 

Pediatric/Adolescent Histories

No physical exam is possible – therefore leave blank in note. Find out the name of the patient, name of the person you are speaking with, and relationship between the family members.

#
p<{color:#000;background:transparent;}. Pediatric History

*
p<{color:#000;background:transparent;}. Prenatal History

*
p<{color:#000;background:transparent;}. How was your health during pregnancy?

*
p<{color:#000;background:transparent;}. Did you get regular prenatal checkups?

*
p<{color:#000;background:transparent;}. Did you smoke or drink during pregnancy?

*
p<{color:#000;background:transparent;}. Were there any problems with swelling or high blood pressure? (preeclampsia)

*
p<{color:#000;background:transparent;}. Birth History

*
p<{color:#000;background:transparent;}. Was the baby full-term?

*
p<{color:#000;background:transparent;}. Did you have a Cesarean section?

*
p<{color:#000;background:transparent;}. Were there any problems with your labor?

*
p<{color:#000;background:transparent;}. How much did the baby weigh at birth?

*
p<{color:#000;background:transparent;}. Neonatal History

*
p<{color:#000;background:transparent;}. How long did you and the baby stay in the hospital after the delivery? (if greater than 2 days indicates a problem)

*
p<{color:#000;background:transparent;}. Did the child have any medical problems when she was born?

*
p<{color:#000;background:transparent;}. Any problems with breathing?

*
p<{color:#000;background:transparent;}. Any problems with feeding, having bowel movements, or infections?

*
p<{color:#000;background:transparent;}. Any problems with yellow skin?

*
p<{color:#000;background:transparent;}. Feeding History

*
p<{color:#000;background:transparent;}. Was the child breast-fed or bottle-fed?

*
p<{color:#000;background:transparent;}. If newborn: Are you having any problems breastfeeding?

*
p<{color:#000;background:transparent;}. If newborn is bottle-fed: What formula are you using? How many ounces does the baby drink? How often? What is the feeding schedule?

*
p<{color:#000;background:transparent;}. If older child: When did the child start eating solid food? How is her appetite? Is she taking a pediatric multiple vitamin? Does she have any food allergies?

*
p<{color:#000;background:transparent;}. Developmental History (more important for toddler, not 12 year old with earache)

*
p<{color:#000;background:transparent;}. Has your child been gaining weight normally?

*
p<{color:#000;background:transparent;}. Has there been any sudden gain or loss of physical growth?

*
p<{color:#000;background:transparent;}. At what age did the baby start to say a few words? To social smile? To roll over? To walk?

*
p<{color:#000;background:transparent;}. At what age was the baby toilet-trained?

*
p<{color:#000;background:transparent;}. Routine Care – if mother has immunization record in her purse – ask to see it

*
p<{color:#000;background:transparent;}. Are the child’s immunizations up to date?

*
p<{color:#000;background:transparent;}. Is the child getting routine checkups?

#
p<{color:#000;background:transparent;}. Adolescent History – ask a little about each category to cover a lot of potential problems

*
p<{color:#000;background:transparent;}. Body Image

*
p<{color:#000;background:transparent;}. How is your child’s body image?

*
p<{color:#000;background:transparent;}. (to the child) Do you feel bad about yourself? Do you like your body?

*
p<{color:#000;background:transparent;}. Eating Disorders

*
p<{color:#000;background:transparent;}. Has your teen’s weight changed?

*
p<{color:#000;background:transparent;}. How much does your child exercise?

*
p<{color:#000;background:transparent;}. Does he frequently go to the bathroom during dinner?

*
p<{color:#000;background:transparent;}. Education

*
p<{color:#000;background:transparent;}. Has there been any change in your child’s grades?

*
p<{color:#000;background:transparent;}. Is your child interested in school?

*
p<{color:#000;background:transparent;}. Friends and Activities

*
p<{color:#000;background:transparent;}. Do you know your child’s friends?

*
p<{color:#000;background:transparent;}. Is your child secretive about his friends?

*
p<{color:#000;background:transparent;}. Does your child have friends and activities?

*
p<{color:#000;background:transparent;}. Drugs

*
p<{color:#000;background:transparent;}. Does your child drink alcohol?

*
p<{color:#000;background:transparent;}. Does he use recreational drugs?

*
p<{color:#000;background:transparent;}. Does he smoke cigarettes?

*
p<{color:#000;background:transparent;}. Sex

*
p<{color:#000;background:transparent;}. Have you talked to your child about sex?

*
p<{color:#000;background:transparent;}. Is your child sexually active?

*
p<{color:#000;background:transparent;}. Have you asked your child if he is sexually active?

*
p<{color:#000;background:transparent;}. Have you discussed contraception?

*
p<{color:#000;background:transparent;}. Has your daughter had the new shot that prevents cervical cancer?

*
p<{color:#000;background:transparent;}. Suicide/Depression

*
p<{color:#000;background:transparent;}. Does your child seem sad or hopeless?

*
p<{color:#000;background:transparent;}. Does your child seem to want to harm himself?

*
p<{color:#000;background:transparent;}. Does your child seem uninterested in activities?

PHYSICAL EXAMINATION

*
p<{color:#000;background:transparent;}. Brief and focused physical exam critical

*
p<{color:#000;background:transparent;}. Don’t do complete head-to-toe physical exam

*
p<{color:#000;background:transparent;}. Have 4 – 5 minutes to complete the exam

*
p<{color:#000;background:transparent;}. Divided into six systems (Pertinent positive and negative findings, for systemic conditions prioritize target organs)

*
p<{color:#000;background:transparent;}. HEENT

*
p<{color:#000;background:transparent;}. Chest

*
p<{color:#000;background:transparent;}. Cardiovascular

*
p<{color:#000;background:transparent;}. Abdominal

*
p<{color:#000;background:transparent;}. Neurological

*
p<{color:#000;background:transparent;}. Joints

*
p<{color:#000;background:transparent;}. Perform physical exam maneuvers most likely on the SP’s Physical Exam Checklist

*
p<{color:#000;background:transparent;}. Do most relevant organ system first (if headache start with HEENT & neurological exam)

*
p<{color:#000;background:transparent;}. Perform a complete or near-complete exam on most relevant organ systems, then go to secondary organ systems (if abdominal pain, secondary exam might be chest, Cardiovascular and HEENT)

*
p<{color:#000;background:transparent;}. Any Specific Exams: If necessary do not hesitate to ask the patient for permission to do a sensitive examination and document information received (refused/declined/arranged exam), elderly (ADLS, IADLs, “get up and go” test), children (developmental screening), depression screening, MMSE, CAGE (alcohol use), domestic violence screen, asthmatics (peak flow), any unusual piece of equipment or paper in the room usually has a purpose, if not done state “additional PE deferred” and consider putting into follow up plan (ie schedule for rectal examination)

*
p<{color:#000;background:transparent;}. When finished taking history, wash hands and say, “Now I’ll do your physical exam. Let me first wash my hands.”

*
p<{color:#000;background:transparent;}. Handwashing:

*
p<{color:#000;background:transparent;}. Wash hands before touching patient for a physical exam, but after giving the drape or shaking hands during the introduction

*
p<{color:#000;background:transparent;}. Squirt soap and rub hands under water for 3 seconds, then dry hands completely

*
p<{color:#000;background:transparent;}. Don’t touch face after washing hands – if sneeze or rub nose re-wash your hands before touching patient again

*
p<{color:#000;background:transparent;}. Gloves

*
p<{color:#000;background:transparent;}. If gloves are put on still wash hands.

*
p<{color:#000;background:transparent;}. Only put on gloves if you have an open wound or infectious disease.

*
p<{color:#000;background:transparent;}. Put on gloves if touch patient’s saliva – try to examine so that gloves are not necessary

*
p<{color:#000;background:transparent;}. Gown and Draping

*
p<{color:#000;background:transparent;}. Give drape during the introduction at the beginning of the encounter

*
p<{color:#000;background:transparent;}. “May I untie and lower your gown so I can examine your chest?”

*
p<{color:#000;background:transparent;}. Allow patient to raise or lower gown on own, assist if in distress

*
p<{color:#000;background:transparent;}. For gown keep patient covered as much as possible – uncover only part of torso being examined

*
p<{color:#000;background:transparent;}. Once finished replace the gown to protect patient’s modesty

*
p<{color:#000;background:transparent;}. Don’t expose abdomen and chest simultaneously

*
p<{color:#000;background:transparent;}. Chest

*
p<{color:#000;background:transparent;}. Lower gown an inch or so below costal margin

*
p<{color:#000;background:transparent;}. Replace and retie gown when chest exam finished

*
p<{color:#000;background:transparent;}. Abdomen

*
p<{color:#000;background:transparent;}. Raise gown an inch or so above costal margin

*
p<{color:#000;background:transparent;}. Replace gown when finished exam

*
p<{color:#000;background:transparent;}. Retie the strings of the gown as soon as the gown is replaced

*
p<{color:#000;background:transparent;}. Only ask for permission when getting patient undressed, including removing shoes and socks

*
p<{color:#000;background:transparent;}. If patient refuses to cooperate explain importance of physical in order to determine cause of condition

*
p<{color:#000;background:transparent;}. Not Allowable Physical Exam Maneuvers

*
p<{color:#000;background:transparent;}. Never do female breast exam, internal pelvic exam, rectal exam, genital/genitourinary exams, corneal reflex exam, gag reflex or sense of smell

*
p<{color:#000;background:transparent;}. Do not hurt the SP

*
p<{color:#000;background:transparent;}. Otoscopy – do not scratch ear canal and do not place deeply into ear

*
p<{color:#000;background:transparent;}. Pharynx – use clean tongue blade and place it only 1/3 to ½ of way back on visible portion of tongue

*
p<{color:#000;background:transparent;}. Fingernails – keep off of patient’s skin

*
p<{color:#000;background:transparent;}. Hands – make sure they’re dry before touching patient

*
p<{color:#000;background:transparent;}. Abdomen – no deep palpation, use gentle touch

*
p<{color:#000;background:transparent;}. CVA tenderness – do not punch patient, only a simple tap (SP will simulate pain)

*
p<{color:#000;background:transparent;}. Simulated versus Real Physical Findings

*
p<{color:#000;background:transparent;}. Accept All Physical Findings

*
p<{color:#000;background:transparent;}. Accept all patients as real, except for the vital signs

*
p<{color:#000;background:transparent;}. Highly unlikely cases will involve malingering

*
p<{color:#000;background:transparent;}. An abnormal finding may not be heard, however the SP will state they have the finding. To record state, “Pt with hx of heart murmur”, write in physical what you actually heard (S1, S2 – nl, no rub, gallop, and murmur)

*
p<{color:#000;background:transparent;}. Notice All Aspects of the SP’s Presentation

*
p<{color:#000;background:transparent;}. Smell patient – if beer then they are intoxicated, if fruity then diabetic ketoacidosis

*
p<{color:#000;background:transparent;}. Pay attention to behavior – if unusual it is part of the case

*
p<{color:#000;background:transparent;}. Inspect the skin carefully

*
p<{color:#000;background:transparent;}. Comment on any simulated findings that need clarification

*
p<{color:#000;background:transparent;}. Note any water (sweating appearance), may see marks/discolorations on skin related to patient’s condition

*
p<{color:#000;background:transparent;}. White powder – pallor, anemia

*
p<{color:#000;background:transparent;}. Yellow powder – jaundice

*
p<{color:#000;background:transparent;}. Purple – ecchymoses, bleeding disorder, trauma

*
p<{color:#000;background:transparent;}. Red – infection, inflammation

*
p<{color:#000;background:transparent;}. Tell patient what you are looking for and what you notice

*
p<{color:#000;background:transparent;}. Properly examine the SPs

*
p<{color:#000;background:transparent;}. Make sure listen to heart/lungs/bowel sounds for a few seconds

*
p<{color:#000;background:transparent;}. May find some actual findings

*
p<{color:#000;background:transparent;}. Don’t Worry about Missing Subtle Physical Findings

*
p<{color:#000;background:transparent;}. Physical findings will not be subtle

*
p<{color:#000;background:transparent;}. Ophthalmoscopy – don’t worry about not seeing much, as long as the red reflex is seen write this and any other findings

*
p<{color:#000;background:transparent;}. Position the Patient

*
p<{color:#000;background:transparent;}. Examine from either side of the bed. Minimize the number of times a patient has to sit up, lie back and stand

*
p<{color:#000;background:transparent;}. Communicate with the Patient during the Physical Exam

*
p<{color:#000;background:transparent;}. Tell patient briefly what you are going to do next as you go through physical exam

*
p<{color:#000;background:transparent;}. Do not give patient results of finding now unless the patient asks

*
p<{color:#000;background:transparent;}. Use new tongue blades, ear speculums, cotton balls

*
p<{color:#000;background:transparent;}. Take BP & HR if patient asks you to or if patient is coming in for a BP check

*
p<{color:#000;background:transparent;}. Remember the Order in Which to Do Your Physical Exam

*
p<{color:#000;background:transparent;}. Start with most relevant system first and do it almost completely

*
p<{color:#000;background:transparent;}. Do less important organ systems less completely or not at all

 

 

 

table<>. <>. |<>.
p={color:#000;background:transparent;}. EXAM |<>.
p={color:#000;background:transparent;}. ASPECTS |<>.
p={color:#000;background:transparent;}. SPECIAL TESTS |<>.
p={color:#000;background:transparent;}. PHRASING | <>. |<>.
p<{color:#000;background:transparent;}. ABDOMINAL

 

If there is:

*
p<{color:#000;background:transparent;}. Abd. Pain

*
p<{color:#000;background:transparent;}. Vomiting

*
p<{color:#000;background:transparent;}. Diarrhea

*
p<{color:#000;background:transparent;}. Jaundice

*
p<{color:#000;background:transparent;}. Urinary tract problem

*
p<{color:#000;background:transparent;}. Pelvic pain

|<>. p<{color:#000;background:transparent;}. Setup: raise pt’s knees and optionally can raise head of bed 20-30 degrees

Inspection: scars, hernia, makeup

Auscultation: listen for 3 seconds in each quadrant. Make sure SP aware you’re warming your stethoscope before you begin auscultation.

Percussion: two taps each on four quadrants, tap out liver size if jaundice/liver/ CHF case

Palpation: palpate all 4 quadrants and the epigastric area for 3 seconds each. Palpate area of suspected tenderness last, otherwise palpate from lower quadrant to upper quadrant. If peritonitis do rebound tenderness palpation (more pain when let go suddenly compared to when you push down slowly) |<>.
p<{color:#000;background:transparent;}. Murphy’s sign: cholecystitis, place hand gently under right costal margin and ask pt to take a deep breath, if pain felt = + Murphy’s sign

Costovertebral Angle Tenderness: kidney stones, pyelonephritis, other kidney pathology; pt sitting/ supine/standing/on side; pain with light tap – + CVA tenderness

Rovsing’s sign: appendicitis, pain in R lower quadrant with palpation of left lower quadrant

Obturator sign: appendicitis, pain in right lower quadrant with flexion of hip to 90 degrees and rotation of hip

Psoas sign: appendicitis, pain in RLQ with flexion of the right hip against resistance |<>.
p<{color:#000;background:transparent;}. “I’m going to examine your belly. May I left your gown?”

Inspection: “I’m looking at your belly. Have you noticed any changes?”

Auscultation: “Now I will listen to your belly.”

Percussion: “Now I’m going to tap on your tummy.”

Palpation: “I need to press on your belly now.” “Does it hurt more when I push down or let go?” – rebound

Murphy’s sign: “Take a deep breath, please.”

Costovertebral Angle Tenderness: “I’m going to tap on your back; please let me know if it hurts.”

Rovsing’s sign: while palpating: “Any tenderness?” If hurts ask: “Where does it hurt?”

Obturator sign: “I’m going to uncover your leg and bend it.”

Psoas sign: “Please bring up your leg. Do you have any pain?” | <>. |<>.
p<{color:#000;background:transparent;}. CHEST

 

If there is:

*
p<{color:#000;background:transparent;}. Cough

*
p<{color:#000;background:transparent;}. Shortness of breath

*
p<{color:#000;background:transparent;}. Chest pain

*
p<{color:#000;background:transparent;}. Resp. Tract Infection

*
p<{color:#000;background:transparent;}. Sputum production

 

*don’t examine over scapulae, place stethoscope on skin, compare both sides, listen to complete resp. cycle, do not talk while auscultating |<>.
p<{color:#000;background:transparent;}. Inspection: Check hands for clubbing and cyanosis

Palpation: check chest wall, spine, paraspinal muscle and CVA tenderness

Percussion: tap two times in six places on the back

Auscultation: check 6 places on the back, 4 on front; listen side to side for crackles, rhonchi, wheeze or rub. On back listen to base of lungs bilaterally (left then right), then listen medially just below scapula, then listen at T3 dermatome between spine and scapula. Say you are warming the stethoscope, ok to use if still cold: “I’ll warm this up for you. Next I’m going to listen to your…” |<>.
p<{color:#000;background:transparent;}. Respiratory excursion: stand behind patient, place hands on either side of lateral chest wall (gown must be open), patient must take a deep breath. Thank patient once completed.

Tactile fremitus: examine both sides at once in three places on back – if increased indicates pneumonia, decreased if pt speaks softly, if hands are placed further from major bronchi, pneumothorax or pleural effusion |<>.
p<{color:#000;background:transparent;}. “I need to look at your back and examine your lungs. May I untie and lower your gown?”

Inspection: ”I’m going to take a look at your back and chest.”

Respiratory excursion: “I’m going to push on your ribs. Please take a deep breath.”

Palpation: “I’m going to push on your ribs”

Tactile fremitus: “Please say ‘ninety-nine.’”

Percussion: “I’m going to tap on your chest.”

Auscultation: “I’m going to listen to your lungs. Breathe deeply in and out through your mouth.” | <>. |<>.
p<{color:#000;background:transparent;}. CARDIOVASCULAR

 

If there is:

*
p<{color:#000;background:transparent;}. MI symptoms

*
p<{color:#000;background:transparent;}. Chest Pain

*
p<{color:#000;background:transparent;}. Shortness of breath

*
p<{color:#000;background:transparent;}. Pedal edema

*
p<{color:#000;background:transparent;}. Syncope

*
p<{color:#000;background:transparent;}. Palpitations

|<>. p<{color:#000;background:transparent;}. Sitting Up Exam: Auscultation carotids: neck bruit, listen for < or = 3 sec.

Palpation: Don’t palpate both carotids at same time

Pulses: Check radial, dorsalis pedis, post. Tibialis bilaterally at same time; check for atrial fibrillation (irregularly irregular pulse), check hands for clubbing and capillary refill.

Auscultation heart: listen 3 sec in each cardiac area, aortic, tricuspid, mitral and pulmonic – doesn’t have to be correct location, don’t put stethoscope on or underneath clothes, if female ask to lift breast |<>.
p<{color:#000;background:transparent;}. Lying Back Exam: exam table at 30 degree incline

JV distension

Hepatojugular reflex: do if pt has CHF

PMI:

Auscultation: All 4 areas

Additional heart sounds: turn pt on left side to listen for S3, S4 or to palpate PMI if cannot be felt in supine position |<>.
p<{color:#000;background:transparent;}. Auscultation carotid art.: “I need to listen to your neck sounds. Please take a deep breath & hold it.”

Palpation carotid arteries: “I need to check the pulse in your neck.”

Pulses: “I’m going to check your hands and feet.”

Extremities: “I’m going to check your legs for swelling.”

Auscultation heart: “I’d like to listen to your heart. Please breathe normally.” “Could you please lift your breast?”

JV distension: “I’m going to look at the vein in your neck. Please look to your left.”

PMI: “I’m going to press on your heart area.” | <>. |<>/6.
p<{color:#000;background:transparent;}. NEUROLOGICAL

 

If there is:

*
p<{color:#000;background:transparent;}. Headaches

*
p<{color:#000;background:transparent;}. Dizziness

*
p<{color:#000;background:transparent;}. Balance or vision problems

*
p<{color:#000;background:transparent;}. Numbness or tingling

*
p<{color:#000;background:transparent;}. Psychiatric problem

*
p<{color:#000;background:transparent;}. Memory problem

*
p<{color:#000;background:transparent;}. Muscle weakness

|<>. p<{color:#000;background:transparent;}. MENTAL STATUS: complete if psychiatric disease, dementia, altered mental status

Orientation – person, place & time

Memory – immediate recall (repeat 3 simple words – cat, apple, table), delayed recall (repeat same 3 words a minute later)

Attention & Concentration – ask the pt to spell the word WORLD backwards

Language – ask pt to name objects you point out or ask to repeat the phrase ‘No ifs, ands or buts.’

Obeys commands – ask pt to close eyes, once completed have pt open eyes again.

|<>. p<{color:#000;background:transparent;}. SPECIFIC NEURO EXAMS:

Meningitis: stiff neck Brudzinski: head flexion, knees and hips flex spontaneously

Kernig: flex hip and knee, try to extend lower leg, positive = pain and stiffness in leg

Plantar reflex: Babinski; normal = great toe flexion, abnormal = great toe extension and toe flaring (upper motor neuron lesion), withdrawal = ticklish

Romberg: balance problem cases, positive = loses balance |<>.
p<{color:#000;background:transparent;}. Orientation: “I’m going to check your memory now.”

“Could you please tell me your full name?”

“What kind of place are we in?”

“What is today’s date?”

Plantar reflex: “I’m going to scratch the bottom of your feet.”

Romberg: “Keep your feet together, arms out, palms up, head back and eyes closed. I’ll be behind you if you feel unsteady.” | <>. |<>.
p<{color:#000;background:transparent;}. CRANIAL NERVES:

II: Snellen chart for vision, if cannot see chart do finger count, if cannot see fingers test light perception. Peripheral vision tested by traditional confrontation.

II & III: PERRLA, direct & consensual reaction

III, IV & VI: extraocular movements; 3rd nerve palsy (ptosis, large pupil, eye turned out); 4th nerve palsy (cannot look downward & inward); 6th nerve palsy (eye turned in)

V: Motor – place hands on jaw, have pt clench teeth, feel muscle contract

Sensory – test 3 branches light touch with cotton balls

IX, X, XII: check palate for symmetrical movement (IX & X), check to see if tongue goes out straight (12) |<>.
p<>{color:#000;}.  

|<>. p<{color:#000;background:transparent;}. V: “I’m going to touch your face lightly.”

“Does it feel the same on both sides?”

“Do you feel this?”

“Now please close your eyes. Do you feel this?”

“Thank you. You may open your eyes.”

VII: “Show me your teeth and lift your eyebrows.”

“Please smile and show me your teeth.”

“Please raise your eyebrows.” (not going to test taste)

IX, X, XII: “Stick out your tongue and say, ‘Ah.’”

XI: “now shrug your shoulders.” | <>. |<>.
p<{color:#000;background:transparent;}. MOTOR: finding gross abnormalities in a stroke pt

  • may need to check only upper or lower extremities |<>.
    p<>{color:#000;}.  

|<>. p<{color:#000;background:transparent;}. “Squeeze my fingers.”

“Pull me in.”

“Kick out, kick out.”

“Now I’d like to check your muscle strength.” | <>. |<>.
p<{color:#000;background:transparent;}. SENSORY: symptoms tingling, numbness or diabetes

Orthopedic injury – check distal sensation if not intact then work proximally

Upper extremity: Tip of thumb (C6); tip of middle finger (C7/median n); tip of fifth finger (C8/ulnar n); dorsum web space (radial n)

Lower extremity: just above patella (L4); lateral lower leg (L5); lateral foot (S1) |<>.
p<{color:#000;background:transparent;}. Light touch – cotton balls, work from side to side

Pain sensation: cotton swab (broken in half) or toothpick; examine side to side, start distal and if cannot feel go proximal

Position sense: diabetics or numbness

Vibration sense: diabetics or numbness; stop tuning fork once felt |<>.
p<{color:#000;background:transparent;}. “I need to check your sense of touch.”

“I’m going to touch your hands lightly.”

“Do you feel this? (pause) Does it feel the same on the other side?”

Pain sensation: “I want to test sharp and dull feeling. This is sharp, this is dull. Please close your eyes and tell me what you feel.”

Position sense: “Tell me if I’m moving your finger/toe up or down.”

Vibration sense: “I’m going to put this tuning fork on your toe. Please close your eyes. Do you feel a vibration?”

“Tell me when it stops.” | <>. |<>.
p<{color:#000;background:transparent;}. Reflexes: if thyroid (biceps reflex only), suspected stroke or suspected spinal cord lesion

- Compare side to side

- if hyporeflexic in upper extremities will be hyporeflexic in lower extremities

Sciatica – test only Achilles and patellar reflexes

Stroke – test biceps and patellar reflexes |<>.
p<{color:#000;background:transparent;}. Biceps: C5, C6

Brachioradialis: C6 (only if you suspect C6 lesion)

Triceps: C7 (only if C7 lesion suspected)

Patellar: L4

Achilles tendon: S1 |<>.
p<>{color:#000;}.  

| <>. |<>. p<{color:#000;background:transparent;}. Cerebellar:

Gait

Finger-to-nose

Heel-to-shin |<>.
p<>{color:#000;}.  

|<>. p<>{color:#000;}.   | <>. |<>. p<{color:#000;background:transparent;}. HEENT

 

If there is:

*
p<{color:#000;background:transparent;}. Headache

*
p<{color:#000;background:transparent;}. Eye pain

*
p<{color:#000;background:transparent;}. Vision changes

*
p<{color:#000;background:transparent;}. Ear pain

*
p<{color:#000;background:transparent;}. Dizziness

*
p<{color:#000;background:transparent;}. Hearing loss

*
p<{color:#000;background:transparent;}. Pharyngitis

*
p<{color:#000;background:transparent;}. Throat pain

*
p<{color:#000;background:transparent;}. Swelling

|<>. p<{color:#000;background:transparent;}. Inspection: “I’m going to look at your head”

Palpation: tenderness, deformities of head, face, sinuses, TMJ joint; lymph glands, thyroid (make sure to have swallow)

Auscultation: Carotid bruits, no more than 3 sec.

|<>. p<{color:#000;background:transparent;}. SPECIFIC EXAMS:

Ophthalmoscope – pupils, sclera, conjunctiva, red reflex, fundoscopy (papilledema, cupping, AV nicking, hemorrhages)

Otoscope – throat and oral cavity (CN 9, 10, 12) with tongue depressor; ears (if pain, discharge, hearing loss; inspect pinna, palpate ear, mastoid, wiggle pinna); nose (push nose up gently, ask ‘Can you breathe through both sides of your nose’)

Rinne/Weber tests |<>.
p<>{color:#000;}.  

| <>. |<>. p<{color:#000;background:transparent;}. BRIEF TORSO

 

If there is:

*
p<{color:#000;background:transparent;}. Back pain

*
p<{color:#000;background:transparent;}. Rash

*
p<{color:#000;background:transparent;}. Depression

*
p<{color:#000;background:transparent;}. Mental status change

*
p<{color:#000;background:transparent;}. Fatigue

*
p<{color:#000;background:transparent;}. Extremity problem(s)

*
p<{color:#000;background:transparent;}. Any time a complete heart, lung and belly exam are not indicated but you want to make sure there are no surprises

|<>. p<{color:#000;background:transparent;}. Lungs: listen in four places on back

Heart: Listen to four places in the heart. Don’t forget to retie gown.

Abdomen: check bowel sounds in one place for 3 seconds

Palpation: palpate four quadrants |<>.
p<{color:#000;background:transparent;}. How to write normal findings in a note:

Normal appearing chest. Lungs clear to auscultation.

Heart: regular S1, D2 without murmur, rubs, or gallop.

Abd: BS+, no bruits heard. Soft, nontender, no masses 4 quadrants.

|<>. p<{color:#000;background:transparent;}. “I’d like to take a look at your back; may I untie and lower your gown.”

“Now I’d like to take a look at your back.”

“Now I’ll listen to your lungs. Please breathe in and out through your open mouth.”

“Now I’ll listen to your heart.”

“Now I’d like to look at your belly. Let me fix the bed to make it comfortable. Can you please lie back? May I raise your gown?””

“Now I’ll listen to your belly.”

“I need to press on your belly now.” | <>. |<>.
p<{color:#000;background:transparent;}. BRIEF NEURO

 

If there is:

*
p<{color:#000;background:transparent;}. Headache

*
p<{color:#000;background:transparent;}. Mental status changes

*
p<{color:#000;background:transparent;}. Dementia

*
p<{color:#000;background:transparent;}. Head trauma

|<>. p<{color:#000;background:transparent;}. Mental status: oriented to person, place, time

Cranial nerves: 2, 3, 4, 6, 7, 9, 10, 12 and do last 5th (sensory with cotton balls & have pt clench teeth by demonstrating action)

Sensory exam: complete with cotton balls. Check tip of 3rd finger on each hand and the top of the foot where the great toe and second toe meet – check both sides at once.

Motor strength: Test both sides of upper extremity at once. Test upper extremity at the same time but lower leg one leg at a time.

Deep tendon reflexes: check brachial and patellar only, ask pt to relax arm if tense

Cerebellar: gait |<>.
p<{color:#000;background:transparent;}. How to write normal findings in a note:

A & O x 3, cranial nerves 2-12 intact. Motor, light touch sensation intact all 4 ext. DTR nl, patella, brachial. Gait normal.

If didn’t check hearing of CN 11, write:

Cranial nerves 2-7, 9, 10, 12 intact

If abnormality found complete neuro exam. |<>.
p<{color:#000;background:transparent;}. Mental status: “I need to test your memory. Can you tell me the date? (Pause for response) Can you tell me where we are? (Pause for response) Please tell me your full name. (Pause for response) Thank you.”

Sensory exam: “I need to check the feeling in your hands.” “Now the feet.” “Do you feel it?” “Same or different?”

Motor strength: “Let me test your strength.” “Squeeze my fingers; pull me in; kick out, kick in.”

Deep tendon reflexes: “I need to tap your arm. Let me put your arm like this.” |

 

 

 

 

Head to Toe Examination

CLIENT SITTING ON BED

 

Head, Face and Neck

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. Skin face & neck – “I am inspecting the skin of your face and neck”

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Moisture

#
p<{color:#000;background:transparent;}. Temperature

#
p<{color:#000;background:transparent;}. Texture

#
p<{color:#000;background:transparent;}. Mobility

#
p<{color:#000;background:transparent;}. Turgor

#
p<{color:#000;background:transparent;}. Lesions

#
p<{color:#000;background:transparent;}. Hair and scalp – “I am inspecting your hair and scalp”

#
p<{color:#000;background:transparent;}. ROS

#
p<{color:#000;background:transparent;}. Have you experienced any hair loss?

#
p<{color:#000;background:transparent;}. Skin rashes?

#
p<{color:#000;background:transparent;}. Skin eruptions?

#
p<{color:#000;background:transparent;}. Sores that grow and/or don’t heal

#
p<{color:#000;background:transparent;}. Lesions changing in size/shape/color?

#
p<{color:#000;background:transparent;}. Itching?

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Skull – tenderness or deformities

#
p<{color:#000;background:transparent;}. CN V

#
p<{color:#000;background:transparent;}. Sensation – light touch with finger, pt’s eyes closed, compare both sides at same time

#
p<{color:#000;background:transparent;}. Jaw clenching – palpate at jaw for muscle contraction

#
p<{color:#000;background:transparent;}. CN VII

#
p<{color:#000;background:transparent;}. Wrinkle forehead

#
p<{color:#000;background:transparent;}. Strength of eyelid closure (open pt’s eyes closed)

#
p<{color:#000;background:transparent;}. Smiling

#
p<{color:#000;background:transparent;}. Eyes

#
p<{color:#000;background:transparent;}. Visual Acuity

#
p<{color:#000;background:transparent;}. Bilateral with visual acuity card 14 inches from pt

#
p<{color:#000;background:transparent;}. Pt cover non-tested eye

#
p<{color:#000;background:transparent;}. Should leave glasses on

#
p<{color:#000;background:transparent;}. Peripheral visual fields

#
p<{color:#000;background:transparent;}. Cover one eye and test at least 4 quadrants with waving fingers

#
p<{color:#000;background:transparent;}. Start with fingers out of pt’s field of vision, test bilaterally

#
p<{color:#000;background:transparent;}. Extraocular muscle function (CN II, IV, VI)

#
p<{color:#000;background:transparent;}. Follow your finger with their eyes

#
p<{color:#000;background:transparent;}. Make a large double “H” 14-20 inches away

#
p<{color:#000;background:transparent;}. Watch eye movements

#
p<{color:#000;background:transparent;}. Convergence – Pt follow tip of finger as move in toward bridge of nose

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. Eyes

#
p<{color:#000;background:transparent;}. Eyebrows/eyelids

#
p<{color:#000;background:transparent;}. Position/alignment eye

#
p<{color:#000;background:transparent;}. Conjunctiva and sclera (color, nodules, swelling)

#
p<{color:#000;background:transparent;}. Cornea and lens

#
p<{color:#000;background:transparent;}. Cornea – opacities with oblique lighting

#
p<{color:#000;background:transparent;}. Lens – opacities by lighting through pupil

#
p<{color:#000;background:transparent;}. Pupils – size, symmetry, shape

#
p<{color:#000;background:transparent;}. CN III – direct and consensual and pupillary reaction

#
p<{color:#000;background:transparent;}. Direct – shine light in one eye, watch pupil response

#
p<{color:#000;background:transparent;}. Consensual – shine light in same eye then watch other eye pupil response

#
p<{color:#000;background:transparent;}. Repeat for other eye

#
p<{color:#000;background:transparent;}. Red reflex bilaterally

#
p<{color:#000;background:transparent;}. Optic Disc & Retina

#
p<{color:#000;background:transparent;}. Ophthalmoscope

#
p<{color:#000;background:transparent;}. Locate optic disc, retina, retinal arteries, retinal veins & macula

#
p<{color:#000;background:transparent;}. “Now I am going to focus more closely on the back of your eye.”

#
p<{color:#000;background:transparent;}. Ears

#
p<{color:#000;background:transparent;}. External – “I am inspecting the outside of your ear.”

#
p<{color:#000;background:transparent;}. Auricle inspection

#
p<{color:#000;background:transparent;}. Size

#
p<{color:#000;background:transparent;}. Symmetry

#
p<{color:#000;background:transparent;}. Deformity

#
p<{color:#000;background:transparent;}. Tenderness

#
p<{color:#000;background:transparent;}. Lesions

#
p<{color:#000;background:transparent;}. External ear canal with otoscope

#
p<{color:#000;background:transparent;}. Discharge

#
p<{color:#000;background:transparent;}. Swelling

#
p<{color:#000;background:transparent;}. Redness

#
p<{color:#000;background:transparent;}. Internal – otoscope

#
p<{color:#000;background:transparent;}. Bilateral Tympanic membranes

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Contour

#
p<{color:#000;background:transparent;}. Cone of Light

#
p<{color:#000;background:transparent;}. Hearing Tests

#
p<{color:#000;background:transparent;}. Gross Hearing

#
p<{color:#000;background:transparent;}. Bilateral, rub fingers together

#
p<{color:#000;background:transparent;}. Weber

#
p<{color:#000;background:transparent;}. Tuning fork firmly on top of pt head

#
p<{color:#000;background:transparent;}. Where hear sound?

#
p<{color:#000;background:transparent;}. Lateralizes to poor ear – conductive loss

#
p<{color:#000;background:transparent;}. Lateralizes to good ear – sensorineural loss

#
p<{color:#000;background:transparent;}. Rinne

#
p<{color:#000;background:transparent;}. Tuning fork on mastoid bone, when sound no longer hears quickly place close to opening of external ear canal and ask if can hear sound

#
p<{color:#000;background:transparent;}. Results

#
p<{color:#000;background:transparent;}. Conductive – Bone>= Air

#
p<{color:#000;background:transparent;}. Sensorineural – Air > Bone but < 2:1 interval

#
p<{color:#000;background:transparent;}. Normal – air 2x bone

#
p<{color:#000;background:transparent;}. Nose

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. Symmetry

#
p<{color:#000;background:transparent;}. Deformity

#
p<{color:#000;background:transparent;}. Nostril Patency

#
p<{color:#000;background:transparent;}. Pt occlude and then inhale through open nostril, repeat on other side

#
p<{color:#000;background:transparent;}. CN I – test smell each individual nostril with different scents

#
p<{color:#000;background:transparent;}. Eyes closed

#
p<{color:#000;background:transparent;}. Occlude non-tested nostril

#
p<{color:#000;background:transparent;}. Nasal Passage inspection

#
p<{color:#000;background:transparent;}. Otoscope

#
p<{color:#000;background:transparent;}. Largest ear speculum

#
p<{color:#000;background:transparent;}. Observe nasal mucosa over septum and turbinates

#
p<{color:#000;background:transparent;}. Deformities

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Swelling

#
p<{color:#000;background:transparent;}. Sinus tenderness palpate

#
p<{color:#000;background:transparent;}. Frontal and Maxillary

#
p<{color:#000;background:transparent;}. Firmly pressing over them

#
p<{color:#000;background:transparent;}. Mouth and Pharynx – wear gloves

#
p<{color:#000;background:transparent;}. Lips inspection

#
p<{color:#000;background:transparent;}. Mouth/throat inspection

#
p<{color:#000;background:transparent;}. Otoscope

#
p<{color:#000;background:transparent;}. Entire mouth/throat – lift tongue and pulling cheeks aside with finger or tongue blade

#
p<{color:#000;background:transparent;}. Oral mucosa/Hard palate/Floor of mouth/Gums

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Ulcers

#
p<{color:#000;background:transparent;}. Nodules

#
p<{color:#000;background:transparent;}. Teeth

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Deformity

#
p<{color:#000;background:transparent;}. Absence of teeth

#
p<{color:#000;background:transparent;}. Parotid/submandibular duct opening identification – “I am examining your salivary gland openings”

#
p<{color:#000;background:transparent;}. Anterior/posterior pillars, tonsils, pharynx

#
p<{color:#000;background:transparent;}. Color

#
p<{color:#000;background:transparent;}. Symmetry

#
p<{color:#000;background:transparent;}. Lesions

#
p<{color:#000;background:transparent;}. Use tongue depressor to hold tongue down

#
p<{color:#000;background:transparent;}. Extended tongue inspection (symmetry, color, texture)

#
p<{color:#000;background:transparent;}. Dorsum

#
p<{color:#000;background:transparent;}. Sides

#
p<{color:#000;background:transparent;}. Undersurface

#
p<{color:#000;background:transparent;}. CN XII

#
p<{color:#000;background:transparent;}. Tongue palpation

#
p<{color:#000;background:transparent;}. Induration

#
p<{color:#000;background:transparent;}. Masses

#
p<{color:#000;background:transparent;}. Mouth floor palpation

#
p<{color:#000;background:transparent;}. Movement soft palate and uvula

#
p<{color:#000;background:transparent;}. Pt say “ah” (CNIX)

#
p<{color:#000;background:transparent;}. Watch back of mouth movement

#
p<{color:#000;background:transparent;}. CN X – say “I have listened to your voice.”

#
p<{color:#000;background:transparent;}. Neck and Lymph Nodes

#
p<{color:#000;background:transparent;}. Inspection – “I am inspecting your neck.”

#
p<{color:#000;background:transparent;}. Symmetry

#
p<{color:#000;background:transparent;}. Masses

#
p<{color:#000;background:transparent;}. Thyroid enlargement

#
p<{color:#000;background:transparent;}. Palpation nodes (occipital, posterior auricular, preauricular, tonsillar, submandibular, submental, cervical (superficial, posterior, deep), supraclavicular

#
p<{color:#000;background:transparent;}. Size

#
p<{color:#000;background:transparent;}. Shape

#
p<{color:#000;background:transparent;}. Delimitation

#
p<{color:#000;background:transparent;}. Mobility

#
p<{color:#000;background:transparent;}. Consistency

#
p<{color:#000;background:transparent;}. Tenderness

#
p<{color:#000;background:transparent;}. CN XI

#
p<{color:#000;background:transparent;}. Trapezius strength – shrug shoulders against firm pressure

#
p<{color:#000;background:transparent;}. Sternocleidomastoid strength – turning head against firm pressure

#
p<{color:#000;background:transparent;}. Palpation thyroid gland from front

#
p<{color:#000;background:transparent;}. Pt swallow for movement

 

 

Thorax

 

Posterior

#
p<{color:#000;background:transparent;}. Inspection – “I am inspecting the back of your chest”

#
p<{color:#000;background:transparent;}. Lesions

#
p<{color:#000;background:transparent;}. Swelling

#
p<{color:#000;background:transparent;}. Palpation – moderately firm pressure

#
p<{color:#000;background:transparent;}. Masses

#
p<{color:#000;background:transparent;}. Tenderness

#
p<{color:#000;background:transparent;}. Check expansion

#
p<{color:#000;background:transparent;}. Wrap hands around lower portion of ribs with thumbs pointing upward

#
p<{color:#000;background:transparent;}. Have pt take a deep breath

#
p<{color:#000;background:transparent;}. Tactile Fremitus

#
p<{color:#000;background:transparent;}. Bony portion of hands (lateral edge of hands on pinky side)

#
p<{color:#000;background:transparent;}. Pt say ‘99’

#
p<{color:#000;background:transparent;}. Upper, middle and lower lung fields

#
p<{color:#000;background:transparent;}. Compare symmetric areas

#
p<{color:#000;background:transparent;}. Percussion

#
p<{color:#000;background:transparent;}. Compare sides symmetrically

#
p<{color:#000;background:transparent;}. Start with upper fields, then middle, then lower lung fields

#
p<{color:#000;background:transparent;}. Auscultation

#
p<{color:#000;background:transparent;}. Lungs

#
p<{color:#000;background:transparent;}. Diaphragm of stethoscope

#
p<{color:#000;background:transparent;}. Pt breathes in deeply through an open mouth

#
p<{color:#000;background:transparent;}. Listen through entire breath cycle each time

#
p<{color:#000;background:transparent;}. Egophony

#
p<{color:#000;background:transparent;}. Pt say ‘E-e-e’

#
p<{color:#000;background:transparent;}. Auscultate posterior lung fields with diaphragm of stethoscope

#
p<{color:#000;background:transparent;}. Compare symmetrically and bilaterally and 3 lung fields

 

Anterior

#
p<{color:#000;background:transparent;}. Inspection – “I am inspecting the front of your chest”

#
p<{color:#000;background:transparent;}. Palpation – upper fields only

#
p<{color:#000;background:transparent;}. Auscultation

#
p<{color:#000;background:transparent;}. Anterior lung fields

#
p<{color:#000;background:transparent;}. Stethoscope between collar bone and top of breast

#
p<{color:#000;background:transparent;}. Breathes in deeply through open mouth

#
p<{color:#000;background:transparent;}. Listen through entire breath cycle

#
p<{color:#000;background:transparent;}. Right middle lobe

#
p<{color:#000;background:transparent;}. Diaphragm of stethoscope

#
p<{color:#000;background:transparent;}. Around right breast to mid-axillary line

#
p<{color:#000;background:transparent;}. Have pt take a deep breath through an open mouth

 

LAYING DOWN

 

Cardiovascular System

#
p<{color:#000;background:transparent;}. Neck

#
p<{color:#000;background:transparent;}. JVD Inspection

#
p<{color:#000;background:transparent;}. Head of exam table at 30 degrees

#
p<{color:#000;background:transparent;}. Place ruler upright at sternal angle then another flat object parallel to floor

#
p<{color:#000;background:transparent;}. Measure distance in cm of pulsation above sternal angle

#
p<{color:#000;background:transparent;}. Do not need to report this finding

#
p<{color:#000;background:transparent;}. Carotid pulse

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Pads of 1st and 2nd fingers

#
p<{color:#000;background:transparent;}. Assess one artery at a time

#
p<{color:#000;background:transparent;}. Auscultation for bruits

#
p<{color:#000;background:transparent;}. Bell or diaphragm stethoscope

#
p<{color:#000;background:transparent;}. Must have pt hold breath

#
p<{color:#000;background:transparent;}. Heart

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. PMI

#
p<{color:#000;background:transparent;}. Pt in left lateral decubitus position if necessary

#
p<{color:#000;background:transparent;}. Locate PMI with Palmar surface of right hand

#
p<{color:#000;background:transparent;}. Then Identify impulse with finger pads

#
p<{color:#000;background:transparent;}. Precordium

#
p<{color:#000;background:transparent;}. Assess for thrills by pressing over aortic, pulmonic, tricuspid and mitral areas

#
p<{color:#000;background:transparent;}. Use area of hand below fingers or lower area of palm

#
p<{color:#000;background:transparent;}. Auscultation

#
p<{color:#000;background:transparent;}. S1 & S2

#
p<{color:#000;background:transparent;}. Diaphragm on entire precordium

#
p<{color:#000;background:transparent;}. In sequence:

#
p<{color:#000;background:transparent;}. Aortic – right 2nd interspace

#
p<{color:#000;background:transparent;}. Pulmonic – left 2nd interspace

#
p<{color:#000;background:transparent;}. Tricuspid – left 3 -5 th interspace at lower sternal border

#
p<{color:#000;background:transparent;}. Mitral – left 5th interspace at mid-clavicular line

#
p<{color:#000;background:transparent;}. S3 & S4 – “I am listening for extra heart sounds with the bell of my stethoscope

#
p<{color:#000;background:transparent;}. Bell lightly placed on chest

#
p<{color:#000;background:transparent;}. Mitral and Tricuspid areas

#
p<{color:#000;background:transparent;}. Peripheral Vasculature

#
p<{color:#000;background:transparent;}. Palpation pulses with 1st and 2nd fingers

#
p<{color:#000;background:transparent;}. Radial

#
p<{color:#000;background:transparent;}. Brachial

#
p<{color:#000;background:transparent;}. Femoral

#
p<{color:#000;background:transparent;}. Popliteal

#
p<{color:#000;background:transparent;}. Dorsalis Pedis

#
p<{color:#000;background:transparent;}. Posterior tibialis

#
p<{color:#000;background:transparent;}. Edema

#
p<{color:#000;background:transparent;}. Inspection of feet and lower legs – “I am looking for swelling in your feet and legs”

#
p<{color:#000;background:transparent;}. Palpation for pitting edema – firm pressure over anterior shins for at least 5 sec

 

Abdomen

*Have full view of abdomen

 

#
p<{color:#000;background:transparent;}. Inspection – “I am inspecting your abdomen”

#
p<{color:#000;background:transparent;}. Contour

#
p<{color:#000;background:transparent;}. Symmetry

#
p<{color:#000;background:transparent;}. Lesions

#
p<{color:#000;background:transparent;}. Auscultation

#
p<{color:#000;background:transparent;}. Bowel sounds – palpation/percussion

#
p<{color:#000;background:transparent;}. Aortic Bruit – midline above umbilicus

#
p<{color:#000;background:transparent;}. Percussion

#
p<{color:#000;background:transparent;}. Lightly in all 4 quadrants to assess distribution of tympani and dullness

#
p<{color:#000;background:transparent;}. Assess liver span

#
p<{color:#000;background:transparent;}. from right lower anterior chest down to the upper abdominal quadrant in midclavicular line

#
p<{color:#000;background:transparent;}. Indicate to pt both upper and lower liver edges

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Light

#
p<{color:#000;background:transparent;}. all 4 quadrants

#
p<{color:#000;background:transparent;}. Note muscular resistance or tenderness

#
p<{color:#000;background:transparent;}. If pain start in quadrant farthest away from the area of pain

#
p<{color:#000;background:transparent;}. Deep

#
p<{color:#000;background:transparent;}. All 4 quadrants

#
p<{color:#000;background:transparent;}. Note tenderness, masses, pulsations

#
p<{color:#000;background:transparent;}. If pain start in quadrant farthest away from the area of pain

#
p<{color:#000;background:transparent;}. Aortic Pulse – abdomen at midline above umbilicus

#
p<{color:#000;background:transparent;}. Liver – check lower edge of liver with deep palpation

#
p<{color:#000;background:transparent;}. Spleen – check lower edge with deep palpation either supine or lying on right side

#
p<{color:#000;background:transparent;}. Rebound tenderness – over a tender area, press down with fingers firmly and slowly then withdraw quickly, “Which hurts more, when I press down or let go?”

#
p<{color:#000;background:transparent;}. Palpate Inguinal Lymph Nodes

#
p<{color:#000;background:transparent;}. Superficial horizontal inguinal nodes over inguinal canal

#
p<{color:#000;background:transparent;}. Visualize area of palpation

#
p<{color:#000;background:transparent;}. SPs prefer approach inguinal area by lifting up leg of shorts

#
p<{color:#000;background:transparent;}. Palpate trochanteric bursa – area exposed, on side

#
p<{color:#000;background:transparent;}. Hip PROM

#
p<{color:#000;background:transparent;}. Extension – pt on side

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Abduction

#
p<{color:#000;background:transparent;}. Adduction

#
p<{color:#000;background:transparent;}. External rotation

#
p<{color:#000;background:transparent;}. Internal rotation

#
p<{color:#000;background:transparent;}. Hip Strength

#
p<{color:#000;background:transparent;}. Flexion – L2 – 4, iliopsoas

#
p<{color:#000;background:transparent;}. Extension – S1, gluteus maximus

#
p<{color:#000;background:transparent;}. Abduction – L4 – S1, gluteus medius/minimus

#
p<{color:#000;background:transparent;}. Adduction – L2 – 4, adductors

 

CLIENT SITTING ON BED

 

#
p<{color:#000;background:transparent;}. CVA tenderness – both flanks percuss with fist for tenderness on back

#
p<{color:#000;background:transparent;}. Peripheral lymph nodes

#
p<{color:#000;background:transparent;}. Axillae

#
p<{color:#000;background:transparent;}. Inspect – expose axilla

#
p<{color:#000;background:transparent;}. Palpate

#
p<{color:#000;background:transparent;}. pt arm down and relaxed

#
p<{color:#000;background:transparent;}. Central, anterior, posterior and lateral nodes

#
p<{color:#000;background:transparent;}. Epitrochlear – each upper extremity

#
p<{color:#000;background:transparent;}. Shoulders

#
p<{color:#000;background:transparent;}. Inspection – “I am inspecting your shoulders and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Acromioclavicular joint

#
p<{color:#000;background:transparent;}. Coracoid process

#
p<{color:#000;background:transparent;}. Subacromial bursa/supraspinatous insertion

#
p<{color:#000;background:transparent;}. Biceps tendon

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Forward flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. External rotation

#
p<{color:#000;background:transparent;}. Internal rotation

#
p<{color:#000;background:transparent;}. Abduction

#
p<{color:#000;background:transparent;}. Adduction

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Deltoids – C5-6

#
p<{color:#000;background:transparent;}. Elbows

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your elbows and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Extensor surface of ulna and olecranon process

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Olecranon process

#
p<{color:#000;background:transparent;}. Epicondyles

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Pronation

#
p<{color:#000;background:transparent;}. Supination

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Triceps – C6-8

#
p<{color:#000;background:transparent;}. Biceps – C5-6

#
p<{color:#000;background:transparent;}. Wrists

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your wrists and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Palmar and dorsal surfaces

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Distal radius – lateral and medial surfaces

#
p<{color:#000;background:transparent;}. Distal ulna – lateral and medial surfaces

#
p<{color:#000;background:transparent;}. Groove of joint on dorsal surface and carpal bones

#
p<{color:#000;background:transparent;}. Front, back and sides of wrists

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Radial deviation

#
p<{color:#000;background:transparent;}. Ulnar deviation

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Wrist flexors (C6-8, radial nerve)

#
p<{color:#000;background:transparent;}. Wrist extensors (C6-8, radial nerve)

#
p<{color:#000;background:transparent;}. Hands/Fingers

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your hands and fingers and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Dorsal and palmar surfaces of hands and fingers

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Anatomical snuffbox

#
p<{color:#000;background:transparent;}. Metacarpals

#
p<{color:#000;background:transparent;}. MCP joints

#
p<{color:#000;background:transparent;}. Medial and lateral aspects of each PIP and DIP

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Fingers

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Abduction

#
p<{color:#000;background:transparent;}. Adduction

#
p<{color:#000;background:transparent;}. Thumb

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Abduction

#
p<{color:#000;background:transparent;}. Adduction

#
p<{color:#000;background:transparent;}. Opposition

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Finger grip (C7-T1)

#
p<{color:#000;background:transparent;}. Finger abduction (C8-T1)

#
p<{color:#000;background:transparent;}. Thumb to Little finger Opposition (C8-T1, median nerve)

#
p<{color:#000;background:transparent;}. Knees

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your knees and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Contour and swelling

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Patellar tendon

#
p<{color:#000;background:transparent;}. Femoral condyles

#
p<{color:#000;background:transparent;}. Medial and lateral collateral ligaments

#
p<{color:#000;background:transparent;}. Joint lines

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Flexion – L4-S2, hamstrings

#
p<{color:#000;background:transparent;}. Extension – L2-L4, quadriceps

#
p<{color:#000;background:transparent;}. Ankles

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your ankles and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Deformities and swelling

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Anterior ankle

#
p<{color:#000;background:transparent;}. Achilles tendon

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Dorsiflexion

#
p<{color:#000;background:transparent;}. Plantar flexion

#
p<{color:#000;background:transparent;}. Strength

#
p<{color:#000;background:transparent;}. Dorsiflexion – L4-5

#
p<{color:#000;background:transparent;}. Plantarflexion – S1

#
p<{color:#000;background:transparent;}. Feet

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. “I am inspecting your feet and I will also inspect for muscle bulk and tone.”

#
p<{color:#000;background:transparent;}. Deformities and swelling

#
p<{color:#000;background:transparent;}. Palpation

#
p<{color:#000;background:transparent;}. Metatarsophalangeal joints

#
p<{color:#000;background:transparent;}. Heel

#
p<{color:#000;background:transparent;}. Plantar fascia

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Inversion

#
p<{color:#000;background:transparent;}. Eversion

#
p<{color:#000;background:transparent;}. Toe flexion

#
p<{color:#000;background:transparent;}. Sensation

#
p<{color:#000;background:transparent;}. Light touch

#
p<{color:#000;background:transparent;}. Pt eyes closed

#
p<{color:#000;background:transparent;}. Symmetric areas on both sides of body

#
p<{color:#000;background:transparent;}. Use finger

#
p<{color:#000;background:transparent;}. Ask pt to tell you when touch is felt and compare both sides – “Does this feel the same as this?”

#
p<{color:#000;background:transparent;}. Shoulders – C4

#
p<{color:#000;background:transparent;}. Inner and outer aspects of forearms (C6, T1)

#
p<{color:#000;background:transparent;}. Thumbs and little fingers (C6, C8)

#
p<{color:#000;background:transparent;}. Front of thighs (L2)

#
p<{color:#000;background:transparent;}. Medial and lateral aspects of calves (L4-L5)

#
p<{color:#000;background:transparent;}. Little toes (S1)

#
p<{color:#000;background:transparent;}. Pain

#
p<{color:#000;background:transparent;}. Pt eyes closed

#
p<{color:#000;background:transparent;}. Symmetric areas on both sides of body

#
p<{color:#000;background:transparent;}. Broken end of cotton swab

#
p<{color:#000;background:transparent;}. Ask pt to tell you when they feel a sharp sensation

#
p<{color:#000;background:transparent;}. Shoulders – C4

#
p<{color:#000;background:transparent;}. Inner and outer aspects of forearms (C6, T1)

#
p<{color:#000;background:transparent;}. Thumbs and little fingers (C6, C8)

#
p<{color:#000;background:transparent;}. Front of thighs (L2)

#
p<{color:#000;background:transparent;}. Medial and lateral aspects of calves (L4-L5)

#
p<{color:#000;background:transparent;}. Little toes (S1)

#
p<{color:#000;background:transparent;}. Temperature

#
p<{color:#000;background:transparent;}. Pt eyes closed

#
p<{color:#000;background:transparent;}. Tuning fork for cool sensation on symmetric dies

#
p<{color:#000;background:transparent;}. Ask pt to tell when they feel a cool touch

#
p<{color:#000;background:transparent;}. Upper arms

#
p<{color:#000;background:transparent;}. Lower arms

#
p<{color:#000;background:transparent;}. Front of thighs

#
p<{color:#000;background:transparent;}. Lateral calves

#
p<{color:#000;background:transparent;}. Vibration

#
p<{color:#000;background:transparent;}. 128 Hz tuning fork

#
p<{color:#000;background:transparent;}. Pt eyes closed

#
p<{color:#000;background:transparent;}. Tap tuning fork and place firmly on joint

#
p<{color:#000;background:transparent;}. Ask pt to describe what they feel and tell when feeling stops

#
p<{color:#000;background:transparent;}. Lightly touch fork with hand to stop vibration then ask pt what they feel

#
p<{color:#000;background:transparent;}. DIP of one finger on each hand

#
p<{color:#000;background:transparent;}. IP joint of both big toes

#
p<{color:#000;background:transparent;}. Position sense

#
p<{color:#000;background:transparent;}. Pt eyes closed

#
p<{color:#000;background:transparent;}. One finger of each hand – holding DIP

#
p<{color:#000;background:transparent;}. Both big toes – holding IP joint

#
p<{color:#000;background:transparent;}. Deep Tendon Reflexes – do not strike tendon more than 3 times

#
p<{color:#000;background:transparent;}. Biceps

#
p<{color:#000;background:transparent;}. Brachioradialis

#
p<{color:#000;background:transparent;}. Triceps

#
p<{color:#000;background:transparent;}. Knee

#
p<{color:#000;background:transparent;}. Ankle

#
p<{color:#000;background:transparent;}. Clonus

#
p<{color:#000;background:transparent;}. Push foot up sharply once and hold to see if foot pushes back down

#
p<{color:#000;background:transparent;}. If pushes down note number of times it does so

#
p<{color:#000;background:transparent;}. Babinski

#
p<{color:#000;background:transparent;}. End of reflex hammer or dull tongue depressor

#
p<{color:#000;background:transparent;}. Stroke lateral aspect of sole from heel to ball of foot

#
p<{color:#000;background:transparent;}. Curve medially across ball

#
p<{color:#000;background:transparent;}. Use only gentle pressure with SPs

#
p<{color:#000;background:transparent;}. Stereognosis

#
p<{color:#000;background:transparent;}. Pt eyes close place object in hand and ask to identify object

#
p<{color:#000;background:transparent;}. Graphesthesia

#
p<{color:#000;background:transparent;}. Pt eyes closed draw number on pt palm and ask to identify number

#
p<{color:#000;background:transparent;}. Rapid alternating movements

#
p<{color:#000;background:transparent;}. Alternate striking palm and back of hands on thighs as quickly as possible

#
p<{color:#000;background:transparent;}. Point-to-Point Testing

#
p<{color:#000;background:transparent;}. Ask pt to touch your index finger then his/her nose, move find about so pt has to alter directions and extend arm fully to reach it. Repeat several times

 

CLIENT STANDING

 

#
p<{color:#000;background:transparent;}. Gait

#
p<{color:#000;background:transparent;}. Normal walking

#
p<{color:#000;background:transparent;}. Tandem walking (heel to toe)

#
p<{color:#000;background:transparent;}. Heel walking

#
p<{color:#000;background:transparent;}. Toe walking

#
p<{color:#000;background:transparent;}. Spine

#
p<{color:#000;background:transparent;}. Inspection

#
p<{color:#000;background:transparent;}. Posture and spinal curvature from behind

#
p<{color:#000;background:transparent;}. “I am inspecting your spine”

#
p<{color:#000;background:transparent;}. Expose entire spine and stand behind pt

#
p<{color:#000;background:transparent;}. Palptaion

#
p<{color:#000;background:transparent;}. Spinous processes of each vertebra

#
p<{color:#000;background:transparent;}. Paravertebral muscles

#
p<{color:#000;background:transparent;}. Sacroiliac joints

#
p<{color:#000;background:transparent;}. AROM

#
p<{color:#000;background:transparent;}. Neck

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Rotation

#
p<{color:#000;background:transparent;}. Lateral bending

#
p<{color:#000;background:transparent;}. Spine

#
p<{color:#000;background:transparent;}. Flexion

#
p<{color:#000;background:transparent;}. Extension

#
p<{color:#000;background:transparent;}. Rotation

#
p<{color:#000;background:transparent;}. Lateral bending (hold pt hips stable if necessary, moves at waist only)

#
p<{color:#000;background:transparent;}. Romberg

#
p<{color:#000;background:transparent;}. Stand for at least 20 sec

#
p<{color:#000;background:transparent;}. Arms at sides, feet together, eyes closed

#
p<{color:#000;background:transparent;}. Pronator Drift

#
p<{color:#000;background:transparent;}. Arms straight out, palms up, eyes closed

#
p<{color:#000;background:transparent;}. Hold this position for at least 20 sec to observe any movement or pronator drift

#
p<{color:#000;background:transparent;}. Mental Status

#
p<{color:#000;background:transparent;}. Orientation

#
p<{color:#000;background:transparent;}. Person – ask pt’s full name

#
p<{color:#000;background:transparent;}. Place – do you know where you are right now? Name of hospital, floor, city, state or county

#
p<{color:#000;background:transparent;}. Time – date, month, year, day of week or season

#
p<{color:#000;background:transparent;}. Recall

#
p<{color:#000;background:transparent;}. Name 3 objects and immediately repeat them

#
p<{color:#000;background:transparent;}. Apple, table, penny

#
p<{color:#000;background:transparent;}. Tell pt you will ask him/her to tell you these 3 words again in a few minutes

#
p<{color:#000;background:transparent;}. Remote memory

#
p<{color:#000;background:transparent;}. Ask for 1-2 historical events relevant to his/her past

#
p<{color:#000;background:transparent;}. Jobs held, birth date, name of schools attended

#
p<{color:#000;background:transparent;}. Recent memory

#
p<{color:#000;background:transparent;}. Ask pt to tell you events about the day

#
p<{color:#000;background:transparent;}. Weather, today’s appointment time

#
p<{color:#000;background:transparent;}. Attention

#
p<{color:#000;background:transparent;}. Ask to spell WORLD backwards

#
p<{color:#000;background:transparent;}. Information and vocabulary

#
p<{color:#000;background:transparent;}. Ask about pt work, hobbies, favorite music/TV programs, current events

#
p<{color:#000;background:transparent;}. Ask about specific facts (name of president, vice president; name 5 large cities in US)

#
p<{color:#000;background:transparent;}. Calculating ability

#
p<{color:#000;background:transparent;}. 1 + 2

#
p<{color:#000;background:transparent;}. Abstract thinking

#
p<{color:#000;background:transparent;}. What’s the same between an apple and pear?

#
p<{color:#000;background:transparent;}. Constructional ability

#
p<{color:#000;background:transparent;}. Please draw a clock showing the time 2:30

#
p<{color:#000;background:transparent;}. Repeat recall

#
p<{color:#000;background:transparent;}. Ask pt to repeat names of 3 objects in #4

#
p<{color:#000;background:transparent;}. ROS

#
p<{color:#000;background:transparent;}. Do you have any known mental health disorders?

#
p<{color:#000;background:transparent;}. Do you feel sad or depressed much of the time?

#
p<{color:#000;background:transparent;}. Alcohol or other substance abuse?

#
p<{color:#000;background:transparent;}. Are you anxious much of the time?

#
p<{color:#000;background:transparent;}. Memory problems?

#
p<{color:#000;background:transparent;}. Confusion?

 

 

 

SUMMARY

*
p<{color:#000;background:transparent;}. communication major part of exam – leave time to discuss your management plan

*
p<{color:#000;background:transparent;}. Never try to save time by ignoring patient’s questions, requests or emotional status

*
p<{color:#000;background:transparent;}. 7 Tasks:

#
p<{color:#000;background:transparent;}. Making the Transition

#
p<{color:#000;background:transparent;}. “Let me tell you what I am thinking”

#
p<{color:#000;background:transparent;}. Tell pt finished physical exam and now to tell him what you think

#
p<{color:#000;background:transparent;}. Paraphrasing

#
p<{color:#000;background:transparent;}. Highlight key historical points and key physical findings, last chance to make sure have correct information

#
p<{color:#000;background:transparent;}. Giving Knowledge

#
p<{color:#000;background:transparent;}. Explain in lay language 1-2 diagnoses.

#
p<{color:#000;background:transparent;}. “I think you may have … or it could be …

#
p<{color:#000;background:transparent;}. Telling what you are going to do

#
p<{color:#000;background:transparent;}. Be definite, tell pt what tests you will order and that you will meet again to go over the test results

#
p<{color:#000;background:transparent;}. “I am going to take a picture of your chest to find out why you are coughing. I am also going to take a blood test to look for infection.”

#
p<{color:#000;background:transparent;}. “When the test results are back I will call you so we can discuss them and make a treatment plan” or “I will have the results in a few minutes. Could you wait here? I’ll be back as soon as possible.”

#
p<{color:#000;background:transparent;}. Counseling as needed

#
p<{color:#000;background:transparent;}. Smoking, alcohol abuse, drug abuse, addiction of any kind, safe sex practices, depression, domestic violence, weight loss, chronic disease management.

#
p<{color:#000;background:transparent;}. “Your health will improve if you stop smoking. I’d like you to attend nonsmoking classes run by our counselor”

#
p<{color:#000;background:transparent;}. “For your health, it is important that you stop drinking. I would like you to speak with our alcohol counselor. I will bring you her number”

#
p<{color:#000;background:transparent;}. “Do not have sex until all your treatment is finished and your partner(s) are treated as well. Then I want you to use a condom every time to prevent infection in the future.”

#
p<{color:#000;background:transparent;}. Asking for questions

#
p<{color:#000;background:transparent;}. “do you have any questions?”

#
p<{color:#000;background:transparent;}. Saying Goodbye

#
p<{color:#000;background:transparent;}. “Call me if you have any problems or any other questions.”

#
p<{color:#000;background:transparent;}. “Goodbye, (patient’s name)”

#
p<{color:#000;background:transparent;}. If not enough time: “I’m sorry; I have to answer this emergency page. I’ll be back as soon as I can.”

 

 

PATIENT NOTE

*
p<{color:#000;background:transparent;}. 50% of Integrated Clinical Encounter

*
p<{color:#000;background:transparent;}. As you finish patient encounter ‘think note’ – ensure you have all info you need, make a mental scan

*
p<{color:#000;background:transparent;}. Ensure use of correct approved abbreviations

*
p<{color:#000;background:transparent;}. Never record anything you did not do or ask

*
p<{color:#000;background:transparent;}. Practice talking to patients for smooth transitions between sections

 

HISTORY

*Note pertinent positives and negatives from HPI, PMH, ROS, FH & SH (write down the left margin of your note)

table<>. <>. |<>.
p={color:#000;background:transparent;}. HISTORY |<>.
p={color:#000;background:transparent;}. WHAT TO NOTE |<>.
p={color:#000;background:transparent;}. EXAMPLE | <>. |<>.
p<{color:#000;background:transparent;}. HPI |<>.
p<{color:#000;background:transparent;}. Start with age, sex, race and chief complaint. Address pertinent positives and negatives. End with what the patient thinks or fears as the cause of symptoms.

|<>. p<{color:#000;background:transparent;}. Patient is a 40 yr old white female complaining of… | <>. |<>. p<{color:#000;background:transparent;}. PMH |<>. p<{color:#000;background:transparent;}. Consider 4 items + 1 in women.

#
p<{color:#000;background:transparent;}. Serious illness, hospitalization, surgery

#
p<{color:#000;background:transparent;}. Meds (OTC, prescriptions, supplements, herbs) with dose and duration

#
p<{color:#000;background:transparent;}. Allergies

#
p<{color:#000;background:transparent;}. Status on preventative issues (immunization, Pap, mammogram, colon screening)

#
p<{color:#000;background:transparent;}. Always document reproductive basics in women (gravidity, parity, live children), menarche, cycle regular/irregular/duration/complaints, contraception; postmenopausal give age and any HRT use

|<>. p<{color:#000;background:transparent;}. Patient denies past serious illnesses, hospitalizations, surgeries. Tylenol 1-4/month for headache. Takes no prescription meds, supplements or vitamins. No known allergies. Up to date on immunizations. Cholesterol “low” at health fair 2 years ago. No other screening. | <>. |<>. p<{color:#000;background:transparent;}. ROS |<>. p<{color:#000;background:transparent;}. Brief scan of key symptoms in each system. Focus on key items in differential of each case. What else could explain the symptoms? What other conditions common in a person of the age/type? |<>. p<>{color:#000;}.   | <>. |<>. p<{color:#000;background:transparent;}. FH |<>. # p<{color:#000;background:transparent;}. Cause of death/significant health problems for parents

#
p<{color:#000;background:transparent;}. Significant health problems in siblings

#
p<{color:#000;background:transparent;}. Close relatives with heart disease, stroke, diabetes, HTN, cancer, or ‘anything that runs in the family’

#
p<{color:#000;background:transparent;}. Other questions depending on the case e.g. ask more in a breast cancer case about relatives with cancer or ask about sudden deaths in a palpitations case.

|<>. p<{color:#000;background:transparent;}. F67, M64, alive & well. F hypertensive controlled with unknown medication. Sibs (38, 40) no health problems. PGF died aged 54 stroke, no other known heart disease, stroke, HBP, diabetes, cancer in family. No known headache, neurological conditions in family. | <>. |<>. p<{color:#000;background:transparent;}. SH |<>. # p<{color:#000;background:transparent;}. Tobacco, alcohol, substances (duration and amount of use)

#
p<{color:#000;background:transparent;}. Occupation and/or educational history (only key exposures and stressors)

#
p<{color:#000;background:transparent;}. Living situation (who lives at home, any stressors, sexually active?)

#
p<{color:#000;background:transparent;}. Health habits (exercise, hobbies)

|<>. p<{color:#000;background:transparent;}. Denies ever used tobacco, illicit drugs. Alcohol1-4 beers/month. College graduate, schoolteacher, enjoys work. Lives with wife and son (6 yrs) daughter (4 yrs). Monogamous, sexually active. No stressors at home/work. Plays basketball on weekends and runs 30 minutes twice/week. |

 

 

PHYSICAL EXAMINATION

table<>. <>. |<>.
p={color:#000;background:transparent;}. EXAMINATION |<>.
p={color:#000;background:transparent;}. WHAT TO NOTE |<>.
p={color:#000;background:transparent;}. EXAMPLE | <>. |<>.
p={color:#000;background:transparent;}. VITAL SIGNS |<>.
p<{color:#000;background:transparent;}. Must be noted, check any abnormal vital signs, additional vitals may be required (orthostatic BPs and pulses in a fainting case).

|<>. p<>{color:#000;}.   | <>. |<>. p={color:#000;background:transparent;}. GENERAL IMPRESSION |<>. p<{color:#000;background:transparent;}. Appearance (body habitus/weight – obese, overweight, thin, appropriate for height, if relevant recent weight loss signs); distress/pain (holding a specific body part, restless, unwilling to move for pain); general affect/demeanor (anxiety or depression, general cooperation or ability to answer questions, anger or hostility, use of inappropriate language); other pertinent issues (dependent on case, skin tone [pale, jaundiced, plethoric, rashes, lesions], sweating or shivering, smells [ketotic, alcohol], clothes and grooming) |<>. p<>{color:#000;}.   | <>. |<>. p={color:#000;background:transparent;}. PERTINENT SYSTEM EXAM |<>. p<>{color:#000;}.   |<>. p<{color:#000;background:transparent;}. HEENT – Inspection, Palpation, Eyes, Ears, Nose, Throat, Lymph glands, thyroid

Abdomen – Inspection, Auscultation Percussion, Palpation (light and deep, rebound tenderness)

Chest – Inspection, Palpation/ Respiratory excursion, Tactile fremitus, Percussion, Auscultation

CVS – sitting (carotid; auscultation; peripheral pulses, edema, clubbing), lying back, head elevated 30 degrees (JVP, PMI, Auscultate a second time)

Neuro – Mental status, Cranial nerves, Motor, Sensory, Reflexes, Cerebellar

Joints – Inspection, Palpation, Range of motion, Motor, Reflect, Sensory, Vasculat | <>. |<>.
p={color:#000;background:transparent;}. ANY SPECIFIC EXAMS |<>.
p<{color:#000;background:transparent;}. If necessary do not hesitate to ask the patient for permission to do a sensitive examination and document information received (refused/declined/arranged exam), elderly (ADLS, IADLs, “get up and go” test), children (developmental screening), depression screening, MMSE, CAGE (alcohol use), domestic violence screen, asthmatics (peak flow), any unusual piece of equipment or paper in the room usually has a purpose, if not done state “additional PE deferred” and consider putting into follow up plan (ie schedule for rectal examination) |<>.
p<>{color:#000;}.  

|

 

 

DIFFERENTIAL DIAGNOSIS

*
p<{color:#000;background:transparent;}. Assesses how well you synthesize data from History and Physical Exam into plausible medical explanations and sense of most probable diagnoses

*
p<{color:#000;background:transparent;}. Can list up to 3, can be fewer than 3

*
p<{color:#000;background:transparent;}. Name specific diseases or conditions (spelt correctly and do not repeat symptoms)

*
p<{color:#000;background:transparent;}. List conditions in order of probability

*
p<{color:#000;background:transparent;}. Evidence for conditions listed must be in the note

*
p<{color:#000;background:transparent;}. Focus is on patient communication and assessment skills, not to guess right diagnosis

*
p<{color:#000;background:transparent;}. Try to not use abbreviations

*
p<{color:#000;background:transparent;}. Be as specific as possible

*
p<{color:#000;background:transparent;}. Noncompliance with medicine or medication side effects are not legitimate diagnoses

table<>. <>. |<>.
p={color:#000;background:transparent;}. Symptom |<>.
p={color:#000;background:transparent;}. Condition |<>.
p={color:#000;background:transparent;}. History |<>.
p={color:#000;background:transparent;}. Physical | <>. |<>/8.
p<{color:#000;background:transparent;}. Headache |<>.
p<{color:#000;background:transparent;}. Tension |<>.
p<{color:#000;background:transparent;}. Band-like headache bilateral

Last for hours or days

Recurrent

Constant, not throbbing

Better with massage |<>.
p<{color:#000;background:transparent;}. Normal vital signs

Normal neuro exam | <>. |<>.
p<{color:#000;background:transparent;}. Classic Migraine |<>.
p<{color:#000;background:transparent;}. Unilateral throbbing

Photophobia

Sonophobia

Aura

Recurrent |<>.
p<{color:#000;background:transparent;}. No fever

No weakness in extremities | <>. |<>.
p<{color:#000;background:transparent;}. Temporal arteritis |<>.
p<{color:#000;background:transparent;}. Throbbing one-sided headache

Fevers

Jaw pain

Visual changes |<>.
p<{color:#000;background:transparent;}. Tender over temporal artery

Age over 50 | <>. |<>.
p<{color:#000;background:transparent;}. Sinusitis |<>.
p<{color:#000;background:transparent;}. Recent URI

Pain in cheek below eye

Dull, constant ache, worse leaning over

Nasal discharge and stuffiness |<>.
p<{color:#000;background:transparent;}. Tenderness to palpation of maxillary sinus

No weakness in extremities | <>. |<>.
p<{color:#000;background:transparent;}. Glaucoma (closed angle) |<>.
p<{color:#000;background:transparent;}. Pain centered over eye

First episode |<>.
p<{color:#000;background:transparent;}. Red eye

Decreased visual acuity

Dilated pupil | <>. |<>.
p<{color:#000;background:transparent;}. Subdural hematoma |<>.
p<{color:#000;background:transparent;}. History of trauma

On warfarin

Headache |<>.
p<{color:#000;background:transparent;}. Mental status changes

Ataxia

Focal weakness

Visual changes | <>. |<>.
p<{color:#000;background:transparent;}. Cluster headache |<>.
p<{color:#000;background:transparent;}. Unilateral

Sudden and intense

Pain behind eye

Lasts a couple of hours and gone

Recurrent same time of day |<>.
p<{color:#000;background:transparent;}. Lacrimation

Blushing of face | <>. |<>.
p<{color:#000;background:transparent;}. Subarachnoid bleed |<>.
p<{color:#000;background:transparent;}. Headache

Syncope

Very severe intensity

First episode

Vomiting |<>.
p<{color:#000;background:transparent;}. Mental status changes

Stiff neck | <>. |<>/9.
p<{color:#000;background:transparent;}. Chest Pain |<>.
p<{color:#000;background:transparent;}. Acute Coronary Syndrome |<>.
p<{color:#000;background:transparent;}. Heavy substernal pressure feeling

SOB

Nausea

Diaphoresis

Lasts minutes to starting couple hours ago |<>.
p<{color:#000;background:transparent;}. Diaphoretic

Abnormal vital signs

No high fever | <>. |<>.
p<{color:#000;background:transparent;}. Pulmonary Embolism |<>.
p<{color:#000;background:transparent;}. Pleuritic chest pain

SOB

Unilateral swollen lower leg

HX of DVT in past

Not on warfarin |<>.
p<{color:#000;background:transparent;}. Tachycardia

Tachypnea

No pain to palpation of chest wall

Unilateral swollen leg | <>. |<>.
p<{color:#000;background:transparent;}. Pneumonia |<>.
p<{color:#000;background:transparent;}. Pleuritic chest pain

Cough

Sputum production |<>.
p<{color:#000;background:transparent;}. Fever

Dullness to percussion

Abnormal breath sounds

Increased tactile fremitus | <>. |<>.
p<{color:#000;background:transparent;}. Pneumothorax |<>.
p<{color:#000;background:transparent;}. Pleuritic unilateral chest pain

Sudden onset

SOB |<>.
p<{color:#000;background:transparent;}. Increased HR

Increased RR

Decreased unilateral breath sounds

Decreased tactile fremitus | <>. |<>.
p<{color:#000;background:transparent;}. Aortic Dissection |<>.
p<{color:#000;background:transparent;}. Ripping chest pain

Sudden onset

Pain may migrate to neck or back |<>.
p<{color:#000;background:transparent;}. Blood pressure difference between arms

Heart murmur (if aortic insufficiency)

Pulse differences between sides | <>. |<>.
p<{color:#000;background:transparent;}. Pericarditis |<>.
p<{color:#000;background:transparent;}. Pain better sitting up and leaning forward

Pleuritic

Started after vial URI |<>.
p<{color:#000;background:transparent;}. Cardiac rub

Fever | <>. |<>.
p<{color:#000;background:transparent;}. Costochondritis |<>.
p<{color:#000;background:transparent;}. Sharp pain

Hurts with movement and twisting |<>.
p<{color:#000;background:transparent;}. Point tenderness causing the pain | <>. |<>.
p<{color:#000;background:transparent;}. Herpes zoster |<>.
p<{color:#000;background:transparent;}. Unilateral

Paresthesia of skin unilateral dermatome |<>.
p<{color:#000;background:transparent;}. Unilateral blistering rash on a dermatome

Fever | <>. |<>.
p<{color:#000;background:transparent;}. Esophageal reflux |<>.
p<{color:#000;background:transparent;}. Heartburn

Sour taste coming up to mouth

Pregnant

Better with antacids |<>.
p<{color:#000;background:transparent;}. No fever

No pleuritic pain

No abdominal pain | <>. |<>/7.
p<{color:#000;background:transparent;}. Shortness of Breath |<>.
p<{color:#000;background:transparent;}. Heart Failure |<>.
p<{color:#000;background:transparent;}. Dyspnea on exertion

Pedal edema

Orthopnea

Hx of HTN, smoking, coronary disease |<>.
p<{color:#000;background:transparent;}. Rales in lungs

Gallop heart rhythm

Distended neck vein

Distended liver | <>. |<>.
p<{color:#000;background:transparent;}. Chronic obstructive pulmonary disease |<>.
p<{color:#000;background:transparent;}. Dyspnea

Cough

Weight loss

Pursed lip breathing

Chronic condition, smoking hx |<>.
p<{color:#000;background:transparent;}. Tachypnea

Increased chest AP diameter

Clubbing of fingers

Decreased air entry

Prolonged expiratory phase | <>. |<>.
p<{color:#000;background:transparent;}. Asthma |<>.
p<{color:#000;background:transparent;}. Recurrent attacks of dyspnea

Cough

Wheezing

Hx of asthma |<>.
p<{color:#000;background:transparent;}. Wheezing | <>. |<>.
p<{color:#000;background:transparent;}. Anemia |<>.
p<{color:#000;background:transparent;}. Fatigue

Generalized weakness |<>.
p<{color:#000;background:transparent;}. Pallor | <>. |<>.
p<{color:#000;background:transparent;}. Airway obstruction |<>.
p<{color:#000;background:transparent;}. Sudden onset

Change in voice

Choked on food or denture |<>.
p<{color:#000;background:transparent;}. Stridor

Cyanosis | <>. |<>.
p<{color:#000;background:transparent;}. Myocardial infarction |<>.
p<{color:#000;background:transparent;}. Substernal chest pain

Dyspnea

Nausea

Hx of smoking, HTN |<>.
p<{color:#000;background:transparent;}. Diaphoresis

(list any abnormal signs) | <>. |<>.
p<{color:#000;background:transparent;}. Anaphylaxis |<>.
p<{color:#000;background:transparent;}. Acute shortness of breath

Wheezing

Hx of exposure to allergens |<>.
p<{color:#000;background:transparent;}. Hives

Hypotension

Tachypnea

Tachycardia | <>. |<>/5.
p<{color:#000;background:transparent;}. Right Upper Abdominal Pain |<>.
p<{color:#000;background:transparent;}. Biliary Colic |<>.
p<{color:#000;background:transparent;}. RUQ pain – intermittent

Can last several hours

Occurs after fatty meal |<>.
p<{color:#000;background:transparent;}. No fever

Tender right upper quadrant | <>. |<>.
p<{color:#000;background:transparent;}. Cholecystitis |<>.
p<{color:#000;background:transparent;}. RUQ pain

Radiates to R scapula |<>.
p<{color:#000;background:transparent;}. Fever

+ Murphy’s sign

Tender right upper quadrant | <>. |<>.
p<{color:#000;background:transparent;}. Peptic Ulcer Disease |<>.
p<{color:#000;background:transparent;}. Epigastric RUQ pain

Taking aspirin or NSAIDs

Blood in stool

Pain may radiate to back |<>.
p<{color:#000;background:transparent;}. Epigastric and RUQ tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Pancreatitis |<>.
p<{color:#000;background:transparent;}. Epigastric and RUQ pain

Hx of alcoholism

Hx of gallstone |<>.
p<{color:#000;background:transparent;}. Epigastric and RUQ tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Hepatitis |<>.
p<{color:#000;background:transparent;}. Fever

Jaundice

RUQ pain

Behavior that leads to Hep virus exposure |<>.
p<{color:#000;background:transparent;}. Jaundice

Tender enlarged liver

*
p<{color:#000;background:transparent;}. Murphy’s sign

fever | <>. |<>/8.
p<{color:#000;background:transparent;}. Chronic Cough |<>.
p<{color:#000;background:transparent;}. Asthma |<>.
p<{color:#000;background:transparent;}. Recurrent attacks of dyspnea

Cough

Wheezing

Hx of asthma |<>.
p<{color:#000;background:transparent;}. Wheezing | <>. |<>.
p<{color:#000;background:transparent;}. Allergic rhinitis |<>.
p<{color:#000;background:transparent;}. Runny nose

Itchy watery eyes

Recurrent with season |<>.
p<{color:#000;background:transparent;}. Rhinorrhea

Watery eyes

Allergic shiners | <>. |<>.
p<{color:#000;background:transparent;}. GERD |<>.
p<{color:#000;background:transparent;}. Heartburn

Sour taste coming up to mouth

Pregnant

Better with antacids |<>.
p<{color:#000;background:transparent;}. No fever

No pleuritic pain

No abdominal pain | <>. |<>.
p<{color:#000;background:transparent;}. COPD |<>.
p<{color:#000;background:transparent;}. Dyspnea

Cough

Weight loss

Pursed lip breathing

Chronic condition, smoking hx |<>.
p<{color:#000;background:transparent;}. Tachypnea

Increased chest AP diameter

Clubbing of fingers

Decreased air entry

Prolonged expiratory phase | <>. |<>.
p<{color:#000;background:transparent;}. Pneumonia |<>.
p<{color:#000;background:transparent;}. Pleuritic chest pain

Cough

Sputum production |<>.
p<{color:#000;background:transparent;}. Fever

Dullness to percussion

Abnormal breath sounds

Increased tactile fremitus | <>. |<>.
p<{color:#000;background:transparent;}. ACE inhibitor |<>.
p<{color:#000;background:transparent;}. Take ACE inhibitor

Dry, nonproductive cough |<>.
p<{color:#000;background:transparent;}. No fever

Normal lung exam | <>. |<>.
p<{color:#000;background:transparent;}. TB |<>.
p<{color:#000;background:transparent;}. Chronic cough

Hemoptysis

Weight loss

Exposure to TB

Night sweats |<>.
p<{color:#000;background:transparent;}. Fever

Lung findings

Low weight | <>. |<>.
p<{color:#000;background:transparent;}. Pulmonary malignancy |<>.
p<{color:#000;background:transparent;}. Hx of smoking

Cough

Chest pain

Shortness of breath

Hemoptysis |<>.
p<{color:#000;background:transparent;}. Weight loss

Wheezing | <>. |<>/5.
p<{color:#000;background:transparent;}. Acute Pelvic Pain |<>.
p<{color:#000;background:transparent;}. Appendicitis |<>.
p<{color:#000;background:transparent;}. Midabdominal pain migrating to RLQ

Anorexia

Feverish

Acute onset |<>.
p<{color:#000;background:transparent;}. RLQ tenderness

+obturator sign

+psoas sign

fever | <>. |<>.
p<{color:#000;background:transparent;}. Diverticulitis |<>.
p<{color:#000;background:transparent;}. LLQ pain

Fever

Diarrhea often

vomiting |<>.
p<{color:#000;background:transparent;}. Fever

LLQ tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Pelvic Inflammatory Disease |<>.
p<{color:#000;background:transparent;}. Fever

Lower abdominal pain

Vaginal discharge

Sexually active |<>.
p<{color:#000;background:transparent;}. Fever

Lower abdominal tenderness

+ pain with cervical motion tenderness

Shuffling gait | <>. |<>.
p<{color:#000;background:transparent;}. Ectopic Pregnancy |<>.
p<{color:#000;background:transparent;}. Lower abdominal pain

May radiate to top of shoulder

Late period or known pregnant |<>.
p<{color:#000;background:transparent;}. Lower abdominal tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Ovarian torsion |<>.
p<{color:#000;background:transparent;}. Sudden onset

Unilateral lower pain

Nausea & vomiting

Can start with exercise |<>.
p<{color:#000;background:transparent;}. Lower abdominal tenderness | <>. |<>/5.
p<{color:#000;background:transparent;}. Blood in stool |<>.
p<{color:#000;background:transparent;}. Hemorrhoid |<>.
p<{color:#000;background:transparent;}. Bright red blood

Streaks usually on stool or toilet paper

Hx oh patient able to palpate hemorrhoid |<>.
p<{color:#000;background:transparent;}. No abdominal tenderness

No fever | <>. |<>.
p<{color:#000;background:transparent;}. Anal fissure |<>.
p<{color:#000;background:transparent;}. Pain with defecation

Bright red blood with straining at stool |<>.
p<{color:#000;background:transparent;}. No fever

No abdominal tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Diverticulosis |<>.
p<{color:#000;background:transparent;}. Abdominal cramps

Blood mixed with stool

May be recurrent |<>.
p<{color:#000;background:transparent;}. Age > 40

Pallor | <>. |<>.
p<{color:#000;background:transparent;}. Infectious diarrhea |<>.
p<{color:#000;background:transparent;}. Diarrhea prominent

Bloody stool

Vomiting

Others with same illness

Acute onset |<>.
p<{color:#000;background:transparent;}. Fever

Diffuse abdominal tenderness

No rebound | <>. |<>.
p<{color:#000;background:transparent;}. Inflammatory bowel disease |<>.
p<{color:#000;background:transparent;}. Fever

Diarrhea

Chronic onset

Positive family history |<>.
p<{color:#000;background:transparent;}. Fever

Diffuse abdominal tenderness | <>. |<>/5.
p<{color:#000;background:transparent;}. Syncope |<>.
p<{color:#000;background:transparent;}. Vasovagal |<>.
p<{color:#000;background:transparent;}. Emotional, stressful situation

Quick recovery in minutes

No seizure activity |<>.
p<{color:#000;background:transparent;}. Normal vital signs (when recovered) | <>. |<>.
p<{color:#000;background:transparent;}. Arrhythmia |<>.
p<{color:#000;background:transparent;}. Palpitations

Chest discomfort

Shortness of breath

Medication history |<>.
p<{color:#000;background:transparent;}. Abnormal heart rate

Irregular heartbeat | <>. |<>.
p<{color:#000;background:transparent;}. Orthostatic hypotension |<>.
p<{color:#000;background:transparent;}. Alcohol ingestion

Medication as cause

Dehydration |<>.
p<{color:#000;background:transparent;}. Tachycardia

Hypotension when standing

Advanced age | <>. |<>.
p<{color:#000;background:transparent;}. Aortic stenosis |<>.
p<{color:#000;background:transparent;}. Shortness of breath

Angina chest discomfort

Family history of same |<>.
p<{color:#000;background:transparent;}. Age 60 and up

Narrow pulse pressure

Displaced PMI | <>. |<>.
p<{color:#000;background:transparent;}. Hypertrophic Cardiomyopathy |<>.
p<{color:#000;background:transparent;}. Palpitations

Dizziness

Shortness of breath

Younger athlete

Family history

Occurs with exercise |<>.
p<{color:#000;background:transparent;}. Heart murmur | <>. |<>/4.
p<{color:#000;background:transparent;}. Unilateral Swollen Leg |<>.
p<{color:#000;background:transparent;}. Baker Cyst Rupture |<>.
p<{color:#000;background:transparent;}. Previous arthritis of the knee

Red, swollen, tender calf |<>.
p<{color:#000;background:transparent;}. Swelling and fullness behind knee | <>. |<>.
p<{color:#000;background:transparent;}. Cellulitis |<>.
p<{color:#000;background:transparent;}. Red, swollen, tender calf

Distal break in skin of leg |<>.
p<{color:#000;background:transparent;}. Fever

Inguinal adenopathy | <>. |<>.
p<{color:#000;background:transparent;}. Lymphatic obstruction |<>.
p<{color:#000;background:transparent;}. Chronic leg swelling

Chronic skin changes

Not red or tender |<>.
p<{color:#000;background:transparent;}. No fever

Inguinal adenopathy

Lower abdominal mass | <>. |<>.
p<{color:#000;background:transparent;}. Deep vein thrombosis |<>.
p<{color:#000;background:transparent;}. Pain and swelling recently in leg

Risk factor for hypercoagulable state |<>.
p<{color:#000;background:transparent;}. Lower leg red

Lower leg warm

Lower leg swollen

Lower leg tender | <>. |<>/4.
p<{color:#000;background:transparent;}. Bilateral swollen leg |<>.
p<{color:#000;background:transparent;}. Heart failure |<>.
p<{color:#000;background:transparent;}. Dyspnea on exertion

Pedal edema

Orthopnea

Hx of HTN, smoking, coronary disease |<>.
p<{color:#000;background:transparent;}. Rales in lungs

Gallop heart rhythm

Distended neck vein

Distended liver | <>. |<>.
p<{color:#000;background:transparent;}. Nephrotic syndrome |<>.
p<{color:#000;background:transparent;}. Foamy urine

Weight gain

Edema also around face

Fatigue |<>.
p<{color:#000;background:transparent;}. Edema bilaterally | <>. |<>.
p<{color:#000;background:transparent;}. Liver failure |<>.
p<{color:#000;background:transparent;}. Jaundice

Fatigue

Right upper quadrant pain |<>.
p<{color:#000;background:transparent;}. Jaundice

Ascites

Right upper quadrant tenderness

Mental status changes

Edema bilaterally | <>. |<>.
p<{color:#000;background:transparent;}. Obesity/venous insufficiency |<>.
p<{color:#000;background:transparent;}. Pain, cramp, paresthesia in legs

Elevated body mass index |<>.
p<{color:#000;background:transparent;}. Red legs and ankles with skin changes

Bilateral edema | <>. |<>/7.
p<{color:#000;background:transparent;}. Vomiting |<>.
p<{color:#000;background:transparent;}. Medications (chemotherapy, general anesthesia, opioids) |<>.
p<{color:#000;background:transparent;}. Temporal history of medications followed by vomiting

No blood in emesis

Vomiting |<>.
p<{color:#000;background:transparent;}. No fever

Abdomen soft, nontender | <>. |<>.
p<{color:#000;background:transparent;}. Gastrointestinal (rotavirus, norovirus, food poisoning, Camphylobacter) |<>.
p<{color:#000;background:transparent;}. May be other people also sick

Abdominal cramps and pain

Diarrhea possible

Vomiting |<>.
p<{color:#000;background:transparent;}. Possible fever

Abdominal tenderness | <>. |<>.
p<{color:#000;background:transparent;}. Vestibular system (motion sickness, benign positional vertigo) |<>.
p<{color:#000;background:transparent;}. Hx of occurring on boat, moving, car

Vertigo

Vomiting |<>.
p<{color:#000;background:transparent;}. Possible nystagmus | <>. |<>.
p<{color:#000;background:transparent;}. CNS (migraine, mass lesion, bleeding, arteriovenous malformation, seizure, trauma, pseudotumor cerebri) |<>.
p<{color:#000;background:transparent;}. Headache

Scotoma (migraines)

Vomiting |<>.
p<{color:#000;background:transparent;}. May have unilateral weakness

Mental status changes | <>. |<>.
p<{color:#000;background:transparent;}. Secondary to Abdominal organs (appendicitis, cholecystitis, acute hepatitis, peptic ulcer disease, bowel obstruction, gonad torsion) |<>.
p<{color:#000;background:transparent;}. Vomiting

Possible blood in emesis

Anorexia |<>.
p<{color:#000;background:transparent;}. Fever

Abdominal tenderness

Possible rebound | <>. |<>.
p<{color:#000;background:transparent;}. Endocrine and toxins (alcohol, diabetic ketoacidosis) |<>.
p<{color:#000;background:transparent;}. Weakness, fatigue

Dehydration

Darkening of skin

Vomiting |<>.
p<{color:#000;background:transparent;}. Dry mucous membranes | <>. |<>.
p<{color:#000;background:transparent;}. Acute cardiovascular illness (MI, PE, aortic dissection) |<>.
p<{color:#000;background:transparent;}. Vomiting

Chest pain

Back pain

SOB |<>.
p<{color:#000;background:transparent;}. Increased respiratory rate

Heart murmur

Unequal pulse |

*
p<{color:#000;background:transparent;}.

 

DIAGNOSTIC PLAN

*
p<{color:#000;background:transparent;}. Limited to 5 priority items

*
p<{color:#000;background:transparent;}. Assesses ability to logically develop a diagnosis and to discriminate between all the possible tests

*
p<{color:#000;background:transparent;}. Sensitive exams, labs, imaging studies, questionnaires and special tests, specific data gathering (BP measures at community sites, keeping pain or symptom or food intake diary)

*
p<{color:#000;background:transparent;}. Write on the first line any prohibited exams (rectal, genital, complete physical exam, etc)

*
p<{color:#000;background:transparent;}. If no prohibited exams, then write on first line any labs or x-rays needed now

*
p<{color:#000;background:transparent;}. First, order simple baseline tests the patient needs now

*
p<{color:#000;background:transparent;}. Group together tests that go together in real life (ie. CBC, electrolytes, glucose, Creatinine, BUN)

*
p<{color:#000;background:transparent;}. Assume all of the tests will be done now, at one time, unless you write otherwise

*
p<{color:#000;background:transparent;}. Incorrect to write diagnostic tests on same line as a particular diagnosis

*
p<{color:#000;background:transparent;}. Diagnostics should help support or exclude the diagnosis considered

*
p<{color:#000;background:transparent;}. If no testing indicated, write “No tests indicated.”

 

 

REFERENCE BOOKS

#
p<{color:#000;background:transparent;}. Kaplan USMLE Step 2CS review

#
p<{color:#000;background:transparent;}. Bate’s Guide to Physical Examination and History-Taking

#
p<{color:#000;background:transparent;}. First Aid for USMLE Step 2 CS

#
p<{color:#000;background:transparent;}. Mastering the USMLE – good cases to practice from with you and a partner

 

 

Page 55 of 55


USMLE Step 2 CS Notes

A list of notes to aid with the study of the United States Medical Licensing Examination Step 2 CS exam for medical doctors. This can be used as a resource and delves into introduction, obtaining a history/physical examination, determining a differential diagnosis and determining which labs to order. Notes are based off of information obtained for various resources, which are referenced.

  • Author: JH Terry
  • Published: 2015-10-10 09:35:15
  • Words: 10949
USMLE Step 2 CS Notes USMLE Step 2 CS Notes