The Interview

Chief concern: "What brings you in today"? HPI: Seven characteristics of a symptom • Onset - how and when did it start? Have you ever felt something like this before? Are there other symptoms associated with it? • Provocative & Palliative- what makes it better or worse? • Quality - what's it like? Is it sharp, dull, piercing, throbbing? • Radiation - where is it? Does it move to other parts of the body? • Severity - how bad is it (on a scale of 1 to 10)? • Timing - does it usually start at a certain time of day? How long does it last? Is it constant throughout, or does it change over time? Does it recur or did it only happen once? • Remember to establish a good timeline • Other things to ask: ◦ Is there anything in particular that you're concerned that it might be? PMH: I'd like to ask some questions about your health in the past, in order to get a complete picture. • How was your health as a child? Any major childhood illnesses? • How has your health been as an adult? Any major adult illnesses? Hospitalizations? Surgeries? • What medications are you currently taking? • Do you have any allergies to foods, medicines, or anything else? Family History: Before we move on, I'd like to ask some background questions about your family's health history. • How has your parents' health been? Any major illnesses, hospitalizations, or surgeries? Are they still living? • Tell me about your brothers and sisters' health. Any major illnesses, hospitalizations, or surgeries? • And your grandparents? Any major illnesses, hospitalizations, or surgeries? Social history: I'd like to know a little more about you before we get started with the exam. • Tell me about what you do for a living. • How far did you go in school? • Do you live with anyone? Are you married, or have you ever been? Do you have children? Tell me about them. • Have you ever used tobacco? How about alcohol? Have you ever used illegal drugs? ◦ If yes: when, for how long, how many packs / drinks / etc. per day (max use).

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Introduction
• Introduce self, say hi • Wash hands before starting exam

HEENT
(tools: Snellen card, opthalmascope, otoscope, tongue depressor) (Patient sitting upright) Scalp/Face (1) • Inspect & palpate Eyes • • • (3) Inspect sclera / conjunctiva Snellen card eye test (cover one eye) Opthalmoscope - lower lights first; find fundus; switch hands with opthalmoscope

Ears (2) • Inspect external ear (x2) • Otoscope - find tympanic membrane Nose (1) • Otoscope (new speculum) to inspect nares Oro-pharynx (2) • Uvula / pallate (inspect, stick out tongue & say "ah", use tongue depressor, raise/lower tongue) • Inspect dentition / gums Neck (4) • Inspect • Palpate sternal notch - trachea midline? • Palpate lymph nodes • Palpate thyroid gland (tilt head & swallow, then palpate)

Neuro
(tools: penlight, tuning fork, cotton swab, reflex hammer) Mental Status (8) Preface with "routine questions" • Awake/alert? • Orientation: name, day, date, time, place • Attention: days of week forwards, backwards • Aphasia (3): ◦ Name 3 objects ◦ Repeat "The sky is blue in Baltimore" ◦ Point to ceiling, point way out of room • Dysarthria (observe)

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• Mood: "How have you been feeling lately?" Cranial Nerves (11) • CN II / III: check pupils (darken room, penlight, oblique, both sides) • CN II / III (2): visual fields ◦ Four visual quadrants ◦ Upper/lower fields • CN III / IV / IV: Extra-ocular movements (cross) • CN V: touch face • CN VII (2) ◦ Close eyes tightly / open widely ◦ Show teeth • CN VIII: hearing (rub fingers, same on both sides?) • CN IX: elevation of palatte (penlight, open mouth, say "ah") • CN XI: shoulder shrug (bilateral) • CN XII: stick out tongue Motor (5) Remember: have the patient resist a force (passive); isolate the joint • Proximal arm: chicken wing (one at a time) • Distal arm: finger extensor strength (Patient sitting on table) • Proximal leg: hip flexor (instruct patient to brace with hands first) • Distal leg: dorsiflex foot • Pronator drift: eyes closed, hold hands out like tray for 10 seconds Sensory (4) (Patient sitting on table with arms out, palms up, on knees) • Light touch x 8 (eyes closed, use cotton swab on upper arm x 2, distal index finger x 2, thigh x 2, distal big toe x 2) • Sharp touch x 8 (eyes open, use broken cotton swab upper arm x 2, distal index finger x 2, thigh x 2, distal big toe x 2) • Vibration (tuning fork on PIP of great toe x 2 - hit tuing fork hard) • Proprioception (shield vision, move great toe up x 5 and down x 5 for each great toe) Wash hands after feet Reflexes (3) - using reflex hammer • Biceps x 2 (palpate first) • Patella x 2 (palpate, then slightly lateral to midline) • Babinski x 2 (warn of discomfort) Wash hands after feet Coordination / Gait () • Finger - nose x 2 (full reach) • Hand tapping (or flipping) • Walk across room (full length) • Romberg (stand with eyes closed, feet together: against wall, provide contact guard) • Tandem walk (drunk walk) • Stand on heels, then toes

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Cardiovascular
(tools: stethoscope, watch, tongue depressors as rulers) Vital Signs (3) • Blood pressure (need stethoscope, pt seated for 5 minutes, estimate using radial pulse, fully deflate cuff between attempts) • Radial pulse x 2 wrists (need watch, 15 seconds, multiply by 4) • Respiratory rate (need watch, keep acting like taking pulse, count resps for 30 seconds, multiply by 2) (Ask permission, then reposition patient onto table supine with 30 degrees elevation. Drape & disrobe) Pulses, edema, JVP (4) • Proximal & distal pulses (radial pulse + dorsalis pedis or posterial tibial) • Peripheral edema (press 5 sec pre-tibial area, look for pitting) • Carotid pulses (ascultate, then palpate 1 at a time - just medial to SCM, upper neck, in carotid triangle) • JVP (use tongue depressors as rulers, assess from sternal angle & add 5 or from midaxillary)\ PMI & Ascultation (2) Ask permission and drape left chest if pt female. Pt 30 degrees supine for ascultation • Palpate PMI (4th-5th ICS in MCL, can have pt lay on left side) • Ascultate (use bell of stethoscope) ◦ aortic = 2nd R ICS ◦ pulmonic = 2nd L ICS ◦ tricuspid = L sternal border ◦ apex / mitral = PMI area ◦ L axillary for mitral regurgitation (?)

Musculoskeletal
(tools: none needed) Basic principles: observe joint / compare with contra-lateral side; palpate joint (warmth / swelling / effusion); test range of motion. Listen for crepitus during movements (Pt. sitting up) Wrist & Hands (7) • Observe for deformity, inflammation (DCP, PIP, MCP, wrist) • Palpate DCP, PIP, MCP, wrist • Fingernails: evaluate for color, look for clubbing • Hands (2) ◦ Finger curl & extension

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◦ Grip strength • Wrists: flex and extend wrists Shoulders (6) • Inspect anterior & posterior • Palpate (acromion process, acromioclavicular joint, coracoid process) • Range of motion (4) ◦ Shrug shoulders ◦ Hands lateral, then over head ◦ Hands behind neck, elbows out (external rotation) ◦ Hands to small of back (internal rotation) Spine (5) • Inspect whole spine (palpate if needed); inspect hips too at this point (anteriorly and posteriorly) • Range of motion (cervical spine) ◦ Chin to chest (flexion; look for vertical palpebral fissure) ◦ Look at ceiling (extension) ◦ Ear to shoulder (lateral bending) ◦ Chin to shoulder (rotation) (Pt. lying on back, knee fully extended) Hips • • • (6) Inspection of hips done with spine Palpate over hips, pelvis, greater trochanter Range of motion x 2 ◦ Raise leg with knee extended (also for sciatica with dorsiflexion of foot) ◦ Flex hip (knee to chest) - also checking knee here ◦ Internally & externally rotate hip (flexed at 90 degrees for hip and knee) ◦ Patrick's test (lateral foot on contralateral knee, press flexed knee down

Knees (5) • Observe for deformity & check for effusion (concave space) • Check temperature (back of hand to patella, shin - compare patella & each patella/shin) • Palpate knee joint x 2 (patella, LCL, MCL, anserine bursa, popliteal fossa) • Bulge sign x 2(milk medial side knee upwards, watch for bulge flowing back) • Passive range of motion x 2 (flex and extend) - done with hip

Pulmonary
(tools: stethoscope) Ask permission to untie gown at back. Have patient sit on the edge of the table, swinging their legs to the left. Note: whenever touching the pt from behind, let them know what you're going to do. Inspection (3) • Inspect from back as the patient breathes • Place hands on pt. back to assess respiratory expansion

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• Inspect from front as pt breathes (accessory mm, lips pursing, costal retractions) Percussion (2) • Percuss side-to-side, down the back (4-5 levels, 2 lateral sides on each side) • Percuss for level of diaphragm (normal tidal breathing, then with inspiration to measure diaphragmatic excursion) Palpation (1) • Tactile fremitus - pt. says "ninety-nine"; use hypothenar eminence down the back (same sites as percussion) Ascultation (2) Have pt. breathe deeply through their mouth. Warm the stethoscope before use. Ask the patient to indicate if he/she becomes lightheaded • Back: side-to-side pattern down the back (use stethoscope; same sites as percussion). • Anterior: upper chest (beneath the clavicle)

Abdominal
(tools: stethoscope, ruler) Stand on pt's right side. Tell pt you're going to examine abdomen. Ask pt. to lie back. Pull out foot rest. Drape lower body. Ask pt. to raise gown to expose abdomen. Make sure abdomen is visible to hair line. Pt. can bend knees upwards if needed to relax abdomen. Inspection (1) • Inspect abdomen from above and tangentially Ascultation (2) Make sure to ascultate before any percussion or palpation; use stethoscope • Bowel sounds (10-15 sec, below and to right of umbilicus) • Arteries / bruits (5) ◦ Renal aa. x 2 - MCL, just medial & infracostal ◦ Aortic a. - epigastrium ◦ Iliac a. x 2 - MCL - just medial, 2cm below umbilicus Percussion (1) • Percuss all 4 quadants Palpation (4) • General Palpation (2): Before palpation, ask pt. if they have pain. Start away from pain and work towards it. Right hand on left using pads of fingers; right applies pressure, left is sensory. ◦ Light palpation - all 9 quadrants ◦ Deep palpation - all 9 quadrants ◦ (Assess for rebound tenderness if pt has pain) • Organ palpation (2): For organ palpation: can have pt inhale, exhale (press), inhale (feel), exhale (remove hand). Turn pt on their right side; use left hand behind rib cage, right hand to feel spleen ◦ Palpate for spleen

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Pt. back to supine position. Stand by pt. head on right side, hook hands around right costal margin ◦ Palpate for liver Hepatomegaly (1) • Use either scratch test or percussion to assess liver size (have pt use finger to mark first spot; use ruler to measure size)

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