History and examination

Dr Alan Shortt

2

including short cases, OSCEs and scenarios

Clinical Methods – Walker Hall and Hurst 1990

http://www.youtube.com/watch?v=nVF0zDs1ABw

http://www.youtube.com/watch?v=K-38JZbD8BE

http://www.youtube.com/watch?v=CrqNa9a9PZY

http://www.youtube.com/watch?v=O7EMJ1WU_eQ

http://www.youtube.com/watch?v=CrqNa9a9PZY

http://www.youtube.com/watch?v=yCBDckS1blI

Clinical history taking
Patient Demographics	name age gender occupation
PC	main problem(s) with duration in patient’s own words
HPC	OPQRST for each symptoms treatments tried
PMH	DM Asthma/COPD Epilepsy Hypertension Heart disease MI Stroke TB Rheumatic Fever DVT PE Operations Hospitalisations Blood Transfusions
Drugs Allergies	Current Medications Dose Frequency Inhalers COC HRT OTC Herbal Supplements Alternative TherapiesMedications Vaccines Elastoplast Iodine Latex – Evidence for allergy – what happened?
Family History	Age Health/Cause of Death Parents Siblings and Partners Children illness in the family
Cardiovascular risk factors	Fixed (male, age, race)Modifiable (smoking BP cholesterol)Partially-modifiable (CVD, CKD, DM PVD)
Social History
General	General Health and Well-being Wt-loss Fever Night-sweats Chills Sleep pattern
CVS	Chest pain SOB Calf Pain Claudication Palpitations Syncope Presyncope Ankle Swelling
Respiratory	SOBAR SOBOE (walking distance MRC Scale) Orthopnoea PND Pillows Cough Haemoptysis Sputum Wheeze Chest Pain
GIT	Appetite, weight, dysphagia, nausea, vomitting, abdo pain indigestion, altered bowel habitConstipation Diarrhoea Blood Slime Mucous Haematemesis Maleana Fresh Blood PR
GU	Dysuria Frequency Hesitancy Nocturia Incontinence (urge/stress) HaematuriaProstatism (stop start poor stream terminal dribbling ISPSS)
Obs Gyne Menarche Menopause	General Health and Well-being Wt-loss Fever Night-sweats Chills Sleep pattern
LMP Regular length of cycle length period length	Heavy Painful Contraception UPSI Pregnancy? Cervical SmearSTI Vaginal dischargePregnancies Miscarriage TOP PND Breast Problems Post Natal Depression
CNS	Fits faints funny turns TIA/Stroke Weakness NumbnessProblems with walking or Coordination
HEENT	Head Injury Headache Visual Disturbance Spectacles/LensesHearing Loss Vertigo Tinnitus Rhinorrhoea Polyps Tonsils

If in doubt go back to first principles. The traditional medical history may seem like a mechanistic trawl but in fact most patients love the attention to detail and it may in fact lead to a comprehensive and useful picture of themselves and their problems cf the dubious medical record or even more dubious “knowledge of the patient” source?

Health related behavior history “Healthy SEEDS”
Substances	alcohol, tobacco, IV drugs?
Environment	hazards at home or work? feel safe?
Exercise	what do you do? how often do you do it?
Diet	any special diet?
Sex	active with m/f/both? >1 partner? safe sex? STD history? difficulty with arousal or orgasm? history of abuse?.
from http://www.valuemd.com/clinical.php …this order works well: patients most expect to be asked about alcohol and they least want to talk about their STD history, but taking a solid HRB history first reassures them that it’s all part of good medical care.

http://youtu.be/f99RK7ew0fs

Clinical examination

Vital signs

http://youtu.be/niGP3d1T08Y

http://youtu.be/QReR2r8Kujk

UCSD Clinical Examination Resources
Practical Guide to Clinical Medicine University of California San Diego
UCSD History of Presenting Complaint
UCSD Rest of History
UCSD Review of Systems
USCD putting it all together
UCSD write-ups
UCSD the oral presentation
UCSD outpatient medicine
UCSD inpatient medicine
UCSD clinical decision making
UCSD a few thoughts
UCSD clinical exam lectures (pdfs)
UCSD clinical exam refs

Routines and checklists

A few routines checklists mnemonics and frameworks

for Good Clinical Communication and thinking on your feet in exams (inc OSCES and CSAs) , interviews and difficult real-life situations

Whilst geared to OSCES and Exams these frameworks are relevant to all patient interactions – that’s why you learn them in the first place.

The busy exprienced clinician can modify and tailor their approach to their circumstances – but none of this stuff is superfluous only for the exam stuff

Maybe you can drive how you like after passing the driving test but it has to be said there are a lot of avoidable accidents on the roads.

As a doctor you always have a patient to consider – right there in the room with you.

The upside is a win win situation – embed a systematic clinically-based approach into your training and practice, don’t slip or wander too far and you will not only pass your exams easy, you will thrive, prosper and enjoy life a clinician.

ICE Ideas Concerns Expectations

ICE TCT (Passtest) examinations/intearctions/ interventions
I	Introduce yourself
C	obtain consent for the examination
E	Explain – at the start and throughout before each individual stepExpose – Expose the necessary parts of the body and position the patientExamine
T	Thank the patient
C	Cover
T	Turn and face the Examiner

WINCER Blundell and Harrison OSCES at a glance Wiley 2009
W	Wash hands
I	Introduce Yourself (and Check patient ID)
N	Notice / Observe
C	Consent
E	Expose
R	Reposition

Interview questions CAMP STAR SPIES
CAMP for background and motivation questions
Clinical
Academic
Management
Personal
STAR for questions requiring an example
Situation
Task
Action
Result / Reflect
SPIES for questions on difficult colleagues
Seek information
Patient Safety
Initiative
Escalate
Support

Objective data
S	Signs and Symptoms (History and Exam)
A	Allergies
M	Medications (inc OTC herbals and vitamins)
P	Pertinent Past History and Pregnancy
L	L Last oral intake (last ins and outs)
E	Events leading up to the episode/injury

Socrates Pain/Symptom History
S	Site
O	Onset
C	Character
R	Radiation
A	Alleviating FACTORS
T	Time course
E	Exacerbating Factors
S	Severity

OPQRST AAA Pain/Symptom History
O	Onset How and when did the pain (or other symptom) begin?
P	Precipitating/palliating factors What makes the pain feel better or worse? Point to where the pain is
Q	Quality Can you describe the pain? Sharp Dull Crushing etc
R	Radiation Relief Does the pain go anywhere? What relieves the pain?
S	Severity How severe is the pain? (Scale of 0-10 0 no pain 10 worse pain imaginable)
T	Time Duration Variation over time Previous Episodes?
T	Treatment tried so far and effect
A	Aggravating / Alleviating Factors
A	Associated Symptoms
A	Attributions
A	Adaptations

OLD CART symptom description
O	Onset
L	Location
D	Duration
C	Characteristics
A	Aggrevating factors
R	Relieving Factors
T	Treatments so far

TIPS AEIOU
T	trauma, temp., thiamine
I	infection, AIDS
P	Psychiatric, porphyria.
S	space occupying lesion, stroke, intracranial hemorrhage, shock, status epilepticus
A	Alcohol, drugs, toxins
E	Endocrine, liver, lytes.
I	Insulin, oral hypoglycemic agents, diabetes mellitus
O	O2, CO2, CO, opiates
U	Uremia, hypertension

MPS mnemonics ACCORD ASSIST

Surgical sieves

Gawande Checklist Manifesto vs managerial/political checklists

POMR / SOAP

Problem Oriented Medical Record

http://youtu.be/k2LWXXS3eu0

Problem Oriented Medical Record Lawrence Weed

Guide to SOAP @ Scrubnotes

ucsd.edu write-ups

SOAPIE SNCSG/Wardrope Driscoll Community Emergency Care
S	subjective	what the patient says.
O	Objective	what the examiner observes including labs
A	Assessment	what the examiner thinks is going on – may be a numbered list in
P	Plan	what they intend to do about it.
I	Implementation
E	Evaluation

250 Questions
*Useful phrases for consultations, COT competencies, and being a good doctor*
How can I help you today?	The Golden Minute– dr michael thomas / calgiari-cambridge – don’t speak just allow the patient to talk uninterrupted for one whole minute Effective Personal Interactions whilst head nodding, “umming and ahhing”, and making eye contact – if you so wish and can do it without looking like Churchill the dog – all the world’s a stage but the authentic practitioner should talk/perform to patients like he/she talks to anyone else
Tell me more about that	whilst shuffling some papers, looking at the computer, checking your iphone for texts or staring at the ceiling /out the window Anything else that you have noticed? (yes you, you Bastard staring at the ceiling)
Cues	You look (tired, sad, low, stressed, anxious), is that how you feel? (or is that how I feel?) You sound (tired, sad, worried etc), is that how you feel? You seem ……… You mentioned ******, tell me more …….
Echoing	back statements and using a hanging (unfinished) sentence or even a single word followed by silence, which encourages them to complete and expand e.g. You mentioned work … Your dad………. Stress?………..
ICE	What does all this mean to you? What do you make of all this? What do you think might be the cause? Can I ask you what you mean by……? Tell me what you mean by ****? Have you considered what might be causing these problems? How/what do you think this has happened? Some people with this problem find ……., has that been a problem for you? If I were to say that you may have ** what does that mean to you? Are you worried about anything in particular? Is there anything you’re worried this might be? Anything else worrying you? Do you have any specific worries about this? Have you thought how I might be able to help? Have you had any thoughts on investigation/treatment.
Psychosocial insights	How’s all this affecting you at home or at work? How are you coping with all of this?
Sign posting chunking checking	Before I examine you I just need to check that I’ve got to grips with all that’s going on. Summarise the problems and then ask – Have I missed anything? So just to make sure I’ve got things right, you have ……… Just to recap, you have had……….. Explaining the problem Do you know much about? If I were to say to you I thought you had …. what does that mean to you? Use pictures, patient information leaflets and the internet to facilitate explanation.
Sharing options	There are a number of options:*, and ****. Which do you prefer? Do any of these options particularly appeal to you?
Checking understanding	Do you have any questions? Is there anything you want to ask me? Does my explanation make sense? Is there anything I haven’t explained? Just to check that I have explained things clearly can you tell me what you’re going to do/how you’re going to take your medication? Just to check that I’ve explained things clearly, how are you going to take …. or what are you going to do?
Safety netting	I’ll see you in ….. weeks. Come back if thing don’t get better. Come back if things don’t get better by …… Come back if XXXXX develops

Don’t get me wrong – it’s not that I knock it – these are undoubted good-things – but can lead to an insincere patronising approach if paid lip service and done without conviction and heart – it might almost seem possible to pass an assessment by making all the right noises without actually drawing upon much clinical knowledge.

However most patients seem to appreciate more rather than less attention to detail on these points and most doctors may fail to achieve their objectives by paying too little rather than to much attention to these considerations.

We hope to expand this page to a whole section of videos, phrases tricks and tips for jobbing Drs and students alike. This is partly the reason we’ve included so much patient oriented material amongst the videos and links on the site already. Being smooth and credible makes for a better experience for clinician and patient alike.

General medical exam

Clinical Methods Walker Hall and Hurst NCBI

General physical examination dartmouth.edu

http://youtu.be/I4jsvqRVfbk

http://youtu.be/jGf8NvqoTNs

CVS exam

Heart examination ucsd.edu

http://www.youtube.com/watch?v=dp5m2tXHDmA

Pulse – rate rhythm character volume

Pulse Rate
Sinus rhythm	40-60 athletes betablockers post MI hypothyroid hypothermia, raised ICP
Sinus bradycardia	Allergies
CHB	30-45 +/- cannon waves in JVP post MI cardiomyopathy idiopathic drug induced
Sinus tachycardia	>100 anxiety fever anaemia ccf thyrotoxicosis
SVT	120-200 paroxysmal idiopathic or due to thyrotoxicosis, ihd, nicotine, caffeine, or preexcitation syndromes.

Pulse Rhythm
Sinus arrythmia	variation with respiration common in young adults
VEBs	ischaemia, hyperthyroidism, cardiomyopathy, caffeine, alcohol, nicotine, young adults (abolished by exercise)
Coupled beats	(bigeminy) digoxin toxicity
Dropped beats	2nd degree heart block
Atrial fibrillation	irregularly irregular in rhythm and volume- may be pulse deficit between radial pulse and apical/ventricular rate. Causes IHD mitral valve disease CCF hypertension alcohol thyrotoicosis
Atrial flutter	with varial block may be intermittently irregular whilst atrial flutter with 2:1 block is a regular 150 bpm – causes IHD thyrotoxicosis digoxin toxicit
VT	120-200 irregular and weak

Pulse Character
Collapsing	rises rapidly and falls away abruptly- seen in AI and v rarely PDA. Demonstrate increased pulse volume on elevation by grasping volar surface of patients wrist with right palm and elevating arm vertically – keeping patients elbow straight with left hand
Jerky	HCOM
Bisferiens	Combined aortic valve disease
Dicrotic	fever and hyperdynamic states
Alterans	alternate high and low volume beats – severe LVF
Paradoxus	exaggeration of normal pulse volume decrease in inspiration (severe asthma, cardiac tamponade and constrictive pericarditis)

Pulsus Paradoxus
Pericardial Effusion
Cardiac Tamponade
Adhesive Pericarditis
COPD
Asthma
Restrictive Cardiomyopathies
Haemorrhagic Shock

Pulse Volume (reflects LVSV)
4+	bounding
3+	increased
2+	normal
1+	weak
0	absent

Low volume pulse	aortic stenosis (slow rising plateau pulse), mitral stenosis, CCF, pulmonary hypertension and hypovolaemic shock
High volume pulse	high output states (pregnancy, severe anaemia, fever and sepsis, CO2 retention, thyrotoxicosis, cirrhosis)
Unequal pulses	Takayasu’s disease, aortic aneurism
Absent radial	congenital, arterial embolus, Blalock shunt
Radiofemoral delay	aortic coarctation

Apex beat
furthest downward and ouward point cardiac impulse is felt	normally 5th ICS mid clavicular line.
thrusting apex
tapping apex	(due to palpable S1) mitral stenosis
double impulse	dyskinetic or aneurysmal LV segment, HOCM
Absent impulse	obesity, pericardial/pleural effusion, emphysema, dextrocardia
Apical thrill	mitral regurgitation and papillary muscle rupture (systolic) mitral stenosis (diastolic)
Left Parasternal heave	RVH

Heart sounds and murmurs
First heart sound	mitral valve (mainly) + tricuspid valve closure	loud in mitral stenosis and hyperdynamic circulationsoft in mitral regurgitation, calcified mitral stenosis, hypotension, severe heart failurevaries in intensity in CHB and VTNormal splitting more pronounced in RBBB
Second heart sound	aortic A2 and pulmonary P2 closure	aortic component occurs first and is louder (in adults) splitting diminishes in expirationincreases in pulmonary stenosis and RBBB fixed splitting ASD RBBB reversed split – LBBB severe aortic stenosis, LVF PDAsingle S2 calcified aortic stenosis, pulmonary stenosis, common truncus, some normal elderly patients
Third heart sound	ventricular filling at time of av valve opening	normal in young people at apex also occurs in rapid ventricular filling – MI, VSD, CCF constrictive pericarditis
Fourth heart sound	ventricular filling due to atrial contraction against a stiff ventricle	CCF, MI, hypertension, HOCM

Mighty Ape MighTy M1 T1 AP A2 P2 first heat sound is made up of mitral component and tricuspid component (in that order) the second heart sound is closure of aortic then pulmonary valves.

hacking-medschool.com/heart-murmers-cvs

Murmer	turbulent blood flow within the heart heared with the stethoscope
Thrill	palpable murmer – like a cat purring

Heart sound sites
Aortic
Pulmonary
Tricuspid
Mitral

Grading Heart Murmers
I	barely audible
II	quiet and soft
III	moderately loud
IV	loud with a thrill
V	very loud with thrust or thrill
VI	can be heard with stethoscope not touching chest

Heart Murmers
Midsystolic	A Stenosis – midsystolic RUSE radiating to neck (+/- apex)A Sclerosis – similar with mewing seagull cryPS /ASD/ MVP/ HOCM -mid-late systolic at LSEInnocent – LSE – hyperdynamic states, pregnancy, chest wall deformity
Pansystolic	MI – apex radiating to axillaVSD – apex radiating to LSERuptured chordae apex-right upper chestTI – RLSE especially on inspiration
Early diastolic	AI – LSE on expirationPulmonary Regurgitation – louder on inspirationGraham Steel – pulmonary hypertension due to mitral stenosis
Mid diastolic	MS – low pitched rumbling, apical louder left recumbant or exercisemay be presystolic attenuationAustin Flint apical diastolic mumer in AITricupid Stenosis (rare) RLSECarey Coombs – short diastolic murner in acute rheumatic mitral valvitis
Continuous	Aortic coarctation, AV shunts, PDA ruptured valsalva sinus Aortic StenosisCombined aortic and combined mitral valve disease

Auscultation Assistant

blaufuss.org

dAdvanced physical diagnosis washington.edu

Littmann education heart lung sounds

http://youtu.be/Tt224yufk5c

http://youtu.be/39n4XWv7flQ

http://www.youtube.com/watch?v=xS3jX1FYG-M

http://www.youtube.com/watch?v=3NapobA3QbI

http://www.youtube.com/watch?v=YJiYUsMW-wQ

Carotid and JVP examination

Visible pulsations of internal jugular vein.

Patient reclined at 45 degrees with neck relaxed. Pulsations visible between heads of sternomastoid.

Differentiate from carotid pulse: not (usually) palpable, biphasic, slow rising and falling, rises if pressure applied over upper abdomen (hepato jugular reflex)

Measure vertical height of column of blood above sternal angle.

If JVP very high may not be visible – look for ear lobe pulsations or sit/stand patient up.

Kussmauls sign – elevation of jvp with respiration – due to obstructed venous filling eg constrictive pericarditis.

http://www.youtube.com/watch?v=OuG-Ru7fryE&NR=1

http://www.youtube.com/watch?v=ATSPY-1vYKc

Corrigans sign – easily visible carotid pulse in Aortic Regurgitation. May also be seen in older patients with arteriosclerotic or aneurysmal dilation (aortic coarctation in the young)

Bruits may be heard in carotid or subclavian stenosis, or radiating murmers especially aortic stenosis.

Respiratory system

ucsd.edu lung exam

http://www.youtube.com/watch?v=hWGzi5h2UR8

Clubbing
Carcinoma lung stomach GI lymphoma
Cardiac – cyanotic CHD bacterial endocarditis
Cervical rib – neurovascular compression upper limb
Chest – CF bronchiectasis TB fibrosing alveolitis empyema lung abcess
Circulation – AV fistula
Cirrhosis
Colonic – crohns UC coeliac
Congenital/familial
CLUB’D
Cyanotic congenital heart disease Crohns disease
Lung disease (chronic suppurative eg empyema CF, abcess), fibrosing alveolitis and cancer (bronchial, mesothelioma) liver disease
Ulcerative colitis
Bacterial endocarditis
Diarrhoea (chronic)
Other causes
Thyrotoxicosis – thyroid acropachy

HPOD

http://www.youtube.com/watch?v=EnjYjbwfzkc

Breath sounds
crackles	inspiratory or expiratoryintermittent like rice crispies or hairs rubbing together
pleural rub	inspiratory continuous superficial low pitched squeekink or grating – like sandpaper ot velcrow
rhonchi	low pitched monophonic snoring mainly but not wholly expiratory
wheeze	high pitched continuous musical whistling mainly expiratory sometimes on inspirationWheeze is an expiratory noise caused by narrowing of airways. Expiratory as intrathoracic pressure is highe in expiration further narrowing the airways.Usually high pitched poyphonic due to narrowing of multiple small airways (asthma, COPD, LVF – airways narrowed by interstitial oedema).Low pitched monophonic wheeze suggests obstruction of large airway (bronchus, trachea) by tumour FB stricture.
stridor	high pitched monophonic crowing heared on inspiration louder in the neck than the chest wall.(ER facts incredibly quick Lipincott 2007)

Breath sounds med.ucla.edu

http://youtu.be/NnuaHGW1cwU

http://youtu.be/h7BtrWATfg8

http://youtu.be/0Q6J0ybSuNo

http://youtu.be/nhUT5BfAFic

http://youtu.be/9C5RFb1qWT8

http://www.youtube.com/watch?v=0Q6J0ybSuNo

http://www.youtube.com/watch?v=h7BtrWATfg8

Abdo GIT exam

250textbooks/abdominal-examination-surgical

abdominal examination uscd.edu

http://www.youtube.com/watch?v=oVWjAeAa52o

http://www.youtube.com/watch?v=jqQ4U_DXKf8

Vascular examination

http://www.youtube.com/watch?v=jsCoSHP4RmE

http://www.youtube.com/watch?v=iGMnZkTnPjk

Breast exam and BSE

ucsd breast examination

250textbooks/bse

http://www.youtube.com/watch?v=9bv0dyTWDmk

http://www.youtube.com/watch?v=Nt10rSVIEGE

Ask patient to remove bra and tops.

Cover with a blanket when you are not examining the breasts.

Position the back of the bed at 45° to the horizontal.

Examine both breasts on all occasions, starting with the normal breast

Three positions used in examining the breast
hands by the side
hands behind the head
hands on the hips

Female genital and pelvic exam

Ask the patient remove pants and to lie on the bed face up, bringing their feet up to their bottom, and letting the knees fall to the sides.

Ensure that the area to be examined is adequately illuminated using a lamp

Examination (with Chaperone)

Inspection From the end of the bed

Scan the patient from head to toe, and note:

Does the patient look well or unwell?

Does the patient have any obvious conditions eg prolapsed uterus.

Genitalia

Note the following:

Pubic hair

Labia

Clitoris

Urethra

Perianal area.

Pay particular attention to any swellings, discharge or bleeding.

Palpation

Ask if there is any pain before beginning palpation, and watch the

patient’s face throughout the examination.

Part the labia majora using the index and middle fingers of your left hand in a ‘scissor-like’ motion. Ask the patient to cough, and look for any

discharge or abnormalities of the vagina walls.

Gently palpate Bartholin’s glands (situated at the 5 and 7 o’clock positions of the labia). Normally, these cannot be palpated. Note any tenderness or swelling.

If appropriate, gently ‘milk’ the urethra, and note the presence of any discharge.

Examination with a bivalve speculum

Inform the patient that you are going to pass a small device into the front passage in order to look at the cervix

Lubricate the speculum with some lubricating jelly. Inform the patient that you are about to insert the speculum.

Pass the speculum slowly, with gentle pressure exerted backwards and downwards. Rotate the speculum as you insert in order to follow the

contour of the vagina. The device should be inserted in a vertical plane, and rotated to lie in a horizontal plane.

When it is in position, open the speculum out, and inspect the cervix.

Look at the shape and size of the cervix, and note any abnormalities. such as erosions, polyps or discharge.

Tell the patient that you are going to remove the speculum, before doing so slowly and gently.

Bimanual examination

Inform the patient that you are going to insert two fingers into the front passage in order to feel the womb.

Lubricate the index and middle fingers of your gloved right hand. Pass the fingers in gently. Rotate the fingers as you insert in order to follow the

contour of the vagina. The fingers should be inserted in a vertical plane, and rotated to lie in a horizontal plane.

Feel the cervix with the tips of your fingers.

Using your left hand, palpate the abdomen starting near the xiphisternum, and work downwards. Try to feel the uterus between your two hands.

Assess its size. shape, motility and tenderness. It may be possible to palpate the ovaries also, and any tenderness or other abnormalities

should be noted.

Tell the patient that you are going to remove your fingers, before doing so slowly and gently.

Clean any lubricating jelly from the patient with a tissue.

Male genital examination

UCSD genital exam

250textbooks/testicular-self-examination

http://vimeo.com/20039553

Digital rectal examination

Inspection

From the end of the bed

Scan the patient from head to toe, and note:

Does the patient look well or unwell?

Does the patient have any obvious conditions, eg prolapsed rectum?

Perianal area Expose the perianal area by lifting up the right buttock. Look for:

fissures

haemorrhoids

skin tags or rashes

warts

fistulae.

Ask the patient to ‘strain down’, and note any rectal prolapse.

Bad Article Des Spence DRE BMJ

http://www.youtube.com/watch?v=4UZLKabyVe8

http://www.youtube.com/watch?v=osWgOCSmkfc&feature=related

ENT exam

http://hacking-medschool.com/ent-examination-routines

Neck and thyroid exam

Palpate goitre bimanually from behind with patients head in neutral or slightly flexed position.

Note size and texture of gland, and whether it moves with swallowing.

Enlargement may be diffuse (Graves, Autoimmune thyroiditis, simple goitre) or nodular (toxic nodular goitre, late simple goitre, Ca)

Tenderness suggests viral thyroiditis but may be seen in autoimmune and Ca. Bruit suggests toxic goitre

Check for downward retrosternal extension by palpating suprasternal notch and percussing sternum.

Thyroid Exam osceskills.com

http://vimeo.com/20039642

http://www.youtube.com/watch?v=kpJ_IzfJDtw

Cervical glands

http://youtu.be/V6g4rDCgtro

Opthalmic exam

http://hacking-medschool.com/eye-examination

http://www.youtube.com/watch?v=J70-ex4uozk

http://www.youtube.com/watch?v=GBatOUe8r7A

http://youtu.be/0ncL3vfHNO4

Eye examination medinfo.ufl.edu

bmj ref

WA Panoptic

Neurological history and examination

neurological history and exam emedicine/medscape

http://hacking-medschool.com/3-minute-neuro-exam

http://youtu.be/RAQycLXSFrU

3 minute neurological examination Dr Michael Ingram
1	Romberg’s test Patient falling with eyes closed.
2	Tandem gait test Heel-to-toe walking
3	Walking on heels Tests pyramidal tractDorsiflexion Plantarflexion
4	Drift of outstretched arms Tests pyramidal tract
5	Finger-nose test Tests coordination
6	Fine finger movements Tests pyramidal and extrapyramidal tracts.
7	Hand tapping. Cerebellar and brainstem disease
8	Visual fields to confrontation
9	Eye movements
10	Face and tongue movements
11	Fundoscopy
12	Reflexes

Rapid screening examination to rule out brain tumour or haemorrhage in patients with headache Dr Michael Ingram

Neurological Exam
Cranial Nerves
1
2
3 4 6
5
7
8
9 10
11
12
Cerebellar function
Gait
PNS

http://www.youtube.com/watch?v=fgwN1P5PDaA

http://www.youtube.com/watch?v=Ay_j9PlZY5c

Cranial nerve examination
1 Olfactory	Smell	Ask patient to identify 2 distinct smells eg coffee/mint through each nostril individually with eyes closedAnosmia may be heriditary, post skull fracture, frontal lobe tumour meningioma, rhinitis
2 Optic	Vision.	Test visual acuity, fields by confrontation and examining the fundus with an opthalmoscope.
3 Oculomotor	Pupillary constriction and eye movement	Examine 3/4/6 together by testing pupillary response to light, ensuring both pupils are equal size.Have the patient follow the examiner’s finger through the entire range of ocular movements.
4 Trochlear	Downward, inward movement of eye
5 Abducens	Lateral movement of eye.
6 Trigeminal	Motor function includes jaw muscles for clenching teeth and moving jaw sideways.Provides sensation to the entire face in three distinct areas:forehead for the 1st branch;cheeks/maxillae for the 2nd branch;mandible for the 3rd branch	Palpate the patient’s jaw while they clench their teeth (masseter) and also by touching both sides of the face in all three distinct areas of sensory innervationAsk patient to open and close jaw against resistance (pterigoid)Test jaw jerk (increased in UMN)Corneal Reflex
7 Facial	Motor function includes eye closing, mouth closing, and wrinkling forehead.Sensory function includes taste on the anterior 2/3 of the tongue	Have the patient puff out their cheeks, show teeth/frown, raise their eyebrows and try to keep their eyelids shut as the examiner attempts to open the lids.Unilateral UMN lesions spare the forehead.Bells sign – exaggerated upward movement of the eyeball on attempted eye closure seen in LMN lesions
8 Auditory	Hearing(vestibular function not routinely tested)	Test overall function by whispering a word into one ear at a time while occluding the other ear.Test Rinnes Weber and perform otoscopy.
9 Glossopharyngeal	Movement of the pharynx and taste sensation in the posterior tongue	Ask patient if there is any change in their voice (dysphonia) or if they have difficulty swallowing. Have them say “ah” and watch for rise of the soft palate (vagus)Check gag or palate reflex (glossopharyngeal) by touching the posterior throat or palate on each side with a tongue depressor or orange stick.
10 Vagus	Movement of the soft palate, larynx, and pharynx
11 Spinal accessory	movement of the sternomastoid and upper trapezius muscles.	Patient shrugs shoulders and attempts to turn their head to the side against resistance. Turning head away from affected side is weak in accessory nerve palsy.Bilat trapezius weakness suggests MND or polio. Weakness of sternomastoid occurs in muscular dystrophy, myotonic dystrophy and MND
12 Hypoglossal	tongue movements	Examine tongue for fasiculations and wasting (LMN)Ask patient to protrude the tongue from the mouth and then move it from side to side.Tongue will deviate to affected side. Tongue movement may be sluggish in bilateral UMN lesions.

http://www.youtube.com/watch?v=pSVw9KsA_mE

http://hacking-medschool.com/cranial-nerve-palsies

The twelve pairs of cranial nerves are responsible for specialized motor and sensory functions. Strokes, injuries and other intracranial pathology may cause deficits to the function of one or more these nerves – cerebrovascular accident; Bell’s palsy; intracranial hemorrhage/hematoma; elevated intracranial pressure; meningitis

Speech assessment

Speech assessment revise4finals.co.uk

http://youtu.be/ttYPN59v9yE

http://youtu.be/8s5gjsoLZKE

Psychiatry history and examination

Mental State Examination

http://hacking-medschool.com/mse-2

Mental State Examination ucsd.edu

Cognitive screening tests

Screening for Cognitive Impairment PUK

AMTS Abbreviated Mental Test Score (Hodkins)
1 Date of birth	Score for correct date and month (year not required)
2 Year	Score for current year only
3 Time of day	Score if correct to the nearest hour
4 Place	Score if exact address or name of hospital given (“in hospital” is insufficient)
5 Monarch / PM	Score for current monarch only
6 Year of WW1	Score for year of start or finish (both not necessary)
7 Count backwards from 20-1	Score if no mistakes or subject corrects himself or herself spontaneously
8 Recognition of two people	Score if roles of two people correctly recognised–for example, doctor and nurse
9 Recall of three point address 42 West Street.	Score if registered correctly near start of test and at end
Score below 7 suggests cognitive impairment AMTS ncbi.nlm.nih.gov

Six item cognitive impairement test 6CIT
1 What year is it?	Correct answer scores zero (no errors), otherwise score 1	4
2 What month is it?	Correct scores zero – wrong scores 1
3 Memory Phrase Im going to tell you an address and would like you to try memorise it then repeat back to me later.Say “John / Brown / 42 / West Street / Bedford” (or similar address with 5 elements)	Make sure patient is able to repeat address correctly before moving on and warn them to try memorise itNo score is made at this stage as you are going to ask them to repeat it again in a few minutes
4 What time is it?	Within 60 mins / 1 hr of correct time then score zero, if not score 1	W3
5 Count backwards from 20 to 1	If they do this correctly they, score zero, one error then score 1 and for 2 or more errors score max 2 w25 Ask patient to say months of year backwards from December. allow plenty all correct then score zero, one error – score one. 2 or more errors score 2 w2
6 Finally ask them to repeat address back to you	All correct = zero, one bit wrong = 1, 2 parts wrong = 2 , 3 parts wrong = 3, 4 parts wrong = 4 and all wrong = 5 w2

6 Item Cognitive Impairment Test (6CIT) PUK

Mini mental state examination MMSE
I would like to ask you some questions to test your memory. Is that OK?
Orientation		10 points
Can you tell me today’s date, month and year?
Which day of the week is it today?
Can you also tell me which season it is?
What city/town are we in?
What county and country?
What building are we in and on what floor?
Immediate Anterograde Recall	I would like you to remember three objects – orange ball treeAsk for the words to be repeated (registration)	3 pointsscore 1 for each correct wordRepeat until all three are remembered, allowing up to six attempts. First repetition determines score
Attention and calculation		5 points
Serial 7s.	Starting with the number 100, subtract 7 and repeat, ie 100, 93,86… Stop at 5 subtractions 65.Alternatively, for those who have a dislike for numbers, ask them to spell the word ‘WORLD’ backwards.	Score 1 for each correct numberScore 1 for each letter DLROW
Delayed Verbal Recall	What are the three words I asked you to remember earlier?Score 1 for each correct word remembered – orange ball tree.	3 points
Language
Naming	Name these objects (show the patient two easily recognisable objects, eg watch, pen)	2 points
Writing	Write a short, simple sentence (eg ‘I went to the shops yesterday’)	1 point
Repetition	Repeat the following phrase: ‘no ifs, ands or buts’.	1 point
Reading	Read this sentence and do what it says(Show ‘CLOSE YOUR EYES’ card)	1 point
3 Stage	Take this piece of paper in your left hand, fold it in half and put it on the floor.	3 points for take/fold/put
Visuospatial – Copying	Can you copy this drawing ?(both pentagons must have five sides and overlap)	1 point
25-30 out of 30 are considered normal18-24 indicate mild to moderate impairment17 or less indicate severe impairment (adapted from Passstest / Folstein et al)

MMSE @ Patient UK

MMSE alzheimers.org.uk

dundee.ac.uk mmsei

almostadoctor.co.uk confusion amts and mmse

Dermatology history and examination

http://hacking-medschool.com/dermatology-descriptors

medrevise.co.uk Lump examination

medicalgeek.com lump

clinical mass examination clinicalexam.com

Examination of a Lump
6 Students and 3 Teachers go for CAMPFIRE
Site, Size, Shape, Surface, Skin, Scar
Tenderness, Temperature, Transillumination
Consistency
Attachment
Mobility
Pulsation
Fluctuation
Irreducibility
Regional lymph nodes
Edge

Gynae history and exam
History
Menses
Fertility
Pelvic Pain
Uroynaecology
Speculum
Pelvis

http://hacking-medschool.com/gynacological-history

Gynae History and Exam PUK

Paeds history and exam
History
PMH
Imms
Developmental
Family History
Social History
Examination
CVS
Resp
Abdo
Neurology
Growth Chart

Neonatal examination / baby check

http://www.youtube.com/watch?v=eO9eHco3SV4

http://www.youtube.com/watch?v=QmII-qlm7Aw

MSK examination
LOOK	– inspect – including gait posture and habitus
FEEL	– palpate
MEASURE	– rom, swelling
MOVE	– active (patient) passive (examiner – watch for pain) and against resistance (helps define site of lesion or identify partially damaged tendons
Special Tests and tests of function
In addition all patients with musculoskeletal or soft tissue injury should have full assessment of neurovascular supply to limb joint or digit.

The key to effective, rapid and thorough MSK examination is to establish and perform systematic set routines.

Demonstrate the movements you would like the patient to make rather than try to explain.

Always compare both sides of the patient front and back.

Expose/undress the patient fully

Consider/examine joints above and below that which is being inspected and also the neck and lower back for the upper and lower limbs.

Always fix the limb near the joint to be examined to properly isolate movements at that joint .

e.g. Knee examination may be indicated for a number of reasons such as direct or indirect trauma to the joint itself, as part of the examination of an injured limb (the joint above and below the injury should always be examined) or due to chronic or acute pain in that or other joints.

GALS Gait Arms Legs Spine
Musculoskeletal screening routine covering essential aspects of individual joint examinations
Three questions	Have you any pain or stiffness in your muscles, joints or back?Can you dress yourself completely without any difficulty?Can you walk up and down stairs without any difficulty?
Gait	Ask the patient to walk to the other side of the room, tum, and walk back to you.
Spine	Inspect the patient standing: from in front, the side and behind.Ask the patient to bend over and touch their toes, keeping the knees straight (lumbar flexion).Estimate the amount of lumbar flexion by putting your lingers on the adjacent vertebrae and noting the distance that they separate duringflexion.Ask the patient to put ‘their ear to their shoulder’ on each side in turn (lateral cervical flexion).Squeeze the supraspinatus muscles Suprasinatus Infraspinatus
Arms	SuprasinatusInfraspinatusInspect the patient’s arms, with the elbows extended by the sideThe position of the arms for inspectionKeeping the elbows by the side (so fixing them), ask the patient to flexthe elbows to 90″ and ask the patient to tum their palms towards the ceiling (supination), then down to the floor (pronation). Squeeze across the 1st-5th metacarpophalangeal (MCP) joints, and note any pain. Ask the patient to touch each finger, in tur, onto the thumb. Ask the patient to make a fist. Ask the patient to put their hands behind their head and to push the elbows backwards.
Legs	With the patient standingInspect when standing from the front, side and from behind (pay special attention to the popliteal fossa).With the patient on the bed (see hip and knee examinations for further details]Inspect the legs close up.Feel the temperature of the knee by placing the back of your hand overthe anterior aspect. Carry out the bulge test (with or without the patellar tap) for a fluid effusion in the knee. Ask the patient to put each heel up to their bottom (active knee and hip flexion). Passively flex the hip. While the hip is still flexed, test internal rotation passively. Extend the knee, keeping one hand over the patella to feel for crepitus. Squeeze across the 2nd-5th metatarsophalangeal (MTP) joints. Inspect the foot closely for callosities and other abnormalities. Look between the toes, at the metatarsal heads and at the heel.
ARC MSK Examination for Med Students

medrevise.co.uk

http://hacking-medschool.com/msk-examination

http://www.youtube.com/watch?v=9jTZ03CbZm0

http://www.youtube.com/watch?v=u4azNJ1HYJQ

http://www.youtube.com/watch?v=YgQ0ujQpaiA

http://www.youtube.com/watch?v=-p0nDhVKAjs

SOFTER Tissues Acronym for non-traumatic MSK problems
Sepsis
OA
Fractures (pathological and stress)
Tendon and Muscle problems
Epihyseal and other conditions of childhood
Refered pain and nerve root

compression……including…Tumours,Ischaemia, Seropositive & seronegative Arthritides, Uric Acid (gout and other crystal arthropathies) Extra Articular Rheumatism (endocrine metabolic) Skin fat and bursae

MRC MSK scales

http://hacking-medschool.com/mrc-scales

MRC scale for strength of muscle contraction
5/5	normal	FROM against gravity with full resistance
4/5	good	FROM against gravity with moderate resistance
3/5	fair	FROM against gravity only
2/5	poor	FRO passive movement (gravity eliminated)
1/5	trace	of muscle contraction (palpable) but without joint movement
0/5	zero	no evidence of muscle contractio

MRC Grading for strength of muscle contraction
M5	normal
M4	some diminished strength compared to other side
M3	weak but stromg enough to overcome gravity
M2	muscle can perform work if gravity is eliminated
M1	fasiculation only
M0	no motor activity

Tendon Reflexes
Biceps C5, C6
Brachioradialis C6
Triceps C7
Patellar L4
Ankle S1

Myotomes
C3,4 and 5	supply the diaphragm
C5 deltoid	C5 deltoid
C6	wrist extension
C7	elbow extension
C8	finger flexion
T1	fingers abduction
T1 –T12	the chest wall & abdominal muscles.
L2	hip flexion
L3	knee extension
L4	dorsiflexion
L5	toe extension
S1	plantar flexion (??)
S3,4 and 5	bladder bowel genitalia anus and other pelvic muscles

Dermatomes

Gait assessment

http://hacking-medschool.com/gait-abnormalities

Gait abnormalities nlm.nih.gov/medline plus

http://youtu.be/occFkFbl3ms

http://youtu.be/g-d52ozo4B0

http://youtu.be/eBvzFkcvScg

http://youtu.be/FpiEprzObIU

http://youtu.be/y160w4sAQNw

Pronation supination inversion eversion

Arm Shoulder Movements

Flexion Extension at the Shoulder

Hip Movements

Knee Examination Knee Meniscal Tests

Ankle foot movements

Inversion Eversion

Plantar Flexion Dorsiflexion

Hand Movements

Pronation Supination Hands

Pronate for pressups

Prayer Position

Abduction Adduction at the wrist

Thumb Movements

Abduction Adduction

PGALS

Paediatric Gait Arms and Legs ARC

Examination of the spine

C spine

T spine

http://hacking-medschool.com/back-and-neck-examination

Upper limb examination

http://meded.ucsd.edu/clinicalmed/upper.htm

Shoulder exam

http://hacking-medschool.com/shoulder-exam

Elbow examination

http://hacking-medschool.com/elbow-examination-2

Wrist and hand examination

http://hacking-medschool.com/hand-examination

Lower limb exam

http://meded.ucsd.edu/clinicalmed/extremities.htm

Hip and groin exam

http://hacking-medschool.com/hip-exam

Groin examination (surgical)

http://youtu.be/VuHsa4kxT0s

http://youtu.be/RlXg-jDfCIc

http://youtu.be/aMq9QPZIvv4

Knee exam

http://hacking-medschool.com/knee-examination-2

Ankle and foot exam

250textbooks/ankle-and-foot-exam

Difficult / angry patients

Remain professional and calm

Try not to be defensive or aggressive

Attempt to diffuse the situation

Listen and be attentive, allow patient to speak

Do not blame others, e.g. “The hospital/nurse is so disorganised”

Ask questions Be inquisitive – allows patient to voice their concerns and also stops the doctor from being defensive: why is patient unhappy? what exactly happened?

Apologise Even if you have done nothing wrong you can apologise, e.g. “I’m sorry you had to go though that”

Acknowledge This makes the patient feel heard and allows them to vent and empathise their anger

This can be done in several ways:

Summarise their concern “So you waited 10 weeks for the appointment?”

Acknowledge emotion “I can see that made you angry”

Empathise “It’s very annoying to wait so long”

Thank the patient “Thank you for bringing this to my attention”

What does Find out what they want you to do, e.g. “Is there anything in patient want? particular you were hoping I could do?”

Emphasise your commitment to helping the patient and ensure there are no other issues that have not been dealt with

“I will raise this at a practice meeting”

“Let’s see if we can stop this occurring again”

Formal Direct patient to official complaints procedure if appropriate complaint “Would you like to make a formal complaint?”

Complaints

Rapid acknowledgment

Explanation and apology

How it will be put right

In writing on practice leaflet

http://youtu.be/1sXDGrjtQyQ

http://youtu.be/mbheToXlm2Y

http://youtu.be/kTFF-354gUo

Abusive patients

Abusive patient allnurses.com

Dealing with relatives

Improving Communication With Older Patients AAFP 2006

oscehome.blogspot.com

Dealing with difficult relatives steve pavlina.com

Relatives gpvts.info

Children and young people

Communicating with children gp-training.net

GMC guidance for Doctors treating children MDU

Childrens and Young Peoples Health RACGP

Deaf patients

hacking-medschool.com/speaking-to-a-deaf-person

Disabled patients

Communicating With and About People with Disabilities US Dept of Labour

Ten rules for communicating with disabled people allbusiness.com

Ethnic patients

hacking-medschool/transcultural-medicine

Breaking bad news SPIKES
Setting up	allow sufficient time, privacy and minimise interruptions.
Perception	what the patient knows (his perceptions), so that you tailor your explanation according to his understanding
Invitation	get the patient’s permission to break the bad news and ask if the patient wants basic information or a detailed disclosure.
Knowledge	give the patient sufficient information, using jargonfree language to enable him to make informed decisions
Emotions	acknowledge the patient’s feelings. Use silence allow the patient to vent his emotions.
Strategy	summarise the information discussed, check comprehension, provide written plans/information and make followup
Baile WF, Buckman R, Lenzi Ret al. (2000)