OSCE 3

Cardio PE Findings

"No chest wall deformities, scars, or pulsations. JVP 2cm H20 and CVP 7cm H20. Carotid pulse 2+ B/L with a brisk upstroke, brief plateau, and a slower downstroke. No thrills or heaves. PMI 5th /C5 L. MCL. 51 and 52 heard. No 53, 54, murmurs, rubs, or gallops"

Respiratory Exam PE Findings

"Thorax is symmetrical with good expansion. Chest wall non-tender, Fremitus equal and appropriate B/L. Lungs resonant. Breath sounds vesicular, no crackles, wheezes. or rhonchi noted. Diaphragm descends 4cm bilaterally"

Cardio PE Comments on:

Comments on the following for the Cardiovascular Examination • JVD and JVP • Inspection of Anterior Chest • Palpation - PMI, Heaves and Thrills • Auscultation - S 1 and S2 S3 and S4 and Murmurs

Abdominal Exam PE Step 0

- Explain examinations to patient and receive consent - Wash hands - Position- Supine with arms at the sides - Drape - Place drape at the level of the symphysis pubis and raise the gown just below the nipple line above the xiphoid process. - Go to the patient's right side Full PE outline: Inspection/hernia Auscultate for Bruit + BS Percuss 9 regions Ask if pain, light palpation, deep palpation Liver span Palpate liver Percuss spleen Palpate for Spleen Kidney palpate Kidney Costovertebral Tenderness DRE

Respiratory Exam Step 0

- Explain examinations to patient and receive consent - Wash hands - Position- examine posterior thorax while patient is sitting with arms folded across the chest with hands resting and anterior thorax in supine. - Drape - Men: expose chest fully, women: cover anterior chest when examining back and drape down over each half of chest as examining other half.

Female Reproductive Physical Exam Step 0

- Explain examinations to patient and receive consent - Ask for another person to assist me with the examination - Wash hands - Position- supine. - Drape - No draping needed. Have the patient be in a gown. - Go directly Infront of patient.

HEENT PE (Headache) Step 0

- Explain examinations to patient and receive consent - Wash hands - Position- Sitting up. - Drape - No draping needed. Have the patient be in a gown. - Go directly Infront of patient. Note: Temporal Arteritis: All, + ROM of shoulders Migraine Headache: No CN V + assess signs of nuchal rigidity and/or muscle tone/strength Tension Headache: Only inspection and palpation + + assess signs of nuchal rigidity

Painful intercourse (dyspareunia) Vulvovaginitis

Thick, white cottage cheese-like, odorless discharge - Intense burning and itching -Painful urination Light vaignal bleeding/spotting

MSK Ankle PE Step 3

Thompson (Simmonds test) - Assess for Achilles Tendon Rupture. • Ask the patient to kneel with both knees on a chair. Palpate the gastrocnemius muscle and the Achilles tendon for focal tenderness and soft tissue swelling. • Squeeze the calf just distal to the level of maximum circumference. If the Achilles tendon is intact, plantar flexion of the foot will occur.

MSK Spine PE Step 3

Thoracolumbar Spine: a. Flexion: Instruct the patient to bend forward and touch his toes b. Extension: With one hand on the posterior superior iliac spines for support, ask the patient to bend backward as far as possible. c. Rotation: Standing on the patient's right side, place your left hand on the left hip and your right hand on the right shoulder. Push the shoulder while keeping the hip steady. Stand on the patient's left side and repeat. d. Lateral flexion: Stand facing your patient. Place your right hand on the left hip for support and ask the patient to lean to the left side as far as is possible. Repeat for the opposite side

MSK Hip PE Step 6

Trendelenburg's Test a) Stand in front of the patient. Palpate both iliac crests and ask the patient to stand on one leg for 30 seconds. Repeat with the other leg. b) Watch and feel the iliac crests to see which moves up or down. Normally, the iliac crest on the side with the foot off the ground should rise. The test is abnormal if the unsupported hemipelvis falls below the horizontal plane. This may be caused by gluteal weakness or inhibition from hip pain, such as osteoarthritis.

Musculoskeletal Examination: Knee Step 6

- Assess for Ligamentous Injury o Valgus Stress Test (MCL) ■ On the right knee, with the knee slightly flexed I'll move the thigh about 30 degrees to the side of the table. I'll place my right hand against the lateral knee and left hand on the medial ankle. I will push medially against the knee and pull laterally at the ankle to assess ligament. I'll do the same on the other side. o Varus Stress Test (LCL) ■ On the right knee, with the knee slightly flexed I'll move the thigh about 30 degrees to the side of the table. I'll place my right hand against the lateral ankle and left hand on the medial knee. I will push laterally against the knee and pull medially at the ankle to assess ligament. I'll do the same on the other side.

Cardio PE Step 0

- Explain examinations to patient and receive consent - Wash hands - Position- Patient supine and head elevated at a 30-45-degree angle. - Drape Men: expose chest fully, women: expose area when appropriate - Go to pt's right side

Musculoskeletal Examination: Knee Step 0

- Explain examinations to patient and receive consent - Wash hands - Position- Standing on inspection, sitting for ROM and supine for special tests. - Drape - No draping needed. Have the patient be in a gown with legs exposed. - After inspection of from anterior, go to the patient's right side

Painful intercourse (dyspareunia) Endometriosis

-Painful intercourse -Pain during menses -Pain with defecation -Abnormal uterine bleeding Chroninc and cyclic pelvic pain -Diarrhea -Constipation during menses -Nausea, vomiting - Infertility

Chest Pain PLAN

1. EKG, 2. CARDIAC enzyme (CKMB, Troponins), 3. Angiography 4. Echocardiogram 5. CXR 6 . BNP ( Heart Failure) 7 . BMP / CMP MI EKG Chest X-ray Transthroacic echocardiogram Cardiac Enzymes (CKMB, Toponins) Pericarditis CBC ECG/Echocardiogram Cardiac Panel - Troponins and CK-MB Endoscopy HF ECG Echocardiogram Chest Radiograph Complete Metabolic Panel or Kidney and Liver Function Tests

Diarrhea PE

1. Patient Preparation, Comfort & Dignity 2. Hand hygiene 3. Exam Organization 4. Examination of the Relevant System Abdomen - Inspection Contour and symmetry - Skin - Umbilicus - Abnormal movements (pulsations or peristalsis) - Assess for hernia Auscultation BS Bruits -General percussion All nine regions -General palpation Superficial (light) palpation for tenderness, guarding or rigidity - Deep palpation for masses Organomegaly Liver o Percuss the liver span o Palpate the liver edge Kidneys Spleen o Percuss the spleen o Palpate the spleen Additional systems R/o pallor Inspect oropharynx ( buccal mucosa for pallor) R/o hypovolemic shock Assess blood pressure and heart rate -Auscultate the heart sounds

Chest pain DDX

1. STABLE ANGINA 1.2 UNSTABLE ANGINA 2.MYOCARDIAL INFARCTION 3.COSTOCHONDRITIS 4.PERICARDITIS 5.MYOCARDITIS 6.GERD 7. PULMONARY EMBOLISM 8. AORTIC DISSECTION 9. ACUTE CORONARY SYNDROME:

Abdominal Pain PE

Abdomen - Inspection Auscultation BS Bruits -General percussion -General palpation Organomegaly ○Liver ○Kidneys ○Spleen Special test R/o Appendicitis Rebound test McBurneys Rebound test Rovsing Psoas sign Obturator sign R/o Cholecystitis Deep palpation test Murphys R/o kidney infections Costovertebral angle test (CVA) R/o ascites Shifting dullness Fluid wave Additional systems R/o pallor Inspect oropharynx R/o hypovolemic shock Assess blood pressure and heart rate -Auscultate the heart sounds

HEENT PE (Headache) Step 3

I'll next perform a fundoscopy exam in a dark room and ask the patient to fixate on an object straight ahead and try not to move their eyes. I'll hold the ophthalmoscope with my right hand and use my right eye to examine the patient's right eye and the opposite for the left eye. Inspecting the optic disc, retina, fovea, and macula. I'll shine the beam of light into the patient's eye 12 inches away at a 15-degree lateral angle ill elicit the red reflex.

Abdominal Exam PE Step 7

Acute abdomen/Peritonitis by assessing for rebound tenderness. I will press down lowly, then withdraw my hand quickly and asses for any pain.

Abdominal Exam PE Step 6

I'll palpate the liver by placing my left hand posteriorly between the right 12th rib and the iliac crest and gently push anteriorly. Ill place the fingertips of my right hand in the RLQ, parallel and lateral to the rectus muscle in the midclavicular line. I'll ask the patient to breathe in deeply and move my right hand upwards and press inward to depress the abdomen during expiration, and then feel for the liver edge on the next deep inspiration.

Musculoskeletal Examination: Knee Step 5

ACL Injury - Assess for Meniscus injury (McMurray test) o Medial Meniscal injury ■ On the right knee, ill place my left hand so that the fingers are aligned along the medial joint line. I'll grasp the patients heal and flex the knee to 90 degrees and slightly rotate the tibia externally, with the other hand applying valgus stress on the lateral side of the knee. I will then slowly extend the knee and feel for a click. I'll do the same on the other side. o Lateral Meniscal Injury ■ On the right knee, ill place my left hand so that the fingers are aligned along the lateral joint line. I'll grasp the patients heal and flex the knee to 90 degrees and slightly rotate the tibia Internally, with the other hand applying varus stress on the lateral side of the knee. I will then slowly extend the knee and feel for a click. I'll do the same on the other side.

Jaundice PE

Abdomen - Inspection Auscultation BS Bruits -General percussion -General palpation Organomegaly Liver Kidneys Spleen Additional systems R/o pallor Inspect oropharynx R/o hypovolemic shock Assess blood pressure and heart rate -Auscultate the heart sounds

Respiratory Exam Step 3

Anterior Thorax: With the patient supine, sitting, or standing with their arms to sides. I'll start at the apex (supraclavicular fossa) moving in a ladder like pattern and move downward, ending at the lateral chest in the midaxillary line at the level of the 6th intercostal space. • Ill inspect for contour and chest movements as well as symmetry and chest expansion • Then, I'll palpate for tracheal deviation by placing my finger along one side of the trachea and noting the space between it and the SCM. comparing it to the other side and noting symmetry. o Then I'll move on to palpate the anterior chest wall tenderness and expansion with the same technique explained for posterior thorax using the anterior thorax landmarks. If the patient is female, I'll skip over the breast tissue. • Then ill perform tactile fremitus using the same technique for posterior chest wall, at the anterior thorax landmarks and asking the patient to displace breast tissue if female. • Next ill percuss with my dominant hand by striking my non-dominant hand as explained before in the anterior landmarks. • Then ill auscultate with the diaphragm of my stethoscope in the anterior landmarks while the patient breaths in and out deeply to identify breath sounds and adventitious sounds

MSK Hip PE Step 3

Assess Range of Motion (ROM) Assess hip ROM and the specific muscles responsible for each movement. Review the instructions to the patient. 1. Flexion "Bring your knee to your chest and pull it against your abdomen." 2. Extension "Lie face down, then bend your knee and lift it." OR "Lying flat, move your lower leg away from the midline and down over the side of the table." 3. Adduction "Lying flat, bend your knee and move your lower leg toward the midline." 4. Abduction "Lying flat, move your lower leg away from the midline." 5. Internal rotation "Lying flat, bend your knee and turn your lower leg and foot away from the midline." 6. External rotation "Lying flat, bend your knee and turn your lower leg and foot across the midline."

MSK Ankle PE Step 2

Assess Range of Motion (ROM) Assess the following joints. • The tibiotalar joint; Dorsiflex and plantarflex the foot at the ankle. "Point your foot toward the floor." "Point your foot toward the ceiling." • The subtalar (talocalcaneal) joint; Stabilize the ankle with one hand and ask the patient to invert and evert the foot by turning the heel inward then outward. "Turn the sole of your foot inward or toward your midline." "Turn the sole of your foot outward or away from your midline." • The transverse tarsal joint: Stabilize the heel and invert and evert the forefoot • The metatarsophalangeal joints; Move the proximal phalanx of each toe up and down.

Abdominal Exam PE Step 2

Auscultation: For bowel sounds ill use the diaphragm of my stethoscope to auscultate the RLQ noting frequency and character. If diminished or absent ill also listen to the other 3 quadrants. I'll next assess for any Bruits, with the diaphragm of my stethoscope in the following areas of projection arteries: Aorta at 2in. Above umbilicus. Then to the right and left of the aorta 1in., for the right and left renal arteries respectively. Then 2inches from the umbilicus to the right and left on a line to the femoral pulses for the Right and left iliac arteries respectively.

Cardio PE Step 6

Auscultation: I'll determine S1 and S2 sounds by palpating the carotid pulse at the beginning of the auscultation in one area. Then using the diaphragm of my stethoscope ill auscultate the Aortic (R. 2nd ICS) Pulmonic (L. 2nd ICS) Tricuspid (L 4th ICS) and Mitral (L. 5th ICS MCL). Then using the Bell of my stethoscope ill assess for S3 and S4 sounds by auscultating in the Tricuspid and Mitral areas as explained before.

Cardio PE Step 1

Inspect for JVD: With the patient supine and head elevated at a 30-45-degree angle, I'll ask the patient to turn their head slightly away to the left and use tangential lighting to inspect JVD on the R side of the neck. Ill identify the highest point of pulsation in the R jugular vein and place straight edge of an object horizontally. Then ill place a ruler vertically to meet the horizontal object at 90 degrees. And measure the point of intersection on the ruler. Add 5cm for CVP

Step 3

Begin the interview with non-focusing skills that help the patient to express her/himself 7. Start with open-ended request/question ✓ The interviewer encourages and lets the patient talk about their problem. 8. Use non-focusing open-ended skills 9. Obtain additional data from nonverbal sources: nonverbal cues, physical characteristics, accouterments, environment, self

Calf Pain PLAN

Bilateral Lower limb ultrasound D-Dimer levels Venogram Ankle Brachial Index

Diarrhea PLAN

CBC ESR/CRP (Inflammation) Colonoscopy (for IBD) Stool Culture Blood test (for parasites) Urine Test (5-HIA for Carcinoid tumor)

Abdominal pain PLAN

CBC Liver function tests Ultrasound/ CT of abdomen Amylase, lipase test. Viral hep serology

SOB PLAN

CBC Pulmonary Function test CXR Chest CT Bronchoscopy Echocardiography Sputum analysis ECG

Cough PLAN

CBC Sputum culture CXR Chest CT ECG Bronchoscopy

Sore Throat PLAN

CBC Throat swab Nasal Swab Anti-EBV Abs (Serology) CD4 count

Respiratory Plan

COPD Chest Radiograph Pulmonary Function Test/ Spirometry Chest CT/MRI Cancer Chest Radiography CJ Chest CT /MRI Mantoux tuberculin skin test Sputum.Analysis fo AFB. Acute Chest Syndrome CBC with differential Chest Radiograph ABG

Respiratory Additional Systems

COPD Comments on auscultation of heart and (rechecks the respiratory rate Cancer Comments on auscultation of heart and rechecks the respiratory rate Acute Chest Syndrome Comments on auscultation of heart and rechecks the respiratory rate Costocondritis Comments on auscultation of heart and rechecks the respiratory rate

Cardio Additional Systems

Chest pain (MI) - Lung auscultation, Recheck BP Chest Pain (Pericarditis) - auscultation of lungs and recheck the pulse Shortness of Breath (CHF) - Auscultation of lungs and pitting edema or rechecking system respiratory rate Chest Pain (Costochondritis) - Auscultation of lungs and rechecking system respiratory rate

Cough PE

Inspect for respiratory distress Inspect - cyanosis or pallor - Listen for audible sounds Inspect use of accessory muscle or retractions Posterior thorax - Inspect Palpate Tenderness, expansion, tactile fremitus -Percussion Auscultate Breast sounds, adventitious sounds (wheezing, rhonchi, crackles, rubs) Anterior thorax -Same as posterior -ADD - tracheal deviation Special test -Egophony -Bronchophony Whisper pectoriloquy Additional systems -Auscultate the heart (S1,S2) Assess oropharynx/inspect septum and nasal passage -Assess lymphadenoapthy

Cardio PE Step 4

For the Point of Maximal Impulse ill: palpate over the L midclavicular line in the 4th and 5th ICS with an open palm to locate the apical impulse. If not felt, I'll ask the patient to turn to the Lateral Decubitus position. Once located, ill localize it with one digit, and using my free hand identify the PMI by counting the intercostal spaces, beginning from the sternal angle.

Abdominal Exam Plan

Crohns Barium Studies of Small Bowel Endoscopy/Colonoscopy Stool studies Oral lactose load/Mild tolerance test Colon Cancer Colonoscopy /Barium Enema Studies Abdominal CT/MRI ANCA/ASCA Stool Assays

Abdominal Exam Additional Systems

Crohns Comments on inspection of mouth and signs of e-xtraintestinal ma~ifestations or anemia or dehvdration Colon Cancer Comments on a signs of anemia - conjunctiva! pallor, capillary refill or buccal mucosa pallor and any other relevant additional based on differentials.

Abdominal Exam PE Step 12

Digital Rectal Exam: Ill position the patient on the side with their hips and knees flexed. I will put on gloves and inspect the sacrococcygenal, perianal regions and anus. I will insert a lubricated index finger to assess sphincter ton, anal canal, and rectal surface. If male, I will also assess the prostate. I will take any fecal residue and perform a guaiac test.

Step 2

Elicit chief concern and set agenda 6. ... 7. Forecast what you would like to have happened during the interview 8. Obtain a list of all issues the patient wants to discuss; specific symptoms, requests, expectations, understanding 9. Summarize and finalize the agenda; negotiate specifics if too many agenda items ✓ The patient is invited to participate in making an agreed plan.

SOB PE 2

Evaluation of the JVP - Inspection of the Jugular Venous pressure (JVP) with a penlight - Measure the JVP Evaluation of the Carotid Pulses - Inspection of the carotid pulses bilaterally - Auscultation of the Carotid pulses for bruits - Palpation of the Carotid pulse for amplitude and contour Inspection of the Precordium: - Inspect for contour, scars, and visible pulsations Palpation: - Point of Maximal Impulse (PMI) or apex beat - Heaves/lifts - Thrills Auscultation 5 For S1 and S2 (Diaphragm) • Aortic area • Pulmonary area • Tricuspid area • Mitral area 5 For S3 and S4 (Bell) • Tricuspid area • Mitral area Special positions for murmurs. o Mitral Stenosis o Aortic Regurgitation

Female Reproductive Physical Exam Step 6

External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervid parous, pink and without discharge. Uterus anterior, midline, smooth and not enlarged. No adnexal tenderness. Rectovaginal wall intact. Rectal vault without masses.

Female Reproductive Physical Exam Step 5

For the Rectovaginal examination, I'll insert my RE-GLOVED index finger into the vagina first then the middle finger into the rectum. I'll then palpate the posterior surface of the uterus by pressing the fingers inserted anteriorly and place the abdominal hand above, over the uterus pressing posteriorly. Then ill palpate the rectovaginal septum by evaluating between the rectal and vaginal fingers. Lastly, ill palpate the ovaries by moving the vaginal fingers into the right vaginal fornix, and the rectal finger slightly to the right while pressing on the abdomen and repeat on the other side. I'll then remove the vaginal finger and rotate the rectal finger 360 degrees to palpate the rectum for masses then remove the rectal finger. If stool present I'll perform guaiac test.

MSK Spine PE Step 5

Faber's test (Flexion, Abduction, External Rotation) to differentiate Sacroiliac Joint from Hip pathologies a) With the patient lying supine, ask them to straighten one leg while assisting to flex the other knee and place the ankle above the knee of the straight leg. b) Push down on the flexed knee, while stabilizing the opposite hemipelvis c) If pain is elicited on the ipsilateral side a. of pressure anteriorly, it is suggestive of a hip joint disorder on the same side. b. posteriorly around the sacroiliac joint, it is suggestive of SI joint pathology.

MSK Hip PE Step 5

Faber's test (Flexion, Abduction, External Rotation) to differentiate Sacroiliac Joint from Hip pathologies. a) With the patient lying supine, ask them to straighten one leg while assisting to flex the other knee and place the ankle above the knee of the straight leg. b) Push down on the flexed knee, while stabilizing the opposite hemipelvis c) If pain is elicited on the ipsilateral side i. of pressure anteriorly, it is suggestive of a hip joint disorder on the same side. Posteriorly around the sacroiliac joint, it is suggestive of SI joint pathology.

Female Reproductive Physical Exam Step 1

First, I'll be inspecting the external genitalia, including the mons pubis and hair distribution, labia majora, perineum, anus, labia minora, clitoris, urethral meatus, and introitus for any swelling, legions, discharge, masses, or erythema.

HEENT PE (Headache) Step 1

First, I'm going to inspect the skull from the front, side and behind the patient for size, contour, and symmetry. Then, ill inspect the scalp and hair by separating the patient's hair in several areas and noting any skin changes to the scalp, the hair texture, quantity, and distribution. I'll inspect the face by observing at rest and during conversation for symmetry, movements, overlying skin changes, and distribution of facial hair. Then, I'll inspect the eyes for position, alignment, and symmetry as well as the pupils using an eye chart if needed for symmetry and pupil size in millimeters. Then, I'll palpate the skull by palpating the entire head and palpate the temporal region bilaterally.

Sore Throat PE

Head - Inspect the skull -Assess for tenderness to skull and temporal arteries Ears - Inspect external ears -Assess for tenderness -Whisper test Nose - Inspect external nose -Assess for tenderness and patency - Inspect internal nose Oral Cavity and pharynx - Inspect lips and oropharynx o Buccal mucosa o Hard and soft palate (note movement of uvula) o Pharynx o Tonsils Neck - Inspect the neck -Assess for lymphadenopathy Additional systems Auscultate for breath sounds + adventitious sounds Percussion of anterior/posterior thorax Re-check respiratory rate

HEENT PE (Headache) Step 4

Headache (Temporal Arteritis) Comments on ROM of shoulders Headache (Migraine Headache) Comments on a sign of Meningitis (Nuchal Rigidity or Brudzinski or Kernia) OR Muscle tone or reflexes or strength. Headache (Tension Headache) Signs on Meningitis (Nuchal Rigidity or Brudzinski or Kernig sign) OR Fundoscopy • Rechecks BP which is the same as door note .

HEENT PE (Headache) Step 5

Headache (Temporal Arteritis) ESR Temporal artery biopsy or Large vessel biopsy CT/MRI of Brain or CT/MRI Angiography of Brain Headache (Migraine Headache) CT/MRI of brain Lumbar Puncture Headache (Tension Headache) CT/MRI Brain/Head

Cardio PE Step 8

Hepatojugular reflex: with the patient supine at a 45-degree angle ill apply gentle firm pressure over the RUQ for at least 10 seconds and then repeat my JVP inspection as I stated before.

MSK Hip PE Step 1

Hip Examination Inspection • Observe Gait. Ask the patient to walk away from you, then back to you on her tiptoes, then away from you on her heels, and finally back to you in tandem gait (heel-to-toe walking). Observe the gait for the stance and swing phases. Look for the width of the base, the shift of the pelvis, and flexion of the knee. • Inspect the hip both anteriorly and posteriorly for symmetry, alignment, atrophy, or bruising

Respiratory Exam Step 1

I'll generally inspect for signs of respiratory distress by: • Observing the skin and mucous membranes for cyanosis or pallor, any audible breath sounds, and use of accessory muscles, retractions, or trachea deviation. • I'll also be observing for Barrel Chest by measuring the anteroposterior diameter

Female Reproductive Physical Exam Step 2

If the patient reports labial swelling, examine the Bartholin glands. Insert your index finger into the vagina near the posterior introitus Place your thumb outside the posterior part of the labium majus. Palpate each side in turn, at approximately the "4-o'clock" and "8-o'clock" positions, between your finger and thumb, checking for swelling or tenderness. Note any discharge exuding from the duct opening of the gland.

Cardio PE Step 5

Ill assess for heaves by pressing the ulnar border of my hand parallel to the left sternal border, and for thrills by using the ball of my hand to palpate the Aortic at the R. 2nd ICS, Pulmonic at the L. 2nd ICS, Tricuspid at the L 4th ICS and Mitral at the L 5th ICS mid-clavicular.

Cardio PE Step 3

Ill then inspect the precordium for contour, surgical scars, or visible pulsations.

SOB PE

Inspect for respiratory distress Inspect - cyanosis or pallor - Listen for audible sounds Inspect use of accessory muscle or retractions Posterior thorax - Inspect Palpate Tenderness, expansion, tactile fremitus -Percussion Auscultate Breast sounds, adventitious sounds (wheezing, rhonchi, crackles, rubs) Anterior thorax -Same as posterior -ADD - tracheal deviation Special test R/p obstructive lung disease Assess diaphragmatic excursion Observe barrel chest (A-P) R/o consolidation ○Egophony ○Bronchophony Whisper pectoriloquy Additional systems Assess for signs of Cor pulmonale Palpate for heaves for RVH Inspect and measure the jugular vein Assess for pedal edema -Palpate for PMI Auscultate for heart sounds, murmurs or gallops Re-evaluate the blood pressure, heart rate, and respiratory rate - Peripheral Vascular System o Examine the peripheral pulses o Examine for pedal edema - Auscultate lung bases for signs of pulmonary edema - Abdominal exam o Palpate for hepatomegaly o Assess for ascites o Fundoscopy

MSK Ankle PE Step 1

Inspection • The patient should be seated on the table with their lower extremity flexed at the knee, with the leg hanging over the edge of the table and feet in free space. • Inspect for deformity, nodules, swelling, calluses, or corns Palpation • Palpate for swelling, bone spurs, or tenderness over the medial and lateral ankle ligaments. metatarsophalangeal (MTP) joints and the medial and lateral malleolus.

MSK Spine PE Step 1

Inspection and palpate with the patient upright • Inspect the patient's posture when entering the room, including the position of both the neck and trunk. Inspect the spine from the side and behind the patient, noting any abnormal curvatures, asymmetry of the shoulders, iliac crests, and buttocks • Observe the gait • Palpate the spinous processes and paraspinal muscles

Musculoskeletal Examination: Knee Step 1

Inspection: I'll inspect the knees with the patient standing for symmetry, swelling, deformities, contours, and atrophy of the quadriceps muscle.

Abdominal Exam PE Step 1

Inspection: I'll look for hernias by asking the patient to turn their head to the side and cough. Then, I'll observe the symmetry and contour of the abdomen, then skin for discoloration, scars, rashes, lesions, dilated veins, or ecchymosis. I'll look at the umbilicus for contour, location, or inflammation. I'll look for any abnormal movements like aortic pulsations or visible peristalsis.

Abdominal Exam PE Step 10

Kidneys: I'll perform ballottement of the kidneys by placing my right hand posteriorly below and parallel to the 12th rib and push anteriorly to displace the left kidney. I'll use my left hand laterally and parallel to the rectus muscle and ask the patient to take a deep breath in and press firmly downward in the LUQ along the MCL and repeat for the right kidney.

Musculoskeletal Examination: Knee PE Findings

Knees symmetrical, no deformities, swelling, or atrophy of quadriceps muscles noted. Non- tender to palpation with no warmth, swelling, bogginess or bony enlargement. Full range of motion with no crepitus. No effusion, meniscal or ligamentous injury noted.

Jaundice PLAN

Liver Enzyme test (ALT/ AST)/ Bilirubin Ultrasound of the RUQ Hepatitis Serology PT/ PTT Serum Amylase and Lipase for pancreatic function

Calf Pain PE

Lower limb - Inspection size, symmetry, and note any swelling color of skin and nail beds distribution of hair on the lower legs, feet and toes leg for varicosities any pigmentation, rashes, scars, or ulcers Assess -Temperature -Palpate the peripheral pulses bilaterally Popliteal Dorsalis pedis Posterior tibia -Assess for pitting edema -Asses for capillary refill Special tests R/o DVT Measure calf circumference Homan's test R/o chronic arterial insufficiency Buerger's test Additional system R/o PE Respiratory rate and pulse rate Auscultate chest for pleural rub R/o DM complications Auscultate the heart sounds Signs of peripheral neuropathy Skin complications

Abdominal Exam PE Step 11

McBurney Point Tenderness: Assess for tenderness in the point that lies 2 inches from the anterior superior iliac spine (ASIS) to the umbilicus Rovsing sign: Press deeply in the LLQ then quickly withdraw your fingers. Rovsing sign is positive when pressure on the patient's left lower quadrant causes pain in the right lower quadrant. Psoas sign: Pain during resisted right hip flexion or passive right hip extension is positive There are two techniques. 1. Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. 2. Ask the patient to turn onto the left side. Then extend the patient's right leg at the hip. Obturator sign: Flex the patient's right thigh at the hip, with the knee bent and rotate the leg internally at the hip. Pain with right hip flexion and internal rotation is positive.

MSK Spine PE Step 4

Modified Schober's test for suspected Ankylosing Spondylitis: a. Standing behind the patient b. Palpate and mark the lumbosacral junction. c. With a measuring tape, measure 10 cm above the junction. d. Ask the patient to bend forward as if touching their toes and measure the distance between the two points again. The difference between the measurements indicates the amount of flexion. e. Positive test is less than 5cm difference indicating a decrease in range of motion possibly due to ankylosing spondylitis.

Female Reproductive Physical Exam Step 3

Next, I'll be performing the internal inspection using a speculum. Using the index and middle fingers of my non-dominant hand, I will depress the posterior fourchette. Then, insert the speculum advancing gently towards the cervix and rotate and adjust the speculum. I'll then open the speculum slowly to inspect the cervix and the cervical os. • The Cervical cytology MUST be the FIRST specimen obtained. Cervical Cytology. Obtain one specimen from the endocervix and another from the ectocervix, or a combination specimen using the cervical brush ("broom"). Pap smear Then loosen the screw on the speculum and withdraw slowly while keeping the blades partially open to visualize the vaginal walls.

HEENT PE (Headache) Step 2

Next, I'll be testing CN 2 and 3 by: • Visual acuity: using the Mini Snellen chart and standing 6 feet away from the patient ill check each eye individually then both. • H-test: checking the extraocular movements by holding one finger vertically at least 50 cm away from the patient and asking them to follow it with their eyes without moving their head. Then I'll move my finger steadily to one side, then up and down, then to the other side and repeat, in a letter H in the air. • Visual fields: By confrontation, ill position myself in front of the patient at eye level, 2 feet away. Ill instruct the patient to cover one eye with their palm and look directly at them. Then, I'll cover my eye on the same side, and test each quadrant by holding my index finger equidistant. I'll start peripherally and move diagonally to the center and repeat on the other eye. Then, I'll be testing CN V by placing my fingers over the temporal area and asking the patient to clench their teeth, noting the strength of contraction and repeat for the masseter muscles

MSK PE: Knee Outline

PE Outline: Inspection Palpitation ROM Bulge sign Patella Ballottement McMurray Test (Medial + Lateral) Valgus Stress Test (MCL + LCL) A/P Drawer Test Note: Arthritis: Need to check Hip & Foot ROM + Assess for joint effusion. ACL injury: Don't need Hip & Foot ROM but need ALL special tests.

MSK Hip PE Step 2

Palpation • Palpate the bony landmarks, muscles, tendons, and ligaments of the hip for swelling, tenderness, or bony enlargement.

Musculoskeletal Examination: Knee Step 2

Palpation: With the patient in supine, ill palpate the anterior and posterior joint line, patella, and supra-patellar pouch on each side of the quadriceps. Noting any tenderness, warmth, swelling, bogginess, or bony enlargement.

Abdominal Exam PE Step 3

Percussion: With the middle finger of my non-dominant hand hyperextended ill press only my distal interphalangeal joint on the skin and avoid any other parts of my hand touching the surface. Then ill percuss with the tip of my middle finger of my dominant hand by striking my non-dominant middle DIP briskly with relaxed wrist motion and withdraw immediately to avoid dampening vibrations and noting distribution of tympany and dullness and noting any tenderness. I'll repeat this step as well as the following light and deep palpation steps in all 9 regions of the abdomen starting with the R iliac, R lumbar, R hypochondriac, epigastric, umbilical, hypogastric, L hypochondriac, L lumbar, L iliac region.

Respiratory Exam Step 2

Posterior thorax: • Inspection: Stand behind pt. In midline then at side: observe contour and chest movements; and symmetry of chest expansion • Palpation: o Chest wall tenderness and expansion: palpate the posterior chest for tenderness. then check expansion by placing hands on costal margins at level of 10th ribs with thumbs pointed upwards and parallel to each other while grasping small fold of skin between them ➔ then ask the patient to inhale deeply and watch the distance between my thumbs as they move apart during inspiration for symmetry. o For the following tactile fremitus, percussion, and palpation of the posterior chest wall I'll be starting at T2 medial to the scapular border and moving in a ladder-like pattern through the 7 pairs of points (comparing opposite sides) and ending at T10. With the patient seated upright and their arms crossed at the front. o For tactile fremitus: using only the ulnar surface of my dominant hand horizontally in the ICS, I'll ask the patient to say 99 when they feel my hand placement moving through the landmarks stated before. • Percussion: with the middle finger of my non-dominant hand hyperextended I'll press my DIP joint horizontally in the ICS on the skin surface and avoid other areas of my hand from touching the skin. I'll use the tip of my middle finger of my dominant hand to strike briskly with a relaxed wrist motion and withdraw immediately to avoid dampening vibrations. I'll percuss with in the same landmarks. • Auscultation: I'll ask the patient to breathe in and out deeply with their mouth open. With the diaphragm of my stethoscope, ill auscultate the same areas of the testing landmarks. Listening for pitch, intensity, and duration of expiratory and inspiratory sound, and identify breath sounds and any adventitious sounds.

Musculoskeletal Examination: Knee Step 3

ROM: With the patient siting, leg extended, I'll ask the patent to bend their knee, assessing flexion. Then with their leg flexed, I'll ask the patient to straighten your leg, to assess extension. Checking active first bilaterally, then, if limitations, passively. Next, ill assess the range of motion for the Right hip, checking active first, then if limitations, passive movements for flexion, extension, abduction, adduction, internal rotation and external rotation. Lastly, ill assess the range of motion for the right ankle, checking active first, then if limitations, passive movements for dorsiflexion and plantar flexion.

MSK Spine PE Step 2

Range of Motion (ROM) Cervical The neck is the most mobile portion of the spine, remarkable for its seven vertebrae supporting the 10- to 15-lb head. Flexion and extension occur primarily between the skull and C1, the atlas. Rotation primarily occurs at C1-C2, the axis. Finally, lateral bending primarily occurs at C2-C7. a. Flexion: Instruct the patient to bend their chin down towards the chest b. Extension: Instruct the patient to look up to the ceiling c. Rotation: Instruct the patient to look over each shoulder d. Lateral bending: Instruct the patient to bring each ear to the shoulder; do not move the shoulder.

MSK Knee Plan

Septic Arthritis CBC Right and Left Knee Radiographs or CT/MRI of Right Knee Arthrocentesis (Joint Fluid Analysis) Osteoarthritis CBC Right and Left Knee Radiographs or CT/MRI of Right Knee Rheumatoid factor (Rf) Anti-CCP Antibodies ACL Injury CT/MRI of Left Knee Radiographs of Left and Right knee

MSK Knee Additional systems

Septic Arthritis Comments on Pulse - rate, rhythm, amplitude and symmetry Osteoarthritis Comments on 2 of the following : inspections of ey-es, inspection of svstem hands auscultation of heart and lunas. ACL Injury Comments on range of motions of left hip and ankle.

MSK Hip PE Step 4

Special Tests Assessment for Hip contractures (Thomas Test) o With the patient supine, place your hand under the patient's lumbar spine. o Ask the patient to bend each knee in turn up to the chest and hold it firmly against the abdomen while the other leg lays flat on the table. o A positive test is when the opposite knee rises off the table indicating a flexion contracture of the hip on that side.

Musculoskeletal Examination: Knee Step 4

Special tests: - Assess for joint effusion o Bulge sign for minor effusion: I'll apply anterior compression to the lower third of the patient's thigh with my left hand, thumb on one side and fingers on other side of thigh. I'll maintain pressure, sliding my hand down to the upper border of the patella, emptying the suprapatellar pouch. While, maintaining pressure ill stroke the medial side of the knee, emptying the medial compartment and do the same with the lateral side. Assess for fluid and bulge medially. o Patella Ballottement for Major Effusion: I'll compress the suprapatellar pouch and with my index and middle finger of right hand, push the patella gently backward, and assess for fluid and patella ballotability.

Respiratory Exam Step 4

Special tests: • COPD: Diaphragmatic excursion: On the posterior chest wall, I'll ask the patient to take a deep breath in fully and hold as I percuss on one side of the posterior thorax from below the scapula in the scapular line until the level of dullness and mark that point. Then ask the patient to breathe out fully and hold and ill repeat my percussion from the same landmark to the level of dullness and mark the point. Then ill measure the distance between the 2 points and repeat on the other side. • Acute Chest Syndrome: ill perform the following 3 exams for consolidation with the diaphragm of my stethoscope in the suspected area of consolidation to auscultate and compare symmetrically o Bronchophony: Ask the patient to say 99 o Egophony: ask the patient to say eee o Whispered Pectoriloquy: Ask patient to whisper 123

Abdominal Exam PE Step 8

Spleen: I'll percuss the spleen at the anterior axillary line at the lowest interspace and note the sound. Then I'll ask the patient to take a deep breath while continuing to percuss and note any changes in sound.

Step 0 Step 1

Step 0 Sanitize hands STEP 1 Set the stage 1. Welcome the patient 2. Gather patient's name and age ✓ The interviewer introduces himself, clarifies his roles, and inquires how to address patient. Uses patient name. 3. Introduce self and identify specific role (student nurse/student doctor/resident/fellow) 4. Remove barriers to communication 5. Ensure comfort and put the patient at ease ✓ The interviewer puts the patient at ease and facilitates communication by using good eye contact, relaxed, open body language, appropriate facial expression, eliminating physical barriers, and making appropriate physical contact with the patient.

MSK Spine PE Step 6

Straight Leg Raise for suspected Sciatic Nerve Irritation: a. With the patient lying supine, raise their relaxed leg while the knee is extended. b. Continue lifting until the patient experiences pain and record the degree of elevation (usually between 30- 70°). c. Dorsiflex the foot and note the change to the pain. d. A positive straight leg raise test will produce radiating pain into the affected side. Pain radiating into the leg is indicative of nerve compression due to disc herniation. e. If positive test, slowly lower leg just until the pain stops, then dorsiflex the ankle. Return of pain is a positive Lasegue's sign

Abdominal Exam PE Step 4

Then ask the patient if there is any abdominal pain. If so ill palpate that area last. Paying attention to any involuntary guarding or facial grimacing. Light palpation: by using one hand horizontally placed with my fingers together and slide the hand to the next region in all 9 regions. Deep palpation: by placing my dominant hand on the abdomen and my nondominant hand on top then pressing deeply 1.5inches and slide to the next region again assessing any painful areas last in all 9 regions. I'll note any palpable masses by location, size, shape, and consistency.

Abdominal Exam PE Step 9

Then ill palpate for the spleen by reaching over and placing my left hand behind the patient's 9- 11 ribs and push anteriorly. I'll ask the patient to take a deep breath in and out and using my right hand ill palpate in the RLQ moving obliquely towards the spleen. If it's not palpable, I'll ask the patient to turn into the right decubitus position and repeat.

Female Reproductive Physical Exam Step 4

Then, I'll be moving on to the Bimanual examination, by first inserting my gloved and lubricated index and middle fingers of my dominant hand into the vagina, palm up. I'll palpate and move the cervix, palpate the vaginal fornixes, and palpate the uterus by placing the non- dominant hand on the abdomen, halfway between the umbilicus and the pubic symphysis and press down. I'll simultaneously place the fingers of the vaginal examining hand posterior to the cervix, pushing the uterus anterior. I'll continue moving the abdominal hand until the fundus of the uterus is located. Next, ill palpate the right and left adnexa by moving the vaginal examining fingers into the right fornix and press anteriorly, and simultaneously with the abdominal hand press down at the level of the inguinal ligament; then ill slide the abdominal hand trying to palpate the ovary between my hands and repeat for the left fornix.

Cardio PE Step 2

Then, I'll move to the Carotid pulse: ill inspect the carotid pulses bilaterally. Then by asking the patient to stop breathing for about 15 seconds I'll use the diaphragm of my stethoscope to auscultate both carotid arteries. Then ill examine one artery at a time, using my first 2 fingers to palpate between the larynx and the anterior border of the SCM at the level of the cricoid cartilage. Assessment Characteristics of the Carotid Pulse • The contour of the pulse wave, namely the speed of the upstroke, the duration of its summit, and the speed of the downstroke. The normal upstroke is brisk; it is smooth, rapid, and follows S1 almost immediately. The summit is smooth, rounded, and roughly midsystolic. The downstroke is less abrupt than the upstroke. • The timing of the carotid upstroke in relation to S1 and S2. Note that the normal carotid upstroke follows S1 and precedes S2. This relationship is very helpful in correctly identifying S1 and S2, especially when the heart rate is increased and the duration of diastole, normally longer than systole, is shortened and approaches the duration of systole.

Cardio PE Step 7

Then, I'll screen for mitral stenosis by placing the bell of my stethoscope at the mitral area and auscultating while asking the patient to turn in the lateral decubitus position. Then for aortic regurgitation ill use the diaphragm of my stethoscope to auscultate at the L sternal border and ask the patient to sit up and lean forward, exhale completely and hold.

Step 4

Use focusing skills to fill in the blanks in the History, and employ NURS 10. Elicit symptom story • Description of symptoms, using focusing open-ended skills to fill in the blanks o Onset/Chronology, Position/Radiation, Quality, Quantity, Related symptoms, Setting, Transforming factors ▪ a chronology of the chief complaint and HPI can be established ▪ the chronology of all associated symptoms is also established ▪ the interviewer does not repeat questions, seeking duplication of information that has previously been provided 13. Elicit symptom story: Description of symptoms, using focusing open-ended skills 14. Elicit personal context: Broader personal/psychosocial context of symptoms, patient beliefs/attributions, again using focusing open-ended skills term-15 15. Elicit emotional context a. Use emotion-seeking skills i. Direct ii. Indirect (Impact, Belief, Triggers & Self-disclosure) 16. Respond to Feelings/Emotions: Use empathy skills to address the feelings and emotions (naming, understanding, respecting, and supporting [NURS]) 17. Expand the story: Continue eliciting further personal and emotional context; address feelings and emotions (NURS)

Female Reproductive Plan

Vomiting (Hyperemesis Gravidarum) Blood/Serum Beta-hCG levels Transvaginal/Transabdominal Ultrasound Complete Metabolic Panel Painful Sexual Intercourse (Endometriosis} Laparoscopy/Endometrial biopsy Pelvic Ultrasound or Transvaginal Ultrasound or CT/MRI Endocervical swab or PCR Chlamydia and Gonorrhea Painful Sexual Intercourse (Vulvovaginitis) Vaginal pH Endocervical or High-Vaginal Swab Wet-Mount Test KOH 'Whiff test' Painful Sexual Intercourse {Atrophic Vaginitis) Serum Estrogen Levels Vaginal pH Endocervical or High-Vaginal Swab Wet-Mount Test Painful Sexual Intercourse {Pelvic Inflammatory Disease) Endocervical swab or PCR for Chlamydia and Gonorrhea Urinalysis CBC

Female Reproductive Physical Exam Additional systems

Vomiting (Hyperemesis Gravidarum) Comments on light and deep palpation of abdomen and a sign of volume depletion or dehydration - capillary refill, tongue mucosa, radial pulse or blood pressure Painful Sexual Intercourse (Endometriosis} Comments on light and deep palpation of abdomen any other relevant additional based on differentials. Painful Sexual Intercourse (Vulvovaginitis) Comments on light and deep palpation of the abdomen Painful Sexual Intercourse {Atrophic Vaginitis) Comments on light and deep palpation of the abdomen Painful Sexual Intercourse {Pelvic Inflammatory Disease) Comments on light and deep palpation of abdomen and CVA tenderness

Abdominal Exam PE Step 5

liver span: I'll percuss from the RLQ in the mid-clavicular line up towards the liver and mark the point of dullness. Then from the nipple line or below the breast ill percuss in the midclavicular line downwards and mark the point of dullness. Then ill measure the distance between the 2 points.

Musculoskeletal Examination: Knee Step 7

o Anterior/posterior Drawer (ACL/PCL) ■ With the patient supine, hips and knees flexed, feet flat on the table, I will stabilize patients' feet. I then will cup my hands around the knee joint, fingers behind, and thumbs anteriorly over medial and lateral joint lines. I will then pull the tibia towards me to assess the ACL and then push away from me to assess PCL. I will compare the degree of movement for each knee.