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ICM Ultra High Yield

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CARDIOVASCULAR EXAM
1. General Exam General inspection -age, sex, appearance, any signs of distress Head - temperature - sclera for jaundice -yellowish discoloration of the skin and sclera with bilirubin levels greater than 2.5 mg/dL -conjunctiva for anemia -blood loss -iron deficiency -folate/B12 -hemolysis -infection -sickle cell -thalassemia -DIC - tongue for glossitis -B12, folate, niacin, B6 or riboflavin (B2) deficiency - underneath tongue for central cyanosis -having central cyanosis implies peripheral cyanosis, but peripheral cyanosis can exist without central cyanosis - bluish discoloration of the skin with reduced Hb in blood greater than 5 gm/100 ml a. CO anemia b. Right to Left shunts c. vasoconstriction d. polycythemia e. pulmonary problems Palms -temperature -moisture -pallor -jaundice -xanthomas -lesions Nails - clubbing nail to nail bed angle is > than 180 a. Right to Left shunts b. infective endocarditis c. bronchogenic carcinoma d. Crohns disease and Ulcerative Collitis e. liver disease -capillary refill (normal 1-2sec) problems with peripheral vasculature a. Diabetes Mellitis b. vasculitis -splinter hemorrhages (subacute bacterial endocarditis) General Exam (cont.)

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Legs Pitting edema (look at patient for signs of pain) a. CHF b. liver disease c. Nephrotic syndrome d. IVC obstruction 2. Arterial Radial pulse: Time for 60 seconds or 15 seconds and x 4 (<60 brady; >100 tachy) Report Rate - beats per minute Rhythm - regular, regularly irregular (heart block), irregularly irregular (atrial fibrillation) Volume - low, normal, increased, increased collapsing ( Water- hammer) Water- hammer pulse a. fever b. anemia c. hyperthyroidism d. aortic regurge e. AV fistula Character - normal Bisferens- Aortic Regurge, Aortic Regurge & Aortic Stenosis Pulsus Alterans - Left ventricular failure Bigeminal - Premature ventricular contraction Plateau - Aortic Stenosis Parodoxical - cardiac temponade, constrictive pericarditis, obstructive lung disease Vessel Tone - non-palpable, palpable (atherosclerosis) Peripheral Pulses Report - presence, symmetry, character Radial Brachial Carotid Femoral Popliteal Dorsalis Pedis Posterior tibial Allens Test - check for patency of ulnar and radial arteries Radial - Femoral Delay Report - not present or present indicating coarctation of the aorta Blood Pressure - check for lymphedema, scars (brachial cutdown), AV fistula Measure cuff size( loose cuff & a short cuff give a high reading) Confirm the brachial pulse Position arm; antecubital crease at heart level Determine target level for inflation (pulse occlusion plus 30) Take blood pressure twice and repeat in left arm Hypertension- BP > than 140/90 a. essential hypertension b. Renin/Angiotensin problem

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A. Shah Coarctation of Aorta Pheochromocytoma Cushings Conns Syndrome

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Venous System Check for varicose veins and caput medusa of abdomen Jugular Venous Pressure Determination of Right Atrial pressure -Position patient a. patients head and torso elevated - 30 b. turn pts. head slightly away from you -Locate internal jugular or external jugular vein use tangential lighting and valsalva maneuver if necessary -Confirm vessel is the jugular and not the carotid a. int. jugular is not palpable b. vein has 2 beats c. veins pulsations are eliminated by pressure -Measure highest point of pulsation from the sternal angle a. sternal angle is 5 cm above right atrium b. normal jugular measurement is <4cm from sternal angle c. if > than 4cm than right atrial pressure is increased -Execute Hepato-jugular Reflux Kussmaul sign- upon inspiration the JVP rises as opposed to decreasing in a normal individual

4.

Precordium Inspection from the foot of the bed Report a. signs of distress b. symmetry c. scars d. visibility of apex beat Palpation -check for dextrocardia -check for thrills (palpable murmurs) over all 4 valve areas -localize apex beat and describe it (know difference between this and the PMI) -use left lateral decubitus position if having problems finding the apical beat a. location b. amplitude (normal, hyperkinetic, hypokinetic) c. diameter d. duration (auscultate- normal, sustained) -parasternal heave (right ventricular hypertrophy) Auscultation Listen for heart sounds, murmurs and rubs (pericarditis) a. listen to all 4 heart areas with both diaphragm and bell

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listen for Mitral valve stenosis and regurge with the pt in the left lateral decubitus position and using the bell listen for Aortic regurge with the pt. sitting up, leaning forward and holding their breath after completely exhaling - use the diaphragm

Reporting of murmurs location timing (systolic, diastolic / crescendo, decrescendo) intensity (1 - 6) radiation character (harsh, blowing) pitch (low, high) Austin Flint murmur : murmur of Mitral Regurge due to a chronic Aortic Regurge Graham- Steele murmur : murmur caused by pulmonary hypertension Diastolic murmurs: Mitral Stenosis, Aortic Regurge, Tricuspid Stenosis, Pulmonary Regurge Systolic murmurs: Mitral Regurge, Aortic Stenosis, Tricuspid Regurge, Pulmonary Stenosis Hypokinetic Apical Beat : Dilated Cardiomyopathy Hyperkinetic Apical Beat : Anemia, Hyperthyroidism, Aortic Stenosis, Mitral Regurge, Anxiety Causes of Murmurs Congenital Ruptured papillary muscle Dilated ring valve Rheumatic Heart Disease

Head & Neck Exam

A. Head inspection /palpation - examine the pts hair (quality, distribution, texture, loss of) (fine hair- hyperthyroidism ; coarse hair- hypothyroidism) -examine the skull for deformities (lumps or lesions) -look for facial asymmetry, involuntary movements, edema or masses -look at the skin (coloration, texture, thickness, hair distribution, lesions) B. Eyes inspection(1) test visual acuity using a Snellen Eye Chart (use any available print if eye chart is not available) presbyopia- impaired near vision found in middle & old age (2) screen visual fields by confrontation (repeat pattern in upper, middle & lower temporal quadrants) -have pt look into your eyes

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-place your hands about 2 ft apart and lateral to pts ears -slowly wiggle fingers as you bring them into pts visual field -tell pt to point to your fingers when they appear *** if defect exists then examine one eye at a time (Bates p170) (3) assess eye position & alignment (eyes protrude in Graves disease & ocular tumors) (4) eyebrows (lateral borders thin in Hypothyroidism) (5) eyelids -width of palpebral fissure -periorbital edema (nephrotic syn., myxedema) -color of lids (inflammation) -lesions (chalazion, sty, xanthelasma) -direction eyelashes point (entropion or ectropion) -eyelid closure (6) lacrimal apparatus (examine for inflammation, dryness, obstructed duct) (7) conjunctiva & sclera (jaundice, episcleritis, corneal arcus, pterygium) (8) cornea & lens (use oblique lighting to inspect for opacities in lens such as cataracts) (9) iris -shine light from temporal side for crescentic shadowing (narrow angle glaucoma; open angle glaucoma has no shadowing ) (10) pupils (size, shape, symmetry) anisocoria- pupillary inequality of less than 0.5mm (benign) miosis- constriction of the pupils mydriasis- dilation of the pupils test pupillary light reaction (darken room) -ask pt to look into the distance -shine light obliquely in each pupil checking direct & consensual rxns direct reaction- pupillary constriction of the same eye consensual reaction- pupillary constriction in the opposite eye test pupillary near reaction (normal room light) -hold pen about 10cm from pts eye -ask pt to look at it and into the distance directly behind it -look for pupillary constriction with near effort (11) extraocular muscles -complete an H test (look for nystagmus) -check the corneal reflection (pt looks into your light) (normal is slightly nasal to pupil center) -test for lid lag & convergence (lid lag and poor convergence if Hyperthyroid) Ophthalmoscopic Exam (darken room and crack open exam room door) (1) use right hand & right eye to examine pts right eye & left hand & left eye to examine pts left eye (keep a finger on the focus dial at all times) (2) start by examining the pts right eye & then repeat all steps for the left (3) have the patient focus on a point in the distance and find the red reflex by standing about 15 inches away from the pt and about 15 lateral to his/her line of vision (red reflex is absent in cataracts, Retinoblastomas & detached retinas) (4) move close enough to the pt until your ophthalmoscope is almost touching the pts eyelashes (5) support yourself by placing the thumb of your free hand on the pts eyebrow (6) locate the optic disc and bring it into focus (7) follow the vessels outward in the 5 positions shown in Bates p178 (8) describe the disc & retina -clarity of disc -color (normal is yellowish orange to creamy pink) -size of central physiologic cup (normally white & < diameter of disc) -character & size of arteries & veins (check A-V crossings) (7) inspect the fovea & macula

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Hypertensive findings in the retina (1) silver wiring- narrowed artery becomes completely opaque (2) copper wiring- artery becomes tortuous & light reflex giving a copper appearance A-V crossings tapering- vein appears to taper down on either side of the artery nicking- vein appears to stop abruptly on either side of the artery banking- vein twists on the distal side of the artery and forms a dark, wide end (3) Superficial hemorrhages- small, linear, flame-shaped red streaks in the fundus (seen in severe hypertension, papilledema & occlusion of the retinal vein) (4) Cotton Wool Patches- white or grayish, ovoid lesions with irregular borders that MC result from infarcted nerve fibers (5) Hard Exudates- small, round yellow lesions with well defined borders that are often in clusters or circular, linear patterns (also seen in Diabetic Retinopathy) Diabetic Retinopathy (1) Deep Retinal Hemorrhages- small, rounded irregular red spots that occur deep in the retina (2) Microaneurysms- tiny, round, red spots seen MC around the macular region. Consist of minute dilatations of very small retinal bl. vessels (3) Neovascularization- formation of new blood vessels that are more numerous, tortuous & narrower than the other vessels. MC seen in late stage Diabetes (4) Proliferative Diabetic Retinopathy- bands of white fibrous tissue that develops in late stages of Diabetic Retinopathy C. Ear inspection- examine the auricle & surrounding tissues for deformities or lesions palpate- press on the tragus and gently pull on the auricle to check for otitis externa -press on the mastoid process to check for possible otitis interna Otoscope exam (pull pts auricle upward, backward & slightly away from the head gently) (1) insert the ear speculum gently into the ear canal & inspect the canal (discharge, foreign bodies, inflammation, cerumen) (2) inspect the ear drum (color, contour) -identify the cone of light (usually anterior-inferior to handle of the malleus) -identify the malleus, incus & stapes -describe the tympanic membrane (normal is pale gray in color) Auditory Acuity (1) while occluding one of the pts ears, rub fingers together next to the unoccluded ear (2) repeat for other ear *** if hearing is diminished, try to distinguish between conductive & sensorineural hearing loss -use a tuning fork with 512 Hz or 1024 Hz Weber Test (lateralization) (1) tap the tuning fork against a hard surface so that it begins to vibrate and then place the fork firmly on top of the pts head (2) ask the pt if the sound is heard in one or both ears (in unilateral sensorineural hearing loss, sound is heard in the good ear whereas in conductive hearing loss, sound is heard in the impaired ear) (3) repeat test if no sound is heard (normally sound is heard equally in both ears) Rhine Test (air & bone conduction) (1) place the vibrating tuning fork on the mastoid bone behind the ear & level with the ear canal (2) when the sound can no longer be heard by the pt, place the fork close to the ear canal & ask the pt if the sound is still audible (3) the U of the fork should be facing forward to maximize the vibration (4) in conductive hearing loss, sound is heard through bone as long or longer than it is through air whereas in sensorineural hearing loss, sound is heard longer through air

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Causes of Conductive hearing loss- obstruction of the ear canal (foreign body, cerumen), otitis media, perforation, otosclerosis Causes of Sensorineural hearing loss- sustained exposure to loud noise, drugs (ototoxicity), inner ear infections, trauma, tumors, congenital disorders, aging (presbycusis) D. Nose & Paranasal Sinuses inspection- examine the anterior & inferior surfaces of the pts nose (1) gently press on the tip of the nose with your thumb to widen the pts nostrils (2) with the aid of a pen light note any deformities or asymmetries (test for nasal obstruction if indicated by occluding one nare at a time and asking the pt to breathe through the nostril that is patent -examine the inside of the nose with an Otoscope using the largest speculum available (1) locate the middle and inferior conchae and the narrow nasal passage between them a. note the color of the nasal mucosa and any abnormalities (swelling, bleeding exudate) b. note any deviation of the nasal septum (inflammation, perforation) c. note any remaining abnormalities (polyps, ulcers) -palpate the frontal and maxillary sinuses by applying pressure with your thumbs over each sinus region and noting any tenderness (possible acute sinusitis) E. Mouth & Pharynx Lips- color (cyanosis), lesions, ulcers (herpes), cracking (angular cheilitis) or scaliness Oral Mucosa- examine the pts mouth with your pen light & a tongue depressor (1) look for ulcers, white patches (leukoplakia), chancres Gums & Teeth(1) examine the gums (color, signs of gingivitis, Pb poisoning (lead lines)) (2) inspect the teeth (any missing, color) Tongue & Floor of mouth(1) check the tongue for glossitis, carcinoma of the tongue, XII nerve lesion (deviated tongue on protrusion) (2) check the floor of the mouth for lesions & abnormalities (Carcinoma) Pharynx- inspect the soft palate, anterior & posterior pillars, uvula, tonsils & pharynx (1) note the color, symmetry, inflammation, ulcers, lesions & any other abnormalities F. Neck inspection- examine the pts neck for symmetry, any masses, scars or lesions (1) examine the salivary glands for enlargement (Parotid & Submandibular) (2) inspect the pts lymph nodes and palpate each one using the pads of your index and middle fingers (3) pt should be relaxed with his/her neck flexed slightly forward -Preauricular -Posterior Auricular -Occipital -Tonsillar -Submandibular -Submental -Superficial Cervical -Posterior Cervical -Deep Cervical Chain -Supraclavicular (4) note the shape, size, delimitation, mobility, consistency, and any tenderness if they are palpable (tender nodes suggest inflammation; hard nodes suggest malignancy) G. Thyroid Gland inspection-

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(1) with the pts neck slightly extended, use tangential lighting directed downward from the tip of the pts chin (2) inspect the region below the cricoid cartilage for the gland (3) have the pt swallow (water is helpful) (4) watch the movement of the gland, noting the contour & symmetry (5) thyroid cartilage, cricoid cartilage, and thyroid gland all should elevate upon swallowing & then fall to their resting positions palpation(1) position yourself behind the pt (2) place your fingers (use both hands) on the pts neck just below the cricoid cartilage (3) have the pt swallow again and feel for the gland rising under your fingers (4) note the size, shape & consistency (nodules or tenderness) (5) if the gland is enlarged listen for a bruit with the bell of your stethoscope Goiter- compensatory hyperplasia of follicular epithelium 2 to impaired production of thyroid hormones that leads to elevated TSH levels; goiters are seen in Hashimotos Thyroiditis, Graves Disease and Iodine deficiency. Hashimotos Thyroiditis- goitrous hypothyroidism due to defective function of thyroid specific CD-8 T cells, resulting in the emergence of CD-4 T cells directed at thyroid and auto-Abs to various components of thyroid such as thyroid peroxidase, TSH receptors and thyroglobulin. Graves Disease- goitrous hyperthyroidism due to a defect in thyroid specific CD-8 T cells which lead to the production of TSH Ab (thyroid stimulating immunoglobulins) and thyrotropin binding inhibitor immunoglobulins that cause increase activity of thyroid epithelial cells

ABDOMINAL EXAM
1. Inspection (from the foot of the bed) (C -U -P -S -S -S) Contour (flat, round, protuberant, scaphoid) Umbilicus (Inverted, Everted) Pulsations / Peristaltic waves Symmetry Significant scars and striae (purple striae = Cushings Syndrome) Superficial veins (Caput Medusa) also look for Masses, Bulges and Lesions Increased Abdominal Pulsations - Abdominal Aortic aneurysm , increased pulse pressure Cullens Sign -Periumbilical darkening of skin from blood, a sign of intraperitoneal hemorrhaging ( ruptured ectopic pregnancy ) Turners Sign -Darkening of skin from blood in the flanks, a sign of retroperitoneal hemorrhaging 2. Auscultation (Done before palpation/ percussion because they may alter bowel sounds) Listen for bowel sounds - wait at least 2 min. before saying absent -listen in all four quadrants or just in the lower right quadrant Report : Present or Absent

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Increased Bowel Sounds - Diarrhea , early intestinal obstruction Decreased Bowel Sounds - Adynamic ileus, Peritonitis, late intestinal obstruction Borborygmi - loud, prolonged gurgle of hyperperistalsis Listen for arterial bruits - (turbulent blood flowing through a vessel), use bell - Abdominal Aorta - Renal Arteries ( Renal Artery Stenosis is a common cause of hypertension) - Iliac Arteries - Femoral Arteries Listen for friction rubs - Inflammation of Liver capsule Listen for a Venous Hum - soft humming noise heard during both systolic and diastolic, indicating increased collateral circulation between portal system and systemic ( Liver Cirrhosis is MCC) 3. Percussion - Percuss all 4 or 9 quadrants ( report either tympanic or dull sounds) - Check Abdomen for Ascites a. Shifting Dullness b. Fluid Wave Transmission c. Puddle Sign (+) - Percuss organs with palpation of each organ Ascites - Accumulation of serous fluid in the peritoneal cavity 1. Alcoholic Cirrhosis 2. Congestive Heart Failure 3. Hepatic Vein obstruction (Budd- Chiari Syn.) 4. Nephrotic Syndrome 4. Palpation Light Palpation (ask pt for any pain present before touching them) - You must sit during Light Palpation - LOOK AT THE PATIENTS FACE - Palpate all 4 or 9 quadrants report presence of masses, guarding or tenderness You must STAND during deep palpation LOOK AT THE PATIENTS FACE Palpate all 4 quadrants and report presence of organs, masses or tenderness Test for Rebound Tenderness and a (+) Rovsings Sign

Deep Palpation

Appendicitis Signs 1. Pain on Cough in lower right quadrant 2. Cutaneous Hyperesthesia 3. Rebound Tenderness 4. Rovsings Sign 5. Psoas Test 6. Obturator Test Organ Palpation Liver - sit down and LOOK at the pts face - Start with percussing for the Liver Span

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percuss up from the lower right quadrant in the mid-clavicular line until dullness heard b. percuss down the mid-clavicular line starting at the 2-3 intercostal space until dullness is heard, indicating the upper border of the liver c. measure span of dullness d. 6 - 12 cm is normal in the mid-clavicular line e. measured from the mid- sternal line 4 - 8 cm is normal - dullness displaced inferiorly can be caused by COPD - false increase in Liver span dullness may be due to a Pleural Effussion or Consolidation - false decrease in Liver span may be due to gas in the Abdomen from a ruptured bowel - Palpate for the Liver starting at the right Anterior Superior Iliac Spine a. have pt take a deep breath while palpating costal margin b. feel for the Livers edge as it shifts position c. can also use the hooking technique (Normal Liver is Smooth, Large and Non -Tender) Large, Irregular Liver - Cirrhosis, Malignancy Large, Smooth and Tender - Hepatitis, Venous Congestion (CHF, Budd- Chiari) Causes of Hepatomegaly 1. CHF 2. Hepatitis 3. Early Cirrhosis 4. Hepatocellular CA - Attempt to elicit Murphys sign for acute cholecystitis a. hook fingers or thumb of right hand under costal margin at border of Lateral Rectus and costal margin (9th intercostal space) b. have pt take a deep breath c. if sudden stop of inspiration and pain occurs then (+) Murphy sign Spleen - Sit and LOOK at the patient - first check for a Splenic Percussion Sign (Splenomegaly) a. percuss along Traubes Space ( area of tympany below lung resonance along costal margin ) b. percuss lowest interspace in Left Anterior Axillary Line - should be tympanic c. ask pt to take a deep breath and hold ; percuss again and if dullness is heard then Splenomegaly is present ( + Splenic Percussion Sign) -palpation -start at the ASIS and progress to Left Costal Margin a. ask pt to take deep breaths as you approach the Left Costal Margin b. feel for the Spleens edge as it shifts position c. roll pt onto their right side and repeat palpation Enlarged Spleen vs. Kidney Spleen - a. medial border notch Kidney - a. tympanic upon percussion b. extends beyond midline b. fingers can get between Kidney c. dullness upon percussion and costal margin d. fingers cannot get between Spleen and costal margin Causes of Splenomegaly 1. CHF 2. Portal Hypertension 3. Early Sickle Cell Anemia 4. Leukemia (Hairy Cell Leukemia, CML)

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Kidney - Stand and LOOK at the patient - attempt to trap the kidney between your hands at the peak of the pts inspiration report a. Enlargement ( hydronephrosis, pyelonephrosis, Renal Cell CA, Polycystic Kidney Disease) b. Masses or Lumps ( CA, Cysts) c. Costovertebral Angle tenderness ( Musculoskeletal Problem, pyelonephrosis, kidney infarcts) Right kidney is more likely too be palpable due to its lower location whereas the Left kidney is rarely palpable Causes of a Small Kidney 1. Congenital Hypoplasia 2. Chronic Pyelonephritis 3. Benign & Malignant Hypertension - Assess Kidney Tenderness (Murphys Punch) a. pt is sitting b. place your palm over the pts kidney ( Costovertebral Margin between 11th &12th intercostal space on Posterior Chest) c. strike the back of your hand firmly with a closed fist d. report any tenderness 5. Rectal & Genital These exams will not be performed with your Abdominal exam but you should let your Preceptor know that you are aware that they should be included in a complete Abdominal exam.

PELVIC, RECTAL & BREAST EXAM

1. Pelvic Exam External Examination - inspect the mons pubis, labia, and perineum Lesions of the Vulva 1. Genital Herpes (MCC by HSV2) 2. Syphilitic Chancre (1syphilis) 3. Condyloma Latum (2syphilis) 4. Condyloma Acuminatum (MCC by HPV type 6&11) 5. Extramammary Pagets Disease 6. Vulvar Dystrophy (Lichen Sclerosus & Squamous Hyperplasia) - separate the labia and inspect a. labia minora b. clitoris (enlarged in masculinizing conditions) c. urethral meatus (urethral caruncle = benign lesion) d. vaginal opening - inspect Bartholins gland ( Bartholins cyst)

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a. insert index finger into vagina near the posterior end of the introitus and place your thumb outside the posterior part of the labium majus. b. palpate between your thumb & finger for swelling or tenderness c. note any discharge from opening of duct (culture it if present) - inspect Paraurethral glands (Skenes gland) a. if you suspect urethritis or inflammation, insert index finger into the vagina and milk the urethra gently from inside outward b. note any discharge from opening of duct (culture it if present) MCC of Urethritis - Neisseria gonorrhea & Chlamydia trachomatis Internal Examination - locate the position of the cervix manually with your 2nd and 3rd finger (if lubrication is needed, use water only) - assess the support of the vaginal walls a. separate the labia with your middle and index fingers b. ask the pt to strain down ( note any bulging of the vaginal walls) Cystocele- bladder bulges into vaginal canal due to weak vaginal musculature Rectocele- rectum bulges into vaginal canal due to weak vaginal musculature Cystourethrocele- both bladder & urethra bulge into vaginal wall Speculum Examination would be done at this time Bimanual Examination (done from a standing position) - lubricate the index finger and middle finger of one gloved hand - insert fingers into vagina (keep thumb abducted & 4th ,5th digits flexed into palm) - palpate cervix ( position, shape, consistency, mobility & tenderness) - an immobile and tender cervix may be signs of Pelvic Inflammatory Disease Lesions of the Cervix 1. Carcinoma of the cervix (MC Squamous Cell CA) 2. Cervical Polyp (benign but may bleed) 3. Cervicitis ( MCC by N. gonorrhea, C. trachomatis ) - palpate all 4 fornices around the cervix

- palpate the uterus a. place your other hand on the pts abdomen about midway between the umbilicus and the symphysis pubis b. while you push on the cervix with your pelvic hand, press your abdominal hand in and down, trying to feel the uterus between your two hands c. note shape, consistency, mobility, masses (fibroids) & tenderness d. place pelvic hand into ant. fornix and palpate the body of the uterus between your hands (pelvic hand will feel the ant. uterine surface while the abdominal hand will feel the post. uterine surface) - if the uterus is non-palpable it may be retrodisplaced (retroverted & retroflexed) ; if this is the case then place pelvic hand into the post. fornix and feel for the uterus pushing against your fingertips - palpate the ovaries (normal ovaries are somewhat tender) a. place the abdominal hand over the LRQ and the pelvic hand in the right lateral fornix b. press the abdominal hand in & down trying to push the adnexal structures toward your pelvic hand c. identify the right ovary or any adnexal masses (size, shape, consistency, mobility & tenderness)

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- assess strength of the pelvic muscles a. withdraw your two fingers slightly, just clear of the cervix and spread them to touch the sides of the vaginal wall b. ask pt to squeeze her muscles around your fingers as hard and as long as she can ( full strength lasts >3 seconds and compresses fingers snugly ) Pelvic Inflammatory Disease (PID)- MCC by N. gonorrhea & C. trachomatis; salpingitis or salpingo-oophoritis that causes extreme tenderness and pain of pelvic region; resolves leaving tubal adhesions that may cause infertility or an ectopic pregnancy Ectopic Tubal Pregnancy - fertilized egg implants in the fallopian tube rather than the uterine wall (MC in the ampulla). If the tube ruptures pt will present with a. faintness b. syncope c. nausea & vomiting d. tachycardia e. shock due to severe hemorrhage

MALE RECTAL EXAM

Inspection a. position the pt on his left side with his buttocks close to the edge of the examining table near you b. flex the pts hips & knees with the top leg slightly ahead of the bottom leg c. put on gloves and spread the buttocks apart - inspect the sacrococcygeal & perianal areas look for lumps, ulcers, inflammation and rashes Anal / Perianal Lesions hemorrhoids carcinoma venereal warts syphilitic chancre Herpes (MC HSV2) - inspect the anus and rectum a. lubricate your gloved index finger and explain to the pt what you are going to do b. tell him that he may feel as if he were moving his bowels but he wont do so c. ask the pt to strain down and inspect the anus as he does so noting any lesions (hemorrhoids, rectal prolapse) - palpation

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as the patient strains down , place your lubricated and gloved index finger over the anus and as the sphincter relaxes, gently insert your fingertip into the anal canal in the direction of the umbilicus (a tight sphincter may be due to anxiety, inflammation, scarring whereas a loose sphincter may be due to neurological disease) b. palpate the posterior rectal wall for any masses, tenderness or induration (induration may be due to inflammation, scarring or malignancy) c. with your finger inserted as far as possible, rotate your hand clockwise to palpate as much of the rectal surface as possible on the pts right side, then counterclockwise to palpate the surface posteriorly and on the pts left side d. note any nodules, irregularities, or induration (CA has irregular borders) e. examine the anterior surface of the prostate gland; tell the pt that he may feel as if he will urinate but that he wont do so f. feel over the lateral lobes and the median sulcus between them noting size, shape & consistency of the prostate (Normal prostate is rubbery and non-tender) *** Gently withdraw your finger and observe it for occult blood or fecal matter; wipe finger over a slide and stain for histology Anal Fissure - a very painful oval ulceration of the anal canal, found MC in the midline posteriorly. Inspection may show a sentinel skin tag just below the anal opening. The sphincter is spastic and the examination is painful Rectal Shelf - peritoneal metastases that develop in the area of the peritoneal reflection anterior to the rectum Abnormalities of the Prostate CA of the Prostate- hardened, irregular, enlarged gland in which the median sulcus may be obscured ; Metastatic Prostatic cancer is osteoblastic. Prostatitis- Acute Prostatitis is an acute, febrile condition caused by a bacterial infection where the gland is very tender, swollen, firm and warm. Chronic Prostatitis does not produce consistent physical findings and may not be tender or warm to the touch. Benign Prostatic Hypertrophy- MC > 50yrs; gland feels symmetrically enlarged, smooth and firm though slightly elastic. Median Sulcus may be absent to palpation and the enlarged gland may obstruct urinary outflow.

FEMALE BREAST EXAM

Inspection - inspect the breasts ( pt should be sitting at the edge of the bed) a. size ( some difference in size is normal) b. symmetry c. contour ( dimpling or flattening of the breast suggests CA) d. color (redness from infection or inflammatory CA) - inspect the nipples (size, shape, color, discharge) a. inverted nipple - if it has been inverted since birth or childhood then it is a normal variant but if it is a recent occurrence then there may be an underlining CA b. nipples should point outward and downward (nipples pointing in alternate directions suggests CA) c. rashes or ulcerations suggest Pagets disease of the breast which almost always carries an underlying CA d. look for discharge ( bloody discharge may be from a benign intraductal papilloma; nonmilky unilateral discharge suggests local breast disease)

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ask the pt to raise her arms over her head and then to press her hands against her hips a. dimpling or retraction of the breasts in either of these positions suggests CA but could also be from trauma causing fatty necrosis b. for cases of large breasts ask the pt to stand up and place hands at the edge of the table while leaning forward palpation (pt should be lying down with a pillow under the shoulder of the opposite side being examined) a. examine each breast with the 2nd to 5th digit of one hand compressing the tissues gently in a rotary motion against the chest wall b. start in one quadrant and move in a systematic fashion until the entire breast is examined including the tail of the breast but leaving the nipple and areola for last c. note the consistency, tenderness, & any nodules present d. if a mass is found describe its -location (quadrant, cm from the nipple) -size (measured in cm) -shape (round, regular, irregular) -consistency (soft, hard, firm) -delimitation (well circumscribed or not) -mobility (freely mobile or fixed to chest wall) examine the axilla a. cup hand and palpate each axilla of the pt for enlarged lymph nodes b. feel for the central, axillary, pectoral, lateral, subscapular, supraclavicular & infraclavicular nodes Pagets disease of the breast - dermatitis of the areola and nipple (eczemalike lesion) with an underlying CA of the breast ( in situ or invasive) Fibroadenoma- benign, solitary, freely movable, rubbery to soft lump found in the breast

RESPIRATORY EXAMINATION
1. Inspection (done at the foot of the bed) -respiration rate ( breaths/min; rhythm, easy or difficult) which muscles are being used (accessory muscles?) a. Cheyne-Stokes Breathing - Hyperpnea with apnea b. Biots Breathing - unpredictable irregularity (shallow or deep breaths with short periods of apnea) -chest shape check symmetry, AP diameter, extent of expansion a. funnel chest - assoc. with possible murmurs b. pigeon chest- increased AP diameter c. thoracic kyphoscoliosis - abnormal spinal curvatures and vertebral rotation deform the chest -check for chest scars -inspect for cyanosis (tongue, lips and nail beds) -check for clubbing 2. Palpation trachea midline a. atelectasis deviates trachea toward same side

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b. pleural effussion deviates trachea to opposite side c. pneumothorax deviates trachea to opposite side d. consolidation has no trachea deviation chest expansion ( symmetry and extent) check expansion 2 places on anterior chest and 3 places on posterior chest non symmetrical chest expansion -broken ribs -musculoskeletal problems -collapsed lung -pneumothorax -pleural fibrosis tactile vocal fremitus (see Bates pg. 24O & 249) -checking for symmetry and presence -ask pt to say 99 as you palpate with bony surface of hand Anterior Chest- palpate 3 places symmetrically Posterior Chest- palpate 4 places symmetrically Decreased Fremitus -asthma -emphysema -pleural effussion -pneumothorax Increased Fremitus -consolidation No Fremitus -atelectasis

3. Percussion - percuss both sides of the chest symmetrically, one side at a time Anterior Chest- start above clavicles and percuss down midclavicular line 4 places and 2 more moving laterally and down anterior axillary line for a total of 6 sites for percussion (Bates pg 249) Posterior Chest- pt should cross arms; percuss 5 places down just medial to scapula and 2 more moving laterally to cover lower lobes for a total of 7 sites for percussion (Bates pg 243) Percussion sounds Dullness (Lobar pneumonia, Empyema, Hemothorax,Hydrothorax ) Resonance (Normal, Chronic Bronchitis, Asthma) Hyperresonance (Emphysema, Pneumothorax, Asthma) Tympanic (Large Pneumothorax) Stony Dull or Flat (Pleural Effussion) 4. Auscultation (ask pt to breathe quietly and deeply through an open mouth ) Anterior Chest - start above the clavicles using the bell, switch to diaphragm and listen to 5 more lung fields moving down the mid clavicular line and out to lower lobes as shown in Bates on pg 249. Listen to symmetrical fields as you move downward Posterior Chest - have pt cross their arms; listen to 7 lung fields in a symmetrical pattern as shown in Bates pg 243 Lung Sounds Vesicular - inspiratory sounds last longer than expiratory; normal Broncho-vesicular - inspiratory and expiratory sounds are equal; may be heard with consolidation Bronchial - expiratory sounds last longer than inspiratory ones ( gap exists between sounds); most often heard in consolidation Tracheal - inspiratory and expiratory sounds are equal (gap exists between sounds)

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Adventitious Lung Sounds Discontinuous sounds - fine crackles & course crackles which are both intermittent, nonmusical, and brief fine crackles - soft, high pitched and very brief (5 - 10 msec.) coarse crackles - louder, lower pitched and longer in duration (20 -30 msec.) - both can be due to abnormalities of the lungs as seen with pneumonia, fibrosis or early CHF - or due to abnormalities of the lung airways as seen with bronchiectasis or bronchitis Continuous sounds - > 250 msec. but do not usually span entire length of resp. cycle; are musical wheezes - high pitched with a hissing or shrill quality (suggest narrowed airways as in asthma, COPD or bronchitis) rhonchi - low pitched with a snoring quality (suggest secretions in lrg. airways) -Alternate tests for located broncho-vesicular or bronchial breath sounds a. Bronchophony b. Egophony ( ee is heard as ay) c. Whispered Pectoriloquy Stridor - wheeze that is entirely inspiratory ; heard loudest over the neck and indicates partial obstruction of the larynx or trachea and is a medical emergency MCC by croup in children or a foreign body obstruction Hammans Sign - a mediastinal crunch heard synchronous with the beat of the heart and not with respiration. MC due to mediastinal emphysema (pneumomediastinum) and is a medical emergency Tension Pneumothorax - air enters the pleural cavity and gets trapped upon expiration. The intra-thoracic pressure increases and compresses the mediastinum and causes torsion of the Great Vessels leading to sudden death.

MUSCULOSKELETAL SYSTEM
(Look - Feel - Move)
A. Head and Neck (pt should be sitting up) Temporomandibular Joint inspection- look for masses, lesions, scars, inflammation and abnormalities feel- place the tips of your fingers (2nd & 3rd ) over the pts Temporomandibular Joint move- ask the pt to open and close his mouth while you feel for -tenderness -swelling -decreased range of motion ( these 3 are present in arthritis ) ** some crepitus is normal Neck inspection- look for deformities / abnormal posture (ankylosing spondylitis, kyphosis) feel- palpate the cervical spinous processes and surrounding musculature for tenderness move- ask the pt to flex: touch his chin to his chest

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rotate: touch his chin to each shoulder lateral bending: touch his ear to each shoulder extension: look at the ceiling B. Shoulders inspection- look for any swelling, deformities, or muscular atrophy of the shoulder and shoulder girdle both anteriorly and posteriorly feel- palpate the following regions -sternoclavicular joint -acromioclavicular joint -subacromial joint -bicipital groove move- ask the pt to (1) raise both arms over his head (2) place both hands behind his neck with his elbows out to the side (external rotation and abduction) (3) place both hands behind his back (internal rotation) cup your hands over the pts shoulder joints as he makes these movements and note any crepitations, pain or decreased range of motion Rotator Cuff Muscles- S-I-T-S- Supraspinitus, Infraspinitus, Teres Minor & Subscapularis (all insert onto the Greater Tubercle of the Humerus except the Subscapularis which inserts onto the Lesser Tubercle) Rotator Cuff Tendinitus (impingement Syndrome)- MCC of pain in the shoulder which often involves the Supraspinitus tendon. Results in acute, recurrent, or chronic pain with underlying edema, hemorrhage and fibrosis. Dislocation of the shoulder- direction of the dislocation is Anterior to the joint but it gets to this position by an Inferior Anterior Superior route C. Elbows inspection- examine the elbow, olecranon process and ulnar extensor surface -swelling -nodules (Rheumatoid) -inflammation feel- palpate the olecranon process and the grooves between the epicondyles and the olecranon -tenderness (Epicondylitis, Arthritis) -thickening -swelling (Epicondylitis, Arthritis) move- ask the pt to flex, extend, supinate, and pronate their arms Rheumatoid Nodules- Subcutaneous nodules that are firm, non-tender and not attached to the overlying skin. Occur MC with Rheumatoid Arthritis and Rheumatic Fever along the extensor surfaces of the ulna Epicondylitis- Lateral (tennis elbow) epicondylitis occurs after repetitive extension of the wrist or pronation - supination of the forearm and results in pain when the pt extends the wrist. Medial (golfers elbow) epicondylitis occurs after repetitive flexion of the wrist and results in wrist pain upon flexion D. Hands & Wrists inspection- look for any swelling, inflammation, nodules, deformities or muscular atrophy feel- palpate the wrist joint with your thumbs on the dorsum of the wrist and fingers beneath it -swelling, tenderness or bogginess (Rheumatoid Arthritis presents bilaterally with all 3) -palpate the distal interphalangeal (DIPS), proximal interphalangeal (PIPS) and metacarpointerphalangeal (MIPS) joints between your thumb and index finger -Heberdens nodes (DIPS) and Bouchards nodes (PIPS) present as hard, painless joints with decreased or no range of motion due to osteoarthritis. -finally, squeeze the pts hand (not too firmly) to check for a tenosynovitis that presents with extreme pain on compression

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move- ask pt to (1) make a fist (2) flex and extend the wrist (3) ulnar and radial deviation Gonococcal Arthritis- N. Gonorrhea commonly infects the wrist joint or tendon sheath and presents with pain, tenderness and decreased range of motion. Osteoarthritis- progressive deterioration and breakdown of articular cartilage, mainly in weightbearing joints, leading to subchondral bony thickening and bony overgrowths (osteophytes) about the joint margins. Rheumatoid Arthritis- a chronic, severe synovitis that leads to destruction and ankylosis of affected joints while also affecting blood vessels, heart, eyes, nerves, skin and lungs. Pannus formation of the joint is characteristic in RA and leads to the bony ankylosis. Boutonniere and Swan Neck deformities can be seen with Chronic RA whereas rheumatoid nodules are seen in both Acute and Chronic RA. Dupuytrens Contracture- flexion contracture of the fingers due to thickening of the flexor tendon of the ring finger or 5th digit at the level of the distal palmar crease Carpal Tunnel Syndrome- MCC of thenar atrophy due to compression of the Median nerve at the level of the wrist due to edema and inflammation within the flexor retinaculum. Both Phalens Test and Tinels Sign can be done to test for Carpal Tunnel Syndrome. E. Hips (pt should be laying down) inspection- look for any deformities, muscle atrophy or scars feel- palpate the (1) hip joint and overlying iliopectineal bursa (2) greater trochanter and trochanteric bursa (3) ischial tuberosity and ischial bursa -note any tenderness or inflammation (bursitis, synovitis) move- the pt should be lying flat on the exam table (1) bend each knee to his chest (2) bring the thigh up and flex the leg to 90; as you then stabilize the thigh, internally and externally rotate the leg (3) stabilize the pelvis by pressing down on the opposite ASIS with one hand and abducting the other leg with your other hand until you feel the iliac spine move (hip disease often restricts abduction); then adduct the leg back past the pts midline for complete range of motion. F. Knees inspection- look for any swelling, scars, normal hollows, inflammation, deformities or atrophy feel- palpate the tibial tuberosity, patella, patellar fat pad & patellar tendon, tibial condyles, lateral & medial collateral lig., and femoral epicondyles ( the pts knees should be at 90 with feet flat on the examining table) -note any tenderness, bogginess, warmth or swelling (bony ridges felt along the joint margins may be signs of osteoarthritis, a painful tibial tuberosity in a child may be Osgood-Schlatter Disease) move- flex and extend the pts knee noting any pain, decreased range of motion or crepitations (patellofemoral disorders present with pain & crepitations along with a Hx of knee pain) Bulge Sign- with the palm of your hand, milk the medial aspect of the knee firmly upward 2-3 times to displace any fluid. Tap the knee lateral to the patellar margin (Bates pg 471). Watch for any return of fluid into the knee hollow medial to the patella. This test will identify small effusions of the knee. (non-tender effusions are common in osteoarthritis) Balloon Sign- Place the thumb and index finger of your right hand on each side of the pts patella (inferior to the patella) and with your left hand, milk the suprapatellar pouch down towards the patella 2-3 times with the last stroke holding the knee firmly just above the patella compressing the suprapatellar pouch against the femur. Feel for any fluid entering into the spaces next to the patella with your right thumb and finger. If any fluid is present, the patella should balloon

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outward. If fluid is seen filling the joint space, then with your right index finger, press the patella backward against the femur to confirm the presence of a possibly large effusion. Drawer Test- with the pts knee flexed to 90 and the foot flat on the examining table, grab hold of the leg just below the knee joint. To test for a competent Anterior Cruciate Lig., pull the leg towards you and push back on the leg to test the Posterior Cruciate Lig. If the leg moves more than what is considered normal then the respective cruciate ligament is torn and gives a positive drawer sign for that ligament. Osgood-Schlatter Disease- epiphysial aseptic necrosis of the tibial tubercle MC seen in children Bakers Cyst- herniation of knee-joint capsule & synovium into the Popliteal space due to increased intra-articular fluid exudate as seen with Rheumatoid Arthritis G. Ankles & Feet inspection- look for signs of swelling, inflammation, scars, lesions, warts, calluses, corns or deformities feel(1) palpate the Achilles Tendon for Rheumatoid nodules (a tender tendon may be a tendinitis or bursitis) (2) palpate the anterior & posterior aspects of the ankle joint and each metatarsophalangeal joint of the foot (an enlarged painful 1st digit may be Gout) (3) feel the plantar surface for tenderness move(1) dorsal & plantar flex the pts ankle (Tibiotalar joint) (2) invert & evert the Subtalar joint (3) with the heel stabilized, invert & evert the Transverse Tarsal joint (4) ask the pt to wiggle his toes (Metatarsophalangeal joints) Gout- recurrent attacks of acute arthritis due to deposition of urate crystals in joints which MC ends in a chronic arthritis. Occurs when the blood concentration of uric acid is > 7 mg/dl and MC occurs in the big toe (50%), ankle and knee Pseudogout- similar to Gout but any joint can be affected (MC the knee & intervertebral discs). It is due to the deposition of Calcium Pyrophosphate Crystals and no Tx exists to date.

H. Spine (the patient is standing) inspection- look at the cervical, thoracic and lumbar curvatures (Scoliosis, Kyphosis, Lordosis & List) ; look for differences in height of the shoulders, iliac crests and skin creases below the buttocks feel- palpate the spinous processes (from a sitting position) with your thumb and the paravertebral muscles for tenderness or spasm. move- ask the pt to (1) touch his toes (flexion) -lumbar curvature should flatten out (2) bend sideways (lateral bending) while you support his waist (3) bend back towards you (extension) (4) twist the shoulders in both directions (rotation) Gibbus- angular deformity of a collapsed vertebra due to a metastatic cancer (osteoclastic cancer) or from tuberculosis of the spine (Potts Disease) List- lateral tilt of the spine due MC to a herniated disc or paravertebral muscle spasms.

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Neurological Exam
Cranial Nerves CN I -check sense of smell with familiar odors (pts eyes are closed) -do one nostril at a time CN II -visual acuity using a Snellen Eye Chart (one eye at a time) -examine visual fields -refer to head and neck exam -examine the optic disc (use your right hand & right eye for pts right eye & left hand, left eye for pts left eye)-refer to head and neck exam (1) locate the red reflex (2) examine the optic disc, macula & fovea CN II/III -check pupillary light reflex (direct & consensual) -check near reaction (accommodation) Argyll Robertson pupil- absence of a miotic rxn to light, both direct & consensual, with the preservation of a miotic rxn to near stimulus (pt can accommodate but not react). This can be seen in both Diabetes Mellitus and Syphilis. CN III/ IV/VI -examine the pts extraocular muscles with the H test -check for convergence & lid lag (lid lag is present & convergence is impaired with hyperthyroidism) CN V -motor: test the strength of the Temporalis, Masseter & Pterygoid Muscles (1) have the pt clench his/her teeth while palpating the Masseter & Temporalis (2) place your hand on the side of the pts chin and resist lateral motion of the Pterygoid Muscle of that same side (repeat for opposite side) -sensory: test the forehead, cheeks & jaw on each side for pain, temperature & light touch sensations (use a cotton swab for light touch) -test for the corneal reflex using a fine wisp of cotton (1) touch the pts cornea with the cotton tip making sure not to touch the pts eyelash (2) CN V is the afferent branch whereas CN VII is the efferent branch in this reflex CN VII -inspection- look for facial symmetry (nasal labial folds present & symmetrical), masses, scars, lesions or any involuntary movements (Tics, Tardive Dyskinesias) -ask the pt to make the following facial expressions (1) raise both eyebrows (2) frown (3) close eyes tightly (as you try to open them) (4) show teeth (5) smile (6) blow out cheeks **note any weakness or asymmetry -check corneal reflex for this nerve too CN VIII- examine the pts hearing (1) occlude one ear at a time and test acuity by rubbing fingers together next to the patent ear (2) if impairment exists do the Weber & Rhine Test to determine whether the loss is conductive or sensorineural (3) check for nystagmus (Vestibular function of CN VIII)

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CN IX/X-

CN XICN XII-

(1) have the pt speak and listen for hoarseness (2) check for dysphagia (3) examine the pts soft palate & pharynx (uvula deviates to opposite side in Xth nerve lesion) (4) test the gag reflex (IX nerve is the afferent branch whereas X nerve is the efferent branch of this reflex) inspection- look for signs of atrophy or fasciculations of the musculature - ask the pt to shrug their shoulders & turn their head against your resistance (note any weakness or asymmetry) (1) listen to the articulation of the pts words (normal or impaired) (2) examine the pts tongue (atrophy, fasciculations, asymmetry or deviation) **tongue deviates to same side as lesion of XII nerve (3) ask the pt to move tongue side to side (4) test the tongue strength by having the pt push his/her tongue against the inside of their cheek while you resist against the outside of the cheek

Motor System inspection examine -the pts body position -involuntary movements (chorea, hemiballism) -muscle bulk/atrophy (diabetic neuropathy, Duchenne Muscular Dystrophy) (1) examine the pts muscle tone -upper limb(at wrist, elbow & shoulder) -lower limb(at knee & ankle) -note signs of spasticity or floppiness (possible cerebellar disease with floppiness) (2) examine the pts muscle strength (grade on 0-5 scale with 5 being normal) -ask the pt to move against your resistance (test symmetrically whenever possible) 0-no muscular contraction detected 1-barely detectable flicker or trace of contraction 2-active movement with gravity eliminated 3-active movement vs. gravity 4-active movement vs. gravity & some resistance 5-active movement vs. full resistance (normal) -upper limb (1) shoulder (shrug up/down, abduct & adduct) (2) elbow (flexion & extension) -C5,C6 biceps-C6,C7,C8 triceps (3) wrist (extension)-C6,C7,C8 wrist (4) grip (cross fingers, middle on top of index, as pt squeezes)C7,C8,T1 (5) fingers (abduction)-C8,T1 finger abduction (6) thumb & 5th digit (opposition)-C8,T1 opposition -lower limb (1) hip (flexion, extension, abduction & adduction)-L2,L3,L4 hip flexion,adduction-L4,L5,S1 abduction- S1 extension (2) knee (flexion & extension)-L2,L3,L4 extension -L4,L5,S1,S2 flexion (3) ankle (dorsi-flexion & plantar-flexion) -L4,L5

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Upper Motor Neuron Lesion Acute Stage Lesion Chronic Stage Lesions -flaccid paralysis -spastic paresis -areflexia -hypertonia -hypotonia - or loss of superficial abdominal & cremasteric reflexes -Babinskis sign -Clonus

Lower Motor Neuron Lesion -flaccid paralysis -areflexia -muscle atrophy -fasciculations

(3) examine the pts coordination (do each side separately) -test for rapidly alternating movements (dysdiadochokinesis in cerebellar disease) -test point to point movements (overshooting in dysmetria) a. finger to nose test b. heel to shin test -examine the pts gait (instability in ataxia) a. have pt walk across room (normal heel to toe, on toes, on heels) (inability to heel walk may be an upper motor neuron lesion) b. have pt hop in place/ do a shallow knee bend c. ask pt to rise from a sitting position without arm support -examine the pts stance with the Romberg Test a. have pt stand with feet together & eyes open b. repeat with eyes closed for 20-30 seconds-hold out your arms in case the pt. starts to fall (difficulty in both a & b is seen with cerebellar ataxia) c. test for Pronator Drift (positive test in corticospinal lesion of opposite side) d. ask the pt to keep their arms up & eyes shut as you tap the arms downward (normal return to horizontal position is lost if pt has lack of position sense) Sensory System -compare symmetrical sides and begin distally in upper & lower extremities (1) Light touch- test in a dermatomal and major peripheral nerve pattern using a cotton swab (touch lightly & do not drag cotton across skin) (2) Pain- test sharp vs. dull in the same dermatomes as in light touch (3) Temperature- test cold vs. warm (4) Position- test at interphalangeal joint in thumb & big toe (if impairment exists then examine proximal joints) (5) Vibration- use a tuning fork with 128Hz or 256Hz and test at bony prominences on both upper & lower limbs starting distally and moving proximally (6) Discrimination-stereognosis -graphesthesia -2 point discrimination -point localization -extinction glove & stocking sensory loss- symmetrical distal sensory loss of a polyneuropathy seen in alcoholism & diabetes Loss of Vibration Sense- MC the 1st sensation lost in the polyneuropathies of alcoholism & diabetes but also seen with posterior column disease in 3 syphilis & vitamin B12 deficiency

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Reflexes -compare one side to the other on a 0-4+ scale with 2+ being normal (if difficulty in eliciting a reflex exists, use reinforcement techniques) upper limbs -biceps (C5,C6) -triceps (C6,C7) -brachioradialis (C5,C6) -Hoffmans lower limbs -knee (L2,L3,L4) -ankle (S1) -plantar response (L5,S1) - Babinski sign (present in upper motor neuron lesions & prior to 2 yrs of age in infants due to lack of myelination) -check for clonus (present with upper motor neuron lesions) if you are asked to perform an exam of the motor system, you will need to include reflexes Spinal Cord Tracts Posterior Column- carries fibers for tactile discrimination, vibration sensation, form recognition, and joint and muscle sensation (proprioception) Spinothalamic- carries fibers for pain & temperature sensation Corticospinal- carries fibers for voluntary skilled motor activity Bells Palsy- peripheral facial paralysis caused by trauma or infection that involves the upper and lower face; this differs from a cortical lesion where the lower half of the face is paralyzed but the upper face is not. This is due to the lower part of the face being controlled by upper motor neurons on only one side of the cortex (the opposite side) and the upper half of the face being controlled by neurons from both sides of the cortex.

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ICM PRACTICAL EXAM To the examiner: We are looking for COMPETENCE & CONFIDENCE and should not be worried about minor variations in technique that may vary between specialties and physicians. Mark each student independently out of 20 on a basis of 14 = pass, 16 = B, 18 = A Please follow the same routine for each student in a session and ask the same questions. For honors students you may ask additional questions if there is time. Please maintain the six-minute time limit.

Self presentation: 2pts Appropriately dressed, greets patient and introduces self. Professional manner. Practical: 14pts Please take the patients blood pressure. Explains & positions patient, (sitting is easier): 2 Checks cuff size, applies cuff correctly, knows how to assemble machine: 4 Checks systole by palpation. Deflates cuff completely: 2 Inflates 2nd time to 30mm Hg above systolic pressure by palpation: 4 Gives reading to 2mm (does not say BP is about): 2 Follow up questions: 2 pts What can cause a BP to be low? Bonus: 2 pts Example: Ask to check BP in other arm

ICM PRACTICAL EXAM To the examiner: We are looking for COMPETENCE & CONFIDENCE and should not be worried about minor variations in technique that may vary between specialties and physicians. Mark each student independently out of 20 on a basis of 14 = pass, 16 = B, 18 = A

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Please follow the same routine for each student in a session and ask the same questions. For honors students you may ask additional questions if there is time. Please maintain the six-minute time limit.

Self presentation: 2pts Appropriately dressed, greets patient and introduces self. Professional manner. Practical: 14pts Imagine that you are seeing the patient for the first time. Please show how you would start a general physical exam and report your findings. Describe initial observations (e.g. - age, gender, build, grooming, distress, slurred speech): Examine eyes for jaundice and pallor: Examine mouth for pallor, cyanosis, hydration, teeth: Examines hands for clubbing and color (note pigmentation) : Examine for edema: 4 2 3 3 2

Follow up questions: 2pts Why might a patient have slurred speech? What is the difference between dysphagia, dysarthria and dysphonia?

Bonus 2 pts ICM PRACTICAL EXAM To the examiner: We are looking for COMPETENCE & CONFIDENCE and should not be worried about minor variations in technique that may vary between specialties and physicians. Mark each student independently out of 20 on a basis of 14 = pass, 16 = B, 18 = A Please follow the same routine for each student in a session and ask the same questions. For honors students you may ask additional questions if there is time. Please maintain the six-minute time limit.

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Self presentation: 2pts Appropriately dressed, greets patient and introduces self. Professional manner. Practical: 14pts Please examine this patients JVP. Explain actions correctly: Positions patient correctly: Inspects neck and identifies internal and external venous pulse: Demonstrates why it a venous pulse (4 reasons): Measures sternal angle with a right triangle: Gives pressure in cms from right atrium: 1 2 3 2 4 2

Follow up questions: 2pts Give two clinical conditions in which measuring the JVP would be helpful. (e.g. - CCF, hypovolemia, cardiac tamponade, SOB, arrythmia, etc.)

Bonus 2 pts ICM PRACTICAL EXAM To the examiner: We are looking for COMPETENCE & CONFIDENCE and should not be worried about minor variations in technique that may vary between specialties and physicians. Mark each student independently out of 20 on a basis of 14 = pass, 16 = B, 18 = A Please follow the same routine for each student in a session and ask the same questions. For honors students you may ask additional questions if there is time. Please maintain the six-minute time limit. Self presentation: 2pts Appropriately dressed, greets patient and introduces self. Professional manner. Practical: 14pts Please examine the patients precordium. Explains actions correctly: Inspection (from the foot of the bed) 1 2

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Palpates and identifies apex: Describes position and character (counts rib spaces from AOL) Feels for palpable sounds and thrills Feels for RVH (parasternal heave)

2 5 2 2

Follow up questions 2pts

What might you find in a patient with long-standing hypertension? (e.g. hyperdynamic, well-localized apex, sustained, displaced; late sign of failure)

Bonus 2 pts

Good luck, Gujju Shah A.