A Step by Step Guide to Mastering the Osce

A Step By Step Guide To Mastering The OSCEs

Edited by

A. Alimari, MD

2006 1

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To My parents, wife, and daughters

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Copyright © 2005-2006 MedInfo Consulting. All rights reserved. No part of this ebook may be copied, reproduced, distributed, or transmitted in any form by any means graphic, electronic, or mechanical without express permission in writing from MedInfo Consulting. Your friends and colleagues are NOT an exception. Protect yourself.

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Content Part One

The Medical Interview

Chapter 1

Introduction.

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Chapter 2

OSCE Exam Formats.

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Chapter 3

The OSCE Examiner’s Checklist.

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Chapter 4

Physician-Patient Communication Skills.

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Chapter 5

How To Prepare For The OSCEs.

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Part Two

History Taking Interview

Chapter 6

The Model.

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Chapter 7

The Minute(s) Before.

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Chapter 8

Self-Introduction.

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Chapter 9

Chief Complaint.

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Chapter 10

History of Present Illness (HPI).

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Chapter 11

Station Appropriate Questions.

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Chapter 12

Standard Questions.

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Chapter 13

Wrap Up.

81

Chapter 14

Counseling Stations.

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Part Three

Physical Examination Interview

Chapter 15

Physical Examination Interview.

89

Chapter 16

Chest Examination.

91

Chapter 17

Cardiovascular Examination.

97

Chapter 18

Abdominal Examination.

103

Chapter 19

Gynaecological Examination.

111

Chapter 20

Hematological Examination.

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Content

Chapter 21

Head and Neck Examination.

115

Chapter 22

Neurological Examination.

119

Chapter 23

- Cranial Nerves Examination.

119

- Mini Mental Examination.

129

- Motor Examination.

131

- Sensory Examination.

139

- Coordination Examination.

144

Musculoskeletal Examination.

149

- Sub Model.

149

- Tempomandibular Joint exam

152

- Shoulder Exam.

152

- Elbow Exam.

154

- Wrist Exam.

155

- Hand Exam.

157

- Cervical Vertebrae exam

160

- Thoracic Vertebrae exam.

163

- Lower back Exam.

166

- Hip Exam.

169

- Knee Exam.

173

- Ankle Exam.

178

Chapter 24

Pediatric examination.

183

Chapter 25

Obstetric examination.

191

Part Four

Emergency Room

Chapter 26

Emergency Room Stations.

Suggested Readings

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PART ONE THE MEDICAL INTERVIEW

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Chapter 1: INTRODUCTION Objective Structured Clinical Examination, OSCE, also called Objective Standardized Clinical Examination is tough. OSCE exams are really difficult and stressful. That is what is it. I’m not going to say it is not, as what clinical educators and OSCE organizers claim trying to make it acceptable for you. OSCE Exams consist of several clinical encounters (called stations) with specially trained actors playing the role of a patient with some sort of a medical complaint (called Standardized Patient, SP). Let’s take a minute here to absorb your situation during the OSCE. This is an important step as you may realize that the first step to deal with any issue is to completely understand what is it. You will find a lot of articles and web pages describing what are the OSCE exam procedures. They present the OSCE in a scientific academic context. I am sure you have already read several of these. Are you? Have you read between the lines? Have you achieved an understanding about how your physical and mental status will be during the OSCE exam? Well, let me explain it for you. Just concentrate. Imagine yourself in a hallway with several other candidates each standing in front of a closed door. Several individuals are watching you for any violation of the exam rules. Then an announcement/buzzer sounds. You have one or two minutes to read a full page hanged on that door describing what the station ahead is about and what is required to do. Usually, you’ll need to read the instructions again because you’re nervous, you heart is racing and your mind isn’t catching what your eyes are reading! Then, a second announcement/buzzer sounds. You knock the door and enter the room. In each room you will find two strangers and a different room setting. In some OSCEs, like USMLE Step 2 CS, there is no examiner in the room, just the SP. You have to hand out one or two of your stickers if present. You may have even looked for the stickers and didn’t find them. Then you have to start as your limited time has already started when the second announcement/buzzer went on. You need to get information from the SP or may be examine or consult him/her. Your voice is low. Your hands are shaking. You look unconfident and don’t know what to say or do. These SPs are well trained not to give you any information unless you specifically ask for it. Unlike real life medical encounters where the patient will say everything when you ask about the reason for their visit. Obviously, you have to know what questions you need to ask to save time. As you were asking, the patient replies by questions for you. Questions like ‘What do you mean?’, ‘Do I have to answer that?’, ‘Is this relevant to my problem?’, ‘Why are you asking this?’ All these questions are intended to shake you if that wasn’t a reflex to your poorly phrased questions. You start to

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The Medical Interview: Introduction lose control over yourself and the encounter. You start to make fatal mistakes like being disrespectful to the patient and unprofessional. And you’ll forget to ask questions that are important to fulfill the examiner checklist! That examiner who is sitting or standing closely observing you or assessing you through the video monitor. Suddenly the announcement/buzzer goes on again. The station is over. Oh my God. There are still tons of questions that I have to ask. I missed this station. You’ll start the process of self-blaming. Then you’ll try to hold yourself together. As you proceed, you’ll find that you had already wasted substantial time of the ‘minute before’ of the next station. The cycle starts again. By the fourth or fifth station, you’ll feel exhausted and headache starts. You’ll feel unable to think about the coming station and you’ll start to give up claiming that you’ll do you best, hopelessly. Did you get what I wanted you to understand? Let me put it in summary: You will be nervous, irritable and cannot think straight. You will be physically and mentally exhausted. Your time is running fast and by all means is not enough. Some SPs will be challenging you intentionally and waist your time. You need to be organized and manage your time efficiently. You need to know in advance what to ask, as there is no time to think. You need to be careful about how to phrase your questions and comments in order to be respectful and empathic. You need to ask your questions intelligently in order not to lead the patient or trigger programmed time wasting and problem evoking conversations. You need to be and appear confident and professional. Is that easy? Of course not. Is it impossible to do? Of course not. Thousands of medical students and graduates have done it. Okay, so it is not easy and also not impossible at the same time. The key is you need to know how to do it and assign the needed time and effort to prepare yourself to the OSCEs by practicing over and over the same steps. You’ll be just fine. But how to prepare yourself? This book, A Step By Step Guide To Mastering The OSCEs, will help you to: Know how to prepare yourself for the OSCEs. What and how to ask in each of these stations. How to communicate in the OSCE exam. How to perform a complete physical exam accurately and respectfully. How to be respectful, attentive and caring. How to appear organized, confident and professional. Let’s start. I can help you pass the OSCEs with high score. You can do it. You just need someone to show you specifically how and I can help. Let’s start.

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Chapter 2: OSCE EXAM FORMATS Objective Structured Clinical Examinations (OSCEs) stations in USMLE Step 2 CS, USMLE Step 3, MCCQE II, PLAB part 2 and medical schools clinical exams or international/foreign medical graduates clinical skills assessmnets are differently designed to assess one or more of your clinical skills depending on the purpose of that exam. However, the required medical knowledge, clinical skills, and communication skills are the same among these OSCEs. It is important to fully understand what is exactly required to be performed in each station and to what medical extent. You will be assessed for only those skills asked for in that station. Tasks other than those requested or more than expected at this stage of your medical knowledge, regardless of whether you performed them correctly or not, wont be counted and most critically will waste your valuable limited time. The length of the OSCE station is generally 5-20 minutes. You will perform a medical encounter with a standardized patient (SP) just like a real medical encounter. An examiner (a physician) may be present during these encounters to assess your clinical skills and communication skills based on a standard checklist. Otherwise, the encounter is video monitored. A nurse may also be present in emergency management stations to receive management orders from you and inform you about the progress. There are mainly four OSCE formats:  Focused History Taking OSCEs  Focused Physical Examination OSCEs  Consult OSCEs  Emergency Room OSCEs Combination of the above formats is common in long OSCEs, like a focused history taking and a focused physical examination, or a focused history taking and a consult.

Focused History Taking OSCEs Focused history taking OSCEs are data gathering stations. Here you will show your medical knowledge concerning the current specific patient case. This is what is meant by focused. This will include; exploring the chief complaint, history of present illness, past medical and surgical history, medications and allergies, family history and social history, occupational history, and sexual history relevant to this case scenario. Although OSCEs are a simulation of simple straightforward common real life presentation, please note that 'focused' does not mean skipping the differential diagnosis. However, the SP role might not be simple. Some history taking OSCEs will have some difficult to deal with patients or ethical issues to be assessed too, like a depressed patient who is unwilling to talk, or a failed to thrive child with a hidden child abuse issue, ..etc. In addition to assessing your medical knowledge, your communication skills 13

The Medical Interview: OSCE Exam Formats and approach to gather data are also assessed. This is an important part of the station’s final mark.

Focused Physical Examination OSCEs In focused physical examination OSCEs, you have to examine the requested body part or system. No head to toe examination. But, if the complete examination of a system requires examining some other body parts, then it is included. For example, a complete cardiovascular examination will include examination of the legs for peripheral pulses and edema as well as opthalmoscopy for cardiac related retinal changes among others. Please, explain every thing you are going to do to the patient taking necessary permission before you proceed. Pay attention to patient’s privacy and draping. Don't harm or repeat harmful maneuvers. If an examiner is present, stand in a way to let him/her watch you and also explain what are you doing giving the findings.

Consult OSCEs Consult OSCEs are talk stations. You will be asked to explain a diagnosis, a prognosis, a lab or medical imaging test result, a drug interaction or side effect, a procedure, an alternative, or any patient’s concern. Ethical stations are mostly consult stations like breaking bad news, obtaining consents,.. etc. There will be some history taking too and some times it will be a combined focused history taking and a consult station. Consult OSCEs require good communication skills as well as good English language skills. These skills usually weigh up to 60-70% of that station final mark. It is obvious how important to develop your language and communication skills. Being attentive and respectful is a must. Your ability to transfer relevant information to the patient in an understandable simple way will be assessed. That is being a good health educator and health promoter.

Emergency Room OSCEs There are three types of emergency room OSCEs scenarios. The ER management scenario; The post management ER consult, and; The ER stable patient as walk-in scenario. In ER management OSCEs, you will be asked to manage the case. A nurse will be present to take your orders and pass back results and patient’s progress. In the post management ER consults, you will be asked to consult the patient for discharge, dealing with ethical issues like breaking bad news, organ donation, or abuse. In the ER stable patient as walk-in scenario, you will be asked to perform any task just like any office setting like history taking, physical examination, or consult.

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The Medical Interview: OSCE Exam Formats So, read the instructions carefully before entering the room to sub-classify the ER station to one of the above types as your task will be different. ER OSCEs require a lot of training and practice to perform all the requested tasks accurately and efficiently. It is very important to show confidence and control of the situation.

Post Encounter Probe (PEP) Some OSCEs end with a one or two-minute oral questions period usually called "Post Encounter Probe (PEP)" (Not in USMLE). During this time, you are not allowed to talk to the SP but only with the examiner. The examiner will ask you 2-4 standard questions that are usually concerning:  What is your one working diagnosis for this patient?  What is your three most relevant differential diagnosis?  What are the risk factors of this patient?  What is your only / three investigation you are going to order for this patient and why?  What is your initial / short term plan of management?  What is your long term plan of management?  Interpret this lab findings / imaging...etc.  Prognosis? If this patient came back in .. days / weeks with .. what will be your explanation In a matter of fact, you should organize your study material for any medical topic in your preparation to both written and clinical exams to cover the above listed aspects. Some OSCEs alternate with a period of written questions PEP covering the same upper listed questions.

Patient Note (Write ups): In USMLE Step 2 CS, the patient note 10 minute post encounter period will be the ordinarily patient medical chart/record note in addition the above issues.

Patient Write ups: These are writing admission, discharge, progress, follow up, pre-op, post-op notes in the patient’s chart. Referral and thank you letters are sometimes requested too. These are pretty simple. There are several ready to fill out forms and instructions over the internet. Pick few of them, memorize them and practice filling up them. There are few other modified formats that fall into one of the above listed types, such us: Consult over the phone with a patient, a caregiver, or another physician. In this scenario, you will find inside the OSCE exam room a phone and some one is talking on the other side of the phone line. Commonly it will be a mother having an acute problem with her child. Another common scenario is a physician

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The Medical Interview: OSCE Exam Formats from a rural hospital wants to arrange for the transfer of his acute case patient to your hospital. Here, just go through the same set of questions that you ask a patient attended to your office. Make sure to take the caller name, position and relation to the patient. No transfer of unstable patients. Be aware of privacy issues and releasing patient information over the phone. Interpretation of diagnostic materials such as labs, microscopic, ECGs, X-rays, CT.. etc. Presenting the case to the examiner. That may include a differential diagnosis, and/or a plan for immediate and/or long term managements as an evaluation of your clinical reasoning. Performing practical skills by using manikins. Such as venepuncture, inserting a cannula into a peripheral vein, suturing a wound, vaginal bimanual exam, rectal digital exam, PAP smear, breast exam, testes exam, prostate exam, ophthalmoscope, diagnostic procedures, basic cardio-pulmonary resuscitation (adults and children), performing urinary catheterization, mixing and injecting drugs into an intravenous bag, giving intramuscular and subcutaneous injections, safe disposal of sharps .. etc. Some of these may also be included in or at the end of the above formats. As you know, all medical students and graduates will take several OSCEs during their medical life starting from the medical school OSCEs then any of USMLE Step 2 CS, USMLE Step 3, MCCQE 2, or PLAB 2 OSCEs. So, develop your clinical skills and use them repeatedly during the OSCEs and, for your benefit, also later in your practice. As in each station within the same exam day you'll encounter a different standardized patient and examiner with each station. So, you may repeat the same skills and even the same words, phrases, and descriptions. Assessment of each station is done separately by different evaluators.

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Chapter 3: OSCE EXAMINER’S CHECKLIST Objective Structured Clinical Exams (OSCEs) cases cover common and important situations that a physician is likely to encounter in common medical practice in clinics, doctors’ offices, emergency departments, and hospital settings in real practice. Thus, you’ll be evaluated as if it is a real life practice. OSCE exams use standardized patients (SP), i.e., people trained to portray real patients. These SPs follow a certain script to play with you during the encounter. These scripts are written in details including patient general look, cloths, gestures, emotions, and all negative and positive answer. It also includes any unexpected behaviours such as the SP turns agitated, upset, violent, restless, impolite, or leaves the room during the encounter. As SPs follow strictly these scripts, OSCEs examiners also have a standard printed checklist or blueprint for each station that they have to fill out while observing you. These checklists are standardized to reduce examiners' bias. On these checklists, there are station specific points and a general performance points to be assessed. There are up to 40 points to be check in each station. Some OSCEs may also include a checklist to be filled out by the standardized patient. SPs will reveal information when specific related questions are asked. They wont voluntarily give you information as some times happen in real life patient encounters. For example, if you don't ask about all their medication now and in the past, they wont show you a printed list of their medication. In some OSCEs, SPs are instructed to follow different paths or ask specific questions according to your performance. For example, turning uncooperative if you are not responding to their concerns or gestures.

What is the OSCE Examiners' Checklist? Checklists are organized to assess the followings:  Medical knowledge specific to this station, such us, symptoms, signs, associated factors, risk factors, prevalence, complications, prognosis, management plans, .. etc.  Data gathering skills: Your way of patient information collection by history taking and physical examination.  Documentation – completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up.  Communication and Interpersonal Skills:  Initiation of interview: acknowledgement of patient, introduces self, at ease, attentive to patient.  Questioning skills: e.g., use of open-ended questions, transitional statements, confident and skilful questioning, appropriate language, use of different question types, or awkward, exclusive use of closed 17

The Medical Interview: OSCE Examiner’s Checklist ended or leading questions, jargon, interrupts patient inappropriately. Information-sharing skills e.g., None given, avoidance of jargon, responsiveness to patient questions or concerns, provision of counseling when appropriate, confident and skilful at giving information, attentive to patient understanding; truthful. Professional manner and rapport e.g., Condescending, offensive, aggressive, judgmental, negative attitude to patient, or polite and interested, warm, polite, empathic, concern for patient's comfort and modesty, examinee's attention to personal hygiene, expression of interest in the impact of the illness. Listening skills: Interrupts patient inappropriately, impatient, or attentive to patient’s answers and concerns. Organization of interview: Scattered, shot-gun approach, logical flow, purposeful, or integrated handling of encounter Closing: Abrupt, or acknowledges end of interview, or attempts closure, or clear closure, or organized, thoughtful closure. Ethical conduct: Markedly inappropriate or awkward handling of ethical issues, or considers and responds to ethical issues with care and effectiveness. Compliance optimization: Did the candidate do everything possible to optimize the patient’s compliance? Physical examination: No consent, awkward, uses jargon, no interaction or acknowledgment of patient, or clear, concise instructions, elicits consent to physical examination, at ease with patient. Attention given to patient's physical comfort: Inattentive to patient's comfort or dignity; e.g., no draping and/or causes pain unnecessarily, or consistently attentive to patient’s comfort and dignity. Organization of physical examination: Scattered, patient moved unnecessarily, logical flow, purposeful, integrated handling of examination. Spoken English Proficiency: Clarity of spoken English communication within the context of the doctor-patient encounter (e.g., pronunciation, word choice, and minimizing the need to repeat questions or statements).

In every sentence you say during the medical encounter, you should have taken care of all the above elements. Difficult?… Yes, but not impossible. In this book you will find sentences that were carefully chosen to meet all of the above requirements. This will definitely save you a lot of effort and time.

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Chapter 4:

PHYSICIAN-PATIENT COMMUNICATION SKILS

OSCE exam is an assessment of clinical knowledge, skills, and attitude. The communication skills you demonstrate and the process you go through in obtaining a history or performing a physical examination are more important than determining the diagnosis. Communication skills are verbal and non-verbal words, phrases, voice tones, facial expressions, gestures, and body language that you use in the interaction between you and another person. Verbal communication is the ability to explain and present your ideas in clear English, to diverse audiences. This includes the ability to tailor your delivery to a given audience, using appropriate styles and approaches, and an understanding of the importance of non-verbal cues in oral communication. Oral communication requires the background skills of presenting, audience awareness, critical listening and body language. Non-verbal communication is the ability to enhance the expression of ideas and concepts without the use of coherent labels, through the use of body language, gestures, facial expressions and tone of voice, and also the use of pictures, icons, and symbols. Non-verbal communication requires background skills such as audience awareness, personal presentation and body language. Effective communication is an essential part of building and maintaining good physician-patient and physician-colleague relationships. These skills help people to understand and learn from each other, develop alternate perspectives, and meet each other’s needs. Hidden agendas, emotions, stress, prejudices, and defensiveness are just a few common barriers that need to be overcome in order to achieve the real goal of communication, namely mutual understanding. High Performers master and continually practice the basics, as well as prepare for these communication pitfalls. Just as successful physicians routinely practice basic medical skills, High-Performers understand that they too must pay attention to communication skills or they risk getting out of shape pretty quickly. Communication skills in a medical setting may include the way you use for:  Explaining diagnosis, investigation and treatment.  Involving the patient in the decision-making.  Communicating with relatives.  Communicating with health care professionals.  Breaking bad news.  Seeking informed consent/clarification for an invasive procedure or obtaining consent for a post-mortem.  Dealing with anxious patients or relatives.  Giving instructions on discharge.  Giving advice on lifestyle, health promotion or risk factors. 19

The Medical Interview: Physician-Patient Communication Skills Your approach to the patient will be assessed all through the encounter, but in some stations communication will be the main skill for which you will be awarded marks. In OSCEs, as well as in life, two aspects of the communication skills are important. The way you choose for your approach to reach the other person, and the effects and outcome of your efforts. The OSCEs examiners will be considering your:

Approach to the patient You should: Introduce and orientate the patient and yourself. Establish an attentive, respectful and non-judgmental relationship. Acknowledge the patient's emotions and concerns.

Listening, questioning and diagnosing You should: Ensure you have understood the patient's symptoms/problem and concerns. Summarize and clarify understanding.

Explaining and advising You should: Enable the patient to understand the problem/situation. Reassure appropriately. Summarize and clarify understanding.

Involving patient in management You should: Explore the patient's expectations/concerns. Propose/ explain management plan clearly. Explore the patient's response. Respect the patient's autonomy, and help him or her to make a decision based on available information and advice. Summarize and clarify understanding. Communication skills are learnable, trainable, adaptable just like any other skill!. Yes, it is not easy to change yourself. But it wasn't easy to be in your current academic achievement either. You can teach yourself these skills, learn them, adopt them, and make them part of the new you! The new medical student or graduate, or even a new start towards being a successful physician!. In this book, you won’t find information for nonverbal communication. Verbal communications are addressed through out you statements in this book. For more information check the ebook: “How To Maximize My Communication Skills For The Medical Encounter”. 20

Chapter 5:

HOW TO PREPARE FOR THE OSCES

There are three aspects that you should take care of simultaneously in your preparation for the OSCEs:  Medical knowledge and clinical skills.  Communication skills.  An approach for the medical encounter.

Medical knowledge and clinical skills: You need to refresh your basic medical knowledge relevant to the OSCEs. This means you should re-study medicine based on common patients’ complaints and physical finding and not based on topics. No patient will come complaining of endometriosis or asking for TB treatment! Patients come to you complaining of symptoms like shortness of breath or a long standing cyclic pelvic pain. For each complaint, find answers to following questions and memorize them: 1. What are the five most common relevant differential diagnoses? 2. How to differentiate between these five diseases? What key elements in history, physical examination, and investigations will help? 3. What are the risk factors of each of these diseases? 4. What is your only / three investigations you are going to order for this patient and why (To differentiate between the diseases)? 5. What is your initial / short term plan of management for each of these diseases? 6. What is your long term plan of management for each disease? 7. Interpret the lab findings / imaging...etc. concerning each disease. 8. Prognosis of each disease? What to inform the patient about what to expect in the near and far future? 9. Complications of each disease? How to prevent them? If this patient comes back in ... days / weeks complaining of ...., what will be your explanation? 10. What are the key issues that you have to ask or counsel the patient about? Write down the above questions and answer it for each symptom. Memorize it. In a matter of fact, this should be your approach to prepare for the written exams too as it is extremely helpful. Written exams are getting more and more clinically oriented. This is the best quick and focused approach to an efficient practice. There are several valuable books and resources that deal with common symptoms and signs and differential diagnosis. Check your local medical library or ask your colleagues and instructors. Clinical skills include history taking, physical examination, counseling, and clinical reasoning. This includes the way you perform these skills too.

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The Medical Interview: How To Prepare For The OSCEs

Communication skills: Your second aspect of preparation for the OSCEs is the most important, your communication skills In OSCEs, verbal and non-verbal communication skills are very important both directly and indirectly. Directly, by showing respect, professionalism, attentiveness, care, interest, and efficiency in acquiring medical data gathering. Indirectly, by leaving a good impression on the OSCE examiner and the standardized patient minds through your look, voice tone, and facial expressions. These two persons will score your performance according to a checklist. OSCE organizers try their best to minimize personal bias from these two. However, what if your performance lies between two categories? Your performance was less than good but better than intermediate, for instance, which one to be checked for you? Here, their impression about you will act for or against you. They will think; either, he/she is better than this but the exam stress made him/her perform less than usual! Or, that is what actually looks like his/her real everyday performance! Do you get it? This will push you one level up or down! I don’t know how to stress the importance of communication skills in OSCEs and in real life practice too. In fact, it is what makes you a good or bad physician in the eyes of your patients in the future. Tell me, how many doctors do you know who are scientifically average but are very famous and rich! … On the other hand, how many doctors do you know who are scientifically excellent but are unknown and their practices are barely making a living! Work on improving your communication skills. It is not what you are and that’s it. Bad communications can be developed, improved, or even eliminated if it is harming you, right?! Yes, sometimes, it is not easy but it is not impossible. Start now. Rebuild the way you look, speak, and behave. Yes, rebuild what you’ve grown up with for a better you for your benefit. Your behavior with people may be sending the wrong message about who are you, or let’s say an inappropriate message for the current context! What about cultural diversity? Some behaviors that are acceptable in your culture may be unacceptable in other cultures or even professionally. So, how to evaluate your communication skills? First, know how are you doing. Assess your current communication skills. Assess your posture, look, hand and head movements, and facial expressions. Assess your voice and tone. Do that by: Watching yourself in a mirror while practicing or videotape your practice and play it back several times focusing on one aspect at a time. Be honest with yourself. Criticize your behavior as if you are assessing someone else. Write done positive and negative behaviors. This might be difficult as your Ego will stand up to defend yourself!. We believe we are perfect or at least suitable. Be honest for the benefit of yourself. The only drawback here is you may not know which is an appropriate behavior or gesture and which is not. 22

The Medical Interview: Notes  The second step is to ask a close friend or relative to watch you and assess. Choose someone who cares for you. Explain to him/her what aspects you want them to watch closely. Make it mutual. If they are preparing for the OSCE too. Assess each other and be open minded constructive and honest.  Finally, read books or attend course about communication skills and ethics in a medical context. Have a look on “How To Maximize My Communication Skills For The Medical Encounter”.

An approach for the medical interview: The third aspect of your OSCE preparation is to develop and practice a specific approach to the medical interview. In OSCEs, as well as in real life medical practice, you have limited time and resources. It is only 5-20 minutes long interview. And you have to ask so many questions, figure out what is wrong with this patient, while being gentle, courteous, friendly, attentive, and caring! You have to develop a step-by-step practical template that helps make the utmost of your limited available time and resources efficiently. You have no choice. You have no time to figure it out during the interview. No way! You will be nervous, irritable and thoughtless! And the patient, playing his role comfortably, enjoys watching you making lethal mistakes! Do not get me wrong. They are not bad guys. Their role is to stress you out to assess your performance. Sounds like you in an OSCE, right. You need a template that you will follow with every patient with the same group of illness every time automatically even if you are mentally exhausted or irritable. You need something to keep you organized and provide you with a road map to follow safely towards your goal of solving the station. You have to be prepared. There is no time to think in the OSCEs. You need a step by step system that makes you perform fast and yet makes you look calm, attentive, listening, and in control. A guide that makes you focused on the patient current situation and yet thorough exploring hidden issues like abuse or denial. You will follow the same steps with every patient. You’ll even repeat the same questions and sentences. Even the same reactions and empathy! In each OSCE room, there is a new patient (and a new examiner, if applicable). They didn’t watch your performance in neither the previous stations nor they will in the following ones. Just repeat! Simple! This book is about this third aspect. You don’t need to develop a template. My colleagues and I did it for you. You just have to memorize the steps and sentences as it is, practice it, then practice it again, and finally practice it until you perform the steps and say the sentences in an autopilot mode!

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The Medical Interview: Notes Medical knowledge and differential diagnosis has been covered in these steps. Verbal communications and ethical issues are also covered. You don’t need to add anything else concerning the medical interview. However, this book does not cover the post encounter questions, write ups, or non verbal communication skills. Visit www.oscehome.com for other resources concerning these issues.

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PART TWO THE HISTORY TAKING INTERVIEW

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Chapter 6:

THE HISTORY TAKING INTERVIEW

The MODEL To be organized, thorough, and not to forget important points, in the 5-20 minutes medical interview, you will follow the following steps IN SEQUENCE:

123456-

The Minute(s) Before the interview. The Introduction box. The Initial History Taking box. Station appropriate questions box. Standard questions box. Wrapping up box.

Use every possible opportunity while going through these boxes to develop a relationship with the patient. You should go through each of these steps in sequence while budgeting your time. I’ll explain each step in detail latter. But here are some tips. Read all of part two once without memorizing it in order to have an idea about how this model is organized. Then read it chapter by chapter. Stop at the end of each chapter. Memorize it. Practice, practice, and practice that chapter until you feel happy with your performance. Now, move to the next chapter. And repeat the same. As you read through the chapters, you may feel that it is impossible to finish all the steps in 5-20 minutes. There are so many questions to ask. The answer is in fact, no, it is not impossible and you can do it! … How? First, when you memorize the questions and practice them over and over, it won’t take long to ask. Remember, you are on autopilot. Secondly, you are going to ask only the screening question. Only if the patient’s reply was positive, you will explore further asking ALL the detailed questions. Third, the patient’s answer will be negative for all screening questions but one or two to be explored. The shorter the station the less positive answers will be. That is how the OSCE is organized. But don’t skip questions or steps. There are check marks that you don’t want to miss! 29

The History Taking Interview: The Model How long does it take to ask a one sentence carefully phrased question with a ‘no’ answer? … Less than five seconds! That’s 10-12 questions per a minute in an autopilot mode! Try it. But be careful, be relaxed friendly, attentive, interactive, and engage the patient. Don’t interrupt the patient or rush him/her. Don’t overwhelm the patient with rapid sequence firing questions. When you eliminate the burden of what to ask now and next. When you don’t have to think about ‘how’ to ask about something in a medically and ethically correct manner. When you are in control of the interview. Then, you’ll have time to think about solving the station. You’ll have time for communication skills and empathy. You’ll feel confident and will reflect that on your performance. Although you don’t have to, but studying your medical knowledge along with each system you practice here will show you the logic of these questions and how are they covering the main possible differential diagnosis. This may make them easier to memorize and remember. You don’t need to do that at the beginning. For example, study history taking, physical examination, differential diagnosis, risk factors, investigations, and management plans of chest symptoms and signs all together. This will cover respiratory, cardiac, upper gastrointestinal, and musculoskeletal systems at least. Master them then move on to another body part or system, and so on. Keep yourself focused on symptom-oriented approach. Find answers to required questions covering each topic. When you practice, don’t explain to yourself or memorize what you will do in the OSCE. This is a recipe for failure. Never do that. Practice by real acting. Imagine yourself in that OSCE exam room talking to the patient. Act as a professional actor. Act in every detail. Train yourself into an autopilot mode. One more thing before you begin. As you reach your last few practice trials for each section, make yourself unconsciously oriented to time. There is no clock in the exam room and it is completely wrong to look on your watch during the medical encounter. This will sent a non verbal message of being not interested. Make a habit of how long it takes to do things in your life other than medicine. For example, it takes you three minutes to shave, or five minutes to wear make up, or five minutes to fry an egg, and so on. Live these minutes and make road marks for yourself. For example, by the time you finish shaving the right side of your face, only two minutes left. Did you get what I mean? You do things in your life every day in a step by step manner! And you do them repeatedly with the same amount of time! Make your OSCE performance the same, a step by step manner for the same amount of time. Practice, Practice, Practice.

30

The Medical Interview Model© Minute(s) Before the interview Introduction Box Initial History Taking Box Station Appropriate Questions Boxes (one or two of:) Respirology

Cardiovascular

Gastrointestinal

Endocrinology

Genitourinary

Neurology

Musculoskeletal

Dermatology

Obstetric/Gynae

Pediatric

Psychiatry

Standard Questions Box A Step By Step To Mastering The OSCEs MedInfo Consulting © 2006

Wrapping up Box 31

32

Chapter 7:

THE MINUTE(S) BEFORE THE INTERVIEW

Ten steps to perform in these one or two minutes before the medical encounter:

1- Have a new blank sheet on your clipboard/ booklet. 2- Put your sticker(s) on your left hand index finger (or on your answer sheet). 3- Write down: Patient’s name (if a child; also; accompanying person’s name and his/her relation). 4- Write down: Patient age. 5- What is the setting?: Use abbreviation, such us - Your office? write OFF; - Walk-in clinic? write WC; - Covering a colleague? write CC; - Emergency Room? write ER. 6- Identify the station type: Use abbreviation, such us - History Taking?  write Hx; - Physical Examination?  write PE; - Consult?  write CON; - Combination?  write Hx & PE, Hx & CON - Emergency?  write ER. Then which ER type: - Management?  write MANAGE. - Post acute phase/ after management by others and stable now?  write Consult. - Any of the above: Hx, PE, Hx and PE. 7- Identify the Chief Complaint (CC) / Consult subject and duration if given write it down. 8- Write down any given findings (Circumstances, vitals or labs). 9- Identify the CC body system(s)? write it down. 10- Remember the station(s) appropriate questions box and differential diagnosis (DDx).

On the whistle/ buzzer/ bell: Knock the door and go in smiling, calm with shoulders up. (Show confidence and friendliness)

33

The History Taking Interview: The Minute(s) Before

TIPS:

34

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Practice this step.

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Memorize the ten steps in sequence.

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Get blank papers and a clipboard or a pocket booklet just like the one you use in the exam. Check your exam official site to know what kind of papers will be given in the exam.

-

Find a door at your home leading to a small room. Any door.

-

Wear a lab coat and decide where are you going to put your pencil, stickers, stethoscope, pen light, hammer, measuring tape, the notebook and any other instruments asked to bring with you. Select places according to your connivance and rapid access.

-

Practice to take out these tools use them and put them back at the SAME place you decided to do. This is very important. As in exams, you will be nervous and you will forget where are these tools and will start looking for them nervously wasting valuable time and showing the examiner and the patient that you are not organized and don’t know what to do next!

-

Take the blank papers and decide how are you going to organize it. Where to write the eight required information like the name, age, station type, etc. It is important to stick to the same format for quick access.

-

It is very important to write every thing as you will be amazed how quickly you will forget them during the encounter due to the exam’s fast pace and nervousness.

-

Place a peace of paper on the door with a stem question written on it. Get stem questions at OSCEs Home at http://www.oscehome.com.

-

Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.

-

Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with ONE minute.

-

After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, gestures, standing position, head position and look Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/Communication-Skills.html.

-

Practice and practice and practice. Never underestimate the importance of acting and living the steps. Don’t tell yourself that you will do so and so, DO IT. Just do it. You can do it !

Chapter 8:

THE SELF-INTRODUCTION

Ten steps to perform in this stage of the medical encounter in 15 seconds: 1-

Give the examiner your sticker, smile and move on (if applicable).

2-

Approach the patient while smiling and relaxed.

3-

Identify the patient: “Mr/Ms…..?” in a questionable tone.

4-

Establish a sense of privacy: Draw a curtain / close the door / suggest that a visitor wait outside (Accept the patient decision).

5-

Introduce yourself confidently, softly, friendly, comfortably: “Hi, I am Dr …….… (last name)”. Shake hands, if you want (Preferred).

6-

Mention your position: one of: - in your office: nothing more. - in a colleague clinic: “I am covering for Dr….today”. - in a walk in clinic / ER: “I am the physician on duty here today”.

7-

Ask the patient about how he/she would like to be addressed: “Mr/Ms….., how would you like me to address you?”

8-

Quickly screen the room: Where is the patient, your chair, stretcher, and TOOLS. Tools in the room are more likely meant to be used.

9-

Ask the patient to sit down (pointing where) if he/she is not already sitting or lying on a stretcher. “Be seated/ lie down (if needed) here please.”

10- Then sit down. Don’t move the chair closer to or away from the patient. Ideally about a meter far and in a narrow angle.

Through out the medical encounter: -

-

Maintain an attentive position: leaning forward 10 % with straight head, back and shoulders up. Maintain eye contact almost throughout the interview. Look at the patient’s forehead at the mid line just above the nose. The patient will think you are looking on his/her eyes, which is a sign of interest in him/her. Looking at the patient’s eyes will disturb your thinking. Avoid that. Minimize distractions, including writing down notes. Give the patient the time to answer in his/her own words, then facilitate and clarify.

Note: Hereafter in this book, sentences addressed to the patient will be in blue color and starts with “Mr/Ms…,” and placed between quotes. However, you don’t have to say Mr/Ms. Choose what the patient decided to be addressed with for at least three times during the interview. Not with every question. 35

The History Taking Interview: The Self-Introduction

Sentences to be memorized in sequence: 1. “Mr/Ms…..?” in a questionable tone. 2. “Hi, I am Dr …….… (last name)”. 3. Nothing or “I am covering for Dr….today” or “I am the physician on duty here today”. 4. “Mr/Ms….., how would you like me to address you?” 5. Nothing or “Be seated please.”

TIPS:

36

-

Practice this step.

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Memorize the ten steps in sequence.

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Imagine the patient is setting on your right (and the examiner on the left) and practice. Now change positions and practice. Imagine the patient is lying down on a stretcher on your right, then left, then in front.

-

Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.

-

Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with 15 SECONDS or less.

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After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, voice tone, gestures, eyes and eyebrows movements, lips movements, standing position, head position and look

-

Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/CommunicationSkills.html.

-

Practice and practice and practice. Never underestimate the importance of acting and living the steps. Don’t tell yourself that you will do so and so, DO IT. Just do it.

-

You can do it !

Chapter 9:

THE CHIEF COMPLAINT

10 steps to be done in ONE minute: 1- “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?” 2- Clarifying the Chief Complaint (CC): “I understand, you have been having some…. (CC from the stem question) ”(best sentence) or “How can I help you?” or “What brings you here today?”. 3- Write down the CC in patient’s words. 4- Make sure what is the real CC: “So, you have …(CC), …. Let’s talk about it, but first, is there anything else bothering you? Are you having any other problems physically? Or, are there any special stresses in your life right now?.” If yes  “Which one do you want us to discuss first/today?” 5- Invite him/her to tell their story “Tell me all about the …(CC) right from the beginning ”. 6- Maintain eye contact, don’t interrupt, facilitate and encourage with sounds (Ah ha, yes, go on, I see), head nodding, and empathy facial gestures. 7- When he/she stops, explore the CC if he/she uses vague terms like tired, dizzy, diarrhea .etc,  “What do you mean by…....?” Offer menu list of 2-3 descriptions. 8- Duration: “When would you say it started?”  make sure “So it started .… ago?”. 9- If CC presents for some time: “What made you decide to get it checked now?” 10- Empathy: Watch your voice tone and facial expressions

Reasons to come now are: 1. Symptoms worsen. 2. Anxiety developed, even if symptoms lessen. 3. An excuse for a hidden CC.

“That must be very difficult for you to cope with?” “I can see you have been under a lot of stress” “How are you feeling about that?” Patient’s non-verbal “How has this been affecting you?” cues of distress: - Avoiding eye contact. “I can see you are/ It sounds like you’re feeling / - Fidgeting. You seem (anxious/ worried/ angry/ upset/ - Shifting around in the frightened) …….. Is that right?” chair. “This is completely understandable. Most people - Holding their body tensely. in similar circumstances would react just as you However, don’t assume are.” that, check it out with “I am sorry to hear that.” them. (? Cultural). “It must be hard for you, what are you unable to do as a result of the …(CC)” “It would be surprising if you didn’t feel (angry / upset / worried / frightened) after hearing that / waiting all that time.” “This can’t be an easy time for you, we’ll work together to get through this.”

Silent or Talkative patient? How to save time and direct the patient? Find out how at the book: “How To Unlock Difficult Patient Encounters”

www.oscehome. com/DifficultOSCEsSenarios.html

37

The History Taking Interview: The Chief Complaint If the patient asked: “Is it serious?” “Am I going to die?” “Do I have..(cancer, heart attack)?” “Do you think that … (my medications/ work/ doctor/ partner….etc) is causing the ..(CC)”  Reply: “Mr/Ms…, I can see you are anxious and I am glad you came here today. We need to look on certain things and run some investigation to be sure. Relax for now, together, we’re going to figure it out” No false information or hope but also no worrisome comments. Keep it neutral and open to both good and bad outcomes!

Sentences to be memorized in sequence: 1. “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?” 2. “I understand, you have been having some…. (CC from the stem question)” or “How can I help you?” or “What brings you here today?”. 3. “So, you have …(CC), …. Let’s talk about it, but first, is there anything else bothering you? Are you having any other problems physically? Or are there any special stresses in your life right now?.”.  “Which one do you want us to discuss first/today?” 4. “Tell me all about the …(CC) right from the beginning ”. 5. “When would you say it started?”  “So it started .… ago?”  “What made you decide to get it checked now?” 6. Empathy sentences: Very important.

TIPS:

38

-

Memorize the ten steps in sequence.

-

Practice the ten steps over and over and over until you feel you are doing them naturally and confidently.

-

Don’t worry about how long it takes to do it at the beginning. Just master the steps first. Then, with time try to be faster and faster to finish it with ONE MINUTE or less.

-

After you master it. Do it in front of family members or study group. Ask them to criticize you honestly and freely. Ask them about your nonverbal communication, voice tone, gestures, eyes and eyebrows movements, lips movements, standing position, head position and look

-

Accept critics openly and adopt changes. Check OSCEs Home communication skill page at http://www.oscehome.com/CommunicationSkills.html.

Chapter 10:

History of Present Illness (HPI) OSCD PQRST UVW + AAA

The following 15 points has to be explored ALL for pain CC. It should also be used to explore any other CC, e.g. vaginal bleeding, cough, shortness of breath, dizziness, vomiting, diarrhea, hematuria ..etc, except place, radiation and quality (5, 6, 7) which will be explored in the station appropriate boxes. 1) Onset: “How did it start? Was it all of a sudden or gradually?”. 2) Setting: “What were you doing when it started?”. 3) Course: “Is it getting worse, better or just the same?”. 4) Duration: “You said it started … ago, does it come and go?” If yes  “How often / frequent does it come?”….. “For how long dose it stay each time?”. 5) Place: “Show me exactly where is it on your body, point where with one finger”. Only for pain CC

6) Quality: “Tell me, how does it feel like?”……   Clarify one at a time: Is it sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning? ” 7) Radiation: “Does it go/ shoot anywhere?”. 8) Severity: “How bad is it, on a scale from 1 to 10, with 1 is the mildest, and 10 is the worst pain?,… Does it interfere with your daily activities?”. 9) Timing: “Is it worst in a particular time of the day?”. 10) U (you) Your daily activities: “Does it change with your daily activities like posture, exertion, rest, sleeping, eating, hunger?”. 11) V (déjà vu): “Has it happened before?” If yes  “When?… How did you handle it?…What happened to it? … Which doctor?… What medication? ..etc Explore. 12) What: “What has worked for you so far?... What hasn’t?… What do you think is causing it?…” 13) Aggravating factors: “What brings it on? What makes it worse?” 14) Alleviating factor: “What makes it better?” 15) Associated symptoms: “Have you noticed anything else that occurs with it?” If the patient ask “What do you mean/ such us what?” “Any thing that you may recall?”.

39

The History Taking Interview: History of Present Illness (HPI)

Summarize:

Important “Let me see if I have it straight. You felt perfectly well until …. ago when you felt….(CC)?.. The….(CC)………”

Interviewing technique:  Start with: General open-ended questions.  Then: Topical open-ended questions.  Proceed to: Lists / Menus questions.  Then: closed-ended questions.  Then: Yes/ No questions.  Use minimal facilitators: “ Yes, uh huh, head nodding, what else?, .. and?.”  Avoid: - Leading questions. - Multiple questions at the same time.

Sentences to be memorized in sequence: “How did it start? Was it all of a sudden or gradually?”. “What were you doing when it started?”. “Is it getting worse, better or just the same?” “You said it started … ago, does it come and go?” If yes  “How often / frequent does it come?”….. “For how long dose it stay each time?”. 5. “Show me exactly where is it on your body, point where with one finger”. 6. “Tell me, how does it feel like?….. Is it sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning? ”. 7. “Does it go/ shoot anywhere?” 8. “How bad is it, on a scale from 1 to 10, with 1 is the mildest, and 10 is the worst pain?,… Does it interfere with your daily activities?”. 9. “Is it worst in a particular time of the day?”. 10. “Does it change with your daily activities like posture, exertion, rest, sleeping, eating, hunger?”. 11. “Has it happened before?” If yes  “When?… How did you handle it?…What happened to it? … Which doctor?… What medication? ..etc Explore. 12. “What has worked for you so far?... What hasn’t?… What do you think is causing it?…”. 13. “What brings it on? What makes it worse?”. 14. “What makes it better?”. 15. “Have you noticed anything else that occurs with it?”“Any thing that you may recall?” 1. 2. 3. 4.

Before you proceed. Make sure that you did memorize and practiced these steps first. Make sure that you have been doing them confidently and naturally. You must be able to finish them in about 2 - 2.5 minutes fluently & comfortably!

40

TIPS: -

-

Memorize the 15 steps in sequence. Don’t worry about how long it takes to do it at the beginning. Then, with time try to be faster and faster to finish it with ONE MINUTE or less.

Chapter 11:

THE STATION APPROPRIATE QUESTION BOXES

This includes symptoms and risk factors associated with the CC organ system. Use only one or two of these station appropriate question boxes at each OSCE station. Decide which one and remember the questions during the “Minute(s) Before” step. Now, as we reached this stage, you must use a transitional statement to prepare the patient to the next stage in the interview and to appear organized. You don’t have to pause. Just after you finished a quick summary of the previous step, the chief complaint, tell the following transitional sentence: “Mr/Ms..., now, I want to ask you some questions about things that may or may not be associated with ....(CC), okay? ” This will show your organizational skill and prepare the patient to what are you both doing next in a respectful way. Many patients will appreciate having road maps about what is going during the medical interview and most importantly WHY you are asking these questions and why should they answer them. This will avoid having the patient jumping in your face with a questioning comments like:

Systems are: Neurology, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, Dermatology, Endocrinology/ Hematology, Musculoskeletal, Obstetrics & Gynaecology, Pediatrics, and Psychiatry.

“Why are you asking this?… Is this relevant?… Do I have to answer that? … Do you thing that’s what’s causing it?, .. etc.” Standardized patients in OSCEs are trained to do so and they love to do it! So, attempt to cut the possibilities of letting them ask you so by using short informative sentences to justify what are you going to ask and prepare them. In each box, there are several SCREENING (underlined) questions. You will ask only these questions. Screening questions are also used for the system review questions. If the patient replies with positive answer for any screening question, then you will explore that symptom with further EXPLORING questions. Exploring question covers all the differential diagnosis for that symptom (even if you don’t know it). Never ask exploring questions if the patient’s answer was negative. Some of these questions may already been asked during the HPI if they are relevant to the chief complaint, use them to explore it. Don’t repeat… Confused?… Don’t worry now!… With practice you will remember these detailed questions while taking the HPI. Questions formats: “Do you have .../ Does he/she have…/ Have you .../ Has he/she …/ What about .../ In what way…?” If yes for anyone explore. NEVER USE NEGATIVE QUESTION, like “And you don’t have ..…(fever) ”. They are leading questions. You are giving the patient the impression that you want a negative answer for this question!

41

The History Taking Interview: Station Appropriate Question Box: NEUROLOGY

Neurology appropriate questions: HLD NeW VHS MTC 1- H eadache: “Do you have headache?” Screening question. Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start?” (thunderclap in Subarachnoid hemorrhage). - Place: “Show me exactly where is it on your head, point where with one finger… Is it on one side or both?”. - Severity: …“Does it interfere with your routine physical activity and work?” - Timing: “Is it worse in a particular time of the day?”( AM: ICP/ PM: Tension, migraine), - U: Does it change with your daily activities like posture (lying down/sitting), eating, hunger, exertion, rest, sleeping/ wakes you up (Cluster))? - Associated symptoms: “Have you noticed anything else that occurs with it?.. feeling sick (nausea) or throwing up (vomiting)?…/ Stiff neck?.../ Eye problems?…./ Pain on chewing?…/ Annoyed by light?”, Warning signs: “Is it preceded by warning signs?… What are they?” (aura in migraine).

2- Loss of Consciousness(LOC): “Have you passed out / blacked out?” Yes  Explore: OSCD PQRST UVW AAA

Seizure or syncope

- Empathy: “Ooooh, did you hurt yourself?” - Duration: “For how long did that last?” - Completely: “Did you lose consciousness completely or could voices be heard?” - Body Position: “What was your position during the attack?” - Body Movements: “Did any body movements occur?” - Tongue-biting: “Did any tongue-biting occur?” - Confusion/ sleepiness after attack: “How did you feel after the attack?” - Urinary/ bowel Control: “Was there any loss in bladder or bowel control?”  Seizures: “At what age did it start? How often dose it happen?” - Warning signs: “Was it preceded by warning signs?.. such us lightheadedness? ”

3- D izziness: “Have you felt unsteadiness (vertigo) or light-headedness (presyncope) ?”

Yes  Explore: OSCD PQRST UVW AAA

- Duration: “For how long?” - U: “Does it change with your head movement?.. Opening or closing your eyes?.. How?” (: Vestibular),.. Does it only occur for a minute in certain head positions? (BPV, VBI),.. Does it change with exercise? (Cardiopulmonary)” - Associated symptoms: “Have you noticed anything else that occurs with it? ... Feeling sick (nausea) or throwing up (vomiting) ?…/or hearing change?(Inner ear disease),... Gait problem? (Ataxia),.. Double vision?, Difficulty speaking? (Brainstem disease) ”. …. Continued 42

The History Taking Interview: Station Appropriate Question Box: NEUROLOGY

Neurology appropriate questions, …Cont 4- Numbness: “Do you have numbness, loss of sensation, or pain anywhere?” Yes  Explore: OSCD PQRST UVW AAA - Place: Where?.. One side or both?” Is it localized to a dermatome? - Quality: “Does it feel like tingling?… prickling?…. warm?…. cold?. pressure?.... Or like a distorted sensation in response to a stimulus?”

5- Weakness: “Any weakness?” Yes  Explore: OSCD PQRST UVW AAA - Place: “Where?…. One side or both?”…. “What activities do you have difficulty with?” Proximal (standing/combing): (myopathy)/ or distal (neuropathy).

6- Visual changes: “Any visual changes recently?” Yes  “In what way?.. One eye or both?.. Any eye pain?.. Tearing? Redness?,.. Does light bother you?,.. Double vision?.. vertically or horizontally?.. Any flashing lights?”

7- Hearing changes: “Any hearing changes?.

Yes  “Do you hear any noises or tinnitus in your ears?…. Earache?… Ear fullness?… Any ear discharge?” Yes, How much, what colour is it?… Is it thin or thick?.. How dose it smell?.. Any blood?”

8- Difficulty Speaking: “Do you have difficulty speaking?” Yes  “In what way?”.

9- Memory/Concentration: “Have you noticed any memory loss/ difficulty concentrating?” Yes  “In what way? ”.

10- Tremor: “Any tremor or involuntary movements?

Yes  “In what way?…. Is it worse with certain postures (Essential postural), movement (Intentional: Cerebellar) or rest (Parkinson) ?” “Any gait problems?””.

11- Bladder / Bowel C ontrol: “Do you control your bladder and bowel motion?” No  “In what way?”.

43

The History Taking Interview: Station Appropriate Question Box: RESPIRATORY

Respiratory appropriate questions:

PCS Wheezes HEAT On Us + Risks

1- Chest Pain: “Any chest pain?” Dry cough: Viral, Interstitial, Allergy, Cancer.

Productive cough: Bronchitis, Bacterial pneumonia, Abscess Bronchiectasis, TB.

Uninfected sputum: Mucoid, transparent, odourless, whitish gray.

Purulent rusty: Pneumococcal pneumoni

Red current jelly: Klebsiella pneumonia

Foul smell: Abscess Frothy pink: Pulmonary edema

Positional: Abscess, Tumor, GERD

Hemoptasis: with cough & dyspnea; red; frothy; may be with pus.

Hematamesis: with nausea & vomiting; red/brown; not frothy; may be with food.

SOB with exercise: Chronic bronchitis / emphysema, CHF.

SOB at rest: Asthma.

Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago (3/d: severe)” - U: Is it worse with deep breathing or cough (Pleuritic)?.. position change (MSK)?.. eating (Esophageal spasm)?” Sharp, one side, worse with deep breathing or cough  Pleuritic. Aching, one side, lateral low down  Spontaneous pneumothorax.

2- C ough: “Do you have cough?”

Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago, does it come and go?” If yes  “For how long it dose stay each time?” Acute vs. chronic (>3 months for 2 years).

- Place: “Do you feel it coming from something in your throat or deep in your chest? ” - Quality: “Is it dry or with sputum / phlegm? Yes  - Sputum: “How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell?” - Blood: “Do you cough up blood?” Yes  Fresh blood or altered? How much blood? How frequent do you cough up blood?” - Timing: “Is it worst in a particular time of the day or season?”, “How often does it come?” (Morning: smoking, Nocturnal: Postnasal drip, CHF, asthma.).

- AAA: “What brings it on? What makes it worse?” “Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”

3- SOB : “Do you get shortness of breath? ” Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start? Was it all of a sudden or gradually (PE)?” - Setting: “What were you doing when it started (Dusting/ Exercise)?” - Quality: “How does it feel like?.. Is it like air hunger, suffocation, or heavy breathing (cardiac) ?,…. Is it like rapid shallow breathing? (chest wall), Chest tightness? (Asthma), .. Increased breathing effort? (COPD/ ILS) ” - Severity: “How frequent?... How many times a week?…” “When you get shortness of breath, are you able to speak?,… Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?” ….Continued

44

The History Taking Interview: Station Appropriate Question Box: RESPIRATORY

Respiratory appropriate questions:

…Cont

- “Any visits to the emergency in the last 12 months?” Yes  “How many times?... Have you ever had a breathing tube down your throat or been on a breathing machine?… Have you ever been admitted to the hospital?,… Intensive care unit?” - Timing: “Is it worst in a particular time of the day or season?.. Is it worse at night? (asthma)” - ADL: “What activities are you no more able to do?” Empathy. - U: “Is it related to exercise?.. Is it relieved by rest?” - Orthopnea: “Are you able to lie flat in bed without becoming short of breath?.. How many pillows do you sleep on at night?”(asthma>COPD) Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal nocturnal dyspnea in HF)”

4- Wheezes: “Do you hear noises in your chest with breathing?.. What about in your throat?”(Stridor?)

5- H oarseness: “Any change of voice?” 6- Exercise intolerance: “How many flights of stairs can you climb/ blocks can you walk?.. So, it is more (grade II)/ less (grade III) than two blocks/ one flight?”.

7- A nkle swelling: “Do your ankles swell on you?”(edema?) , Yes: When did it start?.. How long did it take to go away?”…. “Any pain in your legs?”(DVT.. PE?).

8- Travel: “Any history of travel?.. Where? ”(exposure to TB, SARS, HIV). 9- O ccupation: “What do you do for living?.. Does your ..(CC).. improve during weekends or vacations?”.. “What exactly does this job involve?”

10- Others: “Any exposure to people with HIV, TB, SARS?”.. “Have you ever felt your heart racing?,.. Any face flushing?.. Any diarrhea” (Hormone secreting tumors).

11- URT: “ Any running nose?.. Eye problem?.. Skin rash (Viral) ? Face pain? (Sinusitis),.... Do you need to clear your throat frequently? (Post nasal drip)”

12- Risk factors: Will be asked in the standard questions box: Smoking (+2nd hand), Cold, Travel, Allergies, Pets/ dust, Occupation, HIV/TB, emotional changes, medications (ASA, ACEI, Beta blockers).

45

The History Taking Interview: Station Appropriate Question Box: CARDIOLOGY

Cardiology appropriate questions:

PCS OSAP PLC EAR

1- Chest Pain: “Any chest pain?” Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago (3/d: severe)” - U: Is it worse with deep breathing or cough (Pleuritic)?.. position change (MSK)?.. eating (Esophageal spasm)?”

2- Cough: “Do you have cough?”

Yes  Explore: OSCD PQRST UVW AAA - Duration: “You said it started … ago, does it come and go?” If yes  “For how long dose it stay each time? ” Acute vs. chronic (>3 months for 2 years).

- Place: “Do you feel it coming from something in your throat or deep in your chest? ” - Quality: “Is it dry or with sputum / phlegm? Yes  - Sputum: “How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell?” - Blood: “Do you cough up blood?” Yes  Fresh blood or altered? How much blood? How frequent do you cough up blood?” - Timing: “Is it worst in a particular time of the day or season?”, “How often does it come?” (Morning: smoking, Nocturnal: Postnasal drip, CHF, asthma.).

- AAA: “What brings it on? What makes it worse?” “Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”

3- SOB : “Do you get shortness of breath? ” Yes  Explore: OSCD PQRST UVW AAA - Onset: “How did it start? Was it all of a sudden or gradually (PE)?” - Setting: “What were you doing when it started (Dusting/ Exercise)?” - Quality: “How does it feel like?.. Is it like air hunger, suffocation, or heavy breathing (cardiac) ?,…. Is it like rapid shallow breathing? (chest wall), Chest tightness? (Asthma), .. Increased breathing effort? (COPD/ ILS) ” - Severity: “How frequent?... How many times a week?…” “When you get shortness of breath, are you able to speak?,… Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?” ….Continued

46

The History Taking Interview: Station Appropriate Question Box: CARDIOLOGY

Cardiology appropriate questions: …Cont - “Any visits to the emergency in the last 12 months?” Yes  “How many times?.. Have you ever had a breathing tube down your throat or been on a breathing machine? Have you ever been admitted to the hospital?,… Intensive care unit?” - Timing: “Is it worst in a particular time of the day or season?.. Is it worse at night? (asthma)” - ADL: “What activities are you no more able to do?” - U: “Is it related to exercise?.. Is it relieved by rest?”

4- O rthopnea: “Are you able to lie flat in bed without becoming short of breath?.. How many pillows do you sleep on at night?”(asthma>COPD) Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal nocturnal dyspnea in HF)”

5- Sweating: “Any sweating?” 6- A nkle swelling: “Do your ankles swell on you?”(edema) Yes  Explore “When did it start?..

7- Palpitation: “Have you ever felt your heart racing/ fluttering/ funny?” Yes  Explore “When did it start?..

8- Loss of Consciousness (LOC): “Have you passed out / blacked out?” Yes  Explore: OSCD PQRST UVW AAA Seizure or syncope - Empathy: “Ooooh, did you hurt yourself?” - Duration: “For how long did that last?” - Completely: “Did you lose consciousness completely or could voices be heard?”

9- C olor: “Did your lips turn blue? (Cyanosis),…. Did your face turn pale? (Pallor)”

Yes  Explore: “How long dose it take to go away?”

10- Peripheral vascular: “Do you have pain in your limbs?” Yes  explore OSCD PQRST UVW + AAA Is it with exercise, rest or both?... Any changes in the limb colour?.. Blue, Pale, Dark (cyanosis/ pallor/ pigmentation) ? Do you feel it cold or warm?... Any numbness?... weakness? Any skin or nail changes?.. ulcers?.. hair loss? ”

11- Exercise intolerance: “How many flights of stairs can you climb/ blocks can you walk?.. So, it is more (grade II)/ less (grade III) than two blocks/ one flight?”.

12- Anxiety: “Are you worried?.. Do you have a feeling of impending doom?” Yes Empathy “Ooooh! It must be hard.”

Peripheral vascular 6 Ps: Pain Polar Pallor Parasethesia Paralysis Pulselessness If chronic : + atrophic changes: History of claudication. Loss of hair Dry thin skin. Deformed nails. Ulcerations. Pigmentation.

13- Risk factors: Will be asked in the standard questions box: Previous CAD, HTN, DM, Hypercholestrolemia, Smoking, Family Hx of heart disease 3/day unformed/ Constipation: < 3/week hard stool with staining & sense of incomplete evacuation or blockade)

- Pain: “Any pain with passing bowel motion?”,… Any pain in your bottom?. Yes “When does it occur?” - Lesions: “Any lumps, ulcers or fissures in your bottom?” - Tenesmus: “Any urgency to pass bowel motion but then little to pass?” - Control: “Do you control your bowel or you soil yourself?” - Stool: “Does your stool look as it was before or different? ” No  Explore: - Shape: “Is it wider, more bulky or narrower?.. Softer or harder?.” - Content: “Is it greasy?.. Does it stick to the bowel or float?,.. Any mucus?, .. Pus?.. Undigested food?.. .” - Colour : “What colour is it?: Pale? (Fat)/ Black? (Malena) /Green? (Pus)” - Blood: “Any blood?” Yes  “Is it fresh bright blood (after Splenic flexure) or altered or clots (before)? How much blood?.. A cup?.. Is it gross or only streaks on the stool surface?.. Does the blood appear at the beginning, at the end, all through the motion, or only on the toilet tissue? ” - Smell: “How does it smell?” * Diarrhea: - Onset: “How did it start?.. Was it all of a sudden or gradually?” - Duration: “When did it start? (>2 weeks: Chronic), So it is less/ more than two weeks (Chronic)? Does it come and go?”… Yes  “How frequent does it come?.. For how long does it stay each time?.. Does it alternate with periods of constipation?” - Quality: “Is it loose or watery?. Is it bulky shapeless?” - Timing: “Is it worst in a particular time of the day?” Morning: IBS. Nocturnal: Organic

10- O rthostatic assessment: Only if bleeding, diarrhea or vomiting (DTHU): “Do you get lightheadedness?, ...What about when you stand up or get out of bed in the morning?” (pre-syncope/ Anemia ),... Do you feel thirsty and

your mouth dry?,... Have you ever felt your heart racing?,... Do you void less?” 49

The History Taking Interview: Station Appropriate Question Box: GENITOUROLOGY

Genitourology appropriate questions:

PD UHF SUV FIDO

1- Pelvic Pain: “Any pain?” Yes  Explore OSCD PQRST UVW + AAA. - Place: “Where do you feel it, point with one finger please?” Localized or generalized? Flank (pain or CVA tenderness), Suprapubic, Groin, Testicles?. - Quality: “How does it feel like?.. Colicky or burning?.. Is it sharp?.. Stabbing?.. Dull?.. Tight?.. Cramps?.. Squeezing..? .. Is it constant or waxing and waning?”

2- Dysuria: “Any pain while passing water / voiding/ peeing?” 3- Urgency/ Hesitancy: “Any urgency to void/ pee? .. Hesitancy? .. Straining? .. Any feeling of incomplete emptying?”

4- Frequency: “Is there any change in the frequency recently?” Yes  Explore:

“Is it more or less? What about at night, do you wake up to go void? (Normally < 2 for adult males, none for females)”

5- Volume & Stream: “Any recent change in its volume? Yes  Explore: 

“Is it more or less than usual?..” “What about the stream: is it weaker or interrupted?... Prolonged voiding?.. Any dribbling after voiding?”

6- Urine: “Tell me about your urine” - Colour: “What colour is it?.. Is it dark brown/ tea or cola-coloured?.. Red?..” - Blood: “Any Blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it clear or cloudy?” - Smell: “Does it have a foul smell?”

7- Incontinence: “Do you control your bladder?” No  Explore: “Is it with stress like walking/ standing/ coughing (Stress incontinence) or is it continuous but cannot pee (obstruction overflow/ neurological)?.. Is it leaking with urgency (Urgency incontinence)?”

8- Swelling (Morning face puffing /Ankle): “Any face puffing in the morning?.. Do your ankles swell on you?”

9- Fluids: “How much fluid do you drink in a day?”

50

The History Taking Interview: Station Appropriate Question Box: GENITUOROLOGY

Genitourology appropriate questions: …Cont. 10- D ischarge (Penile/vaginal): “Any penile/ vaginal discharge? ” Yes  Explore OSCD PQRST UVW + AAA. - Colour: “What colour is it?.. Is it white, yellow or green?” - Blood: “Any Blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it thin or thick?” - Smell: “Does it smell?” - Quantity: “How much discharge is it?”

11- Others: “Any eye, joint or skin problems?,… Kidney stones?”

51

The History Taking Interview: Station Appropriate Question Box: ENDOCRINE/HEMATOLOGY

Endocrinology/ Hematology appropriate questions: WENT MSN ENG RPL

1- Weight changes: “Any recent weight changes?” Yes  Explore OSCD PQRST UVW + AAA. “In what way? ... How many pounds?… Have you noticed if certain areas of your body are getting fatter or thinner? (Redistribution)”

2- Energy changes: “What about your energy? Any recent change?”

Yes   “Do you feel more energetic or do you become fatigued easily?”

3- Nervousness /Anxiety: “ Do you feel nervous or anxious most of the time?... Have you ever felt your heart racing?... Any tremor?”

4- Temperature: Heat / Cold intolerance: “Does the heat or cold bother you more than you think it bothers other people?….. How?..”

5- Mood changes: “Any recent mood changes?, Do you feel low?... Have you lost interest in doing activities that were enjoyable to you? (Depression with thyroid) ”

6- Skin changes: “How do you feel your skin; dry or moist?.... ” - Color: “Any rash or pigmentation?... Did your face turn pale?.... ” - Bleed: “Do you easily bleed or get bruised?” - Hair: “Any recent change in your hair growth and distribution?…. ” - Nail: “Any nail shape changes?”

7- Neck swelling: “Have you noticed any lumps in your neck or felt it wider?”

9- Eye changes: “Any recent visual changes?.. Eye pain?… Colour changes like redness or yellowness?… Shape change?”

8- Neurological Screen: “Do you have Headaches?… Do you feel lightheadedness?… Do you feel any pins & needles sensations?.. Where?.. Any muscle weakness?.. Yes  Where?… What activities do you have difficulty with?” (Proximal: Difficulty climbing stairs).. …. Empathy.

10- GI Screen: “Do you feel sick? (nausea) , Did you throw up? (vomiting) ” “How is your appetite?… ” “Any mouth ulcers?... ” “Difficulty swallowing?...” “Any change in your bowel habit?…” Yes “In what way?...” “Any black stool or bleeding from your bottom?...” Yes Explore. … Continued

52

The History Taking Interview: Station Appropriate Question Box: ENDOCRINE/HEMATOLOGY

Endocrinology/ Hematology appropriate questions: …Cont. 11- R enal Screen: “Do you feel thirsty frequently? ... How much fluids do you drink in a day? (polydepsia)... ” “What about passing water/ voiding, any change?... Is it more or less than usual? (Polyurea) …” “Is your urine red or cloudy?…” “Do you have kidney stones?”

12- Pain: “Any stomach,… joint pain,… bone pain,… muscle pain?” 13- Libido (for males) / Menses (for females): “Mr/Ms .., in order to understand your condition, I need to ask you some questions about your sexual history. Is that okay?……...” “Any changes in your sexual desire (Libido)/ menses?... How?”

53

The History Taking Interview: Station Appropriate Question Box: MUSCULOSKELETAL

Musculoskeletal appropriate questions: joint PR STD, ROMAN’S Activity MisS NG

1- Joint Pain: “Any joint pain?”

Yes  Explore OSCD PQRST UVW + AAA - Place: “Which joint?.. Any other joints?… Which joint pain is worst? Does it move from joint to another?.. Is it the same on the other …other limb’s same joint (Symmetrical)?” - Duration: “Does it come and go, or wax & wane? (Constant: Malignant/ Infectious)

- U: “Does it only occur or get worse at rest or movement or both?... What about with posture change?” - Timing: “Is it worse in a particular time of the day, like end of the day (Mechanical/ Degenerative) or at night? (Malignant/ Infectious)”

2- Joint Redness: “Any joint redness?” 3- Joint Swelling: “Any joint swelling?”

Yes  … “Was it sudden (Trauma) or gradual?”

4- Joint Trauma / Procedure / Injections / Surgery: “Have you ever had any trauma, procedure, injections or surgery on any joint?” “Do you have to do the same movements repeatedly at work or home?” Trauma Case: “Have you heard a click when it happened?” “Were you able to bear weight immediately after the incident? ”

5- Joint Deformity/ Gait deformity: “Any deformity in the joint shape?… Do you feel your (joint) unstable? (Ligament/ Meniscus tear)... Locking? (loose body) .. Any change in your gait pattern?”

6- Range O f Movement (ROM): “Is there any reduction in the range of movement of your …. (shoulder/elbow/wrist/finger/thumb/hip/knee/ankle/toe/back) ?” (Mention joints, not limbs).

7- Noise: “Any noises with movement?”(Crepitus) 8- Morning Stiffness: “Any movement stiffness when you wake up in the morning?” Yes  “How long does it take to go away?… So, it is more than (Inflammatory) / less than 30 minutes (Degenerative / Mechanical)?”

9- A ctivities of daily living (ADL): “How has this been affecting your daily activities?.. What activities do you have difficulty with or are unable to do?… Who does the cooking, the shopping, the laundry, the cleaning for you?...”  Empathy: “Oooh, It must be hard, how are you coping with it? ” ...Cont. 54

The History Taking Interview: Station Appropriate Question Box: MUSCULSKELETAL

Musculoskeletal appropriate questions: … Cont. 10- Muscle: “Any muscle pain?.. Weakness?.. Wasting?.. ” Yes Explore:“Where?”

11- Skin changes: “Any change in skin colour?... Redness?... Bruises?... Warmth?... Rash?... Skin tightness on your face or hands? (Scleroderma) … Eye redness or pain?”

12- N eurological: “Any changes in skin sensation like it’s less than before?… Tingling sensation?... Any headache?... Difficulty speaking?... Vision problem?... Do you control your bowel or bladder?… Any back pain?”

13- GI: “Any mouth ulcers?... Difficulty swallowing? (Scleroderma) ... Frequent episodes of diarrhea & constipation?... Bleeding from your bottom? (IBD)” Inflammatory

Degenerative / Mechanical

- Pain worst with rest. - Pain better with movement. - No change during the day - Inflammatory symptoms: Pain, redness, warmth, swelling. - Morning stiffness > 30-60 min - Passive ROM > Active ROM

- Pain worse with movement. - Pain better with rest. - Pain worse at end of the day. - No inflammatory symptoms but tenderness & deformity - Morning stiffness < 30 min - Passive ROM = Active ROM

+ Previous Hx + Family Hx + Sleep disturbances. + Other systems: Neuro / Heart.

Ligament / meniscal symptoms: Joint giving way, clicking, locking, instability. Back Pain: + neurological deficit.

Note: Refereed pains: - Shoulder pain from heart or diaphragm. - Arm pain from neck. & Leg pain from back &

Knee pain from hip.

So, include screening questions from cardiovascular, respiratory, and gastrointestinal boxes if time permits.

55

The History Taking Interview: Station Appropriate Question Box: DERMATOLOGY

Dermatology appropriate questions:

RUSC NJE CHD

1- R ash: “Any skin rash?” Yes  Explore OSCD PQRST UVW + AAA - Duration: “…. Does it come and go?” - Place: “Where does it appear on your body?… Where did it start”. - Quality: “Is it dry?... Any scaling?... Any crusts?... Pus?”

2- U lceration/ Bleeding: “Does it ulcerate or bleed?” 3- Sensation: “Any itching or burning sensation?” 4- Colour changes: “Any change in the skin colour?” (Pale, dark, redness?) 5- Nail changes: “Any change in your nail’s colour or shape?” 6- Joint changes: “Any joint pain or swelling?... Any joint redness or warmth?”

7- Eye changes: “Any recent eye changes?” 8- Causes: “What do you think is causing it?… Any contact with chemicals?... Have you noticed any relation to heat, cold, sunlight?... What about to food or spices? ... What is your occupation?”

9- Family Hx: “Any family history of atopy or allergies?… What about skin cancer?... Psoriasis?”.

10- Penile / vaginal D ischarge: “Mr./Ms…, as you may know, some sexual diseases cause skin changes. That is why I ask all my patients whether they have any sexual disease such as (penile/ vaginal) discharge?” Yes  Explore: OSCD PQRST UVW + AAA - Colour: “What colour is it?.. Is it white, yellow or green?” - Blood: “Any Blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it thin, thick or with pieces?” - Smell: “Does it smell?” - Quantity: “How much discharge is it?” - Timing (FEMALE): “Does it change with your cycle?,… Is it worse before or after the cycle or no difference?”

56

The History Taking Interview: Station Appropriate Question Box: DERMATOLOGY

57

The History Taking Interview: Station Appropriate Question Box: PEDIATRICS

Pediatric appropriate questions: GEEN MS CAM BINDE+/- HEADDSS In OSCE exams, no child will be seen except in teenage scenarios. However 20–25% of the exam cases will be pediatric cases. Pediatric cases will be presented as history taking consult with a parent. Your approach to taking a history should always be developmentally appropriate to the child’s age. There are 4 main age groups: infant, toddler, school age, and teenagers. Involve the child as much as possible in the interview either verbally or by play if present. The child’s chief complaint may not be the main issue, or in fact, the child is not the real patient! Explore the parent’s agenda / fears and parent-child relationship. Angry / Frustrated / Anxious / Demanding / Crying parent are usual difficult scenarios in addition to spouse/ child abuse. Modify the PHx and ‘Standard Questions Box’ according to the child’s age. e.g. child’s exposure to smoking and drugs instead of use. Duration: “When was he/she last being well/ feeding & sleeping well?” Ask the following questions adjusting it according to the child’s age. If the answer is positive, explore in the same way you do for adults.

1- G eneral: “Any fever, rigors or chills?” “Does he/she cry for a long time?,... Being cranky?” “Does he/she look tired, drowsy?” “Does he/she show no eye contact,… not playing?” “Has he/she lost consciousness?,… Had a fit?,… Stiff neck?” “Weight loss or not gaining enough weight?”

2- Eyes: “Any red eyes?,… Eye discharge or crusting?,… Sunken eyes?” 3- Ears: “Any ear pain/ ear pulling (for young)?,…Ear discharge?,… Hearing problems?” Explore.

4- N ose: “Any running nose?,… Nose bleed?,… Discharge?” Explore. 5- Mouth: “Any dry mouth?,… Teething?,… Big tongue? ,… Thrush?” “Any vomiting?” Explore.

6- Skin: “Any rash or itching?,… Skin becomes yellow or blue?,… Easy bruising or bleeding?” Explore.

7- C hest: “Any breathing noises or wheezes?,… Cough?,… Shortness of breath? ,… Pain? … Heart problems?” Explore.

8- A bdomen: “Any belly pain?,.. Distension?,.. Lumps or bumps?” Explore 9- MSK: “Any joint pain?,… Joint swelling?,… Limping?” Explore. … Continued

58

The History Taking Interview: Station Appropriate Question Box: PEDIATRICS

Pediatric appropriate questions:

... Cont.

10- Birth/ Pregnancy/ Newborn : - Birth Hx: “What was the method of delivery? If induced or C/S: Why?... How long did it take?... Any complications during labor like prolonged labor, ruptured water bag, fever?” - Pregnancy Hx: “How was the pregnancy?... Was it term pregnancy?, ... Your (his/her mother’s if not the mother) age at pregnancy?” “Any complications during it?... High blood pressure,… Anemia, diabetes,… infection? ” Explore: What?... How was it treated?... What was the outcome?… Any exposure to a child with rash? ” “Any smoking, alcohol, or drugs use? .. How was your (his/her mother) other pregnancies and children?” - Newborn problems: “How was he/she at birth?,… How much was his/her weight?,... Any abnormalities or complications like being yellow or blue, feverish, or didn’t cry immediately?” Explore: What/ When/ How long? ” Empathy for healthy/ unhealthy pregnancy.

11- Immunization Hx: “What needles has been done so far?... Does he/she have…? (age appropriate immunization)”

12- Nutrition/ Output: “Tell me about his/her feeding/eating habits?”: Is he/she on breast or bottle feeding?,… How much do you give him/her each time?… How many times in a day?,… Any solids, vitamins, iron, supplements?,… What?, when did you start?,… Is it balanced diet?,… Any junk food?,... Any difficulty sucking/ swallowing?,… Is he/she a picky eater?,… Tell me about the feeding setting & facilitation?” Output (Bladder/ Bowel motions): “How many times a day dose he/she pass water?... How much each time?…(Or How many wet dippers a day?),… Smelly urine?,… Red urine? ” How many times a day dose he/she have a bowel motion?… How much each time?…Is it formed or loose?,… Smelling stool?,… Blood?,… mucus?,… What color is it?… Green/ yellow/ white cheesy? Explore. “Does he/she control his/her bladder & bowel? (for >4 years old)”

13- Development: - Physical: “What is his/her height and weight now?” - Milestones “Is he/she able to….. ? (Gross motor, Fine motor, Speech, Social)”Age appropriate now only, no need for previous.

- Social/ School performance: “How is his temper?,... Is he irritable, crying frequently?,... What about sleep?... Does he/she attend school?... What grade?... Any problems at school?… Any failures or suspensions?…What is his/her daily routine?”

14- Environment: “Are there similar problems in relatives, daycare, school?” “Who is usually taking care of him/her?,… How is the family relationships?… How has this been affecting the family?. .. Do you feel your mood low?... Any lost workdays?… How are you managing with the expenses?”.

How sick is the patient & which problem is the most urgent? This is a 100% skill. A skill that you must get right always. The only way to get good at this is to think about the factors that make an illness or problem more or less severe:

1. Differential Diagnosis and/or Complications of a Disease. 2. Prioritized Problem List.

59

The History Taking Interview: Station Appropriate Question Box: GYN / OB

Gynae/Obstetric appropriate questions:

MDP Do Uyou Csee SOOS

“Ms .., in order to understand your condition, I need to ask you some questions about your female organs. Is that okay.”

1- Menstrual Hx: Normally 3580cc/cycle dark red no clots, every 24-32 days, for 3-7 days.

- Last menstrual period (LMP): “When was the first day of your last period?” - Regularity / Frequency: “How regular is/was it usually?… How frequent is/was it?... Every how many days does it come?” - Severity: “For how many days does the bleeding last?... How much is it?... How many pads do you use per cycle?... Is it dark red or bright red?… Any clots? (excessive),... Do you feel lightheadedness on standing?” - Perimenstrual: “Is there any pain or mood changes with the cycle?... How bad is it?”

Lot of empathy for pain, bleeding, & abortion.

* Missed periods: “So you have no regular cycles for more than 4 weeks (Pregnancy/stress/exercise)/ 3 months (+ amenorrhea)/ 6 months (+ menopause) * Menopause: “Any hot flashes?… Mood swings?… Memory problems?… Sleep problems?… Vaginal dryness, itching, or pain?”

Menses:

2- Bleeding: “Is there any recent changes in your cycle regularity?... amount?... duration?... frequency? ”…. “Any abnormal bleeding? ” Yes  Explore OSCD PQRST UVW + AAA - Timing: “When does it occur in relation to the cycle? ” - Severity: “How many days does the bleeding last?... How much is it?... How many pads do you use per cycle?... Is it dark red or bright red?… Any clots? (excessive),... Do you feel lightheadedness on standing? ” “What is your blood group? & your partner? (Rh)”

3- D ates: “At what age was your first (menarche) / last period (menopause)? At what age was your first sexual encounter? (Risk factor)... When was your last sexual encounter? (Only in cases of abuse) ”

4- Pain: “Any lower abdominal or pelvic pain?” Yes  Explore: OSCD PQRST UVW + AAA - Duration: “When would you say it started?.. So, it is less/ more than 6 months (chronic) ” - Place: “Point where do you feel it with on finger?” Suprapubic, RLQ, LLQ? - Radiation: “Does it shoot anywhere?” To labia and inner thighs/ To back - Quality: “How does it feel like?.. Constant or cramps?… How frequent? How long dose it take to go away?” - Timing: “Does it change with the cycle?... How?... Mid cycle?... Any pain with sexual encounters?”

5- Vaginal D ischarge: “Do you have any vaginal discharge?” Yes  Explore: OSCD PQRST UVW + AAA … Continued

60

The History Taking Interview: Station Appropriate Question Box: GYN / OB

Gynaecology/Obstetric appropriate questions: ... Cont. - Colour: “What colour is it?.. Is it white, yellow or green?” - Blood: “Any Blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it thin, thick or with pieces?” - Smell: “Does it smell?” - Quantity: “How much discharge is it?” - Timing: “Does it change with your cycle? Is it worse before or after the cycle or no difference?”

6- Urinary symptoms: “Is it painful to pass water?... Any urgency?... Change in frequency?… Do you control your bladder? (Incontinence)... Any vulvular itching or redness?.. Any warts or ulcers” Yes  Explore “Any face puffing, fingers or ankles swelling? ” Yes  Explore

7- Contraceptive/ Hormonal Rx: “Any hormonal therapy?.. What do you use for birth control?.. For how long have you been using it?.. Any side effects or failures?.. What about in the past, tell me all methods you’ve tried?.. Why did you stop it?(Side effects/failure).. For how long did you use it?”

8- Surgeries, Procedures/ Injuries, Trauma / Blood transfusion / Hospitalization: “Any?………….. ”.  Explore Pap smear: “When was your last Pap smear done & where?.. What was the outcome & follow up?” Any previous women problems?.. Fibroids?.. Pelvic infections?.. Cysts?”

Points for wrap up: Importance of Pap smear, Safe sex, HIV testing, Bring partners if STD.

 Explore

9- Obstetrical Hx:

GTPAL “Any pregnancies, miscarriages, abortions in your life?” Any abnormal pregnancies?” (ectopic/ mole). Explore - Previous (for each): Place/ Date:“At what year?. Where was the delivery/ abortion, at home or the hospital?. - Miscarriages (involuntary)/ Abortions (voluntary): “Why did the first one occur? At how many weeks?” - Pregnancy: “How was the first pregnancy?.. For how many weeks it was?.. Any complications during it?.. What?.. How was it treated?.. What was the outcome?”,…... “Now the second pregnancy.…” - Labor: “What was the method of delivery, natural vaginal, or induced, or cesarean?… If induced or C/S: Why?.. How long did it take?.. Any complications during labor?” - Babies: “How was the baby at birth? Boy or girl? How much was his/her weight?.. Any abnormalities or complications?” Empathy for healthy/ unhealthy pregnancy: “………………………” - Current pregnancy: ABCDE DR: “How is the baby’s movements? (For those > 18 weeks )” “Any bleeding? (explore as above)”.. “Contractions?.. How regular is it?.. How frequent?.. How long each lasts?”.. “Is there any vaginal dripping?.. How much?”.. “When will be your due date?”.. Which doctor is taking care of this pregnancy?”“Are all routine tests & U/S done?.. What are the results?”

GTPAL: Gravida, Term (>37), Preterm (20-37), Abortions (20), Life baby.

ABCDE DR: Activity of fetus, Bleeding, Contractions, Dripping, EDC, Doctor, Routine test

Complication? High blood pressure, diabetes, headache, visual changes, kidney/liver/thyroid disease

10- Others/ Breast: “Any breast changes?,.. Skin lesions?,.. Groin/ axillary lumps?,… Joint/ back pain?”

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The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions: AL MAP CVP SADDD + (FEW SAM MASF + SAFE + HEADDSS) Note: - OSCD PQRST UVW + AAA first. If the patient presented with a somatic CC,  Explore quickly as it is not the real CC. If he presented with a psychiatric CC  Explore in detail.

1- A sk: - “Are you seeing other doctors?” Yes  Explore “What did they say about ... CC?... Any investigations done?... What was the outcome?... Any medication prescribed?.. What?... How much?... How frequent?... For how long you have been taking them?... What was the outcome?... Any side effects?... Are you still taking these medications?”

2- Look: - Look for the patient’s non-verbal cues: Appears sad/ Avoids eye contact looking away/ Slow monotonous or explosive pressured speech/ wandering around in the room/ Restless/ Irritable/ Clean or dirty/ Peculiar… etc. Comment: “You look sad/ upset, is there something bothering you and want to talk about? ” “You look very energetic/ restless/ moving around a lot, can you sit down here so we can talk? ”

3- M ood: 1. Depression (Feeling down): “How is your mood?... Are you feeling down?” “Have you lost interest in doing activities that were enjoyable to you?” Mood and Interest screen. Yes:  Explore OSCD PqrST UVW AAA. - Course: “…, Is it constantly feeling down (Dysthemia) or there are periods that you felt better? (Depressive episode)” - Duration: “..., So, you’ve been felling down for less (Not depression)/ more than 2 weeks? (Depressive episode)” - V: “Has it happened before? ”... When?” (Yes: Major Depressive disorder, No: Depressive episode).

“For how long you’ve been having these episodes on & off?... So, it is more (chronic)/ less than 2 years” - AAA: “How was your feeling before?... Does anything happened or changed in your life?... Are there any stresses at this point in your life?... Were you taking any medications that you stopped recently?” - SPACE SIGM B: 5 of the 9 including mood & interest. - Sleep: “How is your sleep?.. Do you sleep more (atypical) or less (depression) than usual?.. Any early morning awakening?” - Interest: done. - Guilty: “Do you feel guilty, hopeless, helpless, or worthless about something?” … Continued

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The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

… Cont.

- Mood: done. - Energy: “How is your energy level? Do you feel tired?” - Concentration: “Do you have difficulty concentrating or making decisions? .. Has there been a change in your memory?.. In what way?” - Appetite: “Has there been a change in your appetite or weight?.. More or less than usual?” increased in atypical - Psychomotor: - Retardation: “Do you feel slowed down/ Dose it take you longer to get dressed?” - Agitation: “Do you feel restless, agitated?” - Suicide: “Do you have recurrent thoughts of death or suicide?.. Any attempts to hurt yourself? What have you done?.. When?.. Why.. What was the outcome?….. Any plans now?” - Bereavement: “As there are many causes to feel sad, I need to ask you, has any close person to you passed away during the last 2 months?” 2. Mania (Feeling high): “Have others around you noted a persistently elevated, expansive mood, energy, or self-esteem? ” Mania screen. Yes:  Explore OSCD PqrST UVW AAA. - Course: “Is it constantly feeling high (mania) or there are periods that you felt down (Bipolar II)?.. How often does your mood alternate in a year?.. So, it is more (Rapid cyclic)/ less than 4 times a year?” - Duration: “….., So, you’ve been felling down for less/ more than 1 weeks? (Manic episode)” - V: “Has it happened before? ”... When?” (Yes: Bipolar I disorder, No: Manic episode).

“For how long you’ve been having these episodes on & off?... So, it is more (chronic)/ less than 2 years” - AAA: “How was your feeling before?... Does anything happened or changed in your life?... Are there any stresses at this point in your life?... Were you taking any medications that you stopped recently?” - GST PAID: 3 of the 7. - Grandiosity: “Do you feel you are a very important person with special talents, power, mission, or role?” - Sleep: “How is your sleep?.. Do you feel you can get by through the day with less sleep than usual” - Talkative: “Do people say that you are more talkative than usual?” - Pleasurable activities Painful consequences: “Do you drink & drive?... Do you use a substance a lot?... Do you spend more than you can afford?… Do you have inappropriate sexual behaviors?” - Activity: “Do you feel you have increased energy?” … Continued 63

The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

…. Cont.

- Ideas, flights of: “Are thoughts racing in your mind?.. Do people say you jump from topic to topic?” - Distractibility: “Do you get distracted easily?” - Organic causes: STEAM: SLE, Trauma, Endocrine, AIDS, MS 4- A nxiety: 1. Panic Disorder: “Have you experienced a sudden onset of intense fear or discomfort?” “Do you have fear going to closed or crowded places? ” Agoraphobia Panic disorder screen. Yes:  Explore OSCD PqrST UVW AAA. - Timing: “Does it wake you up?” - AAA: Activity, Coffee, Stress, Places, Situations, meds/drugs. “How was your feeling before?... Does anything happened or changed in your life?... Are there any stresses at this point in your life?... Were you taking any medications that you stopped recently?” - STUDENTS Fear 3Cs: 4 of 15 occur abruptly & reach a peak in 10 min. “Do you sometimes abruptly get: …. - Sweating?.. - Trembling or Shaking?.. - Unsteadiness or Dizziness?.. - Derealization: feeling of being unreal?.. - Depersonalization: feeling of being detached from yourself?.. - Excessive heart beat or racing?.. - Nausea or stomach distress?.. - Tingling or numbness?.. - Shortness of breath?.. - F ear of dying?.. Fear of losing control?.. Fear of going crazy?.. - Chest pain?.. - Choking? - Chills or hot flushes? … How long dose it take to reach its peak?” Followed by more than a month of AWC: - Anticipatory anxiety: “Do you have a persistent concern of having other attacks?…. For how long?… So, it is more than a month?” - Worry: “Are you worried about the consequences of the attacks?” - Changes: “Have you changed your behavior accordingly?” 2. Generalized Anxiety Disorder: “Are you a person that has an on going excessive worries or fears about several things but can’t control them?” “What makes you anxious?” Anxiety disorder screen. Yes:  Explore OSCD PqrST UVW AAA. … Continued

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The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

…. Cont.

- Duration: “When did it start?… So, it is more than 6 months?” - What: “What are the thinks that you worry about?” - BE SKIM: 3 (1 in children) of 6, for 6 months: - Blank mind: “Do you feel blank minded? ” - Easily fatigued: “How is your energy level? Do you feel tired?” - Sleep disturbances: “How is your sleep?” - Keyed up: “Do you feel most of the time you are on the edge?” - Irritability: “Do you feel irritable?” - Muscular tension: “Are you having any muscular spasm or pain?” 3. Phobic Disorder: “Do you have a lot of fear or anxiety of something specific like heights, bridges, snakes, social events?” Phobia disorder screen. Yes:  Explore OSCD PqrST UVW AAA. - HE Avoids - “What happens if you are in these places/ situations/ facing these things?” - “Is your reaction reasonable or excessive?” Realize it is excessive. - “Are you avoiding these places/ situations/ things?” 4. Obsessive-Compulsive Disorder: WRITE “Do you have certain thoughts or behaviours over and over that you need to get rid of?” OCD screen. Yes:  Explore OSCD PqrST UVW AAA. - WRITE - “What are they?” - “Are you having repetitive behaviors or mental acts that you feel driven to perform in response to these thoughts?” Compulsions. Yes:  “What are they?.. How frequent do you do them?.. For how long?..” - “Do you consider these thoughts as intrusive and inappropriate or not?” - “Are they time consuming, causing distress, and interfering with your normal routine life?” - “Have you felt that these thoughts & behaviors are excessive or not reasonable?” 5. Post-Traumatic Stress Disorder: “Have you ever experienced or witnessed a major physical or emotional trauma or stress in your life that made you feel intense fear, horror, or helplessness?” PTSD screen. Yes:  Explore OSCD PqrST UVW AAA. - Events persistently re-experienced: 1 or more of 5: 1- Recollections of images and thoughts: “Do you recall any images or thoughts about that event”. … Continued 65

The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

… Cont.

2- Dreams: “Do you have distressing dreams about that event?”. 3- Flashbacks/ Acting out: “Do you feel yourself sometimes as if you are having the same event again?” 4- Distress at exposure to cues that resemble the events: “Do you feel distressed when you come across something that remind you about the event?” 5- Physiological reactivity in response to cues: “Do you feel your heart racing when you come across something that reminds you about the event?” - Persistent avoidness of reminding stimuli: 3 or more of 7: 1- Detachment/ emotional numbness: “Do you feel emotionally detached from those close to you?”. 2- Diminished interest in significant activities: “Have you lost interest in activities that were interesting to you?” 3- Inability to recall important elements of the event: “Do you remember every aspect of the event?” 4- Restricted affect: “Do you have feelings towards someone and are you able to express it?” 5- Avoidness of event reminding situations and activities: “Are you avoiding places, people, or situations that remind you of the event?” 6- Avoidness of event reminding thoughts or feelings: “Are you avoiding thoughts, feelings, or conversations that remind you of the event?” 7- Sense of foreshortened future: “Do you think that you won’t have a normal life as others concerning career, marriage, children, or life span?” - Persistent increased arousal: 2 or more of 5: 1- Difficulty sleeping: “Do you have difficulty falling asleep or maintaining sleep? ” 2- Irritability and anger outbursts: “Do you have periods that you felt irritable or had bursts of anger? ” 3- Difficulty concentrating: “Do you have difficulty concentrating? ” 4- Hypervigilance: “Do you feel excessively vigilant? ” 5- Exaggerated startle response: “Do you get excessively startled by trivial things? ” - Duration: “When did it start?… So, it started more/less than one month ago?”

4- Psychosis: Schizophrenia: 2 of the followings for > 1 month active phase & residuals for > 6 months. 1. Hallucinations: Auditory, visual, tasting, olfactory. “Are you sensing things that others think they are not actually there, like seeing, hearing, or smelling things?” Hallucination screen. Yes:  Explore OSCD PqrST UVW AAA. … Continued

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The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

… Cont.

- Duration: “When did it start?... So it is less than a month (Brief psychosis)/ more than a month but less than 6 months (Schizophreniform)/ more than 6 months? (Schizophrenia)”. - “What?……. Where?….. When?……” - If auditory: “Are these voices familiar?... Whose voices are you hearing?. Are they voices of one or more persons talking?. What do they say?” Diagnostic if two voices conversing to each other or one commenting on his actions: “Are they telling you to do things?... What things?… Are they commenting on your actions?”. 2. Delusions: “Do you believe that there are unusual things happening concerning you?” Delusion screen. Yes:  Explore OSCD PqrST UVW AAA. - Non-Bizarre: - Persecutory: “Are you being followed?” - Grandiosity: “Are you having special power, task, role?” - Erotamia: “Are you being loved by another person?” - Jealous: “Do you think your partner is unfaithful?” Yes:  “ When did it start?” non-bizarre for > 1 month: Delusional disorder. - Bizarre: - Reference: “Are there events having direct reference to you?” - Control: “Are you being controlled by some external sources?” - Thought broadcasting/Insertion/ withdrawal: “Do others know your thoughts?” - Religious: “Are you having a religious mission or task?” Yes:  “ When did it start?” Bizarre: part of schizophrenia.

Delusions are firmly held, fixed beliefs that are irrational to the patient’s culture.

3. Disorganized: “Do you get agitated, excited, or hostile?” 4. Thought disorder: “Are you unable to think straight?” - Loss of association. - Tangentiality: Jumping from subject to another. - Incoherence - Neologism (new words) - Though blocking. 5. Negative Symptoms: - Alogia: Poverty of speech. “Do you have difficulties finding words to explain things?” - Affective flattening: “Do you have less emotional or inappropriate emotional responsiveness?”. - Avolition: “Any loss of motivation, drive, initiativeness?”. - Anhedonia: “Any loss of interest in things were enjoyable to you?”. - Apathy: Lack of interest in the surroundings: “Have you lost interest in things or activities that where interesting to you?” … Continued 67

The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

… Cont.

5- C ognitive Disorders: “ Do you have memory problems or forgetfulness? (Dementia), … Do you feel agitated, irritable? (Delirium)” Cognitive screen. Yes:  Explore OSCD PqrST UVW AAA. - Onset: “How did it start? Was it all of a sudden (Delirium) or gradually? (Dementia) ” - Course: “Is it getting worse, better or just the same?” Worse  “ How fast is it getting worse?” (Slowly progressively: Alzheimer/ Step wise deterioration: Vascular/ Fluctuating: Delirium).

- Duration: “For how long?” (Days-weeks: Delirium/ Months: Dementia). - Severity: - Memory: A must for diagnosis. “Are the memory problems concern recent events or remote ones?” (Recent/ Remote: Dementia/ Marked recent: Delirium). - Sleep-wake cycle: “Any sleep problems?… Sleep like on and off? (Fragmented: Dementia) … Sleep in the morning and awake all night? (Reversed: Delirium)” - Behavior: “Any impairment in your daily living activities or using devices or appliances? (Dementia) ” - Cognitive: 1 of 6: - Liable mood: “Do you have mood swings?….” - Aphasia: “Difficulty speaking?….” - Agnosia: “Difficulty recognizing objects…?” - Apraxia: “Impaired ability to carry out purposeful movement?..” - Impaired executive thinking: Abstraction/ Planning/ Organizing: “Impaired ability to plan or organize things?...” - Judgment impairment: “Impaired ability to make a judgment?...” - AAA: - Wandering attention: “Do people tell you, you jump from subject to subject?….” - Distractibility: “Do you get distracted easily and cannot concentrate?….” - Disorientation: “Do you get disoriented to places or time easily?….” (to people: Delirium: rarely / Dementia: advanced.) - Misinterpretation/ Illusion/ Hallucination: “Are you sensing things that are not actually there, like seeing, hearing, or smelling things?” - Affect: Anxiety/ Fear/ Depression/ Irritability/ Anger/ Euphoria/ Apathy: “Do you feel anxious, fear, depressed, irritable, angry, high, don’t care?” - Psychomotor activities shift: Picking of cloths/ Attempt to get out of bed/ Sudden movements  Then: Sluggishness/ Lethargy “Do you sometimes feel slow and other times feel energetic and want to move around?” …. Continued 68

The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY

Psychiatric appropriate questions:

… Cont.

6- Psychiatric VITALS:

Must ask in all psychiatric cases. 1. “Do you have thoughts of hurting yourself?… Any suicide attempts?... Any plans now?” 2. “Have you ever hurt anyone? … Any plans now?” 3. “Have ever had difficulty caring for yourself?” 4. “How has this been affecting you, your relationship, your family, or your work?... What things are you no more able to do? ” Marked distress needed for all psychiatric diagnoses.

7- Psychiatric Past Hx: “Any other similar complaints in the past? … Any psychiatric illnesses in the past? … How have you been before this?” “Any problems with the police or the law?”

8- Family Hx of SADDD: Suicide, Alcohol, Drugs, Depression, Divorce. “Any family history of suicide?... Alcohol abuse?... Depression?... Drugs?.... Divorce?”

9- Standard Questions Box: FEW SAM MASF + Personal Hx + HEADDSS + Sexual Hx + Safety (SAFE)

Mental Status Exam (MSE) or Mini MSE: = physical exam GET PC 1. 2. 3. 4.

General: Appearance/ Behavior/ Attitude/ Speech. Emotions: Mood/ Affect/ Appropriateness Thought: Form/ Content. Perception: Illusions/ Hallucinations/ Derealization/ Depersonalization. 5. Cognition: Alertness/ Orientation/ Memory/ Attention/ Knowledge & intelligence/ Abstraction/ Judgment/ Insight

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The History Taking Interview: Station Appropriate Question Box: SCREENING

Neurology appropriate questions:

HLD NeW VHS MTC

“Do you have headache?” “Have you passed out / blacked out?” “Have you felt unsteadiness or light-headedness?” “Do you have numbness, loss of sensation, or pain anywhere?” “Any weakness?” “Any visual changes recently?” “Any hearing changes?. “Do you have difficulty speaking?” “Have you noticed any memory loss/ difficulty concentrating? ” “Any tremor or involuntary movements? “Do you control your bladder and bowel motion?”

Respiratory appropriate questions:

PCS Wheezes HEAT On Us

“Any chest pain?” “Do you have cough?” “Do you get shortness of breath?” “Do you hear noises in your chest with breathing?.. What about in your throat?.. Any change of voice?” “How many flights of stairs can you climb/ blocks can you walk?.. So, it is more less than two blocks/ one flight?” . “Do your ankles swell on you?” When did it start?.. How long did it take to go away?”…. “Any pain in your legs?” “Any history of travel?.. Where?” “What do you do for living?.. Does your ..(CC).. improve during weekends or vacations?”.. “What exactly does this job involve?” “Any exposure to people with HIV, TB, SARS?”.. “Have you ever felt your heart racing?,.. Any face flushing?.. Any diarrhea” “ Any running nose? Eye problem?.. Skin rash? ... Face pain, ... Do you need to clear your throat frequently?”

Cardiology appropriate questions:

PCS OSAP PLC EAR

“Any chest pain?” “Do you have cough?” “Do you get shortness of breath? ” “Are you able to lie flat in bed without becoming short of breath?” “Any sweating?” “Do your ankles swell on you? “Have you ever felt your heart racing/ fluttering/ funny?” “Have you passed out / blacked out?” “Did you lose consciousness completely or could voices be heard?” “Did your lips turn blue? ,…. Did your face turn pale? “Do you have pain in your limbs?” “How many flights of stairs can you climb/ blocks can you walk?.. So, it is more/ less than two blocks/ one flight?”. “Are you worried?.. Do you have a feeling of impending doom?” 70

The History Taking Interview: Station Appropriate Question Box: SCREENING

Gastrointestinal appropriate questions:

PAN HSBG JBO +Risk

“Any stomach pain? ” “Any change in your appetite recently?” “Do you feel sick? , Did you throw up? ” “Do you have water brush?.. Any burning sensation in the middle of your chest that radiates to your mouth?” “What about your swallowing, any difficulty?” “Any gases?

“What about your stomach girth?.. Is it bigger?.. Do you feel any lumps or bumps?” “Did your skin or the eyes’ white areas turn yellow or red?.. Any change in your urine color?… Is it dark like tea or cola?… Is your skin itchy?.. Any bad mouth smell?” “Any change in your bowel habit recently?” Only if bleeding, diarrhea or vomiting (DTHU):

“Do you get lightheadedness?, ...What about when you stand up or get out of bed in the morning?”,... Do you feel thirsty and your mouth dry?,... Have you ever felt your heart racing?,... Do you void less? ”

Genitourology appropriate questions:

PD UHF SUV FIDO

“Any pain?”

“Any pain while passing water / voiding/ peeing?” “Any urgency to void/ pee? .. Hesitancy? .. Straining? .. Any feeling of incomplete emptying?” “Is there any change in the frequency recently?” “Is it more or less? What about at night, do you wake up to go void? “Any recent change in its volume? “Tell me about your urine” “Do you control your bladder?” “Any face puffing in the morning?.. Do your ankles swell on you?” “How much fluid do you drink in a day?” “Any penile/ vaginal discharge? ” - Colour: “What colour is it?.. Is it white, yellow or green?” - Blood: “Any blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it thin or thick?” - Smell: “Does it smell?” - Quantity: “How much discharge is it?” “Any eye, joint or skin problems?,… Kidney stones?”

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The History Taking Interview: Station Appropriate Question Box: SCREENING

Endocrinology/Hematology appropriate questions: WENT MSN ENG RPL “Any recent weight changes?” “What about your energy? Any recent change?” “Do you feel more energetic or do you become fatigued easily?” “Do you feel nervous or anxious most of the time?... Have you ever felt your heart racing?... Any tremor?” “Does the heat or cold bother you more than you think it bothers other people?….. How?..” “Any recent mood changes?, Do you feel low?... Have you lost interest in doing activities that were enjoyable to you?” “How do you feel your skin; dry or moist?.... ” “Any rash or pigmentation?... Did your face turn pale?.... ” “Do you easily bleed or get bruised?” “Any recent change in your hair growth and distribution?…. ” “Any nail shape changes?” “Have you noticed any lumps in your neck or felt it wider?” “Any recent visual changes?.. Eye pain?… Colour changes like redness or yellowness?… Shape change?” “Do you have headaches?… Do you feel lightheadedness?… Do you feel any pins & needles sensations?.. Any muscle weakness?.. What activities do you have difficulty with?” “Do you feel sick?, Did you throw up?” “How is your appetite?… ” “Any mouth ulcers?... ” “Difficulty swallowing?...” “Any change in your bowel habit?…” “Any black stool or bleeding from your bottom?...” “Do you feel thirsty frequently? ... How much fluid do you drink in a day? ” “What about passing water/ voiding, any change?... Is it more or less than usual? …” “Is your urine red or cloudy?…”“Do you have kidney stones?” “Any stomach, joint pain, bone pain, muscle pain?” “Mr/Ms .., in order to understand your condition, I need to ask you some questions about sexual history. Is that okay?…….” “Any changes in your sexual desire/ menses?... How?”

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The History Taking Interview: Station Appropriate Question Box: SCREENING

Musculoskeletal appropriate questions: joint PR STD, ROMAN’S Activity MisS NG “Any joint pain?” “Any joint redness?” “Any joint swelling?” “Have you ever had any trauma, procedure, injections or surgery on any joint?” “Do you have to do the same movements repeatedly at work or home?” Trauma Case: “Have you heard a click when it happened?”“Were you able to bear weight immediately after the incident?” “Any deformity in the joint shape?… Do you feel your (joint) unstable?... Locking? .. Any change in your gait pattern?” “Is there any reduction in the range of movement of your …. (shoulder/elbow/wrist/finger/thumb/hip/knee/ankle/toe/back)?” “Any noises with movement?” “Any movement stiffness when you wake up in the morning?” “How has this been affecting your daily activities?... What activities do you have difficulty with or are unable to do?… Who does the cooking, the shopping, the laundry, the cleaning for you?...” “Any muscle pain?.. Weakness?.. Wasting?.. ” “Any change in skin colour?... Redness?... Bruises?... Warmth?... Rash?... Skin tightness on your face or hands? … Eye redness or pain?” “Any changes in skin sensation like less than before?… Tingling sensation?... Any headache?... Difficulty speaking?... Vision problem?... Do you control your bowel or bladder?… Any back pain?” “Any mouth ulcers?... Difficulty swallowing? ... Frequent episodes of diarrhea & constipation?... Bleeding from your bottom?”

Dermatology appropriate questions:

RUSC NJE CHD

“Any skin rash?” “Does it ulcerate or bleed?” “Any itching or burning sensation?” “Any change in the skin colour?” “Any change in your nail’s colour or shape?” “Any joint pain or swelling?... Any joint redness or warmth?” “Any recent eye changes?” “What do you think is causing it?… Any contact with chemicals?... Have you noticed any relation to heat, cold, sunlight?... What about to food or spices? ... What is your occupation?” “Any family history of atopy or allergies?…Skin cancer?... Psoriasis?” “Mr./Ms…, as you may know, some sexual diseases causes skin changes. That is why I ask all my patients whether they have any sexual disease such as (penile/ vaginal) discharge?” “What colour is it?.. Is it white, yellow or green?” “Any blood?” Yes  “Is it drops or more? How much blood? “Is it thin, thick or with pieces?” “Does it smell?” “How much discharge is it?” - Timing (FEMALE): “Does it change with your cycle? Is it worse before or after the cycle or no difference?” 73

The History Taking Interview: Station Appropriate Question Box: SCREENING

Gynae/Obstetric appropriate questions:

MDP Do Uyou Csee SOOS

“Ms .., in order to understand your condition, I need to ask you some questions about your female organs. Is that okay.” “When was the first day of your last period?” “Is there any recent changes in your cycle regularity?... amount?... duration?... frequency?”…. “ Any abnormal bleeding? ” “At what age was your first / last period? At what age was your first sexual encounter?... When was your last sexual encounter? (Only in cases of abuse)” “Any lower abdominal or pelvic pain? ” “Do you have any vaginal discharge?” - Colour: “What colour is it?.. Is it white, yellow or green?” - Blood: “Any Blood?” Yes  “Is it drops or more? How much blood? - Content: “Is it thin, thick or with pieces?” - Smell: “Does it smell?” - Quantity: “How much discharge is it?” - Timing: “Does it change with your cycle? Is it worse before or after the cycle or no difference?” “Is it painful to pass water?... Any urgency?... Change in frequency?… Do you control your bladder?... Any vulvular itching or redness?.. Any warts or ulcers” “Any face puffing, fingers or ankles swelling?” “Any hormonal therapy?.. What do you use for birth control?.. For how long have you been using it?.. Any side effects or failures?.. What about in the past, tell me all methods you’ve tried?.. Why did stop it?.. For how long did you use it? ” “Any? Surgeries, Procedures/ Injuries, Trauma / Blood transfusion / Hospitalization ………….. ” “When was your last Pap smear done & where?.. What was the outcome & follow up?” “Any previous women problems?.. Fibroids?.. Pelvic infections?.. Cysts?” “Any pregnancies, miscarriages, abortions in your life?… Any abnormal pregnancies?” - Current pregnancy: ABCDE DR: “How is the baby’s movements? (For those > 18 weeks )” “Any bleeding? “Contractions?.. “Is there any vaginal dripping?.. “When will be your due date?”.. Which doctor is taking care of this pregnancy?” “Are all routine tests & U/S done?.. What are the results?” Complication? High blood pressure, diabetes, headache, visual changes, kidney/liver/thyroid disease

“Any breast changes?,.. Skin lesions?,.. Groin/ axillary lumps?,… Joint/ back pain? ”

Pediatric appropriate questions: GEEN MS CAM BINDE+/- HEADDSS

ALL

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The History Taking Interview: Station Appropriate Question Box: SCREENING

Psychiatric appropriate questions: AL MAP CVP SADDD + (FEW SAM MASF + SAFE + HEADDSS) “Are you seeing other doctors?” “You look sad/ upset, is there something bothering you and want to talk about?” OR “ You look very energetic/ restless/ moving around a lot, can you sit down here so we can talk?”

“How is your mood?... Are you feeling down?” “Have you lost interest in doing activities that were enjoyable to you?” “Have others around you noted a persistently elevated, expansive mood, energy, self-esteem? ”

“Have you experienced a sudden onset of intense fear or discomfort?” “Do you have fear going to closed or crowded places? ” “Are you a person that has an on going excessive worries or fears about several things but can’t control them?” “Do you have a lot of fear or anxiety of something specific like heights, bridges, snakes, social events?” “Do you have certain thoughts or behaviors over and over that you need to get rid of?” “Have you ever experienced or witnessed a major physical or emotional trauma or stress in your life that made you feel intense fear, horror, or helplessness?” “Are you sensing things that others think they are not actually there, like seeing, hearing, smelling things?” “Do you believe that there are unusual things happening concerning you?” “ Do you have memory problems or forgetfulness? … Do you feel agitated irritable?” “Do you have a thought of hurting yourself?… Any suicide attempts?... Any plans now?” “Have you ever hurt anyone? … Any plans now?” “Have ever had difficulty caring for yourself?” “How has this been affecting you, your relationship, your family, or your work?... What things are you no more able to do? ”

Marked distress needed for all psychiatric diagnoses. “Any other similar complaints in the past? … Any psychiatric illnesses in the past? … How have you been before this?” “Any problems with the police or the law?”

SADDD: “Any family history of suicide?... Alcohol abuse?... Depression?... Drugs?.... Divorce?”

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The History Taking Interview: Station Appropriate Question Box: SCREENING

76

Chapter 12: THE STANDARD QUESTIONS BOX 1- FEW SAM MASF 2- Social/Occupational 3- Sexual Hx 4- Safety (Abuse) 5- HEADDSS (Teens)

Transitional statement: “Mr./Ms…. , now, I am going to ask you some questions about your health that I ask all my patients. Okay?”

“Do you have…?” “Have you had any... recently?” “How about…?” “Do you get…?” “Have you noticed any…?” “Have you ever gotten…?”

Standard Questions Box: FEW SAM MASF 1-

Fever: “Any Fever?... Night sweating?... Chills or rigor?”

2-

Energy/Fatigue: “What is your energy level like?… Do you become fatigued easily?”

3-

Weight change: “Any recent weight changes?” Yes, “In what way?.. How much?” “Any nausea, vomiting, diarrhea, or constipation?” “How is your appetite?” “Tell me a little bit about your eating and exercise habits?” Yes explore GI. “When was your last meal or snack, and what was it?” ER cases.

4-

Smoking:

Pack-Year (# of years / # of packs a day)

“How much do you smoke in a day?.” Yes  “For how many years?” “What about in the past?” 5-

Alcohol: “How much alcohol would you drink in a day?” If not daily: “How much a week?”, “What is it?” “What about in the past?” If > 9-14 drinks/week or suspicious  CAGE: - Cut: “Have you felt the need to cut down your drinking?” - Annoyed: “Have people annoyed you by criticizing your drinking?” - Guilt: “Have you ever felt guilty about your drinking?” - Eye opener:“Have you ever taken a morning ‘Eye opener’ drink?”

6- Medical Hx of illnesses: “Do you have any ongoing medical problem?” Yes explore: - “When was it diagnosed?” - “How was it treated?” Write down all - “When was it lastly checked?... What were the results?” - “Who was the doctor taking care of it?” - “Do you have heart problem?,… High blood pressure?,… Stroke? ” - “Diabetes?,…. High blood cholesterol?” - “Kidney disease?,… Liver disease?” … Continued

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The History Taking Interview: Standard Question Box

Standard Questions Box: … Cont.

FEW SAM MASF

- “Irritable bowel?,… Inflammatory bowel disease?,… Intestinal Polyps?,… Colon cancer?” - “Asthma?,… Allergies,… Joint problems?,… Eye problems?,… Rheumatic disease?” - “Headaches?,… Epilepsy?,… Depression?,… Confusion?,… Memory problems?” - “Anemia?,… Easy bruising or bleeding?,… Thyroid problems?” - “Breast cancer or ovarian cancer?” for females.

7- Medications: “Are you taking any medications now?”

Yes  Explore: - “What are they (Name)? .. ” - “What is the dose?.. How frequent a day?” - “For how long you’ve been taking this (Duration)?.. ” - “Have you noticed any side effects?,.. ” - “Who prescribed it?… ” “What about medications in the past?” NSAID/ Steroids abuse: “How frequent do you take Aspirin, Tylonol, Profen or steroids?” OCP: for females: “Are you taking birth control pills?” Drugs: “What about Street / Recreational drugs?.. Over-The-Counter (OTC) or Herbal drugs?” “What about in the past?”

8- Allergies: “Do you have any allergies?”

Yes:  “To what?,…What happened when you took it?” (side effects or true allergy?)

9- Surgeries or Procedures / Injuries or Trauma / Blood transfusion / Hospitalization: “Any…?” 10- Family Hx (FHx): “Mr./Ms…., I’d like to know a little about your family. Are there any illnesses that seem to run in your family?”,… “Has anyone in your family had a medical problem?” “Has anyone else at home or work been sick lately?” Yes: “At what age? ” “What was the outcome?” “Any family history of ……..(repeat the medical history list above in 6)” Empathy for bad news * If patient becomes anxious:  “You sound anxious, is there anything you want me to know?,… Usually I take some family history from all my patients” …Continued

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The History Taking Interview: Standard Question Box

Standard Questions Box: … Cont.

FEW SAM MASF

11- Personal History (PHx): SOHSS A) Social / Occupational: “Mr./Ms… can you tell me a little about yourself:….” 1- How do you support yourself financially? 2- How have things being going for you at work / home? 3- Do you think that anything at work / home is affecting your health now? 4- What exactly does this job involve?..Sitting, standing, walking? For how long? 5- What about the job before this one? 6- Who live in your household? 7- Are there family members nearby who are willing and able to help you? 8- Who does the cooking, the shopping, the laundry & cleaning, the accounting for you?”

B) HEADDSS: Teenagers only (13-19 year), skip this step for others: “Now I want to ask you some questions about your life in order to know you better. I assure you that all what you’ll tell me stay between us, okay? ” 1- Home: “Where do you live and with whom?... Any recent move?… How is your family relationship?… Have you ever run away?…. (Yes: Why?)…” 2- Education: “Do you attend school?... What grade?... Any problems at school?… Any failures or suspensions?… What are your future plans and goals?” 3- Activities: “Do you participate in extracurricular activities, sports, social events, clubs?… Who is your best friend?… Any gangs involvements?” 4- Drugs: “Do you take street drugs?..” Yes: “What drugs?... How much?... How frequent?... Alone or with friends?” 5- Diet: “Tell me about your eating habits?.. Any history of eating disorders?.. anemia?.. obesity?” 6- Suicide: “Have you ever thought of harming yourself?... What about suicide?... Any plans?... Do you have history of depression” 7- Sex: “I always include questions about sexual problems in my routine medical history taking because they are so common. Is it okay to ask you some questions?”… “What about dating?..” Continue with (C) Sexual Hx.

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The History Taking Interview: Standard Question Box

Standard questions: ……Continued C) Sexual History: “Mr. Ms…, I always include questions about sexual problems in my routine medical history taking because they are so common. Is it okay to ask you few questions?”… Best one. OR “Mr./Ms…, I know sexual concerns can be hard to discuss, especially with a stranger, but it sounds as if you have some concerns, tell me more?” OR “Mr./Ms…, many people in a situation like yours, experience a change in their sexual function. Have you noticed any change? ” 1- Active: “Are you currently in a relationship?” No/or “Are you sexually active?” Yes for any of the question:  “Male, female or both?” 2- Duration: “For how long have you been in the current relationship?... So, more than 3 months (1 : STD risk) ” 9- Abuse: “Any history of sexual abuse or assault?” 10- Money: “Have you ever paid or received money for sex?”

D) Safety: “SAFE”: For elderly and women abuse, psychiatric illness: 1- Safe: “Mr./Ms… do you feel safe in your relationship or home?” 2- Afraid: “Are there situations in your relationship or home where you felt afraid?” 3- Friends/Family: “If you have been hurt, is there anyone that you can tell like a friend or a family member?... Would they be able to help you?” 4- Emergency Plan: “Do you have a safe place to go and the resources you need in an emergency situation?… ” No “Would you like help in locating a shelter?… Would you like to talk to a social worker?” 80

Chapter 13: THE WRAPPING UP BOX Wrapping up the interview is very important. At the last 30-60 seconds of the interview (minute 4.5 or 9 or 14 for 5, 10, 15 minutes stations), start the wrap up even if you didn’t finish the history taking or focused history and physical exam.

Wrapping Up Box: NENDF 1- “Okay Mr/Ms…is there anything else you’d like to tell me or ask me?” 2- Next Step: “I need to examine you and send you for some investigations, but from what you told me so far, your problem is….. (DDx or Dx)” DDx always better. 3- Educate him/her in short explanations about the 1. Illness: “What do you know about … (CC or Dx)?” “This is because of… or … or … which is ……” 2. Prognosis: Clearly & truly inform him/her about the prognosis: If treatable  Assure: “There is nothing to be worried about so far?” If severe/ chronic/ bad  Discuss family & community support: “This issue won’t be solved in a short time. It will stay with you for the rest of your life. Is there a family member or a friend that would be able to help you? We will do our best to help you deal with it. There are also some community resources that you can use. Would you like to talk to a social worker?” 3. Investigations and its results: “I’m going to send you for… (some blood work / X-Ray / CAT scan / Ultrasound), which will help us to figure out the cause or confirm it.” 4. Management/ Medications and their side effects: - Painkiller for now waiting for the further investigations: “I’ll write a pain killer for you now and we’ll discuss your options to deal with this issue later after the investigation results come back.” - Management now: “To deal with this, your option(s) is/are: You can take some medication. It helps in….. (its action). There is a little chance to have side effect like … . If that happens, call me. OR you can…. (eg. go for surgery) ” “What would you like to do?” 4- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT. Clarify his/her and your responsibilities: “Okay, so I’ll send you for the investigations, you will take the medication/ change your life style & report progress ” 5- Disposition: Admission or send him/her home. “Meanwhile we need to (keep you here in the hospital/ send you to the hospital) for a couple of days to ensure close medial care for you. I’ll make the arrangements, okay.” 6- Follow up: “I want to see you next week / in a month.” 7- Last word in the interview is for the patient: “Anything else?…..” “It was nice to meet you, have a nice day.” END 81

The History Taking Interview: WRAPPING UP Box

TIPS: Wrapping up is a must. Never leave the room without it. If you didn’t finish your questions, mention that and proceed to wrapping up the interview: “Mr/Ms ….., There are still some other questions that I would like to ask you. But as we are running out of time today, I’ll postpone that to our next meeting.” “Okay Mr/Ms…is there anything else you’d like to tell me or ask me?” and continue with the rest of the wrapping up box.

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Chapter 14: THE COUNSELING INTERVIEW The counseling interview is in fact a focused history taking and counseling interview. The counseling MODEL: 1- The Minute Before the interview. 2- The Introduction. 3- The Initial Counseling Questions box (confirm what to counsel. Replaces the CC and HPI boxes). 4- The Station appropriate questions box. 5- The Standard questions box. 6- Effect on patient and family. 7- The Counseling box. 8- Wrapping up. You should go through each step while budgeting your time.

1- The minute before: Like in the History taking model.

2- The Introduction: Like in the History taking model.

3- The Initial Counseling questions box: The Initial Counselling questions: “Mr/Ms …, what brings you here today? / I understand you are here today for …(Subject) ”. 1- “What do you know about … (Subject)?” 2- “What would you like to know about … (Subject) ?, What questions did you hoped to get it answered today?”…. “So, you want to know…. ” 3- “Have you had any experience with … (Subject) in the past?” 4- “Why now?” 5- “Have you talked to someone about … (Subject) or read some information or searched the net?” 6- “Is there something you’re worried about concerning the … (Subject) ?, What triggered this issue?”

4- The Station Appropriate questions box: “Mr./Ms…, before we talk about the… (Subject), I need to ask you some important medical questions”. Then ask the questions in the History Taking Station Appropriate Boxes. This will be pretty quick as the patient’s answers will be mostly negative. 83

The Counseling Interview:

5- The Standard questions box: Then ask the questions in the History Taking Standard questions Boxes. Concentrating on subject related risk factors, complications, and contraindications.

6- The effect on patient and family box: Empathy: “Mr./Ms…, how does this issue been affecting you and your family right now?” Or “I can see this issue has been difficult for you, how are you coping with it?”

7- The Counseling box: “Mr./Ms…, let me give you some information about the ….(Subject)”. Then EDUCATE the patient about: SRS AI OEM 1- Subject: In small chunks asking him in between: “Am I making sense?” or “Is that clear?” 2- Risk factors/ Seriousness: of not acting on the subject. (e.g Keep smoking) “As you may realize, …..(Subject) causes …” 3- Side effects and complications of acting on the subject, emotionally and physically, and how to avoid them. “There is a chance to have …. as a side effect. If that happens, you can …./ call me/ go to emergency.” 4- Alternatives: of acting on the subject. “To deal with this, there are other options. …..” 5- Investigations: “I’m going to send you for some (blood work and X-Ray /Ultrasound), which will help us to rule out any contraindications.” 6- Outcome/ Prognosis: Clearly & truly: If treatable/successful  Assure. If severe/ chronic/ bad  Discuss family and community support. See “Prognosis” in page 73. 7- Effect on patient: “Now, how do you feel about that?” 8- Mode of Usage: Pills, puffs, patches, injections, instruments, ..etc

8- Wrapping up: 1- “Okay Mr/Ms…is there anything else you’d like to tell me or ask me?” 2- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT. Clarify his/her and your responsibilities: “Okay, so I’ll send you for the investigations, you will take the medication/ change your life style and report progress ”. 3- Follow up: “I want to see you next week / in a month.”. 4- Last word in the interview is for the patient: “Is there anything else you’d like to tell me or ask me?”. 5- “It was nice to meet you, have a nice day.” 84

The Counseling Interview There are several scenarios for consult cases: 1. ER Consult: After settling of an acute event at the emergency. e.g. MI, Asthma attack, Diabetes emergencies, Fit, Needle stick … etc. 2. Follow up Consult: Follow up after investigation results came back, Management follow up, or Prognosis. e.g. Asthma control, Diabetes control, HIV positive. 3. Consult visit: First time visit for a consult issue. e.g. Contraception, Hormonal replacement therapy, Smoking, Alcoholism, … etc.

TIPS: -

Make a list of common counseling station. Visit www.oscehome.com. For each subject, prepare a one page long of the following information: 1. 2. 3. 4.

Definition, causes, and prevalence. Risk factors and illness seriousness. Solutions or treatments and common alternatives. Methods, frequency, and duration of using the solutions/treatments. 5. Side effects of using each of these solutions/treatments. 6. Contraindications for each solution/treatment. 7. Needed screening and maintenance investigations and follow up. 8. Complications of not taking an action/treatment. 9. Outcome and prognosis of both using and not using the solution/ treatment. 10. Available community services for support, if needed. -

Make sure to address the patient’s concerns and questions. Practice each subject using the counseling model described above.

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PART THREE THE PHYSICAL EXAMINATION INTERVIEW

87

88

Chapter 15:

THE PHYSICAL EXAMINATION INTERVIEW

Physical examination stations will account for at least one third of the cases in any OSCE exam. The following models and actions listed in chapters 15-25 are not for emergency room setting which will be described later in Part Four.

The MODEL Like the History taking interview, you need to be organized, thorough, and not to forget important points, in the five, ten, or fifteen minutes interview. You will follow the following steps IN SEQUENCE while budgeting your time. Use every possible opportunity while going through these boxes to develop a relationship with the patient. Be gentle and friendly and use verbal and nonverbal communications. The MODEL: 1234-

The Minute Before the interview. The Introduction. (15 seconds) The physical examination. (4/8/13 minutes) Wrapping up. (0.5-1.5 minute)

1- The minute before: Like in the History taking model. 2- The Introduction: (15 seconds) 1- Like in the History taking model. 2- Summarize what you have asked to examine: “Mr./Ms. …., I am here to examine your …., I am going to …explain briefly . Are you ready?” 3- Position the patient. “Will you please sit down here/ lie down flat on your back here, please” if is not already in position. 4- Drape the patient. VERY IMPORTANT. Pay attention through out the interview to keep unneeded body parts covered. 5- If the examiner is present, tell the patient: “I’m going to explain what I’m doing to my colleague there, okay?”

3- The Physical examinations: (4/8/13 minutes) - Explain what are you going to do to the patient before touching him/her. - Stand beside the patient’s right side WITHOUT obstructing the examiner point of view as much as you can (if the examiner present). - Tell the examiner your findings. Talk to examiner without looking at him. - Never use the word “touch”, instead, use ‘feel’. - Uncover only the needed areas when needed and cover it back when you finish. - Don’t repeat painful maneuvers and apologize to the patient. 89

The Physical Examination Interview: - If the patient is in pain or asking for a painkiller: acknowledge and say: “I can see you are in pain. I’m going to give you some medication for the pain later if needed as I need first to examine you to figure out the cause, okay”. Station appropriate physical examination: Chest. Cardiovascular. Abdomen. Gynecological. Head & Neck.

Neurological. MSK. Pediatric. Emergency. Obstetrical.

4- Wrapping up: (0.5-1 minute)

NENDF

1- “Okay Mr./Ms….. I’m done here. Is there anything else you’d like to tell me or ask me?” 2- Next Step: “I am going to write my findings in your chart/ inform your doctor/ send you for some (blood work, X-ray. CAT scan, Ultrasound) which will help us to figure out the cause or confirm it.” 3- Educate him/her in short explanatory periods about the: Findings: “I found …?” “This can be due to… or … or … which is ……” 4- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT. Clarify his/her and your responsibilities: “Okay, so I’ll write my findings/ inform your doctor, you will continue with your previous instructions for now.” 5- Disposition: Admission or send him/her home. “Meanwhile we need to (keep you here in the hospital/ send you to the hospital) for a couple of days to ensure close medical care for you. I’ll make the arrangements, okay.” 6- Follow up: “I want to see you again after the results come back in the next few days/ week to discuss our next step.” 7- Last word in the interview is for the patient: “Anything else?…..” “It was nice to meet you, have a nice day.”

Note: Through out the physical examination, you have to explain every step to the patient before you start. In this book, your explanation will be listed after the heading “Ms/Ms,”. Then at the end or while performing it, comment on your findings to the examiner (if present). Your comments will be listed after the heading “To the examiner”. The patient (or the examiner if present) may give you verbal or written findings. This will ONLY happen when you mention what are you doing. For example: when you mention that you are listening to the heart sounds, he/she may inform you that there is a systolic murmur heard. If you don’t mention that, he/she will NOT give you that information. If no examiner is present, these listed comments are your patient note findings. 90

Chapter 16: CHEST EXAMINATION Chest examination: The whole exam is done while the patient is sitting.

1- General appearance: “Mr./Ms..., What is the date today?,… and where are you now?”. To the examiner 1-“Patient is/is not in distress, alert, oriented... 2- There is / is no sweating. 3- The patient is sitting/ lying comfortably/ sitting leaning forward supported by his arms. (SOB)”

2- Ask for Vital signs: To the examiner “What are his/her vitals, please? ” Carefully listen to what the examiner says or read the vitals & comment: e.g. “Normal/ so, he has fever/ tachypnea….”.

Children: Abdominal breathers Men: Upper & lower thoracic breathers Women: Upper thoracic breathers Elderly: Lower thoracic & abdominal breathers.

Cheyne-Stock breathing: Periods of gradual deep breathing alternate with periods of apnea.

“Mr/Ms…, let me feel your pulse” Respiratory rate and pattern: Normally 12-16 bpm. Immediately after taking the pulse and while continuing pretending taking the pulse. To the examiner 1- “Breathing is Regular/ Irregular at … bpm. 2- Uses/ does not use accessory muscles. 3- There is / is no nasal flaring. 4- No/ Stridor. 5- No/ difficulty speaking. 6- No/ Kussmaul or Cheyne-Stock breathing. 7- No/ Pulsus paradoxus.”

3- Inspection:

Patient is sitting

1- Hands: “Mr./Ms…., will you please let me see your hands.” To the examiner “There is / is no…” while inspecting: CSA 1. Color: (Red/ Yellow/ blue) 1) “Palmar erythema”, 2) “Nicotine stain”, 3) “Peripheral cyanosis” (bluish cool fingers, toes) 2. Shape: 1) “Clubbing”, 2) “Muscle wasting”(thenar) , 3) “Contractures” (Dupuytren’s). 3. Asterixis: “Mr/Ms ..., I want you to extend both your arms and back flex your hands just as if you’re stopping a bus like this…. That’s right, now close your eyes……. Thank you.”. To the examiner “No asterixis.”

Causes: Drugs, Cerebral damage, CHF, Uremia.

Hyperpnea (Kussmaul breathing): Rapid deep breathing. Causes: Exercise, Anxiety, Metabolic acidosis

Asterixis: It is brief, jerky downward movements of the wrist when patient extends both arms with wrists dorsiflexed, palms forward & eyes closed. Causes: Hypercapnia

… Continued

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The Physical Examination Interview: CHEST EXAMINATION

Chest examination:

… Cont.

2- Face: To the examiner “There is / is no…” while inspecting: CSM 5. Colour: 1) “Plethora” (pink) , 2) “Jaundice” (while looking on the sclera), 3) “Central Cyanosis” Central: blue lips & buccal mucosa: SO2< 80% 4) “Pallor”. 6. Shape: 1) “Cushinoid / moon face” (round, puffy). 2) “No Myosis, ptosis” (Horner Syndrome) 7. Mouth: “No pursed lips” (emphysema).

Chest Shapes: Barrel chest: (AP =Lateral)

Funnel chest (Pectus excavatum): Sternal depression (with mitral valve disease)

Pigeon chest (Pectus carvinatum): Anterior protrusion of the sternum).

Kyphosis: Abnormal AP curvature.

Scoliosis: Abnormal lateral curvature.

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3- Chest: “Mr./Ms…., I’m going to uncover your chest.” Uncover the chest. Look from the front & back. To the examiner “The chest is/ There is …” while inspecting: CSS 1) Contour: “Symmetric / Not Symmetric” Normally AP diameter < lateral diameter (eye-balling).

2) Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest. No Kyphosis or scoliosis.” 3) Skin: 1) “No Surgical scars or dilated veins.” 2) “No intercostal retraction”

4- Palpation:

Warm up your hands. “Mr./Ms. …, I’m going to feel your neck.” 1. Trachea: Position (midline/slightly to the right) and mobility. Place the right index finger in the suprasternal notch and move it laterally to each side. - Tracheal deviation will be away from the contralateral pneumothorax or effusion. - Fixed trachea: Mediastinal tumor, TB. To the examiner “Trachea is midline and mobile.” 2. Neck lymph nodes: (Supraclavicular, Anterior and lateral cervical LNs bilaterally with both hands fingers in circular movements). To the examiner “There is / is no cervical lymph nodes.” 3. Chest: “Now, I’m going to feel your chest” Patient is still sitting 1) Areas of tenderness: Compress the chest from side to side and front to back for tenderness “Any pain?” To the examiner “There is / is no areas of tenderness” 2) Respiratory excursion: “Mr./Ms…, I want to check your chest expansion. Please hold both your arms crossed on your chest” (to move the scapulae aside while sitting). Place your hands flat on the back of the patient’s chest during normal expiration, with the thumbs parallel in the midline at T10 level & pull the skin slightly to the midline. “I’ll put both my hands on your back…. Now, take as deep a breath as you can and hold it, ….. Breath normally.”... Continued

The Physical Examination Interview: Chest Examination

Chest examination:

… Cont.

Normally, the thumbs should move 3-5 cm symmetrically away from each other. Use your fingers to measure the distance To the examiner “Chest expansion is symmetrical and normal at about 2 fingers. That is about 4 cm.” 3) Tactile Fremitus (TF): Place your ulnar side of the hand on the patient “Mr/Ms.., say ‘99’, … again”. Compare side to side starting anteriorly at the supraclavicular spaces (lung apex) as you move down to the 10 th rib. Then on the back starting at the suprascapular spaces medially down the six posterior positions in a zigzag pattern. To the examiner “Tactile fremitus is symmetrical & normal.”

5- Percussion: To be done on the same areas of the tactile fremitus, front and back. Normal chest is resonant except in the left 3-5 ICS (Cardiac dullness). “Mr/Ms…, I’m going to tap on your chest with my fingers.” Put your left middle finger firmly on the patient (other fingers off) and tab the middle phalanx with your other middle finger moving your wrist only. Examine anteriorly and compare from side to side at the same level. Then “Mr/Ms…, raise your hands above your head” and percuss the axillae and compare both sides. Then percuss the back. To the examiner “Percussion is symmetrical and normal./ hyper, dull on the right at ...ICS.” Diaphragmatic excursion: To locate the level of the diaphragm with deep inspiration and full expiration. Normally 4-5 cm. “Mr./Ms. …., I’m going to draw some marks on your back with a washable pen, Okay?.” Look for the pen quickly. On the patient’s back, percuss from up moving down on one side looking for a change from resonance to dullness while the patient is on quiet breathing. Mark the area. Then, without removing your finger off the patient, ask “Mr/Ms..., take as deep a breath as you can and hold it in”. Continue percussing moving inferiorly to locate the new level and mark it. Then, without removing your finger off the patient, ask, “Now, let as much as you can out and stop breathing”. Continue percussing moving superiorly to locate the new level and mark it. Measure between the two lines. Repeat on the other side. - Report the diaphragm level at the vertebra T.. (count from C7 down), and the excursion for each side. To the examiner “Diaphragm is at T12, the diaphragmatic excursion is 4 cm on the right and 4 cm on the left. Symmetric”

Tactile Fremitus (TF): - TF Increased: Consolidation. - TF Decreased – unilateral: Atelectasis, bronchial obstruction, pleural effusion, pneumothorax, pleural thickening. - TF Decreased – bilateral: Chest wall thickening, COPD.

Loss of cardiac dullness: Hyperinflation e.g emphysema Hyper resonance: Hyperinflation e.g. Asthma, Emphysema, Pneumothorax Dullness: Pneumonia, Pleural effusion, Atelectasis, Tumor.

…..Continued

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The Physical Examination Interview: Chest Examination

Chest examination:

… Cont.

6- Auscultation: Listen to the breathing sounds for: Intensity, Pitch, and Inspiration/Expiration Ratio (I:E Ratio). Listen on the same areas of TF starting on the back. “Mr./Ms. .., I’m going to listen to your chest, I’ll start from the back.” Warm the stethoscope. “Mr./Ms. …, take several deep breathes in and out from your mouth” Listen carefully and compare sides. Normal vesicular breath sounds are continuous. Tracheal

Bronchial

Description:

Harsh

Air rushing tube

Bronchovesicular Rustling, but tubular

Intensity: Pitch: I:E Ratio: Normal location:

Very loud Very high 1:1 Extra thoracic

Loud High 1:3 Manubrium sterni

Moderate Moderate 1:1 Mainstem Bronchi

Vesicular Gentle rustling (Continuous) Soft Low 3:1 Peripheral lung

* Abnormal breath sound locations: - Bronchial breath sounds on lung periphery: Consolidation. - Bronchovesicular breath sounds on lung periphery: Bronchospasm or interstitial fibrosis. * Adventitious sounds: Discontinuous sounds. If present: report location and do Vocal Fremitus below. 1- Crackles (= rales, crepitations): Discontinuous sounds heard on inspiration: - Coarse crackles: Low pitched. - Fine crackles: High pitched. - Early inspiratory crackles suggest bronchiolar obstruction: COPD, asthma. - Non-early inspiratory crackles suggest parenchymal disease: interstitial fibrosis, pneumonia, and pulmonary edema. 2- Wheezes: Abnormal high-pitched sounds caused by air passing through partially narrowed airways on expiration: asthma, tumors, bronchitis (mainly inspiratory), Pulmonary edema, secretions and foreign bodies. Note that decreasing wheezing means either opening or progressive closing of the airways. 3- Rhonchi: Low-pitched, deep sound. Due to transient airway plugging by mucus; may disappear with coughing; “Mr/Ms…, cough several times, please.” suggest bronchitis. …..Continued

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The Physical Examination Interview: Chest Examination

Chest examination:

… Cont.

4- Pleural rub: Grating or brushing sounds heard on both inspiration and expiration peripherally; indicates roughened or inflamed pleura. 5- Stridor: Inspiratory musical sounds over trachea on inspiration: Tracheal obstruction. 6- Sounds like creaking of leather: Pleural effusions. 7- Sounds like walking on snow: Pneumomediastinum. To the examiner “Breath sounds are normal. There are /no crackles/ wheezes/ rhonchi/ on the right lower area. No plural rub or stridor.” 8- Vocal fremitus: If there are no discontinuous breath sounds on the periphery (area of consolidation), don’t do it. To the examiner “ I didn’t hear abnormal breath sounds, so, I don’t need to do vocal fremitus.”. Otherwise: - Bronchophony: “Mr/Ms…, say ‘99’… again.” while you listen on areas of consolidation. It will be louder. - Egophony: “Mr/Ms…, say ‘Bee’… again.” while you listen on areas of consolidation. It will be heard like ‘Baa’ - Whispered Pectoriloquy: “Mr/Ms…, whisper few words… again.”. The whispered words will be heard more clearly over areas on consolidation.

7- Forced Expiratory Time: “Mr./Ms. …, I’ll listen to your breathing here on your neck. I want you to take in as deep a breath as you can and hold it.” Look at your watch and check the duration: “Now, blow all of it out as fast as possible.” To the examiner “Forced Expiratory Time is normal/abnormal at .... seconds”. Normally < 3sec.

8- If there is still some time: Listen quickly to the heart and measure the JVP. Notes for children examinations: -

Infants & children: exam done while sitting in a parent’s lap. Palpation with one finger. No need for chest expansion and tactile fremitus. No Percussion. To rule in pneumonia in children: check: 1- Tachypnea. (Observe the chest for one minute or two 30 sec in a quiet child). 2- Auscultation. 3- Increase breathing work (Nasal flaring, retraction of supra, intra, substernal regions) COVER THE PATIENT

END … Wrap up

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The Physical Examination Interview: Chest Examination

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Chapter 17: CARDIOVASCULAR EXAMINATION Cardiovascular examination: 1- General appearance: “Mr./Ms..., What is the date today?,… and where are you now?”. To the examiner 1-“Patient is/is not in distress, alert, oriented... 2- There is / is no sweating. 3- The patient is sitting/ lying comfortably/ sitting leaning forward supported by his arms. (SOB)” “Mr./Ms..., Will you please lie down there/here flat on your back?”.

2- Ask for Vital signs: “What are his/her vitals, please? ” Carefully listen/read and comment: e.g. “Normal/ so, he has fever/ tachycardia/ tachypnea….”. - Blood pressure: Take it on: 1. Both arms while lying down.. “Mr./Ms…., let me check your blood pressure.” (Keep the cuff on one arm when you finish to do the orthostatic later) 2. Both legs while lying down. Cuff around the thigh and listen to the popliteal artery. “Now I’ll check the pressure in your thighs” Use a thigh cuff. Examiner will stop you giving the results, but start doing it until he/she stops you. 3. An arm standing after one minute (for orthostatic hypotension). “Mr./Ms…., I’ll recheck the pressure in one minute while standing. Will you please stand up here.” To the examiner “I’ll start inspection while waiting”. Examiner will stop you giving the results, REMOVE CUFFS. “Thank you, lie down” To the examiner “Blood pressure is …. mmHg lying and …. mmHg standing. No postural hypotension, No significant upper/lower extremities difference. ”

3- Inspection: 1- Hands: “Mr./Ms…., will you please let me see your hands.” To the examiner “There is / is no…” while inspecting: CS JOC 1. Color: (Red/ Yellow/ blue) 1) “Palmar erythema”, 2) “Nicotine stain”, 3) “Peripheral cyanosis” (bluish cool fingers, toes) 2. Shape: 1) “Clubbing”, 2) “Muscle wasting”(thenar) , 3) “Contractures” (Dupuytren’s). 4) “Splinter hemorrhage” (if with fever): look on all fingers’ and toes’ nail beds.

5) “Janeway lesions” (if with fever: ‘pain away’ painless flat 1-2 cm)

… Continued

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The Physical Examination Interview: Cardiovascular Examination

Cardiovascular examination:

… Cont.

6) “Osler nodes” (painful, raised < 1.5 cm on soles and plantar surface) 7) Capillary refill: “Mr./Ms…., I’m going to squeeze your thumb” press on nail bed & release while looking on your watch: < 3 sec.

To the examiner “Capillary refill is normal less than 3 sec” 2- Face: To the examiner “There is / is no…” while inspecting: CSM+ Eyes (X CSF) 1. Colour: 1) “Plethora” (pink) , 2) “Jaundice” (while looking on the sclera), 3) “Central Cyanosis” Central: blue lips & buccal mucosa: SO 2< 80% 4) “Pallor”. 2. Shape: 1) “Cushinoid / moon face” (round, puffy). 2) “No Myosis, ptosis” (Horner Syndrome) 3) “No Mitral face” (Red cheeks in mitral stenosis) 3. Mouth: “No pursed lips” (emphysema). 4. Eyes: “Mr./Ms.., let me examine your eyes.” 1) “No Xantholasma” yellow lipid deposition on upper and lower eyes’ lids.

2) “No Senile arcus” yellow lipid deposition in cornea at its margins with conjunctiva.

3) “No Conjunctival hemorrhages”. 4) Fundoscopy: “Now, with this scope.” (examiner will stop you). Look for: 1- “Copper wires”. 2- “Soft / hard exudates”. 3- “Roth spots”: erythmatous lumps 4- “Emboli in retinal arteries”. JVP: =< 4 cm Increased: SVC obstruction, RT heart failure, Constrictive pericarditis.

Kussmaul sign: Rising JVP with inspiration: RT HF, SVC obstruction, Tricuspid stenosis Constrictive pericarditis, and Restrictive cardiomyopathy.

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3- Neck: Jugular Venous Pressure (JVP): JVP is a direct assessment of central venous pressure (RA pressure). 1- JVP Height: “Mr./Ms…., now, I’ll do some measurement on your neck. I’ll put your head higher. Is that okay?” - Position the patient at 30o and ask the patient to turn his head slightly to the left. Then adjust the elevation up to 45 o until pulsations are seen. - Look between the two heads of the sternocleidomastoid muscle (at sternal head of clavicle) for pulsations. If difficult, shine a light tangentially across the right side of the neck and look for shadows of pulsations. - Determine JVP by measuring the vertical distance from the sternal angle to a horizontal line from the top of the jugular pulsations. 2- Waveform: Normally double waveform. 3- Kussmaul sign: Only if JVP is high. “Mr./Ms…., take a deep breath.” …Continued

The Physical Examination Interview: Cardiovascular Examination

Cardiovascular examination:

… Cont.

4- Hepatojugular reflex (HJR): Only if JVP is high. - To assess that high JVP is due to RV function and not SVC obstruction. - Let the patient breath quietly from his mouth. “Mr./Ms…., breath normally from your mouth, please”. “I’m going to push on your stomach here for a while.” - Apply moderate pressure over the liver at the RUQ with your hand & sustain it for 10 sec. - A sustained elevation of the JVP height for > 4 cm for 10 sec is pathological. “Mr./Ms…., I’ll put your head down.” To the examiner “No JVP/ is normal double wave at .. cm/ High at ... cm, +ve Kussmaul” 4- Chest: “Mr./Ms…., I’m going to uncover your chest.” Uncover the chest. Look anteriorly & posteriorly. To the examiner “The chest is/ There is …” while inspecting: CSSP 1. Contour: “Symmetric / not”. Normally AP diameter < lateral diameter (eye-balling).

2. Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest. No Kyphosis or scoliosis.” 3. Skin: “No Surgical scars or dilated veins.” “No intercostal retraction”. 4. Precordial pulsation. “No Precordial pulsation.” 4- Palpation: Warm up your hands. “Now, Mr./Ms…., I’m going to feel your chest” 1- Areas of tenderness: Compress the chest from side to side and front to back for tenderness “Any pain?” To the examiner “There is / is no areas of tenderness” “Mr./Ms…., lie down please.” 2- Abnormal pulsations: at 5 areas: Apex, RT & LT 2nd ICS, LLSB, RLSB. 1- Palpable heart sounds: S1 in MS, P2 in PA pulsation, S3, S4 2- Heaves: use your finger pads. 3- Lifts: (in LT parasternal area): use your finger pads. RVH, LAE, severe LVH. 4- Thrills (palpable murmur of loud intensity >3/6): use the heel of your hand. 5- Implanted pacemakers/ defibrillators. (Inferior to left clavicle) 6- Epigastric pulsations: RVH in COPD. To the examiner “There is/ is no palpable heart sounds, heaves, thrills, lifts, Epigastric pulsations, or implanted devices” .. . Continued 99

The Physical Examination Interview: Cardiovascular Examination

Cardiovascular examination:

… Cont.

3- PMI (Point of Maximum Impulse): Indicates LV size. Palpate in supine but better felt in LLD. Describe it as LDAD: 1- Location: SUPINE: Normally 5 th ICS, mid clavicular line. Otherwise displaced or cardiomyopathy if lateral/inferior to that. (Children 3 cm or diffuse : LVH. 3- Amplitude: - Exaggerated: Volume or pressure overload. 4- Duration: =< 2/3 of systole. Check with radial pulse. - Sustained (increased): LVH. - Brief: AR, MR, and LT to RT Shunt. - Morphology: Double/triple impulse: HCCM. To the examiner “PMI is 2 cm at the 5th ICS MCL (while holding radial pulse), single impulse of normal amplitude & duration.”

5- Percussion: Not useful but do it. - Increased cardiac dullness: Pericardial effusion. - Decreased cardiac dullness: COPD. To the examiner “Cardiac dullness is …..” 6- Auscultation: Warm the stethoscope. “Mr./Ms. …, now, I’m going to listen to your heart.” - Listen over 5 areas: Apex, Lt & Rt 2nd ICS, LLSB, and RLSB. - Listen over all these 5 areas in 4 positions: 1- Supine: (USING THE DIAPHRAGM SIDE): For S1 (best at apex), S2 & S2 Splitting (A2 & P2) (best at pulmonary), and murmurs. 2- LLD: “Mr./Ms. …, Will you please turn half way on your side away from me.”(USING THE BELL SIDE): For S3 & S4. (best at apex) 3- Upright: “Mr./Ms. …, Will you please sit up” (USING THE DIAPHRAGM SIDE): Listen to the five areas. 4- Forward upright: “Mr./Ms. …, could you lean forward, please.” (USING THE DIAPHRAGM SIDE): 1.“Take deep breaths in and out.” Listen to the five areas. 2.“Take a deep breath in and hold it.” Listen to apex and LLSB only. 3.“Take a deep breath in and out and hold.” Listen to apex and LLSB only. - Lungs: As the patient is sitting now: listen to the lung bases for crackles. “Now, I’ll listen to your lungs at the back. Take deep breaths in and out.” Listen to lung bases at the back. - Murmurs: If present comment on: 1- Timing: Systolic, diastolic, continuous. 2- Shape: Crescendo, decrescendo, crescendo-decrescendo, plateau. 3- Quality: Blowing, harsh, rumbling, musical, machinery, scratchy. 4- Location: of maximum intensity. 5- Radiation: Axilla, back, neck. … Continued 100

The Physical Examination Interview: Cardiovascular Examination

Cardiovascular examination: … Cont. 6- Duration: 7- Intensity: out of 6. (not an indication of clinical severity) 8- Pitch: High, medium, low. 9- Relationship to respiration. 10- Special maneuvers. To the examiner “Heart sounds are normal/…, no S3, S4, no murmurs. Chest is clear.” Note: 80 % of children have innocent murmurs: Systolic, short duration, low pitched, Lower fields: Inferior compression: Pituitary adenoma - Lower > Upper fields: Superior compression. Parietal lobe cerebral infarcts, hemorrhages, tumors. …. Continued

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The Physical Examination Interview: Neurological Examination

Neurological examination: CN Cont. 4- Fundoscopy: S - Ask the patient to look on a spot in the distance. “Mr/Ms .., I’m going to examine your eyes with this scope. Please fix your eyes on that picture on the wall.” A distant object. Room lights off. - Usually the examiner will stop you and give you the findings. Listen to them and comment. - Look for: 1. Red Reflex: From one foot away, view retina through the ophthalmoscope. Check for corneal or lens opacities: Cataract or retinoblastoma. To the examiner “Red reflex is normal.” 2. Optic disc: looking close to the eye. Check for: - Colour: If pale: Optic atrophy. - Cup to disc ratio. Deep/ pale cup: Glaucoma - Symmetry. - Sharp borders: If blurred margins (cannot see disc well): Optic disc swelling (papillodema due to increased ICP). To the examiner “Optic disc is normal in colour and shape. No papillodema.” 3. Retinal vessels: Follow vessels in all directions. Arterioles: are of bright light reflex, light red colour, smaller than veins. Veins: are absent or inconspicuous light reflex, dark red colour, larger, and pulsating. To the examiner “Retinal vessels are normal.” 4. Retinal lesions: Lesion on retinal background. Describe it: red / black / gray / white, flame-shaped / round, diffuse / spotting. To the examiner “No retinal lesions.” 5. Macula: Located one disc size temporally (lateral). It is avascular, larger than the disc, with indistinct margins. To the examiner “Macula is normal.”

3. CN III (3)–Oculomotor / CN IV (4)–Trochlear / CN VI (6)–Abducens: Motor - Responsible for: extra-ocular eye movements, papillary constriction, and elevation of upper eyelid. - LR6 SO4: All eye muscles are controlled by CN III except: Lateral Rectus by CN 6, and Superior Oblique by CN 4. … Continued 121

The Physical Examination Interview: Neurological Examination

Neurological examination: CN Cont. 1- Inspection: S For: 1- Eye deviation:

Down & Out:

CN 3 lesion

Up & Out:

CN 4 lesion

Down & In:

CN 6 lesion

+ Dilated pupil: + Non-reactive pupil: Nerve compression. + Reactive pupil: Vascular. Can’t move it Down & In, difficulty walking down the stairs or reading: Ischemia (commonest), DM, and HTN. Can’t move affected eye laterally: Horizontal diplopia.

2- Ptosis: CN 3 lesion. 3- Nystagmus: Vertical: CNS or Horizontal: PNS? To the examiner “There is no eye deviation, ptosis, nystagmus. Pupils are symmetrical, normal size & shape / dilated” 2- Pupils: S

- Size (dilated in CN 3 lesion, constricted in Horner’s), - Shape (round), - Symmetry, - Light reflex, - Accommodation test. 1. Light reflex: CN 3 efferent. “Mr/Ms …, I’m going to briefly shine a light into your eyes to test its response.” Shine light on eye ‘A’: It will constrict (direct response) and also eye ‘B’ will (consensual response). Repeat for eye ‘B’. Note: If patient closes his eyes & prevents the light test: Photophobia (meningism). To the examiner “There is photophobia, light test cannot be done.” 2. Swing light Test: To test both CN 2 afferent and CN 3 efferent. After finishing testing the light reflex of eye ‘B’, quickly swing light back to eye ‘A’. If CN 2 of eye ‘A’ is damaged; ‘A’ & ‘B’ will dilate. a 2 e 3 - If eye ‘A’ CN 2 is damaged: Blind eye When light shines on eye ‘A’: No response in either eye (Negative direct & consensual responses). When light shines on eye ‘B’: Positive direct & consensual responses.

- If eye ‘A’ CN 3 is damaged: When light shines on eye ‘A’: No response in ‘A’ (Negative direct), but positive consensual response of ‘B’.

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Neurological examination: CN Cont. 3. Accommodation Reflex: “Mr/Ms .., now, I want you to look on that picture on the wall then look on this pen” - Hold a pen approximately 5 inches in front of his/her nose. Normally the eyes will converge and pupils will constrict when looking on the pen. To the examiner “Normal direct light reflex and consensual response, Swing light test, and accommodation reflex. ”

3- Cardinal positions of gaze: S There are 6 cardinal positions of gaze. - Positions 3, 4, 9 are not included as cardinal positions. - Move a pen in all the six direction in front of the patient in an ‘H’ direction. - “Mr/Ms .., now I want you to look on this pen with your eyes only and follow it while I’m moving it. Keep your head straight. If at any point you see it as two pens, tell me, okay. ”

- Final position ‘9’ is convergence test (when you move the pen close to the patient’s face). - Look for end point nystagmus: Multiple sclerosis. - Test for saccadic eye movements: “Mr/Ms .., I want you to look first on my nose then quickly shift to my finger here and back again to my nose and so on. Keep doing that quickly. ” Put your index finger close to your nose. To the examiner “Normal eye gaze movements, no end point nystagmus, and normal convergence.”

4. CN V (5) – Trigeminal: (V1,2: Sensory, V3: Sensory & motor) 1- Inspection: S For 1- Temporal wasting. 2- Lateral deviation of jaw to side of lesion. To the examiner “No temporal wasting or lateral jaw deviation. ” 123

The Physical Examination Interview: Neurological Examination

Neurological examination: CN Cont. 2- Motor: S 1. Teeth Clenching: “Mr/Ms .., clench your teeth as hard as you can. I’m going to feel your face.” Palpate the masseter and temporalis muscles and compare sides. (Cheeks). 2. Mouth opening: “Mr/Ms ..,open your mouth widely”. Look for deviation to the weak side. (Masseter and pterygoids muscles) “Mr/Ms .., now, open your mouth against my hand.” 3. Jaw diversion: “Mr/Ms .., now, move your jaw to the right against my hand…good now to the left.” (pterygoids muscle). To the examiner “Normal CN 5 motor function.” 3- Sensory: S

1.

V1 (Ophthalmic): Forehead and nose tip. V2 (Maxillary): Medial aspect of cheek. V3 (Mandibular): Chin. Light touch: Apply a tip of cotton wool on all the above three areas comparing sides at each then proceed to the other area. “Mr/Ms .., tell me when you feel the touch of this cotton on your face. Close your eyes.” Ask him/her only once. (Otherwise, he/she will now when are you going to touch). Pain: Same as above but using a disposable pin or broken tongue depressor. Jaw jerk reflex: “Mr/Ms .., open your mouth please, I’m going to rest my index finger on your jaw and tap it with this hammer, okay” (increased in pseudobulbar palsy). Corneal reflex: Afferent: CN 5 (V1). Efferent: CN 7 A5 E7 “Mr/Ms .., I’m going to lightly touch your eyes with the tip of this cotton. Will you please look to the left. Okay, now to the right.” Touch to cornea, not the lashes or conjunctiva. Approach the eye from the sides so that the patient wont see the cotton tip. Examine both eyes.

2. 3.

4.

* For both jaw jerk and corneal reflexes, the examiner will stop you. To the examiner “Normal CN 5 light touch and pain sensory function. Jaw jerk and corneal reflexes are normal.”

5. CN VII (7) – Facial: (Sensory and motor) 1- Inspection: S For 1. Nasolabial fold: ? flattened. 2. Palpebral fissure: ? eyelid sagging. 3. Mouth: ? drooping. To the examiner “Normal nasolabial fold and no eyelid sagging or mouth drooping.” …Continued

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Neurological examination: CN Cont. 2- Motor: S 1. Muscles of fascial expressions: 1- “Mr/Ms .., raise your eyebrow.” Frontalis muscle. 2- “Now, close your eyes tight. I’ll try to open them keep them closed tight.” Orbicularis oculi muscle. 3- “Okay, show me your teeth.” Buccinator muscle. 4- “Now, puff your cheeks out. I’ll press them to check its strength, keep them puffed out.” Orbicularis oris muscle. 5- “Okay, now, tense your neck muscles.” Platysma muscle. To the examiner “Muscles of expression are / are not normal.” 2- Corneal reflex: Afferent: CN V (V1). Efferent: CN 7 To the examiner “Corneal reflexes are/ are not normal.” 3. Sensory: Taste, anterior 2/3 of the tongue: CN 7; Posterior 1/3: CN 9. “Mr/Ms .., Now, I’ll test your taste sense, okay. ” Hold tongue with a gauze. Touch each side of the tongue with sugar, salt, and vinegar. * The examiner will stop you. “Will you please stick your tongue out. I’m going to hold it. Tell me when you taste something and what does it taste like, sugar, salt, or vinegar.” To the examiner “Taste in anterior 2/3 and posterior 1/3 are/ are not normal.” Raise your eyebrow With a lower motor neuron (LMN) lesion (e.g. Bell’s palsy), you lose entire ipsilateral motor function including frontalis muscle: LIFe Bells. While with upper motor neuron UMN lesion (e.g. cortex, corticospinal), you lose the contralateral motor function with sparing of the frontalis muscle. U C no frontalis (You see no frontalis).

6. CN VIII (8) – Vestibulocochlear: (Sensory) WR WR 1. Whisper test (Auditory acuity): “Mr/Ms…, I’m going to whisper few words, letters into your ears.” Distract one ear by wrinkling a paper. Whisper into the other ear “1,2,3”… “Repeat what I said, please”. Repeat for the other ear. To the examiner “Normal whisper test.” …. Continued 125

The Physical Examination Interview: Neurological Examination

Neurological examination: CN Cont. * Only if hearing is impaired with the whisper test, do Rinne and Weber tests. 2. Rinne Test: Strike a 512 Hz tuning fork and place it on the patient’s mastoid process at one side. “Tell me when this sound disappears?”. -When he tells you; immediately place the tines of the fork near the ear without touching it. “Do you hear it now?”. Yes: AC > BC, No: BC > AC Repeat for the other ear. To the examiner “Rinne test is/ is not normal.” 3. Weber Test: Strike a 512 Hz tuning fork and place it on the patient’s forehead. “Tell me, do hear it equally at both ears?”. If no, “Which one is louder?” Lateralization (sound is higher at that side). To the examiner “Weber test for bone conduction is normal/ Lateralization to right.” 4. Romberg Test: See test for balance. Ask the patient to stand up and turn his/her head repeatedly from side to side. “Mr/Ms .., Now, stand up here. I’m going to turn your head repeatedly from side to side. Please relax your neck… How do you feel?” If he says dizzy, “What do you mean?” Hearing defects Conductive Sensorineural

Rinne Test (in deaf ear)

Weber Test

BC > AC (Answer is NO) AC > BC (Answer is YES)

Lateralize to deaf ear Lateralize to good ear

AC: Air conduction, BC: Bone conduction

7. CN IX (9) – Glossopharyngeal: (Sensory) CN X (10) – Vagus: (Sensory, and Motor) 1- Motor: S Pharyngeal muscles. 1. Symmetry: “Mr/Ms .., open your mouth and say ‘AH’”. With torchlight, check the symmetrical movement of soft palate and uvula. - If CN 9/10 damaged at one side: - Uvula deviates to the strong side. - On relaxation: Palate relaxes to the weak side. To the examiner “Soft palate and uvula movements are / are not symmetrical.” … Continued 126

The Physical Examination Interview: Neurological Examination

Neurological examination: CN Cont. 2. Gag reflex (nasopharyngeal reflex): a 9 e 10 “Mr/Ms .., I’m going to touch the back of your mouth with this tongue depressor to test your gag reflex” * The examiner will stop you. Touch the posterior wall of the pharynx. - Palate should move up. - Pharyngeal muscles should contract. - Uvula should remain in midline. To the examiner “Gag reflex is /is not normal.” 3. Swallowing: - “Mr/Ms .., have some water and swallow it” No water should come from the nose. - “Mr/Ms .., say ‘PaTaKa’” Pa: CN 7; TA: CN 9,10,12; Ka: CN 9, 10 To the examiner “Swallowing & speech are /not normal.” 2- Sensory: Taste of posterior 1/3 of the tongue. Done with CN 7.

8. CN XI (11) – Accessory: (Motor to SCM & Trapezius) 1- Inspection: For fasciculations or atrophy at the neck and shoulders. “Mr/Ms .., I’m going to uncover your shoulders to inspect them.” To the examiner “No fasciculations or atrophy of the Sternocleidomastoid and Trapezius muscles.” 2- Motor: S 1. Trapezius: “Mr/Ms ..,shrug your shoulders.”. “Now, again against my hands”. When Trapezius is weak. It is an ipsilateral lesion. To the examiner “Trapezius muscle is normal/ weak on the left.” 2. Sternocleidomastoid (SCM): “Mr/Ms .., turn your head to the right against my hand.”. “Now, to the left”. When SCM is weak at one side, turning the head to the contralateral side is impaired. To the examiner “Sternocleidomastoid muscle is normal/ weak on the left.” * COVER THE PATIENT.

9. CN XII (12) – Hypoglossal: (Motor to tongue) 1- Inspection: S For tongue asymmetry, deviation, fasciculation or atrophy. “Mr/Ms .., open your mouth.”. … Continued

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Neurological examination: CN Cont. To the examiner “Tongue is normal, no deviation or asymmetry, no fasciculation or atrophy.” 2- Motor: “Mr/Ms .., stick your tongue out and move it from side to side.”. To the examiner “Tongue movements are normal, no deviation.” - Tongue deviates to the lesion side (ipsilateral).

END of CN exam .. Wrap up or continue CN lesion combination Unilateral CN 5, 7, 8 Unilateral CN 3, 4, 5 V1, 6 Unilateral CN 9, 10, 11 Bilateral CN 10, 11, 12

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Likely cause Cerbellopontine angle lesion Cavernous sinus lesion Jugular foramen syndrome Bulbar palsy (LMN), Pseudobulbar palsy (UMN)

The Physical Examination Interview: Neurological Examination

Neurological examination: MMSE Cont. 4- Mini Mental Status Exam: MMSE (Folstein) OMALT: O10, M6, A5, L8, T1 = 30 (< 24 is abnormal). “Mr/Ms .., I’m going to ask you few questions to assess your condition, okay.”. To the examiner “I’m going to do the Mini Mental Status Exam.” 1. Orientation: O10 - Time: One point to each of: year, season, month, date of the month, day of the week “Mr/Ms ..,What year is this?….., What season are we in? …., What month is this? …, What is the date today? …, and what day of the week is today?”. - Place: One point to each of: Country, Province, City, street/hospital name, house /floor number. “Mr/Ms ..,What country is this?….., What province are we in? …., What city are we in? …, What is the street/hospital name? …, and what is house/floor number? .”. To the examiner “Orientation is 10/10 or 9/10 for the day of the week.” 2. Memory: M6 - Immediate recall: 1 point for repeating each of: “Honesty, Tulip, Black”. All together. “Mr/Ms .., repeat after me; Honesty, Tulip, Black.”. - Delayed recall: 1 point for recalling each of the above three words after five minutes. Ask later in five minutes. “Mr/Ms .., I’m going to ask you to recall these three words later, okay.”. 3. Attention & Concentration: A5 1 point for backward spelling each of the letters of the word “World” “Now, spell the word ‘World’ backward.”. To the examiner “Attention & concentration is 5/5.” 4. Language Tests: L8 - Comprehension: (Three stage command), 1 point for each stage: 3 “Mr/Ms .., are you right or left-handed?.. Take this piece of paper with your left hand, fold it in half, and place it on the Non-dominant hand floor.”. - Reading: 1 point for reading ‘close your eyes’. “Mr/Ms .., read this and then do what it says.”.

… Continued

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The Physical Examination Interview: Neurological Examination

Neurological examination: MMSE Cont. - Writing: 1 point for writing a complete sentence. “Mr/Ms .., write a complete sentence on that paper.”. - Repetition: 1 point for repeating ‘no ifs, ands, or buts’. “Mr/Ms ..,repeat ‘ no ifs, ands, or buts’.”. - Naming: 2 points for naming two objects (a pen & a watch) “Mr/Ms .., what is this?, …, and this.”. To the examiner “Language tests are 8/8.” (3) “Mr/Ms .., I want you to recall the three words that I told you few minutes ago.”. To the examiner “Memory is 6/6.” 5. Test of Spatial Ability: T1 1 point for coping the following drawing. To the examiner “Test of Spatial Ability is 1/1.” To the examiner “Mini mental status is …/30.” END .. Wrap up or continue

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The Physical Examination Interview: Neurological Examination

Neurological examination: Motor 5- Motor Examination:

Motor examination: 1. Inspection. 2. Muscle tone. 3. Muscle power 4. Reflexes.

- Two important questions to be answered: Where is the lesion? & What is the lesion? - Is the lesion UMN or LMN lesion? - Is it localized to a specific root or peripheral nerve? Appearance Power Tone Coordination Reflexes: Superficial Deep Plantar

UMN Lesions Atrophy, arms flexed, legs extended Weak / absent Increased / spastic Impaired due to weakness

LMN Lesion Atrophy, Fasciculations

Absent Increased / clonus Up going

also Decreased Down going (normal)

also Decreased/ Flaccid also

1. Inspection: “Mr/Ms .., I’m going to uncover you to inspect your muscle built.”. Look on all four limbs 1. Muscle bulk: Atrophy, hypertrophy, & abnormal bulging/depression. 2. Symmetry: 3. Fasciculations: Typically benign. May be associated with ALS. To the examiner “There is/ is no muscle atrophy, hypertrophy, fasciculation, bulging or depression or asymmetry.” 4. Abnormal movements & positioning: - Asterixis: Brief, jerky downward movements of the wrist when patient extends both arms with wrists dorsiflexed, palms forward and eyes closed.

“Mr/Ms .., I want you to extend both your arms and back flex your hands Justas if you’re stopping a bus like this…. That’s right, now close your eyes. Okay, thank you.”. To the examiner “No asterixis.” - Tics: Involuntary contractions of single muscle or a group of muscles. - Myoclonus: Brief (90 0 Elbow flexion/ Supination

Deltoid Biceps

Radial N.

Wrist extension

Extensor carpi radialis

Elbow extension Thumb IP flexion Wrist flexion +6

Triceps

Flexor digitorum profundus

C6, 7, 8

C7

Radial N.

C7

Median N.

C8

Anterior interosseus N.

Fingers flexion

C8 T1 T4 T6 T10 L1 L2 L3

Ulnar N.

Ulnar deviation Fingers abduction/ adduction

Interossei

Hip flexion

Iliopsoas

Femoral N.

Knee extension

Quadriceps

Deep Peroneal N. L4-5

Ankle dorsiflexion +L5

L5 S1

Deep Peroneal N.

Big toe dorsiflexion

Medial hamstrings/ Tibialis anterior Extensor hallucis longus

Ankle Planter flexion

Soleus/ Gastrocnemius

S2

Sciatic N.

Knee flexion

Biceps femoris/ Semitendinosus

L4

Femoral N.

Tibial N.

S3-S4

Pudendal N.

C6-7

C8 T1

L1, 2, 3

S1-2 L5, S1- 2 S 3-4

A Step By Step Guide To Mastering The OSCEs, ©2005, MedInfo Consulting

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The Physical Examination Interview: Neurological Examination

Neurological examination: Sensory Cont. 1- Primary sensory examination: 1. Light touch: S Posterior column and spinothalamic tract function. Use cotton or a tip of a tissue to touch skin. “Mr/Ms ..,I’m going to feel your skin with this cotton on several points of your body. I want you to say ‘yes’ when you feel it just like this, okay.. Let us start, close your eyes. ” To the examiner “Light touch is normal.” 2. Pain: S Spinothalamic tract function Alternate between sharp and dull touches. Ask the patient to identify sensation as sharp or dull. “Mr/Ms .., now, I’m going to feel your skin with this paper pin. Again, say ‘yes’ when you feel it and tell me if it is dull or sharp sensation, close your eyes. ” To the examiner “Pain sensation is normal.” 3. Temperature: Spinothalamic tract function. Not done if pain sensation is normal. To the examiner “Temperature sensation should also be normal as it is also a spinothalamic function.” Run the tuning fork under cold/hot water and check use it for checking hot/cold sensation. “Mr/Ms ..,now, I’m going to feel your skin with this tuning fork. Again, say ‘yes’ when you feel it and tell me if it is hot or cold sensation, close your eyes. ” To the examiner “Temperature sensation is normal.”

Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not. Start with fingers and toes. If intact, stop. If not, map the dermatome

4. Vibration: Posterior column function / Peripheral neuropathy. Struck the 128 Hz tuning fork and place it on the DIP joint. Ask the patient to tell you when the vibration stops. Check the other side and both lower limbs. If it is impaired move up for dermatome distribution. “Mr/Ms ..,now, I’m going to place this tuning fork on your right hand fingers. Tell me when the buzzing stops, close your eyes… now the other hand… now the right leg…the left.” To the examiner “Vibration sensation is normal.” 5. Proprioception: S (Joint Position Sense) Posterior column function. Hold the patient’s finger from the sides. Begin with the joint at neutral then move it up or down and ask the patient to tell you the direction. Return to neutral position before starting again. S big toes only. “Mr/Ms ..,now, I’m going to move your right hand finger up or down. Tell me if I’m moving it up or down, close your eyes… now the other hand… now the right leg…the left.” To the examiner “Proprioception sensation is normal.” … continued

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Neurological examination: Sensory Cont. 2- Secondary sensory examination: Inability to perform these tests suggests a lesion in the sensory cortex or the posterior columns of the spinal cord. 1. Sensory inattention, Neglect & extinction: Parietal lobe function. - Touch right side, left side, and then both. Start with light stimulus and increase intensity of stimulus if extinction occurs. - Patients with parietal lobe lesions will neglect touch on the side contralateral to the lesion WHEN BOTH sides are touched simultaneously. “Mr/Ms .., now back again to feeling your skin with this cotton on your body. I want you to say ‘yes’ when you feel it, okay.., close your eyes? (Right).., (left).., (Both) ”. When the patient says ‘yes’ ask “Which side?” If extinction: Repeat with stronger stimulus. To the examiner “Secondary sensation of inattention, neglect & extinction is normal.” 2. Two point discrimination: S Parietal lobe function. - Using an untwisted paper clip, ask the patient if he feels two pins. - At fingertips: 2 mm; Toes: 3-8 mm; Palm: 8-12 mm; back: 40 –60 mm. “Mr/Ms .., now tell me if you feel this pin on your skin.., close your eyes. (Right).., Is it one or two pins? (left)…, adjust distance between the pin heads at each area. ” To the examiner “Two point discrimination is normal.” 3. Stereognosis: Parietal & temporal lobe function Place objects in the patient’s hand while eyes are closed and ask him to recognize it. “Mr/Ms .., close your eyes and keep them closed. (Put a coin, or pen or key in his right hand) .., Tell me what is this?.. and now what is this (repeat on the left with something different)…,? ” To the examiner “Secondary sensation of Stereognosis is normal.” 4. Graphesthesia: Parietal lobe function Use a closed pen to write numbers on the patient hand while eyes closed. “Mr/Ms .., I’m going to pretend writing a number on your hand with this closed pen,.. close your eyes again and keep them closed. (Write a number on his right hand).., Tell me what was the number?.. and now (repeat on the left with different number)…,? ” To the examiner “Secondary sensation of Graphesthesia is normal.” 5. Point localization & extinction: Sensory cortex. Touch the patient and ask him to point the touched area. “Mr/Ms .., now back again to feeling your skin with this cotton on your body. I want you to say ‘yes’ when you feel it, okay.., close your eyes. (Right)..” When the patient says ‘yes’; ask “Point where was that?.., (left).., (Both in different areas for extinction). ” To the examiner “Point localization & extinction is normal.” … continued 142

The Physical Examination Interview: Neurological Examination

Neurological examination: Sensory Cont. Where is the lesion? & What is the lesion? for primary sensory impairment:

Location of Primary Sensory Lesion

Distribution of Sensory loss (JPS: Joint position sense)

Single nerve

Single dermatome. Commonly: Median N., Ulnar N., Peroneal N., Lateral cutaneous nerve to the thigh

Root or roots

Confined to single root (s) Commonly: C5, 6, 7 in arm, L4, 5, S1 in leg Distal glove and stocking deficit

Peripheral nerve

Spinal Cord: - Complete transaction: - Hemi section:

- Posterior column: - Anterior column: - Central cord: Brainstem Thalamic sensory loss Cortical (Parietal)

Examples

- Hyperesthesia at upper level - WITH loss of all modalities sensations a few segments below - JPS & vibration loss: Ipsilateral below lesion - Pain & temp. loss: Bilateral at level of lesion. - Pain & temp. contralateral 1-2 segments below lesion JPS & vibration: Bilateral loss below level. - Pain & temp. loss: Bilateral below level. - JPS & vibration: Preserved. - Pain & temp. loss: Bilateral below level. - All others: Preserved. Pain & temp.: ipsilateral face & contralateral body All: contralateral Hemisemsory loss of face & body and pain (dysesthesia) e.g. burning feeling All primary sensations are intact BUT with poor localization. Loss of all secondary sensations.

Entrapment: common in - DM, - Carpal tunnel syndrome, - Rheumatoid arthritis, - Hypothyroidism Multiple: Vasculitis (Mononeuritis Multiplex) Compression by disc prolapse - DM - Alcohol related B12 deficiency. - Drugs

- Trauma - Spinal cord compression by: Tumor, Cervical spondylitis, MS

Anterior spinal artery embolism/thrombosis - Syringomyelia - Trauma leading to hematomyelia - Demyelination (young). - Brainstem stroke (elder) - Stroke. - Cerebral tumor. - MS. - Trauma

End of Sensory exam .. Wrap up or continue

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The Physical Examination Interview: Neurological Examination

Neurological examination: 7- Coordination Examination: 1. General: 1- Masked face: 2- Slurred speech (Dysarthria): “Mr/Ms.., say ‘British constitution’.”, 3- Nystagmus (Gaze evoked): “Now, keep your head straight and look with your eyes only to the right.” 4- Tremor (Intention tremor: coarse, absent with rest) “Now, give your hands……, now put them back on your lap……watch for tremor.” 5- Stiff, slowed, non-rhythmic movements. Normally rapid smooth and accurate. To the examiner “Patient’s speech and movements are/not normal. There is/ no mask face nystagmus, tremor or stiff movements.” “Mr/Ms.., now I want you to do some movements to test your coordination ability.”

2. Gross motor coordination: 1. Heel-To-Knee Test: Have the patient slide one foot heel (not the whole foot) down the shin of the other leg starting from the knee. “Slide your right foot heel over your left leg shin starting from the knee down…. Now the left foot over the right shin.” To the examiner “Heel-To-Knee test is normal.” 2. Finger-To-Nose Test: Have the patient to alternate between touching their nose and your finger (placed at an arm’s length from them not closer) as quickly as possible. “Now, touch your nose tip with your right index finger then my finger here and repeat as quickly as possible,.. now your left index finger.” Look for: ‘past pointing’ (touching the same target again without alternating); and tremor as the finger approaches the target. Inability to do the test: Dysmetria (Inability to control range of motion): Cerebellar disease. To the examiner “Finger-To-Nose test is normal.”

3. Fine motor coordination: Rapid alternating movements (RAM): Inability to do it: Dysdiadochokineasia: Cerebellar lesion. 1. Upper limb: Pronate & supinate one hand on the other rapidly. “Now, I want you to do like this rapidly.” Show him how. - Touch the thumb to each finger as quickly as possible. “Now, with your right hand, do like this rapidly,.. okay, the other hand.” Show him how. … continued

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The Physical Examination Interview: Neurological Examination

Neurological examination: Coordination Cont. 2. Lower limb: Let the patient tap the toes of one foot and then the heel to the floor in rapid alternation. “Now, stand up here with your right foot, do like this rapidly,. okay, the other foot.” Show him how. To the examiner “Fine motor coordination is normal.”

4. Gait: “Now let us check your gait, okay,…” “Will you please stand up here and walk straight ahead” “Stop and return to me now on tiptoe” S1 “Now walk away again but this time on your heels.” L5 “Stop, return by walking in tandem gait with one foot placed in front of the other.” Cannot do tandem gait: Cerebellar lesions. To the examiner “Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.”

5. Balance: “Mr./Ms., Now let us check your Balance, okay,…” Note: the patient is still standing. 1. Romberg Test: Have the patient stand in front of you with their feet together, be prepared to catch or support a falling patient by spreading your arms on his sides. “Stand here perfectly still with your feet together,… now close your eyes.” If he is swaying “Please stand perfectly still.” - Positive if the patient fall in any direction, not sway, WITHOUT being aware of the fall: Peripheral sensory denervation, Vestibular dysfunction, and cerebellar disease. To the examiner “Romberg test is normal.” 2. Pull Test: Now while the patient is still standing with his eyes closed, stand behind him and give him a sudden but gentle pull backward. - Normally the patient keeps steady or takes one step back. - Positive if falls backwards or takes multiple small rapid steps: Parkinson. “Sorry Mr/Ms…, that was to test your balance.” To the examiner “Pull test is normal.”

6. Motor: Screen for power, tone, and reflexes.

7. Sensory: Screen for pain, and joint position sense.

END 145

The Physical Examination Interview: Neurological Examination

Neurological examination: Coordination Cont. Pathological Gait pattern 1. Hemiplegia veers toward lesion Unilateral UMN lesio n due to: 2. Parkinsonian Shuffling gait.

3. Spastic / Scissor Legs are held in adduction at hips, thighs rub together, knees slide over each other 4. Cerebral ataxia: Spreads legs wide apart to provide wider base of support, veers towards lesion side 5. Foot drop / Steppage: Takes high steps as if climbing a flight of stairs. 6. Sensory ataxia Romberg +ve Loss of joint position sense due to

.

146

Possible causes 1. 2. 1. 2.

Stroke. Multiple sclerosis (MS) Parkinsonism. Extrapyramidal effects of antipsychotics 3. Major tranquilizers. Cerebral palsy.

1. 2. 3.

Drugs: Phenytoin, Alcohol MS Cereberovascular disease.

Unilateral: 1. Common peroneal palsy 2.Corticospinal tract lesion. 3. L5 radiculopathy (Sciatica) Bilateral: Peripheral neuropathy. 1. Peripheral neuropathy. 2. Posterior column loss.

The Physical Examination Interview: Neurological Examination

Neurological examination

Where is the lesion?

Central nervous system lesions: Location of CNS lesion

Cerebral cortex, Unilateral

Brainstem, Unilateral

Spinal cord, Unilateral

Basal Ganglia

Cerebellar

Motor 1- Contralateral weakness, spasticity 2- Flexion > Extension in arms 3- Planter > Dorsiflexion in foot. 4- External rotation of legs. 5- Hemisphere deficits. 6- Aphasia. 7- Neglect. 8- Visual lose. 1- Contralateral weakness, spasticity 2- Dysarthria 3- CN deficit (See below) Ipsilateral weakness, spasticity 1- Bradykinesia (slowness) 2- Rigidity 3- Tremor 1- Hypotonia 2- Ataxia 3- Nystagmus 4- No Rapid Alternating Movements

What is the lesion?

VINDICATE Vascular Infectious Neoplastic Degenerative Inflammatory / Immunologic Congenital – developmental Autoimmune Toxic / Traumatic Endocrine - Metabolic

Deep tendon reflexes

Examples

Increased

- Cortical stroke. - Coma - Seizure.

Increased

- Brainstem stroke - Acoustic neuroma

1- Contralateral dermatomal loss at level 2- Variable below level

Increased

Trauma causing cord compression

No loss

Normal or decrease

Parkinsonism

No loss

Normal or decrease

- Cerebral stroke - Tumor

Sensory

Contralateral loss

Variable

Brainstem lesions: Mid Brain: CN 3 & 4: - Diplopia - Ptosis - Non-reactive pupil. Pons:

CN 6 & 7: - LMN facial weakness

Medulla:

CN 8 & 10: Medullary Syndrome … Continued

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The Physical Examination Interview: Neurological Examination

Neurological examination:

Where is the lesion? .. Continued

Peripheral nervous system lesions: Location of PNS lesion LMN

Spinal Nerves

Motor Ipsilateral

Sensory Ipsilateral

1- Weakness/ atrophy in a segmental/ focal pattern 2- Fasciculations 1- Weakness/ atrophy in a root innervated pattern 2- Fasciculations sometimes 1- Weakness/ atrophy in a peripheral nerve pattern 2- Fasciculations sometimes

Deep tendon reflexes

Examples

No loss

Decreased

- Polio - ALS

Dermatomal

Decreased

Herniated disc

Nerve pattern

- Trauma - compression - Entrapment

Polyneuropathy

Weakness/ atrophy: distal > proximal

StockingGlove distribution

Decreased

Peripheral neuropathy: - Alcoholism. - DM - GuillianBarre (acute)

Neuromuscular junction

Fatigability, Bilateral symmetrical proximal weakness

No loss

Normal

Myasthenia gravis

Myopathy

Weakness: Proximal > distal

No loss

Normal or decreased

Muscular dystrophy, Polymyositis, Myopathies.

Mononeuropathy

What is the lesion? .. Continued Acute Focal Diffuse

148

Vascular (Infarction / Intracranial hemorrhage Toxic / Metabolic

Subacute Inflammatory (Abscess, Myelitis) Inflammatory (Meningitis, encephalitis)

Chronic Neoplasm Degenerative

Chapter 23: MUSCULOSKELETAL EXAMINATION Musculoskeletal Examination Sub Model: 1. 2. 3. 4. 5. 6.

Inspection (SEADS CAGE). Palpation (No WET MPs) & Range of Movement (ROM). Power assessment / Isometric Movements. Functional assessment. Sensations & Reflexes. Specific joint tests & others. - Always examine the joints above and below site of interest. - If lower extremity: also examine lower back and complete neurological exam of legs. - If upper extremity: also examine neck and complete neurological exam of arms.

1. Inspection: SEADS CAGE “Mr./Ms.., let me have a look on both your …. (hands, elbows, shoulders, feet, knees, hips).” Drape appropriately, compare both sides. 1. Swelling. 2. Erythema. 3. Atrophy of muscles. 4. Deformities in shape, alignment, or posture. 5. Skin changes: Bruising or discoloration 6. Crepitus or abnormal sound in joints when patient moves them 7. Examine the other side for Asymmetry in bony contour, soft tissue, and limb position. 8. General patient’s: - Attitude: apprehensiveness, restlessness. - Facial expressions: discomfort. - Willingness to move & normality of movements. To the examiner “There is / is no swelling, erythema, muscle atrophy, deformity, contractures, skin changes or crepitus. The patient looks comfortable, relaxed, moving his/her … joint normally/ looks apprehensive with limited …. joint movement.”

2. Palpation:

No WET MPs

“Mr./Ms.., now, I’m going to feel your …. (hand, elbow, shoulder, neck, foot, knee, hip, back).” 1- Palpation: - Feel for: 1. Warmth. Feel with the back of your hand (Compare to surround & the other side joint). 2. Skin thickness, texture (Pliable/ soft/ resilient), and dryness/ moisture. (Pull it). 3. Nodules. 4. Effusion. … Continued 149

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination Sub Model: …Cont. 5. Tenderness: Apply firm pressure on the joint: - Grade I: Patient complains of pain. - Grade II: Patient complains of pain and wines. - Grade III: Patient wines and withdraws the joint. - Grade IV: Patient will not allow palpation of the joint. 6. Muscles: for tremor and fasciculations. (Feel muscles above and below joint.). 7. Distal Pulses. Compare with other side. To the examiner “There is / is no warmth, nodules, effusion, or joint tenderness. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor. Distal pulses are present.” 2- Range of Motion: ROM 1- Active movements: voluntary movements by the patient. - Inability to move a limb is due to mechanical or neurological problems. - Show the patient to move the limb in flexion, extension, abduction, adduction, supination, pronation, .. etc. - Look for: - Movements resulting in pain: ask about pain quality and severity. - Amount of movement restriction. - Willingness of the patient to move the joint. - Quality of movements. - Crepitus. “Mr./Ms.., will you please move your arm/ forearm/ hand/ thigh/ leg/ foot) like this in full range… Any pain?” Yes “How does it feel like?... On a scale of 1 to 10 where 1 is the mildest and to is the worst pain, how would you grade the pain severity?” 2- Passive movements: “Mr./Ms.., now let me move your arm/hand//leg/foot the same way, please relax it.” 3- End Feel: - The sensation felt by the examiner in the joint as it reaches the end of the passive ROM. - 3 normal types of end feel: (others are abnormal) 1. Bone to Bone: A hard unyielding compression that stops further movements. e.g. elbow extension. 2. Soft tissue approximation: A yielding compression that stops further movements. e.g. elbow and knee movements stopped by muscle. 3. Tissue stretch: Hard springy movements with slight give. Feels like increasing resistance. e.g. lateral rotation of shoulder/ knee. …. Continued 150

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination Sub Model: …Cont. To the examiner “Active and passive 1range of movement are normal & 2 equal/ Passive ROM is more than active ROM (Inflammatory). There is movement restriction at… (e.g. flexion) . 3 End Feel is normal tissue stretch (All joints except elbow). There is no 4pain with movement / there is pain with movement that the patient graded as .. out of 10. There is / is no 5crepitus. Movement is smooth and the patient is 6willing to move the joint.”

3. Power assessment / Isometric movements: - Movements that consists of strong, static voluntary muscle contraction. - Ask the patient to hold his limb in the neutral position firmly as you try to move it gently against his resistance in flexion, extension, abduction, adduction, supination,.. etc. Stop movement when pain is felt. “Mr./Ms.., now I want you to hold your arm/hand//leg/foot at this position firmly (resting position) . I’ll try to move it in the same way we just did. Resist me, don’t let me move it, I want to assess your power,.. Okay.” To the examiner “Normal power assessment / There is weakness in flexion…”

4. Functional assessments:  Empathy “Mr./Ms.., as a result of this joint problem, How has this been affecting your daily activities? What things are you no more able to do?… How are you coping with it?”. To the examiner “The patient reports no difficulties in activities of daily living (ADL) / difficulty in getting up/ sitting/ walking up the stairs/ .. using the bathroom/ brushing his teeth/ combing his hair/ …”

5. Specific joint tests: This step is different for each joint. On the next pages, certain points in addition to specific tests relevant to each joint are explained.

6. Sensation screen & Reflexes: Quickly as time permits, do only light touch, two point discrimination, and deep reflexes that are relevant to that joint and compare to other side. e.g. only upper limb in cervical, shoulder, elbow and hand joints. …. Continued

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The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

Specific joint tests: * Temporomandibular joint (TMJ):

As any joint sub model plus:

2. Palpation: -

-

Feel both joint with your index fingers. TMJ is in front of the tragus. While still feeling both TMJs, ask the patient to move the jaw as follow: “Mr./Ms. .., I’m going to feel both your mandibles,… will you please open and close your jaw slowly…… now move it from side to side……now bring it forward and then backward… thank you.” Remove your fingers; “Mr./Ms. .., now open your mouth as wide as you can…. (Observe for deviation), I’ll measure how wide is that with my fingers….. relax.”

To the examiner “There is /is no joint tenderness, jaw movements restriction or deviation.” END TMJ Exam, Wrap up

* Shoulder:

As any joint sub model plus:

2. Palpation: No WET MPs - Palpate the sternoclavicular joint and along the clavicle to the acromioclavicular joint AC. - Palpate anterior & lateral aspects of the glenohumeral joint inferior to ACJ. - Feel the biceps groove, subdeltoid bursa and rotator cuff insertion for tenderness. “Mr./Ms. .., I’m going to feel your shoulder, if you feel pain tell me.” To the examiner “There is / is no warmth, nodules, effusion, or joint tenderness. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor. Distal pulses are present.” Range of Motion: Place your hand of the shoulder cupping it to feel for crepitus. “Now, I’ll move your arm, if you feel pain tell me.” 1- Forward flexion (1650): “Raise both your arms from the front straight above your head.” 2- External rotation (700) and abduction: “Now place both your hands behind your neck base with your elbows out to the sides.” 3- Abduction (170 0) and adduction (500): “Now, raise both your arms from the sides straight above your head (Abduction). Now hold your palms together and bring your arms down slowly to your side (Adduction). ” … Continued 152

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. Note: Pain on abduction at 900: Rotator cuff injury. at 1300: Supraspinatus muscle of the cuff. 4- Backward Extension (60 0) and internal rotation (700 ): “Swing your arms towards your back and place your hands between the shoulder blades.” Report the level of the scapula to which the hand reached. To the examiner “Normal shoulder range of motion with no pain or crepitus / There is movement limitation in abduction.”

5. Special tests: Patient is still standing 1- Test for Inferior Shoulder Instability (Sulcus Sign): Ask the patient to stand up and relax his arms beside his body. Hold the arm below the elbow and pull it downwards. Positive for inferior instability if the subacromial indentation occurred laterally. “Mr./Ms.., stand up here, please… relax both your right arm and shoulder…. I’m going to pull your arm down.” To the examiner “Negative/ positive Sulcus sign.” 2- Drop Arm Test: While the patient is still standing, abduct the arm to 900 passively with the elbow extended, then ask him to slowly lower it back to his side. Positive for rotator cuff tear if sudden drop or pain. “Now, I’m going to raise your arm like this. Please return it slowly back to your side… Any pain?” To the examiner “Negative/ positive drop arm test.” 3- Test of Impingement Syndrome (Rotator Cuff Tendonitis): Forcibly flex the patient’s extended arm at elbow against his resistance. Positive if pain. “Now, extend your arm straight, I’m going to bend it at the elbow resist me,.. any pain?” To the examiner “Negative/ positive impingement syndrome test.” 4- The Anterior Apprehension Test: While the patient in supine position; passively abduct the arm to 90 0, with the forearm parallel to his body, then externally rotate it by moving the hand up. At the point of apprehension (patient resists), apply posterior force (up) proximally on upper arm; movement should continue unhindered. “Now let me move your right arm.” 5- The Posterior Apprehension Test: While the patient is still in supine, passively forward flex the patient’s arm at shoulder in the plane of scapula to 900 , apply a posterior force on the elbow and then horizontally adduct and medially rotate the arm. … Continued

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The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. Positive for posterior instability if the symptoms reproduced or movement resistance or patient apprehension. “Now let me move your right arm. ” To the examiner “Negative/ positive anterior and/or posterior apprehension test.” - Supraspinatus inflammation: Shoulder pain radiating down the arm to the elbow when combing hair, putting on a coat, reaching into a back pocket (abduction at 1300). - Infraspinatus inflammation: Diffuse shoulder pain upon moving the humerus posteriorly without radiation. - Rotator cuff tendonitis: Sharp shoulder pain on elevation (abduction at 900) of arm into overhead position with history of chronic use or trauma. - Rotator cuff tear/rupture: Sharp pain over greater tuberosity after trauma. Characteristic shoulder shrug and pain with abduction at 900 and weakness of external rotation. - Bicipital tendonitis: Generalized anterior tenderness over long head of biceps associated with pain mainly at night. Pain appears on resistance to forearm supination. - Dislocation: 95 % anterior. END Shoulder Exam, Wrap up

* Elbow:

As any joint sub model plus:

1. Inspection: SEADS CAGE - Look for swelling or masses: Olecranon bursitis or rheumatic nodules. - Look for any differences with the other elbow in carrying angle: flexion contractures, hyperextension. “Mr./Ms…, let me have a look on both your elbows….. now, with your palms facing up, bend and then extend your elbows.” To the examiner “There is / is no swelling, erythema, muscle atrophy, deformity, contractures, skin changes or crepitus. The patient looks comfortable, relaxed, moving his/her … joint normally/ looks apprehensive with limited …. joint movement.”

2. Palpation: No WET MPs - Palpate for : Olecranon process, medial and lateral epicondyles, and extensor surface of forearm for 3-4 cm distal to olecranon. - Grasp the elbow with your fingers under the olecranon and the thumb next to biceps tendon: Passively bend & extend the forearm feeling for crepitus, tenderness & restrictions. … Continued 154

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. “Mr./Ms. .., I’m going to feel your elbow, if you feel pain tell me.” To the examiner “There is / is no warmth, nodules, effusion, or joint tenderness. The skin is normal in thickness, soft, normal moisture. No muscular, fasciculation or tremor. Distal pulses are present.” Range of Motion: “Mr./Ms .., bring your forearms towards your shoulders and touch your shoulder (flexion 1450),… now place your arms back down (extension 00),… Now keep your arms on the sides and bend your elbows to the front,… now turn your palms up,…now down (supination 800 / pronation 750).. Any pain?” To the examiner “Normal elbow range of motions with no pain or crepitus / There is movement limitation in flexion.”

5. Special tests: Tests for epicondylitis: - Gradual onset pain in the region of the epicondyles of the humerus radiating down the surface of the forearm. - Pain appears when the patient attempts to open a door or lift a glass. - No symptoms & signs of inflammation (swelling, redness,... etc.). - Tests to be done if suspected epicondylitis from history. Test for Golfer’s Elbow: Medial epicondyle: GMs While palpating the medial epicondyle, the patient’s forearm is supinated and the wrist and elbow are extended. Test for Tennis Elbow: Lateral epicondyle: TLp While palpating the lateral epicondyle, the patient’s forearm is pronated, fully flex the wrist and extend the elbow.

*

“Mr./Ms.., now I’m going to move your forearm in certain ways, tell me if you feel pain.” To the examiner “Negative / positive tests for Golfer’s and tennis elbow.” END Elbow Exam, Wrap up Wrist: As any joint sub model plus:

2. Palpation: No WET MPs

of:

1. Distal radius on lateral surface and distal ulna on medial surface. 2. The groove of both wrists with your thumbs on the dorsum and your fingers on the palmar surface. Compare. 3. The anatomical snuff box. (A hollowed depression just distal to the radial styloid process formed by the abductor and extensor muscles of the thumb). Tenderness suggests Scaphoid fracture or carpal arthritis. 4. Capillary refill. “Mr./Ms. .., I’m going to feel both your wrists, if you feel pain tell me.” … Continued

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The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. To the examiner “There is / is no warmth/coldness, nodules, effusion, or joint tenderness. Normal capillary refill at < 3sec. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor.” Range of Motion: 1. Extension (750 ): “Mr./Ms. .., Press the hands together in the vertical plane,… now raise the forearms to the horizontal plane…. Like this.” 2. Flexion (750): “Now put the back of the hands together in the vertical plane,… now raise the elbows to the horizontal plane…. Like this.” 3. Ulnar deviation (350): “Now deviate your hand inward…. Like this.” 4. Radial deviation (200): “Now deviate your hand outward…. Like this.” 5. Supination (800 from vertical plane): “Now hold this pen in your hand vertically and rotate your hand outward…. Like this.” 6. Pronation (750 from vertical plane): “Now rotate your hand inward…. Like this.” To the examiner “Normal wrist range of motion with no pain or crepitus / There is movement limitation in supination.”

5. Special tests: Tests for Carpal Tunnel Syndrome: Altered sensation (tingling, burning, pins & needles, numbness) on median N. dermatome (first three digits), worse at night. Causes: Fluid retention (pregnancy), and repeated forceful movements at work or sports. 1- Tinel’s Sign: T-T: A sharp Tap or pressure directly over the median N. produces pain or tingling. (Median N. located medial to the flexor carpi radialis tendon at the most proximal aspect of the hand.). 2- Phalen’s Sign: Ph-F: Flexion test above for 60 sec will produce paresthesia or numbness in the first three fingers. 3- Extend both elbow and wrist: Produces pain or paresthesia or numbness in the first three fingers. “Mr./Ms.., now I’m going tap on your wrist and move your hand in certain ways, tell me if you feel numbness.” To the examiner “Negative / positive tests for Tinel’s and Phalen’s elbow” END Wrist Exam, Wrap up 156

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

* Hand: As any joint sub model plus: 1. Inspection: for deformity: “Mr./Ms. .., let me see your hand.” Deformity

Description

Interpretation Caused by: damage to extensor tendon due to: Trauma or Rheumatoid Arthritis (RA) Caused by: the central slip of the extensor tendon detaches from the middle phalanx due to: Trauma or RA

Mallet finger / thumb

Flexed DIP

Boutonniere

Hyperextended DIP & flexed PIP

Swan neck

Flexed DIP & hyperextended PIP Hard dorsolateral nodules of DIP may associate with deviation of distal phalanx

Heberden’s nodes HD

RA and others Osteoarthritis (OA)

Bouchard’s nodes BP

Like Heberden’s but of PIP

OA

Dupuytren’s contracture

Flexion deformity of the fingers at MCP and IPs with nodular thickening in the palm

DM, epilepsy, alcoholism, hereditary, repetitive trauma

IP: Interphalangeal joint,

Note:

DIP: Distal IP,

PIP: Proximal IP,

RA: affects wrist, MCP, PIP

MCP: Metacarpophalangeal joint.

OA: Affects: DIP, PIP

To the examiner “There is / is no swelling, erythema, muscle atrophy, deformity, contractures, skin changes or crepitus. The patient looks comfortable, relaxed, moving his/her … joint normally/ looks apprehensive with limited …. joint movement..”

2. Palpation: of: All joints with thumb and index finger. Also capillary refill. “Mr./Ms. .., I’m going to feel your hand, if you feel pain tell me.” To the examiner “There is / is no warmth/coldness, nodules, effusion, or joint tenderness. Normal capillary refill at < 3sec. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor.” Range of Motion: 1- “Mr./Ms. .., make a fist with each hand with the thumb across the knuckles, and then open your hands and spread your fingers.”. During flexion: normal fingers should flex to the distal palmar crease. Extension: to 00 … Continued 157

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. 2- Thumb: Flexion, extension, abduction, adduction and opposition across the fingers: “Mr./Ms. .., now move your thumb like this… then….” 3- Passive motion of all fingers for flexion/ extension at: MCP (Flexion: intrinsics / Extension: communis), PIP (Flexion: flex. dig. superficialis / Extension: lat. bands of ext. dig.), DIP (Flexion: flex. dig. profundus / Extension: lat. bands of intrinsics), Flexor digitorum superficialis: Restrict movement of 3 fingers with your fingers. Patient’s palm up. Ask him to flex the free finger and look for PIP flexion. “Mr./Ms. .., let me hold these fingers. Now, flex the free one.” Flexor digitorum profundus: Restrict movement of proximal and middle phalanges of all fingers with your fingers. Patient’s palm up. Ask him to flex the all finger and look for DIP flexion. “Mr./Ms. .., okay, now all fingers. Flex the terminal parts.” To the examiner “Normal fingers range of motion with no pain or crepitus / There is movement limitation in first finger DIP.”

5. Special Tests: Finkelstein test for De Quervain’s Disease: De Quervain’s disease is tenosynovitis of abductor pollicis longus & extensor pollicis brevis. Patient will feel weakness of grip and pain at the base of the thumb, which is aggravated by some wrist movements. “Mr./Ms. .., again make a fist with each hand with the thumb across the knuckles closing the fingers over the thumb.. now deviate your hand inward like this.” pain reproduced. To the examiner “Finkelstein test for De Quervain’s disease is negative/ positive.”

6. Sensations: Sensory and motor of radial, median, and ulnar nerves at the hand. To the examiner “As I already checked all the motion of the fingers actively, Motor neurological innervations are intact. / There is motor loss of posterior interosseous branch.” - “Mr./Ms. .., let me check the sensation in your hand.” Light touch, pain & 2-point. … Continued

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Musculoskeletal Examination: …Cont. - “I’m going to feel your skin with this cotton on several points of your fingers. I want you to say ‘yes’ when you feel it just like this, okay…. Let us start, close your eyes.” - “Now, I’m going to feel your skin with this paper pin. Again, say ‘yes’ when you feel it, close your eyes.” -

“Mr/Ms ..,now tell me if you feel this pin on your skin.., close your eyes, Is it one or two pins? adjust distance between the pin heads at 2 mm.”

To the examiner “Radial, Ulnar, & median nerves light touch, pain & 2 point discrimination sensations are intact.”

Nerve Radial C6 Posterior interosseous branch Ulnar C8

Median C7

Anterior interosseous branch Lateral terminal branch

Sensory

Motor

Dorsum of first web space None

Extension of fingers, thumb & wrist Thumb extension

- Dorsum of small finger tip, - Palmar of small finger & medial aspect of ring finger - Dorsum of index, middle fingers tip. - lateral aspect of ring finger, - Palmar of index & ring fingers None

- Finger abduction & adduction, - Opposition of little finger, - wrist flexion - Thumb IP flexion, - Index & middle fingers flexion, - Wrist flexion

None

Thumb opposition

Flexion of index & middle finger

END Hand Exam, Wrap up

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Musculoskeletal Examination: …Cont.

* Spine (Back pain): - Thoracic spine pain: rotates around the trunk along the intercostal nerves. - Upper lumbar spine pain: may be felt in front of the thighs & knees. - Lower lumbar spine pain: may be felt in the coccyx, hips, buttocks, as well as shooting down the back of the legs to the heels and feet. - Intensifies with movement. - Worse with sneezing or coughing: Herniated vertebral disc. - Associated with numbness or tingling in lower limbs: ?Nerve root lesion. - DDX: Age related - Degenerative (90% of all back pain): 1. Mechanical: degenerative, facet. }Increased with 2. Spinal stenosis: congenital, osteophyte, central disc}standing. 3. Peripheral nerve compression: disc herniation. Increased with bending. - Others: 1. Infection. (Osteomylitis) 2. Cauda Equine syndrome (large central disc herniation) Surgical emergency. 3. Neoplastic (Mets). 4. Trauma: fracture (compression/distraction/translation/rotation). 5. Osteoporosis 6. Spondyloarthropathies (e.g. ankylosing spondylitis) 7. Referred: Aortic aneurysm/rupture (surgical emergency), Renal (CVA), Pancreas.

Cervical spine: As any joint sub model plus: 1. Inspection: for deformity: 1- In normal sitting position, nose should be in line with manubrium & xyphoid. From side, earlobes should be in line with acromion process. Look on the neck from the front, and then move to look from the side. To the examiner “There is / is no swelling, erythema, muscle atrophy, deformity, contractures, skin changes or crepitus. There is no neck tilting or rotation. Neck is mobile & not short.” 2- Venous obstruction of upper limbs: Check for vein distension, skin discoloration, ulcers. “Mr/Ms.., let me have a look on both your arms.” To the examiner “There are no distended veins, ulcers or skin color changes.” …Continued 160

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. 2. Palpation: You can palpate the neck standing in front of the patient or from behind. Use both hands and compare sides. Palpate for: 3 types of spine trauma: 1. Tenderness. 1. Vertical compression: 2. Trigger points. Objects falling on head: 3. Muscle spasm. stable. 2. Hyperextension: Only 4. Skin texture. unstable if interspinous 5. Bony and soft tissue abnormality. lig. ruptured (a gap). 3. Shearing injury: head rotation: unstable.

- Posterior aspect: 1- External occipital protuberance 2- Spinal processes and facet joints of vertebrae. (No gap = Stable) 3- Mastoid process. - Lateral aspect: 1- Transverse processes and facet joints of vertebrae. 2- Lymph nodes. Cord injury in spinal trauma: 3- Carotid arteries. 1. Tenderness over spinous processes. 4- Temporomandibular joints & 2. Paraspinous swelling. mandible. 3. Gap between spinous processes. 5- Parotid glands. 4. Neurological paradoxical breathing: - Anterior aspect: 1- Hyoid bone. 2. Thyroid cartilage. 3- Supraclavicular fossa.

Chest in with breathing (paralysis). 5. Flaccid limbs with no response to painful stimuli and no reflexes. 6. Painless urinary retention/ priapism.

“Mr/Ms.., let me feel your neck.” To the examiner “There is no tenderness or muscle spasm, no pain with movement. Skin texture, soft tissue and bony structures felt normal.” Range of Motion: - Active: “Now I want to check your neck movements.” - Flexion (900 ): “Will you please touch your chin to your chest” - Extension (700 ): “Now put your head back.” - Side flexion (20-450): “Touch each shoulder with your ear without raising your shoulders.” - Rotation (70-800): “Now turn your head to the left…and right.” - Passive: “Now let me move your neck in the same movements to feel it… relax your neck.” Repeat the above movements to feel the ‘end feel’: Normally: Tissue stretch. To the examiner “Active and passive range of motion is normal. End feel is normal tissue stretch.” … Continued 161

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. 3. Power Assessment/Isometric Movements: For muscle power and neurological weakness originating from the cervical nerve roots. Each of the following contractions should be held for 5 sec against resistance: Compare sides. Stop movement when pain is felt. “Mr/Ms.., now, I’m going to ask you to do some movements of your neck, shoulders, arms, and hands against my hands asking you to keep them in that position for 5 sec to check your power, okay? ” - Neck flexion C1-2: “Will you please touch your chin to your chest again.” - Neck side flexion C3: “Touch each shoulder with your ear without raising your shoulders.” - Shoulders elevation C4: “Shrug both your shoulders.” - Shoulder abductions C5: “Now, raise both your arms from the sides straight above your head. Now hold your palms together and bring your arms down slowly to your side.” - Elbow flexion &/or wrist extension C5/6: “Bend both your elbows / extend your wrists.” - Elbow extension &/or wrist flexion C7/6: “Extend both your elbows / flex your wrists.” - Thumb extension &/or ulnar deviation C8: “Extend your thumbs like this / deviate your hands internally like this.” - Abduction &/or extension of fingers T1: “Spread/ fan out your fingers.” To the examiner “Normal symmetrical muscle power, no weakness.”

6. Sensation and Reflexes: Both arms: - Sensation: “Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your body. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.” Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not. C2: Jaw angle. C4: Shirt collar area. . C6 (Radial): Dorsum of first web space (Thumb). C7 (Median N):.Index finger palmar or dorsal aspect. C8 (Ulnar N): Little finger palmar or dorsal aspect. To the examiner “Sensation is normal.” 162

… Continued

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. - Reflexes: “Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your joints, Okay?” Biceps tendon reflex C5, 6: - See reflexes in neurological examination chapter. “Mr/Ms .., I’ll start here with your elbow. Relax your arm in this position…. (Set the forearm, strike, and watch twice) . Now the other one….” To the examiner “Biceps tendon reflex is normal/ diminished/ increased.” Brachioradialis tendon reflex C5, 6: - See reflexes in neurological examination chapter. “Mr/Ms .., now here near your wrist. (Set the forearm, strike, & watch twice). Now the other one...” To the examiner “Brachioradialis tendon reflex is normal/ diminished/ increased.” Triceps tendon reflex C6 - 8: - See reflexes in neurological examination chapter. “Mr/Ms .., now here at the back of your arm. …. (Set the forearm, strike, and watch twice). Now the other one….” To the examiner “Triceps tendon reflex is normal/ diminished/ increased.” END Cervical Exam, Wrap up

Thoracic spine:

As any joint sub model plus:

1. Inspection: in standing position on uncovered back. “Mr/Ms .., Let me have a look on your back, Will you please stand up here. I’m going to uncover your back.” To the examiner “There is / is no swelling, erythema, skin changes, hair spots, muscle atrophy, rib humps or deformity. Chest is symmetrical, no lordosis, kyphosis or scoliosis. Shoulders and iliac crests are at the same height bilaterally.” Gait: “Now let us check your gait, okay,…” “Will you please stand up here and walk straight ahead” “Stop and return to me now on tiptoe” “Now walk away again but this time on your heels.” “Stop, return by walking in tandem gait with one foot placed in front of the other.” … Continued 163

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. To the examiner “Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.”

2. Palpation: in standing position on uncovered back - Palpate spine, ribs, scapulae posteriorly, costal cartilages, sternum, and clavicles. - Squeeze the chest from the sides and front back asking the patient for pain. “Now I’ll squeeze your chest.. Do you feel any pain?.. now?.” To the examiner “There is / is no warmth, nodules, effusion, bony or soft tissue tenderness. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor.” Range of Motion: in standing position on uncovered back for thoracic (T) and lumbar spine (L). Active: “Now I want to check your back movements.” - Forward flexion (T: 20-450 , L: 40-600 ): “Will you please bend forward and touch your toes …I’ll measure how far is this from the floor.” Normally up to 7 cm. - Extension (T:25-450, L: 20-350): “Now, I’ll hold your pelvis from the sides… arch your back backward.” - Side flexion (T: 20-400 , L: 15-200): “Now, slide your right hand down your leg…I’ll measure how far is this from the floor…. now the same with the left hand.” Compare - Rotation (T: 35-500 , L: 3-180 ): “Now, sit down here. Without moving your pelvis rotate towards your right side… now towards the left side.” Compare. - Chest expansion: Place a tape measure around the patient’s chest at the level of the nipples and measure the difference between rest and full inspiration. Normally => 4 cm. “Now, I’m going to measure your chest expansion with breathing. Let me place the measuring tape around you (measure)…. Take a deep breath in and hold it (measure).” Passive: “Now let me move your back in the same movements to feel it … relax your back.” To the examiner “Active and passive range of motion is normal. End feel is normal tissue stretch.” … Continued

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Musculoskeletal Examination: …Cont. 3. Power Assessment/Isometric Movements: Patient is still sitting now. Each of the following contractions should be held for 5 sec against resistance: Compare sides. “Mr/Ms.., now, I’m going to check your power, okay.. I’ll place my leg behind your buttocks, and wrap you with my arm. I’m going to do the same movements you just did but don’t let me move you, resist me. ” Do flexion, extension, side flexion, and rotation. Stop movement when pain is felt. To the examiner “Normal symmetrical muscle power, no weakness.”

6. Sensation and Reflexes: Both legs. Sensation: L5: Foot dorsum S2: Medial posterior thigh. “Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your leg. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.” Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not. To the examiner “Sensation screen is normal.” Reflexes: “Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your leg joints, Okay?” Patellar tendon reflex (Knee jerk) L2 - 4: “Mr/Ms .., I’ll start here at your knee. …. (Set the leg, strike, and watch twice). Now the other one….” To the examiner “Patellar tendon reflex is normal/ diminished/ increased.” Achilles tendon reflex (Ankle jerk) S1 - 2: “Mr/Ms .., now your ankle ... (Set the foot, strike, and watch twice). Now the other one….” To the examiner “Achilles tendon reflex is normal/ diminished/ increased.”

END Thoracic spine Exam, Wrap up

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Musculoskeletal Examination: …Cont.

Lumbar spine: As any joint sub model plus: 1. Inspection: in standing position on uncovered back See thoracic spine. In infants: look for spina bifida: (vertebral deformity & skin bulge over lumbosacral spine, hairy patches, pigmented spots.).

2. Palpation: In supine position on uncovered back palpate for: Umbilicus, inguinal areas, iliac crests, symphasis pubis “Mr/Ms .., lie down here flat on your back please. I want to feel your abdomen.” In prone position on uncovered back palpate for: Spine, sacrum, coccyx, iliac crests, ischial tuberosities, para vertebral muscles. “Mr/Ms .., now turn on your stomach, back up please. I want to feel your back.” To the examiner “There is / is no warmth, nodules, effusion, bony or soft tissue tenderness. The skin is normal in thickness, soft, normal moisture. No muscular spasms or fasciculation. No hernia.” Range of Motion: as thoracic See thoracic spine “Now I want to check your back movements. Please stand up here.”

3. Power Assessment/Isometric Movements: Patient is still sitting now. See thoracic spine plus the following leg movements: “Mr/Ms .., now, lie down here again flat on your back. I want to check your legs power.” Hip Flexion L2: Place your hand on his knees and slightly push down. “Flex both your hips, lift your legs up.” Knee extension L3: Bend the knees up on the bed and hold the feet to the bed. “Now, extend both your knees, lift your feet up.” Knee flexion S2: With the knees still bended up on the bed, hold the back of the legs & pull. “Now, flex both your knees, pull my hands.” Ankle Dorsiflexion L4: Extend the patient’s legs. Pull the dorsum of the feet down. “Now, pull my hands with your feet only.” … Continued 166

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. Great toe extension L5: Pull the dorsum of the great toes down. “Now, pull my hands with your big toes only.” Ankle planter flexion S1 (or Ankle eversion or hip extension): Push both feet up. “Now, push my hands with your feet only.” To the examiner “Normal symmetrical muscle power, no weakness.”

5. Special tests: 1- Straight Leg Raising Test: For Sciatic N. (L4-S3) stretch Sciatic N. dermatome: - Anal and perianal area. - Posterior part of the medial aspect of the thigh and leg. - Anterior surface of shin and dorsum of foot. With the patient lying supine, the hip is medially rotated & adducted, & the knee extended. Raise the leg straight up (hip flexion) until back or leg pain is reproduced. - Document: - The degree of elevation at which pain reproduced, usually < 700. - Pain quality and dermatome distribution. Then lower the leg slowly and stop at the point of pain relief. At this position, dorsiflex the foot, pain reproduced. “Mr/Ms .., now, lie down here again flat on your back. I want to do some tests on your legs… Keep your leg straight, I’ll rotate it and bring it internally.. now I’ll raise it.. Tell me exactly where you start to feel pain.” Patient felt pain: stop and measure the angle.

Paraesthesia & radiating pain in sciatic N. dermatome suggests nerve root irritation /tension. Pain is worse with sneezing, laughing, or straining during bowel motion.

“Tell me where do you feel the pain?… How does it feel like?… Now, I’ll lower it slowly tell me the point at where the pain disappears… I’ll back bend your foot.. Any pain?.. Does it feel the same?.” Crossed Straight Leg Raising Test: Repeat the above with the unaffected leg. Symptoms will be reproduced at the affected leg: Lumbar disc herniation. “Now, we’ll do the same with the other leg” To the examiner “Straight Leg Raising Test is positive/ negative for sciatic N. root irritation at 500. No / Positive crossed Straight Leg Raising Test for Lumbar disc herniation.” … Continued

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Musculoskeletal Examination: …Cont. 2- Femoral Stretch test: For femoral N. (L2-4) stretch. Femoral N. dermatome: - Anterior surface of thigh and shin. Have the patient lie prone on the stomach. Raise the leg straight (hip extension) with one hand under the thigh and the other on the leg to maintain knee extension. “Mr/Ms .., now, roll over on your stomach. I’ll repeat the same movements on your legs… Keep your leg straight,.. now I’ll raise it.. Tell me when you start to feeling pain.” “Tell me where do you feel the pain?… How does it feel like?” To the examiner “Femoral Stretch Test is positive/ negative for femoral N. root irritation. ”

6. Sensations and Reflexes: See thoracic spine. 7. Peripheral vascular exam: Feel peripheral pulses. Vascular vs. neurogenic claudication. To the examiner “Normal / absent peripheral pulses ”

Vascular insufficiency Pain

- Constant, - Worse with walking - Relieved by rest.

Sensation Peripheral pulses

Stocking type loss Absent

Spinal stenosis - Only with certain position - Relieved in other positions e.g. sitting or bending. Dermatomal Present

Cauda Equina Syndrome: Most frequent cause of large central disc herniation. Progressive neurological deficit presenting with: 1. Saddle anesthesia. 2. Decreased anal tone & reflex. 3. Fecal incontinence (soil himself). 4. Urinary retention with overflow incontinence. (wet himself, but cannot bee). 5. Bilateral leg weakness. …… Surgical emergency to prevent permanent urinary / bowel incontinence. END Lower Back Exam, Wrap up 168

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

* Hip: As any joint sub model plus: 1. Inspection: in standing position on uncovered lower body (just underwear) 1- “Mr/Ms .., Let me have a look on your hips, Will you please stand up here with only your underwear on.” Look from the front and from behind while commenting: To the examiner “There is / is no swelling, erythema, skin changes, muscle atrophy of the buttocks or thighs. No pelvic tilting or deformity. No lordosis. Iliac crests are at the same height bilaterally.” 2- Gait: “Now let us check your gait, okay,…” “Will you please stand up here and walk straight ahead” “Stop and return to me now on tiptoe” “Now walk away again but this time on your heels.” “Stop, return by walking in tandem gait with one foot placed in front of the other.” To the examiner “Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.” 3- Trendelenburg Test: Very important in children to exclude hip instability. Ask the patient to stand on one foot. Pelvis on non-bearing side should rise indicating functioning abductors (gluteal medius muscle) of the weight bearing side. Repeat with the other leg. “Mr/Ms.., Stand on your right leg only…. Now, on your left only… Thank you.” To the examiner “Trendelenburg test is negative (normal)/ positive.” - Positive if pelvis drops. Causes: 1. Gluteal muscle weakness; 2. Pain; 3. Hip deformity. - If negative (normal), continue with the Stork Standing Test & measure true leg length. 4- Stork Standing Test: “Mr/Ms.., again stand on your right leg only & place the left foot on the inner aspect of your right leg …Thank you… Now, repeat with your left leg… Thank you.” If he cannot do it: Positive. To the examiner “Stork Standing test is negative / positive.” … Continued

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Musculoskeletal Examination: …Cont. 5- Balance: “Mr/Ms.., now balance yourself on one leg. Start with the right one….Close your eyes… Thank you, open your eyes.. Now, repeat on the left leg… close your eyes.. Thank you.” To the examiner “Balance is normal.” 6- True & Apparent leg length: Set the pelvis horizontally; place the legs 15-20 cm apart. True: Measure each leg from anterior superior iliac spine to medial maleolus. Apparent: same but from umbilicus. “Mr/Ms.., now I want to measure your legs’ length… stand straight with your feet 15-20 cm apart and level your pelvis horizontally… let me see.. okay, let me measure.” To the examiner “Legs’ lengths are symmetrical.”

2. Palpation: “Mr/Ms .., Let me feel your hips, will you please lie down here flat on your back.” Anterior aspect: 1- Iliac crests, anterior superior iliac spine, symphasis pubis. 2- Inguinal ligament, femoral triangle. 3- Hip joint, and. greater trochanter & trochantric bursa. 4- muscles. 5- Crepitation: place your fingers over the femoral head (lateral to femoral artery below inguinal ligament), then roll the relaxed leg medially & laterally (internal & external rotation). “Mr./Ms.., relax your leg, I’m going to roll it in and out.” Femoral, popliteal, posterior tibial, and dorsalis pedis pulses. Posterior aspect: “Now roll over on your stomach, let me feel your hips from the back.” 1- Iliac crests, posterior superior iliac spine. 2- Ischial tuberosity, greater trochanter. 3- Sacroiliac, lumbosacral, and sacrococcygeal joints. To the examiner “There is / is no warmth, effusion, bony, soft tissue or joint tenderness. No crepitus. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation. Distal pulses are present.” Range of Motion: Patient still prone. - Extension (10-150): “Mr./Ms.., will you please move this leg up to the maximum….. Any pain?” If yes; “How does it feel like?.. From a scale of 1 to 10 where 1 is the mildest and to is the worst, how would you grade the pain severity?” Active movement … Continued 170

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. “Mr./Ms.., now let me move it the same way, please relax it.” Passive movement. “Mr./Ms.., now I’ll do it again, but this time don’t let me do move it. I want to check your strength.” Power assessment. “Now turn back on your back………….”

COVER THE PATIENT

- Flexion (110-1200): Knee also flexed. “Mr/Ms.., now bend both your hip and knee.” - Abduction (30-500): Place your hand on the opposite superior iliac spine to fix the pelvis “Now, I’ll hold your other hip. Please move your leg on the stretcher away from midline.” - Adduction (30 0): “Now, bring it back and cross it over the other leg as far as you can.” - Rotation: With both hip and knee flexed. Move the foot in (external) and out (internal) with both hip and knee fixed in position. - External (40-600): Moving the foot INWARD “Mr/Ms.., now bend both your hip and knee 900…. Now move your foot inward without moving the knee.” - Internal (30-400): Moving the foot OUTWARD. “Now, move it outward.” Passive: “Now let me move your leg in the same way to feel it, relax it.” To the examiner “Active and passive range of motion is normal. End feel is normal tissue stretch.”

3. Power Assessment/Isometric Movements: Patient is still supine. “Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the same movements you just did but don’t let me move you, resist me.” Do flexion, abduction, adduction, and internal and external rotation. Extension already done. To the examiner “Normal muscle power, no weakness.”

5. Special tests: Patient is still supine. 1- Patrick’s Test (Faber or Figure-Four Test): on the affected leg. “Now, place your right/left foot on the other leg knee…. I’ll bring your knee down to the stretcher.” Positive if the leg cannot be brought on stretcher parallel to the other leg. Causes: 1. Hip or sacroiliac joint problem. 2. Iliopsoas spasms. … Continued 171

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. To the examiner “Negative / Positive Patrick’s Test.” 2- Thomas Test: for fixed hip flexion contracture (most common hip deformity). Place your hand under his lumbar spine to obliterate the free space (lordosis). Ask the patient to bend the leg and hold it against his abdomen. “Mr/Ms.., I’m going to put my hand under your lower spine…. Bend your right/left leg and hold it against your abdomen.” Elevation of the opposite thigh, Positive Thomas Test, suggests fixed hip flexion contracture of that hip (the elevated one not the one flexed against the abdomen). To the examiner “Negative / Positive Thomas Test.” 3- Infants: Ortolani Test: for congenital hip dislocation. Infant supine with both hips and knees flexed. Place your hands with the thumbs on the inner thighs & fingertips over the thigh muscles. Abduct each knee until it touches the table. If dislocated: an audible & palpable ‘chunk’ will be produced as the femoral head reenters the acetabulum.

6. Sensations and Reflexes: - Sensation: L5: Foot dorsum. S2: Medial posterior thigh. “Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your leg. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.” Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not. To the examiner “Sensation screen is normal.” - Reflexes: “Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your leg joints, Okay?” Patellar tendon reflex (Knee jerk) L2 - 4: “Mr/Ms., I’ll start here on your right knee (Set the leg, strike, and watch twice). Now the other one.” To the examiner “Patellar tendon reflex is normal/ diminished/ increased.” Achilles tendon reflex (Ankle jerk) S1 - 2: “Mr/Ms .., now your ankle . …. (Set the foot, strike, and watch twice). Now the other one….” END Hip Exam, Wrap up

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Musculoskeletal Examination: …Cont.

* Knee: As any joint sub model plus: 1. Inspection: “Mr/Ms .., Let me have a look on your knees, will you please stand up here. Bring your feet together.” Look from the front and from behind while commenting: To the examiner “There is / is no swelling, erythema, skin changes, muscle atrophy or fasciculations. No bulging on the sides of the patellar ligaments (small effusion) , No knocked-knees (genu valgum: knees close) or bow-legged (genu varum knees apart) or flexion contracture. Centre of hips, knees, and ankles fall in a straight line.” Gait: “Now let us check your gait, okay,…” “Will you please stand up here and walk straight ahead” “Stop and return to me now on tiptoe” “Now walk away again but this time on your heels.” “Stop, return by walking in tandem gait with one foot placed in front of the other.”

Normally, the centre of the hip, knee, and ankle should all fall in a straight line.

To the examiner “Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.”

2. Palpation: Compare warmth to anterior thigh and other knee with the back of the hand. “Mr/Ms .., Let me feel your knee, will you please lie down here flat on your back.” Anterior palpation with knee extended: - Patella, patellar tendon: apply firm pressure on patella asking for pain: Patello-femoral S. - Tibial tuberosity. - Suprapatellar pouch for thickening or swelling starting 10cm above the patella. - Quadriceps muscles. - Medial collateral ligament. Anterior palpation with knee flexed: - Tibiofemoral joint line lateral aspect for swelling (meniscal cyst), Lateral collateral lig. - Tibial condyles. - Femoral condyles. Posterior palpation with knee slightly flexed: - Popliteal fossa for Baker’s cyst. - Hamstrings & gastrocnemius muscles. … Continued

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Musculoskeletal Examination: …Cont. To the examiner “There is / is no warmth, nodules, effusion, or joint tenderness. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor. No baker’s cyst. Distal pulses are present.” For warmth compare patellar surface with lower anterior thigh and other knee with the back of your hand. Range of Motion: Patient still supine. Active: Flexion (1350) and extension (0 0): “Mr/Ms .., will you please bend your knee to the maximum… now, extend it back straight.” Passive: “Now let me move your leg in the same way to feel it … relax it.” - Flexion and extension: - Patellar horizontal movements: Patella moves horizontally to half of its width, parallel to femoral condyles To the examiner “Active and passive range of motion is normal. End feel is normal tissue stretch. Patella is mobile parallel to femoral condyles.”

3. Power Assessment/Isometric Movements: Patient is still supine. “Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the same movements you just did but don’t let me move you, resist me.” Do flexion and extension. Also do ankle planter flexion & Dorsiflexion (for gasterocnemius). To the examiner “Normal muscle power, no weakness.”

5. Special tests: Patient is still supine 1. Effusion tests; 2. Cruciate lig. tests; 3. Collateral lig. tests; 4. Minisci tests.

1- Effusion tests: “Mr/Ms.., now, I’m going to perform some tests on your knee with some pressure on your lower thigh, okay... ” 1. Fluctuation / Balloon Test: - Place your left hand on the top of the femur, about 15 cm above the patella, with your index finger & thumb placed on either side. - Displace fluid from the suprapatellar pouch by sliding your hand distally to just above the patella. With your left hand, compress the suprapatellar pouch back against femur. - Maintain this pressure. - Place your right hand just pillow the patella with the thumb and index fingers beside its lateral and medial margins. … Continued 174

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Musculoskeletal Examination: …Cont. In presence of effusion, feel for fluid entering the spaces next to patella with your right thumb and index fingers. If felt it, press the patella against femur posteriorly with your right hand and feel the fluid returns superiorly to the suprapatellar pouch with the left thumb and index fingers. To the examiner “Fluctuation / Balloon Test for effusion is negative / positive.” 2. Patellar Tap Test / Ballotment Test: - While maintaining pressure with the left hand, - Push down quickly on patella with the right hand thumb & three fingers. In presence of an effusion, a palpable tap (click), will be transmitted & felt by your left hand thumb and index finger on either side of the patella. To the examiner “Patellar Tap Test for effusion is negative / positive.” 3. Fluid Displacement Test: for small 4-8 cc effusion. - While maintaining pressure with the left hand, - With your right hand, stroke upwards on the knee’s medial side to milk fluid to the lateral side. - With your right hand, stroke downwards on the knee’s lateral side to return fluid to the medial compartment. In presence of effusion, a small distension of medial compartment appears within 2 sec. To the examiner “Fluid displacement Test for small effusion is negative / positive.”

2- Cruciate Ligament tests: Patient is still supine 1. Anterior Drawer Test for ACL & Posterior Drawer Test for PCL: - Flex both hips 450 and knees 90 0, - Inspect the joint lateral line (compare to other side) to exclude tibial posterior subluxation due to torn posterior cruciate ligament (Posterior Sag Sign) causing false positive ACL tear. “Mr/Ms.., now, bend both your hips and knees like this. Let me have a look on outer & back aspects of the knees.” For (Posterior Sag Sign) To the examiner “Posterior Sag Sign for PCL is negative / positive.” - Sit close to the foot to steady it, grasp the leg just below the knee with both hands and jerk the tibia forward (towards patient’s head). - Up to 6 mm movement is normal. - Now, jerk the tibia backward to test for Posterior Drawer test for Posterior Cruciate ligament. - Do the other side to compare. … Continued 175

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. “Now, I’m going to sit by your feet. Relax your legs, I’ll hold your leg and shake it forwards and then backwards,… now the other leg.” To the examiner “Anterior Drawer Test for ACL and Posterior Drawer Test for PCL are negative / positive.” 2. Lachmann Test for ACL: most sensitive & specific - With the knee relaxed flexed at 150 , hip externally rotated (knee inward). - Stand by the bed; hold the distal leg (femur) close to the knee with your left hand. - Hold the upper leg near the knee with your right hand and place its thumb on the joint line to detect movement. - Simultaneously, move the tibia up (anteriorly) and the femur down (posteriorly). - Positive for ACL tear if movement felt. “Mr/Ms.., now, relax your leg and bend the knee slightly like this. I’ll hold your leg above and below the knee to check the joint ligament.” To the examiner “Lachmann Test for ACL is negative / positive.” 3. Modified Pivot Shift Test for ACL: Less sensitive, but more specific. - Grab the right foot between your right arm and chest so that the knee is extended and hip slightly flexed. - Grasp the lower leg with both your hands and apply a valgus force (tilting knee inward). - Lean forward to internally rotate the foot, then slowly flex the knee while feeling lateral. - Positive if the lateral tibial condyle appears sublux anteriorly (patient says that feels like ‘giving way’). - Extend the knee, tibial condyle will jerk backwards. “Mr/Ms.., relax your leg, I’ll hold your leg up and do a test.. How does that feel? ” To the examiner “Modified Pivot Shift Test for ACL is negative / positive.”

3- Collateral Ligament tests: Patient is still supine 1. Palpate: - Palpate the MCL and LCL for any opening (tear). “Mr/Ms.., relax your leg, I’ll bend the knee 450 , let me feel the knee again.” To the examiner “No openings felt of the Medial & Lateral Collateral ligaments.” … Continued

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Musculoskeletal Examination: …Cont. 2. Medial Collateral Ligament (MCL): Medial femoral condyle – Medial tibial condyle - Place your left hand on the lateral aspect of the joint preventing it from moving outwards. - Hold the leg with your right hand; push the leg outwards (Valgus force). MCL opens up. 3. Lateral Collateral Ligament (LCL): Lateral femoral condyle – Fibular head. - Place your right hand on the medial aspect of the joint preventing it from moving inwards. - Hold the leg with your right hand; push the leg inwards (varus force). LCL opens up. “Mr/Ms.., relax your leg, I’ll extend the knee and do other tests...(do above 2 & 3),… now, I’ll bend the leg 20 0 and repeat the test.” To the examiner “Good/ impaired joint capsule & ligaments stability, Medial and Lateral Collateral ligaments openings are not felt (no tear).”

4- Menisci tests: Patient is still supine Medial tear > lateral. 1. McMurray Maneuver for Medial Meniscus: -

Place the left hand above the patella with index and thumb fingers along the joint line. Fully flex the knee, externally rotate the foot, and abduct the leg. Smoothly extend the knee with your right hand. If pain appears again or pain with a click (not only click): Medial meniscus tear.

To the examiner “McMurray Maneuver for medial meniscus tear is negative / positive.” 2. McMurray Maneuver for Lateral Meniscus: “Mr/Ms.., I’ll repeat the test but slightly in a different way, relax your leg,… Any pain?” - Similar to above but with foot internally rotated and leg adducted. To the examiner “McMurray Maneuver for lateral meniscus tear is negative / positive.” 3. Anterior Meniscal lesions: (Anterior horns of medial & lateral menisci) - While the patient lying supine; flex the knee. - Press your left thumb and index fingers firmly into the joint line and 177

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. extend the knee. - If pain appears again or pain with a click (not only click): Anterior meniscus tear. To the examiner “Maneuver for anterior meniscus tear is negative / positive.” 4. Posterior Meniscal lesions: (Posterior horns of medial & lateral menisci) - Place your hands as in McMurray maneuver. - With knee fully flexed, move his heel around in an arc. - If pain appears again or pain with a clicks (not only click): Posterior meniscus tear. To the examiner “Maneuver for posterior meniscus tear is negative / positive.” 5. Crouch Compression Test: L4 - Ask the patient to crouch. - Pain in the anterior aspect of the knee suggests: patello-femoral Syndrome. - Pain in the joint line lateral or medial to patella suggests: meniscal problem. “Mr/Ms.., will you please stand up here and crouch….…. Any pain?, … Where?” END Knee Exam, Wrap up

* Ankle & Foot: As any joint sub model plus: 1. Inspection: 1- Standing with weight bearing: “Mr/Ms .., Let me have a look on your ankles & feet, will you please stand up here. Bring your feet together.” Look from the front and from behind while commenting: To the examiner “There is / is no swelling, erythema, skin changes, muscle atrophy or fasciculations. No feet pronation deformity (valgus). No subtalar deformity.” Pes cavus (high arch) / Pes planus (flat foot): Try to slip a finger under the foot arch. “Mr/Ms.., stand still with feet slightly apart, I’ll check if I can put a finger under your feet.” … Continued

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Musculoskeletal Examination: …Cont. To the examiner “There is / is no high arch or flat foot.” Flat foot: if patient has flat foot: - Ask the patient to attempt to arch the foot; to assess foot mobility, and tibialis posterior rupture (Achilles tendon): “Mr/Ms.., try to arch both your feet.” To the examiner “Foot is mobile / is not mobile, tibialis posterior rupture.” - Ask him to stand on his toes to differentiate between a flexible and fixed foot: “Mr/Ms.., try to stand on your toes.” To the examiner “Foot is flexible / is fixed.” 2- Gait: “Now let us check your gait, okay,…” “Will you please stand up here and walk straight ahead.” “Stop and return to me now on tiptoe.” “Now walk away again but this time on your heels.” “Stop, return by walking in tandem gait with one foot placed in front of the other.” To the examiner “Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.”. 3- Supine without weight bearing: “Mr/Ms .., will you please lie down here flat on your back. Let me have another look on your ankles & feet while lying down.” 4- Inspect shoes for wear-pattern: To be done while the patient is lying down in step (3) above. Look for medial aspect wear-out. “Mr/Ms.., let me have a look on your shoes sole.” To the examiner “There is / is no abnormal wear-out pattern.”

2. Palpation: Patient still supine “Mr/Ms .., Let me feel your ankles & feet.” Screen for metatarsal-phalengeal joints (MTP) also by compressing the forefoot between the index and thumb. Check pulses. To the examiner “There is / is no warmth, nodules, effusion, or joint tenderness. The skin is normal in thickness, soft, normal moisture. Distal pulses are present.” For warmth compare foot surface with lower anterior leg and other foot with the back of your hand. … Continued 179

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont. Range of Motion: Patient still supine. Active: - Ankle (Tibiotalar) joint: - Planterflexion (500) and Dorsiflexion (200): “Mr/Ms .., will you please flex your feet down to the maximum… now, up like this.” - Inversion and eversion: (involve several joints) “Mr/Ms .., now invert your feet with the planter surface facing each other… now, the opposite, evert it.” - Supination (45-600) and pronation (15-300 ): “Mr/Ms .., now rotate your feet outwards (supination)… now, the opposite, inwards (pronation).” - Metatarso-phalangeal joints: - Toes flexion and extension: “Mr/Ms .., now, flex all your toes down to the maximum… now, up like this.” Passive: “Now let me move your foot in the same way to feel it … relax it.” - Ankle (Tibiotalar) joint: - Planterflexion (500) and Dorsiflexion (200): Lock the subtalar joint first in inversion, then planterflex and dorsiflex the ankle. - Inversion, eversion, supination, and pronation. - Subtalar joint: Stabilize the ankle with left hand. Dorsiflex the foot. Hold the calcaneus with the other hand moving it in foot inversion and eversion. - Mid-Tarsal, Tarso-metatarsal, Tarso-phalangeal joints, & toes: Stabilize the calcaneous holding it with the left hand. Do eversion, inversion, planterflexion, dorsiflexion, abduction, adduction, toe flexion and abduction. To the examiner “Active and passive range of motion is normal. End feel is normal tissue stretch.”

3. Power Assessment/Isometric Movements: Patient is still supine. “Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the same movements we just did but don’t let me move you, resist me.” Do knee flexion, foot planterflexion and Dorsiflexion, supination, pronation, toe extension. To the examiner “Normal muscle power, no weakness.” … Continued

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Musculoskeletal Examination: …Cont. 5. Special tests: Patient is still supine 1- Anterior Drawer Test for Ankle Stability: - Place the knee flexed at 900 and the foot flat on stretcher. Stabilize the foot by sitting on it and push the tibia towards the patient. (= forward foot pull = Anterior drawer). “Now, I’m going to sit by your feet. Relax your legs, I’ll hold your leg and shake it backwards,… now the other leg.” To the examiner “Anterior Drawer Test for Ankle stability is negative / positive.” For the following ligaments, passively move the foot asking for pain: “Mr/Ms.., I’m going to do the same movements again. Tell me if you feel pain.. Where?. ” 2- Lateral Complex: - Anterior talofibular lig. (ATF): Planterflexion + inversion. - Calcanofibular lig. (CF): Inversion at 900 . - Posterior talofibular lig. (PTF): Dorsiflexion + inversion. 3- Medial Complex:

Deltoid lig. : Eversion.

To the examiner “Maneuvers for ligament injury is negative / positive.” END Ankle and Foot Exam, Wrap up

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Chapter 24: PEDIATRIC EXAMINATION Pediatric examination: General Notes: In OSCEs, usually, there are no pediatric examination stations. However, adolescent and teenage stations are common and are a real challenge. Be organized: You should have a good order to your physical examination, which will help place the patient at ease. Privacy: You should always maintain privacy by using sheets and curtains during the physical exam. Develop strategies: for the four different age groups: Infant, toddler, school age, adolescent/ teenage. Infants are easy because they don't move around too much. Newborns You should learn the screening exam in newborns for congenital defects. It is important to see a bunch of these so that you have an idea what looks normal and what is abnormal. Make sure that you feel comfortable holding an infant. The most important joint to learn to examine in pediatrics is the hip, so make sure someone shows you the hip exam and you feel comfortable with it. Toddlers are the most difficult because they see you as a stranger. If you can be successful 50% of the time, you are doing very well. Trained pediatricians "fail" about 20% of the time and have to leave the room and come back. Its better to give up and come back with toddlers than to drive yourself crazy trying to do the exam. School age children are like adults, but very concrete in their reasoning. They like for you to explain what you are doing, but they are usually very willing patients on whom you can practice a head to toe exam. Adolescents You should always do the physical exam on adolescents with a chaperone in the room because everything you do will be taken in a sexual context. Focused exam: Make sure that your physical exam is focused. Each patient does not need a head to toe exam. It is good to practice occasionally, but make sure that you are doing it when there are few patients and you have enough time to complete the exam.

Tips for: Ear exam: This is a difficult part of the physical exam, especially in toddlers. Your goal should be to always see the tympanic membrane. The ear canal starts into the …Continued

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Pediatric examination: Cont. head in a medial-dorsal direction and then turns to be medial-ventral, therefore you must straighten it. You can do this by pulling on the ear in an up and out direction. Don't be too gentle, you have to pull to be successful. To prevent yourself from hurting the patient, barely put the tip of the otoscope in the ear and torque the canal. Loss of the tympanic membrane mobility is important in the diagnosis of otitis media. This means that you need a bulb attachment for your otoscope.

Throat exam: In a school age kid or above, you should be able to do the throat exam without using a tongue blade. This exam should always be performed when the patient is sitting up.

Murmurs: You are not expected to be able to describe every pathological murmur. You should be able to differentiate pathological systolic murmurs in the left sternal border from functional murmurs. The pathological systolic murmurs are ventricular septal defects (VSD), peripheral pneumonic stenosis (PPS), mitral regurgitation (MR) & aortic stenosis (AS).

Lung: Be able to differentiate wheezing from rhonchi during the lung exam.

Abdomen: Be able to rule out a surgical abdomen.

Know the level of illness of a patient: This is a skill that you have to develop the skill of differentiating a mild illness from a serious illness. As children medical condition changes quickly, it is important to keep in your mind the differential diagnosis and coming complications of each. Prepare yourself ahead and manage to prevent them.

Pediatric Examination Model: 1. General Appearance. 2. Vital signs & Survey. 3. Focused examination by systems.

…Continued

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Pediatric examination: Cont. Patient is lying flat with his arms on the sides. Knees can be flexed to relax the abdomen.

1- General appearance: For alertness, facial expressions and general affect, speech, crying and interaction with others. To the examiner “Patient is/is not in distress. ” “The patient is lying relaxed/ completely still (peritonitis)/ moving in distress (colic)/ curled up in fetal position (visceral pain)/ lying with one hip flexed (splinting).” “ Child name ….., What is the date today? …., and Where are you now?”. To the examiner “The patient is alert. ” * Developmental Milestones: Ask the parents (or watch): To the examiner “Developmental milestones are appropriate for age as the patient can …...(Age related NOW only). ” * Measure Height, Weight (& Head circumference for 60 bpm in an acutely ill child < 2 years old: Hypoxia (Gold standard is oxygen saturation by a pulse oxymeter). “Let me feel your chest.” To the examiner “Normal respiratory rate at….. ” 5. Blood pressure: not for < 3 years old unless indicated (by Doppler ultrasound). Consistently low diastolic pressure: Patent ductus arteriosus. Normal systolic = 80 + (2 X age in years) Normal Diastolic = 2/3 of systolic. “Let me measure your blood pressure.. I’ll wrap this cuff around your arm, and then inflate it with this to squeeze your arm. Then release the air while I listen with my toy to your arm… Okay” To the examiner “Normal blood pressure at….. ”

… Continued

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Pediatric examination: Cont. Average pediatric vital signs: Respiratory Age Rate Infant 6–12 month 2 – 4 years 5 – 8 years 8 – 12 years > 12 years

30 - 50 30 - 40 20 - 30 14 - 20 12 - 20 12 - 16

Pulse

Systolic BP

Weight (Kg)

120 - 160 120 - 140 100 - 110 90 - 100 80 - 100 60 - 90

> 60 70 - 80 80 - 95 90 - 100 100 - 110 100 - 120

3-4 8 - 10 12 - 16 18 - 26 26 - 50 > 50

3- Focused exam by systems: As in adults with some considerations:

Head and Neck: Head: Neonate and infants. Supine 1- Head Shape and symmetry: During first week and only due to vaginal vertex delivery: - Head is occipiato-frontally elongated, - Overriding cranial bone sutures (flattened by 6 months), - Scalp swelling (either: caput succedaneum (subcutaneous edema resolves in few days), or cepahalhematoma (subperiosteal hemorrhage resolves in few months)) A markedly flattened occiput results from consistently placing the infant supine. 2- Auscultate the temples and the vertex: Loud harsh bruits suggest arteriovenous malformation (AVM). To the examiner “Head shape and sutures are normal and symmetrical. No scalp swelling. No loud harsh bruits on the temples or vertex.”

Ears: 1. Inspection: - Position: - The top of the ear is at the level of a line drawn from the outer eye’s corner. - The pinna should only deviate 10 0 from the vertical axis. - The neonate’s ear is flat against the head. - Hygiene: - Absence of wax: Over cleaning, Acute otitis media. - Foul smelling discharge: Ruptured tympanic membrane, recent myringotomy tube insertion. - Bloody discharge: Foreign body, scratching. To the examiner “Ears’ shape and position are normal & symmetrical. Good hygiene. No discharge, normal wax.”… Continued 187

The Physical Examination Interview: Pediatric Examination

Pediatric examination: Cont. 2. Hearing: Infants: clap hands or rattle keys out of the infant’s sight and see if he responds by fixing on you or having a startle reflex. Children: As adults. See CN VIII (8) – Vestibulocochlear: (Sensory). To the examiner “Normal hearing.” 3. Palpation: - Tug at the auricle, push on targus: if pain: Otitis externa. - Palpate the mastoid for tenderness: +ve: Mastoiditis. “Let me feel your ears.” To the examiner “No pain or tenderness.” 4. Otoscopic exam: Child held on parent’s lap and immobilized. - Be gentle, it hurts when speculum is inserted. - Start with the normal ear. - Child 3 years old: pull the pinna up and back. Direct the speculum downward & forward. “Let us see what is in there inside this bear’s /mummy’s ear, see there is a light shining here.. Do you what to try it?… ” To the parent: “Please sit up him/her in your lap and hold his head fixing it… shall we have a look on your ears?” To the examiner “Normal looking tympanic membrane translucent, mobile, light reflex”

Eyes: - Pupillary responses: poor during first 4-5 months. - Pendular nystagmus or roving eye movements after 6 weeks: highly suspicious for blindness. - Visual acuity: - 3 years old: Use Snellen chart. Average acuity: 2-4 years: 20/20. - Visual field: like adults but use a toy instead of a pen. - Fundoscopy: Indicated for children > 4 months old. Look for: - Cataracts, Corneal opacity, or ptosis: to prevent amblyopia. - Red reflex and retinal hemorrhage. - White reflex (leukocoria): Cataract, ocular tumor, chorioretinitis, and retinopathy of prematurity. To the examiner “Normal……………………..” 188

… Continued

The Physical Examination Interview: Pediatric Examination

Pediatric examination: Cont. Finding Strabismus Hypertelorism (wide set eyes) Epicanthal folds

Appearance of sclera between upper lid & iris Drooping eyelid Painful, red, swollen eyelid Nodular, non-tender area Sunken area around eyelids Red conjunctivae Pale conjunctivae Yellow sclera Bluish sclera

Brushfield’s spots (White / pale speckling of the iris) Absence of iris color Notch at outer edge of iris Constriction of pupils (Miosis) Fixed unilateral dilation of a pupil Dilation of pupils (Mydriasis)

DDx Normal up to 6 months Down’s syndrome - Normal in Asian. - Down’s syndrome - Renal agenesis - Glycogen storage disease Hydrocephalus Paralysis of oculomotor cranial nerve. Stye Cyst Dehydrated Bacterial / viral infection, allergy, irritation Anemia Jaundice - Premature baby - Bilirubinemia - Osteogenesis imperfecta - Glaucoma Down’s syndrome Albinism Visual field defect - Iritis - Drug induced (Morphine) - Local eye injury - Head injury - Acute glaucoma - Drug induced - Trauma - Circulatory arrest - Anesthesia - Emotionally induced

Mouth: Check for - Cyanosis - Hydration. Frothy mouth: Esophageal atrasia / tracheoosephageal fistula. - Oral candidal thrush - Signs of trauma, count teeth: first tooth erupts around 6 months. First permenant tooth erupts around 6 years. - Tonsils, hard and soft palate for exudates and erythema: Infection. - Breath odor: indicates: oropharyngeal / gingival infection, dehydration, constipation, poor oral hygiene. - Palpate for submucosal cleft palate. To the examiner “Normal……………………..” … Continued

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Pediatric examination: Cont. Nose: Check for - Close each nostril at a time and see if the child can breath from the other one with mouth closed. - Discharge: Clear thin: Allergic rhinitis. Purulent yellow / green: Infection. CSF: Head injury. To the examiner “Nostrils patent, no discharge……..”

Neck: Check for -

Lymph nodes. Thyroid Tracheal position. Neck rigidity, Kernig’s and Brudzinski’s signs (May not be present < 1.5 years old).

Kernig’s sign: Strong passive resistance to attempts to extend knee from flexed thigh position. Brudzinski’s sign: Abrupt neck flexion with patient in supine position produces involuntary flexion of hips and knees.

END .. Wrap up

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Chapter 25: OBSTETRIC EXAMINATION Obstetric examination Obstetrical examination is uncommon in OSCEs because it is not easy to get an enough number of pregnant women to act as standardized patient for a full day. However, history taking and counseling scenarios are very common and represent about 20% of any OSCE exam stations. Some OSCE organizers will include non-pregnant women as first and second trimester pregnant examinations and use manikins for third trimester examinations. Even though, obstetrical examination is a skill that you will be assessed for all through your medical practice. Following is the steps for all prenatal visits:

1. General inspection: As you already had few seconds with the patient introducing your self, you will be able to assess: Overall health. Nutritional status and pallor for anemia. Neuromuscular deformities. Emotional status: - Happy with the pregnancy or not? - Signs of spousal abuse? Blood pressure: To the examiner “ The patient looks relaxed/ anxious. No obvious neuromuscular deformities. No pallor or wasting. Happy and co-operates interactively.”

2. Ask for Vital signs and Survey: “What are her vitals, please? ” HR, RR, BP. Carefully listen / read and comment:

Until 24 week: sBP 5-10 dBP 10-15 mmHg Nagele’s Rule:

To the examiner “Normal/ so, she has fever/tachycardia/ tachypnea….”. “Ms…, let us check your weight, stand up on the scale please…., thank you.” “How much was your weight immediately before this pregnancy.” “When was the first day for your last period (LMP)?….. Was it regular?… Every how many days it comes? Do you know your due date (EDC) ?” - Calculate gestational age. (If not given or to be sure). - Calculate weight gain. To the examiner “Her gestational age is …., and weight gain is at … lb, normal/ less/ more for gestational age.”

EDC = 1st day of LMP + 7 days – 3 months. Weight gain: 0-12 weeks: Loss < 5 lb. 10-20 weeks: 1 lb/ month. 20-40 week: 1 lb/ week. Total 15-25 lb.

… Continued

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Obstetric examination: Cont. 3. Examination by body parts: Head & Neck inspection: 1- Mask of pregnancy: Cloasma is the irregular brown patches around the eyes or across the nasal bridge. 2- Pallor. 3- Hair loss. 4- Edema. To the examiner “Normal cloasma seen. No pallor, hair loss, or edema.”. 5- Nasal congestion (common) 6- Gingival enlargement and bleeding (common). “Ms…, let me have a look on your nose….. and your mouth, open it, please.” Use penlight. To the examiner “There is normal nasal and gingival congestion. No bleeding.” 7- Marked or asymmetrical neck enlargement. To the examiner “There is / no neck enlargement”.

Chest: 1- Respiratory rate and pattern: Normally 12-16 bpm. To the examiner 1- “Breathing is Regular/ Irregular at … bpm. 2- Uses/ does not use accessory muscles. 3- There is / is no nasal flaring. 4- No/ difficulty speaking. ” 2- Palpation for PMI: “Ms…, let me feel your chest.” Uncover without exposing the breasts. To the examiner “PMI is 2 cm at the 5th (or 4th ) ICS MCL (while holding radial pulse), single impulse of normal amplitude and duration.” 3- Auscultation: for the heart murmurs and lung bases. “Ms…, now, let me listen to your heart…….. and chest from the back.” To the examiner “No abnormal chest sounds or heart murmurs.” 4- Breasts: “Ms…, Now I’ll examine your breasts,.. okay.” Uncover. Examiner will stop you. Look for: 1. Nipples: Asymmetry, color (dark brown), prominent Montgomery’s glands. 2. Palpate for masses. Usually congested, tender and nodular. 3. Nipple compression: ? Colostrum. ? Bloody/ purulent discharge. … Continued

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Obstetric examination: Cont. COVER CHEST.

Abdomen: “Ms…, Now I’ll examine your abdomen,.. okay.” Uncover. 1- Inspection: Look for: Size, shape, contour, scars (C/S), purplish striae, and linea nigra. To the examiner “Abdomen is of normal shape, contour. There are /no scars, purplish striae, and linea nigra.” 2- Palpate: 1. Liver. 2. Masses. 3. Fetal size and movements. > late T2. 4. Fetal presentation, position. >T3 5. Head mobility and engagement. >T3. 6. Uterine contraction. >T3. To the examiner “…………………………..” 3- Symphyseal Fundal Height (SFH): Normally +/- 2 cm of expected GA. 4- Auscultation: Fetal heart: By doptone >12 weeks. Fetoscope > 18 weeks - For: 1. Heart Rate: 160 (early)-120 (late) bpm. 2. Rhythm: 10-15 bpm variability over 1-2 minutes. 3. Location. To the examiner “Fetal heart rate is ……”

COVER ABDOMEN

5- Leopold Maneuvers: T3.

Pelvic/ Genital/ Anal Exam: “Ms…, Now I’ll need to examine your genitalia and feel your female organs internally with my fingers,.. okay.” Uncover. Examiner will stop you. See Gynaecological examination. Look for: 1- External genitalia inspection. 2- Speculum exam. 3- Pap smear. (If not done within the last 6 months). 4- Vaginal/ cervical culture swabs for gonorrhea and chlamydia. 5- Bimanual exam: 1. Cervix: - Position. - Length: > 1.5-2 cm > 34 weeks. - Consistency. - Dilatation. … Continued

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Obstetric examination: Cont. 2. Uterus: - Size/ Shape/ Consistency/ position. 3. Adenxal mass.

Extremities: 1- Hands and legs for edema: 2- Legs for varicose veins. 3- Knee and ankle reflexes. “Ms…, Now let me examine your hands and legs,.. okay.” To the examiner “There is /no edema or varicose veins.” “Ms…, Now I’m going to tap on your knees and behind your ankles to check the reflexes” To the examiner “Normal knee and ankle reflexes.”

Note: Follow-ups:

Monthly: until 28 weeks. Biweekly: 28-36 weeks. Weekly: > 36 weeks. END .. Wrap up

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Chapter 26: EMERGENCY MANAGEMENT Emergency Room Stations: Emergency room stations in OSCEs are of three different types: A patient came to the ER with a complaint: This station is not an emergency station. People come to the ER as an outpatient. Read carefully the station’s stem instructions to know what is required; history taking station, or physical exam station or both. Treat this station the same way as an ordinary station. A stable patient in ER after management for an acute case: In these stations, a colleague had already done the necessary ER management and the patient is now stable. Read carefully the station’s stem instructions to know what is required; consult (usually), history taking station, or physical exam station. Treat this station the same way as an ordinary station. A patient came to the ER with an acute case: In these stations, you are the first physician to see the patient. The station’s stem instructions states to MANAGE the case and a nurse will be present. This is an ER management station and this chapter will explain what to do in such stations. The ER MODEL for management stations: 123456-

The Minute Before the interview. The Introduction. Rapid Primary Survey (RPS) & Resuscitation. Detailed Secondary Survey Definitive Care. Wrapping up.

1- The minute before: Like in the History taking model. 2- The Introduction: 1- Verify identity: “Mr./ Ms…..” in a questionable voice tone. 2- Self introduction: “Hi, I am Dr…(your last name) , I am the physician on duty here today”. 3- Assess consciousness: “What happened?” with shaking if necessary.  EMPATHY “OOH..” 4- Ask for protective gear. “May I have a gown, gloves, mask, and glasses,... thank you.” Wear what is available quickly. 5- Summarize what you are going to do: “Mr./Ms. …., I am here to examine you/ your .., I am going to ……, Okay? Explain briefly.” … Continued

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The Emergency Management Interview

ER Management: Cont. 6- Position the patient: “Will you please sit down here/ lie down flat on your back here, please” If not already in position. Usually not needed. 7- Drape the patient. VERY IMPORTANT. 8- Tell the patient: “I’m going to explain what I’m doing to my colleagues here, okay?”. If a nurse and/or an examiner is present.

3- Rapid Primary Survey & resuscitation: A B C D E

ABCDE

Airway maintenance with C-spine control. Breathing and ventilation. Circulation (pulses, hemorrhage control). Disability (neurological status). Exposure (complete) and Environment (Temperature control).

A common C-Spine collar scenario:

*Restart ABCDE if patient deteriorates.

The patient asks to remove it. Respond with empathy: “Ooh, let me

1. Immobilize cervical spine with collar or sand bags. In Trauma case ONLY.

first examine you to see if you need it or not.”

Always deal with A and B first as they may kill the patient now, not C.

Airway: To the examiner/ nurse “A collar or sand bags please to immobilize the C-spine.” If already present, comment: “Collar/sand bags in place.” 2. Airway assessment: Assess ability to breath and speak. If patient is already responded appropriately to you so far, indicates patent airway and the ability to breath is normal. “Mr./Ms.., Where are you now?…What day of the week is today?”

ETT drugs: NAVEL 1. Naloxone. 2. Atropine. 3. Ventoline (Salbutomol). 4. Epinephrine. 5. Lidocaine.

To the examiner “Patient is alert, oriented, speaking, no noisy breathing, airway is patent.” 3. Airway management: Goals: 1. Adequate oxygenation & ventilation. 2. Give drugs via endotracheal tube (ETT) if IV not available. 1- Basic airway management (Temporary): 1) Protect C-spine. Already done. 2) Chin lift or jaw thrust to open the airway. “Mr./Ms…, I’ll adjust your head position to assure an open airway… I’ll open your mouth to see if there is something loose in there to take it out.” … Continued

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The Emergency Management Interview

ER Management: Cont. 3) Open mouth: LOOK first for foreign body, THEN, if there is something, sweep/ suction to clear the mouth. To the examiner “No foreign bodies or secretions in the mouth, No mouth smell.” - Think about ability to maintain patency in the future. To the examiner “There is no indication now for endotracheal tube.”

GO TO BREATHING if airway is patent.

OR To the examiner “Patient is…., an indication for endotracheal tube.” Indication for Endo Tracheal Tube (ETT): VISA A Ventilation is poor. O2 saturation 80 mmHg Femoral pulse, no radial >70 mmHg Carotid Pulse only >60 mmHg

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ER Management: Cont. 2. IV lines and Investigations: To the nurse 1) “I want 2 wide pore gauge 14-16 IV lines established, please. 2) Start Normal Saline/ Ringer Lactate, one liter on each at 125-1000 ml/h each (choose according to the patient’s BP). 3) Take a blood sample and send for: - Blood group, Rh and cross-match, - CBC, Lytes, (ABGs, CK-MB, Tropinin) if respiratory/cardiac case - Liver function test (ALT, AST, ALP, and amylase), - Renal function tests (BUN, Cr), - Coagulation profile (INR/PTT), - Rapid bedside Blood sugar, - Toxicology screen (if indicated). 4) Also send for: 12- lead ECG, CXR, Head CT (if comatose), C-Spine and pelvic X-rays (if trauma), 5) Foley’s catheter / Nasogastric tube (if needed). “Mr/Ms .., I’ll put a bee tube inside in order to monitor your urine output, okay..?” Note: If blood seen from meatus: NO FOLEY’S (? Urethral injury) Assess Respiratory Function: Change to assisted ventilation or ETT if needed. If BP low:  1. Give bolus 1-2 L N/S (Normal Saline) or RL (Ringer Lactate). 2. Ask for blood reservation of 6 units cross-matched or O –ve. To the nurse “Prepare 6 units blood, 2 STAT type specific or O –ve (for children and females)/ O +ve (for males) , and 4 crossed matched (takes time)”. NB: If JVP high: Cardiogenic shock: No fluids If both BP and HR low (Cushing): Neurogenic shock: Treat as Cardiogenic. If Comatose:  ‘Universal antidotes’: TANG (A= and). 1. Thiamine 100 mg IV or IM before glucose (if alcoholic, malnourished, cachectic), 2. Glucose 50 cc of 50% (D50W): if glucose < 4 mmol/L (70 mg/dL) or no rapid test, 3. Naloxone 0.4-2.0 mg IV: if narcotic toxidrome present.

3. Rule out shock: Classifications: 1- Hemorrhagic shock: Most common. Shock in trauma patients is hemorrhagic until proven otherwise. ...Continued 204

The Emergency Management Interview

ER Management: Cont. 2- Cardiogenic shock: e.g. blunt myocardial injury, arrhythmia, MI. 3- Obstructive shock: e.g Tension pneumothorax, Cardiac temponade, pulmonary embolism. 4- Distributive shock: e.g. Spinal /neurogenic shock, Septic shock, Anaphylactic shock. Clinical evaluation for shock:

TV SPARC CUBE

Thirst AND reduced urine output. Vomiting. Sweating. Pulse – Tachycardia, weak, narrow pulse pressure, reduced central venous pressure. Anxious. Respiration – Tachypnea, shallow. Cool AND reduced capillary refill. Cyanosis. Unconscious.} BP – Hypo } later Eyes – blank } “Mr/Ms…, I’m going to check your pulses and feel your hands?” - Examine: - Pulses, radial/femoral - Capillary refill & Extremities for coolness. To the examiner “Pulses are/ not symmetrical, good volume and rise, there is/ no radiofemoral delay, normal/ reduced capillary refill at .. /sec, there is/ no peripheral cyanosis and coldness.” “Mr./Ms.., Where are you now?…What day of the week is today?…, Are you thirsty?…Do you feel your mouth dry?.. Do you have lightheadedness?.. Do you feel sick?.. Did you throw up since this event?… Are you anxious?.” To the examiner “There are no signs & symptoms of shock. Patient is relaxed, oriented. No sweating, thirst or vomiting. Pulse, blood pressure and respiration are normal.”

 Go to Detailed Secondary Survey OR To the examiner “There are signs & symptoms of shock class 2/3/4.. Patient is ……… Is the mask fitting well?.. Is the Oxygen on 100%?.. Are IV lines and fluids running?”  Go to management below.

...Continued

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ER Management: Cont. Management of hemorrhagic shock: 1 - Ask for vitals again: “What are his/her vitals, please?” Carefully listen /read and comment: e.g. “Normal/ so, he has fever/tachycardia/ tachypnea….”. 2 - Secure airway and O2: Already done but check the mask and O2 level. 3 - Control bleeding by: External:1. Direct pressure. 2. Elevate limb if no evidence for fracture. 3. Vascular pressure points (brachial, femoral). 4. Do not remove impacted objects. 5. Tourniquet: Only as a last resort. To the nurse “Gauze and bandages please to apply pressure. Also a tourniquet just in case we need it.” Internal: Prompt surgical consultation for active bleeding. To the nurse “Call for surgical consultation for internal bleeding.” 4 - Replace lost blood: 1. Run the 2 liters N/S rapidly as mentioned above. To the nurse “How are the IVs?.” 2. Replace lost blood volume at a rate of 3:1: To maintain intravascular volume as only 1/3 of infused isotonic crystalloids remains intravascular. e.g estimated lost is one liter, give 3 liters NS or RL.

Blood transfusion (packed RBCs): Start with 2 pints  still shock  4 pints  still shock  Surgery. Indications: 1. Severe hypotension on arrival. 2. Shock persists following the rapid infusion. 3. Rapid bleeding. Blood types: 1. Cross-matched: ideal but takes time. 2. Type-specific: can be provided in 10 minutes. If not available; 3. For children and women: O-negative For others: O-positive. Note: - Anticipate complications in massive transfusions. - Use FFP (Fresh frozen platelets) if: 1. Clinical evidence of impaired hemostasis. 2. Ongoing hemorrhage with platelets count < 50,000, and PT >1.5. ...Continued 206

The Emergency Management Interview

ER Management: Cont. 3. Operative intervention: if still in shock for ongoing internal bleeding. 5 - Vasopressors: - Not during bleeding. - Used if hypotension persists despite appropriate volume administration. Also for septic and anaphylactic shocks. - Systolic BP: > 100 mmHg Dobutamine 2 - 20 mcg /kg /min 70 – 100 mmHg Dopamine 2.5 - 20 mcg /kg /min < 70 mmHg Norepinephrine 0.5 - 30 mcg/kg/min Class Blood Loss: cc Volume Blood Loss: % of volume Pulse: bpm BP: mmHg RR: bpm Capillary refill Urinary output: cc/hr Fluid replaceme nt

I

II

III

IV

< 750 cc

750 – 1500 cc

1500 – 2000 cc

> 2000 cc

< 15 %

15 – 30 %

30 40 %

> 40 %

< 100

> 100

Normal

Normal

> 120 Decreased/

> 140 Decreased

Orthostatic

SPB45

Decreased

Decreased

Decreased

30

20

10

None

Crystalloid

Crystalloid

Crystalloid + Blood

Crystalloid + Blood

Note: Cushing effect of ICP is opposite shock: HRBP End of Circulation * If Patient is stable now  Proceed to Disability.

If not  Repeat ABC until becomes stable. …Continued

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ER Management: Cont. Disability: LPM 1. LOC (Level Of Consciousness)

AVPU

Alert Responds to Verbal stimuli Responds to Painful stimuli Unresponsive To the examiner “For disability, the patient is alert / responds to verbal stimuli / painful stimuli / Unresponsive. ”

2. Pupils Size and Reactivity - Size (dilated in CN 3 lesion, constricted in Horner’s), - Shape (round), - Symmetry, - Light reflex. Light reflex: CN 3 efferent “Mr/Ms …, I’m going to briefly shine a light into your eyes to test its response.” Shine light on eye ‘A’: It will constrict (direct response) and also eye ‘B’ will (consensual response). Repeat for eye ‘B’ To the examiner “Pupils size, shape, symmetry, and reactivity are normal./ Patient has photophobia, reactivity not checked.”

3. Movement of upper and lower extremities “Mr/Ms …, move your right arm and fingers,.. Good, now the left arm and fingers, … Good, now move your right leg and the toes, .. Good, and the left leg and the toes, ... Good.” To the examiner “Patient moves his extremities normally / cannot move his right arm and leg. There are / are no signs of lateralization.” COVER THE PATIENT. …………………………………….

**Ask for Vital signs: “What are his/her vitals, please?” Carefully listen / read and comment: e.g. Normal/ so, he has fever/tachycardia/ tachypnea….”. “Any investigation results? ”

Exposure / Environment: 1- Undress the patient completely and examine for areas of injury. 2- Keep patient warm with blankets.

“Mr/Ms …, I’m going to uncover you to check for injuries. okay.” To the examiner “There are / are no wounds, bruises or scratches seen. No needles track marks.” … Continued 208

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ER Management: Cont. ** If Comatose:  ‘Universal antidotes’: TANG (A= and) To the nurse “Put him on left lateral decubitus with neck extended and no pillow…Give him/her: 1. Thiamine 100 mg IV or IM before glucose (if alcoholic, malnourished, cachectic), 2. Naloxone 0.4-2.0 mg IV: if narcotic toxidrome present. 3. Glucose 50 cc of 50% (D50W)”: if glucose < 4 mmol/L (70 mg/dL) or no rapid bedside test is available.

** If signs of lateralization: (unilateral sensory/ motor/ visual loss)  ICP To the nurse “Give him: 1. Manitol 1g/kg rapidly IV, (+/- Lasix 20mg IV) 2. Prepare for intubation, hyperventilate to PCO 2 25-30 mmHg, 3. Raise head 200 if not low BP, 4. Call neurosurgeon.”

** For Anaphylactic shock: To the nurse “Give him: Norepinephrine 0.3 mg of 1:10000 SC (5 - 30 mcg/kg/min); +/- Metylprednisolone (Medrol) 100-200 mg OD PO (1 mg/kg); +/- Diphenhydramine (Benadryl) 50 mg IV (if hypotension)”

** IF Status Eplipticus: To the nurse “Give him: 50% glucose 50 cc IV, } Already given if comatose. Thiamine 100mg IM, } Lorazepam (Ativan) 10 mg (0.1 mg/kg) (or Diazepam (Valium) 20 mg) IV infusion at 2 mg/min Failed: Phenytoin (Dilantin) 20 mg/kg IV infusion at 50 mg/min max, Failed: Phenytoin (Dilantin) 10 mg/kg IV infusion at 50 mg/min, Failed: Phenobarbital 20 mg/kg IV infusion at 50 mg/min,

** IF Diabetic Emergencies: To the nurse “Run the Normal Saline at 1000cc/h each; Give 5 (-10) IU Insulin IV bolus, then another 5 (-10)/h by IV infusion” “When Blood glucose reaches 15 mMol/L change the fluid to two third 5% dextrose water (D5W) and one third Normal Saline. Then add 20 mEq/L KCL to the fluid.” “Send for urine glucose and ketones.” …………………………………………………………………………………. To the examiner “Patient is stable. I’ll start the detailed secondary survey.” …Continued 209

The Emergency Management Interview

ER Management: Cont. 4- Detailed Secondary Survey: -

To identify major injuries or areas of concern. Trauma X-ray Survey: Head to toe physical exam. X-rays & CT. 1. C-spine.

History:

2. 3.

Chest. Pelvis

AMPLE + OSCD PQRST UVW AAA + Station appropriate quickly “Mr/Ms…, I’m going to ask you some questions that will help us assess your condition. Okay. ” WRITE THEM DOWN. If comatose, ask who accompanies the patient.

Allergies and Tetanus: “Do you have any allergies?” Yes:  “What happened when you took it?” (Side effects or true allergy?) “When was your last tetanus shot?”

Medications: “Any MEDIC ALERT wrist strap?,… Are you taking any medications now?” Some people with medications or allergies wear a ‘MEDIC ALERT’ wrist strap. Yes  “ What are they (Name)? .. What is the dose?.. For how long you’ve been taking this (Duration)?.. Have you noticed any side effects?,.. Who prescribed it?… What about medications in the past?” “How frequent you take pain killers like Aspirin, Tylenol, profen? What about steroids?…. Herbal or over-the-counter medications?” “What about street /Recreational drugs?”

P ast medical history: Look for underlying causes: “Have you had similar episodes in the past?.. Do you have any medial diseases?.. Do you have depression? .. Alcohol drinking problem?.. High blood pressure?.. Heart problems?.. Diabetes?.. Seizures?” Yes: “ When was it first diagnosed?... How was it treated? Write down. When was it lastly been checked?… Which doctor is taking care of this?”

Last meal: “When was your last time that you ate something? .. What was it? .. How much was it?”

Events related to the injury: “Tell me what happened / how does this happen?” Is it a blunt (most common)/ crashing / penetrating trauma?

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…Continued

The Emergency Management Interview

ER Management: Cont. If Comatose: 1. Onset: Abrupt: CNS hemorrhage / ischemia, or cardiac arrest. 2. Progression over hours / days: Progressive CNS lesion, or toxic / metabolic cause. 3. Condition prior to coma: Confused/ delirious: Toxic / metabolic cause. “Did he/she lost consciousness all of a sudden or gradually?.. How was he/she before loosing consciousness?.. Confused?.. Delirious?” OSCD PQRST UVW AAA +appropriate/ standard box +

EMPATHY

Physical exam: PRIORTIZE

Comatose/ head injury: Head and Neck first, MI/ thorax: Chest first, Abdominal/ Pelvic trauma: Abdomen/ Pelvic first, Limb injury: MSK.

Head and Neck: 1. Face: Inspect and open the mouth to smell the breath. (Acetone: DM; Mouse: uremia, alcohol). To the examiner “There is no rhinorrhea, tongue pitting, odor on breathing, no Raccoon eyes or Battle’s sign. No wounds or bruises.” 2. Palpation of facial bones and scalp: “Mr/Ms .., let me feel your head… Any soar areas?” To the examiner “No wounds or fractures felt. ” 3. Pupils: Repeat if comatose only. AVPU “Mr/Ms …, I’m going to briefly shine a light into your eyes to test its response.” LOC + reactive pupils  Metabolic or structural cause of coma. LOC + non-reactive pupils  Structural cause of coma. To the examiner “Pupils size, shape, symmetry, and reactivity are normal.” “His/her consciousness is better/ deteriorating with pupils being reactive (metabolic/ structural) / non-reactive (structural)”. To the examiner “Patient is alert / responds to verbal stimuli / painful stimuli / Unresponsive.” …Continued 211

The Emergency Management Interview

ER Management: Cont. 4. Extraocular movements and nystagmus: - Move a pen in all the six direction in front of the patient in an ‘H’ direction. “Mr/Ms .., now I want you to look on this pen with your eyes only and follow it while I’m moving it. Keep your head straight. If at any point you see it as two pens, tell me.” To the examiner “Extraocular movements are normal, no nystagmus.” 5. Fundoscopy for papillodema and hemorrhage: “Mr/Ms .., now I want to look inside your eyes with this scope.” To the examiner “No papilodema or hemorrhage.” 6. Otoscopy for tympanic membranes: “Mr/Ms .., now I want to look inside your ears with this scope.” To the examiner “No otorrhea or hematotympanum.”

Chest: If chest case: do complete respiratory or cardiovascular PE. Otherwise: 1. Inspection: “Mr/Ms .., let me have another look on your chest.” To the examiner “No flail segments or contusion. Breathing pattern is normal.” 2. Palpation: “Mr/Ms .., let me feel your chest.” To the examiner “No areas of tenderness, no subcutaneous emphysema.” 3. Auscultate: Apex, upper, lower of each side. Warm the stethoscope. “Mr/Ms .., let me listen to your chest.. Take deep breaths in and out.” To the examiner “Normal breath sounds. Chest is clear. Normal heart sounds/…….. ” 4. Ask for the CXR/ ECG/ Cardiac enzymes/ Investigations: “What about his/her chest X-ray/ECG/Enzymes?.” Read and comment: To the examiner “Chest X-ray is normal/ There is opacity on the left / fluid level on the left…..” “ECG shows……” “Investigations show…” … Continued

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The Emergency Management Interview

ER Management: Cont. ** IF MI: MONAH: “Mr.Ms..., it seems that you’re having a heart attack. I need you to relax for now, we’re taking good control of the situation here, okay?” To the nurse “Give him: Morphine 5 mg IV every 5-10 min as needed, Oxygen at 4L/min by face mask, Nitroglycerine 0.4 mg sublingual every 5 minutes for three times, Enteric Coated ASA 325mg tab OD STAT, Heparin 5000 unit IV then 30000 units per day IV infusion. To the examiner “His blood pressure and Heart rate are OK.” “Mr./Ms.., do you have asthma?… History of heart failure? ” If No: To the nurse “Give Metoprolol (Lopresor, Betaloc) 2.5 mg IV then 25 mg every 12h. ” “Mr/Ms…, we’re giving you now something for the pain. I need to ask you some questions that will affect our decision of whether giving you a drug that dissolves blood clots in your heart vessels, have you ever had a stroke or head injury?.. Any trauma or surgery during the last two weeks?..” To the examiner “His BP is OK and there are no signs of increased intracranial pressure, - ECG shows more than 2 mm ST elevation in two contagious leads and/or new LBBB. - Pain started less than 6 hours ago. ” To the nurse “Contact cardiology for thrombolytic therapy.” ** IF Malignant hypertension: sBP > 180 mmHg Not if stroke. Lower it at a rate of 25% of presenting BP within 2-6 hours and not below 100 mmHg. To the nurse “Give him: Nitroglycerine 100 mg in 250cc D5W at 5-50 cc/h” or; Sodium Nitroprusside 50 mg in 250cc D5W at 5-50 cc/h” or; Esmolol 10-20mg” or; Metoprolol 1-5 mg IV” or; Nifedipine 10mg sublingual.” ** IF Pneumothorax /Hemothorax: To the nurse “Prepare for Chest tube & contact thoracic surgery.” … Continued

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The Emergency Management Interview

ER Management: Cont. ** IF Asthma / COPD exacerbation: “Mr.Ms.., it seems that you’re having an asthmatic attack. I need you to relax for now, we’re taking good control of the situation here, okay? ” To the nurse “Give him: Oxygen at 4L/min by facemask, Salbutamol (Ventolin) 4-8 MDI puffs every 15-20 min for 3 times (or 1 puff every min MAX 20 puffs), then 2 puffs every 6 hours, Ipratropium bromide (Atrovent) 2-6 puffs every 6 hours, Metylprednisolone (Medrol) 100-200 mg OD PO for 7-14 days then Beclometasone (Vente) 5-10 MDI puffs/d, If with infection:

Co-trimoxazole (Septrin) 200 mg, or Ciprofloxacin (Cipro) 500 mg every 12h.”

…………………………………………………………………………… Ask for vitals again: “What are his/her vitals, please?” Carefully listen / read and comment: e.g. “Normal/ so, he has fever/tachycardia/ tachypnea….”. ……………………………………………………………………………

Abdomen: If abdomen case: do complete abdominal PE. Otherwise: 1. Inspection: Scaphoid (? diaphragm rupture) or distended (? ascites or hemorrhage). 2. Palpation: for rigidity, tenderness and rebound tenderness. “Mr/Ms .., let me feel your abdomen.” Uncover the abdomen. To the examiner “Abdomen is not distended or scaphoid. There are no rigidity, tenderness or rebound tenderness.” * If BP is still low or falling despite fluid and blood replacement: Do Diagnostic Peritoneal Lavage (DPL) or ultrasound or CT. If positive call surgeon for immediate laparotomy.

Pelvis: 1. Pelvic Stability: Hold the pelvis from the sides, squeeze it from the sides and AP, and rotate it vertically. Palpate the iliac crests and symphysis pubis. “Mr/Ms .., I’m going to squeeze your pelvis….Do you feel any pain?” To the examiner “No pelvic bony laxity.” … Continued

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The Emergency Management Interview

ER Management: Cont. 2. Genitalia: Inspect for visible injuries or blood. “Mr/Ms .., now I need to check your genitalia for any injuries, okay…?” Examiner will stop you giving the results. To the examiner “No injuries or blood seen in genitalia.” 3. Rectal exam: for: GI bleed, high riding prostate, and anal tone. “Mr/Ms .., now I need to check your bottom. I’m going to pass a finger in, okay…?” Examiner will stop you giving the results. To the examiner “Normal anal tone, Normal prostate, no blood.” 4. Bimanual vaginal exam: “Ms .., now I need to examine you internally through your vagina. I’m going to pass a two finger in, okay…?” Examiner will stop you giving the results. To the examiner “Uterus is soft. No adnexal masses. No cervical motion tenderness.” 5. Tubes: Foley’s and nasogastric. “Mr/Ms .., I’ll put a bee tube inside in order to monitor your urine output, okay..?” Note: If blood seen from meatus: NO FOLEY’S (? Urethral injury). “Mr/Ms .., I’ll put a stomach tube through your nose to see if there is any blood there, okay?” Only if indicated. Indication for immediate laparotomy: 1. 1. 2. 3.

Refractory shock. Obvious peritonitis (Rigidity). Increasingly distended abdomen. Positive DPL or CT

MSK: 1. Extremities: One limb at a time. “Mr/Ms .., let me check your limbs.. Do you feel any pain?” 1- Bone and soft tissue injury: Swelling, deformity, contusion, and tenderness. To the examiner “No deformity, swelling, contusion, and tenderness. No needle track marks.” … Continued 215

The Emergency Management Interview

ER Management: Cont. 2- Peripheral pulses: Radial A., posterior tibial A., dorsalis pedis A. only. (Axillary, brachial, ulnar, femoral, popliteal arteries if you have time). Use both your hands at the same time bilaterally. To the examiner “Radial, posterior tibial, and dorsalis pedis pulses are felt and symmetrical.” 3- Sensations Screen: “Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your body. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.” Upper limb: C6 (Radial): Dorsum of first web space (Thumb). C7 (Median N): Index finger dorsum aspect. C8 (Ulnar N): Little finger dorsum aspect. Lower limb: L5: Foot dorsum. S2: Medial posterior thigh. To the examiner “Normal sensations screen.” 4. Muscle tone: NOT AGAINST RESISTANCE. Move each limb: Do flexion, extension of major joints only. To the examiner “Normal muscle tone.” 2. Back: LOG ROLL the patient, palpate thoracic and lumbar vertebrae for tenderness. “Mr/Ms .., with the assistance of my colleagues here, I need to turn you on your side to examine your back.” To the nurse “Please, help me to log roll him/her.” To the examiner “No injuries, deformity, swelling, point of tenderness.” ** IF Fracture: Immobilize with splint/traction + RICE and analgesics. ** IF Open wound: 1) Irrigate with saline/ remove dirt/ foreign bodies, 2) Debride, 3) Cover with sterile gauze, 4) RICE (Rest, Ice, Compression for bleeding, Elevation), 5) Cefazolin (Kefzol) 0.5-1 g X 3 +/- Gentamycin (Garamycin), 6) Tetanus, 7) Definite care in 6- 8 hours: Suture (unless delayed, puncture wound, and animal bites). …………………………………………………………………………… Ask for vitals again: “What are his/her vitals, please?” Carefully listen / read and comment: e.g. “Normal/ so, he has fever/tachycardia/ tachypnea….” … Continued 216

The Emergency Management Interview

ER Management: Cont. Neurological: 1. Glasgow Coma Scale (GCS): Good indication of injury severity. Changes with time are more relevant than the absolute number. Best Verbal Response 5

Eyes open 4 Spontaneously

4

To voice

3

To pain

2

No response

1

Answers questions appropriately Confused, disoriented Inappropriate words Incomprehensible words

Best Motor Response 6 5

Obeys commands

6

4

Localizes to pain

5

3 2

No verbal response 1

Withdraws from pain Decorticate (Flexions) Decerebrate (Extensions) No motor response

4 3 2 1

Report as : Total: … + … + … + … = … E + V + M = 15 If intubated: No verbal: Total: E + M = 10 + T 13 – 15: Mild injury; 9 – 12: Moderate injury;