What does my UIM attending expect on the Mini-CEX?

Round 2 7/9/15

General Guides

    Mini-CEX - observed history and physical exam-board requirement of the ABIM

Not a “sign off”

Attending – will give you feedback; will not undermine your relationship with the patient Plan the Mini-CEX – no need to do this twice. Chief Complaint as your guide.

General Guides

    Barbara Bates remains a great reference Tailor H/P to Chief Complaint/pertinence Gowns – do not auscultate through clothes!

You need your H&P skills for outpatient Medicine

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Medication history Chronic pain history (psych) Focused physical exam CV exam Lung exam Abdominal exam Musculoskeletal exam Neurological exam Pelvic exam (GYN) Knee exam (Ortho) Shoulder exam (Ortho) Hip exam (Ortho) Teach-back Shared decision making Supervisor

CV Exam

 Which patients?

  Any complaint with cardiovascular elements Hypertension, CHF, CAD  Especially good if you would like to verify findings

CV Exam

   Heart   Auscultation (follow V1-6) Diaphragm then bell       Right upper sternal border Left upper sternal border Left midsternal border Left lower sternal border Apex Left Axilla Palpation - PMI, thrills, heaves Neck   JVD  45 degree angle – find the top of the column Carotids   Auscultation  Ask patient to hold their breath Palpation Extremities   Edema Peripheral pulses

CV Exam Tips

     Feel the carotid pulse when listening to the heart Gallops are heard best with the bell Recall the grading system of murmurs and use this (1-6) and use “the language” Does the murmur radiate?

Identify new murmurs, diastolic murmurs

CV Exam tips

  You do not need to report cm of JVD – it’s OK to use landmarks. “With the patient at a 45 degree angle, JVD noted up to the earlobe” Differentiate murmurs from bruits in the carotids

Lung Exam

    Auscultation  Start at Apex and listen for symmetry side to side   Listen anteriorly as well Ask patient to open his/her mouth to breathe Percussion – if needed only Consider in all patients with complaints (chest pain, SOB, etc.) or a history of lung/cardiac disease Especially good if you would like to verify findings

Abdominal Exam

      Good for any complaint of abdominal pain Observation Auscultate before palpation  One quadrant with bowel sounds is enough Palpation – rebound if needed     All 4 quadrants; begin far from tender area Liver and spleen – start at the pelvic brim Ask patient to inhale; move your hands up after exhalation No need to press hard!

Percussion – if needed Special maneuvers if suspected ascites    Shifting dullness Succussion splash Hepatojugular reflux

Abdominal Exam

 Percussion  Liver edge – start at pelvic brim  Used to estimate liver size   Midclavicular line 6-12 cm Midsternal line 4-8cm

Musculoskeletal Exam

     Symmetry Range of motion Strength (can be under neuro) Joints  Synovitis – bogginess, heat, effusion, erythema   Squeeze tenderness of MCP’s/MTP’s Nodules Tender areas (trigger points)

Musculoskeletal Exam

Musculoskeletal exam

   Patients with pain in multiple areas Patients with joint pain or stiffness Patient with weakness

Neurological Exam

     Headaches Weakness Numbness/tingling History of “stroke” Equipment needed: reflex hammer, wooden cotton-tipped swab, low frequency tuning fork (the big one)

Neuro Exam – basic elements

      Alertness and orientation Gait Cranial nerves (2-12 is sufficient)  Pupils, EOM, visual acuity, eye squeeze, eyebrow raise, show teeth, puff cheeks, bite, tongue protrusion, palatal lift, shoulder shrug Muscle strength  Grip, biceps, triceps, hip flexors/extensors, leg flexors/extensors, plantar flexion, dorsiflexion Reflexes – must do with an actual hammer!

 Biceps, triceps, brachioradialis, patellar, Achilles, plantar Sensation  Light touch, pinprick, temperature, vibration (cotton swab, low frequency tuning fork – the big one)

Pearl

  Percussion and reflex testing are bouncing motions See demonstration and practice!

Pelvic Exam

 Library  Consult Clinical Resources  Procedures

Knee exam

  Observation     Gait Rising from chair ROM Structure of knee (bulging) Palpation        Quadriceps strength Joint line Prepatella bursa Anserine bursa Popliteal fossa ROM for crepitus Instability (if needed): anterior, posterior, lateral, medial

Anserine bursa Popliteal fossa Joint line

Shoulder Exam

  Observation   Symmetry front, side and behind Active ROM     Abduction Adduction Forward flexion Internal and external rotation Palpation      Start with the neck and upper trapezius Scapular spine Acromion and subacromial space Bicipital groove Clavicle including SC and AC joints

Tests for Rotator cuff tear

   Painful arc sign Drop arm test Weakness in external rotation

Hip Exam

   Gait Climb onto the examining table Range of motion   Flexion/extension Internal/external rotation    Palpation of trochanteric bursae Palpation of the SI joints Straight leg raise if radicular symptoms

Great Resource!!

 http://stanfordmedicine25.stanford.edu