Ascm 2 2010 Clinical Skills Handbook Portal 34il

The ASCM 2 Clinical Skills Handbook History Taking and Physical Examination

FACULTY OF MEDICINE 4rd Edition

Lilly Teng

Antoine Eskander

Editor in Chief 0T8

Editor 1T0

Illustrators Willa Bradshaw Sherry Lai Adrian Yen

Ardis Cheng Hyun Joo Lee

Kari Francis Jen Tse

From the Division of Biomedical Communications, Department of Surgery

Supervisor and Managing Editor Dr. Jacqueline James ASCM 2 Course Director

1

Contributors Adee Bross 0T8

Jeremy Cohen 0T8

Andrew Lui 0T8

Katherine Thompson 0T8

Haley Draper 0T8

© 2010 Written permission to copy any part of this material must be obtained from the University of Toronto, Faculty of Medicine, Undergraduate Medical Education, (416) 946-7009.

2

TABLE OF CONTENTS Introduction .......................................................................... 2 Instructions for Use of History Taking Guides ....................... 3 Breast History ....................................................................... 4 Examination of the Breast ..................................................... 6 Urologic History .................................................................. 14 Examination of the Male Genitourinary Tract ...................... 16 Examination of the Prostate Gland (Digital Rectal Exam) ....... 25 Head and Neck History ....................................................... 31 ENT (Otolaryngology) History .............................................. 36 Examination of the Ears, Nose and Throat ......................... 39 Ophthalmic History ............................................................. 52 Examination of the Eye ........................................................ 53 Musculoskeletal History ..................................................... 57 Examination of the Back ...................................................... 62 Examination of the Shoulder ............................................... 68 Examination of the Hand and Wrist ..................................... 85 Peripheral Vascular Disease History ................................ 94 Examination of the Peripheral Vascular System ................. 96 Abdominal History ............................................................ 104 Cardiovascular History .................................................... 108 Geriatric History ................................................................ 112 Neurological History ......................................................... 118 Psychiatric History ........................................................... 121 Respiratory History........................................................... 127 Palliative History ............................................................... 129

3

Introduction ASCM II is a continuation of ASCM I. The course reinforces existing clinical skills and introduces many new skills that are taught in specialty components. The amount of information one is required to assimilate at the ASCM II level can seem overwhelming. This handbook was an initiative of a group of students in OT8 in an attempt to make the challenge of mastering the new skills introduced in ASCM II somewhat easier by summarizing approaches to history and physical examination. The first edition of this handbook was enthusiastically led and edited by Lilly Teng and completed with the help of a highly motivated authorship team consisting of Adee Bross, Jeremy Cohen, Haley Draper, Andrew Lui, and Kate Thompson (OT8). The second edition is made possible with the additional help of Antoine Eskander (1T0). Dr. Jacqueline James (ASCM II Course Director) has been involved in supervising and reviewing content of the handbook, minor changes only have been made in this fourth edition. This handbook was made possible by the extraordinarily talented illustrators from the Biomedical Communications Division of the Department of Surgery: Willa Bradshaw, Ardis Cheng, Kari Francis, Sherry Lai, Hyun Joo Lee, Jen Tse, and Adrian Yen. The ASCM II Clinical Skills Handbook was created by students for students so that the material would be simple, concise, and highly accessible at the second-year level. At the second-year level, students are expected to conduct interviews purposefully. Many students find this to be a challenging transition, and the history-taking guide is the authors‟ attempt to offer some guidance. As with previous handbooks, please note that this handbook is not meant to be used as a comprehensive textbook – rather, it is intended to complement all other ASCM II resources. All students should use a textbook of history taking physical examination for more detailed review of the topics. PLEASE NOTE – the material in this handbook is not meant to indicate what material will be examined on in the course. For expectations as to what students are expected to master by the end of ASCM 2, consult the syllabus, the objectives and skills log. We welcome and encourage any comment or – as that is the only way to make this handbook continuously better for future students. IF YOU DISCOVER ANY PERCEIVED ERRORS IN THIS HANDBOOK PLEASE NOTIFY Dr. James [email protected]

4

HOW TO USE THE HISTORY-TAKING GUIDES This is a summary of topic-specific questions relevant to focused histories that are covered in the ASCM II curriculum and should be considered when preparing for the OSCE. This is not a comprehensive source of information and other resources should be used in conjunction with this, including recommended texts, the syllabus and readings. In this guide, the History of Present Illness includes OPQRSTUVW (O to W), Associated Symptoms, and Risk Factors. For each chief complaint within a particular system, the associated symptoms should include the other chief complaints for that system. For example, in the cardiovascular section, if the chief complaint is “chest pain”, then the associated symptoms should include palpitations, dyspnea, dizziness, presyncope/syncope, etc. Similarly, if the chief complaint is “palpitations,” than the associated symptoms should include chest pain, dyspnea, dizziness, presyncope/syncope, etc. For every chief complaint you should go through as much of OPQRSTUVW (O to W) of the HPI as you can before asking about the associated symptoms, including systemic features and risk factors. If the chief complaint is pain, O to W includes:  O – Onset and duration  P – Provoking and alleviating factors, Progression  Q – Quality of the pain  R – Radiation/location of pain  S – Severity (Scale of 0-10)  T – Timing/Frequency of the pain,  U – How does it affect U in your daily life?  V – Déjà Vu? (has this happened to you before)  W – What do you think is causing it? In addition, you should also ask about Treatment response, and Complications of disease or treatment. Following the HPI, the rest of the history should be obtained, including a pertinent Past Medical History (PMH), Medications, Allergies, pertinent Family History and pertinent Social History including smoking and alcohol. Some sections (ie: MSK) have additional information because it was required to fulfill the objectives in the ASCM II manual. Also, the paediatrics, psychiatry and geriatrics sections have their own individualized formats that will help you during these sections of the course as well as at these stations for the OSCE.

5

BREAST HISTORY

Aspects of the History 1. Chief Complaint and Associated Symptoms o Breast pain o Breast mass o Nipple changes o Changes in skin 2. O to W 3. Associated Symptoms for Breast Malignancy 4. Risk Factors for Breast Cancer A. Major risk factors B. Minor risk factors

1. CHIEF COMPLAINTS AND ASSOICATED SYMPTOMS Breast Pain  O–W  Ask about pain changes during the menstrual cycle o Cyclic bilateral mastalgia (exacerbated prior to menstruation) may be physiological o Non cyclic mastalgia is more likely to be abnormal o Focal pain may be indicative of pathology Breast Mass  Location  4 S’s: Size, Shape, Symmetry, Skin Changes  Ask about mass size changes with menstrual cycle  Cyclic changes in mass size are more likely to be benign Nipple changes  Retraction (exaggerated with arm elevation)  Ulceration and scaling (Paget‟s disease)  Discharge a. color

6

b. c. d. e. 

consistency bilateral versus unilateral spontaneous versus manual secretion ask if the woman is breastfeeding and/or has a child less than 1 year old because this may be breast milk (physiological) 6 S’s: Size, Shape, Symmetry, Skin changes, Secretions, Supernumerary nipples

Change in skin  Color, Texture, Dimpling (peau d‟orange)

2. O TO W o With each chief complaint above go through O to W before going on to associated symptoms. 3. ASSOCIATED SYMPTOMS FOR ADVANCED BREAST MALIGNANCY o Fever o Weight loss o CNS changes o Bone pain or fractures o Hemoptysis o SOB o Cough 4. RISK FACTORS FOR BREAST CANCER A. Major  Female age>50 st nd  Family history of breast or ovarian cancer in 1 or 2 degree relatives  Genetics (BRCA1,2)  Hyperplasia history (cysts etc)  High dose radiation B.        

Minor Nulliparity (have never carried a pregnancy) Age older than 30 at first pregnancy Menarche beginning before the age of 12 Menopause beginning after the age of 55 Hormone Replacement Therapy Obesity Excessive alcohol consumption Breast biopsy history

7

EXAMINATION OF THE BREAST Aspects of the Examination 1. Inspection A. Breasts and nipples 2. Palpation A. Lymph nodes B. Breasts

Helpful Hints  A careful and structured physical examination of both breasts may require at least 5-10 minutes. Sensitivity is improved with duration of palpation.  The most appropriate time for a breast exam is 7-10 days postmenses (an increase in breast size, density, nodularity, and tenderness occurs 3-5 days prior to menstruation)  Always examine both breasts, even if symptoms are localized to one side  The breast exam is usually done in two positions: inspection and palpation of the lymph nodes are done with the patient in the upright position; palpation of the breast is performed with the patient supine.

Wash your hands and introduce the exam to your patient Explain the examination carefully to maximize patient comfort Positioning and Draping  Adequate inspection requires that the patient be disrobed to the waist  The patient can be asked to cover her breasts during examination of the lymph nodes if sufficient access to the axillae can be maintained  During palpation, uncover only the breast that you are examining (i.e., uncover one breast at a time)

1. INSPECTION A. Inspect the Breasts and Nipples  The patient should be sitting upright with arms relaxed and hands resting on her thighs, disrobed, and facing the examiner

8



There is no evidence that examining in other positions is necessary, however, one can ask the patient to assume other postures to facilitate inspection (see Figure 1)

Figure 1: Postures for Inspection of the Breast and Nipples 

Breasts (4 S’s) o size o symmetry (normal breasts may not be symmetrical; left often larger) o shape and contour  abnormal bulging  skin retraction (flattening of a lateral contour or dimpling) o skin changes/ superficial appearance  erythema  edema (lymphatic obstruction manifested by “peau d’orange” or orange peel appearance of skin)  abnormal vascularity due to dilated superficial veins

9



Areolae and nipples (6 S’s) o size o symmetry o shape  inversion (sunken inward)  eversion o skin changes  erythema  eczema  ulcerations/scaling o spontaneous secretion  serous, bloody, amber or opalescent discharge  do not milk or squeeze nipple unless history of discharge or abnormal appearance; nipple should be palpated as part of breast palpation o supernumerary nipples  appear as one or more nipples along the “milk lines”, most commonly in the axilla and below a normal breast

2. PALPATION A. Lymph Nodes Examination 

Supraclavicular and infraclavicular lymph nodes (see Figure 2) o palpate above and below the clavicles



Axillary lymph nodes o to palpate the right axilla (see Figure 3):  patient should be sitting, arm relaxed  slightly abduct the patient‟s right forearm with your right hand, while palpating the right axilla with your left hand  with the pads of your fingertips, reach deep into the axilla, pushing firmly but not aggressively  explore all sections of the axilla (see Figure 2)  pectoral/ anterior lymph nodes: palpate directly behind the pectoral muscles, angling towards the mid-clavicle  subscapular/ posterior lymph nodes: palpate along the side of the chest wall  lateral lymph nodes: palpate along the inside of the arm  central axillary lymph nodes: palpate deep into the top of the axilla, angling towards the neck o to palpate the left axilla

10

 

Reverse the procedure to examine the left axilla with the right hand

Comment on: o size o number o shape o consistency (soft/hard) o tenderness o mobility (whether tethered to skin or deeper structures)

Figure 2: Lymphatic System of the Breast

11

Figure 3: Palpation of the Axilla B. Palpate the Breast  Usually performed with the patient in supine position with arms at the sides  If breasts are large, or for deeper palpation (particularly of the lateral aspect of the breast), have patient place her ipsilateral hand behind her neck and turn her hips and knees towards the contralateral side. A pillow beneath the shoulder may also help.  Always palpate both breasts  Begin with the asymptomatic breast  Palpation boundaries: from the clavical to the bra line/inframammay line) and from the mid-sternum to the midaxillary line, including the nipples and areolae  Use pads of the second, third and fourth fingers o Make small circular (dime size) motions, applying three levels of progressively deeper pressure

12

Although either of the following two methods has been taught to be acceptable, there is some evidence that the vertical strip method may be more thorough (see Figure 4) 

The Vertical Strip Method o visualize the breast area as a series of vertical regions o palpate in small circular motions o begin at axilla and palpate down the midaxillary line ending th at the 6 rib th o for next strip, work upwards from 6 rib to top of the breast, partially overlapping with the first strip o continue in the same antiparallel pattern until the final vertical strip (along the sternum)



The Radial Vector Method o visualize the breast area as spokes of a wheel with the nipple as the center point o palpate in same manner as above o begin at the “12‟o‟clock” position at the outer edge of the breast (below the clavicle) and move inwards along the vector towards the nipple o repeat along the next partially overlapping vector, from the periphery to the nipple (include the nipple each time) o end at the “12‟o‟clock” position

Figure 4: Palpation of the Breast

13



Describe the breast mass (see Table 1) o location (quadrant or clock method; distance from nipple) o size o shape (round; regular/irregular) o consistency (soft/firm/hard) o delineation (discrete/blends into surrounding tissue) o tenderness o mobility



In males: o distinguish between enlargement consisting of soft fatty tissue (obesity) and firm glandular tissue (gynecomastia)

14

Mass Characteristics

Carcinoma

Location

Usually solitary, unilateral (often upper outer quadrant)

Size

Variable

Shape

Irregular

Fibroadenoma

Usually solitary

1-3cm (possibly larger)

Round,disc-like or lobular

Fibrocystic Condition

Solitary or multiple, bilateral

Variable, may increase in size or regress

Round

Soft to firm, elastic; depends on tension of fluid in cyst

Consistency

Firm or hard

Firm and rubbery, may be soft

Delineation

Ill-defined

Well defined

Well defined

Tenderness

Usually Nontender

Usually Nontender

Often tender

Mobile

Mobile

May change in size with menstrual cycle

Increased tenderness premenstrually

Mobility

*Menstrual Changes (elicited on history)

May be fixed to skin or underlying tissues

No

Table 1: Differential Diagnosis of Breast Mass Findings 15

UROLOGIC HISTORY

Aspects of the History 

Chief Complaints and Associated Symptoms



O to W



Non-Specific Symptoms



Risk Factors

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS  Irritative symptoms o Frequency o Nocturia o Urgency o Dysuria  Obstructive symptoms o Straining o Hesitancy o Intermittency o Post void dribbling o Decreased stream o Incomplete emptying  Hematuria o Pain o Clots o During what part of the stream does the blood occur? (beginning, middle, end)  Incontinence o Stress incontinence: urination occurs with increased abdominal pressure (e.g., coughing, laughing, etc) o Continuous Incontinence: occurs continuously (fistula) o Overflow Incontinence: leakage of small amounts of urine from a bladder that is constantly full due to a bladder outlet obstruction o Urgency Incontinence: incontinent when urge to urinate arises. Do you make it to the bathroom on time when you feel the urge to urinate? (cystitis, neurogenic bladder)

16





     

Erectile dysfunction o Firmness of erection o Initiating erection o Maintaining erection after penetration o Ejaculation o Sexual satisfaction o Medical or surgical risk factors Pain  Costovertebral angle (pyelonephritis versus kidney stone)  Suprapubic  Genitals Blood in semen Urethral discharge Scrotal Swelling Testicular mass Hydrocele, spermatocele, varicocele Infection

2. O TO W o With each chief complaint above go through O to W before going on to associated symptoms. 3. NON-SPECIFIC SYMPTOMS o Constitutional symptoms – fever, weight loss, fatigue 4. RISK FACTORS o Previous renal stones o Previous renal or urologic disease o Medication o Smoking - increases risk of urologic cancers o Sexual history (STI‟s)

17

EXAMINATION OF THE MALE GENITOURINARY TRACT Aspects of the Examination 1. Inspection A. Skin and pubic hair B. Penis C. Scrotum and testicles D. Inguinal regions 2. Palpation A. Lymph Nodes B. Penis C. Scrotal contents D. Inguinal regions 3. Percussion A. Kidneys

Helpful Hints  To minimize any embarrassment or discomfort, carefully explain to the patient what you are going to do (and why) before proceeding with each step Wash your hands and introduce the exam to your patient. Put on a pair of gloves before proceeding. The gloves do not have to be sterile. Draping  During inspection the patient should be disrobed from the umbilicus to the mid-thigh  The patient can be asked to cover his penis and scrotum during examination of the cervical and inguinal lymph nodes  During palpation, uncover the penis and scrotum only when you are examining them

18

1. INSPECTION  The patient should be standing or supine with arms relaxed at his sides. A. Skin and Pubic Hair o

o

o o o

rashes  may indicate fungal or other infection  may indicate dermatitis  may indicate psoriasis excoriations  may indicate scabies infection scars, masses crab lice nits (lice egg cases)

B. Penis   



Size o Determination of penile size may be important in staging sexual maturity in a male Skin Glans (head of penis) o if patient is circumcised  be certain patient‟s foreskin is not simply retracted o if patient is uncircumcised  have the patient retract the foreskin, inspecting for:  phimosis (inability to retract foreskin over glans)  paraphimosis (inability to reduce the foreskin after having retracted it – emergency situation that may lead to severe venous and arterial obstruction, resulting in necrosis of the head of the penis)  smegma (cheesy, white material under the foreskin) is normal Meatus o with the glans exposed, note position of the meatus  Hypospadius (meatus on underside of penis)  Epispadias (meatus on upper surface of penis) o open the meatus by compressing the glans anteroposteriorly between your thumb and forefinger o inspect for discharge  bloody discharge (possible ulceration, neoplasm, urethritis)  thick, yellow/gray, copious discharge (gonococcal pus)

19

 

watery and sparse discharge (non-specific pus) note if it is continuous or intermittent

C. Scrotum 

Size and Contour  make sure the room (and your hands) is sufficiently warm to guard against the dartos and cremasteric reflexes  Dartos crinkles (and thus shrinks) the scrotum  Cremaster retracts the testicles, also making the scrotum appear smaller o

o

 

if the scrotum is swollen, transilluminate the scrotum by applying a light source in a dark room  cystic masses (like hydroceles and spermatoceles) transilluminate  solid masses (like tumors, hernias and varicoceles) do not transilluminate  painful swelling – epididymitis, orchitis, torsion, hemorrhagic tumor, hematocele, strangulated inguinal hernia  painless swelling – hydrocele, spermatocele, vacricocele, non-hemorrhagic tumor, unstrangulated inguinal hernia poor development may indicate cryptorchidism (developmental defect marked by failure of the testes to descend into the scrotum)

Skin Veins o assess for varicocele  accentuated by Valsalva maneuver

D. Inguinal Regions 

Masses o Bulges  most often due to inguinal hernias (accentuated by Valsalva maneuver) o Swellings  May indicate inguinal lymphadenopathy due to infection of external genitals or carcinoma of testis involving scrotal skin

20

2. PALPATION A. Lymph Nodes o Lymphatics for the skin and scrotal services drain to inguinal lymph nodes o Lymphatics of the testes drain to the abdomen where they cannot be palpated. 

Left supraclavicular lymph nodes (examine if mass found) o enlargement may indicate tumors of testis and prostate



Inguinal and iliac lymph nodes (see Figure 1) o have the patient lie supine with knee slightly flexed o palpate above and below the inguinal ligament  small (0.5cm) nodes are common in the normal adult

21

Figure 1: Inguinal and Iliac Lymph Nodes B. Penis 

Penile shaft  Can be performed standing or supine o



using tips of fingers of both hands  palpate the shaft of the penis from the glans to the base  palpate the penis along the corpora cavernosa (two tubular shaped structures located on the dorsum of the penis) with index fingers, noting any induration, masses, tenderness  non-tender induration or fibrosis under the skin of the shaft suggests Peyronie‟s disease (see Table 1)  note any unusual curvature to the normally straight penis (may be due to fibrosis)

Urethra  Can be performed standing or supine o

o

using both hands  using your right index finger, palpate along the corpus spongiosum (mass of spongy tissue on the ventral surface of the penis that surrounds the urethra) from the meatus to the base of the penis  to palpate the base, use your left hand to lift the penis and your right index finger to invaginate the scrotum in midline, palpating deeply at the base of corpus spongiosum  note any masses, tenderness if discharge is present, milk the urethra to obtain a sample for microscopy

C. Scrotal contents  Can be performed standing or supine 

Testicles  Palpate each testicle separately o

use both hands (left hand holds superior and inferior testicular poles, right hand holds anterior and posterior surfaces)  note size, shape, consistency, tenderness, nodules, masses

22



    

if a mass is present, attempt to position your examining finger above the mass  if you are unable to do so, the mass is likely due to an inguinal hernia  if you are able to do so, the mass likely originates from within the scrotum if a mass is present, you must transilluminate (see Inspection) any hard mass is malignant until proven otherwise compare both sides normally, the testicles are firm, rubbery, smooth, non- tenderness, and symmetrical

Epididymis and Spermatic Cord  The epididymis is palpable as a ridge on the posterior aspect of each testicle  The spermatic cord is palpable from the epididymis to the external inguinal ring on each side o note tenderness,nodularity, masses

D. Inguinal regions 

Palpate for inguinal hernias (see Figure 2)  Performed standing  Palpate each inguinal region separately o

o

Examination of the right inguinal region  place your right index finger in the patient‟s scrotum above the right testis and invaginate the scrotal skin to reach the external inguinal ring  with the right index finger, follow the spermatic cord through the external inguinal ring into the inguinal canal parallel to the inguinal ligament toward the internal inguinal ring (superior and lateral to the pubic tubercle)  put the fingers of your left hand over the inguinal canal (runs obliquely towards the anterior-superior iliac crest) or on top of any noticeably swelling  ask the patient to cough or bear down (Valsalva)  sudden impulse against either hand may indicate hernia Examination of the left inguinal region  The examination is done the same with, but with hands reversed

23

Figure 2: Palpation of Inguinal Hernia 



Auscultate the inguinal hernia o auscultate on top of the hernia for bowel sounds

N.B. o Hernia is indicated if  the mass is reducible  bowel sounds are present within the mass  no transillumination of the mass 

Direct, Indirect, Femoral Hernia  Direct inguinal hernia:  through external inguinal ring  bulges anteriorly (rarely into scrotum), presses against the examining finger (not through inguinal canal)  can be seen and felt towards the middle of the inguinal ligament

24





Indirect inguinal hernia  through internal inguinal ring  often descends into the scrotum  touches the examining finger through the inguinal canal



Femoral hernia:  below the inguinal ligament (the hernia is seen as a lump below the inguinal ligament)  never into the scrotum  empty inguinal canal

N.B.  Hernias are usually non-tender with no evidence of acute inflammation (i.e., skin edema or erythema).  If tenderness or signs of inflammation are present, there may be incarceration/ strangulation of the entrapped contents –the most dreaded complication of a hernia and constitutes a surgical emergency.

3. PERCUSSION A. Kidneys 

Percuss costovertebral angles bilaterally (see Figure 3) o note any tenderness (may be a sign of pyelonephritis)

25

Figure 3: Percuss for Costovertebral Angle Tenderness

26

EXAMINATION OF THE PROSTATE GLAND (Digital Rectal Exam) Aspects of the Examination 1. Inspection of the anus 2. Palpation A. Rectal walls B. Prostate C. Occult blood

Helpful Hints  Collect urine specimens before prostate exam – prostatic massage will force prostatic secretions into the posterior urethra  To minimize any embarrassment or discomfort, carefully explain to the patient what you are going to do (and why) before proceeding with each step Wash your hands and introduce the exam to your patient. Put on a pair of gloves before proceeding. The gloves do not have to be sterile. Positioning and Draping  the patient should be supine, in Sim‟s position (see Figure 1), or standing bent over the examination table  patient‟s buttocks and perineal region should be exposed, while the penis and scrotum should be draped since they are not part of the examination  examiner should glove both hands  the examining index finger should be lubricated liberally  the non-examining hand will be used to spread the buttocks in order to examine the anus

27

Figure 1: Sim’s position for DRE 1. INSPECTION 

Inspect the peri-anal region  spread the buttocks with the non-examining, unlubricated hand  inspect the anal skin for  inflammation  excoriation  fissures  nodules  fistulae  scars  tumours  warts  bleeding sites  hemorrhoids (accentuated by Valsalva)

28

2. PALPATION  

o o o o o o 

Inform the patient that the rectal examination will now be performed Warn the patient that the lubricant will feel cool and that when the finger is inserted, he will experience a sensation of having to move his bowels – he will not have a bowel movement using the non-examining hand, spread the buttocks place the examining index finger on the anal verge, applying some gentle pressure to relax the anal sphincter instruct the patient to take a deep breath and bear down as if they are trying to have a bowel movement (this helps to relax the external sphincter and should decrease discomfort) as the patient bears down, gently insert the examining index finger into the anal canal assess the sphincter tone slowly insert the full length of the examining index finger into the anal canal N.B.  As you push your finger in, take note of any resistance  If you run into stool, it should move out of the way easily  A mass, such as a large rector tumor, will not move, in which case do not force your finger further into the canal

A. Rectal walls 

Palpate the lateral, anterior and posterior walls of the rectum o palpate all walls by gently rotating the inserted index finger  palpation of 12 to 3 o‟clock regions will require you to turn your back to the patient and hyperpronate your forearm o palpate for polyps  sessile (attached by a base)  pedunculated (attached by a stalk) o note any tenderness, irregularities and masses

29

B. Prostate gland (see Figure 2)  Do not palpate prostate in acute prostatitis (see Table 1) – painful and unnecessary 

Palpate the anterior wall of the rectum, where the prostate lies o orient your finger so that it is directly anterior (i.e., toward the patient‟s umbililicus) and feel for the prostate gland through the wall of the rectum o Palpate  median sulcus (the prostate has two lobes with a cleft running in between)  lateral lobes o Palpate for  size, symmetry  large, soft, symmetrical prostate that protrudes into rectum suggests benign prostatic hypertrophy  masses  tenderness  Tenderness may indicate prostatitis  nodules  hard, irregular nodules producing asymmetrical prostate suggest prostate cancer  if an area of abnormal firmness is felt, see if the prostate is freely mobile or tethered to the pelvis (which may occur via direct extension of a malignancy) by trying to move the prostate with your finger



Inform the patient that you will withdraw the examining finger, and then withdraw



N.B. o Normal prostate:  bilobed  heart-shaped (apex to anus),  4 cm diameter  smooth  firm like the tip of your nose (anything firmer is suspicious for malignancy

30

Figure 2: Palpation of the Prostate Gland

31

C. Fecal occult blood  

inspect the examining finger and note color of stool on the glove test the stool for occult blood (guaiac or benzidine test) o Blue = blood

3. Wrap-up  

provide the patient with towels to clean up dispose of your gloves and wash your hands

32

HEAD AND NECK HISTORY

Aspects of the History 

Thyroid A. Hypothyroidism B. Hyperthyroidism C. Chief Complaints and Associated Symptoms D. Risk Factors for Thyroid Disease



Neck Mass A. Chief Complaints and Associated Symptoms  Local neck mass  Diffuse neck swelling B. O to W C. Non Specific Symptoms D. Risk Factors

3. Lymph Node A. Chief Complaints and Associated Symptoms  Enlargement of lymph nodes  Swelling of extremities B. O to W C. Non Specific Symptoms D. Risk Factors  Non specific risk factors  Specific risk factors for swelling of extremities

33

1. THYROID A. Hypothyroidism Chief Complaints and Associated Symptoms 1. General  Cold intolerance  Lethargy and fatigue  Weight gain with normal or decreased appetite  Decreased libido 2. Emotional/Cognitive  Poor memory/concentration 3. Eye/Face  Puffy face 4. Cardiac  Bradycardia and hypotension 5. GI/GU  Constipation  Bloated feeling  Menorrhagia 6. Neuromuscular  Muscle stiffness 7. Dermatology  Thick dry skin  Coarse dry hair and hair loss  Brittle nails B. Hyperthyroidism Chief Complaints and Associated Symptoms 1. General  Heat intolerance  Weight loss with good appetite  Decreased sleep  Pruritis  Hyperalertness/fatigue 2. Emotional/Cognitive  Anxious & irritable  Problems with concentration 3. Eye/Face  If Graves‟ ophthalomopathy – dry /tearing eyes, diplopia, proptosis 4. Cardiac  Tachycardia & palpitations 5. GI/GU  Increased bowel movements  Polyuria

34

6. Neuromuscular  Fine tremor  Proximal muscle weakness 7. Dermatologic  Warm smooth skin  Increased perspiration  Hair thinning  If Graves‟ dermopathy – raised erythematous pretibial lesions C. Risk Factors for Thyroid Conditions  History of irradiation to head and neck (hypothyroidism, thyroid ca)  History of thyroid disorder and past management  Family history of autoimmune disease, thyroid or endocrine disorders and Family history of thyroid cancer  Medications (lithium – hypo; amiodarone – hypo/hyper; iodine – hyper)  Postpartum  Female 2. NECK MASS A. Chief Complaints and Associated Symptoms o Local Neck Mass  Unilateral/bilateral  Tender/painless  Well circumscribed/diffuse  Rate of growth o Diffuse Neck Swelling o Infection  Inflammation B. O to W o With each chief complaint above go through O to W before going on to associated symptoms. C. Non Specific Symptoms  Cough  Oral pain  Dysphagia  Hoarseness  Features of hyper/hypothyroidism  Constitutional symptoms: fever, weight loss, fatigue  Otalgia

35

D. Risk Factors  Personal or family history of cancer or autoimmune disease  Environmental/occupational exposure  Smoking  Alcohol o Alcohol and Smoking are synergistic risk factors for head and neck cancer  Skin Cancer is a risk factor for developing cancer of the parotid  Irradiation exposure 3. LYMPH NODE A. Chief Complaints and Associated Symptoms 

Enlarged Lymph Node o Location o Number o Pain o Mobility: fixed (malignancy?) versus mobile o Borders: matted (malignancy?) versus well circumscribed o Erythema and warmth (infection?) o itching



Swelling of Extremity o Unilateral versus bilateral o Timing (Intermittent versus constant) and duration of the swelling o Erythema/discoloration and warmth o Ulcer



TB exposure

36

B. O to W  With each chief complaint above go through O to W before going on to associated symptoms. C. Non Specific Symptoms  Pain  B Symptoms: fever, weight loss, fatigue, night sweats D. Risk Factors  Non Specific Risk Factors  Infections  Surgery  Trauma  Malignancy 

Specific Risk Factors for Swelling of the Extremity  Cardiac or renal disorder  Venous Insufficiency  Chronic inflammatory disease (i.e.: Lupus)  Sexually transmitted infection (i.e.: Gonorrhea/Chlamydia)  TB exposure (travel Hx)

37

ENT (OTOLARYNGOLOGY) HISTORY Aspects of the History o

Ear o o o

Chief Complaints and Associated Symptoms O to W Risk Factors

o

Nose and Sinuses  Chief Complaints and Associated Symptoms  O to W  Risk Factors

o

Throat  Chief Complaints and Associated Symptoms  O to W

1. EAR A. Chief Complaints and Associated Symptoms  Subjective hearing loss o is the loss fluctuating or progressive? o is the loss unilateral or bilateral? o is the loss of high or of low frequency sounds? o has the patient been on any medication (e.g.,aminoglycosides)?  Ear infection o is the infection acute or chronic?  Recent upper respiratory tract infection o fever, cough, and associated symptoms  Otalgia (pain)  Otorrhea (discharge from ear)  Vertigo  Tinnitus (ringing in ear)  Hyperacusis (painful sensitivity to ordinary sound levels) B. O to W  With each chief complaint above go through O to W before going on to associated symptoms. C. Risk Factors

38



History of ear infections

2. NOSE AND SINUSES A. Chief Complaints and Associated Symptoms  Sinus infection (acute versus chronic)  Nasal obstruction  unilateral versus bilateral  noisy breathing  night waking  cold symptoms  allergy symptoms (pruritus of nose, eyes)  Discharge from nose (rhinorrhea)  Facial pain  Post-nasal drip  Anosmia (can‟t smell) B. O to W  With each chief complaint above go through O to W before going on to associated symptoms. C. Risk Factors  Environmental/occupational exposures  Smoking

3. THROAT A. Chief Complaint and Associated Symptoms  Cough  productive versus dry  hemoptysis  dyspnea  chest pain  Respiratory obstruction  Neck mass  Dysphagia (difficulty swallowing)  Globus sensation  Hoarseness B. O to W  With each chief complaint above go through O to W before going on to associated symptoms.

39

C. Risk Factors  Environmental/occupational exposures  Smoking  Alcohol  GERD  Previous Head and Neck Surgery

40

EXAMINATION OF THE EARS, NOSE AND THROAT Aspects of the Examination A. Ears 1. External exam A. Inspection B. Palpation 2. Auditory acuity testing A. Whisper test B. Rinne test C. Weber’s test 3. Otoscopic exam B. Nose 1. External exam A. Inspection B. Palpation 2. Internal exam C. Throat 1. Oral cavity 2. Pharynx 3. Larynx

Wash your hands and introduce the exam to your patient.

A. EARS Equipment o Otoscope, 512 Hz tuning fork Positioning 

The patient should be sitting comfortably with arms at sides

41

1. EXTERNAL EXAM A. Inspection 



Inspect the following(see Figure 1)  pinna  helix  antihelix  lobule  tragus  antitragus  external auditory meatus

Note        o

o

position size symmetry scars masses lesions deformities  e.g. “Cauliflower ear” – sign of repeated trauma tophi  hard nodules in helix or antihelix  highly specific, nonsensitive sign of gout discharge  note color, consistency, clarity

42

Figure 1: External Anatomy of the Ear

B. Palpation 

Palpate the following o pinna o mastoid process o

Note  tenderness  pain with pulling of the pinna or with pressing on the tragus may indicate infection of external canal  pain with palpation of the mastoid may indicate suppurative process in mastoid (mastoiditis)  swelling  nodules

43

2. AUDITORY ACUITY TESTING A. Whisper test  See ASCM I Neurological Exam Handbook B. Rinne test  See ASCM I Neurological Exam Handbook C. Weber’s test  See ASCM I Neurological Exam Handbook

3. OTOSCOPIC EXAM Step 1: Setting up the equipment o put the otoscopic head on your oto-opthalmoscope o place a disposable speculum on the end of the scope o be sure to select the correct speculum size  4-6 mm diameter for adults  3-4mm for children,  2mm for infants o the speculum should be small enough to prevent pain, large enough for proper viewing o turn on the light source Step 2: Holding the otoscope (see Figure 2) o when examining the right ear, hold the otoscope in your right hand o there are two methods of holding the otoscope (both are acceptable but it is always important to stabilize the otoscope such that if the patient moves you do not puncture the tympanic membrane or injure the external auditory canal): 1. hold the otoscope like a pencil  hold the otosoe with the handle pointing up  place the tip of the speculum into the opening of the eternal canal (do this under direct vision - not while looking through the scope!)  stabilize your hand by positioning the forearm of the hand holding the otoscope against the patient‟s face 2. hold the otoscope like a hammer

44





hold the otoscope with the handle pointing down  place the tip of the speculum into the opening of the eternal canal  you may find it helpful to stabilize your hand by extending and placing your pinky and forth finger of the hand holding the otoscope on the side of the patient‟s head when examining the left ear, hold the otoscope in your left hand

Figure 2: Holding the otoscope

45

Step 3: Positioning the ear o when examining the right ear, straighten out the right ear canal (to allow easier age of the scope) with your left hand by gently tugging on the right pinna up, out and back o when examining the left ear, use you right hand to pull on the ear Step 4: Looking into the otoscope o look through the viewing window with either eye o advance the scope slowly, orienting slightly towards the patient‟s nose but avoid any up or down angling o move in small, steady increments and avoid wiggling the scope (the external canal is very sensitive) o

N.B. normally there is plenty of room in the ear canal to accommodate the speculum, however, in the setting of infection (otitis externa) the walls become red and swollen and may not accommodate the speculum

Step 5: Inspection o As you advance the otoscope in the ear canal, pay attention to the following:  External ear canal  redness  swelling  tenderness  foreign bodies  scaliness  discharge  

Tympanic membrane (see Figure 3) The normal tympanic membrane is intact, ovoid, semitransparent and pearly grey     

inspect the following: Pars tensa (lower four fifths of tympanic membrane) Pars flaccida (upper fifth of tympanic membrane) Handle of malleus (near centre of pars tensa) Light reflex (cone with apex at lower end of handle of malleus)  the light reflex originates from your scope  in the setting of otitis media (infection of the middle ear) the tympanic membrane becomes diffusely red and the light reflex is lost

46



o

describe the following aspects of the tympanic membrane:  color  integrity  transparency  position  landmarks

N.B. In some cases, your view may be obscured by wax (which appears brownish, irregular and mushy). If this happens, proceed to examine the other ear (do not try to extract the wax unless you have had specific training for this)

Figure 3: Anatomy of the Tympanic Membrane (Right Ear)

47

B. NOSE Equipment  

Otoscope with nasal illuminator attachment Nasal speculum (optional)

Positioning  The patient should be sitting comfortably with arms at sides

1. EXTERNAL EXAM A. Inspection 

Inspect  size  swelling  signs of trauma  congenital anomalies  deviation  nares  symmetry  patency of each nostril  occlude one nostril by pushing on the nostril  ask the patient to inhale  repeat on the other side  air should move equally well through both nostrils

B. Palpation  

Nose (tenderness, firmness) Sinuses  palpate the maxillary sinuses (over the cheeks) and the frontal sinuses (above the eyebrows) for tenderness  may indicate sinusitis

48

2. INTERNAL EXAM 



Positioning  instruct the patient to hold their head slightly back  place your left hand on the patient‟s forehead and use your left thumb to elevate the tip of the patient‟s nose (making a pig nose)  place the end of the speculum into the nares under direct vision and look through the viewing window alternatively, simply use the light source without a speculum to illuminate the internal structures 

Inspection  Inspect the following  position of septum (note any deviation)  Inspect the anterior and posterior septum for deviation or perforation  vestibule  look for inflammation  nasal mucus membrane  normal: pink, moist, smooth, clean  in the setting of infection it can become notably reddened  Little‟s area (or Kiesselbach‟s plexus – anteroinferior part of the nasal septum where numerous arteries anastomose and is the most common area for an anterior nose bleed)  middle and inferior turbinates (shelf-like projections along the lateral wall)  polyps may be associated with allergies and obstructive symptoms 

Inspect for:  exudates  swelling  bleeding  trauma  masses  polyps  discharge o purulent? watery? cloudy? bloody? o clear with allergic reactions o yellowish with infection

49

C. THROAT o N.B. The throat is often scoped using a nasolaryngoscope, but this will not be covered here o The key to a comprehensive oral cavity and oropharyngeal examination is to not just look for the tonsils or look only at the back of the throat. It is essential to look and sometimes feel the entire oral cavity including buccal mucosa, internal aspects of the lips, the floor of the mouth and the hard and soft palate. Equipment o Penlight or headlight o gloves o tongue depressors o gauze pads o dental mirror Positioning  The patient should be sitting comfortably with arms at sides General points  Note tenderness and consistency of any lesion  If patient is wearing dentures, ask him/her to remove them  Inspect face and mouth for abnormalities  Use your penlight to illuminate the structures  Evaluate the patient‟s breath – bad breath may indicate poor oral hygiene or systemic disease  Have patient “open wide” o if the jaw can be opened >35mm, the jaw may be subluxed o any deviation of the jaw may indicate a TMJ problem or a neuromuscular problem 1. ORAL CAVITY 

Inspection  Lips  Buccal mucosa  Gingivae (normal: stippled, pink, firm)  Teeth (adult normal 32)  Tongue  Floor of mouth  Hard and soft palates  Duct orifices of the salivary glands

50

Note:  swelling  color (cyanosis)  lesions  ulcerations  herpetic lesions  mucoceles (blue, cystic, painless, translucent, induced by trauma) o patency of salivary glands (glands not usually visible)  parotid duct orifice (inside of cheek, opposite of the upper second molar)  submandibular glands (below floor of the mouth) o plaques o papules o bleeding o teeth abnormality  number of teeth  deformity, chipping, alignment  malocclusion o oral hygiene o uvular deviation o petechiae (on palates may indicate infective endocarditis, leukemia, viral infections) 

Palpation o Palpate the tongue:  with both hands gloved, instruct the patient to stick their tongue out onto a gauze pad held in your right hand.  holding onto tongue with right hand, palpate the tongue with left hand.  palpate lateral margins of tongue (85% of lingual cancers appear here)  note any induration and/or ulceration (may indicate cancer)  don‟t forget the posterior third of the tongue which is rarely visualized on inspection and requires palpation  Palpate the floor of the mouth (bimanual)  with your left hand (palm up), hold the patient‟s lower jaw with your thumb and third finger (prevent the patient from biting down), leaving the index finger free to palpate under the patient‟s chin

51

  

palpate the floor of the mouth with right index finger (of gloved hand) inside the mouth, and left index finger under the chin note any tenderness or masses

Special test  Examine CN XII (see ASCM I Neurological Examination Handbook)

2. PHARYNX 

Inspection o o o o

instruct the patient to open their mouth wide, stick out their tongue and breathe slowly through the mouth hold the tongue depressor in your right hand, and the light source in your left place the tongue depressor in the middle third of the tongue and depress the tongue against the bottom teeth Inspect the following 

Tonsils  size (enlargement results from infection or tumor)  debris (may indicate chronic tonsillar infection)  pseudomembranous or membranous patch over the tonsils (may indicate tonsillitis, infectious mononucleosis, diphtheria)



Posterior pharyngeal wall  discharge  mass  ulceration  infection  soft palate elevation (“say „ahhh‟”)



Gag reflex  inform the patient that the gag reflex will be elicited  touch the tip of the tongue depressor on the posterior surface of the tongue or the posterior pharyngeal wall

52

3. LARYNX 

Inspection  hold the tongue and insert a small dental mirror into the mouth, positioning it against the uvula (see Figure 4) 

Inspect the following:  Larynx  Vocal cords

o

Note:  swelling  erythema  lesions  pus  masses

Figure 4: Inspection of the Larynx

53

OPHTHALMIC HISTORY

Aspects of the History 

Chief Complaints and Associated Symptoms



O to W



Risk Factors

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS A. Loss of vision  Acute versus chronic  Transient  Gradual  Painless versus painful  Monocular versus binocular B. Ocular pain  Burning, tender, dry, or itching  Pain on blinking – corneal abrasion  Pain on eye movement – optic neuritis  With Headache and nausea – acute angle-closure glaucoma C. Redness  Ask about discharge, photophobia, pain, visual acuity, and pupil size 2. O TO W 

With each chief complaint above go through O to W before going on to associated symptoms. 3. RISK FACTORS  Past ocular history (corrective lens use, prior trauma, surgery, infection, eye disease )  Past Medical History – ocular effects of systemic diseases (diabetes, hypertension, autoimmune)  Family history of ocular problems  Ocular and systemic medications (steroids)

54

EXAMINATION OF THE EYE* * N.B. What is described below is intended to be an overview of the examination of the eye only. A more comprehensive understanding (particularly pertaining to the use of the slit lamp) will be gained through your experiences in the ASCM II ophthalmology sessions (and in clerkship) Aspects of the Examination 1. Visual Acuity 2. Visual Fields 3. Extraocular Eye Movement Examination 4. Extrinsic and Intrinsic Eye Structures 5. Ophthalmoscope Examination

1. VISUAL ACUITY EXAMINATION (please see CN II in the ASCM I Neurological Examination Handbook) 2. VISUAL FIELDS EXAMINATION (please see CN II in the ASCM I Neurological Examination Handbook) 3. EXTRAOCULAR EYE MOVEMENTS EXAMINATION (please see CN III – XI in the ASCM I Neurological Examination Handbook) 4. EXTRINSIC AND INTRINSIC EYE STRUCTURES  Carefully examine the following structures using a slit lamp (if available) or a penlight or ophthalmoscope directed at an angle: o ocular symmetry  media or lateral deviation, relative to the other eye (indicative of eye muscle weakness) o orbit  exophthalmos (eyes protruding out)  enophthalmos (sucken eyes) o eye lid symmetry  difference in amount of eyeball covered by each lid o conjunctiva

55

o

o

o

o

o o

 red (sign of inflammation)  pale (anemic) sclera  discoloration (e.g., icterus; some authorities feel that icterus is in the conjuctiva rather than in the relatively avascular sclera) pupil and iris  round  symmetric cornea  smooth  clear anterior chamber  blood  pus  foreign bodies lens  clear lacrimal apparatus  tearing  discharge  swelling

5. OPTHALMOSCOPIC EXAMINATION 

Step 1. Setting up the equipment o Select the appropriate aperture depending on pupil size  small aperture for undilated pupil  large aperture for dilated pupil o



Select the appropriate lens  “0” lens – if examiner does not wear glasses  “minus” lenses (red numbers) – if examiner is myopic  “plus” lenses (black numbers) – if examiner is hyperopic

Step 2. Holding the ophthalmoscope o to examine the patient‟s right eye, hold the ophthalmoscope with your right hand in front of your right eye (try to keep both of your eyes open) o to examine the patient‟s left eye, reverse your hand and eye o start with the diopter wheel (lens) turned to +5, and rotate the wheel (lens) with your index finger to bring various structures into focus

56

o o



with your free hand, keep the patient steady by placing your hand on their head or shoulder approach the patient at eye level from approximately 15 inches away, at an angle of 15 degrees lateral from the midline; move in until you are no more than 2 inches away from the eye

Step 3. Inspection  Instruct the patient to maintain focus on a specific point on the wall (instruct them not to look at the light from the scope) o

Red Reflex – red glow emanating from the eye if the path of the light from the ophthalmoscope is not obstructed by an opaque lens (e.g., in the case of cataract)

o

Optic Disc – the intraocular region of the optic nerve  to locate the optic disc, follow a vessel as it widens and examine:  margins – sharp borders, although the nasal border is often blurry  colour – pinkish in light skinned people; yellowish-orange in dark skinned people  cup – central, lighter in colour, penetrated by vessels; cup-to-disc diameter ratio <0.5



o

assess for papilledema – optic disc swelling caused by increased intracranial pressure  blurring of margins  filling in of optic disc cup  anterior bulging of nerve head  nerve fiber layer edema  retinal or choridal folds  congestion of retinal veins, lack of venous pulsations  peripapillary hemorrhages  hyperemia of optic nerve head  nerver fiber layer infarcts  hard exudates

Retinal Vessels  arteries – thinner, lighter-coloured, and have a brighter reflex than veins  veins – often exhibit spontaneous pulsations, lack of venous pulsations suggests increase in intracranial pressure

57

o

Macula  keep the ophthalmoscope level with the optic disc and move temporally to view the macula  if you are having trouble viewing the macula, ask the patient to look directly into the light  the macula should be avascular with a pinpoint reflective centre, the fovea

o

Retinal Background  colour – normally reddish-orange  lesions – comment on colour (red, black, grey, white) and shape (flame-shaped, diffuse spotting, cotton wool spots)

58

MUSCULOSKELETAL HISTORY

Aspects of the History * The format of this section differs from the generic format 1. General History for an MSK Exam (including Polyarticular Complaints) A. Pain B. Referred symptoms C. Inflammatory Symptoms D. Mechanical Degenerative Symptoms E. Neoplastic and Infectious Symptoms F. Neurological Symptoms G. Vascular Symptoms H. Articular versus Non Articular Symptoms I. History of t Pain or Arthritis J. Extra Articular Manifestations K. Impact on ADL’s 2. Back A. Clues to Inflammatory Back Disease B. Clues to Mechanical Back Disease C. Patterns of Back Pain 3. Shoulder 4. Wrist and Hand

59

1. GENERAL HISTORY FOR AN MSK EXAM (INCLUDING POLYARTICULAR COMPLAINTS) A. Pain  O to W B. Referred Symptoms  Shoulder pain from heart  Arm pain from neck  Leg pain from low back  Knee pain from hip C. Inflammatory Symptoms  Pain  Erythema  Warmth  Swelling  Morning stiffness (>1 hr) D. Mechanical/Degenerative Symptoms  Pain worse at end of day  Pain better with rest and worse with use  Ligament or meniscal symptoms include: clicking, locking, and crepitus  History of trauma E. Neoplastic and Infectious Symptoms  Constant pain  Night pain  Constitutional symptoms: fever, chills, and weight loss  History of cancer F. Neurological Symptoms  Parasthesia, tingling and numbness  Changes in bowel/bladder function  Headache  Weakness G. Vascular Symptoms  Vascular claudication (see the Peripheral Vascular System section)

60

H. Articular versus Non-Articular Symptoms  Articular - Pain through whole range of motion  Non-articular – pain unrelated to t movement I. History of t Pain or Arthritis  Chronicity  Pattern  Axial involvement J. Extra Articular Manifestations (EAM)  Skin – rash, psoriasis, nodules, mucous membrane lesions, alopecia  Vascular - Raynaud‟s phenomenon  Ocular – sicca, conjunctivitis, scleritis, iritis/uveitis  Genitourinary – urethritis, cervicitis, balanitis  GI – bloody diarrhea, Inflammatory Bowel Disease  Neurological – peripheral and central nervous disorders  Respiratory and cardiac – pericarditis, nodules  Constitutional Symptoms – fever and weight loss K. Impact on ADL’s  See the geriatrics section for an explanation of ADL‟s 2. BACK FOCUSED HISTORY A. Clues to Inflammatory Back Disease  Onset – insidious  Duration - >3 months  Relieved by movement  Age < 40  Location – low back or buttock  Prolonged morning stiffness (> 1 hr)  Extra-articular manifestations o Skin – psoriasis o History of gonorea/chlamydia, dysuria (may be a reactive arthritis) o GI – diarrhea and/or hematechezia (red blood in stool) (may be IBD or reactive arthritis caused by enteropathic gram negative organisms) o Eye– Iritis/Uveitis (all seronegative spondyloarthropathies)

61

B. Key Questions 1. Where is your pain the worst? If you could remove only 1 pain, which one would it be? (Get the patient to specify whether the back or leg pain is worse) 2. Is the pain constant or intermittent? Is there a point during the day when it stops? If it stops does it go to 0 (if not, it is constant st and you should ask about cancer or infection 1 )? 3. Is pain worse with flexion or extension? 4. Do you have problems going to the bathroom (bowel/bladder continence)? 5. What do you do to relieve the pain? C. Patterns of Back Pain (Optional) Pattern 1 (intervertebral discs or adjacent ligaments involvement)  Back dominant (back, buttock, trochanter, groin)  Worse with flexion  Constant or intermittent Pattern 2 (posterior t complex involvement)  Back dominant  Worse with extension and never worse with flexion  Always intermittent Pattern 3 (sciatica – L4, L5, S1, S2)  Leg dominant (below buttock)  Leg pain affected by back movement  Previously or currently constant Pattern 4 (neurogenic claudication due to nerve compression caused by disc herniation)  Leg dominant  Leg pain worse with activity and better with rest (unlike vascular claudication pain does not improve immediately upon rest - i.e., it takes > 5 minutes)  Intermittent – short duration

62

3. SHOULDER FOCUSED HISTORY A. Chief Complaints and Associated Symptoms  Pain  Weakness  Limitation of function, movement  Shoulder Instability  History of trauma/injury

4. WRIST AND HAND A. Chief Complaints and Associated Symptoms  Pain  Numbness or tingling (Carpal Tunnel?)  Stiffness or paralysis  Deformities  Inflammatory Symptoms

63

EXAMINATION OF THE BACK (MECHANICAL/ORTHO) Aspects of the Examination 1. Standing A. Inspection B. Palpation C. ROM D. Motor Screen Part 1: Hip abduction; ankle plantar flexion 2. Kneeling on chair A. Reflex Screen Part 1: Ankle reflex 3. Sitting in chair with feet planted on floor A. Motor Screen Part 2: Ankle dorsiflexion; large toe extension B. Sensory screen Part 1: Distal sensation 4. Sitting on the edge of the examination table A. Reflex Screen Part 2: Patellar reflex; plantar reflex (Babinski) 5. Supine A. Nerve root Screen Part 1: Straight leg raise B. Screen for other conditions (e.g., intra-abdominal, hip, PVD) 6. Prone A. Sensory Screen Part 2: Saddle sensation B. Nerve root Screen Part 2: Femoral stretch test C. Motor Screen Part 3: Tone in gluteus maximus

Helpful Hints  Patients with back complaints often have difficulty moving, thus it is important to conduct the exam systematically and avoid repetition  This handbook guides you through the orthopedic back exam as it is demonstrated in the ASCM II Back Examination video. However, note that there are many variations to the order of the exam depending on the preferences of the clinician and if inflammatory conditions are suspected.

Wash your hands and explain the exam to your patient Draping  In male patients the gown may be removed to uncover the entire upper body  In female patients the gown should be tied at the neck; uncover the back when necessary

1. STANDING

64



Inspection  Visualize the entire back (move the gown off to the sides if necessary), from both posterior and lateral angles  Inspect the back both while the patient is upright and while he/she is in forward flexion  Look for o scars, masses, lesions o kyphosis o scoliosis, rib hump (best viewed in forward flexion) o abnormal contours o deformity o unusual posture o asymmetry (of shoulder height, scapulae, iliac crests) o guarding



Palpation  Palpate along the spine for: o tenderness o trigger points o masses o paravertebral/ paraspinal muscle bulk, tenderness, spasms o bony or soft tissue abnormalities/deformities o altered temperature o swelling



Range of Motion (ROM)  Observe both the rhythm and degree of movement  Have the patient perform the following ROMs: 1. Forward flexion  “bend forward and try to touch your toes” 2. Extension  “arch your back” o stabilize the patient by placing one of your hands on the small of their back and the other hand on their shoulder 3. Side flexions  “slide your hand down your leg” o compare side to side 4. Rotation:  “twist towards each side” o stabilize the patient‟s pelvis by placing your hands on their hips

65

o

compare side to side

5. Chest expansion (thoracic spine) o place a tape measurer around the patient‟s chest o instruct patient to take a full breath o measure the difference between rest and full inspiration 6. Schober‟s Test (lumbar spine)  Performed if ankylosing spondylitis or other seronegative conditions are suspected o have patient stand erect with normal posture o identify the posterior superior iliac spine o mark the midline at 5 cm below the PSIS and mark the midline at 10 cm above the PSIS (resulting in two parallel horizontal lines that are 15cms apart) o now instruct the patient to bend at the waist as far as they can o measure the distance between the two marked lines with the patient in flexed position o the distance between the lines increases at least 5 cm in normal patients but far less in patients with AS 

Motor Screen Part 1  screen nerve roots L2-5, S2-4, and upper motor neurons  that the components of the neurological screen may be performed at any convenient time during the back examination  if the screen is positive (i.e., significant deficiency is noted), a more thorough neurological examination is necessary (refer to “Examination of the Motor System” in the ASCM I Neurological Examination Handbook) 1. Hip abduction (L5)  look for Trendelenburg‟s Sign for hip abductor function (see “Examination of the Hip” in the ASCM I Clinical Skills Handbook) 2. Ankle plantarflexion (S1)  with patient standing, have them place their hands in your hands for balance  instruct them to go on their tip-toes one foot at a time

2. KNEELING ON CHAIR  Reflex Screen Part 1

66

Ankle Reflex (S1)  refer to “Examination of the Sensory System” in the ASCM I Neurological Examination Handbook 3. SITTING IN CHAIR WITH FEET PLANTED ON FLOOR  Motor Screen Part 2  refer to “Examination of the Sensory System” in the ASCM I Neurological Examination Handbook Ankle Dorsiflexion (L4) Large Toe Extension (L5) 

Sensory Screen Part 1 Distal sensation  assess for normal sensation in the distal limbs  refer to “Examination of the Sensory System” in the ASCM I Neurological Examination Handbook

4. SITTING IN EDGE OF EXAMINATION TABLE  Reflex Screen Part 2  refer to “Examination of the Sensory System” in the ASCM I Neurological Examination Handbook Patellar Reflex (L4) Plantar response- checking for Babinski response (upper motor neuron) 5. SUPINE  Nerve Root Screen Part 1 Straight leg raise test  patient should be in supine position, with hips adducted and medially rotated, knees extended  have the patient completely relax the affected leg  cup the heel of their foot and gently raise the leg straight up until their typical symptom (pain or tightness in the back or back of the thigh) is reproduced  symptoms with pain in the leg usually occur between 30 and 60 degrees if there is radicular pathology  lower the leg slightly until pain is relieved, then dorsiflex the foot

67

  o o o



typical pain will be reproduced again if there is radicular pathology

N.B. test is not positive if pain is experienced in the front of the thigh a positive test may indicate irritation of the sciatic nerve or tibial nerve if the test is positive, repeat the same test on the opposite leg (with central disc protrusions, performing the test on the opposite leg may reproduce the same pain experienced in the original leg – this is called the crossed straight leg raise test )

Screen for other conditions o Other conditions may masquerade as back pain (especially low back pain) The following conditions may be relevant to screen for  o o

Intra-abdominal conditions if there is concern that symptoms are referred from the abdomen, a detailed abdominal exam should be performed see the abdominal exam sections of the ASCM I Clinical Skills Handbook and this handbook

 o o

Peripheral vascular conditions check pulses see the PVS sections of the ASCM I Clinical Skills Handbook and this handbook

 o

Hip conditions Gently move the hip through flexion, and internal and external rotation See “Examination of the Hip” in the ASCM I Clinical Skills Handbook

o

6. PRONE  Sensory Screen Part 2 Saddle Sensation (S2,3,4)  Lightly palpate between the buttocks assessing for normal sensation

68



Nerve Root Screen Part 2 Femoral Stretch Test (Prone Knee Bending Test)  have the patient lie prone  ively flex the knee as far as possible without extending the hip, so that the patient‟s heel rests against the buttocks (ensure that the hip is not rotated)  if you are unable to flex the patient‟s knee past 90 degrees due to pathology in the hip, modify the exam by ively extending the hip while keeping the knee as flexed as possible  o o



N.B. reproducible pain felt in the front of the thigh may indicate tight quadriceps muscles or stretching of the femoral nerve unilateral reproducible pain in the lumbar area, buttock, and/or posterior thigh may indicate a nerve root lesion (L2 or L3)

Motor Screen Part 3 Contraction of gluteus maximus (S1)  Instruct the patient to clench their buttocks  Palpate the tone of the buttocks using your fingertips  Compare both sides

69

EXAMINATION OF THE SHOULDER Aspects of the Examination 1. Inspection A. Skin B. Soft tissue C. Bone 2. Palpation A. ts B. Extra-articular structures C. Crepitus D. Sensation 3. Range of Motion A. Neck B. Shoulder 4. Special Tests A. Rotator cuff tear B. Impingement C. Disorders of AC t D. Instability

Helpful Hints  Keep in mind that shoulder pain may be referred from the chest or abdomen

Wash your hands and explain the exam to your patient Positioning and Draping  For male patients, gown may be removed to uncover the entire upper body  For female patients, bra may be kept on, gown should be tied below the axilla, fully exposing the shoulder ts 1. INSPECTION 1. Patient can be standing, or sitting on the edge of the bed 2. Inspect both the anterior and posterior aspects of the shoulder A. Skin 

scars, masses, lesions

70

  B. Soft Tissue       

abrasions, bruising erythema

swelling asymmetry atrophy fasciculations biceps tendon rupture ask the patient to flex their arm biceps muscle will appears as a ball of tissue

C. Bone  

asymmetry deformity o squaring of the shoulders (may indicate dislocation) o prominent clavicle, drooping of shoulder girdle (may indicate acromioclavicular t injury or fracture of the clavicle)

2. PALPATION o watch the patient‟s face for signs of pain or tenderness A. ts (see Figure 1) o palpate both symmetrical ts at the same time (using two hands), comparing the normal side to the abnormal side   



sternoclavicular t length of the clavicle, feeling for discontinuity or asymmetry acromioclavicular t  if the t is difficult to find (e.g., in obese patients), feel for the triangle between the clavicle and the spine of the acromion - the AC t is just anterior to this triangle glenohumoral t  palpate both the lateral and anterior aspects

B. Extra-articular Structures (see Figure 1)  biceps groove  subdeltoid bursa  rotator cuff insertions (supra-glenoid tubercle)

71



rotator cuff pathology often presents with tenderness on palpation of the supraspinatus tendon

Figure 1: Anatomy of the Shoulder C. Crepitus  Palpate for crepitus over the glenohumoral t o stand behind the patient o place your hand over the subacromial bursa on top of the shoulder o using your other hand, gently raise (forward flex) the patient‟s arm and ively circumduct the arm; feel for crepitus over the t

72

D. Sensation  Palpate over the deltoid (axillary nerve) o apply light touch over the deltoid muscles o ask the patient if sensation feels normal and equal on both sides

3. RANGE OF MOTION (ROM) o

Neck  Neck pain may radiate to the shoulder and mimic primary shoulder pathology 

Active ROM 6. Flexion  look down 7. Extension  look up 8. Rotation  turn head side to side 9. Lateral flexion  ask the patient to bring their ear to their shoulder, one side and then the other

o

Shoulder  Both shoulders can be assessed at the same time; compare the normal to the abnormal side  Some of the ROMs are best assessed in combination 

Active ROM o

Forward Flexion/ Elevation  ask the patient to trace out an arc (elbows fully extended, palms down) while reaching forward and up as far as they can  they should be able to raise their arms straight over their head

73

o

Extension  ask the patient to reverse direction and trace an arc backwards as far as they can  they should be able to position their hands behind their back

o

Abduction  ask the patient to raise their arms from their sides and straight up over their head  the patient should be able to lift their arms in a smooth painless arc

o

Adduction and Internal Rotation - Apley Scratch Test (see Figure 2)  ask the patient to put their hands behind their back and reach as high up their spine as possible  note the extent of their reach in relation to the scapula or thoracic spine; they should be able to reach the lower borders of the scapula (~T7 level)

Figure 2: Adduction and Internal Rotation – Apley Scratch Test o

Abduction and External Rotation (see Figure 3)  ask the patient to place their hands behind their neck with their elbows pointing out to the sides; instruct them to push their arms as far back as possible  the patient should be able to align their arms

74

Figure 3: Abduction and External Rotation   

ive ROM If the patient has full, symmetric and painless active ROM, there is no need to further assess ive ROM If the patient has reduced or painful active ROM, or disparity between the two arms, assess the same movements with ive ROM o o o o  



place one of your hands on the patient‟s shoulder over the scapula gently grasp the humerus in your other hand and move the shoulder through the ROM note pain and the movement(s) that triggers it feel for crepitus N.B. Limitations in movement in any direction should be noted  where exactly in the arc does this occur?  is it due to pain or weakness?  how does it compare with the other side? ive ROM that is as limited as active ROM suggests a true contracture; pain or limitation on active ROM but not on ive ROM suggests a structural problem with muscles,

75

tendons, or nerves (which are activated with active ROM but not ive ROM)

4. SPECIAL TESTS o Select the appropriate tests according to the suspected pathology (i.e., there is no need to do all the special tests unless you suspect all the pathologies) A. Tests for Rotator Cuff Tear o The rotator cuff consists of four major muscle groups that allow shoulder movement: supraspinatus, infraspinatus, subscapularis, and teres minor. Each muscle can be tested individually, with the exception of infraspinatus and teres minor, which are tested together  

Supraspinatus strength test (Empty Can Test) (see Figure 4) Responsible for shoulder abduction o o

have the patient abduct their shoulders to 45 with full internal rotation (i.e., hands turned so that the thumbs are pointing downward, as though emptying a can) instruct the patient to resist you as you apply downward pressure on their arms

76

©2007 Kari Francis

Figure 4: Supraspinatus Test – Empty Can Test  

Infraspinatus and Teres Minor strength test (see Figure 5) Responsible for external rotation o

o

have the patient abduct their shoulders slightly (20-30), keeping both elbows bent at 90 (arms positioned as though holding cups) instruct the patient to resist you as you apply inward pressure against the outside their forearms

77

Figure 5: Infraspinatus and Teres Minor Strength Test  

Subscapularis strength test (Gerber’s Lift-off Test) (see Figure 6) Responsible for internal rotation o o

ask the patient to place their hands behind their back, with palms facing out and positioned about waist level instruct the patient to lift their hands away from their back as you apply resistance

78

Figure 6: Subscapularis Test – Gerber’s Lift Off Test 

Drop Arm Test o Adduction of the arm requires both the deltoid and the supraspinatus muscles; a torn rotator cuff leads to the loss of the seamless transition of function as the shoulder is lowered o o o

abduct the patient‟s arm fully with the elbows fully extended instruct the patient to slowly lower (adduct) their arm to their side if the rotator cuff is torn, at approximately 90 the arm will suddenly drop towards the body or the patient will have severe pain  N.B.

79

o

If the patient has severe weakness, it may indicate a very large rotator cuff tear or they may have a nerve lesion (you would need to test the deltoid and peripheral nerves to make a differentiation)

B. Tests for Impingment o Impingment, rotator cuff tendonitis and sub-acromial bursitis are related  impingment can lead to tendonitis and bursitis  the 4 tendons of the rotator cuff all have their insertions on the humerus and must underneath the acromion (see Figure 1)  impingement of the rotator cuff tendons occur when the space between the acromion and the tendons become narrowed – the resulting friction inflames the tendons as well as the subacromial bursa o Impingement tests ively maneuver the tendons such that they are most likely to rub against the acromion, reproducing the symptoms of impingement o Any one of these three tests is sufficient 

Neer’s Test (see Figure 7) o o o o

o o

stand behind or to the side of the patient place one of your hands over the top of the patient‟s shoulder while grasping their forearm with your other hand position the arm in internal rotation with the thumb pointing downwards forcibly but gently elevate the arm through forward flexion, bringing the hand over the head (this jams the greater tuberosity of the humerus against the anteroinferior surface of the acromion) observe the patient‟s face test is positive if pain is produced

80

Figure 7: Neer’s Test 

Hawkin’s-Kennedy Test (see Figure 8) o stand behind or to the side of the patient o raise the patient‟s arm to 90 forward flexion o forcibly but gently internally rotate the arm (i.e., thumb pointing down) o observe the patient‟s face o test is positive if pain is produced

81

Figure 8: Hawkin’s-Kennedy Test

C. Test for Disorders of Acromioclavicular t  Test if palpation of the AC t causes pain or tenderness 

AC t Stress Test o position the patient‟s arm in 90 forward flexion o move the patient‟s arm across their chest (this stresses the AC t) o observe the patient‟s face o test is positive if pain is reproduced

D. Tests of Shoulder Instability  Can be done with the patient upright or supine (either is fine)  Test is positive if the maneuvers causes apprehension or alarm in the patient or leads to the patient‟s resistance to further motion or the reproduction of patient‟s symptoms; pain is not considered positive 

Test of Anterior Shoulder Instability - Anterior Apprehension Test

82

o

Upright (see Figure 9)  stand behind the patient  place one hand on the patient‟s shoulder (fingers over top the glenohumoral t and thumb pressing against the head of the humerus)  use your other hand to grasp the patient‟s forearm and abduct the shoulder to 90  bend the patient‟s elbow and gently externally rotate the arm (pull the arm backwards) while using the hand on the patient‟s shoulder to apply a posterior to anterior pressure against the head of the humerus (trying to sublux the shoulder)

o

Supine - Optional (see Figure 10)  position the patient with their arm hanging off the bed  place one hand on the patient‟s shoulder (thumb over the front of the humerus and fingers against the back of the humerus)  grasp their forearm with your other hand and abduct the shoulder to 90  bend the elbow and gently externally rotate the arm while using your other hand to lift the head of the humerus forward

Figure 9: Anterior Apprehension Test – Upright

83

Figure 10: Anterior Apprehension Test –Supine 

Relocation Test - Optional  Performed if the Anterior Apprehension Test is positive  Maneuver is essentially the opposite of the Anterior Apprehension Test o



Upright or supine  at the point of apprehension, push the humerus in the posterior direction while externally rotating the arm  this maneuver should relieve any apprehension that the shoulder is going to dislocate

Test of Posterior Shoulder Instability - Posterior Apprehension Test o

Upright (see Figure 11)  stand to the side of the patient  place one hand on the patient‟s scapula and use the other hand to forward flex the patient‟s shoulder in the plane of the scapula to 90  apply a posterior force on the patient‟s elbow while stabilizing the scapula with the other hand

o

Supine – Optional (see Figure 12)  position the patient with their arm hanging off the bed  place one hand on the patient‟s shoulder and use the other hand to forward flex the patient‟s shoulder in the plane of the scapula to 90  apply a posterior force on the patient‟s elbow (or shoulder)

84



while applying the axial load, horizontally adduct and internally rotate the arm

Figure 11: Posterior Apprehension Test – Upright

Figure 12: Posterior Apprehension Test - Supine 

Test of Inferior Shoulder Instability (Sulcus Sign) o Performed with the patient standing  

have the patient stand with their arms by their sides and the shoulder muscles relaxed grasp the patient‟s forearm below the elbow and gently pull the arm distally

85



a positive test is indicated by subacromial indentation (depression lateral or inferior to the acromion, known as the sulcus sign)

86

EXAMINATION OF THE HAND AND WRIST Aspects of the Examination 1. Inspection A. Skin B. Nails C. Soft tissue D. ts 2. Palpation A. ts B. Palm 3. Range of Motion 4. Special Maneuvers A. Tests for carpal tunnel syndrome B. Test for tenosynovitis Helpful Hints  A thorough examination of the hand and wrist is important not just for assessment of the MSK system, but is also useful for detecting disease conditions in many other systems

Wash your hands and explain the exam to your patient Draping A. Both hands should be fully exposed well past the wrist

1. INSPECTION 3. Hands should be examined uned (to avoid masking any abnormalities) with elbows flexed at 90 degrees A. Skin 



Dorsal aspect o masses, scars, lesions o erythema (general, and over the ts) o thickening, shininess, tightness o cuts, abrasions, bruising Palmar aspect o masses, scars, lesions

87

o o

palmar erythema cuts, abrasions, bruising

B. Nails  Inspect nails and nail folds for: o pitting o periungular erythema o infarcts, hemorrhages C. Soft Tissue  Inspect and compare both hands for: o swelling o contractures o atrophy (thenar eminence, and hypothenar muscles o fasciculations o pitting or scaring in pulps of fingertips D. ts  Examine from the dorsal aspect   

General misalignment deformity



Inspect the following specific ts: o

Wrist  deformity  swelling  Tuck sign o have the patient flex their fingers and then slowly extend them o look for bunching up of fluid on the dorsum of the wrist, exposing the flexor tendons underneath o a positive sign may be indicative of extensor tenosynovitis (rather than true effusion)

88

o

M  deformity  swelling (indicated by loss of normal valleys between the ts)

o

PIP  deformity  fusiform swelling (swelling that is fuller at the PIP t and tapers at both ends, as differentiated from edema throughout the digit)  bony nodules (Bouchard‟s nodes)

o

DIP  deformity  swelling  bony nodules (Heberden‟s nodes)

89

Abnormality

Characteristics

Clubbing

4 Characteristics:

Leukonychia (White nails) Onycholysis Pitting Splinter hemorrhages

1.) Nail fold angles: nail projects from the nail bed at ~ 180 (normal is ~160) 2.) Phalangeal depth ratio: the distal phalangeal depth (right where the nail bed ends) is larger than the interphalangeal depth (where the DIP t is) (normally the ratio is the reverse) 3.) Schamroth Sign: absence of the diamondshaped window that is normally created when the dorsal surfaces of the terminal phalanges of similar fingers are opposed 4. Palpation: the clubbed nail feels like it is “floating” within the soft tissues Nail bed has white marks across it (partial or completely white nails) Nail appears to be separating from the nail bed Small depressions (< 1mm diameter) in nail bed Red-purple vertical streaks in nail bed

Table 1: Nail Abnormalities

Deformity

Characteristics

Bouchard’s nodes (DIPs) Heberden’s nodes (PIPs) Boutonniere deformity Dupuytren’s contracture

Bony knobs on the dorsal-lateral aspect of the t

Mallet finger/ thumb Swan neck deformity

Hyper-extended DIP, flexed PIP Flexed fingers at the M and IPs due to nodular thickening in the palms and fingers Flexed DIP Flexed DIP, hyperexteded PIP

Table 2: Deformities of the Hand

90

Associated disease OA

Trauma or RA Alcoholism, diabetes, epilepsy, hereditary

2. PALPATION  Written descriptions of proper palpation technique tend to sound overly complicated and are not helpful - instead we highly recommend watching the video of the hand and wrist exam on the ASCM II website for a more effective visual demonstration. A. ts  

  



Distal radial-ulnar t  between the ulnar stylus and distal radius on the dorsum of the wrist True radial-carpal t  follow the length of the third metacarpal and palpate in the indentation at the base of the third metacarpal on the dorsum of th wrist M ts  Assess all M ts including that of the thumb PIP and DIP ts  Assess all PIP and DIP ts, including those of the thumb st 1 carpal metacarpal t  base of thumb on dorsum of hand (in the anatomical snuff box)

Assess for: o

t line tenderness

o

t effusion

o

Bony structures (true radial-carpal t)

o

t stress pain (M, PIP, DIP)

o

Crepitus (1 carpal metacarpal t)

st

B. Palm of the hand o compress the palm between your thumb and fingers o feel along the length of the flexor tendons o palpate for:  thickening  tenderness  nodules (usually in the region of the distal palmar crease)

91

3. RANGE OF MOTION (ROM)  Neutral position is with elbows flexed 90 degrees and palms facing down Active ROM Supination o “palms up” o palms should be facing the ceiling Pronation o “palms down” o palms should be parallel to the floor Wrist flexion o “bring your fingers down towards the floor” Wrist extension o “bring your fingers up towards the ceiling” Ulnar deviation o “keeping your hand parallel to the floor, bend your wrist outward” Radial deviation o “keeping your hand parallel to the floor, bend your wrist inward” Flexion and extension of M, PIP, DIP o “make a fist with each hand, and then straighten out your hand” o on flexion, the fingers should normally be able to make a fully closed fist o on extension, each finger should be able to extend to the straight neutral position o this motion tests the mobility of all the small ts of the hand

92

Thumb ROM (optional) o assess the ROM of the thumb: o flexion o extension o abduction o adduction o opposition o see the “Examination of the Motor System” in the ASCM I Neurological Examination Handbook for detailed instructions on thumb movements  ive (should be assessed if active ROM is difficult or limited, otherwise optional) Wrist flexion and extension o check for stress pain at the end of the ROM 4. SPECIAL MANEUVERS A. Tests for carpal tunnel syndrome o Test for carpal tunnel syndrome if patient complains of numbness and tingling (i.e., neuropathic pain symptoms) in the distribution of the median nerve (on the palmar surface - thumb, index, middle, lateral ½ of ring finger, plus lateral 2/3 of the palm; on the dorsal surface –same fingers as palmar distribution but without the thumb) 

Tinnel’s sign (see Figure 1) o the patient‟s hand in one of your hands, palm up o with one or two fingers of your other hand, tap briskly directly over the median nerve (medial to the flexor carpi radialis tendon at the most proximal aspect of the palm) o the test is positive if numbness and tingling is reproduced in the thumb, index, middle and lateral ½ of ring finger (i.e., the distribution of the median nerve)



Phelan’s sign (see Figure 2) o have the patient flex their wrists against each other and instruct them to hold the position o the test is positive if the patient notes numbness or tingling in the distribution of the median nerve after holding this position for 60 seconds or less

93

Figure 1: Tinnel’s Sign

Figure 2: Phelan’s sign

94

B. Examination of tenosynovitis of the thumb (DeQuervain’s type) o Test for De Quervain‟s disease if patient complains of pain at the base of the thumb on any movement of the thumb (in particular, gripping) 

Finklestein Test o direct the patient to place their thumb in their palm o have them cover the thumb with the fingers of the same hand, forming a fist o ask the patient to gently move the hand into ulnar deviation o the test is positive if their pain is reproduced

95

PERIPHERAL VASCULAR DISEASE (PVD) HISTORY

Aspects of the History 

Chief Complaints and Associated Symptoms



O to W



Associated Symptoms for PVD-Related Conditions o Atherosclerosis o Venous Insufficiency (DVT)



Risk Factors for PVD-Related Conditions o Atherosclerosis o DVT

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS  Pain (especially in calves)  Location o unilateral (DVT) versus bilateral (vascular claudication?)  At rest (neurogenic?) versus upon exertion (vascular claudication)  Reproducibility with similar exertion (vascular claudication)  Night pain  Change in skin temperature and color  Gangrene  Skin ulceration  Arterial versus venous  Swelling o May be associated with congestive heart failure o Unilateral swelling may be due to DVT

96

 

Neurological deficits – paralysis/paraesthesia o Unilateral versus bilateral Chest, abdominal or back pain

2. O TO W o With each chief complaint above go through O to W before going on to associated symptoms.

3. ASSOCIATED SYMPTOMS FOR PVD-RELATED CONDITIONS A. Atherosclerosis  Coronary artery disease – angina, dyspnea, history of myocardial infarction  Neurological – dizziness, presyncope, syncope, headache, TIA and stroke  Intermittent claudication – reproducible pain in muscles of lower extremity (feet, calves, thigh, hips, buttocks) upon similar exertion, which improves quickly with rest B. Venous Insufficiency (DVT)  Pulmonary embolism – dyspnea, hemoptysis, fever 4. RISK FACTORS FOR PVD-RELATED CONDITIONS A. Atherosclerosis  Smoking  Hypertension  Diabetes Mellitus  Dyslipidemia  Family history of atherosclerosis or thromboembolic disease  Lifestyle (exercise and diet)  Stress B.     

DVT Recent immobilization (i.e., post-surgery) Cancer Oral contraceptive pill and other medications Pregnancy Family history of clotting disorders

97

EXAMINATION OF THE PERIPHERAL VASCULAR SYSTEM* *N.B. The general PVS exam is covered in the ASCM I Clinical Skills Handbook. Here, we cover pathology-specific signs and special tests not covered in ASCM I Aspects of the examination 1. Inspection  Venous System  Arterial System 2. Palpation and Auscultation o Venous System o Temperature o Pitting edema o Relative sizes o Arterial System o Temperature o Capillary refill o Pulses 3. Special Tests o Allen test o Pallor on elevation and rubor on dependency test

Wash your hands and introduce the exam to your patient. Positioning and Draping  with patient supine, expose both arms or legs in order to compare side to side  be sure to drape between the patient‟s legs in order to cover their groin

98

1. INSPECTION  Inspect bilateral upper and lower extremities o

Size

o

Symmetry

o

Edema  commonly associated with venous insufficiency (blood return problem)  may get worse when the legs are allowed to dangle for long periods of time below the level of the heart  note how far up the leg (i.e., ankle, calf, knee etc.) and symmetry (focal or diffuse, one leg or both)

o

Vessels  varicosities and engorgements may indicate venous insufficiency or venous obstruction Skin  Venous System  thickened skin (fibrosis), increased pigmentation (dark bluish/purple discoloration) and erythema indicate chronic venous insufficiency  venous ulcers  typically brownish and located around the ankles

o



o

Arterial System  lack of hair, cool, pale and/or shiny skin may indicate chronic arterial insufficiency  pallor  pale skin may be a result of under perfusion (arterial insufficiency)  arterial ulcers  usually painful, rapidly developing, and located distally and laterally on the dorsal aspect of foot  bottom of the foot and between the toes  common problem areas, particularly in diabetic patients (who are predisposed to infections and ulcers due to sensory impairment, arterial insufficiency, or both)

Nails  

blue color indicates peripheral cyanosis nail thickening and deformity often occurs with arterial insufficiency,

99

o

 nail thickening can be seen with fungal infections  Lips, below the tongue  blue color indicates central cyanosis

Chronic Venous Insufficiency  thickened skin  erythematous  warm  increased pigmentation  brownish ulcers over the ankles

Chronic Arterial Insufficency  hairless  pale  cool  shiny  painful, rapidly developing ulcers over the dorsum of the foot

Table 1: Venous and Arterial Insufficiency 2. PALPATION and AUSCULTATION Venous System o

Temperature o assess with back of the hand o warmth and erythema may indicate superficial inflammation of the vein

100



Pitting edema (depression in skin caused by applied pressure) o press firmly with your thumb for more than 5 seconds o dorsal aspect of each foot o posterior to medial malleoli o shins o pitting edema indicates chronic venous insufficiency, or orthostasis o non-pitting edema may indicate lymphatic obstruction



Relative sizes o measure forefoot, smallest ankle circumference, largest calf circumference, or midthigh circumference with knee in full extension o difference >1cm at ankles or >2cm at calf may indicate edema (may also indicate muscle atrophy)

Arterial System 

Temperature o assess with back of the hand o a relatively cold limb may indicate ischemia



Capillary Refill  compress the firm pressure to plantar skin of great toe for 5 s, then assess the time for the pink color to return  normal = <2-3 s abnormal ≥5 s  abnormal test lacks sensitivity for PVD but good specificity  normal capillary refill can be seen in some people with PVD



Pulses (comparing both sides)  Describe: rate, rhythm, amplitude (see Table 2) o

o

carotids o auscultate for bruits before palpating – do NOT palpate if bruits are audible o palpate one carotid artery at a time. brachial o palpate (you may use your thumb)

101

o o

o

o o

o

o

radial o palpate using 3 finger pads abdominal aorta o palpate for pulsations and expansions a few centimetres above the umbilicus o auscultate for abdominal bruits renal arteries o auscultate for bruits  5 cm above the belly button and 3-5cm out from the midline on each side  may listen from the front or back femoral o palpate in the groove of the inguinal ligament o auscultate for bruits popliteal o palpate behind the knees o with patient‟s knee flexed to 10-20 degrees, place both your thumbs on the tibial tuberosity and palpate behind the knee with the tips of 3 or 4 fingers from each hand posterior tibial o palpate behind and slightly below the medial melleolous nd rd th o gently place the tips of your 2 , 3 , and 4 fingers just behind the medial malleolus o do not press too hard as this occludes the pulse dorsalis pedis o palpate lateral to the extensor hallucus longus tendon (you can identify the tendon by asking the patient to flex their toe) nd rd th o gently place the tips of your 2 , 3 , and 4 fingers adjacent to the tendon o do not press too hard as this occludes the pulse

102

o

Rate  <60 = bradycardic  >100 = tachycardic)

o

Rhythm  regular  regularly irregular  irregularly irregular

Table 2: Evaluation of Pulse o

Amplitude  If exaggerated or widened, may indicate aneurysm  Grades  0 = absent  1 = diminished  2 = normal  3 = increased  4 = aneurysmal

103

3. SPECIAL TESTS

Allen Test (arterial system, upper extremity)  instruct the patient to make a tight fist  use one of your hands to occlude the radial artery and the other hand to occlude the ulnar artery  instruct the patient to open their hand  palm should be pale  release the pressure from the radial or the ulnar artery (depending on which artery you are testing)  normal: pink colour returns to the palm immediately (within seconds)  abnormal: refilling of the palm takes a prolonged period of time o if the time to refill differs between the radial and the ulnar arteries, the slower one is likely occluded o if time to refill is equally slow in both radial and ulnar arteries, the occlusion is likely more proximal (thus affecting both arteries) Pallor on Elevation and Rubor on Dependency Test (arterial system, lower extremity; also tests venous refill)  with the patient supine, raise the leg to 45-60 degrees until pallor develops in the foot and superficial veins are empty (approximately 30 seconds)  ask patient to sit up with legs dangling off the bed  normal: o pink colour returns to the dorsum of the foot within 10 seconds o the superficial veins refill within 15 seconds  abnormal:  persistent pallor for more than 10 seconds (pallor on elevation – may indicate arterial insufficiency)  dusky cyanosis (rubor) developing after 1-2 minutes (rubor on dependency – may also be a sign of arterial insufficiency)  > 20 seconds to refill the superficial veins

104

Acute Arterial Occlusion  6 P’s o Pain o Pallor o *Paresthesia o *Paralysis/ Power loss o Polar (cold) o Pulselessnes (late) *Paralysis and Paresthesia are the 2 most important P’s

Deep Vein Thrombosis (Acute)  Pain (if present, in calf)  Unilateral swelling (often the only symptom  >1.5 cm calf discrepancy significant  Erythema, warmth  Venous distention  Fever  Tachycardia  Pulmonary Embolisms (due to DVT) o tachycardia, tachypnea o anxiety, generalized malaise o shortness of breath o fever Table 3: Acute Vascular Occlusions

105

ABDOMINAL HISTORY

Aspects of the History 

Chief Complaints and Associated Symptoms



O to W



Acute Abdomen Differential Diagnosis

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS 1. Pain 2. Abdominal distension/mass 3. Weight change 4. Anorexia 5. Fever 6. Change in frequency of bowel movements 7. Constipation 8. Diarrhea 9. Obstipation (severe constipation caused by intestinal obstruction) 10. Nausea and/or vomiting 11. Food intolerance 12. Heart Burn 13. GI bleed A. Melena (black stool) B. Hematochezia (red blood in stool) C. Hematemesis (red blood in emesis) D. Coffee ground emesis (blood clots in vomit) 14. 15. 16. 17. 18.

Jaundice (yellow skin or yellow conjunctiva of the eyes) Pruritis Change in energy level Dysphagia (difficulty with swallowing) Urinary symptoms

106

2. O TO W o With each chief complaint above go through O to W before going on to associated symptoms. 3. ACUTE ABDOMEN DIFFERENTIAL DIAGNOSIS o With each differential diagnosis there are important symptoms to think about. Here are some key symptoms to ask about for each differential diagnosis. A.        

Pancreatitis History of gallstones or history of ethanol use Nausea/vomit Abdominal distension Fever Epigastric pain Non-colicky pain Constant pain Pain radiates to back and improves with leaning forward

B.     

Cholecystitis Biliary colic Fever Chills Right Upper Quadrant pain Pain is brought on by eating (especially a fatty meal)

C.      

Appendicitis Periumbilical pain that is dull and poorly localized initially Pain may localize to the Right Lower Quadrant Anorexia Nausea/vomiting Fever Diarrhea with increasing intensity of pain

D. Abdominal Aortic Aneurism  Abdominal, back, flank or chest pain  Risk factors are same as Coronary Artery Disease (See cardiovascular section) E. Peptic Ulcer  Dyspepsia

107

F. Duodenal Ulcer  Epigastric burning pain 1-3 hours post-prandial  Pain relieved by eating and antacids  Pain can interrupt sleep G. Gastric Ulcer  Pain exacerbated by eating with or unrelated to eating  Food aversion, anorexia, weight loss H.    

Pyelonephritis Flank pain Dysuria Fever, chills Nausea/Vomiting

I. Diverticulitis  Abdominal pain, often Left Lower Quadrant  Fever  Altered bowel movements  Nausea/Vomiting  Perforation J. Perforation  Pain (may be peritoneal type pain)  Constitutional symptoms: fever, fatigue, etc. K.    L.   

Intestinal Obstruction Pain Nausea/vomiting Constipation/obstipation Biliary Obstruction Jaundice Pain Pale stools, dark urine

M. Renal Obstruction  Pain (may be flank pain)  Obstructive symptoms (see urology section)

108

N. Intestinal Ischemia  Sudden abdominal pain in person with heart disease, arrhythmia  GI bleeding may accompany O. Gynecologic (ectopic pregnancy, pelvic inflammatory diseas, ovarian cyst)  For any abdominal pain in a female, you must consider gynecological causes. P. Metabolic  Diabetic Ketoacidosis may present with acute abdominal pain and peritoneal findings

109

CARDIOVASCULAR HISTORY

Aspects of the History 1. Cardiovascular Disease (Congestive Heart Failure and Atherosclerosis)  Chief Complaint and Associated Symptoms  O to W  Non Specific Symptoms  Risk Factors For Cardiovascular Disease o Major risk factors o Minor risk factors 2. Diabetes A. Chief Complaints and Associated Symptoms B. Risk Factors for Diabetes C. Complications of Diabetes  Macrovascular complications  Microvascular complications 3. Hypertension A. Chief Complaints and Associated Symptoms B. Risk Factors for Hypertension C. Secondary Hypertension D. Complications of Heart Disease

1. CARDIOVASCULAR DISEASE A.   

  

Chief Complaints and Associated Symptoms Chest pain/discomfort Palpitations Dyspnea (Shortness Of Breath) a. At rest versus on exertion b. Orthopnea c. Paroxysmal Nocturnal Dyspnea Dizziness/lightheadness Pre-syncope/syncope Fatigue

110

   

Edema/Swollen ankles Hemoptosis-pink frothy sputum in pulmonary edema TIA, stroke Peripheral Vascular Disease symptoms (see PVD section)

B. O to W o With each chief complaint above go through O to W before going on to associated symptoms. C. Non Specific Symptoms o Nausea/vomiting o Cough o Sweating D. Risk Factors for Cardiovascular Disease  Major  Family history  Diabetes mellitus (see below)  Hypertension (see below)  Dyslipidemia  Smoking  Metabolic Syndrome  Chronic Renal Disease  Other important risk factors  Stress, depresssion  Illicit drug use- especially cocaine  Abdominal Obesity- waist circumference >102 cm men, >88 women  Ethnicity – South Asians, Native Canadians at higher risk  Sedentary lifestyle  Male or post menopausal female 2. DIABETES A. Chief Complaints and Associated Symptoms  MANY with Type 2 DM – asymptomatic  Polyuria  Polydipsia  Nocturia  Weight gain or loss  Visual blurring  May present with a chronic complication of diabetes  Severe abdominal pain/ nausea and vomiting if DKA present  Decreased level of consciousness and dehydration in hypersosmolar state

111

B. Risk Factors for Diabetes  Older Age  Ethnicity (Hispanics, Native Americans, African Americans, and Asians/Pacific Islanders)  Family history  Obesity, especially abdominal obesity  Medications, especially glucocorticoids  Sedentary lifestyle  History of GDM or delivery of an infant weighing > 4 kg,  High fasting insulin levels, impaired glucose tolerance (IGT) or impaired fasting glucose (IPG)  HDL < 1.0 mmol/L, or triglyceride ≥ 1.7 mmol/L,  Polycystic ovarian syndrome,  Acanthosis nigricans  Schizophrenia (risk due to antipsychotic medications) or presence of complications associated with diabetes  Hypertension often associated C. Complications of Diabetes  Macrovascular complications  Neurological - stroke/TIA,  Cardiovascular – i.e.: chest pain/angina (see cardiovascular disease section) or silent ischemia  Peripheral Vascular Disease – i.e.: intermittent claudication (see PVD section)  Microvascular complications  Retinopathy – visual change or asymptomatic  Neuropathy – peripheral polyneuropathy (numbness in extremities starting with feet), acute mononeuropathy, autonomic neuropathy (postural hypotension, delayed gastric emptying)  Nephropathy – asymptomatic proteinuria, flank pain & hematuria if papillary necrosis occurs (rare)  Erectile dysfunction  Cataracts

112

3. HYPERTENSION A. Chief Complaints and Associated Symptoms  Most asymptomatic  May present with neurological complication (TIA, stroke), cardiovascular symptoms (see above)  Malignant Hypertension – diastolic > 120, encephalopathy, blurring vision, papilledema, seizures, cardiac decompensation, renal impairment

B.   



Risk Factors for Essential Hypertension Age Family history Lifestyle  Diet (high salt, low calcium in susceptible)  Exercise  Stress  Weight gain Alcohol

C. Secondary Hypertension 

Consider renal, endocrine, medication causes of hypertension if there are other symptoms and signs

D.    

Complications of Hypertension Heart disease Neurological diseases (TIA, Stroke) Peripheral Vascular Disease Renal disease

113

GERIATRIC HISTORY

Aspects of the History * The format of this section differs from the generic format 

Helpful Hints



Identifying Data



Chief Complaint and HPI



Past Medical History



Medications and Allergies



Social History and Family History



Functional Assessment o Activities of Daily Living (ADL) o Instrumental Activities of Daily Living (IADL) o Sensory Function o Geriatric Giants o Caregiver Interview and Issues



Psychiatric Symptoms o Delirium o Dementia o Depression



Cognitive Assessment o Folstein Mini Mental Exam o Complete Mental Status Exam

114

1. HELPFUL HINTS  The patients may be hard of hearing therefore speak at a higher volume  If the patient appears to have a bad memory or cognitive impairment do a quick mini metal status exam (MMSE) first  Patients may under-report their symptoms 2. IDENTIFYING DATA  Must identify both the patient and the caretaker‟s relationship to the patient 3. CHIEF COMPLAINT AND HPI  Whatever the chief complaint may be go into detail within that system first before moving to specificities related to the geriatric exam.  Things to think about for the HPI  Patients may present with non-specific presentations  Multiple pathology is the rule…not the exception  Adverse drug effects could cause symptoms 4. PAST MEDICAL HISTORY  Try to extract information about all their previous and present medical conditions i.e.: o Diabetes o Hypertension o Falls o Emphysema o Arthritis o Coronary artery disease o Cataracts o Etc. 5. MEDICATIONS AND ALLERGIES  Drug interactions could be the cause of symptoms  Ask about over-the-counter medications (sleeping pills, laxatives, vitamins)

115

6. SOCIAL HISTORY AND FAMILY HISTORY  s for activities of daily living  Stressors  Smoking and alcohol  History of war  Education  Financial state 7. FUNCTIONAL ASSESSMENT A. ADLs  grooming, bathing, toileting, transferring, ambulation, dressing o Do you get out of bed by yourself in the morning? o Do you dress yourself? o Do you go to the bathroom by yourself? o Do you bathe yourself and do your own grooming? o Do you need any assistance getting in and out of the bathtub? o How is your walking? Do you need to use a cane or a walker? o Are you able to stand up from a chair without any assistance? o Do you have any difficulties getting up and down stairs? B. IADLs  shopping, cooking, cleaning, transportation, driving, financial affairs o Who does the cooking, cleaning, laundry and shopping in your home? o Who does the banking, pays the bills, and makes financial decisions? o How do you get to appointments? o Does anyone help you to take your medications? o Do you drive? If so, are there any problems with your driving? Have you been involved in any traffic accidents recently or received any traffic tickets/violations?

116

C. Sensory Function  Vision and hearing o How is your vision? Can you read the newspaper? o How is your hearing? D. Geriatric Giants 

Memory, Incontinence, Falls or Fractures, Polypharmacy o How would you say your memory is? o As some people get older, they sometimes lose control of their bowel or bladder, does this ever happen to you? o Have you ever had any falls or fractures? o What medications are you currently taking?

E. Caregiver Interview and Issues  Ask about embarrassing issues (incontinence, memory, alcohol)  Caregiver issues a. s and stressors b. Personal conditions (i.e.: depression) 8. PSYCHIATRIC SYMPTOMS  Screening question: “Do you often feel sad or depressed”?  A positive response to the screening question indicates the need for further investigation using the Geriatric Depression nd Scale (this is not included here as it is beyond what 2 year medical students are expected to master).

Delirium: acute, often fluctuating cognitive dysfunction secondary to an underlying medical illness; characterized by altered consciousness, poor attention and marked psychomotor changes Dementia: progressive deterioration of cognitive function without impairment of consciousness; affects memory, judgment, intellect and mood Depression: depressed mood + SIGE CAPS (see psychiatry section); can cause dementia-like syndrome in the elderly; decreased concentration and psychomotor retardation can cause depression to be mistaken for dementia

117

9. COGNITIVE ASSESSMENT A. Folstein Mini Mental Exam (MMSE)  You will be expected to memorize the MMSE (including the scoring) for the ASCM II OSCE  To facilitate recall, some students find it helpful to memorize the order of the scoring numbers as cue. That is, memorize 5-5,3-5, 3-2-1, 3-1-1-1. (Try it!)  Maximum score is 30; score <24 indicates significant impairment o

o

o

o

o o o

5 – Orientation to time (1 point each, total 5) o What Year is it? o What Season is it? o What Month is it? o What is the Date? o What Day of the week is it? 5 – Orientation to place (1 point each, total 5) o What is this Place called? o What Floor are we on? o What City are we in? o What Province are we in? o What Country are we in? 3 – Immediate recall (1 point for each item of recall, total 3) o Inform the patient that you will name three objects and that they are to repeat them back to you right away, and they will also be asked to recall them in a few minutes so they should try to them o Try to always use the same three objects so you will recall them with ease o Example: “Orange, Table, Ball” 5 – Attention (1 point for each correct letter or number, total 5) o Instruct the patient to spell “WORLD” backwards OR to subtract consecutive 7s starting from 100 3 – Delayed recall (1 point each, total 3) o Ask the patient to recall the 3 objects that were named earlier 2 – Naming (1 point each, total 2) o Point to two objects (e.g., your watch and your pen) and have the patient name them 1 – Repetition (1 point total) o Instruct the patient to repeat after you: “No ifs, ands, or buts”

118

o

o o

o

3 – 3 Stage command (1 point for each correct step, total 3) o Ask the patient to follow your instructions:” Take this piece of paper in your right hand, fold it in half, and put it on the floor”. 1 – Reading (1 point total) o Write “Close your eyes” on a piece of paper and ask the patient read it and do what it says 1 – Copying (1 point total)  Draw two intersecting pentagons on a piece of paper and ask the patient to copy the drawing 1 – Writing (1 point total)  Instruct the patient to write a sentence on a piece of paper

B. Complete Mental Status Exam  See psychiatric examination section

119

NEUROLOGICAL HISTORY

Aspects of the History 

Chief Complaints and Associated Symptoms



O to W

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS Headache  Onset  Pattern  Migraines: o Associated Symptoms:  Nausea/vomiting  Photophobia/phonophobia  Aura o Risk Factors:  Medications (O)  Consumption (coffee, alcohol, drugs)  Family history of migraines  Infection or Cancer: o Associated Symptoms:  Neck stiffness  Fever  Weight loss  Other neurological symptoms (weakness/numbness) o Risk factors: o Family history of cancer Loss of Consciousness (syncope versus seizures)  Complete LOC or was patient still able to hear voices  How long  Position of the patient during the episode  Tongue biting  Body movements (witnesses)  Lightheadedness beforehand

120

 

Confusion or sleepiness following the attack Continence during the attack

Dizziness (vertigo versus presyncope)  Room spinning (vertigo) versus light-headedness (presyncope)  Nausea, vomit, tinnitus, hearing loss  Change with eyes open or closed  Change with head positioning  Any double vision Visual disturbances  Scotoma, or visual field loss  Double vision (horizontal versus. vertical)  Eye pain  Flashing lights Numbness  Tingling  Prickling  Warm versus cold  Distorted sensation in response to a stimulus  Distribution Pain 

Distribution/pattern of pain (confined to dermatome versus diffuse)

Weakness  Distribution/pattern of weakness (e.g., proximal versus distal, bilateral versus unilateral, para/quadraplegia, fatigability?) Tremor  Worse with movement or at rest or with posturing  Ingestion of alcohol, tea, coffee, chocolate, pop, or other drugs

121

Speech Disturbances (dysarthia versus dysphasia)  Difficulty in articulating words, caused by impairment of the muscles used in speech (dysarthia)  Difficulty with word finding (dysphasia)  Impaired naming, mixing up words (dysphasia)  Difficulty reading, writing, and comprehension (dysphasia) Gait and poor postural stability  Localizing causes of gait problem  Loss of position sense in legs (proprioception)  Sensory impairment  Weakness 2. O TO W  With each chief complaint above go through O to W before going on to associated symptoms.

122

PSYCHIATRIC HISTORY

Aspects of the History * The format of this section differs from the generic format 

Chief Complaints and HPI o Depression o Mania o Delusions o Hallucinations o Anxiety Disorders  Panic Attacks  Agoraphobia  Obsessive Compulsive Disorder  Social Phobia  Specific Phobia  Generalized Anxiety Disorder  Post Traumatic Stress Disorder o Alcohol and other Substance Abuse



Past Psychiatric History



Medication and Allergies



Past Medical History



Family History



Past Personal History

123

1. CHIEF COMPLAINTS AND HPI (See the Mental Status Examination section of this handbook) A. Depression  M – Mood: Depressed most of the day, every day  S – Sleep: difficulty falling asleep, frequent awakening, waking too early, sleeping too much  I – Interest: Lost of interest or pleasure  G – Guilt: sense of worthlessness, self-blaming  E – Energy level reduced  C – Concentration reduced  A – Appetite reduced or increased  P – Psychomotor retardation: talking or moving too slowly  S – Suicide: thinking about or planning suicide B. Mania  G – Grandiosity: inflated self-esteem  S – Sleep: reduced need for sleep  T – Talkative: pressured speech  P – Painful consequences with increased involvement with pleasurable activities (spending money excessively, sex, substance abuse, speeding)  A – Activities that are goal-directed: increased productivity  I – Ideas that race (flight of ideas in the patient‟s head)  D – Distracted easily C. Delusions  If a positive answer is elicited, always ask for clarification to make sure that the patient is not referring to objectively real events Delusions of Reference  Do you notice that the TV, radio or newspaper carry special messages intended specifically for you?  Do you think strangers are taking special notice of you? Delusions of Persecution  Do you think some people are trying to hurt you? Delusions of Grandiosity  Do you think you have special talents, abilities, or powers? Somatic delusions  Do you think you have a serious physical illness that doctors have not found?

124

  



 

Delusions of guilt Do you think you have done something terrible and deserve to be punished? Erotomania o Is someone in love with you, perhaps secretly? Delusions of control o Do you ever feel like someone or something outside yourself is controlling your body or your actions against your will? Thought insertion/withdrawal o Are there ever thoughts in your head that you think were put in there from the outside? o Do you ever feel like your thoughts are taken out of your head? Thought broadcasting o Do you ever think your thoughts are broadcasted out loud so that everyone can hear what you are thinking? Delusion of mind reading o Can people read your mind sometimes?

D. Hallucinations 



 

Auditory hallucinations o Do you hear things that others can’t hear? o How many voices? o Were they talking to each other? o Did they comment on what you were thinking? o Did they tell you to do anything? Visual hallucinations o Do you ever see visions or other things that other people can’t see? o What did you see? o Were you awake? Tactile hallucinations o Do you ever feel strange sensations on your body or your skin? Olfactory and gustatory hallucinations o Do you smell things that other people don’t notice, or experience strange tastes in your mouth?

125

E. Anxiety Disorders 

Panic Attack o Do you ever experience sudden feelings of fright, anxiety or discomfort? o Have these attacks ever come suddenly or out of the blue? o How many times has this happened? o How long do they last? o Have you been very worried about having more of these attacks? o Have you changed your routine since these attacks began? o Elicit associated symptoms: “STUDENTS FEAR the 3 C’s”:  S - Sweating  T – Trembling or shaking  U – Unsteadiness/dizziness  D – Derealization (feel that one is not real) or depersonalization (feel detached from one‟s body)  E – Excessive heart rate/palpitations  N – Nausea and abdominal distension  T – Tingling and numbness  S – Shortness of Breath  FEAR – FEAR of losing control, going crazy, or dying  The 3 C’s – Chest pain, Choking, Chills or hot flashes

 o

Agoraphobia Are you afraid of going out of house alone, being in crowds, standing in line, or traveling on buses or trains?

 o

Obsessive Compulsive Disorder Do you have recurrent and persistent thoughts or images that you find strange, intrusive or distressing, and that you can’t seem to be able to get rid of? (Obsessions) e.g., thoughts of hurting someone, thoughts of contamination Where are these thoughts coming from? Have you tried to get rid of these thoughts? What did you do?

o o

126

o

o o o

Did you ever have to do something over and over again to try to get rid of unwanted thoughts? (Compulsions) e.g., hand-washing, checking that the stove is off many times. How many times a day, or how much time per day would you spend? What would happen if you didn’t do this? Did you ever think that [the obsession/compulsion] was unreasonable?

 o

Social Phobia Is there anything you are afraid to do or feel uncomfortabledoing in front of other people because of fear of being embarrassed?

 o

Specific Phobia Ís there Anything you are extremely afraid of?

 o

Generalized anxiety disorder In the past 6 months, have you been particularly nervous or anxious? What sort of things do you worry about? Do you find it very difficult to stop worrying?

o o  o

Post Traumatic Stress Disorder Did something terrible ever happen to you that kept coming back in some way? For example, in dreams, flashbacks, or daydreams? F. Alcohol and other substance abuse 1. Has there ever been a period of your life where you drank too much? 2. How much did/do you drink? 3. CAGE Assessment:  C – Have you every felt the need to Cut down?  A – Have you ever been Annoyed by other people about your drinking?  G – Have you every felt Guilty about your drinking?  E – Have you ever had an Eye Opener (drink in the morning)? 4. Have you ever been Hooked on a prescribed medicine or taken more than prescribed? 5. Have you ever used illicit drugs? How much?

127

2. PSYCHIATRIC PAST MEDICAL HISTORY A. B. C. D. E. F. G.

Age of with psychiatry Hospitalizations due to psychiatric symptoms Diagnosis of any psychiatric disorders Outpatient s Suicide attempts Legal history: violence Substance use/abuse

3. MEDICATION and ALLERGIES 4. MEDICAL PAST MEDICAL HISTORY  Proceed with a normal past medical history including major illnesses, surgeries and hospitalizations 5. FAMILY HISTORY  Ask about any family history of psychiatric disorders. Ask the same questions from the Psychiatric PMH but for family  Proceed with a general family history 6. PAST PERSONAL HISTORY  Prenatal and perinatal including developmental milestones  Early childhood- temperament, separations  Middle Childhood- school, socialization, avoidance  Late childhood- early relationships, friends, psychosocial development  Adulthood (education, occupation, marital and relationships, religion, social activity, current social )

128

RESPIRATORY HISTORY

Aspects of the History o

Chief Complaints and Associated Symptoms

o

O to W

o

Non-Specific Symptoms of Infection or Malignancy

o

Risk Factors

1. CHIEF COMPLAINTS AND ASSOCIATED SYMPTOMS A. Cough B. Sputum a. Amount of sputum (tablespoon, cup, etc) b. Color c. Blood d. Odor e. Progression C. Dyspnea f. Orthopnea g. Paroxysmal Nocturnal Dyspnea h. Exertional D. Hemoptysis i. Clotting disorders j. Anti coagulants k. Pulmonary embolus from DVT 1. Oral contraceptive pill 2. Recent immobility (e.g.,surgery) 3. Cancer 4. Pregnancy E. Wheeze  History of asthma or COPD 2. O TO W o With each chief complaint above go through O to W before going on to associated symptoms.

129

3. NON-SPECIFIC SYMPTOMS OF INFECTION OR MALIGNANCY  Constitutional symptoms – fever, chills, fatigue  Night sweats 4. RISK FACTORS  Smoking history  Illicit drugs (e.g., marijuana)  Occupational exposure (e.g., asbestos may cause cancer)  Environmental exposure (smoke, allergens: pollen, pets, animals)  Travel and birth place (TB)  Family history of atopy  Previous chest x ray or Pulmonary Function Tests

130

PALLIATIVE HISTORY

Aspects of the History       

Clinical summary Current physical symptoms and functioning Psychological (cognitive dysfunction, depression, anxiety, coping strategies) Spiritual functioning (beliefs, practices, fears and hopes, care setting for death) (Social and Caregiver needs) Medications Goals of care

1. CLINICAL SUMMARY  HPI  PMHx  Tx  Response to Tx (Don‟t delve too much into the clinical summary even though that may feel more comfortable. The clinical history is largely used to summarize the known facts and to assess the patients understanding of these facts.) 2. CURRENT PHYSICAL SYMPTOMS AND FUNCTIONING  With each physical symptom go through O to W and compare to symptoms and functioning previously. 3. PSYCHOLOGICAL  Cognitive dysfunction (memory loss, etc.)  Depression (see psychiatric history)  Anxiety (see psychiatric history)  Coping strategies (how they are dealing with this) 4. SPIRITUAL  Beliefs (religious or otherwise)  Practices (regular attendance at a Church or any religious establishment)  Fears  Hopes  Care setting for death (wishes at end of life)

131

5.  Social  Financial  Needs of caregiver  Guilt associated with need for a caregiver 6. MEDICATIONS  All prescribed and over the counter medications  Herbal medications  Alternative medicines  Symptoms from medications (especially opioids) 7. GOALS OF CARE  Power of Attorney  Advanced care planning  Written Will

Because this is such a difficult session for most medical students, it is sometimes nice to have a set of questions to rely on when you are having difficulty getting the interview moving forward. Please keep in mind that much of this interview has to do with listening to the patient and giving them a chance to express themselves fully. You need to be able to bring up the difficult but important questions. Suggested Questions: 1. What is your understanding about how the cancer treatment is going and what you might expect? (Establish what the patient know about their diagnosis, prognosis, how much the would like to know) 2. What are the things that are important to you at this point in time? Are there any things that you would especially like to do that we can help you with? (Establish goals of maximizing survival, comfort, being at home, maintaining independence, minimizing burden to others etc.) 3. How can we help you to live well, is there something particular that makes you happy or that you would like to see happen? Is there something you would like to achieve?

132

4. What concerns you most about your illness? Do you have any particular fears or worries? 5. What are your hopes for your family? 6. Do you have any spiritual or religious beliefs that are important to you? Would you be interested in speaking to our hospital chaplain? 7. Sometimes people place a lot of importance on living the longest they possibly can, while others place a lot of importance on making sure they have a good quality of life and are comfortable even if for a shorter time. What is more important to you? 8. If you were unable to make decisions or speak for yourself, have you designated someone to represent your wishes. Have you discussed your wishes with that person?

133

NOTES:

134