What does my
UIM attending
expect on the
Mini-CEX?
Round 2
7/9/15
General Guides
 Mini-CEX
- observed history and physical
exam-board requirement of the ABIM
 Not a “sign off”
 Attending – will give you feedback; will
not undermine your relationship with the
patient
 Plan the Mini-CEX – no need to do this
twice. Chief Complaint as your guide.
General Guides
 Barbara
Bates remains a great reference
 Tailor H/P to Chief Complaint/pertinence
 Gowns – do not auscultate through
clothes!
 You need your H&P skills for outpatient
Medicine
Mini-CEX UIM 2013
Item
Date
1.
History of a new
complaint
1.
Medication history
1.
Chronic pain history
(psych)
Focused physical
exam
1.
1.
CV exam
1.
Lung exam
1.
Abdominal exam
1.
Musculoskeletal
exam
1.
Neurological exam
1.
Pelvic exam (GYN)
1.
Knee exam (Ortho)
1.
Shoulder exam
(Ortho)
1.
Hip exam (Ortho)
1.
Teach-back
1.
Shared decisionmaking
Supervisor
CV Exam
 Which



patients?
Any complaint with cardiovascular
elements
Hypertension, CHF, CAD
Especially good if you would like to verify
findings
CV Exam

Heart

Auscultation (follow V1-6) Diaphragm then bell








Right upper sternal border
Left upper sternal border
Left midsternal border
Left lower sternal border
Apex
Left Axilla
Palpation - PMI, thrills, heaves
Neck

JVD


45 degree angle – find the top of the column
Carotids

Auscultation



Ask patient to hold their breath
Palpation
Extremities


Edema
Peripheral pulses
CV Exam Tips
 Feel
the carotid pulse when listening to
the heart
 Gallops are heard best with the bell
 Recall the grading system of murmurs and
use this (1-6) and use “the language”
 Does the murmur radiate?
 Identify new murmurs, diastolic murmurs
CV Exam tips
 You
do not need to report cm of JVD – it’s
OK to use landmarks. “With the patient at
a 45 degree angle, JVD noted up to the
earlobe”
 Differentiate murmurs from bruits in the
carotids
Lung Exam

Auscultation






Start at Apex and listen for symmetry side to side
Listen anteriorly as well
Ask patient to open his/her mouth to breathe
Percussion – if needed only
Consider in all patients with complaints (chest
pain, SOB, etc.) or a history of lung/cardiac
disease
Especially good if you would like to verify
findings
Abdominal Exam



Good for any complaint of abdominal pain
Observation
Auscultate before palpation


Palpation – rebound if needed






One quadrant with bowel sounds is enough
All 4 quadrants; begin far from tender area
Liver and spleen – start at the pelvic brim
Ask patient to inhale; move your hands up after exhalation
No need to press hard!
Percussion – if needed
Special maneuvers if suspected ascites



Shifting dullness
Succussion splash
Hepatojugular reflux
Abdominal Exam
 Percussion

Liver edge – start at pelvic brim
 Used
to estimate liver size
 Midclavicular line 6-12 cm
 Midsternal line 4-8cm
Musculoskeletal Exam
 Symmetry
 Range
of motion
 Strength (can be under neuro)
 Joints



Synovitis – bogginess, heat, effusion,
erythema
Squeeze tenderness of MCP’s/MTP’s
Nodules
 Tender
areas (trigger points)
Musculoskeletal Exam
Musculoskeletal exam
 Patients
with pain in multiple areas
 Patients with joint pain or stiffness
 Patient with weakness
Neurological Exam
 Headaches
 Weakness
 Numbness/tingling
 History
of “stroke”
 Equipment needed: reflex hammer,
wooden cotton-tipped swab, low
frequency tuning fork (the big one)
Neuro Exam – basic elements



Alertness and orientation
Gait
Cranial nerves (2-12 is sufficient)


Muscle strength


Grip, biceps, triceps, hip flexors/extensors, leg flexors/extensors,
plantar flexion, dorsiflexion
Reflexes – must do with an actual hammer!


Pupils, EOM, visual acuity, eye squeeze, eyebrow raise, show
teeth, puff cheeks, bite, tongue protrusion, palatal lift, shoulder
shrug
Biceps, triceps, brachioradialis, patellar, Achilles, plantar
Sensation

Light touch, pinprick, temperature, vibration (cotton swab, low
frequency tuning fork – the big one)
Pearl
 Percussion
and reflex testing are
bouncing motions
 See demonstration and practice!
Pelvic Exam
 Library
 Clinical Resources  Procedures
Consult
Knee exam

Observation





Gait
Rising from chair
ROM
Structure of knee (bulging)
Palpation







Quadriceps strength
Joint line
Prepatella bursa
Anserine bursa
Popliteal fossa
ROM for crepitus
Instability (if needed): anterior, posterior, lateral, medial
Knee Palpation
Prepatellar bursa
Anserine bursa
Popliteal fossa
Joint line
Shoulder Exam

Observation


Symmetry front, side and behind
Active ROM





Abduction
Adduction
Forward flexion
Internal and external rotation
Palpation





Start with the neck and upper trapezius
Scapular spine
Acromion and subacromial space
Bicipital groove
Clavicle including SC and AC joints
Tests for Rotator cuff tear
 Painful
arc sign
 Drop arm test
 Weakness in external rotation
Hip Exam
 Gait
 Climb
onto the examining table
 Range of motion


Flexion/extension
Internal/external rotation
 Palpation
of trochanteric bursae
 Palpation of the SI joints
 Straight leg raise if radicular symptoms
Great Resource!!
 http://stanfordmedicine25.stanford.edu