A Step By Step Guide
To Mastering The OSCEs
Edited by
A. Alimari, MD
2006
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2
To
My parents, wife, and daughters
3
Copyright © 2005-2006 MedInfo Consulting.
All rights reserved. No part of this ebook may be copied, reproduced,
distributed, or transmitted in any form by any means graphic, electronic, or
mechanical without express permission in writing from MedInfo Consulting.
Your friends and colleagues are NOT an exception. Protect yourself.
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Content
Part One
The Medical Interview
Chapter 1
Introduction.
11
Chapter 2
OSCE Exam Formats.
15
Chapter 3
The OSCE Examiner’s Checklist.
17
Chapter 4
Physician-Patient Communication Skills.
19
Chapter 5
How To Prepare For The OSCEs.
21
Part Two
History Taking Interview
Chapter 6
The Model.
29
Chapter 7
The Minute(s) Before.
33
Chapter 8
Self-Introduction.
35
Chapter 9
Chief Complaint.
37
Chapter 10
History of Present Illness (HPI).
39
Chapter 11
Station Appropriate Questions.
41
Chapter 12
Standard Questions.
77
Chapter 13
Wrap Up.
81
Chapter 14
Counseling Stations.
83
Part Three
Physical Examination Interview
Chapter 15
Physical Examination Interview.
89
Chapter 16
Chest Examination.
91
Chapter 17
Cardiovascular Examination.
97
Chapter 18
Abdominal Examination.
103
Chapter 19
Gynaecological Examination.
111
Chapter 20
Hematological Examination.
113
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Content
Chapter 21
Head and Neck Examination.
115
Chapter 22
Neurological Examination.
119
Chapter 23
- Cranial Nerves Examination.
119
- Mini Mental Examination.
129
- Motor Examination.
131
- Sensory Examination.
139
- Coordination Examination.
144
Musculoskeletal Examination.
149
- Sub Model.
149
- Tempomandibular Joint exam
152
- Shoulder Exam.
152
- Elbow Exam.
154
- Wrist Exam.
155
- Hand Exam.
157
- Cervical Vertebrae exam
160
- Thoracic Vertebrae exam.
163
- Lower back Exam.
166
- Hip Exam.
169
- Knee Exam.
173
- Ankle Exam.
178
Chapter 24
Pediatric examination.
183
Chapter 25
Obstetric examination.
191
Part Four
Emergency Room
Chapter 26
Emergency Room Stations.
Suggested Readings
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199
121
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PART ONE
THE MEDICAL INTERVIEW
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Chapter 1: INTRODUCTION
Objective Structured Clinical Examination, OSCE, also called Objective
Standardized Clinical Examination is tough. OSCE exams are really difficult
and stressful. That is what is it. I’m not going to say it is not, as what clinical
educators and OSCE organizers claim trying to make it acceptable for you.
OSCE Exams consist of several clinical encounters (called stations) with
specially trained actors playing the role of a patient with some sort of a
medical complaint (called Standardized Patient, SP).
Let’s take a minute here to absorb your situation during the OSCE. This is an
important step as you may realize that the first step to deal with any issue is to
completely understand what is it.
You will find a lot of articles and web pages describing what are the OSCE
exam procedures. They present the OSCE in a scientific academic context. I
am sure you have already read several of these. Are you? Have you read
between the lines? Have you achieved an understanding about how your
physical and mental status will be during the OSCE exam?
Well, let me explain it for you. Just concentrate. Imagine yourself in a hallway
with several other candidates each standing in front of a closed door. Several
individuals are watching you for any violation of the exam rules. Then an
announcement/buzzer sounds. You have one or two minutes to read a full page
hanged on that door describing what the station ahead is about and what is
required to do.
Usually, you’ll need to read the instructions again because you’re nervous, you
heart is racing and your mind isn’t catching what your eyes are reading!
Then, a second announcement/buzzer sounds. You knock the door and enter
the room. In each room you will find two strangers and a different room
setting. In some OSCEs, like USMLE Step 2 CS, there is no examiner in the
room, just the SP. You have to hand out one or two of your stickers if present.
You may have even looked for the stickers and didn’t find them.
Then you have to start as your limited time has already started when the
second announcement/buzzer went on. You need to get information from the
SP or may be examine or consult him/her. Your voice is low. Your hands are
shaking. You look unconfident and don’t know what to say or do. These SPs
are well trained not to give you any information unless you specifically ask for
it. Unlike real life medical encounters where the patient will say everything
when you ask about the reason for their visit. Obviously, you have to know
what questions you need to ask to save time.
As you were asking, the patient replies by questions for you. Questions like
‘What do you mean?’, ‘Do I have to answer that?’, ‘Is this relevant to my
problem?’, ‘Why are you asking this?’ All these questions are intended to
shake you if that wasn’t a reflex to your poorly phrased questions. You start to
11
The Medical Interview: Introduction
lose control over yourself and the encounter. You start to make fatal mistakes like
being disrespectful to the patient and unprofessional. And you’ll forget to ask
questions that are important to fulfill the examiner checklist! That examiner who
is sitting or standing closely observing you or assessing you through the video
monitor.
Suddenly the announcement/buzzer goes on again. The station is over. Oh my
God. There are still tons of questions that I have to ask. I missed this station.
You’ll start the process of self-blaming.
Then you’ll try to hold yourself together. As you proceed, you’ll find that you had
already wasted substantial time of the ‘minute before’ of the next station.
The cycle starts again. By the fourth or fifth station, you’ll feel exhausted and
headache starts. You’ll feel unable to think about the coming station and you’ll
start to give up claiming that you’ll do you best, hopelessly.
Did you get what I wanted you to understand? Let me put it in summary:
You will be nervous, irritable and cannot think straight.
You will be physically and mentally exhausted.
Your time is running fast and by all means is not enough.
Some SPs will be challenging you intentionally and waist your time.
You need to be organized and manage your time efficiently.
You need to know in advance what to ask, as there is no time to think.
You need to be careful about how to phrase your questions and comments in
order to be respectful and empathic.
You need to ask your questions intelligently in order not to lead the patient
or trigger programmed time wasting and problem evoking conversations.
You need to be and appear confident and professional.
Is that easy? Of course not. Is it impossible to do? Of course not. Thousands of
medical students and graduates have done it. Okay, so it is not easy and also not
impossible at the same time. The key is you need to know how to do it and assign
the needed time and effort to prepare yourself to the OSCEs by practicing over
and over the same steps. You’ll be just fine. But how to prepare yourself?
This book, A Step By Step Guide To Mastering The OSCEs, will help you to:
Know how to prepare yourself for the OSCEs.
What and how to ask in each of these stations.
How to communicate in the OSCE exam.
How to perform a complete physical exam accurately and respectfully.
How to be respectful, attentive and caring.
How to appear organized, confident and professional.
Let’s start. I can help you pass the OSCEs with high score. You can do it. You just
need someone to show you specifically how and I can help. Let’s start.
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Chapter 2: OSCE EXAM FORMATS
Objective Structured Clinical Examinations (OSCEs) stations in USMLE Step
2 CS, USMLE Step 3, MCCQE II, PLAB part 2 and medical schools clinical
exams or international/foreign medical graduates clinical skills assessmnets are
differently designed to assess one or more of your clinical skills depending on
the purpose of that exam. However, the required medical knowledge, clinical
skills, and communication skills are the same among these OSCEs. It is
important to fully understand what is exactly required to be performed in each
station and to what medical extent. You will be assessed for only those skills
asked for in that station. Tasks other than those requested or more than expected
at this stage of your medical knowledge, regardless of whether you performed
them correctly or not, wont be counted and most critically will waste your
valuable limited time.
The length of the OSCE station is generally 5-20 minutes. You will perform a
medical encounter with a standardized patient (SP) just like a real medical
encounter. An examiner (a physician) may be present during these encounters to
assess your clinical skills and communication skills based on a standard
checklist. Otherwise, the encounter is video monitored. A nurse may also be
present in emergency management stations to receive management orders from
you and inform you about the progress.
There are mainly four OSCE formats:

Focused History Taking OSCEs

Focused Physical Examination OSCEs

Consult OSCEs

Emergency Room OSCEs
Combination of the above formats is common in long OSCEs, like a focused
history taking and a focused physical examination, or a focused history taking
and a consult.
Focused History Taking OSCEs
Focused history taking OSCEs are data gathering stations. Here you will show
your medical knowledge concerning the current specific patient case. This is
what is meant by focused. This will include; exploring the chief complaint,
history of present illness, past medical and surgical history, medications and
allergies, family history and social history, occupational history, and sexual
history relevant to this case scenario.
Although OSCEs are a simulation of simple straightforward common real life
presentation, please note that 'focused' does not mean skipping the differential
diagnosis. However, the SP role might not be simple. Some history taking
OSCEs will have some difficult to deal with patients or ethical issues to be
assessed too, like a depressed patient who is unwilling to talk, or a failed to
thrive child with a hidden child abuse issue, ..etc.
In addition to assessing your medical knowledge, your communication skills
13
The Medical Interview: OSCE Exam Formats
and approach to gather data are also assessed. This is an important part of the
station’s final mark.
Focused Physical Examination OSCEs
In focused physical examination OSCEs, you have to examine the requested body
part or system. No head to toe examination. But, if the complete examination of a
system requires examining some other body parts, then it is included. For
example, a complete cardiovascular examination will include examination of the
legs for peripheral pulses and edema as well as opthalmoscopy for cardiac related
retinal changes among others.
Please, explain every thing you are going to do to the patient taking necessary
permission before you proceed. Pay attention to patient’s privacy and draping.
Don't harm or repeat harmful maneuvers. If an examiner is present, stand in a way
to let him/her watch you and also explain what are you doing giving the findings.
Consult OSCEs
Consult OSCEs are talk stations. You will be asked to explain a diagnosis, a
prognosis, a lab or medical imaging test result, a drug interaction or side effect, a
procedure, an alternative, or any patient’s concern. Ethical stations are mostly
consult stations like breaking bad news, obtaining consents,.. etc. There will be
some history taking too and some times it will be a combined focused history
taking and a consult station.
Consult OSCEs require good communication skills as well as good English
language skills. These skills usually weigh up to 60-70% of that station final
mark. It is obvious how important to develop your language and communication
skills. Being attentive and respectful is a must. Your ability to transfer relevant
information to the patient in an understandable simple way will be assessed. That
is being a good health educator and health promoter.
Emergency Room OSCEs
There are three types of emergency room OSCEs scenarios.
The ER management scenario;
The post management ER consult, and;
The ER stable patient as walk-in scenario.
In ER management OSCEs, you will be asked to manage the case. A nurse will be
present to take your orders and pass back results and patient’s progress.
In the post management ER consults, you will be asked to consult the patient for
discharge, dealing with ethical issues like breaking bad news, organ donation, or
abuse.
In the ER stable patient as walk-in scenario, you will be asked to perform any task
just like any office setting like history taking, physical examination, or consult.
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The Medical Interview: OSCE Exam Formats
So, read the instructions carefully before entering the room to sub-classify the ER
station to one of the above types as your task will be different. ER OSCEs require
a lot of training and practice to perform all the requested tasks accurately and
efficiently. It is very important to show confidence and control of the situation.
Post Encounter Probe (PEP)
Some OSCEs end with a one or two-minute oral questions period usually called
"Post Encounter Probe (PEP)" (Not in USMLE). During this time, you are not
allowed to talk to the SP but only with the examiner. The examiner will ask you
2-4 standard questions that are usually concerning:

What is your one working diagnosis for this patient?

What is your three most relevant differential diagnosis?

What are the risk factors of this patient?

What is your only / three investigation you are going to order for this
patient and why?

What is your initial / short term plan of management?

What is your long term plan of management?

Interpret this lab findings / imaging...etc.

Prognosis? If this patient came back in .. days / weeks with .. what will
be your explanation
In a matter of fact, you should organize your study material for any medical topic
in your preparation to both written and clinical exams to cover the above listed
aspects.
Some OSCEs alternate with a period of written questions PEP covering the same
upper listed questions.
Patient Note (Write ups):
In USMLE Step 2 CS, the patient note 10 minute post encounter period will be
the ordinarily patient medical chart/record note in addition the above issues.
Patient Write ups:
These are writing admission, discharge, progress, follow up, pre-op, post-op notes
in the patient’s chart. Referral and thank you letters are sometimes requested too.
These are pretty simple. There are several ready to fill out forms and instructions
over the internet. Pick few of them, memorize them and practice filling up them.
There are few other modified formats that fall into one of the above listed types,
such us:
Consult over the phone with a patient, a caregiver, or another physician.
In this scenario, you will find inside the OSCE exam room a phone and some one
is talking on the other side of the phone line. Commonly it will be a mother
having an acute problem with her child. Another common scenario is a physician
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The Medical Interview: OSCE Exam Formats
from a rural hospital wants to arrange for the transfer of his acute case patient to
your hospital. Here, just go through the same set of questions that you ask a
patient attended to your office. Make sure to take the caller name, position and
relation to the patient. No transfer of unstable patients. Be aware of privacy issues
and releasing patient information over the phone.
Interpretation of diagnostic materials such as labs, microscopic, ECGs, X-rays,
CT.. etc.
Presenting the case to the examiner. That may include a differential diagnosis,
and/or a plan for immediate and/or long term managements as an evaluation of
your clinical reasoning.
Performing practical skills by using manikins. Such as venepuncture, inserting a
cannula into a peripheral vein, suturing a wound, vaginal bimanual exam, rectal
digital exam, PAP smear, breast exam, testes exam, prostate exam,
ophthalmoscope, diagnostic procedures, basic cardio-pulmonary resuscitation
(adults and children), performing urinary catheterization, mixing and injecting
drugs into an intravenous bag, giving intramuscular and subcutaneous injections,
safe disposal of sharps .. etc.
Some of these may also be included in or at the end of the above formats.
As you know, all medical students and graduates will take several OSCEs during
their medical life starting from the medical school OSCEs then any of USMLE
Step 2 CS, USMLE Step 3, MCCQE 2, or PLAB 2 OSCEs. So, develop your
clinical skills and use them repeatedly during the OSCEs and, for your benefit,
also later in your practice.
As in each station within the same exam day you'll encounter a different
standardized patient and examiner with each station. So, you may repeat the same
skills and even the same words, phrases, and descriptions. Assessment of each
station is done separately by different evaluators.
16
Chapter 3: OSCE EXAMINER’S CHECKLIST
Objective Structured Clinical Exams (OSCEs) cases cover common and
important situations that a physician is likely to encounter in common medical
practice in clinics, doctors’ offices, emergency departments, and hospital settings
in real practice. Thus, you’ll be evaluated as if it is a real life practice.
OSCE exams use standardized patients (SP), i.e., people trained to portray real
patients. These SPs follow a certain script to play with you during the encounter.
These scripts are written in details including patient general look, cloths, gestures,
emotions, and all negative and positive answer. It also includes any unexpected
behaviours such as the SP turns agitated, upset, violent, restless, impolite, or
leaves the room during the encounter.
As SPs follow strictly these scripts, OSCEs examiners also have a standard
printed checklist or blueprint for each station that they have to fill out while
observing you. These checklists are standardized to reduce examiners' bias. On
these checklists, there are station specific points and a general performance points
to be assessed. There are up to 40 points to be check in each station. Some OSCEs
may also include a checklist to be filled out by the standardized patient.
SPs will reveal information when specific related questions are asked. They wont
voluntarily give you information as some times happen in real life patient
encounters. For example, if you don't ask about all their medication now and in
the past, they wont show you a printed list of their medication. In some OSCEs,
SPs are instructed to follow different paths or ask specific questions according to
your performance. For example, turning uncooperative if you are not responding
to their concerns or gestures.
What is the OSCE Examiners' Checklist?
Checklists are organized to assess the followings:

Medical knowledge specific to this station, such us, symptoms, signs,
associated factors, risk factors, prevalence, complications, prognosis,
management plans, .. etc.

Data gathering skills: Your way of patient information collection by
history taking and physical examination.

Documentation – completion of a patient note summarizing the findings of
the patient encounter, diagnostic impression, and initial patient work-up.

Communication and Interpersonal Skills:

Initiation of interview: acknowledgement of patient, introduces self,
at ease, attentive to patient.

Questioning skills: e.g., use of open-ended questions, transitional
statements, confident and skilful questioning, appropriate language,
use of different question types, or awkward, exclusive use of closed
17
The Medical Interview: OSCE Examiner’s Checklist
ended or leading questions, jargon, interrupts patient inappropriately.
Information-sharing skills e.g., None given, avoidance of jargon,
responsiveness to patient questions or concerns, provision of counseling
when appropriate, confident and skilful at giving information, attentive to
patient understanding; truthful.
Professional manner and rapport e.g., Condescending, offensive,
aggressive, judgmental, negative attitude to patient, or polite and
interested, warm, polite, empathic, concern for patient's comfort and
modesty, examinee's attention to personal hygiene, expression of interest
in the impact of the illness.
Listening skills: Interrupts patient inappropriately, impatient, or attentive
to patient’s answers and concerns.
Organization of interview: Scattered, shot-gun approach, logical flow,
purposeful, or integrated handling of encounter
Closing: Abrupt, or acknowledges end of interview, or attempts closure, or
clear closure, or organized, thoughtful closure.
Ethical conduct: Markedly inappropriate or awkward handling of ethical
issues, or considers and responds to ethical issues with care and effectiveness.
Compliance optimization: Did the candidate do everything possible to
optimize the patient’s compliance?
Physical examination: No consent, awkward, uses jargon, no interaction or
acknowledgment of patient, or clear, concise instructions, elicits consent to
physical examination, at ease with patient.
Attention given to patient's physical comfort: Inattentive to patient's
comfort or dignity; e.g., no draping and/or causes pain unnecessarily, or
consistently attentive to patient’s comfort and dignity.
Organization of physical examination: Scattered, patient moved
unnecessarily, logical flow, purposeful, integrated handling of examination.
Spoken English Proficiency: Clarity of spoken English communication
within the context of the doctor-patient encounter (e.g., pronunciation, word
choice, and minimizing the need to repeat questions or statements).
In every sentence you say during the medical encounter, you should have taken
care of all the above elements. Difficult?… Yes, but not impossible. In this book
you will find sentences that were carefully chosen to meet all of the above
requirements.
This will definitely save you a lot of effort and time.
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Chapter 4:
PHYSICIAN-PATIENT
COMMUNICATION SKILS
OSCE exam is an assessment of clinical knowledge, skills, and attitude. The
communication skills you demonstrate and the process you go through in
obtaining a history or performing a physical examination are more important
than determining the diagnosis.
Communication skills are verbal and non-verbal words, phrases, voice tones,
facial expressions, gestures, and body language that you use in the interaction
between you and another person.
Verbal communication is the ability to explain and present your ideas in clear
English, to diverse audiences. This includes the ability to tailor your delivery to
a given audience, using appropriate styles and approaches, and an understanding
of the importance of non-verbal cues in oral communication. Oral
communication requires the background skills of presenting, audience
awareness, critical listening and body language.
Non-verbal communication is the ability to enhance the expression of ideas
and concepts without the use of coherent labels, through the use of body
language, gestures, facial expressions and tone of voice, and also the use of
pictures, icons, and symbols. Non-verbal communication requires background
skills such as audience awareness, personal presentation and body language.
Effective communication is an essential part of building and maintaining good
physician-patient and physician-colleague relationships. These skills help
people to understand and learn from each other, develop alternate perspectives,
and meet each other’s needs.
Hidden agendas, emotions, stress, prejudices, and defensiveness are just a few
common barriers that need to be overcome in order to achieve the real goal of
communication, namely mutual understanding. High Performers master and
continually practice the basics, as well as prepare for these communication
pitfalls. Just as successful physicians routinely practice basic medical skills,
High-Performers understand that they too must pay attention to communication
skills or they risk getting out of shape pretty quickly.
Communication skills in a medical setting may include the way you use for:

Explaining diagnosis, investigation and treatment.

Involving the patient in the decision-making.

Communicating with relatives.

Communicating with health care professionals.

Breaking bad news.

Seeking informed consent/clarification for an invasive procedure or
obtaining consent for a post-mortem.

Dealing with anxious patients or relatives.

Giving instructions on discharge.

Giving advice on lifestyle, health promotion or risk factors.
19
The Medical Interview: Physician-Patient Communication Skills
Your approach to the patient will be assessed all through the encounter, but in
some stations communication will be the main skill for which you will be
awarded marks.
In OSCEs, as well as in life, two aspects of the communication skills are
important. The way you choose for your approach to reach the other person, and
the effects and outcome of your efforts. The OSCEs examiners will be
considering your:
Approach to the patient
You should:
Introduce and orientate the patient and yourself.
Establish an attentive, respectful and non-judgmental relationship.
Acknowledge the patient's emotions and concerns.
Listening, questioning and diagnosing
You should:
Ensure you have understood the patient's symptoms/problem and concerns.
Summarize and clarify understanding.
Explaining and advising
You should:
Enable the patient to understand the problem/situation.
Reassure appropriately.
Summarize and clarify understanding.
Involving patient in management
You should:
Explore the patient's expectations/concerns.
Propose/ explain management plan clearly.
Explore the patient's response.
Respect the patient's autonomy, and help him or her to make a decision based
on available information and advice.
Summarize and clarify understanding.
Communication skills are learnable, trainable, adaptable just like any other skill!.
Yes, it is not easy to change yourself. But it wasn't easy to be in your current
academic achievement either. You can teach yourself these skills, learn them,
adopt them, and make them part of the new you! The new medical student or
graduate, or even a new start towards being a successful physician!.
In this book, you won’t find information for nonverbal communication. Verbal
communications are addressed through out you statements in this book. For more
information check the ebook: “How To Maximize My Communication Skills
For The Medical Encounter”.
20
Chapter 5:
HOW TO PREPARE FOR
THE OSCES
There are three aspects that you should take care of simultaneously in your
preparation for the OSCEs:

Medical knowledge and clinical skills.

Communication skills.

An approach for the medical encounter.
Medical knowledge and clinical skills:
You need to refresh your basic medical knowledge relevant to the OSCEs. This
means you should re-study medicine based on common patients’ complaints and
physical finding and not based on topics. No patient will come complaining of
endometriosis or asking for TB treatment! Patients come to you complaining of
symptoms like shortness of breath or a long standing cyclic pelvic pain.
For each complaint, find answers to following questions and memorize them:
1. What are the five most common relevant differential diagnoses?
2. How to differentiate between these five diseases? What key
elements in history, physical examination, and investigations will
help?
3. What are the risk factors of each of these diseases?
4. What is your only / three investigations you are going to order
for this patient and why (To differentiate between the diseases)?
5. What is your initial / short term plan of management for each of
these diseases?
6. What is your long term plan of management for each disease?
7. Interpret the lab findings / imaging...etc. concerning each disease.
8. Prognosis of each disease? What to inform the patient about
what to expect in the near and far future?
9. Complications of each disease? How to prevent them? If this
patient comes back in ... days / weeks complaining of ...., what
will be your explanation?
10. What are the key issues that you have to ask or counsel the
patient about?
Write down the above questions and answer it for each symptom. Memorize it. In
a matter of fact, this should be your approach to prepare for the written exams too
as it is extremely helpful. Written exams are getting more and more clinically
oriented. This is the best quick and focused approach to an efficient practice.
There are several valuable books and resources that deal with common
symptoms and signs and differential diagnosis. Check your local medical library
or ask your colleagues and instructors.
Clinical skills include history taking, physical examination, counseling, and
clinical reasoning. This includes the way you perform these skills too.
21
The Medical Interview: How To Prepare For The OSCEs
Communication skills:
Your second aspect of preparation for the OSCEs is the most important, your
communication skills
In OSCEs, verbal and non-verbal communication skills are very important both
directly and indirectly. Directly, by showing respect, professionalism,
attentiveness, care, interest, and efficiency in acquiring medical data gathering.
Indirectly, by leaving a good impression on the OSCE examiner and the
standardized patient minds through your look, voice tone, and facial expressions.
These two persons will score your performance according to a checklist. OSCE
organizers try their best to minimize personal bias from these two. However, what
if your performance lies between two categories? Your performance was less than
good but better than intermediate, for instance, which one to be checked for you?
Here, their impression about you will act for or against you. They will think;
either, he/she is better than this but the exam stress made him/her perform less
than usual! Or, that is what actually looks like his/her real everyday performance!
Do you get it? This will push you one level up or down! I don’t know how to
stress the importance of communication skills in OSCEs and in real life practice
too.
In fact, it is what makes you a good or bad physician in the eyes of your patients
in the future. Tell me, how many doctors do you know who are scientifically
average but are very famous and rich! … On the other hand, how many doctors do
you know who are scientifically excellent but are unknown and their practices are
barely making a living!
Work on improving your communication skills. It is not what you are and that’s it.
Bad communications can be developed, improved, or even eliminated if it is
harming you, right?! Yes, sometimes, it is not easy but it is not impossible. Start
now. Rebuild the way you look, speak, and behave. Yes, rebuild what you’ve
grown up with for a better you for your benefit.
Your behavior with people may be sending the wrong message about who are
you, or let’s say an inappropriate message for the current context!
What about cultural diversity? Some behaviors that are acceptable in your culture
may be unacceptable in other cultures or even professionally.
So, how to evaluate your communication skills? First, know how are you doing.
Assess your current communication skills. Assess your posture, look, hand and
head movements, and facial expressions. Assess your voice and tone. Do that by:
Watching yourself in a mirror while practicing or videotape your practice and
play it back several times focusing on one aspect at a time. Be honest with
yourself. Criticize your behavior as if you are assessing someone else. Write
done positive and negative behaviors. This might be difficult as your Ego will
stand up to defend yourself!. We believe we are perfect or at least suitable. Be
honest for the benefit of yourself. The only drawback here is you may not
know which is an appropriate behavior or gesture and which is not.
22
The Medical Interview: Notes

The second step is to ask a close friend or relative to watch you and assess.
Choose someone who cares for you. Explain to him/her what aspects you
want them to watch closely. Make it mutual. If they are preparing for the
OSCE too. Assess each other and be open minded constructive and honest.

Finally, read books or attend course about communication skills and ethics
in a medical context. Have a look on “How To Maximize My
Communication Skills For The Medical Encounter”.
An approach for the medical interview:
The third aspect of your OSCE preparation is to develop and practice a specific
approach to the medical interview.
In OSCEs, as well as in real life medical practice, you have limited time and
resources. It is only 5-20 minutes long interview. And you have to ask so many
questions, figure out what is wrong with this patient, while being gentle,
courteous, friendly, attentive, and caring!
You have to develop a step-by-step practical template that helps make the
utmost of your limited available time and resources efficiently. You have no
choice. You have no time to figure it out during the interview. No way! You
will be nervous, irritable and thoughtless! And the patient, playing his role
comfortably, enjoys watching you making lethal mistakes! Do not get me
wrong. They are not bad guys. Their role is to stress you out to assess your
performance. Sounds like you in an OSCE, right.
You need a template that you will follow with every patient with the same
group of illness every time automatically even if you are mentally exhausted or
irritable.
You need something to keep you organized and provide you with a road map to
follow safely towards your goal of solving the station. You have to be prepared.
There is no time to think in the OSCEs.
You need a step by step system that makes you perform fast and yet makes you
look calm, attentive, listening, and in control.
A guide that makes you focused on the patient current situation and yet
thorough exploring hidden issues like abuse or denial.
You will follow the same steps with every patient. You’ll even repeat the same
questions and sentences. Even the same reactions and empathy! In each OSCE
room, there is a new patient (and a new examiner, if applicable). They didn’t
watch your performance in neither the previous stations nor they will in the
following ones. Just repeat! Simple!
This book is about this third aspect. You don’t need to develop a template. My
colleagues and I did it for you. You just have to memorize the steps and
sentences as it is, practice it, then practice it again, and finally practice it until
you perform the steps and say the sentences in an autopilot mode!
23
The Medical Interview: Notes
Medical knowledge and differential diagnosis has been covered in these steps.
Verbal communications and ethical issues are also covered. You don’t need to
add anything else concerning the medical interview.
However, this book does not cover the post encounter questions, write ups, or non
verbal communication skills. Visit www.oscehome.com for other resources
concerning these issues.
24
25
26
PART TWO
THE HISTORY TAKING
INTERVIEW
27
28
Chapter 6:
THE HISTORY TAKING
INTERVIEW
The MODEL
To be organized, thorough, and not to forget important points, in the 5-20 minutes
medical interview, you will follow the following steps IN SEQUENCE:
123456-
The Minute(s) Before the interview.
The Introduction box.
The Initial History Taking box.
Station appropriate questions box.
Standard questions box.
Wrapping up box.
Use every possible opportunity while going through these boxes to develop a
relationship with the patient.
You should go through each of these steps in sequence while budgeting your time.
I’ll explain each step in detail latter. But here are some tips.
Read all of part two once without memorizing it in order to have an idea about
how this model is organized.
Then read it chapter by chapter. Stop at the end of each chapter. Memorize it.
Practice, practice, and practice that chapter until you feel happy with your
performance.
Now, move to the next chapter. And repeat the same.
As you read through the chapters, you may feel that it is impossible to finish all
the steps in 5-20 minutes. There are so many questions to ask. The answer is in
fact, no, it is not impossible and you can do it! … How?
First, when you memorize the questions and practice them over and over, it won’t
take long to ask. Remember, you are on autopilot.
Secondly, you are going to ask only the screening question. Only if the patient’s
reply was positive, you will explore further asking ALL the detailed questions.
Third, the patient’s answer will be negative for all screening questions but one or
two to be explored. The shorter the station the less positive answers will be. That
is how the OSCE is organized.
But don’t skip questions or steps. There are check marks that you don’t want to
miss!
29
The History Taking Interview: The Model
How long does it take to ask a one sentence carefully phrased question with a ‘no’
answer? … Less than five seconds! That’s 10-12 questions per a minute in an
autopilot mode! Try it.
But be careful, be relaxed friendly, attentive, interactive, and engage the patient.
Don’t interrupt the patient or rush him/her. Don’t overwhelm the patient with
rapid sequence firing questions.
When you eliminate the burden of what to ask now and next. When you don’t
have to think about ‘how’ to ask about something in a medically and ethically
correct manner. When you are in control of the interview. Then, you’ll have time
to think about solving the station. You’ll have time for communication skills and
empathy. You’ll feel confident and will reflect that on your performance.
Although you don’t have to, but studying your medical knowledge along with
each system you practice here will show you the logic of these questions and how
are they covering the main possible differential diagnosis. This may make them
easier to memorize and remember. You don’t need to do that at the beginning.
For example, study history taking, physical examination, differential diagnosis,
risk factors, investigations, and management plans of chest symptoms and signs
all together. This will cover respiratory, cardiac, upper gastrointestinal, and
musculoskeletal systems at least. Master them then move on to another body part
or system, and so on. Keep yourself focused on symptom-oriented approach. Find
answers to required questions covering each topic.
When you practice, don’t explain to yourself or memorize what you will do in the
OSCE. This is a recipe for failure. Never do that. Practice by real acting. Imagine
yourself in that OSCE exam room talking to the patient. Act as a professional
actor. Act in every detail. Train yourself into an autopilot mode.
One more thing before you begin. As you reach your last few practice trials for
each section, make yourself unconsciously oriented to time. There is no clock in
the exam room and it is completely wrong to look on your watch during the
medical encounter. This will sent a non verbal message of being not interested.
Make a habit of how long it takes to do things in your life other than medicine.
For example, it takes you three minutes to shave, or five minutes to wear make up,
or five minutes to fry an egg, and so on. Live these minutes and make road marks
for yourself. For example, by the time you finish shaving the right side of your
face, only two minutes left.
Did you get what I mean? You do things in your life every day in a step by step
manner! And you do them repeatedly with the same amount of time! Make your
OSCE performance the same, a step by step manner for the same amount of time.
Practice, Practice, Practice.
30
The Medical Interview Model©
Minute(s) Before the interview
Introduction Box
Initial History Taking Box
Station Appropriate Questions Boxes (one or two of:)
Respirology
Cardiovascular
Gastrointestinal
Endocrinology
Genitourinary
Neurology
Musculoskeletal
Dermatology
Obstetric/Gynae
Pediatric
Psychiatry
Standard Questions Box
A Step By Step To Mastering The OSCEs
MedInfo Consulting © 2006
Wrapping up Box
31
32
Chapter 7:
THE MINUTE(S) BEFORE
THE INTERVIEW
Ten steps to perform in these one or two minutes before the medical encounter:
1- Have a new blank sheet on your clipboard/ booklet.
2- Put your sticker(s) on your left hand index finger (or on your answer
sheet).
3- Write down: Patient’s name (if a child; also; accompanying person’s name
and his/her relation).
4- Write down: Patient age.
5- What is the setting?: Use abbreviation, such us
- Your office? write OFF;
- Walk-in clinic? write WC;
- Covering a colleague? write CC;
- Emergency Room? write ER.
6- Identify the station type: Use abbreviation, such us
- History Taking?  write Hx;
- Physical Examination?  write PE;
- Consult?  write CON;
- Combination?  write Hx & PE, Hx & CON
- Emergency?  write ER. Then which ER type:
- Management?  write MANAGE.
- Post acute phase/ after management by
others and stable now?  write Consult.
- Any of the above: Hx, PE, Hx and PE.
7- Identify the Chief Complaint (CC) / Consult subject and duration if given
write it down.
8- Write down any given findings (Circumstances, vitals or labs).
9- Identify the CC body system(s)? write it down.
10- Remember the station(s) appropriate questions box and differential
diagnosis (DDx).
On the whistle/ buzzer/ bell: Knock the door and go in smiling,
calm with shoulders up. (Show confidence and friendliness)
33
The History Taking Interview: The Minute(s) Before
TIPS:
34
-
Practice this step.
-
Memorize the ten steps in sequence.
-
Get blank papers and a clipboard or a pocket booklet just like the one you use
in the exam. Check your exam official site to know what kind of papers will
be given in the exam.
-
Find a door at your home leading to a small room. Any door.
-
Wear a lab coat and decide where are you going to put your pencil, stickers,
stethoscope, pen light, hammer, measuring tape, the notebook and any other
instruments asked to bring with you. Select places according to your
connivance and rapid access.
-
Practice to take out these tools use them and put them back at the SAME
place you decided to do. This is very important. As in exams, you will be
nervous and you will forget where are these tools and will start looking for
them nervously wasting valuable time and showing the examiner and the
patient that you are not organized and don’t know what to do next!
-
Take the blank papers and decide how are you going to organize it. Where to
write the eight required information like the name, age, station type, etc. It is
important to stick to the same format for quick access.
-
It is very important to write every thing as you will be amazed how quickly
you will forget them during the encounter due to the exam’s fast pace and
nervousness.
-
Place a peace of paper on the door with a stem question written on it. Get
stem questions at OSCEs Home at http://www.oscehome.com.
-
Practice the ten steps over and over and over until you feel you are doing
them naturally and confidently.
-
Don’t worry about how long it takes to do it at the beginning. Just master the
steps first. Then, with time try to be faster and faster to finish it with ONE
minute.
-
After you master it. Do it in front of family members or study group. Ask
them to criticize you honestly and freely. Ask them about your nonverbal
communication, gestures, standing position, head position and look Accept
critics openly and adopt changes. Check OSCEs Home communication skill
page at http://www.oscehome.com/Communication-Skills.html.
-
Practice and practice and practice. Never underestimate the importance of
acting and living the steps. Don’t tell yourself that you will do so and so, DO
IT. Just do it. You can do it !
Chapter 8:
THE SELF-INTRODUCTION
Ten steps to perform in this stage of the medical encounter in 15 seconds:
1-
Give the examiner your sticker, smile and move on (if applicable).
2-
Approach the patient while smiling and relaxed.
3-
Identify the patient: “Mr/Ms…..?” in a questionable tone.
4-
Establish a sense of privacy: Draw a curtain / close the door / suggest that a
visitor wait outside (Accept the patient decision).
5-
Introduce yourself confidently, softly, friendly, comfortably:
“Hi, I am Dr …….… (last name)”. Shake hands, if you want (Preferred).
6-
Mention your position: one of:
- in your office: nothing more.
- in a colleague clinic: “I am covering for Dr….today”.
- in a walk in clinic / ER: “I am the physician on duty here today”.
7-
Ask the patient about how he/she would like to be addressed:
“Mr/Ms….., how would you like me to address you?”
8-
Quickly screen the room: Where is the patient, your chair, stretcher, and
TOOLS. Tools in the room are more likely meant to be used.
9-
Ask the patient to sit down (pointing where) if he/she is not already sitting or
lying on a stretcher. “Be seated/ lie down (if needed) here please.”
10- Then sit down. Don’t move the chair closer to or away from the patient.
Ideally about a meter far and in a narrow angle.
Through out the medical encounter:
-
-
Maintain an attentive position: leaning forward 10 % with
straight head, back and shoulders up.
Maintain eye contact almost throughout the interview. Look
at the patient’s forehead at the mid line just above the nose.
The patient will think you are looking on his/her eyes, which is
a sign of interest in him/her. Looking at the patient’s eyes will
disturb your thinking. Avoid that.
Minimize distractions, including writing down notes.
Give the patient the time to answer in his/her own words, then
facilitate and clarify.
Note: Hereafter in this book, sentences addressed to the patient will be in blue
color and starts with “Mr/Ms…,” and placed between quotes. However, you don’t
have to say Mr/Ms. Choose what the patient decided to be addressed with for at
least three times during the interview. Not with every question.
35
The History Taking Interview: The Self-Introduction
Sentences to be memorized in sequence:
1. “Mr/Ms…..?” in a questionable tone.
2. “Hi, I am Dr …….… (last name)”.
3. Nothing or “I am covering for Dr….today” or “I am the physician on duty
here today”.
4. “Mr/Ms….., how would you like me to address you?”
5. Nothing or “Be seated please.”
TIPS:
36
-
Practice this step.
-
Memorize the ten steps in sequence.
-
Imagine the patient is setting on your right (and the examiner on the left) and
practice. Now change positions and practice. Imagine the patient is lying
down on a stretcher on your right, then left, then in front.
-
Practice the ten steps over and over and over until you feel you are doing
them naturally and confidently.
-
Don’t worry about how long it takes to do it at the beginning. Just master the
steps first. Then, with time try to be faster and faster to finish it with 15
SECONDS or less.
-
After you master it. Do it in front of family members or study group. Ask
them to criticize you honestly and freely. Ask them about your nonverbal
communication, voice tone, gestures, eyes and eyebrows movements, lips
movements, standing position, head position and look
-
Accept critics openly and adopt changes. Check OSCEs Home
communication skill page at http://www.oscehome.com/CommunicationSkills.html.
-
Practice and practice and practice. Never underestimate the importance of
acting and living the steps. Don’t tell yourself that you will do so and so, DO
IT. Just do it.
-
You can do it !
Chapter 9:
THE CHIEF COMPLAINT
10 steps to be done in ONE minute:
1- “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?”
2- Clarifying the Chief Complaint (CC): “I understand, you have been having
some…. (CC from the stem question) ”(best sentence) or “How can I help you?” or
“What brings you here today?”.
3- Write down the CC in patient’s words.
4- Make sure what is the real CC: “So, you have …(CC), …. Let’s talk about it,
but first, is there anything else bothering you? Are you having any other
problems physically? Or, are there any special stresses in your life right
now?.”
If yes  “Which one do you want us to discuss first/today?”
5- Invite him/her to tell their story “Tell me all about the …(CC) right from the
beginning ”.
6- Maintain eye contact, don’t interrupt, facilitate and encourage with sounds (Ah
ha, yes, go on, I see), head nodding, and empathy facial gestures.
7- When he/she stops, explore the CC if he/she uses vague terms like tired, dizzy,
diarrhea .etc,  “What do you mean by…....?” Offer menu list of 2-3
descriptions.
8- Duration: “When would you say it started?”  make sure “So it started .…
ago?”.
9- If CC presents for some time: “What made
you decide to get it checked now?”
10- Empathy: Watch your voice tone and facial
expressions
Reasons to come now are:
1. Symptoms worsen.
2. Anxiety developed, even if
symptoms lessen.
3. An excuse for a hidden CC.
“That must be very difficult for you to cope with?”
“I can see you have been under a lot of stress”
“How are you feeling about that?”
Patient’s non-verbal
“How has this been affecting you?”
cues of distress:
- Avoiding eye contact.
“I can see you are/ It sounds like you’re feeling /
- Fidgeting.
You seem (anxious/ worried/ angry/ upset/
- Shifting around in the
frightened) …….. Is that right?”
chair.
“This is completely understandable. Most people
- Holding their body
tensely.
in similar circumstances would react just as you
However,
don’t assume
are.”
that, check it out with
“I am sorry to hear that.”
them. (? Cultural).
“It must be hard for you, what are you unable to
do as a result of the …(CC)”
“It would be surprising if you didn’t feel (angry / upset / worried /
frightened) after hearing that / waiting all that time.”
“This can’t be an easy time for you, we’ll work together to get through this.”
Silent or Talkative
patient?
How to save time
and direct the
patient?
Find out how at
the book:
“How To Unlock
Difficult Patient
Encounters”
www.oscehome.
com/DifficultOSCEsSenarios.html
37
The History Taking Interview: The Chief Complaint
If the patient asked:
“Is it serious?”
“Am I going to die?”
“Do I have..(cancer, heart attack)?”
“Do you think that … (my medications/ work/ doctor/ partner….etc) is causing the ..(CC)”
 Reply: “Mr/Ms…, I can see you are anxious and I am glad you came here
today. We need to look on certain things and run some investigation to be sure.
Relax for now, together, we’re going to figure it out”
No false information or hope but also no worrisome comments.
Keep it neutral and open to both good and bad outcomes!
Sentences to be memorized in sequence:
1. “Mr./Ms… I’ll be writing down some notes while we talk,.. okay?”
2. “I understand, you have been having some…. (CC from the stem question)” or
“How can I help you?” or “What brings you here today?”.
3. “So, you have …(CC), …. Let’s talk about it, but first, is there anything else
bothering you? Are you having any other problems physically? Or are
there any special stresses in your life right now?.”.
 “Which one do you want us to discuss first/today?”
4. “Tell me all about the …(CC) right from the beginning ”.
5. “When would you say it started?”  “So it started .… ago?”
 “What made you decide to get it checked now?”
6. Empathy sentences: Very important.
TIPS:
38
-
Memorize the ten steps in sequence.
-
Practice the ten steps over and over and over until you feel you are doing
them naturally and confidently.
-
Don’t worry about how long it takes to do it at the beginning. Just master the
steps first. Then, with time try to be faster and faster to finish it with ONE
MINUTE or less.
-
After you master it. Do it in front of family members or study group. Ask
them to criticize you honestly and freely. Ask them about your nonverbal
communication, voice tone, gestures, eyes and eyebrows movements, lips
movements, standing position, head position and look
-
Accept critics openly and adopt changes. Check OSCEs Home
communication skill page at http://www.oscehome.com/CommunicationSkills.html.
Chapter 10:
History of Present Illness (HPI)
OSCD PQRST UVW + AAA
The following 15 points has to be explored ALL for pain CC. It should also be
used to explore any other CC, e.g. vaginal bleeding, cough, shortness of breath,
dizziness, vomiting, diarrhea, hematuria ..etc, except place, radiation and
quality (5, 6, 7) which will be explored in the station appropriate boxes.
1) Onset: “How did it start? Was it all of a sudden or gradually?”.
2) Setting: “What were you doing when it started?”.
3) Course: “Is it getting worse, better or just the same?”.
4) Duration: “You said it started … ago, does it come and go?” If yes 
“How often / frequent does it come?”….. “For how long dose it stay
each time?”.
5) Place: “Show me exactly where is it on your body, point where with
one finger”.
Only
for
pain
CC
6) Quality: “Tell me, how does it feel like?”……  
Clarify one at a time:
Is it sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning? ”
7) Radiation: “Does it go/ shoot anywhere?”.
8) Severity: “How bad is it, on a scale from 1 to 10, with 1 is the mildest,
and 10 is the worst pain?,… Does it interfere with your daily
activities?”.
9) Timing: “Is it worst in a particular time of the day?”.
10) U (you) Your daily activities: “Does it change with your daily activities
like posture, exertion, rest, sleeping, eating, hunger?”.
11) V (déjà vu): “Has it happened before?” If yes  “When?… How did
you handle it?…What happened to it? … Which doctor?… What
medication? ..etc Explore.
12) What: “What has worked for you so far?... What hasn’t?… What do
you think is causing it?…”
13) Aggravating factors: “What brings it on? What makes it worse?”
14) Alleviating factor: “What makes it better?”
15) Associated symptoms: “Have you noticed anything else that occurs
with it?” If the patient ask “What do you mean/ such us what?”
“Any thing that you may recall?”.
39
The History Taking Interview: History of Present Illness (HPI)
Summarize:
Important
“Let me see if I have it straight. You felt perfectly well until …. ago when you
felt….(CC)?.. The….(CC)………”
Interviewing technique:

Start with: General open-ended questions.

Then: Topical open-ended questions.

Proceed to: Lists / Menus questions.

Then: closed-ended questions.

Then: Yes/ No questions.

Use minimal facilitators: “ Yes, uh huh, head nodding, what else?, .. and?.”

Avoid:
- Leading questions.
- Multiple questions at the same time.
Sentences to be memorized in sequence:
“How did it start? Was it all of a sudden or gradually?”.
“What were you doing when it started?”.
“Is it getting worse, better or just the same?”
“You said it started … ago, does it come and go?” If yes  “How often /
frequent does it come?”….. “For how long dose it stay each time?”.
5. “Show me exactly where is it on your body, point where with one finger”.
6. “Tell me, how does it feel like?….. Is it sharp? Stabbing? Dull? Tight?
Cramps? Squeezing? Burning? ”.
7. “Does it go/ shoot anywhere?”
8. “How bad is it, on a scale from 1 to 10, with 1 is the mildest, and 10 is the
worst pain?,… Does it interfere with your daily activities?”.
9. “Is it worst in a particular time of the day?”.
10. “Does it change with your daily activities like posture, exertion, rest,
sleeping, eating, hunger?”.
11. “Has it happened before?” If yes  “When?… How did you handle
it?…What happened to it? … Which doctor?… What medication? ..etc
Explore.
12. “What has worked for you so far?... What hasn’t?… What do you think is
causing it?…”.
13. “What brings it on? What makes it worse?”.
14. “What makes it better?”.
15. “Have you noticed anything else that occurs with it?”“Any thing
that you may recall?”
1.
2.
3.
4.
Before you
proceed. Make
sure that you
did memorize
and practiced
these steps first.
Make sure that
you have been
doing them
confidently and
naturally. You
must be able to
finish them in
about 2 - 2.5
minutes fluently
& comfortably!
40
TIPS:
-
-
Memorize the 15 steps in sequence.
Don’t worry about how long it takes to do it at the beginning. Then, with time
try to be faster and faster to finish it with ONE MINUTE or less.
Chapter 11:
THE STATION APPROPRIATE
QUESTION BOXES
This includes symptoms and risk factors associated with the CC organ system.
Use only one or two of these station appropriate question boxes at each OSCE
station. Decide which one and remember the questions during the “Minute(s)
Before” step.
Now, as we reached this stage, you must use a transitional statement to prepare
the patient to the next stage in the interview and to appear organized. You don’t
have to pause. Just after you finished a quick summary of the previous step, the
chief complaint, tell the following transitional sentence:
“Mr/Ms..., now, I want to ask you some questions about things that may or
may not be associated with ....(CC), okay? ”
This will show your organizational skill and prepare the patient to what are you
both doing next in a respectful way. Many patients will appreciate having road
maps about what is going during the medical interview and most importantly
WHY you are asking these questions and why should they answer them. This will
avoid having the patient jumping in your face with a questioning comments like:
Systems are:
Neurology,
Respiratory,
Cardiovascular,
Gastrointestinal,
Genitourinary,
Dermatology,
Endocrinology/
Hematology,
Musculoskeletal,
Obstetrics &
Gynaecology,
Pediatrics, and
Psychiatry.
“Why are you asking this?… Is this relevant?… Do I have to answer that?
… Do you thing that’s what’s causing it?, .. etc.”
Standardized patients in OSCEs are trained to do so and they love to do it! So,
attempt to cut the possibilities of letting them ask you so by using short
informative sentences to justify what are you going to ask and prepare them.
In each box, there are several SCREENING (underlined) questions. You will
ask only these questions. Screening questions are also used for the system
review questions. If the patient replies with positive answer for any screening
question, then you will explore that symptom with further EXPLORING
questions. Exploring question covers all the differential diagnosis for that
symptom (even if you don’t know it). Never ask exploring questions if the
patient’s answer was negative.
Some of these questions may already been asked during the HPI if they are
relevant to the chief complaint, use them to explore it. Don’t repeat…
Confused?… Don’t worry now!… With practice you will remember these
detailed questions while taking the HPI.
Questions formats:
“Do you have .../ Does he/she have…/ Have you .../ Has he/she …/
What about .../ In what way…?” If yes for anyone explore.
NEVER USE NEGATIVE QUESTION, like “And you don’t have
..…(fever) ”. They are leading questions. You are giving the patient the
impression that you want a negative answer for this question!
41
The History Taking Interview: Station Appropriate Question Box: NEUROLOGY
Neurology appropriate questions:
HLD NeW VHS MTC
1- H eadache: “Do you have headache?” Screening question.
Yes  Explore: OSCD PQRST UVW AAA
- Onset: “How did it start?” (thunderclap in Subarachnoid hemorrhage).
- Place: “Show me exactly where is it on your head, point where with
one finger… Is it on one side or both?”.
- Severity: …“Does it interfere with your routine physical activity and
work?”
- Timing: “Is it worse in a particular time of the day?”( AM: ICP/ PM:
Tension, migraine),
- U: Does it change with your daily activities like posture (lying
down/sitting), eating, hunger, exertion, rest, sleeping/ wakes you up
(Cluster))?
- Associated symptoms: “Have you noticed anything else that occurs
with it?.. feeling sick (nausea) or throwing up (vomiting)?…/ Stiff
neck?.../ Eye problems?…./ Pain on chewing?…/ Annoyed by light?”,
Warning signs: “Is it preceded by warning signs?… What are
they?” (aura in migraine).
2- Loss of Consciousness(LOC): “Have you passed out / blacked out?”
Yes  Explore: OSCD PQRST UVW AAA
Seizure or syncope
- Empathy: “Ooooh, did you hurt yourself?”
- Duration: “For how long did that last?”
- Completely: “Did you lose consciousness completely or could voices be
heard?”
- Body Position: “What was your position during the attack?”
- Body Movements: “Did any body movements occur?”
- Tongue-biting: “Did any tongue-biting occur?”
- Confusion/ sleepiness after attack: “How did you feel after the attack?”
- Urinary/ bowel Control: “Was there any loss in bladder or bowel
control?”
 Seizures: “At what age did it start? How often dose it happen?”
- Warning signs: “Was it preceded by warning signs?.. such us
lightheadedness? ”
3- D izziness: “Have you felt unsteadiness (vertigo) or light-headedness
(presyncope) ?”
Yes  Explore: OSCD PQRST UVW AAA
- Duration: “For how long?”
- U: “Does it change with your head movement?.. Opening or closing
your eyes?.. How?”
(: Vestibular),.. Does it only occur for a minute in certain head
positions? (BPV, VBI),.. Does it change with exercise? (Cardiopulmonary)”
- Associated symptoms: “Have you noticed anything else that occurs
with it? ... Feeling sick (nausea) or throwing up (vomiting) ?…/or hearing
change?(Inner ear disease),... Gait problem? (Ataxia),.. Double vision?,
Difficulty speaking? (Brainstem disease) ”.
…. Continued
42
The History Taking Interview: Station Appropriate Question Box: NEUROLOGY
Neurology appropriate questions, …Cont
4- Numbness: “Do you have numbness, loss of sensation, or pain
anywhere?”
Yes  Explore: OSCD PQRST UVW AAA
- Place: Where?.. One side or both?” Is it localized to a dermatome?
- Quality: “Does it feel like tingling?… prickling?…. warm?…. cold?.
pressure?.... Or like a distorted sensation in response to a
stimulus?”
5- Weakness: “Any weakness?”
Yes  Explore: OSCD PQRST UVW AAA
- Place: “Where?…. One side or both?”…. “What activities do you
have difficulty with?” Proximal (standing/combing): (myopathy)/ or
distal (neuropathy).
6- Visual changes: “Any visual changes recently?”
Yes  “In what way?.. One eye or both?.. Any eye pain?.. Tearing?
Redness?,.. Does light bother you?,.. Double vision?.. vertically or
horizontally?.. Any flashing lights?”
7- Hearing changes: “Any hearing changes?.
Yes  “Do you hear any noises or tinnitus in your ears?….
Earache?… Ear fullness?… Any ear discharge?” Yes, How much,
what colour is it?… Is it thin or thick?.. How dose it smell?.. Any
blood?”
8- Difficulty Speaking: “Do you have difficulty speaking?”
Yes  “In what way?”.
9- Memory/Concentration: “Have you noticed any memory loss/
difficulty concentrating?”
Yes  “In what way? ”.
10- Tremor: “Any tremor or involuntary movements?
Yes  “In what way?…. Is it worse with certain postures (Essential
postural), movement (Intentional: Cerebellar) or rest (Parkinson) ?” “Any gait
problems?””.
11- Bladder / Bowel C ontrol: “Do you control your bladder and
bowel motion?”
No  “In what way?”.
43
The History Taking Interview: Station Appropriate Question Box: RESPIRATORY
Respiratory appropriate questions:
PCS Wheezes HEAT On Us
+ Risks
1- Chest Pain: “Any chest pain?”
Dry cough:
Viral, Interstitial,
Allergy, Cancer.
Productive
cough:
Bronchitis,
Bacterial
pneumonia,
Abscess
Bronchiectasis,
TB.
Uninfected
sputum: Mucoid,
transparent,
odourless, whitish gray.
Purulent rusty:
Pneumococcal
pneumoni
Red current jelly:
Klebsiella
pneumonia
Foul smell:
Abscess
Frothy pink:
Pulmonary edema
Positional:
Abscess, Tumor,
GERD
Hemoptasis: with
cough & dyspnea;
red; frothy; may be
with pus.
Hematamesis:
with nausea &
vomiting;
red/brown; not
frothy; may be with
food.
SOB with
exercise: Chronic
bronchitis /
emphysema, CHF.
SOB at rest:
Asthma.
Yes  Explore: OSCD PQRST UVW AAA
- Duration: “You said it started … ago (<2 months: unstable angina?) , does it
come and go?.. How long dose it take to go away?.. So, it is more
(ischemia) / less (angina) than 15 minutes?”
- Place: “Show me exactly where is it on your body, one side or both?”
- Quality: “Tell me, how does it feel like?. Is it sharp or aching pain?.”
- Timing: “How frequent does it come in a day? (>3/d: severe)”
- U: Is it worse with deep breathing or cough (Pleuritic)?.. position
change (MSK)?.. eating (Esophageal spasm)?”
Sharp, one side, worse with deep breathing or cough  Pleuritic.
Aching, one side, lateral low down  Spontaneous pneumothorax.
2- C ough: “Do you have cough?”
Yes  Explore: OSCD PQRST UVW AAA
- Duration: “You said it started … ago, does it come and go?” If yes 
“For how long it dose stay each time?” Acute vs. chronic (>3 months for 2
years).
- Place: “Do you feel it coming from something in your throat or deep
in your chest? ”
- Quality: “Is it dry or with sputum / phlegm? Yes 
- Sputum: “How much sputum would you say?… A cup a day?..
Is it thin or thick?.. What colour is it?.. How does it smell?”
- Blood: “Do you cough up blood?” Yes  Fresh blood or altered?
How much blood? How frequent do you cough up blood?”
- Timing: “Is it worst in a particular time of the day or season?”,
“How often does it come?” (Morning: smoking,
Nocturnal: Postnasal drip, CHF, asthma.).
- AAA: “What brings it on? What makes it worse?” “Is it worse with
dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”
3- SOB : “Do you get shortness of breath? ”
Yes  Explore: OSCD PQRST UVW AAA
- Onset: “How did it start? Was it all of a sudden or gradually (PE)?”
- Setting: “What were you doing when it started (Dusting/ Exercise)?”
- Quality: “How does it feel like?.. Is it like air hunger, suffocation, or
heavy breathing (cardiac) ?,….
Is it like rapid shallow breathing? (chest wall),
Chest tightness? (Asthma), ..
Increased breathing effort? (COPD/ ILS) ”
- Severity: “How frequent?... How many times a week?…”
“When you get shortness of breath, are you able to speak?,…
Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?”
….Continued
44
The History Taking Interview: Station Appropriate Question Box: RESPIRATORY
Respiratory appropriate questions:
…Cont
- “Any visits to the emergency in the last 12 months?” Yes 
“How many times?... Have you ever had a breathing tube down
your throat or been on a breathing machine?… Have you ever
been admitted to the hospital?,… Intensive care unit?”
- Timing: “Is it worst in a particular time of the day or season?.. Is it
worse at night? (asthma)”
- ADL: “What activities are you no more able to do?” Empathy.
- U: “Is it related to exercise?.. Is it relieved by rest?”
- Orthopnea: “Are you able to lie flat in bed without becoming short of
breath?.. How many pillows do you sleep on at night?”(asthma>COPD)
Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal
nocturnal dyspnea in HF)”
4- Wheezes: “Do you hear noises in your chest with breathing?..
What about in your throat?”(Stridor?)
5- H oarseness: “Any change of voice?”
6- Exercise intolerance: “How many flights of stairs can you climb/
blocks can you walk?.. So, it is more (grade II)/ less (grade III) than two
blocks/ one flight?”.
7- A nkle swelling: “Do your ankles swell on you?”(edema?) , Yes: When did
it start?.. How long did it take to go away?”…. “Any pain in your
legs?”(DVT.. PE?).
8- Travel: “Any history of travel?.. Where? ”(exposure to TB, SARS, HIV).
9- O ccupation: “What do you do for living?.. Does your ..(CC).. improve
during weekends or vacations?”.. “What exactly does this job involve?”
10- Others: “Any exposure to people with HIV, TB, SARS?”.. “Have you
ever felt your heart racing?,.. Any face flushing?.. Any diarrhea”
(Hormone secreting tumors).
11- URT: “ Any running nose?.. Eye problem?.. Skin rash (Viral) ? Face
pain? (Sinusitis),.... Do you need to clear your throat frequently? (Post
nasal drip)”
12- Risk factors: Will be asked in the standard questions box:
Smoking (+2nd hand), Cold, Travel, Allergies, Pets/ dust, Occupation, HIV/TB,
emotional changes, medications (ASA, ACEI, Beta blockers).
45
The History Taking Interview: Station Appropriate Question Box: CARDIOLOGY
Cardiology appropriate questions:
PCS OSAP PLC EAR
1- Chest Pain: “Any chest pain?”
Yes  Explore: OSCD PQRST UVW AAA
- Duration: “You said it started … ago (<2 months: unstable angina?) , does it
come and go?.. How long it takes to go away?.. so, it is more (ischemia)
/ less (angina) than 15 minutes?”
- Place: “Show me exactly where is it on your body, one side or both?”
- Quality: “Tell me, how does it feel like?. Is it sharp or aching pain?.”
- Timing: “How frequent does it come in a day? (>3/d: severe)”
- U: Is it worse with deep breathing or cough (Pleuritic)?.. position
change (MSK)?.. eating (Esophageal spasm)?”
2- Cough: “Do you have cough?”
Yes  Explore: OSCD PQRST UVW AAA
- Duration: “You said it started … ago, does it come and go?” If yes 
“For how long dose it stay each time? ” Acute vs. chronic (>3 months for 2
years).
- Place: “Do you feel it coming from something in your throat or deep
in your chest? ”
- Quality: “Is it dry or with sputum / phlegm? Yes 
- Sputum: “How much sputum would you say?… A cup a day?..
Is it thin or thick?.. What colour is it?.. How does it smell?”
- Blood: “Do you cough up blood?” Yes  Fresh blood or altered?
How much blood? How frequent do you cough up blood?”
- Timing: “Is it worst in a particular time of the day or season?”,
“How often does it come?” (Morning: smoking,
Nocturnal: Postnasal drip, CHF, asthma.).
- AAA: “What brings it on? What makes it worse?” “Is it worse with
dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD).”
3- SOB : “Do you get shortness of breath? ”
Yes  Explore: OSCD PQRST UVW AAA
- Onset: “How did it start? Was it all of a sudden or gradually (PE)?”
- Setting: “What were you doing when it started (Dusting/ Exercise)?”
- Quality: “How does it feel like?.. Is it like air hunger, suffocation, or
heavy breathing (cardiac) ?,….
Is it like rapid shallow breathing? (chest wall),
Chest tightness? (Asthma), ..
Increased breathing effort? (COPD/ ILS) ”
- Severity: “How frequent?... How many times a week?…”
“When you get shortness of breath, are you able to speak?,…
Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating?”
….Continued
46
The History Taking Interview: Station Appropriate Question Box: CARDIOLOGY
Cardiology appropriate questions: …Cont
- “Any visits to the emergency in the last 12 months?” Yes 
“How many times?.. Have you ever had a breathing tube down
your throat or been on a breathing machine? Have you ever
been admitted to the hospital?,… Intensive care unit?”
- Timing: “Is it worst in a particular time of the day or season?.. Is it
worse at night? (asthma)”
- ADL: “What activities are you no more able to do?”
- U: “Is it related to exercise?.. Is it relieved by rest?”
4- O rthopnea: “Are you able to lie flat in bed without becoming short of
breath?.. How many pillows do you sleep on at night?”(asthma>COPD)
Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal
nocturnal dyspnea in HF)”
5- Sweating: “Any sweating?”
6- A nkle swelling: “Do your ankles swell on you?”(edema)
Yes  Explore “When did it start?..
7- Palpitation: “Have you ever felt your heart racing/ fluttering/ funny?”
Yes  Explore “When did it start?..
8- Loss of Consciousness (LOC): “Have you passed out / blacked out?”
Yes  Explore: OSCD PQRST UVW AAA
Seizure or syncope
- Empathy: “Ooooh, did you hurt yourself?”
- Duration: “For how long did that last?”
- Completely: “Did you lose consciousness completely or could voices
be heard?”
9- C olor: “Did your lips turn blue? (Cyanosis),…. Did your face turn pale?
(Pallor)”
Yes  Explore: “How long dose it take to go away?”
10- Peripheral vascular: “Do you have pain in your limbs?”
Yes  explore OSCD PQRST UVW + AAA
Is it with exercise, rest or both?... Any changes in the limb colour?..
Blue, Pale, Dark (cyanosis/ pallor/ pigmentation) ?
Do you feel it cold or warm?... Any numbness?... weakness?
Any skin or nail changes?.. ulcers?.. hair loss? ”
11- Exercise intolerance: “How many flights of stairs can you climb/
blocks can you walk?.. So, it is more (grade II)/ less (grade III) than two
blocks/ one flight?”.
12- Anxiety: “Are you worried?.. Do you have a feeling of impending
doom?” Yes Empathy “Ooooh! It must be hard.”
Peripheral
vascular
6 Ps:
Pain
Polar
Pallor
Parasethesia
Paralysis
Pulselessness
If chronic :
+ atrophic
changes:
History of
claudication.
Loss of hair
Dry thin skin.
Deformed nails.
Ulcerations.
Pigmentation.
13- Risk factors: Will be asked in the standard questions box:
Previous CAD, HTN, DM, Hypercholestrolemia, Smoking, Family Hx of
heart disease <55 years old.
47
The History Taking Interview: Station Appropriate Question Box: GASTROINTESTINAL
Gastrointestinal appropriate questions:
PAN HSBG JBO +Risk
1- Pain: “Any stomach pain?”
Yes  Explore OSCD PQRST UVW + AAA.
- Place: “Where do you feel it, point with one finger please?” (Localized
or generalized)?
- Quality: “How does it feel like?.. Is it colicky/… diffuse/… sharp/…
stabbing/… dull/… tight/… cramps/… Squeezing..?…. Burning?”
2- A ppetite: “Any change in your appetite recently?”
Yes  “Is it more or less than usual?”
3- N ausea / Vomiting: “Do you feel sick? (Nausea), Did you throw up?
(Vomiting)”
Yes  Explore OSCD PQRST UVW + AAA.
- Quality: “Was it digested or undigested food?.. What colour was it?
(dark green: Bile) .. Any blood? .. Yes mixed with vomitus or streak?,..
How does it smell?”
- Severity: “How much?.. How frequent?.. How much blood?.. A cup? ”
“Is it forceful (projectile) or with retching?”
- Timing: “Is it worse in particular time of the day?” (Morning: ICP).
- AAA: “Any headache?.. Stiff neck?.. Weakness? (CNS causes) ”
- Females: “Ms..., As feeling sick and throwing up may occur with
pregnancy and menses, I need to ask you, is it possible that you are
pregnant?.. When was the first day of your last period?”.
4- H eartburn: “Do you have water brush?.. Any burning sensation in the
middle of your chest that radiates to your mouth? ”
5- Swallowing: “What about your swallowing, any difficulty?”
Yes  Explore OSCD PQRST UVW + AAA.
- Course: “Is it getting worse? (Progressive)”
- Duration: “Does it come and go? (Intermittent)”
- Quality: “Is it difficult to swallow liquids (Neuromuscular & mechanical) or
solids (Mechanical)?… Do you feel a lump in your throat?”
- Timing: “Do you feel the difficulty immediately at the beginning of
swallowing (Oropharyngeal) or does food stop in your chest a few
seconds later (Esophageal)?.. Is it followed by vomiting?.. Choking or
cough?..”
- AAA: Screen for:
Thyroid: “Does the heat or cold bother you more than you think it
bothers other people?.. How?..”
Scleroderma: “Any skin tightness on your face or hands?”
CNS: “Do you have Headaches?…... Do you feel lightheadedness?
Do you feel any pins & needles sensations? .. Where?..
Any muscle weakness?.. Where?”
… Continued
48
The History Taking Interview: Station Appropriate Question Box: GASTROINTESTINAL
Gastrointestinal appropriate questions: …Cont.
6- Bloating: “Any gases?
Yes  “Does the gas escape upwards or downwards?... Does it smell?”
7- Girth: “What about your stomach girth?.. Is it bigger?.. Do you feel any
lumps or bumps?” Yes  “Where do you feel the lump?”
8- Jaundice: “Did your skin or the eyes’ white areas turn yellow or red?..
Any change in your urine color?… Is it dark like tea or cola?… Is your
skin itchy?.. Any bad mouth smell? ”
9- Bowel Habit: FP LTCS
“Any change in your bowel habit recently?”
Yes  Explore OSCD PQRST UVW + AAA.
- Frequency: “Any change in your bowel motion frequency?”
Yes .. In what way?.. How often do you pass your bowel?.. Is it more
or less frequent recently?” (Diarrhea: > 3/day unformed/ Constipation: < 3/week
hard stool with staining & sense of incomplete evacuation or blockade)
- Pain: “Any pain with passing bowel motion?”,… Any pain in your
bottom?. Yes “When does it occur?”
- Lesions: “Any lumps, ulcers or fissures in your bottom?”
- Tenesmus: “Any urgency to pass bowel motion but then little to pass?”
- Control: “Do you control your bowel or you soil yourself?”
- Stool: “Does your stool look as it was before or different? ”
No  Explore:
- Shape: “Is it wider, more bulky or narrower?.. Softer or harder?.”
- Content: “Is it greasy?.. Does it stick to the bowel or float?,.. Any
mucus?, .. Pus?.. Undigested food?.. .”
- Colour : “What colour is it?: Pale? (Fat)/ Black? (Malena) /Green? (Pus)”
- Blood: “Any blood?” Yes  “Is it fresh bright blood (after Splenic
flexure) or altered or clots (before)? How much blood?.. A cup?.. Is it
gross or only streaks on the stool surface?.. Does the blood appear at
the beginning, at the end, all through the motion, or only on the
toilet tissue? ”
- Smell: “How does it smell?”
* Diarrhea:
- Onset: “How did it start?.. Was it all of a sudden or gradually?”
- Duration: “When did it start? (>2 weeks: Chronic), So it is less/ more than
two weeks (Chronic)? Does it come and go?”… Yes  “How frequent
does it come?.. For how long does it stay each time?.. Does it
alternate with periods of constipation?”
- Quality: “Is it loose or watery?. Is it bulky shapeless?”
- Timing: “Is it worst in a particular time of the day?” Morning: IBS.
Nocturnal: Organic
10- O rthostatic assessment: Only if bleeding, diarrhea or vomiting (DTHU):
“Do you get lightheadedness?, ...What about when you stand up or get
out of bed in the morning?” (pre-syncope/ Anemia ),... Do you feel thirsty and
your mouth dry?,... Have you ever felt your heart racing?,... Do you
void less?”
49
The History Taking Interview: Station Appropriate Question Box: GENITOUROLOGY
Genitourology appropriate questions:
PD UHF SUV FIDO
1- Pelvic Pain: “Any pain?”
Yes  Explore OSCD PQRST UVW + AAA.
- Place: “Where do you feel it, point with one finger please?” Localized or
generalized? Flank (pain or CVA tenderness), Suprapubic, Groin, Testicles?.
- Quality: “How does it feel like?.. Colicky or burning?.. Is it sharp?..
Stabbing?.. Dull?.. Tight?.. Cramps?.. Squeezing..? .. Is it constant
or waxing and waning?”
2- Dysuria: “Any pain while passing water / voiding/ peeing?”
3- Urgency/ Hesitancy: “Any urgency to void/ pee? ..
Hesitancy? .. Straining? .. Any feeling of incomplete emptying?”
4- Frequency: “Is there any change in the frequency recently?”
Yes  Explore:
“Is it more or less? What about at night, do you wake up to go void?
(Normally < 2 for adult males, none for females)”
5- Volume & Stream: “Any recent change in its volume?
Yes  Explore:

“Is it more or less than usual?..”
“What about the stream: is it weaker or interrupted?... Prolonged
voiding?.. Any dribbling after voiding?”
6- Urine: “Tell me about your urine”
- Colour: “What colour is it?.. Is it dark brown/ tea or cola-coloured?..
Red?..”
- Blood: “Any Blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it clear or cloudy?”
- Smell: “Does it have a foul smell?”
7- Incontinence: “Do you control your bladder?”
No 
Explore:
“Is it with stress like walking/ standing/ coughing (Stress incontinence) or
is it continuous but cannot pee (obstruction overflow/ neurological)?.. Is it
leaking with urgency (Urgency incontinence)?”
8- Swelling (Morning face puffing /Ankle): “Any face puffing in the
morning?.. Do your ankles swell on you?”
9- Fluids: “How much fluid do you drink in a day?”
50
The History Taking Interview: Station Appropriate Question Box: GENITUOROLOGY
Genitourology appropriate questions: …Cont.
10- D ischarge (Penile/vaginal): “Any penile/ vaginal discharge? ”
Yes  Explore OSCD PQRST UVW + AAA.
- Colour: “What colour is it?.. Is it white, yellow or green?”
- Blood: “Any Blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it thin or thick?”
- Smell: “Does it smell?”
- Quantity: “How much discharge is it?”
11- Others: “Any eye, joint or skin problems?,… Kidney stones?”
51
The History Taking Interview: Station Appropriate Question Box: ENDOCRINE/HEMATOLOGY
Endocrinology/ Hematology appropriate questions:
WENT MSN ENG RPL
1- Weight changes: “Any recent weight changes?”
Yes  Explore OSCD PQRST UVW + AAA.
“In what way? ... How many pounds?… Have you noticed if certain areas
of your body are getting fatter or thinner? (Redistribution)”
2- Energy changes: “What about your energy? Any recent change?”
Yes 
 “Do you feel more energetic or do you become fatigued easily?”
3- Nervousness /Anxiety: “ Do you feel nervous or anxious most of the
time?... Have you ever felt your heart racing?... Any tremor?”
4- Temperature: Heat / Cold intolerance: “Does the heat or cold bother you
more than you think it bothers other people?….. How?..”
5- Mood changes: “Any recent mood changes?, Do you feel low?... Have
you lost interest in doing activities that were enjoyable to you? (Depression
with thyroid) ”
6- Skin changes: “How do you feel your skin; dry or moist?.... ”
- Color: “Any rash or pigmentation?... Did your face turn pale?.... ”
- Bleed: “Do you easily bleed or get bruised?”
- Hair: “Any recent change in your hair growth and distribution?…. ”
- Nail: “Any nail shape changes?”
7- Neck swelling: “Have you noticed any lumps in your neck or felt it
wider?”
9- Eye changes: “Any recent visual changes?.. Eye pain?… Colour changes
like redness or yellowness?… Shape change?”
8- Neurological Screen: “Do you have Headaches?… Do you feel
lightheadedness?… Do you feel any pins & needles sensations?.. Where?..
Any muscle weakness?.. Yes  Where?… What activities do you have
difficulty with?” (Proximal: Difficulty climbing stairs).. …. Empathy.
10- GI Screen:
“Do you feel sick? (nausea) , Did you throw up? (vomiting) ”
“How is your appetite?… ”
“Any mouth ulcers?... ”
“Difficulty swallowing?...”
“Any change in your bowel habit?…” Yes “In what way?...”
“Any black stool or bleeding from your bottom?...” Yes Explore.
… Continued
52
The History Taking Interview: Station Appropriate Question Box: ENDOCRINE/HEMATOLOGY
Endocrinology/ Hematology appropriate questions: …Cont.
11- R enal Screen: “Do you feel thirsty frequently? ... How much fluids do
you drink in a day? (polydepsia)... ”
“What about passing water/ voiding, any change?... Is it more or less
than usual? (Polyurea) …”
“Is your urine red or cloudy?…”
“Do you have kidney stones?”
12- Pain: “Any stomach,… joint pain,… bone pain,… muscle pain?”
13- Libido (for males) / Menses (for females): “Mr/Ms .., in order to
understand your condition, I need to ask you some questions about
your sexual history. Is that okay?……...”
“Any changes in your sexual desire (Libido)/ menses?... How?”
53
The History Taking Interview: Station Appropriate Question Box: MUSCULOSKELETAL
Musculoskeletal appropriate questions: joint PR STD, ROMAN’S
Activity MisS NG
1- Joint Pain: “Any joint pain?”
Yes  Explore OSCD PQRST UVW + AAA
- Place: “Which joint?.. Any other joints?… Which joint pain is worst?
Does it move from joint to another?.. Is it the same on the other …other
limb’s same joint (Symmetrical)?”
- Duration: “Does it come and go, or wax & wane? (Constant: Malignant/
Infectious)
- U: “Does it only occur or get worse at rest or movement or both?...
What about with posture change?”
- Timing: “Is it worse in a particular time of the day, like end of the day
(Mechanical/ Degenerative) or at night? (Malignant/ Infectious)”
2- Joint Redness: “Any joint redness?”
3- Joint Swelling: “Any joint swelling?”
Yes  … “Was it sudden (Trauma) or gradual?”
4- Joint Trauma / Procedure / Injections / Surgery: “Have you ever had
any trauma, procedure, injections or surgery on any joint?”
“Do you have to do the same movements repeatedly at work or home?”
Trauma Case: “Have you heard a click when it happened?”
“Were you able to bear weight immediately after the
incident? ”
5- Joint Deformity/ Gait deformity: “Any deformity in the joint
shape?… Do you feel your (joint) unstable? (Ligament/ Meniscus tear)...
Locking? (loose body) .. Any change in your gait pattern?”
6- Range O f Movement (ROM): “Is there any reduction in the range of
movement of your …. (shoulder/elbow/wrist/finger/thumb/hip/knee/ankle/toe/back) ?”
(Mention joints, not limbs).
7- Noise: “Any noises with movement?”(Crepitus)
8- Morning Stiffness: “Any movement stiffness when you wake up in the
morning?”
Yes  “How long does it take to go away?… So, it is more than
(Inflammatory) / less than 30 minutes (Degenerative / Mechanical)?”
9- A ctivities of daily living (ADL): “How has this been affecting your
daily activities?.. What activities do you have difficulty with or are
unable to do?… Who does the cooking, the shopping, the laundry, the
cleaning for you?...”
 Empathy: “Oooh, It must be hard, how are you coping with it? ” ...Cont.
54
The History Taking Interview: Station Appropriate Question Box: MUSCULSKELETAL
Musculoskeletal appropriate questions: … Cont.
10- Muscle: “Any muscle pain?.. Weakness?.. Wasting?.. ”
Yes Explore:“Where?”
11- Skin changes: “Any change in skin colour?... Redness?... Bruises?...
Warmth?... Rash?... Skin tightness on your face or hands? (Scleroderma)
… Eye redness or pain?”
12- N eurological: “Any changes in skin sensation like it’s less than
before?… Tingling sensation?... Any headache?... Difficulty
speaking?... Vision problem?... Do you control your bowel or
bladder?… Any back pain?”
13- GI: “Any mouth ulcers?... Difficulty swallowing? (Scleroderma) ...
Frequent episodes of diarrhea & constipation?... Bleeding from your
bottom? (IBD)”
Inflammatory
Degenerative / Mechanical
- Pain worst with rest.
- Pain better with movement.
- No change during the day
- Inflammatory symptoms:
Pain, redness, warmth, swelling.
- Morning stiffness > 30-60 min
- Passive ROM > Active ROM
- Pain worse with movement.
- Pain better with rest.
- Pain worse at end of the day.
- No inflammatory symptoms but
tenderness & deformity
- Morning stiffness < 30 min
- Passive ROM = Active ROM
+ Previous Hx + Family Hx
+ Sleep disturbances.
+ Other systems: Neuro / Heart.
Ligament / meniscal symptoms:
Joint giving way, clicking, locking,
instability.
Back Pain: + neurological deficit.
Note: Refereed pains:
- Shoulder pain from heart or diaphragm.
- Arm pain from neck. & Leg pain from back &
Knee pain from hip.
So, include screening questions from cardiovascular, respiratory, and
gastrointestinal boxes if time permits.
55
The History Taking Interview: Station Appropriate Question Box: DERMATOLOGY
Dermatology appropriate questions:
RUSC NJE CHD
1- R ash: “Any skin rash?”
Yes  Explore OSCD PQRST UVW + AAA
- Duration: “…. Does it come and go?”
- Place: “Where does it appear on your body?… Where did it start”.
- Quality: “Is it dry?... Any scaling?... Any crusts?... Pus?”
2- U lceration/ Bleeding: “Does it ulcerate or bleed?”
3- Sensation: “Any itching or burning sensation?”
4- Colour changes: “Any change in the skin colour?” (Pale, dark, redness?)
5- Nail changes: “Any change in your nail’s colour or shape?”
6- Joint changes: “Any joint pain or swelling?...
Any joint redness or warmth?”
7- Eye changes: “Any recent eye changes?”
8- Causes: “What do you think is causing it?…
Any contact with chemicals?...
Have you noticed any relation to heat, cold, sunlight?...
What about to food or spices? ...
What is your occupation?”
9- Family Hx: “Any family history of atopy or allergies?…
What about skin cancer?... Psoriasis?”.
10- Penile / vaginal D ischarge: “Mr./Ms…, as you may know, some
sexual diseases cause skin changes. That is why I ask all my patients
whether they have any sexual disease such as (penile/ vaginal)
discharge?”
Yes  Explore: OSCD PQRST UVW + AAA
- Colour: “What colour is it?.. Is it white, yellow or green?”
- Blood: “Any Blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it thin, thick or with pieces?”
- Smell: “Does it smell?”
- Quantity: “How much discharge is it?”
- Timing (FEMALE): “Does it change with your cycle?,… Is it worse
before or after the cycle or no difference?”
56
The History Taking Interview: Station Appropriate Question Box: DERMATOLOGY
57
The History Taking Interview: Station Appropriate Question Box: PEDIATRICS
Pediatric appropriate questions: GEEN MS CAM BINDE+/- HEADDSS
In OSCE exams, no child will be seen except in teenage scenarios. However
20–25% of the exam cases will be pediatric cases.
Pediatric cases will be presented as history taking consult with a parent.
Your approach to taking a history should always be developmentally
appropriate to the child’s age. There are 4 main age groups: infant, toddler,
school age, and teenagers.
Involve the child as much as possible in the interview either verbally or by
play if present.
The child’s chief complaint may not be the main issue, or in fact, the child is
not the real patient!
Explore the parent’s agenda / fears and parent-child relationship.
Angry / Frustrated / Anxious / Demanding / Crying parent are usual difficult
scenarios in addition to spouse/ child abuse.
Modify the PHx and ‘Standard Questions Box’ according to the child’s age.
e.g. child’s exposure to smoking and drugs instead of use.
Duration: “When was he/she last being well/ feeding & sleeping well?”
Ask the following questions adjusting it according to the child’s age.
If the answer is positive, explore in the same way you do for adults.
1- G eneral: “Any fever, rigors or chills?”
“Does he/she cry for a long time?,... Being cranky?”
“Does he/she look tired, drowsy?”
“Does he/she show no eye contact,… not playing?”
“Has he/she lost consciousness?,… Had a fit?,… Stiff neck?”
“Weight loss or not gaining enough weight?”
2- Eyes: “Any red eyes?,… Eye discharge or crusting?,… Sunken eyes?”
3- Ears: “Any ear pain/ ear pulling (for young)?,…Ear discharge?,… Hearing
problems?” Explore.
4- N ose: “Any running nose?,… Nose bleed?,… Discharge?” Explore.
5- Mouth: “Any dry mouth?,… Teething?,… Big tongue? ,… Thrush?”
“Any vomiting?” Explore.
6- Skin: “Any rash or itching?,… Skin becomes yellow or blue?,… Easy
bruising or bleeding?” Explore.
7- C hest: “Any breathing noises or wheezes?,… Cough?,… Shortness of
breath? ,… Pain? … Heart problems?” Explore.
8- A bdomen: “Any belly pain?,.. Distension?,.. Lumps or bumps?” Explore
9- MSK: “Any joint pain?,… Joint swelling?,… Limping?” Explore.
… Continued
58
The History Taking Interview: Station Appropriate Question Box: PEDIATRICS
Pediatric appropriate questions:
... Cont.
10- Birth/ Pregnancy/ Newborn :
- Birth Hx: “What was the method of delivery? If induced or C/S: Why?...
How long did it take?... Any complications during labor like
prolonged labor, ruptured water bag, fever?”
- Pregnancy Hx: “How was the pregnancy?... Was it term pregnancy?,
... Your (his/her mother’s if not the mother) age at pregnancy?”
“Any complications during it?... High blood pressure,… Anemia,
diabetes,… infection? ” Explore: What?... How was it treated?...
What was the outcome?… Any exposure to a child with rash? ”
“Any smoking, alcohol, or drugs use? .. How was your (his/her
mother) other pregnancies and children?”
- Newborn problems: “How was he/she at birth?,… How much was
his/her weight?,... Any abnormalities or complications like being
yellow or blue, feverish, or didn’t cry immediately?” Explore:
What/ When/ How long? ” Empathy for healthy/ unhealthy pregnancy.
11- Immunization Hx: “What needles has been done so far?... Does
he/she have…? (age appropriate immunization)”
12- Nutrition/ Output: “Tell me about his/her feeding/eating habits?”: Is
he/she on breast or bottle feeding?,… How much do you give him/her
each time?… How many times in a day?,… Any solids, vitamins, iron,
supplements?,… What?, when did you start?,… Is it balanced diet?,…
Any junk food?,... Any difficulty sucking/ swallowing?,… Is he/she a
picky eater?,… Tell me about the feeding setting & facilitation?”
Output (Bladder/ Bowel motions): “How many times a day dose he/she
pass water?... How much each time?…(Or How many wet dippers a
day?),… Smelly urine?,… Red urine? ”
How many times a day dose he/she have a bowel motion?… How
much each time?…Is it formed or loose?,… Smelling stool?,…
Blood?,… mucus?,… What color is it?… Green/ yellow/ white cheesy?
Explore. “Does he/she control his/her bladder & bowel? (for >4 years old)”
13- Development:
- Physical: “What is his/her height and weight now?”
- Milestones “Is he/she able to….. ? (Gross motor, Fine motor, Speech,
Social)”Age appropriate now only, no need for previous.
- Social/ School performance: “How is his temper?,... Is he irritable,
crying frequently?,... What about sleep?... Does he/she attend
school?... What grade?... Any problems at school?… Any failures or
suspensions?…What is his/her daily routine?”
14- Environment: “Are there similar problems in relatives, daycare,
school?” “Who is usually taking care of him/her?,… How is the family
relationships?… How has this been affecting the family?. .. Do you feel
your mood low?... Any lost workdays?… How are you managing with
the expenses?”.
How sick is the
patient &
which problem
is the most
urgent?
This is a 100%
skill. A skill that
you must get
right always. The
only way to get
good at this is to
think about the
factors that make
an illness or
problem more or
less severe:
1. Differential
Diagnosis
and/or
Complications
of a Disease.
2. Prioritized
Problem List.
59
The History Taking Interview: Station Appropriate Question Box: GYN / OB
Gynae/Obstetric appropriate questions:
MDP Do Uyou Csee SOOS
“Ms .., in order to understand your condition, I need to ask you some
questions about your female organs. Is that okay.”
1- Menstrual Hx:
Normally 3580cc/cycle dark
red no clots,
every 24-32
days, for 3-7
days.
- Last menstrual period (LMP): “When was the first day of your last
period?”
- Regularity / Frequency: “How regular is/was it usually?… How frequent
is/was it?... Every how many days does it come?”
- Severity: “For how many days does the bleeding last?... How much is
it?... How many pads do you use per cycle?... Is it dark red or bright
red?… Any clots? (excessive),... Do you feel lightheadedness on
standing?”
- Perimenstrual: “Is there any pain or mood changes with the cycle?...
How bad is it?”
Lot of
empathy for
pain,
bleeding, &
abortion.
* Missed periods: “So you have no regular cycles for more than 4 weeks
(Pregnancy/stress/exercise)/ 3 months (+ amenorrhea)/ 6 months (+ menopause)
* Menopause: “Any hot flashes?… Mood swings?… Memory
problems?… Sleep problems?… Vaginal dryness, itching, or pain?”
Menses:
2- Bleeding: “Is there any recent changes in your cycle regularity?...
amount?... duration?... frequency? ”…. “Any abnormal bleeding? ”
Yes  Explore OSCD PQRST UVW + AAA
- Timing: “When does it occur in relation to the cycle? ”
- Severity: “How many days does the bleeding last?... How much is it?...
How many pads do you use per cycle?... Is it dark red or bright red?…
Any clots? (excessive),... Do you feel lightheadedness on standing? ”
“What is your blood group? & your partner? (Rh)”
3- D ates: “At what age was your first (menarche) / last period (menopause)?
At what age was your first sexual encounter? (Risk factor)...
When was your last sexual encounter? (Only in cases of abuse) ”
4- Pain: “Any lower abdominal or pelvic pain?”
Yes  Explore: OSCD PQRST UVW + AAA
- Duration: “When would you say it started?.. So, it is less/ more than 6
months (chronic) ”
- Place: “Point where do you feel it with on finger?” Suprapubic, RLQ, LLQ?
- Radiation: “Does it shoot anywhere?” To labia and inner thighs/ To back
- Quality: “How does it feel like?.. Constant or cramps?… How frequent?
How long dose it take to go away?”
- Timing: “Does it change with the cycle?... How?... Mid cycle?...
Any pain with sexual encounters?”
5- Vaginal D ischarge: “Do you have any vaginal discharge?”
Yes  Explore: OSCD PQRST UVW + AAA
… Continued
60
The History Taking Interview: Station Appropriate Question Box: GYN / OB
Gynaecology/Obstetric appropriate questions: ... Cont.
- Colour: “What colour is it?.. Is it white, yellow or green?”
- Blood: “Any Blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it thin, thick or with pieces?”
- Smell: “Does it smell?”
- Quantity: “How much discharge is it?”
- Timing: “Does it change with your cycle? Is it worse before or after the
cycle or no difference?”
6- Urinary symptoms: “Is it painful to pass water?... Any urgency?...
Change in frequency?… Do you control your bladder? (Incontinence)...
Any vulvular itching or redness?.. Any warts or ulcers” Yes  Explore
“Any face puffing, fingers or ankles swelling? ” Yes  Explore
7- Contraceptive/ Hormonal Rx: “Any hormonal therapy?.. What do you
use for birth control?.. For how long have you been using it?.. Any side
effects or failures?.. What about in the past, tell me all methods you’ve
tried?.. Why did you stop it?(Side effects/failure).. For how long did you use it?”
8- Surgeries, Procedures/ Injuries, Trauma / Blood transfusion /
Hospitalization: “Any?………….. ”.  Explore
Pap smear: “When was your last Pap smear done & where?.. What was
the outcome & follow up?”
Any previous women problems?.. Fibroids?.. Pelvic infections?.. Cysts?”
Points for
wrap up:
Importance of
Pap smear, Safe
sex, HIV testing,
Bring partners if
STD.
 Explore
9- Obstetrical Hx:
GTPAL
“Any pregnancies, miscarriages, abortions in your life?” Any abnormal
pregnancies?” (ectopic/ mole). Explore
- Previous (for each): Place/ Date:“At what year?. Where was the delivery/
abortion, at home or the hospital?.
- Miscarriages (involuntary)/ Abortions (voluntary): “Why did the first one
occur? At how many weeks?”
- Pregnancy: “How was the first pregnancy?.. For how many weeks it
was?.. Any complications during it?.. What?.. How was it treated?..
What was the outcome?”,…... “Now the second pregnancy.…”
- Labor: “What was the method of delivery, natural vaginal, or
induced, or cesarean?… If induced or C/S: Why?.. How long did it
take?.. Any complications during labor?”
- Babies: “How was the baby at birth? Boy or girl? How much was
his/her weight?.. Any abnormalities or complications?”
Empathy for healthy/ unhealthy pregnancy: “………………………”
- Current pregnancy: ABCDE DR:
“How is the baby’s movements? (For those > 18 weeks )” “Any bleeding?
(explore as above)”.. “Contractions?.. How regular is it?.. How frequent?..
How long each lasts?”.. “Is there any vaginal dripping?.. How much?”..
“When will be your due date?”.. Which doctor is taking care of this
pregnancy?”“Are all routine tests & U/S done?.. What are the results?”
GTPAL:
Gravida,
Term (>37),
Preterm (20-37),
Abortions (20),
Life baby.
ABCDE DR:
Activity of
fetus,
Bleeding,
Contractions,
Dripping,
EDC, Doctor,
Routine test
Complication? High blood pressure, diabetes, headache, visual changes, kidney/liver/thyroid disease
10- Others/ Breast: “Any breast changes?,.. Skin lesions?,.. Groin/ axillary
lumps?,… Joint/ back pain?”
61
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions: AL MAP CVP SADDD +
(FEW SAM MASF + SAFE + HEADDSS)
Note: - OSCD PQRST UVW + AAA first.
If the patient presented with a somatic CC,  Explore quickly as it is not the
real CC. If he presented with a psychiatric CC  Explore in detail.
1- A sk: - “Are you seeing other doctors?” Yes  Explore
“What did they say about ... CC?... Any investigations done?... What was
the outcome?... Any medication prescribed?.. What?... How much?...
How frequent?... For how long you have been taking them?... What was
the outcome?... Any side effects?... Are you still taking these
medications?”
2- Look: - Look for the patient’s non-verbal cues:
Appears sad/ Avoids eye contact looking away/ Slow monotonous or
explosive pressured speech/ wandering around in the room/ Restless/
Irritable/ Clean or dirty/ Peculiar… etc. Comment:
“You look sad/ upset, is there something bothering you and want to
talk about? ”
“You look very energetic/ restless/ moving around a lot, can you sit
down here so we can talk? ”
3- M ood:
1. Depression (Feeling down):
“How is your mood?... Are you feeling down?”
“Have you lost interest in doing activities that were enjoyable to you?”
Mood and Interest screen. Yes:  Explore OSCD PqrST UVW AAA.
- Course: “…, Is it constantly feeling down (Dysthemia) or there are
periods that you felt better? (Depressive episode)”
- Duration: “..., So, you’ve been felling down for less (Not depression)/ more
than 2 weeks? (Depressive episode)”
- V: “Has it happened before? ”... When?” (Yes: Major Depressive disorder,
No: Depressive episode).
“For how long you’ve been having these episodes on & off?... So, it is
more (chronic)/ less than 2 years”
- AAA: “How was your feeling before?...
Does anything happened or changed in your life?...
Are there any stresses at this point in your life?...
Were you taking any medications that you stopped recently?”
- SPACE SIGM B: 5 of the 9 including mood & interest.
- Sleep: “How is your sleep?.. Do you sleep more (atypical) or less
(depression) than usual?.. Any early morning awakening?”
- Interest: done.
- Guilty: “Do you feel guilty, hopeless, helpless, or worthless about
something?”
… Continued
62
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
… Cont.
- Mood: done.
- Energy: “How is your energy level? Do you feel tired?”
- Concentration: “Do you have difficulty concentrating or making
decisions? .. Has there been a change in your memory?.. In what
way?”
- Appetite: “Has there been a change in your appetite or weight?..
More or less than usual?” increased in atypical
- Psychomotor:
- Retardation: “Do you feel slowed down/ Dose it take you longer to
get dressed?”
- Agitation: “Do you feel restless, agitated?”
- Suicide: “Do you have recurrent thoughts of death or suicide?..
Any attempts to hurt yourself? What have you done?.. When?..
Why.. What was the outcome?….. Any plans now?”
- Bereavement: “As there are many causes to feel sad, I need to ask
you, has any close person to you passed away during the last 2
months?”
2. Mania (Feeling high):
“Have others around you noted a persistently elevated, expansive
mood, energy, or self-esteem? ”
Mania screen. Yes:  Explore OSCD PqrST UVW AAA.
- Course: “Is it constantly feeling high (mania) or there are periods that
you felt down (Bipolar II)?.. How often does your mood alternate in a
year?.. So, it is more (Rapid cyclic)/ less than 4 times a year?”
- Duration: “….., So, you’ve been felling down for less/ more than 1
weeks? (Manic episode)”
- V: “Has it happened before? ”... When?” (Yes: Bipolar I disorder,
No: Manic episode).
“For how long you’ve been having these episodes on & off?... So, it
is more (chronic)/ less than 2 years”
- AAA: “How was your feeling before?...
Does anything happened or changed in your life?...
Are there any stresses at this point in your life?...
Were you taking any medications that you stopped recently?”
- GST PAID: 3 of the 7.
- Grandiosity: “Do you feel you are a very important person with
special talents, power, mission, or role?”
- Sleep: “How is your sleep?.. Do you feel you can get by through the
day with less sleep than usual”
- Talkative: “Do people say that you are more talkative than usual?”
- Pleasurable activities
Painful consequences: “Do you drink & drive?... Do you use a
substance a lot?... Do you spend more than you can afford?… Do
you have inappropriate sexual behaviors?”
- Activity: “Do you feel you have increased energy?”
… Continued
63
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
…. Cont.
- Ideas, flights of: “Are thoughts racing in your mind?.. Do people say
you jump from topic to topic?”
- Distractibility: “Do you get distracted easily?”
- Organic causes: STEAM: SLE, Trauma, Endocrine, AIDS, MS
4- A nxiety:
1. Panic Disorder:
“Have you experienced a sudden onset of intense fear or discomfort?”
“Do you have fear going to closed or crowded places? ” Agoraphobia
Panic disorder screen. Yes:  Explore OSCD PqrST UVW AAA.
- Timing: “Does it wake you up?”
- AAA: Activity, Coffee, Stress, Places, Situations, meds/drugs.
“How was your feeling before?...
Does anything happened or changed in your life?...
Are there any stresses at this point in your life?...
Were you taking any medications that you stopped recently?”
- STUDENTS Fear 3Cs: 4 of 15 occur abruptly & reach a peak in 10 min.
“Do you sometimes abruptly get: ….
- Sweating?..
- Trembling or Shaking?..
- Unsteadiness or Dizziness?..
- Derealization: feeling of being unreal?..
- Depersonalization: feeling of being detached from yourself?..
- Excessive heart beat or racing?..
- Nausea or stomach distress?..
- Tingling or numbness?..
- Shortness of breath?..
- F ear of dying?.. Fear of losing control?.. Fear of going crazy?..
- Chest pain?..
- Choking?
- Chills or hot flushes?
… How long dose it take to reach its peak?”
Followed by more than a month of AWC:
- Anticipatory anxiety: “Do you have a persistent concern of having
other attacks?…. For how long?… So, it is more than a month?”
- Worry: “Are you worried about the consequences of the attacks?”
- Changes: “Have you changed your behavior accordingly?”
2. Generalized Anxiety Disorder:
“Are you a person that has an on going excessive worries or fears
about several things but can’t control them?”
“What makes you anxious?”
Anxiety disorder screen. Yes:  Explore OSCD PqrST UVW AAA.
… Continued
64
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
…. Cont.
- Duration: “When did it start?… So, it is more than 6 months?”
- What: “What are the thinks that you worry about?”
- BE SKIM: 3 (1 in children) of 6, for 6 months:
- Blank mind: “Do you feel blank minded? ”
- Easily fatigued: “How is your energy level? Do you feel tired?”
- Sleep disturbances: “How is your sleep?”
- Keyed up: “Do you feel most of the time you are on the edge?”
- Irritability: “Do you feel irritable?”
- Muscular tension: “Are you having any muscular spasm or pain?”
3. Phobic Disorder:
“Do you have a lot of fear or anxiety of something specific like
heights, bridges, snakes, social events?”
Phobia disorder screen. Yes:  Explore OSCD PqrST UVW AAA.
- HE Avoids
- “What happens if you are in these places/ situations/ facing these
things?”
- “Is your reaction reasonable or excessive?” Realize it is excessive.
- “Are you avoiding these places/ situations/ things?”
4. Obsessive-Compulsive Disorder: WRITE
“Do you have certain thoughts or behaviours over and over that you
need to get rid of?”
OCD screen. Yes:  Explore OSCD PqrST UVW AAA.
- WRITE
- “What are they?”
- “Are you having repetitive behaviors or mental acts that you feel
driven to perform in response to these thoughts?” Compulsions.
Yes:  “What are they?.. How frequent do you do them?.. For
how long?..”
- “Do you consider these thoughts as intrusive and inappropriate or
not?”
- “Are they time consuming, causing distress, and interfering with
your normal routine life?”
- “Have you felt that these thoughts & behaviors are excessive or not
reasonable?”
5. Post-Traumatic Stress Disorder:
“Have you ever experienced or witnessed a major physical or
emotional trauma or stress in your life that made you feel intense
fear, horror, or helplessness?”
PTSD screen. Yes:  Explore OSCD PqrST UVW AAA.
- Events persistently re-experienced: 1 or more of 5:
1- Recollections of images and thoughts: “Do you recall any images or
thoughts about that event”.
… Continued
65
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
… Cont.
2- Dreams: “Do you have distressing dreams about that event?”.
3- Flashbacks/ Acting out: “Do you feel yourself sometimes as if you
are having the same event again?”
4- Distress at exposure to cues that resemble the events: “Do you feel
distressed when you come across something that remind you about
the event?”
5- Physiological reactivity in response to cues: “Do you feel your heart
racing when you come across something that reminds you about
the event?”
- Persistent avoidness of reminding stimuli: 3 or more of 7:
1- Detachment/ emotional numbness: “Do you feel emotionally
detached from those close to you?”.
2- Diminished interest in significant activities: “Have you lost interest
in activities that were interesting to you?”
3- Inability to recall important elements of the event: “Do you remember
every aspect of the event?”
4- Restricted affect: “Do you have feelings towards someone and are
you able to express it?”
5- Avoidness of event reminding situations and activities: “Are you
avoiding places, people, or situations that remind you of the
event?”
6- Avoidness of event reminding thoughts or feelings: “Are you
avoiding thoughts, feelings, or conversations that remind you of the
event?”
7- Sense of foreshortened future: “Do you think that you won’t have a
normal life as others concerning career, marriage, children, or life
span?”
- Persistent increased arousal: 2 or more of 5:
1- Difficulty sleeping: “Do you have difficulty falling asleep or
maintaining sleep? ”
2- Irritability and anger outbursts: “Do you have periods that you felt
irritable or had bursts of anger? ”
3- Difficulty concentrating: “Do you have difficulty concentrating? ”
4- Hypervigilance: “Do you feel excessively vigilant? ”
5- Exaggerated startle response: “Do you get excessively startled by
trivial things? ”
- Duration: “When did it start?… So, it started more/less than one
month ago?”
4- Psychosis:
Schizophrenia: 2 of the followings for > 1 month active phase & residuals
for > 6 months.
1. Hallucinations: Auditory, visual, tasting, olfactory.
“Are you sensing things that others think they are not actually there,
like seeing, hearing, or smelling things?”
Hallucination screen. Yes:  Explore OSCD PqrST UVW AAA.
… Continued
66
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
… Cont.
- Duration: “When did it start?... So it is less than a month (Brief
psychosis)/ more than a month but less than 6 months (Schizophreniform)/
more than 6 months? (Schizophrenia)”.
- “What?……. Where?….. When?……”
- If auditory: “Are these voices familiar?... Whose voices are you
hearing?. Are they voices of one or more persons talking?. What do
they say?”
Diagnostic if two voices conversing to each other or one commenting on
his actions: “Are they telling you to do things?... What things?… Are
they commenting on your actions?”.
2. Delusions:
“Do you believe that there are unusual things happening concerning
you?”
Delusion screen. Yes:  Explore OSCD PqrST UVW AAA.
- Non-Bizarre:
- Persecutory: “Are you being followed?”
- Grandiosity: “Are you having special power, task, role?”
- Erotamia: “Are you being loved by another person?”
- Jealous: “Do you think your partner is unfaithful?”
Yes:  “ When did it start?” non-bizarre for > 1 month: Delusional disorder.
- Bizarre:
- Reference: “Are there events having direct reference to you?”
- Control: “Are you being controlled by some external sources?”
- Thought broadcasting/Insertion/ withdrawal: “Do others know
your thoughts?”
- Religious: “Are you having a religious mission or task?”
Yes:  “ When did it start?” Bizarre: part of schizophrenia.
Delusions are
firmly held,
fixed beliefs
that are
irrational to
the patient’s
culture.
3. Disorganized: “Do you get agitated, excited, or hostile?”
4. Thought disorder: “Are you unable to think straight?”
- Loss of association.
- Tangentiality: Jumping from subject to another.
- Incoherence
- Neologism (new words)
- Though blocking.
5. Negative Symptoms:
- Alogia: Poverty of speech. “Do you have difficulties finding words
to explain things?”
- Affective flattening: “Do you have less emotional or inappropriate
emotional responsiveness?”.
- Avolition: “Any loss of motivation, drive, initiativeness?”.
- Anhedonia: “Any loss of interest in things were enjoyable to you?”.
- Apathy: Lack of interest in the surroundings: “Have you lost interest
in things or activities that where interesting to you?” … Continued
67
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
… Cont.
5- C ognitive Disorders:
“ Do you have memory problems or forgetfulness? (Dementia), … Do you
feel agitated, irritable? (Delirium)”
Cognitive screen. Yes:  Explore OSCD PqrST UVW AAA.
- Onset: “How did it start? Was it all of a sudden (Delirium) or gradually?
(Dementia) ”
- Course: “Is it getting worse, better or just the same?”
Worse  “ How fast is it getting worse?” (Slowly progressively: Alzheimer/
Step wise deterioration: Vascular/ Fluctuating: Delirium).
- Duration: “For how long?” (Days-weeks: Delirium/ Months: Dementia).
- Severity:
- Memory: A must for diagnosis.
“Are the memory problems concern recent events or remote ones?”
(Recent/ Remote: Dementia/ Marked recent: Delirium).
- Sleep-wake cycle: “Any sleep problems?… Sleep like on and off?
(Fragmented: Dementia) … Sleep in the morning and awake all night?
(Reversed: Delirium)”
- Behavior: “Any impairment in your daily living activities or using
devices or appliances? (Dementia) ”
- Cognitive: 1 of 6:
- Liable mood: “Do you have mood swings?….”
- Aphasia: “Difficulty speaking?….”
- Agnosia: “Difficulty recognizing objects…?”
- Apraxia: “Impaired ability to carry out purposeful
movement?..”
- Impaired executive thinking: Abstraction/ Planning/ Organizing:
“Impaired ability to plan or organize things?...”
- Judgment impairment: “Impaired ability to make a
judgment?...”
- AAA:
- Wandering attention: “Do people tell you, you jump from subject
to subject?….”
- Distractibility: “Do you get distracted easily and cannot
concentrate?….”
- Disorientation: “Do you get disoriented to places or time
easily?….” (to people: Delirium: rarely / Dementia: advanced.)
- Misinterpretation/ Illusion/ Hallucination: “Are you sensing things
that are not actually there, like seeing, hearing, or smelling
things?”
- Affect: Anxiety/ Fear/ Depression/ Irritability/ Anger/ Euphoria/
Apathy: “Do you feel anxious, fear, depressed, irritable, angry,
high, don’t care?”
- Psychomotor activities shift: Picking of cloths/ Attempt to get out of
bed/ Sudden movements  Then: Sluggishness/ Lethargy
“Do you sometimes feel slow and other times feel energetic and
want to move around?”
…. Continued
68
The History Taking Interview: Station Appropriate Question Box: PSYCHIATRY
Psychiatric appropriate questions:
… Cont.
6- Psychiatric VITALS:
Must ask in all psychiatric cases.
1. “Do you have thoughts of hurting yourself?… Any suicide
attempts?... Any plans now?”
2. “Have you ever hurt anyone? … Any plans now?”
3. “Have ever had difficulty caring for yourself?”
4. “How has this been affecting you, your relationship, your family, or
your work?... What things are you no more able to do? ”
Marked distress needed for all psychiatric diagnoses.
7- Psychiatric Past Hx:
“Any other similar complaints in the past? … Any psychiatric illnesses
in the past? … How have you been before this?”
“Any problems with the police or the law?”
8- Family Hx of SADDD: Suicide, Alcohol, Drugs, Depression, Divorce.
“Any family history of suicide?... Alcohol abuse?... Depression?...
Drugs?.... Divorce?”
9- Standard Questions Box: FEW SAM MASF + Personal Hx +
HEADDSS + Sexual Hx + Safety (SAFE)
Mental Status Exam (MSE) or Mini MSE: = physical exam
GET PC
1.
2.
3.
4.
General: Appearance/ Behavior/ Attitude/ Speech.
Emotions: Mood/ Affect/ Appropriateness
Thought: Form/ Content.
Perception: Illusions/ Hallucinations/ Derealization/
Depersonalization.
5. Cognition: Alertness/ Orientation/ Memory/ Attention/
Knowledge & intelligence/ Abstraction/ Judgment/ Insight
69
The History Taking Interview: Station Appropriate Question Box: SCREENING
Neurology appropriate questions:
HLD NeW VHS MTC
“Do you have headache?”
“Have you passed out / blacked out?”
“Have you felt unsteadiness or light-headedness?”
“Do you have numbness, loss of sensation, or pain anywhere?”
“Any weakness?”
“Any visual changes recently?”
“Any hearing changes?.
“Do you have difficulty speaking?”
“Have you noticed any memory loss/ difficulty concentrating? ”
“Any tremor or involuntary movements?
“Do you control your bladder and bowel motion?”
Respiratory appropriate questions:
PCS Wheezes HEAT On Us
“Any chest pain?”
“Do you have cough?”
“Do you get shortness of breath?”
“Do you hear noises in your chest with breathing?.. What about in your
throat?.. Any change of voice?”
“How many flights of stairs can you climb/ blocks can you walk?.. So, it is
more less than two blocks/ one flight?” .
“Do your ankles swell on you?” When did it start?.. How long did it take to
go away?”…. “Any pain in your legs?”
“Any history of travel?.. Where?”
“What do you do for living?.. Does your ..(CC).. improve during weekends
or vacations?”.. “What exactly does this job involve?”
“Any exposure to people with HIV, TB, SARS?”.. “Have you ever felt your
heart racing?,.. Any face flushing?.. Any diarrhea”
“ Any running nose? Eye problem?.. Skin rash? ... Face pain, ... Do you
need to clear your throat frequently?”
Cardiology appropriate questions:
PCS OSAP PLC EAR
“Any chest pain?”
“Do you have cough?”
“Do you get shortness of breath? ”
“Are you able to lie flat in bed without becoming short of breath?”
“Any sweating?”
“Do your ankles swell on you?
“Have you ever felt your heart racing/ fluttering/ funny?”
“Have you passed out / blacked out?”
“Did you lose consciousness completely or could voices be heard?”
“Did your lips turn blue? ,…. Did your face turn pale?
“Do you have pain in your limbs?”
“How many flights of stairs can you climb/ blocks can you walk?.. So, it is
more/ less than two blocks/ one flight?”.
“Are you worried?.. Do you have a feeling of impending doom?”
70
The History Taking Interview: Station Appropriate Question Box: SCREENING
Gastrointestinal appropriate questions:
PAN HSBG JBO +Risk
“Any stomach pain? ”
“Any change in your appetite recently?”
“Do you feel sick? , Did you throw up? ”
“Do you have water brush?.. Any burning sensation in the middle of your
chest that radiates to your mouth?”
“What about your swallowing, any difficulty?”
“Any gases?
“What about your stomach girth?.. Is it bigger?.. Do you feel any lumps or
bumps?”
“Did your skin or the eyes’ white areas turn yellow or red?.. Any change in
your urine color?… Is it dark like tea or cola?… Is your skin itchy?.. Any
bad mouth smell?”
“Any change in your bowel habit recently?”
Only if bleeding, diarrhea or vomiting (DTHU):
“Do you get lightheadedness?, ...What about when you stand up or get out
of bed in the morning?”,... Do you feel thirsty and your mouth dry?,...
Have you ever felt your heart racing?,... Do you void less? ”
Genitourology appropriate questions:
PD UHF SUV FIDO
“Any pain?”
“Any pain while passing water / voiding/ peeing?”
“Any urgency to void/ pee? .. Hesitancy? .. Straining? .. Any feeling of
incomplete emptying?”
“Is there any change in the frequency recently?” “Is it more or less? What
about at night, do you wake up to go void?
“Any recent change in its volume?
“Tell me about your urine”
“Do you control your bladder?”
“Any face puffing in the morning?.. Do your ankles swell on you?”
“How much fluid do you drink in a day?”
“Any penile/ vaginal discharge? ”
- Colour: “What colour is it?.. Is it white, yellow or green?”
- Blood: “Any blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it thin or thick?”
- Smell: “Does it smell?”
- Quantity: “How much discharge is it?”
“Any eye, joint or skin problems?,… Kidney stones?”
71
The History Taking Interview: Station Appropriate Question Box: SCREENING
Endocrinology/Hematology appropriate questions:
WENT MSN ENG RPL
“Any recent weight changes?”
“What about your energy? Any recent change?” “Do you feel more
energetic or do you become fatigued easily?”
“Do you feel nervous or anxious most of the time?... Have you ever felt
your heart racing?... Any tremor?”
“Does the heat or cold bother you more than you think it bothers other
people?….. How?..”
“Any recent mood changes?, Do you feel low?... Have you lost interest in
doing activities that were enjoyable to you?”
“How do you feel your skin; dry or moist?.... ”
“Any rash or pigmentation?... Did your face turn pale?.... ”
“Do you easily bleed or get bruised?”
“Any recent change in your hair growth and distribution?…. ”
“Any nail shape changes?”
“Have you noticed any lumps in your neck or felt it wider?”
“Any recent visual changes?.. Eye pain?… Colour changes like redness or
yellowness?… Shape change?”
“Do you have headaches?… Do you feel lightheadedness?… Do you feel
any pins & needles sensations?.. Any muscle weakness?.. What activities
do you have difficulty with?”
“Do you feel sick?, Did you throw up?”
“How is your appetite?… ”
“Any mouth ulcers?... ”
“Difficulty swallowing?...”
“Any change in your bowel habit?…”
“Any black stool or bleeding from your bottom?...”
“Do you feel thirsty frequently? ... How much fluid do you drink in a day?
”
“What about passing water/ voiding, any change?... Is it more or less than
usual? …” “Is your urine red or cloudy?…”“Do you have kidney stones?”
“Any stomach, joint pain, bone pain, muscle pain?”
“Mr/Ms .., in order to understand your condition, I need to ask you some
questions about sexual history. Is that okay?…….”
“Any changes in your sexual desire/ menses?... How?”
72
The History Taking Interview: Station Appropriate Question Box: SCREENING
Musculoskeletal appropriate questions: joint PR STD, ROMAN’S
Activity MisS NG
“Any joint pain?”
“Any joint redness?”
“Any joint swelling?”
“Have you ever had any trauma, procedure, injections or surgery on any
joint?”
“Do you have to do the same movements repeatedly at work or home?”
Trauma Case: “Have you heard a click when it happened?”“Were you
able to bear weight immediately after the incident?”
“Any deformity in the joint shape?… Do you feel your (joint) unstable?...
Locking? .. Any change in your gait pattern?”
“Is there any reduction in the range of movement of your ….
(shoulder/elbow/wrist/finger/thumb/hip/knee/ankle/toe/back)?”
“Any noises with movement?” “Any movement stiffness when you wake up
in the morning?”
“How has this been affecting your daily activities?... What activities do you
have difficulty with or are unable to do?… Who does the cooking, the
shopping, the laundry, the cleaning for you?...”
“Any muscle pain?.. Weakness?.. Wasting?.. ”
“Any change in skin colour?... Redness?... Bruises?... Warmth?... Rash?...
Skin tightness on your face or hands? … Eye redness or pain?”
“Any changes in skin sensation like less than before?… Tingling
sensation?... Any headache?... Difficulty speaking?... Vision
problem?... Do you control your bowel or bladder?… Any back pain?”
“Any mouth ulcers?... Difficulty swallowing? ... Frequent episodes of
diarrhea & constipation?... Bleeding from your bottom?”
Dermatology appropriate questions:
RUSC NJE CHD
“Any skin rash?”
“Does it ulcerate or bleed?”
“Any itching or burning sensation?”
“Any change in the skin colour?”
“Any change in your nail’s colour or shape?”
“Any joint pain or swelling?... Any joint redness or warmth?”
“Any recent eye changes?”
“What do you think is causing it?… Any contact with chemicals?...
Have you noticed any relation to heat, cold, sunlight?... What about to
food or spices? ... What is your occupation?”
“Any family history of atopy or allergies?…Skin cancer?... Psoriasis?”
“Mr./Ms…, as you may know, some sexual diseases causes skin changes.
That is why I ask all my patients whether they have any sexual disease
such as (penile/ vaginal) discharge?”
“What colour is it?.. Is it white, yellow or green?” “Any blood?” Yes 
“Is it drops or more? How much blood? “Is it thin, thick or with
pieces?” “Does it smell?” “How much discharge is it?”
- Timing (FEMALE): “Does it change with your cycle? Is it worse before
or after the cycle or no difference?”
73
The History Taking Interview: Station Appropriate Question Box: SCREENING
Gynae/Obstetric appropriate questions:
MDP Do Uyou Csee SOOS
“Ms .., in order to understand your condition, I need to ask you some
questions about your female organs. Is that okay.”
“When was the first day of your last period?”
“Is there any recent changes in your cycle regularity?... amount?...
duration?... frequency?”…. “ Any abnormal bleeding? ”
“At what age was your first / last period? At what age was your first sexual
encounter?... When was your last sexual encounter? (Only in cases of abuse)”
“Any lower abdominal or pelvic pain? ”
“Do you have any vaginal discharge?”
- Colour: “What colour is it?.. Is it white, yellow or green?”
- Blood: “Any Blood?” Yes  “Is it drops or more? How much blood?
- Content: “Is it thin, thick or with pieces?”
- Smell: “Does it smell?”
- Quantity: “How much discharge is it?”
- Timing: “Does it change with your cycle? Is it worse before or after the
cycle or no difference?”
“Is it painful to pass water?... Any urgency?... Change in frequency?… Do
you control your bladder?... Any vulvular itching or redness?.. Any warts
or ulcers”
“Any face puffing, fingers or ankles swelling?”
“Any hormonal therapy?.. What do you use for birth control?.. For how
long have you been using it?.. Any side effects or failures?.. What about in
the past, tell me all methods you’ve tried?.. Why did stop it?.. For how
long did you use it? ”
“Any? Surgeries, Procedures/ Injuries, Trauma / Blood transfusion /
Hospitalization ………….. ”
“When was your last Pap smear done & where?.. What was the outcome &
follow up?”
“Any previous women problems?.. Fibroids?.. Pelvic infections?.. Cysts?”
“Any pregnancies, miscarriages, abortions in your life?… Any abnormal
pregnancies?”
- Current pregnancy: ABCDE DR:
“How is the baby’s movements? (For those > 18 weeks )” “Any bleeding?
“Contractions?.. “Is there any vaginal dripping?.. “When will be your due
date?”.. Which doctor is taking care of this pregnancy?” “Are all routine
tests & U/S done?.. What are the results?”
Complication? High blood pressure, diabetes, headache, visual changes, kidney/liver/thyroid disease
“Any breast changes?,.. Skin lesions?,.. Groin/ axillary lumps?,… Joint/
back pain? ”
Pediatric appropriate questions: GEEN MS CAM BINDE+/- HEADDSS
ALL
74
The History Taking Interview: Station Appropriate Question Box: SCREENING
Psychiatric appropriate questions: AL MAP CVP SADDD +
(FEW SAM MASF + SAFE + HEADDSS)
“Are you seeing other doctors?”
“You look sad/ upset, is there something bothering you and want to talk
about?” OR “ You look very energetic/ restless/ moving around a lot, can
you sit down here so we can talk?”
“How is your mood?... Are you feeling down?”
“Have you lost interest in doing activities that were enjoyable to you?”
“Have others around you noted a persistently elevated, expansive mood,
energy, self-esteem? ”
“Have you experienced a sudden onset of intense fear or discomfort?”
“Do you have fear going to closed or crowded places? ”
“Are you a person that has an on going excessive worries or fears about
several things but can’t control them?”
“Do you have a lot of fear or anxiety of something specific like heights,
bridges, snakes, social events?”
“Do you have certain thoughts or behaviors over and over that you need to
get rid of?”
“Have you ever experienced or witnessed a major physical or emotional
trauma or stress in your life that made you feel intense fear, horror, or
helplessness?”
“Are you sensing things that others think they are not actually there, like
seeing, hearing, smelling things?”
“Do you believe that there are unusual things happening concerning you?”
“ Do you have memory problems or forgetfulness? … Do you feel agitated
irritable?”
“Do you have a thought of hurting yourself?… Any suicide attempts?... Any
plans now?”
“Have you ever hurt anyone? … Any plans now?”
“Have ever had difficulty caring for yourself?”
“How has this been affecting you, your relationship, your family, or your
work?... What things are you no more able to do? ”
Marked distress needed for all psychiatric diagnoses.
“Any other similar complaints in the past? … Any psychiatric illnesses in
the past? … How have you been before this?” “Any problems with the
police or the law?”
SADDD: “Any family history of suicide?... Alcohol abuse?...
Depression?... Drugs?.... Divorce?”
75
The History Taking Interview: Station Appropriate Question Box: SCREENING
76
Chapter 12: THE STANDARD QUESTIONS BOX
1- FEW SAM MASF
2- Social/Occupational
3- Sexual Hx
4- Safety (Abuse)
5- HEADDSS (Teens)
Transitional statement:
“Mr./Ms…. , now, I am going to ask you some
questions about your health that I ask all my
patients. Okay?”
“Do you have…?”
“Have you had any... recently?”
“How about…?”
“Do you get…?” “Have you noticed any…?” “Have you ever gotten…?”
Standard Questions Box: FEW SAM MASF
1-
Fever: “Any Fever?... Night sweating?... Chills or rigor?”
2-
Energy/Fatigue: “What is your energy level like?… Do you become
fatigued easily?”
3-
Weight change: “Any recent weight changes?” Yes, “In what way?..
How much?” “Any nausea, vomiting, diarrhea, or constipation?” “How
is your appetite?” “Tell me a little bit about your eating and exercise
habits?”
Yes explore GI.
“When was your last meal or snack, and what was it?” ER cases.
4-
Smoking:
Pack-Year (# of years / # of packs a day)
“How much do you smoke in a day?.”
Yes  “For how many years?” “What about in the past?”
5-
Alcohol: “How much alcohol would you drink in a day?” If not daily:
“How much a week?”, “What is it?” “What about in the past?”
If > 9-14 drinks/week or suspicious  CAGE:
- Cut:
“Have you felt the need to cut down your drinking?”
- Annoyed: “Have people annoyed you by criticizing your drinking?”
- Guilt:
“Have you ever felt guilty about your drinking?”
- Eye opener:“Have you ever taken a morning ‘Eye opener’ drink?”
6- Medical Hx of illnesses:
“Do you have any ongoing medical problem?”
Yes explore:
- “When was it diagnosed?”
- “How was it treated?” Write down all
- “When was it lastly checked?... What were the results?”
- “Who was the doctor taking care of it?”
- “Do you have heart problem?,… High blood pressure?,… Stroke? ”
- “Diabetes?,…. High blood cholesterol?”
- “Kidney disease?,… Liver disease?”
… Continued
77
The History Taking Interview: Standard Question Box
Standard Questions Box: … Cont.
FEW SAM MASF
- “Irritable bowel?,… Inflammatory bowel disease?,… Intestinal
Polyps?,… Colon cancer?”
- “Asthma?,… Allergies,… Joint problems?,… Eye problems?,…
Rheumatic disease?”
- “Headaches?,… Epilepsy?,… Depression?,… Confusion?,…
Memory problems?”
- “Anemia?,… Easy bruising or bleeding?,… Thyroid problems?”
- “Breast cancer or ovarian cancer?” for females.
7- Medications: “Are you taking any medications now?”
Yes  Explore:
- “What are they (Name)? .. ”
- “What is the dose?.. How frequent a day?”
- “For how long you’ve been taking this (Duration)?.. ”
- “Have you noticed any side effects?,.. ”
- “Who prescribed it?… ”
“What about medications in the past?”
NSAID/ Steroids abuse: “How frequent do you take Aspirin, Tylonol,
Profen or steroids?”
OCP: for females: “Are you taking birth control pills?”
Drugs: “What about Street / Recreational drugs?.. Over-The-Counter
(OTC) or Herbal drugs?” “What about in the past?”
8- Allergies: “Do you have any allergies?”
Yes:  “To what?,…What happened when you took it?” (side effects or true
allergy?)
9- Surgeries or Procedures / Injuries or Trauma / Blood transfusion /
Hospitalization: “Any…?”
10- Family Hx (FHx): “Mr./Ms…., I’d like to know a little about your
family. Are there any illnesses that seem to run in your family?”,…
“Has anyone in your family had a medical problem?”
“Has anyone else at home or work been sick lately?”
Yes: “At what age? ” “What was the outcome?”
“Any family history of ……..(repeat the medical history list above in 6)”
Empathy for bad news
* If patient becomes anxious:  “You sound anxious, is there anything
you want me to know?,… Usually I take some family history from all
my patients”
…Continued
78
The History Taking Interview: Standard Question Box
Standard Questions Box: … Cont.
FEW SAM MASF
11- Personal History (PHx): SOHSS
A) Social / Occupational:
“Mr./Ms… can you tell me a little about yourself:….”
1- How do you support yourself financially?
2- How have things being going for you at work / home?
3- Do you think that anything at work / home is affecting your health
now?
4- What exactly does this job involve?..Sitting, standing, walking? For
how long?
5- What about the job before this one?
6- Who live in your household?
7- Are there family members nearby who are willing and able to help
you?
8- Who does the cooking, the shopping, the laundry & cleaning, the
accounting for you?”
B) HEADDSS: Teenagers only (13-19 year), skip this step for others:
“Now I want to ask you some questions about your life in order to
know you better. I assure you that all what you’ll tell me stay
between us, okay? ”
1- Home: “Where do you live and with whom?... Any recent move?…
How is your family relationship?… Have you ever run
away?…. (Yes: Why?)…”
2- Education: “Do you attend school?... What grade?... Any problems
at school?… Any failures or suspensions?… What are your
future plans and goals?”
3- Activities: “Do you participate in extracurricular activities, sports,
social events, clubs?… Who is your best friend?… Any gangs
involvements?”
4- Drugs: “Do you take street drugs?..” Yes: “What drugs?... How
much?... How frequent?... Alone or with friends?”
5- Diet: “Tell me about your eating habits?.. Any history of eating
disorders?.. anemia?.. obesity?”
6- Suicide: “Have you ever thought of harming yourself?... What about
suicide?... Any plans?... Do you have history of depression”
7- Sex: “I always include questions about sexual problems in my
routine medical history taking because they are so common.
Is it okay to ask you some questions?”… “What about
dating?..”
Continue with (C) Sexual Hx.
79
The History Taking Interview: Standard Question Box
Standard questions: ……Continued
C) Sexual History:
“Mr. Ms…, I always include questions about sexual problems in my
routine medical history taking because they are so common. Is it okay
to ask you few questions?”… Best one. OR
“Mr./Ms…, I know sexual concerns can be hard to discuss, especially
with a stranger, but it sounds as if you have some concerns, tell me
more?” OR
“Mr./Ms…, many people in a situation like yours, experience a change
in their sexual function. Have you noticed any change? ”
1- Active: “Are you currently in a relationship?” No/or “Are you
sexually active?”
Yes for any of the question:  “Male, female or both?”
2- Duration: “For how long have you been in the current relationship?...
So, more than 3 months (<3 months: STD risk)”
3- Relation: “How have things being going in this relationship?.. Does
your partner knows about your current situation?”
4- Satisfied: “Are you satisfied with your sexual life?... Any recent change
in your desire? (Libido changes with medical and psychiatric illness)”
5- Safe sex: Not for married: “Are you practicing safe sex, I mean the use
of condoms all the time?”
6- Experience: “What are the types of your sexual experiences? I mean
oral, anal sex?”
7- STD: “Is there any reason for you to be at risk for sexually transmitted
diseases?”…
“Have you ever been tested for sexually transmitted diseases? ”
Yes: “For what?… When?… Results?… Treatment?”
“How about your partner?... Your previous partners or your
partner previous partners?”
8- Number: “Have you ever been with more than one partner at the same
time? (>1 : STD risk) ”
9- Abuse: “Any history of sexual abuse or assault?”
10- Money: “Have you ever paid or received money for sex?”
D) Safety: “SAFE”: For elderly and women abuse, psychiatric illness:
1- Safe: “Mr./Ms… do you feel safe in your relationship or home?”
2- Afraid: “Are there situations in your relationship or home where you
felt afraid?”
3- Friends/Family: “If you have been hurt, is there anyone that you can tell
like a friend or a family member?... Would they be able to help
you?”
4- Emergency Plan: “Do you have a safe place to go and the resources you
need in an emergency situation?… ” No “Would you like
help in locating a shelter?… Would you like to talk to a social
worker?”
80
Chapter 13: THE WRAPPING UP BOX
Wrapping up the interview is very important. At the last 30-60 seconds of the
interview (minute 4.5 or 9 or 14 for 5, 10, 15 minutes stations), start the wrap up even
if you didn’t finish the history taking or focused history and physical exam.
Wrapping Up Box: NENDF
1- “Okay Mr/Ms…is there anything else you’d like to tell me or ask me?”
2- Next Step: “I need to examine you and send you for some
investigations, but from what you told me so far, your problem is…..
(DDx or Dx)” DDx always better.
3- Educate him/her in short explanations about the
1. Illness: “What do you know about … (CC or Dx)?”
“This is because of… or … or … which is ……”
2. Prognosis: Clearly & truly inform him/her about the prognosis:
If treatable  Assure: “There is nothing to be worried about so
far?”
If severe/ chronic/ bad  Discuss family & community support:
“This issue won’t be solved in a short time. It will stay with you
for the rest of your life.
Is there a family member or a friend that would be able to help
you? We will do our best to help you deal with it.
There are also some community resources that you can use.
Would you like to talk to a social worker?”
3. Investigations and its results: “I’m going to send you for… (some
blood work / X-Ray / CAT scan / Ultrasound), which will help us to
figure out the cause or confirm it.”
4. Management/ Medications and their side effects:
- Painkiller for now waiting for the further investigations: “I’ll write
a pain killer for you now and we’ll discuss your options to deal
with this issue later after the investigation results come back.”
- Management now: “To deal with this, your option(s) is/are: You
can take some medication. It helps in….. (its action). There is a
little chance to have side effect like … . If that happens, call me.
OR you can…. (eg. go for surgery) ”
“What would you like to do?”
4- Negotiate with him/her an agreed upon PLAN OF ACTION. A
CONTRACT. Clarify his/her and your responsibilities:
“Okay, so I’ll send you for the investigations, you will take the
medication/ change your life style & report progress ”
5- Disposition: Admission or send him/her home. “Meanwhile we need to
(keep you here in the hospital/ send you to the hospital) for a couple
of days to ensure close medial care for you. I’ll make the
arrangements, okay.”
6- Follow up: “I want to see you next week / in a month.”
7- Last word in the interview is for the patient: “Anything else?…..”
“It was nice to meet you, have a nice day.”
END
81
The History Taking Interview: WRAPPING UP Box
TIPS:
Wrapping up is a must. Never leave the room without it. If you didn’t finish your
questions, mention that and proceed to wrapping up the interview:
“Mr/Ms ….., There are still some other questions that I would like to ask you. But
as we are running out of time today, I’ll postpone that to our next meeting.”
“Okay Mr/Ms…is there anything else you’d like to tell me or ask me?” and continue
with the rest of the wrapping up box.
82
Chapter 14: THE COUNSELING INTERVIEW
The counseling interview is in fact a focused history taking and counseling
interview.
The counseling MODEL:
1- The Minute Before the interview.
2- The Introduction.
3- The Initial Counseling Questions box (confirm what to counsel.
Replaces the CC and HPI boxes).
4- The Station appropriate questions box.
5- The Standard questions box.
6- Effect on patient and family.
7- The Counseling box.
8- Wrapping up.
You should go through each step while budgeting your time.
1- The minute before:
Like in the History taking model.
2- The Introduction:
Like in the History taking model.
3- The Initial Counseling questions box:
The Initial Counselling questions:
“Mr/Ms …, what brings you here today? / I understand you are here
today for …(Subject) ”.
1- “What do you know about … (Subject)?”
2- “What would you like to know about … (Subject) ?, What questions
did you hoped to get it answered today?”…. “So, you want to
know…. ”
3- “Have you had any experience with … (Subject) in the past?”
4- “Why now?”
5- “Have you talked to someone about … (Subject) or read some
information or searched the net?”
6- “Is there something you’re worried about concerning the …
(Subject) ?, What triggered this issue?”
4- The Station Appropriate questions box:
“Mr./Ms…, before we talk about the… (Subject), I need to ask you some
important medical questions”.
Then ask the questions in the History Taking Station Appropriate Boxes. This will
be pretty quick as the patient’s answers will be mostly negative.
83
The Counseling Interview:
5- The Standard questions box:
Then ask the questions in the History Taking Standard questions Boxes.
Concentrating on subject related risk factors, complications, and
contraindications.
6- The effect on patient and family box:
Empathy:
“Mr./Ms…, how does this issue been affecting you and your family right now?”
Or “I can see this issue has been difficult for you, how are you coping with it?”
7- The Counseling box:
“Mr./Ms…, let me give you some information about the ….(Subject)”.
Then EDUCATE the patient about: SRS AI OEM
1- Subject: In small chunks asking him in between:
“Am I making sense?” or “Is that clear?”
2- Risk factors/ Seriousness: of not acting on the subject. (e.g Keep smoking)
“As you may realize, …..(Subject) causes …”
3- Side effects and complications of acting on the subject, emotionally and
physically, and how to avoid them. “There is a chance to have …. as a
side effect. If that happens, you can …./ call me/ go to emergency.”
4- Alternatives: of acting on the subject.
“To deal with this, there are other options. …..”
5- Investigations: “I’m going to send you for some (blood work and X-Ray
/Ultrasound), which will help us to rule out any contraindications.”
6- Outcome/ Prognosis: Clearly & truly: If treatable/successful  Assure.
If severe/ chronic/ bad  Discuss family and community support.
See “Prognosis” in page 73.
7- Effect on patient: “Now, how do you feel about that?”
8- Mode of Usage: Pills, puffs, patches, injections, instruments, ..etc
8- Wrapping up:
1- “Okay Mr/Ms…is there anything else you’d like to tell me or ask me?”
2- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT.
Clarify his/her and your responsibilities:
“Okay, so I’ll send you for the investigations, you will take the medication/
change your life style and report progress ”.
3- Follow up: “I want to see you next week / in a month.”.
4- Last word in the interview is for the patient: “Is there anything else you’d like to
tell me or ask me?”.
5- “It was nice to meet you, have a nice day.”
84
The Counseling Interview
There are several scenarios for consult cases:
1. ER Consult: After settling of an acute event at the emergency. e.g. MI,
Asthma attack, Diabetes emergencies, Fit, Needle stick … etc.
2. Follow up Consult: Follow up after investigation results came back,
Management follow up, or Prognosis. e.g. Asthma control, Diabetes control,
HIV positive.
3. Consult visit: First time visit for a consult issue. e.g. Contraception,
Hormonal replacement therapy, Smoking, Alcoholism, … etc.
TIPS:
-
Make a list of common counseling station. Visit www.oscehome.com.
For each subject, prepare a one page long of the following information:
1.
2.
3.
4.
Definition, causes, and prevalence.
Risk factors and illness seriousness.
Solutions or treatments and common alternatives.
Methods, frequency, and duration of using the
solutions/treatments.
5. Side effects of using each of these solutions/treatments.
6. Contraindications for each solution/treatment.
7. Needed screening and maintenance investigations and follow up.
8. Complications of not taking an action/treatment.
9. Outcome and prognosis of both using and not using the solution/
treatment.
10. Available community services for support, if needed.
-
Make sure to address the patient’s concerns and questions.
Practice each subject using the counseling model described above.
85
86
PART THREE
THE PHYSICAL EXAMINATION
INTERVIEW
87
88
Chapter 15:
THE PHYSICAL EXAMINATION
INTERVIEW
Physical examination stations will account for at least one third of the cases in any
OSCE exam. The following models and actions listed in chapters 15-25 are not for
emergency room setting which will be described later in Part Four.
The MODEL
Like the History taking interview, you need to be organized, thorough, and not to
forget important points, in the five, ten, or fifteen minutes interview. You will
follow the following steps IN SEQUENCE while budgeting your time.
Use every possible opportunity while going through these boxes to develop a
relationship with the patient. Be gentle and friendly and use verbal and nonverbal
communications.
The MODEL:
1234-
The Minute Before the interview.
The Introduction.
(15 seconds)
The physical examination. (4/8/13 minutes)
Wrapping up.
(0.5-1.5 minute)
1- The minute before: Like in the History taking model.
2- The Introduction: (15 seconds)
1- Like in the History taking model.
2- Summarize what you have asked to examine: “Mr./Ms. …., I am here to
examine your …., I am going to …explain briefly . Are you ready?”
3- Position the patient. “Will you please sit down here/ lie down flat on your
back here, please” if is not already in position.
4- Drape the patient. VERY IMPORTANT. Pay attention through out the
interview to keep unneeded body parts covered.
5- If the examiner is present, tell the patient: “I’m going to explain what I’m
doing to my colleague there, okay?”
3- The Physical examinations: (4/8/13 minutes)
- Explain what are you going to do to the patient before touching him/her.
- Stand beside the patient’s right side WITHOUT obstructing the examiner
point of view as much as you can (if the examiner present).
- Tell the examiner your findings. Talk to examiner without looking at him.
- Never use the word “touch”, instead, use ‘feel’.
- Uncover only the needed areas when needed and cover it back when you
finish.
- Don’t repeat painful maneuvers and apologize to the patient.
89
The Physical Examination Interview:
- If the patient is in pain or asking for a painkiller: acknowledge and say:
“I can see you are in pain. I’m going to give you some medication for the pain
later if needed as I need first to examine you to figure out the cause, okay”.
Station appropriate physical examination:
Chest.
Cardiovascular.
Abdomen.
Gynecological.
Head & Neck.
Neurological.
MSK.
Pediatric.
Emergency.
Obstetrical.
4- Wrapping up: (0.5-1 minute)
NENDF
1- “Okay Mr./Ms….. I’m done here. Is there anything else you’d like to tell me
or ask me?”
2- Next Step: “I am going to write my findings in your chart/ inform your
doctor/ send you for some (blood work, X-ray. CAT scan, Ultrasound) which
will help us to figure out the cause or confirm it.”
3- Educate him/her in short explanatory periods about the:
Findings: “I found …?” “This can be due to… or … or … which is ……”
4- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT.
Clarify his/her and your responsibilities: “Okay, so I’ll write my findings/
inform your doctor, you will continue with your previous instructions for
now.”
5- Disposition: Admission or send him/her home. “Meanwhile we need to (keep
you here in the hospital/ send you to the hospital) for a couple of days to
ensure close medical care for you. I’ll make the arrangements, okay.”
6- Follow up: “I want to see you again after the results come back in the next
few days/ week to discuss our next step.”
7- Last word in the interview is for the patient: “Anything else?…..”
“It was nice to meet you, have a nice day.”
Note:
Through out the physical examination, you have to explain every step to the patient
before you start. In this book, your explanation will be listed after the heading “Ms/Ms,”.
Then at the end or while performing it, comment on your findings to the examiner (if
present). Your comments will be listed after the heading “To the examiner”. The patient
(or the examiner if present) may give you verbal or written findings. This will ONLY
happen when you mention what are you doing. For example: when you mention that you
are listening to the heart sounds, he/she may inform you that there is a systolic murmur
heard. If you don’t mention that, he/she will NOT give you that information.
If no examiner is present, these listed comments are your patient note findings.
90
Chapter 16: CHEST EXAMINATION
Chest examination:
The whole exam is done while the patient is sitting.
1- General appearance:
“Mr./Ms..., What is the date today?,… and where are you now?”.
To the examiner 1-“Patient is/is not in distress, alert, oriented...
2- There is / is no sweating.
3- The patient is sitting/ lying comfortably/
sitting leaning forward supported by his
arms. (SOB)”
2- Ask for Vital signs:
To the examiner “What are his/her vitals, please? ”
Carefully listen to what the examiner says or read the vitals & comment:
e.g. “Normal/ so, he has fever/ tachypnea….”.
Children:
Abdominal
breathers
Men: Upper &
lower thoracic
breathers
Women: Upper
thoracic
breathers
Elderly: Lower
thoracic &
abdominal
breathers.
Cheyne-Stock
breathing:
Periods of gradual
deep breathing
alternate with
periods of apnea.
“Mr/Ms…, let me feel your pulse”
Respiratory rate and pattern: Normally 12-16 bpm.
Immediately after taking the pulse and while continuing pretending
taking the pulse.
To the examiner 1- “Breathing is Regular/ Irregular at … bpm.
2- Uses/ does not use accessory muscles.
3- There is / is no nasal flaring.
4- No/ Stridor.
5- No/ difficulty speaking.
6- No/ Kussmaul or Cheyne-Stock breathing.
7- No/ Pulsus paradoxus.”
3- Inspection:
Patient is sitting
1- Hands: “Mr./Ms…., will you please let me see your hands.”
To the examiner “There is / is no…” while inspecting: CSA
1. Color: (Red/ Yellow/ blue)
1) “Palmar erythema”,
2) “Nicotine stain”,
3) “Peripheral cyanosis” (bluish cool fingers, toes)
2. Shape:
1) “Clubbing”,
2) “Muscle wasting”(thenar) ,
3) “Contractures” (Dupuytren’s).
3. Asterixis:
“Mr/Ms ..., I want you to extend both your arms and back
flex your hands just as if you’re stopping a bus like this….
That’s right, now close your eyes……. Thank you.”.
To the examiner “No asterixis.”
Causes:
Drugs,
Cerebral damage,
CHF,
Uremia.
Hyperpnea
(Kussmaul
breathing):
Rapid deep
breathing.
Causes:
Exercise,
Anxiety,
Metabolic acidosis
Asterixis:
It is brief, jerky
downward
movements of the
wrist when
patient extends
both arms with
wrists
dorsiflexed,
palms forward &
eyes closed.
Causes:
Hypercapnia
… Continued
91
The Physical Examination Interview: CHEST EXAMINATION
Chest examination:
… Cont.
2- Face:
To the examiner “There is / is no…” while inspecting:
CSM
5. Colour:
1) “Plethora” (pink) ,
2) “Jaundice” (while looking on the sclera),
3) “Central Cyanosis” Central: blue lips & buccal mucosa: SO2< 80%
4) “Pallor”.
6. Shape:
1) “Cushinoid / moon face” (round, puffy).
2) “No Myosis, ptosis” (Horner Syndrome)
7. Mouth: “No pursed lips” (emphysema).
Chest
Shapes:
Barrel chest:
(AP =Lateral)
Funnel
chest (Pectus
excavatum):
Sternal
depression
(with mitral
valve disease)
Pigeon chest
(Pectus
carvinatum):
Anterior
protrusion of
the sternum).
Kyphosis:
Abnormal AP
curvature.
Scoliosis:
Abnormal
lateral
curvature.
92
3- Chest: “Mr./Ms…., I’m going to uncover your chest.”
Uncover the chest. Look from the front & back.
To the examiner “The chest is/ There is …” while inspecting: CSS
1) Contour: “Symmetric / Not Symmetric”
Normally AP diameter < lateral diameter (eye-balling).
2) Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest. No
Kyphosis or scoliosis.”
3) Skin: 1) “No Surgical scars or dilated veins.”
2) “No intercostal retraction”
4- Palpation:
Warm up your hands.
“Mr./Ms. …, I’m going to feel your neck.”
1. Trachea: Position (midline/slightly to the right) and mobility.
Place the right index finger in the suprasternal notch and move it
laterally to each side.
- Tracheal deviation will be away from the contralateral
pneumothorax or effusion.
- Fixed trachea: Mediastinal tumor, TB.
To the examiner “Trachea is midline and mobile.”
2. Neck lymph nodes: (Supraclavicular, Anterior and lateral cervical LNs
bilaterally with both hands fingers in circular movements).
To the examiner “There is / is no cervical lymph nodes.”
3. Chest: “Now, I’m going to feel your chest” Patient is still sitting
1) Areas of tenderness: Compress the chest from side to side and
front to back for tenderness “Any pain?”
To the examiner “There is / is no areas of tenderness”
2) Respiratory excursion: “Mr./Ms…, I want to check your chest
expansion. Please hold both your arms crossed on your chest”
(to move the scapulae aside while sitting).
Place your hands flat on the back of the patient’s chest during
normal expiration, with the thumbs parallel in the midline at T10
level & pull the skin slightly to the midline.
“I’ll put both my hands on your back…. Now, take as deep a
breath as you can and hold it, ….. Breath normally.”... Continued
The Physical Examination Interview: Chest Examination
Chest examination:
… Cont.
Normally, the thumbs should move 3-5 cm symmetrically away
from each other. Use your fingers to measure the distance
To the examiner “Chest expansion is symmetrical and normal
at about 2 fingers. That is about 4 cm.”
3) Tactile Fremitus (TF): Place your ulnar side of the hand on the
patient “Mr/Ms.., say ‘99’, … again”. Compare side to side
starting anteriorly at the supraclavicular spaces (lung apex) as
you move down to the 10 th rib. Then on the back starting at the
suprascapular spaces medially down the six posterior positions in
a zigzag pattern.
To the examiner “Tactile fremitus is symmetrical & normal.”
5- Percussion:
To be done on the same areas of the tactile fremitus, front and back.
Normal chest is resonant except in the left 3-5 ICS (Cardiac dullness).
“Mr/Ms…, I’m going to tap on your chest with my fingers.”
Put your left middle finger firmly on the patient (other fingers off) and tab
the middle phalanx with your other middle finger moving your wrist only.
Examine anteriorly and compare from side to side at the same level. Then
“Mr/Ms…, raise your hands above your head” and percuss the axillae
and compare both sides. Then percuss the back.
To the examiner “Percussion is symmetrical and normal./ hyper, dull
on the right at ...ICS.”
Diaphragmatic excursion: To locate the level of the diaphragm with
deep inspiration and full expiration. Normally 4-5 cm.
“Mr./Ms. …., I’m going to draw some marks on your back with a
washable pen, Okay?.” Look for the pen quickly.
On the patient’s back, percuss from up moving down on one side looking
for a change from resonance to dullness while the patient is on quiet
breathing. Mark the area. Then, without removing your finger off the
patient, ask “Mr/Ms..., take as deep a breath as you can and hold it in”.
Continue percussing moving inferiorly to locate the new level and mark it.
Then, without removing your finger off the patient, ask, “Now, let as
much as you can out and stop breathing”. Continue percussing moving
superiorly to locate the new level and mark it.
Measure between the two lines. Repeat on the other side.
- Report the diaphragm level at the vertebra T.. (count from C7 down),
and the excursion for each side.
To the examiner “Diaphragm is at T12, the diaphragmatic excursion is
4 cm on the right and 4 cm on the left. Symmetric”
Tactile
Fremitus (TF):
- TF Increased:
Consolidation.
- TF Decreased –
unilateral:
Atelectasis,
bronchial
obstruction,
pleural
effusion,
pneumothorax,
pleural
thickening.
- TF Decreased –
bilateral:
Chest wall
thickening,
COPD.
Loss of
cardiac
dullness:
Hyperinflation
e.g emphysema
Hyper resonance:
Hyperinflation
e.g. Asthma,
Emphysema,
Pneumothorax
Dullness:
Pneumonia,
Pleural
effusion,
Atelectasis,
Tumor.
…..Continued
93
The Physical Examination Interview: Chest Examination
Chest examination:
… Cont.
6- Auscultation:
Listen to the breathing sounds for: Intensity, Pitch, and Inspiration/Expiration
Ratio (I:E Ratio). Listen on the same areas of TF starting on the back.
“Mr./Ms. .., I’m going to listen to your chest, I’ll start from the back.”
Warm the stethoscope.
“Mr./Ms. …, take several deep breathes in and out from your mouth”
Listen carefully and compare sides. Normal vesicular breath sounds are
continuous.
Tracheal
Bronchial
Description:
Harsh
Air rushing
tube
Bronchovesicular
Rustling, but
tubular
Intensity:
Pitch:
I:E Ratio:
Normal
location:
Very loud
Very high
1:1
Extra
thoracic
Loud
High
1:3
Manubrium
sterni
Moderate
Moderate
1:1
Mainstem
Bronchi
Vesicular
Gentle
rustling
(Continuous)
Soft
Low
3:1
Peripheral
lung
* Abnormal breath sound locations:
- Bronchial breath sounds on lung periphery: Consolidation.
- Bronchovesicular breath sounds on lung periphery: Bronchospasm or
interstitial fibrosis.
* Adventitious sounds: Discontinuous sounds.
If present: report location and do Vocal Fremitus below.
1- Crackles (= rales, crepitations): Discontinuous sounds heard on
inspiration:
- Coarse crackles: Low pitched.
- Fine crackles: High pitched.
- Early inspiratory crackles suggest bronchiolar obstruction: COPD,
asthma.
- Non-early inspiratory crackles suggest parenchymal disease:
interstitial fibrosis, pneumonia, and pulmonary edema.
2- Wheezes: Abnormal high-pitched sounds caused by air passing through
partially narrowed airways on expiration: asthma, tumors, bronchitis
(mainly inspiratory), Pulmonary edema, secretions and foreign bodies.
Note that decreasing wheezing means either opening or progressive
closing of the airways.
3- Rhonchi: Low-pitched, deep sound. Due to transient airway plugging by
mucus; may disappear with coughing; “Mr/Ms…, cough several times,
please.” suggest bronchitis.
…..Continued
94
The Physical Examination Interview: Chest Examination
Chest examination:
… Cont.
4- Pleural rub: Grating or brushing sounds heard on both inspiration and
expiration peripherally; indicates roughened or inflamed pleura.
5- Stridor: Inspiratory musical sounds over trachea on inspiration:
Tracheal obstruction.
6- Sounds like creaking of leather: Pleural effusions.
7- Sounds like walking on snow: Pneumomediastinum.
To the examiner “Breath sounds are normal. There are /no crackles/
wheezes/ rhonchi/ on the right lower area. No plural
rub or stridor.”
8- Vocal fremitus: If there are no discontinuous breath sounds on the
periphery (area of consolidation), don’t do it.
To the examiner “ I didn’t hear abnormal breath sounds, so, I
don’t need to do vocal fremitus.”. Otherwise:
- Bronchophony: “Mr/Ms…, say ‘99’… again.” while you listen
on areas of consolidation. It will be louder.
- Egophony: “Mr/Ms…, say ‘Bee’… again.” while you listen on
areas of consolidation. It will be heard like ‘Baa’
- Whispered Pectoriloquy: “Mr/Ms…, whisper few words…
again.”. The whispered words will be heard more clearly over
areas on consolidation.
7- Forced Expiratory Time:
“Mr./Ms. …, I’ll listen to your breathing here on your neck. I want you
to take in as deep a breath as you can and hold it.”
Look at your watch and check the duration: “Now, blow all of it out as
fast as possible.”
To the examiner “Forced Expiratory Time is normal/abnormal at ....
seconds”. Normally < 3sec.
8- If there is still some time: Listen quickly to the heart and measure the JVP.
Notes for children examinations:
-
Infants & children: exam done while sitting in a parent’s lap.
Palpation with one finger. No need for chest expansion and tactile fremitus.
No Percussion.
To rule in pneumonia in children: check:
1- Tachypnea. (Observe the chest for one minute or two 30 sec in a quiet
child).
2- Auscultation.
3- Increase breathing work (Nasal flaring, retraction of supra, intra,
substernal regions)
COVER THE PATIENT
END … Wrap up
95
The Physical Examination Interview: Chest Examination
96
Chapter 17: CARDIOVASCULAR EXAMINATION
Cardiovascular examination:
1- General appearance:
“Mr./Ms..., What is the date today?,… and where are you now?”.
To the examiner 1-“Patient is/is not in distress, alert, oriented...
2- There is / is no sweating.
3- The patient is sitting/ lying comfortably/
sitting leaning forward supported by his
arms. (SOB)”
“Mr./Ms..., Will you please lie down there/here flat on your back?”.
2- Ask for Vital signs: “What are his/her vitals, please? ”
Carefully listen/read and comment: e.g. “Normal/ so, he has fever/
tachycardia/ tachypnea….”.
- Blood pressure: Take it on:
1. Both arms while lying down.. “Mr./Ms…., let me check your
blood pressure.” (Keep the cuff on one arm when you finish to do
the orthostatic later)
2. Both legs while lying down. Cuff around the thigh and listen to the
popliteal artery. “Now I’ll check the pressure in your thighs”
Use a thigh cuff. Examiner will stop you giving the results, but
start doing it until he/she stops you.
3. An arm standing after one minute (for orthostatic hypotension).
“Mr./Ms…., I’ll recheck the pressure in one minute while
standing. Will you please stand up here.”
To the examiner “I’ll start inspection while waiting”.
Examiner will stop you giving the results, REMOVE CUFFS.
“Thank you, lie down”
To the examiner “Blood pressure is …. mmHg lying and …. mmHg
standing. No postural hypotension, No significant
upper/lower extremities difference. ”
3- Inspection:
1- Hands: “Mr./Ms…., will you please let me see your hands.”
To the examiner “There is / is no…” while inspecting: CS JOC
1. Color: (Red/ Yellow/ blue)
1) “Palmar erythema”,
2) “Nicotine stain”,
3) “Peripheral cyanosis” (bluish cool fingers, toes)
2. Shape:
1) “Clubbing”,
2) “Muscle wasting”(thenar) ,
3) “Contractures” (Dupuytren’s).
4) “Splinter hemorrhage” (if with fever): look on all fingers’
and toes’ nail beds.
5) “Janeway lesions” (if with fever: ‘pain away’ painless flat 1-2
cm)
… Continued
97
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination:
… Cont.
6) “Osler nodes” (painful, raised < 1.5 cm on soles and plantar surface)
7) Capillary refill: “Mr./Ms…., I’m going to squeeze your
thumb” press on nail bed & release while looking on your watch:
< 3 sec.
To the examiner “Capillary refill is normal less than 3 sec”
2- Face:
To the examiner “There is / is no…” while inspecting: CSM+ Eyes (X CSF)
1. Colour:
1) “Plethora” (pink) ,
2) “Jaundice” (while looking on the sclera),
3) “Central Cyanosis” Central: blue lips & buccal mucosa: SO 2< 80%
4) “Pallor”.
2. Shape:
1) “Cushinoid / moon face” (round, puffy).
2) “No Myosis, ptosis” (Horner Syndrome)
3) “No Mitral face” (Red cheeks in mitral stenosis)
3. Mouth: “No pursed lips” (emphysema).
4. Eyes: “Mr./Ms.., let me examine your eyes.”
1) “No Xantholasma” yellow lipid deposition on upper and lower eyes’
lids.
2) “No Senile arcus” yellow lipid deposition in cornea at its margins
with conjunctiva.
3) “No Conjunctival hemorrhages”.
4) Fundoscopy: “Now, with this scope.” (examiner will stop
you). Look for:
1- “Copper wires”.
2- “Soft / hard exudates”.
3- “Roth spots”: erythmatous lumps
4- “Emboli in retinal arteries”.
JVP: =< 4 cm
Increased:
SVC obstruction,
RT heart failure,
Constrictive
pericarditis.
Kussmaul
sign:
Rising JVP with
inspiration:
RT HF,
SVC obstruction,
Tricuspid
stenosis
Constrictive
pericarditis, and
Restrictive
cardiomyopathy.
98
3- Neck: Jugular Venous Pressure (JVP):
JVP is a direct assessment of central venous pressure (RA pressure).
1- JVP Height: “Mr./Ms…., now, I’ll do some measurement on your
neck. I’ll put your head higher. Is that okay?”
- Position the patient at 30o and ask the patient to turn his head slightly
to the left. Then adjust the elevation up to 45 o until pulsations are seen.
- Look between the two heads of the sternocleidomastoid muscle (at
sternal head of clavicle) for pulsations. If difficult, shine a light
tangentially across the right side of the neck and look for shadows of
pulsations.
- Determine JVP by measuring the vertical distance from the sternal
angle to a horizontal line from the top of the jugular pulsations.
2- Waveform: Normally double waveform.
3- Kussmaul sign: Only if JVP is high.
“Mr./Ms…., take a deep breath.”
…Continued
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination:
… Cont.
4- Hepatojugular reflex (HJR): Only if JVP is high.
- To assess that high JVP is due to RV function and not SVC
obstruction.
- Let the patient breath quietly from his mouth. “Mr./Ms…., breath
normally from your mouth, please”. “I’m going to push on
your stomach here for a while.”
- Apply moderate pressure over the liver at the RUQ with your hand
& sustain it for 10 sec.
- A sustained elevation of the JVP height for > 4 cm for 10 sec is
pathological.
“Mr./Ms…., I’ll put your head down.”
To the examiner “No JVP/ is normal double wave at .. cm/ High at
... cm, +ve Kussmaul”
4- Chest:
“Mr./Ms…., I’m going to uncover your chest.”
Uncover the chest. Look anteriorly & posteriorly.
To the examiner “The chest is/ There is …” while inspecting: CSSP
1. Contour: “Symmetric / not”. Normally AP diameter < lateral diameter
(eye-balling).
2. Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest. No
Kyphosis or scoliosis.”
3. Skin: “No Surgical scars or dilated veins.”
“No intercostal retraction”.
4. Precordial pulsation. “No Precordial pulsation.”
4- Palpation: Warm up your hands.
“Now, Mr./Ms…., I’m going to feel your chest”
1- Areas of tenderness: Compress the chest from side to side and front to
back for tenderness “Any pain?”
To the examiner “There is / is no areas of tenderness”
“Mr./Ms…., lie down please.”
2- Abnormal pulsations: at 5 areas: Apex, RT & LT 2nd ICS, LLSB,
RLSB.
1- Palpable heart sounds: S1 in MS, P2 in PA pulsation, S3, S4
2- Heaves: use your finger pads.
3- Lifts: (in LT parasternal area): use your finger pads. RVH, LAE,
severe LVH.
4- Thrills (palpable murmur of loud intensity >3/6): use the heel of your
hand.
5- Implanted pacemakers/ defibrillators. (Inferior to left clavicle)
6- Epigastric pulsations: RVH in COPD.
To the examiner “There is/ is no palpable heart sounds, heaves,
thrills, lifts, Epigastric pulsations, or implanted
devices”
.. . Continued
99
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination:
… Cont.
3- PMI (Point of Maximum Impulse):
Indicates LV size. Palpate in supine but better felt in LLD. Describe it as
LDAD:
1- Location: SUPINE: Normally 5 th ICS, mid clavicular line. Otherwise
displaced or cardiomyopathy if lateral/inferior to that. (Children <7
years old: 4th ICS)
2- Diameter: Normally 2-3 cm. Abnormal if > 3 cm or diffuse : LVH.
3- Amplitude:
- Exaggerated: Volume or pressure overload.
4- Duration: =< 2/3 of systole. Check with radial pulse.
- Sustained (increased): LVH.
- Brief: AR, MR, and LT to RT Shunt.
- Morphology: Double/triple impulse: HCCM.
To the examiner “PMI is 2 cm at the 5th ICS MCL (while holding radial
pulse), single impulse of normal amplitude & duration.”
5- Percussion: Not useful but do it.
- Increased cardiac dullness: Pericardial effusion.
- Decreased cardiac dullness: COPD.
To the examiner “Cardiac dullness is …..”
6- Auscultation: Warm the stethoscope.
“Mr./Ms. …, now, I’m going to listen to your heart.”
- Listen over 5 areas: Apex, Lt & Rt 2nd ICS, LLSB, and RLSB.
- Listen over all these 5 areas in 4 positions:
1- Supine: (USING THE DIAPHRAGM SIDE): For S1 (best at apex), S2 &
S2 Splitting (A2 & P2) (best at pulmonary), and murmurs.
2- LLD: “Mr./Ms. …, Will you please turn half way on your side away
from me.”(USING THE BELL SIDE): For S3 & S4. (best at apex)
3- Upright: “Mr./Ms. …, Will you please sit up”
(USING THE DIAPHRAGM SIDE): Listen to the five areas.
4- Forward upright: “Mr./Ms. …, could you lean forward, please.”
(USING THE DIAPHRAGM SIDE):
1.“Take deep breaths in and out.” Listen to the five areas.
2.“Take a deep breath in and hold it.” Listen to apex and LLSB only.
3.“Take a deep breath in and out and hold.” Listen to apex and LLSB
only.
- Lungs: As the patient is sitting now: listen to the lung bases for crackles.
“Now, I’ll listen to your lungs at the back. Take deep breaths in and
out.” Listen to lung bases at the back.
- Murmurs: If present comment on:
1- Timing: Systolic, diastolic, continuous.
2- Shape: Crescendo, decrescendo, crescendo-decrescendo, plateau.
3- Quality: Blowing, harsh, rumbling, musical, machinery, scratchy.
4- Location:
of maximum intensity.
5- Radiation:
Axilla, back, neck.
… Continued
100
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
6- Duration:
7- Intensity:
out of 6. (not an indication of clinical severity)
8- Pitch:
High, medium, low.
9- Relationship to respiration.
10- Special maneuvers.
To the examiner “Heart sounds are normal/…, no S3, S4, no murmurs.
Chest is clear.”
Note: 80 % of children have innocent murmurs: Systolic, short duration,
low pitched, <grade 3, vibratory, change with body position change.
7- Peripheral edema:
As the patient is still sitting now, check for:
- Sacral edema: Press against sacrum.
- Ankle edema: Press against the tibia bilaterally.
“Mr/Ms…, I am going to push on your lower back…. Now your legs.”
To the examiner “There is /is not … pitting or non-pitting edema.”
8- Peripheral bruit: Auscultate with the bell.
1. Carotid bruit. “Mr/Ms…, I am going to listen to the blood flow in your
neck.”
2. Abdominal Aorta. “Now, the blood flow in your belly. Lie down
please.”
3. Renal arteries: 5 cm above the umbilicus and 5 cm to either side from the
midline.
4. Iliac arteries. Below the umbilicus on both sides.
5. Femoral arteries. “Now, the blood flow in your groins.”
To the examiner “There is /is not …carotid, aortic, renal, iliac, or femoral
bruits.” Mention it as you are examining related area.
9- Peripheral pulses:
“Mr/Ms .., I am going to feel your pulses”
Look for: 1. Rate; 2. Rhythm; 3. Contour; 4. Amplitude (volume);
5. Symmetry.
1- Radial pulses: Both at the same time and count for 30 sec.
“Will you please give me both your arms.”
To the examiner “ (rate) The pulse is …bpm, (Rhythm) regular/ regularly
irregular/ irregularly irregular, (Contour) Normal /
rapid/ slow rise pulse, (Amplitude) absent/ weak/
bounding pulse, (symmetry) same volume bilaterally
and symmetrical timing.”
2- Carotid pulse: If there was no bruit heard, no need. One at a time, never
together.
“Mr/Ms…, I am going to feel the pulse in your neck.”
To the examiner “As I heard no bruit, there is no need for palpating
the carotids / The carotid pulses are normal/weak.” … Continued
101
The Physical Examination Interview: Cardiovascular Examination
Cardiovascular examination: … Cont.
3- Aorta: Mid line above the umbilicus. “Now, the pulses in your belly.”
To the examiner “The aortic pulse is normal/ weak, no pulsating
mass.”
4- Femoral pulses: Both at the same time. “Now, the pulse in both your
groins.”
- Radio-femoral delay: One side only. Feel both: an arm and a femoral
pulse together.
To the examiner “The femoral pulses are of the same volume
bilaterally and there is no radio-femoral delay.”
5- Popliteal pulses: “Now the pulse behind your right knee, relax it”
Check the pulse with both your hands’ fingers under the knee at the same
time holding the leg with the thumbs at the sides while lifting the
knee10-20o
“Now, relax the left knee.” Repeat.
To the examiner “The popliteal pulses are normal/weak.”
6- Posterior Tibials: “Now, I’ll feel your feet.”
Palpate behind and slightly below the medial maleolus. Both legs at the
same time with both your hand fingers.
To the examiner “The posterior tibial pulses are normal/weak.”
7- Dorsalis pedis:
Palpate the dorsum of the foot at the lateral to the extensor tendon of the
big toe. Both legs at the same time with both your hand fingers.
To the examiner “The dorsalis pedis pulses are normal/weak/absent.”
COVER THE PATIENT
102
END …Wrap up
Chapter 18: ABDOMINAL EXAMINATION
Abdominal examination:
Patient is lying flat with his arms on the sides. Knees can be flexed to relax the
abdomen.
1- General appearance:
“Mr./Ms..., What is the date today?,… and where are you now?”.
To the examiner 1-“Patient is/is not in distress, alert, oriented...
2- The patient is lying relaxed/ or
completely still (peritonitis)/ or
moving in distress (colic)/ or
curled up in fetal position (visceral pain)/ or
lying with one hip flexed (splinting).”
2- Ask for Vital signs: “What are his/her vitals, please? ”
Carefully listen/read and comment: e.g. “Normal/ so, he has fever/
tachycardia/ tachypnea….”.
- Blood pressure: Take it on:
1. Both arms while lying down.. “Mr./Ms…., let me check your blood
pressure.” (Keep the cuff on one arm when you finish to do the
orthostatic later)
2. Both legs while lying down. Cuff around the thigh and listen to the
popliteal artery. “Now I’ll check the pressure in your thighs” Use
a thigh cuff. Examiner will stop you giving the results, but start
doing it until he/she stops you.
3. An arm standing after one minute (for orthostatic hypotension).
“Mr./Ms…., I’ll recheck the pressure in one minute while
standing. Will you please stand up here.”
To the examiner “I’ll start inspection while waiting”.
Examiner will stop you giving the results, REMOVE CUFFS.
“Thank you, lie down”
To the examiner “Blood pressure is …. mmHg lying and …. mmHg
standing. No postural hypotension, No significant
upper/lower extremities difference. ”
3- Inspection:
1- Hands: “Mr./Ms…., will you please let me see your hands.”
To the examiner “There is / is no…” while inspecting: CSA
1. Color: (Red/ Yellow/ blue)
1) “Palmar erythema”,
2) “Nicotine stain”,
3) “Peripheral cyanosis” (bluish cool fingers, toes)
2. Shape:
1) “Clubbing”,
2) “Muscle wasting”(thenar) ,
3) “Contractures” (Dupuytren’s).
To the examiner “No asterixis.”
….Continued
103
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
Distended
Abdomen:
6 F’s
Fat
Fluid
Feces
Flatus
Fetus
Fatal growth
(mass)
Upper
Abdominal
distention:
? Stomach.
? Left lobe
liver.
Lower
abdominal
distention:
? Pregnancy.
? Fibroids.
? Ovarian
tumor.
? Bladder.
3. Asterixis:
“Mr/Ms ..., I want you to extend both your arms and back flex
your hands just as if you’re stopping a bus like this…. That’s
right, now close your eyes……. Thank you.”.
2 - Face: To the examiner “There is / is no…” while inspecting:
CSM
1. Colour:
1) “Plethora” (pink) ,
2) “Jaundice” (while looking on the sclera),
3) “Central Cyanosis” Central: blue lips & buccal mucosa: SO2< 80%
4) “Pallor”.
2. Shape:
1) “Cushinoid / moon face” (round, puffy).
2) “No Myosis, ptosis” (Horner Syndrome)
3. Mouth: “Mr/Ms.., Show me your teeth,.. now stick out your
tongue.. Open your mouth, please ” reach the patient to
smell the mouth odour.
To the examiner “No Mouth fetor, Gum bleeding, Glossitis,
Cheilosis, dryness”.
4. Hair: “No Hirsutism”.
3- Chest: “Mr./Ms…., I’m going to uncover your chest.” Uncover the chest.
Look anteriorly & posteriorly.
To the examiner “The chest is/ There is …” while inspecting: CSSS GA
1. Contour: “Symmetric / not”. Normally AP diameter < lateral diameter (eyeballing).
2. Shape: “Normal shape, no Barrel, Funnel, or Pigeon chest”.
3. Swelling: “No Parotid or neck swelling”.
4. Skin: “No Surgical scars or Dilated veins”.
5. “No Gynecomastia”.
6. “No Axillary hair loss”.
COVER CHEST
4- Abdomen: “Mr./Ms..., I’m going to uncover your abdomen.”
Uncover the abdomen..
To the examiner “The abdomen is/ There is …” while inspecting from
the bed end for: CC SUM
1. Contour: “Normal contour/ Scaphoid/ Distended,
No Bulging flanks” (in ascites).
2. Colour: “No Ecchymoses” (Gray-Turner Sign: suggests
hemorrhagic pancreatitis, strangulated bowel).
“No Visible peristalsis”.
3. Skin: “No Scars/ striae or spider angiomas”(of pregnancy)
4. Umbilicus: “Umbilicus not everted (with distention),
or bluish (Cullen sign: Hemoperitonium)”
5. Motions: “No visible peristalsis, pulsations, or visible hernias.”
…. Continued
104
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
4- Auscultation: on all four quadrants. Warm up the stethoscope.
“Mr./Ms…., I’m going to listen to your belly.”
1. Bowel sounds: for 30 sec. If negative; listen to all four quarters for 1
min each to confirm:
To the examiner “Bowel sounds are normal so I don’t need to check
it in other quadrants”
Bowel sounds:
- Decreased or absent: Ileus, peritonitis.
- Increased: Diarrhea, Early obstruction.
- Intermittent crescendo with pain onset: Small bowel obstruction.
- Intermittent high pitched not synchronous with pain:
gastroenteritis, dysentery, and active ulcerative colitis.
2. Bruits: Using BELL SIDE.
- Vascular: Aortic, Iliac, and Renal arteries.
- Hepatic: - Bruit: Hepatic cancer, Alcoholic hepatitis.
- Venous hum: Hemangioma, Portal hypertension.
- Friction rub: Cancer, abscess, gonococcal perihepatitis.
- Splenic friction rub: Infarction.
To the examiner “No aortic, renal, iliac, or hepatic bruits. No venous
hum”
5- Percussion: Warm up your hands by rubbing them.
“Mr/Ms …, where do you feel the pain?”…. “Okay, I’m going to tap on
your stomach leaving this area to the end.”
1. Percuss in 3 longitudinal lines starting from below the ribs. Should be
tympanic.
To the examiner “Abdomen is normal tympanic/ There is dullness
/pain on percussion in the … e.g. RLQ”
2. Liver span: “I’m going to draw some marks on the skin with a
washable pen, okay.”. Look for the pen quickly.
- Lower border: Start percussing from the level of the umbilicus upward
in mid clavicular line (MCL) and mid sternal line (MSL)
looking for liver dullness. Mark the border.
- Upper border: Either continue percussing until dullness disappears or
start up from lung resonance downwards. Mark the
border.
- Measure the distance between the two marks: normally 8-12 cm
MCL, 4-8 cm MSL.
To the examiner “Liver span is … cm, normal/ enlarged”
…. Continued
105
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
3. Spleen: Castell sign “Mr/Ms …, take several deep breaths in and out”
- Percuss the 10th ICS at Lt mid axillary line. Normally
tympanic. If dull on inspiration: spleen enlarged. Tell the
patient to: “Breath normally.”
To the examiner “Spleen is/is not enlarged”
4. Ascites:
- Shifting dullness:
“Mr/Ms …, once again, I’m going to draw some marks on your
skin”
With the patient lying supine; percuss from umbilicus towards the
patient’s right to mark the tympanic/dullness margin. Then ask the
patient to turn towards you and repeat percussion.
“Mr/Ms …, turn on your side towards me”
If the margin is closer to the umbilicus (higher): Ascites.
To the examiner “There is/is no shifting dullness, no clinically
detectable ascites.” (Doesn’t rule out ascites).
- Fluid wave: For distended abdomen.
“Mr./Ms …, will you please put your hand like this on your
abdomen.”
(The hand’s ulnar edge on the middle of the abdomen longitudinally)
Tap on the lateral side of the abdomen and assess the transmission of a
wave (fluid thrill) to the contralateral side with your other hand.
Positive if distention is due to ascites.
6- Palpation:
“Mr/Ms …, I’m going to feel your abdomen now.”
Palpate while ALWAYS watching the patient’s face for tenderness.
Start away from the painful area. Don’t repeat painful maneuvers and
apologize.
1. Light palpation:
To detect areas of tenderness, muscle spasm/rigidity.
Use the fingers’ pads with fingers joined. Lift your hand when moving from
area to area, don’t slide it.
1) Start from LLQ to LUQ to RUQ to RLQ back to LLQ. (a circle)
2) One finger palpation: to delineate location of tenderness.
3) Cough tenderness: “Mr/Ms …, will you please cough several times.”,
“Is it more painful during coughing?” Positive with inflammations.
4) Hernia rings. Palpate hernia rings
To the examiner “The abdomen is soft/ is rigid and tender in the ….RLQ.
There is /is no cough tenderness. No hernias felt.”
2. Deep palpation:
Put your left hand over the right and palpate deeply and steadily for masses
and inflammations. Start from LLQ to LUQ to RUQ to RLQ back to LLQ
“Mr/Ms …, I’m going to push hard. Breath normally through your
mouth.”
… Continued
106
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
To the examiner “There is/is no palpable masses.”
Rovsing’s sign: Comment while palpitating the LLQ.
RLQ pain on LLQ palpation. Positive in appendicitis.
“Is it painful?… Where do you exactly feel the pain?”
To the examiner “Rovsing’s sign positive/negative.”
Murphy’s sign: Comment while palpitating the RUQ
Arrest of deep inspiration on RUQ palpation. Positive in cholecystitis.
To the examiner “Murphy’s sign positive/negative.”
Courvoisier’s sign: Comment while palpitating the RUQ.
Palpable distended painless gallbladder. Positive in GB cancer.
To the examiner “Courvoisier’s sign positive/negative.”
McBurney’s sign: Comment while palpitating the RLQ.
Tenderness at McBurney’s point. Positive in appendicitis.
To the examiner “McBurney’s sign positive/negative.”
Rebound tenderness:
Press deeply and hold for few seconds.
Then suddenly release your hands.
“Is it more painful during the take off of my hands?” Positive in
peritonitis.
To the examiner “There is/is no rebound tenderness.”
3. Liver palpation:
Place your right hand vertically on the abdomen parallel to the rectus
abdminus muscle starting from the pelvic brim.
“Mr/Ms …, take several deep breaths in and out.”
During inspiration, push inwards and upwards and repeat until the edge
of the liver felt on your fingers’ tips. Measure the liver length below the
costal margin in MCL (1-2 cm).
Tenderness: Place your left hand on the liver and strike it with the ulnar
edge of your right hand. And look on the patient’s face.
To the examiner “The liver is .. cm below costal margin. The edge is
smooth/ nodular, soft/ firm, tender/ not tender.”
“As I mentioned, liver span was normal and there is
no liver bruit.”
4. Spleen palpation:
“I’m going to lift your left side”
With the left hand, lift the patient’s left rib cage upwards. Place your
right hand obliquely on the abdomen pointed to towards the anterior
axillary line starting from the RLQ moving towards LUQ.
During inspiration, push inwards and upwards and repeat until the edge
of the spleen felt on your fingers’ tips.
To the examiner “Spleen is/ is not enlarged.”
….Continued
107
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
5. Kidneys palpation: Usually not palpable in adults. But check for masses.
Right: “Now lifting your right side.”
With the left hand, lift the patient’s right flank upwards (below the rib cage).
With the right hand palpate deeply.
Left: “Back to your left side.” Like the right.
To the examiner “Kidneys are not palpable.”
COVER ABDOMEN
7- Special Tests:
1) Psoas test: Pain on flexion of the hip against resistance. Positive in psoas
muscle irritation due to inflammation.
“Mr/Ms .., I’m going to hold your right thigh”. Hold the right thigh with
hand, “Bend your thigh up.”, “Is there any pain?” Watch the face.
If yes; “Where?”
Repeat for the left side.
To the examiner “Psoas test positive on the right/negative.”
2) Obturator test: Pain when thigh is flexed to a right angle and gently rotated
first internally and then externally. Positive in irritation of obturator internus
muscle in pelvic appendicitis, diverticulitis, pelvic inflammatory disease in
females (PID).
“Mr/Ms .., I’m going to flex your right thigh.”. “I’ll rotate your leg.”.
Watch the face “Any pain?” If yes; “Where?”
“Now, the left thigh.” Watch the face “Any pain?”
To the examiner “Obturator test is positive on the right/ negative.”
3) Costovertebral angle tenderness (CVA):
“Mr/Ms .., will you please, sit up on the stretcher, I want to feel your
back”,….. “I’m going to tap on your back.”
Strike repeatedly and LIGHTLY the right CVA with your right hand ulnar
edge while moving vertically downwards.
“Does it hurt?”
Repeat on the Left side. “Does it hurt?”
To the examiner “No CVA tenderness./ There is CVA tenderness on the
right side. There is no scars.”
8- Genitalia:
“Mr/Ms .., now, I need to examine your genitalia, is that okay.”.
The examiner will stop you but mention it.
Look for lesions and penile/vaginal discharge.
Males: Feel the scrotum for both testes and epididyms.
9- Vaginal Exam: See gynecological exam for details
“Ms .., in order to complete the physical exam of your pelvic organs, I need
to examine you internally through your vagina, is that okay?….”
The examiner will stop you but mention it for results.
….Continued
108
The Physical Examination Interview: Abdominal Examination
Abdominal examination: … Cont.
10- Digital Rectal Exam (DRE):
For males and females (Females: to be done after the Vaginal exam).
For children: only done if abdominal or pelvic disease is suspected.
“Mr/Ms .., in order to complete the physical exam of your pelvic
organs, I need to examine your bottom with my finger, okay.”.
The examiner will stop you but mention it for results.
DRE: Never done on patients in OSCEs
“Mr/Ms .., Turn on your side away from me and bring your bottom to
the stretcher edge. Lower your underwear, please.”
1- Wear gloves.
2- Inspect for hemorrhoids. “Mr/Ms .., I am going to feel your bottom.”
To the examiner “There are/ no hemorrhoids, oozing openings.”
For young children: Examine Anus: for peri-anal skin redness & rash
(Diarrhea, diaper rash, inadequate cleaning), imperforation &
prolapse, asymmetrical buttocks & thigh folds (Congenital hip
dysplasia).
3- Lubricate your right index finger and inserted slowly. “Mr/Ms .., now,
I’ll feel your bottom internally with my lubricated finger. If you feel
pain tell me.”
4- Feel the anal canal wall for masses, fissures, and stool & blood.
To the examiner “There are/ no masses or fissures felt, hard stool,
blood, mucus.”
5- Male: Anteriorly, feel the prostate for irregularity, masses, firmness,
and high riding.
To the examiner “Prostate contour is regular/ irregular, soft/ firm.
There are/ no masses. Prostate is not high in
position.”
Female: Anteriorly, feel the cervix for irregularity, and masses.
To the examiner “Cervix contour is regular/ irregular, soft/ firm.
There are/ no masses.”
“Mr/Ms .., I am done. You can wipe off the gel with this tissue and pull
up your underwear.”
END .. Wrap up
109
The Physical Examination Interview: Abdominal Examination
110
Chapter 19: GYNECOLOGICAL EXAMINATION
Gynecological examination:
Like abdominal exam but with more concentration on lower abdomen and less
on liver and spleen.
Patient is lying flat with her arms on the sides. Knees can be flexed to relax
the abdomen.
1- General appearance:
See abdominal examination.
2- Ask for Vital signs:
See abdominal examination.
3- Inspection:
See abdominal examination.
4- Auscultation:
See abdominal examination. Quickly for bowel sounds only. No bruit.
5- Percussion: Warm up your hands by rubbing them.
See abdominal examination.
6- Palpation:
See abdominal examination.
7- Special Tests: Important.
See abdominal examination.
8- Pelvic exam:
“Ms .., in order to complete the physical exam of your pelvic organs, I
need to examine you internally through your vagina, is that okay?….”
The examiner will stop you but mention it for results.
Never done on patients in OSCEs
“Have you ever had this done before”
Yes “Okay then, I need you to go to the washroom and empty your
bladder completely, take off your underwear and come back here.”.
No: explain.
Wear cloves for both hands.
… Continued
111
The Physical Examination Interview: Gynecological Examination
Gynecological examination:
…Cont.
- Inspection of external genitalia: Look for lesions, discharge and
bleeding.
“Ms…., lie down here and put both your legs on these stands. I’m going
to uncover you and switch on a light to examine your genitalia”
To the examiner “There are/ no lesions, discharge, bleeding.”
- Palpation of external genitalia.
“Ms…., I’ll feel your genitalia, now”
To the examiner “There are/ no masses.”
- Speculum exam: Look for:
1. Inspection of the vagina and cervix for lesions;
2. Pap smear;
3. Gonococcal and chlamydial cultures swaps.
“Ms…., now, I’ll put in this tool to open up the vagina and have a look
inside. Then I’ll use this brush to take a Pap smear and then this cotton
stick for a swap.”
To the examiner “There are/ no lesions, discharge, bleeding. Cervix looks
normal.”
Do Pap smear and swaps.
- Bimanual pelvic exam: Feel for:
1. Cervix size, consistency & cervical motion tenderness;
2. Uterus size, contour, shape, consistency, position & mobility;
3. Masses
“Ms…., now, I/m going to feel your organs internally with my fingers
and my left hand on your belly.”
To the examiner “Cervix feels normal in size and consistency. There is/
no cervical motion tenderness. Uterus is soft/ firm,
regular/ irregular, small/ enlarged, mobile/ fixed,
anteferted/ retroverted. There are / no masses.”
“Ms .., I am done. You can wipe off the gel with this tissue and wear
your cloths.”
10- Digital Rectal Exam (DRE):
See abdominal examination.
END .. Wrap up
112
Chapter 20: HEMATOLOGY EXAMINATION
Hematology examination:
For hematological, immunological, lymphatic, and endocrine examination.
1- General appearance:
See abdominal examination.
2- Ask for Vital signs:
See abdominal examination. Do orthostatic blood pressure. (Anemia).
3- Inspection:
See abdominal examination but add the followings:
1- Hands: Add: “There is/ no petechia. Hand is/ not cold or clammy.”
No need for Asterixis test.
2- Elbow: “There is/ no epitrochlear lymph nodes.”
3- Mouth: Add:
Use a bright light pen and a tongue depressor. Ask patient to open his
mouth “Open your mouth please.”
Inspect the anterior structures, the tongue and under, the posterior
oropharynx and tonsils. Then ask the patient “ Say ‘Ah’."
To the examiner “ The mucosa is pink, smooth, moist. There are /no
ulcers or lesions. Normal tonsils/ edematous
red/with whitish exudates.”
4- Chest: Add:
1- “Mr/Ms …, I’m going to feel your neck, Okay?”
See head and neck exam, next.
To the examiner “ There is/ no palpable neck lymph nodes or
masses.”
2- “Mr/Ms…, I’m going to push on your mid chest. Any pain?”
3- “ Now, I’ll feel both your axillae.”
To the examiner “ There is/ no sternal pain, palpable axillary
central, lateral, pectoral (anterior), or
subcapsular (posterior), or apical lymph nodes.”
4- “Mr/Ms…, I’ll listen to your heart.”
To the examiner “ There is/ no abnormal heart sounds or
murmur.”
COVER THE CHEST.
5- Abdomen: “Mr./Ms..., I’m going to uncover your abdomen.”
Uncover the abdomen..
To the examiner “The abdomen is/ There is …” while inspecting
from the bed end for: CC SUM
Contour: “Normal contour/ Scaphoid/ Distended,
No bulging flanks” (in ascites).
No need for the rest of abdominal inspection.
…Continued
113
The Physical Examination Interview: Hematology Examination
Hematology examination:
…Cont.
4- Percussion: Warm up your hands by rubbing them.
Liver and spleen. No Ascites test.
“Okay, I’m going to tap on your stomach”
5- Palpation:
“Mr/Ms …, I’m going to feel your abdomen now.”
Only liver, spleen, and inguinal regions for lymph nodes.
6- Sensory:
- Joint position test.
- Vibration test.
See neurological exam.
7- Digital Rectal Exam (DRE):
“Mr/Ms .., in order to complete the physical exam of your pelvic organs, I
need to examine your bottom with my finger, okay.”.
The examiner will stop you but mention it for results.
See abdominal examination.
END .. Wrap up
Lymph node examination:
85% benign.
Describe:
1. Location.
2. Size.
3. Shape.
4. Contour: regular/ irregular.
5. Mobility: in two directions.
6. Consistency: firm/ soft/ rubbery.
7. Tenderness.
8. Overlying skin.
114
Chapter 21: HEAD & NECK EXAMINATION
Head & Neck examination: For endocrine & hematology
1- General appearance:
“Ms. .., What is the date today? …., and where are you now?”.
To the examiner “Patient is/ is not in distress, alert, oriented.
The patient is 1 sitting comfortably, depressed/
apathic or nervous,
2
has a thin/ large built.
3
There is no hoarseness”
2- Ask for Vital signs: “What are his/ her vitals, please? ”
Carefully listen / read and comment: e.g. “Normal/ so, he has
fever/tachycardia/ tachypnea….”.
- Blood pressure: See abdomen.
3- Inspection:
See abdominal examination. In addition:
1- Hands: Add:
3. Texture /Moisture: Thin/thick, dry/moist. “Skin texture is thin / thick
and dry/ moist”
2- Face:
1. Shape: “Skin is dry/ moist”
2. Hair: “No Hirsutism or loss of lateral third of eyebrows. Hair is
thin/ thick and of normal distribution”.
3. Eyes: “No Proptosis, Lid retraction, Lid lag, Red eye, Periorbital
edema”
3- Mouth: Add:
Use a bright light pen and a tongue depressor. Ask patient to open his
mouth “Open your mouth please.”
Inspect the anterior structures, the tongue and under, the posterior
oropharynx and tonsils. Then ask the patient “ Say ‘Ah’."
To the examiner “ The mucosa is pink, smooth, moist. There are /no
ulcers or lesions. Normal tonsils/ edematous
red/with whitish exudates.”
4- Neck: To the examiner “There is / is no…” while inspecting: PST +
mass
1. Position of head. “Head position is normal”
2. Shape: “Neck is symmetrical, no scars or skin lesions”
3. Swelling: “No parotid, neck swelling, muscle wasting.” CN 8,10, 12
4. Thyroid: give the patient a glass of water “Mr/Ms .., take a sip of
water, hold it in your mouth until I tell you to swallow it… give me
the cup/glass”, Put the glass away quickly “Okay swallow it now.”
Watch for thyroid movement.
5. Masses: “No visible masses ”
… Continued
115
The Physical Examination Interview: Head & Neck Examination
Head & Neck examination: …Cont.
4- Palpation:
Either by anterior or posterior approach while the patient is sitting.
“Mr/Ms …, I’m going to feel your neck, Okay?”
1. Lymph nodes: There are 75 LNs on each side of the neck.
- Patient is sitting relaxed with head slightly flexed forward.
- Palpate using the pads of the index and middle fingers, moving the skin in a
circular motion over each area. Normal nodes are non-tender & mobile.
- Palpate both right and left LNs simultaneously for comparison.
Start with:
1. Occipital LNs:
2. Posterior auricular LNs:
3. Anterior auricular LNs:
4. Tonsillar LNs:
5. Submandibular LNs:
6. Submental LNs:
7. Superficial cervical LNs:
8. Deep cervical LNs
9. Posterior cervical LNs:
10. Supraclavicular LNs:
Base of skull posteriorly.
Superficial to mastoid process.
In front of ear.
At angle of mandible.
Midway between angle and tip of mandible.
In mid line, behind tip of mandible.
Superficial to Sternocleidomastoid muscle.
Deep to Sternocleidomastoid muscle.
Along the anterior edge of Trapezius muscle.
Deep at the angle of clavicle with the
posterior edge of SCM. (Left node is often
enlarged with abdominal cancer.)
LN: Painful, soft & mobile: Inflamed. Painless, hard & fixed: Cancerous.
To the examiner “There is / is no enlarged LNs” while palpating:
2. Thyroid:
- Sit face to face with the patient or stand behind him/her.
- Start with the right lobe. Relax the SCM by slightly flexing & turning the
head to his/her right.
- Put your index finger just below the cricoid cartilage on the right.
- Push the trachea to the patient’s right with the other hand.
- “Mr/Ms …, swallow please.” After giving him a sip of water again.
- Feel for the gland rising under your thumb and index fingers.
- Repeat for the left lobe.
Thyroid is soft in toxic goiter, Firm in malignancy and scaring, Tender in
thyroiditis.
3. Isthmus: At mid line.
4. Pemberton’s sign: Patient feels difficult breathing when arms are raised.
Positive in enlarged retrosternal goiter.
“Mr/Ms …, raise both your arms up, how is your breathing now? …
Thank you relax.”
To the examiner “Thyroid is / is not enlarged, rubbery/soft//firm, tender,
nodular”
… Continued
116
The Physical Examination Interview: Head & Neck Examination
Head & Neck examination: …Cont.
5- Auscultation: Only if the thyroid is enlarged.
Listen on both lateral lobes.
A localized systolic or continuous bruit may be heard in hyperthyroidism.
To the examiner “No bruit.”
6- MSK:
1- Proximal muscle weakness (thyrotoxic myopathy)
“Mr/Ms …, I’ll hold your arms from the sides, now, fan out your
arms against my hands, ….. now your thighs, raise them up against
my hands.”
To the examiner “No proximal muscle weakness.”
2- Non pitting pretibial edema. “Mr/Ms …,I’ll feel your legs.”
To the examiner “No pretibial edema.”
3- Reflexes: Delayed relaxation phase or brisk. “Mr/Ms …, I’m going to
tap your knees.”
To the examiner “There is / is no …, reflexes are normal/
brisk/delayed”
7- Heart:.
“Mr/Ms …,I’ll listen to your heart.”
To the examiner “No tachy/ bradycardia or atrial fib.”
END .. Wrap up
Note:
- This is not for neurological exam of the head for neurological CC like
headache. See neurological exam next.
- If the case is for thyroid, allocate more time to the thyroid exam part.
But, if it for a neck lymph node (a mass on the side), allocate less time
for the thyroid exam and do not do related tests.
- 90 % of pediatric neck masses are inflammatory. 90 % of adult neck
masses are metastatic.
- Thyroglossal duct cysts are the most common anterior midline neck
mass in children. To differentiate it from a thyroid nodule, ask the
patient to stick out their tongue. Thyroglossal duct cysts will move up
while thyroid nodule does not.
117
The Physical Examination Interview:
118
Chapter 22: NEUROLOGICAL EXAMINATION
Neurological examination:
When you do a neurological exam, keep in your mind two important questions
to be answered: Where is the lesion? & What is the lesion?.
This will make findings make sense.
Complete neurological examination is a long test. In OSCEs, parts are usually
requested like complete cranial nerves exam or lower limbs sensory exam or
complete neurological exam of a limb only. However, sometimes, the whole
complete exam is requested and here they meant to do a complete screening
neurological exam. You will find in every neurological exam part discussed
here, an S mark with what to be done as a screening exam. This is not what you
do in emergency room setting which will be discussed later in Part Four.
Neurological Examinations parts:
1.
2.
3.
4.
5.
6.
7.
General appearance.
Vitals
Cranial nerves exam (CN).
Mini Mental Status exam (MSE).
Motor exam.
Sensory exam
Coordination
1- General appearance:
“Mr./Ms..., What is the date today?,… and where are you now?”.
To the examiner 1-“Patient is/is not in distress, alert, oriented...
2- The patient is sitting/ lying relaxed/ or
completely still (pain) / or
moving in distress (pain)”
2- Ask for Vital signs: “What are his/her vitals, please? ”
Carefully listen /read and comment: e.g.
“Normal/ so, he has fever/ tachycardia/ tachypnea….”.
3- Cranial nerves exam:
1. CN 1 - Olfactory: (Sensory)
“Mr/Ms …, do you have any trouble smelling?” If yes: do smell test.
Smell test: “Mr/Ms .., I’m going to test your smell sense. Close
your eyes please and close your right nostril.”.
Bring coffee or mint close to the nostril.
“Mr/Ms .., Do you smell something?.. what is it?”
“Now close the left nostril.” Repeat: Unilateral or bilateral loss?
- Most common cause of CN 1 dysfunction is common cold.
- Also frontal lobe damage and cribiform plate trauma.
To the examiner “Smell sense is / is not normal.”
…. Continued
119
The Physical Examination Interview: Neurological Examination
Neurological examination:
CN Cont.
2. CN II – Optic: (Sensory)
1- Visual Acuity: S (tests central vision) by using Snellen chart.
Let the patient sits 6 meters distant from the chart (or 3 meter with a
mirror). Cover one eye leaving the glasses or contact lenses on.
“Mr/Ms .., let us examine your vision. (Come sit down here), cover
your right eye with your right hand. …Tell me what is this letter
there on the wall? And this one?….., now, cover the other eye.”
Ask the patient to read the smallest line and move up until he/she can read
a line.
To the examiner “Visual acuity is 6/6 for the right and … for the left”.
2- Colour: using Ishihara chart. Not usually done.
“Mr/Ms .., Have a look on this book. Tell me what color is this? And
this one?”
To the examiner “Colour test is / is not normal for the right and ….for
the left.”
3- Visual fields by confrontation: S (tests peripheral vision)
- Face the patient. Sit in front of him/her one meter away. Ask the patient
to close his/her left eye and close your right eye. Ask him to look on
your left eye.
“Mr/Ms .., now cover your right eye with your right hand. With
your left eye look on my right eye and don’t move it.”
- Using your finger or a pen, slowly bring it from the outside towards the
center from all four quadrants (upper & lower temporal, upper & lower
nasal).
- “Mr/Ms …, Tell me when you can see the pen. Don’t move your
eye, keep it fixed on my eye.”
- Repeat for the other eye.
To the examiner “Visual fields are normal/ bitemporal hemianopia/
homonomus hemianopia/ temporal field is defective
on the right eye.”
VISUAL FIELDS
DEFECTS
Single eye
LOCATION
OF LESION
Anterior to
optic chiasm
Both eyes: e.g.
Bitemporal
hemianopia
At optic
chiasm
Both eyes: e.g.
Homonomous
hemianopia
Posterior to
optic chiasm
EXAMPLE
- Glaucoma
- Retinal hemorrhage
- Optic neuropathy
- Central retinal artery occlusion (transient
monocular blindness: Amaurosis fugax)
- Upper > Lower fields: Inferior
compression: Pituitary adenoma
- Lower > Upper fields: Superior
compression.
Parietal lobe cerebral infarcts, hemorrhages,
tumors.
…. Continued
120
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
4- Fundoscopy: S
- Ask the patient to look on a spot in the distance.
“Mr/Ms .., I’m going to examine your eyes with this scope.
Please fix your eyes on that picture on the wall.” A distant object.
Room lights off.
- Usually the examiner will stop you and give you the findings. Listen
to them and comment.
- Look for:
1. Red Reflex: From one foot away, view retina through the
ophthalmoscope.
Check for corneal or lens opacities: Cataract or retinoblastoma.
To the examiner “Red reflex is normal.”
2. Optic disc: looking close to the eye.
Check for: - Colour: If pale: Optic atrophy.
- Cup to disc ratio. Deep/ pale cup: Glaucoma
- Symmetry.
- Sharp borders: If blurred margins (cannot see disc
well): Optic disc swelling (papillodema due to
increased ICP).
To the examiner “Optic disc is normal in colour and shape. No
papillodema.”
3. Retinal vessels: Follow vessels in all directions.
Arterioles: are of bright light reflex, light red colour, smaller than
veins.
Veins: are absent or inconspicuous light reflex, dark red colour,
larger, and pulsating.
To the examiner “Retinal vessels are normal.”
4. Retinal lesions: Lesion on retinal background.
Describe it: red / black / gray / white, flame-shaped / round,
diffuse / spotting.
To the examiner “No retinal lesions.”
5. Macula: Located one disc size temporally (lateral).
It is avascular, larger than the disc, with indistinct margins.
To the examiner “Macula is normal.”
3. CN III (3)–Oculomotor / CN IV (4)–Trochlear / CN VI
(6)–Abducens: Motor
- Responsible for: extra-ocular eye movements, papillary constriction,
and elevation of upper eyelid.
- LR6 SO4: All eye muscles are controlled by CN III except: Lateral
Rectus by CN 6, and Superior Oblique by CN 4.
… Continued
121
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
1- Inspection: S For:
1- Eye deviation:
Down & Out:
CN 3
lesion
Up & Out:
CN 4
lesion
Down & In:
CN 6
lesion
+ Dilated pupil:
+ Non-reactive pupil: Nerve
compression.
+ Reactive pupil: Vascular.
Can’t move it Down & In, difficulty
walking down the stairs or reading:
Ischemia (commonest), DM, and HTN.
Can’t move affected eye laterally:
Horizontal diplopia.
2- Ptosis: CN 3 lesion.
3- Nystagmus: Vertical: CNS or Horizontal: PNS?
To the examiner “There is no eye deviation, ptosis, nystagmus. Pupils
are symmetrical, normal size & shape / dilated”
2- Pupils: S
- Size (dilated in CN 3 lesion, constricted in Horner’s),
- Shape (round),
- Symmetry,
- Light reflex,
- Accommodation test.
1. Light reflex: CN 3 efferent.
“Mr/Ms …, I’m going to briefly shine a light into your eyes to test
its response.”
Shine light on eye ‘A’: It will constrict (direct response) and also eye
‘B’ will (consensual response).
Repeat for eye ‘B’.
Note: If patient closes his eyes & prevents the light test: Photophobia
(meningism).
To the examiner “There is photophobia, light test cannot be done.”
2. Swing light Test: To test both CN 2 afferent and CN 3 efferent.
After finishing testing the light reflex of eye ‘B’, quickly swing light
back to eye ‘A’.
If CN 2 of eye ‘A’ is damaged; ‘A’ & ‘B’ will dilate. a 2 e 3
- If eye ‘A’ CN 2 is damaged: Blind eye
When light shines on eye ‘A’: No response in either eye (Negative
direct & consensual responses).
When light shines on eye ‘B’: Positive direct & consensual responses.
- If eye ‘A’ CN 3 is damaged:
When light shines on eye ‘A’: No response in ‘A’ (Negative direct),
but positive consensual response of ‘B’.
122
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
3. Accommodation Reflex:
“Mr/Ms .., now, I want you to look on that picture on the wall
then look on this pen”
- Hold a pen approximately 5 inches in front of his/her nose.
Normally the eyes will converge and pupils will constrict when
looking on the pen.
To the examiner “Normal direct light reflex and consensual
response, Swing light test, and accommodation
reflex. ”
3- Cardinal positions of gaze: S There are 6 cardinal positions of
gaze.
- Positions 3, 4, 9 are not included as cardinal positions.
- Move a pen in all the six direction in front of the patient in an ‘H’
direction.
- “Mr/Ms .., now I want you to look on this pen with your eyes
only and follow it while I’m moving it. Keep your head straight.
If at any point you see it as two pens, tell me, okay. ”
- Final position ‘9’ is convergence test (when you move the pen close to
the patient’s face).
- Look for end point nystagmus: Multiple sclerosis.
- Test for saccadic eye movements:
“Mr/Ms .., I want you to look first on my nose then quickly shift to
my finger here and back again to my nose and so on. Keep doing
that quickly. ”
Put your index finger close to your nose.
To the examiner “Normal eye gaze movements, no end point
nystagmus, and normal convergence.”
4. CN V (5) – Trigeminal: (V1,2: Sensory, V3: Sensory & motor)
1- Inspection: S For
1- Temporal wasting.
2- Lateral deviation of jaw to side of lesion.
To the examiner “No temporal wasting or lateral jaw deviation. ”
123
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
2- Motor: S
1. Teeth Clenching: “Mr/Ms .., clench your teeth as hard as you can.
I’m going to feel your face.” Palpate the masseter and temporalis
muscles and compare sides. (Cheeks).
2. Mouth opening: “Mr/Ms ..,open your mouth widely”. Look for
deviation to the weak side. (Masseter and pterygoids muscles)
“Mr/Ms .., now, open your mouth against my hand.”
3. Jaw diversion: “Mr/Ms .., now, move your jaw to the right against
my hand…good now to the left.” (pterygoids muscle).
To the examiner “Normal CN 5 motor function.”
3- Sensory: S
1.
V1 (Ophthalmic): Forehead and nose tip.
V2 (Maxillary): Medial aspect of cheek.
V3 (Mandibular): Chin.
Light touch: Apply a tip of cotton wool on all the above three areas
comparing sides at each then proceed to the other area.
“Mr/Ms .., tell me when you feel the touch of this cotton on your
face. Close your eyes.” Ask him/her only once. (Otherwise, he/she
will now when are you going to touch).
Pain: Same as above but using a disposable pin or broken tongue
depressor.
Jaw jerk reflex: “Mr/Ms .., open your mouth please, I’m going to
rest my index finger on your jaw and tap it with this hammer,
okay” (increased in pseudobulbar palsy).
Corneal reflex: Afferent: CN 5 (V1). Efferent: CN 7
A5 E7
“Mr/Ms .., I’m going to lightly touch your eyes with the tip of this
cotton. Will you please look to the left. Okay, now to the right.”
Touch to cornea, not the lashes or conjunctiva.
Approach the eye from the sides so that the patient wont see the cotton
tip. Examine both eyes.
2.
3.
4.
* For both jaw jerk and corneal reflexes, the examiner will stop you.
To the examiner “Normal CN 5 light touch and pain sensory function.
Jaw jerk and corneal reflexes are normal.”
5. CN VII (7) – Facial: (Sensory and motor)
1- Inspection: S For
1. Nasolabial fold: ? flattened.
2. Palpebral fissure: ? eyelid sagging.
3. Mouth: ? drooping.
To the examiner “Normal nasolabial fold and no eyelid sagging or
mouth drooping.”
…Continued
124
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
2- Motor: S
1. Muscles of fascial expressions:
1- “Mr/Ms .., raise your eyebrow.” Frontalis muscle.
2- “Now, close your eyes tight. I’ll try to open them keep them
closed tight.” Orbicularis oculi muscle.
3- “Okay, show me your teeth.” Buccinator muscle.
4- “Now, puff your cheeks out. I’ll press them to check its
strength, keep them puffed out.” Orbicularis oris muscle.
5- “Okay, now, tense your neck muscles.” Platysma muscle.
To the examiner “Muscles of expression are / are not normal.”
2- Corneal reflex: Afferent: CN V (V1). Efferent: CN 7
To the examiner “Corneal reflexes are/ are not normal.”
3. Sensory:
Taste, anterior 2/3 of the tongue: CN 7; Posterior 1/3: CN 9.
“Mr/Ms .., Now, I’ll test your taste sense, okay. ”
Hold tongue with a gauze. Touch each side of the tongue with sugar,
salt, and vinegar.
* The examiner will stop you.
“Will you please stick your tongue out. I’m going to hold it. Tell
me when you taste something and what does it taste like, sugar,
salt, or vinegar.”
To the examiner “Taste in anterior 2/3 and posterior 1/3 are/ are
not normal.”
Raise your eyebrow
With a lower motor neuron (LMN) lesion (e.g. Bell’s palsy), you
lose entire ipsilateral motor function including frontalis muscle:
LIFe Bells.
While with upper motor neuron UMN lesion (e.g. cortex,
corticospinal), you lose the contralateral motor function with
sparing of the frontalis muscle.
U C no frontalis (You see no frontalis).
6. CN VIII (8) – Vestibulocochlear: (Sensory) WR WR
1. Whisper test (Auditory acuity):
“Mr/Ms…, I’m going to whisper few words, letters into your
ears.”
Distract one ear by wrinkling a paper.
Whisper into the other ear “1,2,3”… “Repeat what I said, please”.
Repeat for the other ear.
To the examiner “Normal whisper test.”
…. Continued
125
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
* Only if hearing is impaired with the whisper test, do Rinne and
Weber tests.
2. Rinne Test:
Strike a 512 Hz tuning fork and place it on the patient’s mastoid process at
one side.
“Tell me when this sound disappears?”.
-When he tells you; immediately place the tines of the fork near the ear
without touching it.
“Do you hear it now?”. Yes: AC > BC, No: BC > AC
Repeat for
the other ear.
To the examiner “Rinne test is/ is not normal.”
3. Weber Test:
Strike a 512 Hz tuning fork and place it on the patient’s forehead.
“Tell me, do hear it equally at both ears?”. If no, “Which one is
louder?” Lateralization (sound is higher at that side).
To the examiner “Weber test for bone conduction is normal/
Lateralization to right.”
4. Romberg Test: See test for balance.
Ask the patient to stand up and turn his/her head repeatedly from side to
side.
“Mr/Ms .., Now, stand up here. I’m going to turn your head
repeatedly from side to side. Please relax your neck… How do you
feel?” If he says dizzy, “What do you mean?”
Hearing
defects
Conductive
Sensorineural
Rinne Test (in deaf ear)
Weber Test
BC > AC
(Answer is NO)
AC > BC
(Answer is YES)
Lateralize to deaf ear
Lateralize to good ear
AC: Air conduction, BC: Bone conduction
7. CN IX (9) – Glossopharyngeal: (Sensory)
CN X (10) – Vagus: (Sensory, and Motor)
1- Motor: S Pharyngeal muscles.
1. Symmetry:
“Mr/Ms .., open your mouth and say ‘AH’”. With torchlight, check
the symmetrical movement of soft palate and uvula.
- If CN 9/10 damaged at one side: - Uvula deviates to the strong side.
- On relaxation: Palate relaxes to the
weak side.
To the examiner “Soft palate and uvula movements are / are not
symmetrical.”
… Continued
126
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
2. Gag reflex (nasopharyngeal reflex):
a 9 e 10
“Mr/Ms .., I’m going to touch the back of your mouth with this
tongue depressor to test your gag reflex”
* The examiner will stop you.
Touch the posterior wall of the pharynx.
- Palate should move up.
- Pharyngeal muscles should contract.
- Uvula should remain in midline.
To the examiner “Gag reflex is /is not normal.”
3. Swallowing:
- “Mr/Ms .., have some water and swallow it”
No water should come from the nose.
- “Mr/Ms .., say ‘PaTaKa’”
Pa: CN 7; TA: CN 9,10,12; Ka: CN 9, 10
To the examiner “Swallowing & speech are /not normal.”
2- Sensory: Taste of posterior 1/3 of the tongue. Done with CN 7.
8. CN XI (11) – Accessory: (Motor to SCM & Trapezius)
1- Inspection: For fasciculations or atrophy at the neck and shoulders.
“Mr/Ms .., I’m going to uncover your shoulders to inspect them.”
To the examiner “No fasciculations or atrophy of the
Sternocleidomastoid and Trapezius muscles.”
2- Motor: S
1. Trapezius:
“Mr/Ms ..,shrug your shoulders.”.
“Now, again against my hands”.
When Trapezius is weak. It is an ipsilateral lesion.
To the examiner “Trapezius muscle is normal/ weak on the left.”
2. Sternocleidomastoid (SCM):
“Mr/Ms .., turn your head to the right against my hand.”.
“Now, to the left”.
When SCM is weak at one side, turning the head to the
contralateral side is impaired.
To the examiner “Sternocleidomastoid muscle is normal/ weak
on the left.”
* COVER THE PATIENT.
9. CN XII (12) – Hypoglossal: (Motor to tongue)
1- Inspection: S For tongue asymmetry, deviation, fasciculation or
atrophy.
“Mr/Ms .., open your mouth.”.
… Continued
127
The Physical Examination Interview: Neurological Examination
Neurological examination: CN Cont.
To the examiner “Tongue is normal, no deviation or asymmetry, no
fasciculation or atrophy.”
2- Motor:
“Mr/Ms .., stick your tongue out and move it from side to side.”.
To the examiner “Tongue movements are normal, no deviation.”
- Tongue deviates to the lesion side (ipsilateral).
END of CN exam .. Wrap up or continue
CN lesion combination
Unilateral CN 5, 7, 8
Unilateral CN 3, 4, 5 V1, 6
Unilateral CN 9, 10, 11
Bilateral CN 10, 11, 12
128
Likely cause
Cerbellopontine angle lesion
Cavernous sinus lesion
Jugular foramen syndrome
Bulbar palsy (LMN), Pseudobulbar palsy
(UMN)
The Physical Examination Interview: Neurological Examination
Neurological examination: MMSE Cont.
4- Mini Mental Status Exam: MMSE (Folstein)
OMALT: O10, M6, A5, L8, T1 = 30 (< 24 is abnormal).
“Mr/Ms .., I’m going to ask you few questions to assess your
condition, okay.”.
To the examiner “I’m going to do the Mini Mental Status Exam.”
1. Orientation: O10
- Time: One point to each of: year, season, month, date of the month,
day of the week
“Mr/Ms ..,What year is this?….., What season are we in? ….,
What month is this? …, What is the date today? …, and what day
of the week is today?”.
- Place: One point to each of: Country, Province, City, street/hospital
name, house /floor number.
“Mr/Ms ..,What country is this?….., What province are we in?
…., What city are we in? …, What is the street/hospital name? …,
and what is house/floor number? .”.
To the examiner “Orientation is 10/10 or 9/10 for the day of the
week.”
2. Memory: M6
- Immediate recall: 1 point for repeating each of: “Honesty, Tulip,
Black”. All together.
“Mr/Ms .., repeat after me; Honesty, Tulip, Black.”.
- Delayed recall: 1 point for recalling each of the above three words
after five minutes.
Ask later in five minutes.
“Mr/Ms .., I’m going to ask you to recall these three words later,
okay.”.
3. Attention & Concentration: A5
1 point for backward spelling each of the letters of the word “World”
“Now, spell the word ‘World’ backward.”.
To the examiner “Attention & concentration is 5/5.”
4. Language Tests: L8
- Comprehension: (Three stage command), 1 point for each stage: 3
“Mr/Ms .., are you right or left-handed?.. Take this piece of
paper with your left hand, fold it in half, and place it on the
Non-dominant hand
floor.”.
- Reading: 1 point for reading ‘close your eyes’.
“Mr/Ms .., read this and then do what it says.”.
… Continued
129
The Physical Examination Interview: Neurological Examination
Neurological examination: MMSE Cont.
- Writing: 1 point for writing a complete sentence.
“Mr/Ms .., write a complete sentence on that paper.”.
- Repetition: 1 point for repeating ‘no ifs, ands, or buts’.
“Mr/Ms ..,repeat ‘ no ifs, ands, or buts’.”.
- Naming: 2 points for naming two objects (a pen & a watch)
“Mr/Ms .., what is this?, …, and this.”.
To the examiner “Language tests are 8/8.”
(3) “Mr/Ms .., I want you to recall the three words that I told you few
minutes ago.”.
To the examiner “Memory is 6/6.”
5. Test of Spatial Ability: T1
1 point for coping the following drawing.
To the examiner “Test of Spatial Ability is 1/1.”
To the examiner “Mini mental status is …/30.”
END .. Wrap up or continue
130
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor
5- Motor Examination:
Motor examination:
1. Inspection.
2. Muscle tone.
3. Muscle power
4. Reflexes.
- Two important questions to be answered:
Where is the lesion? & What is the lesion?
- Is the lesion UMN or LMN lesion?
- Is it localized to a specific root or peripheral nerve?
Appearance
Power
Tone
Coordination
Reflexes:
Superficial
Deep
Plantar
UMN Lesions
Atrophy, arms flexed, legs
extended
Weak / absent
Increased / spastic
Impaired due to weakness
LMN Lesion
Atrophy, Fasciculations
Absent
Increased / clonus
Up going
also
Decreased
Down going (normal)
also
Decreased/ Flaccid
also
1. Inspection:
“Mr/Ms .., I’m going to uncover you to inspect your muscle built.”.
Look on all four limbs
1. Muscle bulk: Atrophy, hypertrophy, & abnormal bulging/depression.
2. Symmetry:
3. Fasciculations: Typically benign. May be associated with ALS.
To the examiner “There is/ is no muscle atrophy, hypertrophy,
fasciculation, bulging or depression or asymmetry.”
4. Abnormal movements & positioning:
- Asterixis: Brief, jerky downward movements of the wrist when patient
extends both arms with wrists dorsiflexed, palms forward and eyes closed.
“Mr/Ms .., I want you to extend both your arms and back flex
your hands Justas if you’re stopping a bus like this…. That’s
right, now close your eyes. Okay, thank you.”.
To the examiner “No asterixis.”
- Tics: Involuntary contractions of single muscle or a group of muscles.
- Myoclonus: Brief (<0.25 sec) generalized muscle jerk & asymptomatic.
- Dystonias: Muscle contractions that are more prolonged than myoclonus
and result in spasms.
- Athetosis: Slow & writhing spasms. Patient may assume peculiar postures.
- Chorea (Dance): Purposeless movements that affect multiple joints.
- Hemiballismus: Violent flinging movement of half of the body (lesions of
subthalamic nucleus).
- Seizures: Automatism, repeated eye blinks, tonic or clonic motor activity.
To the examiner “There are no abnormal movements or positions
like tics, myoclonus, dystonia, athetosis, chorea,
hemiballismus, or seizures.”
* COVER THE PATIENT.
… Continued
131
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
2. Muscle tone: S
The permanent state of partial contraction of the muscle. Test by flexion/
extension, pronation/supination of joints through its range of motion.
- Hypotonia (Flaccidity): seen in LMN lesions, spinal shock (e.g. early
response after stroke), and some cerebellar lesions.
- Hypertonia: (Spasticity or Rigidity)
- Spasticity: Limb moves, then catches, and then goes again (spastic, claspknife).
It is velocity dependent.
Best seen during rapid supination of forearm or rapid flexion of the knee.
Pyramidal tract lesion (UMN lesions: corticospinal tract in late or
chronic response after stroke).
- Rigidity: Increased tone through out the range of movement (cog-wheel,
lead-pipe).
It is velocity independent.
Best seen during circumduction of the wrist.
Extra-pyramidal tract lesions (Parkinsonism, Phenothiazines).
“Mr/Ms .., Give me your right arm. I’m going to check its tone, relax it.
(Rapid pronation /supination, flexion/extension of elbow)… Now the other arm
(repeat) ... Okay now I’m going to check your right knee (rapid
flexion/extension) … Now the other knee.”.
To the examiner “There is no flaccidity, spasticity, or rigidity. Muscle
tone is symmetrical on both sides and upper & lower
limbs.”
3. Muscle Power: S
Muscle power is measured by active motion of the patient against the
examiner’s resistance. Compare both sides.
1- Axillary N. (C 5, 6) Deltoid: Arm abduction:
“Mr/Ms.., I’m going to hold your arms…(Hold him from the sides as if
squeezing him, now fan out your arms.”
2- Musculocutaneous N. (C 5, 6) Biceps: Elbow flexion:
“Hold my hands and pull them”.
To the examiner “Normal symmetrical Axillary & Musculocutaneous
nerves C5, C6 /or Weakness on the right.”
3- Radial N. (C6, 7, 8):
- Triceps: Elbow extension:
“Now push my hands”.
- Wrist extensors: Wrist extension:
While the patient is still holding your hands, straighten his wrists.
“Now back flex your hands.”
To the examiner “Normal symmetrical Radial N. C6, C7, C8 /or
Weakness on the right.”
… Continued
132
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
4- Median N. (C6, 7) Flexor pollicis longus: Thumb IP flexion:
Hold the tip of his/her both thumbs.
“Now flex your thumbs.”
To the examiner “Normal symmetrical Median N. C6, C7/
Weakness on the right.”
5- Ulnar N. (C8, T1) Interossei of hand: Finger abduction/adduction:
Squeeze both his/her fingers gently.
“Fan out your fingers.”
Interdigitate your fingers with his/her fingers.
“Squeeze my fingers hard.”
To the examiner “Normal symmetrical Ulnar N. C8, T1 /or
Weakness on the right.”
6- Femoral N. (L1, 2, 3) Iliopsoas: Hip flexion:
“Mr/Ms.., now, I’m going to hold your thighs… (Hold them anteriorly
pushing them down gently , now lift your thighs up.”
To the examiner “Normal symmetrical Femoral N. L1, 2, 3 /or
Weakness on right.”
7- Superior gluteal N. (L4, 5, S1) Hip Abductors: Hip abduction:
Hold the thighs from the sides
“Push my hands out.”
To the examiner “Normal symmetrical Superior gluteal N. L4, 5,
S1 /or Weakness on the right.”
8- Obturator N. (L2, 3, 4) Hip Adductors: Hip adduction:
Hold the thighs from the insides
“Now, close your thighs.”
To the examiner “Normal symmetrical Obturator N. L2, 3, 4/or
Weakness on right.”
9- Femoral N. (L2, 3, 4) Quadriceps: Knee extension:
Bend the patient’s both knees and hold both legs at the shins
anteriorly pushing down.
“Mr/Ms. .., Bend both your knees please...(Hold his legs), … Push
my hands, extend your legs.”
To the examiner “Normal symmetrical Femoral N. L2, 3, 4 /or
Weakness on right.”
10- Sciatic N. (L5, S1, 2) Hamstrings: Knee flexion:
While the patient’s knees still bended, hold them from the calves.
“Now pull my hands……...Okay, stretch your legs.”
To the examiner “Normal symmetrical Sciatic N. L5, S1, 2 /or
Weakness on right.”
… Continued
133
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
11- Deep Peroneal N. (L4, 5) Tibialis anterior: Ankle dorsiflexion:
Hold both feet at the dorsum.
“Again pull my hands with your feet.”
To the examiner “Normal symmetrical Deep Peroneal N. L4, L5 /or
Weakness on the right.”
12- Tibial N. (S1, 2) Gastrocnemius / Soleus: Ankle planter flexion:
Hold both feet at the planter surface.
“Now, push my hands with your feet.”
To the examiner “Normal symmetrical Tibial N. S1, S2 /or
Weakness on the right.”
13- Deep Peroneal N (L5, S1) Extensor hallucis longus: Great toe
dorsiflexion:
Hold both big toes at the dorsum.
“Now, pull my hands with your big toe only.”
To the examiner “Normal symmetrical Deep Peroneal N. L5, S1 /or
Weakness on the right.”
14- Posterior Tibial N. (L4, L5) Tibials: Posterior foot inversion:
Hold both feet from the inside.
“Now, pull my hands in with your feet.”
To the examiner “Normal symmetrical Posterior Tibial N. L4, L5
/or Weakness on the right.”
15- Superficial Peroneal N. (L5, S1) Peroneus longus & brevis: Foot
eversion:
Hold both feet from the outside.
“Now, push my hands out with your feet.”
To the examiner “Normal symmetrical Superficial peroneal N. L5,
S1 /or Weakness on the right.”
16- Pronator Drift:
Have the patient stand with their eyes closed and arms held straight
out in front of his/her body with hands in supine position.
“Mr/Ms .., will you please stand up, … close your eyes and hold
your arms straight out like this with palms up … … … … … ...
Thank you sit down.”
If the patient can’t maintain this position: positive pronator drift.
Causes: 1. Muscle weakness: often yields pronation and outward drift
of the arm and hand.
2. UMN lesion: often yields bilateral pronation and upward
drift.
* Use reflexes and other specific tests to differentiate.
To the examiner “No pronator drift / there is pronator drift on the
right with arms moving outwards.”
… Continued
134
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
0
1
2
3
4
5
Grade
Absent
Trace
Weak
Fair
Good
Normal
Assessment
No contraction detected
Slight contraction detected but cannot move joint
Movement with gravity eliminated
Movement against gravity only
Movement against gravity with some resistance
Movement against gravity with full resistance
4. Reflexes:
General rules: - Patient must be relaxed with muscle mildly stretched.
- Strike tendon briskly and compare sides.
- Watch the muscle while striking for contraction, NOT
the tendon.
- If reflexes are absent: use the following reinforcement
while striking:
- Arms: Let him clench teeth or push down on bed
with his thighs.
- Legs: Let him lock his fingers and try to pull
them apart.
0
1
2
3
4
5
Reflexes Grade
Absent
Diminished
Normal
Increased
Hyperactive
Sustained clonus
Reflexes innervations:
(Count from 1 – 8, from ankle up)
S1-2: Ankle jerk.
L3-4: Knee
C5-6: Biceps
C7-8: Triceps
.
Note: Patient is now sitting at the end of the previous pronator drift test.
1- Deep Tendon reflexes: S
These are monosynaptic spinal segmental reflexes.
“Mr/Ms .., now, I’m going to check your reflexes. I’m going to
strike this hammer gently on some points near your joints, Okay?”
1. Biceps tendon reflex C5, 6:
- Forearm is relaxed midway between flexion & extension with
forearm halfway pronated and rested on their knee.
- Place your thumb on the patient’s tendon and strike your thumb
with hammer.
- Look on the biceps muscle for contraction followed by forearm
flexion at the elbow.
“Mr/Ms .., I’ll start here with your elbow. Relax your arm in this
position…. (Set the forearm, strike twice, and watch). Now the
other one….”
To the examiner “Biceps tendon reflex is normal & symmetrical/
diminished /increased.”
...Continued
135
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
2. Brachioradialis tendon reflex C5, 6:
- Arm in same position as Biceps test.
- Strike the stylus process of radius about 2-5 cm above wrist.
- Look for simultaneous forearm flexion at elbow and supination
“Mr/Ms .., now here near your wrist. …. (Set the forearm, strike, and
watch twice). Now the other one….”
To the examiner “Brachioradialis tendon reflex is normal &
symmetrical / diminished /increased.”
3. Triceps tendon reflex C6 - 8:
- Forearm is half flexed at elbow and pulled towards the patient’s chest.
- Strike the tendon 2-5 cm above elbow above the insertion of ulnar
olecranon.
- Look for Triceps contraction followed by forearm extension at elbow.
“Mr/Ms .., now here at the back of your arm. …. (Set the forearm,
strike, and watch twice). Now the other one….”
To the examiner “Triceps tendon reflex is normal& symmetrical
/diminished /increased.”
4. Patellar tendon reflex (Knee jerk) L2 - 4:
- Bend the knee to relax the quadriceps.
- Place your left hand on the patient’s quadriceps and strike the tendon
firmly.
- Look for quadriceps contraction followed by leg extension at the knee
(swing).
“Mr/Ms .., now here at the your knee… (Set the leg, strike, and watch
twice). Now the other one ...”
To the examiner “Patellar tendon reflex is normal & symmetrical
/diminished /increased.”
5. Achilles tendon reflex (Ankle jerk) S1 - 2:
- Dorsiflex the foot then strike the tendon.
- Look for calf muscles contraction followed by planter flexion of the
foot at the ankle.
“Mr/Ms .., now your ankle. …. (Set the foot, strike, and watch twice).
Now the other one….”
To the examiner “Achilles tendon reflex is normal & symmetrical/
diminished/ increased.”
2- Primitive reflexes:
Generally not present in adults. When present signifies diffuse cerebral
damage, particularly of frontal lobes.
- Glabellar: Tap forehead and watch if eye blink.
“Mr/Ms .., I’m going to tap on your forehead.”
- Grasp-Place: Place your fingers in the patient’s palm to see if grasp reflex
elicited. “Mr/Ms .., give me your hand, please.”
To the examiner “No primitive reflexes.”
...Continued
136
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
3- Superficial reflexes:
1. Abdomen reflex: Above umbilicus T8-10. Below umbilicus T10-12
Strike abdomen away from the umbilicus along diagonals of the four
abdominal quadrants. Normally the umbilicus deviates towards the
stimulus.
“Mr/Ms .., I’m going to tap your stomach.”
To the examiner “Superficial abdominal reflex is normal/
diminished/ increased.”
2. Cremasteric reflex: For males.
Draw a line along the patient medial thigh, the ipsilateral testis
elevates in scrotum.
“Mr/Ms .., now I’m going to uncover your thighs and scrotum
and draw a line on your right thigh…..and the left.”
To the examiner “Cremasteric reflex is normal/ diminished/
increased.”
COVER THE PATIENT.
*- Abdominal and cremastic reflexes are absent in obesity, previous
laparotomy, and childbirth. But it is very significant if present. Absent in
ipsilateral corticospinal tract lesion.
3. Corneal reflex: Afferent: CN 5 (V1). Efferent: CN 7
“Mr/Ms ..,I’m going to lightly touch your eyes with tip of this
cotton. Will you please look to the left. Okay, now to the right.”
Touch to cornea, Not the lashes or conjunctiva.
Approach the eye from the sides so that the patient wont see the
cotton tip. Examine both eyes.
* For corneal reflexes, the examiner will stop you.
To the examiner “Corneal reflexes are normal.”
4. Babinski’s reflex: S (Plantar reflex L5-S1)
Strike the sole with a key from the heel to the ball of the foot
curving medially across the heads of metatarsal bones.
Normally downward flexion of the big toe (upwards in infants).
Positive Babinski’s reflex: Dorsiflexion of the big toe (upward) and
fanning of the other toes: UMN lesion, drugs, alcohol, post seizure.
“Mr/Ms ..,now, I’m going to draw a line on your right sole…and
the other one.”
To the examiner “Babinski’s reflex is negative.”
5. Anal reflex: S2-4 reflex arc.
Strike the perianal skin; normally muscles around the anus will
contract. Loss of reflex arc : Cauda equina lesion.
“Mr/Ms .., now I’m going to uncover your bottom and draw a
line on the sides .” * For anal reflex, the examiner will stop you.
To the examiner “Anal reflex is normal.”
COVER THE PATIENT.
...Continued
137
The Physical Examination Interview: Neurological Examination
Neurological examination: Motor Cont.
Reflex Characteristic
Possible causes
UMN lesion above the root at that level.
Increased
Absent
- Generalized: Peripheral neuropathy
- Isolated: Peripheral nerve or root lesion.
Reduced
1. Peripheral neuropathy,
2. Myopathy,
3. Cerebellar syndrome,
4. Spinal shock (early UMN lesion).
Inverted (Absent
LMN lesion at the level of the absent reflex,
reflex but produces
with UMN lesion below (due to spinal cord
higher or lower
involvement at the level of the absent reflex).
reflex. e.g. biceps
reflex is absent, but
produces triceps
response).
Pendular (reflex
Cerebellar disease.
continues to swing
for several beats).
‘Hung’ (slow to
Hypothyroidism.
relax, especially
ankle reflex).
END .. Wrap up or continue
138
The Physical Examination Interview: Neurological Examination
Neurological examination:
6- Sensory Examination:
-
-
-
Sensory examination:
1- Primary sensory exam:
(Peripheral nerves tests)
Overview:
1. Light touch.
2. Pain.
Always explain to the patient while
3. Temperature.
his eyes are open and inform him how
4. Vibration.
to respond before the test.
5. Proprioception.
Have the patient close his eyes before
2- Secondary sensory exam:
the test.
(Cortical sensory function
Always test both sides.
tests)
Start each exam with the fingers and
1. Two-point
toes.
discrimination.
If sensation is intact (distally), don’t
2. Stereognosis.
continue; proceed to the other test
3. Graphesthesia.
explaining to the examiner. S
4. Point localization.
If not, continue to proximal
dermatomes to map out abnormalities.
Compare sensory function: right to left; distal to proximal; peripheral to
spinal nerve dermatomes.
For each sensory deficit, note: location, magnitude, and quality. There is
considerable overlap and variation in peripheral nerve distribution.
Dermatomes:
… continued
139
Sensory dermatomes and motor myotomes©
Sensory
Dermatome
Jaw angle
Shirt collar area
Neck base/ over deltoid
Dorsum of 1st web space
(thumb) S
Dorsum of Index finger
S
Dorsum of little finger S
Nipple level
Xiphoid level
Umbilicus
Above inguinal ligament
Below inguinal ligament
Anterior Medial knee
Anterior mid thigh
Anterior Lateral knee
Anterior mid leg (shin)
Foot dorsum S
Lateral edge foot S &
Over Achilles tendon
Medial posterior thigh
Around anus & genitalia
Nerve
Root
Motor
Myotome
Nerve
C1-2
C3
C4
C5
C6
Muscle
Neck Flexion
Neck side flexion
Axillary N.
C5-6
Musculocutanous N.
Shoulder abduction >90 0
Elbow flexion/ Supination
Deltoid
Biceps
Radial N.
Wrist extension
Extensor carpi radialis
Elbow extension
Thumb IP flexion
Wrist flexion +6
Triceps
Flexor digitorum
profundus
C6, 7, 8
C7
Radial N.
C7
Median N.
C8
Anterior interosseus N.
Fingers flexion
C8
T1
T4
T6
T10
L1
L2
L3
Ulnar N.
Ulnar deviation
Fingers abduction/ adduction
Interossei
Hip flexion
Iliopsoas
Femoral N.
Knee extension
Quadriceps
Deep Peroneal N. L4-5
Ankle dorsiflexion +L5
L5
S1
Deep Peroneal N.
Big toe dorsiflexion
Medial hamstrings/
Tibialis anterior
Extensor hallucis longus
Ankle Planter flexion
Soleus/ Gastrocnemius
S2
Sciatic N.
Knee flexion
Biceps femoris/
Semitendinosus
L4
Femoral N.
Tibial N.
S3-S4
Pudendal N.
C6-7
C8
T1
L1, 2, 3
S1-2
L5, S1- 2
S 3-4
A Step By Step Guide To Mastering The OSCEs, ©2005, MedInfo Consulting
140
The Physical Examination Interview: Neurological Examination
Neurological examination: Sensory Cont.
1- Primary sensory examination:
1. Light touch: S Posterior column and spinothalamic tract function.
Use cotton or a tip of a tissue to touch skin.
“Mr/Ms ..,I’m going to feel your skin with this cotton on several
points of your body. I want you to say ‘yes’ when you feel it just
like this, okay.. Let us start, close your eyes. ”
To the examiner “Light touch is normal.”
2. Pain: S Spinothalamic tract function
Alternate between sharp and dull touches. Ask the patient to identify
sensation as sharp or dull.
“Mr/Ms .., now, I’m going to feel your skin with this paper pin.
Again, say ‘yes’ when you feel it and tell me if it is dull or sharp
sensation, close your eyes. ”
To the examiner “Pain sensation is normal.”
3. Temperature: Spinothalamic tract function. Not done if pain
sensation is normal.
To the examiner “Temperature sensation should also be normal as
it is also a spinothalamic function.”
Run the tuning fork under cold/hot water and check use it for checking
hot/cold sensation.
“Mr/Ms ..,now, I’m going to feel your skin with this tuning fork.
Again, say ‘yes’ when you feel it and tell me if it is hot or cold
sensation, close your eyes. ”
To the examiner “Temperature sensation is normal.”
Never ask
the patient
if he/she is
feeling the
touch
every time
you touch
the skin so
he wont
know if
you are
touching
or not.
Start with
fingers
and toes.
If intact,
stop.
If not, map
the
dermatome
4. Vibration: Posterior column function / Peripheral neuropathy.
Struck the 128 Hz tuning fork and place it on the DIP joint. Ask the
patient to tell you when the vibration stops. Check the other side and
both lower limbs. If it is impaired move up for dermatome
distribution.
“Mr/Ms ..,now, I’m going to place this tuning fork on your right
hand fingers. Tell me when the buzzing stops, close your eyes…
now the other hand… now the right leg…the left.”
To the examiner “Vibration sensation is normal.”
5. Proprioception: S (Joint Position Sense) Posterior column function.
Hold the patient’s finger from the sides. Begin with the joint at neutral
then move it up or down and ask the patient to tell you the direction.
Return to neutral position before starting again. S big toes only.
“Mr/Ms ..,now, I’m going to move your right hand finger up or
down. Tell me if I’m moving it up or down, close your eyes… now
the other hand… now the right leg…the left.”
To the examiner “Proprioception sensation is normal.”
… continued
141
The Physical Examination Interview: Neurological Examination
Neurological examination: Sensory Cont.
2- Secondary sensory examination:
Inability to perform these tests suggests a lesion in the sensory cortex or the
posterior columns of the spinal cord.
1. Sensory inattention, Neglect & extinction: Parietal lobe function.
- Touch right side, left side, and then both. Start with light stimulus and
increase intensity of stimulus if extinction occurs.
- Patients with parietal lobe lesions will neglect touch on the side
contralateral to the lesion WHEN BOTH sides are touched simultaneously.
“Mr/Ms .., now back again to feeling your skin with this cotton on
your body. I want you to say ‘yes’ when you feel it, okay.., close your
eyes? (Right).., (left).., (Both) ”.
When the patient says ‘yes’ ask “Which side?”
If extinction: Repeat with stronger stimulus.
To the examiner “Secondary sensation of inattention, neglect &
extinction is normal.”
2. Two point discrimination: S Parietal lobe function.
- Using an untwisted paper clip, ask the patient if he feels two pins.
- At fingertips: 2 mm; Toes: 3-8 mm; Palm: 8-12 mm; back: 40 –60 mm.
“Mr/Ms .., now tell me if you feel this pin on your skin.., close your
eyes. (Right).., Is it one or two pins? (left)…, adjust distance between the pin
heads at each area. ”
To the examiner “Two point discrimination is normal.”
3. Stereognosis: Parietal & temporal lobe function
Place objects in the patient’s hand while eyes are closed and ask him to
recognize it.
“Mr/Ms .., close your eyes and keep them closed. (Put a coin, or pen or key
in his right hand) .., Tell me what is this?.. and now what is this (repeat on the
left with something different)…,? ”
To the examiner “Secondary sensation of Stereognosis is normal.”
4. Graphesthesia: Parietal lobe function
Use a closed pen to write numbers on the patient hand while eyes closed.
“Mr/Ms .., I’m going to pretend writing a number on your hand with
this closed pen,.. close your eyes again and keep them closed. (Write a
number on his right hand).., Tell me what was the number?.. and now (repeat
on the left with different number)…,? ”
To the examiner “Secondary sensation of Graphesthesia is normal.”
5. Point localization & extinction: Sensory cortex.
Touch the patient and ask him to point the touched area.
“Mr/Ms .., now back again to feeling your skin with this cotton on
your body. I want you to say ‘yes’ when you feel it, okay.., close your
eyes. (Right)..” When the patient says ‘yes’; ask “Point where was that?..,
(left).., (Both in different areas for extinction). ”
To the examiner “Point localization & extinction is normal.” … continued
142
The Physical Examination Interview: Neurological Examination
Neurological examination: Sensory Cont.
Where is the lesion? & What is the lesion? for primary sensory impairment:
Location of
Primary Sensory
Lesion
Distribution of
Sensory loss
(JPS: Joint position sense)
Single nerve
Single dermatome.
Commonly:
Median N., Ulnar N., Peroneal
N., Lateral cutaneous nerve to
the thigh
Root or roots
Confined to single root (s)
Commonly: C5, 6, 7 in arm,
L4, 5, S1 in leg
Distal glove and stocking deficit
Peripheral nerve
Spinal Cord:
- Complete
transaction:
- Hemi section:
- Posterior column:
- Anterior column:
- Central cord:
Brainstem
Thalamic sensory
loss
Cortical (Parietal)
Examples
- Hyperesthesia at upper level
- WITH loss of all modalities
sensations a few segments
below
- JPS & vibration loss:
Ipsilateral below lesion
- Pain & temp. loss:
Bilateral at level of lesion.
- Pain & temp. contralateral
1-2 segments below lesion
JPS & vibration:
Bilateral loss below level.
- Pain & temp. loss:
Bilateral below level.
- JPS & vibration: Preserved.
- Pain & temp. loss:
Bilateral below level.
- All others: Preserved.
Pain & temp.: ipsilateral face
& contralateral body
All: contralateral
Hemisemsory loss of face &
body and pain (dysesthesia) e.g.
burning feeling
All primary sensations are intact
BUT with poor localization.
Loss of all secondary sensations.
Entrapment: common in
- DM,
- Carpal tunnel
syndrome,
- Rheumatoid arthritis,
- Hypothyroidism
Multiple: Vasculitis
(Mononeuritis
Multiplex)
Compression by disc
prolapse
- DM
- Alcohol related
B12 deficiency.
- Drugs
- Trauma
- Spinal cord
compression by:
Tumor,
Cervical spondylitis,
MS
Anterior spinal artery
embolism/thrombosis
- Syringomyelia
- Trauma leading to
hematomyelia
- Demyelination (young).
- Brainstem stroke (elder)
- Stroke.
- Cerebral tumor.
- MS.
- Trauma
End of Sensory exam .. Wrap up or continue
143
The Physical Examination Interview: Neurological Examination
Neurological examination:
7- Coordination Examination:
1. General:
1- Masked face:
2- Slurred speech (Dysarthria): “Mr/Ms.., say ‘British constitution’.”,
3- Nystagmus (Gaze evoked): “Now, keep your head straight and look
with your eyes only to the right.”
4- Tremor (Intention tremor: coarse, absent with rest) “Now, give your
hands……, now put them back on your lap……watch for tremor.”
5- Stiff, slowed, non-rhythmic movements. Normally rapid smooth and
accurate.
To the examiner “Patient’s speech and movements are/not normal.
There is/ no mask face nystagmus, tremor or stiff
movements.”
“Mr/Ms.., now I want you to do some movements to test your
coordination ability.”
2. Gross motor coordination:
1. Heel-To-Knee Test: Have the patient slide one foot heel (not the
whole foot) down the shin of the other leg starting from the knee.
“Slide your right foot heel over your left leg shin starting from the
knee down…. Now the left foot over the right shin.”
To the examiner “Heel-To-Knee test is normal.”
2. Finger-To-Nose Test: Have the patient to alternate between touching
their nose and your finger (placed at an arm’s length from them not
closer) as quickly as possible.
“Now, touch your nose tip with your right index finger then my
finger here and repeat as quickly as possible,.. now your left index
finger.”
Look for: ‘past pointing’ (touching the same target again without
alternating); and tremor as the finger approaches the target.
Inability to do the test: Dysmetria (Inability to control range of
motion): Cerebellar disease.
To the examiner “Finger-To-Nose test is normal.”
3. Fine motor coordination:
Rapid alternating movements (RAM):
Inability to do it: Dysdiadochokineasia: Cerebellar lesion.
1. Upper limb: Pronate & supinate one hand on the other rapidly.
“Now, I want you to do like this rapidly.” Show him how.
- Touch the thumb to each finger as quickly as possible.
“Now, with your right hand, do like this rapidly,.. okay, the other
hand.” Show him how.
… continued
144
The Physical Examination Interview: Neurological Examination
Neurological examination: Coordination Cont.
2. Lower limb: Let the patient tap the toes of one foot and then the
heel to the floor in rapid alternation.
“Now, stand up here with your right foot, do like this rapidly,.
okay, the other foot.” Show him how.
To the examiner “Fine motor coordination is normal.”
4. Gait:
“Now let us check your gait, okay,…”
“Will you please stand up here and walk straight ahead”
“Stop and return to me now on tiptoe” S1
“Now walk away again but this time on your heels.” L5
“Stop, return by walking in tandem gait with one foot placed in
front of the other.” Cannot do tandem gait: Cerebellar lesions.
To the examiner “Gait is normal, there is no shuffling, spastic
movements, wide stance, foot drop, or steppage.”
5. Balance:
“Mr./Ms., Now let us check your Balance, okay,…” Note: the
patient is still standing.
1. Romberg Test: Have the patient stand in front of you with their
feet together, be prepared to catch or support a falling patient by
spreading your arms on his sides.
“Stand here perfectly still with your feet together,… now close
your eyes.”
If he is swaying “Please stand perfectly still.”
- Positive if the patient fall in any direction, not sway, WITHOUT
being aware of the fall: Peripheral sensory denervation, Vestibular
dysfunction, and cerebellar disease.
To the examiner “Romberg test is normal.”
2. Pull Test:
Now while the patient is still standing with his eyes closed, stand
behind him and give him a sudden but gentle pull backward.
- Normally the patient keeps steady or takes one step back.
- Positive if falls backwards or takes multiple small rapid steps:
Parkinson.
“Sorry Mr/Ms…, that was to test your balance.”
To the examiner “Pull test is normal.”
6. Motor:
Screen for power, tone, and reflexes.
7. Sensory:
Screen for pain, and joint position sense.
END
145
The Physical Examination Interview: Neurological Examination
Neurological examination: Coordination Cont.
Pathological Gait pattern
1. Hemiplegia veers toward lesion
Unilateral UMN lesio n due to:
2. Parkinsonian
Shuffling gait.
3. Spastic / Scissor
Legs are held in adduction at
hips, thighs rub together,
knees slide over each other
4. Cerebral ataxia:
Spreads legs wide apart to
provide wider base of support,
veers towards lesion side
5. Foot drop / Steppage:
Takes high steps as if climbing a
flight of stairs.
6. Sensory ataxia Romberg +ve
Loss of joint position sense due to
.
146
Possible causes
1.
2.
1.
2.
Stroke.
Multiple sclerosis (MS)
Parkinsonism.
Extrapyramidal effects of antipsychotics
3. Major tranquilizers.
Cerebral palsy.
1.
2.
3.
Drugs: Phenytoin, Alcohol
MS
Cereberovascular disease.
Unilateral: 1. Common peroneal palsy
2.Corticospinal tract lesion.
3. L5 radiculopathy (Sciatica)
Bilateral: Peripheral neuropathy.
1. Peripheral neuropathy.
2. Posterior column loss.
The Physical Examination Interview: Neurological Examination
Neurological examination
Where is the lesion?
Central nervous system lesions:
Location of
CNS lesion
Cerebral
cortex,
Unilateral
Brainstem,
Unilateral
Spinal cord,
Unilateral
Basal Ganglia
Cerebellar
Motor
1- Contralateral
weakness, spasticity
2- Flexion > Extension in
arms
3- Planter > Dorsiflexion
in foot.
4- External rotation of
legs.
5- Hemisphere deficits.
6- Aphasia.
7- Neglect.
8- Visual lose.
1- Contralateral
weakness, spasticity
2- Dysarthria
3- CN deficit (See below)
Ipsilateral weakness,
spasticity
1- Bradykinesia
(slowness)
2- Rigidity
3- Tremor
1- Hypotonia
2- Ataxia
3- Nystagmus
4- No Rapid Alternating
Movements
What is the lesion?
VINDICATE
Vascular
Infectious
Neoplastic
Degenerative
Inflammatory / Immunologic
Congenital – developmental
Autoimmune
Toxic / Traumatic
Endocrine - Metabolic
Deep
tendon
reflexes
Examples
Increased
- Cortical
stroke.
- Coma
- Seizure.
Increased
- Brainstem
stroke
- Acoustic
neuroma
1- Contralateral
dermatomal
loss at level
2- Variable
below level
Increased
Trauma
causing cord
compression
No loss
Normal or
decrease
Parkinsonism
No loss
Normal or
decrease
- Cerebral
stroke
- Tumor
Sensory
Contralateral loss
Variable
Brainstem lesions:
Mid Brain:
CN 3 & 4: - Diplopia
- Ptosis
- Non-reactive pupil.
Pons:
CN 6 & 7: - LMN facial weakness
Medulla:
CN 8 & 10: Medullary Syndrome
… Continued
147
The Physical Examination Interview: Neurological Examination
Neurological examination:
Where is the lesion? .. Continued
Peripheral nervous system lesions:
Location of
PNS lesion
LMN
Spinal Nerves
Motor
Ipsilateral
Sensory
Ipsilateral
1- Weakness/ atrophy
in a segmental/
focal pattern
2- Fasciculations
1- Weakness/ atrophy
in a root
innervated pattern
2- Fasciculations
sometimes
1- Weakness/ atrophy
in a peripheral
nerve pattern
2- Fasciculations
sometimes
Deep
tendon
reflexes
Examples
No loss
Decreased
- Polio
- ALS
Dermatomal
Decreased
Herniated disc
Nerve
pattern
- Trauma
- compression
- Entrapment
Polyneuropathy
Weakness/ atrophy:
distal > proximal
StockingGlove
distribution
Decreased
Peripheral
neuropathy:
- Alcoholism.
- DM
- GuillianBarre (acute)
Neuromuscular
junction
Fatigability,
Bilateral symmetrical
proximal weakness
No loss
Normal
Myasthenia
gravis
Myopathy
Weakness:
Proximal > distal
No loss
Normal or
decreased
Muscular
dystrophy,
Polymyositis,
Myopathies.
Mononeuropathy
What is the lesion? .. Continued
Acute
Focal
Diffuse
148
Vascular (Infarction /
Intracranial hemorrhage
Toxic / Metabolic
Subacute
Inflammatory
(Abscess, Myelitis)
Inflammatory
(Meningitis, encephalitis)
Chronic
Neoplasm
Degenerative
Chapter 23: MUSCULOSKELETAL EXAMINATION
Musculoskeletal Examination Sub Model:
1.
2.
3.
4.
5.
6.
Inspection (SEADS CAGE).
Palpation (No WET MPs) & Range of Movement (ROM).
Power assessment / Isometric Movements.
Functional assessment.
Sensations & Reflexes.
Specific joint tests & others.
- Always examine the joints above and below site of interest.
- If lower extremity: also examine lower back and complete neurological
exam of legs.
- If upper extremity: also examine neck and complete neurological exam
of arms.
1. Inspection: SEADS CAGE
“Mr./Ms.., let me have a look on both your …. (hands, elbows, shoulders,
feet, knees, hips).”
Drape appropriately, compare both sides.
1. Swelling.
2. Erythema.
3. Atrophy of muscles.
4. Deformities in shape, alignment, or posture.
5. Skin changes: Bruising or discoloration
6. Crepitus or abnormal sound in joints when patient moves them
7. Examine the other side for Asymmetry in bony contour, soft tissue, and
limb position.
8. General patient’s: - Attitude: apprehensiveness, restlessness.
- Facial expressions: discomfort.
- Willingness to move & normality of movements.
To the examiner “There is / is no swelling, erythema, muscle atrophy,
deformity, contractures, skin changes or crepitus. The
patient looks comfortable, relaxed, moving his/her …
joint normally/ looks apprehensive with limited ….
joint movement.”
2. Palpation:
No WET MPs
“Mr./Ms.., now, I’m going to feel your …. (hand, elbow, shoulder, neck,
foot, knee, hip, back).”
1- Palpation: - Feel for:
1. Warmth. Feel with the back of your hand (Compare to surround &
the other side joint).
2. Skin thickness, texture (Pliable/ soft/ resilient), and dryness/
moisture. (Pull it).
3. Nodules.
4. Effusion.
… Continued
149
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination Sub Model: …Cont.
5. Tenderness: Apply firm pressure on the joint:
- Grade I: Patient complains of pain.
- Grade II: Patient complains of pain and wines.
- Grade III: Patient wines and withdraws the joint.
- Grade IV: Patient will not allow palpation of the joint.
6. Muscles: for tremor and fasciculations. (Feel muscles above and below
joint.).
7. Distal Pulses. Compare with other side.
To the examiner “There is / is no warmth, nodules, effusion, or joint
tenderness. The skin is normal in thickness, soft, normal
moisture. No muscular fasciculation or tremor. Distal
pulses are present.”
2- Range of Motion: ROM
1- Active movements: voluntary movements by the patient.
- Inability to move a limb is due to mechanical or neurological
problems.
- Show the patient to move the limb in flexion, extension, abduction,
adduction, supination, pronation, .. etc.
- Look for:
- Movements resulting in pain: ask about pain quality and severity.
- Amount of movement restriction.
- Willingness of the patient to move the joint.
- Quality of movements.
- Crepitus.
“Mr./Ms.., will you please move your arm/ forearm/ hand/ thigh/
leg/ foot) like this in full range… Any pain?”
Yes “How does it feel like?... On a scale of 1 to 10 where 1 is the
mildest and to is the worst pain, how would you grade the pain
severity?”
2- Passive movements:
“Mr./Ms.., now let me move your arm/hand//leg/foot the same
way, please relax it.”
3- End Feel:
- The sensation felt by the examiner in the joint as it reaches the end
of the passive ROM.
- 3 normal types of end feel: (others are abnormal)
1. Bone to Bone: A hard unyielding compression that stops
further movements. e.g. elbow extension.
2. Soft tissue approximation: A yielding compression that stops
further movements. e.g. elbow and knee movements stopped
by muscle.
3. Tissue stretch: Hard springy movements with slight give. Feels
like increasing resistance. e.g. lateral rotation of shoulder/
knee.
…. Continued
150
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination Sub Model: …Cont.
To the examiner “Active and passive 1range of movement are normal &
2
equal/ Passive ROM is more than active ROM
(Inflammatory). There is movement restriction at… (e.g.
flexion) .
3
End Feel is normal tissue stretch (All joints except elbow).
There is no 4pain with movement / there is pain with
movement that the patient graded as .. out of 10.
There is / is no 5crepitus.
Movement is smooth and the patient is 6willing to
move the joint.”
3. Power assessment / Isometric movements:
- Movements that consists of strong, static voluntary muscle contraction.
- Ask the patient to hold his limb in the neutral position firmly as you try to
move it gently against his resistance in flexion, extension, abduction,
adduction, supination,.. etc. Stop movement when pain is felt.
“Mr./Ms.., now I want you to hold your arm/hand//leg/foot at this position
firmly (resting position) . I’ll try to move it in the same way we just did.
Resist me, don’t let me move it, I want to assess your power,.. Okay.”
To the examiner “Normal power assessment / There is weakness in
flexion…”
4. Functional assessments:  Empathy
“Mr./Ms.., as a result of this joint problem, How has this been affecting
your daily activities? What things are you no more able to do?… How are
you coping with it?”.
To the examiner “The patient reports no difficulties in activities of daily
living (ADL) / difficulty in getting up/ sitting/ walking up
the stairs/ .. using the bathroom/ brushing his teeth/
combing his hair/ …”
5. Specific joint tests:
This step is different for each joint. On the next pages, certain points in
addition to specific tests relevant to each joint are explained.
6. Sensation screen & Reflexes:
Quickly as time permits, do only light touch, two point discrimination, and
deep reflexes that are relevant to that joint and compare to other side. e.g. only
upper limb in cervical, shoulder, elbow and hand joints.
…. Continued
151
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Specific joint tests:
* Temporomandibular joint (TMJ):
As any joint sub model plus:
2. Palpation:
-
-
Feel both joint with your index fingers. TMJ is in front of the tragus.
While still feeling both TMJs, ask the patient to move the jaw as follow:
“Mr./Ms. .., I’m going to feel both your mandibles,… will you please
open and close your jaw slowly…… now move it from side to
side……now bring it forward and then backward… thank you.”
Remove your fingers; “Mr./Ms. .., now open your mouth as wide as you
can…. (Observe for deviation), I’ll measure how wide is that with my
fingers….. relax.”
To the examiner “There is /is no joint tenderness, jaw movements restriction
or deviation.”
END TMJ Exam, Wrap up
* Shoulder:
As any joint sub model plus:
2. Palpation: No WET MPs
- Palpate the sternoclavicular joint and along the clavicle to the
acromioclavicular joint AC.
- Palpate anterior & lateral aspects of the glenohumeral joint inferior to ACJ.
- Feel the biceps groove, subdeltoid bursa and rotator cuff insertion for
tenderness.
“Mr./Ms. .., I’m going to feel your shoulder, if you feel pain tell me.”
To the examiner “There is / is no warmth, nodules, effusion, or joint
tenderness. The skin is normal in thickness, soft, normal
moisture. No muscular fasciculation or tremor. Distal
pulses are present.”
Range of Motion:
Place your hand of the shoulder cupping it to feel for crepitus.
“Now, I’ll move your arm, if you feel pain tell me.”
1- Forward flexion (1650):
“Raise both your arms from the front straight above your head.”
2- External rotation (700) and abduction:
“Now place both your hands behind your neck base with your elbows
out to the sides.”
3- Abduction (170 0) and adduction (500):
“Now, raise both your arms from the sides straight above your head
(Abduction). Now hold your palms together and bring your arms down
slowly to your side (Adduction). ”
… Continued
152
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Note: Pain on abduction at 900: Rotator cuff injury.
at 1300: Supraspinatus muscle of the cuff.
4- Backward Extension (60 0) and internal rotation (700 ):
“Swing your arms towards your back and place your hands between
the shoulder blades.” Report the level of the scapula to which the hand
reached.
To the examiner “Normal shoulder range of motion with no pain or
crepitus / There is movement limitation in abduction.”
5. Special tests: Patient is still standing
1- Test for Inferior Shoulder Instability (Sulcus Sign):
Ask the patient to stand up and relax his arms beside his body. Hold the
arm below the elbow and pull it downwards.
Positive for inferior instability if the subacromial indentation occurred
laterally.
“Mr./Ms.., stand up here, please… relax both your right arm and
shoulder…. I’m going to pull your arm down.”
To the examiner “Negative/ positive Sulcus sign.”
2- Drop Arm Test:
While the patient is still standing, abduct the arm to 900 passively with the
elbow extended, then ask him to slowly lower it back to his side.
Positive for rotator cuff tear if sudden drop or pain.
“Now, I’m going to raise your arm like this. Please return it slowly
back to your side… Any pain?”
To the examiner “Negative/ positive drop arm test.”
3- Test of Impingement Syndrome (Rotator Cuff Tendonitis):
Forcibly flex the patient’s extended arm at elbow against his resistance.
Positive if pain.
“Now, extend your arm straight, I’m going to bend it at the elbow
resist me,.. any pain?”
To the examiner “Negative/ positive impingement syndrome test.”
4- The Anterior Apprehension Test:
While the patient in supine position; passively abduct the arm to 90 0, with
the forearm parallel to his body, then externally rotate it by moving the
hand up. At the point of apprehension (patient resists), apply posterior force
(up) proximally on upper arm; movement should continue unhindered.
“Now let me move your right arm.”
5- The Posterior Apprehension Test:
While the patient is still in supine, passively forward flex the patient’s arm
at shoulder in the plane of scapula to 900 , apply a posterior force on the
elbow and then horizontally adduct and medially rotate the arm.
… Continued
153
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Positive for posterior instability if the symptoms reproduced or movement
resistance or patient apprehension.
“Now let me move your right arm. ”
To the examiner “Negative/ positive anterior and/or posterior
apprehension test.”
- Supraspinatus inflammation: Shoulder pain radiating down the arm to
the elbow when combing hair, putting on a coat, reaching into a back
pocket (abduction at 1300).
- Infraspinatus inflammation: Diffuse shoulder pain upon moving the
humerus posteriorly without radiation.
- Rotator cuff tendonitis: Sharp shoulder pain on elevation (abduction at
900) of arm into overhead position with history of chronic use or trauma.
- Rotator cuff tear/rupture: Sharp pain over greater tuberosity after
trauma. Characteristic shoulder shrug and pain with abduction at 900 and
weakness of external rotation.
- Bicipital tendonitis: Generalized anterior tenderness over long head of
biceps associated with pain mainly at night. Pain appears on resistance to
forearm supination.
- Dislocation: 95 % anterior.
END Shoulder Exam, Wrap up
* Elbow:
As any joint sub model plus:
1. Inspection: SEADS CAGE
- Look for swelling or masses: Olecranon bursitis or rheumatic nodules.
- Look for any differences with the other elbow in carrying angle: flexion
contractures, hyperextension.
“Mr./Ms…, let me have a look on both your elbows….. now, with your
palms facing up, bend and then extend your elbows.”
To the examiner “There is / is no swelling, erythema, muscle atrophy,
deformity, contractures, skin changes or crepitus. The
patient looks comfortable, relaxed, moving his/her …
joint normally/ looks apprehensive with limited …. joint
movement.”
2. Palpation: No WET MPs
- Palpate for : Olecranon process, medial and lateral epicondyles, and
extensor surface of forearm for 3-4 cm distal to olecranon.
- Grasp the elbow with your fingers under the olecranon and the thumb next
to biceps tendon: Passively bend & extend the forearm feeling for crepitus,
tenderness & restrictions.
… Continued
154
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
“Mr./Ms. .., I’m going to feel your elbow, if you feel pain tell me.”
To the examiner “There is / is no warmth, nodules, effusion, or joint
tenderness. The skin is normal in thickness, soft,
normal moisture. No muscular, fasciculation or
tremor. Distal pulses are present.”
Range of Motion:
“Mr./Ms .., bring your forearms towards your shoulders and touch your
shoulder (flexion 1450),… now place your arms back down (extension 00),…
Now keep your arms on the sides and bend your elbows to the front,…
now turn your palms up,…now down (supination 800 / pronation 750).. Any
pain?”
To the examiner “Normal elbow range of motions with no pain or crepitus
/ There is movement limitation in flexion.”
5. Special tests: Tests for epicondylitis:
- Gradual onset pain in the region of the epicondyles of the humerus radiating
down the surface of the forearm.
- Pain appears when the patient attempts to open a door or lift a glass.
- No symptoms & signs of inflammation (swelling, redness,... etc.).
- Tests to be done if suspected epicondylitis from history.
Test for Golfer’s Elbow: Medial epicondyle: GMs
While palpating the medial epicondyle, the patient’s forearm is supinated and
the wrist and elbow are extended.
Test for Tennis Elbow: Lateral epicondyle: TLp
While palpating the lateral epicondyle, the patient’s forearm is pronated,
fully flex the wrist and extend the elbow.
*
“Mr./Ms.., now I’m going to move your forearm in certain ways, tell me
if you feel pain.”
To the examiner “Negative / positive tests for Golfer’s and tennis elbow.”
END Elbow Exam, Wrap up
Wrist: As any joint sub model plus:
2. Palpation: No WET MPs
of:
1. Distal radius on lateral surface and distal ulna on medial surface.
2. The groove of both wrists with your thumbs on the dorsum and your
fingers on the palmar surface. Compare.
3. The anatomical snuff box. (A hollowed depression just distal to the radial
styloid process formed by the abductor and extensor muscles of the
thumb). Tenderness suggests Scaphoid fracture or carpal arthritis.
4. Capillary refill.
“Mr./Ms. .., I’m going to feel both your wrists, if you feel pain tell me.”
… Continued
155
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner “There is / is no warmth/coldness, nodules, effusion, or
joint tenderness. Normal capillary refill at < 3sec. The
skin is normal in thickness, soft, normal moisture. No
muscular fasciculation or tremor.”
Range of Motion:
1. Extension (750 ): “Mr./Ms. .., Press the hands together in the vertical
plane,… now raise the forearms to the horizontal plane…. Like this.”
2. Flexion (750): “Now put the back of the hands together in the vertical
plane,… now raise the elbows to the horizontal plane…. Like this.”
3. Ulnar deviation (350): “Now deviate your hand inward…. Like this.”
4. Radial deviation (200): “Now deviate your hand outward…. Like this.”
5. Supination (800 from vertical plane): “Now hold this pen in your hand
vertically and rotate your hand outward…. Like this.”
6. Pronation (750 from vertical plane): “Now rotate your hand inward….
Like this.”
To the examiner “Normal wrist range of motion with no pain or crepitus /
There is movement limitation in supination.”
5. Special tests: Tests for Carpal Tunnel Syndrome:
Altered sensation (tingling, burning, pins & needles, numbness) on median N.
dermatome (first three digits), worse at night.
Causes: Fluid retention (pregnancy), and repeated forceful movements at
work or sports.
1- Tinel’s Sign: T-T:
A sharp Tap or pressure directly over the median N. produces pain or
tingling. (Median N. located medial to the flexor carpi radialis tendon at
the most proximal aspect of the hand.).
2- Phalen’s Sign: Ph-F:
Flexion test above for 60 sec will produce paresthesia or numbness in the
first three fingers.
3- Extend both elbow and wrist:
Produces pain or paresthesia or numbness in the first three fingers.
“Mr./Ms.., now I’m going tap on your wrist and move your hand in
certain ways, tell me if you feel numbness.”
To the examiner “Negative / positive tests for Tinel’s and Phalen’s elbow”
END Wrist Exam, Wrap up
156
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
* Hand: As any joint sub model plus:
1. Inspection: for deformity: “Mr./Ms. .., let me see your hand.”
Deformity
Description
Interpretation
Caused by: damage to
extensor tendon due to:
Trauma or Rheumatoid
Arthritis (RA)
Caused by: the central slip
of the extensor tendon
detaches from the middle
phalanx due to: Trauma or
RA
Mallet finger /
thumb
Flexed DIP
Boutonniere
Hyperextended DIP &
flexed PIP
Swan neck
Flexed DIP &
hyperextended PIP
Hard dorsolateral nodules of
DIP may associate with
deviation of distal phalanx
Heberden’s nodes
HD
RA and others
Osteoarthritis (OA)
Bouchard’s nodes
BP
Like Heberden’s but of PIP
OA
Dupuytren’s
contracture
Flexion deformity of the
fingers at MCP and IPs with
nodular thickening in the
palm
DM, epilepsy, alcoholism,
hereditary, repetitive trauma
IP: Interphalangeal joint,
Note:
DIP: Distal IP,
PIP: Proximal IP,
RA: affects wrist, MCP, PIP
MCP: Metacarpophalangeal joint.
OA: Affects: DIP, PIP
To the examiner “There is / is no swelling, erythema, muscle atrophy,
deformity, contractures, skin changes or crepitus. The
patient looks comfortable, relaxed, moving his/her …
joint normally/ looks apprehensive with limited ….
joint movement..”
2. Palpation: of:
All joints with thumb and index finger. Also capillary refill.
“Mr./Ms. .., I’m going to feel your hand, if you feel pain tell me.”
To the examiner “There is / is no warmth/coldness, nodules, effusion, or
joint tenderness. Normal capillary refill at < 3sec. The
skin is normal in thickness, soft, normal moisture. No
muscular fasciculation or tremor.”
Range of Motion:
1- “Mr./Ms. .., make a fist with each hand with the thumb across the
knuckles, and then open your hands and spread your fingers.”.
During flexion: normal fingers should flex to the distal palmar crease.
Extension: to 00
… Continued
157
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
2- Thumb: Flexion, extension, abduction, adduction and opposition across the
fingers:
“Mr./Ms. .., now move your thumb like this… then….”
3- Passive motion of all fingers for flexion/ extension at:
MCP (Flexion: intrinsics / Extension: communis),
PIP (Flexion: flex. dig. superficialis / Extension: lat. bands of ext. dig.),
DIP (Flexion: flex. dig. profundus / Extension: lat. bands of intrinsics),
Flexor digitorum superficialis:
Restrict movement of 3 fingers with your fingers. Patient’s palm up. Ask
him to flex the free finger and look for PIP flexion.
“Mr./Ms. .., let me hold these fingers. Now, flex the free one.”
Flexor digitorum profundus:
Restrict movement of proximal and middle phalanges of all fingers with
your fingers. Patient’s palm up. Ask him to flex the all finger and look for
DIP flexion.
“Mr./Ms. .., okay, now all fingers. Flex the terminal parts.”
To the examiner “Normal fingers range of motion with no pain or
crepitus / There is movement limitation in first finger
DIP.”
5. Special Tests:
Finkelstein test for De Quervain’s Disease:
De Quervain’s disease is tenosynovitis of abductor pollicis longus & extensor
pollicis brevis. Patient will feel weakness of grip and pain at the base of the
thumb, which is aggravated by some wrist movements.
“Mr./Ms. .., again make a fist with each hand with the thumb across the
knuckles closing the fingers over the thumb.. now deviate your hand
inward like this.” pain reproduced.
To the examiner “Finkelstein test for De Quervain’s disease is negative/
positive.”
6. Sensations:
Sensory and motor of radial, median, and ulnar nerves at the hand.
To the examiner “As I already checked all the motion of the fingers
actively, Motor neurological innervations are intact. /
There is motor loss of posterior interosseous branch.”
- “Mr./Ms. .., let me check the sensation in your hand.” Light touch, pain &
2-point.
… Continued
158
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
- “I’m going to feel your skin with this cotton on several points of your
fingers. I want you to say ‘yes’ when you feel it just like this,
okay…. Let us start, close your eyes.”
- “Now, I’m going to feel your skin with this paper pin. Again, say
‘yes’ when you feel it, close your eyes.”
-
“Mr/Ms ..,now tell me if you feel this pin on your skin.., close your
eyes, Is it one or two pins? adjust distance between the pin heads at 2 mm.”
To the examiner “Radial, Ulnar, & median nerves light touch, pain & 2
point discrimination sensations are intact.”
Nerve
Radial C6
Posterior interosseous
branch
Ulnar C8
Median C7
Anterior interosseous
branch
Lateral terminal
branch
Sensory
Motor
Dorsum of first web space
None
Extension of fingers,
thumb & wrist
Thumb extension
- Dorsum of small finger
tip,
- Palmar of small finger &
medial aspect of ring
finger
- Dorsum of index,
middle fingers tip.
- lateral aspect of ring
finger,
- Palmar of index & ring
fingers
None
- Finger abduction &
adduction,
- Opposition of little
finger,
- wrist flexion
- Thumb IP flexion,
- Index & middle fingers
flexion,
- Wrist flexion
None
Thumb opposition
Flexion of index &
middle finger
END Hand Exam, Wrap up
159
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
* Spine (Back pain):
- Thoracic spine pain: rotates around the trunk along the intercostal
nerves.
- Upper lumbar spine pain: may be felt in front of the thighs & knees.
- Lower lumbar spine pain: may be felt in the coccyx, hips, buttocks, as
well as shooting down the back of the legs to
the heels and feet.
- Intensifies with movement.
- Worse with sneezing or coughing: Herniated vertebral disc.
- Associated with numbness or tingling in lower limbs: ?Nerve root lesion.
- DDX: Age related
- Degenerative (90% of all back pain):
1. Mechanical: degenerative, facet.
}Increased with
2. Spinal stenosis: congenital, osteophyte, central disc}standing.
3. Peripheral nerve compression: disc herniation.
Increased with
bending.
- Others:
1. Infection. (Osteomylitis)
2. Cauda Equine syndrome (large central disc herniation) Surgical
emergency.
3. Neoplastic (Mets).
4. Trauma: fracture (compression/distraction/translation/rotation).
5. Osteoporosis
6. Spondyloarthropathies (e.g. ankylosing spondylitis)
7. Referred: Aortic aneurysm/rupture (surgical emergency), Renal
(CVA), Pancreas.
Cervical spine: As any joint sub model plus:
1. Inspection: for deformity:
1- In normal sitting position, nose should be in line with manubrium &
xyphoid. From side, earlobes should be in line with acromion process.
Look on the neck from the front, and then move to look from the side.
To the examiner “There is / is no swelling, erythema, muscle atrophy,
deformity, contractures, skin changes or crepitus.
There is no neck tilting or rotation. Neck is mobile &
not short.”
2- Venous obstruction of upper limbs: Check for vein distension, skin
discoloration, ulcers.
“Mr/Ms.., let me have a look on both your arms.”
To the examiner “There are no distended veins, ulcers or skin color
changes.”
…Continued
160
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
2. Palpation:
You can palpate the neck standing in front of the patient or from behind.
Use both hands and compare sides. Palpate for:
3 types of spine trauma:
1. Tenderness.
1. Vertical compression:
2. Trigger points.
Objects falling on head:
3. Muscle spasm.
stable.
2. Hyperextension: Only
4. Skin texture.
unstable if interspinous
5. Bony and soft tissue abnormality.
lig. ruptured (a gap).
3. Shearing injury: head
rotation: unstable.
- Posterior aspect:
1- External occipital protuberance
2- Spinal processes and facet joints of vertebrae. (No gap = Stable)
3- Mastoid process.
- Lateral aspect:
1- Transverse processes and facet joints of vertebrae.
2- Lymph nodes.
Cord injury in spinal trauma:
3- Carotid arteries.
1. Tenderness over spinous processes.
4- Temporomandibular joints &
2. Paraspinous swelling.
mandible.
3. Gap between spinous processes.
5- Parotid glands.
4. Neurological paradoxical breathing:
- Anterior aspect:
1- Hyoid bone.
2. Thyroid cartilage.
3- Supraclavicular fossa.
Chest in with breathing (paralysis).
5. Flaccid limbs with no response to
painful stimuli and no reflexes.
6. Painless urinary retention/ priapism.
“Mr/Ms.., let me feel your neck.”
To the examiner “There is no tenderness or muscle spasm, no pain with
movement. Skin texture, soft tissue and bony structures
felt normal.”
Range of Motion:
- Active: “Now I want to check your neck movements.”
- Flexion (900 ): “Will you please touch your chin to your chest”
- Extension (700 ): “Now put your head back.”
- Side flexion (20-450): “Touch each shoulder with your ear without
raising your shoulders.”
- Rotation (70-800): “Now turn your head to the left…and right.”
- Passive: “Now let me move your neck in the same movements to feel
it… relax your neck.”
Repeat the above movements to feel the ‘end feel’: Normally: Tissue
stretch.
To the examiner “Active and passive range of motion is normal. End feel
is normal tissue stretch.”
… Continued
161
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
3. Power Assessment/Isometric Movements:
For muscle power and neurological weakness originating from the cervical
nerve roots.
Each of the following contractions should be held for 5 sec against resistance:
Compare sides. Stop movement when pain is felt.
“Mr/Ms.., now, I’m going to ask you to do some movements of your neck,
shoulders, arms, and hands against my hands asking you to keep them in
that position for 5 sec to check your power, okay? ”
- Neck flexion C1-2:
“Will you please touch your chin to your chest again.”
- Neck side flexion C3:
“Touch each shoulder with your ear without raising your shoulders.”
- Shoulders elevation C4:
“Shrug both your shoulders.”
- Shoulder abductions C5:
“Now, raise both your arms from the sides straight above your head. Now
hold your palms together and bring your arms down slowly to your side.”
- Elbow flexion &/or wrist extension C5/6:
“Bend both your elbows / extend your wrists.”
- Elbow extension &/or wrist flexion C7/6:
“Extend both your elbows / flex your wrists.”
- Thumb extension &/or ulnar deviation C8:
“Extend your thumbs like this / deviate your hands internally like this.”
- Abduction &/or extension of fingers T1:
“Spread/ fan out your fingers.”
To the examiner “Normal symmetrical muscle power, no weakness.”
6. Sensation and Reflexes: Both arms:
- Sensation: “Mr/Ms ..,I’m going to feel your skin with this cotton on
several points on your body. I want you to say ‘yes’ when you feel it
just like this, okay. Let us start, close your eyes.” Never ask the patient
if he/she is feeling the touch every time you touch the skin so he wont
know if you are touching or not.
C2: Jaw angle.
C4: Shirt collar area.
.
C6 (Radial): Dorsum of first web space (Thumb).
C7 (Median N):.Index finger palmar or dorsal aspect.
C8 (Ulnar N): Little finger palmar or dorsal aspect.
To the examiner “Sensation is normal.”
162
… Continued
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
- Reflexes: “Mr/Ms .., now, I’ll check your reflexes. I’m going to strike
this hammer gently on some points near your joints, Okay?”
Biceps tendon reflex C5, 6:
- See reflexes in neurological examination chapter.
“Mr/Ms .., I’ll start here with your elbow. Relax your arm in this
position…. (Set the forearm, strike, and watch twice) . Now the other one….”
To the examiner “Biceps tendon reflex is normal/ diminished/
increased.”
Brachioradialis tendon reflex C5, 6:
- See reflexes in neurological examination chapter.
“Mr/Ms .., now here near your wrist. (Set the forearm, strike, & watch
twice). Now the other one...”
To the examiner “Brachioradialis tendon reflex is normal/ diminished/
increased.”
Triceps tendon reflex C6 - 8:
- See reflexes in neurological examination chapter.
“Mr/Ms .., now here at the back of your arm. …. (Set the forearm, strike,
and watch twice). Now the other one….”
To the examiner “Triceps tendon reflex is normal/ diminished/
increased.”
END Cervical Exam, Wrap up
Thoracic spine:
As any joint sub model plus:
1. Inspection: in standing position on uncovered back.
“Mr/Ms .., Let me have a look on your back, Will you please stand up
here. I’m going to uncover your back.”
To the examiner “There is / is no swelling, erythema, skin changes, hair
spots, muscle atrophy, rib humps or deformity. Chest is
symmetrical, no lordosis, kyphosis or scoliosis.
Shoulders and iliac crests are at the same height
bilaterally.”
Gait: “Now let us check your gait, okay,…”
“Will you please stand up here and walk straight ahead”
“Stop and return to me now on tiptoe”
“Now walk away again but this time on your heels.”
“Stop, return by walking in tandem gait with one foot placed in
front of the other.”
… Continued
163
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner “Gait is normal, there is no shuffling, spastic
movements, wide stance, foot drop, or steppage.”
2. Palpation: in standing position on uncovered back
- Palpate spine, ribs, scapulae posteriorly, costal cartilages, sternum, and
clavicles.
- Squeeze the chest from the sides and front back asking the patient for pain.
“Now I’ll squeeze your chest.. Do you feel any pain?.. now?.”
To the examiner “There is / is no warmth, nodules, effusion, bony or soft
tissue tenderness. The skin is normal in thickness, soft,
normal moisture. No muscular fasciculation or tremor.”
Range of Motion: in standing position on uncovered back for thoracic (T)
and lumbar spine (L).
Active: “Now I want to check your back movements.”
- Forward flexion (T: 20-450 , L: 40-600 ):
“Will you please bend forward and touch your toes …I’ll measure
how far is this from the floor.” Normally up to 7 cm.
- Extension (T:25-450, L: 20-350):
“Now, I’ll hold your pelvis from the sides… arch your back
backward.”
- Side flexion (T: 20-400 , L: 15-200):
“Now, slide your right hand down your leg…I’ll measure how far is
this from the floor…. now the same with the left hand.” Compare
- Rotation (T: 35-500 , L: 3-180 ):
“Now, sit down here. Without moving your pelvis rotate towards
your right side… now towards the left side.” Compare.
- Chest expansion: Place a tape measure around the patient’s chest at the
level of the nipples and measure the difference between rest and full
inspiration. Normally => 4 cm.
“Now, I’m going to measure your chest expansion with breathing.
Let me place the measuring tape around you (measure)…. Take a
deep breath in and hold it (measure).”
Passive: “Now let me move your back in the same movements to feel it
… relax your back.”
To the examiner “Active and passive range of motion is normal. End feel
is normal tissue stretch.”
… Continued
164
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
3. Power Assessment/Isometric Movements: Patient is still sitting now.
Each of the following contractions should be held for 5 sec against resistance:
Compare sides.
“Mr/Ms.., now, I’m going to check your power, okay.. I’ll place my leg
behind your buttocks, and wrap you with my arm. I’m going to do the
same movements you just did but don’t let me move you, resist me. ”
Do flexion, extension, side flexion, and rotation. Stop movement when pain is
felt.
To the examiner “Normal symmetrical muscle power, no weakness.”
6. Sensation and Reflexes: Both legs.
Sensation:
L5: Foot dorsum S2: Medial posterior thigh.
“Mr/Ms ..,I’m going to feel your skin with this cotton on several points on
your leg. I want you to say ‘yes’ when you feel it just like this, okay. Let
us start, close your eyes.”
Never ask the patient if he/she is feeling the touch every time you touch the
skin so he wont know if you are touching or not.
To the examiner “Sensation screen is normal.”
Reflexes:
“Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer
gently on some points near your leg joints, Okay?”
Patellar tendon reflex (Knee jerk) L2 - 4:
“Mr/Ms .., I’ll start here at your knee. …. (Set the leg, strike, and watch twice).
Now the other one….”
To the examiner “Patellar tendon reflex is normal/ diminished/ increased.”
Achilles tendon reflex (Ankle jerk) S1 - 2:
“Mr/Ms .., now your ankle ... (Set the foot, strike, and watch twice). Now the other
one….”
To the examiner “Achilles tendon reflex is normal/ diminished/ increased.”
END Thoracic spine Exam, Wrap up
165
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Lumbar spine: As any joint sub model plus:
1. Inspection: in standing position on uncovered back
See thoracic spine.
In infants: look for spina bifida: (vertebral deformity & skin bulge over
lumbosacral spine, hairy patches, pigmented spots.).
2. Palpation:
In supine position on uncovered back palpate for:
Umbilicus, inguinal areas, iliac crests, symphasis pubis
“Mr/Ms .., lie down here flat on your back please. I want to feel your
abdomen.”
In prone position on uncovered back palpate for:
Spine, sacrum, coccyx, iliac crests, ischial tuberosities, para vertebral
muscles.
“Mr/Ms .., now turn on your stomach, back up please. I want to feel
your back.”
To the examiner “There is / is no warmth, nodules, effusion, bony or soft
tissue tenderness. The skin is normal in thickness, soft,
normal moisture. No muscular spasms or fasciculation.
No hernia.”
Range of Motion: as thoracic
See thoracic spine “Now I want to check your back movements. Please
stand up here.”
3. Power Assessment/Isometric Movements: Patient is still sitting now.
See thoracic spine plus the following leg movements:
“Mr/Ms .., now, lie down here again flat on your back. I want to check
your legs power.”
Hip Flexion L2: Place your hand on his knees and slightly push down.
“Flex both your hips, lift your legs up.”
Knee extension L3: Bend the knees up on the bed and hold the feet to the bed.
“Now, extend both your knees, lift your feet up.”
Knee flexion S2: With the knees still bended up on the bed, hold the back of
the legs & pull.
“Now, flex both your knees, pull my hands.”
Ankle Dorsiflexion L4: Extend the patient’s legs. Pull the dorsum of the feet
down.
“Now, pull my hands with your feet only.”
… Continued
166
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Great toe extension L5: Pull the dorsum of the great toes down.
“Now, pull my hands with your big toes only.”
Ankle planter flexion S1 (or Ankle eversion or hip extension): Push both
feet up.
“Now, push my hands with your feet only.”
To the examiner “Normal symmetrical muscle power, no weakness.”
5. Special tests:
1- Straight Leg Raising Test: For Sciatic N. (L4-S3) stretch
Sciatic N. dermatome:
- Anal and perianal area.
- Posterior part of the medial aspect of the thigh and leg.
- Anterior surface of shin and dorsum of foot.
With the patient lying supine, the hip is medially rotated & adducted, &
the knee extended. Raise the leg straight up (hip flexion) until back or
leg pain is reproduced.
- Document:
- The degree of elevation at which pain reproduced, usually < 700.
- Pain quality and dermatome distribution.
Then lower the leg slowly and stop at the point of pain relief. At this
position, dorsiflex the foot, pain reproduced.
“Mr/Ms .., now, lie down here again flat on your back. I want to do
some tests on your legs… Keep your leg straight, I’ll rotate it and
bring it internally.. now I’ll raise it.. Tell me exactly where you start
to feel pain.” Patient felt pain: stop and measure the angle.
Paraesthesia
& radiating
pain in sciatic
N. dermatome
suggests
nerve root
irritation
/tension.
Pain is worse
with sneezing,
laughing, or
straining
during bowel
motion.
“Tell me where do you feel the pain?… How does it feel like?…
Now, I’ll lower it slowly tell me the point at where the pain
disappears… I’ll back bend your foot.. Any pain?.. Does it feel the
same?.”
Crossed Straight Leg Raising Test:
Repeat the above with the unaffected leg. Symptoms will be reproduced
at the affected leg: Lumbar disc herniation.
“Now, we’ll do the same with the other leg”
To the examiner “Straight Leg Raising Test is positive/ negative for
sciatic N. root irritation at 500. No / Positive crossed
Straight Leg Raising Test for Lumbar disc
herniation.”
… Continued
167
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
2- Femoral Stretch test: For femoral N. (L2-4) stretch.
Femoral N. dermatome:
- Anterior surface of thigh and shin.
Have the patient lie prone on the stomach. Raise the leg straight (hip
extension) with one hand under the thigh and the other on the leg to
maintain knee extension.
“Mr/Ms .., now, roll over on your stomach. I’ll repeat the same
movements on your legs… Keep your leg straight,.. now I’ll raise it..
Tell me when you start to feeling pain.”
“Tell me where do you feel the pain?… How does it feel like?”
To the examiner “Femoral Stretch Test is positive/ negative for
femoral N. root irritation. ”
6. Sensations and Reflexes: See thoracic spine.
7. Peripheral vascular exam:
Feel peripheral pulses. Vascular vs. neurogenic claudication.
To the examiner “Normal / absent peripheral pulses ”
Vascular
insufficiency
Pain
- Constant,
- Worse with walking
- Relieved by rest.
Sensation
Peripheral pulses
Stocking type loss
Absent
Spinal stenosis
- Only with certain
position
- Relieved in other
positions e.g. sitting
or bending.
Dermatomal
Present
Cauda Equina Syndrome:
Most frequent cause of large central disc herniation.
Progressive neurological deficit presenting with:
1. Saddle anesthesia.
2. Decreased anal tone & reflex.
3. Fecal incontinence (soil himself).
4. Urinary retention with overflow incontinence. (wet himself, but
cannot bee).
5. Bilateral leg weakness.
…… Surgical emergency to prevent permanent urinary / bowel
incontinence.
END Lower Back Exam, Wrap up
168
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
* Hip: As any joint sub model plus:
1. Inspection: in standing position on uncovered lower body (just underwear)
1- “Mr/Ms .., Let me have a look on your hips, Will you please stand up
here with only your underwear on.”
Look from the front and from behind while commenting:
To the examiner “There is / is no swelling, erythema, skin changes,
muscle atrophy of the buttocks or thighs. No pelvic
tilting or deformity. No lordosis. Iliac crests are at
the same height bilaterally.”
2- Gait: “Now let us check your gait, okay,…”
“Will you please stand up here and walk straight ahead”
“Stop and return to me now on tiptoe”
“Now walk away again but this time on your heels.”
“Stop, return by walking in tandem gait with one foot placed
in front of the other.”
To the examiner “Gait is normal, there is no shuffling, spastic
movements, wide stance, foot drop, or steppage.”
3- Trendelenburg Test: Very important in children to exclude hip
instability.
Ask the patient to stand on one foot. Pelvis on non-bearing side should
rise indicating functioning abductors (gluteal medius muscle) of the
weight bearing side.
Repeat with the other leg.
“Mr/Ms.., Stand on your right leg only…. Now, on your left only…
Thank you.”
To the examiner “Trendelenburg test is negative (normal)/ positive.”
- Positive if pelvis drops. Causes: 1. Gluteal muscle weakness;
2. Pain;
3. Hip deformity.
- If negative (normal), continue with the Stork Standing Test & measure
true leg length.
4- Stork Standing Test:
“Mr/Ms.., again stand on your right leg only & place the left foot on
the inner aspect of your right leg …Thank you… Now, repeat with
your left leg… Thank you.” If he cannot do it: Positive.
To the examiner “Stork Standing test is negative / positive.”
… Continued
169
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
5- Balance:
“Mr/Ms.., now balance yourself on one leg. Start with the right
one….Close your eyes… Thank you, open your eyes.. Now, repeat on
the left leg… close your eyes.. Thank you.”
To the examiner “Balance is normal.”
6- True & Apparent leg length:
Set the pelvis horizontally; place the legs 15-20 cm apart. True: Measure
each leg from anterior superior iliac spine to medial maleolus. Apparent:
same but from umbilicus.
“Mr/Ms.., now I want to measure your legs’ length… stand straight
with your feet 15-20 cm apart and level your pelvis horizontally… let
me see.. okay, let me measure.”
To the examiner “Legs’ lengths are symmetrical.”
2. Palpation:
“Mr/Ms .., Let me feel your hips, will you please lie down here flat on
your back.”
Anterior aspect: 1- Iliac crests, anterior superior iliac spine, symphasis pubis.
2- Inguinal ligament, femoral triangle.
3- Hip joint, and. greater trochanter & trochantric bursa.
4- muscles.
5- Crepitation: place your fingers over the femoral head
(lateral to femoral artery below inguinal ligament), then
roll the relaxed leg medially & laterally (internal &
external rotation).
“Mr./Ms.., relax your leg, I’m going to roll it in and out.”
Femoral, popliteal, posterior tibial, and dorsalis pedis pulses.
Posterior aspect: “Now roll over on your stomach, let me feel your hips
from the back.”
1- Iliac crests, posterior superior iliac spine.
2- Ischial tuberosity, greater trochanter.
3- Sacroiliac, lumbosacral, and sacrococcygeal joints.
To the examiner “There is / is no warmth, effusion, bony, soft tissue or
joint tenderness. No crepitus. The skin is normal in
thickness, soft, normal moisture. No muscular
fasciculation. Distal pulses are present.”
Range of Motion: Patient still prone.
- Extension (10-150): “Mr./Ms.., will you please move this leg up to the
maximum….. Any pain?” If yes; “How does it feel like?.. From a scale
of 1 to 10 where 1 is the mildest and to is the worst, how would you
grade the pain severity?” Active movement
… Continued
170
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
“Mr./Ms.., now let me move it the same way, please relax it.” Passive
movement.
“Mr./Ms.., now I’ll do it again, but this time don’t let me do move it. I
want to check your strength.” Power assessment.
“Now turn back on your back………….”
COVER THE PATIENT
- Flexion (110-1200): Knee also flexed.
“Mr/Ms.., now bend both your hip and knee.”
- Abduction (30-500): Place your hand on the opposite superior iliac spine to
fix the pelvis
“Now, I’ll hold your other hip. Please move your leg on the stretcher
away from midline.”
- Adduction (30 0):
“Now, bring it back and cross it over the other leg as far as you can.”
- Rotation: With both hip and knee flexed. Move the foot in (external) and out
(internal) with both hip and knee fixed in position.
- External (40-600): Moving the foot INWARD
“Mr/Ms.., now bend both your hip and knee 900…. Now move your
foot inward without moving the knee.”
- Internal (30-400): Moving the foot OUTWARD.
“Now, move it outward.”
Passive: “Now let me move your leg in the same way to feel it, relax it.”
To the examiner “Active and passive range of motion is normal. End feel
is normal tissue stretch.”
3. Power Assessment/Isometric Movements: Patient is still supine.
“Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do
the same movements you just did but don’t let me move you, resist me.”
Do flexion, abduction, adduction, and internal and external rotation.
Extension already done.
To the examiner “Normal muscle power, no weakness.”
5. Special tests: Patient is still supine.
1- Patrick’s Test (Faber or Figure-Four Test): on the affected leg.
“Now, place your right/left foot on the other leg knee…. I’ll bring
your knee down to the stretcher.” Positive if the leg cannot be brought
on stretcher parallel to the other leg.
Causes:
1. Hip or sacroiliac joint problem.
2. Iliopsoas spasms.
… Continued
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The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner “Negative / Positive Patrick’s Test.”
2- Thomas Test: for fixed hip flexion contracture (most common hip
deformity).
Place your hand under his lumbar spine to obliterate the free space
(lordosis).
Ask the patient to bend the leg and hold it against his abdomen.
“Mr/Ms.., I’m going to put my hand under your lower spine….
Bend your right/left leg and hold it against your abdomen.”
Elevation of the opposite thigh, Positive Thomas Test, suggests fixed
hip flexion contracture of that hip (the elevated one not the one flexed
against the abdomen).
To the examiner “Negative / Positive Thomas Test.”
3- Infants: Ortolani Test: for congenital hip dislocation. Infant supine with
both hips and knees flexed. Place your hands with the thumbs on the
inner thighs & fingertips over the thigh muscles. Abduct each knee until
it touches the table. If dislocated: an audible & palpable ‘chunk’ will be
produced as the femoral head reenters the acetabulum.
6. Sensations and Reflexes:
- Sensation:
L5: Foot dorsum.
S2: Medial posterior thigh.
“Mr/Ms ..,I’m going to feel your skin with this cotton on several
points on your leg. I want you to say ‘yes’ when you feel it just like
this, okay. Let us start, close your eyes.”
Never ask the patient if he/she is feeling the touch every time you touch
the skin so he wont know if you are touching or not.
To the examiner “Sensation screen is normal.”
- Reflexes:
“Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this
hammer gently on some points near your leg joints, Okay?”
Patellar tendon reflex (Knee jerk) L2 - 4:
“Mr/Ms., I’ll start here on your right knee (Set the leg, strike, and watch
twice). Now the other one.”
To the examiner “Patellar tendon reflex is normal/ diminished/
increased.”
Achilles tendon reflex (Ankle jerk) S1 - 2:
“Mr/Ms .., now your ankle . …. (Set the foot, strike, and watch twice). Now the
other one….”
END Hip Exam, Wrap up
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The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
* Knee: As any joint sub model plus:
1. Inspection:
“Mr/Ms .., Let me have a look on your knees, will you please stand up
here. Bring your feet together.”
Look from the front and from behind while commenting:
To the examiner “There is / is no swelling, erythema, skin changes,
muscle atrophy or fasciculations. No bulging on the
sides of the patellar ligaments (small effusion) , No
knocked-knees (genu valgum: knees close) or bow-legged
(genu varum knees apart) or flexion contracture. Centre of
hips, knees, and ankles fall in a straight line.”
Gait: “Now let us check your gait, okay,…”
“Will you please stand up here and walk straight ahead”
“Stop and return to me now on tiptoe”
“Now walk away again but this time on your heels.”
“Stop, return by walking in tandem gait with one foot placed in
front of the other.”
Normally,
the centre
of the hip,
knee, and
ankle
should all
fall in a
straight
line.
To the examiner “Gait is normal, there is no shuffling, spastic
movements, wide stance, foot drop, or steppage.”
2. Palpation: Compare warmth to anterior thigh and other knee with the
back of the hand.
“Mr/Ms .., Let me feel your knee, will you please lie down here flat on
your back.”
Anterior palpation with knee extended:
- Patella, patellar tendon: apply firm pressure on patella asking for pain:
Patello-femoral S.
- Tibial tuberosity.
- Suprapatellar pouch for thickening or swelling starting 10cm above the
patella.
- Quadriceps muscles.
- Medial collateral ligament.
Anterior palpation with knee flexed:
- Tibiofemoral joint line lateral aspect for swelling (meniscal cyst),
Lateral collateral lig.
- Tibial condyles.
- Femoral condyles.
Posterior palpation with knee slightly flexed:
- Popliteal fossa for Baker’s cyst.
- Hamstrings & gastrocnemius muscles.
… Continued
173
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner “There is / is no warmth, nodules, effusion, or joint
tenderness. The skin is normal in thickness, soft, normal
moisture. No muscular fasciculation or tremor. No
baker’s cyst. Distal pulses are present.”
For warmth compare patellar surface with lower anterior thigh and other knee
with the back of your hand.
Range of Motion: Patient still supine.
Active: Flexion (1350) and extension (0 0):
“Mr/Ms .., will you please bend your knee to the maximum… now, extend
it back straight.”
Passive: “Now let me move your leg in the same way to feel it … relax it.”
- Flexion and extension:
- Patellar horizontal movements: Patella moves horizontally to half of its
width, parallel to femoral condyles
To the examiner “Active and passive range of motion is normal. End feel is
normal tissue stretch. Patella is mobile parallel to femoral
condyles.”
3. Power Assessment/Isometric Movements: Patient is still supine.
“Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the
same movements you just did but don’t let me move you, resist me.”
Do flexion and extension. Also do ankle planter flexion & Dorsiflexion (for
gasterocnemius).
To the examiner “Normal muscle power, no weakness.”
5. Special tests: Patient is still supine
1. Effusion tests; 2. Cruciate lig. tests; 3. Collateral lig. tests; 4. Minisci tests.
1- Effusion tests:
“Mr/Ms.., now, I’m going to perform some tests on your knee with some
pressure on your lower thigh, okay... ”
1. Fluctuation / Balloon Test:
- Place your left hand on the top of the femur, about 15 cm above the
patella, with your index finger & thumb placed on either side.
- Displace fluid from the suprapatellar pouch by sliding your hand distally
to just above the patella. With your left hand, compress the suprapatellar
pouch back against femur.
- Maintain this pressure.
- Place your right hand just pillow the patella with the thumb and index
fingers beside its lateral and medial margins.
… Continued
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The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
In presence of effusion, feel for fluid entering the spaces next to patella
with your right thumb and index fingers. If felt it, press the patella against
femur posteriorly with your right hand and feel the fluid returns superiorly
to the suprapatellar pouch with the left thumb and index fingers.
To the examiner “Fluctuation / Balloon Test for effusion is negative /
positive.”
2. Patellar Tap Test / Ballotment Test:
- While maintaining pressure with the left hand,
- Push down quickly on patella with the right hand thumb & three fingers.
In presence of an effusion, a palpable tap (click), will be transmitted & felt
by your left hand thumb and index finger on either side of the patella.
To the examiner “Patellar Tap Test for effusion is negative / positive.”
3. Fluid Displacement Test: for small 4-8 cc effusion.
- While maintaining pressure with the left hand,
- With your right hand, stroke upwards on the knee’s medial side to milk
fluid to the lateral side.
- With your right hand, stroke downwards on the knee’s lateral side to
return fluid to the medial compartment.
In presence of effusion, a small distension of medial compartment appears
within 2 sec.
To the examiner “Fluid displacement Test for small effusion is negative
/ positive.”
2- Cruciate Ligament tests: Patient is still supine
1. Anterior Drawer Test for ACL & Posterior Drawer Test for PCL:
- Flex both hips 450 and knees 90 0,
- Inspect the joint lateral line (compare to other side) to exclude tibial
posterior subluxation due to torn posterior cruciate ligament (Posterior
Sag Sign) causing false positive ACL tear.
“Mr/Ms.., now, bend both your hips and knees like this. Let me have
a look on outer & back aspects of the knees.” For (Posterior Sag Sign)
To the examiner “Posterior Sag Sign for PCL is negative / positive.”
- Sit close to the foot to steady it, grasp the leg just below the knee with
both hands and jerk the tibia forward (towards patient’s head).
- Up to 6 mm movement is normal.
- Now, jerk the tibia backward to test for Posterior Drawer test for
Posterior Cruciate ligament.
- Do the other side to compare.
… Continued
175
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
“Now, I’m going to sit by your feet. Relax your legs, I’ll hold your leg
and shake it forwards and then backwards,… now the other leg.”
To the examiner “Anterior Drawer Test for ACL and Posterior
Drawer Test for PCL are negative / positive.”
2. Lachmann Test for ACL: most sensitive & specific
- With the knee relaxed flexed at 150 , hip externally rotated (knee inward).
- Stand by the bed; hold the distal leg (femur) close to the knee with your
left hand.
- Hold the upper leg near the knee with your right hand and place its
thumb on the joint line to detect movement.
- Simultaneously, move the tibia up (anteriorly) and the femur down
(posteriorly).
- Positive for ACL tear if movement felt.
“Mr/Ms.., now, relax your leg and bend the knee slightly like this. I’ll
hold your leg above and below the knee to check the joint ligament.”
To the examiner “Lachmann Test for ACL is negative / positive.”
3. Modified Pivot Shift Test for ACL: Less sensitive, but more specific.
- Grab the right foot between your right arm and chest so that the knee is
extended and hip slightly flexed.
- Grasp the lower leg with both your hands and apply a valgus force
(tilting knee inward).
- Lean forward to internally rotate the foot, then slowly flex the knee
while feeling lateral.
- Positive if the lateral tibial condyle appears sublux anteriorly (patient
says that feels like ‘giving way’).
- Extend the knee, tibial condyle will jerk backwards.
“Mr/Ms.., relax your leg, I’ll hold your leg up and do a test.. How does
that feel? ”
To the examiner “Modified Pivot Shift Test for ACL is negative /
positive.”
3- Collateral Ligament tests: Patient is still supine
1. Palpate:
- Palpate the MCL and LCL for any opening (tear).
“Mr/Ms.., relax your leg, I’ll bend the knee 450 , let me feel the knee
again.”
To the examiner “No openings felt of the Medial & Lateral Collateral
ligaments.”
… Continued
176
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
2. Medial Collateral Ligament (MCL): Medial femoral condyle – Medial
tibial condyle
- Place your left hand on the lateral aspect of the joint preventing it from
moving outwards.
- Hold the leg with your right hand; push the leg outwards (Valgus
force). MCL opens up.
3. Lateral Collateral Ligament (LCL): Lateral femoral condyle – Fibular
head.
- Place your right hand on the medial aspect of the joint preventing it
from moving inwards.
- Hold the leg with your right hand; push the leg inwards (varus force).
LCL opens up.
“Mr/Ms.., relax your leg, I’ll extend the knee and do other tests...(do
above 2 & 3),… now, I’ll bend the leg 20 0 and repeat the test.”
To the examiner “Good/ impaired joint capsule & ligaments stability,
Medial and Lateral Collateral ligaments openings are
not felt (no tear).”
4- Menisci tests: Patient is still supine Medial tear > lateral.
1. McMurray Maneuver for Medial Meniscus:
-
Place the left hand above the patella with index and thumb fingers
along the joint line.
Fully flex the knee, externally rotate the foot, and abduct the leg.
Smoothly extend the knee with your right hand.
If pain appears again or pain with a click (not only click): Medial
meniscus tear.
To the examiner “McMurray Maneuver for medial meniscus tear is
negative / positive.”
2. McMurray Maneuver for Lateral Meniscus:
“Mr/Ms.., I’ll repeat the test but slightly in a different way, relax your
leg,… Any pain?”
- Similar to above but with foot internally rotated and leg adducted.
To the examiner “McMurray Maneuver for lateral meniscus tear is
negative / positive.”
3. Anterior Meniscal lesions: (Anterior horns of medial & lateral menisci)
- While the patient lying supine; flex the knee.
- Press your left thumb and index fingers firmly into the joint line and
177
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
extend the knee.
- If pain appears again or pain with a click (not only click): Anterior
meniscus tear.
To the examiner “Maneuver for anterior meniscus tear is negative /
positive.”
4. Posterior Meniscal lesions: (Posterior horns of medial & lateral menisci)
- Place your hands as in McMurray maneuver.
- With knee fully flexed, move his heel around in an arc.
- If pain appears again or pain with a clicks (not only click): Posterior
meniscus tear.
To the examiner “Maneuver for posterior meniscus tear is negative /
positive.”
5. Crouch Compression Test: L4
- Ask the patient to crouch.
- Pain in the anterior aspect of the knee suggests: patello-femoral
Syndrome.
- Pain in the joint line lateral or medial to patella suggests: meniscal
problem.
“Mr/Ms.., will you please stand up here and crouch….…. Any pain?,
… Where?”
END Knee Exam, Wrap up
* Ankle & Foot: As any joint sub model plus:
1. Inspection:
1- Standing with weight bearing:
“Mr/Ms .., Let me have a look on your ankles & feet, will you please
stand up here. Bring your feet together.”
Look from the front and from behind while commenting:
To the examiner “There is / is no swelling, erythema, skin changes,
muscle atrophy or fasciculations. No feet pronation
deformity (valgus). No subtalar deformity.”
Pes cavus (high arch) / Pes planus (flat foot): Try to slip a finger under
the foot arch.
“Mr/Ms.., stand still with feet slightly apart, I’ll check if I can put a
finger under your feet.”
… Continued
178
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner “There is / is no high arch or flat foot.”
Flat foot: if patient has flat foot:
- Ask the patient to attempt to arch the foot; to assess foot mobility, and
tibialis posterior rupture (Achilles tendon):
“Mr/Ms.., try to arch both your feet.”
To the examiner “Foot is mobile / is not mobile, tibialis posterior
rupture.”
- Ask him to stand on his toes to differentiate between a flexible and
fixed foot:
“Mr/Ms.., try to stand on your toes.”
To the examiner “Foot is flexible / is fixed.”
2- Gait: “Now let us check your gait, okay,…”
“Will you please stand up here and walk straight ahead.”
“Stop and return to me now on tiptoe.”
“Now walk away again but this time on your heels.”
“Stop, return by walking in tandem gait with one foot placed
in front of the other.”
To the examiner “Gait is normal, there is no shuffling, spastic
movements, wide stance, foot drop, or steppage.”.
3- Supine without weight bearing:
“Mr/Ms .., will you please lie down here flat on your back. Let me
have another look on your ankles & feet while lying down.”
4- Inspect shoes for wear-pattern: To be done while the patient is lying
down in step (3) above. Look for medial aspect wear-out.
“Mr/Ms.., let me have a look on your shoes sole.”
To the examiner “There is / is no abnormal wear-out pattern.”
2. Palpation: Patient still supine
“Mr/Ms .., Let me feel your ankles & feet.”
Screen for metatarsal-phalengeal joints (MTP) also by compressing the
forefoot between the index and thumb. Check pulses.
To the examiner “There is / is no warmth, nodules, effusion, or joint
tenderness. The skin is normal in thickness, soft,
normal moisture. Distal pulses are present.”
For warmth compare foot surface with lower anterior leg and other foot with
the back of your hand.
… Continued
179
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
Range of Motion: Patient still supine.
Active:
- Ankle (Tibiotalar) joint:
- Planterflexion (500) and Dorsiflexion (200):
“Mr/Ms .., will you please flex your feet down to the maximum…
now, up like this.”
- Inversion and eversion: (involve several joints)
“Mr/Ms .., now invert your feet with the planter surface facing each
other… now, the opposite, evert it.”
- Supination (45-600) and pronation (15-300 ):
“Mr/Ms .., now rotate your feet outwards (supination)… now, the
opposite, inwards (pronation).”
- Metatarso-phalangeal joints:
- Toes flexion and extension:
“Mr/Ms .., now, flex all your toes down to the maximum… now, up
like this.”
Passive: “Now let me move your foot in the same way to feel it … relax it.”
- Ankle (Tibiotalar) joint:
- Planterflexion (500) and Dorsiflexion (200): Lock the subtalar joint first
in inversion, then planterflex and dorsiflex the ankle.
- Inversion, eversion, supination, and pronation.
- Subtalar joint:
Stabilize the ankle with left hand. Dorsiflex the foot. Hold the calcaneus
with the other hand moving it in foot inversion and eversion.
- Mid-Tarsal, Tarso-metatarsal, Tarso-phalangeal joints, & toes:
Stabilize the calcaneous holding it with the left hand.
Do eversion, inversion, planterflexion, dorsiflexion, abduction, adduction,
toe flexion and abduction.
To the examiner “Active and passive range of motion is normal. End feel is
normal tissue stretch.”
3. Power Assessment/Isometric Movements: Patient is still supine.
“Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the
same movements we just did but don’t let me move you, resist me.”
Do knee flexion, foot planterflexion and Dorsiflexion, supination, pronation,
toe extension.
To the examiner “Normal muscle power, no weakness.”
… Continued
180
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
5. Special tests: Patient is still supine
1- Anterior Drawer Test for Ankle Stability:
- Place the knee flexed at 900 and the foot flat on stretcher. Stabilize the
foot by sitting on it and push the tibia towards the patient. (= forward
foot pull = Anterior drawer).
“Now, I’m going to sit by your feet. Relax your legs, I’ll hold your leg
and shake it backwards,… now the other leg.”
To the examiner “Anterior Drawer Test for Ankle stability is negative /
positive.”
For the following ligaments, passively move the foot asking for pain:
“Mr/Ms.., I’m going to do the same movements again. Tell me if you
feel pain.. Where?. ”
2- Lateral Complex:
- Anterior talofibular lig. (ATF): Planterflexion + inversion.
- Calcanofibular lig. (CF):
Inversion at 900 .
- Posterior talofibular lig. (PTF): Dorsiflexion + inversion.
3- Medial Complex:
Deltoid lig. : Eversion.
To the examiner “Maneuvers for ligament injury is negative / positive.”
END Ankle and Foot Exam, Wrap up
181
The Physical Examination Interview: Musculoskeletal Examination
182
Chapter 24: PEDIATRIC EXAMINATION
Pediatric examination:
General Notes:
In OSCEs, usually, there are no pediatric examination stations. However,
adolescent and teenage stations are common and are a real challenge.
Be organized: You should have a good order to your physical examination,
which will help place the patient at ease.
Privacy: You should always maintain privacy by using sheets and curtains
during the physical exam.
Develop strategies: for the four different age groups:
Infant, toddler, school age, adolescent/ teenage.
Infants are easy because they don't move around too much.
Newborns You should learn the screening exam in newborns for congenital
defects. It is important to see a bunch of these so that you have an idea what
looks normal and what is abnormal. Make sure that you feel comfortable
holding an infant. The most important joint to learn to examine in pediatrics
is the hip, so make sure someone shows you the hip exam and you feel
comfortable with it.
Toddlers are the most difficult because they see you as a stranger. If you
can be successful 50% of the time, you are doing very well. Trained
pediatricians "fail" about 20% of the time and have to leave the room and
come back. Its better to give up and come back with toddlers than to drive
yourself crazy trying to do the exam.
School age children are like adults, but very concrete in their reasoning.
They like for you to explain what you are doing, but they are usually very
willing patients on whom you can practice a head to toe exam.
Adolescents You should always do the physical exam on adolescents with a
chaperone in the room because everything you do will be taken in a sexual
context.
Focused exam: Make sure that your physical exam is focused. Each patient
does not need a head to toe exam. It is good to practice occasionally, but
make sure that you are doing it when there are few patients and you have
enough time to complete the exam.
Tips for:
Ear exam:
This is a difficult part of the physical exam, especially in toddlers. Your goal
should be to always see the tympanic membrane. The ear canal starts into the
…Continued
183
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
head in a medial-dorsal direction and then turns to be medial-ventral, therefore
you must straighten it. You can do this by pulling on the ear in an up and out
direction. Don't be too gentle, you have to pull to be successful. To prevent
yourself from hurting the patient, barely put the tip of the otoscope in the ear
and torque the canal. Loss of the tympanic membrane mobility is important in
the diagnosis of otitis media. This means that you need a bulb attachment for
your otoscope.
Throat exam:
In a school age kid or above, you should be able to do the throat exam without
using a tongue blade. This exam should always be performed when the patient
is sitting up.
Murmurs:
You are not expected to be able to describe every pathological murmur. You
should be able to differentiate pathological systolic murmurs in the left sternal
border from functional murmurs. The pathological systolic murmurs are
ventricular septal defects (VSD), peripheral pneumonic stenosis (PPS), mitral
regurgitation (MR) & aortic stenosis (AS).
Lung:
Be able to differentiate wheezing from rhonchi during the lung exam.
Abdomen:
Be able to rule out a surgical abdomen.
Know the level of illness of a patient:
This is a skill that you have to develop the skill of differentiating a mild illness
from a serious illness. As children medical condition changes quickly, it is
important to keep in your mind the differential diagnosis and coming
complications of each. Prepare yourself ahead and manage to prevent them.
Pediatric Examination Model:
1. General Appearance.
2. Vital signs & Survey.
3. Focused examination by systems.
…Continued
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The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
Patient is lying flat with his arms on the sides. Knees can be flexed to relax the
abdomen.
1- General appearance:
For alertness, facial expressions and general affect, speech, crying and
interaction with others.
To the examiner “Patient is/is not in distress. ”
“The patient is lying relaxed/ completely still (peritonitis)/
moving in distress (colic)/ curled up in fetal position
(visceral pain)/ lying with one hip flexed (splinting).”
“ Child name ….., What is the date today? …., and Where are you now?”.
To the examiner “The patient is alert. ”
* Developmental Milestones:
Ask the parents (or watch):
To the examiner “Developmental milestones are appropriate for age as
the patient can …...(Age related NOW only). ”
* Measure Height, Weight (& Head circumference for <1 year old unless
abnormally big):
1234-
Plot on growth charts.
Focus on growth trends.
Pay attention to crossing of percentile.
Compare with parents’ size.
For infants measure height supine & use infant scale for weight.
“Let me see how tall are you?, Come stand up here let us measure
that….Good… Now, let me see how heavy are you? Come stand up on
this scale…Good... Let me see how big is you head; let me measure it
with this measuring tape? Come sit down here”
Growth
charts are
common in
OSCEs.
It is very
important
to learn to
interpret
them and
explain
finding to
the parents.
To the examiner “Height, weight (& head circumference) are
appropriate for age.”
2- Ask for Vital signs and Survey:
“What are his/her vitals, please? ”
Carefully listen/ read and comment:
To the examiner “Normal/ so, he has fever/tachycardia/ tachypnea….”.
… Continued
185
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
1. Temperature: Take it on:
- Neonate and infants: Rectal (1 inch in for 1 min) or Tympanic (normally
< 380 C).
- Children and adolescents: Tympanic (normally < 380 C) or Oral
(normally < 37.50 C) or Axillary (normally < 37.20 C).
To the examiner “Temperature is … C, normal / high.”
2. Pulse: Take it on both arms, the both femorals for weakness. Aortic
coarctation.
“Let me feel your arms… now your groins here.”
To the examiner “Pulse is symmetrical bilaterally and normal femoral
pulses timing and amplitude. No radio-femoral delay”
3. Heart sounds: Listen: It is normal for children to have sinus arrhythmia.
“Let me listen to your heart with my toy here.. see it.. Do you want me
to listen to mummy/ dole/ bear first?.”
To the examiner “Normal sinus rhythm / sinus arrhythmia.”
4. Respiratory Rate: Place your palm on the child’s xyphoid process and
count.
RR > 60 bpm in an acutely ill child < 2 years old: Hypoxia (Gold standard
is oxygen saturation by a pulse oxymeter).
“Let me feel your chest.”
To the examiner “Normal respiratory rate at….. ”
5. Blood pressure: not for < 3 years old unless indicated (by Doppler
ultrasound).
Consistently low diastolic pressure: Patent ductus arteriosus.
Normal systolic = 80 + (2 X age in years)
Normal Diastolic = 2/3 of systolic.
“Let me measure your blood pressure.. I’ll wrap this cuff around your
arm, and then inflate it with this to squeeze your arm. Then release
the air while I listen with my toy to your arm… Okay”
To the examiner “Normal blood pressure at….. ”
… Continued
186
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
Average pediatric vital signs:
Respiratory
Age
Rate
Infant
6–12 month
2 – 4 years
5 – 8 years
8 – 12 years
> 12 years
30 - 50
30 - 40
20 - 30
14 - 20
12 - 20
12 - 16
Pulse
Systolic BP
Weight (Kg)
120 - 160
120 - 140
100 - 110
90 - 100
80 - 100
60 - 90
> 60
70 - 80
80 - 95
90 - 100
100 - 110
100 - 120
3-4
8 - 10
12 - 16
18 - 26
26 - 50
> 50
3- Focused exam by systems:
As in adults with some considerations:
Head and Neck:
Head: Neonate and infants. Supine
1- Head Shape and symmetry:
During first week and only due to vaginal vertex delivery:
- Head is occipiato-frontally elongated,
- Overriding cranial bone sutures (flattened by 6 months),
- Scalp swelling (either: caput succedaneum (subcutaneous edema
resolves in few days), or cepahalhematoma (subperiosteal
hemorrhage resolves in few months))
A markedly flattened occiput results from consistently placing the infant
supine.
2- Auscultate the temples and the vertex:
Loud harsh bruits suggest arteriovenous malformation (AVM).
To the examiner “Head shape and sutures are normal and
symmetrical. No scalp swelling. No loud harsh
bruits on the temples or vertex.”
Ears:
1. Inspection:
- Position: - The top of the ear is at the level of a line drawn from the
outer eye’s corner.
- The pinna should only deviate 10 0 from the vertical axis.
- The neonate’s ear is flat against the head.
- Hygiene: - Absence of wax: Over cleaning, Acute otitis media.
- Foul smelling discharge: Ruptured tympanic membrane,
recent myringotomy tube insertion.
- Bloody discharge: Foreign body, scratching.
To the examiner “Ears’ shape and position are normal & symmetrical.
Good hygiene. No discharge, normal wax.”… Continued
187
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
2. Hearing:
Infants: clap hands or rattle keys out of the infant’s sight and see if he
responds by fixing on you or having a startle reflex.
Children: As adults. See CN VIII (8) – Vestibulocochlear: (Sensory).
To the examiner “Normal hearing.”
3. Palpation:
- Tug at the auricle, push on targus: if pain: Otitis externa.
- Palpate the mastoid for tenderness: +ve: Mastoiditis.
“Let me feel your ears.”
To the examiner “No pain or tenderness.”
4. Otoscopic exam: Child held on parent’s lap and immobilized.
- Be gentle, it hurts when speculum is inserted.
- Start with the normal ear.
- Child <3 years old: pull the pinna down and out. Direct the speculum
upward.
- Child >3 years old: pull the pinna up and back. Direct the speculum
downward & forward.
“Let us see what is in there inside this bear’s /mummy’s ear, see
there is a light shining here.. Do you what to try it?… ”
To the parent: “Please sit up him/her in your lap and hold his head
fixing it… shall we have a look on your ears?”
To the examiner “Normal looking tympanic membrane translucent,
mobile, light reflex”
Eyes:
- Pupillary responses: poor during first 4-5 months.
- Pendular nystagmus or roving eye movements after 6 weeks: highly
suspicious for blindness.
- Visual acuity:
- <3 years old: Use a bright object and see if the child follows it.
Average acuity: 6-12 months: 20/120,
1-2 years: 20/80
- >3 years old: Use Snellen chart. Average acuity: 2-4 years: 20/20.
- Visual field: like adults but use a toy instead of a pen.
- Fundoscopy: Indicated for children > 4 months old. Look for:
- Cataracts, Corneal opacity, or ptosis: to prevent amblyopia.
- Red reflex and retinal hemorrhage.
- White reflex (leukocoria): Cataract, ocular tumor, chorioretinitis, and
retinopathy of prematurity.
To the examiner “Normal……………………..”
188
… Continued
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
Finding
Strabismus
Hypertelorism (wide set eyes)
Epicanthal folds
Appearance of sclera between
upper lid & iris
Drooping eyelid
Painful, red, swollen eyelid
Nodular, non-tender area
Sunken area around eyelids
Red conjunctivae
Pale conjunctivae
Yellow sclera
Bluish sclera
Brushfield’s spots
(White / pale speckling of the iris)
Absence of iris color
Notch at outer edge of iris
Constriction of pupils (Miosis)
Fixed unilateral dilation of a pupil
Dilation of pupils (Mydriasis)
DDx
Normal up to 6 months
Down’s syndrome
- Normal in Asian.
- Down’s syndrome
- Renal agenesis
- Glycogen storage disease
Hydrocephalus
Paralysis of oculomotor cranial nerve.
Stye
Cyst
Dehydrated
Bacterial / viral infection, allergy,
irritation
Anemia
Jaundice
- Premature baby
- Bilirubinemia
- Osteogenesis imperfecta
- Glaucoma
Down’s syndrome
Albinism
Visual field defect
- Iritis
- Drug induced (Morphine)
- Local eye injury - Head injury
- Acute glaucoma
- Drug induced
- Trauma
- Circulatory arrest
- Anesthesia
- Emotionally induced
Mouth: Check for
- Cyanosis
- Hydration. Frothy mouth: Esophageal atrasia / tracheoosephageal
fistula.
- Oral candidal thrush
- Signs of trauma, count teeth: first tooth erupts around 6 months. First
permenant tooth erupts around 6 years.
- Tonsils, hard and soft palate for exudates and erythema: Infection.
- Breath odor: indicates: oropharyngeal / gingival infection, dehydration,
constipation, poor oral hygiene.
- Palpate for submucosal cleft palate.
To the examiner “Normal……………………..”
… Continued
189
The Physical Examination Interview: Pediatric Examination
Pediatric examination: Cont.
Nose: Check for
- Close each nostril at a time and see if the child can breath from the other
one with mouth closed.
- Discharge: Clear thin: Allergic rhinitis.
Purulent yellow / green: Infection.
CSF: Head injury.
To the examiner “Nostrils patent, no discharge……..”
Neck: Check for
-
Lymph nodes.
Thyroid
Tracheal position.
Neck rigidity, Kernig’s and Brudzinski’s signs (May not be present < 1.5
years old).
Kernig’s sign:
Strong passive resistance to attempts to extend knee from flexed thigh
position.
Brudzinski’s sign:
Abrupt neck flexion with patient in supine position produces involuntary
flexion of hips and knees.
END .. Wrap up
190
Chapter 25: OBSTETRIC EXAMINATION
Obstetric examination
Obstetrical examination is uncommon in OSCEs because it is not easy to get an
enough number of pregnant women to act as standardized patient for a full day.
However, history taking and counseling scenarios are very common and
represent about 20% of any OSCE exam stations. Some OSCE organizers will
include non-pregnant women as first and second trimester pregnant
examinations and use manikins for third trimester examinations.
Even though, obstetrical examination is a skill that you will be assessed for all
through your medical practice. Following is the steps for all prenatal visits:
1. General inspection:
As you already had few seconds with the patient introducing your self, you
will be able to assess:
Overall health.
Nutritional status and pallor for anemia.
Neuromuscular deformities.
Emotional status: - Happy with the pregnancy or not?
- Signs of spousal abuse?
Blood pressure:
To the examiner “ The patient looks relaxed/ anxious. No obvious
neuromuscular deformities. No pallor or wasting.
Happy and co-operates interactively.”
2. Ask for Vital signs and Survey:
“What are her vitals, please? ” HR, RR, BP.
Carefully listen / read and comment:
Until 24 week:
sBP 5-10
dBP 10-15
mmHg
Nagele’s Rule:
To the examiner “Normal/ so, she has fever/tachycardia/ tachypnea….”.
“Ms…, let us check your weight, stand up on the scale please…., thank
you.”
“How much was your weight immediately before this pregnancy.”
“When was the first day for your last period (LMP)?….. Was it
regular?… Every how many days it comes? Do you know your due
date (EDC) ?”
- Calculate gestational age. (If not given or to be sure).
- Calculate weight gain.
To the examiner “Her gestational age is …., and weight gain is at … lb,
normal/ less/ more for gestational age.”
EDC =
1st day of LMP
+ 7 days
– 3 months.
Weight gain:
0-12 weeks:
Loss < 5 lb.
10-20 weeks:
1 lb/ month.
20-40 week:
1 lb/ week.
Total 15-25 lb.
… Continued
191
The Physical Examination Interview: Pediatric Examination
Obstetric examination: Cont.
3. Examination by body parts:
Head & Neck inspection:
1- Mask of pregnancy: Cloasma is the irregular brown patches around the eyes
or across the nasal bridge.
2- Pallor.
3- Hair loss.
4- Edema.
To the examiner “Normal cloasma seen. No pallor, hair loss, or edema.”.
5- Nasal congestion (common)
6- Gingival enlargement and bleeding (common).
“Ms…, let me have a look on your nose….. and your mouth, open it,
please.” Use penlight.
To the examiner “There is normal nasal and gingival congestion. No
bleeding.”
7- Marked or asymmetrical neck enlargement.
To the examiner “There is / no neck enlargement”.
Chest:
1- Respiratory rate and pattern: Normally 12-16 bpm.
To the examiner 1- “Breathing is Regular/ Irregular at … bpm.
2- Uses/ does not use accessory muscles.
3- There is / is no nasal flaring.
4- No/ difficulty speaking. ”
2- Palpation for PMI:
“Ms…, let me feel your chest.” Uncover without exposing the breasts.
To the examiner “PMI is 2 cm at the 5th (or 4th ) ICS MCL (while holding
radial pulse), single impulse of normal amplitude and
duration.”
3- Auscultation: for the heart murmurs and lung bases.
“Ms…, now, let me listen to your heart…….. and chest from the back.”
To the examiner “No abnormal chest sounds or heart murmurs.”
4- Breasts:
“Ms…, Now I’ll examine your breasts,.. okay.” Uncover.
Examiner will stop you. Look for:
1. Nipples: Asymmetry, color (dark brown), prominent Montgomery’s
glands.
2. Palpate for masses. Usually congested, tender and nodular.
3. Nipple compression: ? Colostrum. ? Bloody/ purulent discharge.
… Continued
192
The Physical Examination Interview: Obstetric Examination
Obstetric examination: Cont.
COVER CHEST.
Abdomen:
“Ms…, Now I’ll examine your abdomen,.. okay.” Uncover.
1- Inspection:
Look for: Size, shape, contour, scars (C/S), purplish striae, and linea
nigra.
To the examiner “Abdomen is of normal shape, contour. There are
/no scars, purplish striae, and linea nigra.”
2- Palpate:
1. Liver.
2. Masses.
3. Fetal size and movements. > late T2.
4. Fetal presentation, position. >T3
5. Head mobility and engagement. >T3.
6. Uterine contraction. >T3.
To the examiner “…………………………..”
3- Symphyseal Fundal Height (SFH): Normally +/- 2 cm of expected GA.
4- Auscultation:
Fetal heart: By doptone >12 weeks. Fetoscope > 18 weeks
- For: 1. Heart Rate: 160 (early)-120 (late) bpm.
2. Rhythm: 10-15 bpm variability over 1-2 minutes.
3. Location.
To the examiner “Fetal heart rate is ……”
COVER ABDOMEN
5- Leopold Maneuvers: T3.
Pelvic/ Genital/ Anal Exam:
“Ms…, Now I’ll need to examine your genitalia and feel your female
organs internally with my fingers,.. okay.” Uncover.
Examiner will stop you.
See Gynaecological examination. Look for:
1- External genitalia inspection.
2- Speculum exam.
3- Pap smear. (If not done within the last 6 months).
4- Vaginal/ cervical culture swabs for gonorrhea and chlamydia.
5- Bimanual exam: 1. Cervix: - Position.
- Length: > 1.5-2 cm > 34 weeks.
- Consistency.
- Dilatation.
… Continued
193
The Physical Examination Interview: Pediatric Examination
Obstetric examination: Cont.
2. Uterus: - Size/ Shape/ Consistency/ position.
3. Adenxal mass.
Extremities:
1- Hands and legs for edema:
2- Legs for varicose veins.
3- Knee and ankle reflexes.
“Ms…, Now let me examine your hands and legs,.. okay.”
To the examiner “There is /no edema or varicose veins.”
“Ms…, Now I’m going to tap on your knees and behind your ankles to
check the reflexes”
To the examiner “Normal knee and ankle reflexes.”
Note: Follow-ups:
Monthly: until 28 weeks.
Biweekly: 28-36 weeks.
Weekly: > 36 weeks.
END .. Wrap up
194
195
196
PART FOUR
EMERGENCY MANAGEMENT
197
198
Chapter 26: EMERGENCY MANAGEMENT
Emergency Room Stations:
Emergency room stations in OSCEs are of three different types:
A patient came to the ER with a complaint: This station is not an
emergency station. People come to the ER as an outpatient. Read
carefully the station’s stem instructions to know what is required;
history taking station, or physical exam station or both. Treat this station
the same way as an ordinary station.
A stable patient in ER after management for an acute case: In these
stations, a colleague had already done the necessary ER management
and the patient is now stable. Read carefully the station’s stem
instructions to know what is required; consult (usually), history taking
station, or physical exam station. Treat this station the same way as an
ordinary station.
A patient came to the ER with an acute case: In these stations, you
are the first physician to see the patient. The station’s stem instructions
states to MANAGE the case and a nurse will be present. This is an ER
management station and this chapter will explain what to do in such
stations.
The ER MODEL for management stations:
123456-
The Minute Before the interview.
The Introduction.
Rapid Primary Survey (RPS) & Resuscitation.
Detailed Secondary Survey
Definitive Care.
Wrapping up.
1- The minute before: Like in the History taking model.
2- The Introduction:
1- Verify identity: “Mr./ Ms…..” in a questionable voice tone.
2- Self introduction: “Hi, I am Dr…(your last name) , I am the physician
on duty here today”.
3- Assess consciousness: “What happened?” with shaking if necessary.
 EMPATHY “OOH..”
4- Ask for protective gear. “May I have a gown, gloves, mask, and
glasses,... thank you.” Wear what is available quickly.
5- Summarize what you are going to do: “Mr./Ms. …., I am here to
examine you/ your .., I am going to ……, Okay? Explain briefly.”
… Continued
199
The Emergency Management Interview
ER Management: Cont.
6- Position the patient: “Will you please sit down here/ lie down flat on
your back here, please” If not already in position. Usually not needed.
7- Drape the patient. VERY IMPORTANT.
8- Tell the patient: “I’m going to explain what I’m doing to my colleagues
here, okay?”. If a nurse and/or an examiner is present.
3- Rapid Primary Survey & resuscitation:
A
B
C
D
E
ABCDE
Airway maintenance with C-spine control.
Breathing and ventilation.
Circulation (pulses, hemorrhage control).
Disability (neurological status).
Exposure (complete) and Environment (Temperature control).
A common
C-Spine
collar
scenario:
*Restart ABCDE if patient deteriorates.
The patient
asks to remove
it. Respond
with empathy:
“Ooh, let me
1. Immobilize cervical spine with collar or sand bags. In Trauma case ONLY.
first examine
you to see if
you need it
or not.”
Always deal with A and B first as they may kill the patient now, not C.
Airway:
To the examiner/ nurse “A collar or sand bags please to immobilize the
C-spine.” If already present, comment:
“Collar/sand bags in place.”
2. Airway assessment: Assess ability to breath and speak.
If patient is already responded appropriately to you so far, indicates patent
airway and the ability to breath is normal.
“Mr./Ms.., Where are you now?…What day of the week is today?”
ETT drugs:
NAVEL
1. Naloxone.
2. Atropine.
3. Ventoline
(Salbutomol).
4. Epinephrine.
5. Lidocaine.
To the examiner “Patient is alert, oriented, speaking, no noisy
breathing, airway is patent.”
3. Airway management:
Goals: 1. Adequate oxygenation & ventilation.
2. Give drugs via endotracheal tube (ETT) if IV not available.
1- Basic airway management (Temporary):
1) Protect C-spine. Already done.
2) Chin lift or jaw thrust to open the airway.
“Mr./Ms…, I’ll adjust your head position to assure an open
airway… I’ll open your mouth to see if there is something loose
in there to take it out.”
… Continued
200
The Emergency Management Interview
ER Management: Cont.
3) Open mouth: LOOK first for foreign body, THEN, if there is
something, sweep/ suction to clear the mouth.
To the examiner “No foreign bodies or secretions in the mouth, No
mouth smell.”
- Think about ability to maintain patency in the future.
To the examiner “There is no indication now for endotracheal
tube.”
GO TO BREATHING if airway is patent.
OR To the examiner “Patient is…., an indication for endotracheal tube.”
Indication for Endo Tracheal Tube (ETT): VISA A
Ventilation is poor. O2 saturation <90% on 100% O 2 or rising pCO2 .
Ill patient: GCS <8, trauma, overdoes, CHF, COPD, asthma.
Shock.
Airway cannot be protected.
Anticipated transfer of critically ill patients.
1) Nasopharyngeal airway. “Mr./Ms…,I’ll pass this tube
through your nose to keep the airway open.”. If failed;
2) Oropharyngeal airway (Not if gag present. Check gag reflex
first). If failed:
3) Transtracheal jet ventilation (as a last resort, better ETT).
2- Definitive airway management:
- Endotracheal intubation (ETT):
- Orotracheal +/- RSI (Rapid Sequence Intubation) (No RSI if
face smashed)
- Nasotracheal: Better tolerated in conscious patients BUT
contraindicated with basal skull fracture.
- Surgical Airway: Cricothyroidectomy.
If ETT failed or needed for chemical paralysis for agitated
patients.
… Continued
201
The Emergency Management Interview
ER Management: Cont.
Breathing:
1- LOOK: for: 1. Mental status: anxiety, agitation.
2. Color: cyanosis / pallor.
3. Chest movements.
4. Respiratory rate & effort.
5. JVP. (if collar on don’t remove it. If sand bags, do it.)
To the examiner “Patient is not agitated, no cyanosis or pallor. Normal
symmetrical chest movements, Normal respiratory
effort and rate at…bpm, JVP is....”
2- FEEL: for: 1. Airflow.
2. Tracheal shift. (if collar on don’t remove it. If sand bags,
do it.)
3. Chest wall for crepitus.
4. Flail segments & sucking chest wounds.
5. Subcutaneous emphysema.
“Mr/Ms…, I’m going to uncover and feel your neck and chest, Okay.”
“Any pain?”
To the examiner “There is no tracheal shift, crepitus, flail segments,
sucking wounds or subcutaneous emphysema.”
3- LISTEN:
1. Sounds of obstruction (Stridor) and air escaping.
2. Breath sound and symmetry of air entry. Both sides: apex,
lower, and sides.
3. Heart sounds. If muffled with high JVP: Temponade:
pericardiocenthesis.
“Mr/Ms…, I’m going to listen your chest.”
To the examiner “Breath sounds are normal, symmetrical, no stridor,
normal heart sounds / …. diminished air entry on
the left…..”
Findings
Dx
No air entry +
Hyperresonance
Tension
Pneumothorax
No air entry +
Dullness
Hemothorax
Management
1- Assess respiratory function.
2- Insert a large pore needle (gauge
14-16) immediately in 2 nd ICS mid
clavicular line.
3- Then prepare patient for chest tube
(28F in 5 th ICS Anterior axillary
line).
1- Assess respiratory function.
2- Prepare patient for chest tube (32F
in 5th ICS posterior axillary line.
3- Ask how much blood was drained.
If >1500cc  Call surgeon for
thoracotomy.
...Continued
202
The Emergency Management Interview
ER Management: Cont.
4- Assess Respiratory Function:
To the examiner/nurse “Put him/her on face mask with 100% oxygen.
If not in shock or spine trauma: Raise the stretcher
head 450.”
Ventilation modalities:
- Nasal prongs
 Simple face mask.
Oxygen reservoir.
 CPAP/ BIPAP.
- Venturi mask: for precise oxygen delivery.
- Bag-Valve mask and CPAP: to supplement ventilation.
Will ask for:
Circulation:
Respiratory Function measurement:
1. Respiratory rate.
2. Pulse.
3- Oximetry.
4. Arterial Blood Gasses (ABGs).
5. A-a gradient.
6. Peak flow rate.
1. Ask for Vital signs:
To the examiner/nurse “What are his/her vitals, please?”
Carefully listen / read and comment: e.g. “Normal/ so, he has
fever/tachycardia/ tachypnea….”.
- Blood pressure: If conscious mobile patient, take it on:
“Mr/Ms…, I’m going to check your blood pressure in both your
arms then your leg, (if no collar) and I’ll recheck your arm while
sitting/standing for a minute?.”
Note: Usually the examiner will stop you and give you the results, but
start doing it until he/she stops you.
Measure BP in unconscious yourself on one arm.
To the examiner “Blood pressure is …. mmHg lying and …. mmHg
standing. No postural hypotension, No significant
upper/lower extremities difference. (aortic dissection)”
To the nurse “Put him/her on cardiac monitor and pulse oxymeter.
Repeat vitals every (5-15) minutes & inform me.”
Pulse: is sensitive for intravascular volume.
Capillary refill time: is sensitive for adequate circulation.
Estimated Systolic blood pressure: If you feel:
Radial pulse:
>80 mmHg
Femoral pulse, no radial >70 mmHg
Carotid Pulse only
>60 mmHg
203
The Emergency Management Interview
ER Management: Cont.
2. IV lines and Investigations:
To the nurse
1) “I want 2 wide pore gauge 14-16 IV lines established, please.
2) Start Normal Saline/ Ringer Lactate, one liter on each at 125-1000
ml/h each (choose according to the patient’s BP).
3) Take a blood sample and send for:
- Blood group, Rh and cross-match,
- CBC, Lytes, (ABGs, CK-MB, Tropinin) if respiratory/cardiac case
- Liver function test (ALT, AST, ALP, and amylase),
- Renal function tests (BUN, Cr),
- Coagulation profile (INR/PTT),
- Rapid bedside Blood sugar,
- Toxicology screen (if indicated).
4) Also send for: 12- lead ECG, CXR, Head CT (if comatose),
C-Spine and pelvic X-rays (if trauma),
5) Foley’s catheter / Nasogastric tube (if needed).
“Mr/Ms .., I’ll put a bee tube inside in order to monitor your urine
output, okay..?”
Note: If blood seen from meatus: NO FOLEY’S (? Urethral injury)
Assess Respiratory Function: Change to assisted ventilation or ETT if
needed.
If BP low: 
1. Give bolus 1-2 L N/S (Normal Saline) or RL (Ringer Lactate).
2. Ask for blood reservation of 6 units cross-matched or O –ve.
To the nurse “Prepare 6 units blood, 2 STAT type specific or O –ve
(for children and females)/ O +ve (for males) , and 4 crossed
matched (takes time)”.
NB: If JVP high: Cardiogenic shock: No fluids
If both BP and HR low (Cushing): Neurogenic shock: Treat as
Cardiogenic.
If Comatose:  ‘Universal antidotes’: TANG (A= and).
1. Thiamine 100 mg IV or IM before glucose (if alcoholic,
malnourished, cachectic),
2. Glucose 50 cc of 50% (D50W): if glucose < 4 mmol/L (70 mg/dL)
or no rapid test,
3. Naloxone 0.4-2.0 mg IV: if narcotic toxidrome present.
3. Rule out shock:
Classifications:
1- Hemorrhagic shock: Most common. Shock in trauma patients is
hemorrhagic until proven otherwise.
...Continued
204
The Emergency Management Interview
ER Management: Cont.
2- Cardiogenic shock: e.g. blunt myocardial injury, arrhythmia, MI.
3- Obstructive shock: e.g Tension pneumothorax, Cardiac temponade,
pulmonary embolism.
4- Distributive shock: e.g. Spinal /neurogenic shock, Septic shock,
Anaphylactic shock.
Clinical evaluation for shock:
TV SPARC CUBE
Thirst AND reduced urine output.
Vomiting.
Sweating.
Pulse – Tachycardia, weak, narrow pulse pressure, reduced central
venous pressure.
Anxious.
Respiration – Tachypnea, shallow.
Cool AND reduced capillary refill.
Cyanosis.
Unconscious.}
BP – Hypo } later
Eyes – blank }
“Mr/Ms…, I’m going to check your pulses and feel your hands?”
- Examine: - Pulses, radial/femoral
- Capillary refill & Extremities for coolness.
To the examiner “Pulses are/ not symmetrical, good volume and rise,
there is/ no radiofemoral delay, normal/ reduced
capillary refill at .. /sec, there is/ no peripheral
cyanosis and coldness.”
“Mr./Ms.., Where are you now?…What day of the week is today?…,
Are you thirsty?…Do you feel your mouth dry?.. Do you have
lightheadedness?.. Do you feel sick?.. Did you throw up since this
event?… Are you anxious?.”
To the examiner “There are no signs & symptoms of shock. Patient is
relaxed, oriented. No sweating, thirst or vomiting.
Pulse, blood pressure and respiration are normal.”
 Go to Detailed Secondary Survey
OR To the examiner “There are signs & symptoms of shock class 2/3/4..
Patient is ……… Is the mask fitting well?.. Is the
Oxygen on 100%?.. Are IV lines and fluids
running?”
 Go to management below.
...Continued
205
The Emergency Management Interview
ER Management: Cont.
Management of hemorrhagic shock:
1 - Ask for vitals again: “What are his/her vitals, please?”
Carefully listen /read and comment: e.g. “Normal/ so, he has
fever/tachycardia/ tachypnea….”.
2 - Secure airway and O2: Already done but check the mask and O2
level.
3 - Control bleeding by:
External:1. Direct pressure.
2. Elevate limb if no evidence for fracture.
3. Vascular pressure points (brachial, femoral).
4. Do not remove impacted objects.
5. Tourniquet: Only as a last resort.
To the nurse “Gauze and bandages please to apply pressure. Also
a tourniquet just in case we need it.”
Internal: Prompt surgical consultation for active bleeding.
To the nurse “Call for surgical consultation for internal
bleeding.”
4 - Replace lost blood:
1. Run the 2 liters N/S rapidly as mentioned above.
To the nurse “How are the IVs?.”
2. Replace lost blood volume at a rate of 3:1: To maintain
intravascular volume as only 1/3 of infused isotonic crystalloids
remains intravascular. e.g estimated lost is one liter, give 3 liters NS or
RL.
Blood transfusion (packed RBCs):
Start with 2 pints  still shock  4 pints  still shock 
Surgery.
Indications: 1. Severe hypotension on arrival.
2. Shock persists following the rapid infusion.
3. Rapid bleeding.
Blood types: 1. Cross-matched: ideal but takes time.
2. Type-specific: can be provided in 10 minutes.
If not available;
3. For children and women: O-negative
For others: O-positive.
Note: - Anticipate complications in massive transfusions.
- Use FFP (Fresh frozen platelets) if:
1. Clinical evidence of impaired hemostasis.
2. Ongoing hemorrhage with platelets count < 50,000,
and PT >1.5.
...Continued
206
The Emergency Management Interview
ER Management: Cont.
3. Operative intervention: if still in shock for ongoing internal
bleeding.
5 - Vasopressors:
- Not during bleeding.
- Used if hypotension persists despite appropriate volume
administration. Also for septic and anaphylactic shocks.
- Systolic BP: > 100 mmHg Dobutamine 2 - 20 mcg /kg /min
70 – 100 mmHg Dopamine 2.5 - 20 mcg /kg /min
< 70 mmHg
Norepinephrine 0.5 - 30 mcg/kg/min
Class
Blood
Loss: cc
Volume
Blood
Loss: % of
volume
Pulse: bpm
BP: mmHg
RR: bpm
Capillary
refill
Urinary
output:
cc/hr
Fluid
replaceme
nt
I
II
III
IV
< 750 cc
750 – 1500
cc
1500 –
2000 cc
> 2000 cc
< 15 %
15 – 30 %
30 40 %
> 40 %
< 100
> 100
Normal
Normal
> 120
Decreased/
> 140
Decreased
Orthostatic
SPB<100
20
Normal:
< 3 sec
30
35
>45
Decreased
Decreased
Decreased
30
20
10
None
Crystalloid
Crystalloid
Crystalloid
+ Blood
Crystalloid
+ Blood
Note: Cushing effect of ICP is opposite shock: HRBP
End of Circulation
* If Patient is stable now  Proceed to Disability.
If not  Repeat ABC until becomes stable.
…Continued
207
The Emergency Management Interview
ER Management: Cont.
Disability: LPM
1. LOC (Level Of Consciousness)
AVPU
Alert
Responds to Verbal stimuli
Responds to Painful stimuli
Unresponsive
To the examiner “For disability, the patient is alert / responds to verbal
stimuli / painful stimuli / Unresponsive. ”
2. Pupils Size and Reactivity
- Size (dilated in CN 3 lesion, constricted in Horner’s),
- Shape (round),
- Symmetry,
- Light reflex.
Light reflex: CN 3 efferent
“Mr/Ms …, I’m going to briefly shine a light into your eyes to test
its response.”
Shine light on eye ‘A’: It will constrict (direct response) and also eye
‘B’ will (consensual response). Repeat for eye ‘B’
To the examiner “Pupils size, shape, symmetry, and reactivity are
normal./ Patient has photophobia, reactivity not
checked.”
3. Movement of upper and lower extremities
“Mr/Ms …, move your right arm and fingers,.. Good, now the left
arm and fingers, … Good, now move your right leg and the toes, ..
Good, and the left leg and the toes, ... Good.”
To the examiner “Patient moves his extremities normally / cannot
move his right arm and leg. There are / are no signs of
lateralization.”
COVER THE PATIENT.
…………………………………….
**Ask for Vital signs: “What are his/her vitals, please?”
Carefully listen / read and comment: e.g. Normal/ so, he has
fever/tachycardia/ tachypnea….”. “Any investigation results? ”
Exposure / Environment:
1- Undress the patient completely and examine for areas of injury.
2- Keep patient warm with blankets.
“Mr/Ms …, I’m going to uncover you to check for injuries. okay.”
To the examiner “There are / are no wounds, bruises or scratches seen.
No needles track marks.”
… Continued
208
The Emergency Management Interview
ER Management: Cont.
** If Comatose:  ‘Universal antidotes’: TANG (A= and)
To the nurse “Put him on left lateral decubitus with neck extended and
no pillow…Give him/her:
1. Thiamine 100 mg IV or IM before glucose (if alcoholic, malnourished, cachectic),
2. Naloxone 0.4-2.0 mg IV: if narcotic toxidrome present.
3. Glucose 50 cc of 50% (D50W)”: if glucose < 4 mmol/L (70 mg/dL) or no rapid
bedside test is available.
** If signs of lateralization: (unilateral sensory/ motor/ visual loss)
 ICP
To the nurse “Give him:
1. Manitol 1g/kg rapidly IV, (+/- Lasix 20mg IV)
2. Prepare for intubation, hyperventilate to PCO 2 25-30 mmHg,
3. Raise head 200 if not low BP,
4. Call neurosurgeon.”
** For Anaphylactic shock:
To the nurse “Give him:
Norepinephrine 0.3 mg of 1:10000 SC (5 - 30 mcg/kg/min);
+/- Metylprednisolone (Medrol) 100-200 mg OD PO (1 mg/kg);
+/- Diphenhydramine (Benadryl) 50 mg IV (if hypotension)”
** IF Status Eplipticus:
To the nurse “Give him:
50% glucose 50 cc IV, } Already given if comatose.
Thiamine 100mg IM, }
Lorazepam (Ativan) 10 mg (0.1 mg/kg)
(or Diazepam (Valium) 20 mg) IV infusion at 2 mg/min
Failed: Phenytoin (Dilantin) 20 mg/kg IV infusion at 50 mg/min max,
Failed: Phenytoin (Dilantin) 10 mg/kg IV infusion at 50 mg/min,
Failed: Phenobarbital 20 mg/kg IV infusion at 50 mg/min,
** IF Diabetic Emergencies:
To the nurse “Run the Normal Saline at 1000cc/h each;
Give 5 (-10) IU Insulin IV bolus, then another 5 (-10)/h by IV
infusion”
“When Blood glucose reaches 15 mMol/L change the fluid to two
third 5% dextrose water (D5W) and one third Normal Saline. Then
add 20 mEq/L KCL to the fluid.”
“Send for urine glucose and ketones.”
………………………………………………………………………………….
To the examiner “Patient is stable. I’ll start the detailed secondary survey.”
…Continued
209
The Emergency Management Interview
ER Management: Cont.
4- Detailed Secondary Survey:
-
To identify major injuries or areas of concern. Trauma X-ray Survey:
Head to toe physical exam. X-rays & CT.
1. C-spine.
History:
2.
3.
Chest.
Pelvis
AMPLE + OSCD PQRST UVW AAA + Station appropriate
quickly
“Mr/Ms…, I’m going to ask you some questions that will help us assess
your condition. Okay. ”
WRITE THEM DOWN. If comatose, ask who accompanies the patient.
Allergies and Tetanus:
“Do you have any allergies?”
Yes:  “What happened when you took it?” (Side effects or true allergy?)
“When was your last tetanus shot?”
Medications:
“Any MEDIC ALERT wrist strap?,… Are you taking any medications
now?” Some people with medications or allergies wear a ‘MEDIC ALERT’
wrist strap.
Yes  “ What are they (Name)? .. What is the dose?.. For how long
you’ve been taking this (Duration)?.. Have you noticed any side effects?,..
Who prescribed it?… What about medications in the past?”
“How frequent you take pain killers like Aspirin, Tylenol, profen?
What about steroids?…. Herbal or over-the-counter medications?”
“What about street /Recreational drugs?”
P ast medical history: Look for underlying causes:
“Have you had similar episodes in the past?.. Do you have any medial
diseases?.. Do you have depression? .. Alcohol drinking problem?..
High blood pressure?.. Heart problems?.. Diabetes?.. Seizures?”
Yes: “ When was it first diagnosed?... How was it treated? Write down.
When was it lastly been checked?… Which doctor is taking care of
this?”
Last meal:
“When was your last time that you ate something? .. What was it? ..
How much was it?”
Events related to the injury:
“Tell me what happened / how does this happen?”
Is it a blunt (most common)/ crashing / penetrating trauma?
210
…Continued
The Emergency Management Interview
ER Management: Cont.
If Comatose:
1. Onset: Abrupt: CNS hemorrhage / ischemia, or cardiac arrest.
2. Progression over hours / days: Progressive CNS lesion, or toxic /
metabolic cause.
3. Condition prior to coma: Confused/ delirious: Toxic / metabolic cause.
“Did he/she lost consciousness all of a sudden or gradually?.. How was
he/she before loosing consciousness?.. Confused?.. Delirious?”
OSCD PQRST UVW AAA +appropriate/ standard box +
EMPATHY
Physical exam:
PRIORTIZE
Comatose/ head injury: Head and Neck first,
MI/ thorax: Chest first,
Abdominal/ Pelvic trauma: Abdomen/ Pelvic first,
Limb injury: MSK.
Head and Neck:
1. Face: Inspect and open the mouth to smell the breath.
(Acetone: DM; Mouse: uremia, alcohol).
To the examiner “There is no rhinorrhea, tongue pitting, odor on
breathing, no Raccoon eyes or Battle’s sign. No
wounds or bruises.”
2. Palpation of facial bones and scalp:
“Mr/Ms .., let me feel your head… Any soar areas?”
To the examiner “No wounds or fractures felt. ”
3. Pupils: Repeat if comatose only. AVPU
“Mr/Ms …, I’m going to briefly shine a light into your eyes to test
its response.”
LOC + reactive pupils  Metabolic or structural cause of coma.
LOC + non-reactive pupils  Structural cause of coma.
To the examiner “Pupils size, shape, symmetry, and reactivity are
normal.” “His/her consciousness is better/
deteriorating with pupils being reactive (metabolic/
structural) / non-reactive (structural)”.
To the examiner “Patient is alert / responds to verbal stimuli / painful
stimuli / Unresponsive.”
…Continued
211
The Emergency Management Interview
ER Management: Cont.
4. Extraocular movements and nystagmus:
- Move a pen in all the six direction in front of the patient in an ‘H’
direction.
“Mr/Ms .., now I want you to look on this pen with your eyes only
and follow it while I’m moving it. Keep your head straight. If at any
point you see it as two pens, tell me.”
To the examiner “Extraocular movements are normal, no nystagmus.”
5. Fundoscopy for papillodema and hemorrhage:
“Mr/Ms .., now I want to look inside your eyes with this scope.”
To the examiner “No papilodema or hemorrhage.”
6. Otoscopy for tympanic membranes:
“Mr/Ms .., now I want to look inside your ears with this scope.”
To the examiner “No otorrhea or hematotympanum.”
Chest:
If chest case: do complete respiratory or cardiovascular PE. Otherwise:
1. Inspection:
“Mr/Ms .., let me have another look on your chest.”
To the examiner “No flail segments or contusion. Breathing pattern is
normal.”
2. Palpation:
“Mr/Ms .., let me feel your chest.”
To the examiner “No areas of tenderness, no subcutaneous
emphysema.”
3. Auscultate: Apex, upper, lower of each side. Warm the stethoscope.
“Mr/Ms .., let me listen to your chest.. Take deep breaths in and out.”
To the examiner “Normal breath sounds. Chest is clear. Normal heart
sounds/…….. ”
4. Ask for the CXR/ ECG/ Cardiac enzymes/ Investigations:
“What about his/her chest X-ray/ECG/Enzymes?.” Read and comment:
To the examiner “Chest X-ray is normal/ There is opacity on the left /
fluid level on the left…..” “ECG shows……”
“Investigations show…”
… Continued
212
The Emergency Management Interview
ER Management: Cont.
** IF MI: MONAH:
“Mr.Ms..., it seems that you’re having a heart attack. I need you to
relax for now, we’re taking good control of the situation here,
okay?”
To the nurse “Give him:
Morphine 5 mg IV every 5-10 min as needed,
Oxygen at 4L/min by face mask,
Nitroglycerine 0.4 mg sublingual every 5 minutes for three times,
Enteric Coated ASA 325mg tab OD STAT,
Heparin 5000 unit IV then 30000 units per day IV infusion.
To the examiner “His blood pressure and Heart rate are OK.”
“Mr./Ms.., do you have asthma?… History of heart failure? ” If No:
To the nurse “Give Metoprolol (Lopresor, Betaloc) 2.5 mg IV then 25
mg every 12h. ”
“Mr/Ms…, we’re giving you now something for the pain. I need to
ask you some questions that will affect our decision of whether
giving you a drug that dissolves blood clots in your heart vessels,
have you ever had a stroke or head injury?..
Any trauma or surgery during the last two weeks?..”
To the examiner “His BP is OK and there are no signs of increased
intracranial pressure,
- ECG shows more than 2 mm ST elevation in two
contagious leads and/or new LBBB.
- Pain started less than 6 hours ago. ”
To the nurse “Contact cardiology for thrombolytic therapy.”
** IF Malignant hypertension: sBP > 180 mmHg Not if stroke.
Lower it at a rate of 25% of presenting BP within 2-6 hours and not
below 100 mmHg.
To the nurse “Give him:
Nitroglycerine 100 mg in 250cc D5W at 5-50 cc/h” or;
Sodium Nitroprusside 50 mg in 250cc D5W at 5-50 cc/h” or;
Esmolol 10-20mg” or;
Metoprolol 1-5 mg IV” or;
Nifedipine 10mg sublingual.”
** IF Pneumothorax /Hemothorax:
To the nurse “Prepare for Chest tube & contact thoracic surgery.”
… Continued
213
The Emergency Management Interview
ER Management: Cont.
** IF Asthma / COPD exacerbation:
“Mr.Ms.., it seems that you’re having an asthmatic attack. I need you
to relax for now, we’re taking good control of the situation here,
okay? ”
To the nurse “Give him:
Oxygen at 4L/min by facemask,
Salbutamol (Ventolin) 4-8 MDI puffs every 15-20 min for 3 times
(or 1 puff every min MAX 20 puffs), then 2 puffs every 6 hours,
Ipratropium bromide (Atrovent) 2-6 puffs every 6 hours,
Metylprednisolone (Medrol) 100-200 mg OD PO for 7-14 days then
Beclometasone (Vente) 5-10 MDI puffs/d,
If with infection:
Co-trimoxazole (Septrin) 200 mg, or
Ciprofloxacin (Cipro) 500 mg every 12h.”
……………………………………………………………………………
Ask for vitals again: “What are his/her vitals, please?”
Carefully listen / read and comment: e.g. “Normal/ so, he has
fever/tachycardia/ tachypnea….”.
……………………………………………………………………………
Abdomen:
If abdomen case: do complete abdominal PE. Otherwise:
1. Inspection: Scaphoid (? diaphragm rupture) or distended (? ascites or
hemorrhage).
2. Palpation: for rigidity, tenderness and rebound tenderness.
“Mr/Ms .., let me feel your abdomen.” Uncover the abdomen.
To the examiner “Abdomen is not distended or scaphoid. There are no
rigidity, tenderness or rebound tenderness.”
* If BP is still low or falling despite fluid and blood replacement:
Do Diagnostic Peritoneal Lavage (DPL) or ultrasound or CT.
If positive call surgeon for immediate laparotomy.
Pelvis:
1. Pelvic Stability: Hold the pelvis from the sides, squeeze it from the sides
and AP, and rotate it vertically. Palpate the iliac crests
and symphysis pubis.
“Mr/Ms .., I’m going to squeeze your pelvis….Do you feel any pain?”
To the examiner “No pelvic bony laxity.”
… Continued
214
The Emergency Management Interview
ER Management: Cont.
2. Genitalia: Inspect for visible injuries or blood.
“Mr/Ms .., now I need to check your genitalia for any injuries,
okay…?” Examiner will stop you giving the results.
To the examiner “No injuries or blood seen in genitalia.”
3. Rectal exam: for: GI bleed, high riding prostate, and anal tone.
“Mr/Ms .., now I need to check your bottom. I’m going to pass a
finger in, okay…?” Examiner will stop you giving the results.
To the examiner “Normal anal tone, Normal prostate, no blood.”
4. Bimanual vaginal exam:
“Ms .., now I need to examine you internally through your vagina.
I’m going to pass a two finger in, okay…?” Examiner will stop you
giving the results.
To the examiner “Uterus is soft. No adnexal masses. No cervical
motion tenderness.”
5. Tubes: Foley’s and nasogastric.
“Mr/Ms .., I’ll put a bee tube inside in order to monitor your urine
output, okay..?”
Note: If blood seen from meatus: NO FOLEY’S (? Urethral injury).
“Mr/Ms .., I’ll put a stomach tube through your nose to see if there
is any blood there, okay?” Only if indicated.
Indication for immediate laparotomy:
1.
1.
2.
3.
Refractory shock.
Obvious peritonitis (Rigidity).
Increasingly distended abdomen.
Positive DPL or CT
MSK:
1. Extremities: One limb at a time.
“Mr/Ms .., let me check your limbs.. Do you feel any pain?”
1- Bone and soft tissue injury: Swelling, deformity, contusion, and
tenderness.
To the examiner “No deformity, swelling, contusion, and
tenderness. No needle track marks.” … Continued
215
The Emergency Management Interview
ER Management: Cont.
2- Peripheral pulses:
Radial A., posterior tibial A., dorsalis pedis A. only. (Axillary,
brachial, ulnar, femoral, popliteal arteries if you have time). Use both
your hands at the same time bilaterally.
To the examiner “Radial, posterior tibial, and dorsalis pedis pulses
are felt and symmetrical.”
3- Sensations Screen:
“Mr/Ms ..,I’m going to feel your skin with this cotton on several
points on your body. I want you to say ‘yes’ when you feel it just
like this, okay. Let us start, close your eyes.”
Upper limb:
C6 (Radial): Dorsum of first web space (Thumb).
C7 (Median N): Index finger dorsum aspect.
C8 (Ulnar N): Little finger dorsum aspect.
Lower limb:
L5: Foot dorsum.
S2: Medial posterior thigh.
To the examiner “Normal sensations screen.”
4. Muscle tone: NOT AGAINST RESISTANCE.
Move each limb: Do flexion, extension of major joints only.
To the examiner “Normal muscle tone.”
2. Back: LOG ROLL the patient, palpate thoracic and lumbar vertebrae for
tenderness.
“Mr/Ms .., with the assistance of my colleagues here, I need to turn
you on your side to examine your back.”
To the nurse “Please, help me to log roll him/her.”
To the examiner “No injuries, deformity, swelling, point of tenderness.”
** IF Fracture:
Immobilize with splint/traction + RICE and analgesics.
** IF Open wound:
1) Irrigate with saline/ remove dirt/ foreign bodies,
2) Debride,
3) Cover with sterile gauze,
4) RICE (Rest, Ice, Compression for bleeding, Elevation),
5) Cefazolin (Kefzol) 0.5-1 g X 3 +/- Gentamycin (Garamycin),
6) Tetanus,
7) Definite care in 6- 8 hours: Suture (unless delayed, puncture wound,
and animal bites).
……………………………………………………………………………
Ask for vitals again: “What are his/her vitals, please?”
Carefully listen / read and comment: e.g. “Normal/ so, he has
fever/tachycardia/ tachypnea….”
… Continued
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The Emergency Management Interview
ER Management: Cont.
Neurological:
1. Glasgow Coma Scale (GCS): Good indication of injury severity.
Changes with time are more relevant than the absolute number.
Best Verbal
Response 5
Eyes open 4
Spontaneously
4
To voice
3
To pain
2
No response
1
Answers questions
appropriately
Confused,
disoriented
Inappropriate
words
Incomprehensible
words
Best Motor
Response 6
5
Obeys commands
6
4
Localizes to pain
5
3
2
No verbal response 1
Withdraws from
pain
Decorticate
(Flexions)
Decerebrate
(Extensions)
No motor response
4
3
2
1
Report as : Total: … + … + … + … = … E + V + M = 15
If intubated: No verbal: Total: E + M = 10 + T
13 – 15: Mild injury;
9 – 12: Moderate injury;
<= 8: Severe injury  Intubate.
“Mr/Ms .., how do you feel today? … Where are you? … What
happened?….. Move your arms..”
To the examiner “Glasgow Coma Scale is 4+5+6=15, normal.”
2. Respiratory rate and rhythm:
Watch his breathing pattern while counting.
To the examiner “Normal breathing rate at … Normal rhythm and
pattern.”
3. Full cranial nerves exam:
** IF Comatose:
- CN 2 : Visual equity cannot be done.
Visual fields: Partially done by suddenly moving objects
in front of eyes
- CN 3,4, and 6 Eye movements by :
- Doll’s eyes reflex after clearing the C-spine or
- Oculocephalic reflex (Cold caloric) before clearing C-spine
- CN 5: Corneal reflex.
- CN 7: Facial grimacing in response to painful stimuli.
- CN 9 and 10: Gag reflex.
4. Extremities sensation and motor: Sensation and tone done. … Continued
217
The Emergency Management Interview
ER Management: Cont.
5. Reflexes & Babinski,
Neck stiffness, Brudinski and Kernig signs. (AFTER CLEARING C-SPINE).
** IF Stroke:
< 3 hours: Thrombolytic at stroke center, stabilize for referral/transportation.
** IF Meningitis:
REPORTABLE
To the nurse “Send for coagulation profile: PT, PTT, and head CT;
Prepare for lumbar puncture (LP) if there is no hemorrhage;
Give:
Cefotaxime (Claforan) 2g X 3-4 (300mg/kg/d divided doess) or
Ceftriaxone (Rocephin) 2g X 2
+/- Ampicillin 2g X 4
Dexamethasone: children and adults with ICP
Phenytoin: if seizures.
Morphine: 5 mg IV every 5-10 min as needed for headache”.
** IF SAH: Call neurosurgeon
Signs of Intra-Cranial
Pressure (ICP):
Causes of Coma:
AEIOU TIPS
Acidosis /Alcohol
Epilepsy
Infection (meningitis)
Overdoes.
Uremia
Trauma (head, shock)
Insulin (too little/ too much)
Psychotic episode.
Stroke
1. Deteriorating LOC
(hallmark of ICP)
2. Deteriorating
respiratory pattern.
3. Cushing reflex:
HRBP (opposite
shock)
4. Lateralization:
unilateral cranial
nerve palsies,
Hemiparesis).
5. Seizures.
6. Papillodema (Later)
5- Definitive care
- Continue therapy; or
- Continue evaluation: Send for other investigations; or
- Consultation / OR.
- Disposition: - Send home; or admission.
- Inform the family.
END .. Wrap up
218
The Emergency Management Interview
219
The Emergency Management Interview
220
SUGGESTED READINGS

 John L. Coulehan, Marian R. Block, The medical interview, F.A. Davis
Company, 2001.

 J. Andrew Billings, John D. Stoeckle, The clinical encounter, Mosby, Inc,
1999.

 Keith Hopcroft, Vincet Forte, Symptom Sorter, Radcliffe Medical Press, 2003.

 Katrina F. Hurley, OSCE and Clinical Skills Handbook, Elsevier Sunders,
2005.

 Jo-Ann Reteguiz, Beverly Cornel-Avendano, Mastering the OSCE and CSA,
McGraw-Hill, 2002.

 Sonia Butalia, Hin Hin Ko, Catherine Lam, Jensen Tan, Essentials of clinical
examination, University of Toronto, 2006.

 Michael Swash, Hutchison’s clinical methods, W.B. Saunders Company,
2001.
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