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

1. What does my UIM attending expect on the Mini-CEX? Round 2 7/24/13

2. General Guides • The Mini-CEX, or observed history and physical exam, is a board requirement of the ABIM • The attending physician must observe you as you do portions of the history and physical. Do not ask the attending to “sign off” because you have presented the history or physical findings • Plan the Mini-CEX, tell the attending, then take the attending in the room to watch – no need to do this twice. Use Chief Complaint as your guide.

3. General Guides • Barbara Bates remains a great reference • All of your histories and physicals will be tailored to the patient’s chronic issues or chief complaints (for the rest of your life!) tell the attending what you are going to do and ask if he/she would do anything else • Get patients into gowns for anything involving a stethoscope. Nothing causes your UIM attending more angst than watching you try to auscultate anything through clothes! • You need your H&P skills for outpatient Internal Medicine – this is our main procedure • Approach patients from their right – may not always be practical

4. Mini-CEX UIM 2013

5. CV Exam • Which patients? • Any complaint with cardiovascular elements • Hypertension, CHF, CAD • Especially good if you would like to verify findings

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

7. CV Exam Tips • Feel the carotid pulse when listening to the heart • Gallops are heard best with the bell • Recall the grading system of murmurs and use this (1-6) and use “the language” • Does the murmur radiate? • Identify new murmurs, diastolic murmurs

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

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

10. Abdominal Exam • Good for any complaint of abdominal pain • Observation • Auscultate before palpation • One quadrant with bowel sounds is enough • Palpation – rebound if needed • All 4 quadrants; begin far from tender area • Liver and spleen – start at the pelvic brim • Ask patient to inhale; move your hands up after exhalation • No need to press hard! • Percussion – if needed • Special maneuvers if suspected ascites • Shifting dullness • Succussion splash • Hepatojugular reflux

11. Abdominal Exam • Percussion • Liver edge – start at pelvic brim • Used to estimate liver size • Midclavicular line 6-12 cm • Midsternal line 4-8cm

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

13. Musculoskeletal Exam

14. Musculoskeletal exam • Patients with pain in multiple areas • Patients with joint pain or stiffness • Patient with weakness

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

16. Neuro Exam – basic elements • Alertness and orientation • Gait • Cranial nerves (2-12 is sufficient) • Pupils, EOM, visual acuity, eye squeeze, eyebrow raise, show teeth, puff cheeks, bite, tongue protrusion, palatal lift, shoulder shrug • Muscle strength • Grip, biceps, triceps, hip flexors/extensors, leg flexors/extensors, plantar flexion, dorsiflexion • Reflexes – must do with an actual hammer! • Biceps, triceps, brachioradialis, patellar, Achilles, plantar • Sensation • Light touch, pinprick, temperature, vibration (cotton swab, low frequency tuning fork – the big one)

17. Pearl • Percussion and reflex testing are bouncing motions • See demonstration and practice!

18. Pelvic Exam • See website

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

20. Knee Palpation Prepatellar bursa Anserine bursa Popliteal fossa Joint line

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

22. Tests for Rotator cuff tear • Painful arc sign • Drop arm test • Weakness in external rotation

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

24. Great Resource!! • http://stanfordmedicine25.stanford.edu