Doctor and Patient Mini CEX - Teaching Points Compilation

Doctor and Patient: Integrating the Art and Science of Medicine
Nervous System Block

Class of 2018 - Fall 2014
Key Teaching Points
Muscle Weakness
A. Distinguish true muscle weakness from asthenia
I. Asthenia: patients complain of generalized weakness
II. Muscle weakness: patients complain of inability to perform certain tasks.
Terminology:Date
Hemiparesis is weakness of one side of the body.
Paraparesis is weakness of both lower extremities.
Quadriparesis is weakness of all four limbs.
III. Graded muscle strength (0-5) can help distinguish between asthenia and true muscle
weakness. For grading weakness:
0 = no contraction
1 = visible muscle twitch but no movement of the joint
2 = weak contraction insufficient to overcome gravity
3 = weak contraction able to overcome gravity but no additional resistance
4 = weak contraction able to overcome some resistance but not full
resistance
5 = normal; able to overcome full resistance
IV. The physical examination should begin to allow the localization of the lesion causing the
weakness. The broad categories are:
Upper motor neuron
Lower motor neuron (anterior horn cell, peripheral nerve)
Neuromuscular junction
Muscle
Cardiac exam can help identify etiology if emboli are involved.
V. Distinguish between upper motor neuron (UMN) and lower motor (LMN) neuron
disease
UMN: muscle tone normal or increased, reflexes increased, extensor plantar
response (a.k.a. Babinski sign) present, pronator drift, no muscle atrophy
LMN: muscle tone decreased; reflexes decreased or absent
B. Distinguish between acute and chronic muscle weakness

I. Acute muscle weakness is often an emergency (stroke, Guillain-Barre, some causes of
spinal cord compression); be sure to ask about bowel/bladder symptoms, saddle
(perineal) anaesthesia.
II. Chronic muscle weakness can usually be managed as an out-patient (polyneuropathies,
slowly progressive spinal cord compression)
C. Bulbar symptoms (difficulty holding up head, face/tongue weakness causing difficulty
speaking, swallowing, smiling): consider serious pathology (Guillain-Barre, myasthenic crisis,
brainstem CVA, etc.)

Fall 2014
Key Teaching Points
Headache
A. 90% of headaches fall under the categories of migraine, tension headache, or cluster
headache
B. Migraine headache is the most common headache to present to physicians
i. Most patients with severe episodic headache can be considered to have migraine
headaches
ii. POUNDing1 mnemonic: (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea,
Disabling)
iii. Likelihood ratios for POUNDing mnemonic:
LR for migraine HA is 24 for > 4 criteria
LR for migraine HA is 3.5 for 3 criteria
LR for migraine HA is 0.41 for 1-2 criteria
C. Most chronic headaches may be evaluated non-emergently
D. New headaches or a change in pattern of an old headache should be evaluated promptly
E. When taking history, ask about Alarm Symptoms:
i. Sudden onset/severe headache
ii. First or worst headache of patients life, first headache over age 50
iii. Focal neurologic symptoms, mental status change
iv. Fever
v. Worsening pattern
vi. History of cancer, HIV, systemic lupus erythematosus, etc.
F. When doing physical exam, look for Alarm Signs on:
i. focal neurologic signs
ii. neck stiffness or meningismus (resistance to passive neck flexion)
iii. papilledema (bilateral optic disc swelling due to increased intracranial pressure)
________________________
1
Detsky ME, McDonald DR, Baerlocher, et al. The Rational Clinical Examination: Does This Patient With Headache Have a
Migraine or Need Neuroimaging? JAMA. 2006; 296(10): 1274-1283.

Fall 2014
Key Teaching Points
Tremor
A. Major types of tremors

I. Postural and action tremor: elicited with arms suspended against gravity in a fixed
posture and with goal-directed activity
II. Resting tremor: evident when the affected body part is completely supported and at
rest and diminishes or disappears during voluntary activity.
III. Intention tremor: increases in severity as the hand moves closer to its target and
usually has a large amplitude
B. Resting tremor suggests Parkinsons Disease

I. PD presents with unilateral resting tremor and is usually accompanied by other
characteristic findings such as bradykinesia and a shuffling gait
II. PD is suggested by leg, chin, or tongue tremor
C. Action/postural tremors suggest enhanced physiologic tremor or essential tremor

I. Essential tremor is usually an action tremor and bilateral (can be asymmetric)
II. Essential tremor is suggested by head tremor
III. Essential tremor is referred to as familial tremor when there is a family history (50% of
cases; autosomal dominant)
D. Intention tremors are seen with cerebellar disease, including multiple sclerosis and stroke

Mini CEX- Nervous System Block
Fall 2014
Muscle Weakness
MENTOR: The only component of this Mini CEX to be completed in the students Societies Portfolio
is the Professionalism section below:
Professionalism:
Present /on time
Prepared (readings, etc.)
Engaged and participated
Respectful of others
Absent:
Excused
Unexcused
Comments:
Name and age of patient:
CC/HPI:
O = Onset: When did it begin? Antecedent trauma? Activities performed at onset (e.g., heavy
lifting)?
P = Position, Pattern: unilateral, bilateral? upper or lower extremities?
Q = Quality: Diffuse or focal? proximal v. distal; also ask about sidednesse.g., hemiparesis
R = Radiation (if pain) (N/A)
S = Severity: 1-10. Does weakness impair function?
T = Timing: Constant or intermittent? If intermittent, with which activities does it occur?
Does the weakness worsen later in the day or in the evening? (Myasthenia gravis)
A = Aggravating/Alleviating
a. Does your weakness get worse with exercise or at the end of the day? (Myasthenia
gravis)
D = Duration and progression of symptoms
A = Associated Symptoms
a. Is it difficult to participate in all activities? (often due to functional weakness)
b. Are there any pains that affect or contribute to your weakness (think of diseases that
cause muscle or joint pain such as arthritis)
c. Do you have any numbness or tingling associated with your weakness? (MS, CVA,
polyneuropathies)
d. Can you see your muscles twitching? (ALS)
e. Is the weakness confined to 1 side of body (stroke, TIA)?
f. Is there dysarthria, dysphagia, diplopia or other vision change?
Previous evaluation and treatment
Past Medical & Past Surgical History

Current medications: Aspirin, oral contraceptives or hormone replacement therapy
(depending on gender/age)
Allergies:
Following associated with mononeuritis, polyneuropathies, and ischemic stroke:
1. Diabetes
2. Thyroid disease (hypothyroidism)
Following associated with ischemic stroke:
1. Hypertension
2. Hypercholesterolemia/dyslipidemia
3. History of cigarette smoking
4. Prior stroke or TIA
5. Prior cervical or lumbar disk disease (for upper or lower extremity weakness)
6. Cancer (spinal cord involvement)
Family History:
1. stroke or neurologic disease
2. hypertension
Social History:
High Risk Behaviors/Habits:
Physical Examination: washed hands first

1. Inspection of the muscle
a. Atrophy
b. Enlargement
c. Fasciculations
d. Ptosis
2. Palpation
a. Muscle tenderness
b. Increased tone or rigidity
3. Motor exam (muscle strength testing) using scale of 0-5.
4. Ascertain distribution of weakness (hemiparesis v. proximal or distal if bilateral)
5. Assessment of motor function (e.g., timed 50 foot walk)
6. Deep tendon reflexes
7. Screening neurologic exam
a. Reflexes (biceps, triceps, brachioradialis, knee, ankle, Babinski /plantar response)
b. Motor strength and sensation: upper and lower extremities
c. Cerebellar function (coordination)
I. Finger tapping
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II.
Rapid alternating movements
III.
Finger-to-nose
IV. Heel-to-shin (supine position preferred)
d. Cranial Nerves:
I. Olfactory not usually tested; ask if change in sense of smell
II.
Optic
1. Visual acuity (note whether or not tested with glasses on)
2. Visual fields (by confrontation)
3. Funduscopic exam/optic nerve and retinal vessels
III.
Oculomotor , IV. Trochlear, and V. Abducens
1. Eye movements
2. Pupillary light reflexes
VI.
Trigeminal
1. Corneal reflex-sensory limb of ocular branch (not usually done)
2. Facial sensation (light touch in all 3 trigeminal areas)
3. Motor: jaw strength; open and close against resistance
VII. Facial
1. Facial expression muscles: smile/bare teeth, puff out cheeks, wrinkle
forehead, close eyes against resistance
VIII. Vestibulocochlear
1. Hearing to finger rub or whisper
IX. Glossopharyngeal
1. Ask patient to say aaah: check for symmetric elevation of soft palate
X. Vagus
1. Swallowing, phonation; also tested during mouth exam
XI. Spinal accessory
1. Head, neck, shoulder movements: move head against resistance, shrug
shoulders against resistance
XII. Hypoglossal
1. Tongue movements (stick out tongue, observe for asymmetry)
8. Cardiac examination (sitting and supine)

a. Inspection
b. Palpation of PMI
c. Auscultation
i. Sitting
ii. Supine
iii. Left lateral decubitus (S3, S4, mitral stenosis)
9. Carotid exam

Fall 2014
Headache
MENTOR: The only component of this Mini CEX to be completed in the students Societies Portfolio is
the Professionalism section below:
Professionalism:
Present /on time
Absent:
Excused
Unexcused
Comments:

CC/HPI:
O = Onset: When did this headache begin? First headache ever?
P = Position, Pattern: one-sided, band-like?
Q = Quality: sharp/stabbing, dull, heavy, throbbing?
R = Radiation (if pain)
S = Severity: 1-10
T = Timing: with what activities does it occur? How quickly did this HA reach maximum pain
intensity level?
A = Aggravating/Alleviating: what makes it better/worse? Activity worsened? Have you
tried any medication?
a. Migraine:
i. Is there an aura?
ii. Are there scotomata or sensory/motor symptoms?
iii. Photophobia, phonophobia
b. Temporal Arteritis:
i. Visual loss/eye pain/diplopia
ii. Proximal muscle pain, jaw claudication
c. Brain tumor:
i. Weakness/disequilibrium/neurologic symptoms
ii. Confusion or lethargy
iii. New onset seizure
iv. New onset after age 50
v. Nocturnal awakenings due to pain
vi. Worse with valsalva
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vii. Nausea/vomiting
viii. History of malignancy
d. Meningitis:
i. Fever
ii. Neck pain/stiffness
e. Subarachnoid hemorrhage:
i. Family history of migraine headache or subarachnoid hemorrhage
ii. Thunderclap headache/onset with exertion
f. Cluster headache:
i. Runny nose, nasal congestion, lacrimation, ptosis, conjunctival injection
ii. Headache around the eye

Current medications:
Use of headache medications: NSAID, Acetaminophen, prescription pain medications, or
prescription migraine medications
Allergies:
Family History:
a. migraine headaches
b. CNS aneurysm or subarachnoid hemorrhage
Social History:

a. Use of stimulants (methamphetamine, cocaine)
b. Abrupt cessation of caffeine
Physical Examination: washed hands first, cleaned stethoscope

1. Vital signs (note or perform)
2. Cranial nerve exam
a. CN I (change in sense of smell)
b. CN II (visual acuity, visual fields, funduscopic exam to observe for venous pulsations )
c. CN III, IV, VI (extraocular movements, papillary light reflex [II/III])
d. CN V (sensation of face, chewing movements)
e. CN VII (facial expression)
f. CN VIII (hearing)
g. CN IX/X (symmetric elevation of soft palate)
h. CN XI (head, neck, shoulder movements)
i. CN XII (tongue movements)
3. Palpate temporal arteries (particularly if age > 50)
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4. Palpate neck and shoulder muscles

5. Screening motor examination
__Involuntary movements
__Muscle bulk
__Muscle tone
__Muscle strength
6. Screening sensory examination
__Pain
__Vibration
__Position
__Light touch
__Stereognosis
7. Reflexes
__Biceps
__Triceps
__Brachioradialis
__Knee
__Ankle
__Babinski/plantar response
8. Cerebellar examination
__Finger tapping
__Rapid alternating movements
__Finger-to-nose
__Heel-to-shin (supine position preferred)
9. Gait
__Walk normally
__Walk on heels
__Walk on toes
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Class of 2018 - Fall 2014
Tremor
Professionalism:
Present /on time
Absent:
Excused
Unexcused
Comments:
Name and age of patient

CC/HPI:
O = Onset: did the tremor start gradually or abruptly?
P = Position, Pattern: which parts of the body are affected by the tremor?
Q = Quality:
a. Does the tremor occur at rest (Parkinsons)
b. Does the tremor occur with action (action tremor, essential tremor, cerebellar
pathology, toxins)
c. Does the tremor interfere with daily activities? (e.g., handwriting, eating from
spoon, drinking)
R = Radiation (if pain)
S = Severity (1-10)
T = Timing: with what activities does it occur?
A = Aggravating/Alleviating: Does stress, anxiety, or fatigue increase or decrease the
tremor? (can occur with all tremor types)
a. Does alcohol decrease the tremor?
b. Does alcohol improve the tremor? (65-70% of patients with essential tremor report
improvement with alcohol)
c. Does CAFFEINE make tremor worse?
a. Gait disturbance or falls (Parkinsons or secondary to neuroleptic medication)
b. Neurologic symptoms (muscle weakness, etc.)
c. Hyperthyroid symptoms (heat intolerance, weight loss, etc.)
d. Cognitive dysfunction (Parkinsons disease dementia)
e. Any changes in sense of taste/smell?
Previous evaluation and treatment.
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a. Prescription drugs: (theophylline, albuterol, valproic acid, and selective serotonin
uptake inhibitors can (among others) can cause postural/action tremors)
Allergies:
Family History: is there a family history of tremor?
Social History:

1. Alcohol use
2. Tobacco use
3. Amphetamine use
4. Caffeine intake
Caffeine, nicotine, and amphetamines may have an adrenergic enhancing effect (NOT
alcohol).
Physical Examination- washed hands first, cleaned stethoscope
1. Screening Neurologic Exam
a. Finger tapping
b. Rapid alternating movements
c. Finger-to-nose testing
d. Reflexes (biceps, triceps, brachioradialis, knee, ankle, extensor plantar response
[a.k.a. Babinski sign] is present)
e. Motor strength and sensation: upper and lower extremities
f. Cerebellar function
i. Finger tapping
ii. Rapid alternating movements
iii. Finger-to-nose
iv. Heel-to-shin (supine position preferred)
2. Thyroid Exam
3. Observation of the tremor
a. At rest
b. With action
4. Observation of gait and stability
5. Motor exam
a. Check for increased muscle tone (rigidity)
b. Check for slowed movements (bradykinesia)
c. Muscle strength
6. Mini-Cog
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Doctor and Patient Course

Musculoskeletal Lab- Teaching Points
Class of 2018 - Spring 2015
Knee Pain
1. General approach to knee pain
a. Traumatic vs. non-traumatic
i. Traumatic: high energy (e.g., MVA) vs. low energy (e.g., slip and fall)
b. Extrinsic vs. intrinsic
i. Extrinsic: disorders of the lumbosacral spine, sacroiliac joints, hips, femur;
claudication
c. Intrinsic: periarticular vs. articular
i. Periarticular: patellofemoral pain syndrome, bursitis (anserine, prepatellar,
infrapatellar), medial or lateral collateral ligamentous injury, iliotibial band
syndrome, popliteal (Bakers) cyst, DVT
d. Articular: structural vs. inflammatory
i. Structural: meniscal tear, anterior cruciate ligament rupture, etc.
ii. Inflammatory: gout, pseudogout, septic arthritis, rheumatoid arthritis, etc.
2. Medial knee pain is most common: medial compartment osteoarthritis, medial meniscal tear,
medial collateral ligament strain, anserine bursitis
3. Anterior knee pain is second most common: patellofemoral syndrome, advanced osteoarthritis
involving all knee compartments, prepatellar bursitis, inflammatory arthritis
4. Patellofemoral syndrome is one of the most common causes of knee pain presenting to
physicians
a. Definition: anterior knee pain involving the patella and retinaculum without other
intraarticular and peripatellar pathology; thus, it is a diagnosis of exclusion
b. Most commonly occurs in active adolescents and adults in the second and third decades
of life
c. No consensus exists about its etiology or the factors most responsible for causing pain.
Overuse, patellar malalignment, and trauma are commonly cited causative factors.
d. Treatment: activity modification, short-term use of NSAIDs for the acute phase,
rehabilitation, particularly of vastus medialis aspect of quadriceps musculature.
Reference: UpToDate, version 25.0
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Musculoskeletal Lab - Key Teaching Points
Arm and Hand Pain
1. The anatomy of the hand is complicated. Understanding bony anatomy and tendinous
attachments and insertions can help explain patient hand problems.
2. Osteoarthritis (OA) of the hands is a common disorder, most often presenting in patients over
40 years of age. Pain is typically exacerbated by activity and relieved by rest and generally
affects distal joints of the hands, e.g., DIP.
3. Rheumatoid Arthritis (RA) is more insidious in onset. Hand involvement is common, especially
the proximal joints, e.g., MCP, PIP. Morning stiffness or stiffness after any prolonged period of
inactivity is seen in virtually all inflammatory arthropathies.
4. Dupuytren's contracture is a relatively common disorder that presents as a nodular fibrosing
lesion within the palmar fascia and related structures.
5. Alarm features include:
a. Is there weakness, numbness, burning or tingling?
b. Are there neck complaints?
c. Is there redness or fever?
d. Is there swelling?
e. With arm complaints is it associated with chest pain or shortness of breath?
6. A comprehensive hand examination is the most important method of evaluating patients
complaining of generalized hand arthralgia. Radiographic and serologic testing are nearly always
normal unless the specific maneuvers of the hand demonstrate objective findings of bony
enlargement, synovial thickening, or joint swelling.
7. An efficient screening examination for RA includes general hand inspection, grip measurement,
palpation of the PIP joints for tenderness, the MP squeeze sign, extension and flexion of the
wrists.
8. Tenosynovitis of the flexor tendons always precedes the mechanical symptoms of triggering.
However, not all patients demonstrate active tenosynovitis at the time they are examined. As
the patient tries to avoid the triggering phenomenon (by using the finger less and less), the
tenosynovial signs gradually subside, leaving the patient with a relatively painless mechanical
triggering. In some cases flexor tenosynovitis and mechanical triggering can be so dramatic as
to preclude movement of the finger from a flexed position; this is referred to as a "fixed locked"
digit.
9. Despite their size, tendon cysts rarely lead to mechanical dysfunction.
15

Musculoskeletal Lab - Key Teaching Points
Low Back Pain
1. Acute low back pain: back pain present for < 4 weeks
2. Chronic low back pain: back pain present for > 3 months
3. Classification of low back pain (see table in UpToDate)
a. Mechanical
i. Lumbar strain
ii. Degenerative disease
iii. Spondylolisthesis
iv. Herniated disc
v. Osteoporosis
vi. Fractures
vii. Congenital disease
b. Non-mechanical/inflammatory
i. Neoplasia
ii. Infection
iii. Inflammatory arthritis (HLA-B27)
c. Visceral Disease/referred pain
i. Pelvic disease
ii. Renal disease
iii. Aortic aneurysm
iv. Gastrointestinal disease
4. Most patients with acute low back pain have non-specific lumbar muscle strain
5. Red flags suggest a more serious etiology
a. Recent trauma
b. Weight loss
c. Nocturnal symptoms
d. Fever
e. Immunosuppression
f. History of cancer
g. IV drug use
h. Osteoporosis/prolonged steroid use
i. Age > 70 (some guidelines > 50) or < 18 (more likely to have a secondary cause)
j. Focal neurologic deficit or progressive/disabling symptoms (especially incontinence,
saddle anesthesia- cauda sx/sx)
k. Duration > 6 weeks
6. History focuses on duration, red flags, radicular symptoms, neurologic symptoms
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7. Physical exam focus is on inspection of back, range of motion, palpation/percussion of the spine,
straight leg raising, neurologic assessment of L4, L5, S1 roots, and peripheral pulses in older
patients with exertional calf pain
a. > 90% of disc herniations occur at L4/L5 or L5/S1 level
b. Ipsilateral straight leg raise has good sensitivity but poor specificity for disc herniation;
contralateral (crossed) straight leg maneuver has good specificity (90%) but poor
sensitivity for disc herniation
c. L4: quadriceps extension, patellar reflex, dermatome
d. L5: dorsiflexion of great toe/foot (heel walking), dermatome
e. S1: plantar flexion of great toe/foot (toe walking), Achilles reflex, dermatome
8. Cauda equina syndrome is acute compressive neuropathy of the nerves that comprise the cauda
equine. Symptoms include urinary retention with overflow incontinence, fecal incontinence
(decreased rectal tone on exam) and saddle anesthesia, bilateral sciatica, and leg weakness.
The cauda equina is very rare but is a medical emergency.
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Doctor and Patient Course: Integrating the Art and Science of Medicine
Mini CEX- Musculoskeletal Block
Knee Pain
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
Name & age of patient:
CC/HPI:
O = Onset
P = Position, pattern
Q = Quality
R = Radiation
S = Severity (1-10)
T = Timing
A = Aggravating/alleviating factors (including medications)
D = Duration
a. Knee locking/giving way
b. Popping, clicking, grinding
c. Warm to touch/red/swollen
d. Fever
e. Leg weakness/numbness
Preceding trauma
Limitation in regular activity
Past Medical & Past Surgical History:
Current medications
Allergies
Previous knee trauma or surgery
History of blood clots
Family History:
Venous Thromboembolism
Inflammatory arthritis (HLA-B27)
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Social History:
High Risk Behavior/Habits:

Sexually active
Past work/sports participation
A. Observation (patient standing)
1. Expose lower limb
2. Observe patient walking at least 15 feet in a customary gait and observed from all sides
B. Palpation (patient seated with knees flexed and relaxed)
1. Tibial tubercle
2. Patellar tendon
3. Tibiofemoral joint margins
4. Medial & lateral joint lines and menisci
Palpation (patient supine and knee extended & relaxed)
5. Patella & patellar tendon- test integrity with leg extension
6. Lateral retinaculum
7. Medial and Lateral joint line with knee flexed and relaxed
8. Medial collateral ligament
9. Lateral collateral ligament
10. Checked patello-femoral joint for crepitus
11. Moved patellae medially, laterally, superiorly and inferiorly
12. Performed bulge or ballottement test for joint effusion
C. Range of motion
1. Measured knee extension, actively
2. Measured passively if extension is not within normal limits
3. Measured knee flexion, actively
4. Measured passively if flexion is not within normal limits
D. Assessed ligamentous stability
1. Medial collateral ligament with knee in full extension and flexed 30
2. Lateral collateral ligament with knee in full extension and flexed 30
3. Anterior cruciate ligament using Lachman test
4. Anterior cruciate ligament using Anterior Drawer test
5. Posterior cruciate ligament using Posterior Drawer test
E. Performed meniscal maneuvers
1. Medial meniscus using McMurrays test
2. Lateral meniscus using McMurrays test
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Mini CEX-Musculoskeletal Block
Hand Pain
Professionalism Was the student:
Present/on time
Absent:
Excused
Unexcused
Comments:
CC/HPI:
O= Onset of pain
P= Position, pattern
Q= Quality of pain
R= Radiation of pain
S= Severity (1-10)
T= Timing
A=Aggravating/alleviating factors (including medications)
a. Use of hands at work or at home; better/worse with rest/activity
D=Duration
A= Associated Symptoms
a. Associated/alarm symptoms or history
b. If arm complaint is it associated with chest pain or shortness of breath?
c. Weakness, numbness, burning, or tingling
d. Neck pain or decreased ROM
e. Redness
f. Swelling
Preceding trauma
Previous symptoms or evaluations and treatments
Allergies:
History of RA, osteoarthritis, or other arthropathy
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Family History:
Family History of RA
Social History:
High Risk Behavior/Habits:

Hand
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Palpate C-MC joint of the thumbs

Palpate MCP joints of all digits
Palpate IP joints of the thumbs
Palpate PIP joints of all fingers
Palpate DIP joints of all fingers
Palpate palmar fascia and tendons
Range of Motion: Making fist with thumb across
Range of Motion: Making a claw by flexing the PIP and DIP joints
Range of Motion: Extension & spread of fingers
Grip strength
Wrist
1. Palpate soft tissue and carpal bones
2. Palpate distal radius/ulna including radial & ulnar styloid & anatomical snuffbox (clinical
association with scaphoid bone)
3. Range of Motion: Flexion
4. Range of Motion: Extension
5. Range of Motion: Ulnar Deviation (Adduction)
6. Range of Motion: Radial Deviation (Abduction)
7. Perform tests for Tinels Sign and Phalens Sign (if indicated)
Elbow
1.
2.
3.
4.
5.
6.
Palpate lateral and medial epicondyles

Palpate olecranon process, bursa and fossa
Range of Motion: Flexion
Range of Motion: Extension
Range of Motion: Supination
Range of Motion: Pronation
21
Mini CEX- Musculoskeletal Block
Low Back Pain
MENTOR: The only component of this Mini CEX to be completed in the students Societies
Portfolio is the Professionalism section below:
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC/HPI:
O= Onset
P= Position, Pattern
Q= Quality
R= Radiation
S= Severity (1-10)
T= Timing (with what activities does it occur)
A= Aggravating/Alleviating (including medications)
D= Duration
A= Associated Symptoms
a. Fevers/Chills
b. Dysuria
c. Abdominal pain
d. Unintentional weight loss
e. Weakness/numbness
f. Fecal or urinary (overflow) incontinence
g. Gait disturbance
h. Pain at rest
i. Nocturnal symptoms
Preceding trauma
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Past steroid use
Allergies
History of malignancy
Osteoporosis
Recent intravenous catheter
Immunocompromised state (chemotherapy, HIV, etc.)
Family History:
Social History:
1. Current or past IVDA
1. Vital signs
2. Musculoskeletal
a. Evaluation of movement and gait
b. Inspection of spine and posture
c. Palpation of spine and paraspinal muscles
d. Straight leg raise test
3. Neurologic exam
Motor Strength
e. Quadriceps strength (knee extension) L3/L4
f. Dorsiflexion of ankle and great toe and/or heel walk L4/L5
g. Ankle/foot plantar flexion or toe walk - S1
Light touch sensation
h. Anterior thigh and medial ankle/foot L4
i. Anterior/lateral calf and webspace between 1st and 2nd toe L5
j. Lateral plantar foot and posterior calf S1
4. Deep Tendon Reflexes
k. Patellar reflex L3/L4
l. Achilles reflex S1
5. Rectal tone and perineal sensation (if indicated cauda equina syndrome)
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Cardiovascular Lab Key Teaching Points
Class of 2018 Spring 2015
1. Palpitations
a. Common causes for palpitations are:
i. Cardiac (arrthymias, valvular heart disease, etc.)
ii. Psychiatric (panic disorder, anxiety, depression)
iii. Miscellaneous (habits, medications, thyrotoxicosis, etc.)
b. Although psychiatric disorders are a common cause of palpitations, other possibilities
should be considered and ruled out before accepting psychiatric illness as the only cause.
c. Patients with known structural heart disease (coronary heart disease/MI, cardiomyopathy)
are at increased risk for a serious cause for symptoms of palpitations (e.g., ventricular
tachycardia).
d. Alarm symptoms should prompt a more thorough evaluation: chest pain, syncope or
presyncope, shortness of breath.
e. Evaluation
i.
History & Physical exam
ii.
12-lead ECG
iii.
TSH and CBC to evaluate for hyperthyroidism and anemia (reasonable
but not evidence-based)
iv.
In selected patients: ambulatory monitoring, echocardiogram,
electrophysiologic study
2. Chest pain
a. Most patients who present with chest pain do not have a cardiac cause for their
symptoms.
b. Chest pain due to myocardial ischemia, pulmonary embolus, aortic dissection, or tension
pneumothorax can result in sudden death; thus, these conditions should always be
considered in a patient presenting with chest pain.
i. In most cases, a serious cause for chest pain can be excluded based on the history
and physical alone without further diagnostic testing.
ii. If you suspect one of the above conditions, the patient needs to be evaluated in an
emergency department.
c. A patients probability of having coronary heart disease can be calculated using
traditional risk factors (1):
i. Age > 45 for men, > 55 for women
ii. Dyslipidemia
iii. Hypertension (BP > 140/90 or taking anti-hypertensive medication)
iv. Diabetes Mellitus (considered a coronary heart disease equivalent)
v. Current cigarette smoking
vi. Family history of premature CHD (first degree female relative with CHD before
age 65 or a first degree male relative with CHD before age 55)
d. Typical angina is substernal chest discomfort with a characteristic quality (pressure or
squeezing or heaviness; not sharp or stabbing), provoked by exertion or emotional stress,
and relieved by rest or nitroglycerin.
i. Women with CHD are much less likely than men to present with typical angina
and may describe their discomfort as sharp or burning.
e. Descriptions of pain increasing the likelihood for MI include right arm or shoulder
radiation, radiation to both arms or shoulders, an exertional nature, and left arm radiation
(2)
.
24
f.
Descriptions of pain decreasing the likelihood for MI include a pleuritic nature, a

positional component, a sharp nature, and reproducibility by palpation (2).
3. Edema
a. Edema is usually caused by one or more of the following physiologic effects:
i. Increased capillary hydrostatic pressure (e.g., heart failure)
ii. Decreased capillary oncotic pressure (e.g., hypoalbuminemia)
iii. Increased capillary permeability (e.g., anaphylaxis)
b. Generalized edema is caused by one or more of the above effects plus retention of salt
and water by the kidneys.
c. It is important to determine the location and nature of the edema:
i. Generalized vs. localized, pulmonary, peripheral, ascites
ii. Distribution in limbs, bilateral vs. unilateral
d. Serious causes for edema include heart failure, cirrhosis, venous thrombembolism, renal
failure, nephrotic syndrome, and anaphylaxis.
e. Heart failure is suggested by (3):
i. Historical items: history of heart failure, myocardial infarction, or coronary heart
disease
ii. Symptoms: paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion
iii. Physical exam: elevated jugular venous pressure, pulmonary crackles (if
acute/subacute), peripheral edema (if chronic or has component of right heart
failure), a third heart sound
f. Heart failure (HF) is divided into two main categories: HF with reduced LV ejection
fraction (HFrEF, and HF with preserved LV ejection fraction (HFpEF, sometimes
referred to as diastolic HF).
g. In acute or subacute heart failure, pulmonary edema, dyspnea, orthopnea and paroxysmal
dyspnea predominate.
h. In chronic heart failure, peripheral edema and fatigue may predominate over respiratory
symptoms.
i. Common causes of HFrEF are coronary heart disease, idiopathic dilated cardiomyopathy,
hypertension, and valvular heart disease.
j. Common causes of HFpEF are hypertension, ischemic heart disease, hypertrophic
obstructive cardiomyopathy, and restrictive cardiomyopathy.
References
1. Multiple cardiac risk calculators are available free of charge on line
(http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof) or for smartphones (Qx
Calculate).
2. Swap CJ, Nagurney JT. Value and Limitations of Chest Pain History in the Evaluation of
Patients With Suspected Acute Coronary Syndromes. JAMA. 2005; 294:2623-2629.
3. Wang, C, et al. The Rational Clinical Examination: Does This Dyspneic Patient in the
Emergency Department Have Congestive Heart Failure? JAMA. 2005; 294:1944-1956.
25

Mini-CEX-CPR Block
Class of 2018-Spring 2015
Palpitations
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC/HPI:
O = Onset/Offset
a. Gradual vs. abrupt
P = Position, Pattern
a. Positional component
b. Regular vs. irregular
c. Tap out rhythm of the palpitations
Q = Quality (description)
a. Fluttering, racing, slow, pounding/flip-flopping, etc.
R = Radiation
a. To neck
S = Severity
T = Timing (with what activities does it occur?)
a. Are symptoms terminated by valsalva or rubbing neck?
D = Duration
a. Anxiety
b. Alarm symptoms
i. Syncope or pre-syncope
ii. Chest pain
iii. Shortness of breath
iv. Focal neurologic symptoms: paresthesias, weakness, diplopia, dysarthria,
dysphagia (atrial fibrillation)
26

Current medications
1. General
2. Levothyroxine
3. Beta-blockers recently stopped
Allergies
Coronary heart disease, CHF, valvular heart disease
Hypertension
Thyroid disease
Diabetes Mellitus
Psychiatric illness
Family History:
Social History
Caffeine intake
High Risk Behaviors:
Nicotine
Cocaine
Amphetamines
General appearance
Vital signs
Neck: examination of the thyroid
Cardiac examination (sitting and supine)
a. Inspection
b. Palpation of PMI
c. Auscultation
iv.
v.
vi.
Sitting
Supine
Left lateral decubitus (S3, S4, mitral stenosis)
d. Examination of jugular veins

i.
Pattern
ii.
Estimate jugular venous pressure
Pulmonary examination
a. Auscultation- anterior, posterior, lateral
b. Percussion- anterior, posterior, lateral
Neurologic examination
a. Observation for tremor
b. Reflexes
i.
Biceps
ii.
Brachioradialis
27
iii.
Triceps
iv.
Patella
v.
Achilles
Extremities
a. Assessment of edema
b. Pulses: posterior tibial, dorsalis pedis
28

Mini-CEX-CPR Block
Chest Pain
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:

CC/HPI:
O = Onset
a. Antecedent trauma
P = Position, Pattern, Location
Q = Quality (description)
a. Pressure, aching, tearing, sharp, pleuritic, etc.
R = Radiation
a. Jaw, neck
b. Left and/or right arms
c. Back
d. Epigastrium
S = Severity (1-10)
T = Timing (with what activities does it occur)
A = Aggravating
a. Exercise
b. Stress
c. Eating
d. Laying down
A = Alleviating
a. Rest
b. Nitroglycerin
c. Sitting up/leaning forward
d. Antacids
D = Duration
a. Nausea/vomiting
b. Diaphoresis
c. Syncope or pre-syncope
29
d. Dyspnea
e. Cough
f. Hemoptysis
g. Fever/Chills
Current medications
Allergies
Coronary Heart Disease
Diabetes Mellitus
Hypertension
Dyslipidemia
Peripheral arterial disease
Chronic Kidney Disease
Previous venous thromboembolism
Family History:
1. Premature CHD
2. Venous thromboembolism
Social History:
1. Tobacco
2. Cocaine
1. General Appearance
2. Vital signs and if possible Body Mass Index
a. BP in both arms if aortic dissection is being considered
3. Cardiovascular examination
a. Inspection of chest wall including skin for rashes
b. Palpation of chest wall (reproducibility of chest pain) and PMI
c. Auscultation
i. Sitting
ii. Supine
iii. Left lateral decubitus (S3, S4, mitral stenosis)
d. Jugular venous pressure
e. Hepatojugular reflux/ abdominojugular test
4. Pulmonary examination
a. Auscultation: anterior, posterior, lateral
b. Percussion: anterior, posterior, lateral
5. Abdominal examination
a. Auscultation
b. Palpation, light and deep
c. Palpation of the aorta
30
6. Extremities
a. Pulses
i. Radial (note symmetry)
ii. Posterior tibial, dorsalis pedis
b. Assessment of edema
31

Mini-CEX-CPR Block
Edema
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC/HPI:
O = Onset: When did it begin?
P = Position, Pattern, Location
a. Unilateral vs. bilateral
b. Peripheral vs. central or diffuse
Q = Quality N/A
R = Radiation N/A
S = Severity
T = Timing (with what activities does it occur?)
a. Intermittent vs. persistent
b. All day vs. present in the evening, etc.
D = Duration
a. Progression
A = Associated Symptoms (in addition to those in other categories)
a. General (occurs with multiple etiologies):
i. Weight gain; if so, time frame
ii. Shortness of breath/dyspnea on exertion
iii. Urine output
b. Allergy and anaphylaxis
i. Sensation of swelling in throat/lips
c. Congestive heart failure
i. Waking up at night short of breath (paroxysmal nocturnal dyspnea)
ii. Sleeping with head raised up (orthopnea)
d. Venous thromboembolism
i. Unilateral leg edema/pain
ii. Pleuritic chest pain
iii. Hemoptysis
32
iv. Recent immobility

e. Cirrhosis
i. Abdominal distension
ii. Jaundice (skin/eyes)
Current Medications:
1. General
2. Calcium-channel blockers
3. NSAIDs
4. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (especially
recently prescribed)
Allergies
Coronary Heart Disease and/or CHF
Hypertension
Valvular heart disease or rheumatic fever
Kidney disease
Diabetes Mellitus
Liver disease, hepatitis B/C
Venous thromboembolism (PE or DVT)
Malignancy
Recent surgery
Family History:
a. Venous thromboembolism
b. Premature CHD
Social History:
a. Diet: sodium intake (restaurants, processed foods)
a. Alcohol intake
b. IVDA
1. General appearance
2. Vital signs
3. Cardiac examination
a. Inspection
b. Palpation of PMI
c. Auscultation
i.
Sitting
ii.
Supine
iii.
Left lateral decubitus (S3, S4, mitral stenosis)
iv.
Jugular venous pressure
v.
Hepatojugular reflux/abdominojugular test
33
4. Pulmonary examination
a. Auscultation: anterior, posterior, lateral
b. Percussion: anterior, posterior, lateral
5. Abdominal examination
a. Inspection: caput medusa, distension
b. Auscultation
c. Palpation, light and deep
i. Palpate liver edge using correct technique
ii. Check for splenomegaly
d. Percussion
i. Liver span
ii. Traubes space/ Castells sign (splenomegaly)
6. Extremities
a. Check for edema
i. Check for pre-sacral edema
34
Pulmonary Lab Key Teaching Points

Class of 2018- Spring 2015
1. Cough
a. Cough is classified as follows:
i. Acute cough: less than 3 weeks duration
ii. Subacute cough: between 3 and 8 weeks duration
iii. Chronic cough: 8 or more weeks in duration
iv. Some sources simplify the classification: acute cough < 3 weeks duration;
chronic cough > 3 weeks duration
b. Acute cough is often caused by an acute respiratory infection
c. Subacute cough can be post-infectious; a cough can last up to 8 weeks following
a respiratory infection. Mechanisms include:
i. Post-nasal drip
ii. Enhanced sensitivity of airway nerves
iii. Bronchial hyperresponsiveness due to inflammation following a viral
respiratory infection
d. Chronic cough is most commonly due to:
i. Upper airway cough syndrome (post-nasal drip)
Allergic and perennial non-allergic rhinitis
Vasomotor rhinitis
Chronic sinusitis
ii. Chronic bronchitis (usually smoking history), Bronchiectasis,
Asthma (accompanied by typical wheezing and dyspnea or coughvariant asthma)
iii. Gastroesophageal reflux disease (either with or without typical heartburn
symptoms)
e. Also consider:
i. Angiotensin converting enzyme inhibitors (accumulation of bradykinin)
ii. Pertussis (adolescents and adults; the incidence is increasing in this age
group, and a booster vaccine is available)
f. Lung cancer, which needs to be considered in former/current smokers and in
older patients, is the most feared etiology for chronic cough but is responsible for
< 2% of cases.
2. Dyspnea
a. Dyspnea can be caused by:
i. Primary pulmonary causes (e.g., asthma, COPD, pulmonary embolism,
infection, pneumothorax)
ii. Primary cardiac causes (e.g., congestive heart failure, aortic stenosis,
pulmonary hypertension)
iii. Neuromuscular disease (e.g., myasthenia gravis)
iv. Metabolic causes
Anemia
Metabolic acidosis with respiratory compensation
v. Functional dyspnea (panic disorders)
vi. Deconditioning
35
b. Acute dyspnea evolving over minutes to hours needs to be evaluated promptly.

The causes of acute dyspnea (and examples of associated ROS, symptoms, and
signs) include:
i. Acute myocardial ischemia (substernal chest pressure, risk factors)
ii. Congestive heart failure/pulmonary edema (orthopnea, paroxysmal
nocturnal dyspnea, pulmonary crackles)
iii. Acute cardiac tamponade (chest pain, tachycardia, tachypnea, elevated
jugular venous pressure)
iv. Bronchospasm (wheezing on exam)
v. Pulmonary embolism (pleuritic chest pain, hemoptysis, tachypnea,
tachycardia, hypercoagulable risk factors)
vi. Pneumonia (fever, productive cough)
vii. Upper airway obstruction (aspiration, anaphylaxis)
c. Chronic dyspnea evolving over weeks to months is most commonly due to:
i. Asthma (wheezing, cough)
ii. Chronic obstructive lung disease (> 20 pack years of tobacco use, chronic
cough)
iii. Interstitial lung disease (dry chronic cough, fine Velcro pulmonary
crackles)
iv. Chronic Congestive heart failure/cardiomyopathy (edema, elevated
jugular venous pressure, fatigue)
d. It is important to think about which historical items and which parts of the
physical exam can help you narrow the above differential diagnoses.
3. Hemoptysis
a. The high pressure bronchial arteries are generally a more important source of
hemoptysis than the low pressure pulmonary arteries.
b. Blood originating from the upper respiratory tract and the upper gastrointestinal
tract can mimic hemoptysis.
i. Upper gastrointestinal source is suggested by nausea and vomiting,
history of peptic ulcer disease or liver disease, and lack of cough.
c. Hemoptysis arises from one of three main anatomical locations. These are listed
below with examples (not for memorization):
i. Airways diseases (most common)
bronchitis and bronchiectasis, neoplasms (primary lung cancer or
metastatic disease), foreign body, airway trauma
ii. Pulmonary parenchymal diseases
infection (pneumonia, TB, lung abscess),
vasculitis/inflammatory/immune diseases (e.g., Goodpastures
Syndrome, Wegners granulomatosis, lupus pneumonitis, etc.),
iatrogenic following lung biopsy, coagulopathy, drugs (cocaine).
iii. Pulmonary vascular disorders
pulmonary embolism, pulmonary arteriovenous malformation,
elevated pulmonary capillary pressure (e.g., mitral stenosis)
36
d. The initial evaluation of an adult with hemoptysis should include a history and
physical exam (focusing on the above differential diagnoses) and a chest
radiograph. Up to 30% of patients will have idiopathic or cryptogenic
hemoptysis with no clear cause identified even after extensive work up including
bronchoscopy.
37

Mini-CEX-CPR/Pulmonary Block
Chronic Cough
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC/HPI:
O = Onset
Does the cough occur lying down?
Q = Quality
Dry vs. productive
R = Radiation N/A
S = Severity
D = Duration
1. Hemoptysis
2. Shortness of breath
3. Lower extremity edema
4. Fever, chills
5. Wheezing
6. Rhinitis/post-nasal drip/nasal congestion
7. Recent upper respiratory tract infection
8. Heartburn/GERD symptoms
38

Current meds:
1. General
2. Angiotensin-converting enzyme inhibitors
3. Recently added medications
Allergies
1. Allergic rhinitis/seasonal allergies
Hypertension
CHD/CHF
Asthma/COPD
Previous pneumonia; if so, when
GERD
Sinusitis (recent, recurrent, chronic)
Family History:
Social History:
Tobacco use
Physical Examination: washed hands and cleaned stethoscope
General appearance
Vital signs including respiratory rate
HEENT examination
1. Nasal passages for congestion, drainage
2. Throat
3. Ears (otoscope)
4. Sinus palpation and transillumination (if appropriate)
Neck/adenopathy
1. Inspection (anterior-posterior diameter)
2. Palpation-as appropriate (confirm midline trachea, confirm symmetrical chest
expansion, assess tactile fremitus)
3. Percussion: anterior, posterior, lateral
4. Auscultation: anterior, posterior, lateral
5. Forced expiration
39

Dyspnea
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:

CC/HPI:
O = Onset
1. Dyspnea at rest
2. Dyspnea on exertion
3. Orthopnea
4. Paroxysmal nocturnal dyspnea
Q = Quality
1. Hard to take a deep breath, increased effort to breath, etc.
R = Radiation N/A
S = Severity
A = Aggravating
1. Exertion
2. Laying flat
3. Anxiety
A= Alleviating
1. Rest
2. Sitting up
D = Duration, chronology
1. Progression of symptoms (improving, stable, worsening)
1. Cough
2. Hemoptysis
3. Fever, chills
4. Lower extremity edema
40
5. Chest pain/pressure
6. Wheezing
7. Anxiety
8. Decreased urine output
Current meds:
1. General
2. Recently added medications
Allergies:
COPD/Asthma
CHD/CHF
Valvular heart disease
Venous thromboembolism (DVT, PE)
Collagen-vascular disease
Anemia
Kidney disease
Diabetes Mellitus
Family History:
Premature CHD
Venous thromboembolism
Social History:
Tobacco use
General appearance
1. Able to speak full sentences
1. Inspection
a. Use of respiratory accessory muscles, work of breathing
b. Check for increased anterior-posterior diameter
2. Palpation-as appropriate
a. Confirm midline trachea position
b. Confirm symmetrical chest expansion
c. Assess tactile fremitus
Cardiac examination
1. Inspection
2. Palpation of PMI
41
3. Auscultation
a. Sitting
b. Supine
c. Left lateral decubitus (S3, S4, mitral stenosis)
4. Jugular venous pressure
Extremities
1. Assessment of lower extremity edema
2. Assessment for clubbing
3. Assessment for cyanosis
42

Hemoptysis
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:

CC/HPI:
O = Onset
P = Position, Pattern N/A
Q = Quality/quantity
1. Amount
2. Color
3. Presence of sputum
R = Radiation N/A
S = Severity (relates to amount above)
T = Timing/frequency
D = Duration
1. Chest pain
2. Cough: acute or chronic
3. Shortness of breath
4. Fevers, chills, night sweats
5. Weight loss
6. Recent immobility
7. Nose bleeds or bleeding elsewhere
8. Sinus symptoms
9. Nausea, vomiting
10. Dyspepsia
43

Current meds:
1. General
2. Warfarin
3. Aspirin, NSAIDs
4. Oral contraceptives
Allergies:
Recent surgery
Venous thromboembolism (PE, DVT)
Malignancy
Pulmonary disease/chronic cough
1. Asthma, COPD
2. Recurrent pneumonia
3. TB, TB exposure, +PPD
Sinusitis/allergic rhinitis
Cardiac disease
1. Valvular heart disease
2. CHF
Thrombocytopenia or bleeding disorders
Liver disease
Peptic ulcer disease
HIV
Collagen-vascular disease
Family History:
Venous thromboembolism
Social History:
Recent travel
1. Duration of plane ride
2. Travel to areas endemic for TB
Blood transfusions (especially before 1985)
Tobacco
Cocaine
Intravenous drug use
High risk sexual practices
General appearance
Skin: inspection for bruising
HEENT examination
1. Inspection of nares
2. Inspection of oropharynx
44
1. Inspection
a. Work of breathing
b. Assess respiratory rate if not taken with vitals
2. Palpation-as appropriate
a. Confirm midline trachea position
b. Confirm symmetrical chest expansion
c. Assess tactile fremitus
Cardiovascular examination
1. Inspection
2. Auscultation
a. Sitting
b. Supine
c. Left lateral decubitus (S3, S4, mitral stenosis)
3. Jugular venous pressure
Abdominal examination
1. Inspection
2. Auscultation
3. Palpation, light and deep
Extremities
1. Assessment of edema
45

DMH-B Block
Fall 2015 - Class of 2018
Key Teaching Points
Abdominal Pain
1. Abdominal pain is common; although frequently benign, it can herald serious pathology
2. Triage is important; separate those with possible surgical abdomen and hemodynamic
instability
3. History & physical examination are critically important
4. Alarm features include:
a. Fever/chills
b. Orthostatic symptoms
c. Acholic stools (pale or clay colored)
d. Black stools
e. Bloody stools
f. Change in appearance/character of stools
g. Weight loss or gain
h. Jaundice
i. Pain change with menses
5. Differentiate acute from chronic. Intervals are arbitrary; but, think whether it is an accelerating
process, one that has reached a plateau, or one that is long standing but intermittent
6. Surgical abdomen: condition with a rapidly worsening prognosis in the absence of surgical
intervention (e.g., intraperitoneal hemorrhage, acute appendicitis, or viscus perforation)
7. Can approach other diagnoses by location: right upper quadrant, epigastric, lower abdominal
a. Right upper quadrant pain etiologies include liver or biliary pathology
b. Epigastric pain etiologies include pancreatitis, peptic ulcer disease, non-ulcer dyspepsia
c. Lower abdominal etiologies include diarrheal diseases due to infection, ileal pathology
such as inflammatory bowel disease; left lower quadrant disease including diverticulitis
(also can have pain on the right), and pelvic pathology including menstrual disorders,
pelvic inflammatory disease, ovarian disease, endometriosis, and ectopic pregnancy
8. Other causes include functional bowel disease and irritable bowel syndrome
46

DMH-B Block
Key Teaching Points
Acute Diarrhea
1. Definitions
a. Acute diarrhea: < 14 days in duration
b. Persistent diarrhea: more than 14 days in duration
c. Chronic: more than 30 days in duration
2. Most cases of acute diarrhea are non-inflammatory, self-limited, and due to viral and bacterial
infections. These cases require no antimicrobial treatment.
a. Maintaining hydration is the main treatment
b. Loperamide can be used for symptomatic treatment in immunocompetent patients who
are afebrile and without bloody stools
c. Consider empiric antibiotics for those patients with severe travelers diarrhea,
fever/bloody stools, elderly/immunocompromised patients. Treatment should be based
upon epidemiologic understanding of the most likely pathogens, and culture should be
considered prior to treatment
3. Non-inflammatory diarrhea usually originates from the small bowel and is characterized by:
a. Large volume, watery diarrhea
b. Lack of severe abdominal pain; may have cramps or nausea/vomiting
c. No fecal leukocytes or blood
4. Inflammatory diarrhea usually originates from the colon and is characterized by:
a. Bloody, small volume diarrhea
b. Abdominal pain
c. Fever/toxic appearance
d. Positive fecal leukocytes or stool lactoferrin
5. Most patients do not require a diagnostic evaluation (stool cultures, lactoferrin, etc.)
a. Consider evaluation in patients with severe illness, bloody diarrhea, high risk
(elderly/immunocompromised patients)
b. Consider C. difficile tests if recent antibiotic use/hospitalization
47

DMH-B Block
Key Teaching Points
Type 2 Diabetes
1. Most patients with Type 2 Diabetes Mellitus are asymptomatic until they suffer a microvascular
or macrovascular (myocardial ischemia, stroke) complication.
2. Microvascular complications are:
Diabetic retinopathy
Diabetic nephropathy
Diabetic neuropathy and foot complications
3. Screening for microvascular complications can reduce morbidity:
Retinopathy: dilated and comprehensive eye exams yearly
Nephropathy: yearly test for urine albumin/creatinine ratio
Neuropathy and foot disease: yearly monofilament testing plus either ankle reflexes,
pinprick sensation or vibratory sensation using a 128 Hz tuning fork; perform
examination of feet at each visit
4. Tight glycemic control reduces microvascular complications
The goal hemoglobin A1C, which reflects the average glucose level over a three month
period, is < 7.0%
Modify goal Hgb A1c up (< 8.0) or down (< 6.5) based on patient age, comorbidities and
duration of diabetes
5. Blood pressure control may be as important in Type 2 DM as glycemic control
BP control reduces microvascular and macrovascular complications
Goal BP in DM is controversial
i. JNC-8 guidelines (11/2013) recommend office BP < 140/90 (the same as JNC-8
recommendations for BP control in adults without DM who are < 60 years old)
ii. The 2014 American Diabetes Association (ADA) Guidelines recommend a BP of <
140/80 for most diabetic patients, with an optional goal of < 130/80 for certain
individuals, such as younger patients, if it can be achieved without undue
treatment burden
6. Because DM confers a high risk for macrovascular complications, early statin use is
recommended by the 11/2013 American Heart Association/American College of Cardiology
guideline for lipid management
Patients with diabetes age 40 75 with LDL 70 to 189 and without clinical
atherosclerotic cardiovascular disease (ASCVD) should be treated with a moderate
intensity statin (e.g., 40 80 mg of pravastatin)
Patients with diabetes age 40 75 with LDL 70 to 189 without clinical ASCVD and a 10-yr
risk of ASCVD of > 7.5% should be considered for a high-intensity statin (e.g., 40 80 mg
of atorvastatin)
As with the general population, adults with diabetes and LDL > 190 should be treated
with a high-intensity statin (e.g., 40 80 mg of atorvastatin)
As with all patients with clinical ASCVD, patients with diabetes and clinical ASCVD age 40
75 should be treated with a high-intensity statin (e.g. 40 80 mg of atorvastatin)
48
7. American Diabetes Association definitions:

Normal:
i. Fasting Plasma Glucose (FPG) < 100 mg/dL
ii. 2-hr Oral Glucose Tolerance Test (OGTT) < 140 mg/dL
Increased risk for DM (Pre-Diabetes):
i. FPG 100-125 mg/dL (Impaired Fasting Glucose)
ii. 2-hr OGTT 140-199 mg/dL (Impaired Glucose Tolerance)
iii. Hgb A1C 5.7-6.4%
Diabetes:
i. FPG > 126 mg/dL
ii. Hgb A1C > 6.5%
iii. 2-hr OGTT > 200 mg/dL
iv. Random PG > 200 mg/dL if symptoms of DM are present (weight loss, polyuria,
polydipsia)
v. In the absence of unequivocal hyperglycemia, the first three criteria above
should be confirmed by repeat testing on a different day. If, however, two
different tests (e.g., FPG and Hgb A1C) are available and concordant for the
diagnosis of DM, additional testing is not needed.
49

Mini CEX DMH Block B Acute Abdominal Pain
Professionalism:
Present /on time
Absent:
Excused
Unexcused
Comments:
Name and age of patient (very important in evaluation of acute abdominal pain):
CC: Acute abdominal pain
HPI:
1. O = Onset
b. When did the pain first start?
c. Onset sudden or gradual?
2. P = Position, Pattern, Location
a. Diffuse vs. localized?
3. Q = Quality (type of pain)
a. Dull, sharp, colicky, waxing and waning,
etc.
4. R = Radiation
a. Back
b. Flank and groin (Right or Left)
c. Shoulder
5. S = Severity (1-10)
6. T = Timing -- high risk features include:
a. Sudden onset?
b. Maximal at onset?
c. Pain with subsequent vomiting?
7. A = Aggravating/Alleviating
a. Increased or decreased after eating?
b. Increased or decreased after BM?
8. D = Duration
a. Hours vs. weeks
9. A = Associated Symptoms
a. Fever, chills
b. Vomiting (bloody or bilious)
c. Diarrhea
d. Blood in stools
Key Knowledge:
The evaluation of acute abdominal pain is
different from that of chronic abdominal
pain and includes several potentially lifethreatening diagnoses. This session focuses
on acute abdominal pain.
In evaluating acute abdominal pain, it is

important to search for and exclude:
abdominal aortic aneurysm
mesenteric ischemia
bowel perforation
acute bowel obstruction
volvulus
myocardial infarction
In women of childbearing age, pregnancy
status must be determined.
Three classes of abdominal pain:

Visceral pain: innervation bilaterally at
multiple levels; dull, poorly localized, felt
in midline. Caused by ischemia,
inflammation, or distention of hollow
organs or capsular stretching of solid
50
e.
f.
g.
h.
Vaginal discharge
Dysuria
Shortness of breath
organs.
Parietal pain: innervated on same side

and dermatomal level; more distinct and
localized. Caused by ischemia,
inflammation, or stretching of the
parietal peritoneum.
Referred pain: felt far from the diseased

organ. This is due to shared central
pathways for afferent neurons from
different locations.
Allergies / Adverse Drug Events:

1. Prior abdominal surgery
2. Cardiovascular disease
3. History of HIV infection
4. Obstetric history
Medications:
1. NSAIDs
Family History:
1. Cholelithiasis? Nephrolithiasis? Cancer?
Social History / High Risk Behaviors:
1. Alcohol consumption
2. Recent travel
Key knowledge:
Vital signs are particularly important and
must be accurately measured.
Physical Examination:
1. General appearance
f. Patients age
g. Level of discomfort
h. Motionless vs. changing position
2. Vital signs
a. Orthostatic symptoms
b. Tachycardia
c. Fever
3. Eye exam
a. Scleral icterus
4. Skin exam
a. Jaundice
b. Abdominal or flank ecchymosis
5. Cardiac exam
a. Auscultation
6. Pulmonary exam
a. Auscultation for consolidation at lung
bases
7. Abdominal exam
a. Observation
i. Distension
ii. Visible peristalsis
b. Two minute auscultation
Bowel sounds: normally 5-34 gurgles per

minute. No bowel sounds over 2 min
suggests peritonitis. Hyperactive bowel
sounds suggest blood or inflammation within
the gut.
Periodic rushes of high-pitched "tinkling"
bowel sounds with distention suggest
obstruction.
Rigidity is involuntary spasm of muscles due
to peritoneal irritation.
Voluntary guarding: tensing of the
abdominal muscles due to apprehension or
discomfort.
Rebound tenderness: increase in pain after
quick removal of palpating hand (poor SN &
SP).
Carnett's sign: increased tenderness when
the abdominal wall muscles are contracted
(95% accurate at distinguishing abdominal
wall pain from visceral pain).
51
i. Bowel sounds
ii. Aortic and femoral bruits
c. Palpation
i. Lightly for rigidity
ii. Deeply for localized tenderness
iii. Palpation of aorta (older )
iv. Carnetts sign
v. Murphys sign
vi. Psoas sign
vii. Obturator sign
viii. Rovsings sign
8. Pelvic exam
a. I need to perform a pelvic exam.
9. Rectal exam
a. I need to perform a rectal exam.
10. Extremities
a. Peripheral vascular disease?
Murphy's sign: patient abruptly stops deep

inspiration during palpation of the RUQ. Can
be useful with suspected cholecystitis.
Psoas sign: with patient on his left side, pain
elicited when the right hip is extended
(suggests retrocecal appendicitis).
Obturator sign: pain elicited with passive
internal rotation of the flexed right thigh;
suggests a pelvic appendicitis.
Rovsing's sign: pain in the RLQ with
palpation of the left lower quadrant.
Psoas, obturator, and Rovsing signs have low
SN but good SP for acute appendicitis.
Geriatric patients: accuracy of exam findings

is decreased in the elderly. Abdominal
tenderness may not localize, and peritonitis
may not cause rigidity.
Last Reviewed: 7/2015
52

Mini CEX DMH Block B Acute Diarrhea
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC: Acute Diarrhea
HPI:
1. O = Onset of diarrhea
a. Frequency of stools
b. Character of the stools
i. Semi-formed, loose,
watery?
ii. Blood, pus, mucous?
2. Are you having abdominal pain?
a. If so, then continue with numbers
3-9
3. P = Position, Pattern, Location
4. Q = Quality (type of pain)
5. R = Radiation
6. S = Severity (1-10)
7. T = Timing (with what activities does it
occur)
8. A = Aggravating/Alleviating
9. D = Duration
a. Fever
b. Nausea or vomiting
c. Symptoms of dehydration
i. Orthostatic symptoms
ii. Weight loss
11. Exposures
a. Household contacts?
b. Work contacts (day care center)?
c. Food history
Key Knowledge:
Diarrhea is classified by duration of illness:
Acute - 14 days in duration
Persistent - more than 14 days
Chronic - more than 30 days
Most cases of acute diarrhea are caused by viruses
(most commonly Norovirus); however, bacteria
cause most cases of severe diarrhea.
Onset of symptoms after exposure to offending
food:
6 hours suggests preformed toxin
(Staphylococcus aureus or Bacillus cereus)
8 to 16 hours suggests Clostridium perfringens
>16 hours suggests viral or bacterial
(enterotoxigenic or enterohemorrhagic E. coli).
Initial evaluation should focus on 3 things:
duration, frequency, and characteristics of
stool;
evidence of volume depletion;
evidence of an invasive enteric pathogen (fever
and peritoneal signs).
53
i. Beef, pork poultry

ii. Milk, salad dressing?
iii. Fried rice?
iv. Shellfish, seafood?
d. Foreign travel?
e. Recent camping?
f. Pets or exotic animals?
g. Untested well water?
12. Risk for transmission to others
a. Food service worker?
13. Previous evaluation and treatment
a. History of chronic or recurrent
diarrhea?
Factors that indicate increased risk:

dehydration
bloody stools
fever
> 6 stools per day
duration > 48 hours
severe abdominal pain
elderly patient
immunocompromised patient
Allergies / Adverts Drug Events:

1. Resident in an institutionalized setting
Medications:
1. Any new medications?
2. Recent antibiotics?
Family History:
1. Inflammatory Bowel Disease
Key knowledge:
About 3% of healthy adults are asymptomatic
carriers of C. difficile, but 20-50% of adults in
hospitals and long-term care facilities.
In HIV infected patients, C. difficile is the most
common cause of acute diarrhea (54%).

1. History of high-risk sexual exposures
2. History of intravenous drug use
a. Acutely ill?
b. Abdominal discomfort?
2. Vital signs
a. Tachycardia?
b. Orthostatic hypotension?
3. Cardiovascular Exam: not applicable
4. Pulmonary exam: not applicable
5. Abdominal exam
a. Inspection
i. Surgical scars?
ii. Distention?
iii. Visible peristalsis?
b. Auscultation
i. Presence of bowel sounds
c. Palpation and percussion
i. Palpate in four quadrants
54
for rigidity, guarding,

rebound
ii. Percuss for resonance
(gaseous distention)
6. Extremities: Skin turgor
55

Mini CEX DMH Block B Type 2 Diabetes
Professionalism
Present /on time
Absent:
Excused
Unexcused
Comments:
CC: Type 2 Diabetes
HPI:
1. O = Onset (when DM first diagnosed).
3. P = Position, Pattern, Location N/A
4. Q = Quality (type of pain) N/A
5. R = Radiation N/A
6. S = Severity (1-10) N/A
7. T = Timing N/A
8. A = Aggravating N/A
9. D = Duration (see onset)
a. Weight loss
b. Polyuria
c. Polydipsia
d. Weight gain
e. Loss of foot sensation
f. Extremity/foot ulcerations
11. Previous evaluation and treatment
a. Diet and exercise
b. Oral medications
c. Insulin injections
Allergies /Adverse Drug Events:
Past Medical & Past Surgical History and/or
symptoms of microvascular or macrovascular
disease
1. Hypertension
a. Home blood pressure cuff?
Vocabulary:
type 1 diabetes
type 2 diabetes
microvascular disease
macrovascular disease
hemoglobin A1C (glycohemoglobin)
capillary blood glucose
coronary heart disease equivalent
retinopathy
nephropathy
microalbuminuria
peripheral neuropathy
autonomic neuropathy
gastroparesis
metabolic syndrome
Key knowledge:
7% of US adults have diabetes; on the inpatient
service at UAHN University Campus one-third of
patients require insulin.
Most patients diagnosed with diabetes have
relatively few symptoms. By the time they present
with weight loss, polydipsia, and polyuria, their
blood sugars are above 300.
56
2. Hyperlipidemia
a. Last lipid panel?
3. Coronary artery disease
a. Exertional dyspnea?
b. Orthopnea?
c. Tightness? Pressure?
4. Neurologic diseases
a. Stroke/transient ischemic attack
i. Difficulty speaking?
ii. Focal weakness?
b. Peripheral neuropathy
i. Foot numbness? Burning?
ii. Last foot exam?
5. Kidney diseases
b. Urinary tract infections
c. Renal insufficiency
i. History of proteinuria?
ii. Lower extremity
swelling?
6. Eye disease
a. Vision changes?
b. Last dilated eye exam?
7. Vascular disease
a. Calf pain with exertion; relieved
by rest?
b. Foot ulcers?
8. Gastroparesis
a. Epigastric bloating/pain after
eating?
9. Erectile dysfunction
It is common for diabetes to co-occur with

abdominal obesity, hypertension, and
hyperlipidemia (often called "metabolic syndrome").
Key knowledge:
Because of lack of evidence that early identification
and intervention improves outcomes, the ADA does
not recommend screening stress testing for high
risk diabetic patients.
Key knowledge:
Low-dose aspirin is recommended for all diabetics
with cardiovascular risk factors or a history of
vascular events.
Medications:
1. Low-dose aspirin?
Family History:
1. Diabetes
2. Hypertension
3. Dyslipidemia
4. Coronary artery disease
1. Dietary history
a. Dietary fat intake
2. Tobacco use
3. Exercise pattern
Key knowledge:
In most diabetics, the goal for blood pressure control
is < 130/80.
57
2. Vital signs
a. Calculate Body Mass Index
3. Funduscopic exam
4. Oral examination
a. Periodontal disease
5. Cardiovascular Exam
a. Auscultation for carotid bruits
b. Jugular venous pressure
c. Cardiac auscultation
6. Pulmonary exam
a. Auscultation anterior and
posterior
7. Abdominal exam
a. Auscultation for abdominal and
femoral bruits
b. Palpation, light and deep
8. Extremities
a. Peripheral pulses
b. If claudication, ankle brachial
index
c. Pretibial compression for
edema
d. Inspection of feet
e. Monofilament sensation testing
Key knowledge:
Patients with type 2 diabetes should have a yearly
dilated eye exam by an ophthalmologist.
Key knowledge:
In patients with diabetes, a foot exam should be
performed at every office visit. Screening for loss of
sensation with a monofilament should be performed
annually. Advice for foot care includes:
Avoid going barefoot.
Wash and check feet daily.
Test water temperature before a bath.
Trim toe nails; remove sharp edges.
Shoes should be snug but not tight.
Socks should be changed daily.
Ankle brachial index in diabetics is not an
accurate test due to arterial calcification in distal
vessels. Toe pressure is a better indication of
vascular disease.
58

Mini-CEX: Breast & Pelvic Examinations
Fall 2015 Class of 2018
Professionalism
Present/on time

Absent:
Excused
Unexcused
Comments:
Communication skills
Obtain name and age of the patient and relationship of others if present
Start with an open-ended question
Use appropriate eye contact and body language
Use facilitative listening skills
Demonstrate empathy
Explain the purpose of the examination.
Invite questions now or during the exam.
PHYSICAL EXAMS
Preparation
Check all equipment/supplies
Adjust exam light prior to gloving
Wash hands
General techniques/exam skills
Demonstrate concern for the patients comfort and modesty
Explain to patient what is being done
Enlist the patients cooperation during the exam
Follow a logical sequence of exam from on region to another
Modify the exam to adapt to patient limitations
Avoid unexpected/sudden movements
For the pelvic: wear gloves that remain uncontaminated throughout the exam
Breast Examination
A. Inspect both breasts in following positions
Patient sitting, arms at sides.
Patient sitting, arms above head.
Patient leaning forward with support.
Patient sitting, hands pressed to hips.
59
B. Palpate lymph nodes

1. Use proper technique to palpate supraclavicular lymph nodes.
2. Use proper technique to palpate axillary lymph nodes.
C. Breast palpation
Ask patient to recline

Ask patient to put the ipsilateral arm behind head to aid examination.
Palpate all four quadrants and tail completely and systematically using one of the three
methods
Examine the areola and nipple
Express to check for nipple discharge
Pelvic Examination
A. Positioning
Elevate head of table to permit eye contact.
Turn on and adjust lamp.
Ascertain that patient is comfortable and that drapes are adjusted to maintain eye contact.
Position patient on back, hips to end of table, and heels on foot rest
B. External Genital Examination
1. Put on exam gloves.
2. Start in a sitting position.
3. Inform patient, both verbally and by touch, the examination is to begin.
4. Inspect and identify to patient the following external structures:
a. mons pubis
b. labia majora
c. labia minora
d. clitoris
e. urethral meatus
f. introitus
g. Bartholins glands
h. perineum
i. anus
C. Speculum Examination and Routine Procedures
1. Check speculum prior to insertion. (Mechanically and temperature-use warm water to heat
and lubricant when indicated)

2. Inform patient, both verbally and by touch, that speculum exam is to begin.
3. Hold speculum at 45 angle
4. Insert speculum properly
a. Using one finger at the introitus to help patient relax perineal muscles:
Place one finger at the introitus and proceed with pubococcygeal relaxation
techniques, introducing second finger and pressing down on the perineal body.
60
Insert speculum partially over fingers depressing perineal body without causing
discomfort to the patient by directing speculum toward the posterior vaginal
wall, away from the urethra.
When the speculum is inserted about 1-1 , remove your fingers. Maintain
gentle downward pressure toward the rectum.
b. Using closed speculum place downward pressure to relax perineal muscles
5. Rotate speculum while inserting at a slight downward angle following the natural path of the
vagina. With opposite hand, gently move labia out of path of the speculum to avoid
pinching and discomfort. Speculum is horizontal at full insertion.
6. Open speculum blades slowly to 1 to 2
7. Locate and identify cervix
8. Secure speculum in open position
9. Inspect the cervix
10. Inspect vaginal walls while removing speculum
11. Allow speculum to close completely prior to withdrawal from the introitus.
12. Handle speculum appropriately
D. Abdominal-Vaginal Bimanual Pelvic Examination
Perform exam in standing position.

Apply lubricant to index and middle fingers of dominant gloved hand.
Inform patient, both verbally and by touch, that bimanual examination is about to begin.
Encourage patients participation in relaxation technique of the pubococcygeal muscle of the vagina
to facilitate examination.
Introduce index and middle fingers of gloved hand into the vagina, and turn hand to a palm up
position. Thumb is hyper-extended, 4th and 5th fingers are flexed on palm. Avoid contact with the
clitoral area with your thumb.
Palpation of the uterus

Locate/identify cervix.
Palpate the body and apex of the uterus between vaginal hand and abdominal hand.
Note size and position of the uterus moving hands together laterally.
Palpation of the adnexa and ovaries (repeat steps on both sides)
Move vaginal fingers into vaginal lateral fornix.
Push down with fingers of abdominal hand as if to meet internal fingers just above the midpoint of the inguinal ligament.
Bend the fingers of the vaginal hand up towards the abdominal hand, keeping them relaxed.
Maintaining depth, move both sets of fingers simultaneously toward mons pubis to locate
ovary.
Characterize ovary between both sets of fingers.
If ovary is not located with initial attempt, re-position hands and repeat procedure.
61

Life Cycle Block-Geriatric SP Lab
Key Teaching Points
The Short Geriatric Functional Assessment

The purpose of geriatric assessment is to prevent loss of independence or a significant decline
in a patients level of function. The Short Geriatric Functional Assessment can be performed in
an office visit in about 10 minutes. It typically includes a select medical history (asking about
visual impairment, hearing loss, urinary incontinence, depression, nutritional status, cognitive
problems, and problems with mobility) as well as ADLs (Activities of Daily Living) and IADLs
(Instrumental Activities of Daily Living). Generally, ADLs are what you need to do every
morning after waking in order to get ready for the day such as bathing, dressing, and eating.
IADLs, though, require more executive functioning in terms of planning, knowledge, and skill in
executing an activity such as paying bills, taking medications as directed, and shopping and
preparing meals.
The Comprehensive Geriatric Assessment
Although not covered in this SP lab session, it is important to remember that some geriatric
patients benefit from a formal, comprehensive assessment. This extensive evaluation requires
several hours and typically is performed by a multidisciplinary team including a geriatrician,
pharmacist, physical therapist/occupational therapist, social worker/case manager, and the
patients spouse/caretaker(s). The areas evaluated include the following:
Functional assessment (ADLs and IADLs)

Cognitive assessment (mini-Cog, Folstein MMSE)
Depression/dementia/delirium
Gait and mobility/fall risk/orthostatic hypotension
Nutrition/weight loss/BMI calculation
Osteoporosis risk
Oral health/vision screen/hearing screen
Pain assessment
Deconditioning/frailty/pressure ulcer risk
Urinary incontinence/bowel incontinence
Alcohol dependence or abuse/tobacco use/other drugs of abuse
Polypharmacy including drug adverse side effects and drug-drug interactions
Advanced directives including living will, MPOA (medical power of attorney), code
status, patients goals and preferences about end of life care
Caregiver stress or burnout
Home hazard assessment
62
Cognitive impairment
I.
II.
III.
IV.
Major neurocognitive disorder (formerly known as dementia) is defined as:

A. Evidence of decline as reported by the individual, knowledgeable informant, or
clinician in one or more of the following cognitive domains:
i. Learning and memory
ii. Language
iii. Executive function
iv. Complex attention
v. Perceptual-motor function
vi. Social cognition
B. The cognitive deficits interfere with independence in everyday activities.
C. Cognitive deficits do not occur exclusively during delirium.
D. Cognitive deficits are not better explained by presence of another mental
disorder such as major depression, schizophrenia.
Alzheimers disease is characterized by a gradual onset and continuing cognitive decline
and is not caused by identifiable medical, psychiatric, or neurologic condition.
Vascular dementia is characterized by focal neurologic signs and symptoms and vascular
risk factors. The memory loss may be abrupt in nature and characterized by a step-wise
deterioration.
Work-up for major cognitive disorder is individualized; but, all patients with cognitive
impairment should be screened for vitamin B-12 deficiency and hypothyroidism. Most
guidelines also recommend structural neuroimaging (CT/MRI).
References: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5), American Psychiatric Association, Arlington, VA 2013
http://www.uptodate.com/contents/image?imageKey=NEURO/91276&topicKey=NEURO%2F5083&source=outlin
e_link&search=dementia&selectedTitle=1%7E150&utdPopup=true
63
Falls
I.
II.
III.
IV.
Determine the etiology of the fall: mechanical, syncope or pre-syncope, disequilibrium,

vertigo, etc.
A work-up should be done to address reversible contributing factors to the fall.
A. Work-up is dependent on what factors you believe contributed to the fall
Disequilibrium is a common contributing factor to falls in the elderly. Etiologies include:
A. Peripheral neuropathy/loss of proprioception
B. A musculoskeletal disorder interfering with gait (e.g., osteoarthritis of the knee
or hip)
C. Vestibular disorder (e.g., age related degeneration)
D. Cervical spondylosis due to disturbance in postural control; this is controversial.
E. Parkinsons disease (postural hypotension and gait disorder)
F. Visual impairment
G. Vertebrobasilar ischemia (often associated with central vertigo, but there is
overlap)
H. Medications
I. Multiple sensory deficits (proprioception, visual impairment, vestibular
impairment)
Useful treatments include canes or walkers, physical therapy, balance training, home
evaluations to identify unsafe items like throw rugs.
64

Life Cycle Block
Key Teaching Points
Male Genitourinary Exam
1. Identify the pubic tubercle and anterior superior iliac spine --- the direct and indirect
and femoral hernia occur medial to the midpoint between the two so your tips of the
finger should be on the tubercle while the rest of the hand lies lateral to this point and
parallel to the inguinal ligament.
2. Always examine with the patient standing and lying down. Standing to demonstrate the
hernia and lying down to reduce the hernia.
3. The key landmark separating the direct from indirect hernia is the inferior epigastric
artery and vein. Direct hernias come through medially (through hasselbachs triangle)
and indirect laterally through the internal ring.
4. Femoral hernias are rare; more common in female than male patients. The hernia
comes under the inguinal ligament, and the medial boundary is the lacunar ligament
and the lateral boundary is the femoral vein.
5. Asymptomatic inguinal hernia in elderly patients with co-morbid disease may be
observed. Once symptoms of pain appear then surgery should be done.
65

Life Cycle Block Mini CEX
Falls and Mobility Disorders in the Elderly
MENTOR: The only component of this Mini CEX to be completed in the students Societies Portfolio is the
Professionalism section below:
Professionalism:
Present/on time
Absent: Excused Unexcused
Student Tasks:
Teaching Points:
CC/HPI:
MEDICAL HISTORY - did the student ask the patient or

surrogate about:
Any falls in the last year?
Fear of falling/ balance/ trouble walking?
Use of an assistive device (cane, walker, wheelchair)?
If there was a fall, did the student ask about:
o Tripped or stumbled over something
o Lightheadedness/palpitations
o Loss of consciousness
o Unable to get up within 5 minutes
o Needed assistance to get up
Vision:
Noticed recent vision change
Eye exam in past year
Psychotropic medications:
Neuroleptics
Benzodiazepines
Antidepressants
Other risk factors:
Alcohol use: 2 or more drinks/day; Parkinsons, stroke,
cardiac, neuropathy, severe osteoarthritis, elder abuse
PHYSICAL EXAMINATION
Vital signs
Orthostatic BP
Hearing screen
Vision screen
All patients should be asked about falls annually.

Post-fall anxiety syndrome is well-recognized in the elderly.
Falls in patients rarely due to a single cause:
Age-related decline in balance, proprioception, reflexes
Decreased strength in the lower extremities.
Increased weight.
Benign positional vertigo.
Medication affects (decreased alertness, orthostatic BP)
Joint pain and limited joint mobility.
66
Gait: the timed 'Get Up and Go' test

Direct patient to do the following
Rise from sitting position
Walk 10 feet
Turn around
Return to chair and sit down
Romberg Test
Stand with feet together and eyes open
Close both eyes, stand for 20-30 seconds
Interpretation: Watch for

Hesitant start
Extended arms
Broad-based gait
Heels drag: do not clear the floor
Short steps: heels do not clear toes of the other foot
Path deviates
<20 seconds means adequate gait stability.
>30 seconds means higher risk of falls.
Note ability to stand without support with eyes closed. Loss

of balance is positive Romberg sign.
Postural Stability: the Tandem Stance test

Feet side-by-side, stable 10 sec
Feet in semi-tandem position, stable 10 sec
Feet in full tandem stance, stable 10 sec
Resistance to nudge
Optional: Can pick up a penny off the floor
Neuromuscular:
Quad strength
Can rise from chair without using arms
Rigidity
Bradykinesia
Tremor (cogwheeling)
If indicated, hip and knee exam
DTRs
67

Cognitive Assessment in the Elderly
Professionalism:
Present/on time
Absent: Excused Unexcused
Student Tasks:
Teaching Points:
CC/HPI:
Activities
MEDICAL HISTORY-did the student ask the patient or
surrogate about:
Have you had any memory problems?
If so, then how long?
Are you taking any medications?
Do you have insomnia or sleep problems?
Folstein Mini-Mental State Exam (MMSE)
Orientation:
What is the year?
What is the season?
What is the date?
What is the day?
What is the month?
What country are we in?
What state are we in?
What county are we in?
What city are we in?
What clinic are we in?
Registration:
Say "I'd like to test your memory. Please say these words:
boat, cucumber, wire" (say all 3 words at once, requiring the
person to then repeat all 3 words at once)
Attention and Calculation:
Say "Begin with 100 and count backwards by 7s"
(Alternatively ask patient to spell world backward.)
Recall:
Say "Can you repeat the 3 words I named before?
Commentary
Plan to assess four areas of cognitive function:
Language
Visual spatial function
Memory
Executive function
Notes:
Medications are a common cause of confusion.
Day-night reversal common in Lewy body dementia.
A widely used screening tool used to evaluate patients with
possible dementia.
1 point for each correct answer; total of 5 points.
Name three objects

Score 1 point for each correctly repeated word--total of 3
points.
(Number of trials: ____ )
Serial 7s
Stop after 5 answers. (Answer = 93, 86, 79, 72, 65).
1 point for each correct answer; total of 5 points
Ask the patient to repeat the 3 words above (boat, cucumber,
wire).
68
Language:
Say "Name the following items" (point to a pencil and then
a watch)
Say "Repeat the following: No ifs, ands, or buts."
Say "Take the paper in your right hand, fold it in half, and
put it on the floor." (or on a surface if unable to bend over to
the floor)
Say "Read and obey the following"
Write on a piece of paper "CLOSE YOUR EYES." and hold it so
it can be clearly seen.
Name a pencil and watch.

1 point for each right answer; total of 2 points
Repeat a complex phrase.
1 point for correct answer; total of 1 point.
Follow a 3-stage command.
1 point for each correct action; total of 3 points
Read and obey a written command.
1 point for the correct action; total of 1 point.
Say "Write a sentence."
Write a sentence.
1 point if a sentence is written; total of 1 point.
Visual-spatial ability:
Copy the design shown.
Examiner draws interlocking pentagons and has patient copy it.

Total of 1 point.
Assess and record the patients level of consciousness.
Assess level of consciousness along a continuum

____________ (Alert, Drowsy, Stupor, Coma)
Normal = 27-30.
A score <24 sensitivity of 87% and specificity of 82% for
cognitive impairment.
Mild impairment = Score of 21-26
Moderate impairment = Score 11-20
Severe impairment = 0-10
_____ Total Score
Clock Drawing Test:

Draw a large circle on a sheet of paper.
Ask the patient, Draw numbers in the circle to make the
circle look like the face of a clock, and then draw the hands
of the clock to read 10 after 11."
Alternative Language Screen:

Say, Name all the animals in the zoo, farm, or jungle.
The clock drawing test is typically added to the Folstein MMSE

as it is a better assessment of executive function.
Scoring:
1 - perfect clock
4 - moderate errors
2 - minor errors
5 - severe errors
3 - errors in placement
6 - no reasonable
attempt
Naming animals is a useful alternative means of assessing

memory and language.
Normal 10/minute.
69
Geriatric Depression scale:

Affect:
Ask Do you often feel sad, blue, depressed?
Has there been a change in your interest/participation in
activities that you enjoy?
Physical Exam:
Hearing screen:
Ask the patient to close her/his eyes.
Whisper four random single numbers.
If patient cannot hear >2 numbers = hearing loss.
Vision screen:
Ask the patient, "Because of your eyesight do you have
any difficulty with driving, watching TV, reading, or any
daily activities?"
If yes, then test each eye with a pocket Snellen chart,
with the patient wearing glasses, if used.
Depression is common in geriatric patients (about 20%), and

can cause symptoms which mimic dementia.
In geriatric patients with mild or moderate dementia,
depression screening questions are less reliable. Also, for
unclear reasons, patients with dementia tend to deny
symptoms of depression.
Basically, the physical exam has three main purposes:

1. Screen for hearing loss and visual impairment.
2. Search for undiscovered medical illness, mainly:
Thyroid disease (either hyper or hypo)
Alcohol intoxication, withdrawal, liver disease
Lung disease with hypoxemia
Severe anemia
3. Search for neurologic disease, mainly:
Cerebrovascular disease with prior strokes
Parkinson's disease
Focused physical exam:

General appearance
Vital signs
Oxygen saturation
Pallor (conjunctival, sublingual, other)
Thyroid examination
Heart and lung examination
Abdominal examination
Focused neurologic exam:
Cranial nerve exam
Motor examination
Deep tendon reflexes
Rigidity, bradykinesia, tremor, cogwheeling
Assessment of gait
References:
1) Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading the cognitive state
of patients for the clinician. J Psychiatry Res. 1975; 12:196-198.
2) Cockrell JR, Folstein MF. Mini-Mental State Examination (MMSE). Psychopharm Bull. 1988; 24;689-692.
70
Geriatric Functional Assessment
Professionalism Was the student:
Present/on time
Absent:
Excused
Unexcused
Comments:
Age & name of patient:
CC:
HPI
Onset
Associated event
Timing
Progression since onset
Progression during day
Severity
Changes in sleep habits?
Changes in appetite?
Changes in weight?
Depression Screen
Feeling of depression?
Change in interest/participation in activities you enjoy?
Past Medical and Past Surgical History

- Ongoing medical illnesses
- Medications
A. What medicines do you take (including herbals and OTC)?
B. Have you had pneumonia vaccine? Flu shot?
Prior surgical procedures
Family History
Children?
Social History
71
Who lives with you?

Friends, social contacts?
- Who would help you in an emergency?
- Do you have will, living will, medical power of attorney?
Who would help you with health care decisions if you were not able to communicate your wishes?
Lifestyle Behaviors
- Do you drink alcohol?
- How many falls have you had in the past year?
- Has anyone intentionally tried to harm you?
Review Of Symptoms
Ask about functional assessment issues given the HPI
- Do you have difficulty driving, watching TV, or reading because of poor eyesight?
- Can you hear normal conversational voice?
- Do you have problems with your memory?
Rate each of the following as independent (I), needs assistance (N), or dependent (D) meaning cant do at all
ADLs:
Bathing
Dressing
Grooming
Toileting
Bowel/bladder continence
Transfer bed to chair
Walking short distances/mobility
Stair climbing
Eating
IADLs:
Using the telephone
Driving/arranging transportation
Shopping
Preparing meals
Housework/Laundry
Taking medications correctly
Managing finances
Physical Exam
Blood pressure
Hearing screen
Vision screen
Heart exam
Pulmonary exam
Thyroid exam
72

Life Cycle Block
Mini CEX: Male Genital Exam
Prior to beginning the exam did the student:
1. Brief outline of what the exam entails.

2. Assure the patient that the exam should not be painful. Pain may be a sign of an
underlying problem; so ask the patient to communicate this to you.
3. Assure the patient that although some men may feel embarrassed or get an erection
during this procedure, it is an important exam to screen for possible problems.
4. Give patient simple and clear directions on lowering of pants and/or on the position
for the examination.
5. Explain each procedure and its purpose prior to doing the procedure, using
language the
patient will understand.
Physical Exam Did the student correctly perform the following physical exam skills:
With patient standing:
6. Wash hands.
7. Position lamp if needed.
8. Put gloves on both hands.
9. Make a visual inspection of the genital region.
10. Inspect and palpate femoral pulses.
11. Palpate the lymph nodes in the inguinal and femoral areas.
12. Inspect the pubic hair (checking for lesions, excoriation, lice).
13. Inspect surface of penis. Retract prepuce (foreskin) if present. Replace foreskin in
normal anatomic position. Systematically rotate the penis to view all surfaces. Inspect
the skin of the glans.
14. Palpate shaft of penis including both corporea cavernosa and urethra.
15. Inspect urethral meatus for size and discharge.
16. Systematically inspect all surfaces of the scrotum.
17. Observe for scrotal symmetry or asymmetry.
Note:
Perform #s 18, 19, 20 on the R testicle, and then on the L.

18. Isolate and palpate testicle.
19. Palpate epididymis (posteriorly).
20. Palpate vas deferens (superiorly).
21. Palpate the inguinal and femoral areas for hernias (with sustained valsalva).
73

Life Cycle Block
Mini CEX: Rectal Exam
Prior to beginning the examination, if student is with a patient instead of the manikin, did
the student:
1. Explain procedure for rectal exam.

2. Give patient clear instructions on assuming the correct position for the exam.
Physical Exam Did the student correctly perform the following physical exam skills:
Patient leaning over examination table. Physician seated.
1. Wash hands.
2. Position lamp, if needed.

3. Explain procedure.
4. Place gloves on hands.
5. Retract buttocks. Visually inspect anus, sacrococcygeal and perianal areas.
6. Have assistant place lubricant on finger.
7. Place finger pad against anal sphincter.
8. Apply gentle pressure, reminding patient what you are doing.
9. Perform sweep of rectal wall, rotating hand 180 each way
10. Identify and palpate each lateral lobe of the prostate. Palpate median sulcus.
11. Inquire about pain or tenderness during palpation.
12. Gently withdraw finger while informing patient.
13. Take off and dispose of gloves.
14. Hand patient box of tissue to wipe anus.
74

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Doctor and Patient: Integrating the Art and Science of Medicine

Nervous System Block

B. Distinguish between acute and chronic muscle weakness

Doctor and Patient: Integrating the Art and Science of Medicine

Doctor and Patient: Integrating the Art and Science of Medicine

A. Major types of tremors

B. Resting tremor suggests Parkinsons Disease

C. Action/postural tremors suggest enhanced physiologic tremor or essential tremor

Doctor and Patient: Integrating the Art and Science of Medicine

Past Medical & Past Surgical History

High Risk Behaviors/Habits:

Physical Examination: washed hands first

8. Cardiac examination (sitting and supine)

Doctor and Patient: Integrating the Art and Science of Medicine

Name and age of patient:

Previous evaluation and treatment

High Risk Behaviors/Habits:

Physical Examination: washed hands first, cleaned stethoscope

4. Palpate neck and shoulder muscles

Doctor and Patient: Integrating the Art and Science of Medicine

Name and age of patient

Past Medical & Past Surgical History

High Risk Behaviors/Habits:

Doctor and Patient Course

Doctor and Patient Course

Doctor and Patient Course

High Risk Behavior/Habits:

High Risk Behavior/Habits:

Physical Examination: washed hands first

Palpate C-MC joint of the thumbs

Palpate lateral and medial epicondyles

Past Medical & Past Surgical History:

Doctor and Patient Course

Descriptions of pain decreasing the likelihood for MI include a pleuritic nature, a

Doctor and Patient: Integrating the Art and Science of Medicine

Past Medical & Past Surgical History

d. Examination of jugular veins

Doctor and Patient: Integrating the Art and Science of Medicine

Name and age of patient

Doctor and Patient: Integrating the Art and Science of Medicine

iv. Recent immobility

Pulmonary Lab Key Teaching Points

b. Acute dyspnea evolving over minutes to hours needs to be evaluated promptly.

Doctor and Patient: Integrating the Art and Science of Medicine

Past Medical & Past Surgical History:

Doctor and Patient: Integrating the Art and Science of Medicine

Name and age of patient

Doctor and Patient: Integrating the Art and Science of Medicine

Name and age of patient:

Past Medical & Past Surgical History

Doctor and Patient: Integrating the Art and Science of Medicine

Doctor and Patient: Integrating the Art and Science of Medicine

Doctor and Patient: Integrating the Art and Science of Medicine

7. American Diabetes Association definitions:

Doctor and Patient: Integrating the Art and Science of Medicine

In evaluating acute abdominal pain, it is

Three classes of abdominal pain:

Parietal pain: innervated on same side

Referred pain: felt far from the diseased

Allergies / Adverse Drug Events:

Past Medical & Past Surgical History

Bowel sounds: normally 5-34 gurgles per

Murphy's sign: patient abruptly stops deep