What does my UIM attending expect on the Mini-CEX? Round 2 7/24/13
What does my UIM attending expect on the Mini-CEX?Round 27/24/13
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.
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
Mini-CEX UIM 2013Item Date Supervisor1. History of a new
complaint 1. Medication history 1. Chronic pain history
(psych) 1. Focused physical
exam 1. CV exam 1. Lung exam 1. Abdominal exam 1. Musculoskeletal
exam 1. Neurological exam 1. Pelvic exam (GYN) 1. Knee exam (Ortho) 1. Shoulder exam
(Ortho) 1. Hip exam (Ortho) 1. Teach-back 1. Shared decision-
making
CV Exam Which patients?
Any complaint with cardiovascular elements
Hypertension, CHF, CAD Especially good if you would like to verify
findings
CV Exam Heart
Auscultation (follow V1-6) Diaphragm then bell Right upper sternal border Left upper sternal border Left midsternal border Left lower sternal border Apex Left Axilla
Palpation - PMI, thrills, heaves Neck
JVD 45 degree angle – find the top of the column
Carotids Auscultation
Ask patient to hold their breath Palpation
Extremities Edema Peripheral pulses
CV Exam Tips Feel the carotid pulse when listening to
the heart Gallops are heard best with the bell Recall the grading system of murmurs
and use this (1-6) and use “the language”
Does the murmur radiate? Identify new murmurs, diastolic
murmurs
CV Exam tips You do not need to report cm of JVD –
it’s OK to use landmarks. “With the patient at a 45 degree angle, JVD noted up to the earlobe”
Differentiate murmurs from bruits in the carotids
Lung Exam Auscultation
Start at Apex and listen for symmetry side to side Listen anteriorly as well Ask patient to open his/her mouth to breathe
Percussion – if needed only Consider in all patients with complaints (chest
pain, SOB, etc.) or a history of lung/cardiac disease
Especially good if you would like to verify findings
Abdominal Exam Good for any complaint of abdominal pain Observation Auscultate before palpation
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
Abdominal Exam Percussion
Liver edge – start at pelvic brim Used to estimate liver size Midclavicular line 6-12 cm Midsternal line 4-8cm
Musculoskeletal Exam Symmetry Range of motion Strength (can be under neuro) Joints
Synovitis – bogginess, heat, effusion, erythema
Squeeze tenderness of MCP’s/MTP’s Nodules
Tender areas (trigger points)
Musculoskeletal Exam
Musculoskeletal exam Patients with pain in multiple areas Patients with joint pain or stiffness Patient with weakness
Neurological Exam Headaches Weakness Numbness/tingling History of “stroke” Equipment needed: reflex hammer,
wooden cotton-tipped swab, low frequency tuning fork (the big one)
Neuro Exam – basic elements Alertness and orientation Gait Cranial nerves (2-12 is sufficient)
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)
Pearl Percussion and reflex testing are
bouncing motions See demonstration and practice!
Pelvic Exam See website
Knee exam Observation
Gait Rising from chair ROM Structure of knee (bulging)
Palpation Quadriceps strength Joint line Prepatella bursa Anserine bursa Popliteal fossa ROM for crepitus Instability (if needed): anterior, posterior, lateral, medial
Knee PalpationPrepatellar bursa
Anserine bursa
Popliteal fossa
Joint line
Shoulder Exam Observation
Symmetry front, side and behind Active ROM
Abduction Adduction Forward flexion Internal and external rotation
Palpation Start with the neck and upper trapezius Scapular spine Acromion and subacromial space Bicipital groove Clavicle including SC and AC joints
Tests for Rotator cuff tear Painful arc sign Drop arm test Weakness in external rotation
Hip Exam Gait Climb onto the examining table Range of motion
Flexion/extension Internal/external rotation
Palpation of trochanteric bursae Palpation of the SI joints Straight leg raise if radicular symptoms
Great Resource!! http://stanfordmedicine25.stanford.edu