Associated symptoms

• Relevantpast medical history

• Review of systems questions pertinent to the chief complaint and history of present illness of the system involved. (Note: List each question as either pertinent positives or pertinent negatives)

Example: "This is a 45-year-old teacher who presents for evaluation of burning pain in her stomach..." (This opening statement combines the chief complaint and the beginning of the history of present illness.) Medications/Allergies; Smoking/Alcohol Use1

• Medications and relevant home remedies, over-the-counter drugs, supplements, and any borrowed medications

1 The authors recommend placing this important data at the end of the HPI, but note that these items are often listed elsewhere in the history.

• Allergies to medications and resulting allergic symptoms (e.g., penicillins-rash)

• Smoking and alcohol use Past Medical History

• Childhood illnesses

• Adult illnesses

• Medical conditions

• Obstetric/gynecologic

• Psychiatric Family History (FH)

Major illnesses in the immediate family (parents, grandparents, siblings)

Personal and Social History (PSH)

Personal status, occupation, education, home conditions, interests

Review of Systems (ROS)

In the oral presentation only "unremarkable except for ..." (maximum of three or four items), which are not in the history of present illness

Required Reading

Bates' Chapter 1, An Overview of Physical Examination and History Taking, pp. 1-19.

Bates' Chapter 2, Interviewing and the Health History, 21-57. Bates' Chapter 18, Clinical Reasoning, Assessment, and Plan, pp. 783802.

Tips for Learning

You will polish your interviewing skills throughout your career. The flow of the interview will vary as much as the personalities of the many patients that you will encounter. Reading Chapters 1 and 2 is essential to learning the skills of good interviewing. Focus especially on "The Seven Attributes of a Symptom" (p. 27) and "Facilitating the Patient's Story: The Techniques of Skilled Interviewing" (pp. 30-34).

Although the shape and flow of the interview will differ for each patient, you must organize the patient's history into the standardized format provided on p. 3. Workshop 2: Adapting to the Challenging Interview Learning Objectives and Outcomes

• Identify techniques of verbal and nonverbal communication; review the principles of empathic interviewing.

• Learn strategies to address the challenging interview (i.e., the talkative patient, the angry patient, etc.).

• Discuss the model for cultural competence and guidelines for working with an interpreter.

Workshop Activities

1. Students will role-play various practice cases, provide feedback to the student interviewer, and identify strategies that facilitate the challenging patient interview.

2. Students will discuss the stages of the interview and demonstrate techniques for establishing rapport.

3. Students will demonstrate knowledge of open-ended versus close-ended questioning and subjective versus objective data from the patient.

Required Reading

Bates' Chapter 1, An Overview of Physical Examination and History Taking, pp. 1-19.

Bates' Chapter 2, Interviewing and the Health History, pp. 21-57. Bates' Chapter 18, Clinical Reasoning, Assessment, and Plan, pp. 783802.

Tips for Learning

You will come to remove the word "I" from your interviewing style. The key to a good interview is to focus on the patient's story and to use the skills of good interviewing to enhance and clarify what the patient tells you, especially the chronology of his or her symptoms.

At the same time, through nonverbal behaviors, you will project your empathy and concern for the patient and learn to be attuned to the patient's affect, or mood state. You will find that it often helps to acknowledge directly the patient's sadness, nervousness, or anger by saying, for example "You seem sad today." Once the patient expresses these feelings or realizes that you are aware of them, the interview often flows more easily.

Workshop 3: General Survey, Vital Signs, and Skin Learning Objectives and Outcomes

• Sharpen skills for assessing and describing the patient's general appearance, including:

■ Level of consciousness, signs of distress, apparent state of health

■ Facial expression

■ Posture, gait, and motor activity

■ Dress, grooming, and personal hygiene.

• Demonstrate skills for accurate measurement of blood pressure, heart rate (radial and apical), respiratory rate, and temperature.

• Learn techniques of examination of the skin, hair, and nails, including abnormalities, such as basic skin lesions, vascular and purpuric lesions, skin tumors, and abnormalities of the nails.

Workshop Activities

1. Bring your stethoscope and penlight.

2. Describe the general appearance of

• A hypothetical patient with congestive heart failure (CHF)

• A hypothetical patient with chronic obstructive pulmonary disease (COPD)

3. Demonstrate accurate technique for measuring the four vital signs.

4. Describe five components of optimal technique for recording blood pressure.

5. Describe the difference between systolic and diastolic blood pressure; define auscultatory gap.

6. Describe macule, papule, vesicle, basal cell carcinoma, squamous cell carcinoma, clubbing, spider angioma, psoriatic plaque, and skin findings in neurofibromatosis (including typical location, distribution, arrangement, type, and color).

Sample Verbal Presentation

The patient is a healthy young male who appears fit and muscular. He is pleasant and cooperative. Blood pressure is 120/80; heart rate, 80 and regular; respirations, 16; afebrile. Skin is warm and moist. Nails without clubbing or cyanosis. No rashes, petechiae, or ecchymoses. Required Reading

Bates' Chapter 3: Beginning the Physical Examination: General Survey and Vital Signs, pp. 59-93.

Tips for Learning

The General Survey begins with the first moments of your interview of the patient. You will come to sharpen your powers of observation and learn much about the patient from his or her demeanor. The Vital Signs are critical to all patient assessments, as are oral and written presentations. Learn to be systematic in presenting them. Hair, skin, and nails also provide many clues to the patient's state of health. Learning the proper descriptive terms for findings from the examination of the skin is important.

Workshop 4: Head, Eyes, Ears, Nose, Throat (HEENT), Neck Learning Objectives and Outcomes

• Identify key anatomic structures basic to examination of the head and neck, especially regions of the skull; anatomic detail of the eye; the three bones of the middle ear, auricle, and pinna; the nasal turbinates; the sinuses; and the nine groups of cervical lymph nodes.

• Demonstrate assessment techniques for visual acuity, extraocular movements, pupillary reaction, auditory acuity, oral and pharyngeal mucosa, gums, dentition, cervical lymph nodes, cricoid cartilage, and thyroid isthmus and lobes. Demonstrate appropriate funduscopic examination.

Workshop Activities

1. Bring a penlight, eye card, and tuning fork (256 Hz). The instructor will provide the ophthalmoscopes, otoscopes, tongue depressors, and cups for water.

2. As you practice the skills of Chapter 5, focus especially on use of the ophthalmoscope and examination of the fundi and on palpation of the thyroid gland.

3. List six tips for use of the ophthalmoscope: (1) always darken the room; (2) reduce maximum ophthalmoscope brightness by 20%; (3) go to the small circular dot; (4) stand at a 30-degree angle to the patient; (5) place thumb on eyebrow to support your head as you move in; (6) look for the point where four retinal arteries merge together. It is also helpful to look with the ophthalmoscope toward the patient's nose to locate the fundus more easily.

4. Teach your partner verbally how to examine a thyroid. For example, for the posterior approach, identify the cricoid cartilage, have the patient tip her head slightly forward and to the side, and palpate between the sternocleidomastoid and trachea for rubbery tissue of the ipsilateral thyroid gland.

5. Describe changes of hypertensive and diabetic retinopathy.

Sample Verbal Presentation

The skull is normocephalic/atraumatic (NC/AT). Pupils are 4

mm constricting to 2 mm and equal, round, and reactive to light and accommodation (PERRLA). The discs are flat, without hemorrhages or exudates. TMs clear. Oral mucosa pink; dentition good; pharynx without exudates. Neck supple: without thyromegaly. No lymphadenopathy. Required Reading

Bates' Chapter 5: The Head and Neck, pp. 115-208. Tips for Learning

The most challenging parts of examination of the head and neck are learning to use the ophthalmoscope, seeing the fundi, and examining the thyroid. Don't be discouraged if you can't see the fundus on your first attempt. Remember, if you practice the correct techniques, you will succeed! Be sure to ask your preceptors for help. This workshop is your best opportunity to learn the proper techniques well enough to teach them to your partner, so the tips for examining the fundi and thyroid described above are important. Workshop 5: Thorax, Lungs, and Cardiovascular System Learning Objectives and Outcomes

• Demonstrate the following techniques for examining the lungs: percussion, excursion, descent of diaphragms, and auscultation (including right middle lobe).

• Demonstrate the proper technique for assessing jugular venous pulsation (JVP) and carotid upstrokes. Please note that examination of the JVP and carotid upstrokes is part of the cardiac examination, even though they are in the neck.

• Demonstrate techniques for palpating heaves, lifts, and thrills and point of maximal impulse (PMI).

• Demonstrate use of bell and diaphragm in the six areas of auscultation. Distinguish S1 from S2 and systole from diastole.

• Demonstrate maneuvers to elicit an S3 or mitral stenosis and aortic insufficiency.

Workshop Activities

1. Bring your stethoscope and a clear plastic ruler.

2. Describe the pathophysiology of chronic obstructive pulmonary disease (COPD) and asthma. Be prepared to present orally the physical findings of the lung examination for these two conditions.

3. Describe the normal cardiac cycle.

4. Describe two ways to report your measurement of the JVP: "x" cm above the right atrium or "x" cm above the sternal angle with the head of the bed elevated to "x" degrees.

5. Describe the grading system for murmurs.

6. Describe the pathophysiology of S3, S4, mitral regurgitation, mitral stenosis, aortic regurgitation, aortic stenosis, and pericardial rubs. Give the best location for auscultating each of these murmurs. Demonstrate the maneuvers for eliciting low-

pitched sounds, like an S3, or the murmur of mitral stenosis (isometric hand-grips) and for eliciting the soft, blowing decrescendo murmur of aortic insufficiency (pp. 226-229; 233; 240-243). Sample Verbal Presentation

Thorax symmetric with good excursion. Diaphragms descend 4 cm bilaterally. Lungs are resonant, breath sounds vesicular; no wheezes, rales, or rhonchi.

JVP is 6 cm above the right atrium; carotid upstrokes brisk, no bruits. PMI tapping, 8 cm lateral to midsternal line in fifth intercostal space (ICS). Good S1, S2; no murmurs or extra sounds. Required Reading

Bates' Chapter 6: The Thorax and Lungs, pp. 209-243. Bates' Chapter 7: The Cardiovascular System, pp. 245-295. Tips for Learning

Percussion is an art. Be sure you aim for a medium-loud, clear percussion note. Your third fingernail will need to be short so you can tap against the distal knuckle of the third finger of your "pleximeter" hand (see pp. 223-224). Do not damp out your percussion note by pressing too hard with your pleximeter finger or placing any other fingers on the chest wall. Listen for a dull percussion note by percussing over the scapula, compared with a resonantpercussion note over the lower lung fields. Use the ladder technique (p. 225), which helps you compare adjacent percussion sounds from each lung.

Measuring the JVP is also an art that you will master with practice. One helpful tip is to think about the patient's volume status before you begin the cardiovascular examination. Is the patient euvolemic, hypovolemic, or hypervolemic? Begin by raising the head of the bed to the standard position of 30 degrees. Your goal is to see the meniscus, or top of the column of blood in the internal jugular vein. Remember that if the patient is hypovolemic, as in dehydration or gastrointestinal (GI) bleeding, the JVP will be down and you may need to lowerthe head of the bed. If the patient is hypervolemic, as in congestive heart failure (CHF), the JVP may be upand you will need to raise the head of the bed. Be sure to review p. 266 and p. 267 so that you understand the principles, techniques, and ways to report your measurement of the JVP.

Another tip is to palpate the carotid upstroke with your left hand as you listen to S1 and S2 with your stethoscope. The carotid upstroke coincides with systole, or the interval between S1 and S2. Palpating the carotid artery will help you decide if murmurs are in systole or diastole. Remember, you should always turn the patient to the left side and listen for an S3 with your bell.

Workshop 6: Cardiovascular System and Abdomen Learning Objectives and Outcomes

• Practice the lung and cardiac examination; ask for spot checks by your preceptor.

• Inspect the abdomen for symmetry, scars, and striae. Auscultate bowel sounds. Percuss the liver and measure the liver span. Perform light and deep palpation of the abdomen. Palpate the liver edge. Demonstrate correct technique for examining the spleen. Assess costovertebral angle (CVA) tenderness.

• Demonstrate how to assess for guarding and rebound tenderness.

• Listen for abdominal and inguinal bruits. Workshop Activities

1. Bring your stethoscope and plastic ruler.

2. Demonstrate two methods for examining the spleen.

3. Describe how to assess patients with possible ascites for shifting dullness.

4. Describe at least four "peritoneal" signs.

5. List six items to check when assessing for possible appendicitis (pp. 347-348).

6. Describe Murphy's sign. Sample Verbal Presentation

See the cardiac examination from Workshop 5. Abdomen is scaphoid. Bowel sounds are active. The abdomen is soft, nontender. Liver span is 9 cm in the right midclavicular line (MCL); edge is smooth, palpable one finger-breadth below the right costal margin (RCM). Spleen not felt. No CVA tenderness, no abdominal or femoral bruits. Required Reading

Bates' Chapter 9: The Abdomen, pp. 317-366. Tips for Learning

When you palpate the abdomen, always watch the patient's face for signs of pain or discomfort. This will help you to localize areas of tenderness. When there is tenderness, pain, guarding, or rebound, learn to think about the underlying organs in that quadrant, which might be involved. For example, for right upper quadrant tenderness, consider biliary disease or cholecystitis, hepatitis, or peptic ulcer disease. Workshop 7: Extremities: Peripheral Vascular System and Lymph Nodes

Learning Objectives and Outcomes

• Assess brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

• Compare orthostatic edema to lymphedema.

• Examine axillary, epitrochlear, and superficial inguinal lymph nodes.

• Demonstrate an appropriate sequence of examination, beginning with the General Survey and Vital Signs through the Peripheral Vascular examination.

Workshop Activities

1. Bring your stethoscope, penlight, and ruler. (The instructor should provide the otoscope and ophthalmoscope.)

2. Describe the superficial and deep venous system of the legs.

3. Report five ways to distinguish arterial from venous occlusion. [In arterial occlusion, the patient complains of claudication; skin is cool, blanched, shiny, and atrophic with loss of hair and diminished pulses, progressing to ulceration, ischemia, and necrosis from gangrene. In venous occlusion, skin is hyperpigmented with the bluish-red color of dependent edema, sometimes with swelling and cyanosis, progressing to pain and ulceration (see pp. 462-463)].

4. Describe indications for and techniques of the Allen test.

5. Be prepared for spot checks on examination techniques to date. (Option: Instructors may want to grade student performance.)

6. Be prepared to present verbally the physical examination findings of a healthy patient from the General Survey through peripheral pulses.

Sample Verbal Presentation

Radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric. Extremities are warm and without edema. Calves are supple. No epitrochlear, axillary, or inguinal adenopathy.

Required Reading

Bates' Chapter 14: The Peripheral Vascular System, pp. 441-464. Tips for Learning

As you begin the physical examination with the patient sitting on the examination table, note whether the patient develops dependent rubor with the extremities in a dependent position. Edema may or may not be visible, so always check for pitting. Remember that claudication has two etiologies. It can be vascular, resulting from arterial insufficiency. It can also result from spinal stenosis or arthritis of the vertebra that compresses the spinal cord when the patient is in certain positions (you will learn more about this during examination of the nervous system). Remember that you should always check to see if calves are supple, especially in patients on bed rest, but be aware that the sensitivity and specificity of Homans' sign for deep venous thrombosis (DVT) is only 50%. If you suspect DVT, you must proceed to further testing.

Workshop 8: The Musculoskeletal System Learning Objectives and Outcomes

• Understand the unique features of each major joint and how, for joints, anatomy is destiny: Structure determines function.

• Demonstrate techniques of examination for the neck and spine; the shoulders, elbows, wrists, and fingers; and the hips, knees, ankles, and feet.

• Demonstrate the maneuvers to assess rotator cuff sprain, hip arthritis, and the seven structures of the knee.

• Demonstrate the bulge sign.

• Describe maneuvers to assess carpal tunnel syndrome.

Workshop Activities

1. Describe the three principle types of joints, including the three types of synovial joints.

2. Describe the three bony landmarks of the shoulder and the three joints that articulate at the shoulder.

3. Name the principal muscles of the back.

4. Name the major muscle groups that move the femur and the tibia and fibula.

5. Focus especially on the examination techniques for the shoulder, low back, hip, and knee.

6. Describe at least six differences between rheumatoid arthritis and osteoarthritis.

Sample Verbal Presentation

Good range of motion in all joints. No joint swelling or deformity.

Required Reading

Bates' Chapter 15: The Musculoskeletal System, pp. 465-533.

Tips for Learning

Each joint has its own personality. Learn the special features of each joint as determined by its structure. For example, the shoulder allows the widest range of rotatory motion, but it is barely attached to the axial skeleton. Only the four rotator cuff tendons and their muscle groups suspend the shoulder, so almost any bump or trauma causes shoulder pain and problems. In contrast, the hip joint is deep in the pelvis and highly stabilized by major bony structures and muscle groups. These features are essential for its role in carrying so much of the body's weight. The hip joint is well padded and somewhat protected from fracture until older adulthood. Now, think about the knee. It is amazing that only seven structures stabilize the knee and keep the femur from sliding off the tibial plateau: the medial collateral ligament (MCL), the lateral collateral ligament (LCL), the medial meniscus, the lateral meniscus, the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), and the patellar tendon. So now you understand why knee problems are so common. Be sure to learn the maneuvers to test each of these knee structures and use the appropriate anatomic terminology. Workshop 9: The Nervous System Learning Objectives and Outcomes

• Review the organizing principles of the neurologic examination: symmetry vs. asymmetry and localization of findings to the central nervous system vs. the peripheral nervous system.

• Demonstrate the examination of the Cranial Nerves.

• Demonstrate the examination of the motor system, including bulk, strength, tone, and cerebellar function; rapid alternating movements (RAM); finger to nose (F^N); heel to shin (H^S); and gait. Be sure you know how to grade motor strength.

• Demonstrate examination of the sensory system, including pinprick and light touch, vibration, position, and two-point discrimination.

• Demonstrate effective use of the reflex hammer and proper technique for eliciting reflexes, including the plantar response or Babinski sign.

Workshop Activities

1. Bring your reflex hammer and tuning fork to class. Instructors will provide Q-tips to test sharp and dull.

2. Describe the lobes of the brain and the three components of the brainstem, as well as their vascular supply.

3. Know the functions of each Cranial Nerve.

4. Recite the nerve roots for the following reflexes: biceps, triceps, knee, and ankle.

5. Know the neuroanatomy and physical findings of Bell's palsy versus a central nervous system lesion causing facial weakness.

6. Be prepared to describe the differences between metabolic and structural coma.

7. Review the Glasgow Coma Scale.

8. Demonstrate maneuvers to elicit Kernig's and Brudzinski's signs.

Sample Verbal Presentation

Note the following order for both verbal and written presentations:: Mental Status, Cranial Nerves, Motor, Sensory, Reflexes.

The patient is oriented to person, place, and time. Cranial NervesII through XII are intact. Motor: good bulk and tone. Strength is 5/5 throughout. RAMs, F ^N, H ^S intact. Gait with normal base. Sensory: Pinprick and light touch are intact and symmetric throughout. Reflexes: 2+ and symmetric with toes downgoing. Required Reading

Bates' Chapter 16: The Nervous System, pp. 535-622. Tips for Learning

Always check for symmetry, comparing findings on the right to findings on the left. Begin thinking about how neurologic disorders present in terms of symptoms and physical findings. There are many clinical syndromes in neurology, so you will learn how to interpret the findings in many diagnoses from attendings and neurology consultants. Thus, it is especially important for students to obtain excellent histories and conduct careful and thorough neurologic examinations. Be aware that many clinicians integrate examination of the cranial nerves and upper extremities into their examination of the head, neck, and thorax, respectively, while the patient is sitting. Likewise, clinicians often assess lower extremity strength and overall sensation and reflexes when the patient is supine.

Workshops 10 and 11: Complete Physical Examination and Standardized Patient Assessments Learning Objectives

• Perform a complete adult physical examination.

• Obtain a focused history and perform a focused physical examination on a standardized patient.

Complete Physical Examination

Students will perform these on their partners. Students should wear comfortable clothing (women should wear sport bras) in preparation for when they are "patients." Neurologic and musculoskeletal examinations are EXPECTED. Male and female genitalia examinations are excluded. Standardized Patient Assessments

"Standardized patients" are people trained to act as patients. They are given a mock history and are expected to enact symptoms. (They do not really have the disease under discussion, although some appear really convincing!) These people will provide direct feedback about students' performance of a focused history and physical examination.

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