cse exam Flashcards
Intro questions
introduction
confirm pt name
confirm pt age
state that I’m an M2
chief complaint
ask open ended Q- what brings u here today
ask second open ended question - cna you tell me about your
History of Presenting illness
quality location severity duration frequency presence TODAY radiation aggravating alleviating
previous history
ask about history of similar symptoms
ask about previous history of probably diagnosis
HPI review
summaraize information
is there anything else?
ask pt what they think might be causing it
how does this impact patient function
past medical history
ask general question about health/ medical problems ask about history of high BP heart attack stroke cancer
history of surgery hospitalizations precribed meds over the counter meds herbs or vitamins medication allergies what happens when have the allergy
family history
anything run in the family general question about parents age ask about mother and father hisotry of high BP stroke diabetes cancer ask about siblings
psych history
ask about patients job level of education who lives w patient marital status and history children?
smokes? how much and how long
alcohol? how much how often
illicit drugs?
stressors at work or home?
Order of physical exam
wash hands
vital signs
system exam
symptom specific exam
order of verbal part
intro chief complaint history of presenting illness previous history symtpom specific symptoms HPI review past medical history family history psych history
back pain
DO MSK exam: 1-percuss thoracic and lumbar spine 2-palpate lumbosacral area for tenderness 3- test cervical spine range of motion 4-test lumbar spine range of motion 5-straight leg raise 6-passive hip range of motion 7-lower extremity strength of knees and ankles
- CVA tenderness
- knee jerk reflexes
- achilles jerk reflexes
- distal light touch in 2 locations
shortness of breath physical exam
- check chest expansion
- percuss posterior lungs/thorax (3 places)
- auscultate posterior lungs
- auscultate lateral lung fields
- look for leg edema
- Brachial, ulnar and radial pulses
- apical impulse
- cardiac valves
- JVP
faintness physical exam
cardiovascular
- upper extremity impulses (brachial, ulnar and radial)
- palpate radial pulses simultaneously
- palpate lower extremity pulses (posterior tibial and dorsalis pedis)
- leg edema
- palpate cardiac apical impulse
- auscultate cardiac valves
- JVP
- orthostatic BP and HR (laying -30 sec - sitting
- carotid auscultation
- 4 cranial nerves
- gait xam: walk, tandem, toes, romberg
abdominal pain physical exam
- auscultate bowel
- percuss bowel
- palpate lightly
- palpate deeply
- rebound tenderness
- liver edge
- CVA tenderness
- suprapubic tenderness
- cardiac auscultation
- ask for pelvic
Headache physical exam
- auditory canals
- nose
- mouth and tongue / posterior pharynx
- frontal sinus
- maxillary sinus
- cervical LN
- submanibular LNs
- eye exam
- cranial nerve: facial nerve uppre +lower, CN12, EOM
- peripheral strength: handgrip, biceps and triceps, ankle dorsi and plantar flexion
- rapid alternating
- gait:tandem, walk, toes, romberg
