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 Supervisor

1. 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