USMLE Step 2 CS physical Exam 2023

physical exam - ANSWER-- DO NOT DO A COMPLETE PHYSICAL EXAM!!!! - There are 6 potential systems - Complete the primary system first then do secondary systems - Do not need to do all parts of secondary but do most of primary exam - start it by saying "Now I'll do your physical exam. Do you have any questions while I wash my hands." Hand washing/Draping - ANSWER-- WARING GLOVES IS NOT A SUBSTITUTION!!!!! - drape the patient well before washing hands - must fully expose are under examination - ask to remove robe and shoes/socks (diabetic foot ulcer) - replace items when that portion of the exam is over Skin - ANSWER-- inspect carefully - tell pt what you are looking at (you get credit for them knowing) - pt. may spray water for diaphoresis - white powder - pallor, anemia - yellow powder - jaundice (sclera will be clear -> document that but this is still the jaundice case) - purple - ecchymoses, bleeding disorder, trauma - red - infection, inflammation exam in each system - ANSWER-you must - inspect - auscultate - percuss - palpate - bilaterally abdominal exam - ANSWER-- complete exam when CC: abdominal pain, vomiting, diarrhea, jaundice, UTI, pelvic pain - Inspection (scars, hernias, makeup): "I'm looking at your belly. Have you noticed any changes?" - Auscultation (listen for 3 seconds in all 4 quadrants): "Now I will listen to your belly" - Percussion (two taps per quadrant) "Now I'm going to tap on your belly" [tap out liver size if jaundice, liver (coagulation), or CHF case] - Palpation (palpate all 4 quadrants, epigastric and suprapubic for 3 seconds each) "I need to press on your belly now" Special tests: - Murphy's sign - cholecystitis: place hand under right costal margin and "please take a deep breath and tell me if it hurts." Repeat bilaterally - CVA tenderness - kidney stones, pyelonephritis, other kidney pathology: tap lightly while supine "I'm going to tap/press on your back please tell me if it hurts" - Rebound tenderness - peritonitis: palpate deep slowly then rapidly release "I need to press deeply on your belly. does it hurt more when I push down or let go?" (positive when rapid release is more painful) Appendicitis (RLQ pain) - Rovsing's sign: pain in RLQ when palpating LLQ, "any tenderness? where?" - Obturator sign: pain in RLQ when flexion of right hip to 90 degrees and knee pushed medially and ankle laterally (internally rotate hip) "I'm going to uncover your leg and bend it" - Psoas sign: RLQ pain with flexion of the hip against resistance "please bring your leg up. do you have any pain?" - McBurney's point: 1/3 from the iliac crest and 2/3 from the umbilicus Chest/lung exam - ANSWER-- complete exam when CC: cough, shortness of breath, chest pain, Respiratory tract infection, sputum production - "I need to look at your back and chest to examine your lungs, may I untie your gown?" - Inspection: (check hands for clubbing and cyanosis, check back/chest/sides/under-arm for scars/bruises/trauma) "I'm going to look at your back and chest" - Respiratory excursion (to determine if chest expands bilaterally identifies fluid or air in the plural space) [place hands on back pushing up to get fat out of the way.] "I'm going to push on your ribs, take a deep breath" - Palpation (check for chest wall tenderness): "I'm going to push on your ribs and back. tell me if anything hurts" - Tactile fremitus (place ulnar aspect of hand on pts. back bilaterally x 3) "please say 99" - percussion (3 x bilaterally): "I'm going to tap on your back" - Warm up stethoscope "Let me warm this up for you" - Auscultation (listen left then right to compare 6 on back and 4 on front. listen to complete breaths) "I'm going to listen to your lungs. take a deep breath in and out through your mouth" Cardiovascular exam - ANSWER-- complete exam when CC: suggest MI, chest pain, shortness of breath, pedal edema, syncope, palpitations - 2 exams one sitting up second at 30 degrees Sitting exam: - auscultation of neck bruit (carotid plaque) " I'm going to listen to your neck. please take a deep breath and hold it" - palpation of carotids (DO NOT DO SIMULTANIOUS LY) "I need to check the pulse in your neck" - Pulses (check radial, dorsalis pedis and posterior tibialis [medial ankle] simultaneous bilaterally. Check for clubbing and cap refill. check for A fib irregularly irregular) "I'm going to check your hands and feet" - Extremities "I'm going to check your legs for swelling" - auscultation (four locations, ask pt to lift breast. do not examine over clothes or slide stethoscope under clothes Lying at 30 degrees: - JVD "I'm going to look at the vein in your neck please look to your left" - hepatojugular reflex (press on RUQ for 20- 60 seconds and look for JVD distention or drop in JVD when RUQ released) "continue to look to the left I'm going to push on your belly while looking at your neck" - find PMI "I'm going to press near your heart" - auscultation (four locations, ask pt to lift breast. do not examine over clothes or slide stethoscope under clothes Neuro exam - ANSWER-- complete exam when CC: headache, dizziness, balance or vision problems, numbness or tingling, psych problem, memory problem, muscle weakness - 7 parts - if pressed for time do orientation and gait Neuro part 1 Mental status - ANSWER-- complete exam if psych, dementia, or altered mental status, otherwise just orientation - Orientation (person place and time) "I'm going to ask you a few questions to test your memory" Who/where/when - memory: do immediate and delayed recall, 3 words - attention and concentration: spell 'world' backwards - language repeat "No if ands or buts" - obeys commands "please close your eyes" Neuro part 2 cranial nerves - ANSWER-- "We are going to do a number of exercises to test your nerves, let me know if anything hurts" - CN2 "how many fingers am I holding up" each eye separately - CN2-3: Pupils are Equal, Round, Reactive to Light and Accommodation (PERRLA) "I'm going to shine a light into your eyes and look at them - CN 3, 4, 6 " please hold your head still and follow my finger with your eyes" (3 - ptosis, blown, down, and out; 4 - cannot look down or in; 6 - eye is turned in) - CN 5 motor: (feel jaw muscles) "clench your teeth" sensation "close your eyes and tell me if it feels equal on each side as touch your face with a cotton ball" - CN 7 "show me your teeth and raise your eye brows", "smile and show me your teeth", "raise your eye brows" - CN 9,10,12 " stick out your tongue and say ahh" (9&10 symmetrical palate, 12 tongue is straight) - CN 11 "shrug your shoulders" Neuro part 3 motor - ANSWER-- "Now I'd like to check your muscle strength" - Show all actions - "First your arms" - C5-6: forearm flexion - radial: extend arms - radial: wrist extension - median: finger flection "squeeze my fingers" - ulnar: adduction "don't let me pull you fingers apart" - ulnar: abduction "don't let me push you fingers together" - "now your legs" - L2-3 hip flexion - L4-5 hip extension - L3-4: knee extension - S1: knee flexion - L5: dorsiflexion ankle - S1: plantar flex ankle Neuro part 4 sensory - ANSWER-- complete if CC: numbness and tingling or history/suspicion of diabetes - start distal, if intact move on - use cotton ball for light tough and tooth pick for pain - joint position sense only if CC: diabetic or numbness - vibration: confirm vibration then use other hand to stop vibration and ask pt to tell you when it stops ARM - Thumb: C6 - middle finger: C7/median - pinky: C8/ulnar - back of hand: radial LEG - just above patella L4 - lateral lower leg L5 - lateral foot S1 Neuro part 5 reflexes - ANSWER-- compare both sides - thyroid case: check only biceps (C5/C6) reflex for hyporeflexia - sciatica case: Achilles (S1) and patellar (L4) - stroke: biceps and patellar Neuro part 6 cerebellar exam - ANSWER-- Gait: most important part of cerebellar exam - finger to nose - heel to shin Neuro part 7 special tests - ANSWER-Meningitis - stiff neck - Brudzinski's sign: chin to chest causes knees and hips to flex spontaneously - Kerning's sign: flex hip to 90 and pt will have leg pain/stiffness on extending leg ----- - Babinski: "I'm going to scratch the bottom of you feet" (flexion is normal after 6m and extension means UMN lesion - Romberg's sign: "Keep your feet together, arms out, palms up, head back, and eyes closed. I'll be right behind you if you feel unsteady" HEENT - ANSWER-- complete exam when CC: headache, eye pain, vision change, ear pain, dizziness, hearing loss, pharyngitis, throat pain, swelling - thyroid case: Hx: bowel, hot/cold intolerance, weight change, sleep change. PE: brittle hair, rough skin, tremor in hands, and abn reflex - Inspection: (scars, abnormalities, deformities, and skin changes) "I'm going to look at your head" - palpation: (tenderness/deformities of head, sinuses, and face, check TMJ) "I need to press on your head and face) - examine lymph glands (submental, submandibular, anterior and posterior cervical chain, pre- and post-auricular, supraclavicular) "I need to check your neck for swollen glands" - Inspection: look at neck and thyroid "I need to look at your neck now" - auscultate for carotid bruit - palpate thyroid and offer water to swallow "I need to feel your neck" - Test visual acuity "how many fingers am I holding up" EYE - "look at a point on the wall" use light for pupillary and consensual reflexes - inspect sclera for redness and jaundice - Inspect conjunctiva for pallor or discharge "now I'm going to touch below your eye - Funduscope: dim the lights (if possible) "now I need to look into your eyes, please focus on this spot on the wall" (L to L and R to R) Ear - otocsope: "to look in your ear I need to pull on it a little let me know if anything hurts" Nose: - "any discharge? can you breath out of both nostrils?" Hearing tests - ANSWER-Rinne test: "I'm going to put the tuning fork behind your ear, now in front of your ear, which was louder?" Weber: "I'm going to put the tuning fork on your forehead, which side is louder?" Test the ear suspected of hearing loss first - Normal R: air>bone and W: equal - conductive loss R: bone>air and W: Louder on the side with hearing loss (bone is louder than air due to tympanic membrane problem) - sensorial: R: air>bone and W: quieter on affected side (CN8 has nerve damage) Joint exam - ANSWER-- Inspection - palpation - active ROM and passive ROM, - if passive>active or less painful -> problem is with muscle/tendon outside the joint (extra-articular) - if poor ROM and passive = active -> problem in joint (intra-articular) - Distal motor, reflex, sensation and pulse (MRS P) - Distal Back exam - ANSWER-- Inspection: "I need to look at your back" - palpate: "I need to push down your back" (palpate all spinous processes) DO NOT TOUCH THE PTs UNDERWARE!!! - ROM: flex, extend, lateral bend R/L, rotate R/L "pain?" - MRS test of legs Special tests - gait - straight leg raise to elicit impinged nerve pain (L4 - front of leg, L5 - lateral leg, S1 - back of leg Documentation: - order rectal and prostate exams - consider brief abdominal exam Knee exam - ANSWER-- must compare both sides - Inspection (look for deformity, ecchymosis, swelling) "I'm looking at your knee do you notice anything different?" - palpation: (skin warmth, patella for fracture, ballot for effusion, lower femur and fibular and tibial heads, both menisci -ROM and MRSP - ACL and PCL anterior and posterior drawer sign (pull and push) McMurry's meniscus test looking for pain: - MM tear - supine with knee at 90 laterally rotate tibia and extend leg - LM tear- supine with knee at 90 medially rotate tibia and extend leg hip exam - ANSWER-- diagnose from history - if you need to palpate over under ware ask permission physical findings - short and externally rotated -> hip fracture or anterior dislocation - short and internally rotated -> posterior hip dislocation - Inspect - palpate - ROM - MRSP ankle/foot exam - ANSWER-- Inspect - palpate - ROM