Hypothesis-Driven Physical Exam · sign(s) associate with each diagnostic hypothesis. Otaki, Nishigori, Bordage, Yudkowsky, Riddle & Lowenstein. ... Ectopic pregnancy 4. Pyelonephritis

© 2011, The Board of Trustees of the University of Illinois and The University of Tokyo. Last update: 03/01/2011 v7 (MEdP)

_____________________________________________________________________________________________________________________

J. Otaki, MD, DMedSc Department of General Medicine & Primary Care, Tokyo Medical University Hospital

H. Nishigori, MD, MMEd, PhD International Research Center for Medical Education, The University of Tokyo

G. Bordage, MD, PhD Department of Medical Education R. Yudkowsky, MD, MHPE University of Illinois at Chicago J. Riddle, MD

T. Lowenstein, MD Department of Family Medicine Clalit Health Services, Haifa University _____________________________________________________________________________________________________________________ A Japanese version of this handbook can be found at: http://www.ircme.u-tokyo.ac.jp/activity/hdpe.html

Hypothesis-Driven Physical Exam _________________________________________________

Student Handbook

Otaki, Nishigori, Bordage, Yudkowsky, Riddle & Lowenstein. © 2011, The Board of Trustees of the University of Illinois and The University of Tokyo.

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This project was funded in part by grants from:

- The Edward J. Stemmler Medical Education Research Fund, National Board of Medical Examiners (NBME), Philadelphia, USA. This publication does not necessarily reflect NBME policy and NBME support provides no official endorsement. - Aid for Scientific Research, Ministry of Education, Culture, Sports, Science, & Technology, Government of Japan, Tokyo, Japan.

This document may be reproduced in part or in whole with the understanding that proper reference and attribution to the authors and title of the document will be explicit. Please send any comments or suggestions to Dr. R. Yudkowsky at [email protected].


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Table of content Context 4 How to use this handbook 5 Validation 7 Complaints and Prototypical Diagnoses 8 1. Heart murmur 10 2. Itchy Scalp 12 3. Stuffy Nose and Sore Throat 14 4. Swollen Neck and Fatigue 16 5. Blurred Vision 17 6. Hearing Loss 18 7. Funny Feeling Face 19 8. Shortness of Breath 20 9. Lump in Breast 22 10. Leg Pain on Exertion 23 11. Upper Abdominal Pain 24 12. Lower Abdominal Pain 25 13. Painful Wrist 26 14. Painful Shoulder 28 15. Sore Knee 29 16. Painful Hip 30 17. Painful Ankle 31 18. Unsteadiness 32 19. Back Pain 34 List of maneuvers 36


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Context

The set of complaints and prototypical diagnoses contained in this handbook were

developed as part of a hypothesis-driven approach to assessing the complete, head-to-

toe physical exam in order to better integrate the technical and cognitive aspects of the

physical examination. In a nutshell, you are asked to learn the physical exam

maneuvers in the context of chief complaints, limited prototypical diagnoses, and

discriminating features. When tested on your physical exam skills, you are presented

with a short history and an accompanying differential diagnosis consisting of two

alternative diagnoses; the history is kept short because the emphasis here is on

anticipating and performing a physical exam with specific discriminating signs in mind.

Your task is then:

a) To anticipate the positive physical findings for each diagnosis in the differential

and identify the discriminating findings between the diagnoses;

b) To perform the physical exam maneuvers on a patient instructor exhibiting

certain positive findings (Patient instructors are highly trained standardized

patients who not only simulate clinical findings but also provide instruction to the

students when needed, for example, correcting a poorly or incorrectly executed

physical exam maneuver.);

c) To interpret the findings by proposing a most likely diagnosis;

d) To correct any physical exam maneuvers, as prompted by the patient instructor if

needed, that were incorrectly executed or omitted initially and to revise your

working diagnosis if needed; and

e) To document the findings associated with your physical exam.

We selected 160 physical exam maneuvers that were grouped according to 19 chief

complaints (e.g., blurred vision, shortness of breath) and 60 distinct diagnoses.

Typically, there are three to four prototypical diagnoses for each chief complaint. The

main purpose is to learn the maneuvers in the context of a differential diagnosis and

discriminating features. Special attention was paid to include frequent or prototypical


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diagnoses. As part of your learning experience, you are given in this handbook the

diagnoses and the list of maneuvers associated with each complaint.

How to use this handbook.

On your own, look up the maneuvers associated with each diagnosis and identify the

discriminating positive and negative findings associated with various pairs of diagnoses.

Although the chief complaints may refer initially to a specific anatomical region (e.g., the

neck or lungs), other anatomical structures and systems may be involved as dictated by

the differential diagnosis. For example, if you are examining the lungs for congestive

heart failure, the neck (JVP) and the lower limbs (pedal edema) are also included in that

chief complaint.

As an example, the table below illustrates the discriminating findings associated with a

clinical scenario suggesting a lateral epicondylitis (tennis elbow) compared to an

olecranon bursitis; a diagnosis of septic arthritis could also be possible in an elbow.

The discriminating findings for a lateral epicondylitis and an olecranon bursitis are

highlighted in yellow shadings in the table.

Note. The diagnoses in this example come from a differential diagnosis that is not part

of this handbook.

Clinical scenario: Tina, a 42-year-old women, came to the clinic because her right

elbow has been bothering her for the last 10 days. The discomfort is worse with activity.

You are thinking about a possible lateral epicondylitis (tennis elbow) or an olecranon

bursitis. In anticipation of your physical exam of the upper extremities, list the positive

sign(s) associate with each diagnostic hypothesis.


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Lateral epicondylitis (tennis elbow)

Olecranon bursitis Septic arthritis

M1 Wash hands √ √ √ MA10: Have patient point out location of pain

Points to lateral epicondyle

Points to olecranon process

M90: Assess range of motion of elbows bilaterally

Normal Decreased at the end of extension when large effusion present

M91: Inspect and palpate elbows bilaterally

- Normal to inspection - Tender lateral

epicondyle on palpation

- Swollen, fluid filled sac; possibly warm & erythematous

-Painless swelling

M88: Assess range of motion of wrists bilaterally

Normal Normal

M118: Test grip strength bilaterally

Normal Normal

M120: Test biceps strength bilaterally

Normal or possibly painful at lateral epicondyle

Normal

M121: Test triceps strength bilaterally

Normal Normal

M161: Tennis elbow (Cozen’s) test

Painful Not painful

Avoid the temptation of simply copying the set of discriminating findings from fellow

students. The active search and organization of discriminating findings will help you

better understand the significance of each maneuver and associated discriminating

signs.

A complete list of the 160 maneuvers associated with this hypothesis-driven physical

exam approach is provided at the end of the handbook. Please note that some

maneuvers will include some sub-routines, such as measuring the blood pressure,

checking the jugular venous pulse, or testing sharp and dull sensation. Be sure to


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execute all the sub-routines when examining the patient in order to be fully credited for

having executed the maneuver correctly.

Validation

The prototypical diagnoses and physical exam maneuvers were validated by an

international panel of eight physicians closely involved in teaching the physical

examination to medical students.1 They came from the USA, Canada, Belgium,

Switzerland, and Japan. They judged the appropriateness of the prototypical diagnoses

and the completeness of the physical exam maneuvers selected for an introductory

course. We are most grateful for their input. Their comments and suggestions were

incorporated in the current document. We are however solely responsible for the final

selection. In addition, references accompany each complaint, concerning the

reproducibility, sensitivity, and specificity of the signs.2

_________________________________________

1. Yudkowsky, R, Otaki, J, Lowenstein, T, Riddle, J, Nishigori, H, Bordage, G. A Hypothesis-Driven Physical Exam for Medical Students: Initial Gathering of Validity Evidence. Medical Education, 2009; 43:729-40. 2. Additional suggested readings: ER Black, DR Bordley, TG Tape, RJ Panzer. (eds.) Diagnostic Strategies for Common Medical Problems. Philadelphia: American College of Physicians. 1999. SR McGee. Evidence-based physical diagnosis. (2nd ed.) Philadelhpia: Saunders/Elsivier. 2007. DL Simel, D. Rennie, SA Keitz. The Rational Clinical Examination: Evidence-based Clinical Diagnosis. McGraw-Hill, 2008.


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Complaints and Prototypical Diagnoses

Complaint 1: Heart murmur 1. Mitral regurgitation 2. Aortic stenosis

3. Aortic sclerosis 4. Tricuspid regurgitation

Complaint 2: Itchy Scalp 1. Seborrheic dermatitis 2. Lice

3. Tinea capitis Complaint 3: Stuffy Nose and Sore Throat 1. Acute sinusitis 2. Allergic rhinitis 3. Streptococcal pharyngitis 4. Viral URI (rhinosinitis) Complaint 4: Swollen Neck and Fatigue 1. Hypothyroidism

2. Anemia Complaint 5: Blurred Vision 1. Diabetic retinopathy 2. Transient ischemic attack (TIA)

3. Retinal artery or vein occlusion 4. Cataracts

Complaint 6: Hearing Loss 1. Serous otitis media 2. Sudden viral hearing loss 3. Cerumen impaction 4. Tympanic membrane perforation Complaint 7: Funny Feeling Face 1. Trigeminal neuralgia (V) 2. Bell’s palsy (VII): peripheral facial nerve palsy 3. Stroke: central facial nerve palsy Complaint 8: Shortness of Breath 1. Asthma

2. Congestive heart failure (CHF) (class 3) secondary to ischemic coronary artery disease (CAD)

3. Chronic obstructive pulmonary disease (COPD)

4. Panic attack 5. Pneumonia 6. Pulmonary embolism


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Complaint 9: Lump in Breast 1. Breast cancer 2. Fibrocystic changes

Complaint 10: Leg Pain on Exertion 1. Spinal stenosis

2. Peripheral arterial disease

Complaint 11: Upper Abdominal Pain 1. Alcoholic hepatitis 2. Cholangitis - cholecystitis

3. Small bowel obstruction Complaint 12: Lower Abdominal Pain 1. Appendicitis

2. Colitis 3. Ectopic pregnancy

4. Pyelonephritis Complaint 13: Painful Wrist 1. Carpal tunnel syndrome

2. Rheumatoid arthritis 3. Osteoarthritis 4. Gout 5. Septic (infectious) arthritis

Complaint 14: Painful Shoulder 1. Adhesive capsulitis

2. Bicipital tendonitis 3. Rotator cuff tendonitis 4. Referred pain

Complaint 15: Sore Knee 1. Cruciate ligament injury

2. Meniscus injury 3. Osteoarthritis 4. Gout

Complaint 16: Painful Hip 1. Osteoarthritis 2. Trochanteric bursitis Complaint 17: Painful Ankle 1. Ankle fracture

2. Gout 3. Septic (infectious) arthritis 4. Second-degree ankle sprain

Complaint 18: Unsteadiness 1. Cerebral stroke 2. Cerebellar stroke 3. Acute labyrinthitis (vestibular neuronitis)

Complaint 19: Back Pain 1. Herniated disc L4-5

2. Muscle strain 3. Compression fracture


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Complaint 1: Heart Murmur Prototypical diagnoses: 1. Mitral regurgitation 2. Aortic stenosis

3. Aortic sclerosis 4. Tricuspid regurgitation

Mitral

regurgitation Aortic

stenosis Aortic

sclerosis Tricuspid

regurgitation M1 Wash hands

√

√

√

√

M55: Check for jugular venous distension (JVP)

M56: Palpate aortic area

M57: Palpate pulmonic area

M58: Palpate tricuspid area

M59: Palpate mitral area

M60: Auscultate aortic area (diaphragm)

M61: Auscultate pulmonic area (diaphragm)

M62: Auscultate tricuspid area (diaphragm)

M63: Auscultate mitral area (diaphragm)

M64: Auscultate aortic area (bell)

M65: Auscultate pulmonic area (bell)

M66: Auscultate tricuspid area (bell)

M67: Auscultate mitral area (bell)

M68: Auscultate carotid artery bilaterally

M69: Palpate carotid artery bilaterally

M46: Auscultate posterior lungs fields bilaterally & symmetrically


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Mitral regurgitation

Aortic stenosis

Aortic sclerosis

Tricuspid regurgitation

M78: Percuss liver span

M79: Palpate liver edge

M139: Inspect for peri-pheral edema bilaterally

References: Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277:564-571. McGee S. Miscellaneous Heart Murmurs. Evidence-Based Physical Diagnosis. W.B. Saunders, Philadelphia, 2001, pp. 546-564.


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Complaint 2: Itchy Scalp Prototypical diagnoses: 1. Seborrheic dermatitis

2. Lice 3. Tinea capitis

Seborrheic

dermatitis

Lice Tinea capitis

M1 Wash hands

√

√

√

M7: Examine skull, hair & scalp

M11: Palpate posterior auricular nodes bilaterally

M12: Palpate occipital nodes bilaterally

References: Correale, CE, Walker, C, Murphy, L, Craig, TJ. Atopic dermatitis: A review of diagnosis and treatment. Am Fam Phys, 1999; 60:1191-1210. Williams, JV, Eichenfield, LF, Burke, BL, Barnes-Eley, M, Friedlander, SF. Prevalence of scalp scaling in prepubertal children, Pediatrics 2005; 115: 1-6. www.uptodate.com (v15.2) Approach to the patient with a scalp eruption.


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Complaint 3: Stuffy Nose and Sore Throat Prototypical diagnoses: 1. Acute sinusitis

2. Allergic rhinitis 3. Streptococcal pharyngitis 4. Viral URI (rhinosinusitis)

Acute

sinusitis Allergic rhinitis

Streptococcal pharyngitis

Viral URI (rhinosinusitis)

M1 Wash hands

√

√

√

√

M36: Test patency of nasal cavity bilaterally

M37: Inspect lips, gums, tongue & teeth

M38: Inspect posterior pharynx

M39: Observe elevation of palate

M8: Palpate or percuss frontal sinus

M9: Palpate or percuss maxillary sinus

M10: Palpate pre-auricular nodes bilat.

M11: Palpate posterior auricular nodes bilat.

M12: Palpate occipital nodes bilaterally

M13: Palpate anterior cervical nodes bilat.

M14: Palpate posterior cervical nodes bilat.

M16: Palpate tonsillar nodes bilaterally

M17: Palpate subman-dibular nodes bilat.

M18: Palpate submental nodes bilat.

M33: Perform otoscopic exam bilaterally

MA17: Inspect internal nose with speculum

MA32: Palpate maxillary tooth bilat.


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References: Komaroff, AL. Some Throat and Acute Infections Mononucleosis in Adults, In Black, E.R., Bordley, D.R., Tape, T.G., & Panzer, R.J. (eds.) Diagnostic Strategies for Common Medical Problems, 2nd Edition. Philadelphia: American College of Physicians-American Society of Internal Medicine. 1999, p. 229-242. Chodosh, J. Acute Sinusitis. In Black, ER, Bordley, DR, Tape, TG, & Panzer, RJ (Eds) Diagnostic Strategies for Common Medical Problems, 2nd Ed.. Philadelphia: American College of Physicians-American Society of Internal Medicine. 1999, p. 293-296 Scheid, DC, Hamm, RM. Acute bacterial rhinosinusitis in adults. Pt I: Evaluation. Am Fam Phys, 2004; 70:1685-92. www.uptodate.com (v15.2) Clinical manifestations and evaluation of allergic rhinitis (rhinosinusitis)


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Complaint 4: Swollen Neck and Fatigue Prototypical diagnoses: 1. Hypothyroidism 2. Anemia Hypothyroidism Anemia M1 Wash hands

√

√

MA10: Point out swollen area

M19: Observe thyroid gland by asking patient to swallow

M20: Palpate thyroid gland without and with swallowing

M124: Test biceps reflex bilaterally

M125: Test brachio-adialis reflex bilaterally

M126: Test triceps reflex bilaterally

M127: Test patellar reflex bilaterally

M128: Test Achilles reflex bilaterally

M27: Inspect lid, cornea & conjunctiva bilaterally

References: McGee, S. The Thyroid and Its Disorders. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 270-280 Siminoski, K. The rational clinical examination. Does this patient have a goiter? The JAMA, 1995; 273:813-817.


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Complaint 5: Blurred Vision Prototypical diagnoses: 1. Diabetic retinopathy 2. Transient ischemic attack (TIA)

3. Retinal artery or vein occlusion 4. Cataracts

Diabetic

retinopathy

TIA Retinal

artery or vein occlusion

Cataracts

M1 Wash hands

√

√

√

√

M21: Test visual acuity bilaterally, separately

M22: Test visual fields bilaterally

M23: Check for convergence

M24: Test cranial nerves III, IV, and VI

M25: Test cranial nerve VII (motor)

M26: Observe pupilary responses bilaterally

M27: Inspect lid, cornea & conjunctiva bilaterally

M30: Perform ophthal-oscopic exam bilaterally

References: McGee, S. Diabetic Retinopathy. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 252-260


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Complaint 6: Hearing Loss Prototypical diagnoses: 1. Serous otitis media

2. Sudden viral hearing loss 3. Cerumen impaction 4. Tympanic membrane perforation

Serous otitis

media Sudden viral hearing loss

Cerumen impaction

Tympanic m. perforation

M1 Wash hands

√

√

√

√

M31: Test auditory acuity bilaterally

M32: Inspect external ear bilaterally

M33: Perform otoscopic exam bilaterally

M34: Perform Rinne Test

M35: Perform Weber Test

References: McGee, S. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 839 www.uptodate.com, v15.2 Evaluation of hearing loss in adults


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Complaint 7: Funny Feeling Face Prototypical diagnoses: 1. Trigeminal neuralgia (V)

2. Bell’s palsy (VII): peripheral facial nerve palsy 3. Stroke (CNS): central facial nerve palsy

Trigeminal

neuralgia (V) Bell’s palsy (VII): peripheral facial

nerve palsy

Stroke (CNS): central facial nerve

palsy M1 Wash hands

√

√

√

MA19: Inspect the face

M40: Test cranial nerve XII (tongue)

M41: Test cranial nerve V (motor: masseter)

MA29: Test cranial nerve V (sensory)

M42: VII (motor: show teeth)

MA2: Test cranial nerve VII (raising eyebrow)

M43: Test cranial nerve XI (sternomastoids)

M44: Test cranial nerve XI (trapezius)

References: McGee, S. Facial Nerve. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 708-711. www.uptodate.com (v15.2) Bell’s palsy.


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Complaint 8: Shortness of Breath Prototypical diagnoses: 1. Asthma

2. Congestive heart failure (CHF; class 3) secondary to ischemic coronary artery disease (CAD) 3. Chronic obstructive pulmonary disease (COPD) 4. Panic attack

5. Pneumonia 6. Pulmonary embolism

Asthma CHF

secondary to ICAD

COPD Panic attack

Pneumonia Pulmonary embolism

M1 Wash hands

√

√

√

√

√

√

M4: Measure blood pressure bilaterally

M5: Palpate radial pulse

M6: Measure respiratory rate

M45: Percuss posterior lungs fields bilaterally

M46: Auscultate posterior lungs fields bilaterally

M47: Percuss anterior lung fields bilat. & symmetrical.

M48: Auscultate anterior lung fields bilat. & symmetrical.

M55: Check for jugular venous distension (JVD)

M56: Palpate aortic area

M57: Palpate pulmonic area


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Asthma CHF secondary to ICAD

COPD Panic attack

Pneumonia Pulmonary embolism

M58: Palpate tricuspid area

M59: Palpate mitral area

M60: Auscultate aortic area (diaphragm)

M61: Auscultate pulmonic area (diaphragm)

M62: Auscultate tricuspid area (diaphragm)

M63: Auscultate mitral area (diaphragm)

M64: Auscultate aortic area (bell)

M65: Auscultate pulmonic area (bell)

M66: Auscultate tricuspid area (bell)

M67: Auscultate mitral area (bell)

M139:Inspect for peripheral edema bilat.

References: Badgett RG, Lucey CR, Hulvour CD. Can the clinical examination diagnose left-sided heart failure in adults? JAMA, 1997; 277:1712-9. McGee, S. Diabetic Retinopathy. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 262-260. Wang, CS, FitzGerald, JM, Schulzer, M, Mak, E, Ayas, NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA, 2005; 294:1944- 1956.


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Complaint 9: Lump in Breast Prototypical diagnoses: 1. Breast cancer

2. Fibrocystic changes Breast cancer Fibrocystic changes M1 Wash hands

√

√

M49: Inspect breasts

M50: Inspect breasts while patient raises arms outstretched above the head

M51: Inspect breasts while patient hold hands against hips

M52: Palpate auxiliary nodes (anterior, post., & prox. humerus) bilat.

M53: Inspect breasts while patient raises ipsilateral arm above head

M54: Palpate breasts bilaterally

M15: Palpate supraclavicular nodes bilaterally

References: Barton MB, Harris R, Fletcher SW. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999; 282:1270-1280. Kouides, RW, Mushlin, AI. Breast Cancer. In Black, ER, Bordley, DR, Tape, TG, Panzer, RJ (eds.) Diagnostic Strategies for Common Medical Problems, Second Edition,. Philadelphia: American College of Physicians-American Society of Internal Medicine. 1999, p. 493-496. www.uptodate.com (v15.2) Evaluation of breast lumps in primary care.


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Complaint 10: Leg pain on exertion Prototypical diagnoses: 1. Spinal stenosis

2. Peripheral arterial disease (arteriosclerosis obliterans) Peripheral arterial disease

(arteriosclerosis obliterans) Spinal stenosis

M1 Wash hands

√

√

M70: Palpate femoral pulse bilaterally

M71: Palpate popliteal pulse bilaterally

M72: Palpate post. tibial pulse bilaterally

M73: Palpate dosalis pedis pulse bilaterally

MA9: Inspect lower limb

MA18: Perform Buerger’s Test

MA11: Have patient walk and describe sensation; palpate pulses

References: McGee, S. Peripheral Vascular Disease. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 643-651. Khan, NA, Rahim, SA, Anand, SS, Simel, DL, Panju, A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006; 295:536-546.


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Complaint 11: Upper Abdominal Pain Prototypical diagnoses: 1. Alcoholic hepatitis

2. Cholangitis - cholecystitis 3. Small bowel obstruction

Alcoholic hepatitis Cholangitis -

cholecystitis Small bowel obstruction

M1 Wash hands

√

√

√

M76: Auscultate abdomen (all 4 quadrants)

M78: Percuss liver span

MA35: Percuss abdomen (all 4 quadrants)

M79: Palpate liver edge

M80: Palpate spleen

M81: Palpate abdomen LUQ

M82: Palpate abdomen RUQ

M83: Palpate abdomen RLQ

M84: Palpate abdomen LLQ

References: Trowbridge RL, Rutkowski NK, Shojana KG. Does this patient have acute cholecystits? JAMA 2003; 289:80-86. McGee, S. Abdominal Pain and Tenderness. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 615-632. Cattau, EL, Benjamin, TE, Knuff, TE, Knuff, TE. The accuracy of the physical examination in the diagnosis of suspected ascites. JAMA, 1982; 247:1164-66. Naylor, CD. The rational clinical examination. Physical examination of the liver. JAMA, 1994; 271:1859-1865. www.uptodate.com (v15.2) Diagnostic approach to abdominal pain in adults.


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Complaint 12: Lower Abdominal Pain Prototypical diagnoses: 1. Appendicitis

2. Colitis 3. Ectopic pregnancy 4. Pyelonephritis

Appendicitis Colitis Ectopic

pregnancy Pyelonephritis

M1 Wash hands

√

√

√

√

M76: Ausculate abdomen (all 4 quadrants)

M81: Palpate abdomen LUQ

M82: Palpate abdomen RUQ

M83: Palpate abdomen RLQ

M84: Palpate abdomen LLQ

M111: Perform kidney punch bilat.

MA6: Assess for rebound tenderness

MA14: Assess for psoas sign

MA33: Perform pelvic exam

MA34: Palpate suprapubic area

MA28: Perform rectal exam

MA35: Percuss abdomen (all 4 quadrants)

References: McGee, S. Abdominal Pain and Tenderness. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 615-632. Wagner, JM. Does this patient have appendicitis? JAMA, 1996; 276:1589-1594. www.uptodate.com (v15.2) Diagnostic approach to abdominal pain in adults.


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Complaint 13: Painful Wrist Prototypical diagnoses: 1. Carpal tunnel syndrome

2. Rheumatoid arthritis 3. Osteoarthritis 4. Gout 5. Septic (infectious) arthritis

Carpal

tunnel syndrome

Rheumatoid arthritis

Osteoarthritis

Gout

Septic arthritis

M1 Wash hands

√

√

√

√

√

M85: Inspect and palpate hands bilaterally

M86: Assess finger extension bilaterally

M87: Assess finger flexion bilaterally

M88: Assess range of motion of wrists bilaterally

M89: Inspect and palpate wrists bilaterally

M90: Assess range of motion of elbows bilaterally

M91: Inspect and palpate elbows bilaterally

MA12: Perform Phalen Test


MA30: Assess hand pain diagram

MA31: Test hand sensation


27

References: D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000; 283:3110-3117. McGee, S. Peripheral Nerve Injury: Diagnosis of Carpal Tunnel Syndrome. Evidence-Based Physical Diagnosis, Philadelphia: W.B. Saunders Company. 2001, p. 803-804. www.uptodate.com (v15.2) Evaluation of the patient with wrist pain


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Complaint 14: Painful Shoulder Prototypical diagnoses: 1. Adhesive capsulitis (frozen shoulder)

2. Bicipital tendonitis 3. Rotator cuff tendonitis 4. Referred pain

Adhesive

capsulitis (frozen shoulder)

Bicipital tendonitis

Rotator cuff tendonitis

Referred pain

M1 Wash hands

√

√

√

√

MA10: Have patient point out location of pain

M92: Assess shoulder flexion (empty can test)

M93: Assess shoulder internal rotation

M94: Assess shoulder external rotation

M103: Assess neck flexion

M104: Assess neck extension

M105: Assess rotation of neck bilaterally

M106: Assess lateral bending of neck bilat.

MA1: Palpate shoulder (top, lateral, anterior) bilaterally

MA15: Assess active shoulder abduction

MA16: Assess passive shoulder abduction

References: Woodward, T.W. & Best, T.M. The painful shoulder: part I. clinical evaluation. Am Fam Phys, 2000; 61:3079-88. www.uptodate.com (v15.2) Evaluation of the patient with shoulder complaints


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Complaint 15: Sore Knee Prototypical diagnoses: 1. Cruciate ligament injury

2. Meniscus injury 3. Osteoarthritis 4. Gout

Cruciate

ligament injury

Meniscus injury

Osteoarthritis

Gout

M1 Wash hands

√

√

√

√

M95: Inspect and palpate knees bilat.

M96: Assess range of motion of knee bilat.

MA3: Perform McMurray test

MA4: Perform drawer Test

References: Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001; 286: 1610-1620. www.uptodate.com (v15.2) Evaluation of the adult patient with knee pain.


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Complaint 16: Painful Hip Prototypical diagnoses: 1. Osteoarthritis 2. Trochanteric bursitis Osteoarthritis Trochanteric bursitis M1 Wash hands

√

√


M97: Assess hip flexion bilaterally

M98: Assess external & internal hip rotation bilaterally

References: www.uptodate.com (v15.2) Evaluation of the adult with hip pain.


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Complaint 17: Painful Ankle Prototypical diagnoses: 1. Ankle fracture

2. Gout 3. Septic (infectious) arthritis 4. Second-degree ankle sprain

Ankle fracture Gout Septic

(infectious) arthritis

Second-degree ankle

sprain

M1 Wash hands

√

√

√

√


M99: Inspect and palpate ankle bilaterally

MA20: Palpate both ankles bilaterally

M100: Assess range of motion of ankle bilaterally

M101: Inspect mid foot and toes bilat.

M102: Inspect plantar surface bilaterally

M113: Observe gait while patient walks

MA21: Take temperature

References: Wolfe, MW, Uhl, TL, Mattacola, CG, McCluskey, LC. Management of ankle sprains. Am Fam Phys, 2001; 63:93-104. www.guidelines.gov 2006. National Guideline Clearinghouse. Ankle Sprain http://www.ncemi.org/cgi-ncemi/edecision.pl?TheCommand=Load&NewFile=ottawaankle_criteria&BlankTop=1 http://www.ohri.ca/programs/clinical_epidemiology/OHDEC/ankle_rule/flash_ankle_rule.htm (1999) Loeb Health Research Institute at the Ottawa Hospital


32

Complaint 18: Unsteadiness Prototypical diagnoses: 1. Cerebral stroke

2. Cerebellar stroke 3. Acute labyrinthitis (vestibular neuronitis)

Cerebral

stroke Cerebellar

stroke Acute labyrithitis

(vestibular neuronitis)

M1 Wash hands

√

√

√

M68: Auscultate carotid artery bilaterally

M69: Palpate the carotid pulse, bilaterally

M112: Perform Romberg Test

M113: Observe gait while patient walks

M114: Observe gait while patient walks on their toes

M115: Observe gait while patient walks on their heels

M116: Observe gait while patient walks with tandem gait (heel-to-toe)

M117: Perform drift test (arms out)


M119: Test deltoid strength bilaterally

M120: Test biceps strength bilaterally

M121: Test triceps strength bilaterally

M122: Test hip flexor strength bilaterally but separately

M124: Biceps reflex, bilaterally

M125: Test brachio-radialis reflex bilaterally

M126: Test triceps reflex bilaterally


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Cerebral stroke

Cerebellar stroke

Acute labyrithitis (vestibular neuronitis)


M128: Test Achilles reflex bilaterally

M129: Perform Babinski Test bilaterally

M130: Test finger-to-nose coordination bilat.

M132: Test sharp & dull on fore arms & palms

M133: Test sharp & dull on thighs, shins & feet

M134: Test sharp & dull on trunk

M136: Test position sense bilaterally

M138: Test vibratory sense bilaterally

MA22: Perform Dix-Hallpike maneuver

MA23: Assess hip extension bilaterally

MA24: Assess knee flexion bilaterally

MA25: Assess knee extension bilaterally

MA26: Assess foot dorsiflexion bilaterally

MA27: Assess plantar flexion bilaterally

References: McGee, S. Approach to Weakness. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 733-747. McGee, S. Coordination and Cerebellar Testing. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 816-824. McGee, S. Stance and Gait,. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 63-64. Goldstein LB, Somel DL. Is this patient having a stroke? JAMA 2005; 293:2391-2402.


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Complaint 19: Back Pain Prototypical diagnoses: 1. Herniated disk L4-5

2. Muscle strain 3. Compression fracture

Herniated

disk L4-5 Muscle strain Compression

fracture M1 Wash hands √ √ √ MA8: Palpate spine

M108: Assess thoraco-lumbar lateral flexion

M109: Assess lumbar flexion

M110: Assess lumbar extension

M122: Assess hip flexor bilat. but separately

M123: Test lower leg muscles strength bilat.


M128: Test Achilles (ankle) reflex bilaterally

M133: Test sharp & dull on thighs, shins & feet

MA7: Assess straight leg raise

References: Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about lower back pain? JAMA 1992; 268:760-765. Mazanec, DJ. Back Pain Syndromes. In Black, ER, Bordley, DR, Tape, TG, Panzer, RJ. (eds.) Diagnostic Strategies for Common Medical Problems, 2nd Edition. Philadelphia: American College of Physicians-American Society of Internal Medicine. 1999, p. 401-407. McGee, S. Nerve Roots, Plexi, and Peripheral Nerves. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Company. 2001, p. 803-810. Speed, C. Low Back Pain, BMJ. 2004; 328:1119-21. www.uptodate.com (v15.2) Approach to the diagnosis and evaluation of low back pain in adults.


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36

Physical examination maneuvers (k=160).

M1: Wash hands before starting examination

1 M4: Measure blood pressure bilaterally 2 M5: Palpate radial pulse 3 M6: Measure respiratory rate 4 M7: Examine skull, hair & scalp 5 M8: Palpate or percuss frontal sinus 6 M9: Palpate or percuss maxillary sinus 7 M10: Palpate pre-auricular nodes bilaterally 8 M11: Palpate posterior auricular nodes bilaterally 9 M12: Palpate occipital nodes bilaterally

10 M13: Palpate anterior cervical nodes bilaterally 11 M14: Palpate posterior cervical nodes bilaterally 12 M15: Palpate supraclavicular nodes bilaterally 13 M16: Palpate tonsillar nodes bilaterally 14 M17: Palpate submandibular nodes bilaterally 15 M18: Palpate submental nodes bilaterally 16 M19: Observe thyroid gland by asking patient to swallow 17 M20: Palpate thyroid gland without and with swallowing 18 M21: Test visual acuity bilaterally, separately 19 M22: Test visual fields bilaterally 20 M23: Check for convergence 21 M24: Test cranial nerves III, IV, and VI 22 M25: Test cranial nerve VII motor function 23 M26: Observe pupillary responses bilaterally 24 M27: Inspect condition of lid, cornea and conjunctiva bilaterally 25 M30: Perform ophthalmoscopic exam bilaterally 26 M31: Test auditory acuity bilaterally 27 M32: Inspect external ear bilaterally 28 M33: Perform otoscopic exam bilaterally 29 M34: Perform Rinne Test bilaterally 30 M35: Perform Weber Test 31 M36: Test patency of nasal cavity bilaterally 32 M37: Inspect lips, gums, tongue and teeth 33 M38: Inspect posterior pharynx 34 M39: Observe elevation of the palate 35 M40: Test cranial nerve XII (tongue) 36 M41: Test cranial nerve V (motor: masseter) 37 M42: Test cranial nerve VII (motor: show teeth) 38 M43: Test cranial nerve XI bilaterally (sternomastoids) 39 M44: Test cranial nerve XI bilaterally (trapezius) 40 M45: Percuss posterior lung fields bilaterally and symmetrically 41 M46: Auscultate posterior lung fields bilaterally and symmetrically 42 M47: Percuss anterior lung fields bilaterally and symmetrically 43 M48: Auscultate anterior lung fields bilaterally and symmetrically 44 M49: Inspect breasts


37

45 M50: Inspect breasts while patient raises arms outstretched above head 46 M51: Inspect breasts while patient holds hands against hips 47 M52: Palpate axillary nodes (ant., post., prox. humerus, axil.) bilat. 48 M53: Inspect breasts while patient raises ipsilateral arm above head 49 M54: Palpate breasts bilaterally 50 M55: Check for jugular venous distention 51 M56: Palpate aortic area 52 M57: Palpate pulmonic area 53 M58: Palpate tricuspid area 54 M59: Palpate mitral area 55 M60: Auscultate aortic area (diaphragm) 56 M61: Auscultate pulmonic area (diaphragm) 57 M62: Auscultate tricuspid area (diaphragm) 58 M63: Auscultate mitral area (diaphragm) 59 M64: Auscultate aortic area (bell) 60 M65: Auscultate pulmonic area (bell) 61 M66: Auscultate tricuspid area (bell) 62 M67: Auscultate mitral area (bell) 63 M68: Auscultate carotid artery bilaterally 64 M69: Palpate carotid artery bilaterally 65 M70: Palpate femoral pulse bilaterally 66 M71: Palpate popliteal pulse bilaterally 67 M72: Palpate posterior tibial pulse bilaterally 68 M73: Palpate dosalis pedis pulse bilaterally 69 M76: Auscultate abdomen, all 4 quadrants 70 M78: Percuss liver span 71 M79: Palpate liver edge 72 M80: Palpate spleen 73 M81: Palpate abdomen LUQ 74 M82: Palpate abdomen RUQ 75 M83: Palpate abdomen RLQ 76 M84: Palpate abdomen LLQ 77 M85: Inspect and palpate hands bilaterally 78 M86: Assess finger extension bilaterally 79 M87: Assess finger flexion bilaterally 80 M88: Assess range of motion of wrists bilaterally 81 M89: Inspect and palpate wrists bilaterally 82 M90: Assess range of motion of elbows bilaterally 83 M91: Inspect and palpate elbows bilaterally 84 M92: Assess shoulder flexion (empty can test) 85 M93: Assess shoulder internal rotation 86 M94: Assess shoulder external rotation 87 M95: Inspect and palpate knees bilaterally 88 M96: Assess range of motion of knees bilaterally 89 M97: Assess hip flexion bilaterally 90 M98: Assess external & internal hip rotation bilaterally 91 M99: Inspect and palpate ankle bilaterally (swelling, redness) 92 M100: Assess range of motion of ankle bilaterally 93 M101: Inspect mid foot and toes bilaterally


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94 M102: Inspect plantar surface bilaterally 95 M103: Assess neck flexion 96 M104: Assess neck extension 97 M105: Assess rotation of neck bilaterally 98 M106: Assess lateral bending of neck bilaterally 99 M108: Assess thoracolumbar lateral flexion

100 M109: Assess lumbar flexion 101 M110: Assess lumbar extension 102 M111: Perform kidney punch bilaterally 103 M112: Perform Romberg Test 104 M113: Observe gait while patient walks 105 M114: Observe gait while patient walks on their toes 106 M115: Observe gait while patient walks on their heels 107 M116: Observe gait while patient walks with tandem gait (heel-to-toe) 108 M117: Perform drift test (arms out) 109 M118: Test grip strength bilaterally 110 M119: Test deltoid strength bilaterally 111 M120: Test biceps strength bilaterally 112 M121: Test triceps strength bilaterally 113 M122: Test hip flexor strength bilaterally but separately 114 M123: Test lower leg muscles strength bilaterally 115 M124: Test biceps reflex bilaterally 116 M125: Test brachioradialis reflex bilaterally 117 M126: Test triceps reflex bilaterally 118 M127: Test patellar reflex bilaterally 119 M128: Test Achilles (ankle) reflex bilaterally 120 M129: Perform Babinski Test bilaterally 121 M130: Test finger-to-toes coordination bilaterally 122 M132: Test sharp and dull sensation on forearms and palms 123 M133: Test sharp and dull sensation on thighs, shins, and feet 124 M134: Test sharp and dull sensation on trunk 125 M136: Test position sense bilaterally 126 M138: Test vibratory sense bilaterally 127 M139: Inspect for peripheral edema bilaterally

128 MA1: Palpate shoulder (top, lateral, anterior) bilaterally 129 MA2: Test cranial nerve VII (Raising eyebrow) 130 MA3: Perform McMurray Test (meniscus injury) 131 MA4: Perform Drawer Test (ligament injury) 132 MA6: Assess for rebound tenderness 133 MA7: Assess straight leg raise 134 MA8: Palpate spine 135 MA9: Inspect lower limb 136 MA10: Have patient point out swollen area, location of pain 137 MA11: Have patient walk and describe sensation; palpate pulses 138 MA12: Perform Phalen’s Test 139 MA14: Assess for psoas sign 140 MA15: Assess active shoulder abduction 141 MA16: Assess passive shoulder abduction


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142 MA17: Inspect internal nose with speculum 143 MA18: Perform Buerger’s Test 144 MA19: Inspect the face 145 MA20: Palpate ankle bilaterally 146 MA21: Take temperature 147 MA22: Perform Dix-Hallpike maneuver 148 MA23: Assess hip extension bilaterally 149 MA24: Assess knee flexion bilaterally 150 MA25: Assess knee extension bilaterally 151 MA26: Assess foot dorsiflexion bilaterally 152 MA27: Assess plantar flexion bilaterally 153 MA28: Perform rectal exam 154 MA29: Test cranial nerve V (sensory) 155 MA30: Assess hand pain diagram 156 MA31: Test hand sensation 157 MA32: Palpate maxillary tooth bilaterally 158 MA33: Perform pelvic exam 159 MA34: Palpate suprapubic area 160 MA35: Percuss abdomen, all 4 quadrants

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