Minimal competency

Question 1

General

Answer 1

• appearance, dress, mannerism, and audible noises
• signs of distress: pain, respiratory, CVS
• level of consciousness
• orientation: date, time, and place

Question 2

Head, eye, ear, nose throat, and neck

Answer 2

• inspect for asymmetry (acquired or congenital), any evidence of trauma
• inspect visible portion of eyes - lids, palpebral fissure, sclera (color, injection, discharge),
  
  • Sclera discoloration:
• jaundice
• osteogenesis imperfecta
• beta-carotene
  • Eye injections
• viral or bacterial infections
  • conjunctiva: upper and lower lids (pull up/down) -> look for colour and discharge
  • check pupil size
  • pupillary reflex
  • H-test
• inspect nose for patency, septal deviation, and foreign body in children
• inspect the state of dentition
• inspect external ears (including canal) for patency, discharge and foreign bodies -> use penlight & otoscope
  
  • Check lobule, tragus, mastoid tenderness
• inspect oropharynx for sweliing, masses, injection, and exudate.
  
  • tongue deviations and movement
  • loose teeth
• Palpate LN - head and neck including supraclavicular (ask Pt to take a deep breath), axillary
• identify by palpation the following landmarks - thyroid cartilage, cricothyroid membrane, cricoid cartilage
• inspect and palpate thyroid gland
  
  • Expose to sternal angle
  • mobility: swallowing and drink water; pain upon swallowing
  • also need to palpate supraclavicular (stand behind) and deep cervical LN

Question 3

Thorax and respiratory

Answer 3

1. inspect thorax for chest wall config, asymmetry of shape and movement, respiratory excursion and signs of respiratory difficulty
   * signs of accessory muscle use, resp distress, skin changes, spine deformities.
2. palpate chest wall for tenderness: ask Pt to hug himself for everything on back

• P: spinal and paraspinal
• A: mid-clavicular (rib fractures) and parasternal (costochondritits)

3. Auscultate chest anteriorly and posteriorly to include apices and bases for breath sounds and adventitious sounds during inspiration and expiration.
   * Pt lying down
   * Auscultate @ 12 points (2 on axilla)
   * Note for Axilla: above 5th ICS is upper lobe; below 5th ICS is lower lobe
4. percuss the posterior chest, supraclavicular and upper axial: ask Pt to hug himself for everything on back

• @ 3 levels (2nd space, 3rd, 4th spaces)
• include supraclavicular & axilla

​5. Diaphragmatic excursion by percussion on back during deep inspiration and exhalation o
6. Chest movement/excursion on back

Question 4

CVS

Answer 4

1. inspect for venous distention and jugular venous pulsation
2. Auscultate for carotid bruits then palpate carotid aa. on both sides
3. palpate radial, post tibial, and dorsalis pedis pulses
4. inspect and palpate for peripheral edema bilaterally
5. palpate PMI
6. auscultate with bell for cardiac rate and rhythm
7. auscultate over apex with bell and determine S1 and S2
8. auscultate over cardiac areas with diaphragm (apex, tricuspid, Erb’s, Aortic, and pulmonary)

Question 5

Abdomen

Answer 5

1. inspect ab for shape and visible masses
   * ask Pt to cough opposite side and inspect groin (MCC 6)
   * Drape Pt before they disgow
2. auscultate for BS and bruit when indicated
   * 1 in. above umbilicus & 1 in. lateral to that for > 10 sec
   * Bruits: Aortic, renal (lateral ie. either side of umbilicus), iliac (lateral)
3. palpate for superficial and deep tenderness in all quandrants, rigidity and rebound tenderness
   * Rebound tenderness (RLQ): 2 hands
   * Hepatomegaly inspection: 1 hand vertical, other hand on hand and ask Pt to take deep breathes
   * Splenomegaly: same as hepatomegaly but in LUQ
4. palpate CVA and suprapubic tenderness: feel for 12th rib, gentle hit
5. palpate for hepatosplenomegaly
6. palpate for inguinal adenopathy and groin hernia
   * JUST MENTION THAT WOULD LIKE TO EXAMINE INGUINAL ADENOPATHY, FEMORAL PULSE, DRE

• Peritonitis: fever, intense pain (Pt will not allow to touch)
• Ascites: shifting dullness, mild pain
• Hepatitis: hx of multiple sex partners
• PID: RLQ pain
• Cholecystits: radiates to R. shoulder

Question 6

Skin, hair, nails

Answer 6

• Inspection of the skin for discoloration, rash, swellings, masses and vascular abnormalities
• Inspection of hair - character, distribution
• Inspection of nails – clubbing, spooning, pitting, pigmentation

Question 7

Musculoskeletal

Answer 7

• Muscle strength is for neuro
• Inspection for stance and gait
  
  • report symmetry (comment on scoliosis, kyphosis)
• Inspection of limbs for symmetry and alignment
  
  • report symmetry (varus & valgus)
• Focused joint inspection for swelling, discoloration and alignment, when relevant
• Focused joint range of motion, when relevant

Question 8

Neurological

Answer 8

• Mini Mental status exam (neuro case)
  
  • • orientation
  • • memory:
  • • judgement:
  • • Abstract thinking:
  • • Higher-order fx: serial 7 subtraction
• Full mental status when indicated during psychiatric exam
• Psych case
  
  • • appearance: gait, grooming, gesture,
  • • level of alertness: alert, drowsy, or comatose
  • • speech: normal tone, volume, rate of speech (pressured speech)
  • • behaviour & interpersonal characteristics: eye contact, responsive to questions
  • • awareness/orientation
  • • mood/affect: expansive affect (cheerful), restrictive affect, blunted affect
  • • thought process: thought processing, loose associations, flight of ideas
  • • thought content: hallucination, delusion
  • Insight: into disease
  • Apraxia
• Assessment of speech
• Cranial nerves function CN II to XII
  
  • II, III, IV, VI: Snellen, confrontation testing, pupillary light reflex, H-test
  • V: sensory & motor (jaw-jerk/clench)
  • XI: need to palpate SCM, then raise shoulders
• Motor examination, strength and tone, of upper and lower extremities
  
  • Strength: for extremities only usually
  • Tone: passive in wrist, forearm, arm
• Deep tendon reflexes, biceps for upper and patella for lower, extremities
• Sensory examination, pin prick and position sense, of extremities
  
  • Pinprick Sensation sharp dull: start at sternum
• Inspection for abnormal movements such as tremors
  
  • Cerebellar: finger to nose