Hx/Px Specialized

     

    ASCM2 – specialized exams

    Breast

    History

    • Pain
    • Masses (size, shape, symmetry, skin changes)
    • Nipple changes (ulceration, discharge)
    • Constitutional sx (fever, wt loss, sweats/chills, appetite)

    Inspection

    • Sit upright, arms on thighs facing examiner
    • Comment on Size, Symmetry, shape, skin changes
    • Nipples: Size, Symmetry, Shape, skin, secretion, supernum. Nipples

    Palpation:

    Nodes: (patient sitting upright)

    • Supraclavicular
    • Infraclavicular
    • Axillary (pectoral/anterior, subscapular/post., lateral, central)

    Breast: (patient supine, arms at sides)

    • Start with Axymptomatic breast
    • Masses: (location, size, shape, consistency, tenderness, mobility)
    •  

    Urologic

    History

    • Irritative: Frequency, urgency, nocturia, dysuria
    • Obstructive: Straining, hesitancy, incomplete empty…
    • Hematuria: pain/clots, part of stream?
    • Stress incontinence?
    • Erectile dysfunction? Firmness, initiating, maintaining, ejaculation
    • Blood in semen
    • Discharge
    • Swelling/masses

    Exam

    Penis

    • Size
    • Skin
    • Curvature
    • Glans (ask to retract: check for phimosis, or paraphimosis)
    • Meatus (hypospadius?) discharge?
    • Palpate: using both hands along corpora cavernosa (peyronie’s disease?)
      • Open urethra to check for secretions

    Testes

    • Inspect: swelling, masses, varicoceles, skin changes
    • Warm hands…
    • Palpate both hands (one hand top/bottom, other left/right)
      • Comment size/shape/consistency/tenderness/nodules/masses
    • If mass present, transilluminate (solid vs cystic)
    • Palpate: epididymus, spermatic cord

     

    Inguinal

    • Masses/swellings (ask to valsalva for hernias)
    • Stand up?
    • Palpate (standing?): palpate each inguinal region
      • Put index finger through scrotum along spermatic cord to external and then internal ring, ask to cough.
    • Auscultate for bowel sounds (maybe?)

    Other:

    • Inguinal, left supraclavicular nodes

    Kidneys

    • Percuss bilaterally?  Maybe do the hand strike technique?

    Prostate

    • Patient in Sims position, glove both hands, lubricate finger
    • Use non-exam hand to spread buttocks for exam
    • Inspection: inflam, warts, nodules, tumors, bleeding, hemorrhoids
    • Palpation:
      • Warn pt that lube will feel cold,
      • ask to take deep breath in
      • Check sphincter tone, resistance
      • Turn finger to examine rectal wall (polyps, masses, irregularities)
      • Palpate anterior rectum + prostate
        • Median sulcus
        • Lateral lobes
        • Look for size, symmetry, masses, tenderness, nodules
        • Warn before withdrawing
        • Normal: bilobed, heart-shaped, 4cm diam, smooth, firm

    ENT

    Ear

    • Loss fluctuating?  Unilateral? Frequency? Drugs?
    • Otalgia, Ottorhea, vertigo, tinnitus, hyperacusis
    • Hx of ear infections
    • Exam: (sit arms at sides)
    • Inspection: pinna, helix, antihelix, tragus, lobule, EAM
      • Cauliflower?
      • Tophi?
      • Discharge?
    • Palpation:
      • Pinna
      • Mastoid process
      • Pain when pulling pinna or press on tragus (OE)
      • Whisper test
      • Rinne Test
      • Weber Test
      • Otoscope:
        • Exernal ear canal: redness, swelling, tenderness, dicharge
      • Tympanic Membrane:
        • Color (pearly grey), Integrity, transparency (semi-transparent), position, (ovoid shape), landmarks
        • Pars tensa, handle of malleus, cone of light
    •  

    Nose+sinuses

    • Infections
    • Nasal obstruction (noisy breathing, allergy, rhinorrhea, etc.)
    • Face pain
    • Anosmia
    • Exam:
      • Inspection:
        • Size
        • Swelling
        • Trauma
        • Deviation
        • Nares
        • Ask to occlude one nostril, try to exhale through the other
      • Palpation
        • Nose: tenderness, firmness
        • Sinuses: maxillary, frontal sinuses for tenderness
      • Special inspection
        • Position: left hand on pt forehead, thumb pulling on tip of nose
        • Uses scope or light source
        • Look at:
          • Septum, Vestibule, Nasal mucus membranes, Little’s area (Kiesselbachs plexus), Middle/inferior turbinate’s
        • Inspect:
          • Exudates
          • Swelling
          • Bleeding
          • Trauma
          • Masses,
          • Polyps
          • Discharge

    Throat

    • cough? Productive? Hemoptysis? Dyspnea? Chest pain?
    • Dysphagia
    • Hoarseness
    • Inspection
      • Open Jaw (comment on jaw)
      • Lips, buccal mucosa, gingivae, teeth, tongue, floor, palate, ductal orifices
      • Note:
        • Swelling
        • Color
        • Lesions (ulcerations, herpetic, mucoceles)
        • Patency of salivary orifices
        • Plaques, Papules, bleeding, teeth
    • Palpation:
      • Palpate tongue (use gauze to hold tongue with one hand) (most ca at margins)
      • Bimanual palpate floor of mouth, (tenderness, masses)
      • Examine CN XII
    • Pharynx
      • Use light and tongue depressor
      • Tonsins: (size, debris, exudate)
      • Post pharynx wall (discharge, masses, erythema) “say ahh”
      • Gag reflex
    • Larynx
      • Use dental mirror

     

    Ophthalmic exam

    • Hx burning, tender, red, pain, pain movement, headache/nausea, discharge
    • Exam
      • Visual acuity
      • Visual fields
      • EOM
      • Inspect:
        • Ocular symmetry
        • Orbit (exophthalmos)
        • Eye lids
        • Conjunctiva, etc.
      • Opthalmoscope:
        • Approach 15’’ away, at 15°, move to 2’’ from eye
        • Optic disk
          • Margins: (sharp)
          • Color: (pinkish or yellow-orange)
          • Cup: (central, C:D is <0.5)
          • Papilledema?
        • Retinal vessels (normal, slight venous pulstations)
        • Macula:
          • Colour: (reddish orange, no lesions)

     

    Peripheral Vascular

    • Pain? SEVERE?
    • 6 P’s: Pain, pallor, Paralysis, parasthesia, pulsenessness, polar
    • Claudication: Pain with exercise, Predictable (same exercise), Disappears at rest.
    • Critical ischemia?: Rest Pain, Numbness, Night Pain, Non-healing ulcers
    • Ulcers?  Where? (brownish ulcers near ankle – venous; ulcers at distal,lateral,dorsal – arterial; bottom of foot btwn toes - diabetic)
    • Risk factors:  smoking, HTN, DM, dyslipidemia, FHx, Lifestyle, dialisys
    • Recent surgery, cancer, OCP, pregnancy, FHx clotting.
    • Inspection:
      • Size, symmetry
      • Edema
      • Varicose/dilated veins
      • Skin thickness
      • Ulcers
      • Pallor
      • Nails
      • Lips
    • Palpation
      • Tempearture (warmth, erythema = venous; cold = art.)
      • Edema (pitting, venous)
      • Leg sizes (smallest ankle, largest calf, thigh – compare both sides > 2cm = change atrophy or swelling è venous)
      • Cap refill (norm <3s)
      • Pulses
        • Carotid, brachial, radial, AA, renal, femoral, popliteal, post. Tibial, dorsalis pedis (0-4, 2 norm)
    • Special Tests
      • Allen test – make tight first, occlude ulnar and rad arteries, release each one and see how long to return pink color to hand (try each first)
      • Pallor/Rubor – Normal: pink color returns 10 s, veins refill @ 15s. 
      • ABI

     

    HIV Exam

    • Inspection
      • Skin: Kaposi sarcoma.  Check entire skin (cancer of connective tissue, painless purplish-red to brown plaquelike lesions).
      • Pharynx: Thrush, oral hairy leukoplakia (EBV - raised white plaques on sides of tongue).
    • Palpate
      • Neck, Clavicle, Axillae & Groin for LN enlargement by NH-Lymphoma.
      • Examine abdomen for hepatic/splenic enlargement. 
    • +++ TODO.. other exam features (section unfinished)
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