Articles

Case 2 – Limb Pain

Tim Milligan Peripheral Vascular

You are seeing Ms. Richards, a 45 year old female, in the ER for a two day history of right leg pain. Please perform a focused history and physical examination.

History

  • Onset and duration of pain
  • Severity of pain
  • Location of pain
  • Alleviating and aggravating factors
  • History of trauma to leg
  • Leg swelling
  • Neurologic symptoms in affected limb
  • Association with shortness of breath
  • Fever
  • Diaphoresis
  • Chest pain
  • Hemoptysis
  • Personal history of clotting disorders
  • Personal history of malignancy
  • Pregnancy history
  • Use of hormone replacement or oral contraceptive pill (patient uses OCP)
  • History of immobilization
  • Recent leg trauma
  • Medications/Allergies
  • Smoking history (quantity in pack-years)
  • Family history of thromboembolic disease (DVTs, PEs)

Physical Examination

Inspection

  • Inspects for swelling, edema
  • Inspects for erythema and varicosity in affected limb
  • Inspects for venous ulcers in lower limbs
  • Inspects for joint effusions in affected limb

Palpation

  • Palpates affected lower limb for tenderness
  • Compares limbs for warmth
  • Measures and compares calf circumference for each limb
  • Assesses sensation in affected limb

Case 1 – Acute Paralysis

Tim Milligan Peripheral Vascular

You are seeing Ms. Richards, a 75 year old female, in the ER. She is distraught because she is presenting with a two hour history of complete left leg paralysis. Please perform a focused history and physical examination.

History

  • Onset and duration of paralysis
  • Associated sensory loss
  • History of trauma to leg
  • Leg swelling
  • Pain in leg
  • Parasthesias in leg
  • Numbness in leg
  • Shortness of breath
  • Chest pain
  • Head trauma
  • Weakness elsewhere in the body
  • Sensory loss elsewhere in the body
  • Vision or speech changes
  • Personal history of myocardial infarction and stroke
  • Peripheral vascular disease
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Medications/Allergies
  • Family history of cardiac or cerebrovascular events

Physical Examination

Inspection

  • Comments on color of affected limb (pale)
  • Inspects for hair loss/lack of oil on affected limb
  • Inspects for arterial and diabetic ulcers on feet bilaterally (small ulcer on bottom of 1st toe)
  • Inspects for leg swelling

Palpation

  • Palpates affected limb for tenderness
  • Compares temperature in lower limbs
  • Assesses sensation in both lower limbs
  • Assesses power in both lower limbs
  • Assesses capillary refill in affected limb

Auscultation

  • Auscultates bilaterally for femoral and popliteal bruits
  • Auscultates abdomen for aortic aneurysm

Case 4 – The Sick Child

Tim Milligan Pediatrics

You are about to see 7 year old boy named Bobby. His father has brought him in and tells you that he’s been significantly less active in the last two days, and that he’s been running a high fever. Perform a focused physical examination for a child with a fever.

Physical Examination

  • Explains the nature and purpose of the examination to the child and parent
  • Asks parent for assistance while examining the child when needed

Inspection

  • Comments on overall appearance (looks unwell, diaphoretic)
  • Examines for rashes
  • Examines joints for effusion, erythema

Vitals/Hypovolemia

  • Measures heart and respiratory rate
  • Assesses volume status by examining mucus membranes, skin temperature/turgor, capillary refill
  • Takes temperature of patient (hyperthermic)
  • States that orthostatic vitals should be measured
  • States that the weight of the child should be measured as part of the volume assessment

Head and Neck exam

  • Comments on the presence of erythema and exudates in oropharynx
  • Palpates all lymph nodes of the head and neck
  • Comments on the size, texture, mobility, and location of any identified nodes
  • Asks patient/assesses child for tenderness during examination
  • Examines patient’s ears using otoscope, comments on auditory canal and tympanic membrane
  • Checks for neck stiffness

Respiratory

  • Comments on respiratory status: accessory muscle use, nasal flaring, central/peripheral cyanosis
  • Auscultates in all lung fields
  • Comments on findings

Abdominal Exam

  • Examines for abdominal tenderness in all four quadrants
  • Assesses for splenomegaly
  • Assesses for masses in the abdomen

Case 3 – Tired Teenager

Tim Milligan Pediatrics

You are seeing Haley Schilling, a 15 year old female, who’s coming to your office today at the behest of her mother. She has recently become more tired and her mom is concerned that she has ‘low blood.’ Take a focused history from Haley.

History

  • Determines chief complaint is fatigue
  • Inquires about onset and duration of fatigue
  • Asks patient what she believes is causing her fatigue
  • Inquires about patient’s mood (“I often feel low”)
  • Inquires about association with other systemic symptoms – fever, chills, nausea (none)
  • Symptoms suggestive of thyroid disease (cold intolerance, skin/hair changes)
  • Excessive sleep (yes)
  • Increasing weight, increasing appetite (yes)
  • Feelings of worthlessness/guilt/isolation
  • Pre-occupation with self image
  • Poor concentration
  • Psychomotor activation or retardation (activation)
  • Suicidal ideation
  • Suicide attempts
  • History of self-harm behavior
  • Symptoms of mania
  • Symptoms of anxiety
  • Symptoms of psychosis
  • Establishes social context of child’s home-life and relationship with family
  • Inquires about how the patient is adapting in school
  • Relationship/sexual history
  • Activities outside of school
  • Past medical history
  • Past history of depression and other psychiatric illnesses
  • Current medications
  • Alcohol, smoking, and drug history
  • Legal history
  • Current social supports
  • Family history of psychiatric illnesses

Case 2 – Infant Diarrhea

Tim Milligan Pediatrics

You are seeing Mrs. Bosco, a 25 year old female who recently gave birth to a baby named Michael six weeks ago. Today, she presents to your office because she is concerned about the baby’s health. Take a focused history of Mrs. Bosco’s complaint.

History

  • Determines chief complaint is diarrhea
  • Volume of diarrhea (i.e. frequency of diaper change)
  • Appearance of diarrhea (appears brown, with no blood)
  • Associated nausea/vomiting
  • Lethargy
  • Child’s level of activity
  • Fever and peak temperature
  • Changes in urination, including odor
  • New rashes
  • Symptoms of URTI
  • Recent weight loss
  • Volume of oral intake
  • Infectious contacts
  • Past medical history (none)
  • Asks about developmental milestones appropriate for child’s age
  • Pregnancy history (normal)
  • Vaccinations to date
  • Allergies (none)
  • Current medications (none)
  • Inquires about mother’s stress, caregiver burden
  • Inquires about mother’s support for the care of the infant
  • Inquires about post-partum depression
  • Inquires about mother’s other concerns related to raising her infant

Case 2 – Sore Throat

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Tom, a 10 year old boy, in your outpatient clinic today for a sore throat. Take a focused history of his complaint and perform the relevant physical examination.

History

  • Onset of sore throat
  • Severity
  • Alleviating factors
  • Aggravating factors
  • Change in voice
  • Presence of fever
  • Odynophagia
  • Associated cough, sputum production
  • Shortness of breath
  • Neck tenderness and swelling
  • Otalgia
  • Recent upper respiratory illness
  • Personal history of throat infections
  • Infectious contacts
  • Allergies to medication
  • Vaccination history
  • Development history

Physical Examination

Oropharynx

  • Uses tongue depressor and light to examine oropharynx
  • Comments on the presence of erythema and exudates in oropharynx
  • Comments on other findings in the oropharynx e.g. enlarged tonsils, lesions, deviated uvula

Node Examination

  • Palpates the lymph nodes of the head and neck
  • Names the nodal regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient about tenderness during examination

Respiratory

  • Auscultates in all lung fields
  • Comments on findings

Case 5 – Dizziness

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Rodriguez, a 31 year old man, because he often feels dizzy. Take a focused history and perform the Dix-Hall Pike maneuver.

History

  • Clarifies symptoms are descriptive of vertigo (‘the room spinning around’)
  • Duration of dizziness
  • Frequency
  • Associated activity, especially head turning
  • Other precipitants
  • Aural fullness (none)
  • Decreased hearing from one ear
  • Tinnitus (none)
  • Otalgia (none)
  • Syncopal episodes
  • Chest pain or shortness of breath
  • Nausea or vomiting
  • Vision changes
  • Sensory deficits (none)
  • Motor deficits (none)
  • Trauma to either ear
  • Previous episodes of otitis media
  • Smoking and alcohol history
  • Effect on daily activities

Dix-Hallpike Maneuver

  • Explains procedure to patient, and what they might expect
  • Asks patient to lie down and tilts head back and towards one side
  • Repeats maneuver on opposite side
  • Comments that they are looking for geotropic nystagmus towards affected ear
  • Comments on reversal when leaning toward non-affected ear

Case 4 – Neck Mass

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mrs. Nguyen, a 52 year old woman, because she noticed a large swelling on her neck. Take a focused history and perform a focused head and neck examination.

History

  • Clarifies location of mass (patient thinks it’s on the her right side of her neck)
  • Onset of mass
  • Progression in size
  • Pain
  • Dysphagia
  • Odynophagia
  • Change in voice
  • Symptoms suggestive of hyperthyroidism
  • Symptoms suggestive of hypothyroidism
  • Systemic symptoms – weight loss, night sweats, anorexia
  • Infectious symptoms – nausea/vomiting, fever, diarrhea
  • Past medical history
  • Personal history of malignancy
  • Exposure to head and neck irradiation
  • Exposure to tobacco, smoking, alcohol, and betel nuts
  • Asks patient about ethnic origin (South East Asia)
  • Personal history of thyroid disease
  • Family history of thyroid disease
  • Family history of head and neck cancer

Physical Examination

Inspection

  • Comments on location of mass and any neck asymmetry
  • Comments on stigmata of hyperthyroidism in head and neck (exophthalmos, lid lag, etc.)
  • Comments on stigmata of hypothyroidism in head and neck (skin and hair changes)
  • Comments on size of thyroid and observes thyroid as patient swallows

Palpation

  • Comments on quality, size, and mobility of mass (mass is hard, irregular, and tethered)
  • Comments on size of mass (~2 cm in diameter)
  • Palpates all lymph node regions of the head and neck
  • Names the regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient if palpation is tender
  • Palpates both lobes of the thyroid; comments on size and nodularity
  • Auscultates thyroid and comments on absence of bruits

Case 3 – Hearing Difficulty

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Syed, a 73 year old man, in your outpatient clinic. He says that his family members have told him that they have a difficult time communicating with him because he has poor hearing. Take a focused history, and perform the pertinent physical examination maneuvers.

History

  • Inquires whether patient is aware of hearing loss (he agrees)
  • Onset of hearing difficulty
  • Settings in which difficulty is worst (noisy crowds)
  • Whether hearing difficulty is worse with specific frequency (patient unsure)
  • Otalgia
  • Exudation from ear, including pus and blood (none)
  • Phonophobia
  • Tinnitus
  • Vertigo
  • Associated neurologic deficits elsewhere in the body
  • Vision loss
  • Headache
  • Use of ear plugs
  • Trauma to the ear, including digital
  • Past history of cerumen
  • Use of any hearing aids
  • Past history of hearing difficulty
  • Past exposure to noise (including occupational history)

Physical Examination

Inspection

  • Comments on the gross appearance of both ears
  • Uses otoscope to examine the auditory canal, commenting on its appearance
  • Examines tympanic membrane and comments on its appearance

Special Tests

  • Performs the Rinne Test bilaterally
  • Performs the Weber Test
  • Interprets the results of these two tests
  • Performs whisper test bilaterally

Case 1 – Blurry Vision

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mrs. Woods, a 74 year old woman, in your ambulatory clinic today. She states that her vision has become blurry. Take a focused history of this complaint and perform the relevant physical examination.

History

  • Onset and duration of blurry vision
  • Progression of blurry vision
  • Foreign body sensation, or history of foreign body in affected eye
  • Awareness of a red eye (none)
  • Visual field defects
  • Change in acuity
  • Double vision
  • Eye pain
  • Pain with eye movement
  • Presence of flashes and floaters
  • Photophobia
  • Excessive or poor lacrimation
  • Association with any extra-ocular symptoms: rashes, arthritis, urethritis
  • Change in colour vision
  • Distinguish between blurred vision vs. metamorphopsia (distorted vision)
  • Use of corrective lenses
  • Exposure to environmental irritants
  • History of diabetes, hypertension, cardiac disease, and stroke (risk factors for CRVO, CRAO)
  • History of cataract removal
  • Past ocular disease, including trauma
  • Smoking and alcohol history
  • Medications and allergies
  • Family history of eye diseases, e.g. glaucoma, retinal detachment
  • Inquires if patient is driving since onset of vision changes
  • Effect on daily living

Physical Examination

Inspection

  • Comments on absence of ptosis
  • Comments on appearance of lid, eyelashes, lacrimal glands
  • Comments on appearance of conjunctiva and sclera

CN II

  • Asks patient about prescription for corrective lenses before beginning examination
  • Checks visual acuity using Snellen Chart at 14 inches or 20 feet
  • Assesses pupillary response to light
  • Assesses pupillary accommodation
  • Assesses for RAPD/Marcus Gunn pupils
  • Assesses visual fields by confrontation
  • Performs fundoscopy and comments on findings, specifically the disc-to-cup ratio
  • States that color vision testing should be performed
  • States that a slit lamp examination should be performed

CN III, IV, & VI

  • Comments on absence of nystagmus
  • Assesses all six cardinal movements of the extraocular muscles
  • Asks patients about diplopia in all directions of gaze