Articles

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

Case 5 – Worsening Tremor

Tim Milligan Neurology

You are seeing Ms. Wilmington, a 63 year old woman, in your outpatient clinic. She tells you that her old tremor is getting worse. Take a focused history of her complaint and perform a focused physical exam.

History

  • Onset of tremor
  • Onset of worsening of the tremor
  • Clarifies if tremor occurs during rest or activity (rest)
  • Difficulty performing specific tasks due to tremor (writing)
  • Change in gait – slowing, fewer steps, less arm swing
  • Stability of gait
  • Need for assistive devices for ambulation
  • Difficulty with fine motor skills
  • Posture changes
  • Difficulty initiating movement
  • Psychomotor retardation
  • Change in affect
  • Difficulty with short term memory
  • Change in voice
  • Effect on ADLs
  • Effect on IADLs
  • Personal history of a psychotic disorder
  • Family history of Parkinson’s and/or essential tremour
  • Current medications
  • Addresses patient’s concerns as to what is causing these symptoms
  • Inquires about symptoms of depression
  • Patient’s concerns about independence

Physical Examination

Vitals/Inspection

  • Measures orthostatic changes – comments on hypotension
  • Inspects for masked face (none)
  • Comments on stooped posture
  • Comments on presence of resting tremor
  • Comments on altered speech

Motor Examination

  • Tests tone in upper extremities – comments on presence of cogwheeling
  • Tests for essential tremor, likely not present
  • Tests for intent tremor, likely not present

Sensory Examination

  • Tests reflexes (normal)
  • Tests for primitive reflexes associated with Dementia – palmomental and glabellar
  • States that a sensory examination should be performed, though it would be normal

Gait Examination

  • Evaluates patient getting up from chair, comments on bradykinesia
  • Comments on shuffling gait
  • Comments on stability of gait
  • Comments on festinating gait and lack of arm swing
  • Performs retropulsion test (positive)

Case 4 – Headache

Tim Milligan Neurology

You are seeing Ms. Davis, a 32 year old woman, in your ambulatory clinic today. She states that she has had a worsening headache over the last week. Take a focused history of this complaint. Then, examine all cranial nerves except for I, II, & VIII.

History

  • Onset and duration of headache
  • Location of headache, unilateral vs. bilateral (entire head, bilateral)
  • Severity
  • Frequency
  • Radiation
  • Quality of headache (dull, diffuse)
  • Alleviating factors
  • Triggers for the headache/aggravating factors
  • Temporal association (headache not worse in mornings)
  • Association with nausea/vomiting
  • Vision changes before or during headache
  • New sensory symptoms: weakness, numbness, tingling in upper or lower extremities
  • Photophobia/phonophobia
  • Association with menstrual cycle
  • Systemic symptoms – weight loss, low energy, anorexia
  • Fever and neck stiffness
  • Personal history of head trauma
  • Personal history of migraines
  • Family history of migraines
  • Effect on daily activities
  • Use of oral contraceptive pills
  • Caffeine intake
  • Smoking and alcohol history

Physical Examination

CN III, IV, & VI

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

CN V

  • Examines for light touch in all three nerve divisions (forehead, cheek, chin)
  • Palpates masseter and temporalis muscles and comments on bulk
  • Tests masseter muscle power by opposing jaw opening
  • Tests right and left pterygoids muscle power by opposing lateral jaw movement
  • States that the corneal reflex should be tested and explains the procedure

CN VII

  • Raise eyebrows
  • Tightly clench eyes (and tries to open them)
  • Puff cheeks (and tries to deflate them)
  • Show the lower teeth only
  • Comments on the presence/absence of facial asymmetry/droop

CN IX & X

  • Assesses palatal elevation
  • Assesses gag reflex with tongue depressor
  • Asks patient to swallow
  • Tests phonation
  • States that taste on the posterior 1/3 of the tongue should be tested, and describes how

CN XI

  • Assesses power of both sternoclediomastoid muscles
  • Assesses power of both trapezius muscles

CN XII

  • Examines the tongue for fasciculations
  • Asks patient to protrude tongue, examines for deviation
  • Assesses power of tongue in lateral plane

Case 3 – Seizure

Tim Milligan Neurology

You are seeing Oleg Markov, a 15 year old male, in your ambulatory clinic today. He states that he has recently experienced moments during the day where he loses awareness for minutes at a time but soon fully recovers. Take a focused history of this complaint.

History

  • Onset and duration of awareness deficit
  • Frequency
  • Factors which precipitate these episodes
  • Injury sustained as a result of the seizure
  • Post-ictal symptoms: confusion
  • Associated sensory deficits
  • Associated motor deficits
  • Associated cognitive deficits
  • Muscle spasms
  • Anatomical progression of motor involvement (e.g. Jacksonian March)
  • Symptoms suggesting aura
  • Associated incontinence
  • Tongue biting and salivation
  • Automatisms associated with these episodes
  • Personal history of head trauma
  • Congenital neurological disorder
  • Perinatal infection
  • Medications
  • Drug history
  • Personal history of seizure disorder
  • Family history of seizure disorders
  • Effect on daily activities

Case 2 – Ataxia

Tim Milligan Neurology

You are seeing Mrs. Salamanca, a 45 year old female, in your outpatient clinic. She’s been complaining of unsteadiness when she walks. Please perform a complete examination of her coordination.

Physical Examination

Gait

  • Asks patient to walk to assess gait
  • Assesses toe walking
  • Assesses heel walking
  • Assesses tandem gait
  • Comments on wide, ataxic gait with unequal steps

Balance

  • Performs Rhomberg Test

Motor examination

  • Gross: Performs heel to shin test
  • Gross: Performs finger to nose test
  • Fine: Alternating fingers to thumb
  • Fine: Alternating palm to hand
  • Assesses for intention tremor
  • Assesses for dysarthria
  • Assesses for nystagmus

Case 1 – Cranial Nerve Examination

Tim Milligan Neurology

You are seeing Mr. Grimson, a 39 year old man, for numbness of the face as well as a right facial droop. Please examine cranial nerves V and VII

Physical Examination

CN V

  • Examines for light touch in all three nerve distributions (forehead, cheek, chin)
  • Examines for pain/temperature in all three nerve distributions (forehead, cheek, chin)
  • Palpates masseter and temporalis muscles and comments on bulk
  • Tests masseter muscle power by opposing jaw opening
  • Tests right and left pterygoids muscle power by opposing lateral movements of the jaw
  • Tests the jaw reflex using reflex hammer
  • States that the corneal reflex (afferent V, efferent VII) should be tested and explains the procedure

CN VII
Motor:

  • Comments on the presence/absence of facial asymmetry/droop
  • Tests frontalis by asking patient to raise eyebrows
  • Tests orbicularis oculi by asking patient to tightly shut eyes (and tries to open them)
  • Tests orbicularis oris by asking patient to tightly close lips (and tries to open them)
  • Shows upper and lower teeth
  • Puffs cheeks (and tries to deflate them)
  • Shows the lower teeth only (platysmus)
  • States that the corneal reflex should be tested and explains the procedure (efferent limb)
  • States that lacrimation and salivation should also be tested

Sensory:

  • States that taste on the anterior 2/3 of the tongue should be tested, and describes how this examination could be performed

Case 6 – Hand Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Dawes, a 43 year old female, in your outpatient clinic today. She states that the pain in her right hand is becoming so severe that she can’t even hold a pencil or toothbrush. Take a focused history and perform the necessary physical exam

History

  • Identifies affected hand joints (MCPs, PIPs)
  • Onset of pain
  • Aggravating factors (activity)
  • Alleviating factors (rest, Advil)
  • Character
  • Radiation
  • Association with morning stiffness and duration of stiffness (lasts more than 1 hour)
  • Other affected joints, elsewhere in the body
  • Frequency (intermittent flare-ups)
  • Nighttime pain
  • Fever, night sweats, weight loss, or other systemic symptoms
  • Associated rash
  • Mouth ulcers, dry mouth
  • GI symptoms
  • Associated neurologic symptoms
  • Ophthalmologic symptoms: dry eyes, irritation
  • History of trauma
  • Current medications
  • Personal history of rheumatologic disease
  • Family history of diabetes, thyroid disease, or Celiac disease (autoimmune diseases)
  • Family history of rheumatologic conditions
  • Effect on daily activities

Physical Examination

Inspection of Hand joints, including Wrist

  • Comments on presence/absence of erythema and effusion
  • Comments on deformities, muscle wasting, and deviations

Palpation of hand joints, including the wrist

  • Warmth
  • Tenderness
  • Effusion
  • Crepitus
  • Instability
  • Neurologic exam of hand for power and sensation

Range of Motion

  • Assess active and passive range of motion of all joints in the hand

Extra-articular examination for autoimmune disease

  • General: presence/absence of edema, muscle wasting, cachexia
  • Oral examination: ulcers
  • Respiratory examination: effusions, interstitial disease
  • Musculoskeletal: other effused joints
  • Dermatologic: rashes, ulcers, petechiae
  • Ophthalmologic: iritis

Case 5 – Shoulder Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Kossopoulos, a 26 year old woman, for shoulder pain that has steadily worsening over the last few weeks , during which time she’s been playing softball. Take a focused history and perform a physical exam.

History

  • Onset and duration of pain (began during softball)
  • Progression
  • Alleviating and aggravating factors (worse when bring arm above the shoulders)
  • Quality and location of pain
  • Radiation
  • Presence of night time or morning symptoms (worsens at night)
  • Sensory symptoms in the affected arm e.g. numbness, tingling
  • Motor symptoms in affected arm e.g. weakness, decreased grip strength
  • Associated stiffness
  • Fever and other systemic symptoms
  • Personal history of arthritis
  • Associated trauma/overuse
  • Past shoulder pain
  • Pain in other joints
  • Occupational history as it relates to the pain
  • Family history of arthritis
  • Effect on daily activities

Physical Examination

Inspection

  • Examines both shoulders for SEADS
  • Assesses all active ranges of motion of shoulder
  • Examines the neck for range of motion
  • States that the elbow should be examined as well

Palpation

  • Palpates shoulder for crepitus, warmth, and effusion
  • Palpates the sternoclavicular, acromioclavicular, and glenohumeral joints for tenderness/deformity
  • Palpates all bony aspects of the shoulder joint
  • Tests passive range of motion for affected shoulder

Special Tests

  • Assesses for rotator cuff pathology
  • Assesses for impingement of muscle tendons
  • Assesses for shoulder instability

Case 4 – Worsening Back Pain

Tim Milligan Musculoskeletal

You are seeing Mr. Del Negro, an active 82 year old male in a walk-in clinic. He told your nurse that his back pain has recently become unbearable. Please take a focused history and perform a focused physical examination.

History

  • Onset of back pain
  • Location, and if pain is unilateral/bilateral
  • Quality of pain (dull)
  • Radiation of pain (none)
  • Alleviating and aggravating factors
  • Medications/therapies that have been attempted/are successful to relieve the pain
  • Associated trauma or overuse injury
  • Sensory loss (none)
  • Parasthesia (none)
  • Motor deficits (none)
  • Fever, weight loss, or other systemic symptoms (none)
  • Bladder or bowel incontinence
  • Past history of back pain
  • Personal history of peripheral vascular disease
  • Smoking history (quantity in pack-years)
  • Dyslipidemia
  • Personal history of malignancy
  • Effect on daily activities

Physical Examination

Inspection

  • Comments on shape of spine – kyphosis, scoliosis, as well as posture
  • Comments on any asymmetry of the back, including swelling, scars, or bruising

Range of Motion/Gait

  • Observes all active ranges of motion for the back
  • Assesses patient’s gait

Palpation

  • Palpates along spinous processes and paraspinal muscles of the back for tenderness
  • Performs straight leg raise on both sides, with and without ankle dorsiflexion (negative)
  • Palpates peripheral pulses (present)
  • States that an abdominal exam should be performed to rule out an abdominal aortic aneurysm

Neurological exam

  • Tests foot sensation (L4, L5, S1)
  • Tests for saddle anesthesia (S3, S4, S5)
  • Tests knee (L4) and ankle reflex (S1)
  • Tests Babinski response
  • Tests power of big toe and foot dorsiflexion, as well as foot plantarflexion (S1)
  • Assesses for hip abduction (L5); states that full hip examination should be performed
  • States that rectal tone should be assessed