Author: Tim Milligan

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

Case 3 – Arm Pain Spousal Abuse

Tim Milligan Musculoskeletal

You are seeing Mrs. McNeil, a 31 year old female in your general practice clinic. She states that she recently injured her arm while cleaning her home. Take a focused history of her complaint.

History

  • Inquires about circumstances in which injury occurred
  • Timing of injury
  • Mechanism (patient eventually discloses that she had been physically abused by her husband)
  • Other recent injuries
  • Visits to hospital for other reasons
  • Asks about any medication use
  • Alcohol/drug history
  • Determining social context at home (lives with husband, two young children)
  • Inquires if husband was verbally abusive
  • Inquires if husband was sexually abusive
  • Whether husband has used weapons to harm patient, or has access to weapons
  • Extent of injury in the past
  • Asks if the children have been abused
  • Asks if the children have witnessed spousal abuse
  • Asks if the husband has a substance abuse problem
  • Asks if patient feels safe at home
  • Asks if friends/family are aware of the abuse
  • Inquires about emergency plans to escape in the event of further abuse
  • Asks if she has access to financial resources
  • Asks if she would like help from a counselor
  • Asks if she would like support from community resources
  • Asks if she would like legal counseling

Case 2 – Hip Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Goldberg, a 76 year old female from a nursing home who has been well until today. She presents to the Emergency Department after being found on the floor of her room in her nursing home. She was alert and oriented when she was found, and has felt well in recent days. Take a focused history and perform all the relevant physical examination maneuvers.

History
Physical Examination

Inspection

  • Examines both hips joints for SEADS (swelling, erythema, muscle atrophy, deformity, skin changes)
  • Assesses all active range of motion for both hips (flexion/extension, abduction/adduction, rotation)
  • Assesses patient’s gait (patient refuses due to pain)
  • States that the lower back and knees should be examined as well

Palpation

  • Palpates hips, PSIS, and ASIS for tenderness
  • Determines real and apparent leg lengths (notes that there is a significant difference)
  • Assesses peripheral pulses
  • Assesses neurologic status of effected limb
  • Tests all passive range of motion for effected hip

Special Tests

  • Performs Trendelenburg’s Test assessing for hip abductor strength
  • Assesses for flexion contracture of effected hip while eliminating lumbar lordosis

Case 1 – Knee Injury

Tim Milligan Musculoskeletal

You are seeing Sarah Tseng, a 21 year old female in the Emergency Department. She comes in complaining of severe left knee pain after she fell while running. Perform a focused physical examination.

Physical Examination

Inspection

  • Examines both knee joints for SEADS (swelling, erythema, muscle atrophy, deformity, skin changes)
  • Comments on presence of valgus/varus deformity
  • States that the hips and ankles should be examined as well

Palpation

  • Palpates knees for crepitus, warmth, and effusion.
  • Palpates along left joint-line for tenderness
  • Palpates for Baker’s cysts
  • Tests passive range of motion for effected knee

Tests for Effusion

  • Examines for Bulge Sign
  • Uses fluctuation to assess for effusion
  • Tests for ballottement

Range of Motion/Gait

  • Assesses patient’s gait
  • Assesses active range of motion for both knees

Stability

  • Assesses for LCL and MCL damage
  • Assesses for ACL damage using Anterior Drawer Sign
  • Assesses for PCL damage using Posterior Drawer Sign

Special Tests

  • Assesses for meniscal tears using McMurray Test

Case 4 – Diabetes

Tim Milligan Geriatrics

You are seeing Mrs. Rajwal, a 69 year old woman, who feels concerned about her health. She heard that her sister was recently diagnosed with diabetes and wonders if she is at risk of developing the disease as well. Take a focused history, addressing Mrs. Thompson’s concern.

History

  • Addresses patient’s concerns about diabetes
  • Establishes patient’s ethnicity
  • Polydipsia, polyuria
  • Nocturia
  • Fatigue
  • Blurry Vision
  • Parasthesias/numbness in peripheries
  • Lower extremity ulceration or infection
  • Skin darkening
  • Weight history: gain/loss
  • Asks about diet history
  • Current medications/Allergies
  • Personal history of gestational diabetes
  • Personal history of myocardial infarction and stroke
  • Personal history of renal disease
  • Peripheral vascular disease (patient has intermittent claudication)
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Family history of Type II diabetes mellitus
  • Family history of cardiac or cerebrovascular events

Case 3 – Sleep Problems

Tim Milligan Geriatrics

You are seeing Mr. Le, an 83 year old man, because of recent sleep problems. He says he hasn’t had a full night’s sleep in over a week. He currently lives alone. Please take a focused history.

History

  • Onset and duration of insomnia
  • Amount of sleep per night
  • Quality of sleep
  • Activating medications
  • Activities before sleep: coffee, alcohol, exercise, smoking
  • Disturbances during sleep: night terror, orthopnea, nocturia, restless leg, obstructive sleep apnea
  • Smoking and alcohol history
  • Thought content during periods of insomnia
  • Establishes social context (wife has recently been admitted to hospital for ‘failure to cope’)
  • Effect on daily activities
  • Day time somnolence
  • Inquires about what patient believes the insomnia is due to
  • Asks about guilt
  • Asks about low mood
  • Poor concentration
  • Poor appetite
  • Psychomotor retardation
  • Asks about life stresses, e.g. care-giver stress
  • Homicidal/suicidal ideation
  • Psychotic symptoms
  • Symptoms of anxiety
  • Past history of depression
  • Past history of psychiatric illness

Case 2 – Uncontrolled Blood Pressure and Elder Abuse

Tim Milligan Geriatrics

You are seeing Mr. Sampson, a 71 year old man, for the first time in 3 years. He says he hasn’t had his blood pressure checked recently and would like you to assess it today. He wanted to come sooner but says he couldn’t. Please take a focused history.

History

  • Inquires about patient’s well being since last visit
  • Establishes social context – patient lives alone with son
  • Establishes sons’ social context (has recently lost his job, divorced)
  • Inquires about independence regarding finance, health, transportation
  • Inquires about aggression from son
  • Establishes past history of injuries and abusive behavior by son
  • Extent of medical attention sought/needed for past injuries
  • Inquires if son was verbally abusive
  • If son has used weapons to harm patient, or has access to weapons
  • Substance abuse by the son and quantity (abuses alcohol weekly)
  • Assesses patient’s access to health care/medication
  • Asks if patient feels safe at home
  • Whether friends/family are aware of the abuse
  • Emergency plans to escape in the event of further abuse
  • Asks if he has access to financial resources
  • Asks if he would like help from a counselor
  • Asks if he would like support from community resources
  • Asks if he would like legal counseling
  • Addresses patient’s concern about loss of independence and lack of power