Name M/F Age General Appearance + Vitals

Chief Complaint

Symptoms – OPQRST VINDICATE – For Differential

FIFE  Vascular
 Infectious,
PMHx Inflammatory
 Neoplastic
Major Illnesses  Degenerative
Hospitalisations  Idiopathic
Surgeries  Congenital
Psych  Autoimmune
 Trauma / toxins
Meds
 Endocrine (metabolic)
Allergies
Can also have a differential
based on systems.
Living Situation/ Relationships

FMHx – Father, Mother, Siblings, Children

Social – Exercise, Diet, Tobacco, EtOH, Drugs, Employment, Finances

Review of Systems
General Respiratory MSK Endocrine
 Weight change  Cough  Pain  Heat/cold intolerance
 Fatigue  Sputum  Swelling  Polydipsia
 Fevers / Chills  Hemoptysis  Redness  Polyphagia
 Night sweats  Dyspnea  Cramps  Polyuria
 Skin changes  Wheezing  Weakness  Diaphoresis
 Hair changes  CP
 Nail changes
GI CVS Neuro Psych
 Abdo pain  CP  Headache  Elevated or Depressed
 Heartburn  Palpitations  Numbness Mood
 Nausea  Diaphoresis  Weakness  Suicidal
 Vomiting  Syncope  Vision changes  Homicidal
 Changes in BMs /  Dyspnea  Speech changes  Hallucinations
Bloody BMs  Orthopnea  Memory changes (Auditory/Visual)
 Paroxysmal  Confusion
 Bloating  Anxiety
Nocturnal  Seizures
 Jaundice  Decreased interest
 Appetite changes Dyspnea  Guilt
 Edema  History of abuse
 Claudication
 Varicose Veins
Urologic Gynecologic Obstetric HEENT
 Dysuria  Menarche age Past Obstetric History  Eyes: Vision, Pain,
 Frequency  Menstrual cycle  Pregnancies Redness, Tearing,
 Urgency  Spotting  Complications Discharge, Photophobia
 Hematuria  Last menstrual  Deliveries  Ears: Hearing, Pain,
 Hesitancy period  Abortions Tinnitus, Vertigo,
 Incontinence  Menopause age  Ectopic pregnancies Discharge
 Night time voiding  Pelvic pain  Miscarriages  Nose: Congestion,
Current Obstetric History Drainage, Bleeding, Post
 Bleeding Nasal Drip
 Discharge  Throat: Pain, Swelling,
 Leakage of fluid Dysphagia, Dysphonia
 Fetal movement  Mouth: Pain, Swelling,
 Pelvic pain Malocclusion, Trismus,
 Edema Discharge, Bleeding

*Try to have an answer for everything semi-relevant on this sheet

Initiate The Session
 Establish initial rapport
o Introduces self, role and nature
of interview, obtain consent
o Demonstrate respect and
interest
 Identify Reason for Visit
o Identify problems to address
o Confirms list and screen for
anything else
o Negotiates agenda
History of Present Illness (HPI)
 Exploration of problems
 Help Pt tell story of problem (start to
know in own words)
 Dates and sequence of events
 Ask questions to determine cause
 Onset, provoke, quality, setting, time,
location, associated manifestations and
effect of therapy
 Explore the patient’s feelings about
being ill; their ideas about what might
be the cause of the current problem;
how it is impacting their daily
functioning and their expectations for
care (GOALS)
Medication History
 Current and past medication
 Drug allergies – note reaction
Habits – Incorporate preventative Health
 Habits, including dietary pattern, sleep
patterns, exercise, use of caffeine,
tobacco, alcohol, non-prescription
drugs
 Mind your body language/nervous habits such as smiling, tapping feet, saying “ok great”
or “perfect”
 Have canned responses to awkward situations that are easy for you to say under
pressure but sound genuine. Always remember to be kind!
 Make sure you ask open ended questions as much as possible, remember that you CAN
ask some closed ended ones.
 Don’t stack questions – ask one at a time
Past Medical History
 Review past medical and surgical illness
Family History
 The ages, state of health or cause of
death or mother, father, brothers,
sisters, wife/husband and children
 Any disease that runs in the family
Life Situation
 Explore the context of the illness
Closing
 Is there anything else you would like to
discuss before we proceed to the
physical exam?
Remember to sign post and provide summaries
when changing topics – ex. PMHx to Family Hx
QUESTIONS For When you Get Stuck
 Could you describe…
 When did … begin
 Is there anything that makes … worse,
better?
 Is there anything you do to relieve…
 How long does… usually last
 How has … changed over time
 Does … radiate
 Have you had similar to… in the past
 When … is present do you have any
other symptoms
 What do you think is going on
 Is there anything you’re particularly
worried about with regards to…
 How is … affecting your current
activities
 What were you hoping I could do for
you today
 COUNSELLING PURPOSE WHEN IT’S USED EXAMPLES
MICRO-SKILL
ATTENDING Encourage patients Establishing rapport Attentive body language (eye contact,
BEHAVIOUR to talk and show leaning forward slightly, encouraging
interest gestures, mhmms..)
QUESTIONING Guide the encounter Information “What would you like to talk about
and assist in gathering stage of today?”
enriching the story the interview “When does the problem occur?”
1. What has brought you here
today?
2. Why do you think that?
3. How did you come to consider
this?
4. Could you tell me what brings
you here today?
How, What, When, Where
RESPONDING Confirm with the Clarify and “Let me see if I’ve got this right. You
patient that they are encourage clients’ want to go back to full time study but
being heard stories are worried about your financial
correctly commitments?”
NOTING, Can use when stuck “You feel disappointed because your
REFLECTING, and to move on mother didn’t call you on your
SUMMARIZING birthday.”

“We’ve covered your past medical

history, I like to know a little more
about your living situation.”
OBSERVATION Always observe! When is it NOT Observing body language, tone of voice
used?! and facial expressions, nervous
behaviours.
FOCUSING Direct “I would like to hear more about… your
conversational flow medications.”
into certain areas
INFLUENCING Facilitate a change in Exploring A young person has just been
the way a pt chooses alternatives diagnosed with high BP, you discuss
to think or act the impacts and treat options

Motivational Interviewing: Find out what changes the PATIENT is willing to make. Remember to
take things in steps, only what the patient is comfortable with  no one is going to go from
smoking 5 packs a day to quitting, maybe 4 packs is more reasonable. SMART goal setting.

Establish Goals and Common Ground: Ask what the patient’s goals are (a positive outcome for
them) and work together to achieve them.

Set Boundaries: know what your boundaries are and respect them, respectfully and
empathically make these clear.
General Inspection + Vitals:
Intro + Consent + Confirm Patient Name

Wash Hands and Drape

General Inspection
Comment on general appearance - awareness, dress, speech, posture, gait, greeting and
shaking hands, facial expression, relationship with accompanying relatives
LOC – alert oriented, awareness, mood, articulation
Obvious signs of cardiac and respiratory distress (labored breathing, wheezing, pallor,
diaphoresis or cough)
Body Appearance – body structure (height and weight), body proportions or physical
deformities, posture, position
Skin:
 Central and peripheral cyanosis – (lips, in mouth, under tongue), look at hands and feet,
 Pallor – look at conjunctiva, oral mucosa, nail beds.
 Jaundice – sclera
 Other: dry skin, loss of hair, rashes, bruising
Involuntary movements
Abnormal Odours - alcohol or acetone

Pulse:

Rate: 15 seconds
Rhythm – Regularity
Amplitude – normal, increased, decreased
Contour
Symmetry
Radial, carodid, brachial, popliteal, and two in the ankle

Resp Rate:

Speaking in full sentences, purse lipped breathing, nasal flaring, accessory muscle use,
wheezing, stridor?

Determine – rate (14-20 is normal), rhythm, depth, and effort

Blood Pressure:

Note whether cuff fits appropriately


Assess in both arms for all new patients – during OSCE, offer in both arms
Make sure arm is free of clothing

Palpate brachial artery

Hold arm at level of patient's heart

Apply cuff at least 2.5 cm proximal to the antecubital crease

Estimate systolic pressure by palpation of radial artery while inflating cuff

Add 20 mm Hg to initial reading and reinflate cuff to this point

Auscultate over brachial artery

Deflate cuff at rate of 2–3 mm Hg/sec
Offer to assess for orthostatic hypotension  laying vs. standing, look for 10/20/30 change (10
systolic, 20 diastolic, 30 HR)

Head and Neck Exam

Intro, Consent, Name
Wash Hands and Drape
General Appearance and Vitals

Hair/Scalp
Inspection:
 Hair/Scalp: quantity, distribution, texture, patterns of loss, scaling or lesions
 Skull: size contour and symmetry
Palpation:
 Hair/Scalp/Skull – looking for the same things as on inspection

Face/Neck
Inspection:
 Face: involuntary movements, contour, symmetry
 Eyes: exothalmos, ptosis, swelling, xanthelasma, conjunctiva (cyanosis, pallor,
inflamation), sclera (jaundice)
 Skin: significant discoloration, or lesions
 Neck: symmetry, scars, masses, venous distention
Palpation:
Lymph Nodes: size, shape, mobility, consistency, tenderness
 Preauricular – in front of the ears (parotid salavary gland)
 Posterior Auricular – behind the ears, superficial to the mastoid process 

  Occipital – found posteriorly, at the base of the skull 

 Tonsillar – at the angle of the mandible 

 Submandibular – midway between the angle of the mandible and the tip of the
mandible (salivary gland)
 Submental – in the midline, just behind the tip of the mandible 

 Anterior Cervical – superficial to and along the sternocleidomastoid muscle 

 Posterior Cervical – along the anterior ridge of the trapezius 

 Supraclavicular – along the upper edge of the clavicle, deep in its formed angle 


Thyroid:
Inspection: rest and swallowing
Palpitation:
Thyroid cartilage, cricoid cartilage  below is the isthmus, move laterally to palpate the lobes
** lobes: size tenderness, consistency, symmetry, masses
Swallow while palpating the isthmus
Tracheal Deviation – two fingers

Auscultation: bruit on neck

Sensory Exam
Intro, Consent, Name
Wash Hands and Drape
General Appearance and Vitals

Inspection: SEADS (swelling, erythema, ecchymosis, atrophy, deformity (symmetry), skin

changes, scars nodules
Involuntary movements

Pain (toothpick):
Assess Both Sides – let me know when you feel it, does it feel the same on both sides
Temp (tell them that you did pain)
Light touch – same as pain but using tissue
Vibration – 128Hz tuning fork. Test it on the patient’s forehead to show them what it should
feel like. Vibration on distal interphalangeal joint on index finger and big toe. If deficit move
proximally

Dermatomes: C5, C6, C7, C8, T4 (nipple), T10(umbilicus), L5 and S1.

Shoulder- C5
Lateral Arm- C6
Medial Forearm – T1
Thumb and Index – C6
Middle Finger – C7
Pinky – C8
Medial Thigh - L3
Knee - L4
Middle Shin - L5
lateral calf - S1
medial calf - S2
Big Toe – L5
Small Toe – S1
L4 – arch of foot

Proprioception – hold sides of thumb (pt’s eyes closed), show up and down. Then ask pt to tell
you
Cortical sensory function:
 Stereognosis – identify object in hand with eyes closed
 Graphestheia – trace something on their arm
 Two-point discrimination – two tooth picks, together or apart (eyes closed)
 Point localisation – pin prick w/ eyes closed, and they tell you where you touched

Coordination and Cerebellar Function

Upper Extremity:

Assess Rate Rhythm and Smoothness of movements

Hand on palm and flip (both sides) – then faster
Finger to thumbs – both hands
Finger to nose test – watch for tremor
Heel Shin test – tap patella with heel and move it down

Lower Extremity:

Romberg Test: feet together + close eyes – tell them you’re here to catch them
Gait: Walk to one end of the root to the other then Heel Toe Walking

Motor Function Test:

Intro, Consent, Name
Wash Hands and Drape
General Appearance and Vitals

Inspection: SEADS (swelling, erythema, ecchymosis, atrophy, deformity (symmetry), skin

changes, scars nodules
Involuntary movements
Palpation:
Actual Palpation
 Warmth, tenderness
 Joint effusion
 Edema
 Symmetry

ROM – Active and Passive (tone)

Shoulders:
Inspect
Palpate for Bulk/ evidence of wasting
Hands behind Head (external rotation and abduction)
Hands Behind Back, behind shoulder blade tips (internal rotation and adduction)
Arms crossed – observe shoulder blades for symmetry
Passively (tone) – flexion extension, abduction and extension, internal rotation and external
rotation - Feeling for any crepitus

Upper Limb:
Inspect: swelling, asymmetry, deformity, nodules, erythema
Flex and Extend both wrists, flex and extend fingers – symmetry
Flexion and extension of elbow - Audible Crepitus
Pronation and Supination of Forearm
Passive (tone)
Elbow tone – look for spasticity and rigidity

Lower Limb (pt supine)

Inspect – symmetry, swelling
Palpate for bulk
Flex and Extend both legs
Internal and External Rotation
Flex and Extend Feet
Passive (tone)

Spinal Assessment:

TMJ: flexion and extension (note tenderness) – palpate (crepitus)

Cervical Spine:
Inspect and Palpate
Flexion and extension (chin to chest, look up)
Lateral rotation – look over shoulder
Lateral Flexion – ear to shoulder
Thoracic and Lumbar Spine:
Inspect: any deformity, kyphosis, scoliosis,
Palpate: tenderness

Bend forward and touch toes – forward flexion (check that lumbar vertebrae separate)
Bend as far back as possible – extension
Rotate from side to side
Bend and touch the outside of your knee

Power and Reflexes

Intro, Consent, Name
Wash Hands and Drape
General Appearance and Vitals

Inspection: SEADS (swelling, erythema, ecchymosis, atrophy, deformity (symmetry), skin

changes, scars nodules
Involuntary movements

Palpation:
Actual Palpation
 Warmth, tenderness
 Joint effusion
 Edema
 Symmetry

Power – one side at a time, note symmetry and score 0-5

0 = absent, 1 trace, 2 weak, 3 against gravity, 5 full resistance
 Arms like wings – deltoids (C5 axillary nerve)
 Pull and Push against the resistance of my hands – biceps (C5 C6 musculocutaneous
nerve) and triceps (C6 C7 C8 radial nerve)
 Make a wrist and bend back against mine (C6 C7 C8 radial nerve)
 Spread fingers - adductors and abductors (C8 T1 ulnar nerve)
 Squeeze two fingers (C7 C8 T1)
 Raise knee to chest - iliopsoas (L2 L3)
 Knee to floor – Glutes
 Knee extension and flexion – quads (L2 L3 L4 femoral nerve) and hamstrings (L4 L5 S1 S2
– sciatic nerve)
 dorsiflexion (L4-5; common peroneal nerve) and plantar flexion (S1, posterior tibial
nerve) 

Reflexes: Compare both sides – remember reinforcement

Biceps Reflex: C5 C6 – musculocutaneous nerve

Triceps Reflex: C7 – radial nerve
Brachioradialis: C5 C6 – radial nerve
Knee Jerk: L2 L3 L4 – femoral nerve
Achilles tendon: S1 – siatic nerve

Grades: 0 – none, 1, - decreased, 2 – normal, 3 increased, 4 Pathologic

Cranial Nerve Exam

Intro, Consent, Name
Wash Hands and Drape
General Appearance and Vitals

Face
Inspection:
Face: involuntary movements, contour, symmetry
Eyes: exothalmos, ptosis, swelling, xanthelasma, conjunctiva (cyanosis, pallor, inflamation),
sclera (jaundice)
Skin: significant discoloration, or lesions

Cranial Nerve I – olfactory (close eyes occlude nostril – coffee soap cloves)

CN II : optic nerve (sensory)

 Snellen Chart – cover one eye, make sure vision is corrected, read bottom line
 Visual Fields – cover one eye, wiggle fingers in the middle like a clock, bring them
inwards – tell them to look at your nose
 Pupils – ask patient to look into distance - report symmetry, shape, reaction to light
(direct and consnetual) and size
 Fundoscopy

Cranial Nerves III (oculomotor), IV (trochlear), and VI (abducens) – motor nerves

 Track finger in H pattern (looking for normal conjugate eye movements) – first ask the
patient to let you know if they experience pain or see double, look for end point
nystagmus (they should look with eyes only)
 Convergence – finger to wall

CN V: trigeminal nerve – sensory, motor and reflex – 3 branches

 Temporalis and mastator muscles – clench teeth + palpate
  Light touch on forehead cheek and jaw (close eyes – check symmetry)
 Corneal Reflex – look away, approach from other side, they should bink

CN VII: facial nerve – motor

 Look for symmetry, and involuntary movements
 raise eyebrows, frown, close eyes (resist), show teeth, smile, and puff cheeks (resist)

CN VIII: vestibulocochlear nerve – sensory

 Hear fingers rubbing (occlude one ear)
 Webber (top of head + ask lateralisation) + Rinne (when do they stop hearing it)
o Webber: If lateralization occurs, this indicates the likely presence of ipsilateral
conductive hearing loss or contralateral sensorineural losses 

o sensorineural hearing loss, air conduction > bone conduction (same as normal),
whereas with conductive hearing loss, bone conduction > air conduction

CN IX and X: glossopharyngeal and vagus

 “Ah” while you look with penlight for soft palate and pharynx movement
o Note symmetry, midline rise of uvula
 Gag reflex

CN XI: accessory nerve – motor

 trapezius and sternocleomastoid muscles 

 shrug shoulders and turn head – resistance

CN XII: hypoglossal – motor

 stick tongue out and move to left and right
o fasciculations, symmetry, deviation, movement, and strength of tongue
o push tongue on cheek and press
Nerve Function Type Mnemonic
Olfactory I Smell (only CN without thalamic relay to cortex) Sensory Some
Optic II Sight Sensory Say
Eye movement (SR, IR, MR, IO), pupillary constriction
(sphincter pupillae: Edinger-Westphal nucleus,
Oculomotor III Motor Marry
muscarinic receptors), accommodation, eyelid
opening (levator palpebrae)
Trochlear IV Eye movement (SO) Motor Money
Mastication, facial sensation (ophthalmic, maxillary,
Trigeminal V mandibular divisions), somatosensation from anterior Both But
2/3 of tongue
Abducens VI Eye movement (LR) Motor My
Facial movement, taste from anterior 2/3 of tongue
(chorda tympani), lacrimation, salivation
Facial VII (submandibular and sublingual glands are innervated Both Brother
by CN seven), eyelid closing (orbicularis oculi),
auditory volume modulation (stapedius)
Vestibulocochlear VIII Hearing, balance Sensory Says
Taste and sensation from posterior 1/3 of tongue,
swallowing, salivation (parotid gland), monitoring
Glossopharyngeal IX Both Big
carotid body and sinus chemo- and baroreceptors,
and elevation of pharynx/larynx (stylopharyngeus)
Taste from supraglottic region, swallowing, soft
palate elevation, midline uvula, talking, cough reflex,
Vagus X Both Brains
parasympathetics to thoracoabdominal viscera,
monitoring aortic arch chemo- and baroreceptors
Accessory XI Head turning, shoulder shrugging (SCM, trapezius) Motor Matter
Hypoglossal XII Tongue movement Motor Most
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