 Lecture 2

Level 1 (Problem Focused) Level 2 (Expanded Problem Focused) Level 3 (Detailed) Level 4 / 5 (Comprehensive)

General Multi-System Examination Single Organ System Examination

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Level 1Level 2Level 3Level 4 / 5 number of “bullets” or “things” examined Exam1 - 5 total total >=12 total in >=2 systems >=2 in EACH of >=9 systems

1. Constitutional 2. Eyes 3. ENMT 4. Neck 5. Respiratory 6. Cardiovascular 7. Chest 8. Abdomen 9. Genitourinary 10. Lymphatic 11. Musculoskeletal 12. Skin 13. Neurologic 14. Psychiatric

 THREE vital signs (sitting/standing BP, temp, pulse, respiratory rate, supine BP, height, weight)  General appearance

 Conjunctivae & lids  Pupils & iris  Ophthalmic exam

 Neck  Thyroid

 Ears and nose  Otoscopic exam  Hearing assessment  Internal nose exam  Lips, teeth and gums  Oropharynx exam

 Effort  Auscultation  Palpation  Percussion

 Palpation  Auscultation  Carotid arteries  Abdominal aorta  Femoral arteries  Pedal pulses  Edema / varicosities

 Inspection of breasts  Palpation of breasts and axillae

 Masses/tenderness  Liver and spleen  Hernia  Anus, perineum & rectum  Stool occult blood test

Female  External genitalia  Urethra  Bladder  Cervix  Uterus  Adnexa/parametria Male  External genitalia  Scrotal contents  Digital rectal examination

Palpate TWO of these:  Neck  Axillae  Groin  Other

 Gait and station  Inspection +/- palpation  Digits and nails  Range of motion  Stability  Strength & tone (1) head and neck, (2) spine, ribs, pelvis, (3) right upper extremity, (4) left upper extremity, (5) right lower extremity, (6) left lower extremity

 Inspection  Palpation

 Cranial Nerves (do all except CN 1 & 10)  Reflexes  Sensation

 Judgment and insight  Orientation  Recent / remote memory  Mood and affect

What is the least number of bullets necessary for a Level 2 Multi-System Exam?

Let’s give it a quick try!

“Urg! My chest!”

Level 1Level 2Level 3Level 4 / 5 Exam1 - 5 total total >=12 total in >=2 systems >=2 in EACH of >=9 systems

 Constitutional  Cardiovascular  Respiratory /80 mmHg, 98F, 100 bpm 2. S1S2 present, no murmur 3. No lifts or heaves dorsalis pedis pulses 5. Rapid, shallow breaths 6. Decreased breath sounds over left lower lobe

 Constitutional  Psychiatric  Respiratory  Cardiovascular  Neck 1. Appears stated age /80mmHg, 98F, 100 bpm 3. Anxious and mild distress 4. Rapid, shallow breaths 5. Decreased breath sounds over left lower lobe 6. S1S2 present, no murmur 7. No lifts or heaves 8. No abdominal bruit 9. No carotid bruit dorsalis pedis pulses 11. Trachea midline 12. No jugular vein distention

1. Constitutional 2. Psychiatric 3. Respiratory 4. Cardiovascular 5. Neck 6. MSK 7. Abdomen 8. Skin 9. Chest (breast) 1. Appears stated age /80mmHg, 98F, 100 bpm 3. Anxious and mild distress 4. AAO x 3 5. Rapid, shallow breaths 6. Decreased breath sounds over left lower lobe 7. S1S2 present, no murmur 8. No lifts or heaves 9. Trachea midline 10. No jugular vein distention 11. No chest wall deformity 12. Ribs nontender 13. Abdomen nontender 14. No organomegaly 15. No visible dermatomal papules over chest 16. No stasis dermatitis 17. No nipple discharge 18. No axillary lymphadenopathy

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1. Cardiovascular 2. ENMT 3. Eyes 4. Genitourinary 5. Hematologic or Lymphatic or Immunologic 6. Musculoskeletal 7. Neurologic 8. Psychiatric 9. Respiratory 10. Skin Gastrointestinal system is absent!

Level 1Level 2Level 3Level 4 / 5 number of “bullets” or “things” examined Exam1 - 5 total total >=12 total in >=2 systems shaded: ALL unshaded: >=1 Note: Ophthalmology & Psych have it easy and only need 9 bullets

…What?

Shaded boxes Unshaded box

Respiratory Example

Let’s give it a quick try!

“My head hurts”

Level 1Level 2Level 3Level 4 / 5 number of “bullets” or “things” examined Exam1 - 5 total total >=12 total in >=2 systems shaded: ALL unshaded: >=1 Note: Ophthalmology & Psych have it easy and only need 9 bullets

Ophthalmic exam carotid arteries heart auscultation peripheral vascular THREE vitals General appearance Gait & station Strength Tone Orientation Memory Attention Language Knowledge Sensation DTRs Coordination CN 2, 5, 7, 8, 9, 11, 12 {3, 4, and 6}

 Constitutional  Neurologic /80mmHg, 98F, 100 bpm 2. Oriented to person, place and time 3. Light touch symmetric 4. Cranial nerve 5 intact 5. Cranial nerve 7 intact 6. Cranial nerve 8 intact 7. Cranial nerve 9 intact 8. Cranial nerve 11 intact 9. Cranial nerve 12 intact

 Constitutional  Musculoskeletal  Neurologic /80mmHg, 98F, 100 bpm 2. Full and symmetric strength in upper and lower limbs 3. Oriented to person, place and time 4. Light touch symmetric 5. Quadriceps and biceps reflexes symmetric and intact 6. Finger-to-nose & rapid alternating movement intact 7. Cranial nerves 3, 4, and 6 intact 8. Cranial nerve 5 intact 9. Cranial nerve 7 intact 10. Cranial nerve 8 intact 11. Cranial nerve 9 intact 12. Cranial nerve 11 intact 13. Cranial nerve 12 intact

 Constitutional  Musculoskeletal  Neurologic  Cardiovascular  Eyes  Anxious and mild distress  140/80mmHg, 98F, 100 bpm  Normal gait  Full and symmetric strength in upper and lower limbs  Muscle tone normal  Oriented to person, place and time  Recent & remote memory intact  Serial 7’s intact  Speaks fluently and appropriately  Fundamental knowledge intact  Light touch symmetric  Quadriceps and biceps reflexes symmetric and intact  Finger-to-nose and rapid alternating movement intact  Cranial nerves II-XII intact  S1S2 present, no murmur  No papilledema or AV nicking



“Doctor, my left knee is killing me!”

What do you want to check?

Decide on type and level of exam

Level 1Level 2Level 3Level 4 / 5 General Muti-system Examination bulleted elements bulleted elements >=12 bulleted elements in >=2 of systems Do all Document >=2 in EACH of >=9 systems Single Organ Examination >=12 bulleted elements Do all Document ALL shaded & >= 1 in unshaded

THREE vitals General appearance Peripheral vascular Inspect/palpate FOUR: head/neck trunk RUE Lymph nodes Sensation DTRs Coordination Orientation Mood / affect Gait & station Range of motion Stability Strength and tone Palpation / inspection LUE RLE LLE FOUR areas: (1) head and neck, (2) spine, ribs, pelvis, (3) right upper extremity, (4) left upper extremity, (5) right lower extremity, (6) left lower extremity

1 Bullet  “left knee swollen” or  “patient is anxious” or  “BP 120/80, HR 70, temp 97F” 2 Bullets  “patient is anxious. left knee swollen” or  “left knee swollen, painful left knee extension” 5 Bullets  “patient is anxious, oriented to person & place & time (AAOx3), antalgic gait, left knee swollen, light touch over left leg intact” Multi-Systems AND Single Organ Exam 1 to 5 bulleted elements not enough…

Multi-Systems AND Single Organ Exam 6 to 11 bulleted elements 6 Bullets 1. BP 120/80, HR 70, temp 97F 2. antalgic gait 3. left knee swollen 4. painful left knee extension 5. left knee warm to touch 6. light touch over left leg intact 11 Bullets 1. BP 120/80, HR 70, temp 97F 2. well-groomed & well-nourished 3. anxious 4. AAOx3 5. pedal pulses intact 6. antalgic gait 7. left knee swollen 8. painful left knee extension 9. left knee warm to touch 10. light touch over left leg intact 11. mild pain limited strength Okay…

Multi-System Exam >=12 bulleted elements in >=2 systems 1. BP 120/80, HR 70, temp 97F 2. well-groomed & well-nourished 3. anxious 4. AAOx3 5. pedal pulses intact 6. antalgic gait 7. left knee swollen 8. painful left knee extension 9. left knee warm to touch 10. mild pain limited strength 11. light touch over the leg intact 12. quadriceps reflex intact 1. BP 120/80, HR 70, temp 97F 2. well-groomed & well-nourished 3. antalgic gait 4. left knee warm to touch 5. right knee cool to touch 6. left knee swollen 7. painful left knee extension 8. full right knee extension 9. pain limited left knee strength 10. full right knee strength 11. no left knee ligamental laxity 12. light touch over left leg intact Single Organ Exam >=12 bulleted elements OR constitutional psych neuro MSK CVS

Document >=2 in EACH of >=9 systems Too much?

THREE vitals General appearance Peripheral vascular Inspect/palpate FOUR: head/neck trunk RUE Lymph nodes Sensation DTRs Coordination (e.g, RAM) Orientation Mood / affect Gait & station Range of motion Stability Strength and tone Palpation / inspection LUE RLE LLE FOUR areas: (1) head and neck, (2) spine, ribs, pelvis, (3) right upper extremity, (4) left upper extremity, (5) right lower extremity, (6) left lower extremity