Beyond the NCLEX and USMLE

It is easy to get so caught up in studying for your NCLEX or USMLE exam, that you forget the main point...you are learning for the benefit of your future patients and not just to pass the NCLEX or USMLE. Whenever possible, I like to step back and say, 'how does this effect me on the wards or in the unit'. What follows is one of those application blogs, where you look at the whole forest and not just the trees.

Square Man:

Mr. Square Man was born late one night, hours before a practical exam in health assessment. I memorized all of these signs and symptoms and was trying to organize the steps to the history and physical exam and felt pretty confident with my abilities. That was until I stepped into the examination room and saw the standardized patient and stern look of the evaluator. At that moment I had no idea what I was about to do. Luckily, the little stick figure made of graphite and colored dye leaped out in my mind and saved the day-sans a cape of course. Ever since, I have depended upon Square Man to visualize my way through the history and physical. So, without further ado, may I present square man...

The Subjective History

OK, actually before you see Mr Square Man, we need to talk. No I don't mean you and I need to talk, we need to get the history from the patient through an interview. You will be given a hundred different vital portions, and all sorts of acronyms to make it easier, none of which were any aid to me when I drew the blank on standardized patient day. In my humble opinion, the following is the most important part of the History, and what you should drill into your hippocampus:
• AOx3, oriented to person, place and time
• GCS: Look at me, speak to me, shake my hand
• CC: chief complaint (Whats up?)
• HPI:
• P: palliative/provocative (what makes better/worse)
• Q: quality (what does it feel like)
• R: radiation (for pain); region (for pain)
• S : severity (scale 1-10 for pain); symptoms (for non pain complaint)
• T: Timing (when did it start, course of complaint)
• Other vital history parts:
• M: medications (any meds you are on or have taken, i/c OTCs)
• A: Allergies to meds (what happens when you take?)
• D: Diseases (any other health conditions I should know about)
• D: Drugs (alcohol, nicotine, street drugs)
• Other possible history parts (if you have time):
• Social history (smoking, drinking, drugs, sexual partners, etc)
• Family history (of diseases)

The Objective Vitals...Yes they are vital!
• BP, HR, R, Temp, O2 Sats

The Objective Physical...Square Man appears
• Focus on portion of square man containing chief complaint first, or...
• If complaint is general or in head, then go head to toe through the body

1. The HeadStart here for head complaints (h/a), as well as neuro complaints
CNS: (brainstem)
• PERRL, EOMs, Feel face, Move face, Hearing, Ahhh, Shrug/Turn, Tongue
• Snellen chart if vision acuity check required (20 ft, cover one eye, read smallest)
Ears:
• Need more than hearing is ok

• Webber: lateralization...which ear do they hear better in?
• Rinne: To bad ear: conduct defect; To good ear: sensory defect
Nose:
• Patent
• Sinus tap: over, under eyes
Lymph:
• U under chin (sub mand, sub mental)
• U around ears (pre, post auricular)
• Chain down next strap moves you to next part of square man

Issues of note:
• PERRL problem (dilated, nonreactive pupil, etc): brain herniation, meds, midbrain disease
• CN 5: Trigeminal Neuralgia
• CN 7: Bells Palsy or stroke (forehead spared in cva)
• CN 8: Vertigo too? Acoustic nerve disease (neuroma) or Pons
• CN 9/10: What is HR? if tachy you have CN 10 dz and possible Medulla disease
• CN 11/12: Medulla issue


2. The Neck
Rarely start here, though it doesn’t hurt to take a quick look
Lymph:
• Cervical chains down side of neck
Respiratory:
• Trachea deviation?
CV:
• Complaints of syncope? Carotid bruit? Listen before you palpate!
Musculoskeletal:
• Full range of motion of neck

Issues of note:
• Lymph assess: Painless, fixed? CA; Painful? Infection; May be documented as LAN
• Trachea Deviation?: Towards affected side of chest? Spontaneous Pneumo; Towards unaffected side of chest? Tension Pneumo (DECOMPRESS!!!!)
• Bruit?: Atherosclerosis, stroke risk!
• Nuchal Rigid: Can bend back, not forward? SAH or Meningitis


3. The Chest and Abdomen
Start here for complaints of chest pain, breathing issues, abdominal issues, etc
Respiratory:
• I: shape and config of chest; accessory muscle use
• Pa: Symmetry of breathing; Tactile Fremitus
• Pe: Hyperresonance?
• A:
• Listen in each lobe
• Listen bilaterally
• Listen throughout breath
CV:
• I: Heaves
• Pa: Apical impulse, Lifts
• A: Listen with diaphragm and bell; Listen once at apex in left lateral position
• A: 2ICS, RSB (S1, S2)
• P: 2ICS, LSB (S1, S2, split S2?)
• T: 4ICS, LSB (S1, S2, S3/S4?)
• M: 5ICS, MC (S1, S2, S3/S4?)
Abdomen:

• I: Contour, Skin, Venous distribution

• A: One of two places you listen before you touch; Listen in 4 quadrants with diaphragm, then midway between umbilicus and left costal margin, with bell for abdominal aortic bruit

• Pe: You should hear tympany over most of the stomach

• Pa: First light palpate to illicit pain response, then deep to feel for masses

Issues of note:
• Lack of breathing symmetry: Pneumothorax
• Hyperresonance in chest: Pneumothorax
• Adventitious sounds
• Inspiratory, liquid: Crack
• Inspiratory, whistle: Stridor
• Expiratory, liquid: Rhonchi
• Expiratory, whistle: Wheeze
• S3 : Normal in young; Abnormal in older suggests HF as fluid is left in ventricle
• S4: Never normal! Suggests noncompliant, crunchy muscle from Infarction
• Systolic Murmur:
• Mitral: M Regurg
• Tricuspid: T Regurg
• Pulmonic: Stenosis
• Aortic: Stenosis
• Diastolic Murmur:
• Aortic: Regurg from dissection is bad news!
• Lift/Heave: Migrated? HF, CM



4. The Arms
Compare bilaterally; rarely start here except for specific arm complaints
CNS/PNS:
• Strength: Grips (frontal lobe)
• Sensitivity: Light touch (parietal lobe)
• Coordination: Stereognosis or Graphesthesia (cerebellum)
• Reflexes: Biceps, Triceps
CV:
• Radial Pulses: Rate, Rhythm, Strength
• Cap refill: <>

Skin: Temperature, Color, Turgor, Lesions, Clubbing (profile test)

Musculoskeletal:

• Full range of motion? If not possible perform passive ROM

• Special Tests: Phalens, Tinnels; both for Carpal Tunnel

Issues of note:
Neuro deficit: Problem here indicates cortical or nerve tract disease
• Should you have done a stroke screen? Hands raise, smile, Old dog
CV deficit: Weak pulse or slow cap refill suggests low CO; Pulses unequal suggests vascular disease
Skin:
• Turgor prob? Old or dry
Lesions
• Asymmetry
• Borders
• Color
• Diameter
• Elevation/Evolution

5. The Legs
Compare bilaterally; rarely start here except for specific leg complaints
CNS/PNS:
• Strength: Grips (frontal)
• Sensitivity: Light touch (parietal)
• Coordination: Heel Shin/Gait (cerebellum)
• Special Tests: Romberg (spinal disease)
• Reflexes: Quadriceps
• Primitive Reflexes: Babinski
CV:
• DP/PT Pulses: Rate, Rhythm, Strength
• Leg erythema and/or assymetry of legs?
Skin:
• Temperature, Color, Turgor, Hair distribution, Lesions
Musculoskeletal:
• Full range of motion? If not perform passive ROM
• Special Tests: Balottment

Issues of note:
Neuro deficit: Remember reflexes want to be strong and primitive want to come back but are held down by CNS; Disconnect or CNS disease can lead to hyperactive DTRs or Primitive reflexes
CV deficit: No DP/PTs? Try popliteal or femoral
• Arterial disease: pain with elevation, weak pulses, poor healing, loss of hair/nerves
• Venous disease: Varicose veins, edema, Pain on dorsiflexion (Homans)
Skin:
• Hair distribution prob? Diabetes

So I hope that gives you a quick overview of what is most needed in the history and physical examination. The NCLEX and USMLE expect you to easily recognize signs and symptoms, but in the real world, you can never investigate any of these unless you find them. Good luck...