PETAs!!!

The week after Thanksgiving break will be exciting! We are going to take our practical clinical exam, including a full patient interview and a full physical exam (on a standardized patient actor). To prepare for this grand event, we've been learning the physical exam in sections: head and neck, lung, cardiovascular, abdominal, musculoskeletal, and neurologic exams.

There is a total of 104 things we must to during the 40 minutes we will have with the patient. Some will be ridiculously easy: wash hands, observe patient's general appearance... And most will be really interesting and fun: Inspect ear canals and tympanic membranes using otoscope... the problem is there are 104 of them that need to be done in order and properly.

The Physical Exam Teaching Associate program allows us to practice all aspects of the physical exam on real live people. Today I spend 1.5 hours with another student practicing the Neurological Exam on a PETA. It was fabulous! Below is the checklist for this portion of the exam.

So! If you would like to receive a FREE physical exam from someone who may or may not be able to identify findings, and almost certainly won't be able to explain why you have a bump there or can't follow my finger with your eyes or don't have a Babinski Reflex... please let me know! I'm willing to make house calls. :-) But seriously, I need to practice! This is only 38 of the 104 things I need to be able to do!

H. Psychiatric and Neurologic Mental Status Exam (9 items)

___ Observe level of consciousness: Awake and Alert?

Consciousness and Orientation:
___ Assess orientation: Asks patient: name, day, date, time, place and situation
___ Assess attention: Asks patient to recite days of week forward and backwards

Speech
___ Ask patient to name three objects :
___ Ask patient to repeat, “The sky is blue in Baltimore”.
___ Ask patient to point to the ceiling and point to the way out of the room.
___ Notes speech quality (e.g. clear/coherent; slurred, rambling)
___ Assess mood (predominant emotional state) and affect (emotional expression)

Mood and Thought:
___ Assess thought content and behavior.

J. Neurologic Exam (29 items)
Cranial nerves (10 items)
___ Check pupils and assesses for consensual response-bilaterally
___ Test visual fields; ask how many fingers are seen on each side (not total of both hands)
___ Extra-ocular: Ask to follow finger from center to left to right to center to up and to down.
___ Sensation: Touch quickly V1, V2, and V3 on each side
___ Ask patient to close eyes tightly, then open widely (observe forehead wrinkling). of face
___ Ask patient to show teeth
___ Rub fingers in each ear to assess hearing
___ Observe elevation of palate
___ Ask patient to protrude tongue
___ Test shoulder shrug strength bilaterally

Motor (5 items) - All are bilateral assessments
___ Check for pronator drift bilaterally
___ Check proximal arm strength at deltoid: arms in ‘chicken wing position- test one side at a time
___ Check finger extensor strength bilaterally
___ Check hip flexor strength bilaterally
___ Check dorsiflexion of foot strength bilaterally

Sensation (4 items) - All bilateral assessments
___ Fine touch: Use cotton tip on mid-arm, distal phalanx of index finger, mid-thigh, distal phalanx of great toe- (ask patient to close eyes)
___ Pain: use point of broken wooden shaft of cotton swab for pin-prick on mid-arm, distal phalanx of index finger, mid-thigh and distal phalanx of great toe
___ Vibration- use 128 or 256 Hz tuning fork on PIP joint of great toe bilaterally, counting to 10
___ Proprioception- moving great toe up or down

Reflexes (3 items) - All bilateral assessments
___ Strike tendon on one of biceps or brachioradialis bilaterally
___ Strike tendon on one of patella or ankle tendon bilaterally
___ Assess Babinski reflex, warning patient first of possible discomfort.

Coordination/Gait (7 items)
___ Perform finger to nose testing both sides using two points for each side- bilateral
___ Rapidly tap 5 times on thigh with each hand (rhythm and regularity)-bilateral
___ Ask patient to stand and walk distance of 10 feet (if possible)
___ Ask patient to stand with feet together, then close eyes (provide contact guard)
___ Ask patient to walk with one foot in front of the other (tandem walk).
___ Ask patient to stand on heels then stand on toes.
___ Alternate: heel to shin test-bilateral (may omit if performs all of walking/gait tasks)