How do you say？

　英語で身体診察　～～こんな時なんていうの？？～

Referrence：USMLE Step 2 Clinical Skills (CS) First aid p34~38

<<<Opening of the encounter>>>
“Mr. Jones, hello; I am Dr. Singh. It’s nice to meet you.

• I’d like to ask you　some questions and examine you today.”
• "How can I help you today?”
• “What brought you to the hospital/clinic today?”
• “What made you come in today?”

<<<< HEENT exam>>>>>

WHAT TO DO:
Head
1. Inspect the head for trauma/scars.
2. Palpate for tenderness or masses.

Eyes
1. Inspect the sclerae and conjunctivae for color and irritation.
2. Check pupil symmetry and reactivity.
3. Check extraocular movements.
4. Check visual acuity (Snellen eye chart).
5. Perform a fundoscopic exam.

RULE: “right-right-right”
(ophthalmoscope right hand—patient’s right eye—examiner’s right eye)
and the rule “left-left-left”

Mouth and throat:
1. Inspect with a light.
2. Tooth tapping if needed.
Ears
1. Inspect external ear for discharge, skin changes, or masses.
2. Palpate external ear/mastoid for pain (otitis externa, mastoiditis).
3. Otoscope exam of ear canal and TM (new speculum!)
4. Conduct the Rinne and Weber tests.
Nose:
1. Inspect/palpate the nose/sinuses.
3. Inspect turbinates and septum.

WHAT TO SAY:

“Just hold still please while I take a look at your head and scalp”
“Anything hurt [while I do this]?”
“I need to examine your sinuses, so I am going to press on your forehead and　cheeks.”

“I would like to examine your (XXXXX) now.” XXXXX= eyes, ears, throat, etc.
“OK, bright light here.”
“Follow my finger with your eyes and don’t move your head.”
“Look straight at me please and try not to move your eyes.”
“I am going to check the back of your eyes. Can you please look at the …” (point)

“Can you please open your mouth? I need to check the inside of your mouth and your throat.”
“Say ‘aaahhh’…keep singing please.”
“Can you turn your head towards me please?”
”Does this hurt at all?”

“OK, hold still for me.”
“Tell me when the sound goes away.”

“This might feel a bit funny.”

<<<<<Cardiovascular exam>>>>>>

WHAT TO DO:
Heart
1. Do not lift up the patient’s gown.
2. Pull the gown down the shoulder, exposing only the area to be examined.
NOTE: For women, try to keep breasts covered as much as possible.

4. Palpate the chest for the PMI, retrosternal heave, and thrills.
5. Listen for rhythm and rate.
6. Listen to at least two of the four cardiac areas for murmurs, rubs, gallops.
a. Listen to the mitral area with the patient on his left side.)
b．Listen to the base of the heart with the patient leaning forward.
c. Listen for murmurs with patient sitting/squatting, standing.
7. Listen to the carotids for bruits (use the bell of the stethoscope).
8. Look for JVD (45-degree, use light)
9. Check for pedal edema.
10. Check the peripheral pulses.
11. Check for cyanosis/peripheral bloodflow (palm color)

WHAT TO SAY:

“I need to listen to your heart. May I adjust your gown so I can listen as best I can?”
“Would you please hold your breast aside for me? I am going to protect your modesty as much as possible here.”
“I am going to try and feel for any lumps, bumps, or beats that shouldn’t be there.”
“Hold your breath, please…OK, breath.”

“Can you turn to your left side, please?”
“Can you sit up, please?...Now lean forward a bit.”
“Can XXXX for me?” XXXX=stand, squat, make a tight fist, bear down.
“Turn your head, take a deep breath and hold it.”

“I am going to examine your legs to check for fluid retention.”
“I need to check the pulse in your arms and legs now.”
Can you show me your palms?”

<<<<< Pulmonary exam>>>>>

WHAT TO DO:
IPAP
1.Uncover the front and the back of the chest sequentially.
NOTE: Don’t percuss or auscultate through the patient’s gown.
NOTE: For women, cover breasts whenever possible.
NOTE: Don’t percuss or auscultate over the scapula.

2. Inspect: The shape of the chest, respiratory pattern, deformities.

• Allow a full inspiration and expiration in each area of the chest.

3. Palpate for tenderness, tactile fremitus.
4. Percuss for:
a. tympany : normal or PTX
b. dullness: consolidation
5. Auscultate,for:
{a. crackles

• coarse: (PNA, CHF)
• fine: (fibrosis)

b. wheeze, insp (COPD, asthma)
c. stridor, exp (obstruction)
d. rubs (pleuritis)
e. egophany
f. whispered pectoriloqy}

WHAT TO SAY:

“I need to listen to your lungs now. I am going to try and put my stethoscope directly on your skin.”

“Please cover your front while I listen to your back.”

“I am just looking for any lumps or bumps that shouldn’t be there.”
“Take a good deep breath for me.”

“Can you say ‘99’ for me, please?”
“I am going to tap on your back to check your lungs. Is that okay with you?”

“When I say, take a deep breath in, hold it for 2 seconds, then let it out.”
“ Keep your mouth open when you breath. I can listen to your lungs a bit better that way.”
“Blow out hard for me!”

“Say E E E E E for me.”
“ OK, now whisper ‘99’ for me.”

<<<<<Abdominal exam>>>>>

WHAT TO DO:
IAPP
1. Inspect the abdomen.

NOTE: Keep genitals covered whenever possible.

2. Auscultate all 4 quadrants.
NOTE: Always auscultate before you palpate the abdomen!
3. Percuss all 4 quadrants for:
a. tympany: SBO, ileus
b. dullness: fluid, mass

• Try to localize difference in sounds.

4. Palpate all 4 quadrants:
a. Start from the point that is farthest from the pain; be gentle
on the painful area, and don’t try to reelicit the pain.
b. Check for rebound tenderness, CVA tenderness, obturator sign, psoas sign, and Murphy’s sign.
c. Check the liver span.
d. Palpate spleen, kidneys.

WHAT TO SAY:
“I need to examine your belly/stomach now.”
“I am going to lift up your shirt if you don’t mind.”
“Would you mind undoing the top button of your pants?”
“I am going to listen to your belly now.”

“Now I need to tap on your belly.”

“I am going to press on your belly. Tell me if you feel any pain or
discomfort.”
“Did the pain go anywhere else when I was pressing?”
“Take a deep breath and then exhale from your belly. I am going to press while you do this.”
“Did you feel more pain when I pressed in or when I let go?”

<<<<<Neurologic exam>>>>>

WHAT TO DO:
Mental Status

 1. Quick: Alert? Oriented to person, place, time?
 2. Long: MMSE

Alert to person?.......................................
Alert to place?.........................................
Alert to time?..........................................
Broca’s area....……………………………….
Immediate memory…………………………
Short-term memory…………………………
Recent memory………………………………
Crystal (distant) memory…………….........
Three-step command……………………….
Cognitive functioning……………………….
Judgment……………………………………..

WHAT TO SAY:
“Now I’m going to check your nervous system and brain. I’ll be asking a lot of questions. Are you ready?”

Mini-Mental Status Exam (MMSE)
“I would like to check your memory and concentration by asking you some questions.”
“Can you tell me your name and age?”
“Do you know where are you now?”
“Do you know the date today?”
Show pen:“Do you know what this is?”
“I will name three objects for you, and I want you to repeat them immediately,
okay? Chair, bed, and pen.”
“I will ask you to repeat the names of these three objects in a few
minutes, I want you to remember them.”…wait 3-5 minutes…
“Can you repeat the names of the 3 objects I showed you a few minutes ago?”
“Do you remember what you had for lunch yesterday?”
“When did you get married?”
“Are you left-handed or right-handed?”
“Take this paper in your right hand, fold the paper in half, and put it on the floor.”
“Write your name on the paper.”
“Spell WORLD backwards.” or
“Count backwards from 100 by 5s.”
“What would you do if you saw a fire coming out from a paper basket?”

Cranial nerves

I. Olfactory (Smell)
II: Optic (Vision)
III Oculomotor (Extraocular)
IV Trochlear (Extraocular)
VI Abducens (Extraocular)
V: Trigeminal (face sensation, chew)
VII: Facial (Smile/brow/cheeks, taste)
VIII: Vestibulocochlear (hear, balance)
IX Glossopharyngeal (taste, posterior)
X Vagus (Soft palate motor, gag)
XI Accessory (Neck, shoulders)
XII Hypoglossal (Tongue - motor)

“Can you smell this?”
“How many fingers am I holding up?”
“Follow my finger with just your eyes.”
“Close your eyes, can you feel me doing this? Does it feel the same on both sides?”
“Close your eyes, can you hear this?”
“Shrug your shoulders.”
“Say LALALA, KAKAKA, GAGAGA.”
“Just relax and let me move your arms.”
“Do this…”
“Push against me.” “Pull against me.”
“Squeeze my fingers…harder!”
“Can you stand up for me?”
“Raise your leg.” “Now lower it.”
“Kick out against me.”
“ Hit the gas pedal”

Strength (Motor)

1. Passive motion (cogwheel? Stiff?)
2. Active motion
a. Upper Body: Shoulder, elbow, wrist, hand, fingers.
b. Lower Body: Gluteals, hip, knee, ankle.

Reflexes

Biceps, triceps, brachioradialis, patellar, Achilles, Babinski.

Sensory
Sharp (pin)/dull (cotton swab), vibration, position sense. temperature

Coordination
Cerebellum: Finger-to-nose, heel-to-shin, rapid alternating movements, Romberg sign, gait.

“OK, just relax now. Your arm should be like a dead fish.”
“Link your fingers and pull.”

“Do you feel this? How about this?”
“Does it feel equal on both sides?”
“This is up, this is down. Which way am I moving your toe now?”

“With your right finger, touch your nose. Now touch my finger. And again. Again.”
“Stand up and close your eyes. Don’t worry, I won’t let you fall.”

<<<<<<Joint Exam>>>>>>>>

WHAT TO DO:
1. Inspect and compare joint with the opposite side.
2. Palpate for tenderness and…
a. check for joint effusion.
_ b. check for crepitus.
_ c. check range of motion.
3. Check lower back for

a. Pain/stiffness
b. Range of motion

<<<<<<<Skin Exam>>>>>>>>

1. Patient should disrobe as much as possible, protecting modesty.
2. Disrobe sensitive areas as you examine and then cover as soon as possible.
3. Exam for rashes, masses, lesions.
4. Characterize location, color, texture of rashes.
5. Characterize ABCDE of masses
(Asymmetry, Border Irregularity, Color Variation, Diameter, Evolving/Eroding)

WHAT TO SAY:
“May I see your hands?”
“I am going to have a look at your knees, too. May I?”
“ Does this feel tender when I press?”
“Has this swelling gotten worse recently?”

“Let’s check your back.”
“How far forward can you bend without pain?”

<<<<<<<Skin Exam>>>>>>>>
1. Patient should disrobe as much as possible, protecting modesty.
2. Disrobe sensitive areas as you examine and then cover as soon as possible.
3. Exam for rashes, masses, lesions.
4. Characterize location, color, texture of rashes.
5. Characterize ABCDE of masses
(Asymmetry, Border Irregularity, Color Variation, Diameter, Evolving/Eroding)

“Sorry for the inconvenience, but I want to check as much of your skin as I can.”
“Has this always been here?”
“When did you first notice this?”
“Does this itch or bleed?”
“Has this bump been changing colors or looking different recently? Does it ever bleed?”

<<<<<<Closing>>>>>>>>>>>>

1. Smile, shake hands
2. Help patient with belongings if appropriate.
3. Speak with patient a while before getting up.

“Thank for letting me examine you, Mrs. Jones.”
“Based on what I can tell so far, you may have XXXX, but we need to run some YYYY to check.”

“Okay, Mr. Jones, I’ll contact you when I have your test results. It was nice meeting you.”

“Can I see you again next week? We can discuss some more about your case then.”