https://meded.ucsd.edu/clinicalmed/lung.

htm - Good site for general Physical Exam and

other Clinical based needs
1. Read the note with your partner outside the room, note down and begin to think
of your differential and what questions for the history are going to be important
(Do a more focused history and physical than you would for an SP encounter)
2. When you walk into the room take a look at the vitals – are they struggling to
breath at this point? Ask them -> give nasal cannula if yes
3. Know the treatments for each of the vitals that you can impact
a. Temp – do you need to treat?
b. SaO2 – be conservative; what are your options
c. Nebulizer Meds: what are indications?
d. Other?
4. History
a. HPI
i. When did this start?
ii. Has this happened before?
iii. Are you having any pain? -> Scale /10 -> radiating?
iv. Relieving/Aggravating factors?
v. Do you feel like you are getting better, worse, the same?
vi. Any other symptoms you have noticed?
b. Past Medical history – Diagnosed medical conditions?
c. Family medical history
d. Surgical History
e. Social history
i. Tobacco, illicit drugs, alcohol, occupation?
f. Medicines
g. Allergies
h. ROS
i. Gen: Fever, nausea, vomiting, weight
ii. Skin: Rash, bruising
 iii. MSK: Weakness, fatigue
iv. Neuro:
v. HEENT:
vi. Cardio: Shortness or breath (be sure to clarify when: at rest, during
exercise, during normal walking etc..), swelling in extremities, chest
pain
vii. Pulm: Wheezing, cough
5. Physical Exam
a. Lungs Auscultation– do this bilaterally, 6 spots
i. Above clavicle (missing on picture)
ii. 1st Intercostal space
iii. 3rd intercostal space
iv. 5th intercostal space
v. Mid axillary line around 6th intercostal space
vi. Midaxillary line around 4th or 5th intercostal space
b. Heart - Auscultation
i. Aortic – Below 2nd Rib parasternal – Right Side
ii. Pulmonary – Below 2nd Rib parasternal – Left Side
iii. Tricuspid – 5th-6th rib on the left side just off the sternum on left side
iv. Mitral – below 5th rib at mid axillary line on left side
c. Lungs Percussion
d. Pulses – Radial, Dorsalis Pedis/Posterior Tibialis

5. Interpret the initial vital signs: Pulse, BP, RR, Temp, and O2 saturation
6. As you are assessing your patient, if the oximetry reading is low (<90%) have a
FOCUSED PLAN to improve the SaO2. 
How do I give O2 to my patient to alleviate his hypoxemia? Remember you need to
improve his oxygenation using one of the following items:
a. Nasal cannula
b. Simple face mask
c. Venturi-mask
d. Non-rebreather mask
7. At the same time as you are managing any and all abnormal vital signs, ASSESS
your patient with a focused list of questions:
BRIEF HISTORY, PMH, ROS, SH, ALLERGIES, MEDICATIONS, AND FAMILY
HISTORY
Ask family members if present. Be concise and to the point.
8. FOCUSED PHYSICAL EXAM
-Evaluate the patient's mentation, work of breathing, pulses, mucus membranes, eyes,
chest, lungs, heart, abdomen (if needed) and extremities (if appropriate)
9. DIAGNOSTIC TESTS
- determine if you need to order labs, EKG, x-rays, ABGs, or other tests
10. TREATMENTS
- determine if you need to administer medications, prepare for advanced airway
procedures, or modify your treatment plan based upon available information
11. DIAGNOSIS
- be able to formulate your diagnosis and treatment plan. Be able to present the
patient's history, physical exam findings, diagnostic tests, your initial assessment,
treatment, and ultimate disposition of the patient.
During the Simulation Events:
EVERY ACTION THAT YOU TAKE MUST BE VERBALIZED (CLINICAL
REASONING) IN ORDER TO RECEIVE CREDIT.
Remember these values:
1. PaO2 60 = Sat 90%
2. PaO2 40 = Sat 75%
3. PaO2 27 = Sat 50%

How to Read/Present an X-ray to an attending

 Rule 1: DO NOT GO STRAIGHT TO THE PATHOLOGY

 https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_06
 http://www.lasvegasemr.com/foam-blog/systematic-approach-to-reading-chest-x-rays
 Technique:
o What direction is the X-ray in?
o Is it a good x-ray?
 All structures you want
 Good inspiratory effort (shows 8-10 posterior ribs)
 Proper penetration(see the thoracic vertebrae)
o Medical Devices or lines (Nasogastric tubes/Endotracheal tubes/central lines etc.)
 A – Airway/Apices
o Look at trachea, R/L Main stem bronchi
 o Pneumothorax?
o Deviation -> Tension pneumothorax
 B – Bones
o Fractures
o Symmetrical (is it just posture or is their deformity?)
 C – Cardiac Shadow
o Does the heart look enlarged?
o Widened mediastinum?
o Cardiothoracic ratio
 Heart width/thorax width -> should be less than 50% or it is cardiomegaly
 D – Diaphragm
o Is it even?
o Abnormal here could mean phrenic nerve involved
 E – Edges of image/Everything else
o Edges – look around the outside and see if everything looks proper
o Pneumonia -> remember anatomy to decide which lung field
 Lower lobes should be posterior looking
 Superior lobes should be anterior looking
 F – Lung Fields
o Even, symmetrical
o Pneumothorax
o Pleural effusion