Mini CEX steps

What you should be doing / looking out

for / saying

1. Wash your hands

2. Introduce yourself to the patient and explain what
you are about to do

Wash thoroughly. Humans are fomites.

Hi, I am XXX, a medical student. Can I
examine you? --- basic format. Be nice to
patients!
The 45 degrees is important. Some hospital
beds (NUH, SGH, etc) have the degrees in a
slide by the bed, so pls look down when
raising bed.
Exposure: entire top should be taken off for
guys. For girls with button-up shirts / hospital
gowns on, unbutton and then fold sides up to
armpits. Please ask girls to take off their bra
as well (nicely). You cant auscultate through
bra.
General condition of patient: well / toxic /
respiratory distress.
Colour of patient: jaundice, pallor
Iatrogenic stuff: IV lines (saline, antibiotics,
etc), supplemental oxygen (nose prongs,
masks)
Scars: midline scar (valve replacement,
bypass). For bypass, check for radial artery /
saphenous vein grafts. (optional!)
[Advanced stuff: Marfanoid appearance patient is tall, thin with spidery fingers.]
Ask patient to lift up hands, dorsum-up,
support his hands with your own.
Peripheral cyanosis: purplish tinge to
fingernails
Clubbing: basically curvy fingernails, search
images.google if you dont know what it looks
like. Look at all fingers on both hands.
Pallor: pale fingernails, pale palmar creases
Stigmata of infective endocarditis: Janeway
lesions (round purplish spots on palm),
Oslers nodes (palpable lumps on fingers,
FEEL for them), splinter haemorrhages (in
fingernails), clubbing. These are all VERY
RARE signs.
Radial pulse: rate, rhythm, volume. Take
pulse with index and middle finger, never
thumb.
Collapsing pulse: sign of aortic regurgitation.
While holding onto radial pulse with right
hand and elbow with left hand, ask patient if
he has any shoulder pain, and raise arm up.

3. Expose the patient and position him/ her at 45

degrees

4. Inspect the chest from the end of the bed, asking

the patient to take in a deep breath, look out for scars
(CABG, Mitral valvotomy)

5. Look at the hands for pallor, cyanosis, clubbing

6. Measure pulse rate over 30 seconds. Check for

collapsing pulse. Check for radial-radial delay.

7. Look at face, conjunctiva, sclera, mouth and tongue

for jaundice, pallor, cyanosis

8. Look at the neck for Jugular Venous Pulsation

9. Palpate Carotid pulses, one at a time

10. Feel for apex beat

11. Feel for palpable thrills, parasternal heave,

palpable P2

12. Auscultate the heart in sequence Mitral,

Tricuspid, Pulmonary, Aortic. Time the heart sounds
by palpating carotid pulse simultaneously.

13. Turn the patient to the left side and reconfirm the
position of the apex beat. Listen with the bell at the
apex for MS murmur. (Can be done before or after the
rest of auscultation)
14. Sit the patient up and leaning forward and listen to
the left lower sternal edge in full expiration for AR
murmur.
15. Auscultate carotid arteries for carotid bruits
16. Auscultate the chest posteriorly for crackles
17. Palpate lower limbs for pitting oedema

Pull up upper eyelid to look at sclera (the

white part of the eye) for any yellowing
jaundice.
Pull down the lower eyelid to look at
conjunctiva (reddish bit) for any paleness
pallor.
Shine torchlight tangentially. Put a finger on
pulsation (if it is palpable, it is the carotid
pulse.)
Only one at a time. Permissible to use thumb.
Palpate lateral to trachea.
Start very laterally and inferiorly and work
your way up. Put your finger on the spot and
count ribs down and then span the clavicle to
localize. (E.g. the apex beat is in the 6th
intercostal space, one cm lateral to the
midclavicular line.)
Impalpable apex beat can be due to: COPD
(hyperinflated chest), thick chest wall,
dextrocardia. In doubt, always try the other
side.
Z-shaped pattern:
Thrill: put hand horizontally over apex.
Parasternal heave: put hand vertically left
and parallel to sternum.
Palpable P2: put hand horizontally over left
2nd intercostal space.
Use the diaphragm for all this.
Traditionally youre only allowed to auscultate
once at each location, so listen hard and long
while timing with carotid (NOT radial) before
moving on.
Common radiation ofmurmurs: MR radiates
to axilla, AR to carotids.
Use the bell (MS is a LOW-pitched murmur)

Use the diaphragm. Tell the patient: breathe

in, breathe out, hold your breath. Remember
to tell them they can go on breathing before
they turn blue.
Use the bell. (bruit is also low-pitched),
auscultate both sides.
Lung ends at 10th rib posteriorly. Auscultate
bases of lungs, on both sides.
Press over medial malleolus.

18. Thank the patient and cover up

19. Request to palpate the remaining peripheral
pulses (Brachial, Femoral, Popliteal, Dorsalis Pedis
and Posterior Tibial)
20. Request to check the blood pressure, look at
temperature chart, perform dipstick urinalysis (for
haematuria) and perform fundoscopic examination

Wash your hands and say: I would also like

to palpate the remaining peripheral pulses,
take the BP, look at the temp chart, do urine
dipstick and fundoscopy.

Sample presentation for CSFC (it gets shorter later):

I would like to present Mr XXX, a young / middle-aged / elderly Chinese gentleman. He is
comfortable at rest, not pale, jaundiced, cyanosed and is pink on room air. There is an intravenous
drip in his right hand. There is a midline scar on his chest wall. He has no stigmata of infective
endocarditis. His pulse rate is 64 per minute, regular and of good volume. His jugular venous pressure
is not raised. His apex beat is located in the 6th intercostal space, one cm lateral to the midclavicular
line. There were no palpable thrills, parasternal heaves or palpable P2. On auscultation the first and
second heart sounds were heard (this may not be true if its MR, etc). There was a XXX murmur,
grade X out of 6, with radiation to XXXX. He is currently not in heart failure.