Clinical Performance Examination (CPE) Comprehensive Study Notes

Mandatory Preliminary Steps: Every student must perform the steps from the very beginning (General Survey) up through the skin assessment before proceeding to their assigned focused assessment (Abdominal, Cardiac, or Respiratory).
Grading Structure:
- The total score is calculated based on the number of assessment boxes completed correctly.
- Example: If there are $20$ total items (e.g., $10$ in General Survey and $10$ in Abdominal), the total score of $100$ is divided by the number of boxes ( $100 / 20$ ).
- Each missed item or failure to verbalize a required step results in a point deduction (e.g., missing hand washing results in a deduction of $5$ points, leading to a score of $95$ ).
Final Step: All assessments must conclude with educating the patient.

Introduction and Patient Identification:
- Introduce yourself and ask for the patient's name and date of birth.
- Check for allergies.
Level of Consciousness and Orientation:
- Verbalize that the patient is awake and alert.
- Assess orientation to time, place, and person (A&O x3) by asking:
  - "What is today's date?"
  - "Who is the President?"
Mood and Affect:
- Mood: Defined as what the patient verbalizes (e.g., "I feel okay").
- Affect: Defined as the clinical observation of the face (e.g., no sad expression, no grimacing, normal expression).
Posture and Body Build:
- Observe for upright posture and the absence of spinal abnormalities such as lordosis or scoliosis.
Mobility:
- Observe the patient's gait as they walk to the scale to ensure it is stable with no limping.
- Inquire about the use of assistive devices: "Are you using a cane, walker, or any other assisting devices?"
Anthropometric Measurements and Vitals:
- Obtain height and weight.
- State intent to take vital signs: temperature, pulse, respiratory rate, and blood pressure.
- Numerical/Verbatim Knowledge for Vitals:
  - Normal temperature specifics.
  - Normal pulse ranges.
  - Blood pressure procedure: Apply the cuff, listen for the first sound (systolic), and then listen for the sound to disappear (diastolic).

Inspection:
- Ask about history: "Do you have any cough, asthma, or history of respiratory disease?" "Have you had any surgery?" "Are you using oxygen?"
- Observe for the use of accessory muscles during breathing.
- Inspect chest shape: Look for Barrel Chest, common in COPD patients where the anteroposterior diameter is equal to the transverse diameter.
- Inspect for symmetry and spinal alignment (no scoliosis or kyphosis).
Palpation:
- Palpate the chest for any masses, fractures, or abnormalities.
Percussion:
- Percuss both sides, comparing sounds bilaterally.
- Note that a dull sound may indicate consolidation of the lung, as seen in pneumonia.
Auscultation:
- Use the diaphragm of the stethoscope.
- Sequence: Start at the apex of the lungs.
- Count: $12$ total spots in the front ( $6$ pairs) and $10$ total spots in the back ( $5$ pairs).
- Method: Use a crisscross/zigzag pattern to compare sounds bilaterally.
- Termination: Always finish at the base of the lungs, specifically the midaxillary line.
- Documentation: Note the absence of wheezes or rhonchi.
Thoracic Expansion:
- Place hands on the patient's back and ask them to breathe in and out.
- Observe for symmetrical movement of the hands to ensure equal lung expansion.

Sequence Modification: In abdominal assessment, always Inspect, Auscultate, Percuss, then Palpate.
History and Subjective Data:
- Ask about abdominal pain.
- Inquire about bowel movements (frequency and consistency/Bristol scale concepts).
Inspection:
- Observe the abdomen from at least two different angles/positions.
- Check for skin color, lesions, abnormal pulsations, or hernias.
Auscultation:
- Start in the Right Lower Quadrant (RLQ) and move clockwise (RUQ, LUQ, LLQ).
- Use the diaphragm to listen for bowel sounds.
- Bowel Sound Frequency:
  - Normal: $5$ to $30$ sounds per minute.
  - Hypoactive: Less than $5$ sounds per minute.
  - Hyperactive: More than $30$ sounds per minute.
  - Absent: No sounds heard after listening for a full $5$ minutes; requires physician notification.
- Vascular Sounds: Use the bell of the stethoscope to listen for a bruit (swooshing sound) over the aorta in the midline of the abdomen.
Percussion and Palpation:
- Follow the same RLQ, RUQ, LUQ, LLQ pattern.
- Palpate for masses, protrusions, or hernias.
Costovertebral Angle (CVA) Tenderness:
- Place one hand flat on the back over the kidney area and strike it with the other hand.
- Assess for pain, which may indicate kidney stones or kidney disease.

History and Preliminary Checks:
- Ask about chest pain, cardiac disease history, fatigue, shortness of breath, or history of cardiac surgery.
- Check Capillary Refill: Press on the nail bed; normal return is less than $2$ seconds ( $< 2\,s$ ).
Neck Vessels:
- Auscultate the carotid artery using the bell of the stethoscope to listen for bruits.
- Palpate the carotid artery one at a time to avoid compromising blood flow to the brain.
Heart Sound Auscultation (The Five Points):
- Aortic: $2$ nd intercostal space, right sternal border.
- Pulmonic: $2$ nd intercostal space, left sternal border.
- Erb's Point: $3$ rd intercostal space, left sternal border.
- Tricuspid: $4$ th intercostal space, left sternal border.
- Mitral (Apical): $5$ th intercostal space, midclavicular line.
The "Three-in-One" Step:
- At the Mitral site ( $5$ th intercostal space, midclavicular line), verbalize that this is the Mitral Valve, the Point of Maximal Impulse (PMI), and the site of the Apical Pulse.
- Auscultate the Apical pulse for one full minute.
Advanced Auscultation:
- Repeat the auscultation of all five points using the bell to detect abnormal heart sounds (e.g., S3, S4).
Peripheral Pulses:
- Assess radial pulses bilaterally and compare for symmetry.
- Be prepared to name other peripheral pulse sites if asked.

Bowel Impaction Protocol:
- Impacted patients may show silence (absent sounds) below the impaction and gurgling/hyperactivity above it.
- Pharmacological sequence for impaction: Milk of Magnesia (MOM) $\rightarrow$ Suppository $\rightarrow$ Enema.
Insulin Assessment:
- Following the head-to-toe or focused assessment, students transition to a separate room for insulin administration testing.