Med 1 - 1st Shift - Instrumentation & Physical Exam

Medic ine 1: Instrumentat ion and Phys ica l Examinat ion Sect ion 2A 2015 Dr. Isais Lanzona AY 2012-2013 Lecture 2

Precaut ions to Prevent In fect ion Universal Precautions (UP) Body Substance Isolation (BSI)

• Isolation of all moist and potentially infectious body substances from all patients

• Gloves primarily means of prevention Standard Precautions (UP and BSI)

• Designed to reduce pathogen transmission in hospitals for all hospitalized patients

• Applies to blood, all body fluids, non-intact skin, and mucous membranes

• Use of hand washing, gloves, mask, face shield, gown

• Standards for equipment, environmental control and patient placement

Transmission-Based Precautions

• Designed for care of specific infected patients

• Applies to pathogens spread by air, droplet, dry skin, or contaminated surfaces

Why Learn Bas ic C l in ica l Sk i l l s

• 70% of diagnoses can be made by h istory a lone

• 90% of diagnoses can be made when PE is added

• Expensive tests conf i rm what is found during history and PE

The sk i l l s necessary to perform H & PE are the foundat ion of c l in ica l pract ice and shou ld be cons idered part of the bas ic sc ience of med ic ine . The Phys ica l Examinat ion “It is a safe rule to have no teaching without a patient for a text, and the best teaching is taught by the patient himself.” – Sir William Oslet

Components of the Phys ica l Examinat ion The five senses:

• Looking • Touching • Hearing • Smelling • Tasting • Instruments • Behavior • Maneuvers • Scales

Recommendations for Student Equipment Purchase

• Tape measure • Tuning forks • Penlight • Near vision chart • Stethoscope • Ophthalmoscope • Otoscope • Sphygmomanometer • Centimeter tape measurer • Percussion hammer

Examinat ion Techn ique

• Inspection • Palpation • Percussion • Auscultation

Classic Paradigms – Heart, Lungs, Abdomen

• Inspection • Percussion • Palpation • Auscultation • Special tests

Classic Paradigms - Extremities

• Inspection • Palpation • Range of motion • Vascular • Neurologic • Special tests


The Phys ica l Examinat ion : Inspect ion “Don’t touch the patient – state first what you see; cultivate your powers of observation.” Sir William Osler Inspection

• Process of observation beginning with first exposure to patient and continuing through history and physical examination.

• Guidelines: o Adequate lighting o Unhurried and careful inspection o Validation of findings with patient

Enhancing your Powers of Observation

• Learning physical examination is all about becoming a better observer

• A skilled clinician has enhanced power of observation and the knowledge to use these observations in the care of patients.

“The precise and intelligent recogn it ion and apprec iat ion of minor d i f ferences is the real essential factor in all successful medical diagnoses.” – Joseph Bell The Physical Examination: Inspection

• General appearance • State of nutrition • Body habitus • Posture and Gait • Speech

Case 1:

• Patient is jittery and keeps making fast

frequent movements • Is there anything striking in her

appearance? o Bulging of eyes; peculiar stare o Fast frequent movements –

problem with thyroid

Case 2:

The Phys ica l Examinat ion : Pa lpat ion

• Use of hands and fingers to gather information through touch

• Guidelines: o Keep fingernails short. o Have warm hands. o Be gentle in approach. o Use appropriate hand surface. o Use correct palpation depth.

Touch “The most important innovation in medicine to come to the next 10 years: the power of the human hand.” – Abraham Verghese Surface Anatomy

• Question: What is the important landmark

on the chest? STERNAL ANGLE OF LOUIS! o From there we can know where

it is located – count the ribs, etc… it’s where the trachea bifurcates.

• Question: Borders of Heart? What forms the right heart border?

• 14 year old adolescent boy • what problem does his stature

suggest? o Look at his arm span and

fingers o Patient - Gigantism


Case 12:

• Q: Which cardiac chamber activity is being

evaluated? RIGHT VENTRICLE • From this model, you can see that it is

the right atrium that forms the right border of the heart when you examine the chest.

Case 3:

• What is being examined?

o Left Upper Quadrant: SPLEEN

The Phys ica l Examinat ion : Pa lpat ion

• One object striking against another produces vibrations and sound waves.

• Tapping finger causes vibrations by impact on underlying tissues.

• Sound waves arise from vibrations and produce percussion tones.

• Tone is related to density of underlying tissue.

Percussion – Inventum Novum ex Percussione

Thoracis Humani ut Signo Abtrusos Interni Pectoris Morbos Detegenti

“I present the reader with a new sign, which I have discovered for detecting diseases of the chest. This consists in the percussion of the human thorax, whereby according to the character of the particular sounds thence elicited, an opinion is formed of the internal state of that cavity.” Leopold von Auenbrugger

• A new discovery that enables the physician from the percussion of the human thorax to detect the diseases hidden within the chest

• Leopold Auenbrugger introduced it as a cornerstone in physical diagnosis in 1716

• Dismissed as a plagiarism of the Hippocratic succusion splash

• Recognized when the work was translated into French by Jean Nicolas Corvisart

The Physical Examination: Percussion

• Relates to the tactile sensation and sound produced when a sharp blow is struck to an area being examined.

• Provides valuable information about the structure of the underlying organ or tissue.


Percussion

• Percuss the lung fields alternating from

top to bottom and comparing sides. • Percuss over the intercostal space and

note the resonance and the feel of percussion.

• Keep the middle finger firmly over the chest wall along intercostal space and tap chest over distal interphalangeal joint with middle finger of the opposite hand.

• The movement of the tapping should come from the wrist.

• Tap 2-3 times in a row. • Do not leave the percussing finger on the

chest, otherwise you will dampen the sound.

• Lungs – resonant • Stomach (tympanitic) • Liver (dull) • Thigh (flat)

Jean-Nicolas Corvisart (1755-1821)

• Popularized percussion • Translated Inventum Novum to French

(1807) • Famous physician of Napoleon Bonaparte • Described the palpatory thrill in mitral

stenosis “I could have raised myself to the rank of an author by remodeling the work of Auenbrugger and publishing a work on percussion. But by that I would sacrifice the name of Auenbrugger to my own vanity; that I do not wish to do; it belongs to him, it is his beautiful and rightful discovery which I was to bring to life.” – Jean-Nicolas Corvisart


The Phys ica l Examinat ion : Auscu ltat ion

• Listening to sounds produced by body • Guidelines:

o Perform last in examination sequence.

o Stethoscope is placed on naked skin.

o Listen for presence/characteristic of sound.

o Listen to one sound at a time. o Take time to identify

characteristics of sound. o Don’t anticipate next sound.

Laennec at the bedside

“Laennec’s ear opened to man a new world in

medical science.” – Rogher, “Les Medicinis Bretons” Placement of Stethoscope

• Diaphragm is tightly applied to the chest o High-pitched sounds

• Bell is tightly applied to the chest o Low-pitched sounds

Auscultation

• Auscultate the heart in five locations in a systemic fashion, starting at the apex, moving to the left lower sternal border (including epigastrium) and extend to base of the heart.

o PMI o Epigastrium o Left sternal border o Second ICS right (aortic) o Second ICS (pulmonic)

• Do this with the following: o Diaphragm: which best facilitates

hearing high-pitched sounds including S1 and S2

o Bell: which best facilitates hearing low-pitched sounds including S3 and S4

Classic Auscultatory areas

Cardiac Auscultation

Lung Auscultation

• Question: Which sound is longer?

o Expiration – bronchial breath sounds

• Vesicular expiratory is short


The Stanford 25 An initiative to revive the culture of bedside

medicine • Thyroid Exam • Gait Abnormalities • Examination of the Spleen • Examination of the Liver • Liver Disease, Head to Foot • Ascites & Venous Patterns • Knee Exam • Shoulder Exam • Lymph Node Exam • Deep Tendon Reflexes • Cerebellar Exam • Fundoscopic Exam • Pulmonary Exam • Precordial Movements • Cardiac Second Sounds • Neck Veins & Wave Forms • BP & Pulsus Paradoxus • Ankle Brachial Index • The Hand in Diagnosis • Bedside Ultrasound • Rectal Exam • Pupillary Responses • Involuntary Movements • Internal Capsule Stroke • The Tongue in Diagnosis

1. Thyroid Exam: A good thyroid exam depends above all on knowledge of anatomy and proper technique.

2. Gait Abnormalities: Abnormal gaits are commonly seen in the hospital and elsewhere. Many of them should be recognizable on sight and it would be a shame to subject a person to a CAT or MRI for lack of recognition. We review a number of abnormal gaits and their disease associations.

3. Examination of the Spleen: An enlarged spleen can be easily missed. It is a prime example of how technique matters and even with the best technique, the spleen is not easily felt.

4. Examination of the Liver: The liver, unlike the spleen is easily located when enlarged and its surface can be readily felt.

5. Liver Diseases, Head to Foot: Many if not most of the signs of liver disease are paradoxically to be found outside the abdomen. The clinician needs to be able to elicit and recognize these signs and here we review them from head to foot.

6. Ascites & Venous Patterns: The simple act of observing venous patterns and the direction of venous flow on the abdomen can help us to differentiate inferior vena cava obstruction from portal hypertension from portal hypertension. The techniques for detecting ascites are reviewed here.

7. Knee Exam: The knee is one of the most common causes of

joint pain. A good knee exam helps us to rule out serious conditions such as a septic or inflammatory joint space and can also help make an accurate anatomical diagnosis of ligament or meniscus injury.

8. Shoulder Exam: Careful examination of the shoulder can provide valuable information and help the physician determine when image studies may or may not be helpful.

9. Lymph Node Exam: Do you know what a “shotty” lymph node is? Do you keep your nails neatly trimmed? Learn this and other tips from our experts and watch them perform a meticulous lymph node exam.

10. Deep Tendon Reflexes: Subtle changes in your technique can elicit an otherwise absent deep tendon reflex. Having a proper reflex hammer helps. Here we review those subtle techniques to improve on this import exam skill.

11.Cerebellar Exam: A number of signs and symptoms correlate with cerebellar disease and the clinician needs to be able to elicit them from head to foot.

12. Fundoscopic Exam: When it comes to an ophthalmoscopic exam there's more to it than meets the eye! Here we take a look at the various ophthalmoscopes available to internists and review their proper use.

13. Pulmonary Exam: The pulmonary exam is more than simple auscultation--in fact percussion and inspection often tell you much more than auscultation. Knowing the normal boundaries of percussion and the surface anatomy is critical.

14. Precordial Movements: Palpation is a critical part of the cardiac exam. The size and the character of the PMI (PMI) can speak volumes and predict the presence of an S3 or 4.

15. Cardiac Second Sounds: The second sounds and their variations can tell us volumes about everything from pulmonary or systolic hypertension to bundle-branch block.

16. Neck Veins & Wave Forms: Identifying an elevated jugular venous pulse will almost always affect your management of a patient. An understanding of waveforms can help you recognize everything from canon "a" waves of complete heart block to "ventricularization" of the "v" wave in tricuspid regurgitation.

17. BP & Pulsus Paradoxus: An accurate and reproducible blood pressure reading is a basic clinical skill. We review that skill and discuss how to test for pulsus paradoxus.

18. Ankle Brachial Index: Measuring an ankle brachial index is a simple skill that can be done at the bedside and give you helpful information about a patient's peripheral circulation. This technique is reviewed here.

19. The Hand in Diagnosis: The hands are a window to the body, and changes in the hands are linked to a plethora of illnesses. Recognizing these phenotypic expressions of disease is a basic clinical skill.

20. Bedside Ultrasound: With improvement in technology, the bedside ultrasound is becoming frequent in use. Here we discuss the principles and basics of bedside ultrasound.

21. Rectal Exam: A rectal exam is important to help rule out prostate issues, diagnosing causes of perirectal pain and looking for distal rectal masses. As the saying goes, "If you don't put your finger in, you will put your foot in!"


22. Pupillary Responses: The pupillary response requires a complex integration of nerve fibers. An abnormal pupillary response can be a harbinger for disease or simply a benign process. We review the physiology behind this reflex and discuss situations where it will be abnormal.

23. Involuntary Movements: There are many types of involuntary movements and the diagnosis rests on observation and knowledge of the types of involuntary movements and their causes.

24. Internal Capsule Stroke: A stroke within the internal capsule leads to a unique number of physical exam findings. We review these changes and compare them with strokes in other locations.

25. The Tongue in Diagnosis: Changes in the tongue occur in many situations. Systemic disease such as amyloidosis or lymphoma will affect its size and color. Localized infections may suggest underlying immune disorders. Nutritional deficiencies will cause abnormalities.

Se lected App l icat ions of Po int -of-Care U lt rasonography, Accord ing to Med ica l Spec ia l ty Spec ia l ty U lt rasound App l icat ions

Anesthesia Guidance for vascular access, regional anesthesia, intraoperative monitoring of fluid status and cardiac function.

Cardiology Echocardiography, intracardiac assessment Critical Care Medicine

PG, pulmonary assessment, focused echocardiography

Dermatology Assessment of skin lesions and tumors Emergency Medicine

FAST, focused emergency assessment, PG

Endocrinology and Endocrine Surgery

Assessment of thyroid and parathyroid, PG

General Surgery

Ultrasonography of the breast, PG, intraoperative assessment

Gynecology Assessment of cervix, uterus & adnexa; PG Obstetrics & maternal-fetal medicine

Assessment of pregnancy, detection of fetal abnormalities, PG

Neonatology Cranial and pulmonary assessments Nephrology Vascular access for dialysis Ophthalmology Corneal and retinal assessment Orthopedic Surgery

Musculoskeletal applications

Otolaryngology Assessment of thyroid, parathyroid, and neck masses; PG

Pediatrics Assessment of bladder, PG Pulmonary Medicine

Transthroacic pulmonary assessment, endobrachial assessment, PG

Radiology & Interventional Radiology

Ultrasonography taken to the patient with interpretation at the bedside, PG

Rheumatology Monitoring of synovitis, PG Trauma Surgery

FAST, PG

Urology Renal, Bladder and Prostate assessment; PG

Vascular Surgery

Carotid, arterial and venous assessment; PG

PG = Procedural Guidance

Med 1 - 1st Shift - Instrumentation & Physical Exam

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