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Questions and Answers
What condition is associated with increased vocal fremitus due to transmission through a dense medium?
In the presence of a pneumothorax, which of the following findings would be expected upon inspection?
What test involves asking a patient to whisper while auscultating the lung fields?
What is the expected percussion note on the affected side in a pleural effusion?
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Which of the following is NOT a characteristic finding in a patient with emphysema/COPD?
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What is a typical finding during palpation in the examination of a patient with pleural effusion?
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Which of these changes in vocal resonance is characterized by a louder sound over an area of consolidation?
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Which condition is characterized by a qualitative change in voice, where 'E' is perceived as 'A'?
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Which of the following aspects should be prioritized during the initial on-field assessment of a concussion?
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What is likely the main goal during the management of a concussion regarding return to activity?
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In the context of clinical evaluation of musculoskeletal disorders, which examination would most likely reveal issues related to joint mobility in the knee?
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In evaluating Metatarsus Adductus (MTA), which of the following factors is considered a significant risk indicator?
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Which of the following best describes an important preventative strategy against concussions?
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What does increased vocal fremitus suggest in a clinical assessment of a respiratory condition?
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Which physical examination finding is most commonly associated with pleural effusion?
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What symptom would most likely indicate the presence of left-sided heart failure?
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Which physical examination finding is indicative of consolidation in the lungs?
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What does a positive hepatojugular reflex indicate?
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Which of the following conditions is characterized by diminished breath sounds and vocal resonance?
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In the context of heart failure, what does the presence of crackles (rales) suggest?
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Which symptom would most likely lead a clinician to suspect bronchial obstruction?
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Which of the following conditions is least likely to be diagnosed primarily through a clinical examination?
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Which clinical finding is NOT typically associated with elevated filling pressures in heart failure patients?
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What percentage of heart murmurs in infants are associated with congenital heart disease?
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Which of the following statements regarding heart failure management is accurate?
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Which assessment method is recommended for evaluating the likelihood of a pulmonary embolism?
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Which symptom is classified as bendopnea in heart failure patients?
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What is the primary focus of the emerging classification system for heart failure congestion?
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Why is it essential to screen all infants for critical congenital heart disease?
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What is the typical presentation of Slipped Capital Femoral Epiphysis (SCFE)?
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When is surgical fixation urgently required in SCFE cases?
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At which degree of spinal curvature is MRI indicated for scoliosis evaluation?
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What is the recommended screening procedure for Developmental Dysplasia of the Hip (DDH) in high-risk infants?
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What is the goal of treatment for Developmental Dysplasia of the Hip (DDH)?
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Which condition is associated with red flag symptoms indicating potential serious pathology in low back pain evaluation?
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What is the classification of scoliosis that is most commonly seen in adolescents?
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What degree of scoliosis curvature typically requires bracing treatment?
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Which diagnostic imaging is primarily used for diagnosing SCFE?
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What condition is characterized by a spinal curve greater than 10° as seen on x-ray?
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Study Notes
Vocal Fremitus
- Decreased vocal fremitus can be seen with lung parenchyma, pleura or chest wall issues
- Decreased vocal fremitus can be seen with bronchial asthma, emphysema/COPD, or bronchial obstruction
- Air trapping and decreased lung parenchyma density can decrease lung sounds
- Pleural effusion and pneumothorax cause fluid and air build up between the chest wall and lung causing decreased transmission of low frequency sounds
- Obesity can also decrease vocal fremitus
- Inflammation and consolidation create denser media that increase the transmission of low frequency sounds
- Increased vocal fremitus can be seen with pneumonia, lung abscess, inflammation and consolidation
- Decreased vocal fremitus can be seen with pleural effusion, pneumothorax, emphysema/COPD, bronchial obstruction, and bronchial asthma
Vocal Resonance
- Vocal resonance is an auscultatory finding similar to vocal fremitus
- It is the sound heard when the patient speaks "ninety-nine" or "one two three"
- Bronchophony is a louder sound over an area of consolidation
- Whispering pectoriloquy happens when whispered words can be heard clearly over an area of consolidation
- Egophony (also known as "E to A" change) is a qualitative change in voice; vowel sounds may be distorted as they pass through consolidation
Palpable Findings
- Rhonchal fremitus is a palpable rhonchi
- Pleural fremitus is a palpable pleural rub
Performing the Vocal Fremitus Exam
- Have the patient fold their arms across their chest wall to displace the scapulae
- Have the patient repeat "ninety-nine" or "one, two, three" in a constant tone
- Palpate the chest wall on both sides using the ulnar border of the hand or palmar base
- Begin palpation at the lung apex and move in a mirrored pattern to the opposite side of the chest wall
- Compare vibrations on both sides while moving hands from apex to base of the lung
- Repeat the maneuver on the anterior and lateral chest walls
Pneumothorax
- Inspection: Diminished chest movements on the affected side
- Palpation: Diminished chest movements, decreased vocal fremitus on the affected side
- Percussion: Tympanic note over the affected side
- Auscultation: Diminished breath sounds and vocal resonance on the affected side
Pleural Effusion
- Inspection: Fullness of intercostal spaces, diminished chest movements on the affected side, the apical impulse may not be visualized
- Palpation: Diminished chest movements, decreased vocal fremitus on the affected side, trachea may be shifted to the opposite side, the apical impulse may not be palpable
- Percussion: Stony dullness over the affected side
- Auscultation: Diminished breath sounds and vocal resonance, egophony may be present on the upper border of the effusion
Consolidation
- Inspection: Diminished chest movements on the affected side
- Palpation: Diminished chest movements, increased vocal fremitus on the affected side
- Percussion: Dullness on percussion of the affected side
- Auscultation: Bronchial breathing sounds may be present, increased vocal resonance on the affected side may be associated with bronchophony and whispering pectoriloquy
Patient with Shortness of Breath
- 65 y.o. Caucasian male with progressive SOB over 3 weeks
- SOB with walking, needs to stop halfway on stairs to catch breath
- No pain, palpitations, or chest tightness
- Dry cough started 3 weeks ago
- Breathlessness at night laying in bed
- Wakes up needing to catch breath
- Sitting up with 2 pillows helps slightly
- Fullness in abdomen 3 weeks ago
- Swollen ankles (as day goes on)
Pertinent Positives
- Breathlessness at night
- Dry cough
- Dyspnea on exertion
- Peripheral edema
Physical Exam
- General
- Skin
- HEENT
- Respiratory
- Cardiac
- Peripheral Vascular
- GI
Heart Failure (HF) Signs and Symptoms
- S3 gallop
- JVD
- Hepatomegaly
- Splenomegaly
- Crackles (rales)
- Wheezing
- Peripheral edema
- Positive hepatojugular reflex
Other Important Diagnoses to Consider
- Chest wall pain/costochondritis
- GERD (gastroesophageal reflux disease)
- Panic disorder/anxiety
- Pericarditis
- Pneumonia
- Heart Failure
- Pulmonary embolism
- Acute thoracic aortic dissection
Key Points for Specific Conditions
- Chest wall pain: Often reproducible by palpation
- GERD: Trial of proton pump inhibitor can be diagnostic
- Panic disorder: Validated screening question available
- Pulmonary embolism: Use Wells criteria or Pulmonary Embolism Rule-out Criteria (PERC)
Heart Failure Article Summary
- The clinical exam remains fundamental in managing heart failure patients
- Patients can be categorized based on volume status and perfusion
- Key findings for assessing elevated filling pressures include:
- JVD
- HJR
- Orthopnea
- Square wave blood pressure response to Valsalva maneuver
- Bendopnea
- Assessing cardiac index/perfusion is more challenging
- Traditional signs like pulmonary rales and peripheral edema have limitations in chronic heart failure
- The Stevenson profiles can guide therapy
- Natriuretic peptides can complement the clinical exam but have not been shown to improve outcomes
- An emerging classification system categorizes congestion based on whether right-sided, left-sided, or both ventricular filling pressures are elevated
- The clinical exam is more accurate for assessing elevated filling pressures
- Further research is needed on using right vs. left-sided congestion patterns
Heart Murmurs in Children
- Heart murmurs are common in children
- Most are innocent, some indicate potential heart disease
- In infants, 37% of murmurs are associated with congenital heart disease
- Beyond infancy, only about 1% of murmurs are associated with heart disease
- All infants should be screened for critical congenital heart disease using pulse oximetry, ideally 24 hours after birth
Concussions
- Headaches, Dizziness, Nausea/Vomiting, Blurred Vision
- Direct or indirect blow to the head
- Brief loss of consciousness
- Confusion, memory issues, mood changes are common
- On-field assessment: Assess for any signs of concussion, check airway, breathing, and circulation
- Sideline evaluation: Perform neurocognitive testing, check for signs of concussion
- Hospital or clinic evaluation: History, neurologic exam, imaging (CT, MRI)
- Immediate management: Rest, avoid physical activity
- Gradual return to activity: Gradually increase physical activity
- Prolonged symptoms: Consider referral to neurology
- Preventive strategies: Wear helmets, avoid head contact sports
Musculoskeletal Examination
-
General Principles
- Examine all joints
- Inspect: Look for swelling, deformity, redness
- Palpate: Assess temperature, tenderness, crepitus
- Range of motion: Check active and passive ROM
- Strength: Test muscle strength
-
Specific Joint Examinations
- Shoulder, elbow, hand/wrist, hip, knee, foot/ankle
Shoulder Examination
- Inspection: Look for swelling, deformity, muscle wasting
- Palpation: Palpate the acromioclavicular joint, coracoid process, biceps tendon, supraspinatus tendon, infraspinatus tendon
- Range of motion: Abduction, adduction, flexion, extension, internal/external rotation
- Strength: Abduction, adduction, flexion, extension, internal/external rotation
Elbow Examination
- Inspection: Look for swelling, deformity, redness, muscle wasting
- Palpation: Palpate the medial and lateral epicondyles, olecranon process
- Range of motion: Flexion, extension, supination, pronation
- Strength: Flexion, extension, supination, pronation
Hand and Wrist Examination
- Inspection: Look for swelling, deformity, erythema
- Palpation: Palpate the carpal bones, metacarpals, proximal interphalangeal (PIP) joints, distal interphalangeal (DIP) joints
- Range of motion: Flexion, extension, abduction, adduction, radial/ulnar deviation
- Strength: Grip strength, finger flexion/extension, thumb opposition
Hip Examination
- Inspection: Look for swelling, deformity, muscle wasting
- Palpation: Palpate the greater trochanter, iliac crest, pubic tubercle
- Range of motion: Flexion, extension, abduction, adduction, internal/external rotation
- Strength: Hip flexion, extension, abduction, adduction, internal/external rotation
Knee Examination
- Inspection: Look for swelling, deformity, erythema, muscle wasting
- Palpation: Palpate the patella, medial and lateral epicondyles, tibial tubercle
- Range of motion: Flexion, extension
- Strength: Knee flexion, extension, hamstring strength
Foot and Ankle Examination
- Inspection: Look for swelling, deformity, erythema, clubfoot, pes planus
- Palpation: Palpate the malleoli, navicular, talus, metatarsals
- Range of motion: Dorsiflexion, plantarflexion, inversion, eversion
- Strength: Ankle dorsiflexion, plantarflexion, inversion, eversion
Common Musculoskeletal Disorders
- Focus history and physical exam of the following:
- Rotator cuff tear - Swelling, tenderness, pain with motion
- Carpal tunnel syndrome - Numbness, tingling, pain in hands, particularly at night
- Degenerative joint disease (arthritis) - Pain, stiffness, crepitus
- Spinal stenosis - back pain, numbness, tingling in legs
- Herniated disc - radicular pain, weakness, numbness
- Fractures - Pain, tenderness, swelling, deformity
- Sprains - Pain, swelling, bruising, instability
Common Childhood Orthopedic Disorders
- A detailed understanding of these disorders is essential for pediatricians and other healthcare providers.
- The article provides a concise, practical guide, focusing on important aspects such as evaluation, risk factors, imaging, treatment, and referrals.
Metatarsus Adductus (MTA)
- Evaluation: Foot examination to assess the degree of adduction.
- Risk Factors and Indications for Work Up: Common, often resolves spontaneously. Consider referral to orthopedic specialist for severe cases.
- Treatment and Referral: Conservative management with observation and stretching usually recommended. Surgical correction may be needed in severe cases.
Flatfeet
- Evaluation: Assessing arch height and flexibility of the foot.
- Risk Factors and Indications for Imaging: Typically benign. Imaging may be considered to rule out underlying causes in cases with pain or concerns about other issues.
- Treatment: Conservative treatment with supportive footwear and exercises. Referral to a specialist may be needed if conservative measures are ineffective.
Kyphosis
- Causes: Posture, Scheuermann's disease, vertebral fractures, osteoporosis
- Management: Depends on the cause and severity. Conservative treatment with exercise and bracing may be suitable in some cases. Surgery may be needed for severe cases.
Slipped Capital Femoral Epiphysis (SCFE)
- Diagnosis and Management: Urgent surgical fixation needed. Refer to orthopedics or ED when suspected.
- Complications: Avascular necrosis and future arthritis.
Scoliosis
- Diagnosis and Management: Referral to orthopedic specialists for curves greater than 20-25 degrees.
- Treatments: Bracing and surgery for severe cases.
Limb Length Discrepancy
- Diagnosis and Management: Clinical assessment and imaging to determine the extent of discrepancy. Treatment options include shoe lifts, bracing options, and surgery.
Developmental Dysplasia of the Hip (DDH)
- Diagnosis: Physical exam and imaging to determine the severity of the condition.
- Treatment: Harness, closed reduction, or open reduction depending on age and severity.
Common Causes and Risk Factors for Low Back Pain
- Mechanical Low Back Pain: Muscle strain, ligament sprains, disc degeneration, facet joint arthritis
- General Risk Factors: Age, obesity, lack of physical activity, smoking, poor posture, heavy lifting
Red Flags in Clinical History with low back pain
- Age-Specific Concerns: Younger individuals may have spinal tumors or infections. Older individuals may have vertebral fractures or spinal stenosis.
- Use of Anticoagulants: Increased risk of spinal epidural hematoma.
- Constitutional Symptoms: Fever, weight loss, night sweats, bowel/bladder changes may indicate spinal infection, tumor, or cauda equina syndrome.
Key Physical Examination Findings with low back pain
- Neurological Evaluations: Assess motor strength, sensation, reflexes.
- Genitourinary Symptoms: Consider urinary retention, incontinence, or sexual dysfunction, which could indicate cauda equina syndrome.
Specific Conditions Associated with Red Flags in Low Back Pain
- Spinal Epidural Abscess: Severe back pain, fever, neurologic deficits.
- Cauda Equina Syndrome: Severe back pain, saddle anesthesia, bowel/bladder dysfunction.
- Vertebral Compression Fractures: History of trauma or osteoporosis, pain worsened by movement.
- Malignancies and Metastatic Disease: Pain that is worse at night, weight loss, unexplained fever.
Musculoskeletal Exam (Comprehensive Guide)
- Introduction: A detailed examination of the musculoskeletal system is essential for accurately diagnosing conditions affecting the shoulder, spine, and upper extremities.
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Description
Test your knowledge on the clinical examination of respiratory conditions and concussions. This quiz covers vocal fremitus, percussion notes, and key findings related to pneumothorax, pleural effusion, and emphysema. Enhance your understanding of respiratory assessment techniques and concussion management.
